Friday, October 31, 2008

Melanie's musings

Today was a huge day here at Good Shepherd. The “newly elected” (ie chosen by the King) Prime Minister and Health Minister came out to see the hard workers at one of their leading hospitals. The place was like a circus with people running around like lunatics trying to make the place look better than it actually is. Meanwhile, Chris and I spent our time hidden away in the hospital actually seeing patients. It seems ironic that as the only two staff members who aren’t paid to work here, we were the only ones who were working and not watching various speeches given by Ministers who didn’t actually step a foot in the actual hospital. I shouldn’t be so cynical- I know this happens with politicians everywhere in the world. However, I want to give you a “behind the scenes” insight as to what was actually happening behind all the pomp and ceremony.

I woke up early this morning. On Fridays I give the nurses a tutorial at 7am. I had a splitting headache and for a moment, it crossed my mind that I may have meningitis. I then reminded myself that I don’t have AIDS and despite the fact I have many cases of meningitis on the ward, it is uncommon to get the disease if you have an intact immune system.
I entered the ward and was nauseated by the smell of faecal material. One of my women, who has been with me well over a month, has shocking diarrhoea and the faecal material had leaked out of her incontinence pad and smeared every surface surrounding her. She has advanced AIDS and can barely roll over because she is so weak. Her family have abandoned her and I have no where to send her for her final stages of life. She will probably spend her last amount of time on earth lying perilously in her own excrement.
I then started my ward round, trying to ignore the stench of urine, vomit and faeces that lingered in the air. One of my first patients had been admitted overnight and I was reviewing her for the first time. She was 13 years of age and had been admitted with presumed meningitis. After reading her notes, I went to examine her. No pulse, no respirations and pupils fixed and dilated. Diagnosis: dead. Let me tell you, this has happened before and it’s not a pleasant way to start the day. She was 13, but already looked like she had advanced HIV. You may ask, “How does a 13 year old get HIV?” The sad answer is that many young girls are often sexually abused when they are little and by the time they reach adolescence, they have full-blown AIDS. I’m not sure how common it is here, but certainly in South Africa, there is a belief amongst a small group of people that having sex with a virgin will cure you of your HIV. This puts many young girls at risk and further perpetuates the cycle of HIV. We see a lot of young girls here who have been sexually abused. Thankfully, I have been shielded from having to actually care for them and for that I am grateful. It would destroy what little is left of my spirit.
I then had to see a twenty year old female with advanced HIV and a pneumonia called PCP. I thought I was succeeding in her management, but today she was confused, disoriented and having visual hallucinations. This happens quite frequently here and usually leaves me with a sinking feeling of impending doom. I wrote up some drugs for her and moved onto my next patient. Meanwhile, she falls out of bed trying to reach for something that doesn’t actually exist, and she starts crawling around on the cold cement floor. She was then sliding in between my feet, guided by her visual hallucination but also showing a look of shear horror and fear like she was possessed. I looked at my nurse and said “you better go and get some help”. I tried to comfort the patient and reassure her that she was safe. My nurse was taking an inordinate amount of time trying to find some help but she eventually returned with two of the male student nurses. With a difficulty that was painful to watch, they hoisted the patient back into bed and proceeded to tie her hands and feet to the railings using scraps of fabric. These are the physical restraints that are used here to deal with “difficult patients” and it really disturbs me to see these very frightened, sick people tied down. She started fighting against the restraints and I ended up ordering a drug to try and tranquilise her so that the nurses could manage her. There simply aren’t enough resources for nurses to do one to one nursing here and this was my only “safe” alternative for the patient. I dread to think what will happen to her over the weekend when I am not around. This is another dilemma I face- for two days I feel like I am “abandoning” my patients and there have been times where I have considered dropping in on a few occasions to check on them. I started doing this when I first arrived but I have restrained myself from doing so lately as I simply need to protect myself from burnout and have two days a week where I am not confronted by death and devastation.
I then went to outpatients, where I was the only doctor present. I started seeing copious amounts of patients, most of whom were co-infected with HIV and TB. Their management is incredibly difficult and I found my headache getting progressively worse. By lunchtime, I hit the wall and I went back to my flat and collapsed on my bed. I ended up falling asleep and I missed the afternoon in outpatients. I felt bad, but I was so exhausted and hopefully, now that the PM had left, the other doctors had returned to work.

So now I am at the beginning of a weekend and I hope it will be a pleasant one.

I am starting to get very nervous about the upcoming US election. Although I am not American, I do follow American politics closely and I am a huge fan of Barack Obama. In fact, I think I love him. This week, I even had a dream about him. It probably was influenced by the fact that I am reading his book “The Audacity of Hope” and the election is so near. We, as volunteers have been very concerned about how we are going to watch the election coverage. We lost our TV so we no longer have access to CNN. We were brainstorming all week and I finally got the courage to ask Dr Wahabi (gynaecologist from Ethiopia) if we could use his TV during the election. He happily obliged and we now have plans for Chris, myself, Susan and my Peace Corp friends to spend Wednesday morning (Tuesday evening American time) watching the election coverage. Kristin and Andrew have even volunteered to make pancakes so that we can make a party out of the occasion. However, let me warn you now, if Barack loses, I’m afraid there will be more tears……
Just so you can appreciate just how far reaching the results of the election are, the other day, I had one of the grounds men here at Good Shepherd approach me and ask if I could do him a favour. He wanted me to try and email Obama and let him know that the Swazi’s love him and they hope he isn’t taking the insults that McCain throws at him personally. I couldn’t help but smile. I had to inform him that although the internet was a powerful tool, I didn’t have Obama’s email address and I wasn’t sure how to contact him. The grounds man was most disappointed.

It was Chris’s birthday this week and we went all out to make it a special time for her. She had two parties. The first one was on Tuesday. I made minestrone and Kristin made a cake. Minestrone is my signature dish here in Swaziland. It is the only thing I can make that reliably turns out well enough for group consumption. Kristin’s signature dish is dahl and Chris’s dish is Cincinatti chilli which is chilli beef made with chocolate and cinnamon and served over spaghetti…….Julia makes her own bread and is just a magician at whipping up cakes that delight us all. Chris then had a second party on Thursday night where we invited all the doctors and their wives over for dessert. It was a nice occasion. Birthdays here are important. The average life expectancy here in Swaziland is 33 (yes, you read that right THIRTY THREE), so any birthday after that age is considered extra special. I hope Chris felt special because she certainly is the ray of sunshine here during the dark times in Swaziland.

