Monday, 28 November 2011

Elective 36. A full day with an empty pharmacy.

A very full (and hence fulfilling) day today. First, I assist in an operation to remove a lipoma from above a man's eyebrow. I then spend the rest of  the day in both female and children's wards, until 5.30, first running a ward round, showing Kiwi and Dolittle how it is done, then struggling with treatment alternatives, as the hospital is out of stock of most medications. Dolittle and Kiwi are wonderful company throughout the day and evening, I am glad they have turned up!

The operation to remove the lipoma was pretty standard. Neither Kiwi or Dolittle were allowed by their medical school to assist in surgeries or births (due to the risk of HIV), so I assisted; holding, cutting and swabbing. Not the most glamorous of jobs, but someone needed to do it. I think there is a real art to assisting. To do what the surgeon wants you to do, without needing to be asked, and I am getting better at this, but it is still very dull. I think the only real way to enjoy surgery is to be the surgeon. None the less, this is a successful operation, and a juicy lipoma is  removed. I got to get much more stuck into this procedure than previous ones, helping to remove it using blunt dissection techniques I vaguely remembered from dissection in my first year. I was asked to suture up the wound, but told Dr Bike it would be better if he did it. I have had little practice (and this on plastic pads, and over a year ago) at suturing, and this is on his face! I don't want to mess it up and leave him with an ugly scar for his life.

I work on removing the lipoma with Dr Bike in the anaesthetic room of the theatre, with an open window behind us. 

After this operation, Dr Bike was busy, and as it was a Tuesday, was not planning on doing a ward round. He told us he was happy for us to do it if we wanted, but he was sure it was all fine and didn't need doing. It is a good thing we decided to do the ward round, as things were most definitely not fine. I enjoyed leading the other two as, while they were more experienced than me, having just sat their finals, they had no idea how the hospital worked, or about many of the diseases and treatments that I was now used to.

The main problem today was that most things seemed to be out of stock. Nearly all of the medication people had been put on yesterday had not been given, as it was out of stock at the pharmacy. If something is out of stock, this is just noted on the notes next to where the drug was prescribed, but nothing is usually done about it. As no doctors were reviewing the ward patients, they were just left without medication, or with breaks in drug regimes, as the supplies had run out half way though courses. No ibuprofen was left, or diclofenac tablets (only injections) so everyone had to do with just paracetamol as a pain killer. Antibiotics are a lot worse. Only ampicillin tablets (like amoxycillin but much worse absorption when given by mouth), metronidarole, co-trimoxazole and chloramphenicol remain in the store. All other antibiotics have run out, and the latter two I mentioned have possibilities of quite serious side effects, so I won't be wanting to prescribe those myself, even though chloramphenicol is popular in the third world. This hospital is absurd, how are patients meant to get better!

In female ward, there is a patient who had come in with a floppy left arm, a headache, confused, and a blood pressure of 180/140 (high). The admitting 'doctor' (Tim) had put them on nifedipine and furosemide to control the blood pressure yesterday. Both of these drugs were out of stock, but nothing more had been done since yesterday. Needless to say, the blood pressure was still very high, so heading over to pharmacy, we discovered the other medication that was present that would do a similar job (captopril, bendroflumethiazide and propranolol), which I decided to use instead, though with these stroke-like-symptoms, Dr Bike really needed to see her and tell us what they do for this in Tanzania.

Another patient on female ward was severely dehydrated. We were discussing whether we should prescribe her I.V. fluids now, or call for Dr Bike (which could take hours), as she had been suffering from diarrhoea 3-4 times an hour, and hadn't drunk at all today or yesterday as she felt ill. This is dangerous, and she looked very dehydrated. Fortunately, we didn't have to decide whether to prescribe fluids or wait for Dr Bike, or even which fluids to give, as the nusre told us there were no more IV fluids left in the hospital. They had all run out.

We went looking for Dr Bike (couldn't find him) and asked the man in the pharmacy (the pharmacist is also a reverend) if this was true about the fluids. It was. He had asked for more over a week ago, but had not received them because of the hospitals finances, so now there are none. I really hope there are no emergency operations in the next few days.

We return to the ward, bring back some ORS sachets from the pharmacy for the dehydrated woman. She is still refusing to drink any fluids as she feels so sick. We gave her anti-sickness drugs by injection, and hoped that they would work well enough for her to start drinking. This was starting to feel as though it could be very dangerous. What if she gets so dehydrated she loses conciousness? Nothing can be done! Kiwi has heard you can give a coconut IV (and a search of pubmed proves her correct!), though I am not a fan of doing this, nor do we have any coconuts. We leave the woman with the ORS, after trying to get a nurse to explain the importance of her drinking the fluid, even if she doesn't feel like it. I think the message get lost in translation, unfortunately, as we gave the nurse a lengthy talk about why it was important, and she said one sentence to the woman. It was probably something like "The mzungu are nagging me to tell you to drink the water". I just don't understand why the woman doesn't feel thirsty, she is so dehydrated! We leave the ward to find Dr Bike again, perhaps our fourth or fifth search for him today, and we still cannot find him, but thankfully this time he answers his phone when we call, and tells me he will be there right away. 40 Minutes later, he strolls in, tells us that the lady with the stroke will be fine, continue meds, and tells the dehydrated lady she needs to drink more. He then tells us that it is all fine, and leaves. If you are Tanzanian, life seems so simple. Hakuna Matata.

To finish today with some happy news, Choc got engaged today to his long term girlfriend! Fantastic news, which he told us as soon as he had done it, but which he is now being strangely evasive about. I don't know whether being engaged is seen as not-quite-good-enough here (as it isn't marriage) or he is just messing around. Either way, its fantastic news!

Elective 35. What a view

I start today by getting up at 5am (an impressive thing to do through choice for someone who really isn't a morning person) by heading away from my house and the village to watch the sun rise from a view over the rift valley. A beautiful site. On the way, I had a few encounters with snakes in the dark, a few small ones sliding off the path as I approached in the dark with my wind-up torch, and a large snake that was between the rocks at the view point with stripes on it. I didn't want to disturb it, so took pictures of it and waited for it to leave. Fortunately it did, and I was able to enjoy the beautiful sunrise alone. After this start, hospital life is quiet. Eggs has returned after a long time away, where his ward has not been seen by anyone, and two medical students from New Zealand arrive to keep me company.

A picture of the snake that I almost stepped on. Chief later looked at my pictures and told me it was a "Puff adder", a venomous viper which causes the most fatalities in Tanzania. Good thing I didn't step on it...

