Posted on October 3, 2009 09:00:00 AM
Some things make me feel so powerless (yes, even i can be powerless in the face of incompetence).
I have previously mentioned a thing or two about my opinion of where medical training is going in this country. Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea. Ideas I suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. Well I get to see the consequences up close.
He was referred from an outlying hospital on a Friday. The peripheral hospitals so like to empty their wards for the weekend. After all there is some good fishing in these parts. Thank goodness for good fishing. Otherwise many more would die unnecessarily.
Anyway the patient had free air in his abdomen. This is a sign of a ruptured stomach or intestine and requires immediate operation. In fact the longer you wait the higher the chance of death. What I found interesting is the X-rays that they sent with the patient dated four days before the transfer (but admittedly not just before the weekend) clearly showed the free air.
Now not all that long ago, to miss free air on an X-ray even as a student was a mistake that would fail you. These days you can easily get through medical school without worrying about trivialities like free air on X-rays. Also, to have perforated bowel causes intense almost unbearable pain. Even a street sweeper would be able to pick this up in the patient. Yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days. That is if he even ever examined the patient. Then fortunately a weekend turned up and the patient was referred, well on his way to the great hereafter.
As can be expected, when he turned up he was extremely ill and was already in kidney failure. The catheter bag remained empty. After a few hours of aggressive fluid resuscitation there was at least a bit of urine in the bag. Then it was time to operate.
The abdomen was in a bad condition. To say it was rotten would be somewhat of an understatement. But the interesting thing I noticed was the full bladder. The peripheral hospital had kindly inserted a catheter not into the bladder but only into the urethra. There they had blown up the balloon, just to make sure they did the maximum amount of damage.
So not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do, because they didn’t know how to do it properly, caused further damage to the poor man.
I cast my mind back to when I was still in academic circles. I remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared. I myself was asked to examine a student in a practical exam. I failed her because she was simply a danger to any person unlucky enough to become her patient. And yet the powers that be had so changed the system from when I was a pregrad that she could not be failed and was released into the community.
I’m sure the people who have orchestrated the new system that is so student friendly (but not patient friendly) don’t get to see the disasters out in the periphery that are a result of their hard work. Quite frankly even if they did see them I doubt they would care. After all it doesn’t directly affect them.
*This blog post was originally published at other things amanzi*
Posted on September 15, 2009 09:00:00 AM
M and M was never fun. Sometimes I would walk out feeling I’d just escaped by the skin of my teeth. Sometimes I would feel like my teeth had had too close a shave. But once…just once, it could have been worse.
It was a pretty standard call. It was very busy. In the early evening I was called to casualties for a patient with severe abdominal pain. When I examined him it was clear there was something seriously wrong inside. He had a classical acute abdomen with board like rigidity. He clearly had a perforated peptic ulcer and needed surgery. I set my house doctor to work to get him admitted and on the list. Meanwhile I went back to theater to work through the number of equally critical patients already on the list.
Things then settled down into a rhythm. I was in theater with a student operating the cases one after the other while the house doctor separated the corn from the chaff in casualties. Finally it was time to do the laparotomy for the guy with the acute abdomen. I needed to shoot through casualties before we started so I decided to swing past the ward and make sure the guy was still ok.
The ward was dark. Pretty much everyone was asleep. Without wanting to wake the other patients I turned on the small bedside light of my patient. Even in that dim light I could see a bit of oral thrush. I was surprised. I was thinking to myself how the hell did I miss that in casualties. I felt his abdomen. It was no longer quite so tender. I turned to the student.
“See why it is important to make your decision before giving opioids?” I said with an air of authority. “Now he is actually not so tender but he definitely had an acute abdomen. We must go ahead with the operation.”
I quickly felt for lymph nodes. He had them everywhere. Once again I was quietly thinking that my clinical skills must be slipping because that I also didn’t pick up in casualties. I kept this new information to myself. Imagine the shock to the student if he realised I was not all knowing. i just didn’t want to be responsible for that level of devastation in his life. But I started considering other causes for his condition. It was clear he had AIDS and TB abdomen started looking like a possibility.
While we were still with the patient, the theater personnel arrived to take him to theater. I told them to get things going so long while I quickly shot down to casualties to evaluate a patient the house doctor was unsure about. And off I went at a brisk walk.
I walked into casualties. The house doctor led me to the patient in question, but as we approached his bed my blood went cold. In the exact bed where my acute abdomen had been lying about four hours previously was my acute abdomen still lying there!! I turned and ran back to theater. Fortunately I was in time.
Later I found out what had happened. Once we had admitted the acute abdomen, the porter had come in to take him to the ward. One of the patients lying in casualties was a guy that had just come in. His HIV had wreaked havoc in his life causing a number of unpleasant things, including AIDS dementia syndrome. The exchange went something like this;
“Timothy Mokoena? Is there a Timothy Mokoena here?” the porter called out.
“Here I am, but it’s not Mokoena. It’s Magagula.”
“Ok, Timothy Magagula, I’m going to take you to the ward.”
“Ok, but it’s not Timothy. It’s Michael.”
“Ok, Michael Magagula. Let’s go.”
And thus Michael Magagula, the AIDS dementia patient (not to be confused with Timothy Mokoena, the acute abdomen patient), thinking he had just jumped the queue to see a doctor was carted off to the ward and prepared for theater. He even signed for a laparotomy without even having seen a doctor.
In the end it all turned out well. Timothy got his operation and the hole in his stomach was patched. Michael was referred appropriately to the physicians. But I couldn’t help wondering how this could have looked in the next M and M meeting.
“Well, prof, the patient died on the table basically because I operated him unnecessarily.”
“And how is the other patient? The one you should have operated?”
“Well, he died too because I didn’t operate him.”
200% mortality for one operation. Not easy to achieve.
