Out of Programme Experience at Church of Scotland Hospital, Kwa-Zulu Natal, South Africa

By Stuart Winearls

Introduction

Working at Church of Scotland Hospital has been a fascinating, yet very demanding undertaking.  It has posed emotional, professional, and physical challenges.  It has placed me in a position of responsibility beyond which I had previously been exposed to, and required that I manage often complex problems in a very unfamiliar environment.  I have had to adapt my medical practice to a new setting, dealing with uncertainty, resource constraints and a high degree of autonomy combined with exposure to the full breadth of rural African medical presentations. 

I have divided this report into two sections.  Firstly, a descriptive narrative attempting to portray the setting and character of the place.  Secondly, I have reviewed some of the challenges and experiences that I encountered, reflecting upon how they have affected me and what I have learned.  This year has undoubtedly taught me a huge amount, though many of things I have learnt are hard to define or quantify.  It has been a very experiential form of learning.  Whilst technically and clinically I have definitely improved, I think it is my non-technical skills that have benefited the most.

South Africa, Kwa-Zulu Natal, Msinga and Church of Scotland Hospital

To understand the country and region to which we were sent I would suggest reading the book (in all it’s plain, brutal honesty) from which the following, rather long quotation is taken: My Traitors Heart by Rian Malan.

“The road to Msinga begins in white South Africa and runs for hours through neat and orderly white farmland, not so different in appearance to parts of central California.  Some ten miles beyond the last white town, you cross the border between the first and third worlds, between white South Africa and black Kwa-Zulu.  The border isn’t marked; there is no need.  You know you are coming into a different country a different world.  The white centreline vanishes and the road itself starts rearing and plunging, like a turbulent river rushing toward a waterfall.  The very mood of the landscape changes.  And then you round a bend, and the tar falls away beneath the wheels, and you are looking down into Africa, into a vast, sweltering valley strewn with broken hills, mud huts and tin roofed shanties.  From the rim of the escarpment it looks as though some mad God has taken a knife to the landscape, slashing ravines and gulleys into its red flesh and torturing its floor into rugged hills.  This is Msinga, a magisterial district in the self-governing homeland of Kwa-Zulu, place of the Zulus.  As white South Africa fell away behind me, the country grew barren and dusty. There were no fences.  Goats and cattle strayed into the road.  The deeper I drove into Msinga the worse it got: less grass, less hope, more goats and more hopeless black people sitting motionless as stones in the roadside dust.”

It was twenty years after this passage was written that we drove the same road to Msinga.  So much and so little has changed in this time.  Visually, add a new shiny shopping centre, a KFC, more houses and fewer shacks and you are not far off.  Democracy has swept in bringing hope for a better future and some badly needed infrastructure.  The wire fingers of electricity are snaking their way ever deeper into the district and more houses now have water.  The independent homeland of the Zulus is now part of the province of Kwa-Zulu Natal, in a free South Africa.  Yet corruption, apathy and incompetence continue to hamper the transformation of this dusty corner of South Africa.  We have an empty water tank sat on a hill whose pump is not connected to the grid, in a water crisis!  Sadly, the combined plague of TB/HIV ravages this poor district; it has some of the highest rates of TB/HIV in rural South Africa.  Children grow up with Gogo (Granny in English) as parents flee to the cities for work and a better life, or succumb young to TB/HIV.  There are high rates of interpersonal violence, often directed at women.  Alcohol, the break-up of traditional family social networks, old tribal family feuding, newer taxi violence, unsafe cars, bad roads and worse driving leads to this small area producing a significant trauma burden that also eats into society.  The maimed men obvious, the raped women hidden.  Yet in the face of all this adversity I have never been with a group of people who laugh so much, are so warm, who can weather any storm without even a shrug, and who can all, absolutely every one, sing so beautifully.

