It was the hottest Christmas I had ever experienced.
The air was thick and pungent, the heat was a bit disconcerting and the A&E was rife with every creatures from two to eight legs.
Christmas was only around the corner, so to celebrate in true Mseleni style, at 4pm when starting my Christmas weekend oncall, I received a deathly looking baby from the ambulance that had pitched up.
The poor creature was only 3 days new and had its Zulu style natural selection contest imposed on it in the form of traditional witch doctor medication/poison. The cultural norm, by the grannies mainly, is to give a traditional potent poison orally or if your lucky as an enema that has been bought from the local witch doctor.
My heart sank but I went to auto pilot having been through this scenario many times already - resuscitation, rehydration, replacement glucose and managing multiorgan failure - mainly kidney and liver failure.
Three hours later, baby was no better but no worse, no referral centres wanted the child, the potassium was incompatible with life and I was very openly expressing my disdain at the mother who I was unsure about how much English she could comprehend but spent a lot of time looking down and sheepish.
That night I delivered a cute little boy and the following morning an adorable little girl - The Christmas baby! The midwives have a very cute tradition whereby they place the baby in cot and adorn it in money and then wheel it all over the hospital whilst singing a festive Zulu song and trying to sponge money off anyone around. It was definitely a jovial sight. But my favourite remains the morning prayer songs which are actually carried out every morning but obviously on christmas they are more flavoured for the Christmas theme and generally very beautiful to listen too. So Christmas singing began whilst I pottered around trying to rounds having been already since 5am.
Later that day I gave out my stash of chocolates for the wards, the were received expectantly and gratefully though. After clearing the morning A&E load of patients, a group of us headed towards the paediatric ward - it was time for giving out the presents to the kids on the ward. We had been preparing for this for a few weeks, having wrapped them all meticulously a few nights ago and now selecting the appropriate clientele for toys from mimic Barbie dolls to chess sets and fake nail kits! The medical students were the distributers and myself and another doc were the Christmas photographers. Immortalising the Christmas faces of Mseleni children's ward. It went down pretty well, from a few happy kids to couple of puzzled toddlers, many grateful mothers and ecstatic nurses who were fighting over the girly nail kit!
After father Christmas duties we all set off to prepare our own surrogate family Christmas dinner, a few doctors, a few medical students an OT and a dog - one big surrogate family. Fake spray snow on windows, Christmas crackers, halal roast chicken, gravy and lots of cheesy Christmas music - it was a pretty fine layout.
Just as we sat down to eat, my dear friend who is a fellow GP trainee from the UK and also the biggest shit magnet when it comes to oncalls, barely sat down, when off went the mobile - EMERGENCY in labour ward - fitting pregnant women.
We were all very unsurprised, she ran off like a shot and we sighed and then tucked in to late lunch mercilessly.
All in all a fine summery Christmas day.
PS The lady didn't have a fit on labour ward, just a twitch ;)
Wednesday, 29 December 2010
Thursday, 16 December 2010
I sat down to think about what I do in a day here and this is what I got......
The wake call began at 5.30am with the crazy grass cutters, who start working at the crack at dawn before it boils up during the day. I as whine as I try and close my eyes and catch another hours sleep as my paper thin caravan house walls absorb the sound of the rusty lawn mowers moans. Luckily, we had made a trip to the local cheetah sanctuary yesterday evening. I had two cheetahs sitting on me and one sucking my hand! Couldn't really begrudge the world too much for waking me today......
7.30: hospital begins with a grand ward round, its female medical today, the doctor presents his conundrum of bizarre and sick cases and we all tear him to pieces.
Then I realise that today half of the doctors (exempting myself) have been booked to go to circumcision camp so instead of 10 doctors in the hospital its 5, which means a very quick lunch for me.
After a quick whizz ward round of my antenatal women in various stages of pregnancy, doing a few dating scans, I take myself to the A&E to work on the pile of waiting patients. I am conscious I am oncall today and whoever isn't seen by 4pm is left for me.
TB, HIV, Mseleni joint disease aches and pains, Disability grant requests, remove a ?cockroach from the ear, Incise a purulent groin abscess, then it pick up the card for he paediatric assault case and my heart sinks. It sinks for two reasons, one; it is pretty traumatising for all involved including myself, two; it takes on average about two hours to do.
For those readers who are not familiar with rape assessments (much like myself before I started here), the victim makes the disclosure to the police initially and then they come attended by an officer with the rape 'kit'. The medical officer takes a relevant medical history and of the events for forensics as well as for after care i.e.. HIV prophylaxis, Hep B immunisation, Morning after pill. My 14 year old girl was barely tanners stage 2 and had been raped in the early hours of the morning by a man who was living in the family hut for the last few months. Her mother sat in the room, cradling the younger 6 year old who had cerebral palsy, whilst I took laborious samples from intricate places and hoped that there would be some fruit to this ordeal and the rapist was locked up for a long time.
I continued to see patients throughout the day, then got called by one of the doctors on paediatrics to get some help cannulating a baby with acute gastro secondary to traditional Zulu medication poisoning. The child was a floppy dehydrated mass, actively having runny diarrhoea. In these scenarios when intravenous has been tried almost everywhere, the last resort to rehydrate and save the child is to insert an intraosseous. After a little bit of a fight from the little one, I stuck the needle in and we pumped in fluid ASAP.
4pm; it was end of the day for the others doctors, but the start of my oncall, I had worked like a machine throughout the day and could look forward to a fairly civil evening. By six most people had been seen so I head down to my little park home for some dinner.
After dinner I went to check up on the babies, the poisoned kid had pulled out its IO line but luckily looked less like a dried prune so we compromised on aggressive oral fluids with mummy. Before I could move on the baby opposite, had its iv line fall out and before I knew it I was doing my second IO line of the day.
10pm; labour call and tell me about a pregnant lady who they cannot find the fetal heart. An intrauterine death is never a satisfying diagnosis. Being the bearer of this news is quite a sickening affair, this would be my duty this evening. She was actually in a terrible state, she had a hard rigid uterus and only one thing comes to mind - uterine abruption.
