Christmas in the hospital

Charlotte is the better person to talk about the fun and games on Christmas Eve and Christmas Day, so I will talk about our working week instead!

Unsurprisingly, Christmas in Katete is not the commercial extravaganza that it is at home. At most, people spend more time in Church (there was a service that lasted at least 4 hours on Christmas Eve and another similar length one on Christmas day) and government employees get the day off. As it is planting season, the workload has already significantly diminished, and a lot of our planned cases are now not coming for their operations, I assume because they are in the fields.

The week has however been a busy week for emergencies. Last week we did a string of laparotomies for advanced bowel obstruction or severe abdominal sepsis. By far the worst was the young man on whom we had brought out a stoma because he was critically ill with a typhoid perforation. We had to take him back to theatre, just at the point he was getting better, because his relative had pushed the stoma back inside the abdomen because he did not like the look of it. The week has been another week of multiple laparotomies. On Monday, it was a semi-elective cholecystectomy and a colectomy for an intusussepting polyp. Tuesday was pleasantly quiet, although come Wednesday I had booked four laparotomies. One internal hernia with extensive small bowel necrosis needing a right hemicolectomy, one sigmoid colectomy for volvulus and one quick small bowel intususseption for reduction. The fourth was just too ill to anaesthetise and was managed non-operatively (she had been unwell for two months prior to their referral and showed it).

Friday was a bit quieter, although we still did 5 skin grafts and a string of fracture manipulations. Perhaps the most rewarding op (provided it works) was on a 4 year old boy who had lost a chunk of skin and muscle from his forehead falling over. One of the rural clinics had tried to suture it, but it had fallen to bits. We sought some advice from home, emailing a photo to a plastic surgeon, and did our best to close the defect primarily. In the end though the only way we could cover the bone was with a little rhomboid flap, which currently looks pretty good considering everything.

Next week, I'm looking forward to the division of the groin flap on Wednesday!

Referral

I was once told by a tutor in Cambridge that the only question a doctor really needed to be able to answer was "can I deal with this?" and if not, "who can?" This is a perfectly reasonable approach where there are multiple specialist centres, well staffed with a range of experts, all linked by excellent, affordable transport links. Unsurprisingly, that is not the case in Zambia. The concept of referral is therefore very different from at home.

St Francis' receives a huge number of referrals, most from the Katete district health centres, but a sizeable number from other district hospitals (particularly Nyimba, Petauke and Lundazi) and a lot even from our regional referral centre in Chipata. As I have hinted at in previous posts, we have the only surgeons in the province and so it makes sense that all complicated cases come to us. The other hospitals will however provide some basic surgical services, including Caesarean sections, hernia repairs and fracture management. Referrals, particularly of sick inpatients, arrive in a hospital car, which is often sent only when full. This means we often only see the very sick and unmanageable, or inadequately managed patients from the referring centres, giving us a somewhat distorted view of their work!

The patients we receive generally come for a specialist opinion, which is quite often a disappointing (to the patient) "do nothing". Common examples of this are fractured clavicles, acromeo-clavicular and sterno-clavicular joint dislocations or terribly advanced cancers. Nyimba quite often sends a car on a Thursday evening, which means we occasionally get someone who has had conservative management of an abdominal catastrophe for several days who then needs an emergency laparotomy at night, which can be somewhat frustrating! [Particularly for the Surgeon's wife! - Ed] Others include complications that are related to treatment at the other hospital. Our gynaecologists always have at least one C section complication from elsewhere (normally a ureteric or bladder injury). We most commonly receive problematic open fractures or closed fractures that can't be reduced without performing an internal fixation. This week's disaster was a young man with a degloving injury of his leg and a Gustilo 3 open ankle fracture which had been sutured at another centre one week earlier. We had to debride a huge amount of dead tissue and apply an external fixator, and now it is looking like he will keep his leg.

We also receive a lot of self-referrals, some who are convinced we can do something they have been denied in the main hospital in Lusaka (some are right, like the chap who travelled 8 hours to have a lipoma removed this week, some are wrong, mostly those with complicated urological problems) and others who just want treatment at what is perceived to be the best hospital available.

Perhaps the oddest referral yet came from a wildlife charity worker, who arranged to send a young boy whose chronic osteomyelitis and exposed tibia had been mostly ignored by his local hospital.