Within this district sits Church of Scotland Hospital (COSH), which is simultaneously the most frustrating and inspiring place to work.  The first cases of Extremely Drug Resistant Tuberculosis were isolated from its patients and it was one of the earliest places to provide HAART in rural South Africa.  It has an established link with Yale University Infectious Diseases department.  For a 350 bed hospital staffed by 15 doctors in a rural back water, it has produced some amazing research.  The true back bone of the hospital are two extremely dedicated, long serving South African physicians, Drs Moll & Eksteen.  One runs the TB wards, MDR hospital and a busy outpatient clinic.  The other runs the hospice, ARV clinic, staff clinic and much of the operative burden.  They are always busy but always willing to help.  They have fought the HIV epidemic from the beginning, through dark days of little or no treatment (the nearby forty bed hospice used to turn over weekly) to where we stand today.  They have a serenity in the face of adversity.  They patiently turn the wheels of change accepting that they move slowly.  It is as if they have seen the worst the world has to offer, so nothing can phase them.  When asked ‘How do cope with the insanity of the place?’, one replied “What you see is charcoal.  I have raged and fought so long that now I’m all burnt out.  But what keeps me going and here, is the patient in front of us”. 

The frustrations of COSH are enough to drive you to distraction.  The lack of water, the goats wandering through the wards, the lack of personal accountability, apathy and often sheer laziness of some staff.  You bring water containers to the ward for the dry days only to have them all stolen within a week.  A patient with an acute abdomen waits a day for an ambulance, yet the routine cases are taken!  Results, files, charts disappear into the ether.  You finally get a patient accepted for a specialist review that may save his life, only to have him miss the appointment.  ‘He stood in the wrong place so missed the transfer’, ‘the ambulance forgot him’, ‘he lost his letter’.  More usually just ‘he didn’t go’; no reason, no explanation, no accountability, no connection between personal responsibility and cause and effect.  On the day we arrived we were invited to sit in on a meeting concerning the late running of the outpatient department (OPD).  It started 40 minutes late and achieved almost nothing. OPD still runs late.

Perhaps the day that best illustrates the madness of Msinga is the day of the ‘Water Strike’. The water strike really started, or so the storey goes, in an election defeat.  The Inkatha Freedom Party (IFP) won the Umzinyathi municipality, the area in which we lived.  The ANC, who lost the municipality, control the whole province and unfortunately the water supply to our district.  They refuse to supply water trucks and even refuse to fill trucks bought by the municipality, to spite their rivals and create dissatisfaction with the IFP!  So the IFP municipality resorted to delivering dirty river water to those without taps or wells.  This being Africa and corruption rife, the water truck drivers started charging for delivering the water that they should have been delivering for free!  Costly, dirty, scarce water pushed the populous into action.

I understand their anger; after three weeks of dry taps we as a group of Doctors had to threaten to close the hospital before the water flowed again.  Now the story descends into hearsay.  Some locals (ANC men apparently) get wind of the tuckers scam, and incite a strike to protest against this dirty, expensive water.  So the reckless youth go out onto the street to strike.  The sensible folk stay at home and sigh.  The slight problem with this strike is that unemployment runs at 62%; it is hard to stop working when you don’t have a job.  However, you can stop everything else from working by burning tyres and stoning any car trying to cross the bridge.  A very aggressive, African version of the picket line.  

So our day begins, the Doctors meeting.  This is usually akin to a group therapy session meets a black comedy on a dysfunctional committee.  Somewhere to listen to bizarre edicts from ‘The District’ while the taps run dry and the hospital coffers are bare.  You also hear of some good saves, close shaves, and sad endings.  Today the mood was subdued.  The announcement of the day was that all roads to the hospital were blocked by the strikers and that no ambulances were being allowed in or out.  Looking out of the window you saw the normal calm African scene.  A thick trail of black tire smoke was the only hint of the menace occurring down the road.  As the meeting groaned on there was a flurry of gunshots.  This surprisingly didn’t interrupt the meeting.  It shook me a little, as my pregnant wife sat beside me.  What had she got us into?  Matron knocks, walks in, whispering to the Medical Manager, “Two gun shots in casualty”.  “Dr Mpiana do you minding sorting that out?” was his reply.   Another knock.  It’s Mpiana back, as calm as ever and in his gentle French Congolese accent “Erh perhaps could I borrow a little help downstairs please?”.  One stable shallow glancing gunshot torso, the other a through and through maxillary facial gunshot with a bloody airway and altered mental status.  He goes to sleep in a surprisingly controlled fashion whilst all hands are on deck.  Pressure bandages are applied.  His nose and his mouth are packed in an attempt to control the brisk bleeding.  He now waits.  In fact, he will wait 13 hours; 13 hours for a transfer (which itself will take three hours and require two ambulances after the first is stoned) to the hospital equipped to operate on him.  I have never had to liaise with the Police Chief (and he the angry mob), to transfer a patient before.

