Day 110, Parallels

Day 110, Science fiction loves the parallel universe, the alternate dimension, where the players are the same but everything is askew. Sometimes it feels like patients here are living in this twisted world, where their fate gets equally twisted.

I have a 27 year old man on the ward who is HIV negative and has become unwell over the last few days. He’s spiking fevers, bleeding from his mouth and now not talking. He’s most probably got an infection somewhere but it just doesn’t add up. Whatever it is may have cause bleeding elsewhere, with a particular possibility of a bleed into the brain.

So I send more blood tests, I get an xray of his chest, a CT scan of his head and then we get a diagnosis. I am able to find him a bed in an intensive care unit and he gets transferred without delay. He receives the right treatment and as the infection is controlled he wakes up and as is able to talk to his family and friends about how well he is doing.

In the parallel world the xray machine is broken. His blood tests take forever to come back and give us no clue of what maybe wrong other than there is a process causing him to bleed. The ct scan and intensive care unit are services in a far off hospital that even if they were functional they wouldn’t be able to accommodate him. The best guess treatment we can give has little effect and we watch as he runs out his clock. His mother sits by his bed looking at the various tubes going in and out of his body and asks what is wrong with him.

http://www.youtube.com/watch?v=Xgeed-nkBQQ

Day 107, Cinema

Day 107, After my last blog I thought it would be nice to take a little diversion of topic and discuss something that many know is a passion, nay obsession of mine, the cinema. My nearest cinema is a good two and a half hour drive and even then its selection of films is fairly limited, needless to say I haven’t made the trip.

In amongst all the crazy trips and weekends on call this is the first weekend I’ve found myself with no fixed plans and no friends available to hatch something crazy with. With old habits dying hard I travelled down to Durban and indulged in a behemoth of a multiplex.

I’ll be the first to admit, I’ve taken these for granted in the past. I sneer at the concession stands, get frustrated by the ticket queues and become vexed by the chattering masses. At home I would go every week but choose the late shows where I can be sure to avoid most of these irritations.

However after three months of “sobriety” I embraced the garish joys of the Gateway multiplex cinema. I made sure I was there in time for the trailers, such glorious little vignettes of coming attractions I have no hope of keeping up with! For my momentous return to the throws of the cinema I chose The Social Network.

What has always appealed to me about films is their ability to inspire and elate as well as entertain, but I’ve never really found it a source of escapism. However out here the escapism element is much more relevant to me. It was fantastic to completely switch off from what I encounter on an almost daily basis.

To cap the experience, I can sit a cafe, sip a drink and use their broadband to write about it. It’s amazing what becomes a luxury when you don’t have it. I am sure when I get back to my old life, all of this will be mundane again and I’ll be laughing when I reflect on the simplicity of my life in the bush, wondering how I ever did without this.

For all the fancy and xv adventurous travelling, all the weird and wonderful medicine I am seeing and all the crazy life experiences it is the simple things that I don’t have that will have the most lasting effect on me.

http://www.youtube.com/watch?v=iMqXj-eVCjI

Day 103, The Unpleasant Reality

Day 103, There is a recurrent theme in Mseleni of being tasked with jobs I have no reason to know how to do. I was prepared for this, part of the great experience was to be challenged with situations that were foreign to me. Three months in, the breadth of these experiences still manages to catch me unawares.

Inevitably it was during an on call that I had to perform a task I have never wanted to do nor do I ever wish to do again. The task was to conduct a forensic examination on a 4 year old girl for an alleged sexual assault. She was brought in by the police and her mum, she had been found with a 13 year old boy who had told her they were going to “play” together.

As a doctor I am not naive to the fact that these things happen and that as professionals we are relied upon to help build a case against a perpetrator. Back home this kind of data gathering would be performed by a forensic doctor, not only because they have expertise in the area but by working in that field they have come to terms with psychological aspect of it too.

Once a brief history is taken the evidence collecting begins. The police bring a brightly decorated kit with primary colours and teddy bears on the front, it is the “paediatric sexual abuse evidence collecting kit”. The fact they have a kit indicates just how often it is required. In it are step by step instructions on how to collect the various bits of evidence in a forensic friendly manner.

The evidence required included the child’s clothing, samples of hair, saliva and swabs from everywhere imaginable. It is hard to remember that I am actually doing this for the child’s benefit, it didn’t feel that way when I was expected to be comprehensive with my examination and evidence late at night. Unfortunately despite how tired she was it had to be done within 24 hours of the event for any chance of collecting useful evidence.

It was my first time performing this sort of examination and the experience has left me feeling very unsettled. I am concerned that I may have appeared very clinical in my manner. It is hard to be sure how to react when a situation like that is thrust on you, let alone when everything is being conducted through a translator.

