Have you told them about?

We have now been working here for 10 weeks. I can't work out whether I think it's been a long 10 weeks or a short 10 weeks. All I know is that we have 3.5 months left to go.

In the time that we've been here I've noticed us slowly getting used to the differences between here and home, to the point that I don't really notice them. If you had asked me directly if I was missing things from the blog then I probably could think of a few things but not many. However, I would have been wrong - Abraham pointed it out.

Last week he said to me - I suppose you've told everyone at home about this and that and the other. And I realised that I hadn't, so I thought I'd do that now.

The linking factor in all of this is maintenance and the maintenance department.

When we moved into Katho 2 we noticed that the light fitting in the bedroom was a little dodgy but decided to ignore it. In the living area there was no light fitting but one of the visiting groups had a spare one and I wired that in myself - this, I thought, would probably be faster than waiting for someone else to come. A couple of weeks in we had a night with no power - so we sat in the dark. The following night all the lights were working except the bedroom lamp. Geoff grabbed the metal light shade and tilted the light up to see what the problem was. There was a massive bang, a spark, and darkness. The fuse box, it transpires, is next door so there was no hope of fixing it that evening as Hamish was asleep.

When Hamish awoke he discovered that he had no lights and that the fuse wouldn't go back properly! So we reported the fault in the morning. For some reason Hamish judged this not to be 'urgent' on the form, which I knew meant it wouldn't be fixed any time soon. Three days later, after multiple trips to the workshop, it was fixed. I knew it was fixed because the electrician decided to leave all the lights on to make the point. Only one small problem - there was no fitting on the bedroom light. I went back to mention it - 'We don't have any in stock, we need to get one'. This left us with a bit of a dilemma - the old one was probably fine, the wiring was just loose and we'd short circuited it (we were lucky that the wire didn't touch the shade or Geoff would have had a trip across the room) so in theory we could just re-wire it. Except that there are two switches and so it wasn't clear whether the light was on or off. For the better part of 3 weeks we waited with no light in the bed area (annoying if you want to read in bed, tuck your mosquito net in properly, generally see what you are doing). This also made the spider incident worse...

When I mentioned the lighting issues I also pointed out that the electric rings on the oven weren't working. Was I sure? Yes, pretty much, because one is actually snapped. They didn't have any in stock but they would ask procurement if they could authorise a purchase from Katete stores. Weeks have passed. The guy in procurement hasn't been asked (I met him in Pharmacy and he said not). The men in the workshop don't know that I have a single spare ring and have managed to get one of the rings to work, they clearly just assume that I don't need to be able to cook! I'm tempted to tell them that I'm going home with them one evening to eat their dinner...

So, when the door handle started to become a bit tricky I didn't see the point of mentioning it to maintenance. I knew the Dutch girls had to no avail. The door is of two thin pieces of ply and the handle has been reattached many times. So many times that around the lock the door is mostly hole. I had learnt a knack for carefully getting the key to turn in the lock and the door to open. Geoff had not. Last week the handle started to become loose and a bit of brute force and ignorance was used to 'fix' it. On Tuesday afternoon I went to leave the room only to discover that the handle was no longer attached to the shaft - so I was locked in, all the more entertaining when you consider that there are bars on all windows so the only way out is the door. I wasn't locked in for long though - Geoff's multitool proved useful for my escape and later I removed both sides of the handle and reattached them. I was pleased with my work, which Geoff has managed to break some of already...

Right back at the beginning I wrote a little bit about what I missed from home [people excluded] and I thought I would go over the list again to see if it has changed at all.

Things I miss

• Washing machine - this is still top of the list by a long way. There is nothing fun about doing laundry by hand and I don't think there ever was! When we get back the washer dryer will be working very hard to try and get the stains and dust out of the clothes we have brought here. And I shall always be grateful that in 3 hours I can have clean dry clothes with minimal effort on my part!
• Electricity - we've stopped talking about the power cuts but they happen nearly every day. Seemingly more so in the week, often at dinner times, and we sit in darkness for 5-10 minutes before the generator kicks in [The Mess is on the generator, the houses are not]. I could never really understand why one of the Kiwis sat with his headtorch on his head all the time until he was first off the mark one night whilst I was still fumbling around my water cup! On Geoff's birthday he had asked specifically for boiled eggs for lunch, I had plenty of time so I sat down to read the news a bit, the second I got up to put the eggs on the power went off! Typical. Thankfully it came back just in time so he wasn't late back to OPD. Then one night we had a semi brown out where the 100W lights became as dim as candles but thankfully the wireless router still worked. The fan was rather pathetic too, which was upsetting given how hot it was!
• Water - Turning on the tap to discover that there's no water is getting a little wearing. There does seem to be some pattern to it - works fine until 7.15am then not good until 9am, but it's not an exact science. The other night when Geoff came back late from operating it was working fine, so he got ready to have his shower, only to discover it had stopped working again. So I headed out to the outside tap round the back of our neighbour's house with a torch tucked under my arm. It's hard to carry our wide laundry basin full of water at the best of times but whilst trying to see where you are putting your feet in the night is much more tricky. And to make the point, on the way out (when the bucket was empty) I had completely missed seeing a frog jumping along the path - thankfully I didn't tread on any snakes!!

Things I don't miss

These will make sense more to people that know me very well.

• My car - I don't miss my car. I love my car dearly but there's no where that I need to drive to here that we can't get to relatively easily without owning a car and anyway, it wouldn't survive very long in this weather! I haven't even really missed driving (probably because the roads appear to be covered with very bad drivers!) but expect I'll be rubbish at it when we get back! Abraham, on hearing that I had a car, decided that I should sell it to him. I went through the logistics in my head - its value, cost of shipping, likelihood of it working out here - to determine it wasn't worth it. Only later did I remember that he's paraplegic and couldn't drive it anyway. He assures me that his brother will drive him around and he keeps asking questions about 'my car'. So now he knows what the fuel costs to Chipata and back would be, that it doesn't have a CD player (something thought to be very backward indeed!), that it's only 2 door etc
• My fish - I'm not missing the fish either. I know that they are in very safe hands at home and I have some surrogate pets here. There's the frog in the kitchen, the little lizard in the bathroom (currently AWOL) and the pair of Skinks in the roof. What more could I want?
• The Northern Line at rush hour.

World first: I admit defeat!

I know, it's shocking. Not only have I allowed myself to be defeated and acknowledged this situation to myself but I've then decided to tell everyone about it. I must have taken a bump to the head!

A couple of weeks ago I was discussing the challenges I've been facing with a wise old man that I occasionally ask for advice, and then sometimes I act on what he says. He was telling me that he was only just learning that one can't always get the outcome desired, however perfect you think you are. I said that I'd already worked this out, and I had, but I'm not sure I'd internalised it.

For as long as I can remember I've been told that I'm perfect and can achieve whatever I want. My Mum says so (except for me allegedly not being as generous at sharing sweets as my brother and having fat legs) and my Dad (except for my tendency to chubbyness and inability to suffer fools gladly). Then at school we were taught that we could achieve whatever we wanted if we worked hard enough. Broadly this seemed to be the case all the way through to the end of Uni.

But it seems there was a slight flaw in all of this teaching, [there's a bigger flaw in the school teaching because they totally overlook the reality of gender equality in the average workplace - easy to do if female teachers are in the majority and it's the men that get sidelined at a girls' school], and that flaw is other people. At school and university you only have to control yourself! If you do that then everything goes swimmingly but when you enter the workplace you need others to help you achieve what you need.

In the management books (or self help books, as my Dad calls them) they explain the principle of your sphere of control (those things you can control the outcome of) and your sphere of influence (where you have some degree of ability to manipulate but it's weaker) then there's everything else where you have no chance!

Entering the Pharmacy there was nothing in my sphere of control - I don't work here, I won't be here for long, no one knows me - I have no authority whatsoever. Mr Nyirenda was loosely in my sphere of influence because his boss had asked me to be there and he wouldn't want me to go and complain about him to his boss. But really this wasn't a big concern for him because I was working with his team and it was unlikely that I would find things that he had to do personally.

As with pretty much all of the consulting jobs I've been on, I start from the position of knowing no one and nothing about the project and I've been put there by some high level management but have to deal day-to-day with a lower level of management. No one I have to learn from or speak to wanted me there. And I'm just making work for them. That's fine, I can do this. It's a bit more difficult here because  I don't speak Nyanja so I miss a lot of the interactions between people and it's harder for me to read them because the culture is so different.

Thankfully I quickly discover that Abraham will be a good ally because he can speak Nyanja and he has some degree of influence over Mr Nyirenda, which should mean I can make some of the changes that I need to without it seeming like it's coming from the Muzungu girl. So far so good.

After a couple of weeks it becomes clear that the guys in charge of the stores have no real desire to use the computer or change the way they do things. They don't seem to see a problem with erroneously telling people that something's out of stock or realising too late that we are low on something critical. They do the things we need doing because they are told to by Abraham and Mr Nyirenda. This isn't ideal because it means that they will need supervising closely pretty much every day if they are going to be anywhere near 100% compliant with the data entry.

When I got on to looking at the dispensing staff it suddenly became clear that pretty much all their passwords had expired many months ago and they hadn't told Mr Nyirenda. So their claims to have been doing the dispensing on the computer when they had time were clearly false. OK, this is going to be tricky because now someone is going to need to check everything in the dispensary daily too. I'm pretty sure Mr Nyirenda doesn't have time to do that and there's not really an intermediate level in terms of line management in the team - it's incredibly flat.

