Bicycles and British built machinery in the East

Travelling 650km East opens one’s eyes to the differences from Lusaka.  I have previously spoken about the changing terrain but what really caught my attention was the increasing numbers of cyclists around.

Under strain peddling

There were kids cycling to school on oversized bicycles. There were men toiling away under huge loads of charcoal or wood or maize or feed that were so heavy that they would get off to push uphill and then watching them mounting back on with the frenetic wobbling all over the place from stationary again was quite something. These were mostly seen towards dusk when they were either returning ir travelling to Malawi – apparently via non-policed routes so that they could avoid taxation. In my mind if they managed to pedal that load to the border and further they deserved to keep every tax avoided kwacha! 

Hard work uphill

Just keep peddling!

I even saw two guys cycling with trussed up pigs on the back of their bikes. As we got closer to small towns or large villages there would often be a large congregation of guys with bikes under  a tree. On further enquiry these are in fact the rural taxis. The bikes are equipped with a seat on the back so that they can ferry their human load to the market or back again with their wares. I’m not sure if the cost goes up with increasing BMI…. 

Taxi!

Many of the women preferred walking as their main mode of transportation and used their heads to transport good though of course there were the few women that cycled, clearly wearing their colourful chitengi.

Mind you, I have to admit that by far my favourite sight on a bicycle was a nurse, complete with uniform and starched hat!

Day light proved that Chipata really was placed in a beautiful area and it was quite a shock to wake and see myself surrounded by mountains. Life here, even though it is a provincial captial is a much slower pace. The markets were laden with fresh vegetables. All in season: maize, mushrooms, ground nuts, tomatoes and pumkins.

Chipata hospital is very busy by virtue of being the main one in the region. It also takes referrals from elsewhere which inevitably get here very late in the course of their treatment. Dr Victor (a Ukrainian anaesthetic consultant who has been here for 11 years and is the only doctor anaesthetist in the province!) told me that the women are often moribund from bleeding by the time they get here and consequently they are worried as their maternal mortality is really high. Even St. Francis refer on to here for specialist surgery. Having travelled along the roads yesterday it is unbelievable to me that anybody who is unwell and cannot be dealt with at a level 1 hospital (very basic with no specialist surgery and often no anaesthetist) is then transferred on to a level 2 hospital – St Francis or Chipata. It is easily a three to four hour drive from St Luke’s, an hour from St Francis but who knows how long they take to get to the first referring hospital. The catchment is vast and they are in desperate need of more anaesthetists to get trained and open up more theatres in this area. 

Eastern Province Hospital follow ups as marked by black dots  (also only ones with anaesthetists). Far left is Lusaka then comes St Luke's at Rafunsa, then St Francis at Katete and then Chipata and Up by Mozamique border Mwami Mission Hospital. A vast catchment in the East.

Thankfully two of the clinical officers in Chipata were interns (6 months post qualifying) and they are earmarked to go and open two theatres along the Great East road once they finish in April. Good news indeed that there will be anaesthetic facilities closer to some communities, scary news in the fact that they will have completed a two year training, worked under supervision for 6 months and then be sent to not only open but run, singlehandedly a hospital theatre with no further  help or supervision. One cannot say that the system mollycoddles here at all… Dr Victor was also woeful as he felt he needed to keep the two interns as they were so busy in Chipata (there are easily three or four Caesarian sections done every night). I think he’s right, they do need more man/woman power. In fact the whole country needs more anaesthetists its that simple. Thankfully the MMed programme for anaesthesia is up and running and long term will make a big difference in the country but will certainly not infiltrate the rural areas for some time (years) so the improvement in clinical officer training and more importantly post qualification refreshers and support will be vital for continued improvement in maternal health. That and improving the road infrastructure to allow people to get to hospitals quickly.

Recovery in Chipata is in the main corridor, alone but for the pulse oximeter because the theatres are so busy they cannot spare a nurse to sit with the patient or allow the anaesthetist to do so. The anaesthetists told me they rely on hearing the changes in the pulse oximeter beeping noise to alert them to problems in 'recovery'. Contrast this with the staffed recovery in St Francis. Its plain to see that there is some way to go before theatre care gets to where it should be. Not that Chipata is different from anywhere else. In fact St Francis is the ONLY place I have seen a nurse actually allocated and sitting with patients in recovery.

It was a Saturday and despite all the hustle and bustle in Chipata we were very fortunate that Freddies in Mwami Mission hospital agreed to see us. This mission is run by the 7^th Day Adventists who do not work on a Saturday as it is a day of rest. He did, however agree to meet us and I’m so glad he did as he is an interesting chap – he is not a doctor nor a clinical officer. He is a nurse anaesthetist. He trained as a nurse before heading to Tanzania for a year to learn anaesthetics and then return. He is actually fantastic and it seems that many in the region agree. I'm told that many apparently drive to have Freddie do their anaesthetic for caesarians out of preference to Chipata. Maybe they don't like the wait at Chipata!

He was keen to show us around the theatres and as he did so in the main operating room I could see he had two different anaesthetic machines in the room. On further enquiry it turns out the one he was using was a donated American one (easily identified as that because the Oxygen knob is on the right of the three, whereas all British machines have the Oxygen on the left as their inventor was left handed!) The machine in the corner was a glostavent – basically a drawover with an oxygen concentrator – similar to those used really successfully in St Francis. When I enquired why he was using the big machine with the expensive oxygen cylinders out of preference he stated the sensible reasoning in that the new machine had a ventilator and the drawover- despite being a good one did not. Fair point!

New, donated American machine. Oxygen (green knob is on the right of the three gases). Yellow is air and blue is nitrous oxide - none of which is available here or in the rest of Zambia so far! The two vaporisers are Halothane (standard) and Isoflurane (more modern! I excitedly asked if he used Isoflurane - nope, they don't have it supplied despite having the ability to deliver it and it not being that much more expensive than Halothane to buy!)

 However when he then showed us into the next theatre I noticed he also had two machines in there. This time the expensive American machine was in the corner and one of the oldest Boyle’s machine s in use I suspect in the world was present! It was so old it had the capacity to give both Ether and Cyclopropane (both of which are no longer used in anaesthesia in the UK or Zambia it seems). Despite this there was a cyclopropane cylinder still attached to the machine. When I now enquired why he was using such an ancient machine in preference to the new one he looked quizzically at me and stated as if it was the most obvious thing in the world – because its British and they were made well. Of course – echoes of Lucas at St Francis! It seems that all the pipings in the machine are easy to access and they are metalso he has managed to repair any fault himself, even showing me proudly where he’d welded a bit of piping. I point out that next time it might be wise to remove the cyclopropane cylinder first (highly flammable!). Gulp!

Wisdom and Freddies in theatre. Expensive American machine to the side and British built Boyles in use!

Close up of the Boyle machine - note the oxygen on the left (white knob). The blue is for nitrous, grey is for carbon dioxide - not available and the orange for cyclopropane (an old anaesthetic agent - not used!) Halothane in the vaporiser (red colour - used!) and then the Ether bottle (not used!)

And a cylinder of Cyclopropane mounted on the machine - the only one I have ever seen. Its thankfully not being used!

And that concluded the Eastern part of the trip. A tough two days of travelling and interviewing and teaching and working in theatres. Never mind the European working time directive - the 18 hours and 16 hour days seem ed the only way to get the job done! But it was a hugely enjoyable experience both to work in more peripheral set ups but also to see how they run and to also see how the communities work out here. But no rest for the wicked! Back to Lusaka to sleep before a 12 hour turn around heading West this time!

Eastern province rock formations