Sunday, October 26, 2008

Peace from the Peace Corp

Last week, during one of my darker moments, Kristin and Andrew from the Peace Corp suggested that I come and stay with them for the weekend. I politely declined initially and then I realised that they were living out in a Swazi village for two years- the least I could do was spend one weekend with them.

They came and picked me up from the hospital on Saturday. As part of the Peace Corp, they are not allowed to have their own vehicle so everything is done on foot. We set out for the 40 minute walk along a dusty dirt road with dark storm clouds looming overhead.
Thankfully, it only rained for a short part of the journey and it didn’t distract me from marvelling at all the local people, their houses (made literally of sticks and stones) and the abundance of cattle, goats and chickens that meander alongside you.

We arrived at the homestead that Kristin and Andrew are living in. They are actually living in quite a “flash” abode with concrete walls and a corrugated iron roof that is firmly attached to the base and doesn’t need stones thrown on top of it to keep it in place.
They don’t have electricity and they don’t have running water, but surprisingly, their home is incredibly comfortable and welcoming. They have a gas bottle that fuels their stove and oven and they have purchased some cupboards, a couch and a double bed. Kristin has done a beautiful job in decorating the place and my little flat (which I boast is the best at Good Shepherd) somewhat pales in comparison.
Of most interest to me was the dreaded latrine. I have obviously heard about these amenities and having Noah found in one made me extra curious. Let me tell you- I was horrified. Hopefully Courtney will be able to upload the photos for me, but as you can see the “toilet” is a concrete cylindrical mass that stands to the height of my mid-thigh and it terminates in a pit that is progressively filling with urine and faeces. The stench is overwhelming. You can see that modesty is achieved with some corrugated iron with the sole of a thong used as a lever to open it with. I did use this “toilet” on one occasion but then I refused to use it thereafter- choosing instead to squat behind the building and quickly pass urine. The reason for me choosing to avoid the latrine is that during the night, one of the other members of the homestead had an episode of “explosive” diarrhoea and faeces were covering the entire concrete structure. The structure stands too high so that you can’t just “squat” and I simply couldn’t bring myself to wipe the faecal matter away. Unfortunately, overnight, Kristin also developed an upset stomach and we were faced with a difficult dilemma. I managed to convince her that she simply couldn’t use the latrine, so several times through the day, I went with her to guard against passers-by so that she could relieve herself elsewhere. During the weekend, we brainstormed on alternatives to the latrine (which really is the reason I think Kristin was sick) and I think I helped them come up with some ingenious alternatives that will be put in place as from tomorrow.

I don’t want to concentrate on the latrine too much, because honestly, the weekend was one of the highlights of my Swazi experience thus far. Kristin and Andrew are two of the most amazing people I have ever had the privilege of meeting. They embody the concept of humanity and their kindness, courage and commitment to their calling inspires me every time I am graced by their presence. They are also very funny, very knowledgeable and have a true understanding of both our modern world and the third world we find ourselves living in. We talked for hours and hours and we laughed. I even had the return of my sense of humour that I have lost over the past couple of weeks. I felt so comfortable with them- as though I had known them all my life. They made me feel incredibly special as I was their “first visitor to their home” since they arrived in Swaziland. We stayed up late talking (10pm in Swaziland is considered very late- most of us are in bed by 8pm because we have run out of things to do). They set me up with a roll-out mattress and I was most comfortable. I was a little upset at being woken up at dawn by the roosters announcing the start of the day, but my mood was soon lightened by Andrew making some delicious pancakes and the return of our free-flowing, enjoyable conversation. I feel we know almost everything there is to know about each other. We sat around for hours just talking and laughing. You will be relieved to know that I had the sense not to wear my pink “Winnie the Pooh” pyjamas and I sensibly chose tracksuit pants and a t-shirt. I wore these outside, lounging around inside and then as we walked back to Good Shepherd. It didn’t bother me in the slightest that I had not washed and I looked absolutely dreadful. Here in Africa, that does not matter and the concept is quite liberating for me. That being said, when I got home this afternoon, I jumped in the shower, washed my hair and scrubbed with antibacterial soap. You just can’t teach an old dog new tricks…..
So as I conclude this message, I can assure you that I am feeling much better, reinvigorated and re-inspired to continue my work. Thank you Kristin and Andrew- words will never ever truly be enough to express my appreciation.

Thursday, October 23, 2008

Goodbye Noah

Little Noah died.

I know that he received fabulous medical care, love and attention at the orphange.
I know that everyone there did their best to try and save him.
My heart just hurts so much that I wonder what else could possibly happen in Swaziland that would make me sadder than what I am now.

Tuesday, October 21, 2008

Thoughts from a crazy shrink

It’s been an incredibly busy start to the week. My patient numbers continue to explode and I am confronted with difficult, challenging cases on a daily basis.
I’m still struggling with my own emotions. I find myself crying at least once a day. I had dinner with the Pon’s last night and they provided me with a lot of comfort and reassurance. They are incredibly beautiful people who have such strength and faith that it’s hard not to be inspired by being in their company. They have decided that I would benefit from being part of a family for the rest of my stay and they have organised that I will have dinner with them and their children every Monday. I am sure this will help me a great deal.

It seems rather ironic, that in the face of my own emotional crisis, I have been given the rather unwanted role of psychiatrist here at Good Shepherd. I hate psychiatry, almost as much as I hate orthopaedics and I simply detest orthopaedics. However, if anyone seems to show any hint of an emotional disturbance here, it suddenly becomes a “medical” problem and the patient is passed onto me- much like you would pass on a bad smell.

I had a female referred to me from the gynaecologist. She had been admitted with pelvic inflammatory disease (a medical term that softens the real diagnosis of sexually transmitted disease). Anyway, she was behaving in a rather disruptive manner and she was referred to me with the provisional diagnosis of being “psychotic”.
It was with a sinking heart that I went to interview her with my nurse who would act as a translator. Let me tell you, it’s extraordinarily difficult to take a psychiatric history from someone who does not speak English. It is near to impossible when you have underlying cultural differences that make it difficult to determine whether something can be deemed psychotic, or just a little cultural difference that may be considered completely normal here in Swaziland. Anyway, I was able to elucidate that this woman had HIV, she had just lost her job and her husband (who had kindly given her PID) had just run off with another woman. Now I ask my female readers, who wouldn’t be considered a little mad having to experience all of this? Was Lorana Bobbitt ever considered psychotic? If you ask me, it’s perfectly reasonable to be a little emotional having to deal with all of this. Obviously, my opinion does not count here in Swaziland (yet people continue to ask for it). My prescription of an antidepressant to try and help her sleep at night was not considered adequate psychiatric help and I was forced to refer her to Swazilands only psychiatric service in Manzini. I wonder what the psychiatrist there thought when he received a letter with the opening line- “I’m an Australian medical doctor who does not speak SiSwati and does not yet have an appreciation of cultural norms”…….

