so back at work after a brief studying hiatus, and things seem to be getting a little bit worse, every day... to explain this post i am going to need to give a brief background about the two tiers of healthcare in this country: private care: expensive, requires a 'medical aid' (medical insurance) and top class care in hospitals that look like hotels, plentiful specialists and very little waiting lists. this level of care serves about 10% of the population. the state system: overrun, poorly staffed with underskilled nurses and doctors, rampant with hiv/aids and trauma, long waiting lists (3 -5 years for a hip replacement!) and serves the other 90% of the population, and is obviously free. (or at least cheap).
i work in the state system, in the tertiary care centre in cape town, which, on paper, has everything you could want in a hospital: MRI and CT scanners, all departments represented, including the smaller ones like rheumatology, theatres running 24 hours a day, and dedicated specialists and a lot of registrars (specialists in training), interns and medical students.
in the unit where i work, which is for acute medical emergencies, we see a broad spectrum of medical problems, everything from acute MI's to garden variety pneumonia. we have a triage system which is supposed to ensure that the most critical patients get seen first, and at least 3 doctors on duty at all times.
the problem is this: the level of patient care in this unit is unacceptably low. yesterday on the 4pm ward round, we encountered a patient see in the morning with a DKA (serious complication of diabetes), who had not received any of the meds charted for her, nor had she had her blood glucose checked since 7am that morning. a man was discovered on the same ward round, dehydrated as a piece of bark, cachectic and in pain, without any patient notes. no one was really sure when he had come in, or what his problem was, or indeed what the plan was. a patient was sent back from a referral hospital: she had a CT brain scan in the unit the day before, which noted severe hydrocephalus, and instead of being referred onto the neurosurgery team, was shunted back to the peripheral hospital. i wonder if anyone even checked her ct scan result? by the time we saw her, she was not looking well...
we routinely keep ventilated patients in our unit while they wait for icu beds. while they are in the unit, they will not get any routine obs (not enough staff), and may not even be attached to a cardiac and blood pressure monitor (not enough monitors). two weeks ago a patient went into cardiac arrest and no one knew until half an hour later as the alarm had been disabled on the monitor, and the curtain had conveniently been closed around them. is this the kind of care you would want for your family?
most of the time i can handle this kind of disaster, the persistent denial of the basic right to good healthcare, by doing the best I can personally do, and trying to forget the rest. but somedays, like yesterday, it made me really angry. why is no one doing anything about this? why has the lack of nursing staff not been raised with the nursing admin? why does no one else, especially not the consultants in charge, get angry?? everyone on that ward round just stood and shrugged their shoulders.
it also doesnt help to point fingers and blame people: there is a failure in the system at so many levels, from lack of equipment to lack of staff to simple lack of space and beds.
i know life isnt fair... but really. just because you are poor, does it mean you are entitled to lesser care than those who can pay more? back at work again this afternoon, hoping today's shift will be a bit better. thanks for putting up with the little rant.
Saturday, August 29, 2009
Thursday, August 27, 2009
Exams: done.
Finally completed the awful exams... phys and pathology good, anatomy and pharms not so good... we shall see. It is easy to forget how much information there is for us to learn, and while I've done it all before, that was a long time ago, and now people expect a lot more of you, and the standard is much higher...Also managed to successfully complete my advanced trauma life support course: so feeling particularly academic at the moment! celebrated with a lot of wine with good friends last night. will post more soon, lots of things going on at work!
Friday, July 24, 2009
Back in the homeland
Yes folks, its true, I have returned to beautiful SA and have embarked on a four year specialization program in Emergency medicine. Its good to be back and near my friends and family, and work is going well, although it did take a bit of time to adjust my attitude and expectations back to the state health system here. Will write a more detailed post soon, but let me just say this:
Of all the things that amaze me the most about where I work now, this is the best: I am currently in the Medical emergency dept (ie, only medical emergencies, no trauma) of a tertiary hospital in the second biggest city in this country.... and our (only) ECG machine still uses those old school sucker attachement bits, you know the ones you have to use with that sticky blue jelly? No neat little ECG stickers for our patients. The other charming thing about this particular machine is that lead V5 (chest lead 5) doesnt work. So, if you come in with chest pain and happen to be having a lateral MI, unlucky for you. I think the thing that amazes me the most is the complacency with which these facts are accepted: by everyone including the consultants! Come on folks, this is not the middle of the bush somewhere! This is a tertiary, referral centre! Anyway. That is my little rant for today.
Of all the things that amaze me the most about where I work now, this is the best: I am currently in the Medical emergency dept (ie, only medical emergencies, no trauma) of a tertiary hospital in the second biggest city in this country.... and our (only) ECG machine still uses those old school sucker attachement bits, you know the ones you have to use with that sticky blue jelly? No neat little ECG stickers for our patients. The other charming thing about this particular machine is that lead V5 (chest lead 5) doesnt work. So, if you come in with chest pain and happen to be having a lateral MI, unlucky for you. I think the thing that amazes me the most is the complacency with which these facts are accepted: by everyone including the consultants! Come on folks, this is not the middle of the bush somewhere! This is a tertiary, referral centre! Anyway. That is my little rant for today.
Tuesday, July 7, 2009
Wear sunscreen
Remember the song a couple of years ago, based on a speech that someone gave to a graduating class? I think it starts.. 'Ladies and gentlemen, if I could offer you only one tip for the future, sunscreen would be it.....'
Well here are a couple of photos to show exactly why this is good advice. This young Irish lady took herself off to a holiday in Spain, and thought it best to sit out in the midday sun. She claimed she had factor 50 on, and that she was only out in the sun for 10 minutes, but as my hero Dr House says, ' All patients lie'. The woman could hardly walk!
