Friday, 4 November 2011

Elective 20. Comas

Not much happens at the hospital on weekends, and today is a Sunday. I did go into the hospital briefly to check on a couple of ill and confusing patients (including Ludwig, who has been shuffled over to children's ward and left in a corner while male ward is full of surgical patients. He rarely seems to be seen nowadays. For the rest of the day, I have been reading Red Dragon by Thomas Harris. Smartie came back this evening after spending a couple of weeks in Zanzibar, with the plan of spending another week or so at the hospital before going home. I am very grateful for the company, though have been enjoying all the time I was forced into spending with collegues and village kids because of little else to do. Hopefulyl I can keep spending this time with them, rather than taking the 'easy' route out by just staying at home with her. I did receive a letter from the UK today, though, which was nice. No mail comes close to this village, so for contact with the outside world, the hospital uses a PO box in a town 30-40 minutes drive away. Chief was in the town today, so bought me my letter back; a lovely reminder of England and home, though it did make me feel a little homesick.

Whenever I try to read outside, there always seems to be a goat invasion! How they still find food here, I don't know!

The only patient I saw today other than Ludwig (who has not really changed in condition) was a 40 year old lady who has been in the hospital for about a week now, though she is likely to be leaving soon. How she will leave, to where, and what will happen after she goes, we don't know. I talked about her in a previous post, where she was admitted a week ago after losing conciousness, and had a very low GCS. Since then, I have seen her every day on the ward since then. Her condition seems to vary hugely from day to day as to how well she is. All laboratory investigations available to us have come back negative (though this does nor mean much, just telling us she doesn't have anaemia, HIV, malaria, hypoglycaemia or any organisms visible under a microscope in her urine or Stool.) (that is the extent of tests available). Despite all these tests coming back negative, she spends most of her time in a coma. Not just asleep, but unconcious and impossible to rouse. But she is not in this coma state all of the time. One or two days when I have visited her, she has been sitting up in her bed, admittedly unsteadily, and eating with relatives feeding her. The next day she Seems unrousable again. What on earth is going on?

Conciousness is measured by the 'Glasgow Coma scale' (GCS). This measures the patients responses (eyes, voice and movement) to certain stimuli (e.g. speaking to them, or pressing firmly on them causing mild 'pain') This produces a score between 15 (what you or I would score now [hopefully]) and 3 (The lowest possible. A corpse would achieve this score - no reactions at all). Some of the visits we made to her, she has had a score of 3, while in others she has had a score of 14 (showing mild confusion, but nothing more). This variation from one day to the next is very confusing for everyone (most of all the patient, I am sure)

This patient is dearly a Serious case, as in the UK a score below 8 usually means that the patient should be intubated to protect their airway, as they cannot be trusted to breath properly on their own. This is not really possible here, so she is just left on a bed, while we cross our fingers. Nothing really seems to be done for her at all, and she seems to be just left in a corner of the ward, while we hope she gets better. In the UK, pretty much all cases with a reduced GCS get a CT scan of the head, and I think this is what this lady needs. The history of a collapse, followed by head pain and vomiting, suggest she may have some problem with the blood vessels in her brain. Whether this is a bleed (such as a subarachnoid haemorrhage) or some kind of blocked blood vessel leading to a massive stroke, I don't know, but I think a bleed is more likely. I can, however, guess that this is very unlikely to just get better on its own, sitting her here in hospital.

I am told that Tanzania has 5 CT scanners in the country by Dr Bike. If you can afford (and are well enough) to travel to one of these, and then can afford a scan, there is still a huge waiting list. I have been trying to recommend to her relatives that she gets a CT scan, as in her lucid periods she seems quite well, so perhaps it is a reversible cause, and she can be made better again, though I really don't know. Whatever the case, diagnosis and treatment are certainly not possible at this hospital, but might be at a larger hospital, certainly if the hospital is large enough to have a CT scanner. Basically, the options are to pay an extraordinary amount of money to try and get a CT scan, and hope that whatever is the problem can be fixed, and the family has enough money to pay for this problem to be fixed, or to go home and wait for the inevitable.

Throughout the week her relatives have kept changing their mind as to what they want to do for her. One day they want referral letters to take her to a large hospital for a scan; the next they want to have her discharged from hospital for terminal care at home; then the following they have decided that it would be too hard at home and want her to stay at the hospital for terminal care there; then back to the idea of referral. It must be such a hard position to be in, deciding your mum's/sisters/wife's fate, and trying to balance that against your own food money. People here are very short on money, and this makes me appreciate the good old NHS more and more.
The problem with all this umming  and ahhing from the relatives is that more money is spent paying for this hospital's fees, and the more time goes on, the less likely it is that the disease (whatever it is) will be treatable without some kind of long term effect. I honestly wish her all the best, hence my hopeful visits every day, but sadly I can only really see one outcome on the horizon, and it isn't positive. 

So many sad stories in Tanzania, set against such a beautiful backdrop (here the lake all the water comes from for the village, seen at a sunset wander).


  1. One of those CT scanners was in my hospital, and was functional for four days out of the four weeks that I was there.

  2. Sorry to hear that. I suppose even if you have the equipment, you still need it to be cared for, and you need people trained enough to actually use it, and interpret the results.