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)

Favourite Things

Feigning an illness for sicknotes I've written,

By ladies in labour, my arms have been bitten,

Brown faecal packages, by god it mings!

These are a few of my favourite things.

Cream coloured pustules & crisp panga slices,

Breath smells & foot smells and species of lices,

Wild taxi drivers cause crashes & dings,

These are a few of my favourite things.

Sr Pleses in green dresses that phone about rashes,

AIDS blood that squirts on my nose and eyelashes,

Clinic referrals & the crap that it brings,

These are a few of my favourite things.

REFREIN :

When my salary bites,
When the bullets sting,
When crime waits at my gate,
I simply remember my favourite things
And I want to emigrate.

Dr Zhivodka

After an hiatus from blogging & life in general over the past few months, I have been re-reading a few of my more venomous (and thus unpublished & archived) posts. Having read bongi's amusing post today, doctors for africa I have decided to lift the ban on a post I wrote on Spring Day last year (oh, the joys of spring!).

Now, there is a REASON why I don't buy lotto tickets, gamble, play dice games, go fishing, overtake on a blind rise or walk barefoot on the lawn... I am one of the unluckiest SOB's alive!

It feels like yesterday. My first day at work as an Intern. Triple whammy! I found out :

1. first rotation is Internal Medicine (my fave, right up there with root canal treatment)
   
2. my Registrar is one newly appointed, Dr Zhivodka
3. I'm on call (aargh, Monday Firm - the worst. Weekend-wreck dumping ground.)
   

Typical! I'm not surprised! As an irritating, whistly tune from Monty Python repeats in my head, I try to take advice from the lyrics. Let's not judge Dr Zhivodka by his cover (something like Fargo meets Deliverance, set in Khayalitsha) and give the guy a chance.

Walking off to the medical block, students in tow, I try to make some idle conversation. I notice he says "OK" a lot, even to questions. What I did manage to ascertain was, despite coming from Southern Africa, he studied abroad because of the injustices of the past. Very strange I thought, to not only study medicine in a foreign language, but one which has a completely different alphabet! Sounds dodgy deluxe... But hey, I'm sure they did their background checks before hiring this guy - so just relax. In which case, I'm quite impressed & wonder about the logistics of it all : "It must have been challenging studying in such a vastly different country & language?"
"It was too much nice," he tells me, "we drank so much of vodka and smoked so much of cigars. I miss it too much." Besides sidestepping my question, he stoked the coals of dubiosity & my scepticism is back with "too much of" vengeance. Houston, we have a problem!

Rounds were going nowhere fast. The students seem to notice this too as was obvious by their indiscreet eye-rolling, whispering, giggling & yawning and eventually blatant chatting about what they got up to in the holidays. What became rapidly apparent as the morning developed, I was the new captain of this ship (by default) & we were sailing plumb into the Bermuda Triangle. I got rounds out of the way by emulating what I had seen the Consultants do... we drew blood for everything on everyone.

Right, rounds out of the way - let the call begin.

Dr Zhivodka is very, very slow. For each patient he is seeing, I am seeing three. Dr Zhivodka works according to a pattern, I notice. The referrals come in with a query diagnosis e.g. ?Meningitis and he admits the patient with the diagnosis of Meningitis. He receives a patient with ?Infective Endocarditis and he admits the patient with Infective Endocarditis . Can you guess what the patient with ?Guillain-Barré gets admitted with? I, on the boring hand, was striking one PCP or HIV or PTB after the other (in various permutations, some even hitting the South African Trifecta).

My first big problem case arrives early evening. A young, healthy looking guy but with one impressive tremor on him. No chronic illnesses & kidney functions fine, but a Potassium of 9mmol/l. I phone the lab just to ease my mind and confirm the specimen was haemolysed, only to be told NO HAEMOLYSIS! Shit, I remember this is an emergency - something about the heart & fatal dysrhythmias. I phone Dr Zhivodka, who had conveniently gone home for dinner, to rattle off about the horrific situation. So he tells me, "OK"... and then nothing... I thank him profusely for all his help & slam the phone down in his ear. Once again, problem squarely on my shoulders. No Calcium gluconate in referral room, but I've got the students getting an ECG and hanging up Insulin & Dextrose infusions. In the meanwhile, I'm on the phone again - this time for a high-care bed.

