nCPAP
https://badem.co.za/wp-content/themes/anemos/images/empty/thumbnail.jpg 150 150 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=gBased on on work done in below abstract we are in the process of completing final drafts of a “Quick Reference Handbook on Neonatal nCPAP” (with a focus on use in prehospital / critical care retrieval).
If you are interested in receiving a copy of this booklet when it is complete, or would like more information please email kat@badem.co.za
Interview with Sa’ad Lahri & Kamil Vallabh (ICEM Keynote Speakers)
https://badem.co.za/wp-content/uploads/2016/04/SWEETS.jpg 1024 576 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=gDr Kat Evans from #badEM interviews ICEM2016 Keynote Speakers Sa’ad & Kamil – Cape Town Emergency Physicians:
Who are they?
- Cape Town Emergency Physicians & educators
- Dr Sa’ad Lahri – Khayelitsha Hospital & EMECG (& Barista in his spare time!) – Twitter: @slahri7
- Dr Kamil Vallabh – Mitchells Plain Hospital & of EMECG & Plain EM – Twitter: @KamilVallabh
Kat (#badEM): The theme for ICEM 2016 is ‘Knowledge, action & accountability’. Both being EM Physicians in South Africa with EM being a very new speciality, what do you know now that you wish you had known 5 years ago?
Sa’ad: Some lessons, and especially the hard ones, cannot be taught… They simply must be experienced and only once learning these you get better. EM is a discipline built on relationships and these must be fostered. Resilience and grit are key… Never give up. Lastly… have to be healthy body, mind and soul… to last.
Kamil: EM has evolved so rapidly in our South African context in the last 5 years and I can safely predict that the current generation of EM leaders are paving the way for a very successful and sustainable speciality…impacting patient care on the frontline and having the ability to make a difference in the patient’s healthcare journey. For me, being an EM physician is not solely about clinical service delivery…it is so much more. I get a chance to be a leader, a teacher, a student, a shoulder to cry on and a carer. I get to impact some at their most vulnerable moments and I get the opportunity to give others hope and sometimes consolation. I get the chance to inspire others to be better but most of all I get the privilege to make a difference. Leadership, teamwork and mental fortitude are key elements in EM…I’ve learnt this in the last 5 years. The environment will always be chaotic but manageable if the above elements are kept in alignment.
Kat (#badEM): Your talk at ICEM is entitled “Its not who you are underneath, but what you do that defines you”.. we notice this is a quote from Batman https://www.youtube.com/watch?v=Z-zNnq7kHMI (Check it out at minute 2:23).
I have two questions relating to the above video clip:
- Over the last few years of various EM conferences the two of you have ended up dressed as various Superheros/Batman/Robin/Jedis etc.. What gives you the inspiration?
Sa’ad: All those that work within emergency medicine (doctors, pre hospital, nursing etc) are superheroes once they realise that with great power comes great responsibility
Kamil: No words.. Only..
Kat (#badEM):
- Will the two of you be wearing appropriate swimming attire for the fountain? (0:37)
Kamil: q2…who wears swimming wear for a fountain! ? all will be revealed on the 19th!
Sa’ad: The answer to q2 is that you have to come to the keynote to witness something dramatic
Interview with Surgeon Captain Jason Smith (ICEM Keynote Speaker)
https://badem.co.za/wp-content/uploads/2016/03/jasonsmithdraft.png 1200 1842 Craig Wylie Craig Wylie https://secure.gravatar.com/avatar/e606f94633923ca39e572679d881abe0?s=96&d=monsterid&r=g
Craig Wylie from #badEM interviews Surgeon Captain Jason Smith regarding his up and coming Keynote Speech entitled “Advances in military resuscitation – experience from a decade of conflict” at ICEM (International Conference in Emergency Medicine) being held in Cape Town.
