Am I a voluntourist? Does it matter?

Ever since the Prof raised the issue a few weeks ago in Tiko's I've been thinking about it. At the time we asked him how long he thought someone had to stay here before they were not considered a voluntourist, he laughed and said '7 months...'. His position was clear, although I think that has softened slightly over the past couple of weeks as he sees how much Geoff is actually helping.

But is he right? I think it's too early to come to a definitive conclusion on this one but I thought I'd share some of my initial thoughts. In due course, I will extend it to how I think help should be provided to the hospital in order to maximise its impact - but for a number of reasons, including the forum in which I write, that shall be put aside for now.

So, am I? It really depends how you define voluntourist. Online you can find a number of positive definitions that equate the term to 'crowd-sourcing with an incentive'. You have a dull but earnest task that needs doing - like counting fish in a coral reef - and it would be helpful if 100 people came to do a couple of days' work each and then spent a few days just lying on the beach. As long as the quality was fine, everyone's happy.

For the Prof it has negative connotations. He is using it for people that come solely to make themselves feel better, almost to gloat. And whose contribution to the running of the hospital or the lives of the patients is so minimal as to be insignificant. He would rather have their airfare and foregone wages as cash so that he can make the changes he needs to in theatres. His number one aim at the moment is to make them insect and animal free!! And of course if you pay locals to do what voluntourists do, that money feeds into the local economy.

I can entirely see his point of view. If I am honest, I knew that I could not, under any circumstances, make a significant change here in 6 months. I'm not sure I could do it permanently (i.e. such that it would continue in my absence) in 6 years. But I would quibble with him about whether that means I should not have come. Much of my time over the last couple of weeks has been spent writing surgical protocols or, more recently, amending protocols that he has written. None of this would have happened without me being here - there is no one in the hospital with the time, the IT capability (why is it that Word randomly adds funny lines in the text every so often?) or the medical language understanding to do these. Yet they are required by the Government. And how long would the pharmacy have gone on thinking they couldn't add new products to their stock keeping software if I hadn't taken the time to read the manual and find the correct button?

Of course this all has to be balanced against the 'tourist' bit. Is it a coincidence that I love Africa and we are in Africa? No. Is it a coincidence that we are only 4 hours from a National Park? No. Do we intend to visit the park a few times? Yes, tomorrow being the first! So there is a definite upside to us being here that I would never attempt to deny. I am loving all the smaller animals around the hospital and being able to watch the sun setting in the massive sky. But we've been here 6 weeks now and, illness aside, Geoff has been in the hospital practically every day, with operating lists double the length of UK ones 3 days a week. So I think a short break is deserved in anyone's book.

Therefore, as I sit here right now, I think the answer is 'So what if I am a voluntourist? I am still helping at least as much as I am benefitting.'

Day to day in the hospital this week

For a little while now the hot topic at meal times has been the impending shortage of salt based IV fluids. Preferably those without dextrose (Dex) in. There was debate about whether best practice is to resuscitate with Ringer's Lactate or pure saline - it seems to vary by NHS hospital and department and internet source - but ultimately everyone agreed that they didn't want Dex-Saline or Dex.

I overheard the Acting Medical Superintendent asking the pharmacist about the fluids when he took me to pharmacy the first time last Tuesday. The response was that he had plenty of Dex-Saline. Quietly the AMS said 'but sometimes they can't use that.' Soon the wards ran out of saline, there were rumours of pockets of it - a nurse on the men's medical ward had 'found' a box of Ringer's Lactate that was being reserved for the really sick. Everyone else was getting Dex-Saline. The level of concern at meal times increased.

When I went to pharmacy this Tuesday I needed to ask when the delivery was expected this week. I have promised to help the stores boy with the data entry to make sure the prices are recorded correctly. The pharmacist's response surprised me a little "We aren't expecting a delivery from Medical Supplies [the Govt company] this week and I haven't placed the order for the other things we need yet." When do you think they will come? "I don't know, I will send word when I need you." The little voice in my head was screaming 'Why are you so calm? why haven't you placed the order? I was stood next to a trolley covered in fluid bags - all 10% Dex. The hospital has now run out of all saline IV.

And the Govt inspectors are here this week. In the weekly meeting the Acting Medical Superintendent let people know what they are checking for. 1) they are checking that protocols are being used correctly. A medic asked what protocols they should be using, she hasn't seen any. 'If you can find a hospital one, use that, else use a Zambian one, failing that a WHO one'. OK (but in fact there is a book full of hospital protocols which we use) ... 2) they are checking that staff are wearing their name tags. Same medic (she's persistent) states she doesn't have one. 'No, you don't. We haven't had any new ones printed for 2 years'. OK...

At dinner on Wednesday the Prof and his wife join us in the Mess. We talk about a lot of things and then I get in trouble for trying to organise/help (depending on your point of view) the Prof as he serves the pudding. His wife says 'do you think you would make a good Medical Superintendent?' I said that I thought I could make some positive changes. 'Yes' she says 'I told [the son of the English couple that used to run the hospital] that they should appoint you.' Whatever can she mean? She's only met me about 5 times!

Some pictures from work

[This is Geoff pretending to be me]

I have put some work photos below - the delay was because I had forgotten the reader for my camera, so had to borrow one. I do have some anonymised pictures of the operations we have been doing and complex wounds, which are pretty interesting. It is however a very narrow line between what would be regarded by the powers that be (mainly at home) as acceptable, and what would be regarded as a breach of confidentiality. So, no patient pictures on the blog.

The view from the window of theatres coffee room

Charlotte in scrub dress when visiting theatres (she is in the coffee room, dress is labelled in bold "Property of US Navy")

All you need for a chest drain - plastic bottle with two holes in the lid (not sure what it was first used for), suction catheter, two lengths of plastic tubing, some holes cut in one end

The fire outside theatres one night (there are a lot of fires, all self-limiting, where people burn the scrub)

One photo with a patient in (but completely obscured so I don't think this contravenes any regulations). Me and Prof waiting to operate, anaesthetist at the head end, note the basic but effective anaesthetic set up (bellows for ventilation)

Mukasa, the female surgical ward.

One of the donated pulse oximeters in use

Theatre 2 (the main surgical theatre). Note the C arm in the corner. Fantastic for all the orthopaedics we do, but has not worked in six months and still waiting a technician to come and sort it.

The view heading in to theatres at night.

One of the hospital cats, running out from next to the surgical wards.

An interesting week

So, the Prof was off last week with a bug. In the absence of the Zambian registrar as well, I was the only doctor in the surgical dept. While most of what we do is straightforward, we benefit hugely (every day) from Prof's experience with tricky decision making and complex surgery. It is a novel experience for a UK trainee to be in a position of not having support at least a phone call away! We were lucky to have only one big case that could not be deferred, but the decision making proved quite stressful.

