Ode to Jooste

From top to bottom: "Stop TB" signs in English, Afrikaans and Xhosa; HIV posters; our favorite snack stand outside the hospital (the only food available, and yes it is made from converted shipping container); ME!

Week Four

Special Surgical Scrubs

 

My final rotation at GF Jooste is in the Surgical Ward and it has, so far, been a great week!  Each morning the surgeons perform ward rounds to review the cases of surgical patients. After rounds we move to theater (the operating rooms).  By far, the two most prevalent surgical issues that patients present with are 1) stab wounds, and 2) diabetes related infections requiring amputation.

In the general Cape Flats community, when you mention GF Jooste people will raise their eyebrows in a wary, disapproving way because they say, "that's where you go if you want to die."  The truth of the matter though, is that the hospital is located in one of the worst neighborhoods in the city and so its volume of aggravated traumas is enormous.  But to set the record straight, of the stab wound victims that present at Jooste, they have over 85% "save" rate.

So back to stab wounds in the ward... attackers go right for the heart.  Most of the stab wounds that I have seen have been left upper abdomen wounds.  In fact the first surgery that I observed was a stab wound of this kind that had penetrated and nicked the stomach as well.

The other recurring theme in the surgical ward is diabetes related sepsis and amputations.  This is a huge problem in the aging population, and because patients without medical aid (insurance) do not present for routine medical care, they often end up in the hospital with wounds that have gone too long without treatment.

On my first day in theater, I actually got to assist with an above the knee amputation (AKA).  I was not expecting that privilege whatsoever, but when the surgeon asked me to scrub in, I couldn't say no!  The level of sterility in the OR is mostly on par with standards back in the States, but the surgeons have to be more resourceful with the tools they have at their disposal.  For example, putting patients under general anesthesia is the exception not the rule.  Spinal blocks are used more frequently because they are less expensive and require less concern for recovery.  So the patient who presented for the AKA was awake the whole time!  Aside from the cauterizing tool (which I got to use a lot), everything else in the surgery was performed by hand, using blades, a saw, and a pitcher of sterile saline water.

Scrubbing in for surgery was an amazing way to spend my last week at Jooste.  The level of medical care provided at this hospital is great due in large part because of the Medical Officers (doctors) who choose to work here.  Given its reputation, there are a lot of other places that these qualified providers could find work (including the private sector), but for many of them (native South Africans at that), they come to Jooste because they care about this community; one where the people fight everyday to stay alive - and so they join the fight to help them survive.

WeekEND Wrap Up

This weekend was our last weekend in Cape Town and our last hoorah as a group. We took a half day at the hospital on Friday and drove out to the winelands because neither Jay nor Ryan had been there yet. Our local coordinator emailed us directions on four locations to visit, but her directions were kak (crap in Afrikaans) and so we ended up driving in circles for over two hours! We did make it to Fairview Wine Estate where there was both wine and cheese production; so while my three groupies tasted wine I indulged on very fresh varietals of cheese… yum!

We also made it back to Spier Wine Estate (the place with the Cheetahs) where we ate dinner at the very highly reputed restaurant, Moyo. The food is served all buffet style, and though it was good food the atmosphere of the restaurant was the most stunning element. If you notice on the picture, we all have white face paintings, which is a Zulu tradition for special occasions.

For Saturday we planned a full day trip to drive around Cape Point. We rented a car and left very early in the morning heading due East and then South: traveling through Muizenburg, Fishhoek, Simonstown and Boulders Beach. All of these coastal towns were charming and situated with exquisite ocean views. Boulders Beach is unique in that it is home to the African Jackass penguin population, which we were thoroughly entertained by!

My friend Bridgett met us at Boulders Beach and joined us as we continued South to Cape Point, the southern most tip of the continent. Having worked in the National Parks, Bridgett was a wonderful guide as to the wildlife and scenery… including very sociable baboons.

It's a scary thought that the only thing beyond the horizon is Antarctica...burrrrr.

With no where else to go but North, we drove back along the Western coastline through Hout Bay and Chapmans Peak, where we witnessed a spectacular sunset.

Sunday was pretty unremarkable as Shanley and I took advantage of some R&R (and Vitamin D) on the beach while the boys were off on a shark diving adventure. Of note, however, is the fact that I got to drive the rental car, which was my first experience driving on the left side of the road and shifting the gears with my left hand. It really does require adjusting your spatial orientation, so I was extremely grateful for Shanley’s support as my copilot; I am happy to report though, that we had safe travels.

Week Three

WARNING!
FOR MATURE READERS ONLY

I feel that it is important for me to blog about my week, however, due to the sensitive nature of the clinic I've been in this week, I feel it is also important to alert my readers.  To preface this entry, I have left out all personal and political perspectives because the root of the experience has been about medicine and treating patients.  So without further introduction, this week my clinical rotation was in the T.O.P clinic... or in other words, Termination Of Preganacy.

