Crescendo!

So where do I start… Let’s go with ‘What’s the worst, most hectic thing that could happen on a call?’ The absolute worst thing, in the  medical admissions ward on yet another all-day, all-night call at my little hospital…?

My answer is always the same here. In my setting a diabetic ketoacidosis, the kind of patient I should be paying all my attention to but hec I can’t coz there’ll be 20, 30 odd other admissions over the whole 24 hours. Sure that’s tough, but it happens relatively often so to spice it up a bit I would add an unconscious patient, intubated with the vital signs monitor beeping away all night (infuriatingly!😠)

 

Three. I had to look after three DKAs on call last night!! We were sitting on two, and doing alright until… I don’t really have words to describe what went through my head when DKA numero tres  was wheeled in through the door. Add to that four patients in heart failure,  two of them severely distressed, unable to get off the face-mask oxygen. Next try a phone call from the lab at about 2.30am informing me that the blood results of one of the  heart failure patients (think it was the third one I saw, 60something year old with dreadlocks, smoker…)  showed his Troponin I levels were 1110 (now there’s an ‘oh s#1t’ moment if there ever was one!) That’s a really high number,  some real damage done to the heart muscle there. Heart attack or to be physiologically correct, myocardial infarct. The textbooks say the patient feels like their chest is on fire while being squeezed really powerfully at the same time, you can’t breath, the room is closing in on you. A sense of doom. Dramatic much? 😰

 

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I rushed off from admissions, upstairs to the male ward. “Bed 1” the night Nurse in Charge said as I got there (I had called ahead). A dose of morphine for the pain, an aspirin, and sublingual nitrates to dilate the vessels supplying the heart muscle with much needed blood, nutrients, and oxygen. Keep him on face-mask oxygen. Done, for now. See you the morning ward round buddy, I thought as I walked back down. Another patient in respiratory distress, possible pleural effusion based on my clinical findings, X-ray shows total white-out of the right lung. Poke that, get a sample of pleural fluid and send to the lab. Drain a whole lot more (no more than about a litre) he’ll breath a little easier, admit him to the ward, work him up for possible tuberculosis.

 

A one hour dose-off, awake again at about 6.25am. Casualty has sent across six new patients.  Six!! Why do they do this?! 😩 No way we’ll see six patients by 8am. Some will have to be seen the new shift…

 

I have to admit that as stressful as it was I feel good about that call. Controlled chaos, is what was like. Thirty-four new admissions in all.

 

The consultant that was in charge of the post-intake round this morning is my favourite out of the four physicians in our department at Dora Nginza hospital. He’s a really intelligent guy, very well-read, meticulous. “Let’s talk about acute coronary syndrome” he says to the intern and I. “Sure Doc lets do that…” ‘Cause I haven’t been up all night working,  I need to be stretched just a little bit more 🙂 In his thick Cuban accent “What are the contra-indications to percutaneous coronary intervention?” I return him a blank look, and the intern stares down at her shoes. “Read it, tell me on Monday,” he then says.

I will look it up, sometime this weekend,  sometime in between everything else that happens in the next couple of days,  I want to I do…

Maboneng at dusk...

Maboneng at dusk…

It’s late afternoon now, I still haven’t slept off that call. I’m finishing up on this blog post sitting at a backpacker’s in the Maboneng Precinct in Johannesburg. Got here from the airport just a few moments ago. Meryl will be here in a few minutes. She sounded really surprised on the phone a few minutes ago, she hadn’t known I was coming… 😉

 

 

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Surviving sepsis and the rugger

‘After that magic run in Port Alfred a few weeks ago I was on call on the Monday, we had a heavy one, admitting over 40 patients. There was a public holiday on the Wednesday Heritage day, or braai day as South Africans prefer to call to it. The weather was not conducive to braaing, I spent it indoors studying. The next day after work I managed to drag myself out for a lazy 16km run, then I was on call again on Friday.

