Survived my first on-call – just!

Sorry this is a bit later than planed but I am writing on Sunday evening to say that I somehow made it through my 28.5 hr on-call which started on Thursday morning at 7.30am. I must admit that I was quite anxious about it. I remember working in A+E at Warwick Hospital last December when the staff grade doctor I was working with was useless and slept all night and I was the only doctor working from midnight to seven am in A+E. At the time, I thought it was crazy but now I look back at that quite fondly as I was the only doctor at Mosvold Hospital from 5.00pm on Thursday until 8:00am on Friday. Unsurprisingly, I was somewhat terrified. (There is a second on-call but the general principle is that they only come in if there is a caesarean section to carry out or another surgical procedure).

So, how did it go? Well, the first few hours of the on-call were spent in the outpatient department (OPD) - this is the equivalent of combining the UK emergency department, outpatients department and general practice into one. Two of the South African doctors we are working with have been trying to introduce a triage system but often the order of the patients is decided by the Zulus themselves not on clinical need (this is done in a very ordered happy way – it seems). So, not only am I the only doctor in the hospital but there is also no X-ray or pharmacy services from 4:30pm onwards and so you end up completely relying on your clinical skills. I can’t remember all my OPD cases for the evening but remember a few. (Only read on if you don’t mind medical stories)

One of my patients was a 32 year old woman who was very sick. She had HIV (but was not on antiretroviral drugs – ARVs - yet) and had completed her TB treatment last month. Unfortunately, arterial blood gases (an easy way of seeing how sick someone is) are not available and there is one pulse oximeter (a simple way of checking oxygen levels) but it was playing up. I decided she had a pneumonia and treated her as such – although I was not sure she would make it through the night. The antibiotics that are used here at Mosvold are different to those in the UK. Her blood tests came back and her kidney function tests were the worst I had ever seen. I was pleased to see that she survived until at least Friday!

When I returned to my OPD room (I move between OPD and the RU (resuscitation unit)), I found a patient lying on my couch. This happens a lot here which I find quite odd but also amusing. I understand why patients sneak into consultation rooms as they wait hours to see a doctor but still have not yet got used to it. In the UK, this would most likely be a drunk who had collapsed on your couch but here in Ingwavuma, I have not yet found one alcoholic (I am sure they exist) or someone smelling of alcohol. Anyway, he too had HIV but his CD4 count (the test we do to see if they need ARVs) was too high and so was not eligible for treatment. He had severe D+V (diarrhoea and vomiting) so I gave him lots of fluids which seemed to do the trick!

After seeing a good seven patients or so, I was feeling hungry and Henry had kindly made us spaghetti bolognese (Henry is determined to have meat five days a week which is something that might prove difficult given Spar – our only supermarket – has a random selection of meats). It was delicious but I was only able to enjoy it for 20 minutes before the on-call cell phone went off again. It was the paediatric ward – a baby had stopped breathing. I ran as fast as I could from our house to the paeds ward (less than five minutes) and found a 10 month old with no pulse or respiratory effort. I immediately started paediatric life support but it was futile. The baby looked dead. I asked the nurses to phone the second on-call doctor (who was in charge of the paediatric ward) but he told me over the phone that the baby was very sick – he had come in with pneumonia from a hospital near us which is on strike (more on the strikes in another blog). I continued for another few minutes and then confirmed death. I felt very sad. I broke the bad news to the mum who started wailing and my eyes welled up. I did not say much except how sorry I was. I also suggested that she came to see her daughter and hold her in her arms. I was involved in two resuscitations in the UK during my paediatric job (both with an unsuccessful outcome) but my experience here was so different. In the UK, you continue for an hour or two and there are many doctors around. On Thursday night, I was alone and no one particularly tried very hard. The nurses and second on-call doctor had seen it so many times before and new the attempt would be pointless. I phoned Henry who kindly brought me a cup of tea to OPD and continued seeing patients.

