Acute care common stem (ACCS) CT3 trainee Dr Stuart Winearls reflects on the personal and professional development gained during his 1-year placement at a level one district hospital placement in South Africa, as part of the Global Health Exchange programme.
I emerge from my ‘digs’ for the short, dusty walk to the doctors’ meeting, as the sun rises over the Church of Scotland Hospital (COSH), nestled by the Tugela River in the Msinga municipality of KwaZulu Natal province, South Africa. It is a poor rural area, beset by problems lingering from the past and festering in the present. In his autobiography, South African journalist Rian Malan wrote of this place: ‘The deeper I drove into Msinga the worse it got: less grass, less hope, more goats and more hopeless black people sitting motionless as stones in the roadside dust.’
Twenty years on everything – and nothing – has changed. The land remains dry, overpopulated and overgrazed. Yet what was once the independent homeland of the Zulus under apartheid is now part of a free South Africa. Democracy brought both hope of a better future and badly needed infrastructure. The wire fingers of electricity are snaking their way ever deeper into the district and more houses now have water. Yet mismanagement and corruption hamper the transformation of this dusty corner of the country. Msinga has some of the highest rates of TB/HIV in South Africa. Children grow up with their Gogo (‘granny’ in English) as their parents trek to the cities for work, a better life, or else succumb to TB/HIV. There are high rates of interpersonal violence, often directed at women. Yet in the face of all this adversity, I have never worked with people who laugh so much, are so warm, who can weather any storm with no more than a shrug, and who can sing so beautifully. Today, too, there is a song in the air; voices in harmony as we walk past the nursing college.
The resentment towards the authorities about the lack of water provision had flared. The mostly unemployed populous had gone on ‘strike’.
It is moments like this that make one smile, but there is plenty to make one sigh. COSH is simultaneously a frustrating and inspiring place to work. The first cases of extremely drug-resistant tuberculosis were isolated from patients here, and it was one of the earliest places to provide HAART in rural South Africa. It has an established link with Yale University Infectious Diseases department. For a 350-bed hospital, staffed by 15 doctors in a rural backwater, it has produced some amazing research. The true backbone of the hospital are the two extremely dedicated, long-serving South African physicians, who are always busy but willing to help. They have fought the HIV epidemic from the beginning, through the dark days of little or no treatment (the nearby 40-bed hospice used to turn over weekly) to where we stand today. They display saintly serenity in the face of adversity, and patiently turn the wheels of change, accepting that they move slowly. It is as if they have seen the worst the world has to offer, and so nothing can faze them. When asked: ‘How do you cope with the insanity of this place?’, one replied: ‘What you see is charcoal. I have raged and fought so long that now I’m all burnt out. But what keeps me going and here is the patient in front of me.’
The frustrations of COSH are enough to drive one to distraction. The intermittent lack of water, goats wandering through the wards, the lack of personal accountability, apathy and often sheer laziness of some staff. You bring water containers to the ward for the dry days, only to have them all stolen within a week. A patient with an acute abdomen waits a day for an ambulance, yet the routine cases are taken! Results, les, and charts all disappear. You finally get a patient accepted for a specialist review that may save his life, only to have him miss the appointment. ‘He stood in the wrong place so missed the transfer’; ‘the ambulance forgot him’; ‘he lost his letter’. More usually just ‘he didn’t go’ – no reason, no explanation, no accountability, no connection between personal responsibility and cause and effect.
Our day begins with the doctors’ meeting: a group therapy session meets a black comedy on a dysfunctional committee. We listen to bizarre edicts from ‘the district’ while the taps run dry and the hospital coffers are depleted. You hear of some good saves, close shaves, and sad endings. Today the mood was subdued. The announcement of the day was that all roads to the hospital were blocked by ‘strikers’ and that no ambulances were being allowed in or out.
The resentment towards the authorities about the lack of water provision had flared. The mostly unemployed populous had gone on ‘strike’. Their very aggressive African form of the picket line was to block the road bridge and stone anything that tried to pass.
Looking out of the meeting room window that morning you saw the normal, calm, African scene. A thick trail of black tyre smoke was the only hint of the menace occurring down the road. As the meeting groaned on there was a flurry of gunshots. This surprisingly didn’t interrupt the meeting, though it shook me a little. Matron knocks, walks in, whispering to the medical manager: ‘two gunshots in casualty’. ‘Dr M, do you minding sorting that out?’ was his reply. Dr M soon returns, calm as ever, and in his gentle French Congolese accent: ‘Err perhaps could I borrow a little help downstairs please?’ One stable shallow glancing gunshot torso, the other a through-and-through maxillary facial gunshot with a bloody airway and altered mental status. He goes to sleep in a surprisingly controlled fashion while all hands are on deck. Pressure bandages are applied. His nose and his mouth are packed in an attempt to control the brisk bleeding. He now waits. In fact, he will wait 13 hours; 13 hours for a transfer – which itself will take three hours and require two ambulances after the first is stoned – to the hospital equipped to operate on him. I have never had to liaise with the police chief (and he, in turn, the angry mob) to transfer a patient before. Tomorrow the strike will be stopped to allow grannies to collect their pensions. But tomorrow is another day. Today, our ventilated patient is left waiting in the little casualty as the doctors dissipate to attend to our wards.