My second psychiatric consult was indeed much sadder. It was a 15 year old girl who had taken an unknown quantity of an unknown substance to try and kill herself. Thankfully, she did not suffer any deleterious medical effects, but I was asked to see her to “sort out her emotional state”. I found out that she was hoping to take her life because her family could no longer afford to send her to school and she desperately wanted to continue her education. She saw no hope for her life if she couldn’t receive a decent education. Welcome to life in a third world country. In western countries, we have adolescents who desperately try not to go to school. Kids who have no respect or appreciation for education. It made me sick to the stomach. I knew I couldn’t help this girl. I have already spent a good portion of my money paying for Elsie’s (my housekeeper) daughter to finish school. I simply cannot afford to pay for another girl. Instead, I wrapped this girl up in my arms, embraced her as we both cried and then continued on my ward round, trying to alleviate the suffering of a country that is desperately ill.

Sunday, October 19, 2008

Sundays in Swaziland

Noah is not doing well.
After I posted my last blog entry, I checked my email and the people at the orphanage had written to me to tell me that Noah was having cyanotic episodes (ie going blue). This is certainly not a good sign given that he was born prematurely and in a latrine.
I had mentally braced myself for the possibility that Noah has HIV, but I had not braced myself for the possibility that Noah may die before I see him again.

I was very sombre when I returned to my flat. The Pons called to ask me to a braai (BBQ) at their place, but I politely declined. The last thing I felt capable of doing was socialising. I will have dinner with them tomorrow night instead. It’s often difficult for my family and friends to understand, but when I am really upset, I need to be alone. I need time to reflect, I need to reach for my own inner peace. Anyway, Dr Pons then told me that he had spoken to the local Anglican minister in town and mentioned that I was around. Dr Pons asked me if he could pick me up in the morning so that I could attend mass. This was an awfully sweet gesture as Dr Pons does not even attend this church. I think he just thought that I needed some divine intervention in my life.

I don’t normally attend church. As I have mentioned previously, whilst being brought up an Anglican and receiving an excellent education in a Catholic school, I find that my thoughts on God and spirituality do not fit in with these mainstream religions. My spirituality tends to be reflected in nature, the kindness of fellow human beings and the belief that religion is more the way we choose to live our lives rather than the rituals and symbols presented in formalised religion.
Anyway, I decided to accept the invitation and I went along to St Christopher’s this morning. A very small, simple church ministered by a local Swazi called Father Peter. As always, I stood out with my white skin and the recognition that I was the dokatella from Good Shepherd. The people there were incredibly friendly and delighted to have me as part of their congregation. The service was exactly the same as what I have paid witness to in Australia and I am afraid I did not find the enlightenment or comfort I was desperately hoping to seek. Half way during the service, the minister asked me to get up and address the congregation. I was certainly not warned that this would happen, but very little phases me now and I got up to the pulpit. I explained where I was from and what I was doing here and then I started to cry. This is a curse that has afflicted me since childhood. My inability to control my tears in public. I spoke of the burden of HIV in this country and my feelings of helplessness in trying to relieve the suffering. I told them that I had lost my faith. The congregation responded with rapturous applause and I just stood there a little embarrassed at my public display of emotion, but the people obviously appreciated my frank honesty. One of the congregation members then said a prayer on behalf of everyone and she openly and passionately prayed for me. It was really very touching. We then prayed that the recent political turmoil here would resolve peacefully and then we prayed for rain. Water is scarce here and as one parishioner eloquently explained- people are drinking the same water as the cattle.

I then walked back to Good Shepherd. It was 9am and the weather was beautiful. There was almost no one else in sight and the only sounds I could hear were the songs of birds and the occasional groan from the cattle. It is spring here and the Jacaranda trees are in full bloom. It seems like the whole of Swaziland is coated in a carpet of purple blossoms.
It is these moments that give me peace, comfort and a sense of God.

The rest of my day has been spent resting. I am having dinner with the Peace Corp people tonight. Jenny returned to Scotland on Friday and Julia is leaving next week. I know I will feel a deep void when she leaves. We have a new member of our “family”. Her name is Susan. She is originally from Ohio, but a few years ago, she married a British man and she has been living in England for the past 6 years. She is here for 12 months as a public health consultant and she will be working on a project to try and co-ordinate care in those co-infected with HIV and TB. We get along really well and I have spent the week settling her into Good Shepherd. The irony is- I’m now the “local” showing people all around and explaining all the bizarre things here that only a local could ever understand.

Saturday, October 18, 2008

A really sh-tty week

I’ve had another difficult week here in Swaziland. I have cried everyday. It is becoming increasingly difficult to get out of bed each day. I can’t tell if I’m depressed or whether this is a perfectly normal response to what I am seeing here.

My week started badly in that I was inundated with new admissions. I had 12 new admissions to start my week and this is on top of the 20 or so other patients I already had on the ward. The next day, I had a further 10. It’s not like I have another resident to run around and assist me (like at home). I run the whole show and I do everything from all the paper work, all the procedures and all the decision making.
Not only do I see all the medical patients, I am also asked to consult on the gynaecology patients and the surgical patients. They all have HIV and this is considered a “medical” problem, so I am often involved in their care as well. I find it all thoroughly overwhelming. I am exhausted.

The patients are not simple. In fact that are often far more complicated than what I deal with at home. The problem that I face on an everyday basis is that my patients often present to me in an advanced stage of their illness. People are not getting tested for HIV and they often present to hospital with their AIDS defining illness. For those of you who do not understand the difference between HIV and AIDS, I will give you a very brief and simple explanation.

HIV is the virus that causes AIDS. It infects cells of the immune system called CD4 cells. It destroys these cells so that immunity is lowered and the body is then susceptible to catching really serious infections and malignancies. You can assess the progression of the illness by obtaining a CD4 count. Anything less than 200 is considered AIDS because the immune system is so depressed that it is vulnerable to infections that we, with intact immune systems, can usually deal with. We try to start people on Anti-Retroviral (ARVs) Drugs when their CD4 count is 200 or less.

