Weather - Maximum temperature 39 degrees Celsius
- Weekly rainfall 21mm
Highlights of the week
Christmas day with new friends.
We save two lives at our Kakumbi clinic on Wednesday:
· A two-year-old child having a febrile fit had a prolonged tonic phase and dropped her oxygen saturations to 30%. Good airway and breathing management saved the day.
· Our elusive ambulance appears at the click of our fingers to ferry a 29-year-old woman with an acute abdomen and sepsis to Chipata. Our resuscitation and the miracle transfer should save her life.
Lowlight of the week
Christmas day without family.
The honey badger died. The ignition jammed and then the hot wire switch fell apart. Back to the blue beast.
Some patients deserve a season ticket. Their notes are thick. The quest is constant. Another test, another opinion. Yet the tests are all negative. The clever doctors in their ivory towers shrug their shoulders. They pass the parcel back for another specialist to unwrap the mystery afresh when the music next stops. Functional illness has no diagnostic test. Yet the story is familiar, the signs unmistakable. Recognisable without a scan. Clinicians can tune in their Spidey senses. Up their game. Know that it is there, and the blinkers come off. Commit to what your instinct tells you. It’s time to stop testing. It’s time to stop referring.
Another continent another ball game? Would there be functional illness here in Zambia? In the nineties, in Zanzibar, we had been so busy trying to save lives that nuance did not surface. Our Swahili fluent to a point. But hold a hammer and you will only find nails. In Zambia we now have more tools and less nails. We focus on patient expectations and rely heavily on support from Moses and Joyce to translate. So, in our Kakumbi clinic we use a more extensive repertoire of questions that include all our old English favourites. Favourite questions find predictable answers. No surprises here. Functional illness is alive and kicking in South Luangwa.
Words say everything. Words say anything. Keith and I were both daunted by the prospect of trying to explain functional illness in Africa. We were going to be at the mercy of our translators. Moses and Joyce have no experience of talking about functional illness. Their words might not be our words. The clarity of our explanations teeter on a knife edge. Therapeutic words? Or harmful words? Hit or miss?
Alice felt that she couldn’t go on. Desperate but not suicidal. Her life had been taken over by symptoms. Her clinicians had offered her repeated treatments and referrals. Yet the trail had run dry. Alice had several functional illness patterns. They often travel in packs. Migraine, widespread pain and abdominal gases. Nothing worked. The constant search for understanding and relief seemed to ramp up her distress. Doctor Keith you need to fix me. You really are my last hope. At least Alice was not hampered by a language barrier. Her fluency in English accomplished. Keith would need great skill with words to be therapeutic here.
Empathetic and patient. Keith was up to the job. The key was in recognising the patterns. Excluding the vaguely possible, less important. No alarm bells rang. In any case: no tests could be done. This is Africa remember. Alice shared her fears. Explained her stresses and ideas. Keith’s confidence was better than any test. I see these symptoms all the time. I almost never find anything useful, or important, with tests or referrals. You have migraine headaches, fibromyalgia and irritable bowel syndrome. Have you heard of these before?
Keith charted the way. Alice chose the options that were right for her. From an evidence-based smorgasbord. Keith suggested best buys to suit what he already suspected might work for Alice. Poor sleep had badly affected Alice’s quality of life. Leading to a downward spiral of widespread pains. Alice elected to try a tiny dose of amitriptyline and a regular yoga routine. Yet, even before she had plumped for the old faithful drug, Keith sensed that Alice’s burden had been lightened. She shed a tear as she thanked Keith for listening. Nobody has ever told me what all of these symptoms mean before. Alice took one foot off the Helter Skelter. A glimmer of hope. Her quest for answers was almost over.
Functional illness is a tricky subject for clinicians. Our training often focuses, understandably, on meeting patients’ expectations. Yet this group of patients want what they don’t need. Accede and you create heat, but no light. Don’t just do something. Alice was down a rabbit hole. She needed direction and reassurance. Not riddles and a never-ending search.
Thirty-one years of clinical practice and I’ve just started to find my feet with functional illness. I create boundaries. Draw a line in the sand. I ask what is worrying my patient. What are you hoping that we might do? I often agree to reasonable tests. But I highlight that tests will almost certainly not help. I negotiate an end to the quest. And in exchange: I highlight that their problem is common and well understood. Reassurance needs to be backed with clear explanations that are tailored to the individual. I tell patients that their symptoms are real. But the choice of words is crucial. Nuance everything. In Zambia often my words are not my own.
