Music is medicine

I witnessed something beautiful last week. As I was leaving work on Thursday evening, very excited about the Christmas weekend ahead, I walked past the psychiatric unit as I do every day. As I came closer I heard the sound of two woman singing – one a nurse and the other a patient. The patient was obviously quite heavily sedated on antipsychotics. The nurse had her phone out and was playing a well known song from which both of them were singing along.

As I stopped to admire the scene, the nurse paused the music and said: “Hey Doc, I hear singing and music is very therapeutic.” Then, without another word, the music was back on and they carried on. I sauntered off with a very big grin on my face, not only because it was the weekend, but because of what I had just encountered. As I strolled home I thought to myself: maybe psychiatry isn’t a lost cause here after all.

Merry Christmas from Holy Cross

Just a quick note to say....

******HAPPY CHRISTMAS******

I am on my way to spend the weekend with friends a few hours drive up the coast. There isn’t a snowflake or red santa in sight. Instead, I have a wilting 2 foot fake Christmas tree alongside several crates of beer, some wine and a little fizz piled high in the boot of Mitch.

Surprisingly, this week hasn’t been too busy. I expect all the “”frequent attenders” have decided that they’d rather stay at home and the drunk boys and their sharpened blades are saving themselves for Saturday and Sunday. I’ll let you know.

Instead of the usual sound of wailing drunk perforated young men, there has been the very similar cry of a man that can’t pass urine. Over two consecutive days I had two young guys who both came in with full bladders, unable to pass a drop (urinary obstruction). I’m not really sure why this was – one had had a serious trauma a few years ago, but it didn’t explain why I couldn’t pass a catheter. I expect both men had had nasty cases of gonorrhoea (or is it Chlamydia – my mind lapses) that has resulted in a spiders web of strictures to the extent that not even urine can pass, let alone a catheter. So, for my first and second time, I cut a hole in their abdomen and inserted a catheter  – a suprapubic cathether. Unfortunately, I didn’t have quite the right tools, so had to improvise. You should have heard the wails and screams – imagine having a full bladder and then having some smiling guy in a white coat putting even more pressure on it as he attempts to make a hole to free the urine. Of course, I had anaesthetised the skin and given them both some heavy opiate pain killers (the second a little more after seeing the reaction of the first guy), but the analgesia didn’t quite do the trick. However, both procedures were over in no time at all – the second was slightly messier and I ended up with bloody urine all over my shoes. After taking a much needed call of nature (with a little assistance from myself), both gents had an amazing look of relief on their face. They were very happy customers indeed.

As it happens I have seen a few smiles this week – one of my patients that I admitted back in October who I thought was going to die from a serious HIV related fungal infection around the brain (cryptococcal meningitis), is now smiling and laughing.  She’s coming to see me every month and looking stronger and brighter at each visit. What a lovely Christmas present.

The moustache has now left us - a christmas present from me to you. I do miss it though.

Lesotho snaps

Waking up with the village



The chief and his family (the chief is the old guy at the back on the left)



A brief stop on the only piece of flat concrete in miles around - a bridge

....more photos to come; the internet connection at Holy Cross timed out

Around Lesotho with a washing machine

Another weekend on call is looming. It feels like I only just finished the last one. However, I think I can forgive myself for thinking this as currently we are all working every other weekend. Spending twelve days straight at the grinding stone with three days off in a constant cycle makes my brain go a little fuzzy. Hopefully the fuzz will clear once more docs arrive in the New Year.

Before I carry on with tales about my weekend jaunt, let me just give a brief synopsis on some of the events of the past few weeks:  we had some excellent, eager beaver, students from Cape Town who got their hands dirty for two weeks; I now have a cleaner – she’s called Princess – my house was slowly developing a nice layer of dust before she arrived; I have a washing machine – no more hand washing thank you; I have started digging a garden – with any luck in the next two months I shall have tomatoes, onions, courgettes, herbs and some pansies; Mitch smells of diesel and beer; the work load is noticeably getting heavier in this festive season - plenty of boys post ritual circumcision are coming in with septic members, my paediatric ward is getting very busy and the number of booze related injuries are on the rise; I successfully managed to use the power of talking to calm a psych patient down; I’ve been to see my “KFC” guy who’s face I sutured – the wound is coming along nicely; I grew a moustache; I noticed a definite rise in the number of children crying when I tried to cajole them into being examined; I shaved my moustache; the children don’t seem so afraid of me anymore.

