flora and fauna

A garden in Durban

I met some surprinsingly large snails in Durban a couple weeks ago.  About the size of oranges, and literate too -- this one appears to be reading the newspaper ads, perhaps looking for a new laptop.

A tree I pass as I walk down hill from my residence to the hospital.  It smellls heavenly -- like honeysuckle and grape soda.

moth on the men's ward

mantis that's been living above my sink

Ngiyaphila

means "I am alive."  

more bleeding

Yesterday a beautiful, educated 22 year old woman was brought into our emergency room on the edge of passing out.  Her blood pressure was quite low.  We put in two IV's with wide open fluids, did a pregnancy test which was positive, got an ultrasound which showed her abdomen was full of fluid -- blood.  The ambulance came right away and set out with her for the referral hospital -- if she was to live, she needed emergency surgery for hemorrhage -- likely due to ruptured ectopic pregnancy. 

 

Before and after the ambulance left with her, I spent at least an hour on the phone, making at least 10 phone calls to seemingly every part of the referral hospital, trying to find a gynecologist accepting emergencies.  I spent many minutes on hold for various providers who never got to the phone, called again after many busy signals, never found a doctor to tell about this patient headed for their hospital.   I was finally able to give the patient's name and story to gyn secretary at the other hospital, and she said they'd attend to the young woman. 

Sometimes people die tragically.  It is painful to be there when it happens.  She probably died, but I don't know that for sure.  

I have been reflecting on spiritual teachings as I prepare for another work day today, and asking to be filled with lovingkindness, for myself and for others. 

I am laughing now after reading a quote from Woody Allen,

“To love is to suffer. To avoid suffering, one must not love. But then, one suffers from not loving. Therefore, to love is to suffer; not to love is to suffer; to suffer is to suffer. To be happy is to love. To be happy, then, is to suffer, but suffering makes one unhappy. Therefore, to be happy, one must love or love to suffer or suffer from too much happiness.” 

first the basics

My first on-call day and night were busy -- the themes were babies not breathing and bleeding people -- one a pregnant lady, already a mother of four, with a near term pregnancy, who had suddenly started bleeding rapidly from her placenta.  The baby had stopped moving the day before, and we discovered it's heart wasn't beating using the ultrasound.  Thank god I had back-up from my medical manager. We had to get blood going and freeze dried plasma reconstituted and transfusing.   We sent her to the referral hospital (Edendale) for emergency surgery at 4 a.m..  I don't know if she lived, but she had a decent chance.   Another bleeder earlier in the day was a young woodcutter who was using a chainsaw and amputated most of his right hand. I sent him and his amputated fingers on ice off to Edendale during a thunderstorm.  He waited more than five hours until the ambulance showed up.  Before that, a newborn on the pediatric ward stopped breathing, and for awhile I was the only doctor helping with the resuscitation attempt.  The baby died.   In the night, there was a complicated labor with a 15 year old girl whose fetus was in distress,stuck in the birth canal for quite a while.  I did my best encouraging the girl to push, and she worked really hard at it.  The nurses pushed down and out on her belly to try and help push out the baby.  Hadn't seen that technique before. My medical manager ended up using forceps for the delivery. Then the newly born baby wouldn't breathe.  My medical manager resuscitated her to the point of spontaneous breathing and intact reflexes, if not crying.  He resuscitated the tiny infant despite the lack of proper equipment, using a bag valve mask that was adult size.  Finally someone brought the infant bag valve mask from upstairs in maternity.

With all of these unnerving and motivating experiences, reading about what I don't know becomes fascinating and urgent -- about neonatal resuscitation, bleeding during pregnancy, likelihood of success in reattaching amputated fingers, and on and on.

Reading, no reading, patients dying, patients living, back-up or no back-up, my main goal for this year needs to be simply showing up for work every day.  That and staying healthy.  There is enormous need here, and so many things that could be improved.  But first, the basics.

On the subject of staying healthy, Steven and I have been taking regular jogs, mostly early in the morning before work.  Here's a cellphone snapshot from one of the nearby routes.  The rainy season has started, and soon the grasses will be green.

When we go later in the day, we've tend to acquire jogging companions from among the village teenagers. They trot along up the hills with us, often wearing flip-flops. We try out our Zulu words and they their English.  It is a fun way to make friends.

