Wednesday, 30 December 2009

Killing in the name of?

Mondays on call are officially the worst. And Monday on calls between Xmas and New Year are surely up there in the top worst Mondays.
The evening started fairly steadily with the clearing of OPD but led in to more and more patients arriving until I announced at 9pm that I had to go home and eat before I actually ate a patient. 10 minutes of furious eating later and I was called back to a patient who was fitting. Then to maternity for a woman in labour who was 'failing to progress'. A c-section later and there was a healthy baby boy. I then finished up in OPD and headed home at 1am. As I turned out the light so the on call phone went off; the lady from the c-section was bleeding. I spent a very unprofessional 2 minutes trying to persuade the midwives that they could handle this but at their insistence got redressed in my still warm clothes and headed in to find her lying in about 2 litres of blood and with a haemoglobin of half of the level it had been. A rapid return to theatre revealed no obvious cause for the bleeding but as we'd used up all 4 units of blood that we had in the hospital the helpful consultants at our referral hospital accepted her for transfer (not without the shamefully small voice that had to admit that yes, I had done the caesar). Fortunately when she arrived there 6 hours later she had stabilised (well, probably we had stabilised her, not sure that a ride in an ambulance over a bunch of pot holes is that stabilising) but we all agreed that although unneccessary the transfer had probably been the right call.
But for me, this does raise the question as to whether it is appropriate for untrained juniors to be performing operations overnight, when accessing help in the event of problems is quite difficult. We were lucky that this woman survived and I certainly thought that that wasn't going to be the case at one point. Would her death be something I want on my conscience? On the flip side, without the c-section her son's death would have been there instead. There probably isn't a right answer.

At 5.30am I was called by male ward to inform me that a patient who had been lodged had died. Lodging is what we do with patients who are essentially well but live far away and who either need investigations and have arrived out of hours or who have to await transport home the next day. This was a 38 year old male of unknown HIV status, who had come in in the evening with chest pain, shortness of breath and a cough. With his completely normal observations and examination I had lodged him for bloods and an x-ray. 12 hours later he died. We can only guess that there was a rapid change in his condition, or that I missed something. Probably the latter.

The frustrating thing is that with a lack of feedback I'm struggling to learn from these episodes of poor judgement. And am left merely with a nagging feeling of guilt.

Tuesday, 29 December 2009

uKhisimusi oMuhle!

25th December in Ingwavuma. I was delighted to discover that despite Zulu culture not having Santa Claus, he did visit our house, allowing me at 28 to continue to embrace the concept of a jolly bearded man who delivers presents. But in the 34 degree heat, I hope he has a summer outfit!
We did discover that some festive traditions are international; granny dumping and getting drunk and beating your loved ones up with a broken bottle. These yuletide regulars aside, we had a relatively quiet day at Mosvold and were able to enjoy the hospital braai-ing and general merriness.
On the 26th I embraced a South African Boxing Day tradition and headed for the beach at St Lucia. Much fun playing in the surf and watching hippos (from a safe and not-so-safe distance; at night they walk the streets of the town and graze on the grass verges. A bit of a hazard when walking home after a few drinks!).

Monday, 21 December 2009

Do no harm?

If you do something in good faith that it might help make someone better but they die as a result, is it manslaughter?
Last night at the end of my on call I was called to an HIV positive male, with active pulmonary TB who was fitting. He was unconcious and seemed to be having a one sided seizure. We gave him some medicine to stop this but needed to figure out why it had happened. The commonest causes out here are bacterial meningitis, TB meningitis, cryptococcal and toxoplasmosis (all basically infections of the brain, but all treated with different medicines). The best way to determine the cause is to take some fluid from around the spinal cord (a lumbar puncture) and test it. However this can be dangerous as there is a risk of causing 'coning' which is where the brain comes down through the skull and the patient dies. Various things suggest that you are more at risk of this, including focal neurology. In the UK you would hardly ever do an LP on this sort of patient without first doing a CT scan of the brain. If you had to, you would look at the back of their eyes first as this can also give you a clue. But 'urgent' CTs out here take days to weeks to happen and there is no opthalmoscope in the hospital. So general consensus is that you do more good by doing the LP and starting treatment. However, last night's patient died just hours after I had done the LP (which confirmed that he had TB meningitis and was therefore already on the correct treatment). With no post-mortem, we will never know for sure the cause of his death but given the timing, you have to be suspicious that it was a direct result of my actions.
Death is a daily occurence out here, but today is the first time that I have felt that it was truly at my hands.

Sunday, 20 December 2009

A little pre-xmas miracle.

Deyo got called in on Monday night for an HIV positive pregnant woman, unsure of her dates, with ruptured membranes. And triplets.
Our CTG machine can only do one baby at a time and the midwives thought they could only get one heart beat.
An emergency c-section later (with only 2 resuscitairs because that's all we have) and there were three healthy babies, each weighing in over 2.5kg.
A true miracle.

White wedding. Quite literally.

The first in the run of weekends is mine. Not going too badly; 5 and a half broken hours sleep Friday night, only called in once Saturday night whilst second on and have actually been at home for a couple of hours today. And this despite the fact it's snake bite season (the frogs are mating which brings the snakes out in force. And it seems they can't tell the difference between a frog and a child's arm...).
Anyway, the big event in Inwa this weekend was a wedding. A very romantic tale; Bridget is a white SA who moved here in 1992 to work at one of the schools. She has since, at the request of the community, set up her own English language school and adopted 2 local children. Swifty, an Eastern Caper, worked at the school for 3 years from 1995, and then came back earlier this year. To marry Bridget.
Weddings really are a big community event, especially ones involving people who are very much considered to be family by the locals. The service itself was incredibly joyful, from the wedding march in with the bridesmaids and groomsmen boogying down the aisle, to the sheer volume created by friends and family singing and whooping (I'm not sure there's another word for the noise that is essentially a very high pitched "lalalalala") during it. Weddings at home seem quite formal by comparison.
They had 150 invited guests for the reception at Fancy Stitch, but expecting extras, had catered for 500. And all the food was eaten.
I joined in the festivities with the ultimate Ingwa-accessory; my mobile phone stuffed in to my bra.

Thursday, 17 December 2009

Reconciling myself.

December 16th, Reconciliation Day, nee Blood River Day. It's the date of a famous Zulu-Africaaner battle that apparently used to be celebrated by some and mourned by others. Nowadays in the spirit of a multi-cultural South Africa, it seems to be an opportunity to hit the beach. And have a braii. Naturally.

Except in Mosvold, where we work public holidays. However, with pretty much no patients coming in, I put in a couple of hours on the ward and then headed south to meet up with some friends from the UK for a night in a game park. I had thought that after the last few weeks I'd have had my fill of animals but Thula Thula managed to pull a closer-than-comfortable on-foot elephant experience out of the bag to keep me entertained.
Not that I needed to be; I'd forgotten how lovely it is to spend time with friends who you can totally relax with, as you've known them so long you'd actually have to try really hard to offend them. It was interesting hearing their thoughts on my experiences (as read in the blog) and being reminded of just how surprising some of the things that I now take for granted are. In some ways I worry that being here is toughening me up (not necessarily a bad thing for Princess Caroline some would say) and that I am now much more accepting of things clinically than I would have been at home and have lower expectations. But talking about it, I realised that my attitude is contextual and I'm reassured that I should still be able to respond appropriately to my UK patients and their non-HI-viral illnesses.

Sunday, 13 December 2009

Living for the weekends.

So, now that we are 6, Deyo and I are facing 3 solid weeks of Ingwavuma as we are working alternate weekends. With this in mind, we piled in to the car on Friday and headed down to Manguzi Hospital to join up with some doctors there. Saturday morning we crossed the border into Mozambique for a weekend of fun in Ponta D'Oura (a hedonistic sandy beach resort favoured by Africaaners with their jet skis and quad bikes). There we enjoyed the local R&R (rum and raspberry, served in pints and enjoyable once you've forced the first inch down) and then faced the painful drive back in time for tonight's on call. Life here would be so much better if we didn't actually have to work...


