A weekly blog from a clinical years UK medical student

Ward work and Hitler

2012-01-23T18:57:00.000Z

Hi,

A relatively calm week, compared to the busy time I had last week with all those early mornings, which is a nice break. I still spend some time on the wards, after I enjoyed it so much last week, as other than a Parkinson's disease clinic I have no time tabled clinical sessions, just lectures. I am not sure about the timetable for this rotation; it seems to vary massively between weeks, sometimes meaning you have plenty of early mornings (last week), other times (like this week) with a few lectures dotted around and little else. I have a presentation to do next week, and other out-of-uni commitments, so it is quite nice for me to have some control over my week and when I can go in and when I don't.

In general, neurology is a very 'post-graduate' type of subject. A lot of the things we are learning or seeing we will not be expected to do (or even necessarily know) as junior doctors, and wouldn't be expected to be doing unless we were specialising in neurology after completing our degree, and working as a doctor. While a lot of neurology is very interesting, with the strange symptoms and signs people can have (the brain is pretty damn complicated), it is also very complex. It does often feel as though a lot of the things we are learning we will never have to apply at all. Will I ever have to interpret an EEG to diagnose absence seizures? I very much doubt it, unless I am a neurologist, and in which case, I will need to be taught again as I will have forgotten by then. I suppose you do learn a lot of things you may never need to know again in medical school - though it is a lot more pronounced in the first few years with all of the microbiology that you learn!

I had a great day on the wards on Tuesday, where I just spent the day with the neurosurgery ward team helping with their ward work. The patient I saw last week who had the cranioplasty (skull reconstruction) is doing very well, and I am told that he could well improve faster now this construction has given his brain more space. I spend a full day examining people before operations, helping out with notes and clerking and other day to day activities. The neurosurgery ward is run by more junior doctors most of the time, as the more experienced registrars and consultants spend their days in surgery instead. I really enjoy working on the wards, which is a fantastic sign, as after I graduate, this is where I will be working for a few years at the very least!

The single timetabled slot I had this week was a Parkinson's clinic, where I was with a specialist nurse seeing patients with Parkinson's disease. I had come across specialist nurses before (for example a heart failure specialist nurse) and had been very impressed with them. This time was no different at all, and he clearly knew exactly what he was talking about. By managing a case load of patients, it means they get better treatment than if the GP was managing their Parkinson's (much more experience), and possibly better treatment than a neurologist because of the specialist knowledge of the nurse, though this is debatable. It is certainly cheaper for the NHS, though, which I am sure factors into it. As well as talking to and examining some lovely people with Parkinson's, I got a good amount of teaching. A lot of it was the pretty standard stuff about the difference between Idiopathic Parkinson's and Vascular Parkinson's, which is fantastic for me to learn, but some of the things I learnt were not entirely medical, but none the less interesting.

For one, I was told about 'Parkinson's trait' where people show traits in life which may make them more likely to get Parkinson's. The nurse was saying that many of the people who come in with Parkinson's have been very obsessive people, who have then developed Parkinson's disease. By obsessive, he means people who tend to focus on one aspect of life obsessively, such as model making or train spotting, and focus on this to the exclusion of other things. While (obviously) most 'obsessive' people do not develop Parkinson's later in life, it is very interesting to see that many of the people who do develop it have this 'personality type'. The nurse said that many of the patients who he sees have had mathsy / physicist / engineer type jobs, where its quite possible that being obsessive about small things can be beneficial. I don't know if it is some kind of genetic defect, predisposing people to Parkinson's later in life and making them obsessive early in life, or if it is the act of thinking about a few things obsessively (or gambling obsessively) which over stimulates neurones and can lead to Parkinson's, but it is a very interesting theory.

A video, watch until about 10 seconds in to see Hitler's Parkinsonian-like tremor in one hand behind his back, perhaps explaining why he usually had this hand behind his back or in a pocket.

The other thing I learnt, which I didn't know but probably should have, was that it is assumed that Hitler was developing Parkinson's towards the end of the war. The video above is 'real' footage of Hitler, and you can see up to about ten seconds in that he has a tremor, like that seen in Parkinson's, in his left hand which he keeps behind his back. Supposedly most of the footage showing these tremors was destroyed by the Germans, but some film (such as this Russian film) remains. Back then he would have been treated with anticholinergics. The nurse was telling me (and I don't know how much truth there is in this) that because of Hitler's Parkinson's disease, and the neurological problems it caused (thus ruining his leadership of the German army and nation) this was a reason that the Allies didn't attempt to assassinate him towards the end of the war, and possibly a reason why the Germans made an attempt on his life. Very interesting stuff, but probably more for historians than medical students!

Half a head

2012-01-15T22:45:00.000Z

Hi,

A very productive week this week, spending my time on a neurosurgery placement. I got to see a number of surgeries, which were the highlight of the week really, and spent the rest of the time on the wards and in clinics. A much busier week than many of my previous weeks, which was something I really enjoyed. It reminded me a lot of my third year, with all of the contact time with the patients and doctors, and helping out on the ward, the way I am sure I learn best. The surgeries I saw varied from operations to the spine, to operations on the brain and skull, and lasted for hours and hours each. I was a little disappointed that they were not more complicated, though. I was expecting 'Neurosurgery' to be very complex (everyone assumes it is) but really it just seemed very similar to the rest of the surgeries I have seen. Perhaps rocket science is equally as over-rated.

Before I get into my post, though, I would like to thank the people who run medical-artist.com who, in compiling a list of who they think the top medical student blogs are this year, were kind enough to put mine at the top. I am touched that they thought it was that worthwhile-a-read, and its always good to know what you are writing is appreciated.

Getting back to my week, saying all I did about neurosurgery not being as complicated as I expected, it doesn't mean that I didn't enjoy the operations, or the time I spent in the theatre. I spent half a day in theatre on Monday and a whole day on Wednesday. When I say I spent a whole day, this means the surgical list running from 9AM to 7PM. While the surgeons may be seen as the 'jocks' of the medical world, they sure do seem to work hard! I was with another medical student for both of these sessions, and we were not allowed to 'scrub in' as we have done for other operations previously, letting us hold things for the surgeon and generally help out. This is probably due to the increased risk of infection, and the fact that most of the operations are done down a sort of microscope, meaning the surgeon could look at the minute anatomy more easily down the eye pieces, but there is no room for medial-student-help. The operations were shown up on a screen, making it easy to see what the surgeon could see, but also giving you the feeling that you could just be watching something similar on youtube at home...

Despite all of the time I spent in surgery, I only saw three and a half operations, as they tend to take a long time. On Monday, there was one operation all day for one complicated case, a patient with a meningioma (a type of brain tumour), which was in the posterior fossa of the brain where the cerebellum sits. A complicated operation where part of the skull needs to be removed, and the tumour searched for in the brain meant that this would take a whole day. Unfortunately I was only scheduled in for the afternoon, having lectures in the morning that I couldn't miss. This did mean that I missed the portion of skull being removed, which could have been interesting, but I did get to see the removal of the tumour and everything being put back on again. Seeing the surgeon search for the cranial nerves so they didn't get accidentally cut reminded me why my anatomy was so important, and I regret the fact that I have forgotten so much of the anatomy I had to learn in my first and second years! Interestingly, if the skull cannot be put back immediately (for example, because they think that there will be inflammation in the brain, which will cause it to swell and they don't want it to swell up inside the closed skull causing injury) the part of the skull cannot be kept and given back to the patient at a later date as it used to be. Because bone is a structural material, they used to be able to remove it, sterilise it and give it back at a later date. Laws relating to the use of human tissues mean that this is no longer possible, and instead the skull always needs to be kept with the patient. This means the portion of the skull is kept inside the abdomen along side your guts, where the patient carries it inside them until it needs to be put back (when the inflammation has gone down). The skull can shrink slightly because of the body's macrophages (immune cells) having a little munch on the edges, meaning if it is left in there for some time it can become too small for the original gap, but this is a very interesting concept!

As I said before, my part in the neurosurgery involves standing by the edge and watching what happens. On Monday this involved standing up from 12 'il 6.30 straight, which seemed like a long time, but on Wednesday I was standing from 9 'til 7, though I did get small breaks as they switched the patients around. Working for this long means you have to be tough to be a surgeon, but at least they and the anaesthetist get to sit down as they work. I feel sorry for people like the scrub nurse who have to stand for the whole day! On Wednesday the three operations I saw were the changing around of a spinal cord stimulator, the removal of a pituitary tumour via a transsphenoidal route (via the nose) and the replacement of most of someone's skull which had been removed in a traumatic accident. A long day, which I shared with my fellow medical student and an osteopath who was a friend of the surgeon and had come to watch and learn.

The spinal chord stimulator replacement surgery was pretty simple and only took a few hours. Because there was already one in place, this was more about replacement of the unit which had run out of batteries for a new one. This machine is inside the body, and has a small battery with wires in the spine. The patient is given a remote with which they can control how much voltage is put into their spine. Rather than being the terrifyingly painful experience I would imagine it to be, supposedly it is a great pain killer for chronic pain, working by blocking the pain signals going up the spinal chord.

After this surgery was the surgery for a woman who had been diagnosed with a pituitary tumour. The pituitary gland is a small gland in the brain which controls most of the bodies hormones. Tumours here are usually benign, but they can cause the secretion of many hormones, or interfere with vision as the nerves from the eyes run next to the pituitary gland, and if it gets enlarged it can interfere with these. This surgery is done via the nose, using a similar method to that the Egyptians used to remove the brains from the skull before mummifying their ancestors. This is because the pituitary gland is right behind the nose, and going in this way means you do not need to go through brain, though it does mean that the entire operation is done while looking down one of the nostril! Impressive that this can be done, but it did involve watching a screen for ages as the surgeon fiddled around in the nose. A little more interesting than my experiences of TURPs previously, but only just.

Transsphenoidal surgery route - pretty clever huh! An approach favoured by Harvey Cushing, whose name has become associated with a number of medical syndromes and diseases

The best surgery of the day, and the reason I stayed 'til the end with only a cheese and pickle sandwich keeping me going was the man who had had a serious head injury in April and was having his skull reconstructed. Back in April, he had been hit in the head by a large part of a car while at work, which was travelling at about 70 miles an hour. This had crushed half of his skull, and on admission to hospital he was not expected to survive. Fortunately, with some dramatic surgery, he had recovered and had been living in a rehabilitation home until now. His skull had not been put back on at the time, hough, because of all the inflammation, and because of the large loss of one of his cerebral hemispheres (half of his brain) his head was a very strange shape, missing about a quarter of the top part of his head. It had skin over it, which was growing hair, but he looked distincly different, and wanted to go back to looking more normal, which was the purpose of the operation. A metal plate had been constructed to fit the shape of the skull, and this was going to be screwed in.

I saw him the day before when I was on the ward, to clerk him before the surgery, and was surprised with how well he seemed. Obviously, for someone who was missing half of their brain, he was not perfectly healthy, but other than slow slurred speech, and slight confusion when I asked him to carry out slightly more complex tasks. On physical examination, his body was neurologically normal other than brisk (increased) reflexes across the body. Amazing the sort of injuries the brain can deal with and bounce back - a very plastic organ! Either way, I build up a good rapport with him on this day, and I felt that he really appreciated my presence in the operating theatre before his anaesthetic (he was understandably nervous). As someone who had been a helicopter pilot on the army about a decade ago, this injury had clearly changed his life hugely, but he seemed so determined to do as well as he could. It really puts my problems in perspective! Either way, the surgery went well, the highlight being when the surgeon noticed the surgery lights shining on the plate he was about to insert cast lots of glittery reflections around the walls. He ordered the main lights to be turned off and created a disco... This may seem a little insensitive, but a nice break after hours of painstaking dissection around the edges of the remaining skull. The fact that I really enjoyed talking to the patient about his story (and the theatre-disco) and didn't really care so much about the surgery reiterates to me that I don't think surgery is the sort of speciality for me. It is clever and technical, but so is being a car mechanic.

Almost Automatonophobia

2012-01-08T23:58:00.001Z

Hi,

Back on the weekly posts now, and it feels good. This week there is a ward round in the stroke rehabilitation ward, where patients are looked after post-stroke and health care professionals do their best to help them improve their function. The real fun comes from my GP day, where I see a number of strange cases, the strangest of all was a 18 year old lady who was applying to be a nurse, but who had what she said was a crippling fear of CPR dummies which would stop her from realising her dream.

The ward round around the rehabilitation ward for stroke victims was an experience. Many of the patients were really quite ill, with serious problems meaning they couldn't function normally. They may have physical problems, such as the inability to walk or feed themselves (whether through problems with arms or inability to chew and swallow) and may have cognitive problems, such as the inability to form words or recognise objects. All of these are equally debilitating, but the people with cognitive impairments seem a lot more interesting from a medical perspective. It is very easy to understand why someone may have problems moving a limb, but a lot harder to understand why a person may no longer be able to recognise and name objects such as a pen. The consultant on this ward round was fantastic, taking plenty of time for each patient and talking slowly and clearly to make sure they understood perfectly, crouched down on her knees to get to eye level with them. Some patients stay in this ward for months and months as they slowly improve, to try and get them functioning as well as possible, but she would still take a decent amount of time to ask them how they were and see how things were going. While the area of medicine doesn't appeal to me all that much, if I am going to be a doctor, I would definitely like to be a doctor like her!

Medical school lectures and seminars are not usually the most interesting of times. Don't get me too wrong, you learn a lot and the subject matter can be fascinating, but there are not usually a lot of laughs bouncing around. This changed in a seminar this week on prescribing, though. We were being taught about how to prescribe, and were looking at the BNF (effectively the bible of drugs), going through drugs that are given for infections in different systems of the body. The atmosphere among the ten or so students there was very strange. Not really sure how to explain in, but just one of those strange buzzing sort of atmospheres that seem to be waiting for something to happen, almost like that before a storm... The GP tutor said

"This section of the BNF can be used to help you see which drugs to use for infections to different areas of the body. For example, for skin"...

There was a second of silence as she caught her breath, then the guy next to me let out a snort of laughter, which he was clearly trying to contain and 'whispered' to me "Forskin!". This was definitely not a whisper, and the whole room was giggling away for a good minute. Fortunately the GP tutor saw the funny side as well. Its a little scary how many similarities there are to primary school with us fourth year medical students...

My day at the GPs surgery this week involved a huge variety of patients, some of who were really interesting! Being a GP has never been an appealing idea to me, as it seems as though it may become a bit boring, but these days in GP surgeries definitely make it seem like quite an appealing job! One of the patients who I saw today was a definite hypochondriac, who came to see the GP almost weekly, and had used her own money to pay for many investigations that she didn't need, such as a full body MRI scan. She had had a small lump on the inside of her cheek, which while it wasn't visible, and didn't irritate her in any way, she had wanted it removed. Most people she had talked to had said it didn't really need doing, so she had gone privately. Unfortunately the private doctor who she saw used the equipment in the operation incorrectly, and turned up the diathermy too high. This ended up with her having a large hole in her cheek. A young shopkeeper, she was very unhappy with this result from what was an unnecessary operation, and now had serious health worries. Its important to remember that all operations carry a degree of risk!

This is a child, and a different hole, but you get the idea...

The GP was very busy due to a number of complex patients she needed to see, and I ended up seeing a couple of patients on my own, with the intention of reporting them back to her and making her talks with them shorter. This would hopefully help the waiting times, and give me practice as well. This was, unfortunately, when the most complicated patient turned up, when I was left alone. This wasn't the typical 'complex' patient, with lots of medical problems - just someone that we had definitely not been taught about in medical school. This was an 18 year old, who wanted to be a nurse, but said she had a crippling phobia of CPR dummies. She was afraid that this phobia would hinder her in her training, and wanted it to be cured. How do you approach a patient like that? I have heard of a fear of puppets (Automatonophobia) but never this, though I assume it is similar. It was clearly worrying her, so I tried to be as serious as possible while I got the GP involved, to help me out. In the end it was decided that perhaps she could try CBT to help her out. The GP first suggested 'flooding' by putting her in a room full of the dummies and locking the door. Fortunately she was joking, I don't think that dying from a dummy-induced-heart-attack would look very good. Once home, the internet tells me that she isn't alone, I mean look at the first poster on this facebook page! Some of the things that GPs see and hear about can be really sad, but others can be fantastic!

Hoarder

2012-01-06T22:19:00.003Z

Hi,

I have finally caught up with myself, and this is last weeks blog. This means that, finally, from this Sunday onwards I can be posting that previous weeks bloggings. This will make it a lot easier for me, as I won't feel as though I am constantly trying to write my blog, and a lot easier for anyone who wants to follow me, as instead of having new posts constantly popping up, there will just be one a week to read, hopefully of a higher quality as it won't be so rushed...

I am getting into the neurology rotation properly now, though as this is the week before Christmas there is a short holiday in the middle of the rotation to break it up and let us have a Christmas. A little bit of a shame to have the rotation interrupted half way through, but if the alternative is missing Christmas, I know which I would prefer...

Despite having plenty of lectures this week, which while interesting are no-where near fun enough to write about here, I do manage to spend some time on the wards. One of the patients who I talk to is a lady who was admitted with intercranial hypertension, due to blood clots in her brain. Here the pressure inside her skull increases due to the increased amount of cerebrospinal fluid (CSF) in the skull. This has been caused by some blood clots which have formed in her brain to block the normal circulation of the CSF. As it cannot drain properly, the pressure keeps building up, and she needs to have it drained every couple of days by having a needle put into her spine to let some of it out. This is because of something called the Monro-Kellie hypothesis, which means that the skull, a fixed volume, can only hold a certain capacity. The main things in the skull are brain, blood and CSF. In this case the CSF is increased, so the amount of blood in the vessels in the skull can decrease to a point, meaning that there are few symptoms for a while. Once this reaches a level where the blood can no longer decrease, however, the brain starts to become squished, due to the increased pressure and causes symptoms such as headaches and much worse. This works the other way around as well, for bleeds in the skull causing increased amounts of blood, and the CSF can decrease. I feel really sorry for this lady, as having to have the fluid drained every three days means she cannot go home to her family, and means she has to wait here until after Christmas, when the current plan is for a neurosurgeon to put a shunt into the brain, so the CSF can drain automatically down a tube in the neck into the abdomen, where if can be reabsorbed harmlessly.

The other interesting patient I saw this week was interesting in a much more social way than medical. This was a 50 year old lady, who had been admitted for new onset seizures, to be monitored in the hospital to see if they could get an EEG recording whilst she had a seizure to see if they could diagnose epilepsy. While talking to her, she seemed relatively normal, chatty and friendly, and she clearly took care of her appearance, and was well made up despite being in hospital with leads attached to her head. While this in itself was unremarkable, what the doctor told us about her later was much more interesting. Supposedly, since she had come to hospital, her children had gone to her house for the first time in years to get some of her things to bring to the hospital. They had found her living in absolute squalor, with excrement all over the floor and piles and piles of hoarded items creating a maze throughout the house. They had no idea that she lived like this, as she always seemed so normal on the outside. Unsure what to do, they had called the GP, who had visited and been equally as horrified. The woman still doesn't know that the doctors and children know about this secret - as the children don't really know what to do. This is probably more of a job for social services if this lady seems not to be coping, or perhaps for the psychiatric doctors. She seems so... normal in other respects - personable, well dressed and holding down a decent job. It is a privilege as a doctor to be able to see under people's outer 'skin' and get to know them better. I hope she gets the help she needs.

The start of neurology

2012-01-05T18:33:00.000Z

Hi,

I have finished my oncology rotation now and have moved onto my neurology rotation, where we study everything to do with brains, from the medical to the neurosurgical. I live with someone who studies neuroscience as a PhD, so have high hopes for this rotation. Hopefully whenever I come home confused about something regarding brains, he can help me out. This rotation has a large number of lectures in as well, but unfortunately these are all in a hospital that is an hour away from the main hospital and where I live, so a lot of time is spent this week travelling to and from the lectures and neurological wards. Neurology and neurosurgery is relatively specialist, so it is not carried out in all hospitals, rather in centres of excellence, which in this case happen to be a bit far away...

