For every death theres a birth. A very eventful day

For every death theres a birth. A very eventful day

30th August: Today I saw a patient die for the first time. We had been waiting for the morning meeting when one of the doctors came in and asked us to come with her to see a patient. Assuming she was maybe taking us to see an interesting patient for a teaching opportunity, all 5 of us went along.

The patient turned out to be the lady whose GCS we had checked yesterday. It quickly became clear that the doctor had been called because the patient deteriorated rather than this being a teaching session. The patient was gasping for breath and her GCS was now only 3/15 as she was no longer responding to pain. The doctor listened to her chest and took her blood pressure and then without saying anything started alternating between pushing on her chest and suctioning the patients mouth. It took us a while to realise she was doing chest compressions because to be honest she wasn't doing them correctly (or at least not how we are taught to in England) and how many compressions she did in each set varied and seemed a bit random. To start with I thought she was just massaging the chest to try and loosen secretions so she could suction more fluid out or something. When we realised she was doing some kind of CPR one of the other medical students took over chest compressions and AJ and I alternated pumping the suction pump (unlike the UK its manual) so the doctor could concentrate on just suctioning. However after no more than 10 minutes of this, the doctor decided the patient was not going to recover and stopped rescucitation. No oxygen or adrenaline was given and defibrillation was not attempted(we are not sure if they have a defibrillator here). Very unlike England, but with a GCS of 4 yesterday I am not sure the outcome would have been any different even with a more thorough rescucitation attempt.

To start with I have to admit I didn't feel as sad as I thought I would seeing a patient die and I actually felt quite guilty and inhumane for not feeling more when a relatively young woman has just died. But I think this was because knowing the woman's GCS, there was a great sense of inevitability about her dying and it sort of seemed like it was for the best as she probably wouldn't have recovered a good quality of life after so severe a stroke. Also the whole thing seemed to happen so fast that it was really surreal that I had just watched someone die. I hope this is why I didn't feel too affected by the experience anyway because I don't want to be some kind of horrible doctor who doesn't care if their patients live or die. However I was on the ward waiting for the ward round to start when the patients relatives came to say goodbye. They were very distraught and four of them had to be physically supported in and out of the ward. She was clearly a very loved lady. I didn't feel nothing when I saw their pain though and whilst it doesn't feel right to talk about my feelings when their feelings and grief is far more important, it was very very sad indeed. Maybe I'm not completely desensitised to peoples pain yet.

The doctors told me that although the patient was a known hypertensive, she rarely took her prescribed anti hypertensive medication and didn't attend check ups which was why her blood pressure was so high causing her to have a stroke (systolic BP was 210 on admission). I imagine this makes the death even harder for the relatives as whilst her death is not their fault it must be easy to slide into thinking "if only" and potentially blaming themselves for not making her take her medication.

After the relatives had said goodbye I helped some of the staff prepare the patient for taking her to the morgue. As the woman was unclothed beneath her blankets this involved dressing her before wrapping and tying sheets around her. This was was quite a weird process - its half a good and respectful thing that the patients dignity is preserved in death by not just taking her body to the morgue naked but on the otherhand as I discovered dressing a dead body is not a very dignified procedure at all.

I later found out that the lady was a nurse from nearby and a lot of the staff at the hospital knew her and so the hospital was very understaffed the rest of the day as many people went to pay their respects. Not all the other staff were sensitive of this though, during the morning meeting the doctor who had been running the CPR stated when someone referred to the lady as the patient that "It's not a patient, its a dead body" and several other staff laughed in response. Horrible.

The rest of the day

On the Paediatric / female insurance ward round I saw lots of cases of gastroenteritis/suspected malaria; some suspected enteric fever (AKA: typhoid); a case of dysentery; a 10 year old boy with paraphimosis ("retraction and constriction of the foreskin behind the glans penis" - oxford medical dictionary!) who I felt v.sorry for as his mum wasn't waiting with him and he was clearly very embarrassed at having to show his penis to strangers. Finally we saw a middle aged lady who had trachoma which is a severe chronic form of conjunctivitis which can lead to blindness, in this patients case it definitely had as her eye had been completely destroyed - if there was any eye left it was completely obscured by swelling and pus. Although the patient had insurance she had left her infected eye for 5 months before coming to see a doctor which is why the damage was so progressed. Hard to understand why someone would let an infection progress so far without seeing a doctor, it must have been very very painful but maybe this was due to a cultural difference - here people often try traditional medicine before seeing a doctor.

