In addition to our workload on the wards, every day there was a busy outpatient department to man. Over the years, this had morphed into medicine staffing what was effectively a walk in emergency and general practice type situation, as well as true medical patients – those who we had been seeing in clinic for their chronic medical conditions, follow ups from the wards, and those that were referred from the clinical officers and other hospitals to our attention.
The Surgical department ran clinics on the two days it didn’t have theatre (Tuesdays and Thursdays) as well as getting someone there each day to see the walk in patients. The gynae department also ran clinics on Tuesdays and Thursdays. Somehow they had got away with capping the amount of patients they saw each week, with the perpetual overflow ending up in general OPD and becoming our problem, which was a sore spot for our busy days., especially when the Gynae registrars and medical officers didn’t do clinic at all.
In clinic, we were ably assisted each day by a couple of translators, who when not with us worked as adherence counselors for the HIV clinic. They are a really fun bunch, Limbikani always super helpful and having the paperwork for admission already half completed before you even make the decision to admit to the ward, the energetic Tembo always ready with a big wave across the courtyard and ready to tell the surging throng at the door waiting to get in to calm down and be orderly, Mbatana who initially didn’t want to get out of her seat on the other side of the room so we could hear each other but by the end of it, had her giving me ‘bones’ and coming out of her reserved shell; Betty who was more interested in texting her friends and would seize the opportunity to leave on an errand for more note paper or gauze swabs as I’m sure they all found asking exactly when the patient’s non specific arm pain started very dull; Felistas who was head translator who was always ready to help and full of a big smile; Naomi and Bathsheba who would patiently help us differentiate between a cough that started as a dry cough and now was productive versus one that had been productive for months.
Without their help, we would have been a floundering mess. Although we were all making a solid attempt to learn Chinyanja/Chichewa (the local language – Chichewa being the language of the chewa people which were the major population where we were, and chinyanja being a variant of it that was what was spoken in Lusaka and much of the eastern province), in the absence of many investigations, the history becomes even more important, and our ability to ask yes/no questions only goes so far.
As the translators were so integral to our work, and as I always felt like my incessant questions were a chore for them, I made the effort early on to try and get them all on side. And what better way then flattery. So when Felistas turned up one day barely recognisable due to a change in hairstyle – previously shoulder length hair was now a short bob – it was the logical thing to comment on. “Ah Felistas you have had a haircut – it looks very fine!” was met with giggles from her and the other translator. It should be noted that the far end of the positive/negative spectrum is ‘very fine’. Not good, great, or amazing. Just ‘very fine’!. The next week when her hair was back to being longer, a biologically implausible situation, I had to take Tembo and Limbikani (the only male translators aside). I was kindly explained to that the majority of the women wore wigs, hence the giggles. After having my eyes opened to the status quo, it was readily apparent wherever you looked. The typical hair of Zambians is black and frizzy so anyone with black straight or glossy hair was almost certainly wearing a wig. Over the coming months, the translator team cycles through many different fads in hairstyles. But the polite thing was still to comment on how good the change in hairstyle looked!
‘Room 13’, the room we worked from was a bit chaotic at times. With up to 6 doctors plus students working in the same room of about 5 x 5m, with one examination couch behind a couple of screens, privacy wasn’t the strongest suit in the deck. However, it was the only real way to enable the two translators we had access to, to be shared around by all that needed them. It also enabled us to get easy second opinions for x-rays and cases that were a bit of a puzzle or conundrum.
The routine was we would all take position behind a desk, which was normally shared with another doctor. The patients would be (most of the time) patiently waiting outside, most arriving at around six am to get a good spot in the queue to ensure being seen that day. The front of the queue would enter, give us their ‘cardy greeny’ (green card), the hospital file that they kept with them, which had small pieces of paper stapled to the front for all their OPD visits. Given a lot of them have very limited home situations, I was always amazed that green cards lasted so well, and you could look back to see what had happened for the previous visits. We would then try and work out what the problem was, and then wait for a spot on the examination couch for an examination. Afterwards, if investigations were needed, they would be sent for xrays, ultrasound, HIV testing, routine blood testing, etc and return later that day or the next day with results. Once one patient walked out, another would enter, looking for where the vacant spot had just opened up.
The case mix was wide and varied, and ranged from people with non specific complaints through to the very sick. There was a lot of non specific joint aches, more common in older women, with the litany of ‘muto wawa (head ache), chefua wawa (chest pain), masana wawa (back pain), mendo wawa (leg pain)’ being a common sequence to hear. My guess is that there is a lot of osteoarthritis, especially in the women who are responsible for carrying up to 100L of water a day on their heads, often several kilometres, needing multiple trips. With very limited things we could do for aches and pains, most received some panadol and if it was ongoing, some amitriptyline which would also help if there was a mood component, as I’m sure a lot of mild depression had somatic manifestations as non-specific aches and pains.
