Categories
Bangladesh Medical Thursday Doors

Thursday Doors – outbreak at the clinic

It was Friday, 20th October 2017. My day off. But we were too busy dealing with complicated patients, so I felt I had to go to the clinic to help. Here is a photograph of the open door of the clinic taken looking out at the refugee camp. It looks tranquil.

 

IMG_2293
It needs a lot of skill to carry a load of long bamboo poles from the road into the heart of Kutupalong Balukhali refugee camp.

 

It began with a young boy who came into the clinic complaining of pain in his neck. He had spasm in the sternocleidomastoid muscle, which runs from behind the ear to the end of the collarbone close to the breastbone. This is called “spasmodic torticollis” or “cervical dystonia”. It is quite rare and doesn’t often happen to children. As we have no specific treatment available and the symptoms were mild, I thought no more of it, until later in the day. Two brothers arrived at the clinic with more significant, painful, involuntary contractions of muscles in the neck. The father said that they had taken some medication which was in a pack of food items distributed in the camp. The medication was called Halop.

Halo is a water purification tablet commonly used in Bangladesh. I can understand that some well-meaning philanthropist felt there was a need for the refugees to sterilise water. But there were no instruction leaflets to show how to do it. But this wasn’t Halo, it was Halop.

Halop is actually haloperidol, a potent antipsychotic drug. The family showed us a foil strip of ten 5mg tablets, with two missing.

“We thought it was to treat coughs and colds,” said the father. “I gave one tablet to each of my sons last night and look what has happened to them.”

In my entire medical career, I have never prescribed haloperidol for a child. The initial dose for an adult is 0.5 to 1.5mg daily. The two brothers had taken 5mg, roughly ten times this. The drug blocks D2 dopamine receptors, to reduce psychotic thoughts. However, it also acts on the part of the brain which controls movement and muscular tone, the extrapyramidal system.

These three children were the first of many to come to the clinic with acute dystonic reactions. Their necks were contorted, forcing their heads backwards or to one side. In extreme cases, the eyeballs roll back into their sockets, a condition called “oculogyric crisis”. We didn’t see this, but we did notice many children staring upwards and to one side. Examining the children’s limbs revealed increased tone. On moving the arms and hands, I could feel jerky resistance, so-called “cogwheel rigidity”.

At first, I thought that this was an isolated occurrence, but by the end of the first day, we had admitted eight patients who were so stiff and rigid that they could not eat or drink. One poor chap had taken two tablets; he couldn’t retract his tongue which was sticking out of his mouth. We realised this was an outbreak of poisoning.

P1310886

We tracked down where the food supplies had been distributed and the outreach team spread out through the camp, telling families not to take the yellow tablets in the packs. We contacted the block leaders and imams, asking them to pass on this information. The following day, we distributed colour photocopied pictures of the drugs, warning people to hand them in. We managed to purchase some “antidote” from the nearest town, to give to the patients who were worst affected.

The outreach workers collected over two thousand tablets from the community. We reported the incident through the official channels. A few days later, doctors from the Ministry of Health and WHO visited the clinic to confirm what we had discovered. I assume that they worked out how this had happened, who had supplied the medication and took the necessary action to prevent it from happening again.

It was fortunate that we were able to recognise this problem quickly and take appropriate measures to manage the situation to prevent further harm. All our patients recovered completely after a few days.

 

Categories
Bangladesh Thursday Doors

Thursday Doors in the clinic

This is from my journal, five months ago in Kutupalong Hospital, Bangladesh. There are some photographs of a few doors in this piece, but it is worth reading if you are interested in what it can be like working in a refugee camp.

 

P1320481
Rohingya refugees queueing up by the door of the health post.

 

The young man looked ill. His hair was plastered onto his forehead with sweat. The medical assistant asked him to leave so I could see a different patient. I said, “Wait a bit. He’s unwell. Let’s sort him out first. What’s his story?” Just fever.

Fever for ten days. Ten? Getting steadily worse.

What else? Nothing much. “Bish (pain)?” I asked him.

A headache, bellyache, a bit of diarrhoea, not severe, no blood.

Anything else?

Feels tired, not sleeping, poor appetite.

Helal, the medical assistant, and I looked at each other warily. I said, “Could be typhoid. All he needs to have is a slow pulse and it would clinch the diagnosis.”

Helal took the right wrist, I took the left. The pulse was far too slow for the height of his fever, a characteristic sign of typhoid. We nodded at each other. I remarked that it was a good catch and he prescribed the ciprofloxacin.

 

IMG_2302
There is a door behind the blind man sitting on a green plastic stool. It is made of plastic sheeting stretched over a framework of strips of bamboo

 

The patient he wanted me to see was a little boy with a painful, irreducible hernia. The last child with a painful hernia I sent to the surgeons actually had an inflamed appendix in the sac. He ended up having two operations for the price of one. So I have a low threshold for referring hernias in children. This little chap had so much intestine in his scrotum that you could see the peristalsis, visible movement of the bowel. It was so big that it was a struggle to fit it into his shorts. There was no clearance for him to pass urine properly. I made a clinical decision to refer him, even though it is stretching our guidelines to refer only urgent cases.

 

P1320468
This man is standing in the doorway of the health post. He reminds me of a crazy nun wearing an outrageous wimple, but it is just a split plastic sack, tied around his head to give some relief from the hot sun. He has been bringing supplies up from the road into the heart of the camp, carrying the load on his head.

