Hey all, it has been a crazy week or so. I am at ladysmith hospital, a public secondary hospital in Ladysmith, a town of about 150,000 surrounded by rural communities. I have been shadowing health care workers, mostly interns and doctors. Ladysmith is beautiful, I am staying in a small flat about 10 min away from the hospital with the two other girls from the program who also came to Ladysmith. The first day that we got here we got right into it at the hospital and observed a few surgeries. All of the doctors have been extremely nice, I am working mostly in the trauma center, primarily under the tutalage of Dr Marene Paige, (pronounced mah-ney). He is very much the intellectual, and is a veritable dictionary of information on just about every subject that you could think of. Our first day at the hospital he invited us to a dinner party that he was having, which he generally has every Friday. Most of the interns at the hospital were there, and we got in some good networking.
Saturday we went hiking with some of them in the Drakensburgs, it was Susanne’s (our neighbor here and a physical therapist) birthday, so we had a nice hike up in the mountains with her and some of her friends.
Ever since I have been essentially observing different wards in the hospital, which has been really interesting but also keeps me extremely busy. Here is my daily log for the first few days here, which should give some idea.
10/30/09
Today was the first day at Ladysmith. I went to the hospital at 7, and met Dr. Mgobe I went to the operating theatre and observed an orthopedic surgery, a boy whose tibia and fibula were both broken through. It got pretty intense, so during the surgery I went to another room with Dr. John, who was cauterizing some genital warts and removing part of the cervix for a biopsy on a woman who was about 30. She was HIV+. John said that she had some in august, but she wasn’t on ARVs at that point so she couldn’t be operated on, as the risk of infection was too great for someone with essentially no immune system. He also said that the HIV was very commonly associated with other STIs, because made it much easier to contract other infections. This was a very common procedure, as HPV, AIDS, and cervical cancer are closely linked in many cases.
I then went to the emergency/trauma ward, where I will be working for the next three weeks. I met Dr. Paige, a very nice doctor who was busy suturing a patient. The patient had multiple lacerations on the scalp, face and hands, and Dr. Paige said that someone had assaulted him with a bush knife. Judging by the number of cuts, Dr Paige said that it was likely from his girlfriend, because if a man had wanted to attack him with a bush knife he would be dead. A woman also presented with some trauma to her finger, but she was sent to the Operating Theatre. Another man presented who was rolling around in the gurney. Dr Paige said that it was either kidney stones or an acute pancriatitis, but more likely the latter given the age of the patient. Acute Pancriatitis can be caused by heavy binge drinking, and will onset 2-3 days after heavy drinking. It was fairly slow, but Dr Paige said that it generally picks up on nights, especially Friday and Saturday, so I will be heading in nights as well starting this weekend. 7-1 6 hours
10/31
Today I observed the night shift at the trauma ward. I went in at 8 with Dr Skaape. He showed me how he performs basic suture procedure with a hand needle, which uses much more suture thread, but is also faster. It was the end of the month and a Saturday, so it was expected to be very busy. There were several head trauma cases requiring basic sutures, which were preformed quickly by the doctors on duty. An old Indian woman came in with her family, she had been vomiting and was feeling faint. She was diabetic, and she hadn’t eaten all day, but she had taken her diabetes medication, which meant that her blood sugar was dangerously low. Dr Skaape gave her an injection of sugar, and her blood sugar shot up. She was observed for about an hour and discharged. Next a woman was brought in by ambulance with her two small children. There was no one with her to explain anything about what had happened, but based on the pupil response, and the fact that all three were foaming from the mouth and had severe diarrhea, the doctors deduced that she had organic phosphate or possibly carboxolate poisoning from taking rat poison as an attempt to kill herself and her two small children. They were started on a course of atropine and eventually stabilized. Dr Skaapie told us that an investigation would be opened, but that eventually the children would probably go back to live with their mother, because there was not enough infrastructure to place the children in another home, especially when there are so many AIDS orphans who also need homes. At the same time, a man was brought in who had been stabbed in the chest and had a collapsed lung. A tube was inserted into his chest to reinflate the lung, and the wound was closed. I also observed an interesting technique where an arterial bleeder was closed in a head wound. Instead of sealing the bleeder by tying off both ends, pressure was applied by suturing under the artery against the top of the scalp, and the wound was then closed. In the last case of the night, a woman came in who had been hit in the face with a bottle by her boyfriend. A chunk of flesh was missing from her lip, and her face was extremely swollen. Her lip was sutured closed, and Dr Skaape encouraged her to go and file a police report that night, and to come back for examination.
