Merry Christmas one and all!

A busy few months in the Eastern Cape! Last time I blogged I was just about to pick Gemma up from Mthatha airport and have 10 days off together. We had an amazing time - we did a 5-day hiking trail in the Drakensberg mountains as well as a brief trip up to Lesotho. The wildlife was amazing - from little prairie dog-like ice rats in Lesotho to hundreds of baboons loping around the mountain sides in the 'berg, and stumbling across a group of eland only about 50m to seeing a lammergeier soaring overhead. And the mountains themselves are breathtaking.
We then spent a night at Oribi Gorge, a nature reserve on the Mzimkhulu river which sits perched on the lip of an enormous forested canyon. They offer several extreme sports including the world's highest (possibly only?) canyon jump - I couldn't just walk away from that. It was a bungee jump next to a waterfall - you jump from the lip of the gorge over the falls and plunge down towards the river before they winch you up through the falls. In short, it was terrifying. But there's something quite special about hanging next to a huge waterfall just above the forest canopy, hearing the sounds of the forest and feeling you're the only person there, suspended in midair. After that we had a fantastic 3 nights at the Umngazi River Bungalows and Spa - what a beautiful place. The thatched bungalows are on the river mouth, surrounded by fantastic gardens and looking out over a perfect golden beach. We had all-you-can-eat breakfasts, 3-course dinners and lunches every day, a sunset cruise on the river watching African fish eagles dive for their supper, a canoe trip through a Mangrove swamp, and a massage overlooking the ocean. It's hard to believe this luxury is just a few miles from Isilimela!

Life at the hospital has continued much as usual. It's been getting busier and busier in the run-up to Christmas as the Transkei diaspora return from their homes all over South Africa and further afield to spend the holidays with their families. It's noticeable that for most of my time here we've always had more female inpatients than male; however, now the reverse is true as all the men who work in the big cities return home for the festive season, bringing their TB, HIV and proclivity for stabbing each other to share with the already downtrodden inhabitants of our little corner of Pondoland.

My own medical learning curve has been as steep as ever! I've now performed three Caesarean sections, thankfully always with the support of one of my more experienced colleagues. The second one is particularly memorable for taking place in the evening during an especially violent thunderstorm. Our electricity supply is quite fragile and in electrical storms it often cuts our, which of course it did mid-operation. So for a few (mercifully brief) moments we were actually operating by the light of a mobile phone! I also was able to travel to Port Elizabeth for two weeks of Anaesthetic training where I stayed with a fantastic consultant anaesthetist and his wife who have been incredibly supportive to us out here at Isilimela. It was a real eye-opener to work in a tertiary referral hospital in South Africa with consultants and highly-trained nurses and intensive care facilities, etc etc. But depressing too in that they were also plagued with lack of supplies - they ran out of laryngeal masks and several inhaled anaesthetic agents while I was there - as well as victims of the mind-numbing bureaucracy and appalling management which seems to be the curse of the health service in South Africa. I'm much more comfortable with the basics of anaesthesia since returning from the course and have managed three general anaesthetics since coming back which have all gone very well.

It was also great to be in a proper city for a change. Mthatha, our nearest city, is only barely worth the designation. It's a horrible, sprawling, catastrophe of a city - if you have a mental image of ugly, decrepit, rubbish-strewn cities in the developing world, Mthatha is the archetype. There are no traffic rules other than might is right, there are no pavements, no entertainment facilities or restaurants worth mentioning, and its main purpose for us is that it houses the nearest bank capable of performing any useful services, if of course you have the requisite forms signed in triplicate and your passport, proof of residence and preferably a signed letter of authorisation from the president of the republic, although they are prepared to waive this requirement if you stand in line for most of a day and accept some minor scowling and exasperated sighing at your clearly unreasonable demand to have access to your money. However it is one of those eyesores which you can, in spite of yourself, grow to love. I particularly love the newspaper billboards with their ridiculous headlines. A selection: "THE MYSTERY OF THE GIRL - AND THE COW!!" or "MORE RAIN - BUT NOT HERE!", or my all time favourite, "NGO SAYS, SHOW US THE MONEY, BIKER BABE!". Unfortunately I've never actually come across the newspapers themselves but the billboards always crack me up.

Port Elizabeth, on the other hand, is a nice city with beautiful beaches right in the centre of town, theatres, museums, restaurants, coffee shops, and most interesting to me, an array of motorcycle dealerships. It's called the Friendly City, and is known for its low crime rate (in South African terms). Certainly I felt pretty safe nipping around in my rental car and took advantage of having access to civilisation, stocking up on books, camping gear, nice food, etc. At the weekend my host lent me a tent and I took off to Addo Elephant National Park which most certainly lives up to its name. I have never seen so many elephants - unbelievable. There were also wildebeest, lions, kudu, eland, haartebeest, jackals, ostriches, zebra and innumerable other animals and birds. From there I drove to Tsitsikamma National Park which is really the start of the Garden Route to Cape Town. It's a rugged coastline with steep mountains and deep, dark river canyons. Also very beautiful but unfortunately my experience was significantly hampered by severely bad weather on the second day there.

Also unfortunate was the lack of suitable motorbikes for purchase in PE, despite significant time and effort on my part spent searching. They were all too expensive, too old, or too unsuitable for the rigours of dirt roads in the Transkei. So, regretfully, I booked another bus, this time to Durban where I'd seen a bike on the Auto Trader. The bus was an experience in itself - they take economy class to another level. hbThere are five seats to a row instead of the usual four and I mostly had to sit in the foetal position to avoid either fracturing my kneecaps through repeated collision with the seat in front with every judder of the spluttering engine, or losing circulation to my legs from wedging them underneath the seat in front. Thirteen hours of this - complete with screaming toddlers, ladies of improbable girth in the adjacent seats, interesting aromas, and no on-board toilet (possibly, but not definitely, a causal factor in the disturbances in the olfactory landscape). This is Africa, baby. Anyway I got to Durban thanks to a little help from some friends, and purchased the aformentioned motorbike which now has pride of place in my living room. It's so nice to have some independence - not to have to rely on my colleagues (or much worse, the notoriously unreliable hospital transport) to get anywhere. Every time I take it out, I love it a little bit more. The locals also love it - if you want attention, drive a motorbike through an African village. There seems to be something innate to the African Y chromosome which makes you love bikes - the boys yell, run and caper wildly behind me, the young men make cool hand signals, the older men stare or try to flag me down for a lift. One girl even yelled at me to try and give me her phone number! Not sure if she wanted a date or just a taxi service.

