10 Days in Africa

I lost the login details for the blog so kept a word document of my adventures for the first ten days - I've thrown them all together here. A long read, if you make it to the end, I hope whatever it is you are procrastinating from isn't too much of a torture. 

28/07/2018 

I’ve finally made it to Matatiele! After a taxi, two buses, three planes and a six hour cross country drive into the Drakensberg Mountains – I made it to Tayler Bequest Hospital. 

The past few days days since I arrived in SA have passed in a bit of a blur. I landed in Johannesburg on Tuesday afternoon where it became quite clear that my hotel shuttle was not picking me up. A short detour via Vodacom later and I had managed to organise to be collected by the next shuttle. As I patiently waited on them to arrive, a group of women washing cars in the car park outside the airport began singing traditional songs in harmony – what a welcome! 

We made our way to the hotel which involved navigating the infamous Johannesburg traffic – I see bad driving is an international struggle, not limited to the Sunday drivers on the A96! The lodge where I was staying had ostriches, antelope and lots of livestock in the grounds, it was a great way to christen my new camera! 

The next morning I headed to the airport to meet my new bank manager to do some paperwork before catching a flight to East London – a small city on the south coast. Here I picked up the hire car and drove to meet the HR department of the Eastern Cape Health department – situated in Bhisho. I’d heard of Bhisho before – it was the setting of a massacre during Apartheid and to be honest it felt like a strange place to be. Somewhat isolated in the cape, huge office buildings loom up from the ground and lack pretty much any of the African character I’ve seen elsewhere. 

I spent another night in East London where I was able to catch up with Lerato – she has been my point of contact for the past 18 months whilst navigating the paperwork to get to SA. She was in the cape with three students from Yale who are interning with AHP. We passed two nice evenings together sampling South African gin ‘Buchu’ and chatting about SA. 

Then the day to head to Matatiele began! I set off early loaded up with new bedsheets and snacks for the road. 6 hours of monotonous freeway lay ahead – or so I thought. Within an hour I had narrowly avoided two goats and a fairly threatening looking baboon in the middle of the road. The animal hazards continued as I headed further into the wilderness. The gravity of what I was doing began to dawn on me – I was driving across South Africa, by myself, to work in a hospital where I’d be out of my depth from day 1 – so I put on the Lion King broadway soundtrack and ate some African Opal Fruits. 

I arrived at the hospital at 1500 and was greeted by one of the other doctors from the hospital. We headed to my accommodation – I had been advised I’d be staying on site but we headed off across town to a large two bedroom town house. I was fairly daunted by this as the idea of living by myself, off hospital premises made me feel a bit on edge.  After a bit of discussion, it became clear there had been a mix up and actually one of the other doctors travelling with a wife and kids would be better suited in this house – I would be moving to hospital accommodation on Monday. Phew! 

That night as I sat in the big empty house by myself I felt a bit overwhelmed. Every noise made me jump, and I could hear women shouting in Xhosa across the street. The single pane window meant I could hear every footstep outside, and I suddenly felt very vulnerable being a young woman, alone in Africa, at night. I made the bed with my new sheets and tried to relax with an episode of Grey’s Anatomy I found downloaded on my computer. Despite the best intentions, I lay in bed fully clothed with my bags packed and keys in hand all night. At some point around 0200 I passed out. 

As always, by morning I felt much more myself. I set about trying to find a receptacle to use to wash my hair in the bath. I found an old 5L water bottle and cut the top off with scissors I had in a suture kit. Flashbacks back to washing in a bucket from Ghana reminded me why I got a weave – I wonder how long I will last this time. 

I spent the day revising Obstetrics – I had been advised the day before that I would need to be independent in labour ward soon enough. I later headed off to try and source some kitchen essentials so I could cook dinner for myself, thankfully Matatiele has a couple of reasonable supermarkets. Noone really bats an eyelid at me in the town centre – a different experience to Ethiopia where stares and pointing were the norm. White people aren’t a rarity here, I met a few white South Africans the day before in the town. A wee boy of about 4 came running up to me in the supermarket and wanted to hold my hand – we strolled along a few aisles together before we went our separate ways. 

I managed to cobble together the ingredients to make some beef chilli and rice and headed home to kick the prehistoric stove into life. Dinner was a roaring success even if I did have to wait 40 mins for water to boil. 