After the ward round I went to OPD - out patients department where I sat in a consultation with a clinical officer student. Here even students run consultations, make plans and prescribe drugs on their own. I was shocked when I suddenly realised during the session in OPD that the clinical officer student wasn't asking me questions to quiz me but because he was genuinely asking my medical opinion and was sometimes basing his plan/what he did on my impression of the patient / differentials - eek!

OPD was very different to in England, much less structured. Here as soon as one patient left, the next patient would come in, with no time between consultations. No idea if they were actually the next patient in the queue or not! Sometimes patients would not even wait for the patient before to be finished and instead would stand in the room while the consultation went on - so much for patient privacy!

After OPD I went to maternity to see the others. Discovered while I had been in paediatrics and OPD the others had been very busy in the delivery room. 3 of them had been helping deliver a premature breech stillborn (see later blog ) and AJ had delivered her first baby herself! The baby was fine but from all accounts the doctor (same on as mentioned earlier re CPR..) had delivered placenta badly leading to a massive hemorrhage. AJ went to theatre with the patient to try and stop the bleeding, which fortunately was successful and the mother was ok.

Was happy for AJ but also a lil bit jealous as was yet to see a fully natural birth (nearest I had seen to natural needed forcep assistance) let alone deliver a baby myself! However my jealousy was very shortlived...

We decided to go back into the hospital in the evening as we thought maybe a lady who had been there during the afternoon would be ready to give birth later that night. We were right!

This was the mothers 3rd pregnancy but the last birth had been at home and the baby had died shortly after birth. I think this was the only reason she had come into hospital as in general she didn't seem to like medical people interfering with her labour and she seemed exceptionally keen to preserve her privacy and the midwife kept yelling at her not to cover herself up when they were trying to examine her. Meant it felt a but awkward just being there as a medical student and I wanted to ask her if she was but I did not know how to in Swahili (and the healthcare Swahili dictionary had nothing about asking for consent in it - not sure it is done here, think things are still a bit old school and consent is assumed). We asked the midwife if she could ask if was and she said the mother was glad we were there, but she didn't seem to ask anything so I hope this was true.

The labour was quite strange in that men/relatives are not present during Tanzanian hospital births and so the woman receives very little in the way of emotional support. The midwife did not really give her much emotional support either as she seemed to be going for the "tough love" approach and when the woman was saying that she was in too much pain/ too tired, the midwife would yell at her and sometimes lightly slapped her on the leg. Found this a bit shocking because I am used to UK birth where woman have birth plans saying exactly the kind of experience they want from their labour and some woman bring in things like relaxing music, and changing colour light cubes to create a more serene at her atmosphere. Not too mention usually having at least 1 person with them (and sometimes entire families!). Very different.

- Part of the labour ward here. The small red incubator is now basically just a movable cot - whilst it has a plug, I have never seen it plugged in so I assume it does not work!

When it came to the actual birth the midwife asked which of us wanted to deliver the baby and as AJ already had she said I could. I GOT TO DELIVER A BABY!! I read up quickly before hand how you should manoverue the baby if it doesn't come out easily but when it came to it she came out really easily and I didn't need to do much beyond support her head. The midwife told me to put the baby on the mothers abdomen (N.B. fresh newborns are really slippery, she kept slipping down!) but she didn't start to cry so we had to take her off and rub her to try and stimulate breathing but it wasn't working so the midwife had to quickly cut the cord so we could take the baby to the rescucitation table. I felt so sorry for the mother as no one was explaining to her what was going on but I could not due lack of language ability which was very frustrating. She must have been terrified because she would have been able to hear things like the suction pump but not able to see what was happening.

