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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.

 

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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.

 

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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.

 

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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.

 

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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!”