It’s a bit of a cliché to say time goes by really quickly but it’s hard to believe that my time in St Francis has come to an end. So it’s goodbye to ward rounds in St Augustine, afternoons in OPD, the cockroaches in SCBU, being woken in the middle of the night by the security guard ‘doctor you are called’ and to judging the consistency of the custard in the mess. Medicine is on a different scale here more patients, less doctors, bigger spleens, lower haemoglobins, a hydrocele (fluid in the scrotum) the size of a rugby ball, a CD4 count of 3. As time went by I went from uncertainty and a lot of ‘what am I doing here’ to become more efficient and I hope more competent in the work which helped me to enjoy the medicine much more. However whatever benefits my work here may have had for the hospital and the patients I gained a whole lot more from the experience.
All that’s left to do now is thank all of those who have helped make my time here so rewarding and enjoyable. To Emmanuel (thanks for the farewell lunch), Moffat, John, Cecilia, Setrida, Happy and all the team in St Augustine for putting up with my awful handwriting, west of Ireland accent and only occasional ( I hope) impatience. To everyone in OPD Charity, Tembo, Diana, Naomi, Catherine, Basheba, Patrick, Senida, Precious, Luka, Limbikani and especially Miriam for making sure work could be fun also. To the guys in the lab for never getting too grumpy with my late night LPs. To Laura and everyone in Pharmacy for deciphering my prescriptions. To everyone in Mbusa, SCBU, St Monica’s and the other hospital wards and departments.
To all of the great doctors I got to work with (some for only a short time others for longer) Paul, Nicola, Jenny, Helen, Dayson, Phostina, Jack, Gustav, Al, Sarah, Euan, Bronya and Massoud. To Alex the finest Cornish dentist I ever met. To Drs Mike and Anne Currie for words of wisdom and inspiration. To Ben and Steph. To all of the Students from Holland, England, Scotland, Australia, New Zealand, Malaysia, Denmark, Norway, Greenland, the USA and Ireland for keeping me on my toes and making the mess a fun place. To the guys in the mess for the custard and the other food. To Samuel for looking after my garden. Thanks to Shelagh Parkinson for all the help and encouragement. Thanks to Ian especially for explaining the rules of cricket. Thanks to Katete police for the lift home from Drums. Thanks to the people of Katete and the surrounding areas for their kindness and hospitability anytime I wanted to visit their village, their church or their traditional healer.
Most especially thanks to my family and friends at home. Firstly for raising funds for St Francis which should total over 7000 euro come the end of the fundraising in April. Thanks for reading my rantings on this blog. Thanks for all the support through good times and bad.
Before I return home to the ‘real world’ I am going to see a bit more of Southern Africa. I have my jeep, some maps, a jerry can and the cheapest tent money can buy. On a Sunday morning I pack up my things say my goodbyes to St Francis and get on the road.
Monday, January 31, 2011
Tuesday, January 25, 2011
Village People
Monday 17th January
My last of seemingly endless weekends spent working in St Francis over I am leaving Katete to sample life in a rural village and experience primary care in Zambia. I have spent a lot of the past few months comparing life and medicine here with what I knew at home. But having trained as a GP I want to see how primary care in Zambia compares to Ireland. Obligatory bureaucracy overcome including getting two drafts of a introductory letter for the district Medical officer and trying to liaise with Edward via phone trough crap reception I am on my way to spend a three nights and four days in Mpopo rural health centre.
Mpopo is a large village about 80km from Katete the last section off the tar. I am looking forward to having a relaxing stress free few days. I arrive at a leisurely nine thirty to find Edward who runs the centre has had to go to a training meeting and I am greeted by Roger instead. He explains that the health centre serves a catchment of over eight thousand people and provides acute care, chronic illness management, family planning, antenatal care, looks after about thirty on site deliveries per month and under five care (vaccinations, growth monitoring etc). HIV services are provided by an outreach team.
As well as the labour ward there is an on site ward with three beds where patients can lodge if they are very ill or whilst awaiting transport to hospital. There is a laboratory with a microscope, tests available are blood slide for malaria, haemoglobin (blood count), urine microscopy (to look for infection), RPR (syphilis test), sputum examination for TB and pregnancy test.
There are a load of patients waiting to be seen so we start. Now let me explain the staffing situation in Mpopo. Edward who manages the centre is a registered mid wife. Roger is a microscopist with two weeks training in laboratory techniques. His wife Telesa is a ‘certified daily employee’ whose role is supposedly to give admin support as well as clean and maintain the centre. Limbikani is the night watch man. Thomas is the data clerk, that’s it. When Edward the only trained staff member is away like today, at meetings or workshops, which seems to happen very frequently the others keep the show on the road.
I start seeing the patients with Roger helping to translate and outline how the centre works. We see malaria, pneumonia, chronic obstructive pulmonary disease, a woman with painful periods a child with tonsillitis among many others. About an hour in Roger tells me there is a child fitting on the ward. We go to find a seven year old boy who had been seen by Edward during the night. He is HIV positive but not yet on treatment, he came the previous night with seizures the family had no money for transport so an ‘ambulance’ has been called and is awaited. The child is still seizing he gets more Diazepam, he has had quinine to treat malaria, I suggest penicillin cause he may have meningitis, he needs to be in hospital. The ambulance eventually arrives but he dies later in St Francis.
We go back to seeing patients. I ask Roger how we are doing. His reply a ‘bit fine the way you work’. After thirty or so patients I suggest Roger see the patients and I can make suggestions, maybe things will move quicker and it doesn’t seem like Roger is too interested in learning anything from me. As a lab microscopist he has no clinical training but frequently sees patients. I quickly realise what he meant by ‘the way I work’ which involved getting something of a history and examining every patient if even just to check temperature, heart and breathing rate and check for pallor. Roger simply asks the presenting complaint be it headache, cough or fever. He almost never does any attempt at examining the patient, ‘consultations’ last less than two minutes. Based on the presenting complaint he prescribes some treatment, be it an antimalarial, an antibiotic or just paracetemol.
I would describe it as guess work, I can’t say how often he gets it right as I would need to assess the patients more. However he does frequently seem to make sensible decisions, having a low threshold for malaria treatment in the under fives, telling some patients to come for review if they don’t get better. He asks my opinion on some cases and I make some simple suggestions. Remember he has no training and no way to diagnose malaria (because he is seeing the patients therefore no lab). The last patient is seen just before six. Seventy five patients have been seen since I arrived.