I helped try to resuscitate the baby for a bit but then it was time to deliver the after birth do I had to leave AJ and one midwife to it. Capable hands but I hated not being able to see/know how the baby was doing, but not as much as the mother I am sure. When the placenta was delivered it was quite an unusual colour (a bit greyish) and the midwife immediately asked if she had taken local medicine to cause her to go into labour. The woman admitted she had and the midwife immediately started telling her off and telling her this is why her baby was struggling. I thought this was a little inappropriate when her baby was yet to cry as she must have already been really worried and probably already feeling guilty about taking the herbs. Fortunately soon after we heard the baby cry - such a relief!

The mother was bleeding slightly so I had to remove blood clots and try and stop the bleeding - so first actual vaginal examination done as well! After the mother was ok and dressed I got to have a photo with the mother and the baby, all in all definitely an experience I will remember forever.

When we went to leave the midwives asked us who was escorting us home which we were really confused about because the house was literally 2 minutes away and although it was about 12.30, there were two of us so we figured we would be fine. We found out why when we got home. Apparently whilst we had been gone there had been a lot of commotion at the house....

The normally calm housekeeper had started freaking out and locking all of the doors and was telling the other students that thieves had gone to one of the other houses in the village with weapons and they would be coming to our house next as they will have heard that white people were living there. The other medics called the main doctor here and explained about the housekeeper and so he came round very quickly with several men with guns who shot around the building to scare any thieves off. Its pretty terrifying to think we have made the house such a target by being here.

Apologies for massive excessively long post, but as you can see, it was a helluva a day!

Backnote: 10 minutes after we finished writing up our experiences (AJ is keeping a journal) and turned off our light, we distinctly heard what could only be someone having a try at picking the lock on the back door. Terrifying. Needless to say we didn't sleep well! The hospital have now supplied our house with a guard at night though.

Bubbles and stickers: first day on Tanzanian ward

30^th August 2011: Woke up and got up without pressing snooze for once in my life - was v.excited to being getting back to medicine again. The doctor who met us on arrival came to our house to meet us and take us to the hospitals morning meeting room. We took over medical equipment that we had brought with us - slightly out of date bnfs and oxford clinical handbooks, gloves, stethoscopes, speculums, sutures etc. AJ in particular bought LOTS of things for the hospital and I felt guilty that I had not brought a bit more, but even though we only brought over initially a small amount of the total stuff AJ had brought plus mine they were still very appreciative and announced it in the meeting and clapped us three times which is apparently a way of saying thank you here. Felt a bit awkward though!

During the meeting patients notes were read out in English (and are written in English which is brilliant as means we can both understand notes that have been written by the doctors and possibly write in them ourselves if we see patients by ourselves) but most of the discussions about individual patients were in Swahili so during the discussions we were a bit lost and only able to pick up on the odd medical word. But through a combination of both we got the general geist of the major cases.

We were told that during the night two patients had died: one of meningitis and the other of a ruptured uterus. Both are serious conditions that can be fatal in the UK but at the same time I wondered whether they both would have if they had received treatment in a UK hospital with its wider range of resources. Furthermore I imagine that because healthcare here is not free but conversely most people here are a lot lot poorer than in England, patients may delay coming into hospital to try and avoid the expense and so present with illnesses that are a lot further progressed and so harder to treat. At any rate this is quite a small hospital (93 patients there today, including "well" patients i.e. obstetrics) so two dying over night seems high compared to the UK but maybe it was just a bad night. They also seemed to be talking about (mostly in Swahili so not too sure) other deaths having occurred over weekend so maybe the death rate may have been higher than even 2/93 :(. It must be tough to work here permanently and see so many deaths on such a regular basis.

At the end of the meeting there was tea and food which apparently happens every Monday because longer meeting on Mondays to catch up on the weekends new patients. Will look forward to Mondays now as a result - wish our trusts hospital did this!

After the meeting we were shown around the hospital, which even at a quick glance was clearly much more crowded than UK and quite old fashioned in terms of both facilities and nurses uniforms.

- The hospital ambulance which we saw during the tour. It is broken and has been for some time apparently...

