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Life Medical Zambia

Role Play

In these cold winter mornings, patients tend to arrive at the health centre after 9am. At 8.30am I was getting bored waiting for some action, so I pretended to be a patient. I walked into the waiting area, coughing and spluttering into my face mask, showing signs of being short of breath.

Nurse Kassy washing her hands in the Mother and Child Health clinic

The health worker at the registration-cum-triage desk stared at me for a moment, then burst out laughing, “Doc’s got covid, doc’s got covid!”

“What are you going to do with me, then?” I asked.

“We will do your vital signs and write them in your book,” said the health worker.

“Using the same thermometer as you use for everyone else, the same blood pressure cuff, examining me at the same table?”

“Ooohoooh,” (the timbre of this expression goes up in the middle, then down, signifying now I understand)

“We must isolate you from the other sick patients,” said one of the student counsellors who is working at the centre.

“Where?” I asked.

“You must go to the male ward. I’ll get the nurse to see you there,” she said.

“But are there any patients in the male ward already?” I enquired.

“Yes, there’s an old man with high BP being treated with bed rest,” she replied.

“Knowing what you know about covid-19, do you think that would be a good plan?” I asked.

“Why not?”

“Because covid-19 is more dangerous for older people, especially men and especially those with pre-existing conditions such as hypertension,” I said.

“Ooohoooh,” she replied. “I will ask my supervisor.”

The senior clinical officer appeared on the scene and said that I should be isolated in the new building behind the maternity block where pregnant women stay if they are due but not in labour.

The room reserved for pregnant women who are not in labour, and future covid patients.

“And how will you treat me?” I asked her.

“The treatment is to give oxygen,” she said.

“But we don’t have any,” I replied.

“Yes, that’s right. But the treatment is oxygen.”

I have come across this mismatch between theory and reality on several occasions. Health workers are able to manage the cognitive dissonance of the situation. We know what should be done, but we can’t do it, so there’s nothing we can do.

“So how do you know that I have covid-19?” I asked.

“You are in a high risk group as you have travelled from overseas.”

“But that was nearly a month ago. Surely I would have fallen ill before now if I had contracted the disease in the UK or on the flight out to Zambia,” I said. “How can you distinguish covid-19 from a chest infection, influenza or a common cold?”

“We do a test.”

“But there are no tests available in the health centre.”

Indeed, there is no easy way of diagnosing covid-19 without a specific test. But there are several indicators which might tilt the balance in favour of covid-19 rather than another respiratory infection. I explained about covid-infected patients in the UK who lost their sense of smell and taste. A dry cough, rather than a productive cough, points towards covid-19. We went through other suggestive symptoms, such as lack of appetite, fever, shortness of breath and fatigue. But chest pains, tummy upsets, and runny nose are less sensitive indicators.

At night, I can hear a strange cry coming from a spotted “laughing” hyena. It is more like a croak with a bit of wheeze. We joke that the hyena has covid-19.

Judging by the look on their faces, I could see that the difficulty of diagnosing covid-19 without a test was beginning to sink in.

“But every day we see lots of patients with upper respiratory tract infections. We are not isolating them,” said the student-on-placement.

“So what do you do with them?” I asked. “We have no broad-spectrum antibiotics and are running low on paracetamol. And even Piriton.” This was teasing them about the standard management of the common cold.

“If they are not very ill, they should go back to their home and self-isolate,” said the clinical officer.

Southern Ground Hornbill. He lives on lizards, snakes, fledglings, beetles. He walls up his mate-for-life in a hole in the trunk of a tree until their eggs are hatched.

“And what about the other people in their household? Should they also self-isolate? Or only if they have symptoms?”

“These people are often daily paid (they only get paid if they do a day’s work) or farmers who need to work outside the home. If they don’t work, they don’t eat. They don’t have savings to tide them over.”

“And what if they become more unwell? Will they return to the clinic for help?”

“They should not come back here if they are ill,” said the clinical officer. “We will send them away.”

“But they might not accept that. They could decide to get a taxi to go to the hospital, spreading the disease as they go.”

“We could keep them in the pregnant women’s quarters until the get better.”

“Who will look after them there? Do we have protective clothing?”

“Yes, we have about four disposable gowns, boots and visors,” said the clinical officer. “We had the training some months ago. We know how to put it on and take it off.”

“And you haven’t forgotten?”

“One nurse will stay with them all day, so she can keep the protective clothing on all the time.”

“In September and October, it gets extremely hot and humid before the rains come in November. How is she going to cope wrapped up in PPE?”

Hippos don’t practice social distancing.

“There is an isolation ward just outside Mambwe (less than an hour away by car) where we can send people who are unwell and we cannot manage them,” said the clinical officer.

This was news to me. “Is it equipped and ready to receive patients? Is oxygen available there?” I asked. No one knew.

I told them that the District Officer of Health informed me that any extremely unwell patient requiring oxygen and possible ventilation would be transported to the new hospital at Petauke. I had driven past this brand-spanking-new hospital the day after I arrived in Zambia. It was locked shut.

“How will we know if it has arrived in our locality?”

“We will probably see a cluster of cases, possibly unexplained deaths.” In the capital, Lusaka, people who have been very ill have avoided coming to the hospital for treatment. Perhaps they think that if they didn’t have covid-19 before, they would certainly get it when they were admitted to hospital. Their relatives would bring them to the hospital when they were moribund, and many of the first positive covid-19 tests were done posthumously – BID, brought in dead.

“So, what should we do?”

“Pray!” The nurse in charge of the heath centre is a pastor in the Bread of Life Church in Mfuwe.

And wash your hands, wear masks in enclosed spaces, keep socially distant from others, stay indoors if you have any symptoms, and, yes, pray.

Morning sun over an island in the Luangwa River.
Categories
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.