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Wednesday, 24 April 2013

Holy Cross 4EVA

  
One last Holy Cross sunset


The Craver Clan

Well, it is all over. I finished my job at Holy Cross over three weeks ago now. Since then my family have been over for an awesome holiday, I have had a couple of leaving parties and the slow process of packing my life up after almost two years of living in South Africa has begun. The hospital has seen the arrival of a new doctor all the way from the UK: Dr Rob. He’s taking over my job, house and even Mitch: he’s basically taking over my life. I know he is going to have a swell time; just like I wrote in my first ever post: “It’s going to be an amazing experience.” Well, I certainly have had that and would whole heartedly recommend this to anyone looking for a change or new adventure.



Myself rocking my new attire trying to
 keep up with my main man Soby.
There have been ups and downs; times where the work was exceptionally demanding; points where I felt a little lonely. However, never have I experienced the job satisfaction that I felt here, despite what can sometimes feel like a constant head banging affair. I leave knowing that I have met some wonderful people and made some new friends for life; so many happy memories; even a good bit of ring worm on my shoulder, just so I don’t forget all the children that crawled over me on a daily basis; and, best of all, I leave having fallen in love. I have been nothing but glowing for the past four months, hence, I am incredibly excited to return home. However, I really am going to miss this place and the prospect of starting emergency medicine training back in London does fill me with a little bit of fear and apprehension.

The Holy Cross website is soon to have a new address (www.holycrosshospital.co.za rather than www.holycrosshospitalza.org ) and my colleagues here are going to keep it updated, once they have a spare moment. Things are looking up for the hospital, despite having the usual staff shortage. Dingerman and Femke, the Dutch couple, are taking over the medical management and are planning to stay for a few more years. Even more exciting is that Femke is pregnant, now in her second trimester. Holy Cross is a magical place where people fall in love and babies are made. I’m not even kidding, my boss told me that since he started working here 15 years ago there have been ten babies, two weddings and one love story.  There must be something in the muddy water that comes out of the taps here.


Turns out I'm not leaving, I'm for sale.

In addition to sprucing up the website, Femke and I have been shooting a movie to promote Holy Cross as a fun and lively place to work, which it most certainly is.  The first screening was held in my last week during an impromptu leaving, welcoming and birthday 
doo for myself, Rob and Dingerman, respectively. I had my only pair of jeans pimped up in the traditional Xhosa way and danced for an 80 strong crowd of nurses and other staff with one of the porters, who happens to be an excellent tribal dancer. I didn’t have much say in the matter, but nor was I anti it; in fact, I loved it. As I was en route to the party, I got cornered by a nurse who instructed me to get changed and prepare to dance. Anything goes here. The video of the hospital should be uploaded onto the website soon.
I've never seen such a big cake.


I want to write one more piece about my time at Holy Cross, but, if I don’t get around to it this could be my last ever post on my first, and most likely last, ever blog. It has been great fun to write, exceptionally cathartic and, I hope, spurred a few people on to have similar adventures.
Right now I have one last Holy Cross braai to host and a two week road trip with my good friends from the UK (Ben, George, Andy and Amar) where I’ll be taking them to Afrika Burn festival and some of my favourite spots on the Wild Coast. After that, I’ll be homeward bound, but not without stopping off in Kenya to ascend Mount Kenya and see a few friends there. Life really is wonderful



Spoilt by the nurses on medical ward.

Man sells us a massive fish he just caught. Why not make sashimi out of it. Now, that was a damn fine idea.

A lonely patient.

Sunday, 24 March 2013

Almost Over

I'm going to miss this view.



One of the four preterm (2 twins) babies that I delivered last week.
 This one is shaking my hand after a particular rough ride.

 
HIV is just the most ghastly epidemic. One would think that maybe I’d have become used to its woes by now, but no – everything is more acute; it makes me question my own mortality far more than I ever have. Each day I encounter at least one devastating case of a young girl or boy; someone who should be full of energy and exploring who they are, completely crippled. I am always amazed by how much people age. Just the other day I saw two girls, one 19 and the other 21. Both looked well into their 40’s, and very sick forty year olds at that. Their eyes were full of despair and absolute exhaustion. I try to stop myself thinking too much about each case, but sometimes my mind drifts, and it is easy to do so. As I sit there, while the nurse translates the history, I find myself looking at the young person before me and think: that could be me; it could be any of us. We all know that condoms are very effective at preventing the spread of HIV, but how many times have you decided not to use one? To start with, you need to have them freely available. Anyway, this isn’t about my sexploitations, but about the ease as to which this virus can be spread and how easy, in theory, it could be to stop. I’ve just finished a book entitled: “The Wisdom of Whores,” by Elizabeth Pisani. It is an extremely well written piece, deeply moving, but often light-hearted, analysis of HIV and all the demons that surround it.

