Mango mania

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June 8th 2013
Published: June 8th 2013
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Dear All,

A very warm and wet hello from Masanga. The rain falls very heavily for a very short period, so we have just been outside under the gutter, filling up all our buckets. The mangos have been raining down on the tin roof and now the rain has stopped, the kids are out looking for them. I have even baked my first mango crumble in our new Gas oven, which has now run out of gas, as has the nearest town….

I've been into work this morning and already sewn up two kids with mango picking related injuries.... We have been here for 6 weeks now and the time seems to have flown by. Thank you, as ever, to those who have been in touch. It is always great to hear from home, and when Jo can magic some interweb access, it makes us smile to hear what you are up to. I know that Jo did a blog entry recently, but for the medically inclined, I thought I would delve a little deeper into my new found realms of diagnostic ineptitude and constant confusion. In order to be a confident and fully functioning independent doctor in
Emergency doctor's waiting roomEmergency doctor's waiting roomEmergency doctor's waiting room

Kids with knives, poles, rocks.....they really want those mangos!
a third world setting, I have realised that one should have the capability of an obstetric registrar ( the commonest procedures being C- sections, uterine repair and hysterectomies) a general surgical registrar ( laparotomies with the capability to resect bowel and amputate ) and a half competent paediatrician. I am unfortunately none of the aforementioned so exist in a constant haze of being slightly out my comfort zone, except when it comes to lacerations and broken wrists from falling out of mango trees…

The two Dutch doctors with whom I am working have undergone a specific tropical medicine training consisting of a year of Obstetrics and Gynaecology, a year of general surgery and six months of paeds, but with a much more focused goal of being independently surgically competent at the end of it. Having said all that though, the bulk of the patients are not surgical emergencies, and being an emergency physician in the UK has proved to be a pretty good grounding for the plethora of very sick infants, children falling out of mango trees, teenagers falling off motorbikes, and adults presenting with abdominal pain, ascites, heart failure and TB/HIV in all its various guises that seem to be the bulk of my daily work. I came out here wondering whether I would need to don my theatre gown and spend long hours pouring over the contents of abdomens, but fortunately for everyone, that has not been the case. African obstetrics, in my limited experience is rarely straightforward and rarely has only one problem and the events of last night were typical of an evening on call here.....apologies if the following is a bit medical.

A woman, gravida 6, para 5, alive 3 ( they have the extra bit of information here) presented with a 12 hour history of labour pain, so I duly donned my beginners obstetric hat, and was alarmed to find that she was measuring 47cm, was possibly 4 weeks post term according to her ante natal record, had a BP of 190/120 with no foetal heartbeat, 3/5 head still palpable in the abdomen, and only 7cm dilated after 12 hours of labour pains in a grand multip. She had been given two "pepper" injections IM ( 20 units oxytocin) which is usually the surest way to kill a foetus and rupture a uterus ( 5 last weekend...). She was stable but I
Mr education, our watchman.Mr education, our watchman.Mr education, our watchman.

Note leprotic hands.....
thought this a suitable case to involve Dr Josien. She too could not hear a foetal heartbeat with the handheld Doppler, but being very sensible, sent for the man to put the generator on so that we could confirm Intrauterine death with the USS. The generator goes off after 10 pm... so in order to restart it I had to drive into the village with a nurse who knew which house the generator man lived in, wake him up and then drive him back. Cue some surprise when we found a foetal heart beating well, and the possibility of twins, which is never as easy to tell as it should be..... A C section followed, with an APGAR 1 baby appearing. As the cleaner did CPR and I ventilated, the second, smaller twin duly arrived, also APGAR 1. Another pair of hands appeared to do CPR as I ventilated both, and to my delight and surprise, they both pinked up and started crying in unison, a baby boy and his little sister. Meanwhile, cue a massive PPH from a completely atonic, floppy, multiparous uterus, resistant to medical therapy. I handed over the twins to a very surprised grandmother outside the theatre ( the fathers never come to hospital for a birth) as Josien tied a B lynch suture. Having been involved in a fair few obstetric and neonatal tragedies already, I was ashamed to think that it would be typically African if the twins survived and the mother died after the initial thinking that this would be a CS for a dead foetus. And where was that blood? The forte of Masanga is usually the ability to get blood donated from a relative and into the patient with great haste ( there is only a very limited blood bank, and if the relative is not compatible, they still have to donate a unit to replenish the blood bank). The lab man had been sent for, but had not yet appeared, so we hoped that the bleeding would stop and her BP would hold until the blood arrived. It did, and they were all fine, except possibly the grandmother...….

