Those of a sensitive disposition, please look away now (after pressing “like”). I wandered lonely as a cloud around the market and took these pictures.
The medics and nurses have come to realise how much I like talking to the patients as well as working out what’s wrong with them and trying to fix it. I think they feel I have special persuasive powers when it comes to health education. Of course, I can’t speak more than half a dozen words of Karen, but the medics and nurses do a fine job translating my pearls of wisdom.
“She wants to take the baby home doctor,” said the medic. “You speak to her, I’m sure you can persuade her to stay until the baby has finished the intravenous antibiotics.” So, no pressure then.
I started with the “soft sell”, complimenting her on the beautiful baby she had just delivered. “Of course you want to go home, but you want the very best treatment for your newborn, too.”
She explained that her husband had to go back home to work in the fields. Her mother would have looked after the two year old at home, but she also needed to work. The poor two year old had been left with a neighbour, and the mother felt guilty. She could have looked after both little ones at home quite easily.
“Well you could bring the two year old here and look after them while the baby finishes the course of antibiotics,” said the medic.
She replied saying that it was difficult for her doing the laundry here, the food was good, but not what she was used to, she had no money and she was lonely. She wasn’t sleeping and was homesick. I was horrified to see her eyes well up with tears. My emotional blackmail had worked too well. I put my arm round here shoulders and gave her a hug. I’ve never done this before here. I have no idea whether it was culturally appropriate or not, but it just felt right. I said that we would try and work something out. I felt a real cad. She was probably suffering from baby blues, too.
I checked the baby over again, scrutinised all the results. Everything seemed normal, apart from the short period of high temperature immediately after birth. By this afternoon she would have had three days of powerful intravenous antibiotics (amp and gent). I took the executive decision to discharge her so she could get the bush taxi along with the antenatal women. Mother and baby would be home in Myanmar by evening.
I didn’t feel that it was fair to make her chose to leave against medical advice. I took the responsibility for that decision. I only hope I’ve done the right thing.
Back in the office, I turned to the medic who had previously praised my persuasive powers and said, “That went well, then.” She just looked at me and smiled.
It’s been a bit quieter on SCBU recently. I like to have the time to get to know the mothers and find out a bit about their lives. So I sit on the bedside (well, it’s a raised platform) and chat, with a medic translating. It’s a bit like being a GP.
Baby X (they are usually not named until they are a month old) was not putting on weight. Failing to thrive, as we say. The mother was very experienced, having had eight pregnancies. We went through a checklist of what could be holding the baby back. Perhaps the mother was not breast feeding the baby frequently enough. I asked one of the nurses to keep a close eye on her interaction with the baby.
The following day, the baby had gained some weight and the nurse was satisfied that, under observation, she was feeding the baby well. I wondered about what would happen when she took the baby home. So I asked how she had managed after the home delivery.
“I fed the baby rice at first, as I didn’t have much milk for the first few days,” she said.
I was flabbergasted. “Boiled rice?”
“Yes,” she replied.
“Is this a traditional practice?” I enquired.
Another woman in the bed opposite said, “No it isn’t a tradition for us. I live in the same village as her and no one else does this.”
“Well it’s a tradition in our home,” said the mother. The nurse went into a detailed discussion of the many benefits of colostrum. There might not be a lot of it, but it’s grand stuff. Meanwhile, I wondered about baby rice. At least she hadn’t tried to feed it a banana.
Thirty five years ago, my cardiovascular auscultative powers were at their peak. In other words, my hearing was perfect and I had just finished a job in cardiothoracic surgery. Many of my patients had abnormal heart sounds and I became a dab hand at interpreting thrills, opening snaps, murmurs and clicks. Once you have mastered the mysteries of the murmur, you never lose that skill. It’s like learning to ride a bike. Or so I thought.
Earlier this week, a nurse asked for my opinion. A young man had been complaining of increasing difficulty in breathing over the past week. He had fainted while working, and recently had started vomiting. The nurse had examined him and couldn’t find a cause for his breathlessness.
