On Sunday, our little family got a little bigger. The beautiful Neriah Grace Lowry came into the world at 7:30pm. Just like Joen, the journey to Neriah was hard work.

Once again, thanks to everyone who followed the blow-by-blow account on twitter – read it here - including at least two people over the age of 80. Who says social media is just for young people? Anyway, enough of that, on with the story…

I’m currently working in Lincoln, around 1-2 hours from our home in Boston, and in the month preceding labour, Katherine seemed to enjoy sending me texts containing phrases like “baby’s coming!”. I would frantically call her, where she would explain that she simply meant “at some point”, so she was tidying the house in preparation. By my estimate, I had at least 4 heart attacks in January because of communication like this.

On Friday, my parents-in-law came up to help look after Joen. I have successfully not thrown milk at either of them, which is a significant improvement over last time! It was brilliant to have them around so Joen could get used to them before we disappeared to the hospital.

Just like last time, we sailed past the due date (15th January), and ended up going into labour a few days before we were booked for induction. On Saturday at 4pm-ish, Katherine started to have her first sporadic contractions. By 7pm, they had become regular and painful.

12 hours later, there was very little progress. Lots of pain, but no progress.

At half 8, they were down to every 2 minutes, and rather intense. We rang the hospital, who advised us to come in. I was a little hesitant to do this, since last time she’d had similar symptoms for 10 hours+, but was only 3cm dilated when we made it in to hospital. However, deciding it was for the best, we threw everything into the car and scurried over to the labour ward.

As the tweet below shows, I was right not to be too keen:

From this point until 10:30am – about 12 hours later, there was very little progress. Lots of pain, but no progress. One midwife thought she was up to 4cm, but on re-examination 5 hours later, a different midwife felt that this couldn’t be the case.

They decided to break her waters at 11, which really kicked things off - she had 12 very painful contractions in the space of 30 minutes. She soon ran out of relief from the gas and air, and was given her first dose of morphine.

By 3, the morphine was wearing off, and Katherine decided she wanted an epidural. Unfortunately, the anaesthetists were busy in theatre, and I was going a little bit frantic in wanting to sort her pain. Given that I currently work in palliative care, where I am comfortable prescribing piles of opiates every day, it was so frustrating not being able to hurry up her analgesia.

They eventually gave her some more morphine at 5pm, just an hour and a half after I had suggested it, and she was finally able to settle down a little. The contractions had been going steadily for hours now, and she had dilated to 9.5cm!

It was at this point that a light of rage appeared in Katherine’s eyes.

At 5:50, 10cm was reached, and Katherine began to push. I will open myself up for criticism here and say that I don’t think was really pushing that hard at first. We hit an hour of pushing with no baby, and the Registrar doctor came in, and told us that she was going to have to use forceps as the pushing was going on for too long.

It was at this point that a light of rage appeared in Katherine’s eyes. Given a 15 minute reprieve, and spurred on by the midwife, “Come on Katherine, we don’t need forceps!”, Katherine began to push like a successful Sisyphus. After just 3 more contractions, there was a screaming head sticking out of my wife, and just one more later and our beautiful daughter was released into the world.

Although disappointed not to use her shiny tongs, the doctor seemed happy enough getting to play with needles and thread, sorting out the second degree perineal tear, and even found time to quiz me on the theory of Obstetrics – I will be working under this registrar in April!

We were both fairly oblivious to this, since there was a disgusting, blood covered angel dripping on us, and looking into our eyes. Glorious!

Six hours sleep, and the clocks going back, brought us to our final day at the conference. Following a prayer meeting, discussions over breakfast involved a fairly detailed discussion of New Zealand humour, and a discovery of a fellow Black Sheep lover in Pete Saunders!

Seminar - A challenge to care: the Christian doctor as leader in the ever-changing NHS

Nick Land, the Medical Director for Tees Esk and Wear Valleys NHS Foundation Trust, ran this seminar on how we can manage change and take a positive lead in the NHS.

Some of the changes we face in the UK:

• Change in PCTs -> CCOGs
• Increased litigation
• More complicated treatments
• More IT
• Budget cuts
• Change in clinician/patient relationships
• Ethical changes
• Unhappy doctors

Some research has been done, showing that doctors now have slightly lower workload, much higher pay, yet are much more unhappy. The loss of autonomy, greater external scrutiny, working to guidelines all seem to affect clinician happiness.

What difference does our covenant relationship to God make to our practice as medical doctors?

There is a change in secular understanding of work:

1. Classically, Greeks and Romans believed work was a curse.
2. In the middle ages, there was a secular spiritual dichotomy – it was seen as more holy to be doing a spiritual job.
3. In the Reformation, it was understood that all work can be done to the glory of God.
4. In the Enlightenment, a humanist “God helps those who helps themselves” attitude.

Work was created by God in the beginning…

“The Lord God took the man and put him in the garden of Eden to work it and take care of it.”

Why do doctors go into Leadership?

• Change things
• Ambition
• To help
• Power
• Against their will
• Money
• Buggin’s Turn
• Stop someone else doing it.

Why should Christians get involved with NHS leadership?

• God’s calling
• Esther + Mordecai
• Ethical stance
• Opportunity to protect the vulnerable – both staff and patients

Key points:

1. Management is a means of common grace

“Let everyone be subject to the governing authorities, for there is no authority except that which God has established. The authorities that exist have been established by God.”
Romans 13 

2. We are called to be salt and light in every area.

3. Nehemiah is a great example: he saw the need, heard the call, already had a good job, but took the risk. He dealt with injustice and gave leadership and direction to hopeless people.

4. Jeremiah is another.

“Work for the prosperity of the city where I have placed you”
Jeremiah 29:7

5. Moses father in law gives an example of the benefits of delegating tasks.

What are the dangers of being involved with NHS Leadership?

1. Getting caught up in a powerful and at times ruthless culture.
2. Dishonesty.
3. Anger. Ephesians 4:26
4. Letting Management or the Trust become an idol. Exodus 20:3-4
5. Getting the work/home/worship balance wrong.
6. Cynicism

How should the Christian approach Medical Management?

Do nothing from selfish ambition or conceit, but in humility count others more significant than yourselves. Let each of you look not only to his own interests, but also to the interests of others. Have this mind among yourselves, which is yours in Christ Jesus, who, though he was in the form of God, did not count equality with God a thing to be grasped, but emptied himself, by taking the form of a servant, being born in the likeness of men. And being found in human form, he humbled himself by becoming obedient to the point of death, even death on a cross.
Phillipians 2:3-8 

Really putting the patient and other people first is a servant hearted process: its a radical change of view. Personal convenience, professional status and power have to be abandoned.

Bible Teaching – Faith at Work in our Attitudes

After a final coffee/tea/squash blitz, and the discovery that Vicky Lavy bruised her hand during the slapping game last night (hardcore!), it was time for our last teaching session with Steve Burmester.

“Who is wise and understanding among you? Let them show it by their good life, by deeds done in the humility that comes from wisdom. But if you harbor bitter envy and selfish ambition in your hearts, do not boast about it or deny the truth. Such “wisdom” does not come down from heaven but is earthly, unspiritual, demonic. For where you have envy and selfish ambition, there you find disorder and every evil practice.

But the wisdom that comes from heaven is first of all pure; then peace-loving, considerate, submissive, full of mercyand good fruit, impartial and sincere. Peacemakers who sow in peace reap a harvest of righteousness.”

James 3:13-18

James talks about how our community shapes us. The TV series “UP” followed some 7 year olds, then reviewed them every 10 years. The children have grown into adults so very shaped by the social situation they were in at that tender age.

In his time as a pastor, Steve has seen many people growing up. But it is those who surround themselves with a like minded, gracious and loving community who grow and mature to match that setting. Our primary witness as Christians should be through the community we share together.

The guiding principle of Hell is “I am my own”.
CS Lewis

Steve takes a lot of funerals, mostly for non believers. About 5-10% of them choose to have the song “I did it my way” – an attitude that is counter to the servant hearted, subservient way of the Kingdom.

Saying “I am free to be myself, and owe nothing to anyone else” is the natural desire to please oneself. But Christian living is about the righteous rubbing together of lives. In the aftermath of the Welsh revival, pubs were empty, and prisons had to shut, because lives were changed. The end of revival is caused by spiritual pride.

Spiritual pride is knowing others faults better than your own. Its an air of disdain or contempt towards others.
Pride quickly leads you to separate from those you criticise, or who criticise you.
A proud person is dogmatic, and sure about every point of belief, and cannot distinguish between a major and minor point of belief, because everything is major. Pride loves to confront to win, or doesn’t confront at all because they can’t be bothered.
A proud person is often unhappy with themselves, or self pitying.
Timothy Keller

Humility is not thinking less of yourself, but thinking of yourself less.
CS Lewis 

The opposite of pride is humility. As James 4:6 says - “God opposes the proud, but gives grace to the humble”. In Numbers 12, we see two people acting out of pride, against Moses, who is humble.

James refers to us as “adulteresses”, referring to the image of the Church being the metaphorical bride of Christ. In being selfish and self centred, we violate our relationship with God. When Jesus, who acted only to remain close to God, God chose to cut him off, and its that sacrifice, the ultimate in giving oneself, we can access the grace.

There was a man in the First World War. he was wealthy, and an art collector. He had one son, who was drafted and sent to the front line. Sadly he was killed. Another man, who had been in the trenches with the son, came to visit the old man. He said, I’m no artist alike the painting you buy and sell, but I want to give you this picture which I drew, of your son. The old man was touched, and kept the picture.

When the old man died, they decided to auction all the art in the home. They got everyone together at an auction house. They announced that they had to sell the drawing of the man’s son. We cannot move on until we sell this piece. No one wanted to buy it. Eventually, hesitantly, one old man bought the painting for £10. The crowd breathed a sigh of relief, now they could move on with the auction.

The auctioneer closed his book. I am afraid that the will states, that whoever bought the painting of the son, gets all the fabulous masterpieces.

We must accept the Son, in order to receive all the riches of heaven. Do we have the humility to take up his yoke?

Communion

We closed with communion, reflecting on 1 Corinthians 11:

Let a person examine himself, then, and so eat of the bread and drink of the cup. For anyone who eats and drinks without discerning the body eats and drinks judgement on himself.

And that was it. A final pile of food was shovelled in at lunch, and many sad goodbyes. Then, once I had finally accepted that Beth probably won the chocomilk drinking competition, Beth gave me a lift home.

It was a wonderful weekend, full of passionate, loving and exciting individuals, filled with a desire to help others, make the NHS awesome and share a crazy amount of love to the UK. Hopefully, it’ll encourage me to be more like them.

After a night spent weeing the remnants of my chocomilk binge last night, I got up in time for the 8am prayer meeting in the chapel. Still bleary eyed, I followed this with a painfully substantial breakfast, which, although lacking in vegetarian sausages, made up for it in sheer volume.

We also got to meet the CMF Junior Doctors Committee, and had Vicky Lavy nagging us once again to grab a wheelbarrow, and buy as many books as physically possible from the CMF bookstall.

Bible Teaching – Genuine Faith

Nourishment over, we settled down to listen to Steve Burmester teaching on “Genuine Faith“. We was introduced with a question, due to his background in pharmaceuticals: “What is your favourite drug name?” The answer? “Raloxifene”. Doesn’t it roll off your tongue beautifully?

95 year olds were asked what 3 things they would change if they could live again. They said: 1. they would slow down and reflect on things more, 2. they would risk more, and, 3. they would do more that would live on after they died.

In James 4, he talks about the brief nature of life: “What is your life? For you are a mist that appears for a little time and then vanishes“. The passage makes it clear that we shouldn’t boast and be proud of our own achievements: its pointless. If we feel that we can plan everything of our lives, we will be disappointed – look at the recession. As James says: “Why, you do not even know what will happen tomorrow“.

Just as the old people said in point 2: Risk. As one person said faith is spelt “R.I.S.K.”. It is the perseverence and steadfastness of going through trials that helps us to build our faith, that helps us to put our hope in God, rather than our own plans. As James 1 shows us, its not that we can’t plan, but we shouldn’t put all our hope and security in a future that we can’t predict. We shouldn’t think we can forsee and prevent all difficult times, but instead trust that the God who loves us will see us through the hard times.

How we deal with success and wealth is just as important as how we deal with hardships. Indeed, in the West, we need to learn this lesson more, since we have so much wealth, so many gifts: so many opportunities to bless others, or temptations to feel that “I have worked hard, I have earned this, this is all mine!”

Albert Einstein is travelling across America on a train. The ticket inspector comes, and asks for tickets. Einstein can’t find it anywhere, he is looking in all his pockets, in his coat, but simply cannot find it anywhere.

The ticket inspector says “It’s fine, Mr Einstein: you are a very famous person, I’m sure you bought a ticket!” She walked on, but on looking back, saw Einstein on his hands and knees looking under his chair for the ticket.

She returns, and says, “Mr Einstein, its fine, we know who you are, you don’t need to worry.

Einstein looked at her, and said “I thank you, but I too know who I am. But what I don’t know, is where I’m going…”

Our identity is important, and it is valuable to know who we are. But we shouldn’t be distracted by that into thinking we are in control of every tiny aspect of our lives.

Seminar – Miracles of healing: happening in Britain today?

Our first seminar of the weekend, with Andrew Fergusson - is on whether we see healing in the UK. He is the author of “Hard Questions about Health and Healing“, and a former GP. He mentioned the excellent price that we can pick up the book for about 8 times – I suspect Vicky Lavy had a hand in this…

We went round the group of 20 of us, and it appears that almost every church has some form of regular prayer for healing in church each week, with many having organised healing ministries.

Andrew pointed out that this has changed. 20 years ago, far less churches practiced prayers and ministries for healing.

Margaret had a serious cancer, causing terrible pain in her leg. Medication wasn’t happening. A pastor laid hands on her and prayer, she felt something like “a jolt of electricity” in her leg, and then from that moment until she died a year later, she had no more pain in her leg ever again.

What is that? Is it a miracle? It didn’t cure her cancer, but at the same time, her severe pain stopped permanently.

The dictionary defines a miracle as these below. Is it 1, 2 or 3?

1. An event contrary to the laws of nature and attributed to a supernatural causel
2. Any amazing or wonderful event;
3. A marvellous example of something “a miracle of engineering”.

We can look at some examples of healing, for example Luke 5:12-14; there are a number of apparent likenesses between most biblical miracles:

• Obvious examples of gross physical disease.
• At that time incurable and most remain so today
• Physical means almost never used
• Cures immediate
• REstoration complete and therefore obvious
• No recorded relapses
• Regularly elicited faith
• Verification without publicity.

There is an important element here: as doctors, and as Christians: truth matters. We should not leave our scientific, analytical minds at the door when we look at healing. Evidence matters.

Andrew feels he has never seen reliable evidence of a person having an amputee regrowing a limb, the blind seeing, the dead being raised to life. As he says, “By the dictionary definition, we haven’t seen valid evidence of a level one miracle“. He has seen many, many stories of difficult to explain solutions, and release of pain, or wonderful improvement in health.

As a last, very deep point: If we are going to have a theology of healing, we need a theology of suffering.

Bible Teaching – Faith at work in our actions

After an unendingly vast lunch, and a 2 hour walk, it was time to move on with the afternoon, and our next session with Steve Burmester, on the topic of faith at work. After only about 5 hours of sleep last night, and a fair amount of exercise, I was barely awake – a feeling familiar to me from the Developing Health course.

Many people, on deciding to go paragliding, get right to the edge of the cliff, before deciding they don’t want to go ahead.

James is looking for this doublemindedness in people. The desire to do something good, against the desire to behave badly.

In James 2:1-4, he says “For if a man wearing a gold ring and fine clothing comes into your assembly, and a poor man in shabby clothing also comes in, and if you pay attention to the one who wears the fine clothing and say, “You sit here in a good place,” while you say to the poor man, “You stand over there,” or, “Sit down at my feet,” have you not then made distinctions among yourselves and become judges with evil thoughts?”

 A church invited a guest preacher. The day for the service arrived, and the congregation filed in. There was a tramp, sat at the back of the church, smelling of whiskey, and they sat far from him, leaving him two empty pews to himself.

It came to the point where they were looking around, wondering where the guest preacher was, when the tramp got up, walked to the front, and put on a dog collar, and preached from James 2.

