One Year On



Morning after the rains - view from my window.

The sun is shining and the weather is fine. Yes, that’s right summer is just around the corner for those that live in the southern hemisphere. My daily ritual of signing death certificates is made just that little bit easier when it’s bright outside. The death rate in the medical ward is abysmal, but something that I am sure rings true of many hospitals in this part of the world. Our job would be a lot easier without the burden of HIV and TB. However, it is here and we must face the music and dance. Before this week even started I admitted two young HIV positive individuals who arrived on a bus: one from Durban and the other Cape Town – both very far away. They had nothing but the clothes adorning their wasted bodies. Both had an infection around the brain associated with HIV: cryptococcal meningitis. Unfortunately, neither of them survived.

A young HIV positive man with lesions all over his groin.
It may well be Kaposi's Sarcoma, a rare cancer often seen in HIV.
I have taken a biopsy and await the results.

I see similar stories all the time – young people returning from the cities, their places of work, far too sick to even walk. Each time I am amazed at how they managed to get on a bus. Most of the time, they are beyond hope, but occasionally they bounce back. I always wonder what their stories were: Did they know they were sick? Did they know they had HIV? Had they taken HIV drugs and then stopped as they felt better? Did someone just dump them on the bus home? Does the family know their situation? Why didn’t they come sooner? Were they scared? I could go on. However, the last question is something that I have thought about a lot today.

Today is my one year anniversary at Holy Cross Hospital – to celebrate I thought it only sensible to perform an HIV test on myself. I don’t have any cause for concern and am yet to needle stick myself, but I do occasionally wonder. For example, did any of that spurting arterial blood which just shot past my face get in my eye? Or, did that piece of glass I just found in this guys chest go in my finger or not? My answer has always been: I don’t think so.

My negative HIV test.

A rapid HIV test is a bit like a pregnancy test, except you don’t wee on a stick – you need a drop of blood. As I walked off into the car park with my test I had a sudden surge of anxiety as I paced around waiting, for what felt like a very long time, as it processed – HIV would completely change my life; how could it not. Fortunately, the test was negative. However, I don’t think that I have ever felt so unnerved. Yet, here at Holy Cross we are telling people that they are positive on a daily basis. I can almost see why young people don’t test: for fear, denial, but probably more than anything, that feeling of invincibility. How can something you can’t see affect me?

***

Jan - a running machine. The others are nowhere to be seen.

Last weekend I partook in the Madiba Mission – a 32km run created a few years ago by a British doctor who worked at another government hospital similar to Holy Cross, called Madwaleni. For those that don’t know, Madiba is Nelson Mandela’s Xhosa name. From what I gather, the distance is what he and his mother had to walk to get from their house to the nearest clinic. Not a lot has changed, mind – many people around Holy Cross still travel similar distances. Yes, there is transport, but often one cannot afford it or they are too sick to travel, and ambulances are thin on the ground.

Jan - Winner

Madwaleni is the hospital that I mentioned in a previous post. A friend who worked there had created a petition directed at the Eastern Cape Department of Health, urging it to employ medical staff. As of yet, nothing has happened and the situation is grim. The hospital is now left with one doctor. The amount of death certificates she signs each morning dwarfs my pile. It is a sad state of affairs and the people who are suffering are those at the receiving end.

Disclaimer: When I say I “partook” in the Madiba Mission, I didn’t run. I have the lurgy (fingers crossed it’s not TB – don’t worry Mum, it’s flu season). Instead, I was the water boy for my Dutch friend Jan, who is a doctor at a hospital down the road. He won the race by a mile; all thanks to my superb coaching and water dispensing technique if you ask me.

 

Kids holding the finish line tape - everyone wanted a piece of the action.

An impromptu sing and dance welcomed the runners at the finish line.

People know how to sing and celebrate here.

***

I occasionally jot down some of the bizarre events that occur down in the hospital. I’m not sure if you will find these amusing or sad – for me it is usually a bit of both. However, you can decide:

Xenon lights guide the way.

