Bedsiders

Every single patient admitted to St Francis has a “bedsider", usually a relative, who looks after them during their stay. If we are lucky the bedside will speak English and act as an interpreter, but this is rare in a poor rural area where very few residents have attended secondary school.

The bedsider performs basic tasks of caring for their patient, such as feeding and washing, leaving the nurses to take care of drugs and procedures. Almost all of the bedsiders are female – I didn’t really pay much attention to this in the female ward, but I really noticed it when I entered the male medical ward and discovered that most of its inhabitants were female bedsiders – about 3 for every male patient.

 There is a single male bedsider in the female medical ward at the moment. His wife is in with gross ascites due to liver cirrhosis, and has a hugely distended abdomen with about 25L of fluid. He helps her dress, helps her sit up, and washes her dishes. When one of the doctors drained some fluid from her abdomen, the hole from the drain kept leaking fluid, soaking through the gauze and running onto the floor. Her faithful bedsider took a mop and quietly mopped up the fluid which was running along the floor.

Thank God for bedsiders.

Taxis

As far as I can tell, taxis are local people who own a car and wish to make money from it. Perhaps they have special licences but it’s hard to tell. As you step out into a public place (like exiting an airport, crossing the border or getting off a mini-bus), you are immediately swamped with taxi drivers. The first one to grab your bag wins the fair, apparently, and so they all battle over the luggage.

Like the mini-buses, taxis usually only leave when they are full (hence all the guide books refer to “shared taxis” – there’s really no choice).

 Our mini-bus from Chipata to Katete, a 16-seat van, waited 2 hours before it left the bus station. For the last hour all the seats were full, but people kept coming along needing a ride, so the driver kept cramming passengers in. By the time we left there were 27 passengers on board, including 2 screaming babies. A colourful ride indeed.

EDIT: We hired a driver to take us to Chipata, a 90km trip to from Katete. On the way we were stopped by police and he was told of for “pirating”, or acting as a taxi illegally – they wanted him to paint his car blue to mark it as a real taxi. I’ve never seen a marked taxi, this is the first I’d heard of it. He had to pay a K54,000 fine (about $15) which I think was more of a bribe, before we were able to move on.

Medicine

I don’t know what I’d expected from rural Zambia, but the medicine here is really not too different from home. There is a lot of malaria and tuberculosis of course, and about 80% of the patients are HIV positive, but apart from that the common conditions are the same as home.

My friend and I are currently on the female medical ward “St Monica”. We have patients in with pneumonia, stroke patients, a woman with ascites from liver cirrhosis, a young woman with pericardial effusion, and a few with diarrhoea. I think the threshold for admission might be a little lower than home, because most patients live remotely and don’t have transport.

 

The ward setup is a lot different – you don’t get a private room unless you happen to be the only measles patient in the isolation ward. For most patients, the beds are lined up next to each other along the walls of the ward. There are screens for privacy during procedures such as lumbar puncture, catheterisation and pericardiocentesis (there have been two since we’ve arrived). Normal examinations are just done in front of everyone.

 

Apparently it is quite acceptable to discuss medical conditions in front of a large group, because traditional healers would have everybody in the same room in a circle, and they would go around discussing their ailments.

Similarly, the outpatients clinic is conducted in a small room with three or four doctors all working at once with different patients. There is a single examination bed behind a curtain, and two doctors will usually share a desk – one on each end. Privacy is not even optional, but nobody seems to mind.

Spare Tyres

Our taxi driver from Lilongwe airport manoeuvred between two cars which had been stopped by police on either side of the road. Curious, I asked him what was being checked.

“Licences. And these (tapping on his car’s registration sticker). And spare tyres.”

“Spare tyres?” I questioned

“Yes, if you do not have one, you get arrested. They say if you don’t like someone, you should steal his spare tyre”

Interesting, that people can ride on the back of trucks, our taxi didn’t have functional seatbelts, and many cars have massive cracks across their windscreens, and a spare tyre is the thing that could get you arrested.

That said, our driver from our accommodation in Lilongwe to the bus station carefully arranged my friend and I to keep all the weight off his completely flat tyre. Perhaps he was saving his spare for a police check.

Money

I always find foreign money something of a novelty. I took out some US dollars before the trip, which do not seem like “real money” at all. By the time I’d landed in Africa the notes had all crumpled and looked like they were about to fall apart.

