Wednesday, 16 June 2010

How to alleviate middle-class guilt?

The other emotion complicating things is guilt. When I first came out, a year seemed a really long time, but now that it is nearly over, I can see how short it really is, and how I am only just getting settled and beginning to understand how life here works. And I feel terrible that just as I get to this point, I leave, abandoning patients and staff.
What this rural community needs is doctors who can commit to them for a long time. Young foreign doctors aren't the solution.

Fortunately for me, someone previously had an idea for a solution and set up "Friends of Mosvold", an organisation that sponsors local kids through health-related courses at university, on the proviso that they commit to coming to work at Mosvold in their holidays and for a set period after qualifying. These are the staff who not only understand this community (literally speaking the language) but are also the most likely to settle here.
It's an amazing organistation that I have personally seen benefits from (our lovely social worker is a graduate of the scheme and due to marry and settle here in a few months time).

Watch this space for a way for me to alleviate some of that guilt...

End of a year-a.

The day after our leaving braai, and our final day (bad combination?).
Last night was a lot of fun with all the nurses, doctors, therapists and security guards coming round for a braai. It was Zulu-style, with plenty of meat and pap, quaito music pumping and some serious booty shaking. Some serious heaadaches today too.
As today is a public holiday I only worked until 12 but what an almost final case; an imminent pre-eclamptic with a blood pressure of 211/143. Yikes.
Once that was sorted and she was rushed off to theatre (luckily I'm not on for that) I just had a few dog bites to vaccinate against rabies and I was done.
And now I am finished at Mosvold (with only the procrastination over packing to get through).

I have quite mixed feelings about going; I shall really miss some aspects of life here (my two minute commute, people just popping round unannounced, everyone saying hello to you). But it's time for me to come home. I miss family and friends and realistically, coming here has meant putting life on hold in many ways, and it's time to come back and restart it.

Sunday, 13 June 2010

Feel it, it's here.

So, the World Cup has begun. And how.
It felt like it had started some time ago with all the countdowns, huge numbers of distinctive yellow Bafana Bafana tops (mostly fake) and Wednesday's "5 minutes of blow your vuvzela for SA" (with lots of warm up going on in the days before...). However, on Friday I realised that I hadn't seen anything yet.
We made a last minute dash to Nongoma to watch the opening match on a giant screen erected in the college, with a hall full of thousands of yellow-clad Zulu fans screaming and blowing their vuvuzelas like crazy. The atmosphere was incredible; so friendly and happy and just bouncing.
On Saturday we moved on to a rural fan park in Mtubatuba which did not live up to the dangers predicted, helped by there only being about 30 people there (and about half of them were security). Not sure if it was a lack of interest in Korea-Greece or in the fan park.
It was on to Richard's Bay for the Nigeria-Argentina match where we were taken aback by the lack of interest in the football from the Afrikaaners (at one point, someone was sat in front of the screen). I think rugby is more their game.
So in the end we headed to Durban for the England match where we were joined by thousands of Australians in town for tonight's game. The vibe was incredible, the whole town alive and pumping.
The next month looks to be amazing, and I'm excited to be here for it.

Oh, and I found that blowing a vuvuzela is a lot more difficult than it looks.

Wednesday, 9 June 2010

Ups and downs.

The end of our time here is rapidly approaching and I'm surprised at the very mixed feelings I have about it. A year ago when we arrived, I couldn't imagine lasting 6 months, let alone a year. Let alone be feeling in any way sad at the idea of leaving.
Driving back from clinic yesterday, sun shining, bumping along a red sand road and waving to all the kids running alongside I realised that London will seem very grey in comparisson to life here. I also feel very settled; last night we had "xmas in June" and as we sat in our party hats eating xmas pudding, I realised that I will really miss a lot of the people I have met here and the social life we have.
Fortunately, when I got in the shower, I was reminded of some of the downsides of living here; not only did I have to manouvere myself under a small dribble of hot water but when I reached for the shower gel, I had to have a stand off with a preying mantis.
I lost.

Wednesday, 2 June 2010

Not quite feeding the world.

Like parents, doctors probably aren't supposed to have favourites, but I do.

Nkosinphile is a 13 year old boy with learning difficulties who had a prolonged inpatient stay back when I was running male ward (oh yes, anyone over 9 years is no longer a child- if they can't sleep in a cot, they have to go to the adult ward). He'd come in with severe burns to his legs requiring skin grafts, but it then transpired that there was a fairly dire home situation. He and his 3 younger siblings were orphans under the care of an uncle who found Nkosinphile too difficult to manage so had farmed them out to an old gogo who wasn't really able to take care of the kids.
The social workers spent a long time negociating with the family, during which period Nkosin charmed everyone in the hospital, getting them to play ball games with him and eating so well that we had to find him some new clothes when he went home as he had gotten too fat for his own.
Eventually it was agreed that the family would build a hut about 200m away from the family home for the kids to live in, and they would pay a slightly younger gogo to stay with them and cook for them.
I visited the hut with the social workers as it was being built. It was a concrete two room affair, each about 4x4 metres, one large bed and some cooking utensils and a separate hole in the ground out the back to serve as the toilet. Quite a nice place by local standards. Once it was completed, the children moved in and a week or so later I saw Nkosinphile at his local clinic. He looked happy and well and was keen to play ball games.

When we drove by his hut today it was a very different story. He was sat outside, dirty and dishevelled with weightloss to make a WeightWatcher envious . He was with his younger brother who had had to stay home from school to look after him as the gogo hired to do so had gone off to visit someone. They told us that she only stayed with them during the day, leaving Nkosinphile in charge overnight. They also showed us their kitchen area where there was an array of empty shelves, their uncle who is supposed to buy food for them apparently isn't.

