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Medical Thursday Doors Zambia

Hypertension 1

Pulpation Room sounds like where wood chips are crushed to manufacture paper. It is actually a private area where midwives can examine pregnant ladies’ bellies. As well as being my door of the week, for Thursday Doors.

“I’ve got BP, doc,” said the elderly man lying in the ward. “So why have you admitted this patient?” I asked the nurse. “He has BP, doc,” she said. “We all have BP, otherwise we would be dead,” I answered. “Having blood pressure means that blood and oxygen can get to our vital organs. Why did he come to the clinic? Usually hypertension doesn’t cause any symptoms unless it’s very high.” The patient intervened, “I’ve got problems passing urine, doc. It doesn’t come out as quickly as it used to, it stings and I needed to get up to wee four times last night.”

A Hadeda Ibis having a bath in Mbomboza Lagoon

“So let me guess, when they did your vital signs at the registration desk, they noticed your blood pressure was elevated, so they sent you to the ward to rest, in the hope it would come down?”

“Exactly,” said the nurse. “Well, lying down and resting will reduce blood pressure, but it isn’t a useful treatment for everyday living.” The nurse agreed, but said that she couldn’t send him home if his BP remained high. “But what about the reason he came to clinic?” I asked. The nurse said that she reckoned this was “prostate”. I agreed that this was a likely diagnosis in a man of his age, but was there any way we could find out more? I had in mind the International Prostate Symptom Score, a screening tool checking different aspects of prostatism. “Yes,” said the nurse, “I did a digital rectal examination. It felt big, but I don’t know what a big prostate feels like, really. Can we do the rectal examination again together, so you can teach me?”

Pied Kingfisher, an all year round resident in the South Luangwa National Park.

I was immediately taken back to my days as a very junior hospital doctor. “If you don’t put your finger in, you’ll put your foot in it,” an aphorism that is burned into my cerebral cortex. If I had not done a digital rectal exam on a patient, I would surely be asked about my findings by the consultant leading the team. But here was a nurse volunteering that she had been proactive. I was very impressed. Then I thought, did she do the rectal exam before or after she had checked his blood pressure?

I glanced down at the patient who was looking alarmed. I thought for a moment and decided we could postpone the digital instruction for a week. Three rectal exams in one day would send anyone’s blood pressure through the roof. I told the nurse I would get hold of some guavas of different sizes and practice. I suggested we check a urine sample, which showed signs of an infection, so we treated him with antibiotics.

“But what about the hypertension?” I asked. “He is already taking a calcium channel blocker, but it isn’t controlling his pressure,” she replied. “What other drugs could we use, perhaps one which would help him pass urine more easily?” “A diuretic?” she answered. “Yes, that would make him produce a lot of urine, but his problem is getting it out. Any other drugs?” “Beta blockers?” she ventured. “I was thinking of trying an alpha blocker, which might improve the flow of urine and his blood pressure.” “Never heard of it,” she replied.

Dawn over the Kapani Lagoon, 100m from my house

We made a plan: treat the infection, continue his normal blood pressure treatment, see on Friday next week when we are both in the clinic, recheck his blood pressure, urine and prostate, in that order. He didn’t show up.

Dorcas was 84 years old and had suffered from “BP” for the past 15 years. Muzungu doctors had wrestled with her hypertension without managing ever to get it under control. I read through two tattered school exercise books which serve as patient-held medical records. I suspected that the reason for poor control was the lack of consistent supply of antihypertensive drugs at the clinic. Indeed she admitted that she had run out of medication (so had the clinic) and couldn’t afford to buy more. She was lying in the female ward, resting.

I never tire of watching baboons. But I get fed up with them fighting on my tin roof at 6am each morning.

Ward rounds are good teaching opportunities. I asked the nurse what she might expect to find when examining someone with long term uncontrolled hypertension. “High BP,” she said. “But what might be the effects of high BP?” She didn’t want to guess, so I prompted her. “Why do we try to control blood pressure?” “To stop heart attacks,” she said. “Great, so what might you find when examining her heart?” “High BP.”

I realised I was going to have to go back to first principles. “The heart is a muscle. It pumps blood. The stronger it pumps, the higher the pressure. So do you think her heart muscle will have been affected by chronic hypertension?” “Yes,” she said. OK, how could we detect this? She didn’t know, so I asked her to look at Dorcas’ chest. I could see the apex beat, bouncing away almost in her axilla. Then I asked her to feel for the heartbeat. She correctly located it and described it as “forceful”. “What you can feel is the bottom of the heart tapping on the ribcage. It is typical of left ventricular hypertrophy. Try listening to the heartbeat.” She told me she didn’t have a stethoscope. I offered her mine, “Share my earwax, if you dare.”

