My breasts are examined

Hi,


This is a slightly misleading title, as I don't actually have breasts, but this week I do get to don a pair of fake-boobs and have my other class mates examine me. This is good practice for a beast cancer clinic I sit in on later in the week. I have a number of lectures this, and every week, a lot more than in my third year, which is a shame but it is nice to be spoon-fed information again. I am also assessed on my elective this week, by having to present a poster based around my experience there. All in all, quite a quiet week.


In our teaching sessions, we are often taught how to do an examination or procedure then expected to practice it, such as abdominal examinations or auscultating the heart with a stethoscope. This session was a about breast examinations, and as they had decided that letting us practice on the female members of our class was not the best idea (probably a good idea, as it could get awkward), so had a pair of fake breasts for someone to put on, and let people examine them. These breasts had a range of strange lumps in them that the people examining could try and find. When the seminar leader asked if anyone wanted to be the person wearing them, and be examined, no-one volunteered. Secretly I really wanted to, but I thought it would look strange if I jumped up straight away shouting "Me! Me!", and was relieved with the couple of seconds of silence that followed the question meaning I could volunteer while looking as though I was doing it to save anyone else from having to do it. I do not secretly want to have breasts (but if it was a secret, would I tell you?) but I love wearing fancy dress to parties, and being examined by 20 people is a great way to learn the examination yourself. Win win! The only awkward part came when it was an ex-girlfriend's turn, and she was clearly not impressed that she she had to examine my breasts. Awkwardness aside, a great learning experience, though I am definitely not confident that I could spot small lumps at all.


The breast cancer clinic I did the day after this session was very useful in putting these skills to practice. I was with a male consultant, and so he made sure that there was a female nurse in with him every time he examined a patient as a 'chaperone'. With what is seen as an intimate examination, I suppose its sensible not to take risks, and have women claiming that a doctor and a medical student molested them in an examination room. It is a bit of a shame that female doctors are trusted not to molest people, and hence do not need a chaperone, while male doctors do, but unfortunately I suppose that this is based on history, and the fact that most of the doctors who do behave in a sexually inappropriate way are men. Anyway, it turned out that carrying out these examinations on real breasts and feeling real lumps was a lot easier than it was on the foam breasts. While breasts could be examined to exclude breast cancer, many of the women there were because they were being treated, or they had presented to the GP with a lump they had found in their own breast and been referred. This made things very useful, as they could say where the lump was.

The type of examination breasts I wore. Not the most realistic things, but probably a good idea to get used to these, as they will be used in my examinations

All of the lectures that we are having  this year are starting to become a little boring. I thought I had escaped lectures after leaving my 2nd year, then had a year of them in my intercalated degree, now have another year with quite a few in them now. My third year didn't have nearly this many in it. I hope its just the oncology rotation that will be like this, and the other rotations will have a lot less lectures.They are no bad thing, I mean being told the information is better than the third year where you constantly had to seek it out while at the hospital, but I was looking forward to getting back on the wards and practising clinical medicine. I suppose I have the rest of my life to enjoy that, so perhaps I should enjoy the more laid back pace of the lectures while I can. This week we had three, yes three, lectures on how NOT to prescribe chemotherapy. I know this is a serious topic, as poor prescriptions will kill people (it is a toxic drug after all), but we are not expected (or even allowed) to prescribe chemotherapy as a foundation years doctor, and then hopefully we would be taught properly if we became an oncology registrar? Perhaps I am just feeling grumpy as I need to get up for lectures at 9 again.


At the end of this week, I had the assessment for my elective. I had to sum up my 6 amazing weeks onto one A1 sheet of paper. If I was to say my elective was life-changing it wouldn't really be much of an overstatement, but this isn't really the sort of thing you can write on an assessed poster. Working out how to fit all of the experiences down into such a small space was (almost) harder than eating the disgusting sweet-spaghetti (which I made sure not to mention). Despite all the work, the presentation went very differently to how I expected it to. I got one of the academic professors assessing mine (luck of the draw) and instead of asking all around the subject, as I was expecting, I just got asked academic question after academic question. What were the three main forms of malaria after Plasmodium falciparum? (Fortunate I did that immunology degree, really!), If a young patient presented with low heart rate low blood pressure what would the most likely diagnosis be? (No idea with that one, snake bite?) and so on. I do not think I performed very well at all, unfortunately, but what can you do. Still do not have my mark back, but I would hope that I would have been told by now if I had failed. One more assessment out of the way, and one step closer to being a doctor... 

The Hospice

Hi,


This week I spend a few days working in a hospice as part of my oncology rotation, which is a fantastic experience, being completely different to how I expected. I also attend a gynaecological cancer clinic, which is a long drive away, and spend a day in a GP practice where my assigned GP wants me to run the consultations. I am not sure if I am ready for that here at all, despite doing effectively the same thing in Tanzania all on my own...


The visit to the hospice is intended to let us get some experience of... well.. hospices. The medical school is very keen on showing us lots of out-of-hospital medicine, and I agree, I think it is a good idea to see as much of the varied world of medicine as possible. Not just to let us to plan our careers, but to help us understand how each speciality works when we are specialists ourselves. It is unlikely that a surgeon will be visiting hospices to learn about them once working, but could be referring patients to their care.


