Kwashiorkor

At about 3am on Saturday morning I was trying to get a history out of a non-compliant epileptic with whom I had no language in common, when I heard the unmistakable wailing of a woman who has just discovered her child to be lifeless. A few seconds later a staff nurse came running out of the gastro ward with the floppy body of Yoliswa, a two-year old kwash we'd had with us for a few days, in his arms.

Kwashiorkor occurs in abundance in The Crater and South Africa as a whole because the bulk of the population is dirt poor and people don't have enough money to provide their children with even the most basic nutrition, even though we live in a highly fertile country where the trees hang heavy with fruit and the land is full of livestock, and politicians do million-dollar arms deals even though we'll never go to war, and they grow fat in luxury while the people who voted them in die from starvation. Anyway, you'd think it would be really easy to treat, but unfortunately it has a poor prognosis. We lose many, many children despite aggressive treatment of their opportunistic infections and intense re-feeding.

So here was Yoliswa, small and swollen, with no hair and ulcers all around her mouth and neck and armpits, minus any respiratory effort or pulse. We commenced CPR and miraculously, after one cycle, she resumed her trademark high-pitched kwash-cry, grimacing in pain from our chest compressions. I called her mom into the room, and started preparing for a blood gas, when her crying stopped and the complexes on the monitor started disappearing. Out went the mom and back onto her chest we jumped, but this time thirty minutes of pushing and bagging and adrenalin-injecting produced no results, and at about 03:40 I called the resus off.

We tidied Yoliswa up: pulled out her ET tube, picked up the broken adrenalin vials, pulled the monitor stickers off her chest and put her jersey back on, cleaned her bum and put it in a clean nappy, and wrapped her in a sheet. We called her mom in who, like the non-compliant epileptic, understood no language that I or any of the nursing staff spoke. We tried to explain in English and Afrikaans and Sign Language, our hands open in the universal gesture for 'I'm sorry', but she still didn't get it. Eventually we called in a security guard to tell her that her baby was dead. The wails of almost an hour previously resumed.

After that, I had to get back to the epileptic. I stalled by washing my hands over-thoroughly, wondering what the best way to restart the frustrated conversation would be. I like my job, but sometimes it's just all too depressing for words.

Picture Credits

grind
Originally uploaded by ebola bebop

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I Told You So

This guy came in on my call on Saturday, complaining of a sore neck. Even the AdMan, who's never read an X-Ray in his life, could spot the pathology, but I've made a big red arrow for you in any case. What you're seeing is a C-spine dislocation: bad news.

Guess what he'd been doing? Yep, playing rugby.

Yes, I know, rugby is how modern-day man vents built-up testosterone that would normally have been used to hunt saber-toothed tigers and challenge neighbouring cave-men, but that doesn't make the sport any less dangerous. I'm just saying, is all.

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Saturday Posting

Sorry guys... I know it's been a while since I've done any proper medical posting. The usual things have been going on: yesterday a woman presented with a dislocated jaw. Nothing unusual there, except that it had been dislocated more than a month ago (by my flatmate, The Dentist... hey these things happen...), but ya, why did she wait so long? Who knows. We couldn't get it back in, and she went off to Civilisation so they could give it a go there. Also this week: a man with a tumour that had been growing on his jaw for a year, full of maggots; and a nineteen-year-old (who already had a five-year-old at home) who was induced for PET and delivered a 3.5kg baby boy, even though she swears she had no idea she was pregnant.

We did end up striking, for a whole two hours yesterday morning. This basically entailed a press release that said we were going on strike, and then we saw all the patients anyway. The strike was called off yesterday - our demands have not been met, but the DoH agreed to reinstate the doctors in KwaZulu who'd been sacked if we agreed to go back to work. Does this mean They have won? Probably. I'll tell you next month.