***

I am now halfway into my last ever weekend of work at Holy Cross Hospital. As I mentioned, last Friday, Saturday and Sunday I was the boss. It turned out to be a really quiet shift in casualty: no stabs, no sick babies, no bleeding orifices - all in all, very good. However, maternity was a different story. I ended up performing six caesarean sections. The privilege that we as doctors, midwives and nurses have of being involved in child birth really is special, and I cannot help but smile each time I coax a baby from its mother’s womb. However, I shall be honest: I will be quite happy if I do not have to do any more C-sections ever again. They can be a nerve racking affair, especially when the uterus bleeds, and boy does it bleed. Although, as of yet I haven’t had any problems stopping the bleeding, even when I severed the uterine artery on one occasion a few months back. The main reason I don’t fancy doing more of these procedures is because I am grossly under-qualified. This shouldn’t be how a healthcare service is run, but without my dubious skills over the weekend, the mothers would have had to make a long journey to our sister hospital. Without money or transport, this can be impossible and the ambulance service, as I have said before, is useless at the best of times. So, that is why I do cut: there isn’t really another option, and so far nothing has gone wrong. I take my time, think about my next move and try not to slice anything but the uterus.



Blood stained trousers after a busy weekend.
 Good thing I always wear my trauma goggles.
So, I said last weekend was rather quiet in casualty (it should have been busy – it was pay day); last night was a very different story. I feel as if the community know it’s my last weekend, so they are throwing me as many assaults as they can. As morbid as it sounds, I really enjoyed the trauma I encountered last night. There is often a sense of instant gratification as you can literally save lives there and then. Within the space of an hour a young man had been brought in with multiple gunshot wounds – at this point I was busy performing an assisted delivery with a ventousse (vacuum) on a stubborn baby who came out very flat. I received the call just as the little one popped out. I ran the new born to the resuscitation room, kick started him into breathing and then left the midwives to kindly clear up the mess I had made (my blood stained trousers are evidence of this) and repair the episiotomy I made. When I arrived in casualty, the man was on oxygen (this still impresses me – last year it would take 30 minutes to find an oxygen mask), the sisters were putting in two large IV lines and…… oh, he wasn’t breathing: he was dead.  There really was little I could do (this is the point when I don’t enjoy my job and there is no such instant gratification that I just described). He had been scatter bombed with bullets. I’m no ballistics expert, but this is how I think someone must look if they were shot at with an Uzi. His entire family were there watching. For a second I entertained the idea of cardiorespiratory resuscitation, however, there was another very sick gentleman in the next gurney who had a chance of life and there was only one doctor, myself. I had to move on.




The latest fashion at Holy Cross
The second patient had been stabbed in the chest. The first thing I noted was how pale he looked. His pulse was weak and slow, his neck was engorged and I couldn’t hear any breath sounds on one side of his chest. I thought to myself, could this be a tension pneumothorax? This is when air gets trapped and sucked in between the lung and rib cage. With each breath, the volume and pressure of air increases and eventually squeezes the heart until it stops. What I should have done is listen to my gut and shove a needle into the front of his chest, subsequently hearing the satisfying hiss as the pressure releases (a very heroic manoeuvre – you see it in the movies, often with a BIC biro). However, I didn’t do this. Why? I don’t know, but partly because the chest-drain kit was already there and I had a tube in his thorax within 30 seconds. As the whoosh of air, and some blood, came out of the drain the young man instantly perked up. This was definitely one of those moments I mentioned earlier – a few more minutes and he would have been in the same situation as my first patient: dead. The young guy, and his mother for that matter, was extremely grateful and he promised me he would keep out of fights in the future. I wonder if he’ll keep his word. Just as I thought the evening, well morning – it was 2am – couldn’t get more exciting another curve ball was thrown.



