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 :)
Wednesday, 30 June 2010
The Disability Grant
You will not get through the day without having a patient consult for a DG. It stands for Disability Grant and is a state issued benefit, which rather tragically is the main source of income in this area.
The DG being a finite resource, it is meant to be to candidates who fulfil a specific criteria. Essentially, you have to have quite a serious degree of disability and functionally incapacity (practically dependent on others for activities of daily living) which isn't reversible in order to qualify. Once the benefit is obtained, you have it for life more or less.
The gatekeepers to this grant are us, the doctors. I find this position find highly contentious. Often you have never met the patient before, you rely on information from the records to tell what the problems are and there is the constant factor of poverty that they highlight to you. The aim should be to objective and try and get a functionality assessment and if you are struggling with this, there are Occupational therapists who do these extremely well. Many DGs have been given out to patients who wouldn't technically qualify because of the constant overlying factor of poverty. But spot checks are performed and the rest of the multidisciplinary team frown on spurious handing out of DGs.
Unemployment and opportunities being scarce here, there is little else for people to live on, so a visit to the doctor for a DG is an attempt at survival I suppose. In the past with the advent of HIV, DGs were being distributed out in mass, particularly if you were stage 3/4 disease or had low CD4 counts. Prior to accessible antiretroviral medication, HIV was certainly a terminal illness. Now that antiretrovirals are available and free there has been a shift in the handing out of DGs, so it is based on functional capacity as I have mentioned previously. Unfortunately, we see many patients requesting the DG because of their positive status rather than debilitation.
This scenario highlights resource allocation and obligations we as doctors have in a impoverished region with very limited capital. The balance of trying to look after our patients and their welfare and not bankrupting the state, has and is an unremittingly difficult position. In parallel as a doctor in the UK I have had similar scenario with sick notes and repeated sick notes. But knowing that there was limit and that eventually social services would take the role of determining those who qualify for sick leave benefit by means of their own specific occupational doctors.
The DG being a finite resource, it is meant to be to candidates who fulfil a specific criteria. Essentially, you have to have quite a serious degree of disability and functionally incapacity (practically dependent on others for activities of daily living) which isn't reversible in order to qualify. Once the benefit is obtained, you have it for life more or less.
The gatekeepers to this grant are us, the doctors. I find this position find highly contentious. Often you have never met the patient before, you rely on information from the records to tell what the problems are and there is the constant factor of poverty that they highlight to you. The aim should be to objective and try and get a functionality assessment and if you are struggling with this, there are Occupational therapists who do these extremely well. Many DGs have been given out to patients who wouldn't technically qualify because of the constant overlying factor of poverty. But spot checks are performed and the rest of the multidisciplinary team frown on spurious handing out of DGs.
Unemployment and opportunities being scarce here, there is little else for people to live on, so a visit to the doctor for a DG is an attempt at survival I suppose. In the past with the advent of HIV, DGs were being distributed out in mass, particularly if you were stage 3/4 disease or had low CD4 counts. Prior to accessible antiretroviral medication, HIV was certainly a terminal illness. Now that antiretrovirals are available and free there has been a shift in the handing out of DGs, so it is based on functional capacity as I have mentioned previously. Unfortunately, we see many patients requesting the DG because of their positive status rather than debilitation.
This scenario highlights resource allocation and obligations we as doctors have in a impoverished region with very limited capital. The balance of trying to look after our patients and their welfare and not bankrupting the state, has and is an unremittingly difficult position. In parallel as a doctor in the UK I have had similar scenario with sick notes and repeated sick notes. But knowing that there was limit and that eventually social services would take the role of determining those who qualify for sick leave benefit by means of their own specific occupational doctors.
Saturday, 22 May 2010
16.05.2010 Chopped fingers
It was a very amusing tale: A mother brought her 8month boy who three hours ago had his fingers executed by his five year old brother with the bush knife.
Mother brought the chopped pieces with her, wrapped up in tissue in her coat pocket.
Now the distal ends of the right middle and ring finger were almost sliced at the DIP joints. The freshly cut fingers now posed a problem (for him as well as me), never having dealt with closures of this kind I found myself a bit stuck. I knew the distal ends were probably not salvageable at this stage so it was am matter of closing the chopped ends.
That day all the seniors were out and about - I tried to get hold of one who directed to me to a purple book in the library that has a good hands section. I dutifully went to the 'library' (archaic collection of books from 1800s left and donated by people) and sought out the purple book. Lo and behold I couldn't find it, after another phone call, I managed to get a name for the book and diligently sought out he hands section. Ironically the book was called non-traumatic injuries. (?oxymoron). After painstaking page turning I realised their was no advice on chopped fingers to be found.
