Click on one of the trainee names below to read about their experience:
- Jack Watson
- Claire Hawcroft
- Fiona MacPherson
- Kuki Avery and Matt Noble
- Polly Duncan
- Clare Hollister
- Stuart Winearls
- Rebecca Anderson
- Mohammed Malik
How many hours were you contracted to work each week and how many did you realistically work (taking into account overrunning)?
All district hospitals function a little differently according to their management and staffing levels. I can only really tell you my experience and how it worked in Manguzi Hospital. When we were short-staffed you would stay late to support the on call doctors, this was more out of choice than necessity; the teamwork and camaraderie make it worthwhile. Overall, if I'm honest, the normal working hours and culture felt much more civilised than the NHS!
Handover 7:30-8:30 with a teaching session every morning.
8:30-10:30 session 1
10:30-11:00 Tea break
11:00-13:00 session 2
14:00-16:30 session 3
On-calls- General rule is 3 Doctors on every night.
The 3rd on-call is often a "cutter" or more senior doctor who would not normally be expected to come in unless 1st and 2nd on-call doctor cannot do Caesars between them, or if there is a big MVA. Normally the 3rd on-call person is at home by 17:30.
The 2nd on-call gets home as soon as RU (basically A&E) is under control, this is usually between 7-9pm but will be called in to do the spinal or cutting for Caesars, help in a resus/intubation or help out to support colleagues if it is extremely busy. You will most likely be in bed by 10pm and not disturbed until the morning for over half the ‘2nd on-call’ shifts.
The 1st on-call is tiring but rewarding! From 16:30 to 07:30 the following day you are responsible for medical cover in the hospital. You have a matron and variably useful nurses, but the RU and all the wards are your responsibility. You can call your 2nd or 3rd for advice and help, but it doesn't take long until you are confident and want to manage alone. I never spent my whole night working, it is not a ‘nightshift’ in the UK. On a few occasions I would be home by midnight and would only go in at 6:30am to review a couple of stable patients who had come into RU as the nurses were happy to leave for review by the Dr in the morning.
Other times 1st's can be absolute beasts! If you had a busy day shift it takes it out of you clerking until 3am, you may get a couple of hours sleep interrupted by ward calls, and then have to take a foetal distress to theatre at 6am and still survive your normal day shift until 1pm the following day. These shifts would be rare, and you got a real sense of achievement when you complete them. I don't think your brain is working as fast or as fluently if you were fresh but it never seemed to cause any dangerous decision making and other Doctors were considerate and supportive when they knew you had experienced a really busy and challenging shift.
The weekends would be Fri, Sat and Sun where you work a 1st, 2nd and 3rd on each one of those days. Again they were variable but if you had to do a spinal for 2 Caesars as a 2nd on call overnight you would be surviving on caffeine during your following day as a 1st on call. General rule was 3rd on calls need to be "protected" and go home to catch up on sleep by 1pm and only get called if really necessary.
Overall with a full team of 15 doctors on the on-call roster, you roughly do 2 x 3rds, 2 x 2nds and 2 x 1st a month. Normally you work 1 weekend a month which is great as then you only have a 1st, 2nd and 3rd left to do as weekdays over the full month.
What level of support did you have?
We were three hours from the nearest secondary hospital by road. Frequently this was too far for an intubated patient to make it on the ventilator. This is rural medicine and you had to make big clinical decisions yourself without anyone holding your hand and reassuring you that you are doing the right thing. Sometimes you do the wrong thing, but this is a system very different from what we are used to in the UK and mistakes and mismanagement are inevitable in these remote, resource-limiting settings where Drs a few years out of medical school run the wards.
You can call up Consultants and often discuss patients daily. A neonatal, paediatric, infectious disease and obstetric hotline were a great way of getting hold of a senior and call for a bit of advice. Although it would never be allowed in the UK, WhatsApp was one of the most valuable tools available; videos of distressing neonates, photos of fractures and weird rashes were shared almost daily. All doctors at our hospital were on a group, which you could ask any clinical query or for advice and as a team we would try and figure it out. If you had a resus or a sick patient you needed help with people would be there to assist straight away. As seniors go, we had a couple of Drs who were pretty experienced surgically, but often it is the British GPs who are most knowledgeable medically. You will end up finding your own niche and become a "senior" in your own way.
Did you feel completely out of your depth or was the work manageable?
You learn things remarkably quickly. I remember my first handover, I thought everyone was talking a different language, I didn't understand a word of the maternity, surgical and neonatal admissions they were on about. After a three month teething period though, you do find confidence in your own decision making, something that I could never dream of in my 5 years in the NHS. The buck stops with you. You need to make those decisions. You may feel like you are in the deep end at times but it is exactly that which makes you thrive in your decision making and clinical skills and learn more in a matter of months than you ever would with years as Foundation doctor. I never felt the system was doing patient's an injustice or was dangerous, you learn the safest way to manage a snake bite, crush injury, MVA or inhalation burns despite having little or no experience of them. If it is a life and death scenario and the Doctors on call can't deal with it, such as an unstable ectopic or difficult intubation then we would call a non on-call colleague to get out of bed and come in and take control of the situation. You do feel out of your depth at times, but it is such times which helps you progress, it is manageable even if you are under-confident (as I was when I first went out).
Did you know anyone with partners out there and if so do you know what their experience was like?
I went out with my girlfriend who is a Dr and had just finished CMT. South Africa was such an amazing experience for us as a couple, we got engaged out there!
A couple of Doctors had non-medic partners. It can be pretty tough to get a paid job in another capacity if you do not possess a "critical skill". I think partners who are not working need to find ways to fill their time so they don't get bored. One guy used to make and sell croissants and juice for tea and do an a la carte restaurant evening once a month. Often these events became a bit of a social hub as the partners have time to organise events and get people together. You will find in most hospitals, the doctors and partners live on site (hence why the ‘on-calls’ feel much less taxing), therefore partners are likely to have other non-doctors around during the day and have plenty of people to make friends and spend time with.
