Elective 41. Its a trap!

I am woken at 7.30, still feeling under the weather, by a car sent by the reverend who had invited me to a choir competition some time ago. This was the reverend who had invited me to dinner. I remembered the date as being yesterday, and assumed I had missed it by going on the safari. As the car arrived, I just guessed that I had got the dates wrong, and quickly changed to get into the car. Once I was in the car, I was told that I was being taken to another Sunday service. This meant that I had to sit through another five hours of Swahili preaching. I think they have sensed (with their Christian-sense [what else]) that I am not religious, and are either punishing me, or trying to convert Me. On the journey home, I buy a papaya for the house, and get a marriage proposal from one of the college students taking bible studies, though a translator is needed for this proposal.

The church service had just started by the time I arrived and snuck in.

The service I saw was very similar to before, but now I had seen it once before, it has lost a lot of its novelty and was just a bit boring. It has succeeded in giving my time in Tanzania (now drawing to a close) a cyclical feel to it though. I started with events such as a medical safari and the Sunday service, run by the bishop in Tanzanian, and now I finish with them. On the way home, after picking up a papaya at the local market, I am in a 4X4 owned by the bishop with a couple of the students who study bible studies who need to come to the village the hospital is in. They ask me more and more personal questions, through the driver who can talk some english, moving from whether I was married, though what I would do if I married someone here (stay or take them home) all the way to whether I would marry one of them (they didn't seem too fussed about which one). Very surreal, and I unfortunately had to say no. The first time someone has propositioned me, but I don'e exactly feel all that special...

The church has a lot of singing from the choirs who were down in Tanzania for the choir competition, which I missed yesterday, from cultural songs to break dancing.

Once home I do my last clothes wash. I will be looking forward to having washing machines and clothes pegs again. As I am picking my clothes out of the dust under the clothes line where they were immediately blown after putting them up, the bible studies student who approached me to chat with after the failed football game on Sunday arrives with some of his disciples. I mean friends. I don't know why he is here, I do remember he said he would come around, though I don't think he ever said why. After the 5 hour service this morning, I am almost hoping that he will ask if I am religious (I am a touch annoyed with the church at the moment and would welcome a theological debate) but he can either sense my hidden plan (damn Christian-sense) or cannot remember himself why he came, as less than five minutes after sitting down in our living room, he thanks me and leaves. I still don't understand Tanzanians one bit. It is a 20-30 minute one way walk for him and his friends from the main part of the village to where I live, and there is nothing else down this end of the village...

Following his departure, two nurses arrive to live with us from other areas of Tanzania. One is acting as an external examiner for the nursing school first year exams, while the other is acting as a teacher of psychiatry for the second year nursing students. Having seen no mental health diagnoses or treatment here at all, this is a good sign. They both seem friendly fun people, but the hospital has obviously made a lot more effort in making their room nice than it did for ours. Jealous! While the nurses are moving in, I find Dolittle outside, clucking at Chief's chickens who wander around this part of the village, pecking at the dirt and making him eggs. That girl is either very strange, or has a unique talent. Perhaps a bit of both.

In other news, we are currently running very low on supplies. Our bottled water supplied by the hospital ran out 2 days ago (have been buying our own), and the toilet paper has run out, we are using my emergency supply. The last two days meals have been pasta. Blergh. The nurses have been given their own bottled water, loo paper and are given their own meals in their rooms from the nursing school. I guess they want to treat the external examiner as well as possible, to get the best deal for their students. This does work to our favour with regards to the washing water though. We haven't had water to wash in for a couple of days, but now they have arrived, more water is bought to the house from the lake, letting me do my laundry. Hopefully our other supplies will be restocked soon!

The new flat mate adult nurses have their room done up as above, with sickly sweet pictures and cuddly animals. I would laugh, if I wasn't so jealous!

Elective 40. Rabies planes and miracles.

