Thursday, 28 June 2007

It's not all work, work, work.

I am away in the UK for a couple of weeks. Flicking back through these entries (and boy, some of them are long-winded - did you really read them or did you "skip to the end"?) I fear I may have misled you. My life in South Africa is not, as the balance of my writing might imply, one of entirely selfless dedication to others. This country is after all, one of the most beautiful and varied in the world. If you were sitting with me in the lounge I would whip out my laptop and inflict upon you the 25,000 photos I appear to have taken on my weekend jaunts. Instead (and I no doubt hear you cry "mercifully") I give you half a dozen highlights. Until a fortnight. Sala kahle.

Approaching the Drakensberg.


In the Drakensberg mountains with Dr Tom (centre) and Dan, an elective student (right).


Hippos in the St Lucia Wetlands National Park.


The Umngeni Valley Nature Reserve - looking down from the crags to the river. Excuse the knees - photographic composition dogma required a foreground.


Crossing the swing bridges in the Mkuze Game Park Fig Forest.


A herd of antelopey things - impala I think but I don't know and you don't care. Mkuze Game Reserve.


Ostriches having sex at the Umfolozi River Lodge. Not beautiful but certainly varied. The accomodation for humans was apparently better than this.

Sunday, 24 June 2007

Incommunicado continued

So, as I was saying, we were cut-off.

I turn to the midwife. “Do you have MTN?” I have found on a few occasions that when Vodacom and Telkom fail, South Africa’s other major phone network inexplicably seems to survive. We check all the midwives phones and one has MTN. She only has a few minutes credit but graciously lets me make a call. I phone Nicky, a colleague at Hlabisa.

“Nicky, can you call me back straight away?” She does and I explain the situation. She gets on the case, phoning all our nearby hospitals. The midwives and I chat whilst we wait, the groans from the woman next door getting louder and louder. It seems an eternity before Nicky calls.

“Bad news I am afraid Ed. Nongoma only have one doctor and all the other hospitals said no.”

“What?” I reply, righteous indignation rising like bile in my throat.

“I tried to explain things but they all said that you should send the patient somewhere different.”

I swear again, this time not under my breath. “I will have to send them to you at Hlabisa then.” Nicky gets on the phone again to speak to the Hlabisa on calls and minutes later our medical manager phones back on the nurses phone – he is on call mercifully. I explain the situation and then he rings off promising to sort something out. Two hours have passed since I arrived in maternity.

I nip back to the accommodation and grab a coffee with Olstein. “How will you transfer her?” he asks. We are at least an hour from the nearest ambulance base and they will not come to pick up until we can confirm where she is going. Her transfer is going to get dangerously delayed. As we walk back to maternity an ambulance passes us on the exit road from the hospital having just dropped a patient in OPD.

“Run!” shouts Olstein. We both peg it down the hill to the hospital gate after the ambulance.

“Stop! Stop!” The guard is opening the gate.

“Don’t let that ambulance go!” I shout. The guard is waving it through.

“Stop!” The guard looks up and can only be startled to see two crazy visiting doctors with shaved heads hurtling down the hill, limbs flailing and yelling. He bangs on the ambulance as it drives through. It halts. Breathlessly we both catch up with it. The driver looks at us somewhat quizzically. We explain the situation and, unlike our medical colleagues in other hospitals, he quickly grasps the problem. He radios the headquarters. They give him permission to do the transfer and we all head back to maternity. Dr Adam phones. Nongoma’s medical manager is going in to help their one doctor so they section can be done there.

We load the woman into the ambulance and watch it drive out of the gate.

“I’m definitely changing mobile network,” I say to Olstein as we head back to the house to put our feet up and finish watching "The Lion, the Witch and the Wardrobe."

Saturday, 23 June 2007

Incommunicado

As I palpate the woman’s lower abdomen she winces and gives a soft cry of pain. “How long has she been in this discomfort?” I ask the midwife.

“For an hour, doctor.”

“And she has had a previous Caesarian section?”

“Yes – doctor, 5 years ago. She has been 2cm dilated for the last four hours.”

I am back at Ceza Hospital for a second round. Glutton. Only this week has not been the mellow experience of my last visit. Word has got out – there are doctors at Ceza. Where 2 weeks ago we were seeing just 20 to 30 outpatients a day now there are over 50. Oystein and myself have been working til 7pm. No chance of nipping down the road to the hot springs. And now, just as we were huddling down for an evening of DVD viewing on a 12 inch laptop screen maternity has called.

I scratch my head. The lady is at high risk of needing a Caesarian section – not right away but fairly imminently and possibly as an emergency if she is allowed to continue to fail to progress and ruptures her old Caesarian section scar. There is only one problem. Neither Oystein or myself can do Caesars – we are namby pamby European physicians. Not hard core South African generalists. I have assisted at half a dozen sections. In fact, at the last one Jabu let me do the whole thing under his watchful gaze. I proudly stood back after my first solo sewing up the uterine incision awaiting his approval. He studied the oozing bleeding uterus carefully and then, taking a new needle and suture said, “I’ll just tidy this up a bit” - and then repeated the entire thing. So I guess under pressure I could get the baby out. Just couldn’t put things back to together again.