Firstly, choosing who to operate on, who to approach for help if needs be (one of the gynaecologists has a lot of general experience) and what could wait for Prof was challenging. The one op I did that would be far beyond my sole responsibility in the UK was a laparotomy for an obstructing large bowel tumour. She had had bowel obstruction for a month, and was both very sick and rather difficult to operate on due to the degree of bowel dilatation. I was pretty pleased with the result (just a defunctioning stoma to allow her to get better before definitive surgery) but arrived the next day to discover the "bridge" (a piece of plastic holding the stoma in place) had been removed by either a nurse or a relative. So she has to go back to theatre to bring the stoma back out.

The only other close shave was a six year old with a depressed skull fracture, who looked like he would need a craniotomy (operation on the skull) to release the pressure. Having pestered the Prof (who was still not well) I was all lined up to take the patient to theatre with him. Then the patient woke up and all was avoided. The comment from a neurosurgical friend back home, who I had emailed about the case, was "what did the scan show? Is it an extradural haematoma?". Little does he know the nearest scanner is seven hours away, far too far to make a difference to someone with a head injury! We make our head injury decisions the old fashioned way.

Having talked up the stress of operating, in fact the hardest part of the week was organising the dept (me, two licentiates who are accustomed to working alone and several medical students). I had to plan the clinics, rounds, lists and day time calls. It all worked out until Friday when I was supposed to operate with the visiting orthopod (he comes once a month) and neither licentiate turned up to do their list. Anyway, the Prof returned this week, no major disasters apart from me getting sick at the weekend and missing my opportunity for some decent food (a cheeseburger) in Chipata.

Home improvements

Now that we are in our final abode we have started on some minor home improvements.

The first I hailed some weeks ago, the now infamous 'bucket shower'. It has had pride of place in the bathroom for a couple of weeks or so now and has made a significant impact on comfort (and no doubt smell!).

So here it is (there's a picture next for those of you using Lotus Notes):

Le Bucket Shower

Normally you would lower the bucket to fill it and then pull it back to the correct height. However, this one is tied in place for a number of reasons - primarily being that the L beam in the roof looked like it would cut the rope and the most frequent user isn't strong enough to pull up the bucket and tie it securely on their own. So it hangs there all the time and is filled using the laundry bowl, a dining chair and significant muscles - making up for our lack of dumbbells. In three bowls I can fill it to within one inch of the top and it will run happily for 10 minutes! I think I'm having the longest showers of anyone in the hospital at the moment and all for the princely sum of £20.

As you can see, I also spent £3 on a shower curtain that isn't covered in mould! Perfect!

Once I have acquired a couple of hot plate rings the interior renovations will be complete from my point of view. Geoff is keen to try and cover the windows with mosquito net (this is tricky because of the opening mechanisms and bars) to 'stop snakes coming in'. I have pointed out that they are unlikely to and that probably the biggest threat is spiders. We shall see what happens!

The garden

My next project was a garden. When we arrived there was just a scrubby patch behind the house and the view was open straight to the Rondavel opposite. Living on the ground floor with ill-fitting curtains doesn't provide much privacy at the best of times, without having a busy path and a neighbour's window right outside. So I decided that I quite fancied being "Thane of the Outside Toilet, and that little gravelly patch next to the garden shed". [This is a quote from the best of 80s TV, which anyone that knows that Orange Peel is the only thing to rhyme with Neil will know. And before my brother tries to correct me - I looked up the exact quote...]

Garden before

View from my office

The first step was to locate a gardener - there are lots of people that want to help out with sweeping and gardening at the doctors' houses. We knew one had worked for a long time at Nat and Will's house but they had taken someone else on, so he was unemployed. He's called Moffat and, I'm told, has 5 children.

After I'd already told him what I wanted I realised I should probably ask permission! Thankfully this was forthcoming and I was deemed very generous for offering to commission a communal garden. Work started in a typically African style - I'd been promised a fence by Saturday morning and on Friday morning all I had was a pile of fence building items and some sticks to use as posts. However, the fence was mostly completed by Saturday lunchtime!

Moffat hard at work!

Since then he's added a washing line, 6 beds for growing things (we didn't ask for these but it seems that growing stuff is the only conceivable use for a garden if you are African), a pile of manure (in the middle...) and a very deep hole. I'd asked for a fire pit and gestured with my hands a bowl shape, maybe 6 inches deep, what I got was about 3 feet deep and looked more like a grave. He has subsequently half filled this in but left the extra earth round the edge - I'm not sure he understands that we want to be able to sit around the fire at night! These crazy muzungus - what will they think of next?

Garden after

Juxtaposition of real Zambia against some luxury

On Friday night the resident Dutch Obs and Gynae doctor (Joop) arranged to take us to a Zambian restaurant in Katete. The proprietor is a lady called Phoebe who is probably in her 50s and is half Portuguese half from Mozambique - but really looks more Asian in descent. We had all signed up on a sheet a few days earlier, keen for the genuine experience.

When we arrive we are the only punters and are sat at a long table made of lots of other irregularly sized tables pushed together. We have had a small adventure getting here - squashing into Joop's car with 4 of us across the back seat and an extra row on the seats in the boot. We stopped to gather the visiting Orthopaedic surgeon in our convoy and promptly reversed into a tree in the roundabout at the front of the hospital. A few moments later a car is parked clearly going the 'wrong way' round the roundabout - Joop complains about the poor driving. Before I can stop myself I hear my mouth saying 'I'm not sure you can claim the moral high ground if you've just driven into a tree....' The packed car fell silent...

So I'm glad to reach the restaurant and seat myself at the other end from Joop [No harm done though - he invited us back to his house after dinner for drink!]. Shortly a trestle table is loaded with a buffet. We make our way up to have everything explained. I spot the Nshima at the far end (standard) and the beans at this end. So far so good. Now Phoebe starts to talk - these are fried flying ants (hhmmm), a green vegetable mousse, the little fish from the market, some white aubergine, offal, baloney (described as a vegetarian sausage) and then the piece de resistance - trotters/hooves [There has been debate subsequently as to which animal these were from].  I realise a few things at this point 1) I didn't have a clue what to expect and should have asked, 2) I have no idea how much it's going to cost and 3) I'm a bit wet really. I'm keen for a real Zambian experience as long as it doesn't involve me eating things that I wouldn't normally eat....

Nat is in front of me and I watch her load her plate. Then I start. The pots look small so I don't take too much of anything. I avoid the fish (I just don't do fishy fish particularly not small ones that you get the whole of - these look to be mostly eyes, skin and bone). I look closely at the offal, am heartened by Rory saying 'great! Sausage meat!' but then spot a piece of colon sticking out of the pile and decide to move on. Similar story at the trotters - part of me wants to try it but then I look too closely and can't face lifting one onto my plate. As Nat and I turn back (she has fish and a trotter but no offal) Fi comments on the 'cordon bleu' portions. I decide to watch her closely.

