A short drive up through eastern Africa

 

Mitch, Mimi, Bhamini and Dom - fresh, clean and
 not really sure what to expect on the clean streets of Durban.

 



Botswana: home of possibly the longest, straightest
 road in the world. This is also the location of our
 first, and hopefully last, road kill - a poor bird sandwiched
 between Mitch and Mimi.



This blog, thus far, has generally revolved around my life at Holy Cross. For the most part, this is how I want to keep it. However, seeing as I am currently a few thousand miles from the hospital, sipping a gin and tonic whilst sitting on a veranda looking over Lake Tanganyika in western Tanzania, it is rather hard to write about work. As it happens, yes, the sun is setting and the piece of decking I have my bottom perched on happens to look straight to the west. So, for the rest of July and August, one can expect to hear a few scatty tales of what myself, my friend Bhamini and Mitch have been up to. My intention is not to show off, although I expect some of you may be rather envious of my current situation, as I would be, but to record a few events. The blog is as much for my own future records and nostalgia as it is to share with friends and family.  Secondly, it may also be a nice advertisement to any budding doctors (medicine is your passport to travel) or to anyone at a loose end and wanting a few ideas of what to do next. How about drive halfway up Africa and back?

***



Do not get between an mother and her child.



Since we departed from Durban on the last weekend of June, we have covered the distance of four rather large countries – South Africa, Botswana, Zambia and Tanzania. Thus far, Mitch has delivered us safely from one destination to the next. However, we have all become very dusty as the roads progressively get a little drier and bumpier. In fact, calling some of these tracks “roads” would be something of a debate. A few of these bridal tracks are mini deserts and others are miniature versions or the Rocky Mountains. If it wasn’t for the trusty satellite navigation system (we would be truly lost without it) that I updated with the entirety of the African continent – just in case – I think there would have been a lot of stopping and asking of fellow earth people if this track of theirs actually does lead to that national park that no one goes to because it is a little out of the way, but apparently is a hidden gem, except for the tsetse flies.  



Simba.



 As it happens, that national park – Katavi – in western Tanzania is the hidden gem the guide book says it is. Unfortunately, the guide book is also correct about the tsetse flies and the terrible roads. Mitch turned into a tsetse grave yard as they were flattened by the park map/hand/water bottle/finger or whatever blunt instrument was available whilst we scouted for game at the same time. If you have never been bitten by a tsetse fly, it’s a bit like being gnawed by a horse fly. Mean little critters. However, the flies didn’t ruin our fun. This was the Africa safari experience that I had envisaged before coming here. We camped looking over a river with the largest pod of hippos that I have ever seen. That night we had a quick dinner and made a swift ascension into the safety of Mimi (Mimi is the name of the roof tent as well as Mitch’s weekend alter ego), just after sunset, and waited. The noise was tremendous – Hippos sound a bit like very loud barking pigs doing unmentionable things to each other. Within a few minutes the hungry hippos were roaming around our car and munching on the lush long grass to fill their bellies after a busy day of doing nothing in the mud. It really was extraordinary as we lay there, heads poking out of the tent and watching them eat under the bright glow of the galaxy above, occasionally interrupted by the massive torch I bought for such events.

***

Buses like these driving at 100km per hour down a pot
 holed barren wasteland of road are a not
too uncommon sight in Tanzania.

 South Africa feels so different to every other country that I have been to elsewhere on this glorious continent. Yes, the roads may not be quite as good and there aren’t as many hospitals or politicians to play with budgets. However, doors are open. In general, there isn’t that fear that governs so much of South African society. In addition, literacy appears to be markedly better in the neighbouring republics. Notably, in Zambia, we passed a school every few miles (or at least it felt like that) and comprehension of the English language (the only vague marker I can use of literacy at a glance) is really rather good – something I cannot say for the community who live around Holy Cross. I understand that South Africa is a progressive society, but things feel much simpler and easier outside of it. I expect my glasses are exceptionally rosy as I haven’t had to deal with the oppression of military regimes, humanitarian infringements, and inequality in woman’s rights, homophobia, bent politicians and so forth. However, all I can say is what I see and what I appear to see is happy people. From when I was 18 and travelling/working through Ghana, Togo and Benin to when I was 24 and doing my medical elective in Uganda, and up to now, driving back up to Uganda via several east African countries – people seem happier than they do in South Africa.

