It was a very amusing tale: A mother brought her 8month boy who three hours ago had his fingers executed by his five year old brother with the bush knife.
Mother brought the chopped pieces with her, wrapped up in tissue in her coat pocket.
Now the distal ends of the right middle and ring finger were almost sliced at the DIP joints. The freshly cut fingers now posed a problem (for him as well as me), never having dealt with closures of this kind I found myself a bit stuck. I knew the distal ends were probably not salvageable at this stage so it was am matter of closing the chopped ends.
That day all the seniors were out and about - I tried to get hold of one who directed to me to a purple book in the library that has a good hands section. I dutifully went to the 'library' (archaic collection of books from 1800s left and donated by people) and sought out the purple book. Lo and behold I couldn't find it, after another phone call, I managed to get a name for the book and diligently sought out he hands section. Ironically the book was called non-traumatic injuries. (?oxymoron). After painstaking page turning I realised their was no advice on chopped fingers to be found.
The end result was I didn't quite ascertain what the correct management was so with some help from another junior colleague we figured that interrupted sutures used to pull the skin taught over the bone would do.
The ideal technique I consequently learnt would have been to obtain a bone grinder and grind the distal ends of the phalanges down so the skin could be closed with less tension. Luckily in children they have such malleable skin and bone with excellent potential for healing we did not need to fiddle any further with his fingers (relief on my part).
Saturday, 22 May 2010
12.05.2010 Burnt Flesh
They wheeled in the lady at 7.30am that morning, she was talking, she was coherent, she was completely burnt and still alive.
I left a gogo (granny) in mid consultation to assess the situation quite speedily, the site was unparalleled. This poor lady was covered in a blanket but the patches of exposed flesh, showed she had none. The chocolate coloured dermis was dripping off and lay in crumbs on the floor. As we removed the blanket a wave of more dripping skin wafted to the ground. She had white limbs, white chest and breast and a peeling face.
That morning at 6am a canister holding 5 litres of petrol in the house had accidentally ignited, setting the house up in flames. The patient had been caught in these flames along with her three year old daughter. The door was locked from the outside but there was small window through which the mother intuitively through the child out of. The child was incredibly fortunate to survive with minimal superficial burns. Mother though, as I have already alluded to, did not fair well.
The mortality of burns this severe and this deep is high, infact the percentage burn corresponds to the mortality rate and after stabilisation a thorough assessment of the burns revealed a total of 85%.
The scene was not just visual experience, the olfactory nerves were tainted by the smell of burnt flesh in mass volume. It was an incredible and provoking scene.
Knowing the prognosis, we still felt we should proceed with trying to optimise her as much as possible, the burns unit for referrals, said what we knew already and didn't feel any virtue in transferring her across to them. Airways and breathing she was doing for herself for now, but we could help her with fluid losses if we could only get venous access. I called for more help, with myself , the senior doctor, nurses, phlebotomists we poked the poor lady all over to no avail. We didn't have any central lines and simple cannulation of the external neck veins failed. So after a quick read of the ATLS manual the senior doctor successfully did a venous cut-down of the long saphenous vein and we had access!
The daughter stayed the night on the paediatric ward and in the early hours of the next day mother passed away.
28.04.2010 Four hours drive, four decades apart
South Africa is a remarkable country, not just for the mere obvious attributes, like the superb weather, unparalleled history, Game Parks, Beaches, extraordinary medicine and disease etc.
What I have found quite remarkable is the huge disparity in healthcare within the country.
South Africa is far from a typical African country. Having ownership of a city like Cape Town which feels like an idyllic Mediterranean town, to the other end of the spectrum being KwaZuluNatal - unruly, unpredictable and impoverished but undeniably beautiful in its own right.
Medicine seems to follow a similar path of immense disparity. In KZN we have rural hospitals, with limited money and resources and doctors, in Durban, four hours drive away we have the state of the art tertiary hospital with a mountain of specialities.