Just in case you wanted to know how my poorly updated log book is going, here is a quick summary: In November I documented 27 spinal anaesthetics, 1 vacuum delivery and 9 intubations. Already in December I have logged 11 spinals, 10 lumbar punctures, 4 evacuations of retained products of conception, 1 vacuum delivery, 1 chest drain and 6 pleural aspirations (thoracocentesis). I have stopped recording the amount of joint manipulations and reductions, wound suturing and other common tasks – partly out of laziness, partly because I forget.

So, why does my car Mitch smell of booze and fuel? A question you may want to ask the minister responsible for the roads in Lesotho. Last weekend my Dutch compatriot, Jelleke, and I embarked on a weekend jaunt in the small country of Lesotho. All week the weather in Holy Cross was absolutely fabulous, but as the weekend approached, so did the rain – and oh did the heavens open. Fortunately, rain is no problem when you’re driving a four by four like Mitch. Lesotho is only a 3 hour drive from Holy Cross and covers a mere 200 km from East to West. However, now I’ve been there I can only imagine that it takes several days to traverse the country on the uneven roads even if the weather is dry and you have Jeremy Clarkson and his pals at the wheel of their brand new Land Rovers.

Before reaching Lesotho, we stopped off in our nearest commercial centre to get a few provisions and do a little admin. After two hours in town I had acquired a jerry can full of fresh diesel, 30 bottles of beer, which I had put in ice in the cooler, and a brand new washing machine. Yes, that’s right – I took my washing machine to Lesotho.

We had booked ourselves into quite a nice looking guesthouse somewhere in the mountainous countryside that adorns this country. Unfortunately, we didn’t quite make it to that nice somewhere on Friday or Saturday night. As I mentioned, the weather was dreary in South Africa. However, when we entered Lesotho on Friday afternoon the sky cleared to show off the magnificent beauty that adorns this almost untouched land. After taking in the scenery I noticed two things: firstly there are no fences - the land is entirely shared; secondly, the roads are terrible. However, we were travelling in my car – Mitch – sturdy as they come – a bit like a shire horse on wheels. Shortly after realising how shoddy the roads were, both of us thought that the 150 km drive to our intended destination may not be quite as straightforward as we had anticipated. Unfortunately, neither of us had remembered our guide book or a decent map. To hand we had a large road map of South Africa that had a bit on Lesotho and a satellite navigation system that would only tell us if we were on a road or not, but nothing else (I hadn’t installed the Lesotho maps onto it). So, we just looked at the map and “guestimated” that we would make it to a town about 75km away. It turns out that as you drive further into the country, the roads get worse. So, it came to eight thirty in the evening - we found ourselves in the pitch black, but for Mitch’s bright headlights, driving up and down steep “roads” (the satnav called these roads “alleys”. These alleys resembled a track of some sort with very large collections of boulders) at walking pace. Lady luck was with us though. As Mitch rumbled into a mountain top village we were greeted by the usual hoard of children, but also a young guy who spoke excellent English. With no subtlety at all I enquired if the village would provide us with shelter for the night. After a brief meeting with the chief’s son, who was full of festive cheer, he agreed that we could stay in our new friend’s rondavel (round house). In return we offered beer – unfortunately, most of the bottles had smashed on the rocky roads and the jerry can had also taken a small hit. Hence it smells a bit like someone has had a party on an oil rig in the back of Mitch.

Except for an irate donkey eeyoring at 4am, I had a very peaceful night’s sleep. The following morning I awoke to the quiet sound of the hills and with my dreary eyes took in the beauty of the surrounding scenery as the bright sun beat down on the luscious green mountains. After meeting the chief, his slightly hungover son and the rest of his family, we said our farewells. Not before taking the obligatory family photo, though, which I will send to them in the next few weeks. I am still amazed at the hospitality that we encountered. The young guy that we met gave up his modest house for us to sleep in. It actually belonged to his brother, who died a few years ago. I later learnt that I slept in his death bed – so that’s why Jelleke was so keen to let me have the bed and she sleep on Mitch’s pull out mattress (did I mention Mitch has a mattress in the boot?).

The rest of our trip was mainly spent taking in the awesome scenery and sitting behind Mitch’s dashboard as we drove over mountains in the sun, rain and fog – sometimes all at once. It really was incredible. However, next time we shall plan a little better and take some more provisions and camping gear.

In case of curiosity – the washing machine works just fine. Apart from having to screw a part back in after the bolts fell out, it only suffered a few minor dents.

