Wednesday, October 28, 2009


The fingertips of my right hand have been trained, over the past few years to pick up subtle irregularities in the examination of a patient.

The sensory information gained from these soft pads of palpatory precision, communicate via amazing electro-chemical pathways along my nerves, to send a message of alarm or calm to that central processing unit in my skull.

As doctors, we usually begin our examinations by using these sensitive fingertips of ours to feel pulses.

It's probably the first thing one learns to examine. I remember practicing on my fellow students after our first clinical skills tutorial, and bragging about who had the lowest heart rate and could thus claim supreme athletic fitness.

Such a simple thing, feeling a pulse.

And yet, at it's most basic of functions, it is an ultimate determinate of life, or death.

Lub-dub, lub-dub.

A rhythmical, cyclical affirmation of life, beating a constant reminder into my fingertips that, "Yes doctor, I am alive, don't give up on me yet."

Except that this time, the pulse lied...

She was logged in the book as "???oesophogeal cancer???"

That question mark prefix:

Mostly an indication that the diagnosis is still being worked up.
Often a symbol of hope that our suspicions are unfounded.

I drew the curtains, armed with my cheery and hopeful, yet concerned bedside manner.
The one I've developed over the years to try and lessen the terrors of being in a state hospital and the threat of a disastrous diagnosis.

But I was no match for the enemy that confronted me.

I was physically shocked. My years of service have brought me face to face with the destructive forces of disease and trauma, yet I have never been this physically moved.

There it was.


I did not need to touch her to know what I instinctively felt.


I could hear it cackling at me, callously thrilled to have so viciously ravaged her body.

So confident in its permanence that it willingly revealed itself, showed its hand, tortured me with its unquestionable impending victory over her life.

She lay there, motionless, except for the slow sad movements of eyes sunk deep into the despairing depths of her skull.

In a defeated and very small voice I introduced myself to her.

She responded after a few seconds with only a painful exhalation.

Touching her made me shiver with horror.

Her skin, like old leather that has been trodden on and left outside to be battered by the rain and sun, was stretched unwillingly over her skeleton. I looked at it listlessly collecting in the hollow that used to be her abdomen, and watched it tiredly continuing on its journey over her chest - her nipples the only hint of the breasts that fed the three children huddled around her bedside.

Her arms and hands were like the branches of a dead tree...thin, dry, reaching hopelessly into space.

I knew then that I had no weapons against such an advanced and evil adversary.

I could feel her spine when palpating her abdomen.

I was sickened.

And before feeling it, I saw her abdominal aorta pulsating, valiantly carrying on the physiological fight, regardless of the inevitable surrender.

Why did this lady only present to us at such a late stage?

Because she is poor? Because she doesn't speak English?

Why did the initial slow deterioration of her life not warrant ear-splitting sirens summoning sympathy and support and treatment?!

But it was too late for all of that. The cancer had metastasised.

Any further medical intervention would have been cruel and inhumane, and would only prolonged her torturous demise into death.

I gently informed the family of the very poor prognosis, and let them know that she would most definitely stay in hospital for the night while we tried to find a placement home for terminal care.

When her husband left, he bent over the skeleton that used to be his wife and kissed her forehead. He then turned to me and placed an old washrag and a bar of soap in my hands.
"This is her washrag." he said. "I'm the one who washes her every day with this washrag. Can I leave it here? Will someone wash her while I am away?"

Choking back the tears all I could manage was a nod of the head.

I handed over the washrag to the nursing staff, and finished my shift, dejected.
By the time I arrived the next day, she was gone.

But what remained with me is cancer's destructive power and our frightening inability to conquer this terrifying disease.

Sunday, October 11, 2009

HIV, Will you get me? Not with the help of ARV's.

So I'm taking ARV's.


Sounds like the latest gas-guzzling 4X4 from Pajero.
Or some super-cool new street drug that with one hit can send you on a round trip through the milky way, with a stopover in Heaven and possible delays in Hell.

But, nope.

ARV's are way cooler than that.

They are anti-retroviral drugs!

They can prevent the contraction of HIV, when a doctor exposes herself to it while she is taking blood, very diligently and gently and with gloves on, from her HIV positive patient who moved during the procedure resulting in the bloody needle piercing her thumb.

No biggy.

This is only like the fourth freaking time this has happened to me.

The first time was when I was a fourth year medical student doing my paediatrics rotation. The poor paediatrics registrar was struggling to gain intravenous access on a very sick neonate with veins smaller than the cannula diameter. I was helping her hold the neonate still while she attempted the procedure for the 20th time. After failing, for the 20th time, and understandably frustrated, she threw the needle into the sharps bin. Except that it didn't make it into the yellow sharps container. Instead I watched, in slow motion, as it did a spectacular somersault through the air and embedded itself, rather painfully, in my thigh.