I pick up the phone and dial switchboard. “Could I have Nongoma hospital please?”

“Ah – doctor. I am sorry – all our lines are down.”

“You mean there are no phones at all?”

“No doctor.”

“What about that radio?”

“Radio?”

“The radio in your room for emergencies.”

“Ah – yes. That has not worked since 1990.”

I check my mobile: “No service.” Telkom and Vodacom share the same malady. I swear under my breath. We are in the middle of Zululand. 30km of dirt road separates us from the highway. It would appear we are completely cut off.

Saturday, 16 June 2007

Mental stealth act

I am not sure what to do. The man is standing, shoulders hunched and eyeing me with an expression that can only be described as “baleful” – one of those terms you read in books as a kid and of which you develop a visceral understanding but could never explain in words to someone else. Abruptly he hits out at me – I jump back but not before his fist has closed over the pen with which I was about to write up his anti-psychotic.

When he arrived with his wife a couple of hours ago he was quiet and settled. He was describing three weeks of delusions and hallucinations, particularly severe at night. He was hearing drums and his ancestors were apparently speaking to him. I have come back from theatre to find him aggressive and agitated.

We are now at something of an impasse. 4 security guards stand behind him – but they are not trained for this sort of situation. I am loathe to approach him with my needle until he is restrained. He hits out at me whenever I approach. Nomfundo walks past and eyes it up. “Have you got a death wish?” she says, giggles and walks away. Thanks.

Sipho, one of our younger go-getting OPD nurses walks past. He eyes up the situation. “Need some help?” he says, and without a break in his pace walks into the cubicle, throws his arm around the man’s neck and in a flash has him pinned to the floor. We all stand, momentarily dumbfounded. “Well come on then!” he calls from the ground. I jab my syringe into the guys butt. Sipho stands up and then helps up the man who appears as stunned as we are by his abrupt change in circumstance.

“Boy, I am glad you chose to use your powers for good.” I tell Sipho. He looks rather pleased with himself.

Thursday, 14 June 2007

Of strikes and caesars

I admit it, I am a little nervous about work today. The medical manager spends the morning meeting allocating a named “man” to each ward – women doctors are to keep a low profile, just in case “things get nasty.” I cannot pretend to be a particularly imposing specimen of manhood, in fact none of us can save Jabu. There will probably only be one nurse on each ward, the medical manager explains, and “they will be looking to you for leadership.” Tom (a doctor from London) has come dressed in his jeans today – “so as to blend in,” he explains with a wry grin, looking particularly white and freckly.

After my high care ward round I potter down to my allocated ward. We all spent yesterday discharging patients to get the hospital as empty as possible for today – we had a head start as no one had been coming for admission anyway. To my surprise all the nurses are there, dressed in their civvies. I explain in embarrassed tones that I am their “man” – they look at me doubtfully but dutifully write my cell number on a scrap of paper and promise to call if there are any problems.

In OPD there are more nurses than patients. There are in fact more nurses than there were yesterday on the “non-strike” day. I wander past X-ray. It is open but there is no one around. A sign on the hatch reads, “Gone for tea and picketing. Back in 30 mins.”

I bump into the matron, the medical manager and Dr Kekana as I leave. They are taking the roll call demanded by Head Office. Dr Kekana looks a little embarrassed – “I was asked to,” she mutters. Dr Adam has just come from a teleconference with other hospitals around the province. Ours sounds as if it is one of the more civilised – many are experiencing severe disruption from picketers and poor staff turnout. The nurses and other hospital staff at Hlabisa are as morally behind the strike as anyone else – but from the guy who drives the electro-car that collects the laundry to the ladies who empty the bins to the nurses themselves, every discipline is running if not normally then at least functionally. I am seriously impressed with their dedication – particularly given the intimidation some have experienced from neighbours and some of the union reps.

Nicky tells me later that one of the senior sisters she was working with in OPD looked at her in between patients and said, “Doctor, I am not here. My body might be, but emotionally..” she looked out of the window and gestured to the town hall where the picketers were gathering, “..I am there.”

At lunch time the demonstration reaches the hospital gate. It does not enter the grounds but stops outside. Olstein and I go out and stand on the peripheries to watch. People we recognise wave. One nurses asks, “Are you here to toyi-toyi?” and demonstrates the dance enthusiastically. Another nurses translates the speakers words for us – about the government not listening and how it gets its power from the people and needs to listen to the people. The next speaker accidentally starts his speech in English. He is interrupted by a colleague and there is a brief muttering. “Oh.. sorry..” he says and he starts again in Zulu.

