Abnormal Rhythms
The time is 22h15 on Sunday 15 March. I am writing this from my room, finally having found a moment of stillness after being shocked by the sanguineous shitshow that is Harry Gwala Regional Hospital O&G. I need to get to bed early but, perhaps due to the dread of returning to the job I am so grateful to have, sleep eludes me. So I will try to write about the story of my last O&G call at Greys Hospital.
The Rhythm of Greys
It was just after midnight last Saturday, the 7th of March. I was finishing the midnight bloods in the high care ward, a pocket of artificial light and bleeping monitors in an otherwise dark hospital. The nurses were asleep; the world was quiet and I was content with the knowledge that I would soon be clocking off - what was I going to do with my Sunday?
click...click..click.click..click.....click.click....click..click. I had moved into the next room where there was one patient who I had been asked to take blood from on the handover round. Without the bleeping of continuous monitors in this room I became aware of a metallic clicking sound. It is like the sound of the second hand on a cheap clock that keeps you awake at night, but it's too fast and it lacks the metronomic regularity. By the faint light of the moon and the streetlamp in the parking lot I discern the origin of the sound... A woman lies uncovered, her chest rising and falling gently with each breath. Atrial fibrillation. A sternotomy scar runs the length of her sternum; she almost certainly had mitral valve stenosis complicated by atrial fibrillation which we can deduce by the classic irregularly irregular rhythm made audible by her metallic valve replacement.
On the first day of lectures in medical school, a certain lecturer told us never to become comfortable with nakedness; advice that felt particularly strange at the time. I cannot remember much of what else he said, and whether it constitutes good counsel is a discussion for another day. In my experience in the O&G wards of KZN, modesty is a luxury often discarded without apparent distress. For this patient, her nakedness was simply another clinical fact in the quiet of the night.
I stood there for a moment, thinking about abnormal rhythms: the clicking of the valve, the chaos of my own sleep schedule et cetera. I didn't know then that I was about to register my longest sustained wakeful period ever.
The Longest Day
The call turned into a marathon of resuscitations and ward work, made considerably more taxing by the palpable tension between the registrar and the anaesthetist on call; two people who appeared to be mortal enemies. I didn't manage to figure out what the origin of the feud was. I did my best to become architecturally invisible.
By 04h00, I was starting the postnatal ward round. One room in, I was pulled back to theatre to assist with an evacuation of retained placenta. I am not exaggerating when I say I nearly fell onto the sterile drapes of the patient. Keeping my eyes open was a physical struggle that felt genuinely unsafe. A post-theatre Coca-Cola provided just enough caffeine to stagger back to the wards.
The morning brought cold indirect sunlight and a central air conditioning system that seemed to answer to no one and had settled on freezing both doctors and patients alike. I spared a thought for the women who had been lying under it all night.
There was also the matter of a patient who had sustained a bowel injury at caesarean section. The surgical team, having reviewed her from a comfortable distance, decided she warranted a relaparotomy. From what I could observe, none of them had actually examined her, the indication appeared to be that she was not improving as quickly as anticipated, and so she should be cut open again. I was too exhausted to put up much resistance, but I made a mental note to hand the situation to my senior at the earliest opportunity.
As it happened, nature intervened. She had been receiving therapeutic anticoagulation for a clinically suspected pulmonary embolism. She had had a CT pulmonary angiogram which showed no PE, but nobody had yet to reduced her enoxaparin to standard prophylactic dosing. Taking her back to theatre in that state would probably not have been wise. So inadvertently, she was saved another laparotomy. For one day, at least.
I drove home, stopped to pick up a self-pitying hot chocolate, and was asleep by 14h35. The world was dark again when I woke at 21h30. Dinner was leftover rice with tinned mackerel which was actually better than it had any right to be.
The Gwalian Gulag
Monday meant a new hospital: Harry Gwala Regional, formerly Edendale. If Greys was a marathon, Harry Gwala is a sprint through a minefield.
The volume is extraordinary. Lunch, when it happens at all, is consumed on the move between patients or between theatre cases. Some nights bring eleven or twelve emergency caesarean sections one after another, without pause. I was in theatre for three consecutive days in my first week.
I have been genuinely distressed by some of what I have witnessed in terms of clinical practice. But I suppose that is sometimes the consequence of being so overwhelmed with a never ending patient load. Antibiotics are being routinely prescribed post Caesarean section to all patients. Some of the justifications I have heard include the temperature of the theatre not being optimal and the presence of flies in wards. Western medicine is supposed to have moved beyond pseudoscience. Antibiotic stewardship does not appear to be a concept that has fully landed here, and I can only conclude it is because the people prescribing these courses do not fully appreciate the consequences. Antimicrobial resistance is the slow-moving catastrophe of our generation, and every unnecessary prescription is a small contribution to it.
On Thursday, the exhaustion caught up with me in the most literal way. During the handover round, I sustained a painful needlestick injury from a heparinised syringe while trying to obtain a sample for an arterial blood gas. It went clean through my finger and there were two puncture marks to prove it. There was a sickening amount of blood, a hurried wash, a dressing applied under some urgency, and then straight into theatre to operate.
I am back on antiretroviral prophylaxis, dealing with the expected GI side effects, and I woke the following afternoon with sheets soaked in what I am choosing to call daytime sweats. I hope these are attributable to the heat and the ARVs rather than anything more sinister. I have made a private note: if I develop a cough and start losing weight, the differential diagnosis becomes rather more sinister.
Delirious Reprieve
I survived the week. Thursday's call at least ended at a civilised hour, and by 10h00 on Friday I was at the Upper Milestone Bakery with Raph and Christiaan, each of us post-call, all equally wrecked. Coffee, sourdough, croissants, and the kind of conversation only possible in a state of mutual delirium. About forty-five minutes of it before we dispersed to shower and sleep.
The weekend provided a much-needed reset. An 8km run on Saturday before the heat made any further ambition laughable, and a more successful 10km this morning. Saint Patrick's Day on Saturday brought good company and good fortune: Arsenal clinched it against Everton in the dying minutes, and Max Dowd made history by becoming the youngest player to score a goal in the Premier League. Sunday brought news that Manchester City had dropped points to West Ham. The title race has taken on a very agreeable complexion.
I've finally submitted my O&G assessment, which I had been deferring with increasing ingenuity for weeks. The logbook is up to date. I've assisted on well over two hundred sections now and performed five skin-to-skin myself. I've been thinking about writing an essay on the procedure: the steps, the anatomy, the decisions et cetera partly to consolidate it in my own mind, and partly because the number of them I see every day deserves some reflection.
But the dinner is made, the place is clean, and the bed is calling.
P.S. That patient I got the needlestick from turned out to be Hepatitis B positive. The risk of transmission of Hep B via needlestick is much, much higher than the risk of HIV transmission. Fortunately I am immune and have reasonable antibody titres. I theorise my intense night sweat the following day coincided with clonal proliferation of B-lymphocytes / plasma cells producing more Hep B surface antigen-antibodies. I would like to ask an immunologist if this is plausible and it might be interesting to check my antibody titres now.
