19 September 2008

You Are Not a Real Saffa Doctor Until You Have :

  • filled out a thousand J88's
  • filled out two thousand disability grants
  • seen worms exiting the human body via anus, nose, mouth & laparotomy
  • cauterised warts the size of cauliflowers
  • done a caesar because of warts
  • stopped wearing a mask around TB patients (pregrad)
  • inserted 3 ICD's in 10 minutes (on family members who had an argument)
  • treated hysteria with ethyl chloride
  • been handed a Checkers packet containing the fruits of the TOP clinic
  • done a caesar in under 15 minutes
  • had your fingers in a stab neck whilst rushing to theatre
  • given a BCo & Voltaren injections in a cash practice locum
  • earned more abroad in 2 months, than a year in SA
  • been shocked to see a negative HIV result
  • diagnosed marasmic kwashiorkor
  • had a prescription for paracetamol, amoxycillin & insulin returned as "Out of Stock" x3
  • wiped & wiped & wiped with an alcohol swab, but the skin won't come clean
  • been referred a patient with "multiple electrolyte derangements"
  • heard : "the patient is having a change in condition"
  • survived two 24 hour trauma calls on a pay-day weekend
  • had your first (second & third) needlestick injury and/not completed the ensuing course of ARV's
  • been convinced you are seroconverting
  • washed vaseline and/or zambuk off your hands after an examination
  • gotten a laryngoscope blade stuck in a passion gap
  • medschool friends living in 5 continents
  • witnessed the spoils of initiation school
  • been in the 3rd round of allocations for internship/community service
  • seen sangoma cuts & scratches
  • cut off abdominal, wrist, ankle & neck sangoma strings
  • retrieved a matchstick head from a middle ear
  • been 4th in the queue on the line to the HPCSA - for the past 2 hours
  • recognised the winter aroma of Yardleys You're the Khaya*
  • waited for months for your first pay cheque
  • taken your own toilet paper on call with you
  • heard a patient presented as FUBAR BUNDY
  • scanned through the files waiting in casualties & left the wishy-washy ones for a colleague
  • marveled at what the ID photo looks like when filling out a death certificate for an AIDS victim
  • met a 16yr Grav 3 Para 2
  • achieved the most amazing feats in casualties with the help of pethidine & valium
  • been laughed at by an entire clinic after trying to pronounce the name of the next patient
  • had the phone amicably put down in your ear before you are finished talking with a sister
  • been blamed for poor assisting when the scissors won't cut or suction doesn't suction
  • watched patients picking their nose (+/- eating it)/scratching their privates/hocking lurgies on grand ward rounds
  • been amazed when a 2 minute conversation between patient & translator comes back as a monosyllabic "No"
  • cried with a patient because there is no state funded treatment for a potentially manageable condition
  • cried because a patient has received such poor care
  • cried after seeing what a violent society is capable of doing to people
  • cried whilst treating a child who has been raped
  • cried to see human neglect

*a delicate blend of matured perspiration, with a hint of paraffin and a mystical swirl of wood-fire smoke

13 September 2008


Fueled by the lack of astute assistance by Sister Ples & her Horde of Hobbits, an anaesthetist in state practice develops a notable skill in projectile accuracy. To adapt to the situation, one is forced to throw things around in theatre (only have two hands, can't be in two places at once, often have finger in the proverbial hole in the dyke & can't move etc.)

Take for example, the seemingly simple and common task of ensuring reliable intravenous access - singlehandedly.

