The effectiveness of medicine in an environment like that of SFH depends heavily on a doctor’s clinical acumen. Time is at a premium, the flow of patients can resemble a tsunami close to shore, and available investigations are limited. There is also much less scope for discussing cases with expert colleagues compared with a hospital in New Zealand. 

Accurate history taking and a knowledge of clinical epidemiology are among the most powerful diagnostic weapons in a doctor’s arsenal. However, these are two of the major problems with practising medicine in Zambia. Firstly, epidemiological data is sparse and is usually of questionable accuracy. Secondly, taking histories at SFH is fraught with problems. Time is a major constraining factor and there are considerable language barriers in a country that has over seventy distinct native tongues. 
 

Taking histories from patients in Zambia is truly art-form (one I am far from mastering). I usually had the aid of a nurse to act as translator(*). Zambians as a people do not seem as forthcoming about their symptoms as people back home. Zambian patients tend to focus on only one problem at a time. Thus after recovering from pneumonia a patient will finally mention their genital ulcer or anal fissure, despite having been repeatedly asked if they had any other problems on many previous occasions. 

Many patients in Zambia seem to show a reluctance to tell you what their real problems are. From the first moments in OPD it became clear that many patients were complaining of vague abdominal pain (headache is another favourite). I soon learnt that after discussing the presenting symptom one must always consider the possibility of sexually transmitted illnesses. In fact, questions about dysuria, urethral discharge, and genital ulcers became routine for me. Many Zambians seem too embarrassed to come straight out with what is really bothering them. They presumably hope that whatever treatment they are given for their announced complaint will also solve their real problem. This is a major frustration in the time-pressured atmosphere of a Zambian hospital. 

Aside from their reluctance to divulge certain symptoms, Zambians on the whole have an inherent helpfulness. Many patients will battle furiously in an attempt to tell you what they think they want you to hear. This is a particular problem as open-ended questions often do not get very far in Zambia, and one usually has to resort to a flurry of closed-ended questions. 

The use of negatives is also a common stumbling point. For instance, Zambians will unfailingly answer “yes” in response to “you are not vomiting are you?” if they are no longer vomiting. In contrast, a less grammatically correct New Zealander (such as myself) would probably say, “no, (I’m no longer vomiting)”. 

The difficulties in history taking that I experienced at SFH taught me important lessons. Many of the difficulties were amplifications of the problems that occur back home. Thus the struggles I faced will greatly benefit my history taking skills in New Zealand as well. 

The investigations available at SFH include imaging and laboratory tests. They include the following: 

• Radiography and ultrasound are routinely performed, and the surgeons often use barium meals/ swallows and can also do oesophagoscopy and hysteroscopy. 
• Available biochemical tests include determining concentrations of sodium, potassium, urea, glucose, and enzymes such as aspartate transaminase (AST), alkaline phosphatase (ALP), and acid phosphatase (ACP). Albumin and total serum protein concentrations could also be done. Unless the necessary reagents had run out (O/S on the lab request form means “out of stock”), tests for Hepatitis B and HIV, and the RPR test for syphilis could be performed at SFH.
• Haematological tests available included haemoglobin concentrations, red cell counts and morphology, white cell counts with differentials, erythrocyte sedimentation rates, blood slides for malaria and other parasites, and a test for sickle cell disease.
• Urinalysis (including Bence-Jones protein), swab, sputum, and stool microscopy, rarely some cytology, and facilities for culturing micro-organisms were also available.
• Biopsies were sent to Lusaka for examination by a pathologist. Results were usually not available for at least one or more months.

The departments of medicine and surgery at SFH seem to order investigations differently. The surgeons seem to order chest films at the slightest sniffle (I may be exaggerating a little), whereas on the medical wards every chest film comes into the world only after what seems like a prolonged and obstructed labour. The surgeons, I guess, can claim the need for thorough pre-operative assessment. On the medical wards, a patient with a chest infection will usually only get a chest X-ray once they’ve shown no response to antibiotics for a week, and have no acid-fast bacilli in their sputum – or if their illness is clinically judged to be deteriorating dangerously. 

