Almost Over

I'm going to miss this view.

One of the four preterm (2 twins) babies that I delivered last week.
 This one is shaking my hand after a particular rough ride.

 

HIV is just the most ghastly epidemic. One would think that maybe I’d have become used to its woes by now, but no – everything is more acute; it makes me question my own mortality far more than I ever have. Each day I encounter at least one devastating case of a young girl or boy; someone who should be full of energy and exploring who they are, completely crippled. I am always amazed by how much people age. Just the other day I saw two girls, one 19 and the other 21. Both looked well into their 40’s, and very sick forty year olds at that. Their eyes were full of despair and absolute exhaustion. I try to stop myself thinking too much about each case, but sometimes my mind drifts, and it is easy to do so. As I sit there, while the nurse translates the history, I find myself looking at the young person before me and think: that could be me; it could be any of us. We all know that condoms are very effective at preventing the spread of HIV, but how many times have you decided not to use one? To start with, you need to have them freely available. Anyway, this isn’t about my sexploitations, but about the ease as to which this virus can be spread and how easy, in theory, it could be to stop. I’ve just finished a book entitled: “The Wisdom of Whores,” by Elizabeth Pisani. It is an extremely well written piece, deeply moving, but often light-hearted, analysis of HIV and all the demons that surround it.

***

I am now halfway into my last ever weekend of work at Holy Cross Hospital. As I mentioned, last Friday, Saturday and Sunday I was the boss. It turned out to be a really quiet shift in casualty: no stabs, no sick babies, no bleeding orifices - all in all, very good. However, maternity was a different story. I ended up performing six caesarean sections. The privilege that we as doctors, midwives and nurses have of being involved in child birth really is special, and I cannot help but smile each time I coax a baby from its mother’s womb. However, I shall be honest: I will be quite happy if I do not have to do any more C-sections ever again. They can be a nerve racking affair, especially when the uterus bleeds, and boy does it bleed. Although, as of yet I haven’t had any problems stopping the bleeding, even when I severed the uterine artery on one occasion a few months back. The main reason I don’t fancy doing more of these procedures is because I am grossly under-qualified. This shouldn’t be how a healthcare service is run, but without my dubious skills over the weekend, the mothers would have had to make a long journey to our sister hospital. Without money or transport, this can be impossible and the ambulance service, as I have said before, is useless at the best of times. So, that is why I do cut: there isn’t really another option, and so far nothing has gone wrong. I take my time, think about my next move and try not to slice anything but the uterus.



Blood stained trousers after a busy weekend.
 Good thing I always wear my trauma goggles.

So, I said last weekend was rather quiet in casualty (it should have been busy – it was pay day); last night was a very different story. I feel as if the community know it’s my last weekend, so they are throwing me as many assaults as they can. As morbid as it sounds, I really enjoyed the trauma I encountered last night. There is often a sense of instant gratification as you can literally save lives there and then. Within the space of an hour a young man had been brought in with multiple gunshot wounds – at this point I was busy performing an assisted delivery with a ventousse (vacuum) on a stubborn baby who came out very flat. I received the call just as the little one popped out. I ran the new born to the resuscitation room, kick started him into breathing and then left the midwives to kindly clear up the mess I had made (my blood stained trousers are evidence of this) and repair the episiotomy I made. When I arrived in casualty, the man was on oxygen (this still impresses me – last year it would take 30 minutes to find an oxygen mask), the sisters were putting in two large IV lines and…… oh, he wasn’t breathing: he was dead.  There really was little I could do (this is the point when I don’t enjoy my job and there is no such instant gratification that I just described). He had been scatter bombed with bullets. I’m no ballistics expert, but this is how I think someone must look if they were shot at with an Uzi. His entire family were there watching. For a second I entertained the idea of cardiorespiratory resuscitation, however, there was another very sick gentleman in the next gurney who had a chance of life and there was only one doctor, myself. I had to move on.