10 Steps to IV Access

(when the patient is 5m away from the bin)

  1. Attempt to flush existing drip with saline. Infiltrated/haematoma/thrombophlebitis/never in. From a distance, throw syringe into paper bag (PB), needle into sharps bin (SB).
  2. Remove existing cannula. Flick ball of sticky strapping & hurl filthy infusion set into PB, lob icky cannula into SB.
  3. Disinfect arm. Pitch swab into PB.
  4. Recannulate. Patient performs & knocks safety sheath onto floor. Discard potentially lethal (1:3 HIV) needle by tossing into SB. (Like a bushman shooting his poison-tipped arrow).
  5. Whilst holding cannula in place, tear off piece of strapping with other hand & teeth. Roll finished - strapping too short. Fling into PB. Stretch for new roll, strap cannula.
  6. Cap cannula as Sr Ples disappeared to Hobbiton whilst you thought she was preparing a new infusion set.
  7. Open new IV bag, toss wrapper & cap into PB. Open new infusion line, launch wrapper & caps into PB. Run fluid through.
  8. Stick down with dressing, screw up backing into a ball & shoot into PB.
  9. Clean up bloody spills with gauze, fire into PB. (Red splotch marks target like in a game of paintball).
  10. Catapult gloves into PB.

That's 14ppm (projections per minute) with median accuracy of over 93% (p<0.05)! There is no more satisfying sound than that "thwack!", as the projectile meets its mark. Until this week, that is!

Having transgressed the Draconian Constitution in one of my recent posts, my retribution has been public humiliation. The big gavel in the sky has clapped down & deemed my post inappropriately critical & the punitive verdict has been passed. As attested to by the litter-strewn area around the SB & PB, my projectile accuracy has dropped out the bottom. Es ist die Strafe Gottes.

I have lost my mojo!

05 September 2008

The GCS Chronicals

I don't know what it is about the Glasgow Coma Scale that some doctors find it so difficult to master! Wow, why did I use the word master. Makes it sound like one needs to put buckets of blood, sweat & tears into studying the art of GCS application.

Could it be that the total 15 exceeds the number of digits on a pair of human hands? I know the theatre staff can't count beyond 5 when checking there are no missing swabs. (Theory : 5 fingers on left hand, right hand occupied as index finger outstretched from clenched fist, taps the count out on the fingers of the left hand).

Or marginally more likely, the assessor desirably needs to be GCS 15/15 himself in order to successfully evaluate the assessee.

Perhaps, it is all part of a master plan providing comic relief in dire and sad situations. I must say, I thoroughly enjoy the multifaceted, oftentimes creative interpretation of the GCS! So much so, I have decided to devote space here to relate, from my ever growing repertoire, stories regarding the enigmatic Glasgow Coma Scale...

Ignorance (including face-saving strategies)
Referrals from outside often elicit amusing responses to the question - "so what is the patient's Glasgow Coma Scale?"

"We are a very small, rural hospital. We don't have that scale here."

"We had one, but it is broken."

"Very, very severe."
And my personal favourite, came from an old GP doing sessions in a plattelandse dorpie :
"Hoor hier, Boetie. Toe ek geswot het, het ons nie sulke fancy goed gehad nie. 'n Pasient was óf in 'n koma, óf nie. Nou hierdie ou is in 'n KOMA!"*
Five stars, old man, plus 10/10!

Manipulation of Score
This commonly occurs to avoid having to intubate a patient. Always entertaining when the score is around that watershed 8/15...

"His GCS is 11 at the moment, but it is steadily declining. I anticipate you may have to intubate him by the time he arrives - you know how slow the ambulance service is."

"It is currently 9, but I suspect the patient will need to be tubed soon as her hepatorenal syndrome is likely to get worse before it gets better. Would you like to come do it down here, or would you prefer it when she arrives in the unit?"
I was mightily peeved when a patient for an emergency c-spine fusion arrived in theatre sans tube & GCS 7. Paging through the file, I noticed the patient had been in the ward for 2 days already (just don't ask) and the GCS was dutifully charted as 7/15 by the Interns & MO on multiple occasions. When I started bogging on the MO for leaving a patient so long without a secure airway, the Consultant protectively stepped in.
"I saw the patient myself and the GCS was more like an 8 than a 7."
I couldn't think of a diplomatic way to enlighten him, so I just left it at that. I think, in this instance, it is true what they say about orthopods! So I diffused the situation by making my stale old joke :
"What's the orthopaedic definition of the heart? The organ which circulates Cefazolin through the body."
And we all laughed & (they thought) all was forgiven.
Interestingly, this was the same MO who had written "PEARL"** in the notes of a patient who had had an enucleation decades prior.

