Christmas in Katete

Christmas here in Zambia was a little different to back home! For starters there isn't really a supermarket you can just pop into for food. We have an open market in Katete (about a mile away) which sells basic groceries and live birds or 2 v limited supermarkets over an hours drive away. Since we all have very busy jobs we decided to keep things simple and get everything from Katete. We bought 2 chickens and 2 ducks. The ducks came to us alive, then somehow sadly died of natural causes... 

So we had to pluck and gut them, which was an experience! I have the keys to the empty house neighbouring mine, so we did it in there, which is definitely a good thing since it STANK! I may or may not have perforated its bowel while gutting...

Cooking was then slightly complicated as we had a power cut for the majority of the weekend! Luckily the power came back on half power for a few of hours on Christmas afternoon, so we managed to cook everything very slowly. 

We had a feast! 2 chickens, 2 ducks, roast potatoes, stuffing, onion, cabbage with bacon (trying to be like sprouts + bacon), pigs in blankets, roast beetroot (Sammy's home grown), okra and a classic Christmas lasagne! (Not sure the Dutch have quite the same traditions as us!) And lots for dessert - mango crumble, mango trifle, mango mince pies, Christmas pudding and a chocolate tart. Food here is very seasonally dependent! But we all agreed it was definitely the best meal we've had in Zambia.

From L to R of faces, not round the table - Tim (GP), me (O&G F3), James (O&G reg), Kate (physio), Kars (research officer), Sammy (surgical F3), Adam (surgical CT3), Ken (medical F4), James (medical CT3) + missing Alex (surgical reg - in work) and Marloes (surgical F3 - sadly was sick)

Most of us were on call so spent a large amount of the day in work. I imagine our shifts are similar to the NHS 30 years ago - we're on call a lot (1 in 2 or 3), doing 24h shifts, but don't get called anywhere near as much as we do back home, so it's reasonably sustainable.

Me and Honestasia, one of my favourite nurses, who works on the gynae ward, York

Hope you all had fantastic days back home!

Malawi

Last weekend me and one of the other volunteers, Alex, went to Malawi for a little break. Unfortunately in O&G even if you're not rota'd on-call on the weekend if you're around you're still expected to spend Saturday and Sunday mornings in work doing the ward round, so leaving the country seemed a good way to get a few days off!

We went to Lake Malawi and spent one night in Cape Maclear and 2 nights on Mumbo Island.

Cape Maclear

Driving was relatively straight forward, by African standards, but we did have a few hiccups. When crossing the border we had to visit immigration in both Zambia and Malawi and then customs in both to import and export the car, as well as buying insurance. Unfortunately we accidentally missed one of the stations and didn't import the car to Malawi. Since we'd been waved through the border we didn't think much of it, but after a couple of hours driving we were stopped at a police check and this was picked up. Luckily we were stopped by the nicest policeman I have ever met and not only did he not fine us or ask for a bribe, but he came in the car with us on the long drive back to an immigration office in Lilongwe, found us the right person to speak to and explained what had happened so we didn't get fined there either. 

On the way back to the police stop we were driving behind a truck and the policeman (whose name I've forgotten) told us the driver was the most famous smuggler in all of Malawi. I asked him what he smuggled, expecting him to say drugs or guns or something impressive. Apparently he smuggles groceries! This is because they are cheaper in Zambia and this way he avoids paying tax. Alex asked why he was free if he was so well known. The policeman said that if you arrest him he will make you an offer (bribe) and if you don't accept it, then he will make an offer to your senior who will accept it, so there's no point in arresting him...

We got a bit lost on the second half of the drive. There seem to be about 3 road signs in all of Malawi, so it wasn't very easy! But eventually we arrived (in the dark) at Cape Maclear and found somewhere to stay.

The next day we went to Mumbo Island. Now Mumbo Island is 11km away into the lake - not the island (Thumbi) that you can see in the picture above. Alex had heard that you could kayak there and against my better judgement persuaded me to join him. I enjoyed about 3/4 of the trip! I only agreed to go if we went in a double kayak so he could do the work if I got tired! 

