Solar cooking and plastic surgery

Last week I had the opportunity to see some new and exciting things, which really epitomise why we wanted to come out here.

It's pouring with rain as I write so I'm typing quickly to try and get done before the power goes off as it no doubt will.

Solar cooking

On Wednesday evening the couple from MSG (a Dutch charity that supports the hospital) asked if I would like to accompany them on a solar cooking demonstration the next morning. It would mean being ready for 8am so I'd miss my usual lie-in :) I agreed.

We drove 6km up the Great East Road towards Lusaka and stopped at a centre for children in distress. It has a wide remit - predominantly involving teaching the local villagers how to help themselves be more prosperous.

The teachers for the day were a lady called Beatrice (the hospital social worker) and a lady called Scholastica (who works at Tiko's), who have been trained to use a very simple solar cooker designed by a Dutch NGO. There was a large crowd watching - both men and women, interestingly.

First of all they explained the principles and then set about making a demonstration chicken stew. Beatrice cut up the dead chicken - I noted that she didn't strip the meat from the bones of the wings and leg but rather cut through it and put the whole lot - skin, bones, flesh into the pot. To which she added some tomato, some onion, water and Portugese chicken spice from Shoprite.

The pot was set in the cooker before 10am. Then all we had to do was wait. [and wait and wait - I entertained myself by wandering off with the camera to photograph the nearby homes]

Of course then the clouds came over, which meant that the food wasn't ready until 12ish, but still, it was a very low effort way of making lunch. Some minor cheating happened when the rice was cooked on a wood stove but overall the ladies seemed impressed. Them men didn't want to pay the 70pin (c.£10) for the contraption and thought they should get them free....

It's a great idea but perhaps more relevant in 6 months and not at the beginning of the rainy season!

Plastic surgery

On Friday the visiting Serbian plastic surgeon was operating. He'd very kindly said I could watch a case involving a child that had burnt the palm of its hand. When the wound was healing the child was more comfortable having a closed fist and the skin of the fingers merged with the skin of the palm, meaning that they were now permanently locked down. Goran was going to release them and put a piece of skin from the boy's tummy onto the palm of the hand - it means the boy will have a brown palm permanently but it's better to have usable fingers.

I was told where to stand out of the way. 'And if you start to feel unwell...' 'I will leave the room' I finished. 'No! Squat down. Do not try to leave, you will fall over before you get to the door and delay my surgery even more!' OK then :)

I felt fine throughout - a tourniquet meant that the hand didn't bleed much and it was fascinating watching him carefully removing the skin and stretching out the fingers. It wasn't necessarily ideal watching them screw wires down the fingers to keep them straight but he did it with such precision that it made up for it.

'We need a photo!' he said, brusquely.

I looked around wondering who had clean enough hands to touch his camera - everyone had gloves on.

'Camera!' he shouted. Everyone turned to stare at me. Ooops.

'Now press the round button slo...' I pressed the button 'NO! NO! Slowly - you must wait for the squares and for me to say it is OK' Now was not the time to tell him I'd seen the squares and the first shot was fine. Better not to argue with the surgeon, I find.

The conversation got around to how difficult it can be to arrange immigration papers for sick Africans seeking treatment (paid for by charities) in the UK. Goran believes it's easier for Indians and Pakistanis to get in.

The anaesthetist piped up 'Of course, it's because the colonialists took everything with them when they left'
I was just wondering how we had taken the abundant sunshine, the fertile lands, the copper, the precious stones, the hydro electric power, when Goran responded 'That was 50 years ago - what have you done since?'

'But they took everything, the colonialists took all the things we had, that's why we are in this state now'

'I was in Grade 1 when you got independence. What have you done with it?' Goran repeated

I would like to be in the Zambian Government if you can just blame the British for anything bad that happens on your watch - but I'm pretty sure that's not how it works. No clearer answer seemed to be forthcoming.

'Perhaps if you stopped complaining about things that happened 50 years ago and started doing something about it you would find yourself in a better position. Plus, India and Pakistan were colonies of ours too...' I said

'Exactly' said Goran.

Then I went to Theatre 1 to see the inside of a cyst they'd taken out of a lady's abdomen. It was full of hair.

There quickly followed a Caesarean section. Geoff was convinced I'd feel faint at that but I did not. I wasn't necessarily keen on it happening to me though - there's a reason the drapes are there. I was quite surprised to see the uterus lifted out of the body and put on the tummy to aid stitching up [although Fi has seen that in the UK too] - but it was a good opportunity for a quick anatomy lesson and now I know why ladies that have just given birth still look 3 months pregnant.

It was also really nice to see the baby being swaddled by the male midwife and taking its first breath.

The next day I went to the ward to record the C sections and for the first time I already knew one of the ladies there.

Thunderstorms

Every other day, rainy season threatens to start. By the looks of things, it could be quite spectacular - we sat and watched two stunning thunderstorms pass across the sky the other night, while sat in the sun! The sunsets have also becom incredibly clear. Previously they would be obscured by the dust in the sky. It is now a lot clearer, and we get pinks, oranges, reds and blues illuminating the sky. Sitting under the sunset with a G&T is one of the best parts of the day!

Remind me what everyone looks like, please?

Oh OK, just because it's you... [This is just photos]

Rory doing his ST application with some help

Gemma, me and Fi by the pool in Chipata

Geoff admiring his burn, I mean, tan

Rory, Fi, Geoff, me, Will and Nat by the fire

Fi, me, Gemma, Geoff and Rory in the pool

Abraham

Geoff and the Prof between cases

Will working - glad I don't wash his trousers

Ox cart

Baobab flower

Children in a village

Little lizard

Pig on a bicycle

Weather and other bits and bobs...

Weather

When we realised we were coming out here in wet season we had mixed feelings. It was a time of year that neither of us had seen in Africa before but it also wasn't considered the 'best' time to come. My dad told us that the electrical storms would be amazing and that would make up for the need to pack wellies. I kid you not, we have our wellies here. Geoff's are currently full of lizard poo - I haven't told him this but I'm sure he'll work it out eventually. Although, perhaps I should mention it given that I have to clean his socks!

We were promised the rains would start at the end of October. It's now the end of November (I can't believe this - I feel like it's still August - probably because it's so hot here) and the rains are coming. Something has changed in the weather this week. On Monday we went to watch the sunset only to discover the hospital was surrounded by electrical storms. We sat and watched the lightning all around us. It was amazing, light up the whole sky sheet lightning interspersed with some forked lightning. Fantastic viewing. And, although the electricity went on and off, we didn't see a spot of rain.

The week got really hot again. I ditched my run on Wednesday morning in favour of weights and press ups in the house. It was just too hot even though there'd been a bit of rain in the night. There was rain for half an hour last night too. But this morning was hot and dry.

Then this afternoon the clouds closed in and we've had light showers on and off. There must had been a storm somewhere relatively close by because Geoff's admitted people from a house fire caused by lightning.

