mobile and mwela caves

Our follow up in Kassama was delayed by waiting for the anaesthetist to turn up again. However there was a rather loudly blaring TV in the corner of the reception area which as I settled in to watch a bit of the news decided to highlight some of the sports news (perfect). Even better still they then showed about 15 minutes footage of the netball league that had started that weekend. It seems to be a large affair and I was a bit gutted that it's only started as I am leaving as I would certainly have loved to have gone and tried out for a side... and looking at the skills I think there would have been some sort of niche for me. Great to see minority sports and female sports getting decent coverage out here though.

Green buffalo's playing another Lusaka team in the netball on national TV

However we were there to assess a follow up and after doing so we had a look around the theatre areas too. It was a little shocking - even I have to admit that their storage rooms were very untidy to the extreme that I think were rendered unfunctionable! I hope it wasnt an indication of the general disorganisation of the department! Its probably why there was a preying mantis wandering around - plenty of feeding oporuntities for him!

Storeroom chaos

Preying mantis

 Once we finished the one anaesthetic follow-up we learnt the second one was actually out in the field on a 'mobile theatre clinic week'. It seems that this wasn't as far away as all that so after a phonecall it was confirmed that we could go there and interview him also. We leapt in the car and drove Eastwards towards the royal palace of the Bemba people I'm told and there, in the middle of a school playing field was the whole M*SH set up. I will be honest it was very impressive. Having seen the (very expensive Chinese made) trucs in Chipata (Eastern province) I hadn't seen them all assembled. Victor, the anaesthetist was adamant that I should have a good look at the whole set up as I hadn't been to a field hospital before. I was actually very keen to do so!

Lorries set up in the field hospital

FIeld hospital in full flow

  The trucks were aligned as they each opened up to house not only a theatre but a laboratory and also pharmacy and dental area. There was a big tent between them which functioned as an out patients department where people came with their ailments and were assessed and then treated as needed. There were another three tents - one for female cancer screening, one for male circumscisions and one for recovery. There were loads of people milling around, sitting on the ground and standing in queues. This was likely to be the first healthcare, many of them had accessed for several years.

Queues outside waiting for assessment and potentially treatment

Main tent for assessment/outpatients

Way in to the theatre (truck) from out patient area

We walked up from the main tent and up to the stairs marked theatres (with Chinese inscription above this!). The first thing we saw though was a fully kitted out dental area. A brand new chair, pristine burrs (drills) and various other quipments. I was suitably impressed - maybe a quick scale and polish?! The dental assistant (well that's what he was called - not so sure how much training he'd had) told me the only thing that he offered was extractions... old or young....

We head to the right and then 'enter' the 'main theatre'.... Wow! They had a machine that was fully functioning and oxygen cylinders and in fact had everything you'd need to deliver a safe anaesthetic (was tempted to ask them to drive to Lwingu and set up there permanently!) However as usual, scrape a little under the surface and there is less gloss. The table actually still had blood splattered all over it (I can only assume it was yesterday's blood as they hadn't started that morning's work yet, but I cant be sure how long it had been there).In fact there was rubbish and bits of dirty gauze and even a sharp on the floor. Not so great really. The curtain was there for two reasons - it was to stop the crowd of people outside the truck from peering in and secondly to act as a barrier between the main and second theatre. Second theatre I ask? Oh yes there were so many cases it was faster to have two theatres running than one... I understand the concept of time management but was a little lost with regards equipment and space. 

"Main theatre"

No problem! They found an additional table from the school and brought that in behind the curtain. Trouble is that it was too short for the surgeons to operate  so they improvise (McGuivor medicine as its affectionately know here!) and put it up on four breeze blocks. Crikey! If the fact they only had one machine and monitroing for two 'theatres' was also concerning - its the old adage of using ketamine and allowing the patient to breathe themselves or performing spinal anaesthesia where they dont need a machine. Though I cannot condone no monitoring in this day and age. I ask about the pulse oximeter - ah yes that would have been a good idea says Victor rather than leaving them locked up in the hopsital in Kassama (well at elast they weren't in the storeroom otherwise we'd never have found them ever again!)