In South Africa it is legal to perform abortions up to 20 weeks of gestation.  There are only three doctors in all of Cape Town who perform the abortions (they are all female doctors), and they rotate through both the public and private hospitals.  As with other medical services, GF Jooste is popular location for TOPs and accepts referrals from other community hospitals.  In summary, here is break down of the week:

Monday & Tuesday: up to 35 patients are accepted into the TOP clinic for screening and counseling.  The patients must present a referral letter from their community clinic or general practitioner - this letter alone can cost the patient 200ZAR (about 30USD) which is a steep fee, especially when the cost of all other visits is free.  The patients are accepted first come first serve, so they arrive between 06h00 and 07h00 even though the clinic hours do not officially commence until 09h00.

Everyone is poked and tested for HIV (I helped perform the testing), then brought back one by one for the results and counseling based on their status.  Then all of the patients file into the "theater" room ("theater" is the South African term for operating room/OR) where there is one table separated by a thin curtain.  The patients get onto the table for a quick ultrasound to determine the size of the fetus.  The doctor spends only two to three minutes per patient before they are rushed off the table and back to the waiting area.  I actually got to perform a couple of the ultrasounds, which was a good learning experience.

The group is then divided by weeks of gestation: 6-12 weeks (first trimesters) are given an appointment on Wednesday or Friday for the TOP.  When they return to the clinic they will take Cytotec to help open the cervix for the procedure.  13-20 weeks (second trimesters) are counseled seperately, and are given Cytotec tablets to take at 03h00, 05h00, and 07h00 the morning of the procedure.  Everyone is instructed to bring their own towel and feminine pads - nothing is provided for the patient.

Wednesday, Thursday, & Friday:  first trimester TOPs are done on Wednesday and Friday, with second trimester TOPs reserved primarily for Thursday.  The patients arrive by 07h00 to take the Cytotec; when I arrived at 08h00 some of the girls/women are already bowled over from cramping side effects. The doctor arrives by 09h30 and no time is wasted to get started.  The girls/women are arranged in rows of chairs just outside the theater, seated from earliest gestation to latest. They are instructed to remove all clothing below the waist, and so they sit wrapped in their towels waiting for their turn.

Several of the patients abort before they even make it to theater, and so there is a constant flow between the chairs and a (very) small toilet in the room.  When this happens a nurse is called from theather and the patient is given a small paper bag (like a barf bag) to put the aborted contents in.  Mostly though, the girls/women move perfunctorily into the theater area for the TOP.  It is a quick, albeit gruesome, procedure; about five to ten minutes for first trimesters (who get no local anesthetic), and about 15 minutes for second trimesters (who get 20mls of lidocaine injected into the cervix).

When the procedure is completed for one patient, she is rushed off the table and wraps in her towel quickly before the nurse yells "Next" for  the next girl/women to enter. And so it continues until all of the girls/women have been treated.  Wednesday I was in theater for five and a half hours straight and Thursday there were 24 TOPs before noon.  When I use the term girls/women it is to encompass the full spectrum of patients seen; the age range this week was 13 to 39 years old, with everything in between. Many of the women are married and a majority of the patients used some type of birth control before becoming pregnant.
In total, it was a very profound and emotionally exhausting week.  As an outsider, I felt that there was a lapse in the birth control education as well as the counseling that occurs before the TOP.  For example, the patients are counseled that even if they are taking the pill that they are not protected from HIV and so they need to use condoms, but then the sisters (nurses) really push for the patients to get the contraceptive injection (which still doesn't protect against HIV)... so the output is a very mixed message.

I learned a great deal from the physicians this week and my heart was heavy for the patients that I worked with.  I've seen things that words cannot even begin to express and I have been racked with how to process everything that I've experienced and felt.  What it comes down to is this: is it any different than a patient who presents with lung cancer after a lifetime of heavy smoking? doesn't that patient deserve to receive medical treatment if they choose it? and shouldn't the medical care be delivered with compassion and without judgement?

WeekEND Away

The weekend started early… really early… 05h00 on Friday morning!  Each month the coordinators of the CFHI Cape Town program orchestrate a three day weekend excursion along the Garden Route .  Our group has dwindled down to four because Erin completed her month in Cape Town and is returning home to graduate medical school and begin her residency.  So the weekend crew consisted of me, Shanley, Ryan, Jay, plus two foreign medical students on rotation at Stellenbosch University: Inge from the Netherlands and Shazia from Germany.  Our fearless leaders Avril and Marion packed us into the blue VW van and we set off on a five hour drive to the Eastern Cape.

 

First stop: the Cango Caves which include some very narrow passages that you actually have to squeeze through.

