Diplomacy

I have a patient in the ward in respiratory distress. I ask the nurse to please change the patient from nasal prong to face mask oxygen. She simply doesn't budge. When I ask her again for the mask, she replies that they don't have any. (No face mask oxygen!?!) The patient's saturation has now dropped to 73% and he is very tachypnoiec. I ask her to kindly find a mask. Then she says to me she's not going to because she doesn't think the patient needs oxygen.

This little scene has made me consider the concept of conflict resolution in the workplace. Numerous variables play a role in complicating the issue: The nursing staff are often older than the doctors in South African hospitals as junior doctors have to serve a number of years in state hospitals before being able to move to private practice. This introduces the awkward situation of giving instructions to a lady who may be your aunt or mother.

Secondly, strong cultural divides still exist in South Africa. The indigenous tribes still afford their leaders and nobility a high level of respect. If you happen to be a descendant of a rival tribe or a commoner, you can surely not be taken seriously if you aim to give instructions to a person of a higher social or cultural ranking than yourself. Unfortunately and despite more females now qualifying than males, the male doctor is much more respected than the female. Remarkably enough that divide is most severely enforced by the older female (patient and nurse alike).

There is also the unfortunate age-old conflict between nursing staff and doctors. The two professions run alongside each other and are meant to compliment each other in different and specific ways. When the one encroaches upon the other, either side has to back down and accept leadership from the other. This does not sit well with human nature. Unfortunately I have to acquiesce that doctors have in the past era of paternalistic medicine forced instructions upon the nursing staff with a certain unattractive bossiness. As a result there is a feeling amongst certain nurses, perhaps the ones previously disrespected by an egoistic doctor, to suppress the young doctors' sense of self-importance before it can impact on the nurse.

With that we return to the common goal of treating patients, ensuring their comfort and healing them as far as is possible within our human limits. From my training it is quite clear to me that my patient is in serious need of oxygen. This is not the time for pussy-footing or shying away from a conflict situation. The patient's well-being is the top priority. Before revealing the outcome of this little scene, I'd like to invite you, my reader, to contribute your own tested methods for dealing with workplace-related conflict and suggestions to resolving my patient's dilemma.

In Cold Blood

The South African medical fraternity lost a friend and colleague this week. A young doctor serving his community was murdered in cold blood by an allegedly mentally-ill patient. This same patient had attacked a couple of nurses some years back. This event has sparked a minor outrage amongst other doctors in the public service. We all realise that it may just as well have been ourselves ruthlessly attacked in the line of duty.

A magnitude of perils face the average doctor in South Africa. The transmission of blood- and airborne diseases is a topic quite worthy of its own discussion. Simply focusing on violence in the work place, one has to mention that convicted criminals comprise a large section of the patients seen. I have witnessed, on many an occasion, the guards accompanying prisoners, releasing their shackles and leaving them quite unattended in order that they, the guards, may have a little smoke outside under a tree. This leaves the prisoners free to act in any way they so please. A young, female medical student may, in such a situation, find herself alone with the inmate. His hands are free to grab at her or at any sharp object available in a hospital room. His legs are free to carry him out the door.

When consulting mentally ill or violent patients, we are taught to arrange the consulting room's furniture in a manner that will allow the doctor to be seated closest to the door, the escape route. I've seen this rule followed only once or twice. As a matter of course, patients arrive drunk or stoned in casualties, most often on the first weekend after pay day. In this inebriated state, they are violent and strong. Not only do they show case a vocabulary that would make any sailor proud but they often lunge at one, biting and kicking.

I gather that the Mpumalanga Department of Health is implementing a number of changes in the security systems at hospitals in the province (where the young doctor was murdered). I'd like to remind us all of the daily dangers bravely faced by health care workers in South Africa and challenge the powers that be to improve the security in hospitals countrywide.

Life Force

I hold his heart in my hand, and squeeze, squeeze, squeeze, trying to maintain a steady rhythm of 100 beats per minute. The heart has lost its own ability to maintain the circulation of blood around the young man's body. With my hand cradling the flaccid muscle, I usurp the life-maintaining contraction. At the head of the table, the anaesthetists scurry about, injecting vile after vile of adrenaline, attempting to jerk the heart back to life. The man is not dead yet but kept in a deep slumber unaware of the struggle and the stress around him.

Fifteen minutes earlier, the youngster had been fully awake to this world. He was brought to casualties slumped over the shoulder of his friend, his gangster brother. It was this 'friend' who had applied the blade, with a smooth, vicious thrust, straight into his left precordium. The blade shattered his 5th rib, plunging into the soft recess of his right ventricle. The knife handler had quickly withdrawn his weapon. Knives cost money and he doesn't have all that much to spare at present. 

My hand still cradles the heart, rhythmically squeezing the blood out. By now my hand is cramping but I cannot withdraw. Without an adequate circulation, irreparable damage will occur to the vital organs, including the brain. Then, I feel a slight twitch in my palm, very faint, quite easy to have been my imagination. Then another, stronger now. The man's heart is beating again. I let go, and all the theatre staff peer expectantly at the monitors: a normal sinus rhythm. I thank the Lord, we've been given another chance.

With the blood pressure rising, the stab wound to the right ventricle becomes very obvious again: a fountain of red spurts to the roof with every beat. My finger flies to plug the hole. Now the surgeon's skills will be put to their greatest test. While constantly moving and spurting blood, the surgeon needs to place a suture around the hole and tie it gently but firmly. If he handles the heart too much it may revert to a fibrillating rhythm, or cease beating all together yet again. The coronary artery lies just adjacent to the stab wound. Should the surgeon place his suture through this artery or tie it off, the patient will instantly have a major heart attack and a large section of his heart muscle will die off, severely decreasing his chance at life even if we do manage to close the spurting hole.

Downstairs, the young man's attacker paces the corridor. He prays that the doctors do their job, he's not ready for a murder conviction, just yet.


Miraculously, years of training and practice pay off, the surgeon places his stitches in the perfect position and the spurting stops. Again, I praise the Lord, this time with tears in my eyes.