Zambia | Sunday 25 June
On Sunday, 25 June I travelled on a Malawian Airlines flight to Lusaka before travelling onto Chitokoloki with two colleagues, Chris and Canadian trainee nurse, Hannah. There was good chat all the way on the Cessna 206, 9J-CTO, and on landing we were met by JR, an Irish midwife who functions as hospital manager, surgical registrar, consultant anaesthetist and club foot expert. Dorothy, Kaitlin, wee Owen and members of the maintenance team were also there to welcome us. David McAdam, the only doctor here, had left that morning for Lusaka by road.
Pulling my bag off the plane, JR announced they were expecting an ambulance from Lukulo with a patient who had a suspected splenic rupture. He had been beaten up and was thought to be bleeding internally. He was whisked into theatre while I grabbed something to eat and then went to assess him. He seemed pretty stable with a reasonable pressure and while he had a racing pulse, he was dry and so we gave him a fluid challenge. He responded quite well and so we set some parameters such that if his pulse or blood pressure breached in either direction I should be called. He remained stable all night so a good decision not to rush in!
“I am paining doctor!” | Monday 26 June
Monday started at 7:30 with a long ward round that involved seeing everyone in the hospital. There were lots of patients with uncertain diagnoses largely due to the fact that there is no lab support and no sophisticated imaging available. The ward round was followed by solid out patient work until 13:00.
I went to ‘Sista’ Dorothy’s for one of her unusual lunches. Apart from the odd wee potato like roots which tasted of liquorice – the rest of it was very appetising. Lunch was followed by a monster clinic in the afternoon. I did not even try to count the seemingly endless queue of patients. Towards the end – there were all sorts of patients with little wrong. Failing eyesight. Painful joints with a history going back years. I got to the stage of giving the patients the chance to complain of only one thing. ”I am paining doctor!” If the initial presenting complaint turned out to need no real intervention it seemed as though there were always many other symptoms – totally unrelated to the first complaint, which were then brought into play. Impossible! I need to develop a different tactic. The final straw was the last patient who was complaining of being dull of hearing in one ear. This was many hours in and I was struggling by this stage – the Clinical Officer’s handwriting was so bad – they might as well not bother writing anything. It was just appalling. Anyway it transpired that this guy had had his hearing problem for 15 years! I reassured him and encouraged him out of the clinic! Worked on until 18:15 then went to theatre. JR had been struggling to deliver a stillborn baby with a face presentation. She eventually had to reposition the baby into a breech position and deliver – unfortunately the whole process had appeared to shred the cervix. I made a repair and returned the patient to the ward.
I had listed about a dozen patients for surgery so we have enough work to be going on with. Dr Joel Nkonde from Loloma – about a 3 hour drive away sent on some x-rays for a 20 year old lad with gastric outlet obstruction. He clearly needs surgery so they planned to set off with the patient the following morning at 5:00 to get him here so that I can operate on him. There is also a 16 year old girl in the ward with pelvic inflammatory disease and a big bilateral tender mass in her pelvis – likely a tubo-ovarian abscess. The main differential would be a complicated ectopic pregnancy but her pregnancy test is negative so we will get her prepared for laparotomy tomorrow. In the UK she would have IV antibiotics, a couple of dozen blood tests and a CT scan. She would then likely have a radiological drain placed. None of that is possible here – the only solution is to take a knife to her and make a good sized opening to make a diagnosis and sort the problem out. If we accumulate cases at this rate, I fear there will be no chance of getting them all done.
When I finished I went to Joey and Kaitlin’s for a meal and finally got back to the house at about 20:30. I then prepared a teaching session on acute abdominal pain for Wednesday and collapsed into bed at 23:45.
A chance to cut – is a chance to cure! | Tuesday 27 June
I headed up to theatre and had a quick look in the ITU before getting busy. I ended up operating on a total of 10 patients today. Dr Nkonde’s gastric outlet obstruction boy turned out to have peptic ulcer disease with pyloric stenosis so we did a laparotomy and a Roux-En-Y gastrojejunostomy. I took Joel through the case so he can hopefully tackle this kind of thing in Loloma in the future. ‘See one, assist one and do one’ – only compressed a tad! I then did a couple of hernias, a hydrocele, scoped a patient who turned out to have gastric cancer and will need a distal gastrectomy and reconstruction on Thursday. I also dealt with some minor gynaecology in the form of a cervical polyp, banded some varices, faced an awkward umbilical hernia which had me sweating a bit when some troublesome and unexpected bleeding enforced an enlargement of the incision to sort it out, and did the laparotomy on the young girl with what turned out to be a bilateral tubo-ovarian abscess. The small bowel was plastered to this and it was a little difficult. After Dr Nkwonde left my only assistant was an inexperienced Clinical Officer. However we got the patient back to the ward. Whether she is safe in the ward is another matter altogether. Tragically in this society her problem is the result of teenage sexual activity here. She has ended up with horrendous pelvic infection and is most likely sterile. That too is difficult to bear in this culture.
One highlight of the day was a chance to FaceTime my dad from theatre. He is in his 94th year and had read about the work here and about some of the staff so was intrigued to be introduced to JR over the internet and have a chat with her.
