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Thursday Doors

Thursday Doors Amsterdam Again

More doors from Amsterdam. Around the Tropical Museum area. Enjoy.

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Thursday Doors

Thursday Doors Amsterdam

Here are a selection of doors I photographed in the Zoo neighbourhood of Amsterdam. It is known as Artis – short for Natura Artis Magistra. Enjoy.

Another six next week.

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Bangladesh Thursday Doors

Thursday Door – Scenes at the roadside

A dark blue truck recklessly overtook our minivan on the road to the clinic. It was the Dog Support Unit for the Rapid Action Brigade, known as the RAB. I couldn’t stop myself from thinking of another acronym. Rapid Action Brigade Including Dogs or “RABID”.

Along the roadside, I watched a man carrying a bendy bamboo pole with a clutch of empty blue barrels tied to each end. As he walked, the bamboo flexed. The trick was to time one’s steps with the bounce in the pole, so you were lifting off your foot when the pole was rebounding upwards.

Other men carried earthenware pots in this way. Some cyclists are loaded up with so much plastic stuff that they must need assistance to get back in the saddle once they have stopped. There are some doors in this post, be patient.

The green paddy fields are turning gold as the rice ripens. Each patch has been planted at a different time, so the harvest is phased. Traditionally, they have two crops a year, but with “Chinese” hybrid rice, they can plant a third crop. The rice is all harvested manually, using small sickles. There is very little mechanisation here. To level the fields after the harvest, farmers use oxen or buffaloes to drag a ladder over the ground.

Farmers plant a dead branch in each plot of paddy as a perch for fork-tailed drongos and flycatchers, which keep down the numbers of insect pests. Men take their cows out on a rope so they can graze for their breakfast. Small boys try their luck fishing in the irrigation channels. Two boys sit astride the walls of a bridge, playing ludo or draughts with pebbles.

School uniforms are very smart. Some boys have to wear a military style cap. Girls wear a white headscarf over a primary coloured long shirt dress or kameez. I was amused by a group of boys wearing brightly coloured skullcaps while they played soccer on a dusty field.

A pregnant goat lies in a bed of ashes, still warm from last night. Men cluster outside a shop selling breakfast food. One of the rundown shacks has been named “Dubai”, probably where the owner earned the cash to build it.

In the small towns we pass through en route for the clinic there are tea shops with strings of gaudy foil packets of snacks, hands of bananas and plastic gee-gaws hanging from the roof. It is usually very quiet when we drive out to the clinic because we leave so early in the morning.

At Court Bazaar, there is more action as the market is in full swing. There are carcasses of beef hanging from hooks. Piles of fruit and vegetables, sacks of different types of rice displayed on stalls. In the mud at the edge of the road, there are cycle rickshaws, e-rickshaws with an electric engine, CNG (powered by natural gas) and TomToms (powered by electricity). Lorries and buses joust for position, horns blaring constantly.

At the roadside, there was an umbrella lashed to a post, providing a patch of shade or shelter from the rain, depending on the weather.

At night when we return after dark, the bazaar is more alive. People throng the narrow streets in droves. They don’t dawdle; they look like they are on a mission to get stuff done. The bright lights of jewellery shops make the necklaces sparkle enticingly. The energy-saving spiral bulbs over the fruit stalls attract moths and flying insects. The pharmacies are also well lit, displaying versions of all the popular drugs. I like the restaurants, with their roadside kitchens shielding the diners from the passing traffic. Pakoras and parathas sizzling in massive cauldrons of boiling oil. Flatbreads being cooked on skillets.

Men packed into a pickup or an e-rickshaw. An empty chicken delivery truck. A group of men working on the roadside, putting down a sidewalk with crumbling bricks arranged in a herring-bone pattern. The toxic soup of fish farms and prawn hatcheries.

The furniture shops make what they sell. No flat packs from IKEA here. They specialise in intricately carved bed heads and doors. The barber shops do deep cleaning facial massages as well as shaves, beard trimming and haircuts.