A ‘bystander’ some say.  ‘Just a protestor’, ‘One of the leaders of the protest’ say others.  ‘It was the police that shot him’; and so the rumours fly.  Whilst he waits, the Indian shops in town are looted, the police take pot shots from the station as the looters carry their spoils across the river.  One group managed a fridge!  Apart from the odd battered man, the day is quiet with occasional gunfire reminding one of the menacing disturbance just a hundred yards down the road.  One feels simultaneously safe in our compound yet also uneasy that we are hemmed in by this mob.  That night the hospital is eerily quiet, the populous blocked form arriving.  I finish clearing casualty by midnight; a personal record.  The next day is Pension Day.  A pause is called in the strike to allow Granny to collect her pension!  The day after there is again no water.

Experiences, challenges and reflections

Professionally, this year has been a very steep learning curve.  My job was to run the Male Medical Ward with on-calls covering either Casualty or being ‘Second-on’ covering the wards and giving the spinals for C-sections.  Casualty calls were pretty hectic often seeing 20+ patients overnight with a full day either side.  Being alone in casualty seeing everything from stab chests to severe Kwashiorkor, DKA to cryptococcal meningitis was a real challenge and has taught me to be adaptable, rely on my clinical skills and approach unfamiliar situations in a structured manner.

I have had to adapt to a very foreign medical landscape, treating conditions I had previously only read about and with any deficiency in my knowledge occasionally having very real and sadly fatal consequences.  I have had to manage situations at the limits of my competencies in an unfamiliar environment which was far from ideally set up to manage such situations. Tension pneumothorax by torch light, unresponsive status epilepticus in a paediatric trauma patient, some fairly scary massive haemorrhages and some quite unstable patients needing an anaesthetic, to suggest a few.  Being solely responsible for the care of 40 patients, many with stage 4 AIDS, trying to get them through their opportunistic infections, rehabilitation, and then to keep track of all of the patients coming back for follow up and review, has forced me to improve my time management and prioritisation skills.

It has been a sobering experience working in the midst of the TB/HIV epidemic.  To see young men ravaged by AIDS, wasting away or watching their last gasping breaths as PCP claims another victim.  In the absence of adequate diagnostic and therapeutic interventions, with little senior support, one feels impotent against this tide.  Your own shortcomings laid bare as you sign yet another death notification.  You are better than nothing but wish you knew more, could do more.  The harsh inequality of life presses down upon you.  However, the most emotionally draining aspect of this year has been the paediatric deaths and the rape cases.  Children dying of malnutrition, puffy, skin peeling, in a country where there is also such wealth was especially galling.  Man’s inhumanity to women has been shockingly common, often brutal and most upsettingly not infrequently directed at children.  It really saps at one’s emotional reserves.  I still struggle to know what to say to these poor women as you conduct the forensic medical examination.  I hope I was kind, professional and compassionate. 

I have also found this year physically quite exhausting.  The rota got tough when no replacements arrived for the departing South African Community Service doctors in December.  My ward was running at 40 + patients, 36 beds.  We went down to less doctors than wards at some points.  There was a constant requirement to be covering elsewhere, helping in casualty or theatre, whilst struggling to keep up with the flow into your own ward for which you were the only doctor.  Post on-call time off was rarely practical with the demands of the ward.  You really had to battle to get through casualty on calls as quickly as possible to get some sleep for tomorrow.  Now the staffing has improved again and it’s down to one 24 hour call a week.  I feel pleased that I could cope with the demands asked of me.  I think managing in this tiring and emotionally challenging environment has improved my mental resilience.  I understand that to continue to function, one has to compartmentalise.  Putting to one side in the short term something particularly upsetting to allow you to continue.  However, it is of vital importance to process them before they build up.  Talking and reflecting on them with loved ones is a vital escape valve, as is making the most of your rest time and breaks to recharge your batteries.  I think it is also important to analyse what you can change in yourself and in your situation to improve things for next time.