I watched the sunrise for a good two hours (though the full appearance of the Sun over the horizon actually took about 1 minute, astonishingly fast.) It was stunning, spreading across the flat savannah below me from my vantage point. It was like a scene out of the Lion King! I really enjoyed feeling the sun warm up my skin as it came up and rose, and hearing the villages dotted around below me start up with the sounds of life as the sun came up. A beautiful experience; just a shame I had to wake up so early to appreciate it! The sun seems to climb into the sky very quickly here. I am not sure if it is because we are on the equator, or the landscape here is so flat...

The pre-sunrise glow fills up the valley, while I stand by the metal cross the church has erected on the cliff to look across their diocese. 

The sun rises over the horizon of the savannah down below in the rift valley

Once the sun has risen a little, you can see miles and miles across the rift valley from my rocky vantage point shown

After all this was over, I went to the morning meeting to find Eggs had returned. Fantastic! I asked him if he was well, and he seemed pleased to see me, though gave no indication of where he had been, even when I asked him. The subsequent ward round I do with Eggs is very slow, as he has no idea what most patients are in with, or what has happened over the last week and a half, but I am relieved to have someone official, who knows what they are doing, back in charge of male ward. Despite all his short comings, he does know a lot and its much better having him run things than trying and failing to run things on my own.

Dr Bike is busy today, so persuades me to do his ward round of children's and female wards. I don't do much of note, other than checking on patients and changing around a few medications that had run out of stock. Pretty standard stuff by now. I then go to outpatients, where 3 hours passes with only one case interesting enough to remember enough of to write about it. Perhaps a good reason why being a GP doesn't appeal too much to me. Here, a man came in complaining of a testicular lump. We examined it, and found a non-translucent, non reducible lump that seemed to be a very enlarged left testicle. The man reported that it had come on suddenly a couple of weeks ago, and had been painful. An acute presentation makes a cancer unlikely, so it is hopefully not that, but I have no idea if the patient is being honest, just embarrassed he didn't come to hospital earlier, or there is a problem with the translation. Either way, whatever the problem (such as orchitis) it needs a second opinion because of the risk of serious disease such as orchitis. We decide to 'refer' to Dr Bike to take a look. Refer here means tell the patient to find Dr Bike in the compound, and show him. Dr Bike is usually happy for us to send people to him, if there is a possibility that they may be surgical. I hope this might qualifies!

I suppose that the real bonus of 'GP' like clinics comes from talking to the parents, and I cannot do that here, but as there is nothing else happening at the hospital, I still go to outpaitents regularly even though it can leave me feeling a little annoyed at times. I suppose it is good for learning from Tim's immense knowledge of drugs and their doses, and seeing lots of presentations I would never see in the UK.

After I return from outpatients, and have put the first spoon of rice in my bowl for lunch, two motorbikes pull up outside with the two New Zealand medical students on the backs, along with the skilfully balanced suitcases on the riders' handlebars. They are (in my world) called Kiwi (very patriotic, especially supportive of the rugby team) and Dolittle (later turns out to be able to talk with animals). I get on very well with them both from the start, showing them around the house (Don't use this, thats broken, and so on) then the surrounding area. While giving them the tour of the hospital, we are called into children's ward, where the gentamicin has run out, so the child will be no longer getting any antibiotics. There are very few antibiotics left in the hospital at the moment (we are out of most of the old favourites such as amoxicillin), so I put the patient on erythromycin (its that or metronidazole). We wander back to the house to talk, and so I can help them unpack. Nothing tends to happen in the afternoons. They seem amazed that I am prescribing here, and taking a step back, it is pretty stupid. Its not really safe, but often it is me or no-one to prescribe these drugs. In this case, the child wouldn't have been seen until Wednesday, and there was very little from me to even choose from, due to the poor selection from the pharmacy, but in out patients, Tim and I are expected to act as doctors. I warn them it will be expected of them, and take them to the point where I watched sunrise this morning to watch the shadow of the cliff we stand on grow across the rift valley with the sun set. They tell me they saw Mama and Dada in Dar es Salaam, when they crossed over on their way here, and as Mama and Dada left. Both Mama and Dada spoke of the terrible amenities available here, and neither planned on returning. A real shame. I hope they still plan to twin the two schools.

As the sun sets, the shadow of the cliff we stand on grows rapidly across the rift valley. Here you can see a small village on the far right, half way up, on the picture. People living from much further away than can be seen here have this hospital as their closest medical centre, and no transport. A rapidly shrinking lake can be seen on the left of the picture.

An unfortunate pasta dinner greets us on our return, over which we talked about terrible childrens names. Dolittle said she had seen children named "Abcde" (pronounced Absadee), "Raige Havok Uneek"' and "Jay-a" (pronounced Jaydasha) on her placement in an inner city hospital. I said I planned on calling my son Fellacio (a good Italian sounding name), and my girl Qwerty. Both pretty cute names! I get on well with Kiwi and Dolittke, they share my (puerile) sense of humour much more than Sporty and Smartie did. This is much more fun than being alone. 

Friday, 25 November 2011

Elective 34. Who you gonna call?

Its another lazy Sunday. I stalk the wards, which keeps me out of trouble for an hour. The rest of the day I spend reading, playing with the village kids (in a friendly non-molestey way...), talking with visitors to my house and investigating the very different wildlife here. There is also a report of paranormal activity in the hospital, but I am not allowed to go and investigate this, as Chief doesn't want me to be 'in danger'...

On the ward round, I do little, as people seem to be relatively well. I re-prescribe antibiotics to a baby, as the dose that had been worked out (a calculation based on body weight) was impractical, so the pharmacy had refused to give it. Rather than telling anyone or marking this in the notes, it had just been left out of the regime, and I only found this out by talking with a nurse about whether he was vomiting up his medication or somehow not taking it, as he still seemed very unwell (he has a working diagnosis of entire fever, but without tests it is more of a guess). I rounded the dose so it could be given by snapping a pill in half, meaning the drug would be given. I also made a couple of additions to simple things, like adding extra days of painkillers (only ever prescribed in lots of three days here, for some reason) and prescribing antibiotic eye ointment for a child who looked like she had conjunctivitis. It is absurd to think of me wandering around prescribing, but it needs to be done. Its going to be so different once I get  back to the UK and have everything managed properly. Wonderful, but I will feel like I am going backwards slightly!

Previously I was having some problems with overly flirty nurses on the wards,  but this has gotten a lot worse recently, now they have found out that I am not married (This marriage was a lie I managed to get away with at the start). Really, I should feel privileged, I certainly have never gotten this much attention from ladies before, but I have a feeling it is much more about the fact that I am English, rather than my stunning wit and blistering charm overwhelming them. Shame that.

