I feel a little bit jaded. It has been a relentless week-end on call and eating and sleep have been a luxury. Three caesarian sections, the third of which was complicated by a failed spinal anaesthetic, morbid obesity, a uterus tied down by meteor-like fibroids and comet-tail adhesions and a big 3.8kg baby! The entire hospital ward rounds between two of you and the inevitable surprises like the chap with the sore knee. Pulling back his blankets revealed a hot swollen knee from which, in theatre later, warm yellow pus gushed in a volcanic torrent. I have referred many septic knees to Orthopaedic surgeons before but I had never done a knee wash out myself. A quick visit to our library put me right and their instructions worked perfectly. The chap looks much better on the ward today. Then on the women’s ward another snake bite. The foot that looked a little puffy yesterday was now massive and blistered with swelling extending right up to the thigh. This is common tissue destruction from snakes like the Puff adder. The dilemma was whether to give anti-venom, which is almost as bad as the venom itself with a huge risk of anaphylaxis, and/or to do fasciotomies on her, which involve large incisions up either side of her leg, to relieve the pressure. For the moment we watch and wait. The HIV + man with kidney failure so bad that he is unable to produce even a drop of urine and his body rapidly swells like a balloon as his heart and lungs follow suite. Pressed renal units will not accept him for dialysis if his CD4 count is <200 and some even if he is HIV+. Then the neonate, pushed into the world by her sullen 16yo mother, gasping for breath, blue and floppy. We ventilate him with ambubag and oxygen, thrust needles into his hair-like blue veins and carefully drip neonatal fluid and a concoction of antibiotics into his circulation. He rallies but remains poorly responsive and we wonder whether some more sinister insult has befallen him. Maybe we will be able to get a CT scan next week. So these are the sort of challenges that are woven into our day interspersed with all the other ward patients waiting patiently for their few minutes with the Dokotela.
Runners at the Mseleni Fun run we organised
Then of course there is the perpetual queue waiting in the OPD. The police attend with a 5yo girl. She has allegedly been raped by a 15yo boy. We painfully sift through the forensic rape kit subjecting this little mite to a multitude of swabs and invasive tests in a vain attempt to gather evidence for a conviction that we know is unlikely to ever happen. The process takes nearly an hour which is agonizing on a busy Saturday. We have no counselors, youth workers or support and so simply send her off with her grandfather, clutching the fluffy little white teddy supplied in the kit. Then we ponder whether we should have provided her with HIV prophylaxis. Sometime in the middle of the night I am called for a man who has been attacked with a bush knife. He has a large hole in his elbow. Under local anaesthetic I explore. The cavity is impressive and extends deeply into his elbow joint. The knife has neatly cleaved a slither of bone off his humerus. I copiously wash out the joint and suture the bone back in place with the joint capsule and secure him in a plaster cast. He reluctantly agrees to an admission for iv antibiotics and possibly further intervention. Another knee aspiration, a few miscarriages, the usual AIDS patients with diarrhoea and coughing, kids with fevers, broken bones, psychotic patients with desperate families, chancers hoping for a shorter queue on the week-end, stabbed back with a broken bottle, asthma, snake bites, confusion, abdominal pain. On it goes and the week-end disappears in a blur.
Then there was that on call when I was covering labour ward. Actually I am an ED physician and am not designed for this sort of stuff! It went like this. 16.00; called to LW for a primigravida who has a prolonged latent stage, is on maximum oxytocin infusion, screaming with pain and her cervix is only about 4cm dilated. We settle her with some Pethidine and she delivers 3 hours later. 20.00; back in LW for a prolonged 2nd stage. We contemplate the vacuum but she delivers about a minute later; baby is blue and lifeless and requires vigorous resuscitation. While we are at this a call from next door tells us of a delivery, but the first of undiagnosed twins. Then a second call….”come quick’ something feels odd. A vaginal exam reveals that the 2nd twin is coming down the birth canal with his arm first which potentially will obstruct him. I try in vain to replace the arm and then elect to deliver. Thankfully a healthy 2nd twin is delivered. Then return to flat baby who requires an umbilical catheter to supply fluid and antibiotics. We package him off to the high care nursery. Then to finish things off the twin’s placenta has failed to deliver. We take Mum to theatre and under Ketamine remove the placenta, repair the episiotomy and call it a day. As I trundle off home I suddenly wander if there might have been two placentas!
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