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.
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.”
“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.
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*
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!”
Thursday Jaws, sorry about the pun. Actually, I don’t think the lion (Ginger) thought it was very funny.
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
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
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.
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.
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?”
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).
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.
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.
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.
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).
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
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.
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.
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!
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,
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.
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.
In a small pond by Mopani Spur, in South Luangwa National
Park, there are some lesser moorhens. They are reclusive and very difficult to
spot, never mind to photograph. Just as I picked up my camera, my phone rang. I
am on call 24/7 and have to be available, within an hour of the National Park
gate at any time. I answered the call and made an emergency visit to a lodge
within the Park.
It took a while to sort out the problem, so it was after
10am when I left. Instead of driving out of the park, directly to the village,
where I had other patients to review, I decided to take a short detour around
Mbomboza lagoon and onto River Side Drive. It had been raining when I drove
into the park at 7am, but the roads were passable.
The reason for the detour was that I knew the approximate
location of a special bird’s nest. Pel’s Fishing Owl is very rare and I wanted
to see it on its nest with fledglings. River Side Drive has deteriorated since
we had floods last month. Parts of the road are compacted grit and laterite,
easy to drive on even when they are underwater. Other stretches are muddy and
potholed, and these require more attention and driving skill.
Up ahead I could see two huge potholes across the road. I
thought I could put my passenger side wheels between the potholes, and my
driver side wheels on the edge of the road. Bad move. My vehicle skidded off
the road into thick, sticky mud. The
black cotton soil is notorious for trapping cars.
I engaged four wheel drive, low range and tried to drive
forward, but this just pushed a heap of mud ahead of my front wheel. I tried
reversing and the back wheel dug down deeper into the mud. I was well and truly
stuck. I looked around carefully for wild animals. There are often elephants
and hippos in this area, and occasionally lions and leopards. I tried to open
the driver’s side door, but I was in too deep. I got out the passenger side and
assessed the situation.
I thought that if I drove back and forward repeatedly with
the wheels straight, I could make a firmer base for the tyres. I dug out lots
of thick sludge behind both wheels with my hands and got back into the vehicle.
The passenger side wheels were not getting much traction. Eventually I managed
to get enough momentum to reverse out of the ditch I had created, back onto the
road. I was really lucky. It would have been very embarrassing to have to call
for help from other lodges.
I was rather rattled when I got to the corner where the nest
of Pel’s Fishing Owl was located. The road was flooded. I stayed for a few
minutes waiting for the classic call, but heard nothing. I drove out of the
park and went to an NGO office to wash off some of the mud.
After doing some shopping for medication, sorting out a
clinical problem and buying a data bundle for internet access, I drove home. I
spotted a new red warning light on the dashboard. What have I done now? The
handbrake was not jammed on, but I could see some brake fluid leaking from the
rear driver’s side wheel.
I parked up and a mechanic removed the wheel. The problem was a worn out brake pad and something wrong with the piston which applies the brake. “Did I do this?” I asked him. “No, doc, this wasn’t your fault,” the mechanic replied. I sighed with relief. The wheel had been squeaking for the past six weeks and it had been dismissed as unimportant. It turns out that the safari vehicles get so much mud and crud in the brakes that they need new brake pads every few months.
So I was off the road for a day and a half until they fitted “modified” brake pads. If there had been an emergency, the lodges would have provided transport for me to get to the patients. And I spent most of that time in bed ill with man flu.
Il buono, il brutto, il cattivo – starring Clint Eastwood, Lee Van Cleef, and Eli Wallach
Working today at Kakumbi Rural Health Centre wasn’t really like being in a Spaghetti Western. The variety of clinical conditions cause me to feel joy, sadness, anger and despair, but this would not have been such a good title.
The Good. I have written about this little girl with sickle cell disease in the past. She had a nasty ulcer on her thigh which stubbornly refused to heal until we started daily wound toilet and dressing. Slowly, it began to heal. She stopped screaming when she saw a nurse or doctor because she could see how the ulcer was responding and she became my friend. I hadn’t seen her for a month or so, but she turned up today to get her monthly supply of folic acid (to help produce replacement red blood cells), penicillin tablets (to stave off infection) and anti-malarial prophylaxis (patients with sickle cell disease are prone to more severe attacks of malaria). Sadly, we have run out of folic acid (even for the first trimester in pregnant women), stocks of penicillin have been exhausted and we have never stocked Maloprim. She ate her breakfast while waiting for the pharmacist to tell her we had no drugs to give her and smiled at the camera. Isn’t she beautiful?
The Bad. This man was bitten by a hippopotamus three weeks ago. Bad because he was acting badly when he was attacked by the hippo. He is a very lucky man; most hippo bites are fatal. The wound was debrided and allowed to heal from underneath (by “secondary intention”). This needs a bit more tidying up and he will have an impressive scar, but he has lived to tell the tale.
