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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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Categories
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.”

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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.

 

Categories
Bangladesh Medical

Diphtheria

On 11th November 2017, in Kutupalong hospital, I diagnosed the first case of diphtheria in the refugee camp. Although I had never seen this illness during my professional career, it was instantly recognisable. Three weeks later, the hospital was seeing a hundred Rohingya patients a day suffering from diphtheria, with a mortality rate of 10%.

In 19th Century Britain, diphtheria was known as “Boulogne Sore Throat” as there was an outbreak across the Channel in France. Queen Victoria’s second daughter and her grandchild died from diphtheria within a week of each other.

The French physician Bretonneau first used the Greek word diphthera meaning “prepared hide or leather” to describe the disease in 1826. It refers to the thick, grey membrane of dead skin which covers the back of the throat in patients suffering from diphtheria. This “pseudomembrane” can obstruct the airway, suffocating the patient. No wonder the disease was known as the “strangler”. An epidemic struck Spain in 1613, “el ano de los garrotillos” (the year of strangulations).

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People can be asymptomatic carriers of non-invasive diphtheria which do no harm. But when a bacteriophage (virus) infects the corynebacterium it stimulates the production of the dangerous toxin. This poison kills cells in the throat but has a more serious, delayed action which damages the heart, kidneys, liver and nervous system.

A Prussian military doctor, Emil von Behring, won the first Nobel Prize for Medicine in 1901 after developing diphtheria anti-toxin in 1890. He repeatedly injected sublethal doses of toxin into a horse. The horse’s immune system neutralised the toxin. Horse serum anti-toxin is still used today to treat diphtheria. However, it is in short supply as there are so few cases of the disease in developed countries. Since mass immunisation against diphtheria was introduced in the UK in 1940, the disease has become extremely rare. The last British fatality was in 1994 when an unimmunised child picked up the infection on a trip to Pakistan.

Diphtheria is part of the WHO childhood immunisation schedule. Unfortunately, many of the Rohingya children who fled from Myanmar last year had never been vaccinated. In the overcrowded conditions in the refugee camp, diphtheria can spread rapidly by droplet (aerosol) transmission. Over 300,000 young people needed immunising – three doses, a month apart – to halt the epidemic.

The outbreak in Kutupalong refugee camp in Bangladesh was not an isolated event. Last year there were serious epidemics in Indonesia and war-torn Yemen, with many fatalities.

I have always been a fervent believer in immunisation because I am convinced it prevents mortality and morbidity. Perhaps because it has been so successful at eliminating diseases such as tetanus, measles, rubella, polio and diphtheria, many parents are unaware how deadly these diseases can be and they are frightened about the infinitesimal risk of vaccine side effects. But I have seen what happens when the system for vaccinating children breaks down, resulting in death and misery.

 

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Thursday Doors

Thursday Doors @ Lanhydrock

The National Trust is a wonderful institution. Without it, stately homes would decay and be lost for future generations. It costs about a pound a week to be a member, allowing free entry to the gardens, grounds and buildings. This would not be possible without thousands of volunteers, working as guides or in the guest shops.

Lan-Hydrock means locality around the church of St Hydrock, who was a mysterious 5th Century Irish ascetic who emigrated to central Cornwall. The hall was first built in 1620, but in the late 19th Century, Lord Robartes renovated it to its present state. In 1953, the property was transferred to the National Trust. Since then, it has been the site of the film version of Shakespeare’s “Twelfth Night – or what you will” starring Helena Bonham Carter as Olivia.

Enough of the background, here are some of the doors. First what looks like a door to a secret garden

 

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The gates in the garden (wonderful camellias, see my Instagram account – drprunesquallor) have an ingenious mechanism to allow the gate to open both ways. There is a hinge at the top and a U shaped yoke hinge at the bottom.

The church tower was built in the 15th Century, housing nine bells.

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Around the courtyard, there are some interesting doors with decorative carving.