As in most of the Southern hemisphere, the academic year runs January-January here, so for our community service doctors and therapists, their year in Mosvold is shortly to come to an end. We are also losing our dietician and speech therapist as well as the other British doctor who has been here for 18 months. That's quite a lot of people for a small community. We're still awaiting confirmation of their replacements (we've all recently recieved a copy of a letter from the Dept of Health stating that as KZN is anticipating a high level of year-end over-expenditure, they are implementing a Provincial Recovery Plan. They are freezing all posts. Oh and only heads of dept are to travel buisness class to meetings).
Anyway, going back to the leaving, it was felt that a formal xmas/leaving party was required so, Fancy Stitch was opened up for the evening for a sit down dinner (with all the guests providing various dishes) and a photo-montage power point display.
Now we are 6 doctors until January 1st. And we await our new colleagues and hopefully friends.

Papa don't preach.

So, apparently there is a first time for literally anything. I was asked to preach in the chapel on Wednesday. Really. Admittedly it was just the venue for the start of the '16 days of activism against violence to women and children' (catchy title) and I was preaching on the doctor's role in domestic violence (evidence suggests that women who are being abused want to be asked whereas those who aren't don't mind). It was good to see so many people from different areas (nurses, social workers, local NGOs) coming together on such an important topic. If only it hadn't all been in Zulu... But I think I got the gist of it and even joined in on some of the raised fist shaking and shouting, which I think was "no more violence" but could equally have been something totally different.

Monday, 7 December 2009

A brownie in the oven.

I find myself in an interesting and unexpected moral dilemma. A non-local family living in the area have asked me to provide them with antenatal care through their pregnancy until they travel to Cape Town for the delivery. This in itself is not the dilemma (actually it's my job). What they do however want is to be seen consistently by the same doctor at specific times (dictated by me) rather than join the potentially all day wait in OPD and see whoever happens to be free. In so many ways this doesn't seem to be an unreasonable request, it's what most women in the UK expect. However, it isn't what is done here so would be providing special services for people because they are friends (and make excellent chocolate brownies). I guess ultimately it's like providing a private medical service (with the payment in cakes not cash) and I don't know how comfortable I am with the inequality in health care that that represents. On the flip side, the concept of providing medical care of a standard I feel is good, rather than just about acceptable, with some level of continuity, really appeals to me. And they are exceedingly good chocolate brownies.

Sunday, 6 December 2009

The elephant in the room.

I don't want to speak too soon but I think my automobile curse might be lifting. Not without the final blow from the insurance company that our car is to be written off (some sort of internal bleeding apparently) and that they won't discuss payment until we produce a Swazi police report, which is tricky to get as they need a written request, don't have e-mail and their fax is broken. They suggested that I drive the 3 hours to the police station to request it and then back 4 days later to collect it, but I pointed out that that would be tricky, having no car and all.

However, this weekend, I managed to go to Tembe Elephant Park and go on a game drive without any vehicle mishaps at all. Well, there was the mock charge from a female elephant, cooly dealt with by Tom our driver who ignored our pleas to reverse and sat there as she stamped around, flapping her ears and trumpeting before finally walking off. He summed it up "she's just a young girl, showing off". We all felt she might be young but she was still pretty big.

The weekend was organised by one of our neighbouring hospitals, with a discount rate for doctors working in local hospitals to stay at the 5 star resort. It was a lovely weekend; relaxing and fun, and it was really good to meet other local doctors and compare notes on our experiences, some scarily common. It was also good to have hot running showers as we have yet again returned to a waterless Ingwavuma. The joys of rural SA.

Tuesday, 1 December 2009

An awfully big adventure.

So the conclusion to the car problems was the return of the hire car to Durban this weekend and a debauched night out with some friends.
We then piled in to a car for the 5 hour drive home. 2 hours outside of Durban we came upon a mini-bus crash.
Mini-buses are the transport system used by most locals and some more foolhardy doctors. They charge very reasonable prices by packing themselves full (I've heard tales of being squished between a Zulu-mama and her chickens). And they don't have seatbelts.
It was unclear what had happened but this one was lying on it's roof, with passengers in pools of blood around it. One ambulance had arrived but it was clear that the number of casualties was more than they could handle alone.
With three doctors in the car none of us thought twice as we pulled up and jumped out; it really is a legal and moral obligation. However, we were all quite relieved when one of the boys pulled gloves out of his bag for us.
In trauma speak the crash had 3 reds (severe cases), 5 yellows (moderate) and 9 greens (the walking wounded). There was also a baby without a scratch on it. We spent an hour at the scene, working alongside the paramedics to stabilise patients. At one point a patient's airway was obviously compromised and as he had smashed his face to pieces, the only way to secure his airway was to insert a tube through his neck. The other doctor and I faced each other; I knew the theory from a book and he had done it on a pig. Bravely he picked up the knife. And did an excellent job. Sadly despite all of this, the patient died in the ambulance on the way to hospital.

For non-doctors this would probably seem something we as medical professionals are equipped to deal with however, there is a big difference between being at work and being on a motorway, both in terms of available resources and emotions.
The experience has left us all quite shaken.

Holiday horrors.

We had planned a week long roadtrip to Mozambique, driving up the coast to Tofo, a beach that Lonely Planet refers to as 'legendary'. What we got was a cyclone. And after 24 hours with no sign of letting up, we decided to abandon Mozam for Swaziland (which the weather forecast assured us would be better). And whilst the weather certainly was, our luck was not; we managed to crash the car into a mini-bus just over the border. Fortunately the only injuries were to Bev (the car). There followed an amusing hour or two of hanging out with the Swazi traffic police (at the end of which they asked us for our e-mail addresses so that they could "keep in touch") until a tow truck arrived to take us to the nearest town. Needing to regain our holiday cheer we hired a car and headed for some of Swazi's game parks; a delightful afternoon of horse-riding amongst zebras and impalas was followed by a less delightful self-drive where we got stuck in the mud and had to hike through the game park for help (not the lion enclosure fortunately!).
After all of that, I was almost relieved to be coming back to Mosvold!

Mosvold as a holiday destination?

November has been a month of visitors. Firstly one of my former O&G registrars came for a week (handily the week Deyo was away so I didn't get too lonely) and then my friend Lizzie, who is a Paediatric ITU nurse.
It was interesting to see their impressions of Mosvold and to be reminded of some of the very shocking things that we see here, that I think we are starting to adjust to, but that fresh eyes remind us aren't what we are used to back home. In particular, during the first week we had a maternal death from a post-partum haemorrhage. The review of the case notes the following day would have been laughable had we not been facing a child orphaned through what appeared to be a chain avoidable of clinical errors. Susan helpfully did a presentation on management of these cases but even some of the simple management steps are lacking here (in particular we currently have no blood products).
Lizzie's arrival strangely brought a week of paediatric emergencies with another 27 week premature baby born. This one battled through the night and was actually transferred out but sadly died at our referral centre, leaving his young mother alone and 4 hours from home. My on call was another night of poor sleep, an emergency c-section on a pre-eclamptic woman with APH and the slow demise of a young child from what appeared to be enema poisoning, something that is not uncommon practice in this area.
After all that, Lizzie and I both felt very in need of our relaxing week off in Mozambique...

Thursday, 12 November 2009

Some sage advice?

A further comment on the snake bite patient; I had to break the news of his death to his father today. He took it very much in his stride, showing almost no emotion at the untimely death of his son. I have come to expect this from the Zulu people who respond similarly to death and birth. What I'm not sure is whether they have lower expectations on survival or whether they just show their emotions in different ways. It can make it hard at times to empathise with them.

However, as I had found the case so upsetting, I was taken aback that his family didn't seem to, I was expecting tears or even anger but he merely nodded, patted me on the arm and said "we are all only here for a short time".

Laying the blame.

