Snaps

 I didn't realise Grandmaster Flash spent so much time in Durban

 Myself and Mitch in the Mkambati Nature Reserve at the end of my road. The South Africa National Parks Agency describes the road there as "terrible."

An amazing jazz club just north of Durban call "The Rainbow Restaurant". Very unique; hosts a very diverse crowd.

A local artist at the "BAT" centre in Durban. Excellent place that supports local artists, providing studio space and assisting them to obtain materials and sell their work

The ambulance bay at Holy Cross with the malfunctioning sliding doors that go into casualty. All the locals seem to have great difficulty working out how they open.

Tis the season to be.....circumcised?

Who would have thought it – I haven’t even had time to unpack my bags, but already my new found anaesthetic skills have been put to work. My delightful Dutch colleague gave me a call for some assistance. She had a young mother who recently delivered that was having an extremely tough time of it breathing. The mum was HIV positive and recently started on anti-retroviral treatment. However, unfortunately for her she also had a cancer linked to HIV, called Kaposi’s Sarcoma, growing around the entrance to her windpipe. It was asphyxiating her rather quickly. So quick, that we had to act. It wasn’t quite the slick affair that Dr Carter in E.R. would run alongside Benton and Dr Green. Here’s a condensed version of what happened:

J (Jelleke): “She’s stopped breathing.”

D (Dom): “Fu*k.”

J: “Sh*t.”

D: “Right, errr, there’s nothing in resus. Let me run to theatre and get the gear.”

J: Shouting to the nurses “CAN YOU COME HELP ME. I NEED SUCTION NOW.”

Nurses nowhere to be seen, despite all being in casualty minutes earlier.

D: “Lets do this.”

About 15 minutes later

D: “I’m in.”

J: “Great.”

And at that point we had secured her airway with a tube in her windpipe. We had been able to breath for her by blowing oxygen with a bag through her mouth until I put the tube down. Because of all the swelling in her wind pipe we were ready to perform a surgical airway, which is a bit like a tracheostomy, but a lot simpler. We transferred the patient to our referral unit for intensive care as she had a lot going wrong with her as well as the airway problem. Unfortunately, all our efforts were in vain – she died in the ambulance. I expect the tube fell out of her windpipe. As I have mentioned before, the ambulances don’t have paramedics or experienced technicians that can look after intubated patients.  Maybe some would comment that we shouldn’t have even tried to resuscitate her knowing the problems there are with transportation and the setting that we are in, being resource poor. We had to dedicate a lot of our time to her management (about 4 hours) – other patients had to wait to be seen. However, we are in South Africa – a country that has a large, well funded, but poorly managed, health system. There are specialists, intensive care departments; you name it, they have it. I agree, one has to be pragmatic and know their limitations, but also drink with a glass half full; at least try to the best of one’s abilities. Occasionally, in these desperate situations, there will be a happy ending.  Unfortunately our young mother wasn’t in that category, despite our best efforts. However, there are a handful of others that do make it – for me, that’s what makes what I do feel worthwhile.

On a side note, whilst we were trying to ventilate our lady an ambulance crew arrived with a guy in his twenties who had been in a motor vehicle accident. He was dumped on the resus trolley – he looked very ill. In fact, he was very still; not a sound. My colleague asked the ambulance driver if the man was alive, whilst she tried to ventilate our lady. We were told: “Yes, he’s breathing.” I quickly triaged him: He was dead, although I expect not much time had passed since his heart stopped, but long enough to starve his brain. No family were present; he died alone. I just said: “He’s dead,” and quickly moved back to our lady. In such circumstances one has to act fast and there often isn’t a lot of time for compassion. We acted to the best of our abilities, which sometimes means doing nothing.

In addition to all this pandemonium I have been back on the paediatric ward. At the moment there are a lot of happy punters; many of which were exceptionally unwell a few weeks ago. I have a boy that was literally taken by the horns of a cow; another who was hit by a car at speed who broke several bones and sustained a head injury; an almost mute 5 year old girl who looks like she is 12 months as a result of severe malnutrition (weighing only 10kg), poorly treated TB and, as we recently discovered, sexual assault - but even she is coming on leaps and bounds. I know we are not supposed to have favourites – but she is mine and I encourage all the nurses to interact and play with her. Life as she knows it has been so shitty, and probably isn’t much better now being stuck in hospital, but we can try and make it fun. Currently Holy Cross has six very enthusiastic medical students from Cape Town for the next two weeks. I have asked them to give her as much attention as possible. In return I have been teaching them in hospital (there’s always time for teaching, even if things are exceptionally busy) and feeding them beer outside of work.

