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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.

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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.

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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.

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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.

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Zambia

Leopards and other dangerous creatures

The general manager of one of the nearby safari lodges decided to have a team-building, morale-boosting trip to the National Park for sundowners on Sunday. (It is traditional to find a pleasant spot to watch the sunset while enjoying a drink, hence the term sundowners.) Seven of us drove into the park at 4.30pm, planning to meet up with friends at 5pm on the open plain of WaMilombe.

I really enjoy being driven in an open, high vehicle. The view is so much better than the view from the driver’s seat in the doctor’s car and I can concentrate of seeing animals, instead of trying to avoid potholes. The Luangwa River spills over into WaMilombe during the rainy season, creating a vast, shallow lake. Mud from the river fertilises the soil, creating rich grassland, perfect for herbivores. The floods recede, draining away into streams which carve deeply into the muddy soil, creating excellent cover for carnivores hunting the herbivores. This makes WaMilombe popular with leopards, and people who want to view leopards in action.

The plain is bordered by ridges on two sides, the Luangwa River and its dried-up tributary, the Mushilashi River. Leopards like to rest in trees on the ridges, while they look out for their next meal. Normally, the plain is dotted with antelope, puku and impala, but this evening it was empty. A solitary game drive vehicle was stationary under a tree close to the Luangwa. Game vehicles only stop for refreshments, toilet breaks and when there is something interesting to see. We decided to take a look.

Leopard 1
Leopard 2
Leopard 3

Stretched out in the shade was a beautiful young leopard. We stopped ten metres away and took photographs. The leopard wasn’t interested in our interest. Its belly looked full. The driver of the other game vehicle said that there were two other leopards over by the ridge. As we crossed a deep dried out stream bed, we disturbed another leopard, who trotted away from us, towards the trees. Our driver could see another leopard hiding below the ridge, so we went to get a closer look. As soon as we began to observe leopard 3, leopard 2 sauntered over to leopard 1. As it approached the shady tree, the leopard speeded up, and ran up the tree trunk.

Leopard 2 crossing open ground in WaMilombe, going for second helpings

We realised that there was something attracting leopard 2 to the tree, so we returned and parked under the branches. We could seen the fresh corpse of an impala, draped over a thick branch. Leopard 2 was partially hidden by leaves, but we could see and hear it eating. I wasn’t expecting a sac of antelope intestines to plummet from the tree, just missing by inches the only vegetarian in our vehicle. Partially digested grass and manure splattered against the side of the truck. Leopard 1 decided to capitalise on this good fortune by picking up the guts and returning to its favoured position by the trunk of the tree.

Leopard 1 likes tripe
Leopard 2

Both leopards gorged on the remains of the impala while we watched. The sun began to set so we left the feast and drove to the bank of the Luangwa River, where we could safely get out and have a drink. The sunset was magnificent, but not as impressive as the afterglow which lingered in the sky for twenty minutes, getting deeper and deeper red. I took a selection of photographs of the sky reflected in the river as the light faded. Hippos started leaving the river to eat grass during the night. We could hear baboons giving alarm calls on the other side of the river, but we couldn’t spot another leopard in the gloaming.

Hyena in the headlights

When it was pitch black, we drove back to the leopard tree. A hyena was lolloping about, hoping for some titbits to fall from above. I got a poor photograph using the headlights to illuminate the scene. We were a mile from the park gate when a large grey shape appeared in front of us. I could pick out four elephants, munching away on trees. We drove carefully past and joined the main dirt road leading to the gate. The driver slammed on his brakes, creating a cloud of dust. “There was a puff adder in the middle of the road back there. I’m going to reverse, let me know I am not going to run it over.”

Puff adder

The lighting conditions were very poor, but the puff adder was clearly recognisable, as a short, fat snake, with a triangular head and typical diamond markings on its back. It might look fat and sleepy, but that’s its modus operandi. It stays still, waiting to attack with one of the most rapid strikes of any snake. Its venom causes massive tissue damage. Not the sort of snake you want to step on during a walking safari in the bush.

About a kilometre from my house, we stopped again to allow a lion to cross the road. Bush highway code: animals have priority on these tracks. As we waited for a second lion to emerge from the bush to join its sister, I reflected on how fortunate it was to be able to see these savage beasts in their natural environment. And we had just popped out for a couple of hours on a Sunday evening for a social drink with friends.  

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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.

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Life Zambia

Journey to Zambia

In autumn 1978, before my first medical job overseas, Dr John Seaman, chief medical officer of Save the Children Fund UK, advised me to invest in a proper, sturdy suitcase, a Globe-Trotter. “Go to Harrods and ask the assistant to jump onto the case from a chair to demonstrate how tough it is,” he said. I went to Harrods but the eye-watering price of the Globe-Trotter deterred me from asking for a demonstration. As a result, I have bought a succession of cheap pieces of luggage ever since; false economy. The zip holders on my grey Samsonite case have been replaced twice, and one of its wheels is wonky, but it is fairly secure. The soft-walled Delsey Sidewalk can carry more supplies, but both its wheels have fragmented; I will leave it behind in Zambia.