Of course, the ICU Reg starts giving me flack about not accepting consults from an Intern, rhubarb, rhubarb. A concoction of irritation, fear & desperation can create a monster. Having morphed into Frankenstein on steroids, I begin yelling down the horn like Gatiep on spirits :
"Dr Zhivodka is at home right now, but I can give you his telephone number if you wish. He knows nothing about this case... in fact he knows nothing full stop. He is a fool. Incidentally, I am stripping him of his title - let's just call him Zhivodka from now on, shall we? So take your pick. Intern or Retard?"

I got the patient turfed to safety, only too pleased searching for the cause of the hyperkalaemia was now the problem of somebody with more than 24 hour's experience. I managed to survive the night (only just) but knew we were in for one very long & painful post-intake round with the Consultant.

Walking back to the medical block, following the distinct scent of urine and heading for the source of the medical morning procession of tented guerneys, I am once again reminded of Monty Python.

Let the show begin! Like two cats been out on the prowl all night, we presented our carrion at the feet of our Consultant. I was first up. I had a very emaciated lady with what I suspected was pulmonary TB. Having come in severely dyspnoeic & with a massive pleural effusion of the entire right hemithorax, I proudly presented how well she improved once I inserted an intercostal drain & sent off the fluid for MC&S, biochemistry, ADA & cytology (I thought all these tests were bound to impress). My smile was very quickly erased from my face when the Consultant tells me, "You idiot! What is her albumin? By the looks of her shadow, it's in the ground. Now we're never going to get that drain out." I had switched off to whatever else he had to grumble on about and took solace in the fact that I was soon to be upstaged by Zhivodka. The smile returned.

What a mess. My heart actually bled a little for the fool. All he could get right was the patients' name, age & gender. The Consultant was making mincemeat of him. As in an exam, one could tell he wasn't doing too well as the questions were becoming progressively easier & easier, to the point of ludicrousy for a post-graduate. I clearly remember some of the interchange :

• "What is the cause of meningitis?"

"Protozoa"
"I say meningitis & your first thought is protozoa!"
"Fungus?"

• "How do we treat infective endocarditis?"

"Warfarin"
"You have just killed the patient."
"Heparin?"

• "Do you even know what Guillain-Barré is?"

(Fifth Amendment)
"But you have just told me you diagnosed Guillain-Barré. How can you diagnose something if you don't know what it is?"

The Consultant told me he wanted to see me in his office after rounds. Turns out it is very difficult to get somebody fired, even if there is evidence of gross incompetence. I was asked to document all misdemeanors with dates, times & witnesses (something I would have to quickly get used to doing in state practice).

I was amazed at Zhivodka's resilience. He was treated very harshly by all, but could not be broken. He would be back at work every day, until he was was eventually asked to see the Head of Department after a month or so. Acting as a sounding board after his meeting, Zhivodka shared with me how the HOD told him that perhaps Internal Medicine was not his forte & he should think of pursuing other avenues of healthcare. How typically diplomatic of the HOD! I would have told him that perhaps his forte is NOT healthcare.
P.S.
As a matter of interest and in stark contrast to my hyperkalaemia patient, Zhivodka's Guillain-Barré had a potassium of 1.8mmol/l (hypertensive on diuretics). Hallelujah, he got up and walked after a few bags of PotChlor.
Even more interesting/shocking, a quick search (or should I say, quack search) on e-Register & Zhivodka's still on the roll!

I'll Take the Stairs

In our public hospitals, the cherry on my irritation-cake is the lifts (South African elevators). Often, it's not so much the lifts as the people that (ab)use them - but nonetheless, the lifts are bloody irritating.

Elevator Etiquette (or lack thereof)
It would make sense to me, or any civilised person for that matter, that when the lift doors open, people leaving would have right of way. If you have ever witnessed the Wildebeest Stampede through the Mara River you might know what I am talking about. If you have not, spare yourself the trip to the Serengeti - it would be much cheaper (and way more daring) to visit a South African public hospital, stand inside a lift & wait for the doors to open.
Don't think that people have a sense of priority either. If I were in a lift when the doors open to a scene of tubes, cylinders, cables, alarms & monitors, a blood-spurting patient & a doctor brandishing paddles screaming "Stand Clear" - I would get the hell out of that lift to make way... ehem... well not here. Instead one is greeted with a sea of eyes wielding a "screw you, we were here first" expression.
Or, you would actually make it into an empty lift hoping to get a patient speedily to ICU, when the lift stops on every floor to squeeze in another ten people who bump your elbows & stomp on your toes while you try your utmost to maintain possession of the ambubag.

