I can’t believe I forgot to tell you about Katengo. Many of you have asked about this little girl. She was admitted in May with a facial tumour (Burkitt’s lymphoema). We were shocked when we returned from the UK Congo
Friday 29 July 2011
Thursday 28 July 2011
African Working Time Directive!
We arrived back in Kalene at the end of June to a very different place. The burning season was in full swing, creating a sort of apocalyptic atmosphere, the sky full of smoke, ash constantly raining down but also creating the most beautiful sunsets. The Lunda like to burn EVERYTHING! Chris reckons this is just the place for young pyromaniacs – free reign to burn anything in sight!
The mornings throughout July have been quite chilly and through the night, a forceful wind rips through the bamboo outside our cottage. By midday, it is scorchio again. I took to having a morning outfit and an afternoon outfit!
Although the hospital has seemed quieter in terms of number of inpatients, the workload has remained heavy. With just two doctors now (Chris and John), it is hard graft. Late nights and early mornings are beginning to take their toll. We are very much looking forward to the arrival of Phil (anaesthetics) and Tess (O&G) at the end of August.
As ever there have been plenty of intriguing and challenging cases. There seems to have been a higher than average proportion if patients with difficult AIDS related problems. Its relationship with TB and other opportunistic infections, coupled with the intricacies of the medical management, seems to get trickier the more you become aware of them.
There has been a definite paediatric feel to the surgical scene this month. Apart from the routine children’s surgery of herniae, hydrocele, orchidopexy and burns, there have been a few notable challenges. A seventh month old girl was ‘transferred’ from the nearest government hospital after a few days of unsuccessful ‘treatment.’ She had a bowel obstruction. As ever, the situation was complicated by traditional medicine which she’d received when she first had a little diarrhoea. Although you’ll never know exactly what has been administered, there are certainly some agents that will cause a profound paralytic ileus, in which cases an operation is the last thing they would need. After some tricky resuscitation (an intra-oseus needle infusion, then femoral line, then blood transfusion) we operated. We found an advanced small bowel obstruction caused by an ileocaecal intersusseption. Jedian is slowly recovering.
Charles is a little younger. He again came from the same government institution aged just five days old. He’d been born at home in the village but after not passing any stool for a few days his family took him to hospital. He had a high anal atresia (no bottom hole). We operated on this chap by making an end colostomy and mucous fistula. We’re not quite sure how we’ll deal with things definitively but we’ll cross that bridge…
Just when we thought we’d exhausted our neonatal anaesthetic (let alone surgical) ‘skills’, a baby not yet twelve hours old was brought in from the village (they’re all told to deliver at a rural health clinic, if not the hospital, but do they listen?!) This wee thing had been born with all her internal abdominal organs ‘hanging’ on the outside (a massive ruptured omphalocele). Again after a challenging resuscitation (not least aided by the fortuous arrival of our paediatric ITU nurse, Kirsty) we operated to put things back where they belong. At initial operation (last night) we haven’t repaired things as such – if the whole abdominal content is returned en masse, the heart, lungs and diaphragm won’t cope with the sudden increase in pressure. So we are managing her open abdomen (an IV fluid bag ‘patch’) and in the days to come we aim to close things definitively. She will still be left with a massive incisional hernia but again we’ll cross that bridge etc etc. The family haven’t named this baby girl. They often don’t give a name if they believe the child might not live.
Quote of the month:
‘Now I’ve seen this operation done before…… once……. on YouTube.’ (Dr. John)
Making do
One night, Christopher and I were attending to a young footballer who had suffered a horrible fractured femur just above the knee. In fact, his leg was so deformed we thought he had dislocated his knee. We don’t have use of x-ray at night (or during the day as it happens – we’ve run out of film developer) but we do have an image intensifier, which is a very useful bit of kit. I am not squeamish but I really did feel rather ill as we tried to yank on his poor leg to reduce the fracture. Thankfully, we had help from a varsity wrestler, medical student Conor Murphy! As is often the way here, you can never find what you need and if you can possibly locate it, it will usually be broken! So, at midnight, I was hunting round the hospital for traction equipment but there was none to be found. So I improvised – with a sharps bin filled with Bibles, which did the job very well - the healing power of the Word of God!
Under this heading, Christopher is very happy to report that he has found improvised and emergent medical uses for his duck tape, parachute cord and his knife. He is proud of this fact as he had a bet on with his wife that no use would be found for para cord during our time here. However, she does not feel that FIFTY METRES of the stuff was justified when she could have used the weight allowance for other essential items such as more pretty dresses etc!
Students
The wards became scenes of utter chaos while the students had their practical exams. This process was enough to try the patience of a saint! They were suddenly no longer interested in looking after patients, only in practising procedures, namely bed making and hair care. I wouldn’t have minded this but they were actually found to be terrorising the odd patient and I had to remove one who was making a poor lady cry! They brought pot plants in (‘for decoration’), covered the pots of precious A4 paper, using even more precious ‘strapping’ (AKA surgical tape, which is in very short supply here) and the most bizarre thing was the use of a very interesting technique that I have never seen before. They managed to obtain large bunches of leaves which they scrubbed the concrete floors of the wards with, in order to give them a green tinge. This, I was told, was appreciated by their examiners and for which they would be awarded extra marks. This was going on all around me as I was trying to look after a critically ill patient – it was a fairly surreal experience!
