Elective 32. Back to School

Its back to school for me, but only at the end of a long day. Before this, I walk Smartie to the bus Stop at 6am, it was the gentlemanly thing to do. A quick ward round is then followed by my first (and last) stint in outpatients with Dr BT. This was all topped off with a lovely leaving party for Mama and Dada from the school.

The school we visited, walls bare and old desks crammed into rooms as close as possible. There are no chairs, as they are needed in the canteen for the children to eat their dinner.

Before getting started on this busy day, I would like to say that I was prayed for for the first time yesterday (well, knowingly prayed for, at any rate). The bishops secretary (a Canon) bought around some letters for Mama and Dada at 7.30PM yesterday, but unfortunately they were both already Pj'd up and in bed. While they subtly got up again, I chatted with (read distracted) the secretary. What is it about Tanzania that inspires people to go to bed so early! It must be the lack of things to do in the area, and the dark dark nights (no lights). After the letters had been handed over, the secretary asked the awkward question to Dada (the re-teacher) first. "So, which church do you attend?" While Dada struggled around the "I am not... quite... currently regularly attending any Church" (good thing she didn't mention what she told us yesterday, that she feels she can identify with Islam more) I had the time to think up a good avoidance answer "I live in the diocese of xyz" (not a lie!) which Mama then repeats. Good to know I am essentially helping people to lie to gods messengers. The Canon, apparently satisfied, talked a few more Minutes about how Dada should go to church more, then asked if he could pray before he left. Who are we to deny him this? He gave thanks, and prayed for the teachers safe journey home. He then gave thanks to God for guiding me to come and help their hospital, and prayed that I could carry on doing good here, and learning as much as I could to help others. A little odd to have my choice to come here attributed to someone (or something) else, but the argument for free will has always been a tricky one, so who am I to disagree. It was still lovely in an inexplicable way to have a Canon pray for me. I just realised pray and prey are only one vowel different, and sound very similar. I wonder if anyone has noticed this before. My hand writing recognition keeps mixing them up. Some people don't believe in coincidences...

On the ward round with Dr Bike, there was a patient who had been admitted yesterday with a painful lump in the leg, and difficulty with their breathing. Examining the leg showed a huge lump beside the knee, the size of a melon, but bumpy and growing through the skin, leaking fluid and very painful looking. It looked like some form of very advanced skin cancer or sarcoma. I assume the problems breathing, and abdominal pain the patient complained of, were due to metastases in the lungs and liver. This patient clearly seems a case for terminal care. It is shocking that he presented to the hospital this late, so far into his disease he cannot walk, and was carried here by his family. Even if he presented earlier, the hospital doesn't have any anti-cancer therapies available, so I am not sure it would have helped. Unfortunately, in this hospital they don't seem to understand the concept of palliative care, and Dr Bike spends some time devising a wicked looking treatment plan which will never get rid of the cancer, but will likely ensure the patient experiences many nasty side effects and needs to stay in hospital to die, due to all the IV drugs, rather than going home with his family. Dr Bike isn't interested in my ideas of perhaps debriding the large mass, giving prophylactic antibiotics and letting the patient go home to his family, as this isn't curing him. As l am only a medical student, and have even less idea about Tanzanian culture than medicine (so very little indeed...) I leave it. It is quite possible his plan is the best thing to do, given patient expectations and all that, and I just don't understand the full picture. I just feel sorry for the poor man stuck at hospital.

The football ground we watched a football game on in the afternoon. Just a cleared area of ground, with lots of dust when they play. Football shirts are the common wear for young people in Tanzania. More people here support British teams than in the UK! Random location in text here, just to break up a load of text. Otherwise all the pictures would be at the end!

I spend most of the morning and half the afternoon in outpatients with Dr BT. I hadn't noticed before how the patients waiting to be seen form some kind of self-triage, meaning the sickest, or ill babies see us first, and the more well wait for longer, even if they arrived fist. A very fair and smart system, which avoids the need for a receptionist to triage them and cost the hospital more money. Perhaps just another insight into the Tanzanian attitude towards community and life. 

The first patient who comes through the door, and hence likely the sickest, was an 80 year old man, with a great big cyst below his left cheek, and a large infected, almost gangrenous looking and nearly a foot square patch of skin on his chest below the cyst. The dripping pus, and the smell of off flesh (a common smell in the UK from people with severe ulcers on vascular wards) had attracted a crowd of flies that buzzed in with him. He was a very sorry sight, and it was very hard not to gag whilst he was in the room. It is fortunate that buildings in Tanzania rarely have any glass or any covering to their windows. The resultant barred holes (a little like l imagine being inside a jail would be like) give maximum ventilation for minimal cost. Anyway, this was a simple call to admit and drain the huge dripping cyst, though what will be done with him afterwards, I don't know. The surgical maxim I mentioned before (If there is pus about, let if out) seems to come up here more than I expected. For a number of the next patients, however, Dr BT and I are much less in agreement. Before thinking I am an arrogant upstart, please hear me out. Dr BT wants to give co- trimoxazole to everyone. Even people who almost definitely do not have any infection at all. As I may have said before, this antibiotic is only meant to be used in quite specific circumstances (such as to treat PCP), due to its potential for severe side effects.

