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.

tangled tassels

in quite a few of the cultures in south africa people tie ribbons, strings and tassels around their own and their children's wrists and waists. these tassels are imbibed with power to keep evil spirits at bay, i am told. if these tassels come off then the patient is completely unprotected from any and all marauding evil spirits that may be lurking around. of course, not wanting to be responsible for the unopposed assault by multiple evil spirits, most people are fairly reticent to remove these things. i saw it slightly differently.

as a student i took my lead from my senior. if he removed the tassels then i would be ok with it. if he felt that we should respect the culture of the patient and sort of try to move the tassels out of the way of the operating area or even operate around them, despite the increased infection risk, i sort of reasoned it was his patient and even if i medically didn't agree with him, the reasoning of respecting the patient's culture surely held some water at least and i didn't argue. the fact of the matter was that quite a number of the sisters would become quite aggressive with the doctor if they thought he was going to remove the tassels and strip the patient of his evil spirit protection and i think some of the doctors were scared. then one day something happened that cemented my views and actions for the future.

i was working with a senior doctor that had grown up in one of the 'tassel cultures' of south africa, so when i prepared the gunshot abdomen patient in theater for him to operate, i left the tassels alone. it was one thing calling down the wrath of evil spirits upon me but i was not willing to call down the wrath of my senior. it was not worth it.

my senior walked in. he took one look at the patient lying on the theater table, already anesthetized with a nice round bullet hole in his mid abdomen oozing a mixture of blood and feces and with the tassels tied securely around his waist, left in position by me. without saying a word he grabbed a pair of scissors, walked up to the patient and unceremoniously cut the tassels off and threw them away. the sister immediately layed into him.

"doctor! what the hell do you think you are doing? that is the patient's culture and you have no right to remove that!" i saw the corner of the doctor's mouth edge upwards in a mischievous smile as he answered.

"come now sister. besides the obvious medical and hygienic reasons that i could give for removing a dirty piece of string before we operate, even you must agree, this tassel just doesn't work. i mean it didn't protect him from getting shot in the first place so i think it is safe to assume it is pretty much not going to protect him from anything else. so i am removing it and i don't really care what you have to say about that." his logic was flawless and the sister had to keep quiet. i also tried to keep quiet but the faint sound of a laugh did escape from behind my theater mask.

since then i have cut every tassel off, explaining to everyone that will listen that it clearly is no longer working.

in the dead of night

after having spoken about when you seem to know more than your consultant, i was reminded of another incident from my internship year where a colleague of mine taught me that sometimes it is best to do certain things under cover of darkness.

the patient (a sangoma) turned up at the surgery clinic one day. my colleague asked her what the problem was. without uttering a word she lifted up her shirt to expose her breasts. the left one had a massive tumour that had fungated through the skin probably some time ago. there was a large stinking cauliflower-like mass with central ulceration that caused a fist sized cavity right up to the chest wall. the smell was also remarkable. we couldn't help asking why the patient hadn't sought help earlier, especially seeing that she was supposed to be a so called traditional healer. i mean you didn't have to be a rocket scientist to know that that stinking monstrosity growing right through the chest was not supposed to be there. she simply said that it hadn't been painful, but now she had a cough.

my colleague knew what to do. she would refer the patient to the academic center in bloemfontein in the morning, probably for palliative radiotherapy. to make sure everything was up to date, she took a chest x-ray. it was so impressive she showed it to me. the breast cancer had grown right through the chest wall and had infiltrated the lung below. that is what caused the cough. it was a truly amazing case of neglected breast cancer.

then the cuban surgeon strolled in. this was the sort of thing you just didn't see in cuba. their health system is just too good for something like this to slip through. i suspect they don't have the sangoma problem we are burdened with so on the whole there will be less late stage sicknesses presenting. he was clearly astounded. then he said something that confused both my colleague and myself.

"put her on tomorrow morning's list for me to do a debridement." we looked at him in amazement. my colleague whipped out the x-ray, assuming that after seeing it no sane person would want to put a knife to that thing. i mean where would you stop cutting? in the lung? he looked at the x-ray casually but said nothing.

"you still want me to put her on your list tomorrow?" asked my colleague with more than just a hint of sarcasm in her voice.

"yes." we glanced at each other. maybe there was something we were missing. my colleague entered into a lively debate with him about the rationality of what he was demanding. anyway it was not my patient and i had other things to do so i left as the level of their discussion escalated. i did not envy her position in that she was being asked to do something she knew was not a good idea by any stretch of the imagination.

the next morning i ran into my colleague. she had a broad smile on her face and a somewhat mischievous glint in her eye. obviously the resolution of the matter had been to her liking.

"so," i asked, "did he finally see the light and drop his mad idea?"

"no." she said. the smile didn't falter.

"then what happened?"