Along with the kids that are getting better, there are some that aren’t. We have a young boy who has rabies after being bitten by a dog – it is endemic here, but often people get treatment before progressing to the disease. His mother is a healthcare worker, but she didn’t bring him to get vaccinated after the bite (which was only a very small scratch). The vaccine needs to be given as soon as possible to be effective. He has presented to us already with symptoms of the disease. His hydrophobia (fear of water) is profound – a very bizarre symptom, that is very typical of rabies. Other than that he looks quite well, but there is little we can do and it is likely he will die. Not even the specialists can offer help this time. It’s a waiting game and one where we need to show the boy and his family support and compassion.

In addition to the rabies case I also had another child today who was wheeled into the ward vomiting and taking her last gasps. Again, another situation where I thought to myself – do I try and resuscitate or not. But, how can I not? Especially in a child. Additionally, children have a different make up to adults and the reason their heart stops differs. So, I went for it. It wasn’t a happy ending though – I didn’t want to give her mouth to mouth (she was HIV positive and had vomit all over her); I shouted at the sister to get me a “bag-valve-mask (BVM)” – she ran (I’ve never seen anyone run here – I was very impressed and gave her a big hug and thank you afterwards); the BVM (something we use to help someone breath with an oxygen attachment) was broken and there wasn’t another one; I was left with chest compressions alone; her pupils were fixed and dilated (a sign of brain death); I realised what I was doing was futile; I stopped. I have no idea what was wrong with her, but wonder if she was given a herbal medicine or accidently poisoned as the family said she was completely fine at breakfast.

On a lighter note, the season has begun. No, not the festive season, although I hear that is fast approaching and I am quite looking forward to my weekend off at Christmas. The season I mean is the one where boys become men; Boyz 2 Men; where the woods become a hive of activity; the chanting and the rituals take place. Yes that’s right, it’s the circumcision season. Every summer (winter in the UK – don’t forget, I am in the southern hemisphere) tonnes of teenage boys leave their home and come back a few grams lighter (foreskin-less), covered in white body paint and with the newly acquired knowledge of how to kill a fellow human: apparently they are now men. If this is the case then I would much rather be Peter Pan and fly off to Never Never Land. The “man” recipe when mixed with alcohol makes casualty a fairly colourful place, especially at Christmas when everyone around the globe has one too many sherry’s – a mix of stab injuries, infected penis’s, incoherent patients, incontinence and more stab injuries. Fortunately, some of the kids are a bit savvier and want to join the lost boys, so they run away from the woods. Occasionally, such as on Monday, you get a young male who turns up looking a bit sheepish and uncomfortable. The casualty card read: “Has cut on penis after running away from woods.” When I first read this, I wasn’t too sure what to think – but I knew that I didn’t want to go into the woods. So, it turns out my man (he’s a man in my eyes) was about to get the snip, saw the blade, got a little nick of the skin and legged it. His penis was a bit of a mess and his foreskin was stuck causing his “member” to swell up – it’s called a paraphimosis. Once I reduced it his frown turned upside down. I have booked him to come back in three weeks to have a proper, sterile, circumcision. So as well as not getting a paraphimosis again, his lack of foreskin will mean that he can pretend that he did his manly duties. A win win situation I think. I’m just hoping he returns.

I am off to visit friends on the beach this weekend in a place by the name of St Lucia, South Africa – not the Caribbean. For the next few months it looks like we are all working one in two weekends. However, I shall be making sure Mitch (my car) gets his fair share of action on the ones I have off.

I will attempt to upload some pictures soon, but the internet at Holy Cross is too slow.

P.S. If anyone wants a Christmas card, then please email me your address.

And then he turned water into wine....all of it.

