Monday, 31 October 2011

Elective 17. The lackey

I spend Much of today working as lackey for Eggs. Good preparation for being an F1. The urologist was operating until gone 11PM last night, and looks Set to do this again. I am very impressed with that man's stamina, but even happier that I manage to avoid the TURPs list again. Imagine that, TURPing away until bedtime. Hellish. Instead, I go for a jaunt in the evening to hang our with a biker gang, in the attempt to find some more edible food.

The insects here are HUGE, and probably would make a sizeable snack...

Messing around with paper work today shows how poor the recording is of results and procedures, and more scarily, how irregularly some patients are given the medication (by the nursing students) prescribed (by the medical student). For example, a man with retention, severe constipation and hard Nodular prostate is not seen as candidate for surgery by the  urologist as he is not a simple TURP. The urologist is doing the simple cases in an attempt to do as many as possible. This man, with the nodular prostate and strange bone pain in his right sholder, may well haev prostate cancer rather than the easier-to-deal-with benign prostate hypertrophy (BPH) that TURPs are usually used to treat. This patient is still on the ward after being told that he couldn't have an operation, as he cannot urinate on his own, and has a catheter in. Yesterday Eggs and I prescribed ducolax (a laxative) as he hadn't defecated for days, and was very uncomfortable. When I was talking to the patient today (with the help of an interpretor of course) it turned out that he still hadn't been to the toilet. Looking at his chart, he hadn't received any of the drugs he had been prescribed here for two days, despite being part way through an anti-malaria course and on antibiotics for a urinary tract infection. With all the fuss over the patients getting surgery, or recovering from surgery, there doesn't seem enough time for the nurses to care for the non-surgical patients. 

While I was on the ward, one of the nurses was complaining that she had to wake up during her night shift to do some observations on the post-op patients, something she had never had to do before, and how it wasn't fair. I think perhaps if she came to the NHS, or healthcare in the UK she would have a real wake up call. The nurses here work amazingly hard. Tanzania seems a country of extremes. Some people seem to do so much work its hard to believe (for example, the urologist starting theatre at 8AM, and finishing at 11PM two days in a row so far, or Chief, who seems to be everywhere, doing a bit of everything, and who always has a smile), while other people never seem to do any work at all, such as Eggs, who managed to disappear for three hours in the middle of the day today, leaving me to write referral letters to hospitals I had never heard of and other such things. Because I surely know which patients need referral, which hospitals are best for them, and which patients we can treat here. On his return, he just flicked through the letters, said "asante" (thank you) and left again. I suppose this really is like the thankless task of being an F1, though in the NHS the consultant you work under doesn't usually spend the time he should with patients caring for his chickens.

In other news, Dr Bike is an attractive, unmarried (rare here) man in his thirties, who loves to flirt with the nurses. He has told me he plans on getting married next dry season (in a year), as food is cheaper then and more people tend to be free as they are not working on growing crops. He doesn't know who he will marry yet, but the plans are set. He does love teaching the nurses, which I really admire, even if it is just a ruse to find a wife. I walked past the window to the operating room while they were cleaning up on my way to children's ward, and stopped for a quick chat as I saw him lounging inside. In front of him were shreds of paper where he had been teaching medical facts, seemingly at random, and as I left he was lifting another nurse (clearly uncomfortable with the physical contact) up onto the table in front of him for a quick lesson in heart failure. His behaviour is somewhat risqué for this quiet Christian Village, but all well intentioned. I hope I get registrars that eager to teach when I am a junior doctor.

A wedding procession goes past in the village, celebrating a woman's engagement. The buckets may be symbolic, or perhaps it is just in case they get thirsty

In the evening I was Minding My own business, feeling sorry for myself, and just starting a new book - Messiah by Boris Starling, when I smelt the unmistakable Smell of sweetened spagetti drifting into my protesting nostrils. I cannot take this any more, especially as I don't even feel hungry, but know I should eat something. I cannot stand trying to force that 'food' down through my protesting tonsils. I have heard that there is a group of boys who usually BBQ up food, so walk off in the twilight looking for a BBQ surrounded by motercyclists eating around it. It is surprisingly easy to find, and once I am there, I find it they are very hospitable and sell Me a chipsi omelette for about 30p. This is omelette with chips in. Delicious, but , cooked in conditions that would send health and safety running. I 'hang out' with them mainly just laughing and hand slapping, as both of our language skills are lacking. An hour of non-communication later, and feeling a lot more satisfied, I wander the 20 minutes home. Now it is properly night time, I am fortunate that there is a sliver of moon left, or I wouldn't be able to see a thing. No lights here at all. The Tanzanian Sky is beautiful. Really really beautiful, and seems to have many times more stars than at home. It feels so wonderful living here under the glowing milky way.

Sunday, 30 October 2011

Elective 16. Running the ward

I manage some smooth talking to avoid theatre, though my willingness to do anything but TURPS leaves me organising all of the pre-op investigations. Chaos. I do get my own ward to run, though, and also find the urologist has sneakily been using my PDA!

I work hard today to avoid being on the theatre team with the urologist, whose list today consists of two imperforate vaginas and 8 TURPS. I really don't want to be stuck with those TURPS, though yesterday when I asked the urologist if he enjoyed them, he said ''They are my bread and butter. Of course I do!". Perhaps it is a lot more fun to be the one carving a prostate away using a tube stuck up a penis than to merely be watching someone carry out the act. Somehow I doubt I would enjoy it. In seriousness, though, I hear it is one of the more life changing of surgical procedures. In just as much seriousness, the people who pick up the rubbish every week also have a vital job in society, it is just not a job that appeals to me personally.

Instead Of TURPing,  I help out at the chaos that is male ward in the morning. At least until Eggs (By now I know all about his love for his 200 chickens, and the fact he spends so much more time with them than on the ward) decides to go for his compulsory 10.15am tea break. This break has happened every time I have been with him on the ward, and usually takes well over an hour. This time it takes him over two and a half, time the Urologist needs patients prepared for surgery as he needs to operate on as many patients as possible. Perhaps the busyness of the ward was tiring him out, but it was quite exciting for me to be the person in charge of such a busy ward!

I still feel awful, but these pills should help me soon. Paracetamol, malarone and amoxicillin, they will make me feel like this!

