Friday 21st May St Helena Day

St Helena Day naturally enough is a public holiday and it is combined with the Whitsun Monday Holiday this year to produce a welcome 4-day weekend.
 

The weekend did not start well for me. I had been busy for the preceding days and on Thursday night after enjoying a few end of week sundowners at Donny’s a small group of us had retired to Ann’s Place for a meal and a few more beers. We had finished eating when a lady at the table behind me collapsed over her meal. Although not on call I had no choice but to respond and escort her to the hospital in the ambulance, she appeared to have had a heart attack but fortunately this proved not to be the case. Nevertheless it was 3 am before I finally got to bed.

The weather the following morning was perfect clear sky,

bright sun and a fresh breeze. After checking on the condition of my patient of the night before I  met up with Ann,  Mike and Derrian (the newly weds) on the quay  with whom I had planned a day sailing before the St Helena Day Parade. Although the shops were shut the town was crowded with people preparing for the days events. RMS St Helena was in the bay and loading in preparation for an early departure on the Saturday. 

Also in the bay was the RFA Black Rover paying a courtesy visit to the island.

We enjoyed a wonderful few hours on the water, it is great to be able to get off the island once in a while and look back at it. Even more important is the opportunity to talk about the difficulties and frustrations of island life with trusted friends and not worry about being who else might be listening. The presence of two large ships also gave more purpose to our sailing, we were able to sail around them rather than just sail in circles. 

From the sea we could clearly hear the sound of music from the festivities ashore. There are only 4000 people on the island but most of them seemed to be on the waterfront.





We returned shortly after the parade arrived on the quayside and made our way back to our favourite haunt – Donny’s to enjoy a few more beers and watch the sun go down behind the Black Rover to mark the end of a perfect day.

Saturday and Sunday I have been on-call at the hospital but fortunately not too busy, today I have been one of the “Hares” for the Hash and been out setting the trail for the “Hounds” in the Hash run later this afternoon.

The Hash is developing a good following and we have attracted a number of families with young children so we have set a double course, a fairly demanding run for the enthusiasts and a fun run for the families. Today’s course is on the eastern end of the island where there are barren dry volcanic mud slopes with sparse vegetation consisting mainly of Tungi cactus. Fortunately the weather remained dry, had it rained there would have been some very muddy runners.

After the run there will of course be a few more beers then a party.
Back to work tomorrow but at least its only a 4 day week.

An Island Wedding

Steph and I met Mike and Derrian last year on the RMS when we sailed back to the UK. They had been working on the island for a couple of years and had decided to get married on the island on their return.  I met Mike again soon after I returned to the island in February and we have become good friends and together with Neil who was Best Man for the Stag Night and who was to give Derrian away we have enjoyed several walking and sailing trips together and of course the odd beer.

The build up to the wedding began two weeks ago when Derrian was due to arrive back on St Helena. Neil, Mike, I and Anne sailed out in her boat to meet the RMS carrying a large banner welcoming Derrian back to the island.

Last weekend was the stag night when a large group of Mike’s friends, islanders and ex-pats joined in a pub crawl taking in nearly all of the island pubs.

Sadly I was on-call for Maternity that night and had to follow with a personal supply of non-alcoholic beer. Fortunately the only lady due to deliver in the next 6 weeks had delivered that morning so I was not tied too closely to the hospital.

The evening included the usual rituals of drinking games, rugby songs etc. and ended with a BBQ and a bun fight in the rain.  Wisely Neil had arranged a minibus to ensure that everyone arrived home safely.











The wedding was delightful. The service was held at St Paul’s Cathedral and conducted by the Bishop of the S Atlantic. Bishop John as he is better known is a familiar face and frequently joins us on Friday nights at Donny’s Bar.

Not surprisingly none of Mike or Derrian’s family had been able to come over from the UK so Neil switched roles, having been Best Man for the Stag Night and took on the role of bride’s father. The church congregation consisted of a large gathering of friends and islanders who all knew one another well. The service although held in the cathedral and conducted by Bishop John in the full regalia of his office was a wonderfully relaxed and informal.

The reception was held at the Consulate Hotel in the centre of Jamestown

and lasted well into the evening. Once again I was on-call for Maternity fortunately it was another  quiet day but I had to be content with non-alcoholic champagne.