On the way back to the house, I find it besieged by dozens of baboons eating large solid pods hanging off of the trees outside, which contain what look like runner bean seeds. When I get closer, the baboons all run away, leaving the ground littered with these very solid dried up pods they had been opening with their teeth. Everything is so solid and hard in Tanzania, probably in the fight to survive, but I couldn't even open these pods with my hands... I had a wander, now curious about the other very different wild life here, and hoping to find the troop of baboons which had fled. The only very different mammals I saw were much thinner monkeys, which seemed a lot shyer than the baboons. Insect wise there were some crackingly large ones, some very ugly ones, and even ones that worked alone to make mounds which look like volcanoes in the ground. One wall of the house had a huge stream of ants going along its entire length, and up a spout into the kitchen via the sink. Thats where all the ants in the sugar bowel kept coming from! Most interestingly, there were these sort of 'ground spiders' which formed little craters in the hard dusty soil with dusty slopes, so insects walking into one would briefly be unable to climb out of the hole. In this time, the 'ground spider' would strike, catching the insect. I have no idea what they are really called, but the wildlife here is a lot cooler than back home. I could definitely become David Attenborough.

The ant trail down the side of our house is the black line just below my spray painted red line, entering by the tap outlet. How did they work out to come so far to get into the house! 

A huge beetle lingers on the down pipe, seen in the far right of the picture above, its size made obvious by the tiny ants next to it.

My wandering around my house, peering at the insects, attracts a number of children I have not seen before. Sometimes children come with mums who need to care for them, when the mum needs to give birth, and I assume that these are from the hospital and bored of sitting outside, so I teach them how to play frisbee, and give them all a pencil and rubber each. I still have loads of stationary left, I think I will give them to the primary school before I leave. While I was running about in the dirt with the beetles (there are some huge ones that make a fantastic buzzing noise as they fly, from hat I assume is the parts of their shell over their wings beating together) Tim came over to visit. He refused to join in the frisbee game (spoil sport), so we went inside to chat. It terms out his dad was involved in a motorbike accident yesterday night. While trying to overtake a pair of drunk cyclists, they swerved in front of him and he came off his bike, breaking his arm, but fortunately not coming to much more harm. I had not seen him this morning on the ward, as he had been at a different hospital getting an x-ray. He has fractured both ulna and radius in his forarm. Because he is the only adult at home (Tim's mother is not around), he has been given permission by Chief to sleep in the paediatric ward with his children, while the staff wait for his swelling to go down, hopefully planning to apply a cast tomorrow (assuming the materials are in stock!) After the accident, Tim had to go and get the bike, and drive it the 15km back home, holding his phone torch as a front headlight, as this had been broken in the accident. Tanzanian people are mad! 

Some of the Tanzanian kids are natural break-dancers...

After Tim had left, I started on my dinner, a tub of a vegetable like spinach and very earthy tasting, while Chief came around to visit with the news that I could have two new Muzungo from New Zealand coming to stay, and a ghost Story! All exciting stuff. Even more excitingly, the ghost story had happened right here in this Village, last night! Though I have to say that after hearing it, it had many more elements of a comedy than a scary story...

This event involved a house on the hospital grounds which they were now using to sleep male nursing students, as this weekend a new first year intake had arrived, and there was not space in the normal dorms as the second years had not fully graduated yet. This home had originally been built by the hospital secretary about 25 years ago, but there were no other personal homes on hospital land, and this ended up in a dispute. Unhappy to sell the house for the price the  hospital offered to cover building a new one, it was finally agreed he could stay there under some 'Conditions'. Chief did not tell me what these conditions were. After a year or two, his wife developed a mental illness (Chief thought it was schizophrenia, but the villagers thought it was witchcraft), and they moved to a different town, partially to be easier for her and partially so he could work in a new hospital. He offered to let the house, so a lab-tec started living there, but he was bitten by a snake within a month. Word went around that the house was bewitched, and for the last 20 odd years no-one has stayed in it. Absurd for a village where some people live in corrugated iron shacks, or mud huts. This lack of rent also upset the owner, still living with his mentally ill wife, as this is 20 years of lost revenue. Despite all this time without an owner, the house was built well, and is still on the hospital grounds.

With the recent problem with the overcrowded nursing dorms, it was decided to move all male nursing students into this house, and use the male dorm room for female nurses. There are far more female nurses (as in the UK), and this seemed the only short term option, until the second years graduate and more room becomes available.

The house was unlocked and cleaned yesterday of all the cobwebs and other detritus, and the nurses bedded down. At 2am (from the reports of the nurses) one nurse woke up the others, shouting that he felt as though he had been bitten and felt as though he was on fire (so far explainable). The others then said they felt as though some one was throwing buckets of water over them, though they remained dry, and heard a strange grunting laugh from the ceiling (Chief imitated it "ChugahaChugahuChugaha", this was hilarious in itself). This laugh and the 'fake water' terrified them, and they ran out of the house, shouting, in their underwear, straight to their principal. the principal of the nursing school was also terrified, so they all ran, still shouting and sobbing (yes a lot of grown lads and their teacher sobbing) to Chief, who put them in a hall for the night.

Can you imagine this happening in the UK? Many of the nurses are older than me, but fears of curse and which craft still run strong in Tanzania. I suppose we still get reports of haunted houes in the UK, so perhaps the comparison is a poor one. Chief has no idea what to do with the house. He thinks the only option is to demotion it and build another building, unsure whether people will even accept its use hile 'cursed' as a storage house. Such a waste of resources and time in such a poor hospital. I offered to stay in it (always wanted to stay in a haunted house) but he said that, as a host, he couldn't put me somewhere that people considered dangerous. Perhaps even he is a little spooked by it. I wish I could do some investigation, but after I expressed interest, Chief is refusing to even tell me which building it is!

Thursday, 24 November 2011

Elective 33. The Good Samaritan

Today starts, with an early rise to see Mama and Dada off, then, excitingly, an omelette for breakfast, the first time our chef has cooked one for me! I then spend some time breezing around the wards, catch Dr Bike in a good samaritan style act, then head over to the football field we were at yesterday for the late afternoon/evening. I am now reading Norwegian Wood, a sad, lonely book for all the time I am spending time by myself, but one Smartie had bought with her, and one of the few books left that isn't Chick-Lit... It is also very well written!