By 2pm there is nothing to do. No more patients have made it in today (the taxis are on strike as well), the demo is running our of steam and the wards are quiet. Olstein and I have a game of squash. Just as I finish showering, Jabu phones. “Want to learn how to do a Caesarian section? I’m going to theatre.”

Well why not? Nothing else to do.

Tuesday, 12 June 2007

The calm...

“I am going now doctor,” says the nurse.

She is dressed in her own, actually extremely stylish, clothes. All the nurses came to work in their civvies today. Many of them have been reporting intimidation from neighbours and even friends for continuing to work this week. Some have been getting threatening phone calls. Uniforms have been abandoned in an attempt to blend in.

“Where are you going?” I ask.

“To the strike.”

“Who will be helping in OPD?” She shrugs, smiles, and walks off. I walk around OPD. X-ray is shut, there are no nurses. Thankfully all is calm - only 3 or 4 unseen patients. Our normal number of 80 to 120 a day has dropped in the last few days to just 20 or 30. Those clinics that aren’t shut are operating on a skeleton staff and there have been very few referrals. Many of our outpatients are those with chronic problems that can wait. But many are not – there are a lot of people dying at home this week.

I cannot work so I wander to the front gate. The police are stood on the side of the road watching a crowd of around 100 staff members dancing and chanting. Whenever they begin to spill into the road a man in an ANC T-shirt gestures them back so that vehicles can still pass. The mood is good and they move to let cars and ambulances through the gate. Their chanting is considerably more melodic than their British counterparts.

Strikers dancing with the police looking on in the background

People begin trickling back into work at 3pm and we see those dedicated patients who remained throughout the afternoon.

“What is happening tomorrow?” I ask Mr Zulu, the OPD head. He shakes his head – he doesn’t really know either.

“But Wednesday – that will be a problem.”

A general strike has been called. Cooks, cleaners, telephone operators, patient note filing clerks, nurses, mortuary staff: no one will be going to work.

Apart from the managers.

Oh – and us.

For info on the strike see this Washington Times article and this Reuters online piece. There is amazingly little regarding the extent of the strike in the SA broadcast media, and even the independent newspapers fail to mention the impact on rural health services and make only passing mention of the extent of the morbidity and mortality that is resulting.

Monday, 11 June 2007

Demo

I am on way to outpatients after lunch when I spot Nkosi and Ziggi. There are both wearing bright yellow trade union T-shirts.

“You on strike?” I ask.

“Ziggi was on strike before the strike!” laughs Nkosi.

They explain they are on their way to a big meeting in town – all the public servants – teachers, nurses, local government employees and so on – are gathering for a march. Durban has been paralysed for the last week – our major referral hospitals are accepting no patients, demonstrators are turning away ambulances, all the ITU patients have been transferred to private hospitals (at what cost cannot be imagined) because no nurses turned up for work. It is claimed that the biggest hospital in Durban had only 10% of its staff turn up.

It has been slow to move up to the rural areas – perhaps because money is more scarce (“no work – no pay” is the government policy) and there is a high chance that you know or are related to the people who will be affected. This week however it has begun to hit. Yesterday the medical manager would not allow Nicky to go to the local clinics – government vehicles were being stopped on the road in some parts – and picketers were turning away ambulances from our local referral hospital in Empangeni and our clinic at KwaMsane.

I ask Ziggi and Nkosi about the strike. It centres over the government pay increase of 6.5% (inflation is 6%). Nurses are extremely badly paid. One (very experienced) nurse tells me she gets R4000 a month before tax (£285). They are asking for 12%. They are thinking of striking they tell me. “Strike away,” I say, “but will you let the red-light ambulances through? I don’t mind about the coughs and blood pressures.” They laugh but do not reply.

In OPD things it is silent. Eerily so. Only Mr Zulu, the head nurse, is there. All the others have gone to the meeting. We see a patient. As I finish I hear singing start up outside. Olstein pops up from the next cubicle: “Want to go watch?”. I grab my camera and we run outside.

50 or 60 staff in yellow T-shirts are standing in a circle singing and chanting. In twos or three people enter the circle and dance to the cheers and whoops of the others. Some are waving banners: “Yes to 12%”, “We cannot live on 6%”. The X-ray man leads a conga of dancing people whilst shouting slogans. The noise is fantastic and exhilarating. There is a party atmosphere. Dr Kekana comes out of OPD and joins the line, gyrating along with the best of them. I would like to join but am too Britishly inhibited – and besides, I can’t do what she can do with my hips. Well not my hips. With “ones” hips. She is doing it with hers, not mine.

I notice the head matron speak to the crowd. I turn to Sister Jele who is standing next to me. “What is she saying?”