·         I found out last week that the giant Xenon (i.e. really expensive lights) cross that stands on the hill by Holy Cross at the church was funded by our hospital. I’m not surprised, but could think of some more fitting places for those funds. However, if it makes the community happy, then I’m happy. I just don’t know if it does.

·         I received a call whilst on duty the other night: “Doc, there is a patient here. He is talking plus plus plus.” Maybe he just wanted a chat. Turns out he was exceptionally manic and believed he owned and ran the entire municipality.

·         A member of staff walked into casualty then proceeded to drop to the floor in wailing agony. The thing is I don’t think she was in that much pain, or at least had an exceptionally low pain threshold. My suspicion is that she is a budding thespian. The first thing she asked me was how much sick leave she could get – she probably wanted to go for an audition. I’m not a cynical guy, but sometimes I do wonder.

You can see the healed fracture on the right hip
(left side of the picture).

·         A six year old girl hobbled into my consulting room with her mum. She was fine except for a very short right leg; she fell over in 2008. She had fractured her hip, but was never brought to hospital – maybe it was too far or expensive at the time.

·         The theatre was completely flooded with water at morning handover last Monday. Some young boys who had been stabbing each other the week before and admitted on surgical ward got bored. They plugged up the sinks in the toilets with tissue and let the water run all night. How this wasn’t spotted until the morning, I don’t know. There are plenty of staff on duty at night; I hear it wasn’t very busy, so they were probably sleeping.

Bulungula - an idyllic community based set up near Madwaleni.

Walking back from Bulungula - we parked on the other side of the river.

Jan - adamant that he isn't stuck. He was only a little stuck.

Osteomyelitis of the little finger - the guys bone is protruding through his skin and the join is completely eroded.

Employee enrichment programme - nurses raising money by doing a car wash.
 I paid them handsomely as Mitch was covered in an inch of mud.

Black Mamba in the Outpatient department - fortunately it was killed prior to arrival.



A large mass in a guys chest.



  

Baby boomers

The welcome home party.

I say it is good to be back, however, it has felt a little as if I have had my head dunked in an icy bucket of water and been rudely awoken to the everyday realities of work in rural South Africa. I felt a little “acopic” at the start of the week with the prospect of having to govern the medical and paediatric ward as well as being the second on duty for maternity. We are trying, but really all we are doing is treading water; dousing the fire.

Why such a step back, when things were so good before I went on leave? Firstly, my esteemed colleague Jelleke handed in her notice after two years of dedicated hard work. She has only been gone a week, but the hospital misses her dearly. I miss her too, as now I don’t really have anyone to sit down and unwind with for a beer or cup of tea after work. I cannot blame her though, without a family or any real ties, it is difficult to work somewhere so far out for so long. Hence, I think I will be following her in the New Year. Secondly, our Dutch couple, who have transformed paediatrics and maternity, are on a well deserved holiday. So, in two weeks, when they’re back, I hope we can start to put the fire out, for a short while anyway.

This old guy couln't pass urine - I popped the ultrasound on his bladder and saw this big old mass in his bladder.



***

So, here I am: back at Holy Cross and on call for my first weekend. September is baby season following all the festive fun and frolics last December. Maternity still scares the living daylights out of me. I have never actually done a job in obstetrics and what I know on the topic has been conjured from a combination of reading, sapping knowledge from colleagues and a very small amount of improvisation.



Babies sharing the sole incubator after being a
 bit lazy to breathe and needing a little help.



Last night I resuscitated three neonates. All of them had managed to get in a bit of a pickle and decided that they weren’t going to breath. Fortunately, we managed to inflate a bit of life into the first two and they were happily feeding by the time I came to review them a few hours later. The third and last baby really tried my nerve. I was in casualty and summoned to maternity after being told: “...the baby isn’t breathing.” I ran. I don’t often run at Holy Cross; rarely is there anything that urgent that cannot wait an extra minute while I walk and compose myself. A baby not breathing, however, that needs a little exercise. To my joy when I arrived, the midwives were bagging (giving breaths with a bag and mask) the neonate – in previous times I have found nurses endlessly suctioning the airway, which isn’t much good. I think we have Femke, one half of the Dutch couple, to thank for that. She has spent months trying to instil the importance of neonatal resuscitation in maternity. I digress. To my dismay, the baby was blue, floppy and not breathing. We continued to breathe for the baby and even put a tube in his windpipe to make this easier. After twenty minutes, with the baby only making infrequent gasps, we stopped. 

