Following on from our mid week hiking excursion we've had 3 pretty hectic shifts culminating in a Saturday night which I hope is the nearest I get to practicing medicine in a war zone. Riki, on the other hand, hopes to work in a war zone some day so hey ho, at least he's getting some practice in early.
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Thursday and Friday were quite intense shifts with some pretty sad cases. While it was a nice change to not be dealing with a seemingly never ending stream of drunk people with scalp lacerations +/- C spine tenderness +/- confusion (honestly, the number of patients we see where we have to have discussions about whether we think they're just unbelievably pissed or whether they might have a traumatic brain injury you would not believe), they were replaced with some quite extreme cases of disease. Riki clerked a patient who had lost a lot of movement and sensation in her legs because of TB that had spread to her spine causing fractures which had begun to compress her spinal cord. Very very sad. On a slightly lighter note Riki also dealt with a kid who had developed a blood blister after bumping his foot. Halfway through the procedure to deal with this the accompanying intern (foundation level doctor equivalent here) warned Riki 'Careful in case it pops!' just as the swollen pus and blood filled mass spurted all over Riki's face. Thank god for goggles. We also became highly proficient using a stapler for scalp lacerations - not the general office kind mind you though to be honest there's not a huge amount of difference. It's SO much quicker than suturing and given Johannesburg populace's predilection to batter each other over the head is definitely going to come in handy. In the midst of all of this we met two Australian elective students who will also be based on the trauma unit for the duration of their time here - maybe just maybe I won't have to abandon Riki in Soweto because I was just that sick of only seeing and talking to him.
Our new stapler best friend
After a long day's work on Thursday I was relieved that Riki kindly offered to drive us back from the Hospital for the first time. For a little bit of context Riki passed his driving test in a manual and though proficient in an automatic car has not driven a manual since. Heidi bless her is a manual car. He managed to get through our drive back from the mountains with no real drama other than being unable to reverse at one point (I should have taken this as a sign). The drive to and from the hospital isn't particularly arduous but there's a number of different hill starts which Riki fell foul too due to Heidi's pretty high biting point. The pressure of not stalling is also hugely increased here. At home the worse you can expect from a stall is to get some beeps from waiting cars. Here, that's best case scenario with worst case being getting shot for the inconvenience you've caused another driver (it might sound extreme but we've heard stories). Needless to say I will be driving from now on. Riki's case was also not helped when he tried to reverse out of a parking spot at the local shops, ignored my repeated shouts of BRAKE as we rolled towards the high curb and successfully mounted it with our bumper. Again, Heidi, we are so sorry.
So perhaps the most memorable case from those couple of days came from what on the surface history was a pretty innocuous story. A man came in on a stretcher alert and orientated (which I now take to mean not blind drunk) and was complaining of pain in his ankle. When the nurses were asked what was wrong with this patient which had just been wheeled in they said that he had 'twisted his ankle'. When Riki walked over and pulled back the blanket covering this man he was greeted with the sight of a good chunk of the mans distal tibia sticking out of the side of his ankle. I guess, technically speaking, the nurses were not wrong.
Riki was making valiant efforts to comfort the man who for some strange reason kept looking at his now deformed ankle, getting more and more stressed with each glance. Riki eventually resorted to holding his head down - to protect the C spine right? Well we both found the sight and sound of that getting put back in to place so satisfying that we know we're on the right career trajectories.
So now on to the main event, Saturday night.
The shift got off to a pretty eventful start. Within the first half an hour a young man was brought in with a stab wound to the heart. Everyone was frantically trying to resuscitate him, tubes were flying in left right and centre and an imposing man I'd never seen before barked at me to take a blood gas and put in a catheter. While I was busy with these jobs Riki wondered over and was immediately accosted by this man I'd never seen before who asked him what he was doing here. After telling the man who he was and that he was an elective student this randomer demanded why Riki had not introduced himself at the beginning of the shift.
What Riki wanted to say - 'Well first of all nice to meet you too person who I've never seen despite nearly seven 12 hour shifts working here, it would be nice of you to introduce yourself as well. I have never been told to introduce myself to anyone in particular here, in fact, we have received next to no instruction as to when we should be here let alone any form of etiquette we're meant to follow when we are here and when we asked for an induction we were told we would not receive one as it wasn't worth their time when there were only two students.'
