Cutting Along the Coast

Walking the Wild Coast

 

Sometimes I feel as if I am on one long holiday. Then again, I don’t think I have ever worked so hard. The day to day pressures are huge and involve a lot of self discipline. There is no senior to check if we have done the job “correctly,” or family member asking what on earth is going on with their loved one. In fact, there is very little accountability and an acceptance from lay people that the doctor is always right, which, as we all know is not always true. However, because of this I think there is an even greater importance for us as clinicians to feel responsible for our patients. One has to think: “What would I want done for my family/friend/lover?” We are limited to what we can do a lot of the time, but there are many resources at our fingertips to help.

(left to right) Ben, Sofia, Tom (medical student), Alvin and
Hannah - all enjoying a spot of Sunday afternoon jazz.

So, why does it all feel like a massive vacation? I think the weekends away exploring this beautiful country have something to do with it. The past two weeks I stayed with my lovely friends: Alvin, Hannah, Ben and Sofia. All four are British doctors – two of them have been here over a year now and the others have just arrived. I didn’t just take time off to go party with them in Durban; I went to spend some time at the maternity hospital where Hannah works, to improve my caesarean section skills. In seven days I performed eighteen operations by myself as well as assisting several others. It isn’t the most complicated piece of surgery in the world, however, there are plenty of complications, not to mention that fact that you are dealing with at least two lives. I say at least: I delivered two sets of twins.

Rhino in Kwazulu Natal

I was in two minds about developing my surgical skills. When I started this job just over a year ago, there was an expectation by myself and colleagues that I would be proficient at performing “caesers” within a few months of starting. However, a lack of doctors meant that there wasn’t really time to train me and my other skills were needed elsewhere in the hospital. As more medics arrived it soon transpired that I was the only one that could not “cut.” As a result I spent some time in theatre with my colleagues assisting with the operations. However, as everybody bar me can cut, there isn’t really a need for me to as well. Before, the need was there to help relieve the strain of my colleagues as it can be a bit of a work out to extract a baby from the womb. Secondly, there was the prospect of some fresh blood arriving, much like I did last year, with minimal obstetric experience. Unfortunately, they never arrived due to bureaucratic delays in the Eastern Cape.

Without this current “need”, it has raised an interesting ethical dilemma. Should I really start to train and perform caesers on women around Holy Cross and possibly put them in jeopardy as a result of my own inexperience? Would I not be just falling back into that obscene cliché of “practicing one’s skills on Africans?”

Jazz in Durban

I did a lot of thinking and decided to go ahead with the intensive training up at Hannah’s hospital. My reasoning? For starters, none of us at Holy Cross are obstetricians or anaesthetists, we are all generalists and rely a lot on each other for support with the sharing of ideas, knowledge and skills. Knowing how to get out of a difficult situation at both the top and bottom end of the patient is much easier if there are two of you who know what to do. Secondly, although I expect I shall be leaving next year, one can never tell what the future holds. The same story rings true for my colleagues and some may decide to depart sooner than expected, meaning that more will be required of me. Thirdly, I still have this desire to return to this continent in the future and you never know when a certain skill set will be required, particularly obstetric skills. Fourthly, it was a nice excuse to spend some time with close friends who I haven’t seen enough this past year. Either way, the training that I received at the maternity hospital was invaluable and I would recommend it to anyone interested in a career in obstetrics or rural medicine.

Jazz in Durban

Spending just under two weeks working at a large referral hospital was also very interesting. The centre receives patients from all over Kwazulu Natal, which can mean some exceptionally long ambulance rides and the occasional helicopter flight. Hence, they deal with a lot of unwell obstetric, gynaecological and neonatal cases. I must say I was rather impressed by the amount of doctors, nurses and equipment they have. However, as is often the case, I soon realised that even at a tertiary centre like this one, they face much of the same issues as we do at Holy Cross.

The jazz really was excellent. The Rainbow Restaurant in
Pinetown, Durban - really good vibes.

They need more doctors and nurses as well as better administration. For two out of the seven days I spent there the theatres were without sterile drapes and their CTG machines (devices for monitoring the wellbeing of babies in utero, something we are without at Holy Cross) were out of paper. At least at Holy Cross, when there is an unwell mother or newborn, assuming things are not going off elsewhere, we can spend some time attending to the patient. For my colleagues at the maternity hospital, every patient is sick; many patients need close monitoring, which is nigh impossible in the current circumstances.

****

Rugged coastlines



I mentioned that I took two weeks off to attend caesarean section training. If you have paid any attention you may have noticed that I spent only 7 days of it at Hannah’s hospital. No, it is not that everyone works 3.5 day weeks, as good as that sounds. I spent the second half of week two with friends back in the Eastern Cape traversing the Wild Coast by foot. We walked 61km in four days, along rocky cliffs, expansive beaches and the occasional swollen river. There was sun, rain and lightening as well as a good bit of trudging through muddy paths in the darkness. The walk was from Coffee Bay to Port St John’s. We were joined by a dog whom we christened Pete. There was much talk of adoption of this loyal friend whom accompanied us for the four day hike. However, as quick as he came, he disappeared into the night as we slept at our final destination. Possibly, I hope, to find the next group of wayward hikers and escort them on their way.

Now I am back at Holy Cross and desperate for a wash. There is a distinct lack of water coming from the taps, so the patient’s will have to bear my bodily odour for a few more days. However, with some of the halitosis that gets dished out, I think it is a fair deal.



Expansive beaches - impressive facial hair too.



Biltong break.



Pete looking after some happy hikers

Wild Coast kids

Wild Coast kids enjoying my beard

The end of a very enjoyable walk

Tales from the sky.



"Heritage Day." Everyone dressed up in traditional attire.



