Friday, 18 November 2011

Elective 28. Stitches

The day starts with a ward round, where I learn to take out stitches after a wound has healed. I then assist in the evacuation of an incomplete abortion in theatre, and then the removal of a keloid scar on the ear lobe. I then finish the day with another meal (or should I say feast) at Tim's house.
On the ward round in the morning with Dr Bike, which he somehow completed, seeing over twenty patients, in 12 minutes, there was a baby with severe burns on its forearm and back, with splash burns to the chin and chest. He was crying constantly the whole time we were in the ward, but it takes some effort from myself and Smartie to get the pain relief for the child increased. The mother claims the baby spilt her porridge on himself, but the skin has been completely stripped, and the tissue under the skin severely damaged. I would guess it was oil, because of the damage, but who knows. At least when we returned later this day the crying had stopped. One of the patients on the ward round needed stitches taking out. She had been operated on to remove a bladder calculi by the urologist a week or two ago. The nursing students said they were very busy today, so may not be able to do this until tomorrow. To show how busy they were, and how 'short staffed' the ward was today, below is a photo of the (absurd number of) nursing students crowding around Dr Bike, who was teaching them about burns at the bedside of the child. The nursing school means there are always lots of (usually friendly) nurses around, but lack of formal teaching means that they have to get what they can on the ward. They do appear to want to avoid work as much as possible, unfortunately.

The student nurses crowd around Dr Bike for a teaching session

Anyway. Smartie walked me through how to remove the stitches, though when preparing, instead of the sharp scissors I wanted, I was given a scalpel blade by the nurses. Without a handle. Undeterred (and after checking the patients HIV status) I removed ten stiches in about fifteen mins. This is very slow, in fact it took me longer than Dr Bike spent on the ward round in both women's and children's wards. And I had half as many stitches as he did patients. In my defence, the stitches were very tight, dug into the flesh, And I didn't want to cut the woman with the scalpel blade. There are any number of excuses as to why I was so slow, but really it was because I hadn't done it before and was scared of cutting myself as well. Fortunately no-one complained. It is a Joke that I am barely competent to remove stitches from patients, but am expected to admit and discharge patients, and prescribe drugs. This woman still had a catheter and the urologist hod ordered for if to remain for two weeks after the operation. Not on any antibiotics, and with repeated urine microscopies taken showing many pus cells in the urine, I put her on nalidixic acid, first line here for a UTI, to help treat a possible infection, or to prevent her developing something worse. Dr Bike didn't even talk to this patient, so I couldn't get him to do it. I am not really happy prescribing, but the problem is, if I wasn't doing it, she wouldn't be seen tomorrow, then perhaps she would be given something the day after that. Perhaps not. Absurd.

Fortunately, in theatre, no-one has expected me to carry out any operations. Yet. It has been joked about though, jokes I have met with horror. Today, I assisted in two procedures. Smartie is not interested in surgery and told me she didn't really want to be involved. In all honesty, l am not that interested in surgery either, but always eager for experience, and ever the consummate gentleman. Perhaps. The first procedure was a lady who had sadly had a spontaneous abortion of her baby at around 3 months after conception. This means the baby had died, and the body was getting rid of the dead tissue through the vagina. Most of the blood and tissue had been expelled, but some still remained, and the cervix had closed up, so no more could be expelled. The left over tissue needed to be removed surgically. The procedure was quite simple, essentially using an Instrument with a loop on the end to push through the cervix into the womb, and using it to scrape the womb clean by scraping the sides by feel. I was reminded of the Egyptians and their removing the brain though the nose.
The second procedure I assisted in was relatively minor, and involved removing a large (keloid) mass of scar tissue on a girls ear lobe, that had developed after she had had it pierced. I thought I had been taught in the UK that you should not usually operate to remove cosmetic keloid scars, as it could then scar again (as it did before) and cause a worse keloid scar. This is obviously not the case here and my worries were dismissed without a thought. A quick procedure where as assistant, I did very little, other than dab at bleeding, and cut  thread from stitches. Dr Bike finished the procedure faster than the morning ward round, finishing up by giving the patient the keloid scarred-ear-lobe he had removed to take home with her. The rush suggests that perhaps he is going somewhere special tonight, and needs the time to add another polish to his bike.

Is the evening, Tim invites me for dinner with his family. Smartie is also invited, but is not too interested in coming along. She says she is 'burnt out' regarding Tanzania. With the alternative being sweet spaghetti, the choice is no competition for me. Tim has borrowed his dad's motorbike, and uses this to take me to his house. This is much faster than the 30 minute walk I was expecting, though also much more terrifying, as the scramble bike (Chinese of course) bounces over rocks in the dirt track. Tim's family is very welcoming, I feel bad l never have anything to bring them as a gift, though have been giving Tim the Student BMJs I bought with me to read. Hopefully there will be something of interest/something worthwhile in them. Flicking through, much of if is either about UK politics, or advanced investigations (unavailable here) for diseases which are rare in Tanzania. Oh well. His father is an explosive technician for a gold mine nearby, and invites me to see his work. That sounds very exciting - exploding things! We spend a lot of time talking about the differences between Tanzania (Slow relaxed and friendly) and England (more rushed, More importance placed on money). His father seems like the Ultimate Tanzanian: Slumped in his chair, slow speaking and often pausing for around a minute before answering questions. Either that or he was stoned. I was invited by them to join their meal, which was about 7 different dishes! See the picture below, A veritable feast here! 

The feast that Tim's mum laid out for us. The culture here means that the women cook all the food, but then do not eat when everyone else does, instead staying in the kitchen area. It seems a little sexist to me...

This is definitely the best meal I have had since I arrived at Tanzania, and I said as much. During the meal, various neighbours such as the village 'albino-man' and 'blind-man' who works in the  hospital office answering phone calls (who somehow walks everywhere without a stick or any help) popped in to grab some food. My de-humanising names make then sound like Super heros, which isn't too far from the truth. How blind-man finds his way around, I have no idea, though I see him wandering (slowly) down the path to the hospital each morning on my way back from the morning meeting. Perhaps he uses echo location! Albino man is friends with everyone in the village, though with all of the discoloured lumps on his skin, I am not sure how well he is.  Anyway I digress. Again.

The point was that in Tanzania, it is common to invite people to eat, or people to invite themselves if they are hungry. I commented on this sense of community, and Tim and his family  told they usually have two or three non-family members eating with them every day. I said that this is rare in the UK, possibly because people see their food and money as something they have worked for and want to keep if for themselves (I have got mine, screw you and your problems). They tell me that friends and community are much more important here than money, and it shows. Even though people here have so little, they are prepared to give it away to help someone else. There is so much we can learn from these people for life in England. I love it here.

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