The problem with a country like Ireland (where the sun hardly ever shines) is that when it does get sunshine, everyone goes completely mad and takes off all the layers and roasts themselves outside. The same happens when they go off on their annual trek to Spain/Portugal/Lanzarote/anywhere with a normal amount of sunshine hours per year.
Easily sorted out with some anti inflammatories and cold packs and aqeuous cream, my main advice to this woman was avoid the sun. For the rest of her life!
Thursday, June 11, 2009
How not to annoy your ER doctor
Dear patient presenting to Casualty
The following guidelines may make your visit to us more pleasant:
1) This is an Accident and Emergency dept.... that means if an accident or emergency comes in, it is dealt with before your upper respiratory tract infection or lower back pain that you have had for six weeks. There will be a waiting time. It will not help to complain. Get over it.
2) We know that twisted ankles/broken bones/dislocated joints are painful. So do you, obviously. Then why have you not taken some pain relief before coming in? Paracetamol is available at Tesco!
3) Please listen to what we are telling, it will make your life easier in the long run. Do not interrupt us with long stories of how bad your GP is, or that you are going on holiday next week and cannot come for your follow up appointment. We will only get cross.
4) We really are trying to help you. But not giving us an adequate history, or brushing over important questions will not help us to help you. I know its embarrassing to talk about your last menstrual period or your bowel habits, but really, I am not asking to make conversation, I am asking as I believe there may be a useful tip in this information which will help me make a diagnosis.
5) We are not stupid. Do not lie to us, we wont believe you and will certainly laugh at you privately afterwards. No one believes the story that you 'fell' onto that glass bottle/vibrator/lightbulb that is now wedged in your anus. Nor do we believe you when you say you drink 'only on weekends' but have an alcohol level of 446 on a Tuesday afternoon.
6) Please use your common sense: rinse out your eye if you have something in it, take a pain killer before coming in with a headache, dont drink and then engage in dangerous activity, like driving.
7) If you come in on a spinal board in a hard collar, it is because the paramedics who assisted you felt you were at risk of a serious neck injury: please dont argue with us about having it on you/take it off and start shouting at us/complain persistently. We will in turn, a)get you off the board as soon as possible and b) be nice to you when you are in shock from your accident and c) give you adequate pain relief.
8) Casualty is not a dating service. Flirting with/winking at your doctor is NOT appropriate, especially when you have just come off the farm, are covered in horse shit and have a dislocated ankle. Or ever, actually.
9) We know you think your child is sick. But if they are running amok in Casualty, breaking things and gleefully tripping up old people, we are not going to be too sympathetic. Sorry. If you sit by and watch while your child does these things, we are definitely not going to be sympathetic.
The following guidelines may make your visit to us more pleasant:
1) This is an Accident and Emergency dept.... that means if an accident or emergency comes in, it is dealt with before your upper respiratory tract infection or lower back pain that you have had for six weeks. There will be a waiting time. It will not help to complain. Get over it.
2) We know that twisted ankles/broken bones/dislocated joints are painful. So do you, obviously. Then why have you not taken some pain relief before coming in? Paracetamol is available at Tesco!
3) Please listen to what we are telling, it will make your life easier in the long run. Do not interrupt us with long stories of how bad your GP is, or that you are going on holiday next week and cannot come for your follow up appointment. We will only get cross.
4) We really are trying to help you. But not giving us an adequate history, or brushing over important questions will not help us to help you. I know its embarrassing to talk about your last menstrual period or your bowel habits, but really, I am not asking to make conversation, I am asking as I believe there may be a useful tip in this information which will help me make a diagnosis.
5) We are not stupid. Do not lie to us, we wont believe you and will certainly laugh at you privately afterwards. No one believes the story that you 'fell' onto that glass bottle/vibrator/lightbulb that is now wedged in your anus. Nor do we believe you when you say you drink 'only on weekends' but have an alcohol level of 446 on a Tuesday afternoon.
6) Please use your common sense: rinse out your eye if you have something in it, take a pain killer before coming in with a headache, dont drink and then engage in dangerous activity, like driving.
7) If you come in on a spinal board in a hard collar, it is because the paramedics who assisted you felt you were at risk of a serious neck injury: please dont argue with us about having it on you/take it off and start shouting at us/complain persistently. We will in turn, a)get you off the board as soon as possible and b) be nice to you when you are in shock from your accident and c) give you adequate pain relief.
8) Casualty is not a dating service. Flirting with/winking at your doctor is NOT appropriate, especially when you have just come off the farm, are covered in horse shit and have a dislocated ankle. Or ever, actually.
9) We know you think your child is sick. But if they are running amok in Casualty, breaking things and gleefully tripping up old people, we are not going to be too sympathetic. Sorry. If you sit by and watch while your child does these things, we are definitely not going to be sympathetic.
Sunday, May 31, 2009
The ones that get to you
Emergency med staff can appear to be callous, or cold hearted, or unemotional. We appear this way because we have learnt to protect ourselves against the constant barrage of disaster which appears before us every day: the heart breaking stories we hear and the evidence of human cruelty, day in, day out. Thats not to mention the HUGE amounts of stupidity we are faced with. We have to protect ourselves emotionally, because otherwise we wouldnt be able to do our jobs properly, and none of us would have family lives. So we learn to deal with patients... and then forget (emotionally at least) the things we have seen, so we can carry on.
But I believe every casaulty staff member has a pile of stories of patients that really 'got to them': the ones that you cant forget. These are mine:
The lady who tried to set kill herself by dousing the room, her blankets, and herself in paraffin and then setting the whole lot on fire. She came in alive.... barely. She had about 95% burn wounds (no exaggeration). She died later that night, on a morphine IV line, alone. I cant smell paraffin today without thinking of her.
