Music is medicine

I witnessed something beautiful last week. As I was leaving work on Thursday evening, very excited about the Christmas weekend ahead, I walked past the psychiatric unit as I do every day. As I came closer I heard the sound of two woman singing – one a nurse and the other a patient. The patient was obviously quite heavily sedated on antipsychotics. The nurse had her phone out and was playing a well known song from which both of them were singing along.

As I stopped to admire the scene, the nurse paused the music and said: “Hey Doc, I hear singing and music is very therapeutic.” Then, without another word, the music was back on and they carried on. I sauntered off with a very big grin on my face, not only because it was the weekend, but because of what I had just encountered. As I strolled home I thought to myself: maybe psychiatry isn’t a lost cause here after all.

Merry Christmas from Holy Cross

Just a quick note to say....

******HAPPY CHRISTMAS******

I am on my way to spend the weekend with friends a few hours drive up the coast. There isn’t a snowflake or red santa in sight. Instead, I have a wilting 2 foot fake Christmas tree alongside several crates of beer, some wine and a little fizz piled high in the boot of Mitch.

Surprisingly, this week hasn’t been too busy. I expect all the “”frequent attenders” have decided that they’d rather stay at home and the drunk boys and their sharpened blades are saving themselves for Saturday and Sunday. I’ll let you know.

Instead of the usual sound of wailing drunk perforated young men, there has been the very similar cry of a man that can’t pass urine. Over two consecutive days I had two young guys who both came in with full bladders, unable to pass a drop (urinary obstruction). I’m not really sure why this was – one had had a serious trauma a few years ago, but it didn’t explain why I couldn’t pass a catheter. I expect both men had had nasty cases of gonorrhoea (or is it Chlamydia – my mind lapses) that has resulted in a spiders web of strictures to the extent that not even urine can pass, let alone a catheter. So, for my first and second time, I cut a hole in their abdomen and inserted a catheter  – a suprapubic cathether. Unfortunately, I didn’t have quite the right tools, so had to improvise. You should have heard the wails and screams – imagine having a full bladder and then having some smiling guy in a white coat putting even more pressure on it as he attempts to make a hole to free the urine. Of course, I had anaesthetised the skin and given them both some heavy opiate pain killers (the second a little more after seeing the reaction of the first guy), but the analgesia didn’t quite do the trick. However, both procedures were over in no time at all – the second was slightly messier and I ended up with bloody urine all over my shoes. After taking a much needed call of nature (with a little assistance from myself), both gents had an amazing look of relief on their face. They were very happy customers indeed.

As it happens I have seen a few smiles this week – one of my patients that I admitted back in October who I thought was going to die from a serious HIV related fungal infection around the brain (cryptococcal meningitis), is now smiling and laughing.  She’s coming to see me every month and looking stronger and brighter at each visit. What a lovely Christmas present.

The moustache has now left us - a christmas present from me to you. I do miss it though.

Lesotho snaps

Waking up with the village



The chief and his family (the chief is the old guy at the back on the left)



A brief stop on the only piece of flat concrete in miles around - a bridge

....more photos to come; the internet connection at Holy Cross timed out

Around Lesotho with a washing machine

Another weekend on call is looming. It feels like I only just finished the last one. However, I think I can forgive myself for thinking this as currently we are all working every other weekend. Spending twelve days straight at the grinding stone with three days off in a constant cycle makes my brain go a little fuzzy. Hopefully the fuzz will clear once more docs arrive in the New Year.

Before I carry on with tales about my weekend jaunt, let me just give a brief synopsis on some of the events of the past few weeks:  we had some excellent, eager beaver, students from Cape Town who got their hands dirty for two weeks; I now have a cleaner – she’s called Princess – my house was slowly developing a nice layer of dust before she arrived; I have a washing machine – no more hand washing thank you; I have started digging a garden – with any luck in the next two months I shall have tomatoes, onions, courgettes, herbs and some pansies; Mitch smells of diesel and beer; the work load is noticeably getting heavier in this festive season - plenty of boys post ritual circumcision are coming in with septic members, my paediatric ward is getting very busy and the number of booze related injuries are on the rise; I successfully managed to use the power of talking to calm a psych patient down; I’ve been to see my “KFC” guy who’s face I sutured – the wound is coming along nicely; I grew a moustache; I noticed a definite rise in the number of children crying when I tried to cajole them into being examined; I shaved my moustache; the children don’t seem so afraid of me anymore.

Just in case you wanted to know how my poorly updated log book is going, here is a quick summary: In November I documented 27 spinal anaesthetics, 1 vacuum delivery and 9 intubations. Already in December I have logged 11 spinals, 10 lumbar punctures, 4 evacuations of retained products of conception, 1 vacuum delivery, 1 chest drain and 6 pleural aspirations (thoracocentesis). I have stopped recording the amount of joint manipulations and reductions, wound suturing and other common tasks – partly out of laziness, partly because I forget.

So, why does my car Mitch smell of booze and fuel? A question you may want to ask the minister responsible for the roads in Lesotho. Last weekend my Dutch compatriot, Jelleke, and I embarked on a weekend jaunt in the small country of Lesotho. All week the weather in Holy Cross was absolutely fabulous, but as the weekend approached, so did the rain – and oh did the heavens open. Fortunately, rain is no problem when you’re driving a four by four like Mitch. Lesotho is only a 3 hour drive from Holy Cross and covers a mere 200 km from East to West. However, now I’ve been there I can only imagine that it takes several days to traverse the country on the uneven roads even if the weather is dry and you have Jeremy Clarkson and his pals at the wheel of their brand new Land Rovers.

Before reaching Lesotho, we stopped off in our nearest commercial centre to get a few provisions and do a little admin. After two hours in town I had acquired a jerry can full of fresh diesel, 30 bottles of beer, which I had put in ice in the cooler, and a brand new washing machine. Yes, that’s right – I took my washing machine to Lesotho.

We had booked ourselves into quite a nice looking guesthouse somewhere in the mountainous countryside that adorns this country. Unfortunately, we didn’t quite make it to that nice somewhere on Friday or Saturday night. As I mentioned, the weather was dreary in South Africa. However, when we entered Lesotho on Friday afternoon the sky cleared to show off the magnificent beauty that adorns this almost untouched land. After taking in the scenery I noticed two things: firstly there are no fences - the land is entirely shared; secondly, the roads are terrible. However, we were travelling in my car – Mitch – sturdy as they come – a bit like a shire horse on wheels. Shortly after realising how shoddy the roads were, both of us thought that the 150 km drive to our intended destination may not be quite as straightforward as we had anticipated. Unfortunately, neither of us had remembered our guide book or a decent map. To hand we had a large road map of South Africa that had a bit on Lesotho and a satellite navigation system that would only tell us if we were on a road or not, but nothing else (I hadn’t installed the Lesotho maps onto it). So, we just looked at the map and “guestimated” that we would make it to a town about 75km away. It turns out that as you drive further into the country, the roads get worse. So, it came to eight thirty in the evening - we found ourselves in the pitch black, but for Mitch’s bright headlights, driving up and down steep “roads” (the satnav called these roads “alleys”. These alleys resembled a track of some sort with very large collections of boulders) at walking pace. Lady luck was with us though. As Mitch rumbled into a mountain top village we were greeted by the usual hoard of children, but also a young guy who spoke excellent English. With no subtlety at all I enquired if the village would provide us with shelter for the night. After a brief meeting with the chief’s son, who was full of festive cheer, he agreed that we could stay in our new friend’s rondavel (round house). In return we offered beer – unfortunately, most of the bottles had smashed on the rocky roads and the jerry can had also taken a small hit. Hence it smells a bit like someone has had a party on an oil rig in the back of Mitch.