It's going to be interesting for the next 3 months. Every time the weather is even vaguely stormy within 50km the lights go out. This could a little trying, especially at meal times! I think we've been very lucky to have 3 universally hot months so far - it's only fair that we should join you guys in the UK in needing wellies.

African DIY

When we returned from watching more lightning after dinner on Monday we discovered we were locked out. Turning the door handle did not do anything any more. We got Rory's tools and managed to break ourselves back in. Then it became clear that we weren't quite going to be able to fix the door ourselves and we were loathe to shut it just in case we couldn't open it again - there's no other way out because of window bars.

Thankfully there's someone on call from the workshop all the time. I found him at the hospital entrance and he was soon on his way with me. 'I'm the door and lock doctor' he said to Geoff. He made a repair but said he'd be back at 10.30 the next morning to fix the fact that the door is mostly hole around the handle.

Just after 11.30 he came back with a friend. There was quite a discussion before he asked me whether I'd been planning on going anywhere. I had been planning to go to the market to buy things for Geoff's lunch in an hour.

'I don't think it would be a good idea for you to leave when you have no door.'

I agree. That would be a very silly idea, but I have a door.... OK, now I don't. They pulled it off its hinges and took it out with them. When will you be back? 14 hours.

Right. So not only could I not leave but I also couldn't prevent the sun coming in and heating up the inside of the house. I did an experiment to see how long water took to evaporate off the concrete floor some time after 14. Less than 5 minutes for a whole handful. :) I was bored, what else would you do if you didn't have carpet at home?

Don't worry, I managed to feed Geoff, just!

I could hear a kerfuffle outside at 15.10. 'We are back just like we said we would be!' 'You are an hour and ten minutes late!' 'No, your watch is wrong. We are on time.' I pointed out that they were making themselves have to work for an extra hour with that line of thinking.

They had removed our creepy crawly proofing, saying they would replace it with rubber. This rubber happened to be part of an old car tyre. And they put it on with the door open. The only problem is that the gap between the door and the floor is greatest when the door is shut.....

Pets

I don't consider the cockroaches we've been getting pets - mostly because they all die of their own accord over night. Or perhaps I only see the dead ones.

We had a run of bad luck with pets. I'm afraid that the frog died some weeks ago. I only confirmed on our return from South Luangwa. Unfortunately it's stuck so tight to the wall that I broke its back trying to remove it - and still failed. Natalie finds this hilarious for some reason. :-p

Then the little lizard we had in the bathroom disappeared. He was about 2 inches long and you could only spot him by looking for 2 black dots (his eyes) because he was exactly the same shade as the concrete of the floor. He did a good job of eating ants but then he went AWOL.

Now we have a praying mantis. He's brown and about 3 inches long. He doesn't like getting his feet wet. He turned his head right round to stare at me this morning. I don't think we'll have him long but he's good fun for now.

We still have a pet bigger lizard in here somewhere. I saw him on the bedroom wall the other afternoon but he tends to hide in the roof during the day.

And then there's Tiger, obviously.

Film night

The more childish of my colleagues openly sniggered when I mentioned long dark nights to fill with entertainment. (It's OK, I know that Keckers is too busy to read this - aren't you?) Right back when Fi and Rory came we set up Film night. The idea was that we'd each pick a film to watch, put the name in a hat and pull one out each week. We haven't quite hit the frequency or stuck to the list.

What we have found out is that we are very good at picking exceptionally weird films. If you like the idea of locking someone in an oven then pick either Case 39 or Project X. If you want to hide a Dodo in a beard then 'Pirates in an adventure with Scientists' is for you. [Note: it really really isn't!]. Generally if the film starts with female nudity it's going to be awkward to watch in a group (Chloe).

Last night's film was no exception. Will had downloaded Killer Joe. It was supposed to be great. Any film with a lady opening a trailer door naked from the waist down as its opening sequence is probably going to be alternative. If her stepson is at the door it's weirder. And if the excuse for her opening the door like this is 'Well, she didn't know it was you' then you can probably happily stop watching. Actually, it was a little intriguing to see where the whole plot was going. I'm afraid that I still can't answer that. There was a lot of mindless violence and gratuitous nakedness.

In the middle I spotted Tiger arriving at the screen door. He scared Fi and Gemma by pawing at the  door to make his way in. After inspecting the whole house (everything was in order) he came back to find a seat. First he thought he'd try my lap. He put a paw on each of my thighs (I was wearing light coloured newly cleaned trousers - grrr) and panted in my face. It took me and Nat to remove him. Then he spotted a small gap on the sofa next to Will. He made out he was having difficulty getting up onto the sofa so Will stood up to help him. Immediately Tiger jumped up and settled himself down next to Nat, leaving no space for Will. He he he he he. Will managed to reclaim some space eventually. That dog is smart!

Next time we are picking a film that someone has seen in advance..

Chickens and snakes...

On Friday a miracle happened. The network worked all day long without problem. Abraham and I set ourselves the task of writing the specification for adding the new OPD to the network. To get the lengths of cable right we needed a tape measure. We waited under the mango tree by HR whilst the workshop manager went searching for it.

Behind us 3 ladies had set up their kitchen. There was a fire with a big round pot filled with water on it. Nearby were a few large bowls. I saw a lady pick up a chicken and go behind a big pile of sticks. A while later she came back with a dead chicken.

Here was a chance to see how it was all done. I noticed that one of the large bowls contained some plucked chickens. She laid the dead chicken on the floor and went for another live chicken. I didn't quite have the courage to approach. My chance of learning was potentially passing me by. So I steeled myself to walk over and say hello.

The ladies looked up, smiled at me and then carried on with what they were doing. So here's how it's done:

• Catch your chicken - chances are it's hiding from you somewhere so grab it quickly
• Hold it by the feet as you walk to your desired location
• Place the feet under your right foot with the chicken facing away from you
• Grab the left wing and put that under your left foot
• Grab the right wing and squeeze that under your right foot with the feet - the chicken is now immobile but not silent
• Take a normal table knife
• Stretch the chicken's neck up [Vegetarians and the squeamish should stop reading now]
• Use the knife to hack through the chicken's throat. Do not stop to break the neck. The chicken will bleed to death...eventually
• Keep chicken horizontal until most of the blood has come out onto the ground
• Lift chicken up by its feet until all the blood has drained - this might take a few minutes
• Place chicken in hot water and turn it
• Leave for a minute
• Pluck - remembering to pull all the bits off the feet as well

I didn't get to see what you had to do when it came to the giblets because they were just putting the plucked chickens in a bowl. One of their sons toddled over crying at one point. He was lifted on to his mum's back, tied in a chitenge while she carried on. She was able to bend double to work at floor level with the little (but still quite heavy) boy on her back. Their heads touching. He appeared to be asleep.