Did you have time to explore South Africa on the weekends you were off or did you spend all your off-time trying to recover from work?
Absolutely. You will make more of your weekends than you ever do in the UK. Where we were in northern KZN, there was nothing better than spending a weekend on a Mozambique beach, Swazi music festival, paddle boarding Kosi lake or visiting the endless game parks. If my 1st on call was ok, when I finished work at 1pm the following day I would drive to Tembe Elephant Reserve and be watching lions stalking the plains, or Ellies frolic at a waterhole whilst sipping a post-call beer. And that's a working Tuesday!
You get 22 days annual leave a year but a lot of public holidays you can work and get days in lieu. As it's not a huge amount we maxed out our leave and luckily you get a decent bit of disposable income (which came as a surprise to me). During a four day Easter break we went skydiving in Namibia. One week off we headed to Rwanda, DRC and Uganda to see gorillas, Pygmies, hike active volcanoes and photograph tree climbing lions. A long weekend in Cape town and Stellenbosch wine tasting, another in Kruger, cricket in Joburg, diving at Sodwana, hippo tour in Stock Lucia, watching turtles nest, fishing off dhows, dolphin encounters. The list goes on. You will work hard and if your ward is busy with 35 patients to look after on your own you will without doubt be exhausted but you are your own boss, you can go in at 5am to get the job done to get out at 4:45 and make the Mozambique border by 5.
You will likely be in a completely different area but every hospital seems to have its own attractions nearby.
Do you have any advice regarding factors to consider when looking at individual placements?
I think you will be guided mainly by AHP as they know where the SA government are offering jobs. This year I believe they froze all KZN jobs and heavily recruited to the Eastern Cape as there was a real shortage. Getting in contact with doctors at those hospitals is key as they know how things are on the ground. If you want to know anything more about Manguzi or a nearby hospital, let me know!
Good luck, you'll be great out there. It is the most rewarding thing I have ever done.
One of our Severn Trainees who was recently on placement in South Africa has written a blog about the daily life of a GP Global Health Trainee. It provides a wonderful insight into the types of experiences our trainees have and of the rewarding impact their presence has on a resource poor element of society. Please take the time to read this by clicking this link.
I worked at Mseleni Hospital in rural South Africa from September 2013 to July 2014. I had arranged a placement through the organisation Africa Health Placements, linked to Severn Deanery.
Mseleni Hospital and surrounds
Mseleni is a 217 bed Government run district hospital in Umkhanyakude; it's a rural district on the subtropical north east coast with 97% of the population speaking Isizulu. Umkhanyakude was described as the second most deprived area in South Africa by the District Health Barometer where only 6.6% are formally employed and 70% of the population live on less than R800 per month (approx. £46). Local industry includes agriculture, mining and tourism. The African National Congress is the leading political party and strongly supported. The government is the biggest employer.
The hospital staff includes 15 doctors, a nursing team, and allied health professionals serving a community of approximately 120,000. Clinical departments comprise paediatric, maternity, male and female wards, and an outpatient department (which contains A and E). Mseleni offers Primary Care at eight satellite clinics that have resident nursing staff and an allocated doctor who visits weekly. Specialist clinics are additionally held including a monthly visit from a psychiatrist, TB and HIV clinics, and a clinic for Mseleni Joint Disease (a local familial degenerative osteoarthropathy). Estimated HIV prevalence is 30% with 11% of people taking antiretroviral medication.
My average day began by taking part in a teaching ward round, which rotated through the various wards, followed by a round of patients in my ward. For the first six months this was Maternity, where I learned management of labour, Caesarean section, spinal anaesthesia and neonatal care. From January I worked in Female Medical. Presentations were diverse, with conditions including cryptococcal meningitis, idiopathic thrombocytopenia, catatonia, and HIV related cardiomyopathy. Each doctor also worked a 2½ hour shift in outpatients during the day. The skills required were diverse and it was the support of medical colleagues that enabled me to develop the necessary skills for 'bush medicine'.
On Wednesdays I visited Ntshongwe clinic, about 22km away on a dirt road. The area around the clinic is very economically deprived, and none of the homes have piped water. Accordingly, diseases associated with poor sanitation are common, but I also saw many patients with chronic diseases including hypertension, diabetes, epilepsy and mental health problems.I would see about thirty patients on average in addition to completing my ward round and handing over any urgent jobs before leaving for clinic. We were on call every fourth night and covered either outpatients or the wards and maternity.
Working at Mseleni, I felt I had considerable professional freedom to develop projects that were important to me. The hospital has an impressive record of chronic disease management, having led the district in providing access of antiretroviral therapy for HIV. However I found a gap in provision of care for the significant diabetic population.
I was particularly affected by the experience of caring for a 40 year old diabetic woman on insulin who was admitted to the high care ward after surgery for her foot infection which had necessitated a below knee amputation. Unfortunately she never regained full consciousness following the operation. Post-operatively it was found that in addition to poorly controlled diabetes she also had untreated HIV. She died a few days later leaving two young children. She came from Ntshongwe, the area of my Primary Care clinic, where her passing had significant repercussions on her family and community. I felt that with better primary care she might have lived a much longer, healthier life.
When I arrived, the system saw diabetic patients referred to a doctor for six monthly medication reviews, unless the patient became acutely unwell beforehand. In most cases repeat prescriptions were issued on the basis of a single capillary blood glucose reading and a set of serum urea and electrolytes. Furthermore, lack of screening for the condition meant that diabetes was commonly diagnosed only when the patient presented in extremis. Accordingly many patients had complicated disease from the outset.
