Conferences, clinics and C sections - a recipe for exhaustion

Hello friends! 

I am writing this entry from the comfort of my queen size bed in a forest spa where I have taken myself off to for the weekend. This week threw yet more challenges at our plucky group of doctors and a bit of distance from the hospital was definitely required. 

A little over two weeks since my last entry but it feels like a lifetime again. Time goes so quickly here, a whirlwind of emotional rollercoasters mixed in with weekend jaunts across this amazing country. 

Two weeks ago I went to the RuDASA conference - Rural Doctors of South Africa, in Johannesburg. I decided to drive to the conference to see a bit more of the place. Of course my plans to escape early on the Friday afternoon were scuppered by my beloved but frustrating maternity unit.  

Thursday mornings bring the High Risk Clinic - capital letters for this one because it is a major player in the hectic life of the unit. Each week I find at least 5 women who need admitted immediately for emergency treatment. This has been exacerbated by recent strikes about roadworks - the woman are unable to attend clinic and so when they do finally get to me, they have run out of medication, are stressed as the strike means no employment for their husbands, which exacerbates their already dangerously high blood pressure. (And as it would happen, my blood pressure is subsequently rising). 

The after effects of forty high risk pregnancies attending for review on a Thursday means that Friday is the medical version of Picadilly Circus. This Friday in particular included 4 back to back emergency caesarean sections - when it rains, it pours. 

At one point during this horrendous day, I had to choose between two patients who were in need of emergency sections, but I only had one theatre team - the other patient would need to wait. 

Patient A was a young girl from my H.R.C who I admitted with severe pre-eclampsia. Try as I might to get her to the referral hospital, they had no beds. She then began to get more and more unwell and her CTG - which monitors the baby - was having bradycardia - a tell tale sign that the baby is at risk. Since I arrived, I've had several patients present to the hospital with IUD (intrauterine death) because of this condition - none of them had antenatal care. The HRC is our way of monitoring at risk women closely to stop this happening. 

Anyway, Patient A needed an emergency section - the treatment of severe pre-eclampsia is seizure prevention, BP control but ultimately delivery of the baby. By the grace fo God this baby was big enough to be delivered at my hospital and survive - lots of women are struck by severe pre-eclampsia at 30-33 weeks and their babies are premature and suffer all manner of complications. Unfortunately we frequently see women presenting at under 34 weeks with severe pre-eclampsia. If I deliver her baby here, he or she will be too small to survive the journey to the referral hospital. If I send the mother to the referral hospital (5 hours away) she may a) develop eclampsia on route and lose her baby anyway or b) develop eclampsia lose her baby and die. 

I am not exaggerating or being inflammatory with the way I present these stories to you - this is the reality of obstetrics in this part of the world. The inequalities compared to the developed world are shocking, frustrating and wrong. 

Patient B in this scenario is a 22 year old who came in to the hospital in labour. I have followed her pregnancy again in high risk clinic every two weeks. This girl previously had a stillbirth at 7 months - we don't know why as the notes are not available, though I suspect it was again due to pre-eclampsia. She is the model patient, taking her medication like clockwork (anti-hypertensives and anti-retroviral treatment) - she is an AIDS orphan and contracted HIV from her mother. HIV is no longer passed vertically i.e. from mother to child. With the correct management and treatment, no child needs to be infected with the virus. Indeed, some of my mentors from the UK state they would rather have HIV than Diabetes with the new treatment regimes. I must not digress any further or I'll never get to the end of of this story.

Back to Patient B. She has an STI. The infection caused her to go into labour, just 2 weeks early thankfully and her labour had been progressing well. At the time I made the call to section Patient A, Patient B's CTG took a turn for the worse. Her baby was in distress and she was now draining meconium stained liquor grade 2 (babies get distressed and open their bowels during labour turning the amniotic fluid green - I am planning to do a retrospective audit to prove that there's an unusually high proportion of these babies that are male - trust me, the numbers will back me up). MSL 2 is an indication for caesarean section. But we only have one theatre...

