One might not have got the real flavour of African medicine through my blog yet. That is because (grudgingly) most of that stuff belongs to the sphere of the general clinicians, more strikingly for the infectious diseases guys! That doesn’t mean that I haven’t seen these textbook conditions which I would never dream of seeing in the UK, like rabies (with its Oh so distinctive hydrophobic characteristic) or tetanus (with your pathognomonic risus sardonicus) or measles (Koplik spots- but then I had it myself in Mauritius!), not to mention the vast array of HIV related illnesses (Kaposi’s sarcoma, high pressure CSF of Crypto meningitis, PCP etc). But two cases in the last 2 months have certainly added the exotic flavour to my Orthopaedic caseload too. Not that I want in any way to rejoice about the suffering of the afflicted patients, but one can’t help but marvel at the science of medicine when manifested in such classic cases.
C4 transection
Granted you’re going to see that in the UK too. But most of the time, the patient will have been dashed off to an ICU unit and rigged up to countless tubes and machines far and safe from your regular ward SHO! As a result you (ie me, the SHO) have hardly had a chance to really observe the striking physiological effects of such an injury and the speed at which they progress. This is now the third case I’ve seen already here. It’s quite common in fact, owing to a certain hazard called the “Matola”. This is the open back pick-up truck I’ve referred to already, in which people cram in the back, most sitting on the edge holding on to hardly anything. That combined with the terrains for which these vehicles are reserved (far flung village rocky dirt roads where there is no road access for better vehicles) is a recipe for disaster. After a sudden bump, the patients tend to be jolted right up in the air, often landing on their heads. Those who make it alive rarely present without a crack somewhere. When the break is in the cervical spine and involving the cord, one is left to praying for the best. What with the lackadaisical approach to ATLS and C-spine immobilisation prevailing in this place! The pattern of this neurology is so fascinatingly typical though that it could easily be the equivalent of an anatomy textbook condensed in one clinical presentation. You can map out the level of transaction to the exact dermatome. In this last case you could do so even without laying hands on him. A simple eyeball would tell you that his thoracic respiratory muscles had been knocked out of action. He was reduced to diaphragmatic breathing, of which unfortunately he would very soon tire. Sadly there are no remedies to this diagnosis here. You just hope that some neurology, at least the respiratory control, will return. Any attempt at transferring the patient acutely often only means changing the place of death and, more worryingly, adding to the patient’s distress through cumbersome ambulance journeys. Even if you happen to come off your matola right next door to the spinal orthopaedic hub of QECH in Blantyre, and for that matter in Europe, your chances of survival are still pretty slim. The only difference is that in Malawi, the rapid decline is for all to see, with ITU reserved for only the few cases with a theoretically better chance of survival. Recognising this early is really a knack the tropical doctor must needs master.
Congenital Hypophosphatasia
I admit it. I never even heard of it before coming here. That’s because this condition belongs to the weird and wonderful repertoire of metabolic bone diseases, that, unless you’re running up to an exam or the like, you would never willingly inflict upon your brain. To be more precise, the condition can be specifically attributed to the group of Vitamin D resistance syndromes. Wow! Completely unprepared for it, I got called one morning to review this 1year boy with a bizarre clinical presentation and even ‘bizarre-r’ looking Xray! The difficulty here is that everyone is somewhat expecting this “muzungu orthopaedic specialist” to come up with a spot diagnosis as he must have read about it before! But there I was as perplexed as them if not more. The child had a classic presentation of long bone fractures with minimal trauma and generally didn’t like being handled. The Xrays, I found out as I revealed them to the superior beings that inhabit CURE hospital, was quasi-diagnostic of the condition. It is so rare in fact most of you (medical readers) will never encounter one in your lives. Even google images failed to conjure up any decent pics for comparison. Once again, the treatment for this kind of condition is extremely limited here. Even at Queen’s Hospital (QECH) where the child got referred, the prospect of lifelong phosphate/Vit D replacement is extremely challenging without a family who can assist financially. The usual outcome unfortunately is a gradual decline into terminal renal failure.
So here again, I end up ending on a hopeless note regarding my patient’s outcome. However, in perspective, most conditions we see are common and treatable. We, as medics, have a natural tendency to get excited about rare conditions... I guess to counter the boredom that might arise from applying your 1000th plaster for a wrist fractured in exactly the same way. What can be frustrating is when even the simple stuff gets mismanaged. The danger then is to identify one single person/factor in the entire system to blame. But when the system is fraught with such severe deficiencies of staff and resources, one might instead remember all the cases that are actually being well treated by that person/factor and work on improving the system rather. From that premise however arises the conundrum that some staff feel completely exempt from blame as a result and take liberties with patients’ health. Who and how do you blame? Or should you blame? If you don’t (something or someone), how do you identify the fault? That really is the challenge that working here as a volunteer doc exposes you to. More than the pathology and surgery of medicine, you’re learning things far beyond these borders. And by one year, I can say that is also quite a rewarding experience.
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