Carnage

Every year we get news reports updated almost daily of the numbers killed on our roads in South Africa over the festive seasons (usually April and December). This morning's figure stood at 840 deaths since the beginning of December. This has the ability to dampen the mood of the Christmas season as I think about how many people will be experiencing unexpected sadness instead of the joy that Christmas is supposed to bring. This always brings to my mind a few questions / things to think about.

Firstly, this is a large number, and is horrific, but how does it compare to the rest of the world in eg. deaths per 100 000 population? I have no idea. Ours is 21.96 per 100 000. We have a population of officially about 45 million (but probably more) of which I would estimate at most only about 2 to 3 million (but probably less) own a car and drive.

Secondly, how many people are injured non-fatally? This I'm sure would be an even scarier statistic!

Thirdly, how do these months of the year compare to the rest? Working in a hospital one is definately aware of the increase in workload, especially assault cases, that go with any public holiday / festivity / end-of-the-month-weekend, as a direct result of alcohol consumption, and therefore most of us try our utmost to avoid these shifts! But if I think about it, the number of motor vehicle accidents are much the same as at any other time of year. I have never seen any statistics, and could not find any at the department of transport, for deaths on the roads "out of season". I did find some figures from the Arrive Alive website which showed 14463 fatal accidents in 2008, which if you divide by 12, suggests there are a little over 1200 fatal accidents on our roads every month. This would suggest that this festive season is better than the rest or the year!

Forthly, alcohol is a major causative factor in road accidents, but I believe not in the way everone thinks it is. It is always reported in the media how many drunk drivers have been caught / arrested / fined. I think they are missing the mark. I think the traffic department is using statistics from other parts of the world and wrongly applying it to our situation. The vast majority of road accident victims I have seen when on duty in South Africa  have been drunk pedestrians - knocked down by sober drivers. I believe it is here that the bigger problem lies. The traffic police / Arrive Alive campaigns are focusing on the wrong area. Yes, I agree drinking and driving is a big problem, but drinking and walking is a far bigger problem! The only forensic blood alcohol level tests I have had to do in A&E have been on drivers involved in minor bumper-bashings. Maybe this is just my experience.

I can think of a few reasons other than drunk driving that are also significant causes for the carnage on our roads.

The majority of our population use public transport, of which the majority is probably unroadworthy, and usually drastically overloaded. It is not uncommon to see a bus moving in a way I like to describe as "crab-like", where the rear wheels do not line up with the front wheels, and minibus taxi's designed to carry 16 people, carrying 30 or more. When one of these crashed in my hospital's area, there were often reports of up to 10 dead in one accident!

Deteriorating roads is another cause of concern. Generally, our roads are still in good shape, but over the past 10 years I have noticed an ever increasing rate of decline in the state of our roads. They get repaired, but the repairs don't seem to last very long. I am sure this is and will become more and more important.

Fifthly, today is the 28th of December. A lot of the people travelling the roads of our country are those migrant labourers working in Gauteng, but who all go home to their families in Mozambique, Zimbabwe, and the Eastern Cape for Christmas. If 840 of them died going home, how many will die coming back to work / back form holiday in the new year? This will be in January, and will not be reported in the statistics.

I suppose what I'm trying to get at is, to avoid becoming a statistic, we all should drive carefully, no matter what time of year, make sure our vehicles are roadworthy before we leave, pick the best roads, avoid the busy times, and don't drink and drive.

Differences

I recently was involved with a case of Boerhaave syndrome. This was only the second one I have seen, and I was struck by the difference in the way this patient was managed here, in a first world setting, compared to back home in South Africa.

Here, he came in to the A&E with chest pain after vomiting, after a night out on the town. He was was scanned, resuscitated, intubated, bilateral chest drains inserted, and referred for thoracotomy and repair, all within a few hours.

Here are a few of his pictures (sorry about the poor quality). You can clearly see the pneumomediastinum (air where it shouldn't be in the chest), partucularly circling the oesophagus, and bilateral pleural effusions (fluid where it shouldn't be in the chest - in this case stomach content).