An update on the snake bite; the boy's bite marks didn't stop bleeding and he got transferred to our referral centre. Sadly he arrived at 4.15pm and although the consultant on-call rapidly recognised it as a boomslang bite, requiring specialist antivenom from Jo'burg, he did not recieve it, as the antivenom can only be ordered from 8am-4pm. He died at 3am. The next day I had a long conversation with the consultant about the case, which started off as an enquiry in to why I hadn't transferred the patient earlier and/or faster (for the record I had discussed it with the specialist hospital who whilst advising me on treatments wouldn't allow a transfer until the Monday). The conversation ended as an educational session for me on snake bites.
But it made me question who was ultimately responsible for the mismanagement of the case; should I really be here, not having the appropriate medical knowledge for the area, or should the hospital, knowing that they have an overseas doctor here who is inexperienced in snake bites, ensure that they educate me on it?
Ultimately a 15 year old boy has died, despite appropriately seeking medical advice. And personally I feel terribly responsible.

Monday, 9 November 2009

It's good to talk.

Mosvold is becoming ruraller every day. If that's a word anyway. This weekend, in addition to the intermittent water supply, we had intermittent phone communications. Firstly our referral hospital's lines went down, so we were ringing specialists on their mobiles, then our hospital's lines went so we were ringing specialists' mobiles from our mobiles and then the mobile network went, so we weren't ringing anyone. And keeping our fingers crossed that the haemotoxic snake bite would stop bleeding (it didn't but he was stable enough and got a transfer today with his INR>10).
The whole thing made me realise two things; Mosvold is pretty scary when you're completely on your own up here, and whilst I think I am braving rural SA this year, it would have been a heck of a lot more difficult 10 years ago when mobiles weren't an option and international phonecalls prohibitively expensive.

Saturday, 7 November 2009

Some grave thoughts.

Death is a sadly common occurence here. I'm not sure of the rate amongst our adult admissions, but amongst the children admitted it is 5%. And that in itself is a difficult thing to deal with. But the part that frustrates me is that often we have no cause of death. Take last night;a 32 year old man came in by ambulance in a terminal state, unconcious and gasping. He was accompanied by a family member who could only tell me that the patient worked a long way away, had come home yesterday a little unwell and then today had become worse and worse. She thought that he had been on some medicines but had stopped taking them. As it was night time, all I had available to me was some observations (but no oxygen saturations) and my clinical judgement. He had a high temperature and an unrecordable blood pressure so I treated him for a presumed sepsis with fluids and antibiotics but he died about an hour later.
He won't get a post mortem (and in some ways I am almost relieved by that as post mortems here are done by the doctors, something I have thus far avoided). Most likely we will write HIV as the cause of death on his certificate, assuming that the medicines he had stopped taking were anti-retrovirals (which with an HIV rate of 40% is not an uneducated guess).
But how can we possibly learn from these cases if we don't find the cause of death, or at least try to? Did I miss something that if I had diagnosed it, could have made a difference? What closure can we offer the family for the loss of their loved one? And what about government statistics, upon which spending decisions are made, how can these possibly be accurate when death certificates are not?

Thursday, 5 November 2009

Back of the net indeed.

For anyone who doesn't know, South Africa is holding The World Cup in 2010. And being here you couldn't not know; it's constantly on the radio, there are countdown clocks everywhere from the airport to Macdonald's (which is counting down in days, hours, minutes and seconds) and even Swaziland are getting in with posters up at the border (not even their country). The South Africans are very excited and they have switched the school holidays so that kids have their long break in June/July when it is on. South Africa is going to be a very exciting place to be next summer.
And Deyo and I have tickets!!! Admittedly as yet we only know that they are for Match 25; E1 v E3 but even if it turns out to be Bulgaria v Kazakstan, we'll have been there for a part of the World Cup. Now to learn the rules of football...

Tuesday, 3 November 2009

Losing your head.

Wow, what a start to this evening's on call; snake bite. To the head (apparently it was lying above the door, for all those like me thinking 'HOW??'). And the patient had brought the snake with them. In a plastic bag. Beheaded. Yuck.

Monday, 2 November 2009

High and dry.

We have now been without running water at the hospital for 48 hours, which means no x-rays, limited lab facilities and slightly stinky doctors as we pretty much all live on site.
I'm lucky as there is a rain-water jojo sitting literally outside my door, collecting water from my roof, so getting water isn't too difficult (although collecting and heating enough to wash in is quite time consuming) and we've had quite a bit of rain so far this year so it's fairly full.
I think however, the experience is giving me a good idea of how tricky life must be for a lot of the patients who are permanaently in this position, or worse with no jojo (at about £300 they are quite an investment for most people). One of the doctors was telling me that last year when the rains were late, local people were going down to the river bed at night time and digging holes to collect water. They would use about 6 litres in a day for all their needs; cooking, drinking and washing. Both in the UK and here, I take for granted just turning a tap on for water but when it involves a bit more effort, I can see how careful you would have to be about it's use. Let's hope I can hold on to some of this awareness once they fix the pump.

Sunday, 1 November 2009

Yes, we had petrol.

Oh dear, I'm not having much luck with cars out here. First it was the burst tyre, then our own car required jump-starting a couple of weeks ago and then yesterday, whilst driving back from a shopping trip to Richard's Bay, the car we were in gradually lost power and slowed to a halt on the hard shoulder of the N2. And then the very helpful 'STOP' symbol came on (consultation with the manual revealed that this means that you need to take it to a Renault Dealer immediately. Thanks for that...).
We phoned the breakdown cover people who agreed to send us a tow truck in approximately an hour's time but they would only tow us to the nearest dealership and we had to make our own 150km way home from there. So we sheepishly rang the one remaining person at the hospital who wasn't working and asked if they could come get us (a 5 hour round trip).
And then I recalled in my limited breakdown knowledge that it's not very safe to remain in the car whilst on the hard shoulder, so I piled everyone out and on to the pretty grassy verge where the last rays of sun were still warm. This was fortunate as some hospital transport was passing with a couple of units of blood and recognising us, they pulled up to help. Firstly they attempted to ascertain what was wrong; "did you have petrol?". Yes, half a tank actually. And then they tried to push start it (even I know that cars that suddenly stop whilst driving are unlikely to restart with a push). Finally they agreed that the most helpful thing would be to take one of the passengers and their shopping (there was a lot) back with them.
Whilst this was going on another very helpful person stopped and he turned out to be a car mechanic. He also attempted to find the problem ("did you have petrol?") before poking around under the bonnet and telling us it was unfixable here (something to do with some sort of petrol jet thingummy). He then asked how long we'd have to wait before explaining that this was "a very dangerous stretch". I agreed that the trucks going past were quite big and fast, and he looked at me like I was an idiot before telling me just how many fatal hijackings there had been in the area and that whilst it looked pretty in the daylight, it was fast getting dark. Kindly he then towed us with his car to the nearest town to await the tow truck and our lift. As luck would have it the nearest town is also the home of our former medical manager, a British GP, who had insisted that if I was ever in the area, I should give him a call. So we did. He turned up to collect us, checking what was wrong with the car ("did you have petrol?") before whisking us home for cups of tea until our lift arrived.
After yesterday's excitement, today has been spent lazing in the sun, wondering if the road trip to Mozmabique that I have planned for 3 weeks time is such a good idea!

Tuesday, 27 October 2009

ICE, ICE baby.

My first trip out to clinics. Driving in the 4-wheel drive, up barely-there tracks, smashing through puddles and dodging cows, with a bag of drugs in the back, I really felt like a 'bush doctor', how I had thought SA would be.
But the reality of the clinics is that, not unlike the hospital, we offer an incredibly limited service. My job today was to see the patients that the nurses have selected in the lat 2 weeks as needing MO reviews. This ranged from hypertension and diabetes reviews (but none of the patients have home glucose monitors so even the insulin dependent diabetics only get about one reading a fortnight, and most of these are more than 25) to a child with ambiguous genitalia. But any blood tests will take at least a few days to come back and patients have to come to Mosvold for x-rays. So perhaps a little like a GP practice really. Only that there's no way of keeping good notes (all you have to write on is the handheld cards that the patients carry which are about the size of an appointment card at home, invariably tea- and other substance-stained and regularly get lost) so follow-up is variable at best. It's also incredibly difficult to refer patients to tertiary centres; there's no letter system, you just have to call and hope to get through to someone who will agree to see them (often not for many months by which time the patient has forgotten) and then when they come back, there is rarely any communication so you don't know what happened (I currently have a patient in the ward who I think has metastatic prostate cancer but although he has seen specialists, had investigations and possibly even some treatment, I'm struggling to get this confirmed). Very frustrating.
The other difference to GP is that I was at each clinic for 3 hours and saw 20 patients at each. That's an average appointment time of 9 minutes. Given that it is all done through a translator, I think I can safely say that I am not eliciting their ideas, concerns and expectations!

