Friday, 21 October 2011

Seee time on facebook can be constructive

Seee time on facebook can be constructive!


(Apologies in advance for this post containing lots of textbook style medical detail, its quite difficult to explain the situation without it!)

After being in delivery ward very late for two days running (yesterday we left at gone 2 am and the day before was gone 1 am) and still being in for the 8am ward round I was very very tired this morning. To be honest I was planning on going home after the morning meeting for a few extra hours sleep as otherwise I felt I would be too tired to be useful - not skiving really considering how many extra hours I have done in the evening I figured. However in the end I did not because I actually felt I was too needed/ could genuinely alter a patients outcome quite drastically by suggesting a form of management that wasn't currently being done (not something you ever really feel as a med. student in England!)

Basically there was another lady with eclampsia in labour room (2 in 2 days :S) but unfortunately this lady was not term, she was only 30 weeks pregnant. Eclampsia is very dangerous for both the mother and the baby (maternal mortality of 2% and fetal mortality of 15%), and the baby has to be delivered as soon as the mothers condition is stable enough regardless of how premature the baby will be. The patients condition was being controlled reasonably well (At this point anyway.. A few days later the mother still had very high blood pressure and was supposed to have half hourly checks and instead the doctor discovered her blood pressure hadn't been checked for over 2 days! She had a go at the nurses about this which was kind of fai

r enough but at the same she should really have done a ward round on these two days or at least have reviewed the serious cases like this lady then she would have noticed the lack of monitoring sooner.) The management of the baby however was basically being ignored and apart from fetal heart sounds being checked I felt the baby was pretty much being viewed as a write off.

Even in England 30 weeks is pretty premature but not so pr

emature that the baby doesn't have a reasonably good chance of surviving with the help of all the high tech neonatal treatments that are available. I have been on a neonatal ward round in third year and saw extremely premature babies (from about 24/25 weeks) and all the incredibly sophisticated technology that is available to give them the best possible chance of survival. Here however there are no ventilators, no incubators, no UV light treatments for neonatal jaundice, no pulse oximeters and no machines that bleep warnings if the babies condition deteriorates even slightly; it is very different. In short if a baby is not strong enough to survive with the aid of a bit of (usually badly done) CPR, some antibiotics and a warm room then there is nothing else that can be done for the baby here and it will die :(. This doesn't mean there is nothing that can be done for the baby at this stage however; in England if there is threatened preterm birth before 32 weeks then the mother is given two doses of corticosteroids over a 24 hour period.

At 30 weeks a baby has not yet usually produced surfact

ant. Surfactant is a liquid produced in the lungs that reduces surface tension and so stops the air sacs of the lungs from collapsing. In premature babies that have not yet produced enough of this liquid, the surface tension is too great so the baby develops respiratory distress syndrome. This often needs treating with oxygen for about 5-10 days and sometimes a positive pressure respirator.... Hard enough to treat in England but here in Tanzania where there is only 1 oxygen machine for the whole hospital and no positive pressure respirator, I doubt any premature babies with this condition survive. However if the mum receives corticosteroids like in England as soon as there are signs that premature birth may occur then the condition can be prevented from arising in the first place. Corticosteroids increase synthesis of surfactant over 1-4 days and therefor

e effectively mature the babies lungs so that they have better chance of being able to breathe independently if the pre term delivery does occur. The type of steroids that are needed are available at this hospital so technically this is one easy thing that the doctors can do to reduce the number of premature babies that die (I think though I'm not sure that at 30 weeks like this baby with corticosteroid treatment and then after birth a warm room then the baby would stand a reasonable chance of surviving and not having any long term consequences. Maybe I am being optimistic though, I'm not a neonatologist!). All very well in theory...

In practice when I asked the doctor if she had given the lady corticosteroids for the babies lungs (I figured if they were not going to deliver the baby yet anyway then there may be enough time for the steroids to have a positive effect on the babies lungs), she didn't even seem to know anything about using steroids in threatened premature labours... This is quite shocking when its one of the few things they could do here to improve the outcome for premature babies (and I've seen them try to delay births using drugs that can

slow the labour down by only a day or two - virtually pointless if they are not using that extra day or so to give the steroids time to work!). So I explained the concept of using steroids in this situation as best I could (bearing in mind I hadn't done any research at this stage so was based on very foggy memories of what I learnt in 3rd year!). She seemed to understand the general idea though but asked if steroid were contraindicated at all in eclampsia/ would make the patient even more unstable. Hadn't a clue about this - only had a 4 week ob/gynae placement so although eclampsia is also common in England I haven't seen a case of it let alone a case similar to this one so I could know whether or not they would give the mother steroids. So in order to persuade the doctor to give the steroids I needed to research and find out for sure if steroids are safe in Eclampsia. Sounds easy but this is Tanzania and nothing is straightforward! The problems are that:

1. I only have a limited amount of textbooks with me and there i

s no library here and just a few very outdated textbooks. In my textbooks I could find information on giving steroids in threatened premature labour and information on how to manage eclampsia but nothing that linked the two.

