Saturday, January 23, 2010

By the book

Community service has been a feature of medical practice in this country since 1997. Following internship, newly qualified practitioners are required to do a year of community service. For the most part, at least when we did this, comm service was performed in the rural areas. Thus it came to be that we were sent off to the far reaches of the Northern Province to service the community.

The funny thing about out year in the bush is that it seems to grow better with each passing year. It was dreadful while we were there, but in retrospect it seems like a good idea and I have been heard telling junior colleagues that a year in the rural hospitals will do them good. While saying this makes me sound like an old man, I happen to know that I am right.

There is nothing better for one's skill and confidence as a doctor than to be placed in an environment where resources are limited, and you can't hide behind the laboratory of radiology departments. Clinical acumen, and a couple of good books are the tools by which lives are saved. Take one memorable incident, for example.

We were on call for the afternoon theatre list - a list which is usually populated by the obligatory closed manipulation of a childhood fracture and uterine evacuations following backstreet contraceptions, sorry abortions. Typically there would be two doctors assigned to this list, one to cut and the other to dope. So off we went to theatre, my wife (who was doing her internship) and myself (as the "senior" doing comm service). Imagine our consternation when gazing down the list we see Mr X, who is booked for a drainage of a Quinsy. Now a Quinsy is an abscess of the area around the tonsils. As such, it is very close to the airway and one or two large pipes carrying blood to and from the brain, namely the internal carotid artery. As such, it represents a rather tricky procedure for a junior doctor.

We felt somewhat out of our depth, so we phoned the senior doctor who seemed somewhat disinterested, his advice being, "just drain it carefully, everything will be ok." So armed with this confidence from afar,  we were left with no choice. Fortunately, we remembered that we had a CME journal where this particular procedure was described and we hastened home to fetch it. Having located the article we then proceeded to put the poor chap on the table.

One can only imagine how this fellow felt when he saw that his doctors, who he had been conditioned to believe and trust in implicitly, were using a dog-eared magazine to plan his surgery. My wife elected to be the provider of a compliant patient and set about giving some light sedation. Her job as anaesthetist also included holding the journal open on the right page so I, the dashing wielder of the knife, could place the cold hard steel in the right place. We elected to sit the patient up, and approach this from the front. This required the securing of a surgical blade to a tongue depressor with sleek tape (ubiquitous pink tape that holds hospitals together all round the country). Duly prepared, I set about draining the abscess. Of course, being lightly sedated, the patient was not completely co-operative, and quite a few times he almost lost his tongue. But in the end the abscess was drained, the airway maintained and the patient delivered to recovery in a better state than he was when he came in.

I am convinced that there is a guardian angel that covers doctors in resource constrained environments. When I look back on that procedure and think how we would approach such a case in our hospital, I can't believe we got away with it. At our august institution the patient would receive a full general anaesthetic and there would be much wringing of hands about how the airway would be maintained and protected from the pus which was to be released from the abscess. Yet, similar procedures are carried out on a daily basis in the periphery with very few poor outcomes. We have often said that you only get the complications you know about. This certainly seemed to be the case in the rural areas.


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