Blog 12/1
Well, the semester here is drawing to a close. I can’t believe how fast it has gone, but it also seems like it has been an eternity since I have been back home. The last couple of weeks have been absolutely crazy and busy, but I will try to recap.
I got back from my last little bit of time at Ladysmith on the 23rd. My last week at the hospital was amazing, and I will put my daily log at the end if anyone wants to read it.
Once I got back to Durban I moved back into the Windemere, the apartments on the Durban North Beach. That week was spent writing my final independent study project paper about my time at the hospital. I wrote specifically about Sjambok injuries. This condition causes a plethora of chemical effects in the body which can lead to kidney and heart failure. It can occur when there is extensive muscle damage, such as a beating with a sjambok (a South African whip. These commonly occur in community justice cases or “jungle justice”, when a community feels that a person has wronged them and hasn’t suffered sufficiently at the hands of the justice system. I saw a few of these in my time at the hospital, and they were quite an interesting condition. The entire week was spent writing, 20+ hours a day, which culminated in a 48-page paper and a presentation on Friday. I don’t remember much of the presentation, because I was half-asleep, but it is all over now.
On Saturday I had a great day, I went with some friends shopping at the local markets, then we went to an aquarium, and I saw lots of fish, sharks, and a pretty cool dolphin show. Sunday was spent looking at markets for last minute stuff that I had wanted to buy all semester but hadn’t. I wont have much of a chance to make purchases in non-touristy areas for the rest of my time here.
Monday we headed out into a game preserve area. It has been really touristy compared to everything else that I have done here, but it is a really nice area and we are living in a really nice housing/hostel complex. Today (Tuesday) we got up at 5 and went on a game reserve safari tour. It was pretty neat, but I guess it was different than I expected it to be. We saw a ton of animals, lots of rhinos and zebra and antelope, and a few elephants and giraffes. No lions or leopards, but they don’t really like to be seen. It just seemed like a larger version of a zoo I suppose, although it was pretty fantastic and cool to see the animals so up close and personal. I have another week or so of being in a game park to see what I want to see coming up though, so I shouldn’t base too much on one tour. Tomorrow we are doing a tour of the estuary here, it should be cool to look at some hippos and crocs and such.
11/16
I spent the entire day today in Casualty. I arrived in the morning to find Dr Jones pulling a beetle out of a 13-year-old boy’s ear. This was the second of the day; the other had been in an 8 year old. The beetles had crawled into the patient’s ears and then died. A man was referred in from the Medical Outpatient Department with bleeding hemorrhoids. He was seen after several hours by a surgeon, who prescribed some medication for them.
Dr Jones saw a woman with a tremendous abscess in her auxiliary. He drained it, and also took a sample to send to the lab. He told me that this sample was to test for TB, which sometimes causes these abscesses. The next person that presented was a man who had fallen off of his roof. He had three broken ribs, one of which was quite badly broken, evident even to my untrained eye. Dr Winchester has been great about showing me each x-ray that comes through, and giving me tips on how to look over them thoroughly. He showed me an especially interesting one today. An old man had come with a possible broken hip. When his x-ray came back, Dr Winchester showed me his ureters and bladder, as well as his femoral arteries. They all showed up clearly, and Dr Winchester explained that they were calcified, which is why they were visible on an X-ray.
A man who had been assaulted came in with a stab wound on his upper left back. He was sutured and sent to bring his J88 (medical examination form) to the police station.
Another assault case came in soon after. He had actually been assaulted a week before, and kept having recurring nightmares about it, so his family was concerned he might have brain damage. Dr Winchester, after finding nothing in his examination, told the family that it was probably post-traumatic stress, and that it should lessen in time.
Just after noon, the paramedics brought in a man on a backboard. He had a multiple crush injuries on his limbs, and bruises across his back and elsewhere. He also had multiple lacerations and extensive bruising across his face. Dr Winchester told me that this was called a “sjambok injury”. These injuries are named after the short, heavy hippopotamus hide whip named the sjambok. This weapon was used during apartheid during riot control, and was and is still used in herding cattle. The name comes from the type of injuries that these weapons inflicted, and now has come to be synonymous with large area musco-skeletal injuries. This is both a trauma and a medical issue, as when muscle is destroyed, it releases a multitude of things into the bloodstream, which can cause renal failure. Treatment for this condition involves flushing out the kidneys as much as possible with lots of IV fluids. All in all, it was a very interesting day.
