Saturday, 5 November 2011

Elective 21. The Dead Foetus

What a busy day today. I Started on a ward round where I sat on a hidden dead foetus. Not a good start. I then spent some hours in outpatients seeing patients who I couldn't diagnose, and getting upset with the fact no-one in Tanzania seems to be able to diagnose either. Then maternity, where I saw the fastest delivery I have ever seen, then got called to female ward for a patient who had been admitted and was very ill. While I was ordering investigations, a reverend turned up, and told me I had promised to have dinner with him  and his family tonight. I did vaguely remember this, so went for a nice family meal while the lab tech was called in from home especially to carry out my investigations. I hope they were worthwhile

As you can see, it was a very busy day for me today. Smartie joined me and Dr Bike for the morning ward round, but expressed that she could do with a rest day, so wasn't planning on doing too much. Fair enough, l enjoy the company but have gotten used to managing on my own! The ward round is relatively uneventful for much of it, with the only thing of note happening when I went to take the blood pressure of a woman who had come in at 6 months pregnant, suffering from vaginal bleeding over the weekend. On admission yesterday she had precoded to spontaneously abort the foetus, losing a lot of blood and giving birth to a still born child. Because of her blood loss, and probably emotional upset, she was being monitored and stabilised in hospital before being let back home. After our previous experiences with fabricated blood pressures, in situations where it might be important (for instance, this one) it is safer for us to take a blood pressure ourselves. I went to get the sphygmomanometer, and on my return, asked her to extend her arm, whilst sitting on the bed next to her. She let out a high pitched, shrill scream and shoved me off the bed. I am left sitting crumpled on the flood, very confused, with the whole ward looking at me (no privacy on ward, remember). As I get off the floor, the woman unwraps what looked like a folded kanga on the bed (which is composed of a number of kangas strewn over the mattress due to the lack of bed sheets) to show me what was inside. There was the body of her dead 6 month old foetus. It looks grotesque, and I sat on it. The sitting doesn't seem to have done it any visible harm, and it is dead, but the thought makes me feel sick. I cannot apologise enough, I quickly get her blood pressure, squatting on the floor now (it is still low) and leave as fast as I can. I feel ill, and I am sure that after that experience, my blood pressure must be through the roof.

No time to recover, and at the end of the ward round, when Smartie goes back home to read, I head over to out patients to join Tim. Neither of us really knows enough to do this job, but having heard some of the 'professional advice' given by the actual doctors here, it feels as though we could be doing a worse job. Today we saw a pair of twins who were both presenting with the same symptoms. There was so much crying in the room. We thought it likely to be enteric fever, which they must have both caught from the same source, or each other. My Oxford Handbook
(Seriously, the most useful book for medical students I can think of) said first line treatment was
  Ciprofloxacin. Unsure as to whether this was still the case here, and whether it was available, I walked outside to ask the pharmacist, catching Dr BT on my way as well. Dr BT told us that mebendazole was first line for enteric fever (a drug used for worm infestations) and the pharmacist told us that metronidazole (for anaerobic bacterial infections, not aerobic) was definitely the drug that should be used for enteric fever. Neither of these sounded right and neither of them were in the books. This is just absurd. What am I meant to do!

Later in outpatients, we saw a patient who had been seen here by Dr BT a week ago with a fever, headache and vomiting. Typical malaria symptoms. No malaria test had been done, though, instead she had been given metronidazole and co-trimoxazole. Neither were indicated at all for her condition. No diarrhoea/lung/urinary symptoms. Why was she given these!? On her return (as she still felt awful) today, we did a malaria test. Positive...

One of the more complex patients seen was complaining of headache, and on investigation had a haemoglobin measurement that was much higher than the normal range. In Tanzania, where most  people are well below this 'normal' range due to diet, this was very high indeed. The only things I could think of were conditions such as haemochromatosis or polycythemia. Both conditions that affect red blood cells (haemochromatosis is a disease where you have too much iron, polycythemia a disease with too many red blood cells) but I wasn't too sure if this would be how they could present, how common they were in Tanzania or what we could do about them. The patient refused the expense of having a full blood count, so we went through the complex procedure of trying to find Dr Bike in the village, so we could 'refer' him to him. He saw the patient, who returned an hour later with a prescription for a diuretic and aspirin. What was he hoping to achieve? Diuretic to make him urinate out the extra haemoglobin? Surely losing fluid would just make more red blood cells? The aspirin was possibly a better idea - perhaps if he took too much eh would get a gastric ulcer and bleed out some of that excess haemoglobin. Absurd, just absurd. Anyway, enough of my complaining - sometimes in Tanzania it just seems as though no-one knows anything (myself included).

In the afternoon, I met up with Smartie with the intention of getting some experience in the maternity suite. We got to the labour room to find a very kind and helpful nurse, and one woman in labour. Perfect. This woman's cervix was still dilating, so we were both taught how to do a manual examination to see how far the cervix has dilated. Just after we had finished, about ten minutes after entering the room, this woman's waters broke and their baby just slid out. No fuss, taking less than 15 seconds. That is how giving birth should be! Mind you, this was her ninth child, so she had had some practice (and conditioning). Very pleased for her, but it was hardly practice for us in learning to manage a delivery as it all happened by itself! 

I was called to female ward in the evening, as woman had been admitted in an emergency. Smartie was already in bed. The woman was clearly 'out of it'  flailing her arms around and moaning in confusion. She had fallen to the floor suddenly, then been like this since the fall. No trauma. I ordered a 'real doctor' to come in from home, while I asked for a malaria test (in case of cerebral malaria), a blood glucose (in case of diabetes), haemoglobin, an hiv test and a urine microscopy (in case of something like schistosomiasis). The real doctor (Eggs) gets there in the end and sets up a quinine drip (IV) case of malaria, and gives stesoids in case of swelling of the  brain inside the skull. We will see if she has improved tomorrow.

While this is going on, my dinner party invitation comes along. I don't want to be rude, and the reverend is quite insistent, and I cannot to anything more until the results come back. I hope the lab tech is not annoyed that I called him in from home, but hopefully it is for the best. The meal is a pleasant pasta (i.e. not much sugar) and chips, with his wife and 3 year old daughter. No solar panels from the hospital in his house in the village, so we eat by the light of a kerosene lamp. A very nice family, and I keep being impressed with Tanzanian hospitality.

I walk back home on my own in the dark. It is a cloudy night and it really is very dark. I just about make it back to the hospital, I really should carry a torch. When at the hospital, I find that the tests Show microcytic anemia and a higher than normal range (but not really high) platelet count. Everything else negative. This doesn't  explain her symptoms, and she still seems ill. Perhaps higher platelets have caused her blood to clot  more easily and caused a clot in her brain. Perhaps I just don't know. Perhaps I just have to cross my fingers and hope she is better tomorrow.
The nights, while dark, still look beautiful. While you can still see...

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