Once Eggs returns, and the ward seems to be much quieter, with investigations that were needed (i.e. all the haemoglobin levels that were ordered and needed before surgery was started) sorted out, I wandered over to the women's and children's wards. The patients here are usually managed by Dr Bike, but Dr Bike juggles running this ward with all of the operations int he hospital, all of the HIV work and the good hour a day he spends polishing his bike in his boxers every morning. I wish I was joking. Today Dr Bike has been observing and assisting the urologist with the surgeries (i.e. TURPs) that are being carried out by the urologist. In itself, this makes me very happy, as it makes it look less likely that I will be asked to do it, but it also stops him from doing any ward rounds for this whole week if he decides he would rather be with the surgeon. Fortunately I caught him leaving the theatre on his bike while looking for him. He told me he has helped in two TURPs and has "learnt all he can". I take this to mean he found it very boring as well. He has handed over assistance to a nurse I call Bugsy because of his dress sense, with hat. I have never seen anything else like it over here. Bugsy is rarely here, and I have no idea what he usually does, but I am sure Dr Bike was glad he was around today to let him escape. While the flight of the surgery-obsessed Dr Bike in the face of the TURPs makes my hatred feel a little more justified, I still don't have anyone to help me on the ward round in women and children's ward.

Getting back to my original tale of the striken women and children, and my heroic rise to the challenge of saving them all (yeah right), Dr Bike told me to do the ward round by myself before riding off into the distance. In the ward, the suspicious nurse was still very suspicious of me doing the ward round on my own (as she very well should be) but accepted that if I didn't help out  now the children would likely not be seen until 5 days time when the urologist had left. A whole week without Investigations, assessment, treatment or chance for discharge (they are paying for every day). Ignoring My poor literary skills regarding such hopeless bracket use (written on a PDA using solar power and hand writing recognition, though I am not sure how that would affect my grammar) the head nurse let me do the want round. For something I felt I had to persuade her into allowing me to do, I suddenly felt I didn't really want to do it. Possibilities of missing something and someone dying float through my head, but I did ask for this. Fortunately, all the patients are relatively well (relatively for a hospital, remember) and none are too well that I need to worry abort discharge. I ask for a few cannula to be taken out of children who are now well hydrated and drinking fine without vomiting (doctors here are very quick to give IV fluids) but it is the last child patient who stops my jaunt short of a happy solo completion. A child who had been admitted with pneumonia on Monday had only been given one days worth of treatment, an injected penicillin. This was odd, as normally amoxicillin is needed to continue the treatment. I don't really know what to do, though I know I want to prescribe amoxicillin syrup. To cut a long story short, I went to find a doctor, and persuaded them to come back with me to the child. Chief came back, looked at the notes and said "good job, that's right, next time you can do it yourself" and left back to his busy job running the hospital. I write up the amoxicillin prescription carefully (using my BNF) above Chief's squiggled signature, and feel validated. Perhaps next time I will do it myself. I would prefer not to though...

A good thing I had a nice morning, really, as the afternoon is filled with paperwork. Eggs escapes the male ward quickly; leaving me to make sure all of the pre-op investigations that the urologist ordered for this afternoon and tomorrow are done, and the post-op patients are cared for properly. Not all of the investigations the urologist ordered are available or this hospital (most notably urea and electrolytes (U+E), so I try and substitute what I can. Not such hard work (given the available investigations in the arsenal) but all the orders involve tearing our dozens of Squares of paper to write requests on to send to the lab, then recording the results on their return. Finding notes to record the results is the most challenging part of this, as I do not understand the seemingly biblic (seek and ye shall find) ordering system being used. In fact, after spending some time looking for 4 Sets of notes (Set meaning A4 pages with test results stuck onto them with Plasters [I really wish i was joking]) I have to ask one of the equally busy nurses where they are. The nurses (nursing students) are rushing around to care for normal (non-surgical) patients, the ones waiting for surgery, and these recovering post -op. The useful nurse walks to the emergency first aid Cupboard, opens the door, Lifts a box of drugs, and gives me another dozen notes. I have no idea why they would be in there, but it seemed quite intentional. The only rational argument I can think of is they were special patients in one way or another, and by filing them here it kept them away from the general chaos (or the chaotic medical student).

There are Officially 147 people in the 150 bed hospital now, but dozens of male patients waiting for an operation are 'out patients' meaning they sleep outside. They are seen as too healthy to warrant a hospital bed; the pregnant women sleep outside after after all. Today's list is 10  people long. If it continues at this rate (and I cannot imagine it will get any faster, the Urologist was working until 11PM) all of the people will not be operated on.

Every night, I get to wash in this small red basin. Such a taunt to have a huge bath with broken taps and not enough water to use it.

To finish with, the first beggar approached me today. He was one of the 'outpatients' just generally milling around the front of the men's ward. I Should have been suspicious as his English was much better (as in he knew more than 2 or 3 words) than any of the patients I have met before. He asked me how I was, then asked if he could have 100 Tanzanian shillings   (around 4p). I Was busy and didn't have wallet on me (why would I), so apologised and carried on with my bustle. Being in such an absurdly poor area, I am very surprised I am not asked all of the time. After all, as the only white in the village, I do stand out strongly. When I was in India, which was much richer than here, you couldn't go 5 minutes without someone asking for money. Here I have given away a few biscuits and many empty plastic drink bottles to those who ask (people like carrying around water!) Perhaps this is because everyone is ubiquitously poor, meaning no begging culture develops as no-one has anything to give away.

Elective 15. Pity me!

Today, I receive a lot of misplaced pity, another (preventable this time) death occurs in the hospital, and the specialist urologist surgeon arrives while i spend much of the day in outpatients.

The continual pity that seems to be showered down upon me, because I am feeling (and probably looking) very ill must be because I am a mzungu, either as they want to care for their guests (more likely), or they think it must be hard for me to be ill, as mzungu have no idea about suffering (relatively true). Though I am unable to swallow any food, I can still Speak and intend to keep turning up for things. After all the excitement, planning and cost that went into this, I do not plan on spending it in bed. I have been looking forward to this elective since before I started medical school, and plan to make the most of it. Please see my tonsils, below, for their patchy beauty.

My painful tonsils with all their annoying patches on them. I suppose its better than getting HIV.

