This week I have been in the surgical ward at King Edward. Monday, I watched surgery. In the morning I dug through an unorganized pile to find tattered scrubs that sort of fit, I observed the removal of a large tumor from the back of a 65-yr-old man, and an attempt to remove the point of a knife that had gotten stuck in the back of a 24-yr-old male who’d been stabbed. Despite the surgeon’s efforts, using an x-ray machine in the theater, the knife blade was too deep and they could not remove it. The most frequent surgery of the day, however, was debridement. Damaged and dying tissue in patients’ arms, legs, and hands was cut off and removed, the wound left open to drain.
The surgical wards are large open rooms, filled with beds. Though the nurses can be seen mopping regularly, the oldness makes them seem perpetually dirty. The first day in S-block, as it’s called, I saw a sign warning about a rat problem, and by the second day I’d seen one myself, scurrying around the patient’s bathroom area. Some of the surgical wards are so crowded that the patient’s beds are less than an arm length’s apart, and when we did rounds, the entire team does not fit around a single bed. Though there are curtains on tracks around patient beds, they are rarely pulled closed, even when we examine patients and discuss what might be termed “confidential” information.
“We have a good system,” the surgeon told me. “If you need surgery, you get surgery, even if you can’t pay for it. The problem is we don’t have enough people, and we don’t have enough of the right people.” He was referring to the twofold problem of South African healthcare. There is a severe doctor shortage, and many hospitals and clinics are managed very poorly. As he explained, “Managers don’t have the same priorities as doctors.”
Other problems became clear during ward rounds. When the doc asked an intern whether the psychiatric consult had been called for a man who had attempted suicide, the intern explained that the psychiatrist wanted the doctors to rule out any medical causes first. I balked – I couldn’t think of any more obvious need for a psychiatric evaluation than a patient who’d attempted suicide. “Everybody wants to avoid doing work,” the doctor said. “You don’t see that in the private hospitals, because they can just come and bill for what they do.” His sentiments mirrored things I’d been told before and that, while trying to holdback judgment I’d noticed myself, about the lack of work ethic in South Africa and a tendency toward laziness. During the four days I was on S-block, the psychiatrist did not come.
Like pediatrics, there were some cases that presented differences in treatment from the U.S. and other industrialized healthcare systems. Most often these differences were surgeries deemed too risky and patients left for palliative care, such as those with pancreatic cancer. When it spreads to the portal vein, this is still considered operable in the US. In South Africa, this short distance spread is considered too far, and the patient deemed inoperable.
A large part of why so many patients are resigned to palliative care, I learned, is that they wait so long to come to the doctor. During my team’s shift at the surgical clinic, I sat with the registrar. In just under 5 hours, we saw some 100+ patients. While some were standard follow-ups and other were actually in the wrong place, many had waited so long to come to the doctor that their problems had gotten extremely severe. One woman complained of a blocked vessel in her leg – when the doctor examined her, it was clear that something more than a blocked vessel was causing her pain. One leg was swollen to three times the size of the other, and the color was distorted. She was admitted right away and sent upstairs to the ward.
Patients wait to see the doctor for several reasons. Some prefer traditional healers and only resort to physicians when their situation becomes dire. Others are afraid of missing work and receiving a consequently smaller paycheck, and some are worried about the nominal fees (which are generally waived if patients can’t pay). But another reason became clear when I accompanied the doctor to do a colonoscopy. “Is this just a routine screening?” I asked. He laughed. “We don’t do routine screenings. We think he has cancer.” I was shocked, and I spent a good deal of time discussing this lack of screenings with the doc. Though South Africa is stable, with a relatively effective healthcare system, pap smears, mammograms, and colonoscopies – prescribed at measured intervals in the US – are primarily diagnostic in South Africa, utilized only when it’s believed there is a problem.
Though I gained invaluable insight into the reality of the public hospitals this week, I faced a personal struggle as I found myself, most days, to be rather useless. Without a medical degree (or even any medical training), I couldn’t assist with these riskier patients. A small highlight came when, during grand rounds, I answered one of the doctor’s questions posed to his interns and medical students, suggested that a patient who had slit his neck may have memory loss due to a head injury or substance abuse withdrawal – and turned out to be correct. But for the most part, I resigned myself to listening and watching. In a small attempt to be purposeful, I made it my mission to smile at every patient during rounds each day (something none of the doctors or other student did – many of them did not even greet or make eye contact with the patients). This elicited some smiles in return, although I also got some unwanted advances and leers from the younger patients, and some glares from the angrier ones. The best moment came on Thursday. The man who’d been in for a colonoscopy was small, elderly, and rather confused. During rounds, he’d often follow us around the ward, hanging on other patients’ beds. After his colonoscopy, I tried to talk to him, but he seemed to hardly understand. On Thursday, however, the doctor told him he was discharged, and could go home (cancer-free, at that). When I gave him a smile as the team moved away, he grinned and gave me two thumbs up. I grinned back.
amanda mph 