20th February - Dead Baby and Mother on a Knife's Edge

Today was an emotionally difficult day for me.

I was dropped at the hospital at 9.00am after taking the car back to Johnny at Sodwana. I did a ward round whilst Lyn was in labour ward with a lady with a placental abruption. The baby had died in utero and she was making no effort to deliver it, with her cervix dilated to three centimeters of a number of hours.

She was eventually taken to theatre for a caesarean section under general anaesthesia. She was initially haemodynamically stable with good saturations and blood pressure but as soon as the uterus was cut open blood stained fluid poured into the abdomen and the lady’s blood pressure plummeted.

The dead baby was removed and handed to me to hold and do nothing else until it was taken form me, at which point I ran down to the fridge to grab units of blood. Whilst this was happening, Guy – our anesthetist – was frantically trying to place a second line in the external jugular vein as one of the large bore cannulae had been lost.

As Lyn and Lili worked to control the bleeding the patient received two litres of crystalloid, two bags of blood and two bottles of freeze dried plasma before her blood pressure picked up (from a systolic of 55) and remained stable.

The patient was then monitored by Guy for a short while before being transferred to recovery and back to the ward. Everything had happened so quickly that it hasn’t been until now, writing everything down, that I quite appreciated how much was being done.

I hated not being able to do anything with the baby except wrap it up in a blanket. The experience and specifically that feeling of uselessness will stay with me for a long time. It makes you feel very small to just have a dead patient given to you without any attempt to resuscitate expected from you.

7th February - Rural Clinic

We had the paediatric ward round again this morning and after this we did a quick round on ward two. Today was Lyn’s day to go out to two of the rural clinics so I decided to go with her.

We loaded up the car with boxes of antiretroviral (ARV) medication, some blood results and the disability grant book. Disability grants (“Dee Gees”) are given for physical disability which results in an inability to work; they are also given to patients who are known to be HIV positive with a CD4 count of less than 200 i.e. qualifying for ARVs. You can also get it for six months if you have been diagnosed with tuberculosis and are on treatment.

I observed for the most part in the first clinic (Manaba) and saw a few of my own patients towards the end, including one man who had been left around the corner on a stretcher in retention. He had arrived last so he therefore was seen last, or at least that was what seems to go through the minds of some of the less than capable members of staff, particularly nurses, which work in the clinics.

I saw some of my own patients at the second clinic (Tschongwe) and spent the best part of an hour ringing King Edwards’ and Albert Luthuli Hospital in Durban trying to find out about follow up for a boy who had previously had surgery for Budd Chiarri syndrome. What was quite amusing was doing blood pressure reviews in hypertensive patients without a sphygmomanometer! We had to just look back at the past few months and guess where this trend might take them – not the best medicine in the day and age.

I admitted one patient who was at term with her second pregnancy with headaches and ankle swelling – she might have had a raised blood pressure but that would have to be found out when she arrived at the hospital. What was also difficult was trying to convey to the staff (who were telling her to go in tomorrow if she had plans) how potentially hazardous her condition was. I eventually just said: “she may have seizures and the baby and mother will die”. This seemed to make the point and an ambulance was called.

29th January - First Day of Work

Today was my first working day at Mseleni Hospital and it began at 7.00am when it was already far too hot for me, having just arrived two days previous from nearly ice cold England. We began with the doctor’s ward round on the female surgical unit (ward 2), run by Dr Lyn Dowds. I was a little bit overwhelmed by the heat and had to disappear on two occasions during an hour to splash water on my face.

After the round Victor suggested that I should stay on the female ward with Lyn. Lyn was a doctor from Ireland who had moved over to South Africa in November of last year with her husband Johnny and her 20 month old girl, Cody.

After she had given me a brief run down of her timetable and how a few things ran within the hospital we went to theatre, where I observed a finger amputation under ketamine. The finger was being removed as it had become necrotic secondary to snakebite. What was most striking during the surgery was that the woman sang and talked in Zulu throughout the procedure.

In the afternoon I shadowed Lyn as she worked in the outpatient department (OPD). I saw a number of new and follow up cases of tuberculosis and of note a woman with a huge pleural effusion, likely secondary to TB. Following OPD we had a business round on ward 2 where I was back into my medical student / F1 comfort zone – “request this, swab that”.

After work Lyn and Johnny took me to Sodwana Bay, a beautiful beach about twenty five minutes drive from the hospital. It was stunning and, amazingly, empty! A beach like that with the sun even remotely shining in the UK would have been swamped. The beach was littered with bluebottle jellyfish which I was warned pack one hell of a punch despite their small size. I took some pictures of the beach and some particularly nice ones of the sun setting through the trees.

After the beach I was taken to an Afrikaans restaurant/bar, called Maak ’n’ Jol, where I ate half a chicken which just melted in my mouth. The mosquitoes were out in force though and as it started to get darker we made our way back home to Mseleni.

27th January - Day One!

I landing in Durban in the late morning and was instantly hit by the heat as I left the plane. This was the first time in days that I had been really excited about my elective.

After I grabbed my bag from the carousel I went through the arrivals area of the airport and saw small black man holding a sign with my name on it. I was so relieved to see him that I forgot to even ask him his name – I later found out it was ‘Shakes’. We got on a bus at the airport and went across Durban to a collection of minibuses under a large concrete roof. We found the ‘long haul taxi’ which was going up to Mseleni and sat on it. After an hour or so I was a little concerned that we hadn’t left. It became clearer as more time passed that we weren’t going to leave until the bus was overfilled. So, ninety minutes, later we eventually were on our way.

I kept drifting in and out of consciousness on the five hour trip but did manage to see lots of domestic cows, some plantations and lots of the acacia trees which Maria had talked about as being the thing which defined Africa on her trip to Kenya. I thought about her a lot on the trip up to Mseleni today.