The hospice was lovely, and very different to what I had expected a hospice to be like. I have no idea why, but I had imagined  a hospice to be a little like an old people's home, with dying people sitting in their rooms, or if they could manage it, in large chairs in a circle, not doing very much. This perception was proven wrong from the moment I stepped into the warm, friendly and very professional reception. No strange and stuffy nursing-home-esque furnishings here. The staff were very friendly and accommodating, and despite the clinical feel to the building (I suppose it plays many roles similar to a hospital) it felt a lot more... fuzzy? We had talks from doctors, nurses, volunteers, carers and patients and talked to a number of patients who had come here. While we were learning about the different pain killing medication that was prescribed, we were asked if anyone wanted to try out one of the sublingual tablets. They said 'morphine' on the packet, but we were assured they were placebos. No-one seemed interested, after his talks on their sometimes nasty flavour, but he then said that they were wild berry flavour. Sounds delicious, right? I thought so, as I volunteered straight away to have one. Having put it in my mouth (don't worry, they did turn out to be placebos) there was just a bit of a bitter taste, and certainly no wild berry flavour... It also lasted for over a minute, rather than the 10 seconds to dissolve that he had taught us. I asked him about the flavour, and just said "yes, well, I lied... Otherwise no-one would have had one!" Are doctors allowed to lie?

Sublingual tablets do a similar job to the "pain killing lollipop" that Jade Goody was often seen sucking, which is meant to provide pain killing medication through the mucosa of the mouth.

I had always assumed that hospices were for people who were dying, so they could spend their final days (should they be too ill to go home) in a nicer environment than a hospital, while still receiving the same standard of care. This is one of the roles for the hospice, but it also fulfils many other roles as well. Many of the patients who I saw were not there 'to die', rather because they were ill, and needed somewhere to be cared for carefully for a month, but not so ill as to need to be in an intensive setting such as a hospital. The hospice is a much nicer environment, so attracts this sort of care. Unfortunately the hospice is also not NHS run, but still free to patients. It has about 20% of its cost paid for by the NHS, with the remaining cost sought through fund raisers and donations. I remember as part of the RAG at my medical school a couple of years ago, dressing up in a giant mascot costume and fund raising for the hospice at a shopping centre with some other students in scrubs. Fantastic fun, until the whole thing became far too hot. While I was at the hospice, they had had to close their activities centre, which was a big sociable room where those staying there could relax, talk, and partake in activities organised for them (yes, I know it sounds a little like a nursing home!) All the patients I talked to were very sad about this, as they enjoyed these sessions, but when the hospice is run as a charity, there is no guaranteed income, meaning that these sort of closures sometimes need to be made in order to keep the more essential services running. Hopefully the NHS hospitals don't see its relative cheapness (as it doesn't use NHS money) as a good excuse to put patients there to save themselves money. Hopefully this wouldn't happen, as those who would make these decisions will be far removed from the money aspects. 


Moral of the story: Charity run hospices are wonderful, donate to your local one!


The gynaecological cancer clinic was, unfortunately, a long way away from the hospitals we normally work at, and my accommodation. Fortunately I have a car, and motored us over there. It seemed a little but pointless to go such a long way for 3 hours worth of consultations, but I suppose to fit us into the timetable they need to branch out. Fortunately it was a very worthwhile clinic, with a very good consultant and registrar running the appointments. Unlike the palliative care clinic, there was a lot less bad news, and a lot more patients who had low grade cancers, with the doctors mostly aiming for a cure for most patients. There were a few patients who were not expected to be cured, and were being treated palliatively with treatments such as radiotherapy, to slow the cancers progression and reduce some of the nasty symptoms they were getting. What impressed me most was the fact that all of these patients were well aware that they had an incurable illness. There didn't seem to be any secrets that the doctors were keeping from the patients, and if the doctor was worried that the patient was not curable, the patient would know as well. I don't know what I was expecting, but such upfront honesty and openness with the patients just felt right.


I also get to do GP placements every few weeks in this year, where I spend a day in a GP's surgery in a sleepy country village. I am fortunate in that this is the same GP surgery I spent some time in in my first year, with the same doctor. She is very friendly, informal, and nice, and I am very pleased to have been placed back with her! The surgery is a large polyclinic, so I hope to get a lot of experience in a lot of different fields. We saw about twenty patients over the course of the day, the appointment times being a lot longer as I was there to take up the time. Normally GPs can see about 30-40 patients in one morning! The doctor wanted me to run the consultations, with her able to step in and ask supplementary questions, but I didn't think this would be a very good idea. I don't remember a lot, and felt I would like to see a few before trying them for myself. She seemed to understand, and I participated by adding in questions when she asked me - a much less worrying start! The patient who stood out most in this day was a large man who looked just like Hagrid from Harry Potter who had broken his leg.

The patient's beard and clothing matched Hagrid's almost perfectly. If he wasn't so serious, I would have thought he was joking around.

This man had had a real alcohol problem, put on a lot of weight, and the drunkenness, coupled with the poor vitamin intake from the lack of food had caused him to fall down the stairs. At the moment he couldn't leave the house because of his obesity and broken leg combination (some carers had come to bring him to the GP surgery), and all of his shopping was being done by a well meaning neighbour. This neighbour was sensible enough not to buy this man any alcohol, and for the last month he had not had anything to drink at all. He confessed that although the first week was very tough, he now felt a lot better because of it. A broken leg turning out to help someone out was quite interesting, though unfortunately he confessed that as soon as he could walk on the leg again, the first thing he would do would be to go down to his local and get himself a "pint or twelve". The GP tried hard to convince him not to start drinking again, but he wanted to. Without the patient making the decision themselves that they want to give up, it is unfortunately just not possible to get them to stop any harmful behaviour, whether it be smoking, drinking, other drugs or just plain over-eating. 

