So 4 years is.... quite a long time to be away from a blog.
Anyway! I am back. Older, wiser, and with thicker skin, I am rapidly approaching the end of my registrar/residency in Emergency Medicine. Reading my old posts today has been a little trip down memory lane, very interesting to see how my thought patterns and opinions have changed.
So lets try this again: some musings from an Emergency medicine registrar in South Africa on the state of affairs in my work life, EM in this country and some interesting observations from the literature.
Hope someone is still reading!
Thursday, January 10, 2013
Saturday, August 29, 2009
frustration and a little rant
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.
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.
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.
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