Axes, bullets, a single kwacha and a croc hunt | Wednesday 28 June
Happily all of yesterday’s patients seem to be in good shape. Some are a tad grumpy but since the only meaningful post-operative pain relief is paracetamol I think they can be forgiven. I started today with a teaching session on acute abdominal pain. There was a good attendance from nurses and clinical officers and even a social worker! I had been warned that the local staff don’t like being picked on to answer questions in an interactive teaching session. So I forewarned the COs yesterday that they had better be ready. When they all filed into the classroom, isn’t in interesting how people head for the back row? So just as I started the session I announced that I would only pick on people in the back row. Rapt attention! Good engagement also.
On the wards I was pretty much in my comfort zone until we got to the maternity section. I was only asked about three difficult obstetric questions this morning; and of course, I knew the answer to none of them. How on earth do I know what to do when a mother starts to bleed four days post delivery? At least the girl was warm and well perfused and looked good from the end of the bed. She even smiled at me. A smile is a very important and reassuring physical sign. Rarely do shocked patients or people with peritonitis or major bleeding manage to manufacture a smile. Before getting to the 20 or so clinic patients I was summoned to theatre because a young guy had been chopping something with a large axe. He missed his target but connected with the medial aspect of his left ankle. Blood everywhere! I arranged an x-ray before attempting to explore the wound or sort things out and sure enough he had a compound fracture and had chopped right into the medial malleolus – the lower part of his tibia. Quite a trick with a filthy blunt axe. The wound itself bled but more from the fracture site than the soft tissue so I put him back together and left the question of what to do with the bone for a visiting orthopod next week, I reckon it will be fine – minimal displacement. After he hopped out I saw another chap, Patrick! He had been shot up and ended up with bullets in his abdomen and in his left hip. His left leg had been so wrecked that it had been amputated above the knee before I got here. Now he has an established vesico-intestinal fistula – an abnormal connection between bowel and bladder. He is keen for something to be done for that. I tried to get a cystogram to create a road map so that a reconstruction can be planned. Unfortunately he also now has a urethral stricture so I could not get access to his bladder – more action for tomorrow under ketamine! My old boss used to say that there was no point in doing easy cases. Maybe!
The monster clinic failed to materialise so I went walkabout with my camera and planned to get some shots in the village and surroundings. I came upon an intense football match next to the airstrip. The local team (Chit City) were playing their rivals (Young Stars) and were whipped 3-0. It looked like most of the village were there to cheer them on – quite the community affair.
Wandering back I was accosted by a local. “Doc – Sista JR is looking for you at the hospital.” The bush telegraph – literally. The problem was a wee lad of seven who had swallowed a 1 Kwacha coin and it lodged in his upper oesophagus. X-ray confirmed the position and we anaesthetised him and set about trying to retrieve it with a combination of a rigid cystoscope and a pair of alligator biopsy forceps. Risky business – I never did really learn the art of rigid oesophagoscopy. I was able to grab it, just and no more but did not get enough of a grip to extract it. Plan B was to slide in a flexible endoscope and gently push it on into the stomach. Success. A single kwacha is worth 0.01p!
Making my way home after this I was invited to go on a croc hunt in the River Zambesi. I was too wary the last time I was here but I couldn’t chicken out this time! Tiny boat, fibreglass and an outboard in total darkness – just the spectacular night sky above with an amazing view of the milky way. There were five of us aboard. One driving, one up front with the searchlight, one with the rifle and two spotters. The moon had set by about 10pm and we covered about 5-6 km hunting for the light reflex from crocodile eyes close to the banks for about 90 minutes. No joy. Glad I borrowed an extra fleece – it was pretty cold out on the river.
“What kind witchcraft is this?” | Thursday 29 June
Today felt like an operating day in the NHS – just in a totally different environment. At home the operating rooms are spacious and full of shiny high tech kit. I am used to cupboards being tidy and organised. It is usually easy to find things. Everything is pretty much in the right place. Most items are single use. Here, the working environment is like a total jumble. A bit cramped. All the kit here is second hand and a good deal of it doesn’t work or doesn’t work as expected. Only one person has any fighting chance of finding an obscure instrument or drug and you just have to hope that she is around. Nothing is single use. All the single use items including anything which is not stained or contaminated – indeed almost everything is recycled or re-assigned to a different role. Used (but clean) disposable surgeons gowns are chopped up and used to wrap instruments for autoclaving. Single use surgical staplers are cleaned and submerged in antiseptic rather than being lobbed straight in the bin!
For the major cases today I was assisted by a newly trained clinical officer. He is getting the hang of things and I tried to encourage him and show him a few tricks as we went along. We did a challenging distal gastrectomy for a newly diagnosed gastric cancer, a paediatric hydrocele, a urethral stricture, an abdominal rectopexy and a couple of other unmentionable cases that I should really not describe in a document like this! The stomach case was excellent – we had to take our time around the pancreatic head because of lymphatic extension of the tumour and I was really pleased with the way that went. The rectal case was a bit of a ‘dig’ under spinal anaesthesia and with only modest muscle relaxation, it was something of a fight the whole way.
Anyway in a break between cases I decided to put in a few family FaceTime calls. The only person I could reach was Jenni who was travelling in Edinburgh in a friend’s car. I let her speak to Kayumbo the senior theatre technician here – she knew him from her two previous visits here. He was totally astonished and could hardly put a coherent sentence together being so amazed at the reality of a video call. “Can she see me?” he kept saying. “On no Doc! What kind of witchcraft is this?” which had to be the quote of the day. He was then connected to another previous visitor in Northern Ireland by JR who was also in theatre. Again – lost for words. Best entertainment I have had for a while! Oh, and the kwacha emerged – found you know where, by the patient’s granny!
