After two days in “school”, I desperately needed to get out of the classroom. The final straw was being told off for answering a question without putting up my hand. I was looking forward to the field trip to the National Tuberculosis Hospital at Moneni. We were split into four groups so we could interview a patient and present a case report at the plenary.
The next morning, I was rather late getting down to breakfast at Esibayeni Lodge. There were no vacant places at the delegates’ tables so I sat at the table of a white man who was eating his breakfast while reading his iPad. I said good morning to him and he raised his eyes over the iPad. “Goy-tag”, he replied, returning to his full Afrikaans breakfast. That’s just like a full English, but with extra hanks of boerewors (a vinegary sausage).
“I must have a photograph of this bloke,” I thought. I got out my phone to take a furtive snap while pretending to surf the interweb. I was stopped in my tracks by a loud gunshot. This was followed by the sound of a bolt being pulled back and an empty cartridge being ejected from the breech. I know this stuff; my father had guns.
“Jeez,” I said, “What the hell was that?”
My dining companion apologised and told me that he was playing the role of a sniper on an internet game.
“But surely that is so loud it would give away your position. I thought snipers depended on being silent and invisible.”
“It is loud because it is a 50 cal,” he explained. “The target won’t hear you because this gun can kill from two klicks away.”
Fifty calibre sounded big. But two kilometres? “Have you fired one in real life?” I asked.
“Nah, but I’ve shot a 30 cal when I was in the military,” he replied.
I feigned interest while he rattled on about target circles and minutes of accuracy, all of which flew over my nodding head.
Trying to lighten up the conversation, I asked, “So have you seen the Clint Eastwood movie, “American Sniper”, then?”
“Nah, not that interested in films,” he replied, and went back to his game. Obviously I wasn’t the “right stuff”.
And I had thought he was just checking his email.
I finished eating and went out to wait for the transport to take us to the TB hospital. I was expecting a bus, but we had to squash into pickup trucks for the twenty minute journey to Moneni.
Do you know of any hospitals which are NOT open 24 hours?
The hospital is surrounded by a fence topped with razor wire. There are guards stationed at the only entrance, with a striped barber’s pole hanging across the road. As a senior official of the National Tuberculosis Treatment programme was driving our vehicle, we were waved through without being stopped. I was not sure if the security was to keep people out or to keep highly-infectious patients in.
The hospital was built on the side of a hill, with beautiful views over the town of Manzini. It took a decade to build and opened just over five years ago. If I walk to the bottom of the street where I live, I can see the hospital over the valley. A couple of weeks ago, I was out bird watching on a Sunday and noticed a group of people dressed in white, parading outside the hospital. I thought they might be nurses out on strike, but through the binoculars, I could see they were all dressed in church uniforms. I realised that they were conducting a service outside the hospital ward, for the patients’ benefit.
Our group walked down the concrete causeway, past the outpatients block, the laboratory and an operating theatre. As a medical student in the 1970s I had heard of patients having surgery to remove diseased parts of lungs, or having ribs remove to deflate lungs (thoracoplasty), to treat their TB. “What kind of procedures do they do in the theatre?” I asked a delegate who also worked at the hospital. “They can do anything there, but they do nothing,” she said.
We walked along a long corridor towards the wards. At the laundry storeroom, we were issued with a wraparound overall and a green 3M surgical respirator. I thought that these masks had performed poorly in the “fit test” study at MSF so they were no longer in use. Still, they were better than nothing.
In 2012, the Swazi Observer, a local newspaper, had criticised some nurses working at the hospital for wearing their masks over their spectacles. Obviously the masks would then not form a tight seal over the face, and this would not prevent them from inhaling TB germs. I understand that “fancy hairdos” were also cited as stopping masks from fitting tightly.
We passed a solarium, with floor-to-ceiling windows so the patients could sunbathe as part of their anti-TB therapy. At the turn of the 20th century, rich Europeans suffering from TB travelled to Switzerland, where they were hospitalised in sanitoria in the Alps to get “heliotherapy”. Sunshine increases the amount of vitamin D being made in the skin, and we now know that this vitamin helps the immune system kill TB germs.
Sister’s office had a wonderful view over the town, spread out among the hills. She had an old La-Z-boy reclining armchair in one corner. I wondered if it had a special refrigerated compartment for beer, like Joey and Chandler’s chairs, featured in an episode of Friends. We made small talk then moved to the nursing office where the patients’ files were kept. The ward nurses were ensconced here, safely apart from the infectious inmates.
An Egyptian doctor working in the hospital introduced himself and suggested several “interesting patients” whom we should see. When he realised I was a doctor, he brightened up and asked my advice about a patient who had a medical problem not directly related to tuberculosis. The patient had a very low platelet count and had bled, but unfortunately the blood from the National Transfusion Service was incompatible with the patient’s. He had tried “washing” the blood, but it still wouldn’t cross match. He was at a loss as to what to do next. I told him I’d get some advice from a blood transfusion expert (Christine) and advise him on the best way forward. I got the impression that he felt his job was solely to treat tuberculosis.
A nurse in my group was keen on seeing a patient with eye problems, downstairs in the male ward. This was bright and airy, but none of the louvred windows were open, so there was no ventilation. There were just four beds in each bay. I didn’t see any hospital nursing staff. There was no decoration on the walls and it looked grim. We went searching for the patient, but his bed was empty. Then someone noticed he was hiding underneath. “What was he doing under the bed?” I asked. “He was frightened of us,” said the nurse. I racked my brains, what anti-tuberculous drug has psychological side effects? Cycloserine, but he wasn’t taking it. I suppose that when people suffering from MDR-TB have to spend months as inpatients, having injections which cause tinnitus and deafness, it must have a detrimental effect on their mental state.
The patient cheered up when he realised we just wanted to talk to him. He had been taking ethambutol, a drug which affects colour vision. How could we test this? I had a brainwave. I could download the Ishihara Colour Charts from the internet onto my smart phone. Ishihara plates are those circles of pastel-coloured dots which may, or may not, form numbers.
Pleased with myself, I showed him the plates but he correctly identified all the numbers. Then one of the group said, “He only has the problem with one eye, doc.” So I repeated the test with his good eye covered. Lo and behold, he had red-green colour blindness. But just in one eye.
It is possible to use more sensitive tools, such as the Lanthony Desaturated test, which looks a bit like a socket set with slightly different pastel colours. The patient arranges the colours in order. This can demonstrate deterioration of colour vision at a much earlier stage. But I didn’t expect the ward to have one of these.
While the nurses pored over his notes, I wanted to know why he was still in hospital. His sputum was no longer infectious. He just needed daily injections for a few months. Surely this could be arranged in the community? Once a GP, always a GP.
The problem was that his home is too far from the nearest health centre where he could have his daily injection. But it was just £1.20 kombi fare away. I wondered how much it cost to keep him in the ward. While the nurses recorded the history for the case presentation, I went upstairs to see another patient.
This lady was very thin and her TB treatment looked like it was failing. She was also suffering from HIV. The nurses seemed to want to collect all the information from the hospital notes in order to present her case history. I wanted to speak to her and examine her, but this was not the task we had been set. I chatted to her nevertheless, offering her some comfort. I wonder when “compassionate care” will feature in the Swaziland Health Service?
It was lunch time. The other groups had already left to return to the lodge. We walked to the car park in the sunshine to wait for transport. I was just beginning to dread having to listen to the case histories back in the classroom, when I was saved by the bell, well, by the ringtone. The MSF medical team leader summoned me by mobile phone. I was needed back at the office and would have to leave the workshop. I can’t say I wasn’t relieved.