Kids Do the Darnedest Things

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I must admit, working in Paediatrics compared to Surgery has been heaven.

The day-to-day life is quite relaxed, the ward is never obnoxiously full and the full team works together to get things done.

It can also get a little silly.

I have a 3 year old patient that was admitted with afebrile seizures and I was working up for meningitis. The child had been in the ward for a day, and has been doing well (CSF results showed it wasn’t meningitis). So he’s being treated still in the ward for a lower respiratory tract infection. As expected, he’s quite attached to his mum. She left today after visiting the child and, lo and behold, not 30min after she left, he’s crying and walking around the ward looking depressed. Suddenly he gets the idea to go out the same door as his mother and proceeds (I’m not joking) to open the ward door and walk out!!! He even had enough insight to go towards the exit.

After all of us had a good chuckle, the ward sister ran after our little absconder and got him back into the ward. He’s still upset, especially now that the metal trellidor is being shut as well. Hopefully he’ll be discharged by the end of the weekend, so he’ll be with his mummy soon enough.

Biggest Win of Internship

I think I’ve been blessed to have a few defining “doctor moments” during my internship. Not all of them have been great, but the experiences themselves are what will end up making me a better doctor in the future. A big lesson I’ve learnt these last few months, is about advocating for your patients.

We had a patient, Mr X, who was admitted to the surgical ward for workup for obstructive uropathy. He was also in renal failure, and regardless of whether or not it was from the obstruction, the man was incredibly sick. He was weak, pale and one bad day away from uraemic encephalopathy. Somehow, we managed to send the patient to our referral hospital, a tertiary institute where they would be able to do cystoscopy to determine the exact cause of his illness.

A diagnosis of a neurogenic bladder was made, and the patient was sent back to our hospital to be inducted into the chronic renal program for dialysis until his return date to the tertiary institute. On arrival to our hospital, the patient was re-admitted to the surgical ward. Now, as any doctor will readily know, medical and surgical wards have major discord. The smallest wounds are sent to the surgical ward, regardless of the symptomatic CCF that the patient has been admitted for. Pro-BNPs are done on the regular to prove CCF, in order to send them to medicine. With this patient, the same issues arose. Although he was being seen by Urology, the patient was referred to Internal Medicine, who refused the patient on account of him having been seen at Urology. I disagreed and insisted that the Internal Medicine senior doctor see him. I initially asked the doctor who worked at the renal unit, who directed me to the doctor in Internal Medicine. After contacting her, she asked me to do a long list of blood tests and eventually agreed to accept the patient to her ward. However,  two days later, she told me that the patient was not a candidate for the chronic renal program. She sent the patient back to my ward. I reviewed the bloods: they were within the specifications for the chronic renal program.

I was furious. 

How could they refuse this patient? Mr X had no contraindications for dialysis; in fact, he was being referred specifically for dialysis. What was the hold up? One of the doctors from our team had made the suggestion that the patient go home to wait his return date to Urology. I stopped him and outright refused. Sending the patient home was a death sentence. With a creatinine of 2000 and a urea of 100, that patient would go back to the tertiary institute worse off than when he left, or worse, die while waiting for his return date. To me, this was unacceptable.

It had been a week since the start of this saga. I decided to push my senior doctor to contact the doctor working specifically in the renal unit. Somehow, he agreed and came to put up the dialysis catheter. I was chastised for not coming to him sooner… I had to remind him that I had and had been directed away (had a big eye roll about that one).

Long story short: that afternoon, Mr X had his first round of dialysis.

I ran into him about 2 weeks ago, and he is looking so much better. During that last admission when I saw him, Mr X was unable to walk, he was tired, and pale as a sheet. Following the dialysis, he has some colour, he was able to walk on his own and was even smiling!

Related imageAlthough the only thing he wanted to know was when he would be able to go home, for me, it was possibly the most rewarding moments of my internship.

I had a small part in helping this man get better.

I walked around the rest of the week with a massive smile on my face, knowing that, in whatever small way I could, I had made a difference.

Rock Bottom

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I think there’s always that one moment when you feel like you have genuinely, truly, hit rock bottom.

Whether it is emotionally, physically or mentally, the moment when you realise you have burned out creates an amalgam of emotions as a response. First, you feel pure exhaustion; next is the feeling of frustration, blaming systems and self; then comes the shame, stemming from that superhero mindset which thinks “it could never happen to me”; and finally, the guilt you feel towards yourself and your patients, because you feel like they’re receiving substandard care.

