Sunday 5 September 2010

31 aug

31st Aug

You guys must be thinking what the hell? This girls on elective and all we’ve been hearing about are her non medical Kenyan adventures. Well today, I started back at Dophil, I was meant to be at Siaya hospital but Dr Phill has personally requested that I remain with him at his hospital for one last week, as he is on a month long training course from the 6th of Sep. It is quite hard to say no to someone who has saved you from chronic diarrhoea and so I accepted his request and off to Dophil i went. BIG MISTAKE. Today, I major feelings of frustration which almost boiled over into annoyance. Il take you through my day, I hope that you guys can appreciate the pure and utter feelings of ‘whats the bloody point’ that i had today, I’m ashamed to say that today, I nearly just gave with up with the notion that anything I did was helping anyone. I mean what is the bloody point of short term gain, if the long term is neglected, anyways here goes.

So my day started at eight thirty at Dophil for ward round. I hadn’t been in for a week or so, and so I was unfamiliar with the patients. Two stuck out for me today, one was a gentlemen with pulmonary TB but had some focal neurology signs (signs that perhaps the TB has spread to his brain), He was really thin, coughing like no mans business, fever, refusing to eat. Anyhow the Tb had not been confirmed because the hospital had run out of sputum pots. Before any treatment for TB can be commenced here in Kenya the patient has to have a positive sputum test of confirmation chest x-ray. Ok this is fair enough because the treatment for TB can be a minimum of six months worth of tablets. In Kenya many people stop taking the tablets after a few weeks because they feel well. Little do they know that the bacteria persists for many weeks in their blood stream hence the six month long treatment regime. And so as in the UK, Kenya as adopted a buddy scheme which means a friend or family member or good will citizen can retrieve the drugs for the patient (drugs are free) and ensure that the patient takes them. Or the patient has to come to the hospital everyday for the next six months and be observed taking the medication by a trained practitioner. Why so stringent you ask, this is because TB strains can become resistant, and resistant is dangerous when this disease is spread by direct inhalation of infected mucus samples, spread by coughing.
And so because the hospital didnt have sputum pots into which the patient could deposit a sputum sample and it be tested on site and treatment commenced, treatment has been delayed despite us all being aware that the patient had signs and symptoms of a chest infection that was likely to to be TB and has most likely spread. Needless to say the patient was unmasked and coughing infected mucus all over the ward from his bed. Great.
And so the medical officer that I was with was suggesting that the patient be taken for a chest Xray. Chest xrays are a whole lot more expensive than sputum sampling. I argued that not only was the patient confused, and disorientated, he was too ill to walk to the loo let alone to another hospital. They couldn’t pay for a taxi or an ambulance and to be honest, I continued, why the hell should he when it is our fault that his treatment is delayed as we don’t have the supplies. I wanted to go against the rules and just initiate treatment, as it is bloody obvious that this guy had TB. The medical officer still refused to do so (and correctly so) but I was annoyed that another day would pass and this man gets sicker and infect the air some more. Also the medical officer suggested that we test him for HIV antibodies. Er, I was like he aint talking, how can he give consent? And so the officer was like he cant give consent lets do it anyway. I was like in the Uk you have to counsel a patient, get consent, counsel about the results, implications and treatment etc. In the UK we treat all HIV positive people immediately (if they so wish) here in Kenya (not sure if this is WHO or just Kenya rules –i shall check) Patients are only started on anti retroviral when their CD4 (white blood cells) are at the level of 280 or under?? I suggested that if we tested this man and found that his CD4 was above 280 it wouldn’t change our management of him and I felt really uncomfortable ordering an investigation that at this moment wasn’t the pending investigation and without the patients consent. We didnt do the CD4 count in the end I am (antibodies) and Im glad cause frankly if we cant treat a patient because of the resources that we are lacking, then we cant bend the rules for something else, especially in reference to consent and the absence of a next of kin or legal guardian.
Towards the end of the day a sputum pot was found –hurrah . We shall await the results of the test.

