Tuesday, 27 September 2011

Operating on the wrong patient

Operating on the wrong patient

23/9/11 :

Found out the three year old with ?rabies died yesterday afternoon :(. Very sad and no one here was expecting her to deteriorate so quickly; in many ways probably for the best though as rabies can be a very long drawn out painful death which would have been more distressing for both the girl and her family. Still very sad though.

Quite a few interesting cases/scenarios today:
1. Saw an x-ray of a 6 yr old male who swallowed a 200tsh coin (the widest coin here - about the width of a 50p but circular) and as shown by the x-ray, it was lodged in his throat. X ray was pretty amazing to look at as you can see below!

- A 200 tanzanian shilling coin stuck in the oesophagus of a 6 year old.

2. Saw 2 patients who had been suffering from a hydrocele (a fluid filled sac surrounding the testicle resulting in swelling of the scrotum) - one had been operated on and one was still awaiting an operation.... Turned out that the patient who had originally been booked in for the operation was the one who had not had the operation because the doctor had got confused and when he saw another patient with the same condition, who was about the same age, assumed it was the right patient without checking the name! Good thing it was at least the same condition so the treatment was correct I suppose - otherwise the second patient probably wouldn't have been too pleased to have an unnecessary op. on his testicles!

3. Saw a patient who had needed a splenectomy due to trauma. The spleen is an important part of someone’s immune system so in England patients who have had a splenectomy are put on impaired antibiotics for life to prevent increased infections due to its removal. The other medical students bought this to the doctors attention and although initially he said lifelong antibiotic treatment was not possible here, he did in the end decide to give the patient a 3 month course of prophylactic antibiotic which although far from a lifetime (hopefully!) is better than nothing I guess!

4. A 15ish year old boy who was semi conscious, had massively increased muscle tone, was having small seizures and his mum said he seemed to "be fighting off monsters" during the night - hard to tell if she meant he was awake and having hallucinations or was having nightmares which he was acting out. He also had a wound on his foot. Doctor’s diagnosis? Cerebral malaria or "mental case". Lovely. Though they classify epilepsy as a mental illness here (which is another rant entirely!) and I suppose that is one of the possible differentials though probably not the most likely.

5. A patient with poisoning which no one seemed to know whether was accidental or intentional. Could have been a suicide attempt, could have been a murder attempt, and could have been an unfortunate accident. But the doctor stated the patient was epileptic so he had probably taken the poison accidentally because he was confused... Reduced alertness is a symptom of epilepsy (e.g. during or after a seizure. In one form of epilepsy the seizure does not involve convulsing but just a period of reduced alertness), but confusion where the patient can still move and do things like take a poison? Not a common symptom of epilepsy as far as I'm aware. Epilepsy is a very stigmatized condition here.
6. A MALE patient with ?Cancer of CERVIX written in his notes. Stunning diagnostic skills as ever! Apparently they probably meant prostate. Hope this was an English language fail rather than an anatomy knowledge fail!

Well I will say one thing about the average day here, it's never dull!

Halfadoc x

A three year old with rabies :(

A three year old with rabies :(
22.9.11 :

Very very sad case on the paediatric ward today; a 3 year old girl who had been bitten on the neck by a dog which was suspected to be rabid, six days ago. The dog had being acting excessively aggressive and frothy at the mouth so is quite likely to have had rabies. It had since been killed but not tested to see if it did indeed have rabies.

The girl had only just presented to hospital which is unfortunately too late even if the hospital did have the rabies treatment (which they do not yet, though they are trying to get hold of some to give to the girls family who will be potentially exposed whilst looking after the girl). Rabies is 100% fatal without treatment :(. To have a high chance of success the treatment should be given within 24 hours if the patient has not had prior vaccination against rabies; sometimes treatment is attempted later but if the individual has already developed rabies symptoms then it is too late.

The girl when we saw her was extremely twitchy and agitated in appearance, had obvious hypersalivation, her temperature was 39 degrees and she had vomited multiple times. Hope like hell these symptoms are a coincidence and she has a different treatable condition and the dog was not rabid at all.... But unfortunately this is rather unlikely and it takes very little medical knowledge to realise her symptoms combined with the bite, point to a high chance of rabies. She will probably die within a few weeks (most likely 4-5 days) and she’s only 3. It sucks big time and that is putting it extremely mildly.

In England someone with rabies would be isolated and barrier nursed and all staff would receive rabies vaccination just in case. Obviously that is not possible here, so I hope because she is only little she will be restrained ok if she develops the aggressive features of rabies otherwise the disease might be spread to someone else.

Rest of ward round pretty standard. Several other patients who had confusing symptoms given the differential cause of ?psychological today based again seemingly on simply the doctor's confusion as to the actual cause rather than any psychological features. It’s so unbelievably irritating and frustrating and I wish I knew more medicine so that I could diagnose these patients but realistically without some of the basic investigations they lack here then it is very difficult to do so. Basically if you do not have a classical presentation of one of about 4 diseases here then you are screwed. Today’s been hard and 6 weeks at this hospital feels like long enough the way I feel right now.

Halfadoc x

Cannulation success!

Cannulation success!

21.9.11 :

Today we were in maternity again. Quite an interesting day in that we got to see a vacuum assisted birth for the first time here (have seen one previously in England). The labour was not progressing quickly enough and the baby was starting to go into foetal distress - as shown by heavily meconium stained amniotic fluid that was released when the doctor ruptured the membranes, so the doctor decided to use the vacuum pump (ventouse delivery) to get the baby out. It was good to see something being done quickly about foetal distress for once! Aj had to pump the device (it is manual here rather than suction occurring by electricity like I think it does in the UK) and she was terrified she was going to pump too much and detach the babies scalp as this is a rare complication of using a ventouse. Fortunately this did not happen and the baby was born completely healthy, so good management by the doctor of this birth :D.

Second patient in maternity also had slow progress of labour in that she was not having regular enough contractions so it was decided to give her some oxytocin (promotes uterine contractions) and dextrose (literally sugar for energy). For this drip she needed a cannula put into one of her veins so I asked the midwife if I could have a go under her guidance. I’ve tried once before to get a cannula in while I’ve been here but last time although I initially got it into the vein, it came out before we had it properly secured as the woman was moving her arm about a lot with a contraction. I’ve never tried to cannulate in England except for on a prosthetic arm during a workshop, so I really wanted to get practice doing this while I was here. With help from the midwife (I did make a fair few initial mistakes and definitely needed her guidance) I got it in - Wooooo!! Glad to have one successful cannulation under my belt now – means if a patient asks me in England if I have done it before I can legitimately say yes!

- A cannula being inserted (Not by me! A) I wore gloves and B) my hands were probably shaking too much for a clear picture!)

The midwife also showed me how to do the quick HIV status check on the patient (involves just a finger prick and a test otherwise much like a pregnancy test) as this patients notes said that she was POSITIVE and the midwife wanted to double check. This test showed her to be NEGATIVE. Well I don’t know what the accuracy of the test is but it is pretty shocking if this lady has been told that she had HIV when actually she does not. I hope that was not the case and that the notes had just been written wrong!

She ended up needing a caesarean later in the evening as her labour still was not progressing enough. I watched the operation and the baby was born with a low Apgar score again and required CPR which I assisted in. This time I tried to make sure the CPR was done to the right guidelines and tell the midwives (I was doing the chest compressions so did this to the right number but the midwife was bagging to the wrong number again so I tried to tell her in a polite way what the current guidelines say the ratio should be) what these are…. It didn’t work, they ignored me. So I guess I have my answer to whether in the case of the baby who died (Blog: First do no harm and Who is to blame?) I could have made a difference; realistically they probably would not have listened to me then either. At least I tried to get the CPR done right this time though. This baby did start crying though and his Apgar score improved so I hope he will be ok.

Halfadoc x

Friday, 23 September 2011

The awkward moment when you have to tell a senior doctor he has put his stethoscope in the wrong way round


Today we started in OPD with one of the clinical officers. I know I over use the words “frustrating or frustrated” in my elective blogs, but yet again that’s how this morning left me feeling. The clinical officer we sat in with is not what I would describe as one of the better ones so lots of patients we saw whilst sitting in with him received treatment that was not ideal even for here; however the case that really frustrated me above all the others was that of an 11 year old girl who was presenting with a 1 week history of cough and abdominal pain.