While Roger has been seeing the patients, Telesa has been dispensing the drugs from a limited selection of antibiotics and painkillers and explaining to the patients how much to take and how often. As we are leaving the centre Telesa tells me there is a woman in the labour ward. She proceeds to examine the lady and deduce she is 4cm dilated, she doesn’t use a partogram to chart the labours progress but tells me Ronald does when he is here.
I am pretty disheartened after the day. I ponder that maybe the patients would be just as well off without any health care than what they have got today. I am shown to my accommodation. Like the health centre it has power but no running water. It’s a bare shell of a house with four rooms no furniture or appliances, thankfully I have brought a camping mattress and some bedding. There is a pit latrine round the back, I can’t see a bath room anywhere. Water is from a bore hole near by. I realise that I am hopelessly under prepared, what use is my laptop and mobile phone here. I have some bread, corn flakes and milk but nothing to eat them out of, how I am going to wash?
I walk down to the village to try to find some food. It’s a big place several hundred people must live here. The village square is populated by grazing cattle and playing children. I bump into Thomas the data clerk from the centre. He hasn’t been working today but out in the fields planting. He never got to complete school and was a taxi driver in Lusaka, he got this job ahead of eleven others with more education. His role has been financed by the World Bank under the performance based funding for scheme which I did some inspections for a while back. Since he started working in the centre last March he hasn't been paid. Thomas shows me around the village, the two taverns, three or four shops selling basic clothes, soap and detergent but no food, the various different churches, the cattle shed in the square which he says belongs to a cooperative.
When I arrive back at the centre Edward has returned. We chat in the centre for a bit between seeing a few patients who have arrived to the centre. He tells me there had been four trained staff here but now he is the only one. He seems frustrated and disillusioned with the work, being on call every night. He plans to return to hospital midwifery. I tell him about my background and that yeah things are different in Ireland a centre like this would have probably three GPs a nurse or two as well as support staff. Edward tells me a new teacher for the school has just arrived and will be staying in the house with me. I greet Paul briefly and retire to sleep.
Tuesday 18th January
I wake at six from a dreadful nights sleep punctuated by heat and rolling of the camping mattress to hear Paul outside slashing branches, what is he doing? I go to the bore hole to wash my teeth get some water to drink. I have decided I can’t possibly stay here another night, I will go back to Katete this evening and commute out the other days.
The morning is just the same I sit with Roger seeing patients, there are less today but he still moves super quick. However he seems much more receptive to comments and suggestions I make and I realise that in Ireland it is unlikely anyone with so little training would do as good a job in such difficult circumstances. A lot of the patients like at home don’t have a whole lot wrong with them, like at home the mothers seem to bring all the children to be seen at once. I am starting to feel a little better about things and decide to be more stoic and not return sulking to Katete this evening. At midday I go to get some water and find that the pigs and chickens outside the house have been joined by a team of kids from the school clearing the ground.
Their new teacher Paul is from Katete and has been appointed deputy head master here. His wife and children will be staying in Katete where she also teaches and they have their home. He describes it as a promotion to isolation. He is prepared for life here has a little electric stove, meal to make nshima, tomatoes for relish and eggs along with his laptop and stereo. Earlier he had been cutting branches to repair the houses wash area, a grass fence enclosed square outside which I hadn’t noticed. I ask Paul if he wouldn’t mind sharing some food with me which he enthusiastically agrees to.
In the afternoon I go with Telesa on an outreach visit to another village. Telesa’s duties are listed on the notice board in the centre. Tuesday afternoon is polish the floors day, the floors don’t look like they have been polished in a long time. I drive us a few kilometers down the track to the next village where dozens of women have gathered under a tree with their children. Community health volunteers weigh the babies and organise child health records.
Over the next couple of hours under the tree we vaccinate countless children against measles, diphtheria, polio, haemophilus and tetanus. We give oral and depot contraception to women who understand the benefits of family planning and allowing some time between pregnancies, we give antenatal care to pregnant women including folic acid, iron and intermittent presumptive malaria treatment. One of the community health volunteers gives a talk on nutrition and different food groups. The women sing some songs to the first white visitor to their village in a long time (if ever), everyone is intrigued by my camera and looking at he photos I am taking. Because this is Zambia we don’t leave until after we have been fed with nshima, vegetables and something I think was chicken.
When we get back to Mpopo we see the last of the patients in the clinic. I have a wash (throw a bucket of cold water over myself) in the newly discovered ‘bathroom’, enjoy some more nshima with eggs prepared by Paul and retire much more content than twenty four hours before.
Wednesday 19th January
Still no sign of Edward today. Roger continues seeing the patients with me trying to give some hints and suggestions. A local councillor brings his son in his twenties. He has been coughing for some months has been loosing weight and has had a fever for the past few days. He previously had TB sputums checked a few months ago which were negative. He looks obviously ill, is breathing fast, very thin. Ernest ascertains only that he has a cough for some months. I ask him what he is going to do. ‘Check sputums for TB’. I try to say no as politely as possible. I explain this is a sick patient who needs treatment and investigations in hospital.
Later in the morning a man comes actually referred here form another rural health centre to have his urine checked under the microscope for schistosomiasis as he has been passing blood in his urine recently. I let Roger go and prepare the slide and use a local school teacher who is here with his daughter to translate for a while. When Roger tells me the slide is negative I ask him does that mean the patient doesn’t have Schisto. Yes, he replies because if it was there I would see it. I point out that the microscopy is positive in only about half of cases. I try to explain my rationale (be it right r wrong) for treating schisto – I treat anyone with blood on urine dip with no obvious explanation such as menses or infection. It’s a single dose of safe medication and such a policy would have saved this man coming 20km for a time consuming and ultimately not useful test.
The remainder of the day continues much like this. I know if I was Roger I would having me sitting in asking him questions pointing things out. A lady presents following a bite from a spitting cobra on her foot out in the fields this morning, her whole leg is swollen. Roger is content just to give her some antibiotics and send her home. I have seen enough patients need amputations following local tissue infection after snake bites to persuade him to refer her for IV antibiotics and so the leg can be observed in hospital for a few days.
Often people in secondary care complain about too many referrals from primary care. I feel patients should be referred when a hospital investigation is needed to reach a diagnosis, treatment only available in hospital is needed or where managing the patient s beyond the skills available in primary care. There are a lot of mitigating factors in Mpopo such as distance to hospital, transport costs and patient reluctance but it seems many patients who should be referred are not.
Thursday 20th January
My last day in Mpopo. There is another village clinic today which I am looking forward to. In the morning I spend some time with Roger seeing patients. A mother brings in her 5 year old daughter, she has come frequently with abdominal pain. She is pale I show Roger the importance of checking for pallor. He asks should we check a blood count. No, there is little to be gained in him spending time looking down a microscope estimating this. I explain we should just give her iron, treat hookworm which may well be causing her anaemia and stomach pains and follow her up. Surely this is a more sensible approach in a resource poor setting.