As it happens the ants were just fine - they were just crunchy but didn't have a strong taste. They actually make a good accompaniment for Nshima as they give it texture. The fish were deemed to be very strong - well avoided. The trotters caused contention. Nat attacked hers with a knife and fork, managed to get the skin off it only to discover nothing particularly edible underneath, so gave up. Fi piled her plate high with things and I hear her ask Joop how to eat the trotter. I look up with interest. She has it between her forefinger and thumb, touching it as little as possible - exactly as you might a damp old rag of unknown provenance. She brings it close to her face and sticks her teeth out as far as they will go to take the tiniest nibble. Clearly she misses or fails to get anything off so she tries again. Fails again and gives up - down it goes! I feel better. She still has the high ground, it got on her plate, which was better than I managed. Although I do clear my plate.

NB: The only people that ate the trotters were Geoff and Joop. Geoff subsequently got the trots and Joop hasn't been seen in work today (Monday) either..... coincidence?

Luxury

Those not working have arranged to go to Chipata. Will's away and Nat's working so we have to go by 'taxi'. Geoff stays behind because of his sudden affinity to the bathroom. I feel a little guilty but he wouldn't have fit in the two cars anyway, so perhaps it's a good thing. Halfway the car in front suddenly makes a small swerve and slows rapidly - puncture! These must be common because the two drivers have it changed in about 5 minutes flat.

The next 'issue' is the Police roadblock. The rules on taxis appear to be the same as at home - you need a licence and special insurance. Will and the rest of us normally get waved through the block easily but today things are different. We are ordered to pull over. Rory asks if it's just because someone wants money - they do want money but it's legitimate - sort of. It's quite clear that a beat up car with one local driver and 4 muzungus in it isn't a group of friends on a trip. Two cars in a row makes it even more obvious. Technically I assume the drivers should have been arrested but instead they hand over some money (I didn't ask how much) and we carry on to the hotel!

The pool is so inviting after the heat of the car that we all get changed straightaway and jump in! Lovely! And so much warmer than a few weeks ago! Great. After a short while we get out to warm up. The wind gets up and the parasol I am hiding under makes a bid for freedom, nearly decapitating Fi in the process! We decide to get back in the water - it seemed safer! Just as we leave again we hear splashing behind us. A little boy is climbing down the steps - he appears to fall off the last step (it's hard to see - Nat fell off it last time) and now he's out of his depth. He starts to flounder. His mum yells at us from her sunlounger at the far end to 'help him'. For a moment I'm frozen, time moves slowly, and his eyes suddenly open really wide. Fi has managed to make her legs move before I do and she's down the steps by the time I can reach his arm from the side. He says nothing as we drag him out... and neither does his Mum! Charming!

We eat well before heading to the shops. As seems common, the power is down so only the big supermarkets and petrol station are open (they have back up generators). I buy lots of cheese as a present for Geoff. I considered buying the 2kg block of Gouda but it was 190 pin - well over £20! I get a box of red wine instead 135 pin for 4 bottles worth - bargain!

On Sunday we have a lovely risotto for lunch cooked by Fi. Sitting on their porch in the warmth with a glass of wine is idyllic. There's even a small bat clinging to the bricks supporting the roof!

What can I carry on my bicycle?

I think there's enough variety to warrant an occasional column on the correct use of the bicycle. At home you generally only see a single rider. Occasionally smaller children will have picked up a passenger - perhaps on the back or sat on the seat whilst the rider stands. It is clear that we underestimate the usefulness of this humble means of transport. Here are a few things I've seen:

• Another bike - either crossways across the pannier rack or tied on with the back wheel as an extra axle
• Various lengths of 2 x 4 - strapped longways or crossways depending whether you want to lance pedestrians or just take their legs out
• An unfeasibly large number of large whicker baskets (fine until the wind blows)
• A live chicken held in the right hand of the rider, who is also holding the handle bars with that hand
• A live goat - tied across the pannier rack with bungee cord (note: it will bleat every so often, which could be annoying / distressing)
• A dead pig - on the pannier rack but you might want to cover it in some green vegetation so that passers by are not offended. [I was laughed at by a lady who saw me staring to try and work out what was going on]
• A couple - sit the man on the cross bar by the handlebars and the lady on the pannier rack
• A breastfeeding lady - side saddle on the pannier rack, obviously
• A whole set of garden tools tied on in various places
• If you are the rider and have a baby then just tie them to you with a Chitenga - perhaps on the front so you can keep a better eye on them...

Perhaps you don't need cars after all!!

What's been keeping Charlotte out of trouble?

I can almost hear you all calling out this question - surely she hasn't just been sitting quietly in the corner behaving herself all this time? Indeed she has not!

I have quite a few projects up in the air at the moment but thankfully they are all with different people and moving at different paces so there's always been something to do. Failing that I have developed a good knack of wandering around the hospital smiling at babies - generally they stare wide eyed and I am yet to manage to make one cry!

Hospital Newsletter

I was asked by the English couple that used to run the hospital if I could update the newsletter. It used to be sent out frequently but has somewhat fallen by the wayside in the past year. I have therefore been scouring the hospital for stories - I have found plenty but these must then be filtered into the much smaller and, imho, less interesting bucket of 'acceptable' stories. No mention must be made of the rat in theatre, for example!!

A safe bet was just to update the annual figures for the hospital in terms of outpatients, inpatients, people on HIV treatment etc. I am sent to Medical Records to get the information. I'd been once before to this large room filled with notes - they even have them all the way back to 1947! - stuck in the corner are a couple of people at computers - seemingly typing things in. Still, I'm not hopeful, all the statistics stuck up around the hospital are from 2010 or earlier...

I sit down with the chap in charge and he begins to write down the list of things I need. I don't really know why I'm asking how many people go to OPD - as far as I can see there's no way of monitoring that in the mayhem. I imagine that he's sucking his teeth 'you want this for the whole of 2011?' Yes, please. He says he's printing it, I don't get my hopes up just yet.

And then, magically, I am presented with 4 printed sides of A4 of what can only be described as a management report! They have KPIs on here - blood tests, malaria cases, births with and without assistance. It covers all key areas of the hospital, admittedly at a high level but it's there - annually back to 2009.

Something in my head clicks into work mode specifically 'due diligence'. I find myself scanning the trends and asking questions. Not that he really knows the answers and looks a little scared! Then I remember another piece of data I might need. Does he have Average Length of Stay? [I almost say AVLOS in my hurry before remembering that he isn't a Care Home owner and probably won't have a clue what I'm on about]. He does but they look at 'Bed Days', which appears by month - perfect.

Now the brain is in gear. How do you know your OPD attendance figure is correct? I've seen people just sneaking in! 'Well, they are supposed to register but if they don't and they get a prescription then Pharmacy sends them back to OPD. But if they come and don't get a prescription then maybe they won't be counted.' I tell the guy that I'm going to spend an entire day in OPD counting people, then I'll ask him for his number and then I will show him that he's wrong. He laughs, 'no, then I will show you why you are wrong! Say I am ill, and I take you and you [there's another guy in the room] with me to look after me - now you count 3 people.' I say I will count green forms not people - it's a deal!