Sunday, 25 October 2009

A lucky escape?

The weekend of the Ingwavuma marathon. The months of training coming to a peak. The weather smiling upon us with a warm but not overly hot day.
Sadly I was to be found in Sodwana Bay (on an excellent 'management of obstetric emergencies' course; bring on a septic abortion or a breech presentation with nuchal arm, I am ready!!).
But fortunately Deyo was here to represent our house, and despite being on call, managed to win the women's 10km. And a lovely basket of edible goodies for our house; tins of pilchards and a bag of mealie maize. I arrived back in time for the post-run celebrations, with the obligatory braii and dancing until the wee small hours (10.30pm). There was quite a turn out, with former doctors having come back from Dundee (SA) and Canada (just above the USA) for the weekend. I was intrigued to hear their stories of Mosvold over the years and to see what they've gone on to do with their experiences; some quite inspiring stuff.
The party continues tonight, with our own, slightly belated, Diwali (or Deepa-vali as we're all calling it in honour of Deepa, our Indian-descent therapist who is organising it) celebrations.
Newcastle might be "the 8th best night out in the world" but surely Ingwa runs a close 9th?

Tuesday, 20 October 2009

2 legs good, 8 legs scary.

And finally tonight a quick blog on our house's newest resident. Spid Vicious has taken up residence on the front porch, terrorising us on our journeys in and out the house. At only about an inch across he's by no means the biggest spider but he has scary black and yellow stripey legs and some sort of horns sprouting from his back. He looks pretty mean and I reckon he either is one of the dangerous ones, or he does a good impression.
So far we have attempted his removal through an act of God (a rainstorm) and an act of Thembe and a broom (love, love, love her). However, he is determined and can rebuild his giant web in just a few hours.
We may have to reach an uneasy compromise, or start using the back door.

Trust me I'm a police officer?

The other experience that we had in Mozam was less pleasing but as I'm determined not to let it spoil my experience I'm writing it in a seperate blog; police corruption.
The first evening we were out with a friend in a car with local plates and had no trouble at all, despite the fact that most Mozambiquans seem to think little of driving whilst heavily under the influence of alcohol (for some it improves their driving!). However, the second evening, out in a car with SA plates, we were stopped twice on our 15 minute journey to the bar. The first time a youngish police officer suggested that we had been speeding and driving erratically (neither true), requested our car papers and then suggested that we "make a little plan". Naively I thought that he was suggesting we agree not to drive fast but our SA driver was more savy than me and passed him 50ZAR (about a fiver). Satisfied with this, he let us drive on. 5 minutes further on, we were pulled over again, this time for 'going through a red light' (again not true). Again our car papers were demanded but also our passports, which we didn't have with us. There followed an agressive 20 minute conversation during which we were threatened with being taken to jail (although notably when we suggested going to the local police station or embassy, they weren't that interested). Eventually when we continued to refuse to offer a bribe, they allowed us to go. In some ways the second encounter was amusing (when he demanded to know why if I claimed to be British I couldn't speak Portugese or French when Britain is so close to both those countries and I didn't help by explaining that I had a working knowledge of German and a little Gaelic) but given that this was accompanied by fiddling with the trigger of his gun, it was less so at the time.
I guess coming from the UK, I have a naive impression that all police are trustworthy and honest, something that I may have to adjust whilst in Africa.

Why I had to have 8 spare passport pages...

I'm feeling very rejuvinated from a much-needed long weekend; a 3 day trip to Mozambique for Deyo's birthday. We scooted off on Thursday evening, picking up a couple of passport stamps as we swept through our first border in to Swaziland. A stay over on a lovely farm (run by a fascinating couple who run it as a working farm, B&B and operate a cataract service as well, with their own landing strip. We'll be back sometime to learn more about them!) and then on to Mozam on the Friday. At the border we learnt about Mozambiquan patience; half an hour of negociations with various officials and payments of a variety of taxes and we got a page and a half of pretty stamps and entry to the country. First impressions were that it was very similar to South Africa, which it is in many ways. But it also very much has it's own laid-back mediterranean approach to life, as seen from the border crossing and also from our various experiences in restaurants and bars;

"Do you do cocktails?"
"Just caiparinhas"
"Oh, our favourite, 2 of those please"
...10 mins later...
"We have no limes, just lemons"
"That's fine"
...20 mins later...
"We've got no cachaca, just vodka"

But despite the lack of caiparinahs in that bar (made up for with many in others) we had an excellent weekend, enjoying the laid back atmosphere, Portugese-style hospitality, amazing jazz and eating more than our own body weights in fresh seafood. We also brought back more 'havanias' (see what they've done there?) flip flops than any two girls could possibly need and a selection of the amazing seafood to enjoy at our leisure in Ingwa this week.

Wednesday, 14 October 2009

Thank you.

Wow. When I started this blog, it was with the idea of it being a record for me of my year in SA, and intermittent proof to my mum that I was still alive. But I'm finding that it is also incredibly beneficial to me as a form of dealing with some of the things that I'm seeing and doing (a form of 'therapy' to be all American about it) but also after last night's blog, I've discovered, a way of reaching out and saying 'help, I'm not doing ok'. I've been overwhelmed with the responses I've had since posting, from both family and friends as well as less expected sources of support. And I'm so grateful to everyone. They really do help.
I thought I should write a quick note today to say that I am ok, and I haven't booked my ticket home yet. Half a bottle of wine and an early night worked wonders and today was, by contrast, one of the more positive days here; even my chronically unwell deteriorating HIV/TB patient perked up enough to eat some fried chicken.
Life is full of good days and bad days, or more accurately good bits and bad bit of days. We can all only do what we can do to ride through those bad bits. And there's always sugary tea for the rest.

Tuesday, 13 October 2009

Carlsberg don't do on-calls...

But if they did, I don't think last night would be one of theirs.
I can confidently say that the last 36 hours have been my most harrowing work experience to date in my career. I've cried more than I thought possible and drunk more strong sugary tea than my dentist would approve of.

The day started badly when, before lunch, I'd told a woman that the twins that she was 16 weeks pregnant with didn't have heart beats on the scan. And then promptly delivered one of them on the USS couch, before taking her to theatre to have the other one removed.
It was a busy afternoon, and then at 5pm as I was finishing up the OPD patients I had an emergency call from the Paeds ward. I arrived to an 11 week old girl that had been admitted with a LRTI an hour previously, who had now stopped breathing. Despite going further in Paediatric resuscitation than I ever have before (if there's no one else there to intubate, you might as well try) we weren't able to get a cardiac or respiratory output back and agreed to stop. I was distraught. Paediatric resuscitations are always upsetting but in this setting I can't but help feel that we just can't do enough. We have no way of checking gases or urgent electrolytes or even cardiac monitoring. And whilst we all try hard, we're not experienced or knowledgeable enough to be single-handedly resuscitating children (which is very much the situation you find yourself in). I couldn't recall doses of drugs but couldn't look them up in the critical first 5 minutes as I was bagging and doing chest compressions.
Explaining to a mother that her child is dead when you feel like ultimately we have let her down through lack of resources and skill is heartbreaking.
I found it especially hard as the other staff involved are more used to these situations and were able to carry on with their work as soon as we stopped. When I've been involved in these situations in the UK, you rely on support from your colleagues and try to take time to debrief, something that isn't seen as necessary here. I've also never been the person who has been ultimaltely responsible for the decision to stop nor for telling the parents and then bringing their child to them to hold. I've often wondered how appropriate it is to cry in front of relatives in this setting but last night it wasn't a concious or controllable decision.