10-5, 7 hours
11/17/09
Today was a Tuesday, and so was a fairly slow day in the Casualty Ward. The morning started with a man who had injured his finger in a work accident. The X-rays showed that the last joint of his left ring finger was broken, and he was sent to orthopedics. There were also several dog bite cases, which were all started on rabies treatments. Just after the last of these, a boy of 15 came in with a swollen scrotum. Dr Winchester told him that it was a sexually transmitted infection, and he needed to tell his girlfriend or girlfriends to get treated. The boy said that he had never had sex, but he was treated for the STI anyway. Dr Winchester told me that he didn’t really believe the boy, but whether he did or not the boy would respond to the antibiotics prescribed.
A man next came in who had been referred by a surgeon in town. He was 32, had a history of binge drinking, and had been drinking over the last weekend. A pancriatitis often onsets 2-3 days after heavy drinking, and the patient had presented with an abdomen that felt like a pancriatitis to Dr Winchester upon palpitation. Dr Winchester informed me that the feel of the abdomen could often distinguish different causes of abdominal pain. For example, the abdomen of patients with a pancriatitis often has a boggy, woody feel, somewhere between ridged and soft He said that the movement and location of pain is also important, in an appendicitis the pain starts around the mid-region of the stomach, and after 2-3 days will often move to the right side of the abdomen. The pain of a pancriatitis, on the other hand, will be over a greater area and will not move. Dr Winchester ordered urine and blood tests, because in an acute pancriatitis, high levels of amylase will be present both in the blood and urine, this enzyme is released from the acute pancreas into the blood, and then is filtered out and excreted in urine. Before these tests came back, however, the x-ray and ultrasound results came back. The ultrasound showed no abnormalities of the pancreas or surrounding organs. The X-ray, however, showed an air pocket underneath the right side of the diaphragm. This, in conjunction with this mans other symptoms, was a fairly definitive sign of a perforated ulcer, and Dr Winchester said that it was probably a stomach ulcer given the history of alcohol abuse.
10-5, 7 hours
11/18/09
Today I went into maternity to observe normal vaginal deliveries. The ward is arranged into rooms, women in progressively advanced stages of labor are moved towards the back of the ward. Today was a fairly slow day, there was only one mother-to be in the last room, she was 6cm dilated at 11.00 am. She was still on the bed, 8cm dilated when I left at 4.00pm. Another woman was brought in and began delivering almost immediately. When the baby was delivered the cord was wrapped tightly around the neck, so the cord was cut while the baby was still in the birth canal so that it wouldn’t suffocate. This woman had post partum hemorrhage; she was given a blood-clotting factor in order to help staunch the bleeding. Next, the paramedics brought in a woman who seemed to be in excruciating pain. She was a Para 4, meaning that she was giving birth to her fourth child. Her water broke and the baby was out less than two minutes later. The nurses were still in the process of preparing a tray and putting on gloves when the baby was on the bed. The nurses also showed me how to examine the placenta, which is done to ensure that no parts of the placenta remain in the uterus.
9.30-5.00, 7.5 hours
11/19/09
Today was a very slow day in Casualty. I went in for the evening, since there is generally more to do after the clinics close at around 4. When I came in Dr. Jones was looking for an obstruction in a 5-year-old boy’s nose. The boy had been eating and had apparently shoved some mealies (corn meal) up his nose. The doctor couldn’t see anything, but the mother decided to take the child through to another hospital anyway. The ward was empty after that until about 5, when the other clinics had closed. A man was brought in who was having respiratory issues. He was put on oxygen and the cocktail of adrenaline and steroids to relax his bronchiole. I had seen the patient in the Casualty ward before, and I asked the nurse if he was a suspected TB case. She told me that he was actually on chemotherapy for cancer of the kidney, but they now suspected that it has metathesized to his lungs. The other two cases that came in tonight were both suspected heart attack cases.
