Categories
Medical Thursday Doors Zambia

Hypertension 1

Pulpation Room sounds like where wood chips are crushed to manufacture paper. It is actually a private area where midwives can examine pregnant ladies’ bellies. As well as being my door of the week, for Thursday Doors.

“I’ve got BP, doc,” said the elderly man lying in the ward. “So why have you admitted this patient?” I asked the nurse. “He has BP, doc,” she said. “We all have BP, otherwise we would be dead,” I answered. “Having blood pressure means that blood and oxygen can get to our vital organs. Why did he come to the clinic? Usually hypertension doesn’t cause any symptoms unless it’s very high.” The patient intervened, “I’ve got problems passing urine, doc. It doesn’t come out as quickly as it used to, it stings and I needed to get up to wee four times last night.”

A Hadeda Ibis having a bath in Mbomboza Lagoon

“So let me guess, when they did your vital signs at the registration desk, they noticed your blood pressure was elevated, so they sent you to the ward to rest, in the hope it would come down?”

“Exactly,” said the nurse. “Well, lying down and resting will reduce blood pressure, but it isn’t a useful treatment for everyday living.” The nurse agreed, but said that she couldn’t send him home if his BP remained high. “But what about the reason he came to clinic?” I asked. The nurse said that she reckoned this was “prostate”. I agreed that this was a likely diagnosis in a man of his age, but was there any way we could find out more? I had in mind the International Prostate Symptom Score, a screening tool checking different aspects of prostatism. “Yes,” said the nurse, “I did a digital rectal examination. It felt big, but I don’t know what a big prostate feels like, really. Can we do the rectal examination again together, so you can teach me?”

Pied Kingfisher, an all year round resident in the South Luangwa National Park.

I was immediately taken back to my days as a very junior hospital doctor. “If you don’t put your finger in, you’ll put your foot in it,” an aphorism that is burned into my cerebral cortex. If I had not done a digital rectal exam on a patient, I would surely be asked about my findings by the consultant leading the team. But here was a nurse volunteering that she had been proactive. I was very impressed. Then I thought, did she do the rectal exam before or after she had checked his blood pressure?

I glanced down at the patient who was looking alarmed. I thought for a moment and decided we could postpone the digital instruction for a week. Three rectal exams in one day would send anyone’s blood pressure through the roof. I told the nurse I would get hold of some guavas of different sizes and practice. I suggested we check a urine sample, which showed signs of an infection, so we treated him with antibiotics.

“But what about the hypertension?” I asked. “He is already taking a calcium channel blocker, but it isn’t controlling his pressure,” she replied. “What other drugs could we use, perhaps one which would help him pass urine more easily?” “A diuretic?” she answered. “Yes, that would make him produce a lot of urine, but his problem is getting it out. Any other drugs?” “Beta blockers?” she ventured. “I was thinking of trying an alpha blocker, which might improve the flow of urine and his blood pressure.” “Never heard of it,” she replied.

Dawn over the Kapani Lagoon, 100m from my house

We made a plan: treat the infection, continue his normal blood pressure treatment, see on Friday next week when we are both in the clinic, recheck his blood pressure, urine and prostate, in that order. He didn’t show up.

Dorcas was 84 years old and had suffered from “BP” for the past 15 years. Muzungu doctors had wrestled with her hypertension without managing ever to get it under control. I read through two tattered school exercise books which serve as patient-held medical records. I suspected that the reason for poor control was the lack of consistent supply of antihypertensive drugs at the clinic. Indeed she admitted that she had run out of medication (so had the clinic) and couldn’t afford to buy more. She was lying in the female ward, resting.

I never tire of watching baboons. But I get fed up with them fighting on my tin roof at 6am each morning.

Ward rounds are good teaching opportunities. I asked the nurse what she might expect to find when examining someone with long term uncontrolled hypertension. “High BP,” she said. “But what might be the effects of high BP?” She didn’t want to guess, so I prompted her. “Why do we try to control blood pressure?” “To stop heart attacks,” she said. “Great, so what might you find when examining her heart?” “High BP.”

I realised I was going to have to go back to first principles. “The heart is a muscle. It pumps blood. The stronger it pumps, the higher the pressure. So do you think her heart muscle will have been affected by chronic hypertension?” “Yes,” she said. OK, how could we detect this? She didn’t know, so I asked her to look at Dorcas’ chest. I could see the apex beat, bouncing away almost in her axilla. Then I asked her to feel for the heartbeat. She correctly located it and described it as “forceful”. “What you can feel is the bottom of the heart tapping on the ribcage. It is typical of left ventricular hypertrophy. Try listening to the heartbeat.” She told me she didn’t have a stethoscope. I offered her mine, “Share my earwax, if you dare.”

We discussed the two heart sounds, and how much louder the second sound was: lub-DUB. As I explained where to place the stethoscope on the chest to hear blood flowing through the heart valves, I noticed a pulsatile swelling just to the right of her upper breastbone. Her swollen ascending aorta had distorted the chest wall. The most likely cause of this would be an aneurysm, following decades of untreated syphilis.

I am not sure that it would do any good at this stage, but we treated her with penicillin injections. No heart surgeon would want to operate. Although her aorta was swollen, the wall would be thinner than normal and could burst at any time with catastrophic results.

The more you look, the more you find.

Categories
Medical Zambia

ICAP

There are small groups of buffalo around Mfuwe at the moment. To protect themselves from attack by lions, they merge into huge herds.

ICAP (“International Center for AIDS Care and Treatment Programs”) is an American organisation (Columbia University) which supports health teams managing patients living with HIV. Four years ago, when I was working in Swaziland with Medecins Sans Frontieres, I attended a two day meeting at a hotel in in Pig’s Peak organised by ICAP, where representatives of all health centres in the country presented their data. I recall sneaking away from the prize giving ceremony to watch a soccer match on television (well, it was Manchester United playing my team, Leicester City, in our premiership-winning season). Such mass events are very expensive. The new modus operandi is to use Zoom meetings.