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Finally, a warped door within a gate.P1330726

 

Categories
Bangladesh Medical

All doctors make mistakes

Medicine is not a precise science; certainty is impossible to guarantee. Doctors are fallible. When making a diagnosis, we play the odds, treating what is most likely, with an eye out for rare conditions which we shouldn’t miss. “Common things are common” is a truism, but “when you hear hoofbeats, think of horses, not zebras.” (Well, perhaps not in Zambia.) But even unusual versions of common diseases are more likely than rare diseases.

Kutupalong health facility, November 2017.  I was called into a consulting room to give a second opinion. The nurse told me that the patient had pus coming from both eyes for three years.

“Three years?” I asked. “On and off for three years or every day?”

“Every day,” replied the nurse.

That’s very unusual. Sometimes patients exaggerate the length of time they have symptoms. Perhaps the lack of medical care in northern Myanmar for Rohingya people was a factor, resulting in chronic infection or conjunctivitis.

I looked at the patient. Her eyelids were coated with yellow discharge and her conjunctivae were inflamed.

“What do you think is wrong?”  The nurse didn’t reply, she is very shy.

I gave her a short tutorial on different causes of conjunctivitis and asked her which was the most likely.

“None of them.  She has dacryocystitis,” she said.

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“If she had inflammation of the nasolacrimal duct, there would be swelling here,” I said, pressing the patient’s face, just by the nose and below the eyelid. A spurt of pus welled up over her eyelid and ran down her cheek. A bit like the egg I now had on my face.

“Dacryocystitis is very rare in adults, but your diagnosis is spot on here. Good call. Why did you ask for my opinion?”

“Because I don’t know the best way to treat it,” said the nurse. Fair enough. The patient needs some delicate surgery to sort out the problem.


 

The medical assistant called me to the Emergency Room. “Acute appendicitis,” he said. I asked him to present the history. He had recently joined the team and was unused to speaking English. Perhaps lacking in confidence, he repeated, “Acute appendicitis.”

“What about the details, when did the pain start, where is it, did anything make it worse, did anything make it better, any other problems? You know how to do this,” I asked.

“She had pain for ten days, and fever before then. She is tired and has lost weight.”

“Isn’t ten days a bit long for acute appendicitis?” I asked.

Silence. “Anything else?” I enquired.

The doctor reached out with pointed fingers and prodded the patient’s abdomen. “See, McBurney’s positive!” he said.

Ouch. It even made me grimace. “OK, let’s start by introducing ourselves and putting the lady at ease.” Then I kneeled down by the bed and gently touched her abdomen with the flat of my hand. Her tummy was soft, with no muscular guarding, no signs of peritonitis and I could press down over where her appendix should be (McBurney’s point) without her flinching. But there was some liver enlargement which had gone unnoticed. This clearly wasn’t appendicitis. It wasn’t even an acute abdomen.

“Why do you think she’s breathing so fast?” I asked.

“Because she has abdominal pain,” he replied.

“But the pain isn’t making her anxious. Could it be something else?”

“Pneumonia?” he offered.

“But her blood oxygen saturation is 99%. Her chest is clear. She sounds as if she is breathing like a steam train. We call this Kussmaul respiration. Perhaps she has a metabolic acidosis and she is breathing out more carbon dioxide to compensate. Have you checked her blood glucose? Or her urine for ketones?”

A random blood glucose was more than twice the upper limit of normal – she was diabetic. She didn’t have acute appendicitis. Her abdominal pain was caused by diabetes. Sometimes you have to look beyond the obvious to find the cause of a patient’s symptoms.


 

The little boy had not passed urine for a day. He was in a lot of discomfort caused by a grossly swollen bladder. The foreskin was very tight, so the doctor thought this could be the problem.

“OK, try getting the finest nasogastric tube into the penis to drain off the urine,” I said.

“Not possible, because the foreskin is swollen.”

“Let’s try to reduce the swelling then – try ice packs, covered in cloth,” I replied.

 

The ice pack was successful. The doctor pulled back the foreskin, inserted the tube and out flowed the urine. He proudly showed me his handiwork.

