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Kenya Medical

What am I doing here?

I often ask myself the same question.

We are supporting the Kenyan Ministry of Health’s policy to improve the management of chronic non-communicable diseases (NCDs – hypertension, diabetes, asthma and epilepsy in the first instance) in rural clinics and health centres. Before we started work in Embu in August last year, most people with NCDs went to the local district hospital for treatment or attended a private clinic. We think that highly trained doctors working in hospitals should be treating more complicated conditions, and leave the simpler stuff to primary care. If this scheme is implemented throughout Kenya, it will save the Ministry of Health billions of shillings.

Eleven months later, almost 2,000 patients with NCDs receive their treatment at their local health facility, where local health workers have not just been trained, they have been mentored to improve their knowledge, skills and attitudes.

The usual approach to training rural health workers is to get funding from an aid agency to run a course in a hotel conference room. After eight hours of death by PowerPoint, the health workers get a certificate and are considered trained. We are using a different approach, mentoring.

Our 12-strong team of highly trained clinical officers, nurses and health promoters have been trained to mentor health workers in five rural health centres and two dispensaries. The cycle lasts for six months, with weekly visits, a structured learning programme, one-to-one teaching, observation of clinical practice, etc. The mentoring team uses a set of disease-management guidelines which have been specifically designed for rural Kenya. These can deal with over 90% of the patients we see, but when the guidelines don’t seem to fit, the mentors ask for advice from the expatriate doctor.


All that wheezes isn’t necessarily asthma.

The mentor asked me about a 65-year-old lady with rheumatoid arthritis who had a year-long history of expiratory wheeze, nocturnal dry cough and chest tightness. She said she had cooked for years using dried cow dung in a restricted kitchen area. She didn’t smoke, but her husband had done in the house for years. A few months ago, she had started taking 10mg prednisolone (steroid tablets) for arthritis, which had helped to improve her wheeze. The steroids were stopped and her wheeze came back.

Examining her she had widespread expiratory wheeze. Her peak expiratory flow doubled after salbutamol inhalation. I concurred with the mentor that the diagnosis was adult-onset asthma, which is pretty rare.

Contrast this with a 45-year-old man who had attended the health centre with shortness of breath and a cough a week previously. The nurse (not on our programme) had treated him with two different intravenous antibiotics, oral antibiotics, salbutamol tablets and antihistamines. The nurse had diagnosed asthma and asked him to come for review when the team attended.

On closer questioning, the patient said he was feeling much better. He had similar episodes once every two or three years. Clearly, this was a chest infection, not asthma, as the unmentored nurse had thought.

Another lady with a 20-year history of asthma treated with salbutamol tablets (we stopped using these in UK general practice when I was in medical school) had enrolled in our NCD programme a month ago. She had been prescribed a reliever (salbutamol) and a preventer (steroid) inhalers instead of tablets. She told us that she had only had one attack during the past month when she had been caught in the open by a cold rainstorm while she was farming. It became apparent that she had been using the steroid for relief and the salbutamol for prevention (the wrong way round). Still, even so, she felt better. She will improve even more when she uses the inhalers properly.

It is really important to spend time with patients to understand how to use their inhalers. We don’t have any placebo inhalers to demonstrate technique (I am working on this). When observing our mentor in the consulting room, I saw one lady who managed to use her salbutamol inhaler upside down. When she eventually managed to fire off a dose, the gas was unable to get out of the closed mouthpiece and came up alongside the aerosol canister for her to inhale.

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Categories
Kenya Medical

Psychiatric Unit

“He dropped out of school because he was receiving messages from God,” said Lucy, the veteran nurse in the Psychiatric Unit in Embu. “But his family thought this was very strange because he didn’t even go to church.”