On my trawl of the wards in the morning, it turned out that two patients had died overnight. One was the man I mentioned yesterday, who had the huge skin cancer/sarcoma on his leg. This was to be expected sometime soon, and I hope all the drugs that he was given yesterday had made his last day better rather than worse. The most important medication would have been pain killers, but I think only paracetamol and ibuprofen are available at the moment, so it certainly wasn't a painless last day. Poor chap. The other patient who died was a woman who has been here for about two weeks, after being admitted and diagnosed with HIV. She had malaria a week ago, and yesterday her haemoglobin was measured as being low (6.4g/dl), though I have seen a lot lower with no problems in my time here. It should be above about 11.5g/dl in the UK to be seen as normal, but here people have much lower with little problem. I think it is the poor diet. Because the Hb was low, someone had decided that she needed a transfusion (the blood comes from relatives who are matched, there is no stored blood), and she was given a transfusion last night just before she died. I have no idea why she died. She was talking happily while sitting up in bed yesterday. There do not seem to be coroner's inquests in this part of Tanzania, so I suppose no-one will ever know. The death certificate Said malaria, though this had been treated a week ago and she no longer had the infection. I think it could have been something to do with poorly matched or given blood, as it happened so suddenly and the blood was the only change in her management, but there is little I can do about this. Sometimes I feel so helpless and pointless here. These things 'just happen' but the should't. And I can't do anything about it.

While bad things happen in the hospital, the baboons still come and play outside my house in their gangs, such a  free life!

Today I also went to visit the poorly boy who I had admitted yesterday with an unknown disease. The one who was HIV negative, but had kidney problems and a limp. He was now a whole lot sicker, could not walk at all, and just lay in bed crying pitifully. This illness was getting serious, and still no-one else had seen him apart from me and Dr BT in outpatients, who didn't know what it was, and hoped the doctor on the ward would sort it out. He had severe pain at the top of his left leg in the inguinal region, and after a careful history from the mother, I found that he had had a fall while running, scraping his knee, and the pain had come about a day or two after this. At least, this is what I thought she was saying. All the translating makes things more complicated. Could this be a fracture? The pain and disability was certainly severe enough for this, but the onset days after the fall was strange. I had no idea, so I went to find a real doctor to help me. Dr Bike refused, as he was not the doctor on call (fair enough, though he was just sitting by his bike in the entrance to the hospital relaxing), so after some searching I finally found the doctor on call to come and help out. After they had had an examination as well, while the child was screaming in pain every time the leg was touched, they decided the child had osteomyelitis in addition to the UTI that was already being treated. This meant that the child needed to be started on flucloxacillin to treat it. When I Came back a lot later in the evening, the boy was sitting up in bed, apparently feeling a lot better. I am very pleased I looked for help when I wasn't sure HERE, and am very sure I will be keeping an eye open for osteomyelitis in the future (I hardly knew anything about it until today). Hope he is as well tomorrow and keeps getting better.

While I was wandering the hospital, I came across Dr Bike a number of times. The first time he was taking a basin of water to the 80 year old man who I we admitted yesterday with the large cyst and infected skin. The idea was to give him a sponge bath, as this was not something the nurses liked doing. Dr Bike had operated and drained the cyst yesterday while I was at the school, and the man had turned out to be Dr Bike's god father. I congratulated him on taking good care of his extended family. The good acts did not end here, though. I later caught him sneaking into children's ward With a cardboard box. Curious, I asked him what he was up to. He sheepishly opened the box to reveal a bunch of bananas and a pot of rice and goat meat. He wanted to feed the malnourished child (who I called Ivy) who was suffering from marasmus, and her sister Holly. He was doing this as it was obvious that they had little food. He had been doing this for a couple of days. Wonderful! Making the effort to care when he really didn't need to, then hiding it away and not telling people he was doing it. My respect for Dr Bike has doubled. It reminds me that while people here often seem to lack training and be lazy compared to the UK, they do what they can the best they can because they do care about the patients, and the seeming laziness is likely just a cultural difference rather than actual not-being-bothered.

The football pitch is one of the best in the area, because someone has build goals out of wood!

In the late afternoon, I go back to the football patch I was at yesterday, as yesterday I was told that they would love for me to be involved in some of their football games. Today was a village league game, however, so I just watched, cheered, and tried to chat with other spectators despite not sharing much (any) language. Neither village was the one I lived in, but both were nearby and this was the best football pitch around. The embarrassment came when a teacher from the school invited me to join a couple of kids in a game of 'ball control'  meaning we just punted the ball to each other, showing off out 'skills'. One kid (about 18) did amazing chains of keepie uppies, tricks, the whole lot. The other, a lot younger (around 10), just passed it to one of us if he got it. I am a decidedly average football player (since I left school, I have only ever played it with primary school children when running sports activities as a holiday job), and this was all a bit embarassing. I can manage about five keepie uppies, and if I am lucky about 10. I repetitively let the ball fly away from us and had to go and fetch it, and after one particularly exuberant attempt, I managed to land the ball right in the lap of an elderly spectator of the match, shocking them and making them jump up, then fall over in fright. If I am invited over to play with a school match later, I am pretty sure it will be with the primary school pupils after that performance! Talking with the team captains on my way home, it turns out one of the villages doesn't even have a football, so they find it hard to train, creating balls out of tied together rags. Life here is so different to the UK that its almost alien. 

Tuesday, 22 November 2011

Elective 32. Back to School

Its back to school for me, but only at the end of a long day. Before this, I walk Smartie to the bus Stop at 6am, it was the gentlemanly thing to do. A quick ward round is then followed by my first (and last) stint in outpatients with Dr BT. This was all topped off with a lovely leaving party for Mama and Dada from the school.

The school we visited, walls bare and old desks crammed into rooms as close as possible. There are no chairs, as they are needed in the canteen for the children to eat their dinner.

Before getting started on this busy day, I would like to say that I was prayed for for the first time yesterday (well, knowingly prayed for, at any rate). The bishops secretary (a Canon) bought around some letters for Mama and Dada at 7.30PM yesterday, but unfortunately they were both already Pj'd up and in bed. While they subtly got up again, I chatted with (read distracted) the secretary. What is it about Tanzania that inspires people to go to bed so early! It must be the lack of things to do in the area, and the dark dark nights (no lights). After the letters had been handed over, the secretary asked the awkward question to Dada (the re-teacher) first. "So, which church do you attend?" While Dada struggled around the "I am not... quite... currently regularly attending any Church" (good thing she didn't mention what she told us yesterday, that she feels she can identify with Islam more) I had the time to think up a good avoidance answer "I live in the diocese of xyz" (not a lie!) which Mama then repeats. Good to know I am essentially helping people to lie to gods messengers. The Canon, apparently satisfied, talked a few more Minutes about how Dada should go to church more, then asked if he could pray before he left. Who are we to deny him this? He gave thanks, and prayed for the teachers safe journey home. He then gave thanks to God for guiding me to come and help their hospital, and prayed that I could carry on doing good here, and learning as much as I could to help others. A little odd to have my choice to come here attributed to someone (or something) else, but the argument for free will has always been a tricky one, so who am I to disagree. It was still lovely in an inexplicable way to have a Canon pray for me. I just realised pray and prey are only one vowel different, and sound very similar. I wonder if anyone has noticed this before. My hand writing recognition keeps mixing them up. Some people don't believe in coincidences...

