Getting into the swing of things
The days have started to fall into a bit of a routine. I rise early, usually about 6am, shower and then breakfast in the Lappa though it's quite cold here in the mornings now and so this requires a jumper or jacket until it starts to warm up about 8. When I get dropped off each evening I'm told what time I will be collected in the morning and this can be anywhere between 06:30 and 8 o'clock but on average we seem to get off about 7. Also invariably we drop into the Na/a'n ke se guesthouse for 30 minutes or an hour or so which is on the way to the clinic while Rudi or Marlice have meetings and I write in an effort to try and keep my blog up to date. Today might be the last time I have a chance to do this for a while because on Monday I should be going to Epikuro and there is no access to the internet there. I sat a written test today to check my competency level which is a prerequisite before going out to Epikuro. Spending time at the clinic in Windhoek has been invaluable for someone with no medical background and so whilst I found the test quite hard, I hope I've passed with a sufficiently high mark to be let loose elsewhere. My place will be taken at the clinic by the new medical volunteer who arrived yesterday. Though she is a medical secretary, she has no formal medical background and so will go through a similar experience to me so far. Right now I sitting in my office at the clinic and it makes me smile to use the word 'my'. The office actually belongs to Dr Willem Genis but I've never seen him or met him since I've been here and understand from asking today that he usually spends most of his time at one of the satellite clinics in the town. It's been very useful to use his office though it's situated right next to the cafe and the smell of food wafting in makes me very hungry which isn't helpful when I want to lose the several pounds I have put on since I've been here. The meals at the farm are high carb and with little exercise to burn it off I am finding all my trousers are getting that little bit too tight and my shirts are starting to gape.
My training here has progressed on from medical histories to incorporating a general examination and interpreting the urine analysis and BP taken down at the nurses station before the patient comes up. I check for the outward signs of jaundice, anaemia, cyanosis and odeama and also check for swelling of the lymph glands. It has made me look at people much more critically and it's interesting how much you can tell just from how someone looks and the way they walk or sit. If there are any external signs of illness then I have learnt to check the tonsils for infection and also what kind of sounds to listen for in the lungs if people are complaining of breathing problems.
Several of the patients I have seen have been children and there is a problem here with respiratary problems, so often they get put on an inhaler which delivers a vapour that helps open up their airways. I don't suffer from breathing problems myself normally but the air is very dry here and so much dust is kicked up off the roads by vehicles (particularly on the dirt roads) that I have also felt some tightness and wheezing. I have taken to prescribing for myself two bottles of Windhoek Lager each night and for this particular complaint the treatment seems to be working very nicely so far.
Along with the range of standard complaints there have been a couple of patients that have required more complicated treatment. My favouite so far is patient 15 who has ingrowing toenails on both his big toes that are causing him pain and affecting his walking so need to be removed. It was wonderfully gruesome and while I observed the first toe being dealt with I was invited to do the second myself. I can't believe how eager I was to have a go. Perhaps I've missed my vocation? First I had to inject local anaesthetic into points around the toe. The syringe was metal and felt much heavier than the plastic ones I had used before and the needle was much more fine and flexible. The key was to adminster the local just under the skin rather than deep into the muscle and this took a moment to get a hang off. I was either injecting too deeply or the point of the needle went into the skin and came out again the other side. I felt the patient twitching and gasping as I fumbled about slightly but after two or three goes I started to get the hang of it and I heard the patient's teeth stop grinding and he loosened his grip on the bed. He was one brave soul. I'd watched how the nail on the first toe had been removed and had noted that it required a lot of effort and a kind of pulling and twisting motion. The aim I'd been told was to get the nail out in its entirety despite it being grown over by skin. As I pushed the scissor clamp right under the nail and down to the base I watched for any reaction from the patient and was relieved to see him lying relaxed and apparently undisturbed by what I was doing. The local had obviously kicked in sufficiently well. Getting the nail off was a b*****d. I couldn't believe how much effort and force it took and I succeeded only in removing half of it. I had to hand over the rest to Rudi who had to exert some real force to get the rest of it off. We stemmed the bleeding by cauterising the nail bed and I stood back to assess my work. The toes did not look pretty but the patient seemed happy enough and poddled off, somewhat unbalanced, to pay his account. He would be coming back in the morning to have the wound checked and redressed and I hoped I would get the chance to check on how it was doing.
A close second to the ingrowing toenail event was the opportunity to observe the removal of a melanoma on the lower left leg of a patient. The melanoma was to be removed using a surgical blade and then stitched with simple interrupted sutures. It was not a big operation - it could be done at the nurses station - but I was interested to see how it was done and to watch some suturing again. A local anaesthetic with adrenaline injected into the area reduced the amount of blood and I watched at an eliptical insertion was made around the growth which was then dropped into preserving fluid to be sent off to the lab for testing. The wound looked like the shape of an eye and was quickly pulled together with four or five stitches, the whole time watched by the patient. It has to be said that people seem pretty tough out here.
It's my last day at the Khomas clinic and I know from the information I have been given to read that the Lifeline clinic is much more basic and that I can also dress more casually. I am looking forward to going out there and hope I get an opportunity to be really useful. I'll be able to put into practice all the skills I have been taught, that is, if I've passed my medical test. Still no news.