Just off the main Nairobi – Meru Highway, close to the Isaak Walton Hotel, is the only psychiatric unit in Embu County. It is a square building with an internal courtyard, built in “Public Works Department 1960” style. To gain access, one has to pass through a locked gate by the nursing office. It has two wards, one with twelve male beds and another with six female beds. Adjacent to the female ward, there is an outpatient consulting room. The seclusion room has a steel door secured with a large padlock. There is a recreation room with a caged television and a broken pool table.

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According to a national newspaper, there are only six psychiatrists working in the public sector in Kenya. One of them works here in Embu. Each time I have visited the unit, I have only seen Nurse Lucy, as the psychiatrist spends a lot of time doing medico-legal assessments for the courts. There is only one other psychiatric nurse, who manages the inpatients. Student nurses do placements here, but few of them want to make mental health nursing their career.

On my first visit to the unit in May, all the student nurses were huddled in the nursing office by the gate. No nurses were in the open courtyard where some patients were walking around in the winter sunshine. I asked why the student nurses were not mingling with the patients. It was suggested to me that they found it too cold to leave the office.

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Lucy told me that drug-induced psychosis was common. “Embu is the catchment area for khat,” she said. (I am not sure she got the right word; “epicentre” would have been my choice.) The shrub khat contains two mild stimulants which are released when the fresh leaves are chewed. It is commonly grown in East Africa, where it is known as “miraa“. To get the best price for the leaves in the markets of Nairobi, drug traffickers drive like maniacs from Embu down the A2 highway in the early morning.

Although amphetamine psychosis is well-recognised, I had never heard of khat causing psychiatric disturbances such as hyperactivity, mania, hallucinations and, with prolonged misuse, psychotic depression. I learned that khat is used with other drugs, such as cannabis, to calm down as the feeling of elation recedes.

Lucy regularly visits schools to talk about mental health and the dangers of drugs and alcohol. She supplements this activity by health promotion using social media. Sadly, outreach clinics in the community have ceased. She has no vehicle and there no community mental health workers. Many people think that mental illness is caused by being bewitched. Rural communities tolerate people with severe mental illness until they start breaking things or attacking goats. Then they bring the person to Embu for a psychiatric consultation. During my previous visit, I saw a woman whose hands had been tied with rope sitting calmly in the outpatient waiting area.

Lucy also said that puerperal psychosis, schizophrenia and severe depression were common in patients attending the clinic. If she could not manage patients suffering from these conditions, she would refer them to Mathare Mental Hospital (formerly known at Nairobi Lunatic Asylum) in Nairobi.

It was obvious from visiting the unit that the patients were cared for with compassion. Lucy was a true champion for people with mental health problems. Unfortunately, she has plans to retire in 2022 and at present, there is no one being groomed to be her successor.

Categories
Kenya Medical

Heart Attacks in Embu

“You have chest pain. It might be a heart attack. How do you get an ambulance in Embu?” asked the lecturer. The events room at the Isaak Walton Hotel was silent. I didn’t like to say that I have one sitting in front of my house, on standby.

Someone mumbled that there was an ambulance at a private hospital in town. Another person said that there was one at the “Level 5”, Embu Government Hospital 200 metres away across the Nairobi-Meru Highway. There is even Collo Rescue Team ambulance, in Kirimari Ward, Embu.

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“But what’s the number you need to call?” Dr Mo Jeilan, consultant cardiologist at the Aga Khan University Hospital in Nairobi.

No one shouted an answer. A few people flipped through screens on their smartphones. There is no 999, or 911 or even 111 emergency number in Kenya.

“Well, you had better write this number down. It could save your life one day!”

Dr Jeilan’s next slide showed the main entrance of Glenfield General Hospital in Leicester. “This is where I trained to be a cardiologist,” he said. I turned to a colleague and whispered, “My home is about 5 kilometres from there.”

“Now you have your ambulance, what now?”

“Get an ECG!” shouted a doctor in the audience.

“Do ambulances carry electrocardiograph machines in Embu?” asked Dr Jeilan. “They don’t. So where is the nearest ECG?”