Today started off by being woken up at 5am, freezing cold, with rain pouring into my room through my holes which serve as windows. The lovely rich smell and new sensation of being cold didn't stay pleasant for long, as I soon realised I couldn't close my windows (broken bits of blinds made of glass), and had to move my clothes away from the windows to stop them from getting any wetter. I made a nest in my bed of them, as there are no blankets. At a more civilised hour (6.30), we were picked up by the four by four (borrowed from the school, remember the hospital still has no transportation of its own) and driven for 2 hours to a lone hut. I was not feeling too well this morning so dosed up on paracetamol and ibuprofen before the journey. After arriving at this single hut, by a patch of ground used as an airstrip, Kiwi flew to another location in a plane, while Dolittle and I helped out at this lone hut. This way we were helping at two medical safaris as a group. I am not sure how much use we were. Before we left the safari, a 12 year old boy was bought to us who had had a large bite taken out of his face by a "Crazy, ill dog". We managed to get him onto the plane to take him to a large hospital. Hugely lucky that it arrived at the right time I was feeling a lot worse for the journey home, which was not helped by being squashed onto a seat with far too many people, and having Dr BT fall asleep onto me throughout he journey. I had a very high temperature, perhaps sitting in the sun for so long started leading me towards sunstroke.

The lone hut that we carry the clinic out in, in the middle of nothing, under a tree. A very strange location, but hundreds of people turn up over the day, so clearly a popular location!

To start at the start of the story, the schools 4x4 now doesn't have a working battery, so to start the journey we have to have four people push it to a roll, when the engine can then be started. Despite this little difficulty at the start, the rest of the journey is great, and the journey was very scenic. We admired the beautiful scenery, which was mostly sparse scrubland (beautiful in its emptiness) with the occasional person walking, seemingly hours from the nearest habitation, and occasional villages where people spilt from the houses to watch the car (a real rarity this deep into rural Africa) go by. My favourite location was a vast lake bed which we sped across, where the mornings rain had caused slight puddling in patches. It was just a vast empty space. The road all the way was an uneven dirt track, which couldn't have been traversed by a normal car, often Covered in obstacles such as cattle being herded across, and chopped down trees or bushes. One of these spiky bushes proved too much for the 4X4 and we had to stop for 30 minutes to fix a puncture.

A view across the huge dried out lake bed, you can just about see a hill in the very distance on the left. Everything here is so vast!

Once we got there, the same pilot who flew me on safari in my first week was waiting, so Kiwi took a plane with him, like I did 5 weeks ago (it sounds so long, yet feels so recent), and I stayed with the 4X4 at the hut with Dolittle.

The preacher sings songs with fun actions with the children who are waiting, before we can start the clinic

Our day starts off positively, there is no person playing phone music through a megaphone, and a preacher is instead employed in making lots of noise. Despite all of the people waiting to be checked by us, he needs to give a sermon to the adults, then sing with the children before we can go ahead. I love all the African songs, they always sound so happy! When we start, we are  weighing babies and pregnant women, plotting their heights and weights on their respective charts, while a nurse sorts the charts into those needing a vaccine and there who don't after we have filled them in. The weighing is done under a tree, which is close to the hut (from where the first picture was taken) as the hut is used for antenatal examinations and vaccines. This does mean we are left in the sun for a long time. After a few hours, interrupted only by being asked if we are happy to eat the lunch provided by the village (Yes. Of course. Its rute to turn down food, and I am getting pretty hungry), the supply of people needing to be weighed begins to peter out, and I am asked to go and help with the antenatal checks in the hut.

I head over to the hut where a nurse is examining pregnant ladies inside. A large single window in the side means each lady covers it over from the outside with her kanga before entering, to give her privacy during the examination. I examined a few women's bellies, checking the position of the foetus (head or feet first), foetal heart rate and so on, while the nurse asked the questions and gave HIV tests and took haemoglobin measurements with a little meter. After a few women had been examined, the nurse just left, not saying anything. I waited a minute, hoping she would come back through the door, but when the next woman started hanging her kanga outside the window, I left the hut to stand outside, so I didn't end up expected to examine women on my own. I cannot talk nearly enough Swahili! I stood outside the hut for 15 minutes or so, and when the nurse didn't return, I went to sit with Dolittle by the scales. We waited for over an hour, talking about meaningless things such as what animal we would like to be (swift for me, butterfly for her), all the while surrounded by waiting children and pregnant ladies sitting on the (sun drenched) ground. These people intermittently tried to communicate with us (likely saying, please give me my card back so l can go home) but we didn't understand.

The equipment we are using doesn't give very accurate readings - this scale which gives results in Kg has to be used to weigh little babies, meaning any results cannot be taken too seriously. I love the fact that it says 'made in west Germany' at the top, showing its age... 