My maiden voyage was getting the bike back from Durban which was a 7 hour trip. We broke it up by staying just outside Port Edward in a nature reserve on the Mtamvuna river. There are so many arrestingly beautiful corners to this country, often when you least expect them. The owners of the lodge where we stayed suggested we borrow their canoes and head down the river the next morning. If you've seen Blood Diamond - this is the river where they filmed it, I'm reliably informed. It's a swathe of green between sandstone cliffs with fish eagles in the trees and weaver birds in the reeds. There's also a lot of flying fish, who kept jumping out of the river when we paddled through - amusingly once just as I got a call on my cellphone from Gemma and a fish jumped right at me, only missing my face due to a fortuitously positioned canoe paddle!

Back at the hospital then life feels pretty settled. I suppose as you grow more used to something, certain things which were just different at the beginning, and therefore new and exciting, begin to bother you as you realise that they could and perhaps should be changed. A few of my efforts in this direction have borne some fruit - I wrote letters to the National Health Laboratory Service and to Department of Health bigwigs complaining about the poor service we were receiving and have since had a couple of meetings with them, resulting in the fact that we all (doctors) now have Blackberry mobile phones which link into the Lab's results software. Plus we've seen a real improvement in turn around times for essential tests. I've seen some
improvement as well from the nurses who've attended the training sessions I've organised for them, particularly in shock and fluid resuscitation - I get unaccountably gleeful every time a nurse tells me, 'we noticed this is shock, doctor, so we put up some fluids.' It just didn't happen a few months ago. However there are still a lot of frustrations about which I am powerless to do anything. For instance, last week a private GP transferred me a patient who was paralysed on one side of her body and had a coma score of nine (which is well on the way to being in a coma). He'd had her at his clinic for four days and now decided to transfer her to me, suggesting a diagnosis of Bell's palsy. For the non-medical, Bell's palsy is a short-term paralysis of one side of the face only which certainly doesn't cause you to lose consciousness; while any medical student could probably have identified this patient as a stroke. This is a routine occurrence from the private doctors in this area who seem to be entirely unregulated, and extract huge amounts of money from our impoverished population. Shameful. The ambulance service also seem to be operating in a different universe, refusing to transport patients who are at death's door but then bringing patients in the middle of the night who are suffering from 'painful neck veins'. It's infuriating, and there is no apparent recourse - no one to complain to, no superior to call. And the patients here are so unaware of their own abandonment by the bodies which should be providing essential services to them, or so apathetic in the face of it, that they are unable to complain themselves, as they should, and loudly. We are trying to pick our battles - and be encouraged by every small victory.

This brings me finally to Christmas. It's been strange celebrating in 30-degree heat when Europe seems to be in a deep freeze. It was especially jarring to see fake snow in shop windows in PE, with Christmas trees and Santa chortling, while people walk about in shorts and vests outside and the sun is splitting the heavens. Back at Isilimela we had a lovely day - I made a Christmas pudding and put it on to steam while we went to the beach and caught some waves - perfect temperature. On the way back, the dog was so tired (and probably dehydrated) he couldn't keep up with the bike so my colleague Bregje had to pick him up and wedge him between us on the motorbike, which caused much hilarity. Shame we didn't have a camera. The Christmas pudding was so good I almost wept. There's nothing like it. I was even quite glad that no-one else likes it that much - more for me. We also made a Pavlova as a Kiwi friend has come to spend Christmas with us and apparently it's traditional in NZ. So good times were had by all! My housemate and colleague Annelieke, had her parents coming to stay, who arrived yesterday so we saved Christmas dinner (roast beef with roasted sweet potato and butternut mash) for last night along with opening presents. Santa's elves in Mthatha seem to have a fairly limited repertoire so there was a strong personal hygiene theme in Santa's offerings this year!

Today is the only public holiday in the festive season here - the others fall on weekends and don't get rolled over to the weekdays; I feel slightly cheated. But I've had a great day - we walked to a local waterfall and went swimming in the plunge pool. Perfect. I'm on call over new year's weekend - a 72-hour on call when I expect to sleep very little. Port St Johns is one of the famous destinations in South Africa for new year's eve and there'll be a lot of drink and drug fuelled revelling, which in these parts translates into a lot of stabbings and haemopneumothoraces for me. So spare me a thought as you sing Auld Lang Syne this weekend, I'll probably be groggily hacking at someone's intercostal muscles trying to get a tube between their ribs at 2am local time. I'll be thinking of you all, friends and family in scattered arts and parts, and thankful for all you have contributed and continue to enrich my life with. Sorry it's taken so long for me to update this blog, reply to messages and emails, or respond to Skype requests - combination of increased workload and shocking internet connectivity for the last month or so. But here's to a better 2011 - grace and peace to you all for the coming year, and looking forward to seeing many of you when I come back in February or August.

Donkeys, monkeys, and whales' tails

Spring is definitely sprung in the Transkei, and everywhere little piglets, goatlets, cowlets and donkeylets (is there a real word for a baby donkey?) are scurrying around trying to fatten themselves up on the new grass pushing through the areas which were burned over the winter. Strangely, there's been a bit of a dearth in human births at the hospital (although we do have two kittens born to our resident cats in General ward) but I am far from complaining. My last weekend on call I only got woken up in the night 3 times in 3 nights which I think is some kind of record here. The garden is also starting to look good - we've been eating home-grown lettuce and rocket in salads for the last week or so, and the tomatoes and peppers are starting to flower.

We still have no access to a car but I have been making the most of my mountain bike. It's now three weeks since I cycled to Port St Johns for the weekend for the first time. It's only about 30 miles but the first half is on dirt road and mostly uphill. I'm no geologist but when the Transkei was formed it must have been squashed inwards from the coast - the land is in deep corrugated ripples. So on the bike you're caught in a never-ending cycle of punishing uphills followed by exhilarating downs - 5mph then 50. The downhill on the dirt road is really fun - especially because the taxis (almost the only other vehicles on the road) have to take it quite slow so you can zip right past them. There's nothing a taxi driver here likes less than being overtaken, especially by a cyclist!

