Tropical medicine

A busy week of brainwork for me so far.

Today palliative review of a lady on Wallace ward (the gynaecology ward). Another late stage cervical cancer. She was brought in last week, barely able to sit up, let alone stand. 55yrs and her face is resigned, no glimmer of hope from a body that wants this all to be over.
She came in before Christmas and was given a blood transfusion, this time her haemoglobin is 5.9, not low enough to warrant a transfusion here. There is nothing else the gynae team can offer.
I can tell from the smell that she likely has a colovaginal fistula (the cancer has made a hole through from her cervix to the bowel). She is leaking faeces vaginally, the odour pervading through the ward. Her family's main concern is the swelling in her groin, and the fact that she is barely eating. The gynae team wonder if the swelling is an abscess and contributing to her tummy pain, but it is rock hard and craggy, so I suspect more likely to be the cancer which has spread to the lymph nodes. She winces just to move on the bed and any more invasive examination would be unbearable. I had asked for M to give his surgical opinion on the query about it being an abscess for draining, but he concludes that although they could examine her under anaesthetic she is unlikely to gain anything from this process. The palliative nurse H has explained this to her and her family and we agree that she would be better off being cared for at home by her family.
H has explained one of her frustrations in trying to improve palliative care on the wards is the actual administration of analgesia. She all too frequently writes it up, gets the liquid morphine from pharmacy and gives the first dose herself, only to find no further doses get given. She is at a loss knowing how to change this. It does feel that once the patient has been referred to palliative care, that the rest of the hospital staff shrug off any responsibility. It is something I am discussing with Dr A, the medical superintendent, whether any nursing palliative care training sessions would be useful.

Visits yesterday were bittersweet. Beautiful scenery, mango stalls and sheet upon sheet of drying peppercorns adorn our hours drive out into the foothills of the Usambara Mountains to review the lady I had seen before Christmas with what we think is cerebral toxoplasmosis (an infection of the brain caused by a protozoa). You may have heard of toxoplasmosis from the advice we give during pregnancy to avoid cat litter. An infection could harm the baby, though unlikely to cause serious illness in a healthy grownup. In someone with HIV the effects have been devastating. However, this time we are greeted with smiles all round and our patient is already sat in the living room awaiting us. Last time she could barely be assisted out of bed. Her mother beams saying she is eating well, feeding herself and growing steadily stronger. She can answer our questions directly today, her speech almost back to normal. It seems the medication started by Dr K back in October has helped significantly. My research leads me to advise that we continue treatment for another 6 months. We shall check her CD4 count at our next visit (a marker of how her HIV control is).
Our return journey leads us to drop in on another home bound patient. The hospital discharged him last summer following a stroke. He is only 46, and when his family describe the story of sudden onset of severe headache for 3 days, followed by loss of vision and paralysis on one side I assume a diagnosis of a brain haemorrhage (bleed). He is still unable to speak, 8 months later, and cannot move without help. He is incontinent and they have to wash, dress and feed him. They say his communication is very limited; he responds to his name but often appears to have no understanding of what his family are saying to him. They were advised to seek physiotherapy for him but cannot afford it. The burden on his family is huge, his quality of life negligible. The palliative team have been dropping in to offer the family support and a listening ear. The stark and sobering contrast with the stroke rehab on offer in the UK.

Out on Home Visits

Peppercorns drying in the sun

Another clinic patient testing my realms of knowledge is a 36yr old lady, referred to the palliative care team after coming to hospital after 3 weeks of excruciating epigastric pain (the tummy area just below your ribs), loss of appetite & weight loss. She has been seen by a clinical officer who has done a blood test for hepatitis and arranged an ultrasound scan which shows a large liver with multiple nodules. They have written a diagnosis of hepatoma (liver cancer) but have not told her anything more than to now attend the hospice. She is deeply anxious, her husband sitting on the edge of his seat....they fear the worse...I do too.
It takes a while to start from scratch, I am thrown by the certainty by which they have formed a diagnosis. I ask her when she first noticed she was jaundiced - she said no one had remarked on this, though the whites of her eyes are bright yellow, but it started 1 week ago. By brain is whirring through causes of jaundice & hepatomegaly (an enlarged liver) & liver nodules. They have not established her HIV status, though she tested negative during pregnancy with her youngest child, now aged 5yrs. We arrange a quick test which is also negative.
I take a detailed history, examine her and then talk it through aloud to the room now full with the hospice clinical officer, the palliative care nurse and a visiting Australian medical student who this week is shadowing the hospice. The med student's previous degree in environmental health proves invaluable as we work our way through possible unusual infective causes such as brucellosis, leptospirosis, q fever. Could she have amoebic cysts, though I'm sure these are more likely to be singular lesions. I am not clear as to which hepatitis strains they test for here at the hospital. I am also not sure if I can trust the ultrasound report - are there really nodules? Her liver is certainly enlarged, I can feel it myself. She looks very unwell, her pulse is racing and she is painfully thin. I fear a cancer diagnosis may be likely, whether primary liver cancer which I now know is far more prevalent in sub-Saharan Africa than in the UK, or from metastasis (spread from another cancer).
I decided to start her on antibiotics which cover the possibility of  a few unusual infections and give myself time for some homework. We also sorted out some decent pain relief for her. She'll be back in a few days time. Regardless of diagnosis or no diagnosis, she will certainly need the input of the palliative team over the next few weeks. If it is primary liver cancer she won't have long. I deeply miss the ability to talk directly to her, so much is lost in translation. Her 3 children are the same ages as mine.
I ask the clinical officer what he would've done without me....this is the kind of patient he gets sent all the time.... I get whisked off before he can answer. We have so many topics for our tutorials now!

