Dr Rob Conway, one our regular lecturers on our famous Maldives based Diving & Marine Medicine course flew directly from Male to Johannesberg last year take up a post in South Africa at the rurally located Ngwelezane Hospital. The position was organised through African Health Placements .
Life without pre op.
Anaesthesia in a rural Hospital in Kwa-Zulu Natal
It struck me as I was watching my wife hold a beating heart in one hand and stitching it up with the other that this was one thing that every newly wed couple should do. We have been working in
Northern Kwa-Zulu Natal, South Africa, in a busy district general hospital called Ngwelezane.
I was desperate to get back to Africa and I thought that South Africa might offer both the experience with some form of supervision that I desired. I was keen to do anaesthetics and not a more generalist role that many of the more rural and remote hospitals require doctors to perform. The planning took 12 months and was helped by a charity called African Health Placements (AHP) who facilitates doctors placements in rural South Africa.
Ngwelezane has approximately 500 acute beds and 8 ICU beds. The catchment area covers a population of 4 million people in an area the size of England, and contains 22 referring hospitals. This means that the workload at Ngwelezane is incredibly demanding, with a high emphasis on trauma, emergencies and paediatrics. There is also a nearby maternity hospital where I do mainly regionals for caesareans and crash GA’s are not uncommon.
As it turned out Ngwelezane was struggling. The anaesthetic consultant I had liaised with had left, as had two of the four surgical consultants and all of the medical consultants. There was chaos in the department, which was staffing two sites with 8 staff, many of whom had done under 6 months of anaesthetics.
After a month of plotting how to escape early, I began to enjoy the job. The work is varied and interesting, making for an amazing experience. The nurses sing the day in and their voices drift across the hospital as you check your machine and draw up emergency drugs for the day ahead. There are general, orthopaedic, eye and ENT lists. We deal with emergencies or urgent cases and there is little planned work. Workload is high, hours are long and lists are generally overbooked, as there is a huge volume of work to be done here. As an example, this weekend I have anaesthetised 2 gunshot abdomens, 2 perforated duodenal ulcers, 3 children under the age of 5 and been involved in the triage of a mass casualty motor vehicle accident. I helped with the treatment of an organophosphate overdose, not to forget the numerous other surgical and orthopaedic patients.
There is currently no pre-operative assessment, we just do not have the resources and lists for the following day are not released until late afternoon making organising difficult. Although the cohort of patients are generally much younger and fitter than those that I saw in the UK, the majority have underlying HIV infection and TB. There are also the high risk patients who turn up to theatre without the relevant investigations and it is down to us to make the decision to postpone these patients for further investigations.
Anaesthetists here do not have the extended role that I experienced in the UK. You rarely step outside of theatre and are not involved in either acute trauma in the emergency department or critical
care in intensive care. Sometimes, however, we get the opportunity to help, such as when two packed buses collided and around 40 people arrived at the hospital, many of them children. I was involved in the care of a young girl, age unknown probably 4, who had bilateral open tibia and fibula fractures and a head injury. Her mother had died in the crash and we had no way of contacting a guardian. It was the weekend, no one was around to ask for advice, and I had to make a decision to wait to see the outcome of her head injury prior to rushing to theatre. I still feel that I was not in the right position to do this but I had no one to ask. After two successful trips to theatre we located an aunt to look after her. Her story is not uncommon.
Christmas was insane. My wife and I were working a 24 hour on call every third day. It was relentless, each one consisting of at least four penetrating trauma laparotomies and a number of stabbed hearts. The Zulu’s are tough, stoical and very appreciative of treatment and it amazes me that they can survive to hospital with a stabbed ventricle. I had never really contemplated the anaesthetic considerations for someone with a stabbed heart beyond fixing the defect. After inducing him I turned to the machine and then back to the patient. The next thing I know the surgeon is cracking open his sternum, grabs his beating heart in his hand, looks at me and says “He’s not going to like this”. Mental! He was right, the capnography disappeared and he went into some strange rhythm that I’m pretty sure is not compatible with life. The surgery was quick, the access was large and we filled him with lots of fluid as no blood was available. He went home four days later.
I have seen many weird and wonderful things that are too numerous to include here. The 30cm worm crawling out of someone’s abdomen intra-operatively, the hippo attack, the major trauma, the snake bites, the rare tropical diseases, the use of halothane, ketamine and the fact that I am left to anaesthetise children on my own. A lot of the time I am unsure if I’m doing the right thing and at times it has helped to debrief on doctors.net to ask advice from others who may know better. There are also many non-clinical roles that need to be filled and I have responsibility for the out of hours rota and annual leave as well as looking after the interns.
If there is one thing that would keep me here it is life outside of work. Kwa-Zulu Natal is a gem. We work long hours but are paid well and you can live a fabulous life, if you overlook the lack of security. We have a beautiful home overlooking the Zulu hills minutes from the beach in a small village called Mtunzini. Within two hours there are world class game reserves, two of the worlds top 10 dive sites and surf. A little further away are the Drakensburg or Mozambique and you are only a short flight to Cape Town.
Having had some time to reflect I realise that I have certainly had my ups and downs. The experience, especially the exposure to trauma and paediatrics, has been amazing. This environment has highlighted the value of training as I am out of my depth every day. I want to be both confident and competent in my work and proud of why and how I do it. Would I recommended Ngwelezane, well it depends on what you want out of your time here. If you are after training then not currently, but that may change. If you require a hands on, raw, frightening and yet exhilarating African experience then I don’t think I could recommend anywhere better.
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