entrepreneur

i would like to say this is a south african story, but , truth be told, when people see the opprtunity to make money off the backs of the stupid and vulnerable, then it is pretty much a free for all (eg, eg.)

at the local state hospital, as it should be, there is an hiv clinic. as the name would imply they treat the many people in our area with hiv using modern antiretroviral medication which is proven to lower the viral load and can turn a once deadly disease into a manageable one, not unlike diabetes.

yet still there is a stigma associated with hiv and it gets treated unlike any other disease. you can't simply test someone for it like you would for diabetes. before testing someone, they have to be counseled so they fully understand the implications of knowing about the disease. if they refuse testing, then they are allowed to continue in their ignorance, without treatment of course. also, if they choose to be tested and are found to be positive, before they are permitted to see the doctor who will be managing their newly diagnosed disease, they are required to speak to the councilor once more. this is supposed to be a time where the councilor explains to the patient that hiv is no longer a death sentence and explains the importance of adhering to the treatment plan. yet this is also an opportunity for an enterprising charlatan.

the patient in question was back after having her hiv test the previous week. i think in her mind she actually knew she was positive. there was little else that could explain her symptom complex and she had already accepted the inevitable. all she wanted to do was to get through the obligatory counseling and to get to the doctor so they could work out a treatment plan. she sat down with the councilor.

"you are hiv positive,"

"yes, i thought as much."

"now you are going to see the doctor shortly and he is going to discuss treatment with you." this is exactly  what she wanted. she just wanted to get through this and see the doctor after all. "he will tell you about all sorts of western medicine that you will have to take every day for the rest of your life." again, no surprises. "but there is an alternative." what? this was not in the script. she thought she would rush through this so called post counseling and get to the doctor. yet humans are inquisitive creatures.

"what do you mean?"

"i mean there is another way." with this, she reached under the table and produced a second hand pepsi bottle full of some liquid. the patient looked at it in surprise. it had a slightly green hue to it. the lid had scratches on it indicating that it was probably quite old and had been used many times before. "this is a cure for hiv. it is a mixture that a sangoma has created. unlike the western treatment that the doctor is going to offer you, it has no side effects. the other advantage is, because it is a cure, you only need to buy two bottles and use it for only two weeks and you will be cured. and each bottle costs only two hundred rand." she smiled. it was meant to be a warm, reassuring smile, but the patient saw it for what it really was, an evil smile hoping to snare yet another victim and send her down a slippery slope after fleecing her of her hard earned money.

yes south africans can be entrepreneurs. i don't have it in me though.

mixed feelings

i hate working in the state. i would quit it altogether if i didn't love it so much. such mixed feelings

recently i was called to the state hospital, as usual at an obscene hour. somehow i dragged myself out of bed. i think i woke up half way to the hospital which was a good thing. it makes parking so much easier.

now generally at this time my sense of humour is not at an all time high and i'm not feeling my usual cheery self. yet ironically it is exactly at these times when one needs to be the most malleable in attitude. if not, you will not continue in the state for long. and these were my thoughts as i walked towards theater that night. i thought of past experiences and prepared myself.

i approached the theater. i could see the main door now had a security gate that was locked. i think i was more than partially responsible for this. but the door to the change room was at least open. as i entered i remember saying to myself that if the door was open then nothing i encountered inside would get me down. i knew it would need to be a decision.

in the change room, i found only shirts. at least there were shirts, i thought. i took one and soon had put it on. tucked away in a different corner, away from the other clothes, with less effort than i expected, i found the pants. they were duly donned. there were no shoe covers. it was in the middle of the night so i just assumed that the owner of the boots i loaned would be none the wiser. anyway, it wasn't as if i had much choice. then there was the small matter of head gear. i did not have to resort to things i had done in the past. looking in the female changing room turned out to be all that was needed.

i then made my way past the sleeping theater nurse towards the operating theater. as usual i had to use plaster to stick the inferior mask to my face to prevent my glasses from fogging up. and only then could i scrub in to join the medical officer who had asked for my help.

truth be told, i accept the small irritations of the state. when i'm there i feel like i'm making a difference. i also like teaching and these days it is the only chance i get.

yes, i love working in the state. i would do it all the time if i didn't hate it so much.