A man in his thirties had three small stab wounds on his chest. His breathing was fine and there was no evidence of air or blood in the thorax like the previous fella. However, one of the stab wounds was sitting right over his heart. I did a scan and saw a large sac of fluid encasing the four chambers that pump blood around the body: he had a stab heart and the fluid around it was blood. Fortunately, he was relatively stable and seeing as he was still alive 2 hours after the incident, he had a pretty good prognosis. I did a pericardiocentesis to confirm my findings. This is when one shoves a massive needle, under ultrasound guidance, into the pocket of fluid. A relatively hairy procedure as you can imagine: too deep and you may end up puncturing a ventricle and making the situation a lot worse. First time was the charm and I aspirated 20mls of dark red blood – a good sign. If it was bright red, it would probably mean there was still bleeding, or that I just punctured the heart: not so good.  I observed him for an hour, to make sure the fluid wasn’t building up and squeezing his cardiac apparatus, much like in a tension pneumothorax, and then sent him to the surgeons at our referral unit.

The weekend is almost over now and my time at Holy Cross is coming to an end. I really am going to miss this place.

Cow chilling on the beach - it's what they do on the Wild Coast
 
Mitch - our days together will soon be coming to an end.


Casualty nurses preparing to dance for a movie we're making.
Did I mention we're making a movie to promote Holy Cross?

Wednesday, 13 March 2013

I got the job, I'm heading home.

  
Moon rising over Holy Cross.

There is little else more satisfying than the clonk that comes with relocating a dislocated jaw. Apparently the elderly lady, whose mouth I had my hands in earlier, was doing some serious mastication at the time of the incident. Recently I have been thinking that, as my time at Holy Cross is nearing an end, the amount of trauma seems to have reduced. Of recent, no nasty wounds to suture, chest drains to insert or fractures requiring reduction, pop into my head. However, maybe I just don’t notice these things as much anymore. It seems to take rather a lot to make me squirm and look aghast with a slack jaw nowadays. In addition, I’m just not on call as much as when I first started. Working one in two weekends a year and a half ago was a baptism of fire, but one that really built my confidence in managing exceptionally grim situations, some of which I have written about. I have three weeks of work left: I shall be working straight through as I’m on call both weekends, and on one of which I shall be the most senior doctor on site. Before I have always had the “phone the boss” option; next weekend I am the boss. This strikes rather a large amount of fear into me; it feels as things have been so quiet recently that maybe this is all the calm before the storm.

I say things haven’t been that busy, but as I look at the list I keep of interesting cases, perhaps I could have been mistaken. There’s a good reason for keeping lists: it’s easy to forget things. Here are a few memorable snippets from the past few weeks:

1. A thirteen year old boy on the medical ward decided to go into cardiorespiratory arrest (that’s when one’s heart and breathing stops; the same thing that happens in death) after a nurse gave him intravenous antibiotics. Fortunately, my colleague was on the ward and after thirty seconds they brought him back to life. Neither of us are quite sure if he had an anaphylactic reaction (this would be quite unusual in the way it presented) or just a serious vasovagal (fainting) episode as he was a little needle phobic. Needless to say, I was not willing to try the same antibiotic again.

 

2. I saw a four month old baby girl who was in severe respiratory distress. In fact I had seen her just days before with a mild chest infection and told the Mum to return if things didn’t settle. The baby had developed a massive collection of pus on the right side of her chest (empyema) that was severely compromising her breathing. Initially I inserted a needle to aspirate a little fluid and see what it was: when I saw pus, my first thought was: “Bollocks.” It was Friday afternoon and I was hoping to shoot off for a fun weekend away; it looked as if I’d be leaving a little later than planned. However, the main reason for my swearing is that pus doesn’t come out by itself, it needs to be drained and this would mean putting a surgical chest drain into a tiny little chest. To make things even better, when I put the needle in through her ribcage, I created a pneumothorax (air in the lung). This meant she would definitely require a drain. I have no qualms about cutting a massive gaping hole in the chest of an adult, getting my finger in, having a good poke around before I slide a big tube in. In a little baby, this is a very different business and something way out of my comfort zone. However, without the procedure she probably wouldn’t have survived the weekend. Anyway, without too much deliberation, I inserted the drain and watched the baby improve by the second. She has since been discharged and is doing very well.
The left shows a whole load of fluid (empyema) in the baby's chest. The chest x-ray on the right is following my attempt to aspirate all the pus and in turn creating a pneumothorax.

Pus.



Baby with chest drain in situ.
 She also has a femoral line in her right groin.

 

3. Whilst on call two weeks ago a young girl came in after slashing a big gash in her foot when she was cutting the grass at home. The wound was under a small bandage, but right over an area where a rather large artery runs – knowing anatomy can be key in times like this. I asked the nurse: “Is it a squirter?” She wasn’t sure as she hadn’t applied the dressing. So, having been almost caught out on several occasions before, I donned my goggles, asked the nurse to step aside and removed the bandage. Unfortunately, the side where the nurse stepped was right into a shower of arterial blood. It most definitely was a “squirter.” Fortunately, I managed to tie the bleeding off rather fast, although my nurse wasn’t too happy with the stain on her nice white uniform.