Chief came around last night, for what is becoming his regular chat, peered into my mouth at my spotty white tonsils (image above) and persuaded me to go on amoxicillin. I do not usually take medications, and I am sure that this will go on its own, but I really do want to get better, and he is very experienced so I will do as he says. I know in the UK that amoxicillin is rarely used for these sorts of infections, because of the risk of it being glandular fever. Epstein–Barr virus and amoxicillin can react together and create a rash across the entire body. I tell Chief this but he tells me not to be silly. In some ways, I hope that I do get this diffuse rash all over my body, it would be exciting and kinda prove me right. But in many more ways I just want to feel better.

Today, for ease, I spent most of my time (after a wander through the wards) in outpatients, as here I could sit down. The specialist urologist arrived today, and the OPD department is extraordinarily busy, as word has been spread throughout the region about the specialist's arrival. Unfortunately, most patients have come with non-urology causes, hoping to see the specialist anyway. The assumption here seems to be that specialists are better doctors, so should be the ones to see your problem, whether it is in their field of knowledge or not. Tim the Tanzanian medical student is working in OPD again in one room with a doctor in the other. There is only really one room for a doctor to consult in, so our consultations are taken in a waiting and observation room, where patients wait to be seen, and nurses take temperatures and other observations. Last time I was with Tim I enjoyed the challenge of communal decision making (read: neither of us knowing what to do), and feel I would be more helpful with him than with a qualified doctor (Dr BT).

We see numerous patients with a rainbow of complaints, only three of whom we refer to the urologist. A lady with probable renal stones, and two possible congenital malformations. These are both boys who have repetitively had urinary tract infections, again and again, and various other problems with urination, such as leakage of urine accidentally. These are the sort of people that hopefully the urologist can help. A huge issue here is the small number of diagnostic tests available. Huge amounts rely on the history, which as I will talk about later, cannot always be relied upon. It is amazing how much is available in the NHS hospitals, with specialists just down the corridor to carry out advanced tests just when they are asked to help.

Tim and I have developed a good teamwork technique. As he talks Swahili he talks to the patient or translating relative, relaying information back to me, which I write in the notes.  I suggest further questions (such as, is there blood or mucus in the diarrhoea?) depending on what they have said, which he then translates and asks for me. I have been taught much more thorough history taking skills, and have had much more in-depth teaching about ideas for investigations to be carried out for certain presentations, while Tim has a much better prescribing knowledge, not just of which drugs are available but of which doses are needed, and the length of course required for certain diseases. With his linguistic and drug knowledge, and all of the history taking teaching that has been drummed into me we make a fine team. Jack Sprat and all of that. At least I hope we make a good team, at least no-one has complained yet, and I enjoy being made to feel useful!

Among the afore-mentioned-rainbow of patients seen today was a severely constipated man, who on further questioning revealed that he drank 8L of local brew alcohol a day (home brewed is usually quite weak, Tim tells me), therefore not eating as he wasn't hungry. He refused our reasons for constipation and didn't want to accept our lifestyle advice. He got a de-worming pill (as we have to give every one medications) but I don't think they would have survived all that booze...
There were a couple of the typical fussy mums, complaining that their Children had runny noses, as the child ran around the consulting room in full health. I am sure GPs in the UK see many similar issues to this. I (would like to think that I) would have been more sympathetic if not feeling so poorly myself. Good thing I was not doing the talking!
We also saw a number of gynaecological patients in the clinic today. One was particularly confusing, with symptoms that changed back and forth as the conversation progressed. She may have had endometriosis, PID or fiboids. Or all three. She seemed to have every single gynaecological complaint you could have thought of. Tim comes to the rescue, explaining that some patients present friends symptoms as their own to avoid numerous consultation changes, hoping to get medication for their disease and their friends problems. How complicated! Tim  performs a vaginal examination (much harder than it seems, given that there is not actually a couch in the room, or a lock and only a curtain behind us into the next room rather than a door) and reports a strange smelling discharge. We hedge our bets on PID and offer a follow up to see if it improves.

Today a woman had a still born baby at term (after 9 months). This was pretty upsetting. Not just because a baby was lost, but because there is a chance it could have been prevented. The mother was admitted yesterday with headache and visual disturbance so bad she could not see the keys on her phone to call anyone. On her admission the nurse took the usual obs including a blood pressure of 100/70. Nothing much was done as there were other priorities for a while, and she didn't seem a priority. The foetal heart could still be heard. Later, the woman had a further blood pressure done, which read at 220/160. This is very very high. In the subsequent kerfuffel where nurses tried to find one of the elusive doctors, the woman started bleeding heavily (perhaps a ruptured placenta due to the high blood pressure) and the baby was still born. It seems if is common for nurses to invent obs data if they feel they do not have the time or inclination to actually carry out the tests. The fact Some of the BP machines are broken does not help. Its possible this loss would still have happened even if the BP had been taken the first time, but its possible she could have been observed more closely and prepared for Cesarean. Really,  I thought it was inexcusable. I was very impressed with Chief's altitude towards this though. He was very calm, talking about the importune of taking care with each measurement, and he didn't even suggest anyone was to blame. A fantastic leader. On of my (many) faults is that I do not really suffer fools gladly, and if I had been in his position I would have been very annoyed at this nurse for being involved in this babies death. Things do seem different in Tanzania, though, and this event was never mentioned again. In the UK I am sure there would have been some form of inquest.

In the afternoon, I headed down to help the Urologist carry out his clinic. Seeing all the potential patients for surgeries over the next week, there are dozens of people who want surgery. Dr Bike is outside, and tells Me I Should rest at home. Considerate but I say I would prefer to do something. He tells me to Come back in two hours, at 5 PM. On this return, I am told that I am far too late to help as many patients have already been seen. I am Suspicious of Dr Bike for his motives of forcing me to rest, but do not bring it up. I am sure it was meant to be in my best interests.

The male ward, patients admitted for operations from the urologist. The drip stand on the right of the picture is a plank of wood with a nail at the top.

Resting at home, the urologist returns and we chat, me diplomatically avoiding the fact that while I don't know what I want to specialise in, urology is one of the few on My definite no list. To reward my diplomacy, I am invited to assist in a list of turp operations. Perhaps tomorrow I will be too sick to help... 

