Why, what’s happening in Brazil?!

Apparently there’s some or other soccer tournament thingie happening in Brazil right now, I dunno I don’t really watch soccer. I do know the following: the game is played with a round ball, which is lucky because the players have to use the foot (quite possibly the clumsiest part of the body) to maneuver said ball. It is a very popular sport, possibly the most popular of all sports. Some of the poorest countries in the world while hardly being able to feed their populations, have national soccer teams that partake in games against teams from other countries, including this current competition happening in Brazil. I think it’s the World Cup, or something along those lines of importance. It happens every four years, which is why (I think) people seem to be quite beside themselves about it. Every four years though, England (by contrast a relatively wealthy country, with a thriving league) make what is usually nothing more than a nominal appearence at this tournament. Also, a recent finding is that some of the best players like to take a real bite out of the opposition. I know these things about soccer, or football, or soccer-football 🙂 as some call it because I’m a guy and these are minimal salient points that ought to at the very least keep me in the loop in conversation at any braai or bar if that ever need be.

 

Striker in the Hunger Games!

Striker in the Hunger Games!

 

Quick entry, quick exit!

Quick entry, quick exit!

 

So I haven’t been following really.  What I have and always do pay a lot of attention to,  and unashamedly declare myself an armchair expert in, is the oval ball game, rugby. One of the first things I did when I found out I was coming down to Port Elizabeth was check if the there would be any games potentially good enough to go and watch at the Nelson Mandela Bay Stadium. Indeed the Springboks were due to play against Scotland, just a few weeks after my arrival. I booked my tickets, way in advance! 😀

 

 

Friday 27 June I was on call at the hospital again, I finished work at about 11am on Saturday and went back to the flat to get a couple of hours of sleep. At 4pm my phone rang, I answered, it was my friend Bennie “Mr Mukenge we’re downstairs” I was ecstatic (amped, even), but not quite ready, as is often the case with me. I got my things together and rushed down. Bennie, his wife Kim, and their daughter Serena were there to pick me up. Off we went the game!

Game time at Nelson Mandela bay stadium!

Game time at Nelson Mandela bay stadium!

 

There is something about going to see a live game. Perhaps it is the fact that every weekend (when I’m not on call that is :-/ ) we watch these guys, world class athletes on the television; we read about them in the newspaper; we go online and read the sports blogs and, now at a live game we get a chance to see them doing what they do in the flesh. Is that what it is? Yes, but no, not quite. Perhaps it is the atmosphere, and the fact that you’re with your friends and thousands of other people you don’t know but at least half of whom have your team in common with you? Perhaps it is the way your team makes you feel when they’re doing well, or when their backs are against the wall and they manage to get back into the game? Or when they don’t do well. Those raw emotions that one goes through are amplified when it is a live experience. It is a combination of all of the above I imagine…

From left to right Serena, Yours Truly, Bennie,  and Kim

From left to right Serena, Yours Truly, Bennie, and Kim

 

This little city really knows how to turn up,  it was a capacity crowd,  just about. And it was a good game despite being somewhat one-sided in favour of South Africa. We thoroughly enjoyed ourselves, I know. We stood proudly for the singing of the national anthem. All of us except Bennie, who was outside in the queue for beer. A man must have his priorities… 😛 The game got under way and Kim asked with a very earnest expression on her face “Why can’t I hear the commentators?” I had a good giggle at that! At one point I stood up with my hands in the air to add my contribution to the passing Mexican wave, and sat down to find that yet another try had been scored by the Boks, and I had missed it! :-/ I have since decided to forgo that frivolous distraction of an activity. Why do they call it a ‘Mexican’ wave anyway..?

 

55-6 is not a score line to be scoffed at methinks. We walked out of the stadium with the rest of the PE faithful quite satisfied with the result.

 

 

We made our way to Stanley street and had sushi at Fushin. I’m not very keen on sushi but Bennie and Serena are, they were in their element! I’m also not really one to take pictures of food but there you are..!

At Fushin, Stanley Street.

At Fushin, Stanley Street.

 

Good times,  good people!  Oh yeah and, what’s happening in Brazil again?!