It was heartbreaking to see the dramatic changes in Nkosinphile and even more so when he, who had been desperate to come home to his family, asked me to take him back with me to Mosvold.
The social workers have made a plan to find a place of safety for him but in the short term, all I could offer him was my lunch for the day, which he gratefully took. It's not really a solution ("give a man a fish...") but faced with a child who is literally starving, it felt like the best thing I could do.

Monday, 31 May 2010

All fired up.

This weekend we headed down in to Swaziland for BushFire, a three day music festival. Essentially it's a mini-Glastonbury but with African bands and a much better shower:camper ratio. It was a lot of fun, lazing around in the sun listening to local bands and then dancing until dawn in the crop circle, before crawling in to our tents.
It also lived up to the ultimate festival expectation by pouring with rain on the Sunday.

Wednesday, 26 May 2010

Smelling a rat.

This week's issue is that of unwanted house guests. Or more specifically attic guests. Rats.
We've been gradually aware of increasing noises from above our heads but this week it has got to the point where it is waking us up in the night (and I'm living in fear that the ceiling is going to give way and they'll come crashing through) and on Tuesday night's braai, one of them made an unwelcome appearance in our paw paw tree. At head level.
Fortunately the hospital kitchen also has some unwanted guests; a cat and her 4 kittens. And I think I can see a solution to both of our problems.

Tuesday, 18 May 2010

Not exactly a partridge.

So Sunday's comedy case; I got called to see one of our Kwazihambi (the place where women in their first pregnancy go to wait out the final few weeks before they deliver) ladies as she had a painful ankle, having fallen out of a tree. Whilst picking avocados. At 39 weeks.
She looked suitably sheepish. And was fine.

Sunday, 16 May 2010

Life and death.

An unbroken night's sleep and I'm much less grumpy.
I've had some sad news from yesterday- a lady whose labour I was augmenting delivered a flat baby and despite all resuscitation efforts, the doctor on yesterday was unable to revive it. Labour is a dangerous time anywhere in the world but the risks here are definitly greater as we don't have the facilities to monitor as closely as we would like to, nor to act as quickly as we should.
On a happier note, when I went to Paeds ward, I found that all 3 of the babies who were dicing with death yesterday are improving.
Sadly the one who had the enema, whilst less acidotic and more likely to survive, seems to have some neurological deficits. We will have to wait to see how things progress, but it may well be that some permanent brain damage has been done.
When I consider that the child had made it safely through the dangerous delivery period only to be potentially disabled by well-meaning relatives, I am again frustrated at how hard it is to change a community's beliefs.

Saturday, 15 May 2010


Oh, and I forgot to add that whilst struggling with the cannula for the enema-poisoning child last night, I suggested to the second on doctor (one of our community service doctors; 3rd year post qualification) that perhaps we should call our third on (normally when two junior doctors are on call together, a third, more senior doctor is available for dire emergencies). It was then that we realised we don't have one. So yours truly is the most senior doctor in a 100km radius. Quite a scary thought.

A post-call rant.

On calls can, like at home, be so variable. But this one is a bad one. I barely slept last night and am totally exhausted. But I am also just tired of some of the things that happen, or don't happen here;

It all started at half 3 yesterday afternoon, I was just sending everyone else home early as the department was quiet (almost unheard of) when a rape case arrived. I began by counselling her on her risks of exposure to pregnancy, STIs and HIV and prescribing her appropriate prophylactic drugs for all of these, only to discover that we don't have emergency contraception in our emergency drug cupboard. And with the current pharmacy situation, we don't have an on call pharmacist. So I was faced with using an unlicensed (and less effective) treatment or having the poor girl wait 60 hours for contraception, by which time it's effectiveness has greatly reduced.
An hour later, I was finally completing the rape evidence kit when maternity rang to say they had a cord prolapse. This is an absolute emergency and involved rushing the woman to theatre for a c-section. In the UK, the baby would be out in a matter of minutes but here there can be difficulty impressing such urgency upon staff and everything takes longer. When we finally got the baby out 45 minutes later, he reassuringly cried and I hope that the delay hasn't adversely affected him.
During the section, the theatre sisters enquired how maternity was looking as with no water this week, we haven't been able to sterilise and so only have enough theatre sets for 3 c-sections. Apparently we are unable to borrow these from our nearest hospitals, so have to wait for a central supplier to send some out.
Just as I was closing up, the OPD sisters came to seek me out to tell me that they had a baby with enema poisoning who was shut down. This is a common problem here; people believe in using them on everyone, even very young, healthy babies, and they use anything from herbs to washing up liquid. This can create terrible imbalances in electrolytes causing respiratory compensation and often ultimately death. We actively discourage it but are fighting against a commonly held cultural belief. Ultimately it is child abuse and potentially man slaughter.
An hour of struggling and we finally managed to get iv access in the baies scalp to give fluids to try to combat the imbalance but the child is still very sick.
My final frustration came at 3am when female ward phoned to tell me that a patient had died. She was a 57 year old lady who had been admitted last weekend. When I saw her on Wednesday it was apparent that she was bleeding profusely from her gastrointestinal tract. I rang our referral surgeons to arrange a scope where they could find the bleeding point and stop it. Sadly their scope remains broken and they could offer no help. We rang on to their referral centres in Durban but were told that they weren't accepting patients in readiness for the start of the World Cup. Despite all available medicines and blood transfusions here, the lady bled to death, with what essentially should be a treatable condition.

I knew when I came here that I was coming to a place with less facilities than I was previously used to but I find that 9 months on, I am still totally frustrated by this. Particularly when it seems more logisitcs than just money that is affecting patient care.

Thursday, 13 May 2010

Treading water.

Our perinatal meeting this morning revealed that last month just over 10% of deliveries were to mothers under 18. This is fairly standard for here but pretty shocking compared to the UK. And in addition to all the added complications that young mothers face, in view of our 30% HIV rate in pregnant women, a sad inditement on HIV education in young people.