After resuscitation and analgesia, I grabbed the ultrasound, I could see no fetal heart but could see a large bleed behind the placenta. Management in cases like this is to rupture the membranes and allow delivery of the dead fetus per vagina. We just had to be cautious of a large post partum haemorrhage. She had a slow delivery and finally amount 7am the next day delivered. To my dismay we had no emergency units of blood at all and I arranged for her transfer out to our larger referral hospital ASAP.
After the placenta had delivered she had a massive bleed as expected and this seemed to subside but she had had a considerable bleed and repeat Hb was 5.5. I was getting anxious about when the emergency services were coming, but before I could worry too much, I realised she was re-bleeding! I called in a few more hands and one of them was used as bimanual compression whilst the other was blowing up a surgical glove to use as a balloon tamponade in the vagina to stop further bleeding. My patient who is a local Zulu woman, looked as white as ghost at this stage, all she needed was some blood the one thing we didn't have. 3 painful hours later a helicopter came and transported her up and out.
That was a long day and night, I was exhausted, once my patient was transferred sped through ward round and rushed to my HIV clinic, where I had my list of HIV patients ready and waiting from 7am that morning to be seen by the doctor.
That evening we went to the beach and luck would have i we saw a huge loggerhead turtle make its way out of the sea and slowly crawl up the beach to lay her eggs.
Life is not all that bad and now five days later I have my placental abruption lady back on the ward, looking the colour she should be.
7.30: hospital begins with a grand ward round, its female medical today, the doctor presents his conundrum of bizarre and sick cases and we all tear him to pieces.
Then I realise that today half of the doctors (exempting myself) have been booked to go to circumcision camp so instead of 10 doctors in the hospital its 5, which means a very quick lunch for me.
After a quick whizz ward round of my antenatal women in various stages of pregnancy, doing a few dating scans, I take myself to the A&E to work on the pile of waiting patients. I am conscious I am oncall today and whoever isn't seen by 4pm is left for me.
TB, HIV, Mseleni joint disease aches and pains, Disability grant requests, remove a ?cockroach from the ear, Incise a purulent groin abscess, then it pick up the card for he paediatric assault case and my heart sinks. It sinks for two reasons, one; it is pretty traumatising for all involved including myself, two; it takes on average about two hours to do.
For those readers who are not familiar with rape assessments (much like myself before I started here), the victim makes the disclosure to the police initially and then they come attended by an officer with the rape 'kit'. The medical officer takes a relevant medical history and of the events for forensics as well as for after care i.e.. HIV prophylaxis, Hep B immunisation, Morning after pill. My 14 year old girl was barely tanners stage 2 and had been raped in the early hours of the morning by a man who was living in the family hut for the last few months. Her mother sat in the room, cradling the younger 6 year old who had cerebral palsy, whilst I took laborious samples from intricate places and hoped that there would be some fruit to this ordeal and the rapist was locked up for a long time.
I continued to see patients throughout the day, then got called by one of the doctors on paediatrics to get some help cannulating a baby with acute gastro secondary to traditional Zulu medication poisoning. The child was a floppy dehydrated mass, actively having runny diarrhoea. In these scenarios when intravenous has been tried almost everywhere, the last resort to rehydrate and save the child is to insert an intraosseous. After a little bit of a fight from the little one, I stuck the needle in and we pumped in fluid ASAP.
4pm; it was end of the day for the others doctors, but the start of my oncall, I had worked like a machine throughout the day and could look forward to a fairly civil evening. By six most people had been seen so I head down to my little park home for some dinner.
After dinner I went to check up on the babies, the poisoned kid had pulled out its IO line but luckily looked less like a dried prune so we compromised on aggressive oral fluids with mummy. Before I could move on the baby opposite, had its iv line fall out and before I knew it I was doing my second IO line of the day.
10pm; labour call and tell me about a pregnant lady who they cannot find the fetal heart. An intrauterine death is never a satisfying diagnosis. Being the bearer of this news is quite a sickening affair, this would be my duty this evening. She was actually in a terrible state, she had a hard rigid uterus and only one thing comes to mind - uterine abruption.
After resuscitation and analgesia, I grabbed the ultrasound, I could see no fetal heart but could see a large bleed behind the placenta. Management in cases like this is to rupture the membranes and allow delivery of the dead fetus per vagina. We just had to be cautious of a large post partum haemorrhage. She had a slow delivery and finally amount 7am the next day delivered. To my dismay we had no emergency units of blood at all and I arranged for her transfer out to our larger referral hospital ASAP.
After the placenta had delivered she had a massive bleed as expected and this seemed to subside but she had had a considerable bleed and repeat Hb was 5.5. I was getting anxious about when the emergency services were coming, but before I could worry too much, I realised she was re-bleeding! I called in a few more hands and one of them was used as bimanual compression whilst the other was blowing up a surgical glove to use as a balloon tamponade in the vagina to stop further bleeding. My patient who is a local Zulu woman, looked as white as ghost at this stage, all she needed was some blood the one thing we didn't have. 3 painful hours later a helicopter came and transported her up and out.
That was a long day and night, I was exhausted, once my patient was transferred sped through ward round and rushed to my HIV clinic, where I had my list of HIV patients ready and waiting from 7am that morning to be seen by the doctor.
That evening we went to the beach and luck would have i we saw a huge loggerhead turtle make its way out of the sea and slowly crawl up the beach to lay her eggs.
Life is not all that bad and now five days later I have my placental abruption lady back on the ward, looking the colour she should be.
Saturday, 4 December 2010
3.8.10 My 6month thoughts (blogged at 11months, sorry for delay!)
How well do we prize life, how important is it to be alive and stay alive?
In the developed world, life is sanctioned, its sacred, when death occurs, even if it is expected, it is still shocking and somehow unexpected. In a society that we come from where we are almost immortal, death is a distant and intangible concept.
What if you live somewhere that death is a frequent occurrence in all, be it young, be it old be it in-between. What if you never lived long enough to think about pensions, life insurance or inherited cancers you would develop....?
