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.