“How are you?” “Doc, I am a little bit fine” | Friday 30 June
There is a crazy cockerel close to the house I have been given. It has no sense of propriety. It starts crowing anywhere from 2:30am till 5:00am. Mercifully today was a slightly quieter day. As ever the day starts in the hospital at 7:30am. We assemble and start in the ITU before heading into the seemingly chaotic wards. Some patients speak English and that makes it easy. Some speak a kind of English such that in response to ‘How are you today?” ‘Fine,” I think usually means OK whereas “a little bit fine” can mean that ‘I am feeling pretty dodgy!’ I spent much of the morning fending off patients with guessed diagnoses. It is about as much as you can do when there are no lab values beyond a haemoglobin. On some days of the week we might get a creatinine level. Radiology in its simplest form is available and a portable ultrasound machine is also here – the issue is that you not only have to perform the ultrasound investigation yourself but also try and make sense of the images. A challenge! I even read a 12 lead ECG today – not bad for a surgeon. Normally I would be pleased to manage to hold it the right way up!
I had to think hard about my urology training today. A middle aged man pitched up with a tight urethral stricture. It is possible to stretch the narrowing up by carefully navigating a series of graduated bougies of increasing size and weight through the external plumbing system and round the various corners into the bladder. (Men may wish to skip the rest of this paragraph!) The instruments are kind of J shaped and getting into the bladder with a series of rigid stainless steel instruments is not pleasant for the patient or the surgeon. However, a bit like riding a bike, I managed. I felt chuffed that the task was accomplished without too much in the way of patient protest! I did require a shower soon after the procedure as I was unable to dodge some airborne fluid. Enough said!
I got through the clinical work and after lunch (which is the main meal of the day here) I dealt with some email and wandered off to the river. It is a very impressive and beautiful river. Just a shame that it is hoaching with nasty things like crocodiles, schistosomes and tiger fish. Four wee girls came up to me and walked with me for a while – announcing that they wanted to be my friend and to come to my home in Scotland. They were wearing filthy rags and don’t know about anything beyond their patch of the bush. Despite being 10 years old and attending school the oldest of the four, Happy, was unable to read. The others were Theresa, Precious and Joyce. Joyce was four years old and wandering around being supervised by these other scalliwags!
I am hoping the hospital remains quiet as I am essentially on call 24/7 for the next 16 days! I have also been asked to contribute by speaking at the church service on Sunday morning. I need to give that some thought and be careful to strip out any culturally irrelevant phrases or ideas. I think it might be best to steer clear of any humour. The Glasgow variety just does not seem to hit the spot here.
It’s a bugs life | Saturday 1 July
After a quick tour of the hospital and a minor procedure I spent the rest of the morning preparing what I am going to say in the church service tomorrow.
Seeing the morbidity here makes you wonder about the outcome if only various species would stop biting one another or invading one another’s personal space. Never mind the wildlife in the form of crocodiles, hippos, snakes, dogs, – even people. Most of the morbidity results from bugs. According to the WHO the most significant bug in terms of purveying misery and death is the mosquito. They carry all sorts of really nasty bugs. The second biggest killer is schistosomiasis or Bilharzia (named after Theodor Bilharz; a German physician and surgeon who described the trematode in 1851). For you classical scholars the word schistosoma means ‘split body’ which is because of the shape of the male beastie. This area is awash with both mosquitoes which carry malaria and the fresh water snail hosts which are essential to the life cycle of the schistosomes. A double hit. The mini bugs are certainly holding sway here.
I got off lightly because there was no emergency action in the hospital. One admission caused concern as a possible ectopic pregnancy. Happily she settled and I have stayed out of the way.
Colony death and bush funeral | Sunday 2 July
I managed to give my wee talk in the church via an interpreter – my friend Chambula Chimwanga. He is a teacher in the local school and is involved in church leadership. I was invited to attend a funeral for a poor wee lady who was well known to most of the mission staff here. I was curious as to how this would all play out so went along. The lady who died lived with her husband in the leper colony near the hospital. She was about 80. She had bad asthma and had weathered several critical complications in the past. This time she unfortunately died before reaching help.
The leper colony is basically four rows of tiny single room houses. They are the size of a small garden shed but far less well appointed than most garden sheds I have ever seen. There must be about 60 of these buildings. They have no furniture. They are really a shelter and that is about it. All the cooking is done outside over an open fire. There is no water and no power. They are filthy and some are falling apart. There are not many actual lepers left now but this lady’s husband is one of the remaining leprosy patients. She was his carer. He is unable to walk. He is blind. He has no fingers on either hand. He is however mentally alert and articulate.
The funeral was a real eye opener. About three hundred villagers gathered in a big church building. There was loud hymn singing followed by loud wailing and screeching – almost hysterical – when the simple coffin was carried in. After about an hour everyone set off to walk to the ‘cemetery.’ This involved a trek across sandy soil around the airstip through some very primitive villages to a completely undeveloped area of bush. I followed the crowds and came to a clearing where a deep grave had been prepared in the sand. I think this is the northern edge of the Kalahari hence the nature of the ground. Everyone gathered around – again much wailing. The coffin was brought along a nearby track in a Toyota pickup by one of the Canadian missionaries and several of the hospital staff manhandled the coffin to the edge of the grave. No ropes or cords in sight so I did wonder how this was all going to work.