I felt inspired to improve the service for diabetic patients. I wanted an evidence-based approach to multi-disciplinary diabetic care that would be applicable to my population. From December 2013 I started running quarterly diabetic clinics at the satellite clinics. I ran an education session for doctors and for nurses and worked with the dietician to train nutritional assistants to run patient education classes. With the optometrist we started screening diabetic patients annually for diabetic eye disease – although treatment was available at referral hospitals, none of the hundreds of diabetic patients I saw had accessed it. I acquired glucose meters by donation from a pharmaceutical company and issued them to number literate, organised patients.
The diabetic clinic has been taken over by the British GP trainees who have succeeded me at Mseleni. This sort of project is only truly effective if it can be sustained and I hope this project will be continued and improved in the future.
Mselen is situated in a truly beautiful part of the world and weekends off were mostly spent relaxing at a beach or safari lodge. The hospital is 3km from Lake Sibaya; a world heritage site, home to hippos, crocodiles, fish and birds, and a lovely spot for a sunset braai.
Reflecting on the effect of this year on my professional and personal development, I feel that the greatest impact is on my confidence and adaptability. Although practical skills are an obvious learning need for British doctors arriving in South Africa, the greatest benefit to me was developing my ability to provide high quality care and maintain professionalism through many challenging situations that I would not have faced at home. These included managing high numbers of patients, long and tiring shifts and coping with limited resources far from specialist help.
Similar opportunities would present themselves to other interested speciality trainees doing Out of Programme posts. In addition to being a great learning opportunity for the doctors who partake, this scheme brings medical care to a needy population and is a chance to offer them the benefits of modern Primary Care training – patient empowerment through education, consultation and patient choice. These strategies may be all the more valuable to a society that is recovering from oppression under apartheid and now faces an increasing burden from chronic disease.
The hospital is based in a very rural part of North Eastern South Africa, Kwazulu Natal. We are 10 minutes from the Mozambique border and twenty minutes from the beautiful wild North Eastern coast. There are many wildlife parks surrounding the hospital, and Mozambique is very accessible for exploring! It is a life of two halves with weeks spent battling the terrible march of HIV and TB through sub-Saharan Africa and weekends often spent in luxury safari lodges at discount prices. Our patients are an eclectic mix of Mozambicans jumping the fence for South African health care and local Zulu people who live in mud huts and quite bizarrely shop at the local Spa supermarket.
Kuki is looking after the Female Medical Ward; on average 30-40 very sick patients with end-stage HIV/ TB/ stroke/ diabetes/ psychiatric conditions and cancer. The medicine is absolutely fascinating with patients presenting with advanced medical signs. Such as this lady (look away now if you are eating your breakfast) who could not afford to come to hospital for medical care for her advanced lymphoma. On her daily perusals through the local pathology Kuki has the ever enthusiastic help of a little chicken who follows her on her ward round. Hygiene appears to be an afterthought with the ward sisters here! The chicken is a reminder to her, when times are stressful that this is Africa and we can only do our best!
Matt is managing the Female Surgical Department which involves a daily ward round on inpatients and theatre sessions performing a wide array of procedures from C-sections, tubal ligation (sterilizations), burn/wound debridements, evacuation of miscarriages, lymph node excisions/biopsies and the occasional emergency ectopic. With doctors a scarce resource Matt frequently acts as anaesthetist and surgeon. Quite a terrifying thought!
Thursdays are male medical circumcision day where Matt is greeted by a long line of men with their trousers down, awaiting the removal of their foreskins. Kwazulunatal is the world centre of the AIDS epidemic and the evidence suggests that circumcision helps prevent HIV spread. However, it may unfortunately instill false belief on the prevention of HIV.
The hospital is hugely understaffed currently. Ideally 15 doctors would make work manageable and care reasonable. However, we are down to 8 and so we have just two hours to complete our ward rounds before being allocated to Out Patient Department (our equivalent A and E), where we see everything from chronic hypertensive, diabetic and epilepsy patients to snake bites, pre-eclampsia and stabbings. Work is varied and challenging.
Regular power cuts make work exciting - particularly in theatre! At times water is in scarce supply too. Over the last week we had four days with no water and no water means no X-rays! There are no senior doctors (registrars/consultants) in the hospital and so any senior advice has to be sought from our closest secondary care hospitals (5 hours drive to Durban) and often the phones are down or doctors mobiles are conveniently turned off!
For very unstable patients who qualify for secondary care (i.e do not have endstage HIV), there is an ambulance service, which usually involves a six hour wait for them to arrive and then they often tell us that the patient is too sick for transfer. If the patient meets their criteria they then have a five hour drive in an old bumpy landrover ambulance to Durban! We have been reliably informed that crew frequently stop for KFC on route. It has made us appreciate what incredible service the NHS provides.
On the plus side we are learning so much and getting the most incredible practical experience. Our highlight so far was our first Noble/Avery Caesarian Section together, Kuki as anesthetist and Matt as Obstetrician. Mother and baby both doing well.
I have been working in Manguzi, rural South Africa, for eight months. It has been a fantastic experience so far and I would recommend it to anyone.
The hospital is located in the northeast coast of South Africa 15km from the border of Mozambique. It is a very rural area with a generally poor population suffering from an epidemic of HIV and TB.
The majority of my time is spent working in the primary health care clinics in the area surrounding Manguzi Hospital. There are eleven clinics and three mobile clinics. Nurses manage the clinics, with a doctor visiting each clinic for one day each week. Half of the patients I see have HIV or TB-related problems. The other half are ‘general patients’, mostly with chronic conditions such as hypertension, diabetes, epilepsy and mental health illness. I see patients with acute problems too, such as exacerbation of asthma, TB, bronchiolitis, malnutrition, meningitis and anaemia. I tend to admit about five patients a week to hospital, often driving them back in the hospital car due to limited ambulance services.
I have chosen to work in the clinics for the duration of my OOPE but other doctors rotate around different specialties, including paediatrics, obstetrics, medical wards, surgical wards, outpatient department and MDR TB ward.