The meeting then turned to a discussion on ways to decrease this. There was quite a lot of support for encouraging abstinence amongst young people, something that I personally think is an unrealistic solution.
We also discussed increasing access to healthcare (and therefore contraception) in an open and non-judgemental way. One of the problems of the whole local community recieving healthcare at a clinic is that the teenagers face a lack of confidentiality and the judgement that goes along with that. I am keen that we recognise that teenagers are having sex and tackle the unprotected nature of it. We need to increase our school-based health education programmes but we are hampered in this by an education minister who is set against the provision of condoms in school.

Sometimes I just feel so frustrated that we seem to only be managing problems here rather than looking for solutions to these problems.

Monday, 10 May 2010

Fishing for compliments.

Another weekend off, another border hopping adventure to Mozambique. This time we headed further up the coast to a more secluded beach resort where we shared our unending white sand beach with a handful of people and yet again, ate prawns until we were sick.
However, the highlight of the weekend occurred on the dance floor of Pintos where we were initially mistaken for South Africans by a couple of UK medical elective students, and then when we set them straight, and exclaimed over the medical coincidence, they asked if we too were elcetive students. Made my night.

Resigning ourselves.

So the leaving process has begun; we handed our resignation letters in and have begun to fill in the endless forms that claiming our pensions back involves. We still have a couple of months to go but in the strange way that time has I suspect it is going to fly by (whilst the first couple of months here felt like a lifetime).

Wednesday, 5 May 2010

A cop out.

The bit of my job that I least enjoy here is the role of police doctoring that is forced upon us. So far I have avoided having to do any post mortems, but we see all the assault cases, rape cases and child abuse cases. All of these come with specific forms to be filled and sample kits (that involve swabs being folded up in boxes that require a high level of origami skill) that take a frustrating time to complete. What I find most frustrating though is how unqualified I consider myself to be to be completing these kits (goodness knows how many samples of my DNA I have accidentally provided) and writing down whether I feel a person's injuries could be consistent with their alleged assaults. The knowledge that my opinions can have huge implications for these people's lives in terms of prosecuting is overwhelming.
I also feel that it isn't entirely appropriate that we are seen as part of the police service (taking blood tests for drink driving and rape suspects). As doctors, patients should feel that they can trust us, that we act only in their best interests, as we have sworn to do.

A bum deal?

The long weekend was put to good use with a quick getaway on Friday to St Lucia. There we fully indulged gender stereotypes with the girls going horseriding and the boys going deep sea fishing. Given that we got to eat amazing fresh fish without a 6am start or a dose of sea-sickness, I think we had the better deal, but there again the boys were able to sit down for the braai...

Thursday, 29 April 2010

The ultimate post-code lottery.

Another Thursday, another on call (but I don't complain too much as it gives me a long weekend). Nothing too drastic so far but I have just been to confirm a death on the Isolation ward. A 33 year old woman I admitted on Monday night. I noted that she looked very sick, likely TB, and admitted her for iv antibiotics and TB work-up. I see tonight from the notes that she deteriorated over the next few days, becoming confused. I was then called this evening to confirm her death.
The thing that gets me is that she was HIV negative. In a different setting, her level of care would have been escalated to a much greater level, and her chances of survival would have been good.
We see a lot of young people die here; barely a week goes by when I don't write a death certificate for someone my age or younger. But generally these are HIV related. Tonight's death reminded me of just how much disparity there is in healthcare in the world.

Monday, 26 April 2010

Not quite sat-nav.

Having arrived at clinic today to find that they weren't expecting me, I then got to tag along with the social worker on a home visit. There is a child on Paeds ward who needs to start ARVs but can't until a family member does adherence training so we were going to see if we could find someone appropriate. The first thing we had to tackle however, was finding them at all. We knew that they lived around Madadeni store so drove to that area and began asking around. We quickly found someone who knew where they were and hopped in the car to show us. It struck me that this wasn't ideal for patient confidentiality (though nor is the hospital emblazoned car) but in an area with no streets, let alone street names, it's about the only option we have.

Sunday, 25 April 2010

A hopilless situation.

Thursday was a bad day for pharmacy. Not only were we out of one of our antihypertensive drugs (this is quite normal. I've given up pointing out how unhelpful it is for us to be telling patients how important it is that they take their meds only to then not be able to dispense them as we are out of stock), but we also had no warfarin (we have a lot of heart valve replacement patients due to rheumatic heart disease), no second line HIV drugs (for those patients who have failed to improve on the standard ones. 'Defaulting' treatment is a sure fire way of making sure that the second line ones don't work. And we don't have third line ones) and no TB treatment (a good way to increase our already prolific drug resistant TB). A fairly bare cupboard.

And then we heard that our chief pharmacist is leaving at the end of the month. With no replacement in sight.

Wednesday, 21 April 2010

Best of 3?

So the rest of the GP-led weekend was a little more challenging; our first c-section on Sunday morning and a black mamba bite that afternoon.
Deyo woke me at 7 to say there was a section. We rock, paper, scissored and I got to cut. All went smoothly until it came to actually getting the baby out when I discovered that it was making a valiant bid for freedom the more usual route. Some pushing from Deyo and pulling from me and we persuaded him to trust us that there really wasn't space that way; a real team effort.
Later that afternoon I was called to a snake bite. A black mamba. From my previous experiences I've learnt that the antivenom (and it's 1:4 chance of anaphylaxsis) only has to be given in certain situations but black mamba bites are one of them. So yet again, team GP bravely stepped up;

C: It's been a while since I've done this
D: I've never done this
C: Oh. Fingers crossed then.

Fortunately luck was yet again on my side (3 out of 3) and the patient didn't react.