The end result was I didn't quite ascertain what the correct management was so with some help from another junior colleague we figured that interrupted sutures used to pull the skin taught over the bone would do.
The ideal technique I consequently learnt would have been to obtain a bone grinder and grind the distal ends of the phalanges down so the skin could be closed with less tension. Luckily in children they have such malleable skin and bone with excellent potential for healing we did not need to fiddle any further with his fingers (relief on my part).
Mother brought the chopped pieces with her, wrapped up in tissue in her coat pocket.
Now the distal ends of the right middle and ring finger were almost sliced at the DIP joints. The freshly cut fingers now posed a problem (for him as well as me), never having dealt with closures of this kind I found myself a bit stuck. I knew the distal ends were probably not salvageable at this stage so it was am matter of closing the chopped ends.
That day all the seniors were out and about - I tried to get hold of one who directed to me to a purple book in the library that has a good hands section. I dutifully went to the 'library' (archaic collection of books from 1800s left and donated by people) and sought out the purple book. Lo and behold I couldn't find it, after another phone call, I managed to get a name for the book and diligently sought out he hands section. Ironically the book was called non-traumatic injuries. (?oxymoron). After painstaking page turning I realised their was no advice on chopped fingers to be found.
The end result was I didn't quite ascertain what the correct management was so with some help from another junior colleague we figured that interrupted sutures used to pull the skin taught over the bone would do.
The ideal technique I consequently learnt would have been to obtain a bone grinder and grind the distal ends of the phalanges down so the skin could be closed with less tension. Luckily in children they have such malleable skin and bone with excellent potential for healing we did not need to fiddle any further with his fingers (relief on my part).
12.05.2010 Burnt Flesh
They wheeled in the lady at 7.30am that morning, she was talking, she was coherent, she was completely burnt and still alive.
I left a gogo (granny) in mid consultation to assess the situation quite speedily, the site was unparalleled. This poor lady was covered in a blanket but the patches of exposed flesh, showed she had none. The chocolate coloured dermis was dripping off and lay in crumbs on the floor. As we removed the blanket a wave of more dripping skin wafted to the ground. She had white limbs, white chest and breast and a peeling face.
That morning at 6am a canister holding 5 litres of petrol in the house had accidentally ignited, setting the house up in flames. The patient had been caught in these flames along with her three year old daughter. The door was locked from the outside but there was small window through which the mother intuitively through the child out of. The child was incredibly fortunate to survive with minimal superficial burns. Mother though, as I have already alluded to, did not fair well.
The mortality of burns this severe and this deep is high, infact the percentage burn corresponds to the mortality rate and after stabilisation a thorough assessment of the burns revealed a total of 85%.
The scene was not just visual experience, the olfactory nerves were tainted by the smell of burnt flesh in mass volume. It was an incredible and provoking scene.
Knowing the prognosis, we still felt we should proceed with trying to optimise her as much as possible, the burns unit for referrals, said what we knew already and didn't feel any virtue in transferring her across to them. Airways and breathing she was doing for herself for now, but we could help her with fluid losses if we could only get venous access. I called for more help, with myself , the senior doctor, nurses, phlebotomists we poked the poor lady all over to no avail. We didn't have any central lines and simple cannulation of the external neck veins failed. So after a quick read of the ATLS manual the senior doctor successfully did a venous cut-down of the long saphenous vein and we had access!
The daughter stayed the night on the paediatric ward and in the early hours of the next day mother passed away.
28.04.2010 Four hours drive, four decades apart
South Africa is a remarkable country, not just for the mere obvious attributes, like the superb weather, unparalleled history, Game Parks, Beaches, extraordinary medicine and disease etc.
What I have found quite remarkable is the huge disparity in healthcare within the country.
South Africa is far from a typical African country. Having ownership of a city like Cape Town which feels like an idyllic Mediterranean town, to the other end of the spectrum being KwaZuluNatal - unruly, unpredictable and impoverished but undeniably beautiful in its own right.
Medicine seems to follow a similar path of immense disparity. In KZN we have rural hospitals, with limited money and resources and doctors, in Durban, four hours drive away we have the state of the art tertiary hospital with a mountain of specialities.
Its clearly a socio-economical issue why the standard of health has no uniformity, but the government try to tackle this by ensuring bush hospitals have a supply of doctors, by making it obligatory in their second year to do a community service - comserve. And it is not just doctors, but other health care professionals, like physiotherapists, occupational therapists and dieticians, much to the benefit of everyone really. As it is an obligatory part of the career of most government workers are aware of the healthcare structure, or so you would think.