The little kid who came in when I was an intern, with an hemoglobin of 3,4 and severe jaundice. According to his mother, he had been sick for one day (I doubt it..) He died before we could even start transfusing him, and I never did find out what it was.
The 1 year old who was brought in with 'scabies': sure enough, she had a scabies rash on the backs of her hands, but when I turned her hands over, her palms showed something much more ominous: cigarette burn wounds. Further examination revealed bruising in the shape of fingerprints all over her back, and more burn marks on her stomach. Although I did all the right things medically and legally, it stills upsets me: how can you burn a 1 year old's palm with a lit cigarette?
The 95 year old woman who came in with a pulse rate of 25, awake and talking. Together with her and the family, we decided on no invasive interventions (ie no emergency pacing). She was so polite and grateful for everything we did. She died later that night surrounded by family.
The first family I had to 'break bad news' to: I was an intern, shocked from my first 'real' resus and had to tell the chap's family that despite our best efforts, his MI had got the better of him. They all (of course) started wailing inconsolably, which left me floundering for words and trying not to cry myself.
I cant forget them, even if I wanted to.
But I believe every casaulty staff member has a pile of stories of patients that really 'got to them': the ones that you cant forget. These are mine:
The lady who tried to set kill herself by dousing the room, her blankets, and herself in paraffin and then setting the whole lot on fire. She came in alive.... barely. She had about 95% burn wounds (no exaggeration). She died later that night, on a morphine IV line, alone. I cant smell paraffin today without thinking of her.
The little kid who came in when I was an intern, with an hemoglobin of 3,4 and severe jaundice. According to his mother, he had been sick for one day (I doubt it..) He died before we could even start transfusing him, and I never did find out what it was.
The 1 year old who was brought in with 'scabies': sure enough, she had a scabies rash on the backs of her hands, but when I turned her hands over, her palms showed something much more ominous: cigarette burn wounds. Further examination revealed bruising in the shape of fingerprints all over her back, and more burn marks on her stomach. Although I did all the right things medically and legally, it stills upsets me: how can you burn a 1 year old's palm with a lit cigarette?
The 95 year old woman who came in with a pulse rate of 25, awake and talking. Together with her and the family, we decided on no invasive interventions (ie no emergency pacing). She was so polite and grateful for everything we did. She died later that night surrounded by family.
The first family I had to 'break bad news' to: I was an intern, shocked from my first 'real' resus and had to tell the chap's family that despite our best efforts, his MI had got the better of him. They all (of course) started wailing inconsolably, which left me floundering for words and trying not to cry myself.
I cant forget them, even if I wanted to.
Friday, May 29, 2009
Today
Get to work, full box of files waiting. Nursing staff in a bad mood because no beds in the hospital and casualty acting as an 'overflow', 25 patients on trolleys taking up space. Mad, melodramatic overdose patient arguing loudly with everyone who walks past her that we are abusing her. Walk into resus: one patient on a ventilator (subarachnoid bleed), paeds busy resussing the crap out of a sick kid on the other side.
Go to 'minors' area. See 10 ankle injuries from previous weekend's drinking. 1 fracture. See 8 inappropriate GP referrals of abdo pain (...about 6 weeks doctor...). Convince the American tourist that she does not need an MRI scan to her head after she fell and sustained a 1cm laceration. Explain the term 'neurologically intact'. Explain that what happened to Natasha Richardson was terrible but that she will be OK. Counsel 2 anxious sets of parents that their child who bumped their head on the coffee table is not going to die, and give head injury instructions left right and centre. Panic quietly about the American tourist, find her in the waiting room and administer tetanus toxoid, previously forgotten.
Get called to resus to a 14 year old girl hit by a car. Pupils fixed and dilated. Abdomen hugely distended and blue, blood pouring out of left ear. Resus for all its worth and watch her slip away. Counsel her parents and see the empty desperation in their eyes and the way their lives collapse in front of me. Say a silent prayer that they will be OK.
Pull myself together, go back into minors, see the cutest kid in the world who gives me a hug after I glue his forehead laceration back together. Get a phonecall from the medical on call doc, who tells me that the STEMI patient I thromobolysed yesterday is doing much better, and said to say a special thank you to me. Reduce two dislocated shoulders. Place an elderly woman with dodgy heart and lungs on BIPAP and watch as she improves.
Leave an hour late. Run, cup of tea, blog. Think about the American again. Think about the 14 year old again. Feel extraordinarily grateful for everything I have.
Fall asleep, knowing that this job is just right... for me.
Go to 'minors' area. See 10 ankle injuries from previous weekend's drinking. 1 fracture. See 8 inappropriate GP referrals of abdo pain (...about 6 weeks doctor...). Convince the American tourist that she does not need an MRI scan to her head after she fell and sustained a 1cm laceration. Explain the term 'neurologically intact'. Explain that what happened to Natasha Richardson was terrible but that she will be OK. Counsel 2 anxious sets of parents that their child who bumped their head on the coffee table is not going to die, and give head injury instructions left right and centre. Panic quietly about the American tourist, find her in the waiting room and administer tetanus toxoid, previously forgotten.
Get called to resus to a 14 year old girl hit by a car. Pupils fixed and dilated. Abdomen hugely distended and blue, blood pouring out of left ear. Resus for all its worth and watch her slip away. Counsel her parents and see the empty desperation in their eyes and the way their lives collapse in front of me. Say a silent prayer that they will be OK.