A fellow Pymouth ED reg established the Emergency Admissions Unit in January, and the EAU is developing nicely into something resembling an emergency department and a high dependency unit. The concept of new arrivals to the hospital being seen in the same place, and moving the sickest patients to the area that has the monitor (!) is slowly sinking in and the days of sick patients residing in dark corners of surgical wards has hopefully gone. There are, however, many challenges, not including lack of running water, electricity and medications..... We have a staff meeting every morning at 0815, which is always an entertaining affair, as the style of presenting cases keeps me, as the " senior" doctor my toes. "Aminata Kamara, aged 25, from Magburaka presented last night with abdominal pain, chest pain, nausea, vaginal discharge, headache, back pain and a mass in the abdomen". My mind is now racing, what an unusual set of symptoms, whatever could it be....."The pain was severe and she was screaming. The vital signs were heart rate 110, respiration 32, BP 110/76 sats 98% on air. We sent blood for Hb and cross match, and malaria test. We treated here with paracetamol and an intravenous infusion". I still have no idea where this one is going. "The pain became worse and she then gave birth to a healthy baby boy"...…

Some cases remain a mystery. " Abdul Bangura came with abdominal pain and vomiting of blood. I started a drip but he died." We have some interesting discussions, the main frustration being that we never really know what the diagnosis was, and I have had a few teenage arrests which were unexpected as well as paediatric deaths which we think were, for example cyanotic heart disease, but we will never know. The teaching sessions are always interesting as we try to learn from these cases. Then I do the ward round on EAU seeing the newest/ sickest patients (hopefully). There are three student CHOs ( community health officers, the equivalent of a doctor) currently in Masanga, so I have been adopted as their teacher. I usually make it home for lunch with Jo, before outpatients in the afternoon which is the really weird and wonderful lumps, growths and ulcers that the patient has finally decided to have looked at. Then back to EAU to review the new admissions/ sick post op patients. The days fly by, and now that we have moved into a " doctors house" , we cook in the evenings and enjoy the electricity when it is on between 7 pm and 10 pm, with bedtime being heralded by the lights going out! Our little treat has been a box set on the laptop, I can recommend "The Killing!"

Jo and I are on the management committee for the hospital, which consists of the matron, head of logistics, head of maintenance and the other doctors. Some of the human resource issues are quite entertaining and we had to fire a nursing aid this week for disrespecting authority, the complete story of which was regaled by the matron in approximately 35 minutes. The shortest meeting has so far been two and a quarter hours... We approved a request that the men who run the generator at night should be provided with raincoats and boots, which seemed reasonable, as they are outside a lot, and it does rain a lot. At the next meeting we were told that all the other on call staff wanted the same, even those who work predominantly indoors, the reasoning being that they still had to get to work, possibly in the rain. I, obviously (!), had the point of view that this was a ridiculous proposition and would lead to more requests for this but the matron and other local staff thought it entirely appropriate, stating that salaries for nurses, at $1 per day, are very low, when a raincoat costs $6. Jo, as ever, solved the problem and avoided the purchasing of 40 or 50 raincoats, with a suggestion to buy 10 umbrellas, for communal use, so we will see how this master idea pans out….

Jo's physio aid training is going well and she is clinically very busy. Her course has been approved by the local College, and is now an officially recognised Certificate of Rehabilitation, which paves the way for future visiting physios to run repeat courses. Not a bad legacy! I have also somehow inherited overview of pharmacy and logistics, which is a posh way of saying that when things run out, it is my fault. I am learning that there is a massive difference between ordering drugs and drugs actually being supplied, being in the pharmacy as opposed to the store, let alone being in the drug cupboard in the EAU.....Having met with the chief pharmacist at 10am one day to be told that we were well supplied currently with no immediate shortages ( we just purchased two months supply, or so I thought....) by 2pm there was an a severe laryngospasm caused by secretions from ketamine, which are normally dried by atropine, but we had run out of atropine two weeks ago and none had arrived in the newly purchased drugs, by 4pm we were cancelling operations because there was no ketamine and by 5pm there was no glucose in the hospital and mothers of hypoglycaemic babies were going into the village to buy sugar to be given via NG tube!