I have found on a number of occasions being very confounded by the lack of insight to bush hospital structure, by our referral hospital colleagues. At Mseleni, there is a constant problem with urgent blood samples, running out of cartridges for blood gas machines, finding appropriate equipment when needed, US probe breaking, valves for BIPAP going missing and on and on......
So when the accepting doctor at the referral hospital asks you to do all the above then ring back, my frank refusal and clear portrayal and the resources we have to work with in the time frame the patient has sometimes gets the patient sent across and sometimes not.
So referrirng patients is a challenge but when successful, satisfying.
Friday, 21 May 2010
Thursday, 20 May 2010
Sunday, 2 May 2010
28.04.2010: Butterfly Effect
Being in the middle of nowhere, means News often filters through insidiously through various channels or doesn't at all. So if Michael Jackson came back to life or an Earthquake swallowed the UK, I would be none the wiser.
But when this rather unheard of, previously anonymous volcano, in the middle of the Land of Ice, opened its top and emptied its entire contents into the atmosphere, we couldn't but help get wind of it here. The sheer pandemonium that rose was indeed magnificent.
Friends couldn't catch flights, holidays were cancelled, or extended when others couldn't return (not just a bad prospect), the micro and macro levels of the repercussions seemed boundless.
My sister in Dubai, emailed me to tell me that the meat was out of stock in the supermarkets, signs up on he boards 'Volcano in Iceland disrupted deliveries'. No red meat for them for a while. Even London was not untouched, aside Heathrow chaos (which lets face it is not uncommon), hospitals were feeling the brunt of the after effects. Shabs (my dearest friend) reported that in her hospital they cancelled theatre lists because deliveries of blood were not made and there was a hint of some medication shortage too!!
So while things were looking bleak and depleted in the World, we in Mseleni, well we had a lack of decent meat, no fish, no ice-cream, no shops and our pharmacy department which rarely has anything more than Panado (paracetamol trade name here in case you were struggling), ran out of Panado!!
But this, my readers, is quite independent of any volcano, I am afraid this is a rather chronic state.
Welcome to KZN x
But when this rather unheard of, previously anonymous volcano, in the middle of the Land of Ice, opened its top and emptied its entire contents into the atmosphere, we couldn't but help get wind of it here. The sheer pandemonium that rose was indeed magnificent.
Friends couldn't catch flights, holidays were cancelled, or extended when others couldn't return (not just a bad prospect), the micro and macro levels of the repercussions seemed boundless.
My sister in Dubai, emailed me to tell me that the meat was out of stock in the supermarkets, signs up on he boards 'Volcano in Iceland disrupted deliveries'. No red meat for them for a while. Even London was not untouched, aside Heathrow chaos (which lets face it is not uncommon), hospitals were feeling the brunt of the after effects. Shabs (my dearest friend) reported that in her hospital they cancelled theatre lists because deliveries of blood were not made and there was a hint of some medication shortage too!!
So while things were looking bleak and depleted in the World, we in Mseleni, well we had a lack of decent meat, no fish, no ice-cream, no shops and our pharmacy department which rarely has anything more than Panado (paracetamol trade name here in case you were struggling), ran out of Panado!!
But this, my readers, is quite independent of any volcano, I am afraid this is a rather chronic state.
Welcome to KZN x
01.04.2010 Sangomas and Herbalists
Introduction to Traditional Medicine and Healers
Never having had any particular faith in our complementary medicine 'colleagues', having to deal with the effects of the Zulu Witch doctors edition of alternative therapy, I could easily succumb to a bit of homeopathy or acupuncture (!). Most of you wouldn't mind a few needle pokes, impotent drops of herbal concoction or a few pungent smells, if the choice were between the latter or a toxic therapeutic Enema made of detergent??
The local practice is a universal enema of 'sunlight' soap, Colgate toothpaste plus or minus boot polish in varying amounts shoved up the rectum, to cure all sorts of troubling ailments. Do these manufacturers know how useful and diverse their products really are. Doubt it.
The enema, to be fair, is widely practised method of 'cleansing' but I doubt they usually consist of such toxic ingredients.
The Inyanga (herbalist) will make up a imbiza (medicine from inyanga - the enema usually) which can be taken for a variety of reasons. Men may take it for sexual performance enhancement but little do they know, it may instead lead to frank haematuria and malignant hypertension secondary to severe renal toxicity.