Our access to referral is a little more tricky. Most patients have neither the will nor the money to travel to Lusaka. When they get there, I understand they have to wait for treatment, further adding to the cost. Most will ask us to do everything at St Francis', and I'm sure a significant number of those we do refer on actually just go home instead. So, we try and offer as much as is safely possible.

The question of "can I deal with this?" became somewhat more complicated last week, as due to a clash of annual leave, I was less supported than usual. There is no such thing as a critical care transfer, so if someone is profoundly unwell and needs emergency surgery they either die or have surgery here, by whoever is available.

I am working on the principle that if I do nothing and the result would be worse than if I do something, even if things go wrong, then I should do the most straightforward operation possible. So, while I am still sending off our complicated urology cases (we get a lot of advanced bladder cancers and difficult gonorrhoeal strictures), I have taken on a bit of orthopaedic work beyond my usual UK experience (open reductions of supra condylar fractures and external fixators mainly) and had to take on one complicated laparotomy (a relative decided he did not like the look of the ileostomy we had brought out for a typhoid perforation, so forced it back inside the abdomen). We also (despite not being plastic surgeons) performed a pedicled groin flap to resurface someone's hand. He would not have gone to Lusaka and just gone home with a terrible wound if we had tried to refer him. The flap looks great, and if it had failed we could have done a skin graft, which was our worst case scenario if we didn't do the flap. So even a failed operation would have been no worse than no operation.

Gemma is now back from her interviews, so I have a consultant around all the time again. Last week did however provide an interesting insight into learning my limits and the often complicated decision making around taking patients to theatre.

I have been looking at some interview skills websites for when I get back, and was amused to see a discussion of the question "a patient needs an emergency operation that you have no experience of, and the consultant is unreachable - what do you do?" The answer listed a whole range of options, through calling other consultants, calling other hospitals, calling the MDU and only then considering doing the operation if all else fails. I am somewhat looking forward to the reassurance of having such a wealth of opportunities for help when I get back!

Next in the frog series

On the night of the fire, Will was supposed to be helping Geoff and Jamie with it but was instead scouring our garden for creatures.

He found a frog, which from the markings and secretion on its back we decided was probably poisonous. See! I was right to wonder about the last one. He asked for a cup to take it home in to photograph - I've told him he can keep the cup!

After a while Nat rang to see if he was still alive. He claimed that the poison was neurotoxic and he couldn't move - we just laughed, which made him huff down the phone.

The next day, when I checked my email I discovered this:

Subject: banded rubber frog says...

BITE ME.

I laughed a lot. Particularly because the frog does appear to be taunting you to bite him and it's relevant because I'd been threatening to say that to some people here that had annoyed me!!

We start exploring...

As many of you are finishing work today for the holidays, I thought I'd do an easy post. There's a message from us at the bottom if you are pressed for time!!!

After 4 months here we thought it was about time we did some exploring. Geoff hasn't had the chance yet just to wander about so we planned a walk yesterday from the hospital to Katete. Instead of taking the direct route we chose to go through the villages and live up to our name of Muzungu ("aimless wanderer").

We met many people that would like our 'assistance' and quite a few children that just wanted their photos taken and then to be shown the outcome. It's funny that even the most scared children (many associate white people with pain - they are the doctors after all!) know what a camera is and what they want. We didn't tell any of the children in the photos below how to pose for us - this is their choice :) It seems that you must look stern or angry in photos here.

I have played around with the photos - and yes, some of them would have benefited from a bit less touching up, I'm still learning. Didn't want to put Will out of a job immediately...

Earlier in the week Gemma and I went for a slightly more adventurous stroll - that involved climbing over a tree over a stream to get back to the hospital. Some of the photos are from that.

The sky really was almost this colour!

There is a man in this mango tree - towards the top right

This is a house

MERRY CHRISTMAS!!!!

We keep hearing of new people that are reading this blog, which is always pleasing. We hope that you are enjoying what you read and that you have a wonderful Christmas and New Year.

If you have a few moments to email either of us then we would love to hear from you!

Below is a photo of us making a fire to roast chestnuts on the other night. Apologies to Julie and Gemma, whose faces have become less distinct in my tweaking :) but you can see me better now!

