Tuesday, March 20, 2007

bombay gas abses

just realised i'm not sure how to spell abses in english. no matter. for this post i'll use the afrikaans spelling. i apologise to the purists.

when i was still a registrar (kliniese assistent) we used to warn our house doctors about the bombay gas abses. where the name comes from i do not know. why bombay i also do not know, but that is the name taught to me when i was pre-grad and that is the name we propagated when we told our juniors about it.
the bombay gas abses was actually more a joke than anything else. we would warn the juniors to be careful about an 'abses' that presented in the groin. they would often have an intermittent history and usually be painless. mostly, they could be pushed back into the abdomen. often they had audible bowel sounds in them. occasionally they would suddenly become very swollen and painful and could no longer be pushed away. here there would usually be signs of concommitant bowel obstruction. the stern warning we gave to our juniors was not to drain this particular form of abses, because more often than not gas would come out and it would continue to drain for many a long day. we would all then have a good chuckle and go on with our daily activities. i never actually heard of a case of a bombay gas abses being drained, that is until....

recently we got a transfer in from one of the peripheral hospitals. the history was that an abdominal wall abses had been drained. the wound, they said, continued to drain for a few days and now they noticed it was bowel content coming out. i tried to imagine what sort of hernia would present as an abdominal wall abses. spigellian maybe?

anyway, the child arrived. the call doctor took the patient to theater, but phoned me to join him. the patient lay on the table, already asleep. there was a cut over the inguinal area, not merely abdominal wall. fecal material was freely draining from the wound. the first bombay gas abses that i'd actually seen!!! the entity did exist! somehow when you see it, it's not so funny any more.

so we did a lap. the caecum was perforated. there was soiling in the right paracholic gutter. there was a bit of necrotic material in the area. so we did a right hemi, debrided, rinsed and closed. i felt uneasy about an anastomosis in what was essentially a week old abses bed, so i pulled out stomas for later closure. the patient did well.

this story is such a picture of present day south african medical state care that it really makes even the stout hearted want to cry. interns and community service doctors are scattered across the country with absolutely no senior backup. where such an inexperienced doctor in most other places should be able to ask a senior opinion, these doctors do not have that priveledge. they do what they think is right, but quite often bungle on without even a clue they are totally screwing up. i fear that if i go into the reasons that these people are without supervision and how the government of the day systematically destroyed a system that was quite functional 15 years ago only to replace it with...well nothing, i may sound a tad bitter and full of resent. i'm even likely to be accused of unpatriotic behaviour and the trump card, racism. i therefore think i'll just touch on it for now.

but what really gets me is these beurocrats still sit in their offices, actively engaged in the destruction of any remnant of service that remains. they are like generals in great battles, sending the masses onto the waiting muzzles of enemy rifles. not only are the poor and destitute without good medical care, but these poor clueless doctors are thrown into water far to deep for them to handle. they will also be dammaged and many a good healer will be lost to the profession. they will kill by their ignorance. when this happens, some will not be able to recover from the fact that they are responsible for the death of someone else, even if totally unintentionally. that is a difficult thing to get beyond.

today's post was a spot emotional and i suppose the bombay gas abses was just a catalyst for how i feel. i've decided to post it anyway, because it is how i feel at the moment and this is just one event of many. to be in what can only be likened to a battle where regularly one sees death and suffering which is quite avoidable must have an effect. i don't like to lean to the melodramatic, so maybe i'll seriously edit this later. until then...

10 comments:

Anonymous said...

there's a "c' in the somewhere, and an extra "s"

Sid Schwab said...

We referred to them as a "wind abscess." Never saw one, happily. I did get an urgent call once from a family doc who'd tried to remove a "lipoma" in his office, only to find it was an epigastric hernia.

P.S: your spelling of the word is much more efficient! English spelling is often deeply annoying.

Frances-Anne said...

so ... poor black people in south africa had access to "a system that was quite functional 15 years ago"...?

or was this reserved for the priveleged? who still have access to private healthcare...

are you saying that the poor are WORSE OFF now than under apartheid?

I don't mean to irritate or challenge you, just to understand your perspective.