On the ward round with Dr Bike, there was a patient who had been admitted yesterday with a painful lump in the leg, and difficulty with their breathing. Examining the leg showed a huge lump beside the knee, the size of a melon, but bumpy and growing through the skin, leaking fluid and very painful looking. It looked like some form of very advanced skin cancer or sarcoma. I assume the problems breathing, and abdominal pain the patient complained of, were due to metastases in the lungs and liver. This patient clearly seems a case for terminal care. It is shocking that he presented to the hospital this late, so far into his disease he cannot walk, and was carried here by his family. Even if he presented earlier, the hospital doesn't have any anti-cancer therapies available, so I am not sure it would have helped. Unfortunately, in this hospital they don't seem to understand the concept of palliative care, and Dr Bike spends some time devising a wicked looking treatment plan which will never get rid of the cancer, but will likely ensure the patient experiences many nasty side effects and needs to stay in hospital to die, due to all the IV drugs, rather than going home with his family. Dr Bike isn't interested in my ideas of perhaps debriding the large mass, giving prophylactic antibiotics and letting the patient go home to his family, as this isn't curing him. As l am only a medical student, and have even less idea about Tanzanian culture than medicine (so very little indeed...) I leave it. It is quite possible his plan is the best thing to do, given patient expectations and all that, and I just don't understand the full picture. I just feel sorry for the poor man stuck at hospital.

The football ground we watched a football game on in the afternoon. Just a cleared area of ground, with lots of dust when they play. Football shirts are the common wear for young people in Tanzania. More people here support British teams than in the UK! Random location in text here, just to break up a load of text. Otherwise all the pictures would be at the end!

I spend most of the morning and half the afternoon in outpatients with Dr BT. I hadn't noticed before how the patients waiting to be seen form some kind of self-triage, meaning the sickest, or ill babies see us first, and the more well wait for longer, even if they arrived fist. A very fair and smart system, which avoids the need for a receptionist to triage them and cost the hospital more money. Perhaps just another insight into the Tanzanian attitude towards community and life. 
The first patient who comes through the door, and hence likely the sickest, was an 80 year old man, with a great big cyst below his left cheek, and a large infected, almost gangrenous looking and nearly a foot square patch of skin on his chest below the cyst. The dripping pus, and the smell of off flesh (a common smell in the UK from people with severe ulcers on vascular wards) had attracted a crowd of flies that buzzed in with him. He was a very sorry sight, and it was very hard not to gag whilst he was in the room. It is fortunate that buildings in Tanzania rarely have any glass or any covering to their windows. The resultant barred holes (a little like l imagine being inside a jail would be like) give maximum ventilation for minimal cost. Anyway, this was a simple call to admit and drain the huge dripping cyst, though what will be done with him afterwards, I don't know. The surgical maxim I mentioned before (If there is pus about, let if out) seems to come up here more than I expected. For a number of the next patients, however, Dr BT and I are much less in agreement. Before thinking I am an arrogant upstart, please hear me out. Dr BT wants to give co- trimoxazole to everyone. Even people who almost definitely do not have any infection at all. As I may have said before, this antibiotic is only meant to be used in quite specific circumstances (such as to treat PCP), due to its potential for severe side effects.

It was really awkward being with Dr BT, as if was much harder to discuss the treatment with him compared to how easy it is with Tim. This is just me, finding it hard, as he is a 'doctor' whereas Tim is only a student. I use this term in the loosest sense. I am not usually the sort to bitch behind someone back, but he is absolutely shocking.

For example, the case of a female UTI:
Dr BT: "Lets use Co-trimoxazole".
Me: I think there is a better drug we could use... (Though Co-trimoxazole does actually help in UTI there are drugs which will do the same thing with far less risky side effects)
Dr BT: Then crystal pen? (a penicillin)
Me: Nope...

Dr BT: Erythromycin? (slight desperation in his voice)
Another pause...
Me: The pharmacist recommends nalidixic acid...

Dr BT: Can't we use metronidazole?

This is the conversation we had, I kid you not. This is not a treatment I would have known to use when I got here (In the UK trimethoprim is the first line for UTI), but I looked it up then asked the pharmacist. Why can doctors here not do a little research, for their patients benefit. Drugs like metronidazole are very unlikely to cure the UTI at all, doing more harm than good.

Two other diseases I was told we should Use co-trimoxazole for (in addition to the wealth of viral appearing infections) were bloody diarrhoea (though actually the classic metronidazole is a good choice here) and thrush (though skilfully I managed to "accidentally mishear" him here, and I wrote a prescription for clotrimazole instead). The pessary and cream that my Oxford Handbook recommends. Having that book on the desk is a life saver.

This is absurd. A pretty average medical student with three years experience, leading a doctor to the correct treatments. Its scary. I look forward to being back in the good old NHS, were I can be shouted at for suggesting the wrong antibiotic. What is most worrying is that this doctor is the one in charge of outpatients, and thus the person who 'teaches' Tim, when Tim doesn't know the answer.

After this horrible ordeal, and yes it is horrible seeing how little someone knows and struggling to correct them when you shouldn't really need to, I have sworn never to return to outpatients with Dr BT. Initially I thought I could improve his prescribing, but realised through the clinic that he seems to do what he wants, regardless of what we discussed to do about the previous patient, not learning from previous people. What do I do?) Escaping the outpatients, I went back to the ward to perform HIV tests on two people.

The first test was for a sick child who Dr BT and I had admitted today with apparent kidney disease (urine microscopy showed granular casts present in the urine, showing protein is leaking through the kidneys) and an un-healing injury on his knee. All of this came with severe pain up the leg meaning he had to limp, and enlarged inguinal lymph nodes (at top of leg).  

The second HIV test was for the 80 year old man we saw first in clinic, with the large abscess. Both useful tests as there are presentations that may correlate to having some kind of compromised immune system.

