And then there were 6 (doctors that is).

It has been some time since I last wrote, but not for lack of excitement mind. The night before I set off on holiday I was second on call (i.e. the anaesthetist for caesarean sections) and really hoping it would be quiet as I had to leave at 5am. At midnight, I was called for an emergency section – unfortunately, half way through the procedure, which was slightly traumatic anyway as the spinal failed to work and there was a lot of bleeding from the uterus - the lights went out, shortly followed by the death of the ventilator battery. Fortunately, we managed to safely finish the procedure under a flickering torch.  It felt as we were doing the procedure by candlelight. I must remember to keep my head torch handy for events such as these.

Following a relatively rested night of just one caesarean section, thanks to the power failure, I sped out of the gates and waved goodbye to Holy Cross for a delicious holiday with my Mum. We spent time in Kruger National Park, the wine lands and Cape Town. For all the tinsel clad accommodation I had booked, I think her favourite part of the trip was the one night she spent at Holy Cross. Mum received hugs from nearly all my nurses; I’m still waiting to receive these hugs myself and feel a little left out. I expect she also found being chased by a large bull elephant on heat and walking into a pride of fifteen lions rather exciting too. Note to self, when you see forty female elephants walking rather fast in one direction, it would be prudent to wait to see if they have a very excitable friend in tow. In case you were wondering about the lions – they had just eaten. The entire troupe, including the cubs, were pregnant with food. Hence, I sit here writing with all my limbs attached and no exciting claw marks to regale my grandchildren with of how I wrestled a Lion to its death.

***

I have been back at work for two weeks now. I will be honest, that first day back was a struggle. My body was still in holiday mode and my brain was still firing up the synapses. Fortunately, that first week was pretty uneventful. The new doctor, a local boy called Zola – that’s right, named after the Italian soccer star – has proved his weight in gold. As well as appearing to like his job, he is very good at it and seems to be a real team player. These things make me very happy.  As well as his arrival, a good friend from the UK landed on our shores – she’s working down the road (100km as the crow flies – 250 km by road – a five hour drive – very close by my “rural doctor” standards) and another friend has just arrived up the road (another five hours). More reasons to celebrate. Here’s one more – with the work load easing off slightly (i.e. less on calls) I have been trying to get involved a little bit more with extracurricular hospital life. I found out that many of the staff play regular football and netball. I’m pretty terrible at both, but I can run. Hence, I’ve started running with our workshop guy, Mr Mabena, and am considering embarrassing myself on the football pitch in the near future.  Interestingly, Mr Mabena is also the gentleman that performs all our male circumcisions – yes that’s right, he manages the workshop and in his spare time makes young boys cry.

I cannot emphasise how much difference just one more pair of hard working hands has made here. Since arriving, the emphasis has been very much on providing a service of some kind to the local population - a problem that doctors often face in the UK where we try to be NHS “service providers” and trainees in unison. There have been very little training opportunities, except of course for the abundance of practical procedures. At the beginning I started to write a few ward and outpatient protocols for common conditions that tend to be managed in a disastrous manner for a whole host of reasons that I shall not go into. A condition called “diabetic ketoacidosis” has an incredibly high mortality at Holy Cross – it is generally an ailment of boys and girls in their teens and twenties. However, since I was drafted to the on-call rota in November, my projects have been on the back burner. Now I have more time on my hands I have turned back to these guidelines of mine. They are by no means perfect, but I hope a happy medium that means this condition can be safely managed on our wards. If they are successful, I shall be singing and dancing and you shall be sure to know about it. In addition to a few helpful management kits I have drafted up a weekly teaching session. It is still in the preliminary stages, but I want to get the clinicians together every week (it may turn out to be once a month, depending on the popularity of the idea) to present up to date management on common conditions we encounter at Holy Cross.

***

This week has felt as if the kind folk around Holy Cross herd there was a new doctor. It is as if they are testing our new expanded service by crashing some cars and running over a few children. In just one week we have had a five year old girl, a five year old boy and a whole bus load of children come in on different days. All of them were from the same school. The girl was hit by a car at speed and brought in with her intestines eviscerated – she died shortly after arrival. The coach of kids delivered between fifteen and twenty five to ten year olds – fortunately, despite three being quite critical, I believe they all survived. The five year old boy was my case.

