A testing time

Published on 30 August 2025 at 04:52

Photo of the week: A new leopard for us - trying to catch monkeys up the tree

Highlight of the week: I find out about the wait-a-bit thornbush. An acacia shrub that keeps predators at bay. Even elephants and buffalo stay clear of its fierce embrace.

Lowlight of the week: The cool of the Zambian summer is over. Our aircon struggles to get with the programme.

Maximum temperature: 38 degrees Celsius

Rainfall: The chance would be a fine thing.

To test, or not to test? That is the question.

The answer might be imposed upon you. It’s 1994. Northern Unguja. Zanzibar. I have 5 tests at my disposal. Malaria. HIV. Haemoglobin. Blood group. Stool parasites. Now what was the question?

Imagine that you are reading my blog from 1994. Malaria is rife. Yet the test is rarely done. HIV is, as yet, rare. And that test is predominantly reserved for donated blood. If a child looks pale, they are pale. A haemoglobin of 2.7 g/dl might surprise you in England. But I am rarely wrong in deciding who needs a transfusion here. Test, or no test. And stool parasites are the rule here, rather than the exception. I treat those that need treatment. Not those that I test.

It’s 1997. We are back in England. Zanzibar is like a hazy dream. A quick backpack trip around the world is now merely a collection of images. Albums that are due to collect dust. I am working in my first registrar post in paediatrics. On a 5 year trajectory to becoming a consultant. Throughout medical school I was indoctrinated with the maxim that 80% of diagnoses could be made from the history. But a panoply of tests challenges my doctrine. Why would all of these tests exist if they weren’t needed? Surely, I should be doing more tests!

I also have a computer. My slave? More likely my master! The screen demands. Expects. Insists. What tests are expected? So many options. A tick in a box. Another test requested. As easy as that. I just need to decide which one. Perhaps just do them all? It’s only one small needle into a vein. A few bottles to fill.

I’m on call with Jonathan. My boss. Not yet a friend. A head appears at the door of the paediatric day unit. Jonathan’s disembodied head seeks permission to depart. Dinner awaits. But his body surrenders an opportunity for an early supper, and leads him right into the day unit. PDU a home from home, for all conscientious paediatricians. Resistance is futile. He offers support. A 3 year old girl is taxing my mind.

She has a mild fever. A red throat. Pink ears. Cervical lymph nodes palpable. Nil else. I think it is a virus infection. But I am toying with doing some blood tests. Because I can. I tell Jonathan I am going to do a full blood count. Why? He asks. I reply confidently: Because if the white count is high, I might give her antibiotics. He looks at me thoughtfully. Do you need a blood test to decide that? What would you have done in Africa? Now that gets me thinking. Just because I can do a test, should I? I go back and look at the child. She is full of snot. Virus is written all over her. What further proof do I need? My clinical skills are good. They have had to be for the last 2 years. Why should a random number influence me? Why do we do tests?

This single conversation guides my route through paediatrics. Steers me. Not off on a tangent mind. But changes my trajectory. Tests have a place. In endocrinology, tests are the mainstay of monitoring and managing endocrine problems. Necessary. Useful. And also in acute situations, they help. Guide. Support. But the key to managing problems is a good history. A thorough examination. Sometimes time. But tests are not a kneejerk response. Any test needs to add value. Some will send you down a convoluted rabbit hole. Harming not helping. Costing and not contributing.

Reflex testing is now part of our NHS culture. Nobody wants to miss that needle in the proverbial haystack. Guidelines have become tramlines. Defensive practice stifles the possibility of clinicians using their clinical acumen. The blunderbuss approach has become standard. And we are all paying for it. No rabbit warren is left unexplored. And the golden goose stays quiet. Why honk when your nest is being feathered by endless, profitable tests?

First, do no harm, Hippocrates advised. Today, he is turning in his grave. His timeless aphorism lies in ruins, replaced by a new mantra: Leave no stone unturned. But in our frantic stone-turning, we’re generating more heat than light - much effort, little clarity, and often, unintended harm. I suggest that we stop turning stones and let Hippocrates lie in peace.

Zambian practice has its virtues. Tests are sometimes present. But geography and supply chain issues ration their use. So time remains my favourite test. Natural history and cold hard clinical symptoms and signs guide us to our holy grail. But progress, of a sort, is marching on. Even in deepest, darkest Africa.

We have our wonderful new hospital, up our single tarmac road. Velos currently houses a number of people with injuries. Including a couple of local men, beaten up by a particularly grumpy elephant. Velos has a beautiful purpose-built lab. Radiology facilities, the envy of any DGH in England. Skilled laboratory technicians. But reagents are like hens teeth in this part of Africa. And for your information our hens have beaks just like yours. So I find myself back in the Africa of yore. Familiar territory. Rejoicing that my 5 tests at least do no harm.

It's Friday. Our Kakumbi clinic is quiet. Keith and I are looking for work. Quite unusual in these parts. I hear a rumour of a sick baby. I gravitate towards the cries. I find Joy. One of our staff members. She is cuddling her son, Martin. He is 18 months old. I had seen him 2 days earlier. Martin had a mild fever. But otherwise he was happy and well. I had advised paracetamol. Joy is now very distressed. Martin has now had a high fever for 24 hours. Paracetamol has brought no Joy to Joy. Nor to Martin. Martin’s fever is still high. There are no other symptoms. No cough. No rash. No runny nose. No sneezing. No vomiting. No diarrhoea. I check him over. He is hot. His temperature is 38.5. He is alert and looking around. But he’s unsettled. Miserable. Not irritable. Martin’s examination is otherwise normal. I have excluded a number of conditions. He has neither malaria nor a UTI. No sepsis. I note that he is fully vaccinated – and had his measles jab 3 days earlier. This seems important.

