Clinic Highlights

Today…

I saw a patient whose name was Serious. I asked him why his parents gave him this name, but he said he had never asked them. Very strange. I would definitely have wanted to know. Fortunately, he had nothing serious wrong with him.

We have had a few cases of mumps recently. I found out the traditional Swazi way to treat this illness was for the sufferer to go to a termite mound and shout out, “Take these mumps away from me!” Then the patient had to walk home without speaking to anyone. In contrast, Zambians with mumps would make a bundle of sticks, put it on their head, walk to a fork in the road, stay there until the sticks fell down, then walk home without speaking to anyone. It is all about unloading your problem, I suppose. Fascinating.

This photograph shows five generations. The little girl is with her grandmother and her great-great grandmother. I thought this was remarkable until they told me that on the other side of the family there are six generations still alive. This is the first Zimmer frame I have seen in Swaziland.

Five generations
Five generations

One of my beloved gogos was complaining about her backache (caused by a mix of osteoporosis and spinal arthritis) and she described it as being “like fireworks going off in my backbone”.

Another old lady in her 80s was having trouble with her arthritic knees. “I bet you were a good dancer, back in the day,” I ventured. She told me that she had danced for the previous King, Sobuza II, at umhlanga (reed dance), along with 10,000 bare-breasted virgins. He didn’t pick her to be his bride.

I can see many patients with trivial illnesses, such as having a headache for a few hours, or an episode of diarrhoea last night, and then someone with fungating breast cancer turns up (I am not attaching any photographs, don’t worry).

Today I saw someone who had nursed his brother in his final illness. Shortly after his brother died of tuberculosis, my patient developed pain in his testicles. He had been treated several times for non-existent sexually transmitted infections at hospitals and health centres. He even had an ultrasound scan which showed no abnormality. He thought he had contracted tuberculosis in his testicles. This is very rare; I have only seen it twice in 38 years working as a doctor. I examined him and his package was completely normal. It took a while to convince him that this was health anxiety, probably related to his brother’s death from TB. It can be difficult “re-framing” the problem in these terms, but he agreed to take notice of what was happening in his life when his testicles began to ache, rather than concentrating on his genitals. He’ll come back if he feels this has helped him.

A few patients later, I saw a man who had had “drop” (urethral discharge from gonorrhoea) for a month before seeking medical attention. He dropped his trousers to reveal a painful pair of gonads the size of a couple of tangerines. The infection had tracked inwards from his urethra, down his vas to his testicles, causing epididymo-orchitis (how many points can you get from that in Scrabble?).

The nurse running the under 5s clinic called me to see a 19 month old child with a lump on her arm after having been vaccinated against measles four weeks previously. Not surprisingly, the little girl developed a rash resembling measles about a week after the vaccination. We normally warn mothers about this. However, this mum had taken her child to another clinic, where the nurse diagnosed chickenpox and gave the child an injection of procaine penicillin, vitamins and paracetamol. The lump was the size of a ping pong ball and fluctuant – it felt squidgy and I thought there was some pus deep inside. I aspirated about 2ml of thick, yellow pus and started her on some antibiotics.

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This is unusual, so I had a word with my supervisor who told me that she had seen tuberculosis present like this. I was so surprised that I went back to the clinic room and hunted through the sharps box to find the pus-filled syringe. Normally, this is against all the rules, but the sharps box was so full that the syringes were sticking out of the entrance and it was safe to find the correct one without getting a needle-stick injury. I took it to the lab and asked if we could do a Z-N stain on a smear of the pus to look for mycobacteria.

Finally, I thought a patient’s symptoms might be related to their employment:

“What work do you do?” I asked.
“Nothing interesting,” he replied.

National Museum of Swaziland

The cultural heart of Swaziland is at Lobamba. This is where 10,000 virgins dance for the King at the Reed Ceremony in August. The National Stadium is there, across the road from the Houses of Parliament and the National Records Office. It is possible to visit Parliament when it is in session, but you must be suitably dressed (I have a wacky animal print tie, but I need a jacket). No such formality is required to visit the National Museum. Ascension Day is a public holiday here, and we were the only visitors in the museum.

