How to identify snake bites, and other stories from my elective
In her second installment for Pulse, registrar Dr Suzanne Reilly writes about how her elective in Sri Lankan medicine is teaching her a lot about UK practice too
Since I last wrote for Pulse, I have been fortunate enough to be introduced to a patient with a ‘heave’ so forceful it pushed my stethoscope away with every beat and a ‘thrill’ that fitted the description I had read about only in textbooks – a rarity for a medical students.
I have also discovered how vital it is to have a good reputation.
Depending on a GP’s popularity among the community, an average day can be spent consulting anything from 50 to 150 patients. Because of a lack of protocols and the clinician’s reliance on their own clinical judgment, the investigations and management chosen by each GP can vary greatly. How each doctor’s reputation is built is not entirely clear. However, the patient’s expectation is that they will come away with medicine that is tangible at the end of the consultation or that they will undergo an examination.
One GP I spoke to said that patients would often attend his clinics with empty bottles expecting that they would receive some coloured liquid to take home with them. Now with the reduction of antibiotic use he said that he often gives vitamins to patients who are suffering from colds or flu. Just as in the UK, he explained that patients would not feel satisfied and may be reluctant to return if he did not provide them with a remedy, regardless of its effectiveness or relevance to their complaint.
It is interesting to see that although doctors are highly respected in Sri Lanka, the doctor-patient relationships, especially in primary care are often dictated by patients within a consumerist-style consultation. Culture of investigations is changing. Physicians used to rely on clinical judgment. Doctors would evaluate patients who complained of chest pains without suggesting an ECG. Now it’s routine to offer an ECG to be certain. They don’t rely on a clinical judgment as much as they used to but it costs the patients a lot more
Atrial fibrillation (AF), a condition with guidelines and a wide range of treatment options in the UK, is managed very differently here. Sri Lanka does not follow the ‘Rate vs Rhythm’ strategy but instead adopts more of a ‘one drug fits (nearly) all’ approach. The chosen drug, Amiodarone, a class III anti-arrhythmic, is given as the first-line medical treatment for various AF types without prior identification of stroke risk stratification and co-morbidities outlined by NICE guidelines.
The high side-effect profile of the drug can often be the causative agent in many thyroid disorders in Sri Lanka, which one may presume to be caused by iodine deficiency. Interestingly one manifestation, thyrotoxicosis, can actually limit the efficacy of the Amiodarone, sending the patient straight back into AF; a counterintuitive result.
We also had not one but two remarkable visitors to the emergency department this week.
A 32-year-old male had arrived after being bitten by a snake. Four pinprick punctures could be seen on his finger, but he seemed systemically well. He described what had happened and how he had been bitten while working. It was only after the doctor had completed his questioning in which he attempted to identify the snake when the patient leant into his bag and proudly produced the offender – a brown snake half a metre long in an empty plastic bottle.
A group of doctors and patients formed around the bottle and started an impromptu discussion to identify it. One word I recognised during the Sinhala debate was ‘viper’. It wasn’t until the snake was brought over to the wall chart (where it sits next to the surgery’s healthy eating poster), that the offender was identified to be a water snake – fortunately thought to be harmless. Confidence in the chart wasn’t universal, however, and the team decided that the patient should still be admitted for monitoring in case their diagnosis proved wrong.
One big difference between Sri Lanka and the UK is the prevalence of Ayurvedic medicine, a form of traditional herbal therapies originating from India. Unlike the average reaction from doctors in the UK towards complementary medicine, the general consensus in Sri Lanka is that it is well-respected, with doctors themselves using it for treatment of minor ailments.
One orthopaedic surgeon I spoke to was a big advocate of it in fractures, and said it gave impressive results with “superfast” healing times. With the strong culture of evidence-based medicine I did struggle to imagine an orthopod in the UK suggesting a complementary therapy to a patient for a fracture that didn’t result in wearing a cast for weeks…
Although Ayurvedic medicine is recognised by the community as purely natural, the dangers it can pose should not go unrecognised. One previous patient delayed seeking medical help after a viper bite as he had gone to an Ayurvedic specialist. He later died as a result of renal failure – his case a far cry from the outcomes of evidence-based medicine in the NHS.
My time in Sri Lanka has drawn to a close. I came expecting to experience a different perspective on medicine, and I wasn’t disappointed. Remembering the first line of the national anthem, ‘Sri Lanka Matha’ – Sri Lanka we salute you.
Suzanne Reilly is a fifth year medical student from London, studying at the Peninsula Medical School