Before I go on about the clinic, a little about the Swazi Government. Swaziland is considered the "Last African Kingdom", and it truly is the last absolute monarchy in all of Africa. Technically, Swaziland calls itself a “constitutional monarchy” because power is shared between the monarch (king) and parliament. However, the prime minister is appointed by the King himself, and no decision becomes law without the approval of the king. The Swazis are very proud of the fact that they are a monarchy.
 |
| Matsapha airport. The entry says "Welcome to the Kingdom of Swaziland". |
The current king, Mswati III,
came to power in 1986 at the young age of 18. It is well-known that he lives a
lavish lifestyle. He has 15 wives and somewhere in the range of 20-30 children.
Apparently he has an affinity for nice cars and palaces. His mother, the Queen
Mother, actually has an estate right here in the small town of Siteki, although
she is only here but several weeks a year.
 |
| Swazi newspaper from Aug 7, 2014. The front page shows King Mswati and one of his wives at the White House with the Obamas. |
GSH is situated about 1.5 km outside of Siteki. The eye clinic is in a small building next to the hospital, which, as far as Dr. Fetherston (“Dr. Tim”) and I can surmise, is about 50-60 beds at maximum capacity. There is no medical school in Swaziland, and therefore all doctors are foreign trained. My boss, Dr. Pons, trained in South Africa. The ENT is from India. There are also doctors from Rwanda, Argentina, etc. The hospital does pretty well, all things considered, but there are always challenges.
 |
| Good Shepherd Eye Clinic. Vision is checked outside under the porch. Clinic is on first floor and the operating suite is on the second floor. |
Not two minutes later, in walks a young 14-year-old girl holding a cloth over her left eye. When she took the cloth away from her face and we could have a better look, she was massively swollen on the entire left side of her face. Her eyelids were swollen shut. Upon gently holding her eyes open, we could tell her vision was reasonable, she had no relative afferent pupillary defect (or “RAPD”—a good sign), but her ocular motility was severely restricted in all directions of gaze. It was obvious that this young girl had a raging left-sided orbital cellulitis, likely from adjacent sinusitis.
Now
in the U.S., this would warrant an urgent CT scan of the face and orbits,
urgent ENT consult, hospital admission for IV antibiotics, possible surgical drainage
(depending on the imaging results), vision checks ever several hours by nursing
staff, etc.
Dr.
Tim and I both knew, before even conversing, that a CT was out of the question,
due to lack of availability. We asked for an ENT consult and admission to ENT,
to which Sister Senani (the senior nurse in the eye clinic, who does her job
very well), stated,
“He
is on vacation for the next three days.”
Okay. Plan B.
“Sister,
can we have her admitted to the pediatrics service?” To which sister replied,
“The
pediatrician resigned last week.”
Dr.
Tim and I shared a knowing look across the room. Darn…plan B was also out. But
Dr. Tim, never with a lack of ideas, asked,
“Sister,
could we get her transferred to the Government Hospital in Mbabane?”
Dr.
Tim knew the weekend was upon us (this was, after all, Friday morning).
Sister,
without saying anything negative about the government hospital (which would
have been a several hour car or bus ride), suggested that the little girl might
be in better care admitted to GSH under Dr. Tim and myself. I think it was felt that,
if she was transferred, she would end up in a never-ending queue somewhere,
receiving medical care at best, by the middle of the following day.
Dr.
Tim asked what IV antibiotics I would prefer. I responded with the typical “vancomycin
and Unasyn”, the common cocktail in the U.S. Sister went to look for the
vancomycin. She came back with three bottles: one bottle was already mixed, and
had expired three months ago. The other two doses were usable, but they were
the last two doses in the hospital. And honestly, two doses of vancomycin would
not likely get this child to therapeutic levels. And if we did get her to a
therapeutic level of antibiotic, we had no further doses to give her (she would
need at least 10 doses). So vancomycin was out.
The
next drug, IV Unasyn, was also not available. On to Plan D. There was no IV Ciprofloxacin,
but we could get oral Cipro. And there was IV metronidazole! Hallelujah! So
after going around and around with all possible antibiotic combinations, we
settled on IV metronidazole and oral ciprofloxacin.
Luckily,
over the next few days, the girl continued to improve. She can open her left
eye a bit, and motility is much improved.
We still have her as an inpatient, receiving her IV antibiotics. She saw
the ENT doctor today (returned from vacation, as promised), who added IV
ceftriaxone to our drug regimen as well as decongestants. The X-rays (sinus
views) showed a rip-roaring maxillary and ethmoid sinusitis on the left. I think, in the end, this child will do very
well. It makes me think...are we too
cautious when it comes to medical care in the U.S.? Do we order too many tests? Could
we get by with a lot less?
And
I think the answer is, we do what we have the capability to do in the U.S. with
the resources we have. And we do the same here in Swaziland; we just have much
fewer resources. So we give the best care we can with what we have.
And
that is all for tonight. I am tired. And tomorrow we are off to Manzini to do a
clinic there. It will be a long day!
My
final thought: the ocular pathology here is incredible. We had no formal eye
clinic today, but patients showed up, so we saw them. In three hours I saw:
-
Three patients
with new onset or recurrent anterior uveitis
-
A
corneal ulcer
-
Three
hyphemas, all trauma-induced
-
Episcleritis,
second episode
-
Raging cytomegalovirus
(CMV) retinitis in a patient with AIDS
-
And one
NORMAL eye exam!
No comments:
Post a Comment