8-2, 6 hours
11/1/09
I went into trauma at 8PM. The first case was a woman who presented with dehydration, so IVs were set up to re-hydrate her. She also had Kaposi Sarcoma, a cancer of the skin, which shows up as spots of pigmentation and is an Aids defining illness. The woman was only 55, but looked 80, she was extremely thin and bony and had difficulty moving. After several hours of IV’s she was sent home. There was also a community assault victim. He came in with a swollen eye, lacerations as well as crush injuries (when a person is crushed between two heavy objects) around the head and neck, and a mouthful of broken teeth. His friend said that he had just gotten out of prison for murder after two years. According to Skaape, “when the community feels that the justice system isn’t functioning properly, sometimes they will take matters into their own hands”. The danger with crush injuries is kidney failure, as the destruction of muscle tissue causes an influx of myoglobin, phosphorus and potassium into the circulation. The man was intoxicated and flailed violently when Skaape tried to put in an IV. The doctors decided that he could wait, and left him in a cot out in the hall for the next several hours.
There was a girl who came in with a severe headache, probably meningitis caused by bacteria, a virus, or TB. Spinal fluid was taken and the girl was started on antibiotics in case it was bacterial meningitis, the most common type. Meningitis is common amongst HIV positive (or reactive as the doctors call it) patients, as the population is not generally vaccinated against it because of cost. A small boy also presented with respiratory issues. He was likely HIV positive because his mother didn’t take niviropine before childbirth, which lowers mother-child transmission from 30% to around 4%. The boy’s heart rate was too fast to count, probably around 160bpm, and his respiration rate was also extremely high. He likely had PCP, which in children is indicative of HIV. He hadn’t been tested because the HIV test is an antibody test, and the mother’s antibodies are present for 18mo after birth. The technique used is a DNA amplification that allows for the presence of the virus itself to be determined, but it is expensive.
I also heard a very interesting story from Skaape, when we were talking about a nurse in America who gave a child a toxic dose of sirofractin, which had made the headlines. He said that there was a doctor in the natal ward who, instead of giving babies ivs proportionate to their weight, gave them standard 400ml IVs, killing four before anyone realized what was happening. He was asked to work in another ward, but there was no disciplinary action, much less a news story.
The two children who had been poisoned the night before were doing well, and talking.
A man came in with a stab wound to the chest, and we examined his x-ray, which showed that he was a chronic smoker. It caused his lungs to inflate, and to look extremely enlarged. In people who smoke, the surrounding muscle becomes weak and cannot deflate the lungs fully, so as a result they become grossly enlarged. Another assault victim came in, with a massively swollen eye, several broken ribs, and a lump on the back of his head, which was a possible skull fracture and brain damage. The way Skaape explained the link was, “imagine a pen inside a cucumber, if there is enough force to break the pen, then imagine what would happen to the cucumber”. The man couldn’t see out of the swollen eye, which either meant a detached retina or posterior bleeding, either of which meant that the eye needed to be removed.
8-12, 4 hours
11/2/09
The day started out with a meeting of the Gynecologist that we had been invited to, where they discussed multiple gendered persons. Then I went on labor rounds, where the doctors showed us what to feel for when examining a woman in late pregnancy. First, you feel the top of the stomach to see if it feels hard or soft, this lets you know if the baby is lying normally or is breeched, then feel the sides to see if the child is lying transverse. Lastly, you see the bottom to feel whether the head is in position, and if it is movable the baby is not in the birthing position.
I then went up to surgery and observed two cesarean sections. The first was twins, but one was a stillborn in stage two, which meant that it had been dead for about 48 hours. The other twin was alive, and was immediately placed under incubation. The case had been referred from another hospital, and the c-section had to be perfumed because the dead fetus was lying transverse across the birth canal. The second C-section was supposed to be performed tomorrow, but the nurses brought up the wrong patient, and so they just performed the c-section on the woman that was brought up, she had a bp of 170/117, which was why she was getting a c-section. The surgery went well, but the baby was premature, so was blue and had to be put under lights. The next two procedures were ectopic pregnancies, where the fetus becomes lodged in the fallopian tube and needs to be removed, along with the section of fallopian tube. In the first procedure the cause of pain was unknown, so an endoscopy was performed to determine if it was an ectopic pregnancy. It was determined that the fetus needed to be removed, and the section of tube was removed. In the second ectopic pregnancy, the fetus had outgrown the tube and had burst, so there was a lot more blood than in the first, and the tube had to be repaired where it had burst.
I then went to casualty, where I saw a woman who’d had a spontaneous abortion at 16 weeks. She had presented with shoulder pain, and when the IV was placed, the fetus aborted. There was another laboring woman who presented to casualty as well, but she was sent up to the surgical theatre.
7-6, 11 hours
There you have it. It has been pretty intense so far, and I am still waiting for most of this to become real, it all still seems like it is a TV show, there is just so much disease and death around constantly.
Sala Kashe
-Ben
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