I cannot complain – life is not bad. Not bad at all. Right now I am sitting on a flight to Cape Town cruising at 30,000 feet en route to see friends for the weekend. However, for much of the community that I see at Holy Cross on a day to day basis, I often wonder how they manage.



It appears the security guard has been using the
 Holy Cross sign to do a little mathematics.



For the simplest task, patients must put in a lot of effort. Every evening a group of about twenty line the floor and benches of our outpatient department to get the patient transport  vehicle to be seen by a specialist in our referral centre four hours away. If the bus hasn’t broken down or the driver lost the keys (an all too common mishap) then they set sail at about 4am and return later the same evening. Sometimes it is a wasted journey – maybe their appointment was lost; they got lost; the specialist was on leave; the scanner was broken – a whole host of reasons. Then, it’s another sleep on the bench before making the long trip back home or waiting in another long queue to see one of the Holy Cross doctors for whatever reason.

We have just had six medical students from the local university on their first hospital placement. Their main objective was to find out about the area demographic and disease profile. Despite only living four hours away, they were aghast to find that there are people living in their own country who do not have a clean and reliable source of water or regular food supply. I am sure there are plenty of similar issues that I am naive to back home, but at least water is abundant and plentiful. At least, that is what I am led to believe.



Translation: Take a Condom. Written underneath in pen: Where?



 There are some commendable initiatives led by a selection of our staff. They are all church based groups, but then that isn’t unusual. One programme is aimed at giving patients who have been discharged a bit of spiritual guidance, going to their homes to see what conditions they live in and providing food parcels and clothing donations as deemed fit.  For all the difficulties I see, I really admire the compassion that much of the community hold. One thing you will never see here is someone on the street – it just doesn’t happen. The idea of a homeless person is unthinkable. So, if you have any clothes you were thinking of throwing out or giving to a charity, why don’t you send them to me. At least this way you know the clothing will go to people who need it, rather than landing in the hands of a local entrepreneur to sell on.

If you do want to send out clothing, my address is on the first page of the blog. To make things easier, I’ll write it again:

Dr Dominic Craver

Holy Cross Hospital

Private Mail Bag X1001

Flagstaff

4810

RSA

 

The tomatoes from my garden just don't stop coming.



***

Work is back in full swing and I must say that I am really enjoying it. This “amazing experience” stuff that I spoke about in my first ever post still rings true. However, it is tough. Really tough. They say people that work in the medical field need to detach themselves from getting too emotionally involved in cases. I hear that if we open our hearts too much then there is a possibility that we may all crumble into a big sloppy pile of blubbering jelly like wrecks. However, how can one not get involved: we are all human after all. As long as there is someone to talk to, to open up to, then things will be all right. But, I think a cry now and then is just fine.  

Seeing a child die is probably one of the darkest encounters there is. It is a privilege that I have had on far too many occasions; I remember every single one. This week another such event happened. I was in casualty on Wednesday and just finishing up when I walked passed a two year old boy lying on the gurney next to his mother and gogo (grandmother). Initially I thought he was sleeping, especially as there wasn’t too much concern coming from the family. However, he had stopped breathing – without even asking, I grabbed the child, snatched a nurse and brought him into resus. He was in respiratory arrest.

My colleague Dingerman came from home (a paediatric resus is difficult at the best of times, but on your own is almost impossible) and helped me stabilise the kid. And there the little fella was – helpless and covered in tubes: on the ventilator; a needle shoved into his leg giving him fluid and antibiotics; a catheter coming out of his small penis. Our plan was to keep him overnight and get the helicopter at day break. Unfortunately the weather was too bad and the ambulance was not able to respond fast enough with the correct equipment – they needed a ventilator for the four hour drive. We are not specialists, none of us are intensive care doctors, nor paediatricians. All we do is try our best. At four pm the next day, with no sign of any transport and the child showing signs of irreversible brain damage we had a very difficult discussion with the mother. I couldn’t help but shed a tear as I watched her hug and cry goodbye to her baby, her only baby, before we switched off the ventilator.

This was possibly one of the hardest decisions I have ever made, but not one I did alone. I have asked myself a couple of questions since: Did we have the right to make the decision to turn off the ventilator? Should we have kept it on and waited another day and see if the weather improved? I don’t think so and stand by the decision that we made as a team. Most of my colleagues would not have even begun the resuscitation. However, children can bounce back as quick as they go down. We were just a few minutes too late. The other question is why was he sick? The most likely cause is that the enema and medication he was given by the gogo and sangoma (traditional healer) poisoned him. It is a sad, but all too common cause of childhood morbidity and mortality: herbal intoxication.

"Peau d'orange" and an inverted nipple in a lady
with confirmed breast cancer.



***

On a slightly light note, I walked onto the ward yesterday to see that the old schizophrenic patient I had admitted for a 72 hour observation (our holding period on a medical unit before transfer to the psychiatric unit) had an oxygen mask on. For a second I thought the heavy sedation required to calm him down had knocked out his breathing. However, it turns out he was running around the ward earlier and was wearing the mask as the latest fashion accessory.



Old docs, new docs and a whole load of medical students enjoying an impromptu braai (BBQ) at the hospital.

 

A post braai dance.




My friend Laura and I, posing halfway up Table Mountain. Cape Town.




****DISCLAIMER****

The following photos are not for those with an aversion to

blood.







Another example of clubbing in a patient with previous TB



This guy got stabbed in the abdomen - his bowels came out of their comfort zone.



"Stab ear"




Fixed "stab ear"



A "stab face" with all the cheek
 muscles exposed.

 

Fixed "stab face"

A young boy with a paraphimosis.
What happens here is the foreskin gets stuck
 and things start to swell.

A fixed paraphimosis. The "Craver Penis Block," as my boss likes to call it,

 is the anaesthetic I use to numb the affected member before reducing the foreskin.