The lady who was loosing blood from an unknown source

30 year old female whose folder was locked away in the closed down out patient department with known #neurofibromatosis #bellow knee amputation of left leg secondary to neurofibroma eroding into bone #spinal fusion with prothesis broken at coccyx. Presents with collapse at her physiotherapy out patient appointment. She arrives at casualty with a blood pressure of 50/20mmHg, pulse 160 beats per minute, she was apyrexial and was not in respiratory distress. She was pale with cold, clammy extremities. Her respiratory system was normal and her cardiovascular system showed signs of shock: tachycardia, hypotension, weak / absent peripheral pulses. Her heart sounds were normal. Her abdomen was soft and non tender. She had no guarding, no rebound and no organomegally. She had no neck stiffness and her pupils were equal and reactive to light. She was confused, with a decreased level of conciousness. Her haemoglobin was 9.1g%. She was resuscitated, receiving 7 litres of fluid without any marked improvement in blood pressure. She reached a point where she was no longer protecting her airway and required intubation. Blood results came back showing her haemoglobin dropping to 4g%. Her white cell count was 45.0, CRP 1.2, procacitonin < 0.5, lactate 4-5 and eveything else was unremarkable. A nasogastric tube was passed which drained stomach contents and no blood. There was no blood per rectum or per vagina. An radiology registrar was called. Her supine chest and abdomen x-rays were unremarkable and an ultrasound of her abdomen showed nothing of note. The medics insisted it was a haemorrhage and surgeons insisted it was a sepsis. Her folder was retrieved the following day showing that she had: #recurrent abscesses on left inner thigh #previous fracture left inner thigh She was sent to ICU where she was ventilated and kept on quite a high dose adrenaline infusion to keep her blood pressure high enough to ensure her brain was oxygenated. She received more than 10 units of blood yet her haemoglobin remained low and no site of bleeding was found for 4 days. She was found to have a left ruptured popliteal artery pseudo aneurysm. She was taken to theatre where the aneurysm was occluded using a balloon catheter and the aneurism was repaired. She lost 4 litres of blood in theatre and received 11 units of crystaloid, 7 units of blood and 1 megaunit of platelets. She remains restless yet not fully concious in ICU following the recent withdrawal of sedation.

The end of my Valkenburg Block

My time rotating through Valkenburg was come to its end. I really enjoyeed my month rotation in the male high care ward. On Tuesday and Wednesday I saw all of my patients.

The gentleman who was keeping the peanuts and an olive in his mouth is unchanged, though I did find out that he has been living in ward 6 for the past 30 years. They think that he has stomach cancer. He had a barium swallow, which was suspicious, but he keeps not consenting for the gastroscopy. He will probably die soon.

The perseverating gentleman who got stepped down to ward two, then his family didn’t come collect him for weekend leave and he started fighting with the nurses and causing problems so they stepped him back up toward 4. I assessed him and felt that he was apsychotic. He has an underlying intellectual disability, and I felt that he was at his baseline and needed discharge.

The young man with the second or third schizophrenic episode remains virtually unchanged since I started working at Valkenburg a month ago. He is apsychotic, but has absolutely no insight into his condition and remains guarded. Last week he has this strange delusion that he was going to be able to support himself by blogging and getting corporate sponsorship. The delusion has now become an overvalued idea. He remains in ward 4 and will stay there until he gains some insight.

The psychomotor agitated gentleman in ward four is settling down nicely. He is still suffering from akathesia and tardive dyskinesia. He is calm, engages well and I don’t think he’s psychotic.

The floridly psychotic gentleman with the good insight went on leave for a weekend and he was gone for a very extended period of time, I think over a week. He came back and had a good report so we discharged him.

A gentleman said that his brain was melting and he had a genie on his cock. When he came into the ward round for an assessment he bent forward to show us where the genie was on his head. Another patient, Mr Emergency Delta March has remembered his name, and more recently, his date of birth. A patient in ward 4 no longer feels that his blood is eating him. He did say “I don’t understand why my brain is being roped and scalped. My jugular vein has been slaughter and I don’t think my Adam’s apple can handle it.” He then requested ointment for his Adam’s Apple.