Bongi said...

anonymous, that's exactly how i felt. i messed around with the extra c and s until i just thought stuff it.

frances-anne, there is not a hard and fast rule. in a place like pretoria, the poor black will have roughly the same health care that he had. occasionally better, depending on a few things like where he lives or what disease he has. in the periphery, definitely worse. you see back in those days, although there were separate hospitals for blacks and whites, even the black hospitals worked fairly well. on the whole they were run by older very experienced general practitioners who also kept the pot on the boil by doing private work. when the interns came, they had these very capable doctors to show them the ropes. interns therefore quickly got pretty good themselves.

the present government felt that there would be a conflict of interests if private doctors were allowed to work in the state, so they stopped it. all these doctors resigned (except for a few philanthropic souls who were forced to give up their private practices). the state had no solution to the problem they had created. they instituted a year of community service, thereby having enough doctors. this ensured that there were always inexperienced doctors, even though there were enough. now we essentially have a system where we replace all our doctors every two years with the new batch of clueless docs. in some places they tried to get the old gp's involved again. however most of these doctors that had been loyally serving the community (yes the black community before you ask) for many years took the whole thing as a major slap in the face and did not come back. some places did better than others. just over the mountain from where i live is barberton (from the movie the power of one). they had a gp that did stay and went to a lot of effort to keep things going, so they survived for longer. he resigned recently. nelspruit is a total mess. if you come here, you'd better make sure your medical aid is good, no matter if you're black or white (apologies to michael jackson).

Bongi said...

p.s, dr schwab, thank you for subtly helping me with my spelling. but if abscess is singular, what would the plural be?

frances-anne, one thing the government did do that sort of worked is they made a contract with the cuban government to supply us with doctors. to a large extent they form the backbone of the peripheral state care. the constant factor. there are, however a few problems with this, almost all related to political problems in cuba.

Amanzi Down Under said...

Today I had a medical student who was too afraid to Dermabond a simple laceration (or perhaps too lazy...) Apparently he'd never done one before and needed to watch a few times before he was willing to try.

Anyway as graduates of the 'See one, do one, teach one' system we tended to congratulate ourselves on our balls of steel as we attempted to provide a service to the poor and underserved...

We truly were the last option for the patient who has risen before dawn, to walk several kilometres and hail a combination of public transport to get to the hospital to wait hours to be seen by inexperienced unsupervised us.
If we didn't try to help, there really wasn't anyone else. (In my experience the Cuban doctor was always somewhere else, except where they were paid to be...
Cuban doctor: "Don't worry you can do caesar. If there is river of blood running under theatre door, then you must call me!")

Of course our bravado inevitably resulted in morbidity. I wonder if the 2 year internship has made any difference in bringing down the casualty rate.

Frances-Anne said...

Dear Bongi,
thanks very much for your fulsome reply...
The plural would be abscesses...
but that's an assumption based on a passing knowledge of the english language not of medical terms.

Dr. Bean said...

I am deeply saddened, reading the state of south african medicine as you describe it. I had a very good impression of the system as it was 15 years ago, based on knowing some very fine doctors I met who had come to our medical school in the USA for fellowship training.

In the flush of optimism following the change in government the destruction of this system was one of many unforeseen consequences. Who shall watch the watchmen? or who can make politicians and bureaucrats accountable when they experiment with people's lives?

I have no answer to this question, but to note that lightning bolts from heaven or raining burning sulfur on the wrongdoers appears to be an extremely rare event.

Frances-Anne said...
This comment has been removed by the author.
Bongi said...

i read the deleted comment. just for clarification for that person.

i do not and have never agreed with apartheid. it was in no way good and can't be made out to be. the separate hospital thing they had going in those years was also not good. it was all wrong. all of it. however, the present medical system is worse for the poor, black and white. this is simply a statement of fact. they should have amalgamated the hospitals as they did, but they shouldn't have chased dedicated doctors away. what happened is unrelated to the struggle. it was simply political blundering. the proverbial throwing the baby out with the bath water.
please understand i'm not getting nostalgic for apartheid as you seem to imply, but just because the liberators are now the government does not absolve them of responsibility.

people still die in south africa, but no longer for a good cause.