Estimating when someone will die

Hi,


This week I attend what I thought was a breast cancer clinic, which turned out to be a palliative care clinic, and very sad. I also go on a ward round with the haematology team, who see a lot of blood based cancers as part of their work. In my second week back in medical school, and I have quickly gotten used to the differences. I suppose it is all about what you perceive as 'normal'. The time in Tanzania had me seeing that as almost 'the norm', and coming to the UK had me in some kind of culture shock at seeing how different the healthcare is. This sounds a little drama-queen-ish, but to a mild degree, I think it is true. Now I am used to the UK healthcare, I don't spend my time looking at things twice, or being impressed by a consultant going the extra mile. 


The breast-cancer-turned-palliative-care clinic was the highlight (in some respects) of the week for me. I had been expecting a clinic for those with breast cancer, so had read about breast examinations, important points in the history, and other useful information. Any clinic where cancer is dealt with isn't going to be a walk in the park emotionally, but I wasn't expecting anything mind-blowingly upsetting, as breast cancer tends to have relatively good cure rates (better than many cancers). On my arrival, the clinic turned out to be a palliative care clinic that was focussed around lung cancer. This will make it a lot more upsetting, as it means that only patients who are dying will be seen, rather than everyone. Lung cancer also has a much worse prognosis than breast cancer, progressing faster and with much more likelihood of being incurable.


I was sitting in this clinic with one other medical student and the palliative care consultant. She warned us before it started that some of the patient's cases can be very upsetting, but it is good to see these sort of things as a medical student, and important to come to terms that not everyone can be cured by modern medicine, and am important part of medicine is letting people die comfortably. The first patient who we see is a ex-service man who has come in with his wife, with advanced lung cancer. The cancer has spread to a number of sites in his body, such as the liver and the bone, causing a variety of problems and pains which he wants the palliative care consultant to help him with. This involves a discussion about pain killers and other palliative medication, which is relatively emotionless, as it is all factual. The emotional talk comes later, after the man asks how much time the doctor thinks he has left to live. This is a question that doctors do not like to answer, as it is very hard to tell, and whatever answer they give can make huge impressions on the patient's life. It is possible, though, for the doctor to take a wild guess. The general rule for guessing how much time the patient has left is to look at the frequency with which new symptoms are appearing. If new symptoms (from the illness, such as ascites or bone pain) are appearing at a few a month, then the patients life expectancy is likely to be measured in months. A few a week means it is likely to be measured in weeks and if they are appearing daily, then its likely that the patients life expectancy may be measured in days. This can be very inaccurate, and everyone has heard of doctors giving patients weeks to live, who then turn out to live for years. Despite this inaccuracy, it is fair to give a guess (making sure the patient is very aware that it is only a guess) as to how long the doctor feels the patient may have if the patient asks. You cannot exactly say you will not tell them!


Getting back to the point, when the patient asked the doctor how long he had left to live, in a tactical and roundabout way, his wife started crying, pulling at him towards the door and telling him he should ask such things. He told the doctor that he really did want to know, and the wife started sobbing hysterically, trying to pull him to leave. I decided that this is when medical students can actually be of some use, and take the crying woman by the arm (kindly, I am not dragging her) and lead her out of the room to the waiting room. I chat with her there for 10 to 15 minutes about what she is worried about (I volunteer for Samaritans in my free time, so have had plenty of training for these sort of talks), until the consultant comes along to find me, telling me that there is actually a quiet room for this exact sort of situation, rather than me taking them to the waiting room where there are other patients. I am a bit embarrassed, but take the wife to the quiet room to keep talking, while the consultant goes to finish her consultation with the patient, after checking that the wife doesn't want to return to the room ("definitely not!"). The wife thanks me profusely before leaving, and I feel as though I have been useful, an unusual feeling as a medical student! After the consultation, the other medical student (who had remained in the room) told me that the man seemed to be taking his coming death a lot better than his wife, and once she had left the room had confessed that his biggest fear was how she would feel when he was gone, or very ill at the end stage of his illness. The consultant estimated him to have some months left, though as I said before, this can be very inaccurate, and the patient seemed to accept this.


We see about ten patients in the morning, and despite the fast throughput, the palliative care consultant seems to give each patient as much time as they want, giving them time to talk about their symptoms and the progression of the disease (the reasons for them coming to the clinic) as well as the much more difficult touchy-feely issues around the fact that they are dying. The patient who made the most impression on me was a lovely mannered kind old man who had a very horse voice when we were talking to him. In the first couple of years of medical school, this is taught as one of the signs of lung cancer, as the cancer is affecting the left recurrent laryngeal nerve. This horse voice had only come on in the last week, and was the reason for his visit. It suggested that his lung cancer was progressing (I.e. it is getting bigger, hence why this nerve is now involved) despite the fact that he was currently on chemotherapy). The conversation was based around the fact that, seeing as this was his third different drugs combination, and they all had not worked, it might be a good idea to stop chemotherapy and come to terms that the cancer was not curable. The man seemed to accept this gracefully, and seemed to have been expecting such a statement from the doctor. I found it a lot harder, however, and found myself feeling really upset that this gentleman could no longer be treated, and the fact the treatment was being stopped seemed as though we were 'giving up' with him, and consigning him to death. I know this is not the case, and the fact he was at the palliative care clinic meant that he wasn't being given up on, but this is something that is very important in modern medicine, as everyone dies, but something I know I will struggle to come to terms with.

