Weather - Maximum temperature 42 degrees Celsius
- Rainfall zero
Highlight of the week
2 months in and wanting more
Lowlight of the week
The worry of uncertainty
Managing sick children is my bread and butter. I have thrived on this for the last 30 years. I was proud to be thought of as a safe pair of hands. I know that my juniors felt reassured when I was the consultant on call. Why did they feel this way? I believe it is because I contained everyone’s anxieties. I made decisions. I did not prevaricate. When I needed help, I knew who to go to. I managed my own anxieties by knowing my own limitations and when to go for help. I ensured that the paediatric unit was always under control, even on the busiest day. Oh and….. I did not attract work. I was not a chaos magnet. My shifts were almost always quiet! That made me popular. Clinicians like a challenge, but they rarely like being up to their necks in challenging materials. Brown and smelly, or not.
Chaos has not found me in Africa either. A busy day here does not compare with a busy day in Middlesbrough. I see many more patients here. But these are unfiltered primary care presentations. Plenty of hay to sort through and only occasional needles. Lots of minor illness, with only very occasional sick patients. At the risk of mixing my metaphors: in Middlesbrough the wheat had already been sorted from the chaff. Only the wheat reached my care. Highly trained gatekeepers did that job. GPs and A&E staff initially. After initial sifting, patients had to get through one, if not two, tiers of paediatric trainees alongside some fantastic paediatric nurses. This sifting of wheat from chaff took time. My favourite of all medical investigations. These days patients present directly to me in the South Luangwa Valley. Time has to be created after initial contact, when needed.
In the Kakumbi clinic, patients arrive and check in. They are sorted by age, so that I see all the under 18-year-olds. If possible, they are also sorted by language skills, so that I can see English speakers without a translator. There is no triage, merely a swift measurement of weight and temperature and a diplomatic checking of eligibility for an HIV test. My point is that people don’t book an appointment. They arrive and can potentially see the clinician before you can say Jack Robinson. Time does not pass. The children that I see don’t have time to get better, or worse. They are all what Keith might call undifferentiated. Neither black nor white. Grey. Their stories are too short to have a middle, or even the suggestion of an end. Which of these children will become ill after a further day or so? GPs have vast experience of this, but it’s all new to me.
The same goes for the care that we provide to the members of the medical fund. We are accessible to them at the end of the phone 24/7. Unless our phone has no signal or battery juice. This leads me to the crux of this week’s blog. Might we be too readily available? Let me share Ollie’s story with you.
It was 1730 on Saturday evening. We had driven out to the salt pans. A beautiful location about 10km from home, but 40 minutes’ drive down gravel and sand tracks. We went in search of crowned cranes. The cranes gather there in their hundreds at this time of year. We had been moderately successful in our quest. We saw the cranes. But sadly, they were a bit skittish and flew off as soon as we approached. Still, we got to see these beautiful birds in flight. It was an incredible sight. We also attracted tsetse flies that outnumbered the cranes, one hundred to one. Our windows stayed firmly shut. We stayed in the vehicle to sip our sundowners. Frustrated by not being able to take the evening air we headed home before sunset.
The bat-phone rang. As it tends to do when we are having fun. A member of the medical fund wanted some advice about their 2 year old child. Ollie had a fever and had vomited. Can we safely assess Ollie on the phone? An age-old dilemma. NHS 24 and England’s 111 service seem to always play safe and recommend a face-to-face assessment with a GP. Failing that, A&E mops up a whole lot of uncertainty. Two old hands at this game. A GP and a paediatrician. A few questions largely reassure us that Ollie is not in extremis. As we drive back in Ollie’s direction we vex on how soon we should see him. If we go too soon, we lose the investigation of time. A bit of time passing would help us to get an idea about the evolution of the illness. If we go too late, we risk Ollie becoming more unwell. Might he have malaria or sepsis? Unlikely after our phone assessment. The decision of when to see Ollie is as ever a shared decision. His parents would not have called if they thought self-care sufficient. We took the 111 approach: “We’ll be with you in a jiffy”. The decision we all made depended on our trajectory in time and place. Ollie’s house was on our way home and it suited us to see him before our evening meal.
For better, or for worse, we were at Ollie’s front door within 20 minutes of the phone call. He was asleep. His temperature was 39.1 degrees Celsius. A thorough history did not reveal any major clues. But his examination was quite reassuring. He did not appear septic. There was no obvious focus for infection. And no clear indication for antibiotics. Norovirus was probably doing the rounds. However, we are in the tropics. We were obliged to do a malaria rapid antigen test. It was negative. You will have to wait a while to find out what our next test would be…...