At the end of my call on the Saturday I went across to Seaview, and after a couple of hours of sleep at the flat I went to Kim and Bennie’s. The Springboks were playing against the Wallabies (Australia) that afternoon. Being able to kick back and watch a test match is one of my favourite things, even better when it is with friends. Bennie fussed around outside, making a fire for the braai, and Serina and Dean were in and out of the house the whole time. It was a tense game, the Boks trailed by 2 points (10-8 to Aus) for much of the game, only going up to a one-point lead (11-10) sometime in the second half. In the last 10 minutes of the game in a flurry of inspired activity they scored a couple of tries to end the game as winners 28-10. After the game I found myself apologising to everyone (much to Kim’s amusement 😛 ) for having gotten so excited (I had been shouting wildy at the screen at one point!). We then shared a delicious supper (chops cooked over the braai by Bennie and veggies and a salad prepared by Kim). I retired to the flat after we watched a movie (I watched, Kim and Bennie dosed off on the couch 🙂 )

 

I spent most of Sunday studying and getting to grips with a topic that had been on my mind quite a bit. That being sepsis. A little while before on call I had looked after a patient in sepsis. Sepsis is as bad as things can get for the body. It describes a continuum from systemic inflammation to multiple organ failure.

 

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The underlying cause in most cases is an infection (bacterial, fungal or viral although we always look for bacterial first). At the mild end of the spectrum is the systemic inflammatory response syndrome (SIRS) where one can find a very high or very low white cell count (WCC) (WCC >12 or WCC < 4; normal range is 4-10), fever or hypothermia (body temperature >38ºC or <36ºC), tachycardia (an increased heart rate) and tachypnoea (an increased respiratory rate). Moving up the spectrum (with increasing severity and mortality) there is hypotension (a decreased blood pressure) and some form of organ dysfunction (kidney failure for example). This is severe sepsis. When the hypotension is refractory (not responding to treatment) this is referred to as septic shock. Multiple organ dysfunction syndrome is at the extreme end of the spectrum.

 

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On 16 September we saw a patient on call that I assessed to be in sepsis or some degree thereof. He was a 47 year old man HIV positive with a very low CD4 count, clinically wasted, confused and incoherent.

The intern started seeing him as I was busy with another patient at the time but I looked over and heard the details of the referral as the casualty doctor wheeled him in. I immediately had patient envy…

The intern reported that the blood pressure was 80/40. “Put up a second IV line for fluids and draw blood for blood cultures” I instructed. I also thought that by the looks of him that he would possibly need a lumbar puncture. We also started him on antibiotics.

After an hour or so the blood pressure had not improved. With the accompanying tachycardia and his generally poor state although I didn’t have any blood results yet I started thinking about sepsis. I wanted to use a drug to help increase his blood pressure but wasn’t sure exactly how to. I had prescribed dobutrex (dobutamine), an inotrope (increases strength of contractions of the heart) for refractory hypotension before but that is a drug used in cardiac cases.

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I called the consultant on call and when I mentioned sepsis he said we needed to do blood and urine cultures (this is to find the source of the infection) and give a broad spectrum antibiotic. We had given a stat 2mg dose of rocephin (ceftriaxone) already but he suggested adding flagyl (metronidazole). Regarding the haemodynamics we needed to be aggressive with intravenous crystaloid fluids via two IV lines he said. We had two IV lines up but they were both peripheral, we needed at least one central line. We had already given him 2 litres of ringer’s lactate IV, and “I want to step up to a vasopressor maybe” I said. A vasopressor causes constriction of peripheral blood vessels (vasoconstriction) increasing the pressure against which the heart has to contract. “The first choice in a case like this is noradrenaline, but we don’t have that you’ll have to use dopamine” he said, and he quoted me the dose. “Keep me updated of any further changes” he said before we hung up.

 

We got the patient’s blood results back from the lab not long after that phone call. The white cell count was 41 (😱!!) which all but confirmed sepsis, he had a very low platelet count (50) which ruled out the idea of putting up a central IV line (the risk of excessive bleeding is very high with low platelets). He was also in quite severe kidney failure. It takes a couple of days before we get blood culture results so we wouldn’t have those back by end of the call…

 

Dopamine is a catecholamine, it has the effect of increasing the strength of contraction of the heart as well as the heart rate, and it also causes peripheral vasoconstriction, all of which help increase blood pressure. A 10mcg/kg/hour infusion had his blood pressure up to a much better 110/70 eventually. The goal is a mean arterial pressure of 70mmHg or more. It remained good, as long as we kept the infusion going. The reason one fusses about the low blood pressure is that at such a low level the heart is essentially failing to get blood (with oxygen and other essential nutrients) to the organs around his body. This is the definition of circulatory shock.