Both tests were negative. Great news, but with normal glucose levels and no HIV, why are they both ill? More investigations are needed, along with a lot of clever thinking...

After this busy and frustrating day, I go to school football match with Mama and Dada. When we arrived, I was asked to play, which I would have loved, but was in my 'med student' gear, down to the bottle of alcohol gel on my belt, so said I would love to play another time. There was no chance I was going to be able to play in this heat in smart trousers and shirt! The football pitch was a dusty field, and some of the school children (16 year olds playing against each other) share pairs of football boots, between left and right footed people, to mean they can each have a boot on the foot used to kick the ball.

After the football match (which disappointing ended 0-0), I am invited to the leaving party that the school is throwing for Mama and Dada. I happily accept, I love a party!

The school was littered with signs telling the children to speak English, and 'No English, No Service'. The children are made to speak English at all times at the school to help them learn

Before the party, we are shown around the school. The classrooms are empty, and have desks in that you could imagine your parents using in their schools, crowded into rooms to look at a black board. After a tour of the school, we are taken to the canteen, and as we three mzungu walk with the head master of the school into this canteen/assembly hall, all of the children, chairs lined up pointing to the front (taken from the class rooms earlier) stand up and start singing african music and hymns as we (Tanzanian) shuffle towards the front. We sit at the front of the hall in front of all the children, and we get a series of acts, including a singing and dancing choir and acrobats, all talented pupils at the school. The school then had its dinner, which we joined. Mama and Dada had bought enough money to buy the kids all a soda, and a lot of pencils and other stationary to give out to the kids from the school stationary stores. This did mean that, therefore, the pencils were coming from the British tax payer (as is the cost of  their trip here and subsequently to Zanzibar). I am not sure how I feel about that, but the children (14-18 Years old) were so excited about getting a few pencils each that they were bouncing up and down with joy. It was wonderful that they could bring happiness to a whole school so easily. 

The children sit watching us. The space between us and them is where the fantastic acrobats and dancing choir performed. The last few pencils are being given out at the back

This was then followed by -speeches-. The Tanzanian speeches were all very Christian, each starting with the shout "Praise the lord" (Children chorus "amen"!). Then Mama gave an inspirational thank you  speech back to the children ("You can do anything you want to..." kind of thing) followed by Dada, who gave an emotional thank you, tears running down her cheeks. Both very in character, I apprive. I was then asked to make a speech. Wait. What? I suppose there is no such thing as a free lunch... I just said it was a wonderful welcome for me, despite the fact i didn't even work in the school, and I hoped not to see any of them again as that would mean that they were ill and at the hospital. I thought it was a good joke to think upon the fly, but I think it went over most of their heads, perhaps a language problem. Or I am just not the comedian I thought I was... We were sung out the same way we were sung in, and again, I was left marvelling at Tanzanian generosity and community.

Monday, 21 November 2011

Elective 31. Police investigations and liver enzymes

Some serious confusion over liver enzymes takes up much of the morning, after which I am left alone in outpatients again, and asked to help in a police investigation while I am there. Smartie is leaving today, so from tomorrow I will be properly alone again, though seeing as she has spent a lot of her time in the house reading, I am not sure how much of a difference it will make.

A strange building on the main road coming to the hospital. I am told they never had fuel in this pump. Is it decorative? Did someone live here?

Much of our morning today was taken up trying to interpret the results of the most complex investigation offered by this hospital, a 'liver function test' (LFT). We had ordered this for a very sick patient, and it is a common test in the UK, though here it is so specialised it is only ever carried out when there are a number of patients waiting for it at once, so it is worth putting the reagents into the machine. The machine was bought by USAid, as LFTs are useful for managing patients with infections such as HIV and hepatitis. It is amazing that this is such a 'special' test here, whereas pretty much all patients admitted to hospital in the UK have one just as a screening measure, and just in case. For this sick patient, we got four results back from the lab on a printed slip of paper like a receipt from a shopping till. It gave us the urea and creatinine (more to do with the kidneys than the liver, but never mind) and two 'results' which didn't seem to refer to anything. There were no 'normal ranges' given with the receipt (the reason for doing the test would to be to see if there was any abnormality) and the urea and creatinine were given in completely different units to those we use. Some time with a calculator converted the values into something we could understand, and showed them to be normal, but this still took us about half an hour, despite Smartie's further maths A level and my lowly chemistry A level. At least it was good to know that the values were normal.

The other section was much more problematic, as we were not really sure what it was meant to show. Normally, in the UK, when you order a LFT, you get results such as ALT and ALP, showing the level of certain enzymes (which should be inside the liver) in the blood, thus helping you see how damaged the liver is, by how much it is 'leaking'. OK, its not that simple, but that is the basics behind it. Here, however, the results slip gave values for 'GOT' and 'GPT'. What on earth are these! Without knowing that they stood for, let alone the normal range, we had no way of telling whether they were normal or not, and hence the tests were currently useless as they gave us no information. There were no doctors on the ward today, and so began our quest of epic proportions, quite out of scale with the importance and urgency. Perhaps I am just trying to fight against the Tanzanian laid back attitude. We started with the text books, so as not to trouble anyone, but even the Oxford Handbook of Clinical and Laboratory Investigation (you would have thought that if a textbook was this specialised, it would have all the answers, but no...) failed to answer our questions. We then called around Dr Bike's house (he was outside with the motorbike, no surprise), as it was he we he had ordered the test with. Unfortunately he had no idea. Eggs has a wealth of knowledge, but I haven't seen him at all this week, and he hasn't done a ward round in the male ward since last Wednesday, 6 days ago. I hope he is not unwell, and has not been devoured by his chickens... To come back to the point, we wandered around the hospital asking nurses, only to be met with shrugs. The lab seemed a sensible place to go, and if was one of the first places we tried. A different lab tech was standing in for Choc (I have no idea how the Tanzanian system works) but had no idea what the tests were. We tried looking at the (Very fancy USAid) machine and operating instructions. The button next to ALP/ALT was marked GOT/GPT  but left us none the wiser. Smartie suggests that perhaps it got pressed by accident, which sounds pretty sensible, but if that were the case, where would the reagents come from? They only buy exactly what they need... To cut a long, frustrating story short, we searched for over an hour and a half, only getting the answer when Choc wandered into the lab. He had left his phone at home, which was why he hadn't heard our calls. He simply told us that they were mimilar measures to ALP/ALT, but less specific, and were both in the normal range. All that searching for what felt like nothing, then feeling bad that perhaps you would have felt happier if there had been a problem. As it is, the patient has central, top abdominal pain (called epigastric), and examination shows what feels like it might be a large kidney on the left, but we have no idea what is wrong with her... Choc gets to show off his knowledge again, though, he is one smart cookie!