Sadly both Mike and Derrian have now completed their contracts on the island and will be packing their bags for a honeymoon and a return to the UK. They will both be greatly missed.

And finally  ...   we have potatoes again.  After nearly three months the RMS has arrived with 13 tons of fresh potatoes. There not in the shops yet but I've seen them on the quay so hopefully tomorrow!

Exploring the Island

My work keeps me busy for most of the time during the working week and its quite often well into the evening before I have finished researching problems on the web and writing various reports and presentations which I am expected to give. I do however have time free at the weekends and there is a small but active ex-patriot group who create a busy social life.

The weekend begins at 4:00 pm at Donny’s Bar on the waterfront and by the time I get there, usually about 5:30 the atmosphere is alive with gossip and discussing plans for the weekend. Options are a little limited on St Helena where there are virtually no organised events and culture extends to Country Music but little else. The main activities are walking in the hills and sailing or fishing. Mike and Neil are the ring leaders of the walking group and dream up theme walks, ”Breakfast at the Barn” – which I missed,” Lunch at Lots” and the next is planned to be “High Tea at High Hill”. “Lunch at Lots” was a couple of weeks ago.

“Lot” is a massive basalt pillar set on the steep volcanic slopes of the south side of the island leading down toward Sandy Bay. The latter is a complete misnomer, there is very little sand and what is there is black and stony, the bay itself is exposed to the prevailing SE trade winds with large breakers, far too dangerous to consider swimming. It was still raining when 10 of us set off from near the peaks initially through fields of New Zealand flax which was once the islands main cash crop. The flax was processed on the island to produce string for the UK Post Office. Sadly natural fibre gave way to modern synthetics and the islands main industry disappeared overnight about 30 years ago, a blow from which the island economy has yet to recover. As we descended the weather improved and landscape changed to green pastures with cattle grazing then to dry scrub and finally steep rocky slopes with little vegetation.

The path which had been a farm track higher up gradually petered out until we were struggling to find any signs of a path and finally, despite being led by an ex-Army officer with a map, got completely lost on a steep unstable slope. We retraced our steps with considerable difficulty and eventually found the cable.

The cable was a 100m length of old electricity distribution cable firmly anchored to a gnarled old tree which enabled us to abseil down an otherwise impassable rocky outcrop to reach a ridge which led to the base of Lot.”Lot’s wife” is another similar pillar about a mile away across a barren rocky landscape appropriately called “The Gates of Chaos”. It is possible to climb Lot and a small group of us started up using another length of cable, I retired after about 30m but a couple of the more adventurous members of the expedition managed to get more than half way up.

The way home was back the way we had come using the cable to haul ourselves up over the rocky outcrop and then a long steady climb back to the high plateau where we had left our cars.

The following weekend was much more relaxing, one of the group, Ann, is a keen sailor and she has bought a 36ft old steel schooner from a Saint for a bargain price. In the preceding month several of us had spent a lot of our spare time assisting with maintenance and getting her sea worthy. The weekend after Easter was our first opportunity to go for a sail. We planned to sail around the island preferably without using the engine. We met up before dawn at 5:30 on the quay, took the ferry to the mooring and were on our way as the sun appeared above the eastern horizon. After a week or two of fairly persistent rain we were blessed with a fine day and a fresh breeze.

We made good progress beating into the breeze and rounded the Barn, a massive rocky outcrop on the north eastern tip of the island, where the others had enjoyed breakfast a few weeks previously when I was working, after a couple of hours. Sailing down the eastern side of the island was slower as we were beating into a rough sea on the exposed coast Galaxy however is a well designed yacht strongly built and capable of making headway in difficult conditions.

Ann was content to enjoy her boat and left Neil and I to play with the sails to try to get the best out of her. She, “Galaxy”, has been sailed round the world before and has an interesting collection of sails to set on her twin masts. Although the wind slowly moderated we continued to make good progress with the wind on quarter as we sailed around the southern tip of the island and came up to Sperry Island.

Sperry Island is a very dramatic rocky island stack, home to thousands of sea birds who surrounded the boat and were clearly not there to welcome us. 