Green fingers

Back on an even keel for emotions as we head into the weekend. A lot of brainstorming has gone on the last few days, the most substantial of which was how do we increase our outside time.
This family thrives on the outside world; many a parent will know that if their children come to play at our house they will usually be sent home with grubby knees and the 'dragged through a bush backwards' look. We are missing that here, mainly with the heat, but also with limited 'roaming' space. The girls still understandably don't feel at ease with many eyes looking on and their initial games of football out the front have diminished.
So with great determination, and more than a little help from the hospital gardening team we have tamed the garden behind the house, which to our delight looks all set to provide a shady afternoon play place. Indeed, we reaped the rewards this afternoon with a satisfying round of hide and seek.
Our biggest delight in the midst of all this was Mama Africa's revelation (on requesting some small trees in the 'field' beyond the house to be lopped). Turns out the 'garden' runs down the hill to an area of maize she has planted. We have been vaguely aware of next doors' housegirl disappearing through a gap in the hedge to fetch water from somewhere (mental note; must ask for carrying bucket on head lessons). This morning us shim girls set out to follow the trail down through the wilds of our 'garden' and then onwards through small, carefully kept vegetable patches or farms down to a substantial stream. Suddenly we have an 'easy' area for walking away from the hustle of the town roads. Although we have been advised to be careful of snakes - nothing B likes more than the chance to stomp along banging with a big stick to scare them away. We did also wonder about the likelihood of crocs in the stream...we have yet to establish the whereabouts of the attack on the poor girl M operated on in July.
My 'office' in the hospice has been cleared for me in anticipation and visits lined up for next week. The town is heaving with back to school supplies; R delighted to have purchased new school shoes from a pile on the street (no doubt shipped in from a child labour factory in china) and a mound of exercise books. We did wonder if there would be enough children in the whole of muheza to buy the inordinate number of books on offer.

The hospice car, having gone to Tanga to get new tyres and a jack that works (following our 2nd flat tyre in a week), unfortunately has ended up in the garage after an incident with a boda boda (though I can't help but feel concern for the motorbike which surely will be the worse off for hitting a 4WD).

Hillview: our house is aptly named

Morning walk down to the river

So a fresh start beckons all round....

PDP

Whimsical musings aside...now down to the practicalities of how to make the most of what is essentially now 3 months left.

Today we trialled out our home tutor/babysitter and I slipped into the hospice for the morning. I left her braiding the girls hair so all was calm. 

My biggest question after a full clinic and review of palliative inpatients is will this blog count as enough reflection for my GP appraisal learning diary? Or do I dutifully fill in my learning diary? Inevitably I always leave my annual paperwork to the last minute...tempting this year just to write ‘see blog’ in every section. My PDP for this year was pretty simple.....arrange our adventure to Tanzania and then do it!

I have a natural tendency to self doubt, and even now, many years down this medical road I often feel like I’m just pretending to be a doctor. There are so many things I feel I don’t know enough about and there’s a large part of me wondering what the hospice team here will think of me and what I can possibly offer them. And then I remember that this year I will have been a doctor for 16 years and a GP for half of that. 

Mentoring in clinic today knocked that doubt firmly out the window and boomeranged right back with the knowledge that I am overflowing with offerings....where to begin; teaching, questioning, reflecting, challenging. I have been tentative in wondering about presumed diagnosis.....there is a strong habit here of trying to make a round peg fit a square whole. I shall stop worrying about my scanty knowledge of antiretrovirals!

So many differences; introductions between doctor and patient are presumed (perhaps because the usual round of greetings can take some time!);as is the use of mobile phones, people thinking nothing of breaking off midsentence to reply to a WhatsApp or take a call, both dr and patient alike ; the consulting door left wide open throughout with a shared ownership of the running of the clinic with the next patient being called in by the one who is leaving. On the wards there is limited scope for privacy, but the ladies respect each other’s space, moving away from neighbouring beds if needed, and there is a small side room for more intimate examinations (albeit with clear glass windows at just the wrong height). Could they find me a speculum on the gynae ward, no....though I’m sure M had some in the stuff we brought out. It is stiflingly hot on the wards, the smells that go with cervical cancer require a stiff constitution. Cervical cancer is the commonest cancer in women in sub Saharan Africa......and it is certainly a miserable fate. How fortunate we are for our screening program in the U.K. I have established that they do the vinegar cervical screening here both in the HIV clinic and the family planning clinic, but still so many women only come forward with their symptoms once it is too late. 

I think it will prove satisfying to be working on a more regular basis over the next few months. The time so far has already yielded so much, but it will be far less confusing for all concerned if I have a pattern to when I am available.