If we treat people wrongly, we treat God wrongly: James 3:9 – “With [our tongue] we bless our Lord and Father, and with it we curse people who are made in the likeness of God“. Another passage talking about our double minded behaviour.

Every human life is a reflection of divinity, and every act of injustice mars and defaces the image of God in man.
Martin Luther King, Jr

Just treating someone with inequality, is that it is sin. And thus no better than any other sin.

Lance Armstrong was struck off recently for taking drugs, but the excuse that many cyclists used is that “everyone else was doing it”. Unfortunately “everyone else does it” is no excuse.

Speak and act as those who are going to be judged by the law that gives freedom, because judgment without mercy will be shown to anyone who has not been merciful. Mercy triumphs over judgment.
James 2:12-13

1. We all need mercy.
2. We need to show mercy to others.
3. This triumph is available to us all.

CMF Update

Pete Saunders started talking next to update us on the work of the Christian Medical Fellowship. We started with a video about CMF. Well, we would have done, but there was a technical glitch, so here it is below:

There are currently 4000 CMF doctors, and 800 CMF medical students. It is not a London office, but a national fellowship. They link with churches, hospitals and individuals.

• Twitter at @UK_CMF
• Facebook at facebook.com/ukcmf.

STAT is “Short Term, Able to Travel” – who are people open to Teaching, Specialist service, Locum support, Emergency help in International work.

Conferences

CMF are involved in about 100 conferences, including:

• CMF Student conference
• CMF Graduate conference
• International Christian Medical Dental Association World Congress
• Christian Nurses and Midwifes Student conference
• Where is my Neighbour? conference.

Find out more at the CMF events page.

Advocacy

CMF works to protect those who lose their jobs for protecting moral values, those of concerns about Euthanasia, Abortion, and Faith at work.

Seminar – Time Management, Jesus Style

Richard Vincent was leading the seminar, my final study session of the day.

What are pressures on your time?

• Family
• Work
• Commuting
• Church
• Socialising

• No choice – things I need to do
• Things I should do
• Things I want to do
• Prioritising between them is a varied process
• How they make you feel

What can we learn from Jesus?

“Early in the morning, while it was still dark, Jesus got up, left the house and went off to a solitary place, where he prayed. Simon and his companions went to look for him, and when they found him, they exclaimed: “Everyone is looking for you!”
Mark 1:35-37 

He guarded his quiet time. We all shared our experiences of the difficulties of setting aside time each day, but once interesting fact: we all really enjoy doing it, yet still find it really difficult to set down to it. It is a battle.

“At daybreak, Jesus went out to a solitary place. The people were looking for him, and when they came to where he was, they tried to keep him from leaving them. But he said, “I must proclaim the good news of the kingdom of God to the other towns also, because that is why I was sent.”
Luke 4:42-43

He established priorities. We live unhelpfully busy lives. We also don’t find solitude enough, especially with the intrusion of smart phones and the internet.

“Just then his disciples returned and were surprised to find him talking with a woman. But no one asked, “What do you want?” or “Why are you talking with her?”.”
John 4:27 

He made time for individuals. It can be harder to take the initiative, rather than just see friends that opportunities naturally present each other.

“For we do not have a high priest who is unable to empathize with our weaknesses, but we have one who has been tempted in every way, just as we are – yet he did not sin. Let us then approach God’s throne of grace with confidence, so that we may receive mercy and find grace to help us in our time of need.”
Hebrews 4:15-16

He did not sin. Hopefully our understanding of grace is that that we can show it to others equally well.

“Then Jesus said to them, “The Son of Man is Lord of the Sabbath.”
Luke 6:5 

He rested. We need to plan time off, and have a Sabbath attitude in each day, even when that isn’t possible.

After this, we spent the evening chatting, playing Cranium and “Table slap”, making awful medical and Christian jokes, and I finally went to bed at 2:30am, after a long discussion about how to improve the Malaysian health care system.

I had so much fun that I thought I would attend the CMF Junior Doctors conference. Entitled “Faith at Work”, there are a range of seminars covering a wide range of topics, and some central teaching looking at the book of James. Plus hanging out with lots of similar minded junior doctors, and eating too much tasty food.

Yesterday was the first evening. After nearly 5 hours on the train, and 3 different connections (Boston is annoyingly out in the sticks!), we arrived at the delightful Hothorpe Hall near Market Harborough.

There wasn’t a huge amount of action on the first evening. Lots of chatting, some fantastic dinner, and a great introductory talk from Steve Burmester, our speaker for the weekend, on the Book of James.

He mainly focused on the disease of having a divided heart. Breaking it down medically, he showed us the symptoms of a divided heart: anger, a loose tongue, etc. The treatment is not to try harder, to continually berate ourselves, but to allow more of God’s grace to flourish in us.

The evening was rounded off with myself and my friend Beth had a drinking competition. Of Chocomilk. After 6.75 cups each (don’t ask about the arguments that led to that exact measurement) and a tie-breaking run round the entire building at half past midnight, it was time to go to bed.

See you all tomorrow!

I’ll take you through some of our key moments with some photos:

This is our new home: Orchard Cottage, on Woodthorpe Avenue. It’s on the slightly nicer side of town, but needs quite a lot of work! The garden hasn’t been touched for about 2 years, so we are having rather a lot of pruning done at the end of the month, and some building work after that…

Joen has settled into things well, and both he and the dogs are loving the big new garden. As you can see, there are cat flaps everywhere, coupled with awful red carpet in the kitchen, and mammoth spiders in every room. Katherine hates all 3 of these things, especially the eight legged monsters.

One of the key aspects of our corner of Lincolnshire is that it is as flat as a pancake (In fact, if you read this study, its likely that its considerably flatter, since it would appear that pancakes are not terribly flat). The downside: its a bit boring. The plus side: we can cycle everywhere. Joen has decided to live on the edge though, since he has now worked out how to remove a cycle helmet, rendering it useless.

Alongside the uninteresting terrain, there is considerably more sky visible, so sunsets and dawns are rather beautiful to behold. Sadly, the road I take to work each morning is almost due East for large sections, meaning I can barely see beyond the brain melting glow of the sun. The unending flatness means that a 44 mile round trip is just about doable on bike, although I’m not achieving it every day.

I have begun my GP training, which involves hundreds of hours spent reflecting, signing sick notes and prescribing amoxicillin. Here you can see my office, with a photo of the family, and a coffee mug, recently filled on my most extravagant new purchase, a DeLonghi EC 152 Coffee Machine.

As mentioned above, we have several fantastic beaches, 20 miles or so down the road; and we have made the most of them already. Here you can see Joen swimming, playing and eating the sand on the beach at Chapel St Leonards.

Finally, the most important photo is that of our new child, around 50% ready now. Probably a she (the ultrasonagrapher wasn’t completely sure), we look forward to her arrival in January!

Thanks to everyone for your prayers, support and hot meals over the last month, especially Eagle, Sadie, Daniel, Tammie, Hannah, Helen, Micky & Rachel, and thanks for the unpaid manual labour of Nick & Jon!

Our last day of the course, and the morning prayers were tinged with sadness. It’s been a fantastic two weeks, and I’ve made lots of genuine friends. I’m really going to miss going back to real life…

Dermatology

Claire Fuller gave us our final topic session of the week, based on many years of experience in both the UK and East Africa.

The WHO is working with the Gates Foundation to run a Global Burden of Disease statistics measuring. 600 million cases of scabies worldwide. In the developing world, skin disease is the second commonest reason for attending primary care – but people are still far less likely to attend if they have a rash compared to other types of pathology.

As in many other areas, traditional healers cause many problems – their treatment for lymphoedema is to puncture the legs multiple times to let the fluid out. Sadly, this leaves the door wide open for infection.

Dermatological Examination

Important features to have.

• Suitable location for skin examination
• Satisfactory light
• Examine patient all over – check mouth, nails, scalp, feet, genitalia.
• Distribution of lesions.

The problem is, because don’t want to strip off because the clinic is full of people and no privacy, but then you take them down to the cupboard, and its too dark to see.

Bacterial skin disease

Very commonly this will be impetigo – yellow crust to blisters, generally around nose and mouth.

1. They need to wash the skin – with clean waters and disinfectants. Remove crusts, debris and necrotic tissues.
2. Apply antimicrobial preparation – herbal, honey, hydrogen perocide, chlorhexidine, topical antibiotic.
3. Oral antibiotics – flucloxacillin, erythromycin.

Eczema

Eczema is very common in the developing world. Can be especially aggressive in African skin. Rather than simply affecting the flexures, it can affect the whole trunk, and can cause very high levels of inflammation, which leaves hypopigmentation after resolution.

Often needs emollients and dermovate.

Tinea

Scaly round rashes on arms or trunk related to ring worm. Can be treated with topical antifungals. However, tinea capitis – affecting the scalp – will need systemic antifungals. (See image above on right)

Pyoderma, scabies and renal damage

There is an established association between scabies and pyoderma. In those with scabies + pyoderma, 5-10% will have visible haematuria: so it should be treated.

80% of dermatology consists of 8-10 common diseases. If it smells like pyoderma, it probably is.

Medical implications of skin-lightening products

These can cause local damage, with inflammation and awful stretch marks. In Malawi, around 5-10% of people attending our clinic had problems related to these creams.

Patients will deny using the products, so you have to say “I’ve heard that people who use these creams get these problems”, letting them save face.

HIV/AIDS

Having a skin disease is a risk factor for having HIV, from evidence in Tanzania. Multiple dermatoses is quite specific for low CD4 count. In one study, 88% of adolescents with HIV had a skin disease.

The best way to treat the HIV associated dermatopathology such as Kaposi’s Sarcoma is to treat the HIV.

Ulcers

1. Treat underlying cause.
2. Keep clean without dirsupting healing (antiseptic soaks, water fit for drinking is fit for wound case)
3. Treat secondary infection
4. Greasy covering prevents adhesion and good for pain relief.
5. Compression is very helpful.

Removing suspicious lesions

Podoconiosis

Known as “Podo” – one of the forms of elephantisis. Seen in the highlands of tropical countries with lots of bare feet in muddy professions.

Skin swells and becomes woody and hard. Smells insanely awful. Basically an end stage lymphoedema.

Usually can be dramatically improved with frequent washing and antiseptic. Get children to wear shoes, prevents the condition occuring.

Our scheme in Ethiopia has led to all who are treated being invited to join the team to teach others. 30,000 have now been treated in the scheme!

Teaching… a workshop

Our closing session was from Vicky Lavy, talking us through the wonderful art of teaching, a key tool for all of us, especially in the developing world.

Many of us have done a fair amount of teaching. As a group we came up with lots of words beginning with E, about the important things that teaching needs to achieve:

• Enable
• Enthuse
• Educate
• Empower
• Entertain
• Encourage
• Exchange
• Effect (on patient care)
• Everlasting (sustainability)

What makes a good teacher?

• Clear + interesting
• Acting
• Inventive
• Honesty
• Inventive
• Relevance
• Love for the subject
• Audience
• Approachable
• Knowledge + Preparation
• Experiment

Teaching tools

There are millions of different teaching styles: Participation, Lectures, Scenarios, Practicals, Groups, Role play, Mentoring, Informal, Teach others, Drama & Song, Quiz, Stories, Bed side, Shared consultations, Video, Books, Online, Visual stuff, Thought exercise, Buzz groups.

One week after a lecture, evidence shows that people often only remember around 20% of the information.

Some of these are very effective in developing settings, others not so well. Generally, developing world cultures are used to very didactic of teaching, which means they can learn by rote, but are not well versed in problem solving.

However, once they get used to small groups, which can take some time, they find them useful also. Good to tell people they can use their own language in the groups.

“I was doing some teaching in china, and trying to ask questions, and just getting blank faces. However, over the 3 days, the group slowly opened up, talking about patient cases. By the end, I found they were very engaged.”

• Dealing with wrong answers - Important to a) not embarrass people, but also b) correct dangerous treatment ideas.
• Breaking up teaching sessions is valuable - to keep people awake. Having a buzz group session between talks is helpful. A buzz group is where someone turns to their neighbour and briefly discusses an issue
• Visual aids – showing pictures, to tell stories. One teacher on this course has showed us the manacles used to hold psychiatric patients to the wall. That kept us awake!

Case example: Teaching student nurses in Uganda about immunisation within 1 hour

We broke into lots of pairs and tried to come up with teaching sessions. Then fed back to the group. Huge variation in styles and approaches. Some groups taught basic practical skills, some came up with dramas, some had very ambitious plans to teach a much more holistic community engagement approach.

Closing

Ian’s closing remarks: God did not make us to cope with burdens on our own. Jesus sent people out two by two, not individually. We need to share our burdens together.

We then all held hands and closed in prayer together.

And that’s all folks. Sad to feel we are at an end, but I’ve definitely never enjoyed a medical course, or generally teaching so much. I’d like to give some huge thanks to Vicky and Ian, and the whole of the CMF team. Bless you all!

I had a massive lie in today, and then discovered that the traffic at 8:15 around London is rather horrendous. Happily, arrived only 5 minutes late, in time for…

Towards culturally competent care

Mary Hopper talked to us again, this time looking at the impact of not understanding culture on care…

There has been lots of awareness throughout the course about the impact of culture. Most of the speakers through the last two weeks have mentioned the shocks and surprises of moving between the developed and developing world.

We all contributed things we’ve experienced in different cultures we were not expecting:

• Less personal space: people just turning up at our house.
• Less confidentiality.
• Personal questions: asking things polite British society doesn’t accept.
• Different expectations.
• Facial expressions.
• Time.
• Hierarchy of generations/roles.
• Fatalism.
• Family values.

To many people, not complying with their culture is not an option.

I’ve had people who have come to me, and decided they want to accept Jesus. They’ve become Christians, and then said to me “Now I can’t go home”. Breaking cultural norms can lead to beatings, ostracising, deaths…

Culture has 3 layers

1. Outer layer – artefacts and products.
2. Middle layer – norms and values.
3. Inner layer – laws, generational beliefs.

“It was not the women’s ignorance but their intelligence that led to their refusal to adapt or abandon certain habits. They sought to understand the reason for such changes in terms that made sense to them. Not all those put forward by the health care worker did.”
Currer 1986 

The impact of culture on healthcare can be huge. Pre natal sex selection, communication styles, work force issues, birth marriage and death rituals, issues of consent, organ donation.

Ask yourself the question: Who are you? Where do you get your identity, beliefs, values, skills from? Ethnocentricity is the feeling of “I’m right, you’re wrong”. The feeling that your idea of culture is correct and needs to be taught to others.

We need to challenge ourselves; sometimes the correct thing to do is the culture that has been there for years, not our shiny Western ideas.

Women: Key Issues

• Stewardship of natural resources – women may be in charge of securing food, water, fuel and overseeing family health and diet.
• Reproductive health – issues re-morbitity, expectations of role and childbearing. Could be seen as coercion/force. Infertility is a hugely ostracising problem in some cultures, as is having a female baby.
• Economic empowerment – more women than men live in poverty. potential for economic disparity, less access to food, essential resource for living, property ownership.
• Education empowerment - women do not have access to education: linked to child mortality.

Sociocentricity and Egocentricity is the contrast of being society centred or self centred. The former is often modelled in developing world cultures, with tribes and villages central, rather than the Western individualism. It can be argued that the Socio model is more modelled in Biblical theology and morality: the concern is that there also a huge potential for individuals to be disadvantaged within it.

If used well, Sociocentricity, can be empowering for individuals and communities: its another situation where cultural sensitivity can help us to improve current systems, rather than trying to implant our own.

“We had condom education in our village, and the men came, and demonstrated placing a condom onto a stick. Rather than seeing the example in the spirit it was intended, many people in the village started placing condoms onto sticks.”

Wherever we go, we need to consider: how culturally sensitive are we being, and how can we help by providing culturally appropriate care.

Workshops

The rest of the day involved workshops of Contraception, Gynaecology case studies  & Gynaecology Emergencies. It was great, and very interactive, but sadly not terribly conducive to note taking.

They also told us about Swinfen Charitable Trust, who provide an international medical advice service for professionals – very useful in the field!

After a late night gig in London, I had a rather late night, followed by getting up at 6am to prepare for speaking at the early morning prayer meeting. I also washed everyone’s feet, which was a real honour for me. The upshot of all this was that I didn’t do my preparatory homework for today’s sessions, so apologies if it seems a bit sparse.

Women’s Health in the Developing World.