 

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The Surviving Sepsis Campaign started in 2002, is an international initiative that provides regularly updated evidence-based guidelines on how to diagnose and manage sepsis. We go according to these, or as close we possibly can in our approach to sepsis. That is what I spent that Sunday 28 September pouring over.

 

 

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With all the work that we put in for this patient the numbers looked to be improving in terms of his blood pressure and fluid output but he still looked in a terrible state.. with a decreased level of consciousness and bradypnoea (decreased respiratory rate). He had a very poor prognosis the consultant had explained. I was happy about the fact that he survived the night but I knew that further than that it would be touch and go once he was in the wards. Sepsis is bad news under the very best of circumstances. Patients generally have poor outcomes. According to the National Center for Health Statistics between 1999 and 2005 the sepsis mortality in the United States was 66 deaths per 100 000 people and in a study published in Clinical Microbiology Reviews in 2010 sepsis was found to be the tenth leading cause of death in the US causing 6% of all deaths. The same article mentioned that in Europe an estimated 135 000 people die of sepsis every year. These are statistics from first world settings where one has everything necessary to look after patients as well as possible. Cross over to a resource poor setting such as ours and add to that the poor health seeking behaviour of our population (people seem to only go to the hospital when they are at their very limit of tolerance) and you have a very bad picture. Importantly, sepsis is best treated in an intensive care setting where you have specialised staff giving what is almost one on one care to a smaller number of patients. Compare that to the situation in our medical admissions where we have 6 beds and one professional nurse who may or may not be assisted by a staff or student nurse, trying to make sure that every patient gets everything they need. There is a medical ICU at Livingston Hospital but there are criteria for admission (again due to limited resources) and an HIV positive patient in what is probably advanced AIDS, with multiple organ failure has too poor a prognosis to be admitted unfortunately…

 

“Why internal medicine?” an interns asked me the other day. “It suits my brain” I replied. I like to think my way through problems, slowly. Internal medicine is complex, all the systems affect one another. What’s happening in the lungs has an affect on the function of the heart, and cardiac dysfunction affects the kidneys. You can’t consider a patient’s liver function in isolation, and similarly kidney disease can cause changes in the blood pressure. All these systems and the different ways things could go wrong and what you need to do to help the patient I find really interesting. There is a hec of a lot to know, it is a vast field but I am super keen to get into it. I get ‘patient envy’ when I hear of an interesting case that another doctor has seen, I sit at the weekly internal medicine meetings at LVH and I’m in awe of the registrars and specialists because they know so much, and are so capable of making real change for sick patients. I am still at the beginning of my journey, I have been qualified for less than 3 years and there is a lot I don’t know yet. I definitely want to take it as far as I can. The CEO of our hospital has agreed to let me do the full year of my community service in internal medicine, I won’t have to change departments after the end of this month (this is my sixth month) I’m really happy about that. It will mean more time and exposure to the discipline.

 

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Onto more important matters, that of the rugger! 😛 The New Zealand rugby team (the All Blacks) is the best in the world, up until 2 weekends ago the last time they had lost a test match was in 2012! The South African rugby team (the Springboks) are ranked number 2 in the world. The All blacks are the only team in the world against whom South Africa has a negative win-loss ratio and conversely whenever New Zealand loses a game (this doesn’t happen very often) it is more likely to be against the Boks than anyone else. So this is a serious rivalry.

