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

Cockroaches, mozies and Home schooling

here it is! We turn off the main road that carries on to Mozambique some 40 km away. I can hardly believe that this sign marks our final destination here in South Africa and our base for the year to come.

Two weeks on and the reality of being here has started sinking in. I have been running on “Super Alkaline” batteries:

• Setting up home again has been a challenge but lucky our new park home is not big and we don’t have a huge amount of stuff. We have collected all the house hold items that Stephen (the doctor who sold us the car and who has gone back to Aussie) left for us. I also managed to blow our SA Visa card in 3 days in Pietermaritzburg, buying all the extra supplies we would need here. Luckily we were left a trailer (by Stephen) as we wouldn’t have fitted all the gear in the car with 4 bikes and all! I was shocked to move into a house where the oven and inside cupboards were left filthy and I’ve started a war on cockroaches! I have employed a Zulu lady Bongi to do some domestic work 2 mornings a week. The rate here is $2.50/h (!!!).
• Setting up home schooling. The NZ correspondence school material is not yet here, so I have had to improvise. Lucky again as I brought some great educational material from France (45kg of it!) and some from NZ with some great DVDs (Computer Classroom at Home). The girls have surprised me with how responsive their attitude has been towards learning. I have been blown away by the amazing writing that both Zara and Margot have produced (see blog: “Extract from Diary Feb 2010 by Margot and Zara”). We usually structure the day so school starts at 8:00am with diary writing. Them we do Maths, English, Spelling, or French. Once a week I do a spelling test based on the words they have misspelt in their diary. We integrate cooking, Science and Art with school. It just becomes part of it. What’s amazing for these girls is that they just have to ask “mum, come and help” and I am there with them the next minute, guiding them through their learning. I’ve never had so many “maman je t’aime” and kisses from them ever! It also makes me realize how best they learn and can tailor the lessons accordingly.
• Re-establishing a “circle of friends”, support system and connections is taking time. We are very fortunate to have another doctor’s family with 4 kids (2 to 7yrs old) living near us where the mum (Gerda) is also home schooling. Margot also enjoys the company of Siphesihle (11yrs) from next door and Zara plays with her little brother Mlando (3yrs). There is a great crowd of young doctors that have pretty much started at the same time as us here. They are from SA, UK and the States. The hospital chief doctor, Victor, has a wonderful library at his home with books for all ages. Rachel, his wife, also home schooled all her children. I have also met 2 Frenchies! Mathieu is a teacher at the Sodwana Christian private primary school and Philippe is a “hermit” living near Mabibi campsite.
• Feeling Safe: This area is fairly safe and I have been running on my own to the main road and back (6km). The main danger is dogs so I run with a pepper spray. At night, the real main danger is black cows across the road. The expats suggested putting some reflector tape on their ears so they can be visible!
• Doing shopping: Shopping requires a bit of planning because the main shopping center and decent supermarkets are 2 ¼ hours away. Mbazwana has an African Superspar: massive 20kg bags of rice and a meat department with chicken legs and offal covered with flies! We can buy basic local fruits and cool drinks outside the hospital. Victor sells some fresh eggs from his hens and ducks (a project he runs with the community) and sometimes has rabbits, chickens or ducks for cooking. I have bought a bread maker and I am making my own yoghurt. We have recently discovered Maas, a type of yoghurt Africans eat. It’s really good.
• The heat: this is summer and it is the “wet” season (although we’ve only had a day of heavy rain since we’ve been here and only a very short thunderstorm). It’s very hot during the day (35+) and the temperature becomes bearable at 8:00pm when it falls below 29^oC! We have a portable air conditioner (thanks to Stephen.... again!), a fan and the house air-con (which is useless).
• The mozzies: yes there are mozzies here and very hungry ones but it’s easy to take precautions. All beds have mozzie nets, we use mozzie spray and/or coils. I have installed mozzie nets on the windows. We cover up in the evenings. We are technically in a Malaria area but the cases are few and far between. The last big outbreak was in the 80’s. We don’t take prophylaxis and focus on prevention. Yes, we have been bitten. Yes, we will get tested if we develop a fever.

Now the rewards: Being here is all about experiencing the “African way” and the “bush”, the Zulu language and customs but also to connect even deeper with each other as a family.

