University Teaching Hospital

Moli bwnaje!

So here I am, back at UTH (University Teaching Hospital).  It’s a strange feeling to explain. I am so excited and so pleased to be back and seeing old faces and friends again. It’s all seemed pretty positive (on the welcome back front at least!) so that’s a big relief!

Main entrance to UTH and below inside main entrance looking at the canteen 

 Just to get you all up to speed: UTH is the largest hospital in Zambia.  It not only serves the Lusaka area (estimated population of 1.4million), but is a referral centre for the rest of the country.  It officially has 1655 beds and 250 baby cots (floor mattresses are strictly not counted in these stats). It also serves as a tertiary referral centre for most of the surgical sub-specialties and has a 10 bedded intensive care unit.

Green inner courtyard and corridor
behind trees

It was originally built in the 1960’s and is actually quite an interesting looking building. I, for one really like the red brick part as it has uncovered sides to the walkway so essentially you are outside in the fresh air when you move about – which is great and the various trees and grass that are dotted about give it quite an airy feel. There’s two reasons that’s a plus; firstly when walking along in the morning it is quite possible not only to break one’s neck or fall flat on your bottom due to the floors being shone to an inch of their lives by all sorts of cleaners using a very distinctive polish called COBRA but also to become completely and utterly high on its distinctive smell. Fair play I have never walked on cleaner floors (outside the wards) or tread on more slippery surfaces apart from in the Cardiff ice rink! 

The second reason is that there are a few stairwells that lead from the main entrance to the the ICU corridor and also the ‘canteen’ which if you descend further down take you to the mortuary. It is often beyond description the smell of death that floats up readily from the basement up the stairs. This is particularly bad by the afternoon and also when its hot. So yes, the airy outdoor corridors are a real bonus for me here. As well as the often colourful glimpses of chitengi dress material out on the washing lines/drying on the grass.

 

 However don’t be deceived by the appearance! Not all that glitters is gold. Internally there are huge problems. Maintenance and upkeep seem to have gone missing since the 1960’s and there seems to be a patch up job on top of a patch up job wherever you look! Basic resources like water run out at times (though not so problematic right now in the rainy season!) and surgeons rely on water butts to store water to wash their hands when it is summer and the electricity is unreliable. But that’s by the by to be honest, one can find ways around those problems. 

Water butt for surgical hand washing -
note also the 'disinfectant soap'

However what’s interesting to me is that when I was last here the oxygen plant was being heavily upgraded. They have huge oxygen concentrators (basically clever machines that take the air we breathe filter it through various steps and churn out pure-ish oxygen at the end). Fantastic – just the ticket here where consumables and resources are poor. When I was last here they were sending this ‘pure’ oxygen down the various oxygen pipes to theatres where they were then plugged into the anaesthetic machines for us to deliver anaesthetics. However when I was last here the pipes were so old, leaky and in such poor repair that the pressure in the system was such that by the time you got to the upper end of the corridors to maternity, paediatric theatres as well as sometimes main and the intensive care unit the pressure in the wall pipes was about half of what it should be. 

Basically in simple physics we need 4 bar pressure (4 x atmospheric pressure) to come out of the wall. The anaesthetic machines start alarming in a loud pitched manner constantly when it falls below 2 bar – which was what we got in the theatres on a good day when I was last here. It seems now, however that the pipes have ‘had it’ so we now run all the theatres and intensive care unit and wherever else needs oxygen off large cylinders. Fear not they are still filled up by the new shiny oxygen plant concentrators so that would seem like a reasonable substitution. This unfortunately leads to two big problems: –

Broken pressure dial. On the plus we have plenty of
oxygen left in the cylinder!

Firstly you have to constantly keep checking the cylinders to make sure you are not going to run out and that you call for a new one in time to change over. The second is that the cylinders (which are Chinese) have pressure gauges on them and instead of the usual bar they are in mega pascals and not the usual kilopascals (1 atoms = 1 bar = 100kPa) if their dials work that is. The danger here (and I have only been here two days and have already raised my eyebrows and changed the settings a few times – if the pressure dial isn’t attended to properly and decreased accordingly then the pressure delivered to the patient is colossal and much like pumping a large amount of pressure into a balloon you can imagine what happens next to the balloon or lungs… eek!