The All Blacks perform a what is essentially a war dance 'The Hakka' before every game. I'm pretty sure that uf the Springboks ciuld bring themselves to perform some sort of traditional African dance before games we would also start with some sort of psychological advantage :-P

The All Blacks perform a what is essentially a war dance ‘The Hakka’ before every game. Imagine if the Springboks could bring themselves to perform some sort of African traditional dance! 😛

The two teams played other on Saturday 4 October at Ellis Park stadium. Ellis Park is about two blocks away (a ten minute walk maybe) from my apartment in The Maboneng Precinct in Johannesburg CBD, but here’s the thing: I am obviously in Port Elizabeth. The game was televised obviously, but here’s the thing: I was on call on Saturday… I don’t know why the universe does this to me!! ☹ This month’s roster was such that I couldn’t swop out that call with another doctor. I was absolutely miserable about the prospect of not being able to see what would be the final game of this year’s Rugby Championship. One of the interns was kind enough to bring me a walka (mobile TV thingie) but the signal was poor on the day, so I had to put the game out of my mind and concentrate on the call and having to look after sick people (it was really difficult!) The Boks played an awesome game and won by 2 points I found out later. This means that they are actually able to do well without my watching and supporting. Who woulda thunk?! 😲

South African wing Bryan Habana running rampant!

South African wing Bryan Habana running rampant!

 

The call was not too busy on that Saturday we had 24 admissions, none of whom were in sepsis thankfully 😛 There was one lady that was very distressed, in congestive heart failure with pulmonary oedema. This is when the ‘left heart’ is failing to pump blood out to the body, there is a build up of pressure in the pulmonary vein and smaller vessels feeding into it from the lungs. Simply put, the pressure pushes fluid out of these vessels into the lung tissue. Oxygen by facemask and large doses of IV diuretics are the way to go about managing these patients. I was quite worried about her but she pulled through. I saw her during the week as she was in my ward, she became less oedematous (fluid overloaded) with the diuretic therapy and I discharged her after a few days. It was nice to see her get better.

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Crazy times…

Being on call is the most enjoyable part of my job. I am more stimulated, more on edge when I’m on call than at any other time at work. At this point any medic reading this is pulling a very ugly face in disagreement, but let me explain myself. When you are on call, you’re up and about, and the majority of the patients that you see are brand new (in a manner of speaking) ‘fresh’ cases and you have to apply yourself to elucidate a diagnosis. This is in contrast to everyday ward work, where most of the patients have a diagnosis and you’re just managing them until they are well enough to be discharged home. In the admissions ward however, when you walk out and say “Next patient please” you almost have no idea what’s coming. That makes it interesting, it is something to work on, something to figure out. The energy and stress levels (and excitement, to a certain degree) are definitely above normal. I really enjoy it. The problem though (and here ALL medics will agree with me!) is that we have to do this for 24hours. If you count in the post-intake work the next morning (you have to count it, it isn’t optional) it can actually add up to just under 30hours.

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Not too long ago I was on call 4 times within a period of one week and a half…

We usually finish a call at about 11am, having started at 8am the previous morning. The immediate instinct is to then head straight home and pass out. This normally translates to 2-3 hours of sleep for me, after which I get up and try to make something of the afternoon or evening. That night you get a full night’s sleep and awake the next morning feeling like a million bucs, and you go off to work again. At work as the day goes on you notice that although you feel good for having gotten some good sleep the previous night, you’re not quite 100%. It is only after yet another full night’s sleep that you start to feel like a normal human being (in the sense that your brain and body actually do what you instruct them to do, and not a delayed slower version!).

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This crucial second day post call (when I would normally start to feel like myself again) was stolen from me repeatedly over a 10 day period… 😐 I was on call on Saturday 19 July, then again on the next Tuesday, Friday, and lastly Monday 28 July.

During the second call (Tuesday) we saw a total of 40 patients. I have mentioned before that the average intake at medical admissions at Dora is approximately 30. Less than 20 admissions means that you’ve had an easy call. More than 30 and it’s been a hard one. It also depends on how sick the patients are. You could see only 12 patients but if 2 of them are DKA’s and/or you have someone with decreased consciousness on a ventilator you’ll work pretty hard all night, regardless of the low numbers. So 40 patients was a big night… At about 5.30pm the intern turned to me and said something implying that he had a feeling that we were in for a rough one that night. I didn’t reply, mostly because I agreed. You sort of have a sense for that, when on call, all of which (semi-superstitious as it is) is easy to confirm in retrospect of course.