We had planned to anchor off the next island for lunch and a swim but sadly as we rounded South West Point the wind died away completely and for the next 3 hours we drifted slowly northwards enjoying a leisurely lunch and a bottle of wine. We delayed starting the engine until we calculated that we had no choice if we wanted to get back to our mooring before nightfall when the ferryman would head home leaving us stranded. The engine had only been running for 10 minutes.

“Phoenicia” a replica Phoenician sailing vessel which is following one of the ancient trade routes around Africa and is currently visiting the island. There is however no evidence that the Phoenicians ever came to St Helena which was discovered by the Portuguese in the 15th or 16th century. Well satisfied with our day we retreated to the Consulate Hotel to celebrate our circumnavigation. 

This coming weekend the team are going to sail around the island the other way, unfortunately I have work to do.

My working day

I have delayed writing about my work because of concerns about confidentiality. This blog is accessible to anyone who finds it and the island population is so small that it would be easy for patients to identify themselves. I shall have to be circumspect in what I write and careful not to cause offence.

I knew when I accepted this post that it would be different previous work I have done. Working as a GP in the UK I used to see a huge variety of medical problems and move rapidly from one medical speciality to another as each new patient described their problems. Indeed I often dealt with several totally different problems during a consultation with a single patient. Up to a point it is no different here, when I am working in a general clinic the work is very similar to UK General Practice. It is what happens next that is different. Whereas in the UK there is always a specialist to refer to or take advice from on St Helena there are no specialists. There are three GPs Sarel, Wendy and myself, and a General Surgeon, Ramdas, to do everything.

We do have visiting specialists, there was an orthopaedic surgeon here for a couple of weeks in January but he won’t be back for a year or two. The ophthalmologist should be coming in August but we are awaiting confirmation and we are hoping to find a General Physician, if there are any left, to come for a couple of weeks before the end of the year. It is possible to contact various specialists by e-mail or phone for advice but that is time consuming and you still carry full responsibility for managing the patient. I find myself spending a lot of time on the internet in the evenings reading up about problems I am trying to manage. My two GP colleagues are helpful but unfortunately they do not always see eye to eye and I sometimes receive conflicting advice. Sarel is good on cardiology and obstetrics and Wendy is helpful on gynaecology but in other areas we have no shared expertise at a spcialist level.

I have been given Diabetes, Elderly Care and Psychiatry as my special interest areas and run dedicated clinics. Diabetes is a huge problem on the island with nearly 1 in 3 middle aged women having diabetes. Management in the past has often been haphazard mainly I think because some of the GPs who have worked here do not have the UK approach to Chronic Illness and do not always follow guidelines on best practice. They tend to respond to problems then do little to monitor a condition until the next problem arises. The result is that less than 25% of diabetics are well managed by UK standards and many patients have complications that might have been avoided with better pro-active care. I am attempting to reorganise the diabetic clinic, introduce some simple guidelines and even audit the outcome.
Psychiatric care is rather better organised, I have the support of a UK trained CPN and a monthly teleconference with a South African Professor of Psychiatry who has been to the island and understands the working conditions and constraints we have to adapt to. The GP type psychiatry is straightforward but I also have responsibility for the small psychiatric hospital and patients with learning difficulties as well as children with ADHD and adolescents. The latter group are a particular problem as there have been a series of teenage rapes by older men with family links.  I will also be taking on the child protection work when Wendy leaves.

The General Surgeon at present is Prof Ramdas Rai from India whose interest is endoscopy and GIT tract surgery. He is excellent in his specialist field but a little reluctant to move outside it. Also of course a surgeon requires an anaesthetist and that naturally is the role of the GP. Fortunately my past training in anaesthetics and a couple of sessions of updating my skills at Salisbury before I left has enabled me to take on this work reasonably comfortably. I do a day in theatre every third week and occasional additional emergency cases. I have given about 20 anaesthetics so far without major problems - touch wood!
Emergency orthopaedics is a major weak area. I have reduced and set a couple of minor fractures. Fortunately road traffice accidents are rare and violence uncommon but the lady with a fractured femur can only be managed conservatively until the next ship for Capetown which will be nearly 8 weeks after her fall. It was ironic that I was actually eating at her restaurant when she fell, the family knew me so I left my meal and was able to diagnose the fracture within minutes of her fall but she will wait 2 months for treatment.
We do have an X-ray machine and a nurse trained to take the pictures but must do our own interpretation. There is also an excellent ultrasound machine but again we have to do our own scans, I'm learning slowly.