Except for an irate donkey eeyoring at 4am, I had a very peaceful night’s sleep. The following morning I awoke to the quiet sound of the hills and with my dreary eyes took in the beauty of the surrounding scenery as the bright sun beat down on the luscious green mountains. After meeting the chief, his slightly hungover son and the rest of his family, we said our farewells. Not before taking the obligatory family photo, though, which I will send to them in the next few weeks. I am still amazed at the hospitality that we encountered. The young guy that we met gave up his modest house for us to sleep in. It actually belonged to his brother, who died a few years ago. I later learnt that I slept in his death bed – so that’s why Jelleke was so keen to let me have the bed and she sleep on Mitch’s pull out mattress (did I mention Mitch has a mattress in the boot?).

The rest of our trip was mainly spent taking in the awesome scenery and sitting behind Mitch’s dashboard as we drove over mountains in the sun, rain and fog – sometimes all at once. It really was incredible. However, next time we shall plan a little better and take some more provisions and camping gear.

In case of curiosity – the washing machine works just fine. Apart from having to screw a part back in after the bolts fell out, it only suffered a few minor dents.

Bedlam

Here is one for my psych colleagues. As some of you may know, my last job in the UK was spent working for an incredible psychiatric liaison team at King’s College Hospital, London. I have always had a slight slant for the ones that are slightly loopy in the head – psychiatrists and mental health nurses; I enjoy the interaction with the patients too. As a student I spent many a Tuesday evening with a troupe of terribly enthusiastic psychiatrists, terrifyingly good actors and sheepish pupils like myself – but we soon learned the joys of working in mental health and many of our initial fears in dealing with “difficult to handle” patients soon dissipated. Now, you may ask, how can someone who loves dealing with the blood and gore of casualty also enjoy the long in depth assessments involved in psychiatry? True, they may be on different ends of the spectrum, but both are equally exciting and drab at the same time – in the emergency department you get the stab wounds, but also the sore throats; in psychiatry (often in the emergency department too) you see the floridly manic, but also the young teenagers who come in every week having just taken enough paracetamol to get them some attention, but never enough to die (I must say I do prefer it when they take the non lethal dose; also the conversation that is had is much more interesting than that of someone with a sore throat). As a result of all this I thought I was pretty prepared for dealing with mental health out here. How wrong could I have been?

Psychiatry – the talking medicine. Trying to get a medical history is hard enough here, let alone ask about mental health complaints. The culture and language is so different. Did I mention Xhosa is full of clicks and clocks of the tongue? Now, I am slowly learning this tongue, but at the moment my vocabulary consists of about 40 words and only around 4 of which are actually understood by my patients. According to them I still can’t pronounce the word for “cough” properly. They just give me a vacant stare and turn their head to look at the nurse who repeats exactly what I just said, but with a little extra fairy dust. This magic twist of the tongue turns my patient’s confused frown into a nice verbal response. Unfortunately, I often can’t understand what their reply is. And so, the process reverses as I turn to my nurse with a look of “what did they just say?”

I have quickly learnt that we don’t do too much talking to our patients here that are referred to as: “Doc, we have a mental case – can you prescribe some intravenous sedation?” The first time I was asked this, my initial reaction was – no way, let’s try and de-escalate this situation in a nice step wise manner – I have done a job in psychiatry don’t you know. So, let’s talk first. Plan “A” failed at the starting block when I found 3 security guards sitting on my “mental case”. One guard was gently pushing his foot on the patient’s neck (they had just zapped him with a taser). I didn’t like this one bit and kindly asked the guards not to antagonise our patient any further. Talking didn’t work when I remembered: “Oh yes, I can’t speak Xhosa. I can’t even pronounce Xhosa properly. Silly me.” My nurses weren’t very keen on opening any kind of dialogue so I offered him some oral medication to calm him down. Eureka – he happily swallowed down the cocktail of benzodiazepines and antipsychotics. Half an hour later, he was still causing havoc. At which point my boss showed up and said: “don’t bother with that, just give him the stuff intravenously.” Despite initially objecting, I caved in – the patient got his shot and quickly dozed off into la la land. This had taken about one hour of my time. I have fast realised that we don’t have the luxury to properly give our full attention to these patients, or any patient for that matter. When there is only one of you in casualty and several other people also needing your urgent undivided time, all one can do is temper the situation (and try to stop the security guys from using their taser). This often means heavily sedating our psychotic clients as first line treatment, making sure they are calm enough to put the rest of the department at ease but not so chilled that they stop breathing. The talking happens later, at some point.

We see a lot of psychotic patients. I expect most of the cases are drug induced as there is a serious amount of marijuana smoked here. The stuff grows like a weed. Every disturbed patient I have seen so far inhales chimneys of the stuff. Along with these lively characters, there are a lot of overdoses. Many involve similar circumstances to what is seen daily in a UK emergency department – young boys and girls that take a few tablets because they were having relationship issues, exam stress or just a bit frustrated with the normal ups and downs of life. Unfortunately the drug of choice here is a nasty organophosphate pesticide that is freely available. People use it to preserve millet, one of the staple foods eaten by the local population. Just one tablet needs to be taken and it can be game over. In fact, since I have been here I don’t know of anyone that has survived, but we do try as it is potentially reversible if you have the right drugs and equipment. We occasionally have the former, but rarely the latter. The saddest thing is that when you talk to these patients, the awake ones, they often regret what they have done and want to live. There is often little we can do apart from cross our fingers (not quite true, but it does feel like that is all we are doing).

So, that is a brief summary of the wayward state of psychiatry here – the pathology is present, but the effective management is not. The patients that remain on treatment are often on very old drugs that have many, often irreversible, side effects. They are quickly labelled as a “mental case”, which tends to stick for the rest of their life. However, on the up side, many of these psych patients often have a family member or friend that supports and stays with them – I just hope it is because of the love and affection and not the government grant that people with mental illness receive every month. Food for thought, though.

Minor surgery

This is my guy pre op - the picture doesn't quite do justice to how bad the laceration actually was

Post op - you can see he's almost smiling, right? I went to see him today (4 days later) and the wound is healing very nicely.

A Chelsea smile.

I am currently recovering from a busy weekend on call. Most of my war wounds, however, are on my hands and back after spending a little too much time gardening in the sun on Sunday. I have a glaringly red back and a delicious raw blister on my right palm from all the digging. I think I was slightly delirious after an insanely busy Saturday on call and didn’t really think about the fact that I was excavating beds in the midday sun whilst half naked. As I may have said already, there are two of us on call at the weekend – either you run the show Friday and Sunday or you take Saturday – the other Doctor is just on standby for emergency caesarean sections or when your colleague just wants a reassuring hand (I tend to be the one wanting that hand, especially in obstetrics). We only had one c-section on Sunday, hence all my gardening and wounds to show for it.

Saturday was full of fun. I started at 7 am and, with the exception of a 15 minute lunch break and 45 minute lull in the evening, I finished at 3 am. It was nonstop, wet your pants, fun. Here’s a brief summary of some of the more interesting cases: I had a guy who was run over – he had a massive bit of bone sticking out of his right leg; an eight year old boy who’s father slashed open his shoulder – exposing the bone, cutting right through his deltoid muscle – all because he lost their cows; a young drunk guy that was shot in the chest, but who had no obvious injury in his lung or heart; an old drunk guy that was stabbed in the neck – when the nurse gave the wound a clean a large artery, possibly his carotid, erupted and a steady spurting fountain of fresh blood soon covered my arms and white coat as I attempted to tamponade the bleeding (don’t worry mum, I was wearing goggles, mask and apron); a young boy that was thrown off the back of  a pickup truck, or “bakkie” as it is called here, who sustained a terrible head injury and degloved most of his scalp on the left, from which he lost a lot of blood; the usual stabbed up, occasionally belligerent, drunk boys and girls; a middle aged gentleman with severe respiratory distress who’s left lung was engulfed with fluid (pleural effusion) that I drained to his relief; the usual old boys and girls with chronic conditions such as high blood pressure and diabetes that present with the classic symptom of “pain in my neck veins” that get a bit of paracetamol , a sleep over and sent home.