 
 
 
I love it when patients bring in the stuff that comes out of their gobs and bums. Here's a nice example of a worm that has been having a swell time feasting in a clients intestines.






4. Sunday is a day for church and football over here. Passions run high in both institutions, however, some people really do get slightly over zealous when it comes to kicking a ball about. Within thirty minutes of each other, on the day of “rest” and at 2pm, two grown men were both brought in with stab chests. One felt he was being overly criticised by his team mates for his ball handling abilities, so tried to stab them, but failed and received the knife himself. The second was a spectator who got into an argument with his friend over whose girlfriend was better looking. Well, I would defend the love of my life to the death, but I wouldn’t enter a death fight over how pretty she is. We all had a good laugh about the entire affair, but it does make me a little sad this culture of aggression. 
 
***

In other news, I got the job: three years of emergency medicine training in South London. I have very mixed feelings about leaving, but I think I’m ready to go. More importantly, I cannot wait to get home to see my dear family, friends and, of course, the girl.



A leaving party for Sr Lupondo: the head of casualty. Fortunately on this day the department was empty, which meant everyone could attend for a little dancing, cake and an whole lot of meat.

 
 
A few goodbyes: myself and Sr Ndamase. I know one shouldn't have favourites, but she is definitely the nurse I admire most. She helped me through some very challenging times at the beginning and is exceptionally dedicated. In addition, I share a birthday with her son Bebo, who is a cheeky little chappy.


When oysters cost £18 for 100 delicious nuggets of seaside, it can only mean one thing: breakfast, dinner and lunch. A well deserved weekend off after fiddling with chest drains in babies.

As well as oysters, it's crayfish season. Yum yum in my tum.





Saturday, 23 February 2013

Don't Go Chasing Waterfalls

 
  
Myself and the elective kids.


January would have been an exceptionally challenging month – a distinct shortage of doctors and nurses (what’s new) and an overwhelming number of sick children. To top it all off I was meant to be preparing for UK job interviews. However, the arrival of three medical students from the UK helped me keep my sanity in check. I love having students around, whether I’m home or abroad; it makes for a stimulating and exciting environment: sharing ideas, knowledge and stories. In addition, what made this group (Dom, Mal and Georgie) particularly good was the fact that 
Malik getting sized up for some
new trousers during a ward round.
they like to eat, play and explore: which, is exactly how I roll.  The big house that I live in was finally buzzing with life and now that they’re gone, I must say it is rather quiet. However, they’ve left their footprint – pictures all over the walls from weekend japes, blood smeared from floor to ceiling after several mosquito massacres and some truly excellent memories.



I had initially taken two weeks off to return to the UK for interviews, but cut my trip to 4 days and returned early for an impromptu trip to Madagascar with them. They say you only live once, and the South African government does pay me rather handsomely. Needless to say I am rather broke now, but it was definitely worth it. If you ever get a chance, I would recommend Madagascar to anyone: beautiful people with a real joie de vivre, scrummy food, charming architecture, magnificent scenery and, of course, loads of Lemurs. I only stayed for a week – Holy Cross was beckoning me – but, it was enough to get a taste of its wonder.

Smiley Madagascan children.


"LOVE FOAM" - the only mattress to sleep on in Madagascar.

***

Whilst the students were here, we embarked on some truly excellent weekends; keeping it local and exploring the Wild Coast, a.k.a. my hood. On their last weekend with me, before I flew home for a quick interview, I organised a trip to Mkhambathi: the beautiful nature reserve at the end of my road. There were twenty of us and a lot of fun was had, which included some excellent beach volleyball (courtesy of the students spoiling Holy Cross with a brand new net – I now have to dig up a pitch: watch this space) where Great Britain slammed the Netherlands; plenty of braais (BBQ’s) with some devilishly good dry rubs over the meat; sunsets; sunrises; swimming; frolicking; green shooting stars; and my good friend Ben having a near death experience.

I have mentioned in previous posts that the thing that makes Mkhambathi so special is this magnificent waterfall that dumps straight into the sea. Last time I visited the falls the water level was pretty low; this time, being the wet season, the river was engorged, creating a spectacular thundering aquatic feature.



