Who would have thought it – I haven’t even had time to unpack my bags, but already my new found anaesthetic skills have been put to work. My delightful Dutch colleague gave me a call for some assistance. She had a young mother who recently delivered that was having an extremely tough time of it breathing. The mum was HIV positive and recently started on anti-retroviral treatment. However, unfortunately for her she also had a cancer linked to HIV, called Kaposi’s Sarcoma, growing around the entrance to her windpipe. It was asphyxiating her rather quickly. So quick, that we had to act. It wasn’t quite the slick affair that Dr Carter in E.R. would run alongside Benton and Dr Green. Here’s a condensed version of what happened:
J (Jelleke): “She’s stopped breathing.”
D (Dom): “Fu*k.”
J: “Sh*t.”
D: “Right, errr, there’s nothing in resus. Let me run to theatre and get the gear.”
J: Shouting to the nurses “CAN YOU COME HELP ME. I NEED SUCTION NOW.”
Nurses nowhere to be seen, despite all being in casualty minutes earlier.
D: “Lets do this.”
About 15 minutes later
D: “I’m in.”
J: “Great.”
And at that point we had secured her airway with a tube in her windpipe. We had been able to breath for her by blowing oxygen with a bag through her mouth until I put the tube down. Because of all the swelling in her wind pipe we were ready to perform a surgical airway, which is a bit like a tracheostomy, but a lot simpler. We transferred the patient to our referral unit for intensive care as she had a lot going wrong with her as well as the airway problem. Unfortunately, all our efforts were in vain – she died in the ambulance. I expect the tube fell out of her windpipe. As I have mentioned before, the ambulances don’t have paramedics or experienced technicians that can look after intubated patients. Maybe some would comment that we shouldn’t have even tried to resuscitate her knowing the problems there are with transportation and the setting that we are in, being resource poor. We had to dedicate a lot of our time to her management (about 4 hours) – other patients had to wait to be seen. However, we are in South Africa – a country that has a large, well funded, but poorly managed, health system. There are specialists, intensive care departments; you name it, they have it. I agree, one has to be pragmatic and know their limitations, but also drink with a glass half full; at least try to the best of one’s abilities. Occasionally, in these desperate situations, there will be a happy ending. Unfortunately our young mother wasn’t in that category, despite our best efforts. However, there are a handful of others that do make it – for me, that’s what makes what I do feel worthwhile.
On a side note, whilst we were trying to ventilate our lady an ambulance crew arrived with a guy in his twenties who had been in a motor vehicle accident. He was dumped on the resus trolley – he looked very ill. In fact, he was very still; not a sound. My colleague asked the ambulance driver if the man was alive, whilst she tried to ventilate our lady. We were told: “Yes, he’s breathing.” I quickly triaged him: He was dead, although I expect not much time had passed since his heart stopped, but long enough to starve his brain. No family were present; he died alone. I just said: “He’s dead,” and quickly moved back to our lady. In such circumstances one has to act fast and there often isn’t a lot of time for compassion. We acted to the best of our abilities, which sometimes means doing nothing.
In addition to all this pandemonium I have been back on the paediatric ward. At the moment there are a lot of happy punters; many of which were exceptionally unwell a few weeks ago. I have a boy that was literally taken by the horns of a cow; another who was hit by a car at speed who broke several bones and sustained a head injury; an almost mute 5 year old girl who looks like she is 12 months as a result of severe malnutrition (weighing only 10kg), poorly treated TB and, as we recently discovered, sexual assault - but even she is coming on leaps and bounds. I know we are not supposed to have favourites – but she is mine and I encourage all the nurses to interact and play with her. Life as she knows it has been so shitty, and probably isn’t much better now being stuck in hospital, but we can try and make it fun. Currently Holy Cross has six very enthusiastic medical students from Cape Town for the next two weeks. I have asked them to give her as much attention as possible. In return I have been teaching them in hospital (there’s always time for teaching, even if things are exceptionally busy) and feeding them beer outside of work.
Along with the kids that are getting better, there are some that aren’t. We have a young boy who has rabies after being bitten by a dog – it is endemic here, but often people get treatment before progressing to the disease. His mother is a healthcare worker, but she didn’t bring him to get vaccinated after the bite (which was only a very small scratch). The vaccine needs to be given as soon as possible to be effective. He has presented to us already with symptoms of the disease. His hydrophobia (fear of water) is profound – a very bizarre symptom, that is very typical of rabies. Other than that he looks quite well, but there is little we can do and it is likely he will die. Not even the specialists can offer help this time. It’s a waiting game and one where we need to show the boy and his family support and compassion.
In addition to the rabies case I also had another child today who was wheeled into the ward vomiting and taking her last gasps. Again, another situation where I thought to myself – do I try and resuscitate or not. But, how can I not? Especially in a child. Additionally, children have a different make up to adults and the reason their heart stops differs. So, I went for it. It wasn’t a happy ending though – I didn’t want to give her mouth to mouth (she was HIV positive and had vomit all over her); I shouted at the sister to get me a “bag-valve-mask (BVM)” – she ran (I’ve never seen anyone run here – I was very impressed and gave her a big hug and thank you afterwards); the BVM (something we use to help someone breath with an oxygen attachment) was broken and there wasn’t another one; I was left with chest compressions alone; her pupils were fixed and dilated (a sign of brain death); I realised what I was doing was futile; I stopped. I have no idea what was wrong with her, but wonder if she was given a herbal medicine or accidently poisoned as the family said she was completely fine at breakfast.
On a lighter note, the season has begun. No, not the festive season, although I hear that is fast approaching and I am quite looking forward to my weekend off at Christmas. The season I mean is the one where boys become men; Boyz 2 Men; where the woods become a hive of activity; the chanting and the rituals take place. Yes that’s right, it’s the circumcision season. Every summer (winter in the UK – don’t forget, I am in the southern hemisphere) tonnes of teenage boys leave their home and come back a few grams lighter (foreskin-less), covered in white body paint and with the newly acquired knowledge of how to kill a fellow human: apparently they are now men. If this is the case then I would much rather be Peter Pan and fly off to Never Never Land. The “man” recipe when mixed with alcohol makes casualty a fairly colourful place, especially at Christmas when everyone around the globe has one too many sherry’s – a mix of stab injuries, infected penis’s, incoherent patients, incontinence and more stab injuries. Fortunately, some of the kids are a bit savvier and want to join the lost boys, so they run away from the woods. Occasionally, such as on Monday, you get a young male who turns up looking a bit sheepish and uncomfortable. The casualty card read: “Has cut on penis after running away from woods.” When I first read this, I wasn’t too sure what to think – but I knew that I didn’t want to go into the woods. So, it turns out my man (he’s a man in my eyes) was about to get the snip, saw the blade, got a little nick of the skin and legged it. His penis was a bit of a mess and his foreskin was stuck causing his “member” to swell up – it’s called a paraphimosis. Once I reduced it his frown turned upside down. I have booked him to come back in three weeks to have a proper, sterile, circumcision. So as well as not getting a paraphimosis again, his lack of foreskin will mean that he can pretend that he did his manly duties. A win win situation I think. I’m just hoping he returns.
I am off to visit friends on the beach this weekend in a place by the name of St Lucia, South Africa – not the Caribbean. For the next few months it looks like we are all working one in two weekends. However, I shall be making sure Mitch (my car) gets his fair share of action on the ones I have off.
I will attempt to upload some pictures soon, but the internet at Holy Cross is too slow.
P.S. If anyone wants a Christmas card, then please email me your address.
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