Friday, 28 October 2011

Elective 14. Overflow

Today the hospital is filling up to overflowing, I carry out a number of HIV tests with no privacy at all, I try and make a humane rat catcher for all of the bothersome rats in the roof, have a fantastic example of 'Tanzanian time' and I am feeling awful, with a temperature of 39.5°C, so will keep this post short.
The female and children's wards are stuffed to overflowing today. Dr Bike, who normally (should do) both of these ward rounds is away, and the nurse in charge is not too happy with me seeing patients by myself. This is fair enough, as I have always been very clear I am only a student, not a doctor. But this reluctance makes me wonder what Sporty and Smartie said (or didn't Say) to the nurses to have it accepted they would do ward sounds on their own. After all, people keep Calling me 'Dr' and I am always careful to deny it. I wonder if they bothered denying it at all.

Getting the ward round started takes a very long time as I have to get Eggs to do it with me. He normally just seems to do men's ward (on the normal Mon/Wed /fri pattern). The Men's ward is stuffed because there is a urology surgeon coming from Kenya to carry out operations, and it seems Tanzania has just as much BPH as we do in England. Men's ward is full to overflowing with patients waiting for the Urologist to arrive, and children's ward has filled up with children with congenital defects who hope the urologist can operate on them. It takes quite a bit of persuasion to get Eggs to come from his normal male ward to the other wards, especially as his morning already has a lot more work in it than he expected. I think he misses his chickens if he is in the hospital for too much time. Because of all of this, it is well after the normal 2PM hospital closing time by the time we finish. And there is still much to do. I feel too ill for lunch, and just go home for a bit of a rest. The silver lining here seems that if I am ill, I may be too avoid assisting in any TURPS. I have not forgotten how boring they were when I did my urology rotation in third year!

In the afternoon there are quite a selection of patients who need to be tested for HIV. Here the test is called a PITC test, and is carried out by pricking the finger at the bedside. I come back to the ward in the afternoon, still feeling very sick, and tell the nurses that I need to carry out a number of HIV tests. The nurses then go and crowd all of the patients needing the test (about 7) into the small nursing station at the side of the ward. I try to protest, but my feeble complaints are easily ignored. At least now I am allowed to do something, after all the problems with the ward round in the morning, so I don't want to make any enemies. In this situation, each patient watches as the others are tested and they all watch the test strips, which take five minutes to give a positive or negative answer. The tests are very obvious, and all the patients watching each other being diagnosed makes me uneasy, but it seems pretty standard here. Tanzania just doesn't really seem to do confidentiality, with breasts and scrotums regularly bared for the public ward during examinations with no curtains, while neighbouring beds look on interested. 

A similar HIV antigen-based test to those I was using in the ward. If the patient is positive, two lines will appear in the centre, negative gives one line (a control)

My further experience of 'Tanzanian time' occurs when Eggs and I ask for a patient to be given IV ringers lactate, 1.5 litres over 3 hours, as this patient, since admission Some time ago, has had a blood Pressure of 80/50. This is very low and it has not increased, despite asking her to drink plenty of water. Perhaps she is just not drinking much. I think the intention of this was to give the fluid and see if it increased the blood pressure, to see if it was something else causing the low blood pressure (patient also has HIV) or dehydration. Despite the fluid being written up at 2PM, as a stat dose (to be done now), and several nurses on the ward being asked to do this, when I came back at 5.30, as I said I would, to check the blood pressure again, the patient had only just been hooked up and had received 100 millilitres so far. While not a dire emergency, as this patient had been like this for some time, it makes me wary what would be done in much more important circumstances. Perhaps this annoys me most because I am feeling so ill and would rather be lying down, not traipsing all over the hospital, for what turns out to be wasted time, as there is no point checking the blood pressure now, as little had changed. I will have to check tomorrow (if I am allowed to go around myself), otherwise she will be checked on Wednesday with the next ward round, days after the fluid was last given.

My humane rat catcher is below, so far in its construction. I don't really feel like reading so have decided to try some engineering. I am not too sure if it will work, but it is something fun to do. I have been staying awake until 6PM so my sleep is not too interrupted. Now I am going to bed. Good night.

The rat catcher, it closes whenever a rat goes inside because of the balance. All I need to do now is to make it stay closed... 

Thursday, 27 October 2011

Elective 13. Nurses

Today I am amazed by a spectacular Sunday service at the cathedral, I am angry with some nurses, and  I am disappointed in my recent meals. What a lot of emotions, all in one day!
The cathedral service was an event I had been specially invited to, and I was picked up by the Bishop's 4x4 early in the morning. Before the service, I was invited to breakfast with the bishop. A friendly, smiley and very cool person, perhaps he could be known as 'The Bodacious bishop'. Have any of you ever fist-bumped a bishop? I feel it must have given me some form of 'awesome' blessing. The breakfast included bread, something that is not available at the village, which was pretty exciting. The service at the cathedral was like that which I have only seen in films or heard of before, but with my history of Church going, this is not too hard. It was a very 'contemporary' service: We walked into the cathedral to a person playing hymn sounding tunes on a yamaha keyboard (they have electricity in the cathedral), using electric guitar, synth lead and organ 'voices'  all at once. I have a Yamaha keyboard, so l heel I spotted the voices accurately. In any case, the effect was most unique. The service started, I think, with the Bishop ordaining a number of people, which then seemed to be followed by some kind of 'battle of the bands' in Swahili, with singing, dancing and cultural instruments. I say I think, as everything was in Swahili, so I didn't understand anything. It was definitely a load of fun, though, and though I didn't understand the song words, there were very Catchy tunes and beats. If I was going to go to Church it would definitely be like this!

Singing, dancing Tanzanian bands battle for the bishops blessing... Perhaps...

Unfortunately I am not allowed to just sit there and enjoy myself and am called up to give a 'speech'. Christ. The cathedral Seats 1200, and there are a good few hundred standing around the walls at the back. I say a couple of quick, thanking sentences, which are then translated by the bishop, and then get  given two beautiful kangas (pieces of Tanzanian cloth which are fashioned into clothes to wear). Awesome! Traditional wear! Very generous of them and a very happy Internal Optimist. The service goes on for 4 hours in total, which perhaps is a little longer than I expected. At the end of the Service l am expected to stand by the exit with the bishop and canons, and shake hands with everyone as they left. I mean everyone. That is a lot of hand shaking, and I almost consider myself an expert now. The only awkward thing is that everyone keeps calling me Dr whenever introducing me a title I have not earned, and one I want to deserve before using it.

