As I write, it's almost exactly 14 days until we will chuck our bags into the back of Will's car and head for the Malawian border for a weeks' holiday before flying back to London.
We chose to come for 6 months because we thought it would be just the right length to let us settle in, learn about the culture but not become too frustrated by it to sour our experiences. And so we are looking at the next 2 weeks with a mixture of happiness and sadness. The chosen length has worked.
I'm keen to get back to the flat and discover what our lovely flat sitter has done. We know that she's managed to change the source of the TV (thankfully now corrected by Lt Muir), not found the cooking utensils for 2 months (I'd hidden them in a pot next to the hob) and only just found the dumbbell that's been under the sofa the whole time (I take it I won't be needing to change the hoover bag...). How she tuned the radio to Radio 4 is a slight mystery! And before you complain about being picked on, it's not like I've named you, An... ooppsss :D
But seriously, we are looking forward to getting back to the UK, whatever you say about the weather!!
We have just been on holiday for 2 weeks. Transportation uncertainty meant that we had to stop over in Lusaka for a night at each end. We picked a hotel a bit like a Holiday Inn, which is on the edge of a brand new shopping complex.
It was like heaven - there was a TV! and a marble bathroom with a power shower!! Then we went to the shopping centre and ate a pizza with real cheese on it! It was a little overwhelming, we were surrounded by smartly dressed people and we were in our bush clothes with muddy walking boots. It all felt a bit daunting.
We went to see Skyfall (Lusaka is our nearest Cinema!) and weren't disappointed. At times I felt like I was back home and I took great comfort in seeing that the buildings and roads and Underground were still there. Although I knew full well it had been filmed before we left! There's something very comforting about James Bond in a well fitting suit when you've just been out in chaos.
I was glad we had the time to mooch about and reacclimatise before heading onward to the Falls and then Botswana. [Photos will follow] We even had burgers and a proper Indian meal in a restaurant run by Indians, decorated like they are at home! Amazeballs, as the young people say these days.
On our return, Lusaka looked a little different. We caught a plane from Livingstone, which had some very interesting passengers. In the waiting area I spotted a smart businesswoman in a shift dress, very high heels and an iPad in a smart leather case. There were others with similar displays of wealth. [She didn't do so well when we landed at Lusaka and it was raining cats and dogs and there were massive puddles, but it got me thinking].
Now when we got to the shopping centre it felt different. The diamonds were still in the jewellery shop. The 60 inch TV was in the window. The clothes in Woolworths were still clearly M&S from last summer. But the combination felt somewhat distasteful. We walked around the Food Lovers Market where there was an abundance of fresh or exotic items, I felt like I was on the 5th floor of Harvey Nicks or in Selfridges. And this wasn't nice, this was a problem.
And the problem is this - whatever your view on inequality in the UK, it's so much greater here. Of course there have always been wealthier people - the Missionaries had house servants and lived better than the locals. But, they didn't have 60 inch TVs and marble bathrooms and Mercedes Benzs.
The changes in Lusaka have been dramatic. The changes in Katete far less so. The rural people here still have no running water, no sanitation (they dig their own long drops), no electricity, only mud huts to live in. The only significant change amongst the majority of the rural population since Independence is the mobile phone (which they have to go out to charge) and the occasional solar light.
There have been any number of debates about Africa and how to develop it. I'm not about to join in right now in any depth, there's a significant ennui here associated with well meaning Muzungus trying to tell them how to do things better.
One thing I am certain of is that there will be development, it will be at a pace that most Europeans would find frustrating and it will be done in what is considered an idiosyncratic way. However, at the moment it appears also to be happening significantly at the expense of the rural population and precedents suggest this will be the cause of some discomfort in the future.
The rural population can't and don't travel to Lusaka often. They don't have internet or much TV. They don't know what's happening there. Even if they did go, I expect they'd feel too daunted to walk into the shopping centres and look at the marble bathrooms. But they shouldn't have to.
I'm still a capitalist but I've always considered the role of Government to be to work in the best interest of the whole country. The accumulation of extreme wealth in Lusaka is not to the benefit of the whole country - there are bright motivated people in the distant provinces - they need to be supported. The first thing they could do is build some decent roads - the Romans worked that out for us!
Perhaps some decent tarmac on the main road to Dar Es Salaam would be a good start.... then at least we might not have been close to death so many times yesterday..... as ever, it all comes down to self interest :)
Monday, 28 January 2013
Friday, 25 January 2013
Who to trust?
Learning who to trust is an ongoing task for everyone throughout life. The more time you spend in London, the more you can think that trusting pretty much no one is the best way to go.
Changing to a different country, with a different culture makes the whole task more difficult. Particularly where there is a large wealth gap and some expectation that you should be giving people things just because you are white.
I wrote early on about the bars on all the windows and how this gave us comfort, rather than feeling like a prison. But you can't keep the door shut and everything in sight all the time. So who can you trust? And which requests for 'assistance' should not be turned down?
For the past few months I have been plagued by a particularly delightful young boy (known affectionately as 'the scrote') and his friends. I work with my back to the open door so I normally hear him coming before I see him. 'Oi, stingy!, give me a biscuit'. Right, it never works out that well for him calling me stingy as an opener. He hasn't heeded a single word I've said and normally just laughs in my face. On one occasion he and a friend managed to get in before I realised what had happened - it's tricky keeping an eye on two people at once. They normally want toys, biscuits or pens. They get nothing but mild abuse and told to go away.
The nicer children also get nothing as a gift but more time and consideration. A few months ago, a group came and asked me to teach them to read. I was busy and thought they were just wasting my time so I asked them to come back the next day, which they did, to my surprise. So I sat out for an hour and half going through things with them. When it got dark I suggested they should go home or their mothers would be worried about them. It was dinner time anyway. They left but said they would come the next day.
They turned up again, by which time I'd got proper books from the school at Tiko. Although they were slightly late so I nearly missed my sundowner! At the end I was trying to arrange the next session when one of them said 'When I got home yesterday there was no food for dinner' in as plaintive a voice as he could manage. Unfortunately he misjudged me. The day before he'd told me his dad was a security guard at the hospital, he was well dressed and went to an expensive school. The attempt to extort money was rumbled quickly.
So children - generally not to be trusted
The slightly troubled men that wander around the hospital area (one of whom calls me 'Mummy') are generally to be trusted if they are outside your house. They are honest about what they want - money, plastic bottles, water, food, your shoes etc. And generally respect your decisions on the matter.
Complete strangers that knock on the door as soon as they see a white person are often given short shrift as they look inside eagerly. "Is that a laptop? Can I have it when you go home?" as if somehow I wouldn't be needing it there!
But what about the gardener and maid?
When we got Moffat (the gardener) he'd been unemployed for over a month, where previously he'd worked every morning Monday-Friday. He was desperate so I (naively) thought he'd be quite grateful when I sought him out to give him a job. Even though our garden is tiny, we agreed to pay him for 2 mornings a week. I even persuaded Fi and Rory to take him on.
In the beginning, I thought that some of the things he quoted were quite expensive but I didn't want to be too suspicious and they weren't excessive amounts of money. I did ponder about why we needed an ox cart (at 50 pin) to bring the bundles of grass but when another one was needed to bring some additional sticks we didn't get charged.