Brown–Séquard syndrome is due to a partial injury on one half of the spinal chord, giving split symptoms across one half of the body and the other, as some parts of the spine cross over after leaving, while others do not

Despite all of the lectures I am getting, reminding me of all those wonderful and interesting things we were taught about in first and second years such as Brown–Séquard syndrome, I still do get the chance to spend some time on the wards. We were put into pairs and sent to see patients, in order to report back to the doctor and guess at a diagnosis for each patients. My partner and I talked to and examined a really friendly 80 year old woman, who despite being really lovely and wanting to help us out, was very hard to examine as she could barely hear us and seemed to be unnaturally cold, so as soon as we took the blanket off of parts of her body to examine them she would shiver violently, but insist that we carried on. Our examination showed that she had a strange mix of upper and lower motor neuronal signs, suggesting that both her central nervous system (brain and spine) and her lower motor neurones (all the other nerves) were being damaged. This means that whatever disease she has is affecting both the peripheral and central nerves. The most likely disease we thought to be causing these symptoms was a motor neurone disease such as ALS, but as we didn't know what the patient was really diagnosed with, we didn't tell her what we thought in case we were very wrong, and we didn't want to scare her. You distinguish between upper and lower motor neurone disease by testing reflexes, power and looking for signs such as fasciculations. As medical students we are not very used to what 'normal' is, so it can be hard to tell when things are abnormal, especially seeing as each person is going to have different reflexes and strengths, and older people tend to be quite weak. As it was, when we presented to the consultant she agreed that motor neurone disease was the most likely diagnosis, but it was not confirmed yet, and could be a range of other diseases. She then asked us to name some of the other diseases that it could be, which didn't work out very well for us, with our list of two or three. I hope that everyone is wrong, though. Motor neurone disease doesn't have a very good prognosis, and many of the other differentials will lead to a much better life. It always seems to be the lovely patients who have the worst diseases, odd...

Later in the week, I was on the ward and chatting with a patient who had been in the hospital for a month after getting Guillain–Barré syndrome. She was a mother of two, and a great believer in herbal and alternative therapy over conventional western medicine. She explains to me that, because of this, she doesn't really believe in vaccinations at all, and has avoided them since she was 18. Despite this aversion to them, the GP managed to persuade her to have a flu vaccine a month or two ago, because she has severe asthma, and usually gets severe chest infections meaning she tends to end up in hospital over Christmas. Some days after the vaccine, she started getting a tingling in her legs, a little like pins and needles, which started to progress up her body as her legs became weaker and weaker. As this went on over a few weeks, she saw her GP a few times, who first told her that it was nothing, and then told her that it was probably a trapped nerve in the spine and gave her pain killers. Finally, on her fourth visit, the GP sent her to hospital, but by this time she couldn't walk and to get to the GP she had to be carried to the car by her husband. For the past week she had had to be washed and carried about the house by this man, because she was too weak to move. Guillain–Barré syndrome is pretty rare, which makes it hard for the GP to diagnose, but you would have hoped that he would have noticed that this woman should be sent to hospital sooner, given the fact that she was too weak to even have a bath herself. The illness paralyses muscles of the body, and progresses until it paralyses the muscles used for breathing, killing the person. At least it was caught before this happened.

Guillain–Barré syndrome is an autoimmune illness, which can rarely follow certain infections. It is due to the body's immune system getting confused and attacking the peripheral nervous system which supply the muscles, thus paralysing them. It is very very rare to get this after a flu vaccination - one in millions chance, so I feel really sorry for this poor lady who was so opposed to vaccines getting such a terrible side effect when she finally consented to having one. Once in hospital, she could go on ventilation to help her muscles breath for her, and could be given medication to help the body reverse the damage that was being done. It is very slow to get better, but people often do get better, and the day I came to talk to her she had just eaten orange squash and chocolate for the first time since this all happened. Because of the effect on swallowing muscles, and the fear of food or drink going into her lungs by accident, she had been fed by tube for some time. I was curious as to whether she was giving her children vaccines, and she was, seeming to understand the importance of them. This is good news, and not what I expected from your stereotypical unemployed mum from a rough area. Despite her poor background, this illness seemed to have given her a new lease on life. She delighted in telling me how she planned to not smoke once she was out (being confined to bed for a month had forced her to give up) and wanted to start eating more healthily and get a job. The women around the ward had clearly had part in this and were shouting out encouragement from behind the curtains where we were talking. Drawing the curtains may give privacy for an examination, but offers nothing of the sort for talking! It was really lovely to see how something so bad could have such a positive impact on someone, giving them the feeling that their life really was worth something, and making them want to do something with it. I just hope that she can stick to her decisions after leaving hospital!

The end of oncology

2012-01-04T19:12:00.001Z

Hi,

This week is my last week on oncology, before I change rotation to neurology. I spend some time in a clinic for people with lymphoma, which seems to be much more complex to run than the other clinics I have been in this month, and see some really lovely patients. Later in the week, I am back on my GP placement, where reading between the lines of how a patient is feeling about her possibly having an STI makes me feel like House.

Most clinics in the hospital are run like a GP surgery: you go into a room, chat with the doctor who has your notes, and then go home. Not so the lymphoma clinic! Here there are a multitude of different doctors all in one busy room, and each patient file is bought in, and the patient is first discussed. One doctor then goes off and takes the patient to a room to chat with them, and then comes back and talks to whoever is in the room about them. Another doctor of a different speciality may then go and talk with the patient as well, until the group has made a decision about what the best course for the patient is. It seems like the decision is made by committee, rather than just one person. I think the reason for this is that the lymphoma sufferers are both haematology patients (a cancer of the blood) and oncology patients (doctors who deal with cancers), so the professional input from both specialities is useful. This made the clinic a lot more confusing, making it seem almost archaic in the confusion that occurred, though I hope that from the patient's perspective it seemed to be running smoothly!

While at the clinic, I see a man from the Seychelles who has moved to this country. He has HIV and lymphoma, and while the consultant is running an errand outside, he tells me about how much better the care is in this country than where he used to live. He is currently looking fora job in the country, but cannot get one as he is still having his immigration status checked; I think he is currently applying for asylum. I think it is fantastic that we can still offer this man healthcare and look after him as a country, but I know many people see this as him abusing the system, having never worked here and still being treated for two expensive diseases. I don't really want to get down to the debate, but he clearly wanted to work and give back to the country, and was ever so grateful for the help he was getting. I do doubt that he will ever be able to nearly pay for the expensive treatment he is given with the taxes on whichever meagre job he manges to get. Other than the much better healthcare in this country and other political reasons, he seems slightly confused as to why he is here as well, upset with the stormy rainy weather beating away outside, a far cry from the weather he grew up with I am sure! I am talking to him about his problems with relationships, and his uncertainty as to when to tell people he wants to date/who he is dating that he is HIV positive, when the consultant comes back in and the topic is changed. back to the immediate medical. As a medical student I often find myself talking to patients more about their worries and concerns than medical conditions, but this is no bad thing. Most doctors are far too busy to find the time to do this, and I don't actually know anything, so wouldn't be more useful doing something else. Its a win-win situation!

Other people I saw at the clinic were not as chatty, but just as interesting. A number of them seemed a lot more concerned about other problems they were having other than the lymphoma, and kept trying to change the topic of the discussion onto these. For example, one man was very upset that his mouth seemed to produce a lot of saliva, and it was slightly unusual. The consultant told him that this was unlikely to be due to the lymphoma that he had, but the man kept coming back to it. Perhaps that because lymphoma is such called, rather than "cancer" it seems a lot less scary to patients, and so they do not worry about it as much? I am not sure if this is a very good reason to explain it, as I am sure they have been told what lymphoma is, and that it is a form of blood cancer.

In my GP placement later on in the week, I am now talking to the patients a lot more. Not taking their histories on my own yet, but now it is more of a 'shared' history taking with the GP, which is good as it gives me lots of practice. I see about ten patients in my time there (in the time she would have seen about 30), with a range of different conditions, from the smoker with the chronic cough with a little blood after smoking 50 pack years of cigarettes (pack years are a calculation of how many years you have smoked the equivalent of a pack of 20 cigarettes a day) to the 20something year old with vaginal discharge. The man with a chronic cough got referred to have a chest X-ray, in case of lung cancer, hopefully to be negative. With the 20something year old, we took vaginal swabs and urine to send off to the hospital, in order to screen her for STIs. In itself, this is pretty standard practice and doesn't seem worth remarking on. What was interesting was her reaction to the concept that she might have an STI. We had taken a sexual history, in which she told us that she had a partner but had not slept with anyone else for the last three years. Here, I was thinking 'poor girl, perhaps her partner has been cheating on her', the most sensible assumption to make if it turned out that she had an STI. When it was mentioned, though, her reaction made me think differently. Instead of the expected reaction of suspicion towards her partner that I would have expected, she did seem upset, but said she was afraid her boyfriend would blame her if it was found they had an STI. I asked if there was any reason for her to feel this way, but she said there was no reason at all. From this, perhaps she knows she has done something naughty and she hasn't told us, and doesn't want him to find out about it. You would have thought that if she hadn't done anything, then she would be suspicious of what he may have been up to. This is all an assumption, as perhaps the reaction could be persuaded by other reasons, such as her being afraid of him being angry with her whether she knows its her fault or not, and perhaps being violent, but it didn't sound like this at all. Whatever the real reason, it highlights that listening to patients is very important. Not just for the diagnosis, but to try and work out the juicy gossip about their personal lives!

Is your gran a drugs smuggler?

2012-01-03T23:24:00.001Z

Hi,

This week I sit in on a lung cancer clinic where I met a wonderful pair of drugs smuggling 70 year olds, who talked all about the fun times they are having despite one of them having terminal lung cancer. Later on in the week, we spend time talking to patients who have come in for chemotherapy; the patient who my partner and I are 'assigned' to talk to is a local celebrity from his art, though the side effects from the chemotherapy are ruining his career.

Through all these clinics I have been sitting in on, I am becoming aware of how important research seems in cancer medicine. There are special research nurses here, whose job it is to run all of the drugs trials that are occurring. A large number of patients seem to be on some trial or another, which can be very confusing, as the doctor who is treating them is also not sure which medication the patient is on, or even if the patient is on any medication at all, or just a placebo. Trials can only be carried out if one option is not known to be better than the other. For example, if a drug is known to treat cancer, then trials will usually be done on top of these 'gold standard' treatments, the intention being that the patient will still get the best treatment even if the trial drug turns out to be rubbish. This is clearly the most ethical way forward, but having the patients on a number of drugs can make it very confusing for the doctors to work out which of the drugs is creating the side effects that may stop the patient from taking their medication. I suppose research into treatments against cancer is a very hot topic, with cancer often in the headlines of popular newspapers, so it is only to be expected that the oncology department is so focussed on research.

Does anyone else remember super-gran? Perhaps she was just on crack...

One of the patients who was on such a clinical trial was a 75 year old lady with incurable lung cancer. In addition to the treatment she would normally receive for this disease, she was also being given a drug being trialled. In this case, as with most clinical cases, the patient was a lot more interesting than the medication she was on. She was quite a loud and jokey person, and had come in with her friend who was equally boisterous. This gives the consultation a very different atmosphere to the one I had been getting used to. Normally they are very quiet, mature consultations, as you would imagine when people dying and the "C-word" is being discussed (cancer). Here, the atmosphere was completely different (with a different C-word being used regularly) and laughs all around. This patient and the friend she had bought along to keep her company at the consultation were outrageous! After the standard questions had been asked by the doctor, and he was writing up in the notes, we started hearing some of her stories. It turns out that for the last month she had been on holiday with her friend in spain "getting pissed and stoned". She told us that she was scared about how easy it would be to get drugs in Spain at her age, so smuggled out a "load of pills and weed". After her amazing month, a lot of which she cannot remember, she had realised how easy it was for her to get drugs in Spain, so smuggled back a selection for "personal use" on her way back. She refused to tell us her trade secrets, how she evaded customs, but did offer to sell us some of her stash, at what she claimed were very good rates.I told her, in a jokey way, that she was being a bad influence on us poor young ones, but she just shrugged it off and winked, poked at me and told me that she was sure that we had done these sort of things before.

Despite the legend of a gran, the consultation wasn't all fun and games. She really wanted to stop all of her chemotherapy and enjoy her last few months of life, because of all the side effects she was getting from it. She was getting things like tingling legs and mouth ulcers, things that other patients who we have seen would love to have over the side effects that they put up with, but each person has their own tolerances as to what they would put up with, and these need to be respected by the doctors. I suppose she had decided that she was happy to die, and just wanted to enjoy her last months doing what she wanted, without strange feelings or pains. This was a difficult decision with the doctor, but she was convinced to wait until the next consultation before stopping everything, and was just taken off of the trial medication in case it was causing these effects. It is likely to be the standard chemotherapy causing these, as these are well documented side effects, but this is a chance to see what happens. She was so much fun, I wish her all the best. She did talk about her children and grand-children who she thinks have no idea about her life style. I doubt this is true, but if it is, perhaps someone out there has this rocking gran without even knowing it!

Steve Jobs avoided surgery for his pancreatic cancer for some time, instead choosing to try out alternative treatments

Later in the week, when we are talking with patients who have come in to receive chemotherapy, we meet a local celebrated artist at the centre. He is very demanding that the drugs don't affect his art, but because of the peripheral neuropathies that keep being induced, the time has come for him to choose between continuing treatment or his art, a very hard choice for him. Without the treatment, he will die from his cancer; while with treatment he will probably still die of the cancer, but a lot more slowly and more comfortably. He has already spent all of his savings on avastin, an anti-cancer drug that isn't funded by the NHS (questions about efficacy) as it is possible it could help him. This is understandable from a medical students perspective, but he also spends his money on a lot of alternative treatments. As well as having mistletoe injections twice weekly, he also has tried many other treatments including homoeopathy and talking with a psychic. These are much harder to understand from the scientific background we are taught in, but doesn't mean that they are not popular. Even the great Steve Jobs tried many alternative treatments for his pancreatic cancer, including acupuncture and a psychic, before deciding to consent to surgery. These were decisions that may have let the cancer spread and eventually killing him. Fortunately this patients seems to have a very sensible approach of using the two in tandem, and I am definitely not one to argue with him. If it brings comfort and the thought that something may be helping him, then it would be unfair to try and take away this from him, even if it is just the power of the placebo. He is currently funding his alternative therapy and travel to the cancer clinic by selling his paintings to the cancer centre, which is kind enough to buy them from him so he can continue his treatment. Everyone wins, as they look fantastic on the walls.

My breasts are examined

2011-12-31T14:58:00.000Z

Hi,

This is a slightly misleading title, as I don't actually have breasts, but this week I do get to don a pair of fake-boobs and have my other class mates examine me. This is good practice for a beast cancer clinic I sit in on later in the week. I have a number of lectures this, and every week, a lot more than in my third year, which is a shame but it is nice to be spoon-fed information again. I am also assessed on my elective this week, by having to present a poster based around my experience there. All in all, quite a quiet week.

In our teaching sessions, we are often taught how to do an examination or procedure then expected to practice it, such as abdominal examinations or auscultating the heart with a stethoscope. This session was a about breast examinations, and as they had decided that letting us practice on the female members of our class was not the best idea (probably a good idea, as it could get awkward), so had a pair of fake breasts for someone to put on, and let people examine them. These breasts had a range of strange lumps in them that the people examining could try and find. When the seminar leader asked if anyone wanted to be the person wearing them, and be examined, no-one volunteered. Secretly I really wanted to, but I thought it would look strange if I jumped up straight away shouting "Me! Me!", and was relieved with the couple of seconds of silence that followed the question meaning I could volunteer while looking as though I was doing it to save anyone else from having to do it. I do not secretly want to have breasts (but if it was a secret, would I tell you?) but I love wearing fancy dress to parties, and being examined by 20 people is a great way to learn the examination yourself. Win win! The only awkward part came when it was an ex-girlfriend's turn, and she was clearly not impressed that she she had to examine my breasts. Awkwardness aside, a great learning experience, though I am definitely not confident that I could spot small lumps at all.

The breast cancer clinic I did the day after this session was very useful in putting these skills to practice. I was with a male consultant, and so he made sure that there was a female nurse in with him every time he examined a patient as a 'chaperone'. With what is seen as an intimate examination, I suppose its sensible not to take risks, and have women claiming that a doctor and a medical student molested them in an examination room. It is a bit of a shame that female doctors are trusted not to molest people, and hence do not need a chaperone, while male doctors do, but unfortunately I suppose that this is based on history, and the fact that most of the doctors who do behave in a sexually inappropriate way are men. Anyway, it turned out that carrying out these examinations on real breasts and feeling real lumps was a lot easier than it was on the foam breasts. While breasts could be examined to exclude breast cancer, many of the women there were because they were being treated, or they had presented to the GP with a lump they had found in their own breast and been referred. This made things very useful, as they could say where the lump was.

The type of examination breasts I wore. Not the most realistic things, but probably a good idea to get used to these, as they will be used in my examinations

All of the lectures that we are having this year are starting to become a little boring. I thought I had escaped lectures after leaving my 2nd year, then had a year of them in my intercalated degree, now have another year with quite a few in them now. My third year didn't have nearly this many in it. I hope its just the oncology rotation that will be like this, and the other rotations will have a lot less lectures.They are no bad thing, I mean being told the information is better than the third year where you constantly had to seek it out while at the hospital, but I was looking forward to getting back on the wards and practising clinical medicine. I suppose I have the rest of my life to enjoy that, so perhaps I should enjoy the more laid back pace of the lectures while I can. This week we had three, yes three, lectures on how NOT to prescribe chemotherapy. I know this is a serious topic, as poor prescriptions will kill people (it is a toxic drug after all), but we are not expected (or even allowed) to prescribe chemotherapy as a foundation years doctor, and then hopefully we would be taught properly if we became an oncology registrar? Perhaps I am just feeling grumpy as I need to get up for lectures at 9 again.

At the end of this week, I had the assessment for my elective. I had to sum up my 6 amazing weeks onto one A1 sheet of paper. If I was to say my elective was life-changing it wouldn't really be much of an overstatement, but this isn't really the sort of thing you can write on an assessed poster. Working out how to fit all of the experiences down into such a small space was (almost) harder than eating the disgusting sweet-spaghetti (which I made sure not to mention). Despite all the work, the presentation went very differently to how I expected it to. I got one of the academic professors assessing mine (luck of the draw) and instead of asking all around the subject, as I was expecting, I just got asked academic question after academic question. What were the three main forms of malaria after Plasmodium falciparum? (Fortunate I did that immunology degree, really!), If a young patient presented with low heart rate low blood pressure what would the most likely diagnosis be? (No idea with that one, snake bite?) and so on. I do not think I performed very well at all, unfortunately, but what can you do. Still do not have my mark back, but I would hope that I would have been told by now if I had failed. One more assessment out of the way, and one step closer to being a doctor...

The Hospice

2011-12-30T15:04:00.000Z

Hi,

This week I spend a few days working in a hospice as part of my oncology rotation, which is a fantastic experience, being completely different to how I expected. I also attend a gynaecological cancer clinic, which is a long drive away, and spend a day in a GP practice where my assigned GP wants me to run the consultations. I am not sure if I am ready for that here at all, despite doing effectively the same thing in Tanzania all on my own...

The visit to the hospice is intended to let us get some experience of... well.. hospices. The medical school is very keen on showing us lots of out-of-hospital medicine, and I agree, I think it is a good idea to see as much of the varied world of medicine as possible. Not just to let us to plan our careers, but to help us understand how each speciality works when we are specialists ourselves. It is unlikely that a surgeon will be visiting hospices to learn about them once working, but could be referring patients to their care.