I went back to standing with Abraham, watching men unloading a massive lorry. It had a flat bed trailer with three sets of rear and front wheels. It was large. They had reversed it into the small gap between the mango tree and the HR office - to minimise the unloading distance into the building's store room and make use of the shade of the tree.

Suddenly there was a lot of screaming and all the men ran away from the lorry at high speed. I saw something that looked like a snake move under the rear wheels of the lorry. I pushed Abraham about a foot away and then curiosity got the better of me and I turned back leaving him behind me. It wasn't likely that the snake was going to come flying out and attack Abraham I figured. Although next time I checked on his location he was about 10m further away.

I looked on the floor but couldn't see the snake anymore. It couldn't have come out so it must be up in the axles somewhere. I'd read about this in the Number 1 Ladies Detective Agency - who knew that it was going to prove a good textbook. The men quickly came to the same conclusion. The driver started revving the engine (a good 10m away) to scare it out. That didn't work.

Next he pulled the lorry forward so there was better access to the rear wheels. A man came forward gingerly to throw water into the back wheels to scare the snake out. Another man tried a long stick. All I could hear was people saying 'Muzungu'. They seemed surprised that I wasn't scared. I figured that it was fine as long as I kept a respectful distance - the snake I'd seen was relatively small, it wouldn't be able to strike me without me seeing it first.

The driver grew impatient and suddenly set off at high speed towards the Mortuary. Then he reversed madly back. People tried again with sticks to get at the snake - which was being sighted occasionally. One guy nearly got admitted when the driver set off in reverse again while he was leaning over the wheels at the back. The lorry went all the way back to the front of the hospital before flying forwards. I was more scared of the mad lorry driver than the snake, I thought. We didn't need to make more patients for the surgeons right now!

This time the snake decided to make its exit. It dropped to the ground as the lorry passed me. Immediately a man threw a rock at it, giving it and my foot, a glancing blow. Then the stick man came in to finish the job. I persuaded him to stop when the neck and body were crushed and its bowels were sticking out. He laid the snake on the floor so that I could get a picture and try to work out what it was. It was silver with no other markings and a light belly. It didn't have a coffin shaped head. It looked a bit like a Mozambique Spitting Cobra that I'd seen before but the neck was a bit too mangled to get a good identification. Whatever it was it was a juvenile, probably, only a metre long or so.

The very end of the tail was flicking back and forth. The men assumed this meant the snake was still alive. As if the massive injuries they'd already inflicted weren't enough to protect them. They wouldn't listen to me when I told them it was dead. A further massive pummelling ensued until it was barely recognisable. Then it was paraded around to prove that the massive predator had been felled. The men got back to work.

From the crowd of people watching a man approached. He was dressed smartly.

'I don't think it was a dangerous snake. It's just one that lives in trees eating eggs and things like that. It probably just fell from the mango tree into the lorry.'

'Do you know what it is? I thought maybe a spitting cobra'

'I don't think so'

It's quite a sight to see grown men running afraid from something so small. It's understandable - there are very nasty snakes in the area including spitting cobras, puff adders and mambas - it is better to be safe than sorry, but at the same time I can't help but think that the total snake population is paying a heavy price for the danger posed by only a few species.

Cultural attitudes to medicine

Given the recent shift in attitudes to doctors and medicine in the UK, I should perhaps have expected attitudes here to be occasionally challenging. At home, the intermittent high profile cases of doctors or hospitals getting things wrong has led to a degree of suspicion amongst the public. In Katete, suspicion is unusual, but expectations are often completely divorced from the reality of medical care.

I saw a chap in clinic this week with a high pressure urinary retention. This means he was not emptying his bladder due to prostate problems, but could pass small volumes of urine. The high pressure however causes problems with the kidneys, which were clearly abnormal on ultrasound. Untreated, he will develop renal failure and die. In the UK, treatment would be a catheter then consideration of a prostatectomy once stable. We have a lot of catheters and I explained the situation to him (at length, several times over and through a translator) and offered him a catheter. The only response was increasingly irate protestations in Chichewa, the only part I could understand being "mankwala" (medicine). Clearly someone had told him he could come to St Francis' and get a tablet to take the problem away. He did not want a catheter and would not have it otherwise. In the end, we both left the room frustrated - him because he had not received the (non-existent) drug, me because I know he will become progressively unwell unless he gets a catheter soon.

We had a burns death this week. The patient was a 2 year old girl who had a 20% scald from hot porridge. The injuries were partial thickness and did not need surgery to heal, but a 20% injury is a massive physiological challenge to a 2 year old. In the UK it would be unthinkable for a child to die of this sized burn, and it would require only limited, if any, ITU input. The difficulties come in managing fluid and metabolic (i.e. food) requirements. These increase significantly in both the short and medium term in burns. The best way to manage this is to supplement the patient's oral intake with intravenous then nasogastric fluids and feed. This child had a calorie requirement not far off double that of her usual needs, and was also burnt on the face, neck and abdomen, making feeding painful. I spent a lot of time (probably two hours in total over several days) with nurses translating all of this to the mother. We were initially allowed to put an intravenous line into the child (although this was rapidly pulled out, I'm not sure whether by accident or deliberately by the mother). At no point would the mother allow us to place a nasogastric tube. It transpires that one of her other children had died on the paediatric ward and had had a NG tube. She therefore associated the NG tube with death and refused. The same is often the case with IV fluids, oxygen and lumbar punctures. These are the things done to the sickest patients, a lot of whom die despite treatment. The way this is fed back into the community however must be something like "the doctor put a tube in my baby's nose then he died, so don't let anyone put a tube in your baby's nose". In this case, the child was spoon and breast fed by the mother. At no point did she consume as much as when she was healthy, let alone enough to meet her needs. She deteriorated and died over several days. There was nothing we could do.

Today's case was a little more flippant. A middle aged chap with a cyst on his side. He was adamant that he needed the mankwala to make it go away. I offered him surgery, but he was not interested. There is no drug for cysts, although he probably thinks I'm withholding some magical treatment. In the end, he left unhappy.

I have been wondering whether some of this stems from growing up in a culture where everyone has a local witch doctor rather than GP. Most people seem to trust their witch doctor above us, and indeed sometimes come in to hospital really very sick because they have received traditional remedies. Sometimes we treat them, then they go to the witch for supplementary treatment. One man was lucky to keep his right thumb after a motorbike crash but I reattached it and wired the broken bone together. He came to his clinic review two weeks later pleased as punch with the elephant dung he had put on the wound. One glance at the look on my face and he was at the sink washing it off!

Having never met a witch doctor, I can only speculate, but I suspect they have a treatment for everything. This would cause the attitude that everything can be treated, let alone treated without an operation. To an extent this attitude extends to our nursing staff - it took a lot of effort (and the involvement of the Medical Superintendent) to make the decision to palliate a child with a non-survivable (50%) burn recently.