You mean that it’s all in my head doc? Danal asked. Moses had translated our conversation word for word. Yet, we had missed the mark. Danal was my second patient of the day. I had just recommended against using an antibiotic for her toddler son. Max had a cold again. Danal really wanted him to have antibiotics. They had worked last time. I explained the risks and we agreed with her to let time pass. Danal’s domestic situation was a little fraut. Since she had managed to get to the clinic Danal was keen for me to address some unusual symptoms of her own, as well as cure the common cold. Danal’s most worrisome symptom was that she felt that she could not take a deep enough breath. She’d had it for months. Her clinicians have been flummoxed. I instantly recognised her description of air hunger.
I took the opportunity to flick back through Danal’s record book. Worried that her lungs or heart might explain her symptoms Danal had been shopping for tests and opinions. Each test had given a brief lull in her suffering. I explored Danal’s symptoms and examined her. My considered opinion would need to be clear to trump the collection of opinions that she had already received. You have air hunger Danal. Your symptoms are very typical of air hunger.
Moses spoke my words. I detailed my normal findings and explained the link between her emotional tension and her symptoms. Your symptoms are real and physical we told her. But your mind is currently over-sensitive to normal messages from your body. Messages that you might not normally notice, or worry about, on a good day. This is why you feel OK when you are distracted or busy.
Is everything okay at home? I checked. She admitted life at home was difficult. Husband trouble. She said there was no physical abuse. No alcohol misuse. It was clear she now understood the link between her physical symptoms and her husband trouble. I left it at that. My offer to see her again after two weeks accepted, but never used. Her days of shopping for answers apparently over.
As I arrived in clinic last week, Nurse Thresa was deep in discussion with Monica. Monica is 37 years old. Outside my comfort zone. I loitered silently. Hoping that Thresa would not need me. It was clear that Thresa and Monica disagreed about something. Despairing Thresa turned to me and asked if I could help. Keith had a pile of record books to plough through next door, so I agreed to have a bash.
Monica had a litany of issues, but the worst of them centred on her bowel function and abdominal pains. She bore all the hallmarks of having a season ticket at the clinic and elsewhere. Her record book full of opinion. The working diagnosis changed depending on who was seeing her. It varied between gastroenteritis, pelvic inflammatory disease, musculoskeletal pain and dyspepsia. Each time, she was treated with a short course of medication. Antibiotics. Antacids. Analgesia. The result: side effects but no joy. In desperation a colleague had sent her off for an ultrasound scan at Kamoto hospital. Big mistake.
The scan report was basically normal, but the sonographer had hedged her bets. There may be a small amount of fluid in the pouch of Douglas. This triggered a host of concerns. The team at Kamoto treated her for pelvic inflammatory disease, without reason. Three antibiotics. Monica felt worse. The traditional healer told her with blind confidence that she had acidity in her uterus. Try this local medicine for now. Monica bounced back to Kakumbi and met nurse Thresa and Dr Ginny.
Monica was now hell bent on having a hysterectomy for her irritable bowel syndrome. At the very least she wanted us to refer her back to Kamoto for another scan. I explained what I thought her problem was. I tried to reassure her that her uterus was healthy. The scan was normal. An operation would not fix her pain. Nor would another scan help. I suggested some ways to help her manage her symptoms. My words, or Thresa’s words, fell on barren ground. Monica does not believe that she has irritable bowel syndrome. She picked up her book and left. The shopping goes on.
My heart sank as Monica left the room that day. My colleagues and I had failed her. Monica’s pattern of symptoms clear to the experienced ear. Irritable bowel syndrome another problem that has no definitive test. Basic training and lack of experience ill prepare clinicians to avoid tests. Pattern recognition outside the comfort zone of our colleagues. Referral the easy mistake.
On the wall of my consulting room hangs a list. The list details all the diagnoses that our colleagues learn. It appears that currently they are all using hammers. The reflex is to hit diagnoses from the list provided. Not a single functional problem is on the list. Perhaps it’s time to rewrite the list.
I love the topic, the beautiful photos, & captions that made me laugh. Coming from psychiatry, functional illness is the reason for many referrals. It’s overwhelming for Fam Practice. I think you’ve hit on the right formula with expectation management, naming the illness, boundaries, explaining how some sensations are misread, and that is a syndrome, along with sympatheric listening and frequent visits.
Translation is so important. Medecins Sans Frontieres becameDoctors Without Borders, but when this is translated into Nepali, it became "Doctors who are out of control". Great slogan for the tee shirts.