I bought a coffee in Johannesburg airport – they happily accept US currency, but can only give change back in local money. I’m not sure how it worked out, but I paid $5US for my coffee and received 50c South African in change. I also discovered that the 50c was magnetic when I found it later stuck to my MP3 player.

Withdrawing some cash from an ATM in Lilongwe, Malawi, I was fascinated by the K500 notes (500 Malawi Kwacha), the largest denomination I’d ever seen ... until we crossed the border into Zambia and I withdrew K200,000 from my account (about $40AUD) and was rewarded with K50,000 notes. Amazing!

AFRICA!

I'm in Africa!!

My friend and I (well mostly my friend) have been organising a medical elective term in Zambia since early last year. She's been emailing, we've been researching and shopping, and on Saturday I even started packing - with the help of my boyfriend and his amazing tetris skills.

There wasn't much time to really prepare - we finished our Term 3 rotations on Friday and left the country on Monday, so it was a little bit hard to get excited as we frantically packed our bags.

Even on the plane, it was hard for reality to sink in. 6,000km trip to Kuala Lumpur followed by a 6-hour stopover (our plane was delayed by an extra hour). We slept on our backpacks in the airport and waited for our flight to Johannesburg, which was delayed by an hour, and then I slept for the 10-hour flight, only waking for meals and falling asleep by the time the tray was taken again. On the plus side, we arrived in the morning and I wasn't too jetlagged.

But now we're here in Katete, Zambia, staying at the St Francis Hospital and helping out as much as we can there. My friend and I are both on the female medical ward, "St Monica" for the time being because that's where the fewest medical students are. There are about 15 students at the hospital at the moment, mostly from England and the Netherlands, although most are leaving in a few weeks so we will probably move around the hospital to wherever we are needed most.

I'll try and share some of the stories here.

Infectious

Some might say that I'm taking my Infectious Diseases rotation a little too seriously. I turn up early for the morning ward rounds, I take many pages of notes, I gave a lunchtime presentation, and I know enough about the third cranial nerve anatomy to ask questions that stump the consultant (his fault, he made me look it up). I write in the progress notes, I examine patients, I participate in the team meetings, and I go and see consults.

Oh, and I have pneumonia.

I've been coming in every day with a hacking cough, making my presence felt throughout the hospital. I really should have stayed home, but nobody said that was okay, so I kept on coming in. Pretty dedicated, you might say.

But then I made a fatal error last week and went to a compulsory workshop without informing my supervisor.

The very next day, I was called in for a meeting with absolutely no warning and berated for my "disappointing lack of attendance". Had my supervisor told me off for spreading germs throughout the hospital, I would have understood. Had he focused on my appalling lack of knowledge of antibiotic use, that would have made sense. 

But he was disappointed in my attendance. 

So disappointed that he might just fail me.

Maybe I should cough louder so he knows I'm here.

Signs of Pain

How will you know when your older patients are in pain?

Will it be the classic head-in-hands posture?

The downcast expression?

The phrase, "I'm in pain?"

Will you recognise the signs?

Technique

Many of the patients seen by the Infectious Diseases team are IV drug users. As it turns out, injecting random substances into your veins is actually dangerous. Any bugs that you inject go via the venous system to the right side of the heart, where they can lodge and form vegetations on the heart valves. Once the vegetations become larger, they can affect blood flow, and also flick off to the lungs. From the lungs, apart from causing infections, they can wash to the left side of the heart, and from there … the rest of the body, even the brain.

We have patients with infective endocarditis (infections around the heart), infections in the brain, infections in the blood.

You’d think that Infectious Diseases doctors would be strongly against IV drug use, when patient after patient appears with serious infection, in need of IV antibiotics, with no veins available because they are all scarred and collapsed. What bothers the consultants the most?

“There’s no attempt at sterility at all”

Yes, the consultant is most annoyed about technique.

Last week we were called to see a lady with pus pouring out of her eye due to a bug commonly found in dirt. At first it looked like she’d injected with a dirty needle and the bacteria had entered the bloodstream. Later it emerged that, having ruined all of the veins she could find, including her jugular veins, this lady had injected into her eyeball. Straight in. Turns out the bacteria was just a contaminant on the swab, and most of the damage was done from the chemicals in the drug. I think the eye is being removed this week.

How’s that for technique?

Tests

"With a hammer in your hand, everything's a nail isn't it?" - Infectious Diseases consultant after the Endocrine registrar ordered a variety of (endocrine) tests on a patient with septic shock.