I have just returned to Holy Cross from my two week anaesthetic jaunt in Port Elizabeth (PE). What a rewarding experience that was. I was surrounded by enthusiastic, mainly young, anaesthetists and mentored by an inspirational consultant, Dr Smith.  I have come back feeling energised, full of knowledge, new skills and a slight sun tan. I am not expecting to walk into work tomorrow morning and have lying before me a patient that needs to be intubated. But, just in case there is, I am ready – I just need to make sure I know where the tools and drugs are to perform and make emergency anaesthesia safe. Hence, I’ve written a check list that I hope to use in the coming weeks so that I can pester the management if the hospital is lacking certain drugs or equipment.

During my fortnight in PE I gave my sinuous pins a good workout, hence the slight tan. Most evenings I went running on the beach, whilst the sun was still warm. The crashing of the waves and salty air did wonders for my psyche as I bounded along the walk ways and firm sand of the shoreline.  One evening jog was made even more magical as I looked out to sea and saw a whale do it’s “breathing” thing followed by that nonchalant: “Oh, I think I’ll just poke my tale in the air and slap it down on the ocean with a big splash. Oh what fun.” If whales could converse as we know it, then I expect that is what they would say. For some reason I was reminded of The Hitchhikers Guide to the Galaxy in the scene where a whale suddenly finds himself falling from the sky and the thought process he has as he descends to his quick demise. These are some of the things I think about when I am running.  Maybe I need to start running with other people so my mind doesn’t veer off track so often.

As I said, I met several anaesthetists in PE; almost a new one every day. I remember one conversation with one of the younger trainees, who is my age. We were talking about the difficulties many of the hospitals have, especially in the Eastern Cape (this is my only point of reference). As usual, the same problems were highlighted – poor management; no leadership; terrible stock keeping; substandard nursing; lack of pharmacists, physios, occupational therapists, dentists, doctors etc. Often a problem that we see here is that a lot of the staff, be it managers, nurses, porters, handymen and, shamefully, many doctors, do not often seem to know what is in their job description. You get doctors who go to work, see twenty patients (that’s their daily limit) then go home at midday; nurses who sit at nursing stations all day socialising; porters that need to be called every time to begrudgingly transfer a patient or take a blood sample to the lab; handymen that just sit in the shed all day and don’t do anything “handy” at all. Worst of all, there are very highly paid managers sitting in their office in Bisho (the administrative capital) laundering money from the health system. Well, this is what the anaesthetist had to say and I did have to agree with him on many of his points. I think, however, times are slowly changing and a big shake up of the way the health system is run here is slowly being addressed – at least this is what the politicians are saying, so many remain sceptical. I hear the chaps in Bisho are all getting the boot or a kick up their arse to actually do their jobs and come and work in the local hospitals rather than sit in their nice air-conditioned office.I have just heard that Holy Cross is expecting some new well trained nurses to make sure our team here work efficiently and proficiently. I wonder whether this will change things - I hope so.

 The chat about the difficulties the health system is facing wasn’t really my point though. Whilst we were talking, I started talking about the high number of organophosphate overdoses (incredibly lethal) I have seen at Holy Cross or the difficulty I have had managing diabetic emergencies. Both of which are treatable with the right resources. He was shocked when I told him that we often have no way of monitoring blood sugar, no trained staff to nurse an intubated patient and suction their airway and other, what he felt were bog standard, requirements. I was slightly taken aback by how surprised he was, even though he, being a South African, was talking about the problems hospitals in his country have in acquiring the correct materials. I had similar conversations with other anaesthetists in PE and most had a similar response. I am amazed, but not surprised, that some doctors don’t know quite how difficult it can be to work in the rural hospitals within their own country, as theoretically they should all be well stocked. After all, there is plenty of finance here. It is almost laughable: at Holy Cross we have about eight new fancy defibrillators (a machine to shock the heart back into rhythm), but no soap or paper towels to wash and dry hands with.  I am still clueless as to how the hospital procures items, but when I do, I hope I will be able to address a few essential issues. Number one will be making sure we have enough high calorie milk to feed our malnourished children; it is extremely embarrassing and frustrating when we admit a child and cannot feed them as we have run out of feed.