As can be seen by this anatomy diagram, the left recurrent laryngeal nerve runs under the arch of the aorta, and hence can be affected by grows in the lung. The right doesn't descend as far, and is not affected.

At the end of the clinic, the consultant took me aside to thank me for dealing with the wife I mentioned in a "professional, yet lovely" way. She said it made it a lot easier for the husband to talk about his illness, without her having to ask the lady to leave. She also told me to try and forget about the emotions I experienced in the clinic, instead taking away the knowledge I gained about the conditions I saw, and the service that is offered. It is always good to feel valued, and I think she must have been able to tell that a few of the patients had left me feeling upset.


The haematology ward round that I participated in later this week was a much more positive affair. There were a lot of patients with blood cancers, and all of the patients we saw had good prognoses, with the doctors aiming to cure all of them. Blood cancers are much easier to treat. Some of the patients were in special side rooms, and we avoided going in with the essential doctor and nurses, as the treatments for these cancers can often leave patients with a very poor immune system, meaning it is important not to expose them to infections. My favourite patient on this ward round (I am not sure if we are allowed favourite patients...) was a lady who, as a side effect of her treatment had had a nasty fall down her stairs, and because of her slatted metal bannisters, had torn off a lot of the skin from both of her arms. She was otherwise pretty well, and charming and chatty, so I went back later to talk with her some more. She had her arms wrapped up in two huge bandages around cotton wool, and I asked her if they were inconvenient. She said that the nurses and doctors had offered to change them to something smaller a number of times, but she preferred them like this. She had always gotten cold arms in the past, but now they were always so toasty warm!

The start of fourth year

Hi,


So here I am, back in in the UK and back in my university hospital. I will continue with the weekly blogs, but have a little bit of a back log now, due to the fact that I was posting all of the elective blogs after my return, through my first 8 weeks of rotations. Despite the fact the blogs will be weekly, I will try and post the next few as quickly as possible to catch up with myself, then get back into the old regime. Daily is far too often for me to write, or for you to bother reading, and was only worthwhile for my elective, when so much was happening at once!


My first rotation on my return is Oncology, which will last for about 6 weeks. I hardly saw any oncology patients on my elective, and seeing as I intercalated in immunology last year, this means that I have about a year and a half since I had really done anything in oncology. In fact, I have a year and a half hiatus where I have done very little clinical work at all, excluding the elective (which was so different it hardly counts). Needless to say, I hardly remember anything and am approaching this week with some trepidation.


Having intercalated, whereas much of my university doesn't, I am in a new year, with some old friends and many new people. I was social secretary in my second year, organising many events for the then freshers, meaning that I know the year below (which is now my year). Despite this, it is still strange being in a rotation with new people, after I have gotten to know my year so well over the last 3 years. This isn't all bad, though, and it is nice to get to know people who I have only ever seen out at bars a little better. I am now officially starting my fourth year, even though this is my fifth year at Uni, given my intercalated degree, which makes for slightly complex explanations when people from outside medicine ask which year I am in!


The Oncology rotation seems to be predominantly seminar/lecture based, which is a real shame. The time table tells me that I spend a lot of time in lectures or with free time rather than on the wards. Despite this, I do have some clinical experience each week. Not as much as in my third year, but hopeful;y enough to let me remember all the things I used to know (all two of them...) My first day on oncology sees me in a specialist oncology ward with no real purpose, other than to talk to and examine a few patients, and report back to the doctors in charge of the ward. This isn't really of too much use to the patients, though with all the time I have I may find out something useful that the doctor's didn't know, but it is very useful to me, as I get to practice all of the skills I don't really have. This is a common way of learning used in hospitals, and patients are normally only too happy to help out "You have got to learn sometime!" 


This whole experience was pretty confusing. Not because of my poor history taking and examination skills, though these were sub-par, as expected. It was because of the massive difference to the environment I was used to in Tanzania. I know it sounds cheesy and strange, but the difference really is scary. I suppose I expected it when I went to Tanzania, I expected it to be poorly supplied and poorly staffed, and so wasn't too surprised. Coming back to the UK, I suppose I expected it to be 'normal' - as it was what I would expect to be used to. Perhaps a combination of the fact all the clinical experience I have had in the last one and a half years has just been the gritty Tanzanian hospital, and the fact that the oncology ward is fantastically staffed and well supplied (cancer is, after all, very popular with the media, and hence seems to collect a lot of funding). To say I was 'overcome' would be a little bit of an overstatement, but I really was shocked at how spacious and clean the ward was, and more than anything, how caring the nurses are. I suppose in Tanzania I was used to the nurses who didn't really do anything, patients never got washed and there were not even any bedsheets to clean. Here the nurses take the time to do everything, feeding patients who cannot feed themselves and taking time out to help explain things to us. Perhaps I am just enjoying being back at the bottom of the medical food chain, where everyone knows a lot more than me, and is happy to explain it to me, compared to my opposite experience in Tanzania, but it is lovely here. I love the NHS.