Abraham and I have been in touch with the UK software developers to work out how to unlock the patient dispensing software. It was quite simple in the end. Mr Nyirenda is very pleased and wants to implement it straight away - 'now my reports will be very good!'. Um, no, no they won't because they rely on the data that's in the computer and it's not right..... it's not even close.

The deliveries that have come since Sande showed me that he knew exactly how to book stuff in haven't been booked in and some stuff has already been dispensed. Every time an anomaly crops up Sande and Kapapi just have a massive argument. And the guys in the Dispensary have taken to lying to me and Abraham about who is supposed to be dispensing that day. They also complain at Abraham about 'you and your Muzungu'. Only very occasionally is Mr Nyirenda there to step in [He is busy with lots of meetings and doing his job!].

He made Kapapi do his data entry from the CSSD this Friday (I have done it the past 3 weeks) and I was asked to sit beside him and watch. Amusingly he was quite happy just to sit there and stare out of the window whilst I was sat beside him. At home you'd work much faster if you had someone sat watching you but he didn't care. 'You see, the problem is that I don't like this type of job' Yes, no one does, but the more you do it the faster you'll become! 'I'd rather be jumping up and down' I resisted the urge just to do it myself. For the past few weeks they have tried to make me so frustrated that I would do it myself but I haven't fallen for it. I have been oh so incredibly patient and waited for them to join in.

Right, so where's the defeat? The defeat comes from the initial phrasing of my brief by the Acting Medical Superintendent - 'Can you go to Pharmacy, understand the software and make sure the reports are correct?' Yes, yes, No. The only way I can make the reports correct is to be there all day every day and do every bit of data entry and stock taking myself. But that would be pointless because it would only make the data for November, December, January and half of February accurate. Then I'd leave and it would stop being accurate again.

And anyway, I can't do it. Emotionally, I can't do it. I couldn't work out why I'd been miserable the past couple of weeks and then it struck me. I can't stand being in Stores and seeing critical items going out of stock whilst little is done about it.

On Thursday evening at dinner one of the medics accosted me. 'Charlotte, we've run out of Lente Insulin' Really? I'm surprised you've only just run out, I thought it would run out last week 'It's ridiculous and unnecessary' I told Mr Nyirenda 2 weeks ago, he said there's lots in Petauke [It's about an hour away by car and brings patients here about once a week] 'But we've run out and it's virtually impossible to manage Diabetes on the ward now. I'm going to have send people home to die'. This is not my fault and totally outside my control to change. I noticed the short stock and flagged it. A week later Kapapi flagged it. I'm not going to be made to feel personally responsible for the plight of the diabetics when there was nothing else I could have done.

Yesterday Geoff rang mid-morning (it's operating day and he had a massive list so I was very surprised) to ask if there was really no Ketamine (they use it for anaesthesia) in stores. There is none but Mr Nyirenda says there's plenty in Petauke. He promised they'd send a car and it would be here by 2pm. Geoff rang me again at 3pm - no sign of the car... I hope it came later in the day or operating on Monday might be a little interesting 'Yes, Mrs Phiri, we can do your operation if you wouldn't mind being awake and conscious for it, obviously you'd be able to remember every detail but imagine the tales you could tell your kids...'

Sunday sun

It feels like most of my posts deal with the challenges and rewards of working here. This is a huge part of life (I'm in work seven days a week) but by no means all. So, to show there is more to life, I'm currently sat sunbathing in the garden. My ward round is over and someone else is on call. The view is Of a blooming flame tree, and a huge yellow butterfly is doing laps of the garden. Indeed, part way through the post the iPad overheated and I'm finishing this inside later on. Horribly sunburnt but very relaxed. And next week, we have a few days off on safari...

Zambian culture is very different from the UK, right?

There are quite a few ways in which Zambian culture is very different from UK culture. We have already mentioned a few but I thought I would summarise some more ways here.

The first that we've covered is clothing. Women shouldn't show their knees or stomachs - this prevented me from showing Abraham how much darker my arms are than my tummy! Although it seems that richer Zambians (probably those from towns / cities) are more relaxed as there are a few women around the hospital that wear skirts on the knee and in Chipata the swimming ladies had short shorts on. But in general it's very conservative.

Men are the leaders of the family and it's rare for there to be a woman in authority. There are no female Zambians in any role in Theatres and only 1 female Zambian doctor. Any woman wanting a sterilisation must first have her husband's permission (and before you get too irate about that, it's worth pointing out that this was the case in the UK when I was born).

Music plays a very important role but it's not the type of music popularised by Paul Simon. It tends to be either gospel music or country music! They seemed surprised when I said neither was particularly popular back home, particularly not with people in their 20s. 'You mean you don't have any Dolly Parton? or Kenny Rogers?' [I have one song from each, I can hear my friend Dan Caines groaning at this as he has spent a lot of time trying to educate me about proper songs :) and he's doing an amazing job] I just laughed at them. 'Why don't you like country music?' Err, because it's depressing and it's always about some guy who wants to marry his dog! There is a Zambian pop star - I don't know his name but everywhere I've seen music videos there's always been this one guy on there - he is slightly plump and has many silly hats. Not keen on his music. Anyway, exactly like at home, people wander around playing music out of their phones. There's one key difference - the EU rules about hearing loss and maximum volumes don't apply here - trust me, this EU rule is really a blessing. You could happily join in a phone call here from 10 meters away and be able to hear both sides of the conversation perfectly!

The gospel music hints at my next comment - Church. Religion and going to church are very important.   There are many churches to choose from - in Katete there's a road dedicated to churches and some mad race to see who can build the largest - the bigger your church, the bigger your congregation... Sunday best is still worn to go to Church. The community is still conservative in many ways beyond dress, homosexuality is illegal, for example, which can make some hospital consultations difficult, also it's very frowned upon to have sex outside marriage - Dr Amy treated a lady who was bleeding very badly (I'll explain in a second) who nearly died because she was too ashamed to admit what had happened to her. It was only in theatre that Amy discovered the source of the blood and could save her life.

There's an interesting interplay between abuse against women, HIV/AIDS and marriage. There was a BBC News article from India this week that was similar to what I'm going to say now but without the HIV/AIDS. Each week the hospital sees women (and a distressingly high number of young girls) who have been attacked (sometimes sexually, sometimes not) by 'known' or unknown persons. There are public awareness posters in Chipata urging the community to stamp out this behaviour. Near the administrative centre in Katete Boma there's a painted sign that says 'Rape is not only a violent act, it spreads HIV/AIDS.' I'm not sure whether they think the blokes care more about giving the woman AIDS than mental scarring or whether they are suggesting the women have AIDS and will harm the rapist. Whichever way round, it is clear that rape is a significant issue locally.

For some time I was interested to understand why HIV spread so quickly through Africa. It's easy to point to a lack of education (true), lack of availability of condoms in remote areas (true) and the fact that it went unnoticed for many years before being detected. All of these are correct. But, in normal (as defined by Western practices) consensual sex the chance of passing on HIV is relatively low (falling to 1/900 if the infected person is on ARVs). However, if there is significant tearing on either side and blood to blood contact then it's much higher. It seems to be the preference of men here for that sort of thing to happen (remember the lady earlier) so the chance of spreading the virus is much higher.

It is pushed higher still by the richer men from the towns that come out to the villages with presents to try and procure sex. And some traditional healers still tell people that sex with a virgin will cure them of the virus. Not desperately helpful. There are lots of health posters around the hospital urging women to wait and not to accept presents, to think about their future and career aspirations.

And because unmarried women often feel ashamed of what has happened to them (whether they consented or not) there can be a significant delay in seeking treatment which can, unfortunately, have serious consequences on their health.

But it's not all unlike at home. The other week Nat was approached by a mum who said that her 15 year old daughter had been 'defiled' and she wanted a medical opinion on her police report. Sometimes it can be tricky to be certain of what has happened, particularly if there is a late presentation. In this case the girl was mute in the presence of her mother. Nat despatched the mother to the end of the ward and suddenly it all came out. She hadn't been raped, it had been consensual (if illegal), she was in love with a married man of 22 and she was going to have his baby... Nat had a little feel of her tummy and, yes, more than 20 weeks gone, she was indeed having a baby. Well, that made the police report easier to fill in at least!

A 30th birthday to remember

It seems I turned 21 again today. I woke up expecting a normal day on the wards in OPD followed by goat stew then a couple of Mosi (the local beer) in Tiko's (the local bar). The first half at least was true!

Work was tough - the Prof is away and a major case I did last week (the extended right hemicolectomy for a transverse colon volvulus) has not been doing well. He developed a post op ileus, which is difficult to manage in the UK with IV feeds and complex blood tests as well as intensive care back up. Here it is nigh on impossible and he died while I was seeing him on my round this morning. I don't think it was any error on my behalf (he was sick for ten days before even transferring here and indeed he was so obstructed his bowel was about 15cm in diameter), but it remains a tragedy when a young person dies.

Following this, the rest of the day was pretty straightforward and I got home early to interrupt Charlotte being devious [This was very naughty of him and he really ought to stick to the Prof's 4pm meetings even when the Prof isn't here...]. I was instructed to close my eyes while she left in a hurry. We then had sundowners in front of a beautiful sunset, then a surprise dinner at Nat and Will's, with them and Rory and Fiona. A firelit dinner, under a mango tree and black moonlit sky, is quite a special way to spend a birthday, and we also had a huge chocolate cake. Rory and Hamish only temporarily tried to interrupt proceedings by asking for an empyema to be drained, but then decided not to do it tonight.

