Hazard Perception

It seems like an entire lifetime has passed since I jotted down a few of my adventures for this blog. Partly due to exam cramming (I had a glorious idea to sit MRCS six weeks after arriving here - I had been keeping it to myself for fear of failure but I've since decided that worse things happen at sea...or in South Africa at least).
Work continues to be a rollercoaster of exhilarating highs - mostly when I get the green light to transfer the sickest patients to the referral hospital, and the darkest lows - telling a patient her unborn baby has died. 
I am now the valiant survivor of my first official on call weekend. After a normal day on Friday, I began my on call weekend. From 1600 Friday, to 0800 Monday, I was on call 24/7. We take things turn about, the first 24 hours I cover my blessed Maternity ward, the male and female medical and surgical wards, and paediatrics. The second 24 hours are spent in Casualty, and then back to the ward cover before Monday morning rolls around again - then I go back to normal hours working in Maternity. This weekend was apparently an unbelievably quiet weekend in the hospital - I can only thank my superstar of a Granny for her non-stop prayers since I left Dublin Airport two months ago. My weekend on call was tough, but made 100 times more manageable because three of the other doctors came in on their off days to help me out - I'd take a bullet for those guys. Class A legends.  Trying to balance exhaustion with the never ending closed doors in terms of treatment options for patients is both frustrating and by Monday at 0500 near impossible. I was awake most of Friday night doing a C section for foetal distress and dealing with some other ward problems. I now have my caesars down to 35 minutes - quite a feat for the woman who had never cut a caesar 6 weeks ago. 

The smaller of our two theatres - for 'septic' cases only 

Saturday brought not a lot more than multiple stabbings - nothing too exciting but one patient did have a fairly decent dose of surgical emphysema following a chest stabbing. I was awake for 19 out of 24 hours of Saturday. 

Maternity continues to keep me on my toes. In the UK we used to joke with each other about being s**t magnets - sorry for swearing on the internet Mum, (She never reads these things the whole way through so I think I'm safe). I am the obstetric version of said magnet x 1000. Since my last entry, I have had 4 placental abruptions, one unstable placenta praaevia, three post part haemorrhages, two eclampsia, too many severe pre-eclampsias to count and two shoulder dystocias. The obstetric version of a hazard perception test at every turn. (Alternatively a morbid form of The 12 days of Christmas Song. Dark, I know). This spilled into Sunday night meaning I had a cumulative 9 hours of sleep from Friday to Monday. Deep joy.

I have filled in 4 further death certificates for babies - mostly women who have had uncontrolled hypertension and subsequent pre-eclampsia in pregnancy, which meant the placenta failed and their baby died. Unfortunately a lot of women in the rural areas do not book their pregnancies until they are fairly pregnant, and by then a lot of serious medical problems have set in. 

Every Thursday I have my High Risk clinic. Never again shall I complain about NHS clinic lists again. Between 35 and 40 patients travel up to several hours to come to the clinic. I see each one individually and scan those who need it. My ultrasound skills are coming on in leaps and bounds, thanks to the much appreciated tutelage from the wife of a colleague who is a sonographer back in the UK. I get by with a lot of help from my friends. I mostly manage pre-eclampsia and other medical disorders in pregnancy in the clinic, anything else I send to the referral hospital 4 hours away - no easy task to sit on a crammed bus overnight for my pregnant ladies, but a necessary evil given I am not a consultant obstetrician despite what the hospital expects of me. 

When I do get to spread my wings outside maternity it's mostly in Casualty and the outpatient department. I seem to have a reputation as the local gynaecologist and seem to get all of the lady problems sent to me. Back in the days of FY1 on General Surgery I was the only female on the team and was always sent to sort out any 'women's bits' - it would appear things have not changed. Not that I am complaining - the medical patients here are a minefield - happy to leave that to the other docs for as long as possible. 

That being said, I had a bit of a proud moment on Saturday night. I was asked to review a patient with severe respiratory distress. The notes said he had been admitted that day with pneumonia. There were no blood results, Xray is broken and the nurses are too busy to help. The patient was in acute heart failure with fluid on the lung - he was frothing at the mouth and struggling to breathe. I gave him the wonder drug from the heavens - Furosemide - and his chest improved. There had been no mention in the notes of the fact his catheter was draining frank pus - his lack of diuresis (peeing out the fluid on the lung after the furosemide) made me worry about renal function. I asked the nurses to wake up the labs and have bloods taken. The patient continued to hyperventilate despite the oxygen saturation being ok. It didn't fit with a lung issue - a considerable amount of time passed with me staring at him scratching my head before I realised this was Kussmaul respiration - he was acidotic probably second to the kidney failure. Just as my lightbulb moment peaked the bloods returned - I was right, he had acute renal failure and his potassium was dangerously high. I ran all over the hospital locating the ingredients for my anti- potassium recipe. I then set about preparing for the battle to have the patient transferred for dialysis. The cut off in SA for dialysis is about 55 years old. That would knock out more than half of the fistula patients we operated on when I was on Vascular. If you have HIV then you automatically get denied dialysis here. It is barbaric and one of the most distressing parts of internal medicine here - last week we sent a 19yo girl home to die as she had renal failure due to her HIV. Through some sort of miracle (or perhaps because a histrionic Irish woman screeching down the phone at 2am was too much for the medical registrar to bear), the patient was accepted for dialysis at the referral hospital. Now I just had to convince the ambulance to come and get him. Half the battle of getting a patient the care they need is convincing the paramedics to take them. (Side note - I have been called 'threatening' before when a paramedic refused to take a woman who was about to seize due to eclampsia to the referral hospital. It is apparently NOT appropriate to shout about dying babies across a forecourt, FYI). You will have since realised that my dramatic bone hasn't dried up and died since arriving here. (I've not yet had a patient refused - and have even caused enough of a scene to get an Air ambulance - I deserve an Oscar).

I try and make light of the battle to get patients the help they need, because when we fail our patients it is simply too much to bear. I see my little 30 week baby who died in every healthy baby I deliver. I still hear the cries of the mother who's baby died because we didn't have the right blood component to safely do her caesarean. Then the children on the paediatric ward who have complications of AIDS, and are orphans for the same reason, the need here can be overwhelming. On Sunday I had a genuine moment of thinking I couldn't do it anymore. Every day brings some sort of horrendous situation after another. Shouting and banging my drum loudly is often the only way to get the job done.

A particular delight of the working day is feeding this little munchkin  - this is the baby from a previous post who was close to death with malnutrition - thanks to my friends - he now looks like this!

 Without sounding like I'm blowing my own trumpet, I can see improvements in the hospital already. The nursery (where we put our sick babies) was empty for almost a week. We weren't having blue floppy babies starved of oxygen because there was no doctor to come and do a caesarean. The number of women with undiagnosed pre-eclampsia is falling.  I see this as an indication of good obstetric care. We are recognising complications quickly and escalating appropriately. I'd even go as far to say we are preventing complications before they happen. 

Half of my empty nursery!

Outside of the hospital has been fairly dull due to looming exam. That's out of the way now and we have had three braai's this week. A recipe for boosting group morale: a braai, a horse load of meat and a steady flow of South African wine. I made a quick stop at Durban beach on the way to my exam which was glorious. I'm off to Johannesburg this weekend to attend the Rural Doctors of South Africa  annual conference - excited to share stories and hopefully pick up some good ideas about quality improvement and all things SA!

South Beach, Durban 
More baby spam from happy times in Paediatrics 


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