I am not exactly sure why, but the ICAP Eastern Province team descended on Kakumbi, bristling with laptops. In one small office, 3m x 3m, there were five, with two participants using their own smartphones. The leader of the team had two widescreen laptops. Technical assistants were on hand to overcome any challenges, such as a disruptive “reverb” on the leader’s microphone. The zoom meeting was to allow a dozen medical officers to present last week’s HIV/TB data. The meeting began at 8:30am, but it took another half hour for everyone to log in and get settled. Three doctors didn’t virtually show up at all.

After an introductory speech by the team leader, each district officer commented on their data, which was being streamed as a PowerPoint presentation. The first talk was interesting, but by the sixth (almost identical) talk, I was beginning to fade. Each presentation was in exactly the same format, with the narrator reading the numbers from the screen. Some slides showed no activity, but this didn’t deter the doctor from ploughing through the zeros, rather than skipping deftly to the next slide, “nothing to see here”.

Occasionally, a speaker would highlight certain difficulties, try to explain them, but often without offering a solution. Several districts had the same difficulties. Perhaps they had discussed these problems at previous meetings, but they didn’t now.

For the first time I saw some data relating to Covid-19, which had obviously been “bolted on” to the standard format. We are still waiting for the tsunami to engulf us.

Grey heron perching on the back of an irritated hippopotamus

I learned that there was a screening tool in use at clinics to pick up patients who should be offered  HIV testing. By screening out low risk patients, the positive test rate was about 10%. Our clinic had offered no screening tool data because we hadn’t collected it. I must admit I have not seen the health volunteers using the tool. It looked very cumbersome and complex.

Phew

Some clinics had run out of HIV test kits. It seemed that the 90:90:90 (90% of the population knows their HIV status by having had a test in the past year, 90% of those who tested positive were on treatment, and 90% of those on treatment had no detectable virus) mass testing approach to control HIV was proving too costly.

Once someone is HIV reactive, it is important to offer testing to sexual contacts. This may sound simple but it isn’t easy. Just imagine if the same day that you had been informed you were infected with HIV, you were being interrogated about your sex life, extramarital relationships, use of prostitutes, etc. Not everyone wants to spill the beans at that critical time. But our contact tracing needed to improve.

As a group, children who were living with HIV were most likely to have detectable virus. It seemed obvious to me that this was because of poor compliance – the medicine tastes awfully bitter – but the team leader suggested we needed to analyse this further.

Grey crowned crane colony – over fifty birds – on a patch of marshy ground near my home

About half the patients had switched from an efavirenz regime to one containing dolutegravir, a drug with a cleaner side effect profile. No districts reported a shortage of anti-retroviral drugs, but there did not appear to be enough surplus for stable patients to be issued six or even three months’ supply (to try to reduce travelling during the Covid pandemic). Just 1% of newly diagnosed patients were found to be also suffering from tuberculosis (it was much higher than this in Swaziland).

It is obviously important to make sure patients attend and are not lost to follow up. Treatment supporters managed to contact 90% of those few patients who missed their appointments and successfully got them to come to the clinic.

One district reported having screened almost 1,400 women for cervical cancer (visual inspection of the cervix). Of these, the screeners found 34 with suspected malignant changes, 22 of which were treated with cryotherapy and 4 needed cone biopsies. These results are very impressive for a country which has no cervical cytology programme.

Happy children at one of our community clinics – they weren’t being vaccinated

I was also impressed that not one of the 3,500 patients receiving anti-retroviral drugs in our district had died over the past week.

In an attempt to engage the audience, the team leader asked a colleague to summarise succinctly, telling him he had four minutes. He took ten. The meeting took four and a half hours. I wonder how many clinicians joined the meeting, said their piece and went off to treat patients, leaving their laptop glowing and jabbering away in their office.

One thing I have learned from working overseas is to wait until you have been doing the job for a month or so before being critical and recommending change. If it were me, I would have these meetings every month, or even every quarter. I would circulate a compilation of all the district reports, highlighting how a district deviates (good or bad) from the norm. The district would have to explain why it was an outlying and what it had or hadn’t done to achieve that. But it is a case of “he who pays the piper calls the tune”, and if the Center for Disease Control and ICAP provide the finance, they get to decide what gets done.

I could not believe that the most senior doctors in the province spent 10% of their working week attending a zoom meeting which dealt with a disease which was largely under control, while diabetes and heart disease were disregarded and created much more morbidity and mortality. I mentioned this to the team leader, who agreed with me, but said that HIV was where the money was.

Categories
Medical Thursday Doors Zambia

Working in the Clinic

I interrupted two antelopes, Puku, that were grazing near the lagoon, close to my house

My first tour of duty as a medical volunteer in rural Zambia was in 2014. The clinic hasn’t changed much over the past six years. All of the original staff have moved on, apart from a cleaner and some local volunteers. There have been some renovations – the ward ceiling which was collapsing from the weight of bat excrement has been partly replaced, the labour ward has relocated to a new block and USAID has built a six-room HIV/AIDS clinic. Some small rooms have been divided up into smaller rooms to provide dedicated space for counselling, family planning, HIV and malaria testing. It has had several additional coats of paint.

The clinic failed an inspection a few years ago. The list of improvements is still attached to the wall, and a few have been implemented. For example there is now a dangerous drugs cupboard. This has two lockable doors, but unfortunately someone lost the only key. The only “dangerous” drug supplied to the clinic is diazepam injection, which we use to halt epileptic seizures.

These are your Thursday Doors for this week. The Dangerous Drugs Cabinet.
Avoiding unprotected contact with wild animals is difficult where I live. The baboons clatter across the tin roof at 6am each morning, squabbling, screeching, mating and defaecating.

The covid-19 pandemic is just starting to take hold in Zambia. There are complicated posters on the clinic walls, in English, providing information about the disease. Around the clinic there are buckets of water, basins and bars of soap for people to wash their hands. We have tried to enforce a policy of mask wearing for all staff and patients, but it is difficult to refuse to attend to a sick patient whose mouth and nose are not covered. The main consulting room has three washbasins. I have no idea why, but only one basin has a tap. The tap usually has running water. I donated a towel to the clinic six years ago and remarkably, it is still here. Someone has used bleach to try and clean it, so it looks a bit piebald. I try to avoid using it and re-contaminating myself, but it isn’t easy pulling on latex gloves when your hands are wet.

The curtain arrangement provides basic confidentiality. My old green towel is by the middle sink.
Handwashing station. We have several of these around the clinic.