I was not quite prepared for what happened next. Two guys jumped down into the grave. I was standing nearby but when they jumped in – they disappeared from sight! It must have been about 7 feet deep. They then received the coffin which had to be tipped up to about 60 degrees off the horizontal and gently lowered in. I could not see quite how they worked it – one got out leaving the other guy to position the coffin before climbing on top of it before being helped out. Not quite the reserved decorum complete with top hat and tails that we are used to seeing. There was some praying then preaching and then a team of four fit chaps with shovels started filling the grave in while everyone stood around. There was a flurry of activity with dust flying around and the hole was filled in in about 4 minutes – certainly no more! Then everyone presented a twig from a bush – we were really trampling on bushes as it was a completely unprepared area and all these twigs were placed in a little trench which was prepared in the top of the mound of sand which covered the grave. Then about 15 or 16 women knelt down and sang beside the mound and smoothed the sand off with their bare hands. Quite moving really. After that the old leprous husband was carried to the graveside by one of the mission staff and he spoke in a strong voice – in Lunda so I could not understand, but he spoke about his deceased wife. How he will get on now – I dread to think. Makes you think!
Where is the justice? | Monday 3 July (Heroes Day)
As I completed the ward rounds today there was a real commotion outside the hospital entrance. “It’s a thief!” was the announcement. A chap had been captured in the act of pinching a blanket from an attendee at the wake which followed yesterday’s funeral and not only was he not quick enough to escape, it turned out he was the prime suspect for a number of other thefts which had taken place recently. I could not resist the temptation to go and have a look. Here was this guy wriggling and protesting, hog tied with ropes around his hands, tied behind his back, and his feet tied together. Apparently the police had been summoned to come and take him away but since they had no fuel that was not an option. Community justice took over! He was being huckled into a car and hauled off to be beaten up or worse. There must be a good chance that, should he survive, he will be back in the hospital before the close of play. The prediction is that he is likely to get less of a beating from the family of the victim than from the police so maybe he is better off where his is. Bush justice in action!
Today is a public holiday in Zambia. The Chitokoloki football field is the location for a knockout competition featuring 8 teams from the region. Quarter finals today and semi’s and final tomorrow. These matches are hotly contested at high intensity by enthusiastic, sometimes skilful, players who have to contend with a surface that is more suitable for beach volleyball. The crowds have been large and vocal. It seems like a real community event. The ball squirts and bounces in all sorts of unpredictable directions so the goalkeepers face particular challenges and have been humiliated a few times today.
I was about to give up being a spectator to get out of the sun when the ‘bush’ telegraph located me – “You are wanted at the hospital.” I guess I am conspicuous – the only white guy and the only person with white hair in a crowd of 500 spectators. When I arrived in the paediatric intensive care area the team were trying to resuscitate a 3 month old baby. He was a twin. He had also been operated on for Hirschrung’s Disease which is a congenital bowel problem and having developed problems a few days ago he became progressively worse. His poor parents were so caring and attentive to both the babies and they were distraught at the turn of events. When I saw the child, his heart had virtually stopped and he was having CPR. He was already tubed and ventilated. His blood sugar was OK, he had already had four doses of adrenaline and it was clear that he was about to succumb. I heard the father ask “Is this the end of my son?” as he was given the pathetic little bundle to hold for one last time.
Tragically he was only one of two baby deaths today. The other little one was only 6 weeks old. He was contending with an omphalocoele which is the result of imperfect fusion and integrity in the anterior abdominal wall. The paediatric team in Lusaka agreed to take the patient at 9 months of age. There was virtually no chance of surviving 9 months in conditions here and while we do not know what the mechanism of death was – probably sepsis – I fear that this baby had virtually no chance.
Strangely enough these contrasting accounts in one day call the seeming injustice of suffering to mind. At least the parents of these babies will have some support from the Christian community in the Mission Hospital – a feature which is not so easy to come by in the modern NHS!
Shootout! | Tuesday 4 July
Today was an operating day. Patrick is a young lad who, thanks to a shooting, is without a left leg below the upper third of his thigh. He also has a connection between bowel and bladder or at least between gut and urinary tract. The exact site has been difficult to determine. I had good reason to believe that the problem might be accessible via an approach to his abdomen and pelvis. Wrong. I spent a couple of hours chasing and mobilising his rectum all the way to the pelvic floor and there was no sign of the suggested fistula track which seemed to appear on the contrast radiology from last week. I then decided to have a look from below and identified a low track connecting prostatic urethra to the upper rectum. When we then opened up his perineum, it was possible to disconnect the abnormality and reconstruct things. Four hours of surgery but hopefully with a good outcome. After lunch – I did a routine hysterectomy for big bulky fibroids and a few other cases.
So what about the shootout. Well today, half the hospital staff seemed to be missing. In reality they were about 300 years away at the Chitokoloki stadium. Actually it is a nearly flat patch of a very dusty sandy field with imaginary line markings making it a functional football pitch. The tournament which has been unfolding over the past two days finally came to a climax and as we were finishing in theatre two local teams were contesting the final. There were officials complete with flags and whistles (liberally blown) as appropriate and there were crowds! Those cheering on their teams numbered at least 1500 at an educated guess. I arrived as the two local teams who had managed to see off opponents for other parts of the region were locked at 1-1 with some 5 minutes to play and a sun that was fast sinking on the horizon. No floodlights here. Actually – no lights here! The final whistle was blown and this final was therefore to be decided by a penalty shootout. The crowds surged on to the field and assembled about 8-10 deep in a small area within the imaginary box around one of the goals. The ref paced out the distance and selected the penalty spot and the teams readied themselves. The Young Stars were the competition favourites and played some pretty good football. They were probably the best organised team. The opposition were the Red Arrows – curiously decked out in bright green. Some of the locals could hardly get over my innocent suggestion that they might be better called the green arrows since that was the colour they wore. Anyway to cut through the atmosphere and the palpable excitement the Arrows scored their first three penalties with consummate skill. The Young Stars managed to hit the post and then had their next two efforts saved buy the Arrows keeper. Game over – the favourites lost the shootout. Great drama.