McGuivor solutions

When I asked what scope of procedures they carry out in the mobile hospitals I was rather expecting some lumps and bumps and maybe hernias. Yes, the do all of those but also even thyroidectomies and caesarians - whatever's needed. Rather shocked I ask about the availability of blood... oh there isn't any (mind you  thats not much different to being in the hospital if truth be told!) My big concern was the postoperative management of the patients and also pain relief. Again - "most don't need pain relief". I think the difference between not needing and not asking for is rather different. Especially if you've had a caesarian. As we are about to leave the lorry it then strikes me that we have to descend some steep stairs. Dear me, I think, how do they get patients down these stairs when they are awoken from their operation to get to the recovery tent. That is of course very simple it turns out. They employ some local men who manhandle (I mean carry) these patients down the stairs and then dump them on an unmonitored bed in recovery until they are awake enough to walk back to the village they'd arrived from - even if they'd had a spinal anaesthetic. There are times when words fail me!
  

Stairs down from theatre to ground level!

I thank Victor for his tour and also for taking the time to answer the questions. No problems he says he rather enjoyed the attention. I on the other hand found it really wierd to have all these faces pressed againt one of the tent windows to watch us as we were conducting not only the interview but also the skills set up with the mannequin. The neonatal resuscitation scenario resulted in large hand claps and cheers from the nosy onlookers!

Resuscitation dummy in the field tent!

Once we finished we headed back to the car and en route back to Kassama we stopped at another interesting cultural sight: Mwela cave paintings. The car park alerted us to the local wildlife threats... which after actually seeing a 'so-called' wasp in my opinion was fully justified! Eek!

Large wasp!

We waited around for ages as there was nobody at the entrance and there were no further signs of where to go apart from the no tresspassing ones! Eventually, after loud horn blaring the guide turns up out of the nearby huts! They don't get that many visitors (despite it being a UNESCO heritage site) which is a shame as he is incredibly knowledgable. We walk up the hill to where a seemingly unimportant outcrop of rocks appeared in the undergrowth - much like many of the other rocks strewn around. However this is an old bushman cave dwelling and he shows us various areas that it was thought they had slept and ate and sheltered. There were no paintings in this cave but he went on to say that they had currently discovered over 1,700 painting 'panel' and were still discovering more and took us scrambling up through the cave onto a plateau to view the rocks in the near vicinity - it all became clear why they hadn't extensively found all of them by now! There were thousands of rocks and dense scrub surrounding them. No wonder it is the sight of the densest collection of late stone age paintings in the whole of Africa and is therefore an incredibly important site.

The expanse housing the 'as yet not discovered paintings'

Scrambling down the rock face and into the grass to get to the paintings

After a bit more scrambling over rocks we see the first panel. Apparently there are different types of paintings. They are mainly schematic types of paintings (so I'm told!). The colours were made from natural pigments or egg yolks or blood mixed with saliva and the paintings were often under an outcrop of rock which is one reason as to why they've survived so well. It is amazing to see such prehistoric art that depicts the heritage, intellect and cultures of our ancestors still so untouched and in such good condition. And so close!

Our guide showing us a schematic diagram of a likely warthog being hunted by men

Close up of the warthog and the 'hunters'

Scrambling through a cave opening to see a male fertility painting

Depiction of a female and a tortoise (black spider like structure) and a lizard depicting female fertility... he'd lost me a bit here! Didn't quite follow the significance of lizards and tortoises!

Close up of above painting with the female holding the lizard.. .Apparently. Surrounded bu the finger prints of the artist.

Absent health and safety in Northern Territory

   Northen Territory!

 At long last I'd got to a more rural and 'Zambian' feel after the industrial Copperbelt. The transition through Congo had served as a bit of a watershed as I noticed more and more the houses here were so very different from the rest of the country. These houses are all square and made from mud bricks but are often brightly daubed with various natural pigments to add colour. It made staring out of the window for vast distances an extremely pleasant experience. 

What was noticeable to me was that this was a far more agricultural area but each hut seemed to have a certain amount of land to farm next to it and wasn't the usual collection of huts forming a village. Often each hut would have a small patch of maize growing next to them - a throwback to the good life I'm sure.