"well i was on call last night. so as soon as the sun set and our illustrious consultant went home i bundled the patient into an ambulance and sent her off to the academic hospital. when he got to work this morning the patient was gone. there was nothing he could do." the smile took on an almost sinister look. i was impressed.

years later i employed a similar strategy, but maybe that is better left for another post?

savages

i spoke about foreigners and relative attitudes between them and myself. but, truth be told, one of the reasons they think they are in deepest darkest africa when they are here is because they are!!!

we pick up the story roughly where i left it off. the initial accident claimed two lives. then the young son has to survive a brain bleed and a neck fracture. somehow the neourosurgeon sorts all that out. then in icu he gets acalculous cholecystitis and i meet him, almost in exitus. we fetch him from the pearly gates and tie him up in icu for a while. he survives. he can walk. his maths and science still works. miraculous!

but for a moment imagine the father, the only one not really injured in the accident. he is in a foreign country. he has just lost 50% of his family and there is a real chance his son might die or be paralysed or retarded for life. the daily icu vigil alone must have taken a toll on him. and then things slowly start improving.

after too long away from home they are ready to leave. the son is amazingly well. he is neither paralysed nor retarded. also he is alive which everyone sees as a positive thing. then they have the unpleasant task of getting the bodies of the other two members of the family. what do they find? certain body parts are missing, including one hand!!! stolen from the dead in the morgue. you just can't make this sort of thing up. i dare you to try.

i have spoken before about body parts stolen to be used by sangomas for so called traditional medicine, so i suppose i shouldn't be shocked, but i was. i couldn't help feeling for him. over and above all the terrible things that happened to this man and his family he has to endure the bodies of his departed family being desecrated.

this story so affected me i followed it in the local papers for a while and pretty much put it together. at least some of the people were actually arrested so quite a lot of the story became public. it seems there were people working in the morgue who regularly stole body parts to sell to sangomas. they would target the bodies which were to be cremated and cut out the desired organs just before cremation. no one would be the wiser. the foreigners were targeted, it seems, because the body lay in the morgue so long while the boy recovered in hospital.

so, in conclusion, this is deepest darkest africa and here you will truly be amongst us savages.

colleagues????

the more i read this above sick note from a sangoma the more i find in it to appreciate. there are so many subtleties that just make it priceless.

and our equally ridiculous government wants to put these clowns on equal footing with proper doctors.

madness

so here i am, innocently watching the news. there is a story about a guy who gets sentenced to twelve consecutive life sentences for raping some young girls with the clear knowledge that he is hiv positive. at the end of the story they mention, almost in passing that the girls were all virgins.

now why do i blog this? the news did not talk about the point of the story because it is not pc in the present day south africa. the news writer probably wrote it but it was edited out by the power seekers. the writer did manage to leave one line in that gets to the point. the girls were all virgins.

the point that those in this line of work in our country will immediately click onto is that our great and wonderful sangomas some time ago propogated sex with a virgin as a cure to hiv. i kid you not. the reasoning is something along the lines that you get the virus from sleeping with a not-so-pure woman. therefore you can get rid of the virus by sleeping with a pure girl.

so this man is an example, hopefully, that the modern south africa will no longer endure this. i doubt it though due to the importance the community attaches to these wonderful healers otherwise known as sangomas.

a few questions. what are twelve life sentences? how do you serve that? which girls will not truly get justice? and they conveniently don't mention how many of his victims ended up hiv positive. besides will anyone ever know how many virgin girls he actually raped. (it's interesting to mention that quite recently parents encouraged their children to hide their virgin status because of this belief)

but i wonder who is the real culprit here and who is the scape goat, especially bearing in mind that our ministry of health has put more emphasis on integration of so called traditional medicine to counteract aids than antiretrovirals. not that i would bat an eyelid at the extermination of this particular scape goat.

the powerful horn

the basic topic behind this post it seems to me will tend to reccur. i therefore must accept it and get on with the post.

i presently have a patient in my care who has a very tragic story. he is hiv positive with a cd4 count of 25. (not good). he works in umtata in the eastern cape. there he went to a sangoma, apparently complaining of chronic diaree and generally not feeling too well. the sangoma decided the needed treatment was an enema administered through a strong bull's horn. the horn was duly inserted into the anus, through the anteriour rectum wall and the enema was pumped freely into the peritoneal cavity. (although a strong bull's horn might be the desired mode of administration, possibly because a weak bull's horn would have lesser curing potential, i personally think that something slightly less traumatic may just suffice). as you can imagine, the patient didn't improve. in fact he got worse. he then presented to a surgeon (a few days later) who operated. the rectum was repaired, the abdomen was rinsed and that was that. or was it??

a few days later, the patient developed acute abdomen again. the surgeon took him back to theater. the notes report he found multiple spontaneous perforations of the cecum (completely the other end of the colon) as well as breakdown of the rectum repair. these were all repaired, a transverse loop colostomy was brought out and pensil drains were left in the abdomen. the abdomen was only loosely closed.

