The Kiss of Life

I got up at 6am on Thursday to give my nursing colleagues a tutorial on diabetes management and was greeted by this from my bedroom window.

Something quite astonishing just happened, for Holy Cross at least. I just performed my first “crash call” in casualty – a lady’s heart stopped beating right under my eyes. She was in cardiac arrest. What is more astounding though is that we managed to kick start her heart back into action again, with nothing more than some good cardiac massage (chest compressions) for one minute. More often than not a patient is found dead on the ward, in their chair or on the bench long before any hope of reperfusing their brain, with some very heroic allopathic medicine, would be considered. She really was in the right place at the right time. Unfortunately, her prognosis is still poor – with no known medical history, she seems to have a multitude of problems – apart from her heart stopping for a moment, she appears to have had a massive haemorrhage in her brain (well, that’s my clinical judgement after a thorough examination and history – we have no CT scanner).

A cardiac arrest call was a very common event for me back home (UK). I actually thought I was rather competent at running them. However, being out of sync for so long definitely made me think harder about what I was doing with each step – I used to be so slick, or so I thought. I seem to wear very rose tinted glasses. I don’t think I can entirely blame myself though. The crash trolley looks a million dollars, but contains very few useful items – some broken bag valve masks (what we use to help a patient breath), a missing defibrillator (someone thought it looked better on the windowsill) and a lot of useless drugs. Fortunately, our lady didn’t require any of these items.

Running an arrest should be quite a smooth affair, and despite my complaints, I think we did quite well considering all five of my nurses don’t even have basic life support training. As I ran through the reversible causes I even managed to exclude a cardiac tamponade (fluid around the heart) with my new ultrasound scanning capabilities (did I mention I went on an ultrasound course?).

So, seeing as I have been elected (although, I recollect no election) to head the resuscitation committee, maybe we should start by getting everyone trained in basic life support and sort the crash trolleys out. However, I fear this is not really a key burning issue at Holy Cross – trying to get on top of the HIV epidemic is far needier and still a massive problem. When I started work on Monday morning I had already lost five young women, all about my age, as a result of HIV related illnesses. Cardiopulmonary resuscitation would probably have been futile in these scenarios. So, here’s one for you, boys and girls: STOP HAVING UNPROTECTED SEX. If you do, make sure you get “checked out” after.

A very spritely bunch of medical ward nurses at 6:30am, eager to learn about diabetes. I made a cake that I think everyone enjoyed, although probably didn’t really convey a good message when talking about the subject in hand. They are all keen for more sessions as they are a nerdy bunch and not just cake fiends.

My lady with Steven's-Johnson Syndrome - making long strides towards recovery.

An old lady with a nasty infection of her right eye - she delayed presentation for 3 months and as a result has probably lost her eyesight.

It was peas last week and now it is baby carrots. I completely forgot I was growing them. Delicious.



I have a rather large window in my sitting room - ideal for catching sunrise (above), sunset and lightening shows.



“This house believes that Holy Cross can be saved. Discuss”

Trying to blend into the background at work.

“Good chairperson, would you kindly open this meeting? Shall we start with a short prayer?” I feel as if Holy Cross has become the venue for a public speaking debate, except for the doors are closed and no public or press are allowed to get a whiff of our heated discussions. The Eastern Cape Department of Health has been getting some bad press recently, and probably rightly so. There have been almost daily meetings – some productive, some not – discussing issues that make a few of us a little warm under the collar.

It is an exciting place where I work and we have personal from all over the globe with many different beliefs and values. Recently the notion of us offering a TOP (termination of pregnancy) service was debated: a very sensitive issue, whatever side of the fence one stands. We encounter too many mothers, young and old, who present following an illegal abortion. Without the correct aftercare, a woman could develop severe sepsis or bleeding, potentially resulting in death. As it stands I have been nominated to undergo the training. I think that my values are strong, yet I have no fixed religious beliefs. If a potential mother cannot see any other option but a termination, I would much rather that she does it in a safe and controlled environment. However, what is of more importance than offering this service is good public health measures to prevent women getting pregnant in the first place. This can be difficult in a country where many men see ejaculating (masturbation does not count apparently) as a necessity - otherwise, the semen will back up and congest ones brain, or so I am led to believe.