I was distraught, and upset and got loads of sympathy from family and friends.
I started the ARV's immediately and sweated through the ensuing 28 days, petrified of sero-converting to HIV, and ultimately testing HIV negative. Phew!

That was five years and three similar events ago.

This time I didn't even tell my colleagues until someone saw me squeezing out the blood from my wound. It was near the end of the afternoon shift and I was completely disinterested in myself and my patients. (horror)
But my concerned colleagues forced me to go and open up a hospital folder, have my blood taken and start the ARV's.

So now I'm taking them. twice a day.

These drugs are brilliant, but can result in nasty side effects such as:

Skin Rashes
Bone marrow Suppression
Lactic Acidosis


Luckily I have only suffered mild nausea and muscle pains thus far.

Oh, and I've also suffered at the hands of Dr MB's torturous pranks.

After behaving very sweetly, and drawing my blood very gently, and phoning the laboratory for my initial test results before starting the ARV's...he then stole one of my personal patient stickers from my file, and stuck it into the front room's patient log book along with this made up diagnosis for all to see:

Patient: Dr S

Working diagnosis: Retained foreign body, +/- ?sex toy??


I eventually got my own back though with this entry into the logbook:

Patient: Dr MB

Working diagnosis: ?Haemaphrodite. Vaginal Bleeding, Grade IV prolapsed rectum and dysmorphic buried penis.

Overkill? Maybe.
But that's my style.
I'm ruthless with my retaliations.

I guess that's one way of making fun of a ridiculous situation.

With almost every second patient that we see being HIV positive, it's inevitable that one of us will be accidentally exposed to the virus while trying to treat patients.

It's so common that I don't think I've met one doctor who hasn't been on post-HIV-exposure prophylactic ARV's.

Which is why I keep reminding my husband that he could have married a prostitute, as both doctors and ladies of the night run the risk of contracting HIV from their professions.

Tuesday, October 6, 2009

Comedy Crusaders

Friday morning handover round.
Our team ( The A-team) is handing over the numerous patients we've spent the last night seeing, to the new team coming on for the day.

Dr MB begins one of his patient presentations. The patient is curled up under one of the government issue blue hospital blankets in the fetal position.

Dr MB: "This patient is a 28 year old lady admitted at 06h00 this morning for strange behaviour. She was brought in by her colleagues for bizarre delusions. She believes that she is a doctor and that she is at the hospital to help people get better. She is not a known psychiatric patient but currently displays signs of mania, psychomotor agitation and formal thought disorder..."

The consultant leading the round, Dr G, then decided to wake the patient, and moved over to the head of the bed. She lifted the blue blanket to reveal....

MY very own pretty little face giggling hysterically from beneath the covers.

I was so dog-tired after our long shift that while the rest of my team were busy presenting and discussing another patient, and with no further patients of my own to present, I decided to climb into one of the empty patient beds and rest my weary head. It seemed like the appropriate thing to do at the time.

Which is when Dr MB and I came up with the idea of presenting me as a patient on the ward round.

Luckily Dr G was a young, newly qualified emergency medicine consultant with a sense of humour. She laughed heartily , and then shook her finger at me for being crazy enough to risk catching patient germs in aid of a little comedy...

She doesn't understand the lengths we are prepared to go to for a laugh in this place.

Doesn't she know that every shift is a war between patients and our sanity?

Nonsensical frivolity is sometimes the only defence against impending work induced depression and despair.

Our next practical joke will involve elaborate co-operation from the nursing staff and fellow colleagues. We are planning on bandaging up my head just before the new team arrive at 08h00 for the next handover, and then shocking them with the story that I had been stabbed in the head by a psych patient and had to have my lacerated scalp sutured up and then bandaged.

I think we'll be able to pull this one off.

I am 100 percent certain that the new team will actually fall for it.

After all, similar incidents have actually happened in the past.

Voltaire said that the purpose of the doctor is to entertain the patient as the disease takes its course.

Hopefully, as a defence mechanism against depression and like some kind of comedy crusade, we'll always be able to entertain each other while our shifts run their course.


Friday, October 2, 2009

Friday night Folly

The following is an account of our end of the month friday night shift a few weeks ago. It's long. It has no structure. It might all seem a little pointless...

Which is pretty much a description of the evening itself:

My arrival at work is unfortunately not signalled by the large marching band, fireworks and a rip-roaring guitar solo played by a topless Greek God that I think I deserve.

Oh no...instead I am greeted with that age-old traditional greeting, peculiar to the lesser-incisor'ed native of the Cape Flats:
"Jou ma se poes!" (your mother's cunt!).

