Well Guys, I don't know where the last few months have gone at all! The best things in life always go so quickly I guess, but it's all over now.. And I have had an amazing time! I would recommend all of it to anyone..
- Going to a third world country to experience their healthcare system
- Using Work the World as a company, they are truly amazing, they sort everything for you and the staff in the Dar house were the best and nicest people I think I have ever met, they really did go above and beyond! I can't speak highly enough of them!
- Tanzania as a country is awesome, even if you're just travelling there is so much to see and to do, you could easily spend a month and more just going around as it is a huge country
If you ever get the chance to do any of the above, just do it! You never know what you might find, who you will meet and what's in store for you. I thought I had a pretty good idea of what to expect, but at the end of the day I didn't really and I had some of the best experiences of my life and meet some of the lovliest people I think I ever will.
Thanks to everyone who has been following me, I hope it hasn't been too much of a bore and I've managed to keep you all a little interested in my goings on. If you do want to know anything more or have any questions then drop me a line and I'll be happy to help.. Whether its about the hospital, Work the World, Tanzania (or Kenya) or anything related!
Cheers everyone! :)
Kwaheri!
Whilst in the department the staff gave me statistical information for between 2006 - 2012 about the country and different regions and the variation between the different regions is vastly different, let alone compared with the UK.
Cervical Cancer is the most common cancer (as already known), with 955 cases being treated in '06 rising to 1896 in '12. Patients treated for Prostate cancer in '06 was just 51 and last year 101 were treated. The incidence of Kaposi's Sarcoma and other skin cancers is quite different, Kaposi patients treated last year were 789 and for other skin cancers 147 were treated.
Breast Cancer - 667
Oesophagus - 573
Head and Neck - 386
Lymphoma - 295
Leukemia - 252
Bladder - 168
Eye - 131
(As of 2012)
These relate to the type of cancers I saw and the quanitites I saw them in too.
The number of these patients that came from Dar es Salaam was nearly 10,000, from other regions less than 1,000 were treated. This is as Dar holds the only radiotherapy centre, it is hard for most people to travel this distance; especially if they live in Arusha which is at the northern end of the country. The region of Manyara has the lowest number of patients being treated with cancer.
These statistics don't really have a baring on how many people with cancer there actually are in Tanzania, as most people probably ignore their illnesses anyway. A couple of the staff that I talked to were very keen on travelling around to the different regions and educating their people on their health and cancer. There are lots of things that the staff would love to do to help their people, like creating a charity for those patients they have to help them with travel, food, expenses, etc. - which is lovely, but they are finding it hard to start as they need to get sponsors first.
I saw a lot of pretty horific cases, but a few stuck out for me specifically that I don't think I will ever forget!
1. Anal Carcinoma
This case was one of the first I saw and I only saw it once - after this the patient was too ill to attend.
So in the UK anal cancer is assosicated with the older population (along with most others), however, the population in Tanzania is obviously a lot younger than ours so cancers develop at earlier ages. But I did not expect to see that this man was just 25 when I looked through his notes. He was so frail he did not have the energy or life to lift himself out of his wheelchair, let alone get on to the bed! His father had to lift him up onto the bed. It was so sad having to watch his father care for his ill son knowing that he hadn't got long left.
2. Brain Tumour
This case was pretty similar to above in the respect that this young boys father had to do everything for him as he had no life left in him - he couldn't open his eyes and had to be carried everywhere. This young boy was about 6 and had to be transferred from another hospital everyday to have his treatment. I'm not sure what type of tumour he had as it wasn't recorded in his notes, but his treatment was not nessercary as it was not helping the little boys condition at all - in the UK he wouldn't have been started on treatment.
3. Pituitary Tumour
I watched this lady from the beginning of her treatment to near enough the end as she started when I started my placement.
At the beginning she was so chatty and trying to teach me Swahili and always laughing, but she deteriated a lot and quickly! By the end of three weeks she could hardly put one foot infront of the other, let alone walk in a straight line! Her eyes were hardly open and speech slurred. What struck me was how little care she was given still in this condition! She could hardly get herself on the bed, yet the staff all just left her to it.
