Elective 44. Party time!

Today is my last day in the hospital, which is a sad thought. I have, at times, been looking forward to this day, when I get to go home and see my friends, and get away from all the poor treatments that mean people die who shouldn't, but I am going to really miss all the people here. The day starts with the morning meeting, where the lack of money is being discussed again. Chief is telling the hospital staff that they cannot keep asking the church in the UK which is partnered with this diocese for more money. This does seem to be the natural response "get more money from the UK" whenever money is low, but Chief wants the hospital to be able to sustain itself without the need for outside donations. I think this is a fantastically unselfish (and sensible) way of looking at it, and I am, again, impressed with Chief. On the way back from the morning meeting, where Eggs was wearing another wholly inappropriate shirt, I pass Dr Bike who is, surprise surprise, cleaning his Bike, his morning ritual. I am going to miss all these odd people.

Dr Bike cleaning his bike, still - mercifully wearing a T-shirt with his boxers today.

I start the clinical day with a ward round with Dolittle and Kiwi, without Dr Bike. This as become pretty standard, for us to run ward rounds, but it is scary that I will not be expected (or even qualified) to do this in the UK for quite a few years on my return, but here I am still expected to wander around, prescribing drugs and discharging as I see fit. I am looking forward to being able to shed all this responsibility. The ward round is pretty similar to previous ward rounds, with nothing all that remarkable, but there are patients left who we want to review in the afternoon.

After the ward round is finished, I go to outpatients to have my last stint there, but again, I end up doing some of the consultations on  my own. As I arrived at outpatients after the ward round, Tim was seeing a patient. He told me he thought they had appendicitis and should be admitted. I got him to ask a few questions, and the pain turned out to be in the back, after working a day carrying water back and forth. An examination then showed no pain in the abdomen at all. I don't think this was appendicitis, and Tim admits that he thinks he didn't ask enough questions. It is easier to do this than you might think, as Tanzanians often seem to be quite unconversational, and reply to open questions with one word, or just don't reply at all. It is very strange for me to have a question asked, and nothing said back in return, but it seems pretty normal here. Though perhaps they are so laid back they are taking their time in answering, and preparing an answer for me in an hours time... Either way, this was a very wrong diagnosis, and it is something I am worried will keep troubling me once I have returned to the UK - the knowledge that this will keep happening even though I am not there, and patients are likely to suffer from it.

The consulting desk I use in outpatients. I am not sure how old the building is, but I am assured that it was built by African slaves while the British were in rule

After Tim disappears of on some errand or other, I am left to see the patients (again, fortunately with a nurse to help translate). The first patient I see on my own is yet another teenager from the secondary school who claims he cannot see in the dark. Here, this means they need to be given vitamin A injections, as 'supposedly' vitamin A deficiency causes problems seeing in the dark, and no other symptoms. Admittedly the diet eaten here is not rich in vitamins, but I doubt that all these children who keep coming to see us in OPD are mineral deficient. It is only children from the secondary school which needs more money who come in. The other secondary school in the village which is not 'private' doesn't send anyone in with this complaint. I think that 1) this school provides free medication for the pupils and 2) its just something they tell each other they can do, to get free injections which they must perceive to be helpful. Or perhaps its just cool to go to the doctors. Unfortunately the injections are expensive for the hospital, so I tell him he can have some fish oil and vitamin tablets, which are also very good for him, and they will be fine. He then wants me to write him a note to give him the rest of the day off. This is really like being a GP - before, here in OPD, I have had patients asking for an "ED" note (excused duty) to let them take days off of work. Here, he is clearly not ill enough not to go to school, so I refuse, and he throws a bit of a tantrum, but then leaves when he sees I am not budging. If his symptoms are 'cannot see in the dark' and school finishes around 3PM at the latest, and he lives in the village, I cannot see why he needs time off school. Perhaps I am just a grumpy, vindictive person!

One of the other patients who comes in is called "petrol"  - I assume she got her name from a barrel or a tanker sitting around near the village. She is having a lot of strange symptoms, so I send her for a few random tests including malaria and a urine microscopy. She comes back with schistosomiasis seen in the urine (a wonderful accidental diagnosis). This is a patient who washes in the same water we use to wash, I think I will be very careful to take my medication against this on my return to the UK! 

