Monday, 21 November 2011

Elective 31. Police investigations and liver enzymes

Some serious confusion over liver enzymes takes up much of the morning, after which I am left alone in outpatients again, and asked to help in a police investigation while I am there. Smartie is leaving today, so from tomorrow I will be properly alone again, though seeing as she has spent a lot of her time in the house reading, I am not sure how much of a difference it will make.

A strange building on the main road coming to the hospital. I am told they never had fuel in this pump. Is it decorative? Did someone live here?

Much of our morning today was taken up trying to interpret the results of the most complex investigation offered by this hospital, a 'liver function test' (LFT). We had ordered this for a very sick patient, and it is a common test in the UK, though here it is so specialised it is only ever carried out when there are a number of patients waiting for it at once, so it is worth putting the reagents into the machine. The machine was bought by USAid, as LFTs are useful for managing patients with infections such as HIV and hepatitis. It is amazing that this is such a 'special' test here, whereas pretty much all patients admitted to hospital in the UK have one just as a screening measure, and just in case. For this sick patient, we got four results back from the lab on a printed slip of paper like a receipt from a shopping till. It gave us the urea and creatinine (more to do with the kidneys than the liver, but never mind) and two 'results' which didn't seem to refer to anything. There were no 'normal ranges' given with the receipt (the reason for doing the test would to be to see if there was any abnormality) and the urea and creatinine were given in completely different units to those we use. Some time with a calculator converted the values into something we could understand, and showed them to be normal, but this still took us about half an hour, despite Smartie's further maths A level and my lowly chemistry A level. At least it was good to know that the values were normal.

The other section was much more problematic, as we were not really sure what it was meant to show. Normally, in the UK, when you order a LFT, you get results such as ALT and ALP, showing the level of certain enzymes (which should be inside the liver) in the blood, thus helping you see how damaged the liver is, by how much it is 'leaking'. OK, its not that simple, but that is the basics behind it. Here, however, the results slip gave values for 'GOT' and 'GPT'. What on earth are these! Without knowing that they stood for, let alone the normal range, we had no way of telling whether they were normal or not, and hence the tests were currently useless as they gave us no information. There were no doctors on the ward today, and so began our quest of epic proportions, quite out of scale with the importance and urgency. Perhaps I am just trying to fight against the Tanzanian laid back attitude. We started with the text books, so as not to trouble anyone, but even the Oxford Handbook of Clinical and Laboratory Investigation (you would have thought that if a textbook was this specialised, it would have all the answers, but no...) failed to answer our questions. We then called around Dr Bike's house (he was outside with the motorbike, no surprise), as it was he we he had ordered the test with. Unfortunately he had no idea. Eggs has a wealth of knowledge, but I haven't seen him at all this week, and he hasn't done a ward round in the male ward since last Wednesday, 6 days ago. I hope he is not unwell, and has not been devoured by his chickens... To come back to the point, we wandered around the hospital asking nurses, only to be met with shrugs. The lab seemed a sensible place to go, and if was one of the first places we tried. A different lab tech was standing in for Choc (I have no idea how the Tanzanian system works) but had no idea what the tests were. We tried looking at the (Very fancy USAid) machine and operating instructions. The button next to ALP/ALT was marked GOT/GPT  but left us none the wiser. Smartie suggests that perhaps it got pressed by accident, which sounds pretty sensible, but if that were the case, where would the reagents come from? They only buy exactly what they need... To cut a long, frustrating story short, we searched for over an hour and a half, only getting the answer when Choc wandered into the lab. He had left his phone at home, which was why he hadn't heard our calls. He simply told us that they were mimilar measures to ALP/ALT, but less specific, and were both in the normal range. All that searching for what felt like nothing, then feeling bad that perhaps you would have felt happier if there had been a problem. As it is, the patient has central, top abdominal pain (called epigastric), and examination shows what feels like it might be a large kidney on the left, but we have no idea what is wrong with her... Choc gets to show off his knowledge again, though, he is one smart cookie!

I move across to outpatients as the (self directed, of course) ward round finishes. In out patients I am, initially, working with Tim, though after 10 minutes he goes outside to break the news to a patient we had just diagnosed with HIV in a more private place (the room we use often has patients being weighed by nurses in it as well, and perhaps the next patient to be seen Waiting in the corner) and never returned. It is good practice to be discrete about these things, but I do not appreciate being left alone again. Perhaps because I didn't kill anyone yesterday (or so I assume), he thinks I can easily run things with just a nurse to translate. I don't think so, but I don't want anything bad to happen to prove me right!

One of the patients I see is a severely malnourished baby, all skin and bones, looking more like an old man than a child, She was bought in by her 8 year old sister from 30km away, the sister had walked here over a couple of days with the baby on her back. The tests show severe malaria, so I admit the child. Malaria is usually treated by giving a few pills to take home, but this baby looks close to dead. If if gets any worse, 30Km is a very long way to come back to hospital. Hopefully, on the ward, we can give vitamin supplements and try to feed the poor thing up a little bit. I will call the sister who bought the baby in Holly, because she is protective, and always seems to be holding the baby up, who can be Ivy... (Urgh, I know, I am so sorry...)

Another patient I admitted is a woman with severe mouth pain. She seems to have developed an abscess behind her teeth at the back of her jaw. I think it might need surgical drainage ( the age old "if there is pus about, let it out"), but either way, she can hardly drink, let alone eat. So she needs some proper care.

The hardest case that came in today, while I was on my own, was a woman who claimed she had been raped, and had obtained a police report form for a doctor to fill in after examining her. The idea being the doctor could write down that the evidence suggested this, or not. This was clearly out of my league. I have only ever heard about rape examinations in novels or films, and I wasn't a Tanzanian doctor. It seems like one of those things that a lawyer would love to find when defending, to have a case dropped. I did have a very hard time explaining why I couldn't do it to the nurses and patient, though, who just wanted me to do it and get it done with, as no-one else was available. For all the good it would do, they may as well have not had anyone do it at all - I would have no idea what to do! After my repeated refusals, a nurse finally took her off to find a doctor somewhere, shooting me an evil look on her way out. How dare I not pretend I understand this examination, fumble around a little, and invalidate this woman's case!

Another strange building in the village. It looks like someone just build the top of a castle, or else a whole one and the rest sank. So strange! I had a climb into it to see if anything was in there, and just had some children staring at me throughout. Crazy Mzungu. 

Smartie leaves Tanzania very early tomorrow morning, so I will be alone once again. This shouldn't be too much of an issue, as many of the things I have been doing in the hospital have been without her recently, as she has become a little fed up with the Tanzanian system. I do hope that they will still let me see patients without her there. I am convinced that she told them she was a doctor, or at the least didn't correct them, from the different way we are treated. Perhaps I should have done the same, it certainly would make my life easier, if a little dishonest.

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