The reason for going to Port St Johns was to go on a whale-watching boat trip. South Africa has (apparently) some of the best whale watching in the world and back when I arrived you could barely look at the ocean without seeing a few plumes of whale breath. But the season is drawing to a close now so I wasn't expecting all that much. However the boat trip itself would be worth the money (about £35 for 2 and a half hours) - the captain stopped to say a prayer before we headed out of the Mzimvubu river mouth into the open sea, and once we hit the waves, it's not hard to see why he does this every time! They get a 20 metre swell in these parts and we were in a tiny little boat - he also has to time it just right so that he goes on the crest of a wave over the sandbanks, as otherwise the boat would ground. The sandbanks are also constantly changing position from one day to the next so it's no joke. Pretty extreme.

Port St Johns itself has a stunning situation. The Mzimvubu (Xhosa for 'place of the hippos') river cuts between two hulks of stone, Mount Thesiger and Mount Sullivan, in a deep gully with native rainforest clinging to the sandstone cliffs. The day we went, there was a fine mizzly rain so the cliffs were draped in soft clouds - it made me think of photographs of China or Vietnam. When you get out to the open ocean, then the hills of the Wild Coast stretch for miles with golden beaches at the river mouths punctuating steep green hills covered in aloes and coastal strelitzia.

The first wildlife we encountered was a school of dolphins who, in time-honoured fashion, came to frolic around the boat. They are incredibly beautiful creatures and I can't think of any other experience where wild animals come so close and seem to want to interact with humans so much. I saw one baby dolphin, probably about two feet long. But it was whales we had come to see and we were all scanning the horizon for twin plumes of vapour (the Southern Right Whale has paired blowholes so the spray comes out in a heart shape). In spite of my very low expectations, after about 20 minutes we did see the telltale spray and sped off in jet-propelled pursuit, following the "footprints" that the whales' bodies leave on the surface of the water after they surface. Incredibly, we must have seen over twenty whales that morning, some only about 10 metres from the boat. At one point, a pair of whales just next to our boat surfaced to exhale - we must have been only about 20m away - the boat captain and I both got a faceful of moist whalebreath. Unbelievable. We then set off towards an area where a large group of sea birds had collected as the captain said this suggested dolphin activity. The birds themselves, cape gannets, are quite beautiful white birds with a streak of bright yellow on their heads and black tips to their wings and tails. When we arrived it was a frenzy of activity with dolphins circling, birds diving and little streaks of silver mackerel darting all around the boat. The only thing I can compare it to is that BBC documentary series about the Sea - I've never seen anything like it. As we got to the centre we realised that about 7 sharks had joined the feeding frenzy - I can't deny there was a little frisson of fear as those dorsal fins circled our little boat.

Back in Port St Johns we were staying at Second Beach (there are three beaches with equally original names) in a beautiful lodge with samango monkeys scavenging in the trees outside the window. It's easy sometimes to forget that this is in fact still Africa. But little things, like monkeys outside the window, or no running water for two weeks, serve to remind me every so often when I'm in danger of forgetting.

The hospital too has its share of TIA moments. Not transient ischaemic attacks - I've yet to see one of those here - but the time-honoured foreigner's exclamation, uttered with varying degrees of exasperation, bewilderment, or empathy with another's confusion, "This is Africa." For example, I have an elderly patient who was stabbed in the chest and had a massive haemothorax (blood inside the chest where the lung ought to be) who did quite well after I drained the blood out but was still extremely short of breath. It turns out he had nowhere near enough blood (Hb of 6 for the medics) so I arranged a blood transfusion - of course that takes 4 days as the blood has to go to Mthatha for cross matching and then someone from the hospital has to go to Mthatha to pick it up. Unfortunately after all that, the driver who picked it up decided it was too much effort to actually deliver it to someone in the hospital and so deposited it outside the security lodge at the hospital gates without mentioning to anyone, where it remained throughout the sultry Transkei night until the ward sister found it in the morning. Dilemma - do we give this man the blood which has been outside of the fridge for an unknown length of time and at an unknown temperature with unknown pathogens potentially multiplying furiously? Or do we let him wait, gasping, for at least another week (now a weekend is involved) and get some more, knowing that other, equally improbable, misadventures may befall this second lot? Nothing in my medical training has prepared me for this scenario! Answers on a postcard please.

I read a verse in Proverbs a couple of weeks ago which has been inspiring me ever since as it seems sort of emblematic of what we're doing here. "Rescue those being led away to death; hold back those staggering towards slaughter. If you say, 'But we knew nothing about this,' does not he who weighs the heart perceive it?" (Proverbs 24:11-12) Every so often when I feel what I am doing is insignificant, a bit like Sisyphus pushing that mythical rock endlessly up his mountain, that verse comes back to me. When you see the people I am seeing in our antiretroviral unit in a weekly clinic when I start them on AIDS treatment I really do feel like these people are being carried away to their death - they seem so powerless, trapped in a downward spiral which they have never understood. The treatment we have is far from perfect there have been some truly miraculous recoveries.

My Xhosa is still very limited but beginning to improve. Every so often I understand a little of what the patients say - I can recognise quite a few key words like cough, vomit, night sweats, blood, sputum, painful etc. I can tell patients to sit, lie down, ask them if it hurts where I'm pressing and tell them to breathe in and out. Pretty much the basics I need if I am going to examine someone. The clicks are difficult but I think I'm starting to get the hang of them. It makes the whole ward, and all the nurses laugh every time I do it though! There are three main clicks - x is like the sound you make when you want to make a horse giddy up, at the back of one of your cheeks. Q is the sound you make with your tongue against the hard palate when you want to make the sound of water dropping, or the clip-clop of horses' hooves. C is a sucking noise with the tip of your tongue just behind your front teeth, a bit like a "ts" noise or when you tut at someone (which of course, we all do regularly). I can make all of them now but it's difficult to integrate them into words especially when there's more than one click in a single word. Or difficult consonants are juxtaposed with the clicks - like when c is preceded by g or even ng in words like Ngcobo.

