I love my job. Love is an understatement. I'm obsessed. All I think about is going to work, and staying at work when my shift ends (Except prenatal day, but I'll get to that).
It's been a fascinating and eye opening two weeks. Each crack of dawn when I arrive at 6:50 in the morning I'm filled with anticipation. Brimming with questions. Who will I see today? What will I see? How much can I do for this patient in the time I have with them? How much impact can I have on their life?
In two weeks I can't begin to list the things I've seen... So here's a brief list of some personal highlights. (Luckily, I've been keeping notes each day when I come home of my experience).
Day 3: My first day in the ER (which is combined with the Injections and Bloods room, and shared by two awesome nurses, Sister Billy and Sister Thomas). Ok, as a brief introduction please imagine two tiny rooms (more like hallways) connected by 3 doors. Each door leads to a bed in the ER room which also has 3 curtains and a counter down the opposite side. In the Injections/Bloods room the three doors are opposite a bench with three tables and a sink. This is where Heideveld treats basically everyone. Need your Hb read? What about blood sugar? Do you have hypertension and need to check your blood pressure? Were you sent here by a doctor to draw blood (for literally ANYTHING: creatinine, HIV viral load, CD4, syphilis, pregnancy? The list is nearly endless I promise you)? Do you have chest pain and were sent for an ECG? Did your small child fall and hit their head? Is your chest tight? Do you suffer from asthma? Are you having difficulty breathing? Do you receive a monthly injection of anti psychotic medication? Or injections of any other medication? Do you need a vitamin B12 shot? Do you need a shot of antibiotics for that nasty infection? Of course you do. Welcome to the Injection/Bloods room! (They also see ECGs and do Nebulizations)
So my first day here, I was apprehensive. I felt useless amid the chaos. The nurses didn't know who this random person was and I was generally in their way in the tiny, cramped corridor of a room. Eventually I just started picking things up like labels for blood and folders to help organize and before I knew it they were barking orders my way. By the end of my shift, I felt mildly accomplished. The sisters were serious in their work, but no one hates helpful hands in an underfunded, understaffed and hectic ward served by only two people, generally one of whom was at either tea or lunch.
Skipping ahead, I worked two more days in the ER over the coming weeks. The third day I elected to be there since surgery was closed. I'm currently convinced I will volunteer there after my internship ends. On Wednesday I was charged with treating patients myself and keeping track of them. I am allowed to set up Nebulizations, check Hb and blood sugar, blood pressure as well as the Tb and urine testing. The nurses (and patients who have waited longer than three hours) continually ask me to draw bloods, and I refuse on the grounds that I'm not qualified enough. Perhaps one more day in the chaos and they'll just show me and add it to my list of tasks.
Oh, I should add. The Injections and Bloods room is connected to the ER. This means that throughout the day any ambulance patients (or patients who walk in as emergencies) are also admitted here. They always are triaged as higher priority than the Injections/Bloods patients, who must often wait three or four hours before they are seen by the nurses, the line extending down the bench and out the door into the bustling hallway.
The doctor in Dressings next door sometimes sneaks over to help quell the ER's massive overload of patients. He will come by and do some stitching or tape up some minor lacerations before sneaking back down the hallway. I worked in his room on day two after I was done with the circumcisions, and hope to make it back to his room again. It's with him that I was amazed by 30+ year old infections that had seeped deep into the patient's bone, oozing and reeking of decay and bacterial proliferation. We made casts for assault victims who had fractured arms, slathered dog bites that covered a woman screaming in pain in antibacterial ointment, took stitches out of stab wounds and redressed infected gunshot wounds, doused burn victims in salve and gently checked massive c-section incisions one week post surgery. As a person who's background is heavily rooted in microbiology, the Dressing room was my Mecca. The ER, however, combined all of that with the overwhelming excitement and stress of treating 60+ patients in 9 hours.
