Dom in South Africa: January 2012

I recollect writing a while back that we were expecting the arrival of three doctors in November. Unfortunately, they still haven’t arrived. There seems to be a big problem with delays from the South African health board. Their process of certification is extremely convoluted and puts a lot of potential health care workers off. It’s absurd really: a country so desperate for doctors that has a massive brain drain makes it incredibly hard for foreign medics to come work. I understand that checks need to be made to ensure that you’re not employing Dr Nick from the Simpsons, but in some cases it has taken over a year for the applications to be verified. Together with this, one only needs to give a month’s notice before leaving a job here. Hence, there are plenty of hospitals, like ours, that are running on cotton threads. It’s not just me who thinks this is a problem – the papers are plastered with stories of local hospitals threatened with closure due to a lack of doctors.

I am really enjoying my work here, but am often frustrated with the poor care that we offer for many of our patients. There is a lot that can be improved at Holy Cross – all it needs is a little direction and leadership. Unfortunately, there aren’t too many folk here that are motivated enough to try and salvage this sinking ship – maybe it’s not that bad, but it certainly feels like that sometimes. I hope that the arrival of new doctors will help us rejuvenate this once successful hospital and spur the staff into being a bit more pro-active.

I think being “pro-active” is a bit of a taboo subject here. Earlier this week I arrived in casualty to start seeing patients. At the front of the queue were some very well looking people; slumped in a wheel chair in the middle of the department was a dreadfully sick looking girl of about twenty. To be quite blunt, the triage here is crap. The nurses were sitting and gossiping at their station (a familiar site) and hadn’t blinked an eye at this young female with her mother. It is not uncommon to see cases like this – they often have end stage HIV and already beyond the grave. However, one should never assume that the point of no return has passed. I whisked her onto a bed – myself and her mother; no help from anyone else. Before asking any questions I resuscitated her – she was septic and in a state of shock. I went through my A-B-C (d.e.f.g. “don’t ever forget glucose”) – her blood sugar was dangerously low. She responded well to my treatment and went from an almost comatose state to being able to tell me how poorly she had been. It turned out she was HIV positive, not on treatment, and had just been diagnosed with multi drug resistant TB. The latter diagnosis carries a pretty poor prognosis, but only time will tell. It made me wonder, though: how many other incredibly sick people get brought to our hospital and are left with the assumption that they are far too gone. But then, is my treatment just prolonging the inevitable? Prevention is better that cure. However, you try and tell some of my clientele the importance of condom use.

I feel like I am having a go at my nursing colleagues – I don’t mean to. Many of them are amazing and I love them to bits. Without them, we would be completely stuck here.

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I saw a gentleman last weekend who managed to chain saw his own knee – putting it back together was a bit like a jigsaw puzzle: “This flap here seems to fit with this one there. This tendon fits with that one...” I was quite keen to admit him to the ward so that I could refer him to the specialists the following day. However, he was more concerned about going home to make sure his money and gun were secure. I let him go as long as he promised to return – he stuck to his word and was back later the same day.

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A lot of the time things get lost in translation – my Xhosa is terrible and the Xhosa to Zulu to English translations often get a little skewed. Last week I saw this old fella who was complaining of a sore throat. My first thoughts were: “Come on mate, you’ve travelled how far for me to tell you to take some paracetamol, drink some orange juice and maybe gargle some aspirin?” As the diligent doctor that I am, I had a quick peak in his throat. However, it wasn’t a sore throat he was complaining of, it was a sore mouth. He was a lifelong smoker and had this nasty ulcerating lesion under his tongue – cancer I expect.

***

I saw a fifteen year old in casualty yesterday who was making these very bizarre jerking movements of his limbs, especially when I looked at him. I was pretty convinced he wasn’t having seizures and it didn’t look like a chorea. Basically, I didn’t really know what was going on – so, what did I do, I sedated him a little with some valium, checked his HIV status and did a few blood tests. The same evening I was walking through casualty to do a c-section and there was that same boy being, from all accounts, exorcised by one of the nurses. The whole room was shouting and praying; the nurse was screaming in the boys face: “GET OUT..... LEAVE HIM.....GET OUT.....I COMMAND YOU.” I couldn’t help but smile as I walked through – just what if this works. Sure enough, the next morning he was fine. Maybe they should add Exorcisms to the medical school curriculum.

Photos to come when the internet connection improves. i.e. when I am somewhere other than Holy Cross.

I would like to start this scribble by wishing everyone a Happy New Year. I expect most of you were coiffing a nice glass of fizz or making out with some stranger whilst I was applying the finishing sutures to a chap that had been stabbed six times, as the clock struck twelve. Whilst the bells rang at the church of Holy Cross next to the hospital I tied the final knot and proceeded to shout “HAPPY NEW YEAR” at everyone in my path. In return I was greeted with very enthusiastic “HAPPY HAPPY HAPPY” screeches back in my direction by some very excited nurses and patients. What a sight it was as I walked out of casualty to see six male patients who were admitted over the Christmas weekend, all standing in a line outside, watching the fireworks (well, what they could see of them as it was a rather misty evening) and all carrying their chest drain bottles. If only I had my camera.

