Ferewell Karen

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Karen Chung is a Kiwi doctor who has been working for Medecins Sans Frontieres (Doctors Without Borders) for the past year in Swaziland; I am her replacement. This is her going-away cake, baked by the staff of Matsapha Comprehensive Clinic. On her last day in the clinic, the staff threw a party.

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Lots of food, but not typically Swazi: crisps and cheesy wotsits, mixed together; peanuts, raisins and nuts, samosas and pasties. And to wash it all down, a selection of fizzy beverages, including Iron Brew (sic), Coca Cola and Fanta (the most popular).

Each department gave a short speech praising Karen for her clinical skill, generosity, energy and good humour.

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I was lucky to have a week’s handover with Karen. In that short time, it was obvious that the high praise of the clinic staff was thoroughly deserved. She is an excellent doctor and will be a hard act to follow.

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Karen is on her way back to Auckland, New Zealand (via Berlin) for a well-deserved break. She has a great career ahead of her.

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Kombis

I really enjoy the first few weeks of living in a new country. I look for novelty, difference, quirkiness. After a month or so, odd things become accepted, mundane and attract my attention less.

Each morning at 7am, two Landcruisers collect the expatriate health workers from the team houses and transport them to the clinics at Matsapha and Mankayane. It takes about half an hour to get to the clinic where I work, more if the traffic is dense. I am fascinated by the “kombis”. This is a generic term for mini-bus, no longer VolksWagens but more likely to be modified Toyotas. They are usually packed with commuters at rush hour. Most of them have been named by their owners.

“Secrecy” seems a strange name for a kombi. “Why should it be a secret?” I asked. “Surely it should be publicised rather than clandestine? Perhaps it is for passengers who wish to remain secret?”

“No,” replied the driver. “The secret is where the owner got the money to buy the kombi in the first place.”

Other names which struck me as funny:

“Criminal”

“Why Not”

“Tit for Tat”

“Earn a Living”

The driver pointed out a kombi called “Flying Coyote”. He asked, “What is a flying coyote, doctor?” I told him that a coyote was like a wild dog and he said, “Aah, I understand. Dogs run so quickly that they fly. It is a good name for a kombi.”

“But you have to be careful when naming your kombi. A few years ago, there was a kombi called “Accident” and it got washed away by a flooded river,” he said.

I am collecting my observations to share with you over the coming months.

PS My internet connection is so slow that I am having trouble uploading photographs. I hope to fix this by getting up at 5:30am when fewer households are online, and the connection won’t drop out.

Gigolos

I had just had a cup of tea for breakfast, so I was starving hungry by lunchtime. The clinic staff suggested going up the hill and turning left to Fedic’s cafeteria for a meal or turning right to the local strip mall for a bag of chips (french fries). I plumped for the healthy option and went left. The cafeteria didn’t have any tables and chairs outside. It just served food in polystyrene boxes to take away. I peered through the glass cabinet to see what was on offer. The serving lady was very helpful. When I pointed to a dish, she would show me a ladle-full and dribble it back into the pot. Chicken stew and chicken broth both looked tempting, then a cook brought in a tray of miscellaneous cuts of pork which had been barbecued. We are talking nose-to-tail eating here. I ordered maize porridge (just like polenta) with chicken stew and salad, which cost me just over a pound. The serving lady wrapped the box in clingfilm, trapping a plastic spoon, a toothpick and a paper napkin within it.

I walked back to the clinic to have lunch in the staff room. Everyone else was eating their packed lunches, brought from home. Money is tight for the staff, with another week to go before payday. One of the male nurses noticed I was eating porridge and asked if I knew what it was. I said, “It is nshima. I used to eat it in Zambia. Or sadza if you are from Zimbabwe.”

He seemed to be impressed with my local knowledge and said, “We call it pap. Do you like eating local fruits? Have you eaten marula?” When I told him I hadn’t, he suggested that next week, he would bring me a drink made from marula. “Amarula?” I asked.

“No, just the fruit juice.” From my right, I felt some eyes on me, watching for my reaction. I felt I was being set up.

“Is it fermented? I can’t drink alcohol when I am on duty,” I told him.

“It will give you power,” he sniggered.

“I don’t need power to do anything,” I said. “I’m a single old man.”

The other nurses sitting around the table guffawed with laughter at this remark. I then made a comment about the recent newspaper article about “Male harlots on the prowl in Manzini”. All the nurses had read the article and they began to discuss it fervently.

“These men should stick to other men, and not bother us women.”

“What price were they charging?”

“Fifty emalangeni, but the man said that once the lady had … she would definitely pay more.”

“But how long would fifty emalangeni get you?”

“Ah, this is easy for men. They just pay for the session.”

“But for women it should be for as long as it takes!”

“Eh, if it was me, I would fall asleep.”

At this, I burst out laughing, but then realised no one else seemed to find it funny. Perhaps she was serious?

“Is there a doctor on the flight? Can they please make themselves known to the cabin crew?”

