I collapsed on the sofa when I came home tonight. Clinic went pretty smoothly today I thought, though not quite as quick as I would have liked so I was late home. I averaged just over 10 mins per patient, so kind of your standard GP list (though no tea breaks!). As I lay reflecting on the patients I had seen it struck me what a different spectrum of conditions we encounter from back home, so I thought I’d share a day as a rural primary care doctor with you.
Clinic days are always a bit of a rush. I woke up at 6.30am and tried to get lunch ready and my library bag packed full of medical books. First was grand round in our high care unit where we saw a guy who had been stabbed and had to have his bowel sewn up (glad I wasn’t on call for that one!), a young lady with HIV in severe heart and renal failure and a patient in DKA (diabetic crisis). I then rushed off to do my ward round on maternity including getting consultant advice about a syphilis exposed baby, monitoring another baby with neonatal jaundice, as well as checking that all was stable with the two ladies who had had post-partum haemorrhages in theatre this week. The pressure is always on to do a quick ward round and get to clinic as you know there will be a crowd waiting. Paula and I grabbed the car, then popped to pharmacy where they proceeded to load us up with 30 heavy boxes of medication! Heavily laden we tried to take the speed bumps with care, and drove an hour down the main road, dodging wandering cattle and schoolchildren to get to our clinics. With all my best efforts I arrived after 11.30am and had about 25 patients to see.
It wasn’t a bad clinic – a few admissions, no one desperately sick but plenty of tricky things to think about. So, here goes… one new diagnosis of diabetes with unrecordable high blood sugars, one 52 year old with severe hypertension who had a stroke 3 weeks ago and just presented now, 3 ladies with HIV and possible meningitis, one old man with a new diagnosis of AF (irregular heart rhythm), heart failure and maybe a blood clot in the leg, one young lady with epilepsy and schizophrenia with some mild psychotic symptoms, one 20 year old man with uncontrolled epilepsy (3 seizures a week) and possible neurofibromatosis (rare genetic condition related to grown of nerve cell tumours that can be linked to epilepsy – strictly textbook in the UK but I’ve seen 3 cases already this year), one pregnant lady with high blood pressure, one pregnant lady with chicken pox, one baby with severe nappy rash, one old lady with possible rheumatoid arthritis, one young man with depression and suicidal ideation, one 18 year old girl failing second line antiretroviral therapy for HIV. 3 patients for admission to hospital, several more put on the bus to go to hospital for investigations. And a few chronic medication reviews thrown in there too. And one guy with a cold.
Why do we see such intense things?! HIV complicates the picture always; in our clinics around 30% of patients are positive and rates are higher in the hospital. Not only does HIV leave you open to developing opportunistic infections, but the presence of the virus itself can cause direct damage to many organ systems. We frequently admit even young patients to hospital with HIV related stroke, cardiomyopathy or renal failure. HIV also increases your risk of several types of cancer and we have many young patients with cervical cancer, kaposi’s sarcoma, anal cancer, liver cancer and lymphoma amongst others. The antiretroviral medication is generally very safe, but some will suffer adverse effects such as liver or kidney failure, and one of the groups of medication can cause a ‘metabolic syndrome’ leaving you at increased risk of developing diabetes. TB is also rife here and is one of the great imitators – it is a differential diagnoses for most presentations: cough, chest pain, weight loss, fevers, back pain, abdominal pain, anaemia, headache, chronic diarrhoea…
Patients here often present very late. Imagine waiting 3 weeks to consult after having a stroke. Some of this is due to poor health education and knowledge, sometimes challenges with transport to access clinic services, sometimes fear of hospital or medical staff. Patients here seem to tolerate living with certain conditions that always surprise me – people often consult late about epilepsy or psychiatric illness and lumps and bumps may reach great proportions before they are reported. Often the first port of call for patients will be family members (much like back home, see what Mum thinks) and then traditional healers. Often these healers with treat the condition, but sometimes they do refer them on. Once they make contact with our medical service they get seen by a primary health care nurse who can be just excellent. They keep the bulk of conditions under control and it is only the tricky end of the spectrum that gets filtered through to us.
The primary care clinic is quite impressive. When I walked in today there were about 100 people waiting. There was a nurse seeing HIV positive patients on treatment, one dealing with chronic disease such as psychiatric illnesses and diabetes, 10 mums with babies sat on a bench waiting for immunisations, two nurses taking bloods, one staffing the labour room where they sometimes manage low risk deliveries in clinic. There is a nutrition advisor, an ARV counsellor and our therapists visit most clinics once a fortnight. Our professional nurses are real independent practitioners and are trained in starting treatment and monitoring chronic conditions such as HIV and hypertension, treating acute illnesses and doing minor procedures. They also act as my translator when my three word Zulu phrases fall on deaf ears, and keep up spirits in clinic with compassion and humour.
I hopped in the car to drive home with blood samples and prescriptions for the hospital my return luggage. There was a crowd singing and dancing in political party t-shirts at the end of the road (local elections were yesterday and results are trickling through) so I gave them a wave, and I put my foot down as I drove back through the national park before the sun set. I stopped at our local spar on the way home for some cheeky Cadbury’s chocolate and was glad to put my feet up when I made it back to our park home! A busy but fascinating day as a rural primary care doctor.