A Bangladeshi gentleman with psychotic depression and a 20 year substance abuse history of heroin and codeine containing cough mixtures was transferred to ward 4 but had to be sent back to high care because he continually made inappropriate sexual comments at the nurses and was also touching them inappropriately. He developed multiple medical complaints which were probably drug seeking behaviour.

I enjoyed working with the the team in which I was placed. Our consultant was an amazing man and the registrars were superb.

Today I wrote my written paper, which was quite straight forward. The oral exam also went well.

I upgraded to 4gigabytes of RAM.

I am currently playing Warcraft 3. I am really enjoying it. I was running it in Wine, but I kept getting this memory error when I saved. After searching the internet for quite a while there seems to be no good solution.

Lolita was in touch with me a few days ago which was nice. My reply to her message was a bit too expressive.

I saw a friend of mine and we were discussing this girl I was with a while ago. She has schizoid personality disorder. We were discussing how she was becoming so withdrawn and nobody ever sees her and she failed uni last year. I then got incredibly worried that she was developing schizophrenia and that there issues she was experiencing were a prodrome. After worrying for about 2 hours and actually contacting her for the first time since she ignored me on my birthday, I realised that schizoid personality disorder is so named because it resembles the prodrome of schizophrenia.

I am happy to be on holiday for the weekend. I am still feeling quite lonely, but not that bad. I need to redo a part of my family medicine portfolio this weekend, to which I am not looking forward. I start surgery on Monday

Feeling rough after a rough weekend

Shoo. It has been a rough, rough weekend.

I have not been sleeping well. I know that I do sleep in the night, but I continuously wake up giving me the impression that I am not sleeping. I wake up at 5am every morning for no reason and then I sometimes can doze and sometimes cannot fall asleep again. Eventually my legs get stiff and sore and I have to get up. On the nights when my medication does work properly I get quite strong alpha sympathomimetic effects, peripheral vasodialation and completely blocked nose. I often wake in the nigh with my mouth being completely dry. A while ago I started supplementing my meds with phenergan. I started at 5mg and moved quickly up to 25mg, which is now not working. For the next few days I am going to take phenergan 25mg + allergex 4mg.

On Friday I did not go into university. I was meant to go in for a set of three group presentations. I did not go in because I cannot concentrate in group presentations, I do not gain anything from attending them and get very frustrated and angry when they run overtime. I went to go see the ophthalmologist who tested my eyes very thoroughly and found nothing wrong.

I received two disappointing and worrying phone calls. One was from the doctor who facilitated our group during our family medicine block telling me I need to re-do part of my portfolio. The other was from the doctor who runs the student lead teaching that I bunked telling me she wants to meet me on Tuesday.

I pushed myself incredibly hard this weekend. I covered a lot of work. I went through 9 old exam papers, made a hand-out on delusional disorder and type up 3 patients. I still have another patient to type up plus I need to add bits and pieces to the ones that I have already completed.

I had dinner and saw the movie Milk with some friends on Saturday night. It was enjoyable. I felt depersonalised and socially inept the whole evening.

Yesterday I went to another friend for an hour just to get out of the house.

I am very lonely and very unhappy at the moment.

I have a cold

I slept quite well last night. I had a great bath with a hot facecloth over my eyes. I woke up early in the morning again. I have a runny nose.

On my way to uni I dropped off some recycling and bought tissues and some food for my friend in residence.

I attended a ward 2 pre-discharge ward round which was quite entertaining, though I do not remember the specifics.

I dashed through to Rondebosch where I went to the bank and bought some fruit for my friend in residence. I also went to UCT where I printed a whole lot of stuff.

I got back just in time for the ward round. We heard about two patient. One who has a previous head injury, hectic substance abuse history and who is currently dementing. The other patient has depression with psychotic features. Though the round was entertaining, it was not riveting.

After the ward round I went to smoke nag with my friend in residence. We had a great time and she was really happy about the food I brought her.

I have blown my nose at least 40 times today. It is sore. I am tired.

