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 We took over medical equipment that we had brought with us - slightly out of date bnfs and oxford clinical handbooks, gloves, stethoscopes, speculums, sutures etc.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