Monday, 3 October 2011

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

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