In the first case, a gentleman of about 50 came in with chest pains. He had had them for several hours, and was concerned that he was having a heart attack. The doctor wanted to perform an EKG on the patient, but the machine for trauma was broken. The man was given a rapid results blood test that indicated the presence of a protein that is released when a patient is having a heart attack. If this protein was present, the patient was definitely having a heart attack, but it is possible to be in myocardial infarction without the presence of this protein, so it is not a definitive test. The test was negative, but the man was still given a nitroglycerin tablet and admitted so that he could be given an EKG the next morning. The nitroglycerin tablets are given in angina cases, as they dilate the arteries of the heart, allowing it to move blood more easily.
The next gentleman who came in with a suspected heart attack had no chest pain. He was a 72-year-old diabetic and hypertensive shop owner, who had experienced muscle weakness and uncontrollable sweating early that morning. He had presented to his local doctor, who thought that he might be having a silent myocardial infarction, essentially an asymptomatic heart attack. He was also given nitroglycerin and admitted to the ward for observation.
All in all, today was one of the slowest days I have seen in Casualty. I spent the majority of the day talking to doctors and nurses about the ins and outs of the South African healthcare system.
2-7, 5 hours.
11/20/09
Today was my last day at Ladysmith Hospital, so in the morning I delivered cookies and thank-you cards to all of the nurses and doctors. All was quiet in Casualty, so I headed to maternity. There was a difficult birth in progress, the mother was fully dilated and had began to deliver the baby, but wasn’t. The nurses told me that she didn’t want to push, so Dr. Potter attached a vacuum to the top of the baby’s head and helped the mother by working the baby out slowly, coordinating with her contractions. The doctor also cut a piece of the vagina because the opening was not large enough for the baby’s head to get through. The baby’s head came out cone shaped, but the doctor told me that this was common, it was called molding, and that it would look normal in a day or so. Essentially, the baby’s head had formed into the shape of the birth canal in order to allow it to pass through.
I then went to Casualty, where a boy had broken his arm. I walked him to X-ray and then to the Orthopedics department, he had completely broken both the radius and ulna about 5 inches above his right wrist. A woman also came in who had been bitten by a dog, followed quickly by a 74-year-old woman who had been kicked in the chest by a cow. She had two broken ribs from this incident, but the chest X-ray showed that she also had pulmonary fibrosis and an enlarged heart, so she was admitted to the hospital.
The paramedics came in with a man who had been in a motor vehicle accident. He was given an IV of Plasmalite, (a volume expander to compensate for the blood he had lost) and once he was declared stable, sent to X-ray. He had a suspected neck injury, but the X-rays came back clean, so he was admitted for observation. I then made the rounds and said goodbye to everyone in all of the wards that I had observed in and learned from. It has been a great experience and I have been truly inspired by these people and the work that they do.
10-4.30, 6.5 hours.
After spending the day working on my paper, I went in to the hospital on Sunday night one last time to observe in the casualty ward. When I got there I saw a man lying on the bed who had been shot in the right thigh. He was stable, and was given fluids, bandaged and sent to surgery. About 40 min later, seated on the same bed, a man came in who had been hit in the head with a heavy spear, cutting a 6-inch gash in the top of his head through which the skull was clearly visible. A police officer was standing by his bed. The officer told me that the gunshot victim had been shot by two brothers, who had fled the scene but were caught almost immediately and sent to jail. The brothers of the victim had heard what had happened and had driven up from Petermeritzberg, about 40K away. They did not know what had happened, and so they went after the brother of the two gunmen, splitting his head with a heavy spear. These two brothers were subsequently arrested and put in jail. The officer thought that the story was very funny, with four brothers in the same jail and two in the same hospital, and he was there with the patients to deter any more violence towards them. Later that same night I observed a community assault victim who had been beaten and whipped with a sjambok. He had bruises across his chest and had also been assaulted with a bush knife. From this he had four deep lacerations on his head, and lacerations across his legs, hands and arm. His left arm was also broken. Head trauma was suspected, so he was sent to get a CAT scan. While he was being sutured, a man who had been assisting in moving the patient was pricked by a needle. Blood had to be drawn from the patient and the man who had gotten poked to determine if he had to start ARVs. The patient was positive, and so the man had to go on a month of ARV therapy. In all, it was a slightly harrowing way to end my experience here at this trauma center.
7.30-11.00PM, 3.5 hours.
Sala Kashe,
Ben