I saw a Catholic church at the bottom of the road – I’ve been looking for ways to meet people in Matatiele and I guess finding God again isn’t a bad way to start. I think I’ll head along tomorrow night – I’m secretly hoping they will have a choir I could join – I can’t move to South Africa and not join a gospel choir now can I?! 

So as I look back on the past few days, overall it’s been fairly plain sailing and a good start to my adventure. I’m really excited to get into my accommodation to unpack and start making it feel homely – though I did crack out my Jo Malone candle tonight! Fingers crossed that the first day of work goes smoothly, and that I make some friends in Matatiele! 

01/08/2018 

Well. Three full days at work and it feels like I have been here for a lifetime. I’ve seen more pathology in the past three days than in four months in the UK. 

Rather alarmingly, I am the one woman obstetric team. Day one I was sent to do the ward round in maternity – I’ve now done two c sections, induced four women and am single handedly running the ante-natal unit. We have a high risk clinic on tomorrow – I’m praying the three ?placenta praevias (where the placenta lies over the cervix and can be a cause of haemorrhage before labour) have someone else turn up to scan them or else we will be on a wing and a prayer. 

We’ve had a neonatal death overnight, and one baby with a severe hypoxic brain injury. I’ve been spending as much time as I can reading about the best way to manage him. He had been pretty sick with respiratory distress and I didn’t know if he would make it. He has mad good improvements in the past 48 hours, and today I arrived to him being breast fed by his delighted mother – a first time mum who has really taken it all in her stride. Neurologically he has made a good improvement, I have him on anti-epileptics and he hasn’t seized for 48 hours. I’m cautiously optimistic he is going to make it out of hospital. 

In the afternoons I go to the outpatient clinic to make my way through the patients who attend in the morning and wait to be seen. Some people have to come a few days in a row to see a doctor. There is a triage system in place where sick patients go to casualty, however I’ve admitted three direct to the ward from the clinic already. 

Clinic is the medical version of hazard perception in a driving test. In one afternoon, I had a 3yo boy post colostomy reversal for anal atresia, a new diagnosis of HIV, a potential relapse of tuberculosis or new heart failure, a new diagnosis of lupus and two diabetic feet (my favourite). It has been a total minefield trying to work out what is available and what is not – 80% of my scripts are returned from pharmacy because they don’t have the drug in stock, despite me using a South African formulary. 

I had a 66yo man attend clinic with his wife. He had a few weeks history of worsening fatigue and shortness of breath. He had oedema to the sacrum and could barely walk. JVP raised but lungs clear. Troubled by fevers, he had no lymphadenopathy and had completed treatment for TB about 15 years ago. In the UK there would be a list of investigations as long as your arm for this man. In SA? Our Xray machines are broken and bloods take 24 hours to come back. 

I found a young girl groaning in the post natal ward today. She had been an emergency caesarean over night. Post CS she had a three minute seizure and had been loaded with magnesium - she was thought to be eclamptic. After 20 minutes I found a midwife to help translate for me. The patient had been treated for TB meningitis last year. Since then she had seizures a few times per month, including during pregnancy. She had not had any antenatal care and so no one had flagged this before her emergency section. Where do you even begin with this? Do we treat the baby for TB? How do we image her? By some miracle, I was able to have her transferred to the referral hospital at the coast and she’s off to have a CT and work up there. Feeling out of your depth is the norm here – I’m going on a TB/HIV course which will be invaluable – but its in three months. 

There is something magical about the volume of uncertainty here – when you have a good outcome it feels like an even bigger achievement. One of the first patients I saw and assessed was a primiparous (first pregnancy) girl of 17. She was admitted in labour and with evidence of STI. She was started on IV Abx and throughout the course of the day her contractions continued but she did not progress with her labour. She has a contracted pelvis – common in African women. It became clear a vaginal delivery would not be possible. I organised a caesarean section for her – and this morning I was able to discharge her and her new baby girl home. 

03/08/2018 

I’ve been looking forward to writing this entry all day, it’s cathartic.  Yesterday my boss asked me to do her a favour and be ‘first on call overnight’ and she would be the second on call. Despite being promised this wouldn’t happen for the first month, I could hardly say no to her. 

From 1630 I would be the doctor on call for the whole hospital. If there was an emergency on maternity, neonates, paediatrics, medical, surgical, casualty or psychiatry then I would be called. My boss who is an obstetrician would also be on call to assist me as I needed. Anyone who has done an on call with a senior doc on at home knows that this is a solo on call. 