In a way you learn to deal with the tiredness that comes when you’re currently on call but your body hasn’t quite fully recovered from the last call. You push on and keep working. But the weariness does come across in different ways I think. Like maybe you become irritable… Earlier on during the call I had some tense words with the Nurse in Charge of my ward over the phone. She called me from the ward saying there was a patient that had been discharged without a proper referral note. She was supposed to be followed up at eye clinic or something. Why hadn’t they gotten one of the doctors who was working in the ward during the day to do it, I asked? It was just after 5pm at the time and there was literally nothing I could do about it then. I hung up the phone. I think that I was in the right, but the aggression was probably unnecessary. Later that evening I was obviously still cranky, I refused to accept a referral from psychiatry. The doctor on call for psychiatry called about a patient who had a seizure in their ward. This was a 30something year old lady who had major depressive disorder and epilepsy. She had overdosed on her anti-epileptic medications and as a result had been admitted to the psychiatric ward. The psychiatrists had stopped her anti-epileptics as her blood levels were obviously high on admission. After a few days her levels decreased and became sub-therapeutic, hence she ‘fitted’. So we know the reason she had the seizures, why then should I have to admit her?! “Pull bloods for levels, restart the anti-epileptics and we’ll come and see her when you have the results..” I said. We got off the phone and I carried on seeing new patients. She called me again about 20minutes later, and said that she had just spoken to her consultant, who also happens to be the head of department (HOD) for psychiatry. She said that the matter was not up for discussion, the patient had to be transferred to the physician on call. Sensing that I was starting an inter-departmental incident I accepted that they transfer the patient over to medical admissions. We would pull the blood levels and observe her for further seizures, and sedate her if necessary.

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Psychiatrists only treat pure psychiatry. If a patient presents with a history or symptoms that are obviously indicative of mental illness (depression, mania or psychosis-often substance induced being the most obvious and common) and they find even the slightest derangement in any of the results of the blood tests the assumption is that the presentation has a medical cause and we (that is internal medicine) have to admit and manage the patient. Similarly, if a patient in the psychiatry ward has a cough, they won’t put the patient on antibiotics, they won’t so much as do a chest x-ray! They call us up and transfer the patient to us. To be fair this is not something that is particular to the psychiatry department at my hospital, it is what is done according to the national guidelines. In other words the psychiatrist was right to insist that I accept the patient. I know this but that doesn’t mean I have to be happy about it, and on a night when I’m so busy that I’m certain that neither I nor my intern will get the usual one or 2 hours of sleep, I certainly won’t cheerfully say yes to that sort of bureaucratic nonsense. The patient in question did not have any further seizures while she was in medical admissions. We restarted her anti-epileptic medications as logic (and the most basic common sense) would have dictated.

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The night was very busy. In order to try to make our post call round a little more efficient, from about 5.30am after printing out all the patients’ blood results the intern went to the short-stay ward and brought back all the patients that were ambulent, and had them all sit on the waiting bench immediately outside the admissions ward so that at about 7.30am when we started the ward round with the consultant we would bring the patients into the admissions ward one at a time to be seen and examined by the consultant, a plan would be made for their management, they would then leave the ward and we would bring in the next patient. Naturally this could only be done with the patients that were well enough to be walked up and down. This was much faster than the usual method, where we as a team would go to the patient see them and then have to go back to the admissions ward to check their x-ray on the computer system (there is only one computer in all of medical admissions) and then all walk back to the short-stay ward to see the next patient (this is after having been up since the previous morning!) It was a better system, but we had so many patients that it still took us a hec of a long time to work through them.

Later on that morning I passed by my ward to apologise to the Nurse in Charge for my telephonic aggression the previous afternoon. She was very motherly about the whole thing, saying she understood, and that we were all under pressure. I got off easy I think, I have heard stories of other doctors having to conjure up gifts (in the form of chocolate cake, and the like 😛 ) as penance for not being nice to a professional nurse. Not long after that I received a phone call from my head of department, he was very unhappy. What was this about me not accepting a psychiatric patient, he wanted to know. I explained myself , admitting I had been in the wrong but that ultimately I had accepted the transfer. Not satisfied he continued to rant at me over the phone, I had never seen or heard him like this before. He calmed down a little after a few minutes, and asked me how the patient was doing and asked about her blood anti-epileptic levels. I explained that she was doing fine.