But now I'm remembering something else - some health centres seem to hold on to their very sick patients for too long before referring them here. This means that lives are lost unnecessarily, people might be saved if they came earlier. Can they work out whether any of the rural hospitals are outliers? And then target training there to improve referral speeds? 'I see where you are going with this idea'.

Now that I've found all this amazing data, I have one really burning question. Do you look at it? Do you analyse it at all? 'No, not really, only sometimes if one district is sending us more malaria patients than we'd expect...' Oh! So someone has gone to the effort of setting all of this up but hasn't shown them how to use the Management Information (MI) to help the hospital run more efficiently! Such a shame.

Pharmacy stock tracking software

It's a similar story in the Pharmacy. They have had for a year an amazing piece of software that should be able to track the location of all drugs in the hospital down to which patient was prescribed them and on which ward. But they haven't been able to get it working and they are so busy doing the day job that they don't have time to work it out. Can I have a look?

Initially I had been hopeful but then a team from Scotland came and looked and said the manuals were missing. I go anyway and am sat at a terminal and given two 20 page training guides. From this I discern that the software should be all singing and all dancing but is too complex to learn by doing. Plus I'm pretty sure I'm on the live terminal so scared to do anything bad!

I spend a bit of time chatting to the 'IT guru' Abraham. He's a great chap - in a wheelchair [this is only relevant to help you picture him], quite skinny, very broad smile, really bright white teeth and an amazing giggle. Obviously we talk about the weather - he can't believe it can rain for days in England, I tell him that my ideal operating temperature range is 8 degrees to 25 degrees - this has him in creases (probably because it's been about 25 at night as far as I can tell!), I tell him how long our summer days are. Then I start explaining about the things I'm adjusting to here and say idly 'Obviously I'm used to hot and cold running water and electricity all day every day' - what?!? He's astonished, as if I just said that pigs fly! I hope that one day he will have that luxury too.

After a few hours of reading (the full manuals have reappeared overnight) I can tell the head Pharmacist how to enter new drugs and how to get the proper costs into the system (I promise to show the stores boy next week). I'm afraid I can't unlock the patient data entry part of the system without assistance. But I have 5 months! My suspicion is that a lot of the stock level data in there at the moment is wrong but perhaps if I sit with the stores boy next week then I'll get some evidence that that is the case...

How the hospital as a whole is organised and works (Part 1)

I thought it would be useful to share with you the map of the hospital that I've made and explain how patients move through it on their 'journey'. But first I thought I'd have a bash at highlighting the different groups of people within the hospital.

At this point I'm going to declare a conflict of interest (as I understand from Private Eye that this is now a legal requirement). Whilst I will try to be balanced and not too controversial, I have to accept that however hard I try I will always be biased in favour of Surgeons. So no doubt you would get a slightly different view if you asked someone else!

I've decided to start with Anaesthetists. Pretty much everyone else in Theatres thinks the Anaesthetist has a cushy job (in the UK at least). All they have to do is give a couple of injections, link the patient to the machines, sit down and start doing the crossword. In the unlikely event of something going untoward, the mad beeping of the machine will alert them whilst they think about 6 down. [Out here it's a little different without the machines to keep an eye on the patient!]. The Anaesthetist would point out that a) you can't really do any surgery without them and b) they might look like they are doing nothing but actually they are keeping an eye on the crazy surgeons who are out to 'cut' [cut is used to mean operate on as in 'how much cutting time have you had?] anything that passes by, even if it can't be anaesthetised safely.

Funnily enough, pretty much anyone who isn't a surgeon, thinks that they are crazy and on some sort of mission to 'cut' anything that moves. If it can't be cut or it's been cut then it's not really worth worrying about and clearly is a problem for the Medics! Of course, the surgeons would tell you that there's a lot of skill in knowing where to cut and how not to let the patient bleed to death and that really, they don't want to operate on everything but they really enjoy it when they get the chance to save a life. The positive impact of a surgical operation often being delivered faster than improvements in complex medical cases.

The exception to this is orthopaedic surgery. This is not for the intellectual or highly dextrous individual. This is carpentry by another name. However, out here Geoff's having to embrace it!! To no noticeable detriment to his IQ.

The other type of surgeon that isn't included in the above is the Obs and Gynae team. They tend to be quieter (probably making up for the noise their patients make!) and concentrated on their specialist area. They get a real enjoyment from bringing new people into the world! However covered in slime they might be :)

Finally, the Medics (I'm including the Paeds guys here). Arguably the Medics have a the most difficult job. Their patients are sick in very non-specific ways. There are lots of possible diagnoses for any set of symptoms (especially out here where half the diagnostic tests you'd do at home aren't available). They also, unlike the surgical patients, tend to be chronically sick rather than acutely unwell. And whenever the surgeons can't work out what's wrong with their patient (i.e. it's not immediately cutable) they ping it over to the Medics to palliate!

Map of St Francis'

I have done a basic map of the hospital for new joiners. There was nothing, which made learning the place a little tricky! And I thought it would be useful for you to see how things are laid out. All buildings are single storey. The blue lines are paths that might or might not be covered with a sunshade.  It's possible to get to Theatres under cover from pretty much all wards but the route to X ray is uncovered, which will be fun in rainy season! Augustine and Monica are the Medical Wards for adults, Kizito and Mukasa the Surgical wards, where adult is anyone over c.10 years.

Patient Recruitment

When Geoff said he wanted me to understand patient recruitment in OPD (Outpatients Department, top left), I headed off happily envisaging plates of nibbles, a free glass of bubbly and some flags with silly messages on. I actually found a massive queue that often extends the whole way along the path to the junction with the path to 'York'.

OPD isn't really just Outpatients, it's also A&E and a GP surgery rolled into one. Apart from extreme cases and ladies in labour, all patients must first go to OPD before being admitted to the hospital (if they need to be). The doctors go to OPD when they've finished the ward rounds (on days when they aren't in theatre if they are surgeons). There they sit in small rooms that might have 2 or 3 consultations going on concurrently!! There isn't much in the way of privacy, apart from one screen.

Patients come through the door as soon as the last one leaves or in great bundles towards the end of the day if they are desperate to be seen. For a few days, Nat had no idea how patients came to arrive outside room 15 (General OPD), so I was despatched to find out!

The key questions were: how does anyone know how many patients there are in the OPD? is there a triage system (ie is someone acutely unwell seen faster than someone coming for a regular diabetes check?)? who is sent to sit outside room 15, as opposed to going to another doctor or the clinical officers (COs have basic training and can deal with minor cases but refer anything complicated to a doctor)?

So, I fought my way through the door, found a quietish corner, where I could stand out of the way and watched. If there was a system, surely I'd work it out.

All patients are holding green pieces of paper - this is their notes. Unlike at home, they take their OPD notes away with them (and reliably bring them back!). When they arrive they register at Room 1, if they are new patient they get given green paper.