Many of the doctors who have volunteered here over the past twenty years have done some teaching. It is better to train nurses how to diagnose and manage patients so they improve their skills, than just seeing patients on your own. I taught nurses how to examine ears, throats and eyes using a pocket diagnostic set which I left behind last year. Other doctors have left shiny auroscopes and ophthalmoscopes. Doctors feel “naked” without these basic tools. I found two sets on a shelf covered in dust in their cases. Once I had replaced the batteries, they were perfect. I suppose the clinic doesn’t have funding for such essentials.

Medical equipment which is no longer being used, gathering dust on a shelf

The clinic has a graveyard of ear thermometers which have worn out or succumbed to the dust. They are very useful because they are quick. A more traditional thermometer tucked into an armpit takes a couple of minutes to cook – and then you find it has changed position and not recorded a true temperature.

There is an old mercury sphygmomanometer for measuring blood pressure, but I was told it was “not functional”. There were beads of mercury in the glass tube and I thought it should stay on the shelf because it was dangerous. The registration desk has an electronic sphygmomanometer, but the battery cover has gone missing and it has been replaced by sticky elastic strapping. The batteries were dead yesterday, so I brought some from my own torch at the house to help them out. Today I was surprised to find that someone had bought new batteries and we were in business again. But for the entire morning I was pestered by the staff for the replacement batteries I’d brought. They can wait until I have returned to UK!

Improvised cover for the electrical BP measuring machine, elastic sticky strapping tape.

Last year, the clinic ran out of bandages and gauze swabs, so this time, I brought a supply with me (thank you for the donation, Su). We needed to use some during the first week I was at work. Dressings do tend to disappear quickly so I asked the clinical officer to lock the supplies in the pharmacy store. I separated the kit into piles of dry dressings, non-adherent dressings, different sizes, bandages, tape, gloves and steristrips (thin bits of tape to get wound edges together when stitches or staples are not required). Today, I needed some steristrips to do a bit of first aid and was disappointed to see some of my supplies randomly stuffed into plastic baskets in the corner of the treatment room. I searched for five minutes before finding the strips, and sadly, that was the last packet.

Working in low resource settings isn’t easy. It is not for every doctor. The variety of drugs is limited and “stock outs” are frequent. The range of investigations is restricted, the nearest X-ray machine (when it and the radiographer are both working) is an hour away by car. Taking a history using an interpreter can be difficult, especially when patients don’t understand what you are trying to do – you’re a muzungu doctor, surely you know what’s the problem without asking all these questions? I rely on my physical examination skills and broad experience. This can be frustrating when communicating with specialists who rely more on the appearance of a CT or MRI scan, when I want to know what the chest sounded like to know if it has changed since they last saw the patient.

The nurses in the clinic use me as a consultant to help them with the most difficult clinical problems. This means that I often see patients with untreatable conditions. I can tell them the diagnosis but I cannot always offer treatment or cure. I am trying to improve palliative care here.

In contrast, when I am working in village clinics for children, I am most usefully employed in recording all the details of vaccinations on an incredibly detailed tally sheet. These sheets have been photocopied so many times, that the print is faded and the tiny font is difficult to read. The data we collect must be accurate as it will be scrutinised by headquarters. Injecting an infant with vaccine is easy by comparison.

Being cruel to be kind; vaccinating an infant in the open air, by a baobab tree in the village. 130 infants attended this clinic. Immunisation coverage is much better than UK, no anti-vaxxers here. The mothers know the vaccines protect their children.

It is important to keep calm, equanimity rules. Showing annoyance is considered very bad manners and even raising your voice can cause offence. Although the work can be frustrating, the patients really appreciate what is being done for them. Even if the “free drugs” are only free when they are in stock, else patients have to buy them at the local chemist.

Categories
Medical Thursday Doors Zambia

Monday Morning Meeting

The only door in this post, sadly. It is the door to the admin section of the health centre. Note the height chart written on the wall to the left.

7:30 am start, prompt. Most of the health centre staff who should be here are wearing masks and waiting for the opening prayer. The nurse in charge asks the most timid, quiet staff member to lead the prayers. We all bow our heads while she mumbles into her mask. I can’t understand a word of what she is saying, but I “amen” along with the rest of the team when she stops.

Her next task is to take the minutes book and read out what we decided last Monday. Again, her voice is very quiet but her English is halting as she tries to read the handwriting of the previous scribe. We get the drift.

It is important to adjust your ears so you can detect sounds of danger from all angles

What is on the agenda? The malaria sensitisation campaign is underway. I find this rather strange as the peak months for malaria are April – June. Perhaps now we are less busy treating malaria we can find the time to educate the population about how to prevent it. We are recruiting insecticide sprayers for next month. Unfortunately, we don’t have the capacity to spray all the surrounding villages, but some are complaining that they missed out last year on both spraying and free mosquito nets. I must admit to having seen mosquito nets being used in the gardens to protect crops against birds. And some say they have also been used as fishing nets.

One good idea is for the health inspector to alert community health volunteers when someone tests positive for malaria from their village. They have rapid diagnostic kits and will test people living near the “index case” to snuff out an outbreak. Test, treat and track. Where have I heard that before?

The nurse in charge is a very experienced midwife, but he made a plea for other midwives (and any assisting nurses) to remain calm when there is an emergency. “Don’t panic,” he said. “Don’t run around looking for things to do. Just calmly assess the situation. The women are not going to expire immediately. You have got time to make an assessment.” I find this is usually true, but when obstetric calamities occur, things can go bad very quickly. However, I agree with his sentiment and nod sagely. I wonder what catastrophe happened last week that I was not aware of?

This male kudu has the curly-wurly horns of a mature bull. 360 degrees of antler twist per year

The lab technician seems to be working much better now she is alone in the laboratory. Last year, there were three technicians. Too many cooks spoiling the agar broth, I suppose. She informs us about all the tests which are available, but some we can’t use, because they are reserved for certain patients, people living with HIV or pregnant women. It’s a shame I can’t order a haemoglobin estimation for “ordinary patients”, especially as the local hospital won’t transfuse blood unless I know the patient is very anaemic (5g/dl or less than half the normal amount).

