But if they did, I don't think last night would be one of theirs.
I can confidently say that the last 36 hours have been my most harrowing work experience to date in my career. I've cried more than I thought possible and drunk more strong sugary tea than my dentist would approve of.
The day started badly when, before lunch, I'd told a woman that the twins that she was 16 weeks pregnant with didn't have heart beats on the scan. And then promptly delivered one of them on the USS couch, before taking her to theatre to have the other one removed.
It was a busy afternoon, and then at 5pm as I was finishing up the OPD patients I had an emergency call from the Paeds ward. I arrived to an 11 week old girl that had been admitted with a LRTI an hour previously, who had now stopped breathing. Despite going further in Paediatric resuscitation than I ever have before (if there's no one else there to intubate, you might as well try) we weren't able to get a cardiac or respiratory output back and agreed to stop. I was distraught. Paediatric resuscitations are always upsetting but in this setting I can't but help feel that we just can't do enough. We have no way of checking gases or urgent electrolytes or even cardiac monitoring. And whilst we all try hard, we're not experienced or knowledgeable enough to be single-handedly resuscitating children (which is very much the situation you find yourself in). I couldn't recall doses of drugs but couldn't look them up in the critical first 5 minutes as I was bagging and doing chest compressions.
Explaining to a mother that her child is dead when you feel like ultimately we have let her down through lack of resources and skill is heartbreaking.
I found it especially hard as the other staff involved are more used to these situations and were able to carry on with their work as soon as we stopped. When I've been involved in these situations in the UK, you rely on support from your colleagues and try to take time to debrief, something that isn't seen as necessary here. I've also never been the person who has been ultimaltely responsible for the decision to stop nor for telling the parents and then bringing their child to them to hold. I've often wondered how appropriate it is to cry in front of relatives in this setting but last night it wasn't a concious or controllable decision.
There followed a night of hourly calls (anaphylaxsis to traditional zulu medicines, rape of a 4 months pregnant lady, a 1.5kg baby born at home and brought in) only one of which (not one of the listed ones you'll be pleased to hear) I managed to deflect to allow me two consecutive hours in bed. One of the things I find hardest about the on calls is that I've always favoured bouncing my thoughts about diagnosis and management off another person (even if only to ignore their advice) but at night here, you are the only doctor around (unless you urgently require the second on) and the nursing staff are of very variable quality, so in addition to being physically exhausted, I feel the strain of having to make all the decisions single-handedly without anyone even to say 'I agree'.
By morning I was mentally, emotionally and physically exhausted.
Then at 6am I was called to a lady who was 26 weeks pregnant and having PV bleeding and abdominal pain. Examination revealed her to be fully dilated with bulging membranes. Due to poor equipment here, our cut off for resuscitation of neonates is 28 weeks (as opposed to about 25 in the UK) but as many women are unsure of dates and don't have reliable (if any) USS I wasn't willing to put this lady on the female ward to deliver. So, much to the annoyance of the midwives, I took her to the labour ward. And I was glad that I did as the 850g baby that she delivered cried at birth, and I felt relieved to have some resuscitation equipment to hand. However, after spending an hour and a half resuscitating the boy with fluids, antibiotics and the available respiratory support, his breathing failed and he died shortly before 9am.
Sadly my day was not over there and I still had my ward round to do and a couple of further hours in OPD where my final case was a 15 year old girl requesting termination of her 8 week fetus, fathered by her own brother.
The thing is that any one of these things would have upset me tremendously at home, but being here and facing all of them in one shift, without my usual support networks is almost more than I can bear. The way I feel now, I don't know if I am strong enough to manage the year.
Time for another sugary tea I think.
Tuesday, 13 October 2009
Sunday, 11 October 2009
Not my usual kind of spirits.
Church in Ingwavuma is a big part of people's lives. Many people came here as they felt that God had called them and the day at hospital starts with prayers, which are sung. It is not uncommon for hospital meetings to start and end with a prayer. Sadly I seem to have been out when He called and he didn't leave me a voicemail, but that aside I thought it would be good to go along to church to see what it was all about.
The church most people go to is one set up about 4 years ago by one of the doctors. It is a Christian church and the service runs in English and Zulu. As it is still relatively new, they hold it in one of the school classrooms (where it was fun to see how similar it is to my old classrooms, with the kids divided in to groups named after fruits (apples, oranges, bananas) and a set of class rules that included 1. We must come to school every day and 4. No sleeping in class).