The Ugly. Late yesterday afternoon, a man was fishing in Kapani Lagoon. He had probably bought “muti” from a sangoma – a magic potion which allegedly prevents crocodile attacks. It didn’t work in his case. He was bitten on the left leg and came to the health centre after normal working hours. Unfortunately, the nurse on duty sutured the main gashes and prescribed antibiotics which were not available.
Twelve hours later, he could not walk and had to be carried into the health centre. My colleague, the clinical officer who doesn’t like pus, asked me to sort him out. His leg was swollen and the skin was shiny and tight. The sutures needed to be removed. We have no scissors, so I had to do this with a pair of forceps and a scalpel blade. As soon as I snipped the first stitch, there was a mosi oa tunya (Victoria Falls) of putrid, orange-brown pus which burst from the wound. It stank so much I gagged. It reeked of rotting fish. Crocodile oral secretions are renowned for harbouring multiple pathogenic bacteria. I have never smelled a croc’s breath, but the pus probably smelled like crocodile halitosis.
The second wound I opened up had a different odour, sweet, sickly and fetid. The pus was watery and had bubbles in it. Looking deep into the wound, I could see the muscle had turned brown and black in parts. This is wet/gas gangrene, clostridial myonecrosis (dead muscle). This patient needed urgent surgical debridement, cutting away all the dead, infected tissue. Without a general anaesthetic, this is beyond my skill level. I knew that funds were really tight in the district and there was very little diesel left in store. We begged for an ambulance and were rewarded. I hope that I see him again before I leave and that his leg has been saved.
Because I am morbidly curious, I asked him how big the crocodile was. Like any fisherman, he extended his arms about a metre apart. “That small croc did a lot of damage,” I said. He replied, “No doc, that was the size of its head!”
Here is a dody photograph of the door to an upmarket department store in rural Zambia. Upmarket refers to the location, just up from the market. Department means it sells everything.
In a recent report from Reuters reported in The Guardian, sildenafil or Viagra, as it is more commonly known, has been added to energy drinks in Zambia. I am not surprised that a drink called “Power Natural High Energy Drink SX” was adulterated with Viagra; the name says it all really. However, given the high price of Viagra, I’d hazard a guess that only minute amounts were used to spike the energy drink. The manufacturers exported the drink to neighbouring countries.
The article says that the Uganda National Drug Authority had found Viagra in the drink following a complaint by a customer who suffered a six hour long erection accompanied by constant sweating. In the British National Formulary, priapism (prolonged erection) is a very rare side effect of sildenafil. I have prescribed the drug to hundreds of patients and have never seen or known of a case. Night sweats do occur (independent of vigorous nocturnal activity), but again this is not common. So I found it surprising that the Ugandan authorities went ahead and analysed the energy drink following just one complaint. Perhaps scores of other Ugandan men were not complaining. After all, Private Eye used the term “Ugandan discussions” as a euphemism for sexual intercourse.
Sildenafil is a prescription only drug in Zambia, although it can be bought over the counter in the UK without a doctor’s authority. In practice, the drug is on sale in a variety of forms in our local pharmacy. I give out private prescriptions for men who are “lacking power” which the pharmacist fills. Honest, who works at the pharmacy, tells me it is very popular and he had never had any complaints. But how many men are going to come back to complain that the drug didn’t work?
Looking at the provenance of these sildenafil preparations, I am not convinced that they contain much of the genuine article. But there is often a large psychological component in erectile dysfunction, so a costly drug recommended by the muzungu doctor will have a significant placebo effect.
It’s a pity that Power Natural High Energy Drink SX has been taken off the market. I would have been advising patients to try this cheaper option first before buying the drug.
On my first day at the clinic we had a patient with a ripe
abscess which needed incision and drainage. My colleague is a clinical officer,
but she hasn’t had much practical experience at doing procedures. She
previously worked in hospitals where a doctor would often take over if she felt
unsure. I told her that I would tell her what to do, standing by to assist if
something went wrong. Reluctantly, she agreed and went off to prepare a tray
for the procedure. I realised that she was dragging her feet when she didn’t
come back for 15 minutes.
There was no local anaesthetic, but the abscess was about to burst so the skin was very thin, easy to cut without much pain. She cleaned the skin and started fiddling about with the single-use scalpel. This has a plastic cover over the blade which prevents the instrument from being used twice. She managed to trigger the mechanism before stabbing the patient, so I had to break the plastic to enable her to use it. She was very nervous and said she couldn’t do it. I offered to hold her hand and direct where to cut, but it was no use. Eventually, I agreed to do it and asked her to stand by with a kidney dish to collect the pus. She didn’t want to get too close. I plunged in the blade and a spurt of pus missed the dish, landing on her shoes. She wasn’t pleased with that result and resolved to be more resolute.