So Deyo and I not only survived our first weekend on call together but actually faced my two fears of things we wouldn't cope well with.
As future poly-clinic workers, I think Darzi would be proud.

Saturday, 17 April 2010

Sticks and stones.

My first weekend on call with Deyo. I'm feeling a little anxious in case there are any theatre cases (the untrained leading the untrained...) but we do have 3 seniors around Ingwavuma on standby. And we're one night down with out any problems.
There was the usual selection of chronic cases (and unlike in the UK, asking "why have you come in with this on a Friday night? Has something got worse?" adds nothing except a shrug and a convoluted explanation about a lack of transport) and drunken assaults. One of the latter of these was a well-dressed (albeit fairly blood stained) English-speaking 30 year old who had been hit in the face following an altercation regarding another man talking to his girlfriend. After a quick assessment I suggested we get the blood off his face so I could see whether he needed any stitches. I lead him to the sink and handed him some swabs. He looked at me increduously. Was I suggesting that he wash the blood off his own face? I laughed and told him I wasn't his mother. At this he rounded on me, was I being racist? After a brief consideration I assured him that I didn't think I was being, that I would treat any patient the same way but that around here, that probably wasn't great evidence of a lack of racism. He didn't seem to appreciate that but did let me stitch up his face.
It was an interesting question though and one that I haven't faced here before, presumably for the reason I pointed out. I can't deny that skin colour is something you notice (an unkown white person see in Spar, let alone OPD, will cause a flurry of discussion) but I genuinely don't think that my patient care differs as a result.
More interesting perhaps, would be where his assumption that someone telling him to do something he doesn't want to do must be doing so based on his skin colour, comes from. Does he really believe that or is he just an angry young man?
Personally I think he may have missed where I do think my patient care differs; English speaking patients. I find the inability to communicate with the vast majority of my patients a constant source of frustration, so when I see someone with whom I can have what I consider a proper consultation, I revel in it and they undoubtedly recieve more information and are more involved in their treatment decisions. But then that would be a discrimination that benefited him so perhaps it was less of an issue.

Wednesday, 14 April 2010

Read all about it.

Recently I've had the rather obvious realisation that with writing a blog, my thoughts really are open to everyone.
I was aware that people I know at home have been following it and as that really was it's purpose, I'd be disappointed if they weren't. Out here, I haven't made a secret of keeping a blog and I know one or two people have looked at it.
But I was a bit taken aback when our new physiotherapy elective students arrived and after 5 minutes of conversation announced that they had read it. And even more taken aback when one of the managers in Spar mentioned he had read it. Apparently it now comes up quite easily on Google if you type in the right combination of Mosvold, Ingwavuma and hospital.
I think it was the idea of people who I didn't know having read some of the things I had written. As I've said before, it's become a sort of online diary and I try to write it entirely as me, with at times rawer emotions than I would share with people on first meeting them. I was worried about opinions that people might have formed about me based on things I had written. Particularly people I then see regularly.
However, the students said they appreciated the insight before they arrived (and they've even got in a car with me!), and Spar not only still serves me but has in fact recently started stocking a variety of cheese other than Cheeso, so perhaps I shouldn't worry. Now, did I mention how much we all crave bacon...?

Sunday, 11 April 2010

A bit cheesey.

Fortunately I only had to get through a few hours of Friday's frustrations before I was done for the day and started my long weekend in Kosi Bay with my parents. Had a load of fun hippo and croc-watching and snorkelling (not at the same time, but not as far apart as you might think wise) and stocking up in the fancy Spar there that stocks not only bacon but 4 varieties of cheese. Hopefully those should get me through next weekend's on call.


On Friday I was incredibly grateful that I had had an almost unheard of 6 hours sleep on call the night before, or I think I would have flipped out and lost my post-holiday calm. I was phoning our referral hospital to get the results of a scan that a patient had had there 2 weeks before. They told me that it still hadn't been reported. I asked to speak to the head of department to discuss that this wasn't really appropriate, particularly as our patients travel a long way to see us for their follow-up which is difficult to do without results. She explained that they had no one to report the scans (the hospital has not renewed the one of the radiologist's contracts as they don't have money to pay him, and the other one is on prolonged leave). They're continuing to do scans in the hope that the situation might get resolved.
Next up I rang to book an endoscopy (a camera test down a patient's throat) for a patient. I was told that the piece of equipment needed was broken. It has been for the last 4 months and they're not sure when or even if it will be fixed. Their manager told me that in urgent cases they are using their colonoscope (the one for the other end) but otherwise they advise phoning again in another month.
Situations like these make me feel so frustrated. Things that should be available suddenly aren't and no alternatives are arranged. And part of the problem is money, but it also sometimes feels like there's a lack of desire to provide a good service.
These situations also make me feel fairly useless. I am still so dependent upon tests to help diagnose patients problems. Coming here has certainly improved my clinical diagnostic skills but I think I still have quite some way to go.

Wednesday, 7 April 2010

Good medical practice?

This week has however, not been without it's thought provoking moments. This one a legal and moral quandry. I saw a lady in OPD who was 8 weeks pregnant and who had come in the week before to request a termination. She had been counselled by one of the doctors and referred to the social worker for further counselling. However when she came back to collect a letter to allow her to catch the bus to our local Marie Stopes clinic (some 4 hours away), the doctor who saw her refused and sent her away. Confused by his notes I asked him about this and he informed me that due to his religous beliefs he was not willing to refer her, and that the 3 other doctors avaiable at the time also held similar opinions. He had advised her to come back another day.
I appreciate that this is by no means an ethical issue limited to Mosvold; I have worked with doctors with similar views in the UK and Australia. And I do appreciate that for some people it is a very emotive issue. Normally I can accept that those of us who feel less strongly on this issue should take over these cases. However, in a hospital of only 8 doctors serving a very poor community who can ill-afford multiple trips to hospital, let alone another child, I can't help but feel that refusing to refer a patient on the grounds of our beliefs is a luxury that we do not have.

