Ladysmith Hospital

My last few weeks have been centered around the hospital. However, I did get a chance to go hiking in the Drakensbergs this weekend, which was beautiful. The last few Fridays I have also been going to dinner parties, which are thrown by my mentor in the Casualty Ward. There is always amazing food, last weekend was Middle Eastern food and this Friday was a huge braai. Other than that I have been working and helping out at the hospital, which is really interesting but also draining. I have been updating my daily log from the hospital. (changing some of the names naturally…) But this is essentially what I have been up to for the last two weeks. It is a bit long, and I would encourage skimming =)

11/3/09

Today has been a slow day at the hospital. Things were really not happening in the Casualty department, so I decided to stop in and visit doctors in other areas of the hospital that I had met. This type of feast-or-famine seems to be how the Casualty ward generally operates; it is rare that there is a steady flow of patients. There also are long periods where all beds are full, but the patients are waiting for an orthopedic or surgical consult, which can take anywhere from 10 minutes, to several hours.

I went into the gynecology ward and went on rounds with Dr. Potter, but it was essentially just examinations to see how far dilated all of the women were, and if the baby was lying correctly in the uterus. After rounds, I went back to Casualty, where Dr Winchester suggested I go to ward 3, the orthopedic ward and observe some interesting x-rays. When I got there I saw Jessica, a physical therapist that I had met through Dr Winchester. I went on her orthopedics round with her, which was fairly interesting to observe. I also was able to assist in moving patients and generally helping out. Many of the patients were pre-op, and had been so for a long time. There seemed to be a fairly long backlog for surgery. There was a man who we saw that had been there for 10 days with two broken legs and a shattered spine. I saw his spine x-ray, and it looked like there were gravel fragments all around his back, really pieces of spine. He needed to be transferred to a specialist, and all that Jessica could do to help was to move him around to prevent bedsores. She said that if he developed bedsores, no other hospital would admit him.

I then went back to Casualty, where there were several patients who had been bitten by dogs. Dr Winchester told me that there are essentially three levels of risk when there is human-animal interactions, a level three is when there is blood present at the site of injury, level two is a scratch with no blood, and a level one is a lick or nibbling on unbroken skin. Most of the dog bites that present at Ladysmith are level three interactions, although Dr Winchester said that they are often miss-categorized at the referring clinics, either higher or lower than their actual risk. Ladysmith is a high-risk area for rabies, it is endemic and there are generally a few outbreaks a year in animals in the area. As such, in all bites that are “high risk” where the dog wasn’t provoked and is unknown to the patient, the patient is generally given the full series of rabies shots. If possible, the dogs are also kept under observation by the patient, and they are told to come back if the animal dies within 10 days.

7-2, 7 hours

11/4

Later that night, I went back to the hospital to observe a night shift. There were several men who had been assaulted with knives, but the wounds were all superficial and readily sutured with no complications.

Later, a woman was brought in who looked like she was sleeping. She was 51, with a history of hypertension. She was found lying in her bed, and the family couldn’t wake her. She had clinical signs of a stroke: limb rigidity, no eye movement, and no reflex to protect the airway. She had been dizzy, and gone to bed, about 10 hours before. Dr George told me that if a person who has a stroke can be operated on within 3 hours, brain function could be saved. The woman had a Glasgow Coma Scale of 7 (The GCS is a rating scale that takes into account eye, verbal and motor response, the worst score is 3, the best 15) with a motor response of 4, meaning that she could withdraw from pain. Dr George said that Gray’s would not take a person with under 5 on the GCS motor response, so we went upstairs to get a CAT scan. Easily visible on the scan was a massive interverntricular hemorrhage, or blood in the brain, which meant that the woman had a very low probability of surviving.

A man also presented with a badly infected toe. Dr George called for a surgical consult, which came to clean the toe out. The consultants on call are all residents, who have to undergo 4 months in each field of practice to become doctors. Dr George explained that he had more training than the resident, because he had competed his surgical training while the consultant was only halfway done, but that they had to call them as a part of their training for surgery. A woman also presented with a dry cough, but her lungs sounded clear, which indicated either Pneumocystis Carinii (an atypical pneumonia) or a typical pneumonia, but as the woman wasn’t in respiratory distress, it was more likely to be pneumonia.

