The electricity problems are such that I have decided to buy a medium-sized gas canister and hot plate for use at the house in case of emergency. Today being Monday, Rob and I went into town to lunch at Tasty Bites, the comfortable little cafe under the trees, frequented by many expats.

Good solid Monday lunches here

Good solid Monday lunches here

(Chicken and chips is K795, burger and chips K595, sausage and chips K495.) Next door, there was a small Afrox shop, so I sauntered over to ask if they could fill my new No. 10 canister. Knocking on the door and gazing into the dim interior, I could make out two desks. I crept in and saw two staff lying dozing with their heads on the desks, and one reading a newspaper in a chair, who grunted and carried on reading. It was lunch time, after all. I made some noises and some greetings, and one at a desk stirred and looked up. Greetings were brief and slurred from his side, and I asked about getting my canister filled. There was a long silence which made my heart sink a little before he said “Ah, yes”. I’ve noticed that in Malawi people often say “yes”, even when they answer is clearly “no”. They want to please, it seems. So one has to learn to judge what exactly each “yes” means. The pause before this particular “yes” demanded exploration. I asked if they themselves could fill up the canister, a slightly more direct question. Again the tell-tale pause, and then, usefully, a “no”. “But we will send it to Blantyre and they will fill it there.” Again a little sink of my heart – I wanted gas and I wanted it today! I had really expected them to fill it up there and then. I asked when the canister may come back from Blantyre. “Maybe… next week.” Again, the tell-tale pause cast significant doubt on his already generous time-scale. Fortunately, Rob was going home to Blantyre and returning to Zomba in a few days, so I decided to ask him to do it. One cannot be too ruffled by such minor inconveniences in Malawi.

I returned to M1, the acute male ward, after lunch to find a young man seated next to the desk, head tilted to one side, with a bunch of 3rd year Clinical Officer students peering curiously into his ear. I asked what was going on, and they told me the man had been complaining of a sore ear. They thought they had seen something in there, and didn’t know what it was. There was no torch or otoscope, though even in the dulled sunlight in the office one could see a yellow bulge deep in the ear canal, if one pulled the lobe back firmly enough. We all saw it, and we were all excited. Finally, something tangible to do! A potential cure! We led the somewhat perplexed patient off to the small surgical room at the corner of the hospital, used mainly for dressing wounds. There are some small surgical implements there (forceps, kidney dishes, old glass re-usable syringes, etc) and a hard couch to lie on, covered in a crisp green hospital sheet. We sat the man down on the couch and peered into his ear again. It was still there, the smooth yellow growth. Recalling Professor Prescott’s lectures in fourth year, I asked the clinical officer students how they’d try to get something out of a person’s ear. Quite correctly, they said that one should not stick anything in, otherwise the foreign body would probably be pushed in further. One of them suggested using water, which is the recommended first step: try to flush it out using luke-warm water in a syringe. Well, we tried this a few times, and the object seemed to come out a bit, tantalisingly close the surface, but each time as we eased up on pulling the earlobe back the object sunk back into the dark depths of the ear canal. We tried this a few times, by which time the foreign body was clean and shiny and bright, but still stuck. The patient was sitting and said nothing throughout. I had no idea what to suggest next, apart from breaking the golden rule and begin poking. Well, I would at least poke carefully with a tweezer and try to grab it. I suggested, somewhat pompously, that I should do it because one had to be really careful, but mainly because I love these little procedures and hardly ever get a chance to do them anymore. (One of my most satisfying A&E moments ever was taking a fishbone out of a woman’s throat using a laryngoscope and long forceps. Very simple, but she was so grateful.) The four students lay our hapless patient down on the couch as the anticipation built. Under a green sheet we found an array of sparkling surgical implements (remember, this is the hospital which won Infection Prevention!), and selected a suitably thin tweezer. So I started poking, occasionally turning the young man’s head towards the window for light. I could just grab it, but the tweezers slipped off. At one point it looked like it had been pushed in further. Remarkably, throughout all this, the patient said nothing. Eventually I managed to get a solid grip, and pulled gently, working it slowly up the canal, pulling first one way and then the other. Finally, like a cork from a bottle, the foreign body came out with a firm yank, with cheers from all of us.

How long has this been in there?

How long has this been in there?

It was a very large kernel of corn, and had clearly been in the ear a while as it was somewhat browned, oozy and soggy. The patient got up and shook his head in confusion. One of the students asked him how this kernel got into his ear, and he replied that he had pushed it into his ear in an effort to block out the voices he was hearing. It had not worked, he admitted. What an amazing reminder of how real and distressing auditory hallucinations can be! Fortunately, the hallucinations had improved and no longer bothered him much since he’d been taking the chlorpromazine in hospital – also a nice reminder that the drugs do work! On asking, he denied putting anything in his other ear, but I wanted to check and make sure. We lay him down again, pointed his ear at the window, pulled his earlobe back, and looked into the depths. There was another weird thing there, paler than the yellow corn, but also smooth and a bit shiny. This time the students did it all.

First the syringing, with no luck. Then the gentle careful tweezering. (I remembered that I had my Petzl head-torch in my bag, and gave it to the guy with the tweezer who felt very grand having a surgical lamp attached to his head!) Again, a large corn kernel was eventually plucked out to rounds of cheers and applause. The patient seemed unimpressed, merely sitting up and rubbing his ear. He had also shoved that kernel in to block out the voices, he said. We showed him both kernels but he was unmoved. We however felt that rare satisfaction of having diagnosed and treated a problem with our bare hands in the space of an hour, and in psychiatry that is a rare pleasure.




1 Comment »

  1. charl said

    The Jobson-horne probe is what you want – a nifty little instrument with a small ring at the end set at 45 degrees. You slide it over the foreign body, and pull it out. Et voila. Crocodile forceps push it deeper, unless there is some irregularity e.g. a cockroach to grab onto. and beware of giving the patient the removed article – they are known to put them straight back. And beam at you.

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