Then it was planting time. In two of the beds he'd put the seed packet at the end. For the other beds there was no seed packet. Mysteriously plants only grew in the beds with seed packets at the end...
He needed money for fertiliser for his crops otherwise 5 children and 3 orphans would die. He needed 8 bags at 220pin each. But if Fi and Rory paid for 5 and I paid for 5, that would be OK. Yes, it would be for him, it would also be 10 bags. I asked in Pharmacy and they said that would cover a Hectare, which seemed excessive. Plus bags were only 190pin this year.
We gave him money for 2 bags (£50). He said that would be OK if Fi and Rory did the same. Later we offered to pay him for 4 weeks in advance so he could buy another bag. To his credit he came back and didn't just run off.
We'd heard from Fi and Rory that he had a tendency to make off with their bananas and mangos and just laughed when they expressed annoyance.
He hit on a new way of getting money out of us. He had a funeral to go to. A few weeks later he tried it again (why not? it worked first time). Only this time he had two separate funeral stories - one for me and one for Fi and Rory. As if we might not confer. I wondered if I was employing a toddler.
Gemma wanted the fence extending. This was going to cost more money. We needed more grass - why? I asked, we had plenty left over from last time. Oh! Well, we need money for bamboo slats? Why? I didn't pay last time! It was only £4 so Gemma paid him. Then he wanted money for nails. Why? For the gates! he said. Right, nobody else's gates have nails - the hinges are made of bark strands. I'm not building Buckingham Palace.
Next came a demand for a Christmas bonus. I said I'd think about it. Unfortunately for Moffat, Geoff and I were looking for the slasher (used for cutting grass) that weekend for a photo. It wasn't there. John the engineer told us that his gardener was forever selling his garden equipment. Moffat claimed to have taken it home to sharpen it but the returned article is a different shape and colour...
My patience is running a little low. I don't think it is my personal obligation to give everyone that asks money. If I am going to do it then I wouldn't choose Moffat - he has good clothes, a very nice bicycle etc. There are more needy people in the villages. I'm waiting for him to come and demand a 'Remembrance' from us, as he did to Fi and Rory. Perhaps I'll give him a copy of the photo I took of him in the garden...
Not wanting to let this experience jade us, we decided to trust the maid. We didn't have much choice. The first day she came we needed to go to Immigration before she was done. We locked the cupboard with the valuables in and left her in the house with a key. She'd done a super job by the time we returned. John raised his eyebrows at us leaving her alone.
And this attitude is a problem. None of the ex-pats are prepared to have anyone in the house - so they can't employ a maid (and help local people) - and this is because some people have had things taken. It turns out that our maid probably took some batteries from John one day. The Mess staff took batteries and a mobile phone from the students. There's a general mistrust.
This week a lady knocked on the door and asked if we needed a maid. I said I didn't - I already had one. Abraham caught me later and asked if any of the doctors needed a maid. This lady had hit hard times. She's alone and has 2 children, she really needs work. But without any guidance on who is and isn't trustworthy, she isn't likely to find it amongst the ex-pats.
One person that can be trusted, of course, is Abraham. If you lend him money he will always pay you back :)
Changing to a different country, with a different culture makes the whole task more difficult. Particularly where there is a large wealth gap and some expectation that you should be giving people things just because you are white.
I wrote early on about the bars on all the windows and how this gave us comfort, rather than feeling like a prison. But you can't keep the door shut and everything in sight all the time. So who can you trust? And which requests for 'assistance' should not be turned down?
Children
At home I'd probably err on the side of trusting most children. I certainly wouldn't assume that every 7 year old I saw was out to nick things from me. Here it's slightly different. I am directed not to trust them by a sign on the back of our door. I am not allowed to let them loiter (although it doesn't say how to do this) and I'm not to let them in under any circumstances.For the past few months I have been plagued by a particularly delightful young boy (known affectionately as 'the scrote') and his friends. I work with my back to the open door so I normally hear him coming before I see him. 'Oi, stingy!, give me a biscuit'. Right, it never works out that well for him calling me stingy as an opener. He hasn't heeded a single word I've said and normally just laughs in my face. On one occasion he and a friend managed to get in before I realised what had happened - it's tricky keeping an eye on two people at once. They normally want toys, biscuits or pens. They get nothing but mild abuse and told to go away.
The nicer children also get nothing as a gift but more time and consideration. A few months ago, a group came and asked me to teach them to read. I was busy and thought they were just wasting my time so I asked them to come back the next day, which they did, to my surprise. So I sat out for an hour and half going through things with them. When it got dark I suggested they should go home or their mothers would be worried about them. It was dinner time anyway. They left but said they would come the next day.
They turned up again, by which time I'd got proper books from the school at Tiko. Although they were slightly late so I nearly missed my sundowner! At the end I was trying to arrange the next session when one of them said 'When I got home yesterday there was no food for dinner' in as plaintive a voice as he could manage. Unfortunately he misjudged me. The day before he'd told me his dad was a security guard at the hospital, he was well dressed and went to an expensive school. The attempt to extort money was rumbled quickly.
So children - generally not to be trusted
Adults
This one is a bit murkier. Surely there are some adults that you can trust?The slightly troubled men that wander around the hospital area (one of whom calls me 'Mummy') are generally to be trusted if they are outside your house. They are honest about what they want - money, plastic bottles, water, food, your shoes etc. And generally respect your decisions on the matter.
Complete strangers that knock on the door as soon as they see a white person are often given short shrift as they look inside eagerly. "Is that a laptop? Can I have it when you go home?" as if somehow I wouldn't be needing it there!
But what about the gardener and maid?
When we got Moffat (the gardener) he'd been unemployed for over a month, where previously he'd worked every morning Monday-Friday. He was desperate so I (naively) thought he'd be quite grateful when I sought him out to give him a job. Even though our garden is tiny, we agreed to pay him for 2 mornings a week. I even persuaded Fi and Rory to take him on.
In the beginning, I thought that some of the things he quoted were quite expensive but I didn't want to be too suspicious and they weren't excessive amounts of money. I did ponder about why we needed an ox cart (at 50 pin) to bring the bundles of grass but when another one was needed to bring some additional sticks we didn't get charged.
Then it was planting time. In two of the beds he'd put the seed packet at the end. For the other beds there was no seed packet. Mysteriously plants only grew in the beds with seed packets at the end...
He needed money for fertiliser for his crops otherwise 5 children and 3 orphans would die. He needed 8 bags at 220pin each. But if Fi and Rory paid for 5 and I paid for 5, that would be OK. Yes, it would be for him, it would also be 10 bags. I asked in Pharmacy and they said that would cover a Hectare, which seemed excessive. Plus bags were only 190pin this year.
We gave him money for 2 bags (£50). He said that would be OK if Fi and Rory did the same. Later we offered to pay him for 4 weeks in advance so he could buy another bag. To his credit he came back and didn't just run off.
We'd heard from Fi and Rory that he had a tendency to make off with their bananas and mangos and just laughed when they expressed annoyance.
He hit on a new way of getting money out of us. He had a funeral to go to. A few weeks later he tried it again (why not? it worked first time). Only this time he had two separate funeral stories - one for me and one for Fi and Rory. As if we might not confer. I wondered if I was employing a toddler.