My colleague chipped in, “Level 5 in the Diabetic Department, but no one knows how to operate the machine when the ECG technician is on holiday.”

“Yes,” said Dr Jeilan, “the ECG is usually considered so precious that it is locked away in a cupboard at nights and weekends. And the nurse who has the key has gone home.”

Everyone smiled. It was so laughable, but it was true.

“You have your ECG. Can you read it? Let’s say it is an NSTEMI, a non-ST elevation myocardial infarct. What do you do now?”

Someone shouted out “Troponin!”

“It takes an hour for the troponin levels to rise in a heart attack and another two hours to process the test. Meanwhile, your heart muscle is dying, starved of oxygen.”

Dr Jeilan told us he gets SMS and WhatsApp messages every day from doctors all over Kenya, asking his opinion about an ECG tracing. “A colleague from Meru telephoned me with chest pain. His ECG showed a possible NSTEMI so I asked him how long it would take to get the result of a troponin test. He said two days. Two days! How come? The test has to go all the way to Nairobi to get tested.”

“It’s not like this in Leicester,” he explained, going on to tell the story of a middle-aged man who developed chest pain on the golf course. It didn’t go away after five minutes, so he called an ambulance. The ambulance got there in eight minutes. An ECG showed a heart attack and the patient was being wheeled to the cardiac catheter lab twenty minutes later. Within an hour, the clot in his right coronary artery had been sucked out and a stent inserted to keep the lumen patent. Job done.

“What’s that circular thing on the Xray?” asked Dr Jeilan. I thought it was the metal part of a patch for an ECG lead connection. “No, it’s a nipple ring,” he said. “Men do strange things over there in England.”

“That man’s heart muscle was saved. I see some Kenyans who have had chest pain for days, when it is too late to prevent the muscle from dying and going black, like gangrene.”

There are no cardiac catheter labs in Embu. There are no facilities for “clot-busting” streptokinase either. So what do we have? Chew an aspirin. But the news is that there are two local volunteer cardiac champions who are about to start training.

The next slide showed a scientific paper published just after Kenya gained her independence in 1963. It reported that a Kenyan man had suffered from a heart attack, a previously undocumented event. Fifty years later, the numbers of Kenyans having heart attacks is skyrocketing. The next slide showed a seated man sporting a huge belly. Obesity, the new epidemic, leading to diabetes and cardiovascular disease.

I turned to the surgeon sitting on my right. He was a big man. He looked worried.

Dr Jeilan ended the lecture and handed over to a local doctor whose brief was to talk about diabetes. Unfortunately, the meeting started over an hour late – African time – so the diabetic talk had to be seriously curtailed, or we would have missed supper. The lecturer got a bit flustered, flipped forward and back through his slides. None of the fancy modern drugs to treat diabetes he was talking about is available at the government hospital, unfortunately.

The sponsors of the meeting took the stage to talk about nutritional supplements, antioxidants and micronutrients, then we filed out of the hall to queue outside the dining room. Everyone was chatting excitedly. I eavesdropped and heard that the first ever kidney transplant in Embu was in progress at Level 5. A team from Eldoret had removed a kidney from a live donor that afternoon and it was being transplanted into his brother, who had end-stage renal disease. A historic moment. I wonder how long it will take before the first angioplasty takes place here?

Categories
Kenya Medical

The Art of Medicine

It is admirable that our efforts to prevent mortality and morbidity are based on scientific evidence. But few clinical trials have been carried out in the frail elderly and virtually none at all in rural areas of developing countries.

Our project guidelines have been designed to be simple to apply. We do not ask a nurse to make a therapeutic decision based on the age or frailty of a patient. Some of those decisions come to the expatriate doctor.

I took this photograph of a 104-year-old man who is attending one of the health centres where our mentoring approach is improving chronic disease management. His blood pressure is well controlled on just one medication but he is taking a statin to reduce his cholesterol (which we have never actually measured). I know of no evidence that 40mg of atorvastatin will prolong or improve the quality of his life. He readily agreed to have his photograph taken, especially when I told him that he was ten years older than my own father!