Read more about Surgeon Captain Smith here: http://www.icem2016.org/speakers.htm
Craig: The ‘crossover’ between civilian and military emergency medicine has been on the increase over the last couple of years. What do you think the future holds for mixed military/civilian EM?
Jason: I think we will continue to learn from each other. The patient population, and in particular the mechanism of injury, is different in the patients presenting to deployed medical treatment facilities – over half of the severely injured patients presenting during the recent conflict in Afghanistan were injured by blast – but many of the lessons learned are transferable to a civilian population. Much of the knowledge and many of the skills we acquire on deployed operations can be used to contribute to improving patient care back in our normal work environment.
Craig: What is the next “big thing” coming to the civilian sphere from Military EM?
Jason: I think there are a few things that have transferred really well from military to civilian practice. For example, the use of intraosseous access in adult patients; the use of ketamine as an induction agent for patients with major trauma; and the use of simple tourniquets to control exsanguinating haemorrhage. The principles of damage control resuscitation are well understood but difficult to implement in centres that are struggling to appropriately resource their emergency departments. I think that the management of massive haemorrhage, including proactive replacement of blood and blood products, is key to survival in major trauma.
Craig: What do you think Military EM can learn from Civilian EM?
Jason: A vast amount. My day to day clinical practice is in a national health service hospital in the UK, and my clinical credibility is underpinned by working in a busy emergency department seeing the same kind of patients as everyone else. Working in a busy ED is the best preparation for deploying on a military operation – it means you have the breadth of experience to fall back on when needed.
Craig: What do you feel strongly about in emergency medicine?
Jason: Pain control & communication.
We think we are good at managing pain in emergency patients but if you listen to feedback from those patients it is one of the things that we could do better. We need not only to treat their pain when they come through the door (and there is some evidence to suggest we’re not good at that either) but also control their pain over the subsequent few hours. I think we have a long way to go to achieve analgesic nirvana.
We also could do better when communicating with patients. When we speak in medicalised language to patients (‘I’m going to check your troponin level to see if you’ve got an acute coronary syndrome’) it’s gobbledegook to most of them. We need to speak to patients in a language they understand, which may be different for each individual. This is a core clinical skill, and one that should be valued, taught and developed.
Craig: You will be speaking to us about advances in military resuscitation at ICEM 2016, want to let anything out the bag?
Jason: I’ll be talking about some of the key areas of emergency medicine and resuscitation practice that have developed over the last decade of conflict in Iraq and Afghanistan, hopefully pointing to areas where these lessons can be translated and applied to civilian emergency medicine.
Emergency Doctors without boundaries: we need to talk about violence against women
https://badem.co.za/wp-content/uploads/2015/12/cover_IPV.gif 800 451 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g
Author: Dr Lucy Hindle – Emergency Physician – Gauteng, South Africa
Co-author: Katy Hindle – lawyer with a special interest in gender and health
Edited by: Dr Kat Evans – Emergency Physician – Cape Town, South Africa
What is intimate partner violence?
IPV is violence perpetrated by an intimate partner (so a boyfriend/husband/ex).
Most commonly, it includes:
- Physical violence eg: slapping, punching, kicking, assault with a weapon,
- Sexual violence eg: rape, coercion, or
- Psychological violence eg: intimidation, stalking, withholding money or preventing visits with friends or family.
- But it can also include other forms of violence.
Although both men & women can be victims or perpetrators of IPV, women make up the majority of IPV victims.
Is IPV the same as domestic violence?
The terms IPV & domestic violence are often used interchangeably & South African law refers to domestic violence. There are some important differences though. Domestic violence is violence that happens in a house (as the word ‘domestic’ might imply) & it can occur between any of the people living in the house, they need not be related or in a relationship (so for example a brother assaulting his sister).
By contrast, intimate partner violence is violence perpetrated by an intimate partner & can occur anywhere (in a bar, outdoors etc.). IPV may also occur in a house but this type of violence isn’t characterized by where the violence takes place & it’s not necessary for the people involved to live together. An example of IPV might be where an ex-boyfriend attacks his previous partner at a night club.