The receptionist saw that I was driving an MSF car and charged us local admission rates. I think she was so grateful to see us that she left her cubicle and showed us into the main exhibition hall, pointing out the most interesting displays. I liked the montages of everyday household items, such as three-legged milking stools, porridge stirrers, pots, drums and woven baskets. Even the backdrop was excellent – beautiful line drawings of people using the implements.

I also enjoyed the mannequins dressed in traditional clothing. There were no undergarments on display. I saw a chap wearing a traditional cloak, wrap and furry animal skin in the clinic today. Like a true Scot wearing a kilt, this man had no difficulty showing me what was wrong just by hitching up his loincloth. All was revealed.

There were a few pieces of art created by modern Swazi artists, which were excellent. I was taken by the embroidery: “Women wearing pointy shoes, never do any work, just sit and wait for payday.”

No museum in Africa would be complete without a few dusty dioramas, a stuffed buffalo being chased by a moth-eaten lioness. But there were some witty touches regarding the origins of man and the development of tools.

P1020284The strangest exhibit was a stone statue of Krishna which had been found in Swaziland fifty years ago. No one seems to know how it got there from India. One theory has it that the gilded image was brought across the Indian Ocean from Portuguese colonies (Goa, Daman & Diu) to Lourenco Marques (now Maputo, capital of Mozambique) as a totem to be traded for goods in the hinterland.

My favourite area was a marvellous display of sepia photographs of Swaziland dating from the late 19th century. A collection of ladies posing for the camera wearing ill-fitting brassieres, recently distributed by missionaries, no doubt. King Sobuza II, as a little boy, standing in front of a beehive hut with his mum. In his tribal and British regalia. The post and telegraph office set up by the British in a tent at Mbabane. A poor Boer family of sheep farmers. A Catholic priest’s altar set up on a Norton motorbike. A group of priests resembling the Rasputin Brothers.

Swaziland is a small country, so people tend to know one another. But it was by sheer chance that last weekend, I went game counting with Bob Forrester, the only archaeologist in the country. I found out that he designed the museum, virtually from scratch. He was pleased I noted all the humorous touches. Bob was born in Swaziland and has put together an amazing collection of photographs of the history of the nation. All these pictures can be seen in the digital archive. I think you’ll agree, he has done a wonderful job.

http://www.sntc.org.sz/sdphotos/

Matchstick

Despite her expression, this is NOT the lady concerned.
Despite her expression, this is NOT the lady concerned.

A large elderly lady eased herself gently into the patient’s chair in my consulting room recently. I listened patiently while she went through the inventory of her complaints.

Headache. √

Sides pain. √

Total body pain. √

“Is there something else?” I asked.

She then had a long conversation with my translator, using a quieter voice. Perhaps this was the real reason for her consultation, the “hidden agenda”.

“The suspense is killing me,” I said. “What’s she saying?”

“She is talking about her anus and a matchstick, doctor,” said the translator.

I had this sudden vision of this elderly lady adopting an undignified posture, lighting her farts with a match. My jaw must have visibly dropped in astonishment.

“Her bottom is itchy and she uses a matchstick to scratch it,” explained the translator.

I had to restrain myself from asking two unprofessional supplementary questions to satisfy my natural curiosity.

Which end of the matchstick was she using to ease the itch?

Was she able to use the same matchstick to light a fire afterwards?

I settled on prescribing a soothing ointment for her to use instead.

Feet – not for the squeamish

Last week, I took over from a nurse who had been working for two hours in a consulting room in outpatients. I washed my hands, dried them on tissue paper and stepped on the pedal to open the normal waste bin. It was empty. I flipped open the clinical waste bin and found it was empty, too. I could think of three reasons – the bins had recently been emptied, the nurse hadn’t washed her hands or the nurse hadn’t needed to wash her hands because she hadn’t touched any patients.

I like touching patients. It’s a humane thing to do, reaching out and making contact. It demonstrates concern and compassion. But some health workers are concerned about contamination, especially in a clinic where there are many patients suffering from tuberculosis. I know one hospital doctor who wears an N95 surgical respirator all the time at work, no matter whom he is treating. In an MSF clinic, some nurses wanted to wear gloves when handling patients’ paperwork and medical records, out of fear of contamination.