Among the other people I saw on my own were someone who had somehow managed to put an axe right through their foot while chopping trees, who I admitted to be seen by Dr Bike right away, and a child who had been hit by a motorbike coming into the village, and seemed to have broken an arm - again referred onto Dr Bike right away. Later on, Tim was preparing the axe-foot man to have the wound cleaned and stitched up in the minor operations room (fortunately the axe had gone between tendons for the toes, somehow avoiding causing too much damage). I wasn't there, but Tim ran and fetched me after he injected the lignocaine into the area to prepare it for Dr Bike (who, as usual, was nowhere to be seen. I have no idea why it was being prepared now) and the man started jerking around uncontrollably. It is very important not to inject lignocaine into a vein or artery, but only into the muscle, as otherwise it can be deadly. This was something Tim was afraid of when he ran to get me, but I wouldn't have thought it would present with convulsions. By the time he had found me and we had run back, the man just seemed to be asleep, all vital signs normal. It turned out that the man had epilepsy (which I hadn't asked about - oops) and had had a random epileptic fit on the table, scaring the bejesus out of Tim. In Tanzania, the epilepsy is very poorly controlled, with intermittent drug supply. This is obviously bad, but a lot better than injecting lignocaine into a vein!

Kiwi, Dolittle and I went back to the ward to review some patients in the afternoon. As Kiwi went into the ward to listen to a woman's chest (something we were unable to do in the morning as we had forgotten our stethoscopes) Dolittle and I were reviewing the notes in the nurses station. Kiwi thought she could hear fine crepitations (crackles) in the base of one lung, but wasn't sure, so came to get us from the nurses station for a second opinion. As we went back into the ward to listen to this ladies chest, we saw there was one lady sitting on the bed in the corner, her top rolled up as though someone had been listening to her lungs, and two others sitting on the bed next to her, one of whom was currently taking her top off (no bras used in Tanzania). Dolittle and I were confused as to which the patient was we were meant to be listening to, and as Kiwi had gone to amend the notes, we beckoned a nurse over to help translate. It turned out the women weren't just undressing because my sexy self had entered the room (still hopeful, one day...), but they all wanted an examination. One was the one Kiwi had been listening to, and the one who had now finished undressing (completely) was a friend, who said she was suffering from chest pain, and chest tightness. We found the chest pain was also radiating to the back. A sneaky way of avoiding paying the hospital fees to be seen in outpatients, but I oblige and listen to her lungs and heart. Surprisingly, I find a systolic murmur on listening to her heart, likely due to aortic stenosis. I don't know if this what is causing her complaint (not very likely) or is something she has always had due to something like rheumatic heart disease. Dolittle and Kiwi plan to check on her tomorrow, as she seemed to be relatively well apart from this.

The ward has a hand washing bucket, which would be high-tec if the water didn't have as much infection in it as the patients do!

Before going to the leaving party that is being thrown for me in the evening by the hospital, I buy some Tanzanian spirit for what is effectively £2.50 a bottle. For prices like that it doesn't need to be great quality! I also have a few beers with Kiwi and Dolittle as my own going-away party. Our cook joins us, and offers to plait my hair, Tanzanian style, into corn rows. I consent, but regret it - it is very painful having it all tugged into position! I am glad I am not a girl... I then sidle off to Tim's house for dinner, taking Dolittle and Kiwi with me, letting our cook rest tonight. Another delicious feast and some touching goodbyes.

At the party thrown for me leaving, I am expected to sit at the front of the room where the morning meetings are carried out, while others sit around me. I sit there as people make moving speeches about me and my time here. Doctors and nurses from OPD, male ward, female ward, children's ward, maternity, the group that does medical safaris and even Smiley - the friendly porter who I befriended, despite the fact we cannot understand each each other, all said some lovely things about me and my commitment, which were translated by Chief, who was sitting nearby. I was then expected to give a speech, and said some really lovely things about the family attitude of the hospital and how sad I was to be leaving, which were all true. I was given a wooden carving, some Tanzanian clothing and a certificate in a frame for all of my help. I feel bad that the hospital, with no money, spent all this on me, but also very touched. Choc is the DJ again for this, bringing his music from his house with his generator, and playing me Christian-songs-with-people-in-white-dancing-in-the-background. Not something that would be my first choice of music normally, but Tanzanian, and the whole mood, everyone saying lovely things about me and the gifts make me upset to be leaving. I really hope that my feelings towards this wonderful community don't dampen down over time, once I have come home.

A suitably blurry image of the beautiful art we left behind at the house to decorate it for the next mzungu.