The hospice was lovely, and very different to what I had expected a hospice to be like. I have no idea why, but I had imagined a hospice to be a little like an old people's home, with dying people sitting in their rooms, or if they could manage it, in large chairs in a circle, not doing very much. This perception was proven wrong from the moment I stepped into the warm, friendly and very professional reception. No strange and stuffy nursing-home-esque furnishings here. The staff were very friendly and accommodating, and despite the clinical feel to the building (I suppose it plays many roles similar to a hospital) it felt a lot more... fuzzy? We had talks from doctors, nurses, volunteers, carers and patients and talked to a number of patients who had come here. While we were learning about the different pain killing medication that was prescribed, we were asked if anyone wanted to try out one of the sublingual tablets. They said 'morphine' on the packet, but we were assured they were placebos. No-one seemed interested, after his talks on their sometimes nasty flavour, but he then said that they were wild berry flavour. Sounds delicious, right? I thought so, as I volunteered straight away to have one. Having put it in my mouth (don't worry, they did turn out to be placebos) there was just a bit of a bitter taste, and certainly no wild berry flavour... It also lasted for over a minute, rather than the 10 seconds to dissolve that he had taught us. I asked him about the flavour, and just said "yes, well, I lied... Otherwise no-one would have had one!" Are doctors allowed to lie?

Sublingual tablets do a similar job to the "pain killing lollipop" that Jade Goody was often seen sucking, which is meant to provide pain killing medication through the mucosa of the mouth.

I had always assumed that hospices were for people who were dying, so they could spend their final days (should they be too ill to go home) in a nicer environment than a hospital, while still receiving the same standard of care. This is one of the roles for the hospice, but it also fulfils many other roles as well. Many of the patients who I saw were not there 'to die', rather because they were ill, and needed somewhere to be cared for carefully for a month, but not so ill as to need to be in an intensive setting such as a hospital. The hospice is a much nicer environment, so attracts this sort of care. Unfortunately the hospice is also not NHS run, but still free to patients. It has about 20% of its cost paid for by the NHS, with the remaining cost sought through fund raisers and donations. I remember as part of the RAG at my medical school a couple of years ago, dressing up in a giant mascot costume and fund raising for the hospice at a shopping centre with some other students in scrubs. Fantastic fun, until the whole thing became far too hot. While I was at the hospice, they had had to close their activities centre, which was a big sociable room where those staying there could relax, talk, and partake in activities organised for them (yes, I know it sounds a little like a nursing home!) All the patients I talked to were very sad about this, as they enjoyed these sessions, but when the hospice is run as a charity, there is no guaranteed income, meaning that these sort of closures sometimes need to be made in order to keep the more essential services running. Hopefully the NHS hospitals don't see its relative cheapness (as it doesn't use NHS money) as a good excuse to put patients there to save themselves money. Hopefully this wouldn't happen, as those who would make these decisions will be far removed from the money aspects.

Moral of the story: Charity run hospices are wonderful, donate to your local one!

The gynaecological cancer clinic was, unfortunately, a long way away from the hospitals we normally work at, and my accommodation. Fortunately I have a car, and motored us over there. It seemed a little but pointless to go such a long way for 3 hours worth of consultations, but I suppose to fit us into the timetable they need to branch out. Fortunately it was a very worthwhile clinic, with a very good consultant and registrar running the appointments. Unlike the palliative care clinic, there was a lot less bad news, and a lot more patients who had low grade cancers, with the doctors mostly aiming for a cure for most patients. There were a few patients who were not expected to be cured, and were being treated palliatively with treatments such as radiotherapy, to slow the cancers progression and reduce some of the nasty symptoms they were getting. What impressed me most was the fact that all of these patients were well aware that they had an incurable illness. There didn't seem to be any secrets that the doctors were keeping from the patients, and if the doctor was worried that the patient was not curable, the patient would know as well. I don't know what I was expecting, but such upfront honesty and openness with the patients just felt right.

I also get to do GP placements every few weeks in this year, where I spend a day in a GP's surgery in a sleepy country village. I am fortunate in that this is the same GP surgery I spent some time in in my first year, with the same doctor. She is very friendly, informal, and nice, and I am very pleased to have been placed back with her! The surgery is a large polyclinic, so I hope to get a lot of experience in a lot of different fields. We saw about twenty patients over the course of the day, the appointment times being a lot longer as I was there to take up the time. Normally GPs can see about 30-40 patients in one morning! The doctor wanted me to run the consultations, with her able to step in and ask supplementary questions, but I didn't think this would be a very good idea. I don't remember a lot, and felt I would like to see a few before trying them for myself. She seemed to understand, and I participated by adding in questions when she asked me - a much less worrying start! The patient who stood out most in this day was a large man who looked just like Hagrid from Harry Potter who had broken his leg.

The patient's beard and clothing matched Hagrid's almost perfectly. If he wasn't so serious, I would have thought he was joking around.

This man had had a real alcohol problem, put on a lot of weight, and the drunkenness, coupled with the poor vitamin intake from the lack of food had caused him to fall down the stairs. At the moment he couldn't leave the house because of his obesity and broken leg combination (some carers had come to bring him to the GP surgery), and all of his shopping was being done by a well meaning neighbour. This neighbour was sensible enough not to buy this man any alcohol, and for the last month he had not had anything to drink at all. He confessed that although the first week was very tough, he now felt a lot better because of it. A broken leg turning out to help someone out was quite interesting, though unfortunately he confessed that as soon as he could walk on the leg again, the first thing he would do would be to go down to his local and get himself a "pint or twelve". The GP tried hard to convince him not to start drinking again, but he wanted to. Without the patient making the decision themselves that they want to give up, it is unfortunately just not possible to get them to stop any harmful behaviour, whether it be smoking, drinking, other drugs or just plain over-eating.

Estimating when someone will die

2011-12-29T20:12:00.000Z

Hi,

This week I attend what I thought was a breast cancer clinic, which turned out to be a palliative care clinic, and very sad. I also go on a ward round with the haematology team, who see a lot of blood based cancers as part of their work. In my second week back in medical school, and I have quickly gotten used to the differences. I suppose it is all about what you perceive as 'normal'. The time in Tanzania had me seeing that as almost 'the norm', and coming to the UK had me in some kind of culture shock at seeing how different the healthcare is. This sounds a little drama-queen-ish, but to a mild degree, I think it is true. Now I am used to the UK healthcare, I don't spend my time looking at things twice, or being impressed by a consultant going the extra mile.

The breast-cancer-turned-palliative-care clinic was the highlight (in some respects) of the week for me. I had been expecting a clinic for those with breast cancer, so had read about breast examinations, important points in the history, and other useful information. Any clinic where cancer is dealt with isn't going to be a walk in the park emotionally, but I wasn't expecting anything mind-blowingly upsetting, as breast cancer tends to have relatively good cure rates (better than many cancers). On my arrival, the clinic turned out to be a palliative care clinic that was focussed around lung cancer. This will make it a lot more upsetting, as it means that only patients who are dying will be seen, rather than everyone. Lung cancer also has a much worse prognosis than breast cancer, progressing faster and with much more likelihood of being incurable.

I was sitting in this clinic with one other medical student and the palliative care consultant. She warned us before it started that some of the patient's cases can be very upsetting, but it is good to see these sort of things as a medical student, and important to come to terms that not everyone can be cured by modern medicine, and am important part of medicine is letting people die comfortably. The first patient who we see is a ex-service man who has come in with his wife, with advanced lung cancer. The cancer has spread to a number of sites in his body, such as the liver and the bone, causing a variety of problems and pains which he wants the palliative care consultant to help him with. This involves a discussion about pain killers and other palliative medication, which is relatively emotionless, as it is all factual. The emotional talk comes later, after the man asks how much time the doctor thinks he has left to live. This is a question that doctors do not like to answer, as it is very hard to tell, and whatever answer they give can make huge impressions on the patient's life. It is possible, though, for the doctor to take a wild guess. The general rule for guessing how much time the patient has left is to look at the frequency with which new symptoms are appearing. If new symptoms (from the illness, such as ascites or bone pain) are appearing at a few a month, then the patients life expectancy is likely to be measured in months. A few a week means it is likely to be measured in weeks and if they are appearing daily, then its likely that the patients life expectancy may be measured in days. This can be very inaccurate, and everyone has heard of doctors giving patients weeks to live, who then turn out to live for years. Despite this inaccuracy, it is fair to give a guess (making sure the patient is very aware that it is only a guess) as to how long the doctor feels the patient may have if the patient asks. You cannot exactly say you will not tell them!

Getting back to the point, when the patient asked the doctor how long he had left to live, in a tactical and roundabout way, his wife started crying, pulling at him towards the door and telling him he should ask such things. He told the doctor that he really did want to know, and the wife started sobbing hysterically, trying to pull him to leave. I decided that this is when medical students can actually be of some use, and take the crying woman by the arm (kindly, I am not dragging her) and lead her out of the room to the waiting room. I chat with her there for 10 to 15 minutes about what she is worried about (I volunteer for Samaritans in my free time, so have had plenty of training for these sort of talks), until the consultant comes along to find me, telling me that there is actually a quiet room for this exact sort of situation, rather than me taking them to the waiting room where there are other patients. I am a bit embarrassed, but take the wife to the quiet room to keep talking, while the consultant goes to finish her consultation with the patient, after checking that the wife doesn't want to return to the room ("definitely not!"). The wife thanks me profusely before leaving, and I feel as though I have been useful, an unusual feeling as a medical student! After the consultation, the other medical student (who had remained in the room) told me that the man seemed to be taking his coming death a lot better than his wife, and once she had left the room had confessed that his biggest fear was how she would feel when he was gone, or very ill at the end stage of his illness. The consultant estimated him to have some months left, though as I said before, this can be very inaccurate, and the patient seemed to accept this.

We see about ten patients in the morning, and despite the fast throughput, the palliative care consultant seems to give each patient as much time as they want, giving them time to talk about their symptoms and the progression of the disease (the reasons for them coming to the clinic) as well as the much more difficult touchy-feely issues around the fact that they are dying. The patient who made the most impression on me was a lovely mannered kind old man who had a very horse voice when we were talking to him. In the first couple of years of medical school, this is taught as one of the signs of lung cancer, as the cancer is affecting the left recurrent laryngeal nerve. This horse voice had only come on in the last week, and was the reason for his visit. It suggested that his lung cancer was progressing (I.e. it is getting bigger, hence why this nerve is now involved) despite the fact that he was currently on chemotherapy). The conversation was based around the fact that, seeing as this was his third different drugs combination, and they all had not worked, it might be a good idea to stop chemotherapy and come to terms that the cancer was not curable. The man seemed to accept this gracefully, and seemed to have been expecting such a statement from the doctor. I found it a lot harder, however, and found myself feeling really upset that this gentleman could no longer be treated, and the fact the treatment was being stopped seemed as though we were 'giving up' with him, and consigning him to death. I know this is not the case, and the fact he was at the palliative care clinic meant that he wasn't being given up on, but this is something that is very important in modern medicine, as everyone dies, but something I know I will struggle to come to terms with.

As can be seen by this anatomy diagram, the left recurrent laryngeal nerve runs under the arch of the aorta, and hence can be affected by grows in the lung. The right doesn't descend as far, and is not affected.

At the end of the clinic, the consultant took me aside to thank me for dealing with the wife I mentioned in a "professional, yet lovely" way. She said it made it a lot easier for the husband to talk about his illness, without her having to ask the lady to leave. She also told me to try and forget about the emotions I experienced in the clinic, instead taking away the knowledge I gained about the conditions I saw, and the service that is offered. It is always good to feel valued, and I think she must have been able to tell that a few of the patients had left me feeling upset.

The haematology ward round that I participated in later this week was a much more positive affair. There were a lot of patients with blood cancers, and all of the patients we saw had good prognoses, with the doctors aiming to cure all of them. Blood cancers are much easier to treat. Some of the patients were in special side rooms, and we avoided going in with the essential doctor and nurses, as the treatments for these cancers can often leave patients with a very poor immune system, meaning it is important not to expose them to infections. My favourite patient on this ward round (I am not sure if we are allowed favourite patients...) was a lady who, as a side effect of her treatment had had a nasty fall down her stairs, and because of her slatted metal bannisters, had torn off a lot of the skin from both of her arms. She was otherwise pretty well, and charming and chatty, so I went back later to talk with her some more. She had her arms wrapped up in two huge bandages around cotton wool, and I asked her if they were inconvenient. She said that the nurses and doctors had offered to change them to something smaller a number of times, but she preferred them like this. She had always gotten cold arms in the past, but now they were always so toasty warm!

The start of fourth year

2011-12-28T16:05:00.002Z

Hi,

So here I am, back in in the UK and back in my university hospital. I will continue with the weekly blogs, but have a little bit of a back log now, due to the fact that I was posting all of the elective blogs after my return, through my first 8 weeks of rotations. Despite the fact the blogs will be weekly, I will try and post the next few as quickly as possible to catch up with myself, then get back into the old regime. Daily is far too often for me to write, or for you to bother reading, and was only worthwhile for my elective, when so much was happening at once!

My first rotation on my return is Oncology, which will last for about 6 weeks. I hardly saw any oncology patients on my elective, and seeing as I intercalated in immunology last year, this means that I have about a year and a half since I had really done anything in oncology. In fact, I have a year and a half hiatus where I have done very little clinical work at all, excluding the elective (which was so different it hardly counts). Needless to say, I hardly remember anything and am approaching this week with some trepidation.

Having intercalated, whereas much of my university doesn't, I am in a new year, with some old friends and many new people. I was social secretary in my second year, organising many events for the then freshers, meaning that I know the year below (which is now my year). Despite this, it is still strange being in a rotation with new people, after I have gotten to know my year so well over the last 3 years. This isn't all bad, though, and it is nice to get to know people who I have only ever seen out at bars a little better. I am now officially starting my fourth year, even though this is my fifth year at Uni, given my intercalated degree, which makes for slightly complex explanations when people from outside medicine ask which year I am in!

The Oncology rotation seems to be predominantly seminar/lecture based, which is a real shame. The time table tells me that I spend a lot of time in lectures or with free time rather than on the wards. Despite this, I do have some clinical experience each week. Not as much as in my third year, but hopeful;y enough to let me remember all the things I used to know (all two of them...) My first day on oncology sees me in a specialist oncology ward with no real purpose, other than to talk to and examine a few patients, and report back to the doctors in charge of the ward. This isn't really of too much use to the patients, though with all the time I have I may find out something useful that the doctor's didn't know, but it is very useful to me, as I get to practice all of the skills I don't really have. This is a common way of learning used in hospitals, and patients are normally only too happy to help out "You have got to learn sometime!"

This whole experience was pretty confusing. Not because of my poor history taking and examination skills, though these were sub-par, as expected. It was because of the massive difference to the environment I was used to in Tanzania. I know it sounds cheesy and strange, but the difference really is scary. I suppose I expected it when I went to Tanzania, I expected it to be poorly supplied and poorly staffed, and so wasn't too surprised. Coming back to the UK, I suppose I expected it to be 'normal' - as it was what I would expect to be used to. Perhaps a combination of the fact all the clinical experience I have had in the last one and a half years has just been the gritty Tanzanian hospital, and the fact that the oncology ward is fantastically staffed and well supplied (cancer is, after all, very popular with the media, and hence seems to collect a lot of funding). To say I was 'overcome' would be a little bit of an overstatement, but I really was shocked at how spacious and clean the ward was, and more than anything, how caring the nurses are. I suppose in Tanzania I was used to the nurses who didn't really do anything, patients never got washed and there were not even any bedsheets to clean. Here the nurses take the time to do everything, feeding patients who cannot feed themselves and taking time out to help explain things to us. Perhaps I am just enjoying being back at the bottom of the medical food chain, where everyone knows a lot more than me, and is happy to explain it to me, compared to my opposite experience in Tanzania, but it is lovely here. I love the NHS.

A new badge for me to wear.

Elective 45. Home time.

2011-12-24T17:18:00.002Z

I leave for home today, travelling by bus to Dar es Salaam and meeting a very helpful taxi driver who is a friend of the hospitals. One in Dar, there is a huge quest for pizza, and the taxi driver refuses to take me to sleep in the airport, so I get a shower and a sit down toilet for my last night. An unexpected luxury! There are many mzungu in Dar, and I am actually finding having all these white people around strange. How odd!

Early this morning, there was a snake in Choc's house which spat venom at him. Thankfully he was unharmed, but as I left this morning (as the sun was starting to rise), people from the village were already starting to take apart his roof, in an attempt to find the snake. Dolittle and Kiwi kept me informed by text, and no snake was found, though a nearby hollow tree was smoked out as it contained some kind of snake nest. All the fun happens as soon as I leave!

On my way to the bus, I see a London bag being sold from the village shop. I wonder where they got it!

Dolittle and Kiwi are kind enough to walk with me to the bus, and on the way Tim comes out of his house to walk with me as well. Once I am at the bus stop, Chief joins us on his motorbike. The bus is hours late (no surprise), but they all stay with me, chatting away. I am very touched, Tanzanians really are friendly, and I have been made to feel part of their hospital family. Dr Bike has used his extensive bus connections to get me the best seat on the bus, behind the driver, with plenty of leg room and amazing views out of the wind screen of the rugged, untouched terrain we drive through.

My view from the bus - wonderful to watch the scenery go past.

On the journey a number of films are shown. Dr Bike's wonderful connections have gotten me a lovely bus with a TV and sweeties given out during the journey. Luxury! Of the films, there is Forrest Gump with Mandarin Sub titles (not sure how useful this is for Tanzanians, with their poor knowledge of English and worse knowledge of Mandarin, and being the only foreigner on the bus, I feel almost guilty). The next film is a Tanzanian film about a devil child who seems to explode people. During this (fortunately subtitled) film, the audience is told the devil has made three main advances in the 21st century, 1) in homosexuality 2) in contraception 3) in womens rights. Just the sort of film to show to a country struggling to fight sexism and HIV transmission. Following this absurd and offensive film is one called Uncle JJ where womers rights are seen as good. I think. Its more than a little confusing. As we get closer to Dar, there are very heavy rains flooding the roads, and the area we are travelling through gets much greener. The rain missing back at the hospital and causing all the problems seems to be falling here.

Here is the trailer for the Uncle JJ film. I think it was pro-woman's rights - but it might have been against them. It definitely carried a message regarding woman's rights!

One at Dar, and off the bus, I see a number of holidaying mzungu floating around at the bus station. They look so our of place and odd that I catch myself staring at them. This is weird, perhaps I have turned into a Tanzanian? I check the colour of my skin, and I am still white... I am picked up at the bus station by a taxi driver who is a friend of the hospitals. He is very helpful in finding somewhere for me to change my remaining money back, but will not take me to the airport where I planned to sleep the night to save money, as he tells me it is too dangerous. I protest that I have done this many times before at the end of holidays, in order to save money, but he still refuses and instead offers to have me sleep at his house, or to pay for my hotel himself. I finally give in and accept to go to a CHEAP hotel, which I am not going to let him pay for!

The back wheels of my coach. One of the most important pieces of advice I got whilst in Tanzania was to only get on buses or coaches with doubled up back wheels, as otherwise they can be prone to rolling on the bumpy roads, or punctures can cause them to flip. I heard of two people dying whilst I was in the village from accidents with buses with only single back wheels, so I was always careful to only get into doubled up transport!

When asked what I would like to eat before we go to the hotel, I ask for something different to all my hospital meals, such as a pizza. This idea is taken and he runs with it. He spends ages driving around, looking for a cheap hotel with pizza nearby. This proves very hard, as all cheap hotels are in the less touristy regions, serving Tanzanian people who have come to Dar, and hence don't tend to serve western foods. I don't want to waste his time, and finally persuade him to let me find my own way around. l am dropped of in a nice clean hotel, with a very nice room for the 8 pounds I am paying. The taxi drier wrangles the price down to the Tanzanian price, rather than the western price, for me, then leaves, promising to be back tomorrow morning. With his hospital connections I believe him, and am not too worried, as he wouldn't want to lose all his business from the hospital by missing picking me up. His parting warning to me is to "Be careful with the prostitutes...". He is being serious! I must come across as seriously desperate!

