It's a small world at Chongwe....

  For the second day in a row I find myself on the road and feel ever so fortunate that I am escaping the urban sprawl that is Lusaka! We headed East along the aptly named Great East road. It isn't all that far and it is refreshing how quickly the built up concrete houses and shops and incessant traffic become wider expanses of green fields full of tall grasses hiding the plentiful crops of maize in the fields behind.

We pass little villages hidden under trees and rows of farmers selling neatly arranged mini towers of tomatoes, corn, monkey nuts and mushrooms. Clearly all in season currently. That and the tell tale blackened earth which preceeds the piles of charcoal all neatly packed into white bags ready for purchase.

Tall grasses with maize fields behind outside Lusaka

Upmarket village shop

Bags of charcoal ready for purchase along the road near to Lusaka

We make good time as the traffic is mostly in the opposite direction and get to Chongwe District Hospital, which is easy to find right at the beginning of town. We follow the visting protocol rigidly and set off to find the Medical Superintendent - who, after sitting and waiting for 10 minutes is then discovered not to be in. This means we must now wait as they contact the 'second in command'. She is currently at a meeting and won't be available until 3 hours time. So we are given the go ahead to find and speak to the anaesthetist and then return to see her in retrospect!

  We get to theatres and meet Jackson the clinical anaesthetic officer.  In fact the ONLY anaesthetic officer for the whole hospital of circa 300 beds. He tells me if he is away then all the patients needing operations get diverted to UTH in Lusaka. He is quite a superman though - imagine being on call 24/7 fort eh past FOUR years! We are ushered into his office and I can't help but notice the row of empty Halothane bottles standing on the windowsill edge - very artistic I say. However he is very concerned that I don't interpret this as him only giving general anaesthetics. He stressed that he uses spinal anaesthesia a lot (I have no doubts as he seems incredibly competent) and then shows me the meticulous records that he keeps for each case and how rightfully proud he is that over 60% of his cases are done under spinal anaesthesia. However for me, I think the collection of opaque brown bottles on the windowsill (to prevent breakdown of the contents in direct sunlight into unpleasant substances) is pretty cool!

10 brown bottles sitting on a wall....

Just as we are about to embark on the follow up interview process there is an urgent message .... an emergency caesar (caesarian) for foetal distress. Oh dear he says, "you'll now have to wait at least an hour and a half - is that ok, the surgeons here are very slow!" "No problems", I say,"but actually could we come to theatre with you to see how it runs and give you a hand?" That was indeed well received, so from nowhere myself and my colleague/accompanist Mebby (also a clinical officer in anaesthesia) are whipped up some blues and a hat and shown through to theatre.

Theatre - in the far distance on the wasll a laminated copy of the WHO Surgical checklist. Also in the foreground a resuscitaire in theatre for neonatal life support - unusual. These are usually in a different room out here, but Jackson feels this is better as it means he can help with resuscitation whilst also keeping a close eye on the mother.  

  Much the same as many other Zambian theatres the lady is already in the operating room, lying on the bed shouting with each contraction. She is 39 years of age and this is baby number 8 for her - of which she has 6 children at home. Wowzers, that must be one noisy house!  However, Jackson meticulously goes through his emergency drugs (that he has already prepared) and places the monitoring on the patient with the aid of the theatre porter/assistant. Once he has placed an intravenous cannula and attached fluids he is now content with the situation and asks the surgeon to carry out the WHO Surgical checklist. She does this fairly quickly by taking the laminated copy off the wall and reads through it. It seems quite fluid which makes me really believe that this is pretty standard for Chongwe. Fantastic! Once the checklist is complete Jackson asks us all to take a minute and pray. I was a little taken aback I have to be honest. It is the very first time I have ever witnessed or been part of a prayer being said out aloud in theatre as a part of the checklist. But everybody (including the patient) seems to think this was a logical step and so a quick 5 minute prayer and blessing by Jackson ended the checklist and put his mind into the frame for a spinal.