More teaching and speaking tomorrow and again on Sunday , so headed home to do some preparation.
BID – Brought in Dead (nearly!) | Wednesday 5 July
Wednesday was a routine day in the clinic after a well attended teaching session this morning. I saw all sorts of cases. It is a bit like what I imagine veterinary practice to be. Even with an interpreter it is virtually impossible to take a meaningful history. The answers which come back generally bear no relationship to the questions which are asked. Eventually, I just about gave up. The only excitement was an urgent call to theatre which also serves as the resuscitation area. A young man was brought in – not breathing, unrecordable blood pressure, virtually no circulation and a desperately low blood sugar. This is an open goal and should be an easy fix. He was given 60ml of 50% Dextrose intravenously and he woke up and was chatting in about 2 minutes. Miraculous! It is quite satisfying when someone is brought in looking almost dead and walks out shortly thereafter very much alive. But not before he got one of my lectures about the evils of tobacco and alcohol. He was a bit of a chancer as it turned out. In fact, there is a plentiful supply of ‘ne-er do weels’ and chancers here.
A day of controlled violence | Thursday 6 July
This was probably one of the most intense days of surgical experience that I have ever had. It started simply enough with a laparotomy for reconstruction of a gut in a young woman who had an ileostomy performed after resection for dead bowel back in March. No bother. Then I had two battery acid cases; these were tough. One – a young girl of 16 who swallowed the acid to injure herself in order to make someone against whom she had a grudge, feel bad for her. The problem is that caustic injuries to the oesophagus are devastating. The gullet narrows down over a short period until it closes off altogether. The girl could manage to swallow her own saliva but virtually nothing else. She also had a tracheostomy. Her nutrition is by means of a gastrostomy tube. On passing the endoscope from above it was impossible to be sure of the anatomy of the stricture. It was possible to introduce the gastroscope from below and after much effort I managed to get at the oesophagus from below. It was tricky because of the angle of incidence of the gullet into the upper stomach and it took about an hour of failed attempts until it was finally possible to get at the narrowed section from below. I was then able to thread a guide-wire up and ran a series of graduated dilators over the wire to about 1cm diameter – still not great, but better than a pinhole. I then threaded a long heavy gauge suture up through the track so that it came out of her mouth at the top and out of the gastrostomy in her abdominal wall. It was then possible to pull some successively larger dilators to get it up to about 1.5cm. Result! She ought to be able to eat reasonably well although will need the process repeated on a regular basis over the next several years. Tragic really.
The next case was similar – only worse. However it was technically easier to achieve more or less the same result but I was not brave enough to go beyond 20Fr or about 0.8cm for fear of spitting the gullet and ending up with a worse problem. We had a few more scopes – another gastric cancer picked up, a case of oesophageal candidiasis in an HIV patient and a peptic ulcer. Plenty of pathology for sure. I was glad when the long day was over – except it wasn’t.
I did manage dinner before having to go back to operate on an emergency. A 15 year old lad was sent by the doctor in Zambesi Hospital. He had obstruction, peritonitis and at laparotomy, a caecal volvulus with necrotic bowel and a mid ileal perforation. By the time he was sorted out it was 22:30. There were happily no more cases after that.
A high speed thrill ride | Friday 7 July
The orthopaedic guys are here today with a monster operating list. Dr Georgio Lastroni is the Italian orthopod I have met a few times before and he was accompanied by Jim Turner. Jim is an Edinburgh graduate who trained in Glasgow and Oxford and decided to take on humanitarian work rather than work in the NHS. He has done fellowships in CURE Malawi and in Toronto’s Hospital for Sick Children. CURE is a Christian Mission dedicated to helping children with deformities and they have a chain of hospitals all over Africa. The two visiting surgeons were so impressed by the hospitality and the work ethic. It has a very clever funding model but is heavily supported by churches and individuals in the UK and the US.
I had a slow day. First of all, last night I was introduced to the legendary Dr Roz! She is a paediatric neurologist from near Oxford and comes out here for three months at a time alternating with three months in the UK where she picks up some locum work. It is good to have a professional kids’ doctor who knows what she is doing in the children’s ward. So many of them have various tropical diseases as well as weird and wonderful things that I am pretty much out of my comfort zone in the paediatric ward. We’ll leave it to Roz from now! Maybe I can learn some stuff.
It was quite good to have a slower day after the exertions of yesterday. JR came looking for me about a patient we had done yesterday and who was in the ITU. My phone was charging and I missed the WhatsApp message. She came hunting for me and came to the door of the house. I was sitting around the corner reading a book in the sun. Eventually I picked up the message and JR had been banging on the door of the wrong house! You could hardly script it.