Colourful hut decorations

But in keeping with rural life I saw many waterpumps and people gathered around filling their large plastic containers with water before balancing them deftly on their heads and trudging back to who knows how far away. The strength of these (mainly women and children) in walking with that weight on their heads for what looked to be miles as well as the amazing balance is really a sobering thought when I run the tap to brush my teeth. Others had sensibly found a water tap outside the hospital out patient department and were filling up from there. A relief to see that they were making attempts to use clean water becuase the nurmous rivers we crossed en route seemed like the place where all the clothes and dishes were washed (as well as providing a great place to play for children and cattle to drink!)

Walking back to the village with water containers filled

Using the hospital water supply to fill up

Washing clothes and dishes in the river

By now the road was pretty poor - dirt track with often large ruts which made me think how difficult it is for anybody not in a 4WD to get back and forth to hospital in a hurry especially in the wet season. I was pretty thankful I didn't have any broken bones or pain or loose teeth as we bounced along for 4 hours. And they do have a considerable amount of rain here judging by the extreme lush green vegetation I could see at the roadside.

Beautiful lush green grass alongside the road

Bone shaking, teeth crunching dirt road....

Bad picture but worse road with massive ruts

We were travelling from Mansa to Lwingu which is a small town midway across the Northen Province. It is quite likely to be the most remote place I'd been to for a while.  We eventually arrived at the small hospital cut into the mountainous terrain. It seemed only to have three buildings. We had the inevitable wait for the anaesthetist to come to the hospital (protocol dictates you don't ring in advance of arrival that day but turn up and then ring to announce your arrival!). So whilst he was brought to the hospital by a friend I had a look around.  It is true to say  the longer I walked around the worse the sense of the 'Land that time forgot' became. There were numerous ministry of health and malaria control programme vehicles strewn around minus their wheels, rusting quietly in this unlikely scrap heap. There were piles of motorbikes - formerly used for outreach clinics almost camoflagued with the grass that had penetrated every aspects of their broken motors.

I thought it was only in Merthyr hospital this still happened. 

This was on the day of "Super Saturday" in the six nations rugby tournament also. I had no signal so missed most of the tension. However it seems rather tongue in cheek that whilst staring at these derelict vehicles the wheels were actually coming off the chariots in Twickenham too!

Derelict motorbikes

And if I thought the omens were bad from the outside maintenance then the inside was going to be a complete eye opener. The anaesthetist had now turned up and looked about 12 years of age, annoyingly he is actually a year older than me but was at least a foot shorter and wearing an Argentinian football top. We start off well with him instantly asking me if I knew Gareth Bale or Ryan Giggs on finding out I'm Welsh! The tour around the hospital however was eye-opening and also very sad. I didn't quite believe a place like this would house one theatre let alone two. The first theatre I saw is below. For a minute it looks very basic and antiquated (table) but at least it looks clean.

Main theatre Lwingu

I have this nagging feeling that something is missing. It then dawns on me - there is NO anaesthetic machine. There is however an oxygen concentrator (a machine that makes oxygen from the air - which turns out to be the only one in the hospital so if its being used on a ward there is NO oxygen in theatre...). The only monitor they have is the Lifebox and they share the blood pressure monitor with the labour ward. I enquire as to where the machine is. Maybe it's in the other theatre - they often have to share, maybe it's being maintained.... wishful thinking! There isn't one. None, nada, niet, nil, kolibe, dim.

Theatare two: even more basic

Most anaesthetics are done here under ketamine so they breathe for themselves to negate the need for an anaesthetic machine. If the concentrator is around he straps and oxygen mask to their face. This is desperate as they also do caesarian sections here. Pregnant women are very likely to aspirate stomach contents which is why if they have a general anaesthetic and they should be intubated and placed on a ventilator. I enquire as to how many aspirations he has seen - he reckons only a few. I wonder why he doesn't do them under spinal anaesthetise - better for many other reasons. Plain and simple - he barely ever has Bupivicaine (the local anaesthetic) to do them. It makes me very cross that he has to work and suffer under these conditions. He is a bright and good anaesthetist when I chat to him and he has made several requests to the hospital and medical directors at the province to get a machine - but this has fallen on deaf ears....

