Warning from Tim to his non-medical friends: you might want to wait for the next nice holiday story and pictures

The morning meeting
Every Monday, Tuesday, Thursday and Friday: morning meeting at around 8 a.m. In ‘Swanglish' the clinical officer on night shift informs us about the new admissions. The number of patients who died is mentioned, but unfortunately many times we won't find out exactly why they died. As being a doctor, this is frustrating. Two identical operation reports of two caesarean sections are read, including all vital signs which are often exactly as they should be (blood pressure 120/80 mmHg, pulse rate 80 bpm, temperature 36 C). It would be interesting to discuss the indications for interventions, but the doctor who was on call is often not present. CPD (cephalo-pelvic disproportion) is a common diagnosis, which for me is hard to assess. Sometimes I regret not having spent a year in gynaecology. Then the interesting part for mister Tim: finances. The ‘in-charge' of the reception and the drug dispensary read the daily revenues, which is a list of numbers, good to practise our Kiswahili but unfortunately we don't oversee it all.

Different doctors
I'm lucky, to my surprise one of the new AMO's is appointed to work for 3 months in male surgical ward, where I am working. AMO stands for assistant medical officer. Tanzania has a somehow complicated system with different kinds of doctors. ‘Clinical officers' are trained in training colleges (COTC), which takes 3 years. After their training, CO's work in hospitals and health centres in rural areas, which is appreciated because there is a serious shortage of doctors. They are overloaded with patients and able to work very fast, treating malaria, urinary tract infections and hypertension (which can be cured here with 2 weeks of pills) and everything in between. Our hospital has only 5 CO's who are supposed to see out patients in OPD, one of them specialised in HIV. A CO can apply to study for 2 more years to become AMO. We have 15 AMO's, of whom 4 are away for further studies for unknown period. Some are occupied by special tasks like TB coordinator or teacher at the COTC. Four senior AMO's are really experienced in either obstetrics or surgery (herniorraphy, hydrocelectomy, hysterectomy) or eye problems, and four just graduated as AMO. I'd like to learn a lot from them, and to share my ideas with them. But, because I'm younger, female, and less experienced, I struggle a bit to find my place in the unwritten hierarchy. Also Kiswahili is a bigger barrier than expected. Together with an AMO I'm doing ward rounds in male surgical ward, with 10-20 patients. Our hospital has 4 Medical Officers, two of them occupied by administrative issues (of hospital and blood bank respectively), and two are in the medical departments. Finally, 3 MO's are teaching at the nearby COTC and sometimes helping out in the hospital, or joining us when we go out on Saturday. It takes a while to know all names and functions of all these types of doctors.

The clinical challenges, Blaricum I miss you!
Many times I wish dr Gerrits was here, to assess an ‘acute abdomen', to decide something is malignant, to assess a suspected fracture when X-ray machine is out of order or just to teach me new things like making incisions with only a razorblade without s handle and without diathermy. Unfortunately, we don't operate much because material is often out of stock.
Traumatology (orthopedics) is challenging. A young man fell from his motorbike and appeared to have a T-fracture of the distal femur. We decided to use Perkins traction. Romuald, I could have used some advice. We had the equipment but not the experience. We tried our best, but to wait a couple of weeks before you see results of your treatment requires a lot of patience (of doctor, nurse and patient). While I spent a fantastic holiday with Maartje and Tim (story and pictures will follow shortly), the patient was discharged (own request?) and hopefully went to a hospital some hours away where a surgeon will treat him further. We don't have much equipment like pens and bars for traction or external fixation, so whoever has some spare parts... welcome!
We treat dirty wounds with hydrogen peroxide or Eusol, dr Huisman would be proud of me. Inguinal hernias are more complicated here, due to size (bowels guaranteed) and other techniques (Bassini, dr Huisman help, King has nice pictures but who will show me in practice). The first patient I operated on (emergency herniorraphy) died the same night. I didn't want to operate ever again without a tergooise surgeon next to me. I felt really incapable and ashamed, and it is so frustrating that we'll never know why he passed away. Bowel necrosis with shock, fluid overload in this old man, or did he just bleed to death from a badly tied bloodvessel? Horrible idea. My colleague doctor who was on call texted me: 'Our patient is just died. Pole.' A week later, a patient was admitted with impression of appendicitis. Although I was nervous I was also excited and thought about wise lessons: never make a too small incision, step by step how to open the abdomen, will I do a pursestring to hide the stump and should I apply iodine to it? Try to combine the best things I learned in Blaricum. But it turned out differently. While looking for the caecum, I revealed a loop of small bowel which looked necrotic/ injured, with a nearly perforated hematoma, really fragile, the rest of the bowels looked normal. I was surprised, because there was no history of trauma, nor hernia. Now it was time for dr Briel to pop up into my mind, and I'm proud to say: you taught me how to take care of bowel resection and anastomosis! A bit more difficult without GIA, diathermy, double needle mersilene, good supervision, and proper anesthesia, but we managed with some loose clamps, purple sutures made in india (looked like vicryl), and the patient is still alive.

To be patient
Wednesday 9 a.m. I see some nurses mopping the floor in OPD, no doctor around, it annoys me but fortunately I don't see many patients. Suddenly, I see about 80 patients waiting outside in the burning sun, children, elderly, pregnant. Wednesday is cleaning day. Same story in all wards and theatre, patients just have to wait, and I have to be patient.
Somehow, every day has its frustrations but in the evening I consider the good things. We did a ward round together. We encouraged PITC (provider initiated hiv testing and counselling). I taught some students basic psychiatry because they asked. I did my first c-section and everybody survived. We are getting prepared for an urologist who will pay us a 2 day visit in February. I'm finding out what surgical patients have to buy in the pharmacy (2 sutures, 6 pairs of gloves, small bottle of iodine, spirit, canula, iv giving set, 3L ringer lactate) because the hospital has no money at this moment to provide it.
Driving home we pass by the post office: we got mail! Thanks everybody!! Sitting on the veranda with Tim, enjoying a beer, some pineapple, the view and sounds of the ocean, life is good. Always look on the bright side of life!