 

 

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#keepMerylhere…

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I was done with the post-intake work from the Youth day call by about 11am on Tuesday 17 June last week. Driving off from the hospital, I was tired and worn, but I was also very excited. Meryl my girlfriend was on a flight that had left Johannesburg bound for Port Elizabeth about 30 minutes earlier. I was on my way to pick her up at the airport. She was due to land at 12.45. Not enough time for me to get a quick haircut, or get my car washed, both of which I had kind of been planning to do (Seriously I had kind of planned to… 🙂 ). No matter, after not seeing me for just over a month surely she wouldn’t care about that sort of thing..? I did have just enough time to pass by the flat in town and get changed out of my scrubs before getting to the airport to meet her just a few minutes after she walked out of baggage claims. There I was, just a tad bit late, sporting that post-call-but-I-am-so-happy-to-see-you face. After the obligatory hello-I-miss-you-so-much etc the first thing she said to me was “Why didn’t you cut your hair?!” Seriously… 🙂

At the pier at Summerstrand

At the pier at Summerstrand

Meryl was in town for 5 days. It was awesome having her around, I was in absolute bliss! We went everywhere that I have been to during my short time in PE and more… In Stanley street we had dinner at Posh Eatery on the evening of her first night here. She decided that over the next year on her subsequent visits we are going to work our way down the street and eat at all of it’s many restaurants. It’s a very Meryl-idea and I’m always willing to entertain those. I will update on how that goes…

 

I introduced Meryl to my PE crowd. Everyone loves her (literally everyone!), and I suppose they now understand why I go on about her, and why I feel the way I do about her… On Thursday my friends Kim and Bennie hosted us for dinner at their home in Seaview (my other home away from home 🙂 ), where Meryl met everyone. Kim is of the opinion that Meryl is too good to be true, and that I should promptly marry her and seal the deal (hey, how’s that for an idea! 😛 ). Kim’s daughter Serena had been quite looking forward to meeting Meryl and when they finally did meet they got on like a house on fire, as I had thought they would. She, and her older sister Robyn and Meryl bonded during a day of shopping while I was at work the next day, as girls will do (that sounds very sexist but I’m telling it the way it went down 🙂 ) Serena suggested we start a trend online: #keepMerylhere. I like that, #keepMerlyhere…

 

My other friend Dario, who also lives in Seaview, was over for dinner too, along with his party of six, as I like to call them 😛 They include his wife Jenelle, their 3 daughters and their new son 3 week old Nicholas (who Dario tells me would have had the misfortune of being named Dicholas if he had been born a girl 😀 ) They too, quickly took a liking to my Meryl. The general consensus seems to be that I am one lucky cat. I completely agree. I’m not a bad looking chap if I do say do myself but I will admit that I can be a little bit socially awkward, just ever so slightly. The result is that I’m not exactly a ladies man! We have been together for almost a year now, but every now and then I have to pinch myself just to make sure that this is all real. This girl is an absolute babe and I get to call her my girlfriend!

 

There's a pretty girl turning heads in Port St Francis!

There’s a pretty girl turning heads in Port St Francis!

 

Kim and Bennie have a flat in Seaview that they rent out sometimes. They were kind enough to avail it to us for the duration of Meryl’s stay so she could at least have somewhere to be comfortable.

 

 

It’s a funny thing, Meryl and I talk on the phone about two or three times a day when she is in Johannesburg and while the distance isn’t easy I feel like the constant chatting and messaging keeps us connected. From the moment I picked her up at the airport we seemed to seamlessly connect and, I felt like we hadn’t really been apart for that long. Over the 5 days we did most of the things that we had been planning to do for weeks before. We drove over to St Francis, and had lunch in Port St Francis. We were also in Jeffrey’s Bay, arb’ing around at the factory shops, on the streets and at the beach. All the while being very cheesy and touristy, taking pictures of everything that caught our eye…

Jeffrey's Bay...