Anyway I'm pretty excited as both my medicine and my Xhosa can take a short rest for a while. I have annual leave for the next 12 days as Gemma's coming from Scotland - we're going to be hiking in the Drakensberg then relaxing at the coast for a few days. It's the first time off I've had since our last expedition, to the Western Isles back at the beginning of June. I've rented a car (a Kia Picanto - we shall see how it handles the road back to Isilimela tomorrow) and am currently relaxing with two of my colleagues in the Maloti mountains, just south of Lesotho. We're staying in a backpackers lodge next to a beautiful waterfall run by two kayakers who have renovated an old farmhouse. No electricity and all the water is collected rainwater! Really nice. As I type I'm on the verandah looking out over the river gorge with huge black clouds drifting off into the distance after they have deposited their cargo of rain. It was totally dark about 20 minutes ago due to the clouds and the heavy rain, and now, as it's brightening up, the cockerel is crowing - must think it's dawn again. Driving here last night was the worst visibility I've ever seen - about two metres at times. We were driving in second gear, navigating using the lines on the road which I could just about make out at the tip of my bonnet (although the line on the nearside of the road was usually obscured by the beam from my headlight in the fog so I mostly had to use the line in the centre of the road). Crazy. The sun's coming out now so perhaps it's time for another foray into the outdoors. I'll leave it here but thanks once again to all for writing, texting, phoning, praying. Whale watching season runs April to October so now's the time to start booking for next year...

An eventful few weeks since my last installment - life is settling back into a more usual routine in the hospital after the disruption of the strike, but life is anything but normal here.

The conference I attended in Durban 2 weeks ago was really excellent. The speaker was a very passionate South African specialist in infectious diseases whose enthusiasm was definitely infectious. Unfortunately, that's not the only thing I'd picked up. I started feeling a bit ill even before I left Isilimela and by the middle of the conference was feeling pretty rubbish. We went out for a curry on the night of Eid al Fitr - Durban has a large population from the Indian subcontinent and is famous for its "bunny chow" which is a curry served in half a loaf of bread. I started to feel really nauseated not long after starting mine, and couldn't actually finish it which is almost unheard of for me. Then all that night I was up with a roaring fever and diarrhoea, but still didn't figure out what was going on until Sunday morning by which time I hadn't really eaten in 24 hours due to the nausea. I had a huge (about 5cm) swollen lymph node in my right groin which was really painful every time I moved my leg, and then noticed a swollen welt with a necrotic core just to the side of my right knee. Pathognomonic for tick-bite fever. I should have realised ages earlier but hadn't ever noticed being bitten etc etc. Anyway the upshot was I had to have a week of Doxycycline, couldn't eat a thing for 4 days, and missed a day's work. Back to normal now, thankfully. Apparently it's a bit of a rite of passage for foreigners coming to work in these parts, especially if you're foolish enough to take your dog for a run to the beach through the long grass and the marijuana plantations...

Let me tell you about my run to the beach, in fact. It's just so beautiful that I think I ought to describe it. I have to run down a steep hill from the hospital to join the main (dirt) road that leads to the beach. It goes past the 'spaza' shop which is the only commercial outlet in these parts for miles around, apart from the shebeen (an African tavern, for those of you not familiar with SA slang; and the locale for many of our weekend stabbings). I run along the road until it meets the Siningwana river which I follow as it wends its way through subtropical rainforest - the rains are just getting going properly here so everything is starting to get lush and green again. At the minute the deep greens of the trees are setting the dun hues of the dry grassland off just perfectly in the evening sunshine (or the pale dawn half-light, depending on when I get to go). I have to turn off the road to cut through a little patch of forest where you run through the aforementioned marijuana and long grass. Apparently the British banned the people of Port St John's from growing tobacco as they wanted a monopoly on the trade some time in the 19th century, so they turned to marijuana instead and it's always been a part of local culture since. There's usually a fair number of blokes in rasta hats trying to sell me dagga, the local weed. All the while there are a few groups of local mamas walking home, or kids, or men coming back from fishing, who greet me with, "Molo, doc" or, "Ewe, igqira!" ('Greetings, doc' or 'Hey, doctor!') Then you rejoin another road and start to climb up the hills above the Siningwana valley and that's when you first glimpse the ocean - the beach at Siningwana mouth with its huge cliffs and breaking waves. There's a lagoon, as there seems to be at the mouth of all the rivers here, between the beach and the forest just beneath the road at this point. Not infrequently, you'll see someone out fishing in a canoe. I carry on a bit further over the hills, pass a small village of rondavels painted in the ubiquitous but not unattractive mint green, terracotta and salmon pink that the Xhosa seem to love to paint their dwellings, and start descending through thick forest to Mpande beach. The trees get bigger, there are giant palms and trees with huge gnarled roots which extend right down to the beach. And then suddenly the ocean is in front of you, invariably as wild as this coast's name claims it to be; roaring and making the air thick with its spray. There's rarely ever anyone else there - occasionally a few boys going across to the football field or a solitary figure heading from one coastal village to another. I can head in for a quick swim, then turn around and do the whole thing again in reverse. It's about 5 miles round trip and takes about 45 minutes. Stunning.

Unfortunately I haven't managed it as much as I'd have liked, just a couple of times a week lately. Either I finish work too late and it's dark, or I'm on call and can't leave the house, or I'm knackered after being on call the day before, or it's my turn to cook dinner etc. The on call shifts have been ok although I feel like they're taking their toll a bit as well. I never thought I'd appreciate the European Working Time Directive given how much crap it felt like we had to deal with from it, but there is something really psychologically draining about knowing you are solely in charge of a hospital and all that its catchment area can throw at you for 72 hours straight. In reality, though, last weekend was not as bad as it might have been. I probably averaged 5 or 6 hours sleep a night. I had three stabbings - thankfully people are usually too poor to have guns here so they stab each other when they get drunk rather than shooting which is what they prefer elsewhere in South Africa. Usually they're not very good at it either, and the really bizarre thing is that usually the stabber accompanies the stabbee to the hospital in an apparent act of remorse. So thankfully no major organs were damaged and it just meant I had some creative suturing to do. I also had two ladies with imminent eclampsia and one who had already fitted - but I just had to transfer them all to Mthatha. The really scary point was on Sunday evening just before my colleagues were due to get back I was called to a primigravida in labour who was fully dilated but just not pushing the baby out. Having never before attempted either, and with my instruction from the South African Family Practice Manual, I had to perform an episiotomy and a vacuum extraction for a baby which just didn't want to come out. For the non-medical out there, that's exactly what it sounds like - you basically attach a glorified hoover to a plastic cup roughly the size of a baby's head, attach that to the baby's head, and pull hard. I'm not going to say it went swimmingly well - most of us in the room ended up covered in blood (HIV negative, fortunately) when the cup came unstuck but suffice it to say that both mother and baby did very well in the end, thankfully.

