Cherish the Ideal

As a South African youth, as a woman of colour, as someone who was born into a country which disregarded my rights to dignity, equality and basic freedoms, I pay tribute to one of the many Freedom Fighters Nelson Rolihlahla Mandela, uTata Madiba.

I am too emotional to give a more sufficient tribute, but this: Siyabulela.

Without the sacrifices made by uTata Madiba and countless others, I can not imagine what would have become of my dreams…what would have become of me.

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Dear Parents

Thank you for bringing your children into the Emergency Room/Casualties Dept today. I’m a firm believer that parents need to have an extremely low threshold for seeking medical help when their children are ill enough that it causes either them or you discomfort. You are a great parent just for being here with them and choosing Casualty Club, its doctors, nurses and lone medical student to administer their care.

We will do all that we can to ensure your child receives the best quality of management during their stay so that we can get them back up and playing in the shortest possible time. But while you’re here, we’d like to draw your attention to a few things that may be of importance for this and future visits.

  • Your child’s health is our priority. We want to figure out what’s wrong.
    The fact that you are here is testament enough to the fact that it is yours too. However, in your haste to obtain help, you may have forgotten a few key items and pieces of information that it is imperative we have in order to make the best possible management decisions. We understand that this may be your first experience, so we’ll walk you through it for next time:

      - Please try to keep track of your child’s symptoms. If we ask you when the problem started, how long it’s been going on, when it was worst, how quickly it escalated, and which symptoms came first, the answers “I don’t know”/”How should I know?”/”You tell me”/”Why does it matter” are neither helpful nor acceptable. You need to know how long your child has been sick at the very least, even if you give a rough estimate of whether the symptoms started yesterday, last week or last year.

      - Please pay attention to the things coming out of your child’s body, especially if these things are the reason they’ve come to the Emergency Room. So, if your child is suddenly vomiting, it helps if you’ve actually seen the vomitus. If your child has been having diarrhea, it helps if you’ve been monitoring the evolution of the stool. Yes, we know it’s disgusting and your child is probably nearing school years and you don’t hang that tight anymore, but I’m sure you can appreciate why the presence or absence of blood, or weird colors like black or neon pink, might be causes of concern and might lead us towards a completely different diagnosis. Also, it helps if you know how much of whatever it is the child has excreted. I think the “how many cups?” question is rather stupid, so we might be satisfied if you at least know a little from a lot.

      - When we ask you whether your child has been taking any medication, anything over the counter counts. Anything your sangoma or homeopath prescribed also counts. Your grandmother’s pain pills that you ground into their porridge? Yeah, that counts. The home-administered enema you routinely give your kids every month? That counts. Your store-bought Chinese herbal remedies? They count. Basically anything that has entered any part of your child’s body for whatever reason (that isn’t food) counts. Why? Because we might underestimate just how ill your child is because they’ve taken an NSAID or paracetamol which is suppressing more serious symptoms. And also because whatever you’re giving could interact with whatever we give, causing things to spiral out of control. (Or, but we never say this until absolutely sure, whatever you gave them might in and of itself be harming the kid. Just maybe.) Let us know?

      PS: We don’t know what “those small pink pills” are. We aren’t trained in the art of pill-identification, much as we’d like to be. So if you don’t know the names, bring the boxes. Thanks!

      - If this has happened before, the answer is yes: That is relevant.Thanks for telling us before we ordered a chest x-ray for your otherwise healthy seven year old with a wheeze that he gets whenever he plays sports. And has today. After having played sports.

      - You need to bring your Road To Health Card (or your private equivalent) with you whenever you come. Especially in an emergency case. Not sure what we’re referring to? There is a little booklet or card that you were given when your child was born, that the sisters sign each time he visits the clinic, goes to the doctor, has a check-up or gets an immunization (the injections he gets every once in a while). We need to know your child’s immunization status. We need to know their nutritional status in comparison to the last few months (that’s why we plot their weight so often). We need to see that he or she has been developing well. We need to know they’ve been dewormed. Unfortunately, these aren’t things we can guess. We need the book. Someone can bring it later if you forgot it, but even if we’ve diagnosed the problem we still need it. And we’re going to need it until they are no longer a child, or at least until they get their last immunizations at about twelve.

      There’s a weird gap between five and twelve when they don’t use it all that often and you might be tempted to misplace it. Don’t.