In addition to the multitude of discussions, from how can we improve infant mortality to where we should put the new volley ball net, the boss delivered a very compelling talk to his seven strong team of medics. In a nutshell he was telling us that same old story of how Rome wasn’t built in a day. We all have very different views on how to run a department and come from different backgrounds. I myself stand by the chief – I believe that if change is to be made one must go slow, mould a partnership trust and keep an open relationship with staff; discussing and debating issues as they come, before things get to a boiling point. Unfortunately, many of us foreigners only stay a year or two. Saying that, the boss is a foreigner too, but has somehow had the gusto to stay for over twenty years – he retires next June. I honestly am not sure if we can make any lasting changes. Things are good now, but who knows how things will be next year.

***

Breaking news rippled through the corridors of Holy Cross last week – the national stock of Tenofovir, an essential HIV drug, had run out. This is a very, very bad thing indeed. HIV drugs are often given in a combination of three and work to suppress the virus. If doses are missed or even delayed a few hours, then the clever bug may have time to develop a mutation and become resistant. Fortunately, some of our meetings have been productive and we seem to have a fairly robust contingency plan using old the drugs that were being phased out as an interim measure.

***



Myself closing up the sebaceous cyst wound - if
only this were "smell-o-vision."
 Only then would you be able
 to appreciate the cheesy smell.



On a lighter note I was excising a sebaceous cyst last week – quite a satisfying procedure. The trick is not to burst the cyst as what lays inside smells like an exceptionally ripe stilton. Things were going rather well, and then “kaboom,” out shot a stream of creamy-cheesy-goo, narrowly avoiding   my face (don’t worry Mum, I had my goggles and mask on – safety first) and landing in a big gloop on my trousers. I repeated that same manoeuvre three times before I decided to put some gauze over the cyst and give my mildly saturated trouser leg a shake. The smell followed me around all afternoon, which is probably why some of my patient’s weren’t too keen to stay for a chat.

What happens if you are tetraplegic? I didn't find any parking for them.

For anyone interested, I have now become a pea growing specialist. The trick is to forget about them for a while and then leap with joy and glee when the fruits of your lacklustre labour reward oneself with the sweetest little jewels of bursting goodness.

A young mother who has developed a severe skin rash (Steven-Johnson's Syndrome/Toxic Epidermal Necrolysis) as a result of one of the HIV medications she was taking. Her skin is basically falling off - it can be fatal in upto 50% of cases. Fortunately she is doing rather well. (Note: image used with patient consent).

The classical "target" lesion of Steven-Johnson's Syndrome.



There must be a rabid sheep on the loose - this is it's third victim.



A sixty year old smoker with critical ischaemia of his left foot. Notice his black toes.

Black toes - this is what happens when your arteries fur up with crud.



A 10 day old girl with severe neonatal conjunctivitis secondary to a sexually transmitted infection the mother had in pregnancy. The white stuff coming from her eyes is pus.



Mangrove swamps in the Wild Coast.



Fishy, fishy, fishy.



Friend's enjoying the beautiful coastline of the Eastern Cape.


 

Fire starters and other things.

The "San Clan" - a 30 foot installation at Afrika Burn

The "San Clan" - Burning

The past month things have felt rather quiet at Holy Cross. I think this can be put down to the fact that the on call rota has become very user friendly, rather than our population becoming less dependent on the local health care system. On call is the time when our minds and bodies are pulled, twisted and pummelled. One is spat out the other end either a nervous wreck or a well composed, pragmatic and rounded individual. One learns what is achievable and the goal posts for treatment aims are adjusted. I guess there are two extremes – everyone must be cured or no one can be saved. I think I sit somewhere in a happy medium.

This may sound rather ambiguous, but let me give an example. When I first arrived at Holy Cross I was a little flummoxed at how we managed our hypertensive (high blood pressure) and diabetic patients. “It just isn’t right,” I used to tell myself. People were walking around with a systolic blood pressure of over 200 (that’s rather high) and blood sugars or 25 (it should be between 4 -6). But, then what is right? I see plenty of patients who present following a stroke and I expect a large proportion of them are secondary to poor blood pressure or diabetic control. The difficulty is that, with any population, getting them to attend regular checkups, take their medication and adhere to lifestyle advice is a massive dilemma. Just like back home, it is the same likely characters that re-present time and time again until eventually they give up. As clinicians, one cannot dictate how someone else should run their life, but maybe give a few well informed words of advice. So, when a patient walks in the door with a ridiculously high blood sugar or pressure I try to let them decide how we can manage their body, unless of course they are desperately sick, only then I shall try to run the show. However, try is all I can do – most of the time, it’s a brief admission and then “see you again in a month or so – same again yeah?”

