Last shift

Today I’ll try and write in english, so please try and see through any spelling and grammar mistakes.

Yesterday was my last shift in KDH EC. As with all good byes it is with mixed feelings that I say this. But as with all things that are too difficult to grasp while in it, I say it without fully believing it. Feeling the weight of the words in my moth while repeating them to my self, waiting for me to hear what I just said and react, but the reaction never comes. 5 months we’ve been in Cape Town, of which 3 months spent working in KDH. Yet it’s almost impossible for me to imagine working anywhere else. Indeed have I ever? It’s ridiculous how the mind plays tricks on you when it comes to time and ones perception of the ground state. Already after a day or two in Cape Town everything about Sweden seemed to have been moved into another dimension. It didn’t feel as a part of this life. At the same time as the five moths here have disappeared like dry sand between my fingers, it also feels like we’ve lived here for as long as I can remember.

With my brain locked in this surrealistic state it wasn’t with any particular sense of sadness that I exited my car, making my way in to the EC through the ambulance entrance for the last time. Instead I had the every day feeling of excitement not knowing what to expect from the day, as all emergency physicians are so familiar with and like so much. As I turned the corner and came into Resusc all beds were full and all doctors from night shift and day shift had congregated around one patient. They were busy resuscing an elderly lady that had just collapsed. They had achieved ROSC but she was still bradycardic and had no spontaneous breathing. I assisted the doctor responsible for the airway with putting a tube down while Sa’ad scanned the heart. After a few minutes the bradycardia gradually went into asystole and the decision was made not to continue the efforts due to the poor prognostic. As it so often is in the EC we didn’t have the time to ponder on what happened, why and what could potentially be done differently next time. Instead I immediately had to divert my attention to the other patients in Resusc, whom needed my help to avoid the same faith.

By now I have grown accustomed to death. The patients in Khayelithsa are often in such bad shape when they finally make it to the hospital that there is only so much one can do for them with the limited resources that we have here. KDH doesn’t have a high care unit and thus every patient in need of that level of care has to be referred to Tygerberg. In order to get a patient across there the indication has to be crystal clear and there has to be a bed available. The chances of these two conditions occurring at the same time is slim, but it does happen. And what I like about KDH is that we always aspire to give the best possible care to every patient given the circumstances, so if we feel that a patient would benefit we would try our best to get that patient across. Even with the patients not eligible for transfer the culture is such as to not accept resignation. In fact that sense of personal responsibility that that culture have either grown out of, or imprinted into every doctor – I don’t know what is cause and effect – is probably the biggest difference between here and home. Here every doctor sees it as his or hers own responsibility to be able to solve every possible situation, be it repairing a split nose, delivering a child, intubating a patient or correcting a hyponatremia. There is no excuse for not being able to do what needs to be done, even if you are a junior doctor. This together with an acceptance of the fact that the resources are limited here leads to an unsentimental mentality that make the doctors do all that they possibly can for every patient without being dragged down by feelings of hopelessness or futility. When they reach the conclusion that there is no more to be done for the patient they initiate palliative care and move on to the next patient in need. There is also no acceptance of patients dying while waiting to be seen or dying due to iatrogenic causes. You will see no-one shrugging their shoulders in indifference. Everyone feels accountable and no-one sits back with their hands behind their head blaming the system. If someone complains about a relative not getting a bed, yes, they will get the advice to call their local politician, but in matters of medicine you will hear no excuses. This impresses me and has really opened my eyes to what being a doctor can be like. I hope to bring some of that positive strength back home and hopefully not only adapting more of that attitude into my own learning, but also influencing others to be better doctors.

Speaking of learning, by this time I’m no longer caught in the gut sucking acceleration of my own learning curve. Instead I’m experiencing a form of consolidation of what I’ve learnt so far. As we have been hopelessly short staffed the last two weeks I’ve been more or less upgraded to a regular member of the team, allocated my own pod. When it happened the first time I was terrified. Managing Trolleys is like trying to keep track of 40 moving ice blocks in the arctic sea – there are really only two outcomes; either you loose track of a few ice blocks or you fall in to the ice cold water when focusing too much on the ice blocks and too little on your own step. After that first time off, it has actually felt like the natural next step and I’ve been able to manage fairly well. Learning medicine is a bit like learning to drive. When you are new your’ll be pooring with sweat just by trying to release the clutch in a way that woun’t cause the engine to stall. Your gaze is more on the gear stick than on the road (Me first month at KDH). After a while you’re confident enough to drive one lane roads with the occasional intersection, but will soon be stressed if you find yourself on a two lane freeway with some traffic. Your focus will be on the car just ahead of you and you woun’t see the situation your driving into before it’s too late. You’ll find your self in the most desperate manoeuvres trying to avoid a crash, and if you make it you’ll be catching your breath and laughing nervously with your mate about how close that was (Me until two-three weeks ago). When you’re an experienced driver the driving itself is in your muscle memory leaving the full cognitive capacity of your brain available to analyse the whole situation and draw up possible future scenarios to be able to tackle them by not even driving into them. It would take me another year to be that comfortable behind the wheels of KDH EC, and a whole career to perfect it, but at least I’ve had a taste of it these last weeks, and it leaves me with a a feeling of wanting more.

I’m eternally grateful for having been given the opportunity to work in Khayelitsha. I’m grateful for all the things I’ve learnt medically. Things that I would never been able to learn anywhere else. I’m grateful for the time spent with the Xhosa people, getting to know their way of life, taking part in their happiness and in their sorrows. And I’m grateful and humbled by having had privilege to work with such wonderful colleagues in Team 3. Sven, the team leader. Intimidating at first, but once I knew which movie the local Khayelitsha gang “Vatos Locos”had gotten its’s name from (blood in blood out – if you havn’t seen it, see it!) I was accepted. Sven, you have given me the most important thing – the feeling of me being safe and taken care of, no matter what. With that ground state I was able to take on the hard work with enthusiasm instead of apprehension. Ridwaan, the steady first officer. Always there when I needed a healping hand (weather I knew it myself or not). I greatly admire your mental capacity to se the opportunity in every situation, to se ability in people when they are doubted or when they doubt them selves. The T-shirt “Keep Calm and Carry On” was made with you in mind. Jaci. Such a joy to work with you! We feel we shared the same ethical compass and I could always turn to you in such matters for support. Also good to share a bit of parental complaints in Fika. Christian. Thank you for reminding me that, even though we study hard and work hard, medicine is not all – it is just work. So easy to slip into the idea that our line of work comes above all, the thought being justified by the importance of what we do. But first must come life. Without that perspective we loose our selves and become in-humane. And thanx for being first coffee brewing officer. Thank you everyone else that worked in Team 3 during my time in KDH. Such a strong feeling of kinship with you all. Thank you Hennie Lategan for being such a strong support to us as a consultant. And thank you Sa’ad Lahri for being such a strong force in keeping this insanely chaotic wonderful piece of madness together! You have the rare capability that defines a true leader – the ability to get everyone to understand your goal and exceed their own capability every day to achieve that goal. You’ve inspired me and shown me that it’s possible to do wonderful things even under the most difficult circumstances if one focus on the possibilities instead of the obstacles.

It is with a thousand different feelings swirling around in my chest that I say good bye! I hope to see you all again, in Sweden – where my door will always be open for you – or in Cape Town when I get back!