The exorcist knows best.

I recollect writing a while back that we were expecting the arrival of three doctors in November. Unfortunately, they still haven’t arrived. There seems to be a big problem with delays from the South African health board. Their process of certification is extremely convoluted and puts a lot of potential health care workers off. It’s absurd really: a country so desperate for doctors that has a massive brain drain makes it incredibly hard for foreign medics to come work. I understand that checks need to be made to ensure that you’re not employing Dr Nick from the Simpsons, but in some cases it has taken over a year for the applications to be verified. Together with this, one only needs to give a month’s notice before leaving a job here. Hence, there are plenty of hospitals, like ours, that are running on cotton threads. It’s not just me who thinks this is a problem – the papers are plastered with stories of local hospitals threatened with closure due to a lack of doctors.

I am really enjoying my work here, but am often frustrated with the poor care that we offer for many of our patients. There is a lot that can be improved at Holy Cross – all it needs is a little direction and leadership. Unfortunately, there aren’t too many folk here that are motivated enough to try and salvage this sinking ship – maybe it’s not that bad, but it certainly feels like that sometimes. I hope that the arrival of new doctors will help us rejuvenate this once successful hospital and spur the staff into being a bit more pro-active.

I think being “pro-active” is a bit of a taboo subject here. Earlier this week I arrived in casualty to start seeing patients. At the front of the queue were some very well looking people; slumped in a wheel chair in the middle of the department was a dreadfully sick looking girl of about twenty. To be quite blunt, the triage here is crap. The nurses were sitting and gossiping at their station (a familiar site) and hadn’t blinked an eye at this young female with her mother. It is not uncommon to see cases like this – they often have end stage HIV and already beyond the grave. However, one should never assume that the point of no return has passed. I whisked her onto a bed – myself and her mother; no help from anyone else. Before asking any questions I resuscitated her – she was septic and in a state of shock. I went through my A-B-C (d.e.f.g. “don’t ever forget glucose”) – her blood sugar was dangerously low. She responded well to my treatment and went from an almost comatose state to being able to tell me how poorly she had been. It turned out she was HIV positive, not on treatment, and had just been diagnosed with multi drug resistant TB. The latter diagnosis carries a pretty poor prognosis, but only time will tell. It made me wonder, though: how many other incredibly sick people get brought to our hospital and are left with the assumption that they are far too gone. But then, is my treatment just prolonging the inevitable? Prevention is better that cure. However, you try and tell some of my clientele the importance of condom use.

I feel like I am having a go at my nursing colleagues – I don’t mean to. Many of them are amazing and I love them to bits. Without them, we would be completely stuck here.

***

I saw a gentleman last weekend who managed to chain saw his own knee – putting it back together was a bit like a jigsaw puzzle: “This flap here seems to fit with this one there. This tendon fits with that one...” I was quite keen to admit him to the ward so that I could refer him to the specialists the following day. However, he was more concerned about going home to make sure his money and gun were secure. I let him go as long as he promised to return – he stuck to his word and was back later the same day.

***

A lot of the time things get lost in translation – my Xhosa is terrible and the Xhosa to Zulu to English translations often get a little skewed. Last week I saw this old fella who was complaining of a sore throat. My first thoughts were: “Come on mate, you’ve travelled how far for me to tell you to take some paracetamol, drink some orange juice and maybe gargle some aspirin?” As the diligent doctor that I am, I had a quick peak in his throat. However, it wasn’t a sore throat he was complaining of, it was a sore mouth. He was a lifelong smoker and had this nasty ulcerating lesion under his tongue – cancer I expect.

***

I saw a fifteen year old in casualty yesterday who was making these very bizarre jerking movements of his limbs, especially when I looked at him. I was pretty convinced he wasn’t having seizures and it didn’t look like a chorea. Basically, I didn’t really know what was going on – so, what did I do, I sedated him a little with some valium, checked his HIV status and did a few blood tests. The same evening I was walking through casualty to do a c-section and there was that same boy being, from all accounts, exorcised by one of the nurses. The whole room was shouting and praying; the nurse was screaming in the boys face: “GET OUT..... LEAVE HIM.....GET OUT.....I COMMAND YOU.” I couldn’t help but smile as I walked through – just what if this works. Sure enough, the next morning he was fine. Maybe they should add Exorcisms to the medical school curriculum.