“She is reminding them that they had permission to strike for an hour and they must return to work soon.” Astonishingly they seem to listen. Matron herself gyrates and undulates her not insubstantial form across the crowd back to her office. Sister Jele tells me they made sure there were 2 nurses on every ward and all the rest could come out.

The crowd disperses. I walk back in to an almost deserted outpatients. I see Bongani – a newly qualified nurse I have had beer with a couple of times.

“Hey Bongani – why were you not dancing.”

“Ah – Ed. I am a new employee, on probabtion. It would not do for me to be seen doing that! And besides. I cannot dance.”

That evening as I walk back to the accommodation I pass Thandi, one of the black Comm Serv doctors. “Hi Thandi! I didn’t see you dancing with the demonstrators today!”

“No Ed. I was scared!”

“Scared? Why? It felt like a party.”

“I try to keep my head down. It is OK for you. But for me – if they see me working they will say ‘Why are you not striking with us?’ So I keep out of sight.”

Saturday, 9 June 2007

Departure

“Ed – you must leave immediately!”

I look up from the notes in which I am writing – it is Dr Ndlovu, the doctor from Thulasizwe. “But we are going at 3pm.”

“No – it’s all changed. BB called me and asked me to come over. They can’t use government vehicles to take you back. Benedictine Hospital in Nongoma has closed and they are afraid that the strikers will block any vehicle with government plates.”

“So what’s happening?”

“Someone has agreed to take you in a private car – but they want to get back before dark. Go!”

I find Hendy and we quickly pack. Our lift is from Adolph once again – but this time in his own Toyota Corolla. “I need the money,” he explains. We chat about the strike as we drive. I ask him about Mbheki. “Hey - he has lost the people. He has forgotten what it is like.”

“But you are ANC?” I ask. He nods.

“But here you cannot say that. This is the heart of Zululand. All these people,” he gestures to the huts we are passing on the road, “they are IFP [Inkhata Freedom Party].”

I look at the road. We have taken a different route back to the highway. The communities here are spectacularly poor. Traditional kraals dominate. We pass groups of women walking home with firewood or water on their heads. Then, rather startingly, as we drive over a river bridge I see a car parked in the river. A group of men are washing it. Adolph stops to let me take a photo. The men laugh and wave as I shout, “Siyabonga! Salani kahle!”


We hit the highway again and drive on to Nongoma. There is no evidence of strikers – the hospital is a short distance off the main road anyway. An hour later we are back at Hlabisa. It feels a little like a home coming.

“Where have you been doctor? I have missed you!” shouts one nurse.

“You made it!” says Magnus when he sees us in outpatients. It is full and busy. Welcome back…

Spa

“So do you think we can?”

“I think so. Don’t you?”

We have been talking like this for most of the day. Dr Kekana told us about a spa resort near the hospital which she went to last week. “You must go,” she said, “it is so nice!” We mentioned it to the manager’s secretary and she said she would arrange transport. However it kind of goes against the grain – leaving the site when you are supposed to be available.

“It’s only 7km away – we can be back in 15 minutes if we need to.” I say.

At 5pm a hospital 4WD rocks up outside the house. We climb in and set off. Our driver, Adolph, is a genial fellow who works in the Facilities department. As we chat it turns out he is not Zulu at all but Sotho, from Limpopo. He came to KZN some years ago for work.

The spa is only a few minutes drive down the dirt track. We park and find the bar. It is a highly improbable set up – “luxury” accommodation and a restaurant nestled in a valley in this remote part of rural Zululand and full of elderly Afrikaaners – come to “take the water” I suppose. Villas line the slopes, each with dramatic views over the valley. The spas themselves look as if they have seen better days. The brochure says they are 41 degrees – a dip of a toe reveals this to be an exaggeration.

We sit in the bar for a drink with Adolph and flip through the fliers on the table. Apparently you can also hunt here – shoot a Zebra for only R650.

One of the younger Afrikaaners comes over and gets into conversation with us. He explains to me with great animation how exactly to kill an elephant (shoot out its knee and then blow out its brains just in front of the ear. The skull is too thick if you try between the eyes apparently).

Dinner is steak – fantastic after nice, but slightly same-y hospital food. Adolph watches the Afrikaaner group as they in turn watch the news. There is lots about the strike. Adolph leans forward and whispers, “If they knew I was ANC – phew!”

We wrap up after an hour and half. We are on call after all. We get back and Hendy nips into outpatients. He comes back to the house 5 minutes later. “No one,” he says with satisfaction as he slips “Spaced, series 1” into the DVD player and we both settle back for another tough evening on call.

Strike

“Did your patient make it to Empangeni?” Hendy asks. It is Wednesday morning and we are drinking coffee on the stoep in the morning sun. I was on call last night. Well, I say on call. OPD was empty by 6pm, we watched a DVD and I was not disturbed again. And to think I was reluctant to come here.

“I think so,” I reply, “Why?”

“Because mine got sent back?”

“What?!”