Pull myself together, go back into minors, see the cutest kid in the world who gives me a hug after I glue his forehead laceration back together. Get a phonecall from the medical on call doc, who tells me that the STEMI patient I thromobolysed yesterday is doing much better, and said to say a special thank you to me. Reduce two dislocated shoulders. Place an elderly woman with dodgy heart and lungs on BIPAP and watch as she improves.
Leave an hour late. Run, cup of tea, blog. Think about the American again. Think about the 14 year old again. Feel extraordinarily grateful for everything I have.
Fall asleep, knowing that this job is just right... for me.
Monday, May 18, 2009
Back to school
The torture has begun. In my attempt to further my career, I will be writing an awful set of exams in August, the dreaded 'primaries'. I have decided to shock the old system and actually study a little bit more in advance than I did in my undergraduate years: and oh boy, its going tough. There is a huge amount of work.
Attention all medical students: some advice: PAY ATTENTION in physiology. No matter how hard or imcomprehensible it seems now, it will be much, much worse in 5 or 6 or 7 years time. Take it from me.
Attention all medical students: some advice: PAY ATTENTION in physiology. No matter how hard or imcomprehensible it seems now, it will be much, much worse in 5 or 6 or 7 years time. Take it from me.
The Drunkest Girl in the World
She was 15. She was a mess: eyeliner smeared down her face, hair matted against her forehead, blood pouring out of her scalp wound and pooling neatly around her right ear. Her bright yellow tank top was pulled up to underneath her breasts, revealing a young, soft, round tummy bulging over her 'skinny' jeans. She had several piercings in each ear, and ones on the right were covered in blood, and dripping delicately over everything. She had positioned herself on a chair, propped herself up in the corner, and fallen asleep. She reeked of a lovely combination of cheap 'Charlie' perfume and cheaper 'papsak' wine.
I set up my suture tray, shook her awake and removed the blood soaked bandage. There was a 5 cm scalp laceration that needed cleaning and suturing. However, this is difficult if your patient keeps falling over onto your lap. I tried again and again to wake her up, unsuccessfully. Her boyfriend was at the window, shouting abuse at the casualty staff (he may well have been the Drunkest Man in the World.)
I got one of the nursing staff to hold up while I quickly fixed her up. I didnt even consider using lignocaine, and she didnt notice. After I had stapled her scalp, we got up to get a bandage to cover up her wound, and she slowly slid off the chair. She seemed completely paralysed, with no control over her limbs. She slumped between the chair and my trolley, against the wall. Slowly a puddle began to form under her. We noticed the darkening of her jeans. She had lost control of her bladder and was now lying in a pool of her own bodily fluids, blood and fresh alcohol laced urine. She didnt move a muscle, just continued to pee; it seemed like LITRES of urine. By now all the other patients and staff were staring. Even the boyfriend had shut up.
You can fix people's wounds but you cant always give them their dignity back.
I set up my suture tray, shook her awake and removed the blood soaked bandage. There was a 5 cm scalp laceration that needed cleaning and suturing. However, this is difficult if your patient keeps falling over onto your lap. I tried again and again to wake her up, unsuccessfully. Her boyfriend was at the window, shouting abuse at the casualty staff (he may well have been the Drunkest Man in the World.)
I got one of the nursing staff to hold up while I quickly fixed her up. I didnt even consider using lignocaine, and she didnt notice. After I had stapled her scalp, we got up to get a bandage to cover up her wound, and she slowly slid off the chair. She seemed completely paralysed, with no control over her limbs. She slumped between the chair and my trolley, against the wall. Slowly a puddle began to form under her. We noticed the darkening of her jeans. She had lost control of her bladder and was now lying in a pool of her own bodily fluids, blood and fresh alcohol laced urine. She didnt move a muscle, just continued to pee; it seemed like LITRES of urine. By now all the other patients and staff were staring. Even the boyfriend had shut up.
You can fix people's wounds but you cant always give them their dignity back.
ATTENTION PLEASE
To all the admitting teams I refer to:
I would like to being the following to your attention:
1)We are here to work. YOU are here to work. You are getting paid overtime to be here late at night, and while I appreciate that it is crap, you being snotty to me on the phone at 3 am will NOT help matters. I have been there, I have also done the 36 hours without any sleep, and I know it is bad. I am not waking you up/referring another patient to be funny, I am doing so because they are sick and need admission.
2) Just because A and E officers work 8 or 12 hour shifts does not mean we are lazy. While you deal with pretty much the same, day in and out (with the occasional 'pink canary'), we have to deal with everything and anything that gets thrown our way. Because of overcrowding and a lack of beds, we have to deal with uppity, angry people ALL THE TIME, because they have been waiting 8 hours to be seen. We are at the proverbial front line of people's emotions, all the time. We soften them up for you. We explain whats going to happen, we console. We also provide life saving interventions all day, and do resus after resus after resus. Its very emotionally and mentally draining. We work just as hard as you.
3) If you go to theatre for any period of time and you are on call for casualty, you need to get someone to cover for you. Or at least answer your bleep. End of story.
4) Please trust me. Again, I am not referring patients for a 'second opinion', or because I am trying to be mean. I am doing so because I believe that they have a condition which prevents discharge. This opinion is formed from a)the history I have taken from the patient, b) the examination I have performed and c) the investigations I have done. There is always a reason.
5) If I tell you that a patient is unstable, this is not to try and place undue pressure on you or annoy you. I know you have five patients waiting to be seen. But you need to prioritise. I am only telling you the patient is unstable so we can try get them to theatre/CT scan/ICU a little bit quicker. I will do my best to stabilise and manage the patient as I can, but most will need further intervention.
6) We have protocols in place for a lot of conditions: we use them. Please do not argue with me about a referral if I have followed a protocol/guideline and you are the end point.
