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.

cuts

one of the aims of this blog is to touch on things specific to surgery in south africa. i notice panda is talking about 'alternative healing' so, not to be outdone, i decided to post on the same topic.

she was massive. her bmi must have been hovering around the 50 mark. then she developed severe abdominal pain, complete obstipation and vomiting. as is common, she went to her local neighbourhood sangoma. he did what sangomas do. he made cuts over the area the patient reported to be the problem (her abdomen) and smeared his muthi (in this case, apparently cow dung) into the cuts. the idea, i think, is that the medicine can get to work directly where the problem is.

but what if the problem is an umbilical hernia with strangulated bowel? due to her first being treated by our traditional colleague, by the time she turned up at our hospital, she was not well. systemically she was in septic shock and amazingly acidotic. she had a large necrotic mass over her central abdomen. at that stage the only thing that could be seen were the multiple cuts on the necrotic skin. it seemed like necrotising faciitis. there was no way of knowing that below this necrotic skin in her abundant fat lay strangulated necrotic bowel.

it was the turn of western doctors to take up the knife, like the sangoma before had done. the difference, however, was there was method to their madness. she went to theater. the necrosis was debrided, revealing the dead bowel. a resection was done. i was only a student at the time, so i was pretty far down the table. the smell also had a numbing effect on my faculties, so, to be honest, i can't remember the details of the surgery. suffice to say, an extensive debridement was done. living bowel was brought out (somewhere). and the wound was left open. she did the obligatory time in icu with multiple follow up visits to theater. after many months, she actually made it.

i sometimes look back and wonder if we really can critisize the sangoma. he did take a knife to the patient, which was the right treatment. he did have some concept of the problem having something to do with feces. i may advise that, unlike fire, feces can't be fought with feces, though. but many of the basic concepts where there, albeit in a non western format.

when reflecting on these incidents, i am always amazed by the fact that there is so much leeway given to these 'healers'. they are never made to account. they are never held responsible. they have free license to do what they want. there was even a government statement that the sangoma's 'art' cant be scrutinized like western medicine, because it is based in a belief system rather than science. the ancestors will heal you. believe it and it will be so. and when the patient finally does turn up at our doorstep at death's door (same doorstep?) when we can't actually pull them through, sometimes the sangomas will say "you see! the western doctors just kill you". no mention of the tried and tested methods of smearing feces into open wounds over strangulated bowel.

bariatric surgery

bariatric surgery is on the up and coming in our country. i understand it is very common in the us of a. being from a country that openly advocates alternative forms of medicine (our minister of health publicly supports the eating of garlic and beetroot as an alternative treatment for hiv and aids and does not support antiretrovirals at all and our previous deputy president in open court described taking a shower as effective prophylaxis against hiv after having unprotected sex with a known hiv positive partner. it was a rape case) i decided also to give an alternative opinion about weight loss therapy based on a case i once saw.

a lady presented in casualties. her history was as follows. she had read somewhere (possibly the internet, but i don't really know) that there is something in the urine of pregnant women that causes weight loss. i'm not personally aware of this substance but i don't claim to be an expert on weight loss or chemicals found in the urine of pregnant women. anyway, as it happens, her domestic servant was pregnant at the time. she did what i'm sure we all see as the logical thing armed with her new knowledge; she asked her domestic servant to urinate in a bowl, she drew up the urine and injected it into her abdominal fat. i never heard where she got the syringe and the needle. like many overweight people the patient also had type two diabetes (predisposing to some degree of decreased immunity).

when she presented, she was not in a good way. she was in diabetic ketoacidosis, was in shock and worst of all had subcutaneous crepitations on her abdominal wall around the site of the injection. this is an ominous sign, indicating necrotising faciitis (hyped in the media as the flesh eating disease). she needed to get to theater and fast. the only way to treat this very rapidly spreading infection is to cut away all the affected tissue, right down to the muscle. to get the desired results (arrest of the spread of infection) sometimes takes more than one visit to theater. if she survives the initial onslaught, at a later stage the wounds can get skin grafts.

a colleague of mine did the initial debridement (cutting away the offending tissue) after the appropriate rapid resus. she ended up in icu where she actually improved. the colleague asked me to accompany her on the second visit to theater where we finalised the debridement (mannaged to get rid of all the infection).

once we were finished, the patient was missing all her subcutaneous tissue and skin of half of her abdomen, from the loin region to the shoulder, from the midline to posterior on her flank (almost onto her back). because she had a generous layer of fat, this constituted a massive tissue loss.

fortunately enough, she then recovered pretty much without further incident and was soon discharged to the ward. we then embarked on the ordeal of getting the exposed tissue covered with skin grafts, but after a few more visits to theater, that too was done. she was ready for discharge, alive.

when she left the hospital, she struck a rather pathetic and maybe frightening figure. her left side was still fairly overweight, although the overall ordeal had caused considerable metabolic utilisation of remaining fat. the right side of her abdomen, however, had no fat whatsoever. the skin was directly on the underlying muscle. she was totally asymmetrical.

as she left i couldn't help wryly reflecting that her plan to lose weight had worked better than she ever thought possible. it seems a multidisciplinary approach to weight loss, medical mannagement (in this case the ill advised injection) combined with surgery (debridement) with just the right dose of stupidity can have very dramatic results. i only hope our good minister of health never reads this. she will probably make it part of the national weight loss program.