Bedlam

Here is one for my psych colleagues. As some of you may know, my last job in the UK was spent working for an incredible psychiatric liaison team at King’s College Hospital, London. I have always had a slight slant for the ones that are slightly loopy in the head – psychiatrists and mental health nurses; I enjoy the interaction with the patients too. As a student I spent many a Tuesday evening with a troupe of terribly enthusiastic psychiatrists, terrifyingly good actors and sheepish pupils like myself – but we soon learned the joys of working in mental health and many of our initial fears in dealing with “difficult to handle” patients soon dissipated. Now, you may ask, how can someone who loves dealing with the blood and gore of casualty also enjoy the long in depth assessments involved in psychiatry? True, they may be on different ends of the spectrum, but both are equally exciting and drab at the same time – in the emergency department you get the stab wounds, but also the sore throats; in psychiatry (often in the emergency department too) you see the floridly manic, but also the young teenagers who come in every week having just taken enough paracetamol to get them some attention, but never enough to die (I must say I do prefer it when they take the non lethal dose; also the conversation that is had is much more interesting than that of someone with a sore throat). As a result of all this I thought I was pretty prepared for dealing with mental health out here. How wrong could I have been?

Psychiatry – the talking medicine. Trying to get a medical history is hard enough here, let alone ask about mental health complaints. The culture and language is so different. Did I mention Xhosa is full of clicks and clocks of the tongue? Now, I am slowly learning this tongue, but at the moment my vocabulary consists of about 40 words and only around 4 of which are actually understood by my patients. According to them I still can’t pronounce the word for “cough” properly. They just give me a vacant stare and turn their head to look at the nurse who repeats exactly what I just said, but with a little extra fairy dust. This magic twist of the tongue turns my patient’s confused frown into a nice verbal response. Unfortunately, I often can’t understand what their reply is. And so, the process reverses as I turn to my nurse with a look of “what did they just say?”

I have quickly learnt that we don’t do too much talking to our patients here that are referred to as: “Doc, we have a mental case – can you prescribe some intravenous sedation?” The first time I was asked this, my initial reaction was – no way, let’s try and de-escalate this situation in a nice step wise manner – I have done a job in psychiatry don’t you know. So, let’s talk first. Plan “A” failed at the starting block when I found 3 security guards sitting on my “mental case”. One guard was gently pushing his foot on the patient’s neck (they had just zapped him with a taser). I didn’t like this one bit and kindly asked the guards not to antagonise our patient any further. Talking didn’t work when I remembered: “Oh yes, I can’t speak Xhosa. I can’t even pronounce Xhosa properly. Silly me.” My nurses weren’t very keen on opening any kind of dialogue so I offered him some oral medication to calm him down. Eureka – he happily swallowed down the cocktail of benzodiazepines and antipsychotics. Half an hour later, he was still causing havoc. At which point my boss showed up and said: “don’t bother with that, just give him the stuff intravenously.” Despite initially objecting, I caved in – the patient got his shot and quickly dozed off into la la land. This had taken about one hour of my time. I have fast realised that we don’t have the luxury to properly give our full attention to these patients, or any patient for that matter. When there is only one of you in casualty and several other people also needing your urgent undivided time, all one can do is temper the situation (and try to stop the security guys from using their taser). This often means heavily sedating our psychotic clients as first line treatment, making sure they are calm enough to put the rest of the department at ease but not so chilled that they stop breathing. The talking happens later, at some point.

We see a lot of psychotic patients. I expect most of the cases are drug induced as there is a serious amount of marijuana smoked here. The stuff grows like a weed. Every disturbed patient I have seen so far inhales chimneys of the stuff. Along with these lively characters, there are a lot of overdoses. Many involve similar circumstances to what is seen daily in a UK emergency department – young boys and girls that take a few tablets because they were having relationship issues, exam stress or just a bit frustrated with the normal ups and downs of life. Unfortunately the drug of choice here is a nasty organophosphate pesticide that is freely available. People use it to preserve millet, one of the staple foods eaten by the local population. Just one tablet needs to be taken and it can be game over. In fact, since I have been here I don’t know of anyone that has survived, but we do try as it is potentially reversible if you have the right drugs and equipment. We occasionally have the former, but rarely the latter. The saddest thing is that when you talk to these patients, the awake ones, they often regret what they have done and want to live. There is often little we can do apart from cross our fingers (not quite true, but it does feel like that is all we are doing).

So, that is a brief summary of the wayward state of psychiatry here – the pathology is present, but the effective management is not. The patients that remain on treatment are often on very old drugs that have many, often irreversible, side effects. They are quickly labelled as a “mental case”, which tends to stick for the rest of their life. However, on the up side, many of these psych patients often have a family member or friend that supports and stays with them – I just hope it is because of the love and affection and not the government grant that people with mental illness receive every month. Food for thought, though.

Minor surgery

This is my guy pre op - the picture doesn't quite do justice to how bad the laceration actually was

Post op - you can see he's almost smiling, right? I went to see him today (4 days later) and the wound is healing very nicely.

