The young man needed to be physically examined. He stripped off his shirt to demonstrate various abrasions, lacerations and bruises as proof of his having been assaulted. The problem for me was that these injuries did not appear to have been sustained at the same time. Some appeared to be recent, within a few days, and others looked more than a week old. I began to document all the skin lesions.
“When did this happen to you?” I asked, pointing to a long, thin scar over his heart.
“Can’t remember,” he replied.
“And what about this wound here?”
“Oh, I got that playing football,” he said.
Very unlikely, I thought. But sometimes, I can’t resist saying the first thing that comes into my head.
“Have you been playing against Barcelona?”
“It looks like Luis Suárez has bitten you.”
Another patient had been badly injured in a horrific accident many years ago. He had lost an eye and one arm. Soon afterwards, he went stone deaf. I communicated with him by writing questions on a piece of paper, to which he would reply in speech.
Sometimes, my spontaneous comments can be rather crass.
“Is it possible to use sign language when you only have one arm?” I wrote on the paper.
He smiled back at me and said, “I manage ok.”
Patients are often keen to show you what’s wrong. One chap said he had a boil between his buttocks. Before I could ask him any more questions, he turned his back to me, dropped his pants and bent forward. “Don’t shoot!” I said, “You’ve got piles.” He laughed so much at this that he turned around and shook my hand. Or maybe he was relieved he didn’t have a pilonidal or ischiorectal abscess.
A schoolgirl came to see with skinned knees. The abrasions were surrounded by a dark ring. “What’s this?” I asked. “Oh, it’s boot polish. My friend told me it would heal better if I applied it.” I remember seeing a Karen child in Mawkerthai whose scalds had been treated with toothpaste. Perhaps patients see treatments as being black or white?
Occasionally, consultations can be quite surreal.
“Sawubona, good morning, how can I help you?” I asked a patient yesterday.
“I have a rash on my knees,” she said.
“I can’t see any rash here.”
“It only happens when it is hot,” she replied.
“Can you come back and see me when it’s warmer, please?”
“I’ve got another problem. I have abdominal pains.”
“Tell me more about your pains.”
“They are worse when I am having a period.”
“Are you in pain now?”
“No, I am not having a period now.”
“So it is likely that you are having period pains, then?”
“I don’t know, doctor. But can I have a sick sheet?”
One patient had a magnificent baseball cap, one half of which was covered in conical spikes. But one spike was missing. I had been consulting for almost six hours flat out without a break, so my mind was starting to wander. Was the missing spike the clue I needed to make the diagnosis? Had she sat on the hat, leaving a spike attached to her? Had she eaten it? Were the spikes a device to protect her from radio waves, but only on the right side of her brain? It was obviously time for me to have a cup of (rooibos/redbush) tea, regardless of the queue of patients outside my door.
In the clinic, I have taken an interest in non-communicable diseases, such as diabetes and hypertension. The first few hours of my working day for the past couple of weeks have been devoted to seeing elderly ladies (average age about 70) with wonderful names like Nellie, Mavis, Elsie and Dorcas. Although they may just be attending for a blood pressure check or a fasting blood glucose measurement, it is inevitable that they have another half dozen significant medical problems. Most have signs of cardiovascular disease, high cholesterol, poor dental care, cataracts, deafness, osteoporosis, osteoarthritis in the knees and ankles, urinary problems, prostate enlargement in men and incontinence in women. It is just like consulting as a GP in UK. But it is rather novel here in Swaziland, where most medical problems are infections. Most of these conditions do not even merit a mention in the official Swazi medical treatment handbook.
My translator told me this morning that three of the old ladies had remarked to her in siSwati how pleased they were to have seen a doctor who took an interest in sorting out their multiple problems. “And when a Swazi person says ‘ngiyabonga (thank you)’, they really mean it, doctor.”
There was a record of atrial fibrillation in one lady’s medical notes, so while we were talking, I put a hand on her wrist to feel her pulse for a minute or two. I’m not sure what this old lady thought I was doing, but she put her hand on top of mine and smiled at me.
Old ladies are called “gogos” in Swaziland. I am seeing so many of them that perhaps my new nickname is going to be Dr Gogo.