Medical Thursday Doors Zambia

Hypertension 2

Art in Nature. Wonderful bark.

Now I have seen some high blood pressures in my time, but this old lady’s 285 systolic was one of the highest I have seen here in Zambia. She had been taking two tablets, a calcium channel blocker and a combination diuretic. She claimed that she never missed a dose. When I took her pulse, it was galloping along at over 120 beats per minute. I tried checking with my pulse oximeter, which clips gently onto a fingertip and displays the oxygen saturation of blood, along with the pulse rate. It showed 116.

There are not many options available in rural Africa to treat blood pressure. I have become less keen on using beta blockers after my experience in Kenya that they did very little good. They may reduce the pressure, but there is little evidence that this results in reduced mortality. But they do reduce the heart rate, and this lady’s heart was going like the clappers. I asked her son to go to the pharmacy and buy some atenolol to see if it would help.

Elephants in the dusty evening light, wandering over the salt pan to plunder village gardens

When morning clinic was over, I stopped by the ward to review her. I took her pressure myself and it had fallen to 170/95 with a pulse rate of 76/minute. This is still higher than normal, but I was delighted. I asked the son to make sure that she took the atenolol together with her normal tablets for blood pressure, for the foreseeable future. I said that she could go home and have some decent n’shima (stiff maize porridge) for lunch, but go easy on the salt.

She sat up and swung her legs over the edge of the bed. She started swaying and needed some support from her son as she walked out of the ward into the sunshine. I wondered whether her carotid arteries were so stiff and calcified from decades of atherosclerosis that she needed a high blood pressure to get the blood and oxygen to her brain. I made a note not to treat her hypertension so aggressively in future. I didn’t want her falling over from postural hypotension and breaking her hip. It is important not to follow guidelines slavishly, without taking into account the patient as an individual.

Well-camouflaged ground squirrel

Almost every morning when I do a ward round, there is an elderly person lying on a bed resting to reduce their blood pressure. If the blood pressure is extremely high (250 systolic), the nurses might have panicked and given furosemide (a diuretic), a practice I have advised against. But, if there isn’t anything else in the drug cupboard, what can you do? A group of fussing relatives surrounded a little old lady on the bed. I asked what was wrong. “BP,” came back the answer. I could have guessed.

One daughter could speak reasonable English so I asked her to tell me the history. Her mother had had hypertension for years but had given up taking pills. Perhaps she was being treated by the sangoma (witch doctor) or drinking herb tea (made with aubergine leaves). I have even seen people collecting elephant dung to make antihypertensive tea. Perhaps the elephant had been eating aubergines.

Saddle-billed stork

“And why did you come to clinic?” I asked. Her mother’s hand had become paralysed. Sometimes the local language doesn’t have the vocabulary to express subtle changes, so paralysed might mean not moving because it hurts or no feeling, numbness. “She is moving her hand now,” I said. “Yes, and she has started speaking again.”  I looked at her school exercise book but the notes were very brief and didn’t mention a stroke or transient ischaemic attack.

The old lady looked miserable. Via her daughter, I asked her to squeeze my index fingers with each hand to assess the strength of her grip. “You can do better than that! Go on, try to hurt me!” I urged playfully. Her grip improved as she really put some effort in. The right hand was slightly weaker. I wanted to check her facial movements, so I pretended that she really was hurting me. I made an exaggerated show of trying to pull away from her. Eventually she let go and I waved my index fingers in the air, pretending to get some feeling back. This made her laugh, and I could see both sides of her face moving equally. It looked as though there was no residual neurological deficit. Disregarding social distancing, I put my arm around her shoulders and told her I was impressed with her recovery.

Marabou Stork. How ugly can you get? I am sure that his mother loves him.

I told the family that I was going to add a small daily dose of aspirin to try to reduce the risk of another “mini stroke”. I discovered the pharmacy didn’t have any in stock, so I checked in my stash of drugs in the car and discovered a strip of aspirin tablets about to go out of date next month. As I handed it over, the family started chanting: “May Almighty God bless you and keep you safe,” “We will pray for you and your good works,” “Thank the Good Lord who has sent you to help us.” All for 14 aspirin.

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.