A white coat on red soil

Men vs. women: to take it or fake it?

I have moved between the male and female wards a couple of times now. It is fascinating to reflect on the differences in presentations we see between men and women, most noticeable in mental health. There is a tendency for men to poison themselves, and for women to have ‘hysteria’. Please note that I am a massive feminist and do not in any way suppose that having a uterus causes women to be crazy, because men can be crazy too (and women also poison themselves). The poisoning is horrible and there is a distinctive acrid, burning smell. They drink super strong fertilisers and insecticides used for agriculture, which cause awful side effects which can last for days and require huge and recurrent doses of antidote to prevent. I have a seen a number of deaths from organophosphate poisoning. They essentially drown in their own lung secretions. I will always remember the young guy in his thirties who drank half a bottle after a little row with his wife, wanting to make a point, but accidentally ended his life. The sight of her leaping on the bed, wailing and pulling at his body, as we stopped resuscitation will stick with me (partly because the brakes weren’t on on the bed, so the whole bed moved as she leapt on him, making it even more dramatic). The women and their hysteria are more light-hearted, and similarly occur after a big emotional incident or argument. I have seen fake seizures, asthma attacks and ‘frozen leg syndrome’. Tim has taught me an excellent tool for distinguishing between true and fake unconsciousness. With the patient lying on their back assuming the classic ‘unconscious pose’, you raise the patient’s arm high above their head and directly over their face, then you quickly let go of the limb and see if it lands on their face with a satisfying ‘thud’ (a negative test = possible true unconsciousness) or if it carefully glides past the face to land on the soft pillow (a positive test = probably faking it). My ‘ABCDE’ approach to the unresponsive patient now goes, “hand-face-drop test, ABCDE…” Please don’t tell the GMC.

Medical cases in Zambia vs. medical cases in the UK

We have a lot of the same conditions as you would find on a general medical ward in the UK: stroke, cancer, heart failure, diabetes, high blood pressure, chest infections. Cancer is usually palliative because they cannot even afford tissue diagnosis by way of biopsy, let alone travel to Lusaka for possible treatment. Though in some ways there are similarities, it is really sad to see conditions that back home could be fully preventable or treatable end up with very poor outcomes. One example is of a twenty-five year old man who died from heart failure (with a 6.7cm pericardial effusion!). He had rheumatic heart disease, which is when you have growths on your heart valves, and if he were in the West he could have been helped at every stage in the progression of his disease. But sadly he lived in a place where the causative bacteria are common, and are prevalent among people with poor living conditions. And when he had attacks of rheumatic fever as a child he didn’t get antibiotics or vaccinations, and when he had a heart murmur and couldn’t keep up with other children, he didn’t get a valve replacement, and when he had signs of heart failure, he was not taken to see a doctor because his family needed him to work, and now it is too late because the government do not fund valve surgery for over 18s. It was really sad to have to palliate a man younger than me, for a disease that could have been entirely preventable at every step. It makes me really appreciate how truly incredible the NHS is, and makes me mourn the people whose lives end prematurely because of lack of access to healthcare and health education.

The fact that there is no proper primary healthcare system (i.e. General Practitioners) and very little health education means that people don’t go to clinic or hospital unless something is really wrong. They go through their lives with undiagnosed chronic conditions like high blood pressure or diabetes, and don’t find out until the disease is very advanced. That said, I have been so impressed by some of the stonkingly high blood pressures of patients who still have not had a stroke! [Warning: upcoming medical chat.] The record so far is 280/180 mmHg (normal is around 120/80). I discharged one man on a bucket of medicines that would precipitate immediate death if I took them. He was a strong, muscly man in his 40s and taking nifedipine 40mg BD, atenolol 100mg OD, losartan 100mg OD, amiloride-hydrochlorthiazide 55mg OD, methyldopa 500mg TDS and furosemide 40mg OD!!!

Drugs in the pharmacy vs. drugs in my cupboard

The situation with medical supplies remains rather depressing! The government has a list of ‘essential’ medicines for clinics and hospitals, of which, in theory, we should never run out. In practice it is an entirely different story. We have been out of stock of paracetamol, fluconazole, prednisolone, nifedipine and bags of normal saline, which are pharmacy staples! And we have had no bandages for a few weeks, so cannot put fractures in plaster unless the patient buys their own. And we currently don’t have catheters. This week pharmacy reported that the Medical Stores delivery gave us only 24% of what we had ordered. It has been an enlightening experience trying to procure our own medicine for the department. Tim keeps a modest ‘medical department emergency fund’ for such situations when we are out of stock of essential medicines. When someone is going to Chipata (the nearby town, 80km away), we decide what medicine we need for our emergency box on the ward and we buy it from the private pharmacy. It’s amazing what goodies you can buy over the counter here! In my cupboard I have salbutamol inhalers, omeprazole, ampoules of atropine, and in my fridge vials of insulin and the chemotherapy drug vincristine! And I have even made some homemade medicine: One Saturday morning I went behind-the-scenes in pharmacy to make up some lidocaine cream for a woman who had horrendous genital ulcers so she could use it to numb the area before urinating. I got to weigh out the lidocaine powder using micro scales and then mix it on the bench with my moisturiser using a giant palette knife! I’m not sure dermatologists would endorse such a cream, but hopefully she was able to pee pain-free. And it inspired me for an excellent prank for someone in the future… mwahahaha.