Day 326, Beginning to Leave

Day 326, This evening I had my first farewell from Mseleni. Perhaps it is an odd thing to have a first farewell but I anticipate there will be several more before I actually leave. It has made me realise how the days are winding down and everything I do is potentially the last chance I will get to do it.

Last week was the last public holiday I would have in South Africa, and there has been an inordinate amount of these; Women’s Day, Workers Day, Human Rights Day, Freedom Day and last week’s Youth Day are in addition to the customary Easter/New Year’s and Christmas. This impromptu mid week break led to another last, a final beach day. The early darkness and cooler temperatures have meant fewer trips to the sea of late, and it was a welcome sunny day for a refreshing dip in the warm ocean one more time.

For others around me it is just another clinic or on call or day at the beach, but for me I’ve taken to savouring each event with as much gusto as when I first arrived. I have seen others who have left do the same and I’ve looked on thinking I would be more nonchalant, but alas I am not so different. It is not that I need to make everything special, nor is it that I am regretting leaving it all behind. It is more that this place has now become a part of me and I want to ensure it remains engrained in my mind.

I have moved many times in my life and I have never been completely at ease with it. Yet this time it feels different. I don’t think I will truly understand why for some time yet, but it is probably testament to my time here that I leave with a sense of trepidation. But I came here under the premise that anything worth doing must be scary and I leave with that in mind.

I will miss the crazy adventures, I will miss the improbability of medicine here, I will miss my friends, and I will miss waking up with the sun in my face. But for all the excitement of the final experiences what I will miss most is the also the reason that I must move on; the need to challenge myself.

Saying goodbye shouldn’t be a happy thing, and it is only easy when nothing has mattered. That’s why I am looking forward to multiple miserable farewells before I finally leave.

http://www.youtube.com/watch?v=nabO_UXb6MM

Day 324, White Patients

Day 324, A two tier health system isn’t exclusive to the developing world but the wealth gap just makes it more evident. South Africa’s past means that it isn’t only a wealth but also a race gap which prevails. So it is always interesting to see the dynamics when a white person rocks up at a rural district hospital.

There are broadly two types of white patients that may present; the first are out of towners holidaying in the region who happen to need to some medical attention that do not want the two hour drive to private care; the others are those that have fallen on hard times or Previously Advantaged, Now Disadvantaged (PANDAs). The latter will often come and wait in the OPD with all other patients while the former will insist on being seen immediately.

PANDAs will often be patients who aren’t able to afford medical insurance and will end up in a system that 20 years ago they would not have dreamed possible. We aim to treat everyone equally of course, whilst that is a step up for most Zulu patients compared to the past, for this population group it is a downgrade. It can understandably be frustrating to them and they will often get restless in the waiting room. Chronic illnesses are common in this group and occasionally we will even see a HIV positive white patient; it is slightly sad how they often will be at pains to explain how they contracted it through no fault of their own.

The frustrations for us medics tend to be the out of town patients who will demand instantaneous service such as in a resource rich environment. Our limited staffing means that patients are often left waiting for investigations or to be seen by a doctor, especially out of hours. However those used to private care aren’t always as appreciative of this as our regular population. Their agitation is often contagious to the nurses who will be at pains to point out that it is a white patient waiting, as if this can speed up the delivery of care.

One wonders whether the attitudes of both the white patients and Zulu nurses are a throwback to the institutionalised ideas of the Apartheid era. Perhaps it is simply that the reality of having well dressed white patients sitting in the same waiting room where malnourished babies and tuberculous adults are on death’s door is just socially unacceptable.

The problem with treating everyone equally is that not everyone feels they are equal to others. Some people will always see themselves as more privileged while others will continue to feel they are subordinates. With that in mind the only choice is whether to treat everyone with equal contempt, or equal kindness.

http://www.youtube.com/watch?v=THI4U3OsDQY

Day 319, There but for the grace of god....

Day 319, Not that long ago I was unfortunate enough to be very sick. I was an inpatient in hospital for a prolonged period of time and it has had a lasting effect on me. Working at Mseleni has made me realise just how much of an effect it has had.

I have a 7 year old boy on my ward who was admitted on my birthday. He is an orphan who was living with his alcoholic grandmother and psychotic uncle and had been neglected for a while. He was quite malnourished and came in unable to walk or communicate. We were convinced he was HIV positive but tests proved otherwise.

A lumbar puncture revealed that he was suffering from meningitis cause by tuberculosis. Not that unusual in the grand scheme of things in this setting but his general demeanour was even more debilitated than I had seen. I have had adult patients who have succumbed to this but they have often been unwell for a long time and usually suffering from multiple ailments. When he wasn’t improving we organised for a CT scan several weeks into his treatment. It revealed that he had essentially had a stroke as a result of the infection.

The therapists have worked with him and he has managed to sit up with assistance and he manages to swallow his food now. Yet he is not going to walk again and his communication is limited to gestures and groans at present. We have contacted other members of his family and are slowly making them realise that he will go home not the boy they remember but one that will require constant care.