I am famished after that long journey, so start off looking for food. This is the sot of adventure that wise people would advise taking a map for, but I am for too hungry to try and find one. Anyway, where would I get one from? The hotel is near a main looking street, covered with market vendors selling all items of second hand Clothes and Swahili food such as kebabs, Ugali and chips. All items I had whilst in the village. No-one seems to be doing something different such as pizza. This pizza idea has started to turn into a little bit of an obsession, and I do not think this food is what I want, so I turn right (must remember my directions!) and start my search. This is a very poor local area (hence the cheap hotel) so I will have to go some way for my western food.

An hour later, I still haven't found any food places serving pizza, or even anything un-Tanzanian, but have now made about a dozen turnings which I am trying to remember. I was going to use my camera to take pictures to help me, but am still the only white person around and don't want to draw too much attention to myself. I am pretty sure I have already gone so far I will not be able to find my way back, so I turn back, resigning myself to another night of 'Chipsi' (i cannot remember if I talked earler about the Tanzanian love of putting the letter 'i' on the end of most western words to make them 'Tanzanian' It is already getting dark, and I find myself in a road I definitely didn't come down. Now I am lost, but this is not all bad news, I as l can also see a hotel restaurant at the end of the road with mzungu outside!!!

They don't serve pizza but, almost as good, they do serve curry! I had a fantastic meal, but I have never eaten out or a restaurant by myself before. (why would I have?) I find out that its pretty boring. I snack down my curry quickly (it tastes nothing like any curry I have ever tasted before, but a different flavour to the last four weeks really is wonderful) so I can get back before it is completely dark.

The curry I was given in the restaurant. A very... unusual... taste, but still delicious!

I am too slow, and so have to make my way home on the dark streets, which have no street lights. Being in the City has a very different feeling feel to rural Tanzania, as you are not greeting everyone, but it also has a very different feel to the more developed Indian cities I have been to this year as well. There is no pushy selling, and I am not asked for money once, despite the fact I am obviously a foreigner. This must be because there are far fewer tourists, and those who do come probably go off towards Kilimanjaro or to Safari, rather than hanging around in Dar es Salaam. Despite this, and feeling pretty safe, it was quite dark, and I know some areas can be dangers (Unfortunately I don't know which ones, not that it matters, as I have no idea where I am). I find my hotel pretty easily, by backtracking to where I went wrong, and once I am on the last street back, I celebrate by buying some chopped up sugar cane to munch on, the bag was prepared in front of me for 2 pence. A very Tanzanian snack, but only tasty for the first three chews really...

One in my hotel room, I take my time to enjoy the wonderful facilities, including a Shower and a sit down toilet without a bat (I hope!). There seem to be an inordinate number of cockroaches and other assorted insects in my room, but with all these other luxuries, I am beyond caring. Perhaps all the insects means there are no rats to eat them!

As I cuddle up in bed and check my texts (I didn't want to get my Nokia 3310 out for fear of having it stolen while in town) I find a marriage proposal from a nurse at the hospital, and a text saying she had sent me some money on my phone, as she had assumed my lack of reply was as I had run out of credit. Feeling guilty that I had been taking money from a poor Tanzanian, I tried to be nice in my subsequent text conversation with her, while trying to explain why I cannot marry her. I am not used to turning down marriage proposals, so am not too sure what to say. The truth is that I just don't really want to marry her!

Part of the text I got from the nurse asking me to marry her. Again, I wish it was my good looks and charm that attracted her, but I assume it was my skin colour and nationality which was the main attraction... :(

All in all, this was an exciting last day in Tanzania, much more exciting than I expected for a journey day. I fly tomorrow, so this is the last blog post about my elective. I have loved my stay here, most of all the community and fitting in as part of the village. The parts I found hardest were the language barriers (obviously) and trying to persuade the doctors that the medical care they gave was on occasion awful, and trying to get them to change their practice (or watching people die because they wouldn't change what they did). Despite this, I know that I will really miss the village and the country, and I plan to return when I have got some real skills to offer.

Elective 44. Party time!

2011-12-23T23:41:00.001Z

Today is my last day in the hospital, which is a sad thought. I have, at times, been looking forward to this day, when I get to go home and see my friends, and get away from all the poor treatments that mean people die who shouldn't, but I am going to really miss all the people here. The day starts with the morning meeting, where the lack of money is being discussed again. Chief is telling the hospital staff that they cannot keep asking the church in the UK which is partnered with this diocese for more money. This does seem to be the natural response "get more money from the UK" whenever money is low, but Chief wants the hospital to be able to sustain itself without the need for outside donations. I think this is a fantastically unselfish (and sensible) way of looking at it, and I am, again, impressed with Chief. On the way back from the morning meeting, where Eggs was wearing another wholly inappropriate shirt, I pass Dr Bike who is, surprise surprise, cleaning his Bike, his morning ritual. I am going to miss all these odd people.

Dr Bike cleaning his bike, still - mercifully wearing a T-shirt with his boxers today.

I start the clinical day with a ward round with Dolittle and Kiwi, without Dr Bike. This as become pretty standard, for us to run ward rounds, but it is scary that I will not be expected (or even qualified) to do this in the UK for quite a few years on my return, but here I am still expected to wander around, prescribing drugs and discharging as I see fit. I am looking forward to being able to shed all this responsibility. The ward round is pretty similar to previous ward rounds, with nothing all that remarkable, but there are patients left who we want to review in the afternoon.

After the ward round is finished, I go to outpatients to have my last stint there, but again, I end up doing some of the consultations on my own. As I arrived at outpatients after the ward round, Tim was seeing a patient. He told me he thought they had appendicitis and should be admitted. I got him to ask a few questions, and the pain turned out to be in the back, after working a day carrying water back and forth. An examination then showed no pain in the abdomen at all. I don't think this was appendicitis, and Tim admits that he thinks he didn't ask enough questions. It is easier to do this than you might think, as Tanzanians often seem to be quite unconversational, and reply to open questions with one word, or just don't reply at all. It is very strange for me to have a question asked, and nothing said back in return, but it seems pretty normal here. Though perhaps they are so laid back they are taking their time in answering, and preparing an answer for me in an hours time... Either way, this was a very wrong diagnosis, and it is something I am worried will keep troubling me once I have returned to the UK - the knowledge that this will keep happening even though I am not there, and patients are likely to suffer from it.

The consulting desk I use in outpatients. I am not sure how old the building is, but I am assured that it was built by African slaves while the British were in rule

After Tim disappears of on some errand or other, I am left to see the patients (again, fortunately with a nurse to help translate). The first patient I see on my own is yet another teenager from the secondary school who claims he cannot see in the dark. Here, this means they need to be given vitamin A injections, as 'supposedly' vitamin A deficiency causes problems seeing in the dark, and no other symptoms. Admittedly the diet eaten here is not rich in vitamins, but I doubt that all these children who keep coming to see us in OPD are mineral deficient. It is only children from the secondary school which needs more money who come in. The other secondary school in the village which is not 'private' doesn't send anyone in with this complaint. I think that 1) this school provides free medication for the pupils and 2) its just something they tell each other they can do, to get free injections which they must perceive to be helpful. Or perhaps its just cool to go to the doctors. Unfortunately the injections are expensive for the hospital, so I tell him he can have some fish oil and vitamin tablets, which are also very good for him, and they will be fine. He then wants me to write him a note to give him the rest of the day off. This is really like being a GP - before, here in OPD, I have had patients asking for an "ED" note (excused duty) to let them take days off of work. Here, he is clearly not ill enough not to go to school, so I refuse, and he throws a bit of a tantrum, but then leaves when he sees I am not budging. If his symptoms are 'cannot see in the dark' and school finishes around 3PM at the latest, and he lives in the village, I cannot see why he needs time off school. Perhaps I am just a grumpy, vindictive person!

One of the other patients who comes in is called "petrol" - I assume she got her name from a barrel or a tanker sitting around near the village. She is having a lot of strange symptoms, so I send her for a few random tests including malaria and a urine microscopy. She comes back with schistosomiasis seen in the urine (a wonderful accidental diagnosis). This is a patient who washes in the same water we use to wash, I think I will be very careful to take my medication against this on my return to the UK!

Among the other people I saw on my own were someone who had somehow managed to put an axe right through their foot while chopping trees, who I admitted to be seen by Dr Bike right away, and a child who had been hit by a motorbike coming into the village, and seemed to have broken an arm - again referred onto Dr Bike right away. Later on, Tim was preparing the axe-foot man to have the wound cleaned and stitched up in the minor operations room (fortunately the axe had gone between tendons for the toes, somehow avoiding causing too much damage). I wasn't there, but Tim ran and fetched me after he injected the lignocaine into the area to prepare it for Dr Bike (who, as usual, was nowhere to be seen. I have no idea why it was being prepared now) and the man started jerking around uncontrollably. It is very important not to inject lignocaine into a vein or artery, but only into the muscle, as otherwise it can be deadly. This was something Tim was afraid of when he ran to get me, but I wouldn't have thought it would present with convulsions. By the time he had found me and we had run back, the man just seemed to be asleep, all vital signs normal. It turned out that the man had epilepsy (which I hadn't asked about - oops) and had had a random epileptic fit on the table, scaring the bejesus out of Tim. In Tanzania, the epilepsy is very poorly controlled, with intermittent drug supply. This is obviously bad, but a lot better than injecting lignocaine into a vein!

Kiwi, Dolittle and I went back to the ward to review some patients in the afternoon. As Kiwi went into the ward to listen to a woman's chest (something we were unable to do in the morning as we had forgotten our stethoscopes) Dolittle and I were reviewing the notes in the nurses station. Kiwi thought she could hear fine crepitations (crackles) in the base of one lung, but wasn't sure, so came to get us from the nurses station for a second opinion. As we went back into the ward to listen to this ladies chest, we saw there was one lady sitting on the bed in the corner, her top rolled up as though someone had been listening to her lungs, and two others sitting on the bed next to her, one of whom was currently taking her top off (no bras used in Tanzania). Dolittle and I were confused as to which the patient was we were meant to be listening to, and as Kiwi had gone to amend the notes, we beckoned a nurse over to help translate. It turned out the women weren't just undressing because my sexy self had entered the room (still hopeful, one day...), but they all wanted an examination. One was the one Kiwi had been listening to, and the one who had now finished undressing (completely) was a friend, who said she was suffering from chest pain, and chest tightness. We found the chest pain was also radiating to the back. A sneaky way of avoiding paying the hospital fees to be seen in outpatients, but I oblige and listen to her lungs and heart. Surprisingly, I find a systolic murmur on listening to her heart, likely due to aortic stenosis. I don't know if this what is causing her complaint (not very likely) or is something she has always had due to something like rheumatic heart disease. Dolittle and Kiwi plan to check on her tomorrow, as she seemed to be relatively well apart from this.

The ward has a hand washing bucket, which would be high-tec if the water didn't have as much infection in it as the patients do!

Before going to the leaving party that is being thrown for me in the evening by the hospital, I buy some Tanzanian spirit for what is effectively £2.50 a bottle. For prices like that it doesn't need to be great quality! I also have a few beers with Kiwi and Dolittle as my own going-away party. Our cook joins us, and offers to plait my hair, Tanzanian style, into corn rows. I consent, but regret it - it is very painful having it all tugged into position! I am glad I am not a girl... I then sidle off to Tim's house for dinner, taking Dolittle and Kiwi with me, letting our cook rest tonight. Another delicious feast and some touching goodbyes.

At the party thrown for me leaving, I am expected to sit at the front of the room where the morning meetings are carried out, while others sit around me. I sit there as people make moving speeches about me and my time here. Doctors and nurses from OPD, male ward, female ward, children's ward, maternity, the group that does medical safaris and even Smiley - the friendly porter who I befriended, despite the fact we cannot understand each each other, all said some lovely things about me and my commitment, which were translated by Chief, who was sitting nearby. I was then expected to give a speech, and said some really lovely things about the family attitude of the hospital and how sad I was to be leaving, which were all true. I was given a wooden carving, some Tanzanian clothing and a certificate in a frame for all of my help. I feel bad that the hospital, with no money, spent all this on me, but also very touched. Choc is the DJ again for this, bringing his music from his house with his generator, and playing me Christian-songs-with-people-in-white-dancing-in-the-background. Not something that would be my first choice of music normally, but Tanzanian, and the whole mood, everyone saying lovely things about me and the gifts make me upset to be leaving. I really hope that my feelings towards this wonderful community don't dampen down over time, once I have come home.

A suitably blurry image of the beautiful art we left behind at the house to decorate it for the next mzungu.

Elective 43. The tower

2011-12-22T16:39:00.001Z

Today we meet some unconventional diagnoses and management plans on the ward round, and I buy myself some medication. We go to give some gifts to the primary school, and medically treat one of the kids playing outside out house, while getting heckled by pregnant women. We finish off the day with an intrepid climb up the water tower near our house.

The sunset from behind our house is beautiful as we come back from the water tower.

On the ward round this morning, we encounter an 12 month old child who had presented with 'headache and chest tightness'. Dr BT had admitted him into hospital with these complaints. I am not sure how he found out this baby had 'chest tightness', or even a headache, but he clearly decided metronidazole was the best drug to treat this presentation (very unlikely to be correct). The baby looked fine to us, and all tests were negative, so he was discharged. This was a nice money earner for the hospital, as admissions incur a large charge, but not such good news for the parents. I am sure he didn't admit on purpose to get the hospital some much needed funds, but you do wonder. Metronidazole should be most commonly used here to treat bloody diarrhoea or pelvic inflammatory disease caused by an untreated STI. I am guessing Dr BT didn't think the child had the latter, so perhaps he had deduced that the diarrhoea the child didn't have could have spread to the lungs and head? In some ways, I cannot wait to get back to the UK, where things make sense.

The second 'odd' case was admitted while we were on the ward, so we saw her as soon as she came into the ward. She is a 15 year old schoolgirl, and had come in from the school (it her first day there) with central chest pain and rapid breathing. The doctor who had see her in outpatients had written down "?Angina. Urgently to be seen by ward doctor". Pretty sure that it wasn't a heart complaint in this healthy looking girl, we did a full examination and history anyway. This was helped by the fact she spoke a few words of English, as she went to the school where English must be spoken at all times. The examination seemed to show she was fine, and the history seemed to fit in with a panic attack. Not really sure what to do, and needing to give medication (silly Tanzania) we gave her salbutamol tablets and antihistamines in case its some kind of allergic response or asthma attack. Once admitted, the hospital rules are that the patients cannot be discharged in the first 24 hours, so she is left in the hospital for a day. Perhaps a good thing, as it means she can be checked to make sure there is nothing severe wrong with her. A 15 year old with angina though? Very unlikely.

Later on, when things have quietened down in the ward, I saunter over the the lab to have my full blood count taken by Choc. An expensive test for a Tanzanian, but only a couple of quid for me to see what my blood looks like. Sounds like a fantastic deal, though I am careful to make sure that my blood is taken with a clean needle! It turns out that after these 6 weeks in Tanzania I have become anaemic. Microcytic anaemia - the classic finding here on blood tests. It must be the lack of iron in the blood, or perhaps I have a hookworm infection. My iron is still very high for a Tanzanian person, but is a little below 12g/dl, which would make me anaemic in the UK. Not much I can do about that, apart from eat lots of delicious food once I get home. I cannot wait!

In my spare time, I also pop into the pharmacy to get some medications to take home. Because I have been washing in the lake water all this time, which does have the parasites that cause schistosomiasis in it, and because everyone here seems to have a worm infection, I get two drugs from the pharmacy to treat schistosomiasis and worm infections. I will take them once I get home, hopefully meaning I can be nice and healthy when I return. I don't think I have caught anything nasty than a few stomach bugs when here (apart from that nasty tonsillitis), but much better safe than sorry!

We travel to the primary school that is further on into the village in the afternoon, with the intention of dropping off the stationary that I bought with me, and Kiwi and Dolittle's pencils they bought along as well. What was intended on being a quick stop and drop then back to the hospital, quickly turned into a tour around the school where we spoke to each class room about ourselves and they all said hi, or asked us questions. It was pretty embarrassing, though really sweet. Whatever classes were going on at the time were interrupted for us to come in and talk about ourselves. Proper little minor celebrities!

The primary school children expect us to talk about ourselves to them, despite the fact they speak very little English.

Once we get home, we are playing outside with the kids again. I notice that the hyperactive one (Kev) has been leaving bloody heel prints across our porch, so ask to take a look (well, more gesture, seeing as we cannot talk to the children at all what with the language barriers). He has a large cut on his heel, which after some gestures, I think he got after trying to ride someone else's bicycle. I was all of the sand and grit out of it, sterilise it and then put a bandage onto it to stop it from getting more grit into it, and hopefully to stop it from bleeding. As I start doing this, some pregnant women are walking by the house, and stop to watch, sitting on our porch and under the tree in front of our house. They start shouting things to me, and laughing amongst themselves, though I have no idea what they are saying. I cannot really answer with some witticism, so just keep quiet and bandage away. He thanks me (very rare for Kev) and scampers off after I am done, and I go inside. The pregnant women do not, though, and instead spend some time staring in through the windows at us. We try to retreat to other rooms to avoid their gaze, but they then track around the house to find windows looking into those rooms to continue staring. Its a little like being at the zoo! This only stops when our cook arrives to cook dinner for us, and they all flee from her accusing shouts. I wish I knew what was said.

Some of the women who were heckling us leave, with their collected fire wood.

As the dinner is prepared, I decide that I would like to climb the water tower behind our house. This water tower hasn't been used in years, though was originally put in to try and supply houses with running water. It has a ladder up the side (starting about 6 foot from the ground) and as it is already on high ground, I imagine it would give wonderful views. I persuade Dolittle and Kiwi to come with me, though they assure me that they are unlikely to be doing any climbing up the tower! I feel happy that they will be there, though, and if the ladder breaks or something nasty happens, I can get some medical treatment from them. I also tell them that if something happens, they need to get me to a hospital in the city, rather than let me be treated here! Once at the water tower, and I have climbed up the rickety metal ladder (stick in hand in case of snakes waiting at the top to bite my face) they decide they would also like to come up. With the help of some boosts, they make it to the bottom rung of the ladder and can easily climb to the top. The view is amazing, across the rift valley on one side, and looking at the hospital, the village and the house we live in on the other, covered by a beautiful setting sun.

The view from the top of the water tower, my house is in the middle of the picture, with the hospital behind it, and the rest of the hospital spread out to the right.

Once we are bored with the view, and it is getting dark as the sun sets, we return home for dinner. After dinner we play a 'heads, body, legs' game where each person draws a specific one of these three, linking them to each of the other persons other body parts, blind to what they have drawn, to create amazing (or abominable) creations. These two girls are a lot more fun than Sporty and Smartie were, and we have a lot of fun. See some of our strange creations below!

I am very proud of my man-on-horse idea and House ideas. Very original, and the house works so well with the smartly dressed top! Wonderful.

Elective 42. Sodomy

2011-12-17T19:25:00.003Z

A five year old boy comes into the hospital after being raped, and while while most cases keep confusing us, others are eventually solved. I give a gift to a patient, which makes them cry, and I get given a gift from Tim. In the evening, Kiwi, Dolittle and I walk to the lake where our shower water comes from.

In the morning meeting, another two babies have died during birth, but as well as the worrying fact there are so many deaths, I am worried that I am getting used to this, becoming more accepting of why they died (Oh. Prolonged second stage of labour. I see), rather than asking why they died (shouldn't she have had a c-section?). Perhaps this is what happens to doctors who come here from other areas of Tanzania. An insidious eroding of expectations and general acceptance of death that shouldn't have happened.