A Mosvold welcome.

I returned to Mosvold bearing no chocolates (thanks baboons) but bringing my parents for a visit. Until we arrived I hadn't realised how important it was for me that they see where I have been living and understand some of what I have come to love about the area and the people. Arriving in the dark on the Sunday and seeing my house through their eyes I felt awful, convinced that they would think very little of Ingwavuma.
But these fears were blown away when I took them in to meet some of the nursing staff. They were greeted with such huge smiles and hugs that I can't imagine in any other place that I have worked. Most touchingly of all for me, they were sincerely thanked for all that they had done in raising me and allowing me to come to Mosvold.
I think that might be the first time anyone has thanked my parents for me.

Where have I bean?

Wow, 2 weeks away from the Vuum. The longest since I arrived here. And what a couple of weeks it was; 8 days in the UK catching up with family and friends and testing my liver's tolerance to it's limits and then 6 days holiday back in SA exploring the delights of the Drakensberg mountains and discovering just how clever baboons can be (locked chalet windows forced open. Twice).
I'd had some worries about the trip home, whether it would 'freak me out' and unbalance me but I was pleasantly surprised to discover that after 28 years of living in cities, 8 months away had not caused me to forget what a bus looks like, nor a street full of people. I'm ashamed to say I also discovered that I really do love mass-produced coffee, served in over-sized paper cups.

Another positive aspect is that talking to people about my experiences here has reinvigorated me for my remaining few months in Ingwavuma, reminding me why I came and what I hoped to get out of it.
And amazingly that feeling has even lasted through Monday's on call with it's 2 c-sections and 4 hours broken sleep.

Wednesday, 17 March 2010

Being too tasty for my own good.

In the middle of last week, I noticed that something had bitten me on my left thigh. This is not an uncommon occurence; the mosquitos are only partly repelled by the deet and net combinations (luckily malaria is rarely seen this high up the mountain). However as the week progressed so did the bite and when I noticed a golf ball sized lymph node in my groin on Thursday I decided that the time had come for antibiotics. The benefits of being a doctor meant that I could just help myself to these at 2am during my call (I balance it out that I'm saving them money by not taking time off). 4 days later and the red line tracking up my leg did seem to be slowing down but not exactly reducing. And the chat around campus was that a number of us had similar ?bites. Theories abounded; a spider that comes out in the late summer, tetse fly bite (with the accompanying possible sleeping sickness), and my personal favourite, a fly that lays eggs on your clothes which then hatch and the larvae burrow in to you. I was faced with a tough decision; go on to different antibiotics (but one of the few ones you can't drink alcohol on, just as my annual leave approaches, and more relevantly the ones all doctors claim to be on in early pregnancy to explain their abstinence; rumours would fly!) or wait and see (and potentially be one of the annoying A&E patients you would see with a bit of a temperature who would then casually mention that they were just back from rural SA. And had some dodgy bite...)?
Luckily the GP-style has paid out and the redness (and accompanying fever) does appear to be subsiding. Phew.

Shark attack.

So a belated update on the weekend. Headed down to Sodwana Bay to join our therapists who were completing their NAUI dive course (for those like me who are PADI trained, NAUI is apparently the one for 'real divers'). Was a lot of fun (well, not so much for the early morning divers who suffered after the night before with some underwater fish feeding...).
Sneaked in a couple of dives myself and saw lots of very pretty fish without feeding them, but sadly missed the whale sharks that were allegedly hanging around the Bay. I did manage to see a couple of sharks on the dance floor of the local Afrikaaner bar and was persuaded in to some energetic sooke sooke dancing but we fortunately left before the "lion lope" began (directly translated as "walk like a lion", it involves some nakedness from the boys).

Wednesday, 10 March 2010

A little s-hello.

Another day on the road, another creature throwing itself out in front of me. This time a small tortoise. I spotted it just as we were bearing down on it, with another 4x4 coming towards us. Slamming on my brakes I hoped the other vehicle would miss it. It did. But then an even bigger truck came up behind me (rush hour on the dirt road to Manyiseni clinic) and went to go round me, on a direct course for the shelled proverbial chicken. With hardly a moment's thought, I hopped out, dashed in to the road and snatched him up to safety. As my thanks he hid as far as possible inside his shell whilst I carefully placed him down on the other side.

Saturday, 6 March 2010

Bright ideas.

A weekend on call and some more frustration and anger, but this time at the EMRS (ambulance system). Last night in addition to the usual chest infections and malnutrion, I worked my way through 3 MVAs (with a total of 11 victims of varying severity and one very dead cow; black cows and no street lighting are a dangerous combination) and one stabbing to the abdomen. I'm no surgeon but I figured that bits of omentum hanging out wasn't a great idea and after consultation with some actual surgeons decided that it was probably better to stabilise and send to them rather than have a go here (although I'm thinking laparotomies aren't that different to c-sections, right?). The trouble was that having rung for the ambulance at 1am, when I rang at 3 to find out where it was they told me that there wouldn't be one until morning (6am). This was because out of the two ambulances we have, one "isn't fit" to drive the 3 hours to our referral hospital (although is fit to range around the dirt tracks in this area bringing in patients I then can't transfer out if it's needed) and the other had a broken light in the patient compartment so couldn't be used in the dark. My suggestion that they take a torch didn't go down well.

Thursday, 4 March 2010

Another dip on the emotional rollercoaster.