  • Thank you for your cooperation in this regard. We trust that you will experience a pleasantly high quality of professionalism and efficiency from our staff from start to finish of this (hopefully) brief stay.

    Don’t forget to rate us with the smiley face system before you leave!

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    A Vein Update

    Oh by the way! I posted a while back about how doing the first half of my elective in the private sector was limiting my chances of accessing vasculature–phlebotomists took all the bloods, nurses put up all the drips. I stated that I was nervous, especially since I’m not too good at IVs, that I might be rusty by the time a real emergency hit in the public hospital, leaving me unable to do anything more than bleed the patient to death.

    Someone, I think it was BarefootMed, suggested that I oh-so-subtly invade the nurse’s and phlebotomists space and ask them to show me how they worked and then quietly maneuver that into offering to do their work for them.

    The verdict?

    SUCCESS!

    Not only did the nurses let me watch and help, but when I explained my anxiety when it comes to IV-lines, they came up with the great solution of putting me on Paeds-IV duty. This is how they became confident, because kiddie veins are so tiny and often not visible or palpable, leaving it up to your knowledge of anatomy and a little bit of stick-to-it psychology. (The only thing funnier than that pun was my expression when the nurse said my name in the same sentence as knowledge of anatomy. She clearly didnt know who she was talking to.)

    So since then whenever a tiny person needs a drip, guess who they call?

    That’s right. For the last week, I’ve been putting up all the paediatric IVs. And I can finally say I feel like a bawse doing it. My anxiety has dropped from ten to one, and I’ve finally gotten to the point where I only stick patients–grown and paediatric–once.

    So thank you BarefootMed I would have posted this to your blog’s comments, but my WordPress App is acting funky, and since I’m not using a computer to post this my technical literacy only extends so far. I hope you read this!

    Everyone, go and check out her blog Whispers of a Barefoot Med Student. It’s one of my favorites, not just because she’s blogging from the perspective of a South African medical student and all the drama that it entails, but because she makes you think, laugh and cry.

    Also, she loves books. Of the non-medical variety.

    I mean, come on. What more do you want?

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    Two ends of a spectrum

    The first patient was a middle-aged male who had come in complaining of a painful and swollen left leg. The doctors told me I should see him–I think after a while you get tired of the way private patients treat the Emergency Room like a clinic.

    I walked in, introduced myself and started taking a history. He said his foot had been warm, swollen and extremely tender for the last week, but that the pain had only gotten unbearable that morning. When I dug around for an antecedent incident, he denied any trauma or insect bites. He only admitted to frequent headaches and fever, and said he remembered having a small sore under his foot a few weeks prior. No previous hospitalizations, but a known Type I diabetic who claimed his sugars were controlled.

    “That’s good, what do your values normally look like?”

    “My sugar is usually between sixteen and eighteen Doc.”

    I was so shocked I didn’t even correct him for calling me Doc. “Sixteen to eighteen? Are you sure?”

    “Yes, I test it every day.”

    “Sir,that’s too high. That’s dangerously high. Your sugar really shouldn’t be above eight on a regular basis.”

    “Really? Oh. Well, sometimes it’s twelve.”

    “That’s still too high. How long did you say you’ve been diabetic?”

    “Since I was a child. My sugars have been like that for years.”

    “That’s not good, Sir. It’s not good for your heart, it’s not good for your brain and it’s not good for your kidneys. It’s also not good for your blood vessels and nerves, which is what I suspect is going on with your foot. Can I see it?”

    He took off his socks and treated me to a vision of an oedematous, erythematous lower leg that he could only stand me touching for a few seconds and a time. And right on the plantar surface of his foot, medially, was a crater of about four by four centimeters with a very dark base, yellow bordering and a very clearly demarcated raised edge, like it had recently been a blister that had been cut off. It wasn’t bleeding, and he didn’t complain to much when I touched it.

    “Sir, was there a blister here?”

    “Yes, that’s the sore I told you about. I popped it yesterday.”

    “You didn’t say that,” I pointed out. Then I removed my gloves. “Okay, this ulcer and the cellulitis are evidence that you suffer from something called the diabetic foot. I’m just going to prick your finger quickly, I want to know your sugar value for today. Then we can talk about why this happened and what we need to do now and in future to prevent you having to lose your foot.”

    “Lose my foot? You’re going to amputate me? My mother was amputated, I don’t want that.”

    “Was she a diabetic too?”

    “Yes, I think so.”