Will, Geoff, Jamie, Julie, Gemma, Nat, Charlotte

The advantages of having a Pro photographer as a friend

Yesterday afternoon, towards the end of an email conversation about a piece of photo editing software, I asked Will if he thought I could have a biscuit as I was hungry. The query being posed because of the proximity to dinner time.

The reply said:

the rain frog says go for it.

And so I did. Not that I had a Rich Tea, as instructed. But something struck me about the picture. I recognised the frog (having played with/tortured - depending on your point of view - many on the way back from Tiko's with Will over the past few weeks) and therefore its photo must have been taken in Zambia. Further, as it has Will's copyright at the bottom (he's clearly not very trusting) it must have been taken by Will - but where was his studio? I've been to the house many times and not seen the white sheets and reflectors needed to make this photo.

After dinner I found out. Geoff was on call and therefore doing a Laparotomy - standard. So I was invited over to Nat and Will's for company. In tow was Julie (one of the new doctors) keen to borrow the world's second largest mosquito net. On the front door when we arrived was a massive beetle - probably about 5 inches long with a good set of jaws on it. I pointed it out to Will when he opened the door and he asked if we wanted to photograph it. I said yes, I don't remember what Julie thought! She's not that keen on spider type things.

He scooped it up on his white screen (about 16 inches across) and replaced the screen (somewhat precariously) resting between the back of a chair and the dining table. Unfortunately the beetle was not keen on sitting still and immediately started charging about trying to get off the white area. I tried to control it with a torch whilst Will setup the flash under the screen and his camera. Julie and Nat were enlisted to add additional light using torches. By the time this was all arranged the beetle had escaped at least twice and had to be retrieved from various corners of the room. Needless to say it was no happier and continued to run around. By now I'd swapped the torch for a large spoon - hands were out of the question as the jaws were being put to good, if ineffectual, use. Will issued many commands about the positioning of the model - mostly that he wanted it running towards the camera. This was pretty much the only direction it didn't want to test for its big escape plan. I did offer to swap roles with Will to see if he would have more luck ;) Eventually we decided to give up.

Will took the beetle outside on the screen. The girls started to drink their tea. When the door opened again something brown came flying through the air and landed between Julie's feet. She immediately leapt out of her seat and ran off. It turns out it was a small brown frog - our next subject. The frog was only slightly more disposed to being photographed than the beetle. Julie took on the job of corralling it and was happily holding it in her hands when I asked how she knew it wasn't poisonous. She pointed out that Will had touched it - at which point Nat told her that Will has touched poison dart frogs intentionally in the past and therefore isn't always the best benchmark. To be fair to Julie's courage, this didn't make her let go of the frog! [I don't think there are poisonous frogs here, I just thought Julie should think about the possibility first!]

Shortly the frog was returned to the garden. On his way out Will had said he'd seen another pretty frog out there and was going to bring one in. He was gone a long time. We didn't bother to ask if he was OK, we carried on chatting and drinking tea. When he returned this time he was carrying a stick.... and on it was the largest chameleon we've seen in Katete. About a foot from nose to tip of extended tail. It was green and black - this is odd because at night they go pale green.... Will admitted that he might have annoyed it when waking it up. It wasn't keen on staying on the stick either and he yelled that the door should be shut quickly. Somehow this caused Nat to upset her tea into her handbag. This event must be recorded as entirely Will's fault. [I'm not quite sure why it's Will's fault and not an accident but I understand that this sort of thing happens a lot to husbands ;)].

We had even more fun trying to control the chameleon, probably because of its size. It set off up Will's T-shirt at one point - it has sharp claws and he now has a pierced nipple - then it went onto the curtain. Eventually we got it on the stick again and managed to keep it on there long enough to photograph. It did hiss a lot and threaten to bite us, in a way that was slightly more threatening than the beetle! Probably because he could keep an eye on two of us at once. Ultimately, Will decided that the chameleon was too big for the screen so he couldn't get a single shot of it with a solely white background. It was returned to the garden to go back to sleep.

After he'd forfeit some of his tea to Nat, we decided that that was enough fun for one evening. I know they have a large monitor lizard in their roof. I'm not sure I want to be an assistant when he decides to photograph that in his studio!!

What are you doing for Christmas?

This is a question that I've been asked a lot recently so I thought I'd write the answer here and then you can all be in the know!

The short answer is: working! At least for Geoff anyway.