When I saw him, he looked distressed and anxious, exerting a lot of effort to get air in his lungs. Listening to his breathing, it all sounded perfectly normal. But his heart was making strange noises – murmurs. This just means that the blood flow is turbulent, making an additional sound. For example, if the blood is passing through a tight or leaking valve, you can hear (and sometimes feel) the distorted flow.
Without boring you with details, I diagnosed mixed valve disease probably caused by rheumatic fever, a disease now rare in UK but still common in developing countries. I asked another doctor for her opinion. She wasn’t as sure as I was, and thought there might be another reason for the murmurs, such as a hole in the heart. Our visiting obstetrician offered to scan his heart even though this wasn’t her normal territory, as the patient would not be able to afford investigation at a Thai hospital. We gathered around the oscilloscope in the scanning room and watched mysterious white shapes fluttering on the screen. She wasn’t sure, but it looked as though at least one valve was abnormal.
I haven’t a clue about ultrasonography. It happened after I left medical school. Even when I did obstetrics, only one of the three specialists in the hospital had been trained to scan. Although I’ve always had a hankering to learn to scan, I’ve never been trained.
The patient was looking more and more worried. He had seen three different doctors, all of whom were interested in his abnormal heart. He knew that the more attention he got, the more serious his condition was likely to be. He had a young family to support. He should be out in the fields tending to his crops. He had a panic attack and we had to get him to rebreathe from a paper bag.
Another day, another specialist. This time a trainee cardiologist visited the clinic. He examined the patient and did another ultrasound scan. One view showed a tiny jet of blood flowing from the left to the right ventricle. He couldn’t confirm it, but the same valve that looked dodgy to me yesterday, he thought was fine.
A large hole in the wall between the ventricles doesn’t sound very loud because the flow through it isn’t very turbulent. Vice versa, a smaller hole causes a louder sound because the flow is more tempestuous. Holes just don’t suddenly appear. He had probably had the problem since birth and it had not sealed itself off. It is possible that over exertion had caused his recent symptoms, but it was more likely to be related to the stress and worry about not being able to provide for his family. Now his main problem was anxiety and panic because four doctors were fussing over his heart.
The trainee cardiologist calmed him down. Afterwards, he told me that private cardiologists spend a lot of their time dealing with patients who have nothing wrong with their hearts but who are suffering from “cardiac neurosis”.
I was wrong here on two counts. Firstly, I misdiagnosed the murmur. I should have considered other possibilities before jumping to conclusions. Secondly, instead of making a triple diagnosis (taking into account biological, psychological and social factors), I’d been blinkered by what I was hearing through my stethoscope. I did not assess the murmur in a holistic context.
Even though we’d like to, we can’t get it right all the time. Read the previous blog about the anxious mother. What is important is that we keep an open, enquiring mind, correct our mistakes and learn from them.
In the out patients department, the nurse approached me and said, “This mother is worried about her baby’s breathing but I cannot find anything wrong. Will you take a look?”
I reviewed the nurse’s findings, examined the baby and also found nothing wrong. “Tell the mother that neither of us can find a problem. Ask her to bring the baby back if the symptoms do not resolve by next week,” I explained. “Always listen carefully to a concerned mother and take her seriously. She knows her baby much better than anyone else,” I opined.
Sure enough, next week she was back to clinic with the baby. We examined the baby again and still could find no abnormality. “Why do you think she is so concerned about the baby?” I asked the nurse. “Can you ask her some more questions to get some background information?”
The nurse told me that this was her second child. The first had been born prematurely and had developed an abscess on the chest. It took a long time for the child to recover. Maybe this was why she was worrying. Perhaps at the first tiny sign of something amiss, she felt she ought to take the baby to the clinic, and early treatment could prevent the situation getting worse. I told the nurse that this was classic health anxiety. I thought we dealt with this sensitively and very well. We reassured the mother appropriately, explaining about uncertainty and not reprimanding her for “wasting time”.
The next Monday morning I arrived at the clinic and heard a baby having a coughing fit, followed by a sharp intake of breath. A whoop. I recognised the mother I had so confidently diagnosed as having health anxiety. Our eyes met, and she smiled. I’m not sure what the smile meant: “I told you something was wrong and you didn’t believe me,” or just friendly recognition?