It's been a bit of a week of firsts for me. I also did my first general anaesthetic - entirely unplanned and learning how to work the anaesthetic machine as I went. It was a lady who, for a series of complicated reasons, we discovered had an ectopic pregnancy and was bleeding into her abdomen while she was on the operating table. Unfortunately the spinal anaesthesia had failed (the first time it's happened to me since I got here - not a great moment for that to happen) so we were doing it with Ketamine anaesthesia, but she was getting too much pain and it was impossible to proceed. So we had to convert to a general - but after several attempts couldn't get her teeth open enough to pass a laryngeal mask. So I had to bag and mask her with Halothane for the whole procedure (over an hour.) She did vomit once, so I had to suction a few times, and I was sure I could hear crackles in her right lung at the end of the operation so started her on antibiotics for aspiration pneumonia anyway. Thankfully she was alright afterwards and went home 2 days later looking a picture of health. It was all a bit scary but I think it's encouraging for this general anaesthesia course I'm doing in November - at least I have a better idea of what I need to learn/practice. And I'm probably not quite so terrified as I might otherwise have been, although I'm assured I kept a pretty calm facade throughout the whole fiasco. I also passed my first intercostal drain yesterday - for a 70 year old man with a massive haemothorax (he'd been stabbed on Saturday, attended a neighbouring hospital who sutured his thoracic wound without examining his chest and then attended his clinic on Monday feeling very short of breath - no wonder, his Haemoglobin was 6g/dL). I also had to put in an intraosseous line for a dehydrated 1 year old last week - it's like an ATLS masterclass out here.

Apart from medicine, the garden is coming on nicely. We now have tomatoes, chillies, lettuces, and a few herbs growing pretty convincingly. Unfortunately I suddenly lost a whole load of butternut squash, pepper, courgette and aubergine seedlings at the end of last week and I still have no idea why. One of the many things I have to puzzle over out here.

This weekend I spent in the Drakensberg with my three Dutch colleagues (we have now been joined by a third doctor from Holland). The mountains are just immensely beautiful there. It's such a contrast to the outdoors back in the UK where on any given day in good weather you are just one of a multitude of eager hikers taking over the mountains. I think in three days hiking we saw two other people. So we had these beautiful trails, with huge caves, waterfalls and clear pools for swimming all to ourselves. Unbelievable. Unfortunately my camera battery gave out on day 2 and I'd forgotten to bring my UK adaptor to recharge it so I have little evidence of this beauty but you know, sometimes that's maybe for the best. The plants there are also incredibly beautiful - lots of varieties I recognise from gardens back in the UK where I guess they must've been exported for decorative purposes. But also loads of indescribably pretty little alpine flowers just growing everywhere - especially one called Berkheya which looks so perfect it's hard to believe it's not artificial. The petals are small and papery, in a very architecturally pleasing arrangement (I half-remember something from a poster in a Maths classroom at school about Fibonacci numbers?) Anyway my inner botanist was happy as a clam.

Unfortunately on the way back, the 10-year old Jeep Cherokee which we share here decided once again to throw in the towel. This time it's either the automatic clutch or the transmission fluid - but it refuses point blank to go into any gear. Apparently it's done roughly the same thing 3 times in the last year although with a slightly different flavour, and ultimately a different cause, each time. And in between there's been lots of other problems. The real issue is that we live 17km down a dirt road and the nearest Jeep garage (the only place where they can fix all the electronics in that car) is a 5 hour drive away in East London. It's quite frustrating for all of us, as we're stranded here yet again, but pretty heartbreaking for Annelieke who actually owns it. I think we're going to have to sell it and buy a car we can service/repair in Mthatha, which is a bit of a hassle. I'm definitely thinking about the bike again too. On the subject of bikes, I'm now the proud owner of a beautiful Specialized Hardrock mountain bike which has been great for nipping about the local roads when I haven't quite enough time for running. And it should be good for exploring the Transkei on the weekends as well - there's a few nice backpackers' lodges within a day's cycle.

So all in all, things are going well. South Africa is living up to my expectations - it's beautiful, challenging, fertile ground for learning new skills and remembering old ones. I am really blessed to be here and to have such an amazing opportunity, and doubly blessed to be able sometimes to see that I am also able to be a blessing to others. I should really talk about some of my patients, too, but there's so much to say and this blog is already, typically, wordy. But I love seeing people coming in with their minor traumas and going out with big smiles on their faces. I stitched a man's lip a couple of weeks ago - the plastic surgeons would've gone mental - but he was so grateful afterwards that he no longer had a big gaping hole in his face. And the children who come in malnourished due to TB and leave looking healthier, happier, playing again and gaining weight. Or the lady who was on the ward the whole way through the strike because of Pneumocystis pneumonia who none of us thought would make it, who is now started on ARVs, gaining weight and has gone home looking like a new woman, smiling and laughing. The flip side is there are a lot of people who are just sick for a long time, and don't recover. And often we are not sure what is wrong or whether our treatment is likely to make any difference. But every so often, you have a fantastic surprise. And I guess that's one of the many things that makes life here worthwhile.

Thanks again for reading, and keeping in touch, and praying.

Phew...

So we’re into the 4th week of the strike now – and a resolution is still evading the men in suits in their corridors of power, far from the hills of Pondoland. News trickles in here – we don’t have a working television (the hospital apparently cannot afford to pay the licence fee) and my internet connection is an information superhighway only inasmuch as it is about as fast and reliable as the old dial-up circa 1996. South African media outlets also seem to have moved on little from those times, so it is with some frustration that I have to admit that the lack of activity from the government and trade unions may be real, or only apparent from this media-starved corner of the Eastern Cape.

Just as I’d finished typing that paragraph I received an email from my dad telling me that the strike has been suspended… Checking on the BBC website appears to confirm that which is fantastic news. Just hammers home my point though – I can’t believe that my dad, who is currently in Mongolia of all places, hears about this before we do! It's apparently not an absolute end to the strike - just a suspension while they consider the government's offer. But the trade unions have ordered everyone back to work from tomorrow.