The second memorable patient form the ward round was a young boy of twenty who also had TB. He had initially been commenced on treatment last year, but neglected to compete the course and so was back again, sick looking with absoulty horrible feet.
In Mombassa a Kenyan man had told me about an insect called a Chigga. These are very tiny insects, half the size of a grain of rice that like to live in feet. They attach to the soles of feet and slowly eat away until they reach a blood vessel and then suck their human hosts blood. The only suggestion that a person is infected with these parasites is an insatiable itch in the area. Later ulcers and wounds appear as these animals, multiple and erode the soft tissue, causing painful walking. This infestation usually occurs on the feet of non shoe wearers. Many of the villagers walk bare footed here. Some cause they have no shoes, others cause it is more convenient to walk bare footed in the mud after the rains than walk with flip flops. This boys feet were indescrible. Seriously, I had to take a picture as what I saw was perhaps the worse case of infestation that anyone in the hospital had ever seen. The skin on his feet where thickened and ulcerated almost on every surface. It was grim and looked so bloody painful. This boy was ill, very ill, breathing rapidly, very thin and weak. Turns out he was an orphan, he lived alone in a hut, didnt got to school, and had been abandoned by his older brothers who had left him years ago for the bright lights of Nairobi. All alone this boy had contracted TB and Chiggars. He had presented to the hospital the previous day. Was admitted. Howver, he has since been refusing to eat or drink and did not want any medical care. We think that he needed somewhere warm to sleep and perhaps had come to the hospital to die. Twenty years old this boy was and had make the descion to die. Ah i felt the tug of my heart strings again, dosnt take much now though. I gave the boy my breakfast (dry old cake from a stall). I asked the medical officer to tell the boy that he must eat and drink and that we would help him as much as we could. The great thing about being a female, Kenyan looking but ‘muzongo’ speaking student Dr is that people are often fascinated by me. He hasn’t met a female dr before, I gave him food and talked in a language that he couldn’t fathom. Ha, I had his attention and from that moment due to some ill believed faith that I could solve all his problems he began to co-operate with the staff. Wicked. He allowed one of the nursing staff to clean his feet and he took his meds. I made one of the medical officers tell him that if he co-operated that I would bring in some topical cream that I had that the hospital didnt have but would help with his feet. Score. Futher co-opertaion!!!

Some hours later, well after a lunch of beans and maize ( not like the marks and sparks that I know and love). I noticed that a man had been delivered to the hospital in a wheel chair. This eldery man has one massive lump on the side of hid head. A massive gash oh his leg. A bleeding nostril and was urinating all over the waiting area. The man was confused and drifting in and out if consciousness. I summoned DR Phill and we took him to the surgical area. Annoying, I was told to suture his gashed leg. Er, I was like, shouldn’t we assess him first as it transpired that the man that had brought the patient in was a motor cyclist who had driven head on into him. –yikes. No I was told, he will be fine we need to sew up his leg. This man had one fat bump on his temple, and I being the freshly out of fourth year exams medical student who thinks she knows everything was more concerned with the fact that this man may have a serious head injury. No one was interested in my thoughts. And with hindsight, I guess not because they didnt care but because, all of my findings meant nothing, we have not CT, we have no X ray we have an ultrasound. If this man has a serious head injury, pat on the back for me for the diagnosis, but no prizes for guessing that we have a lack of resources to manage it. We have no neck collar, we had no airways adjuncts, no oxygen, no way of managing his vital stats. Nothing. But guess what we did have sutures for me to suture his gashed leg. So I triple gloved up as every now and again the patient would make an involuntary movement, and god forbid i get a needle stick. After every suture I had to rub the guys chest, just to make sure he was still with us and I wasn’t suturing a dead mans leg. So i sewed up his leg (don’t think the sutures will hold, and im pretty sure hel get an infection despite me almost coating the wound in betadine antiseptic). This whole situation although not unfamiliar to me was annoying me, and I actually surprised my self with how bloody annoyed I was becoming. Simple ABC was not being adhered. Bloody basic life support. All that was being cared about was the bloody gash on his leg. This man was pissing everywhere, so I suggested catheterising him. I was told, no point cause hel pull it out. Five minutes later I came to see him, he had vomited blood stained material. Mate, I felt for this guy, I really really really did. But I left it. I walked away. Nothing I could do or suggested was gonna change his management. The nurses all were saying, hel be fine. Hel be fine. I left it.

Later some guy who had had a stroke in 1984 came to see if I could help him and got really irritated with me when I said that he had his there was nothing we could give him medically to get the power backing his left arm and leg. I suggested some gentle rehab exercises(?) to maybe losen up his stiff limbs. He was fumming. Its really hard to explain anything to an angry Kenyan man and soI just let him rant.He ranted and left. I must admit I did utter moron under my breath, but the patients aren’t here aren’t like those in the Uk – they wont listen to any advice when they are angry, even with my patience and willing, they just want a quick fix and nothing and nobody can persuade them to other things.

Lastly, a man bought in his daughter to see me. She had ear swelling, an infection of the soft tissue. BUT HE WAS SO RUDE TO ME. He was def very educated and I totally knew he felt inferior to me and wanted to a male DR. Okay by now I was just frustrated and just told him that if he couldn’t work with me to help his daughter then he can just leave and il see her alone. I told him that politeness and cooperation is all that I ask, I didn’t care if he didn’t like me, cause frankly I didn’t like him but as I wanted the best for his daughter, I would like him to leave. He apologised and cooperated, prob shocked at my up blatant annoyance. One of the medical officers later told me that the man had asked him to apologise on his behalf for his behaviour,moron couldn’t even apologise to me face to face.

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