As well as working in the clinics, I do on calls in the hospital. There are generally two doctors on call each day. The doctor who is ‘first on’ is the first person that the nurses will call out-of-hours and if they need help they call the ‘second on’ doctor. These shifts can be quite daunting as we are expected to manage everything from obstetric emergencies, to trauma, to paediatrics, to complicated medical patients. They can also be rather sleep depriving as the ‘first on’ doctor is on call from 7:30am to 1:00pm the next day.
Working in Manguzi has improved my decision-making skills. In the clinics I have to make quick decisions about diagnosis; whether or not to admit patients; and whether to send patients for investigations, bearing in mind that many of the patients cannot afford to get to the hospital. I am often on my own and sometimes have no phone signal to ring colleagues for advice. In this way, I am pushed to make decisions by myself. The on calls have helped me to gain some practical skills such as suturing, lumbar punctures, chest drains, intra-osseous needles and joint manipulation. I have had to learn how to prioritise patients and to delegate tasks to nursing staff.
The best part of working in the clinics has been the continuity. Now that I’m coming towards the end of the job, I find that I recognise many of the patients and have treated other members of their family too. I will sometimes see patients in the clinic, admit them to hospital, look after them on the ward during an on call weekend, and then see them back in the clinic once they have recovered.
The most challenging part of working in Manguzi has been sometimes feeling out of my depth. The South African doctors on their ‘Community Service’ year are competent at anaesthetics, caesarean sections and other procedures from day one. I had a very limited experience of these skills prior to working here and at times have felt quite inadequate. The other challenge has been seeing men and women of a similar age to me dying of AIDS related conditions. I found this quite difficult at the beginning but have become more accustomed to it as time has gone on.
To end on a happy note, I have made some close friends during my time here. All of the doctors and therapists live on the hospital site and, working and socialising together, we get to know one another quickly. Manguzi is a great location with beautiful beaches and game reserves close by. I would definitely recommend applying through ‘African Health Placements’, who guided us through the paperwork and supplied us with textbooks including the South Africa treatment guidelines when we first arrived.
I am working at Ngwelezane Government hospital, KwaZulu Natal (KZN) in the department of Family Medicine. In South Africa, Family Medicine covers anything and everything from delivering babies to surgical procedures to managing chronic disease. It is the closest thing to UK GP work you will find. If you work in a smaller, more rural hospital you will be dealing with a diverse range of clinical cases. I am actually working in a bigger referral hospital because of my husband’s work and so am slightly more specialised, generally only seeing adult medical patients.
KZN is the epicentre of the HIV/TB epidemic in South Africa. It is pretty heartbreaking and the limited resources available to fight the battle against HIV/TB make the work extremely challenging. The health care system is stretched to breaking point most of the time. On the ground, it means endless numbers of patients and not enough doctors. It is hard work but the difference you can make to patient care is really significant and very rewarding.
My own clinical experience, confidence and decision making skills have grown immensely. I sometimes doubted my abilities as a doctor in the UK but having been thrown in the deep end here in SA have realised that I have a lot to contribute and can really make a difference, something I guess we all aspire to.
Outside of work, the quality of life is brilliant. We live right by the beach, an hour’s drive from the Hluhluwe Imfolozi Game Reserve where you can find all of the “Big Five”, and only a few hours drive from the stunning Drakensburg Mountains.
We applied for our jobs through Africa Health Placements. It was very useful having their assistance as the process of applying for a work permit is laborious and took us over 6 months. I am happy to answer any questions too; firstname.lastname@example.org
Working at Church of Scotland Hospital has been a fascinating, yet very demanding undertaking. It has posed emotional, professional, and physical challenges. It has placed me in a position of responsibility beyond which I had previously been exposed to, and required that I manage often complex problems in a very unfamiliar environment. I have had to adapt my medical practice to a new setting, dealing with uncertainty, resource constraints and a high degree of autonomy combined with exposure to the full breadth of rural African medical presentations.
I have divided this report into two sections. Firstly, a descriptive narrative attempting to portray the setting and character of the place. Secondly, I have reviewed some of the challenges and experiences that I encountered, reflecting upon how they have affected me and what I have learned. This year has undoubtedly taught me a huge amount, though many of things I have learnt are hard to define or quantify. It has been a very experiential form of learning. Whilst technically and clinically I have definitely improved, I think it is my non-technical skills that have benefited the most.
South Africa, Kwa-Zulu Natal, Msinga and Church of Scotland Hospital
To understand the country and region to which we were sent I would suggest reading the book (in all it’s plain, brutal honesty) from which the following, rather long quotation is taken: My Traitors Heart by Rian Malan.
“The road to Msinga begins in white South Africa and runs for hours through neat and orderly white farmland, not so different in appearance to parts of central California. Some ten miles beyond the last white town, you cross the border between the first and third worlds, between white South Africa and black Kwa-Zulu. The border isn’t marked; there is no need. You know you are coming into a different country a different world. The white centreline vanishes and the road itself starts rearing and plunging, like a turbulent river rushing toward a waterfall. The very mood of the landscape changes. And then you round a bend, and the tar falls away beneath the wheels, and you are looking down into Africa, into a vast, sweltering valley strewn with broken hills, mud huts and tin roofed shanties. From the rim of the escarpment it looks as though some mad God has taken a knife to the landscape, slashing ravines and gulleys into its red flesh and torturing its floor into rugged hills. This is Msinga, a magisterial district in the self-governing homeland of Kwa-Zulu, place of the Zulus. As white South Africa fell away behind me, the country grew barren and dusty. There were no fences. Goats and cattle strayed into the road. 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.”
