“Can you hit my head some more, Dr Ian?”
Last month, I diagnosed a young lady with cervical cancer. Her symptoms of lower abdominal pain, vaginal bleeding and an offensive discharge had been repeatedly treated “syndromically” – in other words, treating the common diseases which would cause these problems without making a specific diagnosis. She had been given several courses of antibiotics which hadn’t helped. Her notes said “Chronic Pelvic Inflammatory Disease”, but no one had ever examined her. A quick look with a speculum and a vaginal exam revealed that she almost certainly had cancer.
Nurse Zulu was impressed and asked me to give the staff a lecture on cervical cancer at the health centre. I agreed and we fixed a date on Friday afternoon at 1500. I put together a quick PowerPoint presentation on my laptop and arrived at the clinic at 1400 after lunch. The door to the staff room/office/antenatal/HIV department was locked. There was an unhealthy queue of patients waiting to be seen, and the nurses would have to work quickly to clear the decks before the lecture. Two nurses turned up at 1430 and opened up the staff room. Perhaps it was “Friday afternoon syndrome”, as they seemed reluctant to see the patients before the meeting. Nurse Zulu asked for some help with a sick lady who might have vomited blood. I asked if she had checked the vital signs, but she hadn’t, so I asked her to do this first.
I did a quick trawl of the patients, sending those who had fever to the lab to have a malaria test done before we saw them. Then I saw the patient with Nurse Zulu. The consulting room had the characteristic odour of malaena (internal bleeding which has been partly digested and comes out of the body as tarry, black motions). No one else recognised this. The patient had a low blood pressure and high pulse. She looked as though she had lost a lot of weight recently and her mucus membranes were pale.
I asked Nurse Zulu if she had examined her and she said no. I explained about malaena and asked the patient for permission to perform a digital rectal examination. I told Nurse Zulu that my gloved finger would be black with stool, and it was. I cleaned the patient and rolled her over onto her back. There was a hard, craggy mass in the epigastrium. I put together the salient points in her history and my examination to make a credible explanation as to what had happened. Nurse Zulu asked me, “How did you know her faeces would be black? How do you know these things? I can understand what is happening now that you are teaching me.”
I talked to the lady and her relatives about what was happening, then shipped her off to Kamoto with a referral letter for a blood transfusion and an upper abdominal ultrasound scan. The next patient was a 50 year old man who looked very ill. He was perspiring profusely, with beads of sweat standing out on his forehead. His temperature was 39.8C, but a malaria test was negative. Without examining him, Nurse Zulu asked her senior colleague what was wrong. “It’s malaria season, repeat the test and even if it is negative, we still need to treat him for malaria.” Not altogether logical.
Before I could act, the patient was ushered out the door and sent to the pharmacy for malaria treatment. I caught up with him in the queue and asked if he minded my examining him there and then. He wasn’t shifting much air into his lower right lung and I diagnosed early pneumonia. Nurse Zulu appeared and I demonstrated the signs:
“While he breathes in deeply, just look at how his chest moves. Tell me what you can see,” I said.
“Nothing,” she said.
“Look more closely.”
“I am looking closely, but I still cannot see anything.”
“Put your hands around his chest and see which moves the most.”
“My left hand,” she said.
“What does that mean?”
“I don’t know.”
I explained that the chest was moving unequally because less air was entering the lower right lung.
“Now listen to the chest.”
“There are no crackles or wheeze, it is normal.”
“But which side is loudest?”
“The left side.”
“And what does this mean?”
“I don’t know.”
I explained about how all his signs were explained by pneumonia. I altered the patient’s medical records, gave him the correct treatment and asked to see him on Monday at the clinic.
Nurse Zulu said, “Can you hit my head some more, Dr Ian? I want you to bang in some knowledge.”
She turned to her senior colleague and said, “John, you must come and consult with Dr Ian. He knows what is wrong with all the patients. He explains it to me and it makes perfect sense. It is wonderful.”
Of course, I haven’t a clue what is really wrong with half the patients attending the clinic. I recognise patterns of symptoms, using 40 years of experience of the natural history of diseases, and hopefully I don’t make many unsafe clinical decisions.
Nurse Zulu said, “You have done it again, worked out what is wrong with the patient. How do you do it?” I explained that I work like a detective, putting clues together to find out who did the crime, making hypotheses and shooting them down when the evidence doesn’t fit. It is no use just writing down what the patient says and giving medication to counter their symptoms. Headache = paracetamol; chest problem = antibiotics; difficulty breathing = salbutamol tablets for asthma; runny nose and sneezing = antihistamines; feeling generally unwell = multivitamins.
History taking is abrupt and I am never quite sure that my words are translated properly into Kunda (the local dialect) or Nyanja, with their limited vocabulary. I can’t request a wide array of investigations. I just have to use my common sense and my five senses to examine the patients thoroughly. If I manage to persuade nurses to do this more often, then I think that my time here will have been successful.
PS The people illustrated above are not those mentioned in the text.