Friday, 30 March 2007

The ear

OK, so I admit it. I should have known better. There is no excuse. Every medical student knows that the smallest thing you should stick in your ear is your elbow. But I was proud. I thought I knew what I was doing. I had done it before and crazed with the flush of success I did it again. I syringed my own ear.

Let me explain myself. It first happened back in December. Newly arrived in South Africa the heat dislodged some ear wax and I lost some hearing, common in new arrivals I was told. After several miserable dinners in which I was incapable of joining the conversation I took the bull by the horns, bought a syringe and spent 20 minutes flushing out the ear. Imagine the joy of seeing the numerous bits of waxy debris fill the basin and the relief as the last rubble of draining soapy water brings with it the crystal clear high fidelity hiss-free noises of the world around for the first time in days.

So when last week I awoke unable to hear out of said ear unless, bizarrely, pulling firmly down on my right ear lobe I felt I knew the drill. After a couple of patient encounters in which the limitations of the ear-lobe-pulling technique were demonstrated (tricky with a stethoscope) I nipped home and spent some time flushing it out. The results were, I admit disappointing. There were no acoustic revelations. The following morning the impediment was slightly worse. The day after that I awoke aware that the ear was discharging and olfactory investigation revealed it to be offensive.

That evening several of us (the doctors) went of to the tourist seaside town for St Lucia for the night, celebrating the fact of the public holiday that followed. By now my ear felt enormous. I could not understand why my colleagues were not commenting on the prodigious size my right pinna must have reached. I asked them, and they examined it and true to their polite and gracious natures said each looked identical. But I know they were simply hiding their horror. That night I awoke almost smothered by my own ear. It throbbed, it leaked, it stank.

I dragged myself over to the lodge reception the following morning. We spent some time on the phone. All the pharmacies were closed for the public holiday. The local GP claimed to have no antibiotics and did not want to see me. The receptionist, moved by my tears, suggested I walk down the road to where the only other GP in town worked. Perhaps he could help.

The reception room held four other people – one white and the other black. The door leading from the reception room opened. Standing in it was the GP, a stocky Afrikaaner in his early 60s, clad in shorts with long socks and sandels. “Next!”

I gestured to the others in the room. They gestured back to me. I said “But you were first.” They shook their heads and indicated I should go. Apartheid would appear to be slow to die in the minds of some. “Well if they want to be so polite that is their right.” said the exasperated GP

In his office I described my problem. He grabbed antibiotics and ear drops off the shelf announcing that he saw a lot of this (the divers apparently). He was more interested in talking about Hlabisa (“You must learn surgery. Here you will see real medicine!”).

“You must come to St Lucia again. Next time you come you must come out on my boat…” He grabbed a flyer: his yacht charter company. “…and stay in my hotel…” Another flyer, this time for a lodge a short walk from where we were. “… and come have dinner at my restaurant.” A third flyer was thrust into my hand: a slightly tacky looking restaurant – with a water chute. Further questioning revealed that he also owned the local (and only) bar club. So, I observed, you could stay in his hotel, go out on his boat, eat as his restaurant before going to his club, getting beaten up in a fight and calling him to stitch you up. He grinned.

I walked out clutching my antibiotics 2 minutes later (“no charge in the profession”) and gulped down the first dose. I am, you will be relieved to hear, now cured. Won’t be syringing my own ears in a hurry again.

Monday, 26 March 2007

Matchmaker matchmaker

Mathonsi looks up as I walk into the outpatients procedure room. “Sawubona Doctor, what do you want?”

“I’m looking for someone to help me see patients.” He turns to the three student nurses dress in white standing by him doing nothing and eyes them thoughtfully.

“Which one do you want?” He takes my hand and pulls me closer. He grabs the hand of one of the nurses. “Here, this one. She is a fine woman. She will do you well. I think you will both be very happy.” He places my hand in hers. Everyone bursts out laughing as we walk arm in arm to the consulting cubicle.


The morning goes briskly. A man with hypertension, a few probably TBs, a gastroenteritis, diabetic reviews, an acute severe pneumonia. The nurses change at 11 for coffee. My betrothed’s replacement is not so enthralled with my work style. She yawns noisily and pointedly whilst I am examining a patient and as I write the treatment card, disassembles her biro and taking the plastic ink tube, sticks it in her ear. “Are you allergic to anything?” I ask the patient. The nurse translates whilst energetically scraping the deep recesses of her ear canal.

“No doctor,” the nurse replies as the patient answers, studying the tip of her biro interior with great interest before wiping the waxy minings off upon her dress. I give her a Paddington bear hard stare in an attempt to communicate that this is puzzling behaviour for the consulting room. She stares blankly back at me. I hold my gaze for a few seconds but, damn she’s good, I have to drop first. She could have taught Paddington a thing or two.


