Thursday, January 22, 2009

The End

All journeys must come to an end and this will be the last entry I make in "Stories from Swaziland".
I have now been back in Australia for almost 3 weeks and I am slowly adjusting to life back in this privileged country. I'm back working in an emergency department. The irony is that I'm working for 6 months in the private sector, so I am treating people who have every resource available to them and I don't have to think twice about ordering tests or prescribing drugs- their insurance will cover everything. No one has HIV and no-one has TB. My working environment is relaxed, pleasant and stress-free. I am surrounded by support and I feel nurtured and appreciated. Yet, if I had to be truly honest, I actually miss some of the mayhem I faced in Swaziland. I miss my patients who were so grateful for the smallest things. There were times where all I could offer was a hug and a smile and somehow that was often enough. I miss my nurses who drove me crazy most of the time but had hearts of gold and treated me with an almost "God-like" status. I miss walking into town and having everyone I pass smile at me and greet me warmly. I miss my friends terribly. I think of Kristin, Andrew and Susan everyday and often wonder what they are doing. I am in regular email contact with them and the other day, Kristin emailed me to tell me of some of the projects they have done recently and I actually yearned to be a part of it. They are doing amazing things in terms of educating their community about HIV/AIDS. Kristin has started giving lectures at the nursing school and I know she will inspire the nursing students and encourage them to learn more. I am so incredibly proud of them. Susan still faces the endless bureaucratic nightmare of trying to co-ordinate care for those suffering HIV and TB and I hope that she knows that I am supporting her in spirit whilst not being there in person. Julia and Chris are settling back into their lives in the States (with their gorgeous new President). Jenny (Scottish medical student) has just finished her medical exams and will start her first year as a doctor.
I was walking through a shopping centre the other day and I saw two young African children. I had to stop myself from going up to them and giving them a warm embrace. In Swaziland, the children would have instinctively run up to me for a cuddle, but here in Australia, children are taught to not be so trusting. I am still in regular contact with my friends at Bulembu and I am sent regular updates on all the children as well as photos to add to my rapidly expanding collection. Sometimes, during my more quiet moments, I think about all those orphans and wonder what lies ahead of them. I still cry randomly and my heart often aches for inexplicable reasons.
That being said, I have adjusted quite well and I'm not sure I've ever felt this happy, nor this comfortable within my own skin. I have this new-found confidence in myself that allows me to think that anything is possible and that nothing is too hard. I appreciate things now that before I have taken for granted. I am able to see beauty in the mundane and I am able to treasure things that others may see as unimportant. This is a true gift that only the heartache of being in Swaziland was able to give me.
People ask me whether I will go back and the truth is, the answer is yes- just not yet. I can't imagine going through the rest of my life without being able to touch lives the way I was able to in Swaziland. It was the hardest experience of my life so far, but that doesn't mean I will shy away from such difficult experiences again. I actually think I will be back in Swaziland sooner than I think. I have some special friends there and although it may mean using the dreaded latrine again, I think my Peace Corp friends will have a visitor sooner rather than later.
I cannot finish this story without thanking some incredibly special people in my life. Many of you sent me warm wishes, support and love in various forms, but there are a few people who deserve special mention:
Courtney- by best friend in the whole entire world. She set me up with the blog and made various adustments to it upon my request. She emailed me every single day I was in Swaziland and her regular contact provided me with comfort that is simply indescribable and will not be forgotten. I think some of my "adventures" caused her quite a bit of angst at times and she has asked me to never embark on this type of thing again, but the amazing thing about Courtney is that her support is unwavering and no doubt will continue on the next crazy mission I undertake.
Mum, Graeme, Dad and Rachel- thank you for encouraging me to step outside of my comfort zone and refusing to let me give up. Thank you for still seeing the special side of me despite the fact I am incredibly "different" to every other 30 year old you know! Graeme- thank you for the 200 tea bags, 6 kilos of coffee and 3 litres of hand sanitiser that you went to such effort to send me. I never got around to using it all, but rest assure, there are many others who are still appreciating your efforts!
Anna from Ireland- despite your own difficulties, you were still able to empathise and encourage. It certainly was fate that brought us together again and I will never forget the support you showed me.
My friend Adam- you patiently listened as I described in graphic detail my various changes in bowel habit, my fears that my skin was infested with bugs and the ailments of my patients that were never quite appropriate to talk about on the blog. Somehow, you just knew the right things to say to settle my hysteria and you gave me a laugh when I needed it most.
All my friends from PA Hospital- I know it still seems bizarre that I had the courage to go to Swaziland, but rest assure I'm a lot stronger for it. Dr Mel has "toughened up"! I still have a propensity for tears, but there are some things you just can't change! Your donations and support mean that you're not just my work colleagues- you're also my friends.
To Kristin, Andrew, Susan, Julia and Chris- words will never be enough to describe how much I love you and how much you affected my life. I will never forget the laughter and tears we shared. I tried to share my experiences on my blog, but only you will be able to truly appreciate my experience of a lifetime.
To everyone who read my blog- those I know and those I don't- the blog was more for me rather than anyone else. As I sat and wrote of my experiences, I never felt alone and somehow sharing the heartache, telling people about this forgotten country and describing my adventures helped eased the enormous sadness I felt at times.
To the people of Swaziland- you have changed my life forever. When the rest of the world ignores your tears, I will not forget you. When you feel pain, I will feel it too. Where you have a glimmer of hope, I will encourage you. You are not alone- my thoughts will always be with you.

