It's Just Another Day

A gentleman in his mid-thirties has presented complaining of a headache, neck stiffness, that began about three days ago. On a quick examination, he has positive Kernig and Brudzinski signs, so clinically he was a textbook presentation of acute meningitis. He was also quite ill-tempered, which wasn’t pleasant, but I guess I might be quite ill-tempered if I was so ill. To complete the diagnosis we need to obtain some cerebrospinal fluid.

While reviewing his history to look for any contraindications to lumbar puncture, I noticed that he had undergone a CT scan of his brain about a year before when he had a similar clinical presentation. (We don't routinely perform a CT scan of the brain before every lumbar puncture like some other centres.) The CT report mentioned a lesion involving the tonsils. I thought this presented a rather important ambiguity. Was it referring to the cerebellar tonsils, suggesting a possible space-occupying lesion in the posterior fossa, or the palatine tonsils at the back of the throat?

For reasons I am too tired and lazy to explain right now (but which are probably intuitive if you've ever thought about a toilet flushing), performing a lumbar puncture in someone with a mass lesion in the brain causing raised intracranial pressure can cause caudal herniation of the cerebellar tonsils through the foramen magnum which can be rapidly fatal as they compress breathing centres in the ventral medulla. That sentence is far too long - sorry.

I tried to contact the radiologist on call. This proved remarkably difficult. After about half an hour of unanswered calls and unsuccessful attempts to access a year-old scan on ageing computers, I eventually got through to someone who managed to review it. The lesion was a small abscess of the palatine tonsil. There was nothing remarkable in the brain.

I was reassured that I could proceed, although also slightly irritated that the process had consumed almost an hour in which I might otherwise spent sleeping. Still, a delay is preferable to inadvertently killing someone.

I gathered the equipment and went back to the patient. While preparing everything, we started chatting. I discovered that he had run the Comrades Marathon in 2022. I told him that I wanted to run it next year. The 2027 race will be the hundredth Comrades Marathon, which seems as good a reason as any to attempt it. The patient was quite apprehensive about my chances of finishing.

It was a very difficult tap... We don't really have the right type of needles. The kind we have available are blunt 'pencil-point' needles that are supposed to be fed through a sharp introducer which gets through the tough skin. We have none of the introducers. Without an introducer, the thin needle tends to bend as you try to insert it. A fair amount of force and perseverance was required. Fortunately, I had been generous with the lignocaine.

After a few attempts, clear cerebrospinal fluid finally appeared at the hub of the needle. I collected the samples, patched him up and advised him to remain lying down for a while.

Phew what a relief. Of the basic procedural skills needed to be a junior doctor, lumbar puncture is probably the one I had the least practise of in medical school. I had probably performed three in adults and perhaps one in a older child before graduating. I have done quite a few more this year, but there remains something slightly nerve-racking about advancing a needle between someone’s vertebrae towards a space containing fluid continuous with that surrounding their brain.

As a side note, there appears to be a belief among interns trained at some other universities that cerebrospinal fluid is exceptionally infectious; far more so than any other bodily fluid. People speak about this as though it is universally established knowledge, but it isn’t something I recall being taught. Perhaps I missed it somewhere along the way, but there doesn't seem to be any obvious reason why CSF should be more infectious (in general) than blood or urine in a patient with an infectious disease. I suppose it may be a location more sheltered from the host immune defences.

In any event, washing one’s hands before and after seeing patients remains good practice, so I did so thoroughly.

I look at the clock and realise it is twenty-five minutes past midnight on Friday, 17 July 2026. It's my birthday. I am now closer to 50 than to zero.

This is the fourth consecutive year in which I have spent at least part of my birthday in a hospital. In 2023, I was on also on an internal medicine rotation at Helderberg Hospital in Somerset West. I was on call in the emergency department with my then clinical partner Jess, and we had cheesecake from Pajamas and Jam. In 2024, I was in Oxford for my medical elective during the splendid English summer. I worked the day at the John Radcliffe Hospital and went to one of the pubs that evening with some friends. Last year, I was rotating through urology at Tygerberg Hospital which was really fantastic training, but probably not the most fun way to spend the day.

This year, I began my birthday on call at Harry Gwala: performing a lumbar puncture, inserting a drip for a guy on death's door, and then catching two hours of sleep under blankets in my car before waking before dawn to prepare for the consultant ward round.

Before I knew it, it was 05h00. We admitted quite a few patients during the night, although most of the details have since dissolved into the indistinct post-call brain fog.

At 08h15, we gathered in the Nursing Home Seminar Room for the weekly morbidity and mortality meeting. Tyra brought me a coffee which was a welcome pick me up. More surprisingly, there was a full cake and a collection of cupcakes. Several of the other interns had remembered, and we had a small celebration before the day’s work began or, in my case, before I escaped the hospital and went home (by 09h30 - unreal!). Fatigue prevented me from feeling too much embarrassment at the celebration which was probably a good thing.

I slept until late in the afternoon and woke determined to go for a run at Midmar Dam. I think it was nearly 16h00 by the time I left home, so I was already cutting things fine.

I joined the N3 and within about a hundred metres, encountered completely stationary traffic. I sat there for approximately forty-five minutes before taking the first available exit and retreating through Hilton. There was no possibility of reaching Midmar before dark.

Instead, I ran around Hilton as the sun was setting. My route took me back past the traffic on Cedara Road, which was still crawling along. Being able to run faster than the cars, was extremely satisfying, but definitely said more about the severity of the traffic than about my current Comrades prospects.

I returned home intending to make dinner, relax and call home. Then Leila and Emily phoned and offered to take me out for dinner so obviously I said I was keen.

When we arrived at A Taste of Thai, the large table was full of familiar faces. Some of my fellow interns had organised a surprise dinner!

It was my first visit to the restaurant. Last year, while trying to experience as many different Cape Town restaurants as possible before leaving, my brother and I went to a the highly rated Thai restaurant Yindee’s on Kloof Street. It was pretty good, but A Taste of Thai in quiet Hilton is even better! I had the Kingklip Massaman curry, which was fantastic. After dinner, everyone came back to my place for tea and cake in the chilly winter weather. It was wonderful.

There are probably more conventional ways to mark the passing of another year. Still, a birthday seems as good a time as any to take stock. At twenty-five, I am a doctor, I have survived more than half a year of internship, and I am considering running ninety-odd kilometres from Pietermaritzburg to Durban despite the scepticism of at least one meningitic patient.

More importantly, I am surrounded by people who will bring me coffee after a night on call, arrange cake in a hospital seminar room, lure me to a surprise dinner and crowd into my cold little home for tea afterward. (What a mushy paragraph.)

That weekend, I went home to see my parents and Leo, who was on holiday from university. We had a braai and spent some time together.

I am not generally a great enthusiast for celebrating my birthday, but I suppose this was one of the better ones.