A day in a district hospital

Today I, the consultant physician (Dan), and registrar (Charles) went to Kasungu district hospital, about 150km north of Lilongwe. The 2 hour drive there took us through fields of newly planted tobacco, clusters of mud huts with thatched roves, and town and villages full of people going about their daily business. Freshly cooked corn on the cob, mangoes, and live chickens for sale by the side of the road.
On arrival we were introduced to the district health officer, an anaesthetic clinical officer (someone who puts people to sleep who isn’t a doctor), in his plush office of fake black leather furniture. We were to see some outpatients first, who had been selected by the only doctor in the hospital (there are I think 2 interns too, that is newly qualified doctors, what I will hopefully be from August) as being difficult cases she didn’t know how to manage. We first see a 16 year old girl who has been on steroids since she was 5 years old for generalised oedema, most likely minimal change glomoerulonephritis. I was shocked by the length of time she’d been on steroids, with apparently no specialist review of treatment for over 10 years. We arranged for her to come to Lilongwe to collect some cyclophosphamide (immunosuppressant) and to make a steroid-weaning plan. While we’re discussing this case, the doctor and clinical officer who are supposed to be learning from the experience so they can further their clinical ability are wandering in and out, drinking fanta orange, and generally not paying attention. Dan tells them they have to stay and listen. They stay, but in my opinion don’t listen, because they don’t give any input at all.
The second patient is an elderly man (I remember I quite like old people and haven’t seen many as patients here) with a long history of a dry cough (i.e. for years). He is otherwise well, and Dan finds out the likely cause of his chest problems: he worked in some form of mine in South Africa. Dan then gets into some chat about lung diseases that are predominantly Western: interstitial lung disease, chronic obstructive lung disease (COPD) and asthma. Of course, no one knows much about these, and there are long periods of silence before I offer answer. Dan gives some inaccurate information about asthma treatment, and in my opinion gives too much information for these people to take in, they stare blankly at him. We need to do an ECG on this patient as palpation of his pulse suggests atrial fibrillation. I am instructed to show the doctors how to do an ECG. Someone eventually finds the ECG machine, and we link the patient up with the sucker-pads attached to his chest. Then we discover there is no paper for the machine, so we can’t record anything! I feel frustrated by this, but then think, what would we have done about it anyway, probably nothing. I can guarantee that the doctors here will not be doing many ECG’s in the future, not only because they don’t know how but because there are no facilities, and its just not a priority.
Next patient has tophaceous gout, very obviously so. He is on ibuprofen for the pain, no one has checked his renal function (NSAIDs combined with gout can cause renal impairment), but the hospital doesn’t do renal function tests. He should be on a drug that lowers his uric acid (allopurinol), the doctors don’t offer this information when asked, and apparently there is no allopurinol (Dan stresses this is a cheap drug and should be available). I think: this is a relatively simple case, why is Dan being asked for input?
The next patient is a young chap complaining of long term central abdominal pain. Only by looking at his abdomen I can see visible peristalsis, and can feel a weakness in the abdominal wall. I think this is a mild hernia, Dan has a few other ideas. This is obviously not a medical case! This guy needs surgical input, so why hasn’t this been arranged? Why did they have to wait for Dan to get this organised?
Dan’s passion is teaching, he takes about 30 minutes to see one patient because he goes off on long tangents, asking multiple questions, which I volunteer answers to and everyone else remains silent. That was the most prominent thing I drew from this morning, that no one answered Dan’s questions. Is this because they culturally don’t answer questions when asked by a senior? But it felt more like they didn’t know the answers! And they weren’t that complicated questions, even I had ideas for most of the answers. This made me worried about this apparently qualified doctor running a hospital....this fear was worsened in the afternoon....more later.
With the doctor, an intern and the same clinical officer that was with us (physically but not mentally) this morning, we move on to the male inpatient ward (there is one ward for men, one for women, on for little ones, and a maternity unit, all covered by this one doctor, with her ?2 interns, 5 clinical officers, and maybe 10 clinical officer students). The wards are much brighter and look cleaner than Lilongwe. There are TV’s blasting out a bible channel from Texas (that is enough to drive anyone crazy). The ward houses medical and surgical patients. There are big permanent signs on the wall in different areas of the ward, stating the diagnoses of patients in that section of the ward: ‘malaria’, ‘pneumonia’, ‘anaemia’, ‘orthopaedics’, ‘surgery’. We are asked to see two patients here. The first is an “HIV positive man with tremor” (he is in the ‘pneumonia’ section, which confuses me). This is the history we get. It soon becomes obvious that this chap has a cerebellar lesion. He has an intention tremor, dysdiadokokinesis, nystagmus, slurred speech, and hypotonia (this is not important for those who are non-medical, it was more the point that it was so obvious, but because the patient had never had a full physical examination, no one had elicited these signs and therefore been able to make a suspected diagnosis). I learn from Dan that cerebellar atrophy (shrinkage of this part of the brain) can occur in HIV infection. Dan asks if the patient has been tested for syphilis, he hasn’t. He hopes that will be arranged.