A sixteen year old girl came in with her left eye covered up with a gauze bandage. The story was that the patient’s sister put a stick in her eye by mistake. As I took off the bandage, I was worried what I was going to see. I was relieved to see that her eye was fine. The area between her nasal bridge and eye were not – there was a hole. With my fingers, I tried to force the edges together but could not see how it would work. I decided to call Shabana – the other UK doctor who started with me last Monday. She kindly came in to assist me (I also wanted to see another doctor as had been working alone for the past six hours). She inserted the lidocaine (anaesthetic to numb the area before inserting stitches) but the wound started bleeding heavily. We could not stop it despite applying pressure. We phoned the second on-call doctor who said not to worry. All I could think of was if lidocaine entered the blood stream it would cause cardiac arrhythmias (and the patient could easily die). In the UK, I had been so careful when I injected lidocaine during a procedure and now this was all going so terribly wrong and all we had was one dodgy temperamental ECG machine. The bleeding did eventually stop and Shabana and I continued. It was by no means the best looking wound – the two stitches simply brought the edges together but a small hole remained. We both felt very bad as she was only sixteen and now her face was somewhat disfigured. She lodged overnight in the hospital and came back to see me on Friday morning in the OPD where her face looked much worse. It had swollen up and was quite badly bruised. My colleague reassured me it would all settle down and look much better when it healed on its own. The patient did not seem to be bothered but then again my Zulu is not good enough yet! I saw one more patient after the sixteen year old girl and then went home to sleep. It was past midnight and I was exhausted!

After twenty minutes in bed, I received a phone call from labour ward. A woman who had previously had five vaginal deliveries was in labour and the baby was distressed (there was meconium). It was 12:50 am and what I feared most – obstetrics – was my next job. I rushed to the labour ward to see more meconium than I thought was possible. I examined the mama (zulu for woman) and noted she was only 5-6 cm dilated. I asked the sister (who had way more experience than me) to also examine and she agreed the vagina was only 6cm dilated! Ummm – what to do. I knew the baby had to get out but was not sure the next move. I decided to wake up the second on-call doctor (I told him I would for anything obstetric as my experience was so limited given I have not worked in obs+gynae since medical school. One minute into our phone call, the sister came to see me to tell me that the baby had delivered and was doing well. I was amazed! I got off the phone and saw a baby crying. I was relieved. I then looked at the mother and noted she was bleeding. The sister was slowly pulling out the placenta (which was intact) but the mama kept on bleeding. I thought to myself – this is what they call a post partum haemorrhage. I quickly asked the nurses to get another big cannula in (IV line) and gave her lots of fluids to bring up her blood pressure. I also gave her a few drugs to stop the bleeding but nothing was working and the blood kept on pouring. There was only one option – to bring the mama to theatre! I phoned the second on-call and he came in. He assessed her and agreed that we needed to go to theatre and stop the bleeding. At 2.30am, I acted up as anaesthetist (third time as had previously done so twice earlier in theatre) and administered ketamine, fentanyl and midazelam as the second on-call tried to stop the bleeding. He found many tears in the vaginal wall (this is what happens if you go from 6 cm to delivery in a couple of minutes) and sewed them up. It took quite some time and I felt tired. Eventually, the patient stopped bleeding and I was hoping to go back to bed. The second on-call doctor certainly was. However, I received a phone call as I was leaving theatre to say that there was a complicated case in OPD.

Sadly, it was an 11 year old girl who had been raped. She was with her mother and had been to the police station. (I had received a phone call earlier in the evening from a nurse in a clinic who asked me what happens in these cases – I explained the girl had to go to the police station and then come to the hospital). I started my consultation with the girl but she was very upset and it didn’t feel appropriate. I thought it was best to let the girl sleep and see her in a few hours time after we both had some sleep. I went to bed and managed to sleep on and off for three hours (I received a few phone calls but was able to manage the cases over the phone). I then headed back to OPD and continued where I left off with the rape case. Rape cases are taken very seriously in SA (as they should be) and take approximately two hours to sort out. We need to gather all the evidence and conduct a complete physical exam which I find hard. I also started the girl on ARVs, three different types of antibiotics as well as some analgesia. I finished the case and headed for tea at 10am.

I then continued until 1:15 pm in OPD and was relieved to finish my shift! Without doubt, it was the hardest thing I have done professionally but I am sure there will be many more challenging shifts to come. I was happy I survived my first on-call and decided I deserved a lunch at a place I had heard about called Fancy Stitch (I think this is the only place to eat out in Ingwavuma – more about this relaxing incredible place in another blog). I phoned one of our new friends up called Kelly (South African who teaches at a nearby school but schools are not open at the moment as they are on strike) and we enjoyed lunch together. They have the most wonderful milkshakes. I am already looking forward to many more! I then came back to our house and we packed for our first weekend away to Tembe Elephant Park! We had the most lovely time which Henry or I will write about tomorrow. But for now, I am tired and about to go to bed. Goodnight and hope you had a nice weekend.

Love M