Minnie -Hello!

 

Hi! I’m Minnie. I started volunteering with the virtual doctors almost a year ago after seeing an inspiring article in the BMJ.

At Vitual Docors I work with Fran providing clinical support. We strive to improve the service and provide good educational material. I write an almost monthly blog called Cases from the field which is on the Virtual Doctors website.

Back in 1994 I worked in a government run hospital in the South  West  of Zimbabwe, which also allowed me to explore a little of Malawi and put a foot into Zambia.A wonderful experience which kindled my love for that very special part of the world.

I trained in Paediatrics in the north east of England where I live with my family. I have 3 boys so life is very active and outdoors.

I really hope that this is the forum you all wanted! It would be great if we can all  get connected and share questions and knowledge.The potential for the Virtual Doctors service is huge. Please get involved and, to echo Fran, make it your own.

 

Fran

 

Hello. I’m Fran and I’m the Medical Director at the Virtual Doctors.  I started volunteering with the charity 4 years ago just after my son was born.

I worked in a mission hospital near Mazabuka in 2001 and fell in love with Zambia and was keen to help improve the population’s healthcare. I’m passionate about primary healthcare and education which is why I volunteer with the Virtual Doctors.

I work as a GP in Oxfordshire, UK and also train junior Dr’s to become GPs.

I have 2 children, Iris 6 years old and Walt 4 years. To relax I run through the countryside with my dog.

This forum is for all the team to share medical information, ideas, concerns. Please us it, adapt it, make it yours!

 

 

 

Mycetoma

 

As we move from Summer to Autumn in the UK and we see rain causing so much disruption and devastation around the world, I wondered about the effects of the changing seasons on health in Zambia. Situated in the tropics, Zambia gets lots of strong sunlight, but the intense heat that comes in the tropics is moderated here by the altitude and rainfall. There are two main seasons in Zambia, the rainy season (November to April), and the dry season (May to October/November). The dry season is divided into a cool and a hot time. The rainy and dry seasons are clearly distinct- with no rain falling at all in June, July and August (usually) followed by hot, wet downpours. Much of life is dominated by the start and end of the rainy season or ‘emerald season’ as it is known and the amount of water it brings. Failure of the rains to come can cause famine. The highest rainfall is in the north with the driest areas in the far southwest and the Luangwa River. Rainfall varies over a range of 500- 1400mm per year.

Flooding occurs every year on the floodplains. Those living in these areas, both people and wildlife, are well adapted to cope with this. However untarred roads become quagmires, many completely impassable. Rivers swell and burst their banks washing away trees, roads and bridges. Many rural areas can be cut off for a few months, making getting anywhere away from the main routes very difficult!

For this month’s case we return again to the Lusaka province which sits on the Zambezi flood plains. This time to Kanakantapa Rural District Health Centre in Chongwe district. Kanakantapa Rural Health Centre serves over 13,000 people from the surrounding communities which are predominantly farming areas. The Kanakantapa river lies to the west of Kanakantapa. It is crossable in the dry season but during the rainy season when the water levels rise and as there is no bridge it becomes impassable, increasing the distance to get to Chongwe by 5 km.

To this clinic, a mother brought her 2 year 11 month old boy to be seen. He is suffering from sores on his feet which have a watery discharge. These sores apparently often returning during the rainy season. The clinical officer (CO) had seen quite a few cases like this and was struggling to treat them. For this child he had tried 2 courses of antibiotics; one oral and the next intramuscular (injection into the muscle) with no improvement. The CO included some good quality photos. These are so helpful in skin cases.

 

The Virtual Doctor (VDr) wasn’t entirely sure what the diagnosis was. But, as it was a particular rainy season problem and antibiotics hadn’t worked, thought it was likely to be a fungal infection. She advised starting some antifugal medicine by mouth. The advice was gratefully received although the clinic had limited supplies so the CO would have to order some medication to be sent. Tricky in the rainy season.

Meanwhile the VDr asked for a second opinion from a dermatologist in the UK. This condition is something not seen in the UK. The dermatologist thought that is was most likely to be Mycetoma. Advice was for further investigation to distinguish between a bacterial and fungal cause by taking a potassium hydroxide slide of the discharge and seeing if fungal elements or filamentous bacteria could be seen under a microscope. A relatively low tech investigation to perform. And then to treat with antifungal medication if fungus was seen. The nails on the patients left foot looked abnormal  (dystrophic), suggesting a fungal infection. The dermatologist suggested trying treatment but noted that the response to treatment in this infection is generally poor.

What is Mycetoma?