After the nurses come back from what it turns out was the lunch break (clearly no mzungu invited), we seem to be surplus to requirements, and are left by the scales, weighing a straggler every 20 minutes or so, but mainly sitting around. Very boring, so we keep chatting, though I am secretly pleased, as I am starting to feel very unwell, sick and headache-y (though I feel I have no right to complain with all the very ill-looking people around).

After a few hours, as things are quietening down, a motorbike speeds up to the hut, and all of the mothers and children crowd around it. Assuming they are all just interested in the motorbike, a rarity this far out, we stay sitting under our tree chatting in the shade, until a man rans up "Doctor! Doctor! Emergency". I don't correct the 'doctor' as I normally would (no point wasting time) and as there are only nurses at this outreach clinic (Dr BT went on the plane with Kiwi), we hurry across to the motorbike, through the crowd of women and children, to find a 12 year boy missing a chunk bigger than his fist from his cheek. The hole starts at the right corner of his mouth, and saliva is dribbling out, uncontrolled, stained red with the blood. The fatty tissue inside the cleaks is clearly visible. We are both clearly mesmerised by this sudden appearance, as the man who initially called us over decides to go on, and says "he was bitten by a dog" I ask if the dog is anyone's pet (thinking rabies) and he replies that it used to be, but now it is crazy and has gone of on its own (I am definitely thinking rabies now!) If only Dolittle had been around to talk the dog out of its craziness! We beacon the kid over to the hut, and as we are walking there, to see what supplies are available, we hear the plane in the distance on its way back with Kiwi and Dr BT. The timing couldn't be any better!

The injured boy is loaded onto the plane while the locals watch. No such thing as privacy in Tanzania! 

I tell Dolittle to go to the plane once it lands to ask about supplies and space for passenger (clearly the boy cannot stay here), and I take the child to the hut for initial treatment (I can be very bossy!). I ask the nurses there if they have any saline/sterile water/pain relief (no to all), so the boys father ends up washing our the wound with our bottled drinking water (more sterile than the lake water), and soap powder. The initial treatment of rabies needs the wound to be washed thoroughly as fast as possible. Since I first saw him, and all through the washing of his (gaping) wound with soapy water, the boy hasn't flinched, said a word, or shed a tear. He is either very resilient (this wouldn't surprise me after some of the things I have seen) or (more likely) is in shock. He has had a large chunk of his face bitten off... After the wound is washed and all our drinking water used up, we take him to the plane, where he is efficiently bundled in with the man who bought him on the motorbike (a friend of his father [family goes a long way in Tanzania]) and flown off to the 'major city' hospital which will hopefully have the rabies vaccine and immunoglobulin needed (our hospital certainly doesn't, hence the need to send him elsewhere). Before leaving, the pilot thanks God that he arrived just at the right time. I agree, it is a wonderful coincidence, and we are so fortunate that not only was the monthly medical visit in the area when the boy was bitten, but there was a plane nearby as well. Bit I think that, if God had his finger in this, then would he let a 12 year old have part of his face bitten off? If it can be repaired, there is going to be pretty horrific permanent scars and loss of function. I do know there are no plastic surgeons where he was sent...

After all this excitement is over, I realise l am feeling a lot more ill, but we soon depart for home. The journey is awful, I can feel every jolt in my super sensitive brain case, I feel very sick and cannot take my eyes from the road. In addition to all of this, I also have Dr BT falling asleep on my shoulder the whole way (not very nice) but I suppose I am fortunate to have a lift. The boy and the man who went off to the major hospital have no way of getting back to their village. No money for transport. Hopefully they can wait a month and then come back on the plane when it next visits.

Once I arrive home at 7, making this a 12 hour working Saturday (why did we volunteer to do this!), I fall asleep on the sofa while Kiwi and Dolittle supply me with water and pain killers. I couldn't ask for better flat mates. Its just sad that I had such a rough end to a day with such excitement.

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...

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...

