May in South Africa – last push for Comrades; pushed to my limits at work; and thoughts on law & order.

Life

The first week of May, I got in a midweek run with Sandra and Franco then sushi and drinks with them and Daniel. Franco had text me earlier in the day as he was still in work saying he was concerned he might be a bit late for running club. Running club! I was so proud to have made a club. Haha.

That weekend, I was down in East London to stay with Karen and her family and got in a couple of races and a long club run, as well as a lovely Sunday lunch at a lodge with ostrich and zebra roaming.

The following week was similar with a midweek evening at Sandra’s and a weekend in East London.

The third week followed the same pattern, but Sandra and I went to stay with one of her friends in Stutterheim Friday night and I did a new parkrun Saturday morning before brunch and a day of playing with the dogs in the sun and feeding the parrots at their parrot farm. We drove down to East London late for dinner and to join the third club run in as many weeks the next morning.

The fourth weekend, I was on call Friday and Sunday so just went to Mthatha Saturday in between to fit in a run. Franco joined me for the first half which helped the miles pass. I went to the gym for a swim and sports massage afterwards, probably my last visit as my 6 month membership is expiring on the 4th of June. One more midweek trip to Sandra’s for a run in the 5th week and then the calendar flicked over to June and my last month in Tsolo / last 10 days of run training until Comrades is done.

Law & Order

There were student riots again in Mthatha this month, something about fees or free accommodation. We drove through town just after the crowds had dissipated, with police having fired rubber bullets at the students and we found debris such as lumps of concrete scattered on the streets.

I had a patient recently attend casualty having been in a car accident. She was the passenger and her husband had been driving and hit a horse. A couple of days later, he came to me to fill in a J88 form. This is a form to document a medicolegal examination which is provided to the police usually when someone is assaulted or raped in order to add evidence to their allegation. I was confused as to the purpose of this form – who were they making an allegation or claim against? He had been driving and surely if she was blaming and claiming against him, he wouldn’t be so accommodating. It was explained they were claiming from the road accident fund. So tax payers money essentially. I expressed my confusion to the nurses afterwards as to how they could do this if he was at fault. Not to mention the poor injured/killed horse, the potential loss of income or only form of transport to the horse owner etc. I get that the horse shouldn’t be wandering in the road, but livestock on the main highways is normal here and why you need to drive carefully. The nurses said even if you crash your own car, you can claim and that “we get a lot of money from the RAF in this country”. Wow, no wonder people drive uninsured and like absolute hooligans when there is so little comeuppance and in fact reward for dangerous driving!

I read an article in an in-flight magazine on an internal flight from Mthatha to Johannesburg. It was written by an ex-pat, mocking her mother still living in the UK for her stress and concern over such trivial matters as people parking without permits or land borders. She implied it was ridiculous and petty compared to the things people have to worry about here, such as a man recently being doused in petrol and set alight in her neighbouring town. She talked about her South Africans are so good at coping in a crisis and during her time working in the NHS how many a time she heard cries of “get the South African doctor!” during an emergency. Well, I’ve worked in many UK A&E departments and never ever heard this. While South African doctors might have more experience with certain types of trauma, and here they are used to coping with different resource availability, I completely disagree with her sentiment and her writing of this piece. It was put in a magazine which will be mostly read by South Africans and makes a mockery of Brits for a start. But more importantly, do we want to become so comfortable with suffering and trauma that we’re great at coping in a crisis. Perhaps law and order, policing the small things is what stops escalation and such high rates of serious violent crime – the constant stream of sexual assault, shootings and stabbings which come through casualty here each evening, more common especially on a Friday than straightforward medical issues. I may be a stickler for rules, but this country in many respects has demonstrated itself to me to be almost lawless, with people getting away with tardiness, unauthorised absence, and murder. I read a quote recently which summed this up well: ‘The innocuous males way for the horrific’. I have seen so many horrifying things here, and heard many more horrifying stories of friends of friends being murdered, attacked, robbed and hijacked; and I am thankful for the law, order, peace and safety we have at home.

Work

Staff sickness in this hospital is rife. Both in terms of absence and also complaining. GMC good practice guidelines at home advise against treating friends and family, and colleagues would generally be considered to come under this bracket. But I am so regularly asked to consult with someone/prescribe antibiotics/authorise an xray/do an ultrasound for someone here. In the space of two days at the start of May, I was asked to sign off a repeat prescription for a relative; examine and order an xray for a painful shoulder; consulted for an allergic reaction to a hair dye for which she had already taken antihistamines and had resolved but she wanted steroids based on a photo of what it did look like; and asked to prescribe two medications from brand names written on a scrap of paper. One was a strong steroid cream which she was apparently using for ‘dark marks’ which turned out to be stretch Mark’s, and one was something she told me was for pimples, which on googling was a skin lightening cream. I declined to prescribe and she said she thought she had got the name wrong as that’s not what she wanted. I told her without knowing the actual name and what it was, it was impossible for me to prescribe. I advised she bring me the packet to see what she really needed but she never did come back to me, further evidence that she was after some dubious treatments and thought I’d just do a private prescription without checking and/or caring. Then an ambulance tech informed me he was feverish and had a sore throat. I advised he was here for an emergency patient transfer for a very sick patient and would need to be consulted properly in an appropriate context. Then the ward matron asked me for antibiotics. I asked why and she said for a fever. I said that’s not a reason for antibiotics- what symptoms of source of infection do you have, to which she told me runny nose, and again I declined. Antibiotic use here is rife and I’m scared about the consequences which will follow, such as an epidemic of resistance.