Next they queue to be weighed and have their blood pressure taken. They either queue down the middle corridor of the room (see the pictures below) or sit on a bench. When I was there the queue in the middle of the room was for the weighing then they sat on the bench to have blood pressure taken. If people weren't concentrating and moving along the bench quickly then there was a tendency for queue jumping, which seemed to be tolerated with a shrug!

OPD at a busy time. The weigh scales are to the left in the foreground. Room 15 is in the far left corner

When the queue is a little less hectic - note the people all focused around Room 15

After that it wasn't obvious so I asked one of the nurses on the blood pressure machine. They ask the patient what is wrong then direct them to wait outside the correct room. I look around, mostly at the throng of people sat on crossways benches outside room 15. How do they know when it's their turn? 'They are queuing, look!' She points towards room 12 where there is a bizarre orderly queue all stood up. Just like at home but with one small difference, each person is pressed up, literally, against the person in front and behind! So many things go through my mind but mostly - surely it's way too hot to be pressed up against some ill stranger??

I point to room 15 - there's no queue there, I say. 'They just know!'. I watch, clearly they don't know, arguments are rife. But there is a cute prioritising system - if you've bagged a wheelchair at the entrance to the hospital then you can just go straight to the front - mostly because you can run everyone else over! I hear that the only thing trumping the wheelchair is if you come in on a hospital trolley! Though quite how you even get one of those to the door, let alone inside the box room I have no idea. I shall return to take a photo of the feat!

So, in summary, in theory all patients are recorded on the sophisticated patient management software (more about this later!). There is some very basic triage but it is likely that many very sick people queue for hours behind diabetes patients. Nurses tell everyone where to wait. If you want to jump the queue - grab a wheelchair!

Climbing the mountain!!

When we first arrived at St Francis' it was pitch black. For the next couple of days I was convinced that we lived somewhere flat because the hospital has many tall trees and is on flat land, so it's not possible to see anything else. It was only when I went on the first run that I realised that actually the hospital is on a hill (not a particularly large one) and out to the northern side is surrounded by a rolling landscape of fields. In the hazy light (I assume it's dust we can see) towards the horizon there is a ring of large hills / mountains. The ring is broken and to the east of the hospital there is a long 'range' with one very high peak and a long flat ridge ending in 3 mobile phone masts.

It is this range that we planned to climb on Saturday morning. I ring the man that arranges it all and am pleasantly surprised by how good his English is. The previous week he had been very late picking up the group and the day had been boiling hot. This meant that the rather underprepared group (they took 1 litre of water each and no food....) had to climb for 4.5 hours in the heat of the midday sun! Mad dogs and Englishmen indeed. We vow to be better prepared so I impress upon Lightwell that we need him ready to leave at 07 hours, please.

Geoff and I did a brief assessment and decided that we needed 6 litres of water and 2 litres of Coke, plus 2 Mars bars and a piece of fruit each. I head to the Chada to acquire the liquids. I've only seen 500ml bottles of water there but perhaps a different shop will have larger bottles. I ask a chap sat outside his shop. 'No, we only do 500ml.' Why? 'Because no one around here could afford to buy a larger bottle. You are the first person to ask for it.' Oh! I retreat to Theresa's shop, it's called Get Busy (they have great names here, we saw one called 'Speed Kills'). I was told Theresa's name by John the engineer and he recommended her. She's probably in her thirties (it's really hard to age people here) and has two small Afro tufts each side of her chin. She greets me but immediately tells me my top is too short. Coming out of the shop she grabs it and gives a strong tug downwards. I had realised it was a little too short (only just reaching my trousers) and I guess the walk to the Chada has caused a crack to form between the top and the trousers. 'I'm sorry! Am I in trouble?' 'Yes'. I quickly re-tie the trousers in some vain attempt to make amends but secretly I'm pleased that Theresa feels able to chastise me!!

Geoff's phone is out of credit so I need top up as well but they are short, the man hasn't been, they have only 2 pin denominations. This is the equivalent of one minute of call time - it barely seems worth it! But Geoff's on call so we need the credit. Of course the phone rings in the night at around midnight. He heads into the hospital and I fail to get back to sleep. It's too hot, there's a ridiculously loud mosquito, I get a text telling me he'll be a couple of hours so I should lock the door, I do that. Then the phone rings again and he needs letting back in - it's 3.45am. I guess that our 6.15 alarm call is going to be painful.

I was not wrong and we are running slightly late but are saved by Rory who was called in at 6.15am and isn't ready yet. We are also saved by the weather - it's cloudy and windy!! Hallelujah. Just before 8 we jump into the nice car that seats all 6 of us comfortably and off we head. When we get out at the foot of the first incline we have to walk through someone's front yard - there are chickens everywhere. And a block of loos with one for Gients. Then, without warning, Lightwell sets off at a ridiculous pace straight up through the trees. There's no path. If I make a guess at the incline people will probably laugh so all I will say is that Rory is two steps ahead of me and his feet are level with my belly button. After 3 minutes I start to wonder why I came! How long can this go on for??? After a few minutes we break and I start on the water. Then he runs off again, calling over his shoulder 'this group is very strong!'. At the third break - we are already very high! he comments on how quickly we are going compared to last week - about that, can we slow down please?!

The breeze is a saviour and when we get to the first peak we are rewarded with an amazing view of the hill behind. Nat is cold and puts her scarf over her arms!! I agree with Will, she must be a reptile of some sort. We benefit from a long flat and can really enjoy the walk now. Lightwell says there are monkeys (he has one as a pet), Impala and Baboons that live up here. I reckon there should be Leopards too but he says not - I still think they are there - it's classic Leopard territory - hills, rocks to hide behind, small prey, no other predators. I spot some poo that my poo book, yes I have one of those - great birthday present, tells me is probably mongoose or similar.

By 10am we've made it to the top of the highest peak and we stop for our 'lunch'. The others have sandwiches and Nat has even got lunchboxes for her and Will!! That's the height of organisation! We think we are doing really well because we haven't realised how much further there is to go. And first we have to go down! A long way down! and it's as steep as the up! I imagine that we are all worried about breaking an ankle as we hurtle down on the dust and sticks. Fi and I scare a lizard that seems to run off like Usain Bolt on its hind two legs. Now the sun is poking through and it's getting warm. We are glad of all the water we have. I have no idea how the others kept the will to live.

Walking along the ridge to the phone masts we can see for miles on each side, out past the hospital in one direction and over the orange farm in the other. There are a couple of baboons ahead that scatter as they hear us coming - a bit of shame really, I would have liked a closer look. After stopping for photos by the masts we head down to the road awaiting our comfy lift home. But now Lightwell is talking about a minibus...... there is a massive clattering sound coming down the road. Right, this was a minibus about 20 years ago. Now, it's.. not fit for the road! The windscreen looks like crazy paving. There are no panels on the inside of the doors. The door doesn't even shut properly. And I'm sat on something that feels like a metal bar. But it's OK because the road is good quality - nope!! we are practically on the verge trying to avoid the holes - very nearly killing a number of cyclists as we do it.