After the tour we were meant to be going to join the ward round but unfortunately we were called back to our house because 3 other medical students had arrived so they wanted us to move out of our room (because we had a single and a double bed) into the room with just a double bed. To be honest this was really irritating and whilst its not their fault, it wasn't the best scenario to meet the new medical students. It wasn't that we minded having a downgrade in room size it was just because the housekeepers called us back from the hospital on our very first morning when we were so excited to be getting started on clinical again. Felt changing rooms could have waited till evening or been done the previous night as apparently they were expecting the other students. Oh well it was very annoying but will have to stay calm and remind myself that I have 6 weeks here so it is not the end of the world.

Did manage to catch the tail end of a ward round though and the teaching we received was really good. The ward round was on a ward which was half paediatrics and half female insurance patients (here patients with insurance are separated from those without who have to pay themselves).

Got to do a brief bit of clinical skills practice - I was told to assess the hydration status of a child which I did ok at (I didn't know how to assess the skin turgor using the skin from the boys belly but otherwise I did ok) and AJ and me were asked to calculate the GCS (Glasgow coma scale score) of a 52 year old lady who had suffered from a severe stroke secondary to hypertension (high blood pressure).

GCS is based on patients verbal, eye and motor reflexes. 15 is the best score you can get (a fully conscious and aware patient) and 3 is the lowest. In England a score of 8 or below is considered very, very serious. When we scored this lady we thought (we cheated a bit and looked up the criteria when the doctor wasn't looking!) she had a score of 4 as her pupils did not respond to light (one was constantly dilated and the other constricted), she had no motor response to pain and made only incomprehensible sounds when we rubbed her sternum (this a technique used to cause transient moderate pain - sounds horrible and it felt pretty horrible but it is important way to assess a patients consciousness). The patients overall score is therefore extremely low and her condition very very serious; I was actually hoping therefore that we had scored the patient wrong but the doctor did not correct us so I assume we were right.

When we asked the doctor about the patients likely prognosis he said he thought she would recover but it would take a long time. I was surprised that he thought she could recover from that debilitating a stroke (especially with the resources available here and lack of long term rehabilitation available) but I really hope he is right.

After the ward round we were planning on going to the outpatients department but unfortunately we were summoned again by our house because a hospital car was going to the nearest small town and they were quite insistent we go with them as it would be our only chance to get food supplies that were not available in the village such as cooking oil. Clinical experience thrawted again! We made up for it though by going into the maternity ward in the evening, no patients approaching delivery for quite some time though so we only stayed about an hour or so, it was good to get to practice Swahili though with some patients and we got a bit of impromptu teaching from the doctor on call so it wad not a waste of time going in. So the bits of clinical experience I have had so far have been really good.

Key Differences I observed between Tanzanian mission hospital and a typical English hospital

• Younger patients in general due to lower life expectancy - no geriatric ward.



• Doctors did not wash/alcohol gel their hands between patients and I didn't see any alcohol gel on the ward at all (let alone mounted to the wall roughly every two centimeters!).



• White coats, ties and wrist watches are yet to be outlawed here.



• Beds were extremely close together - infection must spread like wildfire :s.



• Paediatric examinations seemed quite rough with little warning for the child that they were going to be yanked up by the consultant and examined. On the other hand the children we saw were very quiet and didn't react as much as UK kids I have seen do to much gentler examinations.



• No curtains around patients beds - the lady with a stroke was half naked when she was being examined but had no curtains and only half a screen going round the end of her bed (none of the other patients even had this) which meant she was exposed to most the ward.




• Doctors and nurses in Tanzania seem so far to be *much* more welcoming to medical students than they are in the UK. Often in the UK we feel like we are a massive nuisance and in the way but I didn't feel like that at all today. Also in the UK ward rounds can be a hit or miss teaching wise (depending on the enthusiasm of the consultant running it) whereas today's at any rate was really good from a medical students perspective.




• Less unnecessary blood tests in Tanzania - sometimes in UK doctors get a bit carried away and order standard tests such as FBC and U + E's on patients regardless of whether they really need them. Here however due to lack of resources, bloods tests are only ordered when it is essential for diagnosis/treatment.