It is invariably given to children with gastroenteritis as a treatment for 'anal sores' - and this is the bane of my life on the paediatric ward :( The number of wretched babies/children that come in with potassium levels incompatible with life at both spectrums (K > 7 and <2) is phenomenal.
Infact, to make any diagnosis you must merely ask two vital questions:
1. What is mothers HIV status and
2. When did you give the zulu medication?
Broadly speaking, for those who are not so familiar with South African healers, they seem to take two major forms. The Iyanga, as mentioned above, who is the herbalist, priest, psychologist of sorts. The other is the iSangoma, who is a diviner and can make diagnoses. iSangoma are also closely entwined with the ancestors and are able to communicate with these long demised souls and project to the followers their state of mind on different affairs.
My one and only contact with a iSangoma so far, has been in our outpatient department. He had come to seek treatment for dysuria and penile discharge. I was quite enlightened to learn that penile discharge is one of the few ailments that cannot be treated by traditional means, unlike HIV, strokes, cancers and other generally grave and incurable disease ;)
Never having had any particular faith in our complementary medicine 'colleagues', having to deal with the effects of the Zulu Witch doctors edition of alternative therapy, I could easily succumb to a bit of homeopathy or acupuncture (!). Most of you wouldn't mind a few needle pokes, impotent drops of herbal concoction or a few pungent smells, if the choice were between the latter or a toxic therapeutic Enema made of detergent??
The local practice is a universal enema of 'sunlight' soap, Colgate toothpaste plus or minus boot polish in varying amounts shoved up the rectum, to cure all sorts of troubling ailments. Do these manufacturers know how useful and diverse their products really are. Doubt it.
The enema, to be fair, is widely practised method of 'cleansing' but I doubt they usually consist of such toxic ingredients.
The Inyanga (herbalist) will make up a imbiza (medicine from inyanga - the enema usually) which can be taken for a variety of reasons. Men may take it for sexual performance enhancement but little do they know, it may instead lead to frank haematuria and malignant hypertension secondary to severe renal toxicity.
It is invariably given to children with gastroenteritis as a treatment for 'anal sores' - and this is the bane of my life on the paediatric ward :( The number of wretched babies/children that come in with potassium levels incompatible with life at both spectrums (K > 7 and <2) is phenomenal.
Infact, to make any diagnosis you must merely ask two vital questions:
1. What is mothers HIV status and
2. When did you give the zulu medication?
Broadly speaking, for those who are not so familiar with South African healers, they seem to take two major forms. The Iyanga, as mentioned above, who is the herbalist, priest, psychologist of sorts. The other is the iSangoma, who is a diviner and can make diagnoses. iSangoma are also closely entwined with the ancestors and are able to communicate with these long demised souls and project to the followers their state of mind on different affairs.
My one and only contact with a iSangoma so far, has been in our outpatient department. He had come to seek treatment for dysuria and penile discharge. I was quite enlightened to learn that penile discharge is one of the few ailments that cannot be treated by traditional means, unlike HIV, strokes, cancers and other generally grave and incurable disease ;)
Wednesday, 7 April 2010
My Pigeon Zulu
Its a dual functioning sentence, if you wanted to insult the nurses without offending them, say:
Studla Ma Fekhle Fekhle - Big fat fatty boom boom
Being a fatty is a huge compliment here and of course not so where we're from ;) enjoy
Studla Ma Fekhle Fekhle - Big fat fatty boom boom
Being a fatty is a huge compliment here and of course not so where we're from ;) enjoy
Monday, 5 April 2010
31.03.2010 Grieving and Hugs
This day was unforgettably sad and left a profound imprint on me.
It wasn't that another child died, or another two children infact, it was the emotions that trailed the sequence of events.
On this day, two children died almost simultaneously within the space of a few minutes. It happened in the daytime on a normal round that consists of generally malnourished, disease ridden children.
The first child rather unexpectedly passed away, without mother really noticing let alone the staff and when she did, the shriek reverberated through to the other wards. When i got to the bedside, Mother 1 was wailing and flaying her arms and the crowd watched (student nurses, nurses, other mothers and their kiddies). I stood in disbelief and dismay and requested the nearest nurse to comfort her and usher her to a private area, while i tried to assess the situation. The assessment was: dead child.
Not long after I am rapidly called to child 2, she is now Cheyne-Stoking (not unexpected, i had tried my luck to see if she could be referred) and mother 2 picks up on her imminent death and keels over to cry and wail.
The ward round begun with two deaths, two inconsolable mothers who were contained in the linen room to overcome their acute grief.