Also in the ER around 2 pm the doctor from the ID clinic saunters over to check in and lend a hand. He is also one of my favorites at Heideveld clinic. I had the opportunity to sit in on his consultations and speak with his patients on my fifth day, and was enthralled with how his very quiet corner of the clinic functioned. The ID clinic, which stands for Infectious Disease, treats anyone and everyone who has tested positive for HIV.
The clinic is a short pathway (outside) from the chaos at intake, and patients sit quietly in a dark and cool room to be seen by one of the sisters or the doctor. Each consultation is behind a closed door and very private, even intimate. It is in this ward of Heideveld that patients receive incredibly comprehensive care. The doctor discusses their ARV treatment with each patient, checking their blood work and viral loads, chastising some patients for a spike in their viral count (signifying they were not taking their medication properly, called defaulting) while simultaneously praising those who were on top of their regiment and maintaining a viral load that was LDL (lower than detectable limit). We also sometimes discussed their creatinine clearance, which is a calculation done based on the level of creatinine in the blood, the patient's age, weight and gender. The final number describes the efficiency of the patient's kidneys in removing this compound from the body. If they are not effectively removing this potential toxin, the patient must be switched to a different medication.
If the patient was not taking their ARVs, the doctor discussed with them in great detail why they were not. What were their symptoms? How could we best combat those? Once a patient had defaulted on the first line of treatment options, they were automatically bumped to the second line to ensure they did not develop resistance. While this meant getting used to a new schedule of new pills with new side effects, the doctor fully explained their dosage and requirements while reminding them if they defaulted again on this second line, they would be moved to a tertiary hospital to receive their third line medication, as Heideveld currently only dealt with first and second line cases.
Because this ward dealt with all HIV+ patients, they also were equipped to deal with all the other illnesses that may accompany an HIV+ person, including the familiar instances of hypertension and diabetes. Their medication for those conditions (as well as lifestyle choices) were discussed in detail as well, and always prescribed in conjunction with their ARVs, keeping in mind the potential interactions of those drugs.
In the ID clinic I had the privilege of seeing some diverse cases with daunting twists. Here are some of my most memorable:
A 45+ year old woman came in complaining of ... well let's just say the most infected vagina I have ever seen. Seriously, she couldn't even sit down. While discussing what antibiotics to prescribe for such an advanced infection, I learned that apparently most of the STIs in South Africa are resistant to ciprofloxacin (commonly referred to as cipro). Good to know.
A mother and 16 month old child (who was also HIV+) came in together for general checkup. The mother had defaulted on her ARVs during her pregnancy because of the severe nausea she experienced. In talking with her, it seemed that having a child had given her a new take on life and she was committed to maximizing both her and her daughter's quality of life. No more defaulting for either of them. She also was very keen on staying on top of all the potential threats of being an HIV+ woman, including the need for more frequent pap smears (cervical cancer is more common) and checking for Tb. While it was sad to see such a small child growing up with such a burden, I was glad to see her renewed joy for life. I hope it continues well into the coming decades.
A young (20s) man came in from Tambo Village. He was very tall and threateningly skinny. His voice so quiet we could barely hear him, his breath full of wheezing and rattling I immediately associated with potential Tb. It was obvious he was beyond nervous, vastly intimidated by the world of the ID clinic. Eventually, we sussed out that he had tested positive a year ago and refused treatment. He had been scared, he said. Too scared to deal with the reality of being HIV+. We checked his year old blood work and my heart sank when I saw his CD4 from the year prior was 54. (as a reference generally AIDS is contracted around 200 and treatment with ARVs is recommended anywhere under 500). The doctor guessed that his current number was probably around 10. He was lucky to be alive. Very lucky. Through tears he expressed his desire to start treatment and take it seriously. If he doesn't he will not survive much longer.