The working day starts at 8:30 except on Thursday when we start at 8:00 with each of us taking it in turn to provide a presentation on a subject of recent interest. We have a half hour to discus any problems from the previous day and then go down to the wards to see our individual patients and catch up on paperwork and reports. I then do a morning clinic everyday except when I am anaesthetising.  Three days a week these are in the hospital but on Mondays and Thursdays in peripheral clinics. The Monday clinic is at Half Tree Hollow which is a rather dull dormitory community high on the hill above Jamestown it’s a busy clinic with 20 or so patients but usually fairly straightforward. On alternate Thursdays I attend the Levelwood and Sandy Bay clinics. These are rather ramshackle buildings high on the mountain and often in cloud but with stunning views on clear days. Despite being only a few miles from Jamestown there are patients who hardly ever go to the “town” they all speak the Queen’s English but some of them are barely intelligible. They are stubbornly independent and quite stoical. One lady had fallen and fractured her wrist but waited three days to see me in the clinic rather than come to the hospital. Monday afternoons I run clinic at the Community Care Complex which is a large modern building which provides residential and nursing home care for the elderly. Tuesday afternoons I assist the dentist with sedation for the large proportion of the population who seem to be needle phobic. Wednesday pm is my diabetes clinic, Thursday is catch up time and prison visits and Friday is my mental health clinic at the end of which I am more than ready for sundowners at Donny’s on the waterfront.

We are on-call one day in four but always have to be prepared to help out with an anaesthetic in an emergency especially for maternity cases. Out of hours is when life becomes interesting because whatever the problem you have to find a way of managing you cannot delegate to someone else. When a man died suddenly and unexpectedly I felt unable to provide a death certificate and suggested a post mortem, the next day I carried out my first post mortem. We have to recognise our limitations and acknowledge that some problems are beyond our resources. Last weekend a man was admitted with a leaking aortic aneurism, we did not attempt resuscitation but gave enough morphine to keep him comfortable and ensure that he died peacefully.

For non-emergency problems there is always the option of sending patients to the UK or Capetown for definitive care. This is a very expensive option from the managers point of view because not only must the island fund the cost of the treatment, in South Africa at least but also the cost of travel and accommodation while the patient is away.  Each Thursday morning we have a meeting to discuss priorities and decide which patients justify referral. Not an easy task, there are some guiding principles written down but it is never an straightforward decision.

The most frustrating aspect of work here is the attitude of many of the islanders particularly the older generation who are reluctant to take any responsibility for their health. One of the major reasons for the high prevalence of diabetes is the poor diet and lifestyle of the islanders. Obesity is far worse than in the UK and accepted as the norm. I’ve even had patients of ideal body weight concerned that they are too thin and cannot put on weight. That said I’ve some sympathy for their attitudes, fresh produce is expensive and not always available and the opportunities for exercise are limited if you cannot manage steep hills. Most roads and paths go either up or down there are very few opportunities for easy walking. The problem of attitude to health care remains and includes an assumption that it is the doctor’s duty to care for your health and that it is the Government’s duty to improve health care. They do not want to know anything about the details of their medical problems and often cannot provide a reasonable account of their symptoms or the history of their condition. A common comment about problems they have had before is that the doctor didn’t tell me anything, I’m suspect there is some truth in this but I’m sure that the real problem is that they didn’t ask or didn’t want to know especially when the message was unwelcome.

Minor niggles aside most of the patients are appreciative and supportive, I’m enjoying the challenge of my extended General Practice role and developing new skills though where I will use these skills next is another matter.

Jamestown Hospital

The hospital at Jamestown is the base for my work although I also go out to three peripheral clinics. The hospital is situated near the head of the valley above Jamestown about a mile from the sea with steep rocky slopes on either side but reasonably sheltered by trees.

The buildings are in a Colonial Style about 50 years old but in good repair. There are high ceilings, wooden floors and a veranda. There is no air conditioning but with open windows and fans the temperature is tolerable even on the hottest of days.