    I bit my tongue and excused myself to find a fingerprick glucose testing kit. The nurse offered to do it for me while I finished clerking the patient.

    “Okay, sir, while she does that, I need to ask you a few more questions. Have you ever had ny surgeries?”

    “Not really.”

    “Not really?”

    “I’ve had three eye operations. The last one was in 2010.”

    “Was it to remove cataracts?” I guessed and the patient’s face lit up.

    “Yes, how did you know, Doc?”

    “Lucky guess.”

    “Wow. Maybe you can tell me why I keep having them.”

    “Because your sugar is too high and according to you it’s always too high. What medication are you taking?”

    “Twenty seven, Doc,” the nurse reported. I ignored the Doc-dig–the nurses like teasing me about how the patients complain to them that I’m too young to see them–and stared at her.

    How much?

    “Twenty seven.”

    “Okay, please call the doctor. But so long, bring me ten units of insulin so we can start bringing the sugar down. I’ll put up a drip up.”

    When the nurse left, the patient turned to me and said, rather sheepishly, “It was twenty one this morning…”

    “Did you use your insulin?”

    “Yes, but I ate my breakfast first.”

    “Sir, please explain to me why you ate when your sugar was so high?”

    “I didn’t know it was high.”

    “Then why did you use the insulin?”

    “Because I use it whenever I eat.”

    “Okay, I understand,” I said even though I really didn’t. Diabetic for nearly half a century, and he didn’t understand why he was even taking his medication. “We’ll talk once we’ve gotten your sugar down.”

    * * *

    This patient was a middle-aged paramedic who had been brought in by his colleagues when he had collapsed after they’d noticed that he’d grown progressively more confused throughout his shift.

    He was brought in with an altered level of consciousness, not responding to any stimuli, with cold and clammy peripheries, his clothes drenched in sweat. We performed the primary survey and when we got to DEFG (Don’t Ever Forget Glucose), the little machine beeped out that his blood sugar was one point one. 1.1.

    After putting up an IV with 50% dextrose the man went from staring vacantly up at the ceiling to looking alert if a bit disoriented as we moved on to the secondary survey. Dextrose is a wonderful thing, considering it took less than a minute to bring him back around.

    “Sir, do you know where you are?”

    “Hospital?”

    “Yes. Do you know what day it is? Can you tell me your name?”

    “My name is Mr Hypo,” he said, frowning.

    “That’s right, and the date?”

    “I don’t know. What happened?”

    “Your colleagues brought you in after you collapsed. Your blood sugar is very low. Are you a diabetic?”

    “Yes. I use the tablets.”

    “Did you eat today?”

    “I can’t remember…I think I might have forgotten to.”

    “Has that ever happened before?”

    “No. I was pulling a double shift and I got distracted. What did you say my sugar was?”

    “One. One point one.”

    “Crap.”

    “Yes, crap is a good way to describe it,” the doctor interrupted as he walked in. He read through my notes and then asked me what I planned to do next. I suggested a 5% dextrose infusion and a recheck of his blood glucose. He nodded and then reminded me to educate. “You’ll be fine sir. The student is just going to explain to you why this happened and how to prevent it in future, okay. Oh, and MedicalRose, your notes are still too long.”

    “I know, I’m working on it,” I said. He left me and the patient alone again.

    “I know, I know,” he preempted. “I shouldn’t be skipping meals. I should be having small snacks in between. I should exercise and drink water. I usually do all that, today was a bad day. I feel like an idiot.”

    “Don’t be too hard on yourself, people do forget. But you are aware that you just can’t afford to?”

    “I know. We pick up hypoglycemic patients every day, and I’m always judging them because I feel that they should know better. I feel terrible, this won’t happen again.”

    “Well,” I said, a little deflated by how thoroughly the man wanted to abuse himself. At least he knew what he’d done wrong.

    “Are they still here?”

    “Your colleagues? Yes. Which reminds me, neither of them knew you’re a diabetic. You might want to disclose that to the people you work with, just to be on the safe side. It could save your life next time.”

    “There won’t be a next time, Miss, I promise.”

    “You should disclose it all the same. Just to be safe.”

    “Okay. Thanks for everything. When can I go?”

    “We just ran some blood tests, kidney functions and the like. And we need to change your drip. When that’s done, I think the doctor will let you go.”

    “Okay thanks.”

    “Okay. Don’t forget to tell your colleagues.”

    “I’ll consider it.”