Burnout is real.

And doctors not dealing with burnout is even realer.

My rock bottom was a week in surgery where it seemed like everything went wrong – I had 4 patients die on me in the ward (one of them was post-op, the others terminally ill) and then came my rather eventful call. I had just finished off assisting with the last case in theatre and I received a call – a patient who we had operated on in ICU was crashing. I gave orders over the phone and ran down to ICU to find the sisters in the middle of a resus. They had been resuscitating with no response. We continued but eventually, I had to call it. It was the first time that I had to say the words “Time of death…”

And yet, I had to carry on.

I continued to casualty, where my colleagues were seeing to a child with organophosphate poisoning. Our senior insisted that the patient would recover with atropine, and advised us to wait to intubate the patient. The child was restless, with a lowered GCS, but we dared not try go against our senior. I continued seeing patients. A little while later, while seeing a patient, I heard a sound. A terrible, horrible sound that made the hairs on the back of my neck stand up. It is a sound that every doctor has heard, if they have ever had to resuscitate a child that was found to be unresponsive by the parents.

I went to the P1 bay to assist. Pupils were non-responsive. No pulse was palpable. The senior doctor was busy doing a rapid sequence intubation. The other interns were taking turns to do compressions. They stopped compressions during the intubation and the monitor showed a ventricular fibrillation – a shockable rhythm. I asked for the defibrillator, which was obviously faulty. Somehow, we managed to get it to charge and shocked. Two more times we shocked and three more amps of adrenaline were given. All the while this girl’s chest was pounded in an attempt to restart what had stopped.

Asystole.

We continued, but after 40min, we knew it was futile. We paused to see if anyone had any alternate ideas on how to continue. No-one responded. Our senior called time of death. The girl’s family was called in to see the body. Patients had piled up on the other side of casualty.

And so I carried on.

Two days after this call, I had a theatre case to attend. The patient was an emergency laparotomy, following a septic appendix and subsequent failure of a bowel anastomosis. I had thought that this was reason enough for the previous day’s bloods to be adequate but they were not. The senior anesthetist called me to see the patient. She asked me to look at her, to see if I thought the patient was fit for theatre. Yes, the patient was tachycardic, mildly tachypnoeic, and her mental status had been altered since her initial operation. However, without the op, she would surely die. The anesthetist proceeded to rip me apart – she went so far as to say that without a blood gas on the patient, we wouldn’t know the extent of the patient’s acid-base imbalances and should the patient die, it would be my fault.

Yet, I carried on.

I did the needful to ensure the patient went to theatre. I took bloods, I took myself to the ward when I was called for another emergency, and I returned to the theatre with the results that showed (in fact) that the imbalances weren’t that dire. I stayed on to assist the senior surgeon. The anesthetist came into the theatre room and, during the procedure, continued to tell me all the ways I had, essentially, screwed up. I knew it was to make sure I would do better next time, but every time she said the words “if the patient dies, it will be your fault”, my spirit broke a little more.

Post-op, they needed help taking the patient to ICU. As I went to help, I looked down at the patient’s face and I began to cry. It just happened. The surgeon took one look at me, tapped my shoulder and said in his kindest voice that I should go home.

Every death and every action that I took, that I felt may have cost me my patients that week, culminated to this one moment. I felt silly and embarrassed and ashamed. How could I let this get to me? I understood clinical detachment, it was a tool I used it every day. It is crucial in a doctor’s arsenal, because it is what lets you carry on when, in reality, you should take a moment to process.

I think I broke down that day because I felt like I couldn’t carry on.

Talking helped. Talking to someone not in the medical profession helped more. I was told that I was making a difference, and that one week, even one month, of death and despair shouldn’t take away from that. It took a few days, but I got out of the funk that had gotten hold of me…

And carried on.

The Best Feeling in the World

While working in a department that deals quite a lot with terminal cancer patients, there are few moments that truly feel like those defining “doctor moments”. Turns out, I had one of mine while in Surgery.