Paul and I once tried to take an electrocardiogram (ECG). The machine was old and only read off one lead at a time. After completing three leads, the tracing stopped and we detected a burning smell (a very bad sign given the level of “ambient noise”). Also, the thickness of the line tracing rendered anything more than rhythm analysis an agonising chore. Without an ECG and specific cardiac enzymes (only AST is available) it was impossible to diagnose myocardial infarction. Without an ECG patients presenting with severe chest pain are clinically very challenging, especially given the difficulties in taking accurate histories. Fortunately, such diagnostic dilemmas are relatively rare at SFH, but they rankle a Western-born mind like mine. 

What investigations would I wish for at SFH? Being able to (1) test for creatinine and calcium, (2) rapidly perform an interpretable ECG, (3) perform protein electrophoresis, and (4) measure arterial blood gases would transform the practice of medicine at SFH (oh yeah, a CT scanner would be good to… it’s nice to dream). However, a wish list like this must always play second fiddle to the need for basic medications and ensuring access to basic health care. 
 

A senior doctor was usually available to discuss ward issues. Exceptions were some weekends and public holidays, and a few other rare occasions. Sometimes in outpatients it was difficult to readily get advice from a senior colleague. I have had to make many important decisions completely independently, such as deciding when to do a lumbar puncture or when to start tuberculosis treatment in a sputum-negative patient. I have also independently performed cardiopulmonary resuscitation and procedures such as the administration of cytotoxic medicines. As a result, I now feel confident in performing lumbar punctures, ascitic taps, pleural taps, and needle aspiration of lymph nodes. Thus the clinical responsibility I experienced at SFH greatly exceeded the responsibilities of a trainee intern back in New Zealand. 
 

A wide range of medications are available at SFH. My time at SFH allowed me to become familiar with the prescription of many medications - their indications, dosage and administration, interactions, side-effects (usually from reading rather than first-hand experience - thankfully!), and other pharmacological properties. Most of the medications I used, plus a handful of others in common use at SFH, are listed below. 
 

• Cardiovascular medications (including diabetes mellitus)
• adrenaline, atenolol, atropine, bendrofluazide, captopril, chlorpropramide, digoxin, glibenclamide, glyceryl trinitrate, hydralazine, insulin, lignocaine, nifedipine, propanolol, spironolactone.
• Anaesthetic medications
• halothane, ketamine, lignocaine, promethazine.
• Anti-histamines and anti-inflammatory medications
• chlorpheniramine, cimetidine, hydrocortisone, promethazine (see also NSAIDs in anagesics).
• Anti-microbial medications
• Anti-bacterial medications
• “First line” or commonly available
• amoxicillin, chloramphenicol, cotrimoxazole, erythromycin, gentamicin, kanamycin, metronidazole, nitrofurantoin, penicillin,  tetracycline. 
• “Second line” or rarely available
• ciprofloxacin, clindamycin, cloxacillin, doxycycline.
• Anti-fungal, anti-helminth, and anti-protozoal medications
• Gentian Violent solution, griseofulvin, ketoconazole, mebendazole, nystatin, praziquantel, pyrantel, Whitfield ointment.
• Anti-malarial medications
• chloroquine, Fansidar (sulfadoxine and pyrimethamine), quinine, doxycycline, cotrimoxazole.
• Anti-tuberculosis medications
• ethambutol, isoniazid, pyrazinimide, rifampicin, spectinomycin.
• Anti-viral medications
• aciclovir.
• Miscellaneous medications
• fluids (5% dextrose, 50% dextrose, normal saline, Ringer’s lactate), loperamide, magnesium trinitrate, oxygen, probenicid, salbutamol (tablets and inhalers).
• Psychiatric and anti-epileptic medications
• amitriptyline, carbamazepine, chlorpromazine, diazepam, haloperidol, phenobarbital.
• Palliative care and oncology medications
• Analgesic medications
• aspirin, ibuprofen, indomethacin, morphine, paracetamol, tramadol.
• Anti-cancer medications
• actinomycin D, cyclophosphamide, methotrexate, prednisolone, vincristine.
• Anti-emetic medications
• cyclizine, metocloperamide, promethazine.
• Vitamins and other supplements
• ascorbic acid, ferrous sulfate, folic acid, niacin, pyridoxine, thiamine.