Friends absorbing the magnificent power of the waterfall.
Ben is one of my dearest friends and also happens to be a British doctor working in South Africa. The story is a little vague, but he was walking along the top of the waterfall, lost his footing and slipped. Fortunately, he landed on a ledge. Unfortunately, he was stuck: pummelled with white water and a potential 15 metre drop into a shallow pool, he was holding on with his bare hands to a couple of small rocks and getting very cold. The other great thing about Mkhambathi is that it is really isolated and there is no phone signal; this isn’t so good when one needs help.



Ben - a little stuck. We didn't really take any photos
 as it was shortly after this snap that
 my friends realised he was in trouble.
My initial reaction to what was going on involved a lot of expletives from me, directed at Ben, and complete dismay. I had actually been lagging behind, taking in the scenery and checking out the swell rock pools with a friend before we knew what was happening. By this point, Ben had already been stranded for about 20 minutes. A party had run off to get help: one car was sent to get phone signal and beckon a chopper, if need be, and another returned to the scene with food, blankets and some equipment. Obviously, the car that returned to the scene was Mitch. Unfortunately, a barrier on the track meant we couldn’t get him close enough to use the winch. Instead, four car tow ropes were tied together and thrown down to my stranded friend. At this point he had been in the water about an hour. There was quite a bit of discussion as to how we would pull him out: the rope didn’t have much slack and it would take several people to pull Ben across with the added weight of water pummelling him. We agreed to shimmy him across the waterfall, on its ledge.



The thundering noise of the falls made it almost impossible to communicate with Ben; hence, there were a lot of gesticulating hands. Without further ado, we attempted to pull him across. At one point, he disappeared under the falls. I happened to be the one at Ben’s level, trying to give a few instructions to him or the burly crew handling the rope. Imagine me, shouting at my friends who were pulling him, trying to get them to tug more as I lost sight of Ben under the dramatic blanket of water. It felt like an eternity, but couldn’t have been for more than ten seconds. Minus one pair of shorts, we pulled my dear friend to safety and I gave him the biggest bear hug I have ever given any man. Whether he remembers or appreciated this, I do not know. The relief from everyone was massive; it was one of those “999” (the TV show) experiences, but with a very happy ending.

Once we got Ben back to bed, the fun recommenced, but not before an impromptu dance to the TLC song “Don’t Go Chasing Waterfalls.”

You may be pleased to hear that I managed to get this event into my job interview in response to the question: “So Dr Craver, can you tell us of a time outside of work where teamwork was important?” My answer: “Well, as a matter of fact, yes I can. Just last week…”
 

***

This is probably as good a time as any to mention the fact that I shall be leaving Holy Cross at the end of March. After about 20 months of work, I have finally handed in my notice. It is with mixed feelings that I am leaving, but something I am ready to do; the prospect of returning to my dearest family and friends fills me with glee, but I shall be sad to leave my Holy Cross family.



Busy at work in casualty. One could say it looks like we have too many doctors. Oh how I wish that was true.

 

Dom and Dom.

 
Good TB preventative measures: fashion always wins.


Thursday, 14 February 2013

One Sunday in January

 
 
Before you read this, I have an announcement. My good friend Kim Turley, out of the good will of his heart, has kindly constructed a website for Holy Cross. It is still a work in progress, but do have a quick browse.


***

The weekend was coming to a close: it was Sunday night, I had triaged all the patients in casualty, maternity was quiet and the wards were sleeping. I got to bed at around one am and drifted immediately into slumber land. Within the hour I was awoken by the extremely unpleasant screeching of my house phone– the sound is far worse than any bleep I have ever carried back home.  The sister in casualty had some urgency in her voice – there were two young children with, as she put it: “serious burns.” Now, the staff at Holy Cross see burnt children all the time and they are well versed at managing the less severe cases. On that basis, I knew that I wouldn’t be going back to bed for some time.

I threw on my clothes and ran down to casualty in the rain. What lay before my eyes were two sisters of five and nine years old who were in a really desperate state of affairs. A candle had fallen on their bed whilst they were sleeping and set fire to some extremely flammable bed sheets. Both had deep burns covering almost 60% of their little bodies, which in itself carries a poor prognosis. However, to confound matters both children were freezing: they had been brought by their family through the pouring rain and were sodden.



This is the younger sister, all wrapped up in
 a red bin bag and ready to get in the ambulance.
The girls were in a state of shock, but still alert, talking and crying. I turned the heating on to “full” in our resus department and proceeded to get very sweaty whilst I resuscitated them. With burns, one loses a lot of fluid, hence, what goes out must be put back in. I placed a femoral line (a drip in the groin) in both girls and filled them with warm intravenous fluids as well as catheterising them. Now, I thought, how can I keep them warm? I looked around the department and came back with two large red clinical waste bags. The idea, in burns management, is to reduce the amount of fluid that is lost by creating a synthetic skin; hence, cling film would have been ideal. With my girls relatively stable, lying in bin bags and under several blankets, I referred them to our burns unit.