What Riki actually said on reading CONSULTANT embroidered on the man's scrubs - 'Sorry sir *grovel grovel grovel*'
Ok so on this point, a little bit of a rant to follow. Please feel free to skip to the next paragraph where I'll be talking about some more blood and gore. So we've come here to learn and without a doubt we are definitely doing that but more importantly it feels great to actually be contributing. The doctors here work horrendous hours under what to me seems to be a pretty toxic hierarchical system. The juniors appear pretty terrified of their seniors for the most part, the consultant that was on this particular Saturday in particular. Maybe we've been privileged to work with mostly kind senior doctors who are team players, but from an outsiders perspective the team dynamic here is at points far from ideal. The consultant who had a go at Riki clearly thought he was the bee's knee's which to me seemed slightly inappropriate given the number of problems in the department. There are often patients lying on the floor, no one can find any equipment they need because nothing is ever adequately stocked (despite the fact that the resources do exist within the hospital), in the trauma pit there is absolutely ZERO system for categorising patients or keeping track of their notes so a horrendous amount of time is wasted, patients lie in pain for hours without analgesia because this never seems to be high up in anyone's priorities, patient investigations are massively delayed just because it's not communicated that these patients actually need scans and practical skills techniques are rife that would give our teachers heart attacks. I could continue. All of these problems are things that I think have relatively simple fixes that need people in positions of authority to address - like a consultant *cough cough*. In short I think some people need to spend some time looking at how they can improve their place of work rather than looking for ways to massage their egos.
Ok rant over. On the bright side the dislike for this consultant was actually a pretty unifying force with everyone commenting to Riki following his interrogation that he wasn't exactly well liked. Despite my criticisms the consultant was very kind in letting us view the thoracotomy that was needed for the man with a stabbed heart which was amazing to watch. Riki arrived late and was in blissful ignorance about what was actually going on while I had just sprinted from the theatre to pick up blood for the patient who's blood pressure was plummeting and was having to have his heart manually compressed by one of the surgeons to try to maintain his circulation. Thankfully the patient made it through the procedure. As they were closing up the Anaesthetist phoned ICU to warn them of a trauma patient coming directly from theatre: "What kind of incision have they made?" "They've made a... oh I dunno what that mess is they've cut everywhere." so maybe not the cleanest of thoracotomies then..... We managed to help out a little bit, passing equipment here and then, occasionally cutting sutures. Ryan (one of the ozzie elective students) was less lucky in a later operation where because of the length of time he'd been on his feet already that night his face had an unintended (and quite rapid) meeting with the floor after he passed out.
After this madness the night just got busier and busier. Every time I thought we might be getting on top of the patients that had arrived already, I would turn around and there would be 3 or 4 stretchers waiting at the red line (the entrance to the unit where people are screened as to whether they need to go to the resus area or not).
The rest of the night was full of memorable characters. Please see below for a selection:
- Man who didn't want me to use a stethescope to listen to his chest because he thought that this was going to tell him whether he had HIV or not.
- Guy who came in with lacerations and a hole in his head, turns out he's had a depressed skull fracture since Feb... and oh wait his right leg has been feeling weak and had crampy pains since Feb too.... what a coincidence.
- Man who kept trying to fall asleep while I cannulated him. He soon woke up when there was too little local anaesthetic in his scalp wound I sutured - whoops. Despite this he still WOULD NOT KEEP STILL. I'm not saying I regretted giving him more local but I regretted giving him more local.
- Without a doubt, the most memorable patient was someone who gave literally everyone a headache. This man refused to be treated by most people and had some serious trust issues. He would continuously complain that he was in pain but was too terrified of needles to be given any pain relief. He was taken to x ray twice and twice refused to have it done. He continued to complain at which point Riki snapped, stormed over and shouted at him to 'SHUT UP'. Potentially the most effective episode of communication Riki has ever had because it got exactly the desired effect. After a half an hour long pep talk from Riki and some hand holding he eventually had the x ray done - please see below:
To be fair, I'm not surprised he was in pain
After this long and arduous night Riki made the effort of going to another Emet gym session with our ever enthusiastic coach Nick. I went to sleep.
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