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.