When I had the same condition I was horribly ill and bed ridden for 7 weeks. I cannot really remember the pain but the overwhelming memory is feeling feeble, like the strength had been sucked from my soul. Eventually, through what felt like a herculean effort, I managed to stand up, only to find that I could not see straight. The muscles in my eyes did not want to coordinate and I constantly saw double.

Getting meningitis has had a significant effect on my life since. Aside from leaving me with occasional double vision, it is not a stretch to think that had it not happened I may have never ended up in Mseleni. For my patient, his life has been permanently altered by it. I have been lucky enough to recover and continue on with my life and career, but I fear despite my best efforts he will never be able to do the same.

I don’t do what I do out of some sense of needing to make up for being fortunate enough to be in a position to make a difference. But every morning on the ward round he manages to high five me and for a brief moment I consider how it could easily have been so different.

http://www.youtube.com/watch?v=rmC3kpM3C_k

Day 317, Mseleni Essentials

Day 317, This is the time of year when new people from overseas come to work and as such I’ve had a few enquiries about what they need to bring. I thought it would be useful to go through a few of things that I’ve found most useful.

A flashlight is essential. I was fortunate enough to be gifted a wind up one as a parting gift and I’m sure it has saved me from harm on more than one occasion. Though the sound if it being wound has become a running joke, it has helped me stay snake free to date. Most snake bites in this region are from the lazy puffadder, they seldom move out of the way and tend to bite when stepped on. A light is a must to make sure they don’t dig their fangs into you.

In my career prior to coming to South Africa, despite the reams of notes I would write every day, I have never had to purchase a pen. For the non-medics this is because of the sheer volume of pharmaceutical reps and their very generous donations of pens. Drug reps are few and far between in rural Kwazulu Natal and a steady supply of pens is a necessity, not just because everything is written manually but also because they have an uncanny ability to vanish.

Driving licence, those without are severely disadvantaged. Whether one buys a car or not, the ability to drive a car and carry proof to that effect is a big bonus. The hospital’s eight satellite clinics are all significant distances away and lie on a mix of sandy tracks, gravel roads and proper tar ones. On a weekly basis if not more frequently, it is required to take one of the hospital vehicles, offroading or otherwise out to one of the clinics. Add to that sharing in driving duties for one of our weekend forays into various parts of the country and it becomes a handy skill to bring to the community.

Always useful to have is a sleeping bag. Whether its bedding down in the middle of a big five game park, setting up a tent with an ocean view, or even just in a field next to a major music festival I’ve gained much more mileage from my sleeping bag than I could have anticipated. Of course, even in the confines of the minimally insulated parkhome residences it doubles up well as a duvet in the winter months.

Plenty of entertainment. We do make a lot of our fun in this place but it helps when you’re backed up by games, movies and music. Movie nights are always fun, if more for the arguments over what to watch rather than the films themselves! A constant supply of music can turn long car journeys from tedious to raucous with the choice of the right choon. And nothing works as well as a bottle of pinotage and a game of 30 Seconds to find the last person in the world never to have heard of Nelson Mandela.

The list is clearly not exhaustive and a million things could be essential here but we often get by without much. Above all the most important thing to bring here is one that cannot be bought at any store, and that’s an open mind and a positive attitude, probably the one thing that will ensure you survive here (and don’t forget chocolate, easiest way to make friends!).

http://www.youtube.com/watch?v=seU5S5DLDpU

Day 307, Technical Issues

Day 307, Technological failure is frustrating to me. In the religion of science technological failure is akin to the test of faith. It has happened to me in the past but in Mseleni this spiritual trial feels harsher than ever before.

My cell phone has been my conduit to the outside world, not only does it allow me to speak to friends and family but it is also my modem and thus allows me to stay in touch with news from abroad, arrange my affairs back home and by way of my writings it even helps broadcast my thoughts. So when a piece of the phone broke and then it refused to let me speak through it I felt abandoned by the heavens.

My laptop and external hard drive are the other components to keeping me on the grid. Also, all my entertainment; music, TV, movies, they are all contained in this paraphernalia. Being representative of Mseleni these became infected by contamination from their local counterparts. They still function but are left crippled and weak by the virus. It does make me wonder how cruel the fates can be to give an innocent computer a virus, but science works in often mysterious ways for those who do not understand its’ intricacies.

But technology doesn’t stand still and even in rural Kwazulu Natal those of us that believe in it are trying bring others round to our way of thinking. My friend and I have even been trialling a digital pen to record our clinical notes and decipher our questionable scrawls. It is our hope that maybe through the use of modern ideas and equipment we may be able to improve upon the practices of old to the benefit of the masses.

In the hospital technology is not alien. We have portable ultrasound machines, bedside haemoglobin meters, and even a pocket saturation monitor, albeit these examples are but a small portion of all the things that we are lacking. Perhaps the most useful pieces of tech are other people’s phones (as we’ve already established mine has limited functionality now). Particularly those with Apples or Berries are able to consult my favourite colleague, Dr. Google, on any number of medical conundrums.

It may sometimes test us when the system crashes, a bug appears or we drop that piece of kit into water but ultimately the answer is usually hidden in the readme file or the user manual. It is true that science cannot explain everything though it tries very hard, but through technology shows us a light even in the darkest of places.

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