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The JUPITER trial (dontcha just love the fancy names given to trials?) showed some benefits for statin therapy over the age of 70, but they don’t necessarily benefit everyone. Twenty-nine patients over 70 need to take a statin to avoid one cardiovascular death. But statins have side effects. Lots of older patients complain about statin-related muscle pains, and there is an increased risk of cataracts and diabetes. Also, it takes three to five years for the benefits of statins to accrue.

A mentor asked me to review an 85-year-old man with atrial fibrillation (irregular heartbeat) whose blood pressure was erratic. Electronic blood pressure machines have difficulty when the blood pressure changes from beat to beat. Our approach is to take three readings and calculate the average. I spent some time listening with my super digital amplified stethoscope while taking his blood pressure. The highest systolic figure I got was 150mm of mercury, which I thought was acceptable. He was complaining of dizziness, however. When I palpated his neck, his carotid arteries were calcified like the stem of a clay pipe. He probably needed 150mm pressure to pump blood to his brain! I considered that the benefits of aggressive blood pressure reduction were outweighed by the risk of postural hypotension resulting in falls and fractures.

When assessing a patient, we tend to look at the numbers. How well is a patient’s diabetes or hypertension controlled? We check the HbA1c and the blood pressure. The numbers inform us what we should do next. The nurses asked me to see one old lady (she didn’t know her age but she told me that she was married with three children at the time of Kenyan Independence in 1963) whose diabetes was not well controlled. Her HbA1c was high at 9.6 despite treatment with maximum oral medication. Insulin was the next step. She was terrified of having to use “the needle”, because everyone knows that when you have to start using injections, you are going to die soon.

We had a chat about her diet and compliance with medication. Yes, she often missed doses but she said her diet was fine. I asked if she liked her tea. She brightened up and said that she did. She made “breakfast tea” for the whole family in one pot, stewed with milk and sugar. That was her favourite drink of the day. Now we couldn’t ask her to stop adding sugar to the pot, but perhaps she could reduce the amount? Or only have one cup of breakfast tea in the morning?  If she did that and took her medication as prescribed every day, we could review her in a month and repeat the tests to see if she really did need to start insulin. She readily agreed.

It was a negotiation. Not President Trump style, but a balanced discussion, taking into account the patient’s views and lifestyle.

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Our project aims to do some operations research, perhaps even to publish in a peer-reviewed journal or to present the results at an international conference.

Unfortunately, our project is planned to last for just five years and we don’t have the high numbers of patients needed to do research. But I’d like to know more about the safety of reducing blood glucose levels in older people with diabetes (with the risk of hypoglycaemia); what blood pressure should we aim for in patients who are in their 80s or 90s, and whether or not the risk of treatment with statins and aspirin is worthwhile in these age groups.

Our patients find it difficult coping with polypharmacy, taking lots of different pills for their NCD, with resulting drug interactions and side effects.

Sometimes, less is more.

Categories
Kenya Medical

My first patient in Kenya

“It’s an emergency, Daktari,” said the health worker, as he opened the door of the consultation room. Before I had a chance to respond, he pushed in a distressed middle-aged lady, sprawled across a wheelchair. The team managed to hoist her onto the examination couch. She was gasping for breath.

Everyone looked at me.

I returned their gaze.

“What should we do, Daktari?”

“Manage the situation as though I wasn’t here,” I replied.

The health centre clinical officer started faffing about looking for equipment. The nurses looked on in panic, waiting for someone to do something. The atmosphere of anxiety was palpable, and it was making the patient worse.

“How about starting with the history?” I asked.

“There isn’t any. She was just brought in like this.”

“If she is so breathless she can’t speak, get a history from the person who accompanied her,” I said. “And I am not really here.”

The story from her husband was brief. She had become acutely short of breath that morning. No fever, cough or other illnesses. Not taking medication.

