Wednesday, 30 May 2007

Rainbow

“So, would you socialise with a white person?” I ask, with the brash innocence learned from my American friends.

Sibu looks awkward. “Ahh. That is a very difficult question doctor. It would be difficult to socialise with a white person.”

“Why?”

“We talk together in class and on the wards. But when you are out of the classroom it is different. We do not even greet each other in the corridors.”

“Why?”

“Ach doctor. I do not know.”

Sibu and I are driving to clinic. He and another medical student are doing a 2 week “family health” placement at Hlabisa Hospital.

“But why do you not get on? We get on.”

“It is different doctor.” I had assumed that universities and medical schools would be the melting pot of South African culture – where people divided by race and the class of their upbringing would discover each other as they forged their educational common ground. But it seems not.

“How many white people are there at your medical school.” He looks thoughtful.

“Maybe 15?” There are well over 100 in his year. “And a few more Indians.” Perhaps, I wonder aloud, they feel insecure. A racial minority in a previously black medical school. “If you see a white person and a black person socialising or talking together out of class you can say immediately, ‘Ahh – that is an international student’. It is only the internationals who talk.”

That evening I invite Sibu and his friend to dinner with a few of the other (white) doctors. They sit together on the sofa mostly in silence. One or two (international) individuals initiate conversation with them but the group does not sustain it. After an hour and half they make their excuses and leave. I do not blame them.


Patients waiting outside my consulting room at the clinic at KwaMsane township.

Friday, 25 May 2007

Darkest Africa

It's 6pm. Potatoes are boiling, carrots are ready and onions are frying. Then, abruptly, everything goes black. Really black. Not a UK power-cut pseudo-black. Proper black-as-pitch black. I step out into the car port. I can barely see across to the flats opposite. The stars
above are just amazing and it is clear that power has been cut to the whole area – not just the hospital compound.

Inside the sounds of boiling gradually die away as the hot plates cool. I fumble around for my single candle, cursing. When I arrived there were frequent water shortages and I got into the habit of filling pans and the bath before I went to work. These power cuts are new and I am a poor boy scout – my only torch is a comedy "wind-up" one from Japan that gives light for 25 seconds unless you sustain a rapid, loud and wild winding. Puzzlingly, it also has a built radio.

I wander around the residences with my torch (furiously winding) and locate my dinner guests – unless they like partially frozen fish dinner is off. I try to call it Sushi but no one buys it. Nomfundo says she will pray for electricity – "My prayers are usually answered" she grins, "unless of course you don't have enough faith?!"

In the end Jabu, Nomfundo and two medical students on elective from the Uni of KZN come for drinks. I ask Jabu what he would like to drink. "A cup of electricity," he groans. He has satellite TV and had planned an evening in front of the cup final.

"What about your prayer?" I ask Nomfundo.

"Sometimes he takes his own time to answer," she replies serenely.

Tuesday, 22 May 2007

Monday AM

“So when did the diarrhoea start?” I ask the mother, and then pause. A lone female voice is lifted in song in the outpatients waiting area. Others join in beautiful harmony and syncopation. I look at the nurse who is helping me: “I love the singing – let’s go and see?”

“You want to join in?”

“May be another time – just watch today.” She leads the way out and there, lined up in front of the doors to the consulting cubicles are the OPD day staff singing songs of praise. The patients who have been sleeping in the department overnight join in. Some may have arrived too late to be seen yesterday. Others had to wait for the morning for transport. The harmonies echo off the high ceiling and reverberate around the room.

At the end one of the male nurses, Ziggi, says “Let us pray” or at least I assume that is what he says. A low muttering fills the room as everyone prays under their breath. A couple of the nurses catch my eye and grin.

Then, after a brief silence, the line breaks up and it is back to work. It is 6:30am. I had a good sleep and was woken only to see a baby with severe diarrhoea – the nurses had already stuck in an IV line (just as well because I have yet to succeed in sticking drips into 2 month old babies) and given fluids even as I was hopping around my room in the pitch black trying to find my clothes in a power outage.

I see a couple of other patients and then nip to the office for the tearful Monday morning reunion with my colleagues, my mood of cheerful euphoria at seeing them after 60 hours a stark contrast to their classic Monday morning monosyllabism. I sigh, sit back and contemplate my next Weekend of Fun.