The Prof is in Holland until the 29th and some other gaps in the rota mean that from Monday night, Gemma and Geoff are the only trained surgeons here, and pretty much in the entirety of Eastern Province. As I type it's just Geoff as Gemma's been back in the UK getting her Consultant post (Well done!).

So they will be working most days and that includes Christmas and no one will be going further away from the hospital than Chipata and only when one of the fully trained licentiates is available to get things started if there's an emergency.

What are we doing then?

Well, we have got a Mulled wine and Mince pies party planned for Thursday - this is the evening closest to Christmas that we are all together - Fi and Rory come back from Malawi in the morning and Nat and Will go to Namibia on Friday (very jealous!). Apparently we will be singing Christmas carols! Which is good because I like singing but I'm not sure the boys are that keen.

Nat had suggested Secret Santa but I've pooh-poohed the idea. I know shocking! [I've helped organise it at work for the past 3 years]. I thought it was going to be a bit tricky with no access to decent shops. Fi suggested we give the worst thing we can find in our houses but that prospect is scary and probably a danger to health. So we've all agreed to appease Nat by giving her a sprayed cockroach in a match box. You probably had to be there but suffice to say that Nat hates cockroaches! :) I've managed to find a good 3 incher for my box, I'm just having to extend the box to fit it in and trying to keep it alive until Thursday - anyone know how long they live?

On the day I'll be joining Geoff and Gemma to give out the presents that Gemma, I mean Santa, is bringing for the Surgical wards. Usually the patients get Chicken and Rice for lunch, as a change from Nshima and beans, but I spoke to the head chef earlier in the week and they haven't yet been given the go ahead to buy the food. I'm not hopeful given that last night was a chicken night for us and we had mince. There's been no custard all week - we are back to hot milk - and yesterday's pudding was just mushed mango and sugar...

Either way the lunch will be served by the doctors!! And me, as honorary doctor unless I'm going to be cooking our Christmas lunch! But I doubt they'd be that mean to make me do it alone - or more likely, that trusting!! We will just have to pray for electricity all day!

There will be no presents exchanged in the Roberts' household by mutual agreement. We have one present from his parents that will have to do! Note that both sets of parents were told that we didn't want presents we had to carry as we had too much luggage already ;)

The big event will be New Year. The Prof is coming back from Lusaka in his car and has offered to do a shop there (we need to send him a list!) and bring 2 bottles of Champagne. As he's alone (his wife is staying on a bit longer with her daughter), he's going to be part of our party or we are a key part of his! I think we might need more Champagne.... :D

In the meantime, I've just remembered that they are away and they have an Avocado tree, so I might pop over and see if any are ripe ;)

Late presentation

I have already hinted at some of the differences in medicine here, one of the major issues being the time between people getting sick and presenting to hospital. There is a fine line between apparent hypochondriasis and appropriate presentation, which is very different in Zambia to at home.

In the UK, people are well educated about their health, there are major campaigns about the symptoms of certain diseases (e.g. bowel and breast cancer) and often present in the early stages of illness. There are of course exceptions to this, which I encountered in the population local to Whipps Cross, where we would see much more advanced disease. On the other side, we see a lot of "worried well" in the UK, who normally require only reassurance and observation.

Nearly everyone I see in OPD or on the wards has a definite illness. I'm told the physicians see some "worried well" but again a smaller number than in the UK. I do however see some staggeringly advanced disease.

On Saturday I opened the abdomen of a 12 year old with peritonitis, who had been unwell for 4 weeks. She had 4 litres of bile surrounding her bowels and a sizeable hole in her duodenum. Given the history, I can only conclude the perforation happened at least two weeks earlier and she had been critically ill at home for that long!

Today I saw a lady who had a hysterectomy at another hospital last year and was complaining of a "growth" in her wound. She in fact had a 10cm metastasis growing from her wound and grossly distended bowels. This had been there for 6 months. There is nothing we can offer her, although I doubt there would have been anything we could have done when the problem first started.

We have recently received two burns from another hospital, where they had been managed for four weeks. My burns experience in the UK is that you make an early decision about whether a burn is full thickness and needs grafting, or partial thickness and needs wound care only. These two girls had unhealed full thickness burns that could have been grafted a month ago and they would be healed by now. If they were left they would eventually heal, but with terrible scarring resulting in very poor function.