• In general, infections had to be treated empirically. Rarely would a causative organism be identified or anti-microbial sensitivities be obtained.
• Cephalosporins are not available for the treatment of bacterial infections at SFH. Also cloxacillin and ciprofloxicin are rarely available. Chloramphenicol and amoxicillin were probably the most widely used antibiotics, particularly for respiratory and dermatological bacterial infections.
• Sexually transmitted infections account for a large proportion of the morbidity at SFH. In New Zealand gonorrhoeal disease might be treated with a stat dose of ciprofloxacin or ceftriaxone. At SFH, the usual treatment was a stat dose of kanamycin, due to the unavailability of the medications favoured in New Zealand, and the perceived rates of resistance of the causative organism to cotrimoxazole. First choice for chlamydial infection was tetracycline, whereas doxycycline or azithromycin would be preferred back home. In my experience, contact tracing in Zambia was largely a fanciful concept – all too often the partner had “moved to Malawi” or some other believable location.
• Patients with HIV did not have access to anti-retroviral medications at SFH. One relatively wealthy patient I saw ultimately travelled to South Africa for treatment.
• Patients in Zambia have to be more stoical than patients back home. Procedures at SFH, like lumbar punctures and diagnostic taps for ascites, were routinely performed without local anaesthesia to save on costs. I found this very difficult to get used to.
• There were times when heparin and warfarin would have been useful on the medical wards. Both of these medications were unavailable at SFH. In particular, the management of atrial fibrillation and thromboembolic disease is greatly hindered by the unavailability of these anticoagulants. I tended to use aspirin as an anticoagulant when absolutely necessary. 
• Atherosclerotic disease is relatively unimportant at SFH, compared to its prime importance in  medicine back home. A reflection of this is that lipid levels could not be measured and no lipid-lowering agents were in use, and thrombolytics were obviously not employed for suspected myocardial infarction. Overall, SFH has a poor capacity to manage the important cardiovascular conditions that are the bane of the Western world. While less common than in the West, there is appreciable morbidity due to cardiovascular disease in Zambia. Furthermore, this problem may escalate as more Zambians adopt Western-type lifestyles.  Nevertheless, at present these issues pale in comparison to the continuing crises of AIDS and poverty-related illness in Zambia.
• Complaints of epigastric pain and gastritis or peptic ulcer-like symptoms are common at SFH. Sometimes these complaints actually reflect the presence of other problems such as urethritis or pelvic inflammatory disease. However, often the patient gave a history strongly suggestive of gastritis or an ulcer. Proton pump inhibitors such as omeprazole were unavailable, so a combination of cimetidine and antacids was the most potent available treatment (along with antibiotics for “triple therapy”).
• I had one patient with rheumatoid arthritis, of ten years duration. He was referred from a rural health centre and had only been treated with analgesics. I used chloroquine as a “DMARD” (disease-modifying anti-rheumatoid drug). The only other available option at SFH was methotrexate.
• SFH is able to supply a number of anti-cancer medications to patients free of charge, for conditions like Burkitt’s lymphoma. Patients with AIDS-related Kaposi Sarcoma had to purchase their own supply of cyclophosphamide and actinomycin D (at the prohibitive cost of about US$50 per cycle).  I had one patient with multiple myeloma for whom melphalan, the first-line medication of choice, was unavailable.

Listed below are most of the symptoms, signs, and conditions that I have had to assess, diagnosis, and/ or manage during my time at SFH. The list largely reflects the fact that I spent most of my time working on a medical ward. Note that, given the limited availability of investigations, many of the diagnoses were clinically suspected but could not be confirmed. 

