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