We discussed the two heart sounds, and how much louder the second sound was: lub-DUB. As I explained where to place the stethoscope on the chest to hear blood flowing through the heart valves, I noticed a pulsatile swelling just to the right of her upper breastbone. Her swollen ascending aorta had distorted the chest wall. The most likely cause of this would be an aneurysm, following decades of untreated syphilis.

I am not sure that it would do any good at this stage, but we treated her with penicillin injections. No heart surgeon would want to operate. Although her aorta was swollen, the wall would be thinner than normal and could burst at any time with catastrophic results.

The more you look, the more you find.

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Zambia

Leopards and other dangerous creatures

The general manager of one of the nearby safari lodges decided to have a team-building, morale-boosting trip to the National Park for sundowners on Sunday. (It is traditional to find a pleasant spot to watch the sunset while enjoying a drink, hence the term sundowners.) Seven of us drove into the park at 4.30pm, planning to meet up with friends at 5pm on the open plain of WaMilombe.

I really enjoy being driven in an open, high vehicle. The view is so much better than the view from the driver’s seat in the doctor’s car and I can concentrate of seeing animals, instead of trying to avoid potholes. The Luangwa River spills over into WaMilombe during the rainy season, creating a vast, shallow lake. Mud from the river fertilises the soil, creating rich grassland, perfect for herbivores. The floods recede, draining away into streams which carve deeply into the muddy soil, creating excellent cover for carnivores hunting the herbivores. This makes WaMilombe popular with leopards, and people who want to view leopards in action.

The plain is bordered by ridges on two sides, the Luangwa River and its dried-up tributary, the Mushilashi River. Leopards like to rest in trees on the ridges, while they look out for their next meal. Normally, the plain is dotted with antelope, puku and impala, but this evening it was empty. A solitary game drive vehicle was stationary under a tree close to the Luangwa. Game vehicles only stop for refreshments, toilet breaks and when there is something interesting to see. We decided to take a look.

Leopard 1
Leopard 2
Leopard 3

Stretched out in the shade was a beautiful young leopard. We stopped ten metres away and took photographs. The leopard wasn’t interested in our interest. Its belly looked full. The driver of the other game vehicle said that there were two other leopards over by the ridge. As we crossed a deep dried out stream bed, we disturbed another leopard, who trotted away from us, towards the trees. Our driver could see another leopard hiding below the ridge, so we went to get a closer look. As soon as we began to observe leopard 3, leopard 2 sauntered over to leopard 1. As it approached the shady tree, the leopard speeded up, and ran up the tree trunk.

Leopard 2 crossing open ground in WaMilombe, going for second helpings

We realised that there was something attracting leopard 2 to the tree, so we returned and parked under the branches. We could seen the fresh corpse of an impala, draped over a thick branch. Leopard 2 was partially hidden by leaves, but we could see and hear it eating. I wasn’t expecting a sac of antelope intestines to plummet from the tree, just missing by inches the only vegetarian in our vehicle. Partially digested grass and manure splattered against the side of the truck. Leopard 1 decided to capitalise on this good fortune by picking up the guts and returning to its favoured position by the trunk of the tree.

Leopard 1 likes tripe
Leopard 2

Both leopards gorged on the remains of the impala while we watched. The sun began to set so we left the feast and drove to the bank of the Luangwa River, where we could safely get out and have a drink. The sunset was magnificent, but not as impressive as the afterglow which lingered in the sky for twenty minutes, getting deeper and deeper red. I took a selection of photographs of the sky reflected in the river as the light faded. Hippos started leaving the river to eat grass during the night. We could hear baboons giving alarm calls on the other side of the river, but we couldn’t spot another leopard in the gloaming.

Hyena in the headlights

When it was pitch black, we drove back to the leopard tree. A hyena was lolloping about, hoping for some titbits to fall from above. I got a poor photograph using the headlights to illuminate the scene. We were a mile from the park gate when a large grey shape appeared in front of us. I could pick out four elephants, munching away on trees. We drove carefully past and joined the main dirt road leading to the gate. The driver slammed on his brakes, creating a cloud of dust. “There was a puff adder in the middle of the road back there. I’m going to reverse, let me know I am not going to run it over.”

Puff adder

The lighting conditions were very poor, but the puff adder was clearly recognisable, as a short, fat snake, with a triangular head and typical diamond markings on its back. It might look fat and sleepy, but that’s its modus operandi. It stays still, waiting to attack with one of the most rapid strikes of any snake. Its venom causes massive tissue damage. Not the sort of snake you want to step on during a walking safari in the bush.

About a kilometre from my house, we stopped again to allow a lion to cross the road. Bush highway code: animals have priority on these tracks. As we waited for a second lion to emerge from the bush to join its sister, I reflected on how fortunate it was to be able to see these savage beasts in their natural environment. And we had just popped out for a couple of hours on a Sunday evening for a social drink with friends.