The reason he was so irate with me, he explained later in a much calmer conversation (during which I was very contrite) is because he would have to answer for the incident at the inter-departmental meeting later on. Although I have also heard from other doctors that have worked at Dora for a long time, that the HOD at psychiatry is a woman that is not to be trifled with and that our own HOD, while being an experienced, capable physician is of a somewhat meeker constitution, and it is debatable how well he would fare in a direct consultant-to-consultant pow wow.

We ended our round finally and I had one last task. One of the patients we had admitted was a young lady, HIV positive, in severe renal impairment, florridly fluid overloaded, and acidotic. She was known to the renal unit at Livingston Hospital (LVH) so I gave them a call and they said to transfer her over to them for renal dialysis. I have previously written at length about trying to organize patient care telephonically, and the inefficiencies thereof. Well the simple exercise of organizing to get her to LVH took 6 phone calls… I had to find out who the nephrologist on call was, I then had to get hold of him and explain the case. After he agreed I had to speak to the physician on call at LVH. She wasn’t very nice to me initially (this seems to be a recurring thing between me and whoever is on call at LVH POC.. but it is probably because she thought I was creating more work for her-which I kind of was, but that’s besides the point surely? 🙂 ) and lastly I had to call for the ambulance.

I was done with all of that by about 1.30pm and I left the hospital thinking that since I had the afternoon I should go and get some stuff done, maybe some grocery shopping, get the car washed, and other such admin. All of this instead of the obvious (to get some sleep!!) and after that I thought, I’ll get back and sleep for 2 hours and then go for a run. That was the plan. I was home by about 15.30, and fell promptly to sleep. I set an alarm for 2 hours later, and it may or may not have gone off, I will never know. I remember a brief phone conversation with Meryl, and I may have mumbled something uninteligable to my flat mate when he got back from work, but it is all a blur.

Sleep is but a cousin of death and all that, blah blah blah... post call slumber=dead to the world for a few hours at least

Sleep is but a cousin of death and all that, blah blah blah… post call slumber=dead to the world for a few hours at least

The next day was an average slow day in the ward. Got home in the afternoon and squeezed in a couple of hours of studying and I should have gone for a run but I didn’t, I can’t recall why…

I was on call again on Friday. Friday calls are supposed to be quite relaxed. Who wants to be sick on a Friday, let alone on a Friday night, right? It actually reflects in our numbers, some of the other doctors tell stories of Friday calls when they admitted 15 or 16 patients, or something along those lines. In contrast, our colleagues over at surgery have a much rougher time of it on Fridays. People become very excited at the end of the week, consume copious amounts of alcohol and inflict bodily harm on one another, keeping paramedics and trauma surgeons quite busy.

We saw 29 patients on this call, a welcome respite from the madness of the previous call. And speaking of madness and crazy times, I did receive a call from psychiatry again. They had a 30something year old man that had been transferred from LVH. He had a history of multiple previous admissions for substance (read: marijuana) induced psychosis and his latest presentation was no different. He had been transferred to Dora because he was from our drainage area. In the ward he had developed dyskenias (involuntary muscle contractions) and they suspected he was developing neuroleptic malignant syndrome (NMS). This is a rare phenomenon that can be a side effect of antipsychotics. It involves severe muscle rigidity, a raised body temperature and blood pressure instability. Asides from stopping the antipsychotics,  the management is mainly supportive, keeping the patient’s body temperature down, IV fluids and a drug called dantrolene can also be used. So NMS is a syndrome that can occur as a side effect of medicines prescribed by psychiatrists and it has to be managed by the physicians…

I kept him in the medical admissions ward. He had no further dyskinesias that night, but they did recur unfortunately the next morning, and we had to admit him to one of the male wards.