The clinical officer wanted to get a nebuliser to treat asthma. I butted in again, “What’s next after the history?” “ABC, airway, breathing, circulation,” he replied. “Well, I was thinking of examining the patient. What can you see to start with?” “She’s short of breath,” he replied. “So what kind of problems cause shortness of breath, and target your examination to ruling out each of them.”

He asked for a pulse oximeter. Having been a boy scout, I was prepared. “Here we go,” I said, slipping my own pulse ox onto the patient’s index finger. Her hands were in spasm with her fingers rigid and flexed over her palms. “Can you see this?” I asked. “Yes, 99% oxygen saturation with a pulse of 130/minute,” the clinical officer replied. “But  what else can you see?” I asked. He couldn’t answer.

“This is carpo-pedal spasm,” I said. “Look at the muscle spasm in her hands and feet.”

The clinical officer had never seen this before. I asked him if he could get a paper bag. Paper bags are more common in Kenya because plastic bags have been banned, but there wasn’t one. I took a manila envelope from a pile of correspondence, placing the opening over the patient’s mouth and nose. I spoke calmly and softly to the patient in English, asking someone to translate into Swahili.

I turned to the quizzical looks of the other health workers in the consulting room. “She’s very frightened. It is scary when you feel you can’t get your breath. You feel like you are going to suffocate,” I said. “So you must reassure the patient, keep calm and control the situation.”

“Does anyone know what is going on?” I asked.

Our mentor said it might be a panic attack. “Yes, with hyperventilation,” I replied. “So what is happening to make her hands and feet go into spasm?”

I explained about breathing out too much carbon dioxide causes reduction in calcium in the blood and this causes muscles to contract. Hyperventilation-induced hypocalcaemic tetany, in technical terms. “So when she re-breathes the expired air, it contains more carbon dioxide, and after five minutes or so, she should be feeling a lot better. Talk her down, tell her she doesn’t need to breath so fast or deeply.”

Like magic, the patient responded. Apart from her feet. Her toes were pointed straight out and felt painful, but after another five minutes, they went back to normal.

“Why had she been brought into the Non-Communicable Disease outpatient clinic?” I asked. Someone thought she had asthma. It is common to think everyone with shortness of breath has asthma here. Quite a few “asthmatics” who are enrolled in our programme actually have chronic obstructive airways disease, from smoking or cooking with biofuel for decades in a poorly-ventilated kitchen hut.

“That was the easy bit,” I said. “Now what do we do?”

The patient was now able to talk without gasping. I asked her whether this had happened before. It had but not as bad as this time. Any obvious provoking factors? Not really. Anything which has disturbed her recently. She stopped and thought.

“Every time I go past a cemetery, I start to cry. I think about the stillborn baby I had some years ago. I haven’t been able to get pregnant since then. My husband’s family is criticising me, and telling him he should get a new wife who will give him children.”

This isn’t really our core business, but I felt we needed to give her some counselling about getting pregnant, about how to handle the sad feelings of grief following her dead baby and we agreed on the best way to transmit this information to her husband.

He was summoned to the consulting room and was amazed to see the change in his wife. From being at death’s door, she was now sitting up chatting with the muzungu Daktari.

I just hope that fortune smiles on her in the future.

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I can’t believe that this is what it appears to be

 

Categories
Kenya Medical

Guinea Worm

I saw this poster on the back of a shelter in Embu on the main Nairobi-Meru highway.

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Now as it happens, I have seen someone with Guinea Worm Disease (Dracunculiasis if you must). I have seen lots of people. I have even removed a few female worms from their bodies. But in Burkina Faso, not Kenya, so I guess I am ineligible for the reward of 100,000/- Kenya Shillings. The proof?

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My thumb and index finger. We didn’t use gloves back in the day.