We’ve already discovered some magnificent places nearby:

• Hluhluwe game reserve: 1h away. We spotted white rhinos, buffalos, and giraffes with babies, warthogs, baboons, a martial eagle, dung beetles…
• Sodwana bay: sealed road 35 minutes away. Snorkeled in the bay at low tide with loads of tropical fishes…like real loads!
• Mabibi Campsite : 1h away 4x4 on the beach due east of Mseleni on the other side of lake Sibaya. Great snorkeling long deserted beaches shared with few locals and few high paying tourists from Thonga lodge (we met a guy from London who has flown to the resort for a week’s holiday).
• Lake Sibaya: a 15 min 4x4 sandy drive. We still haven’t spotted hippos or crocs there.
• This coming w/e: Kosi Bay 1 h away. Supposed to be the best beach spot for snorkeling and swimming.

Please keep in touch:

on our email: isinglis@gmail.com

By Mail: Dr Sandy Inglis, PO Box 123, Sibhayi, 3967, KZ-Natal, South Africa

By phone: (+00 27) 355 74 10 04 (ask extention 211)

Voila for now.

Sorry I can only download few pictures as the connection is pretty slow.

These huts are typical of Zulu huts found in the area...I reassure you, this is not where we live!

Baptism by fire....

I promise that I will never, never, winge about being on call in Christchurch again! It started with a prayer, which is the custom here before any procedure in the OR. This teenager had an acute abdomen and we were after his appendix. I was performing my first GA in a long time and did quietly wonder if the Zulu prayer reflected this. Anaesthetics is a simple affair here with Ketamine the backbone, and as he dozed off I felt grateful that I was at least familiar with this drug. Sux, ETT down and then crank up the Halothane and Nitrous and keep him still with a vial of Vec. It all went smoothly and I felt a sense of smug satisfaction as I gazed over the green drapes at Johan digging around McBurney’s. He wasn’t having as much fun. His Babcocks anxiously suspended an open section of bowel which he sadly had plunged into, it being adherent to the fascia above. The appendix mass was an impossible proposition and he repaired the bowel and closed up. I was relieved to wind down the gases, reverse his paralysis and whip out the tube, but this was by no means a slick affair and Johan was long gone by the time I left theatre. Then I made a quick stop on the ward to review my pale yellow patient, who had RVD with a CD4 count of about 100 and both renal and liver failure. I wasn’t surprised to find his Hb was 2.4 and managed to secure the last 2 units of blood in the hospital, to at least give him some symptomatic relief.

At about 01.00 the fun started. “Hello Doctor; this is sister on Labour ward; can you come? The baby is not coming…..”. I ran up past the Mango trees in the dark hoping like mad that a Mamba wasn’t out for an evening slither and sprinted around the hospital trying to remember where Labour Ward was. What greeted me would have been comical had I not been so terrified; an elderly multip suspended in stirrups, fetal head on view, tired and annoyed midwives looking at me expectantly……I gazed hopefully at the ragged CTG, fetal decelerations obvious and remembered something about vacuums….a quick call to the faithful Johan confirmed my attack…”you’re allowed 3 pulls and if it doesn’t come then go for Caesar”. I found some gloves, a scruffy mask and visor (yes, RVD+) and set about connecting the vacuum. Suction was variable but somehow we got it going and with a bit of prompting from the midwives about ‘rocking’ the head, out it popped. The cord was wrapped tightly around the neck and we divided it and then with a bit of a wriggle delivered the body, limp and quiet. Thankfully with a bit of bagging, some oxygen and a bit of rubbing the little critter gave a howl and never looked back.
The drama in LW continued with the birth of a macerated still birth and then another who came in with her tiny dead baby covered in sand and the cord tied with a pathetic little bit of blue wool. A hypertensive mother, reportedly without a fetal heart, turned out to have one and her BP responded nicely to some Nifedipine. Her labour was augmented with some Pitocin, but not before I combed the handbook reminding myself of all the perils of CPD and eclampsia. We ruptured her membranes (ok if she has had her ARV’s at least 4 hours before) and she delivered a healthy boy.

It was now getting light and it was time to tidy up in “OPD”. A policeman with a gunshot thigh was interesting for the lack of an exit wound, “a ricochet” he thought, but was lucky to have normal neurology and sensation and the femur appeared ok, but I was unable to confirm this because the radiographer was away for the week-end. The next chap, with a stab wound to the left costal margin in the midline, also seemed in pretty good shape but again a lack of x-rays frustrated me. I was keen to observe him on my ward but was advised to send him 2 hours down to our referral hospital. The rest was a blur of fevers, ARV’s, TB and abscesses but one did stand out; an 8yo boy with a neck like a Springbok rugby player. It may have been an abscess but lymphoma was also a possibility, so we elected to put him on the ward for a biopsy the next morning. I wouldn’t like to have to manage his airway.

So as the day dawned I reflected on my first night on call and smiled as I thought about my consultant call in Christchurch. Hopefully I had made a difference but perhaps a ripple in a pond. I wandered off to do my ward rounds.

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