I was asked what we would do in the UK, when I said that the technique would be completely different to start with they didn't understand that using right and left laterals was treating too much brain and meaning that the side effects she was having were horrific! I said that if she was in this state, we would have stopped her treatment as we were doing more harm than good to her obviously.
After this day, she didn't return for treatment whilst I was there as she was too ill.
4. Xeroderma Pigmentosum
This was something I had never heard of before I saw this patient. It a genetic disorder than basically means that you're allergic to sun and any exposure to UV leads to skin cancer.
This little girl was just 7 and had skin lesions all over. In her notes it read how she had had lesions on her back when she was younger and a few on her chest. But from that point, she had progressed into a state that was beyond repair and her treatment was very palliative. She had deep lesions all over her scalp that were pusey and scabby, her nose was none exsistant and had been consumed by cancer along with her right eye which she could no longer see through. Her mouth and lips were filled with ulcerative lesions which made eating a struggle. And this little girl was terrified!
On the first day she was too scared to get on the bed and was crying her eyes out! The radiographers had little sympathy with her and it just sounded like they were shouting at her. I felt so sad for her. The next day she hid behind her mum up against the wall, then she saw me and came over and held my hand and then walked with me over to the bed (I don't think she'd ever seen a white person before). On her third day I took some stickers in with me to give to her and when her mum gave them to her, she was extatic! She was smiling with all her might and wouldn't stop playing with them!
The even sadder thing was that her mum still held out hope that she was going to be completely cured soon, but her case was so that even the radiotherapy she was having wouldn't have made too big an impact on her situation.
It's hard to convey just how sad these cases were, without being there I think. But I've done my best for you guys!
So my placement is now over, the last four weeks have flown past and I have no idea where! It's been amazing working there and hasn't felt like work at all!
The staff have all been lovely, there was only one woman in the department and she only works with the caesium machine really. There attitude is so laid back and there is no rush about anything. It's nice in a way, but can sometimes be annoying when patients are waiting around and left on the bed or waiting for their treatment for ages.
They have a poor opinion of UK radiotherapy and the staff. It's been said to me that we don't talk to patients at all, whereas we talk to patients a lot more than they do and have much more of a caring nature. Most of the time all they ask them is for their name and to go into the room and to leave the room. So I'm not sure why they think that their much more patient orientated!
Another statement has been made that we don't talk to each other at work or use our phones. I tried to explain that we do talk to each other and they said no you don't talk about things outside of work, they didn't understand that we did. And the fact that we don't use our phones was a professionalism thing, they didn't grasp that concept either.
They've made a big effort with me though asking lots of questions about the UK and how we do things. Most of them know how we do things though, as the sad thing is that their education at university is the same as ours, but everything is theory as that just don't have the equipment to practice how we do. One man told me how they got told they would get a chance to go to another country to practice, but they never heard anything else about it sadly.
They would all love to see how we did it and come over, but they can't get anywhere as its just too expensive and they have commitments here.
This week a lot of the staff have been off, due to the red they received at the end of last week. There were 7 interns working and 4 jobs were on offer to start when they are qualified at the end of the year. However, none of them were offered the jobs as they decided to offer them to diagnostic technicians and then train them up as this way is cheaper. This means that they know have nowhere to go as there are no other centres in the whole of Tanzania, so the last 4 years of their lives have been with no reward. It's very sad and they were very demoralised, so have not been in to work.
It will be sad to leave them, but I've got their emails and intend to keep in touch and see what's happening our there in the future and if things are changing like they all want it to!
Patient set-ups are all pretty similar out here and easily picked up.
So, the staff will tell the patient to enter the room and then give them a few minutes before entering again. ive been told two reasons for this, one because of the radiation protection and the other because of patient dignity. The patient will get on the bed by themselves, sometimes struggling and I've seen blind people with little assistance trying to get on. They all have to lay their individual kanga's on the bed for their treatments before getting on.