Mycetoma is an uncommon chronic, infective skin and subcutaneous (tissues beneath the skin) disease. It presents with painless lumps under the skin, starting small they can grow, break down and form sores which ooze pus. It can cause the affected limb to become deformed or unusable. If left untreated or treatment fails, it can spread to other areas of the body. Sometimes surgery is needed to cut away infected tissue. Long- term it can destroy underlying muscle and bone. It most commonly affects the foot and it is also known as ‘Madura foot’ after the Indian region where it was first described in 1842. It is a health problem in equatorial regions of Africa, Latin America and Asia known as the ‘mycetoma belt’.

What Causes Mycetoma?

The source of this infection is found in the soil and water and is caused by certain types of both bacteria and fungi. It is likely they enter the body through breaks in the skin. Typically it presents in agricultural workers or those who walk barefoot. It develops over time as it requires repeated exposure of broken skin to the soil and water that contains the microbes. Fungal mycetoma (eumycetoma) is the most common type in Africa. Mycetoma does not spread between people.

Diagnosis and Treatment.

Mycetoma is best diagnosed by taking a small sample (biopsy) of the affected area of the body or the discharge and examined under a microscope to help determine if the infection is caused by bacteria or fungi. Cultures (growing the bacteria or fungi in a laboratory) from the discharge or biopsy can determine the specific type of microbe. Further imaging maybe needed to see how much damage to underlying muscle and bone has occurred.

Treatment depends on whether it is a bacterial or fungal cause:

Bacterial or Actimomycetoma is usually treated with antibiotics and surgery generally not required.

Fungal or Eumycetoma is treated with long term anti-fungal medication, but sadly treatment may not be completely effective. If this is the case then surgery or amputation are sometimes needed.

So early diagnosis and treatment is vitally important and wearing shoes might help to prevent Mycetoma.

 

Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional.

 

 

Asthma attacks

 

I’ve noted a few cases of acute asthma on the VDr system and thought this guideline may be helpful. I realise you may not have the ability to monitor oxygen saturations or even peak flows, but assessing the patient especially their general state, plus respiratory rate and pulse can give a lot of vital information.
Ventolin is best given through a spacer. These can be made by cutting a hole in a coke (or other plastic) bottle and getting patient to breath normally through one end with the inhaler inserted into the hole. I can post a photo if that doesn’t make sense (let me know). Oral salbutamol isn’t any good during an attack.

asthma guidelines

Guttate Psorasis

 

This is a personal topic since I have recently developed this skin condition, hence my knowledge about it (and sympathy to patients with skin conditions) has increased.
It most frequently occurs following a streptococcal throat infection (in my case) or after medications such as NSAIDS (ibuprofen) or B Blockers. This explanation is from Dermnet (a very good site for dermatology you can access through your mobiles):
Guttate psoriasis is psoriasis that is characterised by multiple small scaly plaques that tend to affect most of the body. ‘Gutta’ is Latin for drop; guttate psoriasis looks like a shower of red, scaly tear drops that have fallen down on the body. Lesions are usually concentrated around the trunk and upper arms and thighs. Face, ears and scalp are also commonly affected but the lesions may be very faint and quickly disappear in these areas. Occasionally there may be only a few scattered lesions in total.

The diagnosis of guttate psoriasis is made by the combination of history, clinical appearance of the rash, and evidence for preceding infection. It tends to affect children and young adults and has a good chance of spontaneously clearing completely.
Treatment options include: using emollients, steroid creams, coal tar or phototherapy.
On the drug list I note that aqueous lotion is available-this would be good as an emollient (although we have recently moved away from this in the UK due to some skin sensitivity to it). Patient should both wash with it, like a shower gel, and moisturise as much as possible.
Coal tar can also be applied but can be smelly, so moisturise after application. Steroids of any strength can be used but in my case it is too difficult to apply as I am completely covered in small spots.
I have been referred to hospital for phototherapy which is essentially UV exposure. Sun also works (but beware of sunburn), but isn’t so available in the UK even in summer!
Fingers crossed it works, as I’m very itchy

IMG_20170709_134439566

Tranexamic acid in Post Partum Haemorrhage

 

As a GP I have only ever used tranexamic acid to reduce/stop blood flow in women with heavy periods. So, I was really interested in a recent study in the Lancet which looked at its use for Postpartum Haemorrhage, a major cause of maternal deaths (100,000 deaths per year).
This international trial found that tranexamic acid (1g intravenously) decreased the risk of death from Postpartum Haemorrhage by about a third if given within 3 hours. The World Health Organization said it would update its recommendations for treating postpartum haemorrhage treatment.
Of course the next step is to get iv tranexamic acid available for women who need it the most — women in the poor, remote areas of the world, where maternal mortality is the highest.
I note it isn’t available on the Zambia Essential drug list and hope that this study will alter its availability worldwide.