Dom in South Africa: We keep on trying.

A medical student: ecstatic after two weeks at Holy Cross

The rapper is still alive.

Nosiphe* was brought in by her mother barely breathing. She is thirteen years old and has been in and out of hospital with asthma for the past six years. Her mother said that over the preceding three days she was having some shortness of breath and wheezing, but little else. She lay there on the gurney in casualty struggling to get oxygen in and out of her lungs because her airways had constricted as a result of an acute asthma attack. By the time I saw her she was exhausted and starting to give up: she had the worst case of a life threatening asthma I have ever seen.

What normally comes to mind when I think of an acute asthmatic is breathlessness, wheezing, a fast pulse and a very uncomfortable looking individual. Nosiphe was the opposite: she was barely breathing, her wheeze was minimal and very protracted, her heart rate was slowing down and she was barely rousable. These are all signs of what I like to call: impending doom; if you don’t act fast, there will be nothing left to act on as your patient will be dead. So, we wheeled her into our resus unit and I intubated her. The problem with an asthmatic like this is that because her airways were so tight and constricted, trying to get air in and out of her lungs was a real chore. One can see why someone suffering with this ailment gets exhausted very quickly. We gave her a whole host of drugs to dilate the airways and kept her on the ventilator overnight before transferring her in the morning to our referral hospital.

***

The past two weeks have been extremely interesting, especially from the emergency medicine point of view. As I may have mentioned before, the emergency department is what gets my juices flowing. Admittedly, here it is not quite as sleek and efficient as back in the UK and the team work can be very inconsistent. It all depends on who is staffing the department – some of my nursing colleagues take more of a “step back” approach, or interpret my call of: “Can I get some help here,” to: “I think the doc is ok, shall we go for tea over the road or go get that thingy from theatre that someone wanted yesterday.” However, most are excellent and do help, although I expect we look like a bunch of headless chickens a lot of the time – running around trying to find the right size airway or the connector for the oxygen supply.

Charred to a crisp - the girl who fell fitted in a fire.

Nosiphe’s story is just one out of the hundreds we see weekly here. However, I doubt I will ever see a case of asthma like that again; it is the stuff you really only read about or simula te in teaching scenarios. In addition to Nosiphe’s case, I attended to a girl in her twenties who was found fitting in a fire. The entire left half of her body was covered in full thickness burns and her face was charred to a crisp: all the nose hairs were burnt, her eye lashes singed and there was soot in her mouth. For those that don’t know, this is when the alarm bells start ringing as it may mean that the patient has burnt their airway, which can swell up and occlude the wind pipe. A very unpleasant experience I’m sure, but fortunately it didn’t happen. We stabilised her and carted off the poor girl to the tertiary burns unit. I spent the rest of the day with the smell of charred flesh on my hands.

The burns girl came back a few days following transfer with a very upbeat discharge letter: she died two days later. Why, I don’t know – possibly due to sepsis or dehydration. With full thickness burns one loses the body’s main defence against infection: the skin.

Fractured cervical spine -
C5 body (ignore the small chip)

So, as well as a life threatening asthma and burn case, I tended to a man who had fractured his cervical spine; a boy with diabetic ketoacidosis, which is now a lot easier to manage since I introduced a protocol for it (although, this week we have run out of fast acting insulin and glucometers to check the blood sugar - not ideal); a young man with spontaneous bacterial endocarditis and plenty of sick children who come in on the brink of death thanks to all the enemas their Gogo (grandmother) has given them. It has also been a week for putting needles into hearts: we have had two cases (one adult, one paediatric) present in extremis secondary to a large collection of fluid around the myocardium. A slightly nerve racking procedure later (pericardiocentesis) and hey presto: the patient is a hundred times better. Both are now on the ward and doing well.

All this emergency stuff has been gripping, but the bulk of what we see is all HIV and TB related. Both patients with fluid around the heart were caused by TB. This past month, however, has been tough. Our referral unit has been on a skeleton staff – nurses and administrative staff have been striking over pay and people have died as a result. One of our patient’s who was referred, a toddler, died after some folks, dressed in white coats, ran through the ward, chased out the nurses and removed the oxygen from the little one: absolutely horrific and completely unacceptable behaviour. The strike is also the reason why we are without essential medicines such as insulin. I must say, I can be pretty useless without my tools – what good is a diagnosis if you cannot do anything about it.

A bad case of shingles in an HIV positive girl

A young HIV positive boy with warts throughout his oral cavity.

A left occulomotor nerve palsy (cranial nerve 3)
in an HIV positive patient with TB meningitis - a dilated left
pupil, a "down and out" eye and a ptosis (drooping) of the left eyelid.

***

Apart from all the gloom with the strike, which is just about coming to an end, I am starting to fall in love with this country. Why? I do not know. For all the troubles one sees, there is a real smell of hope and optimism in the air.

***

As a side note to the opening story, Nosiphe didn’t survive. I expect she was without oxygen for too long prior to her arrival at Holy Cross – she died a few days later on the intensive care unit. If only there was a better transport system and emergency ambulance service, she may have lived.

*Nosiphe – this is not her real name.