Later I head out with Telesa to another village. Among the community health volunteers here is Davison the head man. After the vaccines we do the family planning. Telesa tells the women who have got depot contraception to come again on 20th April. I politely point out that the depot is effective for twelve weeks not three months (almost thirteen weeks). How was she supposed to know that after all this afternoon her duties should be scrubbing the walls. After the health promotion talk one of the volunteers promotes his little business selling bottles of chlorine for 800 kwacha (15cent) which would make about 100 litres of this village’s filthy well water a little less unsafe to drink. He is also selling condoms, 500 kwacha for three.
We eat our meal (though I don’t chance the water the chicken here is really good) head back to Mpopo and I pack my things. Where was Edward? Perhaps he was uneasy about me observing him work, perhaps he genuinely had something to do, perhaps he thought he would just bugger off because I was here. I don’t know if things would have been any better with him here. With al due respects to the profession of midwifery it is not a qualification to deal with acute childhood illnesses such as malaria or chronic diseases such as asthma or hypertension. Looking at some of the records it seems he just does the same as Roger does in the consultation, after all it is from him Roger learned to work this way.
I take some photos and say goodbye to Roger and Telesa. They are really nice people who are trying their best in difficult circumstances. They have been welcoming and open to suggestions but I don’t known if their practice will change much from my visit. For me it has been an eye opening experience living in the village completely isolated from he outside world, this is Africa.
So what would I do with this model of primary care? There is a good argument for just closing the centre (and others like it) as the standard of care is so unsafe, but that wouldn’t achieve anything. In fact the government are opening more of these centres thanks to donor money and proudly boasting about the ‘improvements’ in primary care. I think the Zambian authorities should forget about this façade of having trained nurses in the centres because in practice they are not there.
People like Roger and Telesa should be upskilled on how to identify acutely sick patients and have clearer protocols on how to manage them. Chronic care could be provided by a mobile team with a clinician who could visit once a week, this would also help staff training. The community health volunteers could take over the admin side of the centre. I think any pregnant woman with a hint of means would be crazy not to take herself to St Francis for delivery. Centralising maternity services would be difficult and costly. More staff would be needed in the hospital (maybe Edward among them). To entice patients I think you would need to supply a one of payment to each mother who has delivered in the hospital scaled on the distance to her home. While costly this would probably dramatically reduce perinatal mortality.
Whilst the above is an actual account of my experience of primary care in a village in Eastern Zambia the name of the village and the health centre staff have been altered. I would like to thank ‘Roger’, ‘Telesa’, ‘Paul’ and the people of ‘Mpopo’ and its surrounding villages for their kindness and hospitality.
My last of seemingly endless weekends spent working in St Francis over I am leaving Katete to sample life in a rural village and experience primary care in Zambia. I have spent a lot of the past few months comparing life and medicine here with what I knew at home. But having trained as a GP I want to see how primary care in Zambia compares to Ireland. Obligatory bureaucracy overcome including getting two drafts of a introductory letter for the district Medical officer and trying to liaise with Edward via phone trough crap reception I am on my way to spend a three nights and four days in Mpopo rural health centre.
Mpopo is a large village about 80km from Katete the last section off the tar. I am looking forward to having a relaxing stress free few days. I arrive at a leisurely nine thirty to find Edward who runs the centre has had to go to a training meeting and I am greeted by Roger instead. He explains that the health centre serves a catchment of over eight thousand people and provides acute care, chronic illness management, family planning, antenatal care, looks after about thirty on site deliveries per month and under five care (vaccinations, growth monitoring etc). HIV services are provided by an outreach team.
As well as the labour ward there is an on site ward with three beds where patients can lodge if they are very ill or whilst awaiting transport to hospital. There is a laboratory with a microscope, tests available are blood slide for malaria, haemoglobin (blood count), urine microscopy (to look for infection), RPR (syphilis test), sputum examination for TB and pregnancy test.
There are a load of patients waiting to be seen so we start. Now let me explain the staffing situation in Mpopo. Edward who manages the centre is a registered mid wife. Roger is a microscopist with two weeks training in laboratory techniques. His wife Telesa is a ‘certified daily employee’ whose role is supposedly to give admin support as well as clean and maintain the centre. Limbikani is the night watch man. Thomas is the data clerk, that’s it. When Edward the only trained staff member is away like today, at meetings or workshops, which seems to happen very frequently the others keep the show on the road.
I start seeing the patients with Roger helping to translate and outline how the centre works. We see malaria, pneumonia, chronic obstructive pulmonary disease, a woman with painful periods a child with tonsillitis among many others. About an hour in Roger tells me there is a child fitting on the ward. We go to find a seven year old boy who had been seen by Edward during the night. He is HIV positive but not yet on treatment, he came the previous night with seizures the family had no money for transport so an ‘ambulance’ has been called and is awaited. The child is still seizing he gets more Diazepam, he has had quinine to treat malaria, I suggest penicillin cause he may have meningitis, he needs to be in hospital. The ambulance eventually arrives but he dies later in St Francis.
We go back to seeing patients. I ask Roger how we are doing. His reply a ‘bit fine the way you work’. After thirty or so patients I suggest Roger see the patients and I can make suggestions, maybe things will move quicker and it doesn’t seem like Roger is too interested in learning anything from me. As a lab microscopist he has no clinical training but frequently sees patients. I quickly realise what he meant by ‘the way I work’ which involved getting something of a history and examining every patient if even just to check temperature, heart and breathing rate and check for pallor. Roger simply asks the presenting complaint be it headache, cough or fever. He almost never does any attempt at examining the patient, ‘consultations’ last less than two minutes. Based on the presenting complaint he prescribes some treatment, be it an antimalarial, an antibiotic or just paracetemol.
I would describe it as guess work, I can’t say how often he gets it right as I would need to assess the patients more. However he does frequently seem to make sensible decisions, having a low threshold for malaria treatment in the under fives, telling some patients to come for review if they don’t get better. He asks my opinion on some cases and I make some simple suggestions. Remember he has no training and no way to diagnose malaria (because he is seeing the patients therefore no lab). The last patient is seen just before six. Seventy five patients have been seen since I arrived.
While Roger has been seeing the patients, Telesa has been dispensing the drugs from a limited selection of antibiotics and painkillers and explaining to the patients how much to take and how often. As we are leaving the centre Telesa tells me there is a woman in the labour ward. She proceeds to examine the lady and deduce she is 4cm dilated, she doesn’t use a partogram to chart the labours progress but tells me Ronald does when he is here.
