Diagnosis
Written by: Keith and Ginny Birrell
Highlight of the week: Two become three as Joel joins the Kapani set
Lowlight of the week: Elephants claim a 5th victim
Maximum temperature: 38 degrees Celsius
Rainfall: Only in our dreams
It seems important. Putting sick people into categories. Giving them labels.
Clinicians love a diagnosis. People become patients. With that comes the permission to treat. The possibility of cure.
But the sword is double edged. Cutting both ways. Curing in one direction. Carving up when wielded carelessly. A diagnosis often delivers collateral damage.
This week finds me on the trail of a diagnosis. But the trail is fraught with hazards. The goal illusory. Come and explore with me. I’m working at our new District General Hospital. Velos.
I am really enjoying my mornings at Velos. The new district hospital. I guess I’m an acute paediatrician after all. I’ve worked in the Zambian primary care environment for 4 years. Sometimes it is stimulating. But often my mind wanders. I am not as useful as Keith. He is pulled in several directions every day. Eyes. Ears. Psychiatry. Hypertension. Diabetes. He always seems to be seeing and sorting. General practice is his baby. But even babies aren’t really my baby. I am a little too specialised. Sick children are my thing. And in Kakumbi, they are mostly not properly poorly. Lots of flu. Coughs. Skin rashes. But the staff are now pretty happy to deal with most of this. Their antibiotic stewardship is now pretty hot. The staff dole out small rations of paracetamol. Nowadays, everyone is happy with less being more. Patients expect less drugs. Leaving more medicines for those in real need.
But up at Velos it’s all going on. The threshold for admission is high here. Partly because primary care sorts out the chaff from the wheat. But the bottom line is that people only go to hospital if they really need to. Geography controls the paediatric admission rates, even more than our clinicians do. Nobody has a car. So the rate limiting step for hospital admission is the availability of our single ambulance. Secondary care only takes the crème de la crème. This makes a paediatric ward round interesting and eye opening. Rarities are concentrated. Just what my brain needs. A diet of the weird and the wonderful. Throw in the lack of tests and a limited supply of drugs. And my grey cells can really get stuck in.
Tuesday is our 3rd planned visit to Velos. I arrive on the ward to find the ward round prematurely complete. They forget that I’m coming. But I am now African. I adapt and make a plan. Find a role. Find a niche. Plug away. I help with a difficult cannulation. I chat with staff about shared problems. Pet topics. Challenges. Thorny issues. Pain relief and dressing changes amongst them. A screaming child, the blood curdling backdrop to our conversation. As the morning calms down and the screams subside, we firm up plans for next week's later ward round.
It's 11:30. I go on a Keith hunt. Hoping that he has saved me something that might right up my street. My timing is impeccable. He is looking for me. Gin, come and see this child in the emergency room. His face is swollen. Maybe he has nephrotic syndrome?
I head to our mini-casualty. My brain moves into 2nd gear. I find Peter. Twelve years old. Lying quietly on a bed. Surrounded by concern. The team around him. Two clinical officers. Two nurses. A machine is making an annoying beeping noise. Without a thought, I turn to silence the bleep. But my thoughts suddenly intrude. The numbers make me crash through the gears. Peter is properly sick. His oxygen saturation is 78% on oxygen. His pulse rapid at 120. There is a rabbit away. Or should that be a hare? Whatever. I’m set to chase it. Peter looks chilled. Perhaps too chilled. But with it. Alert. His mother by his side. We start at the beginning. With his story.
Peter has been particularly breathless for 1 week. No cold. No cough. He is not eating well and has some vague tummy pain. No fever. No vomiting. No diarrhoea. No constipation. He reportedly started to swell 2 days ago. His face. His abdomen. His ankles. Prior to this, he seemed well. But mum now admits that for a year he has struggled to walk. Getting a bit tired and breathless. He is doing well at school. He’s a 5th grader. Who wants to work in health.
I look more closely at Peter. In medical school I was taught to start with people’s hands. My clubbing aspirations were not confined to the Stage Door in Newcastle. Clubbing. An indication of serious heart, or lung, conditions. Those conditions do not remain nameless. I reel them off, in those confrontational medical school seminars. Not fully connecting with the personal health challenges owned by the owners of these rounded finger nails. But in my career in paediatrics: only one of my hands has been needed to record the children that I have seen with clubbing. But Peter makes me use my other hand. My hand holds his. To wonder at the convexity. To connect with Peter. To offer him support. But my medical memories break the personal connection with Peter. I now have my hands full with his deteriorating health.
Peter has impressive clubbing. His fingers have small drumsticks on their ends. The like I have never seen. These drumstick beads tells me that his illness has been brewing for some time. Months or years for sure. His pulse is weak. Despite 100% oxygen, his oxygen saturation won’t budge from 80%. He is breathing a bit fast. 28 breaths in a minute. But he is not struggling to breath. No noises. His chest is clear. This is not a lung issue. His heart is sick.
Many of you are medical so I will give you few more clues: his heart is working hard. I can feel it through his chest wall. The right side of his heart is oversized. His heart sounds are interesting. He has a loud 3rd heart sound. No murmur. He has a very swollen abdomen. There is fluid in there. His liver feels big. He has ankle swelling. And facial swelling.
The medical team look to me for answers. I have some. But not the key diagnosis. I announce that he has right sided heart failure. Pulmonary hypertension. His lungs are stiff. The pressure in the lung blood vessels is too high. So his heart cannot push blood into them properly. Each time his heart beats, only a small amount of blood goes through his lungs. A lot of blood takes a shortcut. Probably through a big hole in his heart.