Gemma wanted the fence extending. This was going to cost more money. We needed more grass - why? I asked, we had plenty left over from last time. Oh! Well, we need money for bamboo slats? Why? I didn't pay last time! It was only £4 so Gemma paid him. Then he wanted money for nails. Why? For the gates! he said. Right, nobody else's gates have nails - the hinges are made of bark strands. I'm not building Buckingham Palace.
Next came a demand for a Christmas bonus. I said I'd think about it. Unfortunately for Moffat, Geoff and I were looking for the slasher (used for cutting grass) that weekend for a photo. It wasn't there. John the engineer told us that his gardener was forever selling his garden equipment. Moffat claimed to have taken it home to sharpen it but the returned article is a different shape and colour...
My patience is running a little low. I don't think it is my personal obligation to give everyone that asks money. If I am going to do it then I wouldn't choose Moffat - he has good clothes, a very nice bicycle etc. There are more needy people in the villages. I'm waiting for him to come and demand a 'Remembrance' from us, as he did to Fi and Rory. Perhaps I'll give him a copy of the photo I took of him in the garden...
Not wanting to let this experience jade us, we decided to trust the maid. We didn't have much choice. The first day she came we needed to go to Immigration before she was done. We locked the cupboard with the valuables in and left her in the house with a key. She'd done a super job by the time we returned. John raised his eyebrows at us leaving her alone.
And this attitude is a problem. None of the ex-pats are prepared to have anyone in the house - so they can't employ a maid (and help local people) - and this is because some people have had things taken. It turns out that our maid probably took some batteries from John one day. The Mess staff took batteries and a mobile phone from the students. There's a general mistrust.
This week a lady knocked on the door and asked if we needed a maid. I said I didn't - I already had one. Abraham caught me later and asked if any of the doctors needed a maid. This lady had hit hard times. She's alone and has 2 children, she really needs work. But without any guidance on who is and isn't trustworthy, she isn't likely to find it amongst the ex-pats.
One person that can be trusted, of course, is Abraham. If you lend him money he will always pay you back :)
Wednesday, 23 January 2013
African skies
One of the truly stunning aspects of living here is the sky. We have noticed it more in the last few weeks, as the rains have come and we get more overcast days. During the day, we get the most spectacular deep blue panorama, with trails of clouds running across. I don't think I have seen it dosrupted by a single con trail from an airplane in 5 months.
In the evening however it really lives up to the ideal of the African "big sky". We can see the sunset over countryside and a few hills, and we get all shades of red and blue, with clouds intermittently breaking the scene. Watching it with a G&T is a great way to end the day.
Recently, there have been thunderstorms most evenings. Quite often, we can sit out watching the sunset, with lightning flashing all around us, while we are under clear skies. It was very similar late last night - we had a patch of completely clear sky, which means incredible views of the stars.
In the evening however it really lives up to the ideal of the African "big sky". We can see the sunset over countryside and a few hills, and we get all shades of red and blue, with clouds intermittently breaking the scene. Watching it with a G&T is a great way to end the day.
Recently, there have been thunderstorms most evenings. Quite often, we can sit out watching the sunset, with lightning flashing all around us, while we are under clear skies. It was very similar late last night - we had a patch of completely clear sky, which means incredible views of the stars.
Monday, 21 January 2013
People who are pleased to see you...
As expected, people in the hospital are pleased to see us. Patients assume that any white person is a doctor and express gratification freely. I am frequently asked how I am by complete strangers as I pass. What I didn't expect was that we could make an impact more widely...
In the run up to Christmas we either went or sent a shopping list to Chipata most weekends. The logic is the same as in the UK when people choose big supermarkets. Many of the items were cheaper and better quality, plus there were the items you can't get in Katete - like semi skimmed milk. It was easier to buy lots of things than pick and choose. So we stopped buying Coke at the Chada, for example, because it was more economical to buy a 2.5L bottle in Chipata.
I didn't really think about it more broadly. I was still heading to the market for fresh veg and a few other items, like bread and eggs when needed.
Then I stopped at Theresa's shop to buy some things. She didn't have a lot of her usual stock. I was a bit surprised, she's normally really good. Then she said 'You are still here then?' Yes, why? 'I thought you'd gone. You were an expensive customer [by which I understand her to mean that I was a good customer]'
This brought it home. I used to go to Theresa's once or twice a week and spend nearly £8 each time. This might sound a bit pathetic to you, but there are low end supermarkets in Northern England where the average spend per transaction is £4. So, even there I'd be a valuable customer. And then I'd just stopped. It hadn't meant anything to me, it was just a matter of convenience but it was clearly having a big impact on Theresa, especially considering it's rainy season and the hospital in general is quieter.
Since she pointed it out I've made a point of going to her more often. The large bottles of Coke have gone. Our consumption of eggs has increased so much that we'll probably have a heart attack shortly. But she's got her expensive customer back, for now. All I have to do is persuade the others to shop there after we leave... but perhaps the lure of Chipata will prove too much!
Some of the people that are pleased to see you are less obvious. I went to the lab recently to ask them for some data. It wasn't a planned trip so I was surprised when I entered the office to find everyone smiling at me and the In Charge saying he was very pleased to see me.
He invited me into the lab and listened very patiently to my request for statistics. Then at the end he started explaining about the FACS count machine, what it did [they use it to measure the CD4 count of HIV patients] and that it needed to run a control test every day.
'The control test needs to be someone that doesn't have HIV and I am tired of giving my own blood. Please can I have some of yours? I will tell you your CD4 count!'
Now I understand why they were pleased. They'd been arguing in the office in Nyanja about who should have to give blood that day. Then they saw me and clearly thought that they'd found the solution.
Sadly for them, they hadn't. The guy looked at me a little blankly when I explained that I don't like needles, I don't give people blood unless I absolutely have to (it's only happened once and it took 3 doctors nagging me to do it) and I was wearing a tight long sleeve top so the logistics weren't simple either. Even his pleading that he only wanted a small amount didn't work!
I felt a bit bad as I ran away through the rain but, blood and needles, that's just one step too far!
In the run up to Christmas we either went or sent a shopping list to Chipata most weekends. The logic is the same as in the UK when people choose big supermarkets. Many of the items were cheaper and better quality, plus there were the items you can't get in Katete - like semi skimmed milk. It was easier to buy lots of things than pick and choose. So we stopped buying Coke at the Chada, for example, because it was more economical to buy a 2.5L bottle in Chipata.
I didn't really think about it more broadly. I was still heading to the market for fresh veg and a few other items, like bread and eggs when needed.
Then I stopped at Theresa's shop to buy some things. She didn't have a lot of her usual stock. I was a bit surprised, she's normally really good. Then she said 'You are still here then?' Yes, why? 'I thought you'd gone. You were an expensive customer [by which I understand her to mean that I was a good customer]'
This brought it home. I used to go to Theresa's once or twice a week and spend nearly £8 each time. This might sound a bit pathetic to you, but there are low end supermarkets in Northern England where the average spend per transaction is £4. So, even there I'd be a valuable customer. And then I'd just stopped. It hadn't meant anything to me, it was just a matter of convenience but it was clearly having a big impact on Theresa, especially considering it's rainy season and the hospital in general is quieter.
Since she pointed it out I've made a point of going to her more often. The large bottles of Coke have gone. Our consumption of eggs has increased so much that we'll probably have a heart attack shortly. But she's got her expensive customer back, for now. All I have to do is persuade the others to shop there after we leave... but perhaps the lure of Chipata will prove too much!
