Medicine is like a box of chocolates

Shadreck is my next patient in OPD. He is a well dressed gentleman in khaki trousers and a white shirt accompanied by his wife. I recognise him and remember from the ward, he had been an inpatient a short time ago or so I thought. When I examine his green card however I am surprised to see that Shadreck’s admission had been way back in August. It’s a reminder to me of how quick time goes and that my time remaining here is short now. It also reminds me that even though it seems I am stuck in a time bubble here life is probably moving on at home.

Because I left at the start of the Irish ‘summer’ I sometimes think that it must still be summer at home. I have this idea when I arrive home it will be the start of autumn. Being away from home and experiencing life in a completely different country is great but sometimes you forget about the things you miss out at home especially your family and friends.

Shadreck had been treated for severe cardiac failure and required high doses of diuretics to remove excess fluid from his body. Unfortunately since his discharge he has been chronically under dosed with medications and now needs to be readmitted to get stabilised again. He is in good form nonetheless, we talk about ‘Chipata Motel’ the township where he lives in Chipata.

Despite having been here for some time being used to see patients severely ill, adults wasted away from AIDS, children with malnutrition, witnessing death on a near daily basis I am still often shocked at the dire circumstances a fellow human being can find themselves in. My next patient after Shadreck is Mary. She is 19 years old. The first thing I notice about Mary is the smell of urine. But that is not why she has come to the hospital today.

Mary weighs about 40kg, she looks horribly thin. She tells me her problem is cough shortness of breath and weight loss. Examining her there is almost no air entry in her left lung. Her chest X-ray shows a hydropneumothorax, the space where her lung should be is now filed with air and now some of this space is filled with fluid. She does not know her HIV status but is most likely positive. I admit her to the ward, later when someone tries to drain the fluid from her chest several hundred millilitres of frank pus is removed.

I try to ask Mary about her urinary incontinence. It is likely she has a vesico vaginal fistula following obstructed labour. Through an interpreter I try to delicately ask her about her pregnancies and deliveries, if she has noticed any problems, tell her there is a surgeon visiting in the next few weeks who may be able to help her. She denies any problems. She got married at fifteen and has two children but says the labours were fine and the children delivered at the local health centre. Maybe on the ward she will open up to someone about this. As part of my GP training we have to video some consultations we do with patients (with consent) so our communication skills and how we manage the consultation can be assessed. Here mostly working through an interpreter in a busy and hectic environment I fell most of my consultations would unfortunately fail.

Days and weeks pass by quickly, we have less doctors coming up to Christmas, there is more work to do. Sometimes I feel like I am enjoying it more, find the medicine more interesting, that I have an idea what I am doing now and can really make a difference. Other times I feel tired, start looking forward to finishing up in a few weeks, having a holiday, going home. One afternoon after a frustrating morning ward round Pearson walks into room 15 in OPD. I don’t recognise him at first and then think to myself it can’t be, but it is him.

Pearson had been on the ward three weeks ago with a three month history of a massive tumour on his left forehead, growing outwards, down covering his eye and deep, with an X-ray showing some destruction of his skull. He needed treatment quickly. He had some lymph node involvement in his neck one of which was biopsied and sent to the Netherlands for analysis. We gave him chemotherapy treatment for non Hodgkin’s lymphoma thinking that the most likely diagnosis in a HIV positive patient. We told him to come back in three weeks for his next cycle of chemo, the biopsy result may even be back via email then. We doubted that he would make it back.

Pearson is here now three weeks later, his tumour has shrunk dramatically, he feels well. While his left eye is still closed he can now lift the lid and the eye itself and his vision is fine. His results show he has a Burkitt’s lymphoma, a cancer common among African children and in HIV patients. This type of tumour can invade the central nervous system so this time as well as intravenous chemo I have to give him intrathecal methotrexate. This involves inserting a lumbar puncture needle through his back so it is in the cerebrospinal fluid then injecting the medication slowly through this needle. This way the chemo is in his CSF directly into his central nervous system and can reach the brain. It’s not exactly what I thought I would be doing when I decided to become a GP.

After admitting Pearson for his chemo I am seeing the next patient, a lady in for review of her blood pressure, more familiar territory for me. However in the middle of the consultation an emergency case is brought in. An eight month old child is placed on the examination couch, he is warm but not breathing and does not have a pulse.

As I commence CPR and my colleagues come to help me I learn from his father that he has had a fever since yesterday and had not been feeding well today. We continue CPR, can’t get an IV line so give adrenaline directly into the heart. After fifteen minutes his pupils are fixed and not responsive, he has no cardiac output, he is not breathing, he is dead. Probably one of the one million plus children who die from malaria every year in Africa. After barely a few minutes his father picks up his body and leaves for home. I return to my patient with high blood pressure and remind her of the importance of a low salt diet.