2. The internet here is so slow that I'm pretty sure its being powered by a hamster running on a wheel. And the hamster probably only has 2 or 3 legs. It often takes over 10 minutes to load a page in the morning (quicker in evening) so not exactly speedy research.

3. The webpages I was finding kept talking about giving s

teroids in pre eclampsia in case delivery has to be done and didn't refer to eclampsia at all. I think this may be because A) Patients are monitored very regularly in the western world so the condition is more likely to be picked up and managed when it is pre eclampsia rather than presenting as full blown eclampsia and B) I think they might be a bit better at managing eclampsia in England so maybe the patient is stabilised more quickly/ the surgeons are better at recognising when the patient is stable enough to perform an emergency c section. If this is true then the baby may be delivered too quickly for the steroids to have a chance to take effect.

4. The clock is ticking! To be effective the mum needs to be given the steroids at least 24 hours before delivery and as I did not know when the mother would be induced/ have a c section (as this would happen as soon as she was stable enough), it felt like every minute was counting.

The solution? Facebook! Seeing as the internet was taking so long I decided to ask whether any of my medical student friends knew whether you could give steroids to woman with eclampsia / could any of them research this for me! Cheeky request but it worked much quicker than my research on the antique internet was, soon I had printed out info saying that giving steroids in eclampsia was ok. So turns out facebook is not just for procrastinating!

I rushed to labour ward to give the printouts to the do

ctor only to find out that although they had been trying for some time they had not been able to find a fetal heart beat. Oh. AJ and me tried again for some time because they only have Doppler machines here (and a rubbish old one at that - one of the other medical students had donated a nice new Doppler machine that had been one of her wedding present requests and just 4 weeks later it has now gone missing and is suspected to be stolen - who steals a Doppler machine from a poor hospital?!) and unless you listen in the right place you can easily miss a present heart beat. However having listened in lots of areas in case we had misinterpreted the babies position (the best place to listen is the babies anterior shoulder), we were forced to concede it really did look like this baby was one of the unfortunate 15% that die :(.

Gave the notes on eclampsia and steroids to the doctor anyway and explained them. Won't help this baby anymore but maybe she will remember them next time there is a pre term lady with eclampsia or just a threatened pre term labour in general. Probably not, but can always hope!

So bit of a stressful and sad morning in the end. Afternoon however I slept, and it was good (and actually well deserved I think!).

Halfadoc x

Friday, 7 October 2011

Houseman's friend /I will make a vampire yet!

29.9.11 :

1.30am! In labour ward with a patient who is about to go to caesarean as although she has been fully dilated for the last 4/5 hours, she is not having strong enough contractions (in spite attempting to increase with an oxytocin drip) and the baby’s head is still high. Before caesarean the mum needed to have a blood group and Hb test so needed to have blood taken...

As I have said before I realllllly wanted to practice taking blood as I have both not had much chance to practice in England, and am yet to be fully successful at taking blood from a patient (have managed to take it from another medical student in the blood taking workshop but then I deliberately paired up with someone I knew had big veins!) without at least a little help from someone else. In other words have failed at the few singlehanded attempts in a clinical setting that I have had (see blog: A failed vampire).

Was hesitant at asking to take this patient’s blood tonight though because after another late finish yesterday (and no power nap as planned!) I really very tired so I figured I would be more likely to make a mistake / fail to get blood. Decided I might as well try though (with so few blood tests available here, practice is not that readily available).... And I managed, by myself, with absolutely no problems and didn't have to jab her more than the once: D

Took the blood from a vein on the wrist that an F1 told me in 3rd year has the nickname Houseman's friend because it is a good option for both cannulating and taking blood. Glad that F1 showed me that vein as in this patient at any rate it was definitely a good one!

Woooooo one patient’s blood taken!

In other news another patient gave birth earlier as well to a baby which weighed an eye watering 3.7kg - ouch!

Halfadoc x

Monday, 3 October 2011

Pictures of a caesarrean (warning, gory!)