Elective 37. I am emergency aid

Today starts with attending the English service at the Christian chapel with Kiwi and Dolittle, after I was pointedly asked yesterday why I had not gone recently by the reverend who lives across from my house. I don't want him to be upset, and though Sporty and Smartie avoided it after he had a stool-over-head waving shouting and screaming "power of the Anglican church" sermon, I haven't really turned up very much so had nothing to lose from showing the service to my new guests. After the service comes the morning meeting. Three deaths are reported from yesterday, fortunately none of them the patients I was trying to look after on the ward, and then we end up doing Dr Bike's ward round again, and in the evening have to try and work out how to treat two seriously ill patients, despite the hospitals lack of supplies. Here, I actually get a chance to make a difference.

The 3 deaths that were reported in the morning meeting were of two still born babies, and an 8 year old child:

The first was that of a mother who came into hospital in the advanced stages of labour at about 32 weeks, but baby had no foetal heart rate. The child was reportedly born with 'severe lacerations' and the reason for the labour was expected to be because the child had died. Abortion is illegal in Tanzania, but without saying as such, it was clear that the nurses at the morning meeting felt that this woman had had the baby injured in her home village so it would be aborted. Just because something is made illegal, it doesn't mean that people won't do it, and in much less safe situations than would be possible at a hospital.

The second death is another still born baby, one of a mother who has been on the maternity ward for about a week waiting to give birth. Unfortunately, when she came to the doctors to tell them she was having contractions, her baby had already died (no foetal heart rate), meaning there is nothing that can be done other than wait for the dead baby to be 'born'. This time, it seemed that the mother had been having contractions for about 8 hours, but had not presented to the doctors when they started, due to the common belief among the women that if they tell the doctors they have started labour and it doesn't progress fast enough, they will have a C-section, so by leaving it as late as possible, they avoid C-section. By leaving it this late, the baby, which was born with the chord wrapped around its neck, was not monitored in the early stages of the labour, and so the distress which would have lead to an emergency C- section being carried out was not detected, which is the main reason for the mother to be in hospital in the first place. Another example of where health education would make a big difference to people's outcomes in hospital.

The final death was an 8 year old child, admitted around 5PM with a haemoglobin of 6g/dl and with all of the clinical signs of severe anaemia. A blood transfusion was ordered for her, and the doctor left her while the lab tec was called in from his home to carry out the cross match (make sure the relatives blood is the correct group). By the time that everyone had had their dinner, and the blood had been typed, the doctor returned at 12.30AM to carry out the transfusion, only to find the child dead. It seems that no-one had come to see how the child was in all of that time. The other two deaths mentioned in the morning meeting were un-preventable. This child should have received their treatment much more promptly. The reasons for the death (in my opinion) either seem to weigh in at incompetence or negligence, but at the meeting, the facts are given, and the case is forgotten, left as a mark in the 'deaths' column in the meeting paperwork. If issues like this are never discussed, then people will never change their practice and things won't get better.

After such a depressing start to the day, Dr Bike is too busy to do a ward round this morning, so proposes that we do it (Kiwi, Dolittle and me), and then explain what we think should be done with each patient when we talk with him later, making it more efficient. On the ward round, it appears that no-one is dying, but a number of patients need relatively urgent reviews by Dr Bike, so we mark these down. We then spend some time playing with a tube of bubble mixture Kiwi has bought with her in the children's ward to cheer up patients and parents. The children start off petrified of the bubbles, and the parents curious, many having obviously never seen these sort of things before. The children start off hiding behind parents and beds of the terrifying mzungu, while the parents are sitting, trying to catch the bubbles, and rubbing their hands or sniffing their fingers afterwards in bemused curiosity. I think it was a wonderful idea to bring  the bubbles, and the children rapidly grew less afraid and more amazed, saying "Majica" (i assume this means magic) as they chased the bubbles around the room. We left the ward very popular that morning, with the children still begging us to keep waving our magic wand.

Kiwi blows bubbles for the children in children's ward. Holly loved trying to catch them, and was full of energy, seeing as she was the only non-sick child on the ward

We found Dr Bike in theatre, removing a subcutaneous lump, though as we were waiting for him to finish, an emergency C-section came in, followed by the plan to change the dressings of the patient with the large abscess on his face (which had been drained, but needed daily dressing changes). It seemed that Dr Bike was going to be some time in theatre, so we returned to the house for a late lunch. During a good chat after lunch, it transpired that Kiwi and Dolittle had felt that, on my first day, they had thought I was a genius, having studied medicine for less time than them, but still able to prescribe sensibly, and knowing all of the correct doses. Today they have unfortunately already realised that there are a few very common diseases, and only about five common drugs. It is a shame that that illusion was shattered so quickly, but at least I looked like a genius for a day!