Tuesday, January 6, 2009

Reality bites

Everything is so familiar and yet I still feel somewhat of a stranger in my own home, my own state, my own country.

I knew things would be a little strange to begin with and so far it has been a reasonably smooth transition. I have reliable internet access, I have a phone so that I can be contacted anytime, anywhere and if I need to purchase anything, then it's at my finger tips. I'm back in the modern world and I've taken full advantage of all these modern luxuries.

I had dinner with a colleague last night who is also a friend I love dearly. He's incredibly smart and very experienced. We went through some of my clinical photos. During my time in Swaziland I often took photos of interesting cases or things I had no idea what they were and hoped to look up when I returned. He was able to identify some of the mysterious conditions immediately and I started to develop an uneasiness that can only be cultivated in a mind that is still somewhat traumatised by what she has seen recently. I lay awake all night thinking about what I may have missed whilst I was in Swaziland. Perhaps I could have made more of a difference had I been smarter? Maybe it was incredibly naive of me to go to a third world completely unprepared for what I would see. I am still acutely aware of the feeling I used to have when I would see patients and not have a clue what was wrong with them. It was the worst feeling in the world and despite the fact that I had absolutely no resources to investigate any further, I would still feel like I had "failed" the patient. As my time at GSH passed, I got better at dealing with my feelings of complete inadequacy and I would just resolve myself to the fact that patients would die without me ever knowing what was wrong with them. We had no autopsy facilities. This kind of uncertainty just doesn't happen very often here in Australia and as a young doctor (well maybe not so young, I did turn 31 on Saturday), it was confronting to not be able to have the answers we so desperately go in search of here. 
I know in my heart of hearts that I did my very best. I worked my arse off and when I wasn't seeing patients I was often consulting textbooks to try and work things out. I know that my uneasiness is due to my fatigue and my often debilitating self-doubt. I just know that if I decide to work in the third world again, I'm dragging my friend along as my virtual resource centre.....