It was just after lunch on a busy Monday in casualty and I was called from my desk to see an MVA (motor vehicle accident) in the resuscitation bay. One never really knows what will be behind the closed curtains lying on the gurney of resus, so I tend not to guess. My first impression when I saw K was that he looked pretty perky for being hit by a car. As I went through the motions and made my assessment I was aghast by how much damage had been done to this small boy. I realised that this spritely little face, who was smiling at me and telling me to “stop ordering me about; why do you keep playing with my eyes doctor,” was completely stunned. He had suffered massive abdominal trauma, a 4cm anal tear (although, I’m not sure how deep it extended), a deep laceration on his buttock, a pelvic fracture, completely degloved his right lower leg (this is when all the skin is scraped off and the muscle shorn from the bone) and had a head injury. He had lost a lot of blood and showed all the clinical signs of hypovolaemic shock in a child. I resuscitated him and stopped the bleeding by packing the wounds. K was doing just fine considering. Unfortunately, the ambulance to transfer him was nowhere to be seen. Five hours later he was not looking so peachy – I expect he had internal bleeding. Up until then he had remained pretty stable. I could see he was deteriorating and gathered a little help. Within five minutes of K saying he was fine and “can I be with mummy now,” he started gasping for air. After 45 minutes of cardiopulmonary resuscitation, with the assistance of our new doctor, K died.

I must say I have felt quite troubled by his death, although I am not really sure if there is anything more that I could have done. It deeply saddens me how cheap life can be here – somewhere else he may have been saved. Very little responsibility is taken for the future generation: the HIV epidemic seems to be spiralling out of control, drink driving rife and at the end of the day it is the children that carry the burden.

***

It is payday weekend and I am halfway through a 72 hour on call (it’s not actually that bad as there are two of us – one is first on call Friday and Sunday and the other takes Saturday – so sleep is a strong possibility, unless there are a lot of caesarean sections of big polytraumas that require the two of us). I managed two hours sleep last night. As I think I have mentioned – pay day dishes out salaries to the workers and social benefits to the infirm, old, and as far as I can tell, many perfectly healthy individuals. One can almost hear the bell of the cash register singing at the local shebeen (bar) as people go insane on whiskey and beer. I’ve never seen anything like it, except maybe for Leicester Square on a Saturday night. With the booze brings the arguments, which often end up in the fists, knives and guns coming out to play. I don’t think you can fully appreciate the foul odour of alcohol, blood, halitosis and excrement until you spend some time in our noxious casualty on a Friday or Saturday night. It makes the eyes water.  Fortunately, no one died last night, despite trying their best.

Labour ward has also been keeping us busy this weekend with first time mothers, all under twenty, and their babies being very stubborn. Far more exciting than the three caesers, though, was my first successful vacuum extraction of a new born. I was exceedingly pleased with myself, as it is a lot harder, and messier, than it looks at first glance. The past six months have been a cause of frustration in that department. It is all about technique and making sure the patient is suitable. This mother was in her seventh pregnancy, so there was no danger that the baby wouldn’t fit down the birth canal – more a high risk of bleeding afterwards. She only bled a little.



Striking a pose at the top of Lion's Head, Cape Town.



Mum admiring a massive herd of elephants shortly before we get charged by a large bull elephant.

Simba

Mum and I at the end of our stay in Kruger National Park having a "sundowner" - a new term for me - having a drink at sunset.

Wild Dog and her gang on the hunt.

Mrs Rhino - safe for now.

The table cloth at Table Mountain, Cape Town

If only South Africa was this simple - the unifying black and white hand - yet racial divide is still massive.

Always good to know.

One of the elevator lobbies at a very cool art hotel in Johannesburg

The girl on my left is, for me, one of my success stories. She presented with a fungal meningitis, called Cryptococcus. It is associated with HIV. Mortality is rather high and she was desperately ill when I first admitted her in my second week here at Holy Cross. Now, five months later she is well, taking her HIV medications and a very happy lady indeed. Stories like this are some of the many reasons why I love my job.

The young girl in the green top is Wendy. She is the older sister of the girl on her left. Wendy was admitted in extremis with malnutrition, TB and was discovered to be HIV positive. She didn’t smile for two months until the week before her discharge. When I saw her this week she was laughing and running around like a child should. She appears to be thriving. The nurse is my favourite paediatric sister - she's been in the game since 1974.

This lady is on HIV treatment - it appears to be failing. She has presented with a very nice example of a lupus like rash, which may well be HIV associated Lupus. I am waiting for blood results to see if the HIV virus has become resistant to her medication (often a result of patient's not taking medication regularly).