The latest fashion at Holy Cross

The second patient had been stabbed in the chest. The first thing I noted was how pale he looked. His pulse was weak and slow, his neck was engorged and I couldn’t hear any breath sounds on one side of his chest. I thought to myself, could this be a tension pneumothorax? This is when air gets trapped and sucked in between the lung and rib cage. With each breath, the volume and pressure of air increases and eventually squeezes the heart until it stops. What I should have done is listen to my gut and shove a needle into the front of his chest, subsequently hearing the satisfying hiss as the pressure releases (a very heroic manoeuvre – you see it in the movies, often with a BIC biro). However, I didn’t do this. Why? I don’t know, but partly because the chest-drain kit was already there and I had a tube in his thorax within 30 seconds. As the whoosh of air, and some blood, came out of the drain the young man instantly perked up. This was definitely one of those moments I mentioned earlier – a few more minutes and he would have been in the same situation as my first patient: dead. The young guy, and his mother for that matter, was extremely grateful and he promised me he would keep out of fights in the future. I wonder if he’ll keep his word. Just as I thought the evening, well morning – it was 2am – couldn’t get more exciting another curve ball was thrown.

A man in his thirties had three small stab wounds on his chest. His breathing was fine and there was no evidence of air or blood in the thorax like the previous fella. However, one of the stab wounds was sitting right over his heart. I did a scan and saw a large sac of fluid encasing the four chambers that pump blood around the body: he had a stab heart and the fluid around it was blood. Fortunately, he was relatively stable and seeing as he was still alive 2 hours after the incident, he had a pretty good prognosis. I did a pericardiocentesis to confirm my findings. This is when one shoves a massive needle, under ultrasound guidance, into the pocket of fluid. A relatively hairy procedure as you can imagine: too deep and you may end up puncturing a ventricle and making the situation a lot worse. First time was the charm and I aspirated 20mls of dark red blood – a good sign. If it was bright red, it would probably mean there was still bleeding, or that I just punctured the heart: not so good.  I observed him for an hour, to make sure the fluid wasn’t building up and squeezing his cardiac apparatus, much like in a tension pneumothorax, and then sent him to the surgeons at our referral unit.

The weekend is almost over now and my time at Holy Cross is coming to an end. I really am going to miss this place.

Cow chilling on the beach - it's what they do on the Wild Coast

 

Mitch - our days together will soon be coming to an end.



Casualty nurses preparing to dance for a movie we're making.
Did I mention we're making a movie to promote Holy Cross?

I got the job, I'm heading home.

  

Moon rising over Holy Cross.

There is little else more satisfying than the clonk that comes with relocating a dislocated jaw. Apparently the elderly lady, whose mouth I had my hands in earlier, was doing some serious mastication at the time of the incident. Recently I have been thinking that, as my time at Holy Cross is nearing an end, the amount of trauma seems to have reduced. Of recent, no nasty wounds to suture, chest drains to insert or fractures requiring reduction, pop into my head. However, maybe I just don’t notice these things as much anymore. It seems to take rather a lot to make me squirm and look aghast with a slack jaw nowadays. In addition, I’m just not on call as much as when I first started. Working one in two weekends a year and a half ago was a baptism of fire, but one that really built my confidence in managing exceptionally grim situations, some of which I have written about. I have three weeks of work left: I shall be working straight through as I’m on call both weekends, and on one of which I shall be the most senior doctor on site. Before I have always had the “phone the boss” option; next weekend I am the boss. This strikes rather a large amount of fear into me; it feels as things have been so quiet recently that maybe this is all the calm before the storm.

I say things haven’t been that busy, but as I look at the list I keep of interesting cases, perhaps I could have been mistaken. There’s a good reason for keeping lists: it’s easy to forget things. Here are a few memorable snippets from the past few weeks:

1. A thirteen year old boy on the medical ward decided to go into cardiorespiratory arrest (that’s when one’s heart and breathing stops; the same thing that happens in death) after a nurse gave him intravenous antibiotics. Fortunately, my colleague was on the ward and after thirty seconds they brought him back to life. Neither of us are quite sure if he had an anaphylactic reaction (this would be quite unusual in the way it presented) or just a serious vasovagal (fainting) episode as he was a little needle phobic. Needless to say, I was not willing to try the same antibiotic again.