So for the most part I think whilst people may complain about the NHS really we are truly lucky to have such a well run, free hospital, full of resources that take's patients dignity into account when examining them.

Tried to cheer up kids on the ward by blowing bubbles and giving stickers, it worked.. a bit lol. Bubbles seemed to confuse them a bit though - don't think bubbles are common here! Bubbles went down well with the village kids though who came to the house in the evening. We played ball with them and they loved us taking their pictures. A really nice end to the day J

Sisemi kiswahili (I don't speak Swahili )

27th/28th August: Our attempts to learn Swahili are amusing the locals greatly especially as 90% of the time all we say in return to their questions is sielewi (I don't understand) or Sisemi kiswahili and our pronunciation tends to completely crack them up. A group of women came into our lodgings to talk to one of the ladies who lives here and they chatted to us in a mix of English, Swahili (thank you lonely planet phrase book!)and simple body language, slow but effective! We learnt that one (though possibly they all were) of the group was a student nurse and when she left she invited us to come visit her at her hostel. Tanzanians all seem very welcoming!

I think our culture fascinates them as much as theirs does us and the lady who lives in the hostel (I think she is a housekeeper but I'm not sure) has picked up both of our bags and looked through our things, currently she is looking through my housemates camera and asking where all the photos were taken. She looked through our wardrobe earlier and was fascinated when she found our boxes of tampons, I guess that they are not very common in Tanzania. She didn't understand how they worked so we tried to explain to her - very amusing explanation considering there was no common language. At first she didn't seem convinced by them but she was very pleased when we gave her some after explaining, I just hope our explanation was sufficient that if she uses them she uses them right.

Later we went with her to fetch more water, she had a much larger bucket than AJ and me but lifted it onto her head easily and indicated we do the same... I couldn't even lift it up to my head! A man waiting to use the hose lifted it up for me but within 5 seconds it had already wobbled precariously multiple time so he quickly lifted it down again! Maybe I will practice with smaller lighter objects and work my way up!

Saturday dinner was really yummy potatoes and dubious looking meat that after looking at for some time we decided might be bowel (AJ claimed she could see the haustrations, what a medic geek!). AJ wimped out of trying but I gave it a go. Tasted nice enough from the sauce but really weird texture - slimy, ridiculously chewy and had occasional crunchy bits; I didn't go back for seconds!

This morning we have been left on our own in the house while the others living here went to church. Feel a bit awkward because I'm not sure if we were expected to go with them, they didn't ask us to but maybe they would have appreciated it if we offered to come, but on the other hand maybe they would have found it offensive as they have already asked AJ and me what our religion was and we said agnostic/ brought up Christian. Will have to ask one of the doctors what we should do next Sunday.

We went down to the village market and bought some food for tomorrow as we are cooking for ourselves from then, very limited selection of food available in the village: we brought potatoes, onions, bananas and tomatoes and that was literally the only food available so bananas for breakfast and some kind of stew for dinner it is! We also bought some soap and washed our clothes in a tub, Tanzanian style. At the moment this is all quite a novelty and so weirdly fun but maybe in 8 weeks time we will be longing for varied food and a washing machine!

Spent quite a bit of the day revising medicine ready for tomorrow, and with no real distractions here it wasn't hard to find the motivation to do so. Made me think how much more studious I would probably be without internet and TV!

This evening we tried to teach the man who also lives here (there is 1 young woman and 1 young man plus an older woman. We are not sure if they are a family as the younger two call the older woman mother, but sister and mother are also used in Tanzania as generic terms of endearment) to play the card came: slam. This was very difficult without common language but he mostly understood in the end. Later they invited us to watch films with them, we were pleased to be invited but ended up watching 3 very low budget and old American zombie films in a row because we didn't know if it would be seen as rude if we went and did something else after the first film finished! Still its all part of the experience and we got to try and practice some more Swahili :).

Early night now so awake for first day in hospital tomorrow - I'm so excited but also a bit scared!

Halfadoc x