Towards the end of the day we took a call from a village about a guy who had been badly beaten and was having difficulty breathing. I decided to go out in the ambulance with Joey Speichinger driving. The road was a single track sandy path with high grass and potholes everywhere. We had to take an excursion through a forest to avoid a fallen tree and then speed on; rocking and rolling until we arrived at the village. There was a small crowd around the casualty all peering at the funny white guy with white hair. The patient was badly bruised but didn’t have anything critical. I figured he’d be a lot more uncomfortable after the trip back to the hospital in the ambulance. Anyway we lifted him and set off. It took about 40 minutes of driving along ridiculous roads through the bush to get back. We lived to tell the tale and took some video along the way. It has to be seen to be believed.
I had a good chat with Jim Turner who is working for CURE and while he acknowledged the value of the Christian principles behind the CURE organisation and the support from churches and Christians around the world; he himself has a nominal interest and no active Christian commitment. He was so impressed with the missionary team here in Chitokoloki – he feels that they have been treated so well, and with extraordinary kindness and hospitality, he said “This is just like heaven!” A good witness for sure and it is hard to miss the dedication and love shown, by the team here, for the people in their care. It is a privilege to be part of it.
Mufwaha and some late night obstetrics! | Saturday 8 July
A slow day. Saturday started with the nice Italian orthopaedic surgeon wandering into each ward in turn and yelling “Mufwaha” at all the patients. He was merely trying to locate his patients amongst the partially blanketed forms lying in the beds and on the floors – in wards, in corridors and even outside in the courtyard. Puzzled; I asked what this mysterious phrase was. In Lunda it means “Bones!” He was calling for all the Mufwaha patients from the day before so that they could all be seen before they left. Good technique.
I saw the orthopods off the premises and after surveying yesterday’s damage, dealing with a totally hysterical woman who seems like she is dying of acute abdominal pain (when in reality there is very good evidence that there is absolutely nothing wrong with her), learning a very disturbing lesson about our baby death of a few days ago, I went off to sit in the sun and read a book. It was a welcome slow day.
Until 22:30! I was called to see a patient who was essentially in obstructed labour. There had already been two attempts to deliver her with the vacuum device, but no joy. So we thought it best to get this baby out without further delay. Happily it turned out to be a straightforward Caesarian delivery. No anaesthetic just a syringe full of ketamine. Indistinguishable from magic. It was a good call because the baby was becoming increasingly distressed. Dr Roz who has a neonatal background came along to receive the baby and both mother and baby are now fine after the usual trauma of a long then obstructed labour followed by a significant emergency abdominal operation.
Flying surgical service | Monday 10 July
I met at the airstrip with Mr Kayumbo (theatre technician), Mr Katota (Clinical Officer), Dr Roz (Paediatrician) and Chris the pilot. We flew for 15 minutes to a short tree flanked airstrip in Dipalata – a small mission hospital deep in the bush. It would take more than 2 hours to drive there but we had the first case done before 9am. That is not commonly achieved in the UK! In fact, latterly it was almost never achieved because of all the built in and totally unnecessary faffing around that now goes on. I met a nice couple from Northern Ireland – Tommy and Margaret Craig, who have been instrumental in building various facilities on the Mission Station – including the hospital, maternity unit, extension, wells, water towers – you name it!
We had our six cases done by lunchtime. All minors – a hydrocele, two paediatric hernias, a bilateral tubal ligation – what a fiddle that is. It would be far far easier with a laparoscope – instead it feels like fishing around with a finger trying to locate each Fallopian tube in turn and make sure it is divided and ligated. This woman delivered more than a month ago so her uterus was back to normal size. The ovaries were hiding and it took about 10 minutes to secure the first tube. The other one gave up with less of a fight. It seems that vasectomy is not a thing here. The men rule the roost. The women carry the heavy loads.
One of the senior missionary ladies who runs the maternity service here made us the most amazing lunch – huge chicken curry followed by an extremely generous helping of apple crumble. I was so glad I had all the cases done by that time. I went to explore the neighbourhood in the afternoon and walked about 3 miles with a farmer who told me about his life and his philosophy of life in excellent English. He wanted to show me his local river, the Lunyiwu, a tributary of the Mekondo which in turn drains to the mighty Zambezi. I was more than slightly uncomfortable and extremely watchful when I heard all the snake stories he was keen to tell me. He was keen to know about Scotland but has no chance of ever travelling there. He has 5 kids, just about manages to subsist, lives in a mud house with no water, no power and no real furniture. He does have a bike which cost him 100 Kwacha at the market. Riding it must be murder because the roads are all deep sand tracks. It is literally like walking along a soft sandy beach. Every step sinks in enough to make it feel difficult to make progress. After I left him I retraced my steps to meet the plane. A young girl caught up with me and tried to keep in step. She was being heckled by local villagers on either side as they appeared to be teasing her about walking with the white man and when I picked up the pace she would fall behind and then run to catch up. It was clearly doing something for her street cred which she enjoyed. Not quite sure what?!
We took off and flew back to Chit at low level i.e. about 1000 feet until the flood plain beside the big river, then at about 25 feet above the surface of the water. I have strict instructions not to post the video on social media. We’ll see. I watched one poor man in a dugout canoe duck as we flew overhead at about 25 feet above him. I took some video evidence – a highlight to end the action for the day. Facing too many cases tomorrow….
The flying patient service | Tuesday 11 July
Tuesday was a heavy operating day again -13 hours, although admittedly 1 of the hours was a break for a very nice lunch!