On the ward round with Eggs, we visit the man who had the abscess in his neck, which has been surgically drained. Eggs wears some very... interesting... T-shirts while on the ward. My favourite is one which I have seen him wearing a number of times, proclaiming "If I said you had a beautiful body, would you hold it against me". I am serious, this man wears this T-shirt for ward rounds!

On the ward round with Dr Bike, we review a 5 year old boy who was admitted yesterday after being raped. On examination, he still had a significant amount of blood around his anus and on his buttocks. It was very hard to get any history from the parents, as they spoke a tribal dialect rather than Swahili. It seemed they said it had happened while he was playing with other boys. Not really too sure what to do at the moment, we gave pain relief and antibiotics as prophylaxis against infection, and instructed the parents to clean the area (I have no idea why they didn't do this yesterday). An HIV test follow up would be a wise idea. In the evening, we tell one of the nurses who are staying with us about this, as he is a psychiatric educator, in the hope he can try and offer the boy some counselling or something. He tells us that witch doctors give people a medicine, which needs to be taken after raping a male child. This 'medicine' should then make them wealthy. I knew that there was a reason not to trust rich people! In all seriousness, although this hospital has many faults, at least if doesn't advocate the harm of others and genuinely seems to care about people rather than making itself money.

At other stops on the ward round, the baby with hypopigmented patches, who has been in hospital for weeks, is finally ready to be discharged. A few days ago, we guessed it could be excema (after all the guesses at strange fungal infections and so on), and prescribed topical steroids. While we were told these were out of stock, a few days ago I looked through the pharmacy stocks and found some Daktacort, a mixed anti-fungal and hydrocortisone cream. Perfect for a possibly fungal possibly autoimmune infection. After a weekend on this, the baby is a lot less itchy and a lot less red and flaky, though she still has many patches of hypopigmentation. I never knew that eczema could cause changes in skin pigment, but the girls from New Zealand have taught me this. Having people smarter than you on elective is really very useful!

The full blood count for the complex case of the horse voiced girl with oedema in her legs and the inability to walk is finally done (the lab is closed over the weekend). And what a strange result! Microcytic anaemia, but that's par for the course in Tanzania. What's most interesting is that the break down of the white blood cell count has produced an 'error' in the results. The lab people have both tested the machine on another blood sample (which was fine) and then a different sample of the girls blood (error again) [this is very efficient for Tanzania, my guess is that Choc was in the lab yesterday]. The error that is coming up shows a code (T2) written in a box, rather than the numerical result for all of the break downs of blood cells. We visit Choc at the lab to inquire about this error. The lab book tells us that this error is something to do with cell counts being outside of normal ranges. Or unable to differentiate cells. It is kind of confusing and neither Kiwi, Dolittle, Choc or I really understand what this means. My guess is that this is some kind of leukemia, creating strange looking immature cells in the blood, which are confusing the machine, but really I don't know, and we don't have any way of finding out, so us three students try to petition Dr Bike to let us refer the girl to the big hospital, which is quite far away. Dr Bike doesn't really like referrals, but doesn't put up much of a fight this time, probably because he has no idea what to do next (but does suggest a fun cocktail of antibiotics which he thinks might help). I now feel justified in pushing for that full blood count, and eventually paying for it, as it has shown something. We think. I still feel robbed, though, as I still don't know what the diagnosis is!

The baby who was admitted with marasmus, and diarrhoea, who was bought in by his sister some weeks ago and fed up by Doctor bike is being discharged tomorrow. The IHPUK drug pack I bought had a doll in it, and I decided that this baby and sister are the best people to have it. If they cannot afford food, I doubt they have any toys! I bring the doll to the ward, with some pens, pencils and an exercise books for the older sister, so they can both have presents. I find them sitting outside the ward, and hand the doll and stationary to them. The older sisters eyes light up, and she gives a massive smile, but the ill child just starts bawling. He is clearly even more terrified of this doll than a mzungu! This is definitely not the response I was expecting at all! Perhaps he has never seen a doll before? There is not much I can do about it though, so I leave them, hoping that he will get used to it in the end. Or perhaps they will just sell it for some food. so much for a good deed!

The malnourished child flinches away from the terrifying doll from IHPUK, held by her happy older sister

In the evening, Tim comes by the house to deliver me a present, I assume this is to pay me back for the BMJs and pen torch I have given him so far. Yesterday he was in a large city, visiting his gold mining, broken arm-suffering dad, and decided to get me some Carrots as a present. What a star! This sounds trivial, but it is an amazing present. It adds some much needed variety to our meals. Its not as though we don't want to buy more interesting ingredients while here. They are just not available in this village. He clearly had remembered me complaining about the simple food, and had decided to bring me something fun back! While our new carrot based dinner is created by the cook, Kiwi, Dolittle and I walk to the lake, where the villages water comes from. This has some beautiful views, and many villagers washing or swimming in it while others collect buckets for home or let their animals drink and splash around. The water for our cooking and tea comes from here. Urgh. Well, what can you do. It seems that the level is very low compared to where the banks suggest it normally is. I guess we are towards the end of the dry season, with rain expected soon, so it is to be expected.

The lake where the water is collected for the village is drying up. The wonderful scenery is ruined by the phone mast stuck on the cliff, to try and cover some of the rift valley. I shouldn't be complaining, this was my one way to communicate with everyone!

In the evening, after our meal of carrots in spagetti (better than plain spaghetti, but still mouth-curlingly sweet) we do some water colours and drawings with the drawing materials we have for the kids to use. Kiwi and I are just doing it for fun, but Dolittle turns out to be good. Really, very good. Don't you just hate those medical students who have all these hidden talents like drawing and talking to animals. At least she isn't perfect. She loves glee.

Elective 41. Its a trap!

2011-12-14T20:34:00.003Z

I am woken at 7.30, still feeling under the weather, by a car sent by the reverend who had invited me to a choir competition some time ago. This was the reverend who had invited me to dinner. I remembered the date as being yesterday, and assumed I had missed it by going on the safari. As the car arrived, I just guessed that I had got the dates wrong, and quickly changed to get into the car. Once I was in the car, I was told that I was being taken to another Sunday service. This meant that I had to sit through another five hours of Swahili preaching. I think they have sensed (with their Christian-sense [what else]) that I am not religious, and are either punishing me, or trying to convert Me. On the journey home, I buy a papaya for the house, and get a marriage proposal from one of the college students taking bible studies, though a translator is needed for this proposal.

The church service had just started by the time I arrived and snuck in.

The service I saw was very similar to before, but now I had seen it once before, it has lost a lot of its novelty and was just a bit boring. It has succeeded in giving my time in Tanzania (now drawing to a close) a cyclical feel to it though. I started with events such as a medical safari and the Sunday service, run by the bishop in Tanzanian, and now I finish with them. On the way home, after picking up a papaya at the local market, I am in a 4X4 owned by the bishop with a couple of the students who study bible studies who need to come to the village the hospital is in. They ask me more and more personal questions, through the driver who can talk some english, moving from whether I was married, though what I would do if I married someone here (stay or take them home) all the way to whether I would marry one of them (they didn't seem too fussed about which one). Very surreal, and I unfortunately had to say no. The first time someone has propositioned me, but I don'e exactly feel all that special...

The church has a lot of singing from the choirs who were down in Tanzania for the choir competition, which I missed yesterday, from cultural songs to break dancing.

Once home I do my last clothes wash. I will be looking forward to having washing machines and clothes pegs again. As I am picking my clothes out of the dust under the clothes line where they were immediately blown after putting them up, the bible studies student who approached me to chat with after the failed football game on Sunday arrives with some of his disciples. I mean friends. I don't know why he is here, I do remember he said he would come around, though I don't think he ever said why. After the 5 hour service this morning, I am almost hoping that he will ask if I am religious (I am a touch annoyed with the church at the moment and would welcome a theological debate) but he can either sense my hidden plan (damn Christian-sense) or cannot remember himself why he came, as less than five minutes after sitting down in our living room, he thanks me and leaves. I still don't understand Tanzanians one bit. It is a 20-30 minute one way walk for him and his friends from the main part of the village to where I live, and there is nothing else down this end of the village...

Following his departure, two nurses arrive to live with us from other areas of Tanzania. One is acting as an external examiner for the nursing school first year exams, while the other is acting as a teacher of psychiatry for the second year nursing students. Having seen no mental health diagnoses or treatment here at all, this is a good sign. They both seem friendly fun people, but the hospital has obviously made a lot more effort in making their room nice than it did for ours. Jealous! While the nurses are moving in, I find Dolittle outside, clucking at Chief's chickens who wander around this part of the village, pecking at the dirt and making him eggs. That girl is either very strange, or has a unique talent. Perhaps a bit of both.

In other news, we are currently running very low on supplies. Our bottled water supplied by the hospital ran out 2 days ago (have been buying our own), and the toilet paper has run out, we are using my emergency supply. The last two days meals have been pasta. Blergh. The nurses have been given their own bottled water, loo paper and are given their own meals in their rooms from the nursing school. I guess they want to treat the external examiner as well as possible, to get the best deal for their students. This does work to our favour with regards to the washing water though. We haven't had water to wash in for a couple of days, but now they have arrived, more water is bought to the house from the lake, letting me do my laundry. Hopefully our other supplies will be restocked soon!

The new flat mate adult nurses have their room done up as above, with sickly sweet pictures and cuddly animals. I would laugh, if I wasn't so jealous!

Elective 40. Rabies planes and miracles.

2011-12-13T19:42:00.001Z

Today started off by being woken up at 5am, freezing cold, with rain pouring into my room through my holes which serve as windows. The lovely rich smell and new sensation of being cold didn't stay pleasant for long, as I soon realised I couldn't close my windows (broken bits of blinds made of glass), and had to move my clothes away from the windows to stop them from getting any wetter. I made a nest in my bed of them, as there are no blankets. At a more civilised hour (6.30), we were picked up by the four by four (borrowed from the school, remember the hospital still has no transportation of its own) and driven for 2 hours to a lone hut. I was not feeling too well this morning so dosed up on paracetamol and ibuprofen before the journey. After arriving at this single hut, by a patch of ground used as an airstrip, Kiwi flew to another location in a plane, while Dolittle and I helped out at this lone hut. This way we were helping at two medical safaris as a group. I am not sure how much use we were. Before we left the safari, a 12 year old boy was bought to us who had had a large bite taken out of his face by a "Crazy, ill dog". We managed to get him onto the plane to take him to a large hospital. Hugely lucky that it arrived at the right time I was feeling a lot worse for the journey home, which was not helped by being squashed onto a seat with far too many people, and having Dr BT fall asleep onto me throughout he journey. I had a very high temperature, perhaps sitting in the sun for so long started leading me towards sunstroke.

The lone hut that we carry the clinic out in, in the middle of nothing, under a tree. A very strange location, but hundreds of people turn up over the day, so clearly a popular location!

To start at the start of the story, the schools 4x4 now doesn't have a working battery, so to start the journey we have to have four people push it to a roll, when the engine can then be started. Despite this little difficulty at the start, the rest of the journey is great, and the journey was very scenic. We admired the beautiful scenery, which was mostly sparse scrubland (beautiful in its emptiness) with the occasional person walking, seemingly hours from the nearest habitation, and occasional villages where people spilt from the houses to watch the car (a real rarity this deep into rural Africa) go by. My favourite location was a vast lake bed which we sped across, where the mornings rain had caused slight puddling in patches. It was just a vast empty space. The road all the way was an uneven dirt track, which couldn't have been traversed by a normal car, often Covered in obstacles such as cattle being herded across, and chopped down trees or bushes. One of these spiky bushes proved too much for the 4X4 and we had to stop for 30 minutes to fix a puncture.

A view across the huge dried out lake bed, you can just about see a hill in the very distance on the left. Everything here is so vast!

Once we got there, the same pilot who flew me on safari in my first week was waiting, so Kiwi took a plane with him, like I did 5 weeks ago (it sounds so long, yet feels so recent), and I stayed with the 4X4 at the hut with Dolittle.

The preacher sings songs with fun actions with the children who are waiting, before we can start the clinic

Our day starts off positively, there is no person playing phone music through a megaphone, and a preacher is instead employed in making lots of noise. Despite all of the people waiting to be checked by us, he needs to give a sermon to the adults, then sing with the children before we can go ahead. I love all the African songs, they always sound so happy! When we start, we are weighing babies and pregnant women, plotting their heights and weights on their respective charts, while a nurse sorts the charts into those needing a vaccine and there who don't after we have filled them in. The weighing is done under a tree, which is close to the hut (from where the first picture was taken) as the hut is used for antenatal examinations and vaccines. This does mean we are left in the sun for a long time. After a few hours, interrupted only by being asked if we are happy to eat the lunch provided by the village (Yes. Of course. Its rute to turn down food, and I am getting pretty hungry), the supply of people needing to be weighed begins to peter out, and I am asked to go and help with the antenatal checks in the hut.

I head over to the hut where a nurse is examining pregnant ladies inside. A large single window in the side means each lady covers it over from the outside with her kanga before entering, to give her privacy during the examination. I examined a few women's bellies, checking the position of the foetus (head or feet first), foetal heart rate and so on, while the nurse asked the questions and gave HIV tests and took haemoglobin measurements with a little meter. After a few women had been examined, the nurse just left, not saying anything. I waited a minute, hoping she would come back through the door, but when the next woman started hanging her kanga outside the window, I left the hut to stand outside, so I didn't end up expected to examine women on my own. I cannot talk nearly enough Swahili! I stood outside the hut for 15 minutes or so, and when the nurse didn't return, I went to sit with Dolittle by the scales. We waited for over an hour, talking about meaningless things such as what animal we would like to be (swift for me, butterfly for her), all the while surrounded by waiting children and pregnant ladies sitting on the (sun drenched) ground. These people intermittently tried to communicate with us (likely saying, please give me my card back so l can go home) but we didn't understand.

The equipment we are using doesn't give very accurate readings - this scale which gives results in Kg has to be used to weigh little babies, meaning any results cannot be taken too seriously. I love the fact that it says 'made in west Germany' at the top, showing its age...

After the nurses come back from what it turns out was the lunch break (clearly no mzungu invited), we seem to be surplus to requirements, and are left by the scales, weighing a straggler every 20 minutes or so, but mainly sitting around. Very boring, so we keep chatting, though I am secretly pleased, as I am starting to feel very unwell, sick and headache-y (though I feel I have no right to complain with all the very ill-looking people around).

After a few hours, as things are quietening down, a motorbike speeds up to the hut, and all of the mothers and children crowd around it. Assuming they are all just interested in the motorbike, a rarity this far out, we stay sitting under our tree chatting in the shade, until a man rans up "Doctor! Doctor! Emergency". I don't correct the 'doctor' as I normally would (no point wasting time) and as there are only nurses at this outreach clinic (Dr BT went on the plane with Kiwi), we hurry across to the motorbike, through the crowd of women and children, to find a 12 year boy missing a chunk bigger than his fist from his cheek. The hole starts at the right corner of his mouth, and saliva is dribbling out, uncontrolled, stained red with the blood. The fatty tissue inside the cleaks is clearly visible. We are both clearly mesmerised by this sudden appearance, as the man who initially called us over decides to go on, and says "he was bitten by a dog" I ask if the dog is anyone's pet (thinking rabies) and he replies that it used to be, but now it is crazy and has gone of on its own (I am definitely thinking rabies now!) If only Dolittle had been around to talk the dog out of its craziness! We beacon the kid over to the hut, and as we are walking there, to see what supplies are available, we hear the plane in the distance on its way back with Kiwi and Dr BT. The timing couldn't be any better!

The injured boy is loaded onto the plane while the locals watch. No such thing as privacy in Tanzania!

I tell Dolittle to go to the plane once it lands to ask about supplies and space for passenger (clearly the boy cannot stay here), and I take the child to the hut for initial treatment (I can be very bossy!). I ask the nurses there if they have any saline/sterile water/pain relief (no to all), so the boys father ends up washing our the wound with our bottled drinking water (more sterile than the lake water), and soap powder. The initial treatment of rabies needs the wound to be washed thoroughly as fast as possible. Since I first saw him, and all through the washing of his (gaping) wound with soapy water, the boy hasn't flinched, said a word, or shed a tear. He is either very resilient (this wouldn't surprise me after some of the things I have seen) or (more likely) is in shock. He has had a large chunk of his face bitten off... After the wound is washed and all our drinking water used up, we take him to the plane, where he is efficiently bundled in with the man who bought him on the motorbike (a friend of his father [family goes a long way in Tanzania]) and flown off to the 'major city' hospital which will hopefully have the rabies vaccine and immunoglobulin needed (our hospital certainly doesn't, hence the need to send him elsewhere). Before leaving, the pilot thanks God that he arrived just at the right time. I agree, it is a wonderful coincidence, and we are so fortunate that not only was the monthly medical visit in the area when the boy was bitten, but there was a plane nearby as well. Bit I think that, if God had his finger in this, then would he let a 12 year old have part of his face bitten off? If it can be repaired, there is going to be pretty horrific permanent scars and loss of function. I do know there are no plastic surgeons where he was sent...

After all this excitement is over, I realise l am feeling a lot more ill, but we soon depart for home. The journey is awful, I can feel every jolt in my super sensitive brain case, I feel very sick and cannot take my eyes from the road. In addition to all of this, I also have Dr BT falling asleep on my shoulder the whole way (not very nice) but I suppose I am fortunate to have a lift. The boy and the man who went off to the major hospital have no way of getting back to their village. No money for transport. Hopefully they can wait a month and then come back on the plane when it next visits.

Once I arrive home at 7, making this a 12 hour working Saturday (why did we volunteer to do this!), I fall asleep on the sofa while Kiwi and Dolittle supply me with water and pain killers. I couldn't ask for better flat mates. Its just sad that I had such a rough end to a day with such excitement.

Elective 39. Dr Who?

2011-12-08T17:49:00.001Z

Today, a quick ward round with Dr Bike leads to a mysterious patient who seems diagnosable, then Dolittle and I talk with Choc about the set up of the hospital, learning there are no actual people with a medical degree working here at all, just people who have done a 3 year medical diploma (there are two ways to work as a doctor in Tanzania). In the evening, we find the cat that we borrowed yesterday from Chief under a chair, having been hidden there all day. He seems much more confident today than the skittish cat he was yesterday. Dolittle shows us her skills, and it seems she really can talk to animals. The cat spends the evening sitting on the chair in the main room cleaning himself. Since he has been in the house, I haven't heard the rats moving around in the roof at all. Magic.

Chief visits our house, where we have decided to start off adding some art work to make the place more exciting. He isn't too impressed with the modern skew we have given it...

On the ward round I am with Dr Bike and Dolittle, (as Kiwi has gone on safari today), the lady who has been in the hospital for three weeks with abdominal pain, around her left flank / left upper quadrant (? upper urinary tract infection / kidney problems such as polycystic kidney disease) is finally referred to a large regional hospital. This is something I have been trying to make happen for over 2 weeks now, and something Dr Bike has been trying to avoid, as this hospital she has been referred to is more than 100 miles away. A long way for someone with no method of transportation, and no money. She was initially diagnosed with nephritis and hos gone though a good number of different diagnoses since then. Today, Dr Bike was asking which antibiotics she has not been on yet, and whether we could try them. This seems absurd, just trying out different things without working out what the problem is, and I say so. I am backed up by Kiwi, and he does admit that he has no idea what the disease is, and reluctantly agrees that we need to refer her to the larger hospital which will have machines such as ultrasound scanners to help diagnose the problem. A success for persistence, but l feel I should have pushed harder, earlier, saving her the cost and trouble of these pointless three weeks in hospital. And they have been pointless, we haven't even been able to reduce her pain as the best regular pain killer we have is paracetamol.