8-12, 4 hours

11/5

Today I began in Casualty. It was extremely slow, as the orthopedic and surgical clinics were both open, which meant that those cases could be referred instead of being treated at Casualty. These cases account for a lot of the patients presenting during the day. I went over to pediatrics to see what was happening there. I ended up shadowing Dr Jeff on rounds. He pointed out quite a few cases of pediatric vomiting diarrhea malnourishment cases, and also showed me the x-rays for some infant pneumonias as well as PCPs (Pneumocystis carinii pneumonia) which are extremely common in people with HIV aids, including children with HIV/AIDS. I went back to Casualty and saw another PCP case when I got there. Dr Winchester explained that PCP is clinically quite different from pneumonia. Dr Winchester said that the run of the mill pneumonias don’t present with respiratory distress, although they can. On a PCP x-ray, there is a characteristic ground-glass effect, but the lungs sound normal when listened to with a stethoscope. In other types of pneumonia, there is a distinct crackle that can be heard upon clinical examination, although the x-rays can look similar. A man also came in who had been kicked in the face by a cow. He was quite elderly, and required several sets of sutures. He proceeded to show me the scars from all of the various places he had been injured by cows over the years. It seems like a dangerous profession.

11-4.30, 5.5 hours

11/5

This morning started at 7.30 with a general hospital presentation by the Gynecology department about transgender, which was very interesting, both the medical and the psychological side were presented. I then popped into theatre, where Dr Winchester was examining an older woman who had a foot almost completely rotted away by gangrene. It was dry gangrene as opposed to wet, which essentially clinically means that there is less swelling and fluid on the appendage. Dr Winchester said that the leg would need amputation, as the gangrene was progressive.

A man was brought in who had been hit by a car, the emergency protocol was followed and he was immediately started on twin wide bore IVs. He also had a pneumothorax, or air in the chest cavity, for which an underwater chest tube was placed to remove the air and allow him to breathe properly. He had extremely low blood pressure, and after a very quick clinical examination it was determined that he had a broken left femur, left tibia, and several ribs on the right side, which moved up and down as he breathed. He also had head trauma, but the extent couldn’t be determined, as he died in the X-ray room. Dr Winchester said that the cause of death was probably related to the head trauma, since he was otherwise stable when he was sent to x-ray.

A little girl was brought in for vomiting and diarrhea; she had severe myasthmous, a type of malnutrition. She was extremely wasted, and her skin hung off of her in loose folds. She was given an IV for rehydration and admitted to the pediatrics ward.

A small boy was brought in who had a toy shoved up his nose, he was sedated and the toy was removed with a pair of extremely long forceps. A short while later, another small boy was brought in, dead upon arrival. However, the ambulance man said that he had been screaming when he was brought in. Dr Winchester explained that if the boy died in the ambulance, it meant a ton of paperwork for the ambulance driver to do, w so that the ambulance company would have less paperwork to do.

A boy of five was brought in, who had been involved in a minibus taxi accident. He had minor abrasions and was medically fine. He had been walking, holding his four year old sister’s hand, and was pulled down as the taxi drove over her head, which was crushed beneath the wheel. He was held overnight, more for the psychological trauma than anything, and so his parents wouldn’t have to worry about him for the night.

Dr Winchester also loaned me a book on how to read x-rays, which I studied between patients. In the trauma ward, everything seems to happen at once, which is followed by extremely slow periods. These especially occur when the specialty clinics are open, because a number of the patients that are handled in Casualty actually are non-emergency cases, which are usually handled by these clinics.

7.30-5, 9.5 hours

11/6

This morning I began in Casualty. There were several various fractures, which were sent to orthopedics. A man came in who needed head sutures; his minibus taxi had been in an accident.

I talked to a male sister (all nurses are called sister regardless of sex) about domestic violence cases presenting in Casualty. He said that there are far too many, and that after initial treatment, all are sent to a crisis center at the hospital, where there is someone on call 24 hours a day to council and help deal with domestic violence cases. Another doctor told me that most domestic violence cases, as well as assaults and other violence, occur on weekends and especially at the end of the month. This is payday, and the only time there is money around that can be spent on alcohol, which fuels violence and domestic abuse.

Another doctor there told me that the Zulu were generally a very proud people, and also had a vary warlike past, which might attribute to the high levels of violence, but he also said that these levels were present throughout all of South Africa, so there were obviously other factors as well. He also told me that all clinics in the hospital close at 3.30, even though they are supposed to be open until 4 or 4.30. He also told me that there was “no sense of urgency” in the hospital, the nurses might call a doctor to help resuscitate but when the doctors get there 10 minutes later, the nurses might not have even started resuscitating.

11-3, 4 hours.