***

I am forming a love hate relationship with the female medical ward, which I now run since leaving paediatrics.  There are a couple of fantastic nurses and several less so. I do daily ward rounds to show my team that I mean business – because it seems that unless a doctor or one of my driven nurses show their face, then things just stay in limbo and patients either die or get better on their own accord. They could do that at home.  To drum up a bit of morale, the plan is to try and organise a fortnightly morning meeting where we can teach one another about several important issues. I shall be using biscuits to lure my colleagues in before locking the door and not letting anyone out until we are all on the same level playing field. Watch this space.

A gentleman with massive gynaecomastia as a result
of an HIV drug he was once on. Unfortuately the
only "cure" would be a mastectomy.

The ward can be a bit of a head banging affair. Often I become a little frustrated with my own lack of medical knowledge, of which I theoretically should have a bit from all my UK training. The patient’s that we admit can be so incredibly complicated, but also immensely fascinating and warming. This week I have been treating a Sangoma (traditional healer) who is HIV positive and came in with severe exfoliative dermatitis with a super infection on top (it’s basically a nasty form of eczema that engulfs every little last bit of skin and is accompanied by a weeping infection that, if not adequately treated, can be life threatening). I think she was rather pleased with our efforts, although I am not so convinced about her commitment to taking her antiretroviral (HIV) drugs. I have another patient that is desperate to go home, again HIV positive, who came in with multi organ failure and is now in comparatively great shape. However, I know that if I let her go she will just deteriorate again. I am carefully balancing the doses of her medications to her gradually improving renal function and treating her severe anaemia. Just one more week I keep telling her – I’m keeping my fingers crossed.



The lady with exfoliative dermatitis
 at the start of her treatment. She was unable to straighten her arms or legs.



..and towards the end of her therapy.



                         

***

On a side note from work – I have been having the most delicious weekends exploring this energetic country. I spent the last weekend in April experiencing the wonder of Afrika Burn – a festival set 120km down a dirt road in the Karoo Desert, near Cape Town. It is based on The Burning Man and works on a “gifting” economy, i.e. money is worthless there. Everyone had to contribute. Mitch had his fist outing with his new hat and the snorkel was put to good use as we drove through a road that had turned into a river during a massive storm on the way up. There wasn’t a sour vibe to be found in the whole shebang and I largely spent it with an exciting pack on new friends. I literally jumped on their bandwagon, which was a tea trolley come sound system – a “chai-wallah” disco on wheels. So, as we dished out the big beats and sweet treats other revellers would offer massages, haircuts, cinema screenings, DJ sets, drinks, games, art, dance, theatre: you name it, they had it. And, just as I thought the world couldn’t be any smaller – I met not one, but two people from the small town of Lewes from where I originate.

Last weekend almost topped Afrika Burn as around sixteen of us descended on the Mkhambathi Nature Reserve at the end of my road here at Holy Cross. I had no idea there were Zebras in the park until we nearly ran some over driving down on Friday night. The reserve has, in my opinion, one of the best kept secrets in South Africa – it is home to a truly magnificent waterfall that spills over directly into the Indian Ocean: a visual and acoustic explosion of the senses.

So, April and May have been my relaxation and party months after a busy festive season of work. It all feels very fitting as I have just moved into my “late twenties.” I actually tried to hijack the weekend in Mkhambathi as a pre-birthday party. I didn’t need it, however, as my lovely colleagues baked me not one, but two cakes and around fifteen of us shared a scrumptious braai (barbeque). I think I could get used to this lifestyle...

One can take the psychiatrist out of the disco, but one can never take the disco out of the psychiatrist.

An impromptu chai tea and big beats break in the Karoo.

My neighbours enjoy some of the head gear post Afrika Burn

This photo does not do justice to how magnificent this geographical wonder is.