Life seems so less prized here and death is so common fold it is not even thought twice about. The death of children I have often ranted about in my previous blogs, but it is unacceptable and alien to me to have children die in front of my eyes, but here I fear it is normal. The usual culprit of the herbal doctor poisoning continues, with no justice. Post mortems are so rare, there is a very strong cultural resistance to them and the cultural preference supersedes the actual legal requirement, so patients die and we never find out what happened. If we don't know what happens then we can make anyone culpable. Such is the way.
Child abuse is another area that when suspected we investigate medically and socially but the end result seems to be the return of the child to the home. With large numbers of people living together and little elsewhere to go, there is a very little to do. We have social workers who do home visits etc but there is no safe haven and placements are so rare and queues very long. Again collecting evidence, processing it and having valid specialists to process forensic evidence is such a distant reality.
A recent mortality ward audit meeting revealed the actual incidence of young adults dying very abruptly. I have wondered to myself how with a ward with a mortality rate of 20%, I have been relatively impervious to the potential emotional impact whilst the paediatric ward deaths had a profound affect on my mental health.
It boils down to common themes, the language and the culture are miles away from mine, so being to empathise with problems is incredibly hard. Not speaking the language and having a translator immediately takes away a lot of the finite parts of the doctor-patient relationship. You never quite get a right answer to your question and in a reciprocated way the patient never reveals very much as you are as alien to them and I guess they know you wouldn't understand their beliefs, I suppose this is not too untrue. The lack of a true rapport in a way acts as a protective factor against ever getting to 'know' your patients, to having their story of their rubbish social circumstances and daily struggle to get enough food.
Almost everyone is on the brink of starvation, not being able to afford food for themselves or their families, the transport problems - living miles away and having no money buses, having to travel ages to do or get anything, being at the mercy of any driver who will give them a lift.....every now and again you do get tied to one persons story of struggle and feel your arm is being twisted to pay for someone's bus fare or signing someone off for a disability grant.
To retract a bit and home in on the disparity of cultural beliefs, I need to explain via example, stroke is a very good example, here it is not a reason to see the doctor. I have seen numerous patients who are brought in by relatives and are plonked on a stretcher and then come to see the doctor for something completely different, like toe pain, I have come to realise since then that strokes are not seen as medical problems. To the locals it is a form of bewitchment, so when it happens, it is the iSangoma one sees. So for that reason we see few strokes or late stage strokes when they have become difficult to manage at home or developed aspiration pneumonias. Other examples include the psychotic patients (commonly to other cultures too) who are sometimes promoted to iSangoma level for their psychosis.
iSangomas I know I like to hold responsible for societies profanities but having found out recently that they were suggesting to young men with HIV in the area that if they had intercourse with a virgin or young girl they would be cured of the virus!! Which may be one explanation for such high rape rates particularly on the young orphan girls.
Basic explanations of medical conditions can be a real struggle, because some people have never had even basic anatomy lessons or simple medical exposure like you layman off the street does in the UK. People do not often what a heart is let alone where it is, they don't understand after a miscarriage you cannot reinsert the aborted foetus. We take simple layman knowledge for granted, but realise its true worth when trying to make people take responsibility for their health. Patients stopping diabetic medication and hypertensive medication because their BPs were ok and sugars were ok, even after rigorous explanation that the diseases are chronic and not treatable but managed. But i suppose the management of chronic disease is pretty much a worldwide problem!
The human psychology can be strong in many ways to the extent it is cold. I think of the number of death certificates i have signed, it has become pretty much another chore. Those being familiar with defence mechanisms terminology; denial, intellectualisation, projection, run rife here, you see it especially in those who are here long term, and it is perfectly understandable.
Death is a very normal phenomenon, its the end of the cycle of life, on this Earth anyway.
In the developed world, life is sanctioned, its sacred, when death occurs, even if it is expected, it is still shocking and somehow unexpected. In a society that we come from where we are almost immortal, death is a distant and intangible concept.
What if you live somewhere that death is a frequent occurrence in all, be it young, be it old be it in-between. What if you never lived long enough to think about pensions, life insurance or inherited cancers you would develop....?
Life seems so less prized here and death is so common fold it is not even thought twice about. The death of children I have often ranted about in my previous blogs, but it is unacceptable and alien to me to have children die in front of my eyes, but here I fear it is normal. The usual culprit of the herbal doctor poisoning continues, with no justice. Post mortems are so rare, there is a very strong cultural resistance to them and the cultural preference supersedes the actual legal requirement, so patients die and we never find out what happened. If we don't know what happens then we can make anyone culpable. Such is the way.
Child abuse is another area that when suspected we investigate medically and socially but the end result seems to be the return of the child to the home. With large numbers of people living together and little elsewhere to go, there is a very little to do. We have social workers who do home visits etc but there is no safe haven and placements are so rare and queues very long. Again collecting evidence, processing it and having valid specialists to process forensic evidence is such a distant reality.
A recent mortality ward audit meeting revealed the actual incidence of young adults dying very abruptly. I have wondered to myself how with a ward with a mortality rate of 20%, I have been relatively impervious to the potential emotional impact whilst the paediatric ward deaths had a profound affect on my mental health.
It boils down to common themes, the language and the culture are miles away from mine, so being to empathise with problems is incredibly hard. Not speaking the language and having a translator immediately takes away a lot of the finite parts of the doctor-patient relationship. You never quite get a right answer to your question and in a reciprocated way the patient never reveals very much as you are as alien to them and I guess they know you wouldn't understand their beliefs, I suppose this is not too untrue. The lack of a true rapport in a way acts as a protective factor against ever getting to 'know' your patients, to having their story of their rubbish social circumstances and daily struggle to get enough food.
Almost everyone is on the brink of starvation, not being able to afford food for themselves or their families, the transport problems - living miles away and having no money buses, having to travel ages to do or get anything, being at the mercy of any driver who will give them a lift.....every now and again you do get tied to one persons story of struggle and feel your arm is being twisted to pay for someone's bus fare or signing someone off for a disability grant.