Today I was struck by just how unfair life is. Out in clinics I saw a child who is about 2 years old (her date of birth is unknown). She'd been brought in by her aunt who had fetched her from Swaziland the week before, following the death of her parents in January. She'd been in a Swazi hospital in December and her discharge summary states "HIV positive, TB, malnutriton". She'd started ARVs, TB treatment and feed-up but the family who handed her over from Swazi had no medicines for her. It's unclear when they were stopped. She'd weighed 7.1kg on discharge and now weighs 6kg. That's about half of what she ought to. I've brought her in to try to restart all the treatments and involve the dietician and social workers but it may all be too late.
And this brought up in me some emotions that I thought I had already dealt with but which caught me afresh today; I feel angry at the world that in 2010 this is still happening and I feel guilty that I can't change it. It is just too big and complex an issue. But mostly I feel very sad. She is just a child, and life has dealt her an incredibly raw deal that she may not be able to break out of. And the worst part is that she is just one example of many.

Doctors, I presume?

So the funny thing I didn't mention about last weekend was that our rafting group was made up of 6 of us and 4 other people. When we got to the meeting place we discovered the other four were a selection of doctors and medical students from other local hospitals. When you add this to the fact we bumped into a load of doctors in Sodwana Bay a few weeks ago (staying in the next door cabin to us) and were even sat at the next table to a bunch when we went out for dinner in Durban, northern KZN starts to seem very small. I guess we make up a big proportion of the tourists in this area (most SAs consider this to be too rural for holidaying), and there are only a limited selection of activities to do. And most importantly we probably all have the same edition of the Rough Guide.

Sunday, 28 February 2010

Don't feed the animals.

A weekend free and 'the best white water rafting in Southern Africa' right on our doorstep in Swaziland; a roadtrip was in order. 6 of us piled in to a car and set off at 6am on Saturday morning, speeding through the border and to our meeting point in time to grab a coffee (and a £6 fine for 'overloading'; cheaper than the petrol on a second car). There we divided up in to 2-man croc crafts and were pushed out on to the river. We started with a practice capsize, during which my jelly shoes abandoned me to swim with the fishes and then spent the day making our way 16km downriver over rapids graded from 2-4. To add to the fun of falling out, the river does have crocodiles which lurk in the calmer sections. Although we only saw a baby one, it was enough encouragement to swiftly scramble back in.
I'd love to claim to have pulled it off like a pro but at the final rapids came close to drowning after being tipped out and hitting my helmeted head on a rock. Thankfully the guide manhandled me out of the water and I coughed the contents of my lungs in to the bottom of his boat. Not my most graceful moment.
We then spent the night on a game reserve and breakfast fending off an ostrich and some wart hogs who couldn't read the 'don't feed the animals' sign before driving back via our local (about an hour and a half's drive) hotel with it's much needed masseuse.

Wednesday, 24 February 2010

The never ending story.

So another weekend, another car mishap. This time en route to Durbs in Toots with a couple of the teachers for good measure. We noticed some scraping noises as we went over bumps but decided to ignore them. However when a fifth person got in at Mtuba (still 3 hours from Durban), it was continuous and couldn't be ignored. Particularly when we identified it as the right rear wheel scraping off the car. Even I could see that that wasn't a good thing. Having dismissed the idea of leaving one of our party in the middle of nowhere there was some skilled reorganisation of weight and the noise again became intermittent. A nerve-racking drive later and we arrived safely in Durban. The next day I high-tailed it to a garage where initially the mechanics reassured me that this was 'completely normal' but after some persuasion had a look and conceded that our 'shocks were buggered' (that's the suspension to you and me). Probably a result of one too many pothole incidents.

Wednesday, 17 February 2010

No place like home?

Yesterday on the way back from clinics I tagged along with the social worker on a home visit (well, when I say tagged, I was driving). Was all a bit of a sad tale; the patient was a 29 year old lady who had been seen with abdominal pain, but the doctor felt that there was also a psychological element, due to the stress of looking after her nieces and nephews following the death of their mother. All 8 of them, ranging from 3 to 21, in addition to her own 2. The older ones have been misbehaving and causing her a lot of grief and so we were visiting to see what help we could provide.
Arriving at their thatched hut after a 20 minute drive through bushes and down sand tracks, we were greeted by her husband and two friends indulging in some home-brewed amarula beer. They offered us a drink but we declined (and having since learnt that it is fermented with human spit, I am glad!). The lady reported that she was feeling much better but that older children were still being troublesome. They weren't home so we set off in search of them. This turned out to be a bit of a quest which involved picking up countless people along route who were of unclear connection to the case but guided us on to more and more remote locations. Just when I thought I couldn't possibly fit any more people in to the car, we came across the boys minding cows and playing soccer. They were hauled in to the 4x4 and given a firm talking to in Zulu by the social worker, whilst I nodded sagely in the background as if I understood. They apologised and promised to be better behaved, but pointed out that they weren't the only trouble-makers. Their father (her brother) is still alive and recieving a disability grant, but refuses to use any of this money to feed and clothe his kids. The social worker assured them that she would be looking in to that.
The whole experience was really interesting. Not just seeing how some of our patients live but also seeing how the community interacts together. There are definitly some things that we in the UK could learn.

Monday, 15 February 2010

What's in a word?

Had a big, and slightly unprofessional, fight with some of the OPD nurses today. Was working quite hard first thing as the only doctor in the department, when they called me out of my room to give some iv tranexamic acid that had been prescribed overnight. Now I had two issues with this; 1. they'd delayed patient treatment by 3 hours (and this was pretty important as it's a drug to stop bleeding and the patient's blood level was 4.6. That's not good) and 2. iv drugs are on the whole a nursing task (and of late I'm discovering that more and more 'nursing' tasks are being redistributed to doctors, rather unhelpfully at a time when we're losing doctors). I told them as much, however they disagreed and told me that certain drugs (anti-venom, iv morphine, iv pethidine and tranexamic acid) have to be given by doctors. I told them that the first three might be but it was nonsense about the last. I then involved the pharmacist who took my side. However to no avail and so I gave the drug and told them I'd be talking to the head matron.
Over the next hour I slowly calmed down and realised that I had commited the ultimate doctor error; getting the nurses off side. I know from experience just how much of a mistake this is and what the dire consequences can be. So I called a meeting with the nurses involved, the matron and one of my seniors. I apologised for my behaviour whilst also reiterating my frustrations. And then it came to light what had upset them the most. It wasn't that I had questioned their care, nor that I had questioned their nursing skills, nor even that I had involved pharmacy in the disagreement or threatened to complain about them. It was the use of the word 'nonsense'. They feel this to be one of the worst words that you can use (along with 'stupid' and 'ridiculous') and were highly offended by it. A further apology later (and an attempt to explain the definition of nonsensical, ie not making sense) and it was all sorted. Although we still have to give the iv tranexamic and no one was interested in my concerns about patient care.

