Saturday, December 15, 2007

practice


ever wondered why what we do is called practice? one particular story brought it into stark reality.

i was doing my internship in qwa-qwa. the hospital where i worked was a secondary hospital servicing about one million people. but it suffered from the usual problems of no supplies and theft etc. the result was that certain items in casualties were kept under lock and key. these included drip sets, needles, jelcos and at the worst of it, even syringes. you can imagine the chaos in a resus situation.

the next consideration is the difference between a surgical resus and a medical resus. a surgical resus is usually easier. there is usually one problem. keep the patient alive long enough to find the problem, fix the problem and the patient recovers. the patient is leaking blood. find the leak, plug it, fill up the container and all is well.
a medical resus is a completely different animal. once your body has crashed due to a medical problem, your reserves have been used up. there is usually not much that can be done. if you crash because your lungs have been eaten up by tb, no matter what you do, there is not enough working lung to keep the patient alive. when you crash because your liver doesn't have enough normal tissue to detox your blood, no matter what, there is not enough to keep you going. and so one can go on, organ by organ.

so, usually a medical resus is pretty much a waste of time. a surgical resus must be done efficiently and can mean the difference between life and death.

having set the stage, i was on call in casualties when a patient came in very late one night. he was wasted. there was thrush all over his mouth (often indicating terminal aids). he was very nearly not breathing and the occasinal gasping breaths he took sounded gurgling to the naked ear (no stethoscope needed). i knew tb had basically destroyed his lungs (working in qwa-qwa and hearing this breathing was almost synonymous with making this diagnosis). i could feel no pulse and hear no heart sounds (with a stethoscope). it was a pointless situation, like most medical resusses.

then a thought occured to me. bearing in mind the unit was not geared for resus due to the problems mentioned in the opening of this post and bearing in mind surgical resusses would be coming in in the future, it would be good to run through a resus where only i knew that it was pointless.

i jumped to action. i sent one sister to bring the ambubag endotracheal tubes and laryngoscope, another to unlock the closet with the needles and drips and yet another to get the drugs. soon i stood alone next to the patient. yes, that is how a resus went in that hospital all those years ago. you may better understand my desire to do a practice run in a situation where the outcome was already determined.

by the time everyone came back, the patient had stopped breathing. i moved to the head. as i was intubating, i orchestrated a full resus. one sister was put to work doing cardiac massage, two started getting iv access, one attached the ecg monitor and one started drawing up drugs. i tubed and started bagging. during the whole process i explained to the sisters what i was doing and why. i gave some pointers about how better they could perform their respective tasks. everything went well.

and then possibly the worst possible thing happened. the patient's heart started beating and his peripheral saturation began to climb. the sisters where ecstatic. i was worried. i had to find a place for him in the hospital now.

i phoned the physician (cuban). he said the patient couldn't go to icu because of the fact that there were no available beds. he asked me if the patient was breathing on his own. i stopped pumping his lungs and lo and behold, he was breathing. the physician made the call. he should be extubated and take his chances in the ward.

we extubated him and sent him to the ward. he was alive. the sisters in the ward were more than just a little annoyed with me for what they called going above and beyond the call of duty by resuscitating a corpse. they didn't call me when he crashed again. they made sure he was good and dead before they called me. even then i think they waited a few minutes to make sure there was no chance for him.

looking back on this, i realise there are a number of questions my international readers may raise. i even considered not posting it. but i think one must see these events in the context of the unique circumstances we worked under. when the surgical resus did come in, the entire casualty unit was more geared for it and it went better than it would have. those sisters there that night almost without exception thanked me for the entire thing. a rumour went around the hospital that i was the best intern to be on duty with. the only point that i didn't like was the negative attitude to me from the ward staff, but that was something i could easily get over.
then there is the point of available resources. this is a reality in south africa. this blog is supposed to portray uniquely south african stories, so that part of the story also needs to be told.
the point of the combination of hiv and tb, especially in those days when there was no available treatement here also shows a south african slant. that was the fact of the matter at that time and these deaths were commonplace. even these days, thanks to our minister's hiv policy, many people die unnecessarily all the time in similar condition.

i'd be interested to hear comments though.

12 comments:

rlbates said...

Yes, often resources are limited, but wasn't it worth much to "practice" and learn in a semi-calm manner. You were calm and walked them through the entire thing. What a great way to learn! What a great benefit to the next patient on whom the resources would not be considered wasted.

Vijay said...

Great post Bongi.

I guess you were worried if your international readers would have problems with the ethical/moral issues that this raises. Believe me, I come from a place where this kind of thing is common.

I saw that Ramona had mentioned the BTB award in a comment in another post. I'd like to place on record that I gave it to you first, it just didn't occur to me to notify you.

