It has been a long time since we posted our first blog from South Africa and much has happened since then.
Hospital Stuff
As you know when I first arrived in South Africa I did a crash course in Obstetrics at a big Maternity Hospital in Empangeni, about 45 minutes North of Eshowe. I primarily did c- sections and ward rounds as orientation to the hospital system. I started work at Eshowe Hospital in July and worked less than 2 week before I was informed that my registration was incomplete and I should not work. Days later the South African Health Counsel (HPCSA) went on strike and I waited for 3 weeks until the strike was over to finalize my paperwork. By that time my shaky confidence in surgical obstetrics had waned. I have now been back to work for an eventful 2 weeks and have had no terrible mishaps. Will need to spend a lot more time working to really feel comfortable in my “new profession”.
I am in the Obstetrics and Gynecology department with three other doctors; two are community service doctors who have completed 1 year of internship, the other is a Congolese doctor who is a medical officer which means he’s had no specialty training. I spend most days in clinic where I see patients for prenatal care and all problems female. The only medical records are kept by the patients and they are very good about bringing them for their appointments. We all take turns rounding on the wards (antenatal, postnatal and labor) and being on call for labor ward, emergencies and elective c-sections.
The concept of – See one, Do one, Teach one is definitely in effect here!! Last week I examined a 40 yo HIV positive woman who presented in labor. On exam I found the baby was breech ( the head is up instead of down in the pelvis) and had a cord presentation (the umbilical cord was at the opening of the uterus which can then come out first and the baby will no longer have a blood supply). I took her to the operating room for a c-section and both mom and baby are well. Hypertension in pregnancy, pre-eclampsia, and eclampsia are very common in South Africa and often require c-section. I also do D&C for pregnancy loss. This week, I had a patient who came in 4 days after delivering a dead baby at home with sepsis and endometritis. She is also doing well after D&C and antibiotics.
Vaginal deliveries are done by mid-wives; the doctor is only called if there is a problem. Women are given no pain medications, all first time moms get a lateral episiotomy which is sutured with not very much local anesthetic. I’ve seen nurses smack patients when they don’t follow instructions and push down on the abdomen if the mom is having a hard time pushing the baby out. I can’t refrain from telling the nurses to stop!
Fortunately for me, Eshowe hospital has had NO maternal deaths this year and the c-section rate is hovering around 20%. GREAT statistics for this country. The Maternity hospital in Empangeni, which gets all the very high risk patients, has 2-3 maternal deaths a week, primarily from non pregnancy related medical causes and a c-section rate of about 50-60%. HIV is the leading cause of death in this country!!
I think it is odd and certainly not the US model of medicine that patients are cared for by doctors with so little experience in the specialty. If a patient doesn’t follow the usual course of a pregnancy or an illness there are few doctors or hospital facilities in this country up for the challenge and the outcome is often bad. I’ve learned that the model of medicine in South Africa is that all doctors learn the basics of the core specialties – Medicine, Surgery, Obstetrics, Pediatrics and Anesthesia. They are able to care for the majority of patients that present and some patients (a much higher proportion than in the US) die of preventable illness due to the country wide lack of a higher level of care. The US has the opposite problem -- many specialists and super specialists and not enough primary care providers. This is how I get to do Obstetrics without formal specialty training, as a c-section is considered a basic skill that interns master along with pediatrics, spinal and general anesthesia and basic surgery. After working with an Ob in Seattle, I’ve done more vaginal deliveries and scrubbed into more c-sections than the community service doctor who is doing obstetrics with me. I on the other hand don’t even have the basics of anesthesia, peds or surgery. There is much to learn if I am going to fit in with the African model of medicine.
Housing
Short synopsis is our housing situation is not good and we will be much happier when we find another place to live. Not so easy in a small town with very few rentals and no furnished housing. Rentals do not even come with a stove or a refrigerator. We may move to Mtzuni, a small town nearby with more options and a beautiful beach and nature reserve. It will be a much nice place to host guests. Will keep you posted.
Strikes
I have heard about the strikes in South Africa. Last year the nursing staff went on strike and there was no one left to take care of the patients in the hospitals or clinics. The HPCSA went on strike last month delaying my registration. This past week the municipal workers went on strike, vandalized the water pipes so the town including the hospital had NO hot water and very low cold water pressure, enough to drink but not enough to flush the toilet. They also dumped garbage all over the main street of the town. Apparently this is strike season. It seems fairly usual for the government to offer a 6-8% raise when the workers are asking for 18-20% and havoc ensues until the median is reached.