***

I mentioned that the roads are progressively getting worse as we come north. So far, we have been bombing it up the “main roads” so that we can get to Rwanda to see gorillas on July 18^th. But as I said – some are barely roads. However, I think this situation is a rapidly changing one. I remember reading and hearing news of the Chinese and their domination of Africa. It appears that in return for the richness that the soil has to offer, Chinese contractors are building roads, roads and more roads. They seem to have shipped over an entire work force of site managers and all of their own gear (trucks and diggers) to create endless highways of asphalt. We had our first experience of the lush smooth purr of tarmac last night after several hours of off road driving alongside the construction of these superhighways. I do wonder, however, if the roads will be maintained if the Chinese leave after they have had their fill of natural resources. Much like the British and other colonial powers did in former times – wash their hands of the mess that they had created. However, the Chinese haven’t colonised Africa so maybe things will be a little different.

***  



Some exceptionally keen amateur photographers
 in Chobe National Park, Botswana.

We are only 13 days into our trip, but have already covered a considerable distance. The reason we are going so fast, as I keep mentioning, is because we have two very expensive permits to see the endangered gorillas of central Africa.  Hence, we have had a lot of time sitting inside of Mitch and carving out some nice bottom shaped indentations in the seats. To date, we have listened to the audio book of The Hitchhikers Guide to the Galaxy; discovered that it can get very cold during the night in Botswana and that a 1 season sleeping bag does not suffice; made sure that the roof tent always has at least three blankets, as well as sleeping bags; seen how ugly the safari season can be in peak season at Chobe National Park in Botswana – think tens of open top game vehicles loaded with tourists (ourselves included) surrounding an unfortunate pride of lions; seeing how beautiful a safari can be from the  safety of Mitch  with not a human in sight, enveloped by a journey of giraffes, a dazzle of zebras, herds of buffalo, enjoying the odour of a pod of hippos and stumbling across a small pride of lions; rafted down the white waters of the Zambezi river at the base of Victoria Falls; got soaked by the spray of Victoria Falls; camped next to and swam in hot springs in Zambia; tracked chimpanzees in Gombe National Park – famed for Jane Goodall’s pioneering research into the primates.

However, possibly the best thing of all is that we have enjoyed freshly ground coffee every morning thanks to a very nifty little handheld grinder all the way from Japan. Actually, the coffee isn’t the best thing, but you may be able to tell that I am rather proud of this feat.

  

Chimpanze.





Up close and personal with some very shy elephants at Katavi National Park, Tanzania.

Camp for the night, in Katavi. About 30 metres behind me (I'm taking the photo) is a pod of around 100 hippos. 

A giraffe trying to eat whilst we take some snaps from the comfort of Mitch.



  

Hello from Southern Africa (not South Africa)

So, I shall keep this brief. Three weeks ago I flew home to surprise my mum for her sixtieth birthday (sorry for giving your age away, but you know you do not look a day over thirty). I think she was rather pleased. Being at home was absolutely wonderful – it reminded me of how lucky I am and what a surreal life I live at the moment. After an intense nine days in the UK I flew back to South Africa for a mere five days of work. I cannot lie (well, except for lying to my mother – but I had good intentions), it was a tough five days. Am I destined to do this for the rest of my life? I hope not. All I want in life, like most, is a family and to love and be loved. However, my narcissistic life was instantly thrown back to the ground during the one on call I did last week. I was summoned to casualty at 2 am after a car had lost control and collided with a rondavel – someone’s house. Sleeping just seconds prior to the accident were two mothers, each with a young child. Three were surprisingly well; unfortunately the youngest, an eight month old girl, died minutes before I arrived. It really did put things back in perspective. I have committed myself to another year at Holy Cross.

