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Life Medical Thursday Doors Zambia

Thursday Doors – A Great Start to the Morning

I had an appointment to see a patient at 8am, so I arrived 10 minutes early to be properly prepared. The health centre was very quiet, with no out patients in the waiting area, and just a few mothers with their babies outside the Mother & Child Health Clinic (MCH). With the temperature at 15C, it was pleasantly cool for me, but for the Zambians it felt like winter. It is winter for them.

Gradually the health centre staff arrived, first the cleaners to sweep away the dust of the previous day and night. The nurse on night duty came to hand over to the day staff but there had been no events which needed following up.

Because of the nationwide shortage of BCG vaccine, we wait until there are at least 12 neonates present before opening the 20 dose ampoule. It is a tricky vaccine to give, just into the top layer of the skin, 0.05ml. Most of the women were waiting for this for their babes.

I saw a mother with her seven-day-old baby sitting outside the MCH clinic. The baby was wrapped up in a blanket, with just the face visible. Mother was obviously very proud of her baby and wanted to show it off to me. I asked if I could take her photo and she willingly agreed. (I offer to send photos which I have taken via WhatsApp to people who have smart phones, and she was delighted with the picture.)

Promise

I asked her for the name of her baby and she said what I thought was “Premi”. I immediately jumped to the conclusion that the baby had been born prematurely. I agreed it was a catchy name and asked her how early the baby had been born. She looked puzzled and said that the baby had been born on time. “So why did you call her Premi?” I asked. “It isn’t Premi doc, it’s Promise,” said one of our volunteer health workers.

We have two counselling students on placement at the centre. I teased this young man about his Adidas knees – perhaps he was speed praying.

In the meantime, the patient who was supposed to be at the health centre at 8am had turned up at 8:25am. After the consultation, I looked around for the rest of the team accompanying me to the community clinic at K.

We had a discussion about the lack of childhood vaccines. The District HQ allows us a limited number of vials of vaccine each month. This strict control avoids excess vaccine being left at the back of the refrigerator and going out of date. But this “just in time” supply system can cause problems if we mistakenly order less vaccine than we need. There is no back up.

“We will need more vaccine for Thursday,” said D. “Can you drive to HQ and pick it up for us?”

I said that this wasn’t allowed according to my terms of service. The health centre was supposed to be able to arrange monthly deliveries of supplies. There were vehicles coming to Kakumbi from HQ and these could replenish our stocks. Then D asked me if I could supply fuel for the health centre motorbike to make the trip. This was just $5 but I decided to wait and see if they came up with another solution before I dipped into my pocket.

“We didn’t get enough needles and syringes, either,” said R, the senior MCH nurse. Last week, we had been forced to use 5ml syringes and separate needles instead of the prepacked 2ml syringes with needles.

“And I found vials of vaccine which had been partly used, returned to stock. These should be used up within a few days. There should be a date on the bottle,” complained R. She made sure that these vials were the first to be used at the community clinic.

Last week, one of our volunteers in the furthest village we serve asked to consult me about a personal medical problem. I agreed to do so the following day, but ended up having to cancel at the last minute. I felt guilty about this, so I after I had dropped off D at the scheduled clinic with the vaccine and paperwork, I took R with me to interpret during the consultation with the volunteer.

We met the volunteer at the roadside and she got into the vehicle to direct me to her house in the village. I parked in the shade of a tree and we went inside her small mud-brick home. It was very simple and plain, with a table, three chairs and some bedrooms leading off the main room. There were drapes over the doorways, but no doors. The corrugated iron roof was gaping at the apex, allowing a ray of bright sunshine to penetrate the dim interior.

I took her history and examined her. I thought her symptoms could be caused by muscle spasm in her shoulders and upper back, so I palpated this area and felt knots of muscle. When I massaged the tender parts of her trapezius muscle, she became uneasy. I asked if I was hurting her, but she said no. I wondered if it was because doctors and nurses do not often touch their patients when examining them. I moved on to take her vital signs and used an ophthalmoscope to look into her eyes. I could not find anything seriously wrong, so I asked her if there was anything troubling her, and stress or worries.

Immediately she began talking about a family dispute which had upset her greatly. I said that sometimes when doctors cannot account for a physical pain, it might be caused by mental upset and distress. As R explained this to her, I saw her head nodding. She seemed happy to wait and see if her symptoms got better.

As we got into the car, R told me I had made a social faux pas. “Doc, she was uncomfortable when you were examining her shoulder muscles. This is what men do when they want to get their wives ready for sexual relations,” she said.

