Thinking out the box

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David’s face is sliced open from forehead to chin, his flesh pinkly exposed like a thick rasher of bacon. For a couple of hours, he has wandered agitatedly around Kimberley Hospital’s accident and emergency unit, his face framed by a bandage.

Finally it is his turn to be attended to.

Ashton Boggenpoel, a community service doctor, stitches him up neatly, pulling the wound together tightly as he speaks of working conditions in the province.

One of Dr Boggenpoel’s main complaints is that the province’s paramedics, who deliver patients to the hospital, are inexperienced and can’t even put up drips.

‘We’ve got nice new ambulances but it’s a bit pointless if we don’t have the staff,’ he says, pulling at the final stitch.

David, whose girlfriend attacked him with a broken bottle in a shebeen, starts to cry. He expected sympathy but there’s no time for niceties. His face is still coated with blood, but Dr Boggenpoel waves him off the chair.

‘The nurse will clean you up,’ he says, calling in the next patient.

The barren fruits of Kimberley’s bleak social environment manifest themselves in the unit: some 400 stabbings a month, mostly alcohol-related; about 20 teens who try suicide. Car accidents, usually alcohol-inspired, bring in another 300 patients.

Later that night, in the short-stay ward where patients are kept for up to 48-hours’ observation, a psychiatric patient wakes up from a bad dream and bolts out of the hospital wearing only a backless hospital-issue top.

After a long chase, security guards catch up with him at the taxi rank about 2km away and drag him back like a criminal. The sister in charge of the short stay ward, a heavy woman with a limp, orders security to put him in a small lock-up room, then borrows a baton from one guard.

She goes into the room and pulls the door closed behind her. Then she pours out a torrent of abuse on the apparently psychotic patient, punctuated every few seconds by the baton being brought down hard.

After about five minutes, the sister comes out sweating and heaving with exertion. She hands the baton back to the security guard and moves back to her station at the front of the ward as if nothing has happened.

There is some laughter from the guards and nurses, and none of the health workers think to look in on the patient.

Despite this callous public disregard for a mentally ill patient by a senior staff member, the 550-bed hospital ‘ once divided into a black section and a white section ‘ has won a number of awards for management and innovation and is considered a case study in transformation.

In the past six years, it has expanded from employing 38 fulltime doctors to 115, plus 40 community service doctors and 30 interns.

‘We have the second highest doctor-patient ratios after the Western Cape. But we are really struggling to keep nurses,’ says Dr Hamid Shabbir, the flamboyant chief executive officer who could have stepped out of a Bollywood movie with his large moustache, bright clothes and flashy large turquoise rings.

Originally from Pakistan, the exuberant Shabbir has been with the hospital since 1993. He took over as CEO when his predecessor, Deon Madyo, was promoted to provincial head of health

‘The critical thing in keeping professional staff is to provide sufficient respect and make sure that they work in a healthy, safe environment,’ says Shabbir. ‘Salaries play a part, but they come a little lower.

‘Just yesterday, I was approached by a group in Kuwait and offered R140 000 a month tax free to go and work there,’ he says. ‘We can’t compete with things like that.’

Exit interviews with young doctors leaving the hospital found that most were leaving, either to work overseas because they were under pressure to pay off student loans, or to go to an academic hospital so that they could specialise.

‘We took an important decision that has not happened in the country before. Whatever bursaries or loans a community service doctor has, usually around R150 000, we will pay them off immediately if they agree to stay here for three to four years,’ says Shabbir.

‘Ninety percent of the community service doctors have opted for this, and we are about to go one step further and offer this to the interns as well. We have also identified about 40 students from the Northern Cape in medical schools and have offered to take over their loans if they come and work in the province.’

Young Dr Boggenpoel grumbles that the hospital takes too long too keep its promises. But even he has stayed longer than he planned to at the hospital.

Kimberley has also linked up with the University of Free State’s medical school in Bloemfontein, and succeeded in getting accredited as one of its training institution. Those who need to be based in Bloemfontein to specialise are also helped to do so.

But, says Shabbir, nurses remain a critical problem. Last year, enrolments at the nursing college doubled and the previous year, the intake was up by a third. But it takes four years to train a professional nurse, so the province’s 942 professional nurses have to make do for now.

‘Salaries are determined centrally, and we can’t expect a big renumeration package to fall out of the sky. But we would like all professional nurses to get the ‘scarce skill’ allowance,’ says Shabbir.

Many nurses ‘moonlight’ at private hospitals, says Sister ‘JP’ Bezuidenhout, head of both the accident and emergency and surgical units. Then they call in sick when they are supposed to work at their real jobs.

Back in the emergency unit, the nurses work flat-out with little time for a break. The pressure is particularly on with the medical emergency cases, patients who do not have obvious wounds and the source of their pain needs a lot of investigation. Some had waited six hours before being attended to.

‘After hours, casualty is like a glorified primary healthcare clinic,’ says Dr Boggenpoel. ‘Patients come here because the clinics are not working properly,’

At the outlying clinics, say the doctors who also do clinic duty a couple of times a week, there are shortages some of the most basic medicines.

One doctor said he had gone to the medicines depot himself to get medicines that had not been delivered to the clinics, which are managed by district health authorities.

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