Taxi Tales

It takes me about two hours to get to the hospital every morning.

I’m slowly becoming more and more comfortable with the public transport in this province, and although I never fully let my guard down, I think I’ve lost an element of the paranoia I had before that at any time I might get jumped and mugged. (I carry my otoscopy/opthalmoscopy kit, my stethoscope, my tablet and my phone everyday, along with enough cash for the four taxis I use. Let’s not even get started on how depressed I’d be if someone stole my lunch!)

So, since the drives are so long and I’m up at four every morning, I’ve taken to taking short naps en route to work. I never fall deep enough asleep that I’d be too out of it to notice my stop in time to yell “SHORT LEFT!” to the driver, so it was while I was in a state of mildly depressed consciousness that I heard cries of shock and outrage from my fellow taxi-takers. My eyes snapped open just in time to witness another taxi swerve out of our lane on the freeway without any kind of indication and ram into the side of a small car’s trailer. The car, in an attempt to avoid a more serious accident, turned sharply left–and into a concrete barricade.

There was a cloud of pale brown dust and debris as the trailer splintered and shattered. The car rebounded into our lane, but we’d already driven on so that the wreckage was behind us.

Every neck was craned in the direction of the accident, so intent on the horror that it was a surprise to hear someone else cry out an expletive.

“He’s running! That taxi driver isn’t even going to stop!”

We all whipped our heads back in the direction of the pale yellow taxi that was speeding down the freeway.

This, friends, is one of the reasons I hate taking taxis. Your life is in the hands of a total stranger who may or may not be completely sober, safe or sane. Maybe he fell asleep for a moment or maybe he was just being a daredevil. Maybe he was actually disturbed.

Maybe he’s carrying all his passengers away to a slaughterhouse.

Maybe not.

We’ll never know.

Not that any of the other cars stopped to help out, though.

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Taxi Tales

They should teach us Math in medical school.

Oh, hush. I can already imagine everyone throwing up their arms in dissent. We fought through all that Mathematcs just to prove we were smart enough to get into medical school, why torture us after the fact? We do enough, we barely sleep, what use would Mathematics be in a cardiac arrest???

While these are all valid points, let me tell you a little story about The Medical Student Who Couldn’t.

A few years ago, a group of medical students who lived on their medical campus without any private means of transport, decided they were tired of shopping at the nearest mall. It was hardly safe (it included a twenty to thirty minute trek through the crime-filled streets of the community which the hospital was built to serve) and hardly worth the risk when they arrived at the two-story building that only offered two options of grocers and very little variety otherwise. Then they had to carry all of their groceries back through the streets back to campus, which meant they could never buy everything they needed, only what they could carry. Again, hardly worth it.

They decided they would brave the horrors of public transport and grab a taxi (read: minibus death trap) to a mall that was a little farther away which offered greater variety and was in a much safer area.

(Note that these students were still in the theory-intensive phase of their training and had yet to be exposed to the wonders of ward-work.)

They hopped into one such taxi enthusiastically and began fiddling with their pocket change as all the other patrons passed their fare to the front of the taxi.

Since they were seated in the back seats, by convention they were required to pay first.

“How much?” one brave medical student enquired in a hushed voice. You should never ask how much a taxi costs in the more suspect areas. It identifies you as a stranger and you become a target for criminals who may just be chilling in the taxi waiting for easy pickings.

“Seven fifty,” the other said, passing her ten rand note down the row.

“I also only have a ten rand,” the first said. The others all flashed their variants of single ten rand notes and double five rand coins. “We can’t all pay like this. The driver will get annoyed.”

“Okay,” a different medical student said. “There are six of us. We should just send down enough to pay for that and we can sort it out later.”

“Okay,” the rest chorused. Followed by a pause. And then a shifty exchange of glances. And then the clearing of throats.

And then, “So, that means I should just…?”

“What’s seven fifty times six?” someone mumbled.

“It’s…thirty?”

“No, it’s thirty seven fifty.”

“That’s dumb, we’re an even number there can’t be a fifty cents in the answer.”

“Two times seven fifty is fifteen. So three times that is…”

“Thirty-five.”

“Forty five,” someone said, grabbing everyone else’s ten rands and subtracting fifteen rand from the pile before sending it forward. “So everyone should get two-fifty from this change.”

