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.

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!).

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.

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.

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.

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...

Goodbyes.

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.

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.

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.

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...