The critical patient was Maria. She presented two weeks after she gave birth to little Christine. When I say little, she weighed in at 1.4kg! Maria was septic and very anaemic. She had retained products of conception and when she went for evacuation, she was found to have been given village medicine per vagina. Patients / relatives are fined if they are found to have been using local treatments as they often cause a lot of harm. However, in the days that followed, she did not improve and was becoming less and less responsive. She was found to be HIV positive which raised our suspicions of TB meningitis or cryptococcal meningitis (a fungal infection). There two conditions are managed quite differently and it is important to try and get the diagnosis correct. Unfortunately, we are unable to do the specific test required here at Kalene, which is a source of much frustration. She had a lumbar puncture, which though not conclusive, did give us some information and Maria was commenced on treatment for TB meningitis. Her prognosis looks poor as she has failed to respond to treatment thus far. Christine is now doing extremely well and is now nearly the grand weight of 2 kilos! She loves coming home for a bath every couple of days. We are making plans with her family for her to go to Hillwood – do pray that a member of her family can go there to care for her as the orphanage are short staffed and do not have a mama to care for her at present.
There are some lighter moments at KMH. A couple who had been unable to conceive came to see us. This is a serious problem in a culture that measures your value by your childbearing ability. Dr John felt we should check the quality of the husband’s sperm. This obviously made sense. The man came to Fisher Ward with his request. I was about to send him off the laboratory as I felt the chaps there were possibly better placed to deal with this. However, one of our older members of staff had spoken to the man before me. On her return to the office, she explained why he had come but that she had never taken a sperm sample before and wandered if I could show her how to do it!!! Bless her – she was so sincere and sweet. A week later, Edwin, one of our lab technicians, came to me and said, ‘Sister, I have just found this sample [holding up a pot] but I am unable to analyse it now,’ to which I replied that no, it was a bit on the old side. So I found the man and sent him back to the lab. A few days later, Mwape, another technician found me and told me that he had just found a sample that he could no longer analyse. It was getting rather ridiculous. I said that I felt the lab techs were made fully aware and indeed, the samples were produced in the lab (a feat in itself given the condition and atmosphere of our lab!) and if they were not available to analyse the sample at the time, they should have asked him to return later on. Third time lucky and I am happy to report that the man’s swimmers were in fine form! His wife underwent tuboplasty (for blocked fallopian tubes), so we are hoping they will now be able to conceive. Kalene Fertility Clinic is always happy to help!
Thank you, as always, for all your love and support – we are very grateful.
With our love, Emma and Christopher x
PS Sorry for the lack of photos – we have been having a few probs with uploading stuff on our computer. We hope to have some pictures for you next month.
The mornings throughout July have been quite chilly and through the night, a forceful wind rips through the bamboo outside our cottage. By midday, it is scorchio again. I took to having a morning outfit and an afternoon outfit!
Although the hospital has seemed quieter in terms of number of inpatients, the workload has remained heavy. With just two doctors now (Chris and John), it is hard graft. Late nights and early mornings are beginning to take their toll. We are very much looking forward to the arrival of Phil (anaesthetics) and Tess (O&G) at the end of August.
As ever there have been plenty of intriguing and challenging cases. There seems to have been a higher than average proportion if patients with difficult AIDS related problems. Its relationship with TB and other opportunistic infections, coupled with the intricacies of the medical management, seems to get trickier the more you become aware of them.
There has been a definite paediatric feel to the surgical scene this month. Apart from the routine children’s surgery of herniae, hydrocele, orchidopexy and burns, there have been a few notable challenges. A seventh month old girl was ‘transferred’ from the nearest government hospital after a few days of unsuccessful ‘treatment.’ She had a bowel obstruction. As ever, the situation was complicated by traditional medicine which she’d received when she first had a little diarrhoea. Although you’ll never know exactly what has been administered, there are certainly some agents that will cause a profound paralytic ileus, in which cases an operation is the last thing they would need. After some tricky resuscitation (an intra-oseus needle infusion, then femoral line, then blood transfusion) we operated. We found an advanced small bowel obstruction caused by an ileocaecal intersusseption. Jedian is slowly recovering.
Charles is a little younger. He again came from the same government institution aged just five days old. He’d been born at home in the village but after not passing any stool for a few days his family took him to hospital. He had a high anal atresia (no bottom hole). We operated on this chap by making an end colostomy and mucous fistula. We’re not quite sure how we’ll deal with things definitively but we’ll cross that bridge…
Just when we thought we’d exhausted our neonatal anaesthetic (let alone surgical) ‘skills’, a baby not yet twelve hours old was brought in from the village (they’re all told to deliver at a rural health clinic, if not the hospital, but do they listen?!) This wee thing had been born with all her internal abdominal organs ‘hanging’ on the outside (a massive ruptured omphalocele). Again after a challenging resuscitation (not least aided by the fortuous arrival of our paediatric ITU nurse, Kirsty) we operated to put things back where they belong. At initial operation (last night) we haven’t repaired things as such – if the whole abdominal content is returned en masse, the heart, lungs and diaphragm won’t cope with the sudden increase in pressure. So we are managing her open abdomen (an IV fluid bag ‘patch’) and in the days to come we aim to close things definitively. She will still be left with a massive incisional hernia but again we’ll cross that bridge etc etc. The family haven’t named this baby girl. They often don’t give a name if they believe the child might not live.
