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.