That’s a real relief though – the strike has been “heavy, heavy” here in the last few weeks, as the folk around here say. I’ve never had to fill as many different roles in the hospital in my life. Last weekend was seriously busy for us on the medical front; but just as we finished our third Caesarean section of the day, my colleague told me that the cooks had heard a threat that people were coming to beat up hospital staff at Isilimela so they had fled and now there was no dinner for the patients. So she and I had to cook dinner for 28 patients – samp, beans, carrots and boiled eggs. Then last week the pharmacist was so scared that he refused to open the dispensary even for essential drugs, so we had to be pharmacists for a day as well. Not to mention being nurses, physiotherapists, plaster technicians, porters…

It might seem difficult to understand why people are so scared, but for example, a nurse at our referral hospital was stabbed by protestors disguised as patients, and subsequently died from her injuries. At our closest neighbouring hospital, rioting workers on strike set fire to a nurse’s clothing and left her with severe burns. And in the neighbouring province, a nurse was kidnapped by protestors who said they would not release her until the government acceded to the striking workers’ demands. Our pharmacist’s sister, who is a nurse in another hospital, was beaten up by protestors and required hospitalisation for her injuries (in a private hospital, of course, as no public facilities are available.)

So really, while this strike has been absolutely terrible for our patients, we as workers have been lucky, as we have not had any violence at all at Isilimela. It will be incredibly busy in the next few days I imagine as news filters down to the villages and we get an influx of patients who have been hanging on for weeks waiting until they qualify as ‘emergencies’ and hence can come to hospital without risking being beaten up themselves. Already I have been seeing patients who have stayed at home days or even weeks longer than they should have because of the strike, and often by the time they do come, it has been too late. Most of the death certificates I have signed in the past 2 weeks have been for pneumocystis pneumonia or cryptococcal meningitis, which we might have had a chance at curing had it presented even just a few days earlier.

In other news, I have moved house as my Belgian colleague has finished at Isilimela and moved on. So I am now installed in a much nicer house with such luxuries as a toilet which flushes, a bath, a bathroom door, a working oven/hob, cutlery, a microwave and would you believe it, a twin tub washing machine. Hand washing grows very tiresome, let me assure you.

I’ve also inherited a dog, an 8-month old mongrel puppy called Sushi who is full of mischief. He just wants to play all the time – unfortunately his idea of play is mostly just biting, often in very uncomfortable places like your heel, or your thigh. In order of preference, he mostly likes to bite: people, dead things, furniture, sticks, rubbish, excrement of indeterminate origin, and important electrical items. Food probably comes in somewhere between dead things and furniture. He has boundless energy and loves to come running, so I’ve taken to running to the beach and back (about 6 miles) with him every other day or so – it’s nice to have an excuse. An excuse that harasses me constantly otherwise, mind.

So I’ve added dog training to my activities, and also gardening. I planted a Frangipani the other day which I’m pretty excited about, and also a grapevine. Sushi has already uprooted that one twice though, so I’m not sure how well it’s going to do. I also have butternut squash, tomato, and pepper seedlings in trays on the windowsill so, give me a few months and it’ll be veg-tastic out here.

Off to Durban again on Wednesday for another conference – this time on TB, HIV and sexually transmitted infections. Should be very useful.

That’s probably enough for now but thanks again to everyone who has written/texted/prayed, really appreciate it. Will keep you updated as to how the dust settles after this strike – could be interesting!

Strike Update

As you may know, there is a national strike going on in South Africa at the minute, which originated with government employees but seems to be spreading to take in workers from every sector. From my point of view the most significant aspect is that healthcare workers are also on strike – as I work in a government hospital, almost everyone here is a government employee and hence on strike. Today (Thursday) has been declared a day of ‘total shutdown’ by the unions and the vast majority of hospitals in our region have already been forced to close, many by rioting mobs. This week, the closest hospital to ours was attacked, forced to close and one nurse was badly beaten by a mob (which included workers from the Department of Health, no less) who believe that if anyone is working it weakens the strike.

Our staff here are understandably very scared and many left work without authorisation yesterday. We have had several staff meetings to try and determine a response to the crisis, which is affecting us on several levels. The hospital manager has received anonymous threats over the telephone this week as word has got out that we are still working here. Many of our staff are on strike and levels of care are consequently suffering. Furthermore, our supply lines have been cut since the beginning of the strike (over a week now) and we are running out of food and medicines.

It is very difficult to formulate an appropriate response. I wholeheartedly support my colleagues in their quest for more adequate remuneration for the job they do, which is often far from well rewarded. Especially as, if the union members here can be believed, the government and President have awarded themselves around a 50% pay rise this year. However, how can I support a strike that is violently and forcibly closing government hospitals, which are the only source of medical treatment for the poorest members of this society? There is no doubt that people are dying as a result, and more are likely to suffer in the long term from, among other things, the consequences of being unable to get their antiretroviral or anti-TB medicines. Similarly, the public health consequences in the future are hard to quantify but are unlikely to be insignificant.

We were informed this morning that the hospital only had food supplies for another 2 days to feed the current number of inpatients, which has already been substantially reduced. Only those who are critically ill or requiring daily injections have been kept in the hospital. The really difficult thing is that it seems to me to be a choice between allowing extremely sick people either to take their chances without medicine if we discharge them prematurely, or else allowing them to starve in the hospital – patients who are almost all malnourished already. The obvious solution is to buy food ourselves to feed those who must stay. However even this suggestion was met with limited approval, as our transport manager is reluctant to send any of his drivers to town to get food, and our hospital manager is happy for the foreign doctors to spend our money on food for patients if we wish but does not wish to contribute on the grounds that it is “not sustainable.” I can’t believe that we were talking of the sustainability of feeding people who are entirely dependent on us – it seems supremely callous.

The compromise solution was to discharge every patient who could walk, take oral medicines, had a home with food to go to, and could understand the situation. It breaks every principle we’ve ever been taught to send someone home who has not completed a course of antibiotics (for some TB treatment patients need to complete 2 months of daily Streptomycin injections). But if you can’t feed your patient…? And if they want to go home because they are aware that the hospital is unable to provide adequate care or even security? You let them go home with the best possible treatment you can organise and as much good advice as you can offer. We will buy food for the rest.