How common is IPV?
IPV is a huge problem around the world. Estimates by the WHO put lifetime prevalence (the likelihood that someone might experience IPV during their lifetime) at 1 in 3 women. In South Africa the stats are similar but we have the highest rate of women being killed by intimate partners in the world. High profile cases like Oscar Pistorius & Christopher Panayiotou tend to get lots of media coverage but on average, a woman is killed by an intimate partner every 8 hours in South Africa. If you are a woman in South Africa, you are more at risk of being killed by a current or previous partner than by a stranger.
The health issues faced by victims of IPV go beyond just the effects of trauma – women who are abused have increased rates of chronic disease, psychiatric issues & sexually transmitted disease including HIV. IPV also has far reaching consequences on economic development, because women in abusive relationships often miss work or are prevented from working due to injury.
Okay.. So obviously this is bad- but how is this an emergency medicine issue?
All of us in emergency medicine are managing and treating women who’ve been abused, we might just not be recognizing it! We see people at their most vulnerable & often, we are the only interaction with healthcare that victims of IPV have. If we see women who have been abused & don’t identify IPV as the problem or worse, identify it but don’t ask questions or go any further, we are contributing to the culture of silence & shame and to the secondary victimization which so many women face.
Imagine you had been abused & told your doctor what happened and who was responsible for it. If your doctor treats the injury & sends you on your way, that suggests to you that abuse is normal, accepted & that there is nothing that can be done to change the situation.
But other, more supportive situations are equally possible. Our role in EM is to save lives – & IPV is a life-threatening problem just like many others we have been trained to respond to.
So what do I do? Who should I even be asking?
Although asking everyone we suspect might have been the victim of IPV would be ideal, it isn’t always practical in our settings.
We should definitely ask:
Victims of assault/injuries (even if another explanation is given)
Pregnant women: pregnant women are at a higher risk of more violent IPV & pregnancy might be the only time women will come into contact with healthcare providers.
Those with chronic pain (headaches, back pain)
Those with depression or anxiety
Women who are HIV positive: women who are abused may be less likely to be able to negotiate condom use, may have been raped or may be abused because they are HIV positive.
The more we ask patients about IPV, the more routine it becomes & the more we can change the culture of shame and silence that allows it to continue unchecked in our communities.
How do I ask? Won’t my patients be offended?
There’s good evidence that women would like to be asked about IPV & are not offended by sensitive questioning.
A “partner violence screen” was developed specifically for Emergency Departments. It consists of 3 questions, which should be asked in a private place & outside earshot of a partner!
Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?
Okay.. So then what? I feel like there’s nothing I can do so I would rather not ask!
Feeling a little helpless is common – but think about IPV as a chronic illness. You don’t jump in to cure hypertension on a first visit but you still screen, counsel & refer.
If you diagnose IPV there are some simple steps that might make a big difference. For example:
Assess immediate threats to safety, including to any children:
Is there a gun in the house?
Have there been any threats to kill?
Have there been previous serious attempts?
Do you suspect any child abuse? Remember that legally this needs to be reported.
If anything seems immediately life threatening, consider referral to the police, a social worker or to a local place of safety & if your patient agrees, you may want to keep them in hospital until a plan is in place.
NB: The period around when a woman leaves a relationship is high risk for homicide & severe violence so women need to plan this carefully. Only they will know & should decide the best thing for themselves & their children & your role is simply to support this.
Refer to other resources
Legal resources
- Protection order
- This is a legal document that can be obtained at a magistrate’s court & details what the alleged abuser may not do.
- You do not need legal representation to apply for a protection order & an interim protection order is usually issued quickly to protect a person while they are waiting for the final protection order to be issued.
- For example, it might specify that an alleged abuser may not enter a shared property, visit the applicant’s place of work or commit any further acts of violence.