Sunday, 20 May 2007

Sunday afternoon

My phone goes: Maternity unit. My pulse always doubles when maternity call. It is my great area of ignorance (surpassed, some friends would say, only by my ignorance of what goes on before…). Would I please go and assess as lady who is 9cm dilated but the foetal head has not descended.

I warily enter the labour ward – I always feel particularly foreign in here.

“Thank you for coming doctor. This is the lady.” The midwife hands me a pair of gloves. I am a little more adept at vaginal examinations now but could not be described as slick. I think that is the foetal head, and I think that must be scalp caput (bulging of the child’s scalp as it is pressed against the cervix in delivery), what that is I have no idea at all but I can’t feel a cervix rim. The head feels pretty far down to me but to be honest this is only the second time I have felt a foetal head so I have no idea.

I withdraw my hand and try to look thoughtful – like I am an expert with so much knowledge that I am weighing up numerous possibilities that are occurring to me, rather than revving my empty brain in neutral. Luckily Matron walks in. A lady all of us doctors are in awe of. I sidle up to her. “This baby’s head is 2 fifths descended. What do you think we should do?”

She appraises the women from across the room, pulls on a pair of gloves, strides over and examines her herself. She turns back to me. “She is about to deliver.”

“Ah,” I say. “Thought so.”

Sunday morning

I am pulled from a contemplative dose by the noise of my mobile phone. I pick it up. “Hello?”

“Sawubona doctor. It is Head Office in Pietermaritzburg. It is about your patient who is going to Durban.”

“Oh yes?”

“Unfortunately we were not able to do it yesterday but I just want to check that you are happy we do it now?”

“No problem – thank you very much.”

“Sharp! The helicopter will be there soon.”

“Fantastic – thanks so much.” I lie back for a few moments and then a thought crosses my mind. I pick up my hospital extension and call the High Care ward. “Sawubona Sister.”

“Hello doctor.”

“That patient for transfer to Durban…”

“Yes doctor?”

“Is she still alive?”

“Yes doctor.”

“Good.” It would have been hard to explain if the helicopter had flown a 600km round trip for the recently deceased. I check the clock: 7:30am. 7 hours glorious sleep. Fantastic! I feel I can take anything the last 24 hours of on call throws at me.

I throw on my clothes and potter over to outpatients. The marvellous Dr Zulu is still there having only had 4 hours sleep. He has left only 1 patient. I pack him off to bed. I nip into High Care to check on the patient for transfer. There are 2 new people as well: a man with a head injury following an assault and a gentleman with malaria (he travelled to Zimbabwe recently). Half way through the round there is a roar of air overhead – the helicopter has arrived. 15 minutes later the army of red jump-suit clad men fills the ward. The nurses and students who had been clustered around me on my round abruptly vanish to surround the much more interesting Air Mercy Service team. I am left with one student.

They wheel the patient out and a few minutes later the air roars once again and I see the helicopter circle the hospital site before heading south to Durban. I send up a silent prayer that it will all have been worth it for her – but whatever happens on this occasion the system worked and did all it could.

Saturday, 19 May 2007

Saturday

I am dragged from my semi-conscious doze by the characteristic triple ring of my flat telephone. I am not really asleep but neither am I awake. The room is bathed in the dull blue glow of early dawn and the tail end of last night’s gale forces itself through the small window pushing the curtains into an awkward embrace with me as I clamber out of bed. I stagger over to the phone.

“Hello.”

“Hello doctor. How are you?”

“I am fine.”

“I am fine too. Doctor it is H ward. We have a patient who is gasping.” I pause. They might be dead. They might be sick. It is impossible to tell over the phone.

“I am coming.” I hop around the room, pulling off boxers, pulling on socks, pants, trousers and shirts. I walk briskly to the ward. Two nurses are standing over a patient. One commendably bagging and masking and the other doing chest compressions. I look at the notes. A young man with HIV and widespread TB. A quick examination reveals that he is not breathing and has no heart beat.

“We gave adrenaline doctor but it did not help.” I thank the nurse and we decide to stop. I look at the clock. It is 5:30am. 4 hours sleep. Pretty good.

H ward - although not at 5am

I saunter back to outpatients. They have saved me a few overnight: 4 ladies that were in a road accident in Swaziland 3 days ago and wanted to be checked out. One turns out to have a fractured wrist. Nothing was done about it.