“The ambulance got to the hospital and the strikers turned it away.”

Last Friday was the start of the first big general strike since South Africa went truly democratic. Government employees are striking over an unsatisfactory pay settlement. Hospitals, ours included, have been displaying big posters reminding people that hospital staff are considered "essential" employees (from nurses to cleaners) and are not permitted to strike. Ha!

The cities were affected first and badly so. At the weekend we huddled around TVs watching the news run pictures of people being turned away by picketers outside all of Durban’s biggest hospitals – the ones we rely on for many of our complex referrals. The South Africans in particular felt like they were watching the breakdown of society.

"Patients have died in Jo'burg," one of them tells me. A good friend of hers works at Baragwanath hospital in Soweto - there are armed soldiers on every ward at present because the level of intimidation has been so high. People asked me whether we have strikes in the UK. “Sure” I replied. But nurses? Closing hospitals? It made Britain (where firemen check to make sure the army is ready to take over before striking) seem rather tame.

Hendy and I don’t do surgery so we spent our first day busily identifying problems and getting them out of Ceza quickly. He sent a couple of ladies in labour that were progressing badly to the obstetric referral hospital – they made it through. His lady who needed an evacuation of retained products of conception did not and the ambulance had to turn around. He gets on the phone to Hlabisa to ask one of our colleagues there to do it. I nip to Maternity – yes my patient made it. Because, as it turns out, the transfer happened at 11pm and the strikers had got tired and gone home.

There are no strikers at Ceza. Why not, I ask? The answer comes back: it is “No work, no pay” and in these poor communities that is a threat not to be taken lightly.

Friday, 8 June 2007

Ghost hospital

The sun is bright and the air cold as Hendy and I walk to the wards on Tuesday morning. We are, after all, approaching the depth of winter. We enter the central area of the hospital. Ceza is more compact than Hlabisa. It is an old mission hospital, founded in the late 40s. The lab, switchboard, offices and wards all open onto the same covered walkway. Hendy heads off to paeds, I head to the medical wards.

Yesterday Dr Ndlovu, a physician at Thulasizwe TB hospital a few km down the road and in possession of the most dangly ear-rings I have ever seen, gave us a quick tour. The wards are only around a third full and it feels something of a ghost hospital – the word has been spread: there is no doctor at Ceza. Patients are going elsewhere. After our tour I dropped into the wards to introduce myself and ask if there were any problems – it had of course been 3 days since they were last seen. “No,” says Sister, “go home and rest. You can come tomorrow.”

I walk onto female medical. Sister in-charge, a formidable lady with a tremendously loud voice, grabs my hand as I walk in. “Hauw Doctor! Thank you for coming. We will not let you go.” Judging from the strength of her grip she is not necessarily speaking metaphorically. “This nurse will help you.” With her other hand she grabs a hapless junior and throws them at me.



There are just under 20 patients. Some have been admitted by nurses over the weekend – presumably there was no doctor. They have written a line or two (“Difficulty in breathing for three days. Fever and cough. ?Pneumonia.”) and started basic treatment. Most of them were here last week and our colleagues from Hlabisa have assessed them and written plans. One poor 12 year girl has a pnuemothorax from old TB, another lady had a massive gaping wound in her left armpit (I could stick my fist in it if I was sick enough to try) after a private GP tried to do a lymph node biopsy and it became infected. She has big nodes in her neck as well – almost certainly TB. There are even a few patients with non-TB/HIV problems: hypertension, an elderly lady with confusion, an acute psychosis. The round take a couple of hours – I need to learn each patient. I waffle at the nurses, spouting a few facts.

“This lady probably has lactic acidosis – a condition that can occur with certain drugs used to treat HIV.” I say, perhaps a little pompously.

“Ah,” says Mr Buthelezi, the nurse I am going around with, “lactate is produced as a consequence of anaerobic respiration is it not?” I am a little startled. Mr Buthelezi – probably in his 40s - explains that he learned this when he went back to school recently in order to become a nursing student. He also learned the principles of fermentation “but I don’t do that anymore,” he says with a grin, “not since I gave myself to Jesus.”

Male ward is a little quicker and we are all done by 1pm. The hospital manager’s secretary phones me – lunch has been left for us in the office. We have a quiet afternoon in outpatients and all the work is finished by 4pm.

I could learn to like it here.

Thursday, 7 June 2007

Ceza Hospital

I am woken with a jolt. The 4-wheel drive has left the tarmac and we are on dirt road. I look ahead into the hills – the road wends its way high up into the distance.

“How far?” I ask Amos, our driver.

“About 40km.” I settle back and watch as the settlements become less and less pseudo-bungalows and more and more mud rondavels.

The road to Ceza

It was about a month ago that our medical manager first mentioned that we had been asked to help out at Ceza Hospital – a remote rural hospital about 2 hours away. Its medical staff (only 8 at the best of times) had been steadily departing and only one remained. He was leaving at the end of May and they were desperate. Desperate enough to accept help from us.

