Don't shoot.




Sunrise last week; sunset this week.



Before I mumble on with more tales from Holy Cross, could I urge you to  click on the following link and sign the “ePetition,” asking the Eastern Cape Department of Health to get organised. We have already lost one potential doctor as a result and there are other hospitals facing a very real prospect of being “doctor-less” by August – the implications of this are massive.

http://www.change.org/petitions/eastern-cape-department-of-health-south-africa-urgently-provide-contracts-for-new-doctors?utm_campaign=friend_inviter_action_box&utm_medium=facebook&utm_source=share_petition

***

If you stumbled into casualty on Sunday evening you may have wondered why I was standing on top of an 80 year old patient’s bed with my leg in his armpit and pulling the man’s arm with all my might (may I add that my raw strength is probably equivalent to that of a five year old). Firstly, I do not believe for one second that he was 80. However, he was definitely pushing it and was built like the Terminator. This could be a slightly histrionic statement, but that’s how it felt. Years of working the land had made this elderly gentleman rather “ripped.” I guess you may be asking why I was pulling back on his arm, with a nursing colleague giving counter traction via a bed sheet strapped around his armpit. The old geeza had rather impressively dislocated his shoulder. Now, I have done this on two occasions myself (one skiing and one throwing some slightly over enthusiastic shapes on the dance floor) – it is exceptionally painful. Fortunately for myself, as mentioned earlier, I sometimes look a little malnourished (hence, a lack of muscle bulk) and I had my doctor friend George (we were medical students at the time) to slip it back in – I am and always will be eternally grateful for this. Hence, I could almost understand how the old fella was feeling.

In general there are three ways to dislocate a shoulder – either it comes forward (the commonest injury and what I had), goes backwards or heads down, into the armpit. He had all the classic signs of a dislocated shoulder: agonising pain, loss of the angle of the shoulder and reluctance to use the arm. However, his arm was also held abducted (i.e. hanging out – he couldn’t bring his arm to his side). A quick examination revealed that he had also sustained a possible nerve injury and that his humeral head (the ball joint at the top of ones humerus – quite self explanatory really) was sitting in his axilla (armpit). So, I gave him a good dose of pain relief and sedation, then tried my best to plonk it back with the assistance of two nurses.  

It is only the second dislocation I have seen here, but both have been inferior ones – from what I have read, they are rather rare and can be a bugger to relocate (orthopaedic colleagues, please correct me if I am wrong). The reason I keep mentioning muscle bulk is because the more there is, the harder it is to pull a joint back into position. Fortunately, the first time I saw this it was an elderly lady who’s shoulder was only slightly smaller than mine – I reduced it with no problem at all, except for her responding a bit too enthusiastically to the trickle or morphine that I gave her.

After 45 minutes of pulling, twisting, getting the book out, trying different manoeuvres and pulling again, I accepted defeat. I think this point was realised when I found myself using the bed as a pivot to lean back and almost falling over from my own fatigue. So, I sent him to our orthopaedic hospital with plenty of analgesia in his system – a bumpy 4 hour trip is not ideal at the best of times, let alone with a fracture or dislocation.

***

Assaults are common here; so are guns. Hence, there is a big sign on the hospital front that clearly says: “No guns.” It makes sense, hospitals are places for healing; guns are designed to cause harm. There I was performing an examination on a security guard from a supermarket in town, who had been beaten up by a couple of men. He told me that the men were having an argument in the store, so he tried to break up and settle the dispute, or at least move it outside. Instead of agreeing they gave him a few punches and ran off to fight elsewhere.

The guard was fine, but as I asked him to: “Khulula,” (undress, in Xhosa), I found that he was packing heat. For a little clarity, that is the “gangsta” lingo for carrying a firearm. It just so happened that at this point my nurse had popped out of the consulting room and it was only the two of us. I very kindly told him that yielding a gun in a hospital was completely unacceptable, but decided to leave it at that. I was more concerned that if I alerted the security, the situation could have gone from very pleasant to bang, bang.

***



Medical ward can be hard work, both mentally and physically. However, yesterday I discharged a nice lady who had suffered a stroke. Before I had time to blink, she hobbled up to me (it’s not so easy to run when half of your body doesn’t do what you tell it) and gave me lots of kisses and a showering of: “Siyabonga, siyabonga,” (thank you, thank you). It’s these moments of spontaneity that one just doesn’t get in other lines of work – I wouldn’t change my job for anything.

  

A classic CSF picture of bacterial meningitis. Unfortunately, the young man was dumped onto a bus in Durban back to the Eastern Cape and by the time I saw him he was too far gone. He died later the same day.



This is the chest xray of a rather well looking young man who had some persistent TB symptoms. The big blob in the middle is his heart surrounded by a load of fluid (pericardial effusion) that I confirmed on ultrasound. Extrapulmonary TB is the commonest cause of pericardial effusions here.




This lady had fallen over the week prior and was hobbling around in excruciating pain. Notice that her left leg is a little shorter than her right and that the left ankle is rotated outwards. This is a typical of a fractured hip.



A very jaundiced patient. Notice the reflection of my favourite Sister in medical ward.