Some of the people that are pleased to see you are less obvious. I went to the lab recently to ask them for some data. It wasn't a planned trip so I was surprised when I entered the office to find everyone smiling at me and the In Charge saying he was very pleased to see me.
He invited me into the lab and listened very patiently to my request for statistics. Then at the end he started explaining about the FACS count machine, what it did [they use it to measure the CD4 count of HIV patients] and that it needed to run a control test every day.
'The control test needs to be someone that doesn't have HIV and I am tired of giving my own blood. Please can I have some of yours? I will tell you your CD4 count!'
Now I understand why they were pleased. They'd been arguing in the office in Nyanja about who should have to give blood that day. Then they saw me and clearly thought that they'd found the solution.
Sadly for them, they hadn't. The guy looked at me a little blankly when I explained that I don't like needles, I don't give people blood unless I absolutely have to (it's only happened once and it took 3 doctors nagging me to do it) and I was wearing a tight long sleeve top so the logistics weren't simple either. Even his pleading that he only wanted a small amount didn't work!
I felt a bit bad as I ran away through the rain but, blood and needles, that's just one step too far!
Friday, 18 January 2013
Trauma assessment
On Friday prof and I spent a tricky half hour debating whether to take a patient to theatre for a craniotomy. He had been stood on a two metre platform at work, adding caustic soda to a vat of boiling water. Unfortunately, but not unexpectedly, the resultant mix had erupted into his face, giving him 20% chemical burns, a horrific chemical burn to both eyes and causing him to fall on his head.
When he arrived with us three hours later he was comatose. He had been walking around and talking for an hour post injury, but then started fitting on his arrival at a rural clinic one hour later. He had been sedated then transferred here.
The eye injuries and burns, while tragic, were not immediately life-threatening. His story was however suggestive of an extra-dural haemoatoma, which would need immediate decompression. In the UK, in this situation, a CT scan gives a rapid and conclusive answer. Here, we do a clinical assessment and make a decision as best possible with what is available. We have not done a single craniotomy since I arrived, although we came close when we had a comatose 6 year old with a depressed skull fracture. He however woke up before I could get him to theatre - a near miss!
Unfortunately, one of the key parts of the clinical assessment of a head injur is the pupil reaction - something we did not have due to the ocular injury. We spent some time checking his reflexes and muscle tone, and response to painful stimuli. The initial conclusion was that he was hypertonic, but bilaterally so, and possibly still fitting. So, after a further dose of diazepam he was still unconscious but less stiff, and crucially the same on both sides. So no craniotomy indicated. We managed him lying on his side, hoped he did not have an unstable spinal injury and tried to stop him aspirating any vomit. He is now starting to wake up 24 hours later.
Being in the position, on an almost daily basis, of having to make critical decisions with minimal diagnostic support, has given me a new attitude and new set of skills in patient assessment. I am looking forward to having a CT scanner sat waiting to help me with the answer on my return, but I am also expecting to make much better use of my clinical skills before doing the scan!
When he arrived with us three hours later he was comatose. He had been walking around and talking for an hour post injury, but then started fitting on his arrival at a rural clinic one hour later. He had been sedated then transferred here.
The eye injuries and burns, while tragic, were not immediately life-threatening. His story was however suggestive of an extra-dural haemoatoma, which would need immediate decompression. In the UK, in this situation, a CT scan gives a rapid and conclusive answer. Here, we do a clinical assessment and make a decision as best possible with what is available. We have not done a single craniotomy since I arrived, although we came close when we had a comatose 6 year old with a depressed skull fracture. He however woke up before I could get him to theatre - a near miss!
Unfortunately, one of the key parts of the clinical assessment of a head injur is the pupil reaction - something we did not have due to the ocular injury. We spent some time checking his reflexes and muscle tone, and response to painful stimuli. The initial conclusion was that he was hypertonic, but bilaterally so, and possibly still fitting. So, after a further dose of diazepam he was still unconscious but less stiff, and crucially the same on both sides. So no craniotomy indicated. We managed him lying on his side, hoped he did not have an unstable spinal injury and tried to stop him aspirating any vomit. He is now starting to wake up 24 hours later.
Being in the position, on an almost daily basis, of having to make critical decisions with minimal diagnostic support, has given me a new attitude and new set of skills in patient assessment. I am looking forward to having a CT scanner sat waiting to help me with the answer on my return, but I am also expecting to make much better use of my clinical skills before doing the scan!
Wednesday, 16 January 2013
Dogs and other creatures
You have already heard about and seen a picture of Tiger, the communal dog. However, he isn't the only dog around here. There are packs of them that wander around all day and all night. Some of them are friendlier than others. For a while Nat was the only one that complained of being attacked by dogs when alone - to the extent that she would only walk the long way back from our place if Will was away, because she was scared of the dog that loiters at one of the houses.
We mocked her mercilessly. Pretending that she was imagining the dogs and imagining being attacked. Then other people started to be chased and growled at aggressively. The mocking lessened. Finally, I was attacked. I was walking along minding my own business when one of the little sandy coloured dogs decided that I'd looked at him funny. He jumped up, growled at me, charged my leg with his mouth open, shutting it at the last second before head butting me instead. I started to walk the long way to Nat's house if I was alone...
The other endearing trait of the dogs is their howling. Normally at night just as you've managed to get to sleep. If it happens in the evening I've discovered that it's quite easy to stop. One night I was so annoyed I threw our door open and shouted out "I've got an idea, why don't you shut up?". There was silence and thereafter opening the door and shining the torch at them has the twin effect of getting them to be quiet and move away, so they are noisy somewhere else later in the night.
We were promised that the strays would be shot by the Police about 2 months ago. Nothing has happened on that front but someone has clearly taken some action because most of the strays are suddenly incredibly afraid of people, which means they haven't attacked anyone in a while, which is nice.
On the night of the chestnut roasting we had a new visitor. Julie, in the partial darkness, identified the dog as Tiger and invited him into the garden. This was Puppy. Puppy is about half the size of Tiger, plain sandy coloured (where Tiger is ginger and white) and has a very curly upright tail. We haven't yet worked out how Julie got them confused. Puppy is also incredibly timid, so shortly he left the garden.
The next time we saw him, Jamie, Julie and I were having sundowners on the field, sat on our blankets. Up came Puppy and decided that he wanted to be my friend especially. He demonstrated this by coming right up to me and sticking his muzzle in my Gin and Tonic. As Geoff's very allergic to dogs and I wanted my G&T without fleas in, he got short shrift. Julie was employed to stroke him and keep him at a distance. After half an hour her hand had turned black with dirt off his fur. We decided that stroking him was probably out of the question in future!
Now, I know that Katie will be reading this and getting cross about the fact I'm talking about domesticated animals. Tough! Subsequent to the sundowner, Puppy has been an occasional visitor at our house. During the day I let him lie in the sunshine on the warm concrete of our doorway. Sometimes, if he whimpers at me enough and sits on my feet, I'll stroke him (and then wash my hands about a hundred times).