The next boil was on the scalp. Now scalps have tough skin and need a firmer approach. It was smaller and she had previously prescribed antibiotics, which hadn’t stopped the boil from forming. This time she was determined to do it herself. But she couldn’t bring herself to use the requisite amount of pressure. She kept stabbing repeatedly, causing the patient a lot of pain. “Be bold,” I said, “Just do it.” And to the relief of the patient, the next cut released the pus. (If any of you are cringing at this point, and wondering about local anaesthetic, we only have one bottle and that is reserved for obstetrics.)
My colleague has taught me a new technique for removing
foreign objects (beans, beads, stones) from nostrils. I would have formed a
hook with a blunted needle and tried to claw back the object. Her solution was
much more elegant. She removed the inside of a biro and put the external
plastic tube inside the unblocked nostril. Then she told the child to close his
mouth and she blew in the tube, causing a bean to shoot out. Excellent trick. I
will certainly use this in future.
We have been working on consultation skills. She can be rather abrupt at times. “Are you a virgin?” she asked one teenage girl. When the girl said yes, she replied, “Are you sure?” I began to wonder how she might not be sure.
I prefer not to see patients by myself. My Cinyanja is extremely limited to 20 phrases and I don’t want to restrict myself to the privileged few who speak English. It is more educational if I see patients with the clinical officer. She consults and then I help her to sort out the problem in a logical way, translating for me at times. Sometimes, she hands the consultation completely over to me, for example, older men who complain about “lacking power”. With them I ask the usual questions, screen for heart disease and diabetes, then recommend that they try sildenafil, or Viagra. I have seen this at the local pharmacy as an orange-flavoured sachet. It’s a hot seller but it isn’t cheap.
The community health workers are very interested in my being a bachelor/widower. Some of them remember me from 2014 and don’t understand why I haven’t taken a wife. They offer to provide me with a Zambian wife, as “all men need a wife“. To satisfy their needs. I told them that I didn’t have any needs, I’d rather have a cup of tea. They burst into incredulous laughter at this and insisted that I did have needs which only a Zambian woman could awaken. I told them that my kit was “out of service” and had a “flat battery”. “Oh, don’t worry, doc, I know someone who has a beautiful battery charger!” As the investigative sleaze reporter in the now defunct News of the World used to write, “I made my excuses and left.”
One of the expats in the Valley was driving along the main road at about 11am and saw a schoolboy collapse. The nearest ambulance is an hour away, so she pulled over, lifted him into the passenger seat and drove him to the health centre. He did look rather poorly, but his rapid diagnostic test (fingerprick, takes 10 minutes) was negative for malaria. I don’t know whether it is a sixth sense or just experience of having seen thousands of cases of malaria, but the child LOOKED like he had malaria. Instead of just prescribing a few paracetamol, I insisted that the lab technicians examine a thick blood film. This is tedious and takes a lot longer, but it is more sensitive. They found the ring forms of falciparum malaria and he got the correct treatment. My colleagues don’t often deviate from “accepted practice”, perhaps because to do so would open them up to criticism. They lack confidence in their own judgement sometimes.
Having an epileptic seizure in later life is not good news. In the UK I would be thinking of a space-occupying lesion, but here in rural Zambia, my first thoughts were of infectious diseases. Could he have tuberculosis, a brain abscess, cerebral malaria or even cysticercosis? I asked the family a few more questions and it turned out that he really enjoyed eating pork. I am not certain, but I suspect this might be pork tapeworm cysts in the brain (cysticercosis). Without sophisticated investigations I cannot confirm this diagnosis, but if he has another seizure, I will offer him treatment with an anti-parasite medication, covered by a course of steroids (to avoid an inflammatory reaction in the brain to leakage of the cyst contents).
Last month, I saw a very elderly lady who is a regular attender at the health centre. She is very weak, anaemic and thin. Her muscles are wasted and her limbs are like sticks. The family keep bringing her for some medication to make her strong again. When I examined her, she had no teeth. She couldn’t chew food. All she could eat was maize porridge. The treatment was nutritious food cooked in a way that she could swallow it. No drugs, doctor? Well, I succumbed and prescribed a short course of multivitamins and iron tablets.
I was helping out at the family planning clinic recently when a striking young woman marched in. She was wearing tight, day-glo purple shorts and a figure-hugging pink fluorescent vest. This is certainly not the usual attire of women in rural Zambia. Virtually all of them wear a wrap-around skirt called a chitengi, which hides their legs and (sometimes) disguises their buttocks. Their tops are very functional, allowing a breast to be howked out to feed a hungry infant. At first all the other traditionally-dressed women in the queue were silent and in shock. Then they buzzed with indignation at this hussey who was flaunting her body at the clinic. The young lady received treatment and marched out, seemingly oblivious to the stir she had caused.