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.
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