Parenting

Kids are waging a reign of terror against their teachers and their parents.

We have seen an alarming amount of cases in the news recently of kids who assault their teachers with the rest of the class chanting in support.

I'm working in a paediatric trauma unit at present. Not a day goes by that I'm not shocked and saddened by the type of cases I see. Apparently the community is breeding a type of youngster who is entirely wild and ungovernable.

Tween boys rape little girls and threaten to murder them if they tell. An eleven year old is stoned by his nine year old brother while their parents look on. School boys gang up and bludgeon a vulnerable mate till he lapses into unconsciousness from a brain bleed.

The adult example offered to the children is of neighbours from opposing gangs shooting at each other across their front yards. A toddler who happens to be playing outside in his front garden gets caught in the gun fire. His little body takes a shot and he collapses.

Parents leave their four year old to play next to the high way, his only supervision being that of a couple of five year olds. He then, predictably, runs out in front of a passing vehicle and gets run over. 

The parents live out their time oblivious to the value of life, so they don't respect the value of their children's lives and they don't teach them to respect life as a gift from God. 

A two year old is left in the care of a seven year old while the single parent has to go bail out the elder son from prison. While unsupervised, the seven hear old attempts to bath the two year old. He proceeds to overturn boiling water from the kettle onto himself. Not knowing what to do, he goes to his room where his parent finds him hours later, crying from the second degree burn wounds he sustained.

I don't see discipline. It seems that parents have as little control over their toddlers as they have over themselves. I hear parents promising their offspring a wide variety of treats: chips, sweets, fast food and toys to placate them into sitting still and cooperating with the doctor or nurse trying to help them. That never works. They don't respect their parents because the parents do not fulfill a worthy parenting role in their offsprings' lives. 

It breaks my heart to hear a small kid ask to stay in hospital longer when we are ready to discharge him, because "it is nicer in hospital than at home".

My opinion is that this nation's children are lost. They yearn for guidance and protection. Lacking that, they do what comes naturally to youngsters in any of the animal kingdoms: they copy the examples they see in adult society and for the rest, act out. Kids seek attention and leadership in any way they can.

Schools are blaming parents and parents are blaming teachers. The media blames society. We need to realize that we are society. All of us put together is society and none of us can exclude ourselves from the effect our actions have on our world. Our children are the most honest reflection of ourselves. No child picks up a stone or yells out a swear word all of his own accord. They live by example.

Viva Madiba!

May the memory of his kindness continue bringing peace and reconciliation.

Damn the torpedoes!

Damn the torpedoes, full speed ahead! - Admiral David J. Farragut

Flies have infiltrated the squeaky clean fortress that is theater. You'd be in the middle of a laparotomy, when, in your peripheral vision, you'd notice their slow, calculated circling. Every turn brings them closer to their ultimate goal: touch down in your open surgical field. The nurses zap them with lignocaine spray. This technique basically anaesthetises them in mid-flight and they spiral to the floor. We can't use Doom because of the potential toxic risk to the patients' tissue.

Theater is a supremely clean place. These filthy critters are, however, attracted to the smell of dead tissue which is unavoidable in a theater where wounds are debrided. If they can find a way in they will penetrate the ranks. We think they're entering through the air-conditioning system.

There has been ongoing lamentation in theater about how unhygienic and completely unacceptable it is to have flies in a theater. If any of our patients should develop a maggot-infested wound post elective surgery, it would naturally be as a result of the resident flies.

The other day, theater staff were once again complaining about how nothing is being done about the flies. One of the senior members of the theater complement was saying that someone needs to inform the hospital's top management. He would not be that person though because bonus time was coming up and if he were to report the fly problem he'd be seen as a trouble maker and would not be considered for a bonus.

The first and most blaring question is why hospital management would consider recognising the obvious truth, that there are flies in theater, and the reporting of it to the authorities, who can bring in people to clean out the aircon vents and solve the problem, as making trouble. Ignoring the problem does not make it disappear. Saving the hospital from potential law suits once patients do develop wound sepsis by the pre-emptive management of the problem is surely the only correct procedure to follow.

Whether the particular doctor had an accurate view of the hazards he would face if reporting the situation, I cannot say. It only makes sense to assume that he spoke from previous experience of dealing with "the system".

Everything about being a doctor tests our commitment to putting our patient' needs above our own. Working 30 hour shifts without sleep because there are patients who need our help is an obvious example. If we are not prepared to be advocates for our patients, who will be? The system may support ducking our heads and smoothing over the creases but being a darling of the system doesn't make you sleep at night. 

Thank you to the man who has stuck his neck out for that which he believes to be right. Thank you to every person who has fought for a society that advocates freedom: freedom to health care, freedom from persecution, freedom of expression.

Advice to surgeons

"Whenever you encounter massive bleeding, the first thing to remember is: it is not your blood!"
- Raphael Adar

L-O-V-E

Live!

I learned today that a colleague had passed on. He was 36 years old. Gone. Just like that. Heaven's gain is definitely humanity's loss.

The suddenness of his passing jolted me a bit. I shall aim to draw joy from the bounty of life more often; to live abundantly without constraint and to find something to love every day.

At World's End

So, big surprise, the world didn't go up in a puff of smoke on 21 December. But with so much talk about the end of an era and the year drawing to a close, I too find myself mulling over events of the past twelve months.

For me personally, 2012 features as the toughest year in recent times. In some limited ways, my world has ended more than once this year. Luckily I can also say that I've gained invaluable wisdom and strength. Incredible people have enriched my life. I'd say that because of 2012, I'll be better equipped to live 2013.

As far as hospital experiences go, this must surely also have been the year in which the fallibility of modern medicine, the endurance of the human spirit and the incredible comfort of faith in God have come to the fore most poignantly.

