Living the Dream, No power and HIV.

Seeing Zara caressing her first chameleon, Margot debating whether the antelope she has just seen is an Inyala or a Kudu and Ilda negotiating with the roadside Zulu hawkers over a fly covered fish, I am constantly reminded that despite significant adversity, we are indeed, living the dream. Monday was a public holiday, Human Rights Day to be precise, and no better day than to bundle into our trusty Pathfinder and head out on another adventure. We are spectacularly situated here with a dozen game reserves or parks within an hour’s drive and golden beaches isolated and wild beyond belief. This time we are headed for Tembe Elephant Park and joining us are Susie the OT and Cathy, a volunteer doctor, from California. We negotiate a scrappy road punctuated with potholes, the Mozambique border not far off to the North. Ilda has visited the park with the girls once before and directs us on sandy tracks straight to the hide, perched near to a busy water hole. We settle down with breakfast and binoculars and what follows epitomizes why we are here, my family and I back in Africa.

A majestic Kudu bull strides gracefully by, his elegant spiralled horns held proudly aloft; two young bull elephants saunter down to the cool water and drink thirstily; skitterish Nyala probe the water, forever alert to danger; a menacing crocodile cruises, two evil green eyes survey the waters edge hungry for a kill; a massive bull elephant with tusks and penis brushing the ground, grooms himself; powerful jets of water blast ticks from his belly and then a sand bath provides the finishing touches; beautiful fuzzy waterbuck with their comical buttock target and graceful curving horns strut about; a wooly necked stork stands erect as if in prayer, sunning himself and showing off his iridescent plumage; frisky Wildebeest frolic and their playful calves buck, kicking up showers of sand; there appears to be some sort of natural roster at the waterhole as animals silently come and go and an incredible natural order seems to exist, with beasts and birds comfortably cohabiting; playful Zebra, each adorned with the mandatory Ox-pecker, spar and roll gleefully in the warm red dust; another bull elephant with massive curved tusks jets plumes of refreshing water onto his huge belly and back; mum and four baby warthogs wallow in sticky black mud and then prance about with their antennae ever twitching and look hilarious painted half black, half grey; then stage left yet another elephant, smaller but virile, virtually charges towards the water and sucks and spills noisily; and right beneath us dainty Nyala cows and calves nibble on green grass and new leaves, their earlobes heavy with red ticks; and all around this incredible stage, the acacias lie thick, concealing, just, another beast awaiting his turn and above the blue sky is peppered with puffy white clouds.

We reluctantly leave and drive off into the park glowing from this phenomenal show.

My w/e on call was hectic as ever and my survival strategy involves expecting the worst and any sleep or food is a bonus. Obstetrics remains my most anxiety provoking area and this w/e proved no exception. It started on Friday evening with a maybe 24 weeker with heavy PV bleeding; she was sweaty and pale with a pulse of 120 and BP 85/55, massive clots protruding from her vagina; placenta praevia was likely and we wheeled her round to theatre more to save her life than the child. My colleague was to cut and I was in charge of anaesthetics and baby which was a bum deal as her BP dropped to 50 and she was looking somewhat agonal; I had pilfered the last unit of blood in the hospital and squeezed it in with 100mg of Ketamine, no time this time even to pray. Baby came out blue and lifeless but thankfully bigger than predicted and I abandoned mum to the nurse; it was surreal to see her stretching out her hand towards her uterus in her light state but more drugs settled her down. The baby had a pulse and intubation and oxygen perked her up. I catheterized her umbilical vein, gave fluid and after about 30minutes she was able to breathe for herself. Amazingly she survived. Even more amazing was that mum survived thanks to some very skillful surgery and haemostatic control and her Hb of about 5 didn’t seem to worry her!

The drama continued and decision making around suppression of labour in a 32 weeker paled into insignificance. I got another of those stressed labour ward calls; this time a term pregnancy, fully dilated and marked fetal distress. The head was low enough so that a vacuum extraction seemed reasonable. After the first pull the power cut! Now what? We don’t have forceps and, anyway, I’ve never used them so it was off to theatre again. The power then came back on and with a big cup and a snip of the cord around the neck, baby was born. My O&G diploma didn’t prepare me for this!

Finally, HIV. Of course no one calls it that…..E-tick (after the Elisa test), RVD, ‘the test’ and anything else but HIV. The stigma is still massive and reluctance to test or be treated huge. The government is pushing testing hugely this year and we are all to learn to do circumcisions in an effort to curtail the spread. It absolutely amazes me that despite how rampant this disease is and how lethal, there is yet an apathy about it with regards prevention and protection that leaves me speechless and perplexed. One of my colleagues pointed out that there are those who invite the disease because they will qualify for a disability grant once treatment commences, but that is beyond belief.

On my ward they all seem to die in a similar desperate fashion. They present gaunt, pale, dehydrated and desperate. Diarrhoea has ebbed away their last reserves and TB or PCP has taken control of their lungs. We take desperate measures; we put up lines and infuse fluid to ease their thirst, we shower them with antibiotics, give steroids to support and provide oxygen but again and again, to no avail. Too little too late; too futile. We must start earlier. At school, maybe primary school. The message is blunted and stunted and until the stigma is shot we are fighting a losing battle.