Along with all of the above I saw a 22 year old male who works at KFC (he was wearing his work clothes you see, it’s not something I tend to ask about, but it did mean that his English was rather good) who was stabbed in the chest and face by his younger brother. I had to put a chest drain in for all the blood and air that had built up around his lung (pneumohaemothorax). I’ve only ever put a chest drain in on pig and cow thoraces in courses that I have attended in the past. A fresh human chest is a little tougher than a well hung piece of beef, but without gloating too much, I think I did it rather proficiently without the mere mention of a tremor in the hand or bead of sweat down my brow – probably because I was quite sedated with sleep deprivation at this point. Putting a tube in his chest was the easy part; his face was the problem. The laceration was, to put it quite simply: nasty. It bisected his nose almost in two then proceeded to go diagonally down and extended deep into his right cheek. His teeth and jaw were visible despite his mouth being closed – my doctor sense told me that this wasn’t quite right. Over the next two hours I slowly performed my own kind of maxillofacial/plastic surgery. Fortunately the good people of Flagstaff didn’t bring their next bleeding patient in until just after my work was complete. I must say I was rather proud of the end result – the guy looked good as new and had no functional or neurological deficit as a result of the injury or my “surgery”. I’m becoming a bit of a dab hand at these facial wounds – last week I sewed an ear back on (the girl hasn’t yet returned saying it has come off again or become infected, so no news is good news in that respect). Anyway, the chap was very pleased with the results, and despite the tube hanging out his chest, he kept on telling me “doc, you saved my life.” I asked him what he was going to do about his younger brother – the assailant that did this. The answer was: “Kill kim, I’m going to kill him.” I nervously laughed this off, but I fear there may have been a wince of truth in that statement. If he doesn’t attempt to murder his brother and stays in work, then maybe he’ll give me a good deal on a bucket of chicken if I ever get desperate enough to eat at his stomach churning establishment. My boss saw the wound today and all he could say was: “Beautiful.” This was probably a slight overstatement, but nice to hear nonetheless. I’ll upload a picture of his wound pre and post suturing.

I said that the weekend was fun – it was. However, it is deeply saddening when you see all the victims of violent crime, road traffic accidents and domestic violence. I couldn’t believe the father who put a bush knife to his own son. However, maybe those cows were their livelihood; maybe it was everything they owned. I can see how the dad would have turned red in a moment of disbelief and possible rage, but violence can never be the answer. The gentleman has since been arrested and the boys Mum lives far away. Now this 11 year old has a dysfunctional shoulder, a Dad in prison and probably no one to look after him.

More to come

Snaps

 I didn't realise Grandmaster Flash spent so much time in Durban

 Myself and Mitch in the Mkambati Nature Reserve at the end of my road. The South Africa National Parks Agency describes the road there as "terrible."

An amazing jazz club just north of Durban call "The Rainbow Restaurant". Very unique; hosts a very diverse crowd.

A local artist at the "BAT" centre in Durban. Excellent place that supports local artists, providing studio space and assisting them to obtain materials and sell their work

The ambulance bay at Holy Cross with the malfunctioning sliding doors that go into casualty. All the locals seem to have great difficulty working out how they open.

Tis the season to be.....circumcised?

Who would have thought it – I haven’t even had time to unpack my bags, but already my new found anaesthetic skills have been put to work. My delightful Dutch colleague gave me a call for some assistance. She had a young mother who recently delivered that was having an extremely tough time of it breathing. The mum was HIV positive and recently started on anti-retroviral treatment. However, unfortunately for her she also had a cancer linked to HIV, called Kaposi’s Sarcoma, growing around the entrance to her windpipe. It was asphyxiating her rather quickly. So quick, that we had to act. It wasn’t quite the slick affair that Dr Carter in E.R. would run alongside Benton and Dr Green. Here’s a condensed version of what happened:

J (Jelleke): “She’s stopped breathing.”

D (Dom): “Fu*k.”

J: “Sh*t.”

D: “Right, errr, there’s nothing in resus. Let me run to theatre and get the gear.”

J: Shouting to the nurses “CAN YOU COME HELP ME. I NEED SUCTION NOW.”

Nurses nowhere to be seen, despite all being in casualty minutes earlier.

D: “Lets do this.”

About 15 minutes later

D: “I’m in.”

J: “Great.”

And at that point we had secured her airway with a tube in her windpipe. We had been able to breath for her by blowing oxygen with a bag through her mouth until I put the tube down. Because of all the swelling in her wind pipe we were ready to perform a surgical airway, which is a bit like a tracheostomy, but a lot simpler. We transferred the patient to our referral unit for intensive care as she had a lot going wrong with her as well as the airway problem. Unfortunately, all our efforts were in vain – she died in the ambulance. I expect the tube fell out of her windpipe. As I have mentioned before, the ambulances don’t have paramedics or experienced technicians that can look after intubated patients.  Maybe some would comment that we shouldn’t have even tried to resuscitate her knowing the problems there are with transportation and the setting that we are in, being resource poor. We had to dedicate a lot of our time to her management (about 4 hours) – other patients had to wait to be seen. However, we are in South Africa – a country that has a large, well funded, but poorly managed, health system. There are specialists, intensive care departments; you name it, they have it. I agree, one has to be pragmatic and know their limitations, but also drink with a glass half full; at least try to the best of one’s abilities. Occasionally, in these desperate situations, there will be a happy ending.  Unfortunately our young mother wasn’t in that category, despite our best efforts. However, there are a handful of others that do make it – for me, that’s what makes what I do feel worthwhile.

On a side note, whilst we were trying to ventilate our lady an ambulance crew arrived with a guy in his twenties who had been in a motor vehicle accident. He was dumped on the resus trolley – he looked very ill. In fact, he was very still; not a sound. My colleague asked the ambulance driver if the man was alive, whilst she tried to ventilate our lady. We were told: “Yes, he’s breathing.” I quickly triaged him: He was dead, although I expect not much time had passed since his heart stopped, but long enough to starve his brain. No family were present; he died alone. I just said: “He’s dead,” and quickly moved back to our lady. In such circumstances one has to act fast and there often isn’t a lot of time for compassion. We acted to the best of our abilities, which sometimes means doing nothing.

In addition to all this pandemonium I have been back on the paediatric ward. At the moment there are a lot of happy punters; many of which were exceptionally unwell a few weeks ago. I have a boy that was literally taken by the horns of a cow; another who was hit by a car at speed who broke several bones and sustained a head injury; an almost mute 5 year old girl who looks like she is 12 months as a result of severe malnutrition (weighing only 10kg), poorly treated TB and, as we recently discovered, sexual assault - but even she is coming on leaps and bounds. I know we are not supposed to have favourites – but she is mine and I encourage all the nurses to interact and play with her. Life as she knows it has been so shitty, and probably isn’t much better now being stuck in hospital, but we can try and make it fun. Currently Holy Cross has six very enthusiastic medical students from Cape Town for the next two weeks. I have asked them to give her as much attention as possible. In return I have been teaching them in hospital (there’s always time for teaching, even if things are exceptionally busy) and feeding them beer outside of work.

Along with the kids that are getting better, there are some that aren’t. We have a young boy who has rabies after being bitten by a dog – it is endemic here, but often people get treatment before progressing to the disease. His mother is a healthcare worker, but she didn’t bring him to get vaccinated after the bite (which was only a very small scratch). The vaccine needs to be given as soon as possible to be effective. He has presented to us already with symptoms of the disease. His hydrophobia (fear of water) is profound – a very bizarre symptom, that is very typical of rabies. Other than that he looks quite well, but there is little we can do and it is likely he will die. Not even the specialists can offer help this time. It’s a waiting game and one where we need to show the boy and his family support and compassion.