Whilst she might only be attending OPD with a one week history of illness that doesn’t mean you should ignore blatantly obvious signs that the child had been also suffering from some form of severe chronic illness. The girl was mostly carried in by her mother and her legs were absolutely stick thin (and I’m not talking just naturally skinny thin) with obvious muscle wasting. She was completely malnourished. The clinical officer recognized this but only when we pointed her legs out to him – otherwise he was just going to address the problem of her acute symptoms in spite of such obvious malnutrition. Even when we suggested to him that perhaps she was suffering from chronic immune suppression and had been ill for some time he kept just saying she had only been ill for a week.

Eventually though he did ask the questions we were telling him he should (such as has anyone else in the family been ill and have her parents ever been tested for HIV). Turns out her father had died "of a cough" shortly after the girl was born (probably TB or pneumonia secondary to AIDs - both are relatively common opportunistic infections that immune compromised patients suffer and die from). So we said he should test the girl for HIV and he replied he couldn't because she was a child. When AJ and I both simultaneously exclaimed why not he didn't really have a reason for us, and we have since seen other children being tested so not sure what he was on about here! Eventually he agreed that maybe the mother should be tested and finally asked her if she had ever been tested before. Turns out she had been diagnosed as HIV positive a few months back! Why had it taken one of her children to become ill for HIV testing of her children to be considered??! It really is truly baffling.

At least the girl in the end got taken for a chest x ray for ?tb and has been admitted to the paediatric ward. I hope she does get tested for HIV and if it she is positive (sadly I really think she will be) gets the antiretrovirals that she could have done with starting years ago.

The rest of the morning we spent with one of the senior doctors on the female ward round and then went with him to review some patients on other wards which needed a senior review. He asked us to thoroughly examine the cardiovascular and respiratory systems of one patient while he did most of the ward round quickly. When he came back he asked to borrow my stethoscope to listen and confirm our findings, I watched him put in the stethoscope carefully because last time he borrowed my stethoscope I thought he had put it in wrong but hadn't had a chance to look closer before he took it out. Sure enough he put it in the wrong way round again and we had to tell him because with it the wrong way round it would be virtually useless and he would only pick up the most obvious signs (trust me I have just experimented with mine to check I wasn't being unfair in saying this!). Blimey, putting a stethoscope in the wrong way round is to put it bluntly such a rookie mistake - it’s something I remember doing as a 16 year old during medical work experience, not something you expect a senior doctor to be doing regardless of country! I would assume it was just a one of absent minded mistake if I hadn't seen him doing it before. I wonder if he is the only member of staff who does this - going to be keeping my eyes open for this now!
The senior doctor was not alone in his mistake.. Izzy from Greys anatomy often put her stethoscope in the wrong way round too, that said the actress was not really medically qualified or responsible for peoples lives...

A more modern clinic
In the afternoon we went with a different senior doctor (Dr M) to his private clinic in a larger village nearby. Wow, so different from the hospital! Whilst it was not finished yet as he only started the clinic a year ago, the bits that were finished were so much nicer, more spacious and private than rooms at the hospital. The equipment looked more like stuff you see in the NHS - for example the examination bed was one that could be adjusted into the different sitting angles that are required to examine patients more easily. He was clearly very proud of his clinic and gave us a grand tour and told us all the things he wanted to do to it. Eventually he hopes to turn it into a small hospital, I hope he succeeds because I think he would create a pretty good hospital. Most importantly though, Dr M was amazing with the patients and really seemed to have good medical knowledge like you would expect from an experienced doctor. He was also a really good teacher to us and let us takes histories with him as the interpreter and got us to examine the patients under his guidance. All in all a good afternoon and to be honest it was good to see that the hospital we are based in may not be a reflection of Tanzanian health care as a whole.

Found out from Dr M on the way back that he is the only doctor at the hospital who has studied medicine at university, the others were all clinical officers who did some kind of conversion course to become doctors. .... This explains quite a lot! I would say that judging on the kind of clinical ability we have observed that perhaps such conversion courses should not be possible but apparently when Tanzania gained its independence there were only 12 doctors in the whole country (of which I gather Dr M was one) so they didn't have much choice but to find a way to create more doctors quickly. A bad healthcare situation really and I guess doctors who have the ability to treat at least some conditions are better than none at all so maybe I should try and be less critical of the healthcare standards here... I will try, but I'm not going to sit back and do nothing if patients are at risk if I think I could do something/say something that would help.

Halfadoc x

Thursday, 22 September 2011

Another day, another birth

Standard Monday long morning meeting today, most of discussion in Swahili again but did gather there was one patient here who had had his arm bitten off by a crocodile! Well that's definitely not a standard injury in England! Poor guy though, had been treated in a different hospital but now the amputation site has got very infected. Not easy here to be an amputee either I would imagine (and it’s not like its easy in the UK either) here you don't get given prosthetic limbs or in the case of leg amputations even crutches (there is a man who works in the hospital grounds here who has a missing leg and gets around using a 12 ft (ish) long pole which looks pretty exhausting!). So losing a limb causes an even greater decrease in quality of life here than in England.

Rest of day spent in labour ward where we eventually (quite slow progress again) saw another baby being born. Midwife did episiotomy but other than that Aj delivered the baby which was nice and healthy. I sneaked a standard cuddle with the baby afterwards which this time resulted in me getting peed on! Oh well at least the baby has no bladder problems I guess and besides I doubt this will be the last time seeing as I want to be a pediatrician!

The episiotomy repair was once again done by the light of my nokia flashlight, becoming quite standard now! The repair was pretty bad to be honest… the midwife didn’t really seem to know what she was doing and kept pinching the woman’s skin with the instruments and seemingly not realizing she was and wondering why the sutures were not pulling through. Aj had been offered to do the repair beforehand but declined, by the end we were both definitely wishing she had accepted!

Spent the rest of the day waiting for another birth but it ended up going to c section due to failure to progress late in the evening so we didn’t see that birth in the end.

That’s about all, not a fascinating day I’m afraid, just fairly standard one here.

Halfadoc x

Wednesday, 21 September 2011

Wait people expect me to know stuff?? Eeek!


Brief post today as pretty quiet and nothing exceptionally exciting happened.

Went on the paediatric ward round which was really good today as it was just the doctor, one nurse and me, so I got to write in all of the patients notes. This is a double bonus because not only is it good practice for F1 year but it meant the doctor had to explain each case to me in english (sometimes they just talk about the majority of the patients in Swahili and then it is difficult to learn much on the ward round and gets a bit dull.

The vast majority of the children as ever had gastroenteritis/?Malaria. I’m yet to see a positive malarial test here or be bitten by a single mosquito so I am a bit skeptical about the actual prevalence rate of malaria here in the dry season at any rate. I suppose though as it is such a serious condition that it is better to treat initially as though it is malaria rather than waiting for the test results before treating. It does seem though that the staff here are often so obsessed that someone's symptoms must mean malaria that they are blinded to the possibility of any other illness.

The baby who was in traction for a broken femur when we first arrived here was finally released from his traction prison today :). He looked happy to be released and the leg seemed fine when the nurse manipulated it although he is having an x ray to confirm this later.

Houses patient who I have mentioned before was not on the ward during the round this morning as she was having an ultrasound. The doctor did discuss the patient with the nurse though and whilst most of the discussion was in Swahili, I did catch phrases such as "mentally ill" and "psychological" and then lots of laughter... Not cool. Even if the patient is mentally unwell, last time I checked mental illness wasn't a joke.... A vast culture difference I guess.

Rest of day pretty quiet except for getting surrounded in the village this evening by a huge group of student nurses who wanted answers to various medical questions which turned out to be their homework. I guess it’s not like they have a library full of resources here to look things up and the internet is sporadic at best so doing homework must be a bit tricky. It was quite intimidating having all of them throwing questions at me and I tried to explain I was just a student too but that definitely was not a good enough excuse to them and they expected me to know lots. Fortunately I had some textbooks on me so I could look up things I didn't know for them. Still quite a surreal experience and I hadn't expected to be teaching at all while I was out here!

16/17/18th: Spent Friday and the weekend away from the hospital at Lake Malawi which is incredibly beautiful. So weird to see a lake which has waves and no visible land on the horizon! Got to sunbathe, swim in the lake, go snorkeling, indulge in a beer or 3 and eat nice food. Lovely :). So relaxing to be away from the hospital for a bit and now feel rejuvenated again for returning tomorrow morning.

Monday, 19 September 2011

Episiotomy repair by nokia flashlight!

Episiotomy repair by nokia flashlight!