Photos to come when the internet connection improves. i.e. when I am somewhere other than Holy Cross.

Happy Hanukkah

I would like to start this scribble by wishing everyone a Happy New Year.  I expect most of you were coiffing a nice glass of fizz or making out with some stranger whilst I was applying the finishing sutures to a chap that had been stabbed six times, as the clock struck twelve. Whilst the bells rang at the church of Holy Cross next to the hospital I tied the final knot and proceeded to shout “HAPPY NEW YEAR” at everyone in my path. In return I was greeted with very enthusiastic “HAPPY HAPPY HAPPY” screeches back in my direction by some very excited nurses and patients. What a sight it was as I walked out of casualty to see six male patients who were admitted over the Christmas weekend, all standing in a line outside, watching the fireworks (well, what they could see of them as it was a rather misty evening) and all carrying their chest drain bottles. If only I had my camera.

I must be honest, though. New Years Eve was no way near as hectic as I expected it was going to be. The day was all rather quiet, considering. It felt like the calm before the storm. However, the storm never arrived. There was a definite large wave at about ten in the evening when about five very drunk men were dumped in casualty in quick succession. All had potentially life threatening stab wounds to the chest. The most critical patient was also the one that was paralytic with alcohol intoxication. He had a massive hole with three of his ribs exposed and a big gap that was sucking air like a vacuum cleaner. He was so drunk that as I cut another big gash in his thorax to put a drain in, there was barely a groan – at one minute I thought he was dead – no, just absolutely bloto. Apart from a bad hangover, he was fine the next day. I was in bed by 4:30 am.

In the course of the evening I saw plenty of assaults, including several stabbed chests (in case you were wondering – that can be very bad), a nasty head injury; a party of seven all struck by lightning –not as exciting as it sounds; a seven year old who was sexually assaulted; I relocated a dislocated elbow – the loud “clunk” it makes is always very satisfying; a massive dog bite that left a young chap with a very large flap of skin over his calf; and , amongst the rest of the hubbub,  a girl in her twenties who blew her non dominant hand up with a firework.

When I first saw the girl with the ghoulish hand I was told she was “attacked by a cricket.” What kind of monster bug could possibly turn someone’s hand into a thing that looks as if it were straight out of the set of Shaun of the Dead – she had amputated the tip of her index finger, her middle and ring fingers were just bone with nothing on top and the skin folds had turned into flaps of skin. I must say, I have noticed the insects getting very loud outside as the months get warmer -  I’ve got to get myself some stronger insect repellent. But, it turns out – a cricket is a firework. So rather than being attacked, she just let a rocket explode in her hand – I think she learnt her lesson, if a little late.

**

My nurses on the paediatric ward are all very happy at the moment as we have had less than 5 deaths in the past two months. One of them was an infant of four months whom I admitted on Friday. She was dry as a crisp after three weeks of diarrhoea and vomiting and also very malnourished. Her body was in a state of severe shock – she needed fluids, quick. An intravenous line was out of the question, so with a big needle I made a hole in her tibia (leg bone). It’s called an intraosseous line – we don’t have the correct equipment here, so I just improvised and shoved in a large needle. It worked surprisingly well. Unfortunately, despite our best efforts she died early the next morning. I couldn’t believe how late the mother had left it – it took a visiting aunt to raise the alarm and bring her to hospital. However, the mum had seen a doctor in the first week of the illness.