The single most valuable lesson I've learned this year is probably to count my blessings, to appreciate my situation no matter how negative I might feel about it. There are always people who have a harder time of it. This may come across as a cliche and is difficult to stomach when you are struggling through hard times. I have the dubious priviledge, however, to see the best and the worst of the human condition daily. To differing extents, I witness, counsel and share in tragedies so I can truelly say that I'm better off than many, many people.

I tried to comfort a mom when her barely adult son sustained 90% flame burns, a condition incompatible with life. She had lost two other sons that very same week in different accidents.

My housekeeper's niece found herself in ICU after ingesting a pesticide. Her entire family were besides themselves with grief when informed that medical tests conducted to determine brainstem viability all failed and the next step was to switch off the ventilator. They gathered around her bed and prayed with total and childlike faith. The next morning, the girl's corneal reflexes had returned. Soon therafter, she was extubated, moved to the general ward and discharged home with a slight limp the only remaining neurological damage. In the neighbouring ICU bed, a little baby, incredibly ill from pneumonia, also appeared to make a recovery so complete and speedy that her doctors were taken by complete surprise.

Possibly the most remarkable case to cross my path this year is that of a young mother of two. She is exactly my age, which somehow makes her story more real to me. Perhaps I can imagine myself in her position. She developed vague abdominal pain and presented to casualties a couple of days later when it was clear that the pain wasn't subsiding. When she finally got to theater, the rattling discovery was made that her entire small intestine had infarcted.
She had basically had a heart attack or a stroke but instead of her heart or brain being cut off from its blood supply and with that essential oxygen and nutrients this had happened to all 8 metres of her small intestine. One cannot survive without your small intestine because that is where you absorb the food you eat. This lady's intestines were black and necrotic.

We basically closed her up again and sent her to ICU on a T- tube with the very realistic expectation that she would not survive the weekend. And that is the expectation with which I had to counsel the family. I cannot imagine how one could possibly absorb such information. Their young mom, daughter, wife, previously healthy had come to hospital with a bit ofa tummy ache and now this doctor was telling them that medical science expected her to be dead by the end of the weekend and not even to wake up post surgery to say good bye to them.

The weekend came and went, the next week passed and our patient remained haemodynamically stable, non-septic. We started debating whether it would be ethically acceptable to stop the sedation and allow her to wake up and see her family. The ethical questions centred around whether one should inform her about her medical condition and that she has no chance of survival. Her family were well counselled but refused to give up hope of a recovery.

We didn't have long to debate as to what our next step should be because she soon extubated herself.

It is now more that a month later, she looks beter every day and has even gone outside to sit in the sun.

I'd rather not debate on her chance of long term survival but surely, just the fact that she could see her kids again and chat to her husband and her mom is a miracle.

So the world didn't end for my patient at the end of that first weekend. She has had four more weekends and many hours to ponder on her life and its inevitable termination.

Our last day will most probably come when we least expect it. I can but wonder what I would do with borrowed time and whether I could use it in such a way as to improve my stakes in the hereafter. So, perhaps in 2013, I shall aim to live as if my world may end on any given day.

Pandora's Box

A doctor is often seen as a universal helper, a professional, caring outsider with the means to solve a magnitude of problems. Patients share their troubles with us and hope that we'd be able to fix them, whether medical by nature or not. Sometimes they're just seeking a shoulder on which to onload.

Years ago, in my internship, rotating through psychiatry, I interviewed a patient who carried with her Pandora's Box filled with the most wretched heartache and evil humanity can spew forth. She alone had been bearer of the secrets of the Box for more than a decade. Her heart was torn apart by the knowledge she'd been protecting her community and family from. I have never in my entire life heard a more harrowing story and hope that I may never have to again. The truth of the matter is that many, many people suffer at the hands of their fellow man and the degree of evil and injustice on this earth is rattling.

My patient spoke broken English, mostly making herself understood by hand gestures. She had been born in one of our Northern African countries, in a place where civil war and terrorism dictated life. A rural village was home to her entire extended family: mother, father, brothers, husband and five children. This community had been spared much of the brunt of the war as it was mostly fought in the urban areas. News arrived from neighbouring villages that the gorilla fighters were coming. They were on their way to recruit the men and boys to join their ranks and increase their power in the countryside. Young girls and women were raped. The gorillas left death and carnage in their wake; fields were burned, houses ransacked, any items of value confiscated and food plundered.

My patient was there, she heard the warning of the coming evil and when they finally arrived she heard their war cries, now still screaming in her head.
She watched her house with her elderly mother and father still inside go up in flames. They were too old and thus of no use to the gorilla fighters. Her husband and brother refused to join ranks. They were decapitated in front of her.

My patient was in tears. I had some difficulty understanding the details of her description due to the language barrier but the depth of her suffering was blatantly obvious. I understood why she would be so shaken, anyone who had witnessed these things would be broken. Then she shared the next bit.

Her eldest son was still a boy, too young to be considered for active participation in the terrorist group. They were about to kill him as they had his father. His mother threw herself at the feet of the murderers, pleading for her son to be spared. With her were her three younger children, the baby still only a few months old. The group leader presented her with a choice: her life for the life of her first born son. I dare not imagine what I would have done. At this point in the interview, my patient hesitated. Up to now she'd been rambling, the account of the incident spilling from her memory. Here she paused. She'd never shared this story with anyone. Since her flight to South Africa ten years before, she had kept the nightmare of her family's brutal murder to herself. And this she did because the shame of her choice completely overwhelmed her.

Faced with the blood-thirsty vengeance of the terrorist, she made the worst decision a mother could ever be asked to make. Were she to sacrifice herself so her little boy may live, she'd have no guarantee that he would not also be murdered and along with him his three younger siblings. That's after being subjected to whatever other evil deeds the terrorists had planned for them. The mother chose her own life, and essentially those of her other three children, over that of her eldest.