I’m working currently in the female ward, and I see a good 4 – 5 cancer patients on the regular. I had one woman who I met in the clinic. She was a frail lady, in her 70s, and could rattle off her chronic medications by heart. She was complaining of pain in her abdomen, as well as a feeling of general malaise and weakness. As I examined her, it turned out she had a massive midline scar as well as a previous colostomy scar. I asked her what it was for, and she told me, by the way, she had colon cancer. She had a previous colostomy which they reversed. I felt her abdomen and immediately my heart sank. I could feel a mass. Of course, she was admitted to my ward and sent for a sonar, which confirmed the worst: there was a large intra-abdominal mass, possibly an abscess or possibly a consequence of her colon cancer. We prepped her for surgery. I assisted, since she was my patient. Intraop, my consultant realised that the mass was a necrotic tumour, which, of course, had to be drained and excised. Upon inspection of the bowel, another tumor, this one not resectable, was found near the terminal colon, and it was obvious it would cause obstructive symptoms at a later stage. My consultant elected to give her a colostomy again, this time a permanent one.

Post-operatively, she was very poorly. As soon as she got to the ward, her blood pressures began dropping, she was tachycardic and confused. She was very anaemic as a consequence of the blood loss. I put up a second IV line, crossmatched and sent for blood and began trying to pick up her BP. It was an hour past my working hours. I was exhausted. I wanted to fight for this woman, who, through all of this, was always bubbly and pleasant during rounds and attentive and respectful to all the doctors, including myself, the lowly intern. I handed the patient over as a critical case to the docs on night duty. Then I went home and prayed she would make it.

The next day, I was pleasantly surprised to find her doing much better. Her blood pressure was still all over the place, but on the whole, she seemed more lucid and stable than before. However, we began to encounter more issues: her wound became mildly septic, she had temperature spikes (we suspected sepsis as a cause) and she was unable to ambulate.

One week turned into two, and, in the end, she recovered marvelously. She took time, but eventually began to walk on her own, eat well, and her wound (with the help of some antibiotics and daily dressings) was much cleaner than before.

Image result for hard work quotesI won’t forget the day her husband came in with snacks for the whole ward, myself included. It was not two days after that I got to tell them both that she was being discharged. The joy on both their faces was infectious. The way they thanked me, I felt so warmed, so positive that what little I had managed to do had made such a big difference in this patient’s life. Treating this woman had been hard work, but it had never felt like a burden. It ended up being such a rewarding experience for me, and it has not been an isolated occurrence.

In the end, I got to see her walk out of the hospital, hand in hand with her husband.

And I felt like going into medicine was the best decision I ever made.

3am Delirium

Being on call is strange. After enough calls, you feel like you’re finally getting used to the insane hours, workload and fatigue. All it takes is one bad night to set you back to that first call where you prayed the whole night not to see any P1 patients. So it goes without saying that doctors have some strange coping methods.

Some interns I know have a specific fast food that they like to indulge in, but only when they’re on call. Others try their best to clear casualty and take time to go nap before the second wind comes in. Some refuse to sleep even when the opportunity presents itself. Personally, I have a penchant for a certain candy that is my on call staple. A handful at the right time gives me enough energy to push through for a few more hours. Whether this is the sugar rush or just a placebo effect, it helps me cope.

'A little professionalism, people. When asking a patient to undress, we do not giggle.'Sometimes, however, through the exhaustion, you reach a point that I like to call 3am delirium. You’re awake, lucid but somehow the silliest things can throw you into a fit of giggles. There was a night on call where myself and the other intern were in stitches over getting the on call room key. The administrator kept erroneously giving us the wrong key. It ate into precious resting time, but instead we were in hysterics about the whole thing. Any senseless comment would cause us to laugh uncontrollably. We were delirious.

 This delirium may also occur at earlier hours and at more inappropriate times. Case and point was made one night, where I was called to see a gentleman who had a cut on his leg. The sister on call told me that he was stabbed in the leg. I went through to see him and began my usual line of questioning – when did it happen, what was he stabbed with, who stabbed him – and his responses had me thoroughly confused. Initially, I thought he said that this person stole his knife and stabbed him in his leg. I examined the wound; it was located on the lateral aspect of his calf. It seemed an odd place to be stabbed.

“You say that this person took your knife and stabbed you on your leg? Did you know this person? How did they manage to stab you here?” I asked, perplexed.

“No doc, it was my knife. I was running and I got stabbed.”

I was still puzzled. “So how did you get stabbed then?”

He looked a little frustrated and said: “It was my knife. I had it in my boot and it cut me when I was running.”

“So… you mean that you kept your knife in your boot? And as you were running, it cut you… so you stabbed yourself with your own knife?”

