In the course of a day I saw two patients that made me think about how unfair life really is. One patient was a 16 year old who came in for a termination of pregnancy at 20 weeks and was (obviously) denied. When I saw her, she was at 30 weeks and an emotional wreck in a sort of psychological limbo, not wanting the pregnancy but at the same time not accepting that we could offer her no alternative but to continue with the pregnancy. Stubborn and adolescent, she did not attend antenatal clinic and did not give a (insert appropriate profanity) about the child she was carrying.

The other patient was a 22 year old Primigravid at about 6 weeks. I was given the horrible task of reviewing her ultrasound which showed an absent foetal heart. It was terrible, she broke down and cried incessantly. She described how happy she had been when she saw a positive pregnancy test. I thought about how unfair it is that a woman with a healthy baby at 30 weeks would rather not have her baby, whereas just a few patients down the queue another woman envies her ability to carry a pregnancy beyond the first trimester.

When I consider situations like this one, it is difficult to see life as anything but random coincidences. Events like these make me doubt the idea of predestination. Is there really a reason for everything that happens in our lives or is that selective reasoning? Or maybe it’s just something that we say to each other when the event is beyond our own understanding. Maybe nothing is pre-determined. Maybe things happen and we learn from them. Maybe we would have learned these lessons anyway. This debate could run circles in my head.

Triple BabyFeat

It was on the night of a particularly busy Obs and Gynae call with a particularly enthusiastic registrar. Score card reads: 3 abruptios, 2 eclamptics, a septic ICA and a chorioamnionitis.

Baby Feat 1 : Totally awesome resuscitation of 1,2 kg 28-weeker whose Mum had APH. Going to theatre to discuss a case with the registrar, I find my fellow intern running toward me (still scrubbed from assisting in the caesar), with above mentioned 1,2 kg of unresponsiveness in his hands. Turns out the Paediatric intern hadn’t shown up and there was not a stitch of resuscitation equipment to be found in theatre. We ran to labour ward, managed (unpredictably) to startle the sisters into action and performed my most memorable resuscitation yet. From an unresponsive foetus without a discernable heartbeat, to one below 60, then up to 72, then 100, then more than 120. Screaming gratitude ensued.

Baby Feat 2 : A mum comes in with a preterm delivery. Twin gestation. BBA. One was a FSB at 400g, the other a supposed 600g. Turns out the 600g was actually a 1,2 kg, struggling to breathe. We rushed the little one to the NICU and were met with the news that there were no beds available. Determined, we strapped on some oxygen and put the baby on a Sats monitor. Sats of 98%. Yay.

Baby Feat 3 : Doing a casual labour ward walk-through at around 3am, I notice a CTG that isn’t connected too well. I go up to the patient and try to replace the probe but experience some difficulty. The Mum is groaning (as they usually do.) Then I hear an odd sound, lift the sheet and lo and behold: A baby! She delivered without saying anything. (Firstly, this is odd because childbirth is usually accompanied by intense screaming and second because I was right there!) To add to the drama, the baby is not crying. I call for help from the sisters who stare at me in bewilderment. I need a clamp so I can get the baby away to the resuscitation trolley. Eventually, they get up from their sleep-infused, idiocy-maintained stupor and get me what I need. By this time (thankfully), the little tot has decided that crying would actually be in his best interests. Sweet relief.

 Unfortunately, this scene played out only a few steps away from my self and another female intern. Looking around for help, we found ourselves the only non-patients on that end of the ward. Unsure of how exactly to diffuse the potentially dangerous situation, we attempted reasoning with the patients. Surprisingly, not so successful.(De-escalation is a remarkable concept.) Unwilling to physically confront them without help, we looked on temporarily paralysed.  Thankfully, the scuffle that had begun was quickly put to an end by a non-psychiatric patient nearby.

 Yet another example of the inadequacies encountered in public hospitals. Non-psychiatric patients should not have to be responsible for diffusing potentially dangerous situations. In fact, they should not have to share a ward with these patients. Similarly, psychiatric patients should be in their own ward where they can receive the attention they need and be managed by people specifically trained to handle such patients. And in particular, people who are always around. Instead, psychiatry wards have been closed because of a lack of staff to man them. I can imagine the politics, red tape and extensive management meetings involved in attempting to re-open these wards. Till then, maybe it wouldn’t be an entirely bad idea to carry some Ativan around with you.

 The case presentation was that of a patient who as a result of “unmet childhood needs” was now displaying significant social dysfunction. His disastrous relationship Curriculum Vitae was put down to him suffering a mentally unhealthy childhood. The postulation was that a lack of attention, comfort and love as a child led to the development of a somewhat warped view of relationships in general. As such, the patient was unable to deal with relationships that were between the extremes of love and hate. He frequently engaged in multiple relationships so that if one ended (which they frequently did given their intense nature), he would always have another to fall back on. Further, in these relationships he was unable to see the other person as fulfilling any other role but to keep him happy. A warped view indeed.

 This begs the question about human behaviour. How much of our personality is determined by our experiences and how much is just us?