The boy was duelly decapitated in front of his mother. Pieces of his flesh were cut off and my patient was forced to eat it. She was made to eat the body of her son.

She'd tried to rebuild a life for her three remaining children in South Africa. She set up a little cafe selling odds and ends. She put her children through school single-handedly. Never ever did she breath a word of what had happened to their brother. At night the blood-chilling cries of the terrorists still rung in her ears. She had not had a peaceful night's rest in ten years. Sudden movements made her jump, loud noises made her break out in a cold sweat. The smell or sight of meat made her sick to the core of her being. She had not touched another piece of meat since that day.

Being a foreigner in South Africa, she was brutally discriminated against by the local African population. Word on the street was that foreigners were depriving locals of job opportunities. During my internship, xenophobic attacks in the townships occurred frequently. My patient had been a target of such an attack and lost her cafe cart and the source of her income. Somehow she still provided for her own three children and another six South African orphans whom she had informally adopted over the years. A year and a half before I met her, a man she knew to be connected to terrorist activities in her old homeland, came to her house and took her eldest daughter from her to be his wife. She hadn't heard from her daughter since and did not know what had happened to her or how to help her.

I diagnosed my patient with Post Traumatic Stress Disorder ( PTSD) and organised follow up visits with our psychologist. Our social worker could help her obtain grants for the orphans she cared for. I saw her once or twice attending her psychologist sessions since our original meeting and although she would obviously never be free of her harrowing memories, I like to think that she did look a little lighter. No medication could fix what had happened to her but unburdening her sorrow upon someone who did not judge was what she had been yearning to do for a decade.

(As I have no contact details of this lady and do not remember her name, she cannot be traced through this blog post. I have not mentioned the country she is from and have no recollection of that either. I have lost touch with her and do not know her or her family's current whereabouts.)

Heart of a Lion

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>> "A good surgeon has an eagle's eye, a lion's heart and a lady's hand."- English proverb.
>>>>>

Responsibility

Should we not expect our patients to take some personal responsibility for their health? Along with apartheid paternalistic medicine was swept out the door in 1994. Treatment cannot be forced upon a patient who doesn't wish to take part. Our constitution very clearly reflects this principle by ever lowering the age at which consent to medical and surgical procedures may be granted. A 12 year old may now either consent to or opt out of an operation. Even if a doctor knows that the patient is choosing to walk a road which will surely be strewn with nettles, if the patient is of sound mind and has been adequately informed, she can choose not to have life-saving treatment.

Eight months ago I saw a middle aged woman at the clinic with what was clinically quite obviously a cancerous growth in the breast, threatening to break through the skin. The fact that, before presenting to me, she had already waited what must have been several months since she should have realised something unusual was growing in her, made me suspect that she was too scared to face a doctor and for her worst fears to be confirmed. Such a response is quite predictable and, of course understandable. I am not blunted to the human feelings of trepidation and doubt which we all experience. I, thus, obviously counselled the patient and explained, in simple terms, the different options available to her for obtaining local control of the tumour if not to save her life. I ran a set of tests to confirm the diagnosis and prepare the patient for a radical mastectomy within the following two weeks.

Yesterday, the same patient presented to me again at the clinic. She'd never had the mastectomy. She presented on the correct day for her scheduled surgery. An open biopsy was done and she was given another follow up date at the clinic. This is were things got hazy: the next we saw of her was earlier this week. She says admin never gave her a follow up date. Our notes clearly request a follow up date. What I'm getting at is that this patient should have made sure she got to see a doctor again. Whether or not admin booked her into the system, she should have made sure to see us again, to ask for a date. In the subsequent six months she carried that growing tumour with her every day. Surely she should have questioned what was happening to her, thought it strange that after the last surgery she never got to see the doctors again. The constitutional court of law entrusts a 12 year old to consent to an abortion which may complicate and result in a septic uterus, emergency hysterectomy and loss of the ability to ever bare children. Yet, a grown woman, fully counselled, of sound mind, could not ensure that she had a follow up date to see her surgeon.

During the six months since her last visit, the mass in her breast ulcerated through the skin forming a massive crater. It invaded her chest wall and matted her axilla. By now it would have spread to numerous other organs. In a word, it now is irresectable. The smell from that tumour is so pungent, it makes your nose sting. Local surgical control six months ago would probably not have saved her life. It would have saved her dignity.

Putting on the green

My current neck of the woods is somewhat well known for its spectacular golf courses. Acres of manicured green lawns attract some of the great names in the golfing world. With that, of course, comes the inevitable golf estate lifestyle. White gabled villas connected by neat cobbled pathways dot these urban oases. Where previously, wild birds chirped in tree tops, neat ponds have been dug to house the ever popular Egyptian goose. Men in white pants and pink shirts toddle about with silent entourages a respectful distance behind. (Whether silent out of respect or bordom, I'm never quite sure.)

As an ironic comment on societal inequality in South Africa, an informal settlement of 'previously disadvantaged' citizens (though when exactly 'previously' stopped and currently began, I can't say, as things certainly have not improved for them since the days they were 'disadvantaged' ), is located just across the road and around the corner from the fanciest golf course / urban estate of the lot: Fancourt. The ruffians patients who keep me up on a Saterday night treating their post drunken brawl head injuries, suturing their faces back together, inserting intercostal drain after intercostal drain for stabbed chests largely come from that exact informal settlement.