My colleague on the other end of the line was reluctant to take them at first, given the severe degree of their injury, but eventually agreed to have them transferred. The ambulance took eight hours to arrive – our commonest and most frustrating rate limiting factor. The sisters both got into the ambulance and seemed relatively stable, but neither made the 4 hour drive.

Deep down I knew that their prognosis was poor, especially with my limited experience in such cases and the sub-optimal facilities that we offer. However, I had to try; we had to try. The nursing staff at Holy Cross really do try hard, despite all the barriers that they are faced with. Those few times when it works and when things go well, even if there’s an unhappy ending, at least we can say we did the best we could; we achieved something.
***

This fella has a massive pericardial effusion (fluid around the heart).
Normally the heart (the big white thing in the middle) sits snugly in the middle of the rib cage and is rather small. He was exceptionally short of breath as the fluid was causing a cardiac tamponade (squeezing his heart so it cannot function correctly)...
 
...The only way to relieve the tamponade is to remove the fluid. Under ultrasound guidance I inserted a cannula (large needle) into the sac around his heart: a rather frightening, but lifesaving, procedure....
...Out came over 2 litres of blood stained fluid. This is the classic for TB pericarditis. The guy was started on TB treatment and steroids and is now doing very well.

Monday, 11 February 2013

Belated New Year's Greetings


The all too familiar "jump'n'shoot" pose at the top of Port St John's
 airfield with the UK student clan.
Left to right: Me, Mal, Dom (there's another Dom) and Georgie.

I must apologise: Job applications, a couple of flights to the UK, impromptu trips around the Wild Coast, falling in love, working like a dog, playing like a pig in roses and a lack of sleep has put this blog on hold for the past month or so.  However, it hasn’t been for a lack of tales. Oh no, there is plenty to be told, except that I do not want to bore my audience with pages and pages of script. To make things more palatable I shall write a couple of instalments on January.



The halo of clear fluid around the blood is CSF
(cerebrospinal fluid) that was leaking from a
 guys ear who had sustained a skull fracture
 following a road traffic collision.

I shall start where I left: in my last entry I was en route to the UK for a festive week at home with my beloved family. My first day back at Holy Cross was New Year’s Eve. Imagine my glee when I found out that I was to be on call alone for the ensuing 24 hours. Not that I don’t work by myself most of the time when on duty, but it is always nice to have that “phone a friend” option in times of crisis. My main concern, however, was the fact that there would be no anaesthetist for the C-sections. So, I planned ahead and called colleagues at my local hospital informing them that I would have to send any mother that couldn’t deliver vaginally to them. I don’t think they were too happy, but I didn’t give them a choice and in the end I only sent one lady.





One of the many mashed up hands: kids,
don't play with fireworks.

The day had an ominous start – at 9 am I put in my first chest drain into an elderly lady who had been beaten, bruised and stabbed in the chest: a grim and exceptionally sad tale, but something that isn’t uncommon. Fortunately, that was all there was for the next 24 hours of any real note. No knives to the heart, no blades through the lungs, no bullets traversing the skull. There were, like last year, several firework incidents that brought in a delightful selection of blown off digits and thumbs. I had to amputate the end of one guy’s finger whose bone had been squashed like a Panini and then chewed on by a very hungry teething child.



After the slight anti-climax of New Year’s Eve, Holy Cross threw a curve ball. All of a sudden we had gone from 7 to 3 doctors: one had left and three were on leave. It was a pretty cruel two weeks: dousing the fire, telling patients who had just travelled a day to see a doctor that they should return next week as their complaint wasn’t urgent; the wards were all but abandoned and left to survive on their own as we struggled to keep maternity, paediatrics and casualty going. Hence, there was little blog writing time for me.

A lot of children died in January, but I don’t think it was entirely because of the doctor shortage. There had been an alarming number of kids who presented in respiratory distress and renal failure as result of herbal intoxication. Traditional medicine is a very interesting subject, and when done well I’m sure is very good, just like the allopathic medicine that I know and practice. Both fields handle some exceptionally toxic substances. Unfortunately, some of the traditional healers have recently been using some exceptionally potent enemas (that’s right – bum is best over here) to cure a mild cough or a bit of diarrhoea. Instead of fixing the sniffle, children have been dying. When they get to us, with a bit of support and care, they sometimes get better. However on several occasions, as if there had been a massive communication breakdown in explaining why their child got ill, the parent repeats the enema and the child dies. For me, though, the most poignant moment during those hellish two weeks was certifying a beautiful little baby who had died as a result herbal intoxication. She wore a T-shirt with the inscription: “I’m not sleeping, just recharging.”