Today was mostly spent with just one woman who was in labour when we arrived in maternity after the morning meeting. We were told by the midwife she was probably about an hour away from delivering and so decided to stick around rather than going on morning ward round (or in Aj's case instead of going to get an x-ray of a potentially broken foot - injured by jumping off a meteorite for a picture. True story. I failed to get the picture...).

Turned out to be more like 5-6 hours in the end but oh well! For the best in the end as the midwives kept wandering out for literally hours at a time, leaving just me and Aj with this lady who was fully dilated and could theoretically give birth at any time. Not too big a problem if it was a straightforward birth as at least we know how to deal with these now but ideally would have liked to know where help was if we needed it. It was a complicated birth in the end as the woman needed an episiotomy so it’s a good thing the midwives had reappeared. Other than that I delivered the baby, a healthy baby girl.

By the time the repair of the episiotomy was carried out the electricity had gone on one of its frequent disappearing acts and no functioning torches were in the labour room so the suturing ended up being done by the light of my mobiles tiny flashlight! Quite a surreal experience and not one I anticipated when I bought the phone!

Later we heard about a c section that had occurred that morning from one of the other students. The baby had been born with a low Apgar score and required CPR. Having not initially responded to the first few minutes of this the baby had been injected (via the umbilical vein) with adrenaline. This is good… but also odd. We have seen a number of babies during the our 3 weeks here so far that would probably have had a better end outcome if they had received adrenaline as per the resuscitation guidelines but they did not get any. When we have in the past asked why not, we have been told it is because they do not have a large enough supply of adrenaline. However today’s baby did receive adrenaline and the other medics were told that this was because that baby was “a very special baby”. Don’t get me wrong, I’m glad that the baby got adrenaline and apparently he improved a lot immediately after that, but aren’t all babies special and important?? How can they choose one baby over another like that if both babies had equal need of the adrenaline? Well it turned out that this baby was the grandchild of one of the senior doctors and that his mum was 40 years old - so exceptionally old in Tanzania to be having a first child. I guess that explains the preferential treatment of this baby, not sure it would be the correct answer to one of those interview ethics questions about “Who should get the treatment?” though.. But at least someone got it rather than the adrenaline just sitting in a cupboard forevermore.

Aj's foot? Possibly a v. small fracture but some debate - radiologist says yes, senior doctor says no. Management is same either way - RICE, however ice isn't exactly easy to get here and rest/ elevation would involve missing elective...so compression will have to do! Moral of the story? Don’t jump off meteorites in flip flops. Wellll not all morals are universally useful ones :P.

Thursday, 15 September 2011

Born into darkness

Born into darkness

Today did pretty much a little bit of everything:

1. Watched a c section which was performed due to the mother having past history of cervical tear. Both mum and the little boy doing fine though baby was born covered in meconium (a sign of fetal distress.

2. Talked to senior doctor about patient mentioned yesterday. He took my concerns seriously and agreed to examine her with me. No findings on examination but he has stopped all her drugs except magnesium trisilicate (an antacid) in case some of her newer symptoms are a drug reaction and as requested a barium swallow x-ray and also an Hb test. I'm really glad her symptoms are at least still being investigated now.

3. Went to child check up clinic. Didn’t gain much here to be honest - all in Swahili plus seemed to just be weighing kids. Didn't stay long.

4. OPD. Most interesting case today: A young man with VERY obvious jaundice (bright yellow eyes) probable diagnosis = a form of viral hepatitis.

Also I think I successfully diagnosed chronic kidney disease, probably not a great diagnosis for a patient here though as so little they can do. But hopefully with the condition at least known about they might be able to give some drugs to slow the progression / avoid certain drugs which damage kidneys.

Final part of the day was in maternity late this evening where I delivered my 3rd baby (admittedly with a reasonable amount of help from the midwife as the baby didn't pop out quite so easily plus had cord around his neck). Birth occurred during one of the common powercuts so he was born by torchlight! But he was healthy and cried instantly :). Mother was very young (only 16) and not married which is still quite stigmatized here so I hope they will both be ok in the long term.

Halfadoc x

Midnight madness in maternity

Midnight madness in maternity

12.09.11: Went back to hospital this evening planning on heading to labour room to see if anything was going on, computer room was open so we went on internet for a bit, AJ headed to maternity once she was done and was going to phone me if there was anything exciting happening while I stayed on internet (putting up one of blogs!) Unfortunately hadn’t banked on it being so busy that she wouldn’t even be able to call!

When I arrived 15 mins later AJ had already delivered one baby. She had walked into the delivery room to find no midwives about and just one nurse who was faffing about doing something else despite the fact a lady was literally giving birth. However it was not the baby’s head that was protruding from the vagina but its bottom. Uh oh! Breech presentation! Aj managed to deliver half the baby but was struggling to get its arms into the right position when fortunately a midwife arrived and did the rest of the delivery. The baby unfortunately was seriously pale, not breathing and slow heart beat and so in need of major resuscitation. Aj assisted with this (and was able to ensure the right CPR ratio was being done at least initially). When I arrived the baby was crying…sort of. It was the weirdest cry I have heard, definitely not a healthy one so hope the baby recovers ok.

Unfortunately in all the commotion no one had been available to deliver the placenta and now the uterus had contracted too much and it was impossible to get the placenta out safely in the normal manner (we all tried!). In addition there were 2 other ladies in the labour ward, 1 whose baby was going into fetal distress (the heart rate had dropped very low) but was not close enough to normal vaginal delivery and the other who was fully dilated and almost ready to give birth. One doctor had arrived by this time but there were now 2 patients she needed to deal with – 1 requiring manual removal of the placenta and 1 requiring a c section due to fetal distress. She did try to suggest that AJ could do either the c section or the removal whilst she did the other (and I’m not sure she was joking :S) but AJ sensibly declined and told her to phone another doctor regardless of the time!

I went to see the c section (mostly because I was worried that if the baby was in distress then it might need CPR and I wanted to ensure it was done right this time!) while AJ stayed to watch the manual removal. During the caesarean section the surgeon got literally covered in meconium filled amniotic fluid. It’s a good thing she was wearing both goggles and a mask (a scary amount of the doctors here don’t bother with goggles) because if the mum was HIV positive (common here) then amniotic fluid in the eye could infect the doctor although it is quite unlikely. When the baby came out he was fortunately very healthily crying away so I was glad both that he was fine and that I would not to have to say anything about CPR ratios!

As soon as I arrived back in maternity I just had enough time to wash hand and change gloves (note to self, dry hands before trying to shove gloves on!) before helping with the third women’s labour as she was starting to deliver as I walked in. That baby was another boy and also healthy :D.

The placenta from the 1st woman was eventually successfully removed but the lady did lose quite a lot of blood. She was allowed to stay in labour room so she could be carefully monitored – glad to see this done for once as quite often here even very sick patients are left quite far from the medical staffs view!

One of the babies being weighed. The hospitals scales are pretty basic and you have to move a pin along until the scales look balanced.

So yeah, quite a manic few hours, especially for AJ. I think we were both in need of a long sleep when we got home. Kept for a bit longer though because we had just discovered not only were our taps magically working but they were letting out cleanish water! Massive excitement and cue filling as many buckets as possible while it lasted! And then finally sleep :D.

Halfadoc x

A patient for Dr House

A patient for Dr House

Today on the ward round I met a patient who had a confusing set of symptoms and had been given in my opinion a very unsatisfactory diagnosis. I struggled to work out the patient’s exact symptoms and their duration due to most the discussion about her being in Swahili and although I later tried to read through her notes (v.vague) and take her history, neither the patient nor her family spoke much English so it was pretty hard. But the gist of what I think was her history is as follows:
1. Chronic headaches which she presented with 3 weeks ago but had been suffering from them for a long time and they had been getting worse.
2. Chest pain for at least 3 weeks - patient gestured at her sternum so I think it is midline chest pain, she also seemed to indicate the pain was worse on swallowing and then the pain went down, but this was all in gestures so not too certain!
3. Some confusing history of abdo pain,?fever and possibly some diarrhoea and vomiting over past 3 weeks.
4. 5 day history of bilateral leg weakness and some weakness to right hand.

Past history: 1 year ago was treated apparently successfully for ?peptic ulcer disease.