Its clearly a socio-economical issue why the standard of health has no uniformity, but the government try to tackle this by ensuring bush hospitals have a supply of doctors, by making it obligatory in their second year to do a community service - comserve. And it is not just doctors, but other health care professionals, like physiotherapists, occupational therapists and dieticians, much to the benefit of everyone really. As it is an obligatory part of the career of most government workers are aware of the healthcare structure, or so you would think.
I have found on a number of occasions being very confounded by the lack of insight to bush hospital structure, by our referral hospital colleagues. At Mseleni, there is a constant problem with urgent blood samples, running out of cartridges for blood gas machines, finding appropriate equipment when needed, US probe breaking, valves for BIPAP going missing and on and on......
So when the accepting doctor at the referral hospital asks you to do all the above then ring back, my frank refusal and clear portrayal and the resources we have to work with in the time frame the patient has sometimes gets the patient sent across and sometimes not.
So referrirng patients is a challenge but when successful, satisfying.
Friday, 21 May 2010
Thursday, 20 May 2010
Sunday, 2 May 2010
28.04.2010: Butterfly Effect
Being in the middle of nowhere, means News often filters through insidiously through various channels or doesn't at all. So if Michael Jackson came back to life or an Earthquake swallowed the UK, I would be none the wiser.
But when this rather unheard of, previously anonymous volcano, in the middle of the Land of Ice, opened its top and emptied its entire contents into the atmosphere, we couldn't but help get wind of it here. The sheer pandemonium that rose was indeed magnificent.
Friends couldn't catch flights, holidays were cancelled, or extended when others couldn't return (not just a bad prospect), the micro and macro levels of the repercussions seemed boundless.
My sister in Dubai, emailed me to tell me that the meat was out of stock in the supermarkets, signs up on he boards 'Volcano in Iceland disrupted deliveries'. No red meat for them for a while. Even London was not untouched, aside Heathrow chaos (which lets face it is not uncommon), hospitals were feeling the brunt of the after effects. Shabs (my dearest friend) reported that in her hospital they cancelled theatre lists because deliveries of blood were not made and there was a hint of some medication shortage too!!
So while things were looking bleak and depleted in the World, we in Mseleni, well we had a lack of decent meat, no fish, no ice-cream, no shops and our pharmacy department which rarely has anything more than Panado (paracetamol trade name here in case you were struggling), ran out of Panado!!
But this, my readers, is quite independent of any volcano, I am afraid this is a rather chronic state.
Welcome to KZN x
But when this rather unheard of, previously anonymous volcano, in the middle of the Land of Ice, opened its top and emptied its entire contents into the atmosphere, we couldn't but help get wind of it here. The sheer pandemonium that rose was indeed magnificent.
Friends couldn't catch flights, holidays were cancelled, or extended when others couldn't return (not just a bad prospect), the micro and macro levels of the repercussions seemed boundless.
My sister in Dubai, emailed me to tell me that the meat was out of stock in the supermarkets, signs up on he boards 'Volcano in Iceland disrupted deliveries'. No red meat for them for a while. Even London was not untouched, aside Heathrow chaos (which lets face it is not uncommon), hospitals were feeling the brunt of the after effects. Shabs (my dearest friend) reported that in her hospital they cancelled theatre lists because deliveries of blood were not made and there was a hint of some medication shortage too!!
So while things were looking bleak and depleted in the World, we in Mseleni, well we had a lack of decent meat, no fish, no ice-cream, no shops and our pharmacy department which rarely has anything more than Panado (paracetamol trade name here in case you were struggling), ran out of Panado!!
But this, my readers, is quite independent of any volcano, I am afraid this is a rather chronic state.
Welcome to KZN x
01.04.2010 Sangomas and Herbalists
Introduction to Traditional Medicine and Healers
Never having had any particular faith in our complementary medicine 'colleagues', having to deal with the effects of the Zulu Witch doctors edition of alternative therapy, I could easily succumb to a bit of homeopathy or acupuncture (!). Most of you wouldn't mind a few needle pokes, impotent drops of herbal concoction or a few pungent smells, if the choice were between the latter or a toxic therapeutic Enema made of detergent??