Plain Stupidity
I overheard a doctor explaining to a patient's family, that she was brain dead and they should consider switching off the ventilator. I suppose he had been watching too much Bold and Beautiful because the patient was GCS 7/15 and improved to 9/15 a few days later. We managed to pick up the pieces before a case of culpable homicide ensued.
"His Glasgow is 15/15, but he's a bit confused."

"It's about...*heavy, pseudointellectual pause*... 5 to 10."

When explained to above doctor that it can't possibly be zero, he retorted :
"How do you know, you haven't seen the patient!"
Who am I to argue when he did, in a way, have a point.

I often wonder if these doctors ever think back, blushing, about the silly things they have said or done? I know I often do. I am the first to admit that nobody's perfect. However, I doubt many of the above quacks even realised their faus pax.
Oh well, comatose is bliss.

* Roughly translated from Afrikaans "Listen here, kid. When I studied, we didn't have such fancy things. A patient was either in a coma or not. Now this guy is in a COMA".
** Pupils Equal And Reactive to Light.

04 September 2008

Does Anybody Examine Their Patients?

OK, so here's a geyser moment some of you have been waiting for!

I have just had a guts full of this week. Is everybody's clinical skills up to shit these days or am I on drugs? Perhaps I'm the one who needs therapy. I am by no means a special doctor or exceptional at my job - but for crying in a bucket. What the hell is wrong with the surgeons at Mount Doom?!?!?!

First of all, the Spirochaetes want me to dope an ectopic from the night before. Apparently she is stable, that's why she's been left for the morning. Only problem, her potassium is 6.9mmol/l, otherwise she is "fine" & her blood workup is "fine". So I ask if that is before or after treatment. No, actually she doesn't even have a drip up. I almost shat myself! These blood results were 12 hours old. "Please do the patient a favour, put up a drip & give Insulin & Dextrose. Get back to me once the patient is properly resuscitated."

A few hours later, I get a message. She is ready for theatre, her potassium is now 5.9. Right, that's a start. I bet the regime was given only once? Correct. I'm wearing my patience hat : "Now do it again. This time, change your fluid from Ringers (check the recipe on the bag - it contains potassium). You said the U&E was otherwise normal. I see the urea is 20 & creatinine 180. That is not normal, it seems a night of dripless dessication didn't do her any good at all."
I get a message 15 minutes later. "Can we please hurry, her BP is now low."
"How low, is low" I ask, "and what is her Hb?" I feel a sudden twinge of regret for delaying - she has probably just ruptured.
"47/20 and Hb is 9g/dl".

Wait a minute. This sounds very fishy & so not like an ectopic. So I go off to visit the patient in the ward myself...

There she was lying. Acidotic breathing, looking more dehydrated than the Sahara. Pink jelco & green jelco each in a cubital fossa (how aggressive), but with an empty 50ml dextrose & empty 1l Ringers and a unit of blood unneccisarily trickling in. Coffee-ground vomitus, diarrhoea, massively distended and acute abdomen, tympanic on percussion & no bowel sounds.

I put in a CVP & A-line to start a proper resuscitation. Do a blood gas, severe metabolic acidosis. So I stick my neck out against two consultants, a positive B-hCG & sonar evidence of free fluid in Pouch of Douglas. She may be coincidentally pregnant, but this is not an ectopic. Insisted she gets transferred to the Surgeons of Mount Doom for a explorative laparotomy because I'm convinced that this is ischaemic bowel. Now 24 hours since admission - well, well, well. Guess who had a necrotic exploded colon?