Now, why keep this brief? Well, before I give Holy Cross another year of “Dom in South Africa” I am taking two months of unpaid leave. My friend and I have started our trip up to Uganda and are currently in Zambia. For those bad on geography we passed through Botswana before arriving in Livingstone (Botswana), where we are now. Yesterday we stumbled around Victoria Falls (WOW) and today rafted down the white waters of the Zambezi. In four days we should be in Tanzania en route to Rwanda to see the Gorillas on July 16^th. After that we shall have more time to relax and slowly work our way back down the continent.

Internet is bad, so no photos. If we do find a good spot maybe I shall write a bit more on the adventures of Dom and Bhamini (like harmony, but with a ‘B’) in Mitch or MiMi (Mitch’s weekend name).

Don't shoot.




Sunrise last week; sunset this week.



Before I mumble on with more tales from Holy Cross, could I urge you to  click on the following link and sign the “ePetition,” asking the Eastern Cape Department of Health to get organised. We have already lost one potential doctor as a result and there are other hospitals facing a very real prospect of being “doctor-less” by August – the implications of this are massive.

http://www.change.org/petitions/eastern-cape-department-of-health-south-africa-urgently-provide-contracts-for-new-doctors?utm_campaign=friend_inviter_action_box&utm_medium=facebook&utm_source=share_petition

***

If you stumbled into casualty on Sunday evening you may have wondered why I was standing on top of an 80 year old patient’s bed with my leg in his armpit and pulling the man’s arm with all my might (may I add that my raw strength is probably equivalent to that of a five year old). Firstly, I do not believe for one second that he was 80. However, he was definitely pushing it and was built like the Terminator. This could be a slightly histrionic statement, but that’s how it felt. Years of working the land had made this elderly gentleman rather “ripped.” I guess you may be asking why I was pulling back on his arm, with a nursing colleague giving counter traction via a bed sheet strapped around his armpit. The old geeza had rather impressively dislocated his shoulder. Now, I have done this on two occasions myself (one skiing and one throwing some slightly over enthusiastic shapes on the dance floor) – it is exceptionally painful. Fortunately for myself, as mentioned earlier, I sometimes look a little malnourished (hence, a lack of muscle bulk) and I had my doctor friend George (we were medical students at the time) to slip it back in – I am and always will be eternally grateful for this. Hence, I could almost understand how the old fella was feeling.

In general there are three ways to dislocate a shoulder – either it comes forward (the commonest injury and what I had), goes backwards or heads down, into the armpit. He had all the classic signs of a dislocated shoulder: agonising pain, loss of the angle of the shoulder and reluctance to use the arm. However, his arm was also held abducted (i.e. hanging out – he couldn’t bring his arm to his side). A quick examination revealed that he had also sustained a possible nerve injury and that his humeral head (the ball joint at the top of ones humerus – quite self explanatory really) was sitting in his axilla (armpit). So, I gave him a good dose of pain relief and sedation, then tried my best to plonk it back with the assistance of two nurses.  

It is only the second dislocation I have seen here, but both have been inferior ones – from what I have read, they are rather rare and can be a bugger to relocate (orthopaedic colleagues, please correct me if I am wrong). The reason I keep mentioning muscle bulk is because the more there is, the harder it is to pull a joint back into position. Fortunately, the first time I saw this it was an elderly lady who’s shoulder was only slightly smaller than mine – I reduced it with no problem at all, except for her responding a bit too enthusiastically to the trickle or morphine that I gave her.

After 45 minutes of pulling, twisting, getting the book out, trying different manoeuvres and pulling again, I accepted defeat. I think this point was realised when I found myself using the bed as a pivot to lean back and almost falling over from my own fatigue. So, I sent him to our orthopaedic hospital with plenty of analgesia in his system – a bumpy 4 hour trip is not ideal at the best of times, let alone with a fracture or dislocation.