The doctor’s impression?
The patient had been in and out of hospital a few times over the last 3 weeks and had already been treated/ tested for the standard combo of ?malaria, ?typhoid, ?TB, ?HIV plus had been given a chest x ray. As the x-ray was clear and the patient was still ill even after receiving treatment the doctor concluded that her symptoms were "psychological and due to hysteria not a physical condition". The main reasoning he gave to me (beyond exclusion of the above diseases)? "The woman has no husband or children". Whaaaaaaaaaaat! So being single and childless = psychologically ill... Well better diagnose me along with her then! (And they probably would too - some of the midwives have already told me I am crazy when I have said after they questioned that I don't currently have a boyfriend!).

Psychological causes of symptoms in England are supposed to only be diagnosed when all possible/probable organic causes (physical illnesses) have been excluded. Here they definitely have not been, I’m aware they don’t have the facilities to diagnose all possible organic causes of her symptoms but I felt there were still some causes they could investigate that they had not considered. I was writing the notes for this patient and so under “Impression” should have written mental illness as this is what the doctor thought and wanted noted. Well I couldn’t very well not state his impression as I am definitely not in the position to do that but I did change the wording very subtly to “doctors impression”. A small act of defiance perhaps, but not one that would be noticed or was aimed to be, it’s just I wouldn’t feel happy signing my name at the bottom of those notes otherwise as that would imply mental illness was my impression of the patient.

My actual impression/ differential diagnoses?
1. Recurrence of peptic ulcer causing chest pain plus anaemia due to blood loss as a result of the ulcer (which would potentially explain the leg weakness). The patient had not reported vomiting blood but it could be an ulcer lower down so the blood may be being lost through stool instead. The headaches could also be connected in that she may have been taking analgesia such as NSAIDs (eg nurofen, aspirin) for her headaches which can cause ulcers if taken for prolonged amounts of time.

2. Some form of endocrine (hormonal) disorder, possibly secondary to a form of cancer/ cancer metastases which may in itself explain some of her symptoms such as the pain on swallowing. She is quite young to have cancer though as she is only 27. Sadly not impossible though but hopefully not.

3. Electrolyte imbalance. Again this tends to only explain some of her symptoms (particularly the leg paralysis) but can again be secondary to something else like cancer metastases which could explain the rest.

4. Lupus... Ok I'm clutching at straws a bit, but it is a genuine possibility albeit an unlikely one. The reason it always over appears in programs such as house is that it can present with a wide range of symptoms. Therefore if you have a patient with a weird mix of problems it can be a tempting diagnosis in that it neatly explains all of them! Lupus is more common in women and most common in this patients age group soooo it could be a possible differential. She didn't have any of the clear cut signs of lupus though such as a butterfly shaped rash on her face - whilst only 50% of lupus sufferers have this rash, it does mean she is less likely to have this condition.

5. Somatoform disorder. It is a possibility, but I still stand by it being a less likely one than the above possible causes (and undoubtedly there are likely to be other possible causes that I either have not considered or have mistakenly discounted). And as I said before, it a diagnosis that should only be considered once all other possible causes have been excluded WHICH THEY HAVEN'T!!! Okay.. Rant over... For now :P

Well will try and suggest my differentials to one of the senior doctors after tomorrow mornings meeting and see what they say. Will attempt to phrase it in a kind of confused student wanting teaching/ explaining way in an attempt to minimise irritating anyone. I'm not sure what else I can do and I really don't want to do this but if I don't do anything then I don't think anyone will look further into possible physical causes of her illness. Maybe they won't anyway but at least I will have tried.

Halfadoc x

Thank god for Obama

Thank god for Obama!
Running a bit behind on blogging now so this is just a quick catch up on events of weekend to get me back up to date again!
Friday was mainly spent on Maternity where we saw and helped with a couple more births including one where the baby had the cord semi around his neck and had to have it cut whilst he was still coming out. A bit terrifying but fortunately he was ok as were the other babies born that day. Lots of babies being born on both Friday and Saturday – perhaps the popular midwife myth that more women go into labour around the full moon is correct!

On Saturday AJ went into the hospital (and saw 3 more babies being born!) but I was stuck waiting for the electrician to come (he didn’t even come! How very English!) as we now hadn’t had ANY electricity for 5 days. Thought this was a standard longer power cut to start with as we have many shorter ones every day. Turns out though it was just our house that didn’t have any electricity and we also haven’t had anything but muddy water coming out of our tank for over a week. So cold showers and coal fires for food have been our only option for a bit and we don’t even have enough clear water to have a decent shower. It’s fair to say we smell :P.

The other medics have gone to a posh hotel in the nearby big town for the weekend so it has just been me and AJ bumbling around the house in the dark. We are a little too attached now to a Barack Obama themed torch we were lent when we got here that has now been our only form of light most of the time for the past week!

Sunday evening: Electricity finally fixed! Happy days :D

Monday, 12 September 2011

Too much death

Too much death
In retrospect maybe I should have discussed a couple of the OPD cases I saw yesterday because 2 of them were admitted and sadly died.

The first one was a 1 year old baby girl who was very weak, anaemic and malnourished. Contrary to what I thought when before I came here not that many patients tend to be undernourished in fact if anything they tend to be slightly on the larger side. The only patients I have seen who looked emaciated were those who have chronic diseases such as HIV.
So I am not sure if this girl’s anaemia/malnourishment was due to lack of food or because she also was suffering from a long term condition. On the weight chart her weight had dramatically dropped on the last couple of readings. In the morning meeting they reported that she had died over night :(. Just too weak to survive the infection I suppose.

The second patient was a 23 year old girl who had pneumonia as a result of being immune compromised. Her HIV had been diagnosed over a year ago but weirdly she was not receiving any anti retrovirals - these are fortunately one of the few drugs that the government prescribe free of charge so expense is not why she was not getting them. Her CD4 count (these are immune cells that are destroyed by the virus) was very low when checked yesterday at 160 cells per uL. A good CD4 count is over 500, so she really really really should have been receiving treatment and the doctor was not sure why she was not - it was not due to patient refusal. I remember when I saw the patient yesterday that I was struck by how weak and fatigued she looked - she couldn't put her own shoes back on, her mum had to do this for her. I also realised that the girl was basically my age and yet our lives couldn't be more different - all I was worried about yesterday was whether or not I would get to practice taking blood while I was here but she was clearly literally fighting for her life. Whilst I was not surprised to hear she hadn't pulled through because she was clearly very very ill, I was still quite shocked because she was still so young, such a massive waste.

Unfortunately this was not the only death we heard about/ experienced today. In the afternoon we went to OPD and we entered a consultation room behind a nurse (here you can't wait for patients to leave like you would as a student in England because more often than not the next patient will enter whilst the first patient is still there so there is no gap between patients). The nurse was mopping up pus from someone’s leg which was on the floor (Ick!) and the doctor was talking in Swahili to a husband and wife whose small baby lay on the examination bed wrapped in multiple blankets (as commonplace here in spite of what seems to us as very hot weather!). As ever the next patient was standing behind the husband and wife. It wasn't till halfway through the consultation that the doctor turned to us and said the baby was dead on arrival at OPD and he was filling out the death certificate. I was horrified that we had accidentally stumbled in on the middle of what should have been a very private moment for the grieving parents. But at least we had not done so intentionally - why on earth the nurse had been moping the floor during that particular consultation or the next patient had not left the room when he realised what was going on (after all they both spoke Swahili so should have realised pretty quickly), I have no idea. Also the doctor could have simply locked the door (I have seen this done during some consultations) which would have stopped all 4 of us from coming in the first place. From an outsiders perspective who is not used to the culture it seems people here receive very little privacy even when they may need it most. I definitely prefer the way death and grief is treated in UK hospitals.

The rest of the day consisted of watching a vesicovaginal fistula (essentially an abnormal connection between the vagina and the bladder resulting in incontinence) repair, going to a diabetes clinic, and examining a patient with heart symptoms without the aid of a translator. The VVF surgery was unfortunately not successful as the fistula had been there since 1989 and so the acidic urine had eroded lots of structures. In the diabetes clinic we learnt that they only have 1 type of diabetic medication here as the others are too expensive. Therefore if someone’s blood glucose level is not well enough controlled by that 1 medication then they cannot put them on additional different medications like they can in the UK. As a result a lot of the patients we saw still had worryingly high glucose levels.