The whole situation is wholly unsatisfactory. My South African colleagues seem divided – those who are frustrated that they cannot fulfil their duty of care to patients, those who feel strongly that this is the only way to get through to an irresponsible government, and those who are terrified of the wrath of the trade unions. We all have to walk a fine line in trying to fulfil our legal, professional, and moral obligations whilst also striving for equality in this country of stark inequality. I feel my own frustration with the system failures here is only probably a filtered product of the intense frustration felt by people here for years which has boiled over into this strike. And who knows what you could be driven to if those who are supposed to be your allies – for me, the health service, and for ordinary working South Africans, the government – seem so woefully incapable of doing their job in supporting you. In 1995, they went on strike for 3 months…

So we were expecting my first shift on-call to be quiet, as even the taxis are on strike today. However that hasn’t proved to be the case, starting with having to discharge half the hospital this morning. Since then, I’ve had a 4 year old in status epilepticus, a man who had been stabbed through his hand, a malnourished and dehydrated baby, possible cryptococcal meningitis, jaundice/hepatomegaly and 5 ladies in labour to deal with (one stillbirth, one Caesarean, and three still going, hence being up at this late hour.) Plus: parents demanding to take their extremely sick son home against medical advice (apparently, legally, I cannot prevent them from doing this – very frustrating); a ward sister with severe back pain; and another of our nurses going into labour (she is number 5).

Anyway I wanted to let you know what the situation was like on the ground here. Thanks for your support and your prayers – I really appreciate it. My internet credit is running out so bear with me if it takes a while for me to get more – once I get some money in my bank account I should be able to top it up via my mobile but the likelihood of me receiving a salary this month is diminishing by the day!

Beginnings...

So... Welcome to my South African blog - and sorry it's taken me a while to get here. It's been three weeks since I arrived at Isilimela Hospital to begin a year of working as a Senior Medical Officer here. I'll try and give a bit of an overview though as I've been pretty incommunicado since I left.

I've been planning to come to South Africa for this year since January 2009, so you'd think with 18 months worth of preparation I'd have got my mind into the right gear for it when it came to leaving. But flying to Johannesburg, coming over the southeastern coast of Africa into Mozambique and then Zimbabwe before crossing into SA, and looking down at the vast empty expanses below me I have to admit I was surprised at how suddenly anxious I felt about it all. Turns out that agreeing to work and live in a remote hospital where you know no-one, have very limited access to the outside world, and being sundered from the people you care most about, is a pretty big deal. In retrospect, I can almost hear the sound of my carefully-constructed walls of denial crumbling into pieces. But you know, a hefty dose of reality only really strengthened the sense of this being the right thing to do, a massive opportunity and a massive challenge, albeit with a significant emotional price tag.

I have always found travelling alone to be a productive time for introspection, and to be honest I really felt the benefit of a few hours alone in Jo'burg airport to think and pray. So by the time I was getting on the little twin-prop, 15-seater plane which was to take me to Mthatha I was really feeling pretty peaceful again, although it's a shame that wasn't true for all my fellow passengers, some of whom refused to board once they saw how tiny the plane was! But then the sight of the jagged Drakensburg mountains, snow on their southern slopes, huge river gorges coming down from the Lesotho plateau, and the semi-desert Karoo to the west really heightened that sense of peace, with a contrapuntal sense of adventure to set it all off perfectly.

Driving from Mthatha to Isilimela is following the descent of those rivers that run from Lesotho down to the Indian Ocean, so you start in fairly flat, featureless terrain dotted with little round huts (rondavels) which are almost all painted, for some obscure reason, in either salmon pink or mint-choc-chip green. Then the road starts to wind and descend some fairly dramatic hills and you're into the Wild Coast proper, with the same rondavels on every hill, but this really dense, dramatic forest poking out of every valley. About 13 miles before Port St John's there's a turn off down a dirt road and it's 7 miles from there to Isilimela. These have to be taken pretty slowly due to the potholes and rivulets cut in the road by the rain, but also due to the local love of speed bumps which have helpfully been raised at any point where it might be possible to build up some speed! But the views are pretty stunning and apparently due to get much better soon once the rains arrive. It is the end of winter here and there's been no significant rain for months so everything is a bit brown and dusty. But a few of the trees are signalling their intent by blossoming furiously - particularly the coral trees which have put out clusters of fiery orange or red flowers on every branch, but no leaves as yet. The hospital itself is perched on a hillside, and you can almost see the sea from just behind it. It's perhaps another 3 or 4 miles to the beach at Mpande.

I've been adjusting to life here quite well - it's a completely different rhythm though. Work starts at 8am when the doctors (there are 5 of us currently - two Dutch, a Belgian, a Nigerian, and myself, although we'll be down to 4 from the beginning of September) meet to discuss any patients admitted from the day before. Then we each go to our own ward - I've been looking after the General ward which is mixed Medicine, Surgery, Orthopaedics, Gynae, Psychiatry etc - basically anything that's not Paeds, Obstetrics, or TB, which all have their own separate wards. After a ward round, we go to Outpatients and the rest of the day is spent doing a mixture of General Practice and Casualty work - basically seeing mostly patients who are there for review of chronic conditions (largely hypertension, diabetes and epilepsy), emergencies, or new admissions (generally TB or AIDS-related). There's very little elective surgery here but we have a fair number of emergency Caesarean sections so I've also been helping with those either doing (spinal) anaesthesia or assisting the surgeon. Ultrasound is a major diagnostic tool so I've been using that a lot too - and have just been to Durban to complete some basic training in it which was very helpful. The day finishes really when there are no patients left to see in OPD - usually between 4 and 6. It's dark not long after 6 which doesn't leave a lot of time to do anything outside unfortunately. I have been to the beach a couple of times in the evenings - it may be winter but it's still warmer swimming here than it was in Scotland in July!