The next woman to walk in was equally as heartbreaking. I watched with great curiosity as the doctor filled out the first police report for domestic violence I have seen done in South Africa. He drew the bruises that covered her back, face and arms. No photographs, only sketches on a government form with the outline of a human body. I discussed how in the US the photographs were used as evidence in the trial along with the testimony of the doctor. He agreed that photographs would be preferable, but admitted that in four years of working with these cases he had never once been called to court to give testimony. I asked if the clinic had anyone to contact about counseling or victim support. He said that was given at the police station. (No, I thought, it wasn't. No victim wants to go to the most intimidating place you can imagine for counseling). While the doctor asked all of the required questions from the police report ("were you emotional?" Seriously?), I did my best to encourage her to get away from a man who threw her down and stomped on her for catching him cheating with another woman. She mentioned she had no kids with him, though she was pregnant and at five months miscarried. I wondered if it was his fault.
Later, I brought up my surprise at the lack of victim support in the hospital currently to one of the administrators. I was informed that a social worker comes on Mondays and the construction going on next door would contain a brand new ER and a special rape crisis center. That's great, I thought, but does nothing for the woman I saw today.
The next day I was back in the ER/Injections room, running around helping nurses prep a man who had an epileptic fit in the toilet and gashed his head open, and holding down a child who had gotten something stuck deep in her ear canal. At the end of the day I was exhausted, but so fulfilled.
On Tuesday of this week I was assigned to work consulting room 2. Having no idea what that was, I jogged down the hall at 8:30 am (since I spend each morning helping in the file room or doing triage of patients with no appointments) to find the right ward. I knocked on the door and entered to find a sister seated at a desk with a bed and curtain on the far wall. The whole room itself was nearly as big as the entire ER and there were several chairs, a sink, two cabinets and plenty of open space. It was quiet and comfortable. Nearly serene. Certainly a change of pace from my stint in the ER. I sat down after introducing myself and we discussed her work in consulting room two. Antenatals. From 20 to 36 weeks.
I glanced around the room at her posters on the wall. Options for feeding their newborn for the HIV+ mother. Prenatal information sessions. Graphics on growth and development. Ah, I thought. Prenatals. From all the excitement over pregnant women that I had witnessed at the farm between Mandy and Mandi I was keen to learn more about this strange and highly specialized ward. By the 6th prenatal in a row I was getting antsy. All the discussions were so calm and there was so little movement. And no blood. Or infections. Each woman came in, they discussed how far along they might be and their possible due date before she sat on the bed, exposing her swollen abdomen for the nurse to palpate and measure the length of the fetus. The sister would listen for a fetal heartbeat and inquire about diet and vaginal discharge. Over and over again. Even when a 16 year old in grade 10 came in we had the exact same discussion. Each woman was reminded to take their folic acid and iron supplements to keep their Hb up, and sometimes we would test their Hb to make sure it was still within a normal range.
That's when I really got antsy. We were sharing the ER room's Hb monitor since the ER and consulting room 2 are directly across the hall from each other. Each time I'd get up to take the Hb back to the chaos of Trauma I'd get a sneak peek of what I was missing. The lines were massive. People holding rags to various wounds to stem bleeding, ambulance guys in their neon green uniforms bringing people in, kids screaming and crying while the Injection room filled and filled with disgruntled and sometimes very sick patients. I kept making excuses to go back. Each time I returned to the quiet of the prenatal room I'd imagine what was happening next door.
That day was the first and only day I've ever taken a tea break. In South Africa "taking tea" is basically like going on break to have a quick bit of food or relax in between the start of work and lunch. Tea can last a half an hour or so. Nearly every single sister and doctor and intern and whoever takes tea as well as lunch. Except me. I've never taken either.
Except the day I did prenatals. I took a 30 minute tea.
The next day I went to the ER at 8 am without being asked to do so. My supervisor found me there an hour or two later wiping blood off the floor and filling a nebs mask, laughing at my desire to be in the most hectic room of the whole hospital. Don't make me leave, I thought. I found my place.
I'm sure there will be more stories to come, as well as a recount of my day in minor surgery when we couldn't stop the bleeding.
- Rh
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