paediatrics

56 children, 20 new admissions, 1 death. The paediatric ward on Monday. So it was a bit hectic. They’re short staffed on the ward with one or two nurses dealing with all the patients and medication. The sister running the ward is one of these people who are just amazing. Incidentally, it turns out she spent about 5 years in Scotland-in Thurso and in the Borders. Malaria and anaemia are the vast majority of cases with pneumonia, bilharzia, TB and HIV related problems making up the rest. Two oxygen concentrators sit in the corner of the room with the illest wee ones attached. Sometimes newborns in need of oxygen join the ward as there’s no oxygen in maternity, they’re a bit like sardines all wrapped up in chitenges in the one resussitaion trolley. I think the record for most babies at one time is 5.

When I started on Monday, the intern clinical officer was also new so we had fun and games trying to do the ward round whilst trying to remember all the drug doses the senior clinical officer had reeled off before he headed to theatre. The good thing is most children come in very sick and over a day or two they’re back to what seems like their usual selves. The hardest part is, not surprisingly the deaths. 6 weeks on paediatrics at home and I witnessed no deaths, 1 day here and I witness 2, both of which would probably not have happened at home. Life’s crap. The first one was a little boy of almost a year, who had been on the ward for about a week in respiratory distress and appeared to have a pneumonia resistant to a whole host of antibiotics (I’m still getting to grips with what they use here-not that I really know what they use at home if I think about it. According to the BNF, chloramphenicol is only to be used as a last resort due to severe haematological side effects but here they use it left, right and centre and sing it’s praises so I never quite know what’s going on). Just as they were considering starting TB treatment and as I was attempting to sort a clogged up drip in the next bed, his mother shouted and when I went over he was unresponsive, pulse gone, not breathing. I don’t think I’ve ever felt so clueless and useless. We dug out the bag and mask and started chest compressions but I guess it was never going to work. He passed away. The second was a tiny 1 year old weighing 5 kg who had a oxygen saturation of 30% at 8.50am and at 9am she gave up the ghost. Just too much work for one little soul. Survival of the fittest without a doubt but when you weigh less then half of what you’re supposed to the odds are stacked against you.

Discharging home lots of happy healthy children was a relief after that morning. Unfortunately, the time when malnutrition becomes most apparent is beginning and with malaria season too it’s tough for these kiddos. They all have little books called health passports where everything is recorded so we plot their growth, check on vaccinations, vitamin A and mosquito nets. Apparently, lots of people use their free mosquito net for catching birds or fishing. And the men are reluctant to sleep under a net for fear of decreasing their fertility. I guess the later is difficult to prove either way. (I’ve just killed three mosquitos whilst I’m typing this-so strangely satisfying.)

Putting up drips is another thing which takes up a large part of the time on the ward. As all malaria cases get IV quinine to start with. Yesterday, I had a day of spurting body fluids. First one kiddo yanked out their cannula followed by a shot of blood, then I over enthusiastically flushed a cannula which was blocked and landed up with a polka dot white coat for the rest of the day. Lastly, as nappies are either non exsistent or chitenges it was only going to be a matter of time before I encountered a wet puddle forming at my feet. Delightful. Today was more successful on the body fluid front.

So I think I’ll be on paediatrics for the next 3 weeks or so then perhaps a little bit of general medicine before I head back. In one day, I go from thinking I’d love to work in Malawi to being so frustrated at what I’d never be able to do, I just want to leave. (usually when I’m stuck to a child by elastoplast that sticks to everything you don't want it to as I try to put in a cannula without pulling it out again, wishing I could have those nice peel-off-the-back venflon plasters. The small things I guess.) The usual indecisiveness, nothing new there.

Well, that’s another week almost gone. I spent most of it in the Eye Hospital which has turned out to be really interesting. Twice a week they run Mobile Eye Clinics which cover up to 200km away form Nkhoma north and south. So on Wednesday I went along with the group who were heading towards Mangochi, a town on the edge of the lake. We left at 4.30am with the patients who had received surgery on the Monday. These patients were dropped off and then we headed to do the rounds of 4 clinics. Each one was held in a school building, somewhere accessible to large numbers of people (apparently less accessible to a vehicle-down dirt tracks which had nasty steep bits when I was convinced I was going out the windscreen), and each had about 50-60 people waiting to be seen when we arrived there. One of the medical assistants, a nurse and a driver go plus an ophthalmoscope and a box of eye drops and cream. And they work non stop. I was just about dead. There’s lots of allergic eyes, I guess like hayfever, lots of cataracts, glaucoma (sad, as usually in the late stages when the patient has lost much of their vision already), pterygium (I’d never seen these before but they’re common here-growths of the conjunctiva) and uveitis. So anybody they can treat on the spot is treated and anyone who’s a potential candidate for surgery is taken back to Nkhoma in the landrover (it takes about 18 patients plus the staff). After they’ve done the round with the clinics, the next week’s clinics are arranged by speaking with the T/A (traditional authority) for the area who then agrees to the clinic being held, finds a venue and publises in the area. By the time, this was all sorted, it was about 6pm and we were somewhere near the Mozambique border (I’d lost all sense of direction by this time) which meant a long journey back in the dark. Someone also decided to buy fish since we were close to the lake which smelt just great. Cars don’t seem to do the whole dipping headlights thing so just blind everyone in the opposite direction. That’s if they have lights at all. They indicate to the right to let you know here the edge of their vehicle is, kinda good thinking when it’s a whooping great truck taking up most of the road. I was glad I slept most of the way back. At 11pm we arrived back at Nkhoma. I was knackered but it’s all in a days work for the Eye Hospital Staff. Then Thursday we saw all the patients in clinic in the morning and most had surgery that afternoon. Unfortunately some of them are not suitable for surgery and just have to go home empty handed but mostly there seems to be lots of happy seeing patients to go home again on the Saturday.