To retract a bit and home in on the disparity of cultural beliefs, I need to explain via example, stroke is a very good example, here it is not a reason to see the doctor. I have seen numerous patients who are brought in by relatives and are plonked on a stretcher and then come to see the doctor for something completely different, like toe pain, I have come to realise since then that strokes are not seen as medical problems. To the locals it is a form of bewitchment, so when it happens, it is the iSangoma one sees. So for that reason we see few strokes or late stage strokes when they have become difficult to manage at home or developed aspiration pneumonias. Other examples include the psychotic patients (commonly to other cultures too) who are sometimes promoted to iSangoma level for their psychosis.
iSangomas I know I like to hold responsible for societies profanities but having found out recently that they were suggesting to young men with HIV in the area that if they had intercourse with a virgin or young girl they would be cured of the virus!! Which may be one explanation for such high rape rates particularly on the young orphan girls.
Basic explanations of medical conditions can be a real struggle, because some people have never had even basic anatomy lessons or simple medical exposure like you layman off the street does in the UK. People do not often what a heart is let alone where it is, they don't understand after a miscarriage you cannot reinsert the aborted foetus. We take simple layman knowledge for granted, but realise its true worth when trying to make people take responsibility for their health. Patients stopping diabetic medication and hypertensive medication because their BPs were ok and sugars were ok, even after rigorous explanation that the diseases are chronic and not treatable but managed. But i suppose the management of chronic disease is pretty much a worldwide problem!
The human psychology can be strong in many ways to the extent it is cold. I think of the number of death certificates i have signed, it has become pretty much another chore. Those being familiar with defence mechanisms terminology; denial, intellectualisation, projection, run rife here, you see it especially in those who are here long term, and it is perfectly understandable.
Death is a very normal phenomenon, its the end of the cycle of life, on this Earth anyway.
19.11.2010 Circumcision Camp
The day had finally come that I was assigned to circumcision camp.
I was truly quite excited, since the advent of circumcision camps a few months ago when the province of Kwazulu-Natal had introduced mass circumcisions as a way to tackle reducing HIV transmission rates, local hospitals and clinics had been rapidly recruiting all the young lads of the area and turning them into 'men'.
Circumcisions are not traditionally performed, infact it has been out of vogue for more than 200 yrs since the legendary King Shaka had been ruler of the area. With HIV being rampant and incredible data from WHO that show circumcisions can reduce rates of transmission by up to 60%, it was an intervention that needed to be applied on a mass level.
Initially uptake was slow, but with the sanctioning of the local/tribal leaders, not just the parliament leaders, local people were convinced and now boys who are HIV negative queuing to be circumcised.
So there have been 'camps' set up in various areas around the province and I went to one in Hlabisa, a beautiful area of the Hluhluwe-Umfolozi game park, with soft rolling green hills and little huts dotted all over.
I set off from my hospital about 7am and got to the clinic about 8.30am, I was rearing to go but discovered that these things didn't usually start till about 10:30......so I watched, waited and mingled. The place was buzzing, with the matrons and nurses getting ready the feast for us workers.
The pile of food began trickling in, the boys were being labelled and counselled, more nurses were arriving in, the around 9am they all broke out in song - the morning prayers are usually sung in a local gospel form. Its very soulful and quite a beautiful site - everyone singing in pure harmony.
By around 10am had more or less all the bays set up and diathermy active and the cutting began. On the cutting side I was the representative guest from Mseleni hospital and we had the regional medical manager as well as Hlabisa's medical manager and some doctors from the local NGO - Africa Centre.
The procedure itself is relatively simple as long as you manage to cauterise or suture any bleeders thoroughly, it is literally a minor operation and patients walk in and out. The have to keep the dressing on for 3 days and maintain hygienic washing rules and abstain from intercourse for 6/52 as prior to that there is a higher risk of transmission.
We had finished up by 6 pm, had cut about 25 each and had two post op bleeders and one vaso-vagal. All-in-all not a bad days work. I was relieved to catch my ride back to Mseleni, which was still another 1.5hrs on cow infested road, i snoozed most of the way back. But unfortunately and unsurprisingly we met a toppled people carrier bus at the road side. It had tried to avoid kids on the road and swerved and toppled over. All the passengers had already been taken to Mseleni. It made me think yet again how lucky I was and how I didnt want to ever catch a bus in South Africa.
I was truly quite excited, since the advent of circumcision camps a few months ago when the province of Kwazulu-Natal had introduced mass circumcisions as a way to tackle reducing HIV transmission rates, local hospitals and clinics had been rapidly recruiting all the young lads of the area and turning them into 'men'.
Circumcisions are not traditionally performed, infact it has been out of vogue for more than 200 yrs since the legendary King Shaka had been ruler of the area. With HIV being rampant and incredible data from WHO that show circumcisions can reduce rates of transmission by up to 60%, it was an intervention that needed to be applied on a mass level.
Initially uptake was slow, but with the sanctioning of the local/tribal leaders, not just the parliament leaders, local people were convinced and now boys who are HIV negative queuing to be circumcised.
So there have been 'camps' set up in various areas around the province and I went to one in Hlabisa, a beautiful area of the Hluhluwe-Umfolozi game park, with soft rolling green hills and little huts dotted all over.
I set off from my hospital about 7am and got to the clinic about 8.30am, I was rearing to go but discovered that these things didn't usually start till about 10:30......so I watched, waited and mingled. The place was buzzing, with the matrons and nurses getting ready the feast for us workers.
The pile of food began trickling in, the boys were being labelled and counselled, more nurses were arriving in, the around 9am they all broke out in song - the morning prayers are usually sung in a local gospel form. Its very soulful and quite a beautiful site - everyone singing in pure harmony.
By around 10am had more or less all the bays set up and diathermy active and the cutting began. On the cutting side I was the representative guest from Mseleni hospital and we had the regional medical manager as well as Hlabisa's medical manager and some doctors from the local NGO - Africa Centre.
The procedure itself is relatively simple as long as you manage to cauterise or suture any bleeders thoroughly, it is literally a minor operation and patients walk in and out. The have to keep the dressing on for 3 days and maintain hygienic washing rules and abstain from intercourse for 6/52 as prior to that there is a higher risk of transmission.
