Saturday, 28 July 2007
The lab tech hands me the blood results. I quickly scan them. Normal white cell count – I had feared she might have leukaemia. Normal haemoglobin. But there at the bottom, the platelets: 4. Should be at least 150. The platelets play an essential part in the body’s blood clotting system. 4 is well below the point at which spontaneous bleeding can occur. There are a few possible causes but Hlabisa Hospital is not the place to investigate them. I get on the phone to a specialist at our referral hospital who offers to accept the patient for investigation. I pull out the scrap of paper on which I wrote the lady’s cell phone number and call her. As it rings I offer yet again a silent prayer of thanks for the cellphone, a device that has transformed the level of contact we can have with our patients, many of whom have no address to speak of. Somewhat bemused she agrees to go to the referral hospital.
As I hang up I realise that I rather enjoyed myself. In the mass of TB and HIV it is easy to forget that all the conditions we see at home can occur anywhere in the world. Just because the Game Park is full of zebra does not mean that I might not also see a horse.
“So how long have you had the headache?” I ask. I am at one of our most remote clinics. Two hours drive from the hospital, the last 30 mins bumping along dirt road.
“Just today,” she replies. The patient is a teacher in her thirties with excellent English.
“Any other problems?” She shakes her head, and then stops, looking thoughtful.
“I did cough up a little blood this morning.” She opens her mouth wide, and sure enough there is a little fresh blood on her tongue. There is no torch so I angle her head towards the window through which the still hot winter sunlight is streaming in. I pull up her lip and see a small area of the gum is bleeding. And there, on her palate at the back of her mouth are numerous small red spots, petechiae. The rest of her examination is completely normal.
Guiltily I move from “coasting” to “thinking” mode. It is a terrible thing to confess but we see so many people with non-specific “aches and pains” that it is all to easy to adopt the “take paracetamol and come back in 2 weeks if it doesn’t get better” approach. What we as hospital physicians, safely insulated from the public frontline. used to self-righteously joke about as the “GP-way”.
“Have you any rashes on your skin?” She shakes her head. “Any bruising? Fever?” No. “And you have been completely well over the last few months?” Yes. “Have you ever had an HIV test?” Last year and it was negative. I scratch my head. If I had seen this lady at the hospital I would have been able to do various tests there and then. Out here I am a bit stuck.
“Do you have a cellphone?” Yes, she does. I turn to Sister. “Could you take a blood count?” She nods. “Ok – so take the blood count, and I will take it to the hospital tonight. Then I will phone you to let you know the result and what we must do.”
There are a few classic causes of a rash like that in an individual who otherwise looks well – and none of them are great news.
Sunday, 22 July 2007
I see it now, on the bottom of a pile of papers, like a dirty magazine I forgot to hide and hope no one will notice. Even looking at it brings the flush of shame to my cheeks. And the worse thing of all was that I enjoyed it. I enjoyed the fact that the man who built himself a shed in the shape of a Roman temple deserves a story occupying two-thirds of page 3, I enjoyed the sad little picture that appeared to show Prince Charles groping a female soldier, I laughed with excitement and glee when I got to page 7 and found that Kylie will be in the Doctor Who Christmas Special and worst of all, I read all of Ann Widdecombes column. And it didn't make me angry.
So, spare a thought for those of us cut off from British culture and in danger of latching thoughtlessly and desperately onto the nearest thing resembling it - no matter how deceptive. And thank God for my only hope of cultural salvation: the BBC and the internet and the GPRS enabled mobile telephone.
Jabu and I are talking as we walk back to the accommodation after work, discussing some piece of hospital political trivia, when his eye is caught by a gang across the carport. They are standing in a group talking and eating something.
“Hey, Ed, let’s go eat sugar cane.” We walk over and join the circle. Sugar cane eating generally seems to be the equivalent to “Afternoon tea” – an excuse to gather and make small talk.
“How do you eat it?” I ask.
“First you must peel of the outside with your teeth,” says one, Thulani. He demonstrates, rapidly stripping off the bark-like exterior of the cane and spitting it onto the pile that has collected at the centre of the group. I try. “Not like that, use your canines.” I try again with more success.
“Then bite off the inside.” I bite off a chunk of the white moist fibrous interior and chew. It is, as you would expect sweet and tastes a little of tree. I swallow.
“Don’t swallow,” says another member of the party, and she laughs as it sticks in my throat and I gag. I bite off another chunk and then pass the stick on.
“You don’t like it?” Jabu asks.
“Perhaps it is like coffee – I will learn to like it.” I say, and then, being a product of the neurotic fluoride age, nip back to brush my teeth.
Friday, 20 July 2007
I am walking down to do my session at Philanjalo, our anti-retroviral medication clinic where the 450 odd HIV+ patients in the area around the hospital eligible for anti-retroviral treatment are managed. Over 2500 people in our district are on treatment at the moment – an impressive number nationally speaking but still a fraction of those requiring it. I am still chuckling over the wording of a referral note from a local clinic, “Patient suffering from virginal sores – has nasty sores on the virgin.”
I walk into clinic. Sister sees me and shouts.
“Hauw, doctor! Where have you been?”
“I have been in
“But you did not tell me – you just left!”
“I told one of your staff and I arranged Dr Magnus to cover me,” I say somewhat defensively.
“I did not know – you did tell me!”
“I am sorry, I could not find you.”
“But you are our Baba! What kind of father abandons his children like you abandon us!”
“I apologise. I am a bad father.”
“A Baba cannot leave his children. He cannot go away without telling them!”
“I am sorry. I failed you.”
“You did. You are an absent father!” She is smiling.
“I can change,” I tell her, “I can do better if you will let me try!”
“You must! You cannot leave us again.”
“OK – now, come this way.” She leads me to my room and I get to work.
Thursday, 19 July 2007
"Hi Zanele, come in!"
"How are you?"
"Ah – I am well. You are back!"
"Yes – I visited my family. Are you well?"
"Yes doctor." She pauses. "Doctor, may I have two weeks money this time?"
"I have to buy meat to sell."
She goes on to explain that each week she buys a cows head from the butcher and cooks it. She then chops it up and picks a spot near the petrol station in Hlabisa village centre to sell cuts of the meat to passers-by on Friday and Saturday – the days she does not clean. Zanele has six children. Three are her own and three belong to her late sister who died last year of an illness almost certainly related to HIV. Zanele must now earn enough money to pay for the education,
clothing and food for all six.
I tell her no problem, she can have two weeks money. She is very grateful – it will enable her to buy extra meat.
"And thank you doctor for the extra money," – whilst I was away I left her R100 a week rather than R80 as I did not have change – "I was able to buy extra bread for the children."