Undiagnosed congenital heart disease. His heart has dodgy plumbing. Scrambled before birth. The blueprints weren’t followed. A decent baby check would have spotted this. Most likely his oxygen levels have been fine for years. But a stethoscope placed on his heart even in those early days would have trumpeted the plumbing issue. If a decent plumber had been called, back in the day, the problem might have been fixable. But more on that later.
Back in present day Zambia we now have some options. Our state of the art, shiny new hospital lets me look inside of Peter’s heart. To see how it’s built and to see why Peter’s heart has gone south. A fancy cardiac ultrasound machine looks at his heart muscle, valves and blood flow. An ECG checks out the heart electrics. Shining a light on Peter’s dark cardiac health. I ask the staff to give Peter some diuretics to nudge his heart in the right direction and reluctantly leave the hospital. My carriage awaits and I can’t risk it turning back into a pumpkin. We have staff to move around the community.
Peter appears to be up a brown murky creek. His paddle is floating hopelessly in the opposite direction. There is nobody willing, or able, to jump out and retrieve the paddle. Despair is our overriding emotion. Keith and I share our very short list of bright ideas as we drive away. We resolve to phone a friend as we stop to pick up our tired, overheated, community staff.
The following day, my phone pings to relay the dark truth inside Peter’s heart. Tetralogy of Fallot in Zambia punctuates lives with too many commas. Pauses for air, in a breathless existence. And a final full stop. Written much too soon.
Peter has undiagnosed congenital heart disease. A problem called Tetralogy of Fallot. A picture I am very familiar with in the UK. Normally diagnosed within hours, if not days, after birth. British babies are sent to a regional paediatric cardiothoracic unit. They may need early surgery. Sometimes they are given medicines until they grow big enough for corrective surgery. But even then: a magical heart operation is performed by 4 months of age. They can usually expect to lead normal lives. Into adulthood and beyond. Paddles in hand. Battling through rapids. Clean water churning under the robust boat that holds them.
Peter’s journey will not be a positive adventure through his short life. He has complications arising from a poorly plumbed and uncorrected heart. We can’t reverse the damage already done to his pulmonary blood vessels. We will never be able to make him pink. His heart failure might be managed. But never cured. He has a very reduced life expectancy. His breathing will get worse. Oxygen unable to get to his brain and vital organs. His body will become water logged. His parents will likely search for support. Better care. Funding to travel. A quest for medicines, an operation. Some hope. But this short essay is likely to come to a heart twisting, premature end.
The diagnosis is now in Peter’s notes. Paper and transitory. Or virtual and subject to network failure. We have no real treatment to speak of. Peter’s diagnosis spells the end of hope in our adopted homeland. Zambia overwhelmed with late diagnoses that overwhelm people and their families.
One lone olive branch reaches out offering solace. Precious gives us hope for Peter. I diagnosed Precious’ congenital heart disease at 3 months of age. (https://keithandginnybirre.wixsite.com/intoafrica/post/getting-to-the-heart-of-the-matter) We wrote about her during our first year in South Luangwa. She lives on, somehow, against poor odds. We plan to see her next month. To chart her unusual Lazarus-style survival. I hope get to a decent picture of her heart now. To figure out the plumbing and to make sure that no stone remains unturned for Precious.
Meanwhile Peter’s plot Peters out. He dies in the night. In the referral hospital 3 hours to our South. The Southward trajectory of his heart complete. The pings on his monitors stop. Full stop.
We wonder at the possibilities of a future Zambia. Where future Peters, born as short stories might be rewritten as epic novels. With new born vigour in a capable health service that includes wonderful hospitals like our own Velos. Could it be possible that Zambia will no longer be the wrong country to be born in with a scrambled heart? Will Zambia be a place where making a diagnosis will really make a difference?
A Testing Time
Written by: Keith and Ginny Birrell
Photo of the week: A new leopard for us - trying to catch monkeys up the tree
Highlight of the week: Close ups with elephants, with no fear
Lowlight of the week: A sick boy with a life sentence
Maximum temperature: 33 Degrees Celsius
Rainfall: Rather dry
The witching hour. Strange medical things that go bump in the night. 02:00 - 04:00. A time best left to the fairies. Not a time for us mere mortals to be troubled. Bizarrely, I have never seen, or been seen, at this time. For the entirety of my career…. So far…. My juniors never needed to call me…..
Evenings in South Luangwa are typically quiet. Gone are our days of raving. Partying ‘til dawn. Going to work on a hangover. Thinking that sleep is for softies. Our middle names are now Responsible. The irrational vigour of youth spent. We crave our due ration of sleep. Downtime part of the mix. Occasional nights out remind us of the heady days of our youth. Yet even those nights fizzle by 21:00. Especially on a school night.
It's 19:30. We have eaten. Taken our antimalarials. Cleared up. Prepared our bags for the morning. It’s wind-down time. I prepare for bed. Crawl under the mosquito net. Read. Chill. The lights should go out at 21:00. But Keith calls out: Don’t get undressed yet. We have work to do.
I’m tired. Bummer. I groan. It has already been a long day. Nowhere near the witching hour. But still, my relaxation plans have been destroyed. Grumpily, I emerge from the bedroom. We steel ourselves for the next bout.