The first talk of the day came from Christine Edwards, with a talk based on many years of experience in fistula surgery in Bangladesh. 

• There are 360,000 women dying because of childbirth each year.
• There are 2 million newborns dying within the first 24 hours per year.
• There are 2.6 million avoidable stillbirths per year.
• 2 million unplanned pregnancies per year.
• 70,000 deaths due to abortion per year.

Birth complications means many women end up with fistulas that leak urine and faeces continuously. Women are socially ostracised – we watched the story of a lady called Mastula, and her experience of her life being turned upside down by a fistula.

Lifetime risk of dying from childbirth and pregnancy. In the west it is 1 in 4300. In Afghanistan, it is 1 in 11.

In the UK in 1930, maternal mortality rates were similar to the developing now. The UK changed due to 4 changes in services & skills:

1. Midwifery care
2. Blood transfusion
3. Caesarean section
4. Antibiotics

3 delays

It is felt that there are three areas of delay that cause many of these deaths: delay in deciding to seek care (due to socio-cultural constraints, values put on women, beliefs related to pregnancy, traditions, non medical attributed causes), delay in reaching facility (financial constraints, poor transportation, no local facility) & delay in recieving care(Lack of staff (24/7), training, equipment, drugs and money).

92% of Bangladesh births are at home, with 89% totally unattended by health care providers. We worked at the only hospital in Bangladesh (population 160 million) that had an obstetric service available 24/7.

What is needed?

1. Increase in the value put on women by society/ community
2. Increase in community awareness of danger signs and preparedness
3. Increase in the community’s  confidence in EOC (Essential obstetric care) facilities
4. increase in comprehensive and in basic EOC facilities
5. Increase in skilled personnel in an integrated system

LAMB approach

The LAMB hospital is a mission hospital in Bangladesh. Find out more at LHCF.org.uk.

Bible studies for all staff on created in His image, and violence against women. Teaching on how New Testament teaching on how a husband should treat his wife – “husband ought to love his wife as he loves his own body“.

We’ve seen a drastic effect: people working through the verses together: Christians, Muslims, Hindu, all reading the Bible together, and together coming to an understanding of how things should be.

We work with traditional healthcare attendants, giving them some simple points of when they need to refer to the hospital – the WHO feels this is not an effective policy worldwide, but we find it has been helpful in our area. We also train our own community skilled birth attendants, who receive 6 months training, then return to their villages..

Involvement of mother-in-laws and husbands, as decision makers, is very important; mothers will often agree with all our plans, but do not have the authority to make it happen.

That makes this the third day on this course where mother-in-laws have been recognised as an international threat to health. The hospital uses the community to pay for itself. Subsidies are provided for those who cannot afford. Households donate 1 tk per month (less than 1p), with further donations at religious festivals. We have advanced trained midwifes and advanced anaesthetic assistants – an area of contention at the moment. However, having audited our anaesthetic assistants, we have had no deaths directly due to anaesthesia in 5 years.Appropriate review definitely improves our service quality:

• “No blame”, confidential meetings
• Facilitates interdepartmental communication & teamwork
• Addresses areas for improvement
• Regular review of protocols
• Saving Newborn Lives initiative – pilot project in PNDA
• ‘Verbal autopsy’ of all maternal and child deaths in the community

Birth basics

I joined the “Basics” rather than “Advanced” Obstetrics workshop, which was being taught by Mary Hopper, who spoke on Saturday.

Some useful bits and pieces

• Grandmultigravida – more than 5 births.

“In Zimbabwe, we had one lady who was having her 23rd baby. In the next bed, we had her daughter, who was also having a granddaughter for our original patient!”

• Due date can be calculated: add 5 days and 9 months to the beginning of the last period.
• Foetal heart rate should around 130-140 – in the absence of other tools, using a loo roll over where you think the shoulder of the foetus is.
• Amniotic fluid should be around a litre, and should be strawberry coloured. Polyhydramnios (too much) is often seen in twins, pre-eclampsia, and seems to be more common in congenital abnormalities. Oligohydramnios (too bad), if bad, can lead to baby being held in uterus by adhesions.

Stages of Labour:

Onset of labour: from start of contractions until the cervix is completely dilated. Make a peace sign with your index and middle fingers: the distance between fingertips is around 10cm. The cervix generally progresses at around 1 cm an hour.

Our nurses in Zimbabwe couldn’t say ‘dilated’, so they would run and find me and say ‘The patient is fully delighted!’.

Second stage of labour: from full dilation to delivery of the baby. Once the woman feels she is ready to push, check the cervix.

Third stage of labour: from delivery of baby to delivery of placenta. Breastfeeding releases oxytocin, which will speed this up. Usually takes up to an hour.

Presentation, Lie & Position

1. Presentation – what is near the cervix: cephalic presentation, shoulder presentation, breach presentation.
2. Lie – Longitudinal or transverse.
3. Position – Commonest is OA – occipito-anterior. This means the back of the baby’s head is at the front of the mother. OP is the reverse of this, the occipital region of the baby’s head faces backwards. Often, OA you will easily be able to palpate the back of the baby in the abdomen, and mum will say the kicking is mostly to the sides. OP, you won’t easily palpate the back, and mum will say that kicking is all over the place.

Cord Prolapse

If a cord is visible before the baby, it often means the cord has come out, which means it can get stuck, with the baby squashing it, giving the baby hypoxia. Push the baby back in vaginally with your fingers, and get mum on hands and knees with head down.

Is the cord still vibrating? If not, baby is dead. Very occasionally, the cord can start vibrating again once you apply pressure. If the baby is dead, you need to deliver it, but there is no time pressure beyond keeping mum well.

Shoulder distocia

Baby gets it shoulder stuck in the pelvis vertically. You need HELPERRS!

Help – call for help.
Episiotomy.
Lift the legs.
Suprapubic Pressure.
Enter vagina – to try to turn the baby.
Remove posterior arm – try to deliver arm through the vagina.
Rotate the mother onto all fours.
Symphesiotomy if not resolved – pop in a solid catheter, so you can move the urethra out of the midline, then cut through the synthesis pubis and pull out the baby.

Sepsis

Our first afternoon session was with Jacqui Hill, who has been in Afghanistan for the last 3 years, working in Obs & Gynae…

Sepsis is a huge killer in maternal deaths – even in the UK, there were 43 maternal deaths in the last 3 years from sepsis, 13 from Group A Streptoccus/

• Sepsis is a systemic infection.
• Severe sepsis is sepsis with organ dysfunction. (40% mortality in pregnancy)
• Septic shock is sepsis with hypotension. (60% mortality in pregnancy)

Sepsis is dangerous in pregnancy, because the woman is under a lot of physical duress, so has more susceptibility, and pathology presents abnormally, so is picked up late.

The evidence shows that the most important treatment is to get antibiotics into the patient.

Chorioamnionitis

A pregnancy specific sepsis can be chorioamnionitis. This occurs from rupture of membranes early, leading to infection in the amniotic fluids.

With cases of chorioamnionitis, delivering the baby is going to be better for both the child and the mother. Non delivered foetal survival rates are almost non existent.

Inducing a birth is usually done with medication or pessaries in the UK. One thing you can do in the developing world. Putting a catheter into the cervical os: you inflate the balloon to start stimulating the cervix. Also give an oxytocin IV infusion.

We also had session on haemorrhage and eclampsia. I failed to get many notes, but they were awesome! Then I went for a curry and finally got Peshwari chips for the first time!

Driving round the North Circular via the world’s most awful roundabout meant that I nearly didn’t make it to the course this morning. Happily though, I avoiding the lorry that tried to crush me by changing lanes without indicating, and I arrived ready for a day of #…

Trauma Overview

Our first talk came from Chris Lavy, husband of Vicky Lavy, who runs the course. He explained that the reason for his haggard experience was her being away for a week, leaving him alone with the children.

The USA have nearly 1% of the population having an operation each year, whereas in Guyana that figure is 0.002%. There are 1700 surgeons per 100,000 population in the UK, whereas in Ethiopa that figure is around 1 per 100,000.

When I work in London, I don’t even recognise all the other surgical consultants in my hospital. When we lived in Malawi I knew the names, birthdays and spouses of every surgeon in the country.

16% of the global burden of disease is injuries, so we need to take it seriously. The Primary Trauma Care course is basically a very low cost of the ATLS course.

Fractures & Joint Injuries

In the West, it has become common to treat fractures operatively, but in the developing world, conservative treatment is better since it is cheaper, and doesn’t rely on having equipment, with much lower risk of infection.

Fracture treatment:

1. Assess fracture, circulation and nerves.
2. Reduce the fracture
3. Hold or support it until united
4. Encourage movement at all stages.

Remember most fractures will heal without your help.

Fracture healing:

Union = bone moves as one
Consolidation = back to normal strength
Remodelling = returning to normal shape
Non union = still mobile at 6 months.
Mal union = healed in the wrong position.

How long do fractures take to unite?

• 2-3 weeks if metaphyseal eg wrists
• 4 weeks for oblique forearm fracture
• Add 2 if transverse
• Add 2 if lower limb.

Children heal much faster.

Common fractures:

These are all conservative solutions, rather than operative

• Clavicle - put in a sling.
• Humeral - back slab or sling. Encourage elbow movements.
• Supracondylar (see above on right) – forearm traction for several day until swelling gone, then treat in sling.
• Olecranon - sling.
• Radial - plaster of paris potting.
• Metacarpal – no fixing, just regularly flex and make a fist.
• Femoral - traction – raise foot of bed and hang traction off end of bed.
• Tibial – above knee cast for 4 weeks, then below knee walking cast if stable enough. If unstable, will need traction.
• Ankle – plaster of paris pot, will need replastering in around 7 day, since the ankle is almost always swollen.

Don’t forget exercises to stop everything stiffening up!

Open fractures:

Tropical Orthopaedics

Tea break finished, it was time to meet Alan Norrish, and his encyclopaedic knowledge of using drills on people in hot places…

Some Ugandan studies: 3% of all surgical procedures ended up with osteomyelitis, and 18% of paediatric hospital days was related to joint and bone infection.

In the developing world resources are short, so the focus goes on injuries with blood and bones all over the place, rather than long standing musculoskeletal problems that cause a lot of morbidity.

Often there is not enough time or money to operate, but sometimes Alan has found this website rather helpful for giving patients helpful exercises.

Childhood limb specific disorders

Failure of formation

Hemimelia (picture above right) is missing bones or parts of bones:

• Missing fibula
• Missing tibia (autosomnal dominant)
• Missing radius (causes clubbed hand)
• Missing fingers (claw hand)

Failure of separation

• Most common is syndactyly of the fingers and toes.
• Can be simple with bones separate, or complex with bones combined.

Duplication

• Normally extra fingers and toes.

Amniotic constriction bands

• Need removing before the child grows, as get tighter

Undergrowth of bones

• Shortened femur.

Systemic Congenital Conditions

• Osteogenesis imperfecta
• Fibrodysplasia ossificans progressivica.
• Cerebral palsy

Some people spend all their money trying to find a resolution to a long term problem, and sometimes the best you can do is tell them there is no cure, and then they can spend the money on useful things for their life.

Club feet:

• Common in developing world – 1:1000 births.
• Use serial casting in under 3 years
• 3 years to 8 year, needs soft tissue surgery
• 8 years olds onwards need bone surgery.

Osteomyelitis:

• Acute, treatable with antibiotics
• Chronic, will need bone debridement, very difficult to cure.

TB of bones and joints:

• Often present without pulmonary TB.
• Triple therapy is treatment.

Burns & bites:

• Elevate limb and splint joints in functional position.
• The skin can cause a contracture of scar tissue that needs cutting, or serial casting to prevent it limited movement.

Neck injuries:

1. Go and hold the neck. It will increase awareness of the neck to other staff.
2. Rigid collar.
3. Log rolls for moving patient.
4. If facet joint dislocation, you can perform head traction!

Burns

It turns out that I am not very good a paying attention to lectures for 8 days in a row. Eyes practically closed, I grab a coffee with ten sugars in time for the final talk of the morning with Sarah Tucker…

Our three key aims with treating burns in a resource poor setting are survival, prevention of disability and effective use of resources.

We did an audit in Nepal that showed that in six years, no one had survived 40% burns on our burn unit.

Painful as it is to say, this means that it was unlikely to be worth the heavy investment in resources treating people with this level of fatal wound. Burns patients die from injection – sadly we had to make the decision to treat anyone with more than 60% palliatively.

Severity of Burns

To assess percentage coverage, we use the rule of 9s – click the image on the right for more information.

The best way of finding out depth of a burn is to see how quickly it heals. Anything that heals in less than 2 weeks is superficial, longer is deep.

Treating Burns

You need to perform escarotomies if any circumferential full thickness burns to the limbs, chest or neck, to prevent contractures.

The burn needs to be scrubbed clean, especially if any foreign bodies or chemicals. The burn will need to be scrubbed every few days, this removes dead skin, leaving healthy tissue.

The Ideal Burns Dressing

My pet hate is people arriving from the West with boxes of dressings, that everyone leaps on, gets very excited about, and then runs out. Much better to teach everyone to make local solutions that work well.

• Clean
• Available and sustainable
• Cheap
• Non adherent
• Reduced need for analgesia
• Reduced need for changing
• Antiseptic

We started to use banana leaves for burns dressings. They can be autoclaved, boiled and sterilised. They are non adherent. They work better than silicone dressings.

I showed the banana leave dressings to our nurses, then went away for two weeks. When I came back, they had visited all the trees in the area, autoclaved leaves and filled the fridge with them of their own volition – that’s how noticeable a difference they made to the nurses.

Preventing contractures.

If burns are across joints, and the joint is held out straight, inflammation, then scar tissue will cause contractures, which will cause functional problems in future.

There are some finer points, but generally the Edinburgh position (on the right) will prevent the hand losing functionality.

If there are burns on the inside of the hand, you will need to release the splint at night, or splint it straight at night to prevent this.

Practical Skills Workshop

The afternoon was an exciting blend of Plaster of Paris, Disolocations and traction, Skin grafting and Physio sessions. Afraid there’s not much I can say about them – you had to be there! Since you weren’t, you did miss me accidentally removing the skin on my knuckle whilst practicing taking a skin draft on an orange.

After a glorious day off, where I mostly read books and used a petrol strimmer to utterly destroy a number of stinging nettles, I returned to the lovely Oak Hill College for the start of week two…

Anaesthetics

Our first talk today was from Hilary Edgcombe, who started with photos of an elephant and a boa constrictor under anaesthetic, which was cool.

Anaesthesia is the absense of sensation: so this includes local and general anaesthesia.

General perspective on world anaesthesia:

• Good anaesthesia is
• Safe
• Comfortable for the paatient
• Comfortable for the surgeon
• Preferably simple, economical and fast

11% of world’s disability-adjusted life years are lost due to conditions amenable to surgery. Safe anaesthesia is necessary for surgical care.

Safe anaesthesia is not available worldwide:

• In the UK, anaesthesia related mortality is 1 per 185000
• Malawi central hospital: 1 per 504
• Togo teaching hospital 1 per 133
• South Africa: 1 in 4 maternal deaths anaesthesia related: 90% avoidable

Key causes of anaesthesia related mortality:

Of 41 anaesthetic clinical officers in Malawi, 5 had seen a failed intubation. 2 had seen a case of pulmonary aspiration. 9 had seen a case of high spinal (requiring intubation)… in the preceding week!

A lot of this is due to lack of equipment – in one study in Uganda, only 23% hospitals had enough equipment to safely anaesthetise an adult, 12% enough to manage a child and 6% enough to do a C-section.

Golden rules for Anaesthesia

1. Pre-assess your patient: to optimise their condition, to make a sensible plan, explain/allay fears/concerns.
2. Know your equipment.
3. Work out what you expect to happen when:
   your anaesthetic,
   encounters your patient,
   with their surgical problem,
   and their other comorbidities
4. Do a bit of catastrophising: formulate plan B, plan C.
5. Monitor your patient: ideally HR, BP, pulse oximetry, and end tidal CO2. Worst case, make sure you are looking at and feeling the patient.
6. Remember recovery.
7. Don’t get into trouble you can’t get out of: if you think the airway will be difficult, don’t stop the patient breathing, etc.