I return to the ward (alone, as Kiwi and Dolittle want a rest as it is currently very hot) at around the time I would have thought Dr Bike would have finished the surgeries, to find he has left the theatre already. I decide to go to the children's ward to collect the notes for the patients he needs to see together, in the hope he is there, or heading there soon. As I arrive, I am beckoned over by one of the children's parents. The nurses don't seen too bothered by the parents distress, but I persuade one to come and translate for me. The parents think their child has gotten very ill over the last couple of hours, and is getting worse...

This ill baby is about 10 months old, and was admitted with a diagnosis of pneumonia,  gastroenteritis and malaria (it is common for the admitting doctor to try and cover all the bases by diagnosing everything). Tests had shown there was no malaria parasites in the blood, we couldn't listen to the lungs, as she cried whenever we mzungu were near, and has had diarrhoea and vomiting for days in the ward. Last night the doctor on call was called to the ward, as she was having a convulsion. The problem with children crying whenever we try and examine them, or even turn up at the bedside, is so common we don't think about it any more. All the babies here are scared of us, or are a little bit racist. We call it mzungu fever, and it ruins examinations.

In summary, this child has been very sick, though we didn't know what with (assumed gastroenteritis) and now seemed a lot sicker. She was one of the patients we had really wanted Dr Bike to see, though now it seemed a little too late... The baby looked very ill. She was lying on her back in the bed, with her eyes slightly open and not moving at all. I shook her (no response at all), took her pulse ( present but fast, thank god she isn't dead) then quickly examined her body. She had a huge belly, which was bloating out far more than it had been this morning, and sounded resonant on percussion. There were no other obvious problems. The thing that troubled me most was that in all this time with the scary mzungu examining her, the baby hadn't even stirred. This was the child that, for the past few days, we hadn't even been able to listen to her lungs as she was crying so hard every time a mzungu was near her. She was clearly sick. The parents told me that, since the morning when we had seen her (the time was now about 4PM), she had had no more diarrhoea, and had not vomited.

Dr Bike spent most of today in theatre carrying out a number of operations. The theatre is much better kitted out than the rest of the hospital!

I was very worried, and had no idea what was wrong with the baby. Are her bowels obstructed? Or would this cause vomiting? I tried calling Dr Bike four times, but he didn't pick up. Starting to get really worried, I decided to go and look for a doctor to fix things for me. On my way out of the ward, I run into Kiwi and Dolittle, who had felt guilty and come to help me (something I really appreciated right now). I bought them up to date quickly, and we then split up to search the hospital for someone to help us. We found no doctors, but found that the Dr on call was Dr BT. I am not exactly confident of his skill set (he saw the child who died last night of anaemia, who was left for hours without the transfusion) so we decided to get Dr Bike from his house. After all, he still had his ward round to do.

I knocked on his door to find him eating dinner. I explained that there was an emergency, but he said he was busy eating, and would come after he had finished his food. I was sure I wouldn't be able to get him to come in any faster. Dolittle and I head back to the ward, while Kiwi goes back to our house to get her stethoscope, as none of us currently have one on us.

Once back at the ward, I show Dolittle the baby, and Dolittle examines her as well. This time, as soon as Dolittle's fingers touch the baby's head, she stirs and looks around, sneezes in my face (thats another infection coming my way), then lets out a fart lasting for over 10 seconds. I have never heard so much wind in one go, and the abdomen visibly shrinks as she is farting. Not back to normal, but back to a much less scary size. Seemingly relieved, the baby shifts around a little then closes her eyes, and end to our 'emergency' which happens just in time for Kiwi to hurry through the door with her stethoscope in her hand. 


As it terms out, during our search of the hospital for a doctor, I was telling wings how the last time I looked for a doctor in an emergency here, for a child who was crying and writhing with abdominal pain, it turned out to he trapped wind. I was joking about what it would make me look like if this was trapped wind again. How embarrassing for it to happen twice! Perhaps the resonance to percussion should have warned me of this possibility.