From the Mzungu doctor's perspective, this creates a difficult tightrope to walk. On one hand, I want to provide care as close to Western standards as possible. On the other, if I don't respect their cultural sensitivities they will leave and get no treatment.

Another hot week in the mad house!!!

[This is Charlotte pretending to be Geoff, for a change]
You could claim, quite rightly, that it's less than a week since my last update. My response to that would be twofold 1) report me to Trading Standards if you like and 2) it is Thursday afternoon and I am sat in my garden in 35 degree heat with nothing more pressing to do than sit here wittering - where are you?

The week was always going to be busy because it had been long awaited. The official opening of the paediatric ward and the new OPD was on Tuesday, with the guest of honour expected to be the Minister of Health. I had found a copy of an invite last week that rather unhelpfully said it was on Monday the 13th so the hospital secretary had had to rush around, or in local terminology 'run up and down', sending correction memos to all concerned. For some reason, I assume space constraints, she neglected to correct the spelling mistake about the anti-natal services offered. Or perhaps I misunderstand and they are really doing their level best to prevent births on the Maternity Ward.

But it was also going to be busy for me. The IT Manager (the whole IT Dept) was still on a course in Lusaka. This meant that Abraham, with his IT technician hat on, was covering. As his de facto driver, I have become, by extension, Assistant to the IT Technician. Apart from anything else, it is thirsty work because the network is spread all over the hospital with switches placed in obscure places. Last week we had dealt with part of the network failing because someone had unplugged a switch and not bothered to plug it back in after themselves. There are only 6 IP addresses allowed on the internet at any time so the instant messenger is permanently blinking even when everything is running smoothly.

On Monday things went mental. Half the network became separated. They could see each other but not the rest of the network and vice versa. It was time to learn how the whole thing worked. I shan't bore you with the details but I have worked out there are two wired networks, with many switches in each, connected by a wireless bridge. Each half also has a wireless gateway for the non-wired computers. Don't worry if you can't follow, just understand that it is complicated. So when half the network disappears one would assume the bridge was the break point. However, the IT guy did not really leave clear instructions other than a process of going switch by switch and turning them off and on again until things start to work again. It is a hard job, IT. So off we go - out of the hospital, down the long ramp, past the chapel, over the deep sand, over the broken bricks, up the steep ramp the width of a wheelchair into HR. Off and on. Now down the ramp, over more deep sand to Procurement. Off and on. Back round to the front of the hospital, up the ramp, past the medical wards and matron and physio, along to OPD. Over the bumpy concrete to get in there. Room 6. Off and on. Room 2. Off and on. Out again, down the ramp, across the sand (I mention it because it is a bugger to push a wheelchair over sand) to Accounts. Everything appears fine at this end of the wireless bridge. Abraham is despondent. Everything is working, he says. Apart from the network :). I tell him that we must have missed somewhere. Where is the other end of the bridge? He says there is nowhere else. I am reminded of my father's story about finding 5 ends of bowel. There must be a receiver for the wireless I press. He says we can try Medical Records. So off we trot across the sand and up another steep ramp, round 2 sharp corners and into the office. I can see two boxes of tricks. One blinking and one not. Abraham doesn't even ask the owner of the office to check them so I do instead. Mr Phiri fiddled with the cables going into the lower box. Abraham cries out with pleasure 'it is working now. This is why we need Muzungus. They carry on when we have given up'. Of course it is a mixed blessing fixing things - now the requests for Internet access are back!

On Tuesday morning I took our camera to watch the goings on. At the allotted start time the canopy was still being erected above the seating area. This is Africa. The Provincial Minister was expected. Whilst everyone waited some people from Tiko's provided a spectacle. Coming in the side entrance I noticed 3 people. They were noteworthy because one of them was Muzungu - Scandinavian or German - and too old for the cap he was wearing and the woman was wearing hot pants. Do not misunderstand. She was tall, thin, beautiful, had massive sunglasses on and was wearing lots of jewellery. On the streets of any town in summer she would have got admiring glances. In a rural hospital in Zambia when a Government official was expected she drew gasps of shock and disgust. It didn't help that they were openly laughing at the arrangements. Rather unexpectedly I felt a pang of defensiveness. So what if things were a bit odd and the minister had a sofa to sit on. At least they were trying. You can't just rock up uninvited in offensive clothes and then openly poke fun. They were ejected but just before that final moment I gave them a piece of my mind. They just laughed in my face.

On Wednesday we had more fun with the network. This time HR and procurement had been separated from the rest of the world. To make matters worse, the Prof's wife Wieke, had also been disconnected. I bumped into her in the hospital as she was headed to play with some of the boys Geoff had in traction on the surgical ward. She told me about the trainee licentiate calling the Prof in for a guy haemorrhaging blood only for the Prof to rush in and find no blood at all. She also asked me if I knew about dinner at their house on Sunday. Sunday? I thought it was Saturday. My husband hasn't kept me up to date. I said. Oh no, she said. I am sure it is my husband that did not say. Perhaps we will never know. Geoff claims his innocence!!!!

Later we visit the house to try and fix the Internet as Wieke has to send her articles to the Dutch magazine she works for. First we had to get into the house. It is 4 steps up from ground level. Luckily their home help, Aaron, was around to help carry Abraham in. Once in, it became apparent that Wieke's laptop was not playing ball. It is in Dutch, so quite what it was saying was unclear to both of us. I pressed a different button and everything disappeared. Oooppsss!!!! I had to run to the hospital to look at another laptop with Windows 7. I borrowed the Pharmacist's. As I asked to borrow it I noticed my hands cupping in front of me in the gesture of submission I had seen so many times since I arrived. My subconscious is culturally astute. Turns out that Microsoft put the Disable button in a really dumb place, judging by the number of people that hit it accidentally even when working in their first language. We failed to fix both the network and specific problem.

This morning we started again following the same route as Monday. All the switches were fine but I noticed that one fewer lights was flashing on two of the switches than previously. The only thing left was to track the cable from procurement to OPD. I did not like this conclusion because it suggested a cable problem, which I was not really happy about trying to fix. I have never had to reattach connectors to structured data cable before. I followed the cable up the procurement office wall and through into stores. Here it tracked across the roof beams to a connector by a window. I asked a bloke stood by if he could climb up on the bags of beans and a fridge to unplug and replug the connector. He looked confused but did as I asked. Then told me the cable went nowhere from there! I suggested it went out through the window. Oh, you are right! From there i tracked it across a roof and down a wall. The cable passed into a hard plastic pipe for protection. Towards the bottom the pipe was kinked at more than 90 degrees - please don't be broken, I thought. I straightened the pipe. Immediately Abraham, sat under a nearby tree for shade, cried out that it was working. To be sure I bent the pipe. It stopped working again. OK problem identified. I just needed to break the pipe and stretch it out so it didn't pinch the cable. 'do we need to get a man?' called Abraham.'No, I do not need a man!' I shouted back as I kneeled on the floor. It was trickier than I thought and I did not want to damage the cable myself. I tried to use a key to open the pipe back up. 'I think we might need a man!' :)

Abraham decided we needed a rest from all the rushing up and down. I did say that I had only seen him sitting all morning :) so we tried to check the email of a friend of his that is doing a degree. We couldn't get it to work, even when we rang her. I asked what sort of degree someone that couldn't work yahoo could get. 'It is tricky. Muzungus can do it because they are sharp. It is hard for the rest of us.' he said. 'Abraham, you can't say that!' he looked puzzled 'Why not?'. 'Because it is racist. The obverse of what you just said is that black people are too stupid to use email. I would be in trouble if I said that.' I responded. 'but it's the truth...' was his only answer.