Today I embarked on my first trip to a shopping centre. Next week I start a new job working in a private emergency department. Surprisingly, the wardrobe I wore in Swaziland- which consisted solely of t-shirts, jeans and cargo pants- won't be appropriate for this new place of employment! I decided that I would take the opportunity to update my wardrobe, redefine my image and become a little more sophisticated. I was somewhat overwhelmed by the experience. I tried on all these clothes and nothing seemed appropriate. I looked like mutton dressed as lamb and realised that no matter what I wear, I can't remove the fact that I'm actually a person who has returned from a third world country and no amount of flash clothing is going to erase the fact that I'm now a different, less sophisticated person. I didn't buy a thing. In fact I didn't even buy any new underwear- which is virtually unheard of because I actually have an obsessive/compulsive tendency to buy extravagant pieces that are riduculously over-priced and inpractical. (However, my sister does design lingerie so I think the problem is genetic)
I ran into an old school friend whom I have not seen in 14 years. She asked me what I had been up to and I simply said that I had just returned from some volunteer work in Africa. She was enthralled and asked questions that simply cannot be answered in a short response in the middle of a shopping mall. She started telling me that she dreamed of doing something like that and that if she won the lottery, she would just spend her life working as a volunteer in the third world. She asked me why would I ever come back to Australia and I replied "Because I wasn't earning a cent and it was destroying my soul watching a population implode upon itself". Perhaps I could have been a bit more subtle.  I did not respond positively and I think she was taken back by my blunt response. Basically I said that it was very easy to romanticise the altruism associated with "helping the third world" but in reality it's really tough and not always rewarding. In fact, I think my actual words were "You know, it was a fabulous experience and really challenging but there were also times when it was actually shit and I couldn't wait to get out of the place".  She replied with the usual response that is starting to irritate my gut "Well you'll be such a better person because of it". Why does paying witness to utter devastation suddenly make me a better person? I know people are trying to be kind and positive when they say this, but I'd like to think that I was a good person before I even left for Africa. I spend everyday trying to "better" myself. My motivation was simple- I had skills and I wanted to use them where they were needed. I didn't go to "better myself" or because I was "told to go by God", I went with the intention to try and make a difference and the harsh reality is that I made very little difference. Swaziland and it's population are a mess and my very short time there changed nothing. People are still desperately poor and dying tragically from AIDS. This is the reality and perhaps why I cried as I drove myself home. I don't want people to tell me how amazing I am- I'm no different to anyone else who has gone there with the intention to help and every single one of us has returned with the country not being any better off than when we arrived. The problem is so overwhelming, so devastating and so incredibly complex that it's probably why I'm struggling to consolidate the experience and work out just what I need to do next. Perhaps I should just keep my mouth shut and tell people I took a sabbatical for 6 months. No one wants to know what sabbatical is- it sounds too academic.

Saturday, January 3, 2009

Goodbye Africa, Hello Australia

Our last day in Africa was a memorable one- for many different reasons.