There followed a night of hourly calls (anaphylaxsis to traditional zulu medicines, rape of a 4 months pregnant lady, a 1.5kg baby born at home and brought in) only one of which (not one of the listed ones you'll be pleased to hear) I managed to deflect to allow me two consecutive hours in bed. One of the things I find hardest about the on calls is that I've always favoured bouncing my thoughts about diagnosis and management off another person (even if only to ignore their advice) but at night here, you are the only doctor around (unless you urgently require the second on) and the nursing staff are of very variable quality, so in addition to being physically exhausted, I feel the strain of having to make all the decisions single-handedly without anyone even to say 'I agree'.
By morning I was mentally, emotionally and physically exhausted.
Then at 6am I was called to a lady who was 26 weeks pregnant and having PV bleeding and abdominal pain. Examination revealed her to be fully dilated with bulging membranes. Due to poor equipment here, our cut off for resuscitation of neonates is 28 weeks (as opposed to about 25 in the UK) but as many women are unsure of dates and don't have reliable (if any) USS I wasn't willing to put this lady on the female ward to deliver. So, much to the annoyance of the midwives, I took her to the labour ward. And I was glad that I did as the 850g baby that she delivered cried at birth, and I felt relieved to have some resuscitation equipment to hand. However, after spending an hour and a half resuscitating the boy with fluids, antibiotics and the available respiratory support, his breathing failed and he died shortly before 9am.

Sadly my day was not over there and I still had my ward round to do and a couple of further hours in OPD where my final case was a 15 year old girl requesting termination of her 8 week fetus, fathered by her own brother.

The thing is that any one of these things would have upset me tremendously at home, but being here and facing all of them in one shift, without my usual support networks is almost more than I can bear. The way I feel now, I don't know if I am strong enough to manage the year.

Time for another sugary tea I think.

Sunday, 11 October 2009

Not my usual kind of spirits.

Church in Ingwavuma is a big part of people's lives. Many people came here as they felt that God had called them and the day at hospital starts with prayers, which are sung. It is not uncommon for hospital meetings to start and end with a prayer. Sadly I seem to have been out when He called and he didn't leave me a voicemail, but that aside I thought it would be good to go along to church to see what it was all about.
The church most people go to is one set up about 4 years ago by one of the doctors. It is a Christian church and the service runs in English and Zulu. As it is still relatively new, they hold it in one of the school classrooms (where it was fun to see how similar it is to my old classrooms, with the kids divided in to groups named after fruits (apples, oranges, bananas) and a set of class rules that included 1. We must come to school every day and 4. No sleeping in class).
It started with walking in to beautiful harmonious singing from the congregation that seemed to be spontaneous, with one person starting and everyone joining in. Then a welcome by the preacher, and some worship songs. But just as I was getting in to it ('hey, church is a bit like a party'), one of the women was overcome by spirits and had a hysterical fit, crying and falling around and had to be taken outside. Everyone else seemed to take this in their stride and assured me that it was not uncommon for God's presence to draw out evil ancestory spirits. But I felt uncomfortable with it. I also felt uncomfortable watching the poverty stricken local black community singing their hearts out about how God is just and fair. How they can look around them and think that, I am less sure. And I was taken aback to notice that, as in the hospital where the majoirty of doctors are white, and the school where the teachers I have met are white, in the church, the preacher and the leader of the Sunday school are both white. In a predominantly black community, it still seems that many of the positions of responsibility are held by whites, even in the church.
Those doubts aside it was a very positive and happy atmosphere and it was wonderful to feel so welcomed into a community that I only joined 8 weeks ago. I'm not about to become a regular at church, but it's nice to know that if I find myself at a loose end in Ingwa on a Sunday morning, I'd be very welcome.

Saturday, 10 October 2009

But no olives.

Ok, it's blatant e-portfolio avoidance, but thought I would give an insight in to shopping in Ingwa (a certain young lady checks this daily with her tea- this should keep her going for a couple of cups). We've got one main shop; Spar supermarket (I think to call it super is a bit of an overstatement, but it's bigger than your average Spar at home). Sells an interesting and unvaried selection of things (a whole aisle is dedicated to varieties of mealie maize and pap) and when initially faced with it, we really weren't sure what we were going to live on here. But I'm discovering that each time I go, I find new things. Often stored in random places (self-raising next to the washing up liquid, in a seperate aisle from all other baking products, including normal flour). And ususally not in the same place for more than two weeks running. Which keeps things entertaining.
There's a vegetable section where you can buy tomatoes, potatoes, cabbage and green peppers. And occasionally mushrooms. A meat counter where you can buy chicken feet, ox liver, chicken hearts or the extremely unpopular, and therefore only 50p, fillet steak (guess what we're living on).
My favourite finds so far have been in the pharmacy and cosmetics aisle; the "grandpa" headache tablets (perfect gift for Deyo's upcoming 30th) and the SA brands of body lotion (called "lovely") and deoderant (called "she smells great").
And then the checkouts, where the Zulus insist on standing pressed against the person in front of them in the queue, in case anyone should attempt to push in (their queue avoidance does at times offend my British sensibility).
And finally the delightful security guard who checks all reciepts before you can exit the supermarket.

We tend to buy our bread and vegetables from the roadside stall. The friendly lady who runs it is a younger version of the WRVS women (every day the same items will cost you a different amount and your change will bear no resemblance to what you expected. But I think it probably evens itself out). She always has a smile and her small son is adorable.

We also have two random Chinese shops which sell a selection of electrical goods and cheap clothing. These are run by two Chinese families who appear not to be able to speak Zulu or English and all live together in an interesting take on friendly competition.

And there is Fancy Stitch, our art-gallery/tearoom which sells products stitched by local HIV positive women (for whom it is often their only source of income) and will I suspect be my source of cards and gifts for the year. They are actually currently running an exhibition at the Brunei Gallery in London (9th Oct- 12th December) which would be well worth a visit. My favourite of their gifts is the wooden olive spoons that they sell. In a village where you can't buy olives.

Got the power?

The quiet weekend in Ingwa is not going quite as planned; today was supposed to be a chilled out brunch with all the girls and then an afternoon of lazing in the sun. But it's raining. And we woke to no power (and all the houses have electric ovens). Fortunately one of the houses also has an illegal gas stove so we piled over there and cooked up a feast of sausages, eggs, pancakes and fruit. Yum!
As for the lack of sun, my other task for today was to update my e-postfolio and justify my existence here (to the London GP deanery), and the weather might encourage me to do that (after I've e-mailed, facebooked and updated my blog for the 2nd time in 2 days...). Thank goodness the laptop has good battery power.

Friday, 9 October 2009

Keeping your hands inside the vehicle.

Last night's on call has left me broken; more so than normal as it started with a full on assault from a psych patient which left me limping around with scratches all over my stomach (and some bruised pride as the nurses had told me not to go too close). I ignored them, thinking that this poor confused old man just needed a gentle talking to, sat down next to him and utilised my extremely limited Zulu to tell him to relax ("tambisa". It's an amazingly useful phrase; anxious patients, surgical patients, obstetric patients but apparently not psych ones). Next thing he announces, in English, that he does not want to tambisa, he wants to hit me. And does.
Fortunately he is bed bound so I just had to bid my escape to more than an arm's length away before arranging some sedation.
After that and the obligatory 4 hours of broken sleep I am really looking forward to my quiet weekend in Ingwavuma with nothing more exciting than an inaugral trip to church on Sunday to disturb my peace.

Monday, 5 October 2009

Raining men.

So, typical time off; back one day and it doesn't feel like I've been away. Mind, having a week off in the pouring rain in SA didn't feel like I was away. From Scotland that is. But seeing the most amazing wildlife (hippos, elephants, rhinos, giraffes, zebras and not-deer) more than made up for it.
But now I'm back in Ingwa and as I sat in the blazing sun having lunch, it all seemed a distant memory.
Have come back to our merry band of 10 doctors (a mere 11,000 patients each) being down to 9 (a brief calculator use later and that's 12,222.2 each now. Doesn't seem that different really). With no sign of any replacement. Actually, there is sign of a replacement (a girl who used to work here who wants to come back for a few months) but they're not sure if there's funding. I'm sure it's more complicated than it sounds but surely if we needed 10 and were paying 10, we still do and can? But that's why I'm not in management.
The plus side of the reduced numbers is that it has opened up a ward of my very own. The male ward. I'm really looking forward to getting to know the staff well and making small changes to improve the running of the ward. Today's suggestion was that maybe we should put all the sick patients in one area of the ward, near the nurses station and that I should see them first on the ward round... Baby steps.
You have to bear in mind that this is the ward that last week managed to tell a family that the relative that they had come to visit had died.
When he'd actually been transferred to another ward.
This only came to light when the family came back on the Friday to collect the death certificate in readiness for the funeral they had arranged for Saturday. And now the poor guy is still with us for fear that if he'd gone home over the weekend, they'd have freaked and thought he was some sort of spirit.
This certainly isn't something I've faced before.