However, we are really enjoying the work and the simple lifestyle. No running water and no electricity for most of the day is second nature now. Falling asleep to the sounds of the jungle going on around us in a house with no windows only mesh, and listening to the tropical storms sweeping through is exhilarating. It goes without saying that should anyone fancy a visit to the tropics to coincide with the rainy season, they would be more than welcome, and there is probably a very useful job they could fulfil. Accommodation provided! Jo is going on National radio this week to do a 1 minute advert for a management post she has been asked to recruit for. It will be played three times a day for a week, so that almost makes her a celebrity! Applicants are to reply to jdpafrica@ so we eagerly await the replies….

We are looking forward to a weekend off in Freetown, where we will be initiated into the ex- pat waterpolo club on Saturday before staying on the British consulate's private beach. Apparently there is Lions tour on too.....the stuff of dreams! Jo ran her first half marathon last week, the second ever Sierra Leone event, held in our nearest town, Makeni. She did really well on her debut at this distance and is already looking at the monrovia marathon.....There were over a hundred Oportos' (Krio for white person, literally meaning Portuguese from back in the 1400s when the Portuguese were in charge) and after the race we tried to sell them the Masanga bags made out of bicycle inner tubes, one of the business ventures run to raise funds for the hospital. Apparently, being tired and hot is not a great time to be interested in buying bags….!

Most of the medical photos were deemed inappropriate to put on a blog, so apologies if the photos are not as spectacular as the mountain/ desert/ jungle ones that preceded! Love to all, keep in touch x .

Additional photos below
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Two for one with the little ones

9th June 2013

Crying reading twins story x
Well done Jo for half marathon! Dr Dave what an insight keep the stories coming all so fascinating x Jo I saw your Mum she seemed very well. Lots of love to you both Dawn x
11th June 2013

We are so enjoying your blogs - a vicarious enjoyment. Jo's propensity to influence all and sundry so you both stay safe (you should make an ad for Coca Cola!); David, your obvious enjoyment in tackling every new situation that occurs - and winning! And here in NZ we sit out the winter (Doug managing a new week old hip) and me so envious of your adventuring. Keep the blogs coming (when the generator is going) and thank you. PS Of course the generator men need coats and boots! Good decision! :)
11th June 2013

Also crying reading the twins story!!
Hi to you both - firstly we are loving reading your blogs. Each time one comes al & I sit & read it together, they are truly amazing & inspirational. I thought it was only me that would have cried when reading about the twins, being such a softy anyway & with the maternal hormones raging with only 6 weeks to go, so I was pleased to see that I am not alone!!! Things here are hectic and I really don\'t know where the last 34 weeks have gone, we seem to have so much to do before the baby arrives, but I\'m sure it will get done. We decided to get Zachary into a proper big boy bed before the baby comes, which has gone better than I imagined but he\'s woken at least once a night for the last week so feels like the sleepless nights has already begun!
17th June 2013

Well done
Great to hear of your work and that you have both been able to engage in teaching so that when you move on you will leave better prepared local staff. Jo, what a stroke of luck that the Danish physio had done some great preparatory work so that you could concentrate on teaching and making things even better. David, I do not envy you the steamy heat, the night work and the constant lack of diagnostic tools and medicines .... yet even small interventions can make great differences in outcome and again great that you have keen medical assistants wanting to learn. So this side we must keep the pressure up on Government to ring fence Foreign aid and keep at at 0.7% GNP like Holland and the Scandinavians.
18th June 2013

Impressive stuff..
Hi Guys Sounds very impressive. Great stuff. Got a bit lost in the medical jargon, but still thoroughly enjoying the updates. Afraid we're not going to make it up to you guys. Heading back from here (SA) to catch up with the Tour de France for a few weeks before getting back to Brizzle life. But look forward to catching up and sharing travelling stories when you're back! Love / many hugs, Tom (and Amanda)
11th August 2013

What an inspiring blog! You guys are doing such incredible work out there - well done! So, the weather has been lovely in sunny Jersey so we have been making the most of it. We went for a two-hour surf this morning in St Ouen's Bay, which was fantastic. And we have been running and then swimming in the sea at St Brelade's Bay. Ian has had plenty of work since he set up his business at the start of the year and I have been stuck in a court trial all week of a man accused of a grave and criminal assault. due to finish on monday, thank god. all wedding plans seem to be going well, but sure it will get stressful closer to the time. you look amazing in your wedding dress Jo. look after yourselves and keep up the good work!! Love jo and ian xx

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