***

Assaults are common here; so are guns. Hence, there is a big sign on the hospital front that clearly says: “No guns.” It makes sense, hospitals are places for healing; guns are designed to cause harm. There I was performing an examination on a security guard from a supermarket in town, who had been beaten up by a couple of men. He told me that the men were having an argument in the store, so he tried to break up and settle the dispute, or at least move it outside. Instead of agreeing they gave him a few punches and ran off to fight elsewhere.

The guard was fine, but as I asked him to: “Khulula,” (undress, in Xhosa), I found that he was packing heat. For a little clarity, that is the “gangsta” lingo for carrying a firearm. It just so happened that at this point my nurse had popped out of the consulting room and it was only the two of us. I very kindly told him that yielding a gun in a hospital was completely unacceptable, but decided to leave it at that. I was more concerned that if I alerted the security, the situation could have gone from very pleasant to bang, bang.

***



Medical ward can be hard work, both mentally and physically. However, yesterday I discharged a nice lady who had suffered a stroke. Before I had time to blink, she hobbled up to me (it’s not so easy to run when half of your body doesn’t do what you tell it) and gave me lots of kisses and a showering of: “Siyabonga, siyabonga,” (thank you, thank you). It’s these moments of spontaneity that one just doesn’t get in other lines of work – I wouldn’t change my job for anything.

  

A classic CSF picture of bacterial meningitis. Unfortunately, the young man was dumped onto a bus in Durban back to the Eastern Cape and by the time I saw him he was too far gone. He died later the same day.



This is the chest xray of a rather well looking young man who had some persistent TB symptoms. The big blob in the middle is his heart surrounded by a load of fluid (pericardial effusion) that I confirmed on ultrasound. Extrapulmonary TB is the commonest cause of pericardial effusions here.




This lady had fallen over the week prior and was hobbling around in excruciating pain. Notice that her left leg is a little shorter than her right and that the left ankle is rotated outwards. This is a typical of a fractured hip.



A very jaundiced patient. Notice the reflection of my favourite Sister in medical ward.

This is the young mother who had Steven's-Johnson Syndrome - she is on a full road to recovery and I have sent her home to be with her child. She's due to come back for review in two weeks. (Images use with permission of patient)

A massive lipoma (fat deposit) that I removed from a lady's arm. An exceptionally satisfying procedure.

Vacancies.

Vacancies - please submit your CV.

There is a lot of excitement in my household at the moment and, seeing as it is only I who lives within this abode large enough for a family of four, I can dance around with as much glee as I care. For in exactly one month, I shall be saying goodbye to Holy Cross and embarking on a little overland trip with a friend in Mitch, the four by four off road machine, up to Uganda and back. I am sure I will be giving out plenty of snaps from the trip when the time comes and maybe a few tales too. Fingers crossed Mitch is good for it.

***

After originally being struck by the amount of HIV and young people dying in all manner of undignified ways, although I am not quite sure what is a dignified way to go (at home, in bed I suspect), something else bothers me far more. Just the other day I was counselling a girl of 15 who had a threatened miscarriage. One cannot stop people from having sex, even at this young age. However, she, like many before her, laughed when I mentioned the importance of an HIV test and said that she was not ready for one. After a bit more discussion she agreed to the test. If getting young people to test for HIV is difficult, then surly it is even harder to encourage them to practice safe sex.

Last week I performed a sexual assault examination of a 14 year old girl who was abducted and taken 100km away to a location near Holy Cross. However, despite this distressing story, she had clearly been sexually active for some time: her genitals were covered in warts and there was a very offensive discharge. It transpired her boyfriend was not very keen on condoms and that he probably had a few other girlfriends too.

It is always the woman that we see in clinic with the sexually transmitted diseases and early pregnancies. Rarely one sees the men coming for sexual health related issues. It is the men that really need to be educated, and, therein lies the problem. There are a few good initiatives nationwide, but I am not aware of any around here. There is a very successful clinic run on Saturday mornings near Johannesburg led by all male nurses. I expect many men around here have difficulty discussing their “man-hood” with female nurses as local culture still dictates a divide amongst the sexes.