28/9/11 This blog is a work in progress as it will take some time to upload all the pictures I want on it using the internet here but I'm going to start! Eventually it is going to be a step by step picture blog of a caesarrean I saw today - so it is not for the faint hearted! Faces have ridculous shapes on them to shield identities crimewatch style! The patient was having an emergency caesarrean due to Eclampsia (a condition where the patients blood pressure is very high and leads to fits. This condition is very serious for both the mother and the baby).

The patient is anaesthised using ketamine (even though before the operation the doctor said ketamine would not be used because ketamine itself can cause high blood pressure and therefore worsen the patient's condition).

The caesarrean is in progress. Here caesarrean's are done by a midline (also known as classical) incision. This type of incision is not favoured in the UK as it does not heal as well and it more likely to rupture in future pregnancies.

Because the patient has eclampsia her blood pressue is checked very regulary throughout the operation. Fortunately it remains stable although still a little high.

The patient is given dextrose throughout the operation to replace some of the fluid that is being lost during the operation. With no diathermy available here (diathermy stops bleeding from small vessels) blood loss tends to be greater than in the UK. However they also have a severe shortage of blood, so unless bleeding is vast, patients are only given IV fluids to replenish fluid which is lost. Sometimes even when bleeding is vast, there is no blood available for the patient... Fortunately this patient did not bleed too much.

The doctors reach in to try and pull the baby out!

The baby is delivered! He initially scored low on the Apgar scale and needed resuscitation (no pictures of this - a) it didn't feel right as it was uncertain initially if he would pull through and B) I was assisting a bit with the resus. He was doing a bit better after resuscitation and is now in the baby room for extra care).

The patients that made me look foolish/ Eating humble pie

The patients that made me look foolish/ Eating humble pie

27th September 2011:

On todays ward round we saw young girl that Aj and me saw in OPD on the 20th. This is the girl that we felt had HIV complicated by PCP but had to persuade the clinical officer that this was a possibility. She now has been diagnosed as HIV positive and her chest x-ray was indicative of PCP. So an accurate diagnosis by Aj and I but not a great one for the girl. Poor kid :(. But this accurate diagnosis was more than balanced out by a complete diagnostic fail...

When we were sitting down waiting for the doctor this morning we saw a girl walk past on her way to the loo with the bizzarest gait I have ever seen. There's no way I could describe this walk accurately but it involved weird rhythmic arm motions and head movements as well on occasion. Her balance appeared poor and she looked in risk of falling over. We immediately went to look at her notes to see what her diagnosis was and were shocked to see there was nothing about her walk in her notes. We alerted the doctor to her walk and the lack of notation as soon as he arrived on the ward, and he then discussed the patient a bit with the nurse in Swahili before telling us the cause of her walk was psychological. Having seen so many patients recently who were diagnosed as their illness being "psychological" without adequate investigation I was outraged at this and struggled a bit to not make it obvious. I listed off all the possible causes of chorea (jerky involuntary movements that are "dance like" and usually effect the head, face and limbs) as this is what I thought maybe the girls walk could be and was saying to him he should refer her to a neurologist if that is possible here. He laughed at the idea and said he was very experienced in this condition and she was a student and probably wanted to be sent home to her family so it was psychological. I was pretty scornful about this to be honest but I decided to keep quiet and wait till we saw the patient before saying anymore.

Halfway through the ward round the doctor pointed out that a different girl of about 18 was walking up the ward with exactly the same bizarre walk and told us she was from the same school as the first patient... this was a bit suspicious but I was still thinking that maybe one of the patients could be actually ill and the other one just copying her friend for time off school as well. However when we saw the patient it was obvious that the doctor was actually right, as both girls were not particularly brilliant actors and kept bursting into fits of laughter. Plus allegedly they both developed this inability to walk normally very suddenly in addition to abdomen pain at the same time the day before. Not the most convincing story, maybe next time they should just fake a headache. Not a psychological illness either I reckon, just plain bog standard skivealitus. Oh dear, sometimes you have to eat humble pie and laugh at yourself!

The doctor was aware of this but his management plan for the patients was still to keep them in hospital and give them valium. He said the condition would not go away if he sent them back to school…. Well it’s no wonder the teenagers here fake this weird walk a lot (for one of the girls this was the second time she had) if each time they do they get admitted to hospital and given valium! Unfortunately after debating the diagnosis for so long with him I think I had somewhat ruined my credibility for arguing that they should be discharged and not kept in hospital.

