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.

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.

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?

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...

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.

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.

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!