The other interesting patient we see on the ward round is a girl who I admitted yesterday while in outpatients with Tim. She is a very complicated case. She has had a cough for a year now, and her voice sounds like Darth Vaders. Clearly some problem with the throat. Her neck has large lymph nodes in, and in addition to this, she has so much pain in one leg she cannot walk on it, large lymph nodes in inguinal region (above her leg by her groin) and pitting oedema in both legs up to the knees and around her eyes (periorbital odema). She also has a very low blood pressure. This is a very strange mix of symptoms in a 14 year old girl, and all the tests I ordered on her admission (HIV, blood glucose, malaria etc) were negative, but a urine microscopy showed pus cells in the urine (suggesting a UTI). What could she have? This is the exciting thing about medicine - its all detective work!The oedema probably comes from kidney damage (given the pus cells in the urine), but could also be caused by heart problems (though her heart sounds normal). My guessed differentials yesterday were TB, nephrotic syndrome, a strep throat infection (can lead to kidney damage), some form of immunocompromisation, and even hypothyroidism (large throat and low blood pressure). Lots of ideas, but no solutions. Today gets us no closer to the answers, but Dr Bike wants to send her for an X-ray to look for TB in the lungs. I am not sure how likely this is, as they sound completely normal, but what else can be done? We seem to have used up most of our investigations already. I want to do a full blood count to see the state of her white blood cells (all these lymph nodes up, something funky might be happening). She is unhappy to pay for the expensive test, so I offer to pay the 2 pounds needed. Don't think it is selflessness for one moment. I am very curious as to what is wrong with her, and have been annoyed when previous patients have left without a diagnosis. I like answers! Two pounds is very little to pay for this... I do look forward to my return, though, when there are all sorts of investigations available, and a consultant who (at least seems to) knows everything. Life seems so much simpler, which is odd, as the tests are a lot more complicated.

Talking with Choc in the evening, while waiting for Kiwi to return from her safari, Dolittle and I learn a lot more about the qualifications of those at the hospital. It turns out that no-one here has a medical degree. A few of the doctors, I.e. Dr Bike and Chief have advanced diplomas, meaning they can work as a general doctor, but are not allowed to specialise. I find out that Dr BT is actually in his first year of studying a 3 year medical diploma, so isn't actually a doctor at all. I am not sure whether to be scared that the man running outpatients has less experience than Tim (and me), or relieved that he isn't as hugely incompetent as I thought before, and is instead just a first year student and hasn't learnt very much. However I feel about it, it is still absurd. I also find out that the 'full time anaesthetist' that I was so shocked was away from the hospital so often on safaris, is actually a recently qualified nurse who has done 3 months (so far) of an anaesthetics distance learning course. But is still the go-to-guy for all anaesthetic needs. Anaesthetists here seem to be initially trained as nurses rather than doctors, and then learn anaesthetics as a module. This hospital seems crazy, but at least I am less worried about the anaesthetist leaving the hospital without cover now, as I had assumed he was an important and highly trained person! This does explain why when managing a severe asthma attack some weeks ago, I had stolen the oxygen from the theatres and asked for home to come and help, but all he had to say was to stop using so much oxygen, and to put it back as soon as possible. He isn't incompetent, just hasn't been trained.

Choc also tells us about the corruption in Tanzania, from being asked for money while he was studying his diploma in being a lab-tech to 'help' him pass when exams were marked, to patients being expected to give cash in many government hospitals to doctors and nurses for their time, or to lab techs in order to get tests carried out properly and not 'lost' or 'delayed'. He is clearly not a fan of this system, but this does explain why a number of patients have tried to give me cash in outpatients. I had just assumed they wanted to pay for the drugs they had just been prescribed, but Choc assures me its more likely they were giving a cash thank you to make sure they got the drugs they were prescribed, and to ensure they are seen and treated next time. This hospital is very anti-corruption, but its exceptionally common in many other hospitals. Its a shame that it happens in such a poor country, when the patients cannot even afford their drugs or tests, let alone extra to line the pockets of the health care professionals...

Chief's cat lurks behind the curtains. I think the pretence at being asleep means that we don't bother him, and he can jump on the rats!

In the evening, after Chief's cat comess out to join us, having hidden in our house all day when we assumed she had escaped, Dolittle decides to prove her namesake point by chatting the cat up. I am not sure if she was as seductive as she intended, but there is little doubt that they were engaging in some kind of communication. She mews at the cat, the cat mews back. Back and forth, with different tones. I am very impressed. I am sure the cat was really replying "sorry what did you say" and "I really cannot understand your accent, where are you from", and I know Dolittle had no idea what the cat was 'saying', but it did sound like a conversation. An amazing party trick. I wonder if it works on other animals...

Elective 38. Catheterisation

2011-12-06T17:18:00.001Z

Today wasn't as active as yesterday, fortunately, but I still get plenty done. Dolittle is on medical safari today, so I am with Kiwi all day. We start with a ward round with Dr Bike (on a Thursday. Most unusual!) followed by "jobs" created by the ward round. Its like playing at proper little junior doctors. There is an emergency later, and I almost end up donating blood for a patient, then I end up in outpatients where I hear about how wild Africa can be.

However wild Africa gets, we will still be outside playing with the children most days!

Or the ward round with Dr Bike, the dehydrated lady we saw yesterday was a lot better, sitting up and chatting. This was a wonderful sight, and justified all of the fuss we made yesterday. However, now feeling better, and well enough for us to take a history from her, we find out that she has a fistula, causing her to leak urine over the bed as she cannot hold it is. This means catheterisation goes on the jobs list, along with HIV tests for other patients, some discharge forms, some investigation forms and the removal of a cannula.

At the end of the ward round, again done with blinding speed, Kiwi and I work our way through the resultant jobs. I teach her how to work the HIV test kits here, as she has not seen them before, and she shows me how to insert a catheter into a female patient, something I have never done before.

Kiwi talks me through the catheterisation process, as I lay out my sterile field, clean the patient, lubricate the catheter (thank god I managed to find some lube, its like gold dust here) and slip it into the urethra. Thankfully, Kiwi reminds me to have the other end in a tray before sliding it in, my trousers nearly got very wet with the suddenly draining urine... The balloon is then inflated, to keep the catheter inside the bladder. It is a 30ml capacity balloon (as stated on packaging) but I have only got a 5ml syringe, so there is an absurd back and forth 6 times to fill the balloon, a little unprofesional, but nowhere near as unprofessional as soaking my trosers in urine would be. About 10 nursing students are watching my efforts, so it is lucky that it all went well. The end is clipped with a pair of forceps, as the hospital has no catheter bags, so the nurses will have to remember to release the clip regularly to let the urine drain out. I hope they remember, or this could cause some problems! All in all, it was a lot easier than I first thought, the main difficulty being in setting up the equipment. I am very happy that my first attempt went well. I can imagine that if it went badly, spraying me in urine or injuring the patient, I wouldn't want to do another. As if is, I would be more they happy, a good thing too, as I will need to do plenty of these as a junior doctor.

There is an emergency C-section going on through the morning, being performed by Chief, on a woman who had severe vaginal bleeding yesterday night in her 37th week with contractions, but now the contractions have stopped and there is no foetal heart (showing the baby is now dead). She was being left to deliver the dead baby naturally overnight, but then started bleeding severely this morning, meaning an operation is now needed. The hospital (as I am sure I have made clear before) has no useful intravenous fluids, and as this woman was bleeding heavily, she needed something to replace all the lost blood. The only clean fluid available around we could think of was someone else's blood. I volunteered to donate, as she is the same blood group as I am, and was told to go to the lab to give my blood. Kiwi and I first went home to get gloves and the supplies to insert a cannula to get the blood out. Once at the lab, however, some relatives had just arrived, and 2 had the same blood group as the patient, so these people would be used. Good news, but I was slightly disappointed that I couldn't help out directly. Perhaps its better if I get to keep my own blood!

In the afternoon, I see a few patients in outpatients with Tim, while Kiwi stays at home and reads (I have run out of books!). One patient in outpatients is a 1 week old baby with vaginal bleeding. This is a perfect example of why medical students and doctors don't deserve much of the praise that is sometimes piled onto them. In the last week, I had either been told by Smartie, or had read whilst here, that newborn girls can have vaginal bleeding, or even discharge milk from their nipples, due to the hormones in the mother at the time of birth. I relay this information to Tim to give to the mother. Her baby has a normal haemoglobin, so she is told to come back if it continues after another week or two. The mother seems happy with Tim's explanation, and Tim seems very impressed with my knowledge. As a medical student, life seems to be about regurgitating information gained from one source to others. This can be information you were told, or read, or just overheard. No-one would be impressed if I relayed someone's name when asked what they were called, and I don't think regurgitating information like this deserves this sort of recognition or respect. Which is a shame, as regurgitating information seems to be one of my key skills!

One of the nurses (Right of picture) bought his daughter in today dressed in a mock-nursing-student's-uniform he had made (see woman on left) to try and help out with the nursing in outpatients. So cute!

After all of the patients have been seen, I stay in outpatients for an hour or so with Tim, talking about Tanzania. This morning I came across a large snake in the back garden of the house on my way to the toilet, and having taken pictures, I showed pictures to Tim. I was told it was a Black Mamba, a very dangerous snake! Very fortunate that I didn't step on it! This leads the topic onto Africa's wild life. I hear there was a cheetah outside Tim's house last night, supposedly old ones sometimes come to this village to eat dogs, once they are no longer fast enough to catch prey. He reassures me that it will not attack me, and if they can, they will get someone to shoot it. Very recently, a lion was killed in this village, more towards the main road I arrived on than where I live (fortunately). Lions do attack villagers, though rarely, so if one is roaming around, it will be hunted down.

Despite all this, while lions and hyenas present occasional problems to the village, snakes are a much more common, persistent threat, killing a number of people a year though venomous bites. As with the lions, if a snake is reported around the village, the inhabitants will hunt it down and kill it. Tim relays me some information about the snakes that trouble the village, though I cannot be sure as to whether they are facts or local folk lore! I am told that:

1) Vipers can grow long enough that when they stand erect, they will be taller than a standing man. [can they really stand that erect? Impressive, but must be pretty unstable...]

2) Cars often fight snakes and usually win, which is why some people here have cats in their houses. They can protect from both rats and snakes. [hard to believe a cat can beat a massive snake, but I have heard this before]

3) To catch a snake which is eating chicken eggs, you can boil an egg and leave it out, with the unboiled eggs, so when it is eaten the snake can not crack it once it is ingested, and will writhe around trying to break it until morning, when you can catch it.

4) If you run into a snake you should either hit it with a stick as it rears up to break it (unless it is a viper, they are strong), grab its tail and swing it around to disorientate it then crack it like a whip to break it (again, not to be done to vipers) or lie down until it leaves so it doesn't see you as a threat and try and bite you. It isn't going to want to eat you, so don't threaten it. [Apart from not being able to distinguish vipers, the only good plan here is the lying down one. No chance am I going to try picking up a snake!]

5) When hunting snakes, bows and arrows are seen as the most effective tool, as a hole won't necessarily kill a snake from a bullet, but an arrow can pin it down or hinder its movement, so it cannot chase you as effectively.

6) I also heard (possibly tall) tales about vipers surviving being run over by a car, and staying under the car until the end of the journey (they curl up as they are first run over, so often attach to the bottom of the car) when they bite those who open the doors and step out.

I am not sure which of these are true, but I certainly feel that I have a lot more to worry about now than a rabid bat in my toilet. I do miss Batty, though, I haven't seen him in some time. I warned Dolittle and Kiwi about him, who avoid the toilet at night like I do, now. I hope he isn't lonely.

To finish off the evening, we borrow the cat from Dr Bike again, to try and get rid of all the rats who are scampering around the roof. It is absolutely petrified, and after being forcibly carried into our house by one of Chief's sons, it hasn't come out. Chief has two cats, and this is a different one to the one I had last time. We asked Chief if they had names, but he looked surprised, and said "of course not, they are cats"... Silly mzungu...

Elective 37. I am emergency aid

2011-12-04T18:18:00.001Z

Today starts with attending the English service at the Christian chapel with Kiwi and Dolittle, after I was pointedly asked yesterday why I had not gone recently by the reverend who lives across from my house. I don't want him to be upset, and though Sporty and Smartie avoided it after he had a stool-over-head waving shouting and screaming "power of the Anglican church" sermon, I haven't really turned up very much so had nothing to lose from showing the service to my new guests. After the service comes the morning meeting. Three deaths are reported from yesterday, fortunately none of them the patients I was trying to look after on the ward, and then we end up doing Dr Bike's ward round again, and in the evening have to try and work out how to treat two seriously ill patients, despite the hospitals lack of supplies. Here, I actually get a chance to make a difference.

The 3 deaths that were reported in the morning meeting were of two still born babies, and an 8 year old child:

The first was that of a mother who came into hospital in the advanced stages of labour at about 32 weeks, but baby had no foetal heart rate. The child was reportedly born with 'severe lacerations' and the reason for the labour was expected to be because the child had died. Abortion is illegal in Tanzania, but without saying as such, it was clear that the nurses at the morning meeting felt that this woman had had the baby injured in her home village so it would be aborted. Just because something is made illegal, it doesn't mean that people won't do it, and in much less safe situations than would be possible at a hospital.

The second death is another still born baby, one of a mother who has been on the maternity ward for about a week waiting to give birth. Unfortunately, when she came to the doctors to tell them she was having contractions, her baby had already died (no foetal heart rate), meaning there is nothing that can be done other than wait for the dead baby to be 'born'. This time, it seemed that the mother had been having contractions for about 8 hours, but had not presented to the doctors when they started, due to the common belief among the women that if they tell the doctors they have started labour and it doesn't progress fast enough, they will have a C-section, so by leaving it as late as possible, they avoid C-section. By leaving it this late, the baby, which was born with the chord wrapped around its neck, was not monitored in the early stages of the labour, and so the distress which would have lead to an emergency C- section being carried out was not detected, which is the main reason for the mother to be in hospital in the first place. Another example of where health education would make a big difference to people's outcomes in hospital.

The final death was an 8 year old child, admitted around 5PM with a haemoglobin of 6g/dl and with all of the clinical signs of severe anaemia. A blood transfusion was ordered for her, and the doctor left her while the lab tec was called in from his home to carry out the cross match (make sure the relatives blood is the correct group). By the time that everyone had had their dinner, and the blood had been typed, the doctor returned at 12.30AM to carry out the transfusion, only to find the child dead. It seems that no-one had come to see how the child was in all of that time. The other two deaths mentioned in the morning meeting were un-preventable. This child should have received their treatment much more promptly. The reasons for the death (in my opinion) either seem to weigh in at incompetence or negligence, but at the meeting, the facts are given, and the case is forgotten, left as a mark in the 'deaths' column in the meeting paperwork. If issues like this are never discussed, then people will never change their practice and things won't get better.

After such a depressing start to the day, Dr Bike is too busy to do a ward round this morning, so proposes that we do it (Kiwi, Dolittle and me), and then explain what we think should be done with each patient when we talk with him later, making it more efficient. On the ward round, it appears that no-one is dying, but a number of patients need relatively urgent reviews by Dr Bike, so we mark these down. We then spend some time playing with a tube of bubble mixture Kiwi has bought with her in the children's ward to cheer up patients and parents. The children start off petrified of the bubbles, and the parents curious, many having obviously never seen these sort of things before. The children start off hiding behind parents and beds of the terrifying mzungu, while the parents are sitting, trying to catch the bubbles, and rubbing their hands or sniffing their fingers afterwards in bemused curiosity. I think it was a wonderful idea to bring the bubbles, and the children rapidly grew less afraid and more amazed, saying "Majica" (i assume this means magic) as they chased the bubbles around the room. We left the ward very popular that morning, with the children still begging us to keep waving our magic wand.

Kiwi blows bubbles for the children in children's ward. Holly loved trying to catch them, and was full of energy, seeing as she was the only non-sick child on the ward

We found Dr Bike in theatre, removing a subcutaneous lump, though as we were waiting for him to finish, an emergency C-section came in, followed by the plan to change the dressings of the patient with the large abscess on his face (which had been drained, but needed daily dressing changes). It seemed that Dr Bike was going to be some time in theatre, so we returned to the house for a late lunch. During a good chat after lunch, it transpired that Kiwi and Dolittle had felt that, on my first day, they had thought I was a genius, having studied medicine for less time than them, but still able to prescribe sensibly, and knowing all of the correct doses. Today they have unfortunately already realised that there are a few very common diseases, and only about five common drugs. It is a shame that that illusion was shattered so quickly, but at least I looked like a genius for a day!

I return to the ward (alone, as Kiwi and Dolittle want a rest as it is currently very hot) at around the time I would have thought Dr Bike would have finished the surgeries, to find he has left the theatre already. I decide to go to the children's ward to collect the notes for the patients he needs to see together, in the hope he is there, or heading there soon. As I arrive, I am beckoned over by one of the children's parents. The nurses don't seen too bothered by the parents distress, but I persuade one to come and translate for me. The parents think their child has gotten very ill over the last couple of hours, and is getting worse...

This ill baby is about 10 months old, and was admitted with a diagnosis of pneumonia, gastroenteritis and malaria (it is common for the admitting doctor to try and cover all the bases by diagnosing everything). Tests had shown there was no malaria parasites in the blood, we couldn't listen to the lungs, as she cried whenever we mzungu were near, and has had diarrhoea and vomiting for days in the ward. Last night the doctor on call was called to the ward, as she was having a convulsion. The problem with children crying whenever we try and examine them, or even turn up at the bedside, is so common we don't think about it any more. All the babies here are scared of us, or are a little bit racist. We call it mzungu fever, and it ruins examinations.

In summary, this child has been very sick, though we didn't know what with (assumed gastroenteritis) and now seemed a lot sicker. She was one of the patients we had really wanted Dr Bike to see, though now it seemed a little too late... The baby looked very ill. She was lying on her back in the bed, with her eyes slightly open and not moving at all. I shook her (no response at all), took her pulse ( present but fast, thank god she isn't dead) then quickly examined her body. She had a huge belly, which was bloating out far more than it had been this morning, and sounded resonant on percussion. There were no other obvious problems. The thing that troubled me most was that in all this time with the scary mzungu examining her, the baby hadn't even stirred. This was the child that, for the past few days, we hadn't even been able to listen to her lungs as she was crying so hard every time a mzungu was near her. She was clearly sick. The parents told me that, since the morning when we had seen her (the time was now about 4PM), she had had no more diarrhoea, and had not vomited.

Dr Bike spent most of today in theatre carrying out a number of operations. The theatre is much better kitted out than the rest of the hospital!

I was very worried, and had no idea what was wrong with the baby. Are her bowels obstructed? Or would this cause vomiting? I tried calling Dr Bike four times, but he didn't pick up. Starting to get really worried, I decided to go and look for a doctor to fix things for me. On my way out of the ward, I run into Kiwi and Dolittle, who had felt guilty and come to help me (something I really appreciated right now). I bought them up to date quickly, and we then split up to search the hospital for someone to help us. We found no doctors, but found that the Dr on call was Dr BT. I am not exactly confident of his skill set (he saw the child who died last night of anaemia, who was left for hours without the transfusion) so we decided to get Dr Bike from his house. After all, he still had his ward round to do.

I knocked on his door to find him eating dinner. I explained that there was an emergency, but he said he was busy eating, and would come after he had finished his food. I was sure I wouldn't be able to get him to come in any faster. Dolittle and I head back to the ward, while Kiwi goes back to our house to get her stethoscope, as none of us currently have one on us.

Once back at the ward, I show Dolittle the baby, and Dolittle examines her as well. This time, as soon as Dolittle's fingers touch the baby's head, she stirs and looks around, sneezes in my face (thats another infection coming my way), then lets out a fart lasting for over 10 seconds. I have never heard so much wind in one go, and the abdomen visibly shrinks as she is farting. Not back to normal, but back to a much less scary size. Seemingly relieved, the baby shifts around a little then closes her eyes, and end to our 'emergency' which happens just in time for Kiwi to hurry through the door with her stethoscope in her hand.

