Snakebites and sad goodbyes

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Dermatology. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

A final morning chapel followed our joyful late night escapades last night, with a combination of Amazing Grace and We Are Marching to get a bit of the African clapping vibe working. The photo below is from earlier in the week, but since its the last day today, it seems appropriate to share it…

Beautiful_photo_DHC_2014

Dermatology

Clare Fuller showed us lots of very interesting graphs. Dermatology complaints are known to under present, be poorly treated and lead to people avoiding healthcare for other important issues.

In some studies, more than 60% of Dermatological prescriptions were inappropriate in a Developing world setting.

Also, distance effects health seeking behaviour in Dermatology more than other conditions: if there is a clinic within 1km, people attend with their fever, their pain, their rashes. If the clinic is 10km away, they will only go with their fever or pain, according to one study.

Apparently 10-20% of children with scabies will still have haematuria 10 years later! That’s terrifying, and only something that’s recently coming to light.

Skin lightening products

Using topical steroids for skin lightening leads to low birth weight and vaginal bleeding in pregnancy.

Generally dangerous

Cutaneous bacterial infections

Very common in the tropics, can be difficult to identify which one in particular.

Treating cutaneous bacterial infections

  1. Wash skin – clean water, disinfectants
  2. Remove crusts, debris, necrotic tissue
  3. Topical anti-inflammatory/anti-biotics, honey, etc.
  4. Oral antibiotics

Eczema

Acqeous cream should not be left on the skin – can inhibit barrier function.

Otherwise the greasier the better.

Snakebites

Approach will vary depending what snakes you have in your area.

I saw a snake on my balcony, and was concerned, so asked a colleague what to do.

Their response, “Have you tried the exposure test?

“What is that?“, she replied.

Let it bite you, and see what happens

Fond goodbyes

I was feeling desperately sad by the end of the day, but it was time to say goodbye to everyone. I got bullied into starting a Developing Health 2014 facebook group, so feel free to join if you came along – it’d be great to stay in touch.

Thanks to everyone who came along, everyone who donated their time to teach, and the course organisers: I’ll be processing everything I’ve learnt for months…

The Ladies are Dying

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Women’s Health. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

why are  women dying?Maternal death

Afghanistan – “One of the worst places in the world in which to be pregnant”
UNICEF

Has a Maternal Mortality Rate of 6,500 per 100,000. Which is the highest ever recorded, anywhere in the world.

Reducing those MMR stats is simple: we know the answers…

  1. Improve access
  2. Ensure skilled staff at deliveries
  3. Increase Utilization
  4. Education and Family Planning

Female Genital Mutilation

Studies have shown that it is not really a religious tradition but a cultural one. It is barbaric – and the pictures and case studies just confirmed that. I’m pretty proud of our country that they have made it illegal for UK nationals or residents to perform FGM anywhere in the world. Maximum sentence 14 years!

There were some interesting discussions about this though: if you deliver a baby, and the mother gets a tear, relating to her FGM, you breach the law if you repair it to how it was previously, rather than trying to reverse the FGM – regardless of the patient’s choice!

Women, depression and domestic violence

There is a big correlation between depression and suicide in women in the developing world – in the UK, men are about 3 times more likely to be successful in suicide. In Bangladesh, there is no statistic distinction between the two.

Being poor, worrying about family, about health, about money, about social insecurity, domestic violence: all these things are stressful.

In some studies, 20-36% of women in Asia suffer from post-natal depression.

Group work

We had a range of group workshops, where we talked through loads of case studies. Very informative, very useful. Just like yesterday, where I ended up teaching a group how to perform a spinal anaesthetic, today I realised that I actually have something to contribute, based on my professional experience. Last time, I knew very little about gynaecology, but this year I had 4 months on experience, and was able to participate actively in the discussion.

The Cutting Edge…

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Surgery. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

I started my morning devotion with starting to read through John 1. I was completely unsurprised to find that the word enlightened came up immediately, just like Ian’s talk from the first night, and bringing me back to that Ephesians 1 passage again:

The true light, which enlightens everyone, was coming into the world.
John 1:9

Anaesthetics

Following that, Hilary Edgcombe taught us about many cool intelligent things in the world of Anaesthetics.

“Is Ketamine a wonderful drug with terrible side effects, or a terrible drug with some useful side effects?”

She talked about Ketamine: It is not a fail-safe airway option… Give it over 5 minutes to reduce chances of impacting airway.

We touched on the terrible under-resourcing of many Majority world settings, from an anaesthetics perspective. The video below shows a bit of that – I shared it last time as well, but its still interesting.