 There are three main wards, male and female general wards each with 8 beds which are usually half full. The surgical ward is only used on operating days, once a week and doubles up as the recovery area for the operating theatre.

The operating theatre is small but well equipped with a range of modern equipment for use by visiting doctors of various specialities. There are endoscopes and a laparoscope but no image intensifier.

The anaesthetic machine is up to date and very different from the machines I used when I was last giving anaesthetics, all that is missing is the specialist staff to use the equipment. The current surgeon is a Professor of Surgery from India who specialises in upper GI tract work. We currently have a man on the ward with cancer of the pancreas who might benefit from his surgical skills but do not have the ability to provide the specialist post operative care that he would need. 

There is a small Intensive Care Unit for the more seriously ill patients but unfortunately not enough nurses with the necessary skills to provide 24hr cover. There are plenty of nurses on the general wards are enthusiastic about their work and enjoy a good relationship with their patients. However they are not always as careful as one might wish about following care plans for patients. The atmosphere on the wards is wonderful, on such a small island most people know one another and it is fairly normal to find that patients have at least one relative working in the hospital. Extended families are part of the island culture and the wards are often crowded with groups of people chattering and gossiping, not perhaps are quiet and restful as a hospital should be but a lovely place to be working.

There is a small physiotherapy department with a single partly trained therapist who does what she can. The X-ray machine is an old portable unit not really adequate for the task but due to be replaced in the next year, a specially trained nurse takes X-rays of a reasonable quality but of course it is up to the doctors to interpret them. There is a very good ultrasound machine but again it is up to individual doctors to do the scanning. Ultrasound was in its infancy when I started medicine and learning to use the machine effectively is quite a challenge but I’m slowly getting the hang of it. There is quite a comprehensive laboratory set up and the staff are quick and efficient at getting tests done and reporting back. They will even come and find you to tell you about an interesting or important result. 

The pharmacy carries a rather limited range of drugs but the formulary is generally adequate to meet day to day needs and special drugs can be brought in on the next boat when necessary. Diabetes is a major health problem on the island and an optometrist visits twice a year to provide a retinal photography screening service.

The peripheral clinics are held in the other major population centres of the island and although only a few miles away the drive can often take 30 mins or more because of the steep winding roads through the centre of the island.

The views and clinic settings are spectacular and the clinics themselves well maintained if rather basic. Medical records throughout the hospital are partially computerised and we use laptop computers at the clinics.

A pharmacy van accompanies the doctor and nurses so that patients can usually collect their drugs when they are seen. Clinic days in the more isolated communities are a great social event for many of the older people who do not have their own transport to get to Jamestown and nobody minds being kept waiting if the clinic over runs.

The four doctors working on the island each have special areas of responsibility if not expertise, two of my roles are Mental Health and Care of the Elderly for each of which there are separate institutions. Sundale, the psychiatric Unit, (why do they always have such pleasant sounding names) is a compact old brick building shaded by trees in a small garden but perched high a hill with a magnificent view of the ocean, its in a dreadful state of repair but the staff are committed and the atmosphere is very good. By contrast the Community Care Complex (modern name for a modern building) is an impressive new building in a similar location

but with no shade on a north facing (the sunny side) rocky slope. Despite its poor location the building and its facilities put to shame anything in the public sector in the UK. The unit provides Day Care, Nursing Home Care and a secure area for those with Alzheimer’s Disease. Once again because it is a small community most of the residents are old friends and they are cared for by staff who, if not members of their extended family, are at least known to them which generally guarantees a high level of personal care and commitment.

Despite the apparent good doctor patient ratio, 4 doctors looking after 4000 patients because of our extended roles we are actually very busy.

After a very busy and stressful week, more about that next time, I’m enjoying a relaxing weekend off and spent yesterday in a small fishing boat exploring the dramatic coastline.

My South Atlantic Home

It is early Saturday morning and I've just finished my first working week and my second night on-call, I was also on-call on my first day. I have still to go into the hospital to hand over to Dr Wendy (I'm known as Dr Sherwood) who is on for the rest of the weekend. I was woken early this morning by a call from the hospital and am now sitting on the veranda of my flat looking down the valley to the sea. My flat is the red roofed building in the foreground, the hospital is the green roofed building.
The sun is on the mountain tops but its still shady here in the valley, we're expecting another hot day but it is pleasantly cool at the moment.