On the way back to my house in time for a late lunch, I am invited to dinner by the person who runs the village church's house in a week. This is a different person to the person who runs the hospital church. There are many many members of the clergy in Tanzania. Happily accepting this generous offer, I walk to My door and am then Invited to a wedding by a neighbor. I would need to contrbite 10,000Ts (£4) for this, as do all the other guests. Fantastic. I would love to. In a wonderful mood I then go to the table to see what is for lunch and have my good mood ruined. My least favourite dish, very overcooked spaghetti, sweetened with a lot of sugar. I am not a fussy eater at all but I do not like this. Not at all. The problem is that this will now also be my dinner (as the lunch time meal is also the dinner time meal). Unfortunately, this pasta will not get better over time, instead congealing together like some kind of sickening cake. This wouldn't normally bother me too much, after all, if you are hungry, you will eat, but yesterdays lunch and dinner consisted of a bowel of chips. I would like vegetables. Or anything that isn't just pure carbohydrate tomorrow please. Perhaps that fist bump from the bishop will set me up some Godly Grub.

The bane of my food life: The spaghetti...

Other than this minor food-related disappointment, what really annoyed me today was a pair of nurses. I had taken a considerable walk to the shop in the village, to get a pack of plain biscuits to get the taste of spaghetti our of my mouth. On the way back I had to give away half of them as pregnant women strolling past kept asking, and I feel bad saying no to a hungry pregnant lady. And anyway, I lack the necessary linguistic skills to refuse. This is fair enough, and I have no problem with feeding the ladies, As the biscuits are less than 1p each. On my way back from the shop, if it can be called that, one of the patients relatives beacons me into male ward. I  recognise him as the relative Ludwig, the oedematous leg-HIV pistive- malaria infected tuberculosis patient. Poor chap. As I mentioned before, Ludwig doesn't seem to speak Swahili, but the relative does. They are both indicating that Ludwig has abdominal pain, but as I cannot speak with either of them, I go to the nurses station for some help in translation. The nurses really do not seem as though they can be bothered to help me, so I check the notes. Eggs, the doctor in charge of male ward, saw the patient early today. This is both good news (has been seen since Friday) and bad news (the morning nurses must have seen fit to call a doctor, as there is no scheduled ward round on Sunday, so something must have been wrong with him). The notes written this morning just say he was put on frusomide to help reduce the oedema. Unsigned, but I recognise Eggs' tiny hand writing. He has glasses like prisms, and finds reading very hard, I have no idea why his own hand writing is so small. I doubt he can read it himself. Unsure what to do with the patient, I ask the nurses to come and translate for me again, so I can hear more about the problem. They refuse, saying he has always had pain in his leg. I spend some minutes trying to convince them that this is a new complaint (abdominal pain, not leg pain), but they do not believe me. Nor will they come to the bed and help me talk with the patient or even see for themselves. They are too busy chatting with each other. Please let me clarify here that these are nursing students one year into study, not experienced nurses. The hospital nursing is practically run by nursing students (free) rather than paying for experienced nurses... Fed up with them not helping me, I ask if they can contact the Dr on Call. They tell me that this is not possible. I ask them who the Dr on call is. Fed up with me pestering them, they will not tell me. There is a black board outside theatre detailing who is on call, but if hasn't been updated since well before I got here. This information is passed on through the grapevine instead. Well, sometimes passed on, it seems. I feel annoyed with these nurses and leave. The whole topic wasn't going anywhere, and they were now deliberately stopping me from getting help. Now I am at home, I now really regret not pushing harder for the doctor on call's name, or even just a simple translation. I hope Ludwig doesn't die tonight. I really hope Ludwig doesn't die tonight. I don't think it will really be my fault, but regardless of blame, he will still be dead...

Wednesday, 26 October 2011

Elective 12. The washing...

What a dull title for a day in an elective blog, but it unfortunately this reflects the most exciting event today.

While today was a big day, this stream of nothingness worked well for me. I had problems sleeping last night as I felt too hot. I then woke with a fever today, about 40 degrees, though the hospital thermometers are not to be trusted... Throughout the day, I was feeling so cold I had to wrap up in the emergency hoodie I had bought with be, even though I was in the sun. Ever the hypochondriac medical student, I was fearing malaria, especially seeing as every second person in the hospital that we did a B/S on (malaria test - a blood  smear) was positive. Despite this, I felt no need to do one of these tests on myself, perhaps partly influenced by the fact the lab is normally closed at weekends, and to do one would mean calling up the lab tech (Mr Choc) and telling him an emergency had arisen, and he would need to come to the lab. This definitely wasn't an emergency, and I could ride it out. Anyway, I had been taking my anti-malarial tablets religiously, and also had large submandibulur lymph nodes, and throat pain. These suggested that it was perhaps more likely I just had a throat infection, or even worse, Man flu...

Because of this man flu, I was happy to mope around for much of the day. Finishing the 700 page Archer book (not impressed, why do people read his books!) and starting on 'You Got Nothing Coming' a prison memoir with a warning written on the inside cover by the person who had left it here. This warning said that it was an awful book, and told me not to start reading it. There is little more they could have written to make me more interested in it. It is like putting a 'wet paint' sign on a fence...

Anyway. The purpose of this blog  is not a book review. That would just bring back memories of my english essay failures at school. But when the other option is telling how I washed my clothes in two buckets of precious water, and how grey the water turned, I do not know which is the lesser of two evils.

My amazing washing, out the back of the house. One bucket to wash, one to rinse. The main problem was not having any pegs to help with hanging up the clothes, and wherever I put them, they would fall into the dust in minutes, making the wash pointless...

On the subject of water. The village pump is now fixed so in future the water I wash in shouldn't be as green as the picture below. I hope I have not caught anything severe yet. The pump is still a good walk away from the house and only delivers 1500L a day; hardly enough for the hospital, let alone the Village, so I will keep on being careful with the water, unless I want to wash in mineral water.

The water from the lake, that I need to wash in.