It was twenty years after this passage was written that we drove the same road to Msinga. So much and so little has changed in this time. Visually, add a new shiny shopping centre, a KFC, more houses and fewer shacks and you are not far off. Democracy has swept in bringing hope for a better future and some badly needed infrastructure. The wire fingers of electricity are snaking their way ever deeper into the district and more houses now have water. The independent homeland of the Zulus is now part of the province of Kwa-Zulu Natal, in a free South Africa. Yet corruption, apathy and incompetence continue to hamper the transformation of this dusty corner of South Africa. We have an empty water tank sat on a hill whose pump is not connected to the grid, in a water crisis! Sadly, the combined plague of TB/HIV ravages this poor district; it has some of the highest rates of TB/HIV in rural South Africa. Children grow up with Gogo (Granny in English) as parents flee to the cities for work and a better life, or succumb young to TB/HIV. There are high rates of interpersonal violence, often directed at women. Alcohol, the break-up of traditional family social networks, old tribal family feuding, newer taxi violence, unsafe cars, bad roads and worse driving leads to this small area producing a significant trauma burden that also eats into society. The maimed men obvious, the raped women hidden. Yet in the face of all this adversity I have never been with a group of people who laugh so much, are so warm, who can weather any storm without even a shrug, and who can all, absolutely every one, sing so beautifully.
Within this district sits Church of Scotland Hospital (COSH), which is simultaneously the most frustrating and inspiring place to work. The first cases of Extremely Drug Resistant Tuberculosis were isolated from its patients 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 back water, it has produced some amazing research. The true back bone of the hospital are two extremely dedicated, long serving South African physicians, Drs Moll & Eksteen. One runs the TB wards, MDR hospital and a busy outpatient clinic. The other runs the hospice, ARV clinic, staff clinic and much of the operative burden. They are always busy but always willing to help. They have fought the HIV epidemic from the beginning, through dark days of little or no treatment (the nearby forty bed hospice used to turn over weekly) to where we stand today. They have a serenity in the face of adversity. They 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, so nothing can phase them. When asked ‘How do cope with the insanity of the 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 us”.
The frustrations of COSH are enough to drive you to distraction. The lack of water, the 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, files, charts disappear into the ether. 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. On the day we arrived we were invited to sit in on a meeting concerning the late running of the outpatient department (OPD). It started 40 minutes late and achieved almost nothing. OPD still runs late.
Perhaps the day that best illustrates the madness of Msinga is the day of the ‘Water Strike’. The water strike really started, or so the storey goes, in an election defeat. The Inkatha Freedom Party (IFP) won the Umzinyathi municipality, the area in which we lived. The ANC, who lost the municipality, control the whole province and unfortunately the water supply to our district. They refuse to supply water trucks and even refuse to fill trucks bought by the municipality, to spite their rivals and create dissatisfaction with the IFP! So the IFP municipality resorted to delivering dirty river water to those without taps or wells. This being Africa and corruption rife, the water truck drivers started charging for delivering the water that they should have been delivering for free! Costly, dirty, scarce water pushed the populous into action.
I understand their anger; after three weeks of dry taps we as a group of Doctors had to threaten to close the hospital before the water flowed again. Now the story descends into hearsay. Some locals (ANC men apparently) get wind of the tuckers scam, and incite a strike to protest against this dirty, expensive water. So the reckless youth go out onto the street to strike. The sensible folk stay at home and sigh. The slight problem with this strike is that unemployment runs at 62%; it is hard to stop working when you don’t have a job. However, you can stop everything else from working by burning tyres and stoning any car trying to cross the bridge. A very aggressive, African version of the picket line.
So our day begins, the Doctors meeting. This is usually akin to a group therapy session meets a black comedy on a dysfunctional committee. Somewhere to listen to bizarre edicts from ‘The District’ while the taps run dry and the hospital coffers are bare. You also 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 the strikers and that no ambulances were being allowed in or out. Looking out of the window you saw the normal calm African scene. A thick trail of black tire 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. It shook me a little, as my pregnant wife sat beside me. What had she got us into? Matron knocks, walks in, whispering to the Medical Manager, “Two gun shots in casualty”. “Dr Mpiana do you minding sorting that out?” was his reply. Another knock. It’s Mpiana back, as calm as ever and in his gentle French Congolese accent “Erh 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 whilst 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 the angry mob), to transfer a patient before.
A ‘bystander’ some say. ‘Just a protestor’, ‘One of the leaders of the protest’ say others. ‘It was the police that shot him’; and so the rumours fly. Whilst he waits, the Indian shops in town are looted, the police take pot shots from the station as the looters carry their spoils across the river. One group managed a fridge! Apart from the odd battered man, the day is quiet with occasional gunfire reminding one of the menacing disturbance just a hundred yards down the road. One feels simultaneously safe in our compound yet also uneasy that we are hemmed in by this mob. That night the hospital is eerily quiet, the populous blocked form arriving. I finish clearing casualty by midnight; a personal record. The next day is Pension Day. A pause is called in the strike to allow Granny to collect her pension! The day after there is again no water.
Experiences, challenges and reflections
Professionally, this year has been a very steep learning curve. My job was to run the Male Medical Ward with on-calls covering either Casualty or being ‘Second-on’ covering the wards and giving the spinals for C-sections. Casualty calls were pretty hectic often seeing 20+ patients overnight 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.
I have had to adapt to a very foreign medical landscape, treating conditions I had previously only read about and with any deficiency in my knowledge occasionally having very real and sadly fatal consequences. I have had to manage situations at the limits of my competencies in an unfamiliar environment which was far from ideally set up to manage such situations. Tension pneumothorax by torch light, unresponsive status epilepticus in a paediatric trauma patient, some fairly scary massive haemorrhages and some quite unstable patients needing an anaesthetic, to suggest a few. Being solely responsible for the care of 40 patients, many with stage 4 AIDS, trying to get them through their opportunistic infections, rehabilitation, and then to keep track of all of the patients coming back for follow up and review, has forced me to improve my time management and prioritisation skills.