“But only five people paid.”

“No, only five people’s money was used. Everyone paid.”

At this point one of the students leaned over to her peer and whispered, “Is it possible that all the studying has caused our brains to atrophy?”

“Makes sense,” the other replied. “All we do is memorise and regurgitate. I haven’t had to think for myself since I got here, let alone do any maths other than trying to work out how much I need in a test to pass the module.” They all nodded gravely.

Flash forward to the present. One of these medical students is doing her elective two taxi rides away from her place of residence. She decides she wants to change her route to include one taxi that she has just learned drives right past her home so she doesn’t need to get off at a shopping center and walk the rest of the way.

But she doesn’t know how much it costs and she’s alone carrying an expensive stethoscope and opthalmoscopy/otoscopy kit that she’d much rather not be relieved of in the buzzing mass of bodies surging through the taxi-lined streets at the rank.

So she hops into the taxi, sits two rows from the front, pulls out a twenty and waits.

Someone passes forward a fifty rand note and says “Three.”

That doesn’t mean anything. A ride could be anything from five rand to fifteen rand. She waits. Another fifty rand comes past. “Two.” Then a five rand comes back from the front with the word, “Three.” It is followed by a twenty rand and, “Two.”

So. If I were still in high school and having my brain regularly stimulated by the coursework, I might have thought, oh, this is easy. It’s obvious how much I have to pay.

Instead…

A medical student carrying a R20 note wants to know how much to pay for her taxi. Someone pays R50 for three passengers and receives R5 change. Someone else pays R50 for two passengers and receives R20 change. If the cost of a taxi ride is x, solve for x and then state whether the student should expect change or add to her current amount.

50 = 3x + 5

And

50 = 2x + 20

Therefore

3x = 50 – 5 And 2x = 50 – 20

Therefore

3x = 45 And 2x = 30

If we can assume that the medical student can do division, we can solve this problem. However, she s completely useless and only able to add or subtract. Therefore,

3x – 2x = 45 – 30

Therefore

x = 15

20 – 15 = 5. Therefore she must pay fifteen rands and expect five rands change.

Oh, who am I kidding?

I just passed my R20 on to the girl beside me and accepted it when she gave me five rand from her fare. I only managed to do the math about ten minutes later.

The only thing more embarrassing than needing an equation to solve a fifth grade math problem is thinking that, a few years ago, I probably would have given up at the first therefore.

Medical education is so stimulating, no?

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What’s going on here?

At the Academic Hospital, medical students do a lot of grunt work. If a Dr says that a drip needs to be put up, she means a medical student needs to put a drip up. If the intern tells us that certain bloods need to be taken from a patient, she means a medical student needs to take certain bloods from a patient. This has never struck me as unfair or unusual. That’s what we’re there for, to learn.

So you can imagine my surprise when I saw my first patient for my Emergency Med elective who needed IV access (she was haemorrhaging) and as I set up my equipment–did you know that everything you use in private has a detachable barcode or sticker that you need to remove for the records?–the doctor told me the Trauma Sister would be right in to put up the drip and we should move on.

Hold up.

Later, a patient who we’d stabilized after an anaphylactic episode needed bloods taken–this was the first time I’d ever ordered more than baseline bloods and an IgE level in anaphylaxis, isn’t private practice glorious?–and as I was about to go hunting for my needle and syringe, the doctor handed the patient her lab from and told her she just had to go down the passage and turn left to get to the lab where they would take her blood.

Hold up.

I never thought this day would come, but I actually spent the day wondering whether I would ever get to do any grunt work. My drip-skills are below average at best (although I can usually get blood from the darkest recesses) so I was really looking forward to improving in that department.

I’m trying to think of creative ways to hint that I’d like to access some vasculature over the next four weeks. Granted, I’m going to have a stint in a public hospital too, but it’s not going to be very exciting if I’m totally out of practice while a grumpy, underpaid, overworked registrar is screaming at me to get the friggin line up already.

Just saying.

Private practice feels like a parallel dimension folks.

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Taxi Tales

(I’m not using a computer to write this so there may be some formatting issues. Forgive me.)

I’m doing my elective in the supposed hub of South Africa’s economy, alternating between private and public practice in the field of Emergency Medicine. I’m staying with family in the province, but my elective sites are at least an hour’s drive (by private transport) from home and in the opposite direction to where everyone works.