 

Back home, she came in with a practically "spontaneous" oesophagus perforation secondary to severe oesophageal candidiasis (thrush) causing ulceration, with underlying stage IV AIDS. She was admitted to the ward on a morphine infusion to await the inevitable.

Survival

Sometimes our patients survive, despite our best efforts.

I was reminded of a remarkable patient I looked after a while back. I use the term "looked after" in it's loosest sense. He was a resident in my ward for a while, and I made conversation with him everyday while he was there. And didn't do much else.

He was a young man, who had gotten in a fight, and had been skewered by an assegaai as a result. It had entered just to the right of his sternum, and had exited in the right flank. His GP had removed it at laparotomy, but didn't have the experience to sort out the damage, so placed a drain and closed up. He had then referred the patient across the border to me. Referral in his case meant he was given a letter, put in an ambulance with his passport, wished good luck, and told to find a hospital in South Africa that would treat him.

When he arrived, he was already a few days post laparotomy. He was admitted because our hospital had some sort of cross border arrangement with where he had come from. This created a difficult situation for me, as I was the most senior doctor working in the surgical department at the time, and I definately did not have the experience to tackle this.

He was draining bile from the drain in his right flank, and from the entrance wound in his chest. We placed stoma bags over these, and monitored their output. This made it look like we were doing something. His CT scan showed a large, 2cm diameter tract right through his liver.  I tried unsuccessfully to refer him to a bigger center, or find a surgeon for him, but none of them would have anything to do with him. I tried all the local guys, but they were either not interested, or were away, or there were other politicians obstacles standing in the way. Try as I might, I couldn't work a deal for this guy.

A month passed of me making idle conversation everymorning, and checking the colour of his drain content. He patiently listened, with no sign of disapointment, to me relate my unsuccessful efforts at finding a solution to his problem. Then one day one of the interns pointed out that the hole in his chest was much smaller, and had stopped draining, and the one in his side was also draining much less. A week after that, and it had stopped too.

Unexpectedly, he did not develop jaundice, or any kind of obsrtuction. He was eating well, and had no complaints anymore. So I sent him home. He left smiling, and thanked us for all we had done for him!

On day one I would never have imagined this outcome, or even thought of managing it conservatively! Sometimes I am truly amazed at how the body is able to heal itself.

Expect the Unexpected

Leaks in the anaesthesia circuit are relatively commonplace. For this reason we run through specific tests of the machine and ventilator to check for any faults at the start of every day. Even so, leaks still occur.

The most common culprits in my experience are a faulty ETT cuff, or inadvertent disconnection of a pipe from the machine. These are the easiest to identify, and therefore the quickest to correct. If the situation arises that the leak persists even after these have been checked, it can lead to a bit of anxiety for the anaesthesist with a sleeping, non-breathing patient in your care.

For situations such as this, we all have a specific routine to search for, and identify a circuit leak ingrained into our subconscious. There is no time for panic, the leak must be found and plugged (so to speak) as soon as possible to keep the patient breathing.

I recently had to deal with one of these unpleasant situations.

I had checked my machine at the start of the day. Nothing roused any suspicion. I had already used the machine without incident for a couple of patients. I induced the next patient, and hooked him up to the ventilator. It gave the first breath, and then failed to re-fill as expected, and so had no gas for the next breath! This tells me that there is a leak, and it's a big one. I checked the ETT cuff, no problem there. I checked the circuit, no obvious disconnection there either. I increased the amount of gas delivered to the circuit. Thankfully this gave my patient an acceptable short term tidal volume, and bought me some extra time to identify the problem.

I ran through my usual routine. I checked the pipes and bag for holes, no problem. I checked the ventilator housing box, no leak there. I checked the sodalime canister was fitted correctly, it was. I checked that the switch on the front was set to the circuit and not the auxillary gas outlet, it wasn't. I still couldn't find the leak.

I ran through the checks for a second time. When checking the sodalime canister again, I felt a breeze against my arm, and then after a few seconds, again. I followed this intermittent draught, and found a crack in the bottom of the sodalime canister! Of all the places! No wonder I had had difficulty finding it!

I plugged it with my finger and sent a nurse to fetch a new canister. I replaced it, and everything returned to normal. Crisis averted.