I have already talked about the late presentation of people with bowel obstruction, but it is a recurring theme that it takes about a week for someone with bowel obstruction to reach us.

From a medical perspective, there is no doubt that the results of treating very advanced peritonitis or wounds are worse than with earlier presentations. From the patient perspective, there are a lot of reasons for not going to hospital unless absolutely essential.

The first is becoming apparent this week. The rains have started, so it is planting season on the farms. There is neither time nor money to come, and our wards are getting quieter. Three of today's elective cases failed to turn up, I'm sure for this very reason.

Money is a big factor. Our catchment area is huge (as I'm currently on my own in the surgical department, I could claim to be the senior surgeon for an area the size of Scotland with the same population as Wales) and transport is not cheap. Money is apparently more plentiful after harvest, when the crops are being sold, than during planting season when seed and fertiliser are needed. The seasonality of poverty is well demonstrated by the peak of paediatric malnourishment cases in January and February.

Poor health education clearly influences presentation. Many don't understand the meaning of their symptoms and only see the need to present when they are near death. Traditional beliefs about health are often difficult to reconcile with modern medicine. The sites of advanced tumours or long standing wounds are normally marked by the scars of traditional healers. Even when people are here, they will sometimes refuse treatments on the basis that they think they kill people. This encompasses things like oxygen, fluids or nasogastric tubes.

Referrals from other centres sometimes come remarkably late, but that is the topic of my next post.

Finally, a surprising, and incredible, ability to tolerate adversity. The loss of limbs, neurological deficits or festering wounds seem to stop people doing very little. The family support network is often wide and very strong.

I'm now expecting things to be quiet for a few weeks while people pant their crops, then we should get very rapidly busy, as they come in with all the problems they have been storing up while working the fields!

The role of women in society

It can be difficult to assess subtle cultural norms when you arrive in a new country. No one is going to tell you explicitly unless you ask some pointed questions or it just happens to come up in conversation. Sometimes the stories people tell are the most useful way of assessing what goes on, so I thought I'd tell  you a couple of stories.

I've come across a chap that works in the hospital that I'm going to call Dave, safe in the knowledge that there probably isn't a real person called Dave! Dave is a borderline functioning alcoholic. I have seen him in the middle of massive DT episodes as he withdraws after a big night out or weekend but there are other days where he doesn't make it to work at all.

Most of the time he's a lovely smiley man and therefore is good company, on the withdrawal days he's a bit more introspective, probably because of the discomfort of his symptoms.

One day I asked him about his home life. He is married and has two children, one's a toddler and the other is about 9 months old. They live in a house the other side of the Great East Road. His wife doesn't work and she keeps a close eye on the cash. So far, so good.

So what do you do when you are at home? 'Oh, I'm hardly ever there!' Dave's routine runs like this: finish work, go home, spend 10-15mins there with the kids, go out to a bar with his mates, drink Kachasu (lots), come home when the household is asleep, go to sleep. In the morning he says he plays with his baby in the bed whilst his wife makes his breakfast. Weekends is similar - always in the bar, hardly ever at home.

Do your children even know you? 'Oh yes, when I get home they come rushing up, shouting Daddy Daddy Daddy' He laughs, completely oblivious to the undisguised look of contempt on my face - it's not that I'm not sympathetic to the problems caused by alcoholism, I am, it's just the lack of insight or care that bothers me.

I feel sorry for your wife. 'Why?' he looks a bit taken aback but not much 'She knew what sort of bloke I was when she married me.' There's a pause whilst I consider my response to this excuse. 'And, her parents really like me. They are forever telling me how grateful they are for how I look after their daughter. They even give me money when they come sometimes, I use it to buy beer!!' he says, nearly falling over with laughter.

Why on earth would any father be happy that their daughter was married to a bone idle (in terms of domestic/family responsibilities) alcoholic? And why would he give the guy more money for drink? It is Abraham that explained the pieces of the puzzle. Dave's wife comes from a very poor family. They couldn't or didn't afford to send her to school. Therefore she had no job prospects and was just a burden to them. They were happy that Dave took her away and put her up in a house and gave her a family. As far as they can see, Dave has a good job and he doesn't beat her, so it's all good... This is why many girls are 'married' off at 15 or so.