So, when last wednesday afternoon I drove past a group of youngsters from the informal settlement wielding sticks on a patch of grass by the roadside, my first thought was that I should probably call the police because skulls would be cracking soon. Imagine my bittersweet surprise when five more young guys rounded the corner each carrying a single golf club. They were all just meeting up for an innocent round of golf! Some were barefoot, none had any golfing equipment except for the single club but they looked excited to join in the fun of a sport well played and shared amongst like-minded fans. In a town of fancy golf courses and million rand championships, these guys were not going to miss out. Their putting green was jagged, littered with the occasional broken bottle top but that wasn't going to dim their eagerness. They had an appointment with the guys for a wednesday afternoon round of golf.

A doctor's very best friend

Stilettos

Only a woman would wear a pair of stilettos that will inevitably leave her feet two painful blistered wrecks, simply because they are pretty and feminine and make her legs look svelte. (For that reason and of course for the wonderful foot massage her man will give her in the evening!) I worked with an Obs and Gynae reg who insisted that wearing high heels on her overnight calls was more comfortable than the very unflattering flat crocs the rest of us shuffled around in. 

Women are good at ignoring pain or just setting it aside, if there is a worthwhile reason for doing so. It may be the lovely way that your new heels compliment your outfit. Or a more selfless reason: encouraging your kids to spread their wings and leave the nest so they may grow and develop while you cry your heart out because your babies are gone.

I've always been under the impression that if one indulges in emotional pain you give it more power. I thought the best way to deal with hurt and disappointment is to try not to recognise its existance. Pain and sadness is part of life but there's no point wallowing in it. Instead of allowing sadness to affect my person, I would concentrate on getting on with life. My masterplan was not to ever get hurt by simply not allowing myself to FEEL the hurt. I thought that a person who breaks down in a flood of tears over something non-earth-shattering was just being self-destructive by indulging in the bad emotions.

Then I heard about a study conducted by a group of psychologist that unequivocally proved suppressing negative emotions is dramatically more damaging to the body, in a physical sense, than feeling the hurt and crying is. Participants in the study were hooked up to a number of monitors, measuring pulse rate, blood pressure etc. Couples were asked to discuss topics that both parties felt strongly about. These topics evoked strongly negative emotions in both. One of the parties would be asked to suppress all feelings about the topic and remain calm. The other party was instructed to react in accordance with their feelings on the topic. Then they would alternate roles.

The heart rate monitor beeped like crazy and the BP went through the roof every time a participant was suppressing his negative emotions. The cardiovascular derangements lasted longer in the outwardly controlled person that in his "emotional" counterpart who experienced only a brief surge in stress markers with a quick return to normal levels as his emotions were allowed a release.

It appears that the human body is equipped to deal with negative feelings by expressing them. Getting "worked-up", sad or angry over something and really FEELING and expressing the emotions is the healthiest, most natural way of dealing with stress. I was quite shocked, to be honest, to learn that my survival strategy was causing me more long-term hurt than protection from pain, as I'd thought.

So, since I learned of this remarkable study that disproved one of my core principles, I am no longer avoiding my stilettos. I now wear them with the full knowledge that my feet may be blistered by lunch time. If my feet should hurt I'll admit to it and I might even cry about it. Does this strategy seem a little pointless to you? The point is that I'd get to enjoy my legs looking lovely and svelte which wouldn't have been the case if I'd hidden my feet in the protective recesses of my old crocs.

Words

A few of my favourite things... So much meaning lies in a single word. As you read these lovely words allow them to carry you away to a treasured memory or a sweet dream.

Felicity ~ pleasantness                                                  

Ebullience ~ bubbling enthusiasm

Gambol ~ to skip or leap about joyfully

Mellifluous ~ sweet sounding     

Ethereal ~ invisible but detectable          

Halcyon ~ happy, sunny, care-free

Dalliance ~ a brief love affair       

Inglenook ~ a cozy nook by the heath    

Buoyant ~ hopeful               

Luxuriant ~ opulent, lush     

Petrichor ~ the smell of earth after the rain

Serendipity ~ finding something nice while looking for something else

(Picture down-loaded from the blog fanciful-fanciful.blogspot.com)

Perennial rookie

I was still a student when a school friend of mine banked her first adult salary as an actuarial assistant. When I finally graduated and reached the dubiously honourable rank of intern, she was already an actuarial consultant, in charge of large contracts.
In medicine you're never certain of whether you've actually made it. When I was adressed as "doctor" on my first call as intern and I had to make potentially life and death decisions as is expected of a real doctor, I assumed the nurse had addressed someone standing behind me. The community and one's family think you've really achieved something great if you're a doctor. There is still much respect for the profession.
Amongst other doctors though, an uncompromising ranking system is strictly observed.
As a meagre little intern, you might just feel a bit chuffed with yourself for making a good diagnosis or performing a procedure well. Your students might gather around you, eager to see the signs you've picked up in your wisdom. Be assured though when you present the case to the registrar, it will transpire that you missed the most important sign and the patient is sick from something completely different than what you had just been describing to the students. A good thing the sister knows best than to trust your diagnoses: she waited for the reg to see the patient before administering the meds. Your prescription would have been completely inappropriate.
But soon the house of cards come down again. The registrar who appeared so knowledgeable and accomplished the night before, is brought to his knees by the consultant on the next morning's ward round. As it turns out, the reg himself had failed to address a vital aspect of the patient's management. What's more, and a seemingly and infinitely graver mistake is that the reg cannot quote the specific study which proves that the patient should have been managed differently from the way the reg elected to manage him. This entire exchange between the registrar and consultant occurs on the grand ward round, in front of the patient (!), the students, interns and other registrars. The reg feels so stupid and wonders whether he shouldn't just go straight back to med school, or possibly quit medicine all together because he obviously knows nothing at all. Now he has to return to the patient and keep treating him. The patient, having heard the entire exchange, believes his doctor is useless and doesn't trust him anymore.
Don't make the mistake of thinking you've finally made it once you yourself are the consultant. Your colleagues are bound to raise their eye brows at some ofthe diagnoses you make, and some of your treatment plans. As you become more specialised in your field your focus narrows and as a consequence you become less adept at treating diseases you don't deal with daily. You might not be able to answer a general medical question posed to you at a dinner party. Your friends don't understand the subtle nuances of your speciality. They just think its great that you're a doctor and as such must know everything.
While my non-medical friends are settled in their careers, safe in the knowledge that they know what they're doing and can, with relative certainty, expect the same results from similar situations on a daily basis, I keep riding the rollercoaster of knowledge. Each day brings the chance of feeling completely out of my depth, too junior and unsure. The only certainty is that one doesn't outgrow that feeling.