A diagnosis was made and some medications given. I wonder what the mother was thinking – I guess I’ll never know. I think a lot of patients here still think doctors have some God like qualities and that one visit is all you need to patch you up. Often all they want is a quick fix – which often means an injection, a cocktail of tablets and a bandage somewhere – time after time they won’t come back again until they’re at breaking point, even though you requested them to return earlier for a review. They put far too much trust in us and rarely question our judgement. This may sound nice to some – it’s a far cry from the nagging mothers in Dulwich who know what’s best for their little Jonny as he gets fed five different variations of mung bean (“it’s good for his immune system – I read it on the internet – protects against polio and mumps don’t you know – he shall not be needing that vaccine thank you.”). But, we as doctors need to be questioned – often we do things without really thinking. I almost miss those Dulwich mothers.

 I for one need to be stimulated and challenged about my decision making – it’s what I enjoy about my job: the problem solving, intellectual challenge and human interaction. However, often I just get vacant looks or nods when I ask: “Is there anything you want to ask or know?” It is our responsibility to make sure patients come back for the sake of their livelihoods. If they don’t want to, that’s fine, but as long as they are informed about their decision. For this to work we need to tell them why they need to be seen again or give them advice to return if they develop certain symptoms etc. It’s pretty common practice back home. I expect this mother wasn’t asked to come back, or if she was, the reasons why probably weren’t explained. I’m trying my best to get patients to come back sooner rather than later – this has it pros and cons – the work load is greater, but with any luck it will prevent young people rocking up at the sliding doors to casualty almost dead, taking their last breaths. Just like yesterday, and the day before, oh, and the day before that – it’s the same story – young HIV positive girls and boys who don’t really understand the significance of their ailment.  We only see the tip of the iceberg at Holy Cross – the situation in the surrounding clinics is far worse. However, things are slowly improving from what I hear.

**

The holiday season is now coming to a close – mothers and fathers, brothers and sisters, aunts and uncles are all going back. They’re returning to the mines, to the shops, to the factories and to work in the big cities - leaving the children, unemployed, sick and elderly behind. With any luck we shall see a drop in the number of assaults. With any luck that is.  

The "cricket eaten" hand. The photo doesn't quite do justice to how bad it looked in real life. Notice the absence of the index finger tip and the bone sticking out on the ring and middle finger.

Incredibly detailed graphics here.

My vegetable plot - here are some courgette and tomato plants.

The start of Christmas day in our Sunday best.

The end of Christmas day in our birthday suits

Friends soaking up the festive sun

WELCOME TO THE TRANSKEI

Music is medicine

I witnessed something beautiful last week. As I was leaving work on Thursday evening, very excited about the Christmas weekend ahead, I walked past the psychiatric unit as I do every day. As I came closer I heard the sound of two woman singing – one a nurse and the other a patient. The patient was obviously quite heavily sedated on antipsychotics. The nurse had her phone out and was playing a well known song from which both of them were singing along.

As I stopped to admire the scene, the nurse paused the music and said: “Hey Doc, I hear singing and music is very therapeutic.” Then, without another word, the music was back on and they carried on. I sauntered off with a very big grin on my face, not only because it was the weekend, but because of what I had just encountered. As I strolled home I thought to myself: maybe psychiatry isn’t a lost cause here after all.

Merry Christmas from Holy Cross

Just a quick note to say....

******HAPPY CHRISTMAS******

I am on my way to spend the weekend with friends a few hours drive up the coast. There isn’t a snowflake or red santa in sight. Instead, I have a wilting 2 foot fake Christmas tree alongside several crates of beer, some wine and a little fizz piled high in the boot of Mitch.

Surprisingly, this week hasn’t been too busy. I expect all the “”frequent attenders” have decided that they’d rather stay at home and the drunk boys and their sharpened blades are saving themselves for Saturday and Sunday. I’ll let you know.

