Elective 38. Catheterisation

Today wasn't as active as yesterday, fortunately, but I still get plenty done. Dolittle is on medical safari today, so I am with Kiwi all day. We start with a ward round with Dr Bike (on a Thursday. Most unusual!) followed by "jobs" created by the ward round. Its like playing at proper little junior doctors. There is an emergency later, and I almost end up donating blood for a patient, then I end up in outpatients where I hear about how wild Africa can be. 

However wild Africa gets, we will still be outside playing with the children most days!

Or the ward round with Dr Bike, the dehydrated lady we saw yesterday was a lot better, sitting up and chatting. This was a wonderful sight, and justified all of the fuss we made yesterday. However, now feeling better, and well enough for us to take a history from her, we find out that she has a fistula, causing her to leak urine over the bed as she cannot hold it is. This means catheterisation goes on the jobs list, along with HIV tests for other patients, some discharge forms, some investigation forms and the removal of a cannula.

At the end of the ward round, again done with blinding speed, Kiwi and I work our way through the resultant jobs. I teach her how to work the HIV test kits here, as she has not seen them before, and she shows me how to insert a catheter into a female patient, something I have never done before.

Kiwi talks me through the catheterisation process, as I lay out my sterile field, clean the patient, lubricate the catheter (thank god I managed to find some lube, its like gold dust here) and slip it into the urethra. Thankfully, Kiwi reminds me to have the other end in a tray before sliding it in, my trousers nearly got very wet with the suddenly draining urine... The balloon is then inflated, to keep the catheter inside the bladder. It is a 30ml capacity balloon (as stated on packaging) but I have only got a 5ml syringe, so there is an absurd back and forth 6 times to fill the balloon, a little unprofesional, but nowhere near as unprofessional as soaking my trosers in urine would be. About 10 nursing students are watching my efforts, so it is lucky that it all went well. The end is clipped with a pair of forceps, as the hospital has no catheter bags, so the nurses will have to remember to release the clip regularly to let the urine drain out. I hope they remember, or this could cause some problems! All in all, it was a lot easier than I  first thought, the main difficulty being in setting up the equipment. I am very happy that my first attempt went well. I can imagine that if it went badly, spraying me in urine or injuring the patient, I wouldn't want to do another. As if is, I would be more they happy, a good thing too, as I will need to do plenty of these as a junior doctor.

There is an emergency C-section going on through the morning, being performed by Chief, on a woman who had severe vaginal bleeding yesterday night in her 37th week with contractions, but now the contractions have stopped and there is no foetal heart (showing the baby is now dead). She was being left to deliver the dead baby naturally overnight, but then started bleeding severely this morning, meaning an operation is now needed. The hospital (as I am sure I have made clear before) has no useful intravenous fluids, and as this woman was bleeding heavily, she needed something to replace all the lost blood. The only clean fluid available around we could think of was someone else's blood. I volunteered to donate, as she is the same blood group as I am, and was told to go to the lab to give my blood. Kiwi and I first went home to get gloves and the supplies to insert a cannula to get the blood out. Once at the lab, however, some relatives had just arrived, and 2 had the same blood group as the patient, so these people would be used. Good news, but I was slightly disappointed that I couldn't help out directly. Perhaps its better if I get to keep my own blood!

In the afternoon, I see a few patients in outpatients with Tim, while Kiwi stays at home and reads (I have run out of books!). One patient in outpatients is a 1 week old baby with vaginal bleeding. This is a perfect example of why medical students and doctors don't deserve much of the praise that is sometimes piled onto them. In the last week, I had either been told by Smartie, or had read whilst here, that newborn girls can have vaginal bleeding, or even discharge milk from their nipples, due to the hormones in the mother at the time of birth. I relay this information to Tim to give to the mother. Her baby has a normal haemoglobin, so she is told to come back if it continues after another week or two. The mother seems happy with Tim's explanation, and Tim seems very impressed with my knowledge. As a medical student, life seems to be about regurgitating information gained from one source to others. This can be information you were told, or read, or just overheard. No-one would be impressed if I relayed someone's name when asked what they were called, and I don't think regurgitating information like this deserves this sort of recognition or respect. Which is a shame, as regurgitating information seems to be one of my key skills!

One of the nurses (Right of picture) bought his daughter in today dressed in a mock-nursing-student's-uniform he had made (see woman on left) to try and help out with the nursing in outpatients. So cute!

After all of the patients have been seen, I stay in outpatients for an hour or so with Tim, talking about Tanzania. This morning I came across a large snake in the back garden of the house on my way to the toilet, and having taken pictures, I showed pictures to Tim. I was told it was a Black Mamba, a very dangerous snake! Very fortunate that I didn't step on it! This leads the topic onto Africa's wild life. I hear there was a cheetah outside Tim's  house last night, supposedly old ones sometimes come to this village to eat dogs, once they are no longer fast enough to catch prey. He reassures me that it will not attack me, and if they can, they will get someone to shoot it. Very recently, a lion was  killed in this village, more towards the main road I arrived on than where I live (fortunately). Lions do attack villagers, though rarely, so if one is roaming around, it will be hunted down.


Despite all this, while lions and hyenas present occasional problems to the village, snakes are a much more common, persistent threat, killing a number of people a year though venomous bites. As with the lions, if a snake is reported around the village, the inhabitants will hunt it down and kill it. Tim relays me some information about the snakes that trouble the village, though I cannot be sure as to whether they are facts or local folk lore! I am told that:


1) Vipers can grow long enough that when they stand erect, they will be taller than a standing man. [can they really stand that erect? Impressive, but must be pretty unstable...]

2) Cars often fight snakes and usually win, which is why some people here have cats in their houses. They can protect from both rats and snakes. [hard to believe a cat can beat a massive snake, but I have heard this before]

3) To catch a snake which is eating chicken eggs, you can boil an egg and leave it out, with the unboiled eggs, so when it is eaten the snake can not crack it once it is ingested, and will writhe around trying to break it until morning, when you can catch it. 

4) If you run into a snake you should either hit it with a stick as it rears up to break it (unless it is a viper, they are strong), grab its tail and swing it around to disorientate it then crack it like a whip to break it (again, not to be done to vipers) or lie down until it leaves so it doesn't see you as a threat and try and bite you. It isn't going to want to eat you, so don't threaten it. [Apart from not being able to distinguish vipers, the only good plan here is the lying down one. No chance am I going to try picking up a snake!]


5) When hunting snakes, bows and arrows are seen as the most effective tool, as a hole won't necessarily kill a snake from a bullet, but an arrow can pin it down or hinder its movement, so it cannot chase you as effectively. 

6) I also heard (possibly tall) tales about vipers surviving being run over by a car, and staying under the car until the end of the journey (they curl up as they are first run over, so often attach to the bottom of the car) when they bite those who open the doors and step out.


I am not sure which of these are true, but I certainly feel that I have a lot more to worry about now than a rabid bat in my toilet. I do miss Batty, though, I haven't seen him in some time. I warned Dolittle and Kiwi about him, who avoid the toilet at night like I do, now. I hope he isn't lonely.


To finish off the evening, we borrow the cat from Dr Bike again, to try and get rid of all the rats who are scampering around the roof. It is absolutely petrified, and after being forcibly carried into our house by one of Chief's sons, it hasn't come out. Chief has two cats, and this is a different one to the one I had last time. We asked Chief if they had names, but he looked surprised, and said "of course not, they are cats"... Silly mzungu...