I had a deluge of visitors today: Choc asking if I wanted to go into town (too ill); Dr Bike hoping that the europeans were OK, after the news reported an accident elsewhere in Tanzania, then asking if I wanted to go for a drink later (too ill); then finally the friendly and informal head of the hospital (Chief). Why did all my Social appointments for the month seem to happen when I (felt like I) was suffering from malaria. When Chief visited he bought along his Cat. I had told him I had a good number of rats living in the roof, so when he Came for a chat about about the day, He bought his pet lanky, scrawny- born-to-hunt Cat. No time for these fluffy cuddley cats in Tanzania. This Cat was still affectionate (kinda), but also caught a rat in less than 5 mins of being bought into the house. It saw it climbing down the malaria netting and chased it around the house with Chief and I following in a Benny Hill manner. We ended up in Sporty's old bedroom, where the cat was chasing the rat around the bed, when we had closed the door to stop it escaping. Chief was taking a kick at the rat (in sandals) every time it came past us and punting it across the room. It was so cruel, yet still so funny. I was not going to be kicking that rat in my shoes - who knew what it had! The night after the cat arrived, the house was silent for the first time since I arrives, with no scrabbling from the roof. A very effective cat indeed, it seems to have scared all the rats away!

Tuesday, 25 October 2011

Elective 11. Cutting the cord

Today I went to Church for the first time, worked in out patients for a while, played a small part in bringing new life into this world (without marrying Someone who lives in Africa) and had my opinion listened to (something those Married Men Must Miss [alliteration again!] )

Church Starts At 7.30 with a 'bell' being sounded by hitting a piece of metal made from the inside of a car wheel (without the tire) with a plank of wood. I didn't understand any of the service apart from a small extract read from Galatians which was in English, but the singing from the nursing students in the audience was beautiful. I fully believe that you shouldn't knock anything until you have tried it (with obvious exceptions), and going to the church service is all about being part of the Community. On Sunday, I will be travelling to the nearby town to take part in the Sunday Service run by the bishop in the large cathedral I saw before.

The hospital church, with the church bell outside.

After Church finished, the morning meeting informed us that another patient had died yesterday evening. From an asthma attack. This patient had been admitted two days ago, when we had got her to show us how she uses her inhaler. She wasn't using it properly (not inhaling the drug at all), so Sporty, Smartie and I tried to teach her how to inhale properly. This woman had the largest file of notes I have seen so far, about 8 sheets large, showing her multiple recent admissions (old notes are either lost or thrown away, I am not sure which). Because of her regular and severe attacks, the hospital had waived its normal (low) admission and treatment fees, as otherwise she could not afford to come in when she had a severe attack, and would have to suffer at home. Unfortunately it had not helped her this time. It was discussed at the meeting how this woman had died and what could have been done to treat her differently. She had been given a salbutamol inhaler, steroids and aminophylline as treatment before she died. I was invited to talk abort how asthma is managed in the UK (which fortunately I had flicked though yesterday in case this patient had a problem - I now live in fear of being called to an emergency rather than a Dr). Fortunately I had remembered some of the management pathways, and was listened intently to as I talked about them, and then thanked at the end. The main issue here was that the lady had not been given oxygen, the first step to treating a severe asthma attack in the UK. Oxygen is available, but belongs to the theatre building, so the doctor who came to treat her had not wanted to take the gas out of the theatre, meaning this patient died. I don't think this is acceptable, but everyone else in the meeting seemed to understand, and put the death down as unavoidable. There is nothing I can do, even though if oxygen is given to someone else later, it may save their life. This annoys me so much.

I spend much of the working day in outpatients department (OPD). OPD works as a GP practice does in the UK, seeing patients, prescribing drugs, and admitting those who are Severely ill into the hospital. Here I expected to find Dr BT, who I have already given 6 pens to over the course of my time here. He claims not to have one and always asks for another. I am starting to get suspicious. The pens I bought were intended for children, and I don't really want to waste them on a lazy doctor. Dr BT often works in OPD, but today there was no sign of him. Instead there was a young guy working there who was only too happy to have me sit in, see how it worked and learn from what he did. The first few patients I did not learn much from, the usual diarrhoea in children, and fever that needs a malaria test that I had already gotten so used to. A quick chat between patients revealed that this man was in fact a Tanzanian medical student. Having studied for only two years, he was already prescribing and deciding who to admit to hospital and who to send home. I felt uneasy with this, but he explained that he could call on a senior whenever he was not sure. I had no idea where this senior would come from, as he was the only person in OPD, but what can I do? He was efficient at spotting the common problems here such as malaria / diarrhoea / pregnancy, but was glad for my help for slightly more complex cases. I was well aware that in the UK I would never have so much responsibility So early in my career, even as an F1, In my 7th year of training, any clerking I do to admit a patient will have to be checked by someone more senior. Perhaps this is just not possible in the resource poor country of Tanzania. While I was unable to speak with the patients, The student's english was fantastic and we ended up with me asking questions and him translating them to the patient and asking his own questions, and giving me in the answers so I could write them down. I good team, and hopefully better than him doing this on his own. We did often had to put our heads together for the (relatively) more complex cases such as polyarthritis in a 70 year old, or strange lumps within the skin.

The Tanzanian medical student was convinced that every single person we saw had to be given at least 3 drugs, or they would feel cheated by the system, as they had paid (30p) for an appointment. Perhaps the system here is similar to (what I hear) the French system is like, where everyone expects a prescription , though I have not seen a suppository since my arrival. This 'need' to prescribe proved a problem with a few patients, who simply did not need any drugs. He initially tried to give out  amoxicillin to a number of these patients, trying to tell me that, it is a 'soft drug' and it cannot do much harm, only help them fight off infections. I explained why this was not a good idea on all occasions, and as he said they needed to he given a pill or injection of some sort, or they wouldn't come back to us, and would go to Witch Doctors. I am sure that in this sort of situation, health education is much more valuable than useless pills, but am not really in a position to argue strongly. We settled on vitamin pills, or vitamin B injections. Still not Something I was 100% happy with, But I don't want to offend people, least of all my new medical student friend, when I definitely have less experience here than anyone else. I was very impressed with this Tanzanian medical Student's prescribing, he knew all the Common doses and drug regimes by heart, suggesting a very studious person. Either this, or he had been prescribing for some time and had gotten used to the common drugs in Tanzania. Either way, I like this boy and hope to work more with him in the future. Here, he will be called Tim, the Tanzanian Medical student (partially because of confidentiality, partially because I cannot really pronounce his first name, let alone spell it!)

