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

Day 57, Lightning Crashes

Day 57, The Zulu people have a reputation as being a warrior race and a fearless people, with kings such as Shaka Zulu and proud tales of old battles. Until today I had thought there was only one thing they were afraid of, but now I have found there are two.

The first is dogs. They do not like dogs, the bigger they are, the further they stand. On several occasions, whilst walking with my friend and his gentle Alsatian, I have noticed that Zulu people will actively walk on the other side of the road. I have seen genuine fear in a group of teenagers’ faces as she trundles along in her light beacon collar. It does amuse me as she is such a non threatening dog and very much a part of our social setup. However from a local perspective they have grown up with dogs being either wild, rabid creatures that can maim and kill or a reminder of apartheid South Africa when they were a genuine symbol of oppression and fear.

The weather in Mseleni has been changeable of late and today’s storm showers revealed that the Zulu fear of canines is only surpassed by their fear of lightning. During the collective ward round in the morning the skies had started to grey and the rain had begun to fall. As we heard the deep rumble of thunder you could feel the uneasiness amongst the nursing staff. When the lightning begun the patients seemed agitated, particularly the ones by the window. The conversation briefly turned to discussions about people being struck by lightning before we parted to our various wards.

About 20 minutes later a nurse approached me and said, “Doctor, there is an emergency in OPD!” I duly rushed there to find the department rammed full of school kids, about 100 teenagers all in uniform. They ranged from the merely wailing and limping to the ones thrashing about on the gurneys. The tiny cubicles, usually uncomfortable with three were rammed with half a dozen groaning adolescents.

The initial objective was to turf out the time wasters or “debride” them as one of my colleagues put it. I scanned through the ones with no marks and full mobility and duly showed them the door and they slinked away quietly. Not entirely sure of what I was meant to be looking out for I wrote on the hands of anyone I wasn’t sure about and moved them to one side. I spent more than just a few seconds with the ones with burn marks on their clothing.

There was one kid who was causing a commotion on trolley and appeared delirious without any real obvious sign of injury. The preacher that was stood around and praying loudly in Zulu for everyone to hear did not help the situation much. The mass hysteria that prevailed was both mind boggling and comical but was only partly propagated by their innate fear of lightning. The rest was just simply juvenile behaviour as I did spy a few of the boys taking extra care in comforting the obviously terribly distressed girls.

Hopefully the next thunderstorm will be in the school holidays.

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

Day 53, Stranded

Day 53, I never thought a journey from Mseleni to Durban would turn into a mini odyssey but that just shows what I know. The first of my visitors arrived yesterday and I thought it would be nice to meet them in Durban before we took the scenic route back up. Being automobile challenged I had arranged to hitch a lift with a colleague who goes to the city every weekend, the nicest option having being on call the night before. Of course his mother arrives to visit and for the first time in months he decides to spend the weekend in Mseleni.

With no one else going in my direction I had to try and make alternative arrangements. Friday of course was my flying day and I managed to finish my clinics and convince the pilot that I could get a lift back with him to their hangar at Hluhlwe, a tiny crossroads town about an hour south on the road to Durban. As sketchy as they maybe, in my infinite wisdom I thought I may be able to hop on to a minivan taxi. Admittedly I would have to sacrifice any sense of personal space in the hot and sweaty confines along with people’s monthly groceries and perhaps even small livestock.

Yet I was denied the opportunity to experience this as I when the plane landed and the pilots showed me to the taxi rank, there were none going towards Durban that evening. I would have to wait until the following morning before I could get one. I found myself stuck on my own, in a quickly emptying taxi rank in the dusk of Hluhlwe. Etienne, one of the Zumat Pilots I had met only minutes before, obviously took pity on me and graciously invited me to spend the night in his spare room.

My initial reaction, probably induced by my largely urban upbringing, was to be cautious of any such benevolence and check into one of the hotels in the area. Etienne pointed out that the hotels in the area would be expensive and that him and his wife were having friends over for a braai and that I would be more than welcome to join them. He also pointed out that he was doing a tourist run the following morning to Richards Bay which would get me a bit closer to my destination and the airport was big enough to have car rentals.

After brief contemplation I remembered my whole reason for being in Africa was doing things I never would have done back home, and accepted Etienne’s offer. We drove to his bungalow a short distance away and where I was greeted by his wife and two dogs.

Later that on their friends arrived and the braai was fired up. On hearing about why this random traveller had pitched up for dinner they made a few calls and it turned out some of their friends were heading down to Durban the following morning. My stress about the journey relieved I tucked into the braai and wine and found it surprisingly easy to spend the evening chatting away with them about topics ranging from my work at Mseleni, to the prospect of having a helicopter service to the clinics, to even the South African version of Pop Idol.

After a good night’s sleep I was up early yet again to get dropped off by Etienne at my ride’s home. They were a pleasant family of three heading to drop their son off at boarding school after half term. After a smooth further two hours I was finally in Durban and met my brother and sister-in-law.

It was at times farcical but not quite, there were planes and automobiles without the trains. I had heard about African Hospitality but it was down in Hluhlwe that I experienced the kindness of strangers.

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