I think someone once said: "Always expect the unexpected".

As it turns out, the nurse I had sent to fetch a new sodalime canister was surprised when I asked her, as she had only just replaced it, before this case.

Technology

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Technology has the power to amaze. There are always things being invented and improved on that I would never have thought were needed, or needed to improved upon. I suppose this is the inevitable course of progress, and the result of good marketing. Convincing someone they need something they never even thought or would have imagined even using before. All in the name of profit progress. Herewith an example of such an invention.

I was called to the ER to help with the resuscitation of an elderly man who had been a victim of "collapse". I was needed to manage the airway as (in this country) this is the realm of, and only of, the anaesthetist.
I was amazed upon entering the resus room in the ER, to see an alien spider-like contraption straddling the patient, and very efficiently thumping his chest. I had never imagined, never mind seen anything like it before. I felt as if I was Dr Spock entering a set on Star Trek. It even made futuristic pneumatic type noises.

I tubed him and hooked him up to the ventilator. He was then on what I could call fully automated, synchronised CPR. The only medical person making contact was the ER guy checking pulses every 2 minutes and injecting the required drugs (according to the ACLS protocol), while the rest of us stood around and watched in amazement.

After some time, the clerk arrived with the patients old hospital chart, and joined the line to watch the events unfold. It turned out that the patient had prevoiusly signed a DNR due to his age and heart condition, but no-one there had known this. After 65 minutes in total, it was decided that everyone had seen enough of this new machine, and the chief ER guy decided it was time to stop.

To our surprise, when it was stopped, his pulse returned, and stayed there! Irregular, but palpable. I admitted him to the ICU, expecting him to slip slowly into eternity during the night. He didn't. I extubated him the next morning, and was fascinated to find no obvious neurological deficit (this is almost a certainty even after 30 minutes of ordinary CPR, with the exception of cases of hypothermia or drowning). This was a most unexpected, but welcome outcome.


I couldn't help think that this machine would have been of great help back home in one of those one man resus situations that tend to occur every now and then (when the nurses all take tea at the same time).
I think every theatre, ward, ER and ambulance should have one, and store it next to their defibrillator.

It's only disadvantage is that it would encourage the perpetuation of obesity among nurses by removing the only bit of compulsory exercise a lot of them get.

I should state that I have no conflict of interest. I was just utterly amazed by the efficiency of this apparatus.

Bewitched

I was reading some posts on magic here and here, and was reminded of an unconventional cure a family medicine lecturer related to us while still at medical school. He had developed it, in his time as a GP, for what is a common ailment in some South African cultural groups - "snakes in my belly".

The typical case is a rather anxious patient of either sex, who presents with usually a chronic sort of abdominal discomfort. They will describe a feeling of "snakes moving around / wriggling in my belly", similar to mild cramping I suppose. There is usually no vomiting (other than attempts to purge themselves), and no diarrhoea. There is seldom any pain. On further questioning, a strong suspicion or belief of being bewitched or having had a curse put on them for some reason is often apparent. On presentation, they will usually have tried some remedies of their own, including purging by drinking warm salt water, or using home made enema cocktails, often made with dishwashing liquid. All considered, I would compare the symptoms to those of the "western medicine" diagnosis of irritable bowel syndrome.

Of course, all organic causes should be actively investigated and excluded, and the patient should be de-wormed. Conventional treatments for irritable bowel syndrome could then be tried, and sometimes had some success. When this failed, my colleague would attempt his cure, described as follows:

The patient would be given 3 litres of oral contrast to drink as for a barium meal. Abdomial x-rays would be taken, and showed to the patient, with the offending snakes visible for all to see! The patient would then be given methylene blue or similar to take for 2 weeks. This would "draw out the toxins", and they would then appear in the urine, turning it blue-green. The patient would then come back for a follow-up appointment, and have their x-ray repeated after 3 litres of water to drink this time. The x-rays would then be shown to the patient, showing the snakes had gone, and he/she was now cured!

Magic!

Post Exposure Prophylaxis

While on the topic of HIV, I was reminded of a patient I saw a couple of years back, and an ethical dilemma.