Yesterday he was having a nap under our table when Tiger came in. Tiger and I have been having a small dispute, generally about the fact that Tiger pretends to like me when I have food for him but at all other times favours Gemma and then acts as if I haven't noticed. In response to this I've started pulling his ears and folding them one on top of the other, and pulling his tail when he heads under the table at dinner. This has so far only caused him to turn around and look at me severely, which is nice because he can be very vicious with people he doesn't like.
Anyhow, Tiger doesn't think that Puppy should be in our house so he came in to chase him out. After a while Puppy came back and curled up again. Then Tiger returned. This was repeated frequently. On one occasion, Tiger was spotted in our garden. All of a sudden his feet were up on the windowsill and his ears were pricked up as he looked in. The next thing we knew he was coming in through the door to chase Puppy out again.
Puppy is quite plucky, given that he keeps coming back, despite the aggressive jealousy of Tiger. I'm just not sure how long we will tolerate him for. He insists on being right next to any humans. So he followed Geoff to the shower yesterday and back afterwards, sitting on his feet at every opportunity. This might get a little tiresome!
The major new other creatures we have discovered of late are snails. Now the rains are here the snails have come out of hiding. They all have the pointy shells often associated with African snails. I'm a little worried about our veg patch but it seems to be holding up. The other night Will was looking out of our window with his powerful torch. "Errr, you might want to do something about this, I think your cabbages are under threat!" We gathered around him to see what he could see - a massive African land snail about 8 or 9 inches long in the shell right on the edge of the cabbages. Geoff was rapidly despatched with a plastic bag to facilitate the removal of said creature. He [the snail] has not been seen since.
There is also a new pet at the BLs [Nat and Will]. He's called Sprout and he's a baby, that's kept in a tupperware box in their kitchen. He's a chameleon (or if Geoff's telling you, he's a gecko :) ). Will has the care sheet for adults but this is very much a baby. It remains to be seen how well he will do!
We mocked her mercilessly. Pretending that she was imagining the dogs and imagining being attacked. Then other people started to be chased and growled at aggressively. The mocking lessened. Finally, I was attacked. I was walking along minding my own business when one of the little sandy coloured dogs decided that I'd looked at him funny. He jumped up, growled at me, charged my leg with his mouth open, shutting it at the last second before head butting me instead. I started to walk the long way to Nat's house if I was alone...
The other endearing trait of the dogs is their howling. Normally at night just as you've managed to get to sleep. If it happens in the evening I've discovered that it's quite easy to stop. One night I was so annoyed I threw our door open and shouted out "I've got an idea, why don't you shut up?". There was silence and thereafter opening the door and shining the torch at them has the twin effect of getting them to be quiet and move away, so they are noisy somewhere else later in the night.
We were promised that the strays would be shot by the Police about 2 months ago. Nothing has happened on that front but someone has clearly taken some action because most of the strays are suddenly incredibly afraid of people, which means they haven't attacked anyone in a while, which is nice.
On the night of the chestnut roasting we had a new visitor. Julie, in the partial darkness, identified the dog as Tiger and invited him into the garden. This was Puppy. Puppy is about half the size of Tiger, plain sandy coloured (where Tiger is ginger and white) and has a very curly upright tail. We haven't yet worked out how Julie got them confused. Puppy is also incredibly timid, so shortly he left the garden.
The next time we saw him, Jamie, Julie and I were having sundowners on the field, sat on our blankets. Up came Puppy and decided that he wanted to be my friend especially. He demonstrated this by coming right up to me and sticking his muzzle in my Gin and Tonic. As Geoff's very allergic to dogs and I wanted my G&T without fleas in, he got short shrift. Julie was employed to stroke him and keep him at a distance. After half an hour her hand had turned black with dirt off his fur. We decided that stroking him was probably out of the question in future!
Now, I know that Katie will be reading this and getting cross about the fact I'm talking about domesticated animals. Tough! Subsequent to the sundowner, Puppy has been an occasional visitor at our house. During the day I let him lie in the sunshine on the warm concrete of our doorway. Sometimes, if he whimpers at me enough and sits on my feet, I'll stroke him (and then wash my hands about a hundred times).
Yesterday he was having a nap under our table when Tiger came in. Tiger and I have been having a small dispute, generally about the fact that Tiger pretends to like me when I have food for him but at all other times favours Gemma and then acts as if I haven't noticed. In response to this I've started pulling his ears and folding them one on top of the other, and pulling his tail when he heads under the table at dinner. This has so far only caused him to turn around and look at me severely, which is nice because he can be very vicious with people he doesn't like.
Anyhow, Tiger doesn't think that Puppy should be in our house so he came in to chase him out. After a while Puppy came back and curled up again. Then Tiger returned. This was repeated frequently. On one occasion, Tiger was spotted in our garden. All of a sudden his feet were up on the windowsill and his ears were pricked up as he looked in. The next thing we knew he was coming in through the door to chase Puppy out again.
Puppy is quite plucky, given that he keeps coming back, despite the aggressive jealousy of Tiger. I'm just not sure how long we will tolerate him for. He insists on being right next to any humans. So he followed Geoff to the shower yesterday and back afterwards, sitting on his feet at every opportunity. This might get a little tiresome!
The major new other creatures we have discovered of late are snails. Now the rains are here the snails have come out of hiding. They all have the pointy shells often associated with African snails. I'm a little worried about our veg patch but it seems to be holding up. The other night Will was looking out of our window with his powerful torch. "Errr, you might want to do something about this, I think your cabbages are under threat!" We gathered around him to see what he could see - a massive African land snail about 8 or 9 inches long in the shell right on the edge of the cabbages. Geoff was rapidly despatched with a plastic bag to facilitate the removal of said creature. He [the snail] has not been seen since.
There is also a new pet at the BLs [Nat and Will]. He's called Sprout and he's a baby, that's kept in a tupperware box in their kitchen. He's a chameleon (or if Geoff's telling you, he's a gecko :) ). Will has the care sheet for adults but this is very much a baby. It remains to be seen how well he will do!
Monday, 14 January 2013
Breastfeeding
This might seem like an odd topic to select for its own blog post, but there is a good reason why I've chosen it.
In the UK, there is an ongoing debate about the acceptability of breastfeeding in public. Plenty of restaurants and pubs have been vilified in the press for refusing to let mothers breastfeed in the open areas, however discreetly. It seems to be an odd thing to quibble about - I've never really understood what the objections should be - done well, people barely notice. Banning it is effectively telling mothers they can't leave the house for 6 months without the hassle of expressing.
In Zambia, the view is much more liberal. There is no concern about breastfeeding, in fact I don't think there's anywhere or anytime when it's deemed unacceptable. And before any of you generate the naive notion that these ladies are doing the dance of the seven veils with a Chitenge, let me put you right. They aren't.
Most Zambian women, particularly the poor, do not wear bras. This and, we presume, multiple pregnancies from a young age combined with breastfeeding each child for more than 6 months (more on this later), mean that the women are able to articulate their breasts in a way that most British women would wince at. For example, it's perfectly possible, when wearing a polo shirt, to breastfeed your child without removing your top - just pull whichever one you want out through the slit at the neck and move the child in the Chitenge.
One evening I walked past a lady who had been doing this, but when the child had finished and she'd put them back on her back, she forgot to return the breast to the inside of her top. I didn't know what to do. I don't have the Nyanja to say 'Excuse me, Miss, but your boob appears to be hanging out' and I didn't know how she'd take it. I chose to walk on, hoping that someone else would mention it before long.