A new badge for me to wear.

Elective 45. Home time.

I leave for home today, travelling by bus to Dar es Salaam and meeting a very helpful taxi driver who is a friend of the hospitals. One in Dar, there is a huge quest for pizza, and the taxi driver refuses to take me to sleep in the airport, so I get a shower and a sit down toilet for my last night.  An unexpected luxury! There are many mzungu in Dar, and I am actually finding having all these white people around strange. How odd!

Early this morning, there was a snake in Choc's house which spat venom at him. Thankfully he was unharmed, but as I left this morning (as the sun was starting to rise), people from the village were already starting to take apart his roof, in an attempt to find the snake. Dolittle and Kiwi kept me informed by text, and no snake was found, though a nearby hollow tree was smoked out as it contained some kind of snake nest. All the fun happens as soon as I leave!

On my way to the bus, I see a London bag being sold from the village shop. I wonder where they got it!

Dolittle and Kiwi are kind enough to walk with me to the bus, and on the way Tim comes out of his house to walk with me as well. Once I am at the bus stop, Chief joins us on his motorbike. The bus is hours late (no surprise), but they all stay with me, chatting away. I am very touched, Tanzanians really are friendly, and I have been made to feel part of their hospital family. Dr Bike has used his extensive bus connections to get me the best seat on the bus, behind the driver, with plenty of leg room and amazing views out of the wind screen of the rugged, untouched terrain we drive through.

My view from the bus - wonderful to watch the scenery go past.

On the journey a number of films are shown. Dr Bike's wonderful connections have gotten me a lovely bus with a TV and sweeties given out during the journey. Luxury! Of the films, there is Forrest Gump with Mandarin Sub titles (not sure how useful this is for Tanzanians, with their poor knowledge of English and worse knowledge of Mandarin, and being the only foreigner on the bus, I feel almost guilty). The next film is a Tanzanian film about a devil child who seems to explode people. During this (fortunately subtitled) film, the audience is told the devil has made three main advances in the 21st century, 1) in homosexuality 2) in contraception 3) in womens rights. Just the sort of film to show to a country struggling to fight sexism and HIV transmission. Following this absurd and offensive film is one called Uncle JJ where  womers rights are seen as good. I think. Its more than a little confusing. As we get closer to Dar, there are very heavy rains flooding the roads, and the area we are travelling through gets much greener. The rain missing back at the hospital and causing all the problems seems to be falling here.

Here is the trailer for the Uncle JJ film. I think it was pro-woman's rights - but it might have been against them. It definitely carried a message regarding woman's rights!

One at Dar, and off the bus, I see a number of holidaying mzungu floating around at the bus station. They look so our of  place and odd that I catch myself staring at them. This is weird, perhaps I have turned into a Tanzanian? I check the colour of my skin, and I am still white... I am  picked up at the bus station by a taxi driver who is a friend of the hospitals. He is very helpful in finding somewhere for me to change my remaining money back, but will not take me to the airport where I planned to sleep the night to save money, as he tells me it is too dangerous. I protest that I have done this many times before at the end of holidays, in order to save money, but he still refuses and instead offers to have me sleep at his house, or to pay for my hotel himself. I finally give in and accept to go to a CHEAP hotel, which I am not going to let him pay for!

The back wheels of my coach. One of the most important pieces of advice I got whilst in Tanzania was to only get on buses or coaches with doubled up back wheels, as otherwise they can be prone to rolling on the bumpy roads, or punctures can cause them to flip. I heard of two people dying whilst I was in the village from accidents with buses with only single back wheels, so I was always careful to only get into doubled up transport!

When asked what I would like to eat before we go to the hotel, I ask for something different to all my hospital meals, such as a pizza. This idea is taken and he runs with it. He spends ages driving around, looking for a cheap hotel with pizza nearby. This proves very hard, as all cheap hotels are in the less touristy regions, serving Tanzanian people who have come to Dar, and hence don't tend to serve western foods. I don't want to waste his time, and finally persuade him to let me find my own way around. l am dropped of in a nice clean hotel, with a very nice room for the 8 pounds I am paying. The taxi drier wrangles the price down to the Tanzanian price, rather than the western price, for me, then leaves, promising to be back tomorrow morning. With his hospital connections I believe him, and am not too worried, as he wouldn't want to lose all his business from the hospital by missing picking me up. His parting warning to me is to "Be careful with the prostitutes...". He is being serious! I must come across as seriously desperate!

I am famished after that long journey, so start off looking for food. This is the sot of adventure that wise people would advise taking a map for, but I am for too hungry to try and find one. Anyway, where would I get one from? The hotel is near a main looking street, covered with market vendors selling all items of second hand Clothes and Swahili food such as kebabs, Ugali and chips. All items I had whilst in the village. No-one seems to be doing something different such as pizza. This pizza idea has started to turn into a little bit of an obsession, and I do not think this food is what I want, so I turn right (must remember my directions!) and start my search. This is a very poor local area (hence the cheap hotel) so I will have to go some way for my western food.


An hour later, I still haven't found any food places serving pizza, or even anything un-Tanzanian, but have now made about a dozen turnings which I am trying to remember. I was going to use my camera to take pictures to help me, but am still the only white person around and don't want to draw too  much attention to myself. I am pretty sure I have already gone so far I will not be able to find my way back, so I turn back, resigning myself to another night of 'Chipsi' (i cannot remember if I talked earler about the Tanzanian love of putting the letter 'i' on the end of most western words to make them 'Tanzanian' It is already getting dark, and I find myself in a road I definitely didn't come down. Now I am lost, but this is not all bad news, I as l can also see a hotel restaurant at the end of the road with mzungu outside!!!