In other news

Sadly the patient I talked about yesterday with tetanus has already passed away :(. Lots of horrible diseases here and not all of them are tropical. Stay up to date with your tetanus vaccinations!

Halfadoc x

And where should I stick my finger?

And where should I stick my finger?


This morning in the ward meeting, Dr M taught the staff that were present about indications for c section (which causes are absolute and which are just suggestive that a caesarean may be required) and how to use a vacuum device for removing remaining products of conception after an incomplete miscarriage if it had occurred before 12 weeks. It was good to see some teaching occurring here but I’m not sure how well some of the other doctors understood as I watched one of the doctors practicing with the device and he did not set the vacuum up in the way Dr M said and so could not work out how to use it. Hopefully some of the other doctors understood and will use the device in future though (Dr M said that it was better than the traditional method for removing the products of conception as it does not require general anaesthetic so is safer).

The incomplete evacuation device that Dr M was trying to teach the other doctors to us ------------->

The different tubes are so that the smallest possible tube which creates the vacuum can be used thus minismising discomfort to the patient

Today rather than going on specific department ward round, went on a general review of specific trickier cases with several of the doctors. Was a pretty interesting ward round as a result because it was the more difficult/less standard cases that we were seeing.

Firstly was a young man who had fallen from a tree 1 week ago and injured his knee. He had been fine initially but now had been admitted to hospital with symptoms of hyperextension of his neck, neck stiffness and convulsions. Since admittance his consciousness level had deteriorated and it had been noticed by the doctors that the wound on his knee was very dirty looking. His symptoms combined with his dirty knee wound point to a quite likely diagnosis of tetanus. Tetanus is another disease which unfortunately has a high mortality even with perfect treatment. Gold standard treatment of tetanus would include giving the tetanus immunoglobin in addition to giving metronidazole or pencillin. Unfortunately here they do not have the immunoglobin so the best treatment they are able to give the patient is metronidazole. He has the classical symptoms of tetanus - convulsions involving arching of body and hyperextension of the neck, so is unfortunately pretty likely to have caught it, will just have to hope he is one of the lucky ones outcome wise.

We saw the boy from Friday, (patient four, blog : Operating on the wrong patient ) despite a blood sugar being requested by the other medical students before the weekend (because they felt DKA was one possible cause for the boys symptoms) it was yet to be done. DKA is a condition type 1 diabetic’s get where their blood sugar is dangerously high and results in the patient deteriorating into a coma within a few days. The doctors decided to prescribe a dextrose drip because the boy had not been eating, and when we asked if they shouldn't do the glucose test quickly first they said it would be too long a wait because unlike in Europe they did not have a portable glucose testing machine. Very very shortly after this statement, the lab tech appeared with... a portable glucose machine. Hmm guess the doctors aren't too clued up on what the hospital does have! In spite of the conversation we had literally just had however, the doctors directed the technician away to a different patients bed who also needed his blood sugar checking and the boy still would not have had his checked at all if we hadn't asked the technician ourselves to come and check it afterwards. Argh! It was in normal range though, so not DKA at any rate.

Another aggravating case was a four year old girl with a very swollen face which the doctor presenting the case reported as being due to a fall...well yes it technically was a fall but he missed out the bit about it being from a moving motorbike. A bit different.

Went to minor theatre later where we saw some interesting stuff. Saw the male patient with ?cervical cancer... Which apparently was meant to be ?prostate cancer so the patient was in minors for a digital rectal examination (the definition of minor theatre is a little different here!). The doctor felt the prostate was enlarged and got us to have a feel as well, first pr examination! I was glad Aj went first because ...well.. Gravity and old age had taken its toll on the patient’s muscles a bit and it wasn't immediately obvious where his anus was! Aj had to ask where she was meant to put her finger, think I would have been too embarrassed to so I'm glad she went first! Felt a bit bad being the third person in a row to examine him though because here they do not use lubricant so must have been pretty uncomfortable for the man.

Final patient in minors was the man who had had his arm bitten off by the crocodile, he was there to have the wound washed again and then be redressed. The wound looked really really really bad (and smelt even worse!), it is clearly very infected, and the bone is fully exposed with a lot of pus pretty much dripping off around it. I really can't see how that will heal without surgical amputation of more of the arm stump - currently the amputation is literally just that which was taken by the crocodile + debridement of dead tissue. They are not currently planning on removing more tissue instead he is receiving antibiotics and having daily wound cleaning with hydrogen peroxide (which looked incredibly painful for the poor man). Hope that is enough because it looked like the infection was spreading further up his arm :s.

Halfadoc x