We drove back to the community clinic. It was busy with mothers and children, with part of the location having been commandeered by brick makers. Two men were digging clay in a deep pit, filling a wooden mould and turning out blocks. There must have been a kiln in operation as some of these bricks had been fired. I took some photographs, joking with the workmen that they must be building a swimming pool. They didn’t understand this, so I changed the joke from a swimming pool to a fish pond.

This clinic is the busiest in the region. Last month, we reviewed 198 children, checking their weight, monitoring them if they had been exposed to HIV prior to delivery and with breast feeding. We monitor the children’s weight and development, primarily to detect those who are sick or malnourished. In fact, more children are overweight than underweight. About 10-20% of the children are due for immunisations.

Many of the mothers use the occasion to show off their clothes and their children’s fashionable outfits. There is competition between the mums as to whose baby has put on the most weight. I can’t speak Kunda, apart from a few words for diseases and parts of the body, but I could overhear enough English words in their conversation to understand what they were chatting about as they compared their children’s growth charts. “My baby has gained more weight than yours!”

194 children later, just after midday, we finished. One mother brought her baby right at the end. I didn’t like the tone of the voices admonishing her for coming so late, so I went over to her and found out that it was her first baby, born less than a month ago. Her baby would have to wait for BCG until next month, when she could also get the first vaccines. She didn’t have an under 5s card, but had brought a school exercise book, so I entered her child’s demographics and weight and the vaccine schedule on the first page. “So the father is Rabson Zulu, and the baby is also called Rabson Zulu?” I asked. The volunteers behind me shouted out, “Call him Junior!” OK, Rabson Zulu jnr it is.

D is posing with our trusty village volunteers who help to run the clinic.

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Medical Thursday Doors Zambia

Thursday Doors at School

Zambia’s National Immunisation Schedule is very similar to that in the UK. After three injections in infancy against tetanus, there is a booster at school entry and another for school leavers. This isn’t so good for children who don’t go to school, but you have to cut corners sometimes. And children who have to repeat their first year may end up getting an additional jab.

We have been doing the fourth and fifth tetanus (with a small dose of diphtheria) in the local schools over the past few weeks. My job here is to help, support and assist, not to take over the programme. We sometimes end up running out of vaccine or syringes, bringing the wrong kind of syringes (BCG syringes are just 0.05ml, the other vaccines need 0.5ml syringes), forgetting to inform the school that we are coming or have had to alter the date. But we got the job done. I don’t know the precise figures, but we vaccinated about a thousand school children.

Door on its side

Here is a door in a classroom in Mfuwe. It may have been taken off its hinges, or it might have been pushed off by the scrum of schoolchildren crashing through the doorway. So this satisfies inclusion of this post in Thursday Doors.

The health inspector in charge of the programme has not been trained in vaccinations. I asked the nurse in charge of the clinic if it was ok for me to train the health inspector and he said he thought it was a good idea. Now in mass vaccination campaigns, speed is of the essence. You don’t take your time slowly inserting the needle, pulling back, injecting, then looking around for a cotton wool ball to place over the injection site.

It took some time for the health inspector to gain confidence, but after a couple of schools, he was able to inject at speed.

Drawing up the vaccine

Now some of you may have seen a clip on YouTube of a paediatrician playing with a baby before he vaccinates them. This looks marvellous and the doctor is to be congratulated. However, he isn’t trying to vaccinate 200 children in school without their parents being there to comfort and support them. This calls for military-like precision. You line ’em up and jab them.

We had a gang of young men and women who volunteered to help with the school campaign. They did some health education while I was injecting. They helped fill the syringes, recorded the children’s names and wrote out vaccination cards. One young lady’s help was invaluable when dealing with youngsters. They would fling their arms around her thighs, she would cover their eyes so they couldn’t see the needle, she would distract them by asking them questions and she made sure their left upper arm was immobilised.

Last week, there was a thunderstorm brewing and I started vaccinating as the rain started. Lightning flashes at the same time as injections was a double whammy for the children. My assistant was brilliant in this situation.

Ouch!

Sometimes the children would not feel the vaccination, other times they would jerk when the needle entered their skin. On a few occasions, this led to the needle going in deeper and hitting bone. Older girls could become hysterical and if we didn’t deal with this properly, it could become infectious, with all the students panicking.

Lining up for vaccination

We hadn’t reckoned on schools having a two shift system, with some pupils coming in the morning, and the remainder coming in the afternoon. I would return to the clinic, see patients about whom the nurse wanted my opinion, then return to the school.

Health education

We need to give the students a booster in a month’s time. The nurse in charge of the clinic felt that the students should come to us for their boosters, but this would overload the clinic with the risk of students being unwilling to wait and leaving before they had had their jabs. I suggested that we go back to the schools and do the vaccinating there instead. We all agreed that this was a great idea.