Instead of the usual sound of wailing drunk perforated young men, there has been the very similar cry of a man that can’t pass urine. Over two consecutive days I had two young guys who both came in with full bladders, unable to pass a drop (urinary obstruction). I’m not really sure why this was – one had had a serious trauma a few years ago, but it didn’t explain why I couldn’t pass a catheter. I expect both men had had nasty cases of gonorrhoea (or is it Chlamydia – my mind lapses) that has resulted in a spiders web of strictures to the extent that not even urine can pass, let alone a catheter. So, for my first and second time, I cut a hole in their abdomen and inserted a catheter  – a suprapubic cathether. Unfortunately, I didn’t have quite the right tools, so had to improvise. You should have heard the wails and screams – imagine having a full bladder and then having some smiling guy in a white coat putting even more pressure on it as he attempts to make a hole to free the urine. Of course, I had anaesthetised the skin and given them both some heavy opiate pain killers (the second a little more after seeing the reaction of the first guy), but the analgesia didn’t quite do the trick. However, both procedures were over in no time at all – the second was slightly messier and I ended up with bloody urine all over my shoes. After taking a much needed call of nature (with a little assistance from myself), both gents had an amazing look of relief on their face. They were very happy customers indeed.

As it happens I have seen a few smiles this week – one of my patients that I admitted back in October who I thought was going to die from a serious HIV related fungal infection around the brain (cryptococcal meningitis), is now smiling and laughing.  She’s coming to see me every month and looking stronger and brighter at each visit. What a lovely Christmas present.

The moustache has now left us - a christmas present from me to you. I do miss it though.

Lesotho snaps

Waking up with the village



The chief and his family (the chief is the old guy at the back on the left)



A brief stop on the only piece of flat concrete in miles around - a bridge

....more photos to come; the internet connection at Holy Cross timed out

Around Lesotho with a washing machine

Another weekend on call is looming. It feels like I only just finished the last one. However, I think I can forgive myself for thinking this as currently we are all working every other weekend. Spending twelve days straight at the grinding stone with three days off in a constant cycle makes my brain go a little fuzzy. Hopefully the fuzz will clear once more docs arrive in the New Year.

Before I carry on with tales about my weekend jaunt, let me just give a brief synopsis on some of the events of the past few weeks:  we had some excellent, eager beaver, students from Cape Town who got their hands dirty for two weeks; I now have a cleaner – she’s called Princess – my house was slowly developing a nice layer of dust before she arrived; I have a washing machine – no more hand washing thank you; I have started digging a garden – with any luck in the next two months I shall have tomatoes, onions, courgettes, herbs and some pansies; Mitch smells of diesel and beer; the work load is noticeably getting heavier in this festive season - plenty of boys post ritual circumcision are coming in with septic members, my paediatric ward is getting very busy and the number of booze related injuries are on the rise; I successfully managed to use the power of talking to calm a psych patient down; I’ve been to see my “KFC” guy who’s face I sutured – the wound is coming along nicely; I grew a moustache; I noticed a definite rise in the number of children crying when I tried to cajole them into being examined; I shaved my moustache; the children don’t seem so afraid of me anymore.

Just in case you wanted to know how my poorly updated log book is going, here is a quick summary: In November I documented 27 spinal anaesthetics, 1 vacuum delivery and 9 intubations. Already in December I have logged 11 spinals, 10 lumbar punctures, 4 evacuations of retained products of conception, 1 vacuum delivery, 1 chest drain and 6 pleural aspirations (thoracocentesis). I have stopped recording the amount of joint manipulations and reductions, wound suturing and other common tasks – partly out of laziness, partly because I forget.

So, why does my car Mitch smell of booze and fuel? A question you may want to ask the minister responsible for the roads in Lesotho. Last weekend my Dutch compatriot, Jelleke, and I embarked on a weekend jaunt in the small country of Lesotho. All week the weather in Holy Cross was absolutely fabulous, but as the weekend approached, so did the rain – and oh did the heavens open. Fortunately, rain is no problem when you’re driving a four by four like Mitch. Lesotho is only a 3 hour drive from Holy Cross and covers a mere 200 km from East to West. However, now I’ve been there I can only imagine that it takes several days to traverse the country on the uneven roads even if the weather is dry and you have Jeremy Clarkson and his pals at the wheel of their brand new Land Rovers.