In fact, they are so comfortable with breastfeeding that they happily sort the child out whilst having a conversation with someone, even a stranger like me, without batting an eyelid at exposing the entire breast. I suppose this isn't that surprising in some respects, women on the wards are often half naked from the waist up, without seeming worried.
I don't know when they stop breastfeeding - I've seen quite large children still suckling. In OPD on one of my tours with new students, I saw a child of about 3 run across the floor to his mother, reach into her t shirt and grab her. She bent down happily to accommodate him as he stood on the floor in front of her. I was reminded slightly of Little Britain.
And it's not as if you get a respite after your last child. Grandmothers are frequently called upon to help out with the next generation. The Physiology of this is confusing to all of us. The Medics claim to have seen a grandmother produce milk on demand...
So what can we conclude. Part of the difference between the views is that in Zambia breasts aren't seen as sexual organs particularly. The men are much more interested in what a woman is like from navel to knee. Hence there is no embarrassment about public displays of breasts.
In the UK, this is not the case and therefore breastfeeding will always be emotive, as if the baby is interloping where it shouldn't be. This is also why there is a stigma around breastfeeding a child for too long - I imagine this will never change.
However, I think there is a happy middle ground that could be reached where new mothers wouldn't feel embarrassed or ashamed to feed their newborns in the natural way pretty much wherever they felt like it. As long as they didn't give any innocent bystanders an eyeful!
In the UK, there is an ongoing debate about the acceptability of breastfeeding in public. Plenty of restaurants and pubs have been vilified in the press for refusing to let mothers breastfeed in the open areas, however discreetly. It seems to be an odd thing to quibble about - I've never really understood what the objections should be - done well, people barely notice. Banning it is effectively telling mothers they can't leave the house for 6 months without the hassle of expressing.
In Zambia, the view is much more liberal. There is no concern about breastfeeding, in fact I don't think there's anywhere or anytime when it's deemed unacceptable. And before any of you generate the naive notion that these ladies are doing the dance of the seven veils with a Chitenge, let me put you right. They aren't.
Most Zambian women, particularly the poor, do not wear bras. This and, we presume, multiple pregnancies from a young age combined with breastfeeding each child for more than 6 months (more on this later), mean that the women are able to articulate their breasts in a way that most British women would wince at. For example, it's perfectly possible, when wearing a polo shirt, to breastfeed your child without removing your top - just pull whichever one you want out through the slit at the neck and move the child in the Chitenge.
One evening I walked past a lady who had been doing this, but when the child had finished and she'd put them back on her back, she forgot to return the breast to the inside of her top. I didn't know what to do. I don't have the Nyanja to say 'Excuse me, Miss, but your boob appears to be hanging out' and I didn't know how she'd take it. I chose to walk on, hoping that someone else would mention it before long.
In fact, they are so comfortable with breastfeeding that they happily sort the child out whilst having a conversation with someone, even a stranger like me, without batting an eyelid at exposing the entire breast. I suppose this isn't that surprising in some respects, women on the wards are often half naked from the waist up, without seeming worried.
I don't know when they stop breastfeeding - I've seen quite large children still suckling. In OPD on one of my tours with new students, I saw a child of about 3 run across the floor to his mother, reach into her t shirt and grab her. She bent down happily to accommodate him as he stood on the floor in front of her. I was reminded slightly of Little Britain.
And it's not as if you get a respite after your last child. Grandmothers are frequently called upon to help out with the next generation. The Physiology of this is confusing to all of us. The Medics claim to have seen a grandmother produce milk on demand...
So what can we conclude. Part of the difference between the views is that in Zambia breasts aren't seen as sexual organs particularly. The men are much more interested in what a woman is like from navel to knee. Hence there is no embarrassment about public displays of breasts.
In the UK, this is not the case and therefore breastfeeding will always be emotive, as if the baby is interloping where it shouldn't be. This is also why there is a stigma around breastfeeding a child for too long - I imagine this will never change.
However, I think there is a happy middle ground that could be reached where new mothers wouldn't feel embarrassed or ashamed to feed their newborns in the natural way pretty much wherever they felt like it. As long as they didn't give any innocent bystanders an eyeful!
Friday, 11 January 2013
STOP PRESS: SNAKE!!!!
Ever since Will pointed out that we could schedule blog posts, you might have noticed that they often pop up at regular intervals. This has been very useful but it has the drawback of not being particularly responsive. The post from today Geoff wrote a few days ago.
But something exciting has happened, and it's a Friday, so you get two posts today! How lucky!
Last night we were invited to Tiko for pre-dinner drinks to say goodbye to Claire and Dave who have been working there for 3 months. Geoff and I were asked to collect Will and meet Nat at the front of the hospital so we could walk over together. Will was in the middle of the washing up and said he'd meet us at the front door.
We went round the front and played with Tiger whilst we waited. Suddenly Geoff said 'Snake!' There in the tree by the gate was a black snake wrapped round a branch at just above head height. It was making its way down. We stood still about 5m away on the porch of the house and started shouting for Will. "SNAKE!' "WILL" 'CAMERA!' 'WILL!!!!!'. In hindsight, it probably wasn't sensible to yell snake, given that the locals tend to interpret that as a command to find a stick and kill it.
When he came to the door he was bemused. 'What are you two making so much noise about?' 'SNAKE!' [this isn't fear, it's that we know he loves them and wouldn't want to miss it!] 'Oh, I should get my camera!' Yes, that's what we were yelling.
Now, Will has a brilliant snake identifying App. You just have to know how many ventrals the snake has, which requires you to have the snake upside down and still long enough to count them. We can't think of any more useful App in the world. Anyway, invariably we ask Will for the identity of the snake.
He walked forward towards the tree. By this time the snake has clearly had enough of the yelling and the dog (which didn't notice him but ran under the tree 3 times) and is making its way back up. 'Bush snake?' suggests Will. 'Are you sure?' I say. Everyone tells us all snakes are bush snakes and the markings on this one don't look right to me.
'Um, no, actually, I think it's a black mamba.....' Geoff attempts to enter the house but the door is locked. I decide to stay still. Will withdraws. The snake doesn't seem to have noticed and is still making his way up into the higher branches of the tree. It is between 1.5m and 2m long. It's impressive to watch it moving between the branches, it has amazing poise. Then we remember that they can move along the ground with 2/3rds of their body off the ground.....
In case you've forgotten what I said about the mamba, they are one of the world's deadliest snakes. They are territorial and incredibly aggressive when cornered. They can move faster than a human [Correction: they can move at 10-12mph, which my brother claims is NOT faster than an able bodied human...] and one strike is more often than not deadly. The nearest anti-venom is in Johannesburg - we've discussed many times whether we think it's possible to keep someone alive using CPR long enough to get them there. We don't think we could. Sometimes they don't envenom, if they are feeling nice!
I remembered that a few weeks ago I was heading to see Will in the afternoon and there were two men at the bottom of this tree with a stick trying to kill a snake. I told them off and that the man that lived here liked snakes. He does and he wouldn't have wanted it dead, even if it was a mamba, but I have more sympathy for the men now.
We lost sight of it in the second tree, very high up in the branches.
