Day 304, Bush Fire 2011

Day 304, Much to my dismay I have never camped at a music festival. Considering the UK is home to some of the most famous festivals with the biggest bands playing every summer, it is quite a thing that my first festival experience came in the tiny mountain kingdom of Swaziland.

The Bush Fire Festival is described as Swaziland’s premiere arts and music festival, though in all honesty I haven’t really heard of any other such events in the country. Six of us set off sharp after work on Friday, camping gear in hand, dancing shoes on our feet. My knowledge of southern African musicians being limited I was only really aware of one of the bands on the bill but I was enthusiastic nonetheless.

In the UK these events are held in the summer in the hope that the weather is conducive to the festivities. The great consternation is about whether it will rain or not and will the wellies be needed. Being the middle of winter here, we too were concerned about the weather, not a drop of rain poured but the 15 degree dip in temperature at night was very noticeable. Setting up the tents in the dark we wrapped up warm and toasted the night before wandering over to the main stage.

The band I’d known, Goldfish, were headlining the first night and we made it in time to catch their set. The Cape Town duo played their upbeat electronica which proved the perfect kick start to the festival. My friends and I danced nonstop through their performance and awed at their digital gadgetry. Even the open air setting and the chilling conditions were not enough to dampen our mood as we revelled until the wee hours of the morning. The midnight pancakes before retiring to our tents helped to warm not only our spirits but our bellies too.

The following two days were a blur filled with hidden treasures of music I never would have known about. The highlights were the celebrated Oliver Mtukudzi of Zimbabwe and Habib Koite of Mali and South African bands Hot Water and Tonik. The latter played an intricate set of keyboard and tablas as a silent gig, with the audience listening through headphones. A slightly odd idea, it did serve to question the listening experience.

The crowd was a slice of all demographics; older hippies, families with children, black people, white people, Swazis, Saffas and foreigners. There was of course enough interest in football to have it distract for a while on Saturday evening. Of course, aside from the Barcelona and Manchester United shirts the festival was awash with colourful costumes, crazy hairdos and glow sticks. The giant puppets and insane Tshe-Tsha Boys with their boiler suits and clown masks only added to cacophony of bizarre and bright sights and sounds of the festival.

Like so much during my time here, this was yet another thing that I’ve been introduced to that I never got around to doing back home. With a nudge in the right direction from friends I have again managed to widen my horizons. Who knows, I may even have to invest in a pair of wellies.

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

Day 296, The Prawn Shack

Day 296, Under normal circumstances I wouldn’t be partaking in a 500km round trip for a restaurant, but normal has been few and far between lately. This weekend I had the opportunity to participate in a rather indulgent dining experience.

About a 100km outside of Durban, along the coast, is the Amatikulu nature reserve. Not particularly stunning in of its self, it is an extension of the Dolphin Coast with a characteristic network of lagoons. Just set off from the beach is the Prawn Shack. A restaurant open at the weekends catering for an 8 course lunch meal dominated by the eponymous prawns.

Set in what resembles a wooden shanty, the blare of Bob Marley welcomes customers along with the complimentary caipirinhas. The drinks are essential to the meal and it is customary to try a shot of tequila complete with a live prawn in the glass. The oddity of the dining experience is confirmed by the proprietor greeting and instructing guests at the beginning on how the whole thing is meant to work.

The food included some local influences with curry filled buns known as bunny chow as well plates of Zulu sushi. Prawns were represented well in the curry, as well as in pasta form, in a bisque and simply grilled. The feeding started at midday and was scheduled to finish four to five hours later. Recognising the restraining capacity of the human stomach, a walk to the beach is pencilled in after course 5. It is a welcome break from the eating but upon returning we were treated to dessert, camembert with a crystallised caramel layer torched in front of us.

The restaurant is situated next to a campsite, and being quite a journey back after the afternoon’s feasting we bedded down for the night. Despite living near the sea, our local coastline being protected waters means we get very little fresh seafood locally. I suppose it is a true testament to the Bengali love for prawns that I journeyed for 3 hours and slept over by a restaurant just to indulge myself on the delectable crustaceans.

http://www.youtube.com/watch?v=leohcvmf8kM

Day 294, Outcomes

Day 294, Sometimes medicine feels very arbitrary. Things seem to happen that we have no control over, yet an infinite number of decisions lead to it.

Last weekend I was on call again and as with any call I like to avoid disasters. Unfortunately it’s out of my hands whether one strikes. There are factors that can conspire to cause problems and as i’ve alluded to in the past blood for transfusion is a scarce resource, but one that is all too often necessary to function effectively in emergency healthcare. The news at the start of the call that we would have no emergency units came with a sense of foreboding.

Most days we have no real need to transfuse patients but as luck would have it we kept receiving patients that would buck that trend; a woman with a bleed during pregnancy who needed an emergency caesarean, a ward patient who was bleeding after dropping her platelets and a guy with HIV and severe anaemia making him weak and breathless.

Then came a patient I picked up the card for, a man in his twenties who had been started on HIV and TB treatment and was recently in hospital in Johannesburg. He had taken his own discharge from hospital two days previously to come and be closer to his family. They had noted he was anaemic and needed a transfusion. By the time he arrived to us his circulation was being so inefficient that his heart was failing. Johannesburg is a city with millions of people, dozens of hospitals and a vast network of blood banks whilst we struggle to rustle up anything from our whole district.

