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!

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