Next I go to review a couple of patients the other docs asked to look at before they left on their Weekends of Fun. One is a lady who came in psychotic and confused. She has HIV and is on TB treatment but this is new. She was too agitated to do a lumbar puncture on yesterday. She is a little better today. Yet every time I touch her skin with the needle she squirms this was and that and makes to grab me. I start off patient. Then find I am getting annoyed.

“Tell her I have lots of other people who need my help and let me help them,” I grumble. The nurse looks at me.

“I have told her Doctor,” she says reproachfully. We try again and she twists and tries to hit me. I throw the needle to the floor in exasperation and turn away. The patient grabs my arm and says something. “She says she is sorry doctor and please will you try again.” I instantly feel a complete louse. We try another position and with 3 people holding her we finally get the needle in place and collect the fluid.

“Siyabonga Doctor!” says the lady as I label the tubes.

Next is a patient with TB meningitis who is in an increasing coma – probably as a result of hydrocephalus, a building up of fluid in the brain causing high pressure. They tried to arrange a CT scan for her yesterday but there was no transport available. The local hospital that does our scans does not run a weekend service. She is having seizures more or less continuously and is unrousable. A series of long phone calls later and I have arranged a scan in Durban with the neurosurgeons – if the scan confirms increasing hydrocephalus they will need to operate. I am slightly surprised they agreed to take her. Yet again there is no transport. The Emergency Service offers to send a helicopter but the hospital in Durban refuses – if they decide not to operate on her after the scan the helicopter will not be available to fly her back and she will sit in one of their valuable beds.

I am phoned 4 hours later by an apologetic operator. They will take her first thing tomorrow morning. It is now too late for road transport (she won’t get there until late in the evening now). Her conscious level is deteriorating and I take her to our High Care ward so I can intubate her. Her fitting does not stop despite her cocktail of strong anti-epileptics. I pull out my anaesthetic handbook and almost with the nurse pointing to the right part of the “How to do an emergency ventilation” paralyse and intubate the lady.

Next back to outpatients where the day doctor and I sedate and restrain a 4 year old too hysterical to allow me to suture him last night. He is still pretty hysterical and even after a hefty sedative a couple of us have to hold him so Dr Zulu can suture.

OPD is now pretty civilised – Dr Zulu has it under control. It is 3pm. I slip back to the flat, eat half a bar of Dairy Milk, watch an episode of Friends and lie on the bed. If there are any Caesarians or OPD gets crazy Dr Zulu will call me. This might be the only chance for sleep.

Friday, 18 May 2007

The long and lonely night...

“See you, Ed. Good luck!” shouts Olsetin as he heads out of OPD. The sinking feeling in my belly drops at little lower. It is Friday. 5pm. Everyone is leaving. Except me.

I am starting my weekend on call. I started work at 7:30 this morning. I will finish at 5pm on Monday. As I look at the receding back of my colleague heading off on a Weekend Of Fun (how I hate them all right now) it seems like an eternity. That I have just finished 7 weeks of my Weekends Of Fun (a considerably longer period than in any UK rota) counts for nothing.

I turn back to the OPD cubicles. Give the colleagues credit. They have worked solidly and there are only 6 or 7 people still to be seen. I get going and see 2 chronic coughs (“query TB”), an elderly gent with arthritis, a young child with a chest infection, and a 2 day old baby whose mother was sent to the hospital by her local clinic because they thought it was “too big” (birth weight 4.3kg). Sure it looks a big baby but it takes some conversing to establish that that was the only reason the clinic sent her up. I feel terrible that the mother has spent half a day taking taxis to get here only to pay her R20 at the hospital reception and be told it was a pointless trip. I pull out my wallet and give her R20 back – less than £1.30 to me but considerably more significant to her.

The curtain of my cubicle twitches. It is the UK medical student, here on elective. “Ahh, Jenny,” I greet her.

“Actually, it’s Rachel,” she replies. I have been referring to her as Jenny to other people for several days but so far had managed to avoid using it to her face. She looks like a Jenny.

Rachel has a child with fever and neck stiffness. Never done a lumbar puncture on a kid before. I assume it is similar to an adult. We get the Mum to hold the child in a curled up shape and the LP goes fine. “Thanks Jenny,” I say.

“Rachel,” she mutters.