The trouble I face here in Swaziland is that people are presenting to my ward with CD4 counts of around 50, 10 or even 5 (I have had a patient with a CD4 of 3). They basically have no immunity. They present with the most devastating infections such as meningitis (bacterial, fungal, tuberculous), brain infections, pneumonia, diarrhoea, tumours and what is called “wasting syndrome”. If any of you remember the pictures we saw in the 1980s of people who were afflicted by the famine in Ethiopia, then this describes the wasting syndrome perfectly. They don’t just have one illness, they tend to be multiply infected. For instance, I have one patient with a CD4 count of 10. She has what is called HIV encephalopathy which is somewhat like dementia, somewhat like psychosis. She also has PCP pneumonia. She also has pelvic inflammatory disease as well as these horrendous genital ulcers. She also has a raging bacterial conjunctivitis. I have another patient who has PCP pneumonia as well as cryptococcal meningitis. Many of my patients have TB- but not just the pulmonary type- they have TB of the abdomen, pleura, pericardium, lymph nodes and even the skin. We are starting to get Multi-Drug Resistant TB which I see as the next impending disaster here in Swaziland.

I have had a patient on my ward here for sometime and I have been fighting on a daily basis to keep her alive. She was 18 and had advanced HIV with a CD4 count of 35 when she first arrived. She also had lymphoma of the tongue- her tongue was huge and it was difficult for her to swallow. I also think she had lymphoma in her gut because she vomited constantly. We do not have any injectable anti-vomiting drugs here, so I was using antihistamines (which can sometimes help with nausea) and a drug called dexamethasone. I tried everything I could to stop that girl vomiting. Everyday, I would see her and see would be lying in her own pool of vomit. She was so incredibly weak and emaciated that she did not have the energy to roll over and vomit. The nurses were changing her linen constantly, but as soon as she was settled in new sheets, she would vomit again. She was in pain, but the only narcotic analgesia I could give her was oral morphine which she would vomit up. She was so wasted that I could feel through to her spine if I palpated her abdomen hard enough. It destroyed me each day to see her just wasting away. She loved orange juice, so I would go and buy her the juice. She would sip it through a straw because her tongue was so huge with tumour that swallowing any other way was next to impossible. She would then vomit it up, but I knew that she just loved the small time that she had the liquid in her mouth.
This patient died alone on Thursday. Her family never came to see her. She was thrown out when her family found out she had HIV. This happens to many of my women here and it is devastating to me. Despite the fact that the official figures state that 43% of the population here has HIV, it is still an incredibly stigmatised disease. I feel that women here tend to be more affected by the stigmatisation than the men. It is easier for a woman to catch HIV compared to a man. Men here can have multiple wives and multiple partners at the same time and this is considered culturally normal. I feel it is one of the reasons that HIV is so rampant here. Women don’t have many options when they are abandoned by their families or their partners. One of the things which poses a particularly big problem for me and my patients is that in order to be on ARVs, you need to have a treatment supporter who will encourage you to take your medicines. My women are too frightened to reveal their HIV status because they fear abandonment, so getting them on ARV treatment is almost impossible. I have been fighting with my colleagues about this issue, but they are just trying to maintain “national guidelines”. I really feel it is ideal to have a treatment supporter, but what happens to my women when there is no one left around them?

Everyday, I feel that more and more of my soul is being destroyed. I feel overwhelming hopelessness. My sadness consumes me at times. I can’t sleep properly, I look dreadful. My eyes have lost their brightness. I feel so upset by what I am witnessing, that my heart physically hurts at times. At times I am angry and bitter. I don’t like feeling this way. This is not who I am, but I fear it is what I am becoming. I fear that my friends won’t like me when I get home, because the very essence of who I was seems to have disappeared. And yet, I keep going, because everyday I think of my patients. Despite the devastation that surrounds me, I am inspired to keep fighting for them. They are the only reason I am able to find the energy to get out of bed.

On Wednesday, at the height of my despair, I decided to walk into town. I have restarted to walk into town because I need the exercise and it helps improve my mood and clear my thoughts. Instead of the Swiss army knife, I now carry a large umbrella as my “weapon of choice”. It is bright pink and it is called “Mary Poppins”. When purchasing this item, I felt like I was being given a sign. Mary Poppins would never let me down. If needed (and I certainly hope I never have to), I could wield it like a baseball bat.
Anyway, I started off into town. My stomach started to make some rumbling sounds and spasms were starting to make me feel uncomfortable. I kept going thinking that this was just my emotions getting a hold of me. About midway into town I was hit with the sudden realisation that I was about to have my first episode of diarrhoea here in Swaziland. I felt absolute panic. Certainly no public toilets on the way to Siteki. I started to think that I may have to go on the side of the road, but I had two prevailing thoughts:
Firstly- Snakes. What if I was to squat and then have my butt bitten by a mumba?
Secondly- I am the most recognisable person here in Siteki. My white skin, dark long hair
and the fact that I work at Good Shepherd makes me recognisable by most people. I don’t speak SiSwati, but I do recognise that I am a “dokatella” and I can hear people talk about me when I walk past. I simply could not be seen squatting on the side of the road.
I started running back to Good Shepherd. I felt that if I could get my “fright and flight” response going, then perhaps I could try and distract my bowels from relieving themselves. My lungs were burning from the intensity of my pace. My butt cheeks were burning from trying to avoid incontinence. I started cursing myself for wearing my $50 pale pink lace French knickers, because I felt that they may soon be destroyed. I cursed myself for not washing the spinach thoroughly the night before, because this may be the cause of my impending doom.
I eventually reach my flat and I can only describe the experience as an atomic bomb going off in my large intestine. It was horrendous. I then went to flush the toilet and I find that the toilet can’t cope with the volume. My heart stopped beating as I saw the toilet water and its contents rise to the top of the bowl. I was filled with horror and then, by some miracle, it all disappeared before spilling over the edge. I fell to the ground in a heap of relief and exhaustion.
I now have to re-write my list of things most feared on my walk into Siteki:
1. Swazi men
2. Goats and Cattle
3. Snakes
4. A repeat episode of explosive diarrhoea.