The second male patient is elderly, they are unsure of his age but he looks to be in his late 70’s (but its hard to tell with such a weather-beaten face). He is unresponsive, that is all the history we get. Dan states that he is no geriatrician, and this makes me think of the age of most patients I have seen so far in Malawi, and that this is because of HIV. Dan asks the medical staff about the eldest patient’s they have seen with HIV. I am surprised to hear that some have treated patient’s in their 80s. This means these patients must have contracted the virus very late in life. Charles (the registrar) tells me this is because they are either caring for their relatives with HIV and don’t take the necessary personal protection precautions to avoid contact with body fluids, or because there is child sexual abuse within the family where the children are HIV positive (most likely have contracted the virus through mother-to-child transmission). Have the staff through about sepsis in this patient? No chest xray, no investigation for urine infection has been done. The antibiotic he is on would cover a chest infection but not urine. We add in an antibiotic for the urine. From my experience over the two weeks I have been here so far, he will likely not get any investigations, just be treated for the differential diagnoses.
We then move on to the female ward. Its the same size as the male ward but I have never seen a hospital room full of so many people. There is noise and chatter. There are people everywhere. At first it is hard to tell who is who, but then I realise that there are patients on the floor on mattresses between the beds, and sometimes two patients to a bed. The patient’s guardians (not sure if I’ve mentioned guardians, these are the people the patient’s bring with them to the hospital to take care of all there personal needs, i.e. washing, preparing food, feeding etc) are also on the beds, some on the floor, some wandering around. There are crying babies, some of them being breast fed lying be the side of their sick mothers, some being cradled by guardians. Everyone starts laughing around the bed of the first patient (I’m horrified by the number of sick people in this room so am not feeling like laughing is an appropriate reaction, but find that perhaps laughing about the problems that are so obvious is perhaps just what happens here, a way of coping maybe? But it still feels inappropriate, and like they just don’t care). They tell us that this patient states that she “fell out of a plane”. I’m confused. They say it is something to do with witchcraft, and there is nothing wrong with her (despite the fact she can’t move and is in obvious severe pain). Dan pulls an 18month old child off the patients breast and examines her back, and discovers an area of tenderness over her cervical spine (back of her neck). She has had no x-rays taken, and Dan requests that these are done. Otherwise, she has been lying there without a diagnosis, waiting for nothing to happen.
The next lady looks very sick. She is tiny, with arms about as thick as two of my fingers. Her tummy is huge, sticking out so obviously on her tiny frame. She is in pain too. Its hard to guess her age, maybe 40-50? The staff don’t know what to do with her. They have taken abdominal x-rays, and established that the swelling is not solid or fluid but air (its sounds tympanic on percussion). The story is obviously one of intestinal obstruction (in an HIV positive patient). Dan asks them what they are treating, i.e. what are they doing for this patient. The clinical officer says it is palliative. Dan stressed it can’t be palliative unless you know what you are treating. Silence. Has anyone examined her back passage. “It’s not been done” (becomes the most frustrating phrase of the day). We do this examination (and check per vaginum as well because of the high incidence of cervical cancer in the HIV positive population) and discover a rectal tumour (interesting issues trying to carry out such intimate examinations in such a public place. No curtains so we make do with a couple of screens and making other patients turn the other way). There we have a diagnosis, through the simple yet invaluable measures of thorough physical examination. As an aside, the patient has no drip, and no nasogastric tube, despite vomiting on a background of obstruction. Dan suggests these management measures are carried out.
