Monday, 28 November 2011

Elective 36. A full day with an empty pharmacy.

A very full (and hence fulfilling) day today. First, I assist in an operation to remove a lipoma from above a man's eyebrow. I then spend the rest of  the day in both female and children's wards, until 5.30, first running a ward round, showing Kiwi and Dolittle how it is done, then struggling with treatment alternatives, as the hospital is out of stock of most medications. Dolittle and Kiwi are wonderful company throughout the day and evening, I am glad they have turned up!

The operation to remove the lipoma was pretty standard. Neither Kiwi or Dolittle were allowed by their medical school to assist in surgeries or births (due to the risk of HIV), so I assisted; holding, cutting and swabbing. Not the most glamorous of jobs, but someone needed to do it. I think there is a real art to assisting. To do what the surgeon wants you to do, without needing to be asked, and I am getting better at this, but it is still very dull. I think the only real way to enjoy surgery is to be the surgeon. None the less, this is a successful operation, and a juicy lipoma is  removed. I got to get much more stuck into this procedure than previous ones, helping to remove it using blunt dissection techniques I vaguely remembered from dissection in my first year. I was asked to suture up the wound, but told Dr Bike it would be better if he did it. I have had little practice (and this on plastic pads, and over a year ago) at suturing, and this is on his face! I don't want to mess it up and leave him with an ugly scar for his life.

I work on removing the lipoma with Dr Bike in the anaesthetic room of the theatre, with an open window behind us. 

After this operation, Dr Bike was busy, and as it was a Tuesday, was not planning on doing a ward round. He told us he was happy for us to do it if we wanted, but he was sure it was all fine and didn't need doing. It is a good thing we decided to do the ward round, as things were most definitely not fine. I enjoyed leading the other two as, while they were more experienced than me, having just sat their finals, they had no idea how the hospital worked, or about many of the diseases and treatments that I was now used to.

The main problem today was that most things seemed to be out of stock. Nearly all of the medication people had been put on yesterday had not been given, as it was out of stock at the pharmacy. If something is out of stock, this is just noted on the notes next to where the drug was prescribed, but nothing is usually done about it. As no doctors were reviewing the ward patients, they were just left without medication, or with breaks in drug regimes, as the supplies had run out half way though courses. No ibuprofen was left, or diclofenac tablets (only injections) so everyone had to do with just paracetamol as a pain killer. Antibiotics are a lot worse. Only ampicillin tablets (like amoxycillin but much worse absorption when given by mouth), metronidarole, co-trimoxazole and chloramphenicol remain in the store. All other antibiotics have run out, and the latter two I mentioned have possibilities of quite serious side effects, so I won't be wanting to prescribe those myself, even though chloramphenicol is popular in the third world. This hospital is absurd, how are patients meant to get better!

In female ward, there is a patient who had come in with a floppy left arm, a headache, confused, and a blood pressure of 180/140 (high). The admitting 'doctor' (Tim) had put them on nifedipine and furosemide to control the blood pressure yesterday. Both of these drugs were out of stock, but nothing more had been done since yesterday. Needless to say, the blood pressure was still very high, so heading over to pharmacy, we discovered the other medication that was present that would do a similar job (captopril, bendroflumethiazide and propranolol), which I decided to use instead, though with these stroke-like-symptoms, Dr Bike really needed to see her and tell us what they do for this in Tanzania.

Another patient on female ward was severely dehydrated. We were discussing whether we should prescribe her I.V. fluids now, or call for Dr Bike (which could take hours), as she had been suffering from diarrhoea 3-4 times an hour, and hadn't drunk at all today or yesterday as she felt ill. This is dangerous, and she looked very dehydrated. Fortunately, we didn't have to decide whether to prescribe fluids or wait for Dr Bike, or even which fluids to give, as the nusre told us there were no more IV fluids left in the hospital. They had all run out.

We went looking for Dr Bike (couldn't find him) and asked the man in the pharmacy (the pharmacist is also a reverend) if this was true about the fluids. It was. He had asked for more over a week ago, but had not received them because of the hospitals finances, so now there are none. I really hope there are no emergency operations in the next few days.

We return to the ward, bring back some ORS sachets from the pharmacy for the dehydrated woman. She is still refusing to drink any fluids as she feels so sick. We gave her anti-sickness drugs by injection, and hoped that they would work well enough for her to start drinking. This was starting to feel as though it could be very dangerous. What if she gets so dehydrated she loses conciousness? Nothing can be done! Kiwi has heard you can give a coconut IV (and a search of pubmed proves her correct!), though I am not a fan of doing this, nor do we have any coconuts. We leave the woman with the ORS, after trying to get a nurse to explain the importance of her drinking the fluid, even if she doesn't feel like it. I think the message get lost in translation, unfortunately, as we gave the nurse a lengthy talk about why it was important, and she said one sentence to the woman. It was probably something like "The mzungu are nagging me to tell you to drink the water". I just don't understand why the woman doesn't feel thirsty, she is so dehydrated! We leave the ward to find Dr Bike again, perhaps our fourth or fifth search for him today, and we still cannot find him, but thankfully this time he answers his phone when we call, and tells me he will be there right away. 40 Minutes later, he strolls in, tells us that the lady with the stroke will be fine, continue meds, and tells the dehydrated lady she needs to drink more. He then tells us that it is all fine, and leaves. If you are Tanzanian, life seems so simple. Hakuna Matata.

To finish today with some happy news, Choc got engaged today to his long term girlfriend! Fantastic news, which he told us as soon as he had done it, but which he is now being strangely evasive about. I don't know whether being engaged is seen as not-quite-good-enough here (as it isn't marriage) or he is just messing around. Either way, its fantastic news!

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