Talking of family planning – there are a lot of dogs that roam the roads of the Eastern Cape; there are also a lot of flat dogs that line these roads. A colleague pointed this out the other night - how can there still be so many dogs. The boss replied: “It’s canine family planning. Without it, they would overwhelm the area.”

***

On every casualty or outpatient card there is a brief history of the presenting complaint. Often I take a quick glance, but a lot of the time something has been lost in translation. For example, it may read: “15 year old, has been coughing for 5 days, is severely dyspnoeic and unconscious.” A brief inspection of the patient reveals that they are awake and breathing just fine. However, this week I forgot to read the “blurb,” and just dived straight into my history:

Me: What brings you here today?

Patient: I have a cough.

Me: Oh, how long have you had this cough for.

Patient: Since 1982.

Me: *my face scrumples up, I give him an “are you serious” look*

Patient: *gives me “I am deadly serious” look back*

At this point, I decide to read the outpatient card – he had come to pick up medication for his epilepsy. However, now I had started on this cough story, I had to finish. I think I cough more than he does, but, nonetheless he wanted me to give him something for it. It was almost as if he was bargaining with me – he had a pretty good poker face. However, once I agreed to dispense my secret weapon (paracetamol) he relaxed immediately and I advised him to test his sputum at clinic for TB.

***

I would like to end this little piece with a small plea. Perhaps I should have started with it, however, if you are still reading now then you must have, at the least, a small tickling interest in the health system here. Budget constraints or, more likely, mismanagement of funds (what some may call corruption or fraud. This is only my guess and I would never accuse the Eastern Cape Department of Health of such things) has had a visible effect on local health services. Similar tunes are being echoed in the British NHS.  However, it seems as if things are going from bad to worse: the health department has said that they cannot fund any new posts for doctors, or at least this is what I have read in articles and heard from various mouths in management.

Holy Cross, comparatively, has it pretty good at the moment with eight doctors. We are expecting two more, but news has just arrived that they may not be able to work here (despite vacancies) as there is no money. It is likely they will be wooed by one of our neighbouring provinces, such as Kwazulu-Natal. Of more immediate concern, however, are the hospitals that, come August, could possibly be with no clinicians at all. It is a very real possibility and unless the government steps in (who at this moment are piloting a national health insurance scheme) or the local department of health gets its act together, communities shall be without emergency medical, obstetric and paediatric care that could have grave consequences.

So where best to start: a petition. A good friend of mine, who is working in one of these soon to be “doctor free” hospitals, has petitioned the Eastern Cape Department of Health. Please log on, sign it and spread the message.

The link is:

http://www.change.org/petitions/eastern-cape-department-of-health-south-africa-provide-contracts-for-doctors-needed-to-provide-essential-services-4?utm_campaign=friend_inviter_modal&utm_medium=facebook&utm_source=share_petition

If the link does not work, please let me know.

My hand is on the left and on the right is a patient who has a haemoglobin of 2 (severe anaemia). I checked mine and it was 16. Needless to say, she received a blood transfusion to help her gross fatigue and exertional breathlessness.

The Kiss of Life

I got up at 6am on Thursday to give my nursing colleagues a tutorial on diabetes management and was greeted by this from my bedroom window.

Something quite astonishing just happened, for Holy Cross at least. I just performed my first “crash call” in casualty – a lady’s heart stopped beating right under my eyes. She was in cardiac arrest. What is more astounding though is that we managed to kick start her heart back into action again, with nothing more than some good cardiac massage (chest compressions) for one minute. More often than not a patient is found dead on the ward, in their chair or on the bench long before any hope of reperfusing their brain, with some very heroic allopathic medicine, would be considered. She really was in the right place at the right time. Unfortunately, her prognosis is still poor – with no known medical history, she seems to have a multitude of problems – apart from her heart stopping for a moment, she appears to have had a massive haemorrhage in her brain (well, that’s my clinical judgement after a thorough examination and history – we have no CT scanner).