I am pretty disheartened after the day. I ponder that maybe the patients would be just as well off without any health care than what they have got today. I am shown to my accommodation. Like the health centre it has power but no running water. It’s a bare shell of a house with four rooms no furniture or appliances, thankfully I have brought a camping mattress and some bedding. There is a pit latrine round the back, I can’t see a bath room anywhere. Water is from a bore hole near by. I realise that I am hopelessly under prepared, what use is my laptop and mobile phone here. I have some bread, corn flakes and milk but nothing to eat them out of, how I am going to wash?
I walk down to the village to try to find some food. It’s a big place several hundred people must live here. The village square is populated by grazing cattle and playing children. I bump into Thomas the data clerk from the centre. He hasn’t been working today but out in the fields planting. He never got to complete school and was a taxi driver in Lusaka, he got this job ahead of eleven others with more education. His role has been financed by the World Bank under the performance based funding for scheme which I did some inspections for a while back. Since he started working in the centre last March he hasn't been paid. Thomas shows me around the village, the two taverns, three or four shops selling basic clothes, soap and detergent but no food, the various different churches, the cattle shed in the square which he says belongs to a cooperative.
When I arrive back at the centre Edward has returned. We chat in the centre for a bit between seeing a few patients who have arrived to the centre. He tells me there had been four trained staff here but now he is the only one. He seems frustrated and disillusioned with the work, being on call every night. He plans to return to hospital midwifery. I tell him about my background and that yeah things are different in Ireland a centre like this would have probably three GPs a nurse or two as well as support staff. Edward tells me a new teacher for the school has just arrived and will be staying in the house with me. I greet Paul briefly and retire to sleep.
Tuesday 18th January
I wake at six from a dreadful nights sleep punctuated by heat and rolling of the camping mattress to hear Paul outside slashing branches, what is he doing? I go to the bore hole to wash my teeth get some water to drink. I have decided I can’t possibly stay here another night, I will go back to Katete this evening and commute out the other days.
The morning is just the same I sit with Roger seeing patients, there are less today but he still moves super quick. However he seems much more receptive to comments and suggestions I make and I realise that in Ireland it is unlikely anyone with so little training would do as good a job in such difficult circumstances. A lot of the patients like at home don’t have a whole lot wrong with them, like at home the mothers seem to bring all the children to be seen at once. I am starting to feel a little better about things and decide to be more stoic and not return sulking to Katete this evening. At midday I go to get some water and find that the pigs and chickens outside the house have been joined by a team of kids from the school clearing the ground.
Their new teacher Paul is from Katete and has been appointed deputy head master here. His wife and children will be staying in Katete where she also teaches and they have their home. He describes it as a promotion to isolation. He is prepared for life here has a little electric stove, meal to make nshima, tomatoes for relish and eggs along with his laptop and stereo. Earlier he had been cutting branches to repair the houses wash area, a grass fence enclosed square outside which I hadn’t noticed. I ask Paul if he wouldn’t mind sharing some food with me which he enthusiastically agrees to.
In the afternoon I go with Telesa on an outreach visit to another village. Telesa’s duties are listed on the notice board in the centre. Tuesday afternoon is polish the floors day, the floors don’t look like they have been polished in a long time. I drive us a few kilometers down the track to the next village where dozens of women have gathered under a tree with their children. Community health volunteers weigh the babies and organise child health records.
Over the next couple of hours under the tree we vaccinate countless children against measles, diphtheria, polio, haemophilus and tetanus. We give oral and depot contraception to women who understand the benefits of family planning and allowing some time between pregnancies, we give antenatal care to pregnant women including folic acid, iron and intermittent presumptive malaria treatment. One of the community health volunteers gives a talk on nutrition and different food groups. The women sing some songs to the first white visitor to their village in a long time (if ever), everyone is intrigued by my camera and looking at he photos I am taking. Because this is Zambia we don’t leave until after we have been fed with nshima, vegetables and something I think was chicken.
When we get back to Mpopo we see the last of the patients in the clinic. I have a wash (throw a bucket of cold water over myself) in the newly discovered ‘bathroom’, enjoy some more nshima with eggs prepared by Paul and retire much more content than twenty four hours before.
Wednesday 19th January
Still no sign of Edward today. Roger continues seeing the patients with me trying to give some hints and suggestions. A local councillor brings his son in his twenties. He has been coughing for some months has been loosing weight and has had a fever for the past few days. He previously had TB sputums checked a few months ago which were negative. He looks obviously ill, is breathing fast, very thin. Ernest ascertains only that he has a cough for some months. I ask him what he is going to do. ‘Check sputums for TB’. I try to say no as politely as possible. I explain this is a sick patient who needs treatment and investigations in hospital.
Later in the morning a man comes actually referred here form another rural health centre to have his urine checked under the microscope for schistosomiasis as he has been passing blood in his urine recently. I let Roger go and prepare the slide and use a local school teacher who is here with his daughter to translate for a while. When Roger tells me the slide is negative I ask him does that mean the patient doesn’t have Schisto. Yes, he replies because if it was there I would see it. I point out that the microscopy is positive in only about half of cases. I try to explain my rationale (be it right r wrong) for treating schisto – I treat anyone with blood on urine dip with no obvious explanation such as menses or infection. It’s a single dose of safe medication and such a policy would have saved this man coming 20km for a time consuming and ultimately not useful test.
The remainder of the day continues much like this. I know if I was Roger I would having me sitting in asking him questions pointing things out. A lady presents following a bite from a spitting cobra on her foot out in the fields this morning, her whole leg is swollen. Roger is content just to give her some antibiotics and send her home. I have seen enough patients need amputations following local tissue infection after snake bites to persuade him to refer her for IV antibiotics and so the leg can be observed in hospital for a few days.
Often people in secondary care complain about too many referrals from primary care. I feel patients should be referred when a hospital investigation is needed to reach a diagnosis, treatment only available in hospital is needed or where managing the patient s beyond the skills available in primary care. There are a lot of mitigating factors in Mpopo such as distance to hospital, transport costs and patient reluctance but it seems many patients who should be referred are not.
Thursday 20th January
My last day in Mpopo. There is another village clinic today which I am looking forward to. In the morning I spend some time with Roger seeing patients. A mother brings in her 5 year old daughter, she has come frequently with abdominal pain. She is pale I show Roger the importance of checking for pallor. He asks should we check a blood count. No, there is little to be gained in him spending time looking down a microscope estimating this. I explain we should just give her iron, treat hookworm which may well be causing her anaemia and stomach pains and follow her up. Surely this is a more sensible approach in a resource poor setting.