The next lady also has a distended tummy, and is just as thin, but she appears cheerful, and is obviously not uncomfortable. She is perhaps in her 50s-60s. This is a fluid filled tummy, and an ultrasound scan has shown liver lesions (likely malignancy, either primary or spread from somewhere else) but for some reason nothing has been done manage the problem. No fluid has been taken for analysis, so Dan does this now. Then he asks what medication she is taking. I can’t remember what she was on, but not spironolactone, a drug that would help reduce the amount of fluid in her tummy. Dan says how important it is that she be on this drug. He is told by the doctor that they don’t have any. The next patient gives us further info about the lack of drugs available.
She is in her early 30s, and is sitting up on the bed with another patient lying beside her. She is short of breath, and her ankles are oedematous (swollen). Even sitting at 90 degrees her elevated JVP is making her ear lobe wobble. Dan just touches his stethoscope to her chest, then asks the clinical officer to present the patient. He mentions something about shortness of breath and oedema and says she has mild heart failure. HIV can cause a dilatory cardiomyopathy, which in turn can result in heart failure. Dan asks him about his findings when listening to the chest, the clinical officer says there is a murmur (this doesn’t really mean much at all, we need timing a location of murmur). Dan asks us all to listen to the chest. I’ve never heard an S3 gallop rhythm before but this must be it, it so obviously sounds like a galloping horse! And on a background of heart failure/fluid overload that would make sense. No one else comments on their findings, no one has any suggestions about what the altered heart sounds are. I give my gallop rhythm suggestion. This is also what Dan thinks, but he wants the clinical officer, doctor, and intern to comment on what they heard, so that he can be reassured that they are learning from the experience. They just copy what I say when he asks me to reproduce the sounds I heard. Again I think, if I can do this, why can’t they? Dan establishes that this lady has severe (stage 4 New York Heart Failure for you academics) congestive cardiac failure by asking her how much she can manage to do for herself at home. She needs several medications that are not being currently prescribed (she is only on furosemide – which is relevant, and digoxin – not relevant before all the other important treatments fro heart failure have been initiated. Surprise surprise, the hospital has no ACE inhibitors, and again we have no spironolatone. Dan tells us these drugs are cheaper than the nsima (the porridge Malawians eat everday) this patient is eating. He tells me money for drugs is not an issue in Malawi. Where are these drugs? The district health officer’s plush office sneakily slips into the back of my mind.....
The last lady we see is in the TB room. A permanent sign on the wall reads “TB suspects”. There is a lot of coughing going on, and again patients on the floor as well as in beds, and guardians everywhere. The patient we are asked to see is 32 years old, and is sitting up in bed, gasping for breath. She is tiny, her arms as thin as the other two ladies we saw earlier. She has dilated neck veins, and dilated veins in her right arm, with puffiness of the right hand. The right hand side of her chest is about twice the width (in the anterior-posterior dimension) of the other side. There is obviously something growing inside her chest, compressing venous drainage from the right arm and the head (SVC obstruction). As far as I am aware, TB doesn’t do anything like this, and Dan agrees. She doesn’t have TB, but is in the TB ward, where her guardians are at risk of taking TB home to the rest of the family. Nasty nasty chest x-ray showing a sliver of left lung remaining, the rest is compressed my her mediastinum which is shifted far to the left by an unknown mass in the right side of the chest. She has advanced malignancy basically, what sort of malignancy would do that though I don’t know.... They keep taking fluid off her chest, but it keeps coming back. Dan explains that she needs a chest drain, then pleurodesis to stick the pleura to the chest wall to try and stop the fluid coming back, then she needs good palliative care for the distressing breathlessness. They are happy about putting in a chest drain, but not happy with injecting some iodine (“we don’t have” – apparently its only about 30 kwatcha [about 20 pence] in the shop, they could go buy some says Dan) down the tube to do the sticking. This seems a bit funny, seeing as the chest drain is the most complicated bit. The doctor wants to transfer the patient to Lilongwe to have this procedure done. There is no way she will make the journey. We ask for some morphine to alleviate the distressing breathlessness, there is none. Pethidine will have to do. Dan makes the important point that this patient and her family need counselling about her terminal illness, and that she could go home to die. I leave the bedside with the frustrating feeling that none of these things will happen. She won’t get pleurodesis (she will probably die before then to be honest), and no one will counsel her and her family. She did get some pethidine before we left the room.
The doctor then asks Dan to see some children. He reminds her he is not a paediatrician, but she complains that she has very limited paediatric support from Lilongwe. He is persuaded to take a look.
