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International Child Health Section: Articles
Paarl, South Africa
September 21 — November 27, 2009
Kirsten Ebbert
As my plane descended into South Africa, I was awed by the lush landscape and the magnificent waves crashing into the shores of the Western Cape. A trip to Kenya and Tanzania during medical school had sparked my interest in international health. Now those memories were overpowered by a great surge of excitement about beginning another adventure into learning on this colourful, amazing continent. I was finally here. South Africa.
My elective was in Paarl Hospital, a secondary level hospital about an hour northeast of Cape Town. The hospital was being rebuilt, and a tour of the new paediatrics ward and nursery was a definite contrast to the old casualty (emergency) department. The paediatric department included a medical ward, gastroenteritis ward, and a level two nursery totaling 68 beds, as well as an outpatient clinic. When on call, we were responsible for these wards, deliveries, admissions from casualty, and outside calls. We were the IV team, phlebotomists, and respiratory therapists for these patients as well. Overnight, a single intern or registrar was responsible for all of these patients, with no other in-house paediatric medical students or registrars, and a paediatrician on-call from home.
It didn’t take long to realize that the fresh paint on the ward walls did not mean resources were plentiful. After checking the ears on one of my first patients and throwing away the otoscope tip, I learned that the few pieces in the ward’s single portable otoscope case were to be swabbed off and reused. When unable to find any otoscope piece in casualty on a number of subsequent occasions, I regretted tossing that piece. Now back in Canada, my arm always hesitates a little before throwing away those “reusable” pieces.
My time on the ward in Paarl Hospital provided exposure to many general paediatrics problems, many of them being infectious. Admitting a few patients with bronchiolitis, pneumonia, or gastroenteritis was guaranteed every call. I saw more HIV and TB than I have seen in my entire residency, and learned about the many ways these diseases may present. I saw patients with sepsis, meningitis and hepatitis. Non-infectious presentations included seizures, congenital heart disease, intentional and accidental overdoses (e.g., TCAs, organophosphates), neonatal jaundice (including a baby with probable kernicterus), hemophilia and child abuse, to name a few.
Paarl is known as the “centre of Afrikaans.” As a result, communication with patients was sometimes difficult. The majority of patients spoke Afrikaans or Xhosa, although some were able to communicate in English. Although I found the language hard to speak, a few basics like koors (“fever”), rool (“red”), and pronouncing “water” with a v (“vater”) made histories a little easier. Sisters and nurses were often helpful in translating. By the end of my elective, I was worried that I might lapse into cooing “baba” to settle babies back home.
Despite the language barrier, hearing people’s stories and lives was one of my most appreciated experiences. Nearly everyone I spoke with had opinions on South Africa’s past and current political situation. I enjoyed listening to the variety of thoughts people expressed about their country, and was impressed by the political interest and knowledge even young South Africans had. On call, I learned even more about people’s personal situations — from those who
had to wait for a family member or employer to drive them great distances to seek medical attention, to those who explained that their family lived in a horse’s stall, minus the horses. I also began to understand the gravity of the HIV epidemic and its attached stigma, listening to hushed stories behind the curtain in casualty of mothers who had contracted HIV through sexual assault.
My experiences on call, while often busy and difficult, provided me with the opportunity to triage and manage patients who were at times very sick. I attended a delivery for undiagnosed twins, resuscitated a premature baby who was born before arrival, and managed meconium aspiration. I was called to stabilize a child with newly diagnosed seizures who had arrived in casualty after being in status epilepticus for four hours, having stopped taking antiepileptics when she ran out. I improved my skills in IVs, arterial bloodwork, and intubations, often with little assistance. All of these opportunities improved my confidence in being able to manage difficult situations in a peripheral centre with limited support. Sadly, some cases presented too late for help — I vividly recall an apneic and pulseless 8-month baby boy, carried up to me by his father in the casualty department. The baby had Trisomy 21 which was not diagnosed, and his father had driven him to hospital by car from a neighboring town after what sounded like an aspiration earlier that morning. Despite our efforts at resuscitation, the child passed away.
Despite some difficult experiences, I was impressed at the support that the South African people provided each other. After being transferred to Paarl Hospital earlier in the day for assessment of her newborn’s edema, one mother collapsed on the ward and was admitted to the ICU. She passed away the following morning from a brain aneurysm. In the face of this tragedy, the other mothers in the ward took over feeding, changing, and holding the baby until the extended family arrived. Even in less drastic cases, this was the norm. If a child was crying and his or her mother was not at the bedside, the other mothers in the room cared for the child until her return.
In addition to clinical experience, I loved getting to know the medical and nursing team. The team was welcoming, happy to teach me about their practice, and interested in sharing ideas. I was often invited out with them, most usually to the infamous “Braai” (barbeque). I enjoyed sharing a home with a lovely South African family, who were also wonderful about including me in their activities, and teaching me about Paarl and South Africa. Outside of work, I spent some time exploring the beautiful countryside around Paarl. Despite my best attempts at seeing various parts of South Africa, I know I have seen just a glimpse of the beauty and cultural depth that South Africa has to offer.
I thank the people who allowed me that glimpse into their lives and their country, as it has broadened my understanding of both the unique people and culture in South Africa, and of life and health in a developing country. It has provided me with a broader lens with which to view medicine and global health, and I believe this journey to South Africa has had a positive impact on my personal development and the kind of paediatrician I will become. In the words of Nelson Mandela, “Education is the most powerful weapon which you can use to change the world.”
Posted: February 2010
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