at about this stage the patient mentioned he came from nelspruit and was duly posted off to me. when he arrived here, he was in prerenal kidney failure, his liver enzymes were totally deranged (possibly overwhelming sepsis but just as possibly the direct known hepatotoxic effect of many sangoma concoctions) his viral load was as high as his cd4 count was low and his white cell count was a dismal 2,6 as opposed to a crp of over 300. he was leaking feces from everywhere. the entire laparotomy wound was one massive contaminated mess.

what to do?? i decided to operate (after appropriate attention to his fluid state). inside was a sewer. there was no corner of the abdomen spared. my basic plan was to exteriorise everything. inside the cecum was a sieve of multiple holes and necrosis. the rectum had broken down again. there was also a spontaneous hole in the small bowel (middle). i did a right hemicolectomy with an end ileostomy and brought the colon out through it's own site. i debrided and repaired the small bowel hole. i rinsed copiously. i placed drains absolutely everywhere. i placed a post treitz feeding tube. i closed with tension sutures. i bundled him off to icu. i prayed. i might have muddled the order of things, but icu was towards the end. what was interesting to note at operation was the total lack of fibrin or any adhesions in the abdomen. the body wasn't even trying to heal itself.

the patient still developed leaks. i'm now going for controlled fistulas. some things are not so bad. he is no longer intubated. his kidney function recovered. his liver function is on the mend. but quite frankly i wonder what his chances are with zero immune response and zero healing.

i wish i had more time to discuss this case. there are so many interesting points. a starting point may be the fact that my physician friends told me i should have left him to die, arguing that it was not right to dedicate a long term icu bed to someone who would die anyway, thereby depriving the bed from someone else who has a chance. besides the obvious feelings of loss and failure if he dies, i'll be the butt of many of their jokes. the converse is not true. if he lives there will be no acknowledgements or accolades.

the other point is the sangoma and his role in the treatment of hiv. bear in mind our minister of health publicly says their role is crucial. i differ somewhat. (this is not an isolated incident). it is always also fascinationg to me to see how they are totally absolved of responsibility when things go pear shaped. in fact if the patient dies there will be fingers of accusation levelled at the western medical establishment from them. "see even the western doctors couldn't save him" or worse "look how sick their western medicine made him".

but if i could give any advice, when you have hiv and your cd4 count is 25, don't get a rectal perforation. it is not a good idea.

sangoma

just a quick update on my last entry about the gunshot wound. well, remember i said the spleen was enlarged and looked abnormal? because of that i decided to send it away for histology, thinking we might incidentally discover some underlying pathology, not that it would really change things. so we popped it into a bucket full of formalin. my medical officer filled in the relevant forms, requesting histology on it. the next day i was informed the spleen was stolen out of theater!!!! i kid you not!!! someone stole the spleen. now although we have no way of proving this, it is generally believed by all the staff at the hospital that it was stolen to be used by a sangoma (traditional healer or witch doctor. i use the word healer in the very loosest sense)

this now raises a number of questions with me. firstly, being totally untrained in their 'craft' i'm not sure what the therapeutic use of a spleen is. do the therapeutic properties change if the spleen came from a good man or a bad man, or must you just adjust the dose of spleen given? and what about the very real hiv risk in our country, or does one just mix the spleen with garlic and beetroot? (this being our minister of health's answer to the aids pandemic)

my next real concern is about the effect of the formalin on the healing properties of spleen. our man's spleen lay in formalin for some time. i suspect the average spleen used by a sangoma does not. have they done the necessary double blind studies to compare the therapeutic value of formalinised vs unformalinised spleen and where can one read this data?? there are so many such questions.

the next thing that i was later told, although, admittedly not necessarily from a reliable source, is what happened at the scene of the shooting before the man was taken to our hospital. apparently the paramedics initially only worked on the other guy (he was shot through his brachial artery and the bleeding probably looked more impressive) and just left my patient lying there. they only attended to him once the other guy had been packaged off to hospital. he was give plenty of time to move into the dangerous territory of shock. once they got him dripped and ready to transport, they apparently had to further wait for a police escort, seeing as though he was under arrest for attempted murder. this information explains slightly more why he did so badly with us. he didn't experience the benefits of the so called golden hour. he didn't even really get a bronze hour. maybe he got a lead hour.

now although this might be some sort of street justice metered out by the paramedics, i was pretty annoyed when i heard this. i don't think it is our role to play judge, jury and executioner. we don't know what happened. we should all do our best to do our job and save the man if we can. i also feel that we at the hospital mounted a great effort to save him at great cost, totally unaware our efforts had been sabotaged from the outset.

then again, maybe the other man was given priority because his on the scene injuries were more severe and my anger is unjustified. so if i have offended any hard working caring paramedics, i apologise. if i have offended any sangomas, i do not.