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!