[He forgets to mention that we cooked bangers and mash with peas and onion gravy, well, I say we but I mean Nat and Fi! Thanks girls!!! I was helping Rory with the drying up when I realised that he'd covered Nat's floor in sausage fat (Unlikely to go down well). Obviously the next thing to do is cover the fat in washing up liquid 'You're a scientist Charlotte, you should know what I'm doing!' No Rory, I'm a girl, and I know that adding another slippery substance to the first one on the floor is not going to make Nat happy - getting the mop and bucket on the other hand...]

Can I use underwear as swimwear?

This weekend we went to Chipata on Saturday. For a while it looked like Geoff wouldn't be able to come again but he managed to swap his on call. Otherwise I would have felt too guilty to go for a second time without him!

We left as soon as everyone had done their ward rounds and headed straight for the shops. As Will was away we had to get a 'taxi'. We have a regular called Billy whose car can seat 6 passengers. We were 7 people so the back row was not overly pleasant! As has become the norm, we were stopped by the Police at the checkpoint until the usual cop and Billy could come to an agreeable arrangement about the bribe required to get us through. Apparently some of the other 'taxi' drivers drive a long way round off-road to avoid this particular inconvenience.

Shopping done we rushed into the hotel and Billy spent the afternoon ferrying more passengers surrounded by our bags!! We planned to relax by the pool. Just a few problems were evident - 1) there were more of us (the students had all come too) than there were sunloungers and there were other people there and 2) for some reason we were having difficulty getting the staff to bring us towels. This had never happened before and they assured us the towels were coming. All we could see was a man madly trying to pick up towels and running off. Surely they hadn't run out of towels?? After a while the man came back with 2 steaming hot towels which went to some of the students. We resorted to having lunch on their upholstered chairs damp - we had asked enough times. After a while, when the guy tried to take the towels back off us that had taken over an hour to come, it became apparent that they really do only have about 20 pool towels so on Saturday afternoons they are short!

This is OK later in the afternoon because the locals seem to bring their own towels and also their own take on appropriate swimming attire. The last couple of times we had seen small children swimming in underwear and thought that understandable - kids grow quickly, swim kit is expensive, it doesn't matter if they poo in the pool (OK, not the last bit). But today was different, today the Mums were coming swimming too. Nat and I watched a couple of them approaching. Surely the one on the left was wearing a skin coloured basque - that can't be right! It was harder to see the one on the right as she was wrapped in a towel (probably for the best as she wasn't the most svelte of ladies). She was wearing a white bra (we both whispered 'M&S' together) and white cycling shorts. This isn't going to go well - hopefully she has something on underneath!! We can already see that the shorts are on back to front. Thankfully, she is wearing something underneath - black spotty knickers!!

As is becoming standard, a small child jumped into the pool and had to be saved by Fi when it became clear she couldn't swim!!

On Sunday we just relaxed. [Well, after Geoff did his ward round and he was on call, so obviously the phone rang about an hour after we'd gone to sleep so that we both felt like we'd been called back from the dead!]

Communication

As part of the cost effectiveness study we would like to do, we are collecting the data on all the Caesareans completed in a 12 week period. For the past 7 weeks, Amy who is working in O&G has faithfully been collecting the data and providing me with the sheets. Her writing is legible and thus makes a nice break from Geoff's forms...

However, Amy is leaving on Saturday and we decided that probably the best thing would be if I did the collection for the rest of the study as there's no one obvious to take over. On Sunday afternoon she showed me around the delivery suite and maternity ward and this week I am to do the collection alone but safe in the knowledge she can help if I get stuck.

On Monday I headed in at the agreed time, made my way into the office in the delivery area and found the correct book. I got the names I needed and headed out to the ward to try and find the ladies. The first was easy - right by the nurses' station so I could remove the notes quickly with a quick smile to her and her mum and complete my work away from the bed.

The second was in the middle of the bay and it seemed a little too far to drag the notes away. I already knew that the girl was 16 and unmarried (both very frowned upon here). She was also alone. As I got to the end of the bed she looked up at me with large eyes. I knew what they said 'I'm scared, I'm alone and I'm not sure how to get my baby to feed'. The last bit came from watching her actions. I froze because I knew I couldn't help. I can't help because I can't speak to her. I don't speak Nyanja and I can see from her consent form that she signed with a thumb print, so she can't write and therefore can't speak English either. It was a horrible feeling, not because I could have helped her breastfeed if we could speak the same language - I know nothing of that - but because I did have 20 mins or so to spare to talk to her, if it would have made her feel better, and I couldn't. I tried to smile and ask her how she was but she didn't respond - I guess I said it very quietly and don't pronounce it correctly so she didn't understand me. I looked at her notes quickly and left.

This evening I asked Amy what she does. She also doesn't have enough Nyanja to deal with that situation (unless you think that asking if she's bleeding would help!) but she said she just strokes their heads and that's what Dr Joop does too. Isn't that a bit personal? Apparently not, the patients touch her all the time she says and it seems to make them smile. Maybe I'll try that if I ever get stuck again, although I think that might feel even more awkward than not saying anything at all!

This isn't the first time I've experienced this but normally it's different and the meaning of a question can be worked out from the context. Old ladies on the way to the Chada with cupped hands are asking for money. Women yelling at me whilst I'm running are complaining about how I'm dressed or calling me foolish. Men yelling at me are, well, men yelling at me - standard. And occasionally there's someone who wants a conversation and who hopes that if they speak slowly and clearly I will understand. Unfortunately I don't - Nyanja is so unlike any European language in its form that you can't guess anything - you either know it or you don't.

On the way to Maternity on Monday a lady sat on the bench had held out her hand to me quite deliberately. This was unlikely to go well but I stopped. 'Hello' - good sign, we are starting in a language I understand. 'Are you Cairns?' Sounds confusing but is asking me if I'm related to the couple that used to run the hospital. 'You look like Cairns' - Faith had red hair too, although I'm told it's not as strong a red these days. I explain that I'm not related but that I have heard of them and that I'm also from England. 'How many years are you staying?' Ahh, this is tricky. I respond with 'not even one year, half a year'. 'Not even one year??' Today Abraham asked me why the muzungus don't stay longer - 'we need people to stay for much longer than 6 months'. It took a long time to answer talking about money, lost wages, difficulty taking breaks from training and the other things that might make people think twice about staying longer.

Marauding mango trees and other African hazards....

(This is Geoff posting on Charlotte's computer)

Ask most people about dangers in Africa (I'm sure I've covered this topic previously) and I'm sure they'll list lions, elephants, hippos, snakes, spiders and all the usuals. Some may even say road traffic accidents (pretty high on the local causes of death). I doubt many would pick up the two major causes of paediatric trauma seen at St Francis' - mango trees and ox carts.

It seems that falling from mango trees is a rite of passage amongst the youth of Zambia. It has now reached the point that when a child comes into our OPD in a sling I just say "mango tree....?"and the parent nods and smiles. Today (an emergency OPD day only) I have seen four broken wrists, a fractured elbow and a bruised back, all from falling out of mango trees. I also operated on 4 other children admitted over the weekend with fractures from mango trees (most upper limb again, one girl also had a femoral fracture). Some of the children are as young as 5. Most of them seem to bounce to a greater or lesser extent - where you would expect serious injuries from falling from up to 10 feet, they often just have isolated limb fractures. Which is good, because I expect they are back up the tree as soon as they can (I bet some of them in their plaster casts).

Interestingly, the mangos are not yet near ripe, they seem to enjoy eating them when they are quite hard and incredibly tart. It is suspected (as already mentioned) that the recent spate of sigmoid volvuluses is down to eating large amounts of unripe mangos. It is difficult to blame though, when the only fruit readily available is mango and people are both hungry, and keen for a sweet snack. I have however created a new acronym to use in OPD - MTRI - "mango tree related incident".

Having covered the many dangers of the mango tree, I should also point out the more obvious danger of moving ox carts. Cattle are everywhere (they regularly walk outside our house) and are a major source of transportation for people away from the main road to bring their produce to market. Children however do seem to make a habit of tumbling from them. It seems to be just enough to break an arm, or if they get stuck on a wheel to break a leg.

This all makes the more exciting recent crocodile bite a little more exotic!

This week's gory details

I haven't really put that much detail into the blog on what I do in a usual week's operating. I assume some may be interested, so I have taken this week's log book and put its breakdown below:

• Skin grafting - 1 (it's normally more like 3 or 4)
• Examination under anaesthesia and fistulotomy of anal fistula - 1
• Cervical lymph node biopsy - 2
• Closed manipulation of fracture - 5 (these normally include wrist, elbow, humerus and tibia fractures)
• Incision and drainage of abscess - 6 (all over the body)
• Finger amputation - 1 (for chronic osteomyelitis)
• Wound debridement - 4 (including burns)
• Open reduction and fixation or K-wiring of fractures - 3 (forearm, thumb, elbow)
• Above knee amputation - 1 (infected open fracture of the femur)
• Elective inguinal hernia - 1
• Laparotomy - 1 (extended right hemicolectomy for massive volvulus of transverse colon)
• Removal of foreign body - 1 (needle in the hand)
• Excision of lesion - 2 (keloid of the ear and granuloma of the groin)
• Suturing of wounds - 2 (nailbed and face)

Total - 33 (allowing for some patients to have return trips to theatre) It is a proper old fashioned general surgery set of cases!

