Another week in the clinic

My interpreter was not available this morning, so I struggled when seeing patients. When I ask for patients in the queue who speak English, I get a completely different clientele. They are usually middle class or students. It is almost like doing general practice in UK.

We have half a dozen student nurses from Good Shepherd Hospital on work placement at the clinic. One nurse helped me out by translating when she was not dressing wounds or giving injections. Unfortunately she wasn’t very good. She told me one patient was HIV positive and taking anti-retroviral therapy, when just the opposite was true. Luckily the patient knew enough English to correct her.

She called me to the treatment room to see a boy who had fallen from a tree and managed to impale his arm on a broken branch. It was very satisfying to remove a long splinter from his forearm under local anaesthetic.

This is not the boy who fell from a tree
This is not the boy who fell from a tree

MSF don’t like me to do minor operations in the clinic perhaps because it is “mission creep”, taking the project further away from its core business of HIV and TB treatment. But I find it hard to resist fixing minor surgical problems. After all, I have a degree in medicine AND surgery. The patients like it, too. It is simple stuff, such as lancing a boil, resecting a wedge of ingrowing toenail or suturing a wound. It isn’t neurosurgery.

But there can be obstacles. Sometimes there are no sterile instruments, so I have to improvise. A few weeks ago, I struggled to remove a chunk of glass embedded deep in a man’s palm just using my fingers and the flat edge of a scalpel blade. This was not ideal. I knew we had some sterile packs in the Family Planning room. They usually contain instruments (forceps) which we use to apply acetic acid (vinegar) and iodine to the cervix. Instead of Spencer-Wells forceps to hold the cotton swabs, there was just a tenaculum to grab hold of the anterior lip of the cervix. I couldn’t use it to grapple for a fragment of glass, embedded in scar tissue, deep in a hand. But I got it out eventually.

A few days ago, a young man told me that the cleanly-sliced cut on his neck had been done by a screw when he was doing some DIY. My inbuilt lie detector hit the red line. I wonder why he refused to go to the local hospital accident and emergency department? Did he want to avoid the police? This was a sharp knife or razor wound. Again, we had no sterile forceps to hold the needle to suture so I was forced to use my fingers. The curved needle was less than a centimetre across, so this was tricky. I normally use a plastic surgery technique to tie off sutures, but this needs forceps, so I had to tie the knots using my fingers. Remember those hours we spent learning to tie one-handed knots in medical school, Hattie Lupton? Well, my fingers still remember how to do it. My brain doesn’t. When I tried to think it through logically, I failed. My fingers just went into automatic mode. Maybe it is a bit like riding a bike, you never lose the knack.

Wherever I work, I seem to attract pus. A man limped into the clinic with a swollen thigh, caused by a deep abscess in his quadriceps muscle. I lanced it with a blade (no holder), but had to delve my finger deep into the wound to break down any loculations (pockets) of pus. It needed a gauze wick to prevent it healing before the pus had drained, so I had to insert this with my finger as well, because no forceps were available. Two days later, he was walking much more easily when he came for a dressing change. You just make do with the tools you have available.

Another chap turned up to my consulting room waddling as though he had soiled his trousers. He had. There was a large ischiorectal (inside his buttock) abscess which was leaking pus into a makeshift nappy. He had had a previous abscess some years ago which took months of hospital treatment to resolve. This time the pus took the easy way out, through the track of old scar tissue. I’m not very squeamish, but when he said he could feel the pus squirting within his buttock cheek, from one location to another, when he sat down, I felt a bit queasy. The pus was freely draining now. He may need further surgery, but our immediate difficulty was how to apply a dressing in such a tricky location. I leave these problems to the nurses, who know this stuff better than I do.

You always have to be on the lookout for TB and HIV in the clinic. These infections are constantly on my clinical radar. A man told me that he had had bloody diarrhoea for a month. I noticed that his belt had an extra hole poked into it, because he had lost so much weight. His test for HIV was reactive and he went on to start treatment.

Lumps in the neck are quite common. There are many causes, but HIV and TB are most common here. Usually they are firm or rubbery lymph nodes, but once they get “squidgy” (that’s not the technical term we use), I stick a needle in and aspirate the juice. Within a couple of hours, our geneXpert machine will tell us not only if there is any TB DNA present in the sample, but whether it is sensitive to rifampicin or not. I was rather hesitant to do this when I first arrived because there is “a lot of clockwork” by the angle of the jaw. Jugular vein, carotid artery and facial nerve, to name a few. I’m more confident now, but careful not to be too gung-ho.