Jeffrey’s Bay…

 

I’ve been in Port Elizabeth for almost 2 months now and I hadn’t had a chance to get out to Summerstrand and Hobie Beach, which is absolutely criminal! Songs have been written about Hobie beach and it is barely a 10 minute drive away from my flat in PE town. I drove Meryl out there, we got there just as it was getting dark, walked up to the end of the pier, and had dinner at a nice place called the Blue Waters Café.

 

Back in Seaview on Sunday we walked across Maitland road down to the rocky beach and sat there taking in the view, and the sound of the waves crashing on the rocks, cheesy as that might sound…

 

A few hours later on Sunday evening I had to drive us to the airport. As seamlessly as we had connected after she had arrived a few days earlier, I felt as if half of me was missing when I drove back home without her in the passenger seat…

 

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Port St Francis...

Port St Francis…

 

 

Lunch at some or other restaurant in Port St Francis :-P

Lunch at some or other restaurant in Port St Francis 😛

 

 

 

 

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Twelve phone calls…

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The first phone call I received was from the intern down at the medical admissions ward. She was telling me that a new patient had just been brought in, a young lady who had overdosed on iron tablets. “Alright,” I said. “You start seeing her and I’ll be there as soon as I can” It was Monday 16 June, Youth Day public holiday, and we were on call. It was 9pm approximately and I was upstairs in one of the male wards, having been called to see a patient who had pulled out his IV line. He was severely dehydrated, and the nurse in charge hadn’t managed to re-drip him.

 

 

The second phone call was from my consultant calling from the comfort of his home (a privilege that comes with being a qualified specialist), telling me what I already knew, that there was a an iron overdose in admissions, “How long are you going to be in the ward Dr Mukenge?” “Maybe 20mins doc” I replied,  “I have to put in a central line, Nurse in Charge is just preparing everything.” His concern was that we should give the patient deferoxamine as soon as possible. Deferoxamine is a siderophore drug that can be used as a chelating agent that removes iron from the body, preventing it from being absorbed in the gut. “You may have to transfer her to Livingston Hospital, if we don’t have any deferoxamine…” he said. “Sure doc” I hung up and got down to the business of the central line. I was inserting an intravenous line into the femoral vein in the patient’s leg, adjacent to his genital area. Back in my intern days halfway through my internal medicine rotation the head of my unit at the time once asked me if I knew how to put in a central line. At the time I didn’t, and he was displeased. He explained that being able to insert an IV line into one of the large central veins could be the difference between saving and losing a patient. That was then. These days I can insert an IV line into any one of the central veins with one hand tied behind my… no, that’s being unnecessarily flippant 😛 And besides, I digress…

 

The third phone call was one that I made once I got back down to admissions, I called the physician on call (POC) at Livingston hospital to ask if they had any deferoxamine in their admissions ward. “Ja hold on, I’ll have to ask the nurses” she said, before hanging up on me.

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I had a thorough look through the drug drawer in our emergency trolley, then took a walk to casualty down the corridor and had a look in their drug cupboard and emergency trolley just to make absolutely sure that what we needed for this patient wasn’t right there under our noses. No luck. I then walked back to medical admissions intending to make another phone call. When I got there another new patient had arrived. She would need to be seen. She was a lady who had been referred to us earlier by the surgeons at Livingston hospital. They expressed, over the phone that they were somewhat aggrieved (read here: pissed off) at having been tricked by the casualty doctors from our hospital into accepting this lady as a bleeding peptic ulcer. She was most certainly not they claimed, her chronic rheumatoid arthritis was her main problem and she had to be seen by a physician (ie yours truly, on this specific night). After assessing her I had to admit that I agreed. There were no special findings on examination. She had very typical arthritic changes of the hands, almost textbook in fact, and she complained of pain in the joints. These are not reasons to go to hospital in the middle of the night however, so what was wrong I wondered. I logged onto the computer to check her blood results and there was a big clue, deranged liver enzymes with an obstructive picture. Some sort of drug induced liver injury? She wasn’t jaundiced, so what was up with her…? I quickly admitted her to be reviewed by the consultant in the morning. She would at the very least need an abdominal ultrasound. Then I went back to the phone calls.