Later this week, we will be visited by the Regional ICAP (“International Center for AIDS Care and Treatment Programs”) Team to support our work with patients living with HIV. Perhaps this is a reward for the excellent care provided here, which has improved drastically over the past five years (since my first tour of duty here). The clinic provides anti-retroviral drugs for over a thousand patients in Mfuwe. The vast majority are compliant, their disease is suppressed. The last baby to have been infected by their mother during pregnancy was in October 2019. I find it rather odd that they are paying attention to such a small centre, even if we are doing such great work.

Lion cub hanging out with the pride.

What makes me uneasy is the contrast between excellent HIV care and the poor care for diabetes, hypertension, asthma, epilepsy and other chronic diseases. The difference is, of course, that HIV care gets massive funding from the Global Programme for HIV AIDS.

The nurse in charge issues every staff member with a paper mask which must last them for a week. In the UK, these masks are discarded after four hours as they become damp and less protective after being in contact with moisture in our breath. I am pleased to see everyone keeps their nose covered. In a comment aimed at me, the nurse says, “We are forced to make compromises.” Indeed.

The Human Papilloma Virus (HPV) vaccination programme is stalled. Girls who are 14 – 15 years of age are eligible for two jabs, a year apart, to protect them from cervical cancer. It began nationwide last year and Kakumbi Rural Health Centre staff gave 269 girls their first HPV shot. We don’t know for sure, but we estimate that 90% of this cohort of girls go to school. Schools are the obvious location to round up and vaccinate the girls. But with the Covid-19 situation, all schools are closed apart from “examination year classes”. Unlike last year, we cannot just tell the teachers to line up eligible students for vaccination. Our problem is not just the girls waiting for their second shot, but another 270 girls now aged 14 who need their first shot.

Little bee-eaters sharing a perch. I particularly like the blue eye-shadow

Regular readers will have read my previous blog article about my misgivings with a vaccination programme which should have been given to 10 – 11 year olds, before they have become infected with the oncogenic strains of HPV. Once a girl starts having periods, boys consider her ready to have sex. A significant percentage of 14 year olds are not only sexually active, but are already young mothers.

I must have been daydreaming/brainstorming how to solve this problem when the quiet nurse in the corner started talking softly into her mask. “She’s leading the prayers,” I thought, dropping my chin onto my chest and clasping my hands. A few seconds later, I squint up at everyone else; no one is praying. She is actually reading out her minutes for us to approve. Nonchalantly, I try to adjust my posture to disguise the fact that I wasn’t really praying. I couldn’t tell if the other health workers had noticed and were smirking behind their masks. But I am used to making mistakes and they are used to my strange ways.

We finish at 8:15 am, ready to start the busiest day of the week at the health centre.

Categories
Medical Thursday Doors Zambia

Could this be Covid?

This is the Valley Doctor’s car, being protected by a large baboon on the roof. The car door is the only portal in Thursday Doors this week.

She was gasping for breath as they brought her into the consulting room, never mind the patient who was already there telling me about his piles. The nurse ushered the man with piles outside, but the lady was so distressed, she could not sit in the vacated chair.

“Let…me…go…down,” she wheezed and sat on the floor, back against the wall.

My first thought was: could this be covid-19? If it was, it would be the first case we have had in the clinic. My second thought was, this looks like asthma. Experienced clinicians know that “common things are common,” or if you hear hoofbeats, don’t think of zebras – unless you are working next to South Luangwa National Park, as I am. I quickly established that there was a history of asthma and I set to work examining her.

Crawshay’s Zebra. It has intensely black stripes with no faint grey line between.

It is always important to stand back during emergencies and calmly assess the situation. I took my time counting the respiratory rate, observing her use of accessory muscles of respiration, checking she was not cyanosed. She was clearly very unwell. “I…can’t…breathe,” she managed to say. OK, enough masterly inactivity, “Let’s try her on a nebuliser,” I said.

The nurse retrieved the nebuliser from a cardboard box under the sink. It was dusty and battered, but there was a power cable, tubing, a mask and a chamber for the drug. All we needed now was a salbutamol nebule. “Out of stock,” said the nurse. “They never were in stock,” I replied. “The only nebules we have ever had were donated from overseas or brought by muzungu doctors.”

We moved her out of the consulting room to the female ward, but it was full, so she took a bed in the empty male ward. Despite sitting propped up, she became more distressed and said that she felt tired with the excessive effort of breathing. I checked the medical cases in the back of my car but could find neither my nebuliser, nor any nebules. But I did find a salbutamol multi-dose inhaler which I brought back to the ward.

“Do you know what this is?” She nodded yes. “Breathe in the gas from this inhaler.” She put the inhaler in front of her mouth and tried to activate it. No gas came out. “Press harder,” I said. A cloud of salbutamol came out of her mouth as she hadn’t breathed in. “Never mind, try again.”

Big cat in a tree, stretching after a heavy meal of impala in South Luangwa National Park

“I…want…an…injection,” she managed to say. The nurse went off and came back with a syringe and aminophylline. Now, aminophylline works extremely well, but it has a narrow therapeutic window. Give too little, it has no effect; give too much and the heart stops. I wasn’t ready to use this drug just yet, so I used my calming voice to try to reassure her that the inhaler would start to work quickly, just relax, don’t worry, this is going to improve very soon. I gave her a few more squirts from the inhaler, this time ensuring most went into her lungs. “It will just take a few more minutes to work,” I told her. I bought some time by feeling the pulse and checking her arterial oxygen saturation. The pulse was fast, but not tachycardic and her saturation was 99%, which was better than mine.

Just as the nurse drew up the aminophylline into the syringe, the patient became calmer. Sometimes this is bad news, as hypoxia causes sedation and she might be going into respiratory failure. But I knew this lady was well oxygenated, so we waited and her breathing became easier. Everyone smiled as she slowly recovered. After five more minutes she felt comfortable and was able to provide me with more history.

She said that she had been wheezy for about six hours. The night had been cold and windy, stirring up the dust in the village. She thought that this might have been the trigger for the attack.

She had been diagnosed with asthma ten years ago and had been prescribed inhalers in the past by muzungu doctors. But the clinic only stocks salbutamol tablets and inhalers are expensive if bought from the local chemist, so she discontinued therapy.

“So when was your last attack, before this one?” I asked.