The flat that has been rented for me is delightful,it is part of an old farm building, probably 150 years old with thick stone walls and a corrugated iron roof. It is a bit shabby on the outside but clean and tidy inside.

There is a kitchen with whitewashed stone walls and old range
with some rather wobbly furniture but there is a modern stove, microwave, fridge freezer and washing machine. There are a few cockroaches around but they are kept in check by the resident population of geckos. Out the back there is a dusty yard with a washing line where clothes dry in an hour or two.

The bedroom also has white painted rough stone walls with a tiled floor. All the windows have mossie nets and when left open these allow a reasonably cool breeze coming down from the mountain to blow through the room so that by the early hours of the morning the room is pleasantly cool even if in the evening I could do with air conditioning or at least a fan to get some sleep. The bed is a rickety iron four poster that is probably a hundred years old with a mattress to match. There is a bathroom with an old cast iron bath and a shower which is ancient but works adequately.

The dining room is spacious and elegant
with period furnishings and prints and would not look out of place in "Country Life", it is far too grand for me to use on my own, I usually eat in the kitchen or out on the deck.








The living room is my favourite, it too looks like something from another age spoilt only by the large TV (which isn't connected). The furnishings are all antiques and the walls are decorated with Napoleonic prints.

The arm chairs and chaise longe look great but are not terribly comfortable and the desk where I keep the laptop is large if rather wobbly but you can't have everything.
The living room opens through French windows onto the deck which forms the main entrance.

There is nothing stylish about the deck except the view.
Although there is a full time gardener the place is pretty unkempt but the view down the valley with steep rocky slopes on either side then over the roof of the hospital to the sea is wonderful and the air is full of birdsong in the morning and evening. The deck is a great place to work in the evening until the mossies and moths come out. The garden of course belongs to the main part of the house where members of the owners family live but I can enjoy the sense of peace and space that it affords and the fruit that drops from the mango tree.
The flat is only a 5 min walk from the hospital which is just as well as I have been kept very busy especially when on-call. The hospital is a little dated but the staff are very friendly and helpful. The work itself is full of challenges some I expected others perhaps unwelcome at this early stage but I'll write about that later.

A difficult landing

After a a very comfortable voyage we first sighted St Helena at about midday on Friday and were hopeful of disembarking a day early but Neptune had other ideas. The swell that had been impressive on Ascension but barely apparent on the open ocean had built up huge waves that were pounding the waterfront at Jamestown.

There is no harbour here and small boats are used to ferry passengers ashore. The steps where we would normally land were being repeated engulfed by huge waves and there was no question of getting ashore. 

Instead the ship arranged free drinks at sunset and a game of deck cricket and for once the passengers beat the crew. The following morning the seas was still quite rough but we were able to land with the launch rushing alongside to unload a few passengers then standing off for the next big wave before rushing in to unload a few more.





I met Sarel, the senior doctor here, and we went for coffee at the waterfront coffee bar where half of the island had gathered to watch the spectacle. The previous day apparently was the first time in 25 years that the RMS had not been able to land passengers.

Even today the view from the shoreline was awesome with the massive waves throwing boulders across the road where dozens of cars are usually lined up awaiting friends and family returning on the ship. Even more impressive were the efforts of the waterfront men in unloading containers in these conditions.

However without those containers the island would rapidly run short of essential supplies.

After a short briefing from Sarel I collected my baggage, found the car, and heading off to the flat that has been rented for me. Not knowing my preference for small cars and I presume thinking that a doctor needs a car of some distinction I now have a large black if rather old and shabby, BMW! The island speed limit is 40mph and I don’t suppose I will ever get it out of 3rd gear.

The flat they have found for me is delightful, a few hundred yards from the hospital and tucked away in the walled garden of a large house it is an ancient stone cottage with a lovely deck and a superb view. The interior is furnished with antiques, I have a Chaise longue and a four poster bad.
Today I plan to explore the island a little with James the UN volunteer and discover where the peripheral clinics I will have to attend are located. Work begins at 8:30 tomorrow with the doctors meeting then the Jamestown Clinic. On Tuesday I will have my first theatre list.