In Tiko's the other night we got some first hand evidence of the fact that there are worse husbands. Elkie (the owner) said she was expecting a very angry husband, who she alleges is guilty of gender based violence, or what I'd call domestic violence. The wife in question has been admitted to a local hospital and all of her belongings have been removed from his house.

When he arrived it wasn't hard to work out who he was. He was shouting a lot and clearly very angry about what had happened. His version of events is that it's all Elkie's fault. :) Because Elkie had the audacity to give his wife a job and coach her and then supported her to leave him. Elkie should spend some time thinking about the terrible thing she has done.

It's an interesting argument and, as Fi said, it is not false. Unlike most of the other women in the local area, Elkie enabled this woman to be independent of her husband for shelter and food - at that point she was able to leave him - and when he behaved unreasonably, she did. Elkie held the moral high ground until she lost her cool and shouted at the guy to 'shut up!'

Women in authority and even just in the workplace are much rarer here than at home. Without access to free education that situation is unlikely to improve in the short term, but that doesn't mean that even uneducated, unemployed women don't deserve to be treated with respect. There are many men in Africa, in general, that could do with learning that lesson. I hope that, as in India, increasing affluence will allow for larger numbers of televisions in rural areas and women will learn that they could/should be treated differently and start to rebel...

Going back to Dave for a second, he caught me in the corridor the other day to tell me about the trouble with his youngest daughter. She is very troublesome apparently. The trouble manifests itself as a refusal to sit quietly on her mother's back in a chitenge. She wants to be held at the front or, better still, left alone to be independent. I've heard stories about a similar little girl so the answer I gave him was simple. 'This isn't a problem. This means that you have a very bright daughter. You need to start saving now for her school fees and then in the future she will make you very proud...'

Photos of South Luangwa - including elephant close-ups!

I know that some of you might be feeling a little worse for wear today, it being Christmas party season, so I thought something non-challenging might suit!

Not scary elephant

Slightly scary elephant

Scary elephant 

Even scarier

End result!!! 

Yes, the hippo is sticking its tongue out at you. How does that make you feel?

Beat that Will!!! Show me what you got!!

Promised baby warthogs!

Obligatory shot of happy travellers up a tree

I think the tent was bigger than our place here! It certainly benefited from the bath (front right!)

Typhoid

Typhoid fever, or Salmonella typhi is a bacterial gastroenteritis last commonly seen in England in the 19th Century. It is a disease with decidedly Dickensian overtones, resulting from overcrowding and poor sanitation and has largely been eradicated in the developed world through improved housing, public health measures and vaccination.

In Zambia, typhoid remains common. We have had a spate of complicated typhoid cases in the last week, probably due to increased flushing of waste into the water table by the rains. It is easy to think of Victorian diseases like typhoid, cholera and TB as relatively minor, because we see them infrequently and people often recover. Here it is the opposite on both counts.

Typhoid has an interesting presentation, often with the patient being unwell for two or three weeks before they come to the attention of a surgeon. We get involved if they perforate their bowel, which is a rare but devastating complication. By then, they will have suffered a week of general malaise, fever and other non-specific symptoms. Those that perforate then classically have several days of diarrhoea and high fever, then on average 5 days of constipation. Perforation is heralded by severe abdominal pain and unremitting fever, and death if not rapidly treated.

Surgery for a typhoid perforation is daunting. There is extensive peritoneal contamination with small bowel contents and inflammatory adhesions. The perforation is usually small (under 5mm) and difficult to find. There are occasionally multiple perforations. Management is very different to bowel perforations seen in the UK. At home, it would be anathema to repair a hole, or anastomose bowel in a contaminated field. Here, unless there are multiple nearby perforations, the hole is freshened and closed. Resection of the diseased segment would often necessitate the removal of a large piece of bowel and sometimes a partial colectomy, as most of the GI tract is severely inflamed. Creating an ileostomy is a huge morbidity for the patient to deal with and if they have a high output stoma they will die from fluid and electrolyte imbalances. Even antibiotic treatment is different - the first line is IV Chloramphenicol, a drug only used in eye drops in the UK due to side effects. It is however very effective. Roughly half of patients will die in the immediate post operative period of ongoing sepsis or GI tract failure.

Having said that, the young, fit local population (those without HIV, TB or malnourishment) often make a startlingly rapid recovery. It can therefore be a very challenging and very rewarding disease to manage.