During the diabetes clinic a really awkward moment arose where the doctor asked us to write the patients name on the "patient signature" line of her insurance claim form... He said the patient could not write and he could not do it for her because then it would be a forgery as the handwriting would be the same as the rest of the form. Nevermind that it would be a forgery if we were to sign or that surely if this is being done regularly the signatures on past insurance forms must all be completely different. We were not comfortable with signing the form so refused as politely as we could and the doctor went off to find someone else who would do it. While he was gone we tried to explain (by gestures!) that virtually anything would do as a signature even a scribble and she started to practice on a notepad. She could write! Not especially well but definitely well enough for some form of signature. We explained this to the doctor when he came back with a very reluctant looking nurse, but he got the nurse to sign the form anyway. All very odd and ethically dubious. I was particularly disappointed by the whole situation because I had thought this doctor was one of the better ones!

That's all for now,

Halfadoc x

Thursday, 8 September 2011

It's a boy!

It's a boy!


Spent most of the morning in the hospital laboratory as I heard that's the place to be if you want to practice taking blood (which I desperately do, at the moment someone could have a vein the size of the M25 and I would probably still miss!). Unfortunately the first patient who came in was a terrified 8 year old who was shaking like a leaf. The lab technician told me I could take his blood but I declined. I am not going to put a scared child through what will almost certainly be additional pain as would probably not manage to get blood from a kids tiny veins. Will definitely wait until I am confident at taking blood before I try on a child! Unfortunately although the next patient was an adult who had juggernauts for veins, the lab technician did not offer me the chance to take his (presumably because I had declined taking the child's). Massive shame because his veins were obvious enough that even I would have probably managed and I could have done with a taking blood win. Unfortunately even though I stayed a couple of hours more no other patients came to have their blood taken. The lab technician did show me some interesting things like what tuberculosis bacillus looks like through a microscope and how to test someone's blood group, but it was still a bit of a waste of time seeing as I was hoping for some blood taking practice.

Went to OPD for a few hours after, a few interesting patients but I won't go into details today as am trying to make posts a more reasonable length!

After OPD I went to maternity to see how a woman who was in the starting stages of labour in the morning was getting on. During her last vaginal examination a couple of hours previously she was already 8cm dilated so decided to give going home for a late lunch a miss and stick around with Aj because she would probably give birth very soon. Soon the midwives were asking which of us wanted to deliver the baby and because AJ is doing some research which involves having to observe deliveries rather than actively participate, I got to again. Woooo!

The actual delivery this time was harder because the size of the woman was smaller in comparison to the baby's head. In the end the midwife had to perform an episiotomy (cut the tissue at the opening of the vagina in order to try and prevent a less well controlled tear occurring) without even any local anaesthetic - OUCH!! But it was successful in that the baby came out much more easily after this. He was barely out before he started crying! Such a relief after all the seriously ill babies we have seen recently! He was exceeding beautiful too!

This time I got to clamp and cut the cord as well as things were less rushed due to the baby being healthy. Did manage to splatter AJ with cord blood though - sorry!! After I had delivered the after birth and cleaned the mother up a bit, the episiotomy was stitched up. I was asked if I wanted to suture it myself, but seeing as I haven't ever sutured a real person before (fake skin only!) and can't even really remember how, I decided doing so for first time on a fully conscious patient who had no anaesthetic probably wouldn't be the best idea. I settled for a nice long cuddle with the baby instead!

The woman said thank you to me multiple times afterwards, and grabbed my hand to say it again this evening when we were walking through to see if any more ladies were in labour. Patient satisfaction! Feels pretty great :D! (and did I mention how cute baby was ;D!)

Halfadoc x

Wednesday, 7 September 2011

The pregnancy which was not

The pregnancy which was not

6/9/11: Today we had the rare opportunity to observe treatment of a molar pregnancy. This is where there is abnormal placenta formation due to an ovum (egg) being incorrectly fertilised - usually by the genetic material from just 2 sperm (so no maternal material - the egg is empty) but sometimes from maternal material as well (so has 50% extra chromosomes). As a result of the abnormal genetics the placenta invades tissue beyond its normal site and the embryo is incompatible with life, but the pregnancy hormones are still produced and so amenorrhoea and the sensation of pregnancy continues without a fetus. 3% of complete moles (those moles just produced by paternal DNA) develop in a malignant disease - choriocarcinoma (cancer originating from the chorion, the outer layer surrounding the embryo prior to its death).

Ironically in molar pregnancies the symptoms of pregnancy are exaggerated and the patient is likely to suffer from extreme morning sickness and have a uterus which is large for dates.

The treatment of moles in the UK would follow the following steps:

1. Removal of the mole by gentle suction.
2. Weekly hCG (the hormone produced in pregnancy) checks until the level returns to normal. A rise in hCG would indicate possible relapse or invasive mole.
3. Avoid pregnancy for at least 1 year
4. Increased risk future pregnancy will also be molar - ultrasound to confirm is normal
5. Chemotherapy may be required if invasion mole or choriocarcinoma.

In Tanzania however molar pregnancies are removed using D and C (dilatation and curettage - the cervix is dilated and then the lining of the uterus scraped off using a curette), patients are advised to attend follow up in a year but the doctor told us they don't tend to turn up and very few hospitals can offer chemotherapy if it is needed due to expense.

Molar pregnancies are quite rare in the UK (oxford handbooks quotes a rate of 1.54 in every 1000 pregnancies) and are only treated in I think 2 specialist centres - everywhere else refers patients to these. Therefore most medical students or even doctors do not get to observe the treatment of molar pregnancies being carried out. So I guess from the point of view of my training it is pretty lucky to get to see this treatment happening. But from the patients point of view it must have been a horrible diagnosis, going from being 6 months pregnant to not being pregnant at all and instead having material in her uterus which might turn into cancer. When I say I was lucky to be able to observe this operation I don't mean I am pleased the condition had occurred; obviously I would very happily swap this learning opportunity for her to instead have a successful normal pregnancy.

The actual operation was pretty gruesome with lots of large lumpy bits being removed and the patient lost perhaps a litre of blood. Molar pregnancies are supposed to look like frog spawn on removal... Well I wouldn't say that but was quite unusual in appearance.

D and C looked seriously harsh way of treating the condition (think I prefer the sound of the gentle suction recommended in England!). At least this patient was under general anesthetic though - we saw a D and C on a woman who had heavy periods (so ?endometriosis) immediately before this surgery where the woman didn't even have local anaesthetic. Although that procedure didn't last anywhere near as long and involved less curettage, the woman still looked in considerable amounts of pain. The molar pregnancy patient had the same anaethatist as the other day (bowel obstruction patient) - still wasn't impressed with him, he seemed fascinated by the operation which is good but as a result spent a lot of time watching the D and C and very little time observing the patient or her vital signs. Yet again we had to alert him of worrying vital signs or movements from the patient. To quote AJ, he was "about as useful as a chocolate fireguard".

The rest of the day was pretty quiet, no women in labour and OPD was very empty. Aj and I were asked to review a patient on maternity by one of the midwives who thought she looked ill. She did look pretty ill and was tachycardic and tachypnoic (fast heart rate and respiratory rate). We couldn't hear the fetal heart sounds to start with but fortunately this turned out to just be our lack of experience/ ability rather than a genuine problem! The patient had been suffering from abdominal pain for 5 days and the pain was especially on the right hand side, she also had been recorded as having a swinging (temperature up, normal, up, normal etc) fever throughout her time in hospital. Right hand side pain tends to ring alarm bells of appendicitis but I think maybe this patient would be even sicker if it was appendicitis untreated for 5 days and the doctors seemed to have considered it and then discounted it. The doctors had already treated for malaria and now thought the pain was due to myositis which is basically just inflammation of the muscle and can be caused by anything from lupus (which would be Houses working diagnosis no doubt!) to bacterial infection. So a pretty vague diagnosis really and the patient was being given several antibiotics to try and treat the possible infection.

When we took the patients history with the help of a midwife as translator we discovered she had not passed stool or flatus (wind) for the last 5 days either. No one knew this yet because no one had asked. Pretty shocking question to miss out on an abdominal pain history - in England if a patient has abdo pain you always always always ask about bowel movements. Whether or not these symptoms are causing the pain (she could have bowel obstruction, the lack of even flatus in particular is a bit worrying) or the pain has caused the symptoms (if a patient is not mobilising due to pain, their bowel can become more dormant and so they get constipated) is difficult to tell. We asked a doctor to review the patient and as a result he prescribed her some laxatives. Hopefully these might help relieve at least some of her pain.

So much more responsibility here as a medical student than in UK (we see patients in England too but they will always be seen by a doctor afterwards regardless of what we say, here if we don't ask for a senior review then the patient will not get one), great practice for when we qualify though!

Halfadoc x

Tuesday, 6 September 2011

Who is to blame?

Who is to blame?

