Casework

The Virtual Doctors have been asked to advise on a whole range of conditions; some of which we may not see often in the UK. Dealing with these more unusual cases can be both interesting and challenging. However, most of the consultations relate to conditions that we regularly encounter in our UK practice. The challenge here is to ensure the management advice we give to the Clinical Officers is relevant to their setting.

In the UK we have many readily available tests to help us with diagnosis and management.

The Clinical Officers who we work with, may only be able to access a limited range of resources. Rapid screening tests for HIV, Malaria and TB are almost universal; reflecting the local healthcare challenges. The Charity collates information from the Health Facilities that we support, to produce a list of the diagnostic tools available at each site. Our response will be guided by this. The patient may need to travel elsewhere to have basic blood tests or radiological investigations performed. Sometimes this may be impossible because the patient is too unwell or the costs are too prohibitive for them. As Volunteers, we must ask ourselves if an investigation is really necessary; or if diagnostic skills and clinical judgement could suffice. We will often try to offer up a series of management options to the Clinical Officers, according to whether further tests are performed or not. This may help us as Volunteers to critically reflect upon our own use of investigations.

The Volunteers are also given the list of Essential Drugs that should be held in all the Health Centres that we assist. This helps us recommend treatments which are readily available

The case

The case this month comes from Chipapa in Kafue District, Zambia. It is the story of a patient who has had a stroke; a very common condition.

The Clinical Officer reported that an elderly gentleman had been brought to the clinic after suddenly collapsing at home. He explained that the patient was now no longer able to talk or walk. He described that the patient had weakness of his left arm and leg. He believed that he had sustained a stroke. He was concerned both about the gentleman’s blood pressure and also about apparent breathing difficulties. He had tried simple measures, including re-positioning the patient to aid with his breathing. He contacted the Virtual Doctors to seek help regarding ongoing management.

The Virtual Doctor agreed with the diagnosis of stroke from the information he had been given. He said that ideally a CT scan should be done to find out whether this stroke was caused by a blockage in the blood vessels or by bleeding into the brain, as this would affect management. However, he understood that it would be difficult to transport this patient to a facility that had CT scanning available and so went on to advise the Clinical officer how to manage the patient without this information. The description given by the Clinical Officer, allowed the Volunteer to determine the area of the brain that had been affected. He used his clinical judgement and expertise to predict the nature of the stroke.

He stressed that basic care such as positioning of the patient and frequent turning to avoid pressure sores was important. He also advised how to perform a bedside swallow test to check whether the patient could eat and drink safely. He made recommendations about hydration and nutrition if the patient was unable to swallow. He highlighted that it was important to treat any fever promptly with antibiotics; specifically, he recommended carefully monitoring the patient’s chest for signs of infection and treating without delay if there were clinical concerns. Again he was aware that the Health Clinic would be unable to do a chest X ray and so modified his advice accordingly. The Virtual Doctor explained that a chest infection may explain the patient’s breathing difficulty.

He addressed the Clinical Officer’s concerns about the blood pressure; advising not to treat immediately, explaining that it may be part of the body’s response to the stroke. He gave further advice on management; recommending that this patient would need treatment with aspirin, as well as medicines to treat raised blood pressure and cholesterol after this acute phase had settled.

Stroke

A stroke is a brain attack; it occurs when the blood supply to your brain is disturbed by a blockage or bleed. It affects the function of your body and can be fatal. In the UK there are more than 100,000 strokes per year (or one stroke every five minutes). It is the fourth cause of mortality in the UK.

Worldwide it is the second leading cause of death; leading to more than 5 million deaths every year. It is also a significant cause of morbidity and disability.

In Zambia it is thought that the incidence and burden of stroke is increasing (although local data is limited). Risk factors for stroke include certain modifiable factors, such as high blood pressure, as well as lifestyle factors, such as smoking. In a stretched Healthcare system, it has been difficult to address these issues. The WHO Global Action Plan for the Prevention of Non Communicable disease** has important implications for countries such as Zambia as they tackle stroke.

The survival following stroke has improved in recent years in the UK. In part, this has been due to complex treatments - including clot busting drugs and specialist stroke units. Such treatments and services are not available in rural Zambia. However, attention to basic steps such as positioning, maintaining hydration; ensuring infections are treated promptly and treating raised blood sugars or low oxygen levels with simple interventions, have also been shown to have a significant effect upon stroke survival. Most of these supportive measures can be followed to some extent even in resource poor settings. This is why it was so important that simple treatments were highlighted in our case.

NICE guidelines in the UK recommend a CT head scan within 24 hours for patients with suspected acute stroke. This helps to confirm the diagnosis and differentiate between strokes caused by blockages and those caused by bleeding (important because the treatment is different).

The WHO recognises that such targets are impossible in low-resource settings; in fact, many patients may not have radiological imaging at all. This poses a clinical dilemma; aspirin is recommended if the stroke is caused by a blockage but not if it is caused by a bleed. But what to advise if no imaging is available? A WHO bulletin in 2015 recommended a pragmatic approach; suggesting commencing a lower dose of aspirin empirically, except in those patients who had clinical features suggestive of a bleed. The review recommended formulating consensus guidelines for the management of acute stroke from unknown cause in settings where there is no access to CT scanning. The World Stroke Organisation is attempting to address some of these issues. But in the meantime the management must focus on optimising supportive care and using clinical judgment to decide upon management pathways. This is exactly what our team tried to do.

Often the advice we give as Virtual Doctors is very simple. But as with Stroke care, often the simple things done well can make all the difference.

Jo Loveridge

Medical Team Volunteer & Virtual Doctor

**https://www.who.int/nmh/events/ncd_action_plan/en/