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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

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.

 

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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.

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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 Thursday Doors

Thursday Doors

Some doors from Bangladesh. The first picture comes from Kutupalong Refugee Camp. About 650,000 Muslim Rohingya fled from NW Myanmar to escape persecution over the past few months. This camp is currently the biggest in the world. Conditions are squalid. The Rohingya construct their shelters with plastic sheeting and bamboo. This is where I have been working for the past two months.

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Outside the camp, in Ukhiya, the doors are made from metal for security.

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This is a door shop in the bazar. The design is reminiscent of Mughal Art in the 17th Century in India.

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A testament to corrugated tin sheeting.

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This is intriguing. What does the sign say? Does anyone read Chittagongi? Or it might be Bangla?