My ward is Male Medical Ward with my on-calls covering either Casualty or being ‘second-on’ covering the wards and giving the spinals for C-sections. Casualty calls are pretty hectic, often seeing 20+ patients overnight, often with a full day either side. Being alone in casualty seeing everything from stab chests to severe kwashiorkor, DKA to cryptococcal meningitis was a real challenge and has taught me to be adaptable, rely on my clinical skills and approach unfamiliar situations in a structured manner. The day job sees me trying to get round the 36+ patients I am responsible for, many with stage 4 AIDS, others suffering from the full breadth of medical conditions: COPD, terminal cancer, strokes and myocardial infarctions and the occasional fascinating curve ball; a liver abscess and idiopathic thrombocytopenic purpura. It is a constant struggle to get them through opportunistic infections, rehabilitation, and to keep track of the patients coming back for follow-up and review. Indeed, it has been a sobering experience working on a medical ward in the midst of the TB/HIV epidemic, watching young men ravaged by AIDS wasting away. In the absence of adequate diagnostic and therapeutic interventions, with little senior support, one feels impotent against this tide. Your own shortcomings are laid bare as you sign yet another death notification. You are better than nothing, but wish you knew more, could do more. The harsh inequality of life presses down upon you.
It is amazing how quickly someone can go from a bedbound, emaciated, delirious wreck to walking to the toilet and being free of the nappies. Another moment to smile.
As lunchtime looms closer we break for teaching. These sessions started quietly; speaking out of turn is not something Zulu females do easily. Yet now I really do smile as they suggest topics and vie to answer questions. It’s probably the cake that accompanies teaching that keeps them going. Importantly the learning goes both ways in these sessions. It was only recently while doing a teaching session on nursing interventions in renal failure that I realised why, despite my asking, pleading and finally being quite grumpy, I wasn’t getting urine outputs measured properly on even in the sickest of our patients. It was the nursing auxiliaries emptying catheters or bed pans and there was no measuring jug! To measure urine output they were using a syringe.
The sluice with no water in 40C heat isn’t somewhere you want to linger with a syringe.
Returning from lunch, I see one of our recovering TB meningitis patients walking with a Zimmer frame. Bedbound patients are placed in cot beds with nappies, which are changed twice a day – both unhygienic and hideous for the poor patients. When the Zimmer frame order arrived we secured a few for the ward. Now as soon as the patients are stable, we put the cot sides down and teach sitting to standing with the frame. Usually after just a few days we get them walking.
It is amazing how quickly someone can go from a bedbound, emaciated, delirious wreck to walking to the toilet and being free of the nappies. Another moment to smile.
I quickly check on the patients I won’t see fully that day, make my referrals and get advice from specialists at the referral hospital. I then nip down to theatre to give an anaesthetic for a small procedure. That evening I am on call for Casualty, which is thankfully quiet, and I finally get our ventilated patient through the roadblock with a police escort. Later, I crash into bed exhausted.
At the weekend, I sit gazing over the beautiful Drakensberg mountains, and reflect on what this year will have taught me. I am left realising that it is my non-technical skills that have improved the most. While I have gained valuable procedural skills, such as pleural procedures, intubation of critically ill patients, minor operations and basic anaesthetics, these skills are best learned in the structured supervised UK medical system. I have, however, learned a huge amount about the different forms of leadership. One has to lead in acute situations with clear communication and good situational awareness, but also one has to model leadership over the long term. Listening and understanding, and standing up for good practice are of key importance here. Gaining insight into the complex interplay of systemic factors, work-based culture and quality improvement has been a fascinating and valuable experience very relevant to any future career. I have also developed important skills in understanding and managing risk with in the uncertainties of medical practice. I have become more con dent and am able to practise more autonomously, but this is tempered with an awareness of the limitations of my knowledge, and when to seek help.
If you are considering applying for the Global Health Fellowship, it is these skills and the profound effect that the experience will have on you as a caring human being that you will gain most. As I leave COSH I breathe a little sigh of relief that I don’t have to face all this woeful misery in a harsh land. In the same breath I salute those that have the strength to have dedicated their lives to improving and serving this place. I will also be sad to leave a place where you really make a difference, teeming with things to work on, to improve upon. I will miss the craziness, the musicality, the laughter, the sheer lovable, frustrating absurdities, and the people that are COSH.
Dr Stuart Winearls is an acute care common stem (ACCS) CT3 trainee in Severn Deanery, working in Gloucester Royal Hospital.
This article appears in June's Commentary magazine.