Shooting in the Dark

This installment is in answer to a request for more information about the medical aspect of things here at Mukinge. This will likely be of most interest to medical types but all are welcome to read!

It is certainly different than medicine practiced in Canada. There is much more emphasis on clinical diagnoses and empirical treatment. Resources are limited and the nurses in general have more responsibility re diagnosis and treatment.

The hospital is approximately 200 beds and there is an active OPD that services approximately 160 patients per day. There is a pharmacy, lab, xray and ultasound, 2 theater OR, physio services and a 2 year practical nurse training program. Mr. Fumpa – a clinical officer trained in cataract surgery, deals with eye care. Dentistry (mostly teeth extractions) is done by another clinical officer (think goodness – when I was here before I had to do extractions and I could never quite get the local anesthetic blocks right consistently). There are several wards - men’s, female, pediatrics, tb, and obstetrics. Mukinge is a referral center and services a huge area – it is not unusual for people to come from 5 hours away. Currently there 6 doctors – myself, 2 Zambians, 1 Dutch, 1 from New Zealand (surgeon) and 1 American.

History taking – while English is the official language in Zambia and kids learn it in school and upper level classes are conducted in English, the reality is that most people have limited grasp of the language and are more comfortable in their native Kaonde tongue. Therefore, an interpreter is needed for taking a history - we use either one of the clinical officer or student nurses. Often when asking a question to clarify history (is the pain achey, burning or sharp), there is a long back and forth conversation and the result at the end of it is something like “she says she has pain”. Also, I get the impression that the essential element of the history that I am trying to elicit is lost in the translation often and that I am left with far from perfect information to go on. People commonly come in with tbp (total body pain), headache, and palpitations. Everyone says yes to questions about fever chills and night sweats. Of course the differential diagnosis is much different than in Canada with malaria and TB and opportunistic infections much more prevalent. The incidence of HIV/aids in the 15-49 year old population is estimated at 15-17% and in the pregnant female population in the same age group was 24% in 2004 and 30% in 1994. With this incidence of HIV it shifts the whole differential diagnostic consideration to the rare and exotic. Crytospiridium, Cryptococcus, pcp, TB (including extrapulmonary – bone, pericardial and pleural disease, etc) are run of the mill here. In the pediatric age group PEM (protein energy malnutrition) is surprisingly common thought not as much as when I was here last (although part of that may be seasonal since we are not yet into the “hungry season” when crops run out (novemberish).

Investigations – these are generally limited. There is a lab and an xray and ultrasound department (the ultasound is a nice addition since I was here last time). One area where Mukinge is ahead of medical care in Langley is the promptness with which these tests come back. When working in OPD, I send people for xrays and they are back within an hour with the xray film or the ultrasound report! (Compare with 4-6 weeks for an ultrasound in Langley). There are limited labs and I get the impression that the results are not always to be trusted. I heard a story of a child that was sent home to die with leukemia when her wbc had come back at 70,000 (normal 11,000). She was back several months later alive and well – it turns out that the machine was misreading sickle cells as wbc’s causing a falsely elevated result. There are lots of opportunities to stick needles into body cavities. I have done a LP per day (on hiv+ patients) in the last 2 workdays. Pleurocentesis and peritoneal taps are also common. The tests that are available are somewhat odd – one can get a crag (Cryptococcus antigen test) on blood or csf or a cd4 count but creatinines are not currently available and potassium levels are not available (ever?). It makes it a challenge when treating our CHF patients with meds like lasix, ace inhibitors and spironolactone. Diabetic care and monitoring is atrocious. There is essentially no self-monitoring by patients once discharged and even in the hospital there are limited resources with regard to availability of test strips (too expensive). As one of my Zambian colleagues said the other day when I was doing a presentation on managing diabetes “I often feel like I am shooting in the dark” when it comes to making med adjustments (I think this would be a good motto for medicine here in general). I saw a 14-year-old type 1 diabetic patient in the opd the other day. He had come in for his monthly refills of his lente and regular insulin. He had not done any monitoring and I tried to get a history regarding whether he was having any hypoglycemic episodes and all I could get was that he was feeling unwell “when my blood sugars are high”. How he would know they were high and how he was feeling at the time I have no idea. I refilled the meds with a sense of foreboding. Even A1c’s are unavailable so one truly is shooting in the dark.

In general one relies on clinical acumen and some limited testing and a trial and error treatment scheme balancing potential risks with benefits.

Therapeutics – in general the available meds are greater than when I was here before – there is a good array of basic iv and oral antibiotics, 1 ace inhibitor, 1 beta blocker, 1 calcium channel blocker, etc. Interestingly chloramphenical is used quite often (a drug that is very effective but has a rare bone marrow side effect and is not used in the west). Antiretrovirals for AIDs are now readily available and this is making a huge impact on the quality and duration of life for AIDs sufferers. All the drugs are dispensed from the pharmacy at the hospital and for chronic conditions people generally get 1-2 months at a time. I have noticed when people come in for their regular meds (like antihypertensives) all complain of something else – generally tbp (total body pain), headaches or palpitations. I asked one of the nursing students about this and she said that they feel they had to come up with some symptoms or they wouldn’t get their refills.

Hopefully this gives a glimpse into the challenges and issues dealt with in a bush hospital setting in the developing world.