 

 

Phone call number 4 was one I made to the doctor on call at the intensive care unit (ICU) at Livingston hospital to ask if they had any deferoxamine. Reluctant to assist me as she probably realised it might mean transferring the patient to her, she suggested I call the pharmacist on call. Pharmacist on call eh? Hmm… “Nurse do we have a number for the pharmacist on call?” I asked, “There is a pharmacist on call?!” she replied incredulously, “That’s exactly what I thought” I said. “Haibo!” she muttered, as she scuttled off to that secret place that nurses go to find things that doctors are incapable of finding. She returned, sure enough with the telephone number of the head of pharmacy. By this time it was approaching 11pm and I was getting somewhat irate on behalf of the patient. The signs and symptoms of iron toxicity start out fairly benign and patients initially appear quite well apart from some abdominal discomfort and vomitting, but over time it can progress to a full-on gastroentiritis type picture, with bleeding of the gut, metabolic acidosis, and eventually neurological  findings, including decreased consciousness. Not a pleasant condition.

 

 

So phone call number 5 was to the pharmacy HOD. His phone was off, the call went straight to voice mail. I then explained myself to the matron in charge that night (phone call number 6). She gave me the direct cellphone numbers of 2 of the pharmacists who work at our hospital. I called the first (phone call number 7), and after ringing for what seemed like ages the call was finally answered by someone who was either drunk or very groggy from sleep (I’ll give him the benefit of a doubt, it was probably the latter!) It took a good three or four minutes of convoluted conversation for 2 things to be cleared up: firstly, he was not the pharmacist on call; and secondly, he was perfectly willing to give me the number of the person he thought was on call for the week. Having done that, I apologised for waking him up at such a ghastly hour, and we both hung up.

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I finally got through to the pharmacist on call (phone call number 8). By contrast he sounded fresh and very willing to help. What does a pharmacist do when on call? I wondered. Stay up all night at home waiting for one of the on-call doctors to call needing an emergency drug? Surely not. How often does that kind of thing happen anyway? More likely, they stay home and hope the doctor does not call! I don’t know, I must ask a pharmacist friend or colleague at some point. Anyway, he had what we needed. He rushed over to the hospital, asking that someone be there to meet him at the pharmacy. Nurse in charge sent one of the male nurses over. A little while later the pharmacist called me again (phone call number 9) saying that he was at the pharmacy, he had the drug but there was no one there to meet him. At the same time the nurse who had been sent to meet him called Nurse in Charge (phone call number 10?) saying that he was at the pharmacy but couldn’t find the pharmacist (I’m not making up any of this stuff! 🙂 )”He’s there apparently” I said to the pharmacist, “Have a look outside, he’s looking for you.” And it took 2 more irritated phone calls (Calls 11 and 12) from the pharmacist before he decided to just come to us himself and bring the 10 ampules of deferoxamine. Here I must explain, Dora is a relatively large hospital, as I’ve mentioned before, and the pharmacy is way on the other side. One literally needs to drive from medical admissions to get there. To make matters worse,  my understanding is that the nurse ended up at one of 2 entrances to the pharmacy and the pharmacist was at the other, resulting in that comedy of errors. It was about 1.30am when were finally able to put up the deferoxamine infusion for this lady. She was patient number 12 in what turned out to he a total of 19 on this call, a relatively quiet shift.

 

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So there you have it. 12 phone calls in one night just to take care of one patient. Being a doctor can mean having to perform the function of a glorified receptionist.

Doctors have a funny relationship with the telephone. I was in one of the wards not too long ago and, reading a patient’s file I came across a note written by one of the other doctors I work with. It read: ‘The neuro surgeon on call says I must get my consultant to call him back because I don’t sound like I know what I want…’ After having a little laugh to myself I proceeded to call said neurosurgeon. We were seeking clarity on the findings of a CT brain report. Specifically, can we give this patient warfarin which will thin her blood, when there is a risk that the possible vascular malformation in her brain might burst and bleed? “Ah yes I think another doctor from your side there previously called me about this patient but she did not present the case as eloquently as you have…” He actually said that. Well my English teacher would have been proud (no I did not say that aloud! 😛 ). In all fairness to my colleage though, one of our consultants (not wanting to make the call himself) probably asked her to call neurosurgery, and she not being clued up on the case, subsequently bundled the referral.