Even with a generous luggage allowance of two suitcases each weighing 23kg, I couldn’t pack all the medical equipment and supplies I had collected. I packed the cases equally, the more valuable items in the more secure case. I guessed that each weighed about 20kg, but I needed to check. The cases were too big to fit onto a set of bathroom scales, so I stepped onto the scales carrying a case, noted the weight, then put the case down and subtracted my weight from the total. 25kg and 23kg. Perhaps Ethiopian Airlines will allow some leeway for a medical volunteer, I thought.

I packed my iPad, Kindle e-reader, laptop, binoculars, camera and long lens into my secure backpack. It weighed almost 10kg against the allowance of 7kg, but I could justify needing to keep expensive stuff with me on board. Thank goodness this airline allows carry on luggage, unlike some others who fear it will increase the risk of Coronavirus infection.

The only way I could carry both cases was by dragging them behind me. They were so wide that it was an effective way of keeping a social distance from others. Heaving them up and off the train to London St Pancras was trickier. The underground was quiet, even at “rush hour”, though I did struggle to get the cases down a few short flights of stairs, huffing and puffing behind a mask.

I found the check-in desk at Heathrow Terminal 2 and had more difficulty manoeuvring the cases around the maze of narrow, roped-off paths. The first attendant scrutinised my passport and documents before telling me that I had to see her supervisor at the end of the row. I dragged my cases past other check-in desks and smiled sweetly at the supervisor. She told me that she would have to call the station manager for the flight, could I wait a few minutes.

She took photographs of all my supporting documents, visa and passport to email to the manager. Five minutes later, she called the manager again and I was granted permission to fly. I heaved my cases onto the weighing scales while she was tapping on her computer keyboard, hoping she wouldn’t notice the excess. She tagged the cases and attached “heavy” labels to them before asking me where I wanted to sit. I said, “Away from everyone else, please.” She assigned me three seats in a middle row at the back of the plane.

The inflight entertainment system was not working, but I didn’t mind. I was able to scrunch down into three seats, wrapped myself in a blanket, extended the middle seatbelt as much as possible so I could lie on my side and fasten myself in. I pulled up my mask so it covered my eyes as well as my nose and mouth and managed four hours of fitful sleep.

Being seated at the back of the plane meant there were fewer passengers around me, but I didn’t get a choice of meal and there was no coffee left. We landed in Addis during a thunderstorm and had to stay on board for 20 minutes until the tropical rain eased off. After waiting for a couple of hours in Bole International Airport, I boarded the flight to Lusaka. I had three seats to myself at the front of the plane, perfect for a quick disembarkation. I had heard that it could take three hours to get through immigration and health checks, so I was perfectly positioned.

At Kenneth Kaunda International Airport, all passengers fill out three similar forms, declaring their lack of covid-19 symptoms and how they can be contacted if their test, or the test of a nearby passenger, turns out to be positive. One health worker noted my temperature and collected one of my health declarations. An immigration officer asked for my papers. Her raised eyebrows indicated that she was impressed I had managed to obtain a visa. “Go to the diplomatic channel,” she ordered. The next immigration officer in the kiosk was confused by my supporting documents. He saw that I had been in Zambia last year and asked his boss what to do. The boss nodded his head and the officer started typing my details into the computer using two forefingers. On the narrow desk there was not enough room for the keyboard, so half of it was unsupported. Each prodded keystroke risked it falling off the table.

I was disappointed not to get a pretty page stuck in my passport. The immigration officer just stamped my entry onto a cluttered page and waved me through to the health desk. The health clerk misspelled my name on the request form and swab container and handed it back to me. I said, “I have proof of a negative test from four days ago, done by the NHS.” She wasn’t interested and waved me over to the swabbing team.

Two nurses in full “Ebola-style” personal protection suits, hoods, visors, masks, wellington boots and double gloves took nasal swabs from all the passengers. I asked if I needed to quarantine, and she said, “No, but we will contact you if we need to in the next 14 days.” I thanked her and collected my luggage from the conveyor belt. A customs officer inspected the baggage tags and waved me through. My taxi driver, Friday, was waiting for me outside. He said that he remembered me from my first visit, six years ago. He had parked his taxi 400 metres away, across the official car park, in the apron of a petrol station, probably to avoid exorbitant airport parking fees.

During the journey to the hotel, I looked out for familiar landmarks, but could not see anything I recognised. There were lots of new buildings and shopping malls, but the streets were eerily quiet. There was a statue of a giant chicken commanding a roundabout near the city centre. It is probably called ZamChick. I would have remembered that, I’m sure.

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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
Flying Life Thursday Doors Zambia

Goodbye Thursday Doors

The picket fence and door to the very cosmopolitan Zee World Bar.

