Elective 18. Murphy's...

Today is another busy day trying to organise Eggs into doing the necessary things in male ward, advising a reverend about medication (finally earning some keep from those hours in pharmacology lectures), and persuading Dr Bike to accompany me on a ward round of children's and woman's wards. While on these ward rounds with Dr Bike, we disagree over a diagnosis, which makes me sound pretty presumptuous writing this, seeing as he is a doctor...

The organisation in the Male ward is the same as it was in previous posts. It seems that without me prompting that 'this needs to be filled in' or 'that patient hasn't been seen for a few days' or even 'this patient needs this medication' that things would get done a lot slower, or nor at all. Perhaps l just need to chill out and get tuned to Tanzania time. On the ward we came across a patient on our ward  round in acute urinary retention. This is where the patient cannot urinate, and the bladder just gets more and more full. Here it is due to the TURP causing clotted blood to block the catheter, so urine cannot leave the bladder. At this point, Eggs checks the time, and shock, it is 10.17. Tea time is urgently required and Eggs tells the nurses he will be off to get tea. I think he is joking, and let a little snigger out, but no, Eggs and all the nurses leave for tea time, walking out of the door and leaving me along in the ward with the patients, and the patient groaning in pain in retention. What can I do? This man is clearly in pain, with a bladder so full it is bulging out visibly between his hip bones in his starved stomach. I chase Eggs and ask if we can flush out the catheter to let the urine flow (a five minute job) but he thinks I am joking now "don't be silly, its tea time, we can do it after tea". There is nothing I can do. I cannot even talk to the patient, as there are no nurses left now, so have to leave him lying in the middle of his bare bed (no water to wash bed sheets so very few bets have sheets). After 45 minutes of apprehensive waiting and willing his bladder not to explode (though at least if it does there is a urological surgeon here at the moment) two nurses return and I persuade them to flush out the clots to get his urine flowing. No apparent harm in waiting, perhaps I should just get with the Tanzanian time and stop rushing around!

Tanzanian life is like this Tanzanian tree by the hospital. Slowly slowly. (This tree is so awesomely fat! I love it...)

Later in men's ward,  I am talking with a rarity of a patient, someone who understands some English. The second patient I have seen who can speak some English (after that beggar asked me for money). He does not speak much, but I can get my point across without nurses. He is a reverend who was on the surgical list for a TURP, but untreated very high blood pressure meant he could not have the operation this week. I was trying to console him with the fact he could catch the urologist on his next rotation in another hospital in the region in two months time, when I remembered my pharmacology lectures from all those years ago. There was a drug which would be perfect for this patient. I scuttled off to Eggs, who had never heard of it, but said I should give him a note so he could go and find it at a pharmacy in a town or city. After checking doses and contra-indications carefully in the BNF, I wrote down "TAMULOSIN 0. 4 mg OD" on a piece of paper. I took it to the reverend, and took a nurse with me to make sure that I could explain myself properly. Tamulosin is an alpha-blocker and both reduces high blood pressure and makes it easier to urinate with a large prostate. Both problems he needed sorted out. While an easy drug to get in the UK, this hospital does not have it, and he will have to go to a city to get it. This will not be too hard for him, as he is relatively well off (clothes have few holes on them). All of those (seemingly) pointless hours spent sitting in some exceptionally boring pharmacology lectures in first and second years are starting to pay off. I suppose you do learn things for more than the marks in the exams. The best bit is how grateful the reverend is, smiling and thanking me profusely. I feel pretty doctor-y for the first time, having decided on something that should help someone which wouldn't have been thought of if I wasn't here. I am rising out of that paperwork like a phoenix, but I doubt that I will escape it!


I finally persuade Dr Bike to do a ward round, though to give him his due he was in theatre in the morning, and in the CTC earlier seeing HIV positive patients. He flies through the patients on the ward round with his normal Speed. "Discharge" "Do B/S" and "Give Co-trimoxazole"; I cannot keep up. Co-trimoxazole is his favourite drug. I have tried arguing there are better, and safer antibiotics for many of the diseases he prescribes it for (from UTI to diarrhoea diseases), well, according to my BNF, but his Zealot-like devotion is hard to fight when you have little knowledge (as I do) so I do not push it and let him have his co-trimoxazole for some of the patients, though I do disagree and get it changed for patients where it is obviously the wrong drug choice, such as in a patient with bloody diarrhoea.

One of his diagnoses on the ward round, however, is just not right though, and I do push this one. "Diagnosis, acute abdomen, give hyoscine stat" -he loves to do things Stat. I pipe up. If he thinks its an acute abdomen he cannot just leave it without knowing what it is. You have to work our what it is! What if it is something serious.

He palpates the abdomen, then borrows my stethoscope, listens, and declares "Increased bowel sounds. Patient is obstructed". I start to get the nurse to ask the patient about their bowel habit, but at that moment, our patient proceeds to fart, loud and long. Amazing timing (if he was obstructed, he wouldn't be able to fart, as gas wouldn't be able to get through). This doesn't deter Dr Bike, though "Gut spasms, hyoscine stat."
I have to disagree again, you cannot just keep making these sort of diagnoses when you feel like it, and tell him I would like to feel the abdomen myself. This is clearly knocking precious minutes off of Dr Bike's legendary 10 minute ward round, and he flounces off to the next patient. He does always have a lot to do around the hospital, so I suppose its understandable he wants to get to the next patient as soon as possible, but that's no reason to ignore the 'hassle' of having to diagnose someone. Fortunately a couple of (student) nurses stay with me, and help translate as I have a good feel of his belly and ask some questions. The patient has epigastric pain (top middle of belly) and has a positive Murphy's sign. This sign is because of pain created when the hand is placed in the upper right of the abdomen and the patient is asked to breath in. Pain suggests that there could be a problem with the gall bladder, as this moves down on inspiration to press against the examining hand. Not a guarantee that this is the problem, but it does suggest towards certain diseases such as cholecystitis, inflammation of the gall bladder. Either way, I think it suggests that there is something more going on than 'gut spasms' (if there are spasms, then why?!). I seek down Dr Bike, and tell him my findings, not really sure what investigations or treatment for this sort of presentation is available at the hospital (and, in part, to show off my amazing finding. So proud!) Dr Bike told me to leave the patient to him, as we should finish the ward round now, then he would like a break. This is fair enough, I think Dr Bike's breaks are a lot less questionable than the breaks Eggs takes... On my return I found the patient had been given five days of amoxicillin and discharged. I assume the amoxylillin was for possible cholecystitis, but I have no idea. No, In Tanzania I never seem to have any idea about what is going on at all. Perhaps that is all they can do here? It is a shame that such a successful find like that seems to be taken away from you, but you cannot have everything. I hope the patient is OK.

I am still playing outside with the children each day in my spare time!