Strangely, the second we draw level with the drive to the water and sewerage company the road becomes tar! Geoff has been talking to Lightwell. He imports precious stones (Emeralds) from Mozambique but he's 'short of capital'. This is interesting because in the past 3 weeks he has taken 1 million Kwacha off doctors from St Francis'. Compared to the other locals, he has no capital issues at all.

The value of money

I have been trying to work out the value of money to the locals. Something like purchasing power parity but not as scientific. I was thinking more along the lines of a £10 note at home is equivalent to X pin here. It varies a bit by person but for the average Zambian I think 1pin (13 pence) is about £1. So it's really helpful that the ATM only issues 50pin notes. If I want to buy anything from anyone, other than Theresa, I get horrified looks as I get out a note. A bit like one of my colleagues who tried to buy their morning coffee with a £50 note.

On Sunday I went to the Chada. The market was quieter than normal and as I approached I could sense the desperation. I try to visit a different lady each time but was tricked into going to the same one twice last week. I won't make that mistake again. I want 3 tomatoes, that is all. They pile them up in 4s but you can have any number in reality. I pick a stand. The lady starts filling a bag. 'You will take a 4th?' OK, we are quite hungry. '2 pin please?'. Now, this feels steep. I'd get 4 onions for that normally and they are more expensive than tomatoes. And these aren't very big tomatoes. But what is she asking me to overpay by - 8 pence? 10 pence? Will it make any difference to me? No. Will it make a big difference to her? Yes, probably. Do I feel ripped off? No. I leave pleased - they were lovely tasting tomatoes and perhaps she's slightly less worried about feeding her children.

Creatures in the house

Saturday was the day for creatures in the house across the hospital. After dinner we went to a party at the students' house. They had lit the living room with candles in beer bottles (mostly out of necessity as they appear to have only one lightbulb in the room) and decorated it with random bits and bobs. I'm looking at the Impala skull and horns in the corner when I see something moving on the floor. I grab our massive Maglite - that's better. It's a big spider!! Not massive, just big - about 5 inches across. It has substantial but not furry legs and is stealthily making its way around the edge of the room - extending its two long front legs slowly then pulling itself forward.

I mention it to a Zambian nurse called Emmanuel who is at the party. He's a legend in his own lifetime. He tells me this sort is common in the run up to rainy season and they are always in the houses (this reminds me of the big spiders at home that come out at harvest time and scuttle across the living room floor). As quick as a flash he's whipped off his shoe and squashed it. It wasn't poisonous he says. But, the bigger ones are! 'Bigger ones? Oh, you mean the hairy ones with brown and white stripes?' [We had one in the mess a few days ago, it was spotted lowering itself head down from the doorframe with its legs spread to about 7 inches across. The second it hit the floor it set off at pace towards me - I despatched a pest control professional] Yes, those ones are rare but poisonous! And they move more subtly (?). If you get bitten go to hospital. Right!! How rare can they be? One in the mess this week and 2 weeks before in the students' house! Eeek!

When we get back to the house there's a kerfuffle behind me. 'There's a bat or a bird or a bat or something in here!!!'. It was a little bird that had come in through the open windows [they have bars on so nothing bigger than a human arm can get in]. Nightmare! I'm tired, it's scared, there are many places for it to hide. Eventually with the help of the laundry bowl and a towel we usher it out of the window. I hope it didn't die of shock - they tend to do that!

Now, the students went clubbing after we left. I will tell you about the nightclub when I summon up the effort to go. They got well refreshed and then decided to walk home along the road. This is the closest you can get to wanting to commit suicide here. 'We had no torch, the lights of the cars blinded us but didn't light the way...' Happy times. Anyway, Simon got back drunk and probably scared to find a creature in his room. Happily he had the presence of mind to film it! It was a type of snake about 2 feet long, silver and blind (we later discover). It can be seen in the video writhing about trying to make its way across the smooth concrete floor and being obstructed by the wardrobe door. Obviously the best way for Simon to remove it was to use his flip flop to flick it along the ground and out through the door...

I'll stick with the birds, thanks!!!

HIV

If you ask most people in the UK about the top three health issues in Africa, they are likely to name HIV/AIDS as one of them (and I suspect malaria and malnutrition as the other two). This is true, but with the widespread availability of HAART (highly active anti-retro viral therapy) HIV can be regarded more as a chronic disease than an immediately fatal diagnosis than most would expect. The local population in Zambia is thought to have a prevalence of HIV of around 16%. In the terminal phases of the disease, they do present with classical opportunistic diseases (certain infections and cancers have a particular affinity for people with the form of immunodeficiency seen in AIDS), but they also suffer from all the other diseases found everywhere in the world.

This means that a large number of my surgical patients have diagnosed HIV and are either on, or awaiting the start of, treatment. A significant number will also have undiagnosed HIV. Interestingly, there does not appear to be a huge stigma attached to the diagnosis of HIV here. It is a routine part of any consultation to ask about someone's HIV status or suggest they get tested (it is referred to as VCT, or voluntary counselling and testing) and they will often answer honestly despite there being other patients or relatives in earshot. Having said that, the doctors working on the medical wards, who deal with a lot of advanced HIV and related deaths, say that families are often very resistant to having HIV written on a death certificate.

The reality, or possibility of HIV infection, does render the job of surgery very different here as opposed to the UK. Firstly, we have to consider a completely different set of differential diagnoses for patients with presentations like enlarged lymph nodes or abdominal masses. These could commonly be TB, lymphoma, late-presenting abdominal or breast cancers or indeed just enlarged nodes because of HIV. Whilst doing a biopsy could be academically interesting, the lack of available treatment for most of those conditions does mean we have to have good reason for operating.

Secondly, HIV infection does affect the prognosis of other diseases. Acute infections, like osteomyelitis or soft tissue infections, are likely to be more virulent. Cancers tend to present with widespread metastases, although this may also be due to the lack of primary health care and late presentation. We recently palliated a relatively young man with advanced HIV, a blocked stomach outlet due to cancer and liver metastases. While there was an argument for inserting a feeding tube, the terminal HIV would have made it a futile gesture.

Thirdly, the impaired wound healing seen by many of these patients increase the risk of complications of routine surgery. One of the licentiates had listed a patient for examination under anaesthetic and removal of a painful haemorrhoid. On examination she had a small skin tag and very small pile, both of which I left alone as her (treated) HIV would have made post operative infection a significant risk.

Fourth, we must consider a patient's long-term prognosis when planning time-consuming treatment. Earlier this week we elected to amputate the leg of a man who we felt had a shorter prognosis from his HIV than it would have taken to repair his multiple open leg fractures using surgical fixation. He will be better off at home with an amputation than spending the last year of his life in and out of hospital with a useless leg.