And while we are at it:
To the doctors I have referred patients telephonically to while sitting at a peripheral hospital, terrified and desperate:
a)Yes, I might be more junior than you, but I am not stupid. Please do not treat me as such. I know you are stressed, so am I! If there is something missing from what I am telling you, or something you want me to do tell me exactly what it is, and let me phone you back. I am phoning for your help. Please give it.
b) It is easy to forget what it is like to work in a hospital that has no CT scan, no after hours blood laboratory, no after hours Xray, insufficient or undertrained staff and no consultant support. That is where I am. Picture it for a minute and then please give appropriate advice. Thank you.
And that said:
To all the doctors in Ireland and South Africa who have been friendly, kind, helpful and supportive, THANK YOU. Know that A and E has got your back.
I would like to being the following to your attention:
1)We are here to work. YOU are here to work. You are getting paid overtime to be here late at night, and while I appreciate that it is crap, you being snotty to me on the phone at 3 am will NOT help matters. I have been there, I have also done the 36 hours without any sleep, and I know it is bad. I am not waking you up/referring another patient to be funny, I am doing so because they are sick and need admission.
2) Just because A and E officers work 8 or 12 hour shifts does not mean we are lazy. While you deal with pretty much the same, day in and out (with the occasional 'pink canary'), we have to deal with everything and anything that gets thrown our way. Because of overcrowding and a lack of beds, we have to deal with uppity, angry people ALL THE TIME, because they have been waiting 8 hours to be seen. We are at the proverbial front line of people's emotions, all the time. We soften them up for you. We explain whats going to happen, we console. We also provide life saving interventions all day, and do resus after resus after resus. Its very emotionally and mentally draining. We work just as hard as you.
3) If you go to theatre for any period of time and you are on call for casualty, you need to get someone to cover for you. Or at least answer your bleep. End of story.
4) Please trust me. Again, I am not referring patients for a 'second opinion', or because I am trying to be mean. I am doing so because I believe that they have a condition which prevents discharge. This opinion is formed from a)the history I have taken from the patient, b) the examination I have performed and c) the investigations I have done. There is always a reason.
5) If I tell you that a patient is unstable, this is not to try and place undue pressure on you or annoy you. I know you have five patients waiting to be seen. But you need to prioritise. I am only telling you the patient is unstable so we can try get them to theatre/CT scan/ICU a little bit quicker. I will do my best to stabilise and manage the patient as I can, but most will need further intervention.
6) We have protocols in place for a lot of conditions: we use them. Please do not argue with me about a referral if I have followed a protocol/guideline and you are the end point.
And while we are at it:
To the doctors I have referred patients telephonically to while sitting at a peripheral hospital, terrified and desperate:
a)Yes, I might be more junior than you, but I am not stupid. Please do not treat me as such. I know you are stressed, so am I! If there is something missing from what I am telling you, or something you want me to do tell me exactly what it is, and let me phone you back. I am phoning for your help. Please give it.
b) It is easy to forget what it is like to work in a hospital that has no CT scan, no after hours blood laboratory, no after hours Xray, insufficient or undertrained staff and no consultant support. That is where I am. Picture it for a minute and then please give appropriate advice. Thank you.
And that said:
To all the doctors in Ireland and South Africa who have been friendly, kind, helpful and supportive, THANK YOU. Know that A and E has got your back.
Back in the game
I suppose its not the best idea to start a new blog, post a couple of posts... and then disappear for three weeks. So I am sorry budding fan club, we are back! Was on a brief holiday home to South Africa. And yes, thank you for asking, it was FABULOUS. Got to see my good friends Karen and the Adman, and lots of other awesome guys and gals. I cannot wait to get back for good... yes its true folks, I am going Home, and will be starting an amazing job in the Cape in July. But never fear, this blog will continue... I have a feeling there's no cure for stupidity in South Africa either.
Wednesday, April 22, 2009
Old people
In the state system in South Africa, we didnt see old people. Not REALLY old people. The combination of HIV/AIDS, poorly controlled diabetes and hypertension and trauma meant that sadly, if you made it to 75, you were lucky.
In Ireland, we have the flip side of the coin.(I am sure this is true of most '1st world countries'). People get Old here. Really old! I did 6 months of medicine last year, and it was a massive crash course in geriatrics. I had no idea of the intracacies of taking a history from an aged person, or which are the right questions to ask, or how to ask them, or what differential diagnoses you need to consider. It was a steep learning curve, but I got there in the end, and now feel pretty confident with the oldies.
I have mixed feelings about the aged population: they can be VERY difficult to deal with, and sometimes their families are even worse. So here are a couple of thoughts about old people...
1)Their bowel movements are REALLY important to them. I once (accidentally!!) made an old lady cry when I told her I needed to put on a backslab for her elbow fracture: she wasnt upset by the fracture or the backslab, but the fact that she needed to have a bowel motion at 8 am every day, and wouldnt be able to successfully do so with backslab in situ.
2)Their families can be their best allies... or their worst enemies. People who care for the aged fall into two categories: excellent or appalling. The former are supportive, visit their old person regularly, dont mind helping change dressings or adult nappies, provide practical help with food and walking aids etc, and are generally well informed about the medical conditions, medications and are willing to practical and realistic when the time comes to make big decisions, eg resus decisions.
The latter are the opposite: they are overly 'possesive' of their old person, but without any thought to how to really help: I have seen old men who live with their daughters coming in with weeks worth of dirt caked in their fingernails, dirty greasy hair, and toenails creeping under the bottom of their toes- could you not run your dad a bath? could you not help him clip his toenails? With his arthritic back and hips he probably cant manage to do these things on his own anymore.