In addition to the rabies case I also had another child today who was wheeled into the ward vomiting and taking her last gasps. Again, another situation where I thought to myself – do I try and resuscitate or not. But, how can I not? Especially in a child. Additionally, children have a different make up to adults and the reason their heart stops differs. So, I went for it. It wasn’t a happy ending though – I didn’t want to give her mouth to mouth (she was HIV positive and had vomit all over her); I shouted at the sister to get me a “bag-valve-mask (BVM)” – she ran (I’ve never seen anyone run here – I was very impressed and gave her a big hug and thank you afterwards); the BVM (something we use to help someone breath with an oxygen attachment) was broken and there wasn’t another one; I was left with chest compressions alone; her pupils were fixed and dilated (a sign of brain death); I realised what I was doing was futile; I stopped. I have no idea what was wrong with her, but wonder if she was given a herbal medicine or accidently poisoned as the family said she was completely fine at breakfast.

On a lighter note, the season has begun. No, not the festive season, although I hear that is fast approaching and I am quite looking forward to my weekend off at Christmas. The season I mean is the one where boys become men; Boyz 2 Men; where the woods become a hive of activity; the chanting and the rituals take place. Yes that’s right, it’s the circumcision season. Every summer (winter in the UK – don’t forget, I am in the southern hemisphere) tonnes of teenage boys leave their home and come back a few grams lighter (foreskin-less), covered in white body paint and with the newly acquired knowledge of how to kill a fellow human: apparently they are now men. If this is the case then I would much rather be Peter Pan and fly off to Never Never Land. The “man” recipe when mixed with alcohol makes casualty a fairly colourful place, especially at Christmas when everyone around the globe has one too many sherry’s – a mix of stab injuries, infected penis’s, incoherent patients, incontinence and more stab injuries. Fortunately, some of the kids are a bit savvier and want to join the lost boys, so they run away from the woods. Occasionally, such as on Monday, you get a young male who turns up looking a bit sheepish and uncomfortable. The casualty card read: “Has cut on penis after running away from woods.” When I first read this, I wasn’t too sure what to think – but I knew that I didn’t want to go into the woods. So, it turns out my man (he’s a man in my eyes) was about to get the snip, saw the blade, got a little nick of the skin and legged it. His penis was a bit of a mess and his foreskin was stuck causing his “member” to swell up – it’s called a paraphimosis. Once I reduced it his frown turned upside down. I have booked him to come back in three weeks to have a proper, sterile, circumcision. So as well as not getting a paraphimosis again, his lack of foreskin will mean that he can pretend that he did his manly duties. A win win situation I think. I’m just hoping he returns.

I am off to visit friends on the beach this weekend in a place by the name of St Lucia, South Africa – not the Caribbean. For the next few months it looks like we are all working one in two weekends. However, I shall be making sure Mitch (my car) gets his fair share of action on the ones I have off.

I will attempt to upload some pictures soon, but the internet at Holy Cross is too slow.

P.S. If anyone wants a Christmas card, then please email me your address.

And then he turned water into wine....all of it.

I have just returned to Holy Cross from my two week anaesthetic jaunt in Port Elizabeth (PE). What a rewarding experience that was. I was surrounded by enthusiastic, mainly young, anaesthetists and mentored by an inspirational consultant, Dr Smith.  I have come back feeling energised, full of knowledge, new skills and a slight sun tan. I am not expecting to walk into work tomorrow morning and have lying before me a patient that needs to be intubated. But, just in case there is, I am ready – I just need to make sure I know where the tools and drugs are to perform and make emergency anaesthesia safe. Hence, I’ve written a check list that I hope to use in the coming weeks so that I can pester the management if the hospital is lacking certain drugs or equipment.

During my fortnight in PE I gave my sinuous pins a good workout, hence the slight tan. Most evenings I went running on the beach, whilst the sun was still warm. The crashing of the waves and salty air did wonders for my psyche as I bounded along the walk ways and firm sand of the shoreline.  One evening jog was made even more magical as I looked out to sea and saw a whale do it’s “breathing” thing followed by that nonchalant: “Oh, I think I’ll just poke my tale in the air and slap it down on the ocean with a big splash. Oh what fun.” If whales could converse as we know it, then I expect that is what they would say. For some reason I was reminded of The Hitchhikers Guide to the Galaxy in the scene where a whale suddenly finds himself falling from the sky and the thought process he has as he descends to his quick demise. These are some of the things I think about when I am running.  Maybe I need to start running with other people so my mind doesn’t veer off track so often.

As I said, I met several anaesthetists in PE; almost a new one every day. I remember one conversation with one of the younger trainees, who is my age. We were talking about the difficulties many of the hospitals have, especially in the Eastern Cape (this is my only point of reference). As usual, the same problems were highlighted – poor management; no leadership; terrible stock keeping; substandard nursing; lack of pharmacists, physios, occupational therapists, dentists, doctors etc. Often a problem that we see here is that a lot of the staff, be it managers, nurses, porters, handymen and, shamefully, many doctors, do not often seem to know what is in their job description. You get doctors who go to work, see twenty patients (that’s their daily limit) then go home at midday; nurses who sit at nursing stations all day socialising; porters that need to be called every time to begrudgingly transfer a patient or take a blood sample to the lab; handymen that just sit in the shed all day and don’t do anything “handy” at all. Worst of all, there are very highly paid managers sitting in their office in Bisho (the administrative capital) laundering money from the health system. Well, this is what the anaesthetist had to say and I did have to agree with him on many of his points. I think, however, times are slowly changing and a big shake up of the way the health system is run here is slowly being addressed – at least this is what the politicians are saying, so many remain sceptical. I hear the chaps in Bisho are all getting the boot or a kick up their arse to actually do their jobs and come and work in the local hospitals rather than sit in their nice air-conditioned office.I have just heard that Holy Cross is expecting some new well trained nurses to make sure our team here work efficiently and proficiently. I wonder whether this will change things - I hope so.

 The chat about the difficulties the health system is facing wasn’t really my point though. Whilst we were talking, I started talking about the high number of organophosphate overdoses (incredibly lethal) I have seen at Holy Cross or the difficulty I have had managing diabetic emergencies. Both of which are treatable with the right resources. He was shocked when I told him that we often have no way of monitoring blood sugar, no trained staff to nurse an intubated patient and suction their airway and other, what he felt were bog standard, requirements. I was slightly taken aback by how surprised he was, even though he, being a South African, was talking about the problems hospitals in his country have in acquiring the correct materials. I had similar conversations with other anaesthetists in PE and most had a similar response. I am amazed, but not surprised, that some doctors don’t know quite how difficult it can be to work in the rural hospitals within their own country, as theoretically they should all be well stocked. After all, there is plenty of finance here. It is almost laughable: at Holy Cross we have about eight new fancy defibrillators (a machine to shock the heart back into rhythm), but no soap or paper towels to wash and dry hands with.  I am still clueless as to how the hospital procures items, but when I do, I hope I will be able to address a few essential issues. Number one will be making sure we have enough high calorie milk to feed our malnourished children; it is extremely embarrassing and frustrating when we admit a child and cannot feed them as we have run out of feed.