The ubiquitous piles of fetid rubbish rotting by the roadside add to the scented aroma of biryanis on the evening air. A grocery store has a television blaring out into the street, surrounded by a cluster of small boys sitting cross-legged and goggle-eyed.P1310409

What a privilege it has been to live and work here in rural Bangladesh.

Categories
Thursday Doors

Thursday Doors Buckingham Palace

Buckingham Palace opens to the public for six weeks every summer. You can buy a ticket for the house, the art gallery, the gardens and the stables. Don’t miss out on the audio guide narrated by the Prince of Wales.

These doors are from the state carriages, bearing coats of arms. Can you see which is the Australian coach?

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Bangladesh Medical

Diseases which should never happen

Before today, 11th November 2017, the only person I knew who had diphtheria was my Aunty June, who had contracted the disease in 1935.¹

“Have you seen the woman with the white throat?” Dr Nadim asked me.

P1320703At first, I didn’t click. What did he mean by a white throat? Was he describing vitiligo on the front of her neck? It was a shock when I saw the patient. There was a thick, greyish membrane on the right side of the back of her pharynx, inside the mouth. Her neck was diffusely swollen, known in the trade as a “bull neck”. She looked uncomfortable and couldn’t swallow without pain. It was just like it is described in textbooks – but diphtheria is so rare nowadays that it only merits a brief entry in the Oxford Handbook of Clinical Medicine. There is nothing else which causes this appearance. (See my previous blog post about diphtheria for more information)


In our other isolation room, we have three children with tetanus. Two have neonatal tetanus, a disease which has been virtually eliminated from the world by vaccinating women in the antenatal period. I have seen seven Rohingya patients suffering from tetanus in the two months I have been working here in Kutupalong.


Some diseases are so feared that we may not speak their name. Cholera has become “severe acute watery diarrhoea”. Poliomyelitis is “acute flaccid paralysis”. The Bangladesh Health Ministry has organised vaccination campaigns in the refugee camp to prevent both these diseases, but not before one boy contracted “acute flaccid paralysis” which could have been wild-type polio. We admitted him to the ward for observation, but his symptoms did not progress, and we discharged him after a week.


The only letter I have ever written to The Times newspaper was to criticise Nigella Lawson’s view on measles vaccination, which she felt was too risky given that measles was not “a serious disease”. I wrote that measles could be lethal. I recall admitting twenty children suffering from measles to a hospital ward on a single day in 1980 in Southern Sudan; by the next morning, only twelve were still alive. Nigella didn’t reply.

Here we have a measles isolation tent. Six months ago, Cyclone Mora blew the tent onto the roof of the hospital laboratory. It was retrieved and fixed more securely to the ground. When I visited the tent last month, it was hotter than Hades.

The mothers were complaining that there were no fans in this furnace of a ward. The children looked irritable and ill, lying on mats on the floor. I checked them for dangerous complications of measles and we said we would get one of the logisticians to bring a power cable into the tent to run a standing fan.

The following day, the mothers were delighted at the cooling breeze from the fan. I was less than delighted with the increase in numbers of ill children.

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The waiting area where we assess children with measles to determine whether they are so unwell that they need admission to the tent. Note the logo on the tee shirt of the man wearing a blue checked lunghi.

 

A week later, the mothers were angry again. The fan had stopped running. I saw that the plug had come out of the socket, perhaps when moving the fan to make room for another mattress. I moved the fan closer and replaced the plug. The fan remained dead. The mothers looked downhearted.

I couldn’t give up and lose face, so I tried twiddling the switch governing the speed of the fan. Still no good. Then I tried a bit of “percussive therapy” – I bashed it and the fan spun into life. A cheer went up (mainly from me). Everyone was happy. The spotty children were all doing extremely well and would soon be discharged.

The logistics team have now fixed up a massive awning over the top of the tent to provide some insulation from the hot sun. The patients find it much more bearable now.

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Measles tent with protective bamboo roof/shade 

 

The misery caused by all these diseases could have been prevented by routine immunisation. This has been so successful that many parents (like Nigella) in developed countries have become rather blasé about having their children protected. Sadly, many Rohingya in Myanmar have not had the luxury of that choice; they had no access to vaccination. The consequences of this are plain to see in the hospital.

