Categories
Life Medical Zambia

The Good, the Bad and the Ugly

Il buono, il brutto, il cattivo – starring Clint Eastwood, Lee Van Cleef, and Eli Wallach

Working today at Kakumbi Rural Health Centre wasn’t really like being in a Spaghetti Western. The variety of clinical conditions cause me to feel joy, sadness, anger and despair, but this would not have been such a good title.

Not a pretty scar, but at least the ulcer has healed

The Good. I have written about this little girl with sickle cell disease in the past. She had a nasty ulcer on her thigh which stubbornly refused to heal until we started daily wound toilet and dressing. Slowly, it began to heal. She stopped screaming when she saw a nurse or doctor because she could see how the ulcer was responding and she became my friend. I hadn’t seen her for a month or so, but she turned up today to get her monthly supply of folic acid (to help produce replacement red blood cells), penicillin tablets (to stave off infection) and anti-malarial prophylaxis (patients with sickle cell disease are prone to more severe attacks of malaria). Sadly, we have run out of folic acid (even for the first trimester in pregnant women), stocks of penicillin have been exhausted and we have never stocked Maloprim. She ate her breakfast while waiting for the pharmacist to tell her we had no drugs to give her and smiled at the camera. Isn’t she beautiful?

Deep wound from hippopotamus bite, healing slowly but well.
Peek-a-boo behind the bushes, a hippo out of water.

The Bad. This man was bitten by a hippopotamus three weeks ago. Bad because he was acting badly when he was attacked by the hippo. He is a very lucky man; most hippo bites are fatal. The wound was debrided and allowed to heal from underneath (by “secondary intention”). This needs a bit more tidying up and he will have an impressive scar, but he has lived to tell the tale.

Crocodile bite. Shiny, tight skin. The calf is full of pus in the deep tissues.

The Ugly. Late yesterday afternoon, a man was fishing in Kapani Lagoon. He had probably bought “muti” from a sangoma – a magic potion which allegedly prevents crocodile attacks. It didn’t work in his case. He was bitten on the left leg and came to the health centre after normal working hours. Unfortunately, the nurse on duty sutured the main gashes and prescribed antibiotics which were not available.

Crocodile bite – thigh. Deep wounds, sutured in error, now with necrotic muscle visible in the base.

Twelve hours later, he could not walk and had to be carried into the health centre. My colleague, the clinical officer who doesn’t like pus, asked me to sort him out. His leg was swollen and the skin was shiny and tight. The sutures needed to be removed. We have no scissors, so I had to do this with a pair of forceps and a scalpel blade. As soon as I snipped the first stitch, there was a mosi oa tunya (Victoria Falls) of putrid, orange-brown pus which burst from the wound. It stank so much I gagged. It reeked of rotting fish. Crocodile oral secretions are renowned for harbouring multiple pathogenic bacteria. I have never smelled a croc’s breath, but the pus probably smelled like crocodile halitosis.

The second wound I opened up had a different odour, sweet, sickly and fetid. The pus was watery and had bubbles in it. Looking deep into the wound, I could see the muscle had turned brown and black in parts. This is wet/gas gangrene, clostridial myonecrosis (dead muscle). This patient needed urgent surgical debridement, cutting away all the dead, infected tissue. Without a general anaesthetic, this is beyond my skill level. I knew that funds were really tight in the district and there was very little diesel left in store. We begged for an ambulance and were rewarded. I hope that I see him again before I leave and that his leg has been saved.

Because I am morbidly curious, I asked him how big the crocodile was. Like any fisherman, he extended his arms about a metre apart. “That small croc did a lot of damage,” I said. He replied, “No doc, that was the size of its head!”

Categories
Medical Zambia

Sickle Cell Anaemia

I have seen more children with sickle cell disease during this stay in Zambia than my other two tours. It is a miserable, dreadful disease.

It is a genetic disorder of haemoglobin which alters the biconcave disc shape of red blood cells into a crescent or sickle. Being an autosomal recessive condition, a sufferer needs to inherit a sickle gene from both parents to be severely affected (HbSS). Only having one gene (sickle cell trait, or HbS) causes no problems (unless the oxygen level of the blood is reduced) and confers some protection against malaria. (This may be why evolutionary pressure has not eliminated the disease.) Paradoxically, patients with sickle cell disease (HbSS) are more susceptible to the dangerous form of falciparum malaria which can be fatal. 

Fetal haemoglobin (HbF) helps to protect babies for the first six months of life, but as HbF disappears, the affected child starts to become symptomatic. The abnormally-shaped red cells clog up the micro blood supply to bone marrow, causing acute and long-standing pain in the bones. The deformed red cells cannot revert to normal and they burst or haemolyse. The child becomes anaemic with less than 50% of the amount of haemoglobin as a child without sickle cell disease.

The sickling blood cells are filtered out by the spleen, which grows in size and then becomes destroyed as its capillaries clog up. The spleen is the location of immunological memory cells, which are lost when the spleen infarcts. This makes the child more susceptible to bacterial infections, especially streptococcal, meningococcal and salmonella (typhoid) infections.

Sickling cells also damage the lungs, causing chest pains and difficulty breathing. A stroke can result from sludging of red blood cells in the brain.

The child’s growth falters and the child is often stunted. Leg ulcers are a common complication which are very slow to heal.

Sickling crises can occur spontaneously but may be precipitated by lack of oxygen, dehydration or altered body temperature.

At the health centre, on Fridays, the laboratory runs a batch of tests for sickle cell disease. A drop of blood is mixed with a reducing agent to take away oxygen, which causes the cells to change into their classic sickle shape, seen under the microscope. Unfortunately, we have run out of reagent to do this test, so we have to send suspected children to the nearest district hospital, an hour away by bush taxi.

There is no cure for sickle cell disease apart from a stem cell transplant – but this is not an option in Zambia. We can correct the anaemia by blood transfusion, but this may only last a few weeks. We avoid giving iron tablets because of the risk of iron overload from frequent transfusions. Sadly we don’t have any stocks of folic acid, which helps red cell production. At the time of writing, we don’t even have paracetamol to treat painful crises. We do have polyvalent pneumococcal vaccine.

This is another condition where we can make the diagnosis but offer only limited symptomatic treatment with no hope of a cure. Most of our patients will not reach adulthood. It makes me feel depressed and impotent.