Strike two

The Greek philosopher Heraclitus supposedly once said ‘War is the father of all and the king of all’. He believed in perpetual change ‘nothing ever is, everything is becoming’. He might have used Zithulele as the exemplar of his thesis. Continual change is the watchword and it is perpetually like wartime.

Our pharmacy supplies are starting to trickle through and the drug charts at the end of the patients’ beds now more often have medication signed for and given rather than bearing the OOS (out of stock) acronym, which was becoming worryingly common. Many drugs like Ciprofloxacin and Diazepam however are still absent.

The excellent news is that injectable antibiotics are back in stock.

The anti HIV drug Efavirenz has been at critical levels. All patients on anti HIV drugs in which Efavirenz is part of the combination (which is the majority of the 3,000 patients receiving therapy here) are going to be at risk of failing treatment. The virus will potentially also develop resistance to the other two drugs they are on with Efavirenz and all three then become ineffective. If it does run out a rapid and potentially risky switching of regimes will have to occur; a large and very undesirable exercise, medically and logistically.
As an amusing aside, in training patients to take their HIV medication they are expected to remember the names of their pills. The fact that many Xhosa words begin with ‘I’, especially borrowed words (ibhokisi – box, ibhasi – bus, ikeyiki – cake) means that the name Efavirenz has mutated into iFiveRands.

Mo the indefatigable (and eternally cheerful) pharmacist, another hero of the conflict, tells us today that intravenous fluids are going to be tight since the depot only sent one twentieth of the order she had requested.

Despite this there is a cautious degree of relaxation around as the resources filter back. Just like wartime there are rumours of larger change at higher levels which foster some hope in the long term; not just long overdue peace talks but structural change to the system. It’ll all be over by Christmas – as they said about World War One…..

On the ground strikes are still ongoing at Mthatha, and the conflict has spread to my friend Amy’s hospital in Bizana where the nurses are also up in arms about money. Amy now has a single nurse on her ward and nothing gets done after 4pm. The sum of salary money involved is something like £50. Yet for this, peoples’ principles of care for the sick turn out to have the durability of tissue paper in a monsoon.

At Zithulele the nurses are working normally. Like nurses everywhere there are grades of commitment and excellence. Some feel that seniority brings with it an absolute right not to get physically involved in patient care. There is nothing unique about this; nursing staff worldwide include those who from the start are wannabee managers. I have sympathy with not wanting to do heavy lifting of patients as the years pass. The attitude of some that it is unacceptable soiling of their hands to do, or even contribute to, hands-on dealings with patients, because that should be done by their juniors, leaves me sad at the arrogance and loss of perspective. Although there are similarities between here and Cambridge, my nursing colleagues in Addenbrooke’s don’t have the same level of concern with their own dignity that I see here, nor do they revel quite so much in hierarchical self-importance. One nurse in maternity here was busy on the phone and declined the request from the doctor to get the urgently needed oxygen during a desperate resuscitation of a baby; to do this being clearly below her station.

I digress. The latest ‘carers’ to get the industrial action bug are the ambulance crews.

At its best this service is unreliable, hopelessly unpunctual and frustrating. To transfer a patient to another hospital one has to phone the ambulance service directly; something only the referring doctor is permitted to do. It can take literally hours to get through. You are obliged to provide vast amounts of information about the patient that you want transported, and about yourself. They take your cell phone number and the phone number of the doctor to whom you are sending the patient so that they can ring that person to check they are expecting them.

I am all for double checking but there are few jobs less replete with satisfaction here than ordering an ambulance, so why I would deliberately do it for a referral that was fraudulent is beyond me. Why would I want to send a patient whose interests I am trying to advance on a fruitless trip up the N2 to a Consultant who didn’t want to see them? I have far better ways of spending my daylight hours than making fake bookings.

After having made the booking (not to mention the number of times the line goes dead or the ambulance control phone reception decide they need to tell their life story to a passing friend while you are holding), after that there is still a sporting chance that nothing will arrive; frustration for us, frustration for the receiving team, and an appalling way of treating someone who needs help.