Here are more Drakensburg wildflowers, sprouting in an area where the grass was therapeutically burned.

Happy birthday to my brother Brook, whom I admire, love and respect more with each year that passes.

Nkululeko

It's early on a Tuesday morning.  My internet connection has been off and on, so with luck this posting attempt will work.  We went for a stunning hike on Sunday, encountering a herd of eland that included an enormous male (supposedly they can weigh up to 700 kg) and several babies in groups.  Also came fairly close to a Rinkhals, a poisonous snake.

The hike was to the Pinnacles, pictured above.  It was so quiet there.  I napped in the shade of the tallest rock.

Work has been quite challenging.  This is my second week in the "OPD," which is emergency, urgent care and chronic illness clinic wrapped into one.  Yesterday's two big themes were sick babies and nasty fractures.  There's no X-ray or transportation on the weekend, so every Monday morning there's an accumulation of patients that've gotten sick over the weekend or have waited for X-rays of their fractures.  I admitted five babies to the hospital.  For the fractures, thank goodness for the orthopedists where we refer (Edendale).  I must've called them eight times yesterday for help with fracture management, and they agreed to see everyone that needed it.  The patients seem incredibly stoic -- for example sleeping in a chair for 2-3 nights with a fracture waiting for an X-ray, and living with a great deal of pain. 

The work week started off yesterday with a lady lying on a mat on the floor dying of disseminated Kaposi's sarcoma.  She'd been there overnight because there was no open bed in the hospital.  Her sister was with her, and told me how beautiful and light-complected she had been, pointing to my skin and to her sister's skin. 

Triaging here is different than I could've imagined.  I understood rationally that this a place in crisis with a great deal of physical human suffering, and that is one of the reasons I came here -- because I can help to some degree.  Yet actually being with those who are so ill and in so much pain, and not having time or resources to help them is quite baffling and sad at times. The sickest patients often have disseminated infections.  If we can get an IV in them, we can give fluids and antibiotics, but several are already crossing death's threshold, and how long do you try when 30 other people are waiting for you to see them and the pharmacy closes at 4 p.m.?  So far I haven't found enough human or material resources to do effective advanced life support.   I must realize again and again that I am in the middle of an epidemic that is thousands of times bigger than my reach.  And realize also that there are situations every day where I can make a difference for individual patients.

I've met several men and boys named Nkululeko, which means freedom.  The people I meet have so much more in life than pain and suffering.  Freedom is here too, and love and joy.  We cannot lose sight of how much there is to being alive.

Mountains

The Southern Drakensburg Mountain range is an hour's drive away.  Yesterday I went for a hike around the rock peaks, ridges, valleys, for a swim in a river, for the spring wildflowers.  There I found a beautiful refuge for this work-cramped mind to stretch and refresh itself.

Steven got me on the trail. 

There is a drought. Nevertheless, lots of flowers.

The road back to work. 

Monday morning has come, and I start refreshed.

Lots of thoughts

Rise up!

On Wednesday the 8^th, I visited the village of Mqatsheni , travelling up dusty winding roads leading toward the majestic mountains South Africa shares with Lesotho.   I was visiting the Khuphuka project, a rural community health and outreach organization run by the people of Mqatsheni, and started by Dharmagiri, the Buddhist hermitage nearby.   This past April I spent eight days with Sangha Seva and young people from the village turning over the reddish soil in families’ gardens, then weeding and planting a winter crop of cabbage, spinach, carrots and celery, to launch Khuphuka’s community gardening project.  Malnutrition due to lack of food security is common here because much of the working-age generation has been wiped out by the HIV and TB epidemic.   The gardening project is back to the land: digging, seed-sowing and watering the way toward better community nutrition.   Our shovel and chicken-wire-toting group from the UK and the US was warmly welcomed, and Mqatsheni quickly found a place all of our hearts.  Here are some then and now pictures:

Chris, Gugu and Julie planting in April

Skhumbuzo, Matt, Spire, cabbages and carrots this month.

