Day 80, Referral

Day 80, Asking someone for their help seems a simple enough idea. It is particularly a good idea when you know that the person helping you has more knowledge or more resources to find answers to your questions. Of course if the reasons are genuinely unselfish then there should be no reason to be obstructive, should there?

In the medical world asking for someone’s help is known as a referral. It is almost a special skill in itself because despite it being a completely rational thing to do one will be made to question their very existence in order to carry one out successfully. Of course this is not confined to Mseleni hospital and its various referral centre located miles away in towns that can be reached in a mere 8 hours, if waiting for an ambulance is concerned.

During my time in accident and emergency in the UK referral was an art form. You feel like partly like hostage negotiator and partly like a used car salesman. The aim was to get your patient across to the appropriate intake team and their objective was to stop you. It was almost a game where we argued semantics over a patient lying on a hospital gurney.

Like everything in Mseleni, the principles are the same but the execution is that much harder. To make a referral here your first hurdle is to get the switchboard to agree to putting your call through. Even though the eventually always will, you still have to dance the dance of outlining who you are and what your purpose is. They will then try and put you through to a relevant hospital switchboard who will in turn connect to a department. That department will tell you there are no doctors available and ask to call back to their switchboard. They will give a mobile number for the doctor and I will have to ring through again via the same rigmarole, this time through the shoddy connection where I struggle to hear over the din of the OPD. If the process takes less than an hour you can consider yourself a real charmer

Once through to the actual doctor the real hard sell begins. Back home it is tough enough and can take a considerable length of time and if your skills are good enough they will yield. In Mseleni even if you can talk your way into your colleague agreeing to accepting an obviously sick patient under their care, they will then turn around and explain they have no means to help them and to ring back in a month. While the month passes, often so does the patient.

To my surprise, probably owing to some cosmic alignment I was unaware of, this week I spent a mere fifteen minutes before speaking to a consultant rheumatologist who entirely agreed with my assessment and wanted my patient over in Durban ASAP. Alas she had no one to look after her children and I had to relinquish her bed and hope that when she returns I, and she is equally fortuitous.

It is sad that being able to essentially ask for someone’s help to try and get medical attention to the very sick becomes a series of negotiations. But I suppose I would be naive to think that it would be any different simply because of altruism. That doesn’t really change whether your patient lives in Mseleni or Manchester, only the scale differs.

www.youtube.com/watch?v=uWhkbDMISl8

Day 76, PMB

Day 76, It is almost a year since I underwent the application and interview process for my year in South Africa. It wasn’t really a competitive interview, it was more aimed at checking that the candidates were aware of what this year would entail. I remember trying to envision what it would be like and putting together my presentation and I obviously convinced them that I knew what I was letting myself in for.

I can’t really remember what I was thinking at the time but I’m pretty sure that I didn’t imagine my life here as it is. I wasn’t naive and I knew the hours would be long, the demands would be hard and that I would be battling to keep patients alive every day. In more ways it is with all the things outside of work which I have surprised myself.

This weekend I had signed up for an anaesthetics course with four of my colleagues in the provincial capital of Pietermaritzburg, a city known as the “the sleepy hollow” for its lack of excesses. As usual on Friday I flew to my clinics, an experience that will struggle to lose its novelty. The others managed to finish early and picked me up as we set out on the journey. As we reached the first town of Hluhlwe one of the two cars started to sputter. With the weekend plans hanging precariously I contacted my pilot friend after his recent hospitality. A few minutes later we had the car given the once over a by a local mechanic and with some minor work we were back on track.

The rest of journey was relatively drama free. Whilst heading south the storm clouds gathered and soon we were driving through pounding rain with lightning blazing across the night sky. I was staying with my colleague at his friend’s place. When we finally arrived after four hours on the road they were cooking a poikie, a casserole cooked in an iron pot on a braai. We tucked into it with a healthy helping of local reds.

The following day we were up at half past six to attend the course. Aimed at rural doctors it covered a range of topics about anaesthetics and particularly in obstetrics. Not only was I up again at hours I never knew existed back home on a Saturday, but I actually paid attention throughout. As a bonus I was able to finagle the pharmaceutical reps into giving us some freebie equipment for the hospital, a genuine boost to my conscience.

After the course we met up with some of the others and headed to dinner at the finest, and possibly, only Thai restaurant in the city. As with any group of medics anywhere in the world food leads to wine which leads to shameful attempts at dancing and obscene amounts of drinking. I can only apologise to the poor patrons of Crowded House, Maritzburg’s premier nightspot.

With heads still heavy, the following morning we decided we wanted to do something before the marathon trek back up to Mseleni. Inspiration hit us that naturally the best thing to do would be zipping along from treetop to treetop at 60km an hour suspended hundreds of feet in the air on the hillside. The exhilaration of speed, the calls of wild birds and views of the expansive valleys in front of us it was the perfect way to cap off the weekend.

I couldn’t help but think that during that presentation a year ago I never would have thought I would be driving back in an electrical storm from a weekend course, staying with strangers, dancing with new friends and swinging from trees with a hangover, delightfully bizarre.

http://www.youtube.com/watch?v=TfJe8hQ8ha0

Day 71, Choices

Day 71, Choices, we all make them every day. Some more trivial than others, ketchup or mustard, drive or take the bus, one more drink or not. In medicine no matter where you are choices are crucial. However many would argue that it is becoming less so in the UK, at least for the individual doctor. The government tells you what you can offer, and NICE tells you what the best medications are. When you prescribe a drug there are usually local guidelines which mean it can often be a tick box decision.

In rural South Africa things often get more creative. It is almost paradoxically so as our repertoire of medications is so much narrower, but you have more free reign to prescribe. There are a number of factors which influence this creativity. Perhaps most commonly is the lack of stock, you then have to start thinking about the best alternative ways to treat people. You try and follow best practice guidelines but this is often not possible.