I don’t think I can yet formulate how incredible awful those moments moving to hours were. It was torturing on many levels; that two deaths should occur together; that i felt quite helpless; that the language and culture barrier held me back from offering some sort sympathy; that HIV and malnutrition is a rife problem.
One of the difficult aspects to this day was my inability to emphasise. I felt as well as not having the language skills i couldn't comprehend the form of expression of grief. So I consulted ward sister. The grieving is a form of utter break down, the griever cries intensely and audibly, they will physically melt down and do not hear or register others, hence why everyone watched them and didn't intervene. They will remain in such a state till they tire and then will be responsive to others.
Your role as the doctor should be to finish the cycle of care and though i dreaded it very much i went with sister to speak to the two mothers. I offered my sincerest apologizes and listened to sister speak in Zulu for what felt like ages. I looked down and tried to not look awkward but eventually just asked what was going on. The mums were saying they were what happened was inevitable and they felt that we had done all we could. I was relieved in one way to know that the ultimate acute emotion wasn’t aimed at me. At this moment i couldn't hold back a surge of overwhelming tears. I spontaneously reached out and gave them each a hug, they were a taken by surprise but clearly quite moved, all three of us the shed silent tears and sister led a prayer in Zulu.
A medicinal hug should be introduced to the grieving process here, its got to be healthier than the solitary soul crying in the linen cupboard. A final note to end on: though death in childhood is a common phenomenon and accepted as common place, its not easy to get used to no matter now unattached you may think you are.
It wasn't that another child died, or another two children infact, it was the emotions that trailed the sequence of events.
On this day, two children died almost simultaneously within the space of a few minutes. It happened in the daytime on a normal round that consists of generally malnourished, disease ridden children.
The first child rather unexpectedly passed away, without mother really noticing let alone the staff and when she did, the shriek reverberated through to the other wards. When i got to the bedside, Mother 1 was wailing and flaying her arms and the crowd watched (student nurses, nurses, other mothers and their kiddies). I stood in disbelief and dismay and requested the nearest nurse to comfort her and usher her to a private area, while i tried to assess the situation. The assessment was: dead child.
Not long after I am rapidly called to child 2, she is now Cheyne-Stoking (not unexpected, i had tried my luck to see if she could be referred) and mother 2 picks up on her imminent death and keels over to cry and wail.
The ward round begun with two deaths, two inconsolable mothers who were contained in the linen room to overcome their acute grief.
I don’t think I can yet formulate how incredible awful those moments moving to hours were. It was torturing on many levels; that two deaths should occur together; that i felt quite helpless; that the language and culture barrier held me back from offering some sort sympathy; that HIV and malnutrition is a rife problem.
One of the difficult aspects to this day was my inability to emphasise. I felt as well as not having the language skills i couldn't comprehend the form of expression of grief. So I consulted ward sister. The grieving is a form of utter break down, the griever cries intensely and audibly, they will physically melt down and do not hear or register others, hence why everyone watched them and didn't intervene. They will remain in such a state till they tire and then will be responsive to others.
Your role as the doctor should be to finish the cycle of care and though i dreaded it very much i went with sister to speak to the two mothers. I offered my sincerest apologizes and listened to sister speak in Zulu for what felt like ages. I looked down and tried to not look awkward but eventually just asked what was going on. The mums were saying they were what happened was inevitable and they felt that we had done all we could. I was relieved in one way to know that the ultimate acute emotion wasn’t aimed at me. At this moment i couldn't hold back a surge of overwhelming tears. I spontaneously reached out and gave them each a hug, they were a taken by surprise but clearly quite moved, all three of us the shed silent tears and sister led a prayer in Zulu.
A medicinal hug should be introduced to the grieving process here, its got to be healthier than the solitary soul crying in the linen cupboard. A final note to end on: though death in childhood is a common phenomenon and accepted as common place, its not easy to get used to no matter now unattached you may think you are.
26.3.2010 Preterm or prepreterm?
Benjamin Button - was a movie based not entirely of untruths:
I had a miracle preterm baby delivered this weekend. The mother went into spontaneous labour at a said 22 weeks. Though who knows, it my have been anywhere from 22 to 28 weeks, keeping track of your last menstrual period is not the done thing and an ultrasound is a rarity that we needn't touch on.
Unsurprisingly, she delivered vaginally without much fuss and surprisingly it was far from a dying or dead foetus. This tiny creature was fully formed and spontaneously breathing. Weighing a mere 600g, with a grey-pink shade, skin wrinkled like wise old man and the size of my hand (granted my hands are a little large). It makes you consider how fine a line exists between the extremities of ages.
