Sunday, 6 November 2011

Elective 22. Absconding patients and multiple wives

Today I spent most of my time in outpatients with Tim again, as there were no doctors or nurses on any wards until after 3, and without translation I cannot do anything. I do, however, manage to drop by the woman who was admitted yesterday with low conciousness (flailing and moaning), to see how she is doing.

In the Morning meeting, which I attend every day (though I am not sure why, very few people usually turn up) we talked about a number of patients who had absconded (run away without paying) after their TURPs. The hospital is charging the patients who received a TURP quite a lot of money for a Tanzanian, 150,000 Shillings (or £60). This money, however, was worked out just to cover the cost of the fluids used in the operation (about 30L worth of dextrose solution per patient) and the hospital is making a sizable contribution to the cost of the operation, paying for everything else. It is a shame that the hospitals generosity is taken advantage of and the hospital is being left even more out of pocket that they would have been. The lack of money now means that the hospital cannot afford to buy more sterile gloves. The hydrocele operations that were due to take place today, carried out by Dr Bike, cannot go ahead, as the hospital has no sterile gloves. It is absurd how close to the edge of bankruptcy the hospital manages to survive.

In the morning I try to go with Smartie to the wards to see a few of the more sick patients, but there are no nurses or doctors anywhere. Without anyone to translate, there is nothing we can do. We find out from the pharmacist that all of the doctors have gone to the city at the head of the region to sign a contract to try and get more money (though I am not sure why they all needed to be there), and all of the nurses are at a presentation at the Secondary School. Yes. All of them. I hope that the patients con look after themselves. Welcome to Tanzania.

Smarrie is annoyed at the situation (understandably, so am I) and returns to our house for a few hours to read and wait for any medical personnel to return. After all, we cannot do anything without someone to translate; being able to talk is so useful in medicine! I decide to join Tim in outpatients, as he is struggling there on his own. With us the only outpatient room running (sometimes there are two, the other run by Dr BT) we have to see about 40-50 patients.

One of the cases is a baby with hypopigmented patches on his head. It is absurd that two medical students are expected to deal with this, a case I have never seen before in my life. The skin is not white, as you would see in vitiligo, where the pigment in the skin is destroyed, rather brownish and lighter in patches than the black skin. I have borrowed Smarties' Oxford Handbook of Tropical Medicine and in there find that (other than leprosy) it could be a yeast called pityriasis versicolour. I am so out of my depth here it isn't funny. The alternative, however, is to leave Tim on his own to see the patients without even having this book. We prescribe itraconazole to try and treat the possible fungal infection.

Most patients are quite straightforward cases of malaria or gastrointestinal infections. Today, however, there seems a slew of gynaecological related presentations. A number of heavy, painful periods, a woman bleeding years after her menopause (?endometrial cancer) and a lot of patients experiencing foul smelling vaginal discharge (?Pelvic inflammatory disease). Fortunately there is an obs+Gynae specialist visiting in two months, but this seems too far away for some of the more urgent patients (such as the patient who possibly has endometrial cancer). One of the patients we saw with vaginal discharge was particularly difficult. It was a good chance for us to practice our sexual history taking. This particular woman, baby strapped to her back in that sensible way that is so common here, using a folded kanga, told us she was one of three wives, but the husband had refusal to come to the hospital with her, and the other wives had had similar symptoms to her. This was clearly an STI, and easy to treat. But what then? Re-infection once she returned home, most likely. With the many wives, this presented very different social problems to those we come across in the UK. I asked Tim to ask her if it was possible to get her to use condoms to prevent re- infection, but he laughed. "I don't think you understand. The man is dominant here always. He does what he wants"... A very different situation to the UK indeed. What could we do? Vaginal discharge cannot be cultured here, so organisms cannot be identified. This means that treatment is empirical (guess work). I  gave her antibiotics and Tim tried to get her to see the importance of coming in with the whole family, so they could all be treated. She said she would mention it to the husband. Fingers crossed they all come in, but I am not getting my hopes up. Life can be so different here, it is almost alien.

The woman in the foreground has attached a baby to her using her Kanga, pressing it to her back. This is a normal way of baby transport, leaving your hands free, and is a fantastic idea - definitely something to do in the UK!

Throughout seeing all of there patients in outpatients, there was one theme running throughout. A massive over use of antibiotics. The sort of use that would never be considered in the uk. Running nose? Five days of amoxicillin, and if you are unlucky, metronidazole or co-trimoxazole as well. I am unfortunately not exaggerating.  I went to the pharmacist to ask if there are any lozenges for tickley coughs, After a child diagnosed with malaria also had a dry cough we wanted to help him with. The pharmacist told me that there were no lozenges, but I had to give five days of amoxicillin if anyone had any cough, as it was 'Standard practice". I think it is a waste of resources for a poor hospital, and leading to some serious drug resistance in a decade or so. I try to argue with Tim, or Dr Bike, or whoever is throwing around the metronidazole like smarties. Always, I get nowhere. "Its the way we need to do things in Tanzania. It is dirtier here than in the UK". What can I do? I give up.

In the afternoon I head into the women's ward with Smartie. We want to check on a few patients, and the lady from yesterday is top of the list. When we poked our head in in the morning, she was lying motionless. Better than the writing and moaning from before, or a whole lot worse, I have no idea. Now she was sitting up in bed drinking tea! Fantastic news. All she had received in treatment was quinine against malaria and steroids against encephalitis (swelling of her brain). The malaria test was negative, but single blood smears can be wrong. Either She had cerebral malaria, cured by the quinine (most likely) and missed on the blood smear, or encephalitis,  possibly from a virus, cured by the steroid. Or neither, and she just got better on her own. Medicine is so hit and miss her, but successes like this patient drinking her tea (even if not  understood or really earned) are still amazing, and make all that angst against the doctors who are never here, or the pharmacy which is perpetually out Of stock, melt away.

1 comment:

  1. They should charge them before operating then!