 

 

At every hospital I’ve ever been in, as a medical student and after I qualified I’ve always noticed that in a ward full of health care workers, both doctors and nurses alike will not jump to answer the phone. It’s a funny thing, we seem to always wait and let the phone ring for a good little while in the hope that someone else will pick it up or alternatively the person on the other end will give up! This I have realised, is because a phone call invariably means yet more work coming our way.

You can have a bit of fun with it though, I have discovered. “Nurse please just tell them I’m not here” is my most frequent grinning response to “Phone call for you doctor” The nurse will invariable have a quiet giggle (if she has a sense of humour that is 😛 ) and pass me the phone. Imagine the medico-legal ramifications of the doctor on call refusing to come to the phone to accept referrals!

I was on call again not too long and as is always the case at medical admissions the phone was constantly ringing. Doctors from clinics or GP practises in the area call to refer patients to us. I picked up the phone and the doctor on the other end started rattling off at a clip “Hi this is Dr So-and-So, is that the physician on call?… Ok good. I have a patient here that I want to refer to you, he has a…” I interrupted him “Sorry Doc, where are you calling from?” and he answered “Motherwell Clinic, oh yeah!” I don’t know how I stopped myself from laughing out loud… 😀

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All in a day (night)’s work…

It is 2:35am and I am hunched over at the desk making notes in my latest patient’s file. The intern walks in and stops, startled at what she sees. All 4 bays in the medical admissions ward are filled, each occupied by a patient.  Things had been a little clearer when she had gone off to get a little bit of sleep at about 22:30. We have both been on call since the previous morning, working pretty much flat out. Just before midnight the doctors at casualty down the corridor had offloaded a whole bunch of patients to us before the start of their new working shift. This meant that in addition to the packed admissions ward we had 4 patients lined up in the corridor outside, 3 of them on stretchers, one seated on the waiting bench squeezed in between the other patients’ family members. Organised chaos, or rather chaos that needs to be organised.

 

My intern on this particular night is a super smart, efficient doctor. She works through the patients fast, which the nurse in charge tonight loves because there’s nothing she likes better than to clear the patients out of admissions once we’ve seen them, to their designated places, either off back home, or the short stay ward or the in-patient wards. This is so we can have a relatively clear space to work in, in admissions. This night was not one of those nights however, as we had a couple of sickies on our hands. ‘Sickies’ as one of my registrars back in Bara days used to call them refers to patients who are relatively critically ill and need particularly close attention the entire time that they are there. They have to stay in admissions. Out of the 4 patients 2 were diabetics. They were the ones we were worried about. One was a 16 year old boy who had come in the previous afternoon in diabetic ketoacidosis (DKA). DKA is one of the worst things that can happen to a Type 1 Diabetic. Very simply explained, their blood sugar levels go very high, but because of a lack of insulin (they may have been skipping their doses or be on an inadequate regimen) the body can’t use that sugar, and burns body fats instead, producing ketones which are acidotic. The acidosis makes the patient feel very ill and they present at the hospital with stomach cramps, vomiting, and sometimes with decreased consciousness. In managing them the aim is to correct the acidosis. We were giving this young man a lot of fluids very fast in one intravenous line, and a slow insulin infusion in another IV line, while keeping his electrolytes in check. We were winning the battle with him, his blood sugars had been steadily decreasing, and his acidosis improving until one point the previous evening when the nurse reported a sugar reading that wasn’t in keeping with the trend, presumably because at some point in the evening while our attention was elsewhere,  he had a snack! This was probably provided by his mother, who was there the entire time. The other patient was an elderly lady who also had high blood sugar, and all the features of DKA except acidosis, which had me kind of stumped. She was in fact in a metabolic alkalosis, her blood pH and bicarbonate levels were sky high. What on earth do I do to correct alkalosis? I mused to myself. How often does one see one of those…? Keep it simple,  I decided. Get her blood glucose down and see how she does. I wrote up continious fluids for her as well and an insulin infusion.