Pulse Oximetry

Hilary then showed us a video about an exciting push to get pulse oximetry machines worldwide:

Oxygen sources and delivery

For the sick patient (who needs more oxygen or who can’t get it to their cells effectively), or for some anaesthetic techniques, oxygen is helpful. It can be difficult getting hold of O2 in the developing world for logistical reasons.

She shared a story of a patient who died due to the oxygen cylinders being full of NO2, and another of a paedriatic ward that had a 2,000 litre cylinder that they used with neonates with no pressure control, so the babies were practically being inflated by the force of gas…

Pipes:

• Lucky you!

Cylinders:

• Money – expensive
• Logistics
• Safety – have they been maintained?
• Safety – which gas?
• Safety – what pressure?
• Safety – traumatic injury?
• Duration

Concentrators:

Ketamine

Ketamine is a super drug, its a hypnotic, analgesic, amnesic. It is not a muscle relaxant. It has some weird effects, since it can lead to patients have their eyes open throughout, and causes emergence delirium (the reason we don’t use it in UK).

Other key points, some positive, some negative:

• Tend not to end up hypotensive – slight rise in BP, HR and RR.
• Patients tend to maintain their own airways.
• Probably the least dangerous anaesthetic to use.
• Can cause laryngospasm due to hypersalivation, but less commonly than thiopentone.
• Can cross the placenta, giving you a spaced out baby.

Key Ketamine Safety Points

An introduction to spinal anaesthesia.

A local anaesthetic block of all the nerve exiting the spinal cord below a particular level. Low risk – but not “no risk”.

In an adult, the spinal cord ends around L1/L2, so going in below that, you are unlikely to hit the spinal cord.

There are two types of any spinal drug. Normal, and heavy – the normal types are roughly the same weight as CSF. The heavy types are mixed with glucose, and obey gravity going low. However, due to the lumber lordosis, if you give someone a heavy drug and lay them down immediately, the agent can pool in the thoracic region – see diagram on right.

Common local anaesthetics: lidocaine, bupivacaine, tetracaine. Need to know relative baricity and appropriate doses for the drug. Exclude preservatives: since they can cause neurotoxicity.

In the West, we tend to give some opiates with the spinal, but this is not something generally done in the developing world.

Problems with Spinals:

Immediate

• Block doesn’t work.
• High spinal (cardiovascular compromise)
• Very high spinal (cardiovascular & respiratory compromise)
• Total spinal (cardiovascular, respiratory and CNS compromise)

Early

• Headache

Late

• Haematoma
• Infection
• Ongoing nerve damage

Contraindications

You need:

1. IV access and fluids
2. Some sort of vasopressor and atropine
3. Someone to monitor the patient
4. Resuscitation equipment
5. Position the patient well, and use aseptic technique
6. To look for delayed hypotension

There is a free Developing Anaesthesia Textbook available at www.developinganaesthesia.org

Surgery for the non-surgeon

John Rennie and Colin Binks shared the next talks about surgical matters. They both apologised for the dwindling capacities of their ageing neurones, but assured us that with enough prompting they would be able to recall the more important arteries, etc.

“You must take your bible, your toothbrush, your anti-malarials and the Textbook of Primary Surgery. It’s brilliant, full of pictures, and perfect for those of you who are far more comfortable cutting sausages than cranial burr holes”.

Acute abdomen

Does my patient need surgery NOW?

• Bleeding (immediately)
• Strangulated bowel (need to stabilise patient first).
• Peritonitis – perforation, pus (need to stabilise patient first).

Does my patient need surgery at some time?

• Think: what resuscitation or other treatment is needed whilst observing?
• Can I do the surgery?
• Action: Active observation/resuscitation/refer.

Does my patient definitely not need surgery?

• Respiratory problems – basal pneumonia
• Gut problems – gastroenteritis or ileus
• General illness – diabetes, viral infections, uraemia, sickle-cell crisis
• “Surgical” – cholelithiasis, pancreatitis
• Gynae – ovulation pain, salpingitis
• Nerve pain – herpes zoster

Fluid Resuscitation

• Clinical assessment: if a little dry, potentially 5% dehydration, with very shut down, sunken cheeks, 10%.
• Deficit (ml) = % dehydration x Wt (kg) x 10
• This is 7000 ml for 10% dehydration in 70 kg adult and 1000 ml in a 10 kg child.
• Use N-saline or Ringer’s lactate for deficit
• Resuscitation for fluid deficit will normally take 3-5 hours to optimise patient’s condition.
• Patients with active bleeding need surgery as soon as possible.

How to find a perforation in the developing world…

• CT scan – unavailable
• Bowel sounds – unreliable
• Rebound tenderness – unreliable
• Loss of liver dullness – a valuable, underused resource. Air in abdomen will reduce dullness on percussion.

In Uganda, there are currently 27 surgeons for 10 million people. Last year in Ethiopia, there was only one new surgical graduate in the whole country.

Differential for Acute Abdomen

How to Operate for Dummies (AKA Medics)

1. Get a nice sharp knife.
2. Cut through the midline.
3. Go through the fat.
4. Carefully cut through the rectus sheath.
5. Cut through the peritoneum, hold it aside from some clips.
6. There will be a big woosh of horrible contents, if there has been a perforation.
7. If there is bowel contents in there, use some sterile water to wash it out. If you haven’t got that, tap water is an awful lot cleaner than what is already in there.
8. Find the hole in the bowel.
9. Gentle drag the omentum over the hole, and put some big loose stitches around it.
10. Leave a drain in the abdomen, through a separate hole.
11. Using some strong nylon, take all the layers together and close in a mass closure technique. If you have no strong thread, buy some fishing line and sterilise it.
12. Put some loose sutures in the skin, closing it properly a few days later.
13. Fill them with antibiotics.

“You can do good surgery without electricity, although it is rather nice to have a lightbulb…”

Popping in a chest drain

1. Use clinical signs to ascertain which side.
2. Use some local anaesthetic all the way through – which then tells you that you are in the right place.
3. Wait several minutes
4. 5th intercostal space, mid-axillary line.
5. Go just above the rib – because the vessels hang underneath the ribs.
6. Make a small cut with a scalpel, then push through a Spencer Wells (see right).
7. You will go through skin, then fat, then pleural.
8. Open the forceps, and pop your tube through the gap.
9. There will be pus, fluid or air that comes out.
10. Put the other end of the tube under a water seal.
11. Keep the underwater seal lower than the patient.

Suprapubic catheter

1. Needs a full bladder, dull on percussion.
2. Find the point an inch or so above the pubic tubercle, in the midline.
3. Pop in lots of local anaesthetic.
4. Make a small vertical incision – just 2 inches high – but add another inch for each depth of fat in obese people.
5. Dissect down through the fat to the lineo alba – a white line down the midline.
6. Carefully slice this in half, then hold the two sides apart.
7. If there is any gut in the way, push it aside.
8. Make a very small cut, and pop a Foley Catheter through the wall of the bladder.
9. Stitch it in place.

Ascitic tap

1. Lay patient on side.
2. Measure 5 or 6 inches from the midline laterally, avoiding rectus sheath.
3. Pop it in.

Practical Sessions

After lunch, we had an afternoon of practical workshops with the team from this morning. My spinal actually worked!

Performing a spinal

We had a practice at both upright and lateral spinals on some models. Rarely, I didn’t hit spinous processes, and got loads of juice out, and popped some in! Good times…

Wound management

• Wash out the joint, especially if there is debris in the wound.
• Deal with it within 6 hours, to prevent infection.
• Use anaesthesia.
• Examine blood supply, nerves, tendons, other structures.
• Bone chips should be removed from trauma wounds.
• Tendons and nerves should be tied end to end with silk stitches, and keep the wound moist.
• Give tetanus prophylaxis.

You would often not stitch the wound after you have debrided it, since you need to allow muck to escape. Different areas of the body will have different rules: click picture on right for more details.

• Primary Suture – immediate closing
• Delayed Primary Suture – delayed closing after 3-5 days.
• Secondary Closure – often for older wounds that have began to heal themselves through granulation, and may need skin grafting.

There was also a fantastic Dentistry Basics session, which involved pulling teeth from a pig, and a Suturing Basics session. By the end of the day, I was definitely very ready for a curry. Which was lucky, since I was about to go to the East End for one.

I cycled today! 14 miles on my dad’s mountain bike. Excellent practice for a potential 26 mile cycle to Skegness on my next rotation. I decided that this exertion deserved a reward with a croissant, before the morning session began…

Caring for the carers

Mary Hopper has lived and worked in Rhodesia/Zimbabwe and South Africa for many years, and also runs a counselling and trauma workshop for those working in resource poor settings.

Elijah was afraid and ran for his life. When he came to Beersheba in Judah, he left his servant there, while he himself went a day’s journey into the wilderness.

He came to a broom bush, sat down under it and prayed that he might die. “I have had enough, Lord,” he said. “Take my life”.
1 Kings 19 

Following this, God strengthened Elijah, takes him to a quiet place, given a word of encouragement: and then gives him another difficult job to do.

The passage from Kings is a word to those who have grown wearing in well doing. Also a word to those who think that this will never happen to them. Huge list of people who have shown stress in history: Jeremiah, David, Charles Spurgeon, Martin Luther

Stress

Both acute and chronic stress have physiological effects. Its a common problem in the field of world mission. 20% have taken anti-depressants since becoming missionaries.

46% of missionaries suffer psychological problems (mainly depression) - their home organisations only knew of about 7.5%.

What can cause stress and burnout in resource poor settings?

• Frustration
• Feelings of inadequacy
• Busyness and tiredness
• Conflict within teams
• Cultural differences
• Language barriers
• Distance from local church – no fellowship
• Sad spouse, stuck at home
• Personal healthcare issues

Greenhouse effect: a plant in a greenhouse in the UK won’t grow out of control. Pop it into the Congo jungle, and it will grow out of control. Social conventions in the UK can reign back behaviours: drinking too much, driving, marriage problems. etc – without that control, it can worsen abroad.

Children especially can find returning home to the very civilised culture in the UK very difficult. No one at school will understand the freedom of running around barefoot under the sun. Studies show that children struggle with moves most, especially when they have to leave friends behind.

Single women can have problems: cultural expectations are often that must be prostitutes.

Further problems

• Questioning the meaning of life
• Loss of purpose
• Loss of hope
• Changes in beliefs
• Doubts
• Giving up faith
• Anger
• Feeling far from God

“I felt as if my life had ended; I just had to do things for other people; I couldn’t do enough for them.”

It is normal to feel low/disorientated when adjusting to a new culture. People who accept this is normal, and seek support, soon start to feel normal.

What is our theology of suffering and poverty?

When surrounded by dying and suffereing, how do you respond to “How can there be a God, if all this is happening?!”

“When working in a relief programme and witnessing a lot of death, poverty and suffering, I found my spiritual beliefs gave me a lot of comfort, and helped me “lay it all to rest” in my head.”

“Are you tired? Worn out? Burned out on religion? Come to me. Get away with me and you’ll recover your life. I’ll show you how to take a real rest. Walk with me and work with me—watch how I do it. Learn the unforced rhythms of grace. I won’t lay anything heavy or ill-fitting on you. Keep company with me and you’ll learn to live freely and lightly.”
Matthew 11:28-30

Helping yourself: Prevention

• Take a day off every week.
• The Sabbath principle
• Don’t overwork – do a Bible study on when Jesus said “no”, or didn’t meet needs”
• Do things you enjoy
• Have an attitude of gratitude

Savour the culture!

Mary has learnt far more from the people culturally in her area than she’s ever taught them. Coming home can be difficult because we have changed. She is no longer English – she is Shonglish: Shona and English. You come back, and you bring both cultures with you. One story she told us was very revealing:

“When I first went to Rhodesia, I still liked men to allow me to walk through doors first. There was one paramedic who seemed very rude – sometimes he would push me out of the way! One day, I confronted him, ‘Why are you so rude?’.

He explained, ‘In this land, I am the man, I must be first through the door. If I am first through the door, it is me who will be shot, it is me who will be blown up by the landmine.’

This rather turned my theology of manners upside down!”

Sabbath living

It is good to try to live out a Sabbath principle, even if we can’t necessarily have a set day each week.

God has called us to be a living sacrifice, so there will be times where we do have to work very hard, at the same time there are periods where he takes us behind still waters, times to get up on the mountain out of the crowds.

God has also called us to be members of a body – teamwork is an integral part of sharing a workload, jointly serving.

Managing teams across cultures

Standing barefoot in the sun for 20 minutes made me feel ready to sleep in the sun, but before that, we had Jane Bates heading up our final session for the weekend.

Cultural intelligence is a valuable skill, since our personal cultural situation so affecst the way we think, live and relate to one another. Jane shared some of the insight she has to this as a half Indian woman, raised in the UK by an English mother, and currently working in Malawi.

A simple model of different culture: our Prime Minister is the leader of our country, in Malawi, the President Joyce Banda is called the Mother of the Nation.

• How do people greet each other?
• How do people behave when they disagree with each other?
• How do people behave when they disagree with you?
• Do people publicly question/teach one another?

“A fish only discovers its need for water when it is no longer in it.”

We all have our own culture, but we may not recognise it until we are out of it.

Going beneath the surface

There are different layers of culture: “tip of the iceberg” culture is anything you can perceive with your five senses. Such as clothing, temperature, geography, smells. But its the deeper things that will affect your relationships more:

• opinions, viewpoints & attitudes
• philosophies & values
• convictions
• rules about relationships
• attitudes to time
• how the individual fits into society
• role of the family
• different role expectations
• fear of losing face
• attitudes to money & corruption

Case studies

What is your response, and what cultural issues may you need to consider?

You are part of a team of a team about to set out for a community visit and are waiting for team members to arrive. The last member of the team is over an hour late and gives no excuse on arrival.

• “Initially I found this very frustrating, but as time passed, I settled into their culture and became more late myself. Important meetings, I would tell them an hour earlier than I actually wanted them there.”

As team leader your office manager is one week overdue in submitting a report for donor funds. The donors are hassling you for the report.

• “Frustration”
• Cultural clash from donor expectation

The hospital you work at has run out of oral liquid morphine. Last week your staff went to the pharmacy to get distilled water, and you contacted the pharmacy warning them of this impending shortage.

• Frustration, understanding of problems with electricity.
• Increase your stocks – create buffers.
• Perhaps the pharmacist is not aware of pain being caused.

Overseas donors question why you have failed to extend the contacts of one of your staff members who they found ‘warm and personable’ on their recent visit.

• Everyone can have several different faces.
• Discussing problems, differences in living and working with people rather than seeing them on a visit.
• Important to have knowledge local labour laws and local contracts.

A visiting foreign doctor in the department of which you are head has one month left on his contract. He disappears and emails a week later saying that he has “decided to get some experience in accident and emergency before he leaves”.

• Considering his own advancement over his responsibilities. 
• Need to look at the contract.
• “?He is avoiding anyone losing face: if he came to me to ask for more experience, and I couldn’t provide it, then I’d be losing face”.

Your team refuse to go into the field unless you provide money a cold drink and a daily allowance.

• Assess the normal amounts and behaviour.
• Definitely provide a drink.
• Bargain 

Patient on the ward is the wife of one of your staff team. She has tested positive for HIV but only you are aware of this result.

You get back from two weeks leave to find that only two home visits have been done instead of the usual 8-10.

You are planning to do an HIV awareness campaign in a local community. Your staff workers return from their day’s visit saying they failed to do the activity as religious leaders “refused permission”.

Your staff team are regularly seeing and treating relatives of staff with general health issues regularly during time for your palliative care clinic.

Within your team, rumours have reached you (from a senior team member) that another staff member is having a sexual relationship with one of her immediate juniors. The junior staff member is about to come up for his appraisal.

Keys for managing a team:

Lead by example

Teach forward planning

Delegate

Transparent process of recruitment and selection

Train those starting work

Fixing salaraies and offering incentives

Seek opportunities for professional development

Team building get togethers

This marked the first day I arrived early enough to

Introduction to Paediatrics Abroad

The first step today was a presentation from the energetic Ian Spillman, with piles of horrific statistics. Sadly, as he said, behind the statistics are real children…

We live in a world of difference. For many families, feeding is a case of “have the rains come?”. 40% of under five deaths are neonatal. If you improve sanitation, you see ~25% improved in under 5 mortality. The most common causes of death are diarrhoea, birth asphyxiation, diarrhoea and malnutrition.

In Malawi, half of all mothers have had at least one child die.

