Yesterday, as I drove to the clinic, I saw a man at the roadside, flagging me down. Normally, I wouldn’t stop (the medical association discourages picking up hitchhikers), but this man was in uniform. And he was carrying a very large rifle. I pulled over and he got into the cabin. We greeted each other and I told him I would drop him off at the village, which was fine with him. He told me he was a scout for ZAWA, Zambia Wildlife Authority. His uniform was jungle camouflage; policeman have green uniforms with a wavy red pinstripe, I should have known. I asked him if the gun was loaded and he shook his head. Nevertheless, I drove very carefully, gingerly picking my way between the potholes.
I picked up F from the craft shop by the fuel station and took her to the clinic. She was extremely helpful when we were doing health education sessions in schools, but had been ill recently. Her employers had asked me to offer her a consultation. F and I came to a shared understanding of the problem and how she might try to fix it. I brought her back to the craft shop and another lady working behind the counter asked me to see her. This time I did the consultation in the vehicle, with F translating for me. I worked out what was wrong and gave her some advice. Before I could leave, yet another lady collared me that she had “side pain”. I had been called to see someone staying in the Park, so I told her I would return to see her later in the day.
As I was driving back through the Park, a young man stepped out in front of the vehicle, waving his arms frantically. He looked rather strange, and not just because he was wearing a Manchester United football club shirt. When I stopped the car, another man hobbled over to me and asked for help. He recognised me as the Valley doctor because of the blue twin cab pickup I was driving. He showed me his swollen foot. There was a laceration right across the sole, caused by him stepping on a broken bottle. “I went to the clinic yesterday. No bandages, no dressings, no Panado,” he said. He had been given erythromycin and sent away. Despite the “no passengers” rule, I drove him back to the clinic and discovered his aunt worked there. She cleaned and dressed his wound, and I gave him some of the paracetamol which had been donated by kind ladies from the British National Police Aid Convoys. He needs to take a week off work to rest and elevate the foot. It was too late to attempt primary wound closure, it would have to heal by secondary intention.
As I was walking back to my car, I saw a gravely ill child, about 10 years old. “He’s got respiratory distress,” I said to the registration clerk. “No, it’s malaria, doc,” she replied. I dropped into the lab to check and see how many new cases of malaria we had diagnosed. The figures are still high, but are dropping gradually from their peak in May. As I left the clinic, I saw the mother struggling to carry the ill child on her back. It was really hot, so I stopped the car and asked where was their village. It was less than 5km away, but I felt I had to take them home. When we got there, I pulled over and examined the child. He had right lower lobe pneumonia and a fever of 39.8C, breathing rapidly, moaning softly and in obvious pain. I checked the medication he had been given and was relieved to find he had been prescribed anti-malarials, painkillers and antibiotics. As they got out of the car, I asked if anyone spoke English. A man came over and I explained that if the child was not better by tomorrow morning, they must return to the clinic. The man thanked me and picked up the child to take him home. I wondered if he would have received better care if I had referred him directly to hospital.
I drove back to the craft shop and took the lady with side pain into the store-room. I must admit, I suspected that this might be a fruitless consultation. Then I got the whole story. She told me that she had been unwell for months, with chest wall pain, night sweats and productive cough. She had been to the clinic and was prescribed antibiotics, but they hadn’t helped. I asked her if she had lost weight, but she had no access to scales. “Do your clothes feel loose?” She didn’t know because she used a chitengi, wrap around skirt. I examined her chest and there were reduced breath sounds in the lower left lung, where she was feeling pain. “I want to rule out tuberculosis,” I said. “Go to the clinic on Monday morning and produce some sputum for a TB slide. We may need to refer you to hospital for a chest Xray.”
I only worked at the clinic on Wednesday and Friday this week. I assisted with the under 5s outreach on Thursday, when we did our first ever mobile antenatal clinic. No pregnant women came. We obviously need to improve our publicity. On Friday, the nurse in charge wanted me to review the HIV patients. I saw a young woman with full blown AIDS; a new patient with a pleural effusion, which was very likely to have been caused by TB; someone with possible Pneumocystis pneumonia; a man with a swollen testicle and epididymis, again probably caused by TB; two people with declining CD4 counts (immunological failure, possible resistance) who swore that they never missed a dose of medication – they need viral load estimation; a man with a submandibular salivary gland abscess, which Nurse Zulu lanced with gusto and delight as it produced lots of pus.
Apart from the people living with HIV, I saw several other patients who had been referred to me. One young lady had a necrotic abscess caused by a spider bite – it resembled a mini Vesuvius. A middle aged man who, despite completing six months treatment for tuberculosis, had deteriorated. His voice was hoarse, the left lung was collapsed and he had an enlarged liver. I told him that he probably had lung cancer, not TB, and he said that this was what the doctors at St Francis Hospital Katete had said, too. Another man had a septic arthritis. I diagnosed a retropharyngeal abscess in another patient. A 40 year old woman came with her mother, both of whom had dense cataracts in their left eyes, they matched. They suspected sorcery; I suspected untreated glaucoma in one and corneal scarring in the other. But I was happy to find that my hypomanic patient, whose family had chained him to a door, was doing well once he had started taking anti-psychotic medication.
There’s never a dull moment in Kakumbi Rural Health Centre. At times, I felt I was flying by the seat of my pants over the past three months, but I thought I coped quite well. I am going to really miss it.