During the same call I got called to one of the male wards about a patient who had jumped out of a window (the medical wards are on the first floor). What kind of a patient jumps out of a window? A psychotic patient. What is a psychotic patient doing in a medical ward? I hear you ask… He has a lower respiratory tract infection, which needs antibiotics, which cannot possibly be given by psychiatrists…

Crazy doctors, and patients aside, we also saw a 30something year old lady who had previously had TB. She presented with a 4 day history of shortness of breath. She was clinically wasted, and somewhat dyspneic. Her chest x-ray showed a pneumothorax on the left side. Roughly speaking, this is when there is air between the chest wall and the lung. Not a healthy situation. It can occur spontaneously due to the changes in the lung of a patient that has previously had TB, or a long time smoker that has emphysematous lungs. The lung ‘collapses’ away from the chest wall, and this effectively decreases the amount of air that can enter the affected lung, hence the shortness of breath. The potential danger with a peumothorax, is that the ‘air pocket’ between the lung and chest wall can get bigger, making the patient hypoxic.

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Our lady was not overtly distressed, her blood oxygen saturation was 99% in room air (anything above 90% is acceptable).

The next morning I inserted an intercostal chest drain (ICD) into her. This involves inserting a drain (tube) in between 2 ribs into the chest into the space between the chest wall and the outside of the lung, and stitching the the drain to the chest wall. Over time air is sucked out of that space through the tube and into a drainage bottle. I did this insertion under the supervision of my intern and the doctor that was next on call. This is because funnily enough, with all that I had seen and learnt at Bara hospital before, I had only once or twice had the opportunity to insert an ICD. Both times it was under the supervision of a registrar. I had never done one on my own so I wasn’t comfortable doing it during the night on call. The intern had done a few during his first 2 months at Livingston Hospital and the other medical officer had inserted plenty. I inserted the ICD successfully, and that was the end of that call.

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I am happy to say that I saw that lady in the wards sometime during the next week, the ICD had been removed because a repeat chest x-ray after a couple of days showed that the pneumothorax had resolved. She looked better, less short of breath.

I got home at about noon that saturday, got the obligatory 3 hours of sleep and actually managed to get myself up for a 14km run that evening. Being post call, it was a sluggish effort, quite possibly the slowest 14km ever run through the streets of PE on a saturday evening :-P. I just felt that I had to, having not run since the previous Monday. Sunday morning came and I slept in till about 9am, taking full advantage of not having to be up for work or a call. After eventually dragging myself out of bed at about 9.30am I did about 2 and a half hours of studying. I have been going through Ganong’s Review of Medical Physiology for the last few months at a veritable snail’s pace. I am currently on the 3rd chapter out of a total of 7. I put in 2-3 hours of studying 2-3 times per week. Sometimes I’m lucky if I get one good study session in the whole week. There is so much to get through, it is actually a little bit scary. There are doctors out there who are married with kids and they manage to do this. I have a much simpler life than that and I don’t know how they do it! This is what I feel I have to do though, just to take the first steps towards becoming a specialist physician one day… Having said that I have given up on setting myself a time by when I have to finish, I will simply keep studying until I’ve covered enough material that I feel ready to register for and write the internal medicine primaries.

Work study, run. Work study, run. Work study, run...

Work study, run. Work study, run. Work study, run…

I was on call again on Monday 28 July.  We had another quietish one thankfully, 26 patients admitted. No psychiatric referrals this time. After that I wasn’t rostered to be on call again for an entire week. The crazy times I was happy to note, were over for a little while…

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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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Bara Dora, potato potaato…?

My entire experience as a medical doctor thus far is coloured by the fact that I spent the last 2 years working at Chris Hani Baragwanath hospital (Bara), in Soweto. Asides from the short stints we did as students at the other public hospitals in and around Johannesburg, Bara is where I learnt how to function as a medic and it is almost all I know of the inner workings of a hospital. So I wasn’t surprised, just a little amused, when a few days ago, I found myself telling a patient to “…take your script to the pharmacy here at Bara…” I had to stop myself. “Sorry ma’am I meant Dora, the pharmacy here at Dora Nginza hospital…” Bara, Dora. The 2 almost sound the same in my head sometimes. The Dora experience thus far however, has been quite dissimilar…

 

