Friday, 28 September 2007

Retrospective

Got a few hours on broadband - so let me give you a couple of short videos from the strike in June.

video video

Converting?


Perhaps it is rubbing off on me, or maybe it is the cabin fever – living in a closed community with few distractions – but suddenly birds seem quite interesting. For example, even I stood for hours, well OK, not hours but several minutes.. 5 at least, watching these Weaver birds. Stripping fibre vigorously from the palm leaves they then flew across the garden to the tree in which they were building their nest colony and got weaving. Amazing.



Wednesday, 26 September 2007

Twitching

Olstein and our guide, Amy.

The thing about Olstein is that he is not only a twitcher. He is a Twitcher. His tally of individual bird species seen in his 6 months in South Africa stands at over 250. He can tell you not only what he saw but where exactly in South Africa he saw it. So when he hands me a pair of binoculars as we head out for a guided walk on the Lebombo hills of Northern KwaZulu it is not a casual gesture. It is akin to being handed a Bible by the earnest friend who invites you to church. In fact, I realise, walking with Olstein visits upon me the exact sensation I spent my earnest years visiting upon others whilst in the University Christian Union. It is like visiting church and standing next to a fervent Charismatic when you yourself are “just interested”.

“Look! Over there!” he exclaims.

“Where?” I look in the direction of his pointed finger.

“There – it is a blurdy blurdy blur [substitute some South African bird] !”

“Really?” I lift my binoculars to my eyes and singularly fail to locate with them the distant speck I can see with my naked eye. I wave the bino’s in ever decreasing circles in the hope of stumbling upon the speck.

“Oh – its gone. Did you see it?”

“Yes,” I lie, feeling very much like some cousin that has had to repeat grade 1.

Our guide, Amy, is very impressed with Olstein.

Amy is something of an eccentric. We discovered her through the hotel when we said we wanted to go walking. She has lived in the African hamlet of Ubombo for 2 years and grows bonsai trees, collects fossils, writes (“I’m not yet published”) and paints. The only other white people in the village are the owner of the hotel we are using (with an improbably posh house complete with swimming pool and satellite dish – looking decidedly out of place next to the shacks just meters away) and some local land-owners (“I’m allowed in their house when I pay the rent”). She leads us along the animal tracks of the hills, through small settlements and undergrowth. Children wave, smile, and ask for money. We wave, smile, and tell them no way.


She does not seem entirely sure of the way. At one point our route leads to the entrance of a kraal (the collection of huts that comprise a dwelling – with several family members living together). “I’m not sure we can go through here,” she says, not entirely necessarily given the fencing and barbed wire. She leads us back the way we came.

Afterwards we go back to her house for tea and she shows us fossils. Here at least, I can trump Olstein on nature. I ask whether something is an “ammonite” before he does. It is the only fossil I have heard off. Luckily, it is.

Last year's Protea

Thursday, 20 September 2007

Radical measures

Sister turns to me.

“Doctor. I have an idea. A way to stop HIV-AIDS.”

“Really?”

“Yes. The problem is the men. It is the men that give us the HIV.”

“Yes?”

“So what the government must do is kill all the men. Kill all the men!” She slices her arm vigorously through the air in a chopping kind of gesture. “The less men, the less the HIV.”

“It is a good idea,” I reply. “You should write to the Provincial Government.”

“Of course, after a while when the country had no children there would be problem. But we women could have a few good years before that. I will write to the President!”

She storms off muttering to herself.

Monday, 17 September 2007

Chicken dinner

As I finish my ward round on High Care one of the nurses pulls me to one side.

“Doctor, can I see you?”

“Certainly.” She drags me into the small nurses office and begins describing her symptoms. I try to listen earnestly but find it difficult to concentrate. In the background there is what can only be described as the sound of gentle gobbling. I look around. It seems to be coming from behind the nurse. I try to look over her shoulder. She moves to block my view and carries on describing her symptoms. I nod seriously a couple of times and edge to one side. She moves again, but not before I succeed in localising the sound to a plastic carrier bag on the floor.

