Follow up start: Southward bound

3^rd March I get up at 4am and got picked up on the dot at 5am! There was a huge Toyota 4x4 (can’t tell you the make or the colour I’m afraid – it was dark!). Inside it however was Patrick (the governmental driver who was infinitely brilliant at waiting for us whilst we conducted the follow ups. It later turns out that he represented Zambia at chess in the African chess championships and was third two years running, so it figures why he's so patient!) and Wisdom a senior clinical officer who is now instrumental in advising the ministry of health on matters arising in anaesthesia and a general amazing organizer and logistician. So we threw my bags and two resuscitation dolls in the boot and headed off on an adventure to Southern Province.

Now, if I hadn’t quite appreciated the scale of Zambia before this trip – I certainly will do by the end of it I’m sure!. The map indicating our destinations (in Southern province are below). Its not just a question of scale but also of lack of road infrastructure and tar in places (mega potholes) not to mention a paucity of actual signage! Anyway Patrick and Wisdom knew where they were going thankfully!

 

So we visited (in order from Lusaka) : Chirundu, Chikuni (near Gwembe), Monze, Choma, Maamba and Livingstone

SO we drove in pouring rain – lashing in fact – just like awful winter days at home. We were off to Chirundu first and as we got going I reaslied I’d been there before – its literally on the border with Zimbabwe where there is a brand new suspension bridge. Its from where I went to the Lower Zambezi via boat with my friends Hannah and Sian last time. The road was pretty epic. In the pouring rain we snaked up and over mountains with blind switchbacks and low cloud shrouding the forrets and steep escarpments. There was constant  large trucks and lorries traffic passing us on the other side or for us to get stuck behind. All of which made far more exciting in the darkness and emerging dawn. This gave rise to school children on their way to school giggling in their uniforms under a mass of colourful umbrellas.

Mountains in the rain

Numerous lorries from Zimbabwe

The road!

                                                                              

We get there 2.5h later and drive up a red mud river of  a road to Mtendere Mission Hospital. Mtendere means peace, and it certainly was a sea of calm inside the Italian quadrangle  built Hospital, I actually had to double take that there wasn’t a giraffe or an elephant in the grounds! In the eearly morning sleep deprived state they were pretty convincing!

Mtendere = peace

An almost life-like scene of a giraffe and elephant in the grounds!

We met up with our anaesthetic host who was pretty amazingly at work considering her brother was found dead in Angola yesterday. Puts a whole different perspective on work ethic for sure. As we arrived in theatre there was an 8year old boy awaiting a hernia repair, so we ended up assisting with this. It was a difficult challenge as he was originally from Zimbabwe and spoke no English or any vernacular languages so verbal communication was impossible. I'm not sure how it all gets funded but as its a Mission hospital run by Italian nuns, it seems pretty inclusive, and long may that continue!

Me, Wisdom and Christabel in theatre

That challenge aside the theatre itself was pretty fantastic -light and airy, spacious with sensor operated sliding doors. Electric operating tables that moved at a mere flick of a button an a fairly up to date Datex Ohmeda anaesthetic machine... pretty snazzy kit for here. I was just about to sign up to work there myself when they brought out their only children's face mask - it was black. They dont have the clear ones that we normally use here. Not only are they pretty frightening to the person underneath but they have been removed from the UK as they are unsafe (you cant see if the patient regurgitates/vomits or their lips turn blue!) So underneath the pristine surface many of the old challenges with equipment and drug shortages remain. Anyhow the case started and I managed to conduct the follow-up interview. However what I wasn't expecting as a response to my "Have you ever looked after a sick patient in the past 3 months - male/female or child?" to be "yes, a man savaged by a hippopotamus - it seems this is unusual however, the common occurence is amputation secondary to crocodile bites... the mighty Zambezi and its inhabitants certainly keep these guys busy.

See theatre ledger entry box second from bottom on left!

We jumped back in the care and headed back  along the road which we'd ravelled earlier and what a difference three hours makes. The rain had stopped whilst we were inside and it was warm and almost sunny and amazingly the ground was almost dry! We travelled ast goat lined roads with mud huts and thatched roofs dotted about. Farmers were sellign their wares by the roadside and we eventually succumbed to a bunch of bananas for 10kw - circa a pound at the 'Livingstone' turn off. We were lucky to just buy those as when a vehicle stops there is an almightly scramble of women with plates laden with apples/tomatoes/bananas trying to be the one that gets a sale. We luckily scampered away with out bunch and left at least one happy woman!

The seller's minibus scrum!