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    A Test Of Patients

    The patient had been constipated for five days and, after being worked up, was due to receive an enema. I hadn’t seen him myself, but I’d read his summary in the clerking book so when the doctor asked me to go and check on whether he’d had a bowel movement or not, I didn’t think it was too unreasonable a request.

    Until I entered the room.

    I hadn’t stepped into it for more than two steps before smiling awkwardly at the prone patient and backing out faster than the speed of light.

    The smell, my less-than-eloquent brain screamed. THE SMELL.

    “I think he’s been,” I said quickly to the doctor. He stopped me as I passed him.

    “You think? Did you ask him if he had?” he asked.

    “It certainly smelled like he had,” I shuddered, thinking of the overwhelming waft of evil-smelling warm air that had assaulted my senses. “I didn’t think to ask.”

    I knew this was the wrong answer as soon as the words left my lips. One of the cardinal rules of Emergency Medicine is never to assume anything. And it was very quiet in Casualties, so I really had no excuse.

    “I’ll go and ask him,” I mumbled before the doctor could tease me for being squeamish.

    My second exposure wasn’t any easier.

    “Hello, Sir,” I said, introducing myself. “I understand you’ve been constipated for a while now. Can you tell me about it?”

    “Well, since my surgery last Monday, I haven’t been able to go to the toilet at all.”

    Surgery, I thought. Ileus?

    Again, making completely baseless assumptions.

    “Oh,” I said, “and this surgery was for…”

    “My abscess.”

    “Okay,” I said, paging through his admission book to find the doctor’s notes. “So after you woke up–”

    “I was never put to sleep.”

    “I’m sorry?”

    “They said it wouldn’t be necessary and they just used local anesthetic.”

    “Wait. You had surgery under local anaesthetic?”

    “Yes. For my abscess.”

    I finally asked the question I should have asked initially. “And where exactly was this abscess?”

    “My ass.”

    “I’m sorry?”

    “My ass.” Only then did I realize that the patient was still prone, and had been prone throughout our short interview. He pulled down his pants and I felt the room tilt slightly as the shock of what I was seeing registered. Right there, smack bam in his perinatal area, was a massive gaping hole of mixed pink and grayish red tissue. And pus. Lots of very smelly, very sticky pus. “They cut it open for me.”

    Yes. You know why they say you should never assume? Because you make an ass of yourself and others. And I had just literally made an ass of myself. The patient hadn’t had a bowl movement. He had an infected perinatal abscess.

    “Sir,” I managed to say, when my brain reconnected to my mouth, “do you know your HIV status?”

    Look, it’s South Africa. A perinatal abscess in a young, fit-looking man basically equals some immune compromised status. But no more assumptions were going to cross my lips unsubstantiated.

    “No. And I don’t want to. I’m not ready. My last doctor tried to convince me, the doctor here just tired to convince me. I already said I don’t want the test.”

    I admit, I gaped at the patient in a completely non-neutral, unprofessional manner.

    “Sir, did they explain why they think you should test. I could go through all the benefits of knowing your status with you right now–”

    “I have already heard it all. I’m not ready. Just help me with this constipation and this pain and I’ll be on my way.”

    “Sir, you’re probably constipated because of the abscess. Don’t you want to know why you have it and what options you have available to you?”

    “No.”

    “Okay, can I examine you quickly–”

    “The other doctor already did. Just give me my enema, please, girlie? I don’t want to be bothered any more.”

    After about a minute more of trying to convince the patient to at least let me examine him (he wouldn’t) I left the room and headed to the doctor who was smirking smugly from behind the receptionist’s counter.

    “How are you feeling?”

    “Frustrated! He won’t let us do what we’re here to do.”

    “It’s his decision,” he reminded me.

    “Well that’s just a dumb decision. I can’t imagine how many times he’s refused testing. If he would just let us council him, he might feel more ready.”

    “He’s been counseled plenty of times. But he’s also been judged a lot. Try to understand his reluctance to give that judgement validity.”

    The patient never did agree to testing, and was referred back to his primary physician after the enema did what it was meant to, with a prescription and a handshake from the doctor.

    I politely wished him well as he left, but I felt I was less convincing than the doctor was. I just couldn’t reconcile the idea of coming to the emergency room for help and then ultimately refusing that help. This is why I could never last in primary care. Facing patients every day who don’t comply with their medications, don’t pitch for follow ups, don’t adhere to their lifestyle guidelines, just generally don’t care as much about their health as you feel you do despite you doing your utmost to educate and counsel them. They’d see right through me in a second. They’d know every time they came back with the same problem that I’m just thinking How is this difficult? How is accepting help when you are sick difficult?