The main road between the village/hospital and the tarmac road. The rural feel is ruined by the power lines being put up in an attempt to connect to the grid electricity, and the phone masts run by generators towering across the skyline.

The only other thing of interest that I did today was being called to assist in another C-Section. There is nothing like the distinctive smell of placenta before lunch. Urgh. Able to assist a little more effectively this time, I even cut the cord as the baby was removed. In the UK, this seems to normally be reserved for fathers or doctors, I felt privileged to be the one to separate mother and baby, letting the child survive on its own for the first time. I know its silly, but this seems almost a symbolic act of finalising the birth, and something that felt as though it had real meaning. I felt a bit giddy after this, which was either the strong crying of the newborn (always a beautiful sound) or the absurd heat in the theatre. The theatre gets very hot, especially in the layers of scrubs, aprons and sterile dressings, despite the fact that all of the windows are left open to the dusty outside. At least they have mosquito nets over them!

Monday, 24 October 2011

Elective 10. New responsibility?

After finishing writing this blog yesterday, I had the excitement of being called up by Dr Bike at 1AM, and asked to be surgical assistant in an emergency C-Section.I scrubbed in, washing my hands using water from a barrel and a jug (no running water remember) followed by using a blue spirit which looked like meths to drench my hands. I guess the last step is needed as the water I was using to wash my hands was from the schistosomiasis lake, where people wash and animals drink. I then put on a sterile gown, which I have seen hung out in front of theatre before, with the surgical drapes, after being cleaned. These have been reused so many times there are dark stains across them from old blood that cannot be washed out. I hope they are sterilised after being hung outside to dry!

The gowns and drapes are hung out after an operation by the theatre. This is the middle of the hospital, with the out patients entrance visible behind the washing line.

With regards to the operation, no diathermy is used (no grid electricity), and a longitudinal incision is used, going down vertically from the belly button, rather than the standard horizontal UK cut along the bikini line, but otherwise the operation was very similar to those I have seen in the UK. I was definitely not the best assistant at all, often getting confused by the Swahili/English mix spoken, and the surgeons terse and short  commands. I would love to say that if was the time of night and my brain wanted to be in bed, or even that the language and accent confused me, but in all honesty I think that the real problem was that I had not assisted in a surgery for over a year, and even then had only participated in a few C-sections. I just couldn't remember what I should be doing. If an assistant knows the procedure well, then the surgeon hardly needs to speak, as they will be able to see what needs to be done, such as changing the position of the tools holding the cut open, or helping suture. I was not this good. However, I  am assured  (/warned)  that there are a fair few C-sections a month, which will give me plenty of time to get my hand in with assisting. Not the most exciting of procedures, though this is just from my point of view, and the repetition of surgery doesn't appeal to me. The scariest moment came when the baby was pulled out of the (obviously black skinned) abdomen, and it was very pale and not moving. Very very pale. It took a few minutes to fully rouse, but that must have been the ketamine used for the C- section affecting the baby. The baby still looked very pale, which was when I realised that is was an albino baby. A child born with a genetic condition meaning that it had no pigment (melanin) in its skin. While this condition occurs in the UK, I can imagine that it is much more of a problem in Africa, where the constant sun, and inability to afford sun cream, gives you a high risk of skin cancers. In fact, there is an albino person in this village, who is always wrapped up against the sun with long sleeves, hat and sunglasses. Despite this protection, he seems covered in blotches which must be skin cancers. I hope the baby does not suffer like this, perhaps he can save up money and move somewhere like Finland!

The day following this night time intermission was the day I had both feared and looked forward to. With sporty and Smartie gone, if doctors show up late for a ward round, or continue doing them on alternate days as is the Schedule, then I will be left to attempt want rounds on my own. It is easy to say I just won't  do them, as I am hardly qualified, and don't actually seem to know any medicine, but then if no-one is doing them other than me on these days, I would feel very guilty for missing them. I had intended to keep 'safe' by hardly interfering, and just making sure that patients didn't seem to be dying or massively dehydrated (a big problem with all of the diarrhoea and vomiting diseases, and lack of available water here)

I told Doctor Bike my fears early this morning, while we were doing the C-section. Today I came out of the morning meeting (still every day at 8AM, though many people don't turn up) to find he had seen most of the patients already instead of attending the meeting (not that I have seen him here yet). This wasn't exactly the help I was looking for, as I will likely have to do it on my own at some other point (I doubt he will keep this up) and this means I couldn't learn by him being here. He hadn't written in half of the patients notes "Don't worry, its all in head!" and the other half he had scrawled a couple of words in each. Not the best learning conditions! As well as this, he had discharged an interesting patient who still seemed ill, without me getting to what may be the root of the problem.

This was the patient l mentioned two days ago, whose parents were not happy with our offer of an HIV test. The child had initially presented with diarrhoea and vomiting, very non-specific signs, and had been treated for a gut infection (the most common cause here), while keeping her hydrated. The child had stayed very 'spaced out' despite the hydration and treatment. Hence the HIV test, looking for something more sinister, which was fortunately negative. Yesterday I had noticed white patches on her tongue, which looked like a candida infection. This infection doesn't really infect healthy people (like infections such as chicken pox, or the cold) and often infects people who have problems with their immune system. HIV would be the most likely suspected cause here, but the tests have already come back as negative. Last night I had read up about this and come up with my own war plan. It can occur in patients with diabetes, so I could carry out a blood glucose measure, and I also planned to carry out a full blood count with Choc's new lab machine. While expensive for the patients, and often avoided because of the cost, I thought this might be very useful as it would give a picture of the immune cells present, showing any problems, and might show diseases like leukaemia, which can immunocompromise patients. The best laid plans of mice and men and all that... Unfortunately by the time I got to the ward, Dr Bike had discharged the patient, writing in the notes "Diagnosis: improved. Discharge". Very informative. He said he hadn't looked in the mouth, as he doesn't read the notes so hadn't seen what I had written. I do trust Dr Bike, he is after all a qualified and experienced doctor, so perhaps it is for the best that I am not wasting the patients money on expensive investigations that they do not need. I am disappointed that I didn't find out what was causing the oral candidiasis, but I hope it is nothing serious.