How the hospital works (Part 4)

I think the time has come to talk all things Maternity. I still haven't seen a delivery yet, I'm waiting for a medical student to tag along with, but my daily trips to 'Bethlehem' have equipped me with the knowledge I need...

I don't have exact figures for the local area but my experience suggests that most mothers do not give birth at home. The first port of call (if no high risk factors are identified ante-natally) is the rural health centre where the midwives and clinical officers will assist with the delivery. For some women, St Francis' is their nearest centre and they will come in labour. If any rural health centre has any concerns then they will refer the lady to the hospital for treatment.

However, these are not the only ladies that the hospital treats by a long way. Ladies from further afield with a POH or BOH (Poor/Bad Obstetric History) or where there is some concern for the birth can come and wait to give birth. They are known as the Waiters and have their own accommodation block behind OPD. Here they stay for sometimes many weeks just waiting to go into labour. Then hey presto they waddle over :)

For women where the concern for their health is more acute, there are two bays of beds in the ward reserved for them and they get to sleep more comfortably until the day comes. The ward is a large open rectangle, bays are marked out by waist height walls only. So these ladies have to wait in a room with new born babies.... it's not exactly peaceful at times! And the showers at the far end seem to fill the ward with hot steamy air so it feels a bit like a rainforest in there at the moment.

When the woman is in fully developed labour she goes to the delivery suite. At home this would be a set of relatively large private rooms (yes, I have been watching one born every minute) where the woman and her relatives can pass the time. In SFH, there are no men (excl staff) in delivery and rarely on the ward. The suite is actually more like a corridor with bays coming off it, that have a bed and a chair in, but are completely open. Rather unthinkingly the first time I went looking for the delivery book I set off down the corridor only to see out of the corner of my eye that the first bay was occupied by a very naked lady - I averted my eyes and walked on quickly. Most women have their mums (I assume) with them on the ward, so I'm guessing the mums are also in delivery sometimes but I don't know this for sure yet. The process is done quietly - any shrieking is discouraged by the midwives so all that can really be heard is heavy breathing and some mild wailing. It's a bit eerie to listen to from the office as I collect info.

If the birth goes well the woman stays in delivery for about 2 hours before getting dressed, picking up her things and the baby and walking to the main ward. Yes, that is what I wrote. Very often she is sent home that day, carrying her things, with the baby in a chitenge on her back (or front or side).

Sometimes things don't go well. SFH delivered 3,176 live babies in 2011. Of these, nearly 700 had to go to SCBU (Special Care Baby Unit) and of those nearly 150 died. A further 192 were stillborn.

There is a 'myth' at home that giving birth is a natural process and therefore it must be relatively low risk and African ladies can do it alone safely. This turns out not to be true and the hospital lost 11 mothers last year. The Caesarean Section rate is over 25%, almost as high as in New Zealand (28%) and just above that of the UK...... In Holland it is c.6%.

Why is this? A number of reasons. Some C sections have to be done for reasons like the baby being breech or getting into distress. Without the detailed ante-natal care at home some complications that could perhaps have been picked up on are not found until the last moment and the mother's life is at risk pushing the emergency rate up a bit.

But, unlike at home, a lot of the sections are in relatively young women, by which I mean 14-22 years old. These girls have had some degree of malnourishment for their whole lives and are relatively small, they may not even have stopped growing - even at 22. So a normally sized baby just can't fit out through their hips...
And once you've had 1 c-section, the likelihood of your uterus rupturing if you try to give birth naturally the next time is higher, so some doctors like to be very cautious and swap them to c-sections for life. I'm reliably told that this is OK up to about 4 but becomes increasingly suspect after that point.

After a c-section the baby/babies (I've seen lots of twins!) and mum are kept in for 6 days. This isn't strictly necessary but the Consultant likes to give them a rest from home. When I collect data I can see how many children each lady has (and whether they are still alive). The most I've seen so far is 10 but over 5 is very common. Survival varies considerably, some ladies have had 10 children only for every single one to die. And some ladies had 10 and they all survived!!! Football team here we come!

I'll write a separate bit on breastfeeding because it's a whole topic in itself but it is encouraged immediately and can continue for a number of years from what I've seen! The ladies on the ward seem quite relaxed most of the time. Even when the babies are crying. They work methodically through - hungry, needs changing, cold/hot, needs a cuddle. If none of that works they just put the bundle back down again and carry on with what they are doing. I also often find the beds occupied solely by a baby swaddled in a chitenge or blanket with the mothers outside or in the shower room. It feels like a long way from the 24 hour attention advocated in the UK. Thou shalt never let baby cry or be out of your sight...

I imagine that having so many mothers so close together is a good way for new mums to learn the ropes - especially if their mum isn't there. But it has its downsides - specifically around privacy - there is none. The other day a baby started crying loudly on a bed. I looked over to see what the mum was doing and she was sat bolt upright on the bed staring away from it. She didn't look round or even seem to acknowledge the noise. After a few minutes another lady (too young to be her mum) came with a chitenge, swaddled the baby, picked it up and started giving it water off a spoon. Even your troubles with your baby are not private.

Before our trip away I went into the Maternity ward first thing - just after 7am - to collect the data from the night before, just in case the ladies had been discharged before our return. I could see the ward-round in progress, but thankfully they had cleared the first bay of beds where I was headed, so I sat down with the first set of notes. A high clear male voice filled the air, it was hard not to listen so I tuned in 'the baby was found motionless at 23.10. It was declared dead at 23.30' I looked up to see who was talking 'the other baby was moved to SCBU'. Throughout, the mother sat at the head end of her bed, facing away from the group at the foot end of the bed, staring into space. Even your grief must be shared...

But it's by no means all doom and gloom and I enjoy seeing the new babies all wrinkly being held so tightly by their mothers. And there is comedy to be had in OPD as well.