Finally, we must consider the risk to ourselves. HIV can be transmitted by body fluid exposure in the course of patient care. While it will not pass through intact skin, a needlestick injury carries a 1/300 chance of catching HIV and a splash to the eye a 1/1000 risk. This can be reduced to near zero if a month's course of medication is started immediately on exposure, however for patients with unknown HIV status a very tricky risk / benefit analysis must be undertaken, as the medications are not without complications. I have not been exposed to this point, but have operated on plenty of HIV positive patients, several being extremely high risk because of their advanced disease. I have found myself examining both sets of gloves (I double glove) when I remove them for any evidence of holes. Indeed, there are instances in operations where you pick up a sharp instrument, or slip when suturing (the needles and needle holders we have aren't the best) where you have to be extremely careful. I doubt I'll completely lose that paranoia in the next few months, despite the fact that I would feel it if I was cut in the hand while operating!

Crucially, now HIV is a chronic disease, it is important to make funding available for the other, perhaps more run of the mill, diseases that people living with HIV will encounter. This was a big reason behind our cost effectiveness research, as it is very possible that somewhat neglected procedures, like hernia repairs, caesarean sections and the management of fractures, could turn out to be essential, and relatively cheap, to the health of this part of the world.

Surgical dogma

Some things are the same the world over. I was reminded of this last week in theatres, when I arrived to operate on a burnt child to be told by the anaesthetist and the scrub nurse that I couldn't do the operation the way I had been taught in the UK. Which was also the technique favoured by the Prof. In fact the approach they were insisting upon would be regarded as somewhat substandard in a Western unit. But, there is a technique that has always been followed here and has worked for decades, so why should anyone want to do anything differently?

I suspect the world of surgery is not unique in perpetuating attitudes like this, just the immediacy and pressure of the work focuses it. Performing surgery on someone brings all the concerns, of a whole theatre team, to the fore. This is coupled with the stress of potentially harming a patient through your actions and knowing that you will be held acutely responsible for what you do.

I think it is understandable that an outsider, with different training and attitudes, and indeed a completely different cultural background, should be met with a degree of suspicion. What I found challenging was the obstruction to me even debating the reasons for my course of action, or listening to any attempt to alleviate their concerns. If our roles were reversed however, I can fully understand. A stranger arriving and insisting on doing things completely differently to the norm would be met with suspicion anywhere in the UK.

This brings me back to my original point. Surgery is exactly the setting where we should embrace new ideas and evidence and constantly change what we do. Indeed, it would be criminal to stick with outmoded, inferior techniques. But of course, the temptation to stick with what you know is often over-riding. Even in our surgical mortality meeting this morning, where I was criticising the habit of clinical officers in the hospital to treat everything from haemorrhoids to major burns and bowel obstruction with antibiotics, I met the "we've always done this just in case" attitude. This was despite me and the Professor being very clear on the indication for antibiotics in such cases.

Back to the burnt child. The best I could do was reach a compromise. The concerns from the theatre staff revolved around blood loss and anaesthetic time if I debrided and grafted a large area. I wanted to remove all the dead skin at least, so did so under tourniquets. It took 40 minutes and barely bled, but I couldn't graft. The immediate outcome was a success and I think will have won some support. Unfortunately the child was at the limit of a survivable injury without an intensive care unit and died overnight. Perhaps once I have fought a similar battle over the critical care of these patients on the ward things might change!

Anaesthetic monitoring

Close monitoring of patients under anaesthesia is a key part of surgical safety. In the UK, there are a raft of possible measures - everyone gets ECG, oxygen level and blood pressure monitoring, and those undergoing major operations can have all sorts of lines and probes inserted to make surgery safer.

On arrival here, I learnt the monitoring was provided by the anaesthetist resting their stethoscope on the chest and a finger on the pulse - clearly not as accurate as a fancy machine. Fortunately, we brought three pulse oximeters out with us. They were provided by Lifebox and funded by Smiletrain and fundraising by Charlotte. For £160 they provide continuous monitoring of the patient's oxygen levels and heart rate. They have alarms which provide immediate warning of a patient's condition deteriorating.

I did not break them out for the first week here, instead getting to know the theatre team and set up so I'd know how best to distribute them. In fact, the team is motivated and had been missing good quality monitoring. There had been one death in the recovery area the week before I arrived, which possibly could have been averted by better monitoring. In the week before we used the use oximeters, I had been doing a major abdominal case and had to tell the anaesthetist the patient wasn't getting enough oxygen because their blood was too dark!

So, the team here is pretty excited by the monitors and it is making a big difference on a day to day basis. Today I was operating and the patient had an unexpected cardiac arrest - the monitor picked it up straight away and I'm sure early CPR played a big part in us being able to resuscitate him successfully. He is only 38, and, while seriously ill, I would like to think he has a fighting chance of survival. Thank you to everyone who donated money for the monitors - once these ones are bedded in and being well used, we should be getting some more sent down to stock up the recovery area.

Things start to hot up!

The weather is getting distinctly hotter, which is quite scary given that it's not going to start raining until the end of November! We might have boiled by then. The locals keep asking how I'm coping with the heat as if they expect me to melt shortly! That said, today there is a nice cooling breeze which made me wish it had been a running day.

I have attached a couple of photos of our new place (from the outside) and the Chada and surroundings...

The back! to the hot water tank decoration

The front of Katho 2

The Chada shops

The Chada market - at sufficient distance you can't see the flies!

Mobile phone masts Zambian style... MTN was previously using the water tower!

Daily life

I thought it would be a good point to explain a little about daily life and the trials thereof. Starting with the utilities!!

Electricity

This is where the whole cycle begins! The hospital is served by Zesco, the national electricity provider. Supply has been reliable by recent standards since we arrived. A few months ago there were a series of planned outages (every other day no power) after an extended period of sudden unannounced lengthy black outs. The hospital building (plus some other buildings cheekily wired into it - including the Mess and one of the doctors' rooms) has a back up generator. However, at the moment this is awaiting parts from South Africa so it doesn't help!

Currently we are getting one or two power cuts a day but they are typically lasting only 10-15mins. The longest one was about 2 hours - annoyingly timed when I had no laptop battery left so I had to sit outside and read my book - gutting!

However, when the power is on it doesn't necessarily mean that things work correctly. The voltage goes up and down (you can tell by looking at the lights and listening to the fridge). I was tempted to get a voltmeter so I could watch what was going on (yes, sad I know!) until the Prof told me that he has one and he's been watching - quite often we have only 110V against an optimum 220V. No wonder it's dim around here and they aren't using non-dimmable CF bulbs!!

Water

The hospital isn't on any piped water or sewerage system. There is an aquifer below us and a series of pumps are used to bring the water up. You can see where this is going... So, when the power is on everyone's happy. When the power is off we have no light AND no water. On particularly bad days this affects the hospital wards as well - not ideal when you are supposed to wash your hands between patients!