- If the alleged abuser contravenes the specifics of the protection order, they can be arrested.
- A protection order is not the same as laying a criminal charge. However, if there was a crime of assault or rape a criminal case can be opened by the police.
Click here for a great guide by the women’s legal center on the domestic violence act and the process involved in applying for a protection order. http://www.wlce.co.za/images/domesticviolenceguide.pdf
The stop gender violence helpline is a toll free, 24 hour helpline & can provide advice, counseling & information.
Other related reading:
About the author:
Emergency Physician – Gauteng, South Africa
Interests: systems improvements, woman and child health & travel.
Baring all: Being vulnerable
https://badem.co.za/wp-content/uploads/2015/10/6963514390_afceba7b78_b.jpg 1024 688 Willem Stassen Willem Stassen https://secure.gravatar.com/avatar/38c944ce032af5c17bf315a4aec94502?s=96&d=monsterid&r=gAs a young man, I have always tried to be the one in charge. I have always wanted to be the smartest, strongest & right – I always wanted to be right. For the longest time, I have been that guy, not exposing my weaknesses, not exposing my uncertainties. I’m supposed to always know the right thing to do.
Well, thankfully, life ends up catching up with you & you cannot run from personal (emotional) development forever. For the last three years, a recurring theme has crept into my life – this theme of vulnerability. I would like to be all academic & fancy & say that it happened when I first heard about the patient safety movement & the no-blame culture. Yet, to be honest, it
started when I took leave. I was forced to face myself, in my own home, with my own dominating personality. I realised that I wasn’t a very nice person, even though I cared deeply. Why? I 
refused to expose my own uncertainties & my own vulnerabilities. I developed this intense desire to be authentic & cultivate connections 
with others. To do this, I had to be brave.
I read three books. The first was “The Art of Happiness” by the Dalai Lama who mentions that the secret to being happy is the human connection & being authentic within our dealings with others. The second book is by Amanada Palmer, called “The Art of Asking”. In her book, Palmer speaks about her journey with asking for help, & ceasing this endless desire of humans to go at it alone, & prove how wonderfully independent we are of everyone else. She speaks about exposing our own vulnerability & connecting with others. She has a fantastic TED Talk I would recommend watching.
The final book is based on the qualitative research by Brene Bworn, PhD (see her TED Talk here): Daring Greatly: How the courage to be vulnerable transforms the way we live, love, parent & lead.” This book has bowled me out completely. Brown speaks in her book about how our fear of being vulnerable & our fear of shame prevents us from innovation & connection. Any fear of failure translates to a fear of shame. She mentions that the first thing we look for in 
another individual is their vulnerability, which exposes their humanity & makes them approachable. The last thing we wish to display to others is our vulnerability. This “vulnerability is not knowing victory or defeat, it’s understanding the necessity of both; it’s engaging. And being all in.”
Our patients are no different in that they seek to see vulnerability (& humanity) in us. Except, our patients have no choice but to be vulnerable in front of us – they are in one of the worst situations, at our mercy – they have no choice but to be vulnerable. Perhaps, it’s a consequence of emergency medicine, perhaps a defence mechanism or perhaps our
inherent personalities, but our clinical demeanour protects us from our own vulnerability being exposed to patients & other clinicians. We hide behind a façade of jargon & blood results, failing to connect with the patient. Our patients are lost refugees, not understanding the system, with a foreign language all around them. They wish to feel safe, with humans who care. Show some humanity, some empathy.
Africa is vulnerable & our healthcare system is strained. We often have to make decisions based on the resources that we have available, despite knowing best evidence. Giving Rocuronium to one patient means not intubating another. However, Brown states that vulnerability is absolutely essential to innovation. Africa needs innovation & African Solutions to African Problems (#AS2AP).