Surgical fatigue

One of the pieces of advice I was given before coming out was that I could be working all the time, day and night, and I would have to watch out for myself. This is starting to prove true - I have had a fantastic, if hard work, few weeks but feel like they are starting to catch up with me now.

The working week is currently set with a full day (0800 to 1600 and sometimes later) operating Monday, Wednesday, Friday. Before the list we do the round (at the moment my ward has about 50 patients) and after we check on the sick patients and any new admissions. Generally there is a medical student or trainee licentiate on call on those days, so we have to check on what they have done and review any ward referrals with them. Tuesday and Thursday are for detailed rounds and OPD. We are supposed to do one OPD day a week each, but there aren't enough to do that at the moment. Emergency operating happens whenever it is needed, but most can wait for a regular theatre list.

At the weekend, one person has to see each ward every day. This weekend it is me and Sidney, last it was two medical students so I went in and saw the critically ill patients and new admissions each day. At night, there is an on call system. Every night there is someone who can do emergency obstetrics (this does not yet include me as I have had no time to learn!) but not always someone who can do emergency surgical operating. When the Prof is here, he expects to come in for every major case anyway. When he is away, Sidney and I informally cover that on top of our rota'd commitments (hence I did a midnight colectomy on Thursday night when not on call).

So, things do seem to pile up in a way that they don't in the UK. Coupled with living in the hospital and rarely getting away (we did have a burger and a swim in Chipata after my round yesterday) I'm starting to notice how fatigued it is possible to be. I suspect those familiar with the "good old days" of medicine in the UK probably experienced it in a much more consistent fashion.

While I'm not at the stage of making mistakes through fatigue yet, I have started to prioritise what I do and how I do it in order to prevent myself getting to that stage. Things that don't need to be done urgently can be left to a ward round or routine list, I'm leaving a lot more dressings to nursing staff (even when persistently asked to do all the basic wound care on the wards) and I'm making sure I get home, have a shower and a sit down before dinner at night.

I think the message is, things are busy, they are enjoyable, but if you work with the same intensity as in the UK you will burn out very quickly!

The heat is beginning to be exhausting!

For the past few days, although I thought the temperature had gone down a little, we all seem to be complaining of non-specific tiredness. I've been yawning through the afternoon and Geoff's been nodding off in his chair much earlier than usual - it's 9pm and he's very much asleep already.

My only conclusion is that it must be the heat and it is exhausting. Even the Zambians are complaining about how hot it is. Not that that has stopped them wearing t-shirts under their shirts and other bizarrely hot clothing. I even saw a guy wearing a wooly hat today!

There is one set of shelves that still needs counting in the Pharmacy stores and a set of boxes that needs moving to the other store. I sense in the morning that it's unlikely to happen. Sande has busied himself fulfilling a requisition and is complaining that the shelves I'm pointing at are inaccessible because the fluids are stacked up against them.

I'm not going to fight him on my own, I need Abraham to lay down the law. So instead I head into the antibiotics storage room to check if the aircon is on. I know that it's 80% likely that it isn't on. And I'm right. I press the button but have limited success in getting it to come on and stay on. I look at the thermometers. There are 2 in the room - one taped at eye level to the shelving (which they don't use) and one lying on a shelf (which they do use). All the temperature recordings are suspiciously similar so that a typical week of maximum temps looks like 25, 25, 25, 25, 25, 25, 25. Very convenient when the max temp of the drugs is 25. The first thermometer with a watch-like face reads 27 degrees - that feels about right.

The second thermometer is more curious. It's of an older sort with the bulb of fluid at the bottom and a glass tube. It appears that a good few inches of the top have broken off. My suspicions are confirmed when I put my thumb on the bulb and try to heat it up - nothing happens. I also notice that very conveniently it has been shifted in its casing so that the 'temperature' lines up with the mid-20s on the scale. Unfortunately the genius that did this time- and stress-saving manipulation didn't look too closely at the scale in question - it's the Fahrenheit scale... And whilst I might have had difficulty proving that the room was 27 deg C and not 25 deg C, I'm pretty sure it's definitely not 20 degrees Fahrenheit.

I am frustrated. I can understand and sympathise with people not wanting to use the computer software if it's complicated and they don't really understand it. Especially if they have to do paper as well. I can understand that it's difficult to run an efficient store if other people take things and jumble up your shelves when you aren't there. I cannot understand why a grown adult who has chosen to work in a hospital would do something as childish as manipulate the temperature readings of essential drugs. Well, I can understand - it saves you the work of having to fix the aircon and worry if the drugs are still viable, of course. And it isn't you that's ill so you won't benefit if the drugs actually work, but really? Is this the level of apathy in Pharmacy?? (at least amongst some of the staff). I was still hoping that I'd misinterpreted the apparent apathy when critical items go out of stock or that babies are suffering because the oxygen concentrators they need are in boxes in the stores. Maybe it is a case of out of sight, out of mind. Certainly the patients coming for their HIV drugs get treated well.

After speaking to the Workshop Manager, who comes to look at the air conditioning unit and change the settings, I decide to go home and do some other work. And that's not just because he tells me that the unit in the big chilled room is known to be malfunctioning but isn't a priority to fix! I don't know what my priorities would be, and probably this wouldn't be no1, but I'm hoping that keeping the drugs cool would be high up on the list. Probably above the cost of painting my bathroom, which is allegedly happening tomorrow morning at 7.30.

In the afternoon Abraham and I try to persuade Sande to start with the shelf tidying. I'm saying persuade Sande not because I don't want to do it but because I refuse to do it without him. There is no point me doing it by myself (the previous time he was stood with me but not moving, this time he was going to be in the Dispensary) because he won't notice or care or take any pride in it and the shelf will just get messy again. He must be doing most of the work with me helping. There's a very animated debate in Nyanja that Abraham summarises to 'he's too tired today (it's 2pm), he will do it tomorrow first thing and he knows he will (even if he does it with an angry face) because otherwise I will tell Mr Nyirenda!'

The items that were in the wrong store room have miraculously made their way to the correct one but I'm a little concerned that they were missed in our stock taking exercise and I'd like Sande or Kapapi just to check a few numbers so that we can be happy everything is fine. An argument breaks out with all manner of finger pointing and aggression. I interpret from the movements that Sande believes that Kapapi is at fault and therefore Kapapi must sort it out. I try to point out that we are one team working towards the same goal and perhaps fighting with each other isn't the best way to make sure we can work together happily in the future. Plus, it's wasting time and we could be halfway through counting by now if we weren't having domestics in the corridor.

Now that I've written out what I've been up to, I wonder whether it is just the heat that's making me tired! And Geoff has been operating all day. Including an unfortunate incident with the Prof slipping and possibly cutting him with one of the instruments. [The patient is 80 and tests negative for HIV].

I spent a little of the rest of the afternoon talking to Abraham and now I think I know his whole story and also that he can't count! It started with me asking his age and him telling me to guess - I took Geoff's estimate and said 44. He squealed at me and stuck out his tongue. Then he pretended to be 29. After a time he told me he was 32 and born in January 1979 - I pointed out that either he can't count or he was lying to me again! He thought I was 34!! [which, on reflection, was probably less insulting than my 44] and then found it hilarious when I huffed at him that it was very rude to say 'Really????' if a girl tells you her age and you think she looks OLDER!

Anyway, he has known the hospital since 1988 and I think he will be a good source of stories and anecdotes over the coming weeks!

Parental food advice

I know this is two posts in quick succession but it's too good to miss...

After the posts about the goat (there was more this evening) both sets of parents have offered advice about the best approach to tackling the meat shortage - principally 'is it worth trying to buy a live chicken and convert it to food'

Charlotte's Mum: 'Don't expect the surgeon to do it. In my experience they have no idea and will complain it's not in their skill set' [I think this has been her experience with pheasants at home]

Geoff's Mum (to Charlotte): 'does the surgeon not know how to kill and clean a chicken?
If not he should speak to his dad - sounds like a kill and clean will be much needed!!'

OK, so we already have conflicting advice on the advisability and who should be tasked with the job. I have subsequently inquired of Joyce whether she thinks a tiny kitchen with unvarnished wooden surfaces is the right location for this act - apparently it's fine if we have a sink.

We have just returned from Tiko's to find what I imagine will become an infamous email from Geoff's dad...

Hi Charlotte

As the only member of the Roberts clan to have killed and cooked a chicken "in the field" I should add let me explain.

1. The Kill  Grab the head in right hand and body in left. Apply tension and with teeth bite firmly 1-2 cms below the back of head. Crunch through the vertebrae (they are quite soft really) and apply increasing tension until the head detaches from the body(or you could do as you find on youtube!). The chicken is now actually quite dead though it may still appear quite active. Dispose of the head. [He's kidding right??]
2. Do not pluck, it is time consuming and measy [He's been drinking? Yes, John, I know you are reading this]. simply skin the chicken and hey presto no feathers!
3. Personally I would at this point take off the breasts and the legs and wings roast with some garlic, herbs, balsamic and lemon serve with crusty bread and a good chardonnay but if you want to roast a whole chicken I believe they have a "vent" Do you know any vets?, they may be of assistance at this point, you may even get an egg when you open the vent and stick your hand in to drag out the entrails. [Um, I think we are good with the goat for now, surely?]

good cooking

always at your service

Dad

Does anyone know a good psychiatrist based in the North East that has a few moments to spare over the next week or so? I would be most grateful...

A taster of the rainy season flora and fauna

I should really be rinsing my clothes but we seem not to have any water at the moment, which isn't in any way convenient but I guess I would be more annoyed if I really needed a shower.

