Breaking Point

It was a cold day in Durban. Sixteen degrees Celsius is cold for us on the East Coast of sub-tropical Africa. 

I had made a trip through the suburbs to drop something off for my theatre scrub sister.  The roadblocks are manned by community commandos, most of who are my patients and it’s easy to pass through. 

On the way back to the hospital I passed a que of cars more than two kilometres long. They were on the road to the Galleria Mall or maybe just the filling station. There was an air of dejection and desperation hanging over the cars waiting. Ordinary South Africans waiting to get food or petrol. I was disheartened to see lone drivers trying to push into the que of orderly people.

I parked at the hospital. The doctors parking area was at about 30% full today. The last few days it has been at 10%. The faster cars don’t seem to be able to make it to the hospital.

I walked from the parkade toward the tunnel that goes under the medical centre to the hospital. I hate wearing only scrubs in winter. It is way too cold for sleeveless bravery. A striking young woman caught my eye as I laboured through messages on my phone. She was bald, well dressed and made up. Vibrant. No hair.

She was clutching a form and stopped me.

“Excuse me, is Ampath closed?”

Trying to wrestle my attention away from the little screen, I stopped to talk to her. “Yes, we didn’t have any lab service yesterday, and today we have one technician for the whole hospital. I am sorry” the famous South African refrain. “The lab is closed. Why?”

I glanced at the laboratory request form in her hand. In orthopaedics we keep it simple and don’t really ask for all the  tests after which  Elon Musk might name his children. This list was for things that scared me. Cancer markers.

“I need to have these tests before my chemotherapy tomorrow…”

I felt like crying and giving her a hug. Neither were an option. So I excused myself while I scrolled through my messages looking for something about laboratory closures and openings. In the end I called one of the doctors who knew how to work the system. In seconds my unknown patient took a photo of my screen and left to get her blood tests done in the nearby industrial area. 

I went into my office. It is a safe place that is more of an art gallery than a doctors room. That’s the way I like it. We have been closed to the public all week. I am not sure I like that. I had the tedious job of completing a report of a patient whose lawyer was suing the province for negligence. In this case there was no negligence. She just had bad luck. 

Instead of going home I went and did rounds in the hospital. Not the surgeon rounds where I check a patient’s limb  and movement. A round where I chatted to nurses and tried to understand their issues.

I ended up in the trauma unit. Luckily the first patient I saw had an undisplaced fracture of the wrist and I knew what to do. I showed a keen student how to apply a cast and explained the care to the patient, the father of a neurologist in another city.

Then they called me to see another patient. I am not an experienced general doctor. I decided soon in my training, after realising internal medicine was not for me, that I would concentrate my energies on the simple and straightforward subject related to bones. This lady was bleeding from her flank. I could see the bump on her tummy that meant she was pregnant. She was stable, fortunately. Her abdomen was soft and it seemed she and the five month old foetus had escaped major injury. I numbed the bullet wound with local anaesthetic to relieve her pain. The student put up a drip. I called the obstetrician and general surgeon. Their movements were hampered by riots. The patient was admitted to the maternity ward where the loving maternity nurses would care for her.

My day ended with humanising visits to friends to feed me and charge my emotional batteries.

I am very blessed to have such friends and to be associated with a medical team that cares so much. But we are all at breaking point. Remember that.

Baptism on Durban beach… praying for the rebirth of South Africa.

Another Stray Bullet

I had an uneasy weekend.

One the one hand I was watching the Covid-19 figures around the country and in my region of KwaZulu-Natal. We are waiting for the third wave to hit our hospital. Last week we stopped planned surgeries and reviewed our planning and capacity to deal with the surge.

On the other hand I had been sunk by the images and reports of violent protests related to the imprisonment of our former president on the charge of contempt of court.

Last year the local provincial department of health closed my hospital following an early community outbreak of Covid-19. The bottom fell out of my practice. I had obliquely thought about the chances of this happening but the scenario where my patients would dry up and there would be no work seemed impossible. But it happened. I still don’t think that should happen to an orthopaedic surgeon, but it happened again this week.

I had a small case planned for surgery on Monday. The patient was supposed to have had the procedure three weeks ago but she tested positive for Covid-19 at the time so surgery was delayed. She remained asymptomatic and was booked for surgery on Monday without needing another test. There is a lesson in that for people and companies who expect a negative PCR Covid-19 test for return to work (or to attending mass parties or sports events) after a positive Covid test. My patient called the hospital early on Monday morning to cancel surgery as the road she needed to travel was blocked by protestors. Violent protestors. My adjective. I have seen the damage to the roads with my own eyes. I have been too scared to risk driving up to a protest. I want to keep safe.

I had consultations booked after my Monday morning surgery. As news filtered through the hospital group and patient grapevine ( I do not use social media), all my patients who were booked for consultation were postponed. The next day I decided to cancel all consultations for the week.

Monday was the start of my week of orthopaedic call for my community hospital. We are not a level one trauma unit so we deal with community accidents that often stay overnight and have planned surgery the next day. I don’t work at night except before Covid when I had big operating slates that took 12 or 14 hours to finish.

My first and only patient in my office on Monday was a local carpenter who had broken his toe while fishing the night before. He was a pleasant and polite man. He was very happy when I reduced the fracture under local aesthetic and sent him on his way.

Then I did a ward round. I have a patient who is lingering for medical reasons, but whose hip replacement is fine. Then I was called to see a new admission. At 830 am. A 24 year old smartly dressed lady who had been involved in a motor vehicle collision at 2 am earlier in the morning. Remember, we have a curfew from 9 pm to 4 am. So I asked why?

“I was at an after-tears funeral party”. I have an ounce of Irish blood in me, so I understood about wakes but was not in the mood.

“Were you drinking and driving?”

“I only had one drink.”

I examined her. She had minor injuries but needed a CT scan to exclude anything major. So I said we would book it and that I would order some standard blood tests.

“I will also do a blood alcohol level. I am asking you for your consent to do that.” She was stunned and said nothing, so I walked off.

An hour later the laboratory technician called to say the patient had refused the blood alcohol test. I did not need the result to know why she had the collision.

At home later on Monday afternoon I took two calls within thirty minutes of each other. The apologetic trauma doctor was referring a patient who was shot in the leg. And then another who was shot in the thumb. Stray bullets. They were both admitted on antibiotics and pain killers and had a Covid test. I made a few calls to book surgery for them the next day. No answer at the hospital. I called the manager.

“We don’t have staff. I don’t know when you can do them. All the other hospitals are in the same situation so we cannot refer out.”

I swore to myself. I was angry that I had to deal with a drunk funeral reveller and people shot by stray bullets. South Africa has a problem with stray dogs too, I thought to myself.

Then a general practitioner who is close to me called. His wife had just fallen and she had broken her wrist. It was deformed.

Normally I would say and organise at the same time: “Let’s get her admitted. Take her to the trauma unit. Get an x-ray. They can put a splint on and elevate it. She can have morphine overnight and I will operate in the morning.”

Instead I had to apologise. “We don’t have capacity at the moment. No-one has. Can you put a splint on her and keep her comfortable at home? If you need morphine call me and I will arrange with the night super. I am sorry”.

It was not even the end of the first day of the week and this is what had happened. My hospital has been closed again. Not by Covid, but by violent protests in a young African democracy that should have grown wiser by now.

Cheetah kill in the Kgalagadi. No stray bullet.