I have noticed some important communication points in the last couple lf months. ‘Aye’, which would universally be supposed to mean yes, actually means no. A non-committal ‘neh’ sound means yes. And being told someone ‘feels nothing isn’t cause for alarm as I first thought, worried about someone having reduced sensation and a spinal cord injury, but is a way of describing an absence of any complaints.

It’s been a tough couple of months, constantly covering 2-3 wards with doctors on leave and some leave periods overlapping. I’ve also had to go and help in maternity and done 4 caesareans this month taking my total up to 24.

There were a couple of times I was pushed too far. Once in outpatients, I called for the next patient and 10 patients rushed at once and tried to force through my doorway at once. I got up and told them all loudly to sit down. I tried to get on with seeing my one patient but they were all braying and complaining loudly in the waiting room about how this patient wasn’t next. I couldn’t hear myself think and had to go out and shout at them to be quiet or get out, I would see them one at a time, but with the noise they were making couldn’t and wouldn’t see anyone.

The following week, I was covering the surgical ward and encountered a nurse I hadn’t met before. We had visiting surgeons doing an operating list the next day, and one didn’t have a consent form signed. The nurse wanted me to do it, but aside from the matter of informed consent and it really should be the person doing the procedure or at least someone proficient in the operation to take consent, his outpatient file was missing so I didn’t even know the intended procedure. I tried to explain this but we were going round in circles and he was raising his voice, not understanding or not trying to understand my point, making out that I was being obstructive and unhelpful, and essentially trying to bully me into doing the consent form in front of 5 other nurses and 6 patients. I asked him if we could please discuss this outside. “Yes” he said, “go and discuss it”, and didn’t follow me out of the bay. He clearly thought I didn’t know what I was doing or talking about and and that I would speak to a colleague who would side with him. I called him into the office, explained the whole thing clearly and he still wouldn’t take it. I told him he was trying to bully me and I wouldn’t have it. Still, he didn’t back down. So I asked him what operation I would write and he waved his hand dismissively “it’s his face!”….oh yes, I will consent him for a ‘face operation’. He kept going on about “the patient” and when I said I wouldn’t accept his bullying, he started saying he was just trying to find out what we would do for the patient and the next steps. I had already stated this clearly several times but he just wouldn’t listen so I put my foot down and was firm but gave up. Later in the ward round, I went to the sharps bin and when I came back, I found the clinical associate students playing with my phone. When I walked in, they looked surprised and sheepish and put it down without saying a word. I picked up my papers and my phone and walked out, shut myself in the office and dealt with my referrals and discharge paperwork. One did come to apologise and they were just taking selfies but it was the behaviour they showed when I walked in which made it a bigger problem than if I’d just found the selfies on my phone later and been amused. And the fact I was already upset to the point I was shaking with anger and frustration at the bullying nurse. That afternoon I went to my own ward to finally start my own wardround and all the nursing staff were sat behind the desk. I wanted to start but noone made any moves to help or move out of my way for me to get behind the desk myself so I reached over to pick up the patient files, and in doing so knocked over a large box of condoms. Still, nobody moved to help, not even the man sat on that part of the desk who was surrounded by the condoms, so I picked them all up myself. This man really is one of the most unhelpful men I’ve ever met. I’ve previously asked for an emergency drug be given to a patient and it wasn’t available so someone called around to locate a supply on another ward and then he told me they had said I had to go and fetch it. Really? They said I had to fetch it rather than him? “Yes” he replied, “I’m useless”. It was as if he was annoyed and thought I thought he was useless. Well the thing is I don’t, but he was certainly acting it! Another day, he was sitting behind the desk, literally snoozing and I asked if he could please help me with something (a 30 second task for him), and the dramatic sigh he let out was white incredible, then he looked around obviously to see if there was someone else who could do it instead. I apologised and said I would look for someone else if he was very busy. The sarcasm went over his head, but he did get up and slowly come to help. That evening, my housemate (who only stays once or twice a month) was on call. She left to go and answer a call and text me saying “your 500g baby just demised. It felt like I was being blamed when really the prognosis was poor, and I had seen the baby just once earlier in the day when I was called in an emergency as the paediatric doctor wasn’t here and I had stabilised the baby. I played devil’s advocate to myself and thought perhaps I should reassure her that the prognosis was poor and there was nothing she could have done rather than assuming she was making a dig at me. Then she replied saying “great start to my on call”. Never mind Then, your evening ruined, so you decided to ruin mine too?