Day back to Valkies after the Easter Long-weekend

I slept very well last night, though I did wake up at some ungodly hour and couldn’t fall asleep again, though I was feeling quite relaxed while I tossed and turned, which is abnormal. I think the bathing is helping me sleep in the evenings.

This morning we had review ward rounds in the high care ward, ward 6 and ward 4. They were interesting. Of my 5 patients two were moved from high-care to ward 4 and the other two remained in ward 4 and ward 6.

My floridly psychotic gentleman in ward 4 is still floridly psychotic and still in ward 4. He is dressed normally, besides the pair golden sunglasses. His mood is ethymic and his affect is reactive. His speech is normal. His thoughts are logical He has numerous bizarre delusional systems and auditory and visual hallucinations. He experiences passivity phenomena where he feels his thoughts are broadcast to others. He feels that other people can insert thoughts into his head. He thinks he is a robot. He hears voices from above, bellow and inside his head. He still see cats which turn into women and talk to him. His judgement is average. He knows he is sick and has complicated advice regarding changing his medication which is probably some form of delusion.

My patient who remains in high care is still not well. He claims to be feeling well, sleeping well and eating well. He denies any side effects of his medication. He is dressed in a Valkenburg uniform. He engages poorly and mumbles so badly he is often incoherent. He was severely psychomotor agitated and he had a fast opening and closing tremor of his jaw. He constantly crossed and uncrossed his legs. His mood was elevated and his affect was blunted. His speech was incoherent, though not pressured. He was formally thought disordered with derailment, tangentiality and circumstantiality. The content of his thought was difficult to assess. He denies any hallucinations. His judgement, cognition and insight were poor.

Both of my two patients who were moved from high-care to ward four were essentially the same.

The one was a well groomed young male. His mental state examination was entirely normal. He denies all documented past psychotic symptoms and wants to be discharged home.

The other was a poorly groomed young male with food on his face. His mood was euthymic but his affect was blunted. His speech was repetitive, but normal in volume and was not pressured. He responded to almost every question with a request to go home. It was difficult to assess the form and content of his though, though he did definitely exhibit perseveration. He denied any delusions or hallucinations. His judgement and insight were both poor. On termination of the interview he became very invasive and aggressive demanding discharge and money. He also interrupted my subsequent interview with similar feelings. I want to assess him for an intellectual disability.

We had teaching in the afternoon. The consultant who runs the teaching is somebody who I dislike intensely. She is one of the fattest people I have ever met. She constantly goes off topic and gives her opinions about random controversial topics and then goes on and on about them. She really frustrates me intensely. The girl I am working with and I did a presentation on delusional disorder. I need to type up a hand-out for next week.

I collected a a 2.5” external hard drive enclosure and a webcam which I had bought on my way home. Lolita and I chatted briefly on MSN. She is well. She has a boyfriend. I felt sad for about 5 minutes. Her phone was lost or stolen, which is why she has not been replying to my text messages.

I spent a while trying to get the webcam to work. There is some issue with the webcam and the Intrepid Ibex. I will only start dealing with the issue once I have upgraded to the Jaunty Jackle.

I am finding that I want to go to bed very early, but then I try to force myself to find other things to do to fill my time so that I don’t go to bed early and wake up even earlier than previously. I have good sleep hygiene at the moment. I am not napping in the afternoon.

The emptiness

Sometimes, especially towards the end of the day, or when I am tired, or when something rough happens I feel empty. Empty is a weak way of describing it, but I could probably write an entire book on the feeling and it still would not describe it totally.

It is the emptiness of space without any hope of a big bang.

It is the the last dying thought of a mother who failed to save their family.

It is that intimate knowledge of all your shattered dreams the moment before your death.

It’s that puppy of yours that just died in your child’s arms, scarring him for ever.

It’s the summation of all my rejections, all my shattered dreams, all of my desperate hopes, all of the loss, all of the death all of the nights spent truly alone with know possible end or escape

It is.

It is within me.

It hurts.