Getting back my mojo

The Urban Dictionary defines one's mojo as your sense of purpose and meaning in life. Your mojo is your personal energy and charisma, your cool or style essence. Mojo is that little bit of majic that sets you apart from everyone else. Its that sparkle, the passion that makes each person totally awesome in their own unique way.
Sounds just epic to me! Wonder where I could buy me a bit of that stuff. I never knew I had me a little mojo until there was a void where my mojo used to be. I had regressed to a place where I hated my job. It had become monotonous and frustrating and didn't stimulate me as it used to do. Despite that, my personal life was being neglected as I was spending all my time at work. I was stuck in a rut.
Now, I refer you back to my very first post on this blog. Its all about a stab heart. I just LOVE stab heart cases! I don't mean that in the figurative sense but actual knife-through-the-heart surgical cases. I do say this with the utmost respect to the patient involved. To be so close to the physical life force keeping a body pulsing, and to really see the fragility of life in such a dramatic way, can only jolt one's mojo back into your own personhood.
The specific patient I refer to was rushed into casualties by highly charged ambulance men, very aware of the urgency of the situation. A jagged 10cm long wound cut across his left precordium. Blood bubbled out in gusts with every gasp he took. I explored the wound with my finger. Under the sharp edge of his fractured rib, I could clearly feel his, already weak heart beating. After rapid resus efforts we rushed him to theater; sawed open his chest; stopped the bleeding; and with God 's grace, granted him another chance at life.
The adrenaline and, I guess, the sense of achievement jolted life back into me too.
As we pushed the patient into theater, he stopped me. With effort, he whispered, "Doctor, do your best." I was truelly moved. I don't only have the responsibility towards myself to be connected to my job and my life but other people depend on me to pour my energy and passion into being the best doctor and surgeon I can be.

Entitlement

The current economic environment and pricey private medical care has lead to many previously advantaged people now having to rely on state medical facilities. A state-employed doctor's worst nightmare patient nowadays is no longer the drunk, verbally abusive guy dumped at casualties by a police pick-up van with a couple of stab wounds in the chest and as many scars from previous drunken brawls who vomits stale papsak wine on you. Recent times have created a much more feared patient: the PANDA ( Previously Advantaged Now Disadvantaged ). This is the white lady with the manicured nails and beehive who can no longer afford her private GP's fees so has to submit to state provided medical care. She always arrives at hospital with an entourage: the highly-strung husband who feels like a utter failure for having to bring his pretty wife to a state facility where she is forced to sit in the same queues as her garden boy and domestic worker. Instead ofverbalising his feelings to his wife, he has become moody, added 20 kg to his midrif and has been banned from attending family get togethers following a certain incident concerning his brother-in-law, CEO of a successful company, and a black eye. Also in tow is the bored teen who would rather be slouched in front of his play station but couldn't be left home alone after his mother discovered a little packet containing an unidentified white powder in his sock drawer. And of course, the concerned granny, because the patient needs some form of support and the husband and son clearly don't fit the bill.

So here's the scenario: casualties is busy, as per usual. There are long queues of patients to be seen. The folders are stacked high. As per protocol patients are classified as red, orange or green. Red meaning they are seriously ill and often in mortal peril. Obviously those are seen first. Green patients have non life-threatening complaints and stable vital signs. You are rushing about trying to sort out your patients as best and as fast as you can when a very agitated PANDA husband comes up to you, "Excuse me, girly,  when will my wife be seen?" 
"I am Dr Guinevere, Mr Panda. Have you opened a folder yet?"
"We arrived before the man you've just been examining, and my wife is tired, and I have to be at work in the morning. We can't wait any longer."
You look to where the man is gesturing and quickly spot the only white patients in the waiting room. Sure, the wife looks tired, the son morose, the gran is apparently admonishing the young girl with babe in arms beside her for her teen pregnancy.
"I'm sorry you're having to wait, Sir. I had to see the gentleman who arrived after you, first because he is very seriously injured was about to die. You might have seen the paramedics bring him in on a spinal board with head blocks, noticed the endotrachial tube in his throat and the nurse giving him oxygen via a face mask. Perhaps you also saw that his leg had been severed just above the knee, was oozing blood in a steadily weakening stream as his blood pressure was falling and his heart quickly weakening, on the brink of asystole. I had to help him as a matter of emergency, you do understand, Sir."  Mr Panda goes to sit down and is placated for a full 5 minutes. Or is it perhaps queasiness with the mildest green tinge you spy round his mouth? Wife and gran give hubby a look that says so clearly they both think he's an absolute loser for not being able to afford the luxuries of the Mediclinic waiting room. Not 10 minutes later, Mrs Panda stands before you.  Mascara slightly smeared  and lips too pale but still poised on high heels, she holds on to granny's arthritic hand for support. The sullen teen has obviously been told to get up and help his mother but he drags behind, dying from embarassment behind his greasy fringe. Just as your eye catches Mrs Panda's, she starts moaning bitterly and grabs hold of  her abdomen, bending over double. 
"Dear Mrs Panda, won't you sit down before you hurt yourself. I'll ask the nurse to give you something for the pain." 
"I don't want an injection, I want the doctor to see me." She drops the charade and hands you her cellphone. "Here, speak to Mrs de Klerk, she's the dominee's wife you know, and her son-in-law is an orthopaedic surgeon in Australia. She'll be able to tell you how serious my condition is and that I am to be seen right away. And do remember that I can't have penicillin or voltaren because of my delicate constitution."
"I am sorry for the delay Mrs Panda, kindly sit down and await your turn. Everyone in this casualty is ill and will be attended to." You hand her telephone back to her and indicate the full waiting room. There is a dehydrated baby with sunken eyes you know you'll have to attend to quickly. An old man is coughing up blood. He has either TB or a lung tumour. A mom is comforting her toddler who has a rash that looks suspiciously like measles. Next to her is a man covered in bloody crusts from a wound to his scalp.