The next day, I was covering two wards only, but the two family medicine registrars were at their teaching in the afternoon so I had to cover those in the afternoon too. Someone else had called in sick so there was only one doctor on maternity and I had to go and do a caesarean mid morning. Afterwards, I was getting multiple calls from the same bully nurse on surgical ward with problems arising mostly from my instructions not having been followed and which hadn’t been raised with the ward doctor before he left (it turned out he hadn’t done his rounds that morning, but hadn’t told anyone so no-one had). Two days earlier, a patient had come from another hospital for a booked outpatient appointment at the monthly clinic run by visiting urologists, and the doctor he presented to admitted him to the ward as a lodger to wait. I’d seen him the previous day and said he just needed to go to outpatients in the morning, but they hadn’t sent him. Instead they had put up a drip and waited until afternoon to call the urologists and summon them to review a patient on the ward and then informed me the urologists needed a referral from me. I said they did not as the patient had already been referred by the other hospital and to take them to outpatients as that was the only reason they were here. Another call, the urologists had apparently refused to see him as he was now an inpatient so needed discussion. I said he’s not an inpatient and here for no other reason than this appointment. I said they did not need the urologists to come to the ward and just needed to take the patient to the outpatients department to be seen. Another call, the urologists had apparently sent him back and wanted me to go and talk to them. So I did and explained he was not an inpatient or acutely unwell, just lodging. They said fine and to send him to the outpatients department. Why the nurses didn’t explain this simple fact without drawing me into it, I don’t know. I went back to the ward and told the nurses to send him to outpatients and they refused saying they just had and he’d been sent back. I said I’d been to discuss and he was to go there and quickly as the doctors would be leaving soon and he would miss his long awaited appointment. They still refused. So I took the patient myself. Then I got called back again to speak to a relative who wanted his 20 something year old son (who wasnt sick but broke a bone when driving drunk) transferred to a tertiary hospital because he lived nearer to it. I tried to explain it wasn’t possible but he was insistent and refusing to listen to the reason or to the fact it really wasn’t my decision. The same nurse was sat there smirking and could really have explained this to the relative without involving me when I was by now covering 5 wards as the maternity doctor had left early too, and I still hadn’t started my own ward round. I then had them both going on and on at me, and I started to cry. When they finally released me, I walked straight to the CEOs office, as I was pushed to my limit and felt she needed to know the staffing levels and about this nurse’s attitude and that I just couldn’t do anything. But she wasn’t there. So I just got on with things. Several nurses pointed out I was being used an abused, people taking advantage of my conscience and that I will always be in work and on time, that I give an inch and people take a mile; and then one of the doctors said the same to my surprise, so the next day I resolved to put my foot down.

The next day, two people were on leave in addition to the two who were off for two weeks and the one on maternity leave. These leaves weren’t on the leave calendar or in the leave book and hadn’t been declared earlier in the week in order to help us plan. Then two more called in sick. One wasn’t a surprise to me as she’d said the previous day she’d be finding a reason not to come today to punish her colleague for taking a sick day the previous day, even though she knew, and I quote “Gush would suffer too”. (Indeed, she found an excuse as promised and took the whole of the next week off too.) Thankfully, the shortages were known early in the day so the workload was more evenly distributed than the previous day, and my day wasn’t as bad, but I did have to go and take over in casualty an hour early for my on call, and the person taking over from me arrived late with multiple sick patients arriving just as I was due to go so I got stuck there almost an hour late the next morning too.

Friday night on call in casualty was particularly horrible with two Caesars and to go and do the spinal for in between many stab victims including one with a deep abdominal wound and some unidentified abdominal viscera protruding from it as well as significant faecal matter; and someone who had been in a car accident with abnormal neurological examination and potential brain and/or spinal cord injury for whom I had to call the neurosurgical on call three times before I convinced her to accept transfer of the patient.

Something which has been irritating me during my on calls a lot but I haven’t previously talked about is the sense of urgency with which things are conveyed to me. I’ve been called to patients about ‘hiccups’ and find them in a state of peri-arrest, and get called to patients who are said to be peri-arrest when what they meant to tell me was the patient was already dead and not getting any more dead. In the UK, we are taught the SBAR system for referrals but here I will listen to someone listing 15 normal findings for a woman in labour, with me straining my ears to pick out the abnormal feature that has prompted them to call me (if indeed there is one). It’s particularly annoying because the mobile phone network is so bad so it’s difficult to here and if I need to go, I will always go so I wish they’d just tell me the pertinent points. Even when I’ve said I’m coming they often keep talking and talking, thereby delaying me coming.