Streamlining
I always imagine that there is some sort of circuit board or computer coordinating the various lifts in a building for maximum efficiency. One would assume that with four lifts (plus two patient elevators and a service lift), the fastest way from the 7th floor down to ground & back again would not be via the stairs. This theory and assumption was first disproved during my student rotation through vascular surgery.
Professor Atherosclerosis* was notoriously vicious, but in a very creepily calm way. He asked told me on our first academic rounds, to fetch a patient's angio from radiology "on the double!"
When I got to the lifts, all of them were on floor 6 & were heading downwards - one floor at a time. I decided (decision driven by terror) I could manage the 7 flights of stairs at a sprint. By now, I'm sure you can pick up on a trend. When the elevator circuitry left me in the lurch again, I decided the punishment of a 7 flight ascent was way more lenient than what Prof Ath could dish up, should I keep him waiting.
I arrived back at rounds both with the angio & living proof that a person can be both a pink-puffer & blue-bloater simultaneously.

Elevator Mentality
OK, so I have a few observations...
Myth 1 : the more you press the button, the faster the lift will arrive. If the elevator did indeed have some form of sentient circuitry (disproved-see above), it could perhaps be fooled into "thinking" there are lots of people on that certain floor & therefore give it priority.
Myth 2 : By pressing both the up & down buttons, your wait is shorter & reach your destination quicker. But put an idiot like you on every floor & you get 20 waypoints to your journey, which starts by heading in the opposite direction.
Myth 3 : If the light is already shining, you don't have to press the button again. The guy waiting before you did a good job of the button-pressing - the light confirms that he got it right.
Fact : The one hospital I currently work at, has an up & down button on the ground floor!

Murphy's Law
When you need the lift most, it will always be one floor away heading for the extreme altitudinal opposite.
The lift you are waiting for, will never come. A porter or cleaner has wedged an object (trolley, bucket, linen bag) in the door to keep the lift from leaving before they have completed their errands/duties on that floor.
When you give up waiting & take the stairs, you are still within earshot of the arriving lift, but too far away to make it back in a dignified manner.

Did You Ever Think?
...The people who can least afford to, use the lifts.
...There is a worse breed of human than those who take the lift up one storey! The type that take the lift down one storey.
...If the lift cable were to snap, you would jump up on the spot one second before impact.
...Look at the weight restriction plaque, glance around you & give a nervous giggle?

Elevator Storeys (pun intended)
One evening at a dinner party a few years on, I met up with a former Nuclear Medicine Registrar. We got chatting & reminiscing about good 'ole Alma Mater Academic Hospital when she asked if I remembered the one lift that didn't quite line up properly (it sagged about 10cm below the floor). I did, very clearly & was surprised when she admitted responsibility for the damage! Apparently, she had arrived super-early for her first day at work as a registrar. There was a patient who needed a bedside special investigation and she had planned to show her Professor how hard working she was by having everything prepared before he arrived. Instead of using the service lift, she wheeled one of the hulking nuclear imaging machines into an ordinary lift & stretched the cable. She tried the "look & see if anybody saw you - then leave quickly" tactic, but she couldn't pull the wheels over the step she had created. She said she scored a solid 10/10 on the Shit-First-Day-At-Work-O-Meter.

Dr Sanitary Pad*, superintendent of Sandwich Ham Hospital, had made the genial decision to move theatres back up to the top two floors. Due to the very reliable electricity supply in our country, it was decided that the lifts need not be connected to the back-up generator supply since the battery backup was sufficient... The ramifications during long power failures when the battery ran flat, ranged from humourous to most gravid indeed.
At the end of one day, I remember having a chuckle as the dialysis unit on the 3rd floor were taking patients down the stairs in wheelchairs (Come get dialysed now, we'll throw in one Powerplate Session absolutely FREE).
More serious though was getting emergency patients to theatre on stretchers up the stairs.
So as you can imagine, during times like this, the switchboard was jammed with calls needing urgent attention from Dr Sanitary Pad. I wonder if the problem ever got fixed.
One fine day, somebody got stuck in the lifts and was frantically ringing the emergency bell. As fate would have it, Dr Sanitary Pad was not available in his office & his cellphone was switched off. Typical! The eternal ostrich whenever there is a crisis!
But life can be sweet! When the doors of the lift were finally pried open about 2 hours on, there in the lift stood a one very red-faced Dr Sanitary Pad. My mind changed that day - I am now VERY content there is no cellphone reception in the lifts. Apparently his voicemail was inundated with very rude messages regarding his whereabouts during office hours & especially during the time of a crisis.

Conclusion
A good friend of mine (real not imaginary) once told me, she doesn't see the lift-frustration as a negative. While she runs about up & down the stairwell when oncall, she just thinks "calories, calories!".

*not his real name.