Medicine over the Mountain

My year of community service in Oudtshoorn is drawing to a close and it has been quite an experience. Working in the periphery is a whole different ball game with its own challenges and frustrations, but also plenty of growth opportunities. I can honestly say that I would have turned out a totally different doctor had I not spent this year in a peripheral hospital. 

The reason I’m calling it peripheral medicine and not rural medicine is because as far as Oudtshoorn goes, is it really rural? I mean, technically the closest Woolies is more than 50km away so yes, it is rural, but some people might not agree with that reasoning. 

When I applied for Com Serve, Oudtshoorn wasn’t even on my radar but life happens and here I am, 50 weeks down, two to go. Its been a while since I wrote a blog because well, as I said, life happens, so I thought it was about time (also, I’m supposed to be studying and this feels like a worthy form of procrastination). If you care to procrastinate with me, let me share some of the ups and downs of my year in “rural” Oudtshoorn with you:

I definitely think one of the biggest frustrations of rural medicine is getting patients to a higher level of care. Transferring a patient to a referral centre is more work than the actual task of stabilizing and managing the patient itself. Obstacle number one is getting through to the referral centre’s switch board. You would think that this would be easy since the primary job of switch is to answer the phone. Think again. I have no idea what those people are doing, but most of the time it is does not involve any phone answering. Next, you have to get through to the right doctor – this usually involves having to get past obstacle number one multiple times.  When you eventually end up with the right person, you have to work dam hard to get them to accept the patient. Trust me, convincing a medical officer in a secondary hospital to accept a patient is a work of art. They should really have a whole module on it in med school. After all, the first thing medical officers are taught at referral centers is how to bat patients, aren’t they? 

“Oh that sounds more like a PID than an appendix, maybe discuss with the gynaes… Oh it’s a male patient. Probably abdominal TB then”

“Yes, this HIV positive man with a CD4 count less than his age most likely has a tuberculoma but he could also have had a head injury that we don’t know about – discuss him with EC first.” 

“Are you sure the patient is even pregnant? Maybe she just has a really distended abdomen.”

Okay, so I’m exaggerating but you get the point. It’s a struggle. 

And once you have performed the miracle of getting a patient accepted, you still actually have to get them there. Phoning the EMS control centre is always so entertaining. They ask a million and one questions for which most of the answers have no meaning to them whatsoever. The other day I was transferring a newborn and was asked for the GCS score. For my non-medical friends, obtaining a GCS score requires a patient to be able to talk and obey commands – I don’t know about you, but I have never heard a newborn baby tell me their name, let alone the date or time. As for following commands, any new mother will tell you that “Stop crying!” isn’t gonna cut it. 

There is also a common misconception that doctors in peripheral hospitals are lesser doctors. I know this because I worked in a referral centre and I’ve heard the things that are said. It’s really funny actually, you can work in a secondary or tertiary hospital and be considered a good doctor and the second you move to a district level hospital it’s like you lose all credibility. If I only remember one lesson from this year, it’s that for every one idiot that calls you from a peripheral hospital there are at least three incredibly talented, competent and diligent doctors working along side him. It’s really been a privilege to work with some of the people I have worked with this year. Medicine in the periphery is not easy. You don’t have access to X-rays and labs 24-7 and you really have to rely on your clinical skills and judgement. You have to transition from doing a vacuum delivery to resuscitating the baby, to putting in a chest drain for stab chest to counselling a diabetic on their lifestyle all in one shift. Most of the doctors I have worked with this year are truly well-rounded and dedicated clinicians. 

While we are on the topic of referrals, let me tell you about the GPs in rural towns. On second thought I probably shouldn’t because I’m just going to offend somebody – Oudtshoorn is a small town and its guaranteed someone reading this has a friend or family member who is a GP here. Let me just say that I’m pretty sure the last time some of them read a medical journal or looked at a protocol is when they graduated in 1932. 

One thing that doesn’t change no matter where you work – there will always be Pandas (see previous blog post for clarity). They are just on another level here in Oudtshoorn. They usually know someone who knows someone who works at the hospital, which makes them feel a whole lot more entitled, and frankly a whole lot more annoying. A classic example is the lady who laid a complaint via a doctor’s wife because she was admitted to the children’s ward (where she even got a private room) because the female ward was full. But she was “booked” for the female ward and it’s “unacceptable that a bed wasn’t kept open for her.” Or the woman who refused to see anyone else but a specific doctor – because that is “her doctor” and “she’s the only one who knows my illness”. I can’t deal. 

Now for the ups – one of my favorite things about working in such a small hospital is getting to know everyone on a first name basis. From the nursing staff, to the clerks, to the cleaners. And not just getting to know them on a “take a selfie and post it on Facebook #nursesarethebest #multidisciplinaryteam” kind of way, but really getting to know them. I have spent so much time in the early, quieter hours of the morning confiding in nurses and making jokes with porters and hearing about families and hobbies and lives outside of the hospital. If you know me well, you will know that I’m not exactly the chatty type, but there’s something about warmth that the people in rural places exude that just gets you to open up. Oudtshoorn Hospital knows too many of my secrets, and when I say “Hospital” I really mean it – when one person knows, the whole hospital knows. 

I’ve also gotten to know some patients very well. Like Tannie Katy (not her real name) who I have probably seen in casualty at least twelve times – every time with a different complaint but no real pathology. She just needs a little TLC every now and then, so we give her a neb and liter of magic saline and send her on her way. You get to walk a much closer path with patients in smaller hospitals. And when a patient gets transferred to a bigger hospital, they usually find their way back to you. If not, you can always stalk them on ECM. A classic example is a patient I saw at De Rust clinic who I referred to the hospital, and ended up being the one to see her in Labour Ward when she arrived (effectively I wrote a referral letter to myself – one of many). She was transferred between George and Oudtshoorn multiple times, but when her and her new baby were ready to be discharged months later it was me who ended up writing the referral letter back to the clinic. A full circle. 

Apart from how to drink coffee, this year spent in a “rural” hospital has taught me that Medicine is so much more than illness and disease. It’s about interpersonal relationships and social constructs and family units. It’s about finding a balance between traditional beliefs and scientific facts. It’s just as much about healing spirits as it is about healing bodies. And most importantly, it has taught me that a secondary or tertiary hospitals really means nothing if there aren’t people willing to do the dirty work in the periphery. 

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