Medical Zambia

Clinical Titbits Two

On my first day at the clinic we had a patient with a ripe abscess which needed incision and drainage. My colleague is a clinical officer, but she hasn’t had much practical experience at doing procedures. She previously worked in hospitals where a doctor would often take over if she felt unsure. I told her that I would tell her what to do, standing by to assist if something went wrong. Reluctantly, she agreed and went off to prepare a tray for the procedure. I realised that she was dragging her feet when she didn’t come back for 15 minutes.

Juvenile Puku looking cute with eyelash extensions

There was no local anaesthetic, but the abscess was about to burst so the skin was very thin, easy to cut without much pain. She cleaned the skin and started fiddling about with the single-use scalpel. This has a plastic cover over the blade which prevents the instrument from being used twice. She managed to trigger the mechanism before stabbing the patient, so I had to break the plastic to enable her to use it. She was very nervous and said she couldn’t do it. I offered to hold her hand and direct where to cut, but it was no use. Eventually, I agreed to do it and asked her to stand by with a kidney dish to collect the pus. She didn’t want to get too close. I plunged in the blade and a spurt of pus missed the dish, landing on her shoes. She wasn’t pleased with that result and resolved to be more resolute.

The next boil was on the scalp. Now scalps have tough skin and need a firmer approach. It was smaller and she had previously prescribed antibiotics, which hadn’t stopped the boil from forming. This time she was determined to do it herself. But she couldn’t bring herself to use the requisite amount of pressure. She kept stabbing repeatedly, causing the patient a lot of pain. “Be bold,” I said, “Just do it.” And to the relief of the patient, the next cut released the pus. (If any of you are cringing at this point, and wondering about local anaesthetic, we only have one bottle and that is reserved for obstetrics.)

Knob-billed duck splashing about in the lagoon

My colleague has taught me a new technique for removing foreign objects (beans, beads, stones) from nostrils. I would have formed a hook with a blunted needle and tried to claw back the object. Her solution was much more elegant. She removed the inside of a biro and put the external plastic tube inside the unblocked nostril. Then she told the child to close his mouth and she blew in the tube, causing a bean to shoot out. Excellent trick. I will certainly use this in future.

We have been working on consultation skills. She can be rather abrupt at times. “Are you a virgin?” she asked one teenage girl. When the girl said yes, she replied, “Are you sure?” I began to wonder how she might not be sure.

Mother teaching her baby survival skills

I prefer not to see patients by myself. My Cinyanja is extremely limited to 20 phrases and I don’t want to restrict myself to the privileged few who speak English. It is more educational if I see patients with the clinical officer. She consults and then I help her to sort out the problem in a logical way, translating for me at times. Sometimes, she hands the consultation completely over to me, for example, older men who complain about “lacking power”. With them I ask the usual questions, screen for heart disease and diabetes, then recommend that they try sildenafil, or Viagra. I have seen this at the local pharmacy as an orange-flavoured sachet. It’s a hot seller but it isn’t cheap.

The community health workers are very interested in my being a bachelor/widower. Some of them remember me from 2014 and don’t understand why I haven’t taken a wife. They offer to provide me with a Zambian wife, as “all men need a wife“. To satisfy their needs. I told them that I didn’t have any needs, I’d rather have a cup of tea. They burst into incredulous laughter at this and insisted that I did have needs which only a Zambian woman could awaken. I told them that my kit was “out of service” and had a “flat battery”. “Oh, don’t worry, doc, I know someone who has a beautiful battery charger!” As the investigative sleaze reporter in the now defunct News of the World used to write, “I made my excuses and left.”

Great white egrets having a punch up over a territorial dispute

One of the expats in the Valley was driving along the main road at about 11am and saw a schoolboy collapse. The nearest ambulance is an hour away, so she pulled over, lifted him into the passenger seat and drove him to the health centre. He did look rather poorly, but his rapid diagnostic test (fingerprick, takes 10 minutes) was negative for malaria. I don’t know whether it is a sixth sense or just experience of having seen thousands of cases of malaria, but the child LOOKED like he had malaria. Instead of just prescribing a few paracetamol, I insisted that the lab technicians examine a thick blood film. This is tedious and takes a lot longer, but it is more sensitive. They found the ring forms of falciparum malaria and he got the correct treatment. My colleagues don’t often deviate from “accepted practice”, perhaps because to do so would open them up to criticism. They lack confidence in their own judgement sometimes.

Having an epileptic seizure in later life is not good news. In the UK I would be thinking of a space-occupying lesion, but here in rural Zambia, my first thoughts were of infectious diseases. Could he have tuberculosis, a brain abscess, cerebral malaria or even cysticercosis? I asked the family a few more questions and it turned out that he really enjoyed eating pork. I am not certain, but I suspect this might be pork tapeworm cysts in the brain (cysticercosis). Without sophisticated investigations I cannot confirm this diagnosis, but if he has another seizure, I will offer him treatment with an anti-parasite medication, covered by a course of steroids (to avoid an inflammatory reaction in the brain to leakage of the cyst contents).

Last month, I saw a very elderly lady who is a regular attender at the health centre. She is very weak, anaemic and thin. Her muscles are wasted and her limbs are like sticks. The family keep bringing her for some medication to make her strong again. When I examined her, she had no teeth. She couldn’t chew food. All she could eat was maize porridge. The treatment was nutritious food cooked in a way that she could swallow it. No drugs, doctor? Well, I succumbed and prescribed a short course of multivitamins and iron tablets.

Another striking young lady

I was helping out at the family planning clinic recently when a striking young woman marched in. She was wearing tight, day-glo purple shorts and a figure-hugging pink fluorescent vest. This is certainly not the usual attire of women in rural Zambia. Virtually all of them wear a wrap-around skirt called a chitengi, which hides their legs and (sometimes) disguises their buttocks. Their tops are very functional, allowing a breast to be howked out to feed a hungry infant. At first all the other traditionally-dressed women in the queue were silent and in shock. Then they buzzed with indignation at this hussey who was flaunting her body at the clinic. The young lady received treatment and marched out, seemingly oblivious to the stir she had caused.