The Library Museum

Perhaps indicative of a shift towards electronic references, the bookshelves in the Infectious Diseases office are stacked full of dusty, outdated textbooks. Titles such as "The Quinolones" from 1986, "The New Generation of Quinolones" from 1990, a cassette tape about Hepatitis B, and "Current Chemotherapy" from 1977 line the shelves. Until a 2010 White Pages appeared, the 1996 street directory was the newest book in the room. It's like a tiny little museum.

Like Pulling Teeth

People cringe and shudder when I tell them I had all four of my wisdom teeth out on Friday. In the chair, as opposed to under general anaesthetic in the operating theatre. I was a bit trepidatious at first too, having sat with my sister while she had hers removed a few years ago. I still remember the crunching sounds.

Now that I am officially in the aftermath of the whole operation, I believe I can safely say that the most painful part was getting the dexamethasone injection to the arm. Of course I'm very glad I got it - it stopped me from getting a giant swollen "chipmunk face" after the operation. And it only hurt as it was being injected ... and for a few minutes afterwards - but as my Dad always says, "it'll stop hurting once the pain goes". Surprisingly, it was even more painful than the local anaesthetic which had to be pushed in through the bone of the lower jaw.

If you're already a little squeamish, I suggest you stop reading now. The following passage contains graphic details of an operation that I technically didn't see or feel.

- insert transition music here -

Like any surgeon, the dentist wants to get the operation over and done with as soon as possible. He lets the anaesthetic work its magic, and then says, "Ok I'm just going to push" as he slices the gum with his scalpel. Grabbing the tooth with his pliers, he gives it a knock, and with a quick crunch the tooth is separated from the jaw.

My tongue is almost completely numb with anaesthetic, but I have mild shooting pins and needles and I am convinced I can feel arterial blood spurting onto my tongue. The assistant passes some gauze and it is packed against my bleeding gum. "That came out easily" she says, and indeed it did.

The dentist pulls out the top two first and then moves on to the bottom teeth, which he says are usually more difficult. He has approximately ten million years of experience (he's been my dentist my whole life), and as it turns out, he is right. 

The first of the lower teeth comes out easily enough, but the final tooth clings to the lower jaw and does not want to leave. Blood begins to pool in the back of my mouth - so much that the assistant has to switch the suction device to a larger one - as he cuts, pulls, wiggles, drills and taps at the tooth and gum. I request to spit, but he tells me that I can't spit straight and that I should just breathe through my nose and let the assistant suction out the blood. I tell him that I can feel him moving the tooth around, and start freaking out that I'll feel the excruciating pain of the nerve being torn when the tooth finally lets go. He tells me to "hang in there" because it's nearly over.

And finally, it is over. I'm allowed to sit up, and start drooling blood into an emesis bag that my boyfriend thoughtfully brought along. The dentist was right - with my tongue and lower lip completely numb, spitting is a challenge that for the moment is beyond me.

I am convinced that I am going to bite my giant, swollen lower lip. I am convinced that my face is distorted beyond recognition. I try to convey these thoughts to the dentist and my boyfriend, but they just laugh. They are mostly laughing at my speech - with my tongue and lip anaesthetised I am not particularly articulate. The dentist shows me a mirror so that I can see my completely normal-looking face.

Well ... normal apart from the blood around my mouth. And the blood in my teeth. And the blood that is coating my tongue. I mop it all up as best I can with tissues, and am sent on my way with scripts and recovery instructions.

My sister leaves work early to pick us up. She wants me to talk so that she can laugh at my numb blabbering, but at the same time keeps freaking out at the blood that keeps appearing on my teeth. In the end she overcomes her squeamishness, and her and my boyfriend make fun of me for several hours until the anaesthetic wears off and I can speak normally again.

Recovery has been surprisingly uneventful. I can eat normal food, I can talk normally and I'm not in any significant pain. Much, much better than I'd expected.

One Track Mind

Me, catching a bus to the city: "One student ticket please"

Bus driver: "I'm not going up to the university!"

Me, "No - you're going to the city"

Bus driver, "Oh. Well, yes"

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How to: not get sued

One interesting tidbit that came out of last week's Patient Safety Workshop was a handy guide to "which doctors are likely to get sued".

Apart from the fact that male doctors get sued much, much more often and for much, much more money than female doctors, here are a few of the factors that influence whether or not your patients will sue you:

Doctors who are "late, rude, inattentive, poor/non-communicators, and apathetic" are more likely to get sued.