I started the child on erythromycin immediately for probable whooping cough. We don’t have reliable diagnostic tests for this, but the clinical picture was typical. We kept the child under observation for the rest of the week, by which time her awful coughing spasms had lessened. Apparently, the Chinese term for whooping cough is “100 day cough”. We explained that in spite of the antibiotics, the child would continue to cough for some time. The coughing spasms became infrequent, bothered the baby less, and there were fewer episodes of whooping and vomiting. Mother was happy to take her child home. She’d done her maternal duty and this baby had received prompt care.
That week, at every morning’s ward round, I got the same smile from the mother. During the day, if I was passing the ward and heard the baby coughing, I would stop and look in at the child. When the mother saw the concern on my face, she would break into another smile, but I don’t think that she was enjoying my discomfiture. I felt she was happy to have been proved correct. Maternal intuition beats clinical science. Our only problem is how to manage the next occasion when her brings her child to the clinic and we cannot find anything wrong.
This evening, I invited our visiting obstetrician to join me for supper at my local restaurant, Mai Thai. We sat out under an awning to protect us from the weather. Just after we’d finished eating, two bedraggled Burmese children sneaked into the courtyard to beg. They looked about 10 and 14 years old and were soaked to the skin.
I make it a point not to give money to beggars, but my companion said, “Why not buy them some food to eat?” We got the cook to rustle up two plates of rice and veg, while the children sat at the next table and chatted to the Burmese waitress. She made them feel at ease while their meals were being prepared.
The children were starving and wolfed down their food. As they left the restaurant to go back out into the rain, I gave them my umbrella. I just live a hundred metres from the restaurant; I’d no idea how far they would have to walk in the rain to get to the place they called home.
There was no obsequious gratitude, not even a word of thanks. Perhaps I just detected a nod of the little boy’s head as he left, trying to catch up with his sister who was holding the brolly. Buddhists believe that those who give to the poor or donate to charity do not need to be thanked as they are already earning “merit” for their good deeds. That seemed fine by us this evening.
Thirty years ago, I was the medical officer of a leprosy camp. This was in addition to my role as Regional Medical Officer in Eastern Gambia. To be honest, the residents were all end-stage, “burned out” patients for whom I could do little apart from supportive care. I visited the camp every week or so to see how the dozen patients were getting along. When HRH Princess Anne (now HRH Princess Royal) came to visit The Gambia in 1984, I showed her around the camp, much to the consternation of her “minders”.
Nominally I was also in charge of the supervised leprosy treatment programme in Eastern Gambia, but the health workers rarely called for my help.
So I know a bit about leprosy. And when this thin, gaunt man staggered into the clinic at MKT, his feet bandaged with rags, the diagnosis flashed through my mind. He was leaning on a stout stick with one hand, while the other grasped his young son’s shoulder. As he entered the outpatients department, he shuffled out of his shoes. These were modified Wellington boots which he’d cut away to allow his bandaged feet to fit.
He had been suffering from a deep ulcer in his heel for six months, another in his great toe for two months, and now he had developed a third ulcer between the toes of his other foot. He told us he had not had a proper shower for six months because he was afraid that the water would adversely affect the ulcers on his feet. Not surprisingly, he was dirty and smelled rather ripe. But the filthy rags binding his feet stank to high heaven.
After he’d showered, we examined him, but I could find no thickened nerves, skin or eye problems, characteristic of leprosy. The blood supply to his feet was excellent. Blood and urine tests for diabetes were negative. The other routine blood tests were normal apart from an elevated C-reactive protein, which is a non specific indicator of inflammation. Given the state of his feet, I expected this.
When the medic cleaned out the biggest ulcer, he could insert the gauze swab half an inch deep into the heel pad. This should have been excruciatingly painful, but the patient didn’t bat an eyelid. The ulcer on the toe was so deep that the nurse could feel the bone of the terminal phalanx as he swabbed out the detritus. The odour was sickening. Again, the patient said he felt no pain.