Bongi said...

vijay, yes. if you read my post about keyhole on our world (http://other-things-amanzi.blogspot.com/2007/10/keyhole-on-our-world.html)
you will see i have been worried about the take that people who are not exposed to our world have on what is written. but in the end if you want to get an honest take on our world, here it is. if it offends, it is not supposed to.

rlbates said...

Vijay, I gave you top billing when I mentioned that we both had given him the award. Same with several of our friends. :)

Sid Schwab said...

It seems clear the benefit outweighs any other considerations. I doubt the patient consciously suffered any, and the next patient to come along ought to be grateful. It's not unlike the intubations after expiration we practiced as med students.

Lynda said...

Interesting post. My reaction to it was that in a way your 'treatment' of the patient kind of shows that you are in a way a victim of the violence/death etc South Africans suffer/face all the time, in that your response was so densensitized - he is going to die anyway, so lets just forget his rights etc and make use of him for our own benefit. Difficult to explain what I mean, but as a South African now living abroad - I find that South Africans have this disregard for life caused by the SA situation - as though living with the threat of death just results in total devaluing of life. I don't mean it as a criticism my own parents still live there and I am often shocked at how casually they can tell me about some or other crime that would make headlines here but doesn't even get a mention there. I know you're a great doctor and there were benefits to be had etc etc but still doesn't sit well with me.

Buckeye Surgeon said...

You live in a different world. Great story. Nothing immoral about your actions. We "practice" all the time on humans, even in America. Gross anatomy labs. Inguinal hernias on patients at VA and Charity hospitals. The early days of organ transplantation. Triple zeroes (no BP, no HR, no respirations) that came in through the trauma bay always got the full workup, even ED thoracotomy occasionally, (the trauma attending knowing full well the patients chances were nill.) If it prepares the team for the next patient, some 15 year old clinging to life, then what's the harm?

I don't know if I could do what you did in the setting of florid HIV and no treatment options. Crash intubations and resus scenes can get a little messy......

Ladyk73 said...

I think the difference is in the fact that in other parts of the western world, perhaps someone would not get that sick if they treated...as in...most people here with HIV will get treated before it got that bad...and when it got that bad they would be dying hopefully without so much pain in Hospice.

Gosh.... bit to have the TB double whammy...

My friend is a critical care nurse and she tells me about all the "slow" codes for people without DNRs

pelican said...

Hmmm, I suspect your concern about comments wasn't about your decision to run the code, but about the ward sisters' decision to let the patient cool before calling you when he expired.

This is an issue in the "developed West" as well, but our default is to "do everything" for a 98 year old patient with advanced Alzheimer's- someone who has no awareness of life, let alone quality thereof.

Check out Panda's
http://pandabearmd.com/blog/
most recent post, I'd be curious to hear your comments, coming from a system where cost vs benefit is acknowledged as a significant factor in medical care decisions.

Bongi said...

lynda, thanks for your comment. the feelings we south africans have to violence is different to first worlders. i posted on a similar topic under the heading stories of guns. take a look.

but my treatment and line of thought was the result of being a doctor. the doctor commenters here had no problem with what i did, even the americans. one of the aims of this blog is to give a keyhole into our world. sort of like er, only truer. it seems that it is achieving it's goal.

pelican, my concern was about my decisions. what the ward sisters did i had no say over. i didn't like it. but i couldn't do anything about it.

at the time, one of my thoughts was that if we could bring him back, then maybe his lungs weren't as bad as i suspected. if he had the benefit of icu and tb meds, maybe he would have had a chance. the decision to deny this patient an icu bed, although justifiable, probably had a lot to do with his eventual demise.

dr_clairebear said...

hello. i'm a doctor from the philippines, although I just finished my residency training in a charity tertiary hospital rather than a rural hospital.

i related very much to your story. limited resources are the bane of our existence in our health care setting, and just as you were called on to make a decision regarding what type of care to allocate to this patient, we also face these kinds of decisions every day. maybe some people may think we are playing God, but the truth is that we are just making the most of a bad situation.

It's just logical to give the most resources to one who will benefit from it the most. This doesn't mean that these same decisions don't come back to haunt us or hurt us. They just become an additional burden for doctors who practice in this kind of environment to carry. And that is what makes it so sad.

Karen Little said...

in some places, stage fours are not even entitled to blood products or IV antibiotics. Where I work, we have a really good infectious diseases team who can bring these people back from the edge pretty miraculously, but intubation of a stage four patient is still very muh frowned upon.

We practice a lot on stab hearts, though - guys who come in pretty much dead, but we still go through the motions of a full front-room thoracotomy on. We hope that it will iron out the glitches in the process so that when somebody who an be saved comes in, we can do a good job.