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.