He shared a story of a 1 week old in Uganda that had been 3.5kg at birth, and 2.5kg on presentation. They waited a week, with this child vomiting every feed. The family, both parents teachers, had been to a traditional healer, instead of seeking health care support. There is a cultural problem, complicated all our medical efforts.

One UN Millennium Development goal was to see a reduction by two thirds in child mortality between 1990 – 2015. We are currently about halfway there…

Resus key practical skills

Ian then showed us clips of a video from a APLS course. Key points:

• We saw expiratory grunts, pertussus, inspiratory stridor, don’t forget systemic causes – heart failure, acidosis, ketoacidosis.
• With a neonate, you need to dry the baby immediately.
• Umbilical vein catheterisation. Open it up with forceps, insert a pre-flushed saline catheter and tape in place. You can still access the umbilical vein up to around 7 days.
• Interosseus is inserted into the tibia around 3cm below the top of the tibia, medial to the tibial tuberocity. Ideally used for resus, allowing you to gain venus access.

Care of the Newborn

The next talk was from Hannah Blencowe, speaking on neonatology in resource poor settings.

Globally around 135 million births each year, with around 57% in  health facility. The evidence is that birth in a health facility may be safer… but this isn’t really feasible in all settings.

Whilst worldwide, the under 5 mortality rate is dropping steadily, the newborn percentage of that is fairly static: we are getting better at treating the under 5s, but not neonates.

The top 3 causes of death are preterm birth complications, neonatal infection and birth asphyxia.

The majority of neonatal deaths are at home. This is due to delay in 3 areas, only one of which is medical:

1. Delay in recognition and decision to seek care.
2. Delay in transport to care.
3. Delay in receiving quality care.

Resuscitation of babies

• 136 million – normal.
• 10 million – need rubbing and drying to stimulate breathing.
• 6 million – needs respiratory support with bag and mask ventilation.
• <1 million – need advanced neonatal support.

More hospitals in developing countries have neonatal resus equipment than staff trained in neonatal rescucitation. Training would save far more lives than buying new shiny machines.

Many neonates brought in have hypothermia to some degree – some studies in the developing world show a prevalence of 60-90%. Incubators are expensive and can cause infection – the best initial treatment is kangaroo care – baby skin on skin with mother, wrapped in a blanket. Using this for stable babies frees up resources for the more unwell children.

Early and regular breastfeeding is vital. Some hospitals have closed neonatal wards that only allow mothers in every 3 hours, and if they miss their slot, they aren’t allowed in and the baby is fed with water and glucose instead: this should not be encouraged.

Hygiene is important, especially in hospital. Many washing, clean facilities, washing the patient, etc. However, cord care is valuable also, and the recommendations are changing to cord care with chlorhexidine. Remove cannula if not needed, since can be a key focus for infection.

Ideally primary care transfers and patient self referrals to hospital need to increase. However, if this happens, most developing world hospitals will struggle to cope.

Integrated Management of Child Illness & Triage

Next up to the plate was James Bunn, teaching us about the tool of IMCI, for implementing an integrated approach in order to impact child health.

Integrated Management of Child Illness (IMCI) was started in 1997, and has 3 components :

• To improve case management skills of health workers
• Health care system improvements
• To improve  family and community practices

More than 8 million children die each year from just 5 causes. Pneumonia, Diarrhoea, Measles, Malaria, Malnutrition.

Some studies now show that healthcare workers, if using a simple clinical syndromic approach to these key conditions, can provide an equal quality of care as doctor to 50% of patients – sometimes better.

A pneumonia traffic light system:

• Normal RR – no pneumonia: simple remedies.
• Raised respiratory rate - pneumonia: give antibiotics.
• Subcostal indrawing - severe pneumonia: refer, admit, or give parenteral ABx.

(Inabilty to feed, stridor, convulsions, reduced conscious level, malnutrition are all red flag features too)

Whilst IMCI hasn’t been as successful as hoped, it has shown that there have been systemic changes in practice, which has improved outcomes. For example, the evidence showed that after training, staff were going back to their healthcare offices, and attempting to rectify lack of resources, diagnosing more successfully, and assessing better. This did reduce over time, but still clearly showed an improvement.

IMCI can reduce overall costs of treatment despite actually providing a more comprehensive care for the child.

One study in Pakistan, they made of doctors use an IMCI protocol, instead of providing individualised treatment to each patient. The doctors hated this: but they saw their survival rate from Pneumonia increase from 91% to 96%, whilst also seeing their ABx use drop from 52% to 19%!

In other words: you don’t need a stethoscope to diagnose pneumonia.

The problem with IMCI (and all good health care) is it needs frequent retraining. The courses take 11 days. Obviously, this is expensive and so needs.  icatt-training.org

Triage

Emergency Triage, Assessment and Triage (ETAT) is a process of triaging queues in clinics, to walk around and check for red flag signs regularly, bringing people to the front of the queue in order of priority. With small amounts of training, a low level healthcare worker can provide this service.

Case Studies of Paediatrics

After a practical session involving practising interosseus fluids, infant bag and mask and umbilical cannulation, we had some lunch, then returned for some intriguing case presentations from Ian Spillman. 

He took us through a number of conditions in children, that we never see in the West due to screening, folic acid in food, etc:

• Dehydration
• Imperforate Anus in Downs
• Hydrops
• Spina bifida
• Gastroshisis
• Haemorrhagic disease of the newborn
• Albinism
• Ilial performation in typhoid.
• Pott’s disease
• Cardiac Failure
• Hypothryoidism

Beware the damage from traditional healers: some things they use cause blindness, increased infections.
Neglect causes problems, with clubbed feet, neglected osteomyelitis, non healed bones.

Seminars & Case Studies

We worked through some IMCI case studies next with Mark, and then some neonatal case studies with Hannah.

Jaundiced baby – if occurs in first 24 hours of life, always pathological. Common causes haemolysis, infection – syphillis. Treat quickly with light therapy, either phototherapy with special bulb, or put near window. Also use fluids. Aiming to prevent Kernicterus.

Floppy, apnoeic baby after a 3 day labour. ?Sepsis, ?Hypoxic damage. Check hypoglycaemic, with ABx: Pen & Gent. Replace fluids, get breast feeding as soon as possible. If starts feeding, higher survival rate.

Malnutrition

After this, we had a final talk from Marko Kerac on Malnutrition. The AC was on full, and I had coffee, so there was at least a tiny chance I would stay awake…

Causes of Malnutrition

Over 50% of developing children are stunted, wasted or underweight. This causes cycles, since it leads to stunted adults, who have deficient babies, who becomes affected adults, who become… etc.

Being malnourished makes conditions worse, worsens mortality and morbidity. See the picture in the IMCI template – it underpins all the child mortality..

Zinc and Vitamin A deficiency kills nearly 1 million children worldwide. Why can’t we resolve this?

Levels and types of Malnutrition

An upper arm circumference (MUAC) of less than 11cm in a 6 month to 5 years child implies dangerously underweight.

• Marasmus: wasting malnutrition. Generally wasted, thin arms (MUAC), thin face, “old man”, ribs visible, sunken eyes, lack of skin turgor.
• Kwashiorkor: oedematous malnutrition. Bilateral pitting oedema, englarged liver, angular chelitis.

Remember the Car

The basic of therapeutic supplementation is to remember a car. If your car is stuck, you can’t just start at 60 and drive off – you need to work up the gears.

In someone chronically malnourished, all their body systems have slowed down: low stroke volume, low renal function, low gastric motility, etc. You need to start feeding them very slowly, or the car will stall, eg. the patient will become overloaded. Their appetitie will slowly return, and this is helpful: it is a good sign that their other body systems are catching up: so you can rev the engine!

Start with an inpatient stabilization, followed by outpatient therapeutic feeds, then outpatient supplementary feeds, as the car becomes able to drive itself.

Community treatment

Mum’s prefer community based approach, takes the workload away from the ward. Some places have managed to make an locally sourced peanut butter based ready to eat nutrition.

UNICEF can help provide ready to eat nutritional supplementation. The Emergency Nutrition Network is an excellent resource to use to ask questions.

It’s all very well worrying about breast feeding passing on HIV. But what’s the point in being HIV free if you are dead?

Important to breast feed babies – dying from malnourishment is not a successful outcome – HIV Free Survival, not just HIV Free.

Whilst I drove to Oak Hill College, I listened to Radio 4, with a very relevant Thought for the Day, that I’ve completely forgotten. If I get an opportunity, I will look it up. I then drank lots of apple juice, then sat in the lecture hall…

The Global Picture of HIV

Gisela Schneider opened the day on HIV. She told us two stories, one of a bishop at a national conference, washing the feet of those with HIV, and another, of a pastor apologising, in tears, to a woman who said how she has been unable to speak publically about her HIV status. The pastor apologised, because Christians too easily judge it as a moral problem, and forget that there are people in the midst of it who simply need the love of Christ.

When she first worked in Gambia in the 80s, HIV arrived, but it was simply referred to as “the disease”. No-one would talk about it, no one would accept it, and it was simply hoped that the patients would die and take away the shame from the family. The Lancet article in 1985 was the first to describe a hetrosexual disease spread by sexual contact. At that time, patients simply died.

We have seen a wonderful precedent in the speed that civil society identified that ARVs needed to be patent free. If left to pharmacutical industry, ARVs would not be patent free until 2016 – whereas since 2000 we have actually had more than 6 million people started on treatment.

We asked our clinic users what they wished to be called by us. They did not want to be “patients”, or “clients”. They said “Call us friends”. We must be in a partnership to defeat HIV.

In global politics, HIV is beginning to be seen as a resolved problem: governments are starting to reduce funding, public interest is waning: new causes such as global warming are taking a place on the global agenda. We must fight to keep a public interest alive in HIV. If not, funding will be cut, patients will not recieve medications, and a treatment resistant form of the disease will spread, unopposed.

There have been some successes – 20% reduction in HIV Transmission from 2006-2011. The numbers of infected people are stablising, but there are still 7,000 new infections a day worldwide.

Some examples, of the varying leading risks for infection.

• Lesotho – stable heterosexual couples
• Kenya – multiple partners
• Benin – sex workers

In Lesotho, being married is the best indicator of risk for HIV infection!

Africa is ahead of the game. In places such as India and the rest of Asia, there are some shocking statistics – in Lahore, 82% of sex workers did not think they were at risk of HIV infection.

History of HIV

• 1981: First AIDS case reports
• 1984: First HIV tests
• 1990: First HAARTs
• During 80s & early 90s: the focus was on Prevention. Scaring patients, increasing awareness. This wasn’t terribly effective. Spending on AIDS globally was around 200 million.
• Late 90s & 00s: we began aiming for Universal Access, with a political backing. The key change was DOHA, which created a mechanism to allow WTO members to issue compulsory licences to export generic versions of patented medicines to countries with poor. Spending on AIDS globally is now around 20 billion.

One downside is that drug companies are now showing hesitancy to invest in HIV treatments due to the risk they will have their drugs stolen as generic drugs, and make no money.

Discussion: What are the main challenges in HIV today?

1. Western economic crisis, increasing instablity in Africa leads to programmes falling apart.
2. Primary Care settings, often the drugs are not available.
3. Some places, such as PNG, are way behind the curve.
4. Sustaining the enthusiasm politically and locally.
5. Treatment has meant that people are less scared of the disease, and more complacent.
6. Stigma is still a huge problem.
7. Cultural norms, gender inequalities.

Stigma is worldwide. In Germany in 2012, a lady from Togo with HIV and Cervical cancer, wasn’t being treated for the cancer, because the Gynacologists were scared to operate due to the virus.

The New Approach – SAVE

Safe practices – ABC, Circumcision, Safe infections, etc.
Access to treatment – Reduction in Viral load reduces transmission, PMTCT, etc.
Voluntary counselling and testing – Stigma free counselling, etc.
Empowerment of children, women and youth – families, communities, leadership, PLWHA, etc.

“The greatest good you can do for another is not just to share your riches, but to reveal to them their own.”
Benjamin Disraeli

HIV Basics

A tea break, before she sent all the experts out, leaving just the idiots like me who don’t know anything about HIV…

There are a number of different viruses involved, HIV1 M, HIV N, HIV O, HIV 2. The process of CD4 infection is through CD4 attachment, then Co-receptor binding with gp120 joining to surface proteins, with gp41 joining to CCR5 receptors in the cell wall, allowing the RNA inside to be released into the cell.

Once inside the cell, the RNA is integrated into the DNA of the cell, creating provirus. This process takes several days. This is the point at which lifelong infection begins. Once the RNA is integrated into one cell, the virus (currently) cannot be eradicated from the body.

The initial stage, of introduction of RNA to the cell takes around 2 hours – some preventative drugs work on this process – which is why post exposure prophylaxis ideally needs to happen within 2 hours.

Once CD4 cells are infected, they become disorganised. They are still there, but they can no longer react to immune problems correctly. Over the next 12 weeks, the virus is replicated, sometimes causing an acute viral “conversion” syndrome – click the graph on the right for a larger version. There is an excellent explanation of this process that Gisela mentions in her slides at The Naked Scientist.

Testing is a key area of discussion, with the basics of 5Cs – Consent, Confidentiality, Counselling, Correct testing, Linked to Care.

Telling a patient they have HIV is so life changing, so painful, that you should not test patients if you cannot provide them with this fivefold support.

After infection, progression to an AIDS syndrome can take <5 years (10-20%), 7 years (60-70%),  >10-15 years (5-10%). Less than 1% do not progress.

WHO staging

She advised us to print this list, and laminate it. We won’t be able to remember it, but we can refer to it as we see patients.

Stage I

Asymptomatic

Stage II 

• Moderate weight loss (<10%)
• Recurrent respiratory infections (sinusitis, bronchitis, otitis media etc)
• Herpes Zoster
• Angular cheilitis, oral ulcers and sores
• Papular pruritic eruptions (PPE)
• Seborrhoeic dermatitis
• Fungal infections of nails

Stage III

• Unexplained weight loss >10%
• Unexplained chronic diarrhoea > 1 month
• Unexplained persistent fever > 1 month
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis
• Severe bacterial infections (e.g. pneumonia, empyema, meningitis, pyomyositis etc)
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
• Unexplained anaemia (<8g/dl), neutropaenia (<0.5 x 109/l), thrombocytopaenia (<50 x 109/l)

Stage IV

• HIV wasting syndrome
• Pneumocystis pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (> 1 month)
• Oesophageal candidiasis
• Extrapulmonary tuberculosis
• Kaposi’s sarcoma
• Cytomegalovirus infection (retinitis or other organ)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Extrapulmonary cryptococcosis
• Disseminated non-tuberculous mycobacterial infection

Case studies of HIV

Gisela then walked us through some case studies, through common presentations of ?HIV patients. Opportunistic infections - important markers for clinical stages. Need to be treated before initiating ART:

Fever of unknown origin – commonly due to TB, Malaria, PCP, Cyptococcus, Toxoplasmosis.

Focal neurological lesions – commonly due to Toxoplasmosis, Tuberculoma, Primary CNS lymphoma, Brain abscess, Stroke.

Diarrhoea – less common now in areas with high ARV treatment, but in ARV naive areas, commonly due to Cryptosporidium, Microspora, Cyclospora, Isospora.

Basic preventative therapy:

Good studies showing that provision of the following can make a difference – but the community needs to be involved, as had been said all week. Go to a village, given them nets, they won’t use them. Work with a village, if they ask for help, then it becomes part of the village culture.

• CtX prophylaxis.
• Malaria protection (ITN).
• Clean water supply.
• Condoms.
• Nutritional support.

Anti Retrovirals Therapy

A 5 minute break during which people laughed on hearing that the BMA just passed a motion calling for Andrew Lansley to resign. Then back to ART…

Nucleoside Reverse Transcriptase inhibitors (NRTI)

• Backbone of therapy.
• Side effects of Anaemia (AZT), Polyneuropathy(D-drugs), lipatrophy, lactic acidosis.

Non Nucleoside Reverse Transciptase inhibitors (NNRTI)

• NVP – Can cause hypersensitivity, lead in. Hepatotoxic
• Efavirenz – Teratogenic.

Protease Inhibitors

• 2nd line treatment (but first for HIV 2). More expensive but effective.
• Difficult to take due to side effects – Diarrhoea bad. Also cause hypergylcaemia and hyperlipidaemia, long term cardiac risk.