“It was when I got tear gassed by the police,” she replied. I had a sudden vision of my patient attending a political demonstration in Mfuwe.

The nurse explained that there had been a disturbance some months ago, when a horde of villagers descended on a dying elephant with machetes to chop themselves a hunk of uber-fresh meat. To restore public order, the police had to fire tear gas into the crowd. Or perhaps it was to allow the elephant to die in peace.

I will have to add tear gas to my list of possible provoking factors for asthma.

At the local chemist, I bought a course of prednisolone and a replacement inhaler for the patient and returned to the ward. She was fast asleep as she had been struggling to breathe since midnight. When she awoke, I asked her to come for review in two weeks at the clinic.

Categories
Life Medical Thursday Doors

Emergency

BASICS isn’t basic. The British ASsociation of Immediate Care (BASICS) is an organisation which trains volunteer health workers to provide healthcare assistance in support of the emergency services.

Last weekend, I did a three-day BASICS residential course dealing with a wide range of emergencies, from car crashes to falls, heart attacks to carbon monoxide poisoning, electrocution to stabbings.

The course was intense. It began at 8.30am and continued till 7.30pm, with some sessions taking place outdoors as Storm Ciara threatened. It was very cold and windy. “Typical weather, good practice for you,” said the instructor.” All we need now is some rain.”

The organisers encouraged us to bring personal protective equipment, and some participants looked cool in their high visibility gear. All I had was a suit of orange overalls, handed down from my father. He used to be a postman, so instead of “paramedic” or “emergency doctor”, the label on my chest spelled out “Royal Mail”. The organiser told me that this was a first.

A fireman gave us practical instructions on how to get people out of a smashed up car. I think he enjoyed sharing his gory tales of derring-do. I had no idea how many airbags a modern vehicle contains, and what damage they can do when they go off as you are struggling to get someone out of a wreck. He referred to extraction implements as “toys”. I will keep my Kevlar gloves and eye protection specs in the glove compartment of my car.

The practical tests were interesting. I had to deal with someone who had been burned and blown up at a fireworks display, a lad who had been smashed in the face by a thug wielding a baseball bat, a pedestrian hit the bull bars on the front of a 4×4 and an elderly man who collapsed in the newsagents. My colleagues on the course were brilliant actors.

For the last seven years, I’ve dealt with emergencies in “resource poor environments”, often without oxygen, defibrillators and drugs. For 25 years before that I worked as a general practitioner in primary care. So the last time I put paddles on a chest and shocked a patient’s heart back to a normal rhythm was 34 years ago in North Devon District Hospital. In 2020, the standard equipment which “first responders” keep in the boot of their car is more sophisticated than the kit I was using in hospital in 1986. It was a vertical learning curve. But I passed the exam.

Now I’m a lot more skilled at managing critically ill patients away from hospital. I can use a Kendrick splint to stabilise a femoral fracture. I can remove a motorcyclist’s helmet safely. I even feel confident cutting a hole in the cricothyroid membrane. I might even be competent to assist paramedics if I come across a road traffic accident. *Basks in warm glow*

Cold, bright morning, close to the River Soar, Leicester
Where the old Bowstring Bridge used to be. The Pump and Tap is now the Queen Elizabeth II Diamond Jubilee Leisure Centre

Early on Monday morning, I swam 40 lengths at the local sports centre, showered and was just putting on my underpants when I heard a scream from the pool. “HELP!”

The new training kicked in so my mind did not go blank with panic. “First assess the scene, it will tell you what injuries you are likely to find.” Swimming pool? Drowning or cervical spine injury from diving in at the shallow end. Think – where’s the oxygen? Is there a defib? But I know they have an extraction board. I didn’t expect to be called upon to use my new skills so soon.

I peeled off my pants and wriggled back into my wet swimming costume, tucking myself in as I slithered out of the changing area. “Remember, your own safety is the most important. Don’t slip and fall, becoming a second casualty,” I said to myself.

I knew something wasn’t right when I saw the life guard still sitting on her high chair at the poolside. No one seemed to be bothered. No one seemed to have been injured. It was just a life saving class. I breathed a sigh of relief and looked plaintively at the life guard. She waved two upright thumbs at me and said, “See you at aquarobics on Wednesday!”

The climbing wall. Just waiting for someone to fall off while I am swimming.

Categories
Life Medical Thursday Doors Zambia

Thursday Doors – Compare and contrast medicine in the UK and Zambia

Thursday Jaws, sorry about the pun. Actually, I don’t think the lion (Ginger) thought it was very funny.

But here is a proper door, even though it looks like the rear end of a zebra.

This sounds like an examination question! Recently I have been working in the community as a general practitioner, a family doctor, here in the United Kingdom. I must do this for at least a month each year in order to retain my medical licence, without which I would be unable to work overseas. Also, I need to have an annual appraisal and every five years the UK’s General Medical Council considers whether to revalidate my licence.

Five similarities between working in primary care in the UK and Zambia

1 Not all my patients speak English

I enjoy being able to consult in English, but having said that, about half of my patients here don’t speak it as a first language. This is because I work in an inner city, a very cosmopolitan area. 95% of the time, I manage to get by with a limited vocabulary and basic grammar, but I still need an interpreter for a few patients.

This can cause some administrative problems, because of the revalidation requirement to collect anonymised, written feedback from at least 35 consecutive patients. This isn’t easy if some of my patients (in the UK) can’t speak or read English well.

In contrast, only 10% of my Zambian patients speak English fluently enough for me to consult effectively. These are mostly the well-educated and well off. I don’t want to be restricted to caring for the most privileged, so I always try to work with a Zambian nurse or clinical officer. They take a history from the patient and we discuss their clinical management. It turns the consultation into a useful teaching exercise.

2 Lack of free medication

It was frustrating to be unable to prescribe common medication in both countries, for cost reasons. In the UK, NHS prescribing for about 75% of the population used to be free. However, many of the most frequently prescribed medications, such as simple painkillers, antihistamines, antibiotic eye ointment and certain skin creams are no longer free; patients have to buy these products from a pharmacy or a supermarket.

In Zambia, medication prescribed at a health centre is free, but in such short supply that the range of drugs is very limited. Occasionally the health centre ran out of basic items like paracetamol and intravenous fluids. I would regularly write out a private prescription for the patient to take to a pharmacy in Mfuwe or Chipata.