They don't serve pizza but, almost as good, they do serve curry! I had a fantastic meal, but I have never eaten out or a restaurant by myself before. (why would I have?) I find out that its pretty boring. I snack down my curry quickly (it tastes nothing like any curry I have ever tasted before, but a different flavour to the last four weeks really is wonderful) so I can get back before it is completely dark.

The curry I was given in the restaurant. A very... unusual... taste, but still delicious! 

I am too slow, and so have to make my way home on the dark streets, which have no street lights. Being in the City has a very different feeling feel to rural Tanzania, as you are not greeting everyone, but it also has a very different feel to the more developed Indian cities I have been to this year as well. There is no pushy selling, and I am not asked for money once, despite the fact I am obviously a foreigner. This must be because there are far fewer tourists, and those who do come probably go off towards Kilimanjaro or to Safari, rather than hanging around in Dar es Salaam. Despite this, and feeling pretty safe, it was quite dark, and I know some areas can be dangers (Unfortunately I don't know which ones, not that it matters, as I have no idea where I am). I find my hotel pretty easily, by backtracking to where I went wrong, and once I am on the last street back, I celebrate by buying some chopped up sugar cane to munch on, the bag was prepared in front of me for 2 pence. A very Tanzanian snack, but only tasty for the first three chews really...


One in my hotel room, I take my time to enjoy the wonderful facilities, including a Shower and a sit down toilet without a bat (I hope!). There seem to be an inordinate number of cockroaches and other assorted insects in my room, but with all these other luxuries, I am beyond caring. Perhaps all the insects means there are no rats to eat them!

As I cuddle up in bed and check my texts (I didn't want to get my Nokia 3310 out for fear of having it stolen while in town) I find a marriage proposal from a nurse at the hospital, and a text saying she had sent me some money on my phone, as she had assumed my lack of reply was as I had run out of credit. Feeling guilty that I had been taking money from a poor Tanzanian, I tried to be nice in my subsequent text conversation with her, while trying to explain why I cannot marry her. I am not used to turning down marriage proposals, so am not too sure what to say. The truth is that I just don't really want to marry her!

Part of the text I got from the nurse asking me to marry her. Again, I wish it was my good looks and charm that attracted her, but I assume it was my skin colour and nationality which was the main attraction... :(

All in all, this was an exciting last day in Tanzania, much more exciting than I expected for a journey day. I fly tomorrow, so this is the last blog post about my elective. I have loved my stay here, most of all the community and fitting in as part of the village. The parts I found hardest were the language barriers (obviously) and trying to persuade the doctors that the medical care they gave was on occasion awful, and trying to get them to change their practice (or watching people die because they wouldn't change what they did). Despite this, I know that I will really miss the village and the country, and I plan to return when I have got some real skills to offer.

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. 

Elective 43. The tower

Today we meet some unconventional diagnoses and management plans on the ward round, and I buy myself some medication. We go to give some gifts to the primary school, and medically treat one of the kids playing outside out house, while getting heckled by pregnant women. We finish off the day with an intrepid climb up the water tower near our house.

The sunset from behind our house is beautiful as we come back from the water tower.

On the ward round this morning, we encounter an 12 month old child who had presented with 'headache and chest tightness'. Dr BT had admitted him into hospital with these complaints. I am not sure how he found out this baby had 'chest tightness', or even a headache, but he clearly decided metronidazole was the best drug to treat this presentation (very unlikely to be correct). The baby looked fine to us, and all tests were negative, so he was discharged. This was a nice money earner for the hospital, as admissions incur a large charge, but not such good news for the parents. I am sure he didn't admit on purpose to get the hospital some much needed funds, but you do wonder. Metronidazole should be most commonly used here to treat bloody diarrhoea or pelvic inflammatory disease caused by an untreated STI. I am guessing Dr BT didn't think the child had the latter, so perhaps he had deduced that the diarrhoea the child didn't have could have spread to the lungs and head? In some ways, I cannot wait to get back to the UK, where things make sense.

The second 'odd' case was admitted while we were on the ward, so we saw her as soon as she came into the ward. She is a 15 year old schoolgirl, and had come in from the school (it her first day there) with central chest pain and rapid breathing. The doctor who had see her in outpatients had written down "?Angina. Urgently to be seen by ward doctor". Pretty sure that it wasn't a heart complaint in this healthy looking girl, we did a full examination and history anyway. This was helped by the fact she spoke a few words of English, as she went to the school where English must be spoken at all times. The examination seemed to show she was fine, and the history seemed to fit in with a panic attack. Not really sure what to do, and needing to give medication (silly Tanzania) we gave her salbutamol tablets and antihistamines in case its some kind of allergic response or asthma attack. Once admitted, the hospital rules are that the patients cannot be discharged in the first 24 hours, so she is left in the hospital for a day. Perhaps a good thing, as it means she can be checked to make sure there is nothing severe wrong with her. A 15 year old with angina though? Very unlikely.