Combination Therapy

• Generally two types, combined. Commonly 2 NRTI + 1 NNRTI. Sometimes 2 NTRI + PI.
• Important to avoid some combinations due to side effects.

Response to ART

Threefold improvements:

1. Virological – Ideally level falling to an undetectable viral load.
2. Immunological – Rise in CD4 count, around 10/month.
3. Clinical – Weight gain, Disappearance of symptoms.

Highest risk of ART toxicity will be in the first 1-3 weeks. After this, the next few months 16% of patients in stage 4 starting ART will respond with an IRIS (Immune Reconstitution reaction). Common cause is CMV, TB or cryptococcal disease. Highest risk of death in in the first 3 months, worsened risk by low CD4 count – can be avoided if we start treatment early!

Treatment Failure

Clinical treatment failure: a new or recurrent stage IV event.
Immunological treatment failure: fall of CD4 to baseline. 50% fall from peak. Persistent low levels of CD4.
Virological treatment failure: viral load > 5000 copies.

ART Counselling

Counselling is one of the most important factors in useful ART treatment. You need cultural sensitivity, there must be understanding, real communication and community support. Indigenous health workers are the most effective at this, so they can be the best contributors to good compliance.

HIV in Pregnancy and Childhood

Lots of Quorn sausages later, I walked through the gardens barefoot in the 27 degree heat, chatting about Somalia with a fellow CMFer, and wishing that there was ice-creams. Then we returned to the expert world of Gisela…

“No child should be born with HIV, no child should be orphaned from HIV, no child should die from HIV”
11 year old HIV orphan, Ebube Taylor, speaking to a UN panel

48% of eligible adults are receiving ARTs. Only 23% of eligible children receive ART.

Seven year follow up of Gambian pregnant women living with HIV-1. Mothers who died within 7 years: 34%. HIV infected children who died 69%. Orphans who died irrespective of their HIV status. In other words: being an orphan is as bad for your mortality as being a child with HIV.

Reducing vertical transmission

20% of maternal deaths in Africa are due to HIV. Avoid this by using ART, and aiming for quick normal deliveries, avoiding instrumental delivery. Where feasible, elective CS.

Ideally start combined ART for all pregnant women, continuing for life. Some places use a single dose nevirapine to prevent mother-to-child transmission – but there is a widespread resistance to this. When mother on ART, breast is best, and relatively safe!

Mother on ART throughout pregnancy reduces transmission from 30-40% to 2%.

Childhood HIV

• Category 1: Die within 1 year. (25%-30%)
• Category 2: Symptoms early in life, die aged 3-5 (60%)
• Category 3: Develop symptoms >age 8. (10-15%)

Test all children with a dried blood spot test with the first review after birth. HIV children present commonly in first year of life with PCP. Treat with high dose ABx.

Treating children is very complex. Much better to heed Ebube Taylor’s words, and prevent vertical transmission.

Palliative Care in Resource Poor Settings

Unsurprisingly, the 27 degree heat, coupled with 5 hours of very intense discussion of medications with long names and scary side effects, I nearly fell asleep. 2 pints of coffee later, and AC turned on in the lecture theatre, I steeled myself for our final lecture from CMF’s own Vicky Lavy.

Vicky spent several years establishing and running Paediatric Palliative Care in Malawi. She then wrote a Palliative Care toolkit for use by others, and much of her teaching is from that.

A nurse we had been working with for several months said “Doctor, I do not see how this Palliative Care can work – the patients, they just keep dying!”
Caring rather than curing. A revolutionary concept to many places in the world.

Palliative care is looking after people with illnesses that cannot be cured, relieving their suffering, and helping them through difficult times. The “care” is key. As Jesus said:

“When I was sick, you looked after me”.
Matthew 25:36.

In the developing world, very often Doctors say “There is nothing we can do”. But Palliative Care never says this – no matter how small, there is always something we can do.

Counselling and psycological support is a vital part of palliative care. Often forgotten in favour of exciting discussions of oxycodone doses, but actually is probably more important. Truth is one of the most powerful medicines available to us, but we still need to develop a proper understanding of the right timing and dosage for each patient. Despite cultural differences, there are studies across the world showing that telling patients the truth has a positive medical effect.

Pain management should be done by the mouth, by the clock, by the ladder. Oral, regularly, and according to the WHO pain ladder. Codeine is very expensive, so we usually pass from Step 1 to Step 3 quite quickly.

Top tips

1. Topical metronidazole for smelly wounds. Smelly wounds are stigmatising, but just crush metronidazole can resolve problems.
2. Metronidazole pessary for vaginal discharge. Similar to above, with Cervical Ca
3. Opiates for breathlessness and diarrhoea.
4. Gentian Violet paint for candida and skin sores.
5. Prednisolone for mouth ulcers.
6. Franjipane juice for Herpes Zoster. Common African flower, sticky juice inside a flower.

 Taking a spiritual history

Always something that can be helpful, but a very important part of Palliative Care

• “I ask everyone about this, as part of our routine assessment.”
• Do you have a faith which helps you through difficult times?
• Do you ever pray?
• What helps you make sense of life?
• What things are most important to you?
• Have your thoughts about life changed since you became ill?

Almost late today, which meant we failed to do the proper British thing of sitting in the same place every day. The front row seems like a scary place, and I’m further from the toilet too. Not much I can do about that, so it’s time to pay attention. Today started with Vicky Lavy discussing how the course is acredited, and all the tiresome exciting repercussions of the new UK revalidation process. After this, it was time for…

Tuberculosis

Our first talk of the day was by John Day, who spoke yesterday. By telling us that between a third and half of the world’s population have been infected with TB, he warned us that it was likely to be relevant to all of us, regardless of where we are working in the world.

Fuelled by the HIV epidemic, disproportionately affecting the poor, disenfranchised, and hard-to-reach group, and steadily become resistant to many ABx, TB is a unique problem. Taking 6 months of a combination antibiotic is an enormous challenge – I can appreciate this, since I have never successfully completed a 7 day course myself, generally missing out between 1 and 6 days worth.

Diagnosis of TB

A 58 year old Kenyan woman with 1 month cough, sputum, weight loss, night sweats. 1 week of pyrexia & haemoptysis. Non smoker, no previously unwell. EXAM: 55kg, pale conjunctiva, no lymphadenopathy, crackles L chest.

• All patients with more than 3 weeks of cough should be suspected for TB.
• All patients suspected of having pulmonary TB should submit at least two sputum specimens for microscopic examination. Needs sputum microscopy for acid-fast bacilli (AFB).
• Chest XR would be very helpful.
• Good records are important, since we are following up patients for at least 6 month: level of certainty of diagnosis, anatomical site, bacteriology.
• For all previously treated patients, specimens for culture and drug sensitivity testing are needed before starting a new course.

Treatment of TB

Generally an intensive phase of HRZE (Isoniazid, Rifampicin, Pyramidizine, Ethambutol) lasting two months, followed by a continuation phase of HR for 4 months. This changes in areas of high resistance to Isoniazid, etc.

• Isoniazid: Bacteriacidal. Quick reduction in infectivity.
  Side effects of peripheral neuropathy & hepatitis.
• Rifampicin: Bactericidal. Effective against semi-dormant bacilli. Expensive.
  Side effects of Gastrointestinal, Hepatitis, Drug interactions (COC), Red Urine.
• Pyrazinamide: Bactericidal. Low potency (not worth giving for more than 2 months), good at intracellular sterilisation.
  Side effects of Joint pains & Hepatitis.
• Ethambutol: Bacteriostatic. Low potency. Well tolerated.
  Side effect of optic neuritis.

Untreated TB has a mortality rate of 60%. Treated well 90% will survive (almost all from TB, fatal hepatitis from treatment is incredibly low). Relapse rates are less than 5% with current treatment regimens.

Follow up of TB

Ideally, daily observed therapy is the best way to ensure good adherence. If unavailable, checking colour of urine is useful tool to confirm Rifampicin use.

If sputum smear +ve at diagnosis, repeat at: 2 months, 5 months (start retreating if +ve), 6 months (cured if -ve).

Group discussions

You have been asked by the National Treatment Programme of Bolivia to describe the impact of TB-associated stigma and make recommendations on how to reduce it. How will you respond?

• Government wide programme of education, and engaging with local and community leaders.

You are the infection control committee of a 200 bed district hospital in India who have been investigating a number of recent cases of TB amongst hospital staff. What measures would you recommend to reduce nosocomial (in hospital) transmission?

• Masks.
• Hand washing.
• Living arrangements.
• Staff HIV testing.
• Lots of little things to make a difference, through staff education.

You are a team working for the Zambian Ministry of Health, with a large aid budget to develop joint TB and HIV services. What will be your spending priorities?

• Two vertical programmes, integrating them always causes friction.
• Need to work with people at the top – have to get all the top people together in a room.
• Debated whether or not the two programmes should be combined, or improved to communicate between each other better.

Malaria

After a cheeky biscuit break, we return to learn about Malcolm Molyneux’s endless admiration for the dashingly intrepid malarial protozoa.

A very complex diagram explaining the pathogenesis and cycle of Malarial disease was put on the screen. Malcolm proceeded to (briefly) rhapsodise about each stage. I struggled to take it all in, but I have included it on the right – click for a larger version.

The commonest cause of human malaria is P falciparum. The most reliable blood test in the developing world is a thick blood film, which is most sensitive for confirming presence of infection; thin films allow positive identification of species.

Around 0.5 to 1 million deaths from malaria each year worldwide. Around 10 deaths from malaria each year in UK.

Interestingly, in the UK, an asymptomatic phase of disease is very uncommon, since there is no innate immunity. The well documented sickle cell trait protection against malaria reduces serious disease, but doesn’t stop individuals developing symptomatic disease. Young infants are relatively protected from malaria with maternal IgG, and by presence of fetal haemoglobin.

A very worrying property of Malaria is that it can develop into severe illness very rapidly. Uncomplicated malaria is simply a febrile illness, clinically indistinguishable from other causes.

Features of severe Malaria:

• Severe anaemia - most common in babies.
• Encephalitis (Cerebral Malaria) – floppy, seizures, coma
• Acidosis – heavy breathing
• Respiratory Distress syndrome (seen in adults)
• Acute Renal Failure (seen in adults)

Fatality rate is 10-40% – the more of these three present, the worse the prognosis. Hypogylcaemia worsens prognosis but can be treated. “Black water fever” is black urine that occurs due to haemoglobinuria, generally accompanied by renal failure.

4 Ophthalmological signs of severe Malaria (tying in nicely with yesterday’s Ophthalmology session): this is a helpful confirmation of diagnosis, rather than diagnostic in of itself.

1. Retinal whitening
2. Vessel changes
3. Retinal haemorrhages
4. Papilloedema

Treatment is based on your local policy of antimalarials. Generally an Artemisinin Combination Therapy (ACT), since they are faster than Chloroquinines, generally given as a dual therapy with an older remedy, to try and reduce resistance: there is none evidenced yet.

Quinine is still used widely – it is very cheap, and there is only moderate resistance. It is less effective than Artesunate, with roughly 40% higher mortality in severe Malaria, but still effective. Impregnated Bed Nets is a valuable tool in Malarial control, alongside a number of useful tools in the relevant country’s National Malaria Control Programme (if they have one).

There is an optimistic but worthwhile aim to eliminate Malaria worldwide within 40 years. 40 countries have eliminated it, but 80 remain with active transmission. e=mc² : Elimination = Money x Commitment²

Tropical Medicine

Lunchtime came, with the chef actually making me a vegetarian option for the first time today. After this we began a futher 3.5 hour session with John & Malcolm on the entire field of Tropical Medicine.

Man aged 42 years, French professor from the DRC. Admitted to hospital with poor concentration, insomnia, emotional distress, unable to cope. Had been tortured in the Congo, escaped, spent a year living in the jungle, managed to escape to Canada.

He had a labile affect. Delusions, Auditory & visual hallucinations. Displayed minimal discomfort in describing his harrowing experiences. (unlike post traumatic stress disorder). EXAM: Hb 10.9. Diagnosed as reactive depression with psychotic features. Treated with setraline olanzapine and other drugs. Continued to deteriorate…

• Tested for HIV, and many other infective, parasitic and neoplastic conditions.
• Ultimate cause was trypanosomiasis.
• Look for a chancre – see on the right – from the bite of a tsetse fly.

We covered a vast number of horrible little things, including cysticercosis, tapeworms, hydatid disease, liver flukes, roundworms, hookworm, trichuris, ascaris. I did not take notes on these, because much of it went straight in one ear and out the other. However, when I asked John, his advice was:

You need to know the common burden of disease in your area, common presentations of those parasites, and what medication is available. Ideally, you should back up all cases with a laboratory diagnosis.

Malcolm then taught us a little more on Malaria, but I’ve put this above with the rest of the Malaria teaching, to stop things getting confusing, but then moved onto another species that he holds a concerning amount of love for…

Shistosomioasis

The live in snails that live in reeds on the waters edge. If you swim at least 100 metres out, you will be okay. Probably. If you get infected, you will know, because you will get a “Swimmer’s Itch” – this is the irritation from the larvae wiggling through your skin. This itch is worse with non human shistosomes, since the larvae struggle in vain to get through the skin.

From there, they head to the lungs, to breed. You can get a bit of a cough, depending how many of them went in through your skin. They then head to the liver as they are growing. The whole wonderful journey takes several weeks.

The liver is the Gretna Green of Schistosoma. Two worms pair up, and remain extraordinarily faithful for their remaining 3 years, always by one another’s side.

They then pass eggs continuously out of your body, causing calcification in the bladder wall, and eggs in stool or urine.

Shisto disease

The great majority of adult infections are asymptomatic. But rarely, there’s an abnormality, which can cause serious problems:

• Katayama fever – serological response to egg antigens.
• Chronic granulomatous response to eggs:

1. eggs in usual place, but too many – eg. hydronephrosis after obstruction in bladder, bladder cancer.
2. eggs float to wrong destination – liver fibrosis
3. ectopic adult worm couple, sending eggs in wrong place – eg. spine, genitalia

Prevention

Chemotherapy treatment to communities reduces disease burden. Trying to encourage behaviour to stop passing stools or urine near lakes, cutting off the cycle of eggs maturing on snails, preventing further disease.

I left a little earlier today so that I could skip the traffic. This was successful to some extent, saving me about 15 minutes. Unfortunately, failing to get a swipecard yesterday meant I spent around 15 minutes waiting outside until someone let me in. Eventually though, I managed to get a cup of coffee before the first session began…

Mental Health

Maureen Wilkinson (who spoke yesterday) started us with another picture:  “I’d like you to come with me to the edge of the Sahara. You are visiting an old lady, in a cut, nearing the point of death. On the vast horizon, a dust cloud appears, and it become clear that its a group of Arabs on horses. The riders are wearing bright blue robes. The constrast in vitality between their life and the dying lady is vast. Africa is a land of many contrasts. 

A few hundred miles away, there is a hospital. A shiny clean new building, with new wards. It is a pleasant place to be. However, a few hundred metres away there is a shack with blacked out windows. Patients are chained to the wall and fed once a day. This is the Mental Health Unit. Africa is a land of contrasts, and few none are as stark as those between the physically and mentally ill“.

Is there any other group in history that have been so set apart, forced to live in exclusion, ostracised? Lepers. And how did Jesus deal with lepers? He touched them. We need to touch those with mental health disorders. Looking at which disorders cause lost years of life due to disability, psychiatric illness leads the pack more than threefold over the next area. It causes 15% of the global burden of disease, but gets less than 1% of health spending worldwide.

On first visiting Mission Hospitals in the 70s, Maureen would ask “How do you treat those with mental illness”. They often replied “We don’t”.

Worldwide challenges include: disruption to community, absence of social welfare net, adverse social dynamics; gender inequality, women & children vulnerability. Traditional practices can cause a problem: some hospitals have established referral pathways from traditional healers – you can’t stop people using them, but if they don’t have success, encourage them to send people to the hospital. This was tried in Malawi, which led to children with burns due to epileptic fits coming into hospitals for the first time, and numbers of burns falling…

Drugs and alcohol are a major problem in the developing world, especially Africa. Causes chronic ill health, risk taking behaviour, spousal abuse, RTAs. Community solutions and local awareness and leadership engagement can impact this.

