Saturday, December 15, 2007
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.