 

I had to take a walk to the neonatal intensive care unit (NICU). NICU has one of only two blood gas machines in the entire hospital and I had a blood sample that I needed to run. Dora is a pretty big hospital and the walk is relatively long. It gave me some time to think about this lady’s situation.  She was hypertensive so perhaps it was the diuretic medication that she had probably been on for years. These could be causing her to lose potassium,  also making her alkalotic. Maybe…? I thought. But still, what do I do for it? At a loss for an approach, I whipped out my cell phone and tapped on the Medscape reference app. Chloride responsive and chloride resistant metabolic alkalosis came up. Jeepers I thought, as I started reading,  it’s 3am and now I have to start conjuring up what I do (or don’t! ) remember about acid-base balance,  or imbalance as it were.  A sodium chloride infusion is what will help correct a metabolic alkalosis I discovered, so I may have been right to have ordered the IV fluids. If she did in fact have a chloride responsive alkalosis.  I would only know after her next blood gas sample, which I had planned for a couple of hours later.

 

When I got back to the admissions ward I saw another new patient, a 50something year old man who turned out to be in mild right heart failure and had a lung infection. Relatively simple: admission, intravenous diuretics, and antibiotics. And also work him up to exclude tuberculosis. Then I saw a young man in his twenties, brought by his mother. He had ingested half a cupful of engine oil after having a row with his girlfriend (cue heavy sigh!). He was relatively stable clinically,  and had no psychiatric history so we did basic blood tests and admitted him for observations. He was patient number 33 since the start of our call the previous morning. When I was done with him it was about 5.30am and I was ready to get a little bit of shut-eye so I retreated to the doctor’s room. At 7am the intern knocked on the door. I had asked her to wake me up,  my cell phone battery was at it’s end and I couldn’t set an alarm. As I walked out of the doctor’s room she showed me the latest results of the blood gas samples of our 2 diabetic patients. The young boy was looking good, not quite out of acidosis but definitely improving, and while the older lady’s blood glucose had decreased somewhat her alkalosis was actually worse! Luckily the consultant would arrive soon for the ward round to see the new admissions. He would know better how to approach this.

 

The consultant strolled in just after 8am and we were busy until about 11.30 presenting all 35 patients we had newly admitted. You can learn a lot on a post intake ward round. The consultant might suggest a different approach to manage the patient,  or suggest a diagnosis you had not thought of. Metabolic alkalosis is apparently not a medical emergency, so no need for yours truly to have been freaking out (here read: keeping cool despite being somewhat perplexed 😉 ) Of note, he asked us to discharge the DKA boy, even though his acidosis wasn’t quite corrected. He did look much improved clinically but the specialist physician’s last words “The DKA will resolve itself…” had both the intern and I gawking a little…

 

I got back to the flat in town in the afternoon and collapsed to a deep sleep. I was awake about 3 hours later. I have this thing about not sleeping all day post call because I feel it’s a waste, even though I’m usually too tired to then do any reading or hec, anything constructive really.  I did get started on this latest blog post though, while I still had some of the patient details still relatively fresh in my head. Still later I finally fell asleep while watching a movie on my tablet.

Up early the next day (today, that is) and at work by 8am (8:10am I’ll admit I was a little sluggish this morning!) In a doctor’s meeting until about 9.30 and then  on to the ward. I had to see all the ward patients on my own today. Normally this work would have been shared between 3 doctors, one other medical officer (MO) and an intern, but the MO was post call and the intern was off sick. “Do doctors have to hand in a sick note after being off sick?” my girlfriend asks me during a quick phone call while on my way to the ward… 😛 It’s slow tedious work seeing every single patient and trying not too miss anything. The blood results from the previous day, dealing with new symptoms etc. By mid-afternoon I was finally done. I walked across to the other ward to find the intern there also busy with her last patient. So I didn’t have to help her out. My work day was done. I went off home.

 

Not too long later I found myself in Stanley Street,  and the waiter at Posh Eatery offerred me a seat at a table inside. My usual friday afternoon blog spot Yiayia’s, is closed for some reason.  It is late evening now and I have just finished writing this post. The

weekend’s plans include running, and reading up on acid base disorders…

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