Anyway, it gives me a moment to write about the flora and fauna of rainy season. I'll start with the flora (briefly) as I guess people will find that less interesting :). When we arrived, the Jacarandas were just starting to flower. Amazingly the two waves have kept us surrounded constantly by purple flowers all the time. On the way to the Mess we walk over a carpet of purple flowers - it seems a shame every time Alick sweeps them up!

A few weeks ago the Frangipanis started to flower. Nat has one in her garden and when we arrived the weekend before last she had a flower in her hair - very exotic. Last Friday morning I noticed that the leaves were coming out on the Baobab on the running route - I'm sure they weren't there at all on the Wednesday, so they must have started quickly. I'm really looking forward to it getting its full complement because I've never been in Africa when they've had leaves before!

Most recently a tree with bright red flowers has flowered. Nat refers to them as fire trees, but I'm pretty sure that's not their real name!

All of this activity points in one direction - the rains are coming soon!! Everyone tells us the 24th of October and we've only recently realised that this is because it's Independence Day!

And we've noticed a difference with the animals too. The prevalence of snakes has definitely increased over the past couple of weeks. Nat nearly trod on one. We saw one on the way back from Tiko's the other night. Two people were bitten on hospital grounds this weekend. There was one wrapped around the loo seat at the students' house and they found another this evening. Things are waking up.

Unfortunately this also extends to the spiders. The students first, with another of the big spiders with ultra long front legs that we saw at their party. They are known round here as Red Romans or Sun Spiders - they are Solifugae and, if Wikipedia is to be believed, can travel at 10mph! Except if Pete has splatted them with his shoe.

Next to 'benefit', as some of you on Facebook know, was the Roberts household. Yesterday morning Geoff got dressed only to make mad shaking movements as he attempted to get a spider off him (it was on his clothes when he picked them up - a common trick apparently). This was soon dispensed with.

In the evening I was sat by myself doing some data entry for our study. Geoff was on call and had headed in to see a fracture. I saw something move out of the corner of my eye - normally this would be a cockroach or lizard. Tonight it was a rather large (but I have to admit not one of the two largest sorts of) spider. It saw me see it peeping out from around the half wall to the bedroom and quickly made a dash for the shoes. A cunning move designed to prevent me from arming myself. I thought I had outwitted it by reaching for the bug spray that works 'ultra fast'. I sprayed the offending area only to see the spider shoot out of its hiding place and return to the bed area (where there is still no light!). This was not ideal.

I returned to my chair to work out what to do. I decided that I could see the main aisle from my seat and  that it was likely to try and come back towards the shoes shortly. So I should just sit and wait. I forgot to arm myself with a shoe. Just as I realised this mistake it came peeping out around the wall again. I flinched towards the shoe at which point it made a break for it, heading towards our bed on the other side of the room. I decide that this is unacceptable. I'm not having it sneaking around my bed so the bug spray will have to be used again. I sprayed it hard. Nothing happened. I sprayed again. It did a forward roll. I sprayed again. It did another forward roll. [I'm waiting for it to do what everything else does and flip on its back.] More spray. This time it lies on its belly and lifts all its legs in the air. Maybe this is what I've been waiting for. Now is my chance to whop it with the shoe but I remember that Mum wanted a photo of the spiders and I can't splat it! Not much of a photo. As I'm debating whether it's safe to turn my back it starts to move. Very slowly it lowers each of its legs in turn and crawls off under the rucksack. This is too much. This spider is immortal, unkillable and like a zombie. It is also, clearly, a man eater.

I retreat to my chair and lift my feet off the ground. Who knows where the bloody thing is now? This is the first time that part of me wishes I was back in the UK and another part of me is quietly pointing out that I laugh at anyone (mostly girls) that say they stand on chairs to get away from spiders until their boyfriends return. However, I'm not getting down until back up comes. Suddenly I hear a noise over my left shoulder and on the floor is a large cockroach being chased by a very small lizard. I'm in a zoo!!

I have chronicled the events on Facebook and, just as I text Geoff to tell him my position, I get a call from Nat offering to be back up for me - as long as I kill the cockroach! I get off the chair and do the deed - simple enough. When she arrives we decide that she should have the weapon (her own bug spray) and a torch and I will have a torch and the mop to poke the rucksack with. We prepare for the worst (OK, I prepare for the worst and Nat is left wondering why I've allowed the bodies of 3 dead cockroaches to remain under my bed - in truth, I thought there was only one (and I was leaving it as a warning to others, as you would a dead crow) and now I can see the dust under there I'm a little embarrassed). Anyhow, I poke gingerly at the rucksack and immediately it becomes apparent that the spider crawled under it to die - for there it is just twitching slightly. Nat sprays it with Doom for good measure and it becomes motionless.

Now it's safe to photograph (see below - yes, I know, there's no scale). On reflection, I might have overreacted slightly but I still insist that holding a torch, a weapon and a poking device is really a 2 man job - plus two sets of eyes to watch the crafty things are essential! In the past 24 hours we have sealed all the windows and ventilation bricks with mosquito netting and blocked the gap under the door - take that, suckers!

Man eating spider - was about 4.5" across fully extended

Pet frog turning black, showing it is coming out of hibernation

Where did my dinner money go?

I had intended to keep a weekly food diary to let you know what the food is that we are getting out here. I did keep the diary but never made time to write it up, but you've probably picked up on the references to goat by now. In truth, we aren't 100% sure it is goat but it doesn't look or taste like beef and it certainly isn't pork or lamb...

However, what used to be a plentiful if a bland, unimaginative, repetitive repertoire of food has become markedly depleted over the past couple of weeks (in portion size as well as content). We get dinner free every night, which is a main course and pudding. I eat the lunch there on operating days - which also normally has pudding although this was bananas pretty much every day for the first 6 weeks.

The first thing to go was jelly. (Yes, we loved getting jelly 3x a week, it was like going to a child's birthday party all the time, ahem). Then the custard mysteriously stopped, so the rather dry cake became somewhat inedible. I think to placate us they hit on the bright idea of serving it with hot milk. The first night no one touched the milk but tonight it all went! We are getting somewhat desperate.

Inadequacies in the puddings can be coped with as long as the main course is fine. However we appear to be suffering from a major chicken shortage. It started on Friday a week ago. Friday is a chicken night but there was goat again. We grumbled - this isn't fair! We put up with the goat because we normally then get lots of chicken to make it all right.

But it's OK, Sunday is always roast chicken night. We piled in eagerly to find 3 small chickens to feed 19 people... the grumbling got a lot louder. Portions had to be re-divided to stop fighting breaking out. We decided we would really complain if they didn't give us rice pudding. Miraculously (perhaps they heard us), rice pudding was forthcoming. The riot was averted.

There was no chicken all week and it became clear that they are running short of lots of other basic ingredients too so the goat stew became the daily staple. At day 4 some people just walked straight back out of the Mess. Even the chips (first time in 2 months) on Wednesday lunchtime didn't placate the students much.

Thankfully, for Nat's birthday today, we had cheeseburgers and chips for lunch followed by the chocolate cake that Geoff and I made secretly yesterday. One of the students told us to expect chicken for dinner - we hoped that normal service had resumed. We bundled in together (there are now 21 of  us) to see 2 small chickens.... um... 'there's also some beef'. Nice beef? Nope, about as tough as shoe leather.

This isn't funny because we have almost no alternative. Tonight for example, the power was off from 6.30pm until 9pm and we only have electric ovens. Also, it's really difficult to get the ingredients that you need. Really you have to go to Chipata, which is ruinously expensive if you don't have a car. We discovered last week that we can get meat in Katete (and none of us died) but you have to trust it's been kept frozen since processing and with all the recent power cuts that's not really feasible. None of us has the skills to buy a live chicken and turn it into diced chicken... even though we could have a chicken for 30pin (c.£3.50).

Although, now I've cooked in the Mess kitchen, I do wonder if I shouldn't be seeking an alternative. I'm not sure what I think is the worst of the following points but, as far as I could see, there's no soap, there are ants and flies on everything, there's a hideous stench of rotting meat coming from somewhere and they are clearly comfortable with rats. When we said there was a rat in the dining area last night (second night in a row we'd seen it) the guy came out and said 'Oh, it's only a small one'!?!? Yes, my friend, it is small but it's still a RAT. He then came out with a broom to kill it. Unfortunately it escaped but it was amusing when he shouted in rather broken English 'Oh!! I missed it!'.

Not that this is the point. Doctors contracts include the provision of food (which we assume is funded in the same way as salaries - with money direct from England) and the students are paying £8 per day for their food and board (which is much more than they cost the hospital) so there is no excuse for the food running out. So my question is - where did my dinner money go?

Death

One of the things that can make doctors seem a little peculiar in the UK is the constant exposure to illness and death and how that makes their attitudes differ from that of society at large. Here, things are completely different again, and at times completely incongruous.

To me, I go to work every day (7 days a week) and see people dying of conditions that would be curable in the UK. This is partly due to late presentation and lack of good preventive health care, and partly due to our resources (we recently discussed the set up of our burns unit and realised that the budget of the whole hospital paled in comparison to that of a western burns unit). To the locals, they come here because we are their best hope, and a significant number of them have their lives improved or prolonged.

This makes the attitudes to death and dying somewhat different from those at home. Amongst the staff, there is at times an incredibly fatalistic attitude. Sometimes we won't see a patient on the round and just be told they "collapsed" overnight. Death is much more readily accepted, and people are less likely to try and work out what went wrong and more likely to accept it as a result of working with the limitations we have here.