Next, a 16 year old stabbed in the back whilst playing football. I cannot hear any air entry on the right side of his chest. I call out the X-ray man and 10 minutes later a chest X-ray confirms the stabbing has deflated one lung slightly. I stick in a chest drain (in essence hacking a hole in his chest for the air to drain out – along with, as it turns out, a fair bit of blood that had leaked into his chest after the stabbing).

Then a flurry of children with diarrhoea, head lacerations, a lady the same age as my Mum who fell out of a tree trying to pick oranges and a drunk paramedic who tries to convince me his ankle is broken and he must have an X-ray (he only turned whilst walking along the street and it is not even tender).

The activity dies down. Rachel looks around. “I think I’m going to go now. Can I come on Sunday to help as well?”

“No problem – you’ve been brilliant. Thanks for helping J.. Rachel.” She rolls her eyes and walks away. I walk out of OPD – the patients I saw earlier are getting ready to sleep over – there is no way they can make the long journeys back home at this time. Mattresses have been laid on every piece of available floor space and people are curling up with blankets. Some nights there may be 20 or 30 people we haven’t had time to see – tonight is good. Everyone has been seen.

20 minutes later I am in my flat. It is midnight. I am about to climb into bed. Sleep seems someway off – it is hard to release the knot of nervous anticipation. I could be called at any moment...

Saturday, 12 May 2007

Gives me fever

“Where is Stefan?” someone asks.

We look around the table – it is 7:45am, our morning meeting; the hour in which we exchange news, frustrations and attempt catharsis before leaping up to carpe diem. Stefan – the longest serving member of Hlabisa’s medical staff at a grand total of 11 months – is not there. “He won’t be in today,” says the medical manager, “he’s feeling a bit sickish.” We all murmur our commiserations. I secretly feel a little envious. I wonder whether what he has got is catching – I quite fancy a day in bed. A few hours of rigors would be a price worth paying.

The following morning Stefan is still sick. Apparently he had swinging fevers all night. Someone mutters “malaria”. I grab some blood tubes and needles and wander over to his flat. It is locked and the curtains are drawn. I call his mobile. There is no answer. I imagine him lying in his bed, shivering and delirious. How could his girlfriend have left him in such a state? Has she no heart?

My mobile rings. It is Stefan. He is in outpatients. He sounds remarkably coherent for a delirious man.

In outpatients Stefan looks fine. A nurse is taking his blood for a malaria rapid test. He went to Mozambique 3 weeks ago and hiked in a northern KwaZulu-Natal game park 2 weeks ago. “It is strange,” he says, “I was feverish and shaking all night and now I feel fine.” He is indeed afebrile now.

I examine him – carefully omitting anything below the hips. Nothing to find. Any rashes? “No,” he says, and then pauses. “Apart from this.” He lifts his trouser leg. On each ankle is a small inflamed area with a black centre. Any swollen glands? I let him examine his own groin. One should never examine the groin of an individual into whose eyes you need to be able to look at work the following day. Yes, there is swollen gland.

We conclude that Stefan has tick bite fever. I prescribe him a course of antibiotics and he is back at work a couple of days later. Wonder how many times I have missed the diagnosis in the general outpatients? Make note to self: long trousers when walking.

African tick bite lesion. This is not Stefan's (not his real name) groin. That would be sick.

Wednesday, 9 May 2007

Occupational health

I breeze on to High Care ward for my morning ward round. Well, I say High Care. What I mean is it is the ward in the hospital where patients have their blood pressure measured and urine output charted. More a sort of Care Care ward. The nurses here went to nursing school and ask questions. Perhaps most strikingly of all when they call you to tell you a patients “is gasping, Doctor” it generally means they are still alive but very sick. Nomfundo was called urgently to a ward last week for a “gasping patient” only to discover they were cold and had clearly been dead for a few hours.

The ward is strangely quiet today. Sister is hunched over the desk, her arms wrapped around her head. The other nurses stand nervously round her muttering. I go to the desk. Sister’s shoulders are shaking and she is clearly crying. I ask what is wrong. She does not answer. I sit next to her and ask again. Slowly it comes out. She was placing an IV line into a baby with severe malnutrition and dehydration and stuck her finger on the needle as she took it out.

I look at the baby. It is emaciated. Skeletally thin. I check the notes. The mother is HIV positive. Looking at the baby it is hard to persuade myself that it might be negative. Any “it is not necessarily positive” platitudes would be misplaced.