The entire patient safety movement requires that we be vulnerable as healthcare providers. We are required to be honest about our mistakes & report them. In this leap of faith, we have no choice but to trust the inherent humanity of our clinical management teams & the system within which we report & function. Self-reporting requires us to be vulnerable too. If we do not have the courage to be vulnerable, self-reporting will not occur, & our patient safety initiatives will fail. Therefore, it requires bravery.
For my PhD, I am undertaking one of the first prehospital randomised controlled trials in Africa. I’m dreadfully afraid to fail at this because in my mind I would then automatically be seen as a failure myself. Sure there are people who may believe that I am a failure yet, knowledge will still be generated – even if it simply shows how not to do prehospital RCTs in Africa. My fear of failing at the RCT should not encourage me to not attempt it. Your fear of failing something shouldn’t either. In Africa, we need innovators who bravely take the plunge towards improvement. Be brave.
I have been invited to speak at the Swedish Society of Medicine in December, & decided to be frank about the problems in Africa & exposing our vulnerability – because sometimes we have no choice. Except, our vulnerability places us in the perfect position for innovation, & we have overcome so many difficulties because of this vulnerability. We can connect with many! I will showcase these initiatives. This is what I believe badEM is about – understanding & acknowledging our vulnerability, but using it towards patient connection, innovation & improved clinical care.
It’s okay to be scared & uncertain about a step or innovation. Don’t let this stifle your innovation. We need your braveness here!
Willem
Ubuntu #3: The Michelin Man: The case of a ruptured bulla
https://badem.co.za/wp-content/uploads/2015/10/michelin-man-e1470521675974.jpg 992 757 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=gUbuntu #3 The Michelin Man: The case of a ruptured bulla
Author: Dr Kylen Swartzberg | Editor: Dr Kat Evans
The Case: Presented in real time
Friday Night, Ubuntu Emergency Department.
21:15 – 53 year old male patient rushed into triage in a wheelchair by his panic stricken wife. She shouts to the triage nurse that her husband’s lips & face started swelling up 10 minutes ago whilst at a braai & states he is allergic to Penicillin.
Two ED doctors happen to be walking past during the exchange & notice the swollen face & air-hungry patient. They grab the wheel chair & rush into the resus bay activating the resus alarm.
21:16 – Whilst one doctor & nurse move the 100Kg looking patient onto the bed & start face mask O2, the other doctor administers 0.5mg adrenaline IM in the right thigh. The next dose is drawn up & kept aside.
21:17 – Further colleagues have arrived & lines are prepared. The patient is only able to speak 2 words per breath. The first line is up in the right cubital fossa & hydrocortisone & promethazine are given IV.
21:18 – Monitors are being connected & whilst the 2nd IV line is being inserted, one of the doctors exclaims that there is a lot of crepitus in the arm & hand. The doctor speaking to the patient & adjusting the face mask also notices that there is diffuse crepitus of the entire face & scalp.
21:19 – The senior doctor asks the patient if he smokes? With a deep breath & a raspy voice he says ‘yes’. The senior excitedly proclaims that she knows what this is & that she has seen this once before…..
21:20 – Whilst the BP cuff is inflating the seconds of suspense feel like a TV game show taking an ad break. “It’s a ruptured bulla!” There is a brief sigh of relief as anaphylaxis is shifted off the working diagnosis. The vitals monitor beeps in 200/110. (Due to the IM adrenalin & subcutaneous emphysema) Saturation on non-rebreather mask is 92%.
21:21 – The senior directs preparation for a definitive airway due to extensive upper airway & neck subcutaneous oedema as well as bilateral IC drains. (Xrays will take too long & due to diffuse subcutaneous emphysema, from scalp to inguinal ligaments, ultrasound lung evaluation is not currently of use).
21:23 – The patient reports worsening difficulty in breathing. Induction agent & muscle relaxant given.
21:24 – A difficult airway is anticipated. The most senior doctor is ready with laryngoscope in hand. Video laryngoscopy is at the bed side as backup. ET tube goes in, in seconds. The team member who assisted with external laryngeal manipulation keeps his finger on carotid pulse.
