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... 

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!

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...