Categories
Medical Zambia

Renewing Old Friendships

Last week, young Desmond (see a previous blog Desmond Doktah), saw me in the doctor’s vehicle negotiating the muddy potholes of the street outside the police station which leads to the clinic. He hauled himself up onto the running board and grinned at me. I grinned back. I had heard that he had been unwell, but he looked fit and healthy. He said that he would come for a consultation with me at the health centre during the school holidays.

I enjoy re-establishing links with people whom I have met or treated in my two previous missions here in Kakumbi. Of course, the doctor has a high profile, and everyone recognises the doctor’s car, even if they confuse me with another male muzungu doctor.

Occasionally, I will see my writing in someone’s health records, a cheap school exercise book and it strikes a chord. Or at least, I can see how I was thinking about the clinical problem at the time.

Most of the health centre staff are new to me apart from six: Jesse, the cleaner and register keeper, Erina and Margaret, who help in the mother and child health block, Celestino and Mike who are community HIV support workers, and John Mbewe who is the enrolled nurse in charge of HIV care.

John Mbewe vaccinating while wearing his waistcoat “Champion Against Open Defaecation”

Daillies, my former translator, and Helen, who was so skilled at handling hysterical patients using the power of Jesus, both work at the Airport Clinic now. Chanda, who volunteered at Kakumbi for ten years without pay, now has a post at the district HQ in Mambwe. Mr Chulu has taken over as environmental health officer at Kamoto District Hospital. I have met them all again (apart from Helen).

Maurice, another one of our volunteer community health workers, weighing babies

Dr Mashanga, my supervisor at Mambwe District, warmly welcomed me back to the Valley and promised to get me the additional drug supplies to enable me to treat patients with mental illness, asthma, hypertension and diabetes. We now have atenolol, nifedipine, metformin and glibenclamide in stock at Kakumbi.

I also visited Caroline Mwanza, the District Commissioner. I could see her outside her office, under the shade of a magnificent tree. I waved at her and she cocked her head onto one side, wondering who on earth this old muzungu could be, coming to greet her. Then her face beamed into a smile as she recognised me. We hugged and embraced each other before she marched me off to her air-conditioned office for a long chat.

It’s great to be appreciated and greeted so warmly by everyone. Zambians are so friendly (and so are the expatriates living here).

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
Bangladesh Medical

All doctors make mistakes

Medicine is not a precise science; certainty is impossible to guarantee. Doctors are fallible. When making a diagnosis, we play the odds, treating what is most likely, with an eye out for rare conditions which we shouldn’t miss. “Common things are common” is a truism, but “when you hear hoofbeats, think of horses, not zebras.” (Well, perhaps not in Zambia.) But even unusual versions of common diseases are more likely than rare diseases.

Kutupalong health facility, November 2017.  I was called into a consulting room to give a second opinion. The nurse told me that the patient had pus coming from both eyes for three years.

“Three years?” I asked. “On and off for three years or every day?”

“Every day,” replied the nurse.

That’s very unusual. Sometimes patients exaggerate the length of time they have symptoms. Perhaps the lack of medical care in northern Myanmar for Rohingya people was a factor, resulting in chronic infection or conjunctivitis.

I looked at the patient. Her eyelids were coated with yellow discharge and her conjunctivae were inflamed.

“What do you think is wrong?”  The nurse didn’t reply, she is very shy.

I gave her a short tutorial on different causes of conjunctivitis and asked her which was the most likely.

“None of them.  She has dacryocystitis,” she said.

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“If she had inflammation of the nasolacrimal duct, there would be swelling here,” I said, pressing the patient’s face, just by the nose and below the eyelid. A spurt of pus welled up over her eyelid and ran down her cheek. A bit like the egg I now had on my face.

“Dacryocystitis is very rare in adults, but your diagnosis is spot on here. Good call. Why did you ask for my opinion?”

“Because I don’t know the best way to treat it,” said the nurse. Fair enough. The patient needs some delicate surgery to sort out the problem.


 

The medical assistant called me to the Emergency Room. “Acute appendicitis,” he said. I asked him to present the history. He had recently joined the team and was unused to speaking English. Perhaps lacking in confidence, he repeated, “Acute appendicitis.”

“What about the details, when did the pain start, where is it, did anything make it worse, did anything make it better, any other problems? You know how to do this,” I asked.

“She had pain for ten days, and fever before then. She is tired and has lost weight.”

“Isn’t ten days a bit long for acute appendicitis?” I asked.

Silence. “Anything else?” I enquired.

The doctor reached out with pointed fingers and prodded the patient’s abdomen. “See, McBurney’s positive!” he said.

Ouch. It even made me grimace. “OK, let’s start by introducing ourselves and putting the lady at ease.” Then I kneeled down by the bed and gently touched her abdomen with the flat of my hand. Her tummy was soft, with no muscular guarding, no signs of peritonitis and I could press down over where her appendix should be (McBurney’s point) without her flinching. But there was some liver enlargement which had gone unnoticed. This clearly wasn’t appendicitis. It wasn’t even an acute abdomen.

“Why do you think she’s breathing so fast?” I asked.

“Because she has abdominal pain,” he replied.

“But the pain isn’t making her anxious. Could it be something else?”

“Pneumonia?” he offered.

“But her blood oxygen saturation is 99%. Her chest is clear. She sounds as if she is breathing like a steam train. We call this Kussmaul respiration. Perhaps she has a metabolic acidosis and she is breathing out more carbon dioxide to compensate. Have you checked her blood glucose? Or her urine for ketones?”

A random blood glucose was more than twice the upper limit of normal – she was diabetic. She didn’t have acute appendicitis. Her abdominal pain was caused by diabetes. Sometimes you have to look beyond the obvious to find the cause of a patient’s symptoms.


 

The little boy had not passed urine for a day. He was in a lot of discomfort caused by a grossly swollen bladder. The foreskin was very tight, so the doctor thought this could be the problem.

“OK, try getting the finest nasogastric tube into the penis to drain off the urine,” I said.

“Not possible, because the foreskin is swollen.”

“Let’s try to reduce the swelling then – try ice packs, covered in cloth,” I replied.

 

The ice pack was successful. The doctor pulled back the foreskin, inserted the tube and out flowed the urine. He proudly showed me his handiwork.

“Well done, but don’t forget to pull the foreskin forward again. We don’t want to convert a phimosis into a paraphimosis (where the foreskin is stuck in the retracted position),” I warned.

“No, it is better to leave it like this. If we pull it forward, it will cause urinary retention again,” said the doctor.

“Hmm, I would prefer it if you pulled it forward,” I said.

I don’t like saying “I told you so” but the next morning, the same doctor came up to me and said, “You told us this would happen,” showing me the swollen retracted foreskin. “Back to the ice packs,” I said.

“If this fails, should we insert needles into the skin to allow the oedema fluid in the prepuce to escape?” asked one enterprising doctor.

“How on earth did you discover that trick?” I asked. Not on earth – it was via the internet.

“Hopefully we won’t need to insert any needles.”

But I was wrong. This time, ice packs didn’t work and the doctor had to stick needles into the swollen skin. Enough tissue fluid oozed out, allowing him to ease the foreskin forward again into its usual position.

“What do we do now?” the doctor asked.

“Well, he is almost three, that’s when he would normally be circumcised. This would provide a definitive solution. Can you ask the father to arrange for this to be done?”

“Good idea, doc.”