Sunday, October 12, 2008

Back to Bulembu

OK, so I panicked last week. I was fragile and feeling really vulnerable and after reading a few comments on the blog, I started to think that perhaps the words I write could be used against me and endanger my safety. I’ve just read the book “A Mighty Heart” and this probably planted thoughts in my head that were out of proportion to the reality I live in. I emailed Courtney and told her to restrict access to my blog. I didn’t know who I could trust. Courtney is beyond any doubt the most incredible friend anyone could ever be blessed with and she immediately responded to my fears and adjusted the blog for me.
I now realise I was a little hasty. I have absolutely no political affiliation here in Swaziland. I am simply a humanitarian trying to do my work at a grass roots level. There is no reason for anyone to use my experience here to perpetuate their own political agenda.
Very few people in the world even realise that Swaziland exists. Few people know what it is like to live in Africa and very few of us know the devastating effects HIV/AIDS has on this population. My words are just describing what I see and in no way have any hidden agenda.

It was quite timely that after my most difficult week in Swaziland so far, that I was taken back to Bulembu. As I have said previously, Bulembu is an old deserted mining town that was bought by some philanthropists with the vision to create a self-sustaining town that would safely house orphans. What they are doing there simply defies anything I am able to put into words. It is ingenious. It is inspiring. It gives hope and it is a place that I have fallen in love with.
I was very privileged to be there for the Board meeting. Philanthropists from all over the world were meeting to discuss logistics and future goals for the town and the almighty project that they are undertaking. Most of them were from the USA, but a few were from South Africa and Swaziland. I was overwhelmed to be in the company of such amazing humanitarians. My role in Swaziland seems to pale in comparison to what they are doing. I am trying to fight the problems as I come across them, these people are trying to create a better future.
Whilst they were in meetings all afternoon, I took myself down to the house where the orphans aged 3-4 are cared for. I spent the afternoon playing with them. I took along some colouring-in books and crayons and I lay down on the floor with them simply colouring. It was incredibly therapeutic. Despite the fact that it has been some weeks since I was originally there, the children recognised me and I was greeted with lots of smiles, cuddles and kisses. I then had dinner with the Board members and I had a truly enlightening experience talking with them, getting to know their backgrounds and what drives their passion to help Swaziland. I was giddy with excitement and hope to actually realise that there are people in the world who not only say they care, but actually show they care.
I woke up to the breath taking beauty that is Bulembu. I was then taken with the other Board members to see some of the projects being put in place. Whilst Bulembu has the ultimate goal to raise orphans in a safe, nurturing environment, it also realises that with this concept, you also need to provide infrastructure, jobs and the ability for Swazis to create a self-sustaining environment for themselves.
We visited the new sewage treatment plant- essential for any community. Who would have ever thought that I would be interested in the workings of sewage treatment, but I was fascinated and appreciated just how essential this was to the project. We then visited a school that is being renovated to accommodate over 200 students (Kindergarten to Grade 12). The school will be opening in January and it looks amazing. This is where the orphans will be educated as well as the children of the workers in the community. I then went to see how houses were being renovated. When the mine closed down, hundreds of houses were left behind in various stages of disrepair. These houses need to be renovated to accommodate orphans. It is hoped that 6 orphans of similar ages will be accommodated with one “mother”. The mother will be a Swazi woman especially chosen by Bulembu to care for the children. The work that is being done on these projects is simply mind-blowing. Progress is slow (remember all this is being achieved with donated money and there is no government input).
I then saw where they have established hives so that honey can be locally produced and then sold outside of Bulembu to generate income. I was enlightened as to how bees work and how difficult it can actually be to run efficient hives!
Off we then went to the factory that will be responsible for bottling spring water. There is an abundance of spring water surrounding Bulembu and this natural resource will be used to bottle water and sell. Again, generating jobs for local Swazis and providing income to house the orphans.
My final stop was the old hospital that remains. Whilst the others went back to their meeting, I was given a set of keys and asked to explore what was left of the old hospital. It was quite an adventure for me. The keys allowed me access to some places but not to others. I ended up climbing over fences, trying to see through windows and at times I thought I would break my neck in doing so, but since being in Swaziland I have started taking risks that I normally wouldn’t whilst in Australia! I felt like an international spy! I found an amazing amount of stuff and I know that this discovery of mine will lead to the equipment being used there and in Good Shepherd- we just need to find a way to break in!

The last part of my time in Bulembu was spent at the orphanage that currently looks after 42 babies from birth to 2 years. An absolutely incredible place run by an extraordinary woman called Robyn and her husband Gerry. They are assisted by numerous other staff members who spend their days feeding, burping, changing nappies, bathing and spending time cuddling babies. It is always a hive of activity and simply one of the most delightful places on Earth. I was instantly drawn to their new arrival. A little boy, about 2 weeks old and weighing 2 kilograms. He was found at the bottom of a latrine (yes, you read that correctly- at the bottom of a pit toilet). He was tiny and incredibly sleepy. I suspect he was somewhat premature because his suck is not great. They are waking him every two hours to try and feed him because he is incredibly weak. I sat with him for 3 hours and during this time I tried to feed him. I am grateful for my time spent in Special Care Nursery back home, because the nurses there taught me how to encourage babies who don’t feed well. I managed to feed him and I was completely besotted. A man, who has never met before, walked up to me and told me that I looked like a complete natural, as though this baby was my actual own. I felt a deep, mystical connection to this child which is unexplainable. Anyway, I had to leave because my ride back to Siteki was about to leave. Robyn approached me and said “this child has not yet been named Melanie and I would like you to name him”
I was simply overwhelmed but I knew immediately that I wanted to call this boy “Noah”. This is perhaps the only child I will ever be able to name and I cried my eyes out as I left. Since leaving Bulembu I have thought about him every minute and I can’t wait to get back there to see him.
Emotions have surfaced that I am finding difficult to deal with. I am 30. Men are simply not interested in me and I realised not so long ago, that my chances of getting married are very slim. Whilst this does not cause me great anguish in itself, the fact that I may travel this life without a child causes me a great deal of grief. It is a thought that I struggle with constantly. (As my step-father Graeme keeps telling me- “My eggs are rotting”) I have always considered adoption, but as a single person, who lives in Australia, this is almost impossible. It breaks my heart that I cannot take a child who was dumped in a latrine and provide him with the enormous amount of love and a future that I am perfectly capable of giving him.
I will now return to my little flat, read a book and try to renew my spirit so that I can face another week of challenges here in Swaziland.

Thursday, October 9, 2008

A note of clarification

I woke up suddenly at 1am this morning and I was filled with dread that I had perhaps said things on the blog that I shouldn’t have made public. The truth is, when I created the blog I only thought 3 people would read it- my Mum, my step Dad and my best friend Courtney. I had no idea that others would read it, I didn’t think that my adventures here in Swaziland would interest anyone else. It certainly never occurred to me that people here in Swaziland would ever stumble across my blog and make a connection with me.