As I said – a month ago – but it was only last Thursday that I found myself agreeing to go. Two of the others had been that week. I phoned them to ask what it was like.

“There are no words to describe it,” said Nomfundo, “speak to Dr Kekana.” Dr Kekana comes on the line and after humming and hah-ing agrees. There are no words to describe it.

“You cannot hear – you can only see it.”

It was not encouraging. On Sunday night I texted Nomfundo. Was there anything I needed?

“GOOD LUCK – YOU WILL NEED THAT” came the reply a few minutes later. Great.

The transport from Ceza arrived at our OPD Monday at 11am. We load our bags and set off.

“How is Ceza?” I ask Amos.

“It is nice – but we have no doctor and a hospital with no doctor is not a hospital.”

The road from Hlabisa is tarmac for 15km and then turns to dirt. 20km later it is tarmac again as we enter the town of Nongoma. Amos tells us this is the nearest Spar so we stop for provisions. 30km out of Nongoma we turn off and hit dirt once again.

Arrival - Hendy with Amos

The hills get steeper and the road zig-zags up. The view is spectacular as I look out of the window to the valley below – peppered with small Zulu kraals and settlements. We arrive at the hospital and Amos takes us to meet the hospital manager. “Call me BB,” he tells us, and instantly organises us some lunch, thanks us effusively for coming and takes us to our accommodation. We are startled – a proper house. Hendy's startlement evolves to ecstatic delight at the discovery of hot water - something he has been without in his accomodation from the day he arrived a month ago.

We think we might like it here.

Lunch on the stoep

Tuesday, 5 June 2007

The primitive trial.

We’ve been planning it for weeks: The iMfolozi Primitive trail; a guided walked through the Game Park, sleeping in the open, cooking over an open fire, taking turns to watch over the camp through the night in case of predators. I was so excited at the prospect I did not think to ask the price. I ask Olstein in the car on the way and nearly run off the road. I had no idea that this level of primitivity came at such a premium.

Setting out

We start rather late and our guides keep up a fierce pace. One of them, Samora, tells us he has 8 bullets – one for each of us if we cause any trouble. We look at him doubtfully. “Just joking,” he says.

“Are you married?” someone asks him.

“Oh no! I am 24 – I do not want to get married. I will get married when I am 30.”

“That’s what I said when I was 24,” I mutter.

The light begins to fail, they call a halt and declare the rock we are standing on by the river side the campsite. “Now, “ says Sinodi, the leader, “you must divide into 2 groups. One to dig for water, the other to collect firewood.”

“Sure,” I say. “We’ll go for water. What shall we put it in?”

“Use the pots.”

“Great – where are the pots?” He looks at me in puzzlement.

“You have them.”

“No. I never saw any pots. Did anyone see any pots?” I ask the others. Most people shake their heads. One person says he thinks he might have seen them in the guide’s truck on the way to the starting point but not since. Everyone checks their bags in the hope that, surreptitiously, a sly cooking pot might have crawled its way into the rucksack. Sadly, lacking (as they do) opposable thumbs, none has.

“So what are we cooking with?” someone wails. We all stare at each other.

It begins to rain. A lot. In fact, one might use the word torrential. We rush to our bags and wrap ground sheets around them in an attempt to keep things dry. Within seconds we are soaked.

An hour later we are sat around a fire trying to warm our soaking bodies and dry our sodden sleeping bags. Dinner is apples. We study the pack of mince that was to be our dinner. “We could heat stones and make burgers,” someone suggests. No one takes him up on it. I remember reading in Prince Caspian (by C.S. Lewis) how when the child heroes were lost in the woods the dwarf “had some quite excellent ideas regarding cooking”. I cannot remember what they were.

We attempt to roast an apple in foil with peanuts and sugar. Tastes OK but there is only enough foil for 2 and we burn our fingers trying to unwrap them and our tongues trying to eat them. Someone produces a metal mug – we fill it with water and in turn everyone gets a hot drink.

We divide up the night watch and one by one people climb into their sleeping bags. Most of us have also been provided with what is essentially a sleeping bag condom – a waterproof tube to pull over the sleeping bag. I climb into mine – pull the condom over it and lie back on the sleeping mat which does little to soften the rock. I try imagine what the stars would look like were they there. Cloud rolls ominously back at me.

The word “interminable” is perhaps best suited to describe the night. The rain comes and goes – sleep frequently interrupted by the “pit… pit… pit.. pit.. pit pit pit pit” of rain showers, each necessitating a tortoise-like complete withdrawal into the condom. At one point the sky clears and the moon comes out – full and bright illuminating the river valley in which we are camped and making everything seem almost worth it. Tom tells me on his watch at that point he saw rhino in the valley and heard the barking of baboons.