The local practice is a universal enema of 'sunlight' soap, Colgate toothpaste plus or minus boot polish in varying amounts shoved up the rectum, to cure all sorts of troubling ailments. Do these manufacturers know how useful and diverse their products really are. Doubt it.
The enema, to be fair, is widely practised method of 'cleansing' but I doubt they usually consist of such toxic ingredients.
The Inyanga (herbalist) will make up a imbiza (medicine from inyanga - the enema usually) which can be taken for a variety of reasons. Men may take it for sexual performance enhancement but little do they know, it may instead lead to frank haematuria and malignant hypertension secondary to severe renal toxicity.
It is invariably given to children with gastroenteritis as a treatment for 'anal sores' - and this is the bane of my life on the paediatric ward :( The number of wretched babies/children that come in with potassium levels incompatible with life at both spectrums (K > 7 and <2) is phenomenal.
Infact, to make any diagnosis you must merely ask two vital questions:
1. What is mothers HIV status and
2. When did you give the zulu medication?
Broadly speaking, for those who are not so familiar with South African healers, they seem to take two major forms. The Iyanga, as mentioned above, who is the herbalist, priest, psychologist of sorts. The other is the iSangoma, who is a diviner and can make diagnoses. iSangoma are also closely entwined with the ancestors and are able to communicate with these long demised souls and project to the followers their state of mind on different affairs.
My one and only contact with a iSangoma so far, has been in our outpatient department. He had come to seek treatment for dysuria and penile discharge. I was quite enlightened to learn that penile discharge is one of the few ailments that cannot be treated by traditional means, unlike HIV, strokes, cancers and other generally grave and incurable disease ;)
Never having had any particular faith in our complementary medicine 'colleagues', having to deal with the effects of the Zulu Witch doctors edition of alternative therapy, I could easily succumb to a bit of homeopathy or acupuncture (!). Most of you wouldn't mind a few needle pokes, impotent drops of herbal concoction or a few pungent smells, if the choice were between the latter or a toxic therapeutic Enema made of detergent??
The local practice is a universal enema of 'sunlight' soap, Colgate toothpaste plus or minus boot polish in varying amounts shoved up the rectum, to cure all sorts of troubling ailments. Do these manufacturers know how useful and diverse their products really are. Doubt it.
The enema, to be fair, is widely practised method of 'cleansing' but I doubt they usually consist of such toxic ingredients.
The Inyanga (herbalist) will make up a imbiza (medicine from inyanga - the enema usually) which can be taken for a variety of reasons. Men may take it for sexual performance enhancement but little do they know, it may instead lead to frank haematuria and malignant hypertension secondary to severe renal toxicity.
It is invariably given to children with gastroenteritis as a treatment for 'anal sores' - and this is the bane of my life on the paediatric ward :( The number of wretched babies/children that come in with potassium levels incompatible with life at both spectrums (K > 7 and <2) is phenomenal.
Infact, to make any diagnosis you must merely ask two vital questions:
1. What is mothers HIV status and
2. When did you give the zulu medication?
Broadly speaking, for those who are not so familiar with South African healers, they seem to take two major forms. The Iyanga, as mentioned above, who is the herbalist, priest, psychologist of sorts. The other is the iSangoma, who is a diviner and can make diagnoses. iSangoma are also closely entwined with the ancestors and are able to communicate with these long demised souls and project to the followers their state of mind on different affairs.
My one and only contact with a iSangoma so far, has been in our outpatient department. He had come to seek treatment for dysuria and penile discharge. I was quite enlightened to learn that penile discharge is one of the few ailments that cannot be treated by traditional means, unlike HIV, strokes, cancers and other generally grave and incurable disease ;)
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