It was really awkward being with Dr BT, as if was much harder to discuss the treatment with him compared to how easy it is with Tim. This is just me, finding it hard, as he is a 'doctor' whereas Tim is only a student. I use this term in the loosest sense. I am not usually the sort to bitch behind someone back, but he is absolutely shocking.

For example, the case of a female UTI:

Dr BT: "Lets use Co-trimoxazole".

Me: I think there is a better drug we could use... (Though Co-trimoxazole does actually help in UTI there are drugs which will do the same thing with far less risky side effects)
Dr BT: Then crystal pen? (a penicillin)
Me: Nope...
Silence...

Dr BT: Erythromycin? (slight desperation in his voice)
Another pause...
Me: The pharmacist recommends nalidixic acid...

Dr BT: Can't we use metronidazole?
Speechless...


This is the conversation we had, I kid you not. This is not a treatment I would have known to use when I got here (In the UK trimethoprim is the first line for UTI), but I looked it up then asked the pharmacist. Why can doctors here not do a little research, for their patients benefit. Drugs like metronidazole are very unlikely to cure the UTI at all, doing more harm than good.

Two other diseases I was told we should Use co-trimoxazole for (in addition to the wealth of viral appearing infections) were bloody diarrhoea (though actually the classic metronidazole is a good choice here) and thrush (though skilfully I managed to "accidentally mishear" him here, and I wrote a prescription for clotrimazole instead). The pessary and cream that my Oxford Handbook recommends. Having that book on the desk is a life saver.

This is absurd. A pretty average medical student with three years experience, leading a doctor to the correct treatments. Its scary. I look forward to being back in the good old NHS, were I can be shouted at for suggesting the wrong antibiotic. What is most worrying is that this doctor is the one in charge of outpatients, and thus the person who 'teaches' Tim, when Tim doesn't know the answer.

After this horrible ordeal, and yes it is horrible seeing how little someone knows and struggling to correct them when you shouldn't really need to, I have sworn never to return to outpatients with Dr BT. Initially I thought I could improve his prescribing, but realised through the clinic that he seems to do what he wants, regardless of what we discussed to do about the previous patient, not learning from previous people. What do I do?) Escaping the outpatients, I went back to the ward to perform HIV tests on two people.

The first test was for a sick child who Dr BT and I had admitted today with apparent kidney disease (urine microscopy showed granular casts present in the urine, showing protein is leaking through the kidneys) and an un-healing injury on his knee. All of this came with severe pain up the leg meaning he had to limp, and enlarged inguinal lymph nodes (at top of leg).  

The second HIV test was for the 80 year old man we saw first in clinic, with the large abscess. Both useful tests as there are presentations that may correlate to having some kind of compromised immune system.

Both tests were negative. Great news, but with normal glucose levels and no HIV, why are they both ill? More investigations are needed, along with a lot of clever thinking...

After this busy and frustrating day, I go to school football match with Mama and Dada. When we arrived, I was asked to play, which I would have loved, but was in my 'med student' gear, down to the bottle of alcohol gel on my belt, so said I would love to play another time. There was no chance I was going to be able to play in this heat in smart trousers and shirt! The football pitch was a dusty field, and some of the school children (16 year olds playing against each other) share pairs of football boots, between left and right footed people, to mean they can each have a boot on the foot used to kick the ball.

After the football match (which disappointing ended 0-0), I am invited to the leaving party that the school is throwing for Mama and Dada. I happily accept, I love a party!

The school was littered with signs telling the children to speak English, and 'No English, No Service'. The children are made to speak English at all times at the school to help them learn

Before the party, we are shown around the school. The classrooms are empty, and have desks in that you could imagine your parents using in their schools, crowded into rooms to look at a black board. After a tour of the school, we are taken to the canteen, and as we three mzungu walk with the head master of the school into this canteen/assembly hall, all of the children, chairs lined up pointing to the front (taken from the class rooms earlier) stand up and start singing african music and hymns as we (Tanzanian) shuffle towards the front. We sit at the front of the hall in front of all the children, and we get a series of acts, including a singing and dancing choir and acrobats, all talented pupils at the school. The school then had its dinner, which we joined. Mama and Dada had bought enough money to buy the kids all a soda, and a lot of pencils and other stationary to give out to the kids from the school stationary stores. This did mean that, therefore, the pencils were coming from the British tax payer (as is the cost of  their trip here and subsequently to Zanzibar). I am not sure how I feel about that, but the children (14-18 Years old) were so excited about getting a few pencils each that they were bouncing up and down with joy. It was wonderful that they could bring happiness to a whole school so easily. 

The children sit watching us. The space between us and them is where the fantastic acrobats and dancing choir performed. The last few pencils are being given out at the back

This was then followed by -speeches-. The Tanzanian speeches were all very Christian, each starting with the shout "Praise the lord" (Children chorus "amen"!). Then Mama gave an inspirational thank you  speech back to the children ("You can do anything you want to..." kind of thing) followed by Dada, who gave an emotional thank you, tears running down her cheeks. Both very in character, I apprive. I was then asked to make a speech. Wait. What? I suppose there is no such thing as a free lunch... I just said it was a wonderful welcome for me, despite the fact i didn't even work in the school, and I hoped not to see any of them again as that would mean that they were ill and at the hospital. I thought it was a good joke to think upon the fly, but I think it went over most of their heads, perhaps a language problem. Or I am just not the comedian I thought I was... We were sung out the same way we were sung in, and again, I was left marvelling at Tanzanian generosity and community.