Organ Donation, Unwinding and the Black Market

Organ donation is becoming more and more of an issue. It should have been a huge issue ages ago.

Nazirah wrote a great post about it here. I recently read Unwind by Neal Shusterman. You need to read it. It is a warped and really freaky story. The fictional concept of unwinding is the process of donating an entire live child for organ harvesting, because by the law’s weird rationale, the child is not killed as it “lives on”.

And here’s how it starts:

“If more people had been organ donors, unwinding never would have happened.”

South Africa had an organ scandal a few years ago. And when I went to China last year, people warned me about the black market there.

Disclaimer: I’m not an organ donor. Yet. I want to be. I think voluntary organ donation is a truly wonderful thing. If my dad could see by receiving donor corneas (he can’t, it’s a retinal problem) I would want him to do it. If my mom’s pain could be cured by a donor organ, I would tell her to go for it. But for me it’s a biggish decision that doesn’t just involve me. One I believe I’ll make, soon.

This picture on pinterest inspired me to write this post. It’s a little morbid, but it’s educational and wonderful.

Are you an organ donor? Why or why not? Do you believe the matter is being under- or overplayed?

Can A Pill A Day Prevent HIV?

As medical students, the threat of needle-stick injuries and the subsequent use of Post-Exposure Prophylaxis (PEP) is a constant looming presence. Side-effects are sucky, viral resistance is sucky, HIV is sucky.

I don’t know how I missed it, but apparently there have been some significant trials for pre-exposure prophylaxis (PrEP). The article I found can be read here, and the original paper published in the NEJM is available on Google Scholar.

 

What it comes down to is that the trials were done with cohorts of men who have sex with men and/or transgender women who have sex with men. They were given Truvada, which is a combination ARV of Emtricitabine and Tenofovir. These are both Nucleoside Reverse Transcriptase Inhibitors and they basically inhibit replication of the HI-virus.

The study basically found that PrEP lead to a significant reduction in HIV-contraction. Which is awesome.

But what I want to know, is how does that work, physiologically? If NRTIs prevent viral replication, how can it be considered to be true PrEP? Truvada is often given as PEP. So, perhaps, it’s still just PEP, given before the risky event occurs. But doesn’t this kind of continuous ARV administration bring about a risk for resistance if the person does acquire HIV?

There are some costs attached to PrEP, as with any drug. Which makes it quite likely that the rich will be able to afford it and the poor… will have to stick with condoms.

I want to know about side effects: Truvada has them. Lots of them. But different people react differently to them, as with any drug. Would this be a viable option for medical professionals? Would it be worth it, for medical professionals?

And why on Earth did I only hear about this now?

As always, I’d love to know your thoughts on this – whether you are gobsmacked with me, or you actually have answers to my confusion.

So Radiology Is Kinda Cool?

This week I am on a short radiology rotation.

A lot of people really want me to declare Radiology as a specialisation. The income is ridiculously good compared to the workload and working conditions – even in public South African health care. With the growth of telehealth in South Africa, there are even excellent opportunities to either work from home or effectively have two jobs at one time.

I’ve never been too interested. I am not great at interpreting scans. I like working with patients.

It looked kind of like this picture.

But I have to say, it does have its appeal. We did a barium enema on a one-month old child with a “query obstruction”. The poor little child has had problems since birth and has already had surgery. He was clearly uncomfortable and the abdomen was hugely distended.

We saw a stricture in the hepatic flexure of the colon. If all goes well, he should be more comfortable soon.

Radiology has a lot of rules. I like having rules – and I like being able to break them. So I guess that’s problem (and oddity) number one.

The radiologists are super clever. We attend their meetings, and the way first year registrars just rattle off terms and interpretations is very impressive.

The biggest problem is this: I suck at anatomy. That really is not an understatement. So yeeeeeh…

The most ubiquitous statement we have been hearing is,

“If you are good at anatomy, you will love Radiology.”

My Wish for World TB Day

As posted yesterday, today is World Tuberculosis Day. StopTB has this really cool campaign where you can make your own stopTB poster about your goals for this disease. The theme is “Stop TB in my lifetime”, which I think is an excellent motive.

This is the poster I made:

One is allowed only to click on pre-decided slogans. My real, and most pressing TB issue today, is this:

That health care workers will take greater care of their own lungs. In the Western Cape, where I live, TB is more concentrated than anywhere else in the world. Yet I too often see doctors and nurses walking among TB patients in the wards and examining them without the appropriate masks.

We would not operate without gloves because we are aware of the HIV/AIDS risk. So why do we not protect ourselves as adequately against another chronic disease with severe mortality and morbidity?

To some extent, much is to blame on the government. When I was on family medicine, there were no N95-TB masks available.