***




"Kiss me," the caption on one of the pairs of slippers that the
night staff were wearing.
It’s not been all doom and gloom though. There have been plenty of smiles, and even tears of joy, brought to my spritely face on a daily basis here at Holy Cross. They say it’s the small things, and when I looked down at the feet of the nursing staff running a busy Saturday night in casualty to see them all wearing pink fluffy slippers I couldn’t help but giggle. Although, it was a two way affair as they find the fact that I wear my wellington boots during the night shifts hilarious. However, I believe they are very practical: I get snake protection for the 300 metre walk from my house to the hospital; blood and other products can be wiped clean; I can pretend I’m at Glastonbury – not so practical, but it keeps me sane.





A gathering of "believers" collecting
 passers-by as they trundle down
 the corridors. To where though,
I have no idea.
During the end of that exceptionally exhausting and emotionally draining first two weeks of January I was greeted by a mass of people blocking my way to the ward. They were slowly marching down the corridor, banging their drums, dressed to the nines and singing the most sublime chorus. It brought a tear, well several tears, to my eyes. I have a real admiration for the faith that some of the people in this community have, even though I don’t share the same beliefs or attitudes towards life as they do. However, I could not help but be moved in a deeply visceral way.

***

I shall leave it there for now and write more on January soon where I had waterfall filled excitement with friends and a swell trio of UK elective students.
Myself and Mitch riding the wind atop of Port St John's airfield.

Myself in an extremely precarious spot above Port St John's.



Remember this guy? He came in weighing 10kg at 10 years old.
 Just over a month later and he now has life in his cheeks,
 a spark in his eyes and is now weighing in at almost 20kg.
 I didn't recognise him at first.



Friday, 21 December 2012

Cuttim Skin Blo Het Blo Kok



Women and children greeting myself and Ding (top right)
 after we visited a boma.
Christmas is upon us and that means two things at Holy Cross: stabbings and circumcisions. To be fair, both happen all year round, but there is a particular abundance of cases over the festive season. Why so many circumcisions? In the Eastern Cape, getting a traditional snip is a big deal; it is a coming of age thing, a boy becomes man affair, a rite of passage etc. I am not too sure on the history of it all as I have been told several different stories, but I am sure Google will give those interested a good answer.