I have had to assume a leadership role on my ward, which required that I integrate into and lead a team of people from a very different professional and cultural background than myself.  It has been fascinating learning to lead, to set an example, to improve care, to stand up for good and against poor practice, without burning bridges or being imperious.  I may be biased but I feel there is a lighter, more positive atmosphere on the ward.  It was the ward no doctor wanted to be assigned to.   Hosting the first ward Braai (BBQ to you and me though with more meat, dancing and car stereos pumping Afri-beats) helped break down some barriers.  Wednesday morning teaching for an hour also seems to have helped.  The sessions started quietly; speaking out of turn is not something Zulu females do easily.  I really do smile now as they suggest topics and vie to answer questions.  I think the cake that goes with teaching probably helps.  The learning goes both ways in these sessions.  It was only recently whilst doing a teaching session on nursing interventions in renal failure that I realised why, despite my asking, pleading and finally being quite grumpy I wasn’t getting urine outputs measured properly on even in the sickest of our patients.  It was the nursing auxiliaries emptying catheters or bed pans and there was no measuring jug!  To measure urine output they were using a syringe.  The sluice with no water in 400 heat isn’t somewhere you want to linger with a syringe!  I went to stores to ask for a jug; “No that’s a non-stock item.  It can be ordered but it will take three months.”  Three months for a jug!  I bought one from Spar.  Now the nurses understand why I ask for urine outputs and now I understand why they weren’t being done.

One of the tougher challenges came in my first few weeks, finding we had a problem of un-prescribed sedatives being used to keep unruly patients quiet at night.  I was new on the ward, trying to build trust and cohesion with the nurses but this was obviously very wrong.  Having tried to establish who was doing this illegal administration I met a brick wall. I reported it to the Medical Manager and was given a very un-reassuring response.  So I invented a pharmacy requested stock take of all sedative agents which I conducted weekly, as obviously as I could during the nursing handover.  The problem miraculously disappeared.  Having been on the ward longer I now have my suspicions on who the main culprit was and have done some ‘subtle’ education on the dangers of sedatives.  Sadly I realise that without my constant badgering, ‘Don’t feed the patients lying down’, ‘Why are these cot sides still up?’, ‘Why hasn’t this medicine been signed for?’, ‘Who is mobilising the rehab patients?’, things will probably slide backwards, but at least I have tried.   I think I understand much more the challenges of this type of management and leadership.  To be able to foster a positive attitude in the team, to encourage and congratulate appropriately but also to stand firm when things are being done badly.

Being one of only two doctors with any significant exposure to critical care and anaesthetics has meant that I am often called to help (whether on call or not) with the more critical situations.  I often have to lead these high pressure situations.  I have learnt that this is a balancing act.  One has to clearly take the lead but also encourage suggestions from the team.  At pause moments I usually say “Can anyone think of anything that we have forgotten or could be doing?”.  It seems to invite useful suggestions at an appropriate time.  One has to perform tasks if you are the best person to do so, but also try and remain detached, reviewing the progress towards stabilisation.  Pre-empting the situation has been a valuable lesson.  If something is likely to be needed but takes time to prepare then ask early before you need it.  Instructions have to be issued clearly, to a specific person and one has to check that they are being carried out but without appearing aggressive or domineering.  I recently received a lovely message from our referral ICU congratulating us on saving a young girl who developed hypovolemic shock and coagulopathy secondary to a ruptured ectopic.  She had a very rocky anaesthetic and we only had 2 units of blood available but she made it; that was a real smile moment.

I have tried to be involved in Quality Improvement (QIP) as much as possible, with varying degrees of success.  I spent a few hours each week running a session on basic life support for the nurses.  So far around one hundred nurses have been through the sessions.  I was recently called back to casualty late one night for a collapsed patient and found the nurses bagging properly having put a guedel airway in; hooray, I taught them that!  Alas the patient died.

The intervention on my ward which has made the most difference, is Zimmer frames.  Bed bound patients are placed in cot beds with nappies which are changed twice a day, which is both unhygienic and hideous for the poor patients.  When the Zimmer frame order arrived I secured a few for the ward.  Now as soon as the patients are no longer delirious, we put the cot sides down and teach sitting to standing with the frame.  Usually after just a few days we get them walking.  It is amazing how quickly someone can go from a bed bound, emaciated, delirious wreck to walking to the toilet and being free of the nappies.  We have to share the frames currently, with those that are about to start rehabbing being put in adjacent beds so two patients can use one frame.  I recently re-labelled a wheel chair with Male Medical Ward stickers; it has become quite a success.  The patients push each other around.  Though I did find them pushing one of my frequent flier committed smokers with advanced COPD out for a cigarette; well you win some, you lose some.  I think we can learn a lot at home about the benefits of encouraging movement and rehabilitation.