11/6/09

I also came into later at night, and met Dr Pierce, a nice older gentleman. He let me listen to the chest of a woman who came in with a severe asthma attack. Whenever she breathed in or out I could hear a rasping sound. She was put on steroids, adrenaline and oxygen, and a half hour later I listened to her chest again, which sounded clear. I also heard some great stories from Dr Pierce, about how he performed his first surgery at 18, and many other stories from his long career doctoring all over the world. There were also several stab wounds to the back that were sutured, and a blunt force trauma injury to the back of the head. These traumas all have a distinct pattern; severe swelling, and an extremely tender area around an open wound with a fairly undefined edge as a result of the skin bursting due to the force of the injury.

9-12, 3 hours

11/7/09

Today I went in a bit later in the day, and when I got there I saw a man who had cut his thumb off with a saw. He was belligerently drunk and on frequently broke out into Natasha Bedingfield songs. He had bled all over everything, and a trail of blood followed him around the waiting room and Casualty ward. I got him a bag of ice for the thumb, but as he’d had it in his pocket for several hours, it was no longer viable tissue. He kept asking people if they wanted to see his thumb, and pulling it out of his pocket to wave in their faces. Dr George told me that the thumb probably wouldn’t be re-attached even if it was viable, as there just weren’t the resources for it.

A woman also came in with suspected TB; she had a chronic cough and a chest x-ray with some suspected TB spots on it. Another woman was brought in by her husband; she was a stage four Aids patient and couldn’t move or walk.

Another assault victim was brought in with several cut fingers on his hand. The doctor called it a defense injury, as the man had caught the knife blade in his hand when he had been assaulted and refused to let go. He was sutured and released

3-6, 3 hours

11/9/09

This morning was fairly slow in Casualty. However, there was a man who came in with a leaking chest tube. He had been stabbed several days before, and the blade had penetrated his diaphragm and nicked his stomach. Apparently when they opened him up the first time, he’d had stomach contents in his chest, and had to have his chest washed out. He was given a colostomy bag for drainage, but now it was leaking so he was back. Dr Winchester said that he would most likely need another surgery to clean out his chest cavity, as there was fecal matter in the tube.

A baby was brought in with a broken leg. I was surprised because the baby showed no signs of discomfort although her tibia was completely broken. Also on the orthopedic side of things, a woman presented with a swollen ankle. Dr Winchester suspected a break, although there was nothing visible on the x-ray. The ankle could have been sprained, but sprains are commonly swollen on the lateral side of the ankle, and this ankle was predominantly swollen on the medial side, so she was sent to orthopedics for a consult.

Next, a man came in with a prolapsed rectum, which had been prolapsed for several days. The procedure for repairing this is just to gently re-insert the rectum through the anus. This process is extremely painful, and the patient needs to be put under anesthesia.

A woman also presented with a large abscess on her neck, which was drained by the surgical doctor. A man came in who had been assaulted with a rock several days previously, on Saturday night whilst out drinking. He couldn’t be sutured because the tissue had already began to heal and was too delicate to hold a suture.

10-4, 6 hours

11/10/09

Today was fairly slow in Casualty, so I went up to surgery to observe orthopedic surgeries. The first was an older woman who had fractured her femoral neck. The surgeons first inserted a screw through the head of the femur, and then attached it to a plate they had screwed onto the femur below the fracture. The next patient was a 15-year-old boy with a fractured right radius. A plate was attached to the bone to place the two ends in proximity to each other. The last surgery of the day that I observed was an Austen Moore hip replacement on a 78-year-old woman. In this surgery, the head of the femur is removed, and the femur is cut at an angle. A metallic prosthesis is inserted into the femur, and the top is then rotated back into the hip socket.

I then popped into the MOP Department to visit Dr Pierce. I ended up spending the rest of the day in the exam rooms with him. He was extremely efficient, and saw patients quite rapidly. There were a variety of patients; many were TB patients, who he saw for a variety of complications due mainly to their TB. He also saw an extremely overweight patient who had no cartilage left in her knee. He gave her a hard time about eating so much, and told her to get on a diet. Most of the patients that he saw he joked with while he gave them medical advice and care. A woman came in with shingles all over her back and breasts. Dr Pierce said that this was an HIV indicator. The woman also had been in a month earlier with bleeding gums from gingivitis. Dr Pierce said that these opportunistic infections often took advantage of a destroyed immune system. A man also was seen who had brain inflammation, which Dr Pierce told me was another example of an opportunistic infection.