Thursday, 24 September 2009

One in the eye.

Well, I managed 29 safe days in Ingwa but today I had my first blood exposure incident.
Not, as I had expected, a needle stick injury (yesterday I was doing LPs on HIV positive patients with the electricity flickering on and off), but actually blood in my eye. Nice.
Half-way through a c-section (baby was out and I was attempting to rejoin the two halves of the uterus) I managed to flick blood under my eye shield (why out here are the shields attached by elastic around the forehead leaving them loose over the end nearer the patient??) and in to my left eye.
Following the "rinse it" procedure I promptly welled up, with added lip trembling and voice shakiness, and told the anaesthetist. I guess the plus side of being here is that he could then scrub in so that I could go and properly rinse my eye (and the other one for good measure). Unluckily we have a 25-35% HIV rate amongst our pregnant patients (the group we routinely test).
Rapidly checked her notes and then some internal debate went on; she was last tested 6 weeks ago and was negative (phew!), I wear contacts, surely women who are 8 months pregnant don't do a lot of sleeping around (help me out here placenta head girls?), it's actually quite difficult to get HIV in this manner and PEP (post-exposure prophylaxsis) makes you feel incredibly nauseous and generally rubbish. So I'm not taking it. This time.
What a great start to my week of annual leave; heading off on a game park/beach trip to think about what I have done.

Wednesday, 23 September 2009


So bloggees, it has been a week since I last posted, but I have a good excuse; I have been living it up in the big city. Yes, after 5 weeks here, Deyo and I cracked and headed for Durban. We were also booked on to an HIV/TB/STD course, as an aside.
The 5 hour drive down was a testing time (I re-discovered that I have a Y-chromosome when it comes to being directed; "what do you mean, 'I think this street leads in to that one', you have the map" and "why are you turning the map around?") but we finally arrived at our hostel late Thursday evening.
Friday, Saturday and Sunday were spent on the course learning the theories of diagnosis and management (I say theory as the concept of holding off TB treatment until you have a positive culture, when cultures take 6 weeks to come back and the patient in the meantime is infecting the 12 people they live with is just not practical) by day (with a couple of early finishes which allowed us to hit the beach...) and getting to know the other doctors and the bars of Durban by night. Was interesting meeting other doctors, many of whom are also foreigners working in rural hospitals, and comparing notes, but also frustrating at how common some of our experieneces are.
The weekend also provided us with our first true SA experience when our hostel was robbed (despite the electric security gate). Fortunately our room was left untouched but it reminded us that as protected as we are in Ingwa, where we can leave our door open, the rest of SA is still risky. A scary reminder to be fore-front in our minds as we drove back up our little pot-holed road to Ingwavuma in the pitch black. And blew a tyre. Now, I pride myself on knowing the theory of tyre changing, but in the pitch dark I was less sure. And just as we were debating how much damage it could do to the government car if we drove an hour home with a flattie, a car pulled up. An even rapider debate occurred as to whether we ought to flat wheel-spin off (both Deyo and I were thinking of all the assault and rape cases we've seen in the last 5 weeks) but another car also stopped and a total of 5 very friendly Zulu men surrounded our car, sympathised with our situation, were amazed that we actually had a spare tyre and rapidly sorted us out. A very pleasantly surprising outcome, but not one we shall rely on.
As we invest in our own car, I think we'll be investing in a hefty torch and some decent breakdown cover!

Wednesday, 16 September 2009

Shiver me timbers, I'm 28!

You'd have thought that I'd have learnt from Oz that expecting very little from your birthday inevitably leads to an excellent day, but no, I was yet again preparing myself for a miserable day, far from home (small violins at the ready). In reality it was a great day from start (discovering a birthday present in my pigeon hole at quarter to twelve on the 14th- thanks mum and the SA postal service, a mere 11 days!) to finish (10.30pm drunkenly putting myself to bed).
Was a little unsure about the fun of being on call on the night before your birthday but I lucked out with 4 hours straight sleep, and the trade off was having the afternoon off on my birthday. Headed to Fancy Stitch Tea Garden (oh yes, Ingwavuma has an eating out option; although I believe we are pretty much the only people to ever go there) for a long birthday lunch in the sun with various doctors, therapists, teachers and others.

I'm fast learning that no SA celebration is complete without a braii and my birthday was no exception; a "Pirates and Princesses" fancy-dress one. Cue plentiful homemade costumes (I take full responsibility for any world shortage of tin foil), some illegally smuggled in wine (as we live on hospital property we are not supposed to have alcohol and we get searched coming in. However, security happily come to our parties and merrily drink any that we have got in. So South African.) and copious well-done meat. Oh and my present from Deyo; an array of beautiful little cupcakes (one of which I secreted in a cupboard to ensure that I did get one, then forgot and discovered it to my surprise and delight today. Yummy!).

Sadly the other thing that I discovered today is that too much buccaneering the night before is not conducive to a pleasant day in OPD. Unlike myself, hangovers do not improve with age!

Sunday, 13 September 2009

Oh deer.

So, it finally happened. After 4 weeks in South Africa, I have seen an animal bigger than a monkey (that isn't a cow or a donkey). Having worked last weekend (and Deyo having decided to stay behind and be my personal shopper and chef) we felt like we really needed to get off the mountain this weekend. And luckily two of the other girls obliged with a trip to Pongola Game Reserve. A fairly upmarket private game reserve, we enjoyed a sunset cruise on the Pongola river (complete with sundowners), drifting amongst crocodiles, hippos, and a variety of exotic birds, whilst various not-deer and warthogs watched us from the bank (the SAs were amused at my insistence that I had spotted a deer and pointed out that there are no deer here. So not-deers it is). We also spied elephants from afar and girrafes from not so afar, having to stop the car to let them cross the road in front of us. An evening of braii fun of the afore-mentioned not-deer and poker with the guides and then a day in the spa today and we're like new people (particularly our feet which being permanently in flip flops/ slops, are becoming increasingly hobbit-esque).
We were a little taken aback by some of our fellow-guests who it turned out were on a weekend's hunt. Something the park allows as there are no natural predators to the animals (they have no cats) and the money brought in by the hunting goes in to conservation. Shockingly the list of available animals includes rhino, but the starting price of 250,00R (plus a cost per inch of horn) is inhibitory to most. It made us think twice before pointing out animals from the breakfast balcony in the morning.

Wednesday, 9 September 2009

Stemming the tide of the comfort-eating muffin-top...

So, you are now reading the blog of Ingwavuma Running Club's newest member. Well, strictly speaking it's more of a jogging club. And I think calling it a club is a bit overambitious, but it is a group of people (and not even all people who work at the hospital!) who meet and go running. Some faster than others. Personally I'm blaming the altitude. And we're working towards a goal; the Ingwavuma Half Marathon in October. 7 years in Newcastle and my first half marathon is in South Africa. Why aye indeed pets.

Bloody 'L'.