As it terms out, during our search of the hospital for a doctor, I was telling wings how the last time I looked for a doctor in an emergency here, for a child who was crying and writhing with abdominal pain, it turned out to he trapped wind. I was joking about what it would make me look like if this was trapped wind again. How embarrassing for it to happen twice! Perhaps the resonance to percussion should have warned me of this possibility.

Needless to say, when Dr Bike arrived, he seemed a little put out it didn't seem to be the emergency we had made out. Despite the 'downgrading' of this 'life-threatening wind', the child still looked very sick. Dr Bike said that bowel movement can be disturbed by electrolyte dis-balance, so we should give Ringers Lactate to the child to correct this problem (no capacity to measure electrolytes leaves a lot to guess work). Dr Bike then refused to see the other patients on the ward, and left to go home. A little irresponsible to be in a strop, but I cannot blame him. He had been working in theatre all day, and wasn't ever the doctor on call for us to be troubling.

We decided we should go and check on the other patients who worried us in the morning, but checking out female ward led to new worries. The woman we tried to convince to drink water yesterday and this morning has drunk only 200ml over these two days (we know this as we were providing her with all her water) whilst having diarrhoea every couple of hours. She complained she was too sick feeling to drink water this morning, so we gave her a promethazine injection. Since this morning, she still has not drunk any water, and now does not talk to us or the nurses, she is just lying there, grunting, and weak. She has a thready pulse and a very low blood pressure. She is clearly not well. At this time, the nurse comes in from children's ward to remind us that the Ringers Lactate that Dr Bike ordered is still not in stock, and the only fluids the hospital has is 5% dextrose. This is because boxes and boxes of it were bought for the urologist to use as a flush during the TURPs. It is no good for rehydrating patients. Great, the child can wait. A very sick woman here who really needs fluid, and no available fluids (the 5% dextrose could be dangerous). This is exactly what I didn't want to happen yesterday. The nursing students on the ward were not helpful at all, refusing to trouble her by asking her to try and sit up and drink (as she seemed sleepy), and saying they wouldn't give her fluids if we found them, as the cannula were in short supply on the ward, and they didn't want to wake her from her sleep. The opposite of the child who I was talking about - there the parents were worried and it turned out to be nothing. Here no-one is worried, and I am very sure that something terrible is happening.

Due to the lack of fluids, this clearly needed some kind of Tanzanian-Doctor-Magic to help us, and we decided it would be unfair to bother Dr Bike again. As it was an emergency, we decided to go straight to Chief's home, catching him just as he was getting on his motorbike. I explained the problem, and Chief was happy to come right away and help (right away here, meaning after he had told us about the historical value of the Site of the hospital, and the need to preserve it, but hey, this is Tanzania). I apologised for interrupting his evening, but Chief replied "This is someone's life, this will always be more important'. I love Chief.

I rode on the back of chiefs motorbike the 100 meters between his house and the hospital (why walk when you can ride) arriving at the same time as Kiwi and Dolittle who walked. When at the hospital, Chief quickly examined the woman. His bedside manner is fantastic, talking slowly and gently with the woman, trying to get her to respond. He quickly reached the same conclusion that we did. It is fortunate that I am not embarrassed a third time by calling doctors to patients who are not such, but very unfortunate for the patient, who is very ill.

Chief then spends some time calling up other members of the hospital, trying to get some fluid that is not 5% dextrose, that can be put into the woman, while Kiwi, Dolittle and I wander the wards, checking in cupboards for a single bottle of fluids that has been left there and forgotten that we could use. In maternity we find that they did have one bottle as an emergency, but it had been taken away 30 Minutes ago for children's ward, for the farting baby, by an unusually efficient nurse (annoyingly efficient now!) So we didn't need to worry about the farting baby any more, but we still needed fluid for the woman.

The search goes on for an awfully long time, but Chief is very persistent. Eventually, 500ml of Ringers Lactate is found, after chief calls the chief nurse in from home to unlock the decontamination room to look in there. I have no idea why it was stored in what is basically a big cleaning cupboard, but very thankful that it was found. We take this, with one of the many 5% dextrose bottles to the patient, and give them both to the very efficient nurse (a real nurse, rather than a nursing student, and it really shows). This is clearly someone we can trust to insert a cannula and run the fluid, and fast. We really would want to give more than a litre, but it is better than nothing. As the efficient nurse sets up the fluid, the patient still hasn't moved and doesn't interact or even flinch away as the cannula is pushed through her skin. If she gets better (and I really hope she does) I will feel that we really contributed to her care. If she gets worse, or dies, at least we did all we could. The whole episode was very exciting, and hopefully similar to that of the job of a junior doctor. Recognising sick patients (hopefully not flatulent patients) and getting appropriate help. I love it!

Elective 36. A full day with an empty pharmacy.

2011-11-28T18:13:00.001Z

A very full (and hence fulfilling) day today. First, I assist in an operation to remove a lipoma from above a man's eyebrow. I then spend the rest of the day in both female and children's wards, until 5.30, first running a ward round, showing Kiwi and Dolittle how it is done, then struggling with treatment alternatives, as the hospital is out of stock of most medications. Dolittle and Kiwi are wonderful company throughout the day and evening, I am glad they have turned up!

The operation to remove the lipoma was pretty standard. Neither Kiwi or Dolittle were allowed by their medical school to assist in surgeries or births (due to the risk of HIV), so I assisted; holding, cutting and swabbing. Not the most glamorous of jobs, but someone needed to do it. I think there is a real art to assisting. To do what the surgeon wants you to do, without needing to be asked, and I am getting better at this, but it is still very dull. I think the only real way to enjoy surgery is to be the surgeon. None the less, this is a successful operation, and a juicy lipoma is removed. I got to get much more stuck into this procedure than previous ones, helping to remove it using blunt dissection techniques I vaguely remembered from dissection in my first year. I was asked to suture up the wound, but told Dr Bike it would be better if he did it. I have had little practice (and this on plastic pads, and over a year ago) at suturing, and this is on his face! I don't want to mess it up and leave him with an ugly scar for his life.

I work on removing the lipoma with Dr Bike in the anaesthetic room of the theatre, with an open window behind us.

After this operation, Dr Bike was busy, and as it was a Tuesday, was not planning on doing a ward round. He told us he was happy for us to do it if we wanted, but he was sure it was all fine and didn't need doing. It is a good thing we decided to do the ward round, as things were most definitely not fine. I enjoyed leading the other two as, while they were more experienced than me, having just sat their finals, they had no idea how the hospital worked, or about many of the diseases and treatments that I was now used to.

The main problem today was that most things seemed to be out of stock. Nearly all of the medication people had been put on yesterday had not been given, as it was out of stock at the pharmacy. If something is out of stock, this is just noted on the notes next to where the drug was prescribed, but nothing is usually done about it. As no doctors were reviewing the ward patients, they were just left without medication, or with breaks in drug regimes, as the supplies had run out half way though courses. No ibuprofen was left, or diclofenac tablets (only injections) so everyone had to do with just paracetamol as a pain killer. Antibiotics are a lot worse. Only ampicillin tablets (like amoxycillin but much worse absorption when given by mouth), metronidarole, co-trimoxazole and chloramphenicol remain in the store. All other antibiotics have run out, and the latter two I mentioned have possibilities of quite serious side effects, so I won't be wanting to prescribe those myself, even though chloramphenicol is popular in the third world. This hospital is absurd, how are patients meant to get better!

In female ward, there is a patient who had come in with a floppy left arm, a headache, confused, and a blood pressure of 180/140 (high). The admitting 'doctor' (Tim) had put them on nifedipine and furosemide to control the blood pressure yesterday. Both of these drugs were out of stock, but nothing more had been done since yesterday. Needless to say, the blood pressure was still very high, so heading over to pharmacy, we discovered the other medication that was present that would do a similar job (captopril, bendroflumethiazide and propranolol), which I decided to use instead, though with these stroke-like-symptoms, Dr Bike really needed to see her and tell us what they do for this in Tanzania.

Another patient on female ward was severely dehydrated. We were discussing whether we should prescribe her I.V. fluids now, or call for Dr Bike (which could take hours), as she had been suffering from diarrhoea 3-4 times an hour, and hadn't drunk at all today or yesterday as she felt ill. This is dangerous, and she looked very dehydrated. Fortunately, we didn't have to decide whether to prescribe fluids or wait for Dr Bike, or even which fluids to give, as the nusre told us there were no more IV fluids left in the hospital. They had all run out.

We went looking for Dr Bike (couldn't find him) and asked the man in the pharmacy (the pharmacist is also a reverend) if this was true about the fluids. It was. He had asked for more over a week ago, but had not received them because of the hospitals finances, so now there are none. I really hope there are no emergency operations in the next few days.

We return to the ward, bring back some ORS sachets from the pharmacy for the dehydrated woman. She is still refusing to drink any fluids as she feels so sick. We gave her anti-sickness drugs by injection, and hoped that they would work well enough for her to start drinking. This was starting to feel as though it could be very dangerous. What if she gets so dehydrated she loses conciousness? Nothing can be done! Kiwi has heard you can give a coconut IV (and a search of pubmed proves her correct!), though I am not a fan of doing this, nor do we have any coconuts. We leave the woman with the ORS, after trying to get a nurse to explain the importance of her drinking the fluid, even if she doesn't feel like it. I think the message get lost in translation, unfortunately, as we gave the nurse a lengthy talk about why it was important, and she said one sentence to the woman. It was probably something like "The mzungu are nagging me to tell you to drink the water". I just don't understand why the woman doesn't feel thirsty, she is so dehydrated! We leave the ward to find Dr Bike again, perhaps our fourth or fifth search for him today, and we still cannot find him, but thankfully this time he answers his phone when we call, and tells me he will be there right away. 40 Minutes later, he strolls in, tells us that the lady with the stroke will be fine, continue meds, and tells the dehydrated lady she needs to drink more. He then tells us that it is all fine, and leaves. If you are Tanzanian, life seems so simple. Hakuna Matata.

To finish today with some happy news, Choc got engaged today to his long term girlfriend! Fantastic news, which he told us as soon as he had done it, but which he is now being strangely evasive about. I don't know whether being engaged is seen as not-quite-good-enough here (as it isn't marriage) or he is just messing around. Either way, its fantastic news!

Elective 35. What a view

2011-11-28T00:32:00.032Z

I start today by getting up at 5am (an impressive thing to do through choice for someone who really isn't a morning person) by heading away from my house and the village to watch the sun rise from a view over the rift valley. A beautiful site. On the way, I had a few encounters with snakes in the dark, a few small ones sliding off the path as I approached in the dark with my wind-up torch, and a large snake that was between the rocks at the view point with stripes on it. I didn't want to disturb it, so took pictures of it and waited for it to leave. Fortunately it did, and I was able to enjoy the beautiful sunrise alone. After this start, hospital life is quiet. Eggs has returned after a long time away, where his ward has not been seen by anyone, and two medical students from New Zealand arrive to keep me company.

A picture of the snake that I almost stepped on. Chief later looked at my pictures and told me it was a "Puff adder", a venomous viper which causes the most fatalities in Tanzania. Good thing I didn't step on it...

I watched the sunrise for a good two hours (though the full appearance of the Sun over the horizon actually took about 1 minute, astonishingly fast.) It was stunning, spreading across the flat savannah below me from my vantage point. It was like a scene out of the Lion King! I really enjoyed feeling the sun warm up my skin as it came up and rose, and hearing the villages dotted around below me start up with the sounds of life as the sun came up. A beautiful experience; just a shame I had to wake up so early to appreciate it! The sun seems to climb into the sky very quickly here. I am not sure if it is because we are on the equator, or the landscape here is so flat...

The pre-sunrise glow fills up the valley, while I stand by the metal cross the church has erected on the cliff to look across their diocese.

The sun rises over the horizon of the savannah down below in the rift valley

Once the sun has risen a little, you can see miles and miles across the rift valley from my rocky vantage point shown

After all this was over, I went to the morning meeting to find Eggs had returned. Fantastic! I asked him if he was well, and he seemed pleased to see me, though gave no indication of where he had been, even when I asked him. The subsequent ward round I do with Eggs is very slow, as he has no idea what most patients are in with, or what has happened over the last week and a half, but I am relieved to have someone official, who knows what they are doing, back in charge of male ward. Despite all his short comings, he does know a lot and its much better having him run things than trying and failing to run things on my own.

Dr Bike is busy today, so persuades me to do his ward round of children's and female wards. I don't do much of note, other than checking on patients and changing around a few medications that had run out of stock. Pretty standard stuff by now. I then go to outpatients, where 3 hours passes with only one case interesting enough to remember enough of to write about it. Perhaps a good reason why being a GP doesn't appeal too much to me. Here, a man came in complaining of a testicular lump. We examined it, and found a non-translucent, non reducible lump that seemed to be a very enlarged left testicle. The man reported that it had come on suddenly a couple of weeks ago, and had been painful. An acute presentation makes a cancer unlikely, so it is hopefully not that, but I have no idea if the patient is being honest, just embarrassed he didn't come to hospital earlier, or there is a problem with the translation. Either way, whatever the problem (such as orchitis) it needs a second opinion because of the risk of serious disease such as orchitis. We decide to 'refer' to Dr Bike to take a look. Refer here means tell the patient to find Dr Bike in the compound, and show him. Dr Bike is usually happy for us to send people to him, if there is a possibility that they may be surgical. I hope this might qualifies!

I suppose that the real bonus of 'GP' like clinics comes from talking to the parents, and I cannot do that here, but as there is nothing else happening at the hospital, I still go to outpaitents regularly even though it can leave me feeling a little annoyed at times. I suppose it is good for learning from Tim's immense knowledge of drugs and their doses, and seeing lots of presentations I would never see in the UK.

After I return from outpatients, and have put the first spoon of rice in my bowl for lunch, two motorbikes pull up outside with the two New Zealand medical students on the backs, along with the skilfully balanced suitcases on the riders' handlebars. They are (in my world) called Kiwi (very patriotic, especially supportive of the rugby team) and Dolittle (later turns out to be able to talk with animals). I get on very well with them both from the start, showing them around the house (Don't use this, thats broken, and so on) then the surrounding area. While giving them the tour of the hospital, we are called into children's ward, where the gentamicin has run out, so the child will be no longer getting any antibiotics. There are very few antibiotics left in the hospital at the moment (we are out of most of the old favourites such as amoxicillin), so I put the patient on erythromycin (its that or metronidazole). We wander back to the house to talk, and so I can help them unpack. Nothing tends to happen in the afternoons. They seem amazed that I am prescribing here, and taking a step back, it is pretty stupid. Its not really safe, but often it is me or no-one to prescribe these drugs. In this case, the child wouldn't have been seen until Wednesday, and there was very little from me to even choose from, due to the poor selection from the pharmacy, but in out patients, Tim and I are expected to act as doctors. I warn them it will be expected of them, and take them to the point where I watched sunrise this morning to watch the shadow of the cliff we stand on grow across the rift valley with the sun set. They tell me they saw Mama and Dada in Dar es Salaam, when they crossed over on their way here, and as Mama and Dada left. Both Mama and Dada spoke of the terrible amenities available here, and neither planned on returning. A real shame. I hope they still plan to twin the two schools.

As the sun sets, the shadow of the cliff we stand on grows rapidly across the rift valley. Here you can see a small village on the far right, half way up, on the picture. People living from much further away than can be seen here have this hospital as their closest medical centre, and no transport. A rapidly shrinking lake can be seen on the left of the picture.

An unfortunate pasta dinner greets us on our return, over which we talked about terrible childrens names. Dolittle said she had seen children named "Abcde" (pronounced Absadee), "Raige Havok Uneek"' and "Jay-a" (pronounced Jaydasha) on her placement in an inner city hospital. I said I planned on calling my son Fellacio (a good Italian sounding name), and my girl Qwerty. Both pretty cute names! I get on well with Kiwi and Dolittke, they share my (puerile) sense of humour much more than Sporty and Smartie did. This is much more fun than being alone.

Elective 34. Who you gonna call?

2011-11-25T21:38:00.005Z

Its another lazy Sunday. I stalk the wards, which keeps me out of trouble for an hour. The rest of the day I spend reading, playing with the village kids (in a friendly non-molestey way...), talking with visitors to my house and investigating the very different wildlife here. There is also a report of paranormal activity in the hospital, but I am not allowed to go and investigate this, as Chief doesn't want me to be 'in danger'...

On the ward round, I do little, as people seem to be relatively well. I re-prescribe antibiotics to a baby, as the dose that had been worked out (a calculation based on body weight) was impractical, so the pharmacy had refused to give it. Rather than telling anyone or marking this in the notes, it had just been left out of the regime, and I only found this out by talking with a nurse about whether he was vomiting up his medication or somehow not taking it, as he still seemed very unwell (he has a working diagnosis of entire fever, but without tests it is more of a guess). I rounded the dose so it could be given by snapping a pill in half, meaning the drug would be given. I also made a couple of additions to simple things, like adding extra days of painkillers (only ever prescribed in lots of three days here, for some reason) and prescribing antibiotic eye ointment for a child who looked like she had conjunctivitis. It is absurd to think of me wandering around prescribing, but it needs to be done. Its going to be so different once I get back to the UK and have everything managed properly. Wonderful, but I will feel like I am going backwards slightly!

Previously I was having some problems with overly flirty nurses on the wards, but this has gotten a lot worse recently, now they have found out that I am not married (This marriage was a lie I managed to get away with at the start). Really, I should feel privileged, I certainly have never gotten this much attention from ladies before, but I have a feeling it is much more about the fact that I am English, rather than my stunning wit and blistering charm overwhelming them. Shame that.

On the way back to the house, I find it besieged by dozens of baboons eating large solid pods hanging off of the trees outside, which contain what look like runner bean seeds. When I get closer, the baboons all run away, leaving the ground littered with these very solid dried up pods they had been opening with their teeth. Everything is so solid and hard in Tanzania, probably in the fight to survive, but I couldn't even open these pods with my hands... I had a wander, now curious about the other very different wild life here, and hoping to find the troop of baboons which had fled. The only very different mammals I saw were much thinner monkeys, which seemed a lot shyer than the baboons. Insect wise there were some crackingly large ones, some very ugly ones, and even ones that worked alone to make mounds which look like volcanoes in the ground. One wall of the house had a huge stream of ants going along its entire length, and up a spout into the kitchen via the sink. Thats where all the ants in the sugar bowel kept coming from! Most interestingly, there were these sort of 'ground spiders' which formed little craters in the hard dusty soil with dusty slopes, so insects walking into one would briefly be unable to climb out of the hole. In this time, the 'ground spider' would strike, catching the insect. I have no idea what they are really called, but the wildlife here is a lot cooler than back home. I could definitely become David Attenborough.

The ant trail down the side of our house is the black line just below my spray painted red line, entering by the tap outlet. How did they work out to come so far to get into the house!

A huge beetle lingers on the down pipe, seen in the far right of the picture above, its size made obvious by the tiny ants next to it.

My wandering around my house, peering at the insects, attracts a number of children I have not seen before. Sometimes children come with mums who need to care for them, when the mum needs to give birth, and I assume that these are from the hospital and bored of sitting outside, so I teach them how to play frisbee, and give them all a pencil and rubber each. I still have loads of stationary left, I think I will give them to the primary school before I leave. While I was running about in the dirt with the beetles (there are some huge ones that make a fantastic buzzing noise as they fly, from hat I assume is the parts of their shell over their wings beating together) Tim came over to visit. He refused to join in the frisbee game (spoil sport), so we went inside to chat. It terms out his dad was involved in a motorbike accident yesterday night. While trying to overtake a pair of drunk cyclists, they swerved in front of him and he came off his bike, breaking his arm, but fortunately not coming to much more harm. I had not seen him this morning on the ward, as he had been at a different hospital getting an x-ray. He has fractured both ulna and radius in his forarm. Because he is the only adult at home (Tim's mother is not around), he has been given permission by Chief to sleep in the paediatric ward with his children, while the staff wait for his swelling to go down, hopefully planning to apply a cast tomorrow (assuming the materials are in stock!) After the accident, Tim had to go and get the bike, and drive it the 15km back home, holding his phone torch as a front headlight, as this had been broken in the accident. Tanzanian people are mad!