At 1am I felt so disturbed that I wanted to get out of bed and clarify my previous blog entry with you all. I didn’t do this for two reasons:
It’s now cold again and I wasn’t brave enough to leave my warm, comfortable bed.
If I was caught by the security guards that patrol the grounds, they may have been so startled by my wild “bed hair” and pink Winnie the Pooh pyjamas, that they may have shot me- mistaking me for a wandering lunatic.

So I am now here, trying to clarify a few things. First and foremost, the events of Monday are in no way a reflection on the Good Shepherd hospital or its doctors. The hospital is regarded as one of the best in Swaziland. People think the care here is of such a high standard that they travel across the country to be seen by the staff here.
Secondly, the doctors here are doing their best. They are devoted and hard working and they try their best to make a difference despite the gross lack of resources. The surgeon who performed the tracheostomy was amazing and incredibly brave. He actually approached me this morning and told me how proud he was of me. I was the only one in the hospital who was prepared to step in and intubate the patient if the proverbial shit hit the fan. He told me I had “balls” that he had never witnessed in a female before. I have never been told that I have “balls” and I have decided to interpret it as a compliment.
Thirdly, after discussion with the surgeon, we both agree that this situation was doomed to be a disaster in the first place. The trachea was deviated so much that it was underlying the ® clavicle. We have all learnt much from the experience. The patient is still alive and he is grateful that he can breathe.
My reaction to the events that unfolded was completely “normal for Mel”. I am extremely passionate about my work, my patients and the way I am perceived by my colleagues. I know, that even back in Australia, my colleagues find it a challenge to understand me and why I take things to heart so easily. Believe me, I wish I knew why. It can be incredibly lonely at times when you want to fight for your patient, their dignity and comfort, only to meet resistance along the way.
It is my hope that I can continue to write of my experiences here in Swaziland and not have anyone abuse the trust that I have placed in my readers. I hope that you all understand that my patients are people who deserve compassion and dignity. Whilst some may argue that I am breaking doctor-patient confidentiality, I actually see my blog entries as giving a voice to all those who are unheard. As humanity, I believe we have an obligation to care for other regardless of nationality, religion or creed. I believe that ignorance is the fundamental reason why we do not live in peace. It is my hope that I can enlighten some of you to the daily privileges we in the Western world take for granted. Along the way, I will probably use gruesome detail because this is exactly what I pay witness to on a daily basis. It can be overwhelming and it can be sickening. It can make me feel completely hopeless and desperate. It is by using these emotions that I try find the inner strength to do the best I can and try and make a difference. I share the stories with you because I want you to be aware of the suffering that plagues this country and the fact that the rest of the world lives in blissful ignorance.
Please respect my patients and try to understand my emotions. It would cause me a great deal of suffering and anguish if my stories were to be talked about as some idle gossip or if they were ever submitted to Swazi media. I would stop writing the blog and the people I love would no longer have access to a story that is about me and the country I am trying desperately to support. Please respect my colleagues. Whilst I may not agree with some of the practices that occur here, I respect their commitment, their knowledge and their desire to try and achieve some of the goals that are exactly the same as mine.

Wednesday, October 8, 2008

The roller coaster continues

I think one of the most difficult things about being here in Swaziland is the day-to-day fluctuations of my emotions. There are times when I am upbeat, positive and truly feel like I am making a difference and then there are days when I am devastating low and feel completely overwhelmed and hopeless. I had one of those days on Tuesday.

I need to tell you about Monday, so you can understand Tuesday.

