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.
Subscribe to:
Posts (Atom)