This means I have to make use of public transport to get to and from the hospital every day. The most ‘convenient’ mode of public transport considering my destination is a taxi. Now, taxi in many first world countries refers to a yellow or black little vehicle with metered billing and a guarantee that you’ll get where you’re going.

Taxis in South Africa are cramped and crowded death traps minibuses which are packed to overflowing, usually not roadworthy and manned by sometimes suspect individuals who ignore it when traffic officers signal them to pull over on the roads.

Also, with South African taxis, there’s no schedule or specific destinations. They leave when they’re full and they go wherever they’re planned to go and you’d better wish that your destination is en route.

Today was my first day taking a taxi outside my home province. The journey involves two legs; one ride to town to the main taxi rank and then another to my final destination. I reverse this journey (albeit via a separate, smaller rank in town) using another two taxis. Each taxi costs roughly R15. So that’s about R60 a day on a journey that can take me anywhere between one to two hours either way. At this point, my external supervisor and I have yet to discuss my time requirements. But let’s assume I will be working at least five days a week. That’s R300 a week. Over a thousand rand a month; the equivalent of what I spend on groceries and necessities during a month at university. Clocking in an average of sixty hours spent on the road.

This is obviously neither cost- nor time efficient.

One could argue that since I’m staying with family for my elective, I cut the cost associated with food and lodging and the exchange factor I might have had to cover had I left the country. So, financially, I’m getting off rather easily.

But this is where the time (and taxi) factor come in.

Coming from living, studying and working in a hospital in the TB hotspot of our country, naturally I’m paranoid about developing the disease. I’ve had more TB patients than I care to remember, so I know I’m already infected–for those who might not yet have covered TB pathogenesis, being infected by Mycobacterium tuberculosis is not equivalent to having TB disease; many are called but few are chosen–but I know that certain things about our occupation (duration and frequency of exposure, the effect of high stress on immunity, etc.) put us at greater risk of developing the disease.

Whenever I usually think of my risk for getting TB, I’m thinking about white coats and facemasks and nebulisers (metaphorically speaking). So it was jarring to find myself in the back of a taxi with twenty other people, sandwiched between an emaciated old man and a voluptuous middle-aged woman, sweating bullets because all I could picture every time either of them coughed were the gleeful little bacilli leaping from their respiratory tracks to mine.

This is a frequent visual for me.

I spent nearly an hour in that stuffy taxi, trying not to breathe too deeply, wishing we could open some windows (the driver refused because he said it would lead to increased petrol usage), wishing I wasn’t waiting for the last stop, praying for some sort of miracle that would speed up the journey.

Eventually, I decided to hop of about half a kilometer from my actual drop-off point and rather walk the rest of the way. (This decision was also prompted by the fact that I wasn’t sure if I would be able to recognize the landmarks in the zigzagging taxi since I’d only visited the hospital once a few days before to map out my transport plan).

It is nearing the end of my orientation day and I’m convinced that taking that taxi was riskier than walking into casualty this morning.

I think I may have a very specific variant of OCD.

Or all those anti-TB talks are getting to me.

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Old Fashioned

Almost monthly, some or other ancient consultant is decrying (or sometimes promoting!) some archaic practice that hasn’t been adhered to since the Dark Ages when they probably were trained.

Sometimes it’s stupid stuff, like telling students on their first day of a rotation that they will be promptly failed if they are ever caught sticking used needles in the patients’ mattresses between venepunctures–something that I understand was probably done in the 80s or 90s but definitely hasn’t been done this side of the twentieth century if our interns’ eye rolls are anything to go by. We have sharps bins and safety protocols in teaching institutions these days, Prof. Thanks, Prof.

Sometimes it’s more serious things. Things that could influence a student’s entire future, their education, career and health. Like when consultants and professors belittle or dismiss legitimate concerns from a student about personal safety or the barriers to effective learning.

This year I had the misfortune of experiencing a module and a clinical rotation where I felt both my personal and professional future were being put at risk because those in charge were, to put it respectfully, a little old fashioned.

Okay. Very old fashioned.

