General Practice, but not as you’d know it

A day in the life of Matsapha Comprehensive Health Care Clinic.

The day didn’t start well. The King’s motorcade drove through Manzini at 7am, the start of rush hour, causing traffic chaos. We were late being picked up by the driver, and it took longer than usual to get to the clinic.

The last patient I had seen yesterday was a man with a genital ulcer. I suspected syphilis, but typically the chancre is painless and this wasn’t. I’d asked him to return for a blood test to confirm my suspicions. As I walked into the clinic, I saw him sitting outside my consulting room, clutching a piece of paper. Positive RPR.

I thought I would give him an injection of benzathine penicillin before my teaching session, so he could get off to work. The treatment, benzathine penicillin, is tricky stuff to deal with. I normally add local anaesthetic to the powder, to numb the pain after the injection. The suspension is renowned for clogging up the needle, so I used the widest bore available. I took him into the consultation room, closed the louvres and locked the door. He dropped his pants and I aimed for treble 18 (assuming his buttock was a dartboard).

After injecting about 1 millilitre, the needle blocked and I began to sweat. I felt sure I could force it through with a bit of brute force. Something had to give. The spray from the end of the syringe covered my face, shirt, trousers, the floor, the patient and couch. I looked up at the patient, he looked down at me and we both burst out laughing. I apologised and he said, “Don’t worry, no problem.” Some things nurses do a lot better than doctors.

I went into the conference room and our new nurse took one look at me and realised what had happened. “You look like you’re covered in glitter,” she said.

“Does it look awful? Should I wash it off?” I asked.

“No, it looks rather nice,” she said. I didn’t know whether to believe her, but there was no time. I lurched into an interactive seminar on hypertension.

“What exactly is blood pressure?” I asked the massed nurses.

Silence.

“OK, what is it about the words ‘blood’ and ‘pressure’ that you don’t understand?”

It was going to be a rough session, I thought. Until I got their attention by asking how high the blood would squirt if you chopped someone’s head off? Not in a Jihadi John ISIS-style beheading. More a hypothetical horizontal slice. Yes, the blood would easily hit the ceiling.

Fifty minutes later, buzzing with adrenaline following the teaching session, I went back to the consultation room, determined to redeem myself. First up was an elderly lady (remember “gogo”?) who had recently had a below knee amputation. She had been released from hospital after a prolonged stay. In a scenario very familiar to British GPs, she had no discharge notes, no medication details and no follow up arranged.

She was in a wheelchair, but our portakabin consultation rooms are raised about 40cm above ground level. We have heavy metal ramps which are dragged into position to permit access for disabled patients. Against my advice, the carer insisted on pushing, not pulling, the wheelchair up the ramp. The small front wheels on the chair can whiz around through 360 degrees and one slipped off the side of the ramp. The chair slumped sideways. The patient had to be rescued by two other patients, who hauled her chair into the consultation room.

An interesting start to the day: what did she want me to sort out? Her poorly controlled hypertension? Her rampant diabetes? The deteriorating circulation in her remaining foot? Her depressed mood? No, she just wanted the dressing changing on her stump.

I am in charge of the Sexual and Gender Based Violence unit. This means I get called, as an emergency, away from my outpatient duties, to attend to survivors of rape/sexual assault. We have a good relationship with the local police who bring the survivors to the clinic for assessment and management of psychological and physical problems. Today the police brought in two girls, both under 16.

I try to do my job, compassionately and efficiently, making sure the girls get the best treatment. But the horror experienced by the girls is infectious. It leaches into my brain. I can’t parcel it away like I do when dealing with other tragic events. I find it difficult to comprehend how someone could do this to a child. And even more difficult to write about.

Our new nurse suggested we get a nice box of tissues for the survivors, instead of offering a few feet of thin paper roll, which is normally used to dry hands. I dismissed this at first as pandering to our western sensibilities, but on reflection I think it is a great idea. The only time I ever see a “survivor” smile is when we give them a dignity kit. This contains some toiletries (soap, toothbrush and toothpaste), a towel and new underwear. I am sure they would appreciate some soft, scented tissues to dry their tears.

Back at the outpatients department, I saw two small boys in the queue. They looked subdued and quiet, so I knew something serious was wrong. The first had fallen and scraped his knee. Instead of cleaning the wound, applying some antiseptic cream and covering it with a dressing, it had been neglected for a few days. It stank and was dripping pus. His knee was so swollen that he could not bend it more than 20 degrees. I needed to rule out a septic arthritis by sticking a needle into the joint and trying to aspirate pus. This was clear, so he went to the nurse for “wound toilet”.

The next boy had a tense swelling of the lower leg, with a shiny, thin patch of skin next to his shinbone. I lifted him onto the couch and told him that I needed to let the poison out of his leg so it would get better. It would hurt, but just for a short time. He looked up at his mum for reassurance. She nodded her head in my direction, signalling to get on with it. There was so much pus from deep inside the leg that I was worried he might develop osteomyelitis, so after dressing his leg I asked his mother to make sure I saw him when he came back for a dressing change.