orchestrator

team work in an operation is essential. usually i can just get on with my job and trust the anaesthetist to keep the patient going (alive). i don't have to worry too much about him. however in state sometimes i need to orchestrate everything.

the case was unusual. blunt trauma to the abdomen often causes the left diaphragm to burst, causing the intestines to migrate into the chest. this time the trauma was to the chest. the diaphragm burst from above. the x-ray picture was the same with the stomach in the left chest, but at operation it looked quite different.

they had apparently already done a full resus in casualties before even getting the patient to theater, so the patient wasn't in the best of shape.

the anaesthetist was a doctor from some outlying peripheral hospital that usually didn't do more than very simple cases and didn't even have a diploma in anaesthetics. he was doing his best and at least trying to meet a need in our local state facility. i opened in the midline. i found it a tad disturbing to find the heart free in the abdomen, just above the liver. i considered saying,
"i don't think this is supposed to be here!" but i thought better of it.

the diaphragm was destroyed. the pericard was destroyed. the heart had wondered off to the left and the lung had shrivelled up to hide somewhere out of sight. it didn't take a genius to realise this was not good. i realised this was not good.

i started the repair. then the heart stopped. it was easy to diagnose. i could clearly see the heart in front of me. i informed the gas monkey (anaesthetist). he looked at me. i put my hand around the heart and started to squeeze. the gas monkey looked at me. i realised he simply didn't have the beginning of an idea what to do. i realised this was not a team work situation. i needed to take control of everything. i was the gas monkey consultant suddenly. i took control. i orchestrated what needed to be orchestrated.

"you!" to the gas monkey, "give adrenaline now! you" to house doctor floating around like an unwanted fart on the wind, " draw up x ampoules of adrenaline and put it into y ml saline!" all the time i compressed the heart. now i have occasionally compressed a heart against the sternum from inside the abdomen, but seldom have i stood with the heart completely in my hand. i quickly adjusted to the correct amount of pressure to apply directly to a naked heart. it is quite a bit less than one on the other side of a diaphragm and decidedly less than one hiding behind a sternum. soon i was applying compressions with thumb and two fingers. that was all the pressure that was needed.

the adrenaline did the work and the patient came back. we went on. then things went south again. this time i put my hand around the heart and clearly felt the gentle vibrations of ventricular fibrillation.
"you!" to the wide eyed floor nurse "get the defibrillator now! you!" to the surgical medical officer, "get ready to shock and give me ample bloody warning because if you shock me i will not be happy!" all the time the heart was cradled in my hand with my three fingers doing the necessary.

we defibbed once and the patient came back.

the patient crashed twice more and i orchestrated the relevant resus. i then sent the house doctor to icu to ensure they prepared an adrenaline infusion and started closing. the patient had had better days but she was alive. i closed, gave the last necessary instructions and left.

when working with true gas monkeys we work as a team. but it is times like these when i work with junior doctors who find themselves in deep water that i remember what a priveledge it is to have well trained colleagues.

philosophical

this is not an easy post.

i try to be philosophical. i really do. if i'm not there worse would happen, i tell myself. but somehow i struggle to believe my own spin.

the state hospital is struggling. if i get called there it is usually in the middle of the night and i usually am not that enthusiastic about it. but if i must, then i must.

recently i was called to help with a complicated appendix. i use the word complicated, but i really mean african complicated. it was a mess worse than i can describe. suffice to say a cuban trained (the south african government send a handful of medical students to get trained in cuba) medical officer (junior doctor) was doing calls as the surgeon on call. he cut into a hapless victim without having clinically evaluated her. truth be told, i think he did evaluate her but he didn't have the clinical savvy to figure out what he was dealing with. his south african trained junior had actually made the right clinical call but was out ranked and had to concur. only when the wrong incision had been made and wrongly extended, all just after midnight, was i called to try to save what remained to be saved. fortunately i am not particularly intimidated by such surgical challenges. i dealt with what i got.