I bend down to look and tweak the bag open. There, looking up at me, is a small white chicken. Unlike most chickens I have encountered in carrier bags it is not skinned, cling film wrapped and indeed, dismembered. It clucks at me, as if to emphasise the fact and then shits industriously.

The nurse glances at me, looking highly embarrassed. More at the fact of the presence of the chicken than its tendency to defaecate in public I decide.

“It is for my sister,” she says.

“For what?”

“For dinner.”

Thursday, 13 September 2007

Dead Man's Beds

We are struggling on the ward. We have discharged 3 patients so far but as fast as the beds are vacated new occupants take up residence. They have spent the night on the floor in OPD, and OPD wants them out. I glance at the benches lining the wall of the ward – another 4 people sit there clutching the yellow admission papers, awaiting a bed. There are already another four people using mattresses on the floor.

Sister is getting stressed, and my colleague and I are also getting a little twitchy. We turn to the next patient. He is virtually moribund: unresponsive, eyes rolled up into his head, breathes slow and gasping. “Ah!” says Emma, “Brilliant - we will soon have another bed!” She slaps her hand over her mouth, looking shocked at her own words. Sister hoots with laughter and points to another patient across the ward.

“Yebo! And there is another over there!” We follow her finger and turn just in time to hear the death rattle of the other imminent corpse. This week at least admission to this hospital is a matter of “Dead Man’s Beds”.

Tuesday, 11 September 2007

Shot

As I cut through his skin the young man turns to look at me. He is lying on one of the couches in Resus, panting and groaning in pain, his face obscured from my view by his oxygen mask. He reaches out his hand to touch me and then rests his arm across my shoulders in a clumsy embrace. Just one hour ago he watched as his girlfriend was killed by the same gunman who shot him through the chest.

I work rapidly. The bullet entered just right of his sternum and exited in the right loin – ripping through the lung and liver on its way. From my quick assessment when I was called it is clear his chest cavity is filling with blood impairing both his breathing, and as the heart is compressed by the pressure, his circulation. As I enter the chest cavity there is a gush of blood over my hand. I insert the tube and connect it to the drain bottle. The blood pours out – 200mL, 300, 500. A litre.

“Someone run to the lab and get all the blood they have,” I bark. “Someone else, get some fluid running in that line.” One nurses squeezes a bag of fluid into the line in his arm and I get the biggest IV cannula I can find and stick it into the femoral vein. A nurse stands and squeezes a second bag into that.

The blood arrives – we set up a third line and soon there are three nurses squeezing various fluid. His blood pressure begins to pick up. I check the drain bottle – 1.5L of blood.

I go to the phone and start making the calls to get him transferred to the surgeons. The surgeon accepts him no questions asked. The ambulance service is more problematic – the phones are answered by clerks with no medical knowledge at all. I answer all her routine questions. “So what is the problem doctor?”

“He has been shot in the chest.”

“And when is this transfer for? Tomorrrow?”

“Now! Urgent!”

“Now?”

“Yes! Now now!”

The whole thing takes 30 minutes. I return to the man. “How is he doing?”

“Not so well doctor. The blood pressure is dropping and he is not responsive.”

“Shit.” In my absence he has filled another drain bottle completely – 4 litres of blood. The nurses are squeezing in the 4th unit of our stock. We have only 2 left in the entire hospital. I call one of the other doctors to come help me as I stick in a neck line.

The phone rings as I finish the line and the nurses holds it to my ear as I stitch – it is the helicopter coordinator in Pietermaritzburg. She sounds jarringly cheery. “Hello! How are you?”

“Fine.” I mutter.

“Good. I’m fine too. We were just called about your patient with the gunshot.”

“Just called? But I phoned the emergency service an hour ago!”

“Really? Well they only just called the helicopter service. How is your patient?”

“Not good.”

“Would you still like the helicopter?”

“Yes! As soon as.” She asks a few more questions and assures me it is leaving its base and will be there in 30 minutes.