 

Next stop: an ostrich farm.  I have no doubt that these animals have prehistoric origins – they are down right creepy to look at up close.  That didn’t stop me from getting an ostrich hug, or from taking a ride on the back of one though!

 

Next stop: We zip-lined through parts of the Tsatsikamma Forest as part of a canopy tour; supported only by a harness and metal cables.  It was a real thrill with some of the cables running 65 meters in length and 30 meters above ground.

 

Next stop: Bloukrans Bridge where you can take the plunge on the world’s highest bungee jump 216 meters.  Shanley, Ryan and Jay did the jump, but I hate the feeling of free fall so I declined.  However, I didn’t miss out on all the fun, so I zip lined across the underside of the bridge instead.  (Shanley has lots of pictures on her blog from the jump.)

 

Next stop: Knysnsa Elephant Park where we fed and walked with a dozen elephants, big and small ones.  Elephants are very gentle in nature but their size is still intimidating.

 

Last stop: We concluded our trip Sunday with a leisurely three hour game drive at Botlierskop Reserve.  It has four of the “Big Five”  animals: Elephants, Rhinos, Lions, Buffalo (no Cheetahs).  There are various other animals on the reserve too; in size there are about 300 hectres of land where all of the animals roam at will (except the lions which have a gated enclosure).

 

As you can imagine, it was a busy weekend, but we enjoyed every minute immensely!  It was another five hour drive back to Cape Town and then back to work this Monday morning with a new clinical rotation.

Week Two

It was another week in the Casualty and See & Treat clinics, and a very full week at that.  The first week I think I was still adjusting to seeing some of the diseases and medical conditions that present at Jooste, but this week I think the shock was more about the volume of patients that are seen on a daily basis.  In the See & Treat clinic alone there are 3 physicians at any one time and the load is usually pushing 40 patients before lunch! 

Most of the visits in See & Treat are nothing spectacular: DVTs and cancer diagnosis, but occasionally there was a patient that would stand-out.  One in particular was a 26 year old female who hobbled into the exam room with a leg brace and a scarf around her neck.  The brace was for a deformity caused by childhood polio (something I hadn’t seen until now), and the scarf was to cover bulging TB nodes.  The patient had been on TB treatment for 5 months already, so this flare was likely a sign that she had become drug resistant – a strain called MDR (multi drug resistant).  To be sure though, one of the nodes needed to be aspirated and drained; so I assisted the physician with that procedure and saw the milky TB fluid first hand.  Compounding the situation is that the patient is HIV positive.  For me this patient was so memorable because she is not so much older than myself, but on the spectrum of patients in South Africa she is not so unique: her myriad of medical problems are the same problems of the majority of people in the Cape Flats and represent the overall health crisis of this country.

We also watched a film on Tik that features one of the doctors at GF Jooste; it was a sobering look at the addiction of many of the patients we see - an addiction terrorizing the neighborhoods just outside the hospital walls.  This weekend Tik hit close to home when our home stay house was broken into.  There are metal bars and gates and padlocks everywhere in the Cape Flats, but in this case the kids on Tik cut the padlock to the garage gate and stole all of Mr. Snyders power tools.  They also tried to take the copper pipes from the water heater, which resulted in no hot water last night.

WeekEND Review

Our first week of clinical rotations ended without incident. All five of us are at GF Jooste Hospital in the Cape Flats area. This is a public hospital (meaning that you don't need insurance to be seen here), as well as a district hospital that serves a population of nearly 2 million people who are primarily from the townships. The healthcare system in South Africa, as I understand it so far, is a three-tiered system beginning at the bottom with community hospitals. The community hospitals act like a primary care offices, operating eight hours a day Monday through Friday. If the medical condition cannot be cared for in this setting, the patient is referred to a district hospital for treatment. Then if the condition requires specialized treatment, a referral is made to a tertiary hospital that has more resources at hand.

Shanley and I have both spent our first week at GF Jooste in the Casualty Department, which is equivalent to an Emergency Room setting. Depending on how busy Casualty is, we also help over in the See-&-Treat Department, which operates like an outpatient primary care facility. In the first week alone, I have learned a lot! I did my first blood draw today (success!), I’ve assisted with two lumbar punctures, performed a couple of EKGs, and am learning to read X-rays better each day. The most prominent health concerns facing the providers at GF Jooste are: HIV/AIDs, TB, and TIK (meth use).

At the end of clinic week, we spent most of the weekend together as a group. It was Erin’s last weekend in Cape Town and so we did the two things she hadn’t yet done: visit Robben Island and climb Table Mountain. Both activities require decent weather, and we lucked-out with perfect conditions the full weekend.