3 Restricted prescribing

In UK primary care, all medical records are computerised. Sometimes, when I decided a patient needed a certain drug, the computer would try to change my mind. “Try this form (tablet, capsule, syrup) of the drug, it is cheaper.” Or I would be urged to switch to a similar drug, which might have fewer side effects or is less likely to interact with other drugs. The computer might not think I was competent to prescribe a drug (even though I know that this is what a specialist would prescribe if I were to refer the patient to hospital). GPs and specialist pharmacists have produced treatment algorithms and guidelines based on clinical evidence and if I don’t follow it religiously, I will be asked to explain why. I may be censured if my explanations are not considered good enough.

Sometimes the patient tells me that they have already tried the drug recommended by the computer and it hasn’t worked or they cannot tolerate it. Or it interacts with another drug they are taking which has been prescribed by a hospital specialist, unknown to the computer.

Occasionally I reject the guidelines because the patient doesn’t like a drug’s taste or doesn’t want to take it in a gelatine capsule as they are vegetarian or it is considered”haram” or forbidden. Artificial intelligence tends to assume all patients are similar; I treat them all as individuals, sometimes quirky, but with valid opinions about their medical care.

In Zambia, certain essential drugs may not be available, particularly for non-communicable diseases. I had to beg a local charity to provide three months’ supply of haloperidol to treat the dozen or so patients suffering from severe enduring mental illness in Mfuwe. We only had limited stocks of a tricyclic antidepressant with troublesome side effects (amitriptyline) even though fluoxetine (Prozac has been in common use in the UK for over 25 years) is cheap and well tolerated.

We had no insulin and oral medication for diabetes was often out of stock. We had no inhalers to treat asthma and had to use oral salbutamol tablets instead – an ineffective practice we stopped doing in the UK 50 years ago. The range of drugs to treat high blood pressure was very limited and stocks were often in short supply. We would occasionally run out of basic drugs to treat epilepsy.

4 Many patients consult with self-limiting illnesses

People in the UK and Zambia often seek medical advice because they think that they are unwell and that the doctor or nurse will be able to treat them. In both countries, care is free at the health centre or community clinic.

In the UK, patients with a cold or viral upper respiratory tract infection will have often tried taking simple preparations, either traditional (tamarind, honey, chilli and lemon juice, any combination) remedies or cough syrups from the pharmacy for several days with no resolution to their symptoms. Some patients feel their symptoms are so severe that they need treatment with antibiotics. Others would prefer to avoid antibiotics but consult to see if the doctor thinks they need them.

In Zambia, patients with minor self-limiting illness expect to be given medication, and often resent being given a scientific explanation why antibiotics won’t work. Traditional healers (sangomas) understand the value of placebos and encourage the patient to return, as this is how they make money.

In both countries, with easy, free access to healthcare, patients often have a low threshold for seeking advice. One of my patients in the UK brought in her infant son because he had been awake from 2am to 4am that morning. A patient in Zambia brought in her daughter because she had vomited once just an hour previously.

5 Obstacles to referring patients to specialists

In the health centre in UK where I have been working, it is reassuring to have hordes of specialists in our three city hospitals available to see patients who require further investigations or surgical procedures.

Twenty years ago, I knew most of the hospital specialists and could write a personal referral letter. I knew that Ms A was the best orthopaedic surgeon for shoulder problems, Mr S was the best gynaecologist for patients whom I thought did NOT require a hysterectomy, for example. The consultant would read the letter and decide on how quickly they should see the patient based on the quality of information in the letter. Those days are long gone in the NHS.

Now I have to use a complicated referral system called PRISM which leads me through a box-ticking pathway of algorithms to ensure that my patients meet strict referral criteria. For example, if the patient is 64, not 65 years old, or if I haven’t prescribed drug X, my referral could be rejected.

This approach stops whimsical referrals from GPs (in the past, some might just write, “Dear Dr, please see and do the needful.”) but it erects barriers for patients to access specialist care. I think that limiting access in this way amounts to rationing care.

There is an express “Two-Week Wait” referral for patients who might have cancer but they must meet even stricter referral criteria. Not all patients meeting the criteria are found to be suffering from cancer (about 15-20% are) but conversely, some patients who don’t meet the criteria are found to be suffering from cancer when they eventually see a specialist several months after the GP referred them. Perhaps this is why Cancer Research UK recently revealed that cancers are diagnosed later in the UK than other comparable European countries.

In rural Zambia, if we don’t have the resources or expertise to treat a patient, we can refer that patient to hospital. This may not be as simple as it sounds. The nearest district hospital was 50 kilometres away, manned by a single junior doctor assisted by a modest number of nurses and midwives. The provincial hospital had more staff but was 150 kilometres away. There was a very limited supply of fuel for ambulance transport in emergencies, so most patients (or their families) had to pay for private vehicles to take them to hospital.

There is a strict referral pathway, clinic to health centre to district hospital to provincial hospital to University Teaching Hospital in the capital, Lusaka. If I wanted to refer directly, I could telephone the District Health Officer or a specialist at UTH in exceptional circumstances, such as childhood cancer or leukaemia.  

Sunday best or party dress? Got to look good when visiting the doctor

And one difference, consulting children

I enjoy interacting with patients wherever I am. I am touched by the Zambian children who wear their best clothes to come to the community clinic or health centre. They are much quieter and more reserved than children who see me in the UK. They are usually mute and refuse to describe their symptoms in their local language. They stare fearfully at the strange muzungu doctor, like rabbits at night caught in the headlights. Their parents tell their stories for them, not always reliably. “My son has a headache,” they might say because the child has a fever and has been crying. They don’t understand the need to answer detailed questions because they view the doctor as omniscient, like any traditional healer or sangoma.

This baby is all in blue, must be a boy
This baby is wearing a dress, must be a girl

Children at the health centre in the UK tend to be more communicative and occasionally rather naughty. A mother brought her infant and two older children to the health centre, and while I was examining the infant, the other children started jumping up and down on my examination couch.

Their mother said, “I’m sorry doctor, but they were behaving so badly outside, I told them that the closed-circuit TV camera would have recorded it all and they would be punished by being forced to spend the night in the health centre.”