• Acute medicine and toxicology
• Acid-base and electrolyte disorders (usually only suspected)
• Bites – snake and human
• Cardiac arrest/ respiratory arrest
• Confusion
• Coma and loss of consciousness
• Diabetic ketoacidosis
• Drug side effects – especially isoniazid, quinine, erythromycin, nifedipine
• Epistaxis
• Hypoglycaemia – induced by insulin, alcohol, and malaria
• Poisons – organophosphates, snake venom
• Seizures – including febrile convulsions
• Syncope
• Shock – cardiogenic, hypovolemic, septic
• Cardiology
• Acute coronary syndromes – stable/ unstable angina, myocardial infarction
• Atrial fibrillation
• Endocarditis
• Heart failure
• Heart murmurs – innocent murmurs, aortic stenosis, aortic, tricuspid and mitral regurgitation, additional heart sounds (S3, S4, gallop rhythm), carotid bruits
• Hypertension – including malignant
• Palpitations – arrhythmia, anxiety
• Rheumatic heart disease
• Dermatology
• Albinism
• Allergic rash (amoxicillin-induced)
• Cellulitis and other skin infections
• Dermatitis
• Urticaria
• Xeroderma pigmentosum
• Endocrinology and nutrition
• Diabetes mellitus – type 1 and 2
• Malnutrition
• Gastroenterology and renal medicine
• Ascites
• Constipation
• Epigastric pain and heartburn – gastritis, gastro-esophageal reflux disease, peptic ulcer disease
• Hepatocellular carcinoma
• Hepatomegaly
• Liver cysts -? cause
• Nephrotic syndrome
• Pancreatitis – acute
• Portal hypertension – secondary to alcoholic and schistosomal liver disease
• Renal failure – acute and chronic
• Haematology and oncology
• Burkitt’s lymphoma.
• Chronic myeloid leukaemia – acute phase
• Kaposi Sarcoma
• Lymphadenopathy – including generalised and /HIV-related
• Multiple myeloma
• Palliative care – pain, hiccups, vomiting
• Prostate cancer
• Sickle Cell Disease
• Splenomegaly
• Testicular cancer
• Von Willebrand’s disease
• Infectious diseases
• Acquired Immunodeficiency Syndrome (AIDS) and human immunodeficiency virus (HIV) infection
• Ascaris lumbricoides (roundworm) infestation
• Candidiasis – oral, esophageal, vulval
• Fungal infections – including disseminated skin infections
• Genital ulcers – syphilis, chancroid, herpes simplex
• Herpes simplex (genital)
• Herpes zoster – ophthalmic and truncal.
• Hookworm
• Leprosy
• Lymphadenitis
• Malaria –cerebral malaria, complications
• Meningitis – bacterial, tuberculosis, cryptococcal
• Orchitis
• Otitis media – acute, suppurative, and chronic
• Pyrexia of unknown origin
• Schistosomiasis
• Septicemia – including septic shock
• Strongyloidiasis
• Syphilis
• Tetanus
• Toxoplasmosis
• Trichomoniasis –male gastrointestinal tract infection with diarrhoea!
• Tuberculosis – pulmonary, miliary, extrapulmonary
• Urethral discharge – gonorrhoea, chlamydia
• Urinary tract infections – bacterial and fungal, including pyelonephritis
• Neurology and psychiatry
• Acute flaccid paralysis 
• Brain abscess
• Brain tumour
• Cavernous/ Venous Sinus Thrombosis
• Cerebral palsy
• Cervical spondylosis
• Delirium
• Dementia – including AIDS related
• Epilepsy – often due to cystercicosis
• Guillain-Barre syndrome 
• Headache – tension, migraine, systemic illness, raised intracranial pressure 
• Papilloedema
• Peripheral neuropathy – idiopathic, or related to HIV, isoniazid, diabetes mellitus, alcohol, thiamine deficiency
• Psychogenic hiccups
• Stroke
• Tropical spastic diplegia
• Obstetrics and gynaecology
• Amennorrhoea
• Infertility
• Miscarriage – complete and incomplete
• Pelvic inflammatory disease
• Pregnancy and morning sickness
• Puerperal fever
• Retained products of conception
• Vesicovaginal fistula
• Vulval itch
• Respiratory medicine
• Asthma
• Bronchiectasis
• Chronic obstructive pulmonary disease (COPD)
• Croup
• Lower respiratory tract infections – acute bronchitis, pneumonia, and  tuberculosis
• Pleural effusion
• Pneumonia –  typical, atypical, Pneumocystis carinii
• Upper respiratory tract infections – pharyngitis, sinusitis
• Rheumatology
• Osteoarthritis
• Rheumatoid arthritis
• Shoulder pain – e.g. painful arc syndrome
• Rheumatoid arthritis
• Surgery (including specialities)
• Abscesses and pyomyositis
• Eye disorders – amblyopia, cataracts, uveitis
• Hernias – paraumbilical, inguinal.
• Hydrocephalus
• Inguinal lumps – hernias, hydrocoele, tumours.
• Lipoma
• Neck masses – tumours, lymphadenopathy
• Osteomyelitis – acute and chronic
• Paraphimosis
• Septic arthritis
• Urethral stricture – secondary to STIs
• Wound dehiscence

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