There were only 30 reported cases last year in just two countries. I remember being told by Professor Richard Feacham at the London School of Hygiene and Tropical Medicine that the disease would be eradicated “in the next few years”. That was in 1981.

But Kenyans can now relax, as WHO has declared Kenya “guinea worm free”.

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Categories
Kenya Medical

Suicide

Maggie was painting the inscription on the wooden cross which would mark the grave of Francis Thumbi. In the obituary columns of the newspaper, people eschew “Born” and “Died” for the terms “Sunrise” and “Sunset”. She was waiting for the family who had commissioned the casket to confirm the exact dates. “Well, sunset is going to be 2018, isn’t it?” I asked. She laughed and agreed with me. “I think he was born in 1990,” she said. “And do you know how he died?” I asked. “Yes, it was suicide. He killed himself, aged 28. He was not even married.”

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I said that in England many years ago, people who committed suicide could not be buried in consecrated ground, in a churchyard. “Why is that?” she asked. “I suppose because it is against God’s law to kill yourself.” “Then you should burn the body,” she said. “Here, he will go into the ground in this casket, under this wooden cross.”

“When I die, I have asked that my body should be used for medical science. They will take it so medical students can cut me up and learn anatomy,” I said. “Waaaah!” said Maggie, “We would not do that here in Embu.”

I turned to scrutinise the coffin. She proudly showed me her handiwork. There was a metallic sign saying “RIP” above a small inspection panel, with a fancy metal knob. I pulled it down and looked inside. The casket was lined with pale blue shiny cloth. There was also what looked like a pair of pants, which Maggie whisked away before I could make a positive identification.

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I asked Maggie if she thought that being married might have helped prevent Francis from killing himself. She said it might have, but there were too few women around to marry here in Embu. I begged to differ. “There are many nice Kenyan girls here,” I said. “What about you, Maggie, are you married?”

“No, do you want to marry me?”

“I don’t, Maggie. I am too old for you.”

“Age doesn’t matter. Do you want me?”

“We hardly know each other!”

“Well, take me with you to Japan,” Maggie said.

“But I am from England,” I replied

“No matter, England is better,” she said. “If you won’t marry me, then sponsor me.”

“I can’t do that, Maggie. I am a volunteer working here in Embu.”

“What is your work?”

“Mimi ni Daktari,” I said.

“Then you have plenty of money to sponsor me!”

I heard gales of laughter coming from the neighbouring corrugated iron shack, a hair salon. Obviously, they were enjoying eavesdropping on our conversation.

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I tried to change the topic of conversation. “Is this funeral shed your business?” I asked, hoping she would say yes.

“No, I just work here. The business is called Leemak,” she replied.

“Lee Mack is a comedian in my country,” I said.

“What?”

“Never mind”, I said. “Can I take your photograph with the coffin?”

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She refused but invited me to take photographs of the coffin. As I did, I noticed some of the white paint used on the cross had dripped onto the metal rail at the side. I tried to rub it off, but Maggie said she would use some spirit to clean it all up.

She went inside the shed and I took my leave, saying, “Faida – goodbye.”

As I walked away, I wondered about poor Francis who had killed himself. In last weekend’s newspaper, there was an article about a schoolboy aged 15 who committed suicide after his family failed to pay his school fees and he was turned away.

Our project here may well expand to cover mental illness. We already have anti-depressants and anti-psychotic drugs on standby in our store. I know that there have been successful primary care psychiatric projects in Uganda and Tanzania, so I am optimistic it could work well here in Kenya. And we might be able to help prevent young men like Francis and the schoolboy from taking their own lives in future.

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Bangladesh Medical Thursday Doors

Thursday Doors – outbreak at the clinic

It was Friday, 20th October 2017. My day off. But we were too busy dealing with complicated patients, so I felt I had to go to the clinic to help. Here is a photograph of the open door of the clinic taken looking out at the refugee camp. It looks tranquil.

 

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It needs a lot of skill to carry a load of long bamboo poles from the road into the heart of Kutupalong Balukhali refugee camp.