The next few patients were referrals from the nurse. Old ladies with hypertension which was not under control, two patients who had recently had strokes, and a patient with a strange genital rash. This has the impressive Latin name “molluscum contagiosum”. I can diagnose it, I can even spell it, but the treatment is more medieval than Latin. Better to let it vanish by itself over the next year or so (luckily the person concerned was HIV negative).

After a quick cup of redbush tea, I returned to the fray. I was called to see a patient with suspected tuberculosis. Yesterday, I had examined her and on percussing her chest, I thought both bases were dull. Something solid was underneath. Could be liver on the right but not on the left. Maybe fluid, maybe consolidation. I’d ordered a chest radiograph to make sure. It showed a left pleural effusion, almost certainly caused by tuberculosis.

Another young girl had multiple, discrete, firm lumps in her neck. I knew she was having anti-retroviral treatment but was this just HIV lymphadenopathy, or could it be tuberculosis or even cancer? I asked one of our experienced nurses to try to get her to produce some sputum to look for TB. Another hospital manages her HIV, so I wrote her doctor a short note.

Patients often come to our clinic when they feel that they haven’t been treated properly elsewhere. A pregnant lady living with HIV came for a second opinion yesterday. She had lost almost a quarter of her body weight over four months, her breathing was very rapid, she looked pale and frail. She told me she had been put on oxygen by her local health provider, but was sent away after a chest Xray was apparently normal. Her temperature was normal when she arrived, but she felt hot to me. My fancy ear thermometer showed she was febrile at 39C. I listened to her lungs and convinced myself there were some signs at the right base.

Should we send her back to hospital or try to sort her out at the clinic? The consensus was to run some tests and give her treatment for pneumonia. I saw her today to review her. The antibiotic treatment seemed to have worked. Her temperature was down, her breathing was easier and she felt much better. Just when I was preening myself at having sorted out her problem, the geneXpert TB test result came back positive. She had tuberculosis after all. This should not have responded to the antibiotic I had prescribed. There is a lot of art in medicine, which doesn’t appear in the textbooks.

Back in outpatients, I saw a man who was diagnosed with HIV last year. He had developed an abscess on his abdomen which was not healing. A biopsy showed it was cancerous, a lymphoma. He had come to ask questions and seek advice about what to do next. Swaziland has only limited capabilities to treat cancer. He would need chemotherapy in South Africa (if he could find funding).

A teenager with “asthma” was next. He had been given treatment by nebuliser, but when I listened to his chest it was bubbling with secretions. If he was suffering from asthma, his chest should have been quiet or wheezy. Slowly I pieced together the clinical picture. Born with HIV. Tuberculosis in childhood which had badly damaged the airways in both lungs so he now had bronchiectasis. To explain this, I compared his lungs to a tree. The main trunk is the windpipe and the branches get progressively thinner and more leafy. This is where the oxygen is exchanged. The main branches in his lungs had been pollarded, producing thick stumpy branches. He seemed to have been following the analogy well upto this point, but now he looked puzzled. I realised that they don’t pollard trees in Swaziland.

I saw a couple of patients who had defaulted from anti-retroviral treatment and needed to be “reinitiated” on medication. This involves lots of paperwork, but it is easy once you get the hang of it.

Finally, a young woman came to my consulting room looking like death warmed up. The nurse who had seen her thought she might have meningitis, but in fact she had the worst migraine I have seen for a long time.

I returned to my shared house feeling rather shell-shocked. The adrenaline high keeps you going when the pressure is on, but now I was back at home, I felt exhausted. At work, I had been weighing up patients’ symptoms, evaluating clinical signs and making important decisions all day. At home, I couldn’t even decide what to have for supper.

Advertisements

6 Replies to “General Practice, but not as you’d know it”

      1. I can only imagine…

        Do you mind if I ask more about the logistics of your day? How many patients do you see? Is it mainly responsive to patient need or is there pro-active disease monitoring e.g. calling in patients for BP reviews? How do you record the consultations…is it a system akin to the Lloyd Georges?

  1. Its a big clinic, we see 300-400 patients per day. Some of these consults are to pick up ARVs every three months, we prescribe to 5,000 HIV positive patients. I leave home just after 7 and arrive at the clinic at 7:40. I am responsible for improving the care of patients with non communicable diseases. They come early for reviews. Then I see all the tricky patients the nurses refer to me. I see any HIV positive patients who consult between review dates when they are unwell. I also assess the patients suspected to have tuberculosis and patients already on tb treatment who run into problems with side effects, need pleural effusions or cold abscesses tapping. As well as this, I’m in charge of the service we offer to survivors (not victims) of sexual violence and rape. About 2-3 per week but they take a lot of time.

    Patients with HIV or TB have chronic care files which we keep on site. Others have patient held records in a school exercise book. The patients do doctor shop, so they may have scraps of paper from hospitals across the country.

    We do actively seek out tb patients who default. HIV patients we are less active, but we will text (everyone has cell phones) to find out why they didn’t attend. I want to set up a register for diabetics and hypertensives, so we hold information and can audit care.

    I run the nurse training programme, an hour per week on Tuesdays, plus do lots of on the job teaching.

    I finish work when the patients stop coming, usually about 4, so I’m done by 4:30 and leave for home. There are meetings of course outside this time. It’s still fun after three months, but quite tiring. I hope this gives you a better view if what I do.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s