Wake Up Call

Three recent stories in the news here,  here, and here (somewhat satirically), describe how some people are taking advantage of our high crime rate to make a bit of extra cash at the soccer world cup. Our government is understandably outraged at the suggestion that these "stab-proof vests" are even necessary, and that they are inciting fear. Unfortunately, fear sells.

My opinion is that these are a waste of money, as our criminals tend to be very cunning and skilled, and would not be fooled by these measures. I think if people make sure they are aware of whats going on around them, and don't do anything stupid, and don't drink too much, they should have an uneventful, enjoyable experience.

Is this maybe the wake up call for our government we have been waiting for, that our country is not flowing with milk and honey in all areas, and that we might actually have a crime problem? I certainly hope so..

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

(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.

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!