On Monday I heard that a patient had arrived with an enormous tumour on the side of his neck. I was quite intrigued (in a morbid-doctor type of way). Never in my wildest dreams could I have imagined what I saw. This young man with HIV had a tumour on the side of his neck the size of a soccer ball. I am not exaggerating. It was so huge that it was compressing his trachea (windpipe) to the other side of his neck. He had a marked stridor (a noise that is made when the trachea is partially obstructed) and he was drooling because he couldn’t swallow his saliva properly because his oesophagus (foodpipe) was also partially obstructed. It was horrifying and we all agreed that he needed an urgent tracheostomy (a surgical airway to keep it open). We do not have anaesthetists here at GSH, but rather we have excellent technicians who are able to do various types of anaesthetics very capably. However, I offered to provide a helping hand if it was needed. I had everything set up for a “difficult airway” and I sat for a little while mentally preparing myself as to what steps I would take if one of my airway manoeuvres failed. Unfortunately, it was not communicated to the technicians that I would be in charge of the anaesthetic and this perhaps was the start of one near disaster.
The surgeon wanted to do the tracheostomy under local anaesthetic. I voiced my concerns about this, but being a foreigner and being female, I think my concerns were dismissed. The two surgeons present kept telling me that if we sedated the patient we would lose his airway. I was convinced that this would not happen and that I could titrate the drugs to just make him somewhat calm. Anyway, they started the procedure regardless of my concerns. I was with the patient at his head- I kept talking to him in soothing tones, gently massaging his head and trying my unique way of trying to comfort patients during distressing procedures. It worked really well for a while, but the surgeons were having difficulty accessing his trachea. The patient started to get agitated and I kept saying “We need to sedate him, he’s not coping and this is all going to go really bad”. I was simply ignored and the technicians wouldn’t give me the drugs. Finally the patient got so frightened that he jumped off the bed, retractors and surgical clamps still hanging from his neck. It was a nightmare. People came from everywhere and held him down whilst the technician, without my knowledge, administered a rapidly acting paralysing agent. I was then told to intubate the patient. I was very frightened and nervous. It all happened so quickly and my initial strategic plans were thrown down the toilet. I thought I could see part of the cords. I asked for a bougie and then slid the tube down. During this time and chaos, I think I slipped. One of the technicians listened to the chest and told me he could here breath sounds. I wasn’t convinced I was in the right place. I ended up yelling at the technician to let me have his stethoscope so I could hear for myself. Anyone who knows me knows that I have never raised my voice before in a clinical situation, so it just goes to show how tense I was. As soon as I listened, I knew the tube was not in the lungs. I wanted to try again, but the surgeons insisted on going for a surgical airway and thankfully they succeeded. I then started yelling at the technicians to give the patients some pain relief and they finally allowed me to administer some pethidine. My medical colleagues will be able to read between the lines of this scenario, but I can tell you, I was completely traumatised. The patient was alive and he had an airway, but I felt like a complete failure. I kept ruminating on what the experience was like for the patient and I was physically sick. I had to take valium which I thankfully have easy access to here.
I didn’t sleep. I woke up the next morning and just wanted to die. I had organised to go in early and do my ward round because I was supposed to be taken into Mbabane to get my well overdue visa extended. I did my ward round and went to the administrators office. She told me that I would not be going to Mbabane as some of the documents were incomplete. I can tell you, I almost had a complete meltdown. The visa is not a life or death issue but it’s important because for 6 weeks I have been asking people to get it organised for me. For 6 weeks they have had my documents and nothing has come to fruition. It was the straw that broke the camels back. Chris was with me and she noticed immediately that I was going to explode. Not only had I been through a nightmarish experience the day before, not slept, but I had also got up early to see my patients before my planned trip to Department of Immigration. She pulled me out of the office and we went outside and I started crying. She immediately said “You can’t work today” and we started to walk into Siteki. I cried all the way. I admitted to the helplessness I was feeling. I told her about a patient I had on the ward who has advanced AIDS and lymphoma of the tongue. I told her that my patient is dying of malnutrition because she can’t eat. I told her that on a daily basis I pay witness to people dying the most tragic, agonising deaths that I can’t do a damn thing about. I told her I wanted to go home and that I simply couldn’t cope anymore. She hugged me and told me that she loved me. She told me that I had to keep remembering all the successes I keep having- the ones I tend to forget when they are overshadowed by all the tragedy. I tried to use the internet in Siteki. I wanted to talk to one of my colleagues in Australia and let him know about the incident that had traumatised me so much. Of course, the internet wasn’t working. Chris and I took a taxi back to Good Shepherd. I told her that I would have a coffee and then meet her in outpatients. I had the coffee, but then I went to bed. I desperately needed to feel safe and comforted and my bed was the only place I felt some semblance of peace. I cried and I cried. My tears soaked the pillow and then I fell asleep. I didn’t make it to OPD. Later in the evening I managed to clean myself up as I promised to go to Jenny’s birthday party. I was extraordinarily low, but I honestly think I put on a “good show” and no one was aware of my fragility. The party was a success and Jenny had a good time.
I woke up this morning with a splitting headache, but a good cup of tea and two types of pain killers got me to the ward. Before I even started working, I was told that I would not be working today as Dr Petros was taking me himself to the Department of Immigration. We drove all the way in only to find that more documents were needed from the hospital- I have to go back next week. I knew this would happen. The silver lining was that I suggested that we stop for a cup of coffee. Dr Petros bought me a fantastic cappuccino and a blueberry muffin. It was all I needed to start feeling human again. So I find myself back at the hospital, still unregistered and still trying to alleviate suffering in a country that seems to have no end to suffering. I will stay, I will be strong and I will come out the other side stronger. I hope.
PS. The patient with the tracheostomy is doing well. Despite the ordeal, he smiled at me and gave me a hug. I wish I had the strength of these people.

Sunday, October 5, 2008

Extraordinary people

I thought I would take this opportunity to tell you about a few remarkable people that I have met recently.

Jenny is a 5th year medical student from Aberdeen, Scotland. She has been with us for 6 weeks and sadly she leaves us next week (but not before we throw her a big Swazi birthday party on Tuesday!) Jenny and I get on famously because we both share a passion for any food that is sweet. It is no exaggeration when I tell you that Jenny consumes large quantities of chocolate and sweets on a daily basis. On a particularly good day, she will also eat cake. Whilst I share her passion, I sadly cannot partake in her daily menu. Her metabolism is AMAZING and she maintains her super-model figure despite the thousands of calories she consumes. She is 22 on Tuesday and I keep telling her that once she reaches the dreaded 30 she will no longer be able to eat like this, otherwise she’ll end up with a butt as big as mine.
Jenny also loves shopping and when we are particularly bored, we will sit and imagine what we would buy if we were back home in our respective Western Countries. Last weekend, Jenny and I went away together and spent a great weekend shopping for local souvenirs and eating good food. I will always look back fondly on that weekend as we drove home, with barely any petrol in the tank and dodging cattle, goats and policemen as we made the treacherous journey home.

Last weekend, I also had the privilege of meeting two friends of Julia’s who were here to visit for a short time.
Emerald is a young girl, with a big heart from Maine in the USA. She went to university with Julia. Emerald has been working in Uganda for a year now. She is working on a project which houses, feeds and educates children who are orphaned by HIV/AIDS. Emerald is gutsy and very brave. Nothing phases her and she works very hard, in a difficult country, to try and bring some decency to lives of these children. Emerald is returning home in January. She is returning to the States via Kenya, Rwanda, Egypt, across the Gaza Strip and into Palistine and Isreal. I think she is crazy and I told her so.

Farrah is a delightful girl from Ireland. She studied gender issues at university and now she works for Non-Government organisations in Uganda trying to ensure that men and women receive equal benefit from these charities. Farrah tells me that in Uganda, women are not only second class citizens, a car is considered more valuable than them. It simply breaks my heart. Farrah has just renewed her contract and will be staying on for her third year in the country.

The girls told me a lot about Uganda. In comparison, they thought Swaziland was incredibly civilised and simply amazing. From what I understand, they live in conditions a lot rougher than I am privileged to be in. Their options for food are a lot more limited and their accommodation not so comfortable. They were overwhelmed by the facilities at Good Shepherd. In Uganda, if you go to hospital, you have to take your own bed linen, your own food and your own relative to care for your daily needs. The floors are not washed daily and there is excretement and vomit everywhere. Patients lie on the floor between beds. Violence is common and if you are caught stealing you can possibly be stoned to death or have your hand amputated. Since hearing their stories, I realise how lucky I am to be in Swaziland. For all its problems, I can assure you that here at Good Shepherd, the patients are cared for and I am not allowed to enter the ward until all the patients are washed and the floors have been cleaned. I am truly grateful.