Two khwethas from the illegal
boma - we took them home to their
parents.
For all this coming of age stuff, these young men risk a lot. Last season (we call them seasons, there are two per year and both coincide with the school holidays) we had one death and three auto-amputations – that’s when a man loses his penis secondary to infection: a particularly grim affair. Someone could go from attempting to become a man to losing probably one of the biggest symbols of their man-hood. However, when done right, the ritual is an impressive affair: Day one the foreskin gets chopped (traditional style) and put on the initiate’s, a khwetha’s, forehead – this is called the torch (something about shining the light forward and no looking back – well, they’ll never get their foreskin back); day 1-8 the khwethas stay inside a boma (a small hut built for the occasion), aren’t allowed to go outside, get little food and water and have to chant all night to scare off the witches; Day 8 they come out, eat a freshly slaughtered goat and do man stuff (singing, collecting firewood, putting clay on their face – that’s for witch protection – and so forth); for the rest of their time, about a month, they live in the boma, do a lot of chanting and get the occasional beating, possibly to show others how masculine they are; at the end of it all, the boma is burnt, they wash in the river and hey presto: MAN!
The kids were very excited after our trip to a boma.
My colleague Ding teamed up with some local healthcare workers, including a guy named Patrick who has done wonders for men’s livelihoods, to improve the public health campaign on safe circumcisions. They really have done a sterling effort and this season has seen only three admissions (that’s rather low) at Holy Cross. I stepped in for Ding last week and visited four camps, including one illegal site where I had my own police escort. I felt exceptionally privileged to get a glimpse of this local tradition, as without the guise of being a doctor on a special mission, no regular person would be let in. To be honest, all of the penises looked pretty nasty and it took some time to work out what was acceptable and what not. In the end, only one boy got taken back to hospital for admission. Fingers crossed he will make it back for his crossing the river ceremony, penis intact, and leave Holy Cross a man.
****
The young man - chest drain in, eviscerated bowels, about to
be wheeled to theatre.
Circumcisions going wrong are one thing, stabbing and the occasional gun shot is another. Matters have not been helped by our recent shortage of intravenous fluids, which has made resuscitation rather difficult. Last week a young guy was wheeled into casualty with his intestines out for all to see. His friends were obviously concerned, as all five left straight away – maybe they weren’t his friends at all. As I assessed him I noticed these findings: he was heavily intoxicated with alcohol, in a fair amount of pain, had blood and air in his right lung (a haemopneumothorax) from a very small stab wound on his back and  had eviscerated his bowels. So, I popped a tube in his chest to drain the blood and air, gave him our last bag of IV fluid and asked my boss to come help repair the small bowel lacerations before sending him to our referral unit. All went pretty smoothly, I was working with my favourite selection of nurses, which is always a bonus, and the man was relatively stable. Unfortunately, he was bleeding into his abdomen and needed major surgery – something we cannot do. I hear he made it to our referral unit and I am led to believe he got to theatre, but he died later the evening as a result of his injuries.
Why do I mention this case? It is not a particularly uncommon occurrence. However, I just wanted to highlight the difficulties we have with stabilising our critical patients (a lack of fluid and blood) and getting them transferred for definitive care. A surgeon and anaesthetist would be nice, better administration and management would be the dream.
The man made it to the referral unit,
but died later of his injuries. In the red
is Mr Beja - one heck of a nurse.
****
Working at Holy Cross constantly stretches my abilities, and nerves for that matter. There is uncertainty every day and staying sane can be tough at times, however I do seem to thrive off it. Saying this, there are occasions when I wish I was in the comfort of a big NHS hospital with lots of support around. I have just come off working 18 days straight, which included two 72 hour weekends on call. During the first weekend I was called to assess a mother in labour at about 2 am on Friday night as the baby’s hand was coming out of the cervix (for those that don’t know, head first is the usual way and occasionally feet first, but hand first just doesn’t work). The midwife wasn’t wrong: as I felt inside the mother’s vagina I was greeted by a tiny little handshake. I tried to push the arm back, but the baby really didn’t want to let go, so we went for a C-section. I performed the procedure and delivered a very healthy boy. However, getting the new born out was probably the easiest part (normally, it’s the hardest).
To start with, the uterus was rather vascular and bled quite a lot. Bleeding is normal, but sometimes there is too much of it. Secondly, the placenta was stuck (placenta accreta), so I had to manually remove it, which took a few moments. Thirdly, well initially I thought there wouldn’t be any thirdly – the procedure was almost over. I closed the uterus, tied the tubes (she had requested a tubal ligation as she already had four other children) and stopped all the bleeding. Or, so I thought. As I assessed the wound I saw a very unpleasant pulsatile ooze coming from one corner. Turns out I severed the right uterine artery, something you really do not want to do. This may have happened during the all too easy delivery of the baby. I couldn’t clamp it, so instead I tied a catheter (a tube usually reserved to help people pee) at the base of her uterus to tamponade the bleeding. As I, or my boss, were unable to ligate the artery, I left the catheter in situ (a salvage procedure) to stop the bleeding, closed her up and referred her to our obstetric unit 4 hours away for a hysterectomy.
This was a particularly good learning point for me – all procedures carry risks and having a decent idea of how to prevent and manage these outcomes helps. Tying the catheter at the base of the uterus is something I have only read about, but at least I knew about it and I knew what to do: DON’T PANIC. As a result, the lady made a good recovery.
****
By the way, “Cuttim Skin Blo Het Blo Kok” is Tok Pisin (national language of Papua New Guinea) for circumcision. I did part of my medical elective there as a student and have fond memories of assisting circumcisions, mainly because as we would near the end of the procedure we would say “clos to pinis now,” which means almost done.



This young boy has disseminated varicella zoster virus (chicken pox) all over his body - inside and out. He is HIV positive and was neglected for quite some time, but now he is doing very well.



This is a reminder card that I designed for HIV treatment initiation - there are still some changes to be made, as this is the pilot scheme, however, I was very excited to see it being used by one of our local clinics.

A 10 year old boy weighing 10kg - this is something nobody should ever see. He is severely malnourished due to HIV and a probable underlying TB infection. Fortunately, he is improving and now weighs a spritely 14kg.

Dancing in Durban at The Rainbow Restaurant - possibly one of my favourite haunts. I'm the guy in the black on the right - I'm now beardless.