One great story is where a group in Uganda got together with the hospital, local leaders, government and churches, and held a large community meeting. Different people stood up, asking people to stop using cannabis, influential leaders and community members each trying to engage with the youth. Finally, the local government minister stood up and said “You must all stop using it, I believe very strongly in this!”. However, someone at the back of the crowd shouted “You! You grow this evil weed, and I know where your field is!”

Catatonic schizophrenia is much more common in developing countries, and is rarely treated in the way it needs to be – thought to be evil spirits or “madness”. Commonly seen with waxy flexability and auto-obedience. Older drugs calm down patients, but it is the newer drugs which are really effective at treating the disease. Depot preparations are often more easily usable in a developing world context. Chlorpromazine, Haloperidol and Fluphenazine are common and cheap options.

There are high levels of post-natal depression, especially if a girl is born, since cultural expectations are often for male babies. Mother-in-laws are a worldwide problem!

Depression often present with somatization. There is poor cultural awareness of mental health disorders – some languages do not even have words for depression.  It can present with total body pain, crawling over body, or other non-specific symptoms. In some countries, sadness is thought to be caused in the heart, and so presents with palpitations and abdominal pain. Once you get behind the story, you can often find common biological and cognitive symptoms of depression, that the patient might not have been aware of. Amitriptyline and Fluoxetine are good drugs to use: advise asking pharmacy if they can stock SSRIs, since they are cheap now, and safer in overdose. Remember to ask for risk of self harm/suicide, and be aware of increased risk at start of treatment as energy levels rise, but mood stays low.

Always think in consultations:

1. Is this person physically ill?
2. Are they under influence of drugs or alcohol?
3. Then… could they have mental illness?

 General Medicine

Our second morning session was a joint effort from Malcolm Molyneux & John Day. We were given case studies to read and then discuss points about medicine in resource-limited settings.

The fundamentals of clinical practice and disease are the same everywhere. Pneumonia, Hypertension, Diabetes, Gastroenteritis and many other conditions remain common. Whilst there are changes – less IHD, more HIV/AIDS, increased endemic infection, etc – the underlying science of treatment and diagnosis remains static.

Expectations of patients remain unpredictable. The man who’s life we saved, but then complained that we had lost his pajama bottoms is an example of this.

It’s important to find locally who can advise and teach you, and also nationally: maybe try to make it to a grand round one a month? Try to run a regular weekly teaching session, or join an online group. We did a straw poll amongst us: In a group of 35 doctors with an interest in developing world medicine, only two won’t have access to internet. It’s becoming a highly accessible tool worldwide. Key observations:

1. Fundamentals of good clinical practice are the same everywhere.
2. But there are important differences in practice.
3. Acquire local recommendations / guidelines.
4. Learn who can help.
5. Devise ways to confer regularly with staff and colleagues.
6. Maximise and appreciate what you CAN do, rather than bemoan what you can’t.
7. Promote other cadres to do things well.
8. Note first impressions of what’s good/bad.
9. Re-visit your recorded first-impressions a few months later.
10. Write: record events, ideas, progress: for publication, for your own records.

Case studies:

36 year old male in rural India. Severe breathlessness since this morning, no cough/haemoptysis. Has had increasing abdominal swelling over past 3 weeks. No vomiting. EXAM: very dyspnoeic. Chest and heart normal, Abdo: ascites ++, ?hepatic mass. No peripheral oedema.

• TB Pericarditis – Common cause of ascites and hepatomegaly after R heart failure. Feel for pulsus paradoxis. Could be an acute presentation, even though usually chronic.
• ?Hep B malignancy - Most cases of Hep B are caused due to transmission in infancy. Commonly leads to hepatocellular carcinoma.

40 year old mother of 6. Vomitedx3 this morning, and had one loose stool. Then began coughing and seemed breathless. 2 hours ago had a seizure, and has been restless but not responsive since then. EXAM: GCS 8/15. Making restless, purposeless movement of all limbs. BP 110/70, pulse regular 60/min, T 36C. Breathing noisily – ?secretions ++. Chest: widespread crackles.

• Ingested toxin: organophosphates. Small pupils, floppy patient. Fasciculations. Treat with atropine.
• ?Ingested toxin: chloroquine.
• ?Hypo/hyperglycaemia.

49 year old policeman been more drowsy over last 24 hours. Now talking, but not sensibly, and can’t walk since this morning. He has complained frequently of headache during the past 2 weeks. EXAM: GCS 7/15. BP 140/100, pulse 56. T 53.3C. R pupil larger than left. R pupil does not constrict to light shone into either pupil. L pupil constricts to light shone into either pupil. Makes some movements of all limbs – seems to move right limbs more than left.

• Cerebral TB.
• ?HIV Cryptococcal/Toxoplasmosis.
• ?Sub-dural haematoma.

General Medicine Part 2

I used the lunch break to run home and pick up my wife, who was being driven slightly mentally unwell by her entrapment in a home with a child and 3 dogs. After gulping down some creamed spinach, we started again, with a brief talk from myself about Social Media and the #cmfdevhealth hashtag, before moving on to Part 2 with Malcolm & John again.

More case studies:

66 year old former athlete complains of a couple of months of tiredness and weakness, poor appetite and some nausea. A dry cough and slight breathlessness, taking laxatives for constipation and variable left-sided chest pain. EXAM: Alert, Mucosae very pale. Mild oedema of ankles, and face looks puffy. BP 170/115, P52, R24, T34.6C

• Renal Stones – stream positional? Common in developing countries, ideally needs ultrasound.
• ?Shistosomiasis.

18 year old with episodes of wheezy breathlessness since aged 11. Well between episodes. This year, episodes lasting a few days have recurred 1-3x per month. Has been attending the clinic and is on Ventolin by inhaler. Despite this, has got much worse this week and now can’t go to work. EXAM: R32/min with audible wheeze, BP 105/70, P110 reg, T36. Chest: widespread wheezes only.

• Asthma. Hugely common in third world. Poor inhaler useage. Could be living in a smoky home, workplace. Poor washing of mites. Pets, etc. Try homemade spacer with plastic bottle. Try an extra steroid inhaler. If not available, use steroid inhalers. Oral ventolin
• ?Cardiac asthma, retained fluid during period with congenital heart defect.
• ?Current episode worsened by TB.

A 42 year old woman with polyuria. She has been feeling icnreasingly thirsty recently, and drinks a lot. Thinks she has lost weight. EXAM: Alert. ??slightly dry. BMI 36. BP 150/95, P72, R18, T36.1. Normal physical examination.

• Diabetes Mellitus – check a BM. Try metformin. Treat BP.
• ?Diabetes Insipidis – any history of post partum haemorrhage, which could have infarcted the posterior pituitary?

A 19 year old woman from Yorkshire is working in Uganda and has been having joint pains. Feeling feverish for 3 days, with nausea and loss of appetite. Symmetrical pain and stiffness in wrists, arms and hands. Today has noted general itchiness, especially of palms o hands. EXAM: T38C, BP 110/68, R14, P84. No visible skin lesions. Can’t make a fist easily – slight swelling of joints in both hands. Exam otherwise NAD.

• Hepatitis B.
• ?Shistosomiasis. Katayama fever – takes 3-6 weeks after exposure. Check raised eosinophilia.
• ?Reactive arthropathy to a streptococcal infection.

26 year old fisherman sent to you with progressive weakness in both legs – last 2 weeks. Also numbness in feet. UNable to pass urine, catheter inserted as bladder distended. EXAM: T36, P72, BP140/90, R23. Unable to walk, no movement in legs, with reflexes+++, Clonus++ in legs. Arms normal.

• Endarteritis Obliterans caused by syphilis. Ridiculous.
• ?Infarction secondary to sickle cell, vasculitis (HIV).
• ?Shistosomiasis.
• ?Testicular tumour metastasing.
• ?Cord compression.
• ?Pott disease – TB discitis – Hunchback of Notre Dame had this.

Ophthalmology

David Yorston gave us our final talk of the day. As ever, I was nearly asleep by this point, despite many excellent cups of tea, but bleary eyed (get it?) I turned my attention to the exciting developing world of optic disease. 

There are two main causes of visual impairment worldwide: Cataracts and Refractive error. This is good, since both of these are resolvable with surgery and glasses, respectively. There are many causes of blindness, some of which are harder to resolve, but Trachoma, Onchocerciasis and Childhood blindness are key areas of attack by the WHO’s Vision 2020 campaign. In great part thanks to Vision 2020, the worldwide picture (get it?) for eye health is improving.

In an Ophthalmology history, you will see (get it?) a few key problems:

• My eye hurts – Acute Red Eye, Trauma
• I can’t see – Gradual loss of vision, Sudden loss of vision.
• I can’t read – Presbyopia.

Acute Red Eye:

David talked about some key red eye conditions. One that stayed with me was Supporative Keratitis, which has a very scary pus line in the anterior chamber (see picture on right), and is the treated by intensive hourly topical antibiotics – no point in giving systemic, has to be given orally.

Acute iritis is almost always idiopathic. Meaning the doctor is an idiot, and the explanation is pathetic.

Trachoma is an eye infection from Chlamydia trachomatis. It used to be a minor cause of blindness in the UK, but was eradicated when we started to wash our faces. You treat it with oral azythromycin. In many developing countries, trials of prophylactic ABx to children are used if prevalence is above 10%. The key is to encourage people to maintain basic facial hygeine.

Cannot See:

Blindness is a major cause of morbidity, impacting wealth, health and social circumstances. There is real evidence that Cataract surgery cures poverty. Below are some key preventable/treatable problems.

• Refractive error – Corrected by pinhole.
• Cataract – Helped by pinhole, cloudy pupil, reduced red reflex.
• Glaucoma – Not helped by pinhole, sluggish pupil.
• Corneal scar – Visible corneal opacity.
• Diabetes – Diabetic retinal changes, neovascularisation, flame haemorrhages.

A Final Thought:

“He will do even greater things than these, because I am going to the Father.”
John 14:12

This verse has always been a big inspiration to David. Jesus healed many blind people in the gospels, but there are only a handful of documented cases. Through CBM, they are doing nearly half a million cataract operations a year: following in His steps we really are starting to do greater things…

Arriving at the beautiful Oak Hill College for the first day of this course, I was taken aback by the peaceful grounds. 5 miles inside the M25, it was a rather a surprise to drive into a green, leafy park, with a large period building with a refreshingly cool, modern interior. Seriously, I think I want to live here.

Global Overview

After a vital cup of tea, we kicked off with the first talk, from Ted Lankester. He is an engaging, amusing speaker, with an obvious passion for helping those in the world who don’t have access to adequate healthcare. He runs InterHealth, which heads up the Community Health Global Networks.

There were lots of shocking statistics, talking of a billion people in extreme poverty and extremes in inequality – in Nairobi some areas have an under 5 mortality rate of 15 per 1000, others have a rate of 254 per 1000. 29,000 children dying each day, mostly from diarrhoea, malaria, neonatal infection, pneumonia, preterm delivery: preventable disease. A general picture of a world that not improving, probably getting a little worse.

He pointed out that in the last 30 years, there’s been a realisation that the hub of the health system is families and communities, not doctors and hospitals. The future is primary care, recognizing common problems and working upstream to prevent them.

Filled with anecdotes and humour, I ended this talk wishing I could leave right now, get on a plane and go somewhere, anywhere to help…

Establishing an effective primary healthcare service

Helen Shawyer came next, doing rather well at giving me a destination for that dream, with a discussion about her 18 months helping establish a local health setup in South Sudan: the world’s newest country.

An inspiring story of her experiences working with an influx of refugees, government turmoil and life saving individuals rising up from the community.

There was a lot of information, but I’ll leave you with her lessons learnt:

1. Community Involvement and ownership is vital. Weekly meetings with community commitees enabling you to…
2. Have a shared vision. Get local stakeholders involved, make sure the team is on board, that everyone feels welcome.
3. Prioritise. You can’t do everything well.
4. The value of monitoring. Signs of improvements, guidance for change and demonstrates accountability.
5. Partnerships can be a great encouragement. Google groups, charities, NGOs, nearby.
6. Our God is faithful. Without resources, wisdom and energy, God is your fortress. Met as a team to devote each morning.

ABC of Community Health.

Ted came back, to talk in more details about the advantages, challenges and downfalls of building community health teams. He split his talk into 6 points, meaning his talk should have been called Six Steps to Community Health. Oh well…

Step 1: Consider community assets and needs - There’s been a big change of emphasis over the last decade: assessing assets – needs are important, but find the strengths also. Has the community requested a programme? Does the community have major health needs? Are there any other programmes working in the area? Is the community ready to work with you? If there is no community: eg refugee camps, you need to work slowly, and wait for relationships and leaders to emerge.

Step 2: Gather your team – Its vital you encourage an affirming, motivated and unified team. Lead by personal example and accessible leadership. Ensure excellent management, treat your team as your most precious resource – remember their birthdays!

Step 3: Know your community - Build friendship with community leaders, live with them: “drink tea and play football” with them. Listen to their fears, their needs and their hopes. Recognize their gifts and their abilities. Do not inappropriately raise expectations.

Step 4: Work with the community - Engage with the community to grasp their needs. Use focus groups, participatory appraisal, community mapping and surveys. Listen to the community’s ideas on how they can meet their own needs and use their own assets. Work together on agreed tasks and projects. Go for one or two quick wins, and something long term and sustainable.

Step 5: Set up a CHW programme - Community health workers. Generally selected community members trained in primary care functions. Currently 325,000 health guides in India currently, aiming to have more. Ethiopia training 30,000 female community based extension workers. If done right, can be very effective. They should be paid/shoudn’t be paid… an ongoing argument best dealt with a balanced approach.

Step 6: Set up community groups - Use existing groups or consider setting up women’s groups, adolescent groups of community action groups. Working in schools and setting up a child-to-child programme (teach the children, and they will teach one another and adults). Use local congregations and faith groups – but they must serve on the basis of “need not creed” or it can be divisive (as well as blatantly un-Christian).

Disaster Relief

After a welcome lunch break, Emma Roberts welcomed us back with a very informative talk about the practicalities of disaster and conflict relief.

The nuts and bolts of getting on the ground after a crisis are apparently festooned with acronyms. It was an insightful explanation of standard charity procedure on a grand scale as the NGO and WHO machine roars into action. Accompanied with plenty of practical advise about how to act if you find yourself first on the ground, and details of how charities co-ordinate a response.

Not my specific area of interest, but enlightening none the less, and if nothing else it taught me about Sphere. If I’m ever stuck in a crisis, and need to know such key details as minimum food & water needs per person? Sphere’s my (other) Bible.

Mental Health for Refugees

Dropping us in straight at the deep end, Maureen Wilkinson began to build a picture: “You are living in a village with your friends and family, and you hear that the rebels are coming. You hear bullets whistling through the undergrowth, and now you have to think… What next?”

She worked us through emotions, beliefs and actions that refugees experience: “Will my family be killed?”, “If we have to run away, which child do I leave behind?”. Children will have been raped, seen murders, been separated from their families.

We need to be aware of the tremendous impact on mental health that such widescale loss, fear, trauma and bereavement can cause. Every time a refugee has to have another hostile interview, these emotions can come straight back. Our lack of awareness of cultural behaviours can cause problems too – if a woman considers it to be totally inappropriate to be in a room with a man on her own, how distressed will she be if a young male doctor tries to start a consultation?

Post Traumatic Stress Disorder, crippling Anxiety, severe Depression, all are common. Evidence shows that there is no proven benefit to universal debriefing after events, but we need to provide a space for those that need to talk, working through those emotions, beliefs and actions. Appropriate approaches are vital: for example, allowing children to draw, dance, sing and talk will allow healing.

What does it mean to be Faith-Based?

The final talk of the day, from Nick Henwood, was a very interactive session, looking at some of the conflicts that medical professionals have between their training and faith. He put us in small groups, and tried to make us fight each other.

There are many different world views, and ours will define how we practice. We will have differing values as we look at God, Self, Others and Creation, and this also changes our behaviour.

Nick drew simplified versions of a secular “Me” model, an animalist “We” model and the Christian model of “Interdependence”. The point being that a Western self centred ideology can be unhealthy, whilst an Eastern model of laid back acceptance of life can be unproductive. Ideally, Christianity gives us that valuing of self through valuing others.

The way that we understand health involves “Minding the Gap” – ensuring we do not allow a chasm to form between our strict biomedical view of health and a more holistic understanding of spiritual health. We looked ways of integrating our faith and mission into medical practice with a couple of case studies: Umoja & Micah (can’t find links, will email Nick for them).

