Lightning strikes

1-2 Dec 2008:

Monday brought another day at Greys Hospital with Dr Gounder, the former Edendale registrar turned private doc who attends at Greys a couple days a week. We saw another pacemaker insertion in the morning… but this one was more complicated, as first he entered an artery instead of a vein, and then later the patient had sustained ventricular tachycardia (a bad heart rhythm) upon pacer insertion. He stayed stable and talking to us throughout, but it probably lasted for 5-10 minutes before it stopped. Suboptimal. Since this case took longer than normal, we were left with less time for morning rounds, which meant they were less interactive and less didactic, which was also suboptimal. Alas.

That evening Rachel and I again fulfilled our obligation as part of the Zulu meal plan to cook, and we chose to do a Mexican night. I made veggie quesadillas (mushroom, tomato, avocado, cheese, and kidney beans since they have neither black nor pinto beans here), and Rachel made tacos. They had never tasted anything like it, and they liked it. Their reaction to the crispy taco shells was “this tastes like Doritos” – they assured us this was a compliment. We taught them gin rummy as an alternative to Go Fish, but this was complicated by the fact that the deck is missing a king, a queen, and a two (easier to work around in Go Fish). I spent a fair bit of time that night preparing my talk on the HIV transmission paper before turning in.

Tuesday we went on another Red Cross trip (driving instead of flying again), this time to Christ the King Hospital in Ixopo. I enjoyed exploring the region featured in Cry the Beloved Country; it was indeed an area of beautiful green valleys and rolling hills. Fortunately the hospital was not as bible-thumping as its name might have suggested. We again started the day with the third iteration of our sepsis talk, and we probably got the most engagement on the subject that we have had on these trips. It evolved into a discussion of how to manage medical illness in resource-limited settings where blood products, monitoring, and opportunity to mechanically ventilate are scarce. We then saw a lot of patients on the male and female wards; the two medical officers had very different presentation styles, and I was again struck by how much the manner in which a patient is presented affects the ease of providing input for a consultant. Lessons there beyond medicine, I’m sure. We were again able to provide input on many of the patients. One had been admitted overnight and was septic; the medical officer put our talk into action right away, which was good to see.

Another interesting and sad case was a woman who had been brought in having collapsed a week earlier. She had since been functionally quadriplegic and was being treated as a stroke patient. We examined her thoroughly and found her able to open her eyes to voice, cough, and track sounds with her eyes, but she seemed unable to make any other movements with her limbs. Reflexes were normal throughout. I asked how they felt a stroke might explain these symptoms, and they weren’t sure. Our best guess is that she had “locked-in” syndrome, an unusual and devastating type of stroke of the basilar artery that feeds the brainstem, leading to loss of cortical control of the body. Patients in this state can open their eyes and perceive the world around them (as she seemed to be able to do) but not move at all. This is the type of stroke described in “The Diving Bell and the Butterfly”, a book (and recent movie) by a French magazine editor who actually suffered this type of stroke. He “wrote” the book thanks to a speech therapist who heroically devised a way for the patient to communicate using a card with letters and a series of blinks. She would scan her finger over the card and when she came to the letter he wanted to write next, he would blink his assent. Thus, letter by letter (!), he wrote the 100-page book that was published within a few days of his death. In any case, this was our best shot at explaining her symptomatology, and we quickly arranged for transfer to a hospital with Neurology and an MRI and CT scanner for diagnostic purposes. Sadly, after a week of symptoms, if we are correct, nothing can be done to reverse the damage.

After seeing the inpatients, we wandered over to the outpatient department to see a select set of patients who had been referred to the attending clinic due to difficult management issues. Again, I found it more uplifting to see ambulatory patients who were overall quite well. We saw patients with cardiac issues or difficult TB management that were beyond the training of the NPs or residents who normally see them. After this, we had a quick meal and headed back to PMB.

On the way, it began to rain, and as we descended into a valley approaching PMB, I saw a bolt of lightning strike a hillside in the middle of a bunch of homes in PMB, followed closely by thunder. When we got home, the lightning and thunder were becoming more frequent and closer together, and the thunder built in intensity. Around 5 pm, as I walked past the doorway, I saw a flash touch just outside the door, heard a staticky sizzle, and immediately afterwards heard the loudest thunder I’ve ever heard. The lights immediately went out in the house. Two minutes later, it happened again – the flash, the simultaneous sizzle, and the immediate roaring thunder. We had been hit by lightning not once, but twice! Doesn’t that define an unlikely event? Upon inspection, it seemed to have hit the electrified fence that surrounds the house. Turns out the power went out because the surge tripped a circuit breaker; once I flipped this back on, the lights (as well as the internet’s warm glowing warming glow) returned. But the motorized gate to our house no longer worked, and a look at the wiring showed some black, charred connections. Unbelievable!