Monday, 30 April 2007

When ER came to Hlabisa

The relative solitude of the resuscitation bay is abruptly invaded as the doors from the waiting area slam open. A trolley bursts in, surrounded by people dressed in the white and red garb of the Emergency Medical Rescue Service, KwaZulu-Natals ambulance organization. They look a little bewildered. One of them is squeezing a breathing bag attached to the tube that issues from the mouth of the body that lies on the trolley. The door opens again and a big man in an orange jump suit strides in. His label identifies him as a member of AMS, the Air Mercy Service – the charity that runs the air ambulance and other high tech services.

He catches my eye. “Hi doctor. So this lady came to clinic with 3 weeks of breathlessness and I happened to be visiting the clinic when the ambulance came for her. I thought she looked bad so I followed them.” He grins. “Just as well because she stopped breathing half way through the game park. I tubed her and gave her adrenaline.” He looks around. “Where are your ventilators?”

I mutter something incoherent. I don’t like to admit that we only have one and I checked it the other week and a piece is missing. It probably hasn’t been used since it was purchased. He then rattles off a string of information in ER-speak. It feels like a little piece of Johannesburg or Chicago has dropped into Hlabisa. And Hlabisa does not really know what to do. He turns to the nurse.

“I think you need to set up an adrenaline infusion.” The nurse looks at him blankly and then to me, her eyes pleading for help. No one has ever asked her to do this before.

“There will be some adrenaline in the resus trolley,” I say helpfully. The AMS tech rattles off doses. I move over to the patient and quickly assess her. She has clearly been unwell for sometime and is almost certainly infected with HIV. She has probably developed PCP, a specific form of severe pneumonia not uncommon in those with advanced HIV. She is making no respiratory effort at all – all the breathing is being done by the now rather bored looking nurse who is squeezing the bag.

The jump suit dressed man tells me he is nipping out to do the paperwork. He leaves. Everyone looks at each other. We have no ventilator. We have no ITU. The nearest unit is 2 hours away and they will not take people with advanced HIV and hopeless pneumonias. A nurse could squeeze the bag for a few days I suppose. It will be difficult to find volunteers. This poor lady is going to die. I find myself strangely embarrassed that following all the efforts of the paramedic there is absolutely nothing we can do.

I examine her again. Nothing has changed. Her pupils are fixed. If I stop squeezing the bag she makes no effort to breathe. I write up the notes and my examination findings. I look up. The AMS tech has left on another job. The nurse and I look at each other and in unspoken agreement (confirmed immediately after in word and writing) we disconnect the tube.

Sunday, 22 April 2007

The emphatic breast

It is the end of the day. The weather has turned – it has been raining and we have all worn jumpers for the first time this year. I amble back through the residences. The nursing Matron is standing in the doorway of her flat chatting to a couple of teenage blokes – perhaps family members. She calls me and waves. I wander over.

“Sawubona. Gunjani?” I say in my broken Zulu ("Hello, how are you?"). She smiles benignly.

“Siyapela!” she replies (“We are fine.”) “Dr Moran, you are learning Zulu?!” I confess that I try a couple of words a day but my progress is poor.

“But,” I say with some pride, “I worked out how to ask whether the babies were drinking well: ‘Uyaphuza kahle na?”

“Hauw! Good! But you need to ask whether they are sucking well.” She rattles off a phrase and illustrates it by grasping her own breast through her clothes and waving it to illustrate her point. The family members grin at me as I repeat the phrase a couple of times. It does not stick in my mind – I am a little distracted by the emphatic mammary tissue. I can feel myself beginning to flush with mild embarrassment and make my hasty broken-Zulu farewells. “You will be speaking properly soon – Zulu is very easy!” Matron calls after me as I back away.

Tuesday, 17 April 2007

The Heliemetry

The Hlabisa Hospital Heliemetry

I am in outpatients. Abruptly a roaring, vibrating sound fills the air and thunders over the building. “What was that?” I ask Mr Zulu, the nurse in charge of OPD. He does not know. I wander outside but can see nothing to explain it. Shrugging mentally I return to my consulting cubicle.

Half an hour later I am walking back to my flat for lunch. The road to the residences is lined by a high wall. The wall is new, built in the last couple of years. I have never really thought about what lies behind it. Today however rising high above the wall are the blades of a helicopter rotor. I walk around the corner and find an open gate. A strange and incongruous site greets me. The helicopter dominates the grassed area the wall contains. It is new, painted in the classic colours of the emergency medical rescue services across the world. And it sits in the middle of a grave yard.

The wall has clearly been built to hide the hospital cemetery, a facility which presumably seemed appropriate when the Lutheran mission out of which the hospital grew was first founded in the 1930s. A couple of years ago I imagine someone in the Department of Health felt that it was inappropriate welcome for patients and visitors arriving at their local (and only) health care facility.

I run to get my camera. But by my return the helicopter has left. All that remain are a few onlookers eating their lunch on the gravestones.