If you're ever anywhere near Malawi I would seriously recommend visiting Mumbo Island. It's SO beautiful. This is the view from our little cabin:

The island is privately owned and has about 6 of these little cabins on it and an all inclusive restaurant. Otherwise it is totally secluded.

There were a couple of South African ladies staying, and a South African lady who was hosting as well as about 5 Malawian staff who did the cooking and cleaning, but apart from that we had the island to ourselves.

It was so interesting talking to the 3 South African's about life. They were really lovely, but is it fair to say they were very colonial? There was a lot of "us and them" chat in terms of race, and it really surprised me when they referred to themselves as Europeans, despite being 4th generation immigrants. 

We went kayaking and snorkelling and explored the island and went on a sunset boat trip. It was so much fun! 

The drive home was difficult because there was torrential rain virtually the whole way. I think we must have been in a bit of a bubble out on the lake because it looked like it must have been raining all weekend for the rest of the country. There was almost apocalyptic flooding in some of the villages.

Wishing you all a very Merry Christmas from Zambia!  

An Interesting Case (Not for the faint hearted...)

I haven't been sure how much to share with you guys about the kinds of things I'm seeing day to day in the hospital. A lot of the things I've been seeing are really very tragic and I'm not sure how fair it is to expose you all to that. Like most doctors, I've developed quite a thick skin, so unlike when I was in Ghana as a student, now not much will shock me. But I realise many of you are living very different lives and I don't want to upset anyone. Having said that, this is reality; we live in a broken world. Whilst most tragedy back home is hidden behind closed doors, it is happening and maybe it's ok to recognise that? 

However, the majority of the broken-ness I'm seeing here involves dead babies (being O&G) and I realise that can be particularly upsetting for some people, so I'll leave it to your discretion whether you want to read any further.

Yesterday I had a particularly interesting case, and whilst it had a partially negative outcome, I think it's an example of different specialities working together really well. I'm trying to promote unity between specialties so think it's worth highlighting!

I was on call for O&G and had a referral for a lady on the medical ward who was very unwell. She was a 15 year old girl with a positive pregnancy test and vaginal bleeding, who had also been vomiting with fevers for a week. On seeing her it was soon clear that she was very unwell. (For the medics...) she was tachycardic  ~140 (fast heart rate), febrile 39.3, and very tender on the right side of her abdomen with guarding. Initially we were concerned she might have had an ectopic pregnancy as they normally present in early pregnancy with L or R sided abdo pain and vaginal bleeding. James my reg did a bedside ultrasound scan, and found a pregnancy in the uterus (i.e. not ectopic - pregnancy outside of uterus that can --> death), but he couldn't find a heart beat so I took her to the ultrasound department for a proper scan. Adam, the surgical SHO, came to review her too as we thought it could also be an appendicitis.

She really wasn't at all well, but I managed to get her to the ultrasound department in a wheelchair and up onto the scanning bed. The sonographer started scanning, and there was the baby in the uterus, but again she was unable to get the fetal heart beat. As she was looking the baby moved across the screen. It took me a second to understand what had happened, but then I looked between the girls legs, and there was the baby on it's way out. After delivering the baby I tried to deliver the placenta but because the baby was so premature (probably about 20 weeks) with a bit gentle traction the cord snapped. This left me with a very sick young girl on the ultrasound bed with a retained placenta and literally no equipment, medications or midwives to assist me and 2 perplexed sonographers who really had no idea what on earth was going on.

I quickly wheeled her to labour ward, trying not to alarm the rest of the waiting room on the way out, and gave her some oxytocin (makes the uterus contract) and luckily the placenta passed shortly without too much difficulty. She was still very tachycardic, so I gave her some fluids and had a bit of a think. The whole story didn't really add up. It would have been tempting to be entirely distracted by what had just happened and say having a miscarriage at 20/40 is enough reason to be in a lot of pain and as a result be tachycardic, but the tachycardia persisted and there was the fever to explain. The baby showed no signs of an infected uterus (no pus/smell) and miscarriages at 20 weeks are unusual without an underlying reason. 