Before reaching Lesotho, we stopped off in our nearest commercial centre to get a few provisions and do a little admin. After two hours in town I had acquired a jerry can full of fresh diesel, 30 bottles of beer, which I had put in ice in the cooler, and a brand new washing machine. Yes, that’s right – I took my washing machine to Lesotho.

We had booked ourselves into quite a nice looking guesthouse somewhere in the mountainous countryside that adorns this country. Unfortunately, we didn’t quite make it to that nice somewhere on Friday or Saturday night. As I mentioned, the weather was dreary in South Africa. However, when we entered Lesotho on Friday afternoon the sky cleared to show off the magnificent beauty that adorns this almost untouched land. After taking in the scenery I noticed two things: firstly there are no fences - the land is entirely shared; secondly, the roads are terrible. However, we were travelling in my car – Mitch – sturdy as they come – a bit like a shire horse on wheels. Shortly after realising how shoddy the roads were, both of us thought that the 150 km drive to our intended destination may not be quite as straightforward as we had anticipated. Unfortunately, neither of us had remembered our guide book or a decent map. To hand we had a large road map of South Africa that had a bit on Lesotho and a satellite navigation system that would only tell us if we were on a road or not, but nothing else (I hadn’t installed the Lesotho maps onto it). So, we just looked at the map and “guestimated” that we would make it to a town about 75km away. It turns out that as you drive further into the country, the roads get worse. So, it came to eight thirty in the evening - we found ourselves in the pitch black, but for Mitch’s bright headlights, driving up and down steep “roads” (the satnav called these roads “alleys”. These alleys resembled a track of some sort with very large collections of boulders) at walking pace. Lady luck was with us though. As Mitch rumbled into a mountain top village we were greeted by the usual hoard of children, but also a young guy who spoke excellent English. With no subtlety at all I enquired if the village would provide us with shelter for the night. After a brief meeting with the chief’s son, who was full of festive cheer, he agreed that we could stay in our new friend’s rondavel (round house). In return we offered beer – unfortunately, most of the bottles had smashed on the rocky roads and the jerry can had also taken a small hit. Hence it smells a bit like someone has had a party on an oil rig in the back of Mitch.

Except for an irate donkey eeyoring at 4am, I had a very peaceful night’s sleep. The following morning I awoke to the quiet sound of the hills and with my dreary eyes took in the beauty of the surrounding scenery as the bright sun beat down on the luscious green mountains. After meeting the chief, his slightly hungover son and the rest of his family, we said our farewells. Not before taking the obligatory family photo, though, which I will send to them in the next few weeks. I am still amazed at the hospitality that we encountered. The young guy that we met gave up his modest house for us to sleep in. It actually belonged to his brother, who died a few years ago. I later learnt that I slept in his death bed – so that’s why Jelleke was so keen to let me have the bed and she sleep on Mitch’s pull out mattress (did I mention Mitch has a mattress in the boot?).

The rest of our trip was mainly spent taking in the awesome scenery and sitting behind Mitch’s dashboard as we drove over mountains in the sun, rain and fog – sometimes all at once. It really was incredible. However, next time we shall plan a little better and take some more provisions and camping gear.

In case of curiosity – the washing machine works just fine. Apart from having to screw a part back in after the bolts fell out, it only suffered a few minor dents.

Bedlam

Here is one for my psych colleagues. As some of you may know, my last job in the UK was spent working for an incredible psychiatric liaison team at King’s College Hospital, London. I have always had a slight slant for the ones that are slightly loopy in the head – psychiatrists and mental health nurses; I enjoy the interaction with the patients too. As a student I spent many a Tuesday evening with a troupe of terribly enthusiastic psychiatrists, terrifyingly good actors and sheepish pupils like myself – but we soon learned the joys of working in mental health and many of our initial fears in dealing with “difficult to handle” patients soon dissipated. Now, you may ask, how can someone who loves dealing with the blood and gore of casualty also enjoy the long in depth assessments involved in psychiatry? True, they may be on different ends of the spectrum, but both are equally exciting and drab at the same time – in the emergency department you get the stab wounds, but also the sore throats; in psychiatry (often in the emergency department too) you see the floridly manic, but also the young teenagers who come in every week having just taken enough paracetamol to get them some attention, but never enough to die (I must say I do prefer it when they take the non lethal dose; also the conversation that is had is much more interesting than that of someone with a sore throat). As a result of all this I thought I was pretty prepared for dealing with mental health out here. How wrong could I have been?