ROAD SIGNS...Keep looking!

This is a sign before a wilderness walk at St Lucia Wetland park, a world heritage site some 2 hours South from Mseleni. Look below for close up details but basically, you are warned that you might come face to face with crocs, hippos or leopards!! At your own risk!

Voici une pancarte au debut d'une ballade a St Lucia Wetland Park, un site protege de renommee mondiale, situe a 2 heures de route au Sud de Mseleni. Details sur le zoom ci-dessous. En resume: s'aventurer a ses propres risques. Vous pourriez vous trouver face a face avec crocodiles, hippos ou leopards!! et Oui nous avons bien fait la ballade....et oui nous en sommes revenus!!

Lake Banghazi, St Lucia Wetland Park. On the edge of the lake lay some monster Nile crocodiles...and some people need a reminder not to go fishing there!!

Lake Banghazi a St Lucia Wetland parc. Sur les bords du lac, on peut voir d'enormes crocodiles ...mais certaines personnes on besoin d'une pancarte pour les rapeller qu'il est deconseille de pecher!!

Entrance sign at Mkuzi game reserve, 1 hour South of here. We didn't see one turtle.

Pancarte a l'entree du park de Mkuzi, a une heure de route de chez nous. Nous n'avons pas vue de tortue. Par contre nous avons pu observer des hippos de pres.

Sign at Monteco private reserve near Montagu (little Karoo 3hours from Cape Town).

Sign on the way to Kosi Bay lake situated 1 hour North of here.

Pancarte a l'entree de l'acces qui mene au lake de Kosi Bay. "reserrer vos elastiques de brasiere et enlever votre dentier...route carrosable en mauvaise etat".

Addo Elephant Park: Viewing sight where one definitely "looks around!"

Road sign on the R22, the main road on the way to Mseleni. Hippos roam free here.

Pancarte sur le bord de la route principale qui mene a Mseleni. Les hippos se balladent en liberte dans les environs. Le lac Sibhaya a 10 minutes de 4x4 de chez nous en ai remplit.

On one of the picnic sights at Hluhluwe game reserve, 1 hour south from here. One has the honour to share a picnic with the big 5!

This sign was taken at Addo Elephant park. We had to swerve out of the "dunggies" way as there was so many elephant poos on the roads.

This is self explanatory stuff so no need for comments from me. I will keep loading signs up so keep looking...

Sangomas, stabbings and surprise caesars.......

On Thursday I had my favourite patient. She was a Sangoma or Zulu traditional healer; a slightly shy pretty young lass with braids, cowhide bracelets, colourful costume and mandatory dried gall bladder perched high upon her head She initially seemed reluctant to talk but on gentle prompting from my nurse interpreter, revealed that it would be ok for me to question her without paying a fee, but that on her return home she would apologize to her ancestors! (It is usual custom to pay the Sangoma before you can speak to her). I felt deeply privileged and asked her about her seizures. It seemed that her control was not good and I modified her regimen. I did reflect on the fact that she was daily delivering traditional Zulu remedies so alien to our scientific prescriptions, and yet, here she was happy not only to consult me, but also to swallow our poisons! We parted on great terms!

Being on call here is no relaxed affair! After your day of ward rounds and Outpatient clinics and perhaps time in the OR, when everyone else is trotting off home, your day is just starting! Invariably OPD (outpatients, GP surgery and ED all in one) is heaving and patients anxiously await your arrival. Many have been there since the morning. The work is very variable from desperately ill to desperately mundane, including the dreaded Disability Grants or ‘DG’s’. Rumour has it that the DG is the top income earner in this area. Basically it is a sickness benefit and is preyed upon by all, particularly those with HIV who frequently are entitled to it during their first 6 months of ARV treatment when they are likely to feel pretty bad and are unable to work. This week OPD is heaving and a 2 week old infant is carried in by a seemingly nonchalant mother. The child is deathly pale and has every sign of respiratory distress possible. Her respiratory rate is about 80 and pulse rate about 200; her feeble frame trembles with the effort and we hope to save her with antibiotics, fluids and oxygen. Miraculously she survives the night and is transferred to a tertiary hospital for ventilatory support in the morning.

We wade through wounds, fractures, foreign bodies and disgusting suppurating abscesses but mostly it is HIV and its complex array of pathologies. Most are concentration-camp-like in their appearances, gaunt, cachectic and wasted, with protruding bellies and stick-like legs. I admit for iv rehydration, maybe antibiotics, perhaps an ascitic tap, but it seems somehow futile; hopefully their last days will be more comfortable. At last I trudge back in the dark to our Park home hoping to see the girls before they are asleep.

