The Big 5

Since I am working like a dog & don't have the luxury of being close to the Kruger National Park, I have been forced to look around me & appreciate nature from the confines of the theatre walls.

I present to you - the BIG 5 à L'Afrique du Sud State Theatre...

1. Blattodea
I call this little chap Nelson. Nelson is a nice cockroach. He eats all the dirt that the cleaners shift from the middle of the floor into the corners of the theatre.
Nelson has a very large family, but they are rather camera shy. They scurry away so quickly before I can get the shot. They look just like Nelson, only some are even larger & some smaller.



2. Diptera
Meet Louis XLCIXIVII. He is from famous lineage - as in Louis THE Fly, from the advertisements that grossed the hell out of me as a child.
Well Louis has moved on from rubbish bins to theatre drapes, where he finds excellent meals in the form of laparotomies & evacs (the photo of him conquering the summit of Mons Pubis was deemed inappropriate for publishing here).
Louis is of the brazen variety. It takes a lot of "shooing" and flailing to get him to move along. But he studied at the Aboriginal School of Boomeranging, so he's back on the drapes before very long.







3. HIV/AIDS
You probably can't see these little suckers with the naked eye, but given our statistics I can assure you they are there.
So, good to know that the sharps bin safely conceals the bevelled little bearers of the "groot griep". Pity it doesn't get disposed of more regularly.
I arrived on call with the biohazardous sharps bin looking like this. Although, I must say that I have seen worse!








4. Ascaris Lumbricoides
This is Willy the Worm. He made his appearance via a lap for stabwound abdomen of a rather uncouth, intoxicated gentleman - let's just call him Willy Warmer.
Willy Warmer told me, quite proudly that he takes drugs, drinks, smokes tobacco & dagga and is on Nevirapine (probably black market/stolen). I'm quite amazed at how resilient ascaris is, to survive despite an assault from all of the above!

(btw Willy told me to send you his regards, Bongi)





5. Anopheles
Mildred the mozzie is sitting (quite ironically) in the caution area - around 610 mmHg of this pressure bag.
I still question that HIV cannot be transmitted by mosquitoes. How do you know that this specific mozzie doesn't suffer from oesophageal reflux?
The assistant in this case (Mildred also made several guest appearances on the drapes around the open abdomen) wondered if the patient's intestines would itch post operatively... hypothetically.



But my gas-mechanic nurse was fully prepared for such invasions as is evident in the following unstaged photo. Quite tickled my fancy & scratched my itch! Wonder if this photo would pass as evidence of a theatrical (?) epidemic?

P.S. Anybody interested in being a co-author in my trial - "Tabard Nebs - an Accidental Cure for Malaria".

Five Surgeons...

from big cities were discussing who are the easiest patients to operate on :

The first surgeon, from Cape Town says, "I like to see accountants on my operating table because when you open them up, everything inside is numbered."

The second, from Johannesburg responds, "Yeah, but you should try electricians! Everything inside them is colour-coded."

The third surgeon, from Durban says, "No, I actually think librarians are the best, everything inside them is in alphabetical order."

The fourth surgeon, from Bloemfontein chimes in, "You know, I like construction workers.... Those guys always understand when you have a few parts left over."

But the fifth surgeon, from Pretoria shut them all up when he observed, "You're all wrong. Politicians are the easiest to operate on. There's no guts, no heart, no balls, no brains and no spine, and the head and the ass are interchangeable."

Responsibility & Telephones & Lazyness, Oh My!

I am unsure whether it is a total lack of insight or just plain laziness which is the doctrine of state sector hospital employees. My concerns are with those occupying the other very important positions in health care delivery who avoid responsibility. A telephone is the wicked accomplice to those in question.

Here ensues three stories to illustrate my point.

Switchboard Operator & Nurses
I receive a call from a very flustered colleague. She has her hands full with a patient who has complicated intra-operatively and needs an urgent ICU bed. She is working in another hospital nearby, which only has a high care facility without ventilators. So she has been trying to arrange for a bed in the hospital where I am on call. She is calling from her personal cellphone to mine. Apparently, she can't get through to our ICU or find out who the doctor on duty is because switchboard is not answering the phone.
"Not a problem", I reassure her. "Just sit tight, I'll get this sorted out from my side"

This shouldn't be a problem since I have the advantage of the internal short dial for ICU & will arrange the bed on her behalf.