A Chelsea smile.

I am currently recovering from a busy weekend on call. Most of my war wounds, however, are on my hands and back after spending a little too much time gardening in the sun on Sunday. I have a glaringly red back and a delicious raw blister on my right palm from all the digging. I think I was slightly delirious after an insanely busy Saturday on call and didn’t really think about the fact that I was excavating beds in the midday sun whilst half naked. As I may have said already, there are two of us on call at the weekend – either you run the show Friday and Sunday or you take Saturday – the other Doctor is just on standby for emergency caesarean sections or when your colleague just wants a reassuring hand (I tend to be the one wanting that hand, especially in obstetrics). We only had one c-section on Sunday, hence all my gardening and wounds to show for it.

Saturday was full of fun. I started at 7 am and, with the exception of a 15 minute lunch break and 45 minute lull in the evening, I finished at 3 am. It was nonstop, wet your pants, fun. Here’s a brief summary of some of the more interesting cases: I had a guy who was run over – he had a massive bit of bone sticking out of his right leg; an eight year old boy who’s father slashed open his shoulder – exposing the bone, cutting right through his deltoid muscle – all because he lost their cows; a young drunk guy that was shot in the chest, but who had no obvious injury in his lung or heart; an old drunk guy that was stabbed in the neck – when the nurse gave the wound a clean a large artery, possibly his carotid, erupted and a steady spurting fountain of fresh blood soon covered my arms and white coat as I attempted to tamponade the bleeding (don’t worry mum, I was wearing goggles, mask and apron); a young boy that was thrown off the back of  a pickup truck, or “bakkie” as it is called here, who sustained a terrible head injury and degloved most of his scalp on the left, from which he lost a lot of blood; the usual stabbed up, occasionally belligerent, drunk boys and girls; a middle aged gentleman with severe respiratory distress who’s left lung was engulfed with fluid (pleural effusion) that I drained to his relief; the usual old boys and girls with chronic conditions such as high blood pressure and diabetes that present with the classic symptom of “pain in my neck veins” that get a bit of paracetamol , a sleep over and sent home.

Along with all of the above I saw a 22 year old male who works at KFC (he was wearing his work clothes you see, it’s not something I tend to ask about, but it did mean that his English was rather good) who was stabbed in the chest and face by his younger brother. I had to put a chest drain in for all the blood and air that had built up around his lung (pneumohaemothorax). I’ve only ever put a chest drain in on pig and cow thoraces in courses that I have attended in the past. A fresh human chest is a little tougher than a well hung piece of beef, but without gloating too much, I think I did it rather proficiently without the mere mention of a tremor in the hand or bead of sweat down my brow – probably because I was quite sedated with sleep deprivation at this point. Putting a tube in his chest was the easy part; his face was the problem. The laceration was, to put it quite simply: nasty. It bisected his nose almost in two then proceeded to go diagonally down and extended deep into his right cheek. His teeth and jaw were visible despite his mouth being closed – my doctor sense told me that this wasn’t quite right. Over the next two hours I slowly performed my own kind of maxillofacial/plastic surgery. Fortunately the good people of Flagstaff didn’t bring their next bleeding patient in until just after my work was complete. I must say I was rather proud of the end result – the guy looked good as new and had no functional or neurological deficit as a result of the injury or my “surgery”. I’m becoming a bit of a dab hand at these facial wounds – last week I sewed an ear back on (the girl hasn’t yet returned saying it has come off again or become infected, so no news is good news in that respect). Anyway, the chap was very pleased with the results, and despite the tube hanging out his chest, he kept on telling me “doc, you saved my life.” I asked him what he was going to do about his younger brother – the assailant that did this. The answer was: “Kill kim, I’m going to kill him.” I nervously laughed this off, but I fear there may have been a wince of truth in that statement. If he doesn’t attempt to murder his brother and stays in work, then maybe he’ll give me a good deal on a bucket of chicken if I ever get desperate enough to eat at his stomach churning establishment. My boss saw the wound today and all he could say was: “Beautiful.” This was probably a slight overstatement, but nice to hear nonetheless. I’ll upload a picture of his wound pre and post suturing.

I said that the weekend was fun – it was. However, it is deeply saddening when you see all the victims of violent crime, road traffic accidents and domestic violence. I couldn’t believe the father who put a bush knife to his own son. However, maybe those cows were their livelihood; maybe it was everything they owned. I can see how the dad would have turned red in a moment of disbelief and possible rage, but violence can never be the answer. The gentleman has since been arrested and the boys Mum lives far away. Now this 11 year old has a dysfunctional shoulder, a Dad in prison and probably no one to look after him.

More to come