This doesn't fit very well with a case I came across this week. Suffice to say, it involved a child with a non-survivable, but not immediately fatal injury. To survive, the child would have needed specialist surgery, intensive care, huge amounts of blood and a three month hospital admission. The nearest unit in which they would have had a chance is probably in South Africa. Even with that, there would be a significant chance of dying. We made the decision not to do anything painful or distressing to the child and allow them to die. This was met with a lot of resistance from the nursing staff. It seems here that it is culturally very difficult not to give maximal treatment, even when everyone knows it is futile. I have spent a lot of time talking to the mother (with the nurses translating), but was still asked this morning when I was taking the child to the operating theatre. Indeed, the Medical Superintendent tells me we have to be very careful in this situation, as patients who perceive that they have not received the same treatment as others are quick to complain and sometimes sue! We have however stuck to the principles of not doing anything futile and distressing and are keeping the child comfortable.

Things are however sometimes different. We recently had a case with advanced HIV, which was resistant to most treatment regimes, coupled with metastatic cancer. After a long discussion with the patient and family, they died comfortably surrounded by friends and family. I today performed an amputation for gas gangrene in a severely ill gentleman. When I had explained that he might die despite surgery, the first comment from the wife was "should I take him home then?". She seems very accepting of what is going on and almost matter of fact about how ill he is. I'm sure such abrupt news would be met with a much more emotional response in the UK.

Of course, when someone dies, there is the wailing. It is difficult to describe, but there is a noise made by recently bereaved relatives, or occasionally very distressed patients. We encounter it every day, often with groups of relatives leaving the hospital or sat in the grounds. It can be quite distressing to hear, particularly the first few times you hear it, but is clearly the local way of expressing their grief.

Death is perhaps best seen here as something that is a little bit closer than we see it at home. The constant risk of car crashes, falling from trees, snake bites and severe infections (worse in those with HIV) means everyone is exposed, and at risk, every day of their lives. This makes attitudes what they are.

Donations, kit and chucking out rubbish

It seems to be a peculiarity of this place that everyone becomes a hoarder. Theatres are remarkably well equipped, but not a lot of what is there gets used, and the stuff that is used is invariably the really old battered stuff.

This morning Prof and I had planned to put an external fixator on a child's severely broken forearm following a crocodile attack. We were delayed by a C section so had ample opportunity to have a hunt through the store room (which was needed as all the external fixators had been creatively filed away). There is an incredible amount of stuff there, stored as best as possible in the limited space:

• Loads of orthopaedic kit (screws, plates, k wires, nails)
• Vascular grafts (not sure when we'd ever use those but they went out of date 18 years ago)
• A full urological kit for doing cystoscopy and trans-urethral resection (currently no one here does these)
• Cupboards full of random elderly instruments (including some old wooden mallets)
• Tracheostomy tubes
• Endoscopic kit including biopsy forceps
• More orthopaedic kit
• Loads of basic instruments (brand new, really good quality)

It's a bit challenging to find all of this, given we use needle holders which have all the grip worn off and forceps with bits broken off. Some of the kit is clearly decades old. I think there really is a mentality that if something just works it has to be used, so nothing is ever discarded.

We're now working on getting the new kit into circulation and throwing away some old stuff. Maybe it will be a start on getting things organised and a proper flow of kit through ordering, stores and theatres. I suspect that this will only really happen once they no longer depend on donations and have to pay for their own kit.

Patience being tested... to the limit? Not yet

It is a well known fact that I'm not the most patient of people in particular circumstances. My father said just before we came out here that it was a good thing I didn't follow him into surgery because I didn't have the right personality for it - which was his way of saying certain things would annoy me like hell! Personally, I think I would be too upset to tell people they are going to die or tell families that their loved one has died. However, I can't really argue with the patience comment.

Having been to Africa a few times before, I had steeled myself for the change of pace and different way of thinking about things that can be frustrating to British people coming out here for the first time. At the beginning of the week in Pharmacy (I've been doing full days there this week) I was doing well. Abraham was getting annoyed and complaining to me about some of the lax things that were going on! I was calm and stoical and got on with entering things in the computer.

I'd also found a useful sideline in being able to tell people in the Mess about the things I'd found that day. So yes, Fi, we do have Salbutamol inhalers (43 off), and I've found some Granisetron (a drug that stops chemotherapy patients from feeling sick) which none of the guys giving Chemotherapy (nor the Pharmacist) knew we had. It was a little frustrating that it was sat next to two vials of chemo that had gone out of date..... criminal given that it's used every day here and we often run out!! [We run out because the drugs are comparatively expensive and the rural health centres have realised they can save money by not buying any but sending all their patients here, which is great for them I'm sure, but less good for the patients]

Wednesday was a turning point though. I got to Pharmacy a bit after 9am. I probably wasn't in the best mood because I'd done my run with music for the first time and hence run a bit faster than normal, only to get back to find no water pressure inside. So I had to lug the water from outside and quite frankly didn't have the energy to make the 6 trips needed to get enough water to wash my hair. So I was hot (because even the shower I did have didn't cool me down) and annoyed about having sweaty hair.

Sande was busy booking out that morning's requisitions from the wards so Abraham suggested I start the stock take of the general store myself. The place doesn't even look like organised chaos, it is literally chaos. I asked where to start. No answer was forthcoming so I chose the shelves nearest the door so that, in the unlikely event that Medical Stores Ltd came later, I wouldn't be in the way. This is the catheters.

Before I can start I have to get to the shelves. There are 4 boxes of assorted Anti-Retrovirals (ARVs for HIV) in the way. Shouldn't these be on the shelves? No, they are for Outreach. Fine, but shouldn't they be in the chilled rooms? [Three rooms of the stores have air conditioning units that battle valiantly to get the temperature to 21 degrees when they are on and people remember to shut the door - it's an attempt to keep the drugs properly that doesn't always work. The doctors report that sometimes the antibiotics don't work and I'm going to guess it's temperature related!]. Anyway, it was made clear that they were happy with the drugs where they were and they weren't going to move them. So I kicked them out of my way with my foot.

The shelves are overflowing. 'Oh, you don't need to count these, they are all out of date'. Why have you let so many go out of date?? When are you going to remove them from the stores if they aren't going to be used? I start to count the packs that are in date. I spot some individually wrapped self catheters for intermittent use!?! They look expensive and go out of date in 2 weeks. 'What are these?' One of the assistant pharmacists responds with 'Oh, them, they are not important...'. Silly me, I thought that if you were running a hospital reliant on donations that everything was important. It's time to leave stores and go somewhere else.

Abraham suggests we go to the other store room to count the things in there that weren't counted last week. For some reason the man in charge of that store decided only to count the things he gives people and not everything else! I set about persuading him that we need to count everything. He doesn't look pleased. 'Why are we counting the buckets? We aren't going to get any more, they were a donation'. 'OK, but they are still here, they could be used?' 'But we won't get any more!' Yes, I got that bit but I still don't really understand why we can't use them - I said if he felt like that we should take them to the market and sell them and use the money to buy drugs.

My day isn't improving. There are literally thousands of needles in here that have gone out of date. Everything is jumbled. Lots of stuff has been attacked by termites. I find some BD items that are in date and look valuable - I get them stacked neatly and note down what they are. A ray of light perhaps? I'll see what they say in the Mess later. Another find is some type of fixing plaster from Holland that is priced at 250Euros per box. The guy says no one ever asks for it. Funny that, given they don't know you have it. I translate the cost into Kwacha - it's more than his monthly salary.

After lunch we are back to data entry. Sande has counted all the easy things in room 1 and room 2. I point out to him that I know he hasn't counted the sutures or the ORS or most of room 1. He's even forgotten the 3way catheters I was stood in front of that morning. But, there's always tomorrow.

Today I arrived a little more hardened to the task. If the staff didn't care about the messy shelves then I could still tidy! I got the step ladder and started to stack the shelves properly from the top. This shelf was mostly easy because the items on it are ordered frequently and used - gauze roll, gauze pads. I corralled all the paper packs of gauze that had fallen about the place. The next shelf was more tricky it looked as if someone had just thrown things from a box onto the shelf many months or possibly a year or more ago - it's always quite dusty so ageing by the amount of dust is unreliable. Sande looked at me concerned. I suggested that we sort all the mess out. 'But there are only a few of each thing, no one uses them, there is no point putting them in the computer.' I agreed about the computer but still thought it was worth arranging things so that people can see what there is and use it. Otherwise, I said, we might as well take it all outside now and burn it because it's taking up space. We set to!

After a while he started to join in properly and ask me about things and take an interest. He even found another box on an adjoining shelf to start organising. When we finished Sande even exclaimed at how much space there was now! I had made a list of all the good things we'd found so I could ask the others what they were worth. Then Sande wanted to go on a break - I realised we'd been at it for nearly 3 hours and it was well past his usual break time. Still a bit early for me to leave to organise lunch I had another look around. There was a box on the floor that said 'Oxygen concentrator' on it.... surely it was just a sturdy box that could be used to pack other items, there wouldn't actually be an oxygen concentrator just sat in its box would there? 'That's an oxygen concentrator and there's at least one more over there'. Next to this is a box that says 'Cold light operating lamp' - yes, you guessed correctly, theatre 3 has no operating lamp... .Time for lunch, definitely time for lunch. This place is enough to drive anyone to drink.

Abraham says the oxygen concentrators are meant for Theatres. They will definitely be out of their boxes within 24 hours, I don't care where they are but they will be being used.