We spent the day at the De Wildt Cheetah sancturay which is an internationally recognised sanctuary for breeding the endangered cheetah. We had a great time getting up close with the baby cheetahs and then going on safari to see cheetahs in their natural, albeit, controlled environment. At the end of our day, we were able to touch a cheetah and get a special photo opportunity which will inevitably end up "in the pool room". (sorry to my international readers, but this infamous aussie phrase from the movie "The Castle" aptly describes the significance of this photo).
We then made our way to Johanessburg airport and this is where the chaos began. The computer system was down and it took us over two hours to check in. Our plans to shower prior to boarding the plane were thawted as we literally had to run to the boarding gate. Mum, Rachel and Graeme had seats allocated together, but I was seated alone. This did not upset me much because by this stage, all our nerves were frayed and a few comments between my sister and I were blown out of proportion and I was more than happy to spend the 10 hours in solitary confinement....
First, there was the inevitable problems of seat allocations and double bookings which proved to be our iniial delay. Then there was a problem with getting the passenger manifest to Hong Kong and apparently a vital piece of paper had to be on board the plane before we could legally take off. The searing heat of Johanessburg started to take its toll and there was no air-conditioning. The temperature within the cabin rose dramatically and babies started screaming, pregnant women started to complain and the only resolution to the problem was to open the doors of the plane to allow fresh air in. In total, we spent nearly four hours waiting on the tarmac for this vital piece of paper. Again, instead of complaining along with everyone else- I sat and smiled about how typical this all was for Africa. I had two lovely girls sitting next to me and we laughed and shared our unique stories to pass time.
We at last left Africa and I was doing really well until I open my gift that was given to me from Kristin and Andrew (Peace Corp). You see, it was my 31st birthday and they had been so thoughtful as to give me a present to open whilst I was on the plane. The card they gave me was overwhelmingly kind and sincere and I started the inevitable crying. By this stage, I well and truly had run out of tissues, so Qantas serviettes had to suffice in mopping up the voluminous snott and tears that poured from my face. It didn't help when I listened to the Crowded House CD "Recurring Dreams" which reminded me of my Australian roots. I was a pathetic, lonely mess and I'm sure the sight was enough to frighten young children.
We eventually arrived in Sydney, having missed our connection to Brisbane. We had to wait 4 hours for another flight, but thankfully during this time, I was able to indulge in my first decent coffee in five months and my spirits rose.
We got into Brisbane at about 10pm- 21 hours after we first got on the plane at Jo'Burg. We were met by my delightful cousin Natalie who greeted me warmly with a gorgeous bunch of 12 long stemmed white roses. A beautiful way to celebrate my birthday which had passed without event. Her family had also bought me a spa package for my birthday and I eagerly await the opportunity where I am able to have some of the Swazi dirt scrubbed off my face and the tension eased from my aching muscles.
I didn't get to bed until 1am and it's now 5am and I am sitting here updating my blog. I think it's going to be a long day. I decided to get up as I was lying there ruminating about work which starts in a weeks time. I am starting a new job in a place I have never worked before and I am starting to feel anxious. The truth is, it has been six months since I have practiced modern medicine and I feel a little rusty. At the airport, my family were joking that in a months time, I'm going to be called into the Directors office and he's going to ask me why I've ordered so many HIV tests and why I have sent so many sputum samples to be tested for TB. I'm worried that a patient is going to be wheeled in and the first question I'm going to ask is "What's the CD4 count?" The past five months have immersed me in AIDS, TB and infectious diseases that we only read out here in Australia. My practice of medicine was so vastly different to what is done here and what is expected by my colleagues and the public. This morning I was smiling as I recounted some of the procedures I performed there that I simply would not do here in Australia. I frequently put needles into lumps and bumps that would normally be done under ultrasound guidance here in Australia. I often did procedures where I had to be creative- for instance- we didn't have chest drains, so instead we used urinary catheters to drain massive pleural effusions (collections of fluid around the lungs). I did almost 100 lumbar punctures whilst I was there. My medical colleagues would cringe if they knew the conditions I did this risky procedure under. The patient would lie on their sides. I would not have sterile drapes. My gloves were not sterile. I would have a cotton ball dipped in anti-septic solution which I would use to sterilise the skin. I would not use local anaesthetic. The patients, due to the conditions they lived in, would often be caked in dirt and despite my scrubbing, I would never get that dirt off before I inserted the spinal needle. I would then collect the spinal fluid in a basic blood collecting tube and the procedure, done at the bedside with no privacy curtain and in cramped conditions, would then be left to await the results which often took 1-2 days to receive. Thankfully, I was often able to differentiate the cause of meningitis (ie bacterial or fungal) by simply looking at the spinal fluid and assessing the pressure at which the fluid came out of the needle. With cryptococcal meningitis (fungal), the spinal fluid would be under such pressure that it would come spurting out of the needle and if the fluid was clear, I automatically made the diagnosis and commenced my patients on anti-fungals. I didn't need the laboratory to give me the diagnosis- my accuracy rate was almost 100%. This new diagnositic technique that I developed will be completely useless here. I also had no problem obtaining the spinal fluid. My patients were so thin and cachectic that I didn't need to feel between their spinous processes. I was able to see the correct space and just insert the needle. Australia is one of the fattest nations on earth and I'm now going to have to re-adjust myself to the challenges of performing procedures on obese people again.
I suspect I will have a few sleepless nights ahead of me before I start work in one weeks time. In the meantime, I will spend my days at the hairdressers in an attempt to rectify the disaster which is my hair. I will have my skin scrubbed and my toenails perfected. I'm back to my normal existence and somehow it doesn't seem right to look such a mess. I will keep the blog going for another week or so- this way I can describe the adjustment phase after what has been the challenge of a lifetime for me. I think I will miss the blog and the stories I was able to share with you. Somehow I don't think this will be the last story I tell. It will take a few years, but who knows, maybe my next blog will read "Stories from Sudan" of "Stories from the South Pole"....

