Sunday, 20 November 2011

Elective 29. Visitors

Exams today mean that the ward round cannot be carried out, so I spend the morning in outpatients. Because of the lack of other things going on, Smartie joins me and Tim here, for the first time. In the evening, we have two unexpected visitors from the UK.

The nursing Students are having exams this week, which take place on patients in the ward.Because there are no ward rounds on Tuesdays, this is a perfect time for the examiners to plan out the exams, so there are many nurses on a sort of rotation around the ward all day, showing how they wash their hands, record patient's blood pressure and temperature and so on. They look very very similar to exams I have had at medical school in my time. Unfortunately, these exams made it impossible for Smartie or me to see any patients or the ward today, as all of the nurses are too busy to translate, and all of the patients are being 'used' by nurses and examiners. I suppose they were not going to get seen anyway, but it is a shame that we cannot check on the woman who was operated on yesterday, or see how the burnt baby is getting on.

Instead of spending time on the ward and as nothing else is going on, Smartie decides she will join me in outpatients. A job she has previously said she would hate, and adamant to be right, she hid in the corner for the four and a half hours it took to get through all of the patients. She didn't participate with most of the consultations, but came up with some very good questions or ideas of a differential for a few which she did speak for. She is, after all, very smart! Afterwards she apologised and admitted she was getting a little fed up and was looking forward to going home. Understandable, she has been in Tanzania for a long time, but seems to be in a generally Jaded mood and started complaining about how those applying for medicine and first-year medics were so "naïve" and ''stupid" in thinking the NHS was good, and how everyone was chewed up by the system and spat out. I can partly understand where she is coming from, as there doesn't appear to be enough support for junior doctors, but in general, I had to say I disagreed completely. I still think the NHS is "good" and while it is far from perfect, I support the ideals behind it strongly. Perhaps I am 'naïve', but in my opinion, that is better than jaded, hateful cynicism, as long as there is the knowledge that "good" is not something to be fully content with, and it can, and should, be improved on. I think Smartie is a big fan of privatisation, something I am opposed to. We spoke our sides of the argument, but she was still unconvinced by me, pulling rank and telling me I would feel as she did next year, when I had experienced more of the NHS. I really don't think this likely to happen in a year, and I hope that I never feel as jaded as she does.

Whenever things are tough, this beautiful view point next to where I live is lovely to come to and relax at. You can see across the rift valley, at the tiny occasional villages below, in the massive flat expanse.

Back to Medicine. In outpatients, I am slowly making progress against the massive overuse of drugs. When I was last talking to Choc, he told me he went to a national conference, were they were told that if a blood smear is negative for malaria, unless the patient is very sick, they shouldn't be given antimalarials, but instead should be told to return in a day or two for a second blood smear. This would catch malaria if it was missed the first time, and helps combat the over use of antimalarials (which is significant). Despite the protesting patients this new tactic was working quite well today, though how difficult it was for the patient to get back to the hospital had to be factored into the decision. That is, it was going well until one of the nursing students presented after vomiting once, after starting nalidixic acid for a UTI. We ordered a blood smear to check for malaria just in case, but thought it could be down to a side effect of the drug. As the nurses can speak English, when the blood smear came back negative, I explained to her that she didn't have malaria, and could pop back in in a few days time to just double check this with another test. Not difficult, seeing as she worked in the hospital. She seemed upset with this, and said that she wanted anti-malarial drugs. Despite all of my attempts at explaining why she didn't need them as it was very unlikely she had malaria (she didn't even have symptoms) she gave up on talking with me, and instead turned to talk to Tim in Swahili. Tim prescribed her the malaria medication she wanted and she left, despite the fact that, really, we still don't know what she has, if anything. This was a bit upsetting, being undermined by Tim, so I ask him why he felt he should prescribe her the drugs. He tells me it is because she felt sure that she had malaria. A very strange way to make a diagnosis, but seeing as I have very little knowledge about malaria or even Tanzania, I can hardly be annoyed at someone disagreeing with me. I don't really know why the student nurse wanted the pills. Perhaps she genuinely thought she had malaria. Perhaps she wanted them for a non-nurse friend who seemed to have malaria, but who would need to pay for the consultation and drugs, whereas nurses get them for free. Perhaps she just wanted to sell them. Perhaps I am on the slippery slope to becoming as jaded as Smartie!

In the evening, two English people arrived at our house. We were told earlier this afternoon that someone called Dewy would be arriving to live with us for a month. On their arrival, they are both female, not called Dewy, and staying here for a couple of days. The Tanzanian grapevine is a little inaccurate at times. They are both teachers, and looking to set up a partnership with the village secondary school. One, In her mid fifties, was very obviously mindful of her age, and kept referring to herself as though our mother ("Imagine how your mother would feel..." "They will think I am your mother" and so on), so I will call her Mama, the other was mid twenties and seemed to do whatever Mama said, so I will call her Dada. Swahili for mother and daughter (don't tell me I am not trying to learn this silly language!). It was obvious that neither of them were expecting such accommodation, with Mama complaining that she had been told there was a shower and an inside toilet "how would your mother feel if she was here", but has decided not to complain  and to stick through with it. Good old stiff upper lip. Dada was a lot quieter, and almost seemed in shock at the (delicious) dinner of cabbage and rice. Cabbage is a rarity, and something to be pleased for! Just wait until she sees the spaghetti! They will be fine though, they are only here for 3 more days before a week holiday in Zanzibar. Personally, I am really enjoying it here despite everything, and relish the fact I have three more weeks remaining. 

As meals go, cabbage and rice is pretty tasty!

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