As I stated earlier I don’t really feel it is a job for someone like me to do but here it is either us or nothing, and no hope of a prosecution if we don’t step up. In reality prosecutions are few and far between and the tragedy is we see sexual assaults and rapes fairly often in both adults and children. Before my year is up it will be as familiar to me as the simplest of medical procedures, but I cannot envision a time where I will be comfortable with it.

http://www.youtube.com/watch?v=UCXnJIAQd1o

Day 98, Camp Circumcision

Day 98, Whilst the UK government impresses on health initiatives such as HPV vaccination, five a day, and fit for life campaigns in South Africa the emphasis is clearly on HIV. As such, on the basis of minimal but convincing evidence, the new push here is for male circumcisions. The figures show a slight reduction in HIV transmission in those not sporting hood ornaments. Of course this is slightly tempered by the increased rate of transmission in the first six weeks where we hope these eager young men are not keen to test drive the new look.

As part of this initiative camps are being set up regularly where men are encouraged to come, get tested and get their circumcisions done. I got my first experience of these camps today up in Mosvold, in the foothills of the Lebombo mountains. The camp had been set up in a school on this occasion and pupils wishing to make the lifestyle choice were free to rock up after finishing their exams.

The setup is to “process” the willing candidates in a conveyor belt like system whereby they start with being counselled and receiving a rapid HIV test. Should they be negative and consent they get moved to the operating theatre. There they were cleaned and given local anaesthetic by the nurse before it was our turn the boys into men.

The theatre was a classroom divided into four cubicles by draped room dividers. Despite the rustic look our equipment was not unreasonable with even diathermy available. Once on the table it was up to me to do the deed. Of course I had never seen, let alone done a circumcision so I got shown one. I then was left to crack on with the others.

What surprised me more than the fact that I got that hang of it fairly quickly was the interest with which the patients were looking on at the process. I never imagined that anyone would want to watch that part of the anatomy being attacked with a scalpel. After it was done, they all walked out with a sheepish green and instructions not to play with themselves.

http://www.youtube.com/watch?v=zDKO6XYXioc

Day 94, CPR on the Beach

Day 94, As a doctor you always wonder about the day when you may be called into action for the man on the street. I’d never considered that it could be a beach rather than a street, but yesterday the nightmare scenario became reality.

I was sat on the beach soaking up the Mozambique sunshine, taking pictures of waves crashing over my friends who were in the water. One of them had started to struggle with the strong current and was calling for help. The others managed to get to her as commotion started breaking out on beach. They came back in swiftly and then we realised that there was a mozambiquean man who was out far in the water and couldn’t be seen. One of his group ran past me saying he was dead.

I couldn’t quite comprehend what was happening. Some other locals, good swimmers, dived in to try and find the man and I turned and ran towards the beach lodges to call for help. I ran over the sand bank past a young woman stood looking out to the sea, she was wailing and bawling. I managed to get someone to try and call for a boat and ran back to the beach to find that the man had been brought ashore and my friends had started CPR.

As expected there was a throng of onlookers without much productivity. People had been sent to find equipment and call for an ambulance. Without any pocket masks or ambi bags we were unable to give him any of what he really needed, oxygen. Our main focus became to continue giving chest compressions. His pupils were already not reacting and he had spewed copious amounts of vomit. This likely meant that he had aspirated this into his lungs along with the salt water already in there.

With bizarre and unhelpful suggestions from the bystanders we continued on with what was shaping up to be increasingly futile. I swapped into the compressions position and realised for the first time how young he looked. He was barely in his twenties if not his teens. My hand kept slipping with sweat in the heat of the afternoon sun, the vomit smell became more pungent. We stopped at regular intervals to check for a pulse but continued on each time we found none.

Eventually a trickle of equipment arrived; I rummaged through one bag with 2 IV cannulas amongst other things and attempted to site it. I was sharply reminded by my friends that I should use the gloves which I had forgotten in the commotion. I didn’t get a flash back and as I withdrew the needle it pierced through the cannula. We were left with no oxygen and no means giving any fluids. Time was passing and he was receiving no oxygen to his brain. It was at least 25 minutes before a portable defibrillator arrived and confirmed that we should continue chest compressions.

With no ambulances within an hour’s vicinity the crowd murmurings started towards getting the patient over the border to Manguzi hospital, 45 minutes driving on sand roads. Our murmurs were more concerned with the purposefulness of resuscitation given the likely prognosis. Yet we continued, we could not do otherwise under the circumstances. Eventually more kit arrived that would allow us to start oxygenating him but he had been deprived of oxygen for too long.

A bakkie (pickup truck) had been mobilised and we manoeuvred him onto the back and continued with the compressions. As we set off the beach we reviewed the reality facing us, that it was unlikely that he would ever have a pulse again and in the event that a miracle were to occur that he would be in a horrible vegetative state. I continued with compressions on the back of the truck with difficulty as the bumpy road it made it nigh impossible to be consistent. We took him to a local clinic, a two room hut with very little staff or equipment, and reached a consensus. After close to an hour of continuous CPR, being attended to by 6 doctors, and given whatever drugs and oxygen was available we would not continue with our resuscitation attempts.

In a matter of minutes the idyllic weekend getaway had become another patient we were powerless to help despite our best efforts. In the aftermath I was left to reflect on the cruelty of fate and the fragility of life. It could have happened anywhere in the world, but in Africa I’m beginning to expect the unexpected.

http://www.youtube.com/watch?v=u_2i7ziBcZ4