Later I head out with Telesa to another village. Among the community health volunteers here is Davison the head man. After the vaccines we do the family planning. Telesa tells the women who have got depot contraception to come again on 20th April. I politely point out that the depot is effective for twelve weeks not three months (almost thirteen weeks). How was she supposed to know that after all this afternoon her duties should be scrubbing the walls. After the health promotion talk one of the volunteers promotes his little business selling bottles of chlorine for 800 kwacha (15cent) which would make about 100 litres of this village’s filthy well water a little less unsafe to drink. He is also selling condoms, 500 kwacha for three.
We eat our meal (though I don’t chance the water the chicken here is really good) head back to Mpopo and I pack my things. Where was Edward? Perhaps he was uneasy about me observing him work, perhaps he genuinely had something to do, perhaps he thought he would just bugger off because I was here. I don’t know if things would have been any better with him here. With al due respects to the profession of midwifery it is not a qualification to deal with acute childhood illnesses such as malaria or chronic diseases such as asthma or hypertension. Looking at some of the records it seems he just does the same as Roger does in the consultation, after all it is from him Roger learned to work this way.
I take some photos and say goodbye to Roger and Telesa. They are really nice people who are trying their best in difficult circumstances. They have been welcoming and open to suggestions but I don’t known if their practice will change much from my visit. For me it has been an eye opening experience living in the village completely isolated from he outside world, this is Africa.
So what would I do with this model of primary care? There is a good argument for just closing the centre (and others like it) as the standard of care is so unsafe, but that wouldn’t achieve anything. In fact the government are opening more of these centres thanks to donor money and proudly boasting about the ‘improvements’ in primary care. I think the Zambian authorities should forget about this façade of having trained nurses in the centres because in practice they are not there.
People like Roger and Telesa should be upskilled on how to identify acutely sick patients and have clearer protocols on how to manage them. Chronic care could be provided by a mobile team with a clinician who could visit once a week, this would also help staff training. The community health volunteers could take over the admin side of the centre. I think any pregnant woman with a hint of means would be crazy not to take herself to St Francis for delivery. Centralising maternity services would be difficult and costly. More staff would be needed in the hospital (maybe Edward among them). To entice patients I think you would need to supply a one of payment to each mother who has delivered in the hospital scaled on the distance to her home. While costly this would probably dramatically reduce perinatal mortality.
Whilst the above is an actual account of my experience of primary care in a village in Eastern Zambia the name of the village and the health centre staff have been altered. I would like to thank ‘Roger’, ‘Telesa’, ‘Paul’ and the people of ‘Mpopo’ and its surrounding villages for their kindness and hospitality.
Friday, January 21, 2011
Chifkuwa?
‘We did it because we were with a missionary society’ Shelagh Parkinson St Francis Medical director tells me. As my time in St Francis comes an end I am beginning to think about what it was that motivated me to come here in the first place and indeed what it is that motivates others to spend some of their lives volunteering their skills in developing countries like Zambia.
On the most basic level I came back here because as a medical student in 2003 I had been impressed by the work the hospital was doing in difficult conditions for people that had much less access to health care than those in Ireland yet greater needs. I decided that after I graduated I would come back as a doctor to help in that work. But really there are a whole stream of other motivating factors like uncertainty about my future career, dissatisfaction with my life, some kind of Christian desire to do ‘good’ and really not having anything better I could think of doing. This is only seven months of my life and while it’s been hard work and a huge financial sacrifice I can go home soon and should be able to earn a comfortable living.
Ian and Shelagh Parkinson have been working at St Francis hospital for twelve years. Some of their six children have been born here, four are still in school in Zambia while their youngest Josh is yet to start school. Whilst doing missionary work was their original motivation to come they hadn’t planned to be here long term. ‘I find the work here really rewarding’ explains Shelagh while Ian who is the hospitals administrator responsible for managing the budget and staff adds ‘Shelagh was born in Kenya so there was always that kind of pull back to Africa. My job is less day to day rewarding but it is still rewarding at times’.
In the UK they would earn big salaries as a consultant Paediatrician and a hospital manager and I ask if this financial sacrifice has been difficult, ‘Money is just money, we have been really happy here and we wouldn’t have been able to stay if we didn’t have savings from before’ Shelagh outlines, ‘We’re talking number one on the ARV (HIV medicine) register still alive, to have that feeling you have contributed to making a difference’. Ian also feels that and individuals skills and work can have a greater impact here than back home where ‘you are just a big fish in a pond’.
While they have found raising children here difficult especially having to send them to boarding school they also benefits in having a family here. ‘We have given up a lot whilst the lifestyle is more simple here the kids have not benefited from that they have avoided the negatives’ Shelagh explains.
I have noticed a lot of changes and improvements in St Francis in the seven years since I came here as a student. There is much greater availability of treatment such as HIV drugs and chemotherapy. Recently though he hospital ran out of frusemide a really important drug used in cardiac failure and other conditions. Ian comments on this ‘how can you run out of frusemide, sometimes you do ask what have we achieved have we achieved anything at all?’ Overall the hospital saw a steady improvement in funding from both donations and the government up to two years ago. Ian explains that there have been recent allegations of fraud in the Ministry of Health and international donors pulled out. Last year the hospital got 10% less than two years previous from the ministry. Ian was then told last month that December’s grant wouldn’t be arriving and to make do with what they got in November!
He also points out that Chipata general hospital gets double the budget. I have never been to that hospital and I am sure there are many people there working hard but I find it strange that they have a higher budget when they refer patients here and indeed many people from there travel to Katete for treatment of their own choice. Ian says the ARV (HIV treatment) programme has cushioned the blow. This is funded from the US thanks to former president Bush ‘George Bush whatever other things he has done wrong, the AIDS relief programme people are alive and working’.
Shelagh adds that the availability of meds has had a d dramatic impact ‘We used to have quarterly board meetings and there were always three deaths per quarter among staff. ARVs changed that. Some staff even transferred here in the beginning to be close to ARVs’. I ask Shelagh a little more of the difficulties of dealing with staff health. There is obviously no occupational health department here so member of staff who need medical care simply approach one of the doctors (usually Shelagh) in the corridor. ‘The staff I really don’t mind it’s the VIPs, but that’s just expected but that’s just expected, its not a priority to change it just the VIPs will always be there but if your not going to deal with them you just won’t do well’.
Having worked in the Irish health care system I am well used to VIPs, consultants private patients getting extra attention in the public hospital. At home not looking after them well could lead to less income for that consultant. Here not taking extra care of a chief’s wife or a politicians nephew could lead to loss of goodwill among the establishment or worse still negatively impact on government funding vital to treat all patients.