On the Developing Health USB stick, there is an amazing link to a free online Developing Anaesthetia textbook for use in resource poor settings. It’s pretty brilliant…

A quality history and decent examination are important before anaesthetics. Just like Ian has been saying all week, a probing history, a thorough examination, appropriate investigations and careful synthesis is the fundamental base of clinical medicine.

She also recommended http://update.anaesthesiologists.org – which is a good resource for information about coping in resource poor areas.

Surgery

surgical questionsColin Binks and Mike Puttick took us through the next session on Surgery for the Non-Surgeon.

Two big questions: Can I do it? Should I do it?

Seeing red

If you see haemorrhage, pack it, pack it, pack it, pray, pack it, etc.

If the liver won’t stop bleeding, give the portal vein a squeeze.

Seeing green

Likely small bowel or gallbladder perforation. Wash and go approach.

  1. Clean it out.
  2. Close it up.
deadbowel
Necrotic Bowel – its black, so you excise it

Seeing black

This means there is necrosis.

  1. Excise the dead stuff.

The Acute Abdomen

An interesting talk, with lots of stuff that was way over my head: I think I am not competent to start popping in bowel anastamosis yet. The message was repeated from yesterday that:

“The solution to pollution is dilution.”

Lots of irrigation with saline in your friend in surgery.

With both talks, it was really useful looking at case studies, saying “What can you do, what should you do?”. It was recommended again that we buy the Primary Surgery book, which helps with knowing how to do things, if we decide doing them is the right option.

Anaesthetics tutor

We had some group work in the afternoon: in one of the sessions, the anaesthetist was teaching how to do a spinal anaesthetic. Given that I had more experience in this area than anyone else, I ran one of the stations. Whilst I may not have been particularly good, it was quite uplifting for me – namely that work I’ve done in previous years to learn clinical skills has led to me having skills that my 2012 self did not.

That’s a professional development reflection for my e-portfolio right there…

One cool tip the tutor gave us for finding the spine, especially if someone is laying on their side:

A patient can always find the middle of their back, so if you are struggling to find it, let them point to it for you.

Late night fellowship

Fellowship has been a great component of our time together on the course. Late this evening, me, Marli, Mike, Jakob, Justus and Linda all sat in my room, and shared Coke, alcohol free beer, prayer, bible verses, songs (inconsiderate after midnight?) and stories of how each of us came to know Jesus.

It was very uplifting, if a little tiring (we went to sleep after 1am). We ended by reading Philippians together:

Brothers, join in imitating me, and keep your eyes on those who walk according to the example you have in us.

For many, of whom I have often told you and now tell you even with tears, walk as enemies of the cross of Christ. Their end is destruction, their god is their belly, and they glory in their shame, with minds set on earthly things.

But our citizenship is in heaven, and from it we await a Savior, the Lord Jesus Christ, who will transform our lowly body to be like his glorious body, by the power that enables him even to subject all things to himself.

Therefore, my brothers, whom I love and long for, my joy and crown, stand firm thus in the Lord, my beloved.

Philippians 3:17-4:1

Joining bones (and mission partnerships)

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Orthopaedics. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

New Relational Partnership…?

We started this morning with a meeting with the missions agency that phoned me last week. Katherine, Joen and Neriah all came out to Oak Hill college with me, ready for the meeting. We met with a lovely chap with an accent that can best be described as “miscellaneous”, since he has lived in about 5 countries for significant periods of his life. His wife was also there.

Just that little fact made me feel more comfortable: if you meet with a corporate CEO, or similar, there would never be such an immediate focus on relationship, on meeting our family as we meet theirs.

UBurn Contracture Healednderstanding the concept that he is not alone in working – as a married couple, all our work, to some extent, is done in partnership.

Anyway, it was a thought provoking meeting, that may lead to a long term partnership: more on that as it develops…

Orthopaedics

Due to our meeting, and my general tiredness, I missed most of the morning, by the earnest, funny and heartfelt Chris Lavy (I sat with him at lunch, he was awesome). I did catch two recommended websites for finding recommended physio techniques and general reference material: Summit Medical Adult Health and WheelessOnline.com.

However, I managed to attend most of the afternoon sessions with tutorials and workshops on fitting people for casts, putting legs in traction, and how to splint burns.

I think the biggest take home message for me was that burns need appropriate splinting, for at least 6 months to prevent developing significantly disabling contractures (see right).

Ideally you want a burn to heal within 2 weeks, as that makes risk of contractures much less likely.Burn Contracture Healed

The Hidden Introvert

The Mission Agency asked us to identify our Myers-Briggs types: Broadly, Katherine is an INFJ, and I am ENTP. Which is nice, as the conventional wisdom is that having 1 field the same (possibly) makes for stronger relationships. It’s interesting to read through – not a massively evidenced based approach, but an interesting window to use to inspect your own mentality.

