First, do no harm

Weather - Maximum temperature 43 degrees Celsius

- Weekly rainfall: A few spots

Highlight of the week

We meet a new orphan. Wamwayi is a 2 month old baby elephant. Curious and healthy.

Lowlight of the week

Zambia goes back on the red list

I was disappointed not to swear the Hippocratic Oath on my graduation day. My expectation had been fuelled by Doctor in the House and hearsay. I had visions that I would instantly be able to perform lifesaving procedures and generally save the world. My halo would be recognisable as I walked about the community. People would somehow know that I was a thoroughly good egg. The reality was a relative disappointment.

Despite the lack of a formal reading or a written contract: the Hippocratic Oath bound me then and binds me now. The General Medical Council (GMC) have processed it a little. Good Medical Practice guidance from the GMC now still insists that clinicians should first do no harm. I do my best.

We have previously talked about the availability of tests and medications in the UK. A plethora of tests and medicines bulge out of UK laboratories and pharmacies. Zambian shelves meanwhile are almost bare. We have also waxed lyrical about shared decision making. Keith’s special interest. Many had commented, prior to our departure from the UK, that we wouldn’t be doing much of that in Africa. Africa, the last bastion of the clinician centred consultation. A land that progress has forgotten.

Please bear with me. There is a connection between my oath to do no harm, the tests that we do and the treatments that we prescribe. I shouldn’t really use the word prescribe anymore. It’s a doctor centred word. But this is Africa. And the word is relevant to my story. There is also a connection between all of these things and shared decision making.

Remember those bare cupboards? That paucity of tests and a scarcity of medications? Many might think that a land where there are no choices would be a poor place for shared decision making. But they would be wrong. Our clinic pharmacy in Kakumbi actually has a pretty healthy stock of injectable medications. Some of these medications undoubtedly save lives. But the use of injectables is a double-edged sword. More of the harm that injections can do shortly. Local protocols push local practitioners with a basic training toward prescribing risky treatments. In an emergency, clinicians fall back on protocols. Sharing options and risks with patients take a back seat. It is important that we balance the possible benefits against the very real risks of injections. Shared decision making should always be on our minds.

The use of injections seems ingrained in medical culture here in Zambia. Many say patients have great belief in the power of injections. Vaccinations appear to have almost magical properties. Injectable treatments for malaria and serious infections can bring people back from the brink of death. These experiences have instilled faith in patients and clinicians in the power of injections. Clinical protocols suggest injections as first line treatments for sick patients. Which came first? Chicken or egg? Are patients’ expectations pushing the demand for injections? Or are clinicians over egging them?

When we started working in Zanzibar in 1994, we were shocked at the over-use of injections. Injectable drugs were supplied within an essential drug kit. A monthly supply of drugs that the WHO recommended. In Zanzibar, these injections were mainly Benzylpenicillin and Chloroquine. An antibiotic and an antimalarial. Appropriate to have for unwell, vomiting patients. But injections were over-used. Given to well patients because there were no other medicines available. HIV was the new kid on the block. New needles were hard to come by and sterilising methods uncertain. We often saw nasty injection abscesses and nerve damage caused by the injections. Hippocrates turned in his grave.

When we left Northern Zanzibar in 1996 it was a different place. Our health care workers had stopped injecting in the buttock near to the sciatic nerve. They now only injected into the lateral thigh or upper arm. Our medical staff knew when to use the injections. And when to first do no harm. Our two-year teaching programme for medics in Northern Zanzibar had reduced the use of injections by 50%. With no increase in serious illness or death. No harm done. Abscesses and nerve damage slipped off the radar.

Our medication supply in modern day Zambia is much better than it was in Zanzibar in the 1990s. But with the smooth comes the rough: More injectable medications mean more injections. Our team follow national protocols. Flowcharts meant as guidelines become tramlines. The guidelines target sick patients needing reliable but risky injections. A basic training does not allow our fellow clinicians licence to use their judgement. The tramlines dictate that symptoms need treatment. Our colleagues worst fear is under treatment. Over treatment is a new concept to most of them. When they work the night shift, alone, their treatment choices often fill half a page of notes. During the day, when we are present, they share their decisions with us and with the patient. The choices made are usually less draconian. Less medicine. Less injections. Less harm.

Every week, I see injections being over-used. I reviewed Jessi last week. She is 9 months old. She had presented with a one-day history of fever. She had had a runny nose and a cough. She had vomited twice because of her cough. She was otherwise a bit miserable, but able to eat and drink. When she had arrived, her temperature was 39.5 C. She was not pale. She was well hydrated. She was alert and very snotty. There was no sign of increased work of breathing. The national protocol had driven the staff to give her an injection of penicillin. Into her buttock. Even though her diagnosis was a viral upper respiratory tract infection. When I first saw Jessi, three hours later, she looked really well. We decided not to give her any more antibiotics. She had some paracetamol to reduce the discomfort associated with her fever. She went home.

It is hard to criticise our staff for following their training. They have not spent 5 years at medical school. Nobody else here has 31 years of experience under their belts. They have had no chance to hone their skills. After a basic 3-year course, they have been sent into the bush with no further training. No supervision. Their course was based on basic clinical skills and learning protocols. There are no doctors in the Zambian bush to provide supervision and further training. Volunteer doctors don’t grow on trees. Nor do they come reliably when you need them. Unless you work at Kakumbi. At Kakumbi this July two doctors just happened to come at once. Just like busses.