The man is stirring a little now – his blood pressure is better, but he is increasingly unstable. I call for one of the sisters from high care – she arrives with the anaesthetic drugs. She explains to him what I am about to do. He nods, closes his eyes and I sedate, paralyse, intubate him and stick him on our portable ventilator. I offer silent thanks to ITU Southmead in Bristol where they taught me how to do this stuff. I look up – the resus room has filled with silent nurses in 2 rows watching. Standing at the back are some people who appear to be on a tour of the hospital. One pulls out a camera and takes a photo. I want to shout at them. But don’t.

We have used up all the blood. He is well into draining the 8th litre from his chest and it looks not so much like blood as rose wine – the majority of it being the saline we are pouring in. One of the doctors gets on the phone to an old boss to find out whether we can safely re-infuse what is coming out of his chest: auto-transfusion. But even as she does so the helicopter team arrives.

They take their time transferring him onto their equipment. I am getting agitated: don’t they understand he needs blood and surgery! Sod this! But they methodically continue. As we move him he gives a cough. A great flow of blood erupts from the chest wound – we stick on extra dressing and press hard. His blood pressure is falling and I give him a shot of adrenaline.

At last the helicopter team are satisfied. They wheel him out and load him on, finally leaving 3 hours after my call. As I watch I wonder whether he will even survive the transfer.

I suddenly remember I am supposed to be at a meeting at a nearby research centre – it started 2 hours ago. I phone to apologise. The organiser (a German – not that it is of significance) says I shouldn’t worry. No one else has arrived yet. I burst out laughing. That is so South Africa. “I am glad you find it funny because I do not,” he grumbles.

The rest of the day is a blur. At the end I phone the surgeon who took the man. He went to theatre – they removed the damaged lung and packed the liver. He is on ITU and stable.

I walk home and decide that I will have a (very brief) weep. Of relief.

So I do.

Saturday, 8 September 2007

Stillbirth

The phone rings and I open my eyes blearily, attempting to focus on the clock: 3am. I stagger over and answer. It is Andrew – there is a Caesarian. I pull on my shorts and step out of the flat into the cold night air. The sky is clear and the stars are burning bright and splendid, the Southern Cross hanging directly over the hospital.

I walk down the dark road to theatre, the wind blowing cool and dry across me, whistling slightly in the palm leaves above. The patient has just arrived. “She had grade 3 meconium in the liquor,” Andrew explains. That is a sign of significant foetal distress and in our setting an indication for Caesarian in most cases.

I stick in the spinal anaesthetic – I am having a good run at the moment, it takes only one stab. I turned one poor lady two weeks ago into a veritable pin cushion – I could not feel any of her spinal bones through her ample skin. This lady is significantly thinner.

“Do you want to cut?” asks Andrew.

I have done four Caesars under close supervision. I feel a bit pathetic but at 3am, given the choice between Andrew and a 45 minute operation, and me and a 2 hour operation, I choose Andrew every time. At the start of my last effort I told the nurses that they should feel free to nip off for tea at the start of the third hour. They laughed, but at the end one of the sisters came to me and said with a grin, “Dr Moran, we thought you were joking. But you were not.”

I scrub in to assist. Andrew dissects down to the uterus and reveals the baby’s head. He delivers the head and quickly suctions the mouth before delivering the rest of the baby. There is no cry. The midwife plucks the child from him and takes it to the resuscitation area.

I eye what is going on, even as I hold the retractor. It is instantly clear things are not going well. I leave the operating table, pull off my bloodied outer gloves and join the midwife with the baby. There is no pulse and no respiration. The midwife begins chest compressions as I suction the airway and use the bag and mask to ventilate. I am getting good chest movements but there is no sign of the child getting pink. We give adrenaline and I grab the laryngoscope. I get a good view of the vocal cords and ask impatiently for the endotracheal tube. I pass it down throat through the small gap between the cords. Pulling the mask off the bag I connect it to the tube and ventilate the baby.