Some aspects of quality improvement have been less successful.  We realised early on that no one actually calls the doctor for the deteriorating patient with abnormal vitals, until they are peri-arrest.  “Docotela the patient is gasping can you come?”, which means the patient has Cheyne-stokes breathing and is likely to be dead when you arrive.  I therefore adapted the concept of the Early Warning Score.   Calculating a score would be too complicated for our nurses.  So instead we created a new chart that had action trigger points.  For example, if oxygen saturations are less than 90% put on oxygen and discuss with doctor.  I presented this idea and supporting evidence to the doctors meeting, where it was shot down because it would make on-calls too busy.  I was really depressed with the attitude of my colleagues that day.

I also realised that the hospital was brewing a nasty drug resistance problem.  I audited the microbiology data from the lab and showed that we had a 20% ESBL rate and have a high rate of multi drug resistant organisms.  There was also a 50% resistance rate to one of the first line antibiotics for UTI in pregnancy.  The response from the Medical Manager was that no one had asked for this audit to be done (I had actually agreed to do it during a child mortality review meeting which he had chaired) and it was too short a time period so ungeneralizable and therefore wouldn’t be acted on.  Despite his intransigence, the two inspiring doctors have taken note and there are plans afoot for a quarterly microbiology review and discussions with the laboratory to enable us to send microbiology samples outside the Monday to Friday 9-5 window that we currently do.  Knowing COSH, I doubt anything will actually move forward though.

This year has given me valuable insight into quality improvement work.  I have come to realise the importance of understanding how the work place culture, with its behavioural norms and accepted practices affects attempts to drive forward change.  It can be a problem as simple as the lack of self-esteem of the team.  If you are always thought of as the ‘worst team’, why try and be better?  If you feel nothing can change, why try?  There is often a learnt helplessness in teams.  I also appreciate that for even simple changes there is often a complex set of factors that lie beneath the surface.  One really has to question and examine these before suggesting an improvement.  Listening and investigating are probably the most important skills here.  I have come to realise that enacting change within an organisation is a slow process and requires a careful negotiation between different groups with often opposing motivations.  This negotiation requires strong leadership.  Without this strong leadership and ability to effectively manage different groups, and without organisational motivation to change, little can happen.  I would love to learn more about how to navigate this world though I think I may find it a little exasperating.

Finally, I think one of the most important things I will take from this tough, interesting and challenging year is an awareness of how to build upon these experiences and move forward in my own professional progression.  I would love to be involved in helping future Global Health trainees.  I think there is huge scope for development an educational programme to prepare trainees for their global health year.  In global health terms I do want to be involved in the future.  A global health role which focuses on developing the capabilities and systems of local health care institutions rather than on service delivery would be the ‘dream’, though probably will require a distance learning Masters in Public Health or similar higher level degree.   As I move toward my registrar years I recognise the requirement to seek opportunities to develop non-clinical, managerial skills.  I can see how improving a system can be very rewarding even if the road to that improvement is exasperating.  Clinically the year has taught me that I do get a lot of job satisfaction from managing the more acute side of medicine, but also that I love seeing the progression of an acutely ill patient to someone walking off of the ward.  

As we approach the end of our time in rural Zululand, mixed emotions abound.  There is obviously excitement to see loved ones again and to be back in a country where things actually work.  However, I will also be sad to leave a place where you really make a difference, teeming with things to work on, to improve upon.  I will miss the craziness (no cows in the High Street in Bristol), the musicality, the laughter, the sheer lovable, frustrating insanity of this place.  I will also breathe a little sigh of relief that I don’t have to face all this woeful misery of a harsh land.  In the same breath I salute those that have the strength to have dedicated their lives to this place.

People of the Sky

In a harsh land under an African sun

Bones protrude where flesh should run

Sits a place that works, but works not well

People of the sky, it is here you fell

So unready for your name marked holes

Lie these forty brave Zulu souls

Through your sunken eyes, a hopeless look

You face this plague and the lives it took

Upon your feverish skin laid bare

Nurses hands do their best to care

Though to save you we try, try and try

We watch your broken generation wait to die.