The two birthday boys warming up for the braai. Did I mention I share a birthday with my neighbour?

Where did all the tomatoes go?

I seem to have lost the title of “trauma magnet.” The trend over the past few months is that I would walk into casualty to show my face and say: “Hi, I’m on call,” the nurses would sigh and say: “Aybo! Doc, you get too much traffic.” What they are very politely trying to say is that whenever my name is on the rota, I seem to attract chaos – be it the result of a fracas, a road traffic collision or obstetric and gynaecological problem. This means work for me and work for my nursing colleagues. My blood stained sneakers are good evidence of how messy some affairs can be. However, I think I have lost my magnetism. Friday night saw only one gunshot wound in the knee and nothing else. I had some very sweet dreams.   

The expansion of our medical team has meant that we are all on call a lot less (probably why I am no longer so magnetic – probability always wins). The downside of fewer on calls means that I don’t get to deal with so many “juicy” cases. However, the upside is that we can really start to think about how we can develop Holy Cross into a centre of excellence. I may have used the wrong abstract noun there, but it is all relative – we need to strive to provide a better service at least.

This week saw our first meeting, to be held monthly, where we discuss issues with clinical and non-clinical staff and attempt to resolve them. In fact, the meeting was held on the same morning as the teaching programme that I have started. Needless to say, I have postponed the discussion until next week as the forum went on for some time. There were plenty of topics debated – our water supply (currently we only have running water between 6 and 8 in the morning – obvious dilemma with hygiene, but also with hydrating our patients and staff); out of hours radiology service (the radiographer said that he was on board with the idea if he gets paid extra. However, he also said that if he did get paid, it would still be voluntary.); management and fast tracking of sexual assault victims; broken machines all over the hospital (including the monitor in theatre – quite essential to monitor a patient’s heart rate, blood pressure and oxygen saturations.); pharmaceutical supplies. It was actually a very interesting and dynamic meeting, with some good contributions from nearly everyone present – although, I’m not sure about the views of the radiographer and his volunteer paid out of hour’s service. Surely that is a massive oxymoron. I just hope we can be productive and put plans into action rather than just debate issues over and over.

***

Whilst on call yesterday, during a lull, I found enough time to donate blood. The donation van comes around every two months, but quite ashamedly, I hadn’t donated until now. This is largely because I either had no idea it was here or I was too busy. I’m not sure if giving blood at the start of a 24 hour shift is a good idea – fortunately, Friday night was super quiet. I was quite surprised by how many people were reluctant to donate. There were plenty of vague excuses, although I’m sure some of them had good foundations, such as being HIV positive but, quite reasonably, not wanting to disclose the information to me. There is a massive shortage in blood stocks everywhere, so, if you’re reading this: GO DONATE TODAY.

***

My car Mitch has recently been accessorised with a lovely hat and pipe, more commonly known in the industry as a roof tent and snorkel, respectively. This is all in preparation for the two months I am taking off in July and August to drive up to Uganda (if time permits).

“Why have a snorkel?” I hear you ask? “To drive through rivers,” I say. “Oh,” you say.

The tent has already been tested for sturdiness by my neighbours, who decided to clamber all over the canvas. It shall have its maiden voyage next week when I drive to the Karoo Desert (near Cape Town) for a festival called AfrikaBurn. It’s based on the Burning Man in the Nevada Desert. Hopefully I won’t come back zombified and wearing nothing but a loin cloth.

***

The vegetable patch has been coming on just swell. Unfortunately, for all its luscious looks (the flowers are radical – my house has lots of empty beer bottles donned with pink, yellow and red bloomers) I haven’t been able to be self sufficient. There seems to be a tomato thief lurking in the shrubs as every time I go away for the weekend, the toms that were about to get that “sun kissed” look disappear. I just hope they go to a good home. Thyme, parsley and coriander play a heavy role in my cooking – it just so happens I have an abundance of them growing in my patch.

First festival of the season: Splashy Fen. Friends walking down the promenade - no need for wellies (although people were still wearing them). 



Splashy Fen, this man had the most incredible mullet. One cannot really appreaciate it in this photo, but I quite like it nonetheless.



First meeting of clinical and non-clinical staff since early 2011.