Then to the ward. Sister Jenny, an elderly nurse whose rolling antalgic gait is a consequence of her bad hip arthritis, eyes me. “Doctor,” she shouts, “are you married.”

“No,” I reply. A chorus of mutterings and laughs erupts among the nurses.


“Hauw Doctor! You must find yourself a Zulu wife. A good Zulu wife. Our old medical director. He was English and he found a Zulu wife. You should too.” The other nurses take up the chorus and I back out, throwing on one of the paper masks – useless at preventing TB but brilliant at hiding chronic embarrassment.

The road to work

Wednesday, 21 March 2007

Monday morning

I slowly inject the anaesthetic through the needle I have just placed into the lower part of the woman’s spine. She is sitting on the edge of the operating table leaning forward into the arms of the large operating theatre sister who embraces her, holding her in a slightly hunched position to ease the insertion of the spinal needle. Did I say ease? It still took 10 minutes of sweating and stabbing on my part. I am the third person asked and I confess to succeeding not so much by skill as necessity – everyone else is stuck in Monday morning’s outpatients. The drugs flow easily and I remove the syringe and long spinal needle. We give her a couple of minutes and then the surgeon tells her to lie down. Dr Kekana has been on call all weekend and only had a couple of hours sleep last night. I even inadvertantly overheard her bed calling her.

I busy myself at the “head end” of table. I am, for want of a better term, the “anaesthetist”. I was called in at the last minute I forgot my book of drug doses. I hope nothing goes wrong. All the Caesarians here are done under spinal anaesthetic – none of us really know how to do safe general anaesthetics. But we have read the right chapter in the book. I try to look busy. Prepare a couple of drugs, copy a few blood pressures from the monitor screen to the chart in front of me.

Dr Kekana starts the operation. Sister says something to the mother-to-be who is staring at the ceiling, her view of her own lower half mercifully obscured by green drapes. She begins singing, lifting her voice in improbably gusty and melodic song. It is Zulu, but “Jesu” features prominently. She stops after one verse. A theatre nurse takes up the tune and after a breath mother joins in once again, this time in harmony. A male theatre assistant walks in with a box of swabs. As he walks across the theatre he adds a resonant deep bass line, filling in the beats after each line the women sing. Sister finally joins in, four voices echoing around the small theatre to the beat of the heat rate monitor’s beep and Dr Kekana’s softly muttered requests to her assistant. I have not been concentrating. The mother’s blood pressure has dropped, a side effect of the spinal anaesthetic. I give her some intravenous fluid and a small shot of a drug to help push it up again.

A new song has begun, this time in English. “I worship you Jesu,” the four voices sing. It appears almost to the beat of the music that the child is born from the mother’s belly, his mouth opening in a cry even before his body is fully out. The cord is cut. The child gives two more half-hearted cries and promptly falls asleep, covered in fluid and blood. The theatre nurse plucks the baby up, dries and swaddles him and brings him to the mother who breaks into a broad grin. She kisses him, a single tear trickling from one eye. The baby is taken to the heated cot as Dr Kekana starts to close the uterus and abdomen. It is a stark and welcome contrast to the Caesarian last week, in which the mother greeted her baby with a bleak look and a request for a tubal ligation.

Dr Kekana has finished and the mother is wheeled to recovery. She wearily writes her notes but, we both say, whether finishing an knackering weekend on call, or starting a Monday morning can there be many better ways than this?

I mean apart from still being in bed. Obviously.

Monday, 19 March 2007

Le weekend

The phone only rings twice before someone answers.

“Lidiko Lodge, can I help you?” answers a heavily Afrikaans-accented lady’s voice.

“Hi, yes,” I say. “I’m phoning from Hlabisa Hospital. I want a bed, a telly, a hot bath and a swimming pool. Do you have those?” She bursts out laughing.

“Yes, yes we do. When do you want to come?”

“Now. 2 nights”

“Now? Yes, we can do that. What’s the name?” I give my details and hang up. It is 3pm on Friday. I am standing in a hectic outpatients department and feel an overwhelming need for restaurants and hot water. The resort town of St Lucia is only 75 minutes drive away and is an ideal bolt hole for Hlabisa doctors. My flat has been without hot water for 3 weeks now – the boiler elements keep burning out due to their unexpected and repeated attempts to heat air each time the water runs out. My reluctance to wash in cold water has lead to me smelling pretty bad.