5th september

Death of a newborn
Another very tough day.

Found out at the ward meeting today that the newborn baby the midwife, AJ and I rescucitated late thursday evening had died at 11pm on friday. I was shocked and horrified by this news. As you can see from my last blog, I thought this baby was now doing ok and I was hoping he wouldn't suffer any long term consequences as a result of his birth asphyxia.

Aj and I have been wracking our brains trying to work out why he deteriorated again and whether anything could have been done to prevent his death. From a self centered point of view we really wanted to know whether our own actions contributed in anyway to him not surviving.

The baby’s notes say that on Friday morning he had started breastfeeding but at 11pm the doctor had been called because the baby had no vital signs and he then failed to respond to resuscitation.

Why? At birth he was probably suffering from Meconium aspiration syndrome (MAS) which is where the fetuses draw amniotic fluid containing fetal stool into their lungs. This only occurs when the baby was already asphyxiated in the uterus (as he would have been due to the uterine rupture) leading them to effectively gasp for air but as they are still in the uterus they take in the amniotic fluid surrounding them instead. The meconium both irritates the lungs and causes a sort of valve where the baby can inhale air past the meconium blockage but can't exhale it back out again meaning their lungs soon distend too much to inhale anymore. This plus the asphyxia in the uterus means the babies vital organs may have been without sufficient oxygen for some time leading to anaerobic respiration and the buildup of lactic acid and other acids - the acidaemia/tissue ischaemia can damage organs. Some damage can present later - e.g. if the kidneys were damaged eventually electrolyte imbalance would occur due to filtration failure which can lead to cardiac arrest. So perhaps something like this happened causing the babies delayed deterioration that occurred after breast feeding (so potentially when there were more waste products to be filtered/removed?) this is all just academic debate though and as no post mortem is going to be carried out, the exact cause of his death cannot be known.

Did anyone cause his death/ could anyone have prevented it?

• The mother presented very late to hospital (well into the 2nd stage of labour) even though she had had 2 caesarreans in the past so should have known she needed to have him this way as well. Sadly if she had presented earlier then the uterine rupture could undoubtedly been avoided and so the woman would not have needed a hysterectomy, plus in all likelihood her baby would have been born healthy. So mothers fault? Unfortunately probably quite a lot of the blame might be hers, but by no means all as there are other factors. One such factor might be poor education of patients - possibly she didn't understand she had to present to hospital early/ had to have another c-section.
• The style of caesarreans carried out here is the "classical" form and is more prone to uterine rupture than the form done in the UK. So maybe had the original surgeons performed the better form of c-section then the uterus would not have ruptured...
• Slow action of medical staff in getting the mother into theatre - AJ has researched and in the case of uterine rupture there will be significant neonatal mortality if the baby is not delivered within 18minutes of there being signs of fetal distress (and apparently blood loss like seen in this patient is a later sign than fetal distress). Well fetal distress was not checked for and I do not think they delivered the baby within 18 minutes of seeing blood so the baby’s chances of survival were decreased as a result.

• Actions during resuscitation - this refers to the actions of the midwife and me; did we carry out CPR in the best way possible? I wish I could say we did everything textbook perfectly, but as I said in last blog, I don't think we did. Some of this was to do with lack of resources and some of it was to do with the midwifes incorrect instructions to me on how many chest compressions I had to do to each of her bag squeezes. Therefore some of the reason for imperfect CPR was also my own failure to speak up and quote the current guidelines rather than meekly following her directions. Could a better ratio have made a difference? Potentially yes, more chest compressions could have meant more oxygen got to the babies vital organs (rather than just being bagged into his lungs but exhaled out before it could be picked up by red blood cells and carried away in the blood) meaning less hypoxia and damage but it’s hard to know though whether a critical amount of damage had already been done before CPR was even attempted.

• Better monitoring of babies who had required special care at birth. Whether or not this particular baby could have been saved if his deterioration had been observed, I don't know but babies here are definitely not observed closely enough in the first days and for some of the neonatal deaths that occur I'm sure closer observation would make a big difference.
• Lack of proper newborn examination, separate problem? Could have had a congenital heart defect or something that also contributed to the baby’s poor condition. Unlikely but possible.

I guess all I can console myself with is the thought that had I not been there the CPR ratio would not have been done any differently (and indeed I think we tried to do the right ratio when the midwife wasn't there, but it’s already all a bit of a blur so I can't remember 100%). So did I personally kill that baby? No. Did I possibly fail to prevent the baby’s condition from deteriorating further when I might have been able to make a difference? Yes. If I could go rewind time and tell the midwife my opinion about the advised CPR ratios rather than doing what she told me to, would she listen to me? If she did listen to me would it make a difference to the end outcome? I don't know and I guess I never will and it sucks. I wish I could rewind and try again though and I hope an infinite amount that by not saying anything to the midwife I didn't cause an unnecessary death.

One thing’s for sure, I’m definitely going to try and find away to educate staff about CPR now.

Attempted murder of a newborn

When we visited the labour ward later to see if there were any imminent deliveries we could assist in we were told that one lady had given birth but then thrown her baby head first into a toilet. Fortunately a nurse had found the baby. The baby was ok but put in warm baby room as it was very cold and is now being given penicillin to prevent infection as a result being in an unhygienic toilet.

Apparently the mother had hidden her pregnancy from everyone throughout the 9 months so it seems she hadn't wanted the baby for some reason (abortion here is illegal so it would have been difficult for her to terminate the pregnancy had she wanted to). I don't know if the woman was married (single mothers are VERY frowned upon here) but she worked as a maid so maybe it was the child of her employer or someone else that it shouldn't have been.

Perhaps more likely considering the extremity of her actions is that she was not just acting out of desperation but suffers from some form of psychiatric condition. I don't think it could be post natal depression though because it seems too soon after the birth - normally occurs around 6-12 weeks, but this doesn't mean she didn't have another psychiatric condition causing her to not be to blame for her actions. Though with the seriously substandard mental health care I have experienced here I doubt she will be successfully diagnosed / treated if she is suffering from a psychiatric condition.

I hope the child will be looked after somewhere safe.

Death of an expectant mother and foetus

We also discovered when we visited the labour ward that a 7 month pregnant lady had just passed away due to hypovolemic (decrease in volume of circulating blood) shock secondary to internal haemorage. One of the other medical students was there when she died and was not convinced she received the best possible care. For starters the hospital did not have any large cannulas available which means she was being given fluid through tiny cannulas - in hypovolemic shock you need to get lots of fluid in very very quickly. Also as the doctors thought the cause of the internal hemorrhage was uterine rupture or rupture due to an ectopic pregnancy, she should have been rushed to theatre as soon the cannulas were in where the damage could be repaired (and baby delivered just in case it could be resuscitated - there were no fetal heart sounds) before she lost even more blood.

If it was an extra uterine pregnancy (ectopic) then in England this would have been detected a long time before 7 months of pregnancy due to the widespread use of ultrasound check ups. The actual cause of her internal haemorrage will remain unknown though because apparently here post mortems need permission from the police or relatives. The relatives did not give permission - apparently post mortems are not very acceptable in tanzanian culture. I suppose people don't particularly like them in England either but if patients die under particular circumstances then legally they are required and no permission is needed.

But to summarise this is yet another tragedy we have seen caused by lack of resources and poor management of uterine rupture. Not a good day.

Rest of day consisted of a ward round on the male ward in the morning, which was interesting as AJ and I got to alternate writing in doctors notes or prescribing under doctors directions, great practice for being an F1. Then we spent some time in OPD- this time with a fully qualified and experienced clincal officer but even so for a number of patients he didn't know what the problem was and asked AJ and me and used our impression and plan in the notes. Pressure!

Nothing going on mid afternoon onwards so we went home for a bit then went back to labour ward early evening, but still no imminent labours so gave them our phone number and asked them to call, no matter how late if someone was giving birth. 11pm now and no call as of yet! Update: no call all night, so at least lots of sleep.

