Local Time:17:00 Sunday 1st June 2014 – (Or 11:00 in Swahili notation)
Location: Traffic. Just outside of Dar es Salaam
We are seated on the Dar express, the luxury coach we have
been on since 7am this morning, when we boarded it in Moshi. Compared
to the other transport we’ve experienced so far this bus is certainly luxurious
– Mary and I have seat each and don’t having to squeeze next to Tanzanians. Currently
the vehicle is stationary in a colossal traffic jam, amidst fumes and chaos as
zillions of people and vehicles compete for space to manoeuvre. Like most of
Tanzania (but more so), the road is shared by buses, cars, pick-up trucks and
daladalas, all of which are heaving with
passengers and cargo and around which buzz pikipiki (motorbike taxis), bajajis
(rickshaws), hand carts, and people selling anything and everything. The
majority of the highway code seems to have been lost in the translation but
they do at least drive on the left, most of the time. Our vehicle has just been
hit by a car, an event which ought to be far more common . It seems that our
bus is unharmed but the car has lost its front bumper and its owner seems quite
annoyed.
Some Bajajis in Tanzania
The bus journey has been quite an uneventful 10 hours, and it has been nice to watch the world go by out of the window in between snoozes. It was a
mostly smooth ride since the
Arusha-Moshi-Dar highway is one of the few paved roads in Tanzania, but
punctuated by frequent and unforgiving (but necessary) speed bumps and quite a
lot of dirt track and temporary road surfaces, road work crews and road rage.
En route I thoroughly enjoyed a complimentary ginger beer.
So we’re on a
completely smooth, motionless, section at the moment and I can record the last
bit of medicine for a while – I’ve finished the 4 week elective placement but
I’m staying to look around Tanzania and Zanzibar for another few weeks.
The Children’s ward
I haven’t ruled out paediatrics as a future speciality, perhaps
because I haven’t studied it at all so far.
Misanthropic though I might be, I find it hard to dislike people
who are too young to have done anything wrong. And from an efficiency point of
view it seems like a good idea to try hard to cure ill children since arguably
you get more bang for your buck than with (mostly elderly) adult patients. To
be clear, “bang” is a QALY – quality adjusted life year. And bucks are pounds.
So I was excited to see some paediatric medicine at Machame,
despite knowing that here more than ever I wouldn’t understand much of what was
going on. Like in UK hospitals, the paediatric ward is a bit nicer than the
rest of the hospital – It’s a bit more colourful and there’s a large
tingatinga-style animal mural on the wall. The names of the rooms could be
improved however: malaria room, pneumonia room, diarrhoea room and isolation
room.
The first patient we saw was an extremely cute 2yr old
Maasai girl. She was tiny – 8.4kg (18lbs) and very anaemic – her haemoglobin
level was 5.7g/dL but she seemed paradoxically active and alert. She had had a
cough, problems breathing and a fever so a diagnosis of pneumonia was made, and
she improved with antibiotics. There were several other children with similar
presentations, organised by room.
The doctor explained how for a lot of these children
nutrition is a big factor in their health. Breastfeeding is usually
recommended, except for HIV+ mothers due to the risk of vertical transmission.
High energy formula milk and foods are available but come at a cost, and
parents must provide food for their children whilst in hospital, so doctors try
and recommend foods that the mothers are more likely to be able to access at
home - for example many Maasai eat almost exclusively cow’s milk, cow's blood or raw
flesh. It is clear to the doctors that many children will continue without adequate
nutrition and so are more likely to succumb to further infections, so common in
Africa - particularly when the drinking water is not the safest.
In the isolation room there was an unfortunate 9 year old
girl with quite severe skin lesions. She had previously had a fever and was
covered in fluid-filled vesicles –
particularly around the neck and armpits. Initially this was diagnosed as
chickenpox but soon the condition progressed, the lesions enlarged and some
became filled with pus, and eventually there was extensive ulceration around
her mouth. It brought to mind some autoimmune skin conditions I know only from
textbooks (bullous pemphigoid and pemphigus vulgaris) but both are much more
likely found in adults. The doctors decided to treat it as a severe adverse drug
reaction, though there was no history of any medications, on the severe end
of the continuum of erythema nodosum– Stevens-Johnson syndrome and Toxic
epidermal necrolysis. The name and cause of the condition less important than
the outcome: the girls was started on steroids and greatly improved.
For another young patient I offered that the appearance of red spots on the
chest might help diagnose typhoid fever. It wasn’t a great suggestion: the
doctor pointed at me and snorted, “Perhaps visible on your skin!”
A case from outreach
One Thursday Rhi and Laura went on outreach to another
difficult to access village and came back quite distressed about a case they
had seen, and I think it’s worth briefly telling their story (not plagiarised -
I got their permission).
Near the end of the afternoon the girls saw a particularly nervous-looking
15 year old boy who came with his parents. He was small and weak and complained
of problems breathing, a problem that had been affecting him for several years,
preventing him from playing football with his friends or functioning normally. It
was clearly necessary to examine the boy’s chest but he was extremely reluctant
to uncover his torso. After a lot of coaxing the cause of his anxiety became
clear – he had a large chest deformity. The centre of the boys chest extruded
alarmingly forwards creating a sharp bony prominent sternum – known as pectus
carinatum, or pigeon’s chest.
One of the Dutch students auscultated the chest and reported
that the lungs sounded normal but the heart sounded abnormal, possibly there
was a murmur (myself included, when asked to listen to a heart students will
always say “I’m not sure but there might be a murmur”). The clinical officer
recommended that the boy should come to the hospital for an ECG and X-ray.
The girls were concerned that the boy might have a
significant illness, possibly some congenital heart problem or a severe lung
disease. Pectus carinatum can be asymptomatic and idiopathic but the history
the boy gave made this case seem more worrying. Further, both of his parents
were HIV+ but the boy didn’t know whether he had the virus himself.
The clinical officer then revealed that he thought it unlikely
that the boy would come to the hospital, the family were very poor and the
journey difficult. The tests at hospital, and any treatment would need to be
paid for and it didn’t look like the family would be able to afford anything. The girls offered to contribute to
these expenses but remained concerned as to whether the boy would come to the
hospital, or indeed whether this would result in any treatable diagnosis. They
spent the night worried about the boy.
Miraculously, the boy did turn up at Machame very early the
following morning. Rhi and Laura found him and his family (all wearing their
finest clothes) in outpatients after church, and thanks to the girls’ funding
it was arranged for him to be seen by Dr Sartori, the hospital director and
most senior doctor. Happily, after some more tests the boy was diagnosed with
simple asthma and given the necessary inhalers. Supremely common, usually
benign, very treatable asthma – a good result indeed.
An example of pectus carinatum. (This patient is not Tanzanian.)
This story doesn’t have any fancy presentations or shocking
diagnosis, and that’s why it’s worth telling – representative of so many people’s
stories in Tanzania. Its a good example of how individuals, and most especially those who are poor, can
be terribly affected by even very simple diagnoses. I don’t think it’s an exaggeration
to claim that the concern Laura and Rhi showed, and the (by western standards) smallish
amount of financial help they provided, vastly improved the lot of a young Tanzanian
boy and his family, an appreciated gesture that won’t quickly be forgotten.
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