Overall things have improved greatly in the past few years which I have found really encouraging. Shelagh explains ‘in most areas it has got bigger, peoples expectations have increased and their access to health care has improved. That can make it more difficult with people living longer with HIV there are incredibly complex cases on the wards’. Ian adds that staff numbers have improved there are more government employees, more nurses and nurses with higher training.
Another thing I have noted is that there are more foreign doctors to compliment the few Zambian doctors working in the hospital. I tell Ian and Shelagh that I have assumed this a deliberate strategy to improve standards of care. Ian agrees there have been more in recent years. I enquire as to what they think of all the different doctors coming and going most for only six months or so. One of the interesting things I have found here is seeing the different medical students from different countries, they must feel the same about the doctors. Shelagh adds ‘the vast majority come with a great attitude open wanting to learn. I have found them really good, very hard working, low maintenance. A few come with slightly over ambitious ideas of saving the world and slightly over critical but the majority have been very good’.
Whilst these are volunteers it does cost the hospital money to accommodate them and give them some food, I ask their thoughts on this. ‘Its cheap for what they do, we wouldn’t be getting anywhere without the volunteers. Sometimes you wish we got longer term locals, it’s a vicious circle they (the government) don’t post doctors as they know we can get them from outside. Before, we had clinical officers on the ward, me overseeing and trying to race around. In the early years it was really hard going.’
Ian adds that ‘a good number of staff stay long term, you need freshness, which is another thing the ex-pats bring. Being here a while there is a danger you start to accept things you shouldn’t accept’. Ian adds that includes the countless students who come for 6-12 weeks each giving particular mention to the students hat come form Galway every year ‘the Irish students bring such enthusiasm, I think it is because they spend a long time planning the visit and raising so much money’
So what things do they think could be improved in St Francis. They identify stock control (departments including pharmacy not reordering items until they have actually run out) and nursing standards. There is a low staffing level in nursing here, only one nurse per ward at night, but often that nurse is sleeping. Ian puts it ‘there is not many nurses so they can’t do much so they don’t’. I point out a few things I feel could be really improved on including palliative care and staff training.
St Francis wouldn’t be anywhere close to what it is now were it not for Ian and Shelagh and before them James and Faith Cairns who spent 35 years here. In many ways its easy to find motivation to come here for six months or so but to dedicate a huge part of one’s life takes a special kind of commitment to trying to make the life’s of those less fortunate just a little bit better.
On the most basic level I came back here because as a medical student in 2003 I had been impressed by the work the hospital was doing in difficult conditions for people that had much less access to health care than those in Ireland yet greater needs. I decided that after I graduated I would come back as a doctor to help in that work. But really there are a whole stream of other motivating factors like uncertainty about my future career, dissatisfaction with my life, some kind of Christian desire to do ‘good’ and really not having anything better I could think of doing. This is only seven months of my life and while it’s been hard work and a huge financial sacrifice I can go home soon and should be able to earn a comfortable living.
Ian and Shelagh Parkinson have been working at St Francis hospital for twelve years. Some of their six children have been born here, four are still in school in Zambia while their youngest Josh is yet to start school. Whilst doing missionary work was their original motivation to come they hadn’t planned to be here long term. ‘I find the work here really rewarding’ explains Shelagh while Ian who is the hospitals administrator responsible for managing the budget and staff adds ‘Shelagh was born in Kenya so there was always that kind of pull back to Africa. My job is less day to day rewarding but it is still rewarding at times’.
In the UK they would earn big salaries as a consultant Paediatrician and a hospital manager and I ask if this financial sacrifice has been difficult, ‘Money is just money, we have been really happy here and we wouldn’t have been able to stay if we didn’t have savings from before’ Shelagh outlines, ‘We’re talking number one on the ARV (HIV medicine) register still alive, to have that feeling you have contributed to making a difference’. Ian also feels that and individuals skills and work can have a greater impact here than back home where ‘you are just a big fish in a pond’.
While they have found raising children here difficult especially having to send them to boarding school they also benefits in having a family here. ‘We have given up a lot whilst the lifestyle is more simple here the kids have not benefited from that they have avoided the negatives’ Shelagh explains.
I have noticed a lot of changes and improvements in St Francis in the seven years since I came here as a student. There is much greater availability of treatment such as HIV drugs and chemotherapy. Recently though he hospital ran out of frusemide a really important drug used in cardiac failure and other conditions. Ian comments on this ‘how can you run out of frusemide, sometimes you do ask what have we achieved have we achieved anything at all?’ Overall the hospital saw a steady improvement in funding from both donations and the government up to two years ago. Ian explains that there have been recent allegations of fraud in the Ministry of Health and international donors pulled out. Last year the hospital got 10% less than two years previous from the ministry. Ian was then told last month that December’s grant wouldn’t be arriving and to make do with what they got in November!
He also points out that Chipata general hospital gets double the budget. I have never been to that hospital and I am sure there are many people there working hard but I find it strange that they have a higher budget when they refer patients here and indeed many people from there travel to Katete for treatment of their own choice. Ian says the ARV (HIV treatment) programme has cushioned the blow. This is funded from the US thanks to former president Bush ‘George Bush whatever other things he has done wrong, the AIDS relief programme people are alive and working’.
Shelagh adds that the availability of meds has had a d dramatic impact ‘We used to have quarterly board meetings and there were always three deaths per quarter among staff. ARVs changed that. Some staff even transferred here in the beginning to be close to ARVs’. I ask Shelagh a little more of the difficulties of dealing with staff health. There is obviously no occupational health department here so member of staff who need medical care simply approach one of the doctors (usually Shelagh) in the corridor. ‘The staff I really don’t mind it’s the VIPs, but that’s just expected but that’s just expected, its not a priority to change it just the VIPs will always be there but if your not going to deal with them you just won’t do well’.
Having worked in the Irish health care system I am well used to VIPs, consultants private patients getting extra attention in the public hospital. At home not looking after them well could lead to less income for that consultant. Here not taking extra care of a chief’s wife or a politicians nephew could lead to loss of goodwill among the establishment or worse still negatively impact on government funding vital to treat all patients.
Overall things have improved greatly in the past few years which I have found really encouraging. Shelagh explains ‘in most areas it has got bigger, peoples expectations have increased and their access to health care has improved. That can make it more difficult with people living longer with HIV there are incredibly complex cases on the wards’. Ian adds that staff numbers have improved there are more government employees, more nurses and nurses with higher training.