An older woman came in wanting a disability grant, and she was sent to the special “grant doctor” that deals with all disability grants at the hospital. He also would not see patients if they didn’t have a letter of referral from a clinic, since this was a secondary hospital.

The doctor talked about how the government couldn’t provide jobs for the people, but they still needed votes to stay in power, so they provided grants instead, which fed peoples dependence, but also gave them money for food, so he was of a mixed opinion. In all, Dr Pierce saw 42 patients in his shift, one after another.

After this I stopped by Casualty, but it was fairly quiet. On the way out Dr. Winchester was stopped by a man who had jaw cancer that had metastasized to his ear and throat. He was being transferred to Gray’s hospital for surgery at 3.00 AM, and would have to sleep in the rooms that the hospital provided for transfer patients. He had a long conversation in Afrikaans with Dr Winchester about how he didn’t want to sleep in a room with “them” (black patients). Dr Winchester later explained the conversation to me and told me that he was often put in that position, where white racists expected him to sympathize with their views because he was white and spoke Afrikaans.

8.30-4.30, 8 hours

11/11/09

I started my day in Casualty, where a man came in with a laceration on the back of the head. He had gotten assaulted there last Saturday, 4 days ago, so the skin was too weak to hold sutures and a dressing was put on it. Another man came in, with a laceration that had been sutured but was now infected, so the sutures were removed and the wound cleaned and dressed. A woman came in with a severely malnourished baby that was dehydrated. Four doctors spent about 30 minutes trying to insert an IV line in the baby, but her veins were so small because of the dehydration that a line couldn’t be placed. At this point Dr Winchester came in and inserted an IV line directly into the right tibia. He explained to me that it was an emergency procedure, but the baby was severely dehydrated and so it needed to be done to get the baby fluids. The baby was then admitted to the Pediatric Ward. There were also five dog-bite cases in the morning, all of which were high-risk and the patients were started on the series of rabies shots.

A man was brought in the early afternoon; he had been assaulted with an iWisa, or Knobkierrie. This weapon is a stick with a large knob on one end, and is common among the Zulu communities. It was traditionally used by the Zulu as a war club, and Dr. Winchester told me that it is commonly found as the weapon in assault cases because of its widespread popularity as both a walking stick and symbol of authority amongst the Zulu. The man had been drinking, but “only a little” and he didn’t know why he had been assaulted. He said that someone that he knew from his village had assaulted him, possibly because the man was unemployed and jealous of his new job. He told me that he was considering exacting revenge, but that he didn’t want to risk jail so it was better to just let the police handle it.

After this it slowed down in Casualty, and I went and sought out the medical library, which was quite old but had some interesting journals about trauma.

I came back a short while later, and a TB patient had been brought in. A woman later came in who had been run over by a minibus taxi, at first she came in with only x-rays of her ankle and knee, but she was sent back for foot x-rays. When they came back Dr Winchester showed me the x-ray, and I saw that her lateral four medial phalanges had been dislocated laterally by nearly a centimeter.

An older woman who had fallen was brought in by her family; she was 80 and had fractured both of her hips within the last ten years. Dr Sipho determined that her pelvis was not fractured, and that it was probably a bone bruise.

8.30-5, 8.5 hours

11/12/09

Casualty was slow at the start of the day, so I went over to MOPD (medical out patient department) to observe some chronic patients, and also to help out by doing small tasks such as changing beds and taking vitals. There were a variety of patients there, although most had TB, Aids, hypertension, or diabetes and were coming in with complications of these diseases. I met several new doctors, who were all very nice and explained some of the complications that can arise from these conditions.

In the afternoon, I went back to Casualty and talked to Dr Winchester for a bit. He has given me some wonderful textbooks in electronic form on trauma and medical complications that can arise as a result of traumas to different areas of the body.

There was a motor vehicle accident victim who presented today, and although he only had a minor laceration on the back of his head, Dr Sipho, the other Casualty doctor, sent him for x-rays. He explained to me that the government had special funds for car accidents, work related injuries, and certain other types of injuries, and so they could take extra care of these people because the hospital would be reimbursed. There was also a small girl whose family told the doctor that she had been in a motor vehicle accident; her entire face was so swollen that she couldn’t see. She had been in an accident on Tuesday, and it was now Thursday. I asked the doctors how no one would have brought her in sooner, and they said that some more distant relative was raising her, and it was actually the neighbors who had called her mother to say that the child needed care. This story seemed incredible, and I found out the next day that her mother had actually hit her, and that the neighbors had called an ambulance for her. There were also several babies who presented with vomiting and diarrhea, malnourished children. They were all rehydrated and sent to Pediatrics. Also a small girl who had fallen ad split open her head, she was given some sleeping medication so that she wouldn’t cry and the cut was closed with Dermabond, which is basically medical superglue. This glue is used to bring the two sides of the cut together without sutures, which will minimize the appearance of the scar. The cut had a small arterial bleeder, which would have not allowed the doctor to use Dermabond, but he put adrenaline directly into the cut to constrict the artery, as adrenaline is a vasoconstrictor. This slowed the bleeding enough to allow the glue to set.

