More rest for the wicked!

4 hours… I got 4 hours of sleep while on call on Sunday night. 4 hours of guilt-edged shut-eye. It was the quietest of calls, we only admitted 10 patients in all. I couldn’t believe it!

It went as a Sunday call really should go quiet, slow and almost uneventful. I say almost because this is internal medicine and this is me, completely uneventful would have been too good to be true, evidently.

My most serious case on this call was, as Murphy would have it, very serious. It was about 11.30am and I was writing notes in a patient’s file, only the third of the day at that point when a nurse wheeled in a lady on a stretcher. If I don’t look up from this file, and try to pretend that they didn’t just arrive maybe the case won’t be that serious I dumbly thought to myself… 😔 “Doc…” the nurse interrupted my note making. “This lady’s just been sent from casualty, I think she’s quite serious (again that word, serious :-/ ). I had a quick look at her notes from casualty: HGT (bedside glucose test) was ‘Hi’ which means that her blood sugar was very high, too high for the glucometer to measure. Urine positive for glucose (obviously), and ketones most importantly. At this point before even looking at the patient one knows the diagnosis. I did go and examine her though: decreased consciousness, very low blood pressure, dehydrated. A venous blood gas a few minutes later confirmed a severe metabolic acidosis. DKA…

After struggling to insert a second peripheral IV line I had to put in a femoral intravenous line, and we started her on the DKA cocktail. Aggressive IV fluids, and an insulin infusion. IV potassium, and antibiotics.

Not many other patients were sent to us during the rest of that day, only 2 or 3 as a matter of fact. She became progressively less acidotic and the HGT decreased over the day and into the night. As the numbers improved she regained consciousness and was able to hold conversation, at one stage even asking when we would send her home! 🙂

Patient's pH was 6.8 at initial clerk, then 7.02, 7.28, and 7.31 the next morning.

Patient’s pH was 6.8 at initial clerk, then 7.02, 7.28, and 7.31 the next morning.

At about 10.30pm there wasn’t much happening, and I thought I would go and lay my head down for a bit. I set an alarm on my phone to wake me in an hour, or at least I thought I did… I woke up on the bed in the doctor’s room at about 1.45am! I completely freaked out, thinking there would probably be a long line of patients newly arrived and waiting to be seen. Why had the intern, or nurse not woken me? I wondered. I walked into the admissions ward to find that nothing new had happened, no new patients had arrived. Relieved, I did another venous blood gas on the DKA lady and found that she was still improving, pH decreasing, Bicarbonate levels increasing and HGT steadily going down. Winning!

Again as luck would have it, now that I was up 2 more patients arrived, almost at the same time. They were the only other patients who had me a little bit concerned on this call.The first was a woman in her sixties with chronic hypertension. She had not taken her medication for many years and had previously had a stroke. She had a one day history of confusion, decreased consciousness and left sided weakness of the face and arm. Normal blood glucose levels, a very high blood pressure 220/110 (normal is 120/80 mmHg give or take a little), and her blood sugar was normal. It was most likely that she had just had a second stroke.

The second patient was another lady, also in her sixties who came in with decreased consciousness. Her HGT at casualty was 1.4 (normal blood sugar is approximately 4-7), they had given her IV glucose and the HGT had gone up as high as 13.1 but she remained unconscious. Because brain cells can only use glucose for energy (unlike other organ systems which can break down fats and eventually proteins in times of ‘starvation’) low blood sugar (hypoglycaemia) can cause decreased consciousness. But patients normally wake up almost instantaneously once they are given some sugar. So there was something else wrong here. This lady was a recently diagnosed diabetic and had just started on sugar-lowering medication, roughly a week previously. I thought it highly likely that she had been started at excessively high doses. Her family explained that she had ‘not been well’ since starting on the diabetic meds. So this may not have been the first time she had become drowsy or unconscious. Working diagnosis: hypoglycaemic brain injury. This is as good as having a stroke, where blood to a part of the brain is cut off (by a blood clot, or a bleed) starving that part of the brain of oxygen, and glucose.

I called LVH to argue for an urgent brain CT scan for both of these patients. The physician on call at LVH said that they had 8 patients waiting to have brain scans and that I should send my patients at first daylight. This is far from ideal, but given the limited resources it is an oft repeated scenario. We don’t have CT scan facilities at Dora Nginza hospital so we have to organize for patients to be transferred to LVH. This means an inevitable delay due to having to wait for an ambulance to arrive and take the patient across. So one calls for the ambulance, they log your call and you wait. When a patient is critical the best you can do is call them repeatedly so that they realize the urgency. I gather from the numerous times I have had to do this, that there are a limited number of ambulances, and when we call they have to finish with the patient that they are transporting before coming to us.

Having done my part and called for the ambulance I went off to get a couple more hours of sleep. The intern would hold the fort for a little bit, and the nurse knew to keep calling if the ambulance didn’t come. I woke up just before 6am, called for the ambulance again and had to see 2 more patients, neither of whom were seriously ill. It was nearing daylight and the consultant would arrive soon.

We had admitted a total of 10 patients. I thought this kind of easy call only happened to other doctors.. 😖

Our lady with DKA was a lot better, her last VBG done at about 7am showed a pH 7.3 and Bicarbonate 15. Both of those are just outside of normal, and clinically she was much improved. When he saw her the consultant said to stop the insulin infusion and admit her to the ward for glucose monitoring and control.

