Double Standards

Photo of the week

Highlight of the week: Wild dogs interrupt our breakfast on Puku plain

Lowlight of the week: Over-committed we barely surface for air on Tuesday. We miss a farewell sundowner.

Maximum temperature: 34 degrees

Rainfall: Diddly squat

Spoiler alert: I’m about to rant. And it’s going to get rather medical. Sorry.

What constitutes a medical emergency? Should it be the same wherever you are? Who decides? Whose opinion counts? How sick do you need to be, to get emergency treatment?

In the UK, there are algorithms and codes. You feel ill. You dial 999. You explain the symptoms to a call handler. They interpret what they hear. Refer to the guidelines. And make a life-or-death decision. They choose a category. 1-4. Do you deserve an ambulance within 7 minutes; 18 minutes; 120 minutes; 180 minutes? Or do you need to phone a friend?

The ambulance service in the UK may have its failings. And the National Health Service may appear to be on its knees. But at least there are criteria and aspirational standards in the UK. Targets are the bane of our lives back home. But there is method. Not madness. A system.

Mondays in our Kakumbi clinic are always busy. Crowds throng as we pull up in Mzungu. People mill around the wards. Waiting to be treated. Many more bodies wait for their ailing wards to be seen. Each bed is surrounded by satellite bodies. Patients and carers mingle. 6 beds. Sometime there is a melee of 24 people in two small rooms.

Our mission, should we accept it: to separate the wheat from the chaff. To hone in on the sick. To lay on healing hands. One bed is occupied by sick twins. But my Spidey sense tells me that the twins can wait. As can the other pair of infants in the next bed. Keith veers away, to look for sick adults and he hits the jackpot. Saulos, who has been on night duty, wants Keith to see a patient who came in without a blood pressure!

Saulos has been unable to measure Joy’s blood pressure with an automated blood pressure machine. Since there are no beds left as Joy arrived at 02:00, she now occupies one of the screening rooms. The useless blood pressure cuff on her arm. Constantly saying “No”. Could this mean that her blood pressure is through the roof? A dose of enalapril doesn’t seem to have helped.

Could Keith please use his manual blood pressure machine to break the stalemate? Keith likes a mystery and sets to. The story was a little vague. Not Double Dutch. But halfway between Nyanja and Bemba. Almost Swahili. And of course, Keith speaks Swahili. Right up his street. Joy has palpitations. She is breathless and worried. Keith reaches for his pulse oximeter. Less interested in Joy’s oxygen saturation. More interested in her heart rate. Keith’s blood pressure cuff remains in its holster.

Gin, are you busy? Keith’s voice slightly on edge. I’m next door. I am congratulating a Reduce Stroke Programme participant. Thomas is a member of staff from one of the far-away camps. Thomas tells me he has lost 4cm from his waist, following our visit 4 weeks ago. Everyone loves a success story, but Keith’s voice sounds more pressing.

I pop my head in. Give me a hand please Gin. This lady has SVT. Her pulse is 220. Joy, pale and distressed. I check the numbers with Keith. Her oxygen level is 98%. Her breathing fast at 20 breaths per minute. Even Keith’s manual BP machine says No. Joy’s pulse too fast. Supraventricular Tachycardia. SVT. An abnormal heart rhythm, which makes the heart beat way too fast. Fast enough to cause the heart to work to rule. It goes on strike. Failing to pump adequately. SVT can also cause angina. Joy breathlessness and uncomfortable. A medical emergency. Category 2. I ask for an 18 minute ambulance. And then I wake up in Africa.

We move Joy to a bed to allow her to lie down. The treatment room is the best that we can do. The ward is heaving. With support from Joy’s husband, George, we shuffle Joy onto the examination couch. And then we make a plan.

Making a plan is what we often do in Zambia. Sixty shared years of training and experience does not necessarily prepare us to know exactly what the right thing is to do in Zambia. Pieces of our medical management jigsaw are usually missing here. We have to make do. We have to make a plan.

The perfect plan is a little medical. I make no apologies to the non-medics, but my medical mates will want me to show my working here. We need to slow Joy’s heart down. In the UK we have 3 choices: Vagus nerve stimulation; Drugs; Electricity. We often try them in that order. In reality, vagus nerve stimulation is the least likely to work. But it gives us something to do whilst someone fishes out the drugs. Sticks in an IV cannula. Works out the drug doses.

The vagus nerve. One of our important cranial nerves. My anatomy demonstrator gave it a number. The number 10 for those people counting. The vagus nerve has many actions. One action is to pace the heart. When stimulated, the vagus nerve slows the heart down. And there are some very clever ways to stimulate it. Some pretty unpleasant. Some less so.

For babies, we can wrap them up, and stick their faces into a bowl of iced water. This evokes the diving reflex. A very powerful vagus nerve stimulus. Babies know little about this. But their parents might be horrified. Without a sympathetic explanation their heart rates will go in the opposite direction. Drowning would undoubtedly slow the heart down a tad too. A rather drastic remedy. Fortunately, the baby instinctively knows not to breathe under water.

