Late presentation

I have already hinted at some of the differences in medicine here, one of the major issues being the time between people getting sick and presenting to hospital. There is a fine line between apparent hypochondriasis and appropriate presentation, which is very different in Zambia to at home.

In the UK, people are well educated about their health, there are major campaigns about the symptoms of certain diseases (e.g. bowel and breast cancer) and often present in the early stages of illness. There are of course exceptions to this, which I encountered in the population local to Whipps Cross, where we would see much more advanced disease. On the other side, we see a lot of "worried well" in the UK, who normally require only reassurance and observation.

Nearly everyone I see in OPD or on the wards has a definite illness. I'm told the physicians see some "worried well" but again a smaller number than in the UK. I do however see some staggeringly advanced disease.

On Saturday I opened the abdomen of a 12 year old with peritonitis, who had been unwell for 4 weeks. She had 4 litres of bile surrounding her bowels and a sizeable hole in her duodenum. Given the history, I can only conclude the perforation happened at least two weeks earlier and she had been critically ill at home for that long!

Today I saw a lady who had a hysterectomy at another hospital last year and was complaining of a "growth" in her wound. She in fact had a 10cm metastasis growing from her wound and grossly distended bowels. This had been there for 6 months. There is nothing we can offer her, although I doubt there would have been anything we could have done when the problem first started.

We have recently received two burns from another hospital, where they had been managed for four weeks. My burns experience in the UK is that you make an early decision about whether a burn is full thickness and needs grafting, or partial thickness and needs wound care only. These two girls had unhealed full thickness burns that could have been grafted a month ago and they would be healed by now. If they were left they would eventually heal, but with terrible scarring resulting in very poor function.

I have already talked about the late presentation of people with bowel obstruction, but it is a recurring theme that it takes about a week for someone with bowel obstruction to reach us.

From a medical perspective, there is no doubt that the results of treating very advanced peritonitis or wounds are worse than with earlier presentations. From the patient perspective, there are a lot of reasons for not going to hospital unless absolutely essential.

The first is becoming apparent this week. The rains have started, so it is planting season on the farms. There is neither time nor money to come, and our wards are getting quieter. Three of today's elective cases failed to turn up, I'm sure for this very reason.

Money is a big factor. Our catchment area is huge (as I'm currently on my own in the surgical department, I could claim to be the senior surgeon for an area the size of Scotland with the same population as Wales) and transport is not cheap. Money is apparently more plentiful after harvest, when the crops are being sold, than during planting season when seed and fertiliser are needed. The seasonality of poverty is well demonstrated by the peak of paediatric malnourishment cases in January and February.

Poor health education clearly influences presentation. Many don't understand the meaning of their symptoms and only see the need to present when they are near death. Traditional beliefs about health are often difficult to reconcile with modern medicine. The sites of advanced tumours or long standing wounds are normally marked by the scars of traditional healers. Even when people are here, they will sometimes refuse treatments on the basis that they think they kill people. This encompasses things like oxygen, fluids or nasogastric tubes.

Referrals from other centres sometimes come remarkably late, but that is the topic of my next post.

Finally, a surprising, and incredible, ability to tolerate adversity. The loss of limbs, neurological deficits or festering wounds seem to stop people doing very little. The family support network is often wide and very strong.

I'm now expecting things to be quiet for a few weeks while people pant their crops, then we should get very rapidly busy, as they come in with all the problems they have been storing up while working the fields!