We had finished up by 6 pm, had cut about 25 each and had two post op bleeders and one vaso-vagal. All-in-all not a bad days work. I was relieved to catch my ride back to Mseleni, which was still another 1.5hrs on cow infested road, i snoozed most of the way back. But unfortunately and unsurprisingly we met a toppled people carrier bus at the road side. It had tried to avoid kids on the road and swerved and toppled over. All the passengers had already been taken to Mseleni. It made me think yet again how lucky I was and how I didnt want to ever catch a bus in South Africa.
Friday, 20 August 2010
STRIKES 18/9/10 till.........
Day 1
So the long anticipated strike hit our hospital today, as it did in throughout the rest of South Africa.
Unions affiliated with Cosatu, South Africa's main union federation, went ahead with the strike after the government failed to rise up to their request of an 8.6% rise, but did place a no unreasonable 7%. Generally the strike took a slow start but this would be made up in the coming hours and days.
It all seemed a bit unreal in many ways, we abandoned our usual grand ward in the morning and people scattered to assess the damage the wards, we had no real preconception of what the following days would be like.
But I had heard strikes by unions in general, are far from civil marching, in preceding years people have been intimidated, verbally abused and physically beaten.
So when I went down to the front gate which is where all the protesters were singing and dancing and blowing Vuvuzela's, I got to see the crowd in full view, police cars were lined up and the security guards were surrounding the gate. Several protestors were carrying snooker poles and bats and someone was just sporting a Robert Mugabe tea towel on his back. I was amused at this general folly which was to later to turn to dismay. I managed to take a few sneaky pictures though people in the frontline, though we kept getting shouted at to not take pictures.
Then I heard that some poor older security guard had been bashed with a cricket bat for turning up o work, by a thuggish HR worker. We were of course outraged and Victor, the manager was infuriated and had that man down a definite sack when the protest was over.
Going to the wards felt very odd, it was extremely peaceful and quiet, there were a few matrons around and some senior sisters and no other nurses. The matrons worked brilliantly, doing all the cleaning, changing all the beds, dishing out medications. I cracked on with my ward round, very aware I had a full ward with very sick people in it. But with the help of my medical student and the dietician (Elvis) to translate, we whizzed by. I rushed off to my antiviral (ARV) clinic, which surprisingly was full and the patients had been let through luckily. But staff levels being low at clinic meant that getting notes and drugs was a bit of a hassle.
The A&E section was almost bare as no patients were coming through, I suppose many people were worried they would be attacked or not receive help so decided the best bet was to stay at home.
All of us united in the doctors office at the end of the day, a little confused by it all but not terribly overwhelmed.
Day 2
The strike heats up, tempers rise and strikers get more confident, luckily for us most atrocities occur in the cities. Horrendous stories of people being beaten, stripped naked, nurses dragged out of theatre. Its awful.
Here in Mseleni, the picket line was hot with dancing and chanting but fewer people it seemed.
Far far fewer nurses turned up to work too, it was only the matrons really, who were already broken from yesterday.
It was unclear if the reason was because they were actively wanting to protest, or fearful of being targeted or if they were just taking advantage of an excuse the not turn up to work. I have to admit the latter did seem to dominate most of our minds. Wrong though it may be to say, nurses working here, more often than not, are not nursing for any interest or care for the job. Infact 'nursing' seems to be far from what a lot of them are interested in. Nursing as a job here, is a career that enables you to make a lot more money than you would normally, consequently enabling you to get a new hairstyle a week.
Wards were being emptied at a rapid rate and people being told to look after their sick at home, with uncertain cleaners, linen and kitchen staff, this was a crisis. Then suddenly, from the local town a load of volunteers turned up and were distributed to help out anywhere they could. They put on aprons and gloves and were sent to all sectors to carry out various jobs.
Us doctors we marvelled, A&E was still quiet, but we did our observations and gave our inpatient's medications, dished out prescriptions in pharmacy, took bloods, treated the sick and did so cohesively.
That night, nurses were sparse, one for two wards. They were sparked with fear and were planning to leave at 4am so as to not risk being followed home if they lest at their usual shift end time. After hours two doctors man the hospital, but this evening we all pitched up to do the drug rounds and general reviewing of sickies, the camaraderie was great and the oncall doctors felt the love.
Day 3
It had been a stormy night and the weather carried onto the day, it was chilly and windy, I donned my trainers and a scarf. The picket line seemed lower in numbers but still loud in volume and conviction, as nursing levels were at their scarcest. Bins hadn't been changed, linen not washed, surgical equipment not autoclaved, the place was coming to a standstill.
I began by discharging the last of my patients, with 'to go home' medication and appointments to return after the strike - Renal failures, cryptococci meningitis, liver failures - if you could breath without oxygen and stand, you went.
Then went round all the other wards mopping up jobs, discharges, medications to be done. Being oncall for labour ward too, I was summoned to theatre to help with a c-section. We had one nurse and the wife of the other doctor who carrying out the section and proceeded relatively smoothly. We functioned and we were cohesive and we genuinely wanted to do the best we could.
Today felt different though, because it felt that this outlandish event was finally real. The disbelief that clinical staff could actually strike and compromise and actually cause death was inconceivable to me . Going to the gate at lunch to take a look, I was very dismayed when I saw several staff members that were that I thought were good workers and my friends, at the front line dancing away and blowing Vuvuzela's. Our viewing got cut short as protesters shooed us away and said we couldn't watch and of course banning us from taking pictures. The security guards got very twitchy and said we must leave. The concept of a public protest that the 'public' couldn't watch is a ridiculous concept and surely defies the point of a protest? Apparently not.
These are truly eventful times, certainly for an outsider like myself, where in the UK such strikes from medical staff would be inconceivable.
How do professionals responsible for life and death of people defer on a mass scale and reject their responsibilities?
Its made me think a lot about my role as a doctor, I grant that many people do not have a choice to often choose a career for its mere satisfaction, but they do a job because it is a job and an income. The healthcare profession though, has to be different because it incorporates the responsibility of sanctioning life and relieving pain. So even if you could on legal grounds be allowed to strike for the sake of a point to be made or changes to occur, how can you on a moral level carry the burden that someone somewhere being unable to receive life saving treatment and died - it could be your mum or sister or daughter?