Needless to say, when Dr Bike arrived, he seemed a little put out it didn't seem to be the emergency we had made out. Despite the 'downgrading' of this 'life-threatening wind', the child still looked very sick. Dr Bike said that bowel movement can be disturbed  by electrolyte dis-balance, so we should give Ringers Lactate to the child to correct this problem (no capacity to measure electrolytes leaves a lot to guess work). Dr Bike then refused to see the other patients on the ward, and left to go home. A little irresponsible to be in a strop, but I cannot blame him. He had been working in theatre all day, and wasn't ever the doctor on call for us to be troubling.

We decided we should go and check on the other patients who worried us in the morning, but checking out female ward led to new worries. The woman we tried to convince to drink water yesterday and this morning has drunk only 200ml over these two days (we know this as we were providing her with all her water) whilst having diarrhoea every couple of hours. She complained she was too sick feeling to drink water this morning, so we gave her a promethazine injection. Since this morning, she still has not drunk any water, and now does not talk to us or the nurses, she is just lying there, grunting, and weak. She has a thready pulse and a very low blood pressure. She is clearly not well. At this time, the nurse comes in from children's ward to remind us that the Ringers Lactate that Dr Bike ordered is still not in stock, and the only fluids the hospital has is 5% dextrose. This is because boxes and boxes of it were bought for the urologist to use as a flush during the TURPs. It is no good for rehydrating patients. Great, the child can wait. A very sick woman here who really needs fluid, and no available fluids (the 5% dextrose could be dangerous). This is exactly what I didn't want to happen yesterday. The nursing students on the ward were not helpful at all, refusing to trouble her by asking her to try and sit up and drink (as she seemed sleepy), and saying they wouldn't give her fluids if we found them, as the cannula were in short supply on the ward, and they didn't want to wake her from her sleep. The opposite of the child who I was talking about - there the parents were worried and it turned out to be nothing. Here no-one is worried, and I am very sure that something terrible is happening.


Due to the lack of fluids, this clearly needed some kind of Tanzanian-Doctor-Magic to help us, and we decided it would be unfair to bother Dr Bike again. As it was an emergency, we decided to go straight to Chief's home, catching him just as he was getting on his motorbike. I explained the problem, and Chief was happy to come right away and help (right away here, meaning after he had told us about the historical value of the Site of the hospital, and the need to preserve it, but hey, this is Tanzania). I apologised for interrupting his evening, but Chief replied "This is someone's life, this will always be more important'. I love Chief.

I rode on the back of chiefs motorbike the 100 meters between his house and the hospital (why walk when you can ride) arriving at the same time as Kiwi and Dolittle who walked. When at the hospital, Chief quickly examined the woman. His bedside manner is fantastic, talking slowly and gently with the woman, trying to get her to respond. He quickly reached the same conclusion that we did. It is fortunate that I am not embarrassed a third time by calling doctors to patients who are not such, but very unfortunate for the patient, who is very ill.


Chief then spends some time calling up other members of the hospital, trying to get some fluid that is not 5% dextrose, that can be put into the woman, while Kiwi, Dolittle and I wander the wards, checking in cupboards for a single bottle of fluids that has been left there and forgotten that we could use. In maternity we find that they did have one bottle as an emergency, but it had been taken away 30 Minutes ago for children's ward, for the farting baby, by an unusually efficient nurse (annoyingly efficient  now!) So we didn't need to worry about the farting baby any more, but we still needed fluid for the woman.

The search goes on for an awfully long time, but Chief is very persistent. Eventually, 500ml of Ringers Lactate is found, after chief calls the chief nurse in from home to unlock the decontamination room to look in there. I have no idea why it was stored in what is basically a big cleaning cupboard, but very thankful that it was found. We take this, with one of the many 5% dextrose bottles to the patient, and give them both to the very efficient nurse (a real nurse, rather than a nursing student, and it really shows). This is clearly someone we can trust to insert a cannula and run the fluid, and fast. We really would want to give more than a litre, but it is better than nothing. As the efficient nurse sets up the fluid, the patient still hasn't moved and doesn't interact or even flinch away as the cannula is pushed through her skin. If she gets better (and I really hope she does) I will feel that we really contributed to her care. If she gets worse, or dies, at least we did all we could. The whole episode was very exciting, and hopefully similar to that of the job of a junior doctor. Recognising sick patients (hopefully not flatulent patients) and getting appropriate help. I love it!