Hardly have I drifted off before the next call comes; “Doctor gun shot wound to foot….”. He is stable, has an exit wound and is cleaned and dressed and can wait for morning. Barely an hour later; “Doctor, stab wound to back and loin”….”OK, I’m coming”. Amazingly he too is stable with a deep wound beneath the tip of his left scapula and another about 10cm long across his left loin. I delicately probe to assess depth and both are deep. I clean and suture and a chest x-ray excludes nastiness. His urine is clear. Given our isolation, I elect to transfer him to our referral hospital 2 hours away. I don’t fancy doing a thoracotomy at 04.00! I steal a few hours sleep and then am back at 06.30 to mop up the stragglers. My family joins me to listen to the angelic singing of morning prayers…the angst of the night is forgotten.

My caesarian section score now rests at six. I still tremble and consider this a pretty scary business. On the w/e my colleagues had one that went bad and she ended up being transferred and losing her uterus. My 3^rd section was twins, which other than the power cut as we were about to cut, went well; my 4^th section was alarming because mum became hypertensive and breathless after her spinal…..thankfully that settled; my 5^th oozed and my 6^th was spectacular. The uterus looked odd and yes it was….she had two! Baby came out of one and the second, about the size of a pear, bore the left ovary and tube and connected to the main one just above the cervix. Bicorneate uterus I think!

And so life here goes on. Nothing is as it seems. Also expect surprises!

Extract from Margot and Zara Diary

Zara’s writing (24 February 2010) from her diary (corrections in brackets so you can understand) :
I have got a new book marcer (marker) that is called Bery Bow Bowes. I love my new tooth but it is stil (still) growing. When I loos (lose) my teeth I pote (put) my teeth under my pillow (pillow). I love the tooth mouse. Doo (do) you now (know) houw (how) my tooth fale (fell) out? “No” said mum in a soft vois (voice). In the night. In the middle of the night the tooth mouse came and she came in to my bed and she rane (ran) up to my pillow and she went under my pillow (that was quit (quite) a lot of werc (work)) and she toce (took) out her ten Rand and rowt (wrote) a little note and she toce (took) my tooth. Then in was morning and wowc (woke) up to show dad that I found something (something). Mum is still dooing (doing) her woshing (washing). I think the tooth mouse is nise (nice).

Zara

Margot’s writing (23/2/10) from her diary (no correction has been done):
Yesterday I couldn’t wake up, despite all of mum’s effort my eye lid’s wouldn’t budge. I was deep inside a dream, a mysterious dream, a dream where pig’s flyed and rainbows streamed over the wet land’s. The sweet land was inhabited by pink fairies, fluttering everywhere… “Margot it’ school time!” I got such a fright that I jumped out of bed, grabbed a towel and ran strait into the shower. I chucked the towel over the rail and turned the cold shower on. I felt a shiver come up my spine. In the distance I bearly heard dad’s voice as he walked out the door .”See you this afternoon, when we go to the beach”. The beach. It rang in my head. The beach! We were going to the beach. I could ask mum if we could see Julia! I was so excited I hardly got any work done. Every 5 minutes I reminded mum to put her phone in her pocket but every time I remined her she got distracted by something else like “OK but first I’ll get the toggs off the line”. And after she got distracted she would forget about the phone so I would reminded her again. After a while I stopped reminding her, hoping that she would remember what I had told her a million times. Mum read us a book about what would I do if I was a clown and about 2 litte shoes. At the end of the book there was a recipie that looked very inviting, so we got all the ingredients (as you can see on the left) and started baking, dad arrived home with another doctor called Lyn. She is very Irish (with a strong accent). For lunch we had couscous and mixed veges. It was very tasty meal for a such hungry girl (Me). I love eating. Eating is my favorite subject. I could eat all day if you told me to. Soon after Wentzel, Analou, Uju and Lize arrived. We all went outside and played on the hammock for about half an hour. Then I got bored of playing with Wentzel, Analou, Uju and Zara so I took Lize’s hand and we brang the chairs into my room and sat down. Lize’s only two so it’s hard to chat with her, but it’s fun because she repeats everything you say. A few minutes later Siphesihle and her little brother Mlando, knocked on my door. I let her in and she started reading my magazine. When everyone was gone we hopped into the car. I got onto dad’s lap and controlled the stearing wheel all the way to Sphesihle front door. Dad drove the rest of the way. We passed Julia’s dad’s work and realized mum forgot her phone. I was angry but I held it in. When we arrived at the beach we got into our toggs and got our boogie boards and ran for the waves.Mum got her snorcling gear and swam to the rocks. Dad came with me and Zara boogie boarding.We boarded for ten minutes. Mum was snorcking for ten minutes too but soon after she swam over to us. “Oh, girls you must come over to the rocks, there are lots and lotts of ausome fish! Come on quick!” I got out before Zara and slid my flippers on, got my mask and ran over to were mum was standing. As far as my leg’s would, I jumped into the water, as far as I could. I dived down, wat a sight! There were lots and lots of shoals of fish. It was the most amazing sight in my life. Seeing fish this close was amazing. I love the sight of fish! This morning I got up early and wrote this story just for you!
Margot