Case of the Week: 16th July

July 16, 2018

This week's case comes from two of our lovely Elective students, Lizzie and Lucy:

 

As part of medical training in the UK, students have the opportunity to go abroad for several weeks to experience what healthcare is like outside of the NHS; just one of the many healthcare systems around the world. As students going into our final year of training, we wanted to use this time to better understand medical care in a low-resource setting. We heard about the fantastic work of HIPZ and decided to come to Zanzibar for our Elective to see how local staff and volunteers are working together to improve care for the people of Zanzibar.

 

When thinking of healthcare in developing countries it is easy to jump straight to tropical diseases and infections that are easily managed or rarely seen in the UK. While we knew these would not be the only conditions we encountered, we were surprised by the large amount of time local doctors spend helping people with the same long-term conditions we do at home – diabetes, high blood pressure, asthma and cancer to name just a few. These conditions require daily medications and regular monitoring in the community to keep them under control. When left untreated, they often have very sudden and severe consequences; as is the case with our patient of the week.

 

Our patient is a 65-year-old lady who we first encountered in the emergency room while shadowing local doctors and HIPZ volunteers. She has had high blood pressure for many years but only takes medication intermittently. Having also spent time in a high blood pressure clinic we have seen that patients are often given only 2 weeks of medications at a time, despite being seen much less frequently than this. Even when these have been prescribed for longer, many don’t receive enough. This is due to many reasons including shortages at local pharmacies and a lack of understanding by the patients for the need of consistent daily medications.

 

On the day we met her, AMA’s blood pressure was very high. She was unable to walk or talk and had difficulty swallowing. At this stage it wasn’t possible to confirm the diagnosis we suspected – this would require access to a CT scanner, which we do not have at Kivunge. With constant care and attention from her family members and the effort of local doctors AMA was kept as comfortable as possible, however, after many days without improvement it became clear that we had been correct – AMA had had a stroke.

 

While it is unlikely that she will regain the independence she previously had, there are steps that we can take to maximise her safety and comfort. One such step is an NG tube. This is a tube travelling through the nose, down the throat and into the stomach. While initially unpleasant to put in place the tube does not cause discomfort once inserted. It is not a complex procedure and doesn’t require expensive equipment or lots of staff. It is a relatively simple way to ensure that a patient can be fed safely without risk of choking and accidentally breathing food into their lungs. Choking sometimes happens if the muscles of the throat are weakened and can cause infections which may be fatal.  

 

Our patient’s family initially rejected the insertion of a tube. Local staff explained to us that patients and their families are commonly hesitant to accept NG feeding. Many people requiring an NG tube have a serious illness. In the UK, access to long term rehabilitation and professional care in the community means that people are given a greater opportunity to recover some of their previous function and independence. In Zanzibar, due to a lack of resources and education, improvement after serious illness is less likely and some patients unfortunately pass away. Patients along with their families mistakenly fear that the insertion of such tubes will hasten the death of a loved one.

 

Similar misunderstandings exist in the UK. During training at home, we have seen similar fears regarding the use of painkillers and sedatives in patients receiving end of life care. Both at home and abroad, this can often been overcome with good communication and transparency of the medical team. Thanks to the time given by both the local doctors and the HIPZ team, the family were reassured and the patient can now feed safely through her tube.

 

The future for our patient is still uncertain, however we hope this is one step towards improving the quality and length of her life going forward. Even in the UK, life after a stroke can be very difficult. It is always better to prevent these situations from occurring, and there are many effective medications and lifestyle changes that exist. This is why HIPZ is currently working hard in collaboration with the Zanzibari Ministry of Health to develop a clear strategy to manage conditions like high blood pressure in a better way.

 

By Lizzie and Lucy

 

 

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