Chasing Shadows

About three weeks ago I engaged one of my single female friends in a conversation about my chronic failure to enter into intimate relationships. I spoke about my honest feelings about this. About my sense of frustration, hopelessness, failure, sadness, loneliness and pathos. She spoke about how she cannot find somebody she likes enough. Ultimately the conversation left me feeling hollow and empty. I had been reminded about my failures and felt very lonely and shit.

My patients might not be well, but neither am I. My days have the long, empty hollow quality to them. Everything I feels like it is just there to fill the gaps between sleeps. I feel like I spend my time chasing the shadow of hope that some girl will like me, or running away from the chase saying “No I must stop chasing,” but my heart is never in it.

For example I thought “I like this person. I will try to make plans with them. I will send them neutral smses regularly keeping in touch and trying to arrange plans.” Then I smsed them routinely at the beginning and end of the weekend asking how they were, what they have been doing and whether they wanted to go out for coffee. No I have a stopped smsing them because I feel like an idiot for investing time and effort into this empty hope. I feel stupid and pathetic for not succeeding. I should never had tried.

I’ll go to facebook and look at photos of girls I like. Just look, nothing hectic. But I’ll go back and look again. I look at the photos of the people who don’t care, of the friends I’ve lost, of the relationships that’ll never be, of the live partners that cannot exist and I will feel terrible and empty and alone.

On Saturday my resolve broke and I smsed Lolita to see if she wanted to make plans. As my day unfolded I kept her posted about what I was doing. She never replied and each sms I sent I got more anxious and felt more down. I eventually sent her a message when I was drunk asking her to just email me or send me an instant message to say hi and everything ok. Now whenever I’m online I look for the message it never comes.

Two weeks ago I went twice to Kenilworth Clinic to speak to the counsellor there who knows me better than I know myself. We spoke at length. The conclusions we reached were that I don’t believe, on an emotional level, that anybody will ever be able to meet my emotional needs. That I give to much and don’t know how to take. That I don’t look after myself and that I am not kind to myself. There was little advice about how I could change that…

At the moment I am sitting at my PC. Skype and messanger are open and my mail client is regularly checking the server. I see contact, comfort and care. I don’t find it and I feel empty and lonely

The rest of the long weekend

Once I had returned from the third seder I spent quite a while worrying about a friend of mine. I don’t understand why she is so busy. She is a fantastic women, warm, friendly, intelligent, capable, funny, beautiful, etc. When most people tell me they are too busy to see me I don’t believe them and I try to find out what there days are actually like. This girl is actually too busy. She is working 3 jobs, doing uni and habo. My gut feeling is that she is trying to run away from something. I just wish I could help her…

On Saturday I woke up at 10h30 and went, via the local supermarket, to an Italian friend of mine that with whom I grew up. She is studying in Italy at the moment. She and I have not been in touch for ages, but we’re always on good terms. It was great to see her. Her family had a Mediterranean brunch as a send-off for her, which was great. I saw lots of other friends.

I then went to the Bayit where I had some fun annoying a working tsevet. I then sat in one of my friend’s cupboards reading a book until he was done with his meeting. We had a nag then he got frustrated and left. I stayed there chillin’ because I was expecting to see another friend but she cancelled on me at the last minute.

My resolve cracked and I contacted Lolita who ignored me which made me feel anxious and shit for two days. I am frustrated that I still have not heard from her.

One of the guys at the bayit, who is far from a stable, well-adjusted human being, started opening up to me about some issues and I had to sms somebody to come and save me. I drove one of my friends who’s in Joburg for the year back to his house where he got changed and then we missioned though to Constantia for the 4th seder.

As I arrived I had an embarrassing and ridiculous fight with one of my closest friends about nothing. It frustrates me how I am just so unstable sometimes. I know why I had the fight with him, but I behaved so pathetically. I arrived and just started shouting at him. Fuck I feel like such an idiot.

After discussing it for a while everything was resolved. Two of our friends who are notoriously late arrived and the 8 of sat down to a pesach “pub” quiz and then a good meal. I got drunk and had a really enjoyable night.