It has been a sobering experience working in the midst of the TB/HIV epidemic. To see young men ravaged by AIDS, wasting away or watching their last gasping breaths as PCP claims another victim. In the absence of adequate diagnostic and therapeutic interventions, with little senior support, one feels impotent against this tide. Your own shortcomings 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. However, the most emotionally draining aspect of this year has been the paediatric deaths and the rape cases. Children dying of malnutrition, puffy, skin peeling, in a country where there is also such wealth was especially galling. Man’s inhumanity to women has been shockingly common, often brutal and most upsettingly not infrequently directed at children. It really saps at one’s emotional reserves. I still struggle to know what to say to these poor women as you conduct the forensic medical examination. I hope I was kind, professional and compassionate.
I have also found this year physically quite exhausting. The rota got tough when no replacements arrived for the departing South African Community Service doctors in December. My ward was running at 40 + patients, 36 beds. We went down to less doctors than wards at some points. There was a constant requirement to be covering elsewhere, helping in casualty or theatre, whilst struggling to keep up with the flow into your own ward for which you were the only doctor. Post on-call time off was rarely practical with the demands of the ward. You really had to battle to get through casualty on calls as quickly as possible to get some sleep for tomorrow. Now the staffing has improved again and it’s down to one 24 hour call a week. I feel pleased that I could cope with the demands asked of me. I think managing in this tiring and emotionally challenging environment has improved my mental resilience. I understand that to continue to function, one has to compartmentalise. Putting to one side in the short term something particularly upsetting to allow you to continue. However, it is of vital importance to process them before they build up. Talking and reflecting on them with loved ones is a vital escape valve, as is making the most of your rest time and breaks to recharge your batteries. I think it is also important to analyse what you can change in yourself and in your situation to improve things for next time.
I have had to assume a leadership role on my ward, which required that I integrate into and lead a team of people from a very different professional and cultural background than myself. It has been fascinating learning to lead, to set an example, to improve care, to stand up for good and against poor practice, without burning bridges or being imperious. I may be biased but I feel there is a lighter, more positive atmosphere on the ward. It was the ward no doctor wanted to be assigned to. Hosting the first ward Braai (BBQ to you and me though with more meat, dancing and car stereos pumping Afri-beats) helped break down some barriers. Wednesday morning teaching for an hour also seems to have helped. The sessions started quietly; speaking out of turn is not something Zulu females do easily. I really do smile now as they suggest topics and vie to answer questions. I think the cake that goes with teaching probably helps. The learning goes both ways in these sessions. It was only recently whilst 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 400 heat isn’t somewhere you want to linger with a syringe! I went to stores to ask for a jug; “No that’s a non-stock item. It can be ordered but it will take three months.” Three months for a jug! I bought one from Spar. Now the nurses understand why I ask for urine outputs and now I understand why they weren’t being done.
One of the tougher challenges came in my first few weeks, finding we had a problem of un-prescribed sedatives being used to keep unruly patients quiet at night. I was new on the ward, trying to build trust and cohesion with the nurses but this was obviously very wrong. Having tried to establish who was doing this illegal administration I met a brick wall. I reported it to the Medical Manager and was given a very un-reassuring response. So I invented a pharmacy requested stock take of all sedative agents which I conducted weekly, as obviously as I could during the nursing handover. The problem miraculously disappeared. Having been on the ward longer I now have my suspicions on who the main culprit was and have done some ‘subtle’ education on the dangers of sedatives. Sadly I realise that without my constant badgering, ‘Don’t feed the patients lying down’, ‘Why are these cot sides still up?’, ‘Why hasn’t this medicine been signed for?’, ‘Who is mobilising the rehab patients?’, things will probably slide backwards, but at least I have tried. I think I understand much more the challenges of this type of management and leadership. To be able to foster a positive attitude in the team, to encourage and congratulate appropriately but also to stand firm when things are being done badly.
Being one of only two doctors with any significant exposure to critical care and anaesthetics has meant that I am often called to help (whether on call or not) with the more critical situations. I often have to lead these high pressure situations. I have learnt that this is a balancing act. One has to clearly take the lead but also encourage suggestions from the team. At pause moments I usually say “Can anyone think of anything that we have forgotten or could be doing?”. It seems to invite useful suggestions at an appropriate time. One has to perform tasks if you are the best person to do so, but also try and remain detached, reviewing the progress towards stabilisation. Pre-empting the situation has been a valuable lesson. If something is likely to be needed but takes time to prepare then ask early before you need it. Instructions have to be issued clearly, to a specific person and one has to check that they are being carried out but without appearing aggressive or domineering. I recently received a lovely message from our referral ICU congratulating us on saving a young girl who developed hypovolemic shock and coagulopathy secondary to a ruptured ectopic. She had a very rocky anaesthetic and we only had 2 units of blood available but she made it; that was a real smile moment.
I have tried to be involved in Quality Improvement (QIP) as much as possible, with varying degrees of success. I spent a few hours each week running a session on basic life support for the nurses. So far around one hundred nurses have been through the sessions. I was recently called back to casualty late one night for a collapsed patient and found the nurses bagging properly having put a guedel airway in; hooray, I taught them that! Alas the patient died.
The intervention on my ward which has made the most difference, is Zimmer frames. Bed bound patients are placed in cot beds with nappies which are changed twice a day, which is both unhygienic and hideous for the poor patients. When the Zimmer frame order arrived I secured a few for the ward. Now as soon as the patients are no longer delirious, 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 bed bound, emaciated, delirious wreck to walking to the toilet and being free of the nappies. We have to share the frames currently, with those that are about to start rehabbing being put in adjacent beds so two patients can use one frame. I recently re-labelled a wheel chair with Male Medical Ward stickers; it has become quite a success. The patients push each other around. Though I did find them pushing one of my frequent flier committed smokers with advanced COPD out for a cigarette; well you win some, you lose some. I think we can learn a lot at home about the benefits of encouraging movement and rehabilitation.