Nursing in my mind, has as much as a role in duty to care and relieve distress as doctors. But I fear nurses here do not have that inclination, considering almost all of them were on strike. It is a mere job, that doesn't even pay enough. And the nurses who did turn up spent a considerable amount of time moaning about the fact they were here, though face-to-face I thanked them and made them feel as appreciated as possible, always reinforces good behaviour if it occurs;)
Patronising it is and also quite disheartening, that I the foreigner, having no real tie or connection to the patients, didn't question why i was here and why i didn't get a tea break and why I was working the job of a doctor and ten nurses. The fact is, I am a doctor and I have a duty to care and will fulfil it and be able to live with myself. For nurses, it seems it is a favour they bestow upon us to help us, rather than the cause is ultimately in everyone's benefit, to help people, save lives and do what is right.
And the protesters rejoiced in their perceived feat for the day, starting to dissipate at 4 (when work finishes!) and to return for another day or not? We all decided to stay on the grounds this weekend, so if disaster shrikes and a sudden boom of patients enter through the doors we are prepared.......
So the long anticipated strike hit our hospital today, as it did in throughout the rest of South Africa.
Unions affiliated with Cosatu, South Africa's main union federation, went ahead with the strike after the government failed to rise up to their request of an 8.6% rise, but did place a no unreasonable 7%. Generally the strike took a slow start but this would be made up in the coming hours and days.
It all seemed a bit unreal in many ways, we abandoned our usual grand ward in the morning and people scattered to assess the damage the wards, we had no real preconception of what the following days would be like.
But I had heard strikes by unions in general, are far from civil marching, in preceding years people have been intimidated, verbally abused and physically beaten.
So when I went down to the front gate which is where all the protesters were singing and dancing and blowing Vuvuzela's, I got to see the crowd in full view, police cars were lined up and the security guards were surrounding the gate. Several protestors were carrying snooker poles and bats and someone was just sporting a Robert Mugabe tea towel on his back. I was amused at this general folly which was to later to turn to dismay. I managed to take a few sneaky pictures though people in the frontline, though we kept getting shouted at to not take pictures.
Then I heard that some poor older security guard had been bashed with a cricket bat for turning up o work, by a thuggish HR worker. We were of course outraged and Victor, the manager was infuriated and had that man down a definite sack when the protest was over.
Going to the wards felt very odd, it was extremely peaceful and quiet, there were a few matrons around and some senior sisters and no other nurses. The matrons worked brilliantly, doing all the cleaning, changing all the beds, dishing out medications. I cracked on with my ward round, very aware I had a full ward with very sick people in it. But with the help of my medical student and the dietician (Elvis) to translate, we whizzed by. I rushed off to my antiviral (ARV) clinic, which surprisingly was full and the patients had been let through luckily. But staff levels being low at clinic meant that getting notes and drugs was a bit of a hassle.
The A&E section was almost bare as no patients were coming through, I suppose many people were worried they would be attacked or not receive help so decided the best bet was to stay at home.
All of us united in the doctors office at the end of the day, a little confused by it all but not terribly overwhelmed.
Day 2
The strike heats up, tempers rise and strikers get more confident, luckily for us most atrocities occur in the cities. Horrendous stories of people being beaten, stripped naked, nurses dragged out of theatre. Its awful.
Here in Mseleni, the picket line was hot with dancing and chanting but fewer people it seemed.
Far far fewer nurses turned up to work too, it was only the matrons really, who were already broken from yesterday.
It was unclear if the reason was because they were actively wanting to protest, or fearful of being targeted or if they were just taking advantage of an excuse the not turn up to work. I have to admit the latter did seem to dominate most of our minds. Wrong though it may be to say, nurses working here, more often than not, are not nursing for any interest or care for the job. Infact 'nursing' seems to be far from what a lot of them are interested in. Nursing as a job here, is a career that enables you to make a lot more money than you would normally, consequently enabling you to get a new hairstyle a week.
Wards were being emptied at a rapid rate and people being told to look after their sick at home, with uncertain cleaners, linen and kitchen staff, this was a crisis. Then suddenly, from the local town a load of volunteers turned up and were distributed to help out anywhere they could. They put on aprons and gloves and were sent to all sectors to carry out various jobs.
Us doctors we marvelled, A&E was still quiet, but we did our observations and gave our inpatient's medications, dished out prescriptions in pharmacy, took bloods, treated the sick and did so cohesively.
That night, nurses were sparse, one for two wards. They were sparked with fear and were planning to leave at 4am so as to not risk being followed home if they lest at their usual shift end time. After hours two doctors man the hospital, but this evening we all pitched up to do the drug rounds and general reviewing of sickies, the camaraderie was great and the oncall doctors felt the love.
Day 3
It had been a stormy night and the weather carried onto the day, it was chilly and windy, I donned my trainers and a scarf. The picket line seemed lower in numbers but still loud in volume and conviction, as nursing levels were at their scarcest. Bins hadn't been changed, linen not washed, surgical equipment not autoclaved, the place was coming to a standstill.
I began by discharging the last of my patients, with 'to go home' medication and appointments to return after the strike - Renal failures, cryptococci meningitis, liver failures - if you could breath without oxygen and stand, you went.
Then went round all the other wards mopping up jobs, discharges, medications to be done. Being oncall for labour ward too, I was summoned to theatre to help with a c-section. We had one nurse and the wife of the other doctor who carrying out the section and proceeded relatively smoothly. We functioned and we were cohesive and we genuinely wanted to do the best we could.
Today felt different though, because it felt that this outlandish event was finally real. The disbelief that clinical staff could actually strike and compromise and actually cause death was inconceivable to me . Going to the gate at lunch to take a look, I was very dismayed when I saw several staff members that were that I thought were good workers and my friends, at the front line dancing away and blowing Vuvuzela's. Our viewing got cut short as protesters shooed us away and said we couldn't watch and of course banning us from taking pictures. The security guards got very twitchy and said we must leave. The concept of a public protest that the 'public' couldn't watch is a ridiculous concept and surely defies the point of a protest? Apparently not.