After this, I do not know what happened. We brought the baby to the mother and explained the graveness of the situation. Then, as if that maternal touch has some healing powers, the bubba started to wake up. I will admit, I was rather bleary eyed during the whole procedure and maybe the baby was taking very shallow breaths, but still, these neonates, they’re tough little critters. I checked on him this morning, and he was looking well. I wonder how his future will turn out.

***

After two months of neglect I would have thought that my tomatoes would be goners. On the contrary, what is left of my vegetable patch are thirty or so big green juicy fruits ready and waiting to turn red. I’m getting about four a day. Doesn’t that keep the cancer away?

***

The new facial hair has received a mixed reception by my colleagues. For a brief moment, before news spread of my return, a surprising number of staff thought that I was a new doctor. To be honest, I think it is a pretty nasty scraggy piece of scruff, but it has provided me with a lot of entertainment and the names I have been called makes me giggle:  “Hey doc, you look like Jesus;” “Hey doc, you look a Jew,” (another Jesus reference I believe); “Ha, it’s Chuck Norris;” “Are you a Hindu now?;” “Barely recognise you with the Robinson Crusoe look.” I cannot decide whether to grow it out until Christmas – I have visions of dressing up as Santa Clause in paediatrics, but I’m not sure if I have the staying power.



 

This is the young lady with Steven-Johnson's
 Syndrome that I mentioned in previous posts.
 I forgot to upload her photo - bar some scars,
she was happy as larry.



This young guy has shingles affecting his forehead and is at a high risk of damaging his eye without the correct treatment. Unfortunately, our pharmacy is closed on the weekend and the medication he requires won't be available until Monday so we shall have to keep our fingers crossed. It is likely he is also immuno-compromised.

Changing tyres is easy.

Bhamini relaxing above Lake Malawi at Mushroom Farm.

The dream is over; the trip has ended. Right now, I am huddling inside my rather large house at Holy Cross whilst the rain and wind beats down on my oversized sitting room window. Instead of beautiful vistas, it is just cloud and gloom. A pathetic fallacy some may say. However, despite a few first day blues, it is good to be back.



In case you were interested, let me try and scan over the last two weeks of our tour around east Africa in Mitch. As I left it, Bhamini and I had tended to a baboon stricken dog on top of a beautiful camp site looking over Lake Malawi in the north of the country. We didn’t really want to leave, but then it wouldn’t be a road trip – one must keep on moving. Malawi seemed to be full of medical students on their elective taking exceptionally long weekends away from their hospitals to explore the country. Not that I can blame them. In fact, I am pretty sure I did exactly the same thing. You’re only young once and all that.

 

Bhamini taking a photo of a pig on bike.



We were slightly anxious about entering Malawi as there were rumours of a fuel shortage, specifically diesel. Mitch drinks diesel like I drink tea (I love tea; I also wee a lot). Our nervous laughs and smiles were slightly amplified when the first two petrol stations we visited were e mpty. Good thing I brought jerry cans and a tow rope, I thought. However, it was a false alarm as every other filling pump in Malawi was more than happy to inject Mitch with his favourite juice. So, fuel not a worry, we were able to drive the length of Malawi.

At a small Italian run guest house we overheard a girl talking: “...so, these two doctors happened to have an entire medical kit in their car. They managed to stop the bleeding and patch the dog up. He would have died if they weren’t there.....,” or something like that. The dog incident was in the north of the country; we were 800km away in the south. For a second I thought we had become famous. However, it turned out that she was the girlfriend of the dog’s owner and happened to be passing through. It was the best thing our “medical kit” was used for over the two month trip. Right now I am slowly working my way through various medications from the box of treats to rid a few parasites that I probably picked up whilst swimming in the lush blue lakes of east Africa.