20 minutes, 1 naloxone and 2 adrenalines later and there has been no change. The baby never stirred, and never took a breath of its own accord. I ask the Sister in charge to explain this to the mother before we finish. Sister goes to the mother and with great compassion in her face and manner explains what is going on. I watch the tragic conversation, the mother listening even as, behind the green sheet the obscures her view, the surgeon continues to close her abdomen. Sister comes back. “She understands. And she would like to cancel her tubal ligation.” The surgeon nods silently.

The midwife and I stop resuscitation. She takes the baby and wraps it up. I go to the mother. She looks at me and whispers, “Siyabonga.”

The spinal anaesthetic is wearing a little thin now. She winces and give small gasps of pain. I give her a shot of sedative to ease the discomfort for the last 5 minutes of the operation. I time it badly: the midwife comes to show her the dead baby, carefully wrapped in a sheet. She is too spaced out to really notice.

Wednesday, 5 September 2007

Consulting God

The man walks onto the ward and makes a beeline for me. He talking loudly and expressively in Zulu, his arms waving dramatically to emphasise whatever point he is making. He is a little unkempt but not obviously drunk or high. He sees I do not understand and switches to Afrikaans.

“I don’t speak Afrikaans. Try English.”

He obliges instantly. “Doctor, I am here for my medication. I need my medication. Can you write me for my medication? I have run out and I need more.”

“You must go to outpatients sir. They will help you with you tablets.”

“I need haloperidol, chlorpromazine and epilim. You can write me up for them can’t you?” They are antiepileptic and anti-psychotic medications.

“Go to outpatients sir. They will sort you out.”

“Ah yes. Thank you doctor.” He pauses and watches me. I turn back to the patient I am seeing. He begins talking loudly to the nurse.

“Could you keep your voice down sir? It is hard to hear the patients!”

“Of course! Of course! It is very irritating isn’t doctor when people show no consideration?” There is a hint of irony. He is nodding enthusiastically and looking at me seriously. As I continue on my round he wanders off. 20 minutes later he is back with one of the OPD nurses Bongani in tow to make sure he doesn’t get up to any mischief.

“Ah! There you are doctor. You must help me. These people do not realise that I am God. You must tell them who I am. You know who I am don’t you?” A spray of spittle gets me in the eye. “And there is another thing. Can you help my vision?”

“What is wrong with your vision?”

“It goes dim. But only when I read the New Testament.”

“It is OK when you read anything else?”

“Yes – there is no problem with anything else.”

“OK – let me see if I can help you.” And God and I nip over to outpatients to sort out His anti-psychotics.


Outpatients

Monday, 3 September 2007

Spring

I wind down the window and stretch my bare arm out into the onrushing wind. The heat and humidity are testament to the arrival of Spring and I open my hand to catch the breeze as it hurtles by at 120 kilometres per hour. I reach the crest of the hill – the highest point of the highway as it traverses the game park – and the landscape rolls away into the haze on all sides. Vervet monkeys leap out of the way as I head down again. I turn up my (you might say cheesey) African themed music.

As I round the corner the car in front slams on his brakes, as I do in turn. An elephant is crossing the road. We both watch from our vehicles. As I pass the driver he turns to me and gives a broad smile and gestures animatedly to the elephant beside him. I smile and wave back and then pull away.

You gotta love this country.

When Jesus calls

Sister on C ward

I am half way through my round on C ward, the female medical ward. Out of the corner of my eye I become aware of two well dressed women standing a couple of metres away and radiating that powerful aura that so effectively says “I am waiting for you” to your subconscious. I have never learnt how to ignore it and within a few seconds find myself completely incapable of concentrating on the task in hand.

I turn to them. “Can I help you?” They step forward, clutching the familiar bulk of the death certification papers.

