Читать книгу Postmortem - Maria Phalime - Страница 7

I graduated from the University of Cape Town (UCT) in 1999, one of the nearly 200 students who made it through the six years of rigorous study. At our valedictory ceremony one of our professors remarked that only 75 per cent of us would still be practising medicine in ten years’ time. I was taken aback, baffled that anyone would go through all that training and then not use it. I didn’t yet know that there was a big difference between studying medicine and being a doctor.

I loved studying. When I first arrived at UCT in 1991 I enrolled for a Bachelor of Science degree. I’d been accepted to study medicine at Wits University in Johannesburg, but I was fixed on moving to Cape Town and starting over, even if it meant taking the long road to my goal. On the first day of lectures the head of the science faculty gave a speech that I imagine was his standard warning to all new students at the beginning of each year. “Many of you are here because you are hoping this will get you into medicine. I’ll say it now – forget it!” he said.

He couldn’t have known that his attempt at tempering our expectations was just the kind of challenge I thrived on. I studied hard, my eye constantly on the ultimate prize – a place at the acclaimed UCT Medical School. I was fortunate to be awarded a full bursary by the British Council during my first degree; it helped to ease the financial burden on my mother. I sailed through to my graduation in 1993.

My education wasn’t only confined to the lecture halls, though. I partied as much as I studied; on most weekend evenings you’d find me deep in the middle of a dance circle at a residence party or nightclub. But I never allowed my social life to derail my mission. Come Monday morning I’d be back in the lecture hall, diligently pursuing my dream.

When I was accepted into medical school after completing my BSc I was elated. At last all the hard work had paid off; I was on my way to becoming a doctor. I threw myself into my studies, starting with the three pre-clinical years that formed the foundation phase of our training. Here we were taught about the body’s anatomy and physiology, about the chemical and hormonal processes that allow the various systems to function as a co-ordinated whole, and we gained an understanding of the different ways in which these systems could fail.

I was in my element. My analytical mind was amply stimulated by all the theory, though a part of me yearned for the onset of the clinical years when we would put the theory to practical use. Aspects of what was to come were slowly introduced, though in a highly sanitised form. In our second-year anatomy course, we were assigned cadavers to dissect as part of the practical component of the subject. We worked in small groups, and each week we would come back to our designated cadavers to work on a particular part of their anatomy, dissecting the muscles, nerves, vessels and organs that we had read about in our textbooks. In addition to the cadavers, each group was also given a complete set of skeletal bones to study. We spent hours familiarising ourselves with each one, studying the various grooves and prominences where blood vessels and nerves ran and where muscles, tendons and ligaments attached.

We would chat and laugh among ourselves while working on the various anatomical structures; I imagine an outsider looking in on that scene would think they had stumbled on a bizarre satanic ritual conducted by deranged people in white coats. Such was the case when a fellow student’s domestic worker caught a glimpse of a medical student’s often-mysterious learning methods. My classmate Philippa* had taken her group’s bones home, thinking nothing of having human remains in her living space. Unfortunately when her domestic worker came to clean the house she made the gruesome discovery and jumped to the conclusion that either foul play or witchcraft had taken place. The police were notified and Philippa was at pains to explain to them that the bones were in fact her study aids. It was only when the university authorities verified Philippa’s assertions that the police decided to abandon their investigation. The domestic worker was not convinced, however, and she was never heard from again.

At first it felt odd having a dead person on the dissection table in front of me, but that feeling quickly passed. I imagine the brain adapts to these seemingly abnormal experiences, slotting them into compartments so that we are able to attend to the task at hand. This desensitisation was aided by the formaldehyde treatment that the cadavers were given in order to preserve them. It gave the tissues and organs a muddy grey colour and the skin a waxy consistency, and this made it easy to forget they were once infused with life-­giving blood. We were never told anything about the cadavers – who they were, where they’d come from, how they’d died – so I guess it was easy to fool myself into thinking that they were never really human.

I never thought to question the wisdom of my being in that environment, given my previous history with death and loss. I was ambitious and determined, and I operated almost entirely from my intellect, disregarding or rationalising away any hint of discomfort that arose. I was so wrapped up in my ideal that even when fate opened the door for me to make an early exit from the medical profession, I failed to heed the warning.

One evening during third year I was required to spend a few hours in the emergency room at Groote Schuur Hospital. I was there as an observer; the exercise was intended to give us a preview of the drama we would face once our clinical training began in fourth year. I stood nervously in the busy casualty unit, quietly observing the buzz of activity around me as patients were wheeled in and doctors rushed from bed to bed, performing life-saving manoeuvres that I didn’t yet understand. One doctor noticed me standing there and she paused momentarily from the notes she was making in a patient’s folder.

“What year are you in?” she asked.

“Third year,” I responded.

“You’ve still got time. Get out, now! I mean it,” she barked before turning back to her work.

At first I thought she was joking so I laughed. But the resignation in her eyes and the desperation in her voice told me she was dead serious. I quickly dismissed what she’d said and forged ahead on my path. There would be countless opportunities that would edge me back to that door.

