Another day, another clinic

Friday is the second busiest day of the week at Kakumbi Rural Health Centre. I arrived early and got to work seeing those patients who spoke English. During May, about 60% of the people attending the clinic have malaria, so I have been trying to get the clerk who registers the patients to take their temperature and to refer those with a fever directly to the lab for a malaria test. But the protocol is that she is not allowed to do this, because she is not a doctor or a nurse.

I saw a well-dressed lady with her two children who both had colds. She told me that they had had a fever three days ago, when the coughing and sneezing started, but they looked fine now and a brief examination revealed nothing worrying. Paracetamol and fluids. Next patient.

“But doctor,” said their mother, “Aren’t you going to give them antibiotics?”

“No, they have a virus,” I replied.

“And what about malaria? Are you going to order a rapid diagnostic test?” she said.

“No, I don’t think they have malaria.”

“But are you sure, doctor?”

“OK, let’s do a deal. I will order the tests and if they are negative, you pay the cost of the tests. If they are positive, I pay you.”

“But doctor, I am a clinical officer at XXX and 90% of our clients have malaria.”

“Well, this isn’t XXX. We have plenty of malaria, but I don’t think your children have it at the moment. Do you want to take me up on the wager?”

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She agreed and took the children to be tested. As I opened the door, there was a posse of students carrying a patient like a roll of carpet. The patient was screaming and shouting incoherently. They barged into the room and laid her on the examination couch, where she rolled around spasmodically.

“What’s wrong?” I asked.

“She says she has got heart pain,” said the student leader of the group.

“When did she become ill?”

“An hour ago. She fell on the floor and can’t walk. We had to carry her here.”

“Is there any other history? Does she take any medication? Has she done this in the past? What is going on?” I asked.

“She’s got heart pain, doctor, that’s all we know.”

I ushered everybody out of the room except the patient. I quietly spoke to her, but she replied with groans and shrieks of pain. I noticed that as she rolled around the examination couch, she never came close to falling off. She turned onto her belly and lifted up her torso, as though she was doing push ups without using her arms. For a moment, I thought this was opisthotonos, possible tetanus or strychnine poisoning, but this behaviour was bizarre. I listened to her heart between spasms and checked her temperature, pulse and BP which were all normal. Clearly, I wasn’t getting anywhere. I suspected that this was hysteria so I called in the registration clerk, Daillies (Dilys).

Daillies bent down to the patient and spoke firmly into her ear for a minute or so. The patient stopped convulsing. I asked Daillies if we could move the girl to the ward, and to my surprise, the patient got off the couch and staggered out of the room with Daillies supporting her.

The girl’s father was waiting outside, but she disregarded him and lay on a bed in the female ward. I called to the father and he explained that she had suffered two previous episodes of heart pain. The nurses at a rural clinic had diagnosed hypertension. “Well, if they took her blood pressure when she was raving, of course it would be high,” I said. “I took her BP just now and it was fine. I am sure that this is not the problem. Has she been under any stress recently? Has anyone been bullying her at school? Does she have a boyfriend? I know that there are some exams coming up, has she told you that she is worried about them?”

Nothing, no clues. “Wait a bit, doc,” he said, “The last time this happened she had drunk a lot of sweet pop. Could this be the cause now?”

I was rather sceptical about this theory – a sugar rush causing hyperactivity? Nevertheless, I checked her blood sugar (4.7 normal) and did a rapid test for malaria (negative).

Daillies had continued to talk to the girl and she was now responding almost normally. She sat up on the bed and I sat next to her. “What happened?” I asked. She eventually told me that she had been physically punished twice by a teacher for something she hadn’t done. She could not stop thinking about the injustice and it turned into a frenzy. I explained that her behaviour was a strong reaction to stress, that her heart was normal, her blood pressure was fine and the tests I had done showed nothing abnormal.

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We spoke for ten minutes about how to handle stress, what to do when you feel cornered with no options, how to seek help from supportive fellow students or teachers. I invited her to return to the surgery and have a chat with me if she felt under pressure in the future, and she got up to leave. Her father gave me a strong handshake and warmly thanked me. I turned to go to the lab and looked at the results of the children of the clinical officer – both negative, but they had vanished. I wouldn’t have collected on the bet, of course.

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