Jack is having some kind of mental health crisis. Can we help? We try to gather more information. We are told that Jack is staying in a camp up the road. He was due to fly out today. But he was too distressed to get on the plane. Could you see Jack? He might need sedation. We do a quick stock check. Oral and intramuscular magic. Cushions for the mind. Medicines that calm and protect. We hop into Mzungu. Our white Hilux. And head toward the camp. Thinking aloud.
Thinking is allowed. Although many clinicians seem to fire from the hip, way too often. A great joy of medicine is the challenge that it offers. No two patients are truly alike. Our shared job as Valley Doc a precious thing. For each conundrum we see things with different eyes. We bring differing views. Approaches. Spin things different ways. Synergistically, not oppositionally. Problems halved or at least shared.
Our journey to see a patient is a crucial phase. Thoughts collected. Approach negotiated. Tasks apportioned. A flexible plan, mapped out. A goal at least. In this way, we arrive with purpose. Our clients see confidence. To inspire confidence. Part of the battle. Anxiety muddies the water. Clarity is needed.
Jack sounds agitated. Clouded thoughts. The product of medical, chemical or psychiatric forces. But we must not jump to false conclusions. Run before we can walk. My task will be to gather information from those around Jack. Keith will aim to engage with Jack.
The phone rings again. There is confusion. Jack is on the move. No longer at camp. His colleagues have taken him to a clinic. But which one? Kakumbi? Or Velos? We stop on the road. Ten minutes triangulating. Velos the new plan. Our drive resumes. Velos is a short schlep. 30 minutes under Mzungu steam.
It’s 21:00. We arrive at Velos hospital in synch’ with Jack. He is sat in the front passenger seat of an open game viewer. Held fast in a caring embrace by a young lady. Settled? We rashly venture. But as we approach, it becomes clear that all is not well.
A flash of anger. Menace. Fearful eyes. Words betray his paranoid state. The car door thrown open. A stare, insistent that Keith should not approach.
Jack’s agitation propels him away from us. Fortunately, the hospital parking lot is a safe space. Well lit. Fenced off and elephant-free. He mutters at nobody in particular. Pacing. His girlfriend heads his way. To shepherd him. At least there is no suggestion of any getaway plan. But Jack’s inner turmoil, and our challenge, won’t be resolved anytime soon.
Whilst our patient mutters and paces, I peel off to focus on my preassigned task. To seek further information from Jack’s colleagues and his partner Lucy. Keith phones a friend. Jack’s best friend. Jack’s brother. Rudi.
No history of fever. No rash. No unusual insect bites. No illness. A four week steady decline in work ability. Change of attitude. Reports of being confrontational. No history of alcohol abuse. No drug use. He hasn’t slept well for the last week. Not at all for the last 24 hours.
Keith speaks to Rudi, one thousand kilometres away. Rudi and Keith share their intel. And then Keith begs a favour: A reference from Rudi that will likely help Keith gain Jack’s trust.
Nothing in the gathered stories suggests an acute medical illness. Nor a toxic response to chemicals. That leaves a psychiatric issue. Acute paranoia. Disturbed thinking, without a physical or so-called organic cause.
The phone is spirited to Jack. Opening an intracontinental dialogue. Initially, Jack’s paranoia puts the kybosh on our preferred way to Jack’s heart and mind. The phone is thrust away. The tarmac impacted by the phone’s resilient case. Strike one. The use of someone else’s phone is eschewed. Not to be trusted. Try harder Doc.
Reaching the end of the opening salvo of our plan: Keith and I reconvene. The plan needs some refinements. Some detail. Some contingencies. Trust is key. A shared plan with patient and docs might involve sleep and calm. Chemically induced calm, for a troubled mind, is best taken by choice. But how do we help Jack to realise that our choice can also be his choice? A photo of Jack’s chosen medicines give Keith an in. Sleepers seem to be an acceptable option. Lucy is tasked to ask Jack if he would like a sleeping tablet. Photo of the week: A new leopard for us - trying to catch monkeys up the tree
Highlight of the week: I find out about the wait-a-bit thornbush. An acacia shrub that keeps predators at bay. Even elephants and buffalo stay clear of its fierce embrace.
Lowlight of the week: The cool of the Zambian summer is over. Our aircon struggles to get with the programme.
Maximum temperature: 38 degrees Celsius
Rainfall: The chance would be a fine thing.
To test, or not to test? That is the question.
The answer might be imposed upon you. It’s 1994. Northern Unguja. Zanzibar. I have 5 tests at my disposal. Malaria. HIV. Haemoglobin. Blood group. Stool parasites. Now what was the question?
Imagine that you are reading my blog from 1994. Malaria is rife. Yet the test is rarely done. HIV is, as yet, rare. And that test is predominantly reserved for donated blood. If a child looks pale, they are pale. A haemoglobin of 2.7 g/dl might surprise you in England. But I am rarely wrong in deciding who needs a transfusion here. Test, or no test. And stool parasites are the rule here, rather than the exception. I treat those that need treatment. Not those that I test.
It’s 1997. We are back in England. Zanzibar is like a hazy dream. A quick backpack trip around the world is now merely a collection of images. Albums that are due to collect dust. I am working in my first registrar post in paediatrics. On a 5 year trajectory to becoming a consultant. Throughout medical school I was indoctrinated with the maxim that 80% of diagnoses could be made from the history. But a panoply of tests challenges my doctrine. Why would all of these tests exist if they weren’t needed? Surely, I should be doing more tests!