As this was not an abortion, I had to act, getting some advice down the phone line to the referral hospital i found out that under 800g neonates do not make it to incubators and supportive care was the height of care. So i inserted my first umbilical vein catheter (with a neonatal feeding tube) and this acted as a means of nourishment for the next few days, till the fragile being took its last breath.
I had a miracle preterm baby delivered this weekend. The mother went into spontaneous labour at a said 22 weeks. Though who knows, it my have been anywhere from 22 to 28 weeks, keeping track of your last menstrual period is not the done thing and an ultrasound is a rarity that we needn't touch on.
Unsurprisingly, she delivered vaginally without much fuss and surprisingly it was far from a dying or dead foetus. This tiny creature was fully formed and spontaneously breathing. Weighing a mere 600g, with a grey-pink shade, skin wrinkled like wise old man and the size of my hand (granted my hands are a little large). It makes you consider how fine a line exists between the extremities of ages.
As this was not an abortion, I had to act, getting some advice down the phone line to the referral hospital i found out that under 800g neonates do not make it to incubators and supportive care was the height of care. So i inserted my first umbilical vein catheter (with a neonatal feeding tube) and this acted as a means of nourishment for the next few days, till the fragile being took its last breath.
Monday, 29 March 2010
Don’t think about committing suicide, Death will find you in some form or another in Mseleni, here are a few prime examples:
1. Flying pumpkins’
2. Throwing yourself out of a moving vehicle
3. Fish slaps
4. Pus balls
5. Bush knives
6. Accidental midazolam flushes
7. Snake bites
8. Ataxic dung beetles
9. Starving
10. Gluttony
2. Throwing yourself out of a moving vehicle
3. Fish slaps
4. Pus balls
5. Bush knives
6. Accidental midazolam flushes
7. Snake bites
8. Ataxic dung beetles
9. Starving
10. Gluttony
The children of Mseleni
I have basically been running the Paediatric ward by myself – it has been quite terrifying for a while as well as just plain upsetting on many occasions. The children can be so sick when they present and it’s inconceivable how they were allowed to be so sick before bringing them hospital. Malnourishment is a major problem particularly those with underlying HIV that hasn’t been diagnosed yet. More than often I have felt quite helpless as medical management alone doesn’t suffice and they inevitably die. And there is little hope of transferring these children to referral hospitals when their baseline is poor and they lose the battle for beds – equity versus pragmatism.
I remember the cry of one Zulu mother quite vividly. The manner of mourning in the Zulu society is quite an audible process. When her poor baby died, after a haggering battle with severe sepsis, dehydration and malnutrition, she had inconsolable shrieking which i remember just piercing into my heart. I was truly very dismayed.
However, after the perpetual toll of admissions and 24 hr takes, you realise pragmatism has to supersede in order to survive this, particularly when dying babies is a common place phenomenon and actually accepted.
I began to analyse the steps to this process of demise and you realise that so many factors beyond your control determine the likes of these children. The likes of socio-economical factors, culture, access, government, politics etc..... we at the hospital front actually sit probably at the end of this chain of events.
On the happier end not all the babies die here, there are some really cute chubby ‘Michelin’ babies and not all sick ones have a miserable end. It can be quite dramatic when the helicopters land in the pad and the emergency service crew waft through to carry your kid to somewhere ‘safe’ with facilities! That does give you a feeling of change and you climb a few steps on this slippery ladder.
It’s important to utilise the weekend, a visit to the beach and watching sunset, does wanders to wash the burden of the week away into the vastness of the universe. It is a beautiful place with much beauty to discover.
I remember the cry of one Zulu mother quite vividly. The manner of mourning in the Zulu society is quite an audible process. When her poor baby died, after a haggering battle with severe sepsis, dehydration and malnutrition, she had inconsolable shrieking which i remember just piercing into my heart. I was truly very dismayed.
However, after the perpetual toll of admissions and 24 hr takes, you realise pragmatism has to supersede in order to survive this, particularly when dying babies is a common place phenomenon and actually accepted.
I began to analyse the steps to this process of demise and you realise that so many factors beyond your control determine the likes of these children. The likes of socio-economical factors, culture, access, government, politics etc..... we at the hospital front actually sit probably at the end of this chain of events.
On the happier end not all the babies die here, there are some really cute chubby ‘Michelin’ babies and not all sick ones have a miserable end. It can be quite dramatic when the helicopters land in the pad and the emergency service crew waft through to carry your kid to somewhere ‘safe’ with facilities! That does give you a feeling of change and you climb a few steps on this slippery ladder.