When Magnus comes to get me for my watch at 5am I am not sleeping. I boil some water in the now carbonised metal cup and drink tea whilst watching the sky around me turn from black to grey to lighter greyer to a slightly lighter grey than that.

Just as I wonder whether I should wake the others it starts raining again and that does it for me. The guide comes up. He thinks we should head back to base camp to dry out, get the pans and then do our walks from there – we can have a dry night in tents tonight. Everyone agrees and we pack up and head off.


Striking camp

2 hours later we are back at base camp. It is a hive of activity – tables are being set up and cooks are preparing food. The guide looks a little sheepish. He had forgotten, he confesses, that it is the leaving party of the park’s recently retired head.

One of the party looks close to tears. A couple of the others (and me I suspect if there were a mirror) look close to exploding. Three of us head to the park office and couple of kilometres away. I find the trails manager and, drawing on the heritage of my father (a strong proponent of what he called the “creative alternative”) and my silver-spoon English accent explain “how much have enjoyed all our previous KZN Wildlife excursions, so imagine our disappointment when…” She listens carefully and agrees to a transfer to the nearby Cape Vidal resort (log cabin by the Indian Ocean) and a refund of the balance.

As we drive out the rain intensifies – the windscreen wipers are on maximum and I can see only 20 metres ahead. “You know,” says Olstein, “it is a very good thing that Sinodi forgot the pots.”

“Why?” I ask.

“If he hadn’t we would have been in the park – walking and sleeping in this.”

You gotta love those small mercies.

On Cape Vidal beach the following morning after a wonderful dry nights sleep.

Monday, 4 June 2007

Now what?

The euphoria passes. Matron looks at me.

"Hauw! Doctor! I did this at nursing school but not for years now! It is coming back to me but slowly!" And there is the problem: I have a paralysed, intubated teenager (see Brown Trouser jobs). But our hospital has no ITU, no reliable ventilator and it is midnight – it will be several hours before a transfer is possible. As the girl begins to stir and cough on the tube unceremoniously thrust through her larynx I am also aware we have no intravenous infusion pump and I need to keep her unconscious somehow. I give her another injection of sedative – it will last 15 minutes.

I pick up the phone and call our referral hospital. I finally find the doctor in charge of ITU. They have only 1 bed and do not want to take our patient. Try Durban. I try one of the big teaching hospitals. I speak to the ITU registrar. He asks a lot of questions and demands tests which we cannot perform here. I get a little angry and tell him not to be ridiculous – does he have no idea what rural hospitals are like? I instantly regret it – I am supposed to be talking him into doing me a favour. He has only one bed and doesn’t want to put my patient in it. I try Albert Luthuli Hospital. They are full. I phone Addington Hospital and finally find a friendly registrar – they only have one bed but sure, no problem. I must just ask the surgeon's permission. A further 4 phone calls later I have an ITU bed - the whole process took three quarters of an hour.

By this time the girl has begun to stir again – I stick a big dose of sedative into a bag of saline and try to guess a rate to run it at that will keep her asleep. Then I phone the ambulance service. I give the details and then they phone back 20 minutes later. She will need to go by helicopter but it does not fly at night (our heli pad is dangerous at night - what with the trees and gravestones and all) so she will be transferred after 7am.

I hang up and look at my watch – 2am. 5 hours to go.

___________________

It is morning. We are sitting in our pre-work meeting. I am experiencing the euphoria of the sleep deprived. I cannot stop talking about last night – I am little over excited. Suddenly a roar fills the air. I nip outside and look up. The helicopter is circling.

Having sat up most of the night with this girl I find myself getting a little emotional. I grab my camera and run to the graveyard. I am told afterwards my “little boy” enthusiasm was infectious - 4 of the others are running behind me. We all pull out our cameras and get a great sequence of shots of the helicopter descending through the trees. 20 minutes later the patient is loaded up and on her way. Suddenly I feel knackered. But tremendously peaceful. In the mass of people with HIV and TB and the death we see everyday it can be hard to see that we make a difference. But today we did.

Sunday, 3 June 2007

Brown Trouser jobs

“Doctor! Come quickly! This girl is having difficulty breathing.”

I am in OPD and it is coming up to midnight. I have just been seeing a group of three babies with gastroenteritis. I keep getting them mixed up – they all look the same (despite what their mothers would claim), all have basically the same symptoms, and the nurses have put them all in the same cubicle.

I follow the nurse’s voice. They are supporting a teenage girl who has an immensely swollen face and dragging her to the resus room. I had spotted her in the waiting area half an hour before and she looked fine then.

They lie her on a trolley. “What happened?” The nurses translate for the mother. Apparently she was well earlier today but during dinner her face began to swell, her lips, and then her eyelids. I ask whether there were any new foods, or insect bites, or stings? No. None at all. Has this happened before? Yes, a couple of times a year ever since she was 6 years old. Can they think of anything that sets it off. No, they cannot.