Quote of the month:
‘Now I’ve seen this operation done before…… once……. on YouTube.’ (Dr. John)
Making do
One night, Christopher and I were attending to a young footballer who had suffered a horrible fractured femur just above the knee. In fact, his leg was so deformed we thought he had dislocated his knee. We don’t have use of x-ray at night (or during the day as it happens – we’ve run out of film developer) but we do have an image intensifier, which is a very useful bit of kit. I am not squeamish but I really did feel rather ill as we tried to yank on his poor leg to reduce the fracture. Thankfully, we had help from a varsity wrestler, medical student Conor Murphy! As is often the way here, you can never find what you need and if you can possibly locate it, it will usually be broken! So, at midnight, I was hunting round the hospital for traction equipment but there was none to be found. So I improvised – with a sharps bin filled with Bibles, which did the job very well - the healing power of the Word of God!
Under this heading, Christopher is very happy to report that he has found improvised and emergent medical uses for his duck tape, parachute cord and his knife. He is proud of this fact as he had a bet on with his wife that no use would be found for para cord during our time here. However, she does not feel that FIFTY METRES of the stuff was justified when she could have used the weight allowance for other essential items such as more pretty dresses etc!
Students
The wards became scenes of utter chaos while the students had their practical exams. This process was enough to try the patience of a saint! They were suddenly no longer interested in looking after patients, only in practising procedures, namely bed making and hair care. I wouldn’t have minded this but they were actually found to be terrorising the odd patient and I had to remove one who was making a poor lady cry! They brought pot plants in (‘for decoration’), covered the pots of precious A4 paper, using even more precious ‘strapping’ (AKA surgical tape, which is in very short supply here) and the most bizarre thing was the use of a very interesting technique that I have never seen before. They managed to obtain large bunches of leaves which they scrubbed the concrete floors of the wards with, in order to give them a green tinge. This, I was told, was appreciated by their examiners and for which they would be awarded extra marks. This was going on all around me as I was trying to look after a critically ill patient – it was a fairly surreal experience!
The critical patient was Maria. She presented two weeks after she gave birth to little Christine. When I say little, she weighed in at 1.4kg! Maria was septic and very anaemic. She had retained products of conception and when she went for evacuation, she was found to have been given village medicine per vagina. Patients / relatives are fined if they are found to have been using local treatments as they often cause a lot of harm. However, in the days that followed, she did not improve and was becoming less and less responsive. She was found to be HIV positive which raised our suspicions of TB meningitis or cryptococcal meningitis (a fungal infection). There two conditions are managed quite differently and it is important to try and get the diagnosis correct. Unfortunately, we are unable to do the specific test required here at Kalene, which is a source of much frustration. She had a lumbar puncture, which though not conclusive, did give us some information and Maria was commenced on treatment for TB meningitis. Her prognosis looks poor as she has failed to respond to treatment thus far. Christine is now doing extremely well and is now nearly the grand weight of 2 kilos! She loves coming home for a bath every couple of days. We are making plans with her family for her to go to Hillwood – do pray that a member of her family can go there to care for her as the orphanage are short staffed and do not have a mama to care for her at present.
There are some lighter moments at KMH. A couple who had been unable to conceive came to see us. This is a serious problem in a culture that measures your value by your childbearing ability. Dr John felt we should check the quality of the husband’s sperm. This obviously made sense. The man came to Fisher Ward with his request. I was about to send him off the laboratory as I felt the chaps there were possibly better placed to deal with this. However, one of our older members of staff had spoken to the man before me. On her return to the office, she explained why he had come but that she had never taken a sperm sample before and wandered if I could show her how to do it!!! Bless her – she was so sincere and sweet. A week later, Edwin, one of our lab technicians, came to me and said, ‘Sister, I have just found this sample [holding up a pot] but I am unable to analyse it now,’ to which I replied that no, it was a bit on the old side. So I found the man and sent him back to the lab. A few days later, Mwape, another technician found me and told me that he had just found a sample that he could no longer analyse. It was getting rather ridiculous. I said that I felt the lab techs were made fully aware and indeed, the samples were produced in the lab (a feat in itself given the condition and atmosphere of our lab!) and if they were not available to analyse the sample at the time, they should have asked him to return later on. Third time lucky and I am happy to report that the man’s swimmers were in fine form! His wife underwent tuboplasty (for blocked fallopian tubes), so we are hoping they will now be able to conceive. Kalene Fertility Clinic is always happy to help!
Thank you, as always, for all your love and support – we are very grateful.
With our love, Emma and Christopher x
PS Sorry for the lack of photos – we have been having a few probs with uploading stuff on our computer. We hope to have some pictures for you next month.
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