One day last week I had spent a goodly part of the afternoon negotiating with the ambulance ‘control’ (hollow laughter) centre and had finally confirmed that one would arrive the next day to take a patient with a gangrenous toe to the vascular surgeon at Mthatha. After a few tries I have learned that one must ask the name of the person you are speaking to. They don’t like giving it out, since a request cannot then be conveniently or carelessly lost anonymously, there is now a named person responsible. Taking their name and saying thank you and that you are writing in the notes that so and so has confirmed the ambulance will arrive seems to raise the concentration level a little.

In spite of this precaution, no transport arrived the following day. I phoned the control centre again and after an initial brushoff got more attention when I mentioned the name of the person who had taken the booking. There was much fluttering in the dovecotes and a promise to ring me back when they had traced where the request had got to. Remarkably within 10 minutes I got a call to say an ambulance was on its way.

Said vehicle arrived at 10.30 am and two young male ambulance staff swaggered on to the ward, took one look at the patient and said he didn’t need an ambulance. Anyway, they added, the surgical clinic closes at 11 so we can’t get him there in time. At this the nursing sister, Sister Kakele, who for me rates amongst the best nurses I have ever worked with anywhere, let off a stream of invective in Xhosa which had them reeling as though tongues of fire were licking over their naked flesh. I took a step back myself. This charming, superbly competent, quietly spoken mature lady with a gentle, slightly mischievous smile had metamorphosed into a latter day Boadicea and was at them on her chariot, scythed wheels whirling furiously. One of them made a brief and ill-advised attempt at a rebuttal and she merely turned up the volume and speed of delivery and he retreated, a withered charred shadow.

I decided to leave the carnage and went out to phone the relevant Consultant, a delightful man. I said the ambulance had said his clinic closed at 11. He was incredulous ‘They are talking nonsense’ he said (‘talking nonsense’ is a big insult locally as it hits the red dignity button squarely).

I returned to the ward to find the patient being meekly shepherded out by the ambulance crew. It was barely necessary to add my information, but I did for good measure, and it prompted a further furious tirade from Sister Kakele.

The two ambulance staff with the patient in a wheelchair disappeared down the corridor, tails between their legs, followed by a final stream of fiery advice from the Sister. I would love to have understood even half of it. My guess is that those two won’t want to come back to Zithulele.

They certainly won’t be back anytime soon as they are now on strike and we are without ambulances. Helicopters can be called for vitally urgent cases but other than that if our own patient transport vehicle is full then no one can get a ride to Mthatha without paying and we can send no urgent cases there such as acute appendicitis, road accidents, acute brain haemorrhage etc.

It is remiss of me not to have mentioned before now that we have no X-rays. This has been the case for the last three weeks. A replacement part for our machine has to come from Japan apparently and the situation wasn’t helped by a missed or inadequate service, I forget which.

When it is in operation the X-ray department is a hub of activity. At any one time you can meet one, two or more of your colleagues there perusing the films of their latest patient. Without it we rely entirely on clinical examination. Chest examination is doable without X-rays (note to students – never forget vocal fremitus, it can be critical). Suspected limb fractures are trickier. Abdominal distension due to intestinal obstruction, when it next occurs, will be a challenge since we can’t get a radiological diagnosis – but we can’t send anyone to the referral hospital anyway.

It is predicted that we will be without a functioning X-ray machine for another 4-6 weeks, so I may have seen my last Zithulele X-ray.

It is odd and somehow alarming how one just adapts to not having a facility whose temporary absence from a UK hospital would provoke expressions of amazed disbelief and a complete shutdown of clinical activity.

At least the pathology lab has been working – until this morning when the computer went down. Samples can be sent but no results from the last 48 hours are available. The result of the lumbar puncture I prided myself in doing last night in the patient in whom I suspected meningitis, and from whom the spinal fluid did not look normal, is as inaccessible to me as if I hadn’t done it.

The only choice is to treat with intravenous ‘domestos’, a combination of drugs which will treat all the probable causative infections.

Luckily injectable antibiotics are back in stock

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