 And to throw in a third for good measure, we have been assigned 20 new anaesthetic machines  (though we only seem to have two at present and one has already broken) – delivered from China – picked out by a hospital matron and Surgical Director with no discussion with any anaesthetist…. But I won't go on about the failings of this particular system or make but suffice to say it has a special anaesthetic tool called an Oxygen analyser attached to it. It is a small little fuel cell that detects the concentration of oxygen in the supply – essentially a little quality control test. Interestingly, these lose their powers of deduction over time as the fuel cells get old. Anyway these are brand spanking new. They are detecting the oxygen concentration correctly. Each cylinder that comes from the oxygen plant is meant to be close to 100% oxygen. When all else fails and the patient has low oxygen you give them 100% oxygen, it’s the back up (well and only solution here as we don’t have any other gas (no air or nitrous oxide to give anyway). However thanks to the new machine we have now removed that aura of security blanket of 100% Oxygen. No cylinder has yet to supply more than 56% oxygen… Oh dear…. 

On the plus side – the machine does come with Isoflurane (anaesthetic vapour agent) vaporisors and we currently HAVE a supply of Isoflurane to use as well as Halothane (another older agent). HOW exciting, yes I know its almost obsolete in the UK but the knock on effects here are amazing – especially in those patients who have liver failure or repeat anaesthetics (Halothane is bad for the liver).

 And as I have heavily harped on about the subject of physics and anaesthetics I throw in a last little gem of a picture for the gas board amongst you. Here is an anaesthetic machine I spied on my return. It is not being used (at present!) but was brought down to us for use during the centenary celebrations. Yes that is Ether and Cyclopropane on the back bar! Its so amazing I’d love to bring it home, but fear the excess baggage cost would exceed a box of Suggamadex!

Boyle's machine with Halothane, Ether and Cyclopropane

So this has turned into a bit of a anaesthetic heavy post – apologies for that! But it gives a bit of a flavor of some of the challenges anaesthetics face out here. Hopefully a few clinical caveats to come!

Hello Zambia!

When I first heard I was flying with Ethiopian airlines I had a few images conjour up in my brain - and not many were that positive. However on arriving in Terminal 2 LHR I was impressed to realise that they are a part of the star alliance group, so maybe not all that shoddy after all. I killed an hour or two wandering round aimlessly with everybody else in the duty free before settling down to read my book until the gate opened. Thankfully I was flying to Africa, as the replica London Taxi looked a bit too breezy for me!

Once I got onboard I managed to stay awake for long enough to see the lights of London pale away before heading off to a deep sleep. That's the beauty of working 5 night shifts in a row - the ultimate plane sleep strategy! Landing in Addis Ababba for 3 hours was interersting in that there were lots of beautiful mountains to see on descent and they also had state of the art Ebola testing on the way in. Basically temperature measurements for all passengers.

On the deck in Ethipoia

Ebola check

 Then it was re-board the flight and a quick 3 and a half hours later (well it was quick for me as I was still asleep when we landed!) I'm back in Zambia. A beautifully hot, sunny day to welcome me back to the home of Vic falls!

Inevitably there was the recall that the word queuing means mass scrumaging in Zambia and isn't widely understood. Being Welsh and a dab hand at getting served at the bar during the 6 Nations this was not much of an obstacle and then I breezed through security on the strength of my old work permit and a little bit of broken Nyanga chat, dredged up from the back of my mind. I must work on getting it up to scratch asap though. 

Mike the taxi driver filled me in on the election shenanigans by virtually yelling at me on the car journey - this was basically as the radio reading the constituency and media reports were full blast. And this was not in isolation, every car seems to be tuned in to the news here. And it was actually interesting to hear people speak passionately about politics (as well as corruption and personal gains!) It was refereshing to hear the way the media questions were answered by all parties and the electoral commission - who to be fair have had a difficult job with the huge rainfall keeping people at bay, disrupting getting the ballot papers to the correct places etc. So it sounds like only 1m of 5m have actually been able to vote - but that was partly due to them running the election on the people registered 5 years ago. Apparently there are people in their early 20's that arent allowed to vote as they were underage at the last one! Crazy! Inveitably there will be a new president as of circa 18.00. Lets hope it doesn't all kick off then! It seems unlikely as Zambia has been stable for 50 years and is full of level headed people. However I have bought some essential supplies if there is to be lockdown.... a pint of milk, some bread and some Mosi - so I should survive for the next fortnight!