21:25 – No pulse is felt. A wide eyed medical student begins chest compressions. Bilateral finger thorocostomies are done simultaneously by a doctor on each side. Air gushes out of the right thorocostomy incision. The first paddle check is done after about 15 seconds of compressions & completion of thorocostomies. An organized rhythm & a palpable central pulse.
21:26 – The now haemodynamically stable patient is seated at 45 degrees. X-rays are on the way, the medical team is notified to prepare an ICU bed. Excitement & team high fives all around.
21:45 – The patient looks 20Kg lighter & his face looks like he is a different person as the subcutaneous emphysema rapidly begins to decompress. “He is beginning to deflate” are the words used on the handover round by the doctor who affectionately dubs this patient ‘The Michelin Man’.
Outcome:
The patient is extubated in ICU during the early hours of the morning & found later that day to be eating a meal. He is only identifiable as he is the only patient in the general medical ward with bilateral chest drains. His face looks entirely different as he has now fully ‘deflated’. He reports feeling great except for having a very painful chest.
Discussion & Learning points:
Bullous lung disease is a spectrum of disease with multiple causes, most commonly smoking 1,2
Patients with bullous emphysema, especially large bullae are at higher risk for pneumothorax 1,3
There are numerous case reports in the literature of ruptured bullous lung disease. So this is definitely a topic to keep in mind when patients with a smoking history or emphysema present with shortness of breath & chest pain.
In this case it was a very different presentation to which normally is the case & given the very brief history of known allergy & facial swelling & breathing difficultly, the possibility of this being anaphylaxis was real & it was a good move to start treatment for it. Besides the increased BP, no obvious harm was done in the process. Possibly an earlier history could have been gained from the wife regarding other conditions & habits.
Always touch your patient. How important was this in this case? The doctor verbalizing to the team what he was feeling was key to triggering the memory of the senior who had just walked in & had not yet had the opportunity to touch the patient.
This leads on to the need for good & clear communication between team members & team leader during a resuscitation. One doctor can not be doing, feeling & seeing everything at once so good communication is vital.
The case also highlights that there are no shortcuts to experience. In other disciplines there can be a monotony of cases but this is obviously not the case in emergency medicine. This forms a major component of why many of us love EM. It may take years to see or experience a specific condition & when that happens, take stock of it, read up about it, take it in & store it. You never know when your single experience will save the life of the next patient or help others learn. There is a dictum that I always rely on: “no effort is wasted”. Even if there are at present no obvious results or rewards, the time will come when the effort pays off.
This case also demonstrates how absolutely crucial it is for the entire team to be engaged. Every one doing their part to make the whole come together. All aspects of the resus were happening in parallel. Oxygen, lines, drug prep, IC drain prep. As well as anticipating the course of disease/events. The anticipation of the possibility of airway compromise, the possibility of the airway being difficult, the anticipation that when PPV was started IC drains were not yet ready, so staff at the ready to perform finger thoracostomies.
Things can escalate rapidly here in the ED of the Ubuntu hospital and when working as a team, lives are saved on a daily basis.
Edited by: Dr Kat Evans
Author: Dr Kylen Swartzberg
Emergency Medicine Registrar – Johannesburg, South Africa
Passion for all things emergency medicine, teaching & sharing of knowledge.
A love for the outdoors and scuba diving.
Ubuntu #2: Divination and a Diagnostic Dilemma
https://badem.co.za/wp-content/uploads/2015/09/SangomaLR-001.jpg 2058 1500 Victoria Stephen Victoria Stephen https://secure.gravatar.com/avatar/f905145b7c8cc71a326cde65d252f1c1?s=96&d=monsterid&r=gUbuntu #2: Divination and a Diagnostic Dilemma
Author Victoria Stephen
Edited by Kirsten Kingma
You are on duty at uBuntu Hospital Emergency Department on a Tuesday evening when a 37 year old male is brought in by EMS. His neighbour had called EMS when she had noticed that he had not ventured out of his house all day. She doesn’t know his medical history but she is aware that he hasn’t been feeling well over the past week. Paramedics found him in bed, unconscious. His vital signs from triage are: blood pressure 115/66, heart rate 121 BPM, respiratory rate 28 breaths per minute, Sats 82% in room air, temperature 39.2 C and his finger stick glucose is 7.2 mmol/l.
