Medcine rounds, plaster of paris, and TB-o-rama

Only doing a single entry this week. I have somehow gotten a nasty sore throat, lots of posterior lymph nodes, and not sleeping well. Not been easy to focus when I leave the hospital.

This week I was assigned to the medicine team, but still attended community and orthopaedic clinics. Medicine team is constantly slammed with a number of very sick HIV+ patients, with various TB related issues. In order to receive anti-retroviral treatment at the ARV clinic, patients with TB need to be on atleast 2 weeks TB treatment. If you start ARVs right away then can get IRIS, an immune reconstitution syndrome where your white cells gain strength at HIV is suppressed and then vigorously attacks the TB. I only knew about IRIS with regard to chemotherapy and transplant patients. Only issue is figuring out who has TB… They do an X-ray, sputum looking for TB, and then a screening ultra sound. The u/s was surprising to me, but I guess they frequently can see lesions in the spleen and liver. Many patients are just treated for TB with enough supportive sx (night sweat, spiking fevers, cough) and family members with TB.

Some of you may be thinking, so what precautions are taken for these patients to prevent hospital workers from getting TB. Well… there is an open window policy, and some patients are made to wear masks, So basically minimal. No negative ventilation rooms, or fancy hepa masks. I still cringe a bit when someone is coughing and sputtering… Just kinda the way it is here.

There are serious limitations on the hospital financially. Deep venous thrombosis prophylaxis has been an issue, since they do not have pneumo boots or even TED socks. I guess those simple socks are not cheap in south Africa. So they rely on heparin. LMWH is too expensive.

Resources to address psychiatric and psychologic needs are very limited in the region. They have issues getting of those positions filled in the public sector. Social workers take on a lot of that responsibility. There is no psych ward or anything like that at the hospital, again managed to the best of their ability by the family med docs.

On Thursday I went to ortho clinic again. It is so much fun to play with the younger patients. There is not very much play or fun with patients. I think that is a by-product of the high patient load, and possibly the more old school doctoring. I am slowly introducing them to my clown nose…

In ortho we had a really crazy case. A 40 year old wheel chair bound guy came to clinic cause he thought his elbow was infected. The notes were very skeletal, so all we knew is that he had two recent open reduction internal fixations of his distal arm. Presumably from trauma. His x-ray was so abnormal, severe osteomyelitis, just eating away at his bones. We took off his bandage and plasma like fluid just gushes out… What a mess. Not sure what led to the breakdown of his care, but he bought himself a ticket to tygerberg to sort out a repair.

Rest of the clinic was looking at some dramatic spiral and oblique fractures from various traumas. I find it strange that none of the kids draw on their casts! When I broke my thumb in elementary school I got this awesome glow in the dark fiberglass cast and had friends draw on it. I’m encouraging the kids to do it, next week I’m gonna bring markers and stickers.

What else. Oh, so I have seen a common trend with patients in which they are referred to the hospital by their private general practitioner. My understanding was that the private system was only for people with ample money, but it seems many will pay some money to be seen urgently at a clinic. Still the private hospitals are reserved for those who can pay upfront or who have insurance plans with them.

It is so refreshing to work in a place that has no money exchange between patients and providers. No talk about insurance or hospital representatives coming into your room to make patients sign their payment responsibility forms.

That’s all for now. I was in casualty until late last night, so am struggling a bit energy wise. This weekend I will be in Sea Point staying with family.