 I wouldn't very much like to wait hours on end in this waiting room full of unpleasant smells and infectious diseases. Some of us have experienced air conditioned waiting rooms with old editions of Fair Lady and Weg to page through. Others have never had this luxury. No matter how uncomfortable a state hospital's  casualty set-up is, all the South African hospitals I've worked at have provided care of a very high and academic standard to their communities. With the advent of the NHI ( National Health Insurance ), patients from the extremes of social backgrounds will be thrown together more often. It will make for a very interesting study in social adaptation and human tolerance. Whether South Africa is ready for such a dramatic amalgamation of the classes I find doubtful. 

Mrs Panda, glances over her shoulder, in a soft voice, discreetly, she says to  you, "Ag, kom nou, Sussie, jy's mos een van ons. Sit nou die Tannie se leer bo-op die hoop dat ons volgende gesien kan word."

I will survive!

What makes a person survive stressful life events? Over the last, say two months, I have collected a crippling burden of stressful events. I share these with you not to invite pity but to illustrate humanity's caring nature and the endurance of man's will to survive. My life crises come nothing close to what we know many individuals to be faced with in war and famine and natural disaster situations. I don't claim that my lot is at all comparable, only to recognise that each person's little problem is huge to them, as it affects their daily life and future plans.

So, within the past two months I have endured the death of a close family member; the break-up of a romantic relationship; I moved towns and provinces meaning that I've had to make new friends and get to know new colleagues; moved to a new job with much more responsibility and strenuous working hours; become a student again and faced majorc career choice questions; survived a financial crisis; faced possible eviction; had a tumultuous emotion-laden Christmas and holiday season including unpleasant in-law encounters and a major change in social life and circumstances.

The Life Event Stress Scale ranks a number of stressful life events according to their likelihood of leading to stress-related illness. I tipped the scales well over the 350 mark with my recent collection of stressors. So I am well warned of having a 'high susceptibility to stress-related illness'. (You'd be glad to know I'm taking my vitamin Cs religiously.) I have included a link to the above mentioned scale at the end of this blog.

The question is thus, how do we carry on when our dreams are shattered, when our foundations are crumbling underneath us, when there seems to be no hope left in the world? Drink and drugs are always an option. Make of this what you will. Life has to go on and even though we cannot face doing much other than sticking our heads in the sand and pray for time to mend our worlds, responsibilities can be shirked only for as long as our colleagues and friends will pick up the slack. Even before we can imagine doing so, life forces us to start anew and just get on with it. I'm still waiting to catch up with my life that has seemingly continued around me, without me.

The point I want to get to is that there was love and hope to be found in the most unexpected places when I most needed it. Let me illustrate: not knowing a single soul in a new town especially during a time when I needed my friends and family around me was extremely daunting. I felt very much alone, left out in the cold to wither and wilt in my own hopeless, lightless hole of self-pity. The first ray of light strove to break through when I discovered a beautiful arrangement of wild flowers from my garden on my kitchen counter. My new maid, whom I'd met only once or twice had heard about the passing of my loved one and did something truelly thoughtful and kind for me. It touched my my heart deeply. The second blessing came in the form of a plate full of delicious, steaming, home-cooked food delivered to my front door by darling neighbours. Their timing was just right. I had nothing appetising in the fridge, it had been an especially long day at work and I was seriously considering having Kellogg's for supper. Theyd didn't know me but for having shared a coffee over the fence; I was hardly going to have a heart-to-heart with my brand new neighbours but they showed such care and support in a very practical way, it brought me to tears. I felt more part of my new community than living there for ten years would have done.

Then there is the ex-landlady left behind in Cape Town two years ago who shows me pure, unselfish support. She regularly phoned or emailed me over the past few weeks just to pray for me or share a few words of strength and guidance. When I was too overcome with grief to answer much in return, she understood and never allowed her support and kindness to wane. Her messages always arrive at the most applicable moments - when I'm on call at work and in need of divine strength or home alone and needing a pick-me-upper. I cannot neglect to mention my family, especially my mom and aunt, who despite having to face their own tremendous sorrow, have carried me through the very bleakest of moments, completely neglecting their own well-being in order to see to mine. There is no greater love than that.

Even though the road is wrought with pot holes and all sorts of miserable, nasty things, there remains a beautiful side to human nature. Love and kindness are alive in this world. Thank you to my angels for showing that you care.

Quote by Steve Jobs

“You’ve got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle.”

Hear hear!

RIP

Amandla!

I have a patient in my ward; shall we call him Mr T; a sweet young man who has been an inpatient in the ward for many weeks. He has full thickness burn wounds to his leg and foot. Obviously such an injury is accompanied by excruciating pain particularly during the dressing changes which are done every second day. Patients who call hospital wards their homes for extended periods of time become accustomed to the routine of the ward and even adopt some of the medical jargon they pick up when communicating with the ward staff. This particular gentleman has become adept at doing his own dressing changes and is quite an expert at describing wounds in medical terms (using words such as granulation tissue, although he calls it ‘graduation tissue’).