So, enough about the disastrous management here, what about my own? After weeks of complaining about my lack of organisational skills to stock the house with beer, I now have a very attractive looking stock cupboard filled with various pilsners, cider and a bottle of wine (I had 3, but managed to break two – dropped one and the other popped in the back of Mitch, probably as I hurtled over a few pot holes). I got back to base last night and found out that we have no water supply. Oh, what sweet irony. I guess I shouldn’t complain too much as I have a very large rain collector outside. However, I seem to have put a small hole in it whilst trying to work out how to turn the tap on. What makes the situation even funnier is that it is raining cats and dogs outside and there is a massive thunderstorm with more lightening than you can shake a stick at. A massive bolt of electricity has been illuminating the hills every minute for the past hour or so. It is an amazing spectacle, as I sit here gazing out from the safety of my sitting room. But it means I can’t even go outside to shower in the rain for fear of being struck. 

Back to work tomorrow. I hope the water supply fixes itself soon so that we can wash our hands, whether or not we have soap or towels.

Some notes by the sea

I’ll tell you what: time goes exceptionally fast here, just like it does when you’re anywhere new and exciting. According to this blog, I last wrote an entry about two weeks ago. Two weeks ago feels like two months ago, especially when there are so many new japes occurring every minute. It would be a mean feat to write about everything that has happened, so I’ll just summarise a few key points and then probably go off on one about this or that.

So, what has happened? I got paid; I bought a car; Dr Jelleke returned to work; I did my first solo on call; I attempted to resuscitate new born babies; I have had the return of some happy customers; I left Holy Cross.

Let me expand on a few of these points. I got paid last week. I am not really sure what happened, as I was reliably informed by several people (some that work here, some that have worked here and some that plan to work here) that it could take several months to get a pay cheque. The same day the money entered my account, it left. Hence, I am now the proud owner of a very big, ugly and exceptionally uneconomical, four by four. But, for all Mitch’s (the car’s a Mitsubisihi – see what I’ve done there?) brute and unwillingness to save the planet, he can take me to the far and beyond of the rural Transkei region where I live.  I shall let you know about my off road escapades in due course.

With the return of Dr Jelleke you can almost hear everyone breathe a sigh of relief, except maybe for her. Jelleke is a Dutch doctor who has been here for a year or so. She has just returned from what sounds like a delightful three month vacation. With our numbers now slowly on the rise, we will be able to get a slightly firmer hold on the issues that face the hospital and local population. We are expecting three more doctors in early 2012.  Of course, none of us can expect to make a “real difference” here as we come and go for one or two years at a time. This was never really my intention, despite the slightly over idealistic ideas I often hold. What we can do is to try and give the local population some sort of decent health care whilst we are here. If we can continue to get a rolling influx of diligent doctors, then Holy Cross shall be able to address and support the massive healthcare issues that the hospital is faced with on a daily basis. Not that this is the ideal. The ideal, I expect, would be that Holy Cross saw the arrival of some permanent, experienced (i.e. not myself) doctors and managers who could provide some sort of lasting programme. Preferentially people that speak the language and are aware of the cultural challenges that are present: i.e. Holy Cross and the surrounding hospitals need medical staff who grew up in this region. The problems lies in the fact that many of the local clinicians do not want to work in these very rural areas. I haven’t quite got to the bottom of why this is, but I expect it has a lot to do with the dysfunctional management that is commonplace here, the heavy workloads and the prospect of living in areas where there are no “good schools” to send their children to locally. The latter is a theme I hear a lot and the South African doctors that I have spoken to want to work somewhere that it is safe for their family; many talk of emigrating. Holy Cross is safe, but it is quite isolated. Hence, I can understand what they are talking about. For this reason, hospitals such as mine shall have to rely on a foreign, often young and inexperienced, workforce to provide medical care for the time being.

I did my first 24 hour on call last week. I realise I have been here for about two months now and have worked three weekends, but not been put on the on call rota properly until now. Dr Kakooza wanted me to become more comfortable with unfamiliar specialities such as obstetrics and paediatrics. Now, I must be frank: pregnant women still scare the living daylights out of me – well, only when they are fitting, bleeding or the baby won’t come out. I think I am ok at managing the first two points, but the last one is what I dread the most. This is because it is me that has to decide what to do next. If the little one can’t squeeze out naturally then how can I coax it out? And why is it not coming out? Are there some surprises lurking inside that I or our hospital is not equipped to deal with? We are not in a specialist obstetric unit after all. If the baby is just simply “stuck,” there are plenty of options, the last resort being to do a C-section and cut it out (although it seems like this is often the first port of call). My on call started without a hitch, in fact I was quite pleased with myself as I thought I made some sterling diagnosis and management plans that involved one young girl who had a probable ruptured ectopic pregnancy whom I stabilised and transferred. I slept for about 4 hours, which I thought was extremely decadent.  

Just as I was getting comfortable, and with one hour of the night left, I got a call from maternity saying that a mother was in labour, but not progressing well. First thoughts: “bollocks – the baby’s stuck.” On arrival I could see and feel that the baby’s head was very low in the pelvis and so close to the exit. It needed to come out quick as all that pressure on the head from the mother squeezing starts to make baby upset after a while.  The mother wasn’t pushing well, so I tried to assist her: I attempted to use a device to pull the baby out with a vacuum. This didn’t work. At this point, I told the midwives to get the mother ready for theatre as she needed an emergency C-section, whilst I called the boss. It was too little too late, the baby had been stuck for too long and when she came out she was very flat and floppy. It is at points like these when I am exceptionally grateful for courses, such as the Advanced Paediatric Life Support (APLS) one where I learnt a bit of neonatal resuscitation. I intubated the baby and performed CPR and managed to get her heartbeat back. Unfortunately, she just didn’t want to breathe for herself and a few hours later she stopped. We tried our best, but this time didn’t succeed.  It was the mother’s first pregnancy.

It is not all gloom and doom though; we do have plenty of happy endings. Whilst doing my paediatric ward round I was greeted with a massive hug by a very happy five year old. It took me a few seconds to work out who he was because the last time I saw him he was sick as a dog and struggling to breath. I had sent him to our referral unit and they found he had a big growth around his vocal cords that was growing quite quickly and slowly asphyxiating him. Oh what a delight it was to see him running around and chatting. The previous doctors that had seen him had all given the boy a diagnosis of asthma, which is quite different. What they thought was a wheeze was in fact his windpipe slowly closing up and causing a stridor. I gave myself a pat on the back for that one – good job Dom. The next patient I saw was a rather malnourished infant who decided it would be a good idea to poo all down my leg when I picked her up – I could tell she was improving as she gave me a big smile after that. It provided quite a lot of amusement for the mums, kids and staff on the ward. I really do need to invest in a washing machine.

Oh yes, I also mentioned that I have left Holy Cross – only for two weeks though. I’m currently attending an anaesthetics course in Port Elizabeth (the maritime industrial hub of SA), which is about 8 hours south of my hospital. I have been working alongside the anaesthetists here and spend most my days assessing patients, putting them to sleep or making their legs numb with a spinal anaesthetic and then bringing them round. I am halfway through and have been absolutely enthralled by it all. The training here is quite different to the UK and all the anaesthetists I have worked with are my age and have been qualified only a year or two longer. As an intern, which is the equivalent to the UK foundation years (what I have just finished), they spend two months purely doing anaesthetics. Actually, the idea of intern training in South Africa is so that after completion, the doctors are ready to work in rural hospitals. Something I find quite ironic – as when I tell my new colleagues what I am doing, they often look at me in amazement. Yet, they are far more qualified to do what I am doing. Another fairly amusing observation is that the doctors here are constantly complaining about the “bad management” (a bit like I expect I have started to do) – stating that they don’t have the correct bandages to secure intravenous lines down etc. So it seems, the poor management is a universal issue here in SA. I wonder if we will improve anything at Holy Cross.