It started off with a man whose name was Fairness – there are some great names here. Lots of Bible characters but not the ones we find in the UK like John, James, David, Esther, Deborah etc. No, here there are plenty of personifications of Job, Moses, Enoch, Ezekiel, Isaiah, Tabitha and many more. Just a sample of the more unusual examples I have come across include Marvellous, Pretty, Happy, Wisdom, Gift, Prince Philip, Socks and even Nobody! We should adopt this policy in Scotland. “Hi, nice to meet you, I’m Nobody!’ Perhaps not!
So there was plenty of banter in theatre today. Some good quality Zambian slagging was being traded between the Scottish surgeon and two of the more experienced staff, Kayumbo and Katota. Great workers but not averse to displaying the characteristics of a couple of chancers when the circumstances permit.
Poor old Fairness had a resectable gastric cancer – the staff are getting used to seeing a gastrectomy with Roux loop reconstruction and they anticipated all the tools we would need. Impressive. I did some more gullet stretching for the two acid swallowers and managed to stretch them both up so that they will be able to eat – something they have been unable to do for many months. I was about to start a tubal ligation when the plane with Jonathan and Jo Lake (respectively pilot and midwife) from Kalene Mission arrived with an Angolan lady who had been obstructed for about a week. She was as sick as anyone I have seen here and of course we have no lab work, no X-rays, just a potted history and a referral letter which gratifyingly informed us that some unspecified blood tests were normal a week ago! I did not feel reassured by this encouraging but totally useless piece of information. One might even say that it was not exactly relevant to this presentation in a woman who had been vomiting and becoming increasingly dehydrated for days on end. What chance does one have with all the odds stacked against this poor patient? From examination it was clear that she needed opened up. I found a really large bowel obstruction with a pelvis full of fixed tumour. The only option was to divert her bowel and hope that she will be more comfortable. She is not long for this world I’m afraid.
So that took up a good chunk of the afternoon and the queue of patients sitting on the bench outside the theatre were told that their surgery would have to be delayed and to return
‘Koomadiki’ (tomorrow). The response was typically polite, “Eh Mwan” which roughly translated means “Yes please!”
So I only now have three days to tidy up here and hopefully leave everyone appropriately treated. There will be no surgical cover for the ensuing 10 days before Dr Andre Trutter from Canada flies in, a week or so before the resident surgeon, David McAdam returns from the UK. It does leave things rather exposed.
To be honest I wouldn’t fancy being a patient in any African hospital I have seen, even here, let alone in a hospital that couldn’t get me out of a surgical pickle if required. Time to appeal to a higher authority!
Just a bit! | Wednesday 12 July
All the post-operative contenders from yesterday seem to be in good shape. After the ward round and the essential tea and buns at 10am it was off to the clinic. The queue was as for an execution.
Trying to take any kind of history from a local Zambian patient is, I have reluctantly concluded, a lost cause. It seems that if they can indicate the approximate anatomical area(s) wherein resides the malady – they have done all that is necessary. Attempts to elucidate symptom pattern, associated features, even duration are largely fruitless and totally confused. Symptoms also seem to flit around – pain and odd feelings in the abdomen are not infrequently accompanied by oddball pains in the legs, the upper arm and the back of the head. After giving strong reassurance on the basis of the consultation and giving an opinion that nothing serious is wrong and no treatment is required; that is when a new suite of previously unheralded symptoms are brought to the fore. I have given up and just adopt a more veterinary approach. Physical signs I can see or feel – they have a reassuring objectivity. The subjective stuff is just impossible. A steadily increasing proportion of outpatients are now being sent away with the strong message that there is nothing wrong with them. They mostly do have some chronic disease of course, malaria, bilharzia, anaemia and nutritional issues and they clearly have symptoms of some kind – but no signs, so they leave downcast with no new treatment. Frustrating! Case in point – a woman came to the clinic today complaining bitterly of pains in her joints. Which joints? All the joints! No exceptions! All swollen, unable to walk, hardly able to move. Well she moved pretty swiftly to the examination couch. No joint swelling visible. Range of movement – impressive. No other discernible features. No fever, no malaria, no sickling. Zilch. The solution? Well for a diagnosis, I have literally no idea. The treatment – a cinch! “Panadol 2 tabs three times daily and come back in a month if you are no better!”
Amidst the apparent malingerers and complainers there are some really sick people. An elderly man came today – his official year of birth was 1908 making him 109 years old. Mmmmh, unlikely. More probably that something has been lost in translation. He needed a 60000 mile service including cataract surgery, prostate surgery and a few other things best left unsaid. I have another woman who has been a diagnostic puzzle for the last two weeks. There are times when she seems fine – eating, drinking, moving around – no fever and here is the key point – nothing objective. Yet she moans and complains and writhes around the bed – mainly when the medical team arrive mind you. On examination – totally normal. Well today her husband sought me out to show me something she allegedly ‘passed.’ Passed from which orifice I wanted to know. On examining the said object it was about 3-4 cm across somewhat spherical, black and decidedly unpleasant looking and roughly the shape of an onion! (You do not want to know which orifice but it was one not normally associated with the passage of any kind of solid or semi solid object). I suspect that the witch doctor has been having a poke around and has inserted some village ‘medicine.’ I am sure she is a NOAP. (Non Organic Abdominal Pain).
I have also given up trying to understand the meaning of the stock response to the question “How are you today?” The answer invariably is “Just a bit.” I have tried the obvious and logically coherent follow on. “Just a bit, what?” No point; “just a bit” is all you are going to get. I even tried a series of leading questions – insert as appropriate; ‘just a bit, better? Or worse? Nope, none of these. Just a bit!
