Elective 24. Episiotomy?

Smartie has gone on (medical) safari today, so I am left alone. I do my (becoming regular) stint in outpatients, where I get a bit annoyed at the system, then spice things up with a night in maternity, where I refuse to do an episiotomy when asked to use some shockingly inappropriate  equipment. Otherwise, l am now reading Paperweight by Steven Fry in my evenings. As a book, it is a bit bits-y for the chunks of time I have here. I think it was designed to fit around a busy life, not a Tanzanian life!

The time in outpatients is similar to the other times I have been there, though with a slightly different selection of patients obviously. Tim and I see a child with scabies (a disease he easily diagnoses, but I have never seen before). Scabies is notoriously hard to treat here, as the child is likely to just go home and get re-infected by the home and friends, regardless of whatever medication and advice is given. A woman who has lost a series of babies before birth comes in with vaginal bleeding in her 8th month of pregnancy, scared of losing this child as well. I ask for a syphilis test from the lab (other than HIV, its the only STI we can test for here) and it comes back positive. I feel pleased with myself for a minute for possibly spotting a cause and getting a diagnosos, but then as wel keep talking to her, we find that her husband has a number of wives,  and an aversion to hospitals. In fact the female she came in with, whop we had assumed was her sister or a friend, is actually another one of the wives. Weird. This many wives thing seems like it may become a theme of my time here. Her baby is still alive, though we are worried about the more long term effects the syphilis during her pregnancy will have had on the child. I prescribe antibiotics for the syphilis (thank you Oxford handbook) and send her to maternity for a more experienced opinion.

The patients can get pretty upsetting in Tanzania, but the scenery is just so beautiful!

The annoying case of the day comes along early afternoon. It is a child who has still got pneumonia as he lost  his amoxicillin (fair enough) with his irritating mother. The boy is quickly dealt with, I have a listen to his chest (as he was previously diagnosed with pneumonia) which sounds unhealthy, so I prescribe him a course of amoxicillin to replace the one he lost. THe mother also wants to check herself in as a patient, however. She tells us she wants a b/s (blood smear) and Hb (haemoglobin) - the normal tests done if malaria is suspected. When asked if she has any symptoms she tells us no, but she feels she has malaria. She obviously has some experience with healthcare, as she wouldn't know the tests to order otherwise. We are unable to argue, and she gets the tests, showing us her Insurance Card, meaning the tests are free for her. Government employees get health insurance for themselves and families, meaning consultations and many medicines are free. On her return, with negative test results, she demands malaria treatment. We double check her history. No, she has no fever, no headache, in fact no complaints at all, other than the 'feeling' she has malaria. I express my doubts about whether she has malaria (blood smear can miss it, but not having Symptoms as well? Perhaps everyone has malaria?) Which Tim translates for her. Suddenly she claims to have a terrible headache, and fever at night (but not now, hence her normal temperature) - but claims she didn't want to mention if before. Now she is holding head in hands, perhaps aiming for the next Oscar. She demands malaria medication, and Tim wants to give it to her. I really don't, but am not in a position to say this. She gets her pills, and we fill in the forms that mean she pays no money for them. Then she bounces out of the door with a big grin on her face. The forms seem to have an amazing effect on her health, perhaps they should be prescribed to all patients? This annoys Me; I may be wrong but it seems this woman is abusing the heath insurance scheme set up by the government to get pills she doesn't need. Whether she will take them anyway, or sell them, I don't know. Perhaps this annoys me because it is close to home. The NHS is far better funded than this country, and people in the UK can seem to misuse the system, seeing their doctor when they don't need to, and demanding treatments or investigations they do not need. It is a shame that any healthcare system where you do not need to pay at the point of access seems to attract this sort of abuse, but perhaps it is only natural.

Lunch and dinner today was different - some kind of spinach - exciting but very earthy... Not sure how good it is just having it on its own though

Wanting to cheer myself up in the evening, I mosey on down to the labour room to get all misty eyed over some babies. I am lucky. Often there is little happening here, meaning little for me to do. As I arrive a woman is having contractions. I talk with the two nurses looking after her (nurses are also midwives here) and ask permission (via translator) from the woman. Everyone is happy for me to try to help out. The woman is circumcised, having had the clitoris and much of the labia removed. This is something I had not seen before, a practice which is now officially illegal in Tanzania, though still popular in some tribes, and practised still. I help monitor the progress of the woman, and am taught how to feel for the dilation of the cervix, how to estimate how many centimetres dilated it is by feel, and so plot the progression of labour. When the babies head is starting to poke out, I get to rupture the membranes "breaking her waters". The baby, however, is very big and causing some serious stretching. I am told this is especially dangerous in women who have been circumcised, as it can cause the scar where the clitoris was to rip. The head nurse decides it is necessary to perform an episiotomy (a cut to widen the opening) to prevent any tearing, something we would readily do in the UK. The plan is that a simple cut is much easier to repair, than an awkward tear in a place which may damage other organs. The nurse then hands me (I am standing by the mother in apron after having just been assessing her dilation, gloves still dirty) a pair of rusty, blunt scissors. I am sure (or at least hopeful that) they had been through the sterilisation process, So were (hopefully) clean, but the rust made them look as though they had been found at the bottom of a garden. I was not happy to do this, what would be my first episiotomy, with such rubbish equipment, and asked whether the mother would be given local anaesthetic, such as lignocaine, to numb the pain. The nurse told me it was not needed, as the mother would not be able to feel anything due to the contractions. I didn't believe this, (though it may be true, I have no idea but I doubt it). Needless to say, I was not happy to try and cut someone 'down there" with such blunt scissors and no anaesthetic. I Said I wasn't happy to do this, so a student nurse stepped in and tried. She attempted some heroic sawing, which the mother most definitely could feel, and ended up creating a messy tear after about a minute. Really not very nice at all. After this, the student nurse then delivered the baby and placenta. I am sad I missed delivering the baby, as I missed this by stepping away from the episiotomy,  but very glad I didn't try using those scissors. I stuck around until the mother went back around 3AM, then went to bed, hoping to avoid scissor-genital related nightmares.