 Let’s assume that each one of us is born with a sort of neutral mental composition (please don’t expect a definition, this is a hypothesis), and are then moulded or influenced in some way by family, social circumstance and early experiences. It follows then that we’d be saints, sinners or in-betweens depending on whether we grew up with Tutu or Hitler, mind the parody. Unfortunately, this does not explain the vast difference in character and temperament that is often observed between siblings that did in fact share the same parents, social circumstance and sometimes, the same early experiences.

Logically, we are then led to believe that there is a “just us” component that contributes significantly to who we are and the manner in which we behave.

 How does this understanding apply in the case of criminal behaviour? Or does it at all? Sex-crimes are probably the most relevant here. If a person who suffered sexual abuse in childhood displays inappropriate sexual behaviour leading to molestation or rape, to what extent is that person responsible for their actions? One point of view is that the behaviour can be explained or perhaps reasoned by the persons own history. Another is that not all victims of child abuse become abusers themselves thereby dismissing the experience as a trigger for such behaviour. This presents a moral dilemma. Where an understanding for behaviour is found, is that behaviour sanctioned? Should convicted rapists with a history of sexual abuse be treated differently from those without?

 What I am getting at is that it is evident that Psychology has taken considerable strides in explaining human behaviour. But does an explanation of the behaviour sanction it? Can we dismiss our shortcomings with a Mama-didn’t-love-me pout and Daddy-didn’t-care shrug? My opinion: decidedly not. An understanding of behaviour is only helpful if it assists in correction of bad behaviour. Otherwise, it becomes an excuse not an explanation.

 The social welfare grant has become as common as pain as far as main complaints go.Having spent the past month working at an ARV Clinic, I have seen many patients, SASSA-forms in hand, a determined yet pained expression on their faces, clamouring for a sought after signature.

 I remember one of these patients quite clearly. She was dressed in a smart red blouse, one of those wide waist-belt contraptions and snug denim jeans with accompanying red heels. Tottering in to the consulting room, she sat down and proceeded to list her non specific complaints, abovementioned pained expression down to a T. One of these complaints was that she didn’t have money for food. Really? And the red heels? Now I don’t wear heels and that’s besides the point, but if I were desperately hungry I would spend my money on something, I don’t know, just a tad more edible.

 The sad thing about this situation is that this patient might actually be successful in her application for a social grant while someone in the situation that she pretends to be in, someone who really has no food on their table and no means of getting it there, someone who doesn’t even have access to medical care when they desperately need it, someone who genuinely deserves financial assistance, might not get it because she did.

 Public hospitals are rife with an ideology that dictates that money is owed to the HIV positive. I find this attitude highly disturbing. Not in the least so because it removes all responsibility from the careless (read irresponsible) individual that decided not to wear a condom, or ask their boyfriend to or enquire about their partner’s status. Now I know that not all HIV positive patients are in that situation because of a personal fault so let’s excuse those patients from what I’m sure you will see as a judgement on my part. I have seen, in the past nine months as an intern, far too many young and educated people who turn a blind eye when it comes to the issue of HIV. People who would rather ignore and wish away the reason for their massive weight loss or Tuberculosis than be tested for HIV. Mothers who watch their child fall off the growth curve before they are persuaded to have an HIV test done. Teenagers who giggle when asked about their sexual history and number of partners.

Yes, this is judgement but can you honestly say that it is not well deserved?

 The grant offered to HIV positive patients by SASSA (South African Social Security Agency) is a temporary disability grant. It is a monthly R1010 and is dependent on criteria that include clinical staging, CD4 count, degree of disability, the financial situation of the household, number of dependants and many other factors. Unfortunately, many people have become aware of this criteria and attempt to manipulate them in order to qualify for a grant. So, it is not uncommon to see patients who are not so pleased when you show them their blood results and their CD4 count has risen. But this does not even come close to the issue of fraudulent CD4 counts. It takes a whole new breed of criminal to fake a CD4 count so he can sit at home and collect a monthly remuneration for his efforts.

 On the other hand, the child support grant is a meagre R240 a month. An amount that barely covers diaper costs but is often used to support an entire household. Not to mention that a child support grant is now a reason to get pregnant. Is that desperation or idiocy, I cant tell.

Cowardly corners constructed to confine

Ambivalent blueprints

 They disclose and

They hide

 Words tip-toeing on your page

Tread lightly, you said

But I can’t say that I tried

 Curiosity’s victim

 My own culprit

I would’ve bled for the truth

Could’ve killed for the lie

Words tip-toeing on my page

Tread lightly, I said

 But I wouldn’t have you try

This experience is, thankfully, not my own. I have, however, been subject to many discussions on the presence of vermin in call rooms at Edendale and (surprisingly) Greys Hospital as well. These sightings have led to a compulsory (usually violent) search of call rooms before attempted sleep. Thankfully, sleep is not frequent on call at Edendale and the vermin ritual is not often carried out.

That been said, I am unashamedly deathly terrified of rats and am prone to running like a little girl at the sound of a suspicious squeak. I can, therefore, only imagine the horror (and this is a true story) of finding a rat in the pillowcase of the pillow you are sleeping on.