I finish in female medical tomorrow (Friday 1st of June), and have just one month left in outpatients and casualty before I leave.

Training

30th April – 6th May

Monday: REST

Tuesday: REST / On call

Wednesday: 1 mile steady swim and sports massage.

Thursday: 6 mile run of 3 Sisson street hill reps with Sandra and Franco.

Friday: REST

Saturday: Diesel depot 15km race followed by Sunrise-on-sea parkrun.

Sunday: Oxford Striders long Sunday club run up to marathon distance with going back to fetch slower runners.

Total weekly mileage: 44.5m/72k

7-13th May

Monday: REST

Tuesday: 5km easy run around the hospital, supposed to be an hour but I got a call I’d been waiting for and had to go back into work, followed by 20 mins Yoga with Adriene video focusing on hamstrings.

Wednesday: 15 mins Yoga with Adriene video focusing on neck and shoulders in the morning, then 35 mins strength and conditioning plus 1000m easy swim in the evening.

Thursday: 3.7 mile run with Sandra in the morning. We did a warm up then 11 short hill reps alternating hard up/easy down and easy up/hard down. After work, I went back out for 5.2 easy miles with Sipho.

Friday: This morning was a struggle, mentally and physically. I forced myself to do 5km even though I couldn’t face a 5th lap of the hospital and just wiggled around back and for after 4 laps to get the last kilometre done.

Saturday: Sunrise on Sea parkrun plus jog there and back for 4.4 miles total. I was feeling strong but my shoe split open and my food made a bid for freedom out the side. It was slippery underfoot so I had to take care. My friend ran a PB for the course and I think I may not have been far off mine had I been able to go for it. Let’s hope I have enough Saturdays to be able to go back again.

Sunday: Oxford Striders long Sunday club run for 22 miles. I was over it by about 8 miles but I kept going. One man brought his dog and we later gained a second stray too. No amount of shooing would dissuade this keen runner and someone even picked him up and carried him off course to distract him from the other dog but he sprinted to catch up. He got bored and gave up when we stopped for water. And then at the next water stop, the dog who was legitimately with us had to have his protective boots put on as the weather was hearing up the roads. So cute. I neeeed a dog!

Total Weekly Mileage = 41.5m/67k

14-20th May

Monday: REST

Tuesday: 40 mins S&C as a full body circuit including 4 rounds of 14 exercises back to back with no rest.

Wednesday: 4.3 miles of warm up, 13 short hospital hill reps, and cool down with Sandra and Franco. The hill reps were alternately easy up/hard down and hard effort up/easy jog down except I did an extra hard down at the end and then an extra bonus rep which I kept pushing for so ended with quintuple hard.

Thursday: 5 miles easy hospital laps with Sipho.

Friday: REST

Saturday: Stutterheim Parkrun

Sunday: 18.6 mile / 30 km Oxford Striders long Sunday club run. I enjoyed this one much more than last week. It was a bit shorter and a straight out and back to incorporate some big hills.

Total weekly mileage: 31m/50k

21st-27th May

Monday: 4.6 miles easy with Sipho.

Tuesday: 6.7 miles as 2k warm up, 30 x 125m hill reps, half hard up and recovery down and half easy up with hard effort down and 1k cool down, plus back and for to the laundry room.

Wednesday: 30 mins stability and core circuit then 30 mins Yoga with Adriene.

Thursday: 3.1 miles easy run around the hospital.

Friday: On call but fitted in early morning run at the request of a doctor who has recently started working here. She spotted me running Thursday morning and asked if she could join me the next day, but then she couldn’t make it as she was on call and had to go to an emergency in maternity. So I did 4 miles, including 3 with Sipho.

Saturday: Long run day squeezed in between two on calls. I went to Mthatha and met Franco for 6.5 miles easy before he left for work and I did another 7.5 steady. It was a mile longer than planned but just as I was so close to finishing, I encountered some aggressive dogs so had to go the long way round.

Sunday: REST / On call

Total weekly mileage: 32.5m/52k

28th-31st May

Monday: 3 x 1 mile efforts around the hospital with 90 seconds rest between each.

Tuesday: 3.1 miles including 7 short hospital hill reps but maintadining even and continuous level of effort for the ups and downs. I started the run with Sandra but the rain was pouring and there was lightning so she went back, not wanting to risk getting a chest infection with her asthma, and I kept going for a short session but minimum 5k.

Wednesday: 4.3 miles including 2 long Sisson Street hill reps, again maintaining an even RPE for the ups and downs.

Thursday: REST

Planning on a parkrun and a 6-8 miler at the weekend, roster pending for a total weekly mileage of around 20 miles / 32 km.

Total monthly mileage = 160.5 m / 258 km.

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