Bye bye Cardiff!

Well, here it is at last - the start of another adventure!

 It's been a bit frantic over the past fortnight with lots going on at work, quite a few busy night shifts done and trying to get stuff organised in the day. Eventually something had to escape the organisational blitz ... the car's imminent MOT expiry date for example was a lucky discovery, and I am deeply indebted to Sarah and Emma for sorting that out for me whilst I sit down on a plane to Africa!!!

  But the packing is now finally done: passport - check, toothbrush - check, credit card - check!!!

With my standard packing requirements complete I added another essential for Zambia though: antimalarials. Its rainy season out there which means loads of puddles which are just the ticket for mosquito's to breed plentifully. I am unfortunately very tasty to them too - bah! Which is not good news as the blighters out there are carriers of Falciparum - the worst type of malaria (if there is a worst type) to get. So I am not taking any chances!

So on my walk down to the chemist to pick up the 100 Doxycycline tablets I couldn't help but enjoy the beautiful crisp winter's air and the amazing sight of Cardiff Bay.

Penarth and the barrage from across the Bay 

Pierhead building and the Armadillo (Wales Millennium Centre)

I will certainly miss the 'diff and the sight of the sea (travelling to a landlocked country) but I'm sure Zambia will throw up its own amazing sights and spectacles for me. So for now its bye bye Cardiff, see you soon!

A right circus act!

 Roll up roll up.... Monday the 12th of January 2015

The date of the Final ARCP (an acronym for Annual Review of Competence Progression) - or maybe whilst in the process it feels a bit more like: Anaesthetic Registrar's Circus Performance

It is basically checking you reach the right standard every year on the training scheme until you get to the final one... where they check that you are ready to finish and get your ticket a.k.a CCT (certificate of completion of training). So each year you produce a small rainforest of paperwork (see I am old - I was pre this electronic malarkey) that proves you've done enough clinical cases, managerial, education and research stuff. It is what has to happen to progress from one year to the next and is the source of much frantic running around in May and June usually. The 6 month's stint in Zambia pushed mine to the rather unfamiliar territory of January this year though.

  So this process started 7 and a half years ago for me when I embarked on anaesthetic training in 2007 and initially it felt like:

Then it felt a bit more like this:

Then further years became a little more tricky...

And then it all got a bit serious and grown up, but...

Basically it turns out it's a bit of a balancing act between working really hard, ticking off all the paperwork boxes and walking a tight line without looking too much like a clown! Easier said than done (the clown bit that is!)


And then... it all happens... the holy grail of medical training: The CCT, the golden ticket, the key to the future. Or essentially being ejected off the training scheme into the big wide world but now with a certificate that says you CAN do it!!

So there it is. I am finally getting kicked out of the realms of being a 'Trainee" as of the 28th of January. It is a wierd thing to think about. 14 and a half years of training has amounted to this piece of paper and a hefty payment cheque to the General Medical Council to make it official.

But to me it is so much more than a piece of paper. It is a culmination of hard graft over 15 years that has seen me move up the ranks as an apprentice in the amazing worlds of surgery first and then anaesthesia. Its been an amazing 15 years and though this is the end of the chapter - or maybe the book of Lowri's training  it is the start of Lowri's training volume 2... and how exciting is that... a whole new book of blank pages, just waiting for me to fill them. 

 
Can't wait to see what fun I have doing that - starting with Zambia and then Great Ormond Street!

  But meanwhile, after returning to work after ticking off the box at the ARCP I was quickly levelled back down to earth with a fair few emergencies. Felt a bit like being thrown into the big top at the trapeze and desperately trying to hold on to the flying artiste.

One was a pretty awful and very very sad case; one was pretty awful but miraculously had an amazing outcome and there were quite a few in the middle of all of these that were equally as important to those involved but slightly less high octane, adrenaline pumping than the rest! And yes, its a tough job at times, and we deal with tough things, but what I didn't expect to affect me was the following thursday (now known as favourite Thursday!!!!) when I turned up to work and found a note and a bunch of cakes ... for me.... Totally blown away. I work with amazing people and I am eternally grateful for that.