Saturday, 14 April 2007

Sister Amen

It is my last day on T ward. The doctor I have been covering for these last weeks is back from the UK on Monday and I will be moving to outpatients. I am working my way around the male half of the ward with Sister Hlabisa. Surnames are often taken from the location and there are a lot of Sister Hlabisas. I call her Sister Amen on account of her involuntary exclamations of praise.

I examine the chest X-ray of a 20-something man admitted with pus in his chest as a result of TB. I put in a drain last week and after the initial 2 litres drained only a few millilitres drain each day now. The X-ray confirms that the pus is gone and the lung fully re-inflated. “Very good,” I tell Sister, “this drain can come out today.”

“Amen!” proclaims Sister. She explains to the patient who grins, gives me 2 thumbs up saying “Sharp sharp!” which apparently means “Cool”.

The next patient has completed 2 months of inpatient TB therapy which required injections – he lived too far from his local clinic to make the daily journey. He speaks fluent English and we have enjoyed our brief daily chats. “Hey doctor, I will miss your rounds when I am gone. I will miss your smiling.” I am wearing an enormous duck-bill like respirator mask and ask how on earth he could know whether or not I was smiling. He grins. “Your ears go up.”

I write up his take-home medication and hand it to sister. “Praise the Lord!” she proclaims.

The last patient is an elderly man, severely confused as a result of high blood calcium almost certainly due to cancer. I have been hydrating him which has helped a little but what would really help are the expensive calcium lowering drugs routinely used in the UK but not available here. Nor will I be able to get a scan in an attempt to identify where his putative cancer is – if I knew what could I do about it? Not much at this stage. I look at him sadly. His wife is by the bed. I ask Sister to explain what is wrong. She does so and the wife nods, saying “Ohhh” in a manner incongruous to my British ear, as if a beautiful firework had just lit the night sky.

“I do not think we can do much more for him,” I tell Sister. She shakes her head and mutters a sombre, “Amen”.

Saturday, 7 April 2007

The Resuscitator

I am standing at the mother’s head in the theatre. I have given the spinal anaesthetic and the surgeon is cracking on with the Caesarian. My mind is wandering a little – it is late in the evening and I have yet eaten. The mother needed the Caesarian after it became clear the baby was becoming distressed with a high heart rate and meconium appearing in the mother’s liquor.

I am broken out of my reverie by the midwife. Like me she is dressed in surgical scrubs with a blue theatre cap and mask.

“Dr, will you help me with the baby?” She is clutching a sterile sheet, ready to take the baby from the surgeon when the time comes. I throw off my daze and nip over to the Infant “Resuscitator”, a small mattress with a heater, oxygen, suction and set of airway tubes. I have never seen one this close before. I nervously open drawers, pretending to check for things which I think should be there. I have, of course, no idea what. I spot a laminated A4 sheet stuck to the wall, obviously placed there in the distant past by some predecessor – it is a step by step account of how to resuscitate a new born baby. I start reading feverishly – my increasing nervousness significantly impairing my ability to retain the facts.

I turn back to the operating table. The baby’s head is out of the uterus and the surgeon is just releasing the shoulder. The body is delivered. The midwife takes the baby and wraps it in the sheets. There is no cry, no noise. She rushes over to the resuscitator and places the baby on it. It, a he, is blue and unmoving. The midwife sucks out the secretions from the nose and mouth and checks the pulse. He stirs a little but there is no breathing and no cry. I grab the bag and mask, turn the oxygen to full and place the mask over the baby’s mouth and nose. I gently squeeze the bag looking for movements. Nothing. I squeeze a few more times. The knot in my gut gets tighter – I don’t think I am getting any oxygen into the baby’s lungs.

I take a deep breath – I’ve never done this before: “Sister, can you pass me the laryngoscope?” She passes me the silver device used to find the vocal chords so the airway tube can be inserted correctly. I gently pass the blade to the side of the baby’s tongue, pushing it to one side. “Suction please.” The midwife passes me the slim suction tube and I suck away the meconium and secretions that obscure my view. I catch a glimpse of the chords and, acutely aware of the seconds passing during which the baby is getting no oxygen, pass the slim airway tube down between them.

I pull out the scope. It feels like ages but has probably only taken 10 seconds. I rip the mask off the bag and push the bag onto the tube. The midwife fits the stethoscope to my ears and I gently squeeze the bag whilst listening to the baby’s lungs. The relief is a physical wave down my body – I can hear the air in each lung. “Is there a pulse?” The midwife checks and yes, there us. I continue working on the bag and watch as the lips turn pink. A hand twitches. The midwife rubs the baby. He moves a leg. A hand. Both hands. His face contorts and I realise that if my tube were not stuck between his chords he would be using them to make a hefty cry.

I pull out the tube and the theatre is filled with sound, a sound I have heard many times before but this is surely the first time I have classed it as beautiful – the wail of a newborn baby.