Another thing I have noted is that there are more foreign doctors to compliment the few Zambian doctors working in the hospital. I tell Ian and Shelagh that I have assumed this a deliberate strategy to improve standards of care. Ian agrees there have been more in recent years. I enquire as to what they think of all the different doctors coming and going most for only six months or so. One of the interesting things I have found here is seeing the different medical students from different countries, they must feel the same about the doctors. Shelagh adds ‘the vast majority come with a great attitude open wanting to learn. I have found them really good, very hard working, low maintenance. A few come with slightly over ambitious ideas of saving the world and slightly over critical but the majority have been very good’.
Whilst these are volunteers it does cost the hospital money to accommodate them and give them some food, I ask their thoughts on this. ‘Its cheap for what they do, we wouldn’t be getting anywhere without the volunteers. Sometimes you wish we got longer term locals, it’s a vicious circle they (the government) don’t post doctors as they know we can get them from outside. Before, we had clinical officers on the ward, me overseeing and trying to race around. In the early years it was really hard going.’
Ian adds that ‘a good number of staff stay long term, you need freshness, which is another thing the ex-pats bring. Being here a while there is a danger you start to accept things you shouldn’t accept’. Ian adds that includes the countless students who come for 6-12 weeks each giving particular mention to the students hat come form Galway every year ‘the Irish students bring such enthusiasm, I think it is because they spend a long time planning the visit and raising so much money’
So what things do they think could be improved in St Francis. They identify stock control (departments including pharmacy not reordering items until they have actually run out) and nursing standards. There is a low staffing level in nursing here, only one nurse per ward at night, but often that nurse is sleeping. Ian puts it ‘there is not many nurses so they can’t do much so they don’t’. I point out a few things I feel could be really improved on including palliative care and staff training.
St Francis wouldn’t be anywhere close to what it is now were it not for Ian and Shelagh and before them James and Faith Cairns who spent 35 years here. In many ways its easy to find motivation to come here for six months or so but to dedicate a huge part of one’s life takes a special kind of commitment to trying to make the life’s of those less fortunate just a little bit better.
Thursday, January 20, 2011
Did they know it was Christmas time at all?
Back home I expect the Christmas decorations will have come down, post Christmas sales are in full swing and people’s ears will be spared Band Aid on the radio for another ten months or so. Christmas in Zambia was certainly different to home. Whilst the expensive shops in Lusaka and other big towns were probably decorated like at home most Zambians would not have had means to decorate their homes.
Most people I talked to weren’t making a big deal of Christmas. For many Christmas day was going to involve going to church and having a family meal. For a small number of others it was just like a bank holiday and an opportunity to spend the day in a bar drinking. It also seems Rudolf and his fellow reindeer don’t have the distance capability to allow Santa Claus to visit children here.
At home almost every patient in the hospital wants to be discharged before Christmas. In the week leading up to Christmas on St Augustine I was surprised to find many patients not bothered whether they had to stay in over the weekend or not. However come Christmas day the ward was just half full, even paeds wasn’t too busy despite the fact malaria season is upon us now. The age limit on paeds isn’t fourteen or sixteen like at home, all children admitted over ten years are on the adult wards. As all the kids in Mbusa are getting small presents for Christmas I try to find something for a twelve year old and a thirteen year old on St Augustine. I find a football left behind by the Irish medical students in the summer and a kite left behind by a Cornish dentist.
I decide to give the kite to the younger child as I don’t think he is up to playing football. After the ward round on Christmas morning I try to instil some Christmas cheer by making a fool of myself running up and down outside the ward getting the kite to fly in the absence of much breeze. Joseph smiles a little but doesn’t seem overly impressed probably understandable as he has just started HIV medicines a few days before and is breathless even at rest from cardiomyopathy and bronchiectasis (heart and lung damage secondary to chronic infection). His form does improve after a few days when he is well enough to be discharged home.
There is a special Christmas lunch for the patients served up by the doctors. Instead of the usual nshima (ground maize), beans and rape at Christmas there is chicken and rice. In addition every patient is presented with a bag of sugar, a bag of salt and a bar of soap. There are also sweets for everybody brought back by Paul and Nicola (two of the doctors) from a recent trip back to the UK.
After finishing serving the patients we have our own Christmas dinner at the Parkinson’s house. Shelagh and Ian are the hospitals medical director and administrator. They invite all the volunteers left around to enjoy a fantastic dinner with them and their kids.
The week between Christmas and New Year is just like any other week in the year, I guess at home it seems quieter as ‘non essential services’ are usually wound down whereas here there aren’t really any non essential services. On New Years Eve there is a staff party in Malo Gardens one of the pubs in Katete stores. Whilst there isn’t a big turnout, many Zambians don’t take alcohol and for others the 50,000 ticket price (€9) may have been prohibitive and many attend church service, its good fun. There is plenty of food with barbecued goat, steak and chicken. There is beer and wine (not much for me as I have to work the following day). The highlights though are the entertainment and the fireworks.
Frank from the lab has organised the party and has hired ‘CK’ for the entertainment. CK functions as all things, MC, DJ, karaoke singer and comedian. One minute he is spinning some tunes, the next he is doing some political satire of Zambian politicians, then he is organising a press up competition. His best trick is as a ‘singer’. He lets us non Zambians know he is going to do some rock and roll for us as we like that music. He then proceeds to do some karaoke along to a track that goes something like ‘I’m going to give it to you a hundred percent my love’, its more Westlife than rock and roll as he plays the stage even getting the air guitar out. There are further opportunities to make a fool of myself as Frank summons various people onto the stage to display their dancing talents or lack of.
At midnight there are fireworks of the variety where one fears for their safety. Guys light fireworks with ridiculously short fuses on some barrels, they then fly of in random directions some scrape over the roof of the building others just clear the heads of the crowd. At one stage Paul gets struck in the chest by one of these, he lets out a scream but thankfully is not injured beyond the pain.
Christmas and New Year celebrations are lower key than home with more a focus on the religious aspect of Christmas but like home people want to have fun and celebrate together. As the theme of the St Francis staff new years party went ‘Have fun while you live’. Happy new year.
Most people I talked to weren’t making a big deal of Christmas. For many Christmas day was going to involve going to church and having a family meal. For a small number of others it was just like a bank holiday and an opportunity to spend the day in a bar drinking. It also seems Rudolf and his fellow reindeer don’t have the distance capability to allow Santa Claus to visit children here.