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This announcement usually quickens the pulse of any medic on board. I still remember with horror the air traveller who collapsed with a tension pneumothorax on a transatlantic flight about 15 years ago. A group of British hospital doctors were returning from a medical conference in the USA and saved the patient’s life using tubing from an intravenous giving set, a plastic bottle and wire coat hanger. I am not sure I would attempt this on my own. One thing I have learned from working abroad in remote areas is not to act like a gung-ho cowboy. I ask myself, “If this doesn’t go according to plan, what’s your exit strategy?” That thought focuses the mind perfectly.

The overnight flight from London to South Africa had dimmed the lights after midnight. Most of the passengers were asleep when the tannoy crackled into life. I paused the video I was watching (“Joe” starring Nicholas Cage) and sat up to see if anyone had volunteered. No one moved in my section of the plane so I got up and walked to the curtained off area at the back of the plane. As I did so, a strange man resembling Bilbo Baggins got up and walked down the other aisle. He looked a bit older than me, with curly grey hair, wearing an extravagantly checked lumberjack shirt with purple braces (suspenders).

Behind the curtain, a delirious passenger was being restrained in a four point seatbelt. She was arguing with the cabin crew, wanting to get free, even if this meant she would die. She said she was in pain, clutching her left breast with one hand and her neck with the other. My medical colleague asked her methodically about the pain, but her answers were vague and inconsistent. When she spoke to me, her breath smelled of stale alcohol.
We two doctors looked at each other and put our cards on the table.

“Family doctor?” I asked.

“Yes, you too?” he replied.

“Is it that obvious? Yes. Do you have any other skills which might come in useful, such as psychiatry? I know a bit about mental health,” I said.

“No,” he responded while gently attempting to prod the lady’s abdomen. She reacted angrily and swore and he retreated.

“Looks like I am in the lead role here,” I said.

My rapid initial assessment was that she was disinhibited, under the influence of alcohol. But she could be suffering from another metabolic problem, such as diabetic hypoglycaemic attack, or a head injury, or hypoxia from chronic lung disease. I needed more information. Had she declared any illness before boarding the flight? Was she taking any medication? Could the flight attendants recall how much alcohol she had been served? I drew a blank. The patient became more aggressive and insisted on going back to her seat, saying, “I don’t have a personality disorder!”

The captain left the flight deck to assess the situation in the tail. “Is this a life threatening situation?” he asked. “We are flying over Bangui in Central African Republic. Do you need me to land now?” The passenger wasn’t phased by this; she said she would rather go to a police cell in Bangui than be restrained on board the plane. I discovered that the doctor’s bag on board did not contain any tranquillisers.

The captain told the passenger that if she didn’t co-operate and quieten down, she would be handcuffed and prosecuted. She relented and a crew member undid the seat belt. She then flopped onto the floor and had to be lifted to her seat by her arms and legs. Luckily the seat next to her had been vacated. I sat down next to her and used my experience and skill to defuse the situation. The crew were happy to leave me alone with her.

We talked about her pet, her job and her holiday plans, avoiding confrontational issues. After 20 minutes, she was calm and relaxed. I encouraged her to get some sleep and she agreed.

I walked back to the crew area in the tail of the plane to liaise with the staff. In the same chair I found another passenger who had taken ill. He had passed out twice on the way to the toilet. This problem was easier to solve, probably a mixture of contributing factors – no food for 12 hours, recent antibiotics and anti-inflammatory drugs on top of his usual cardiac medication and a bit of postural hypotension when he rose from his seat. After a sugary drink, he felt much better and he was able to return to his seat without assistance. So was I.

I made an attempt to get to sleep, but I was wide awake by now. A crew member brought me a couple of forms to complete, so I would be taking responsibility for the decisions and actions I took, rather than the airline. I watched another film, a biopic about James Brown, the Godfather of Soul, which was excellent.

This isn’t the first time I have been called upon to provide medical assistance in the air. We took advantage of Cathay Pacific’s discounted airfares to fly to Queensland via Hong Kong during the SARS epidemic. It didn’t look such a bargain when I was called to see a Chinese lady who was feeling unwell on the flight to Cairns. Luckily for us both, it was just hypotension – low blood pressure after she had taken a double dose of antihypertensive pills because of the time difference. I had an unpleasant conversation over a radio telephone with the insurers about whether the captain should divert to Sandokan airport in Sabah, or did I think the passenger would not die before reaching Cairns.

On an Emirates flight to Bangkok via Dubai, a man collapsed in front of me and the crew allowed me to open the doctor’s bag so I could perform an Electrocardiogram (ECG) and check his blood sugar using a diagnostic stick. But I had to prove to them that I was a “real doctor” by providing evidence – my surgery identity badge – before they would let me loose on a glucostick.

I have heard of “good samaritan” doctors who received an upgrade on the next leg of their journey, or a complimentary bottle of champagne for ministering to the sick on board. But all I have had was thanks and gratitude from the cabin crew. My medical indemnity insurance would not have covered me for decisions I made while flying, so perhaps I should have been more demanding and assertive.