She is conscious but distressed and drooling because she cannot swallow her own saliva. Her airway is clearly as swollen as her face and she is danger of suffocating in front of me.

“Can I have some adrenaline please!” The nurses run around in circles looking – the night staff are not always as familiar with the layout of the place as the day. I take advantage of the delay to check the dose in my British National Formulary – it is so long since I have done this it is embarrassing. We also give her a nebuliser. She appears to settle a little but her face is still swelling and this is only going to end one way unless we do something. She is beginning to have stridor (a haunting gasping noise that one can emulate by breathing whilst compressing your own trachea – do not try this at home), an indicator that her airway is close to obstructing completely. She is looking exhausted and drowsy. She is on 100% oxygen and the monitors confirm she is well oxygenated but things will change quickly.

I take a deep breath. “OK – we are going to have to sedate her and paralyse and ventilate her.” The nurses all stop. They haven’t done this before. But that is fine because I haven’t either.

I ask for the drugs I need (quickly looking up the doses in my trusty BNF). They all look at each other. “I will phone Sister Nene on High Care. She will know where they are,” says the Matron. They move with commendable speed and Sister Nene arrives with the drugs within (several) minutes. They explain to the patient what we are about to do.

I start praying – if this goes wrong I will have killed her. I ask Matron injects the sedative and once she is unconscious I paralyse her with the second drug. I grab the laryngoscope – the device that lets me see down the throat to the vocal cords, through which I need to pass the breathing tube to protect the airway. I pass it over her tongue. I cannot see anything – everything is swollen up. I have intubated several times before but never in this situation. I beginning praying under my breath. I insert it again. And again, trying to get oriented and find landmarks that will show me where the cords are. I cannot even see the epiglottis – or perhaps that enormous swollen thing is the epiglottis. In which case are those the cords? They cannot be – normally the cords are thin and widely apart leaving a clear black hole that leads to the lungs. These white things are completely stuck together. There is no space for a tube.

“Pass me that wire please,” I say tersely not moving my gaze from the laryngoscope view. They pass me a long piece of rigid wire that was clearly a coat hanger in a previous life. I carefully push it down the throat and probe at the line that divides the white lump in two. On the second go it parts slightly, admitting the wire. “The tube,” I bark. I can hear the tone of the oxygen monitor dropping in pitch as the girl’s oxygen levels begin to fall. They pass me an intravenous giving set. “Not that tube, the other tube.” They pass me an oxygen tube. “Not that, that!” The pitch of the oxygen monitor is falling quickly now. They pass me the endotracheal tube. I thread it over the wire, pushing it down the throat. It stops at the cords. I push harder and twist. Suddenly there is a give and it passes down. We attach a breathing bag to the tube and I listen with a stethoscope as a nurse squeezes air into the lungs – there is clear air entry in both sides. I let out an involuntary “Hallelujah, thank you Jesus,” which the nurses enjoy.

Suddenly, I need the lavatory.

Saturday, 2 June 2007

Girlfriends

“Do you have a girlfriend?” I ask. Sibu and Adolph have been not backward in suggesting individuals at the hospital that they believe would be suitable for me, a lippiness at odds with their insistence on calling me “Doctor” all the time. I therefore feel I have carte blanche to ask similarly invasive questions.

They both look rueful. “The thing is, doctor, that the girls at university, they want a man with money.”

“What do you mean?”

“They want someone who can take them out to dinner. And not just once on the first date. They want someone who will take them out all the time. Someone who will buy them fancy things.”

“But surely someone who really likes you does not worry about that kind of thing?”

“You would think so – but they all compete for what their boyfriends get them.”

“So no girlfriends this year?”

“Not until the first pay cheque.”

Friday, 1 June 2007

First Cheque

"So what will you do with your first pay cheque when you start work?" Sibu, the final year med student, and I are walking through the car park at the doctors residences. I am eyeing the brand new BMW's, Mercedes and 4WD's. It seems that the first thing you do when you get a well paid job in South Africa is buy an enormous car on credit. Sibu sighs.

The first thing I will do is build my parents a better house."

"Where do they live?"

"In a township outside Pietermaritzburg. It is a very small house. Four small rooms – they built it themselves."

"Does your father have a job."

"Sometimes – but they are very poor. I nearly had to leave medical school in the third year because they had no money. I did not get a bursary." This surprises me – he is bright fellow and on pushing admits he got 84% overall in his first year.

"Why not?"

"I do not know but I think it is because they give the bursaries to people from the rural areas – the 'previously disadvantaged'."

I feel stupid – as a foreign doctor it is easy to feel rather self-righteous about driving your beat up Toyota and parking next to the interns (just qualified) BMW. But if I had experienced poverty, struggled through medical school with little support to fall back on, not been able to go out and do things many of my friends were doing I suspect I would go a little wild with my first pay cheques.