The nurse puts him on face mask oxygen and IV fluids are started. He is unconscious and responds only to pain with no obvious focal neurological deficits. You identify his GCS as E2V2M3 = 7/15. His pupils are sluggish. His chest is difficult to auscultate due to transmitted sounds from his upper airways, but breath sounds are reduced on the right. After intubating him and getting him settled on the ventilator, you examine him more thoroughly.
He appears slightly wasted and has generalised lymphadenopathy, but what catches your eye are multiple small superficial lacerations over the 6th intercostal space of his anterior chest. What do they mean? Could they point towards a possible diagnosis?
These incisions are scarification marks; known as “izingcabo” in isiZulu, which is one of South Africa’s 11 official languages. They are made by traditional healers when patients consult them for their various illnesses and concerns. Traditional medicine is rubbed into the freshly made incisions in order to try cure the ailment the patient is suffering from. The contents of traditional medicine vary but usually consist of herbs, bark, leaves and minerals. Traditional healers are common in South Africa, with 60- 80% of the population consulting them for various illnesses and social problems. Patients frequently will consult a traditional healer in their community before seeking medical attention, especially in rural areas where hospitals and clinics are few and far between.
There are different categories of traditional healers in South Africa, the most common being herbalists (inyangas) and diviners (sangomas). Herbalists dispense traditional medicine made of plants, inorganic substances and occasionally animal extracts. Diviners believe that they can discern the cause of a patient’s illness by speaking to the patient’s ancestral spirits.
Scarification marks are usually made with razor blades. They are commonly made at the site of the patient’s pain, or over a swelling, such as over oedematous feet. They may be seen over the left hypochondrium if splenomegaly is present. In cases of sciatica , they may follow a dermatomal distribution. They are also made over the back of the neck, on the sternum, or around the umbilicus when a patient desires protection from illness or harm. Scarification sites can become infected particularly if traditional medicine is applied in the wounds, so they should be carefully inspected.
You pick up the ultrasound probe and out of curiosity you scan over scarification site, and this is what you see:
An abdominal ultrasound image of the right upper quadrant in the longitudinal plane: The liver is seen on the right of the screen. A densely consolidated lower lobe of the right lung is seen on the left.
This patient had community acquired pneumonia, which was complicated by meningitis. He had consulted a traditional healer after he had fallen ill. It may be that he had reported right sided pleuritic chest pain to the sangoma who then made the scarifications in an attempt to cure him. It is useful for medical doctors to know what scarifications signify as their presence can offer clues to a diagnosis. It’s also important to be aware of the cultural beliefs our patients may have and to educate them as much as possible about the aetiology of their illness.
Further reading:
Traditional healers and paediatric care. De Villiers FPR, Ledwaba MJP. SAMJ 2003;93:664-665
Ubuntu #1: Not another tachypnoeic pregnant patient!
https://badem.co.za/wp-content/uploads/2015/09/ECG.jpg 1470 827 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=gUbuntu #1: Not another tachypnoeic pregnant patient!
Guest Author: Dr Neville Vlok | Editor: Dr Katya Evans
History
- Mrs V is a 35 year old G3P2 female at 32 weeks pregnant by dates. She was referred to Ubuntu hospital for IVI antibiotics after being seen at the local clinic with a diagnosis of “severe pneumonia”.
- Complaints: dyspnoea & cough x 10 days – already receiving her second course of oral antibiotics.