A cardiac arrest call was a very common event for me back home (UK). I actually thought I was rather competent at running them. However, being out of sync for so long definitely made me think harder about what I was doing with each step – I used to be so slick, or so I thought. I seem to wear very rose tinted glasses. I don’t think I can entirely blame myself though. The crash trolley looks a million dollars, but contains very few useful items – some broken bag valve masks (what we use to help a patient breath), a missing defibrillator (someone thought it looked better on the windowsill) and a lot of useless drugs. Fortunately, our lady didn’t require any of these items.

Running an arrest should be quite a smooth affair, and despite my complaints, I think we did quite well considering all five of my nurses don’t even have basic life support training. As I ran through the reversible causes I even managed to exclude a cardiac tamponade (fluid around the heart) with my new ultrasound scanning capabilities (did I mention I went on an ultrasound course?).

So, seeing as I have been elected (although, I recollect no election) to head the resuscitation committee, maybe we should start by getting everyone trained in basic life support and sort the crash trolleys out. However, I fear this is not really a key burning issue at Holy Cross – trying to get on top of the HIV epidemic is far needier and still a massive problem. When I started work on Monday morning I had already lost five young women, all about my age, as a result of HIV related illnesses. Cardiopulmonary resuscitation would probably have been futile in these scenarios. So, here’s one for you, boys and girls: STOP HAVING UNPROTECTED SEX. If you do, make sure you get “checked out” after.

A very spritely bunch of medical ward nurses at 6:30am, eager to learn about diabetes. I made a cake that I think everyone enjoyed, although probably didn’t really convey a good message when talking about the subject in hand. They are all keen for more sessions as they are a nerdy bunch and not just cake fiends.

My lady with Steven's-Johnson Syndrome - making long strides towards recovery.

An old lady with a nasty infection of her right eye - she delayed presentation for 3 months and as a result has probably lost her eyesight.

It was peas last week and now it is baby carrots. I completely forgot I was growing them. Delicious.



I have a rather large window in my sitting room - ideal for catching sunrise (above), sunset and lightening shows.



“This house believes that Holy Cross can be saved. Discuss”

Trying to blend into the background at work.

“Good chairperson, would you kindly open this meeting? Shall we start with a short prayer?” I feel as if Holy Cross has become the venue for a public speaking debate, except for the doors are closed and no public or press are allowed to get a whiff of our heated discussions. The Eastern Cape Department of Health has been getting some bad press recently, and probably rightly so. There have been almost daily meetings – some productive, some not – discussing issues that make a few of us a little warm under the collar.

It is an exciting place where I work and we have personal from all over the globe with many different beliefs and values. Recently the notion of us offering a TOP (termination of pregnancy) service was debated: a very sensitive issue, whatever side of the fence one stands. We encounter too many mothers, young and old, who present following an illegal abortion. Without the correct aftercare, a woman could develop severe sepsis or bleeding, potentially resulting in death. As it stands I have been nominated to undergo the training. I think that my values are strong, yet I have no fixed religious beliefs. If a potential mother cannot see any other option but a termination, I would much rather that she does it in a safe and controlled environment. However, what is of more importance than offering this service is good public health measures to prevent women getting pregnant in the first place. This can be difficult in a country where many men see ejaculating (masturbation does not count apparently) as a necessity - otherwise, the semen will back up and congest ones brain, or so I am led to believe.

In addition to the multitude of discussions, from how can we improve infant mortality to where we should put the new volley ball net, the boss delivered a very compelling talk to his seven strong team of medics. In a nutshell he was telling us that same old story of how Rome wasn’t built in a day. We all have very different views on how to run a department and come from different backgrounds. I myself stand by the chief – I believe that if change is to be made one must go slow, mould a partnership trust and keep an open relationship with staff; discussing and debating issues as they come, before things get to a boiling point. Unfortunately, many of us foreigners only stay a year or two. Saying that, the boss is a foreigner too, but has somehow had the gusto to stay for over twenty years – he retires next June. I honestly am not sure if we can make any lasting changes. Things are good now, but who knows how things will be next year.

