As Saturdays go…

Something woke me up. It was about 8.30am which as far as I’m concerned, is much too early for a non-work day! 😛 What is that sound? I thought, oh yes my phone was ringing, it was Meryl. “You’re still in bed?!” she said, “Uh huh…” I replied. Yeah I was still on bed!

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We hung up after a short conversation and since I was up (No. Awake, but definitely not up!) I then downloaded and watched a movie on my tablet, in bed (as one does!) I felt like something light and meaningless. Maybe it was a romcom and maybe it wasn’t, I shan’t say.

By the time that was done it was about 11am, a much more appropriate time to arise I thought. And so I did, transferring myself from the comfort zone that was my bed to the equally comfy, though not nearly as laid back chair at my desk. Book time methinks, I said to myself and proceeded to put in a couple of hours of studying. I’ve been in a good groove lately, doing at least a couple of hours almost everyday. I call it my #geekmode. It’s a good place to be in if one has a bunch of material that one needs to get through. Immunity, infection and inflammation is what I’m currently perusing, a mildly interesting but necessary section on my quest to recap all basic medical physiology.

 

#geekmode!

#geekmode!

Living in a place like Port Elizabeth makes it just about unforgivable to spend all day indoors, so in the afternoon I went out for a run, an easy 13km. The weather has been awesome for the last few weeks, getting into summer. The shorts-and-slops are definitely out again, although there is still that incessant PE wind.

Baakens street,  Port Elizabeth Central.

Baakens street, Port Elizabeth Central.

 

 

PE Central.

PE Central.

I run a slightly different route everytime I get out onto the road,  but invariably pass through some very disparate bits of the city.

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Beach road,  Humewood.  Just at the waterfront.

Beach road, Humewood. Just at the waterfront.

The tree-lined La Rouche road in Humewood.

The tree-lined La Rouche road in Humewood.

Got back to the flat in town in the late afternoon, did a quick work out, shower and then got back to watching movies 🙂

Absolute bliss. I didn’t have to be at work, I wasn’t on call, and there wasn’t anything else really pressing. A day as free as this one was (even though it is the weekend) is a rarity in my adult life. When one like it does does come around I embrace it wholeheartedly! 🙂

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Jozi, Meryl and Ulysses…

 

Johannesburg...

Johannesburg…

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Meryl and I chilling. That's my post-call face on Friday evening

Meryl and I chilling. That’s my post-call face on Friday evening

If anyone asks, I’m off to go see about a girl… Those were my last words as I left Port Elizabeth for Johannesburg on Friday afternoon. For some odd reason I have had Matt Damon and Robyn Williams on my mind a lot lately. So come Saturday morning Meryl and I were at our favorite little DVD shop on Queens street in Kensington on a mission to fulfill my latest little resolution. Unbelievably they didn’t have Good Will Hunting… “It’s too old,” the lady said, “Too old?! 1998 isn’t old… and besides it’s a classic!” I said in exasperation. It was the second DVD place I had been to that morning that didn’t have it. The nice lady even called another branch but they also did not have the film, presumably for the same reason. “…Unacceptable!” I exclaimed, only half joking…

So we proceeded to choose another one, then two, then six movies, mostly because we couldn’t agree on what to get (we never do apparently, according to the lady that works there 😌) Walking out with that number of movies meant that it was officially going to be that kind of afternoon, which neither of us minded as that really is one of our favorite things to do together.

Getting breakfast at Uncle Merv's, Maboneng.  Highly recommended,  they have an awesome selection of smoothies :-P

Getting breakfast at Uncle Merv’s, Maboneng. Highly recommended, they have an awesome selection of smoothies 😛

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There was a rugby game later that afternoon, the Springboks are currently in Europe and were due to play against England. I was forbidden to take time out to watch 😓! “It’s just 2 hours I’ll be across the road at the Troyville Hotel and back here immediately after…” I pleaded. “So it’s QT vs the test match eh? are you going to defy your woman?” Rodney, my best friend over the phone, having a giggle at the tussle I was in. As a married man he has much experience in these delicate matters. I like to think I’m an intelligent man, so there was no rugby that day. My (subtle) sulk was met with a dismissive “You can always Youtube the highlights later!” Really…

 

Tha evening Rodney came over and he, Meryl and I hung out with a new acquaintance of ours, Ashley. She is an American living and working in Swaziland, who was passing through Johannesburg (as one does) on her way to Cape Town. We all got stuck into one of the most interesting conversations I have had in a long while; gentrification, reincarnation, heaven and hell, Anglicans and Catholics, and child rearing. How’s that for a list of topics? And all before any of us had any dinner! 😋

The next day I turned 31. Just like that. “Je ne sais pas comment j’en suis arrivé à ce point!” Me, in a conversation with my dad on the phone. Time really does just go on, regardless of and in spite of you paying attention. I mean I know exactly what I’ve been up to for these past 31 years and it’s not that I have any regrets or anything but jeepers has it been 31 years already?!

Just the other day I was like 19 years old! :-o

Just the other day I was like 19 years old! 😮

Not that I necessarily would have but there wasn’t much opportunity for any kind of celebration as I had to fly back to Port Elizabeth in the afternoon. I got what I wanted though, some time with my girl over the weekend, and seeing Rodney the night before. My mother, and both of my sisters also called, Muriel in particular sent me a video over WhatsApp of a bunch of little Smurfs singing happy birthday, which I quite enjoyed! 🙂 Henriette, a friend of mine, came over and she met Meryl for the first time. We all shared a quick lunch at Maboneng’s weekly Sunday Market. Then I was off to the airport, and back to PE.

Curiocity Backpackers

Curiocity Backpackers

A good place for a night or two if you ever pass through Jo'burg

A good place for a night or two if you ever pass through Jo’burg

The walls of Curiocity Backpackers, where we stayed over the weekend are adorned with words, parts of Lord Alfred Tennyson’s ‘Ulysses’ one of the greatest pieces of writing ever penned. ‘… I cannot rest from travel… How dull it is to pause, to make an end, to rust unburnished…’ Fitting, for a place continuously housing restless travellers but also I think, as the writer may or may not have intended, quite inspiring for a cerebral soul such as myself. Everytime I walked past a paragraph on a wall I couldn’t help thinking and imagining. I felt overwhelmed with a sense of possibility that the words seemed to suggest.

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That is what was on my mind as I got onto the plane. One could go anywhere (in the world) if one wanted to really…

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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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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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