I went home at 1500 and changed into scrubs and a hoodie (it’s absolutely Baltic here at night but 200 degrees in labour ward so I normally alternate between Oz clinic Hannah and Aberdeen winter Hannah). 

At 1800 I had my first call – a 32 weeker had arrived about 4cm dilated and contracting. The baby would be too small for delivery here – it would require care that we (i.e. me) couldn’t offer. I called the referral hospital 2 hours away who told me unless she had severe pre-eclampsia she would be staying put. Thankfully for her, and less so for me, she had no evidence of pre-eclampsia. My boss examined the patient and asked the nurses to call me if the baby was delivered under 2kg which she certainly would be. I immediately went and checked my neonatal resus kit and had a quick glance of the guidelines. No time to panic though, I had to go and see the casualty patients. 

A 78yo with RUQ pain, evidence of infection and Murphy’s positive (probably a gallbladder problem). In the UK she would get IV Abx, fluids and a USS. In Africa, she got the only antibiotic I have, some fluid and I prodded her belly with a scanner – no gallstones, no free fluid but any more than that and I’m out. 

A few other patients with various musculoskeletal complaints but only pethidine and paracetamol for analgesia. I had to send rib fractures home on paracetamol – previously I’ve organised a thoracic epidural. I didn’t have much time to think about this though – one of the nurses came running through to say there was an emergency on the male ward. 

I’ve never been to the male ward and so one of the nurses escorted me. The first bay I entered was filled with emaciated patients connected to IV lines – Ringer’s Lactate – the only fluid we have. Each one looked more in need than the last – but these men were well compared to my three patients. The first – a hepatic encephalopathy who’s sats were all over the place. XRay is broken, there is no blood gas machine and 15L via face mask is the best I can do. His chest was clear – I couldn’t even use my trusty Furosemide to help me out. The nurses hadn’t met me before – any of you who have done an FY1 shift know that having nurses on side is the difference between sleeping all night and crying into a sharps bucket in a sluice (maybe that’s just me). There was nothing to be done for this patient – I couldn’t image his chest, I couldn’t do a gas and he was on the max oxygen we could provide. The nurses thought I was braindead. 

The next – a 61yo found at home collapsed. In casualty he had a left hemiplegia and GCS 9. Hypertensive on arrival, the diagnosis was haemorrhagic stroke. He now had dropped his sats and audible secretions could be heard at the end of the bed. Even in the UK the outlook wasn’t good – but at 61! The only mannitol in the building was out of date by two weeks. I thought about it, but decided against it. I discussed with the referral hospital for my own sanity – this man deserved a scan at least to see what the diagnosis was. Again, not for transfer now, too unwell. I made him comfortable and phoned the family. 

The next – a 26 yo with HIV and white froth from the mouth – severe oral candidiasis (thrush) and probably oesophageal too – an AIDS defining illness. He had been admitted with a diarrhoeal illness. I couldn’t get the fluid into him quick enough. He need ICU care – but so do the other 4 men in the same boat beside him. I threw antifungals, PCP prophylaxis and Abx at him. He’s dying – I can’t fix that. 

By this stage I was almost beside myself when I got asked to review the analgesia of a patient in the surgical ward. A 26yo with metastatic oesophageal cancer. He had a tracheostomy and that textbook look of a dying man on steroids. At 26. I felt my stomach turn over. The strongest analgesia I had was Pethidine (IM) so this poor man with metastatic cancer and chronic pain got a needle in the buttock every 4 hours. I left the ward completely downtrodden and retreated back to the safety of labour ward to await the arrival of my preemie. (Since when did a labour ward become a safe place ?! two weeks I would have rather had a root canal than cross the threshold). 

I walked onto the ward and heard the familiar song of a labouring woman. My preemie was crowning. I pulled my jumper off and threw on some gloves. The resus station was primed and ready and my heart was in my mouth. Meconium stained liquor. The last thing this baby needs is meconium aspiration. We have a baby with an ischaemic brain injury from meconium aspiration syndrome and at this point I really cant take another bad outcome. The baby is delivered and is term. He screams and urinates all over the bed. I just about hold in my cries of joy. With a bounce in my step I head over to casualty – maybe I can do this job afterall. 