The hypertensive lady somehow ‘woke up’ about an hour before the consultant arrived. She regained full conscious and on examination was without any focal neurological signs. It was quite unexpected. I then had to consider another differential diagnosis for her: transient ischaemic attack. This is similar to a stroke. Actually it is a stroke, but one the symptoms of which do not persist. The patient recovers fully, there is no lingering one sided weakness or other physical dysfunction that is the usual feature of a stroke. The consultant thought different: “Todd’s paresis” he said. This is weakness of one part of the body (usually an arm or a leg) that occurs after a focal seizure. The weakness resolves within 48 hours. The last time I heard about Todd’s paresis I was in 5th year at medical school… 😮 We discharged her on antiepileptics and antihypertensives, after trying very hard to impress upon her the importance of actually taking them! An ambulance finally arrived during our post intake ward round to take the hypoglycaemic lady to LVH for the brain scan…

When I was in high school I used to hear an advert on the radio that ended with a voice saying “No rest for a budding MD!” The phrase is always triggered off in my head when I hear the much more common ‘No rest for the wicked’ and I would think of it whenever as a budding MD myself back at medical school I couldn’t find anytime to sleep or actually just chill because of all the studying and later after qualifying, whenever the calls were so bad that you couldn’t get any rest. Well after getting a whole 4 hours or so of sleep on call I thought it perhaps not entirely impossible for there to be ‘more’ rest for the wicked… 😉

I felt so fresh when we finished the post intake round (at 9.30am 😀 ) that when I got back to the flat in town I just freshened up, and then went out, it was awesome! (Can you tell, by any chance that this was a big deal for me? 😛 ) I drove out to Seaview, got to Kim and Bennie’s Hardware shop sometime in the early arvo, grabbed a key to their flat that I use whenever I go to them, went upstairs threw my stuff down and then went next door to say hello to Robyn, Kim’s daughter. Robyn has just started working again after 4 months of maternity leave. She and her husband Conrad are the proud parents of 2 boys Liam and 4 month old Alex (or is he 5 months now?). Liam is a little bit shy and has only now gotten to greeting me back when I say hello. Alex is just chubby and makes baby noises. I left after a little bit to do some blogging, as one does…

This is the kind of view that hits you as you drive into Seaview!

This is the kind of view that hits you as you drive into Seaview!

Seaview...

Seaview…

That evening I was at Kim and Bennie’s house for a braai. The occasion was Kim’s birthday. It was a full house. Her parents were up from Cape Town for a couple of days. Serina, Kim’s other daughter was there with her new guy, Dean. Robyn and Conrad and their boys were there too. It was good, happy times. This family has been really good to me for the whole time that I have been in PE. Literally since the first day that I arrived they have more or less adopted me 🙂 My free time outside of work, being at the flat, my running, and studying is almost always spent in Seaview under their hospitality. Kim’s stock phrases are “Anything you need Pascal… call anytime you like.. come by whenever you want…”. They are an absolute Godsend, and they have made my PE experience comfortable beyond anything I would have expected or asked for.

From left to right Conrad with little Liam on his lap, Robyn with baby Alex, Bennie,  Dean, and Serina

From left to right Conrad with little Liam on his lap, Robyn with baby Alex, Bennie, Dean, and Serina

They are a really interesting bunch too. Really fun to hang out with. Kim’s parents, who I met for the first time that night are (in Robyn’s words 😛 ) like something out of the sixties. They have a shared irreverent sense of humor, they party harder than their children 😂 and they aren’t shy to share a funny story or two…

The birthday girl Kim

The birthday girl Kim

Dario and Jenelle made a late appearance. It was good to have them there, I felt it completed the picture. I have mentioned before that they have 3 daughters and a baby boy (a couple of months old now). His name is Nicholas. He seems to be growing exponentially (as infants will do I suppose), just the other day he was just a handful (literally) and now, well he is two (or three, or four) handfuls! He also just makes baby noises… Dario’s youngest daughter Victoria is an absolute ball of energy, always up to something, always on top of something and altogether entirely unpredictable. She is the life of any gathering and an absolute pleasure… 🙂

Dario with his son Nicholas, and Bennie

Dario with his son Nicholas, and Bennie

Supper was delicious! At some point in the evening a refractor telescope made an appearance. A couple of us stood on the balcony for a little while. Against the the background of Seaview’s clear sky we saw the surface of the moon, and the rings around Saturn. It was beautiful!

IMG-20140904-WA0009

Took this beauty of a pic with my phone looking through the telescope!  :)

Took this beauty of a pic with my phone looking through the telescope! 🙂

I left their house late that night, and as I was going to my car I could hear Kim trying to convince Bennie to join me for an early run the next day. “I’m on my fourth beer…” I heard him reply 😛

I was up just before 5am the next morning and I went for a 13km run along a road that runs along the shore until just before you get to Maitland beach. I went just over 6km up and then turned to run back. There is nothing quite like that run early in the morning. It’s still dark, no one else is up at that time. It’s just you, the road, and the sound of the waves crashing on the rocks. Needless to say Bennie didn’t join me that morning but he has done that run and many others before. I’ve done that run with him before in fact. Having done 2 Comrades Ultramarathons, and many mountain bike races, he is no slob. The sun was just coming up by the time I got back. 12.81km, 1hour 8mins, not a bad way to start a Tuesday morning 🙂

I showered and dressed, joined Robyn and Conrad for a quick breakfast, then got onto the N2 to Dora to start another work week.

The view from the balcony of the flat in Seaview

The view from the balcony of the flat in Seaview

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