Fourth year was a turning point in my life as a medical student as it marked the start of the clinical training. From then on the most important learning happened at the bedside, where we learned to connect with the patient, to take a clinical history and to examine the various systems in order to arrive at a diagnosis. We were taught that, just by speaking to patients and examining them thoroughly, we could arrive at a differential diagnosis – a shortlist – of the likely cause of their complaints. Special investigations such as blood tests and X-rays served to exclude certain possibilities and to confirm the definitive diagnosis.

We were based at Groote Schuur Hospital and rotated to various primary- and secondary-level hospitals and clinics in small groups. Each subject was taught over an eight-week clinical block or module, and our rotations depended on the blocks we were assigned. We would all meet back for lectures at Groote Schuur on Friday afternoons, an occasion few of us relished. We were, after all, still young people with active social lives to pursue.

I learned a lot more at the bedside than just the science of medicine. By observing the more senior doctors I got to see that managing patients was much more nuanced than our textbooks suggested. How far to pursue a diagnosis, how aggressively to treat, when to provide supportive treatment instead of aiming for a cure . . . These decisions required a level of clinical judgement that could only come from experience.

Fourth year also introduced us to the complexities of dealing with patients. The doctor-patient relationship requires stepping into the personal space of a patient in a way that you wouldn’t ordinarily do with a complete stranger. Intimacy is established from the get-go, unlike in most relationships where it is allowed to develop over time. In this intimate space you are confronted not just with the organs and systems to be treated, but you also encounter the person behind the patient, individuals with their own fears, hopes and crises. This can be a tricky milieu to navigate, as I learned in my primary health care rotation.

The intention of the subject was to introduce us to a reality that was sometimes easy to forget when working in the confines of academic medicine – that patients’ social circumstances and psychological make-up contributed to the symptoms that brought them to seek help at a health care facility. A seamstress who spent much of her working day hunched over her sewing machine and worrying about the job cuts sweeping through her industry would require a different approach to the labourer whose back pain had come on suddenly and was associated with a tingling sensation down the back of his leg. This so-called bio-psychosocial approach would enable us to be aware of the patient as a physical, psychological and social being and to understand their challenges better so that we would be more equipped to help them.

We were also encouraged to work in partnership with patients in order to bring about the desired improvements in their health. Traditionally the doctor-patient relationship saw doctors positioned at the superior end of a paternalistic relationship. In this role they doled out instructions, castigated patients for perceived wrongdoing and mumbled incoherent and often poorly understood diagnoses in doctor-speak. This did little to empower patients to take an active role in looking after their own health. We were taught to establish a therapeutic partnership in which patients became active partners in the management of their health.

My group was posted at the Heideveld Community Health Centre, where we saw patients at their first point of contact with the health care system. Most had minor complaints, which was consistent with studies that have shown that only one per cent of patients presenting to health care professionals have ailments serious enough to warrant hospitalisation. As I saw patients, I was conscious of the importance of building a therapeutic relationship and I paid particular attention to the psychosocial factors – such as their home environment and psychological stressors – that could be contributing to their symptoms.

On the third morning there a male patient in his early forties came into the consulting room complaining of intermittent chest pain.

“I’ve been here before with this, Doctor, but nobody can tell me what’s wrong,” he said. He looked distressed by this unexplained symptom.

I took a thorough medical history, asking questions about previous illnesses, medication and treatments. In the bio-psychosocial approach it was still important to exclude biological factors related to a patient’s symptoms; it would be disastrous to miss a potential heart attack while asking a patient how he felt his social circumstances could be contributing to his pain. As the consultation continued I learned that this man was otherwise well, and he had none of the medical conditions that would predispose him to heart disease like high blood pressure, diabetes or abnormal cholesterol.

Then I began to probe further, delving into the psychosocial factors. “What do you think is causing this pain?” I asked.

“Well, it might have something to do with the stress that I’ve been under lately,” he said. I encouraged him to continue.

“It’s my wife, Doctor. She’s causing me a lot of stress.”

“Tell me more about what’s going on between you and your wife. How is she causing you stress?”

“Well, she’s always complaining about money. She says there’s never enough. What can I do? I’m trying my best,” he said.

I nodded and immediately his posture relaxed. He sat back in his chair and smiled for the first time. The relief was evident on his face. “I’m glad someone is finally listening to me,” he said.

I was thrilled and proud of myself. I’d made a breakthrough with this man by taking his complaint seriously and probing deeply enough to uncover the real cause of his complaint. Too often he’d been dismissed with the assurance that there was nothing wrong with his heart.

I still needed to examine him, even though the history pointed to family stressors as the primary factor contributing to his symptoms. He continued to smile as he took his shirt off and lay on the examination table.

I was still a novice at examining patients so I started from scratch, beginning first with a general examination before concentrating my focus on his chest and cardiovascular system. I was slow and methodical.

“Do you have a husband?” he asked suddenly.

I was startled; I hesitated for a few seconds but then dismissed the question as mere small talk.

“No,” I said and I continued my examination.