 

 

¹ My father and his siblings were quarantined at home, issued with a bottle of “Thymo-Cresol” disinfectant and not allowed to go to school. Crucially, this impacted on his performance in the grammar school entry examination, the Eleven Plus. He said,” With this period of isolation, all my dreams of becoming Prime Minister came to an end.”

Categories
Bangladesh Medical

Double trouble

The telephone call woke me up. The Emergency Department doctor on duty wanted to discuss the management of a baby boy who could not pass urine properly because there was a stone blocking the flow. I looked at my watch, it was 5am.

“How do you know there’s a stone?” I asked.

“Because I can see it,” said the duty doctor.

“Have you tried to get it out?”

“My forceps can’t get a grip on it,” he said.

“Give him some pain relief and I will see him as soon as I arrive at the clinic,” I responded.

The stone was well and truly stuck. It was completely blocking the urethra. To deal with this, I made a  fine hook, using a hypodermic needle with the point broken off and bent over. I am sometimes able to ease the needle past and behind the stone, turn it 90 degrees to hook it and pull it out. Not this time. I telephoned the surgeon and explained the problem. He agreed to see the child.

About ten days later, I visited Dr Martin, the surgeon, and asked about the child. “He’s in traction to align his broken thigh bone,” said Martin. “Wrong patient,” I said. “Right patient,” said Martin, who went on to explain what had happened.

In order to find out where the stone was in the urinary tract, Martin had taken some x-rays. These showed a fractured femur, so he put the boy in traction. The stone was a minor problem. Martin asked the mother how the child broke his thigh, “Had there been any trauma?”

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This was the first X-ray, clearly showing the fractured right femur

 

She said that she had been carrying the child as she was running away from soldiers who were trying to kill Rohingyas. She tripped and fell onto the child. This had happened a day before she crossed the border from Myanmar into Bangladesh. It was probably how the bone was broken.

We went to see the child, who was lying on his back, with his legs vertically upright, hanging from a pole above the bed.

 

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The boy’s face is hidden to preserve confidentiality. The bags of intravenous fluid are used to provide traction to align the fractured ends of the thigh bone

 

 

A week later, the child was having trouble passing urine again. This time Martin could see the stone in his penis. Using the correct instruments, he was able to remove it. The child left hospital with a plaster cast keeping the bone ends aligned. Both problems solved.

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The lateral X-ray shows the fractured femur AND the stone in the tip of the penis

 

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Martin kept the stone in a glass tube

Hernias in the groin are common in childhood. They don’t usually cause serious problems unless the bowel becomes trapped or twisted. The little boy was crying. I could tell there was something wrong because the swelling in the groin was very tender. I diagnosed a strangulated hernia. He needed an operation so I referred urgently.

Two weeks later, the boy returned for review following the operation. I was disappointed to see that there was still a lump in the inguinal canal going down into his scrotum. I happened to have an internet connection via a dongle so I sent an email to the surgeon. He told me that the operation had been difficult and there had been a lot of bleeding. This had formed a clot which extended into the scrotum, a haematoma. He expected that this would reduce in size over the coming month.

“Why was the operation difficult?” I asked.

“Because the hernia was so large it contained the first part of the large intestine, the caecum. And on the end of his caecum there was an inflamed appendix,” said Brett.

“So he had appendicitis AND a hernia? I have never heard of that before,” I said.

“Yes, he got two operations – a hernia repair and an appendicectomy – for the price of one!”

 

Categories
Thursday Doors

Thursday Doors in Rococo Gardens

Painswick House has a delightful garden called the “Rococo Gardens”. Apart from the architecture (late Baroque), it is famous for its drifts of early snowdrops.

Benjamin Hyett designed it as a “fanciful pleasure garden” in the 1740s. This red summer house looks like it is only two-thirds finished, with the right wing yet to be built. The stained glass windows are inscribed with Latin verses from the Bible. The garden is surrounded by beautiful, rolling Cotswold hills.