A young man arrived in my casualty on a Sunday morning. He wouldn't tell anyone what was wrong, but wanted to speak to the doctor (me) privately. This sort of thing does happen, and usually relates to something urological.
When his turn to be seen arrived, I asked why he was there. He then proceeded to relate his situation, which was causing him much anxiety. He had the previous night engaged in extra-marital relations with a girl at a party. Only this morning had he heard from some friends that she quite a reputation for her less than ideal morals. He now wanted me to provide him with anti-retrovirals to prevent him from getting HIV.

I told him that that was not hospital policy, and therefore was not possible. I told him that if he still wanted to persue the subject, he should bring in the girl, and his wife, and I would test them all for HIV, and we could then take it from there. Thankfully, he declined, thereby saving me the difficult decision of whether to provide them to him or not. He didn't want to tell his wife what he'd been up to - pretty selfish I'd say, worried about getting HIV himself, but not about passing it on to his wife! (I have written about this attitude before)

He left me with some interesting questions though: (some of which really put pressure on my ethics training at medical school!)

1. We provide the "morning after pill" to prevent pregnancy, which is a life altering complication of poorly planned sexual relations.
2. We provide PEP (post-exposure-prophylaxis, ie. anti-retrovirals) for occupational exposure to blood or body fluids, and rape cases, and for mother to child transmission. In all these cases the recipient can be described as an "innocent" victim.
3. The man in this case made a bad decision (as in the situation of (1) above), but is not an innocent victim - he had time to think about what he was doing and took a calculated risk, but could have made a better choice. Is he then also entitled to PEP as it is also a life altering complication of his mistake? Should we now condemn him to a life living with HIV?
4. If we provide PEP to people in this situation, will we not reduce the spread of HIV? (admittedly, other sexually transmitted infections (STI) would still run rampant, but isn't this still a better alternative?)
5. If we start providing PEP to people in this situation, will it lead to an alternative to, and therefore a reduction in condom usage? This would then cause an increase in the incidence of other STI's.
6. The side effects of these drugs can be severe, and the compliance is poor (at least it is amongst my colleagues who have had to use it after needle-stick injuries). Would this lead to more resistant strains of the virus). I suppose you could argue that the side effects aren't worth providing the drugs everytime you have intercourse, but what if it's only "every now and then"? And you could argue that it's a small price to pay to avoid living a life with HIV?
7. Also keep in mind that there aren't even enough of these medications available to treat everybody already infected with HIV.

What do you think? Would you have given them to him?

Stigma

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This week our president made some of the first positive statements I have heard from the government regarding the AIDS epidemic in our country. Hopefully this will mark the end of the denial phase in the process of grieving for our country's slow death from HIV. I pray that now, as our country must inevitably move through the rest of the stages, that we will come to accept that AIDS is here to stay, and then move forward in developing strategies to fight it's rampant spread. This has been a long time coming.

You may ask what is fuelling this rampage? I have some ideas, and although they are not by any means a comprehensive list of all the factors, I suspect them to be some of the major role players. The stigma surrounding HIV, and denial of it's existence (supported by the government up until now) and the belief that "it will never happen to me" lie at the heart of it.

Why is it that a patient will come to hospital (or even bring their infant or child), and then not want to find out what is wrong with them and refuse treatment? Why seek help in the first place?
The prevailing attitude is: "If I dont test myself for HIV, I dont have it, and I dont have to make any lifestyle adjustments."

I am of the opinion that HIV is no different from other chronic or terminal illnesses. It's survival rate is comparable with that of ischaemic heart disease and diabetes (untreated, you may have HIV for 5 to10 years before developing any symptoms), and is better than most forms of cancer! The difference is that it is infectious, and you have to make adjustments to your lifestyle to avoid giving it to others (ie. stop sleeping around). This is the hard part, giving up the risky behaviour, and the topic for another post.