  Well, rest assured on our way back from our trip a few days later we called in the provincial medical office and spoke to the provincial medical officer where I relayed my utter disbelief and real fears and concerns about the likely mortalities that would be directly caused from this serious omission. I told him I thought the poor anaesthetist was not only operating with his hands tied behind his back but was actually being blindfolded as he didn't have the drugs to deliver alternative safer techniques. It's not on.  It's not fair. They received the message loud and clear! I was assured that they look at this procurement as a priority. And I am pleased to say that having returned to Lusaka, Wisdom has sourced an old, disused anaesthetic machine at UTH and the province are sending a truck to pick it up on Saturday if at least only as a temporary measure. If nothing else on this trip I hope this will at least make the lives of the people of Lwingu safer bearing in mind the large catchment area and the atrocious state of the roads that people needed to travel to get there. Though at present I'm not sure they're getting a good deal!

After such a shocking experience we needed cheering up and luckily enough as we approached Kassama we turned off to view the beautiful Chishimba falls. In fact it's a conglomerate of three separate waterfalls. The first was almost jurassic in appearance.

The second a series of beautiful rapids cascading along

The second was a series of fantastic rapids before we set eyes on the 20ft drop that is the main Chishimba falls. My absolute favourite thing about these falls is that they are one of probably ten different waterfalls dotted around Northern province that are just not visited by the usual tourist as they are so far away and not well marketed compared with Mosi oa Tunya. However some of them are just as breath-taking and also completely devoid of other people!

Main Chishimba falls 

Overlooking the 20ft drop

View down the valley

 My other favourite thing was the complete lack of health and safety! It is so refreshing to actually be able to walk up to and see things without being constrained by fences and barriers.  Mind you having come from Lwingu with no regard to health or patient safety maybe it's a theme.... Though I'm not sure Wisdom would agree as he was having a minor heart attack as I stood on the edge of the top of Chishimba. Patrick (the driver) on the other hand was killing himself laughing - from a safe distance and videoing the whole thing! Maybe he was hoping I'd topple over so he could redeem the footage for "You've been framed!"

Health and safety?!

Kitwe and Congo

Kitwe is certainly a totally different vibe to Ndola. Although Ndola is the provincial captial it has a laid back airy, leafy feel. Kitwe is certainly a big urban town that has copper mining right at its heart. The day started as usual with a trip to the hospital. This is now called Kabwe District Hospital but formerly was known as Kitwe Mine Hospital. It was taken over by the government a fair few years ago now and things have certainly become a little more run down since then. It's a sizable hospital and interestingly the theatres and ICU are actually on the third floor - dependent on a lift. Only one of them was working when we got there (though we used the stairs!) I dread to think what happens when the second breaks down and people on trolleys need to be operated on....

View from the window in theatre across to the copper mine

It is interesting to me on my travels around a few of these old mine hospitals that at some stage they had access to a far larger spread of drugs that most which include muscle relaxants that have a fast or medium offset such as Vecuronium or Atracurium instead of Pancuronium which is universally found in Zambia. Some of them even had Ephedrine ( drug used for increasing low blood pressure - used like water in the UK but restricted here due to a misguided assumption that it is a drug of abuse). You can see that they previously also had decent equipment.

Previously modern monitor - now more antiquated than my TV at home

 which has among other things been called retro!

The once decent theatre table is now full of rust

They even had oxygen in pipes not just in cylinders so that you can plug the pipes into the main supply so to speak.... Well they worked in the past! Now they are reliant on cylinders as the pipelines are so old and unmaintained they leak too much and the pressure is too low!