I reminds me of reading Mary Douglas text on pollution and taboo while studying Social Psychology at Cambridge. In 1991 it was listed by the TLS as one of the 100 most influential non-fiction books published since the Second World War: http://en.wikipedia.org/wiki/Purity_and_Danger

Medical students learn that making a diagnosis involves three basic steps. Taking a history, examining the patient and carrying out special investigations. The history provides most of the information, with examination and investigation helping to support or refute your diagnostic hypotheses.

Given my non-existent communication skills in siSwati, my history taking is rudimentary. I don’t have access to a wide range of fancy laboratory investigations. So, the physical examination of the patient assumes greater importance for me. I use all my own high quality instruments, brought from UK – I need all the help I can get!

I’m trying to improve the care of our 200 diabetic patients. This means examining their eyes and feet. When I am checking feet, I sometimes sneak a peek at my translator who can’t hide her distaste. Occasionally, I have trouble, too.

This man could not feel this deep ulcer in the sole of his foot because he had lost all sensation of pain.

The patients in wheelchairs usually have the worst feet, mainly because they can’t walk on them. Last month I saw a man with one foot blackened rigid from gangrene. Last week I saw another patient who had been bed bound for four years at home following a stroke and vascular dementia, with pressure sores eroding his heel bones.

I called the local hospital about this lady’s gangrenous big toe. The SMO said it wasn’t an emergency and she should come to surgical outpatients next week.

Complete desquamation of the sole of the foot is rare. This happened two years ago in an Zambian cross country runner who did not use shoes at the Mfuwe Sports Day. The hard sole just sheared off from excessive friction.

The photograph below shows a man who has had bacterial cellulitis for two weeks before seeking medical care. The skin of his leg has already peeled off, with just the sole to go.

Sometimes I am amazed by the fragile condition of patients’ socks. They can look so worn out that there are more holes than material. It is a mystery how they manage to put their socks on without them falling to pieces…or perhaps it isn’t.

Gifts from a patient

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It’s unusual for doctors to receive gifts from patients in Swaziland. I was delighted to get this branch of bananas, sack of sweet potatoes and sugar canes from a grateful patient.

I have posted this image here because I cannot add it to my comment in ABetterNHS blog “Giving and Receiving” on http://wp.me/pBQAA-1h9

Link

What’s in the news today?

The news this week has been dominated by marijuana. Among pot smokers in Europe, “Swazi Gold” has a good reputation as a quality product. Here it’s called “dagga”. The best dagga is grown in the high veld. The growers are often quite elderly. It is not uncommon to read reports of gogos being arrested for being in possession of hundreds of kilos of marijuana. Perhaps they are just sitting on the product at home, rather than being involved with production.

I find it amusing when the newspaper expresses the value of a confiscated batch of dagga down to the last cent. For example, recent in Hhohho region, police seized “2,447,313 kg with a street value of 1,468,387.80 Emalangeni” or £79,158.70 at today’s rate.

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The Royal Swaziland Police Force called in the Press to witness the destruction of more than 4 metric tonnes of dagga in a furnace.

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A worrying development is the appearance of a drug called “nyaope” which is a mixture of drugs used to treat HIV, rat poison and marijuana. Some people must be desperate.

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Other stories included coverage of a fundraiser for Leonard Cheshire Homes, which do a great job with disabled children, rehabilitating people who have had strokes. Look at the expression on Princess Phumelele’s face when she was told about a disabled person who became an engineer.

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The King recently proclaimed an end to AIDS in Swaziland by the year 2022. This clipping has an obvious misprint, “an AIDS free generation by 20222”, a long way in the future.

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Finally in the National News section, a Headteacher has been accused of being pompous. It’s all gripping stuff.

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What, more animals?

I drove Dr Srinu and Kei, the MSF technical/laboratory adviser, to the Royal Hlane Game Reserve last Saturday. We did a guided tour to see the main attractions – lions, rhinos and elephants – and after lunch, we did our own game drive, looking for giraffes and zebras. We didn’t have much success, but I have posted a few photographs to share with you.