My replacement arrived. We had the obligatory sundowners on Kapani Pan (where there had been lions just a few days before). I said my goodbyes to the expats and local staff at the health centre. No tears, just hugs. After my final early Monday morning meeting, I left behind some medical kit for the clinical staff, an electronic thermometer, a thousand candle power head torch to illuminate nooks and crannies, an otoscope which you can’t turn off without dissembling and a few tongue depressors.

It took about an hour to pack. One bag contained 540 origami cranes to be hung at my daughter’s wedding; it weighed less than 2kg. The other bag had my medical kit, some clothes which survived the “Boom” and handwashing of Theresa and a few presents. I travel light apart from technical stuff and electronics.

I had my laptop, mouse, two cameras, lenses, Kindle, music player, binoculars, battery chargers and iPad. This always causes problems at airports because I have to carry them as hand luggage to avoid theft from checked bags. At Nairobi Airport transit, my carry on bags looked so suspicious that I had to unpack completely. The security officer swabbed everything to detect any residue of explosives. I noticed that the screen of my laptop was dusty and asked the officer if he could clean it while he was checking. “Ah, sir, sorry. We don’t offer that service,” he apologised.

At Mfuwe International Airport, the checks were less stringent. I sat in the departure lounge after checking in, chatting to a Naturetrek birding tour party. An airport official interrupted me, “The District Commissioner wants to see you!”

For a brief moment, I thought I was going to be detained. Or perhaps they finally had my plastic Temporary Employment Permit card. But DC Caroline just wanted to bid me farewell and express her gratitude for my work in the Valley. I said goodbye to her and to F who had also come to see me off.

District Commissioner Caroline Mwanza, in a fabulous outfit with a new hairdo. My hair hasn’t been cut for over three months.

The my flight from Lusaka arrived so I went through security again, telling the staff the same joke about my trousers being about to fall down because I had had to remove my belt. “Those with boarding cards for the Proflight to Lusaka, please come to the gate.” Oops, while I was chatting outside with the DC, they had issued boarding cards and I didn’t have one. (Regular readers may recall that on the flight out to Mfuwe, the airline staff gave my boarding card to someone else.) No problem, they just printed off another card and I joined the queue of Chinese tourists taking selfies on the runway by the aircraft steps.

I feel sad at leaving. It is almost my second home now, my sixth visit to Zambia. But it is time to go, to move on. I have lots to look forward to in 2019. Including my appraisal and revalidation.

Sunset in the clouds as we fly over the River Luangwa (just visible bottom right)
Categories
Life Zambia

The wheels come off

Well, only one wheel and it didn’t go bouncing down the road in front of me; it just bent outwards.

I first noticed that the steering was sluggish in Chipata. The car was not as lively when I accelerated. I thought that the power steering had stopped working. Perhaps there was a hydraulic system which needed topping up. However, being 150km from Mfuwe, I decided I should drive carefully home rather than going to a garage in Chipata or calling for help from the lodge which services the vehicle.

The journey back was enjoyable and I didn’t notice a problem with the steering when manoeuvring the car over the high speed bumps on the road. The rolling hills were verdant and fecund. I chased a thunderstorm as it passed through, getting deluged with heavy rain and emerging into bright, clear sunshine.

The following day, the fault seemed to have corrected itself, but I made a mental note to contact the maintenance men to check it over in the afternoon on my way to do a home visit. We did a community clinic in the morning then after lunch I was driving on a bit of road that was part tarmac, part dirt. Driving at no more than 30kph, I suddenly felt the front passenger side of the car dip down and the vehicle pulled to the left. I braked but was unable to control the car’s swerve to the verge of the road. The car stopped before it careered down the embankment. I thanked my lucky stars and got out of the vehicle.

Dislocated ball joint – you can see the ball, looking like a ping pong ball in the dirt.

The front passenger wheel was at an impossible angle and the ball joints which attach it to the axle had failed. I am a complete novice when it comes to making mechanical diagnoses, but the clue was the ball (from the ball joint) sitting in the dirt. There was some liquid dripping from the axle. I tried to call the maintenance men, but the mobile network was down. I decided to use the car’s radio instead for the very first time and I was told help was on the way.

It is considered good manners to stop when you pass a vehicle which has broken down to see if there is anything you can do to help. Half a dozen vehicles stopped for me and one chap told me that he had a spare whatchamacallit in his garage if I needed it. Another person offered the opinion that the car had already done 240,000 km and with the state of the roads it was driving on, she was surprised that the ball joints hadn’t gone already. The same problem had occurred with a local chief, but his vehicle careered off into the bush with him frantically turning the steering wheel to no effect.

I was rescued and taken home within the hour. If anyone needed medical attention, they would have to send a car to pick me up until another vehicle could be pressed into service. The next day I grabbed a lift to the village and R took me to the scout training camp deep inside the national park to do a first aid workshop. Gunshot wounds, fractured limbs, vehicle accidents, animal attacks, snake bites? All of the above, but mainly basic hygiene, using medication properly, keeping wounds clean and avoiding infection where possible.

On the day I left Mfuwe, the ball joints and other parts had arrived from Lusaka, but the car had not been fixed. I hope I have not developed a reputation as a car wrecker!