Over the next three hours in casualty I admit three women between 58 and 71 with acute pulmonary oedema (fluid on the lung). Thankfully through the grace of god we have a diuretic to give them to pee out the fluid. Two of the women have previous TB and their chest exam would support another relapse. No Xray to confirm and definitely no gases. I give them a bit of Ampicillin (the only antibiotic I have that might cover chest) and just wait for them to slowly improve. The sickest of the three was the youngest. She arrived with crashing pulm oedema and sats of 68 on 15L. In the UK I would have started a furosemide infusion, called CCU/HDU, considered GTN, CPAP, hell I don’t even understand all of the things that we could do for this woman. In Africa? IV Furosemide for as long as her BP can handle and pray. We can do FBC, U+E overnight and that’s about the height of it. She had no sign of infection so I wondered about an ischaemic event. When I asked about troponins – the nurses looked blank. To cut a long story short, I held this womans catheter bag in my hand for over an hour and watched as she slowly diuresed. Her BP was maintained by the grace of god and her sats eventually rose to 88 on 15L. A big shout out to my long suffering uni pals for their whatsapp support as I threw a wobbler about managing HDU patients in a clinic setting. 

I managed to sneak off home about 0430 (21 hours after I left the house) to have a bite to eat and freshen up – the toilets at the hospital are not worth the trauma and I only live across the street.  At 0500 I was passed out on the bed and got called to say there was intestine protruding from an abdominal stab wound which had been repaired in casualty the day before. I wearily made my way to the hospital to have a look. To my relief, but also annoyance – there was a bit of omental fat sticking out. No bowel and the patient was totally well. I must have been in a bad way – because instead of getting my knife out, I stuck a bit of gauze on it and asked the nurse to get the day doc to sort. 

I’ve forgotten to mention the emergency c section we did at midnight for cephalon-pelvic disproportion. I’m not sure how much faith I put in this diagnosis – it’s a daily occurrence here despite the literature saying otherwise. It’s 0005 and I’m not doing a c section at 0500 with a distressed baby so we cracked on and delivered a term baby. I did the spinal (!) and would be expected to do the section only my second on call is the head of maternity – glory be. She goes on to have a post partum haemorrhage – I was in my casualty-come-HDU/CCU at the time and so my boss had to attend. (Sorry boss!).

By the time the day team arrives I can see the light – sadly the light is obscured by the maternity ward round which I need to conquer first. I see all the post caesarean women and prepare them for discharge at varying stages over the weekend. My first task is to write a letter to the employer of a patient’s husband. She had a stillborn baby two days ago and her husband needs a letter to excuse his time off work. My stomach flips over again. I review her wound and ask her ‘gubu hlungu?’ – are you in pain? In Xhosa…the look on her face tells me this isn’t the pain I can treat with IM Pethidine. 

My PPH girl is doing ok, she’s lying in a pool of dried blood but there’s no evidence of ongoing bleeding. I quickly see a few antenatal women to send them home – STIs in late pregnancy are rife here and the current protocol is three days of IV Antibiotics – too many inpatient days for our unit. I make a mental note to review the protocol soon. 

I deliberately leave the neonates to last. There’s something so peaceful about the NNU – five tiny babies sleeping peacefully and I love sitting among the mums as they learn to do kangaroo care for the babies – it’s a method of swaddling and breast feeding for newborns. I’ve made a project of auditing our documentation of weight and feeding. I found a preterm infant at the start of the week who was born at 1900g and was now 1300g – her growth chart had been neglected so no-one realised. How the child was still alive is a miracle. These babies are tough – they have to be. Neonatal mortality in Africa is among the highest in the world. All of ‘my babies’ – I’m very attached now, are feeding and growing. The sickest of the group – the baby with the hypoxic brain injury is breastfeeding on demand now and isn’t having any apnoeic episodes anymore. I’m hoping to wean him off oxygen early next week. I check all of their weights are recorded and call it a day. 

28 hours on call at the end of my first week. I survived it – just about. In five days I’ve been learning to do c -sections, spinal anaesthetics, obstetric ultrasound, abdominal ultrasound, a beginners amount of Xhosa (the local language), and then of course dealing with TB, HIV, AIDS, basically re-learning all of obstetrics and finding myself as the local neonatologist. I come straight out of work at 1200 and go and pick up a burger and chips – I mean you’ve got to treat yoself, right?