The neighbours modelling alongside Mitch and his new accessories.

Giving blood between patients - it's in their interests, but maybe not in the short term if I start feeling a little faint.

Miracle Makers

Easter has begun and I am fortunate enough not to be working the long weekend. Word in the hospital is that Easter is much like Christmas: families and friends coming together with knives and fists. People keep telling me it’s a cultural thing. I am sure there is a simple enough equation that can explain the festive fun: ((Money × Alcohol²) + difference of opinion) ÷ (Love + rational thought) = x. ‘x’ may be a kiss on the cheek or a stab in the face, depending on the weight of the different variables. Take away the liquor and I expect one would see a massive reduction in violence.  However, life isn’t that simple and one cannot simply things down to a silly equation. The social issues and inequalities here in South Africa are gargantuan – something that I am still trying to get my head around.

Not working Easter apparently means I should be spending it at Church, according to my nurses. “Gawping amazement” is how I would describe the look on their faces when I tell them I don’t subscribe to their school of thought and that I shall be spending most my time at a music festival. However, occasionally I feel I could almost believe in some kind of supernatural force: the seven month old infant that was shot in the chest last week in the hands of her dying mother came back today. By some miracle, the bullet prodded it’s way around the lung and ended up in the muscles surrounding her abdomen.  She was giggling and smiling while I stood there with a massive grin slapped over my face. I discharged her with the bullet still lodged inside. The aunt will look after the baby. On a side note – the aunt found the helicopter ride terrifying.

***

Often one is presented with an interesting history written on the casualty card. Often this is the result of a dodgy Xhosa to Zulu to English translation. The first time I saw: “Struck by lightning,” written down I felt my own heart beat accelerate rapidly – however, a quick glance at the smiling patient swiftly relieved my initial fear. Being struck by lightning in the physical sense is a very loose term here – however, the social and cultural connotations are massive. A home that has been “struck” by lighting must be abandoned and if a person is “hit”, they may be ostracised by the community. Lighting is the ancestors saying: “We are not very happy with your affairs at the moment – you must be punished.”

This week I have seen two patients where I assumed the history on the casualty card was misinterpreted.  The first was a girl in her early twenties who came with the story: “glass stuck in foot for three years.” Obviously it was three days, and not years. No, I stood corrected, it was three years. Being slightly cynical of her story I examined her. She was rather tender in the said area, but still I didn’t believe it. Glass shows up remarkably well on an x-ray, especially the two large shards that she had in her foot. I referred her to my surgical colleagues.

The second history was that of: “Tick in ear.” How can one possibly know it’s a tick in the child’s ear? It could be anything – far more likely to be a bean or cotton bud. The mother hadn’t seen it, but, without giving any reasonable explanation, she was adamant it was a tick. Much like the other pathognomonic sign for worms that grandmothers often like to describe: “The child is grinding their teeth at night.” Low and behold, the child had a gargantuan tick in their ear gnawing away at a tasty bit of ear canal.

***

I thought I had turned into a miracle worker yesterday. I reduced an angulated forearm fracture of a child under ketamine with that satisfying grinding click of the opposing bones realigning under a bit of manual pressure. The subsequent x-rays looked as if he had never broken his arm in the first place. For a brief second I thought that I had manipulated and plastered the wrong arm; then I thought I had performed some sort of divine intervention; finally I realised the two repeat x-rays were of the same view (one always needs to look at the bones in two angles to create a kind of 3D picture). The second x-ray showed that the results were not perfect, but pretty good if I do say so myself.

***

I should probably mention that this week was my last on the paediatric unit. One of the sister’s in charge was extremely upset when I told her the news – very flattering. However, it is time for a change and with our new cohort of doctors we can spread our wings a little. I shall be spending the next four months trying to help the medical ward recover from a dismal year of neglect and try to clear the cobwebs from my murky medical brain.

The mega tick that I fished from a toddler's ear. Notice the hunk of ear canal still being gnawed on by a very alive critter.

I shall miss paediatric ward rounds - the kids start to join in once they've been around for a while.

Now you see it, now you don't. The fractured forearm that I thought I had miraculously reduced. Unfortunately, the image on the right shows the same view. However, the arm is much better than it was.

Happy punters.



"slash and burn" next to the diesel generator tank.