I am used to time passing on a paediatric in-patient unit. Paediatric nurses will do observations as often as requested. Junior doctors are on hand to review the patient if anything changes. Simple tests, like urine samples can be collected and processed easily. But away from the in-patient setting Keith’s experience comes in handy. This is his comfort zone. Would he send Ollie into hospital at this point in the UK? He assesses parents’ responses and capabilities. Could a GP like Keith provide basic care and safety net advice to Ollie and his parents? Are Ollie’s parents happy with symptomatic care and the passage of time? Ollie’s parents are intelligent and measured in their anxieties. Home was going to be the best place to provide his care. Yes, you guessed it, our next test was time.
Elicit, provide, elicit. The modern mantra for sharing information. Ollie’s parents wanted to know the likely diagnosis. Might this be a Norovirus or a urinary tract infection? They were anxious that his fever had been so high. In itself, the height of Ollie’s fever did not worry me. We explored options to manage his discomfort whilst time passed. Paracetamol should help, with minimal risk of harm. I discussed worrying things to look out for and how to contact us for follow up. I asked Ollie’s parents to try to collect a urine sample. Although we were keen to examine Ollie’s urine, we were really more keen to let time pass. Our investigation of choice was a good sleep overnight for everyone and a short game drive first thing the following morning for us. Time.
Our alarm chirped at 0530. A silent night, with radio silence. That was promising. But then: a WhatsApp message pinged in at 0555. Ollie had been hot all night with a definite temperature and he was still vomiting a little. He seemed no worse. Could we call by at 1000? We offered an immediate review, but Ollie’s parents preferred a later appointment. 1000 would be great. Go and enjoy your game drive. They knew we would happily bid adieu to any creature in favour of Ollie if he appeared worse. We’d talked ourselves into a corner and headed into the park.
Time passed. The cape turtle doves told us to work harder. Elephants told us not to forget our duties. And buffalos judged us. My imagination went into overdrive. What was I doing looking for lions and leopards when I had a sick child to see? What was causing Ollie’s illness? Could he now be septic? Or have meningitis? You see: time allows an illness to evolve. What looked like a viral infection or a slow burner yesterday could now look like a very different beast today. And how would I know if Ollie really was sick? In Middlesbrough, with this kind of story, I might now be looking to do further investigations. A blood test to help to guide me on what kind of infection was lurking. We might need help from the nursing team to get a urine sample. Even a lumbar puncture might be worth considering. Time would pass and junior doctors and paediatric nurses would watch.
I wake from a wakeful dream. We are in the middle of Africa. We have no access to blood tests or lumbar punctures. Junior doctors and paediatric nurses don’t exist. Keith shared my uncertainties. This was GP territory. Familiar and predictable but always changeable. The parents are sensible he said. We were very clear about safety netting. They know to call us if anything changes. However, the shine had now been taken off our game drive. It did not sit easy with me. So, we cut things short and headed home to review our patient.
We arrived at Ollie’s door at 1000. We knocked, but there was no answer. Uncannily, the bat phone rang. A message on our answerphone: Our patient had slept some more and woke up at 0800. His temperature had broken. He had eaten a small amount of breakfast and had had a drink. All of that had stayed down, so they had taken him out for a drive to get some air. Follow-up appointment cancelled. Clinicians take on patients’ and carers’ fears and anxieties. Sometimes this is not fully appreciated by our wards. Should our safety net have included a suggestion to let us know if and when Ollie had improved? This was probably not a priority compared to the red flags that need to be highlighted. The decision is yours.
If Ollie had been in England, we may have subjected him to a battery of unnecessary tests. The test that saved the day here was time. Arguably the best test of all. The illness evolved and showed all of its colours with time. Not always a beautiful plumage. But at least a fully-fledged collection of feathers. Imagine adapting to a new specialty in a country with few resources. I now value more than ever the skills of GPs and competent parents. My lesson from all of this? To trust my instincts. This was unlikely to be a severe illness. But when uncertainty seeps in: check your sources again. A quick call to Ollie’s parents would have allayed my fears. Uncertainty evolves into certainty with time.
Great blog. Passage of time great tool, but unnerving for a worry pants like me!
I think you and Keith are going to be an impossible act to follow!!