It’s important to utilise the weekend, a visit to the beach and watching sunset, does wanders to wash the burden of the week away into the vastness of the universe. It is a beautiful place with much beauty to discover.
Sunday, 21 March 2010
Part 1 - The Initiation
My Dear Friends,
I have just survived my second week as the Paeds doctor and seen three babies die in front of my eyes, stayed awake for more than 36 hours as I got shat on my second 24 hr oncall and just had my interview for the post today!!!
But it is pretty amazing out here and now as I write this I am hoping this crazy temperamental internet dongle doesn’t fail on me again.
When I arrived more than two weeks ago in J’burg I had Jo meet me at the airport and pick me up (Jo for those who don’t know her is my sanity saviour now, we are on the vts together and very fortunately have come out here together). I already had my drill of preconceptions of J’burg hammered into me from everyone, so when i got to the airport i had my belongings strapped and taped to me (almost) and gave daggers to anyone who came near me ;)
So Jo came very gallantly and picked me up in her monster 4x4 killer machine and just as we exited the airport w e had the pleasure of the police officer pull our vehicle over. He was a dodgy, pot-bellied specimen of an officer and after requested Jo’s drivers licence, bless poor Jo, she thought she’d forgotten it and when the officer didn’t get the licence he said there was a fine for not carrying ones license in J’burg, we did try the whole ‘we are new in town and fresh off plane’ but then he proceeded to claim that you can be put in jail for not carrying your license! The banter went on for a bit and was heading in the direction of what kinda bribe can I get out of you’ and then like a sudden spark of lightening Jo remembers she brought her UK drivers licence and showed it t him quick – poor guy, looked really pissed off and shooed our car away!
We took a long drive over two days to get to KwaZuluNatal and our destination and luckily had prepared for the basic minimum J
Jo and I ended up with a ‘parkhome’, it looks like a port-cabin with two bedrooms and a living rooms, after an intensive few hours of scrub down with bleach and other forms of bug and mould killer – it started to look more like a home..... few shopping runs later, we have some cutlery and pans, butternut (yummy) and I am waiting to buy a specialised dustbin for the kitchen.
Being here is really surreal, though everything is so universally different to what we are used to you just adapt and get on with it. I suppose having a reasonable degree of pre-knowledge (thanks to Neera’s help and advice) was what as helpful, having very low expectations of the place and remembering – this is Africa so nothing happens fast ;)
Before I talk medicine, I would like you all to picture this:
We had induction yesterday; it couldn’t have been a more comical event. The induction board contained all the important bureaucratic bodies and the opening speech was given by the hospital manager – after five minutes the medical manager (Dr Fredlund) interjected and told her she must speak up because he was sitting next to her and couldn’t hear a word she was saying! Unfortunately when we could hear her - the essence of her speech was the number of children she had, when she became a widow, where she lived and which tribe she belonged...hope your getting the idea J The hospital manager enthused us with hope and inspiration by telling us not to get HIV, be faithful and don’t travel alone as Rapes were not uncommon. .......to top it up the useless excuse for a HR manager ended his tuppence worth with ‘we force you to join a Union of your choice’ – can anyone point out the oxymoron????
Sorry guys, to give you such a pleasant impression so far but had to share the delights of African bureaucracy with you all J
On a more serious note, there are no brown people here and everyone is really friendly, like freakishly friendly, it’s a bit of a shocker for the British reserved front. There are a really nice gang of doctors and physio/OTs and as we all live on the hospital camp we have to get on.
It’s beautiful though – the African sky is gorgeous and there is a phenomenal grandeur about the clouds – i know clouds!! But they don’t move and seem embedded in static motion.... The game is good – though just seen zebras, giraffes and impalas so far.....
Medicine is really crazy, people are properly sick but because everyone is so f!^#ed you end up having to decide who is the most f?@~#ed to get admitted. HIV is rife and malnutrition is tragic – such a basic failure in health development. Kwashior/maramused children are very difficult to manage and having HIV and TB and being poisoned by witch-dr meds ontop mean they just don’t have a chance sometimes. Things work in a much slower pace here. Bloods take 24 hrs, sometimes can get them is 10hrs. Xrs may or may not happen. Any special test like LFTs (??) and Ca2+ and PO4+ can take longer.......
Oh man, it’s the weekend and i feel i have scribbled more than enough for now. I hope you are well and getting as enough excitement as me (?).....If anyone wants to come out here, its a gorgeous so lemme know in advance and will bk annual leave. If my portacabin doesn’t excite you guys there are lush resorts in the vicinity and tourist areas too xxxxxxxxx
Afsana – (yebo gogo)
PS sorry its on facebook for those of you who are specifically adverse to it – Hitesh! – but I don’t have your email address ......