I recall another patient who was a long term resident of a medical ward, mainly because he suffered from brain damage and could not remember his own address or any next of kin contact details. This guy quietly observed the nurses going about their daily duties. One morning he joined them in making the beds, perfectly copying their particular way of folding the corners and rolling the blanket into a tight sausage at the base of the bed. Needless to say, as soon as the patient revealed his very useful bed-making talent he quickly received an invitation to stay as long as he wanted to.

But I digress, back to Mr T: we took him to theatre today to cover his burn wounds with skin grafts. This we perform under cover of spinal anaesthesia, numbing the patient’s legs while his consciousness remains intact. Mr T was acutely scared of the procedure and especially concerned that the spinal might stop working at any moment during the procedure, flooding his nerve ends with unbearable pain. We needed to constantly reassure him that everything was okay. We guided him through every step of the procedure. The operative site is hidden from the patient by a green fabric shield so he could not visually follow what we were doing. (And thank goodness for that as I cannot think of anyone who’s stomach could stand seeing an operation being performed on themselves).

At one point we needed to take a split skin graft with a machine called a dermatome. Unfortunately this contraption makes a terrifying noise, just like a grinder splitting through bone. In reality it very smoothly and effectively removes a super thin top section of skin (epidermis) from the dermis. Mr T was understandably completely freaked out by the hair-raising screech of the dermatome. He quickly realised though, that the spinal was indeed working perfectly because he had no sensation of pain at all! I think it was the whole stress of the situation and his extreme fear combined with the sweet realisation that he was not going to feel any pain after all, that made him burst out in, first giggles and then, deep tummy guffaws. He kept saying how he felt no pain from the grinder! The atmosphere in the theatre, previously sombre and a bit stressed by the patient’s panic, changed so drastically that we all started laughing along with him. Then he started singing the praises of all the doctors in the theatre saying how wonderful we are to give him new skin and save his leg.

At the completion of the surgery, still on the theatre table but nicely wrapped in bandages, the patient punched his fist in the air and bellowed “Amandla!” Now, this cry was used during the Apartheid years as a cry of togetherness by the ANC party members. It means power. One person, usually at a political rally would call out, “Amandla!” and the crowd would answer, “Awethu!” meaning, “Power to the people!” Most white South Africans, including myself, not really understanding the beautiful meaning behind the words, experience debilitating fear when we hear those words called out in great crowds. Or, at least, we would have during those dark ages of Apartheid. When exclaimed by the voice of a thousand people at a political rally it sounds like a proclamation of civil war.

The most amazing thing is that today when my patient, Mr T, cried, “Amandla!” I really HEARD him. He was celebrating that he had power in his court again: he was strong enough to survive the fear of surgery; strong enough to survive the burn wound and strong enough to take on life after months of being incapacitated in hospital. But he wasn’t doing all this alone. He invited us to join him in jubilation. We had walked the path with him, daily. We gave his legs the power to carry him. He gave us power to serve our other patients and to do it with an abundance of energy.

And we answered, “Awethu!”!

the inner room

Each of us has a space deep in our person where we retreat to when we need to be with just ourselves. Some of our inner rooms are neglected, dusty spaces like forgotten attics. We keep boxes of past experiences beneath layers of dust. We clearly do not enjoy ruffling through those past experiences, though some may bring recollections of beautiful times. Our outer lives may simply be so busy that we don’t have the time to retreat to our inner rooms. As that space gathers more and more dust and spider webs, it becomes exceedingly unwelcoming. We stop going there. We would certainly not invite anyone else there.

Then there are the inner rooms that are often visited. Some look like well-lived-in family homes. I imagine scatter cushions haphazardly thrown onto deep, soft couches, flattened in the centre from wear. Dirty coffee mugs stand around from previous visits. A room like this is certainly a regular haunt. Perhaps the visits aren’t always treasured,happy times, but they are real. The owner of such a room may not appreciate his own wondrousness but he is comfortable with who he is and happy to chill with his private self.

The most beautiful rooms are spaces of candle light. The glow is soft and warm and forgiving. Our most valuable treasures are placed on gilded pedestals. Owners of such rooms retreat there often: it takes a high level of maintenance to keep the space sparkling and clean and golden. The most outwardly flawed people may own lovely sanctums like these. They have gained perhaps the most valuable asset in this world: the knowledge that God loves us despite our weaknesses and human inadequacies just because we are His children. What arrogance we have to impose stricter judgements upon ourselves than He does on us!

Owners of lovely inner rooms make mistakes like the rest of us. They sin like we all do; they even have grave embarrassments to hide. These self-esteem ravishers burrow their way into inner rooms. They make their homes in corners. They throw scary shadows among the candle light. For the light to survive, we need to face these dark demons. Almost daily spring clean may be needed. The human nature is such that we err on a daily basis despite our best intentions. Shadows cannot survive where there is light yet many of us create our own barriers against the light. We seem to think that we need to wallow in shame and self-pity when we’ve acted in a way that darkens our inner rooms. God offers us candles of forgiveness in abundance. In His Great Book He has forgiven us a long time ago while we still hold onto the shame that comes with the self-imposed darkness. A candle lit in a dark corner drives out the scary shadows and restores the golden glow of our inner rooms.

For some people, inner rooms are so private that they hardly invite themselves inside. Certain inner rooms are sealed with re-enforced steel walls, pin codes and laser eye alarm systems. What would happen if we were to invite an outsider in? Could they steal our treasures? Would they sell our shames to gossip papers? I don’t know... Is there truly anyone in this world that could be asked to be a safe keeper of our private selves? Is it not sufficient that each inner room has one supreme owner with God reigning over them all?