She was still very tender on her RUQ so I thought perhaps she might have cholecystitis (gallbladder infection) which caused the miscarriage. I called Adam who was on his way to review her again. He agreed that something wasn't right, although it wasn't entirely clear what. We didn't have any blood results back and she hadn't actually had a proper ultrasound scan, as we'd been a little distracted!

Adam thought it was more RIF, fitting with an appendicitis, so spoke to his boss about taking her to theatre. Proff (head of surgery) felt sure it was all gynae related but eventually agreed to do a laparotomy (open her up) anyway. Nothing happens quickly in Zambia, but later that night I got a text from Adam saying he was right, she had a gangrenous appendix and Proff owed him a bottle of wine!

So whilst there was one loss, less unwell patients have died here because things were missed, as could have so easily happened here if we'd been satisfied with "gynae pain" being a generic diagnosis. Nothing's straight forward here because we have such limited investigations and patients present SO much later here than they do back home (no one, even non-pregnant, EVER sits at home for a week with appendicitis in the UK).

We have a weekly morbidity and mortality meeting where each specialty takes turns presenting the deaths from that month. Often it gets really awkward because so many deaths here wouldn't happen back home, for a whole host of reasons, so people from other specialties can often be very critical. I really like this case because instead of a tragic death, every specialty contributed to saving her life: we had a very speedy referral from the medics, lateral thinking from O&G and good operating from general surgery (OK so no paeds...).

Kachipu Village

There's a man called Benson who works as a gardener for a couple of my colleagues and over the last few weeks I've become friends with him. He and his sons Daniel and Ferdinand have helped me with my garden a bit (more on that later) and he's just generally a really sweet guy. He has good English too, so it's really nice to be able to have a proper conversation with someone who doesn't work in the hospital.

He lives in a village a mile or two down the road from where I live and every now and then runs "village tours". This basically involves his kids picking us up in the ox cart (I think the same one the manure came in!) and then him showing us round the village, watching a dance/singing and then eating dinner that his wife makes.

This is Danger, one of our dogs. Or at least there are a number of animals who live on the hospital grounds that seem to be fairly communal and beg for food from whoever's silly enough to give them any - silly because as Kate, the latest arrival, discovered feeding them means they come scratching on your door at 5am! 

Danger decided to come with us to the village, uninvited, and spent the entire journey running between the oxen barking at them and biting their legs! I'm seriously surprised he didn't get kicked or impaled on a horn. Then as soon as we arrived in the village about 10 local dogs saw him and chased him round very aggressively for about 10 minutes! None of us were too upset - we tried to stop him coming, he's not unfriendly but can be a bit bitey, so isn't very popular!

The children in the village were VERY excited to see the mzungu and ALL wanted their photos taken about 20 times. I suspect they don't have mirrors so it's unusual for them to see their own faces.

So excuse me for the barrage of photos! This is the tip of the iceberg  just the ones where they stood still long enough to take a half decent photo!

 

About 10 minutes into the tour these boys came out, apparently dressed as ghost warriors  whatever that means! One thing travelling has shown me is that kids really are essentially the same wherever you go.

The girls put on a little dance for us. I took a video but the internet definitely won't cope with that!

This is my favourite picture from the day. I love how serious they are.

The girl on the right is called Margret Zulu and she insisted on holding my hand the entire tour. To be fair lots of kids insisted on holding my hand, but she was the most persistent!

These women saw me taking pictures of the kids and wanted photos too. Then they wanted a photo with me, which they thought was HILARIOUS! I know they look very serious in the photo, but between snaps they were wetting themselves about getting a photo with a mzungu! Then they saw their brother and called him over for a photo too.

Collecting water

Benson is the man with the white cap, and the other mzungus are L-R: Alex (medical student), Adam + Sammy (both surgical SHOs), Kate (physio) and Robin (another medical student)

After looking round the village Benson's daughter Christa got the kids sitting down to sing us some nursery rhythms. None of the kids were really paying much attention, there was a lot of wandering about, but it was cute. I love how in this picture every child is moving except one who's looking at the camera.

 Then after the singing we had a candle lit dinner, made by Benson's wife, which was delicious. I'll do a blog someday on Zambian food!