It started with walking in to beautiful harmonious singing from the congregation that seemed to be spontaneous, with one person starting and everyone joining in. Then a welcome by the preacher, and some worship songs. But just as I was getting in to it ('hey, church is a bit like a party'), one of the women was overcome by spirits and had a hysterical fit, crying and falling around and had to be taken outside. Everyone else seemed to take this in their stride and assured me that it was not uncommon for God's presence to draw out evil ancestory spirits. But I felt uncomfortable with it. I also felt uncomfortable watching the poverty stricken local black community singing their hearts out about how God is just and fair. How they can look around them and think that, I am less sure. And I was taken aback to notice that, as in the hospital where the majoirty of doctors are white, and the school where the teachers I have met are white, in the church, the preacher and the leader of the Sunday school are both white. In a predominantly black community, it still seems that many of the positions of responsibility are held by whites, even in the church.
Those doubts aside it was a very positive and happy atmosphere and it was wonderful to feel so welcomed into a community that I only joined 8 weeks ago. I'm not about to become a regular at church, but it's nice to know that if I find myself at a loose end in Ingwa on a Sunday morning, I'd be very welcome.
The church most people go to is one set up about 4 years ago by one of the doctors. It is a Christian church and the service runs in English and Zulu. As it is still relatively new, they hold it in one of the school classrooms (where it was fun to see how similar it is to my old classrooms, with the kids divided in to groups named after fruits (apples, oranges, bananas) and a set of class rules that included 1. We must come to school every day and 4. No sleeping in class).
It started with walking in to beautiful harmonious singing from the congregation that seemed to be spontaneous, with one person starting and everyone joining in. Then a welcome by the preacher, and some worship songs. But just as I was getting in to it ('hey, church is a bit like a party'), one of the women was overcome by spirits and had a hysterical fit, crying and falling around and had to be taken outside. Everyone else seemed to take this in their stride and assured me that it was not uncommon for God's presence to draw out evil ancestory spirits. But I felt uncomfortable with it. I also felt uncomfortable watching the poverty stricken local black community singing their hearts out about how God is just and fair. How they can look around them and think that, I am less sure. And I was taken aback to notice that, as in the hospital where the majoirty of doctors are white, and the school where the teachers I have met are white, in the church, the preacher and the leader of the Sunday school are both white. In a predominantly black community, it still seems that many of the positions of responsibility are held by whites, even in the church.
Those doubts aside it was a very positive and happy atmosphere and it was wonderful to feel so welcomed into a community that I only joined 8 weeks ago. I'm not about to become a regular at church, but it's nice to know that if I find myself at a loose end in Ingwa on a Sunday morning, I'd be very welcome.
Saturday, 10 October 2009
But no olives.
Ok, it's blatant e-portfolio avoidance, but thought I would give an insight in to shopping in Ingwa (a certain young lady checks this daily with her tea- this should keep her going for a couple of cups). We've got one main shop; Spar supermarket (I think to call it super is a bit of an overstatement, but it's bigger than your average Spar at home). Sells an interesting and unvaried selection of things (a whole aisle is dedicated to varieties of mealie maize and pap) and when initially faced with it, we really weren't sure what we were going to live on here. But I'm discovering that each time I go, I find new things. Often stored in random places (self-raising next to the washing up liquid, in a seperate aisle from all other baking products, including normal flour). And ususally not in the same place for more than two weeks running. Which keeps things entertaining.
There's a vegetable section where you can buy tomatoes, potatoes, cabbage and green peppers. And occasionally mushrooms. A meat counter where you can buy chicken feet, ox liver, chicken hearts or the extremely unpopular, and therefore only 50p, fillet steak (guess what we're living on).
My favourite finds so far have been in the pharmacy and cosmetics aisle; the "grandpa" headache tablets (perfect gift for Deyo's upcoming 30th) and the SA brands of body lotion (called "lovely") and deoderant (called "she smells great").
And then the checkouts, where the Zulus insist on standing pressed against the person in front of them in the queue, in case anyone should attempt to push in (their queue avoidance does at times offend my British sensibility).
And finally the delightful security guard who checks all reciepts before you can exit the supermarket.
We tend to buy our bread and vegetables from the roadside stall. The friendly lady who runs it is a younger version of the WRVS women (every day the same items will cost you a different amount and your change will bear no resemblance to what you expected. But I think it probably evens itself out). She always has a smile and her small son is adorable.
We also have two random Chinese shops which sell a selection of electrical goods and cheap clothing. These are run by two Chinese families who appear not to be able to speak Zulu or English and all live together in an interesting take on friendly competition.