***

Breaking news rippled through the corridors of Holy Cross last week – the national stock of Tenofovir, an essential HIV drug, had run out. This is a very, very bad thing indeed. HIV drugs are often given in a combination of three and work to suppress the virus. If doses are missed or even delayed a few hours, then the clever bug may have time to develop a mutation and become resistant. Fortunately, some of our meetings have been productive and we seem to have a fairly robust contingency plan using old the drugs that were being phased out as an interim measure.

***



Myself closing up the sebaceous cyst wound - if
only this were "smell-o-vision."
 Only then would you be able
 to appreciate the cheesy smell.



On a lighter note I was excising a sebaceous cyst last week – quite a satisfying procedure. The trick is not to burst the cyst as what lays inside smells like an exceptionally ripe stilton. Things were going rather well, and then “kaboom,” out shot a stream of creamy-cheesy-goo, narrowly avoiding   my face (don’t worry Mum, I had my goggles and mask on – safety first) and landing in a big gloop on my trousers. I repeated that same manoeuvre three times before I decided to put some gauze over the cyst and give my mildly saturated trouser leg a shake. The smell followed me around all afternoon, which is probably why some of my patient’s weren’t too keen to stay for a chat.

What happens if you are tetraplegic? I didn't find any parking for them.

For anyone interested, I have now become a pea growing specialist. The trick is to forget about them for a while and then leap with joy and glee when the fruits of your lacklustre labour reward oneself with the sweetest little jewels of bursting goodness.

A young mother who has developed a severe skin rash (Steven-Johnson's Syndrome/Toxic Epidermal Necrolysis) as a result of one of the HIV medications she was taking. Her skin is basically falling off - it can be fatal in upto 50% of cases. Fortunately she is doing rather well. (Note: image used with patient consent).

The classical "target" lesion of Steven-Johnson's Syndrome.



There must be a rabid sheep on the loose - this is it's third victim.



A sixty year old smoker with critical ischaemia of his left foot. Notice his black toes.

Black toes - this is what happens when your arteries fur up with crud.



A 10 day old girl with severe neonatal conjunctivitis secondary to a sexually transmitted infection the mother had in pregnancy. The white stuff coming from her eyes is pus.



Mangrove swamps in the Wild Coast.



Fishy, fishy, fishy.



Friend's enjoying the beautiful coastline of the Eastern Cape.


 

Fire starters and other things.

The "San Clan" - a 30 foot installation at Afrika Burn

The "San Clan" - Burning

The past month things have felt rather quiet at Holy Cross. I think this can be put down to the fact that the on call rota has become very user friendly, rather than our population becoming less dependent on the local health care system. On call is the time when our minds and bodies are pulled, twisted and pummelled. One is spat out the other end either a nervous wreck or a well composed, pragmatic and rounded individual. One learns what is achievable and the goal posts for treatment aims are adjusted. I guess there are two extremes – everyone must be cured or no one can be saved. I think I sit somewhere in a happy medium.

This may sound rather ambiguous, but let me give an example. When I first arrived at Holy Cross I was a little flummoxed at how we managed our hypertensive (high blood pressure) and diabetic patients. “It just isn’t right,” I used to tell myself. People were walking around with a systolic blood pressure of over 200 (that’s rather high) and blood sugars or 25 (it should be between 4 -6). But, then what is right? I see plenty of patients who present following a stroke and I expect a large proportion of them are secondary to poor blood pressure or diabetic control. The difficulty is that, with any population, getting them to attend regular checkups, take their medication and adhere to lifestyle advice is a massive dilemma. Just like back home, it is the same likely characters that re-present time and time again until eventually they give up. As clinicians, one cannot dictate how someone else should run their life, but maybe give a few well informed words of advice. So, when a patient walks in the door with a ridiculously high blood sugar or pressure I try to let them decide how we can manage their body, unless of course they are desperately sick, only then I shall try to run the show. However, try is all I can do – most of the time, it’s a brief admission and then “see you again in a month or so – same again yeah?”

