lift me up

getting things done in south africa is subject to numerous unique frustrations, some of which i might have allured to in the past. one such typical case had to do with the lifts (elevators) in the old academic hospital in pretoria.

the old academic hospital was made many years ago. then over time as medicine advanced it got bigger in increments. finally it was a poorly designed conglomeration of buildings with multiple small wings all connected with sometimes tiny corridors. over and above that the eastern half of the hospital was totally different. it was a single story sprawling mass of wards, all opening to the outside world. the theaters were on the second story in the western half of the hospital. to get a patient to theater from casualties therefore you needed to take the lifts.

the hospital had a total of ten lifts, a few for each section of the strangely laped together place, but, as is typical of the maintenance ethic in south african state hospitals, only one lift worked at any given time. this added a unique aspect to an already high stress resus effort in casualties.

so generally in the high stress resus efforts, when you get to the exciting stage when you rush the patient to theater with all the fanfair usually only seen on american television medical dramas, one of the things that must be added to the mix is the identifying of the working lift. at this stage, what is required is to send three students ahead to the different lift areas to identify the working lift and to summon said lift. he then was required to shout down the passage to the other students that he had the lift. they, in turn, would relay the message to us and we would go directly towards that lift. i would always stay with the patient, usually bagging the patient with an ambubag.

after this usually the operation itself could not really deliver any more stress than had already been experienced.

foreign gratitude

this post is also about foreign relations, but, unlike the last, this actually has to do with surgery.

one thing about nelspruit is when people visit the kruger, if something goes wrong, they end up here. one such group was a european family that stopped by the hospital after a pretty devastating car accident. two people died on the scene, one walked away with minor injuries and one passed under the knife of our neurosurgeon for a brain bleed en route to icu where he was destined to spend some time.

after a few days in icu the patient's condition started deteriorating severely. his blood pressure just wouldn't stay up and his temperature wouldn't go down. then his kidneys started having trouble. his neurosurgeon excluded the head as a source of his sepsis. he then did a ct of the abdomen to make sure there wasn't something else alltogether that he was missing. with ct in hand he called me.

"he is deteriorating fast and the head is not the problem." he told me, "but the radiologists say he may have acalculous cholecystitis. what do you think?" acalculous cholecystitis is inflammation of the galbladder without the presence of galstones. it is usually seen in the very sick or in icu patients. however it is very rare. most consultations for this condition turn out to be false alarms. however, if you miss it you may really have a problem.

"it is very rare," i said, "however if you miss it you may really have a problem." i then went on to say the thick galbladder wall was often a result of a generalised edematous state much more commonly seen in icu patients. i however assured him i'd stop by and take a look.

the patient was still heavily sedated post craniotomy, but i could still elicit pain in the area of the gallbladder. hemodynamically he was in deep trouble. he seemed to be in septic shock and his kidneys were in early failure. i stopped by at the radiology suite and glanced at the scan. the wall was much more edematous than the rest of the patient. putting everything together i felt there was no choice but to operate. the only question was whether i should attempt a cholecystectomy, to remove the gallbladder or to just do a cholecystostomy, a less invasive drainage procedure reserved for people who may be too sick to survive the larger operation.

we started the operation late at night. i decided to start laparoscopically and decide what to do once i could see what was going on inside. the fundus of the gallbladder was totally necrotic, but lower down the tissue could still be worked with. a laparoscopic cholecystectomy looked feasible. and that is what i did with a bit of difficulty.

after the operation the patient improved in leaps and bounds and in two days time was out of the proverbial woods. i was feeling pretty chuffed. once i was quite happy a day or two later, i handed him back to the neurosurgeon for the rest of his sojurn with us.

some time after this the neurosurgeon got a call from the family doctor from their home country. he was indignant. he wanted to know why the gallbladder had been removed in such a young male, a group that usually does not have gallbladder problems and that in the absence of gallstones. he felt it was totally unnecessary and demanded an explanation. i could imagine him seeing us as knife wielding african savages seeking what we could cut out of unsuspecting civilised peoples. i mean after all what would doctors from a backward place like south africa actually know about medical conditions and the treatment thereof. fortunately the neurosurgeon wasn't in the mood to mess around. he educated the poor fool about the existence of the condition acalculous cholecystitis, which he had clearly not heard of. he then referred him to a few articles about the management of the condition and invited him to phone back afterwards if he still had questions.

when i heard all this i was not impressed. the fact of the matter is that we had saved the boy's life life. it seems from the call from his home country that there he may not have been so lucky. yet no doubt his family had been told that we were money grabbing knife mad morons randomly lopping out organs as the fancy strikes us. then i became more philosophical.

until fairly recently south african medical training was up there with the best in the world. so until fairly recently such attitudes were absolutely uncalled for, but as i have mentioned before, this high standard may be slipping a bit under the careful mentorship of the present regime. so maybe it is becoming progressively more justified when foreigners express reservation in our knowledge and skills. anyway, i knew that i could be proud of what i had done and i left it at that.

doctors for africa

a previous minister of health (who was then married to the present president of the anc and the future president of this country. can you guess who it is?) made the comment that she wants to train african doctors for africa. then she proceeded to degrade the degree. after all, life in africa is cheap and africans don't need quality health care. i couldn't help thinking back to my own experience of african doctors for africa.

in the apartheid era russia was kind enough to train a few doctors up for africa. interesting to note that their qualification was not recognised in russia. they were only good enough to treat africans. i worked with a few of them. here follows one story.

she was a russian qualified doctor. she had been chucked out of a surgical registrar post at medunsa (who gets chucked out of medunsa?) and by some administrative shocker, she had been given a post at our university. she and i wrote primaries together. it was my first attempt there. it was her third.

the last exam was the anatomy oral. basically they showed cadaver specimens and asked us questions and to point out specific structures. my oral didn't go too well. when they went on about waldayer's fassia i struggled a bit. most of the other stuff i answered. her oral was a feast.

when she went in, the first specimen they showed was an open abdomen with everything removed except the retroperitoneum. they started easy. they pointed to the ivc, only the biggest vein in the human body, and asked her to identify it. she could not. after an awkward silence they moved on. maybe the ivc was a bit too difficult. they pointed at the left kidney. even in a second rate russian medical school the kidney must be an organ that can be identified without too much difficulty. she smiled;
"that i know," she piped up with confidence, "that's the spleen!" the examiners were a bit shocked. where do you go after a kidney is mistaken for a spleen? maybe they needed another specimen. they went for a pelvis cut through the middle. there was a clear bladder with a pipe exiting below and moving through a gland. it then continued on its merry way towards the penis. they asked her to identify the gland that pipe went through. she moved uneasily. it was clear she had no idea. then suddenly she redeemed herself, but only a little. she suddenly grabbed the penis and proudly proclaimed;
"i know what this is. this is the penis!"

the examiners did not share the anc's enthusiasm for producing pathetic doctors in a possible attempt to thin out the population. they therefore felt it was important to give a proportional mark. they felt that zero percent was too low because she did know what the penis was and it is as anatomical structure. however even twenty percent seemed a bit high because all she knew was the penis and that is maybe a bit too little for a future surgeon, even an anc approved surgeon. they settled on 5%. i thought it was a bit high, but possibly fair.

after failing three times and killing a quite a number of hapless patients she was thrown out of our university. many years later i saw her hanging with wits registrars at a symposium. the future looks bright.