 

2. I saw a four month old baby girl who was in severe respiratory distress. In fact I had seen her just days before with a mild chest infection and told the Mum to return if things didn’t settle. The baby had developed a massive collection of pus on the right side of her chest (empyema) that was severely compromising her breathing. Initially I inserted a needle to aspirate a little fluid and see what it was: when I saw pus, my first thought was: “Bollocks.” It was Friday afternoon and I was hoping to shoot off for a fun weekend away; it looked as if I’d be leaving a little later than planned. However, the main reason for my swearing is that pus doesn’t come out by itself, it needs to be drained and this would mean putting a surgical chest drain into a tiny little chest. To make things even better, when I put the needle in through her ribcage, I created a pneumothorax (air in the lung). This meant she would definitely require a drain. I have no qualms about cutting a massive gaping hole in the chest of an adult, getting my finger in, having a good poke around before I slide a big tube in. In a little baby, this is a very different business and something way out of my comfort zone. However, without the procedure she probably wouldn’t have survived the weekend. Anyway, without too much deliberation, I inserted the drain and watched the baby improve by the second. She has since been discharged and is doing very well.

The left shows a whole load of fluid (empyema) in the baby's chest. The chest x-ray on the right is following my attempt to aspirate all the pus and in turn creating a pneumothorax.



Pus.





Baby with chest drain in situ.
 She also has a femoral line in her right groin.

 

3. Whilst on call two weeks ago a young girl came in after slashing a big gash in her foot when she was cutting the grass at home. The wound was under a small bandage, but right over an area where a rather large artery runs – knowing anatomy can be key in times like this. I asked the nurse: “Is it a squirter?” She wasn’t sure as she hadn’t applied the dressing. So, having been almost caught out on several occasions before, I donned my goggles, asked the nurse to step aside and removed the bandage. Unfortunately, the side where the nurse stepped was right into a shower of arterial blood. It most definitely was a “squirter.” Fortunately, I managed to tie the bleeding off rather fast, although my nurse wasn’t too happy with the stain on her nice white uniform.

 

 

 

I love it when patients bring in the stuff that comes out of their gobs and bums. Here's a nice example of a worm that has been having a swell time feasting in a clients intestines.



4. Sunday is a day for church and football over here. Passions run high in both institutions, however, some people really do get slightly over zealous when it comes to kicking a ball about. Within thirty minutes of each other, on the day of “rest” and at 2pm, two grown men were both brought in with stab chests. One felt he was being overly criticised by his team mates for his ball handling abilities, so tried to stab them, but failed and received the knife himself. The second was a spectator who got into an argument with his friend over whose girlfriend was better looking. Well, I would defend the love of my life to the death, but I wouldn’t enter a death fight over how pretty she is. We all had a good laugh about the entire affair, but it does make me a little sad this culture of aggression. 
 

***

In other news, I got the job: three years of emergency medicine training in South London. I have very mixed feelings about leaving, but I think I’m ready to go. More importantly, I cannot wait to get home to see my dear family, friends and, of course, the girl.




A leaving party for Sr Lupondo: the head of casualty. Fortunately on this day the department was empty, which meant everyone could attend for a little dancing, cake and an whole lot of meat.

 

 

A few goodbyes: myself and Sr Ndamase. I know one shouldn't have favourites, but she is definitely the nurse I admire most. She helped me through some very challenging times at the beginning and is exceptionally dedicated. In addition, I share a birthday with her son Bebo, who is a cheeky little chappy.

When oysters cost £18 for 100 delicious nuggets of seaside, it can only mean one thing: breakfast, dinner and lunch. A well deserved weekend off after fiddling with chest drains in babies.

As well as oysters, it's crayfish season. Yum yum in my tum.