I also have a computer. My slave? More likely my master! The screen demands. Expects. Insists. What tests are expected? So many options. A tick in a box. Another test requested. As easy as that. I just need to decide which one. Perhaps just do them all? It’s only one small needle into a vein. A few bottles to fill.
I’m on call with Jonathan. My boss. Not yet a friend. A head appears at the door of the paediatric day unit. Jonathan’s disembodied head seeks permission to depart. Dinner awaits. But his body surrenders an opportunity for an early supper, and leads him right into the day unit. PDU a home from home, for all conscientious paediatricians. Resistance is futile. He offers support. A 3 year old girl is taxing my mind.
She has a mild fever. A red throat. Pink ears. Cervical lymph nodes palpable. Nil else. I think it is a virus infection. But I am toying with doing some blood tests. Because I can. I tell Jonathan I am going to do a full blood count. Why? He asks. I reply confidently: Because if the white count is high, I might give her antibiotics. He looks at me thoughtfully. Do you need a blood test to decide that? What would you have done in Africa? Now that gets me thinking. Just because I can do a test, should I? I go back and look at the child. She is full of snot. Virus is written all over her. What further proof do I need? My clinical skills are good. They have had to be for the last 2 years. Why should a random number influence me? Why do we do tests?
This single conversation guides my route through paediatrics. Steers me. Not off on a tangent mind. But changes my trajectory. Tests have a place. In endocrinology, tests are the mainstay of monitoring and managing endocrine problems. Necessary. Useful. And also in acute situations, they help. Guide. Support. But the key to managing problems is a good history. A thorough examination. Sometimes time. But tests are not a kneejerk response. Any test needs to add value. Some will send you down a convoluted rabbit hole. Harming not helping. Costing and not contributing.
Reflex testing is now part of our NHS culture. Nobody wants to miss that needle in the proverbial haystack. Guidelines have become tramlines. Defensive practice stifles the possibility of clinicians using their clinical acumen. The blunderbuss approach has become standard. And we are all paying for it. No rabbit warren is left unexplored. And the golden goose stays quiet. Why honk when your nest is being feathered by endless, profitable tests?
First, do no harm, Hippocrates advised. Today, he is turning in his grave. His timeless aphorism lies in ruins, replaced by a new mantra: Leave no stone unturned. But in our frantic stone-turning, we’re generating more heat than light - much effort, little clarity, and often, unintended harm. I suggest that we stop turning stones and let Hippocrates lie in peace.
Zambian practice has its virtues. Tests are sometimes present. But geography and supply chain issues ration their use. So time remains my favourite test. Natural history and cold hard clinical symptoms and signs guide us to our holy grail. But progress, of a sort, is marching on. Even in deepest, darkest Africa.
We have our wonderful new hospital, up our single tarmac road. Velos currently houses a number of people with injuries. Including a couple of local men, beaten up by a particularly grumpy elephant. Velos has a beautiful purpose-built lab. Radiology facilities, the envy of any DGH in England. Skilled laboratory technicians. But reagents are like hens teeth in this part of Africa. And for your information our hens have beaks just like yours. So I find myself back in the Africa of yore. Familiar territory. Rejoicing that my 5 tests at least do no harm.
It's Friday. Our Kakumbi clinic is quiet. Keith and I are looking for work. Quite unusual in these parts. I hear a rumour of a sick baby. I gravitate towards the cries. I find Joy. One of our staff members. She is cuddling her son, Martin. He is 18 months old. I had seen him 2 days earlier. Martin had a mild fever. But otherwise he was happy and well. I had advised paracetamol. Joy is now very distressed. Martin has now had a high fever for 24 hours. Paracetamol has brought no Joy to Joy. Nor to Martin. Martin’s fever is still high. There are no other symptoms. No cough. No rash. No runny nose. No sneezing. No vomiting. No diarrhoea. I check him over. He is hot. His temperature is 38.5. He is alert and looking around. But he’s unsettled. Miserable. Not irritable. Martin’s examination is otherwise normal. I have excluded a number of conditions. He has neither malaria nor a UTI. No sepsis. I note that he is fully vaccinated – and had his measles jab 3 days earlier. This seems important.
Then I spot the cannula in his arm. Joy tells me: I came here last night. We have started him on ceftriaxone. Intravenous Domestos. A catch all antibiotic. An understandable approach. Martin’s fever has everyone stumped. On edge and unwilling to miss a treatable rabbit. This rabbit shouldn’t get away. And yet, I know that Martin is not septic. His fever is almost certainly a response to the measles jab. And 16 hours later, Martin’s fever is unabated despite the antibiotics.
Joy remains very worried. Wanting more answers. I think I may take him to Velos. She tells me. Away from the only paediatrician in the District. I don’t say. What will the team there do for Martin? Comes out of my mouth. I could get a full blood count.&nb
Hospital madness - A magician at work
Written by: Keith and Ginny Birrell
Highlight of the week: Close ups with elephants, with no fear
Lowlight of the week: A sick boy with a life sentence
Maximum temperature: 33 Degrees Celsius
Rainfall: Rather dry
The witching hour. Strange medical things that go bump in the night. 02:00 - 04:00. A time best left to the fairies. Not a time for us mere mortals to be troubled. Bizarrely, I have never seen, or been seen, at this time. For the entirety of my career…. So far…. My juniors never needed to call me…..