but if what i got was not enough, what i was told i truly struggled to deal with. you see, i try to be philosophical. in december when i did a thoracotomy for a gunshot wound, a procedure that is not actually supposed to be in the armamentarium of a general surgeon, all went well. later i heard second hand that the patient had died because he was transferred to another hospital because of a lack of icu beds at the local hospital. the only problem was he was transferred in a sub optimal ambulance. the short version is he died. i was devastated, but philosophical. i reasoned i had done my best and he would have died anyway if i wasn't there. i did my bit but my bit was not enough in the greater scheme of things. philosophically i try to reason with myself that in a war situation there will be casualties. there will be people who die unnecessarily. i must do all i can to prevent and limit this but it will happen none the less.

then that night, the cuban trained junior doctor who was doing calls in surgery in a setting where he in all reality could not be expected to cope, told me about another consultation he had turned away. i knew he had the habit of turning people away and because i knew he was not equipped to deal with most of what came his way i sort of understood. however the night in question i was on cover for him. there was no excuse.

he calmly informed me a peripheral hospital had phoned about a stab wound neck that was bleeding actively. the hospital in question had no surgical cover and couldn't operate such a case. he apparently refused the transfer on the grounds that the patient was bleeding. simple logic i thought would inform most people that the bleed needed to be controlled before there was any hope of survival and this could only be achieved surgically. it seems simple logic was not one of the subjects in the cuban medical curriculum. he refused the patient on the grounds that the patient was bleeding when that was the exact reason the referring doctor was seeking to refer the patient. i told the medical officer the patient would die without surgery. he cooly and calmly said in that case the patient will already be dead because they phoned six hours ago. i was shocked. even my usual philosophical outlook could not justify this. my philosophy relied on me doing my best and after that accepting the outcome based on the system. to accept the patient died because a junior doctor refused to accept a transfer because he hoped for a bit more sleep that night was just a bit too much even for my flimsy philosophy.

he maybe slept well. i did not.

collateral damage

i'm not a war doctor. well not in the truest sense of the word. but sometimes i think there are similarities between whatever it is i am and a war doctor. i'm not talking about the fact that i have operated more gunshot wounds than i can count because of the amazingly high crime rate in our country, although that is probably part of it, but i'm talking about being first hand witness to collateral damage.

when the new government came to power they decreed that no state doctor could do private work. bearing in mind almost all state hospitals were run by private doctors, in one fell swoop they got rid of almost all their senior doctors. they realized their mistake, but it was too late. those doctors did not return. the next plan was to import doctors from cuba. but having doctors from a somewhat less than free country working in an essentially free one was wrought with problems. their numbers gradually decreased as they defected. the next plan was to introduce a community service year after the intern year. they then had enough doctors but they were always junior. this is pretty much the way it has stayed up until now. then there was a change in the training of doctors. it seems that the powers that be felt that it shouldn't be so difficult. some pretty dodgey doctors were created.

the problem with having your hospitals manned by junior doctors is that they tend to be junior. junior doctors are quite often not so clued up. experience may be lacking. and this brings me to a story by way of explanation. unfortunately this is not an unusual story.

there is a physician (internist) who does a session in the state hospital in a smallish town some distance away. one day when he was there they asked him to evaluate an x-ray of a patient they said had heart failure. they had made the diagnosis largely due to laboured breathing which they attributed to pulmonary edema. they had been treating her for three days to no effect. he took one look at the x-ray and was dismayed to see free air under the diaphragm (this pretty much implied that the actual diagnosis was a perforated peptic ulcer). the physician was shocked. he told them to send the patient to some place where she could be operated.

i was doing a gunshot wound in our local state hospital as a good war doctor should when i heard the patient was on the way. i knew it would take some time, so after finishing i shot off to the private hospital to quickly do another case. after that they phoned me back to the state hospital to oversee another gunshot abdomen. while there i was informed that the patient had in fact arrived but promptly died. i suppose three days with a perforation and fluid restriction (which is part of the management of heart failure but not too good for perforation) were just too much for her to handle.

one thing i have realized is i can't change the world, much less do much about the government's policies of death and destruction. all i can do is the best where i am. just like in a war there will be people who die, people who have nothing to do with the corridors of power, because of the decisions of their leaders. it is also not really the fault of the poorly equipped (intellectually) junior doctors in these small towns. they are simply the results of political blundering. so yes in many ways i am a war doctor. sometimes that is the only way i can deal with some of the things i see.