***

I am forming a love hate relationship with the female medical ward, which I now run since leaving paediatrics.  There are a couple of fantastic nurses and several less so. I do daily ward rounds to show my team that I mean business – because it seems that unless a doctor or one of my driven nurses show their face, then things just stay in limbo and patients either die or get better on their own accord. They could do that at home.  To drum up a bit of morale, the plan is to try and organise a fortnightly morning meeting where we can teach one another about several important issues. I shall be using biscuits to lure my colleagues in before locking the door and not letting anyone out until we are all on the same level playing field. Watch this space.

A gentleman with massive gynaecomastia as a result
of an HIV drug he was once on. Unfortuately the
only "cure" would be a mastectomy.

The ward can be a bit of a head banging affair. Often I become a little frustrated with my own lack of medical knowledge, of which I theoretically should have a bit from all my UK training. The patient’s that we admit can be so incredibly complicated, but also immensely fascinating and warming. This week I have been treating a Sangoma (traditional healer) who is HIV positive and came in with severe exfoliative dermatitis with a super infection on top (it’s basically a nasty form of eczema that engulfs every little last bit of skin and is accompanied by a weeping infection that, if not adequately treated, can be life threatening). I think she was rather pleased with our efforts, although I am not so convinced about her commitment to taking her antiretroviral (HIV) drugs. I have another patient that is desperate to go home, again HIV positive, who came in with multi organ failure and is now in comparatively great shape. However, I know that if I let her go she will just deteriorate again. I am carefully balancing the doses of her medications to her gradually improving renal function and treating her severe anaemia. Just one more week I keep telling her – I’m keeping my fingers crossed.



The lady with exfoliative dermatitis
 at the start of her treatment. She was unable to straighten her arms or legs.



..and towards the end of her therapy.



                         

***

On a side note from work – I have been having the most delicious weekends exploring this energetic country. I spent the last weekend in April experiencing the wonder of Afrika Burn – a festival set 120km down a dirt road in the Karoo Desert, near Cape Town. It is based on The Burning Man and works on a “gifting” economy, i.e. money is worthless there. Everyone had to contribute. Mitch had his fist outing with his new hat and the snorkel was put to good use as we drove through a road that had turned into a river during a massive storm on the way up. There wasn’t a sour vibe to be found in the whole shebang and I largely spent it with an exciting pack on new friends. I literally jumped on their bandwagon, which was a tea trolley come sound system – a “chai-wallah” disco on wheels. So, as we dished out the big beats and sweet treats other revellers would offer massages, haircuts, cinema screenings, DJ sets, drinks, games, art, dance, theatre: you name it, they had it. And, just as I thought the world couldn’t be any smaller – I met not one, but two people from the small town of Lewes from where I originate.

Last weekend almost topped Afrika Burn as around sixteen of us descended on the Mkhambathi Nature Reserve at the end of my road here at Holy Cross. I had no idea there were Zebras in the park until we nearly ran some over driving down on Friday night. The reserve has, in my opinion, one of the best kept secrets in South Africa – it is home to a truly magnificent waterfall that spills over directly into the Indian Ocean: a visual and acoustic explosion of the senses.

So, April and May have been my relaxation and party months after a busy festive season of work. It all feels very fitting as I have just moved into my “late twenties.” I actually tried to hijack the weekend in Mkhambathi as a pre-birthday party. I didn’t need it, however, as my lovely colleagues baked me not one, but two cakes and around fifteen of us shared a scrumptious braai (barbeque). I think I could get used to this lifestyle...

One can take the psychiatrist out of the disco, but one can never take the disco out of the psychiatrist.

An impromptu chai tea and big beats break in the Karoo.

My neighbours enjoy some of the head gear post Afrika Burn

This photo does not do justice to how magnificent this geographical wonder is.

The two birthday boys warming up for the braai. Did I mention I share a birthday with my neighbour?