First stop was Robben Island which is where Nelson Mandela and other political offenders were imprisoned during Apartheid. The prison is no longer operational, but tours by ex-prisoners are part of the experience. Even within the prison setting, “black” and “coloured” prisoners were subject to marginalized living conditions/treatment.

Shanley & Me standing on Robben Island with Table Mountain in the background

Our second adventure was climbing Table Mountain, which is named for its plateau-like top; when there is cloud coverage over the mountain, the locals call it the “table-cloth.” The hike took the group about 2.5 hours at a pretty relaxed pace, but not without some extreme upward climbing. It’s only about 3,500 feet to the top (smaller than Mount Si) and there is a cable-car that runs service from the base to the top. As it turned out, we hiked to the top then rode the cable car back down. The ascending views and panoramic scenery from the top is incredible and worth the effort to see.

View from the top!

Week One

This week has been backed full of new information, both in the cultural and clinical settings.  Monday and Tuesday were public holiday here (for Easter) and so we had our program orientation and a township tour on those days.  The townships are, in one word: incredible.  There are more than 100 townships in the Cape Town vicinity, and the hospital where we are doing our clinical rotations is the district hospital serving some of the roughest of these communities.  Boundaries between townships blend together, so that when you look out it appears a vast sea of shanties... ubiquitous poverty.

Our guide for the township tour was a native Capetonian, Colleen, who had in fact lived in District 6 during her childhood and was part of the notorious forced removals during Apartheid.  We visited the District 6 Museum with her, which was a truly one-of-a-kind experience. 

I should back up just a little bit and redefine my “we” pronoun!  This is the group (from Left to Right: Shanley, Me, Jay, Ryan and Erin). 

Jay, Ryan and Erin are all graduating medical school this spring and entering their residencies (Anesthesia, General Surgery, and Obstetrics, respectively).  Jay and Ryan started the program with me and Shanley, but Erin has already been here for two weeks and has been a great help to all of us in adjusting at our clinic site. Over the past week, we’ve warmed up to each other and actually have a lot of fun as a group!

Parting Words

As Shanley and I move from the holiday portion of our travels into the actual internship, I am not confident in what our access to internet will be over the next several weeks.  I do anticipate finding means to blog, but until I secure such arrangements, I wanted to leave things with something poetic that speaks to work that I will be doing:

I keep six honest serving-men
They taught me all I knew,
Their names are What [Ini] and Why [Ngobani]
and When [Nini],
And How [Kanjani] and Where [Kuphi]
and Who [Ubani].
                -Rudyard Kipling

The words in brackets are Zulu (one of the 11 national languages spoken in South Africa).  I came upon this poem in a text I've been reading/studying about "Communicating With The African Patient."

Last Night

Literally, last night was our last night in the heart of Cape Town.  Today we meet our host family and will be living in a southern suburb of Cape Town called Athlone.  But last night we were fortunate to meet up with my friend Bridgett, who has been living in South Africa for the last two years. 

Bridgett and I worked together as lifeguards during our high-school and college summers.  She previously did an internship in Kenya at a wildlife reserve and now her work with a UK-based nonprofit in South Africa is centered around environmental conservation and community development.  We met at the Two Oceans Aquarium at the V&A Waterfront, which was a wonderful display of native South African aquatic wildlife.  I was particularly captivated by the giant sea turtles!

We then went to a restaurant called, Mama Africa.  This place was highly reviewed by all of our tour books as well as local brochure guides that we've collected around town, and it was better than I even anticipated!  The atmosphere was an ecclectic assortment of all things Africa, there was live African music, and the food was beyond comparison.  It was a perfect end to our holiday in Cape Town and in good company no less :)

This One's for You, Ben

My friend Ben has recently endeavored into the wine-making business.  He's a Tacoma native like myself and has a strong sense of being a "local" in the best way possible.  Although I don't drink myself, I think his ambition and progress so far is pretty impressive: http://www.21cellars.com/ .   Which brings me to the point of this blog posting...

Yesterday, Shanley and I took a Winelands tour, which was stunningly beautiful and richly informative.  Again, the tour group was intimately small: Margaret from Oxford, Bob & Kathy from Toronto, then Shanley and me (we were the runts by at least thirty years).  Our tour guide Wilmot is a native South African (ironically, he was also a non-drinker) and he delivered a wealth of information.

The tour consisted of wine and cheese tasting at estates in Paarl and Stellenbosch, as well as a visit to Spier.  Stellenbosch is sort of a University-town and has a lot of Dutch influence, and at Spier I opted to pet the Cheetahs instead of doing the wine tasting.  The drive alone, prime landscape viewing, was worth the price of the tour (we paid less than $75 each)!

This last photo is a stop we made at Victor Vester (the other prison where Nelson Mandela was kept, different than Robben Island).  Note, the people in orange jumpsuits are actual prisoners.