 

It began with a young boy who came into the clinic complaining of pain in his neck. He had spasm in the sternocleidomastoid muscle, which runs from behind the ear to the end of the collarbone close to the breastbone. This is called “spasmodic torticollis” or “cervical dystonia”. It is quite rare and doesn’t often happen to children. As we have no specific treatment available and the symptoms were mild, I thought no more of it, until later in the day. Two brothers arrived at the clinic with more significant, painful, involuntary contractions of muscles in the neck. The father said that they had taken some medication which was in a pack of food items distributed in the camp. The medication was called Halop.

Halo is a water purification tablet commonly used in Bangladesh. I can understand that some well-meaning philanthropist felt there was a need for the refugees to sterilise water. But there were no instruction leaflets to show how to do it. But this wasn’t Halo, it was Halop.

Halop is actually haloperidol, a potent antipsychotic drug. The family showed us a foil strip of ten 5mg tablets, with two missing.

“We thought it was to treat coughs and colds,” said the father. “I gave one tablet to each of my sons last night and look what has happened to them.”

In my entire medical career, I have never prescribed haloperidol for a child. The initial dose for an adult is 0.5 to 1.5mg daily. The two brothers had taken 5mg, roughly ten times this. The drug blocks D2 dopamine receptors, to reduce psychotic thoughts. However, it also acts on the part of the brain which controls movement and muscular tone, the extrapyramidal system.

These three children were the first of many to come to the clinic with acute dystonic reactions. Their necks were contorted, forcing their heads backwards or to one side. In extreme cases, the eyeballs roll back into their sockets, a condition called “oculogyric crisis”. We didn’t see this, but we did notice many children staring upwards and to one side. Examining the children’s limbs revealed increased tone. On moving the arms and hands, I could feel jerky resistance, so-called “cogwheel rigidity”.

At first, I thought that this was an isolated occurrence, but by the end of the first day, we had admitted eight patients who were so stiff and rigid that they could not eat or drink. One poor chap had taken two tablets; he couldn’t retract his tongue which was sticking out of his mouth. We realised this was an outbreak of poisoning.

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We tracked down where the food supplies had been distributed and the outreach team spread out through the camp, telling families not to take the yellow tablets in the packs. We contacted the block leaders and imams, asking them to pass on this information. The following day, we distributed colour photocopied pictures of the drugs, warning people to hand them in. We managed to purchase some “antidote” from the nearest town, to give to the patients who were worst affected.

The outreach workers collected over two thousand tablets from the community. We reported the incident through the official channels. A few days later, doctors from the Ministry of Health and WHO visited the clinic to confirm what we had discovered. I assume that they worked out how this had happened, who had supplied the medication and took the necessary action to prevent it from happening again.

It was fortunate that we were able to recognise this problem quickly and take appropriate measures to manage the situation to prevent further harm. All our patients recovered completely after a few days.

 

Categories
Kenya Medical

Accident

I caused an accident last week.

A saloon car driving up Embu’s Main Street (Nairobi – Meru Highway) decided to turn right into a side street. Coming down the hill, a motorcycle taxi (“boda-boda“) driver spotted me walking on the opposite side of the road and was distracted. Even though I’m not the only muzungu in the village (there is a blond, young, Danish man working with us), I still can attract rapt attention. The car driver cut the corner, probably expecting the motorcyclist to slow down or take evasive action, as they usually do.

It’s live and let live here, rather than obsessively obeying the Highway Code.

It was too late for the motorcyclist to react, so he laid the bike down and slid into the front of the car. The pillion passenger and the driver of the boda-boda were not injured. The bike sustained some damage from scraping down the tarmac. There was also some minor damage to the radiator grille, front bumper and number plate of the car.

I didn’t need to intervene medically, though I do have access to a magnificent emergency backpack at the office. It is huge, bright red with yellow reflectors and two extra panniers on each side. It weighs about 25kg so I don’t relish having to yomp a long distance to attend an incident. There is so much equipment inside that I could probably perform major surgery.