Our TB specialist doctor thought we ought to admit him to a separate room, to be on the safe side. I felt that he needed antibiotics to deal with a deep anaerobic infection and possible osteomyelitis of his toe bone: metronidazole and clindamycin. He said he had lost 10 kilos in weight over the past year because he didn’t have the money to buy food. I prescribed him with extra folic acid, B1 and B12 vitamins and he could eat as much of the clinic food as he wanted. I ordered daily wound cleaning and dressing and we waited to see how he progressed.
Leprosy is only one of the dozens of diseases which can cause peripheral nerve damage (neuropathy). We had ruled out diabetes (one of the commonest causes in UK), poor blood supply, liver and kidney disease. Leprosy, tuberculosis, immune deficiency, syphilis and damage from alcohol were the next diseases to rule out. Quite often, we never find a cause.
The patient told us he’d sought advice from other doctors. No one seemed to know what was wrong. He had been treated unsuccessfully with acupuncture. He had refused to attend the local hospital because he was frightened that they would cut his legs off. He was pessimistic about being cured and thought that the best we could do for him was to fix him up with a set of crutches.
What a bonus we had our French infectious and tropical disease consultant visiting the clinic. He too thought that this was leprosy and he advised me carry out some special tests to confirm or refute this. He wanted to see the ulcers for himself so the nurses took down the dressings.
The nurse and I were both astonished by what we saw. The ulcer on the heel was half as deep as before and the ulcer on the toe was almost healed. This was after just three and a half days of antibiotics, food, vitamins, rest and cleaning. I showed the French consultant photographs of the lesions when we started treatment to prove how dramatic the improvement had been. Rather cheekily, he said that I was the only doctor he knew who could successfully treat leprosy with clindamycin.
When we got back to SMRU base later that day, the specialist started to poke fun at me. He told my colleagues about my “remarkable clinical skill” and jokingly bowed his head in my direction, a traditional Burmese mark of respect.
As Michael Myers (in the film “Wayne’s World”) would say, “I’m not worthy.”
I got lucky.
Correction: the patient and I both got lucky.
He’s not out of the woods yet. As his ulcers heal, the sensation is coming back and he is feeling more pain. We are still trying to find a cause for his symptoms#, but at least it looks like he isn’t going to need those crutches he was asking for.
# we know what germ we’re dealing with now, too.
A French infectious disease specialist from Paris visited MKT clinic on Friday. He accompanied me and the team on morning rounds. Our first patient was in SCBU. While I was concentrating on the neonate, the visitor was looking at the mother.
“How old is she?” he asked. “How old do you think?” I replied. “40?” he said. She was 33, but looked much older, as do many displaced Karen people, living from hand to mouth. Her black hair was streaked with silver. It was tied into a bun at the back of her head and secured with a porcupine quill. There was a small lump of grey fibrous matter impaled on the point of the quill which looked odd. I asked what it was. “Ginger,” she replied. “It keeps the Evil Eye away.”
I asked her how many children she had. This was her seventh. I joked that in France she would get a medal for raising a large family, but the visitor corrected me. “She would get two!”
“Are they all alive?” I asked. She said she thought so. I asked her what she meant and it transpired that she had given one child to her brother and he had sold the baby to someone at a hospital in Burma. I was gobsmacked. The nurses told me that this was not unusual. The people were so poor that they could not afford to feed an additional child, so they would sell it.
Perhaps I was overreacting. There probably were few orphanages in rural Burma and a significant number of couples must be childless, so this could be a reasonable local arrangement. Unplanned surrogacy, if you like. But when I discussed this with another colleague, she commented that this could be viewed as trafficking. Some people might buy a child to be brought up as a family servant or maid. Worse still, quite a few Burmese young girls get sucked into the Thai sex industry.
When a Burmese or Karen baby is born in MKT clinic, the birth is noted in our records but cannot be registered in Thailand. The children are not Thai citizens. Similarly, if babies are born outside hospital in Burma, they are unlikely to be registered. They have no papers; officially they don’t exist.