Here's a shot that Will took. It's an ID shot, not a creative shot. And yes, there's no head in it [the mamba has a distinctive coffin shaped head - it wasn't as distinctive as I'd hoped!]. We won't mention it to Will again because when I made this comment yesterday he called me 'the pain that a Zebra feels when it's bitten on the bottom by a Tsetse fly' in Afrikaans.
To identify snakes you need the shape of the head and the scales. The mamba has very distinctive large scales - as seen here. If you want to give us an alternative identification (and in some respects we'd welcome that) please feel free :)
But something exciting has happened, and it's a Friday, so you get two posts today! How lucky!
Last night we were invited to Tiko for pre-dinner drinks to say goodbye to Claire and Dave who have been working there for 3 months. Geoff and I were asked to collect Will and meet Nat at the front of the hospital so we could walk over together. Will was in the middle of the washing up and said he'd meet us at the front door.
We went round the front and played with Tiger whilst we waited. Suddenly Geoff said 'Snake!' There in the tree by the gate was a black snake wrapped round a branch at just above head height. It was making its way down. We stood still about 5m away on the porch of the house and started shouting for Will. "SNAKE!' "WILL" 'CAMERA!' 'WILL!!!!!'. In hindsight, it probably wasn't sensible to yell snake, given that the locals tend to interpret that as a command to find a stick and kill it.
When he came to the door he was bemused. 'What are you two making so much noise about?' 'SNAKE!' [this isn't fear, it's that we know he loves them and wouldn't want to miss it!] 'Oh, I should get my camera!' Yes, that's what we were yelling.
Now, Will has a brilliant snake identifying App. You just have to know how many ventrals the snake has, which requires you to have the snake upside down and still long enough to count them. We can't think of any more useful App in the world. Anyway, invariably we ask Will for the identity of the snake.
He walked forward towards the tree. By this time the snake has clearly had enough of the yelling and the dog (which didn't notice him but ran under the tree 3 times) and is making its way back up. 'Bush snake?' suggests Will. 'Are you sure?' I say. Everyone tells us all snakes are bush snakes and the markings on this one don't look right to me.
'Um, no, actually, I think it's a black mamba.....' Geoff attempts to enter the house but the door is locked. I decide to stay still. Will withdraws. The snake doesn't seem to have noticed and is still making his way up into the higher branches of the tree. It is between 1.5m and 2m long. It's impressive to watch it moving between the branches, it has amazing poise. Then we remember that they can move along the ground with 2/3rds of their body off the ground.....
In case you've forgotten what I said about the mamba, they are one of the world's deadliest snakes. They are territorial and incredibly aggressive when cornered. They can move faster than a human [Correction: they can move at 10-12mph, which my brother claims is NOT faster than an able bodied human...] and one strike is more often than not deadly. The nearest anti-venom is in Johannesburg - we've discussed many times whether we think it's possible to keep someone alive using CPR long enough to get them there. We don't think we could. Sometimes they don't envenom, if they are feeling nice!
I remembered that a few weeks ago I was heading to see Will in the afternoon and there were two men at the bottom of this tree with a stick trying to kill a snake. I told them off and that the man that lived here liked snakes. He does and he wouldn't have wanted it dead, even if it was a mamba, but I have more sympathy for the men now.
We lost sight of it in the second tree, very high up in the branches.
Here's a shot that Will took. It's an ID shot, not a creative shot. And yes, there's no head in it [the mamba has a distinctive coffin shaped head - it wasn't as distinctive as I'd hoped!]. We won't mention it to Will again because when I made this comment yesterday he called me 'the pain that a Zebra feels when it's bitten on the bottom by a Tsetse fly' in Afrikaans.
To identify snakes you need the shape of the head and the scales. The mamba has very distinctive large scales - as seen here. If you want to give us an alternative identification (and in some respects we'd welcome that) please feel free :)
 |
| Mamba making its way down a branch |
Limb threatening injuries
I've been struggling to come up with a clinical topic for the blog, but a comment in the notes from one of the physiotherapists gave me an idea. It was "limb-threatening injury. High risk of significant contractures of elbow and shoulder". The patient is a 20 year old lady, who has a child of 6 months. She suffered a full thickness burn to her non-dominant arm, which was managed expectantly at another hospital for three weeks. As could have been predicted, the wound did not heal and she started to scar with her arm stuck straight at the elbow and in at her side. Since her arrival, we have excised the burn and grafted the arm. It was also splinted, but she removed it because of discomfort (twice) and so she is starting to develop more contractures.
Major limb threatening injuries are something we see quite commonly at SFH. They are either due to comminuted open fractures with significant tissue loss, massive soft tissue trauma or burns. The first two are normally due to traffic incidents. In the UK, I have had limited exposure to these injuries, as they are managed by teams of surgeons (plastic, orthopaedic and vascular) in tertiary centres, with most operations done by consultants. Open fractures are graded from 1 to 3, depending on the degree of soft tissue damage. Fresh grade 1 fractures can be cleaned, sutured, placed in plaster and given antibiotics. All others need cleaning, fixation (often externally) and sometimes skin flaps or grafts to cover the defect. Infected open fractures need external fixation and scrupulous wound management, as well as antibiotics.
What we are able to do here is more limited than at home, but still normally saves the limb. I was discussing with a visiting orthopaedic consultant from Addenbrooke's what he would do differently in the UK, as he operated on a comminuted open knee fracture. Interestingly, the only big differences were the need for vascular imaging to rule out an arterial injury, and intra-operative radiology. So, we have the majority of the kit needed to do things properly, and the skills (Prof is trained in trauma surgery), what often hampers us is the level of understanding in our referral centres, or even junior staff.
One of the things I have been trained in since arriving at SFH is application of external fixators, and I have now operated on quite a few open fractures. The very pleasing ones are those that come early, with limited infection or soft tissue loss, who can then be fixed and discharged with the fixator after a week or so. Others are more of a challenge. We have one young man in hospital at the moment, who had a huge devolving injury of his leg, with an open ankle fracture (following an assault). He was sutured and put in plaster by another hospital, and came here after two weeks, with a huge soft tissue defect and pus pouring out of his ankle. After two weeks of external fixations and wound care, we have now grafted his leg and expect to be able to put a flap on his ankle in the next month or so. What was very much a limb-threatening injury appears to be salvaged.
There is however a lot of dogma associated with open fracture management (and limb burns, which I will touch on later). One of our difficult patients at the moment presented with a fresh grade 1 (open) tibia fracture (it is in fact in four pieces), and the on call debrided the wound and placed it in plaster. Unfortunately, despite the instructions in the notes, and the assistant saying the fracture should be sutured, the wound was left open, with exposed fracture at the base. Essentially an iatrogenic grade 3 fracture. We then had to apply an external fixator and make a fasciocutaneous flap to cover the defect. When asked why he had ignored the departmental policy and written instructions, I was just told that open fractures should never be closed. The patient will however keep his leg, and regardless of how it was fixed, he is going to be a long time recovering (we are considering plating his tibia in the next few weeks).
We do have some failures. One recently discharged patient had an infected open ankle fracture sutured, and needed external fixation and a flap to save the leg. The fixator has just been removed (it became infected) and the fracture does not look well healed. He is however a very elderly man, so I suspect that having a leg that partly works is acceptable, and we are going to see how he does. We have also amputated a few terrible open fractures in the last few months, that for reasons of infection or vascular compromise were just not salvageable.
