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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.

Categories
Medical Zambia

Health Centre Meeting

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

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

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 I have some in stock, but it is out of date and waiting to be disposed of. If the situation arises where I judge it to be life threatening, I will use the out of date medication and face any consequences. But we must not have any out of date stock on the shelves at the health centre.

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

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

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

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

Melvin and Elvis, twin boys less than a week old

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

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

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

Categories
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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