So, enough about the disastrous management here, what about my own? After weeks of complaining about my lack of organisational skills to stock the house with beer, I now have a very attractive looking stock cupboard filled with various pilsners, cider and a bottle of wine (I had 3, but managed to break two – dropped one and the other popped in the back of Mitch, probably as I hurtled over a few pot holes). I got back to base last night and found out that we have no water supply. Oh, what sweet irony. I guess I shouldn’t complain too much as I have a very large rain collector outside. However, I seem to have put a small hole in it whilst trying to work out how to turn the tap on. What makes the situation even funnier is that it is raining cats and dogs outside and there is a massive thunderstorm with more lightening than you can shake a stick at. A massive bolt of electricity has been illuminating the hills every minute for the past hour or so. It is an amazing spectacle, as I sit here gazing out from the safety of my sitting room. But it means I can’t even go outside to shower in the rain for fear of being struck. 

Back to work tomorrow. I hope the water supply fixes itself soon so that we can wash our hands, whether or not we have soap or towels.

Some notes by the sea

I’ll tell you what: time goes exceptionally fast here, just like it does when you’re anywhere new and exciting. According to this blog, I last wrote an entry about two weeks ago. Two weeks ago feels like two months ago, especially when there are so many new japes occurring every minute. It would be a mean feat to write about everything that has happened, so I’ll just summarise a few key points and then probably go off on one about this or that.

So, what has happened? I got paid; I bought a car; Dr Jelleke returned to work; I did my first solo on call; I attempted to resuscitate new born babies; I have had the return of some happy customers; I left Holy Cross.

Let me expand on a few of these points. I got paid last week. I am not really sure what happened, as I was reliably informed by several people (some that work here, some that have worked here and some that plan to work here) that it could take several months to get a pay cheque. The same day the money entered my account, it left. Hence, I am now the proud owner of a very big, ugly and exceptionally uneconomical, four by four. But, for all Mitch’s (the car’s a Mitsubisihi – see what I’ve done there?) brute and unwillingness to save the planet, he can take me to the far and beyond of the rural Transkei region where I live.  I shall let you know about my off road escapades in due course.

With the return of Dr Jelleke you can almost hear everyone breathe a sigh of relief, except maybe for her. Jelleke is a Dutch doctor who has been here for a year or so. She has just returned from what sounds like a delightful three month vacation. With our numbers now slowly on the rise, we will be able to get a slightly firmer hold on the issues that face the hospital and local population. We are expecting three more doctors in early 2012.  Of course, none of us can expect to make a “real difference” here as we come and go for one or two years at a time. This was never really my intention, despite the slightly over idealistic ideas I often hold. What we can do is to try and give the local population some sort of decent health care whilst we are here. If we can continue to get a rolling influx of diligent doctors, then Holy Cross shall be able to address and support the massive healthcare issues that the hospital is faced with on a daily basis. Not that this is the ideal. The ideal, I expect, would be that Holy Cross saw the arrival of some permanent, experienced (i.e. not myself) doctors and managers who could provide some sort of lasting programme. Preferentially people that speak the language and are aware of the cultural challenges that are present: i.e. Holy Cross and the surrounding hospitals need medical staff who grew up in this region. The problems lies in the fact that many of the local clinicians do not want to work in these very rural areas. I haven’t quite got to the bottom of why this is, but I expect it has a lot to do with the dysfunctional management that is commonplace here, the heavy workloads and the prospect of living in areas where there are no “good schools” to send their children to locally. The latter is a theme I hear a lot and the South African doctors that I have spoken to want to work somewhere that it is safe for their family; many talk of emigrating. Holy Cross is safe, but it is quite isolated. Hence, I can understand what they are talking about. For this reason, hospitals such as mine shall have to rely on a foreign, often young and inexperienced, workforce to provide medical care for the time being.

I did my first 24 hour on call last week. I realise I have been here for about two months now and have worked three weekends, but not been put on the on call rota properly until now. Dr Kakooza wanted me to become more comfortable with unfamiliar specialities such as obstetrics and paediatrics. Now, I must be frank: pregnant women still scare the living daylights out of me – well, only when they are fitting, bleeding or the baby won’t come out. I think I am ok at managing the first two points, but the last one is what I dread the most. This is because it is me that has to decide what to do next. If the little one can’t squeeze out naturally then how can I coax it out? And why is it not coming out? Are there some surprises lurking inside that I or our hospital is not equipped to deal with? We are not in a specialist obstetric unit after all. If the baby is just simply “stuck,” there are plenty of options, the last resort being to do a C-section and cut it out (although it seems like this is often the first port of call). My on call started without a hitch, in fact I was quite pleased with myself as I thought I made some sterling diagnosis and management plans that involved one young girl who had a probable ruptured ectopic pregnancy whom I stabilised and transferred. I slept for about 4 hours, which I thought was extremely decadent.  