Later on, when things have quietened down in the ward, I saunter over the the lab to have my full blood count taken by Choc. An expensive test for a Tanzanian, but only a couple of quid for me to see what my blood looks like. Sounds like a fantastic deal, though I am careful to make sure that my blood is taken with a clean needle! It turns out that after these 6 weeks in Tanzania I have become anaemic. Microcytic anaemia - the classic finding here on blood tests. It must be the lack of iron in the blood, or perhaps I have a hookworm infection. My iron is still very high for a Tanzanian person, but is a little below 12g/dl, which would make me anaemic in the UK. Not much I can do about that, apart from eat lots of delicious food once I get home. I cannot wait!


In my spare time, I also pop into the pharmacy to get some medications to take home. Because I have been washing in the lake water all this time, which does have the parasites that cause schistosomiasis in it, and because everyone here seems to have a worm infection, I get two drugs from the pharmacy to treat  schistosomiasis and worm infections. I will take them once I get home, hopefully meaning I can be nice and healthy when I return. I don't think I have caught anything nasty than a few stomach bugs when here (apart from that nasty tonsillitis), but much better safe than sorry!

We travel to the primary school that is further on into the village in the afternoon, with the intention of dropping off the stationary that I bought with me, and Kiwi and Dolittle's pencils they bought along as well. What was intended on being a quick stop and drop then back to the hospital, quickly turned into a tour around the school where we spoke to each class room about ourselves and they all said hi, or asked us questions. It was pretty embarrassing, though really sweet. Whatever classes were going on at the time were interrupted for us to come in and talk about ourselves. Proper little minor celebrities!

The primary school children expect us to talk about ourselves to them, despite the fact they speak very little English.

Once we get home, we are playing outside with the kids again. I notice that the hyperactive one (Kev) has been leaving bloody heel prints across our porch, so ask to take a look (well, more gesture, seeing as we cannot talk to the children at all what with the language barriers). He has a large cut on his heel, which after some gestures, I think he got after trying to ride someone else's bicycle. I was all of the sand and grit out of it, sterilise it and then put a bandage onto it to stop it from getting more grit into it, and hopefully to stop it from bleeding. As I start doing this, some pregnant women are walking by the house, and stop to watch, sitting on our porch and under the tree in front of our house. They start shouting things to me, and laughing amongst themselves, though I have no idea what they are saying. I cannot really answer with some witticism, so just keep quiet and bandage away. He thanks me (very rare for Kev) and scampers off after I am done, and I go inside. The pregnant women do not, though, and instead spend some time staring in through the windows at us. We try to retreat to other rooms to avoid their gaze, but they then track around the house to find windows looking into those rooms to continue staring. Its a little like being at the zoo! This only stops when our cook arrives to cook dinner for us, and they all flee from her accusing shouts. I wish I knew what was said. 

Some of the women who were heckling us leave, with their collected fire wood.

As the dinner is prepared, I decide that I would like to climb the water tower behind our house. This water tower hasn't been used in years, though was originally put in to try and supply houses with running water. It has a ladder up the side (starting about 6 foot from the ground) and as it is already on high ground, I imagine it would give wonderful views. I persuade Dolittle and Kiwi to come with me, though they assure me that they are unlikely to be doing any climbing up the tower! I feel happy that they will be there, though, and if the ladder breaks or something nasty happens, I can get some medical treatment from them. I also tell them that if something happens, they need to get me to a hospital in the city, rather than let me be treated here! Once at the water tower, and I have climbed up the rickety metal ladder (stick in hand in case of snakes waiting at the top to bite my face) they decide they would also like to come up. With the help of some boosts, they make it to the bottom rung of the ladder and can easily climb to the top. The view is amazing, across the rift valley on one side, and looking at the hospital, the village and the house we live in on the other, covered by a beautiful setting sun.

The view from the top of the water tower, my house is in the middle of the picture, with the hospital behind it, and the rest of the hospital spread out to the right.

Once we are bored with the view, and it is getting dark as the sun sets, we return home for dinner. After dinner we play a 'heads, body, legs' game where each person draws a specific one of these three, linking them to each of the other persons other body parts, blind to what they have drawn, to create amazing (or abominable) creations. These two girls are a lot more fun than Sporty and Smartie were, and we have a lot of fun. See some of our strange creations below!

I am very proud of my man-on-horse idea and House ideas. Very original, and the house works so well with the smartly dressed top! Wonderful.

Elective 42. Sodomy

A five year old boy comes into the hospital after being raped, and while while most cases keep confusing us, others are eventually solved. I give a gift to a patient, which makes them cry, and I get given a gift from Tim. In the evening, Kiwi, Dolittle and I walk to the lake where our shower water comes from.

In the morning meeting, another two babies have died during birth, but as well as the worrying fact there are so many deaths, I am worried that I am getting used to this, becoming more accepting of why they died (Oh. Prolonged second stage of labour. I see), rather than asking why they died (shouldn't she have had a c-section?). Perhaps this is what happens to doctors who come here from other areas of Tanzania. An insidious eroding of expectations and general acceptance of death that shouldn't have happened.

On the ward round with Eggs, we visit the man who had the abscess in his neck, which has been surgically drained. Eggs wears some very... interesting... T-shirts while on the ward. My favourite is one which I have seen him wearing a number of times, proclaiming "If I said you had a beautiful body, would you hold it against me". I am serious, this man wears this T-shirt for ward rounds!