- Background: she admits that she is sharing not only cigarettes, but also illicit smoked drugs (methamphetamines) with someone that has active pulmonary tuberculosis. Previous encounters with healthcare services included 2 previous uncomplicated vaginal deliveries & a stab wound to the left chest which required an intercostal-drain.
Examination
SaO2 95% | BP 96/56mmHg | HR 119bpm | Temp 36*C | RR 25bpm
Whilst looking at Mrs V you notice that personal hygiene is poor, she appears acutely ill and significantly distressed.
“Not another substance-abusing woman in labour” you think whilst the melody of moans, groans & monitor-alarm overtones fill the hospital.
- Obstetric & abdominal exam: non-significant with the uterus size corresponding with the 32 weeks given as history.
- Resp exam: decreased air entry in the lower left zone
- CVS: low-output status is suspected – pulse is noted to be of low volume, rapid with cool peripheries & soft cardiac tones. Jugular veins are distended
- Calves: soft, which is reassuring
Investigations:
Chest X-ray
Note: Globular heart with increased cardio-thoracic ratio. (Also note: X-ray being held up against window in true Ubuntu Hospital style due to lack of functional X-ray viewing box / electronic X-rays.. gives clue as to developing world location of patient..)
12 Lead ECG
Notice the electrical alternans in V2, attributed the heart swinging around in the pericardium.
Point of care ultrasound
You grab the ultrasound & start scanning for any clues that might help. You expected a large, dilated, obstructed right heart, because pulmonary embolism just seems to be the obvious diagnosis. You don’t see any pulmonary pathology or even a small pleural effusion you were hoping for. You do a quick subcostal view to look at the heart and pericardium and see this surprising finding.
Management
Yes! You diagnose your first cardiac tamponade at Ubuntu hospital and with a quick, perfectly placed stab of a largebore-needle under ultrasound guidance another life is saved in Ubuntu Hospital!!!
Diagnosis
- Working at Ubuntu Hospital your number 1 differential is TB pericarditis as you acknowledge the major difference in the aetiology of pericardial effusion in developed vs developing countries.
- TB accounts for 69% in developing countries compared to only 4% in developed!
Outcome
- After pericardiocentesis – admitted to the obstetric highcare unit for cardiovascular & fetal monitoring.
- Diagnosis of HIV infection was made with a CD4 count of +/-500 & high viral load.
- Whilst awaiting culture & biochemistry of pericardial fluid she was started on standard 4-drug TB regimen as well as 10mg Prednisone on advice of the cardiologists.
- Day 4: Her stay was uncomplicated & she spontaneously went into labour, she delivered a healthy female infant via C-section with no complications.
- Day 6: discharged from the highcare to the ward.
- She was kept for another 14/7 of observation in the medical-obstetric ward, discharged with no recurrence of the tamponade, only a small residual uncomplicated effusion.
- 3 sets of sputum were negative for TB (?poor technique/non productive cough), as well as TB culture from the pericardial fluid. Cytology revealed scanty atypical cells of uncertain origin. Thus the diagnosis of TB not microbiologically proven, but favourable response on anti-tuberculous treatment prompted a 9 month course of TB treatment.
Dr Neville Vlok
2nd year intern in Johannesburg.
Budding critical care physician
Other interests: prehospital emergency medicine, PoCUS, photography, travel & a good bottle of red wine.
“How to get brave: The three steps for implementing change” with Almero Oosthuizen
https://badem.co.za/wp-content/uploads/2015/09/IY-Fires-1.jpg 3000 1714 Jo Park-Ross Jo Park-Ross https://secure.gravatar.com/avatar/d0351afdbac39f9910e9004b40381265?s=96&d=monsterid&r=gPodcast: Jo Park-Ross and Almero Oosthuizen
Are you keen for change? Not sure how to be part of the change you think is needed?
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This is just the beginning, relish the challenge!
Cover photo of fire in a Cape Town informal settlement. Photo by Matthew Rosenberg.