Seems that one of the psych patients has escaped from the front room, and is currently freaking out in the parking lot outside the unit, screaming obscenities at everyone. He is wearing a hospital blanket and shoes. As I walk past him into the unit, the security guards rush past me to try and capture him...but this one is a wily little bastard who immediately dropped the blanket, exposing his naked buttocks to the world and took off running like a man escaped from prison into the darkness...They might catch him, they might not.
Judging by the pendulous belly on the security guard, my money is on the patient.

I walk into the unit giggling...but this false sense of fun is soon arrested when I realise that there are no other doctors to be seen. Alarm bells start ringing when no-one is in the front room, it's a sign that they are somewhere else. And that somewhere else is usually in the resuscitation room, where there is probably some major shit going down.

I sheepishly shrink off to the tea-room to deposit my things, before braving the carnage I'm certain is waiting for me.

I'm not disappointed.

Dr MB and Dr Mommy are busy doing CPR on a morbidly obese lady in one corner.This happens in the resus room all the time. HOwever, what is peculiar about this is that they are performing this potentially lifesaving manoeuvre on the floor! Hospital is at capacity so no more stretchers available. Silly me to expect stretchers, in a fucking hospital.

What's that Department of Health? Oh, you don't give a shit? Tell me something I don't know.

Oposite them, Dr K and the surgeon are frantically trying to gain intravenous access on a patient. This man has been shot through his chest, possibly through his heart/aorta/lungs/trachea/oesophagus....blood pressure is dropping very quickly and things are looking pretty grave over there...

I notice the medical intern at the back of the room struggling to intubate one of his patients in severe respiratory distress...Looks like that's where I'm needed most, so I make my way over to help.

However, my efforts are thwarted by the head nurse who thrusts a fat folder into my hands and tells me that there is an old man having a heart attack in the waiting room. ARGH!

Sorry little're on your own.

As expected, the old man is of the Kentucky Fried Chicken-loving kind, and I can see the nicotine-stains on his teeth. According to his clinical symptoms and ECG he most definitely is having a heart attack.

By this time the resuscitation on the lady on the floor has been called off.
We couldn't save her and she couldn't save herself. Call the family. Break the bad news and move her out of there. My heart attack guy needs a bed in resus so that we can initiate treatment and try to save what's left of his myocardium, so that he can get to work on destroying that too .

As I wheel the old man into resus the gunshot wound patient is being wheeled out of resus to the trauma theatre...
He doesn't make the few metres to the operating table, and goes into cardiorespiratory arrest in transit.
All efforts to resuscitate him fail.
I wonder why he got shot? Was he the bad guy or the good guy? I suppose it doesn't really matter..

I stabilise Heart Attack Guy ( we speak about our patients in terms of their diseases, rarely bothering to learn their names) and hand him over to the medical team.

What a start to the shift! As I walk out of resus and back into the front room I am confronted with a warzone.

The front room looks like it has been the site of a recent explosion, people shouting, people wandering around aimlessly, people crying, people everywhere.

In five years time I am gong to have post-traumatic stress disorder and then I'm going to have Vietnam-war-like flashbacks to this moment.

I am immediately cornered by the staff from the ambulance vehicles who have brought us five patients involved in an MVA. Where in God's name are we going to put these people? As I wearily start accepting the patients I hear the door creak open to reveal the paramedics wheeling some more people in on stretchers.

Doesn't it ever end?

Despite the ambulances dropping off new patients, there are still about twenty unseen patients names in the book from the previous shift. Some of them have been here for more than six hours waiting to be seen. They are scattered all over the front room. standing, sitting, lying on the floor. There are no more stretchers available and the super-intendant is taking forever to close the hospital despite being at full capacity. I secretly want to curse the previous team for leaving us with so many to see, but I know that they were just as busy as we are and that I can't really blame them.

A little while later I hear a commotion in the corner, and look up as the police escort two violent psychiatric patients into our unit for assessment. While trying to wrestle them to the ground, the policemen are sending impatient looks our way as they wait for one of the three of us on for the night to sedate the patients so they can carry on with their jobs. I ignore them.

Almost immediately some traffic officers join the party and escort in three drunken drivers for blood alcohol testing. I most definitely ignore them.

Christ almighty I'm seriously hungry. Not sure when I'll get a chance to eat.
While contemplating how many patients could have been seen in the time it takes for me to eat supper, I notice an old demented granny using the dustbin to poo in.
After I shouting at her not to do so she stops, mid-poo and trundles back to her bed...dripping the rest of the interrupted evacuation in neat little puddles on the floor behind her.