At weekends there is no pharmacist available, and as the doctor on call you will have the keys for pharmacy. This means that when I want to prescribe medications to take home it is often limited by what I can actually find, there is not always a functional catalogue system. Whilst playing pharmacist you also have to try and find medications for the wards as they may not have restocked prior to weekend. Again when you can’t locate the stock you will have to get creative otherwise the patients won’t receive any medications.

Perhaps the most difficult choices I have to make in Mseleni are the ones where I know the resources are limited and I have patients competing for them. Do I take a chance and transfuse the guy who is having a bleed or do I try and keep our emergency blood supply in case there is an obstetric emergency? I suddenly have to take into factors such as their HIV status and their relative chances of a positive outcome, playing judge and jury.

The temptation, and our training is to treat the patient in front of you. Here you have to think about the bigger picture as well. Today I decided that I wouldn’t send a young guy with a neurological problem on an ambulance for a CT scan because it would tie up the only available ambulance for emergencies in the region.

Having to operate with the rationing of resources in mind is not the burden it would seem but almost empowering. Though most of the decisions are hopefully correct ones, taking a chance means inevitably there are times where I’m getting it wrong. But here the only really unforgiveable decision is the one not to make a choice at all.

http://www.youtube.com/watch?v=H0HR_ZgprFw

Day 69, Weekend II

Day 69, So I’ve just finished another marathon weekend on call, 80 hours in a row of being available to be called if I wasn’t at the hospital already. The surprising thing was that it was pretty tolerable. I don’t know whether it was that I’m becoming used to the work here or whether it was simply a quieter weekend but I don’t feel as overwhelmed as I had after my first weekend.

Despite the easier ride it still had its typically Mseleni hairy and surreal moments. The fact that the first night was accompanied by thunderstorms was less than amusing. Trudging around in the dark isn’t fun at the best of times but doing so with the downpour of tropical rain washing mud and rain down the hill I have to walk up was not what I wanted to do at 2 in the morning. But alas there was a caesarean to cut and the lack of sleep meant that the whole weekend felt a bit of a sleepwalk.

The weekends are split up so you alternate whether you’re covering for the OPD, and hence the emergencies or whether you’re covering the wards being responsible for all the inpatients. The latter can be unsettling at night as the nurses have to inform the doctor of any death. Regular readers may have inferred that mortality rates are quite high which means that you can usually expect to be woken up at night to be informed of a death. The nurses don’t really expect you to do anything further and so all it does is provide for slightly disturbing dreams as you struggle to fall back to sleep.

The other call they are particularly fond of is “doctor, the patient is gasping”. To the non medics gasping is a pretty late and pre-terminal sign, basically for most patients it is a point of no return. So the futility of being informed of this is quite frustrating. Especially as even if resuscitation were attempted at this point as most of these dying patients are HIV positive I wouldn’t be able to get them an intensive care bed anywhere. So often it turns out to be a response of “lets try and keep them comfortable”.

This weekend we didn’t have an xray department which added a new depth to the challenge, as medics we use xray as our sixth sense. Much as with the other senses, when you lose one, the rest becomes heightened. I found my clinical skills and diagnostic abilities having to be that much sharper to try and overcome this disability.

Perhaps the best thing about working a weekend is when you complete one you know you don’t have to do another for a month. It’s akin to hitting your head against a brick wall, it feels such a relief when you stop. Added bonus is the weekend is over, the sun is shining again and the rest of week seems a bit of a doddle by comparison.

http://www.youtube.com/watch?v=cMoc4wWF9LY

Day 60, Ponta do Ouro

Day 60, I have come to think of Mseleni as quite a rural place. The hospital is the largest development in town and we don’t really have any shops to speak of. It does however have a good network of tarred roads leading up to it. These roads are fairly new and I’ve heard many a tale of the bad old days with dirt track roads. It was hard to imagine until this weekend.

That is because the past few days have been spent in the little Mozambiquan town of Ponta do Ouro. Just across the border it is remarkable how different it is from what we have here. Going through the ramshackle border should have prepared me but as our transport drove us through the undulating mounds of sand, Mseleni by comparison was positively urban.

Once in the town the vibe was similarly quaint. The main strip consisting of a few restaurants, an ATM, a supermarket and a smattering of surf shops. Just beyond it however lay a magnificent bay onto the Indian Ocean which for the most part was devoid of human traffic. I was there with my brother and his wife and we had rented chalets on the hillside. These were comfortable log cabins sat on stilts with verandas from where you could hear the waves crashing.

As with any family visit much impetus was on the food. Whilst the Zulu people are not fans of fish, their cousins to the north are much more indulgent. The restaurants are brimming with various types of seafood and their lust for it is perhaps exemplified by the serving of prawns by the kilo. My months requirement of seafood was satisfied in the mere long weekend.

Of course it isn’t an island but it certainly feels like one, probably this accentuated by the abundance of water based activities. Surfers, both kite and traditional, and divers are aplenty. Not being qualified to dive I was restricted to the ocean safari. This is essentially a boat trip around the bay looking for sea mammals, the twist being if conditions are optimal then one can interact. With the weather being temperamental our boat failed to find any whales but we did encounter a group of dolphins. Within a few minutes with snorkels and fins on we dived in to swim with them. To my chagrin in the excitement of swimming amongst the dolphins I started to gulp the salty water and by the time I had recovered my composure they had moved on.

The portugese influence is clear to see with the Mediterranean style houses, the language and even the pasteis pastries being sold. But the colonial infrastructure building was clearly not a priority. In some ways the wilderness feel to the town gives it its uniqueness, an idyllic weekend getaway.

http://www.youtube.com/watch?v=jNsaoVQ-vfs