Time to work......

Today I started my new job in Africa. Only 28 degrees from the equator and a mere 40km from the Mozambique border, and perched on a little hill near Lake Sibaya, Mseleni Hospital has jolted me out of my cool comfortable Christchurch consultant life. My job description is Chief Medical Officer but so far there has been nothing ‘chief’ about it as it’s all hands to the grindstone and time here seems to determine who calls the shots! I feel naïve and out of my depth and crave for anything trauma related or vaguely emergency where I can perhaps flex a bit of muscle. The hospital has 190 beds and is generally well equipped and staffed (we are flush with about 10 doctors) and has clean OR’s where even the occasional hip replacement is carried out for the local “Mseleni Hip Disease” and many C-sections. Following a whirlwind tour of the hospital by CMO Kobus, a burly South African, I have my first shift in “OPD” which is ED, GP, and sort of OPD all wrapped up in one. The waiting room heaves with sweat and murmurings and babies crying and 3 doctors jostle for small bays and the all essential interpreter. It horrifies me to see the 3 “resusc” bays being used to prepare patients for the OR next door and I feel somewhat guilty as I incise a large abscess on the chest of a one year old (nicely sedated under Ketamine) in the bed next to a woman waiting her T/L. We are allocated 3 hour blocks in OPD which is wise and ensures survival I think.

Then it is up to my allocated ward; ward 4 (men’s surgical and medical) and I am hugely grateful to Martin, a young British doctor who has had a few months here to come to grips with the complexities of African medicine. The first chap has recovered from tonsillitis and I discharge him, lulled into a false sense of security. Then I see an (ex) taxi driver who rolled his bus; he is 5 weeks post his traumatic brain injury and type one peg #; he has a filthy Phili collar on and is wallowing in his own shit and his Pauls tubing lies dribbling on the floor. I wretch and plead with nurses to clean him up. Then the fun starts; this patient has RVD (retroviral disease…we are not allowed to say HIV!) and his CD4 count is 50; he is on RHZE treatment for Pulmonary TB, LFT’s are through the roof, jaundiced and has a huge palpable liver; is it ok to get going with 1a anti-retroviral protocol not wanting to cause an IRIS if we do not have his TB under control; we need help and call one of the longtermers…yes get going; whew!
And on it goes… a chap with cuffs on his ankles and his legs, buttocks and back bruised black from “the community justice”; his urine looks ok and we encourage fluids and will watch his creatinine; an old boy off his legs, demented and, we think, Parkinsonian…he need sedation and we hope urine test will confirm UTI; another RVD with a high lactate
(usually due to Stavudine or D4T) who also seems to have a peripheral neuropathy and marked renal impairment and we are forced to stop his antivirals; then this elderly man who has had his acute CCF treated (no CPAP or GTN but Lasix, Spironolactone and Enalapril) whose ALT is 2113 and may be due to the Zulu medicine he tried before coming to see us…but we are not sure.
We crawl into the next ward and review a # mandible and then nexto him a chap on antiretrovirals, PTB and STD treatment; an advanced alcoholic liver disease who has had 17 litres of ascites drained and yet another peripheral neuropathy, this time maybe from his TB meds; More RVD and pleural effusion drained of 1200mls but still looking very sick and nexto him an acute psychosis whose organic w/u including LP are normal, so we can discharge; the next psychosis has an abnormal LP with 200 lymphs so he gets the full treatment and we have a CT booked for about 2 weeks time in the nearest big town 2 hours away.

My ED in Christchurch seems a long way away but I am here on a fabulous adventure with my wife Ilda and two daughters, Margot 9 and Zara 6. Ilda has charged into this grueling African experience with vigor equipping our rectangular “park-home” box with all the essentials and home schooling the girls. They too have embraced this new life and now revel in collecting insects, climbing trees and identifying antelope in the many game parks around here. The decision to leave was a big one but we are here to explore this beautiful country and I was keen to see more of my immediate family as well as expose my family to the richness of Africa. I had always hoped to work in a remote location in a developing country and now it has happened; after day one I now realize how little I really know.

My first 2 weeks were spent at the tertiary hospital in Pietermaritzburg were I did my internship 20 years ago. The hospital is almost exactly as I remember it; infinite queues of patient patients; the same muddy floors; scant facilities and massive wards full to bursting; but the mood is buoyant and the tolerance fabulous. I am hosted by an old fellow intern who is now HOD of surgery; he guides me around the campus; this is where the bullet holes were in the locker in ICU; this is where we watched live gun battles from the OT tea room (we were there in 1990 at the height of ANC / Inkhata political war) and this is where our old pub and heart of our youthful social life used to be, the hospital bar and pool (Easy Riders) which is sadly now the Occ Therapy dept. and the pool and squash court gone. I am assigned to the OR and start the morning assisting with a complex peritonitic appendicitis, glad that I had not accepted the offer to perform the operation. I am delighted to hear that, to confirm pathology here, myriads of investigations are not the norm, but then mostly diagnoses are fairly obvious. A long ward round is fascinating for the number of stab and gunshot wounds and a mass of road trauma from the w/e but sadly not for a young woman with #pelvis, ruptured spleen and liver lacs who died on the table. Then back to OR for a fasciotomy of lower leg on a lad who was bitten by a snake and has severe local toxicity as well as a coagulopathy; the constricted muscles flop out of the wound relieved to be freed but some of the muscle looks a bit like biltong (dried meat); we decide to give it a chance and see if it will survive. I am surprised to be called into a hospital management meeting and introduced as an “A&E expert from NZ” but enjoy sharing some ideas on ED design for their new hospital.
The next day is spent entirely on doing massive skin grafts on desperate burn victims; the dermatome neatly peels off layers of fresh skin which we mesh and then reapply on the burnt bare areas. I remember doing this 20 years ago too!
I join the O&G team for the second week. Wow! Trying to remember how to analyze a Partogram, assess the cervix and manage GPH and eclampsia! I angle for the OR as much as possible and enjoy the buzz and action there; I assist with a messy ruptured ectopic and a belly full of blood but she does well; many c-sections but I am competing with interns who need 10 sections each. I at last get to cut and revel in the experience and extracting the baby; the first one goes well but the second one bleeds quite a bit and has me worried. (my supervisor, 3rd year out, is happy though!)
And so our life in Africa has started. We have learnt so much already, but know that we haven’t even scratched the surface.


Sandy Inglis FACEM
Chief Medical Officer
Mseleni Hospital
Zululand