Unsurprisingly, I am classified as an Extrovert. But, I have a hidden Introverted side that I never knew existed…

This week has been socially intense, making instant, deep, wonderful friendships with people from all over the world, but with fairly similar visions and life views to me. I’ve had a fantastic time, but it has been hard work. For the first time… ever… I had to go and spend an hour in my room on my own this afternoon!

I was excited about this: Vicky Lavy pointed out that the fact that after an hour I was back out, talking to everyone, means that I’m unlikely to be at risk of reverting to total extroversion…

Africa and Zulu

The evening talk was a chat with Peter Saunders. His story was slightly haunting for me: around 20 years ago, he felt called to work in Africa for a year, went to work in Kenya for a year with his wife, a 1 year old and a 3 year old. They felt convinced they would end up in Africa long term: but never lived there again…

My last activity before bed was my first Zulu lesson with my SA friend Linda. I discovered my first concepts of Zulu prefixes, and learnt to say Kubu Hlungu Ikhanda (My head hurts).

I am not fluent yet.

Baby, baby (and other paediatrics)

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Paediatrics. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

After all the fun of last night, it is no surprise that there was lively worship this morning. After two hours last night, and half an hour this morning, my fingers are tired of strumming!

Greeting from BotswanaNeonates in the Developing World

There were some big messages, and scary statistics.

No more shall there be in it an infant who lives but a few days, or an old man who does not fill out his days, for the young man shall die a hundred years old
Isaiah 65:20

If you include stillborn babies, then 75% of deaths in under 5s are in neonates.

50% of neonatal deaths are in the first 24 hours. 75% are in the first week.

Malnutrition

Nutrition is responsible for 30-50% of child deaths, and also leads to low birth weights due to maternal mortality.

Urgent referral for kids:

  1. Inability to drink or breastfeed
  2. Vomiting everything
  3. Convulsions
  4. Lethargy or unconsciousness

32% of children in developing countries have stunted growth due to malnutrition

Stuff to read, when I stop being useless…

  • On our CMF USB stick, there is a highly recommended Pocket Book of Hospital Care for Children, which I shall read, when I sort myself out.
  • Unicef State of Child Health.
  • Lancet Global Health Series can be read free online.

 

Bugs, and passions that won’t let go

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Tropical Medicine. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

Two things made today different. Firstly, for the next two days, my mum has joined the course. It has been lovely: so nice to spend time with her; we are both doctors, and having a shared purpose and heart is a joy. We are in three families together; biological, professional and spiritual, and that makes me very happy.

Secondly, I got in from a stag do at 3:30am, and was not able to pay attention tremendously well today…

Tropical Medicine

One person shared about the fact that in some areas of endemic shistosomiasis infection, it is widely accepted that boys have a menarche. In other words, the parasitic infection causes blood in the urine, and it is so common, that it is thought that boys have a period, just like girls, in their wee. On many levels, it is amazing that something so wrong can be accepted as the normal.

We had some small group sessions where we talked about how to deal with hospital workers getting TB. There was a great idea bout offering hospital staff free healthcare (obviously more relevant in countries without free universal coverage), and of automatically offering an XR and sputum analysis for anyone who has had a cough for more than 3 weeks.

I’ve definitely been getting excited about the potential for community health development in Tonga, when we get out there, and some of these ideas are a big challenge.

Mortality and Malaria

The Malaria lecture ended with a shocking reminder: 1,000,000-3,000,000 deaths/year >90% among African children.

140,000 people died when we dropped atomic bombs on two Japanese cities in 1945. There is a memorial to these people in London. However, its important to remember that in 1945 in Africa, around 3,000,000 children probably died from Malaria. And in 1946 in Africa, 3,000,000 children died from Malaria. And in 1947… 1948…

Why do we not hear about this more? Because malaria is predominantly a condition affecting young african children living in absolute poverty.

Malaria LifecycleMalaria Lifecycle

  • 1 mosquito bite
  • 15 sporozoites
  • Each Sporoziote matures in the liver and releases 40,000 Merozoites.
  • The Merozoites join a red cell and become a Trophozoite.
  • These mature, and become Schizonts and release more Merozoites – 16 per cell.
  • Finally, at some point, Gametocytes are formed from Trophozoites.
  • They are then picked up by a mosquito drinking your blood.

Absence of fever DOES NOT rule out Malaria!

Interpreting a blood film.

Three things to know:

  1. Infecting species
  2. Density of infection – no limit to % – people have been known to survive 70%.
  3. Stage (trophozoites vs schizonts) – if there are lots of schizonts, its a sign that within the next 24 hours the density of the infection is about to massively increase.