Surgeon conducting the checklist whilst the midwife (back) attends the patient on the bed. Jackson the anaesthetist listens intently and there are students at the foot of the bed.

Well, the prayer must have done wonders  (or maybe it was the gospel music in the background) as the woman is moving around the bed like a whirling dervish but Jackson darts in the spinal in double quick time (with a proper spinal needle - not a cannula) and before the blink of an eye we have an anaesthetised patient who, despite the table not tilting as its broken being wedged to the left with the placement of a few bags of fluid. The anaesthetic block is satisfactory and the surgeons begin. Soon the baby is extracted. There is no sound as she is carried to the resuscitare. I walk across to observe the midwife who is busily drying and rubbng the baby in a clean warm towel and with that the baby starts to wail. Good strong healthy lungs! A healthy little girl to go home with Mum to join her 4 sisters and 2 brothers. The causative agent for the distressed baby and slow heart rate is soon found when the cord is cut. A knot in the umbilical cord. A lucky baby that she got to theatre quickly. 

Knotted umbilical cord

Theatre porter recording vital signs for the patient as Jackson
 prepares some antibiotics and oxytocin
(hormone to contract the womb)

 As we get to the end of the case  (which has been long as they were tying off the tubes too). Jackson is now busying himself with drawing up further drugs. I go over to investigate what he is planning. He informs me that he is preparing to place a TAP Block (transversus abdominus plane block - essentially a nerve block in the side of the abdomen that targets nerves that cause pain in the area of the operation). This is commonly used in the UK after Caesarians though usually with ultrasound (though using anatomical landmarks is also common). However to do so you require a regular supply of plain Bupivicaine (local anaesthetic). This has been a real stumbling block during my whole time here at UTH and also elsewhere as it seems that it is very difficult to get onto a hospital ordering system for some unknown reason. On further delving into how he has some in Chongwe he tells me its donated. In fact a team from Mothers of Africa (a Cardiff based charity) come out at least twice a year. More details of Mothers of Africa here:
http://medicine.cf.ac.uk/mothers-africa/

Jackson keeps all the donations of Bupivicaine so that he can do either TAP blocks or some other specialised blocks such as axillary blocks for arms. He is now on his last 4 vials (2 left after this case) so he is very relieved to tell me that the Cardiff team are on their way to visit next week and also as he has run out of the Ephedrine that they also have brought him and taught him how to use, he is now currently using adrenaline like everybody else in Zambia!  Now I know that Mothers of Africa come to visit as a friend of mine, Dr Cerys Richards went to Chongwe not long after I had returned to the UK in Feb 2014. I recall her telling me that she had taught Jackson the merits of putting in the TAP blocks post operatively. However he told me himself that he was eternally grateful as in his own experience he notices that those patients that do have the block are ambulatory far quicker and get discharged home sooner than those that do not.  Interesting to hear this statement of observation  from Jackson (despite knowing it's true myself). My colleague Mebby was very interested in the block having neither witnessed or heard of it. What happened next was amazing.
   I witnessed Jackson talking and teaching the purpose and procedure of the block along with the anatomy (and marking it correctly on the patient with a red marker pen). He has clearly done a lot of his own reading up on the block also. He then proceeds to show and teach Mebby how to do the block and allows her to do the other side. I am watching quietly and completely impressed by the lack of me having to step in or help out such was his correctness and confidence in the subject. A truly wonderful event to witness. It just goes to show that education can truly give others the tools to improve healthcare themselves. Mebby was overjoyed to have learnt this new technique and very thankful for the unexpected opportunity. Its a shame that the lack of pharmaceutical supplies will be the rate limiting factor on her using it in the future as it stands.

Mural on the hospital wall from Rumney Primary School

After the theatre duties were complete we reported back to the medical superintendent's office, several hours after we first came! Whilst waiting to meet the deputy I spied a mural up o nthe wall and could see it was actually a peice of artwork created by children from Rumney primary School, Cardiff - it really is a small world after all!