His final points:

1. Ensure your helping does not hurt.
2. You don’t change on the plane – put integrated approaches into practice now.
3. Explore some community development plans and try them out.

 And with that, the day was over, and I escaped. More tomorrow!

For years now, I’ve had a real passion about Africa, and, also for years, I’ve been in training as a doctor. They are passions that have grown together, and my excitement about them overlaps.

I’ve also been a fringe member of CMF – the Christian Medical Fellowship – since my first year in medical school, and recently I discovered that they run an annual course entitled “Developing Health“. It seemed too good to pass on, so this summer I managed to corral the required annual and study leave, and am attending.

I blogged about the course each day, and have each below as a record of the course. If you want to learn some bits and pieces about developing world medicine, the stuff I learnt on this course was solid gold!

Day One: Community Health
Day Two: Medicine
Day Three: Tropical Medicine
Day Four: HIV/AIDS
Day Five: Paediatrics
Day Six: Aspects of Mission Work 
Day Seven: Surgery
Day Eight: Trauma & Orthopaedics
Day Nine: Women’s Health
Day Ten: More Women’s Health
Day Eleven: Conclusion 

And yes, I’m 5 ft 9, and yes, I can’t shoot straight, and yes, I’m rather unfit, and yes, I always try to spin the ball on my finger, but instead drop it every time, but the fact remains – I love basketball.

I think it epitomizes everything I enjoy in life: simple, achievable goals; competition; sunshine; spending time with friends; Michael Jordan; being shamed by 12 year olds at the park…

Today I challenged one of the practice partners, Dr Hegde, to a game. I left this message on his screen:

I brought a basketball to work today. The question remains…
Are you man enough? …

Halfway through my second patient, a reply popped back on my screen:

Although I am sure I would undoubtedly teach you a basketballing lesson, I have a meeting this lunchtime, why don’t you use the time to have a practice.
Regards,
Air Magic Hegde

My impression? I need a basketball nickname! Recommendations in the comments please…

Today, I am boasting sharing about my greatest achievement in geekdom so far: I have become a medical expert advisor to Lifehacker.com!

Now, many of my friends don’t know what Lifehacker is. I know this, since the last two weeks has been littered with many conversations along the lines of:

Me: “Hey, ever heard of Lifehacker.com?”
Person: “Err, no? Why?”
Me: [sigh] “Never mind”

Lifehacker, by their own description, is a site with “tips, tricks, and downloads for getting things done“. It appeals to geeks who would like to take the same approach to their life and productivity as they do to their computers. Just as I am not happy when my mouse stops working, or my PC is slow, why should I be happy being overly reliant on caffeine to wake up, or getting poor value when haggling prices?

Anyway, my input to this venerable temple to the ironic procrastination of  20-somethings is a medical opinion on the best way to wipe your bum.

Read the article on Lifehacker to see how they used my input, or see my full article, “Medical Evidence on Wiping Your Bum” over at the MedRevise blog.

More guestpostness tomorrow, after which I promise to return to original material!

Katherine and Joen (click for bigger pics)

Waiting for Joen to arrive was a pain. Actually having him arrive was also a pain (Katherine can attest to that). Luckily we had a huge amount of support, with about a hundred people following the blow-by-blow action on my twitter account.

Thank you to everyone at home following the feed, it really felt great to know so many people cared. Thanks as well to the supportive tweets from people we don’t even know – @pmphillips, @em_cooper and @HeidiSiena especially!

In the run up to Joen arriving, we’d been ready for about a month, every day thinking “this could be the one!” I usually get lifts with people to work, for environmental/financial reasons. After Christmas, however, we felt it was safest I drive, since the due date was the 17th, so I needed to be ready to scoot home when I got the call. In the end, I drove in every day for 4 weeks, each day getting at least one call from Katherine, that I answered with “IS THIS IT? ARE YOU…”, and she would interrupt and ask me if I wanted carrots for dinner.

Sunday night, when she was a week overdue, she had a bad lower abdominal pain, worse than any before. Excitedly, I grabbed my phone and set off the stopwatch, timing between the contractions. When I woke up the next morning, the stopwatch read “7 hours 37 minutes”. I went to work, slightly deflated.

Then, on Thursday, her waters broke. A bit. Maybe. Still, the midwife wanted her in, so I set off home. Or tried to. The friendly driver of a black BMW had parked behind me in the car park. And then disappeared off the face of the earth. After ringing every single room in our unit, to no avail, I got the car next to me to move out, and, borderline levitating my car, managed to escape out of the side. Of course, this was the only time this happened, during a month of parking in the same car park.

Anyway, we got back, went to the hospital, waited around for ages, and they told us… her waters hadn’t broken. We went home, and then, around midnight, Katherine had a contraction. By now I didn’t even believe her. This proved to be a wise decision, as although they kept her awake all night, they became less common and less painful throughout Friday.

Timing contractions on my phone.

Just as we were settling down to watch Naked Gun on Friday evening, the contractions came back with a vengeance. Powerful, painful – it was clear that these were the real deal. I started timing them on my phone, and we called the midwife when they reached a rate of every 5 minutes. She came and examined Katherine, to tell her that she was not even 1 centimetre dilated.

The rest of the night was spent with Katherine moaning in pain, and me trying to find different places in the house to sit that wouldn’t hurt her. Two baths later (not to mention several trips to the bedroom and the nursery laden with fifteen pillows), her contractions were every 2 minutes, and we rang the Jessop Wing, who told us to come on in.

Kat, with a machine going PING!

In we came, where they set up all kinds of machines that go “PING!”, and told us that both baby and momma were well, but that mummy’s cervix was only about 3cm dilated. At 10cm, birth can begin, and generally the rule of thumb is that it dilates a centimetre an hour. We were soon to take that thumb, and stamp on it again and again and again.

From 5am that morning, to 4pm that afternoon, Katherine went through a huge amount of pain, hundreds of drawn out contractions, and a moderate amount of despair at the task ahead of her.

Around 20 hours, Gas & Air much in use.

At 4pm, she was assessed by the midwife again, which showed that all her work, all her sacrifices of blood and sweat over 11 hours had resulted in the cervix widening from 3 centimetres… to 4!

At this point, we became a little depressed. Neither of us had slept at all on Friday night, and Kat hadn’t slept since Wednesday night. Coupled with this, we still had a long way to go, down a road that was already proving exhausting to Katherine, and showing signs that it would be beyond her capacity to withstand pain. So then, reluctantly, we made a decision to go for an epidural. We were reluctant because epidurals have a few rare but serious side effects, and can make labour last longer.

A well earned rest.

The epidural went in at 8pm, after an anaethetist made 5 attempts to get a cannula in, and then gave up! Eventually a colleague got it in, bring Katherine’s total number on cannula attempts during labour to 9! The next 4 hours were pretty good. Katherine was suddenly pain free, and she got some desperately needed sleep, whilst her body carried on getting itself ready. As best it could.

At around midnight, Joen’s heartbeat started dropping, probably because his head was getting crushed by Katherine’s superhuman pelvic floor muscles. It recovered quickly, but it continued to happen, so it was decided that we needed to have this baby soon.

Joen's first skin on skin with Mummy.

Another examination at 3am showed that the cervix had stubbornly stopped… at 9cm. By now, both myself and Katherine just wanted the baby out, and safe; so the decision for a caesarian section was a relief.

And that’s about it. 56 minutes later, after a mere 31 hours of labour, Joen James Lowry entered the world. Ain’t that just fabulous?

I started thinking about how, actually, I was quite enjoying myself. This led to my first Resolution:

1. Spend more time with friends and family this year.

Then I realised that I was having way more fun than I do at work. That I would rather spend 40 hours a week washing up and listening to club classic interspersed with punk epics, than spend it caring for people as a doctor.

In reality, I can’t do this, and more importantly, I shouldn’t want to do this. Hence my second Resolution:

2. Start enjoying my job more.

And then I realised that I was on my laptop at 10:50 writing a blog post, feeling a bit low about life and careers and, the ultimate question – how to clean custard off a frying pan – when I should be next door beating my mother-in-law at Wii Mario Kart. Hence my third and final:

3. Stop complaining so much.

I’m off to enjoy the next year. Please invite yourself round to dinner if you haven’t seen me about, asking me about the world of Medicine, and tell me off if I complain!

Love you all!

PS. A brief glimpse of my soapy haven below…

2 nights ago, one of the patients, Doris, an elderly lady with dementia, spent the night shrieking, and making a fuss. This has an impact on everyone in the bay; no one had much sleep that night.

In the bed opposite was Jean, a retired lady with all her wits about her. Sadly, she had hardly had any sleep, and spent the whole day miserable and exhausted. When we saw her on the ward round, she was very unhappy. We apologised and everyone hoped for a better night following.

The next day, we went to see Jean. She looked much brighter, and said that the night had been much better – Doris had been noisy at first, then relatively quiet. All seemed normal, until one of the nurses had a word with me…

“Last night,” she said, “We noticed the curtains around Doris’ bed were shut. We thought that was a bit odd, as none of us had done it. So we went to see why.”

“Why? What happened,” I said, with mild trepidatation, hoping that Doris hadn’t passed away in the night without any of us noticing on the ward round.

“About 10pm, Jean got up, walked across the bay, closed the curtains, and thrown a full jug of cold water over Doris!”

I walked back over to Jean’s bed. “Jean, err… was there an *ahem* incident, with a jug of water last night?” It was quite funny to see Jean’s reaction – she went bright red, like a guilty schoolgirl caught flicking elastic bands in class.

“I don’t know what came over me!”, she exclaimed. “I just couldn’t stand it anymore, it was so unfair, and I was so angry, and… I just had to do it!”

It was hard to maintain a stern manner, especially since all three doctors (myself included) started gaffawing. The shame of having to own up seemed to do the trick anyway, as she cringed and said “I was really hoping no one would ask me about it!”

With a promise from her that she wouldn’t do it again, we left her to the rest of her day. As Aristotle said, “The virtue of justice consists in moderation, as regulated by wisdom“. Fairly sure, in the circumstances, a single jug is still classed as moderation.

NB. I am thoroughly committed to being a great doctor, which includes respecting patient confidentiality. All information about patients on my website is anonymised, and often altered drastically so that whilst it still makes a good anecdote, it is unrelated in sex, time, location, age and/or ailment from the original facts.

Whilst a great time to get some real hands-on experience, there is a key problem in working nights. It goes thus:

1. Most of us are not naturally nocturnal.
2. Most of us have jobs in the day time.
3. Night shifts usually only have a day’s grace between day shift and night shift.
4. It takes more than one day to completely upend your circadian rhythm.
5. Therefore, you always feel completely, exhaustedly, hungover-jetlagged-coma-after-a-trainwreck tired.

There are two methods for attempting this changover. One is to try and stay up as late as possible the night before, sleep all day, and go to work (hopefully) refreshed. I tried this. The result was that I was so tired on the first shift that I started having visual hallucinations about 4am, attempted to wear a commode around 5, and woke up the next morning completely naked in the middle of the M45.

The other method is to sleep normally the night before, stay up all day, and have a two hour nap before the start of the shift. My SHO used this method. The result was that he became so tired that he began to have paranoid delusional beliefs around 3am, attempted to order the demolition of the hospital library about 6, and woke up the next morning on a ferry to Bergen, with a new tattoo. Of the Queen. On his face.

Obviously there’s a bit of exaggeration there, and neither of us actually developed first rank symptoms of schizophrenia, but we were very tired. Aside from this, the weekend was actually fairly enjoyable. There’s a bit less red tape and paperwork on the night shift, and less distractions.

One highlight was a tired A&E clerking on Friday night from another doctor, who had written “Patient is a resident in a residential home” twice in three paragraphs. Some would say that this is not particularly useful information, even when written twice. The doctor had failed to mention that the woman was profoundly deaf, and severely demented. Which would you rather know?

My most memorable event of the weekend came at about 5:30am Monday morning. I was hungry, so I went to the vending machine to get a packet of crisps.

5:30 I put in my 45p, and selected some Prawn Cocktail Walkers. They fell out of the holder, and got stuck halfway down the machine.

5:31 I got annoyed, and tried to shake the machine. A lot. It didn’t work, the crisps remained stuck.

5:32 Rammed the machine again, and another packet of crisps fell out, Cheese and Onion this time. It also got lodged. Right next to my other packet. Nudged it again, to no avail.

5:34 Tried ringing the vending machine company, asking for a refund of my 45p. Oddly enough, no one there when its barely dawn.

5:36 Decided I *needed* crisps, so used my might again. This time a Capri-Sun fell out.

5:39 Having drained the last drop of the Capri-Sun in a contemplative manner, I hit upon an rational plan of action – purchasing the chocolate bar directly above the crisps will cause it to fall, thereby dislodging my crisps!

5:40 The Kit Kat chunky holder turned, and then the chocolate bar twisted out, began to fall and then… got stuck in the mechanism.

5:42 I finished screaming, and decided to whack the machine again.

5:43 Still whacking.

5:44 Another Capri-Sun fell out, but still neither crisp packet nor chocolate bar is released from the vending machine’s iron grip…

5:45 After a final heave, the Kit Kat fell, dislodging both packets, and I left the machine clutching half a newsagent’s in triumph. (Feeling a little guilty at my windfall, I later went to the reception desk in the hospital, who congratulated me on my honesty, but told me to keep the food!)

There ends my summation. At 9:15am Monday I left the hospital after 36 hours of attendance, with mild tooth decay and a mite more experience as recompense. Plus I think I’ll get paid at some point too, but right now I’m more excited about the Capri-Sun.

NB. I am thoroughly committed to being a great doctor, which includes respecting patient confidentiality. All information about patients on my website is anonymised, and often altered drastically so that whilst it still makes a good anecdote, it is unrelated in sex, time, location, age and/or ailment from the original facts.

My first job is a four month stint in Cardiology, and my first ever day as a doctor was a 12 hour emergency on call. It was a sharp learning curve, with little prior explanation of even the simplest proceedings.

My first hurdle was the “bleep”. Your bleep is your electronic dog lead; anyone can use it to make you heed to their beck and call. Obviously that’s good if someone has a heart attack, and you are needed for resus. It’s less good if a secretary the other end of the hospital wants your signature on some mildly unnecessary form, whilst you are trying to finish a ward round.

This combined with my non understanding of the system on the Emergency Admissions unit to make me look an absolute idiot in my end of day handover. Day rating: 7/10.

On Thursday, I wasn’t on call, but I did have to conduct the ward round and all the ward jobs all on my own, with my SHO, Registrar and Consultant all on leave or busy. Whilst this was mega intense, and frankly not a lot of fun, I did manage to get everything done, and went home (nearly) on time. My Consultant seemed happy enough, so I’m not too worried, although I would like to have lunch at lunch time more often, rather than eating a sandwich on the toilet at 3:30pm, combining two time occupying jobs into one. During the last hour of my shift, I turned on the CD player in the nurses station: the only CD we had was one of Christmas hits. The tacky music alone made this an 8/10 day.

Friday started out very well. By lunch time – and it says a lot that I was even having lunch – we had finished the ward round, and started on the patient care endless paperwork. And then I discovered I had to attend a compulsory 2 hour introduction, hand washing and blood taking lecture. I got back to the ward, and almost immediately got bleeped to go write a TTO for a patient I’d never met, who needed a slightly complicated bit of warfarin prescribing. I was also approached by rather a large man, looming over me as he asked:

Large man: Are you a doctor then?
Me: Well, yes, just about.
Large man: Can you write me a prescription then?
Me: Err… are you a patient here?
Large man: Yes.
Me: In that case, what for?
Large man: Can you prescribe me a hug?

Needless to say, both of us ended up with a hug. Unfortunately, by the time I had finished on that ward, returned to my own, and finished seeing all the patients, reviewing all the drugs, and filling out all the bits of paper, it was 6:45. I only get paid until 5, but I suspect the NHS aren’t too bothered about that. Despite the lateness, I got a hug off a somewhat threatening man, so the day has to get a 9/10.

So far, the best thing about the ward is all the wonderful nurses, pharmacists, receptionists and porters. Without them, I would actually still be in the hospital, probably gibbering quietly, and completely naked except for drug charts sellotaped all over my body.

Stay safe kids, and remember – don’t get sick in Chesterfield!

I’m going to listen to the Slackers now, and drink some coffee. See you soon!