Mqatsheni's valley in April

 September sunset behind the school in Mqatsheni

The word “khuphuka” means “rise up” in Zulu.   Khuphuka uses a holistic approach toward community health, training and employing villagers as community care workers who visit and assist neighbors who are unable to function due to chronic illness, trauma, or death of family members.  Khuphuka also trains and employs child health workers, does HIV counselling and testing, runs a mentoring group for teenage boys, women’s support groups, and offers community education.  Upon learning about the prolific training and outreach they’ve done over the past five months, anyone's spirits will rise up.   Check out the website: www.khuphuka.org.

After Mqatsheni, I joined Steven, the other new Centocow doctor, from Belgium (Flanders, for certain Walloonies who will wonder), at a three-day educational conference on HIV, TB and STI’s in Durban.  Steven is a peach in that he is kind, easy-going, helpful, and because his head is round and covered with blond fuzz.   He is already a great resource and friend.  He knows a lot more than I do about how to treat late stage HIV patients.  He’s finished a tropical medicine course and is heading toward subspecialty in infectious diseases.  He’s blazed a trail at the hospital, starting a couple weeks earlier than I did.   

At the conference in Durban, there was one person teaching us infectious disease management for rural South Africa, public health principles and practicalities for three days straight.  We were ~50 recently-arrived foreign doctors, South African doctors and South African research nurses.   She did an awesomely energetic, entertaining and intellectually rigorous job of it.   Her name is Dr. Dube.  She is originally from Zimbabwe, and is a professor at one of the medical schools in S.A..   She is an inspiration, about as quick-thinking as anyone I've ever met, and someone who demonstrates that it is possible to make a difference in the fight against HIV and TB in Africa. 

Durban was also great because of the scrumptious South African Indian food, the immaculate backpacker’s lodge, the beach with surfers bobbing out in the light blue waves, and the funky gay bar and restaurant, BBB, where, halfway through dinner, Steven and I realized what scene we were in (abundant cute guys, not a lot of women).

Ms. N-95

Work for me started five days ago, on the 15^th.  I was given responsibility for Ward 10, the men’s general ward, and Ward 9, the men’s TB ward.  My census has been about 20, which seems fine compared to the clinic doctors who see 40-60+ patients daily.  How to describe my first days of work?  Chaotic, poignant, sad, and humorous at times.   The patients are endearing, stoic, grateful and quite ill.   Of the eight patients per room, those who are alert enough get to know each other form a bit of a community at times.  It reminds me of Aleksander Solzhenitsyn's novel Cancer Ward. Some of the main types so far I’ve seen: burn patients, head trauma patients, TB +/- HIV patients, HIV patients that have brain damage from opportunistic CNS infections, HIV patients with GI problems, bedbound stroke patients.   The tight-fitting N-95 TB mask all day every day gives me groovy cheeks.

My interactions with the nurses and the expectations of me as the doctor are quite different from what I’ve experienced before.   I repeatedly find myself huffing with frustration when they don’t do what the nurses at Hitchcock automatically do, so I need to stop and have a reality check.   These nurses are coming from a far different background-- the culture, nursing education, way of communicating – all are different, and unfamiliar to me.  It is interesting to watch my mind jump to conclusions about them and shortly thereafter realize I’m incorrect – so human.   I have a lot to learn. 

My care of these 20 or so men has felt patchy so far.   There are moonlighters on call over the weekend and the ward doctors don’t round on the weekend, so for two days in a row no ward doctor sees the ward patients.  I went in and saw the sicker ones for three hours yesterday a.m., of which I’m glad, but when I look ahead to working week after week and doing overnight calls every week, I’ll almost surely take the weekends off like my colleagues here do in order to avoid burnout.   A lot of patients die in this hospital, and I'm already wondering if I could’ve saved one Wednesday night had I worked more.  Time for another reality check – I am just one person working in a low resource setting in the midst of a major public health crisis.  Poverty, disease and lack of education exist next door to privilege, comfort and abundant resources here.  In the 200 meter walk between my residence and the ward, I cross between parallel universes.

More pictures coming soon.

More pictures

Where I live -- on the hilltop above the hospital

the most critical room in my new residence

the most common cause of a traffic jam:

The hospital and the mission next to it.

This is it

St Apollinaris hospital, in Centocow, KwaZulu-Natal, where I will work and live this year. It contains ~158 beds.  Three other doctors are working in the hospital now.  