Evenings in South Luangwa are typically quiet. Gone are our days of raving. Partying ‘til dawn. Going to work on a hangover. Thinking that sleep is for softies. Our middle names are now Responsible. The irrational vigour of youth spent. We crave our due ration of sleep. Downtime part of the mix. Occasional nights out remind us of the heady days of our youth. Yet even those nights fizzle by 21:00. Especially on a school night.
It's 19:30. We have eaten. Taken our antimalarials. Cleared up. Prepared our bags for the morning. It’s wind-down time. I prepare for bed. Crawl under the mosquito net. Read. Chill. The lights should go out at 21:00. But Keith calls out: Don’t get undressed yet. We have work to do.
I’m tired. Bummer. I groan. It has already been a long day. Nowhere near the witching hour. But still, my relaxation plans have been destroyed. Grumpily, I emerge from the bedroom. We steel ourselves for the next bout.
Jack is having some kind of mental health crisis. Can we help? We try to gather more information. We are told that Jack is staying in a camp up the road. He was due to fly out today. But he was too distressed to get on the plane. Could you see Jack? He might need sedation. We do a quick stock check. Oral and intramuscular magic. Cushions for the mind. Medicines that calm and protect. We hop into Mzungu. Our white Hilux. And head toward the camp. Thinking aloud.
Thinking is allowed. Although many clinicians seem to fire from the hip, way too often. A great joy of medicine is the challenge that it offers. No two patients are truly alike. Our shared job as Valley Doc a precious thing. For each conundrum we see things with different eyes. We bring differing views. Approaches. Spin things different ways. Synergistically, not oppositionally. Problems halved or at least shared.
Our journey to see a patient is a crucial phase. Thoughts collected. Approach negotiated. Tasks apportioned. A flexible plan, mapped out. A goal at least. In this way, we arrive with purpose. Our clients see confidence. To inspire confidence. Part of the battle. Anxiety muddies the water. Clarity is needed.
Jack sounds agitated. Clouded thoughts. The product of medical, chemical or psychiatric forces. But we must not jump to false conclusions. Run before we can walk. My task will be to gather information from those around Jack. Keith will aim to engage with Jack.
The phone rings again. There is confusion. Jack is on the move. No longer at camp. His colleagues have taken him to a clinic. But which one? Kakumbi? Or Velos? We stop on the road. Ten minutes triangulating. Velos the new plan. Our drive resumes. Velos is a short schlep. 30 minutes under Mzungu steam.
It’s 21:00. We arrive at Velos hospital in synch’ with Jack. He is sat in the front passenger seat of an open game viewer. Held fast in a caring embrace by a young lady. Settled? We rashly venture. But as we approach, it becomes clear that all is not well.
A flash of anger. Menace. Fearful eyes. Words betray his paranoid state. The car door thrown open. A stare, insistent that Keith should not approach.
Jack’s agitation propels him away from us. Fortunately, the hospital parking lot is a safe space. Well lit. Fenced off and elephant-free. He mutters at nobody in particular. Pacing. His girlfriend heads his way. To shepherd him. At least there is no suggestion of any getaway plan. But Jack’s inner turmoil, and our challenge, won’t be resolved anytime soon.
Whilst our patient mutters and paces, I peel off to focus on my preassigned task. To seek further information from Jack’s colleagues and his partner Lucy. Keith phones a friend. Jack’s best friend. Jack’s brother. Rudi.
No history of fever. No rash. No unusual insect bites. No illness. A four week steady decline in work ability. Change of attitude. Reports of being confrontational. No history of alcohol abuse. No drug use. He hasn’t slept well for the last week. Not at all for the last 24 hours.
Keith speaks to Rudi, one thousand kilometres away. Rudi and Keith share their intel. And then Keith begs a favour: A reference from Rudi that will likely help Keith gain Jack’s trust.
Nothing in the gathered stories suggests an acute medical illness. Nor a toxic response to chemicals. That leaves a psychiatric issue. Acute paranoia. Disturbed thinking, without a physical or so-called organic cause.
The phone is spirited to Jack. Opening an intracontinental dialogue. Initially, Jack’s paranoia puts the kybosh on our preferred way to Jack’s heart and mind. The phone is thrust away. The tarmac impacted by the phone’s resilient case. Strike one. The use of someone else’s phone is eschewed. Not to be trusted. Try harder Doc.
Reaching the end of the opening salvo of our plan: Keith and I reconvene. The plan needs some refinements. Some detail. Some contingencies. Trust is key. A shared plan with patient and docs might involve sleep and calm. Chemically induced calm, for a troubled mind, is best taken by choice. But how do we help Jack to realise that our choice can also be his choice? A photo of Jack’s chosen medicines give Keith an in. Sleepers seem to be an acceptable option. Lucy is tasked to ask Jack if he would like a sleeping tablet. A chill pill. A rest.
Amongst our contingencies is the nuclear option. If anxiety, anger and agitation make it impossible to play the softly-softy approach, our plan B is an injectable chemical cocktail. Designed to go into a big muscle and to work fast. But fast is a relative term. Intramuscular injections take several minutes to down an angry bull. We just can’t fire from a safe distance. We need to be up close and personal. Jab into a held thigh. Hold the anger and the power of the challenged creature. We have a collection of burly security officers and clinicians on hand, ready to hold limbs. To take the strain.