Saturday, 13 February 2010

The big freeze.

Another week, another doctor leaving. This takes us back to 8 doctors, with only 7 of us covering the 123 out of hours work per week (so only 17.5 hours extra first on call each on top of our 45 hours standard). The latest from the department of health is still that all funding for posts is frozen but we were pleased to hear that they are "busy with a proposed proforma for 2010/2011 for filling of posts ". In the meantime they have suggested that "managers must manage" and questioned why there are so many managers in District Hospitals. I'm wondering why we have 6 people working in the HR office if we aren't hiring any new people...
On the plus side, Anna leaving meant another farewell braai last night, and the resultant redistribution of belongings from her house today- we've gained a throw for our sofa and a small wooden giraffe. Our house feels almost homely.

Tuesday, 9 February 2010

A gruff story.

Another day, another maiming at my hands. This time on the road. Driving back from clinic, I watched 3 goats amble across the main road at a comfortable distance from me. Then as I approached, a fourth straggler jumped out. Our eyes locked. I swerved but sadly so did she, jumping under my wheels. I braked hard and jumped out as a bleating, bleeding goat limped it's way under a nearby bush. I felt awful and also a tad worried I didn't have enough money on me to pay off a goat owner (the going rate is about £50 a goat).
The social worker who had ridden along with me also jumped out and began shouting in Zulu at anyone standing near. No owner could be found although a lady who thought she knew who the owner was promised to find them and sort the matter out.
The social worker then explained to me that I was wrong about the pay off; the guilt is actually on the part of the owner at allowing their animal to roam around and that often they won't admit to the animal being theirs in case there has been damage to the vehicle. So whether the lady was in fact the owner, or just saw the potential for a good meal tonight I'm not sure.
Either way I feel terrible that I have damaged the goat of someone who can potentially ill afford it, and then not paid some form of compensation or at least apologised. As for the goat, I just hope that someone put the poor creature out of it's misery.

Thursday, 4 February 2010

Taking from the 'rich'.

Bit of a moral dilemma in clinic today. Followed up a patient that we had done a thumb resection on last month (very gangrenous looking, foul-smelling digit). Histology came back showing an invasive melanoma. Had organised for staging scans and re-resection early next week but when I told him this he said he couldn't come down until Wednesday "if" the bus was running (it hasn't come for the last two weeks). His other option is to get a mini-bus taxi but he couldn't afford the £2.50 that this would cost.
Obviously the answer to this is that SA needs to sort out it's healthcare provision to include transport for it's most rural patients. But faced with an individual where no transport could have a big impact on his outcomes, I reached in to my purse.
I'm aware that this isn't a long term solution; I can't do this for all the patients. It may not even be a short-term one as he may spend the money on something else, like food, that he feels has an even greater short-term benefit. But it felt like the right thing to do.

A retched journey.

Today I yet again broke the 'no patients in clinic vehicles' rule to bring in a lady who was in labour. Was a tad nervous about the hour long journey with her in the car (although as I'm on call I was also wondering whether hitting the pot holes would help with the descent of the head and therefore avoid a c-section...). And then it all backfired on me. No, not stopped by the police. Instead her mother (who had come along for the ride) became very travel sick. And politely vomited in to her handbag.
I think my learning point will be to issue sick bags to all the people I agree to take.

An act of God?

An amusing update for anyone who has had the pleasure of speaking to Mosvold switchboard. Last night we had an absolutely enormous thunderstorm and at one point there was a huge crash and a big blue flash. This morning we discovered that the telephone wire had been hit, so there is now no outside line to the hospital. This is making tonight's on call rather quiet, particularly for the lady on switchboard who, despite there being absolutely no phone calls for her to deal with, has remained at her post. What a legend.

Tuesday, 2 February 2010

Do the drugs work? They certainly make you worse.

A weekend spent in the company of rural SA doctors and there was the fairly standard stats; 2 out of the 15 on HIV drugs for post-exposure prophylaxsis. Back here this week and 2 of my 8 colleagues have had to start them too.
It's a scary thought that you'd have to be careful and/or very lucky to get through this year without needing to take them. Although watching your friends throwing up their breakfasts daily certainly encourages you to be very careful.
It also makes me think about how many patients we hand them out to and how disapproving we are of any signs of poor compliance. In drugs with such horrible side-effects, I'm impressed that any of the patients continue taking them.

Monday, 1 February 2010

TB or not TB.

The SA government has this week announced (or in fact reiterated) policy that all HIV patients starting anti-retrovirals without signs of active TB should be treated prophylactically with Isoniazid (a TB drug).The reasoning is that this treats latent TB, which can flare up in patients as their immune system improves, with dire consequences. However, TB is absolutely rife here; along with (and not unconnected from) HIV it is the thing we see most of. And with limited resources (and even with good resources) it can be difficult to diagnose and we're almost certainly undertreating it. If we give all these patients Isoniazid when they actually have undiagnosed active TB, we will fairly certainly soon have widespread resistance.
We're already facing patients who for a number of reasons are unwilling or unable to take the medicines and so we are seeing increasing numbers of MDR (multi-drug resistant) and XDR (extremely drug resistant) versions.
In an ideal setting these patients would be isolated until no longer infective but as we have no MDR ward, we are faced with the difficult decison of whether to keep them in hospital, spreading and mutating it with other TB patients, or to let them go home, putting their family and community at risk and creating more MDR TB cases.
It's all rather scary. If the current situation continues, South Africa will shortly produce a version of TB which is resistant to all treatment. And as disease doesn't recognise borders, that will be a problem for the whole world.