The reason it's variable is that some pumps function better at low voltages than others. Hence my newly learned skill of finding taps at varying heights so I can chase down the water however low the power. The hospital's pump is the most accommodating of low power, so it works pretty much all the time there is some electricity. The old house was great because it had an outdoor tap, a bath, two sinks (same height as the loo) then the shower (then the hot water geyser miles in the sky) - a good hunting ground for pressure. Here we have only the shower and kitchen sink (the bathroom sink being an ornamental towel rail supplied by the fictional hot water). Since Saturday the shower has worked twice - once for a minute to trick me into thinking I could have one! And once for about 30 seconds for Geoff. The laundry bucket has proved useful! But shortly it will be replaced by the bucket shower! Everything is ready, all we need to do is get the rope in place...

Laundry

A week ago Nat asked us all what, if anything, we missed from home [people excluded, before you get huffy] and we all unanimously said 'nothing'. And, that's still true to a greater or lesser extent BUT there are some things that I will appreciate far more on my return.

The greatest of these is my beloved washer-dryer. I already loved it quite a lot but that was against only a vague idea of the pain that it helped me avoid. Now I have a much better idea!

There is a communal laundry here but we've been warned not to put anything in it that you really like and want to see again. Strangely, I'm quite fond of my clothes - particularly my underwear given that even a small attrition rate will cause significant problems quite quickly! So we've decided to wash some things by hand. I say 'we' for reasons that I don't really understand because I've been doing it!

Socks are the worst - they are full of dust and are almost impossible to get clean! Plus Geoff's are up to their usual trick of elaborate hide and seek. However, I thought I'd got the process nailed until one of the Kiwis asked how I was drying them..... "Outside like everyone else?" Every house, the families of patients in the hospital, the hospital laundry dries clothes outside in the sunshine, naturally...

Now, my Dad did tell me that if I went for a swim in Lake Malawi I was not to dry my costume outside but to do it inside because of Putzi flies. Sensible - I don't want some hideous fly larvae burrowing into my skin and living there for 2 weeks - ugh! Except that the Putzi fly (under many guises like Tumbu fly, Mango fly, really annoying fly) is prevalent here too. The only solution is to iron everything that's been dried outside! Suddenly this whole clothes preservation malarkey becomes more tiresome - I don't iron at home either!!

Of course we are both wearing clothes I washed at the time we make the discovery. Immediately all bites become suspicious and everywhere is itchy...

Sleeping

This is the most important part of my day. The problem is that I'm not very good at it when it's hot! And  in our new place it's hot at night. The tin roof warms up all day and then helpfully radiates all night, so no matter how much I've cooled the place with the windows open it's always hot inside at night.

When Will came back from Lusaka the other day he brought them an electric fan. It feels like every day since Nat had some story "Will was too cold with the fan last night" or "We knew the power was low this morning because the fan was slow" Grrrrr, jealous making so I decide that I will find myself a fan.

Yesterday I headed to Katete alone to get rope and a fan. A hospital car dropped me off (saving me the experience of the bicycle taxi - another day!) and pointed to where I might find a fan. The shop does indeed have a fan in the corner, a bit bigger than I'd expected (on a floor stand about 4' high) but beggars can't be choosers. "The fan is 190 pin" - 190,000 Kwacha - I'm still in holiday mode where the funny money doesn't really count but thankfully am starting to get a feel for what's a lot of money - that feels like too much. "It's my last one. [Of course it is] It's really good quality [Of course!]. I'll even give you my number so you can ring me and tell me how much you like it". OK, so salesmen have the same chat the world over. This guy's English is too good. He doesn't need my custom. I leave telling him that I can't carry that round the market with me.

As I enter the market area I begin to wonder whether coming alone was sensible. I know I'm perfectly safe but it's actually quite intimidating to stand out so much and not understand what's being said around you. A few people stop to practise their English on me as I wander (I'm looking for a hardware store that Will and I found but I don't succeed). I pick up the rope from the shop we bought the tap from. They seem surprised that I want 15m of rope "It's 3 pin a metre!" :) It's OK, I'm pretty sure I'm good for £7.50. The boy laughs in a slightly scared manner when I say that my husband is large and he needs tying up... I guess it's how you tell them.

I spy a small shop that looks like it might have fans. I head in. It's quite dark inside and takes me a second to register that the 3 people in the shop are sitting on the floor eating. They do have fans (just as large as the last one but 170pin - much better price [I've saved less than £3]). The guy grabs a box off a massive cupboard - he appears to be struggling. Too late I wonder if I'm going to be able to carry it. "Take a seat-y" [They have a bizarre habit of adding -y to words]. Why do I need to take a seat? Surely I just hand over the money and leave with the box? Aaahh, it's in pieces and they are going to assemble it. Without a screwdriver. I stare at the lady assembling my fan. She has no concept of how not to cross-thread things, she uses a lot of brute force and ignorance and now she's using a wall bracket as a screwdriver. Dear god. Fine, I'll just get it home then disassemble it and reassemble it. It reminds me of some colleagues who said that Rovers (new ones) were designed fine, you just needed to take them apart and put them together again properly if you wanted them to work!

I take in the rest of the shop - a whole glass cabinet filled with massive tower hifis, one wall for cooking pots and electric rings (I'll be back for one of those another day) and one of CRT TVs. Everything looks slightly dusty. It is only when I look back that I realise the fan has a two pin plug - not much use in a 3 pin plugged house!!! But they have 3 pin plugs in the shop and she's moving the fan towards it to show me it works. She jabs the plug in the wall and the fan works! Perfect! [I need Jamie (who lived out here for 17 years) to show me how to use a biro to press in the safety catch in the earth terminal to allow the live terminals to open up, back at the hospital - don't do this at home kids!]

I leave the shop with my massive fan and try to work out the quickest way to find a taxi to get me back. I pass 3 blokes sat on a corner. They yell at my back "Oh, she was looking for a fan-y". Now is not the time to correct their English. A nice man called Joseph drives me back in the most beat up car I've ever been in and it's only just wide enough for the fan!

***

Whilst I'm working later in the day the Prof's wife brings the son (he's 54) of the couple that used to run the hospital to see me. I need to speak to him about the Newsletter I'm writing but I also wanted to bend his ear a little about the Administration office. After the usual introductions he suddenly says "You can't leave me here with her! [The Prof's wife looks confused - he only just asked to be brought over] "She's gorgeous!" Not the usual reason that people don't want to be left chatting to me!!

We talked about all sorts of things but two bits really stuck out... "If there are no showers, how are you washing?" "Using a bucket" "But you can't get properly clean like that! Aren't you able to bathe at all?" "Um, we've been using the swimming pool at the hotel in Chipata [big grin]" I know he's going there later in the day, no doubt for a swim - he he he. "What do you know about who is going to take the role as Medical Superintendent?" I tell him a censored version of what I know, missing no key point  "Is that all you know? Interesting, very interesting" Oi!! There's more gossip and you are just going to stand there and not tell me! But... fine, I'll redouble my efforts. He's back Monday, I'll make sure I find it out by then!

Selection of wildlife

White frog in Katho 2

Skinks

On call Zambian style!

Boys climbing mango trees

The mangos aren't ripe yet but the boys are already picking and eating them. They fill the hospital at this time of year with broken limbs and sore bellies.....