Tuberculous cervical lymphadenitis used to be common in Britain a few centuries ago. It was given the name “scrofula” and could be cured by the touch of a monarch.

Of course, you get sad cases where patients turn up late. One lady had suffered from post-coital bleeding for three years, thinking it was because she was using injectable contraception. I discovered a bleeding ulcer on her cervix, which is very likely to be cancerous. There isn’t a national cervical screening programme here. Even when we do find suspicious patches on the cervix, the waiting list for colposcopy at the local hospital is six months. Women living with HIV have a much higher risk of developing cancer of the cervix, so we would like to offer them annual screening. At present, only one nurse in our clinic has been trained to do this. She would have to screen 11 women every day to reach this target. But she has other duties to carry out and we don’t have a dedicated room to do the procedure. This is a problem we can tackle using a “QI” approach – Quality Improvement, not Stephen Fry’s Quite Interesting TV programme.

When you are living with HIV, you can get strange cancers. The most common is Kaposi’s Sarcoma. I see about one new case every couple of weeks. Last week, I saw a lady with a fleshy growth on the corner of her eye which my colleague assured me was likely to be cancer of the conjunctiva. I hope that the surgeon sends the specimen for histology so this can be confirmed. My “eye expert” (Mr John Sharp) in UK tells me that these are really tricky to treat, requiring “excision, double freezing/thaw cautery, topical mitomycin C and alcohol application”. If I was doing the surgery, I’d need some alcohol application afterwards, too.

P1030044

I have developed a reputation for diagnosing strange neurological conditions. The main reason for this is that I discuss these patients with retired professor, Steve Brown, who lives in Cornwall. I send him videos, photographs and case histories via email. Although we might not be able to cure the patient, with Steve’s help, at least we can begin to understand what has happened and formulate a management plan.

I didn’t need his help to diagnose cerebral palsy in an eight year old child with a spastic, tiptoe gait last week. The child didn’t walk until aged four, but perhaps because she was HIV positive, no one had made the diagnosis. We do have a physio/occupational therapist working at the clinic, but her work is exclusively with TB patients. Luckily, there is a Cheshire Home about a kilometre away from the clinic where the child can get help with rehabilitation.

This next patient was either very lucky or extremely unlucky, depending how you look at him. First of all, he was involved in a road traffic accident. He was a passenger in a kombi which left the road and hit a tree. His arm was crushed, but it was also bitten by an angry snake which was apparently living in the tree. It took eight hours before he was transported to hospital and his arm started to swell alarmingly. The swelling squeezed the forearm muscles in their sheaths, stopping their blood supply. Surgeons cut open the fibrous tissue confining the muscles (called fasciotomy) to prevent Volkmann’s ischaemic contracture. But the radial nerve in his arm had been damaged, causing wrist drop.

Massive amounts of protein leaking from the crushed muscle caused his kidneys to fail (what I used to call acute tubular necrosis, but it is probably termed acute kidney injury nowadays) and he required renal dialysis for a short while. To cap it all, he needed split skin grafting to cover the gaps caused by the cytotoxic effects of the snake bite. His nerve is recovering and his kidneys are doing well. After all this misfortune, he is lucky to be alive.

Some readers have commented that they like to hear what I am doing in the clinic. I apologise if this post is rather gruesome and medical. It describes part of MSF’s work in Swaziland – this is how your charitable contributions are spent. I don’t spend all my time walking in game reserves and attending music festivals.

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5 Replies to “Another week in the clinic”

  1. I count myself among the (fairly) squeamish, but it’s a good post, bringing me into the realities of your world. Thanks for writing it.

    And I’m particularly struck by the thought that your fingers remember what your mind can’t. It doesn’t surprise me, but it does delight me.

  2. WOW! This was some writing! Putting these together will make a book and it is all interesting reading. THANK YOU, i had better give something to MSF again

  3. Hey Ian, Keep fighting the good fight. Hope you are wearing good gloves when you are reaching into all that pus. Your clinical remove reminds me of your hilarious lecture in Kira Kira in 1987 about how and why HIV is most likely to be transmitted, during which several of the local big men looked quite uncomfortable…. Take care

    1. Yes, Mike. That was an interesting talk, which I remember very well. I do wear decent gloves. I did a cracking abscess this morning on a 20 month old, who no longer views me as a friend. But it was gratifying to see her smiling after I evacuated about 50ml of “laudable pus” from her upper arm. Botched vaccination probably caused it. How is life with you? Email me off blog.

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