27 November 2009


(image source)

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.

04 November 2009


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!


01 November 2009

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?