The afternoon is spent organising the sutures. I know now why Sande didn't want to count them before. The shelves were a mess and the sutures spread across lots of mixed boxes. It's also in the darkest part of room 2 where there is no bulb in the lamp fitting. [The electrician was in fitting a smoke detector - I asked if he could remove the bulb fitting because we are missing the one in our bedroom and that one's not being used ;)]. Together we devise a system for sorting the sutures between the two shelves and start unpacking and stacking and counting. The result is great imho! And I'm sure it will give the guy from Theatres a shock when he comes to pick them next time :D. Sande looks pleased and keenly makes new bin cards for them. And starts to open up about how hard his job is when people just come and take things and leave the stores a mess. I said that I appreciated that, and he must have heard me saying exactly that to the Pharmacist. I think together we can make a good change here.

We also find some misplaced bowel cancer drugs.... and with that, I'm off to let the medics know the good news!

Another interesting week!

We returned from our R&R on Monday just as the Prof was off to Lusaka for a whistlestop trip home. This time Sidney, the excellent Zambian trainee, was also here so we ran the show together. There really wasn't too much major going on, but a few big emergencies came in which we dealt with.

First up was an elderly man with a gangrenous leg which I amputated. This is actually now feeling rather old hat (we do a lot of amputations) so was by far the least challenging of the emergencies.

Then, while Sidney operated on a huge (at least watermelon sized, but above knee on the African "above knee/below knee" scale) incarcerated hernia I did a laparotomy. This seems to be sigmoid volvulus season (a volvulus is where bowel twists on its blood supply and becomes blocked then dies) and we have seen several this week. The trick is to operate before the bowel dies and resect the offending bit of colon. The case that I did was a compound volvulus, so the sigmoid colon had twisted, then 1.5m of small bowel had wrapped itself around the volvulus and died. The sigmoid was so far gone it was green and about to rupture. This is something I have read about in textbooks and thought "that never happens." Clearly it does, and respecting a huge amount of bowel is quite hard work. But he is now much better, all the ends are joined (stomas are not ideal here so we avoid them at all costs) and I think he might make it. Certainly he is up and out of bed this morning!

I'm on call this weekend, and arrived yesterday morning to be presented with a 13 year old with a splenic rupture by the night staff. He proved really tricky - most people here have huge, fragile spleens due to malaria and his was twice the size it should be. He had injured it in a really low impact injury two weeks ago, then become progressively more unwell. Ideally, we try and avoid removing their spleens, because they are then incredibly vulnerable to infections (mainly malaria here). It is also unlikely that they will take the necessary antibiotic and antimalarial prophylaxis for the rest of their life. To do this, you have to try and work out if they have stopped bleeding on their own. You also have to assess the risk of them starting bleeding again (higher than at home because of the pathologically large spleens). If we had access to a CT scanner, it would have been really easy to tell if he was still bleeding. We didn't, so we watched him for the day, then decided he was getting more unstable and took him to theatre. Sidney was still around, so he came and helped, which meant between us we had done two precious splenectomies. This was a nightmare, because it was stuck fast to the underside of the diaphragm and I actually put a hole in the diaphragm while getting it out. But, after taking out the shattered spleen, the 2 litres of blood in his abdomen and fixing his diaphragm, he is in good shape. This morning he is complaining about his catheter, which I take to be a good sign.

I have just returned from taking a 3 year old to theatre in a hurry. He had received some chemo into a tissued cannula a few weeks ago, resulting in a huge wound on the inside of his elbow. We had debrided the wound and skin grafted it this week. We brought him in today for a graft check, to discover the whole area was infected, the graft was dead and what looked like his brachial artery (the main one in the arm) was shooting blood across the room. So we took him to theatre, set everything up for a major vascular case (there are even some grafts in the cupboard, although they all went out of date when I was still at school) and phoned the Prof (who is in Lusaka) for a spot of advice. In classic form, he gave me a solution (vein patch or take one of the veins from the leg and produce a venous bypass) and signed off with "good luck!" Luckily, when we opened things up the artery was intact and it was just a bleeding side vessel.

Now I'm just waiting for the next emergency to come through the door (from the barbecue at Nat and Will's place, Carlsberg don't do on calls, but if they did.......)

How the hospital works (Part 2)

So last time I spoke about patient recruitment and how patients get admitted. This time I thought I'd cover the Medical Wards (St Monica (F) and St Augustine (M)). They are positioned in the middle of the hospital and are long 'Nightingale' wards. Some of the young doctors here think they are very old-fashioned, which they are, but you will still find them in the NHS - at Whipps Cross and Leeds for example.

St Monica

The picture (courtesy of the incredibly talented Will Burrard-Lucas http://www.burrard-lucas.com [do you think this is enough of a plug given that I didn't technically ask to use his pic?]) was taken on an unusually quiet day with the back half of the ward not in use. Will was at the main door to the ward, in the foreground is ITU. The only difference between these and the other beds (leaving aside the severity of the patient's illness) is the proximity to the nurse station (halfway up on the right). There is a side wing that runs along the ward that was previously a covered colonnade - the TB patients are here where there is better ventilation. It is a touch ironic that it's been closed in given that drug resistant TB is increasing along with the number of vulnerable patients with HIV...

The ladies that you see sitting at the end of the beds are called 'bedsiders'. Each patient needs one because it is their responsibility to do a lot of things you'd expect a nurse to do at home. They bring food (the hospital provides 3 meals a day but they only amount to 1000 calories and 40g of protein), do basic cleaning and generally assist the patient to get up and down, go to radiology etc. Patients without a bedsider tend to struggle but the nurses do try to help - the Prof's wife also brings food parcels for them and patients whose families can't afford to buy food at the Chada market...

At night the bedsiders sleep next to the bed (often on the floor). There are 3 visiting 'hours' - actually 45 mins - that are identified by a man hitting a cut off length of scaffolding pole hanging from a tree with some rebar (we can hear it from our house - a nice 6.30am wake up call!). If you try to enter or exit the hospital around the start or end time you have to fight through the throng!!

Illnesses

There is a suggestion that the average patient on St Monica isn't as sick as that on St Augustine. I'll discuss why this might be the case in a second. Common to both wards are Malaria, TB (often secondary to HIV), AIDS related diseases like Kaposi's Sarcoma and 'overdoses/poisoning'. Lots of patients claim to have swallowed insecticide in a bid to kill themselves. They are treated for organophosphate poisoning even if their symptoms are exactly opposite organophosphate poisoning because it's not possible to work out what else they drank. Often they make a full recovery.

On St Augustine they also see men who have drunk the locally brewed drink (Kachasu). The problem with it is two fold - no one knows how strong each batch is so it might be nearly 80 proof for all you know and it might be meths not ethanol, which would be unfortunate. All we know is that if you drink it and come to the hospital because of it you aren't going to be the same again. The majority leave as vegetables, maybe they can walk with assistance, maybe they can't. I think they see at least one a week, mostly young men. Such a waste.

But, the reality is if you come with something identified above, or inoperable cancer, it's unlikely you are going to make a full recovery. Yes, there is some chemotherapy for the sarcoma but the greatest role is often palliation. It is frequently heard at dinner at the end of discussing a case 'We did all we could for them so we've sent them home to die' because, frankly, that's preferable to dying in the ward.

Now, what about these other ladies on St Monica? Well, two things - there's the worried well - as in Europe, women present earlier than men with complaints. And some of them don't really have anything much wrong. However, this is still preferable to the men who present too late and have to be palliated in pretty much every case. The other type are the women who are escaping their abusive husbands. They have terrible non-specific systems whenever he's in sight but as soon as he's gone they smile and are happy. The hospital provides a few days of respite.

Patients are moved around the ward as their status changes. If you get better you move further from the door, if you get worse you move to ITU near the door. It took a few days for Nat to work out what was happening to her patients and then why. The nearer the door you are the less disruption is caused by the  coffin trolley. Deeply practical.

Each ward has one oxygen concentrator (or there might be 3 between the 2 wards, it's not clear). These machines concentrate the oxygen from the air and mean that the hospital doesn't have to store oxygen cylinders. It looks like in the past there was one large oxygen concentrator that pumped oxygen through tubes around the wards. The doctors must assess who their sickest patient is to make sure they get the oxygen. Sometimes this can mean taking it away from someone else that they know would benefit. It's a tough call every time. But quite often the patient or their family won't accept it because 'oxygen kills you'. Correlation is not causation but most patients that go on the oxygen die... it's the same with lumber punctures and some other procedures.

At the bed

Being ill can be a great leveller so I guess it's human nature that people want to be able to retain some of their social status in the ward. This is done by bringing your own blankets. The more fluffy blankets the richer the patient. We find it slightly baffling given that many of these people have fevers and it's over 37 degrees anyway - but blankets there are!

On St Monica you have to be particularly careful of a pile of blanket. Because it might not be that at all!

As Nat is beautifully demonstrating, it might be a baby! Mothers with young babies have them in the bed with them either in a separate bundle of blanket or breastfeeding! This is often a great surprise to the doctor doing an examination on the ward round :-D

The blue nets above the bed are the mosquito nets. Only about 10% get used on the adult ward. We have heard lots of explanations - the people sleep soundly under them, dream and then think they are possessed by evil spirits, they are too hot to sleep under, the adults all have malaria anyway. Fine but for every patient carrying the parasite that doesn't use the net the greater the chance is that I get bitten by a mosquito with it. This is selfish behaviour. And it's very ironic given the number of staff wearing t-shirts urging the use of the nets... This story is repeated in the villages. I'm sorry if you have donated money towards providing mosquito nets but I guarantee you it isn't being used. They use them to make bags and ropes and best of all fishing nets!! They make great fishing nets until you realise you've completely emptied the lake of all fish...