We touch base again with Rudi. Jack’s brother is resigned to a compulsory detainment approach. His words consent to the use of necessary force. Rudi is in the loop. He knows of the need to protect the safety of Jack’s carers. He recognises the therapeutic properties of the proposed sedatives. Keith arms himself. With a mixture of drugs that he is familiar with. Just the right blend of anxiolysis and counter-paranoia. A syringe of the possibilities lies up his sleeve. Yet Keith bides his time. Seeking even now, to find a key to Jack’s heart. A key to Jack’s mind.
The prospect of a scrum, centred on Jack is not relished. It would take away Jack’s dignity and his free will. It’s rarely therapeutic to act in this way. Occasionally a necessary evil. A route toward mutual safety. But it is also a retrograde step. A step backward from trust. After forceable detainment and chemical assault, it’s an uphill battle to re-establish trust. Keith later tells me: that in 24 years as a GP he had never sectioned a patient. Not a single patient, sad, mad or bad, had needed treatment, against their will, in 24 years. I suspect witchcraft. Why else would all of his patients follow the party line, pied piper of Hamlyn style, for all of that time? But I had never seen this wizard casting spells before now.
Jack and Keith dance. Not the traditional steps. But they size each other up. From a distance, at first. Jack brushes Keith off. You are using the wrong words Doc. He chides. Keith takes the verbal punch. But he now knows that he is inside Jack’s armour. Somehow, they end up physically closer. On the floor. Keith ventures an arm. Holds Jack’s back. Physically and figuratively. Keith offers Jack medicines to allow him to rest. To calm his over paranoid mind. They joke about the phone holding Jack no ill will. Keith’s sleeved arm hidden from view. Just because you’re paranoid, doesn’t mean that nobody is out to stab you. Keith laments inwardly.
Keith borrows Jack’s phone to call Rudi. Rudi’s voice calm and measured. Rudi and Keith wrap Jack in emotional cotton wool. They talk of common passions and pet hates. They guide him back to what usually makes him tick. And how to put his tick back.
To read the rest of this blog, click on the link: Hospital madness - A magician at work / BLOG | Into Africa
Hospital Drama
Written by: Keith and Ginny Birrell
Highlight of the week: Our weekly drive in the park nets us 22 wild dog puppies moving dens
Lowlight of the week: I tweak my shoulder again and am forced to rest it
Maximum temperature: 32 degrees Celsius
Rainfall: Not yet
Hewn out of primordial bush. By plant machinery bearing the name Velos. And so, our new, all bells and all whistles District General hospital acquires its colloquial name. Velos. Near but far. Near to the airport and not too far for those who have motorised vehicles. Far from our crowds. With no transportation infrastructure to speak of. Shanks’ pony and clever Mike excepted.
The building is stunning. Throw a stone and you can hit planes as they take off from Mfuwe International Airport. There is no question that health services in Mambwe district need a shot in the arm. The Mambwe District Hospital was opened in 2024 by President Hichilema Hakainde. First impressions are good. Stacked full of pristine kit. With a floor that you can eat your dinner off. But will this punt from UK export finance be a timely hit? Or a pricey miss?
A couple of weeks back - we are greeted by the charming medical director of Velos. He desperately needs to man his brand-new pumps. Bodies on the ground. Bums on seats. Docs in scrubs. Our predecessor is pulled away from primary care. Away from his prime duties. He goes rogue. With good intentions. He tries to fill the void. But nonetheless, he leaves primary care and his paymasters rather in the lurch. Our mission, should we accept it, is to redress the balance. We still want to bolster the blossoming, secondary care Mecca that is nicknamed Velos. And yet, we need to maintain the momentum of our push to reserve hospitals for repairs, by empowering people to choose health in the community. Accessibility is key.
We make a plan. We arrange to spend one morning a week at Velos. I will do a paediatric ward round and some teaching. Keith will work with the outpatient staff. After dropping the Kakumbi outreach team. The under 5 village clinic staff can save concerns for our return. They still get a taxi service and our expertise.
It’s Tuesday morning. Our first Velos day. The alarm goes off, as usual, at 06:00. Our normal alarm clock of baboons has become a little less reliable. It’s hit or miss whether the baboons choose to jump on our roof at 05:30. Meaning that we now have to set an alarm to reliably rouse. I am not sure which is worse. A loud crash on the roof? Or a tinny annoying tune from the phone? Seedling. Chosen from the iPhone alarm menu. I switch off the phone and fall back into doze mode. Groggy. Not fully awake yet. But a second, more insistent alarm, spoils my slumber. Shimmer. Not a loud crash. Not a gentle nudge. But the doc phone’s determined cry for help. Instantly awake now. We are needed. Can you come and see one of our clients? She has fallen from her roof tent. Her wrist is at a funny angle.
We leap into action. Crash through the gears. Dressed. Banana breakfast. No coffee. Only a 5-minute drive to camp. Yet long enough to reminisce. From September last year. You may remember our Blue Peter blog (https://free-4448611.webador.co.uk/blog/1970109_blue-peter-is-alive-and-kicking). We pull a broken wrist and splint it in the bush. Old hands. But this year, everything is different. We now have a functioning hospital. Access to X-ray. To good pain relief. Anaesthesia. A plaster technician. Gone are the good old days of manipulation in the bush.