First patient up today on emergency list. "We want to drain an abscess."
"Where?" - "The left knee."
"Is she systemically septic?" - "Hmmmm?"
"What is her pulse & BP?"..... no idea.
"Why does she have an abscess? Is she diabetic? HIV? Trauma? Is it not a septic arthritis?"..... no idea.
Pissed off with their inability to answer a few ELEMENTAL but ESSENTIAL questions, I go ahead and slap in a femoral block & like fool didn't examine her knee properly myself.
When checking if the block has taken effect, I realise that granted, the knee was swollen, but the area of greatest fluctuation is actually popliteal (where a different block is needed). So I ask the surgeon where he is going to cut? Fail, fail, fail! Better get a crossmatch, I can just see that popliteal artery getting in the way of the I&D. You see, one has to think ahead for these monkeys!
"You should examine your patient properly, especially since you are about to cut into her in the wrong place!" I spit at him.

Then a friend asks me to cover for him in his theatre. It's his last case, but has to leave urgently. The intern is about to put in a spinal & will look after the patient when all is settled. (Fine, because I've got a stable brachial plexus block on my table for ORIF etc.) The patient is apparently quite sick, renal failure, blah blah and needs a below-knee guillotine. Anaesthetic plan is unilateral spinal. So I direct the intern with the spinal, ask the surgeon (& his assistant) which side they're working. "Left", they ALL tell me, "LEFT". Somebody checks the consent - "Left". Having used heavy bupivacaine, I turn her onto the left side. The surgeons sit watching me & the patient for 5 minutes while the spinal settles. When I flip back the sheets, I see a normal left leg & rotten right foot! Can't be! I don't know who was more shocked - me or the surgeons when I called them bloody retards and stormed out of the theatre. Feeling sorry for the patient, I went back to finish the job a few minutes later. By the heavy atmosphere in the theatre, I discover that I AM THE BAD GUY! For crying in a bucket, I was going out of my way to help! This is not even my patient, but was willing to go the extra mile to help! I didn't get my sides wrong - but I'm the bad guy with the nasty temper.

Last case of the day. Another patient with a rotten limb - foot this time. They would just like to do a bit of debridement and redressing. First to piss me off is, this adult has a paediatric 22G jelco which isn't even patent. No good should any complications (happen often at Mount Doom) ensue. I struggle for a good 15 minutes to get a 18G into an arm with none of her spidery veins left unpunctured. (All the while, surgeon just standing watching me - no help whatsoever). So I make a snide remark, "I wish patients would come to theatre with proper IV access. That way there would be more time for surgery & less anaesthetic faff time." But I have been saying this for ever and a day, so why waste my breath? Pop in a popliteal block, and off we go. Off come the dressings on the lady's foot... Well, well, well. The patient said it herself - "Oh no, you're going to have to cut off my leg now, hey?"

How does this nonesense happen in theatre? If doctors would just examine their patients properly BEFORE theatre, the appropriate course could then be followed. I'm so sick and tired of surprises, but also refuse to do the entire workup, and especially surgical advisory, of the patient. Besides not going down well with the surgeons, it is not my domain, responsibility or area of expertise.

Reminds me of one evening, they brought a patient for left above knee amputation. With my two-minute interview & examination - I ascertain the patient has had surgery a few months ago on the left hip. I have a quick look & see it was probably an intramedullary nail. So I tell the surgeons what they missed on their history and examination, but they ignore me and go on. I just sat back and watched with pleasure when they reached the bone & finally discovered the steel rod in the way.

This shit can only happen in state practice. But it doesn't make it less criminal. I've had a guts full. :( Today just sucked! And sorry for the bitch & moan session, but I need the (free) therapy! I'll delete the post once I have cooled down. I miss my Alma Mater. Surgeons were cool there!
Lessons learned :

  • I MUST follow what a wise man once told me about anaesthetics :
  1. Don't believe anything anybody tells you (especially a surgeon)
  3. Give oxygen
  • Don't use blocks at Mount Doom. Rather do GA's - that way, when the surgical plan changes at the last minute, you are not caught with your pants down.
  • When you lose your temper, YOU become unpopular, whether you were right or not. Don't ever visibly lose your rag.
  • Snide remarks, hints & jibes don't work. People are too thick-skinned.