Later in the week, I met Andrew and Kristen. This married couple, both 25 and from Boston, have come here as part of the Peace Corp.
Andrew was a social worker who worked for the Department of Child Safety and Kristen was a paediatric oncology nurse.
The Peace Corp was established in 1960 by John F Kennedy when he challenged students at the University of Michigan to serve their country in the cause of peace by living and working in developing countries. It has now become an international agency devoted to world peace and friendship. Peace Corp volunteers can work in education, youth outreach, community and business development, agriculture and the environment and health and HIV/AIDS.
Andrew and Kristen are in Swaziland under the umbrella of health and trying to develop a programme to help prevent/ treat or alleviate the suffering of HIV. They are required to stay with a local family and get to know the local community so that they can design a project that best suits the local community. They live with a Swazi family of two adults and 3 adolescent children. They live without electricity (like most people in Swaziland) and they share a communal latrine with the family and a few neighbours. When I say latrine, I mean a pit toilet. This is something I simply could not cope with. They do not have a shower or bathing facilities. They use a bucket and water that they need to retrieve themselves daily. I understand that they have a little gas stove and Andrew is currently trying to look at novel ways of creating a refrigerator that does not require electricity. We cooked them a great meal and we intend to make this a regular occurrence for these extraordinary people. I think they are among some of the most delightful people I have ever met and I know that we are going to become firm friends. They simply embody the concept of humanity. They have given up everything to help this country and unlike myself, who can take a shower everyday and have electricity (most of the time), they are doing it at a grass roots level. I have enormous admiration for these people. They are committed to two years here and they are unable to stay away from their community for even a night. They had to walk for about 40 minutes to reach us here at the Good Shepherd and we offered them a bed because it was late when they were about to leave. They had to decline because it is against the ethos of the Peace Corp for them to stay elsewhere. I asked them if there was any food that they particularly craved and they unanimously said “Italian”. This was an incredibly sign, because basically, that’s all I’m able to cook well. Next Saturday, we plan to put on a big Italian feast for them after we search this country high and low for a few key ingredients!

Friday, October 3, 2008

Mumba madness

Thursday was my hottest day in Swaziland so far. It was more like what I imagined my time in Africa would be like. So far, it has been extremely cold at times and I have often cursed myself for not bringing warmer clothing. I sat in Outpatients, pouring with sweat and fanning myself with a piece of paper between patients. It was most uncomfortable.

The arrival of the warmer weather has also heralded the arrival of my greatest fear in Swaziland- the Black Mumba.

It was about midday when one of the doctors ran into my consulting room asking me to urgently see a patient who had been bitten by the feared creature. I quietly cursed under my breath (sorry Mum, but yes, I do actually swear) and thought to myself “Why is it that I am always called to see the most unsalvageable patients?”

I went into the emergency room and there was absolute chaos. The patient was lying on the stretcher moaning and groaning and everyone was looking on helplessly as if he was about to die eminently. Thankfully, I have been trained well in emergency medicine and despite the chaos, I was able to think clearly. He was breathing and had a good pulse. I instructed the nurses to get bandages and something to immobilise his arm. His co-workers (at a local school for the deaf) had tied a tourniquet with a plastic bag. Once I had applied the pressure bandage, I removed the tourniquet and performed a much more thorough examination. It was soon evident that despite the large bite on his hand, he had not been envenomated. I was able to instruct the nurses on the vital signs and symptoms they needed to monitor and instructed them when to notify me. After peace had settled upon the emergency room, I went back to OPD.

I was soon called by one of the nurses, the patient was fine. However, the police had arrived and they had the “offender” in the back of their paddy wagon. They insisted that I go and look at their proud capture. I am absolutely terrified of snakes and was extremely reluctant to go and see it, but I thought it might be useful for my own protection to be able to identify the creature. I was first proudly shown the bullet that was used to blow the snakes head off. I politely congratulated the shooter and silently wished that he could escort me into Siteki every time I go in for shopping. He was obviously a good shot. I was then shown the feared creature- sans head. It was terrifying and revolting at the same time. A huge crowd had gathered around to pay witness to the big event and it was obvious that this would be the biggest news to hit Siteki all week.

This event has left me with a perpetual sense of dread. I know that my friend Iain has reminded me that I come from a country that is infamous for its dangerous snakes, but thankfully, I have always lived in the suburbs where the risk of an encounter has always been low.
I am now living in RURAL AFRICA and my little flat just happens to be perched on what is known by the locals as “SNAKE HILL”. Apparently, the hill is densely populated with snakes and encounters with the deadly creatures are common. This is why, when I first arrived, I was warned to always keep my windows closed so that I didn’t get any unwanted visitors. Last night, I got out of bed several times to ensure all the windows were closed.
Chris and Jenny also had a scorpion in their house on Wednesday and I have been told that I need to check my bed before I get in each night and check my shoes before I put my feet in. I truly am terrified.
Just so you don’t think I’m a paranoid lunatic (although I’m close to becoming one…), I had found some information on the dreaded Black mamba that I would like to share with you. Read closely and understand why I feel like I’m risking my life every time I step outside my door….

The Black Mamba (nicknamed The Shadow of Death) (Dendroaspis polylepis) is an elapid snake. They are one of Africas most dangerous and feared snakes.[1] The black mamba is the largest venomous snake in Africa and the second longest venomous snake in the world. Only the King Cobra is longer. Adult black mambas have an average length of 2.5 meters (8.2 ft) and a maximum length of 4.5 meters
The black mamba is reputed to be the fastest moving snake in the world, and has been claimed to move at up to 19.2 km/h (12 mph).
A single bite from a black mamba may inject enough venom to kill 20-40 grown men, easily killing one unless the appropriate anti-venom is administered in time. When cornered, they will readily attack. When in the striking position, the mamba flattens its neck, hisses very loudly and displays its inky black mouth and fangs. It can rear up around one-third of its body from the ground which allows it to reach heights of approximately four feet. Black mambas are diurnal snakes that hunt prey actively during the day. When hunting small animals, the black mamba delivers one or two deadly bites and backs off, waiting for the neurotoxin in its venom to paralyze the prey. When killing a bird, however, the black mamba will cling to its prey, preventing its departure. When warding off a bigger threat or feeling very threatened, the black mamba usually delivers multiple strikes, injecting its potent neuro- and cardiotoxin with each strike, often attacking the body or head, unlike most other snakes. It can strike up to 12 times in a row.
Black mambas are among the most venomous snakes in the world. With a LD50 of 0.25-0.32 mg/kg, the black mamba is 3 times as venomous as the Cape Cobra, 5 times as venomous as the King cobra and about 40 times as venomous as the Gaboon viper. Black mamba venom contains powerful, fast-acting neurotoxins and cardiotoxins, including calciseptine. Its bite delivers about 100-120 mg of venom on average, however it can deliver up to 400 mg of venom; 10 to 15 mg is deadly to a human adult
Depending on the nature of a bite, death can, and has resulted in as little as 15-30 minutes or it may take up to 120-180 minutes.