Saturday, October 03, 2009


some things make me feel so powerless (yes, even i can be powerless in the face of incompetence)

i have previously mentioned a thing or two about my opinion of where medical training is going in this country. basically the powers that be are not-so-gradually degrading the degree. to them somehow it seems like a good idea. ideas i suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. well i get to see the consequences up close.

he was referred from an outlying hospital on a friday. the peripheral hospitals so like to empty their wards for the weekend. after all there is some good fishing in these parts. thank goodness for good fishing. otherwise many more would die unnecessarily.
anyway the patient had free air in his abdomen. this is a sign of a ruptured stomach or intestine and requires immediate operation. in fact the longer you wait the higher the chance of death. what i found interesting is the x-rays that they sent with the patient dated four days before the transfer (but admittedly not just before the weekend) clearly showed the free air.

now not all that long ago, to miss free air on an x-ray even as a student was a mistake that would fail you. these days you can easily get through medical school without worrying about trivialities like free air on x-rays. also, to have perforated bowel causes intense almost unbearable pain. even a street sweeper would be able to pick this up in the patient. yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days. that is if he even ever examined the patient. then fortunately a weekend turned up and the patient was referred, well on his way to the great hereafter.

as can be expected, when he turned up he was extremely ill and was already in kidney failure. the catheter bag remained empty. after a few hours of aggressive fluid resuscitation there was at least a bit of urine in the bag. then it was time to operate.

the abdomen was in a bad condition. to say it was rotten would be somewhat of an understatement. but the interesting thing i noticed was the full bladder. the peripheral hospital had kindly inserted a catheter not into the bladder but only into the urethra. there they had blown up the balloon, just to make sure they did the maximum amount of damage.

so not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do , because they didn't know how to do it properly, caused further damage to the poor man.

i cast my mind back to when i was still in academic circles. i remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared. i myself was asked to examine a student in a practical exam. i failed her because she was simply a danger to any person unlucky enough to become her patient. and yet the powers that be had so changed the system from when i was a pregrad that she could not be failed and was released into the community.

i'm sure the people who have orchestrated the new system that is so student friendly (but not patient friendly) don't get to see the disasters out in the periphery that are a result of their hard work. quite frankly even if they did see them i doubt they would care. after all it doesn't directly affect them.


Anonymous said...

failure to fail

Jayne said...

I must admit that I'm worried about the repercussions of our 'no fail' system, as it seems like (unfortunately) doctors like yourself will be left to pick up some very messy pieces. It's bad enough that medical aids now accept sangoma/witchdoctor diagnosis', so the consequences of having utter idiots 'treating' patients truly is a nightmare. I am genuinely grateful that there are still doctors like yourself here :-)
*thinks to herself: how many hours will it take to nut through to Nelspruit for an appointment? LoL

Jade said...

We are not all bad bongi. We have had interpretation of x-rays and other radiological films drilld into us per speciality along other basic things. Yes, i personally know a few people that wil tell u that they failed a year but got pushed foward. . .And they are white (since ppl think its a black/non-white students phenomenon)!! Not all recent graduates are reckless and clueless just as not all old generation graduates are competent. not all peripheral hospital doctors are SA trained and med school is still hard, 15 end of year exams hard!

Bongi said...

jade, yes, like all generalizations, this one is not 100% true. also the level of truth varies between universities.

however i saw the old and i saw the new and there is a difference. i also have seen some of the products of the new system and there is a difference.

in the end if you are dedicated and you realise what it is you are becoming and the ramifications thereof, you can come out of medical school these days well equipped. unfortunately you can be a veritable hazard and you can get your degree.

enrico said...

At a Red Cross rotation the last year I was in Mexico the attending doctor berated another student (not classmate, on diff rotation) on a similar miss after a stab wound suggesting we should get a head CT suspecting free air in his cranium (roughly translated). LOL

Jabulani said...

Bongi, dedicated practitioners (in whatever field) find incompetence wearing. The bad always reflects negatively on those of us who are good. I sometimes wish I was not
"in the same boat" as some of the idiots out there.

Jayne, you echo a sentiment I've had since reading Bongi's blog. If I ever go home to SA, man I'm gonna make sure I'm close to Nelspruit and proper medical care!!

Jade, I'm sure you are right; generalisations often exclude some good folk but, in the main, I find generalisations hold water. It's not only medicine either. My brother who did building something-or-other experienced a similar push-through policy. If you escape incompetent doctors, just don't go climbing any high-rise buildings!!

Bongi said...

jabulani, reminds me of a funny incident last week in nelspruit. they are building a highway to bypass nelspruit at the moment. as can be expected they need to make bridges. last week one of the bridges that was only partly complete spontaneously broke and a large chunk fell off.

the department of road works etc blamed it on drivers speeding past next to the bridge. typical government answer.

so, as long as this bridge that they are building as part of a highway never has to experience cars going at speed, all should be well.

does your brother know of ant of these people he is talking about that came to nelspruit.

Amanzi Down Under said...

I cannot forget the time a "new graduate" put a chest drain into the wrong side of the chest because he a) couldn't identify clinical signs of a tension pneumothorax and b) couldn't tell left from right on a chest Xray. (Don't even ask me why a tension pneumothorax had a CXR to start with.)
This doctor was "pushed through" medical school before my eyes on political grounds, the very same medical school I and the esteemed Dr Bongi attended. That experience taught me that a degree from a previously well respected institution is no guarantee of competence and I therefore advise all competent doctors to obtain postgraduate diplomas or qualifications to distinguish yourselves from these guys/murderers. Now I must return to my textbooks as I'm preparing for my Medical Council Exams of a first world country.

Jabulani said...

Bongi, that would be an interesting question to ask him. I suspect it unlikely. At his graduation he says he was surprised by the number of students awarded the same degree as he; people whom he'd never seen in his class!
Then again, perhaps they weren't in the lectures because they were already conducting on-the-job-training in Nelspruit...

Tut, it seems bridges in SA have no staying power - falling down at the slightest speeding driver. What sissies. Then again, maybe it saw a driver on the right side of the road, hmm??

Anonymous said...

So, did this poor person make it? And, can they get any sort of retribution for the pitiful 'care' at the other facility? My gosh..that would be an award winning lawsuit in the US!!

Bongi said...

anonymous, one of the aims of this blog is to elucidate life and medicine here. this is not usa. this is africa. this patient did make it, but there was no talk at all of litigation. to be honest, i did not even think of lawsuits until your comment. after all, this is africa. here you count your blessings if you survive.