I must be honest, though. New Years Eve was no way near as hectic as I expected it was going to be. The day was all rather quiet, considering. It felt like the calm before the storm. However, the storm never arrived. There was a definite large wave at about ten in the evening when about five very drunk men were dumped in casualty in quick succession. All had potentially life threatening stab wounds to the chest. The most critical patient was also the one that was paralytic with alcohol intoxication. He had a massive hole with three of his ribs exposed and a big gap that was sucking air like a vacuum cleaner. He was so drunk that as I cut another big gash in his thorax to put a drain in, there was barely a groan – at one minute I thought he was dead – no, just absolutely bloto. Apart from a bad hangover, he was fine the next day. I was in bed by 4:30 am.

In the course of the evening I saw plenty of assaults, including several stabbed chests (in case you were wondering – that can be very bad), a nasty head injury; a party of seven all struck by lightning –not as exciting as it sounds; a seven year old who was sexually assaulted; I relocated a dislocated elbow – the loud “clunk” it makes is always very satisfying; a massive dog bite that left a young chap with a very large flap of skin over his calf; and , amongst the rest of the hubbub, a girl in her twenties who blew her non dominant hand up with a firework.

When I first saw the girl with the ghoulish hand I was told she was “attacked by a cricket.” What kind of monster bug could possibly turn someone’s hand into a thing that looks as if it were straight out of the set of Shaun of the Dead – she had amputated the tip of her index finger, her middle and ring fingers were just bone with nothing on top and the skin folds had turned into flaps of skin. I must say, I have noticed the insects getting very loud outside as the months get warmer - I’ve got to get myself some stronger insect repellent. But, it turns out – a cricket is a firework. So rather than being attacked, she just let a rocket explode in her hand – I think she learnt her lesson, if a little late.

My nurses on the paediatric ward are all very happy at the moment as we have had less than 5 deaths in the past two months. One of them was an infant of four months whom I admitted on Friday. She was dry as a crisp after three weeks of diarrhoea and vomiting and also very malnourished. Her body was in a state of severe shock – she needed fluids, quick. An intravenous line was out of the question, so with a big needle I made a hole in her tibia (leg bone). It’s called an intraosseous line – we don’t have the correct equipment here, so I just improvised and shoved in a large needle. It worked surprisingly well. Unfortunately, despite our best efforts she died early the next morning. I couldn’t believe how late the mother had left it – it took a visiting aunt to raise the alarm and bring her to hospital. However, the mum had seen a doctor in the first week of the illness.

A diagnosis was made and some medications given. I wonder what the mother was thinking – I guess I’ll never know. I think a lot of patients here still think doctors have some God like qualities and that one visit is all you need to patch you up. Often all they want is a quick fix – which often means an injection, a cocktail of tablets and a bandage somewhere – time after time they won’t come back again until they’re at breaking point, even though you requested them to return earlier for a review. They put far too much trust in us and rarely question our judgement. This may sound nice to some – it’s a far cry from the nagging mothers in Dulwich who know what’s best for their little Jonny as he gets fed five different variations of mung bean (“it’s good for his immune system – I read it on the internet – protects against polio and mumps don’t you know – he shall not be needing that vaccine thank you.”). But, we as doctors need to be questioned – often we do things without really thinking. I almost miss those Dulwich mothers.

I for one need to be stimulated and challenged about my decision making – it’s what I enjoy about my job: the problem solving, intellectual challenge and human interaction. However, often I just get vacant looks or nods when I ask: “Is there anything you want to ask or know?” It is our responsibility to make sure patients come back for the sake of their livelihoods. If they don’t want to, that’s fine, but as long as they are informed about their decision. For this to work we need to tell them why they need to be seen again or give them advice to return if they develop certain symptoms etc. It’s pretty common practice back home. I expect this mother wasn’t asked to come back, or if she was, the reasons why probably weren’t explained. I’m trying my best to get patients to come back sooner rather than later – this has it pros and cons – the work load is greater, but with any luck it will prevent young people rocking up at the sliding doors to casualty almost dead, taking their last breaths. Just like yesterday, and the day before, oh, and the day before that – it’s the same story – young HIV positive girls and boys who don’t really understand the significance of their ailment. We only see the tip of the iceberg at Holy Cross – the situation in the surrounding clinics is far worse. However, things are slowly improving from what I hear.

The holiday season is now coming to a close – mothers and fathers, brothers and sisters, aunts and uncles are all going back. They’re returning to the mines, to the shops, to the factories and to work in the big cities - leaving the children, unemployed, sick and elderly behind. With any luck we shall see a drop in the number of assaults. With any luck that is.

The "cricket eaten" hand. The photo doesn't quite do justice to how bad it looked in real life. Notice the absence of the index finger tip and the bone sticking out on the ring and middle finger.