Some aspects of quality improvement have been less successful. We realised early on that no one actually calls the doctor for the deteriorating patient with abnormal vitals, until they are peri-arrest. “Docotela the patient is gasping can you come?”, which means the patient has Cheyne-stokes breathing and is likely to be dead when you arrive. I therefore adapted the concept of the Early Warning Score. Calculating a score would be too complicated for our nurses. So instead we created a new chart that had action trigger points. For example, if oxygen saturations are less than 90% put on oxygen and discuss with doctor. I presented this idea and supporting evidence to the doctors meeting, where it was shot down because it would make on-calls too busy. I was really depressed with the attitude of my colleagues that day.
I also realised that the hospital was brewing a nasty drug resistance problem. I audited the microbiology data from the lab and showed that we had a 20% ESBL rate and have a high rate of multi drug resistant organisms. There was also a 50% resistance rate to one of the first line antibiotics for UTI in pregnancy. The response from the Medical Manager was that no one had asked for this audit to be done (I had actually agreed to do it during a child mortality review meeting which he had chaired) and it was too short a time period so ungeneralizable and therefore wouldn’t be acted on. Despite his intransigence, the two inspiring doctors have taken note and there are plans afoot for a quarterly microbiology review and discussions with the laboratory to enable us to send microbiology samples outside the Monday to Friday 9-5 window that we currently do. Knowing COSH, I doubt anything will actually move forward though.
This year has given me valuable insight into quality improvement work. I have come to realise the importance of understanding how the work place culture, with its behavioural norms and accepted practices affects attempts to drive forward change. It can be a problem as simple as the lack of self-esteem of the team. If you are always thought of as the ‘worst team’, why try and be better? If you feel nothing can change, why try? There is often a learnt helplessness in teams. I also appreciate that for even simple changes there is often a complex set of factors that lie beneath the surface. One really has to question and examine these before suggesting an improvement. Listening and investigating are probably the most important skills here. I have come to realise that enacting change within an organisation is a slow process and requires a careful negotiation between different groups with often opposing motivations. This negotiation requires strong leadership. Without this strong leadership and ability to effectively manage different groups, and without organisational motivation to change, little can happen. I would love to learn more about how to navigate this world though I think I may find it a little exasperating.
Finally, I think one of the most important things I will take from this tough, interesting and challenging year is an awareness of how to build upon these experiences and move forward in my own professional progression. I would love to be involved in helping future Global Health trainees. I think there is huge scope for development an educational programme to prepare trainees for their global health year. In global health terms I do want to be involved in the future. A global health role which focuses on developing the capabilities and systems of local health care institutions rather than on service delivery would be the ‘dream’, though probably will require a distance learning Masters in Public Health or similar higher level degree. As I move toward my registrar years I recognise the requirement to seek opportunities to develop non-clinical, managerial skills. I can see how improving a system can be very rewarding even if the road to that improvement is exasperating. Clinically the year has taught me that I do get a lot of job satisfaction from managing the more acute side of medicine, but also that I love seeing the progression of an acutely ill patient to someone walking off of the ward.
As we approach the end of our time in rural Zululand, mixed emotions abound. There is obviously excitement to see loved ones again and to be back in a country where things actually work. However, 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 (no cows in the High Street in Bristol), the musicality, the laughter, the sheer lovable, frustrating insanity of this place. I will also breathe a little sigh of relief that I don’t have to face all this woeful misery of a harsh land. In the same breath I salute those that have the strength to have dedicated their lives to this place.
People of the Sky
In a harsh land under an African sun
Bones protrude where flesh should run
Sits a place that works, but works not well
People of the sky, it is here you fell
So unready for your name marked holes
Lie these forty brave Zulu souls
Through your sunken eyes, a hopeless look
You face this plague and the lives it took
Upon your feverish skin laid bare
Nurses hands do their best to care
Though to save you we try, try and try
We watch your broken generation wait to die.
Global Health Reflections of a Core Medical Trainee
Excitement, and apprehension were the overriding feelings that I felt when I said goodbye to my family and friends, and boarded my flight at Heathrow. “Am I up to this?”, I repeatedly asked myself, “have I got it in me?”. I was fresh out of Core Medical Training in the UK, and was qualified to take up the mantle as a Medical Registrar and begin my training to become a Gastroenterologist. The problem is that I wasn’t ready. Yes, I was capable and equipped with the knowledge and skills, but I was also fatigued by the discontent within the NHS, and needed a different kind of challenge; one that would reignite my passion for medicine and remind me why I chose it as a career. But as the tyres hit the tarmac in Durban, that knot of nervousness in the pit of my stomach grew tighter. What was I doing? Was this all a big mistake?
The landscape changed dramatically on the 5-and-a-half-hour journey North. As I moved away from the dizzy heights of commercialised Durban, the roads became pot-holed and lined with cattle, the guarded, gated mansions reduced to reed-roofed clay huts and everything became just that little bit less shiny and polished. And then, suddenly, just before the border post with Southern Mozambique, I arrived at the dusty town of Manguzi, and its 280-bed rural hospital, which would become my home for the next year.
Work in Manguzi started at 0730 with a handover meeting. That is where I met the mixture of South African, European and British doctors that I would be working with. They seemed kind, and grateful to have more hands available. I just hoped my hands would be more help than hindrance.
After a short induction, I was placed in the Outpatient Department, which was essentially a combination of outpatients and A+E. The attitude was one of, “get on with it, ask questions, and learn as you go”, which differs hugely from the supervising shroud provided by training in the NHS. And so, with the help of KP, a wonderfully vibrant and gold toothed interpreter who would call me “Gooorrrrggggeous!!” for the rest of the year(!), I took a deep breath and saw my first patient. I was at the start of an exponential learning curve of practising medicine in a new country and culture, with a different demographic and language, and an entirely unfamiliar range of pathologies and treatments.
