Paludism – or malaria to you and me

I don’t like to say this, but I am starting to struggle a bit during consultations. Being here for just three months means that it is not worth trying to learn the language well enough to be able to speak to patients with ease and accuracy. I usually have an interpreter, Daillies, who will chatter away with the patient for 30 seconds before turning to me and saying, “Doctor, the patient thinks they might have malaria.” The temptation to write, “Female, X years, ?malaria, please do rapid diagnostic test or blood slide,” as the sum total of my medical notes, is hard to resist.

Of course, if the test comes back negative, I have to decide whether I really do think it is malaria after taking a more thorough history, or to look elsewhere for a cause for the symptoms. Occasionally I will ask Trogness, the laboratory technician, to repeat the blood slide if I am convinced the patient has malaria and quite often I am proved right.

However, Occam’s Razor* is blunt in rural Africa. Having malaria is so common that patients sometimes have another disease as well. This taxes my diagnostic skills, especially when we are diagnosing about 25 patients per day with laboratory-proven malaria. I suppose I rely on my gut instinct as a clinician, asking myself, “Does this fit the clinical pattern of malaria? Or am I missing something?” I try hard to rule out meningitis whenever I see a patient who is very unwell with cerebral malaria, for example.

This is the log of malaria blood films done on 2nd May 2014. The left hand column is the village, the result is on the right. Red writing, 1+ pos means positive for malaria parasites.
This is the log of malaria blood films done on 2nd May 2014. The left hand column is the village, the result is on the right. Red writing, 1+ pos means positive for malaria parasites.

Today, I saw three patients with normal temperatures, who looked fit and well, but they said they had malaria. So I requested the test, thinking that they were not ill enough, but they were correct. One had a really heavy parasitaemia (3+) with minimal symptoms.

It was getting to the stage that I was considering asking all the patients to get tested for malaria before they saw the clinician. Over 75% of the patients we send for testing do have malaria at this time of year. The Rapid Diagnostic Test kits are easy to use, take just 15 minutes to read and can be performed by a health volunteer. But they cost about $5, so one cannot be profligate with their use. We received our monthly ration of 350 kits today. If we test those we think might have malaria, we will probably need 1000 kits this month. When I arrived here in early April, we had no kits in stock. I picked up more supplies when I visited the District Medical Officer to pay my respects, and these ran out a few days ago.

With no kits, our lab technician, Trogness, has to work extremely hard. She doesn’t just do tests for malaria, but it is the major part of her job. She logs the patient details, pricks their finger, spreads blood on a glass slide and allows it to dry. Sometimes she has to unplug the microscope and plug a hairdryer into the socket to dry the slides more quickly. She makes up her own Giemsa reagent and stains the slides for 12 minutes, washing them and drying them again, before she looks at them under the microscope. She then records the result and calls the patient in to take their medical records back to the clinician.

This is the diminutive Trogness, our lab technician. She needs a high stool to see down the microscope.
This is the diminutive Trogness, our lab technician. She needs a high stool to see down the microscope.

Of course, all the patients don’t come in together. They arrive every 5-10 minutes. So Trogness has several sets of slides on the go, at different stages in their processing. It is truly mind boggling and the potential for error, such as writing the result in the wrong set of notes, is high. She looked unwell today, so I offered to help her out and brush up my lab skills at the same time. I won’t tell you the result of her malaria slide.

*Occam’s Razor was a reasoning tool devised by William of Occam, in the 14th Century. When trying to explain a series of phenomena, the best solution is one which takes into account all the facts, in the simplest manner rather than having multiple, complicated explanations. In other words, for a clinician, the best diagnosis would be the simplest one to account for all the clinical symptoms and signs. Of course, when patients have several different diseases, it is less applicable and diagnostic reasoning becomes more tricky.

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