Today's scary thing wasn't medical. It was a driving test. Not something I was expecting 10 years after first passing my test, nor when I am currently in possession of not only a full, clean British license, but also an international one (available from the AA for only £7.99 and the cost of a photo but that's not the point). But apparently, that's not enough for Mosvold hospital Transport Department.
Let me explain why they care. Twice a week the hospital runs clinics in outlying areas (one so far away that we used to go by plane but sadly they cut the plane a couple of months ago. Something to do with costs I think. Now we just drive there). Access to these areas is pretty bad so they don't send us off alone in cars. They send us off alone in 4x4s. We can also borrow the hospital vehicles for approved trips out, like our HIV course in Durban next weekend. But to be allowed to drive these government vehicles, you have to be ok'd by the afore-mentioned Transport Department. Hence the driving test.
We'd already gone through the bureaucracy of having to get certified photocopies of our passports and licenses. No, showing them the real thing and allowing them to copy it wasn't enough. Instead we had to take them to a local public notary (oh yes, notaries, I've come across these before...) who didn't look at the originals before stamping the copies as accurate. Then today's test.
Was feeling a bit nervous; would the bad habits that I'd picked up over the years count against me? Walked over to the normal car (yes, I know that the test is for whether we can drive 4x4s but this is SA, why would they test us on that?). Got in, carefully adjusted the seat and mirrors, checked the mirrors (in the very obvious way that you're supposed to), slowly reversed out, checked the mirrors, then horror of horrors, crossed hands on steering wheel. Damn. Carried on, out the hospital down the mountain. Would I be penalised more for driving on the wrong side of the road or for going through the tyre-busting pot holes? And what about avoiding goats, pigs and dogs? I know in the Uk you're supposed to keep going straight at them but I don't think the South African livestock are aware of this rule. Longest driving test ever although admittedly we did only go straight down the one road for half an hour, turn around and come back. No emergency stops, 3-point turns or reverse parking in sight.
And I passed! The only comment I got was that there was really no need for me to slow down as we approached the group of children walking on the road (there being no pavements) because "they'll get out the way".
So now the outlying clinics await.

Saturday, 5 September 2009

What it's like when you have a baby?

36 hours in to my first weekend on call. I've had a grand total of 2 hours sleep overnight (when I was first on) and 4 after getting home this morning (I'm second on today). Called back in to do a c-section, interrupted by calls from the Paeds ward for a child who is fitting and the OPD for a snake bite. Offered to stay and help the first on but she assures me that I need to rest today as I'm first on again tomorrow (and may get woken through the night). I'm fairly certain that this is a form of torture used in interrogation, and I can see why. If there was anything they wanted to know now I'd tell them. Although I seem to be struggling to recall any helpful medical knowledge right now.

Thursday, 3 September 2009

Not exactly a piece of cake.

So, the first on call. Started well with a quiet afternoon, leading in to a quiet evening (I had time to come home and bake a cake, not something I've ever done before on call. But pretty useful as I took it in to bribe the OPD nurses. Some things really are international). Pottered back in about 9 to sort some things out and agreed with the nurses in OPD that they would ring me if anything urgent came in, or once there were 5 or so pateints waiting (not for "every Tom, Dick or Harry". Their phrase not mine). I would then come back at 5.30 to mop anything up before they hand over at 6. Came home, went to bed. And there it started to go downhill. A phonecall at 10 that I managed to deflect, then a call at 11.30 for a pregnant lady haing contractions and ?ruptured membranes. Went to see her, unsure of the baby's position so took her to scan and discovered one of the delights of the OPD at night; as many of the patients live a long way from hospital, if they are going elsewhere for an appointment the next day, they will come and sleep in the OPD the night before in order to catch the 5am transport. So to do the scan, I have to kick about a dozen people (including babies and elderly patients) out of the scan room. Wonder how sensible it is for the MDR TB patients to be sleeping in the same room as the babies. Fortunately baby is the right way up (or down really) so I send her off to the midwives. Deal with the minor injuries waiting and head back to bed about 1. Called again at 1.30. A really sick and gasping patient, GCS 7, massive ascites and hepatomegaly, previous diagnosis of ?a heart problem ?a liver problem. The neighbours accompanying are unsure of HIV status. So I jump in with a plan to do some obs (the nurses sometimes take some encouragement), send some bloods and get some x-rays. And discover that what appears to be limited resources during the day is non-existent at night. No bloods. No x-rays. It really is all on clinical judgement (guess work). Discover a blood sugar of 1, head in with some dextrose and he perks up a lot. Chuck in some diuretics and iv antibiotics for good measure and cross my fingers. Then do some stitching on the knife attack patient in the next bed (head and chest, I leave the hand for theatre in the morning). And it's now half past 3. Renegage on my originally agreement of half past 5 and tell them to ring me at 6 if there are any patients waiting. They ring at 6 to tell me there aren't. And my alarm goes off at half past to start the day. A morning of OPD (reviewing all the patients that I lodged overnight) followed by a well-earned afternoon off!
Apparently this does count as a busy on call (phew- I'd been thinking that if they were all like this I wouldn't survive the year!). Let's hope this weekend (my first weekend on) is better.

Apologies to non-medics for medicalisation of this post but I'm sort of hoping some clever doctors might be able to send me suggestions of what else I could have done for the poorly patient. He's now alert but still massively swollen up with an ECHO (USS of his heart by me) that suggests poor contractility.

Sunday, 30 August 2009

Doesn't matter if you're black or white? Alegedly so.

Another weekend, another trip away. As I am working next weekend, we thought we'd make the most of this one. And we needed to get to a bank as without accounts, we aren't going to get paid. So, a trip to Jozini, the nearest town. An interesting experience for both Deyo and I. Finding myself the only white in the town, and the attention that attracted was a strange experience. It wasn't in any way a threatening one, just a feeling of being different and people noticing that. Deyo's take on it in comparrison to her own experiences as a black person in Edinburgh made for interesting discussion.
We then headed a couple of hours on to Sodwana Bay which is a holiday resort in the area, popular with Jo'burgers and their 4x4s. It's just down the coast from the beach we went to last weekend, but nowhere near as beautiful, with the beach torn up by vehicles. And funnily enough, there too we had an interesting experience. All the guests were white. And all the staff black. And I felt more uncomfortable with that than I had at any point in Jozini.
We both agreed that we have much to learn about people's attitudes in South Africa, but the voluntary segregation that we are already seeing is disturbing.
On a less thoughtful note, we joined up with a group from the hospital for body boarding and the obligatory braii. And we're now back at Mosvold preparing for another week and our first on calls.

The best meal we've had so far.

Friday night we recieved a dinner invite from Vuma, one of the nursing students here. She took us to her home, across the road from the hospital. It is a small cement builing consisting of a bedroom, kitchen area and living room, in total smaller than my room at the hospital (about 4x4metres). She and her husband built it 5 years ago when they moved to the area and they now live there with their 5 year old son and two older girls that they have 'adopted'. It's a very interesting dynamic that we're discovering here; people who really have very little themselves will share that with others who are needy, in this case the orphaned daughter of a relative and a neglected neighbour's child. She made us an amazing dinner of local zulu food (curry and a sort of rice/cous cous made of ground meal) which we ate by candle light, there being no electricity. It was an amazing insight in to how people live (particularly bearing in mind that with Vuma working at the hospital, they are considered to be on a good income) and in to why so many children come in with burns.
And also a stark reminder of how lucky we are in the opportunities we have had in life.

Natural selection?

So, as well as being the evening for declaring my love for Thembe, Thursday was also my first, second-on on-call. Let me explain. Every day one person is the 'on call', this means they hold the mobile phone which all the outlying clinics ring for advice and from 4.30pm until 7.30am they are called if anything requiring a doctor occurs. And remember this is a hospital that has 7 wards (Paeds, SCBU, maternity, male, female, TB and isolation) as well as being the local casualty. As one of the things that is often required overnight is a c-section, there is also a second on who gets called for those, and also for any major incidents. Actually, as we pretty much all live in, I think we'd all be called if there was a major incident. The person who is first on then works a half day the following day, finishing at 1.30pm. Oh yes, a 30 hour shift. Eat your little EWTD hearts out!
Anyway, shortly after my love decleration, my phone went off. The 32/40 PET lady with deep variable decels on her 10 minute CTG trace who we'd been planning on transferring to the nearest specialist centre, a mere 3 hours down the pot holed road, was now flatlining (for non-medics, a lady who was pretty sick with a premature baby had just got a whole lot worse). So we'd decided to section her.
I was to be the anaesthetist. And the paediatrician. Caring for two quite unwell patients at once. Scary biscuits. Not as scary however as when the baby came out looking pretty ropey, breathing a lot faster than is normal and grunting away (not good). I'm going through my usual resuscitation procedure. And then some. And I suggest to the surgeon that I attempt to intubate to give the baby some medicine directly to the lungs to help it's breathing (not something I've ever actually done before but I've seen it done and I'm learning that that's what counts). And he looks blankly at me. "Surfactant?". When I explain, he replies that we don't have that. So I suggest CPAP (breathing apparatus). We don't have that. I decide to just ask what we do have. Just oxygen. By nasal prongs. And a warm room. So that's what we do. Miraculously the next day, the baby is still alive and looking perky. The midwives assure me that "black babies are a lot tougher". And apparently it's true. They kind of have to be.
Interestingly enough, there is a plane that we can call for to take babies to the bigger centre. But it only flies between 8am and 3pm. On sunny days.
Fortunately that was it for my on call and I slept until morning. And then did a full day in clinic. Not looking forward to my first first-on on call on Tuesday.

