Magazi

The most useful treatments in medicine are not the high tech patented medications that pharmaceutical reps constantly push on GPs and other doctors at home. In fact the most useful treatments are not even medicines per say. Oxygen, fluids and blood are usually the first priorities and the most effective interventions for seriously ill patients few other treatments are as beneficial and work so quickly. One might think then that these simple low tech treatments would be easily available here in St Francis, unfortunately not so.

We do have some supplemental oxygen. This does not however come from ports in the wall connected to a mains supply like in a hospital at home. Nor does it even come in refillable and mobile cylinders like a GP would have at home. Oxygen is delivered through a few oxygen concentrators. These are helpful but can only deliver low flows of oxygen up to four litres per minute (giving maybe 28% oxygen, hypoxic patients at home would receive up to 100%). For paeds and neonates one concentrator can serve a few patients but for the adults its just one machine per person. With two to three available on each of the male and female medical wards this can often lead to difficult decisions as to who it is gets the supplemental oxygen.

But fluids should be in good supply, and they are in fairness, just not consistently the same fluids. A bag of fluids costs the hospital about $5 so we are encouraged to be judicious in the use of fluids, ‘if the gut works use it’. Through some complex ordering and procurement process the hospital gets essentials like fluids from medical stores in Lusaka. Problem is medical stores don’t always issue what is ordered. With fluids one month we may have ample supplies of normal saline and little dextrose, the next month the reverse. Then the next month again we may have little but ringers lactate.

At the Tuesday morning clinical meeting we get a list from pharmacy what is out of stock. Items currently out include oral cloxacillin (in the absence of flucloxacillin an essential drug for us to treat staphylococcal infections), spironolactone (a very useful potassium sparing diuretic, used in cardiac and hepatic failure to help the body clear excess fluid) and even cotton wool.

Oh and blood, though we have just got some in last evening. Being short of meds and fluids is an inconvenience and we have to search for alternatives. However when a patient needs blood there is no alternative treatment. When I cam here as a medical student in 2003 the hospital sourced its own blood supply. The staff would go out a couple of times per week usually going to schools and encouraging teenagers to donate (this group less being likely to be HIV positive if not yet sexually active and beyond the age for asymptomatic maternal transmission). The blood was then screened in house. When I went to donate then it was just a matter of going to the lab having a needle put in and letting the blood out into a giving set. There was rarely a shortage of blood.

Since that time the blood bank has been centralised. Blood supplies are managed nationally, screened centrally. The hospital now has to order blood from the nearest blood bank in Chipata. The blood comes pre typed with A+ or O- or whatever on the label but there is little trust in the system and all the blood is retyped here. There are frequently shortages of particular blood types and from time to time we go a few days with no blood what so ever. Patients die because there is no blood. This is progress, Zambia style.

So what can you do in the absence of blood? Use you own, your colleagues, the medical students. This should be easy but as part of the centralisation process the hospital no longer has access to sterile blood giving sets. That leaves us literally putting an IV line into the donor withdrawing 20mls, giving it to the recipient, getting a new sterile syringe repeat the process etc (over twenty times for one unit of blood).

This is a tedious process and can be messy, its hard not to spill a small amount of blood when swapping for a new syringe. The patient or parent needs to give informed consent, the donor needs to be screened for HIV and Hepatitis B. Fortunately one of my colleagues has taken on the mantle of managing this process when it needs to happen. She has a clear knowledge of what donors are available, their blood types and who needs blood the most, particularly amongst the children. The other evening I helped her take 400mls from one of the medical students with the desirable O negative blood group and split it between three sick children who are all doing well since.

I am a little envious as my previous donation went to a middle aged woman with anaemia secondary to her HIV medication AZT. I was fairly pleased that her haemoglobin went from 1.9 to 8 after 400mls of my blood (the margin of error in the lab is plus or minus 2) but unfortunately I learned she died a few weeks later, but at least not from anaemia.

A centralised blood transfusion service makes sense in a country like Ireland with first class infrastructure. Zambia covers a huge area with sparse population centres and disastrous infrastructure and really it would make more sense if certain hospitals could be licensed to manage their own blood supplies. There could be regular inspections to ensure proper screening and quality control is available. In theory there are more risks to transfusions this way but every transfusion carries a risk and the biggest risk to a patient with critical anaemia is not getting blood.