And there is Fancy Stitch, our art-gallery/tearoom which sells products stitched by local HIV positive women (for whom it is often their only source of income) and will I suspect be my source of cards and gifts for the year. They are actually currently running an exhibition at the Brunei Gallery in London (9th Oct- 12th December) which would be well worth a visit. My favourite of their gifts is the wooden olive spoons that they sell. In a village where you can't buy olives.
There's a vegetable section where you can buy tomatoes, potatoes, cabbage and green peppers. And occasionally mushrooms. A meat counter where you can buy chicken feet, ox liver, chicken hearts or the extremely unpopular, and therefore only 50p, fillet steak (guess what we're living on).
My favourite finds so far have been in the pharmacy and cosmetics aisle; the "grandpa" headache tablets (perfect gift for Deyo's upcoming 30th) and the SA brands of body lotion (called "lovely") and deoderant (called "she smells great").
And then the checkouts, where the Zulus insist on standing pressed against the person in front of them in the queue, in case anyone should attempt to push in (their queue avoidance does at times offend my British sensibility).
And finally the delightful security guard who checks all reciepts before you can exit the supermarket.
We tend to buy our bread and vegetables from the roadside stall. The friendly lady who runs it is a younger version of the WRVS women (every day the same items will cost you a different amount and your change will bear no resemblance to what you expected. But I think it probably evens itself out). She always has a smile and her small son is adorable.
We also have two random Chinese shops which sell a selection of electrical goods and cheap clothing. These are run by two Chinese families who appear not to be able to speak Zulu or English and all live together in an interesting take on friendly competition.
And there is Fancy Stitch, our art-gallery/tearoom which sells products stitched by local HIV positive women (for whom it is often their only source of income) and will I suspect be my source of cards and gifts for the year. They are actually currently running an exhibition at the Brunei Gallery in London (9th Oct- 12th December) which would be well worth a visit. My favourite of their gifts is the wooden olive spoons that they sell. In a village where you can't buy olives.
Got the power?
The quiet weekend in Ingwa is not going quite as planned; today was supposed to be a chilled out brunch with all the girls and then an afternoon of lazing in the sun. But it's raining. And we woke to no power (and all the houses have electric ovens). Fortunately one of the houses also has an illegal gas stove so we piled over there and cooked up a feast of sausages, eggs, pancakes and fruit. Yum!
As for the lack of sun, my other task for today was to update my e-postfolio and justify my existence here (to the London GP deanery), and the weather might encourage me to do that (after I've e-mailed, facebooked and updated my blog for the 2nd time in 2 days...). Thank goodness the laptop has good battery power.
As for the lack of sun, my other task for today was to update my e-postfolio and justify my existence here (to the London GP deanery), and the weather might encourage me to do that (after I've e-mailed, facebooked and updated my blog for the 2nd time in 2 days...). Thank goodness the laptop has good battery power.
Friday, 9 October 2009
Keeping your hands inside the vehicle.
Last night's on call has left me broken; more so than normal as it started with a full on assault from a psych patient which left me limping around with scratches all over my stomach (and some bruised pride as the nurses had told me not to go too close). I ignored them, thinking that this poor confused old man just needed a gentle talking to, sat down next to him and utilised my extremely limited Zulu to tell him to relax ("tambisa". It's an amazingly useful phrase; anxious patients, surgical patients, obstetric patients but apparently not psych ones). Next thing he announces, in English, that he does not want to tambisa, he wants to hit me. And does.
Fortunately he is bed bound so I just had to bid my escape to more than an arm's length away before arranging some sedation.
After that and the obligatory 4 hours of broken sleep I am really looking forward to my quiet weekend in Ingwavuma with nothing more exciting than an inaugral trip to church on Sunday to disturb my peace.
Fortunately he is bed bound so I just had to bid my escape to more than an arm's length away before arranging some sedation.
After that and the obligatory 4 hours of broken sleep I am really looking forward to my quiet weekend in Ingwavuma with nothing more exciting than an inaugral trip to church on Sunday to disturb my peace.
Monday, 5 October 2009
Raining men.
So, typical time off; back one day and it doesn't feel like I've been away. Mind, having a week off in the pouring rain in SA didn't feel like I was away. From Scotland that is. But seeing the most amazing wildlife (hippos, elephants, rhinos, giraffes, zebras and not-deer) more than made up for it.
But now I'm back in Ingwa and as I sat in the blazing sun having lunch, it all seemed a distant memory.
Have come back to our merry band of 10 doctors (a mere 11,000 patients each) being down to 9 (a brief calculator use later and that's 12,222.2 each now. Doesn't seem that different really). With no sign of any replacement. Actually, there is sign of a replacement (a girl who used to work here who wants to come back for a few months) but they're not sure if there's funding. I'm sure it's more complicated than it sounds but surely if we needed 10 and were paying 10, we still do and can? But that's why I'm not in management.