Thursday, January 1, 2009

2009 in Johannesburg

I'd like to say that I lived the high life when I celebrated New Years in Johannesburg. Unfortunately, I'm not one for big celebrations and I was in bed by 9.30pm.
We left Cape Town and arrived at Jo'Burg airport to be met by a tour group leader who took us out to a fabulous elephant sanctuary, just outside the city. It was a wonderful experience getting up close to the animals, feeling their leathery skin and muscular trunk. They were so docile and gentle despite being enormous in size. They were rescued elephants who are being rehabilitated and the sanctuary is doing amazing work.
We came back to our hotel and we had high hopes of having a nice dinner to see in the New Year. Unfortunately, the restaurants nearby were all closed and we were left with the prospect of having a very subdued New Years. This did not bother me in the slighest, but it bothered my sister Rachel. There was no way she was going to sit in a hotel room, so she madly searched the internet trying to find somewhere to celebrate. She found a very large casino nearby and decided that we should take our chances by just turning up to see if any of the restaurants had a table. After the previous nights episode of tears, I knew that going to a large place, with large crowds and unpredictable plans was definitely not a good option for me so I told them I was staying behind. I think this upset my Mum somewhat, but I was defiant and they ended up going without me. I had a vegetable soup from room service, read my book and feel asleep long before midnight. I know many of you will think this a rather depressing way to celebrate New Years in a big city, but it was how I wanted to spend my time. I'm not the girl I used to be and it's going to take some time before I can get into the social scene again (was I ever really on the social scene??)
This morning we did a guided tour of Soweto. I have recently finished Nelson Mandela's "A long Walk to Freedom" so my memory was fresh with the stories of apartheid and the ANC etc. I have to admit, I was a little disappointed with the experience. Nelson's house was boarded up as it is being converted into a museum and I couldn't see Desmond Tutu's house as it was behind a large cement wall. The surrounding houses were certainly not flash, but certainly did not display the poverty that was typical of Swaziland.
In the afternoon, Mum, Graeme and Rachel went to a lion park whilst I joined my friend Niel. You may remember that Niel was the paramedic I "worked" with in Bulembu during my volunteer time there. He offered to take me out on an ambulance shift and I jumped at the opportunity to have a first hand experience at treating patients in one of the world's biggest trauma cities.
It certainly was fascinating and I will elaborate more to my emergency medicine colleagues when I get home, but for those of you who are interested, let me just say, it was an eye opener.
For our first call out, we were going to a patient who had been the recipient of "mob justice". This is where the local community decides to take the law into their own hands and issue their own form of punishment. This patient had being stabbed to the head and douced in petrol. We arrived before he was set alight. Getting to the scene was an adventure in itself. At one stage, we were travelling at 180km/hr and I was terrified. I thought I would be returning to Australia in a coffin. Apparently there are other ambulance drivers that travel at speeds of up to 200km/hr and I was grateful that we were taking things "safely". The patient was fine (we had police and fire department as an escort into the community as apparently the people can become violent against the paramedics). He kept commenting that he thought "the white girl was really pretty" (ie. me), but he was soon speechless when Niel told him sternly (in Zulu) that if he made any moves, he'd cut his testicles off. I was touched to be so well looked after....
We were on our way to a second case when I looked at an overpass above the freeway and saw a man hanging over the side. He was attempting suicide and we stopped to see what we could do. As we were running to the scene, Niel asked me "Mel have you ever talked anyone down from a situation like this?". The answer, "Never" and I had no idea what I would say when I got up there. Thankfully, two local men had reached over the side and brought the man up for us. We soon found out that last night, the patient's parents had both been murdered in an armed robbery. They owned a butchery that was randomly targeted last night. After a very long discussion, we handed the man over to mental health services and went on to our next call.
This time it was a major car accident. A combi carry 18 passengers and being driven by a 17 year old unlicensed driver had rolled and there were 18 casualties. I had absolutely no intention of doing an medical work, I was purely there to observe, but when I saw so many casualities, I got involved. I treated the driver who had significant burns and lacerations as well as a closed head injury. I rode in the back of the ambulance to the hospital with him. The ambulance was not equipped at all to deal with paramedics and there was no where for me to sit. We were travelling at ridiculous speeds and being thrown around the cabin. In the meantime, Niel and I were trying to get IV access, using sharps on a patient who may have had HIV. I had blood all over my hands and arms and I have to say, for the first time since I have been in Africa, I started to feel nervous. We made it to the hospital without event and I arrived to what Niel described as the "Baghdad of Johanessburg". It really was madness and I have no idea how the poor people of this country survive any trauma. There was no resuscitation team, in fact, no doctor and the nurse didn't seem too interested at all. Other patients were alongside us, unconscious, unstable and still waiting to see a doctor. My immediate instinct was to just jump in and start treating, but I realised I was unregistered and unable to provide any assistance (legally). It was all so surreal. For a country that appears to be a first world country, it certainly does not offer a first world health service. We also saw other stabbing injuries, but nothing too exciting to write about.
Tonight, Niel, his girlfriend and I join my family for dinner and now we are about to go to bed for my last night in Africa. We are spending tomorrow at a Cheetah park before we fly out in the evening. Can you believe my adventure has ended so quickly? My next entry should be from the comfort of my parents home in Australia.