Source: Health-e (Cape Town)
Our doctor-turned-blogger continues her rural awakening as she is confronted by illiteracy and mother-to-child HIV transmission on a long night shift in the wards.She looks up at me and nods, but I'm almost sure she doesn't understand.
"You need to have this operation because the baby is getting tired," I say. "Sign here that you agree... "
The nurse translates my English into Xitsonga, but the young teenager in front of me still looks confused.
She picks up the pen with her right hand, wrapping all five fingers around it like a two-year-old child holding a crayon. She looks down blankly at the piece of paper in front of her. I'm slightly annoyed by how long this is taking.
I repeat, "Just here. Sign here," as I point to the line at the bottom of the "Consent for Operation" form.
She lifts the pen and put its down on the dotted line, timidly. She looks up at me and, speaking in her native tongue, says "I can't."
"What does she mean, sister?" I ask the nurse. "Why can't she have the operation? Did you explain to her why she needs it?"
"No Dokotela, she understands, but she can't write," the nurse says.
I am stunned that a 17-year-old could be illiterate and the nurse replies that the girl doesn't go to school.
It's 11pm and I'm too tired to question this further. I'm too tired to think about why we have a 26 percent teenage pregnancy rate at our hospital, let alone why some of those teenagers have never been to a day of school despite having access to an education.
I resign to solving this riddle another day. I pull out my stamp, dislodge the ink pad, grab her right thumb, press it into the ink and then above the dotted line.
"Prep her for theatre, I'm going to scrub," I tell the nurse.
Find out more about the rate of teen pregnancy where you live
The endless search for a bed
"With the limited number of beds in the province, and nationally, HIV-positive patients are often excluded from getting beds because of their poor prognosis"
By midnight we're finished in theatre, but then I have six missed calls on my phone...
First I head to Ward 5, where a 21-year-old tuberculosis patient is struggling to breathe. Next, I make my way to Ward 8 where I have to certify the death of 8-month-old baby Nofundo, whom I'd seen earlier that evening.
Luyanda* was HIV positive and had been started on antiretrovirals a week ago but had developed a condition called immune reconstitution inflammatory syndrome (IRIS), in which the immune system recovers infections that had been lying dormant and the body's newly reconstituted immune system is suddenly in overdrive.
He was very ill, the flesh between his ribs drew in with each gasp he took. He needed to be intubated and ventilated in the intensive care unit.
With the limited number of beds in the province, and nationally, HIV-positive patients are often excluded from getting beds because of their poor prognosis. I called both of our referral hospitals but neither of them would accept him. I prescribed what I could, put him on oxygen and explained to his mom that he was fighting but didn't stand much of a chance.
As predicted, he took his last breath a few hours later.
Born into trauma
At 2 am, I'm called back to the labour ward to see a baby that scored poorly on a common health tests given to newborn babies.
When I get to the cot, the midwife is still "bagging" the child. Placing a mask connected to an inflatable bag over the child's nose and mouth, the nurse is working to pump the bag in an attempt to push oxygen into the corners of his lungs.
I tell her to continue and pick up the baby's umbilical cord between my ungloved fingers.
I'm relieved to feel a good pulse, at least two beats in every second.
I ask the nurse to stop bagging and watch as the baby's chest rises and then falls. He's breathing by himself, but it's been almost half an hour since he was born and still he hasn't cried.
His arms and legs are floppy, and when I put my finger in his palm, he doesn't grasp - his reflexes are completely absent. It appears that he has suffered a severe injury to the brain, and may well go on to develop cerebral palsy.
I do the few small things I can to prevent further damage - turning the warmer off so that his temperature drops to a cool 34 degrees, which slows the metabolism and limits the amount of ongoing brain damage.
I put a tiny feeling tube into the vein in the stump of his umbilical cord, draw blood for tests and start giving him fluid. I prescribe some medication that the nurses can administer if he starts to fit, which is often the case.
Rude awakening
"I'm terribly sorry for her loss. I'm not sure she understands, but she nods and then walks on, joining the back of the queue for morning tea"
It's after 3 am by the time I get back to the doctors' quarters but no sooner had I brushed my teeth then do I get an angry call from the matron.
"Doctor, is it true that you are freezing our babies?," she demands to know. "His temperature is 34, isn't he going to die of hypothermia?"
I patiently try to explain to the matron that actually cooling the child is the best possible thing we could do, and refer her to the protocol book in nursery for further information.
At 5am, I swing past nursery after certifying another two patients who died during the night, only to find that despite my explanation the baby warmer is back on, and the child is being warmed to a displeasing 37 degrees.
Annoyed, I flick the switch and head back towards Ward 2. On my way there, I pass Luyanda's mom in the corridor.
She looks up at me and I drop my gaze, shake my head and say that I'm terribly sorry for her loss. I'm not sure she understands, but she nods and then walks on, joining the back of the queue for morning tea.
*Name changed to protect the child's identity