“Yes, doctor.”

At this point, I believe my logical brain shut down. My basal instinct to laugh was uncontrollable. A chuckle slipped out. I had to shove my hand in front of my face and apologise profusely to the gentleman who was sitting in front of me. Luckily for me, he had a sense of humour and had a chuckle himself. I excused myself and went to a corner to let out the laughter and regain some composure. To this day, if I recount this story I still have a chuckle. The silly situation, coupled with my 3am delirium gave me a good laugh that night.

So whether you need a Big Mac, or a bar of Dairy Milk chocolate, or just a good laugh, ride that 3am delirium wave all the way to the end of call. (and be safe driving back home post-call too!)

Making Mistakes

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A huge misconception is that doctors are flawless, all-knowing and faultless; this couldn’t be further from the truth. Doctors, especially young doctors, make mistakes. Experienced doctors also make mistakes, although theirs are fewer, and theirs are sometimes more fatal.

As a young doctor, errors are justified either by a lack of experience or by a deficiency in knowledge. Both of these can be rectified, although, a limited scope of knowledge is not looked at kindly by any senior doctor who may witness your mistakes. These can range from the basic (not taking bloods for workup from a casualty patient before sending a patient to the ward) to the more serious (missing lacerations that need to be sutured on a patient who was bandaged everywhere) to the potentially life threatening (missing a pelvic fracture on x-ray). I was lucky enough to have an MO help me for all these situations, who supported me and firmly taught me how not to make the same mistakes again.

When it comes to senior doctors, however, I’ve noticed a pattern: errors arise from too much experience. A typical patient presents to casualty and the MO will be certain of the condition, since he has seen hundreds of patients with the same clinical features. However, in his haste, he may miss a small crucial piece of information or a small alteration in the clinical picture. Spot diagnoses are a favourite amongst some medical officers. An example was a patient who presented with TB induratum. My fellow intern was treating her and asked me to confirm the diagnosis. It was the first time I had ever encountered the condition outside of a textbook. Vesicular and ulcerated lesions were found all over the body in a patient with existing pulmonary TB. Our MO, on the other hand, stuck his head into the consultation cubicle, took one look at the patient and said “Herpes zoster, treat with acyclovir and discharge”. Now, from afar, it may have seemed like shingles, however, without talking to the patient and observing that there was a clear absence of dermatomal distribution of the lesions, the MO missed the diagnosis. The patient would’ve been treated inappropriately for her condition. This was a non-life threatening incident, but there have been plenty of those as well. “Dodgy discharges”, as we like to refer to them, are plenty, and many patients end up coming back to the hospital at a later stage as DOAs.

Truthfully, it becomes difficult to remember that we are only human. We are in an impossible situation where the lack of staff, scarce resources and constant exhaustion work synergistically to create a situation where mistakes can be made easily. And although patients hold us to a high standard of excellence, I believe that we as doctors hold ourselves to an even higher one. The objective is to learn from your mistakes and prevent similar ones in the future. The end goal is to become a damn good clinician. All doctors (whether they like to admit it or not) are type A personalities, and are usually pedantic about one or more aspects of their work. We strive for flawlessness, for success, and for exceptional patient care.

We just need to make sure that our quest for perfection isn’t littered with mistakes.

Patience For Your Patients

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A big chunk of life as a health professional involves patience. The ability to be unfazed when presented with every kind of patient that you would encounter. However, I must admit, there are times that patients can test the composure and sanity of a monk. The leading cause for this is simple: patients lie. I remember watching House (the TV show) and remembering the titular character Dr House echoing my sentiments exactly: everybody lies. It was a rare moment where TV indeed reflected reality. The fear of judgement from the doctor eggs the patient to “forget” (read: omit) certain crucial aspects of their illness. Our work becomes doubly hard, trying to read between lines in order to reach a diagnosis. Their impatience with us breeds animosity and a feeling of neglect, which is counterproductive to all parties involved.

My first encounter with a lying patient was a casualty referral. He was sent from one of the small clinics in the location (township) to us with a swollen hand. He denied having any trauma to the limb and claimed that an insect had bitten him. I, having established that the bite was not from a spider or any other venomous insect, decided that it would be treated well with analgesics and anti-inflammatories. He asked if he needed to stay in the hospital and I almost laughed. With the problem of bed shortages, insect bites were definitely low, if not non-existent, on the list for admission criteria. Since the bite was small and it seemed to recover with similar medication from the clinic, I prescribed him medication, deemed it unnecessary to prescribe antibiotics and sent the man on his way.