What happens if there isn't a free bed?

When the ward is full, they squidge the beds up closer to each other and put mattresses on the floor. When that's not enough? Then they put two patients on each mattress - starting with the smallest. On St Augustine a couple of weeks back they were so full they had two fully grown men sharing a mattress. No one complains because they are getting the treatment they need, given by a Muzungu, which is why they came here. The rest is just fluff.

Getting to grips with the Pharmacy

On Tuesday I was standing in the garden when a security guard from the hospital came with a note. It was addressed to 'Roberts Charrautte'. He looked appealingly at me in the hope that I could identify this bizarrely named person. I tell him that this is me. He doesn't believe me but doesn't want to argue. I realise quickly the confusion - he's expecting a man! He hasn't realised that Roberts is a surname. This is the same difficulty that Geoff has in Theatres - Prof Robert and Dr Roberts are easily confused!

The note is brief 'We have received the items. Would you come to Pharmacy today? Jeremiah'. [I always think of a bullfrog when I think of his name (if you are too young to understand the reference - ask your mum) - and in some respects he does look a bit like a bullfrog!]. So I make my way over to the Pharmacy to find out what's going on.

The Stores boy (although he's about 25) shows me how he raises orders retrospectively and receives the goods. He has been putting the prices in so my next challenge will be to work out why the ones on the system aren't right! We work through the day's receipts together for a while before I get frustrated at the inefficiency and tell him I'll do it myself. The 'problem' is that what's written on the invoice doesn't match the name in the system, now, you'd think that Sande had been helping me with this but no. A typical interaction went:
Sande: Zinc Oxide Tape
I would then try Zi for Zinc and Ta for Tape - neither of which would work
Charlotte: Sande, I can't find it!
Sande: Try Strapping
OBVIOUSLY! How silly of me...
Repeat over and over with different permutations of names or trade names or reinterpretations. So I am better off doing it myself and collecting a list of things I can't find!
Foolishly, I suggest to the Pharmacist that the best way to fix the prices is to go back through all orders for the last year and manually adjust the prices on the system. Sande brings the book of goods received (in triplicate). However, we have only the copies which are at times illegible. Oh well, I've got all day and all of the following day if necessary...

There is an upside to being left alone with the system though. It means I can poke about - look at the stock levels, prices and what orders have been left in the system accidentally. I might have deleted some things... but then again I might not :). I noted that when I booked in the Ringer's Lactate it was already showing a stock of 3,453 litres - given that we know the hospital had completely run out this seemed a little optimistic. I mention it in passing to the Pharmacist who immediately draws up the page and then becomes cross - goods are only ever received, no one has booked any out.... The Stores boy gets an earful and faithfully promises to come at the weekend and do a full stock check.

I know this sounds dire but there's really a very simple cause for all of this. The hospital shouldn't have got this system. It doesn't need it, the software is too complicated and the day to day staff aren't computer literate enough to use it easily. So all the computer work is left to one person who is too overworked to do it and it doesn't matter anyway because no one checks the output. I feel sorry for Sande, he's having to use the computer system and paper system in parallel and do his job plus that of the dispensary. The computer made his life harder, not easier.

But, there is still hope. Abraham and the Pharmacist seem to have been impressed with my work and I've broken the problems down into little pieces that we can tackle a day at a time. Hopefully by Wednesday the stock levels and prices will be accurate for all products. The chap in charge of dispensing a selection of the products from a separate store (only on Fridays) has been taught how to use the system and told he must do it every week. So that leaves just the Inpatient and Outpatient Dispensary to tackle - 5 staff in all.

This is the first week where I've managed to make a significant difference to the running of the hospital. It feels good but it was a little frustrating. I've decided I can only do 2 hours at a time in the Pharmacy, so 4 hours a day. Otherwise I get too wound up by the lax attitude of some of the staff and illogical things that happen. We lost half an hour trying to work out why the goods received books go 5001-5050 then 5451-5500 - answer: someone in stationery can't count.

But I've been using the downtime to chat to and amaze Abraham some more. One afternoon a Sister (of the Nun type) came to the office to drop off a small bag of shopping for him. I said it was like in the UK when you can order your food online and a man brings it to your door! 'What? So you don't go to the shops anymore?' And you can buy lots of other things too. 'Even clothes?' Yes. Then he was baffled by the idea that we have the broadband on all the time and it's pretty much always working.

At one point we are sat in the Pharmacist's office (all 3 of us) and a lady arrives at the doorway. I don't recognise her. She hands over a letter that the Pharmacist has written with loads of corrections and tells him to do them. He says he did exactly what she asked and if it's wrong she can do it herself. She snorts at him and says that she's far too busy. After a couple of seconds Jeremiah says 'I know that you are too busy but I'm going to come and see you later anyway.' The face the lady pulled as she turned on her heel and clicked off was amazing. Abraham and I exchanged a look but nothing was said. A little while later I summon the courage to ask who the lady was. 'She's the Head of HR. She wants us to discipline one of the staff so he needs a letter. She's told us what to write but it's not right and she won't help us make it right.' :) That's funny, I've only ever known HR in the UK to be supremely helpful and keen to get hands on when there's that sort of issue...

I know that I've gained their trust when we need to go to a store room and Abraham says 'Today you can drive me!'. I try to point out that this is a really bad idea - I've never pushed a wheelchair before and I'm not that coordinated at the best of times (coxing aside). The corridor from Pharmacy is narrow and has a dog leg in it right by the dispensary window where lots of people are loitering. Several people nearly lose feet. Then we rattle along the uneven concrete and Abraham has to lift himself up in the chair to get comfy. Shortly I discover why there are regulations in the UK about the width and incline of wheelchair ramps. We go down one that's barely wider than the chair and I risk upending him into the flowerbed. Then the ramp to the store starts with a foot high step up and is ridiculously steep. I get him halfway up before it's clear the doors aren't open wide enough and I have to hold him there! He's really very trusting - I think he thinks I'm joking when I tell him I'm going to invest in L plates for our next trip!!

When we return to the Pharmacy I need to pop into another office. There's a little girl of maybe 3 years with her mum. She hides behind her mum's Chitenga when she sees me (I assume this is the usual shyness). I try to smile at her but this makes the situation worse. She becomes more agitated so I retreat to the corridor. Her mum tries to leave the office but the girl has grabbed her hand and dug her heels into the ground, refusing to move. I hide in a different office out of sight. When they pass the doorway with the girl now on her mum's back she starts to scream!! What did I do? The theory is that she's been treated on the Paediatric ward where the white people have stuck needles in her so she associates us with pain :(

In a break I have returned to Medical Records to see the 'Assistant Hospital Information Officer'. As an ice breaker I ask him why he hasn't been promoted yet :). He shows me how the database works by using himself as a dummy patient - he claims to be 39. On this particular day he's wearing a Hawaiian shirt, his ringtone is of a screaming cat and his desktop picture is of his wife looking grumpy (as usual) sat at his desk. None of this, nor how he looks, supports the assertion that he's 39 so I fall about laughing. Then he gets out his ID card to 'prove' it. I tell him that I know for a fact one of the nurses has lied about his age on his passport so I'm not convinced!! While we are going through all this he does admit that he's thought about what I said last time and I'm right, they are not capturing every patient that comes through the door like they should be. Good! Because now I don't have to get up at dawn to stake out OPD!! Pride was going to make me do that but it was going to be tricky without access to a loo or drinking water or food :-D

We get back to the matter in hand - he needs some help manipulating data and getting reports out of an Access database. I had training on this on the first day of my year out - I'm sure I can work it out - but why hasn't he asked Abraham? 'Abraham won't know how to do this!' That's funny because I'd just been talking to Abraham about the database he was about to make and the reports he was going to generate in Visual Basic... (so Abraham knows far more than I do!)

[Later I mention this exchange to Abraham 'Oh but he can't ask me!' Why not? 'Well, because then he'd have to admit to not knowing something. I've worked with him before.' But he admitted it to me the first day I met him?! 'Ahh but you are Muzungu.' Yes, but I thought that was worse. That no one would want to admit that the Muzungu can help them with anything. Because everything is just fine without the Muzungu running the place. Abraham smiles 'Yes but this is a matter of facts and everyone knows the Muzungu knows how to do things']

As I get up to leave Adamson says 'You asked me why I haven't been promoted.' Yes but I was teasing you. 'There is a reason, I don't have the qualification that I need. You have to have a diploma in information and I only have a certificate in IT but I've been doing this job for 9 years. The hospital was supposed to send me on training in January, then they said June, now they say January again. I don't think they will pay for me to go...'. This is the second time I've been asked this question [being - will you pay for my training?] The first was by the legend of a nurse Emmanuel who wants to train to be a nurse trainer. For now I am using the African approach to this (here's a tip for you) - when you are asked a difficult question remain silent as if you never heard the question. It's really uncomfortable for a British person to do, it feels awkward, but it's perfectly normal here.

On my way home I pass one of the little boys that comes to my door demanding pens/toys/biscuits and calls me stingy when I refuse. He's the brightest one with the best English who has to translate all the demands. He's with his mum. As soon as we draw close he says very clearly 'Excuse me, what is your name? I have forgotten it'. I answer him but all the while want to point out to his mum what he gets up to when she isn't supervising him!! Cheeky little blighter!