Not all who wander are lost

The Hobbit (JRR Tolkien) is quite possibly the first adventure 'travel book' that I ever read. It is also apt that he came up with this quote which seems to fit in with my psyche. It suddenly struck me that Tolkien's Hobbit and Lord of the Rings has some marked similarities to Zambia.

In keeping with the theme of Lord of the Rings and middle earth it is pretty uncanny that Zambia sits very much in the middle of the world being in the South East part of Africa. And it is a vast country being over 5 times geographically the size of the UK but has only around 14m population.

They have one of the natural wonders of the world in Victoria Falls (Mosi-o-ai-tunai) which is by far, in my opinion, more superior to that of Rivendell (the Elven outpost in Lord of the Rings)

Rivendell and the mighty Mosi-o-ai-Tunai (the Smoke that thunders) below

Smaug and the Orcs are out muscled by some of these amazing wildlife dotted around in the various areas of protected wildlife natural parks. Some of which are actually larger than Wales or Belgium in size!

                        

                          

Gandalf the wise, and widely travelled wizard draws parallel comparisons with David Livingstone - though magic powers might have helped him complete his final quest to discover the source of the Nile. The magic powers of Chief Chitambo nearby, however is pretty well known about and sought locally!

But not everybody lives in a palace.... in fact most Zambians, especially in the rural areas live on under a dollar a day.

Rural Life: picture from Rebecca McEvoy

So I feel a bit like Bilbo Baggins at the minute holed up in my Cardiff flat before nights, thinking about my quest to come and what interesting adventures and undoubtedly tough situations I have ahead. Although I am old I have not yet reached the 111 years that Bilbo hit for his birthday but I am sadly older than Frodo when he started his travels. So I feel it is right to leave the comparisons there, especially as I am about to embark on packing... I fear that the book, sword, hooded cloak and coat will not be sufficient for my travels!

Heading South again!

Hello! 

This is me, Lowri wearing my work clothes and trying to look as professional as possible on the outside, whilst inwardly plotting an overseas visit! 

I was fortunate enough to spend a fantastic 6 months in Lusaka, Zambia as a part of the Zambian Anaesthetic Development Project which taught me so much about international health and probably far more about myself than I thought possible in August 2013 to Feb 2014. See the following links of a previous blog entry for further details:

http://thetblogging.blogspot.co.uk/2013/10/anaesthesia-trainee-in-zambia-volunteer.html

http://thetblogging.blogspot.co.uk/2013/12/anaesthesia-training-in-zambia.html

 Since then I have certainly gained in my everyday work practises and have been itching to get back to spend some time in Zambia....

And so.... Over the Christmas period I put up my decorations... I mean, what Christmas tree doesn't need a hippo and an elephant....

Christmas Tree in Cardiff

...and then went to get further enlightenment (and quality family time) in Lapland - taking in the phenomenal Aurora Borealis and getting photobombed by a Reindeer in my quest to ask Father Christmas for some help in the matter of travelling to Zambia

Aurora Borealis to see in the New Year

Rudolph getting up close and personal

Luckily for me Santa dropped by with a few necessary books: a travel guide, passport and a work permit. And so it seems that getting there was sorted, now I need to sort out something to do!

And, luckily for me, there have been a few offers on the table for different things. I'm really excited to get back to do some teaching and clinical work at the University Teaching Hospital, Lusaka - where I spent my 6 months and joining up with old friends especially Dr David Snell all of which is supported by THET (Tropical Health Education Trust) who without their support, we would never have been able to run the MMed programme or provide such good teaching for the trainees. As well as that I will be doing an new exciting project to go round Zambia collecting follow-up information from over 60 delegates who came on two courses that I was a part of teaching on whilst I was there previously, namely: LIFEBOX(http://www.lifebox.org) and SAFE OBSTETRICS. This will allow vital information to how the teaching of the courses went, the long term effect of the courses on healthcare as well as give us feedback on how to improve the courses in the future. Its also hoped that it will be a vital time to spread the word about anaesthesia as a specialty and enthuse and hopefully recruit some other doctors into the training programme.

 So.... watch this space for more updates as I get more organised. I'll fill you in on the background as I get going. However I just wanted to stress that the contents of this blog is certainly all my own thoughts and they will represent no official organisational stance - just in case anybody gets offended!