Jonathan has been helping us out in Kakumbi Rural Health Centre as part of his medical training. He styles himself “Dr Jonathan” and wears a white coat, prescribes medication and makes referrals. It seemed a bit strange to me, especially when he left last week to go to Lusaka to prepare for his examinations at the end of his fourth year of medical studies.
I think he enjoyed working with me, acting as a translator and discussing clinical decisions. At least he told me that he was learning a great deal, especially from the one-to-one teaching. I taught medical students for ten years in my practice at Leicester, so it was easy for me to employ those skills again. He needed to brush up on his clinical examination technique. Actually, he needed to examine people more than he did.
If we spent twenty minutes with a patient whose problems were complicated and difficult, the patients in the waiting area would get restless. There would be a knock on the door and a face would peer around it, looking to see if we were still busy. Those patients whom we had sent off for a malaria test would push into the consulting room to present their results while we were in the middle of dealing with another patient. A nurse would come in and ask for an opinion, or to get a piece of equipment. The clerk would come in and slap a pile of medical notes on the desk, in an attempt to hurry us along.
The clinic was very busy and we were having to cut corners when dealing with patients. Without being arrogant, I think my 39 years of experience being a generalist has equipped me on how to cut corners safely. Most of the patients give hardly any history. A typical story would be “headache”, “body hot”, “chest pain/cough”, for example. So deciding who is genuinely ill and who is just a bit under the weather can be tricky.
I had just told the medical student that when seeing children, the first question to ask yourself was, “Does the child look ill?” This child looked happy, well and was afebrile. But on examining the chest, there was a patch of crackles in the left lower lobe of the lung which was worrying. Children can die quickly from pneumonia in developing countries, so we prescribed antibiotics and fixed up a follow up appointment in a week’s time. “That is the exception which proves the rule,” said Dr Jonathan.
Working quickly with basic history taking can lead to errors. One lady complained of an itchy vagina. Nothing else. Dr Jonathan correctly identified the most likely infections were yeast and trichomonas, and was just about to prescribe nystatin and metronidazole, when she said that she had been given that treatment a month ago and it hadn’t worked. Now he had to do an intimate examination to find out what was going on. This showed the lady had herpes. It is normally more painful than itchy, but patients don’t always have the vocabulary to express what they are experiencing. Lesson learned, don’t get cocky, keep your clinical wits about you and look for inconsistencies. Don’t assume everyone has a cold or self limiting illness. If something seems strange or odd, check for HIV and syphilis.
And malaria can mimic anything. One patient with a core temperature as low as 35.7C had malaria. But when you are sweating from the midday heat under a corrugated iron roof and a patient enters the consulting room wearing a quilted down jacket, you know something isn’t right.