On the ward round with Dr Bike, we review a 5 year old boy who was admitted yesterday after being raped. On examination, he still had a significant amount of blood around his anus and on his buttocks. It was very hard to get any history from the parents, as they spoke a tribal dialect  rather than Swahili. It seemed they said it had happened while he was playing with other boys. Not really too sure what to do at the moment, we gave pain relief and antibiotics as prophylaxis against infection, and instructed the parents to clean the area (I have no idea why they didn't do this yesterday). An HIV test follow up would be a wise idea. In the evening, we tell one of the nurses who are staying with us about this, as he is a psychiatric educator, in the hope he can try and offer the boy some counselling or something. He tells us that witch doctors give people a medicine, which needs to be taken after raping a male child. This 'medicine' should then make them wealthy. I knew that there was a reason not to trust rich people! In all seriousness, although this hospital has many faults, at least if doesn't advocate the harm of others and genuinely seems to care about people rather than making itself money.

At other stops on the ward round, the baby with hypopigmented patches, who has been in hospital for weeks, is finally ready to be discharged. A few days ago, we guessed it could be excema (after all the guesses at strange fungal infections and so on), and prescribed topical steroids. While we were told these were out of stock, a few days ago I looked through the pharmacy stocks and found some Daktacort, a mixed anti-fungal and hydrocortisone cream. Perfect for a possibly fungal possibly autoimmune infection. After a weekend on this, the baby is a lot less itchy and a lot less red and flaky, though she still has many patches of  hypopigmentation. I never knew that eczema could cause changes in skin pigment, but the girls from New Zealand have taught me this. Having people smarter than you on elective is really very useful! 

The full blood count for the complex case of the horse voiced girl with oedema in her legs and the inability to walk is finally done (the lab is closed over the weekend). And what a strange result! Microcytic anaemia, but that's par for the course in Tanzania. What's most interesting is that the break down of the white blood cell count has produced an 'error' in the results. The lab people have both tested the machine on another blood sample (which was fine) and then a different sample of the girls blood (error again) [this is very efficient for Tanzania, my guess is that Choc was in the lab yesterday]. The error that is coming up shows a code (T2) written in a box, rather than the numerical result for all of the break downs of blood cells. We visit Choc at the lab to inquire about this error. The lab book tells us that this error is something to do with cell counts being outside of normal ranges. Or unable to differentiate cells. It is kind of confusing and neither Kiwi, Dolittle, Choc or I really understand what this means. My guess is that this is some kind of leukemia, creating strange looking immature cells in the blood, which are confusing the machine, but really I don't know, and we don't have any way of finding out, so us three students try to petition Dr Bike to let us refer the girl to the big hospital, which is quite far away. Dr Bike doesn't really like referrals, but doesn't put up much of a fight this time, probably because he has no idea what to do next (but does suggest a fun cocktail of antibiotics which he thinks might help). I now feel justified in pushing for that full blood count, and eventually paying for it, as it has shown something. We think. I still feel robbed, though, as I still don't know what the diagnosis is!

The baby who was admitted with marasmus, and diarrhoea, who was bought in by his sister some weeks ago and fed up by Doctor bike is being discharged tomorrow. The IHPUK drug pack I bought had a doll in it, and I decided that this baby and sister are the best people to have it. If they cannot afford food, I doubt they have any toys! I bring the doll to the ward, with some pens, pencils and an exercise books for the older sister, so they can both have presents. I find them sitting outside the ward, and hand the doll and stationary to them. The older sisters eyes light up, and she gives a massive smile, but the ill child just starts bawling. He is clearly even more terrified of this doll than a mzungu! This is definitely not the response I was expecting at all! Perhaps he has never seen a doll before? There is not much I can do about it though, so I leave them, hoping that he will get used to it in the end. Or perhaps they will just sell it for some food. so much for a good deed!

The malnourished child flinches away from the terrifying doll from IHPUK, held by her happy older sister

In the evening, Tim comes by the house to deliver me a present, I assume this is to pay me back for the BMJs and pen torch I have given him so far. Yesterday he was in a large city, visiting his gold mining, broken arm-suffering dad, and decided to get me some Carrots as a present. What a star! This sounds trivial, but it is an amazing present. It adds some much needed variety to our meals. Its not as though we don't want to buy more interesting ingredients while here. They are just not available in this village. He clearly had remembered me complaining about the simple food, and had decided to bring me something fun back! While our new carrot based dinner is created by the cook, Kiwi, Dolittle and I walk to the lake, where the villages water comes from. This has some beautiful views, and many villagers washing or swimming in it while others collect buckets for home or let their animals drink and splash around. The water for our cooking and tea comes from here. Urgh. Well, what can you do. It seems that the level is very low compared to where the banks suggest it normally is. I guess we are towards the end of the dry season, with rain expected soon, so it is to be expected.

The lake where the water is collected for the village is drying up. The wonderful scenery is ruined by the phone mast stuck on the cliff, to try and cover some of the rift valley. I shouldn't be complaining, this was my one way to communicate with everyone!

In the evening, after our meal of carrots in spagetti (better than plain spaghetti, but still mouth-curlingly sweet) we do some water colours and drawings with the drawing materials we have for the kids to use. Kiwi and I are just doing it for fun, but Dolittle turns out to be good. Really, very good. Don't you just hate those medical students who have all these hidden talents like drawing and talking to animals. At least she isn't perfect. She loves glee.

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!