On Sunday I did some university work and visit a friend of mine in Milnerton. I also spent a very long and frustrating time trying to install an operating system on my dad’s Acer Aspire One. NTFS formatted flash drives do not boot. I don’t care what anybody says. They done. I found two really excellent articles in the net about improving the speed of the Netbook.

After two days of work it is now working well and I am happy with it.

Today I had a relaxed day. I slept in and finished my portfolios for Obs and Gynae. I stopped by at large local shopping centre to get a new lanyard for my cellphone and a smoothie. I finished installing and setting up the laptop. It was quite a productive day.

I have discovered this new thing which I really like. I enjoy bathing and putting my head under the water and lying in the silence. It’s awesome

Some IT work after a bad sleep

Today I woke up at 4am with my legs feeling sore. I felt as though I had not slept, but had spent the night tossing and turning. After feeling really uncomfortable and sore for an hour or so I got up, checked my email and went back to bed. I still felt terrible. After lying there for a while I got had bath, had breakfast, brushed my teeth and went back to sleep for 3 hours.

Shortly after I awoke I received a phone call from a new client who needed me to sort some stuff out on his mother’s PC. After contacting one of my friends to plan the rest of my day I drove through to town where I spent 3 hours at his house and then another hour dropping the PC off at his mother’s house and configuring it. He was a really pleasant, funny and decent guy.

After quite a frustrating time trying to get the font the right size on his mom’s pc I went down to my car, which would not start. When I turned the key the engine make a single click and that was it. I eventually got two security guards to push-start my car and gave them R20. I went to the video store where I took out Saw III on my friends contract, but had to pay R15. The movie was crap tastic. The plot was confusing and not contained. It was a poor sequel to two brilliant movies.

Towards the end of the movie two other friends arrived and then a third friend arrived shortly after it finished. We spent a good time laughing and talking.

I then drove though to the Habo third seder which was awesome. I saw a lot of people that I have not seen in ages. It was great to catch up and laugh hard and laugh when I wasn’t supposed to but couldn’t control myself. I had fun.

My patients are not well

My patients are not well.

On Tuesday I went through to Valkies where I sat and read my book during a “journal club.” Afterwards there was a little buffet for all the doctors and final year medical students. It is really so nice to be fed. It makes us almost feel wanted. After the journal club the girl I am working with and I went to go see our patients.

There are 5 patients under my care. 3 in the high care ward and 2 in the medium care ward. We started off in the high care ward. My three patients were surprisingly sane. None of the had any hard evidence of psychosis when I saw them, though I wasn’t ready to send them home.

I discovered a mouse under the desk and my colleague and I tried to save it, but it managed to save itself.

My patients in the the other wards are really not well. I do not understand why they are not in highcare and why my highcare patients cannot be stepped down to medium care. The one guy was keeping an olive and 5 peanuts in his mouth. He dropped one of the nuts on the floor. I asked him what it was and he said it was a peanut. I then asked him what he was doing with it. He said that he was keeping them in his mouth and he will eat them later.

My other patient was floridly psychotic. He thought he was Michael Jackson and is not sure if he sleeps at night because “something else is in his head and its not human.” He also thinks that his face is burned, which it isn’t. He demonstrates the passivity phenomena of thought broadcasting and thought insertion. He was also elevated.

There was a long and boring lecture about brain development in twins during which I read my book. I then sat around for over two hours waiting for new patients to arrive. The hospitals that were sending them didn’t bother ordering ambulances so I went home at 4 and worked on my family medicine portfolio. In the evening I saw a good friend of mine. We smoked nag at UCT and then went out for Sushi

On Wednesday I went in a little late. I saw a new patient who I truly do not believe is psychotic. We then had a wardround in the pre-discharge ward. I excused myself and went home with the intention of going to see my GP. My eye balls have been hurting for about a week. It’s a deep seated pain that kept me awake the previous night.

We went to my cousins house for the seder last night. It was a lot quiter and quicker than I am used to, but it was nice to see my family.

Today I slept in and finished my family medicine and most of my obs and gynae portfolio. I also watched cum dog jizz in my hair.