Part 1 - Toi Toi Nation

A rather large piece of corn that I removed from this child's nose (parental consent obtained).

Hello: I am still alive. It has been a few weeks since I last updated the blog. There are two good reasons for this:

1.       Work has been insanely busy.

2.       I have been filling out my UK Emergency Medicine job application .

As I have been kept on my toes at work, there is a lot to write about. Hence, I may break down the past few weeks into two parts.

Another case of ophthalmic shingles in an HIV positive lady.

The rash spares the nasal ridge, which means there is a reduced

chance of the eye being involved

.

The Eastern Cape Department of Health (the body that governs Holy Cross) has been in a bit of a crisis recently.  Strikes, or “Toi Toi’s,” have been rife throughout. It started with the nurses at our referral centre, then our pharmaceutical depot and finally the ambulance service. Unfortunately, rather than all go to the picket at the same time, it was spread out. So, once the referral unit opened back up, the pharmacy went on strike. Then, when the ambulance went on strike, we were really stuck. We had to keep unwell patients who required surgery, dialysis or higher care at Holy Cross and often just watch them die. To improve matters, we ran out of nearly all our essential drugs. A doctor is nothing without his or her tools of the trade.

There are many things that we all could have done better. There is a tendency here to put the blame on failing services to someone else; in this case, the pharmaceutical depot and ambulance. However, we managed to acquire essential magnesium sulphate (life saving for mothers with eclampsia), intravenous fluids and antibiotics from neighbouring hospitals after a few phone calls. Unfortunately, myself and colleagues always seem oblivious to medical shortages until we get told we have just used the last bag of saline or penicillin injection. We are now having talks with our pharmacist and nursing staff to find out ways that this can be prevented in the future.

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He was beaten by the local community - a strong image. I liken it to how the health service here is currently being hounded.



This guy got stabbed in the back twice. I inserted a chest drain on
each side as he had developed bilateral pneumothoraces (air
around the lung)



The strikes have been terrible; however, a few weeks ago the hospital encountered a self made crisis – a result of poor planning from us, the doctors. Currently there are seven of us, but one Thursday this month we were three – one was on leave, two were at a course and the fourth had to take his car for a service (probably not the best choice of days). We can manage with three, as the hospital has done in the past, but patient care is grossly compromised. Unfortunately, that day we had three emergency c-sections, hence taking two doctors away from the outpatient department and leaving one in casualty. By the time I got to OPD in the evening, there were about 30 patients waiting even though we advised everyone to go home and return the following week. I felt terrible as I sent all, but one, home; to be seen the following week. I knew that some probably could not afford to return.

An impressive case of Malassezia furfur - a
benign yeast infection of the skin. The
gentleman is also HIV positive.

During the ambulance strike I had an unwell HIV positive young male on my ward. He had developed confusion secondary to gross renal failure and was falling into a coma. I tried to kick start his kidneys back into action by giving him enough intravenous fluid, although this became difficult when I realised I had used our last bag of saline in the hospital (except for a few that we keep for c-sections). I discussed the case with colleagues and the specialists at our referral unit. He required emergency peritoneal dialysis (PD) – this is when you insert a tube into the abdominal cavity, pour in some salty-sugary fluid, rinse it about for an hour or so, then drain it with all the bad bits inside that the body doesn’t want anymore. We don’t do PD at Holy Cross. However, without any means of transport I was faced with a dilemma. Do I let this patient die, or do I try something a little heroic. PD isn’t complicated, I know the theory and the procedure (it is very similar to something called a diagnostic peritoneal lavage) and with the prospect of strikes ending imminently, maybe it would tie him over before getting definitive care. I went ahead with the procedure after discussing it with the family and colleagues. All went smoothly, but unfortunately it wasn’t enough. He died four days later; the ambulance service resumed the next day.

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A septic child (burns) who developed necrotic finger tips, probably from a combination of dehydration and infection. He will probably lose his fingers.

I attended a course a few weekends ago on HIV and TB management. There were some very interesting discussions around the HIV burden. South Africa is now the leader with this respect: it has the highest number of HIV and TB cases worldwide. Why is HIV still growing? There is plenty of health promotion, hoards of condoms and free HIV drugs. Do people still not understand how it is transmitted? I heard an amusing, if slightly worrying story, of a gentleman who kept developing sexually transmitted diseases despite being adamant that he used a condom religiously. It turned out he used to tie it around the base of his penis as, he told the doctor: “I remember from first aid that if you tie a limb after a snake bites you can stop the venom creeping up; the same applies here.”

One slightly controversial comment raised was that we should de-stigmatise HIV. At the moment it is still a very segregated service: patients go to a special HIV clinic, get tested in a special HIV room, get special counselling – basically, they get told they’re special. But what if we adopted the view: you have HIV, so what? It’s now a chronic disease if treated correctly. It’s not even that infectious; nothing like TB. When I say not infectious, I mean there are very simple measures to prevent it: wearing a condom (correctly) is one. What if we dealt with it like we deal with diabetes and hypertension? All require lifestyle changes, often lifelong treatment and have grave consequences if neglected. It’s food for thought anyway.

You don't see this very often - "waxy flexibility" in a patient with catatonic schizophrenic.

I had a beard.

Now I don't.

You may remember from previous posts the young HIV positive man with diffuse Kaposi's Sarcoma. He is receiving chemotherapy and doing very well; he's now walking.

My friend, an exceptionally strong willed young man, living with Kaposi's Sarcoma and improving every day. You may also notice my terrible moustache.

Finally - if you get bitten by a human, seek medical attention early. This guy waited for 10 days and his index finger became infected down to the bone. I thought this was a bit of pus, but when I wiped away the debris this piece of bone came out. Remember, humans have filthy mouths.