Sometimes they are moved to make sure that they are straight but they are mostly just given directions as to what to do to get themselves in the right position. Sometimes I disagree with what they are doing because they can move their ankles and legs after the field has been positioned, altering the position of the field possibly.
For cervix patient anatomical surface markers are used for the set up on every patient; as I blogged in my last post.
For other patients most of them have plaster markings around the edges of the field so that their is some guidance as to where to go. Although this is a good idea, the plasters are often put on by nurses outside of the treatment room. This means that the field light is not on the area and the patient is in a different position, therefore it can be non-representative of the actual treatment field. Another issue is that they do not stay on very well after washing etc. so if they fall off and patients re-position them (like they often do) it is hard to know where the exact place is. For patients having lateral fields treated the field is only marked on one side so this too can make the positioning hard as the bed can be unreliable with the measurements and movements. Obviously no movements are made from these plasters as they represent the actual field that needs to be treated.
The accuracy is better than what I thought it would be, even if it is a bit dubious sometimes! Most of the time I feel comfortable to set up and switch on with the set-up they have done as it is all that can be achieved with their equipment. To start using tattoos would require a large change in the department and a lot of time and money; but hopefully in the future.
Explaining the techniques used in ORCI will not take me long as they are very basic and all very much the same. Not because they know no different, because they all get taught the same things as us (but their knowledge is just all theoretical rather than practical), but their techniques are the way they are because of the equipment that they have sadly.
As there sinulator is a bit tempormental and most techniques are just done by the book and with surface markings, after a few days picking the set-up was easy.
For cervical cancer - most of what I see - they are mostly late stage and the technique used is SSD100 (or SSD80 if you're on the other machine) and a field arrangement of anterior and posterior parallel opposed pair. Field sizes have to be large to encompass the large extent of disease (which you can often see bulging and can smell from a distance sadly for these women). The general field size is 15 x 15cm, which is sometimes coned down to 10 x 10cm or 12 x 12cm after their initial 25 fractions and review by their doctor. As these patients don't have marks on their skin, surface anatomy is used to position the field. The lower border is the anterior commissure and the upper is just below the umbilicus, to position the lateral borders the Sagittal laser is positioned running through the middle of the vulva.
For almost every head and neck cancer right and left parallel opposed fields are used. The field size for these is not as predictable and will vary depending on the extent of the disease and where exactly it is obviously. Some may be 8 x 5cm for example, while others 12 x 10cm. The decision on field size is made by the radiographer a treating the patient on the first day and their knowledge on the cancer and patient; so this can be very subjective. But their textbook knowledge is very good so they know how it should be.
Some lymphomas of the head and neck and other more superficial cancers are treated with direct single anterior or posterior fields - also varying in size depending on the tumour.
As you can see, the techniques are very much palliative in their style and although the majority of patients are very late stage it is not ideal. But Asides from these three techniques anything else is very much impossible due to their lack of equipment and money and the fragility of the equipment; I have been told by one that they don't like moving the jaws of the machine too much as it makes it very tempormental, like i wrote in my last post. They would all love to be able to move on to greatest things, but right now they are doing the best they can for their patients.
Their technique for breast is however nearly identical to our technical, the only difference being that they used an SSD of 100 as they don't have the facilities for planning obviously. So the standard treatment is medial and lateral tangentials; they were surprised when I said we were doing the same in the UK! They even use half beam blocking for the medial border, but not for the superior border of the field where it mets the supraclavicular field. There is a difference with the patients too. Because the majority are caught late stage this means they have all had mastectomies, I don't think I have seen one patient without one. As this is the case, it also means that they all have supraclavicular fields too - with the exception of one patient I have seen.
Sorry I haven't been here in a while my last couple of weeks have been so busy exploring I've ran out of time to get down to updating you all on what is going on in the hospital! I think this week may be my last post/s while I'm out here too, as I'm off on safari on Saturday - no idea where the last four weeks have gone its very scary!
Hopefully I'll be able to catch you up on everything within the next few days though and if not then will do when I get back.