An early start | Thursday 13 July
It is not that hard to describe your emotions when your phone rings at 3:18am and a voice says “Fancy coming to do an early morning section?” It is certainly not a great feeling. Pulled on some clothes and wandered up to the hospital which is about a 5 minute walk. I did the section and was back in bed by 0430. Result!
I agreed with the rest of the team to a 09:30 kick off rather than a 07:30 start. I managed one hernia before being summoned to the delivery room where a young woman had become very unwell. She was at about 35 weeks in her second pregnancy and to all intents and purposes looked like she had peritonitis. The baby’s heartbeat was not detectable on ultrasound whereas 24 hours before it had been fine. I interrupted the planned operating schedule and took her straight to theatre for laparotomy and Caesarean section. On opening the abdomen – there was a lot of blood – it looked like a major intra-abdominal haemorrhage. At first I wondered if we had twins on board but in fact the baby was lying in the abdominal cavity but outwith the uterus and with it’s membranes intact. We delivered the baby and puzzled for a few seconds as to what was going on. Then it dawned – the patient had ruptured her uterus. A little more exploration revealed the extent of the problem. The entire front of the lower half of the uterus was wide open, bleeding profusely and so after delivering the placenta, we set about getting control. There was no prospect of putting the uterus back together again so I ended up doing a subtotal hysterectomy. These complicated obstetric cases are pretty difficult.
To cut a long story short, we completed the rest of the list of 10 minor cases* and as I was leaving the hospital I went to see this girl again. She didn’t look great and about an hour later I got a call to return as soon as possible because she was clearly bleeding again. All the signs were that we were not able to keep pace with the loss and she was as pale as an African could possibly be. We took her back for another laparotomy – under ketamine again (unbelievably magic stuff), found a modest bleeder in the right adnexa and an abdominal cavity full of blood. The measured drain and surgical loss was some 3.5 litres! She was on the point of arresting when we managed to get some un-cross- matched blood into her. Two of the missionaries with O negative blood came to the lab and donated 500 mls of fresh blood each and when that went in she began to clot again and turned the corner. By this time it was about 8pm.
I told Kayumbo he could have the rest of the day off! He giggled at that thought, on and off for the next half hour. Eventually I made it to Joey and Kaitlin’s for a cheeseburger, most convivial; sitting around their patio fire under a canopy of magnificent starlight.
What a day!
*Mainly lumps and bumps, biopsies, an epigastric hernia, a cervical polyp, a submandibular gland, a funny granulomatous thing on a finger and a couple of urethral dilatations. Come back Dr McAdam – all is forgiven!
It’s Owen’s birthday – Cake Smash | Friday 14 July
Happily it was a slower day today. Unfortunately almost as soon as I walked past the guard at the hospital door I was told of an emergency in the male ward. An elderly man that we have been looking after for the last 3 weeks collapsed. An airway was established and he was whisked quickly out of the ward and along to theatre; not because he needed surgery, it’s just that all the resuscitation equipment, oxygen, etc. is available there. We did make an attempt at CPR. He had fixed dilated pupils and was asystolic on ECG – no electrical activity from his heart. Breaking such news to a family though an interpreter is not the most pleasant way to start the day. I saw about 2 dozen clinic patients and did a couple of minor procedures before heading for the Cake Smash.
I wrote about Owen last year when he was just born. His mum – a 16 year old girl delivered him in a remote bush village across the river and about 5 hours away on foot from Chitokoloki. Her wee boy was delivered after a prolonged labour but unfortunately she bled. Without any medical help she had little chance of survival and she passed away on an ox cart on the way to hospital. The father, a young destitute boy whose life was focussed on keeping body and soul together by subsisting on whatever he managed to grow was in no position to feed or look after the baby. So, a young American missionary couple, Joey and Kaitlin (he is an aircraft mechanic and all round fixer of everything and anything and she is a nurse) offered to foster this wee fellow. They named him Owen. His natural father was so pleased with this that he was keen that they go ahead and adopt him formally and after a year of due process that has now officially taken place.
Owen is a real wee character. Standing and staggering around holding on to furniture he is nearly walking without help. Today was his birthday and part of the celebration involved a cake smash. Now this is a somewhat foreign concept and having seen it, my view is that it is almost entirely without merit. All the many guests at the afternoon birthday party were offered the kindest of hospitality. All had a mini birthday cake in the form of a very nice homemade cupcake. So far so good. However, the birthday boy took up position in his high chair and an enormous cake (such as would have fed all the guests with plenty left over for the rest of the week) was placed in front of the little boy. He proceeded, tentatively, at first to dig into the heavily iced sponge with his bare hands. After a few minutes the entire cake was well contaminated by baby slobber so anyone who thought they might be offered a slice had certainly lost any appetite or aspiration to share! Nevertheless, he seemed to enjoy his day and was quickly on a major sugar high!
Being more philosophical; what a transformation in his destiny has taken place as a result of the turn of events. He will now have the opportunity of a loving and well equipped home, an education, proper health care, and real opportunities for the future. If his mother had lived – he would be dirt poor, living in squalor and indescribable poverty and exposed to every disease around here. The legacy would be one of a lifetime of chronic illness, without opportunities for education or to fulfil his potential. A real conundrum.
Heading to the airstrip for 8am tomorrow for the flight to Lusaka where I anticipate Emirates will transport me back to a different sort of insanity. Take care.