  As we travelled further South the terrain became more plain-like or flat. New fields of maize and sugar plantations became the norm with the mountains now a distant vista. As we passed through more villages I noticed the bikes! There were more and more bikes about and I was reminded of the amazing abilities of Zambians to balance with towers of wood or bags of charcoal behind them on their bikes.

Modest amount of charcoal on the back

 Up along another dirt track (thankful for the good suspension) we arrived at our next destination - Chikuni Mission Hospital run by Catholic/Jesuit nuns. We have to (as protocol dictates) wait for a meeting with the medical superintendent before meeting the anaesthetist. We sit and wait under framed pictures of the late Pope Ratninger and current Pope Francis and somebody else who I can only assume to be a high standing African cardinal. Eventually we meet Dr Caludia who has singlehandedly run the hospital for about 20 years. She is an obstetrician from Milan and introduces us to John the anaesthetist. They are happy to help with the follow up and we get started.

Glad to escape the office and religious effigies inside we head for theatre. I have a grand tour and again realise that so far. all Zambian theatres have green floors at least! I feel for John as he has two theatres but only one that he actually uses (apart from being the lone anaesthetist) the anaesthetic machine in the one of them doesnt work. in fact the one he is using is an ancient Italian model where the ventilator doesnt actually work anyway so he has to hand ventilate the patients throughout the operation as it is. He also has black masks and an even bigger paucity of equipment. However he is keen as mustard and when I ask him how he finds working there - he tells me its boring as its not as busy as his old hospital! Oh to have that work ethic infiltrated amongst some of the other healthcare workers at UTH!

  We conclude the follow-up interview as Dr Claudia arrives and announces that there is a case to do - a ruptured ectopic pregnancy.  They weren't originally convinced it was an ectopic prior to this as she is on 'family planning' apparently. The depot injection is what is used here as its strictly Catholic and there are no condom use (despite several posters advising of it on the walls!) Consequently the HIV rate is also high - at  at least 12% - close to the national average. Dr Claudia had eventually stuck a needle into the woman's abdomen and found frank blood. Her blood tests yield her haemoglobin is 5 and she has two units of blood available. 

She is brought to theatre and is not in great shape. She is pale and her heart rate is fast and she is entering a level of shock that decreases her blood pressure. Ideally we would have liked her to be more stable and pouring fluids and blood in is one way of dealing with this but until the bleeding is stopped it would be pretty futile - like trying to fill a bath with the plug removed. SO we have little option but to anaesthetise (put her to sleep). She also had about 3 inches of beads wrapped around her stomach as a tribal decoration that got removed before we started the surgical safety brief! Once the ritual removal of beads and checklist completed we started inducing anaesthetic. Thank goodness for Ketamine (I wont harp on about it - ready the earlier blog for more information). However Ketamine was available and is a drug that induced anaesthesia without dropping the blood pressure - which could be catastrophic in this situation. We managed to get her to sleep and maintain her using ketamine boluses and not Halothane (as this also decreases the BP). The surgeon was quick to open the abdomen and she lost over 3.5-4l of blood. Half of which ended up all over the drapes, floor and surgeon's feet as the suction didn't work (despite one of the questions in the checklist being - are you happy with all your equipment and instruments.....Hmmmmmm.....) It continued to seep up towards the anaesthetic end of the table like the red sea tsunami. We managed to get blood and start transfusion through some big drips and with some frantic bodging of the suction seal the sucker worked and our feet were saved!

The red tsunami of blood heading up towards the anaesthetic end of the table

The procedure was thankfully fine and as soon as they located the rupture the bleeding stopped as she stabilised. She did remarkably well considering and I for one was very relieved that we had access to Ketamine and also some blood (even though two was all we got it was better than nothing). The Lifebox oximeter was to hand as they have n monitoring usually other than that, except they have borrowed the monitor from the back of the ambulance recently to have in theatre so they can do not only ECG but BP and oxygen sats too. However they don't have a recovery bay and the lady was woken up in theatre and then transferred to the corridor (this is usual practice in most Zambian hospitals that I have been to). This is another reason the Lifebox is so good - small and portable and has a loud audible beeping so can be heard by the anaesthetist wherever he is in the theatre complex.

Recovery in the corridor with the Lifebox monitor on

  That was one lucky escape for that lady in hindsight - has she waited much longer she might well have had a different outcome. However it was good to be able to be a part of a team that managed to be successful despite the many challenges. 

 However it was late on us leaving - 18.00 so we had to abandon the plan to see the next hospital as it was getting too dark to travel that far (road driving at night here is a whole different ball game). We decided to divert to Monze but not before the 2 head sisters of the mission came to thank us for our help with the case! Good news travels fast!  We got to Monze in the pitch blackness and eventually found our way to a guest house called Relaxing sleep Inn... we'll see!