When you suggest to this type of person that the old person needs to go home with a catheter/have dressings changed daily/have someone supervise medication, they will argue loudly with you and explain why they cant possibly do this, even though they are the 'carer' (and sometimes, getting the state 'carer's allowance!).
3) They are NOT stupid, but people treat them like they are. For the first time in my life, I encountered patients here who have never been told their diagnosis, even when its something like cancer!, because their family 'thought it best' not to tell them. What a load of hooey.
4) Loneliness is what kills most old people. (Apart from strokes and MI's obviously!). My heart breaks for these old ladies who have outlived their husbands by 30 years, or old chaps who live on their farm with their equally old brother, unable to farm anymore, but without anyone to sell or give the farm to. There is a big problem of alcohol abuse in the elderly here, but I understand it to an extent: They go off to the pub every day and have lunch there, both for the food and the company, and end up with a life long habit of 2 or 3 pints a day.
I'm not a big fan of oldies, and those who know me will know that I am not the most patient or people: but in dealing with the elderly I have learnt a bit of compassion, and also what it means to really be the patient's advocate: someone needs to stand up for them! Then again, maybe I'm just getting older myself, and a bit soft in the head:)
In Ireland, we have the flip side of the coin.(I am sure this is true of most '1st world countries'). People get Old here. Really old! I did 6 months of medicine last year, and it was a massive crash course in geriatrics. I had no idea of the intracacies of taking a history from an aged person, or which are the right questions to ask, or how to ask them, or what differential diagnoses you need to consider. It was a steep learning curve, but I got there in the end, and now feel pretty confident with the oldies.
I have mixed feelings about the aged population: they can be VERY difficult to deal with, and sometimes their families are even worse. So here are a couple of thoughts about old people...
1)Their bowel movements are REALLY important to them. I once (accidentally!!) made an old lady cry when I told her I needed to put on a backslab for her elbow fracture: she wasnt upset by the fracture or the backslab, but the fact that she needed to have a bowel motion at 8 am every day, and wouldnt be able to successfully do so with backslab in situ.
2)Their families can be their best allies... or their worst enemies. People who care for the aged fall into two categories: excellent or appalling. The former are supportive, visit their old person regularly, dont mind helping change dressings or adult nappies, provide practical help with food and walking aids etc, and are generally well informed about the medical conditions, medications and are willing to practical and realistic when the time comes to make big decisions, eg resus decisions.
The latter are the opposite: they are overly 'possesive' of their old person, but without any thought to how to really help: I have seen old men who live with their daughters coming in with weeks worth of dirt caked in their fingernails, dirty greasy hair, and toenails creeping under the bottom of their toes- could you not run your dad a bath? could you not help him clip his toenails? With his arthritic back and hips he probably cant manage to do these things on his own anymore.
When you suggest to this type of person that the old person needs to go home with a catheter/have dressings changed daily/have someone supervise medication, they will argue loudly with you and explain why they cant possibly do this, even though they are the 'carer' (and sometimes, getting the state 'carer's allowance!).
3) They are NOT stupid, but people treat them like they are. For the first time in my life, I encountered patients here who have never been told their diagnosis, even when its something like cancer!, because their family 'thought it best' not to tell them. What a load of hooey.
4) Loneliness is what kills most old people. (Apart from strokes and MI's obviously!). My heart breaks for these old ladies who have outlived their husbands by 30 years, or old chaps who live on their farm with their equally old brother, unable to farm anymore, but without anyone to sell or give the farm to. There is a big problem of alcohol abuse in the elderly here, but I understand it to an extent: They go off to the pub every day and have lunch there, both for the food and the company, and end up with a life long habit of 2 or 3 pints a day.
I'm not a big fan of oldies, and those who know me will know that I am not the most patient or people: but in dealing with the elderly I have learnt a bit of compassion, and also what it means to really be the patient's advocate: someone needs to stand up for them! Then again, maybe I'm just getting older myself, and a bit soft in the head:)
Nights
Midnight to 8 am is a funny shift: it sounds awful, but is actually pretty great. I dont mind nights at all: you get to miss most of the bullshit that parades through casualty in the day, and actually help (mostly) sick people, and you get to take guilt free naps all day. It gives me a secret thrill when I get into bed at 09h30, knowing that most people are just starting their working day.
Doing a week of nights does warp your perspective of time a bit: usually I'm not sure what the date or day is, someone has to tell me at the start of every shift. I am a great procrastinator, and this gets worse on nights, where, before you realise it, its the end of the week and you have done NOTHING productive except work and take numerous naps in the day. My running program takes a pause during my weeks of nights, and sadly, I end up eating the same thing 5 or 6 nights in a row (usually make a big dish of lasagne or whatever... ).
I quite like the vibe at 4 am: casualty never sleeps, there is always something happening....I always wonder about people who come in to hospital in the early hours of the morning: obviously if you wake with crushing chest pain, thats one thing, but people who come in with say, a recently twisted ankle, at 5 am. What were you doing to twist your ankle at 4 am? Why weren't you SLEEPING?Anyway, I dont really mind, it keeps things interesting.
The only other down side of nights is that it really buggers up your sleep pattern for a couple of days.... I usually cant get to sleep for at least 2 or 3 nights after nights... its quite frustrating!
Last night was a good night: wrestled with a man's shoulder until it popped back with a satisfying clunk, helped 3 MVA victims (they were all fine), listened to numerous old grannies and their dodgy hearts and lungs, reassured patients and their families, referred on all my patients without any arguments with the admitting teams (I'll write another post about this another time...), and still had time for coffee and a hot cross bun at 4 am. Sometimes I REALLY love my job:)
Doing a week of nights does warp your perspective of time a bit: usually I'm not sure what the date or day is, someone has to tell me at the start of every shift. I am a great procrastinator, and this gets worse on nights, where, before you realise it, its the end of the week and you have done NOTHING productive except work and take numerous naps in the day. My running program takes a pause during my weeks of nights, and sadly, I end up eating the same thing 5 or 6 nights in a row (usually make a big dish of lasagne or whatever... ).