I jump in the car at 6pm and head out of the hospital nearly hitting a Department of Health 4WD on my way out. “Hey doctor,” says the guard, “you nearly hit him.” I smile ruefully. I am drifting off as I enter stretch of road that runs through the game park and have to employ my patented stay-awake-whilst-driving technique (which involves abrupt tugs on one’s groin hair through one’s pocket). Ten minutes into the park I pass three rhino grazing by the side of the road. Suddenly the patented technique is redundant.

I pass through the now familiar settlements that line the side of the road, then the town of Mtubatuba (one shop sign reads “Tombstone World”) in which hordes of people are pouring out of Spar and into KFC, Wimpy and Nando’s, and finally hit the stretch of forested road that leads to the coast and St Lucia. It is as if I have passed through some improbable “portal” – only 20 minutes from mud huts, African markets and road goats, St Lucia could have dropped out of Florida: the carefully kept lawns, roads and shops; the 4WD vehicles all towing power boats; the streets and restaurants all full of wealthy looking white people. I am embarrassed at how delighted at it all I am.

I spot the lodge and park the car, walking up the steep path through the garden to the porch. I am instantly spotted by the Afrikaans lady I spoke to. “You must be the doctor from Hlabisa. Come let me show you to your room, and then you must come and join us – we are having a braai. We don’t normally do dinner.” The lodge is great – 10 rooms in a square all opening onto the pool. I dump my stuff and head back to the stoep with my book. She calls me over, “Now you have a choice – you can either sit all by yourself over there with your book or you can come join us – this is my husband and this is Rob – he works for the Wetlands park.” Food and beer are gently forced upon me and I join them. They are very interested in what the hospital is like at the moment – they have had several doctors visit from there before. They keep calling me Ned. The moment for correcting has passed. I am too embarrassed to say anything now. They tell me all about their local GP who is an entrepreneur – “He is a one stop shop – you can go fishing with his boat hire company, have dinner in his restaurant, get drunk and beaten up at his bar, and then call him to stitch you up.”

Before bed I have a swim in the pool – it is pitch black above me, Orion and the Southern Cross clearly visible.

In the morning, as I head out, the husband stops me and introduces me to a couple. “This is Ned, he works at Hlabisa Hospital.” They chat cheerfully with me a few moments – South Africans now living in Canada before wishing “Ned” a great day.

I meet with a couple of the other doctors and we go down to the beach with a bottle of wine and some crisps. The sea pounds on the dramatic rock formation around us – there is no one else here save the crabs that scuttle on the rocks and beach just south of where we are sitting. “Another rubbish day in Africa,” sighs Alison as the sun slowly sets behind us.

I get up and walk aimlessly down the beach a little. As I round the headland a new expanse of sand opens up before me. Crawling from the sea onto it are thousands on tiny crabs. The waves sweep them up from time to time, pulling them back to the ocean. A few are beyond the waves and seem to be eyeing me. I walk along the beach. As I approach they change direction, scuttling back into the see one after the other in a Crustaceal-Mexican wave. I stop. Their bulbous stalked eyes examining me as they slowly crawl up the beach again.

The following morning I check out of the lodge ready to head to another stretch of beach with my body board. My hosts shake my hands warmly. “You must come again Ned.” I say that yes of course I will, knowing that of course I will not. I cannot. Not now they firmly and irrevocably think my name is Ned.

Monday, 12 March 2007

Pus

There is a satisfying give and I feel the rush of hot brown pus over my gloved finger. I work my finger a little more, widening the hole I have made in the man’s chest. He winces a little but the morphine and diazepam given a few minutes ago have spaced him out somewhat. As I injected them he said to me, “Doctor, what makes this fluid in my chest.” I told him it was the same bug that had caused his TB. “So it is not my food or drink?”

"No," I said, "that is very unlikely." He nodded and dozed off.

As I enlarge the hole the pus runs faster soaking the sheets. Sister is watching and looks a little put out, but says nothing. She hands me the drain tube and I push it through the hole between his ribs until 15cm or so of tube has passed into his chest cavity to drain the TB-infected fluid that has been sitting around his lung. Sister connects the tube to a bottle on the floor. I start suturing the tube to the man’s skin to prevent it dropping out and he begins to wake as the diazepam and morphine levels drop. “Done already?” he asks. I nod. He looks at the drain with interest. “Doctor,” he asks, “What makes this fluid in my chest.” I tell him it was the same bug that caused his TB. “So it is not my food or drink?” No, I say, once again, that is very unlikely. He nods.

Sister returns with the dressings for the drain. I have finished stitching. She looks with interest. “Doctor,” she asks, “What makes this fluid in his chest.” I tell her it is the same bug that caused his TB. “So it is not anything he eats or drinks?” No, I say, once again, that is very unlikely. She nods.