When you interview for medical school, everyone says they like science and that's why they want to be a doctor. If you like science, then medicine is not for you young grasshopper. Hands down the single most useful skill I gained in high school was in GCSE Drama. Doctors are actors. I don't mean in that they act like they know all the answers (which, FYI none of them do - except maybe some of the anaesthetists come close) - but rather that every single day, particularly in my current role, I have to wear a poker face most of the time. In this scenario in labour ward I wanted to put on my coat, get in the car and drive off the edge of a cliff. Instead, I calmly told the matron - 'Ok, we have a sick baby, but we also have a sick baby with a sick mum - so she goes first'. The midwives disagreed with me and thought I was making the wrong call. This is the obstetricians version of smashing a mirror. You do NOT disagree with a midwife - you'll have bad luck for seven years, your hair will fall out and you'll probably get struck by lightening. 

I picked up the chart and calmly walked back to theatre and informed the nurses the decision had been made. I don't know where my big balls of steel came from that day, but I can tell you that I staged a coughing fit to try and explain how red my big red face was. 

I bribed the theatre nurses with promises of treats from Jo'berg if they could turn the theatre around quickly in between cases. We had a break of 8 minutes from Patient A going off table and Patient B coming on. What makes up for the glaring holes in the resources of this environment is the dedication and passion of the staff. The NHS is paralysed by processes and policies - none of that here. The promise of cake and a doctor mopping the theatre floor means s%£t gets done. 

We delivered two beautiful baby boys who both cried at birth that afternoon. I cried too, I might think I'm a bad ass but I'm still an emotional wreck. Also note the baby who pooped inside mother was again, a boy! 

This post is very long and I've only talked about one day. I may split this instalment in two so as not to bore you to tears. 

The caesarean marathon meant that I was late leaving for the conference. I had to drive in the dark. Google maps then took me along a 60km gravel road. I figured it couldn't potentially get any worse so took my chances with potential carjackers. 

I shouldn't joke about such things, I thankfully arrived in one piece at Ladysmith five hours later. I stayed in a BnB to break up the drive and continued on at 0500 the next day to the conference. In true conference style we (new doctor pals and myself) bailed on the second day and went into Johannesburg. We spent the morning at the Apartheid museum. A sobering experience all together. Pun not intended as I was working off a wine hangover from the night before. There were tears. It is mind-blowing to think this was going on just a few short years before I was born. 

The Apartheid museum gives each visitor a different card 'white' or 'non-white' with separate entrances.
Not too long ago this was reality 

The afternoon brought us to a food market, several bars (recurring theme) and lots of African trumpery later we left Johannesburg suitably refreshed for another week at work. 

Some of the AHP gang at RuDASA 

The following week at work went past in a blur again, I'm struggling to remember anything particular which happened. The sheer volume of pathology I come across on a daily basis is staggering. If I wrote about it all I'd get a DVT from sitting, 

We've now been joined by two new docs from the UK and our little gang is complete. It feels like we can now really get down to business. It's remarkable how much I have learned in my short time here. I find myself giving out advice and tips to the new guys, it feels like just yesterday I was a duck out of water here myself. I guess now I'm part of the furniture. The midwives told me they can't remember what it was like before I came. 

My proudest achievement to date is definitely grasping the Xhosa language. I'm now able to speak to my patients in Maternity fairly independently. Things get trickier with the patients in casualty - most of my vocabulary revolves around pelvic exams and symptoms of pregnancy. I don't have much use for 'When was your last period?' when treating the weekend influx of young men who have been stabbed. 

One of the new docs has been placed in Maternity with me. This is a very welcome addition. None of the UK doctors have much experience in Obstetrics and so since I've been thrown in here by myself, I find that I have taken on the role of local obstetrician. It's a lot of pressure to be able to give safe advice without much senior support,  I'm very glad to be able to share the privilege with my new comrade. 

I'll leave things there tonight. I find it so cathartic writing things down from work on this blog. I really want to have this to look back on once my adventure is over but it's even more special that you guys get some enjoyment out of reading about my escapades.

I've been offered the opportunity to go on an outreach project next week to establish a small clinic in one of the underfunded areas nearby. Reportedly the President of SA is coming to drum up support for his upcoming election campaign. I've been assured I can have my picture taken with him, instagram look out!

Hamba Kahle! 

(A Xhosa farewell) 

Stretched the legs after work and got this great shot of town