Happy punters make happy workers.

The nature reserve (Mkhambathi) at the end of my road is magnificent.



Burger boy.



The South Africans love a braai (BBQ). I have turned my fire place into an indoor braii - my new favourite cooking station.

Improvisation can be key sometimes - this lady was referred from clinic with a septic operation wound. They have used sticky labels as tape - the adhesive, unfortunately, can be an irritant. Her skin was fine, however.

Here she is - the 7 month old infant who was shot in the chest. A very moving tale and a true wonder that she survived.

CHOPPER.

Something rather exciting happened yesterday. I gave a presentation on the recently updated WHO (World Health Organisation) tuberculosis management guidelines. After the presentation I went to theatre to perform my 90^th (documented) spinal anaesthetic since I have arrived. That is almost 100. Maybe I’ll celebrate by giving my patient something a little something special on the centenary, such as a sticker congratulating my one hundredth patient or a little intravenous shot of fentanyl (an analogue of morphine – don’t worry, I’m not going to do that). Nope, as thrilling as that all sounds, this is not what I want to talk about. What I want to mention is something that my paediatric nurses were trying to call me about just before I walked into theatre Thursday morning to perform spinal anaesthetic number ninety. There was a seven month old infant admitted in Calloway (the paediatric unit) having suffered a gunshot.

When I was informed of the news, two things surprised me. It wasn’t that the baby had been shot whilst in her mother’s arms, who was killed alongside the aunty. What surprised me the most was that the infant had been admitted to my ward (the usual protocol is that ANY gunshot victim should be stabilised and transferred to a surgical unit – bullets can be very unpredictable) and secondly that she was still alive.

A brief assessment revealed that the baby was pretty stable. She had an entry wound in the top left corner of her chest and the bullet had ended up in her abdomen. There was bleeding around the lung (a haemothorax) and, I expect, a whole load of punctured bowel. Kids can be very deceptive – one minute they are fine, even if a large bullet has made a small journey through some of their vital organs – and suddenly, they will decompensate and die very quickly if not managed appropriately. Quite frankly, I have had enough of children dying from traumatic injuries and it feels like it has happened far too often recently – such as the five year old who suffered severe internal bleeding after being struck by a car a few weeks ago. If only he could have got to a surgical facility in time. We waited for five hours until the ambulance never arrived and he said goodbye to this world.

As mentioned before, the ambulance service is pretty dismal here (I guess the flip side of the argument is at least we have one). However, there is one exception: Did I ever mention Holy Cross has a helicopter pad?

 Once the infant was stabilised I called Metro (the ambulance control board) and explained my case; I asked for air support as I was worried the infant would suddenly turn. The response I got was: “You want a chopper? Ok, I’ll call you back.” Four brief phone calls later I spoke to a lovely paramedic in East London, where the chopper is based – about 6 hours drive from here. I was expecting to be let down, instead her final words were: “OK then, we’ll be with you in about an hour.” Eureka! The adrenaline started flowing through my veins – I can’t explain why – I was teaming with excitement. However, I didn’t let this show – I wanted to remain composed in this delicate situation. The response of my nurses when I told them was of sheer joy – so, I let them do the singing and dancing whilst I nervously waited and checked on the baby every fifteen minutes whilst I continued with ward rounds as usual.

After a slight detour from being given the wrong coordinates, the pilot called me from the aircraft for directions – a lot easier than you would expect: “Just follow the tar road and look for me waving.” The plan worked very well. It was a magnificent site to see the chopper circle round the hospital and land on what the pilot described as: “The best chopper pad I have had pleasure of landing on in the Transkei. We’ll happily return.”

The infant made it to the referral unit: I am eagerly waiting to hear of her outcome. News on the grape vine is that she was transferred onto an even higher level of care.

This is a supine xray of the baby - the bullet went in just by the "L" mark in the top right hand corner of the image and ended up in her abdomen where you can see it. Notice the opacification in the left side of the chest - that's a haemothorax (blood on the chest - the infant is lying flat, so there's no fluid level)

My colleague caught a snap of me - I think the image speaks for itself: Relief.

I think I'm quite excited, but am pulling a very contorted expression.

Chopper

Three TB patients on TB ward catching a few rays and enjoying the helicopter spectacle.