Elective 39. Dr Who?

Today, a quick ward round with Dr Bike leads to a mysterious patient who seems diagnosable, then Dolittle and I talk with Choc about the set up of the hospital, learning there are no actual people with a medical degree working here at all, just people who have done a 3 year medical diploma (there are two ways to work as a doctor in Tanzania). In the evening, we find the cat that we borrowed yesterday from Chief under a chair, having been hidden there all day. He seems much more confident today than the skittish cat he was yesterday. Dolittle shows us her skills, and it seems she really can talk to animals. The cat spends the evening sitting on the chair in the main room cleaning himself. Since he has been in the house, I haven't  heard the rats moving around in the roof at all. Magic.

Chief visits our house, where we have decided to start off adding some art work to make the place more exciting. He isn't too impressed with the modern skew we have given it...

On the ward round I am with Dr Bike and Dolittle, (as Kiwi has gone on safari today), the lady who has been in the hospital for three weeks with abdominal pain, around her left flank / left upper quadrant (? upper urinary tract infection / kidney problems such as polycystic kidney disease) is finally referred to a large regional  hospital. This is something I have been trying to make happen for over 2 weeks now, and something Dr Bike has been trying to avoid, as this hospital she has been referred to is more than 100 miles away. A long way for someone with no method of transportation, and no money. She was initially diagnosed with nephritis and hos gone though a good number of different diagnoses since then. Today, Dr Bike was asking which antibiotics she has not been on yet, and whether we could try them. This seems absurd, just trying out different things without working out what the problem is, and I say so. I am backed up by Kiwi, and he does admit that he has no idea what the disease is, and reluctantly agrees that we need to refer her to the larger hospital which will have machines such as ultrasound scanners to help diagnose the problem. A success for persistence, but l feel I should have pushed harder, earlier, saving her the cost and trouble of these pointless three weeks in hospital. And they have been pointless, we haven't even been able to reduce her pain as the best regular pain killer we have is paracetamol.

The other interesting patient we see on the ward round is a girl who I admitted yesterday while in outpatients with Tim. She is a very complicated case. She has had a cough for a year now, and her voice sounds like Darth Vaders. Clearly some problem with the throat. Her neck has large lymph nodes in, and in addition to this, she has so much pain in one leg she cannot walk on it, large lymph nodes in inguinal region (above her leg by her groin) and pitting oedema in both legs up to the knees and around her eyes (periorbital odema). She also has a very low blood pressure. This is a very strange mix of symptoms in a 14 year old girl, and all the tests I ordered on her admission (HIV, blood glucose, malaria etc) were negative, but a urine microscopy showed pus cells in the urine (suggesting a UTI). What could she have? This is the exciting thing about medicine - its all detective work!The oedema probably comes from kidney damage (given the pus cells in the urine), but could also be caused by heart problems (though her heart sounds normal). My guessed differentials yesterday were TB, nephrotic syndrome, a strep throat infection (can lead to kidney damage),  some form of immunocompromisation, and even hypothyroidism (large throat and low blood pressure). Lots of ideas, but no solutions. Today gets us no closer to the answers, but Dr Bike wants to send her for an X-ray to look for TB in the lungs. I am not sure how likely this is, as they sound completely normal, but what else can be done? We seem to have used up most of our investigations already. I want to do a full blood count to see the state of her white blood cells (all these lymph nodes up, something funky might be happening). She is unhappy to pay for the expensive test, so I offer to pay the 2 pounds needed. Don't think it is selflessness for one moment. I am very curious as to what is wrong with her, and have been annoyed when previous patients have left without a diagnosis. I like answers! Two pounds is very little to pay for this... I do look forward to my return, though, when there are all sorts of investigations available, and a consultant who (at least seems to) knows everything. Life seems so much simpler, which is odd, as the tests are a lot more complicated.

Talking with Choc in the evening, while waiting for Kiwi to return from her safari, Dolittle and I learn a lot more about the qualifications of those at the hospital. It turns out that no-one here has a medical degree. A few of the doctors, I.e. Dr Bike and Chief have advanced diplomas, meaning they can work as a general doctor, but are not allowed to specialise. I find out that Dr BT is actually in his first year of studying a 3 year medical diploma, so isn't actually a doctor at all. I am not sure whether to be scared that the man running outpatients has less experience than Tim (and me), or relieved that he isn't as hugely incompetent as I thought before, and is instead just a first year student and hasn't learnt very much. However I feel about it, it is still absurd. I also find out that the 'full time anaesthetist' that I was so shocked was away from the hospital so often on safaris, is actually a recently qualified nurse who has done 3 months (so far) of an anaesthetics distance learning course. But is still the go-to-guy for all anaesthetic needs. Anaesthetists here seem to be initially trained as nurses rather than doctors, and then learn anaesthetics as a module. This hospital seems crazy, but at least I am less worried about the anaesthetist leaving the hospital without cover now, as I had assumed he was an important and highly trained person! This does explain why when managing a severe asthma attack some weeks ago, I had stolen the oxygen from the theatres and asked for home to come and help, but all he had to say was to stop using so much oxygen, and to put it back as soon as possible. He isn't incompetent, just hasn't been trained.


Choc also tells us about the corruption in Tanzania, from being asked for money while he was studying his diploma in being a lab-tech to 'help' him pass when exams were marked, to patients being expected to give cash in many government hospitals to doctors and nurses for their time, or to lab techs in order to get tests carried out properly and not 'lost' or 'delayed'. He is clearly not a fan of this system, but this does explain why a number of patients have tried to give me cash in outpatients. I had just assumed they wanted to pay for the drugs they had just been prescribed, but Choc assures me its more likely they were giving a cash thank you to make sure they got the drugs they were prescribed, and to ensure they are seen and treated next time. This hospital is very anti-corruption, but its exceptionally common in many other hospitals. Its a shame that it happens in such a poor country, when the patients cannot even afford their drugs or tests, let alone extra to line the pockets of the health care professionals...

Chief's cat lurks behind the curtains. I think the pretence at being asleep means that we don't bother him, and he can jump on the rats!

In the evening, after Chief's cat comess out to join us, having hidden in our house all day when we assumed she had escaped, Dolittle decides to prove her namesake point by chatting the cat up. I am not sure if she was as seductive as she intended, but there is little doubt that they were engaging in some kind of communication. She mews at the cat, the cat mews back. Back and forth, with different tones. I am very impressed. I am sure the cat was really replying "sorry what did you say" and "I really cannot understand your accent, where are you from", and I know Dolittle had no idea what the cat was 'saying', but it did sound like a conversation. An amazing party trick. I wonder if it works on other animals...