One week into the course and I have done plenty of spinals, a fair few general anaesthesias and even helped the paediatric intern successfully resuscitate a new born. After our triumph the intern came up to me and thanked me for my assistance. Of course I didn’t tell her that this was only my second neonatal resuscitation – the first, which I mentioned earlier, did not go so well. Maybe my cool demeanour gave her the sense that I knew what I was doing – which I think I kind of did. Unfortunately, when I am back at work I shall rarely have the luxury of a colleague to give me that reassuring nod or whisper in the ear. Hopefully, this will only make me stronger and sharper, rather than lazier and disillusioned. Do not worry; I shall never become the latter. Besides, things are set to change soon when our new doctors arrive.

I am sitting here writing this from a cabin that is sat right on the sea. It is just magical. This is what I came to South Africa for – the intense work and the breathtaking vistas. Stunning.

A couple of snaps

The frontage

What I wake up to each morning

Just another sunset

Friends up in Kwazulu-Natal

A sombre moment

Death can be sad, it can be funny; sometimes it feels right, sometimes it feels stolen. This morning as I skipped merrily into the paediatric ward I learnt that a five year old boy I had seen the day before was dead. Death is quite a common theme around here, especially with the amount of young children and infants I see with HIV related illnesses. However, this one was quite unexpected, if I can refer to it in that way. Yesterday the boy was all gay and happy; twelve hours later his heart stopped.

He was admitted the previous night, accompanied by his family, after a horse had kicked him. This is not an infrequent presentation here. Often the kids bounce home after a brief admission for observations, with only a few cuts and grazes to show. He was no different from any of the other children I have seen; in fact I would have said he looked far better. He had a niggling tummy pain, like many of the children do, but no other signs or symptoms of impending doom. He was very much “stable”. I kept him in for observations. During the night he started vomiting and became very agitated, according to the staff on shift. He was probably bleeding internally. No doctor was called and he gradually deteriorated. Why observe someone if you’re not going to act on the results?

I saw the mother this evening. She presented to casualty in a state of hysteria. It all felt so unjust. He was so well. Learning from your mistakes is one thing, but when it takes the life of a child it is a very different matter indeed. I am not trying to say that a child’s life is worth more than anyone else’s, but for whatever reason, it can sometimes feel more significant. What could I have done differently? Or, more to the point, what could we have done differently? Could we have prevented this untimely death? A question I’m sure his family are pondering, as well as myself.

I keep asking the nurses to call a doctor if a patient’s observations jump the wrong way, but the message doesn’t seem to have quite got through yet. Instead, I often get told the next morning that a child’s condition has changed and that they have “rested” (i.e. died). Hence, I try to get all my unstable children transferred to a better staffed unit. Often there isn’t a lot we can do, but in a case like the above, we could have definitely tried. I don’t blame the nurses though. I can see their point of view. They are very short staffed too, frequently have inadequate training and often have difficulty, to the extent where it is almost impossible, to get hold of a doctor. This is especially true at night when there is only one clinician on call. Hence, I visit my ward at least once a day and liberally dish out my speed dial so that I can be called.

There is so much to address, but we will get there one little bit at a time.

I love the NHS

It is difficult to decide on what to write about when every day I am encountering new, often exciting, commonly daunting, situations that I want to share. But, if I did that then these entries would be very long and probably quite dry. Surely I need to keep my readers engaged? I guess I shall start with a quick round up of a few of the things I have done so far. As an aide memoir I have created a log book of procedures and the occasional interesting case. It’s a little geeky, but so what. I try to document as much as I can remember; however, I often let a few days slip here and there. Since commencing the record on October the 11^th I have done 14 spinal anaesthetics; 6 lumbar punctures; 2 evacuations of retained products of conception (that’s when someone has a miscarriage or abortion and they have the “products of conception” still within the womb. They need someone to tempt them out); 1 dilatation and curettage; 1 incision and drainage; 2 joint manipulations; and today I performed my first caesarean section and tubal ligation (sterilisation). It took me a steady hour and a half (I think the average time for the doctors here is about 20 to 30 minutes). I sweated out half my body weight – it’s quite nerve racking when there is so much that could go wrong. Fortunately nothing did; it all went swell and the little thing that popped out made the very reassuring sound of “whaaaaaaaa whaaaaaaaaaaaaaaa [crying].”

 I guess some of you must be wondering what else has happened the past couple of weeks, no? Well, here are some highlights (or lowlights, depending on how you look at them):

Yesterday I was woken by the night doctor to give me a handover. A young gentleman had been shot at close range in the abdomen whilst robbers tried to hijack his car. When I arrived in casualty, there he was, obviously unwell. However, unlike the normal young kids we get who turn up intoxicated with a few friends, this chap, a teacher, was accompanied by an ever growing mass of family and friends. There must have been about 100 people, which was rather a daunting sight when I first assumed they were all patients.  Whilst I made sure the gentleman was stable and tried to get him, unsuccessfully, transferred by air, the growing mass kept coming in to pray, a few at a time. For an outsider like me, it looked and sounded like they were all trying to perform an exorcism, as one man chanted: “Jesus, make this evil spirit leave him. LEAVE EVIL SPIRIT. LEAVE, LEAVE, LEAVE.” Maybe the bullet that was lodged somewhere deep in his viscera, was the evil spirit – in which case, I definitely had to agree with them. However, I think an experienced surgeon would be more effective than shouting at the metallic object. After five nervy hours in the department, the paramedics and a doctor arrived (this was a man with health insurance – the level of care one gets is far superior. We are so lucky to have the NHS in the UK) and shot off into the mist. The mist is what stopped the helicopter coming. I’m waiting to find out how he does.

I’m quickly getting used to dealing with sick kids. In my first week on the paediatric ward I had two infants die within hours of admission. I remember feeling a little helpless. I recognised that both children (one had a severe HIV related pneumonia and the other bronchiolitis) were absolutely exhausted. It doesn’t take rocket scientist to spot this. However, I also knew that both probably needed respiratory support as they were starting to struggle. The problem, as I may have mentioned before, is that we don’t have any higher care (e.g. ICU) here and the nearest centre is at least 5 hours away from the point of referral to arriving at the Nelson Mandela Academic Hospital (NMAH). In fact, that is not strictly true – we do have a “high care unit,” but it is not up and running yet due to staffing issues. I have absolutely no experience in looking after a ventilated child, but I may have considered intubating the children if I was present at the time when they stopped breathing and I knew we could manage them in house or refer them safely. Unfortunately the local ambulance service we have here has some serious limitations, unlike those in the private sector. It is more of a glorified taxi service where the driver wears a uniform and gets to drive with flashing blue or red lights; there are no paramedics. It can be a desperately sad and frustrating situation, especially when limited by one’s own inexperience and lack of facilities locally. However, I hear there is a helicopter that comes with a paramedic or doctor. Unfortunately it’s only dispatched in certain scenarios. I’m waiting to find out what these are and eagerly awaiting my first transfer in the chopper.  

I spent last weekend visiting friends who work up in Kwazulu-Natal, the province north of mine, where Durban lies. The five and a half hour drive shot by as I took in the scenery, blasted out my music and sucked in the clean air of the expansive roads. The journey was only interrupted for a few car viewings. What a weekend – I got my fill of beer, conversation, food, beach, late nights and general hedonism. It appears that we lead quite different lives outside of hospital. I am very happy with mine in Holy Cross, but it’s nice to know that if I want a bit of a release then I can just shoot up north.

More to come.

Apres ski

I was going to write another entry about more of my medical joys and woes, but then I thought: “No, I won’t bore people with yet another tale of how I didn’t quite save the day. What they need is a little light reading: an interlude.” So, I thought I’d scribble something about what I get up to outside of work. Saying that, however, the job has been very engrossing; I say that in the most positive way. Hence, my etchings may seem rather thin, but I think they have been rich and rewarding.