 

I see the most horrendous eye conditions. Every day, three or four people come to the hospital with incurable eye problems – penetrating injury by splinters of bamboo, blunt trauma, corneal ulcers and cancer. My last teaching session to the staff was on the subject of eye disease. I have a complete set of illustrations of the common eye conditions the doctors are likely to see, all photographed here in the hospital. I would like to say a word of thanks here to HughdeBurg, for his swift replies to my requests for ophthalmological advice. I hope that this will help to reduce unnecessary referrals to Chittagong Eye Department, six hours away by road. I have donated my personal ophthalmoscope to the clinic so the doctors can examine patients properly.

My day is often like this. I hardly ever see anyone who is not sick. Quite often, the doctors call me in to confirm that there is nothing more we can do for patients. They want me to be the one to deliver the bad news. The disease is too advanced or too difficult to treat in this setting. Patients suffering from end-stage kidney disease, a cirrhotic liver which is decompensating, cancers, heart failure, or ruined lungs from a lifetime of cooking with biofuel in a confined space. I feel I am a harbinger of doom.

Every now and then I see patients who have scraped together enough cash to pay for the opinion of a local specialist. Even when the evidence is incontrovertible, the specialist will never tell them they are dying or that they have incurable cancer. Perhaps it is traditional to do this, not to take away any slim hope of recovery. Maybe I am more cynical, thinking that a desperate patient will pay for more consultations and treatments as long as the stark truth is withheld from them.

 

Categories
Bangladesh Medical

Noma or Not?

WARNING – CONTAINS A GRAPHIC IMAGE WHICH MAY BE UPSETTING

October 2017, Kutupalong refugee camp, Bangladesh.

It began with a misunderstanding. I asked the Rohingya mother how her baby had developed an evil-looking purple swelling on the side of its nose. I thought the nurse translating said that it had been caused by boiling water. It seemed to make sense – fragile newborn skin being splashed with hot water during cooking, perhaps in a dark, plastic-covered hovel in the migrant settlement area. It looked superficial, it should have healed swiftly.

I misheard. The nurse translating the mother’s response actually said that it started with a boil on the face, a small spot, a furuncle. Over the next few days, the skin changed from the colour of a bruise to a dark patch of necrotic (dead) skin. Another dull red patch developed on the baby’s ear. The neonate had already been started on antibiotics but without much obvious benefit. The lesion started to ulcerate. We added another antibiotic specifically for staphylococci and yet another for fusobacteria. We even added an antifungal drug, in case the baby’s immune system was so compromised that this was an opportunistic infection.

 

P1310606
I have crudely blacked out the baby’s eyes to preserve confidentiality.

 

There is a great online tool for doctors working in remote settings called Telemed, which allows us to seek the opinions of a group of specialists from all over the world. With the mother’s permission, I posted a photograph of the baby on the Telemed website and waited for paediatric dermatologists to give their opinions.

The infection got worse. We asked for help from the Memorial Christian Hospital, who thought that the baby had Noma, otherwise known as oro-facial gangrene (cancrum oris). This normally affects older children and is incredibly rare in the neonatal period. The hospital doctors thought the baby might benefit from a special antibiotic only used to kill multi-drug resistant bacteria. The ambulance was ready to take them for therapy, but the mother refused. She needed permission from her husband to leave Kutupalong.

Did he have a cell phone? No.

Was he going to visit her soon? No, he was looking after the four other children.

A nurse suggested sending the police out to find him and bring him to the hospital to get his permission. We dismissed this as too heavy-handed.

The mother said that she wanted to leave the ward, against our medical advice. She said she needed to discuss with her husband and that she would return if he agreed.

A day after she left, the Telemed paediatric dermatologists came up with another possible solution – a strawberry birthmark (capillary haemangioma) which had ulcerated and become infected. There is a cure for the birthmark, propranolol, though we would struggle to find it in Bangladesh. We’d probably have to improvise and use a different drug, which is not licensed for this condition. The baby would still need treatment for the flesh-eating bacteria, however.

The mother never brought the child back to the ward. I still think about this child. How could we have handled this better? Tragic cases, like this one, occurred every day in Kutupalong.

Categories
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
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.

P1320829
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.

P1320769
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?”

P1320325
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.

 

P1320320
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.

P1320324
The lateral X-ray shows the fractured femur AND the stone in the tip of the penis

 

P1320323
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
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).

P1320697

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.

 

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.

P1320214

“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

 

IMG_2084
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.

P1320647

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.

P1310506

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

P1320182

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.

P1310820

P1310825

 

Categories
Bangladesh

Journal entry, October @ Ukhiya

IMG_2201“I am sitting on the concrete flat roof of our apartment building at 7:30 sipping morning tea. You could cut the atmosphere with a butter knife, the humidity is so high. Visibility is restricted to about half a kilometre by fog so I cannot see the hills of Myanmar to the east. To the west, the forest bordering the paddy fields is cloaked in the miasma. I can hear thunder beyond the trees, like the rumblings of a dyspeptic ogre’s stomach. It is usually uncomfortably hot by this time, but the sun has not yet burned off the mist. In an hour or so, the sun’s heat will make the jungle steam.”

P1320081

IMG_2203