The plus side of the reduced numbers is that it has opened up a ward of my very own. The male ward. I'm really looking forward to getting to know the staff well and making small changes to improve the running of the ward. Today's suggestion was that maybe we should put all the sick patients in one area of the ward, near the nurses station and that I should see them first on the ward round... Baby steps.
You have to bear in mind that this is the ward that last week managed to tell a family that the relative that they had come to visit had died.
When he'd actually been transferred to another ward.
This only came to light when the family came back on the Friday to collect the death certificate in readiness for the funeral they had arranged for Saturday. And now the poor guy is still with us for fear that if he'd gone home over the weekend, they'd have freaked and thought he was some sort of spirit.
This certainly isn't something I've faced before.
But now I'm back in Ingwa and as I sat in the blazing sun having lunch, it all seemed a distant memory.
Have come back to our merry band of 10 doctors (a mere 11,000 patients each) being down to 9 (a brief calculator use later and that's 12,222.2 each now. Doesn't seem that different really). With no sign of any replacement. Actually, there is sign of a replacement (a girl who used to work here who wants to come back for a few months) but they're not sure if there's funding. I'm sure it's more complicated than it sounds but surely if we needed 10 and were paying 10, we still do and can? But that's why I'm not in management.
The plus side of the reduced numbers is that it has opened up a ward of my very own. The male ward. I'm really looking forward to getting to know the staff well and making small changes to improve the running of the ward. Today's suggestion was that maybe we should put all the sick patients in one area of the ward, near the nurses station and that I should see them first on the ward round... Baby steps.
You have to bear in mind that this is the ward that last week managed to tell a family that the relative that they had come to visit had died.
When he'd actually been transferred to another ward.
This only came to light when the family came back on the Friday to collect the death certificate in readiness for the funeral they had arranged for Saturday. And now the poor guy is still with us for fear that if he'd gone home over the weekend, they'd have freaked and thought he was some sort of spirit.
This certainly isn't something I've faced before.
Thursday, 24 September 2009
One in the eye.
Well, I managed 29 safe days in Ingwa but today I had my first blood exposure incident.
Not, as I had expected, a needle stick injury (yesterday I was doing LPs on HIV positive patients with the electricity flickering on and off), but actually blood in my eye. Nice.
Half-way through a c-section (baby was out and I was attempting to rejoin the two halves of the uterus) I managed to flick blood under my eye shield (why out here are the shields attached by elastic around the forehead leaving them loose over the end nearer the patient??) and in to my left eye.
Following the "rinse it" procedure I promptly welled up, with added lip trembling and voice shakiness, and told the anaesthetist. I guess the plus side of being here is that he could then scrub in so that I could go and properly rinse my eye (and the other one for good measure). Unluckily we have a 25-35% HIV rate amongst our pregnant patients (the group we routinely test).
Rapidly checked her notes and then some internal debate went on; she was last tested 6 weeks ago and was negative (phew!), I wear contacts, surely women who are 8 months pregnant don't do a lot of sleeping around (help me out here placenta head girls?), it's actually quite difficult to get HIV in this manner and PEP (post-exposure prophylaxsis) makes you feel incredibly nauseous and generally rubbish. So I'm not taking it. This time.
What a great start to my week of annual leave; heading off on a game park/beach trip to think about what I have done.
Not, as I had expected, a needle stick injury (yesterday I was doing LPs on HIV positive patients with the electricity flickering on and off), but actually blood in my eye. Nice.
Half-way through a c-section (baby was out and I was attempting to rejoin the two halves of the uterus) I managed to flick blood under my eye shield (why out here are the shields attached by elastic around the forehead leaving them loose over the end nearer the patient??) and in to my left eye.
Following the "rinse it" procedure I promptly welled up, with added lip trembling and voice shakiness, and told the anaesthetist. I guess the plus side of being here is that he could then scrub in so that I could go and properly rinse my eye (and the other one for good measure). Unluckily we have a 25-35% HIV rate amongst our pregnant patients (the group we routinely test).
Rapidly checked her notes and then some internal debate went on; she was last tested 6 weeks ago and was negative (phew!), I wear contacts, surely women who are 8 months pregnant don't do a lot of sleeping around (help me out here placenta head girls?), it's actually quite difficult to get HIV in this manner and PEP (post-exposure prophylaxsis) makes you feel incredibly nauseous and generally rubbish. So I'm not taking it. This time.
What a great start to my week of annual leave; heading off on a game park/beach trip to think about what I have done.
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