Of course there were things that I found particularly difficult, namely paediatrics, neonates and obstetrics. But how could I not learn to treat the stunted 8-year olds who came in with disseminated TB? Or the malnourished babies, illegally brought through the Mozambique border fence, septic from an umbilical cord cut with a dirty blade? Or the 15-year-old girls, booking their pregnancy at 30 weeks, with a new diagnosis of HIV and a positive Syphilis test? I did my best, asked hundreds of questions, and my confidence and competence slowly grew.
After a month, I was given the role of running the male medical unit, a 32 bed ward, with crumbling paintwork, stained mattresses and a demonstrable lack of curtains and privacy. My patients aged from 12 upwards and were usually ravaged by the effects of poverty, HIV and TB. On the whole, South African doctors preferred the excitement of surgery, obstetrics and paediatrics, and thus the medical wards were often considered of secondary importance and, at times in the past, had been woefully neglected. I wanted to change that and use my medical background to fight for these shadows of men and give them the best chance of survival, or at least provide them with a comfortable and dignified death.
It was hard, but I loved every moment of it. I went in to work early, sometimes starting my ward round at 6am, and leaving after 8pm. The 4 hours of ward-time allocated on my rota was simply not enough to provide optimal care. But each dawn and dusk, the beautiful harmonies of the nurses’ hymns soared through the corridors of the hospital and somehow soothed my stresses. My passion and drive were shared by my team of nurses and allied care professionals, and together, we strived to make a difference.
With time I became adept at starting and changing HIV regimens, dealing with horrific liver injuries induced by toxic medications and treating patients with Malaria, to name but a few. I made friends with the doctors in tertiary centres, which allowed me to successfully refer patients for specialist treatment. At times there were frustrations, however. Arranging an urgent CT scan was almost impossible, and even when accepted, the under-resourced ambulance service was often unable to transfer the patient in time. We frequently ran out of essential medications, and decisions about whether to transfuse a patient were influenced by the amount of blood (if any) available.
It was incredibly humbling how my patients, even when they were weak and barely able to speak, would grab my hand, smile and thank me for what I was doing. They did not complain about the lack of curtains, leaky ceilings or uncomfortable beds. I wished I could have done more for so many of them. They did not deserve such a premature end to their lives.
There was great sadness in the job but we had many triumphs as well. One particular patient, in his 20s was brought in on the back of a truck, unable to stand or talk because he was so weak, suppressed by HIV and the consequence of non-compliance with medication. He was dying. But I treated his sepsis, DIC and renal failure, I changed his HIV medications and I transferred him for drainage of the psoas abscess that had made him so sick. I saw him, a month or so later, in the OPD and barely recognised him. He was 10kg heavier and well. He threw his arms around my neck and cried, “Thank you Docotella”. He was one of many patients who will stick with me. One more success story. One more victory.
As well as my ward duties, I alternated between the main OPD, the MDR TB and HIV clinic and psychiatry clinic, which added variety to each day. The psychiatry was particularly interesting as I had to differentiate between genuine mania or psychosis and the ingrained traditional beliefs of the local tribal communities. I also had to manage the effects of drug and alcohol addiction, that unsurprisingly featured strongly in Manguzi, where unemployment was rife.
Summer came and the heat and humidity were all-consuming. There were no fans or air-conditioning on my ward, but however unpleasant it was for me, I knew that it was 100 times worse for my patients. I carried on regardless, doing those lumbar punctures for cryptococcal meningitis and surgical chest drains for TB effusions, even though I was drenched and exhausted. I did it because I wanted, so much, to help my patients.
My colleagues soon became my best friends and makeshift family. We spent weekends exploring the mountains, beaches and game reserves of South Africa, becoming acquainted with its idiosyncrasies and hidden gems. We also supported one another when things got tough. When the taps ran dry, and the electricity and signal went down for days on end, we were still having the time of our lives.
The last few months went by in a daze and suddenly my time in Manguzi was coming to an end and I had to pass the medical reins to another Global Health Fellow. The cramped bungalow, with the holes in the ceiling that reduced me to tears when I arrived, had become my home. The gaps in knowledge and poise, that had worried me so much before arriving, were a thing of distant memory. I was returning to the UK a refreshed and better doctor, and a more rounded human. I cried as I drove through the gates and waved to the security guards for the final time. “Hamba Kahle Manguzi. For now, at least”.
"My OOPE was arranged through the Severn deanery with the help of Africa Healthcare Placements (AHP). I was placed in Mseleni Hospital, near the Mozambique border.
I was part of a team of approximately 15 doctors who were charged with caring for a 150-bedded hospital, as well as running a busy OPD and weekly peripheral clinics. The rota was very intense and getting to know the nurses and the local culture was challenging. Fortunately, we were extremely well supported by brilliant senior colleagues, who were always approachable. I was given responsibility of one of the outreach clinics, in an area called Mnoqobokazi. I found this to be the most interesting aspect of the whole experience, as it was most similar to general practice. Engaging patient’s health beliefs and trying to encourage them to take responsibility for their own health was both challenging and enjoyable.
The most difficult aspect of the year, was doing shifts in labour ward, and being on call for 24 hours. The 24-hour shift was done weekly, where one would cover the wards, and OPD alone overnight, having worked the day previously. This was both stressful and terrifying, and yet has improved my clinical decision making, and helped me grow as an individual and doctor.
The hospital provided us with many learning opportunities. This included weekly teaching sessions, and responsibilities for specialist clinics. I shared the psychiatry clinic, and with input of the psychologist learnt how to manage acutely aggressive psychotic patients.
There was a lot of time to explore the local area. It is rich in game reserves, and the local wildlife was beautiful. The beaches were pristine and were a good place to relax with friends after a long day’s work.
I would encourage any young doctor looking to work abroad to take the opportunity of a global health fellowship, I feel it has enhanced my professionalism, ability to make decisions and use of resources. All of which is vital in general practice."