We arrived in Mseleni and were dropped at Victor’s house by one of the other doctor’s wives we happened to meet at the roadside. Victor and his wife Rachel were older than my imagination had led me to believe but both seem very warm and inviting. After sitting and talking about my trip I phoned both my own and Maria’s parents to let them know I was safe. Their voices were so comforting but at the same time so far away and I felt homesick again. I wish I could contact Maria to tell her I was well and to check she was ok but I had no means to do so.

I had a shower and moved into my own room at the Fredlund’s house. It was a lovely room which had a gorgeous view, looking down to the lake which I had read about on the hospital website.

I was glad to have arrived but was exhausted and just passed out as soon as my head hit my pillow...

One month to go!!!

It is now one month until my elective begins and I’m more excited about that than anything else… including Christmas! Ten weeks in thirty five degree heat whilst everyone at home sits in the cold and gloom of British winter is quite appealing. With the exception of a few bits of clothing (which I intend to buy in the January sales) I am ready to go!

Between Christmas and New Year I intend to make some headway with my elective report (5000 in total) and take the pressure off myself when I’m probably just going to want to sleep for a few days.

As well as all the expected problems associated with being alone for ten weeks away from family and friends I am very happy to say I have another problem… a new girlfriend who is off to India for the same time period.

If I don’t write before, I hope to keep people up-to-date whilst I’m travelling.

Roll on 2007! Roll on Africa!

Progress…

Over the past few weeks I have made great progress with my elective.

Insurance – bought!
Flights – booked!
Rabies jabs – jabbed!

I have also been giving more consideration to what I will be focussing my report on. I am intending to work closely with the HIV/AIDS and TB teams so I will try to focus my studies on the management of newly diagnosed patients in a rural setting.

This should raise some interesting topics with regards to availability of resources, compliance with treatment and educating patients (e.g. sexual health, etc). I am going start researching this whilst I’m still here in the UK to get a basic idea of the principles and theory of management and then hopefully follow a few cases to demonstrate the real world situation.

Looking forward to it but I need to make some good progress before I go out or God only knows when I’ll actually have time to do it!

Risk assessment: passed!

It took two attempts but my risk assessment finally got up to scratch and my elective plans have been approved. I can now start to focus on the fine details of my elective such as flights and accomodation.

It is now only six months away and I have begun to appreciate how life changing the experience may be. I have found a few people who have been to similar areas in Africa and their advice has ben invaluable. I have also started to learn some (very) basic Zulu to help me during my elective.

This page should get a little more interesting over the next few months so please keep reading. I cant wait...

Instrument (and stationary) Appeal!

As part of my elective I have been in contact with one of the doctors at Mseleni Hospital to ask what I could bring with me which might be of benefit to the local community. I have to say I was a little surprised by the answer I received.

I had expected him to say things like gloves or sterile dressings and, although he didn't specifically mention that these were needed, I will take as many of these as I can possibly get away with. What he did say would be appreciated are musical instruments! The community around the hospital has a music group and new equipment would always be appreciated.

So my missions for the next few weeks are:

1. Steal as many rubber gloves as possible

2. Approach medical stores about getting hold of dressings, etc

3. Write letters to everyone under the sun (bands, wholesalers, music shops) to ask whether they might donate anything

4. Approach drug companies to ask for stationary for the children so they have something to write with at school


If anyone has any ideas about who might be worth approaching for any of these things please leave a comment for me.

Risk Assessment

As part of my elective profile I must perform a risk assessment to assess my potential for exposure to hazardous situations and how I will avoid these situations or deal with them as they arise.

Exposure to Disease

1. HIV/AIDS and TB

1 in 4 people in South Africa are HIV positive; at Mseleni Hospital, 30% of student nurses and 7% of doctors are HIV positive. TB is the biggest killer of individuals with HIV/AIDS (8% mortality).
I am most likely to be at risk of exposure during surgery or in the event of a needlestick injury (also risk of exposure to other blood borne viruses e.g. hepatitis). To minimise exposure I will practice universal precautions as per my teaching clinical skills and also read up on the UK Dept of Health's Guidelines regarding exposure to blood borne viruses. If exposed to TB I will make contact with occuptional health in the UK to discuss chemoprophylaxis.

2. Malaria

Malaria is less of a problem in South Africa than it was only a few years ago due to the widespread use of pesticides. Reducing risk involves prophylactic anti-malarial medication, wearing clothes which cover the limbs and using repellents and mosquito nets.

3. Bilharzia

This is caused by exposure to water borne flukes found in the lakes and pools local to my elective hospital. Exposure may result in short term fevers and itching, but long term risks of urinary stones and bladder cancer are significantly increased. I will minimise my own risk of exposure by not entering pools of water in the area.


Other

To consider:

1. Bites and poisoning

2. Travelling around SA

3. Europeans in SA (political consideration)

Setting the Scene

I suppose I should give a little background on the reason for this webpage, particularly for those who may read this and not be familiar with the concept of medical electives.

To cut a long story short, this is an assessed part of my fifth year at medical school when I must arrange a period of study (at least nine weeks) outside of the set curriculum. For a lot of people (though not all) this means the opportunity for travel and study outside of the UK.

I am currently arranging my elective in a 184 bed hospital in South Africa, in a place called Mseleni. It seems from recent conversations that even people from South Africa don't necessarily know where this is, so here is a map (the little red arrow beside Lake Sibaya is where i'll be going)...



Over the coming months I plan to keep this site updated with my experiences of trying to plan this elective, primarily as part of my elective assessment is concerned with planning of the placement and also so that anyone who might consider going to Mseleni on their own elective may find the information included to be useful.

Hope you enjoy reading my page!