And, I got a puppy! Two weeks ago I found her shivering outside one of the clinics in the neighbouring township that I do 'outreach' at once a week. Someone had dumped her there and thrown rocks at her. She couldn't stand up by herself and had a temp of 40. I took her to the vet who drained a big abscess behind her ear, and de-wormed and de-flead her. In the two weeks I've had her her body-weight has doubled: she now weighs three whole kilograms. Here she is:

Her name is Pepper. Before you ask: she is a Pavement Special, or a canus africanus, if you want to be fancy.

And then, I'd just like to direct y'all to a lovely blog I discovered via my old friend Arcadia: 66 Square Feet. Marie Viljoen is a fellow South African living in New York, who designs gardens for a living. Her blog has nothing to do with medicine, and is beautiful, just beautiful. Go and have a look.

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Half Way

Tonight at midnight I'll be halfway through my community service.

Whenever I run a race (something that happens far less often than it should these days), I love getting to the halfway mark because after that I can tell myself that all I have left to do is so much less than what I've managed to do so far.

On the one hand, I'm glad that the year is going so quickly: I miss The AdMan and my Civilised friends, I miss Civilisation's restaurants and malls and movies, and I miss being surrounded by a large network of medical people, instead of being an outsider who occasionally needs to tap into the network for help.

On the other hand, I'm enjoying The Crater: I like my work (and the work-load) here, I like getting to know individual patients and families in the small community we look after, I like my colleagues, and I like the hospital staff. Also, I don't like wishing parts of my life over: time already disappears so quickly, it would be a shame to want it to go even faster.

Anyway, here I am. It's been an interesting six months: I've learnt a lot, and grown a lot. I hope the next six have as much to offer.

Picture Credits
half way line
Originally uploaded by r0b1

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My Five Cents' Worth

A blog by a South African com-server would not be complete without some comment on the current doctors' strike. For those readers who are not from these parts, or those who are not really sure of what the story is, it goes a bit like this:

Around this time last year, the government promised all doctors in the public sector a significant increase. That is, not one that would make us rich, but one that would at least put us on par with other professionals in public service. A year later, we're still waiting. The significance of this reaches more deeply than our pockets: it's not only about the fact that we're not able to purchase homes and so on, but also that because South African doctors are paid so poorly, many of them simply opt to leave either the public sector, or the country entirely. This in turn puts a far heavier workload on the shoulders of those who remain, who then end up offering a sub-optimal service. In addition, the government is not only stingy about doctors' pay: they're stingy when it comes to health care in general. Most hospitals are poorly equipped and generally badly staffed. Even in places where doctors are willing to work, many posts have been frozen, due to 'budget issues'. There are not enough beds for all the patients that need them, and not enough theatre time for all the procedures that need to be gotten through. Sometimes the pharmacies run out of vital medicines - anti-retrovirals, antibiotics, pain-killers, to name a few - and often the depots run out of basic equipment, such as plaster of paris and alcohol swabs and drip sets.

Now, doctors are saying: we will no longer be the representatives of this system. We did not create it, and we do not condone it.

There have been many protests and marches over the last few months, but last week it finally got all ugly as doctors in Kwazulu Natal went on strike and crippled health care services in the province, followed soon after by doctors in the Eastern Cape, Western Cape, Free State and Gauteng. Right now, the Western Cape is only running emergency services - all clinics and elective procedures have been suspended - but they threaten to down tools completely on July 3 if their demands are not met.

It's a very sticky ethical situation. The public is suffering, and there is a good chance that people will die as a consequence of the strike. On the other hand, the public suffers massively and thousands of lives are lost every day as the government continues to under-fund and mismanage the health care system. The doctors striking say that they are doing it with the bigger picture in mind: they believe that if their demands are met it will mean better care for all in the long run. The tragedy is that we live in a country where extreme measures are needed before any attention is paid.

In The Crater, we're not striking - we're the only source of emergency care in a hundred-kilometre radius, and it really would be unethical to strike. But I would like to say that I support the strike and am grateful to my colleagues who have been brave enough to take action - and put their jobs on the line - for the sake of us all.

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