4121 - engaged
4122 - rings, rings, rings
4123 - engaged
4122 again - engaged
(the nurses are making private phone calls)

9 - rings, rings, rings
(switchboard operator still sleeping/on tea/away)

After retrying for 10 minutes or so I finally get through to ICU.
I tell the sister I am trying to urgently arrange for a bed et cetera. She abruptly tells me to phone the doctor on 4137 & puts the phone down in my ear.

4137 - rings, rings, rings

Phone back to ICU. Engaged or ringing again. Persist & finally get through. I tell the sister the doctor is unavailable on 4133. I ask her who the doctor on call is, but she doesn't know!
"Ask one of the others, please"
"We don't know, we are the new shift." (so much for handover rounds, which was 2 hours ago mind you)
"Please could you look on the roster for me, Sister."
"Where is the roster?"
"I don't know, I don't work there - you do"
"Find out from switchboard" and she puts the phone down in my ear again before I can tell her nobody is answering at switchboard.

By now I am breaking out in a sweat from fury. I am about to sprint to ICU in person to wring a few necks & vent my frustrations. Lucky for them, I have a case on table.

We eventually solved the problem by phoning a random ICU doctor & asked who was on call. All was sorted out in 2 minutes.

This is the reason why I pay for a business cellular phone contract, privately. Many of my calls are for the state, which gives me no phone allowance and pays me peanuts in thanks.

Laboratory Technicians
We had a patient on table the other day - very ill, very urgent. I was unwilling this time (with the patient's best interests at heart) to blindly start the procedure in good faith that the blood results would be available "soon".
We knew the specimens were at the laboratory because an Intern had kindly made the two kilometre round trip to deliver them in person (you see, the messengers don't respond to sentences containing the word "urgently").
Problems :

1. nobody answers the phone at the laboratory - it just rings & rings & rings
2. when it rings too much, it is irritating to the lab tech's, so they take it off the hook
3. then the phone stays engaged
   
4. there is no computer system for us to personally check results
   
5. it is far to run to the laboratory each time
   
6. smoke signals would contravene certain laws (besides, they would be too stupid to understand it, or be too busy sleeping to notice)
   

So we had no choice. I left the patient under the care of my intern. The surgeon & I climbed into the car & drove to the laboratory.

The techies didn't even notice us standing at the counter. Music was blaring. One was sleeping in the laboratory & two were having an animated conversation in the corner near the phone which was ringing because I had dialed it on my cellphone.

We were only noticed after my earsplitting whistle. I thought the two of us standing there, in theatre attire, would perhaps draw at least an apology for the inconvenience caused or mild embarrassment at such poor service rendering. In fact, they didn't even flinch when I asked them if they weren't going to answer the phone whilst waving my cell in the air.

Blood Bank Technician
I'll spare you the details. We called for 4 packed cells, 6 fresh frozen plasmas & 1 mega unit of platelets.
The blood bank technician felt our order was overkill and only dispensed 1 unit of packed cells and a message via the porter that we can ask for the remainder as we need it.
After struggling with the phones and eventually, much explaining to the insightless but frugal-due-to-low-blood-stocks tech, the rest of the products finally arrived just as the sisters were preparing the corpse for the mortuary.
I KNOW she would have made it, but we missed the window of opportunity.
And the struggle continues because blood bank doesn't have to break the news to families, therefore no culture of responsibility.

I wish I could enlighten those who hide behind the telephone :

You may enjoy the anonymity and use it as a scapegoat for sloth and ducking responsibility....
You may enjoy ignoring the phone because you know it brings more work...
You may enjoy removing the phone off the hook because your sleep is then uninterrupted...
How corny, but what if that phone call is your life hanging in the balance?

People die everyday because of phones, lack of responsibility & lazyness.
Shameful!

Kodak Moments

It has been suggested to me, by several people on numerous occasions, to keep a
diary of the frustrations we as South African doctors in state hospitals have to
endure. So here begins a series of "Kodak Moments" I wish outsiders could
witness. Oh, and these recounts apply to every State Hospital I have worked in
thus far.

It has happened once again. The damned electricity is down. There have been serious problems with the airconditioning for months. Working in a sauna is already a debilitating circumstance.