I quite like the vibe at 4 am: casualty never sleeps, there is always something happening....I always wonder about people who come in to hospital in the early hours of the morning: obviously if you wake with crushing chest pain, thats one thing, but people who come in with say, a recently twisted ankle, at 5 am. What were you doing to twist your ankle at 4 am? Why weren't you SLEEPING?Anyway, I dont really mind, it keeps things interesting.
The only other down side of nights is that it really buggers up your sleep pattern for a couple of days.... I usually cant get to sleep for at least 2 or 3 nights after nights... its quite frustrating!
Last night was a good night: wrestled with a man's shoulder until it popped back with a satisfying clunk, helped 3 MVA victims (they were all fine), listened to numerous old grannies and their dodgy hearts and lungs, reassured patients and their families, referred on all my patients without any arguments with the admitting teams (I'll write another post about this another time...), and still had time for coffee and a hot cross bun at 4 am. Sometimes I REALLY love my job:)
Sunday, April 19, 2009
Why I love the Irish
1) Their belief in the fact that everything, and everyone, has some Irish heritage. When Barack Obama was elected president, the newspapers were full of new about his great great great grand uncle, who is from county Mayo (or something). The Irish press recently ran a story on how surfing was invented in Ireland. Surfing? There are surfers here but I very much doubt whether they could compete with the 'big wave' riders of say, Hawaii. At first I thought they were joking, but these articles appear in major newspapers, not tabloid junk, so I can only assume they are being serious!
2)They all know each other. This is a bizarre thing, and unsettled me at first. They will also deny this fact vehemently but it is true. The fact remains that Ireland and its cities remains a collection of 'big small towns' - even Dublin, the capital, has a population of only one and a half million people. The other thing is that families are big here, and close: cousins and nieces and nephews are much closer than at home. So these facts set us up for a situation where everyone seems to know everyone, and if they dont know each other yet, they will find someone that they have in common to break the ice in about 5 minutes.
3) They talk about the weather. A lot. Its because the weather is so crap here, and thus occupies a lot of thought and talk time. And its not small talk either, people will introduce the weather as a legitimate topic of conversation all the time.
4) They are a proud nation. This sort of ties in to no 1), and is a bit hard to explain. But I think I notice it because South Africans are quite similar: despite having a lot of problems in both countries, we are both proud people and very patriotic. (Although.... this has changed a bit with the big recession.) When they won the Six nations this year, you should have seen the amount of green clothing and rugby memorabilia floating around.
5) They are obsessed with death. There seem to be a lot of complicated and prolonged dates and rituals associated with dying (for example, a funeral takes three days!!!). There is the funeral itself, the remembrance mass one year, 5 years and I dont know how much longer afterwards. The newspapers are bursting of death and in memoriam announcements... and here is the thing: its not just old ladies in nursing homes who read them. Young people my age read the death notices every day! Down in Tralee, the local radio station announced death notices every day at lunch time.
6) The way they talk and little grammar expressions they use. My favourite ones: the random use of the word 'so', and in "See you later,so." (Encountered this one down in county Kerry). Also, the expression 'I'm just after': it literally took me weeks to figure this one out but basically it means, 'I've just come from', eg "I'm just after getting some bad news". The word 'like' is also liberally added to the end of sentences left right and centre.
It hasnt been easy adjusting to a foreign culture and lifestyle (and the weather certainly didnt make it easier!) but somewhere along the line I decided to stop complaining and start seeing the funny, or at least endearing side of things. No, its not the same as SA, and the people are VERY different, but thats not always a bad thing!
2)They all know each other. This is a bizarre thing, and unsettled me at first. They will also deny this fact vehemently but it is true. The fact remains that Ireland and its cities remains a collection of 'big small towns' - even Dublin, the capital, has a population of only one and a half million people. The other thing is that families are big here, and close: cousins and nieces and nephews are much closer than at home. So these facts set us up for a situation where everyone seems to know everyone, and if they dont know each other yet, they will find someone that they have in common to break the ice in about 5 minutes.
3) They talk about the weather. A lot. Its because the weather is so crap here, and thus occupies a lot of thought and talk time. And its not small talk either, people will introduce the weather as a legitimate topic of conversation all the time.
4) They are a proud nation. This sort of ties in to no 1), and is a bit hard to explain. But I think I notice it because South Africans are quite similar: despite having a lot of problems in both countries, we are both proud people and very patriotic. (Although.... this has changed a bit with the big recession.) When they won the Six nations this year, you should have seen the amount of green clothing and rugby memorabilia floating around.
5) They are obsessed with death. There seem to be a lot of complicated and prolonged dates and rituals associated with dying (for example, a funeral takes three days!!!). There is the funeral itself, the remembrance mass one year, 5 years and I dont know how much longer afterwards. The newspapers are bursting of death and in memoriam announcements... and here is the thing: its not just old ladies in nursing homes who read them. Young people my age read the death notices every day! Down in Tralee, the local radio station announced death notices every day at lunch time.
6) The way they talk and little grammar expressions they use. My favourite ones: the random use of the word 'so', and in "See you later,so." (Encountered this one down in county Kerry). Also, the expression 'I'm just after': it literally took me weeks to figure this one out but basically it means, 'I've just come from', eg "I'm just after getting some bad news". The word 'like' is also liberally added to the end of sentences left right and centre.