We arrive at the camp. 15 minutes after the call. No blue light needed. But still faster than your average 999 ambulance in the UK. A single giraffe knows to give us a wide berth. Our patient, Patricia, is sat at a picnic table. Head down. In obvious agony. Her right wrist is the shape of a bent dinner fork. A Colle’s fracture for sure. We check the blood supply to the hand. All good. So, no major rush for any heroics. We listen to the story. She is helping to pack up the roof tent. Coming down the ladder. She misses the last rung and steps back. Onto a wobbly log. Falling about 1 metre. Onto her outstretched hand. Pain in the wrist. No other injuries. We give her some tramadol. Make a good job with a triangular sling, for once. And arrange her transfer and admission to the district hospital. Keith calls the boss and requests that we do an MUA this morning. A Manipulation Under Anaesthesia our code words for bone setting.
The stars align. We are due at Velos today anyway. Our first day at school. We arrange to meet Patricia and her family at the new DGH in a couple of hours.
Back home, we have breakfast. Coffee. Plan our day. No time for morning exercise. We are at the clinic in Kakumbi by 08:30. Ready to take the staff to their outreach clinic. Yesterday was Farmers Day. A national holiday. So, the weekly staff meeting is bumped to today. The morning meeting is still going on. No work gets done until the meeting has finished. The clinic is relatively quiet. No emergencies. So, we sit and wait. And wait.
I am learning to be more African. Inside, I am British. Impatient. A spring that needs to uncoil. We have work to do. Eventually the meeting finishes at 09:15. The staff pile out laughing and talking. Oblivious to our time pressures. I jolly them along. But there is only one pace today. Zambia pace. We finally hit the road at 09:30.
In reality, there is no rush. Things take a long time to tick over in hospitals. We get to the hospital at 10:00. We find our patient. Comfortable. Already x-rayed. In the process of giving consent. For an MUA. We are able to reassure Patricia and her family. Explain what will happen. Make a plan with the medical team. But we have a major obstacle to overcome. We do not have scrubs. We will not be allowed in theatre without scrubs. We cannot go into theatre wearing our outdoor clothes. We don’t need to be sterile for this procedure. After all we’ve done this kind of thing out in the bush twice already. But all of the anaesthetic kit lives in theatre. So, we need to make a plan.
We stand and scratch our chins. Finally, we are told that we can wear disposable gowns over our clothes. And some theatre crocs. Progress.
Amazingly, at 10:45, we take Patricia to theatre. Bernard is our clinical officer, trained in anaesthetics. James our physio, a bone setter ready with plaster of Paris. Elvis our radiographer. Whilst still in the building, Elvis is capable of giving us instant x-ray images in theatre. In total we have ten bodies in theatre, including the patient.
Everything goes like clockwork. Patricia drifts off to sleep. Ketamine and inhalational gases on board. Keith holds Patricia’s hand firmly. James applies an equal and opposite tractional force from Patricia’s elbow. The wrist reduces beautifully. The dinner fork again matches the set. Normal shape appears. An x-ray from Elvis confirms perfect positioning. James’ team applies plaster of Paris. The plaster sets quickly. After 5 minutes Elvis gives a second magic image. All set. Patricia is allowed to wake up. After 15 minutes of fame. Or should I say 15 minutes of drug induced torpor? Isoflurane gas now switched off. Patricia slowly rouses. Practically pain free and all set to safari again.
It's sometimes grim to be a doctor. You gravitate towards those affected by misfortune. Share their tribulations. But it is often possible to turn things around. Patricia rather got out of the wrong side of bed this morning. This was made more unfortunate by her sleeping 2 metres in the air. We reflect on the highs and the lows. Patricia will not be sleeping on top of the Land Rover for the next few days. But at least the trip can go on. For now. Pain free. Healing. Set. Patricia reaches Lusaka. But the thought of a further 4 weeks in the bush with one arm in a sling is too much for her. She chooses to fly home. However, the rest of the family carry on. With their 4-week, self-drive holiday of a lifetime. Zambia, Botswana, Namibia, South Africa.
First class care provided in South Luangwa is the great success story of Mambwe District General Hospital. We play a bit part. But the staff, skills and facilities of Velos Hospital are the headline act. A state-of-the-art facility hewn out of the bush. The UK investment in Velos appears to be a big hit.
We miss our Blue Peter days. The days when the buck stopped with us. Making do with double sided sticky backed plastic. But how amazing it is now to be able to deliver such 1st class care, deep in the bush.
We find ourselves at Velos 3 times this week. Our new DGH is not an esoteric niche. But I’m getting ahead of myself. More of this later. We dream that the Valley Doctor role will become superfluous as new services become more established in South Luangwa. But this is likely a pipe dream. For now, we are happy to support the development of both primary and secondary care in our Valley.
To view the photos which accompany this blog, simply click the link below!
Hospital Drama / BLOG | Into Africa
Chunk and Check
Written by: Keith and Ginny Birrell
Photo of the week - we find Lucy out hunting
Highlight of the week: 500 recruits are now in our stroke prevention programme.
Lowlight of the week: A late night call saps our energy.
Minimum temperature: 11 degrees Celsius
Rainfall: Still waiting
Before you master the stethoscope, you’ve got to master the art of connecting with people. As a medical educator who's been around the block a few times, I’ve learned that the earlier you reach them, the better. Nowadays, as soon as the nappies come off, students get a diet of ICE. Ideas. Concerns. Expectations. We waxed lyrically about this in 2023. On graduation, the patter becomes refined. Forget it at your peril. Resurrect it to leap those little hurdles as you progress through your medical career. It’s a framework that keeps the chaos at bay. Omit it and you risk unhappy punters and confusion.