I move across to outpatients as the (self directed, of course) ward round finishes. In out patients I am, initially, working with Tim, though after 10 minutes he goes outside to break the news to a patient we had just diagnosed with HIV in a more private place (the room we use often has patients being weighed by nurses in it as well, and perhaps the next patient to be seen Waiting in the corner) and never returned. It is good practice to be discrete about these things, but I do not appreciate being left alone again. Perhaps because I didn't kill anyone yesterday (or so I assume), he thinks I can easily run things with just a nurse to translate. I don't think so, but I don't want anything bad to happen to prove me right!

One of the patients I see is a severely malnourished baby, all skin and bones, looking more like an old man than a child, She was bought in by her 8 year old sister from 30km away, the sister had walked here over a couple of days with the baby on her back. The tests show severe malaria, so I admit the child. Malaria is usually treated by giving a few pills to take home, but this baby looks close to dead. If if gets any worse, 30Km is a very long way to come back to hospital. Hopefully, on the ward, we can give vitamin supplements and try to feed the poor thing up a little bit. I will call the sister who bought the baby in Holly, because she is protective, and always seems to be holding the baby up, who can be Ivy... (Urgh, I know, I am so sorry...)

Another patient I admitted is a woman with severe mouth pain. She seems to have developed an abscess behind her teeth at the back of her jaw. I think it might need surgical drainage ( the age old "if there is pus about, let it out"), but either way, she can hardly drink, let alone eat. So she needs some proper care.

The hardest case that came in today, while I was on my own, was a woman who claimed she had been raped, and had obtained a police report form for a doctor to fill in after examining her. The idea being the doctor could write down that the evidence suggested this, or not. This was clearly out of my league. I have only ever heard about rape examinations in novels or films, and I wasn't a Tanzanian doctor. It seems like one of those things that a lawyer would love to find when defending, to have a case dropped. I did have a very hard time explaining why I couldn't do it to the nurses and patient, though, who just wanted me to do it and get it done with, as no-one else was available. For all the good it would do, they may as well have not had anyone do it at all - I would have no idea what to do! After my repeated refusals, a nurse finally took her off to find a doctor somewhere, shooting me an evil look on her way out. How dare I not pretend I understand this examination, fumble around a little, and invalidate this woman's case!

Another strange building in the village. It looks like someone just build the top of a castle, or else a whole one and the rest sank. So strange! I had a climb into it to see if anything was in there, and just had some children staring at me throughout. Crazy Mzungu. 

Smartie leaves Tanzania very early tomorrow morning, so I will be alone once again. This shouldn't be too much of an issue, as many of the things I have been doing in the hospital have been without her recently, as she has become a little fed up with the Tanzanian system. I do hope that they will still let me see patients without her there. I am convinced that she told them she was a doctor, or at the least didn't correct them, from the different way we are treated. Perhaps I should have done the same, it certainly would make my life easier, if a little dishonest.

Elective 30. Running outpatients on my own

Today I get thrown into running outpatients on my own, learn about some sneaky Tanzanian methods of getting free medications, and spend an awkward evening doing nothing with the new visitors.

The wards rounds today are difficult, because all of the nursing students are still having exams. Fortunately a nurse I get on well with, Gabs, passed his exam with flying colours. His main examination question was on how to give a patient a sponge bath. I am pleased he passed, and feel he will go far as he has a very positive altitude, and genuinely seems to like caring for and helping people. It is a shame, however, that I have never seen a patient sponge bathed here, instead they often seeming to be left caked in their own blood or dirt if they cannot get out of their bed and wash themselves. Dr Bike was not available to run the word round (I can only assume that something arose concerning his bike's health), so Smartie and I did it by ourselves. During the ward round, we were inconvenienced by the fact that a patient had been admitted with a mild asthma attack, but there were no inhalers in stock, so we couldn't give her anything but salbutamol pills to try and manage her asthma when she was sent home.

Some more problems with the water supply means all the water to the village now needs to be delivered in barrels by truck. This barrel holds twice as much as the well can supply in one day. Having water (clean or not) is something we take so much for granted in the UK, but it is so important here!

After the ward round, I moved onto outpatients while Smartie had a little grumble and went home. Here I was again working with Tim, as there were no doctors in outpatients today. In fact, many days there are no doctors there, though I don't know what they do instead, as people like Dr BT certainly aren't seen in the hospital! After we had seen two patients, Tim said he had something urgent to do, I should keep going, and then just walked out. I know we are both inexperienced, but being left alone to diagnose and treat patients is petrifying. At least when he is in outpatients with me, we both had a 'safety net' as if were, where the other could spot something obvious that we had missed out. This time, I was left with a few nursing students, which was very fortunate, as otherwise I would not have even been able to speak to the patients. This was exactly the sort or position we had been warned against, and told to avoid, by the medical school while we were on elective. But what could I do? Fortunately, there were no terrifyingly complicated or confusingly tropical cases (or if they were I definitely missed them), and I was very careful with everything I did. I hope I didn't kill anyone. I can joke about it here, but really I think its a realistic fear that people should have, if you go and leave a medical student in charge, without even being able to speak the language, and no support from anyone with more than a years nursing experience. Having the nursing students there to translate in some ways made it worse, as their benign requests for me to teach them by explaining why I thought it was a certain disease over another, or why I had chosen a certain treatment, made me doubt my already shaky reasons for each choice. Needless to say, I was very glad when Tim returned. I had seen less than a dozen patients, and that was more than enough. At least with Tim here, I can hope that if I make a huge mistake (or he does) it will be spotted. Being a GP must be a lot more stressful than I first thought...

On Tim's return, I see him filling in a medical insurance form with a somewhat bizarre collection of drugs, even for Tanzania. I couldn't imagine what sort of patient he would be wanting to treat here, so ask about this and he, shame faced, tells me that the patient who he was filling it in for only needed one of them, and the other four are for him to treat his sick neighbours. I am not sure where I stand on this Tanzanian drugs-scam. On one hand, it is obviously illegal, and takes advantage of those paying for the insurance, using the money they pay in and reducing the pot available to treat those contributing. On the other hand, these people are poor, sick and need to be cared for, and should be treated, even if they cannot afford the drugs. After all, Robin Hood is usually seen as a hero...

The little goats that frolic around all the time are so cute! Sad to think that these little bouncy kids are going to be  served up for food soon...