Then I spot the cannula in his arm. Joy tells me: I came here last night. We have started him on ceftriaxone. Intravenous Domestos. A catch all antibiotic. An understandable approach. Martin’s fever has everyone stumped. On edge and unwilling to miss a treatable rabbit. This rabbit shouldn’t get away. And yet, I know that Martin is not septic. His fever is almost certainly a response to the measles jab. And 16 hours later, Martin’s fever is unabated despite the antibiotics.

Joy remains very worried. Wanting more answers. I think I may take him to Velos. She tells me. Away from the only paediatrician in the District. I don’t say. What will the team there do for Martin? Comes out of my mouth. I could get a full blood count. She replies. We are in familiar territory. If you can do a blood test, should you? We have a discussion about the merits of a blood test. Martin is already on antibiotics. So it won’t help with decision making. He is looking unwell, but not critical. Perhaps a number will make her feel reassured. But it will involve a 1 hour ride to the hospital. The cost of a taxi. A needle in Martin’s arm. I suggest that we give him some ibuprofen. And do a more important test. The test of time.

I explain to Joy that I am almost certain that Martin is having a febrile reaction to his measles jab. He will feel grumpy with the fever. But happier when it settles.

Measles vaccines. A total life saver. Especially here. But the one major side effect is a fever. And grumpiness. No blood test would help with this. We give him quarter of a tablet of ibuprofen. After an hour, I pop back to see Joy. Martin is considerably happier. He is being strapped to Joy’s back. I am taking him home. I remind Joy that she has my number. She should call me if she is still worried.

It's now Monday. 3 days later. Farmer’s day here in Zambia. A national holiday. That means we have a day away from the clinic. Our day is quiet. No calls. Perhaps illness is getting with the programme? Catching on - so to speak. Don’t get sick on a holiday. But we hear on the grapevine that Martin is now at Velos hospital. Joy took him up on Friday after all. I message her. His temperature is better. He is just very weak now. We are due at Velos tomorrow. I promise to drop by to see him.

I find Joy and Martin in a private room. Off the paediatric ward. Martin does not look right. He is alert. His vital signs are normal. But his abdomen is distended. Constipated. He is floppy. Weak. Not as vital as a toddler should be. He moves in slow motion. Unable to sit unsupported. Unable to support his head properly. Not speaking. He clearly knows what he wants. But he can’t articulate it. All his reflexes are absent. His brain is working normally. But his nerves and muscles are not singing from the same hymn sheet. He has an acute flaccid paralysis.

My brain is working too. Double quick time. I work through the possibilities. Could this picture fit with acute polio? Unlikely. He is fully vaccinated. But stool has to be collected to rule this out. Again I follow a guideline. And test against my better judgement. Acute botulism? Again unlikely. His face looks normal. Martin can swallow. His fever doesn’t fit with Botox paralysis. Another tropical disease? I can’t think of anything tropical with this pattern of illness.

I review all of Martin’s notes. Lots of tests have been done. Blood tests. A malaria test. A blood film. A chest x-ray. An ultrasound scan of his abdomen. A cardiac echo. All normal. It seems they have looked at their test list and ticked all of the boxes. Joy tells me that Martin is booked for a CT scan of his head. The medical team think he has meningitis.

I return to my original hypothesis. A reaction to the measles vaccine. Now, I know there will be clever doctors reading this. Who are yelling the diagnosis at me. My hypothesis may be incorrect. This looks like a mild case of Guillain Barre Syndrome. Mild, as he is already getting better. An illness with many causes. It has been linked to vaccination. Extremely rare. Where the nerve sheaths are damaged. Causing a lack of nerve impulse to the muscles. They become weak. But the brain still works normally. Treatment is supportive. Without a magic wand. Most people get better on their own, over time.

I explain my thoughts to Joy. I can’t prove it. There is no test. I suggest cancelling the CT scan. Lots of radiation with no benefit. She agrees. I also try to stop the antibiotics. This request falls on deaf ears. I inform the physiotherapy team. I talk about time. I understand it is hard to do nothing. To stop looking for answers. To stop active treatments. To be patient.

I arrange to see Martin again 2 days later. We keep in regular contact via WhatsApp. Martin improves quickly. When I next visit, he is sitting unsupported. Reaching for toys. Supporting his head. Not yet walking and talking. But Joy appears happier. He has improved faster than I had expected. A big relief. He is discharged 2 days later. To complete his recovery at home.

In the UK, we would have run even more tests. A gamut. A comprehensive, catch all collection of rarities would be excluded. A lumbar puncture. More bloods. Nerve conduction studies. An MRI scan of the spine and brain. A paediatric neurologist would run the show. Perhaps some fancy treatment would be started. But the outcome would have been the same. Martin gets better despite us. Not because of us. Martin is fortunate to have a self-limiting condition. His mother now relieved and happy.

We have all been tested. Martin more that most. Perhaps we should include an extra test in our medical list of tests. It’s time.

Don’t just do something. Stand there. Wait a bit.