So tomorrow, I’m going to go off again with them before starting paeds on Monday.

They operate here on Tuesday’s and Thursday’s for elective lists doing prostatectomies, tubal ligations as part of family planning (these are free for women, so they do them only under local anaesthetic in the skin where they make the incision. It must be far from comfortable.), laparotomies, hernia repairs and Vesico-vaginal fistula repairs. I’ve only seen general anaesthetic being used once with the super laid back practically horizontal anaesthetist who remains totally unconcerned even if the patient oxygen sats keep dropping to below 80%, the patient is waking up in the middle of surgery or if I’ve given a bit too much ketamine. I think when he’s worried then we’re all doomed. Otherwise they use local anaesthetic-spinals for the most part. Patient’s are very uncomplaining and ladies in labour are mostly silent. In fact they’re told to be quiet. I’d be giving the doctors a good whack if they told me to keep quiet in the throws of labour thank you very much. Though things are in short supply there are always plenty of gloves and sterile needles etc but they use much less disposable things. For example gowns, drapes, suction machines are all washed and reused. The best part of theatre here are the stunning, very flattering scrub dresses which women wear. There are trousers but to avoid exposing those thighs which would imply all sorts of associations with promiscuity dresses are a must. Also needed is a petticoat. I should have known better. I thought they were pretty darn opaque these dresses but the theatre sister discretely told me to take one with me next time. Who’d of thought legs could cause so much trouble. Mind you no one cares what so ever about your top half. So I hope now I’m not offending anyone with my scandalous dressing. My thighs are safely tucked away.

the first

As you can tell from the total lack of posts the internet is a bit fickle here. The room is only open during the week a for a couple of hours in the morning then closes for lunch then opens for another couple of hours in the afternoon, then between the internet not working at all, being v slow and the power out it’s tricky.

But I’m determined to get something up here since it’s been over 2 weeks since I left.

So, here goes.

I eased myself in slowly by spending my first weekend at the lake. A wee group who were already at the hospital were going so I took the chance to join them, forgetting that it would be hotter at the lake than it was here at Nkhoma so I baked nicely for 2 days then got back to the hospital and found the temperature pretty comfortable.

It’s threatening to rain big time just now so I’m hoping I make it to the market without getting soaked-I don’t appear to have packed anything waterproof. The hospital is on the side of a hill, maybe over-ambitiously called Nkhoma Mountain, with a sprawling village surrounding it. It’s an old mission place so there’s an active CCAP church, which I think is something akin to the church of Scotland but don’t quote me on that, and several old colonial style houses where the ex pat doctors live as far as I can tell. The guesthouse, another old colonial looking place, where I stay is just 2 mins away from the hospital so no excuses for being late in the morning. At the moment there are 2 nurses, a doctor and another medical student there. German, Dutch, American and me.

There’s the children ward, male and female general medical wards, surgical ward, TB isolation ward (right up top, all too easy to forget to see the patients there on ward rounds), an outpatient department, maternity and the eye hospital. Oh and not to forget the Casualty room and the physiotherapy room with no physiotherapist.

This week I’m in the Eye Hospital where they do lots of cataract surgery, some glaucoma operations and other bits and bobs. The whole eye hospital is run separately by 2 ophthalmologists, an eccentric older man in a world of his own and a younger one who listens to the Manic Street Preachers on repeat whilst doing surgery. Between them though they’ve almost done 4000 cataract operations this year alone and have implemented training programme for the suture-less cataract surgery they perform. It’s kinda of like a production line but a very effective one that’s literally life changing overnight for the patients. Most have pretty severe cataracts with vision limited to seeing hand movements or perception of light only. They line the patients up outside with dots over the eye to be operated on and give the local anaesthetic. There’s 4 beds in the theatre so while 2 are having surgery, 2 are ready in place scrubbed up so they do about 20 ops in 2-3hours. They collect the patients at mobile clinics which go up to 200km away and some come over from Mozambique too. Tomorrow I’m going to hopefully join them at the totally absurd hour of half past four in the morning to go to Mangochi, a town near the lake, and see it in action.

Hmm, ok I think that’s enough for just now. It hasn’t rained yet so I’m going to chance it and make a dash for the market-I’m loving the mangos but after having beans 3 nights on the trot I think a break is in order.