In the evening, I have started reading Paperweight by Steven Fry. A very witty author. Smartie went to bed after dinner, at about 6.30, leaving me to try and make conversation with Mama and Dada. We had already talked about our respective days in the afternoon over tea ("I liked the sewing machines they had in School. I am Sure your mother would as well"...) leaving a rather awkward gap in conversation for the evening. It seems a very common phenomenon in those who have only recently met, if forced to spend a lot of-time together. Too much time for the usual pleasantries and superficial questions, but not having spent enough time together in the past to reflect back and laugh on previous experiences, or even let your guard down a little, and be a little less on your 'best behaviour'. You know what I mean, when you have just met people, especially those much older than you, and you cannot be your full jokey self for fear of insulting or upsetting them, as there is so much about them you do not know. Despite this gap in conversation, I couldn't exactly get up and get a book to read, showing how bored I was, so we sat in mostly silence for a good  length of time. It seems to be something the serene Tanzanians are very good at, so perhaps I should put this down as a cultural learning experience. All I know is I found if pretty boring. Perhaps I am not serene enough to accept Tanzanian lifestyles. 

Sunday, 20 November 2011

Elective 29. Visitors

Exams today mean that the ward round cannot be carried out, so I spend the morning in outpatients. Because of the lack of other things going on, Smartie joins me and Tim here, for the first time. In the evening, we have two unexpected visitors from the UK.

The nursing Students are having exams this week, which take place on patients in the ward.Because there are no ward rounds on Tuesdays, this is a perfect time for the examiners to plan out the exams, so there are many nurses on a sort of rotation around the ward all day, showing how they wash their hands, record patient's blood pressure and temperature and so on. They look very very similar to exams I have had at medical school in my time. Unfortunately, these exams made it impossible for Smartie or me to see any patients or the ward today, as all of the nurses are too busy to translate, and all of the patients are being 'used' by nurses and examiners. I suppose they were not going to get seen anyway, but it is a shame that we cannot check on the woman who was operated on yesterday, or see how the burnt baby is getting on.

Instead of spending time on the ward and as nothing else is going on, Smartie decides she will join me in outpatients. A job she has previously said she would hate, and adamant to be right, she hid in the corner for the four and a half hours it took to get through all of the patients. She didn't participate with most of the consultations, but came up with some very good questions or ideas of a differential for a few which she did speak for. She is, after all, very smart! Afterwards she apologised and admitted she was getting a little fed up and was looking forward to going home. Understandable, she has been in Tanzania for a long time, but seems to be in a generally Jaded mood and started complaining about how those applying for medicine and first-year medics were so "naïve" and ''stupid" in thinking the NHS was good, and how everyone was chewed up by the system and spat out. I can partly understand where she is coming from, as there doesn't appear to be enough support for junior doctors, but in general, I had to say I disagreed completely. I still think the NHS is "good" and while it is far from perfect, I support the ideals behind it strongly. Perhaps I am 'naïve', but in my opinion, that is better than jaded, hateful cynicism, as long as there is the knowledge that "good" is not something to be fully content with, and it can, and should, be improved on. I think Smartie is a big fan of privatisation, something I am opposed to. We spoke our sides of the argument, but she was still unconvinced by me, pulling rank and telling me I would feel as she did next year, when I had experienced more of the NHS. I really don't think this likely to happen in a year, and I hope that I never feel as jaded as she does.

Whenever things are tough, this beautiful view point next to where I live is lovely to come to and relax at. You can see across the rift valley, at the tiny occasional villages below, in the massive flat expanse.

Back to Medicine. In outpatients, I am slowly making progress against the massive overuse of drugs. When I was last talking to Choc, he told me he went to a national conference, were they were told that if a blood smear is negative for malaria, unless the patient is very sick, they shouldn't be given antimalarials, but instead should be told to return in a day or two for a second blood smear. This would catch malaria if it was missed the first time, and helps combat the over use of antimalarials (which is significant). Despite the protesting patients this new tactic was working quite well today, though how difficult it was for the patient to get back to the hospital had to be factored into the decision. That is, it was going well until one of the nursing students presented after vomiting once, after starting nalidixic acid for a UTI. We ordered a blood smear to check for malaria just in case, but thought it could be down to a side effect of the drug. As the nurses can speak English, when the blood smear came back negative, I explained to her that she didn't have malaria, and could pop back in in a few days time to just double check this with another test. Not difficult, seeing as she worked in the hospital. She seemed upset with this, and said that she wanted anti-malarial drugs. Despite all of my attempts at explaining why she didn't need them as it was very unlikely she had malaria (she didn't even have symptoms) she gave up on talking with me, and instead turned to talk to Tim in Swahili. Tim prescribed her the malaria medication she wanted and she left, despite the fact that, really, we still don't know what she has, if anything. This was a bit upsetting, being undermined by Tim, so I ask him why he felt he should prescribe her the drugs. He tells me it is because she felt sure that she had malaria. A very strange way to make a diagnosis, but seeing as I have very little knowledge about malaria or even Tanzania, I can hardly be annoyed at someone disagreeing with me. I don't really know why the student nurse wanted the pills. Perhaps she genuinely thought she had malaria. Perhaps she wanted them for a non-nurse friend who seemed to have malaria, but who would need to pay for the consultation and drugs, whereas nurses get them for free. Perhaps she just wanted to sell them. Perhaps I am on the slippery slope to becoming as jaded as Smartie!

In the evening, two English people arrived at our house. We were told earlier this afternoon that someone called Dewy would be arriving to live with us for a month. On their arrival, they are both female, not called Dewy, and staying here for a couple of days. The Tanzanian grapevine is a little inaccurate at times. They are both teachers, and looking to set up a partnership with the village secondary school. One, In her mid fifties, was very obviously mindful of her age, and kept referring to herself as though our mother ("Imagine how your mother would feel..." "They will think I am your mother" and so on), so I will call her Mama, the other was mid twenties and seemed to do whatever Mama said, so I will call her Dada. Swahili for mother and daughter (don't tell me I am not trying to learn this silly language!). It was obvious that neither of them were expecting such accommodation, with Mama complaining that she had been told there was a shower and an inside toilet "how would your mother feel if she was here", but has decided not to complain  and to stick through with it. Good old stiff upper lip. Dada was a lot quieter, and almost seemed in shock at the (delicious) dinner of cabbage and rice. Cabbage is a rarity, and something to be pleased for! Just wait until she sees the spaghetti! They will be fine though, they are only here for 3 more days before a week holiday in Zanzibar. Personally, I am really enjoying it here despite everything, and relish the fact I have three more weeks remaining. 

As meals go, cabbage and rice is pretty tasty!