One particularly fraught and busy afternoon Rory called the next female patient:

Rory: what can I help you with?
Patient: I have swollen legs
Rory: anything else?
Patient: a swollen belly
Rory examines the patient
Rory: you know you are pregnant?
Patient: yes!
Rory: that probably explains the abdominal swelling? it will go down after you give birth....
Patient leaves
Next patient enters
Rory: how can I help you?
Patient: I want to have a baby...
I'll leave the rest to your imagination!

My week in numbers...

7 days
40 in patients seen daily
50 outpatients seen on Tuesday
5 cystoscopies
4 skin grafts
2 hydrocoele repairs
4 excision biopsies
1 lipoma excision
5 fracture manipulations
2 abscesses drained
3 amputations
1 flexor sheath wash out
1 sequestrectomy
2 inguinal hernia repairs
2 laparotomies
1 open fracture fixation
1 para phimosis reduction
1 removal of foreign body
4 wound management ops
1 circumcision
1 Denham pin
1 incarcerated umbilical hernia
[1 unscheduled but probably deserved nap on Sunday afternoon - Ed]

Does the wet-boiling cycle do as much harm as freeze-thaw?

We are definitely heading into the transition between dry season and wet season. For the moment we seem to be sharing the worst of each! We are getting the hottest of the hot weather - feeling like 39 degrees most days - ick - and the inconvenience of the creatures and flooding of the wet season!

When we got back on Sunday we headed straight to dinner in our muddy clothes. This caused no end of amusement to the others. Although Claire from Tiko's just looked at my t-shirt and asked if the splatterings were just part of the pattern. Little did I know that they wouldn't come out in the wash the next day, so they are now the pattern on a once plain t-shirt. Oh well!

After dinner we had the, now almost daily, fire pit at Nat and Will's. The boys displaying their amazing talents with balancing logs, getting damp wood to light and using t-shirts to fan the flames. It's an art that no girl is allowed to comment upon.

On Monday (bonfire night) the venue moved to Fi and Rory's for the first fire there. Geoff had been doing an operation so we were late (standard) but there was no doubting we were in the right place - the whole world was full of smoke. In fact it was spreading at ground level rather like a fog. The light breeze was moving the fog away towards the football field thankfully, there's only one house between Fi and Rory's house and the field. Helpfully this isn't occupied by anyone important...ahem.... like the Acting Medical Superintendent - whose garden was already filled with a dense fug so it was barely possible to see his windows. A little investigating identified the source of the smoke to be a beam brought by the Dutch students - it seems that Creosote burns rather smokily. Do you think it's carcinogenic?

To commemorate the occasion there was a small Union flag next to the fire, which it transpired had been put in the middle of the territory of a 'Scorpion Spider'. These spiders use their long front legs to catch prey and can be seen running back and forth in S shapes, especially in the light from porches. I previously mentioned that they are the fastest invertebrate in the world. This one kept running over Fi's foot. She didn't seem to enjoy the attention!!

On Tuesday night we went to Nat's to pick up the video Will took in time lapse from the bonnet of his car on Sunday. We are planning on making a video showing our footage from a different car, Will's bonnet cam and Nat's view from inside the Prado, we just haven't got very far yet! Anyway, Nat's porch is well known for being a bug and Scorpion Spider haven so we approached with caution. Disappointingly there were no spiders to be seen only really stupid beetles. They are gold and like bullets, about 1-2cm long and they can't fly for toffee despite their practising. Typically they fly into your head or shoulders and feel like something much larger, so in the dark you feel compelled to squeal before you can see what it is!

We shut the screen door and looked out. Then Nat spotted that there was, in fact, a large and juicy spider on the screen - on the outside. We wanted a better look but weren't keen on going back out with it still alive. Nat Doomed it. Nothing happened except a lot of beetles inside the screen went mental. She Doomed it again. Nothing happened. Then she and Geoff started to get a bit agitated - what was with this invincible spider? When it set off up the screen that was enough and they retreated. Of course I was too humble to point out that they had both slightly mocked my fear of a similar spider when I was a) ALONE and b) it was actually INSIDE. Anyway, it died after a few steps and I used our torch to knock it off. It hit the ground with a loud splat - unexpected!

I think that's its blood over on the left, it landed upside down so we had to turn it. Unfortunately the Doom and fall seem to have mangled it a bit but you get the idea. Note the big teeth at the front. And you have Geoff's chubby finger for scale this time - yes yes, not parallel or at the same level. Whatever!

On Friday afternoon the heat was getting a little tiring but clouds started to form in the sky. Presently I could hear a gentle patter on the roof of Pharmacy. A shower! A few large drops were falling from the sky. Occasionally it would ease off a bit but the clouds seemed endless. I knew I needed to get to the Chada to buy Geoff some talk time and it had been a frustrating day so at just after 4 I set off. This was the heaviest point in the rain so far and no one else was out and about. I enjoyed the walk - it's only water after all and I'd been really rather supremely hot before. Plus, it seemed to be drying quite quickly on my clothes so I wasn't actually getting drenched. It stopped as soon as I got to the shops and everyone else materialised again. As soon as I got back to the hospital the spitting started again - I didn't like the look of it. Abraham and I decided to call it a day. His 'driver' had come and was waiting in the porch. Abraham said we should run for it :) or rather, he requested his driver run for it! I was glad I'd passed over the reins because I was worn out from pushing him in the heat.

I moved quickly back towards the house and got inside. The rain was beating on the tin roof. Then suddenly it became deafening. Hhhmmm, I wouldn't be able to sleep through this! I closed the bathroom door (the only place without a hung ceiling) - that didn't seem to help. What on earth was falling from the sky? I looked into the garden to see it covered in hailstones! About 1.5cm across - aaahhh, that would do it. We had just received our parcels from home (sent 2 months ago) so I plugged my electric toothbrush in with glee and set about videoing the nurses over the way screaming about the hail and then torrential rain. All of a sudden the sky lit up with lightning - hhmmm, I unplugged everything! nuts!

It was still light outside so I could get good photos of the paths turning to rivers and a large pool of water forming outside the nurse training school. Then I remembered that I have a husband who was still in the hospital! he he he! So I was nice and offered to bring him his waterproofs and wellies. However, the rain stopped before 6pm so this was not needed. Rory tells me authoritatively that in the hour of rain a good 3" fell. All I would say is that the annual rainfall for the region is 1.5m and I have some difficulty believing 1/20th could fall in one hour of intermittent rain. You can come to your own conclusions of course!

Saturday was spent at Nat and Will's having a bbq in honour of his parents coming. It was great. Then when Geoff headed in to do some operations (specifically the 39th and 40th of the week - at home he never got above 15) we went to Tiko's to see some puppies. Two week old German Shepherd puppies are very cute but somehow I returned without one stuck up my t-shirt - shame!