Ironically the SA goverment required me to prove that I didn't have TB before they granted my visa to work here.

Tuesday, 26 January 2010

The Mother City.

Last week was a week off and I headed to Cape Town. And fell head over heels in love with the city; awesome mountains, white sand beaches, funky bars and beautiful people. Basically a completely different world (or at least a country) to Ingwavuma.
Or so it appears on the surface. However scratch it with a township tour (not quite as naff as you might imagine, although did feel a little uncomfortably like being on safari in people's homes) and I realised that South Africa's problems are widespread, they're just hidden a little better in some places.
And I also began to understand why so many of the mothers leave their small babies in the rural areas with their gogos rather than taking them to the city where they work; 17 people living in a small room is not an ideal place to bring up your child.
The rest of the week however I managed to ignore all social guilt (except the guilt of laughing at a couple of tourists who managed to get three, count them, three, baboons stuck in their car) by exploring the delights of Cape Point, Franschoek, Constantia and the Waterfront.
All too quickly it was back to the Vuum, and after 2 days (and half an on call) it feels all too familiarly like I was never away.

Wednesday, 13 January 2010

Making a difference?

This week has seen the start of my new role as the clinic doctor. I am going out to the outlying clinics 4 days a week to see patients and do some teaching to the sisters there. This will surprise anyone who read my comments on my first clinic visit but since then I have begun to recognise the importance of providing good care to patients near to their homes (so many patients cannot afford to make the journey to hospital) and also the need to support the nurses who work so hard out there and can sometimes feel very isolated from us (as we feel isolated from our referral hospital).
So daily, I will pack up my little lunch, climb in to my enormous 4x4 and bump off down some dirt road to a small building where up to 40 patients are awaiting my arrival.

Day one was however not a good start. At about half past 9 in the morning I saw a baby who had been born at home the day before as his mother couldn't afford to come to hospital. It was her first baby and luckily she managed a normal vaginal delivery (due to the commonest pelvic shape here, a lot of women struggle with this). She had come in for a check-up and the baby had been found to have a very high temperature but otherwise seemed well. In such a young child you admit them to hospital for intravenous antibiotics whilst looking for the cause of the fever. I duly organised the paperwork and drugs and the nurses called an ambulance.
At half past 3 as I got ready to leave, I realised that they were still there.
Officially the government vehicles are only supposed to be used for transporting staff and goods and ambulances are to be called for patients. Apparently if you are found with 'illegal people' in your vehicle it can be impounded by the police. However, I felt that I could argue my case for this one (he had already waited literally half his life for an ambulance).
I bundled them in to the back of the car, teaching the mother how to use a seat belt and trying to ignore the complete lack of a car seat. We then drove the 45 minutes to Mosvold.
On arrival, the baby was dead.
And I know in my heart that I couldn't have done anything differently had I known at the clinic or en route, but the idea that it died in the car, or possibly even worse that I didn't notice as they got in makes me not only feel like a bad doctor, but also quite sick.

Monday, 11 January 2010


Deyo and I are three again. The addition of a cute little white Ford Fiesta to our family has delighted us both. She will give us the freedom to get off the mountain when (much-) needed and explore some more of the area. She drives like a go-kart, and has enormous alloy wheels that have bought us some serious street cred with the Zulu male security guards.
Sweet as a nut.

Tuesday, 5 January 2010


Another life-event in Ingwavuma this evening. The running club (now just me and Deyo) was cut short when we came across a tiny grey kitten on the road outside the hospital. It was obviously in a lot of distress and limping. A closer examination revealed a worm-infested wound on it's right back leg. Much to the amusement of the watching Zulus we scooped it up in my t-shirt and brought it back to the hospital.
We realised that without any vets around the wound meant a prolonged and painful death. Even with vets, it would probably have been at least an amputation and then a disabled kitten dependent upon people who leave in 6 months time. After some discussion we felt that the kindest thing would be to put it out of it's misery and so we gave it a lethal dose of im ketamine. Obviously putting animals down is something that even animal-loving Brits are aware of the need for, I've just never personally done it.
I also couldn't help but draw some parallels to some of our work here where we give patients life-prolonging treatment that makes them dependent upon the health care system which may also not be around forever (money and staff deplete as it is).

Monday, 4 January 2010

You're only as old as the ?woman you feel...

Some of the more amusing sorts of cases that we see in OPD are requests for changes on id documents. Mainly these are people claiming that their date of birth has been incorrectly filled in and that rather than being 54 (or even 39 in one case!), they are in actual fact 60. Conveniently the age at which the government pension starts... It's a little unclear to me what exactly the state department think we can do to confirm the ages of people who often have no birth certificates and don't even know their birthdays. Perhaps they imagine that we can cut their legs open and count the rings like a tree.
The other change that we are asked for is the sex. In 5 months I have seen about 10 cases of people whose id documents state them to be male when on examination they are clearly female, or vice versa. Those are easier to confirm.
Today's case was a highlight; a heavily pregnant lady came in most upset as the state department were refusing her maternity benefits as her id document stated that she was male. The proof quite literally was in the pudding.

Saturday, 2 January 2010

Feliz Ano Novo!

2010. The year of South Africa. And we saw it in in Mozambique. What a party! And what a shame I came back to an on call shift...