The hospital is rather far out of town. There is no bar or discotheque in the local area that I can just “pop down to” for a beer and a boogie, unlike in Camberwell. Actually, there is a bar about 5km up the road; however, it tends to be the scene of a lot of the stab wounds we see in the evenings. So, when I say there isn’t a bar, I mean not one that I would feel entirely comfortable in. This is especially true when my local colleagues tell me I would be giving myself a death sentence, or more likely a few cosmetic alterations. Either way, I’m not too keen on finding out. Unfortunately, my fridge has a distinct lack of beer or wine at the moment, so I have resorted to drinking a lot of tea and coffee as a sun downer in the evenings. But, just in case there is an impromptu party in the area, I have plenty of glow sticks primed and at the ready.

Work is meant to finish at 4:30pm, but at the moment with the shortage of doctors we tend to finish a little later. Hence, I tend to finish as the sun is setting, which is about 6pm at the moment. If I’m lucky and get out in good time, I don my trainers and hit the local surroundings for an evening jog. I used to be a very keen runner, and still am, but after sustaining an injury in May, together with a 4 month job in psychiatry, I somehow ended up spending a lot of time in the pub. My once running prowess took a stroll. It’s only recently that I’ve really got back into the swing of things. However, the local geography is not kind on drainpipe legs that are out of shape. When I exit the hospital grounds I have two options – run up hill right or run up hill left. I always go right: seawards. The road meanders along rolling green hills towards the Indian Ocean. Unfortunately, I am not quite fit enough to make the 45km to the coast at the moment, but I’ve put it on my list of things to achieve whilst out here. Instead, I run as far as I dare, knowing that I’ll have to turn around and get back in good time before it gets dark. The bandits, rabid dogs, snakes and vampires come out when the sun goes down, don’t you know. If, however, I finish work at this witching hour, then I tend to run circuits around the hospital grounds, but it’s not as fulfilling and I tend to get bored quite quickly. Once the construction workers leave the hospital at the end of the year, we’re going to make a volleyball court. Something I’m exceedingly excited about.

The evenings are rather quiet here. I have an absolutely incredible view of the valleys beyond from my sitting room and porch. They’re both great places to take a pew with some dinner, write a few notes or delve into a book. So far, I have been steadfastly reading about HIV, TB, obstetrics, gynaecology, paediatrics, medicine etc. whilst dabbling in and out of a novel to keep me sane. It’s interesting, because without the distraction of the hubbub of city life I’ve found it really easy to sit down and swot up. Something I was never too good at back home. I expect it is partly because there are fewer distractions, but I think there’s another more overriding reason. I think I’m compelled to read up more on the diagnosis and management of certain conditions because I know that the decisions that I make here actually count. They make a difference, whether good or bad. I hope I mainly make the former. Maybe this is why in the UK I never really had that gravitas to delve into the books each night because I always knew I had colleagues or seniors to help if I was having difficulty with a particular case. However, I expect the draw of the local social scene was a large contributing factor in that case.

Once things calm down on Fridays, I pack my bags and shoot off to new lands. However, at the moment, this shooting off requires me to borrow a car – something one really needs out here to be independent. So far I have seen small snippets of the “Wild Coast” consisting of tremendous jungle lined cliff tops dropping down into the rolling waves of the ocean; spent a weekend in Durban, where I failed to get a curry or a motor, but instead met up with friends. I’ve worked 2 out of 5 weekends up until now. Hence, I haven’t really had the chance to explore that much.

As one may gather, it is quiet here, but I am enjoying the tranquillity outside of working hours. It can be quite demanding in the hospital. But don’t worry, I haven’t started meditating or converted just yet. My sanity remains, or at least I like to think so.

By the way, sorry for the lack of photos - my internet connection is too slow at the moment.

The kids are (not) alright.....

This is my house (yes, it is rather big for one person as I said) and the massive red thing on the left is the most petrol thirsty beast I have ever driven. Sadly, it's not mine. It belongs to Jelleke, the dutch doctor who's currently on leave until November. I'll upload some hospital pictures soon.

I’ve been delegated the task of looking after the paediatric ward, as well as assisting in Out Patients and Casualty.  After all, I did tell the boss that I wanted to get more emergency department experience.

I’ll start with paediatrics. Looking at my CV, I could kid myself into thinking that I have a little bit of experience – I had a rewarding rotation as a medical student, spending 3 weeks of it at the King Edward Memorial Hospital in Bombay. However, I seem to remember spending most of my time watching cricket and sitting on our apartment rooftop. Maybe I should’ve paid attention. The only real experience I have had is doing paediatric A&E at King’s in London and my Advanced Paediatric Life Support course (a last ditched attempt to kid myself that I would be fine down in South Africa). So far, I’ve had no major catastrophes. Kids are pretty simple: when they’re sick, they look sick; when they’re well, they punch you in the balls and then hide behind their parents. The main problem I’ve had is knowing what to do with the kids who are somewhere in between castrating you and knocking at deaths door. How do I really know if that infant has TB? What on earth do I do when there’s a child with cardiac failure or nephrotic syndrome? When do I start HIV treatment in a child who’s looking close to heaven? These are all questions I pose my two bibles – one is yellow, one is blue. So far, they’ve been my guiding light as some of my colleagues don’t give me a straight or very helpful answer. Actually, that’s not true, but it’s a pain to discuss every single patient.  When they’re really sick, I just phone the referral centre for advice/transfer. However, sometimes they’re just too sick to be transferred. This was the case with a 2 month old bubba I admitted with a severe pneumonia secondary to probable HIV infection. I was sure she would pick up with aggressive treatment, but she died within a few hours of admission. HIV is an absolute epidemic here and kills a remarkable number of infants. Often the mothers don’t know they are HIV positive themselves until they present to hospital in labour, where HIV testing is routine. I still have so much to learn about HIV management.

Out patients, or OPD as it’s called, has only one word to describe it: INSANE. I’ve seen people with undiagnosed end stage HIV all the way through to someone with a minor sniffle and sore throat (but one does always wonder if that’s the patient seroconverting – for the non medically inclined, that’s when someone first gets the HIV virus). Most of the time I feel like I don’t really have a clue what’s going on, but if they look unwell I keep them in and just make sure I’ve covered ALL the bases with treatment and hope they improve. This may not be quite evidence based or the best use of resources, but it seems to work.

Casualty is like any other emergency department, just with a load more knife and gunshot wounds than I’m used to (even coming from Camberwell in south east London – supposedly an area with the highest proportion of gun and knife crime in Europe). If you don’t know what I mean, then you should go hang out in one some time. It’s incredibly fun.

On the way to work each day I walk past the “mental ward” and get asked by the patients: “eh Doc, you gonna come discharge us today?” Each time I sheepishly reply “Uhh, no, I’m not the doctor looking after you, but I’ll ask him.” I eventually asked him today and he said that they say the same to him, but they’re just not ready to be discharged yet. However, I must say I haven’t seen him visit the ward in a while, so maybe he’s not being straight with me or his patients.

Here is something you might find interesting; something I find quite odd. A couple of the doctors do a prayer before commencing a caesarean section, or any procedure for that matter. Now, I don’t know about you, but if I heard the doctor/surgeon praying just before cutting a nice big hole in my belly I would not be reassured at all. However, maybe that’s just one of many cultural differences.

This week I have been trying to get my head, and hands, into obstetrics (amongst other things). Within the next two months or so I need to be efficient in managing obstetric emergencies and competent at performing a number or procedures including caesarean sections. The idea of this is quite daunting when I think about everything else I am quickly attempting to absorb. On the other hand, it's very exciting too. However, the glutinous blob of jelly that sits in my skull is fully saturated after a week of work and reading. So, as a treat I've left the countryside and arrived in Durban. I'm planning on eating a lot of curry (there’s a big Indian contingent here) and see if anyone wants to sell me a car.