I have just survived my second week as the Paeds doctor and seen three babies die in front of my eyes, stayed awake for more than 36 hours as I got shat on my second 24 hr oncall and just had my interview for the post today!!!
But it is pretty amazing out here and now as I write this I am hoping this crazy temperamental internet dongle doesn’t fail on me again.
When I arrived more than two weeks ago in J’burg I had Jo meet me at the airport and pick me up (Jo for those who don’t know her is my sanity saviour now, we are on the vts together and very fortunately have come out here together). I already had my drill of preconceptions of J’burg hammered into me from everyone, so when i got to the airport i had my belongings strapped and taped to me (almost) and gave daggers to anyone who came near me ;)
So Jo came very gallantly and picked me up in her monster 4x4 killer machine and just as we exited the airport w e had the pleasure of the police officer pull our vehicle over. He was a dodgy, pot-bellied specimen of an officer and after requested Jo’s drivers licence, bless poor Jo, she thought she’d forgotten it and when the officer didn’t get the licence he said there was a fine for not carrying ones license in J’burg, we did try the whole ‘we are new in town and fresh off plane’ but then he proceeded to claim that you can be put in jail for not carrying your license! The banter went on for a bit and was heading in the direction of what kinda bribe can I get out of you’ and then like a sudden spark of lightening Jo remembers she brought her UK drivers licence and showed it t him quick – poor guy, looked really pissed off and shooed our car away!
We took a long drive over two days to get to KwaZuluNatal and our destination and luckily had prepared for the basic minimum J
Jo and I ended up with a ‘parkhome’, it looks like a port-cabin with two bedrooms and a living rooms, after an intensive few hours of scrub down with bleach and other forms of bug and mould killer – it started to look more like a home..... few shopping runs later, we have some cutlery and pans, butternut (yummy) and I am waiting to buy a specialised dustbin for the kitchen.
Being here is really surreal, though everything is so universally different to what we are used to you just adapt and get on with it. I suppose having a reasonable degree of pre-knowledge (thanks to Neera’s help and advice) was what as helpful, having very low expectations of the place and remembering – this is Africa so nothing happens fast ;)
Before I talk medicine, I would like you all to picture this:
We had induction yesterday; it couldn’t have been a more comical event. The induction board contained all the important bureaucratic bodies and the opening speech was given by the hospital manager – after five minutes the medical manager (Dr Fredlund) interjected and told her she must speak up because he was sitting next to her and couldn’t hear a word she was saying! Unfortunately when we could hear her - the essence of her speech was the number of children she had, when she became a widow, where she lived and which tribe she belonged...hope your getting the idea J The hospital manager enthused us with hope and inspiration by telling us not to get HIV, be faithful and don’t travel alone as Rapes were not uncommon. .......to top it up the useless excuse for a HR manager ended his tuppence worth with ‘we force you to join a Union of your choice’ – can anyone point out the oxymoron????
Sorry guys, to give you such a pleasant impression so far but had to share the delights of African bureaucracy with you all J
On a more serious note, there are no brown people here and everyone is really friendly, like freakishly friendly, it’s a bit of a shocker for the British reserved front. There are a really nice gang of doctors and physio/OTs and as we all live on the hospital camp we have to get on.
It’s beautiful though – the African sky is gorgeous and there is a phenomenal grandeur about the clouds – i know clouds!! But they don’t move and seem embedded in static motion.... The game is good – though just seen zebras, giraffes and impalas so far.....
Medicine is really crazy, people are properly sick but because everyone is so f!^#ed you end up having to decide who is the most f?@~#ed to get admitted. HIV is rife and malnutrition is tragic – such a basic failure in health development. Kwashior/maramused children are very difficult to manage and having HIV and TB and being poisoned by witch-dr meds ontop mean they just don’t have a chance sometimes. Things work in a much slower pace here. Bloods take 24 hrs, sometimes can get them is 10hrs. Xrs may or may not happen. Any special test like LFTs (??) and Ca2+ and PO4+ can take longer.......
Oh man, it’s the weekend and i feel i have scribbled more than enough for now. I hope you are well and getting as enough excitement as me (?).....If anyone wants to come out here, its a gorgeous so lemme know in advance and will bk annual leave. If my portacabin doesn’t excite you guys there are lush resorts in the vicinity and tourist areas too xxxxxxxxx
Afsana – (yebo gogo)
PS sorry its on facebook for those of you who are specifically adverse to it – Hitesh! – but I don’t have your email address ......
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