Cycling back from a trip to buy cheap clothing at the out of town TK Garment factory shop, I came across a funeral. Some of my regular readers might be thinking that I already spend a lot of time thinking and writing about death. But it seems just part of life here.
The procession was led by a man with a smoking pot of incense on a bamboo pole over his shoulder. Actually, a dog was leading the way, but I’m not sure if he’d been invited. Behind the incense carrier was a man carrying a thin pole to which was attached a paper cut out of a human figure. Perhaps this is a symbol of the deceased person’s soul? Seems logical.
These two were followed by a troop of monks of varying ages, holding onto a white rope. I think they are supposed to be chanting buddhist scriptures. The relatives and friends of the deceased came next, also holding the rope, which was attached to the funeral pickup. It carried the coffin and the sound system. Two men were hanging off the back of the funeral pickup, in true Thai style.
The cortege was causing quite a traffic jam in the busy street late on Saturday morning. It was overtaken by several vehicles and an impatient police motorcycle rider. I was tempted to tag along but decided against it.
The little girl looked very poorly. She was semi-conscious, draped across her mother’s arms, with a fever of 39C. Mother showed me a bag of tablets and capsules. With a bit of detective work, I reckoned she had been taking some ampicillin and a selection of vitamins. It must have been difficult getting a child under three years of age to take these, I thought.
“Where did you get these?” I asked. With some reluctance she told me that “someone in the village” had given her the medication. She would not tell me if this was a private doctor or just someone working freelance.
“Has she taken anything else?” I enquired. Mother brought out another plastic bag containing used ampoules of gentamicin (a potent antibiotic) and diclofenac (a non-steroid anti-inflammatory drug, sometimes used as a painkiller). I had no idea how much of each ampoule had been injected into the child. Mum said she had received the drugs intravenously. Injectable diclofenac should not be administered to children at all. And if she had received the whole ampoule, it would have been an adult dose.
Mother told me that it was three days since the injections and her daughter was getting worse, so she had come for help at the clinic. I examined the child carefully and was convinced that she had meningism, the clinical signs of meningitis. Her neck was stiff, Kernig’s sign positive, Brudzinski negative. I really thought this little girl had half-treated meningitis.
She was moaning and clearly distressed. The medic had taken blood for routine “fever tests”, but I had to decide on whether to submit the child to a lumbar puncture. Because she had already had antibiotics, it would be unlikely for us to find the germ causing her illness, so I decided to just give the most powerful broad spectrum antibiotic we have. It’s a bit like Domestos – “kills 99% of all household germs” – as the advertising copy states. And hope for the best.
The following day it was still touch and go. With typical doctor cunning, I tried to get her to bend her neck to suck on a straw in a pack of orange juice. But she wasn’t able to. Her temperature was still high and mum had sent for her father to come.
After three days of intravenous ceftriaxone, her fever settled and she was able to move her neck. I was mightily relieved. Then we received the results of her initial fever tests. They showed she had dengue fever.
Dengue is a viral infection transmitted by mosquitoes in warm climates. The main symptoms are fever, headache and generalised muscular pain. It can rarely cause inflammation of the linings of the brain, resulting in meningism. Usually there is a rash, but she didn’t have one. Most people recover in a week or so, and the mortality rate is low.
The word dengue is Spanish for fastidious, or careful. This reflects the way that people with dengue walked, slowly and gently because of their excruciating muscle and joint pains. In the West Indies, slaves with dengue were said to walk like a dandy – an aristocratic fop – leading to the term “dandy fever”. My favourite term is breakbone fever, coined by Dr Benjamin Rush, one of the US Founding Fathers.
The only treatment is supportive. My intravenous antibiotics were useless. I kick myself (metaphorically of course) for missing the diagnosis at first. Perhaps a more experienced physician would have recognised that this was dengue and not started antibiotics. But doctors play dice, we weigh up the odds while simultaneously working out what is the worst that could happen if we make the wrong decision. We call this safety netting. And we try not to practise “just in case” medicine to cover every eventuality, however rare it might be.