Psychiatry – the talking medicine. Trying to get a medical history is hard enough here, let alone ask about mental health complaints. The culture and language is so different. Did I mention Xhosa is full of clicks and clocks of the tongue? Now, I am slowly learning this tongue, but at the moment my vocabulary consists of about 40 words and only around 4 of which are actually understood by my patients. According to them I still can’t pronounce the word for “cough” properly. They just give me a vacant stare and turn their head to look at the nurse who repeats exactly what I just said, but with a little extra fairy dust. This magic twist of the tongue turns my patient’s confused frown into a nice verbal response. Unfortunately, I often can’t understand what their reply is. And so, the process reverses as I turn to my nurse with a look of “what did they just say?”

I have quickly learnt that we don’t do too much talking to our patients here that are referred to as: “Doc, we have a mental case – can you prescribe some intravenous sedation?” The first time I was asked this, my initial reaction was – no way, let’s try and de-escalate this situation in a nice step wise manner – I have done a job in psychiatry don’t you know. So, let’s talk first. Plan “A” failed at the starting block when I found 3 security guards sitting on my “mental case”. One guard was gently pushing his foot on the patient’s neck (they had just zapped him with a taser). I didn’t like this one bit and kindly asked the guards not to antagonise our patient any further. Talking didn’t work when I remembered: “Oh yes, I can’t speak Xhosa. I can’t even pronounce Xhosa properly. Silly me.” My nurses weren’t very keen on opening any kind of dialogue so I offered him some oral medication to calm him down. Eureka – he happily swallowed down the cocktail of benzodiazepines and antipsychotics. Half an hour later, he was still causing havoc. At which point my boss showed up and said: “don’t bother with that, just give him the stuff intravenously.” Despite initially objecting, I caved in – the patient got his shot and quickly dozed off into la la land. This had taken about one hour of my time. I have fast realised that we don’t have the luxury to properly give our full attention to these patients, or any patient for that matter. When there is only one of you in casualty and several other people also needing your urgent undivided time, all one can do is temper the situation (and try to stop the security guys from using their taser). This often means heavily sedating our psychotic clients as first line treatment, making sure they are calm enough to put the rest of the department at ease but not so chilled that they stop breathing. The talking happens later, at some point.

We see a lot of psychotic patients. I expect most of the cases are drug induced as there is a serious amount of marijuana smoked here. The stuff grows like a weed. Every disturbed patient I have seen so far inhales chimneys of the stuff. Along with these lively characters, there are a lot of overdoses. Many involve similar circumstances to what is seen daily in a UK emergency department – young boys and girls that take a few tablets because they were having relationship issues, exam stress or just a bit frustrated with the normal ups and downs of life. Unfortunately the drug of choice here is a nasty organophosphate pesticide that is freely available. People use it to preserve millet, one of the staple foods eaten by the local population. Just one tablet needs to be taken and it can be game over. In fact, since I have been here I don’t know of anyone that has survived, but we do try as it is potentially reversible if you have the right drugs and equipment. We occasionally have the former, but rarely the latter. The saddest thing is that when you talk to these patients, the awake ones, they often regret what they have done and want to live. There is often little we can do apart from cross our fingers (not quite true, but it does feel like that is all we are doing).

So, that is a brief summary of the wayward state of psychiatry here – the pathology is present, but the effective management is not. The patients that remain on treatment are often on very old drugs that have many, often irreversible, side effects. They are quickly labelled as a “mental case”, which tends to stick for the rest of their life. However, on the up side, many of these psych patients often have a family member or friend that supports and stays with them – I just hope it is because of the love and affection and not the government grant that people with mental illness receive every month. Food for thought, though.