I am also of the opinion that the stigma is no different from syphilis, or TB. Why is it then that these are notifiable diseases, and HIV is not? I think that this is the first step to de-stigmatising the disease - make it notifiable, and bring it out into the open. Let clinics, employers, insurance companies etc. test people routinely. Changing the existing HIV testing policy (VCT) from an "opt-in" to an "opt-out" type process (as suggested recently by some Western Cape Health Department MP's) would be the first step. With the prevalence then revealed, it would be very difficult to discriminate against those infected with HIV, as I suspect the incidence would be much higher than expected. (The antenatal prevalence is 29% in our country, and I believe this reflects the working population). This is the best way to increase awareness of the seriousness of the disease, and get people to start thinking about the risks they are taking. Infected individuals would, with the knowledge of their status, be able to access treatment earlier, and therefore most likely live longer and healthier. Their partners would be able to take proper precautions too, and reduce their risk of infection.

Everybody wins.

Eavesdropping?

When one of my patients is emerging from an anaesthetic, I often ask them to open their eyes as confirmation that they are awake before moving through to the recovery room. I never really wondered before what their level of awareness might be before this point.

A patient came for a routine incision and drainage of an abscess, and recieved a routine anaesthetic for the procedure. The whole process was completed uneventfully. As the surgeon was about to place the dressing, a nurse pointed out to him that the particular dressing he was using was inappropriate, and suggested another (as she had previously been a rep for a company manufacturing dressings, and knew what she was talking about). The surgeon changed his mind, and used the suggested dressing. When this was done, I closed the gas and woke the patient.

The next day, the nurse sought me out to tell me that the patient had thanked her for suggesting the alternative dressing to the surgeon! The patient had heard, and remembered every word of the conversation! I must say, I was taken aback.. to my eyes the patient had been asleep, there had been no signs of possible awareness, she had not even been breathing on her own at the time (no muscle relaxants were on board) and this implied a deep level of sedation! (In addition to my usual approach wherein I tend to give more of an agent rather than less - this is the first such case that I know of in one of my patients). The nurse re-assured me that the patient had not seen it as a negative experience. I assume therefore that she must thankfully have had an adequate level of analgesia. Unfortunately, I didn't get a chance to talk to the patient myself.

This led me to wonder how often this happens? Maybe more often than we think, and the patients just never say anything? How many and how much of our conversations are they actually evesdropping in on? Thats quite a scary thought...

Maybe I should play them some music, or maybe I should start using the entropy monitor more often...

A Beginning

For some  time now I have been reading and enjoying blogs. I have found them to be informative, entertaining, encouraging, and a number of other similar adjectives. I have on occasion thought 'that happened to me once', and 'thats a good idea', but never thought to start writing myself. Recently, I read about the blogworld expo, where Dr Val would be moderating a panel on the topic 'Blogging for  change: How to influence healthcare through blogging', where a friend of mine would be speaking. Also, recently, I was listening to an interview with the same friend here, when he made an interesting point. He was asked if he knew of any other medbloggers in South Africa, and he said he didn't.. This sparked a thought - how can we effect change in our health care system through blogging if there are so few here! I decided I needed to start writing, so that maybe, on the off chance that someone of any importance stumbled across these pages, they might be enlightened to the plight of a South African doctor and his patients.


First off, a little about me. I am a medical doctor, with experience in the state and private sectors in South Africa, and more recently in the first world. I have spent the majority of my time working since my community service in what felt like a deeply rural hospital (and was staffed like one), although it isn't.. it is a referral hospital, for rather a large area. At this hospital, I spent my time split almost equally between surgery (daytime hours), and anaesthetics (after hours). I am currently looking for a post to begin specialising in surgery. I will let you know what happens in this regard in due course..


Secondly, my intentions for this blog:

1. I believe I have a rather unique viewpoint from inside the operating theatre, in that I have experience from working on both sides of the so-called 'blood-brain barrier', sometimes even at the same time, and that this would make for some entertaining reading.
   
2. It is a way to share interesting experiences, ideas, and case studies, and sometimes even give some advice I myself would have liked to have had.
3. It is a means to de-brief, and even 'rant' if necessary.
4. It is a place to share successes/ failures/ joys and frustrations.
5. My wife has a blog, and I need to show her I can do it too.
6. And lastly, I should be studying, and this is another means of procrastination.

There, thats it.. a beginning..