The heat is back so the only thing to do is sit outside reading a good book. And if it feels like there's something crawling over your foot during the day - there probably isn't, it's more likely a drop of sweat heading down from the back of your knee. Nice!! At night the day after some rain, it will be a flying ant and you should eat it! :D

How the hospital works (Part 3)

I know we have both made some mention of HIV in previous posts but this has always been about the sick HIV patients. The reality is that many HIV positive people in Zambia are perfectly well because they have access to ARVs (anti-retrovirals) locally, free of charge (see below for the details).

Before we came out I read an article in the weekend paper about a lady who cycled from village to village dispensing drugs and educating people. The other day I saw a CHAZ (Churches Health Association of Zambia - Zambia's largest health NGO) lorry parked by the hospital. Abraham told me that it often delivers bicycles. What for, I said, completing forgetting the article! Doh!

The latest stats we saw suggest that the HIV positive population peaked at around 23% and has fallen to around 16% currently. This is partly because of treatments but considerably driven by premature death. Many families in the vicinity have taken in orphaned children - no mean feat when they often have 8 of their own.

The prevalence means that people's status is not far from the mind of doctors on the ground, both to aid diagnosis but also for personal safety. So how does the system work?

For most people, the first step in finding they are positive comes when they visit a VCT clinic. This is voluntary counselling and testing. At St Francis' this clinic is based by Xray. The hospital completed almost 10,000 tests last year for all purposes. From there they would be referred to the Sandy Logie Clinic in OPD. This clinic is named after a Scottish doctor who contracted HIV (and died) whilst volunteering at the hospital in the 1990s. His wife still has close links to the hospital and was here in September.

At the SLC they get a review (including of their CD4 count, which is used as a measure of the progress of the disease) and the correct medications for their particular stage and responsiveness to treatment are prescribed. There are two schools of thought when it comes to privacy and Zambians' desire to keep their status private. Some think that people are very open and others suspect that some people lie and/or are embarrassed. I think it's a mixture of the two, the problem is that in over crowded places, privacy is hard to come by.

The queue for the SLC is on the other side of the old OPD from the medical and surgical queues. It doesn't take a genius to work out who is positive. I am told that the new OPD will work differently and it won't be so easy. However, once they have their prescription they must head to pharmacy to pick up the drugs...

The room nearest the stores (ie furthest from the outpatient dispensary) is where the ARVs are kept and dispensed. There are two benches outside the room where people queue - in full view of anyone walking round to x-ray or paeds or maternity or surgery or theatres. It is far from private.

The room itself is a box room. The back wall has shelves covered in drugs, in front is a large table used as a desk. To the left of the door in a gap as wide as they are are 2 chairs at 90 degrees to the desk. The far right hand corner has a sink and behind the door is Abraham's computer and a small chair.

It's not ideal for a number of reasons. The door is not closed between patients. Abraham and anyone helping him are in the room most of the time and when he has to get out the patients have to squeeze out of the way so he can get his wheelchair out. There's often another member of the pharmacy team in with the dispenser. Occasionally there's another member of staff sat on the chair nearest the desk so the patient has to lean over them to get their notes to the desk :) And then there's the muzungu that hangs about!

But it's a great room for seeing what an HIV positive person looks like and I can report that they look perfectly normal. Some are fat, some are thin, some are rich, some are poor, some have well behaved children, some have monsters, some can understand when to take the drugs, some can't. But they are all there, about 100 per day.

One day a man in a wheelchair with two stumps where his thighs would have been came into the room. I was a bit surprised because I hadn't seen him in the queue when I'd walked up a few minutes earlier. There was some shouting from outside. Upon seeing me he started speaking in English (I think to show he could). 'Disabled people should be able to jump the queue shouldn't they? Always??' Ha ha ha. I said that they did get privileges in the UK, yes. Mr Nyirenda dispensed his drugs and said 'Next time, Mr Zulu, you will queue like everyone else...'

Yesterday I was tucked on the little chair behind the door (effectively invisible to everyone) when I could hear 'muzungu' in the conversation. Then Luckson, the dispenser, requested that I come out from behind the door because the little girl (silent) wanted to see me. I got up. She just looked at me and didn't even smile! The cheek! I suppose it was better than the last request I got which was that I should give the lady my ring - 'but that's my wedding ring! I can't give her that!'

One thing that has impressed me is the time taken over each patient to explain how to take the drugs. A great number of people can't read and can't tell the time. Some tablets must be taken twice a day, others once. I've watched everyone going through this patiently over and over and over again, without a hint of frustration. And simple solutions are the best - one line on the box means one tablet a day, two lines means two. And timings are done off meals.

So where do these drugs come from? Simple answer is - The Americans. The money comes from PEPFAR to CRS (Catholic Relief Services - US NGO). At the moment CRS coordinates everything in Zambia and set up all the logistics to get the drugs and support money to where it's needed. However, the US Govt has stipulated that more control must be passed to local organisations and the Americans should start to withdraw control. The aim is to make the local Govts start to contribute. In Zambia this means that CRS is passing control over to CHAZ. So far so good.

There's just one concern. For some reason (as yet not fully understood) hospital Management believes that the CRS funding is disappearing at 20% per year and they will have to make drastic cuts! This isn't what the PEPFAR website says, it isn't what CHAZ says and the chairman of CHAZ is Joop the O&G doctor. Quite who is maintaining this myth and to what end is yet to come clear... However, all the SLC patients can sleep easy, their drugs will keep coming.

Disaster!

So it has been topping forty Celsius for the last couple of weeks, and it seems someone forgot to keep on top of the ice cube supply [Quite, my G&T is getting warm... Ed]. My left ear has started to melt and I'm seeing oases on every horizon!

Seriously though, it is hot. I'm starting to envy the siesta culture of the Med, sometimes it feels just too hot to do anything! But work keeps coming. We returned from a stunning (if wet) trip to see the hippos to crazy amounts of work. My Monday list lasted from 8am to 10pm, with 14 cases (one abscess, fracture manipulations, two biopsies, skin grafts, a hernia, some skin tumours, three cystoscopies, two hydrocoele repairs and an amputation for a dead leg just to round things off).

Tuesday's clinic was crazy - there must have seventy patients, to be seen by me, a medical student and a student licentiate. Prof has been working hard to try and keep some patients in Chipata (the regional referral hospital that currently lacks a surgeon) and so spent the day there sorting stuff out. The good news from that is we should start to get fewer minor referrals clogging up the ward, outpatients and theatres when they could be managed in Chipata. Anyway, Tuesday was rounded off with the drainage of a flexor sheath infection before dinner. This is an incredibly painful abscess that in the UK presents very early, and is one of the few things that will get a plastic surgeon out of bed to operate. This chap had been ill for five days and the infection had destroyed all the tendons to one of his fingers, which could be very disabling for him.