Not two days later, I encounter the same patient in casualty. The swelling in his hand had worsened and the fingers were now warm to touch – a skin infection. I asked the nurse to triage him, while I finished up with another patient. Upon reading his new triage form, the history of illness that he gave the nurse was that the hand had begun to swell following an accident while gardening, resulting in him hurting himself. He also was complaining that his shoulder was sore following an injury while playing soccer. However, upon asking him again about how he hurt his shoulder, his story changed – now he had knocked it against a doorframe. Confused, I asked the intern in Orthopaedics to assist me in assessing whether this man had a fracture or dislocation. His assessment was similar to mine: there was no fracture or dislocation. Still, upon the patient’s insistence, I ordered an X-ray, which confirmed our diagnosis – a soft tissue injury, without fracture or dislocation. Once again, I was asked if admission was necessary. Again, I dissented. This time around, I prescribed antibiotics and more analgesics, and discharged him.

I was certain that I had made the right decision.

Alas, one more day passed and he greeted me, yet again, in casualty. This time, the infection had spread to his forearm. The man wept bitterly and begged me to admit him, to help him, not to send him away again. He was curled up on the ground, against the wall of the nurses’ station, crying and cradling his inflamed arm.

This, for me, was one of those defining moments as a young doctor in training. It was in this instant that I was able to fully comprehend that I quite literally had someone’s life in my hands.

This man had been unable to go to work and earn his livelihood because of the infection. Having little faith in the doctors who saw him, he may not have taken his medicine correctly. Now he would definitely need admission. I felt like crying, I was shocked, embarrassed and felt helpless. A small seed of doubt rose within me: had I treated this patient to the best of my ability? Had I listened and tried to figure out the real story that would correlate with the man’s injury?

My senior medical officer (MO) saw the exchange between my patient and I. He came to help me out and told me to go on a break, that he would see this patient. I felt worse. My MO seemed to think I couldn’t handle this either. It was frustrating. I went back to my rooms on a break and called my parents. I cried to them on the phone, expressing my fears that I was an unsafe doctor. They lent a sympathetic ear but ultimately told me that I would need to harden myself. This was the first time, but it definitely wouldn’t be the last time that this would happen.

When I returned to casualty, the MO and the nurses said that I shouldn’t get upset – it seemed likely that he hadn’t collected his medication, he had been drinking heavily and he was looking to be admitted. Again, I was reminded not to personally invest so much of myself into a patient. Empathy is a good quality, but clinical detachment is key. I had treated this man to the best of my ability, although I still needed to learn how to sift through the lies that the patient had presented to me. He was eventually admitted and put on IV antibiotics, and responded well to treatment.

A sillier version of the lying patient trope is a young woman who came into casualty with lower abdominal pain, 10/10 and who seems to be truly writhing in pain. She had come in about 30min before we were meant to knock off work. Still, bound by our Hippocratic oath, we clerked and examined the patient. The woman, as it turns out, was experiencing dysmenorrhoea, also known as period cramps. Now, as a woman, I understand the pain associated with painful menses. Some women do experience menstrual pain that equals that of appendicitis. However, as a doctor, it seems utterly ridiculous that my colleagues and I should be dealing with period cramps in the same space as a stab wound or a DKA. The woman knew that lower abdominal pain would bump her higher on the triage list, and used it to her advantage. Safe to say, none of the health care workers in casualty were amused. Reaching our limit for the day, we quickly treated and discharged the woman.

In one short month, I’ve already been conditioned to grill my patients because my first thought is that they will lie to me. Rather unfortunately, this does hold true for the majority; lying, whether directly or by omission, encourages this knee jerk reaction I have. Nonetheless, the onus remains with me to sift through the falsehoods and nonsense in order to reach the truth. I feel that in order to be successful in this regard, one needs a combination of good medical training, excellent social skills and patience. A persevering charismatic doctor is far more fruitful in their cross-examination of a patient than one who is more clinical or exceedingly methodical. But where does one draw the line between the two?

Truthfully, it is a paradox: being clinically detached while maintaining charm and an engaging rapport with the patient. It is a skill that I will have to hone, as I have done any other procedural skill, with repetition and practice.