Some of the Tanzanian kids are natural break-dancers...

After Tim had left, I started on my dinner, a tub of a vegetable like spinach and very earthy tasting, while Chief came around to visit with the news that I could have two new Muzungo from New Zealand coming to stay, and a ghost Story! All exciting stuff. Even more excitingly, the ghost story had happened right here in this Village, last night! Though I have to say that after hearing it, it had many more elements of a comedy than a scary story...

This event involved a house on the hospital grounds which they were now using to sleep male nursing students, as this weekend a new first year intake had arrived, and there was not space in the normal dorms as the second years had not fully graduated yet. This home had originally been built by the hospital secretary about 25 years ago, but there were no other personal homes on hospital land, and this ended up in a dispute. Unhappy to sell the house for the price the hospital offered to cover building a new one, it was finally agreed he could stay there under some 'Conditions'. Chief did not tell me what these conditions were. After a year or two, his wife developed a mental illness (Chief thought it was schizophrenia, but the villagers thought it was witchcraft), and they moved to a different town, partially to be easier for her and partially so he could work in a new hospital. He offered to let the house, so a lab-tec started living there, but he was bitten by a snake within a month. Word went around that the house was bewitched, and for the last 20 odd years no-one has stayed in it. Absurd for a village where some people live in corrugated iron shacks, or mud huts. This lack of rent also upset the owner, still living with his mentally ill wife, as this is 20 years of lost revenue. Despite all this time without an owner, the house was built well, and is still on the hospital grounds.

With the recent problem with the overcrowded nursing dorms, it was decided to move all male nursing students into this house, and use the male dorm room for female nurses. There are far more female nurses (as in the UK), and this seemed the only short term option, until the second years graduate and more room becomes available.

The house was unlocked and cleaned yesterday of all the cobwebs and other detritus, and the nurses bedded down. At 2am (from the reports of the nurses) one nurse woke up the others, shouting that he felt as though he had been bitten and felt as though he was on fire (so far explainable). The others then said they felt as though some one was throwing buckets of water over them, though they remained dry, and heard a strange grunting laugh from the ceiling (Chief imitated it "ChugahaChugahuChugaha", this was hilarious in itself). This laugh and the 'fake water' terrified them, and they ran out of the house, shouting, in their underwear, straight to their principal. the principal of the nursing school was also terrified, so they all ran, still shouting and sobbing (yes a lot of grown lads and their teacher sobbing) to Chief, who put them in a hall for the night.

Can you imagine this happening in the UK? Many of the nurses are older than me, but fears of curse and which craft still run strong in Tanzania. I suppose we still get reports of haunted houes in the UK, so perhaps the comparison is a poor one. Chief has no idea what to do with the house. He thinks the only option is to demotion it and build another building, unsure whether people will even accept its use hile 'cursed' as a storage house. Such a waste of resources and time in such a poor hospital. I offered to stay in it (always wanted to stay in a haunted house) but he said that, as a host, he couldn't put me somewhere that people considered dangerous. Perhaps even he is a little spooked by it. I wish I could do some investigation, but after I expressed interest, Chief is refusing to even tell me which building it is!

Elective 33. The Good Samaritan

2011-11-24T17:03:00.002Z

Today starts, with an early rise to see Mama and Dada off, then, excitingly, an omelette for breakfast, the first time our chef has cooked one for me! I then spend some time breezing around the wards, catch Dr Bike in a good samaritan style act, then head over to the football field we were at yesterday for the late afternoon/evening. I am now reading Norwegian Wood, a sad, lonely book for all the time I am spending time by myself, but one Smartie had bought with her, and one of the few books left that isn't Chick-Lit... It is also very well written!

On my trawl of the wards in the morning, it turned out that two patients had died overnight. One was the man I mentioned yesterday, who had the huge skin cancer/sarcoma on his leg. This was to be expected sometime soon, and I hope all the drugs that he was given yesterday had made his last day better rather than worse. The most important medication would have been pain killers, but I think only paracetamol and ibuprofen are available at the moment, so it certainly wasn't a painless last day. Poor chap. The other patient who died was a woman who has been here for about two weeks, after being admitted and diagnosed with HIV. She had malaria a week ago, and yesterday her haemoglobin was measured as being low (6.4g/dl), though I have seen a lot lower with no problems in my time here. It should be above about 11.5g/dl in the UK to be seen as normal, but here people have much lower with little problem. I think it is the poor diet. Because the Hb was low, someone had decided that she needed a transfusion (the blood comes from relatives who are matched, there is no stored blood), and she was given a transfusion last night just before she died. I have no idea why she died. She was talking happily while sitting up in bed yesterday. There do not seem to be coroner's inquests in this part of Tanzania, so I suppose no-one will ever know. The death certificate Said malaria, though this had been treated a week ago and she no longer had the infection. I think it could have been something to do with poorly matched or given blood, as it happened so suddenly and the blood was the only change in her management, but there is little I can do about this. Sometimes I feel so helpless and pointless here. These things 'just happen' but the should't. And I can't do anything about it.

While bad things happen in the hospital, the baboons still come and play outside my house in their gangs, such a free life!

Today I also went to visit the poorly boy who I had admitted yesterday with an unknown disease. The one who was HIV negative, but had kidney problems and a limp. He was now a whole lot sicker, could not walk at all, and just lay in bed crying pitifully. This illness was getting serious, and still no-one else had seen him apart from me and Dr BT in outpatients, who didn't know what it was, and hoped the doctor on the ward would sort it out. He had severe pain at the top of his left leg in the inguinal region, and after a careful history from the mother, I found that he had had a fall while running, scraping his knee, and the pain had come about a day or two after this. At least, this is what I thought she was saying. All the translating makes things more complicated. Could this be a fracture? The pain and disability was certainly severe enough for this, but the onset days after the fall was strange. I had no idea, so I went to find a real doctor to help me. Dr Bike refused, as he was not the doctor on call (fair enough, though he was just sitting by his bike in the entrance to the hospital relaxing), so after some searching I finally found the doctor on call to come and help out. After they had had an examination as well, while the child was screaming in pain every time the leg was touched, they decided the child had osteomyelitis in addition to the UTI that was already being treated. This meant that the child needed to be started on flucloxacillin to treat it. When I Came back a lot later in the evening, the boy was sitting up in bed, apparently feeling a lot better. I am very pleased I looked for help when I wasn't sure HERE, and am very sure I will be keeping an eye open for osteomyelitis in the future (I hardly knew anything about it until today). Hope he is as well tomorrow and keeps getting better.

While I was wandering the hospital, I came across Dr Bike a number of times. The first time he was taking a basin of water to the 80 year old man who I we admitted yesterday with the large cyst and infected skin. The idea was to give him a sponge bath, as this was not something the nurses liked doing. Dr Bike had operated and drained the cyst yesterday while I was at the school, and the man had turned out to be Dr Bike's god father. I congratulated him on taking good care of his extended family. The good acts did not end here, though. I later caught him sneaking into children's ward With a cardboard box. Curious, I asked him what he was up to. He sheepishly opened the box to reveal a bunch of bananas and a pot of rice and goat meat. He wanted to feed the malnourished child (who I called Ivy) who was suffering from marasmus, and her sister Holly. He was doing this as it was obvious that they had little food. He had been doing this for a couple of days. Wonderful! Making the effort to care when he really didn't need to, then hiding it away and not telling people he was doing it. My respect for Dr Bike has doubled. It reminds me that while people here often seem to lack training and be lazy compared to the UK, they do what they can the best they can because they do care about the patients, and the seeming laziness is likely just a cultural difference rather than actual not-being-bothered.

The football pitch is one of the best in the area, because someone has build goals out of wood!

In the late afternoon, I go back to the football patch I was at yesterday, as yesterday I was told that they would love for me to be involved in some of their football games. Today was a village league game, however, so I just watched, cheered, and tried to chat with other spectators despite not sharing much (any) language. Neither village was the one I lived in, but both were nearby and this was the best football pitch around. The embarrassment came when a teacher from the school invited me to join a couple of kids in a game of 'ball control' meaning we just punted the ball to each other, showing off out 'skills'. One kid (about 18) did amazing chains of keepie uppies, tricks, the whole lot. The other, a lot younger (around 10), just passed it to one of us if he got it. I am a decidedly average football player (since I left school, I have only ever played it with primary school children when running sports activities as a holiday job), and this was all a bit embarassing. I can manage about five keepie uppies, and if I am lucky about 10. I repetitively let the ball fly away from us and had to go and fetch it, and after one particularly exuberant attempt, I managed to land the ball right in the lap of an elderly spectator of the match, shocking them and making them jump up, then fall over in fright. If I am invited over to play with a school match later, I am pretty sure it will be with the primary school pupils after that performance! Talking with the team captains on my way home, it turns out one of the villages doesn't even have a football, so they find it hard to train, creating balls out of tied together rags. Life here is so different to the UK that its almost alien.

Elective 32. Back to School

2011-11-22T23:59:00.002Z

Its back to school for me, but only at the end of a long day. Before this, I walk Smartie to the bus Stop at 6am, it was the gentlemanly thing to do. A quick ward round is then followed by my first (and last) stint in outpatients with Dr BT. This was all topped off with a lovely leaving party for Mama and Dada from the school.

The school we visited, walls bare and old desks crammed into rooms as close as possible. There are no chairs, as they are needed in the canteen for the children to eat their dinner.

Before getting started on this busy day, I would like to say that I was prayed for for the first time yesterday (well, knowingly prayed for, at any rate). The bishops secretary (a Canon) bought around some letters for Mama and Dada at 7.30PM yesterday, but unfortunately they were both already Pj'd up and in bed. While they subtly got up again, I chatted with (read distracted) the secretary. What is it about Tanzania that inspires people to go to bed so early! It must be the lack of things to do in the area, and the dark dark nights (no lights). After the letters had been handed over, the secretary asked the awkward question to Dada (the re-teacher) first. "So, which church do you attend?" While Dada struggled around the "I am not... quite... currently regularly attending any Church" (good thing she didn't mention what she told us yesterday, that she feels she can identify with Islam more) I had the time to think up a good avoidance answer "I live in the diocese of xyz" (not a lie!) which Mama then repeats. Good to know I am essentially helping people to lie to gods messengers. The Canon, apparently satisfied, talked a few more Minutes about how Dada should go to church more, then asked if he could pray before he left. Who are we to deny him this? He gave thanks, and prayed for the teachers safe journey home. He then gave thanks to God for guiding me to come and help their hospital, and prayed that I could carry on doing good here, and learning as much as I could to help others. A little odd to have my choice to come here attributed to someone (or something) else, but the argument for free will has always been a tricky one, so who am I to disagree. It was still lovely in an inexplicable way to have a Canon pray for me. I just realised pray and prey are only one vowel different, and sound very similar. I wonder if anyone has noticed this before. My hand writing recognition keeps mixing them up. Some people don't believe in coincidences...

On the ward round with Dr Bike, there was a patient who had been admitted yesterday with a painful lump in the leg, and difficulty with their breathing. Examining the leg showed a huge lump beside the knee, the size of a melon, but bumpy and growing through the skin, leaking fluid and very painful looking. It looked like some form of very advanced skin cancer or sarcoma. I assume the problems breathing, and abdominal pain the patient complained of, were due to metastases in the lungs and liver. This patient clearly seems a case for terminal care. It is shocking that he presented to the hospital this late, so far into his disease he cannot walk, and was carried here by his family. Even if he presented earlier, the hospital doesn't have any anti-cancer therapies available, so I am not sure it would have helped. Unfortunately, in this hospital they don't seem to understand the concept of palliative care, and Dr Bike spends some time devising a wicked looking treatment plan which will never get rid of the cancer, but will likely ensure the patient experiences many nasty side effects and needs to stay in hospital to die, due to all the IV drugs, rather than going home with his family. Dr Bike isn't interested in my ideas of perhaps debriding the large mass, giving prophylactic antibiotics and letting the patient go home to his family, as this isn't curing him. As l am only a medical student, and have even less idea about Tanzanian culture than medicine (so very little indeed...) I leave it. It is quite possible his plan is the best thing to do, given patient expectations and all that, and I just don't understand the full picture. I just feel sorry for the poor man stuck at hospital.

The football ground we watched a football game on in the afternoon. Just a cleared area of ground, with lots of dust when they play. Football shirts are the common wear for young people in Tanzania. More people here support British teams than in the UK! Random location in text here, just to break up a load of text. Otherwise all the pictures would be at the end!

I spend most of the morning and half the afternoon in outpatients with Dr BT. I hadn't noticed before how the patients waiting to be seen form some kind of self-triage, meaning the sickest, or ill babies see us first, and the more well wait for longer, even if they arrived fist. A very fair and smart system, which avoids the need for a receptionist to triage them and cost the hospital more money. Perhaps just another insight into the Tanzanian attitude towards community and life.

The first patient who comes through the door, and hence likely the sickest, was an 80 year old man, with a great big cyst below his left cheek, and a large infected, almost gangrenous looking and nearly a foot square patch of skin on his chest below the cyst. The dripping pus, and the smell of off flesh (a common smell in the UK from people with severe ulcers on vascular wards) had attracted a crowd of flies that buzzed in with him. He was a very sorry sight, and it was very hard not to gag whilst he was in the room. It is fortunate that buildings in Tanzania rarely have any glass or any covering to their windows. The resultant barred holes (a little like l imagine being inside a jail would be like) give maximum ventilation for minimal cost. Anyway, this was a simple call to admit and drain the huge dripping cyst, though what will be done with him afterwards, I don't know. The surgical maxim I mentioned before (If there is pus about, let if out) seems to come up here more than I expected. For a number of the next patients, however, Dr BT and I are much less in agreement. Before thinking I am an arrogant upstart, please hear me out. Dr BT wants to give co- trimoxazole to everyone. Even people who almost definitely do not have any infection at all. As I may have said before, this antibiotic is only meant to be used in quite specific circumstances (such as to treat PCP), due to its potential for severe side effects.

It was really awkward being with Dr BT, as if was much harder to discuss the treatment with him compared to how easy it is with Tim. This is just me, finding it hard, as he is a 'doctor' whereas Tim is only a student. I use this term in the loosest sense. I am not usually the sort to bitch behind someone back, but he is absolutely shocking.

For example, the case of a female UTI:

Dr BT: "Lets use Co-trimoxazole".

Me: I think there is a better drug we could use... (Though Co-trimoxazole does actually help in UTI there are drugs which will do the same thing with far less risky side effects)
Dr BT: Then crystal pen? (a penicillin)
Me: Nope...
Silence...

Dr BT: Erythromycin? (slight desperation in his voice)
Another pause...
Me: The pharmacist recommends nalidixic acid...

Dr BT: Can't we use metronidazole?
Speechless...

This is the conversation we had, I kid you not. This is not a treatment I would have known to use when I got here (In the UK trimethoprim is the first line for UTI), but I looked it up then asked the pharmacist. Why can doctors here not do a little research, for their patients benefit. Drugs like metronidazole are very unlikely to cure the UTI at all, doing more harm than good.

Two other diseases I was told we should Use co-trimoxazole for (in addition to the wealth of viral appearing infections) were bloody diarrhoea (though actually the classic metronidazole is a good choice here) and thrush (though skilfully I managed to "accidentally mishear" him here, and I wrote a prescription for clotrimazole instead). The pessary and cream that my Oxford Handbook recommends. Having that book on the desk is a life saver.

This is absurd. A pretty average medical student with three years experience, leading a doctor to the correct treatments. Its scary. I look forward to being back in the good old NHS, were I can be shouted at for suggesting the wrong antibiotic. What is most worrying is that this doctor is the one in charge of outpatients, and thus the person who 'teaches' Tim, when Tim doesn't know the answer.

After this horrible ordeal, and yes it is horrible seeing how little someone knows and struggling to correct them when you shouldn't really need to, I have sworn never to return to outpatients with Dr BT. Initially I thought I could improve his prescribing, but realised through the clinic that he seems to do what he wants, regardless of what we discussed to do about the previous patient, not learning from previous people. What do I do?) Escaping the outpatients, I went back to the ward to perform HIV tests on two people.

The first test was for a sick child who Dr BT and I had admitted today with apparent kidney disease (urine microscopy showed granular casts present in the urine, showing protein is leaking through the kidneys) and an un-healing injury on his knee. All of this came with severe pain up the leg meaning he had to limp, and enlarged inguinal lymph nodes (at top of leg).

The second HIV test was for the 80 year old man we saw first in clinic, with the large abscess. Both useful tests as there are presentations that may correlate to having some kind of compromised immune system.

Both tests were negative. Great news, but with normal glucose levels and no HIV, why are they both ill? More investigations are needed, along with a lot of clever thinking...

After this busy and frustrating day, I go to school football match with Mama and Dada. When we arrived, I was asked to play, which I would have loved, but was in my 'med student' gear, down to the bottle of alcohol gel on my belt, so said I would love to play another time. There was no chance I was going to be able to play in this heat in smart trousers and shirt! The football pitch was a dusty field, and some of the school children (16 year olds playing against each other) share pairs of football boots, between left and right footed people, to mean they can each have a boot on the foot used to kick the ball.

After the football match (which disappointing ended 0-0), I am invited to the leaving party that the school is throwing for Mama and Dada. I happily accept, I love a party!

The school was littered with signs telling the children to speak English, and 'No English, No Service'. The children are made to speak English at all times at the school to help them learn

Before the party, we are shown around the school. The classrooms are empty, and have desks in that you could imagine your parents using in their schools, crowded into rooms to look at a black board. After a tour of the school, we are taken to the canteen, and as we three mzungu walk with the head master of the school into this canteen/assembly hall, all of the children, chairs lined up pointing to the front (taken from the class rooms earlier) stand up and start singing african music and hymns as we (Tanzanian) shuffle towards the front. We sit at the front of the hall in front of all the children, and we get a series of acts, including a singing and dancing choir and acrobats, all talented pupils at the school. The school then had its dinner, which we joined. Mama and Dada had bought enough money to buy the kids all a soda, and a lot of pencils and other stationary to give out to the kids from the school stationary stores. This did mean that, therefore, the pencils were coming from the British tax payer (as is the cost of their trip here and subsequently to Zanzibar). I am not sure how I feel about that, but the children (14-18 Years old) were so excited about getting a few pencils each that they were bouncing up and down with joy. It was wonderful that they could bring happiness to a whole school so easily.

The children sit watching us. The space between us and them is where the fantastic acrobats and dancing choir performed. The last few pencils are being given out at the back

This was then followed by -speeches-. The Tanzanian speeches were all very Christian, each starting with the shout "Praise the lord" (Children chorus "amen"!). Then Mama gave an inspirational thank you speech back to the children ("You can do anything you want to..." kind of thing) followed by Dada, who gave an emotional thank you, tears running down her cheeks. Both very in character, I apprive. I was then asked to make a speech. Wait. What? I suppose there is no such thing as a free lunch... I just said it was a wonderful welcome for me, despite the fact i didn't even work in the school, and I hoped not to see any of them again as that would mean that they were ill and at the hospital. I thought it was a good joke to think upon the fly, but I think it went over most of their heads, perhaps a language problem. Or I am just not the comedian I thought I was... We were sung out the same way we were sung in, and again, I was left marvelling at Tanzanian generosity and community.