There were a lot of sad cases that would present to clinic, with high hopes. One of the most memorable for me was a young boy who as soon as he was brought in, was obvious he had cerebral palsy. His mother was worried that age four, he was not able to walk. This was the first time he had seen a doctor in his life, with them living a long way from hospital. He had missed all of the normal childhood development milestones, and in addition couldn’t speak, couldn’t crawl, couldn’t pick things up. He had been born at home, and most likely suffered brain damage at the time of birth. It was obvious as soon as you looked at him, with abnormal posturing of his limbs and spasticity of movements. It was a particularly hectic day in clinic, where I was the only doctor there, and the line was getting impatient outside as it was already after lunch. Even in a well resourced paediatric clinic with a full range of multi-disciplinary team members, management of these kids is difficult and is just mainly a case of trying to assist them to develop as well as possible, given that irreversible damage is already done. In our setting, the best I could do for them, was referral to physio to see if they had any aids like a frame that would assist the boy in learning to walk. When I explained after the couple of minute consultation and examination that it was all irreversible, and that although we were the experts in the region, the mothers hopes had been quashed, the tears soon flowed. In families already living below the poverty line, where parents have to work in the fields all day to make ends meet, and children’s development to the stage where they can also help is keenly awaited, raising a child with disability can be crippling for a family. All I could offer was a simple ‘pepani’ (I’m sorry} before the next person took their seat, ready to tell me of their woes.
When not being harangued by the management about the waiting times in OPD which somehow we were miraculously expected to have under control, OPD could be a lot of fun. It was a bit of a team effort, with my limited gynaecology and general practice experience being offset by more experience in medicine and knowledge gained doing the Tropical medicine diploma. We seemed to get a fair amount of dermatology, most of which was a case of picture matching to weird and wonderful pictures from my ‘Dermatology in Africa’ textbook. One day, one of the recently arrived UK doctors I was working with, had a man with dark scaly rash on sun exposed surfaces. She was a bit perplexed, and as I waited for my next patient to enter, I looked up and spied his characteristic skin changes. My limited dermatology knowledge had at least lent me a few clues, with across room consultations of “does he have diarrhea?” and “is he confused at all” to which the answer was “yes” to both. “Yip, its Pellagra”. “What?”. “Look up page 58 of the book”. “Oh yip, so it is”. The local maize based diet meant that people ended up deficient in several different vitamins, including vitamin B3 (niacin), of which a deficiency lead to the ‘four Ds’ of Pellagra – Dermatitis, diarrhea, dementia, and eventually death. The hospital didn’t stock Nicotinamide, the replacement form of Niacin, only having B multivitamins. I was a bit apprehensive about giving him 40 B multivitamin tablets a day, but after checking the other components wouldn’t be toxic in such high doses, we got him started on them, and he made a good recovery.
Being the general point of call for any sick undifferentiated patients meant having a guerney bang through the doors was not uncommon. One day, I was just about to finish up with Laura, a Scottish doctor, with the rest of the team already having left. Within two minutes, there were two guerneys, with 3 patients. The first had jumped off the top of a moving truck where he was hitching a ride, as he thought it was about to crash, and figured his chances were better to not be on the truck. The end result was a fractured left humerus, nasty looking knee injury, and a mangled face. We were just trying to get a drip into him, when the door banged open again, and there was another trolley, with a agitated guy lying, with different bits of his body wrapped up in tied-up tshirts. It turned out there was a local by-election on, but reports were that one of the parties were cheating and trying to rig the election. The end result was an alcohol fueled machete fight, with our 2nd patient being on the receiving end (and possibly the giving end). Undoing the tshirt around his head revealed a big flap of skin and thin sliver of skull, where the back of his head had received a glancing blow from a machete. His wrists weren’t much better with both having slashes down to the bone, cutting tendons and all. It can all turn chaotic pretty quickly, especially as these rooms are not set up for such trauma. With lots of blood everywhere, personal protective equipment such as gloves and glasses are important, especially as the second guy was HIV positive it turned out., although it was common to end up with blood on your clothes in the mayhem. We bandaged them up, got some fluids running, and called the surgeons who needed to take them both to theatre to fix them up properly. The third guy was just sitting there with a machete gash across his temple, but was able to be stitched up by the clinical officer that normally manages the acute patients out of hours.
Just a standard afternoon in OPD.
Please note: photos included in this blog of patients or medical images have be deidentified, and verbal consent for publication gained. Please do not reproduce them.