“Well done, but don’t forget to pull the foreskin forward again. We don’t want to convert a phimosis into a paraphimosis (where the foreskin is stuck in the retracted position),” I warned.

“No, it is better to leave it like this. If we pull it forward, it will cause urinary retention again,” said the doctor.

“Hmm, I would prefer it if you pulled it forward,” I said.

I don’t like saying “I told you so” but the next morning, the same doctor came up to me and said, “You told us this would happen,” showing me the swollen retracted foreskin. “Back to the ice packs,” I said.

“If this fails, should we insert needles into the skin to allow the oedema fluid in the prepuce to escape?” asked one enterprising doctor.

“How on earth did you discover that trick?” I asked. Not on earth – it was via the internet.

“Hopefully we won’t need to insert any needles.”

But I was wrong. This time, ice packs didn’t work and the doctor had to stick needles into the swollen skin. Enough tissue fluid oozed out, allowing him to ease the foreskin forward again into its usual position.

“What do we do now?” the doctor asked.

“Well, he is almost three, that’s when he would normally be circumcised. This would provide a definitive solution. Can you ask the father to arrange for this to be done?”

“Good idea, doc.”

 

Categories
Bangladesh

Bamboo

 

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Bamboo scaffolding and ladder (with handrail)

 

Bamboo is the basic building material in rural Bangladesh. It comes in all sizes, thick and slender, short and long. Flatbed trucks have bamboo layered horizontally five metres high, with stouter stems fixed vertically at the edges to keep the load from sliding off.

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There are stockpiles at the side of the road. Compressed Natural Gas (CNG) powered tuk-tuks transport smaller quantities to building sites. Men carry bamboo on their heads into the more remote parts of the camp.

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Others squat on their haunches to split thinner staves into thin strips, then plaiting them into fences, walls or screening panels.

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It is ubiquitous. Perhaps that is why it causes so many medical problems. People fall onto sharpened bamboo staves, causing serious lacerations and penetrating eye injuries. Even worse, a bamboo pole fell from a truck and pierced the windpipe of a pedestrian, exiting through the top of his lung. Incredibly, this person survived thanks to prompt action at our hospital and transfer to Memorial Christian Hospital by ambulance.

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Categories
Thursday Doors

Thursday Doors Suffragette

The Old Vicarage, Cirencester. The door is covered with black plastic, reminiscent of the plastic-sheeted doors of the refugee camp in Kutupalong, Bangladesh. But last week was the centenary of the Representation of the People Bill when 8 million women gained the right to vote. Grace Hadow, suffragette and the ViceChair of the Women’s Institute, lived in this house until 1917.

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Thursday Doors

Thursday Doors Dyrham Park

Dyrham is pronounced “deer-ham”. Not surprisingly, it is an ancient deer park. It was the country seat of Mr William Blathwayt, constructed at the end of the 17th Century. It looks rather ethereal in the murky gloom and drizzling rain of early February.P1330649.jpg

In 1668, Blathwayt entered the diplomatic service and was sent to the English embassy in The Hague, where he learned Dutch. When King James II was succeeded by William of Orange (King William III), Blathwayt was one of the few civil servants who could speak Dutch and communicate with the new King. His career took off when he was appointed Secretary At War. He played a great part in administering the fledgling North American colonies, became wealthy and built Dyrham. This is the view of the front of the house, with St Peter’s Church on the left. Different architects designed the front and the back of the mansion.

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There is a wonderful trompe l’oeil painting through an internal door which leads the eye through several more doors. I particularly like the cat and dog. Samuel Pepys remarks on this painting in his famous diaries. The real wooden flooring changes to black and white tiles in the painting.

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View of a Corridor by Samuel van Hoogstraten, 1662

In modern-day footballer mansions, or in Mar-a-Lago, an Orangery would actually be a tanning salon, but here its purpose is to grow citrus fruit in a temperate climate.P1330652.jpg

The original St Peter’s church was built in the 13th Century, but it was renovated during the construction of Dyrham. P1330658

The door to the Church Tower, with notices pointing out the cost of heating the place.P1330659