Possibly the most fascinating case of the day was a 58 year old man who had been repeatedly bludgeoned with a knobkierrie. He had apparently gotten into an argument with another older gentlemen and it had come to blows. He had loss control of his facial expressions and Dr Winchester told me that he had expressive aphasia, and that in this condition; a patient who has sustained head trauma cannot articulate their thoughts correctly. They will often speak slowly and haltingly. They have full mental capacity, but cannot express themselves vocally. The man’s CAT scan showed distended ventricles, and the entire brain had atrophied. Dr Winchester said that these were chronic conditions, however, and may or may not have had any bearing on the present condition. The ventricles were probably the result of increased intracranial pressure in the brain, which would have taken quite a while to build.

A man who had been bitten in the hand by a dog while hunting also came in, and was started on rabies vaccinations. There was also a woman who had been bitten by her cat. These bites were deep, and there were a number of them on her leg. They were judged high risk, as the cat had no history of aggression and had not been vaccinated. In addition to the rabies vaccines, the woman was given rabies immunoglobin, which was injected directly into the bitten area.

A 74-year-old woman was brought in by ambulance with cuts and skin missing from her neck. She said that her grandson had choked and tried to kill her. Judging by the marks, he had held her throat with his left hand only, there was a clear point on the left side of the throat where a thumbnail had sank in, and the skin on the right side of the neck and jaw was missing a good amount of skin, presumably from the fingernails. The entire frontal neck area was about 30 percent bruised. She said that he had been drinking and smoking dagga (marijuana) and had tried to kill her when she refused to give him her pension money.

10-6, 8 hours

Saw today so far

11/13

Today was a fairly slow day at the hospital. I began the day in Casualty, which was empty. I then talked to Dr Winchester for a while, and wandered over to MOPD, which was also entirely empty. After a bit I headed to maternity, where I observed a childbirth. The birth happened fairly quickly, as it was the woman’s fourth delivery, and there was an enormous amount of blood.

I then stopped back at MOPD, which was still empty, so I talked to the doctors for a bit. They told me that today was a pay period, which generally meant that there would be lots of assault cases and car accidents due to the fact that people had money for alcohol. Dr Molandie also discussed assault cases with me. He told me that in his experience, the Okapi, a local knife, is the most common weapon used, followed closely by Knobkierries. He also told me that most assaults happen by someone that the victim knows, which is a theme that I have also seen in the multitude of assault cases presenting in trauma. This is such a recurring theme that he told me there is a saying, “If you are shot, it was by an enemy, if you are stabbed, it was by a friend.” I have heard this same saying from Dr. Winchester as well on several occasions.

There were a few cases in Casualty when I went back. A man had an extremely swollen foot with clean x-rays. Dr Winchester said was probably a result of infection, although there were no visible cuts or wounds on the foot. He also said that it could be a case of atypical gout, and gave the man medication to cover both possibilities. An 8 year-old girl also came in, her foot had been run over by a minibus taxi, and she had two broken toes. An older woman was brought in who had been kicked in the chest by a cow. There were no broken ribs, but Dr Winchester spotted a lung infection on the x-ray, and gave the woman antibiotics.

10.30-4.00, 5.5 hours

I went back for a night shift tonight, because in addition to being a Friday night, it was a payday for all government employees. However, when I arrived at around 9PM, there has been very little activity. Surprisingly, most of the patients were medical patients with chronic conditions, such as diabetes and hypertension. There was a 15-year-old boy, who had been hit in the forehead with a rock, but there was no internal damage, and only a small, deep cut on the head. There was also a 26-year-old man who had gotten into a knife fight on his way to work. He had a small laceration on his forearm, but was otherwise fine. All in all, there were very few patients and it was a quite evening in Casualty.

9-2, 5 hours

That is about all she wrote. I am still amazed at the dedication from some of the doctors and nurses here, and the apathy of some others.

Sala Kashe,

Ben