Sunday, 4 September 2011

First do no harm, part 2

First do no harm, part 2

1st September: In the evening we went to the delivery ward to see if there was anything going on. There was 1 lady who was having her first child and was fully dilated when we arrived but the baby’s head was not fully engaged in the birth canal. 3 hours later the doctor came and examined her and the baby still had not descended and the membrane had not yet ruptured (in other words her waters had not yet broken) and decided if the baby had not descended within 3 hours then they would perform an emergency c section as they thought there may be cpd (babies head too big for mums pelvis). About an hour later the membrane did rupture spontaneously but there was meconium (foetal stool – it is a bad sign because the baby can swallow it leading to foetal distress) in the waters, the midwife examined the mother again (it was hard for her to feel the head before as the membrane was bulging and in the way) and decided that there was no way the woman was going to be able to deliver vaginally and she would definitely need a caesarean. With this statement made the midwife sat back down and didn’t contact the doctor…

We were very confused because if the patient was definitely going to need a caesarean plus with the meconium in the water there was a risk of foetal distress, then why wasn’t the midwife calling the doctor to get the caesarean done sooner than 2 hours time – surely there was no point the patient having to go through another 2 hours of unnecessary labour pains when she wasn’t going to be able to deliver vaginally anyway. We tried to tactfully say this to the midwife and ask if she was going to phone the doctor (trying to phrase this in a way where we did not seem bossy/ rude). The midwife did not seem to understand us when we said it would save the patient a lot of pain, I really don’t think maternal pain is something they take much into account here, and she basically just said that the doctor would be back of her own accord at some point. Finally about an hour later the doctor did come back and agree the patient needed a caesarrean but sadly for the patient by the time her blood had been taken for blood grouping and the stretcher had just arrived (the patient was literally about to sit on it) another patient came in who needed a caesarean and needed one more urgently than the first patient.

The second patient had had 2 past caesarean deliveries and had presented very late to hospital, you could literally see the baby’s head on examination already, but the baby was not coming out on pushing and instead blood was indicating that she was probably having a uterine rupture due to the scar from her previous caesareans splitting. So this patient was rushed straight to theatre and the first patient had to wait even longer for her caesarean – which was frustrating because she could have already been finished in theatre by this point if the doctor had been contacted when it was first clear that a SVD (spontaneous vaginal delivary) was not possible.

We went to surgery with the second patient, the emergency caesarean was clearly very necessary as when they opened her there was a lot of blood already pooled beneath the surface. When the baby came out he was very blue, not breathing and when I checked his heart rate it was beating but initially definitely below 60bpm (guidelines say that if a newborns heart is 60 beats per a minute then you should initiate chest compressions). So AJ and me and a midwife intiated resuciation, suctioning (the baby had a lot of secretions in his lungs) and rubbing/ lightly pinching the baby to try and stimulate the baby into taking a breath. When it came to cardiopulmonary resusciatation I was doing the chest compression and the midwife bagged him for a bit before the midwife was needed elsewhere and then AJ took over the bagging and the midwife occasionally came back over to check everything was going ok. To be honest it was better when it was just AJ and me doing the resuscitation because the midwife was instructing us to do the wrong CPR ratio’s – we had looked up the current guidelines for newborn resusciatations following the caesarean the other day when the other medical students had ended up doing CPR on that baby. The midwife didn’t even have the ratio the right way round and was instructing us to do far too many breathes through the bag and not enough compressions. There’s no point putting an excess of oxygen into the baby if the heart is not pumping enough for the oxygen to reach the babies brain! This is the second time we have experienced staff seeming to be unaware of the most efficient CPR protocols since we have been here which is a bit scary seeing as it was only the fourth day and as they do not have advanced resuscitation equipment here, basic CPR is something they really really need to get right. I don’t blame the staff, I think this is probably a case of poor medical education and not being able to easily keep up with current guidelines (trust me getting on functioning internet here is akin to getting blood from a stone, which is why my blogs are very dull without pictures at the moment – will try and fix this when I can!). But as someone who is aware of the cpr guidelines, I think I probably have a responsibility to try and educate the staff about these but I have no idea how on earth to do this in a way that staff might actually listen too and follow the guidelines in the future and how to do so without causing offense to staff and making an awkward atmosphere. If anyone has ANY ideas about how we could do this, please comment below J .

We eventually managed to get the baby breathing and his heart rate was going at a much healthier 120, SUCCESS! Unfortuantely though he still was breathing a bit wheezily and was floppy and yet to cry. There wasn’t much more we could do though apart from wrap him up tight to try and keep him warm and try and stimulate him a bit more into crying but sadily he still hadn’t cried by the time he was taken from us to go to the baby room, so after checking someone was definitely keeping an eye on him we went home. Came into see him early Friday morning before the meeting and was pleased to see that he was in the middle of a full scale cry :D, for once was very happy to hear a baby crying!

The second caesarean (of the orginal patient) happened whilst we were still trying to resuscitate the baby so we didn’t get to see this birth, but I didn’t mind as was just very glad that the patient was finally receiving her caesarean after all that waiting. Her baby also initially had some problems but was breathing slightly from the start and we heard the baby give a nice loud cry whilst we were still trying to resuscitate the other baby

I’m aware my last two post are very critical, and I hope I don’t sound like an arrogant medical student, far from thinking I know everything I am very aware how little I know, but it was just scary how many simple mistakes/ things that even I could see were bad clinical practise have occurred during the last couple of days and indeed entire week. As of yet no one has died from any of the mistakes (though I am worried about the bowel obstruction patient as I can't see how she will not obstruct again) as I think the stroke patient would have died even if the CPR had been done perfectly, but I am terrified that at some point a patient will while I am here. This is only the end of the first week :S ...

First do no harm

First do no harm

1st/ 2nd September 2011: The last few days have been quite frustrating from a medical perspective. I knew when I came here that the quality of medical care wouldn't be anywhere near as good as it is in England due to lack of resources, but I don't think I had considered the impact that possibly poorer medical education of the doctors, nurses and midwives would have on the quality of care. I'm not sure all of the mistakes I have seen in the last few days can even be accounted for by inferior education (possibly - I’m assuming so due the country being a lot poorer and so having less money available to train doctors) though; some of them seemed to be due to just poor judgment and arrogance/ laziness on the part of some of the doctors. I don't like to be so harsh but I really have seen some shocking clinical practice in the last couple of days.

Will have to split these mistakes up I think or this post will be farrrr to long. :S. So starting with Thursday morning:

Thursday morning we were all due to watch an exploratory laparotomy on the patient mentioned yesterday who had a bowel obstruction. This was meant to be happening first thing and by about 9.30am the patient was ready and lying in the operating theatre. So far so good.

Unfortunately for the patient before the operation could start, another patient was rushed in to the other major operating theatre for an emergency c section because the patient had taken local herbs (this seems v.v common) and they were worried about fetal distress. Apparently there were not enough staff available to fill 2 operating theatres today because it was a public holiday. This meant the patient had to wait lying on the operating theatre for was almost another 2 hours whilst they performed the caesarean. Not ideal, in England public holiday or not, enough healthcare staff have to be available to safely run the hospital and this is what you sign up for when you train in a healthcare field. Still I don't blame the staff for this, this just how the system is arranged here. Also obviously the emergency patient had to take priority, but what I don't understand is why the staff left the poor patient just lying in the theatre waiting for two hours when there was a room just opposite with sofas etc which surely would have been more comfortable and less frightening for the patient. When the operation finally did start the patients BP was very very high (210/160 ish) even though it had been on normal range when she was on the ward. The anesthetist even said that maybe this was because she had been kept waiting in theatre so long, so they obviously do understand here the effect that fear can have on patients general conditions so I don’t understand why they had not taken just a little bit of time to make sure she was more comfortable. As it was, the operating theatre she had to lie in was connected to the operating theatre that was in use by an open doorway listening to the operation going on which I imagine must have been terrifying! Still this wasn’t a life threatening aspect of clinical care, so it wasn’t this in itself that really annoyed me. Side note, we also watched the c-section and when the baby came out she was not breathing, the other medics resuscitated her and she was breathing but not very well and not properly crying when she was taken from them to go to the warm baby room, here there were no staff to observe her condition and the baby was going to be left completely on her own there if the students hadn’t decided to stay and look after her until the family arrived to take over.