“You’re a beautiful woman,” he said. He looked straight at me. My hands were flat on his naked chest.

I may have been a novice doctor but I was a seasoned woman. I knew a chat-up when I heard one. I said nothing, and continued the rest of the examination in silence. His mouth was curved in a smug grin throughout, and I felt that the therapeutic partnership I had tried so hard to establish had left me very exposed.

Initially I was upset and confused. I didn’t know if I’d acted correctly, what recourse I had in that kind of situation. Should I have stopped, refused to continue the examination? Or perhaps I should have reported him to the doctor in charge?

By the time I got back to medical school, however, I had rallied my internal resources enough to view the incident as a learning opportunity. I wrote an essay on it in which I discussed the complexities of the evolving doctor-patient relationship and the challenges that women faced in what was previously a male-dominated profession. I wasn’t going to be beaten by this man who couldn’t see beyond my gender. In many ways this single-mindedness served me well. I was a fighter, and I used this trait to push my way through.

Though I was defiant the lesson of that incident stuck in my mind. I realised that as educated and accomplished as I was, in some patients’ eyes I was still just a woman with a petite frame and a friendly smile. Getting too close to them could land me in trouble.

In fourth year I also learned the value of a healthy sense of humour. As I would later appreciate, sometimes laughter was the saving grace that helped to diffuse the pressure of the environment in which I worked.

I was introduced to the field of obstetrics in the second half of the year. I’d been looking forward to the eight-week block as I would now take on the responsibility of delivering babies.

At the start of the rotation we were each given a blue book in which to record the various procedures that we were required to perform or observe. There were fifteen standard deliveries that we had to manage; in addition we had to observe complex procedures such as forceps deliveries, episiotomies and Caesarean sections.

Unfortunately I began my rotation at Mowbray Maternity Hospital, a secondary-level maternity hospital in the southern suburbs of Cape Town. Women who came to Mowbray were referred there from the clinics with complications such as prolonged labour or gestational hypertension. Many of the deliveries required intervention by an experienced doctor, and there was little opportunity for the students to manage their own deliveries. As a result, by the fourth week I was running behind on my procedures, while I knew that my colleagues at the clinics had already filled their delivery quotas. I was extremely competitive in those days and when my turn came to go to the clinics, I went in like a dog after a bone.

I was posted at the midwife obstetric unit in the Cape Flats township of Mitchells Plain. As the name implies MOUs were obstetric units run almost entirely by midwives. They were primary health care facilities, often physically located on the grounds of a local clinic. Here women with uncomplicated pregnancies gave birth naturally with little medical intervention, but with the added advantage of having trained personnel on hand in case of difficulties. There were usually no problems; women would arrive in labour, give birth, nurse their babies and then go home.

I went into that first day at the MOU determined, but I needn’t have worried. Babies were just dropping out, some quite literally. I had a field day in the delivery room. In many ways I wasn’t really doing anything. I was reminded that in days gone by women would go off on their own to give birth, that their bodies knew what to do. What modern medicine was doing was improving the chances of survival for both mother and baby.

The midwives were skilful and efficient, and their guidance was invaluable to my learning. I clocked up many deliveries and at some point I was elated when I realised that I’d have more than enough for my blue book.

I’d been working non-stop when a woman arrived in the late afternoon. She had been in labour for a number of hours, but her labour pains weren’t the only discomfort troubling her. She had taken a laxative some time before, and the active ingredient was starting to work.

For the uninitiated, it is important to understand that the sensation a woman feels when she is in the final “pushing” stages of labour is similar to the sensation of needing to defecate. We would use this fact to our advantage to coach inexperienced mothers through the labour. “Push like you want to poo-poo,” was the mantra, and once they got over the embarrassment of what we were asking them to do, they settled into the process and pushed their babies out.

Sometimes women took laxatives in the early stages of labour to clear their bowels in preparation for pushing. Timing was key, of course, as it was important that the laxative had completed its work before the pushing phase began.

The woman who came into the MOU that afternoon hadn’t managed the timing correctly. She was now in full labour and the laxative was just kicking into action. As she started to push she did what her body naturally demanded in order to push her baby out, in the process also evacuating what seemed like the entire contents of her alimentary canal onto the bed in front of us.

The midwife and I stood at the busy end of the bed in silence, heads down, doing what needed to be done. The woman was oblivious to anything except her own pain; I concentrated my focus on the baby orifice while the midwife worked double time to clear away the semi-solid faeces that were emanating from her rear. Sheet after sheet of incontinence dressing was changed as she continued to push.

I was relieved when her bowels were finally empty and we could concentrate our energy on helping her to give birth to her baby. My relief was short lived, though; when the next contraction came it was accompanied by an almighty explosion of wind from her anus.

“Sorry,” she chimed.

I glanced up at her face and she looked genuinely embarrassed. I burst out laughing; here this woman was, having just emptied her bowel in front of us without so much as an acknowledgement, and now she was apologising for a fart! Tears streamed down my face as we worked, and I was aware that given the earlier events, laughter was all that had kept me from crying.