At home almost every patient in the hospital wants to be discharged before Christmas. In the week leading up to Christmas on St Augustine I was surprised to find many patients not bothered whether they had to stay in over the weekend or not. However come Christmas day the ward was just half full, even paeds wasn’t too busy despite the fact malaria season is upon us now. The age limit on paeds isn’t fourteen or sixteen like at home, all children admitted over ten years are on the adult wards. As all the kids in Mbusa are getting small presents for Christmas I try to find something for a twelve year old and a thirteen year old on St Augustine. I find a football left behind by the Irish medical students in the summer and a kite left behind by a Cornish dentist.
I decide to give the kite to the younger child as I don’t think he is up to playing football. After the ward round on Christmas morning I try to instil some Christmas cheer by making a fool of myself running up and down outside the ward getting the kite to fly in the absence of much breeze. Joseph smiles a little but doesn’t seem overly impressed probably understandable as he has just started HIV medicines a few days before and is breathless even at rest from cardiomyopathy and bronchiectasis (heart and lung damage secondary to chronic infection). His form does improve after a few days when he is well enough to be discharged home.
There is a special Christmas lunch for the patients served up by the doctors. Instead of the usual nshima (ground maize), beans and rape at Christmas there is chicken and rice. In addition every patient is presented with a bag of sugar, a bag of salt and a bar of soap. There are also sweets for everybody brought back by Paul and Nicola (two of the doctors) from a recent trip back to the UK.
After finishing serving the patients we have our own Christmas dinner at the Parkinson’s house. Shelagh and Ian are the hospitals medical director and administrator. They invite all the volunteers left around to enjoy a fantastic dinner with them and their kids.
The week between Christmas and New Year is just like any other week in the year, I guess at home it seems quieter as ‘non essential services’ are usually wound down whereas here there aren’t really any non essential services. On New Years Eve there is a staff party in Malo Gardens one of the pubs in Katete stores. Whilst there isn’t a big turnout, many Zambians don’t take alcohol and for others the 50,000 ticket price (€9) may have been prohibitive and many attend church service, its good fun. There is plenty of food with barbecued goat, steak and chicken. There is beer and wine (not much for me as I have to work the following day). The highlights though are the entertainment and the fireworks.
Frank from the lab has organised the party and has hired ‘CK’ for the entertainment. CK functions as all things, MC, DJ, karaoke singer and comedian. One minute he is spinning some tunes, the next he is doing some political satire of Zambian politicians, then he is organising a press up competition. His best trick is as a ‘singer’. He lets us non Zambians know he is going to do some rock and roll for us as we like that music. He then proceeds to do some karaoke along to a track that goes something like ‘I’m going to give it to you a hundred percent my love’, its more Westlife than rock and roll as he plays the stage even getting the air guitar out. There are further opportunities to make a fool of myself as Frank summons various people onto the stage to display their dancing talents or lack of.
At midnight there are fireworks of the variety where one fears for their safety. Guys light fireworks with ridiculously short fuses on some barrels, they then fly of in random directions some scrape over the roof of the building others just clear the heads of the crowd. At one stage Paul gets struck in the chest by one of these, he lets out a scream but thankfully is not injured beyond the pain.
Christmas and New Year celebrations are lower key than home with more a focus on the religious aspect of Christmas but like home people want to have fun and celebrate together. As the theme of the St Francis staff new years party went ‘Have fun while you live’. Happy new year.
Friday, December 31, 2010
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.
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.
Tuesday, December 28, 2010
Happy Christmas!
Just to say (now that the internet is working again) I hope all those who read this blog had a happy Christmas and good luck for the new year. Thanks again to all those who have contributed to my fundraising efforts for St Francis.
What’s in a name?
Surnames are pretty boring here in Eastern Zambia. Much like most people on Achill Island having either Gallagher or Kilbane as their surname, here well over half of the patients have either Banda (which in English means plain) or Phiri (meaning hill or mountain) for their surname. The remainder comprise a scattering of Zulu’s, Tembo’s, Sakala’s or Mbewe’s. In fact when I see a patient with an unfamiliar surname I usually enquire and find that they are originally from a different part of the country.
Perhaps as a means of making it easier for people to identify themselves and keep numbers of John Banda’s or Mary Phiri’s Limited people here are extremely imaginative when it comes to forenames. Some of these names parents seem to pick in the hope that their children will grow up well, to be Good people, Innocent of any faults, live a Happy life, be Smart and do well in school, to be Humble and Decent.
Some I feel are pretty bad choices. I know being overweight here is a sign of affluence but I struggle to understand how anyone could call their daughter Fatness, or Vast for that matter. I think parents should love all their children just the Same no matter what Size they are. To many parents the arrival of a child is seen as a Gift, a Beauty something Precious. And while it’s good to spread the Love, Lovemore sounds like a chick from a James Bond movie.
Maybe parents pick names in the hope that they are Lucky. Calling your child Fertiliser may lead to a good harvest. Perhaps rather than a child they would have preferred the arrival of a new pair of Shoes or a Table. It’s difficult to put together the Chain of events that leads some choices though such as Tennis or Lightmaka or Butterfly or Dynamo to Note just some.
Sometimes the names bear Witness to the child’s arrival into this world. A boy delivered after a difficult labour is not let forget the fact for the rest of his life and often gets named Mabvuto (trouble). Some mothers are thankful for a Nice and Easy labour though. I hope it is Obvious to the reader that all words in italics are actual names of patients I have come across here working as a Doctor. Goodbye.
Perhaps as a means of making it easier for people to identify themselves and keep numbers of John Banda’s or Mary Phiri’s Limited people here are extremely imaginative when it comes to forenames. Some of these names parents seem to pick in the hope that their children will grow up well, to be Good people, Innocent of any faults, live a Happy life, be Smart and do well in school, to be Humble and Decent.
Some I feel are pretty bad choices. I know being overweight here is a sign of affluence but I struggle to understand how anyone could call their daughter Fatness, or Vast for that matter. I think parents should love all their children just the Same no matter what Size they are. To many parents the arrival of a child is seen as a Gift, a Beauty something Precious. And while it’s good to spread the Love, Lovemore sounds like a chick from a James Bond movie.
Maybe parents pick names in the hope that they are Lucky. Calling your child Fertiliser may lead to a good harvest. Perhaps rather than a child they would have preferred the arrival of a new pair of Shoes or a Table. It’s difficult to put together the Chain of events that leads some choices though such as Tennis or Lightmaka or Butterfly or Dynamo to Note just some.
Sometimes the names bear Witness to the child’s arrival into this world. A boy delivered after a difficult labour is not let forget the fact for the rest of his life and often gets named Mabvuto (trouble). Some mothers are thankful for a Nice and Easy labour though. I hope it is Obvious to the reader that all words in italics are actual names of patients I have come across here working as a Doctor. Goodbye.
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