Just as I was getting comfortable, and with one hour of the night left, I got a call from maternity saying that a mother was in labour, but not progressing well. First thoughts: “bollocks – the baby’s stuck.” On arrival I could see and feel that the baby’s head was very low in the pelvis and so close to the exit. It needed to come out quick as all that pressure on the head from the mother squeezing starts to make baby upset after a while.  The mother wasn’t pushing well, so I tried to assist her: I attempted to use a device to pull the baby out with a vacuum. This didn’t work. At this point, I told the midwives to get the mother ready for theatre as she needed an emergency C-section, whilst I called the boss. It was too little too late, the baby had been stuck for too long and when she came out she was very flat and floppy. It is at points like these when I am exceptionally grateful for courses, such as the Advanced Paediatric Life Support (APLS) one where I learnt a bit of neonatal resuscitation. I intubated the baby and performed CPR and managed to get her heartbeat back. Unfortunately, she just didn’t want to breathe for herself and a few hours later she stopped. We tried our best, but this time didn’t succeed.  It was the mother’s first pregnancy.

It is not all gloom and doom though; we do have plenty of happy endings. Whilst doing my paediatric ward round I was greeted with a massive hug by a very happy five year old. It took me a few seconds to work out who he was because the last time I saw him he was sick as a dog and struggling to breath. I had sent him to our referral unit and they found he had a big growth around his vocal cords that was growing quite quickly and slowly asphyxiating him. Oh what a delight it was to see him running around and chatting. The previous doctors that had seen him had all given the boy a diagnosis of asthma, which is quite different. What they thought was a wheeze was in fact his windpipe slowly closing up and causing a stridor. I gave myself a pat on the back for that one – good job Dom. The next patient I saw was a rather malnourished infant who decided it would be a good idea to poo all down my leg when I picked her up – I could tell she was improving as she gave me a big smile after that. It provided quite a lot of amusement for the mums, kids and staff on the ward. I really do need to invest in a washing machine.

Oh yes, I also mentioned that I have left Holy Cross – only for two weeks though. I’m currently attending an anaesthetics course in Port Elizabeth (the maritime industrial hub of SA), which is about 8 hours south of my hospital. I have been working alongside the anaesthetists here and spend most my days assessing patients, putting them to sleep or making their legs numb with a spinal anaesthetic and then bringing them round. I am halfway through and have been absolutely enthralled by it all. The training here is quite different to the UK and all the anaesthetists I have worked with are my age and have been qualified only a year or two longer. As an intern, which is the equivalent to the UK foundation years (what I have just finished), they spend two months purely doing anaesthetics. Actually, the idea of intern training in South Africa is so that after completion, the doctors are ready to work in rural hospitals. Something I find quite ironic – as when I tell my new colleagues what I am doing, they often look at me in amazement. Yet, they are far more qualified to do what I am doing. Another fairly amusing observation is that the doctors here are constantly complaining about the “bad management” (a bit like I expect I have started to do) – stating that they don’t have the correct bandages to secure intravenous lines down etc. So it seems, the poor management is a universal issue here in SA. I wonder if we will improve anything at Holy Cross.

One week into the course and I have done plenty of spinals, a fair few general anaesthesias and even helped the paediatric intern successfully resuscitate a new born. After our triumph the intern came up to me and thanked me for my assistance. Of course I didn’t tell her that this was only my second neonatal resuscitation – the first, which I mentioned earlier, did not go so well. Maybe my cool demeanour gave her the sense that I knew what I was doing – which I think I kind of did. Unfortunately, when I am back at work I shall rarely have the luxury of a colleague to give me that reassuring nod or whisper in the ear. Hopefully, this will only make me stronger and sharper, rather than lazier and disillusioned. Do not worry; I shall never become the latter. Besides, things are set to change soon when our new doctors arrive.

I am sitting here writing this from a cabin that is sat right on the sea. It is just magical. This is what I came to South Africa for – the intense work and the breathtaking vistas. Stunning.