It meant we had hardly any patients for those days as it was only people who lived on the far side of the hospital who could get here - I don't think anybody was sorry when we weren't getting called at all hours of the night because the ambulances couldn't get through either... I've never been in the situation where ambulances have to divert away from the hospital I'm working at before - it always seems to be the other way around.Last time I blogged I was about to start my weekend on call over new year's and expecting it to be a total shocker. It was ridiculously busy but not for the reasons I expected. I didn't have a single stabbed chest the whole weekend - unbelievable! Plenty of stabbings in other parts including one man who'd had most of the skin and muscle over his shoulder flayed - ten out
of ten for originality, if nothing else. But the real issue was, as usual, obstetrics. In particular we had one horrific caesarean on new year's eve where my colleague who was operating just couldn't get the baby out of the uterus, which eventually tore and bled profusely. I was anaesthetising and having to manage a very unstable patient with only two units of blood available for the whole hospital, for the whole weekend. We lost one patient over the weekend because we didn't have adequate supplies of blood. Very traumatic for all involved. There was one fatality in Port St Johns from a shark attack, but the patient was dead at the scene so they didn't bring him here in the end.It's been quite a busy month at the hospital all round, even now that most of the tourists and migrant workers have gone home. We did have one notable
achievement in that we performed our first ever hysterectomy at the hospital for a lady with uterine fibroids and chronic bleeding. I think we were all quite nervous as it is a fairly major operation and I was certainly extremely nervous about the anaesthetic. All went well in the end, although there was one slightly panicked phone call to a consultant anaesthetist when I had a problem with the anaesthetic gas causing abnormalities in the ECG trace... It's just great to see that patient happy and healthy and not bleeding for the first time in years though. I heard today about a patient I'd seen over the festive season who'd been bludgeoned with a knobkerrie (half club, half walking stick - bit like a shillelagh for the Irish) and stitched up at the local clinic, then referred to me as he'd had a seizure. I inspected the wound
and discovered the stitches had come loose so was just planning to stitch it up again, but thought I'd give it a good clean and inspect it first. Anyway as I felt the edges of the wound with my finger I felt a few bits of broken bone and then suddenly hit something soft and squidgy - not good! I initially thought I'd just stuck a finger in his brain but quickly realised it was probably just clotted blood sitting on top of the brain. Still not good, so phoned the neurosurgeons who refused to see him, then the general surgeons who also refused and finally managed to get the surgical officer in A&E to accept him for transfer. Anyway he came back today, still doesn't know who he is or where he is - they apparently diagnosed a "minor head injury" without taking the dressings off his head and sent him home. Eh???!??! This is tertiary referral centre for the whole region. Also this week I had an elderly lady transferred back from the orthopaedic hospital who'd waited here for almost two weeks before they had a bed for her. They'd admitted her and discharged her 4 days later, writing on the discharge summary that they'd done a hemiarthroplasty (half a joint replacement). Unfortunately they didn't transfer her back here for another 2 weeks
after discharging her (and they wonder why they have no beds?!) and when I decided to inspect the wound discovered that there was no wound/scar. They'd done precisely diddly squat. When I phoned for an explanation they said they must have confused her with another patient... Would you trust these people to look after your granny's broken hip? I certainly wouldn't. I phoned the superintendent of the hospital to ask him to investigate but I don't have high hopes that anything will change.I've been working at Isilimela for 6 months now - the longest period of time I've ever worked anywhere. It's been really good to settle into the job and form good working relationships with people. But I suppose the longer you stay the more the total lack
of management becomes apparent. A far cry from the NHS where the very word "manager" was almost always uttered under your breath, I really notice the lack of any coherent system of management here. Nobody takes responsibility for things that go wrong, particularly when supplies run out of essential items like Oxygen, batteries for blood glucose monitors, or swabs. The wards are frequently abandoned as all the nursing staff take their lunch and tea breaks (of indeterminate duration) at the same time. The doctors are just as bad really - a case of too many chiefs and not enough indians meaning that nobody really takes responsibility for us either. We really need a senior doctor in charge.Outside of the hospital, we've been up to our usual gallivanting of course. The first weekend after the new year I headed to
Cintsa, near East London, which is yet another beautiful Wild Coast beach town. Even though we're only 4km from the beach here, there's something really cool about waking up and stepping onto a beach in just a couple of minutes. And if I'm honest, it was fantastic to have a nice bar where you could sit outside in the evening, have a few cold ones, listen to some normal music (not the weird fusion of Afropop/garage/house 
music called Kwaito that's usually blasted on car stereos around the hospital in the evenings, usually two or three songs on loop) and share a few laughs. There's also a private game reserve there with loads of game including white lions which were truly impressive. I'm also strangely fascinated by giraffes - they are just so graceful - and they were there in abundance.The weekend after I decided it was time to put the bike through its paces and did a 1200km (750 mile) trip to Port Elizabeth. Really good to get a bit of wind in my hair, get away from the hospital and the hospital chat, and see some awesome scenery. Highlights included:
- seeing three little kids, the oldest of which can't have been more than three years old, hanging out by the side of the road entirely unsupervised and going absolutely mental as I passed them on the bike - clapping, bobbing up and down, waving furiously. Ridiculously cute.
- coming into Port Alfred and seeing the bridge over the Kowie river at sunset after a long day on the bike, knowing that I'd made it just before dark.
- walking along the beach in PE in blazing sunshine and meeting up with Dr Smith, the anaesthetist I stayed with in November
- riding through the arid country near Grahamstown with cactus-like euphorbias making weird shapes and shadows all around
- having an open-air bath under the stars in the forest near Hogsback
- riding down the mountain in the early morning from Hogsback with the bike just ticking over in third, hearing the sounds and smelling the smells of the forest in the morning sunlight
- the thousands of yellow, green and white butterflies that scatter from every puddle as they hear my engine go past
- the sign as you cross the Kei bridge and enter the Transkei with a picture of a cow and warning of "Animals on Road - next 400km". No kidding.
Not really a highlight, but on the Sunday as I was heading back to Isilimela it was unbelievably hot - felt like I was riding into a hairdryer or one of those heaters they have above doors as you walk into department stores in winter. Unfortunately I ended up getting badly sunburnt on approximately 2 cm2 of my skin overlying each ulnar styloid - the only exposed part of skin between my jacket and my gloves... Makes for an interesting tan line!Definitely feeling the Africa love - but the last few weeks have also been time for me to start thinking about going back to the UK as I have job interviews next week in Edinburgh and Dundee for further training. In some ways it's difficult to even imagine
working back in the UK again as it's become so normal to deliver a baby by vacuum at 5am, then do a joint medical/surgical/gynaecological/orthopaedic/psychiatric ward round, then mixed general practice and outpatients before being an anaesthetist in the afternoon. But while I'm learning a huge amount here, I think I owe it to my future patients to undergo a formal training programme. And of course there are other, perhaps even more compelling, reasons to move back to the UK... So I'll be heading back on Friday for a flying visit to Scotland and NI - would be great to see as many folks as possible but I'm only around for a week unfortunately before I have to get back to work here. I'll be the guy wandering around wearing about seven layers and a conspicuously new thermal jacket I felt the need to purchase on the internet when I saw the temperatures back home... Anyway looking forward to catching up with many of you next week! Over and out...