I replied, “So that’s why they are trying out the bed, is it?”

Categories
Medical Zambia

Nsunko – warning

Warning this post contains graphic sexual material which may be offensive to some

When I am consulting in the health centre, I normally work with a female clinical officer. We see the patients together. She takes the history in Cinyanja and summarises the problem; I ask further questions for clarification.  She doesn’t normally examine patients, so I do that and point out any physical signs. We usually see one or two ladies with gynaecological problems in each session. They could be suffering from a variety of disorders – anything from dysfunctional uterine bleeding to carcinoma of the cervix; genital herpes to secondary syphilis. The clinical officer regards me as an expert, so my examination of the patient becomes a teaching session (with the patient’s consent, of course).

Close up of an elephant, no relevance to this post

We had just seen one lady with post-menopausal discomfort, dryness and pain on intercourse. I made a diagnosis of oestrogen-deficiency resulting in atrophic vaginitis but the clinical officer asked if this could have been caused by Nsunko. I had never heard of Nsunko. She told me that it was a herb which was used in various forms to improve sexual pleasure by tightening the vagina. “For the man, right?” I asked her. She laughed and said, “For both. But it is mainly to make the vagina warm for the man.”

I was aware of certain astringent herbs which some women put inside their vagina, but these act by shrinking the vagina and can cause painful scarring. The clinical officer said that Nsunko could be used like this, but it can also be inserted into the anus for several hours at the same time as the woman has vaginal sex. It seemed farfetched, but she insisted that the chemical could diffuse from the anal canal to exert an effect on the vagina. This technique was commonly used by female sex workers.

Always being curious, I asked, “How do they do that?” She told me that women boiled herbs in water and soaked strips of cloth in the resulting liquid. They would then push the cloth into their anal canal.

In parts of Africa, men prefer “dry sex” for increased friction and pleasure. However, traumatic intercourse is associated with increased transmission of sexual infections, including HIV, because of abrasions on the sexual organs.

In Zambia if a wife has sex with another man, the husband is entitled to an immediate divorce. However when a husband is unfaithful, it does not mean that the marriage is over – “ubuchende bwamwaume tabutoba inganda”.

She told me that she had worked in other regions of Zambia where there had been a sexual health outreach programme targeting sex workers. “We could go to the Obama Bar at midnight and offer sexual health screenings,” she said. I wasn’t sure about extending my working day that long. And I had been warned about the perfidious practices of  “harlots” in the village bars by Mrs Mwanza, one of the nurses with whom I worked in 2014. You can read about this here.

I told her that if she brought it up at the next health centre staff meeting, I would support her, but she backed down. She didn’t want to be associated with such a sensitive initiative.

Elephant squirting mud onto its back

PS I was saddened to hear that the infamous “Penis Inn”, a hotel-cum-brothel where the local Rotary Club used to meet, has now closed down. The Rotary Club now meets at the new Tinta’s Restaurant. Chicken and chips, US $4 with complimentary popcorn.

Categories
Medical Zambia

Medical Detective

African open-beaked stork – of no relevance to this post at all

She looked me straight in the eye and said, “I’m itchy in front and I’ve got warts.” Zambian teenagers are not renowned for such direct talk. I asked her if she was sexually active, “Kuchin dahna*?” It is a phrase I use so often in the Kunda dialect, it slips off the tongue. She shook her head and vehemently denied it. “So how did you get genital warts, then?” She averted her gaze and I realisedI had been rather too aggressive in my approach.

The nurse came to my rescue with some softly-spoken words in local language. “She has agreed for you to examine her, doc,” she said. I pulled the dirty curtain down over the barred windows and adjusted my hundred-candle-power head-torch while she got up onto the couch. She had genital warts with an inoffensive, white vaginal discharge, but there were no other signs of a yeast infection.

Bushbuck wandering past my house one morning

Zambian health centres follow the WHO guidance using syndromic management of suspected sexually transmitted diseases without needing to do laboratory tests. This is directed at the lowest skilled health workers.

Vaginal discharge? Blanket treatment for all STIs which cause this, using a sawn-off shotgun approach. Last of all, consider bacterial vaginosis and yeast infections, strangely enough, which are the most common causes. Multiple antibiotics will make candidiasis worse, of course.

Genital ulceration? Blanket antibiotic treatment for syphilis, lymphogranuloma venereum, granuloma inguinale, chancroid – but we don’t have drugs to counter genital herpes, which is the most common cause.

I detest these syndromic guidelines with a vengeance as I feel they will cause massive problems with antibiotic resistance, something which is being recognised with dismay in Thailand. It is sloppy medicine. But it makes the patient and health worker feel that something has been done. They have ticked the box, even if the treatment is ineffective, no one can criticise them (apart from me).

There is an expatriate dentist in Mfuwe who charges cut price rates for locals, but not crocodiles.

Already gonorrhoea has developed resistance to the recommended drugs. With the approval of the District Health Officer, I had produced an alternative regime utilising gentamicin, an injectable drug which used to be supplied to the health centre. Supplies of this drug dried up, so the nurses reverted to a failing regime, much to the annoyance of their patients. Eventually, their gonorrhoea will burn itself out, leaving a legacy of urethral strictures, epididymo-orchitis, salpingitis and infertility.

The latest Zambian treatment guidelines recommend giving long-acting penicillin injections for genital warts, even when secondary syphilis has been ruled out by a blood test. Penicillin doesn’t cure genital warts. Illogical.

I ordered rapid tests for syphilis and HIV, and went on to see more patients. Half an hour later, my patient returned with the test results – syphilis negative, HIV reactive. Whilst we diagnose up to five people a day with HIV in the clinic, I was not expecting this result. We took some more history from the stunned teenager. She now revealed that she had attended in January and had been given some injections. This would fit with the Zambian (in my view, flawed) treatment guidelines. She then said that she had been told a blood test was positive. So why wasn’t she offered immediate treatment with anti-HIV drugs? Something wasn’t right.

This elephant is indicating that she is about to turn right.

I left her with the nurse and went to the lab. I looked through the register of all the serological tests done since the start of 2019 but couldn’t find her name. I showed the book to one of the three lab workers, one of whom said, “Oh, I must have got the results muddled up.” She crossed out the word “reactive” in red pen next to the HIV test request and altered the syphilis result to reactive.

