Rural Reflections

BLOG: Reality check!

Written by Lace

I’m surprised by how natural it feels. I step into theatre, armed with my SAMF*, stethoscope, pen and permanent marker, and take a deep breath.

Operating_theatre

“I wouldn’t say its like riding a bike. It more like when you take the training-wheels off and realise that – holy shit – you’re still going forward.”

The cool, conditioned air fills my lungs. By the time I exhale, all the apprehension that I’ve been carrying for the last two weeks has melted, seeping out of my pores and collecting in my borrowed once-white gumboots. With my fears far away, and my mind clear of distraction or recollection, I take a confident stride through the sliding doors of theatre two… I’ve got this.

Dokotela!” In one movement a stout nurse on my right points first at me, then at her covered mouth and back at me.

“Where is your mask?” she demands.

I’m the only one in theatre without a surgical mask. I recoil. Backing into the scrub room, I feel apprehension gushing back into my veins.

I’m slipping up before I’ve even started!

In my defence, at Chris Hani Baragwanath Hospital – where I was an intern – there were a few antiquated nurses who insisted masks be worn by everyone in the operating theatre and not just  surgeons.

The literature suggests that there is no difference in the rate of post-operative infection if a mask is worn or not so most anaesthetists go without. But I’m new here, and don’t want to step on any toes so I keep my mouth shut and “mask.”

Giving it a second bash, I join Xolile who has already started doing the spinal anesthetic …  As soon as she’s done, she instructs the expecting mother to lie down and almost immediately the monitors start beeping. The patient’s blood pressure drops so significantly that she mutters something about being dizzy.

This is expected, not alarming. I do recall my horror when seeing this dramatic effect for the first time some years ago however.

Xolile and I calmly work together, drawing up the appropriate drugs to counteract the effect of the spinal anaesthetic.

I haven’t been introduced to all the doctors yet, but I can tell off the bat that the one cutting as part of the  Caesarian delivery is senior. He’s quick and confident, softly talking to his assistant as he blunt-dissects the layer of fat beneath the skin.

Checking first that the patient’s vitals* are back to normal, I walk around to the foot of the operating table to get a better view of the rest of the procedure. It’s been a year and a half since I performed a Caesarian, and even then it was under supervision.

Not exactly like riding a bike

Out here, it won’t be long until I’m the one with the knife, flying solo, so I’m grateful for this quick recap.

The baby is delivered with ease, and sneezes and cries before the umbilical cord is cut. All in all, it’s an uneventful Caesar and I’m relieved. As it turns out, six years of medical school and two years of internship at Chris Hani Baragwanath Hospital did actually teach me a thing or two.

I wouldn’t say its like riding a bike. It more like when you take the training-wheels off and realise that – holyshit – you’re still going forward. You’re a bit wobbly perhaps but if you just keep peddling you might not fall off. [quote float=”right”]Why does the unimaginable always come to mind first?”

Despite my initial nerves, there is an curious comfort in getting back into this routine. A month hiatus from medicine, miles between here and home, and an entirely new team, but none of this feels foreign to me. Even the imperious scrub sister seems familiar.

The only real difference from what I’m used to is that there are no specialists here so the doctors alternate between doing the anaesthetic and doing the procedure depending on their level of skill, the patient’s condition, or just what they feel like doing that day. Nevertheless, we are all working together like a pit crew; not many words are exchanged but they don’t need to be – everyone knows their role. We do one more Caesarian, two evacs* and a couple of debridements of septic wounds.

Why does the unimaginable always come to mind first?  

The next case is a little boy, not yet two years old, who has been booked for repair of a rectal prolapse*. He’s a healthy little chap and very serious with wide eyes. Unlike the other children I’ve met here, he’s not interested when I show him the ‘talking cat’ app on my phone. He sits under the bright theatre lights and doesn’t make a sound. I check his drip, attach the monitors and then give him some medication to make him a bit sleepy. He drifts off quickly and my colleague lifts his legs with one hand to examine him.

If there was a prolapse it has already been reduced, and what’s left is a ring of lacerations around his anus. Could this be? Surely not, he’s only a baby.

Why does the unimaginable always come to mind first?

Not wanting to jump to conclusions we call for a third opinion, and talk through the options. It could be nothing serious perhaps a fissure resulting from severe constipation , or maybe it started with prolapse and his mother tried to ‘fix it’ using an object  to return the bulging mucosa to its normal position, injuring him in the process.

Or maybe… I shudder at the thought, maybe the prolapse is not the primary problem at all but the consequence of a much more sinister evil.

Maybe this quiet and beautiful child has been raped…

*SAMF: South African Medicines Formulary. A small book filled with drug dosages, indications, side-effect etc.

*Vitals: Vital signs which include blood pressure, heart rate, respiratory rate and temperature.

*Evac: evacuation of the uterus – the procedure done to remove any retained products of conception (placenta etc) after a miscarriage.

*Rectal prolapse: where the end of the gut prolapses (falls down) from its normal position and is seen protruding from the anus.

 

Used with permission. Read previous posts by Lace, a rural community service doctor in South Africa here.

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Lace