PERIPHERALIA

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I work in a large suburban general practice clinic. We are 
9 general practitioners, 6 dentists as well as a dietician, 
a psychologist and a pharmacy.   We have 5 nurses, 3 
day beds, 2 procedure rooms, and an X-ray department.   
A pathology laboratory collects blood tests about 4 times a 
day from the clinic.

The other day a patient came in to see me for my 8.00 am 
appointment. She said she had a small pigmented mole on 
her shoulder that had appeared three months ago. I took her 
down to one of the procedure rooms where one of the nurses 
laid out an excision tray and I injected local anaesthesia.  
I used one ampoule of lignocaine with adrenaline 
under each end of the mole and then one ampoule of 
plain lignocaine at the sides, and lifted the mole off the 
underlying tissues with the local anaesthetic (8 minutes).  
I then scrubbed up and put a number 15 blade on the scalpel 
handle and unwrapped a number 3 nylon suture and fixed 
it on the needle holder by which time the local had worked 
(5 minutes).  I then cut the mole out including a margin of 
skin (2 minutes) and then stitched up the skin (4 minutes) 
while talking with the patient about the unseasonable 
weather we are having at the moment and also about her 
daughter in Australia.  Happily the histology received later 
was a benign pigmented dermatofibroma.

This patient was in and out of the rooms in under half an 
hour and afterwards went back to work.  In many countries 
in the world she would have been referred to the local 
hospital (one day lost from work) and then told to come 
back for the procedure at another date (another day lost 
from work).  Long ago there was a study from the NHS in 
the United Kingdom that worked out that it was 15 times 
more expensive to refer small procedures such as these to 
hospitals.

There are several other situations where comprehensive 
general practice saves money and saves the country 
millions in saved work time. Patients with gastroenteritis 
and dehydration who have been up all night with diarrhoea 
and vomiting get intravenous hydration and medication 
in one of our day beds and may be back at work in the 
afternoon.  An asthmatic can get intravenous medications 
and nebulisation in our nebulisation room. She can then get 
back to her business meeting on time.  Patients with minor 
lacerations are stitched within an hour and off they go.

It is not only procedural general practice that is well-
organized.  Diagnostic processes can be fast and efficient.  
A patient of mine came in from Mozambique with a fever 
and I had the positive malarial blood test back in three 
hours.  In cases of chest pain we do a finger prick Troponin 
enzyme and send a full test for cardiac enzymes off to the 
laboratory even if they have a normal ECG and the results 
are back very quickly. This takes a lot of burden off hospital 
emergency departments.

One last example is a patient who came into to see me 
recently and said he seemed to have difficulty in breathing.  
“Sometimes I feel I cannot get air in,” he said. He had no chest 
pain and was fit except for moderate hypertension that was 
controlled.  He had no leg or abdominal pain or evidence 
of a DVT. The chest was normal to auscultation but I am an 
old fashioned pulse, temperature and dipstick-in-the-urine 
doctor.  I get an extraordinary amount of information from 
these signs and tests.  His temperature was normal but his 
pulse rate was raised to 108 per minute. This was the only 
physical sign, but for me this is a pulmonary embolism until 
proven otherwise.  We went down the corridor to X-ray and 
the chest X-ray was normal (25 minutes).  One relaxes a bit 
at this stage but microemboli are still not excluded.  Off 
goes the D-dimer and the patient goes home. A D-dimer 
result takes about 2 hours to come back so I phoned him 
later in the day to tell him to go to hospital as the D-dimer 
was positive. Lung scans showed multiple microemboli. He 
now thinks I am the most amazing doctor.  As you know,  
I can take praise in any form you would like to give it. Just 
ladle it on in thick layers.

This is not to say that everything is perfect in our clinic. 
Things still go wrong.  I get tired, the staff get sick, the 
equipment breaks. On some days everything falls apart. 
This is the same for any service that requires multiple 
functioning parts in the chain of delivery. Even though 
we work in a state-of-the-art clinic we spend a lot of time, 
over tea, whinging about anything that we can find wrong 
– especially the performance of the Proteas’ middle order 
batting. 

Despite these occasional hiccups it is a privilege to work in 
this system. It makes the practice of medicine both efficient 
and rewarding. 

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

E mail: cristobalellis@gmail.com

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