Impeccable timing too as I had just started slipping drugs into the next patient on the maxillofacial list, sending Queen Mab in her chariot riding over the patient's, in this case, badly marred face. The generators did kick in. Is it me, or is that lagtime before backup power resumption increasing at a exponential rate? Well, my "Chillin' on da Beech" cocktail of Sublimaze, Robinul, Morphine & Decasone is already in - I'm reassuring the patient and telling her to breathe big ones for me when... I felt the tap-dance of a split-hooved creature on my left shoulder.
"Go on, do it. You've started already! Things will be fine."
I picked up the Propofol syringe and connected it to the injection port when the theatre doors gave way to Matron (our villiage crier) brandishing her officious clipboard. "Finish up the cases on table now. Don't start any new cases. We will resume once the electricians have sorted out the problem" That could take all day. They have been busy for months & there is no sign of improvement.

So I apologised to the patient & made off to the anaesthetics tea room, for a nice hot cuppa java. With the entire theatre squad sitting there... idle time... idle minds... I now declare the January 2009 Slagging Olympics open.
"we can't even boil the kettle"
"the milk is going sour in the fridge, and my coke is tepid"
"wonder what's happening with the cricket"
"it won't help to phone the superintendent - it's a waste of time"
"Ray phoned the superintendent the other day when there were no porters & we had came to a standstill. Do you know what he said?"
"So, what's wrong with the doctors? Are they crippled?"

I was gobsmacked. I already push the patients into theatre myself, get them onto the table. I have carried patients post-operative "like a bride over the threshold" to get them onto a guerney. Pushed them to recovery room alone. Let alone all the other fetch & carry I do with the equipment myself. Since that day I have become crippled on principle.

Some of the surgeons mop the blood & mess off the floors themselves. I am sorry, I draw the line right there!

But this all got too depressing so I raised my eyes to stare distantly at the roof & hope for better times only to be distracted by a swarm of blue-arsed-flies circling the tearoom just waiting for the sour milk to be left outside the fridge. First it was just the mosquito's in the corner by the flea-infested on-call bed, next to the cockroach cupboard.

"Eish, I've explained to our patient that she will be cancelled & postponed until next week. She is totally happy and accepting." my Maxfax tells me.
I think to myself, with Fentanyl & Morphine on board, I would also be totally happy & accept anything.

Pressures & Pulsations

It all transpired on a burns list. Dr Esmeralda* sought her consultant's advice on a patient who had extensive injuries. She was unsure as to how she would record the patient's blood pressure during the procedure, since both arms & both legs were unspared of what was no doubt the result of another shack fire, or paraffin-revenge of a lover scorned. Her solution would be to put in a radial arterial line, but fixing it in position was once again a problem.

Glancing at the extent of the patient's burns, the Consultant said, "Don't bother with an A-line, just use a BP cuff & put it over the dorsalis pedis artery".
Esmeralda exclaimed, "Oh, can one take a BP there? Amazing, I didn't know."
Consultant, "Of course, one can take a BP anywhere an artery can be circumferentially occluded. It might not work, but at least give it a try. If the cuff fails, then you can always cannulate the artery."

A while later, a mexican wave of raucous laughter had reached the anaesthetics tearoom. The consultant wanted to know what was going on, but he was told to go & look in burns theatre for himself - there was a Darwin Award Nominee at work!

Hanging in the doorframe, Consultant asked if everything was OK.
Esmeralda replied, "I am absolutely amazed! It is working like a charm. It took a while to find the right sized BP cuff, so we are a bit behind schedule, but we are getting beautiful systolic readings. It just doesn't seem to register a diastolic though..."

The Consultant was a little confused. "What size BP cuff did you use? Why a neonatal BP cuff?" when the penny dropped, "Not the dorsalis penis artery, you idiot, dorsalis pedis".

I shudder to think, had there been no systolic reading, how & what she would have done to that poor patient in order to "cannulate the artery".

Esmeralda didn't leave too much longer after that incident. Apparently, she had developed quite a reputation in the city. It wasn't so much her professional- as her social reputation which was to be the deciding factor. Ironically both concerned an organ which apparently doesn't have a diastolic blood pressure.

*apt pseudonym (if you knew her history)