So this is my wish: That you will take care of your lungs as you would want your parent or your child to do.

TB Awareness Month

March is South African TB Awareness Month. Tomorrow is World TB Day. I cannot remember a time in my life that I was unaware of this disease, or a time where I was not afraid of it.

I want my patients to be more aware of the risks. I want people to stop thinking that just because they are wealthy or HIV-negative, they cannot get it.

I have seen too many people struggling through horrible drug side-effects.

Today, please do yourself a favour and become more aware of TB warning signs. Night sweats, unexpected weight loss and an unremitting cough should warrant a visit to the doctor.

Clever Patients and Patient Education

During my two weeks in the Rural Western Cape, only two of my patients had finished high school. One was an elderly lady from a privileged background.

It was shocking to see how low the literacy rates were in that little place and how that affected patient education. Medicine compliance, smoking cessation, family planning… it’s tough. Especially with the high rates of FAS in the region (lots of vineyards).

But the biggest lesson was not health education to these patients. Rather, I learned not to slack on health promotion of the more “educated” patients. I look at my class, of whom probably 50% smokes regularly. Intelligent people make stupid life decisions.

I almost skimped on speaking to my patient (who had finished high school many years ago) about smoking cessation. Good thing I changed my mind. Turns out he thinks that puffing eliminates the cancer risk. So we had a nice discussion about oral cancer (yum).

You want to save the world? Figure out why health promotion rarely works. And find a way of making it work.

Lessons in Unexpected Places

You think you know it all when you hit fourth year. Okay, you know you don’t know some stuff. But HIV, TB, childhood illnesses and pregnancy? You do think you know as much as there is to know.

And then you come to a little rural area, and a foreign girl from deep in Africa walks into casualty and requests the removal of some sort of injection from her arm.

And you think perhaps she is delusional, but when you palpate her arm, sure enough there are two longitudinal rods.

There is a language barrier, so after much mixed language and signing, you figure out that whatever this is, is supposed to be a contraceptive.

We know about all the medication, all the hormonal devices, all the barrier contraceptives, all the surgeries. But never, NEVER were we taught about subcutaneous contraceptive devices. The doctors here had no idea what it was either, so we ended up using Google.

Two little rods, can you imagine…

Male Medical Circumcision in Rural South Africa

Last year, I wrote about traditional circumcision and the dangers thereof.

The government has started an MMC-drive. MMC = Male Medical Circumcision. Non-traditional circumcision has its own benefits such as HIV-prevention, STI-prevention and apparently hygienic benefits too.

The goal is also to have traditional circumcisions performed in hospital, where health care workers are trained in the procedure and where infection control is better managed. It will take a while to achieve this in Africa, because having the procedure done in the hospital is often viewed as being “unmanly”.

Yesterday, the clinic in the rural town where I am now did an MMC-outreach. Initially we were only supposed to observe, but our supervisor decided we could assist. Which was totally super cool! I feel so much more confident with sutures and blades now.

I have to say, the patients were remarkably calm for the type of surgery they were going through… and it is done using only local anaesthesia. Brave, brave people.

You may recall that I hated surgery last year. Mayhaps it was just because we weren’t taught so eagerly.

Giraffe Eyes for Great Granny

In a moment of childish impulse, the boy and I decided to watch Disney’s The Lion King.

This movie used to make me cry time after time.

This time, though, the image that gave me goosebumps was this:

My great-grandmother apparently loved giraffes. It was their big, beautiful eyes and long lashes. Such was her admiration that at a ripe old age, my granny who was afraid of thunder walked straight up to a wild giraffe for a photo.

She passed on at the age of 88 – when I was only eight years old. I loved her and she loved me and my siblings – I know that. But I am always a little sad that there had not been allwance for a time where I would be mature enough to bond with her, to learn from her.

Her death was difficult on my granny, who was with her mother until the end. Due to staff shortages, she had to man and watch the intercostal drain. She had to nurse her mother.

May I never give a brokenhearted relative that job. May I learn to give the dying their last moments in dignity.

In Honour of Family Medicine

Today I leave for a two week family medicine rotation in a small rural town in the Western Cape.

This year, family medicine will supposedly be a lot more fun than in third year. Calls will be a mish-mash of every rotation. Lady in labour? We catch it (yay!). Stitches, we do it (uh-oh…).

Here’s something I have learned about family medicine:

If a young lady of reproductive age enters the consulting room with her mother and claims to have a headache, you politely ask the mother to leave the room. You can then expect the girl to admit that she actually has a discharge.

It sounds terribly stereotypical, doesn’t it? But in primary care this is such a common finding. Several times last year I would do a full headache workup, find nothing, counsel the patient, prescribe analgesics and tell her to return should it not improve. And, just before she gets up she would say, “uhm, doc, there’s this discharge…”