It will require patience, which I shall also endeavour to have while interacting with all my patients.

(Well. Unless they come into casualty 10min before I clock out.)

Sink or Swim

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I don’t think 6 years of medical school ever prepares you emotionally for that moment where you finally see your first patient. My first day in casualty was horrendous. What was meant to be an “orientation” turned into a half-day’s worth of work. I was so nervous. Our senior saw the first two patients, with us, the interns, alongside him. He was showing us the ropes. Thereafter, it was our duty to clerk, diagnose and manage the remaining patients in casualty. My uneasiness grew. Being out of practice for close to two years was a blow to my confidence. I had lost that keen eye that you cultivate in your final clinical years in medical school. I ended up scribing for my fellow intern rather than taking the plunge and seeing patients alone. After seeing three patients together, we headed back to the nurses station, where it was suggested by our senior that we each see, on our own, at least one patient today. His keen eye, it seems, extended beyond medicine.

I bit the bullet. I opened the curtain to my first ever patient. My heart was pounding. Would I remember to maintain good bedside manner? Would I forget to ask the important questions? I greeted the patient and began the consult. Turns out that the universe was throwing me a bone – my patient was an uncomplicated urinary tract infection (UTI). I managed to diagnose her and prescribe her treatment. The nurses were incredibly helpful, especially when it came down to remembering drug doses, which is the bane of my existence.

The next patient I saw, I needed to take bloods. I remember reaching for the Vacutainer needle and holder. My senior immediately laughed at me and told me that he would be making sure I unlearn the reflex of using a Vacutainer. He told me to get a needle and syringe and a glove. Since there were no non-sterile gloves on the casualty floor, I picked up a pair of surgical gloves. Turns out, the glove was to be used as a tourniquet, and the needle and syringe were actually much easier to use than the Vacutainer.

Being in South Africa, a big fear is HIV. Our policy is to assume a patient is HIV positive until proven otherwise. So taking bloods without gloves was immediately a big problem. Worse still, was that the problem stemmed from a vast shortage of non-sterile gloves. It was shocking that we were suddenly told to try conserving the sterile gloves and learning to take bloods with, quite literally, our bare hands. I felt troubled, anxious and wary as I took samples thereafter; in my mind, it was an extra, unnecessary risk I was taking. I ended up using sterile gloves, but one glove at a time, over my dominant hand. Our senior chuckled and told us, rather matter-of-factly, that we would be taking bloods without gloves soon enough. The idea initially horrified me, but by the end of the day, it felt rather normal not to. I suddenly realised that it shouldn’t feel normal, later that afternoon, when I was taking blood from an HIV-positive patient, and his wife asked me why I wasn’t using gloves. It was a small reminder that patients see and understand a lot more than health professionals give them credit for.

The last, and most interesting, case was that of a man with a sudden onset of localising signs. As my fellow intern and I clerked the patient and tried to decipher what could be the root of the patient’s problem, our senior came over and began to ask us more questions. We concluded that he had a probable space-occupying lesion in his brain. A CT scan would be necessary to confirm. Luckily, our hospital has a CT scan. Unfortunately, our CT technician was on leave, which meant no scans could be ordered until his return. We would have to refer the patient to the far-away provincial hospital to get his scan. The frustration I felt was real – how could we have facilities but be unable to use them? Have equipment in the hospital, but no one to operate it?

In this moment, I learnt the nature of medicine in South Africa. The majority of the hospitals in the country are not like the tertiary and quaternary hospitals of the urban jungle, where you can order a CT as easily as an X-ray (as long as you’ve got the indication for it). Rather, they are the smaller, fuller secondary hospitals and CHCs which do what they can with the resources handed to them, who spread themselves thin and look for shortcuts so that they can see all their patients. Where nurses step up to do work to ease the burden on the doctor, so that they can see more patients.

They use Band-Aids to attempt to fix the cracks in their foundation.

This is the sad reality of rural hospitals.

However, I must admit, my realisation ended up making me somewhat hopeful. Perhaps our exposure to shortages will instil in us a deeper appreciation for the facilities available in metropolitan hospitals. Perhaps the scarce resources will hone our clinical skills. Perhaps our rural setting will give us a richer understanding of our local patients.

Perhaps with the influx of doctors into our little hospital, we’ll be able to affect some kind of change in the system, no matter how small, for the benefit of our patients.

After all, it’s only the beginning.