In good hands

By Ntsiki Mpulo

Eyes bulging, lips cracked, ribs clearly visible under taut skin; the man appears on the verge of taking his last breath. He speaks in a whisper and, over the din in the emergency room, anyone wishing to have a conversation with him has to lean in close. This is the scene in the emergency room at East Griqualand Usher Memorial Hospital just outside Kokstad in deep rural KwaZulu-Natal.

Doctors are huddled around the man who was brought into the hospital the night before. It seems he had ingested near lethal doses of an unknown substance. His common-law wife of 22 years says he had been taking traditional medicines for several months. She suspects that this is what had led to his severe deterioration over the last few days.

Forty-one-year-old Fikile Ngaleka speaks haltingly as she relates the events that had forced her to have her husband admitted. ‛He started feeling ill around November last year and started getting thinner but all the while still carrying on with young girls,’ she says between bouts of heaving sobs. Her red-rimmed eyes are full of tears. She occasionally covers her mouth as she talks.

‛He went with his sisters to a traditional healer and they came back with some powder that he had to lick twice a day and some kind of pink liquid that he had to drink half a glass of everyday,’ she explains. ‛All of this made his tummy run uncontrollably and I begged him to stop taking these medicines. He would stop for a few days but then start again.’

She pleaded with him to visit the doctor.

 

He either blatantly refused or lied, saying he had gone but that doctors had found nothing wrong with him.

Then, one Wednesday evening, Badanile Thomas Mjojo (47) simply collapsed. He could no longer walk. He was admitted to EG Usher Memorial. He had been diagnosed with HIV, found to have a CD4 count of below 200, and had recently started on antiretrovirals. When he was admitted, his potassium levels were twice the normal levels indicating that he was suffering acute renal failure.

Things were not looking at all good for Mjojo. Few specialists work in deep rural areas like East Griqualand and even if the specialists are there, the state-of-the-art medical equipment is often hundreds of kilometres away.

Yet, thanks to a somewhat unusual government programme, things are looking up for Mjojo by Thursday morning. After a short bumpy flight from Pietermaritzburg to the Bastard Farm Airstrip some 15 km outside Kokstad, Dr Brett Cullis is asked to look at Mjojo’s case. He is in good hands; Dr Cullis is a private nephrology specialist who consults at Grey’s Hospital in Pietermaritzburg. Once a month he boards a small 12-seater aeroplane to EG Usher Memorial, where he provides support to doctors who lack expertise in kidney-related issues.

Cullis quickly determines that Mjojo requires emergency dialysis. He needs to be transferred to Grey’s Hospital in Pietermaritzburg, some 250 km away. Given the advanced stage of renal failure, road transfer is the most appropriate means of getting the patient to the tertiary hospital.

Dr Nigel Hoffman, the Acting Clinical Manager at EG Usher springs into action, calling emergency services personnel to arrange the transfer. But there is a snag. None of the three ambulances based at EG Usher Memorial will be available in time to transport the patient.

‛In his case, there’s not enough time to wait for an ambulance to take him to Grey’s,’ says Dr Cullis. ‛We will start peritoneal dialysis with a make-shift device until he is stable enough for us to transport him to Pietermaritzburg.’

As Mjojo is wheeled the short distance from emergency room to theatre and is being prepared for surgery, the hospital is suddenly plunged into darkness. The power had failed and the new generator, which had been installed just two weeks before, has not switched on.

Dr Hoffman calls the maintenance department. The news isn’t good. It will take over an hour for power to be restored.

Working in the half-light, the doctors make sure the patient is comfortable, with a drip feeding him an essential saline solution to flush his system. With nothing more to be done until power is restored, Cullis attends to outpatients he was scheduled to see before the emergency occurred.

Finally the lights flicker back on. The physicians don their sterilised scrubs and head back to the operating theatre.

‛We cannot risk putting the patient under general anaesthetic – we don’t believe his system would handle it. So we are going to use a local anaesthetic,’ explains Dr Cullis.

He speaks quietly to Mjojo. He explains in broken Xhosa that he will inject his stomach with anaesthetic, make a small incision below the belly button and insert a tube into which he will pump saline solution. Once inside the belly the solution will draw out impurities in the blood through osmosis and will then be drained via the same tube. Ordinarily, dialysis is done with a small 2 mm tube into the blood stream, but without the right equipment the doctors will improvise with a chest tube.

The operating theatre is quiet as the doctors go to work. Mjojo moans in discomfort, the only sounds in the operating theatre apart from the beep of the blood oxygen monitor. Dr Cullis struggles to insert the tube and adjust it to make it into a two-way valve system that would allow for fluid to be both injected and drained. Now and again, a quiet whisper. The tension and focus in the room is palpable.

Finally, after an hour of alternatively widening the site of the incision and placing the tube deeper into the abdomen, the procedure succeeds. The doctors give a muted cheer.

‛I did not want to dig too deep in case I punctured the bowel and so, what would ordinarily take 10 minutes with the right equipment, has taken an hour,” explains Cullis. ‛But this is a good outcome under the circumstances.’

‛Often the issue is that people take too long to come into the hospital and get onto dialysis and, as a result, they die,’ says Cullis. ‛If we had sent him to Pietermartizburg without performing the procedure, he may not have made it.’

For the time being, Mjojo has been stabilised. Soon, the ambulance will transfer him to Grey’s Hospital where he will receive further treatment.

The outreach programme that flies Dr Cullis to EG Usher once a month is not available in all provinces, and in some provinces it has collapsed after previously being functional. Like many public programmes, it has become mired in disputed tenders and the spurious awarding of contracts.

Dr Lindiwe Simelane, general manager for clinical support services in the Kwazulu-Natal Department of Health says the outreach programme is invaluable in the delivery of services to the rural areas of her province. ‛There is a global shortage of medical professionals, and doctors in particular. Our particular challenge is in retaining doctors in rural areas. They come as community service doctors and, once they’ve completed their two years in the public service, they leave,’ she explains.

‛A robust outreach programme is part of the solution because senior doctors and specialists are able to go out into the rural areas and support our young doctors,’ she says. ‛Indeed, we have built teams of roving doctors who are able to provide expertise in their specialisation which we don’t have at a regional and district level.’

‛The idea is that patients should not go to tertiary hospitals until they have been seen at a clinic, and district and regional hospitals. They need to have a referral letter from a general physician seeking specialist care at tertiary level,’ she explains. ‛Part of the outcome for outreach is to decongest the system and to ensure that the referral system works.’

Dr Cullis is pioneering a programme to deliver life-saving kidney dialysis treatment to remote places in South Africa and across the continent using a technique called peritoneal dialysis (PD). Dialysis is a way to remove waste products from the blood when the kidneys can no longer do the job adequately. The most common form is haemodialysis, which involves using a machine to filter the blood ,removing impurities. In many countries, haemodialysis is inaccessible due to cost and lack of infrastructure. A peritoneal dialysis is a procedure that uses the inside lining of the belly to act as a natural filter to perform the functions of a kidney and is much more cost effective, and affordable, for most developing countries.