To qualify for the blog, I have to insert a door or two. This is the door (blocked with branches) of a local barbershop. The message on the tree reads “Welcome”, with a bench for people waiting to be clipped. Marky C, the owner of Get Smart Barbershop, appears to have disappeared. This is in Cropping Village, Mfuwe, Zambia.
It was on the cards, really. All the danger signs were there. The baby had failed to thrive and a few weeks before I started work at the clinic, she had been referred to the local hospital as an emergency. The hospital diagnosis was pneumonia, and the doctors had asked the mother to come to Kakumbi for follow up a week after she had been discharged.
The infant looked thin and gaunt. She was breathing quickly and using additional muscles of respiration to suck in as much oxygen as she could. Her mother was clearly very anxious and concerned. I asked her to remove her daughter’s outer clothes so I could examine her. The child’s chest looked deformed, as though there was a lump under the lower breastbone on the left. The spaces between her ribs were indrawn at each breath.
I laid my hand on her chest and counted the pulse – 200 beats per minute. The chest wall seemed to push up against my fingers and I could feel a thrill, a palpable murmur caused by turbulent blood flow within the heart. It was like a thrumming sensation moving from left to right. Listening with my stethoscope didn’t help me much because of the rapidity of the pulse and the noisy breathing. There were some crackling breath sounds at the base of the right lung but they didn’t sound like they were caused by infection. There were no peripheral signs of bacterial endocarditis.
I hesitate to write “my heart sank” but that is what I felt. This child almost certainly had a ventricular septal defect – a hole in the heart between the left and right main pumping chambers. Part of the blood which was meant to be pumped into the aorta and around the body was being diverted into the right ventricle. This had become grossly enlarged and had deformed the chest wall. As the swollen right ventricle contracted, it “heaved” against the inside of the ribs. The abnormal flow of blood from left to right ventricle was causing the vibration I could feel with my hand.
Was I sure? I had no access to the hospital notes regarding the admission for pneumonia (if indeed, this is what it was). I could not see a chest radiograph or get the results of a cardiac ultrasound (ECHO). I was relying solely on my clinical examination.
Sometimes, small holes create loud murmurs as there is a more distorted flow of blood, whereas bigger, more significant holes can cause less turbulence, resulting in a quieter murmur. This is known as “Maladie de Roger”. I hoped that the thrill I felt meant a smaller defect, as these can sometimes spontaneously close as the child grows. But the rapidity of the heartbeat was very worrying. The heart was working flat out.
Having made the diagnosis, what could I do about it? There is no access to surgery to repair complex congenital heart problems in Zambia. I told the mother that the baby was very ill with a heart problem, there was little we could do, but I would review her in the village at next month’s community clinic. I did not think that returning to hospital would help. I tried to convey the seriousness of the baby’s condition without pronouncing a death sentence.
Sadly, she returned that night to the clinic with the baby in extremis. An ambulance took the baby to hospital but she died on admission.
One might think that having a doctor working at the clinic must be beneficial. Doctors have more training, more skills and knowledge than the clinical officers and nurses. But just being able to diagnose the problem doesn’t mean you can solve it, especially when you have the meagre resources of a developing country.
“The good news is the doctor knows what’s wrong with you; the bad news is that the doctor can’t cure you.”