One of the biggest challenges I have found since being in Tanzania is being understood. I don’t know whether it’s my kiwi accent, or just the fact that what I am asking is so foreign that any question I ask is assumed and the answer I receive may be something entirely different to what I am expecting. Either way, it usually takes about five attempts of going back and forth before I get a reply that is only slightly on par with what I want. When at all possible I will speak what very little Swahili I know – thanks to my iPhone app and help from my host family my vocabulary is now approximately 30 words! But even then, that can create more hassle than it is worth, as it will be assumed you are fluent and from then on in the conversation is almost exclusively Swahili. At this point I nod, smile and pretend to follow what’s going on. It seems the only place I am remotely understood is the hospital, where the language spoken is medical jargon, a truly universal language. That being said, I’m still completely out of my depth when it comes to tropical medicine. It is an area of medicine that is not taught to any great extent in NZ medical schools, mostly due to the extremely low incidence of tropical diseases that we would ever come across. So, my introduction to adult general medicine was somewhat like being thrown into a deep ocean and not being able to swim. My ward round on Day 1 went something like this:
Patient 1 – A middle-aged Maasai man with tuberculosis. The most fascinating part of his history was the fact he had 3 wives and 30 children (yes, 30 children!)
Patient 2 – A young man who upon being questioned by the doctor as to why he was in hospital, responded with “Doctor, it is because I have no blood”. We never did get to the bottom of his true complaint, let alone make a diagnosis.
Patient 3 – a 29yo male with alcohol-induced liver disease and renal failure. He thought that abstinence from alcohol was making him worse, thus resulting in his admission to hospital. In part he was entirely correct, as he was suffering with alcohol withdrawal. However, in terms of his liver damage, that was irreversible.
Patient 4 – A young HIV positive woman whose disease was at the stage where the virus had essentially diminished most of her CD4+ immune cells. She had recently started anti-retro viral medication, meaning her immune cells were beginning to recover, however this caused a massive widespread auto-immune attack of her body. She was semi-conscious and it was unknown whether she would survive the onslaught.
Patient 5 – A young 8yo boy with appendicitis, who had been symptomatic for 10 days but did not have easy access to the hospital so consequently suffered in an outlying village for many days. I’m not sure why the child was in the adult’s ward, and despite a request for urgent surgery it was 3 days before anything happened. Luckily the appendix didn’t rupture.
Patient 6 – A middle-aged woman with a blood sugar level of 30mmol/L (normal is 7-11mmol/L). Clearly they don’t have diabetic monitoring at home!
Patient 7 – An HIV positive woman with pulmonary tuberculosis who was non-compliant with her medication. This was of particular concern as she requested to be discharged, yet at home there were a couple of young children, to whom she posed a huge risk of transmitting Tb.
Patient 8 – A woman with typhoid fever – that is all I can report on as it was one of those ‘lost in translation’ moments on the ward round. I think I’ll do a google search.
Patient 9 – A known hypertensive woman in her 60s who was also non-compliant with her medication. She presented that morning with chest tightness and within 1 hour of reviewing her on the ward round, prior to her even making it for blood tests and a chest x-ray, she passed away.
And this was only the first of four rooms!
One thing that has struck me most since beginning my placement at St Elizabeth’s hospital is the reliance on a thorough history and physical examination of the patient. Consultants in NZ have often reinforced the importance of taking a good history and not forgetting to carefully examine the patient physically. Much of this lands on deaf ears to many of us, as we are all too familiar with the plethora of investigations available at our finger tips which will often provide the answers to allow us to formulate our diagnosis. But even the most basic investigations, which we take for granted, are not readily available in Tanzania. Liver function tests measure only 2 enzymes in Tanzania, yet in NZ we are provided with the results of 6 or more enzymes (which still confuse me!). Something as simple as a blood film can take over a day to return a result, meaning doctors must treat based on an assumed diagnosis, from what they have deduced from the history and examination. Not an easy task, especially when patients aren’t always specific with their details, nor are they willing to disclose certain information for fear of being judged by the doctor. And forget about getting a radiology report – interpretation of x-rays and ultrasounds is left the doctor in charge of that patient. If you’re the on call doctor you are left in charge of looking after the entire hospital afterhours – a thought that terrifies me!
I have spent a couple of hours this week teaching four visiting Tanzanian medical students who are doing a 1 month placement at St Elizabeth hospital. They are in their second and third years of study. Gaps in their knowledge are pointed out by the daily occurrence of quizzes by the general physician, much to the entertainment of many of the patients who listen so astutely to EVERYTHING the doctor says, regardless of whether it is relevant to them or not. As previously alluded to, privacy in this hospital is a luxury that could only be dreamed of so everybody knows everything about each other’s problems, medical history, last bowel motion and every other bodily function.
On Wednesday following the ward round I assisted a doctor with an antenatal and postnatal clinic. The clinic typically starts with a 1 hour education session – providing information to parents about appropriate care for their child. This is the first example of any health education imparted by doctors or nurses to patients that I have witnessed, which really surprised me. Even a small degree of health literacy amongst the Tanzanian population would go so far in preventing so many of the problems that are encountered and which cost so much in terms of human and financial resources. The number of people that lack knowledge in basic hand and food hygiene is incomprehensible. The clinic was attended by over 50 women, mostly without their husbands, and every single one of them was HIV positive! Worst still was the fact that many of the babies had been exposed to HIV during delivery meaning they too were infected. A sad reality of the state of antenatal care in Tanzania. As the entire clinic was in Swahili, the extent to which I could assist was limited to taking blood pressures and weighing the patients. A small but hopefully helpful contribution.
Tomorrow (Friday) I head to Dar es Salaam on a coach bus, a trip that is meant to take 10 hours. Only time will tell how long it will actually take. I am spending Saturday in Dar, before taking a 2 hour fast ferry to Zanzibar on Sunday morning. I fly back to Arusha on Tuesday evening, ready for 3 days of surgery. I plan to do nothing other than lie on the beach, soak up some Vitamin D and drink cocktails – a much needed respite from the craziness of St Elizabeth Hospital.
