Saturday, December 12, 2009

Back pain and Triple A

At the entrance to the front room there is an old steel trolley that rules my life. On it lies the patient log book: The book of life and death. Every patient that requires our team's attention is recorded in this cruel master of the shift...

She is a terrible slave-driver, relentless in her ass-whipping...doling out her punishments with cruelty and wicked irony - throwing out the sucker punches of end-stage cancer/HIV/TB at one moment, and then blasting you with the shotgun shells of stabbed hearts, cracked skulls and eviscerated bowel post knifing. And then, right at the end of your twelve hours overnight, she cackles, and slaps you in the face with a flat, blue, not breathing baby that has just been delivered at home on the floor of the mother's kitchen.

Sometimes her torture is just slow and when she sends you the patient logged as "back pain".

Argh - the worst, the worst of the worst. What a vague awful random non-emergency type of complaint. Yes, there are life-threatening conditions that can present with back pain:ruptured abdominal aortic aneurysm, peptic ulcer disease, pancreas issues.

But mostly, it's the complaint of the the overweight or old and arthritic - and not exactly something I'm ever in the mood to deal with at three in the morning inbetween the heart attacks and incomplete abortions.

So what happens is that the back pain patient gets skipped over...and after sorting out one patient and approaching the book of life and death for my next beating, I purposefuly bypass the back pain for something I think is more worthy of my early morning attention. I know my colleagues are doing the same, and we are each secretly hoping that someone else will be the better doctor and go and sort that patient out, but are not willing to take the plunge ourselves.

We had exactly such a patient one day - and because she presented near the end of the shift she unfortunately was not seen by the time the handover round started. That morning, the consultant in charge of the handover was none other than the Godfather of medicine in the Western Cape, a legendary figure whose initials, Triple A,are both his nickname and the medical abbreviation for Abdominal Aortic Aneurysm...and he is just as deadly.

Triple A is renowned for his spot diagnosis and unparalleled clinical skill - having the uncanny and inspiring ability to diagnose a patient's condition from the end of the bed - sometimes by just looking at them, not even one question asked.

Not only is he an astute medical genius, but he is also a staunch atheist, a lover of incrediby rude jokes and also wholeheartedly committed to the poor patients accessing state health care.

The stories that circulate about him are the stuff of legend. One of them being that one morning on the hand-over ward round he developed chest pain, and went to lie down on the floor next to a plug on the wall.
When people asked him what was happening he replied that he was probably having a heart attack, and since the ECG machine was situated on the other side of the front room and that he knew there were no extension cords, he decided to lie next to a plug, thus could someone please go and fetch the damn thing and check him out. The poor intern did the honours, trembling all the while, not believing that he was bent over his grand master, and then exclaimed while reading the ECG that there were no classical ST elevatory changes to indicate a myocardial infarction.

Triple A, lying on the floor had a slug's-eye upside down view of the ECG and promptly exclaimed, "Fuck you, man, there's an R-wave in lead V1, I'm having an inferior infarction, get the streptokinase!". He then refused to be moved to another hospital, exclaiming that if he didn't have faith in his own place of work, then how could he expect his patients to do the same.

When we arrived at the bedside of the old, overweight lady with back pain, we presented her as an arthritis. But we might have been talking to the walls - Triple A wasn't listening. Ignoring us, he asked her to describe her pain, where it radiated to and what time she felt it during the day. That was all. And then he looked at us and proclaimed: "This woman has cancer of her pancreas". He hadn't laid a finger on her. We all balked. And there were mutterings that perhaps the senile dementia had finally got to him...But he insisted, she was sent for an ultrasound, and the report came back that there was a mass in her pancreas, most likely a malignancy.

We all felt like fools. Like shits. Like we knew nothing about anything worthwhile. Like we were mere amoebae in the presence of this medical guru.

Needless to say, I've changed my behaviour towards the back pain patient...and when the book of life and death throws that one at me, I'll accept the punishment gladly to try and atone for my previously wicked behaviour!


kelley said...

You are brilliant! Flip I miss Aboo and Birch.....

Stupidosaur said...

I guess he isn't into Bollywood eh?

Otherwise you could use the Andaz Apna Apna style comment

"...balke main toh kehta hoon aap purush hi nahin ho (pregnant pause)...mahapurush ho!"

Your version will be

"O Godfather, you can't claim to be father...(pregnant pause..wait, not a father, and yet pregnant there some nested joke here?)...cos you simply God!"

Hopeless 'jokes' apart, he's really great!

Stupidosaur said...

BTW funny you recently added XKCD to your blogroll. I discovered it just 3 weeks back and finished the whole 640ish entries in a few days.

The timing of both of us reaching the same website is funny coincidence (I didn't reach it through here), cos as far as I know it wasn't put up here a few weeks ago.

Ketan said...

Yes indeed, I too have heard of such medical gurus.

Incidentally, never came across one. ;)

Why would, but inferior wall infarction present with R wave in V1? R wave would anyway indicate activity in the Purkinje fibers, rather than the myocardium proper, right? I believe, changes in the QRS complex indicate old infarcts - especially the low-amplitude R waves or Q waves. An inferior wall transmural MI should've shown ST elevation in VF, II and III. Please do clarify on these issues - it could help me. Was his diagnosis confirmed? Or was it one of those fancy NSTEMI? ;)

But then if you (whose skill I consider to be pretty good) are in awe of him, he definitely must be good. :)

And you're unlikely to understand what Stupidosaur said above in Hindi. Here it goes.

Andaaz apna apna is a very famous Hindi movie, and the meaning of the title roughly translates to "one's own unique style"

""...balke main toh kehta hoon aap purush hi nahin ho (pregnant pause)...mahapurush ho!" translates to:

"... In fact, I am saying you're not a man (pregnant pause)...but, you're a superman!" Okay, actually Mahapurush translates better to 'great man', rather than superman. But many times, it's difficult to capture the native flavor of a language in translating it verbatim. :(


MAGUS said...

wow..i simply love the way u describe sounds so challenging n fun.

btw,everybody learns by experience.I'm sure triple A is no exception.but whatever,kudos to him!

Dr S. said...

Kelley - Honestly, you're my biggest South African fan...THANK YOU! :):):)

Stupidosaur - XKCD is totally brilliant, have been following for a while - which is your favourite comic? And - "I found the Andaz Apna Apna style" comment quite funny, but I think the complete hilarity of it is maybe lost on my lack of Indian culture knowledge?!?!

Ketan - thanks for trying to elucidate further! I can always count on you for that! Also - lead v1 is not supposed to have an R wave, and when one is present it can be a subtle indicator of a few things, one of them being(along with other signs) an inferior infarct ( apparently, according to the godfather that is - and I wouldn't question that)

Magus - thanks - and it really truly is like that, no embellishment. It's a warzone and us casualty officers are on the front line...


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