 Despite many experiences like this, nothing is being done to remedy the situation. The usual meetings are held, quality improvement personnel are still occupying their positions, budgets are still being suspiciously overspent and “Chicken Thursday” meetings proceed with a vengeance. The rats are comfortable in Labour ward and surrounds. They feed off leftover chicken bones, uneaten call-food and perhaps the odd placenta. Occasionally, they lose one of their impatient mates who venture out during the daylight hours and is subsequently maimed to an unrecognisable pulp by a broom-wielding labour ward sister (again, true story). But, this does not deter them. Come nightfall, they scurry about making their presence known. An entirely different pitter patter of little feet!

 I deeply regret not having “rambled” at the outset of my internship. Beginning internship at POPD at Edendale Hospital was in itself the definition of ramble material. Now, those experiences have faded into vague memories and I have, for the most part, dealt with those issues. If I have learned one thing from Paediatrics it would be the truth that there are many mothers out there who are undeserving of the title. The story I choose to share about Paediatrics is however, not the most severe example of this. It is just one that I remember vividly. Equal parts frustration and awe.

 It was in POPD at Edendale Hospital, a place that is by no stretch of the imagination a sanitary one. Not even a minute after it has been cleaned. I was in consultation with a Mum regarding her ill child. While she sat on the chair across from me, I asked her questions regarding the child’s illness. During the interview, however, the child spat his pacifier onto the abovementioned unsanitary floors. In a most unprecedented manoeuvre, the Mum casually picked the pacifier up from the floor and put it into her mouth, sucking from it unknown debris that had latched onto the object within seconds of it reaching the floor. She then put it back into the child’s mouth. I screamed out in shock. She was unfazed. Now, I have heard of the three (sometimes five) second rule but this was really pushing it.  Perhaps I should search for the silver lining ie. that she did attempt to clean the pacifier before replacing it in the child’s mouth. It’s just that silver linings like those, most unlike the gunk on the pacifier, are often difficult to see.

 The catharsis continues. This time the venting is as a result of shameless behaviour by a colleague. A senior, as it were. Dr. M should have damn well stayed in the DRC if his only purpose in our country is to get paid for being a terrible doctor. It’s a good thing for him that patients in the public sector aren’t allowed to choose which doctor they are seen by because if that were the case I doubt that he would have many patients come to see him. Apart from being lazy, the man is unashamedly rude.

 A scene from today: It is 09:00 and the clinic is alive with patients, nurses and very few doctors each doing their best to get through the mound of files that have already accumulated on an unsuspecting trolley in the corridor.  Dr. M sits slumped in his chair. He lethargically reaches out for a file on his desk and shouts out the name written on it through a closed door. He is not heard. He then proceeds to ask (not politely) the patient I am interviewing to get up and call so and so from outside. Strike One. He greets his patient hurriedly and gets into the flurry of questions he knows he must ask. The patient doesn’t understand English. Dr. M doesn’t understand Zulu. (He is Congolese). This is not an uncommon occurrence. Language barriers are commonplace in South African hospitals. Most doctors, however, handle the situation by getting up from their chair and going to find a staff member that is willing to help. This either does not occur to Dr. M or it interferes with his plan of not moving from his chair. He proceeds to ask my patient (not nicely) to translate the problems of his patient. The ethics involved in this situation do not cross his mind. He is easily frustrated by both these patients and their attempts to be heard. They sigh because the one just wants her problems to be heard and the other is only trying to help. He does not see this.

 At 12, Dr. M decides that he is going to take his lunch break. This is despite the fact that the designated lunch hour is from 1-2 pm. Dr. M knows this. So when he returns at 1pm (which he never actually does) most of the nursing staff will be on their lunch break and as such there will be no patients to be seen. He has been reprimanded about this but subsequently had a heated argument with his senior about the issue and accused him of treating him like a child. He also used profanities while in the presence of a patient while discussing this issue. Not childish in the least.

 Later, I ask his advice regarding the management of a patient. I ask because I don’t know. I ask because the patient’s issue is rather different to the scenarios in our handbook. He proceeds to give me a dodgy answer, all the while sounding suspiciously like he is trying to convince himself. He discusses scenarios similar to the problem my patient is having and tells me their management. These are all in the handbook which I have read and still do not give me the answers I am looking for. Later, once we have carried out his plan of management I try again to explain that my patient’s problem is different to the one he is referencing. Light bulb moment. He remarks casually that a patient like this should in fact be seen by a specialist. I am looking straight at him but in my head, my eyes are rolling.

When I get back from my lunch break (45 minutes to his 1 and ½ hours), he has evidently been reading his handbook and I am subjected to a quiz of its content. He sits back and smugly discusses the differential diagnosis of lactic acidosis. I know that he has just read these differentials because I can see his handbook facedown on his desk and because he rattles them off in the same order in which they are written in the handbook. I sit in awe. No doubt, he assumes this is in awe of his intelligence. Rather I am awed by his transparency.

 I have three more days of shared consultation with Dr. M. I have no doubt that I will learn much during this time, none of it medical.