I was dumbstruck. I had been relying on the fact that all positive HIV test results are double checked with another test (“Determine“). “I have just been talking to this young girl about how her whole life is going to change with a positive diagnosis for HIV, and now you tell me that it was an error? If I hadn’t come to investigate her previous results, would you have informed me?” I asked angrily.

Now, displaying anger is considered ill-mannered and uncouth in Zambia. Perhaps the embarrassment I had caused by getting visibly annoyed (I wasn’t shouting, just being calmly furious) made the lab technician laugh. “There’s no problem, doc, she isn’t HIV positive,” she said in an off handed way. Dismissing the issue in this manner didn’t improve my mood. The lab tech didn’t apologise or show any degree of remorse. I didn’t know whether to believe her, so I walked out of the lab and took ten minutes trying to re-establish a degree of equanimity.

Mating Jacana (otherwise known as lilly-trotters)

Where was her previous treatment record? Filed away in the labyrinthine medical records room, inaccessible without her registration number (she had lost her ticket). So I checked through the attendance register for January and found no record of her having attended. And the Sexually Transmitted Infection register, again no record.

The lab technician came to me and asked what she should do with the patient’s medical record. “It’s her fault for losing the ticket which would have allowed us to retrieve her old notes,” she said. I told her to repeat both tests and bring me the actual test strips. These confirmed that she had had syphilis. She recalled that her initial tests had been done in November, not January, so I had been looking in the wrong year.

The syphilis test we do is actually an antibody test which is positive for life. We don’t have quantitative tests (such as Rapid Plasma Reagent or Venereal Disease Research Lab tests) which would let us know if she had been effectively treated for syphilis after she had had three doses of benzathine penicillin in November. I considered whether these warts could be condyloma lata (secondary syphilis), rather than condyloma accuminata (common or garden genital warts). She could even have been re-infected with syphilis from an untreated boyfriend. Time to re-treat; better not to compound an error. If only we had access to the old fashioned quantitative tests.

The patient was mightily relieved that she was not HIV positive and expressed no anger at the lab technician’s error. Phew, that was a close shave.

Footnote: I am writing this as a physician who worked in a hospital genito-urinary medicine (STI clinic) once a week for 25 years in Leicester.

* I was informed by the nurse that the phrase “Kuchin dahna?” can also be translated as “Do you want to have sex?” Context is all!

Categories
Medical Zambia

Health Centre Meeting

I arrived first to the meeting room at 6:59am for the 7am weekly Monday meeting. I would have been earlier but the police had barricaded off the muddy track to the clinic and I had to make a detour. Three male health workers turned up in the next few minutes and we began with a prayer at 7:10 when no one else had joined us. At least this time, we did not pray for God to speed the missing nurses to the meeting.

The nurse in charge of outpatients said that he had been seeing many babies with pneumonia. The National Immunisation Programme includes polyvalent pneumococcal vaccine which is given at 2, 3 and 4 months, but babies were getting sick before they had completed the course. The only intravenous antibiotic we have is benzyl penicillin. In other settings, intravenous gentamicin and ampicillin would have provided better treatment.

He also complained that we had no asthma drugs at all, not even salbutamol tablets. He asked if I could help out with salbutamol nebuliser solution. I have some in stock, but it is out of date and waiting to be disposed of. If the situation arises where I judge it to be life threatening, I will use the out of date medication and face any consequences. But we must not have any out of date stock on the shelves at the health centre.

No one turned up to clear the weeds and rubbish from around the health centre last weekend. Not even the health inspector who suggested that we should do it. One volunteer buttonholed me saying that he had done my share of the work and wanted reimbursement. I told him that I was a volunteer, too.

Another volunteer managed to persuade a health worker to lend him the Health Centre motorbike over the weekend for a “family emergency”. He was caught at a police road block and the bike keys were confiscated. The District Health Officer will decide on his punishment.

On the subject of police road blocks (revenue raising activity), I was stopped today because my vehicle was muddy. The policeman asked me why I didn’t clean it. I told him that the road to my house was atrocious and the car would be splattered with mud again as soon as I drove to work. He grunted and accepted this.

The nurse in charge told us to be on the lookout for unhealthy activity around the health centre. Last week he had come across a young mother who was bathing her newborn baby in brown water which looked like it had been collected from a nearby pond. The water was cold and the newborn was shivering. Most young mothers are accompanied by their own mothers or an auntie, who teach them how to look after their new baby. This new mother had no support, unfortunately.

Melvin and Elvis, twin boys less than a week old

On a brighter note, a mother gave birth to twin boys last week, Melvin and Elvis. They are doing very well. However, another set of twins (boy and girl) have not gained any weight since being born six weeks ago. They have both been admitted with pneumonia. The girl was just 1.4kg but instead of making sure she got the first feed, her mother was favouring the boy who was 1.8kg. I told her that girls were just as valuable as boys, that I had three girls myself and she agreed to pay more attention to her daughter.

Zambian health workers are able to deal with cognitive dissonance remarkably well. There is a course to train nurses how to perform medical terminations, when abortion is still illegal under the constitution. Every patient is encouraged to have an HIV test to know their status, but because this approach has a low pickup rate and is expensive, we are being castigated. Instead, we have been told to target those people who are most at risk, even if this is against national policy. We heavily promote condoms to the young while at the same time preach abstinence before marriage. Perhaps if you don’t think about it too hard, you can cope with conflicting policy and advice.

I had been hoping to provide antipsychotic drugs for the dozen or so people with severe enduring mental illness in the area. Unfortunately, the District Medical Officer told me that the psychiatric ward at the provincial hospital were so short of medication that they could not spare any. I was told that there are (at the time of writing) no antipsychotics in the public health system in Zambia. Basic drugs like haloperidol cost just 10 cents a tablet. I have been out with my begging bowl and thanks to an NGO (you know who you are, Karen) we now have enough drugs to treat the most disturbed patients for the next three months. It is not helpful to say that such a situation is intolerable without doing something about it. Seriously unwell patients are forced to tolerate the toxic effects of continued psychosis which will have a permanent, detrimental effect on their future lives. If they have a future.