Thursday, 27 August 2009

A reason to never leave Ingwavuma.

Her name is Thembe. And she's our cleaner. She comes once a week, cleans our house from top to bottom, polishes our floors, changes our sheets, hand (yes, hand) washes all our clothes, and irons them too. And for this we pay her the princely sum of 100R (about a tenner).
I think I'm in love. (although having your underwear handwashed and ironed by someone else does feel a tad strange)

Tuesday, 25 August 2009

A wealth of experience.

So, I'm delighted at how many geeks there are out there bothering to read this (I can see how many times my site has been viewed, now who's the geek?!) and really touched by the comments you're leaving.
It's weird though because in some ways I don't feel like I'm touching on what's really happening or what I'm thinking or feeling about things. But that's because I'm not really sure yet what I think or feel about things. So it's hard to write it down.
Last week we went for a quick drive outside of the hospital. One of the girls was explaining that 50 metres down the road from the hospital, running water stops and at 100 metres electricity stops. So for many of my patients, the house I described as basic, is in fact luxurious.
And today I had a trip to Welfare, which is the local social services. Once a week, one of the doctors goes there to decide which patients get disability grants. There are really no hard and fast rules about who should get them and it seems very much up to the individual to decide what makes a patient deserving of the money. I found it hard watching patients ill with HIV and TB being turned away as they had already had 6 months DG. Especially in the knowledge that for many families, one person's DG is the only income they have. I fear that I am going to be the weakest link in Welfare.
I joked a lot before coming out about this year making me a 'better person', but I think it would be very difficult to come back unchanged from this experience. And I certainly don't think that's a bad thing.

Sunday, 23 August 2009

Not exactly Mozambique, but pretty damn good.

A weekend off. Something that I am soon to appreciate as pretty precious I think. So we made the most of it. Saturday we unfortunately went to an amazing, beautiful, empty beach, lolled around in the sun (25 degrees, and it's winter!), braii'd and body boarded to our hearts content.

I say unfortunately as it was also the Zulu King's daughter's wedding in Ingwavuma this weekend (there's long been dispute over the border with Swazi so the king built a palace up here and installed his 6th wife). And there were rumours that Jacob Zuma would be attending. And maybe visiting the hospital. I was desperate to attend the royal wedding (it is a free invite system) but the more experienced hands out here advised that they can be rather painfully long experiences where you want to sit at the back but that if invited to sit at the front by the king, it would be rude to refuse. So the beach won. And it was a great day.

Today (Sunday) we checked out the alleged border with Swaziland. According to Google Earth, it's at the top of the dirt road leading to the mountain edge but locally it's thought to be the bottom of the mountain. So sandwiches in backpacks, we hiked all the way down, taking the 'coffin route' (lots of our patients come from Swazi but, if they die, it's very expensive to repatriate the bodies so they carry the coffins down the very steep path). There we picniced and then hiked back up again. So I've officially and illegally been to Swazi.

Thursday, 20 August 2009

Whatever happened to see one?

Wow, the first week is almost over. Not soon enough. We are exhausted in the way that new jobs always are, but a million times more once you throw in the moving country, foreign language and lack of your normal back up support network.
Yesterday was my second day in theatre. Quite an experience. There are always 2 doctors on for theatre (one to do the anaesthetic and one to do the surgery!) and I was in with the boss which I thought would be good for experience but turned out not to be as he really is a believer in sink or swim. And despite my total inexperience, he was keen for me to 'give it a go' on the caesarian front ("just do whatever you think"). But now I've done two c-sections almost unaided. Could have been a third today but I drew the line at my first breech c-section also being my first twin section and my first vertical scar. So I assisted one of the other juniors. And now I've seen one...
It's just so different to home. I think I'm almost going to have to stop comparing. With the twins today, we had only two junior doctors and a med student in theatre for what at home would have required at least 5 doctors (2 O&G, 2 Paeds and an anaesthetist), 3 of whom would have been more senior than anyone we had today. And normally we'd only be two doctors; one to operate and one to do the anaesthetic and resuscitate the babies. Luckily everyone was ok (patients and doctors!!).
I then spent today in OPD which would be the equivalent of A&E/ the local GP, and is our main work. Saw a total range of things from someone needing physio after a hip fracture to a abdominal gunshot wound. Finding it so hard to figure out not only what to do with things I'm inexperienced in but also what to do here with things I would know what to do with at home.

Anyway, one more day and then it's the weekend and there's talk of a trip to Mozambique. I think both Deyo and I are feeling the need to get out of the hospital and remind ourselves of the positive things about coming to SA. Mozambique is definitly one of those!

Monday, 17 August 2009

The end of day one.

Ok, rather hastily posted last blog (due to rush to get to afore mentioned Survivor evening of fun). Two things: 1. I can spell anaesthetics. And soon will be able to do them too... 2. Apologies to anyone who may have recognised any part of an e-mail there. Cut and paste-tastic.

Survivor itself is missable (think an American version of Shipwrecked) but the evening was fun with plentiful tea and cake (it was one of the med students b'days) and chat. And an early finish so that everyone can be in bed by 10pm. Really. They argue that it's necessary for the 7.30am start, but with no commute, I'm not sure I need that much sleep. Nor should I get used to it if I'm ever to survive London again.

Day one at Mosvold Hospital

Mammoth journey later and we arrived. The chat in the pick up tailed off as we drove closer and closer and Deyo and I were fairly silent by the time we arrived. And deadly silent when we saw our new home for the next year. Basic is one word that springs to mind. Clayton Road are two others for those who ever saw the place.
Our hospital boss Daniel came to meet us. And scared the pants off us by asking about our surgical and anaestheitc experience. Erm, none.

First day today was all a bit daunting. So many people with really unfamiliar names, a huge hospital ground in which to get lost (twice) and scary new medicine.
I've been placed in Paeds which was reassuringly familiar in many ways (bronchiolitis, gastroenteritis) and not in others (an 8 year old with kaposi's). Also had my first theatre session; a D&C and a skin biopsy both of which were fine. Unnerving to discover that the anaestheitc options are a spinal or sedation with a diazepam/ketamine combo. But apparently if I want to play around with the propofol and iso I can... The anaesthetists do make it look very easy at home.

The people seem very nice which certainly helps. There's 10.30am tea in someone's house evry day. And we're going round to someone's house to watch "Survivor" tonight; apparently it's the Monday night social. Quite taken with the idea of everyone socialising, but then I found out that Wednesday's social is bible study group. It's certainly not Desperate's.

Friday, 14 August 2009

The penultimate day.

So it's the day before I fly.

My whole life for the next year is next door, packed into two bags (plus some maxing of hand luggage).
In just 48 hours I'll be landing in Durban, picking up my "bag of books and doctor's coat" and driving 4 hours to my new home. And I'll be starting work just 12 hours later.

Still doesn't really feel real. Not sure quite when it will.

Have been giving it the "I'm going to keep a blog" chat for some time now but finally pulling it together for the purposes of giving me something to do with myself, giving me something to look back on and letting my mum know that I am alive. It's also the alternative to those awful send-all e-mails.

So here it is, read as you wish.

Some links for you:

You really can find out about anything on wikipedia.,_KwaZulu-Natal

Possibly a little stalker-ish but this is the link to some med student's elective photos of Mosvold Hospital. I'm thinking my through-my-phone e-mail connection may not allow fantastic photo uploadage so these are an alternative. And she has put them on the web...