I got very excited as we passed by a room and saw an image intensifier (basically an x-ray machine - in the shape of a C that can be used during operations to help check and set fractures better and quicker), However on further enquiry it was broken. The anaesthetist though was pleased I'd noticed it as it was being stored (?why) in the third anaesthetic theatre. The picture below depicts what I saw. As I looked closer I could see the blue mattress cover on the thetare bed and under the window was an antiquated machine. There was no oxygen cylinder or monitoring. I enquired as to really what happened in there - he told me proudly that they carried out all the fracture re-alignments there under ketamine. I tried not to be rude when I enquire again HOW exactly they oxygenate and monitor their patients if there is no monitor and there is no cylinder.  Ah, well there is no need for oxygen they are quick procedures and anyway the machine is broken so we just let them breathe on air. There hasn't been a problem yet. YET.....

The "third" theatre

We then continued with our trip around the various old mining hospitals passing plenty of slag heaps, industrial lorries and of course the mines themselves! We conducted a few more follow ups in each old mining hospital - a very busy day it turns out before we ended up at a Mufulira at 17.00.

An apparently Dangerous lorry!

Lorries tipping their contents

Another 'positive' slogan seen on the industrial belt. If the sky isn't the limit then I'm unsure of what actually is!

View literally across the road from Nchanga North Hospital

Mufulira had a different feel to it - a far more relaxed affair and green! And basically less metalwork around! The hospital was set in some decent grounds and had the seemingly obligatory plastic safari animals to adorn the front entrances!

Ronald Ross with grazing zebra and fish eagle!

 However we didn't have much time to enjoy the peaceful surrounds as we were in a bit of a hurry! Looking at the map for the rest of the journey we realised we had two options once we finished here. We either turned around and drove back to Kapiri Mposhi to the branching off of the Great North Road and then travelling to Mansa - some 700km at least in the dark or we drive through the pedicle (this is the area of the Congo that seems to stretch in to Zambia rather inconveniently separating an easy passage to the North! I'd raised this as a possibility a few times during the preceeding weeks as there is a road that runs through it connecting both sides. It had been turned down with flat no's on every occasion with a scalding that it is not safe! Then it was a no because it wasnt safe for overseas nationals, then it was because we had a government number plate.... Anyway somehow, I'm not sure but I do think that the time of day and also the potential decrease in driving mileage added to the sudden safety u-turn! So it all hinged on the follow up timing. Luckily enough the anaesthetist at this hospital was super keen and bright and he sailed though the questionnaires and skills. 

Resuscitation Muthani (renamed from the usual Annie) set up for skills on the bed in recovery at Ronald Ross

We actually finished at 17.40. A quick bye and then we dashed (literally hurtled at 150kmph down dirt tracks) to make border control by 18.00. Made it with 2 mins to spare!The driver then gets out and does whatever he needs to do to get a pass. I'm under strict instructions not to get out and not to show my passport. That is uneccessary apparently as it would only serve to increase the cost of the crossing! So I didn't get out! A few minutes later the driver is back and the gates are opened and we head to the Congolese border control. They are even less interested and again I stay in the vehicle but take in all the French signs above the tiny restaurant huts in the dusk. And then we are through! In the Congo!! What a way to spend Friday night! Travelling illegally, with no exit or entry stamp in passport through Congo!

Douane/Customs at the border

Vehicle permit for travel

  We then drive at high speed through the Congo - initially the road is long and well tarred. We are of course now driving on the right hand side of the road which feels odd after being on the left for a while in Zambia! This of course was too good to be true and soon descended into a red rubble road still under construction but was certainly firm enough that the foot on the pedal was still to the floor! It turns from dusk to dark night and the stars are very easy to see as there is no other lights around.

  I did observe some villages before totaly darkness descended though. They seemed a little more poor than their Zambian counterparts but the houses were squarer and had bigger thatches. They all seemed to be built around termite mounds (of which there were hundreds - which is strange as I hadnt seenth at many in the Copper belt). Two hours later we get to the border and almost clear it until the guard spots a Muzyngo in the car and demands payment. he gets short, sharp shrift from the driver about this being a medical visit and we then pass on unhindered and cross a bridge that denotes our arrival back in Zambia! An exhilarating 2 hour trip through the Congo for sure and somewhere I'd love to get back to and explore properly at some stage!

Congo road whilst it lasted and before night!

Congo road in 'full throttle'!