I have suddenly lost my appetite.

Straight ahead lies an epileptic patient who is confused after having a seizure. He promptly whips out his penis to pee on the floor next to the bed. Some of it splashes on the escort of the patient lying next to him and a fight ensues between the escort and the confused epileptic.

Inhale. Exhale. Inhale. Exhale.

I try to comfort myself with the fact that I'm gaining invaluable experience tonight that I probably wouldn't have learned anywhere else.

What I'm actually learning from these patients is how to make the most of one's Friday night:

Get drunk, drive a car, crash and fracture your pelvis. Get drunk, walk through the ganglands alone at night, get stabbed multiple times. Get drunk, get high on tik, walk in the middle of the road and get hit by a car, fracturing you tibia in three places. The fact that you are too high and drunk to realise that your leg is moving in the most sickening paradoxical motion unintended by nature's design is a testament to the analegesic effects of beer. I can feel the pieces of your shattered tibia grinding against each other while applying the plaster of paris. I think I'm going to vomit.

And what about you lady? What lesson will I learn from you? I see that you are lying face down on the stretcher and you have decorated yourself with long curly braids, earrings, and a large knife handle protruding from your back. I assume that the blade is stuck somewhere in your chest cavity. Tell me, what style of knife handle is in fashion now? MUST get myself one of those for the summer.

Luckily for you, the knife gods divined that the blade should only penetrate superficially under your skin so I can proceed to cut the thing out of your back.

Cool! At last something fun to do! we go right on time at 04h00 hours. It's the nightly on-call entertainment, performed by the resident nutjobs.

Settle in y'all ! Grab the popcorn! Tonight it's a gut-wrenching caterwauling ballad from psych patient number 6 of the evening. The verse is an ecclectic mix of beautiful arabic verse sporadically punctuated by "Julle vokken holnaaiers". (you fucking bumfuckers). The chorus consists of her screaming obscenities as we wrestled her to the ground to sedate her.

Furthemore her insane soliloquy is manifested by an interpretive movement piece performed by psych patient number 5.
He has been pacing around the big doctor's desk in the middle of the front room incessantly for the last half an hour.
Round and round and round on a mission to nowhere, wearing nothing but a hospital gown and a cool leather hat on his head.
It's impossible to stop him circling.
I dodge bumping into him for the nth time that evening, as I bend down to take blood from another patient (who is lying on the floor). As I do so,the flesh above the back of my jeans is unintentionally revealed. This sets the psych patient into a maniacal hypersalivatory state, resulting in him screaming at me to:

"sit jou hol weg. Maak toe jou hol! Dis MY hol, net ek kan jou holle sien!!!Die ander mans kan gaan kak!" (Put away your bum! Close up your bum! That's MY bum, only I can see your bum! The other men can go to hell!)

And that's when we rugby-tackled him, stapled a note that said "please abort" to his forehead and injected enough valium to send him straight back to his days as a fetus in the womb. Hopefully his mom would read the note and take our advice.

My sense of humour is nonexistent at this point and EVERYTHING is irritating me.

Even this poor 17 year girl who was depressed enough to try and take her own life by ingesting shampoo, hair gel, and toothpaste.

Even this 20 year old girl with multiple bruises after being beaten up by her boyfriend, and claiming that it was her fault she got hit.

Even the very frustrating fact that the nurses are only taking the temperatures of every second patient and not testing anybody's urine.

Speaking of urine - I should have gone to pee three hours ago.

But I'm NOT using the front room toilet. I don't care that I'll probably develop a urinary tract infection or an atonic bladder from keeping it in, but the last time I went in there, there was a delirious patient pissing all over the walls. And there was runny poo in the bowl.

The night is almost over anyway, I'll just keep it in until I get home and then burn a hole into the porcelain when I do eventually relieve myself.

Soon the new team arrives. I barely make it through the handover ward round, mumbling through my presentations of the numerous patients I don't remember that I've seen...I'm sure the consultant thinks I'm a retard.

Bleary-eyed and hypomanic from sleep deprivation, I stumble through my front door.
How did I get home? Did I drive? I can't remember.

While undressing I discover a huge blood stain on my sock. With no sign of injury to my foot I can only assume that the blood belonged to one of the trauma victims I saw last night.

What the FUUUUUUUCK!?!?!

What other bodily fluids have been deposited on my person that I don't know about?!?!


I scrub myself raw with nuclear waste just to make sure I killed whatever was lurking on my skin.

I then collapse into bed like a boneless toneless fleshy lump. The most I can manage is to open my mouth while my husband feeds me breakfast...

I'm barely alive, but I survived the Friday night nastiness...

Only ten hours till I'm back for the Saturday night slaughter...


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