It hasnt been easy adjusting to a foreign culture and lifestyle (and the weather certainly didnt make it easier!) but somewhere along the line I decided to stop complaining and start seeing the funny, or at least endearing side of things. No, its not the same as SA, and the people are VERY different, but thats not always a bad thing!
Thursday, April 16, 2009
INTRODUCTION
Hi folks:) Now i know there is a lot of shite out there on the internet, this is just my small contribution. Anyway, i have been inspired my friend karen little, and seeing as there is always something floating around in my head begging to be written, it seemed it was time for a blog. Hope you're all not bored to tears.
Now as any doctor who has ever worked in Casualty will know, there really is no cure for stupidity. All countries have their share of fools and most of them float through A and E at one point or another (let me just say at this point that I do love my job and have no problem with genuinely sick people, in fact, I will go the extra ten miles for them.) The only difference usually is language and skin colour.
When I was working back in SA,I used to get very frustrated at patients who only came to 'Western' doctors as a last resort: they would go to traditional healers and sangomas first and only present to us much too late, when things were really getting out of hand. SA docs are often frustrated at the lack of education in state patients, and how difficult it is to explain concepts like viruses, bacteria or cancer to them and their families. Language barriers are only a part of the problem: even with translation, some patients genuinely refused to accept that their family member had, for example, bacterial meningitis, and insisted that they had rather, for example, been possessed by angry spirits. Ignorance and poor education are big problems. It was tough.
However, not nearly as tough as what I have encountered here in Workingclassville in Ireland. Here, we have a much more dangerous beast: the 'Educated and a little bit paranoid' patient. Like Mr X who I saw with a lower respiratory tract infection.
'Sir, I do need to tell you that you are in the 'morbidly obese' category. You weight is becoming a health risk factor in itself, and you are headed for heart disease, diabetes, and hypertension. You need to lose about 15 stone(thats about 100 kg for the metric world)to be a healthy weight for your height.'
"Well you know doctor, all the men in my family are this big... and I eat the same food as my wife and she's tiny."
'Riiiiight. Well, anyway, here is a short course of antibiotics for your infection. You may also want to stop smoking marijuana, its certainly not doing your lungs any good'.
''Well atually I've done my research on the Internet and theres no trials that show that its actually bad for you."
'Riiiiiigggght. You may also want to take some regular paracetamol for your fever and generalised body aches.'
"Well doc, I'll take the antibiotics but not the paracetamol."
'So you'll smoke marijuana (a mind altering, brain destroying, cancer inducing drug) but not take paracetamol (one of the most effective pain and fever relievers we have, with minimal side effects)?'
"Doctor, marijuana has been used as a medicine for thousands of years. Paracetamol is poison provided by drug companies looking to make money."
Right. Of course, Big Pharma's out to get you. He then proceeded to tell me that he wouldnt take high blood pressure or diabetic medications either, becuase 'they can be managed naturally'. The irony is of course, that people like this keep Casualty departments in business, so I really cant complain too much.
I do think it hilarious and fascinating though, that someone from a first world country with a good education system and access to all the information in the world can still be as frustrating and difficult to counsel as a patient from SA who has no high school education, even though we speak the same language.
Now as any doctor who has ever worked in Casualty will know, there really is no cure for stupidity. All countries have their share of fools and most of them float through A and E at one point or another (let me just say at this point that I do love my job and have no problem with genuinely sick people, in fact, I will go the extra ten miles for them.) The only difference usually is language and skin colour.
When I was working back in SA,I used to get very frustrated at patients who only came to 'Western' doctors as a last resort: they would go to traditional healers and sangomas first and only present to us much too late, when things were really getting out of hand. SA docs are often frustrated at the lack of education in state patients, and how difficult it is to explain concepts like viruses, bacteria or cancer to them and their families. Language barriers are only a part of the problem: even with translation, some patients genuinely refused to accept that their family member had, for example, bacterial meningitis, and insisted that they had rather, for example, been possessed by angry spirits. Ignorance and poor education are big problems. It was tough.
However, not nearly as tough as what I have encountered here in Workingclassville in Ireland. Here, we have a much more dangerous beast: the 'Educated and a little bit paranoid' patient. Like Mr X who I saw with a lower respiratory tract infection.
'Sir, I do need to tell you that you are in the 'morbidly obese' category. You weight is becoming a health risk factor in itself, and you are headed for heart disease, diabetes, and hypertension. You need to lose about 15 stone(thats about 100 kg for the metric world)to be a healthy weight for your height.'
"Well you know doctor, all the men in my family are this big... and I eat the same food as my wife and she's tiny."
'Riiiiight. Well, anyway, here is a short course of antibiotics for your infection. You may also want to stop smoking marijuana, its certainly not doing your lungs any good'.
''Well atually I've done my research on the Internet and theres no trials that show that its actually bad for you."
'Riiiiiigggght. You may also want to take some regular paracetamol for your fever and generalised body aches.'
"Well doc, I'll take the antibiotics but not the paracetamol."
'So you'll smoke marijuana (a mind altering, brain destroying, cancer inducing drug) but not take paracetamol (one of the most effective pain and fever relievers we have, with minimal side effects)?'
"Doctor, marijuana has been used as a medicine for thousands of years. Paracetamol is poison provided by drug companies looking to make money."
Right. Of course, Big Pharma's out to get you. He then proceeded to tell me that he wouldnt take high blood pressure or diabetic medications either, becuase 'they can be managed naturally'. The irony is of course, that people like this keep Casualty departments in business, so I really cant complain too much.
I do think it hilarious and fascinating though, that someone from a first world country with a good education system and access to all the information in the world can still be as frustrating and difficult to counsel as a patient from SA who has no high school education, even though we speak the same language.
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