These are truly eventful times, certainly for an outsider like myself, where in the UK such strikes from medical staff would be inconceivable.
How do professionals responsible for life and death of people defer on a mass scale and reject their responsibilities?
Its made me think a lot about my role as a doctor, I grant that many people do not have a choice to often choose a career for its mere satisfaction, but they do a job because it is a job and an income. The healthcare profession though, has to be different because it incorporates the responsibility of sanctioning life and relieving pain. So even if you could on legal grounds be allowed to strike for the sake of a point to be made or changes to occur, how can you on a moral level carry the burden that someone somewhere being unable to receive life saving treatment and died - it could be your mum or sister or daughter?
Nursing in my mind, has as much as a role in duty to care and relieve distress as doctors. But I fear nurses here do not have that inclination, considering almost all of them were on strike. It is a mere job, that doesn't even pay enough. And the nurses who did turn up spent a considerable amount of time moaning about the fact they were here, though face-to-face I thanked them and made them feel as appreciated as possible, always reinforces good behaviour if it occurs;)
Patronising it is and also quite disheartening, that I the foreigner, having no real tie or connection to the patients, didn't question why i was here and why i didn't get a tea break and why I was working the job of a doctor and ten nurses. The fact is, I am a doctor and I have a duty to care and will fulfil it and be able to live with myself. For nurses, it seems it is a favour they bestow upon us to help us, rather than the cause is ultimately in everyone's benefit, to help people, save lives and do what is right.
And the protesters rejoiced in their perceived feat for the day, starting to dissipate at 4 (when work finishes!) and to return for another day or not? We all decided to stay on the grounds this weekend, so if disaster shrikes and a sudden boom of patients enter through the doors we are prepared.......
Monday, 12 July 2010
Snake Bites of Mseleni
I needed to write something about snakes - I dislike snakes very much, but living here you have to take some interest in them as they are a fairly common occurrence, having the capacity to kill nearly 20,000 people per year in both South Africa and Swaziland, they are a little bit of an environmental hazard.
I was very ignorant to the various species of snakes in existence, the spectrum of sizes, colours and head shapes and of course venomous qualities. Having acquired some knowledge of them, I still quite dislike them but have gained a new found respect and admiration.
I thought I would educate myself and you all on snakes that pose dangers to us and the community in Mseleni.
We should start with Black Mamba Snake, it is the largest and deadliest and most feared snake in Africa and is not black at all, the 'black' arises from the fact that the inside of its mouth is black. The black mamba is very agile and is said to be the fastest snake in the world, capable of moving at 4.5-5.4m/sec (16–20 km/hr). It has yellowish-green to light greyish skin and reaching an average length of 2.5m but can reach up to 4.3m. Its notoriety lies in its fatal neurotoxic venom. The mortality rate is nearly 100%, unless the snakebite victim is promptly treated with antivenom. Black mamba bites can potentially kill a human within 20 minutes, but death usually occurs after 30–60 minutes. Fortunately, we have a polyvalent antivenom produced by SAIMR (South African Institute for Medical Research) to treat all black mamba bites from different localities.
Next up is the Puff Adder; they grow be a metre in length but are quite stout. Though not as notorious as the black mambo, it is considered to be Africa's deadliest snake because it is responsible for the most human fatalities. The incidence of puff adder bites are high for a variety of factors; they are common and widely distributed; their preference to camouflage rather than flee; their habit of basking by footpaths and general willingness to bite with their quite potent venom. The venom has cytotoxic effects, which means it may cause local tissue swelling, pain, tenderness to ulceration and considerable necrosis, as well as severe bruising and bleeding systemically. If not treated carefully, necrosis will spread, causing skin, subcutaneous tissue and muscle to separate from healthy tissue and eventually slough. Gangrene and secondary infections commonly occurs and can result in loss of digits and limbs. Despite this, deaths are exceptional and probably occur in less than 10% of all untreated cases.
Final up is the Boomslang, which is an extraordinarily dangerous snake but luckily human fatalities are rare, since this snake is remarkably timid. It is a tree-dwelling snake (Boomslang means "tree snake" in Afrikaans), with reaches an average length of 1-1.6m. The Boomslang has exceptionally large eyes proportionate to its distinctive egg-shaped head. Females are brown, and males are light green with black highlights. Their fangs interestingly lie at the back of their jaw. The Boomslang venom is primarily a haemotoxic - which disables the blood clotting process and may cause death as a result of internal and external bleeding. Because the venom is slow to act, symptoms may not be manifest until many hours after the bite. On the one hand, this provides time for procuring the serum, while on the other hand it may lead victims to underestimate the seriousness of the bite.
I wouldn't underestimate a snake and completely understand why locals fear them most fervently.
I was very ignorant to the various species of snakes in existence, the spectrum of sizes, colours and head shapes and of course venomous qualities. Having acquired some knowledge of them, I still quite dislike them but have gained a new found respect and admiration.
I thought I would educate myself and you all on snakes that pose dangers to us and the community in Mseleni.
We should start with Black Mamba Snake, it is the largest and deadliest and most feared snake in Africa and is not black at all, the 'black' arises from the fact that the inside of its mouth is black. The black mamba is very agile and is said to be the fastest snake in the world, capable of moving at 4.5-5.4m/sec (16–20 km/hr). It has yellowish-green to light greyish skin and reaching an average length of 2.5m but can reach up to 4.3m. Its notoriety lies in its fatal neurotoxic venom. The mortality rate is nearly 100%, unless the snakebite victim is promptly treated with antivenom. Black mamba bites can potentially kill a human within 20 minutes, but death usually occurs after 30–60 minutes. Fortunately, we have a polyvalent antivenom produced by SAIMR (South African Institute for Medical Research) to treat all black mamba bites from different localities.
Next up is the Puff Adder; they grow be a metre in length but are quite stout. Though not as notorious as the black mambo, it is considered to be Africa's deadliest snake because it is responsible for the most human fatalities. The incidence of puff adder bites are high for a variety of factors; they are common and widely distributed; their preference to camouflage rather than flee; their habit of basking by footpaths and general willingness to bite with their quite potent venom. The venom has cytotoxic effects, which means it may cause local tissue swelling, pain, tenderness to ulceration and considerable necrosis, as well as severe bruising and bleeding systemically. If not treated carefully, necrosis will spread, causing skin, subcutaneous tissue and muscle to separate from healthy tissue and eventually slough. Gangrene and secondary infections commonly occurs and can result in loss of digits and limbs. Despite this, deaths are exceptional and probably occur in less than 10% of all untreated cases.