It was what occurred during the operation that scared/frustrated me. When the patient was opened up it was clear just how obstructed she was – her bowels were so filled with air that they literally looked like balloons. Firstly the doctor thought the bowel obstruction was caused by adhesions which are a common cause of obstruction (although are usually caused by past surgery which this patient hadn’t had) so she removed these and compressed the bowels to try and deflate them. They didn’t deflate so rather than thinking that there must still be an obstruction somewhere further down which realistically must have been the case or the bowels would have deflated on compression, the doctor decided to puncture the bowel and deflate the bowels that way and then close up the patient because the adhesions were gone… Mistake number 1 and 2. I’m pretty sure that puncturing the bowel is something that you are meant to avoid at all costs due to the infection it would most likely cause and even if I’m not right about this (AJ and I both think we remember this from our G.I surgery placements but that was a while ago)the logic of assuming you have fixed the problem when the distension cannot be pushed down the bowel (when closed!) and out is very very odd. I don’t think I’m explaining the scenario very well, but basically if the bowl is still distended then there must be distension still further along the bowel and the doctor hadn’t even checked for this before assuming everything was ok and she was going to close the patient up. It was only because we asked well why is the large bowel still distended (it was the small bowel she had punctured and emptied) that she decided to look closer at that bowel and then said she had found a mass below the sigmoid colon. However she was still just going to close the patient up and refer her to see the specialist who was visiting in about 1months time... Again I get that they don't have the resources to do that much here and there are things they cannot treat but without some kind of treatment the patient would just obstruct again and so the surgery and the pain associated with it would be for nothing. I think the surgeon noticed our shocked faces at this because she asked us what we thought she should do. We asked if they were able to perform colostomys (where part of the bowel is brought through the skin of the abdomen and opened out so can be attached to a stoma bag and stool will pass out of this opening into the bag, rather than through the rectum - so an area of blockage in the bowel beyond the stoma can be bypassed and so bowel obstruction prevented) at the mission hospital, she said they could and after deliberating eventually called the doctor on the team who specialised in colostomys.

By the time the colostomy specialist had arrived the patient had been on the table for quite a long time. During this time (and at times during both the first and second part of the operation) the patient’s blood pressure dropped dramatically several times and it was obvious she need more fluid to compensate for the blood loss caused by the operation and a couple of times the patient would either move or grimace in pain indicating the anaesthetic was wearing off. Whilst there was an anaesthetist in the room, he seemed to pay very little attention to how the patient was doing and was not very good at checking these signs. Several times AJ and I had to go tell him that either the BP seemed very low or the patient was moving (he was frequently standing at the window looking out rather than observing the patient) and only then would he give her either more fluid or more anaesthetic. Mistake number 3 :S.

The colostomy didn’t happen in the end because they could no longer feel the mass they felt before and decided it had just been a kink in the catheter, they removed some more fistulas they found lower down but the bowel remained distended. At this point they decided to do a PR examination (feeling in the rectum with a gloved finger – not nice but necessary) to check there wasn’t a mass or something in the rectum. I can’t believe they hadn’t done this before doing a full exploratory laparotomy!!! In England all junior doctors are taught that if you don’t put your finger in it you put your foot in it – in other words potentially this very scenario, don’t open up the abdomen if there’s potentially something that could have been fixed without doing so in the rectum. They didn’t however find anything on this occasion, but that for me doesn’t change the fact that they could of and that the patient could have been going through all this pain for nothing, also the original doctor very arrogantly stated that “It's not a doctors job” which annoyed me no end. It might not be a job that we enjoy doing, but it is checking the patient’s health so it IS a doctor’s job. In the end they closed up the patient whilst her bowel still looked very distended declaring that fistulas were the cause, regrettably I don’t imagine she will have a great outcome but I really really hope I am wrong.

Friday, 2 September 2011

Patients seen on a typical day on a tanzanian ward

Patients seen on a typical day on a tanzanian ward

31st August 2011: Very tired today from the events of yesterday and lack of sleep but with help of Kahawa (coffee) managed to be vaguely alive in time for the 8am meeting. Less descriptive post today and more of a list of conditions I saw or was told about on the ward round. Lots of obstetric cases because manily obsteric ward round today. Warning, probably of not of interest to those from a non medical background!


  • Human bite to lip/jaw - caused by husband!
  • Malaria
  • Female adult with partial intestinal obstruction- gas on percussion, diminshed high pitched bowel sounds, dilated loop of ?small bowel (doctors unsure as to which bowel!)on abdominal x ray. Commonest cause bowel obstruction in adults here = volvulus (twisting of the bowel) , kids = introsusseption (the telescoping of one part of the bowel into another). Patient going to theatre soon.
  • PID - pelvic inflammatory disease (caused by STI's)
  • Meningitis
  • Bleed from R. Inguinal area unknown cause.
  • Patient recovering from Perineal tear from labour, and pph (post partum haemorrage).
  • Inevitable miscarriage (due to premature labour start) which occured yesterday - stillborn breech at what then was thought to be 22weeks but based on the size of the baby the doctor thought perhaps 29 weeks (I think this is perhaps even more tragic, because possibly in the UK this baby could have been delivered by an emergency c-section and with the resources available in England would have had a good chance of surival).
  • 13 year old boy with peritonitis (inflammation of one of the membranes in the abdomen)
  • The patient whose baby I delivered yesterday. I think she was still in so the baby could be observed for a bit longer because they had said that normally here woman who have given birth leave within 4 hours and when we saw her on the ward round today she had already been in for about 11 hours since her daughter was born.
  • Patient who had a c section a few days ago due to Cpd (cephalo pelvic disproportion, basically babies head too big for the mum)
  • Patient who had a C section on 27th - indicated due to previous pregnancy scar.
  • Pregnant patient with ?malaria
  • Recent C section - indicated due to big baby and poor progress of labour (4.6kg!) - due to gestational diabetes.
  • Patient who had a C section 6 days ago due to foetal distress where baby hard to extract, lots of blood loss - pph, resulted in subtotal hysterctomy being performed (subtotal = cervix and ovaries left behind) - very young patient, 19 and was first baby.
  • A patient who was on her 8th preg but of these had only had 1 svd (spontaneous vaginal delivary) and the other pregnacies had resulted in 4 miscarriages and 2 premature labours (which I think were too early to be viable). Was admitted to investigate cause of previous failed pregnacies in order to try and prevent the recent pregnacy progressing same way. The cause was found to be due to rhesus incompatibility. This is when the maternal and foetal rhesus factors are mismatched (rhesus factor is one aspect of some ones blood group - blood groups can be A, B, AB, O and then in addition rhesus positive or negative). Rhesus incompatibility occurs when the mother is negative and the foetus is positive.The foetal blood and maternal blood mix during birth and so if the foetus is rhesus positive and the mother is negative the maternal immune system views the positive factor as foreign and so produces antibodies against it. These antibodies cross the placenta in subsequent pregnancies and so if future babies are also rhesus positive the maternal immune system attacks the babies red blood cells causing rhesus haemolytic disease of the foetus. The first baby therefore escapes this disease (which is why the patient had one svd and since has been unable to carry a baby to term). The current pregnancy was successful so presumably this baby was rhesus negative like the mother.

In England rhesus status is checked as a matter of course and if the woman is negative she is given prophlactic anti-d to prevent the formation of the antibodies in the first place.

  • Next patient was 5 month pregnant, slight contractions - salbutamol given to try and prevent full labour, membranes had ruptured so antibiotics given to stop infection.
  • A patient whose due date was apparently 2nd august! This is dangerously late so hopefully date mix up. Baby alive and does not seem big so date mix up likely.
  • Lady admitted 6th june - 2 month amenorrhea, admitted because no babies - bad obsteteric history. 2 miscarriage at 2 and 3 months. Impression: cervical incompetence. Admitted for complete bed rest (only allowed up for toilet), also receiving salbutamol. Now 24 weeks and feeling foetal movements. Homesick but husband visits every day.
  • 7month pregnant patient admitted 2 days ago because abdo pain and thought maybe labour but now abdo pain subsided.
  • Patient who was 4month pregnant, low abdo pain 2/7 prior admission, no bleeding. Past ob hist: 1st = miscarriage, 2nd= baby, 3rd= miscarriage. So bed rest and awaiting proper obstetric examination. ?cervical incompetence.
  • Patient whose obstetric history was: 1st preg = c section, 2nd svd but child died shortly after, non pitting oedema on hospital arrival, lmp (last menstral period unknown but fundal height suggests term. Advised to stay and await labour.
  • Patient who had suffered from uterine rupture due to obstructed pregnancy. Catherterised but still wetting bed, suspected fistula formation.

I found the obstetric ward quite shocking today as its was very overfilled - not only were all tne beds filled but there were 5 other mattresses on the floor (even though there was very little space between beds as it was), 1 of which was underneath another bed so the patient couldn't even sit up and wad forced to lie down at all times. One of the patients who was on the floor was the woman who had had the stillbirth yesterday. Not very nice for the grieving mother. On the otherhand I don't know what else they could have done - overcrowding is probably better than sending away patients in desperate need and the only ambulance here is broken so its not like tney could easily transfer patients to a different hospital.