You can bring about a 60% reduction in all cause mortality in under 5s by sleeping under a bed net.

Which is so much more effective than the value of statins, or extra antihypertensive agents. But we don’t hear about it.

Missions Fair

IrresistableRevolutionBeing surrounded by people on medical mission, I’ve noticed that almost everyone is going out with an agency or some sort of organisation supporting them. It’s important to have a church that sends you out, but sometimes they do not have the breadth of cross cultural experience that can be helpful in international mission .

Me and Katherine talked about it, and agreed we wanted to see if there was an organisation that would be interested in providing that support.

So I went to the missions fair, where there were 20ish organisations that provide training, support, finances, programmes to join, short term trips to fulfill. And I said

“Hi, we kinda want some sort of support, but don’t really know what… Can you provide that? Oh yeh, and we fly out to South Africa for a year in like 6 weeks…”

To say that people visibly recoiled wasn’t altogether inaccurate. Ultimately of the 20+ agencies, nobody really felt they could help us. Probably pretty wisely.

I spent the evening in crazily deep conversation with Jon (the collie dog owner from yesterday) and discovered that he and his wife are joining a fairly radical group of “New Monastics“, a concept I’ve previously come across through reading various books by Shane Claibourne (see right). In fact, its a passion both me and Katherine have both shared so passionately that we spent our first two years of married life living in community

So, long story short, I spent my last hour before sleep chucking emails at missional community based organisations, along the lines of Urban Neighbours of Hope, The Simple Way, InnerChange, Word Made Flesh. I couldn’t sleep until I read Ephesians 1 again either! Our email is below, a quick, honest missive to see if God has anyone for us…

Hey there,

My name is Chris Lowry. My wife and I, and our 1 year old and our 3 year old
are going to Africa for a year in AUgust.

We aren’t going with a missionary organisation (yet) but we do feel God wants
us to go. I’m a doctor, so we will be working in a hospital out there in
Tonga, in Mpumalanga (SA) and we have a wage coming in.

Err, would you provide (non financial) support to people like us?

C

Changing the world

dhThese notes are about the CMF Developing Health Course 2014.

The focus of today is Community Health. I made notes on the whole course in 2012 – you can read about this day here.

Each day I’m just going to write about things that impacted me, and things I need to read later…

An interesting morning

Ted LankesterTed Lankaster spoke first. Chatting to him at breakfast made me realise that we need to talk to InterHealth about vaccinations, because we leave in about 6 weeks now, and we still haven’t organised ours!

Some cool things he said:

Inverse care law: the availability of good medical care tends to vary inversely with the need for it in the population served. We are seduced by the west, and that leads to a paucity of doctors in the developin world.

One solution is task shifting – ensuring tasks are carried out by the least qualified person able to competently do it: you don’t have your doctor cleaning the bins in the hospital…

He also recommend we read some of the emails sent out by Jeffrey Sachs – who is the head honcho at the UN Sustainable Development agency. I will endeavour to read some, and maybe even blog about it…

Tanzania and change

Next up was a great personal account of living and working in Tanzania, from Irene McClure.

She shared the problems with clean water, where every time it rained the infectious disease goes crazy because of poo in the fields being washed into the water. Stopping the disease is easy with medication, but breaking the cycles of ill health is a whole different story.

Tippy tappies are a simple idea: an empty plastic bottle, hanging by the doorway, to remind people to improve hand hygeine before cooking. It’s an easy placement of reminder and opportunity to change. I wonder what lesson is there for us in something like that?

She recommended we read “Half the sky: how to change the world“, and left us with a final challenge:

Unless a vision is too big to be achieved by man,
its not from God.

If you want to do something and have no power to do it, it is povertyPoverty tutorial

Before lunch, Nick Henwood, led us in a challenging tutorial, about the difficulties of westerners going in and trying to solve everyone’s problems for them, how it feels to be on the “receiving” end of that “aid”.

One of the tutorials involved thinking about myself, looking at areas of myself. Self, spiritual, others, rest of creation. Many of the principles are lifted straight out of a book called “When Helping Hurts“, which I’ve bought Edit: And can HUGELY recommend as a book that anyone passionate about helping the poor in society should read.

For me, the course just, it just confirmed my thoughts about this course: I need to take some time to reflect. I don’t always need to achieve things: I’m using the next two weeks for peace, for reflection, for a deeper emotional learning than simply cramming more medical knowledge into my brain.

One thing Vicky said today was a wonderful mix of Christian and Medical that I love at CMF:

Fortunately prayer has a long halflife

I’m really seeing how the things God has been doing in our lives over the last year (and years) have been layers building up a bigger picture. Presumeably there’s minimal renal excretion of Holy Spirit…