“Yes please doctor. Could you sign these?” says the first in perfect English. I take the papers. There are several of these most days – my record is 7 deaths (20% of the ward but that was over a weekend and shouldn't be counted). They must be signed by a doctor to confirm the cause of death before the body leaves for the undertaker. Half the cases we have no idea what actually killed the patient and write “Pneumonia, ?HIV”. A GP in a town 50km away did a week long course on how to do post-mortems apparently – we send the suspicious cases to him – but there is no system for confirming causes of death in those cases where the diagnosis is unknown as there is in the UK.

I flick through the papers and look up at them in dismay. “But this lady was doing fine yesterday!”

“Yes doctor. We came yesterday and she was well. She told us she was being discharged.”

“Yes – but she was young and she was nearly completely better. I am so sorry. I don’t know what happened.”

“Oh doctor. Do not worry.”

“But she was better. She was walking around and complaining that she was bored.”

“Doctor. There was nothing you could have done.”

“Thank you but I am so sorry.”

“Doctor. If Jesus calls someone then there is nothing even you could do about it.”

I sign the papers, again having to make something up as I have no idea what killed the poor woman. Do you know what the a South African’s life expectancy is these days?

48. Much lower if you take out the wealthy city people.

It seems to me that if the lady’s logic were true Jesus seems to want an awful lot of young Zulus.

Saturday, 1 September 2007

Ghost Mountain Inn

It is dusk as we pull in through the gates of the Ghost Mountain Inn in Mkhuze. It nestles at the foot of the Lebombo Hills in KZN and is one of our more luxury getaways – we are using it as a stop over on the way back from the conference. My mind turns to our first visit here a couple of months ago.

We were in the bar in the evening and got chatting to a pleasant Scandinavian couple. He was Swedish, she was Norwegian I think – both incredibly snappy dressers. Since we had a Swede and Norwegian in our gang conversation flowed fast and multi-lingually.

“What are you doing here?” I asked them.

“I am setting up a football academy,” he replied.

“Here?!” Mkhuze is not exactly the centre of the world. It is a small town in the middle of a large rural area with few services and little employment. He was, I imagined, some kind of social-conscience development type, using his football skills as a means of community development and empowerment.

“Yes, but we live in Durban.”.

The girlfriend broke in, “I am house-hunting in Umhlanga.” Umhlanga is one of the most upmarket beach areas in the Durban suburbs. Housing there is not cheap. My vision of a social-conscience development type did not fit well with buying a house on the Umhlanga beach front.

“So where are you living now?”

“Here,” she replied.

“In Mkhuze?”

“No, in the hotel.” I was vaguely aware that some of these European development organisations can have rather excessively generoues expense allowances but there are cheaper ways to live than R540 per night per person.

“Wow! Nice!”

“Well its OK, but of course no hotels will let me have my dog and it is really a problem when you are living in hotels for a while.”

“You got the dog here?”

“No, we brought her from home. She had to spend 6 weeks in quarantine poor thing. It was so expensive but she is out now.”

“So do you have the dog in this hotel?”

She lowered her voice to a whisper. “Yes. But when we check in a have to dress her up as a baby in a blanket and carry her in my arms as if she was a asleep!” She sat back in her chair with a triumphant look on her face. I could feel a slightly hysterical smile creeping irrepressibly over my face and tried to think of something sad.

After a couple more drinks they made their excuses and left. Olstein sat back with a conspiratorial look on his face. “You know who that was don’t you?”

“Who?” I asked.

“Swedish. Into football. Setting up a football academy.”

I struggled and failed to make the connection.

He paused dramatically - I could almost hear the drum roll. “It was..."

"Yes?"

"Sven Goran Erikson’s son!”

“What?! How do you know?!”

“I met one of his work colleagues earlier in the afternoon and he told me.”

“Are they are hear doing social development projects?”

Olstein laughed heartily. “It is not a social project. They are talent spotting and then exporting trained players overseas for loads of money.”

It suddenly all makes a bit more sense.


Then, with the outside company gone we regressed to childhood and spent the remainder of the evening challenging each other to snog the various wooden animal statues that decorate the bar without the foyer guard seeing.