Domx

The adventure begins

Thursday 29^th September 2011

Hello family, friends and curious folk, I have been missing you all. You may be pleased to hear that I arrived in South Africa safe and sound just over a week ago.

Just for a little orientation: I am working as a “Level 1 Medical Officer” at the Holy Cross Hospital, which is 20km outside the small and chaotic town of Flagstaff in the Eastern Cape Province. We’re situated about 40km from the coast, referred to locally as “the wild coast” for its sheer beauty and isolation. Holy Cross was set up in 1923 by some philanthropic missionaries. In the past decade it has undergone a massive rebuild and looks very modern and glam. Unfortunately, for what is has in glitz, it lacks in numbers of doctors and well trained clinical staff. The hospital has about 450 beds, but only around 250 to 300 are currently active. There is a casualty, out patients, a medical ward, a TB ward, a surgical ward, a paediatric ward, a maternity ward, a psychiatric ward and theatres. It serves a local population of about 300,000 and has satellite clinics to provide the people with basic health care as well as HIV and TB treatment and monitoring. For all this, the hospital has a mere 4 doctors, of which I am one. It’s the smallest amount for doctors the hospital has had in a long time. However, 3 more are coming later this year. 10 would be ideal, but 7 shall do for now. All the doctors live on site in houses within the hospital compound. I have a large 3 bedroom house to myself with lovely views over the rolling hills surrounding the hospital. So, plenty of space for visitors.

Since I landed, I have been through a lightning bolt induction and straight into the thick of it. I have been supervised by Dr Kakooza, the delightful and experienced Ugandan doctor who’s been running the show for almost two decades. So far, I have been left to my own devices in casualty where I have seen extremes from a heart sinking patient, younger than me,  with advanced HIV and TB who died before I got to see him (quite a common situation) to the more absurd such as a gentleman who was bitten on the end of his penis by a spider. 

During my fist week here I have admitted a child with a nasty snake bite; plenty of adults and children with large burns; pregnant women who just don't stop bleeding; managed poly trauma victims; incised and drained a large abscess, getting pus everywhere; administered spinal anaesthesia (under supervision); and all the things I am more used to such as diabetic ketoacidosis, chest infections, strokes etc. – however, even these conditions, which I am more than capable of dealing with, become difficult to manage in the way I am comfortable with. For example, I find that there are no BM stix to monitor blood sugars, meaning a sliding scale would be unsafe. So, one has to improvise to make sure things are done safely. Well, that’s the theory.  I have so much to learn, particularly with regards to TB and HIV management, hence, I’ve spent most evenings reading about them. Of note, I haven’t seen one ECG since I arrived – we don’t have an ECG machine. Whether this is because heart disease is uncommon, despite the high prevalence or hypertension and diabetes, I do not know.

Rather than spending my first weekend exploring the local flora and fauna, I agreed to spend it on call with Dr Kakooza. A weekend on call means that you are on duty from 12:30pm on Friday afternoon until 8am Monday morning. The weekend was busy, but pretty uneventful until about 10pm on Saturday night when I had a phone call from the boss to see if I could give him  a hand in casualty. I walked the 2 minute stroll down the hill to find that A&E was choc-a-bloc and an ambulance had just arrived with another 4 seriously injured patients – nearly all of whom were from a large road traffic accident involving one over laden vehicle. The dangers of not wearing a seat belt – kids, pay attention. There was also a handful of young men who decided to stab each other (very inconvenient) – it seems to me that they all know where to direct a lethal blow as the knife wounds were deep into the chest and abdomen. Why can't they just give each other a little poke in the arm or leg? Apparently the young men are taught how to kill someone when they go through an initiation from boy to man, i.e. having a ceremonial circumcision.

Before I arrived, Dr Kakooza had already attempted to resuscitate a 4 year old child with multiple long bone fractures – she died. I was greeted with massive deep lacerations, open fractures, open head injuries. It was insane, but once I got into the flow, there was a certain buzz about the whole evening. Together we pulled the breaks and applied plaster; washed and sutured the wounds and attempted to make sure no one was so critical that they needed transfer to a hospital with surgical facilities. We admitted about half of them. Pethidine is the drug of choice out here for pain relief, but I think a lot of the patients still had to bear stoical agony, although some not so stoical. There’s a distinct lack of morphine.

During my 2 years as a doctor I have never seen so much trauma, and all piled into one night. We triaged the patients ourselves, quickly seeing the sickest first – making sure they were alert, giving analgesia, IV fluids and blood in some cases. I attempted to treat each patient with the ATLS (Advanced Trauma Life Support) principles. However, needless to say, no one came adorned with a neck collar or on a spinal board and everyone complained of neck pain associated with plenty of distracting injuries and some alcohol on board. I did the best I could and stuck to my ABC’s. Fortunately no one we encountered (apart from the child, that died) had any immediate threat to life. It was a night for the orthopods, apart from the fact that there are no orthopaedic surgeons at Holy Cross.

Unfortunately for the orthopods, they’d have no xrays to look at. After hours and on the weekend, the hospital has no radiology or laboratory service. It’s clinical acumen all the way. I was so pleased I did the shift with Dr Kakooza (and I think despite his wealth of experience, he was grateful I was with him too). In normal conditions, at the moment with the shortage of medics, there would only be one doctor on call at the weekend.

In one night I learnt how tread water in relatively limited conditions . Throughout the pandemonium, there was relative calm and all the nursing staff, porters, security and cleaners all chipped in with a little encouragement. I kept a smile on my face and a click in my step.

I remember commenting last year whilst at King’s that doing medicine there felt as if one was constantly treading water and keeping the storm at bay. Well, I was wrong, that was a mere breeze.  Here, the medical, and every other ward/department, is a full blown typhoon and it’s more like trying to bail out an already sinking ship. One analogy my boss used was: “It’s like the tap is broken and the water keeps running, so we keep mopping it up. However, what we need to do is find a way to turn off the mains, but no one has a wrench to do so.” It’s often the case that on the wards or in casualty, you’ll know what to do, but not have the resources or facilities to do it. For example, I admitted a young guy with probable meningitis. It was out of hours, so I couldn’t do a lumbar puncture, any bloods, imaging etc. It’s now two days since he was admitted, and I still haven’t been able to do any of the above. He’s on the right treatment though, and improving, so maybe that’s enough, but it doesn’t feel quite satisfactory.  However, we are working to the best of our abilities and one has to be pragmatic about it all.

It’s not all chaos and pandemonium though. One of the most enchanting aspects of working here is the singing. Most mornings and occasionally at lunchtime you’ll see and hear the hospital staff standing around and singing gospel anthems. Now, maybe they should be attending to their clinical/clerical/whatever duties, but oh it is lovely and gives some light to the bedlam. For example, while there was a lull in casualty last Saturday evening the nurses all started singing. For the few minutes that it lasted, it gave me time to reflect on the day and take in all that had shot past. Luckily, there was an abscence of gun shot wounds that evening.

I’m not working this weekend, so maybe I’ll be able to explore some of the local surroundings.

Just one more thing, in answer to the statement that so many people posed before I left: “Wow, that’ll be an amazing experience “– I think you were right, it’s already turning out to be that. So, do you want to have an “amazing experience” too? As I mentioned earlier, the Holy Cross is in desperate need of more doctors, dentists, physios, dieticians, OT’s. Get involved and go tell the people at AHP (African Health Placements) that you want a job here. You can come and live in my house; I have space for two more.

I'll post some photos of the place soon. Internet is pretty non existent here.

If any of you get bored, please send me a letter/post card. It’ll be a nice distraction from reading my medical textbooks.

Dr Dominic Craver

Holy Cross Hospital

Private Bag X 1001

Flagstaff

4810

South Africa

Domxxx