As well as doing the “day job” supporting Kenyan health workers in providing high-quality care to people in rural areas suffering from chronic diseases (such as asthma, chronic obstructive pulmonary disease, diabetes, epilepsy, and hypertension), we have to be on the alert for other medical calamities which could occur in our locality. My predecessor picked two of the most likely outbreaks (cholera and methanol poisoning) to prepare for and stocked up on specific equipment and appropriate medication. But even if we are called upon to help in these situations, I don’t think I will be lugging the massive red rucksack.

Post Script: Methanol poisoning is caused by drinking illicitly distilled liquor. Ethanol – ethyl alcohol – in beer, wines, and spirits, is metabolised in the liver to acetaldehyde (which wakes up you a few hours after overindulging, making you feel unwell) and finally acetate. But methanol – methyl alcohol – is metabolised to formaldehyde and formic acid, which can be fatal. It might seem odd to non-medics, but the treatment for methanol poisoning is to give the patient ethanol.

So perhaps I ought to have a wee dram in a hip flask attached to the emergency backpack?

 

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This man is at risk of methanol poisoning

 

 

Categories
Bangladesh Medical

Noma or Not?

WARNING – CONTAINS A GRAPHIC IMAGE WHICH MAY BE UPSETTING

October 2017, Kutupalong refugee camp, Bangladesh.

It began with a misunderstanding. I asked the Rohingya mother how her baby had developed an evil-looking purple swelling on the side of its nose. I thought the nurse translating said that it had been caused by boiling water. It seemed to make sense – fragile newborn skin being splashed with hot water during cooking, perhaps in a dark, plastic-covered hovel in the migrant settlement area. It looked superficial, it should have healed swiftly.

I misheard. The nurse translating the mother’s response actually said that it started with a boil on the face, a small spot, a furuncle. Over the next few days, the skin changed from the colour of a bruise to a dark patch of necrotic (dead) skin. Another dull red patch developed on the baby’s ear. The neonate had already been started on antibiotics but without much obvious benefit. The lesion started to ulcerate. We added another antibiotic specifically for staphylococci and yet another for fusobacteria. We even added an antifungal drug, in case the baby’s immune system was so compromised that this was an opportunistic infection.

 

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I have crudely blacked out the baby’s eyes to preserve confidentiality.

 

There is a great online tool for doctors working in remote settings called Telemed, which allows us to seek the opinions of a group of specialists from all over the world. With the mother’s permission, I posted a photograph of the baby on the Telemed website and waited for paediatric dermatologists to give their opinions.

The infection got worse. We asked for help from the Memorial Christian Hospital, who thought that the baby had Noma, otherwise known as oro-facial gangrene (cancrum oris). This normally affects older children and is incredibly rare in the neonatal period. The hospital doctors thought the baby might benefit from a special antibiotic only used to kill multi-drug resistant bacteria. The ambulance was ready to take them for therapy, but the mother refused. She needed permission from her husband to leave Kutupalong.

Did he have a cell phone? No.

Was he going to visit her soon? No, he was looking after the four other children.

A nurse suggested sending the police out to find him and bring him to the hospital to get his permission. We dismissed this as too heavy-handed.

The mother said that she wanted to leave the ward, against our medical advice. She said she needed to discuss with her husband and that she would return if he agreed.

A day after she left, the Telemed paediatric dermatologists came up with another possible solution – a strawberry birthmark (capillary haemangioma) which had ulcerated and become infected. There is a cure for the birthmark, propranolol, though we would struggle to find it in Bangladesh. We’d probably have to improvise and use a different drug, which is not licensed for this condition. The baby would still need treatment for the flesh-eating bacteria, however.

The mother never brought the child back to the ward. I still think about this child. How could we have handled this better? Tragic cases, like this one, occurred every day in Kutupalong.