Were we to share all of ourselves with our families, friends and partners except that which we keep in our inner rooms would that mean depriving them of our true selves? Surely our inner rooms are just the treasured essence of the rest of us, of the outside bits. I think that the problem lies in the fact that we are primarily so harsh and unappreciative towards ourselves. If we loved who God created us to be with our very human imperfections and the influence of sin in tow, we would remain comfortable with who we are in our private thoughts whether other people also see us there or not.

What would happen if we were to the world who we are to our private selves in quiet moments?

The Girl is a Surgeon

Women are surely perfectly suited to the field of surgery. We are lauded for our ability to handle numerous tasks simultaneously. Women generally express care especially towards the vulnerable members of society: babies, the elderly and the sick. A woman on a mission will persevere in the achievement of her goal until she has spent all her resources. If a cause close to her heart is neglected, a woman will take up a cross and protect the weaker party as a lioness protects her young.

The fairer sex is known for single-mindedly persevering in spite of their own needs. Women display great aptitude in the hands-on management of disasters without getting side-tracked by ego-sparring as their male counterparts often do (which prevents finding a speedy resolution to a problem). Attention to detail and multi-tasking comes naturally to a woman.

Han Suyin (1917-____), a Chinese physician and writer, accurately noted “There is nothing stronger in the world than gentleness.” A gentle woman can achieve so much more; can break down many more barriers than a forceful man.

Perfecting the art and science of surgery is a passionate business. The practice of surgery holds drama, suspense, commitment and love. We all thrive on these, don’t we, girls? We can turn even the most mundane work into passionate artistry.

You ask: but what of the difficult hours, emergency cases inevitably come in at 3am. Babies have been waking women at ungodly hours for thousands of years. You say: but its hard work.  How many families are not reliant on a single mom to keep the pot boiling, the kids clean and healthy and a hospitable roof over their heads? Now THAT’S hard work. A woman’s ability to multi-task combined with the extra will to prove her worth in a male-dominated field more than compensate for lack of brawn. Surgery is a craft, it’s just glorified needlework. Are women not the ultimate seamstresses?

The Human Sciences Research Council (HSRC) of South Africa declared that feminisation of medical schools in this country is progressing rapidly. At undergraduate level, female enrolment in medical school in 2003 had increased to nearly 55% nationwide and 63% at the University of Cape Town (UCT).

Female doctors often practice in the public service, in primary care and among the poor. Women favour certain disciplines such as public health (80% - 93% of doctors in this sector are female), psychiatry, internal medicine, obstetrics and gynaecology and paediatrics. Those disciplines are considered to be more ‘family friendly’. Only a small percentage of female doctors even consider general surgery, and a tiny amount of them enter the field. At UCT women made up only 11% of enrolments in general surgery in a seven years enrolment period studied. Some surgical disciplines had no female students at all. The trend at UCT has been confirmed at national level by the Association of Surgeons in South Africa (ASSA), which found that across the country female doctors amounted to only one-tenth of the number of male doctors specialising in general surgery.  International surveys reflect trends shown in South Africa. US studies showed that only 6% of young female doctors even allowed surgery to cross their minds.

The feminisation of medical schools combined with so few females going into surgical disciplines implies that before long there will be a shortage of surgeons to fulfil the work load. International studies note that such high proportions of female medical graduates can lead to problems in health-system provision.  Dr Sharona Ross, director of surgical endoscopy and assistant professor at the University of South Florida (USF),  said, "if half of all graduates are women and so few are going into surgery, we are eventually going to have a shortage of surgeons.’ Dr Ross launched the USF Women in Surgery initiative. They organised a national symposium for women who are or hope to become surgeons. The aim is for experts from across America to share their experiences of life as surgeons and provide support and advice through a mentorship program to upcoming female surgeons. Dr Ross aims to attract more women to general surgery and support those who are already there through the USF Women in Surgery initiative. "We want to explore what steers women to or away from surgery,'' she said, "and promote mentoring to advance or enrich their careers."

Mignonne Brier and Angelique Wildschut, researchers for the HSRC Review of November 2006 very eloquently noted, ‘The debate has highlighted some difficult underlying issues about the gender division of labour in the home and traditional expectations of medical work. The medical profession traditionally demands that doctors should work inordinately long hours. Men have managed to do this because they have been supported in the background by women. But many women doctors do not have that support because society still expects them to bear the brunt of child and home care. Because they cannot work these long hours, they choose part-time appointments. However, it is not only women who would prefer more time for family and leisure. Male doctors would like this too. The answer to the problem lies in the sharing of the ‘invisible’, unpaid labour in the home and society and in humane working conditions for all.’ Actually, more men than women said the lifestyle and workload would keep them from choosing a career in general surgery.  

An article in the journal Archives of Surgery (2006) concluded that the real deterrent to women is the ‘chauvinistic image’ of the profession. Female medical students and registrars view surgery as an "old boys club.’ There are numerous shocking tales of sexual discrimination directed at female medical students, registrars and qualified surgeons by other male surgeons.

The Association of Women Surgeons (AWS), an international organization with members in 15 countries, is another organisation committed to supporting the professional and personal needs of female surgeons at various stages in their careers. They wish to break down barriers that remain for women in surgery.

The age of the chauvinistic, all male surgical team is over! A softer, feminine touch is spreading over the world like a Mexican wave. And I’m cheering all the way!

"It is not easy to be a pioneer -- but oh, it is fascinating! I would not trade one moment, even the worst moment, for all the riches in the world." – Elizabeth Blackwell, the first woman to receive a medical degree in modern times. She founded the London School of Medicine for Women in 1875.

References:

1. HSRC Review - Volume 4 - No. 4 - November 2006

2. Female Surgeon in Tampa Encourages other Women to go into the Field by Irene Maher. Published in the St Petersburg Times in    February 2010.

3. www.womensurgeons.org