Wednesday was a quiet day - only 9 cases on my list. Currently the Prof and I each have our own lists, as the Zambian registrar has left and the fully-trained licentiates are on leave. I have learnt to give some minor anaesthetics so I can do the minors list. Although "minor" is a little more stretched than at home. Probably the most stretched procedure was a sequestrectomy in a 7 year old boy. This was removal of his infected dead tibia and closure of the wound with a local flap - quite a big undertaking! The rest of the 9 procedure minors list was biopsies, skin tumours, fracture manipulations, a hernia and two above knee amputations (the last two under spinal, not sedation!)

Work here is hard. There is no disguising the fact that you could be on the ward or in OPD 24 hours a day and there would be work to do. Learning at what point to step away has been one of the big challenges and one with which I am only just getting to grips. But, if you are tired you make bad decisions, do bad operations and lose your temper with colleagues and patients. So sometimes stepping away and just saying no is best for all.

Anyway, today was quieter - just two minor emergencies (a para phimosis (look it up [ooo grumpy! Ed]) in a sixteen year old - they are the same the world over) and a foreign body removed from a foot in OPD. I also got to start trialling the new burns protocols and paperwork on Kizito and it was generally welcomed. And because everyone in Eastern province came to OPD on Tuesday (or so it seemed) clinic was quiet. Hence I am sat in the warmth, just about to get a G&T (hopefully with some new ice) and enjoy the evening.

Does anyone know Noah's phone number?

When we decided to go glamping for the second time from Wednesday to Sunday last week, I thought it would be an opportunity for a low hassle blog post. Surely all I needed to do was download the SLR photos (unlike last time), compress them and post them. Job done.

Unfortunately events transpired to make that a less than accurate record of what happened. But, it started like this... [Photos follow]

This is a Civet cat, slightly blurred

Then the guide said he'd take us to see the Wild Dogs. These are really hard to see in the wild, even Will hadn't been able to get the shots he wanted on Beetlecam and he was really excited. So we headed there in the morning. Our guide was a little green and of the ilk that thinks clients want to be driven from animal to animal, take a few photos and then leave. When he suggested we leave the Wild Dog pack after about 15 minutes he was told firmly that we were waiting until we and the Burrard-Lucas' were the last car there... Our persistence paid off, we saw them playing together and squeaking to each other, learning about Beetlecam and then taking some tentative goes at the herd of Buffalo and a Monitor Lizard!!!

 Perfect. Then we had a quiet and uneventful evening drive looking for Eland. They clearly got the memo saying we were coming and decided to hide! We dressed up and headed for dinner. Just as we got there a few spots of rain started to fall - should they move the table in from outside?? They decided that would be safer and it was a good decision because almost immediately it started to pour with rain. The camp shuts on the 7th of November each year, before the rains come... and therefore it's not set up for the wet. The central bar area has a thatched roof but no walls - which doesn't protect you from horizontal rain! Dinner was a little damp - the plates were damp, people's faces were damp but spirits were high - it wouldn't last long...

When dinner was over the rain showed no sign of abating and the centre of the storm was above us. The thunder was deafening and the sheet lightning was so bright we could see all the way across the river. It was as if the sun was a faulty strip light flashing on and off, it was almost as bright as day! Emergency ponchos were brought to ferry us back in pairs to our rooms. The dry sand I'd walked across to dinner was now covered in at least an inch of water and boggy mud. My feet were filthy.

Back at the tent we make another learning. The last camp we stayed in (I didn't show pics of that one) had two basins - one inside and one outside and only an inside loo. That camp is open into the wet season. This was our bathroom this time...

The loo is on the left behind the door. We look out into the storm to see that the light - an energy saving bulb with a standard bedside table type switch - is flashing ominously like a firefly - clearly not a good idea to try and use that! Hhhmmm. The only way to make it to the loo is to have someone inside shining a torch through the door. And the only way to minimise dampness is to go naked.... or in my case - naked with a shower hat. Geoff did not attempt to hide his amusement at the scene as I ran out holding loo roll tightly in the ball of my hand. Back in bed (two massive single beds with double sheets and a double duvet) we feel very comfortable. Through the tent doors we can see the lightning lighting up the whole river and the hippos. The thunder is so loud it's vibrating our internal organs as if we are at a rock concert. Somehow we fall asleep quite quickly.

When we wake it's still raining - hang about, this isn't what was agreed! The morning activity is cancelled. We make our own fun with the B-Ls (there's Nat and Will and Will's parents) and start playing Balderdash. The bush is quiet apart from the sound of our laughter and the hippos joining in occasionally. Geoff and I have never played before and we were not doing well for a long time. Then suddenly I got lucky. This was both good and bad as they are, perhaps, one of the most competitive families in England. Will was clearly wanting to win very badly.

A turning point came when Mr B-L (aka Steve) said that you knew a fake answer if it was lewd because 'the Balderdash writers are never lewd'. I was dasher next and the question in front of me was about premature ejaculation and the 'solution' provided by a witch doctor - too good to turn down. I waited expectantly for the answers. One read 'stretch it, iron it, pour iced water on it [by now I'm wondering if I'd read the question correctly] and then touch it with a live electrical wire'. I shan't mention who that was for fear of disturbing her retirement. The answer was a sexual act with a hedgehog, obviously. And this pushed me to within reach of the win. In the final round it came down to Will winning if he got the right answer and me winning if he didn't. I think it worked out well for all involved with Will taking the win. I could sleep easy that night :) Only kidding Will.

No cars left camp for 2 days so we entertained ourselves with walks. I shan't write much, the pictures say enough - just be aware that rivers were previously either completely empty or about 2 inches deep, all ground was very very dry. And the current generation of men could learn a lot from successful business men, as Steve very carefully collected a bunch of sausage tree flowers for his wife and carried them through the wet bush. 10/10

For the two nights after the rains, we were bombarded at dinner by flying ants. The table was kept in darkness but still you would find them in your soup or on the butter. These aren't ants like at home that are tiny, nope. The first night they were about 1.5cm long with two sets of big wings so they made an impact on your meal. Will's mum hid under a shawl :). The guides assured us they were only a one night phenomenon so we enjoyed ourselves and tried not be annoyed by them committing suicide in our dinner. After an hour and a half they died down - well, mostly, they died or their wings fell off and then ran across the floor. This attracted massive millipedes and centipedes, as well as spiders and snakes and scorpions. Good good. We went to bed. When they came the second night they were bigger. Actually there were 2 sorts, one an inch long and one about 2.5 inches long. The larger ones were more idiotic and took to flying into people's heads. This did not endear them. Once we were safely installed in bed I thought I'd have some fun with the Doom. Note to self: do not do excessive Doom'ing when lying in bed without a mosquito net when the room is full of bugs - sure enough the bed was soon covered in little bugs.... Oh well, it was fun!

On the Sunday they sent a tractor to save us. It took 4 hours to make what is a 1 hour journey in the dry. There was mud. Lots of mud. When we arrived they said there'd been 150mm of rain in 12 hours - 1/10th the annual average rainfall. Final set of pics should say it all... [Geoff's doing Movember]