The first of these was a theory block. Fourth year’s biggest monster academically was this teeny little subject called Anaesthesiology. Of course, I was amped for it. I’m a physiology girl, and anesthesiology is basically applied physiology (in the same way Surgery is applied anatomy, which is confusing because I hate anatomy but love surgery. But more on that some other time). I did all the over-eager things I do when I anticipate that I’ll enjoy a module. Pre-read, spend some time on google, schedule my life so that I don’t miss a single lecture, buy a ring binder. A ring binder, people.

Unfortunately, my first foray into the world of hypnosis, paralysis and analgesia was not as positive as I would have hoped.

The first sign that we were going to be dealing with an old fashioned system was the introductory lecture. The study guide was barely five full pages with no outcomes, no module layout. Just themes and a timetable. We were told outcomes were impractical because in Anaesthesiology, it only helps to know everything. Cue first eyebrow quirk.

Then we were promptly told that any complaints we had about the module and its mode of delivery would be pointless and a waste of breath, because the person we were likely to be complaining about was more powerful than we could know in this faculty and people had been complaining for years. Years. Yet nothing ever changed and nothing ever would change and by the way said lecturer was still in the faculty while complainants were conspicuous only by their absence. But feel free to try. Cue second eyebrow quirk.

Then we were introduced to our other, slightly younger lecturers. Also consultants for the most part, but less grey. They were reasonable, accommodating. Patient when information bore repeating. Thoughtful about the language requirements of our rapidly dwindling number in attendance during lectures. There seemed to be less hostility and stubbornness radiating from them, but that didn’t matter because they weren’t in charge. Yes, they understood that the language policy of the module was restrictive and outdated and mildly prejudiced, but that didn’t matter because they weren’t in charge. Yes, the textbook that was our prescribed examinable material was based on evidence that was half a century old and had often since been invalidated which meant we had to learn one thing for the test and another for the real world, but there was nothing they could do about it because they weren’t in charge. It seemed nobody actually agreed with whoever was in charge but, ehem, there was nothing they could do about it. Cue deeply furrowed brow.

Then came the ultimate sign that we were suddenly studying medicine as taught in the eighties. When time came for lecture podcasts to become available, we were told we’d only get access to them two days before end of block, if at all. Two days. Because apparently podcasts are the devil that binds students to non-attendance. So we would have to either be in class or flop. Cue mask of confusion.

(Three thoughts on the above. Firstly, as someone who regularly attends lectures and makes frequent use of podcasts for consolidation or revision, I find that entire line of reasoning offensive. Who is anyone to tell someone else, especially adult, fully grown students, what methods of study to employ. So what if someone opts to use podcasts in lieu of attending lectures? What business is that of anyone else’s? If someone can find more productive ways to use the five to seven hours of lecture time we get a day, if they choose to spend that time reading through the material, making summaries or even just lying on the beach that is their prerogative. We’re way past the dark days where it was assumed that everyone learns the same way or that there is a correct way to assimilate information. Secondly, screw that. If you insist on delivering scientific content in a language that only a third of those in attendance in class understand to begin with, podcasts are essential for the rest of us to labour through after-hours so that we don’t miss out on all the valuable information that flew right over our heads. It’s only fair. Lastly, students have been bunking lectures for as long as lectures have been in existence, so pinning poor attendance on podcasts is so ridiculously weak. Try again.)

Needless to say, the podcasts were posted and then promptly taken down, accompanied by a message berating us for relying on technology instead of good old fashioned work ethic. Who knew the two were mutually exclusive?

Ultimately, I still loved the subject content-wise (it’s in my top 3 specialities now) but I felt cheated and disappointed by the end of the block. I said as much in the feedback, but nobody seems to read those things anyway. And it’s just so disheartening that in this day and age, ‘important’ professors are given leeway to basically do whatever they want to students with no regard for how that will affect their academic progress or their chances of not only competing the course, but becoming safe and competent doctors.

Which brings me to the second experience, which is actually a multitude of experiences that were so uncannily similar that I’ll condense them into one for the sake of space.

During most of my seven clinical rotations this year (and almost all of my rotations in third year) I have had the misfortune of having to deal with multiple sputum-positive TB patients. Now what’s interesting about (most) of these patients is how positive and easy to interact with these patients are. They are usually not difficult about the precautions put in place for the safety of others in the wards and if you take the time to explain things to them properly they are more than happy to cooperate when it comes to things like isolation, adherence to medication and the wearing of surgical masks.