I say I can't remember what we did in Malawi - but, how
could I forget this campsite on an island in the lake that we had to
Kayak to. Domwe Island - check it out.



Other than eating nice cheese and some excellent gnocchi, tales of Malawi seem so far away. After that it was on to Zambia, where we failed to see any Leopards (they can be damn sneaky) and then commenced the long trip home. There I was, thinking that apart from two speeding tickets (the second in Malawi) and with three days left, we had managed to get through the entire trip without a hiccup. Cue: burst tyre.

It's all about the "High Vis."

Changing the wheel of a large car, or shall I say small truck, is rather difficult. Thank god we had our high visibility, a.k.a. we haven’t a clue, jackets on so that we could be spotted by some lovely guys from the local town. Without them we would probably still be there trying to undo the wheel bolts. With the new tyre safely on, we bombed it through Zambia and then drove the length of Zimbabwe in a day. And there it was, trip over. We met some friends in Johannesburg and waved an emotional goodbye to Bhamini: she flew back to the UK after

 a year in South Africa.

I have hundreds of stories, but I need to save some for the dinner table. I have compiled a brief list of some nice places to stay, just in case you decide to do a similar trip. You may notice that most places I recommend involve good food: I like to eat. They are in order of the route we took, rather than preference.

1.       Kapishya Hot Springs (ZAMBIA, in the northeast): Excellent food using vegetables from their garden, a very eccentric owner, off the beaten track (i.e. private transport is needed) and loads of friendly dogs of all shapes and sizes. Oh yeah, and there’s a really lush hot spring that you can soak your dirty body in until it goes white and leathery. Yum.

2.       Katavi National Park (TANZANIA, in the west): If you like tsetse flies, you’ll love this. They try their best, but a few bites and the prospect of sleeping sickness cannot put one off the untouched feel of this park. The campsite is set above one of the largest pods of hippos I have ever seen – an exhilarating camping experience.

3.       Paradis Malahide Hotel (RWANDA, Gisenyi): On the shore of Lake Kivu is a little gem where one can relax and do nothing but sleep, eat (really good fish, not surprisingly) and swim in the crystal clear waters for the tenth of the price of a gorilla permit.

4.       @theriver (UGANDA, Ishasha): Just outside Uganda’s infamous park that is home to tree climbing lions is a very affordable campsite that does some excellent grub and has pretty cool open showers looking onto the river where others like to wash.

5.       Bery’s Place (UGANDA, Ssese Islands): Not really a guesthouse, but as I described in a previous post, more of a refuge. However, Bery does take volunteers who can help with his foundation – the accommodation, food and company is really nice; the view of the lake isn’t bad either.

6.       Ruaha National Park (TANZANIA, in the middle): Not a tsetse fly in sight and there is more game than Noah would know what to do with. Not as unspoilt as Katavi, but not as overridden as the Serengeti.

7.       The Old Farm House, Kisolanza (TANZANIA, Iringa): the campsite looks like an English orchard – whether that’s what you want or not when in Africa is debatable. However, the three course dinner is scrummy and the restaurant has been converted from a derelict mud hut.

8.       The Crazy Crocodile (TANZANIA, Matema): Run by a German dude called Thomas, this new joint on the unspoilt beaches (well, now slightly spoilt) around Matema is a great base for a few days. It’s all about the food, although the portions are occasionally a little small.

9.       Mushroom Farm (MALAWI, Livingstonia): The place I mentioned in this and a previous post – campsite set on top of a cliff looking over Lake Malawi with some very enthusiastic dogs that like playing with baboons. The owner, Mickey, cooks a good steak.

10.   Casa Rossa (MALAWI, Zomba): Run by a couple of really nice Italian’s. They make really good cheese and pasta – I love cheese and pasta. Enough said. The accommodation isn’t bad either.

Charting our journey with stamps. Who needs a Sat Nav when you have one of these?

Tea and cows - the base of Mount Mulange, Malawi.

The last night - we had a duel.

Don't you forget it.

Two months on the road with one pair of shorts (the original colour is at the bottom)

Neanderthal