I was warmly received. There were many empty beds today, unlike on my prior visit.  I don't have a clear answer as to whether the emptiness was due to the strike. 

The ARV (antiretroviral) clinic, run by a non-governmental organization (NGO), has been open.  There was a long line of patients at the clinic waiting to pick up their monthly supplies of ARVs.  I gave one of them a ride home.  Let's call her Jeanne.  Jeanne is married with four children and works for a neighbor doing childcare and housework to support her family. She has a seventh grade education and speaks English well, although she does not believe it when I tell her so.   A while ago she started feeling tired, developed a rash and a cough and began losing weight.  She went to a clinic, told them she had "symptoms of HIV," and asked a nurse to test her.  She ended up having both HIV/AIDS and TB.  Her husband as well, but not their children.  Since then they've both been on antiretrovirals and anti-TB treatment.  Jeanne has regained her strength fully, although her husband hasn't and is unable to work.  It takes her all day to pick up their medications each month, traveling in minibus taxis.   Although life remains difficult, her story is a hopeful one-- strength regained after she took action to deal with her illness.

The hospital's backyard, with orange trees.   There is a staff residence higher up on the hill where I'll move in tomorrow.  

The valley floor on the way to the hospital, looking at a marshy area, with livestock grazing in the distance.

A typical hillside view near the hospital, with blooming cacti in the foreground.

A few of the many adorable creatures I passed on the road.  I had to wait for several cows, bulls, calves and goats to amble out of the way.

Also exciting, I acquired an isiZulu (Zulu language) teacher today!   Hence I must study now before I go to sleep.  Good night from South Africa.

Photos

Sunset last night on the N3 highway with Drakensburg mountains in the far distance:

Two views from my jog this morning, more peach trees.

New growth after the area was burnt to make a fire break.  It is very dry here.  A bit like California.

Buds of September

It is springtime, and peach trees are blooming in yards, next to creeks, in shantytowns. After driving 400 miles from Johannesburg, crossing the yellow and brown savannah, passing ostriches, guinea fowl, swans, going onward over a windy pass through northern Drakensburg mountain range, I reached the hills and valleys of KwaZulu-Natal. My trip ended last night on the idyllic doorstep of this Buddhist hermitage.

I want to start my journey in this land as awake and aware as I can be.  I hope to emulate my hostesses at this hermitage.  They are open-hearted and generous in an unadorned way.

I flew into Jo’burg this past Wednesday night after a series of farewells to beloved friends and family in Vermont and New Hampshire. Lucky for me, a petite young woman from Africa Health Placements (AHP) and her brother kindly picked me up from the airport and took me to a hotel in Troyeville, an inner suburb of the city. Troyeville is amazingly diverse, with a large group of immigrants from Mozambique among many other places. I met people there from Malawi, Zimbabwe, Cameroon, Australia and KwaZulu Natal. The second picture is a view of Jo’berg from my hotel window.

My first day in Johannesburg, I visited the apartheid museum. I will be going back there and taking others with me. It was better than my already high expectations. Looking at the recent identity cards helped me realize how little time has passed here since the apartheid era. Reading about racial classification and segregation methods, the splitting up of families and forced labor helped me understand better some of the history of South Africa, the context in which apartheid’s misguided and destructive policies came about, and the grievous results. There was an excellent exhibit about the life of Nelson Mandela, and many inspiring and spiritual quotes of him, illustrating his humanistic attitude toward all, including his former oppressors. Examples:

"For to be free is not merely to cast off one's chains, but to live in a way that respects and enhances the freedom of others."

"A good head and a good heart are always a formidable combination."

"After climbing a great hill, one only finds that there are many more hills to climb."

-Nelson Mandela

Anne's rental egg at the supermarket

Tomorrow I will go to my hospital. It seems that most of the health care workers are on strike, as are teachers and other public servants all over South Africa. I’ll try to add my observations about that soon.

Thank you, my family and friends, for helping me get here: from cleaning the oven for my tenant, to picking up my international driver's license, to swearing under oath that I really am a doctor, to feeding me, to carrying my moving boxes, to creating the Brouha-HA, to driving me to the airport, to all of the other million things.  I love you, and not just because you do so much stuff for me!  Please come visit.