So the ‘misfortune’ usually has nothing to do with them. It’s the outdated, unbelievably stubborn and arrogant consultants that we sometimes have to deal with that cause the majority of problems.

During a very hectic rotation this year, we had to leave ward rounds early in order to make it in time for a clinical teaching/consultant Tut on the other side of the hospital. The premise of these Tuts was to work through the diagnostic process of a single patient with obscure, rare or interesting signs or to be exposed to more common diagnostic dilemmas (like a poorly controlled asthmatic who has a positive TB contact, a positive mantoux but negative smears and an inconclusive chest x-ray). We were more than excited as we bounded through the passages that link the wings of the hospital.

We arrived just in time in front of the designated ward and were greeted by a kind-faced consultant of clearly advanced years who introduced himself as Prof Invincible. Our group of six introduced ourselves to him as he led us into the ward. We walked past all of the open, common rooms and right to the end of the ward where most of the single rooms were situated. Instinctively, we started patting our pockets in search of N-95 masks. Anyone who works in a South African public hospital knows that nine times out of ten, a patient is in a singe room because they have pulmonary tuberculosis. Anyone whose paid attention over the last five years knows that there is no difference in the transmissibility of drug sensitive and drug resistant PTB. You always wear an N-95 respirator.

Unfortunately, by the time we reached the room at the very back of the ward, we realized we’d all run out of respirators. We asked to be excused to find the ward sister in charge in order to get a few and were given such a sharp look that we promptly shut up.

“We’re running late,” Prof Invincible snapped, digging into a box of surgical masks on the trolley outside the patent’s room. He handed a stack to us. “Put these on and come with me.”
“Prof,” one brave soldier said timidly. “Surgical masks keep pathogens in, not out. We need respirators.”
“Let me tell you something, girls,” he said condescendingly, “I have been working with patients for twice as long as you have been alive and I have never contracted TB. People who get TB are the immune compromised and the afraid. If you worry about TB, you’ll get TB.”

Cue screeching of mental tires.

Say whaaaaat???

We all stared at each other with wide eyes as we double-masked ourselves. I’m ashamed to admit that we caved in and followed him into the room, right past the colorful sign pleading with us to protect ourselves and our colleagues, and spent the next half an hour talking to and examining the patient. I spent that time imagining quite uncomfortably how the little TB bacilli leaped gleefully out of the patients airways and into mine each time he laughed or coughed. I refused to percuss him, which annoyed the consultant, but my defiance was too little too late. We’d lost the battle the minute we’d let him bully us into that room.

And all for what? All the latest evidence shows that healthcare workers are actually more likely to contract TB than non-healthcare workers. We spend more time with them, repeatedly, in closed quarters with barely adequate sunshine and ventilation. We percuss them, ask them to cough up sputum for us, tell them jokes that make them laugh so we can build rapport, have long winded conversations about compliance and resistance, suction their airways–all of these leading to higher levels of exposure.

But we let some old-fashioned, outdated superior convince us to put our own Heath at risk because this is how he’s been doing things for the last one hundred years and who the hell do we think we are suggesting that he’s been wrong all this time.

Wow, this post is getting long.

I guess my point is that the system needs new blood. Yes, we learned a lot from Prof Invincible. He has the experience and instinct that every student doctor aspires to attain, and he is actually not a generally difficult man. But his brain, like the brain of our Anesthesiology adversary and so many other older, stubborn members of faculty, is stuck at that stage where you really can’t teach an old dog new tricks (with all due respect).

Times are changing. Medicine and education in general are experiencing such exciting advances in terms of information, technology, best-practice, good old humanity that to those of us at the bottom they feel less like “valuable members of faculty” and more like extremely dangerous dead weight. By making it more and more difficult for students to learn the art of evidence-based practice, they are not only endangering our patients but also directly endangering our lives.

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Under Construction

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Please forgive the lack of posting in the last 6 months. In the interest of patient and institutional confidentiality (and my own butt-saving) I’ve been re-evaluating the way I blog about my medical school experience.

Rest assured, the posts are ready and waiting.

Welcome to all the new subscribers!

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Health & Disease in Communities

Health & Disease in Communities

Ah, the fun we have…

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August 7, 2013 · 11:22 am