Four weeks ago, I first met Daudi. He was 4 years old. He had been back and forth to the health centre for the previous two weeks. He had an itchy rash. He was given various treatments which had not really helped. Antihistamines. Antibiotics. Antifungal creams. No one had considered that this might be scabies. Amazingly, our staff do not appear to recognise scabies. It is probably not on their algorithms. Despite scabies being extremely common. Hardly a day goes by when I do not diagnose a case. I am trying to teach the staff what it looks like. The treatment is very straightforward. A topical lotion. The box of lotion bottles in our pharmacy remained unopened until July. Nobody knew what the lotion was for.

I digress. Back to Daudi. His rash was no better despite antihistamines, antibiotics and antifungals. It was very itchy. I guess there was logic to what happened next. Despite an oral antihistamine having no impact on Daudi’s symptoms, one clinician casted around to find something that might help the itch. So, our anonymous team member decided to give him an injection of promethazine. Into his right buttock. Promethazine is an antihistamine which we use for severe nausea and vomiting. It can also be used in severe allergy for example anaphylaxis. It is no better at calming an itch than an oral antihistamine. It is certainly not indicated for any itchy rash caused by scabies.

Mum brought Daudi back to clinic a few days later as he was not walking properly. He was complaining of pain in his right leg. His itchy rash was as bad as ever. The protocols had reached a dead end. Daudi needed to see the Mzungu doctor. Their new protocol brought Daudi, a small person, to my door.

Mum told me that Daudi had stopped walking after his injection. He was struggling to use his right leg. There was no swelling of the leg. There was no history of any falls or injuries. He was otherwise well. I diagnosed his scabies and sorted out some treatment for that. Then I took a look at his leg. There was nothing really to see. No swelling. No obvious area of tenderness. No obvious infection. No abscess at the site of his injection. His leg appeared a bit weaker on the right side. Especially at the foot. He was able to stand on that leg. He struggled to walk in a straight line. He tended to favour the left leg. I wondered if the injection might have caused some damage. I explained this to his mum and gave her some exercises to do. I asked her to come back for review after 2 weeks.

I caught up with Mum and Daudi yesterday. She tells me that Daudi is still not walking normally. He complains of pain around his big toe and on the inside of his right foot. His toe and foot are very sensitive to touch. There is no rash or swelling. I can see some wasting of the muscles around the arch and the ball of the right foot. He is able to walk but there is a degree of foot drop. His sciatic nerve has been injured by the injection. Harm done. Hippocrates is convulsing.

Duty of candour. The new buzz phrase in the NHS. When you make a mistake, own up and tell the patient or their family. But what to tell this family? Your son will be disabled due to an inappropriate injection given in the wrong place? There is no culture of claiming against medical negligence here. No quest for money. The system has no money anyway. I vexed over how to communicate our culpability in the right language. Daudi needs physiotherapy. He will probably need help with walking as he grows up. He would benefit from orthotics. Special shoes to support his foot drop. None of these is readily available here. A trip or two to see a physiotherapist in Kamoto, an hour away by car seems beyond their grasp. As Daudi gets older, he may never remember the time when he could run around with no thought to his disability.

I told his mother that I was worried. I said I thought his leg had been damaged by the injection. I could not fix it. I gave her some exercises to do. She shrugged and left the clinic with Daudi. She declined a referral to see the physiotherapist in the distant village.

Keith wondered idly: Who did the injection? I did not tell him. I didn’t know. No-one else signs medical records here. I did not recognise the handwriting in Daudi’s record book. A witch hunt is not needed here. Barely trained clinicians need supervision, support and further training. I spoke to the clinician in charge about the error. I gently suggested that buttock injections are dangerous and probably should all be swapped to thigh injections.

The clinician in charge will deal with this sensitively.

We all need to learn from this lesson. In the NHS, we try to learn from our mistakes. We are all human. Human factors are key in most medical negligence cases. If we can prevent one Daudi by reflecting on this mistake, it will be worth it. We need to reduce our reliance on injections. But if injections are really needed, we should change the site where they are given. We should avoid the buttocks and use the thigh.

We changed a culture in Northern Zanzibar in the 1990s. Our book Diagnosis and Treatment, first published in 2000 by VSO and Macmillan suggested a safer option for giving injections: Give intramuscular injections into the front outer part of the upper leg as shown in picture 52. Do not inject into the buttocks. Do not inject into the buttocks. I feel that I am repeating myself as I write the same words again. We have the ear of our District Medical officer and our nurse in charge at Kakumbi. Diagnosis and Treatment will be republished with support from VSO in 2022. Our local colleagues and world experts will ensure that the manual is relevant and safe. It will be free of charge and downloadable from the internet. We will print the same words to echo our policy recommendation, first made in 1996: Do not inject into the buttocks.

First do no harm. Let’s keep Hippocrates happy.

Do not inject into the buttocks.

Occasionally an injection is required. We drained a huge abscess.

COVID vaccines have arrived in the valley. The queue starts to form at 0700.

Wamwayi and his new keeper, Aaron

Waiting for the midwife to arrive