Yesterday I went on medicine ward rounds with the internal medicine team. As expected, the common denominator was TB and HIV. My intern recommended to answer any question asked by an attending with “it is likely caused by TB.”
I kept hearing the team refer to RVD, and RVD treatment. Given the strong stigma associated with the term HIV, they just refer to it as Retroviral disease… Not sure if I agree with this technique. With so many south Africans having the disease, I don’t know if using a code word around patients really makes sense.
Our hospital has a laboratory on site for basic labs, and sends out to the regional lab for more sophisticated tests. No electronic charts, which is refreshing. People write very succinct, but effective notes. If you want an IV, you place it. If you need blood, you draw it. Supporting staff and services are limited, but it still works surprisingly well. X-ray is widely used, as well as ultra sound. Physical exam skill are emphasized and very important in the assessment and plan.
What I find so interesting is how many similarities there are to medicine in the states. It is kind of neat that there is this thing we call allopathic medicine, which is conserved across nations. Similar presentations of patients, transudate vs. exudates, liver disease, BMPs… Just a shift in the diseases… They have a major issue of immigrants to south Africa from other African nations who go and visit their home and return with malaria. People assume they are immune but are not.
Today I attended orthopaedic clinic. This is run by a retired doctor who just comes in a few days a week to help out. He practiced 23 years in a very remote south African village as the family doctor. This clinic is mainly for assessing fracture healing, casting and cast removal. Same routine, grab a chart and just go for it…
Cutting off casts is a ton of fun. We had the vibration saw and scissors. My first patient must not have known the saw will not cut skin because he just about hit the ceiling when I bumped his skin… He had an open fracture, and when we removed the cast we found a few skin staples and a partially extruded bone fragment. Hmm, that must not have helped the wound heal… Came right out and he was on his way.
The common denominator at this clinic was “xxyo post MVA” or “PVA (pedestrian versus auto).” One of my patients was hit by a township taxi, which are these crazy taxis that drive by their own rules, stop anywhere, honk a ton. Casting is good old plaster. It gets the job done, patients seem very happy, especially when we remove the casts. Many fragrant smells to save the least. Many patients had been prescribed a drug called Panado… I’m like, what the heck is this panado. It is Tylenol. Why so many names!
It is very interesting to me the patient population. There are many xhosa speaking patients, and Afrikaans. But there are a number of older white Afrikaans speaking people who grew up in Strand and Somerset west. They speak excellent English and tell me they are very pleased with the governmental care they have received. They actually remind me of rural Minnesotans, haha. What a unique mix of patients here.
In the afternoon we did group neurology clinic with a visiting neurologist from the major tertiary tygerberg hospital. It was interesting because I was part of a group of doctors and interns (about 10), and we were sitting facing the neurologist and patient. Surprisingly the patients didn’t seem to mind the crowd.
Our first patient only spoke xhosa, somehow we found a person to translate. He had been having “spells” for the past year. He has them 2/week, and says his vision and brain go black. All of a sudden he turns his head to the right and stopped responding to our questions. He stand up, pulls his phone out of his pocket, and begins to lick it, walks outside and urinates, then comes back and sits down in a very tired state. All the us observers look at each other trying to figure out what was going on. Our patient conveniently showed us his complex partial seizure. Crazy timing. We just increased his phenytoin dosage, hopefully it helps.
Another patient is a white woman in her 50s with multiple sclerosis. Unlike in MN, MS is very rare so many general practitioners do not have much experience in management. She was dx in 2001, and since then has been taking cortisone. I mean, high dose, she said 8-10 pills per day (not sure of dosage). She came in on a wheelchair, very frail, big red cheeks with moon facies, muscle atrophy, tremor, skin brusing and lesion from thinning, stasis ulcers on back and ankles. The neurologist said it was the most extreme case of chronic cortisone overuse. They are going to very slowly reduce her prednisone.
Well those are some more of my experiences. I will be heading back to Cape Town for the weekend, but might spend Friday night in casualty. They get a lot of stabbing trauma on the weekends, and tons of opportunities to suture and place chest tubes.
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