Final up is the Boomslang, which is an extraordinarily dangerous snake but luckily human fatalities are rare, since this snake is remarkably timid. It is a tree-dwelling snake (Boomslang means "tree snake" in Afrikaans), with reaches an average length of 1-1.6m. The Boomslang has exceptionally large eyes proportionate to its distinctive egg-shaped head. Females are brown, and males are light green with black highlights. Their fangs interestingly lie at the back of their jaw. The Boomslang venom is primarily a haemotoxic - which disables the blood clotting process and may cause death as a result of internal and external bleeding. Because the venom is slow to act, symptoms may not be manifest until many hours after the bite. On the one hand, this provides time for procuring the serum, while on the other hand it may lead victims to underestimate the seriousness of the bite.
I wouldn't underestimate a snake and completely understand why locals fear them most fervently.
24.6.2010 GUNSHOT WOUNDS
I never thought much about gunshot wounds before today, I suppose I never really needed to.
But after I had encountered a lady who was shot in the right side of her abdomen at close range and remained pretty much unscathed, because the bullet routed itself through her womanly 'muffin' abdominal excess and came out the other side, leaving the intra-abdominal cavity untouched, I was just very intrigued by the effect of the bullet on human tissue.
After a spot of reading around the subject, I discovered, that an entrance wound, would characteristically leave soot on the outside skin or lacerate the skin from the gas effects (exception is when an airgun is used!). The closer the range shot, the more soot stippling on skin. Distance shots tend to lack the soot component but will exhibit a hole that approximately equates to the calibre of the bullet fired.
When the bullet is in, the injury sustained depends on a number of factors - bullet deformation, bullet fragmentation, characteristics of the bodily tissue impacted on.
Relative density (mass/volume) is vital to understanding tissue damage, the greater the density the greater the damage. Whereas, elasticity reduces the level of damage. So we can then see why lung tissue with a low density and high elasticity would be damaged far less than muscle, and even more less than organs like the liver, spleen, brain. Bone, has a more dramatic effect of causing fragmentation of both the bone and bullet, which goes on to do collateral damage and make the hole much larger too. Then we have fluid filled organs, which just explode and release their contents, which itself can be even more problematic.
The bullet itself may vary in its quality and ability to execute damage, a hollow point bullet will actually give you an increase in volume of disrupted tissue and fragmentation, without giving you an exit wound. A fully coated metal bullet will give you an exit wound, but these may also recoil off bone.
My patients bullet did exit out very neatly, however most bullets are designed not too exit (then they do more damage of course). If you were try and distinguish between exit and entrance wounds, you would note the exit wound is larger, as the bullet has expanded or deviated from its initial alignment. There may also be less gunshot residue. You might also need to bear in mind there may be more than one exit wound (fragmentation of the bullet resulting in secondary missiles ) and the exiting bullet will necessarily come out at the opposite end to the entrance, as the bullet is unlikely to make a linear track out. The bullet track can be influenced by the targets position, so the organs affected on the sitting target will alter from that of the standing targets.
This patient, was extremely lucky, she got away fairly intact despite a close range bullet shot, a few sutures at the entrance and exit wounds, were the (physical) remnants of her encounter with a bullet.
And me, I feel I have acquainted myself very well to bullet trajectory and if I dwell any further it wouldn't provide anyone with any additional benefit and I might be labelled as slightly fanatic :)
But after I had encountered a lady who was shot in the right side of her abdomen at close range and remained pretty much unscathed, because the bullet routed itself through her womanly 'muffin' abdominal excess and came out the other side, leaving the intra-abdominal cavity untouched, I was just very intrigued by the effect of the bullet on human tissue.
After a spot of reading around the subject, I discovered, that an entrance wound, would characteristically leave soot on the outside skin or lacerate the skin from the gas effects (exception is when an airgun is used!). The closer the range shot, the more soot stippling on skin. Distance shots tend to lack the soot component but will exhibit a hole that approximately equates to the calibre of the bullet fired.
When the bullet is in, the injury sustained depends on a number of factors - bullet deformation, bullet fragmentation, characteristics of the bodily tissue impacted on.
Relative density (mass/volume) is vital to understanding tissue damage, the greater the density the greater the damage. Whereas, elasticity reduces the level of damage. So we can then see why lung tissue with a low density and high elasticity would be damaged far less than muscle, and even more less than organs like the liver, spleen, brain. Bone, has a more dramatic effect of causing fragmentation of both the bone and bullet, which goes on to do collateral damage and make the hole much larger too. Then we have fluid filled organs, which just explode and release their contents, which itself can be even more problematic.
The bullet itself may vary in its quality and ability to execute damage, a hollow point bullet will actually give you an increase in volume of disrupted tissue and fragmentation, without giving you an exit wound. A fully coated metal bullet will give you an exit wound, but these may also recoil off bone.
My patients bullet did exit out very neatly, however most bullets are designed not too exit (then they do more damage of course). If you were try and distinguish between exit and entrance wounds, you would note the exit wound is larger, as the bullet has expanded or deviated from its initial alignment. There may also be less gunshot residue. You might also need to bear in mind there may be more than one exit wound (fragmentation of the bullet resulting in secondary missiles ) and the exiting bullet will necessarily come out at the opposite end to the entrance, as the bullet is unlikely to make a linear track out. The bullet track can be influenced by the targets position, so the organs affected on the sitting target will alter from that of the standing targets.
This patient, was extremely lucky, she got away fairly intact despite a close range bullet shot, a few sutures at the entrance and exit wounds, were the (physical) remnants of her encounter with a bullet.
And me, I feel I have acquainted myself very well to bullet trajectory and if I dwell any further it wouldn't provide anyone with any additional benefit and I might be labelled as slightly fanatic :)
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