Larsen, Jon

South African Medical Journal (SAMJ)

April 2003, Vol. 93, No. 4  SAMJBRIEWEIncreasing stresses in O & Gunits in district hospitalsTo the Editor: It is time to express our  mounting concernabout a number of issues that combine to make work in O & Gunits in district hospitals increasingly difficult and stressful,particularly for senior medical staff. Our unit in EshoweHospital is a good example. 1. Four of the 6 medical staff in the unit are replaced by newtrainees (interns and community service doctors) every 4months. A heavy clinical load has been mitigated, but largelyreplaced by a heavy teaching load. I am fortunate in that Ihave a senior medical officer (SMO) as part of my team. Manyother units do not have that luxury. The need to begin againwith a new team every few months is demoralising andexhausting, especially if you are the only senior person in theunit and you are trying to maintain a high standard.2. There is a steady attrition in the number of experiencedmidwives, especially advanced midwives, as a result of foreignrecruitment and the drift of personnel into city hospitals andthe private sector. One result of this is that no clinics in ourarea now do deliveries, and all deliveries done in the publicsector must be done in hospital. A second result is that this lossof personnel also increases the amount of personal patientsurveillance required of the permanent medical staff.3. The redirection of the care of rape survivors from districtsurgeons to district hospital medical staff has placed aconsiderable load on permanent medical staff because of thehuge escalation in the number of rapes. These cases take about2 years to get to the courts in our area, so it defeats the ends ofjustice if the community service doctors see them.A high proportion are juveniles, and their accurateassessment requires considerable experience. Therefore themajority must be seen by senior doctors. The primaryassessment of a rape victim takes about 1 hour (providingemotional support, collecting DNAsamples, filling the J88form, prescribing anti-retrovirals and other prophylaxis, etc).We follow them up for 6 months if adults, 1 year if children.For the past year I have had 2 - 3 court subpoenas per month,and one of the courts is 50 km away. In 2002, we looked after158 rape survivors (106 children aged 15 years and under),compared with 70 (48 juveniles) in the first 10 months of 2001,so we expect this court work to increase.4. There is considerable complication in having about 35% ofour O & G cases HIV-positive. This means additionalcounselling and care is needed to ensure that mothers andbabies get their Nevirapine, etc. As the epidemic matures, weare looking after increasing number of very ill women in ourantenatal, postnatal and gynaecology wards, and even havingto provide terminal care in each of these sites.The first three sources of stress listed here are unfortunatespin-offs of medico-political decisions, and solutions arepossible. I record them here in the hope that those with thepower and responsibility to address them will be able to findsolutions. Useful first steps could be:• To ensure that every unit that trains interns and communityservice personnel has at least a post for a head of unit andanother for a SMO.• To speed up the process of training forensic nurses to take onmuch of the care of rape victims.• To recruit and train midwives in numbers that takecognisance of the attrition rate in the profession.It is clear that quite urgent action is required if these stressesare not to add to the continuing loss (from burn-out) ofexperienced medical personnel from our hospitals as theirtasks become more and more difficult.The epidemics of rape and AIDS should be put together. It istime that we, as a profession, stopped pretending that acondom morality will make any contribution to solving theseproblems. We must also stop pretending that the profession cancontinue to cope with steadily escalating numbers of patientswho have been overwhelmed by these disasters. We reallymust state unequivocally that a return to traditional biblicalmorality is a sine qua non for national survival. Threeimmediate steps would seem to be desirable:• The will and legislation to reduce access to pornography inthe nation.• Strong moral leadership promoting family values from ourpolitical and ecclesiastical leaders.• The redirection of resources currently poured intoorganisations that promote hedonism in the guise of sexeducation toward programmes that encourage norms such aspremarital chastity, marital faithfulness and the sanctity ofthe individual.Jon LarsenEshowe HospitalPO Box 1241Eshowe3815Stress and resilience in SouthAfrican firefightersTo the Editor: Post-traumatic stress disorder (PTSD) was onceconsidered a normal response to an abnormal event. Implicit inthis idea was the presumption that most individuals exposedto a traumatic experience would develop symptoms regardlessof pre-trauma considerations. However, given the substantial236

Increasing stresses in O&G unit in district hospitals

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Increasing stresses in O&G unit in district hospitals

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South African Medical Journal (SAMJ)