As can be seen in this post, this is what impresses me most with the doctors who work here. The stunning diversity of fields they have to work in. Without backup.  For example, Dr Bike (By now I have noticed his love affair with his motorbike, as he cleans it every morning in his boxers) was the doctor who Carried out the C-Section early this morning (obstetrition). He then did the general ward round (paediatrics, Gastroenterology, neorology and others) and then in the afternoon I worked in the 'CDC" with him: an outpatients clinic for those with HIV, where he tried to get me to work out  which of the many regemes I should be starting newly diagnosed HIV patients on (HIV specialist) All of these jobs are done by specialists in the UK, but here they are all filled by one man. While it can be argued that less needs to be known about each field due to the lack of diagnostic tests and investigations available, trying to diagnose without the investigations must be very hard, and the breadth needed huge. 

On a Somewhat less brown-nosing-esque topic, with the others gone l have had to find new ways of amusing myself in the afternoon other than reading to each other. I have usually been writing this blog after they go to bed around 7.30, but what about before then? I have started reading a book by Archer 'As The Crow Flies' but it is not very good. In the afternoon I ended up handing a few coloured crayons to a few of the village kids hanging around the house, along with some paper to do some drawing, and quickly developed a following of 8 children. I had bought plenty of materials to give to the kids (for games, no paedophilic intentions) and spent a good few hours drawing things. with the older ones were telling me the Swahili name for each object while I told them the English. I made paper planes for the little ones. I could be a teacher! If only kids in England were this happy to please!

I collect a following of children after handing out some pencils and crayons I bought over. I would make a very good paedophile.

Sunday, 23 October 2011

Elective 09. The first death

Today, among other things, I visit the bishop and the first patient dies. Among other things.

Firstly, Ludwig made it to and from the large hospital today, returning late in the evening (it is a long way away!) He travelled with the lady with two broken arms. Perfect planning! The X-ray for Lugwig shows opacity in both lungs, which (perhaps) shows something such as miliary tuberculosis (TB). I say might, as the doctors here are not used to interpreting X-rays (rarely see them) so are not all that sure. And I don't know! Either way, there is something very wrong with the lungs, a diagnostic success for me (secretly pleased, and feels like I am actually kinda useful here), though not good news for Ludwig. Now he has HIV, malaria and possibly TB. This could explain all of the symptoms, though, as if the TB has disseminated (spread around the body) it could be in the lymph node, blocking the drainage of fluid from the leg and trapping the fluid there. TB spreading elsewhere could cause the other symptoms, i.e. if it is in his liver, this could lead to the ascites we can see in his abdomen. The doctor in charge of male ward will be called Eggs, as he keeps 200 chickens in his house and spends all his time with them, rather than on the ward. Eggs decides that the HIV medication he started yesterday (don't need to wait for a CD4 count if there are certain infections, medication should be given straight away) should be stopped, and TB medication started to avoid Immune reconstitution inflammatory syndrome (IRIS). This is something I know all about, due to a large essay on IRIS caused by TB in HIV patients I had to do last year. It is caused by the HIV treatment making the immune system strong again, and the system reacting so strongly to the infection (TB in this case) that it can damage the body. That intercalated degree is starting to pay off already!

Ludwig's chest X-ray held against the hospital light box

Moving to the more mundane, I was invited to Visit the bishop of this diocese over lunch time. A very friendly, kind, out going, some May even say "cool' Man. I was driven by his personal 4x4 to the nearby town where the cathedral is, feeling I was wasting precious resources by this trip. Once there, and with a little admin dealt with, the bishop showed me around their 'HQ". The highlight of the trip was either seeing the gorgeous Cathedral (seats 1200) or being given some Cold water from a fridge to drink. It sounds silly, but after always drinking warn water or sodas (Only one fridge in the whole village back 'home', and its used to store vaccinations) this was a wonderful treat! The Cathedral was the nicest building I have seen since arriving in Tanzania. Shame, in a way, that all of that money goes into a Cathedral rather into the hospital and Curing patients, or into a school and teaching Children. On the other hand, I suppose that this is only form my point of view. Were I a Christian, then investing into my and every one else's eternal souls may sound like a pretty good idea.

Unfortunately on my return, one of the patients on the male ward died. He was a new admission, admitted around 1PM, referred from a rural clinic because he looked so ill. And he did look very ill. Currently being treated for a TB infection on top of HIV (diseases sometimes seem like buses...), he was too confused to talk, and on examination his abdomen was too ridged to feel anything. Able to spot  that this was even more out of our league than most patients - we Eggs involved in the care, with a view to handing over to Dr Bike after the patient was stabilised, as he deals with all HIV cases in the hospital.

Coming back Later to check on the patient on my own (Sporty and Smartie were packing) Eggs and two nurses were standing around the bed, and the patient was now on a drip. I asked if the patient had been referred to Dr Bike yet, who deals with all HIV cases. Eggs just said "the patient is deceased." I was more confused by this than anything. 2 hours ago he had hardly been well, but had been writhing and moaning, and clearly alive. This was so fast. I would love to say l was grief stricken at this young mans death, but I was just confused. Not confused at how he had died, he was very unwell when admitted. More confused at why I wasn't as upset as I thought I would be. Don't get me wrong, I was Sad at this waste, and disappointed that more couldn't be done in this hospital, with no ITU or similar facilities. Perhaps I had expected myself to he inconsolable when patients I had care over died. After all, this was the first patient I had had some kind of care over who had died. Perhaps my lack of reaction was because we couldn't talk to begin with because he was so ill, or perhaps it was because I had been expecting myself for many deaths on this elective, and had been expecting this in an underfunded, under equipped hospital. I was pleasantly surprised that after a week, this was the first  one. Guiltily, I can say I was in a small part relieved that, despite feeling our of my depth much Of the time, that this first death was not my fault.

The hospital lab, with one of the assistants working in it, creating blood smears to check for malaria

On a lighter note, My companions, sporty and smartie, are leaving first thing tomomrow. I am excited about all of the responsibility that this will leave me with, but a hell of a lot more scared about said responsibility than excited.