It very much counts as one of the diseases here that is completely different to anything at home, including the basic principles of surgery! It is also interesting to see the disease that gave "Typhoid Mary" her name and killed Prince Albert.

Elephants and Leopards

I'm afraid that things are going to get slightly out of chronological order because I'd rather relate the events of this weekend whilst they are still fresh in my mind. Photos will have to follow.

We went to South Luangwa for our third and last time. We were staying at a camp deep in the bush about 3 hours from the main lodge - the one we stayed in the first time for 1 night, which had an indoor loo...

Not wanting to miss the evening drive on Friday, we planned to set off in the hospital car at 7am. Unfortunately our driver thought that 7am was a good time to be checking the oil and water on said vehicle and rather patronisingly told me that it was better these things were done before a long journey. It is indeed better, it would have been even better if you'd done them the night before.

Anyway, we still arrived at Mfuwe Lodge in time for lunch and then the drive to the camp. We had to enter the lodge by the back because an elephant was eating the wild mangoes at the front door. They have taken to walking all the way through reception at times to get to the mangoes.

After lunch we jumped in the car with our guide, Willy. Although the idea is to make good time and hence drive quickly, the car did stop when there were interesting things to see. The first being a very baby elephant with a massive ball of mud hanging from the end of its tail. It looked like a Christmas decoration.

Then Geoff fell asleep. He was so asleep that he slumped into the middle seat between us and woke up abruptly asking what had happened. Then he slumped out of the car and it was decided he should sit in the middle to prevent premature exits. This he did until he suddenly jumped up holding his thumb. I was aware of a clattering noise and a dull pain in my shoulder and the back of my head. Something had flown up and hit the side of the car and us. The thumb was grazed but not broken - we carried on. Geoff stopped sleeping.

By the side of the road I spotted a shape under a tree. We were travelling too quickly for me to form the words to shout before we were alongside. It was a Marshall Eagle - the biggest in Zambia and it took off alongside the car as we passed. Geoff could have touched it it was so close to his head. The next excitement were bush pigs (only seen 3 or 4 times a year by these camp staff) and a Hartebeest.

When we arrived the camp manager wanted to know if we were still keen for the night drive, given all the driving we'd done that day. We said Yes! And that we would want our tub filling - remember Nat getting it filled for us last time?

Bar two exceptional Leopard spottings and the company of 2 slightly odd old Americans, the drive was uneventful. As was the walk the next morning. It was just Geoff and I because one of the ladies couldn't walk very well.

After brunch we decided we needed a nap (we were up at 5am) and to let the water in the tub warm up. I looked out of the 'window' for which you could read wall, as it is all screen, to discover a large male elephant coming round our fence into the garden. The back half of him was pleased to see me. The front half was more suspicious and he was sniffing the air with his trunk. I said hello. I reasoned (although the manager did mock me later) that I was stood in the shade, he was in the bright sun, and that elephants have poor eyesight and it's better not to startle them. If I made noise he would know I was there and could retreat if necessary. He moved further into the garden and started eating a tree. I opened the screen door gingerly to take some photos without screen in them. Next he moved into next door's garden - we could see his back and the top of his head over the fence. At one point the fence was dented by a falling Mopani tree (probably done by an elephant). In the gap a large eye appeared suddenly and looked at us suspiciously.

After a few seconds the elephant decided to return. They are surprisingly quick, even at turning about, and he was very quickly back in our garden. For the first time he was walking directly at us. My subconscious told me it wasn't happy - I think there'd been a slight shake of the head or flapping of the ears (both signs of annoyance) - we held our breath. I reached forward to close the door - an action that would almost certainly have saved my life against a lion or leopard or hyena and almost certainly made bugger all difference to an elephant. After a few seconds the elephant decided he was bored of scaring humans and walked back out of the garden never to be seen again. So we spent 2 happy hours in the bath reading our books.

On the night drive we saw another 2 leopards and discussed that we were almost certainly not going to see Lion or Hyena this trip now. We had been too lucky already.

