Friday, 21 October 2011

Elective 07. Closed reduction

Today the ward round was, again, mostly carried out by us medical students, where we saw some very poor nursing, I had a stab at diagnosing Ludwig (The oedematous-leg-patient who I mentioned before), and we assisted in a closed reduction and plastering of a fractured wrist, where we find out the cause of the fracture is a little darker than she had first said. We finished the day by joining the man who runs the lab (His name really is Choc) for a film at his house.

The hospitals pump is still broken, but every day children are sent to wait with buckets in the hope it will be fixed, and they can get water for their families

As we did on Friday, we started the ward round alone, only this time we were lucky to later be joined by Doctor Bike (though when almost finished). On the woman's ward there was a lady who has been in since Friday, when she was admitted with a GCS score of 6 (suggesting severe brain injury. Supposedly she had just fainted and been like this ever since. With no more diagnostic tests (e.g. in the UK she would have a CT scan of her head) available, I have no idea what will happen to her. Even if we can diagnose her (i.e. an inter-cranial bleed), how would we treat it? Since she was admitted, the GCS score had improved (now 10), but over the weekend, she was meant to have a nasogastric tube fitted and IV fluids (to provide her with food and water) and a catheter inserted (seeing as she wasn't conscious enough to leave the bed to go to the toilet). When we visited the patient today, she was barely rousable, though it was immediately obvious that no IV access or nasogastric tube had been set up on Friday, and while a catheter had been inserted, the catheter had disconnected from the tube intended to drain it into a bedpan, leaving the bed sheets soaked in urine. I have no idea how long she had been left lying in her urine. We asked the nursing students nicely for this all to be fixed, not really feeling it was in our remit to complain about her treatment, but when the Dr found out about how we had found her, he was annoyed and berated the nurses. It is disgusting that this can happen, and while the nurses fault, if doctors came into the wards at weekends (barring emergencies), hopefully one would have noticed this. If the nursing students (students do practically everything as there are very few nurses here, but a nursing school on site) cannot even look after a patient basically like this, how can they be expected to call a doctor if a patient clinically deteriorates? I suppose we are fortunate in the UK that this sort of occurrence is a shock, here it seen as bad, but little seems to come of it...

On the Male ward, Ludvig, the patient with the oedematous leg, who had been diagnosed with HIV and malaria, was still in the hospital. He cannot be given HIV medication without first checking his CD4 count (a type of immune cell), as if this is high, there is no need for the medication (yet). This investigation needed for CD4 count is called FACS, and is too advanced for this hospital, so the blood needs to be sent elsewhere for this to be carried out, which takes time. As he is still in hospital and his puffed-up-leg is not getting any better we check in on him. After all, HIV and malaria are not usually reasons for unilateral oedema.  It is possible that one of the reasons the oedema is not going down could be that he doesn't understand our requests to keep the leg propped up, to help the fluid drain out. It is very hard to communicate with him. Leafing through the notes (a single page of A4 paper with his name at the top, sequentially  scrawled on by doctors...) I realise that no-one has actually given him any of the general examinations that are usual in the UK. Pretty much everyone in the UK has their lungs and heart listened to when they are admitted to hospital, just to see how they are, but this doesn't seem to be the case in Tanzania, though this could be because very few people seem to have stethoscopes. The only things that have been examined with this patients are his two legs. I suggest the examination to Sporty and Smartie, but because of the smell of the patient, they are not keen on examining him at all. After some (embarrassing) miming, I get Ludwig to sit up in bed, and listen to his lungs from his back. At least I remembered to bring my stethoscope! There was a strange sounding patch in his right lung, sounding echoey and hollow, so I persuaded Sporty and Smartie to come and listen where I had my stethoscope bell (they could listen at an arms length away. Very lucky the patient spoke no English with some of their comments!). I thought perhaps this was some kind of cavity from a tuberculosis or fungal infection, in this immunocompromised patient (after all - he does have HIV). They agreed! I feel very pleased with myself, spotting a possible diagnosis, but very bad for the malaria-HIV-?Tuberculosis infected Ludwig. Later on, I talked about this with a doctor who suggested we send him to the (far away) 'local' hospital with an X-ray machine, to see if there are problems with this lung. Feeling even more useful now, and more justified in my being here (and a little smug that I wanted to examine him properly, and it was very useful!)

In the female ward, the relatives of the patient with the fractured wrist have finally made it back to the hospital with the plaster of paris. Dr Bike is planning on carrying out the procedure (open reduction) with paracetamol as a pain killer (reasoning: Tanzanian people are strong). I would love to think he was joking, but I really don't think he was. Seeing as the broken bone ends had been calcifying in the wrong position for Some time, it was likely to be very painful for her. I hadn't Seen any reductions before, so I was happy to assist and learn about them. Fortunately, in the end, the lady was given ketamine as an anaesthetic (under the advice of a nurse in the end, not a doctor), before the closed reduction started. The aim of a closed reduction is to pull the bones apart from their wrong position to get them in a correct position, end to end, then use a plaster cast to maintain this position. An open reduction would involve cutting into the arm to set the bones that way, this way the skin is never broken. As You can see from the picture below, this reduction took a lot of effort. In fact, there were not enough people reducing the arm as I took the picture, meaning that I had to join in after the picture was taken. Even with the hefty dose of ketamine, the lady was groaning in pain. Dr Bike was happy with the end result, and I hope that the arm fixes properly after all that pain and waiting. She needs to be sent for a follow up X-ray to make sure the bones have been joined properly. We also found out that the real story behind her fracture was not that she had fallen, but had been pushed. By her own Son. This only came out as over the weekend, she decided to go to the police with her complaint, and this will require medical forms to be filled in for them. The choice to Make a police complaint about your own son? A good idea!. Any person prepared to push around their own mother and with such force as to break both of her wrists cannot be too safe to society.

Dr Bike (Left) attempts a closed reduction with Sporty and Smartie (right). The bones are too calcified, so I need to join as well, to create enough force to pull them apart.

The day finished by being invited over to the house of the chap who works in the laboratory. Mr Choc. He loves films and TV, and has bought a small petrol generator go he can run a TV and DVD player in his house. He has bought 25 DVDs, a stock he sees as huge! We watched 'The Last King Of Scotland', a film about a Scottish doctor going to Uganda in the 197Os and the problems that occurred then, which overlaps nicely with our history lesson from Chief, yesterday. At the start, it is only the two girls, Choc and myself, but part way through the Rector who lives next door (in charge of the hospitals services) decided to join us. I suppose he could hear the noise of the film, and the generator is certainly noisy enough for us to hear it as far away as our house when it is running. Unfortunately, this film has a Sex scene in it. While sitting through the obvious lead up to this scene was pretty embarrassing, having the rector huff and get up, go to the video player and fast forward through it pointedly, then continue it playing after it had finished was more embarrassing by far.


  1. What about lymphatic filariasis for Ludwig? High prevalence in Africa, and can cause unilateral leg swelling.

  2. A fair guess, anonymous poster, and something we had questioned the doctors on, after finding diseases such as Loa Loa in the Tropical medicine handbook.

    The response? lymphatic filariasis has never been seen in this region or hospital so it cannot be that. If it is, there is no diagnostic test or treatment we can offer...

    Not really happy with that response myself, but you would hope that doctors knew the diseases prevalent in their region.

    Regardless, at the moment, if this lung problem we found is TB, it could well be a miliary TB infection disseminating to the lymph node, and stopping drainage of the leg.

    This hospital is so frustrating, in the way that most diseases can neither be diagnosed (lack of tests), nor treated (lack of drugs)