This is the young mother who had Steven's-Johnson Syndrome - she is on a full road to recovery and I have sent her home to be with her child. She's due to come back for review in two weeks. (Images use with permission of patient)

A massive lipoma (fat deposit) that I removed from a lady's arm. An exceptionally satisfying procedure.

Vacancies.

Vacancies - please submit your CV.

There is a lot of excitement in my household at the moment and, seeing as it is only I who lives within this abode large enough for a family of four, I can dance around with as much glee as I care. For in exactly one month, I shall be saying goodbye to Holy Cross and embarking on a little overland trip with a friend in Mitch, the four by four off road machine, up to Uganda and back. I am sure I will be giving out plenty of snaps from the trip when the time comes and maybe a few tales too. Fingers crossed Mitch is good for it.

***

After originally being struck by the amount of HIV and young people dying in all manner of undignified ways, although I am not quite sure what is a dignified way to go (at home, in bed I suspect), something else bothers me far more. Just the other day I was counselling a girl of 15 who had a threatened miscarriage. One cannot stop people from having sex, even at this young age. However, she, like many before her, laughed when I mentioned the importance of an HIV test and said that she was not ready for one. After a bit more discussion she agreed to the test. If getting young people to test for HIV is difficult, then surly it is even harder to encourage them to practice safe sex.

Last week I performed a sexual assault examination of a 14 year old girl who was abducted and taken 100km away to a location near Holy Cross. However, despite this distressing story, she had clearly been sexually active for some time: her genitals were covered in warts and there was a very offensive discharge. It transpired her boyfriend was not very keen on condoms and that he probably had a few other girlfriends too.

It is always the woman that we see in clinic with the sexually transmitted diseases and early pregnancies. Rarely one sees the men coming for sexual health related issues. It is the men that really need to be educated, and, therein lies the problem. There are a few good initiatives nationwide, but I am not aware of any around here. There is a very successful clinic run on Saturday mornings near Johannesburg led by all male nurses. I expect many men around here have difficulty discussing their “man-hood” with female nurses as local culture still dictates a divide amongst the sexes.

Talking of family planning – there are a lot of dogs that roam the roads of the Eastern Cape; there are also a lot of flat dogs that line these roads. A colleague pointed this out the other night - how can there still be so many dogs. The boss replied: “It’s canine family planning. Without it, they would overwhelm the area.”

***

On every casualty or outpatient card there is a brief history of the presenting complaint. Often I take a quick glance, but a lot of the time something has been lost in translation. For example, it may read: “15 year old, has been coughing for 5 days, is severely dyspnoeic and unconscious.” A brief inspection of the patient reveals that they are awake and breathing just fine. However, this week I forgot to read the “blurb,” and just dived straight into my history:

Me: What brings you here today?

Patient: I have a cough.

Me: Oh, how long have you had this cough for.

Patient: Since 1982.

Me: *my face scrumples up, I give him an “are you serious” look*

Patient: *gives me “I am deadly serious” look back*

At this point, I decide to read the outpatient card – he had come to pick up medication for his epilepsy. However, now I had started on this cough story, I had to finish. I think I cough more than he does, but, nonetheless he wanted me to give him something for it. It was almost as if he was bargaining with me – he had a pretty good poker face. However, once I agreed to dispense my secret weapon (paracetamol) he relaxed immediately and I advised him to test his sputum at clinic for TB.

***

I would like to end this little piece with a small plea. Perhaps I should have started with it, however, if you are still reading now then you must have, at the least, a small tickling interest in the health system here. Budget constraints or, more likely, mismanagement of funds (what some may call corruption or fraud. This is only my guess and I would never accuse the Eastern Cape Department of Health of such things) has had a visible effect on local health services. Similar tunes are being echoed in the British NHS.  However, it seems as if things are going from bad to worse: the health department has said that they cannot fund any new posts for doctors, or at least this is what I have read in articles and heard from various mouths in management.

Holy Cross, comparatively, has it pretty good at the moment with eight doctors. We are expecting two more, but news has just arrived that they may not be able to work here (despite vacancies) as there is no money. It is likely they will be wooed by one of our neighbouring provinces, such as Kwazulu-Natal. Of more immediate concern, however, are the hospitals that, come August, could possibly be with no clinicians at all. It is a very real possibility and unless the government steps in (who at this moment are piloting a national health insurance scheme) or the local department of health gets its act together, communities shall be without emergency medical, obstetric and paediatric care that could have grave consequences.

So where best to start: a petition. A good friend of mine, who is working in one of these soon to be “doctor free” hospitals, has petitioned the Eastern Cape Department of Health. Please log on, sign it and spread the message.

The link is:

http://www.change.org/petitions/eastern-cape-department-of-health-south-africa-provide-contracts-for-doctors-needed-to-provide-essential-services-4?utm_campaign=friend_inviter_modal&utm_medium=facebook&utm_source=share_petition

If the link does not work, please let me know.

My hand is on the left and on the right is a patient who has a haemoglobin of 2 (severe anaemia). I checked mine and it was 16. Needless to say, she received a blood transfusion to help her gross fatigue and exertional breathlessness.