Sunday morning we did another walk. We stopped a few metres from a 6 foot high bank down to a river tributary. It was a beautiful view and we looked about happily. Then the guide said 'Lion' and sure enough, in the middle of the water walking straight towards us at a distance of 50 metres or so was a lion. We stood still and I found I wasn't scared - clearly my subconscious believes the lion is more scared of me than I am of him. It was a cub anyway, about 18 months old - the size of a very large dog. The guide believed it was one of 2 that were orphaned after their mother died. She walked all the way across, disappeared from view behind the bank and then came up immediately in front of us at 10m, looked at us and lay down. She was very thin. After a few minutes her brother crossed a little further away and the two wandered off together. We walked in the opposite direction and found a fallen tree to have some juice and a cookie on.

So far so exciting, right? Indeed. In the evening we were the only guests in the camp. The night drive was quiet. I had cursed it by saying that we had seen so much we didn't deserve to see any more. For the first half an hour we saw only 2 bush buck. I intended to ask Mishek (our guide) at sundowners whether he'd ever had a completely animal-free drive. Up ahead was an elephant. It looked angry, as it was shaking its head. But we couldn't see what it was about, there was a bush in the way.

We drove around the bush, only to find the rest of the family and nothing more. The elephant took exception to us and suddenly charged the car on Geoff's side. It had its ears out, trunk down and was trumpeting phenomenally. It stopped 10m from the car and turned to walk back. I was kicking myself that I didn't have the video handy - can you imagine how great that would have been? Just as I think this, of course, she charges again. I can't believe I've missed it twice! I know the theory about something rare happening more than once in quick succession because the conditions are right. So I grabbed the camera post haste.

The family was departing and it transpired the elephant was female. I'd been assuming that the irrational anger was a male thing. I know that all the males reading this think I'm a fool. Perhaps, but it was quite aggressive with it! Definitely more of a male thing! The guide reverses a little and nothing bad happens but he's hesitant to try and leave because he says they can follow you. Instead of sitting steady he follows the elephants round the next bush. This was a mistake, probably his second, but that's by the by.

The elephants are now on my side of the car and I have the video running. She charges again. Straight at me. She comes within 5m and the video drops as I move my hand. I don't remember what action I was proposing to take. She withdrew. But before I knew it she came again. And closer. This time my hand drops faster. The trainee guide in the seat behind me is pulling my hair to get me to move to the middle of the car. He is clearly petrified. It's an unnecessary gesture. I'm already moving, I don't care if I'm sitting on cameras, binoculars, sun glasses - they are a small price to pay to get a foot further away from the murderously angry elephant.

Mishek has engaged first gear and we are off. The elephant, as he predicted, is following us. The film just shows ears through the fly screen at the back. The car accelerated hard. I stop videoing to hold on. I don't want to survive an elephant attack only to die in an RTA. He swings the car round to face the elephant and now we are heading for a head on with it. He stops the car and cuts the engine. The elephant doesn't stop. She still doesn't stop. She still doesn't stop. There is no sound in the whole world apart from her footfall. The elephant didn't stop until it had made a very strong connection with the bull bars on the front of the car. Her trunk scratched the paint of the bonnet and dented it, in a sideways flick she knocked off the aerial for the radio. We probably can't contact the camp now.

You could hear a pin drop, we were all holding our breath. What was she going to do? Thankfully she was tusk less so she had no leverage to roll us. She remained with her mouth pressed against the car for what was probably 10 seconds, but felt more like 30 seconds. Then she stood up again. I reached to start the camera - the buttons are small but OK normally, with a heavy dose of adrenaline making my hands shake it was nigh on impossible to turn on. The footage begins again when she's backed a couple of metres from the car. Over the next 2 minutes she slowly edges back to her family and two others that have joined them to watch the furore.

When we are comfortable she'd gone the guys picked up the aerial and drove us away to the river bank. 'Would you like a G&T to take away the anxiety?' asks the trainee guide. 'Yes'

There followed a romantic dinner for two on our decking, a drive back to the lodge, a couple of swims and a drive home with a fat baby (not mine), but none of that is particularly interesting after a near death experience.

Lesson of the weekend: Lions are not scary, Elephants are scary!

[Mishek accelerated to give himself room to turn the car. He did this because he knew the elephant would just follow us forever (or more likely until we ran out of road) otherwise. The Land Rover is also far more vulnerable at the rear as it lacks the bull bars and she would have hit directly into the seating. So the only strategy left was to turn and face her, even though she wasn't going to stop.

Also, because I asked this, he was scared too. Nothing like that has ever happened to him before. I dare say he'll keep a slightly greater distance from angry elephants in the future...]