The first kid makes me cry. He is a little boy of about 9 sitting on the side of his bed. He has a puffy face, puffy ankles, and a hugely distended tummy. He lifts up his shirt obediently to be examined. They have tried to drain his tummy and its still leaking from the hole they made because of the high pressure. The notes and the staff say he has heart failure. Dan takes a history from the boy’s mother, and the swelling started in the tummy, not the face and legs, meaning this is more likely a liver problem, not originating from the heart (of note his heart sounds normal). He needs to see a paediatrician. Apparently he was in Lilongwe two weeks ago but was discharged. Dan says this was a mistake, and happened because the consultant paediatrician in Lilongwe doesn’t see patients, the clinical officers run the show instead. We make arrangements to transfer him back to Lilongwe, and Dan will make sure he is seen by the consultant. I cried because he is so sick, and because he is sitting in a room waiting for nothing to happen. And because he was so compliant with these people who are doing absolutely nothing for him. And because if he was somewhere else things could be so different.
The next little boy has lots of large lymph nodes. Obvious lympohoma. He needs a biopsy, but the hospital doesn’t have formalin to keep the specimen in. Otherwise he is unnecessarily in hospital. Dan reminds everyone that because his Dad is with him in hospital, soon the other children in the family will be admitted with malnutrition because the family won’t be able to afford to feed them.
The last patient is a boy with likely herpes encephalitis. Instead of listening to the conversation I go and find a healthy looking smiley baby without anyone looking after it to gurgle at and play with. We have a special 10 minutes together.
I’ve no idea how many beds the hospital has but there must have been over 50 female patients, about 20-30 male patients, and probably about 50 children. We didn’t see the maternity unit. No wonder this doctor is ?overwhelmed/?out of her depth.... What about the obvious lack of enthusiasm and drive though? All she did when Dan asked why certain management hadn’t been carried out was giggle (I was ready to throttle her at the end). And the clinical officer was too busy trying to do as little work as possible to make any effort whatsoever. Dan kept telling the doctor how easy it was to order drugs from the pharmacy in Lilongwe, but then told me she doesn’t really have any power over what the district health officer (DHO) orders (apparently the DHO now has hypertension and diabetes – i.e. he has money he didn’t have before). Dan also told me that the doctor we went around the hospital with is actually employed by the UN, rather than the Malawian Ministry of Health (she is a UNV – a Uninet Nations Volunteer). This is why she has no power.
It’s sad and frustrating, because the patients we saw today do not have access to simple and straightforward treatment. But what seems somewhat worse, is that patients seem also not to have access to simple and straightforward clinical knowledge that doctors/clinical officers should have, which means they are not diagnosed, either at all or correctly, and therefore can’t be managed appropriately. This seems to be mostly down to clinical training. On the way back in the car, in between buying mangoes from the side of the road, Dan tells me that the training of clinical officers especially (but also medical students) is out of date, and carried out by lecturers who have limited clinical experience, because by the sounds of things, they can’t be bothered to work on the wards. The clinical officer students in Kasungu spend 16 weeks in this district hospital, without any teaching other than what the doctor has to offer (I would be extremely worried if she was teaching anyone based on her knowledge I witnessed today). These people need knowledge, but also they need empowerment to make them care about the outcome of the patients they are looking after.
This makes me tired. I manage supper then an early night while everyone else goes for drinks and a game of pool.
The next day we drive north to Mzuzu, the largest city in the north of Malawi, about 400km from Lilongwe. The countryside is very different up here, lots of pine trees, cooler, wood planks lining the side of the road explain the deforestation, mountainous, and generally much more lush and beautiful. The road is windy, and our little car doesn’t manage the steep hills too well! At Mzuzu we turn right (east) and drive another 50kms downhill on a small road (mostly tarmac) to Nkata Bay. Lake Malawi appears infront of us as we come over the last hill, and a busy bay town. We find our accommodation: a place called Mayoka Village, built on the steep rocky shores of the lake, a maze of bamboo huts and steep stone steps, and a very lively bar area full of (far too) friendly Malawians and backpackers. We pitch our tent, and dive in the very warm lake before waiting for the “fantastic Friday night BBQ”, lots of delicious food. We manage a few drinks with the locals before bed. Today we are taking a boat trip and will hopefully see fish eagles, go snorkelling, and jump off a cliff (that is what the offer is anyway!). The weather is very heavy and cloudy, but perhaps it will clear up some this afternoon for a wee bit of bronzing opportunity (we look very pale compared to the other people here who have been doing beach things for years probably).