Wednesday, 7 March 2007

First day

I know what to expect intellectually. I have heard about it. I have seen it in photographs. I have read about it. Still, it is a quite different matter, the emotional impact of seeing for yourself: a ward with 30 beds holding 45 people, some on the floor, others sharing mattresses; the nurses stepping over a 30-something year old man, demented as a consequence of HIV, as he crawls on the floor smeared with his own excrement; the wizened, emaciated bodies of those with multi-drug resistant TB; the crowd that masses each day at the outpatient department, some waiting 2 or 3 days before they are seen.



The hospital main entrance - the sign on the right proclaims the hospital "baby friendly".


I am spending my first week shadowing the doctors that are here already. Each morning begins with a 7:30 gathering in the medical director’s office. He is an enthusiastic South African Indian obstetrician. It is impossible not to like him. Each morning he gives a run down of the day’s hurdles: the hospital development is on hold – the 2010 Football World Cup has taken priority, all the boreholes have run dry – the hospital’s water is being bussed it each day so we will only have water at our accommodation for a couple of hours in the morning and evening, a new doctor is coming next month – but the accommodation is full at the moment. Some mornings everyone finds it funny, other mornings all that prevent us from hanging ourselves with our stethoscopes is the lack of readily available hooks. Things are looking good this morning however. I bring the number of doctors to 15, the highest for some years. Last August there were just 5.

I spend the morning with the doc covering T ward – the TB unit. At least 50% of people are infected with HIV in parts of this region and this has fuelled the TB epidemic. Only a handful of people of the TB ward are HIV-negative. Most people start TB therapy in outpatients. The ones that are admitted are those too sick to manage at home either because they come to hospital only when they are extremely weak, or because their treatment has failed (perhaps because they quit taking it, or because they have resistant organisms). Some come with complications of treatment or with other problems entirely, ending up on the ward because they are TB infected. Like an old UK fever ward , it is built right at the back of the hospital – well away from everyone else.

The TB ward

We do the ward round with one of the sisters. She translates for the patients of whom only a handful speak fluent English. This is a rural Zulu area. I learnt the basic Zulu greetings on a previous trip but otherwise I understand nothing. I pick up one phrase that keeps being repeated: “Kubuhlungu”, “I have a pain”. Several people have chest drains – pipes inserted into the chest cavity between the ribs in order to the drain the collections of pus that can form as a consequence of TB. One man drained 2 litres of the stuff after his drain was inserted yesterday. Another has had his drain for weeks. It stinks and the wound oozes continuously. But the drain must stay in – the TB damaged his lung badly and it would rapidly deflate without it. With every breath lightening flashes of pain flicker across his face as the drain rubs on his inner chest wall – we increase his morphine prescription. Three or four patients are fit enough for home now. They are discharged with firm instructions on the importance of adhering to their therapy. The increase in MDR (multi-drug resistant) TB has followed in the wake of poor adherence to standard treatment. Half way through the round a nurse brings the doc two sets of forms to complete – the death certificates from yesterday.


The outpatients department

After the round we go to OPD – the outpatients department. It serves as Casualty and non-urgent outpatients. There is no culture of booked appointments - the means of communicating with people is very limited and many do not have postal addresses. We double up in the cubicles, 2 doctors sharing each space, divided by a curtain and assisted by a nurse to translate and help with any procedure. The place is swarming with people. Each time the door opens for a patient to leave a hundred faces look in your direction and the next person leaps up. My first patient is a baby. There is no “Paediatric clinic” – we all do everything. His mother has brought him because he is not growing. She has brought the growth chart she was given when he was born. He is 9 months old and has not put on any weight since he was 3 months old – and has in fact lost 100g in the last 4 weeks. He is wizened and dehydrated and has not even the strength to cry as I examine him, issuing only a hoarse wheeze. “Why hasn’t the mother brought him sooner?” I ask the nurse. A brief discussion ensues between them. The nurse shakes his head.

“The journey here is too expensive.” A few more questions and it turns out the mother was found to be HIV positive in pregnancy. The baby has not yet been tested but will almost certainly be positive as well. I admit the baby and find the doctor who covers the paeds ward who gives me a brief tutorial on the management of marasmus (the classical name for this kind of malnutrition).

We are supposed to finish at 4:30pm - we started at 7:30 - but there are crowds of patients outside still and no one feels they can leave their on call colleague alone quite yet. We finish at 5:45pm and the doctor on call for the evening begins the task of moving through the queue to identify those patients who need to be seen tonight. That will keep him occupied until 1 or 2am. The others will have to wait until tomorrow.






The residences complete with palm tree feature.