I was instantaneously frustrated by the decision he had taken to leave the city and recognising the seriousness informed him and his father that we will try to find him blood but that the worst may happen. When a unit of blood was kindly given us by a neighbouring hospital I had to weigh up the plausibility that an obstetric emergency could need it at any point. I tried to manage him conservatively, and held on to the emergency unit. As it happened we used the blood for another patient and though he survived the weekend he eventually died without enough blood getting to us.

His decision to leave the city, our lack of blood supply, my decision to hold back on the emergency unit, these were all decisions that eventually led this twenty year old to die. Each juncture represents an opportunity for a different outcome. Though he had influence on the events he eventually had no control on the result, much as I didn’t. As with so many other patients in Mseleni this made me aware how arbitrary life and death really is and how ultimately powerless medicine can often be.

http://www.youtube.com/watch?v=EUBsz10Lv5U

Day 281, Medicine to Astound

Day 281, It’s like being slapped in the face with a wet fish. Medicine here really isn’t about half measures. Whether its clinical signs or attitudes to treatment, it never cease to amaze. I’d like to be able to say that it was just the odd case but looking back through my time here I have been gobsmacked on so many occasions that my face is in a permanent state of stupor.

Quantity, that’s a big thing. This is perhaps particularly applicable to the sheer volume of pus and extraneous fluid that can be collecting inside a person’s body. There was a patient who presented with mild chest pain, from the x-ray we realised that there was a collection of fluid around his heart. When we eventually relieved him of it we had taken out 3 litres of fluid. That’s 3 coke bottles of fluid in a sack that’s not meant to expand significantly, against which his heart had to pump. In terms of quantity that was only outdone by the man with a bulge over his liver who drained five litres of pus. Presuming that it has the equal density of water (in actual fact it is probably much denser) that is a minimum of 5kg of infected material dwelling inside the man’s liver.

Extent, never ceases to amaze me. I have literally had patients waiting at home until there foot falls off before coming into hospital. The usual culprit is the HIV related Kaposi’s Sarcoma but we have ischaemic legs, much the same as would be seen in any hospital in the UK, with gangrenous feet requiring amputation. I have asked about why they will wait until the extent of the disease is so advanced, and the answers have been varied. Some say it is because it is hard to get to the hospital if you have painful legs and for others it is because they will try traditional medications first. My favourite is that they are afraid if they go to hospital they will have their leg cut off, of course waiting so long turns this into a self fulfilling prophecy.

Stoicism, by and large the people in rural areas are very stoical when it comes to health. From not flinching during lumbar punctures without anaesthetic, as is the practice is here to walking around doubled over with two sticks as support from their crippling arthritis, it is hard not find the locals very stoical. Sure, we get our share of screamers and shouters, usually younger individuals, but it is both admirable and frustrating to see people just put up with poor health because in the past there was no other choice.

Scepticism, there is definitely more than a healthy share of scepticism towards conventional medicine. I have had asthmatics who I can hear wheezing across the consultation room just because they are scared of inhaled medication. Even more frustrating can be the ease with which many believe that antiretrovirals make you sicker whilst they are quick to believe when the Minister of Health states that beetroots will cure HIV.

It is the wonderful quirk of working in an environment such as ours that every time I make the mistake of thinking I’ve seen it all, a patient pitches up to say or show me something that is completely unbelievable. That is the reality of medicine here.

http://www.youtube.com/watch?v=waacof2saZw

Day 179, Negotiating Africa

Day 179, Is everything really negotiable in Africa? That is not meant to be a disparaging remark but rather an appreciation that there is usually a deal to be done. With my background I’ve always been comfortable looking for a deal, but here bargaining has taken on a new level.

During my time here there have been numerous occasions where I tried to haggle my way to a better deal. Usually it is at the little tourist markets when I’ve tried to buy a curio or other memento of my time in South Africa. The store owners are however canny folk who have been doing this a lot longer than I have. They are brilliant at making me think I’ve got a great deal when really I’ve negotiated my way to a price they are happy with.

Negotiating is of course part of my job too. As a doctor anywhere in the world half the battle is bargaining with the patient to get them to accept treatment. Once we manage that we have to be equally persuasive with lab staff to get results, radiographers to get xrays, and referral centres to accept care. This is not even considering the amount of finagling needed to get holidays.

Negotiations are not always a pleasant repartee but can be decidedly distasteful affairs. Recently I was stopped by the traffic police for the incredibly innocuous offence of the backseat passenger not wearing a seatbelt. Being an offence I tried to talk my way out of a ticket but soon realised the real negotiation would be over how much of a "roadside fine" the policeman was after. He had no interest in issuing me a ticket but I managed to ensure that his fine wasn’t overly taxing.

With any negotiation it always helps to have bargaining chip of some form, in our little corner of the country, working at Mseleni Hospital is often good currency. Not only have we managed to organise for discount rates at many of the nearby game parks and entertainment facilities but this weekend I even used it at the Mozambique border. The visa fees for foreigners have become somewhat exorbitant and given that I was only there for two nights I felt their price did not represent good value. I was successfully able to negotiate a special rate with an unashamed reminder of the good work done by the hospital.

Haggling is a cultural norm here and some would suggest it is simply individualistic with everyone out to gain any sort of advantage in face of the harsh reality of life. But to me, the willingness to recognise the contribution of the hospital’s work is synonymous to people here valuing not just money, but all manner of things. At the end of the day a good bargain is about making sure all parties come away happy with the result, and ultimately what can be more communal than that?

http://www.youtube.com/watch?v=vyeoW4ifNik