I have evoked the diving reflex once in my career. With success I might add. The baby’s heart rate dropped immediately. SVT terminated and normal sinus rhythm resumed. Not so easy to do on a 50 year old lady. We did try a bag of cold water to Joy’s face. But to no avail. Next, we tried to massage her carotid sinus. Another vagus nerve stimulus. Again, no effect. Pressing on the eye balls. Firm pressure. No effect. Now what? Phone a friend. In the meantime, Keith gives Joy some oral medication. Ten milligrams of bisoprolol. A beta-blocker. It’s all we have.

I happen to have our portable Wi-Fi pebble with me. I decide to call Jonathan on WhatsApp. My friendly paediatric cardiologist. He is on holiday. On the Isle of Man. I know this, because I have seen all his lovely Facebook posts. I hope that he won’t mind being disturbed. Amazingly, we connect straight-away. I pick his brain. He suggests a couple of tricks. And helpfully sends me some illustrations. We talk about the next options. Drugs. Electricity. He leaves me with a good luck message and returns to his holiday musings. Keith and I try out the next manoeuvres. Still no joy for Joy.

By this time, Joy has had her SVT for at least 8 hours. She is coping, but not looking too crisp. Keith and I have run out of options at Kakumbi. The drugs we need are not available in our clinic. Nor in our village pharmacy. Too specialised. We don’t think they will have them at Kamoto Hospital either. Kamoto is an hour up the road. She may need to go to Chipata to get the right treatment. But our protocol says she must go to Kamoto first. Frustrating. This will cause a major delay. But at least Kamoto is en-route to Chipata.

We are heading together towards the bottom of my list of options. We now need a very special type of electricity for Joy. A defibrillator, set to stun the heart. Kamoto hospital can have a defibrillator, on a good day. In the past decade or two, portable defibrillators (AEDs) have started to appear all over the UK. But AEDs are only to be used on people who have suffered a cardiac arrest. The dose of electricity they supply is large. To shock the arrested, fibrillating heart, back into a normal rhythm. Using an AED on a person who has not yet had a cardiac arrest is not wise. A real shock to the system. Best reserved for the unconscious. We hear that Kamoto has a proper defibrillator. The right tool to give joy to Joy.

A couple of our safari camps have invested in AEDs. We are uncertain that those camps could ever see a return on their investment. Even though AEDs certainly deliver on their promise. Then what? There is no cardiac intensive care within easy reach.

But for a lightly sedated Joy, the right type of defibrillator, in the right hands, might just deliver a little zap of electricity and reboot her dicky ticker.

With all this buzzing through my mind, I speak to the duty nurse in charge. Can you call the ambulance please. This lady needs to go to Kamoto. It’s an emergency. I am met with a blank face. And an almost imperceptible shake of the head. The nurse walks away. Next, I try our clinical officer. He eventually tries to call for an ambulance. But no one is answering. He says he will send a WhatsApp to them. Meanwhile Joy at last gets a bed on the ward. A place to rest. She waits patiently with her family. And she waits.

Whilst our most critical patient is being patient, we complete the ward round. 3 babies with sickle cell crises. A man with severe hypertension, diabetes, a UTI and confusion. A baby with a viral infection. Another baby with severe malaria. Our meagre bag of medical tricks allows us to sort all of these problems well within the response time of our emergency transport for Joy.

Our patient continues to wait patiently. Whilst my patience is running out. Her heart rate stays north of 200. Finally, the clinical officer finds me again. He divulges the hard truth. There is no ambulance for Joy. Better the family find some money and get a taxi to Kamoto. She is unlikely to die on the way he explains to me. So finally: I get some idea of the definition of an emergency here.

The ambulance never materialises. Instead Joy’s husband calls in a favour from a family friend. His response time stretches from 18 minutes to over 3 hours. Most of our sick patients head home, well before Joy leaves Kakumbi at 12:00.

I find the double standards here hard to take. A couple of weeks ago, Keith and I spent 7 hours ensuring that a tourist, Mary, was evacuated to a state of the art medical facility in Jo’burg. Mediated via an aeroplane with full paramedic support. I was able to facilitate Mary’s transfer. And make sure that Mary got best care. But Joy is a local of limited means. I shipped Joy off in a friend’s car. With a wing and a prayer. To a place where I have no definite knowledge of the skills, medicines and equipment that await her in Kamoto and Chipata.

We are often asked about the difference between practicing medicine in Zambia and practicing medicine in the UK. How we cope with the lack of drugs, equipment and know-how? These are fair questions. There is no simple answer. What I do know, is that the standard of care that we hope to deliver is no different here. We always strive to do our best. Even when the going gets tough. We explore the options. Make a plan that suits the situation. And come up with the best available choice. Joy may have received faster, better, treatment in another setting. But Joy received better care because we were here.

Low resource settings impose constraints on us, but we will always strive to provide a very British standard of emergency care. Wherever we work. We don’t just cope.

African fish eagle - a birds eye view

Tickle my tummy