When a sick child is admitted, we carry the parents and the family with us. Inform. Be honest. Update. Avoid jargon. Sometimes be guarded. But always communicate. And check understanding. Students are taught to chunk and check. Break it down. Bit by bit. Medicine is complicated. Explaining illnesses and treatment is vital.
Zambia is rather behind the times. Communication the except. Not the rule. Involving patients in decision making, almost unheard of. We would like to buck that trend. Our efforts may seem token to some. This week Keith and I see William, a 67-year-old man. We have a room full. Family. Patient. Three clinicians. William’s problems need unpicking. He has been told that he has prostate cancer. Yet his prostate feels normal. His prostatic ultrasound is reassuring. Keith spends some time explaining his thoughts. The possible diagnoses. Chunk. And the possible ways forward. Chunk. Keith then checks. Do you have any questions? Silence. William slowly turns to the clinical officer and states: I don’t know what to ask. William has never been asked if he has any questions before. No-one has ever tried to explain his illness, or the possible investigations with him before. Let alone the possibility of him being able to share decisions about his own care. Dumbfounded, William smiles. He likes this approach, but William is not quite with the programme just yet. The family sigh with relief. They have been unhappy with clinician centred care that has given no clarity.
Our first week back in the clinic is heartening. Old friends greet us warmly. New colleagues look on with interest. I choose to spend my first morning in the clinic with Agatha. A new nurse. We aim to see paediatric patients. It’s winter here. I lose count of the number of children with viral colds and flu. Only one child today has malaria. Our needle in a haystack. Every child with a history of fever really needs a malaria test. A finger-prick blood test. If we are lucky, a result within 10 minutes. At the moment we are waiting 1-2 hours for those results. No rapid tests today. Just old-fashioned blood films. For staining. Examined meticulously under the microscope. We have to limit our tests. Hedge our bets. Our haystack is taking a while to process today. I pray for respite. Something to break the monotony. Answering my prayers: Keith comes to find me. Can you come and see a child? I’d like you to do a developmental assessment please. There is no need to ask me twice!
Peter is 11 years old. He is with Janita, his stepmother. Janita worries about him. He is not doing well at school. She would like to know why. I probe a little further. He only plays with younger children. Girls. He can be giggly. He often wets himself. Needs help on the toilet. He is in year one at school. He has been in year one for 3 years. His teachers say he’s not ready to progress. He is not learning well.
I put my paediatric hat well and truly on. I decide to start at the beginning. The pregnancy. His birth history. Janita looks at me blankly. He only came to live with us this year. I have been with his father for 6 years. He had a nasty divorce from his ex-wife. I didn’t know him then. I have no idea about his early life. But mum, Caral, will help.
Caral comes on the phone. She speaks fluent English. I explain who I am. I offer to help to find some answers. She appears to remember all the details. Peter was born on time. Normal pregnancy. No infections in pregnancy. No drugs or alcohol. Peter cried at birth. Fed well. Grew well. Walked and talked at the expected times. There were no issues. He changed when he was 8 years old. I’m puzzled. How odd! No further information is offered. No history of head injury. No accidents. Caral fails to mention his epilepsy and the new medicine that has stopped his unmentioned fits. The trail seems cold.
I scratch my head. What is going on? I decide to stop asking open questions. Perhaps a few closed, yes/no answers are needed? Has he ever had a severe infection? Like severe malaria or meningitis. Caral answers: Yes, immediately. He had severe malaria when he was 7. He had lots of convulsions. He was in hospital for a couple of weeks.
Eureka. Finally, a breakthrough. Of course, Zambian hospital care is nothing like we are used to in the UK. No large multidisciplinary teams. Peter was admitted with his malaria. And given treatment. But the condition was never explained to his parents. No assessments after he got better. No clinic follow up. No community support. He started to have fits shortly after this episode. But these were looked at and treated in isolation. The epilepsy team probably never even knew that he had had cerebral malaria. Notes rudimentary. Dots not joined. He was doing well at school until the age of 7. Then he dropped off a cliff. No educational assessments. No educational psychology. Peter’s teachers just reported a lack of progress.
This surely must be the smoking gun. I explain to Caral and Janita that I think Peter’s episode of cerebral malaria has damaged his brain. Janita phones Andrew, Peter’s dad. I share the situation with Andrew too.
My crystal ball comes out. In truth, I have no idea what Peter’s future holds. But I have no doubt that understanding why he is having difficulties will be really useful to the family. I reiterate the importance of continuing with his education. I ask them to seek out a special education needs teacher in the valley. I guess that someone in this special Valley has relevant skills. I urge Andrew not to punish Peter for his apparent failures. But to celebrate his successes. To concentrate on self-cares skills. Help him to find a hobby. Something he loves.
Peter may well find a manual skill at which he can excel. He is never going to be an A* academic pupil. But there is no reason why, with gentle support and directed input, he shouldn’t be able to live an independent life. Perhaps he might farm. Thrive. Be accepted. Embraced. Become part of a community that can make invisible disability able. Putting ability in capital letters and dissing the lower-case impairment.
I sum up my day with a high and with a low. With a rose and with a thorn. The contrast emphasising any victory and any setback. My thorn today, that Peter has been left not the full shilling. My rose today, that understanding Peter’s deficits will allow his parents to reset their expectations. Peter’s future is what it can be.
Remember to click the link below to view some incredible photos!
Chunk and Check / BLOG | Into Africa