Sister continues crying. When did it happen? Just a few minutes ago. We talk about the chance of transmission if positive, the drug treatment she can take to reduce the risk of acquiring HIV. She begins to calm down. I send her off to the Staff Clinic where she will be started on a month long course of anti-viral medication. The side effects can be pretty grim – many people do not complete the month’s therapy. I talk to the mother who has now started crying as well, devastated at what has happened and the upset it has called. She agrees to allow the child to be tested.

I pop back in the afternoon. Sister is back. She is sitting with the mother. I ask how she is.

“I am just telling the mother I am fine and she must not worry about anything.” Sister is smiling now. She has taken her first dose. “I do not think I will get any side effects. It is what is in your head that is most important and up here,” she says, tapping her temple, “I am very well!”

Monday, 7 May 2007

Mellow

It has been a fairly mellow day and there can be only one reason. I haven’t been working at the hospital. I have been visiting one of our outlying clinics at the settlement of KwaMsane. It is one of our busiest – even more so this week of all weeks: National Polio Vaccination week. Just as I was about to leave the hospital site this morning the Transport department shoved 2 nurses, 3 cool boxes of vaccine, numerous needles, syringes and sharp bins into the Department of Health vehicle I was using. It was complete mayhem at the clinic: hordes of children for vaccinations, hordes attending the anti-retroviral clinics and about 20 for me.

I drive back to the hospital through the game park at dusk. The sun is blinding red on the horizon in front of me. The animals are out in force this evening. A herd of zebra grazes on the roadside to my left. A few minutes later a herd of buffalo on the right. Then I spot a small group of cars stopped in the road. I round the corner and there, busy destroying the “Beware of the Elephant” sign is an elephant. The driver opposite gives me a big smile and a thumbs up before driving away.

The elephant continues adjusting the sign to a more pleasing 45 degree angle before filing his tusks on the barrier and moving on across the road.

Thursday, 3 May 2007

Of Warthogs and Wardens

Nicky twitches the curtain of the cubicle in which I am seeing patients. “Ed, can you come and have a quick look at this knee?”

I excuse myself from the patient I am seeing (another “query TB”) and go to Nicky’s cubicle next door. On the couch lies a man, his left leg slightly bent, the other extended. The entire back of his knee has been ripped open. I can see tendons and layers of muscle. When I ask him to move the leg I can see them move over each other.

“He was hunting in the Game Park,” Nicky tells me, “and a warthog attacked him from behind!” I admire how gross it looks but cannot think why Nicky wanted me to look. I am not an orthopaedic surgeon. I ask why. “No reason. Just looks gross,” she smiles.

Later that afternoon I am asked to see a man who has been brought in unconscious. I walk into the cubicle. The stench hits me immediately, almost to the point of making me gag. I don’t do smells.

The man is indeed unconscious and his left arm is swollen and covered in bandages soaked right through with pus. With the nurses assistance I gingerly unwrap the bandages all the while wishing my gloves reached to my armpits. His entire forearm is red and hot. The skin over the back of his hand has disappeared. I can see the tendons and muscle. All down his arm areas of skin have died and pus is pouring out. At his elbow I can see bone poking out through a hole right on the joint.

“How long has he been like this?” I ask. His friend does not know. He last saw him 3 weeks ago when he was fine. The wound is typical of a snake bite. He must have been bitten a couple of weeks ago and did not seek any help then. Chunks of muscle and skin died as a result of the cytotoxic poison and then became infected. He is now septic and shocked. I start fluids and antibiotics and ask our surgeon to come and see him. He will need all the dead tissue removed – probably an amputation this late into the proceedings.

My last patient of the day is wearing the green outfit of the KwaZulu-Natal Wildlife service, the organisation that runs the regions parks. She has sprained her ankle. I look at the X-ray taken earlier. It looks fine. I ask how it happened.

“She was running away from a charging rhino and twisted her ankle on a stone,” the nurse replies. It sounds the coolest reason for spraining an ankle I have ever heard. I ask whether she enjoys her job, naively thinking it must be quite amazing to work in the open with this kind of full-on wildlife. The nurse translates my request and the lady gives a small shriek by way of answer and speaks rapidly in Zulu. A slow grin spread across the nurse’s face. “No doctor. She does not like it. She hates the animals. There are all kinds of dangerous animals. Who would want to work where lions might jump on you at any moment?!”

I suppose if you look at it that way…