    I just don’t have the patience for it.

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    Taxi Tales

    One of these days I’m going to have an anxiety attack on the taxi.

    Today I had to ride in a taxi that had no brakes. Yes, you read that correctly.

    The taxi did not have working brakes.

    I know this because we had three near-collisions during which the driver simply swerved instead of changing his velocity, and every time we changed lanes we got hooted at because he just sort of skidded across to wherever he wanted to be.

    Oh. And the indicators weren’t working.

    And he sometimes forgot to use hand signals.

    One would think this would be reason enough to feel overly anxious at six in the morning on a weekday. But alas, my blood pressure was raised for a completely other reason.

    In the seat in front of me, there was a woman who looked like she was in her early twenties (although I’ve discovered while working in Casualties that I am horrible at dating women’s ages) with a small child who looked no older than two on her lap. The child was pressed against her mother’s breast in what I was assuming was supposed to be a breast feeding position, wheezing and coughing loudly throughout the drive. Only the feeding didn’t look very effective since she was barely suckling and looked so lethargic. Her eyes were lidded and her posture was limp. And she was so tachypnoeic. One minute I measured her breathing to be fifty-five.

    And all I could think the entire time was Please let this mom be taking her to the hospital and not to some daycare centre… I don’t usually give medical advice to strangers–it comes across as obnoxious and pompous especially if you’re someone with no kids trying to advise parents on their children when they didn’t specifically ask for it.

    But I knew that, knowing what I know from just four years of medical school, this child was seriously ill. Like, General Danger Signs in IMCI sick. Like, put up an IV, administer antibiotics and admit to a paediatric ward sick.

    And I said nothing.

    I could have struck up a conversation with the mom–albeit awkwardly considering I was sitting directly behind her–and subtly dug around to see whether she knew just how ill her child was, casually dropped the fact that I knew a little bit about child health and made some recommendations. I could have helped get that child to help, or alternatively just assuaged my guilty conscience with the knowledge that that was where she was headed already.

    But I said nothing.

    Then I hopped off the taxi as it rolled slowly past my hospital and deluded myself with the belief that I was making a difference in the lives of the patents that I saw the rest of that day.

    And I’ll never know what happened to that poor baby.

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    Overrated

    The doctor finds me in the nurse’s kitchen and wordlessly hands me an x-ray of a right hand. There is an obvious dislocation of the PIP joint of the fifth finger. The finger is flexed at an uncomfortable-looking angle. I raise my eyebrow at him.

    “Ouch,” I say.

    “You haven’t seen ouch yet,” he replies. “Come, I’m about to reduce it and I want to show you how so that you can do the next one.”

    I hop up excitedly and follow him out.

    “The patient is a friendly old man with a toothless smile who actually reads my badge and greets me by name.

    “How did this happen?” I ask him in a broken attempt at his native language.

    He grins up at me and begins to recount the story. He has linoleum floors in his kitchen, but tiled steps leading to the paving outside. I’m not sure how this is relevant until he starts talking about his gardening passion and how, in his rush to water his darlings, he dropped a pail of water at his doorway and subsequently slipped on the linoleum, slid down the tiled steps and landed–hand first–onto the concrete beyond.

    “Wow,” I said, genuinely impressed by the mechanism of injury. I’d really only been asking to distract him while the doctor prepared some analgesia.

    Or so I thought.

    “Okay, Mr GreenFinger, we’re going to reduce your finger now.”

    “Okay.”

    “Wait,” I interject. Both men turn wide eyes to me. “Aren’t we going to give analgesia?”

    “I’m a man.”

    “He’s a man,” the doctor echoes. Then he pulls the finger out and up.

    Not even a minute and a wince later, the previously deformed finger is looking a little swollen, but otherwise no worse for wear. He’s about to splint it but this is Private Practice so it’s nothing more than a Pre-packaged foam peg with plastic supports and some bandaging. (No need for improvising and resourcefulness here!)

    “I’m not quite sure I learnt anything just now,” I half-joke, thinking about all the things we’d heard about adequate analgesia before reductions, assessing neurovascular status, etc. I’m not even 100% sure the doctor did more than pull.

    “That’s okay,” he smiles. “It took me a while to realize dislocations are overrated, too.”

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