Doctors who ask questions, laugh with their patients, explain everything, and allow sufficient time for a consult are less likely to get sued. It also helps to be honest and apologise if you do make a mistake, and not just hand the patient to a different doctor.

As one GP told me last year, "if your patients like you, you have to do lots of things wrong before they will sue you".

So now the question is, should we spend more time learning how to be nice, or how to be competent? Or should the less likeable amongst us be trying even harder at med school?

I'm on the wards!

Clinical Pharmacology term is over, Infectious Diseases term has started, which means ... I'm back on the wards! And back amongst all the craziness that will appear if you just see enough humans in one day.

Standing at the nurses' station writing in patient notes yesterday, I observed a patient in a wheelchair zooming along at an alarming rate using just his one arm and one leg to propel himself.

After a few laps, as his anxious face started to become red and shiny with exertion, the nurses began to question him. As he flew past he explained breathlessly, "I've put on a kilo in one day! I have to get it off!"

And therein lies the danger of the Daily Weigh.

Save the ... car?

I almost sold my car this week. Pulling out of a multi-story carpark, I was stopped by a middle-aged man in his tradie ute. 

"How much?" he asked.

I gave him a funny look as I tried to come up with an answer - I couldn't recite the carpark's hourly fee.

"How much FOR YOUR CAR?" he rephrased

I explained that it wasn't for sale.

"Change your mind?" he asked, pointing at the signs in my back window.

I tried explaining, but after several minutes I had to physically pull down the signs so he could read them ...

How to: put your audience offside

Assume they're going to be rude and inattentive, and immediately get defensive and try to counteract it. 

Try saying something like, "I respect your experience and knowledge, and all I ask is for you all to do the same for me please. Thank you."

It should take a good ten minutes before they look at you with anything but resentment.

Mission accomplished!

Patient Safety Workshop

One third of the Year 4 class wasted their entire Thursday at a 'Patient Safety Workshop' - the other 2/3 will do the session later in the year. I also wasted my Wednesday doing the pre-readings and answering thought-provoking questions such as "What are the potential holes in the Swiss cheese?"

Today we sat through lectures, watched videos, split into groups and brainstormed, and wrote on whiteboards. On the plus side, some parts were quite entertaining, it was good to see classmates, and we got morning tea and lunch. But overall it was quite long and tedious and could have been summed up with, "Do your best, but we're only human and we need systems and protocols for the protection of ... well, everybody".

However, I wouldn't have liked to miss the first video. Picture this: a stressed ED doctor had just hung up the phone - "it's not good enough, really. It's -really- not good enough" because the lab had lost some blood samples. In sauntered the ED nurse who got in nice and close to him, flirted briefly and then asked suggestively, "is there anything I can do to help?"

At this point, about 30% of the group was convinced we were about to watch porn.

Highlight of the day.

Journal Club

It was my turn to present an article at the Clinical Pharmacology Journal Club yesterday. This was something I took very seriously and I spent hours analysing my chosen article and working on my Powerpoint presentation. I also prepared a batch of delicious biscuits to bribe my audience into listening attentively.

In hindsight, I probably shouldn't have chosen a review article about a drug  that was written by someone on the payroll of the drug company. And I could have found a more reputable journal than "Swiss Medical Weekly" which, I think, is only published online. But it gave me plenty to talk about, I learned a little about dronedarone (an amiodarone derivative that is less effective but less toxic - unless you count the liver damage), and now everybody has heard of a journal called Swiss Medical Weekly. 

So we all learned something.

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Let's get medical ...

You might be wondering about the lack of medicine-related posts on here. Just to scan through, it would appear that I have switched my priorities to politics, and that's not good for anyone. 

Yes, I am still studying medicine, and my faithful pink stethoscope tags along with me every day. It's just that ... well, I'm doing a Clinical Pharmacology term, and whilst nobody can truly claim to know what Clinical Pharmacologists do, one thing they don't do is see patients. And seeing patients is where all the best stories come from.

No wait, I remember, we did see a patient today. We ventured down to Intensive Care because we'd heard that a patient there had a high Vancomycin level. The levels should be between 15-20 - below 15 the antibiotic is ineffective, and above 20 it starts to become toxic to the body. This man had a level of above 60. After standing at the foot of his bed and staring at his chart, we established that he'd been given a dose last night when it should have been withheld. 

My supervisor chatted briefly with his treating doctor, and then we went for coffee.

Good story.