While everyone here has more experience than I do, none of us are very senior, and in fact (for what it's worth, which is not very much) I actually have the most experience working in internal medicine as the others have been trained in surgery and Ob/Gyn primarily. It means we have a fair number of diagnostic as well as management dilemmas which we struggle to get any senior opinion on. Our referral hospital is in Mthatha and while some of the consultants are apparently very helpful, my own experience of asking for advice from there has been very frustrating. The pathology is very diverse and patients tend to present very late - often with CD4+ counts in the low teens and twenties (i.e. well-established AIDS for the non-medical among you). TB presents in all sorts of ways as well - from the malnourished child to the elderly with meningitis, to the HIV positive patient with cauda equina syndrome from TB in the spinal discs. I guess it's an uphill struggle all the way, compounded by the fact that death is such a feature of life here to the extent that life is treated as if it's very cheap. Though I am assured that things are a hundred times better than when the first two foreign doctors arrived here last year, the nurses still often fail to give essential medicines like antibiotics, or don't inform you when a patient is unwell (they waited almost a full day until a ward round to tell me that a patient had a BP of 69/36, a pulse of 158 and a temperature of 39.7 degrees - all assiduously entered in the notes without so much as a 'doctor informed' - and were surprised when I asked them to get me a bag of intravenous fluids asap). Pain management is also not a priority and usually doesn't extend beyond Paracetamol, even for palliative patients with extensive metastatic cancer. The spectrum of psychiatric pathology is also quite different from what I have seen in the UK and we have had to admit a few patients with quite dramatic physical presentations which then turn out to be entirely functional. We don't have a laboratory (although I'm trying to see if we could get the one microscope here up and running to be able to do Gram and possibly India ink stains on CSF) and any investigations take between 3 and 4 days to come back - so by the time we get the results the patient has already got better or died in many cases.

My lack of ability to communicate in Xhosa (it's that language with 6 clicks in it which seem to be almost unpronounceable for the European tongue) is also very frustrating. For example, I have a patient who was sent from our referral hospital where he had been sent for dilatation of a malignant stricture of his oesophagus. Unfortunately they don't have any balloons to do the dilatation there so they sent him back to us with succinct instructions to give him IV fluids and morphine. After careful questioning, it appeared that at no point had anyone explained to him that he has cancer which cannot be cured and that this is why he cannot swallow solid food and has permanent pain in his throat. He had been complaining every day about this, and believed that once they got a part for a machine which he didn't quite understand, he would be cured - hence wanting to stay in hospital rather than going home to his family. Trying to break this news to him through a translator was extremely difficult. Especially as I'm not sure how the nurses translate it, but going by the amount of talking amongst themselves and giggling, I guess they probably wouldn't pass a communication skills OSCE station. Then again, I often have to take a step back and admit that I don't know this culture, I don't know how people here want to be treated/spoken to, and perhaps this is the culturally appropriate way to do things. But that doesn't change the fact that it just feels wrong.

Thankfully, I've been given a bit of time to adjust before having to take on full on-call duties (although I have had to get up and assist in theatre overnight a couple of times), but my first 24h on-call is on Thursday. I'm particularly worried about the Obstetrics as this appears to be a bit of a black hole in my medical repertoire, and there is a lot of Obstetrics going on here. Particularly, the women seem to develop eclampsia astonishingly quickly and start fitting at the drop of a hat. Without the capability to do general anaesthesia (currently but hopefully in the future) here we then have to transport them to Mthatha for Caesarean, which can take hours to arrange as we don't have an ambulance service.

Another huge frustration here is the paperwork. Basically I'm still not formally employed here despite receiving a job offer in May for a job starting on the 1st of August for which I have submitted all the requisite documents months ago. It's hard to understand but believe me, much as I may have complained in the past, bureaucracy in the UK is nothing. As many of you will no doubt be familiar, developing countries have embraced the concept of bureaucracy wholeheartedly - they seize on the opportunity for paperwork, letterheads, stamps, meaningless job titles, clasp it to their bosoms and nurture it like an only child. I had a job interview on the day I arrived where I was asked a bunch of ridiculous (and quite amusingly abstract) questions by people who have never before held a job interview in their lives. Said interview questions were the result of a full morning's worth of meeting to plan and devise them. Apparently the fate of my employment currently depends on a signature on a memo which, at the last update 5 days ago, was on the desk of the correct person whose hand is able to provide the required signature. No word has been forthcoming as to whether this hand is temporarily incapacitated or perhaps as to whether the memo is drowning in a sea of other memos from hospitals who wish to perform other routine tasks like purchasing medications or needles or loo roll, which all also require signed memos. Lack of official employment has made it difficult to get a bank account and hence register for a mobile phone and internet access which partly explains the delay in achieving these goals - however I decided to fight fire with fire on Friday and took every official document I could procure to the bank, replete with as many rubber stamps as I could get it stamped with, and they appeared to not notice that I didn't have a contract until my colleague politely asked, "should he bring his contract once he gets it?" Thankfully at this point the account had already been opened...

Anyway apart from attempting to practise medicine and wrestling with bureaucracy I've been able to travel a little bit - I've stayed one weekend at the Kraal backpackers which is just at the end of our road, on a small peninsula between the beach at Mpande and another beach. Every morning, a school of dolphins patrols back and forth just at the edge of the peninsula, so you can watch them as you eat your breakfast on the veranda. The annual migration of Southern Right Whales is also taking place at the minute so I've been lucky enough to see a few of those too. Last weekend I went to a place a few hours up the coast towards KwaZulu Natal and stayed in a really nice hotel - it was a collection of thatched rondavels in traditional style right on the beach, in the forest. Really nice to walk along the coast, see the whales, watch the Wild Coast live up to its name (the waves are pretty spectacular). And then just this weekend I was in Durban - which feels like a trip abroad, it's a completely different experience. The city is huge with massive freeways, enormous suburbs, and the biggest mall I have ever been in. I don't even know how big it is as I never actually saw the end of it, but it's apparently the largest in the southern hemisphere. Certainly I walked in one direction for about 20 minutes and didn't come to the end.

I think that's more than enough for now - I'm not sure how many people will read this, or what proportion will actually make it through to the end but it has been quite some time since I've been able to communicate with most people so I thought it's worth writing a decent update. I was also wondering about maybe putting a few of our difficult diagnostic cases on here, maybe some X-rays to see if any of you medical minds could offer any suggestions? We shall see. Anyway thanks also to everyone who has written/messaged, sorry I've not responded to very much at all but I will be working through the backlog over the next wee while. Keep in touch and of course, visitors would be very welcome!