Sunday, 27 November 2011

On African dermatology, student prayers and why Josh wants a fever

(written on 26 november but no internet available)

Zac woke us up with a high fever on Thursday night and spent the night as a kicking hot water bottle in our bed.  Don’t worry it is too early for malaria and I understand there is a viral infection going around –just like in the UK only Tanzanian flu is more exotic than boring UK flu.
Therefore, Zac was allowed to stay at home on Friday, as a swimming gala in the rain didn’t seem the best idea with a temperature.  Josh then turned into a cross between a tantruming 2 year old and a grunting Neanderthal teenager as he didn’t want to go to school either and told us the swimming teacher was an ogre and made them swim a whole length before they could get out (all said of course in a very whiney voice).   Zac’s answer to that happening to him the previous day was to ask to go to the toilet and then he got changed and went to a different club!  Josh’s constant refrain was “I wish I could have Zac’s fever – Mummy take my temperature as I have a poorly tummy”.  He went off to school in a huge huff and they were caught in a tropical downpour on the way.  Luckily for Josh it rained all morning so the gala was postponed but, he was very grumpy to discover that Zac’s class ate all the popcorn Daddy had made for the planned picnic.
I was very glad of the umbrella that Jane kindly brought out for me for my 15 min walk to work.  You can see from the photo that the landscape is somewhat different and my walk takes me past goats, termite mounds and through lots of mud when it is wet. 
I have now had a full week at work and am reflecting on the experience.  The Regional Dermatology Training Centre is unique in being the only Dermatology training available outside South Africa.  The RDTC was established I think by Barbara Leppard and Professor Grossman with its remit to train Dermatologists and non-medical officers in Dermatology.  In Africa there is huge burden of skin disease as surprisingly many patients suffer from all the common conditions of atopic dermatitis, psoriasis and acne.  These conditions are then seen to extreme in the high number of HIV positive patients who also present with skin diseases of the immunosuppressed such as Kaposis sarcoma, lymphoma and extensive viral warts.  Anti-retroviral are free in Tanzania and in the Kilimanjaro Medical Centre people are started on treatment in both the Infectious Diseases unit and within Dermatology.  The RDTC has fantastic facilities and was built only 15 years ago.  You walk into an airy atrium complete with “water feature” where patients arrive and sit on long wooden benches.  Clinics are run on a Monday, Wednesday and Friday and patients arrive at around 8am.  They then sit and sit without complaining and after our 8am morning meeting we take tea (very British) as it seems to take 2 hours for the nurses to bring the files over so we rarely begin before 10am.  I have tried to establish why it takes 2 hours but apparently it just does and no-one seems the least bit perturbed by this delay.  Sebastian – a German volunteer counsels me in patience over tea and gives me the low-down on the political situation at the centre.
There are 10 clinic rooms off the corridor, 2 theatres, a pharmacy and an HIV test counselling room.  One half of the corridor benefits from enough light to see the patients’ skin but on the opposite side due to the frequent power cuts and the trees outside the window we resort to looking at skin with the light from mobile phones and the torch I have now learnt to bring in.  I haven’t really understood yet who goes in which room.  We teach 4th year medical students, the Diploma students and the Dermatology Residents (the doctors in training).  Some rooms have five people in them taking a history and examining the patients and some only have one.  It seems that the larger the number of students in a room the lower the interest level of that group in learning.  Mondays are smaller general clinics and follow-up patients and Fridays is the Paediatric clinic leaving Wednesday as a massive general adult clinic.  On Wednesday we worked from 10am – 3pm without a break or lunch so imagine how grumpy I was at the end!  As the morning merged into the afternoon the rooms became emptier and emptier as first the medical students disappeared and then many of the Diploma and Dermatology Residents until at the end it was just the foreign volunteers seeing the patients! 
Yesterday a lovely nurse came and found me at 4 pm in the library, as I was the only doctor to be found.  That’s the problem with having a shared list…  However, earlier on in the clinic everyone is very keen to learn and I have re-discovered my love of teaching.  Getting an accurate dermatology history is challenging as the patient often changes their story and is very taciturn.  As the dermatology residents and diploma students come from all over Africa there is often a hilarious 3-way conversation going with the few Swahili speakers in the room.  It is heart-breaking to see how late so many people with obvious HIV present.  Commonly people have CD4 counts of 14 and after 5 days I am frequently diagnosing Kaposi’s sarcoma and other HIV related skin disease.  It is excellent that patients can be immediately counselled and have an HIV result within an hour and then start on anti-retrovirals, I only wish they had come earlier.  Wednesday was a fascinating day as in one clinic I diagnosed two rare genodermatoses (that’s genetic skin disease to you)– Tuberous sclerosis and Neurofibromatosis and will give a lecture on these on Tuesday morning to all. 
Last night the second year Diploma students held their annual party to welcome the first year Diploma students to the course.  All the doctors were invited to the Aventure outdoor restaurant for the formal occasion, which was opened with solemn prayers thanking God, Professor Masenga (our Principal) and the King of the RDTC hostel.  Professor Masenga gave a speech memorable in it’s brevity and content stating that he had been in a very boring meeting all day and had another one tomorrow so regrettably he had to go home and could not stay for the party.  It was therefore left to Dr Nabrato to open the proceedings by dancing with Prosperina.  We had a great evening and as the Serengeti and Kilimanjaro beer flowed the dancing became more energetic until at 10pm Michael (a lovely retired Dutch consultant) sensibly rounded us up to go home as they were setting off at 6am for the Kilimanjaro Hash.  I will leave Aaron to tell this tale as I, after another broken nights sleep with Zac, spent the day with the boys in town.
Now as the electricity has been off for 2 hours, which means I will have to bake my bread in the morning, I will take my torch and go to bed………

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