I was on call for the first time out here a few days ago. From 8am on Monday to 8am on Tuesday morning I was the physician on call, or POC as they call it at my new hospital. During that time the intern and I saw about 35 patients and admitted 28. It was during this time in the admission area that my perception that my current place of work is so different from my previous hospital was most distinct. During my time on call I would clerk a patient, and while doing that I would start forming an idea in my head, of what I thought their diagnosis might be, and once I had finished the examination I would have a bit of a think about it, and maybe add to, or change something in my notes. Or perhaps I would come to the conclusion that what I had already written down was ok, and that I was happy with my working diagnosis.  I  was on call, and I had the time to think about what I was doing. I actually had time…

 

The first 4 months of my internship back at Bara hospital in 2012 were in internal medicine, the same department that I have chosen to work in now for my community service. On a day call, if it was a bad day I would  see the same number of patients (about 30) in a single afternoon. The best description I can come up with regarding those 4 months at Bara is that it was like being caught in a fast flowing river, going downhill. You just went with the current,  and you had very little control. Then you went home, invariably a lot later than you would have liked, slept, got up ridiculously early the next day and got swept up by the current again. Ward rounds, bookings, ward work, the odd meeting and next thing you know it’s way past 4.30pm in the arvo and you’re still at work. You finish up as much as you can, go home, sleep, and repeat the cycle on the morrow. I must admit that I speak only for myself. Although I know that there were other interns who felt the same way, there were those who were awesome, and thrived in that intense environment. Mostly I tried to manage the heavy workload as best as I could. Medical internship should ideally be a good balance between learning, and working like a slave. At Bara there were some days when I got that balance right and (or but? 😛 ) there were more days when I was just a workhorse (or a rat, yes more like a rat in a big warehouse). I learnt a very fast, instinctive type of medicine. Fast triage, a brief clerk getting the history and examination almost simultaneously, a provisional assessment, investigations and move on to see the next patient while awaiting the results of the tests you’ve requested. The pressure was such that very often the emphasis was on seeing and managing patients as quickly as you possibly could while being safe, because for every patient that you were seeing at a given moment there were invariably numerous more waiting to be helped. That was the typical situation when on call in the admission ward. Once a patient was admitted and in the wards it was the daily slog of seeing them and each of the 20something other patients you might have on your slate, making sure that they were well managed. You did this under the guidance of a registrar, and a specialist consultant, but as the intern you did shoulder a fair amount of responsibility. The number of patients one always had though, was such that all the time you remained conscious of how much there was to do, and how little time there was to do it all.

 

Dora Nginza hospital is less busy, and I feel somewhat more in control, I can be a little more deliberate in everything I do regarding patient management. I feel that it is a better pace that I can learn at and develop further. The physician in charge of the ward I work in keeps me and our 2 interns on our toes by asking very probing academic questions on the daily ward rounds, and there isn’t a day that goes by without his giving each of us a topic to read up on and present in a short sit-down discussion the following day. One of my fears after having left Bara, which is an academic hospital was that I would end up in a new work environment with doctors who hadn’t read anything new in years and I wouldn’t learn anything further than I had in my short career thus far. There doesn’t seem to be much danger of that happening, thankfully. Asides from being in a coastal town that is quite outdoorsy, catering to my sporting needs it seems that there will be no halting the learning curve. Along with my own studying towards hopefully writing SA College of Medicine exams sometime soonish (specialists don’t make themselves!) I’m having to squeeze in extra material every day that helps us better manage our ward patients too. Port Elizabeth was a good, lucky pick I think…

 

As I’m writing this it is late afternoon on Sunday. I just woke up, having slept since about 11am when I got back from the hospital where I was on call again since yesterday morning. We had a busy one for a weekend call, having again admitted about 30 patients. Some were seriously ill, others not so much. One gentleman that comes to mind is a 40something year old who was referred to us from casualty in a considerable degree of respiratory distress. We put him on oxygen by facemask but he just didn’t seem to get better, writhing and breathing laboriously. I ordered an X-ray of the chest, and while we were waiting to be able to view the film his girlfriend, who had escorted him in explained that he hadn’t been to the toilet in about 3 weeks. So we had a closer look and on further questioning he explained that most of his discomfort was in fact in the abdomen. He was given an enema, passed a little bit of stool and suddenly was much brighter, saying that he felt a lot better! His chest x-ray did show an extensive opacity in the left lung so we did admit him, but his story did provide for a fair giggle with the consultant on the ward round the next morning 🙂

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