Returning to the first case, the burnt arm, I suspect she will always have a poorly functioning arm. Ideally, earlier grafting and splinting would have made things much better. The policy in a lot of hospitals of referring only when burns do not heal means we start trying to save the limb a step behind where we would like to be. Patients do seem more likely to remove dressings and splints than at home, so compliance is also a major issue. But, working within the limitations of our skills, and the available kit, I think we do alright!
Major limb threatening injuries are something we see quite commonly at SFH. They are either due to comminuted open fractures with significant tissue loss, massive soft tissue trauma or burns. The first two are normally due to traffic incidents. In the UK, I have had limited exposure to these injuries, as they are managed by teams of surgeons (plastic, orthopaedic and vascular) in tertiary centres, with most operations done by consultants. Open fractures are graded from 1 to 3, depending on the degree of soft tissue damage. Fresh grade 1 fractures can be cleaned, sutured, placed in plaster and given antibiotics. All others need cleaning, fixation (often externally) and sometimes skin flaps or grafts to cover the defect. Infected open fractures need external fixation and scrupulous wound management, as well as antibiotics.
What we are able to do here is more limited than at home, but still normally saves the limb. I was discussing with a visiting orthopaedic consultant from Addenbrooke's what he would do differently in the UK, as he operated on a comminuted open knee fracture. Interestingly, the only big differences were the need for vascular imaging to rule out an arterial injury, and intra-operative radiology. So, we have the majority of the kit needed to do things properly, and the skills (Prof is trained in trauma surgery), what often hampers us is the level of understanding in our referral centres, or even junior staff.
One of the things I have been trained in since arriving at SFH is application of external fixators, and I have now operated on quite a few open fractures. The very pleasing ones are those that come early, with limited infection or soft tissue loss, who can then be fixed and discharged with the fixator after a week or so. Others are more of a challenge. We have one young man in hospital at the moment, who had a huge devolving injury of his leg, with an open ankle fracture (following an assault). He was sutured and put in plaster by another hospital, and came here after two weeks, with a huge soft tissue defect and pus pouring out of his ankle. After two weeks of external fixations and wound care, we have now grafted his leg and expect to be able to put a flap on his ankle in the next month or so. What was very much a limb-threatening injury appears to be salvaged.
There is however a lot of dogma associated with open fracture management (and limb burns, which I will touch on later). One of our difficult patients at the moment presented with a fresh grade 1 (open) tibia fracture (it is in fact in four pieces), and the on call debrided the wound and placed it in plaster. Unfortunately, despite the instructions in the notes, and the assistant saying the fracture should be sutured, the wound was left open, with exposed fracture at the base. Essentially an iatrogenic grade 3 fracture. We then had to apply an external fixator and make a fasciocutaneous flap to cover the defect. When asked why he had ignored the departmental policy and written instructions, I was just told that open fractures should never be closed. The patient will however keep his leg, and regardless of how it was fixed, he is going to be a long time recovering (we are considering plating his tibia in the next few weeks).
We do have some failures. One recently discharged patient had an infected open ankle fracture sutured, and needed external fixation and a flap to save the leg. The fixator has just been removed (it became infected) and the fracture does not look well healed. He is however a very elderly man, so I suspect that having a leg that partly works is acceptable, and we are going to see how he does. We have also amputated a few terrible open fractures in the last few months, that for reasons of infection or vascular compromise were just not salvageable.
Returning to the first case, the burnt arm, I suspect she will always have a poorly functioning arm. Ideally, earlier grafting and splinting would have made things much better. The policy in a lot of hospitals of referring only when burns do not heal means we start trying to save the limb a step behind where we would like to be. Patients do seem more likely to remove dressings and splints than at home, so compliance is also a major issue. But, working within the limitations of our skills, and the available kit, I think we do alright!
Wednesday, 9 January 2013
Rainy season is accurately named!
We seem to have been waiting months for the rainy season to start.
We had gotten used through December to massive thunderstorms in the early evening after an increasingly hot day. This week, however, we seem to have got some UK weather. It's been grey and drizzly for most of the days so far. So I think we can safely say that it's finally arrived and will stay installed until we leave in February. Yesterday we had an episode of 'that real fine rain that soaks you right through' as Peter Kay described it.
The other weekend it was slightly different. Geoff and I were sat inside with the windows and doors open watching the grey clouds approaching from across the garden. Gemma had told us that one day she'd spotted it raining in the garden but not at the front of the house. We looked carefully and could see the same thing happening.
The clouds seem to have very distinct boundaries and the rain falls heavy and vertical so it's possible to see exactly where it starts and stops. Soon it was raining all around the house and the noise on the tin roof was almost deafening.
It got heavier and heavier. I was watching the tomato plants taking a battering. I thought I might take some photos but as I walked towards the cupboard the wind got up. All of a sudden rain was being blown in through the door and onto my laptop. I managed to slam it shut but there was already a puddle on the floor. The kitchen window had been ripped open from its partially shut position and now the deluge was coming in from there. Geoff was despatched out of the front door to push it shut. :) Definitely a man job, that one.
While this was happening we didn't notice that water was actually flowing in under the door and making its way into the cupboard where, amongst other things, the SLR camera is kept on the floor. Tasks were divided with Geoff sent to shut the remaining windows and check for leaks in the bathroom whilst I sorted out the new swimming pool.
I moved one of our foldable chairs out of the way only for an unseen glass bottle to fall from the armrest and promptly explode across the floor. Tiny shards of glass now covered the width of the bed and breadth of the living area.
Then, obviously, the lights went out.
After much cursing (although, notably, no blaming of Geoff who had put the bottle in that position) the situation seemed to be under control.
Half an hour later the sky cleared and the sun came out. Before long the ground looked dry. You'd never know there'd been a storm at all...
We had gotten used through December to massive thunderstorms in the early evening after an increasingly hot day. This week, however, we seem to have got some UK weather. It's been grey and drizzly for most of the days so far. So I think we can safely say that it's finally arrived and will stay installed until we leave in February. Yesterday we had an episode of 'that real fine rain that soaks you right through' as Peter Kay described it.
The other weekend it was slightly different. Geoff and I were sat inside with the windows and doors open watching the grey clouds approaching from across the garden. Gemma had told us that one day she'd spotted it raining in the garden but not at the front of the house. We looked carefully and could see the same thing happening.
The clouds seem to have very distinct boundaries and the rain falls heavy and vertical so it's possible to see exactly where it starts and stops. Soon it was raining all around the house and the noise on the tin roof was almost deafening.
It got heavier and heavier. I was watching the tomato plants taking a battering. I thought I might take some photos but as I walked towards the cupboard the wind got up. All of a sudden rain was being blown in through the door and onto my laptop. I managed to slam it shut but there was already a puddle on the floor. The kitchen window had been ripped open from its partially shut position and now the deluge was coming in from there. Geoff was despatched out of the front door to push it shut. :) Definitely a man job, that one.
While this was happening we didn't notice that water was actually flowing in under the door and making its way into the cupboard where, amongst other things, the SLR camera is kept on the floor. Tasks were divided with Geoff sent to shut the remaining windows and check for leaks in the bathroom whilst I sorted out the new swimming pool.
I moved one of our foldable chairs out of the way only for an unseen glass bottle to fall from the armrest and promptly explode across the floor. Tiny shards of glass now covered the width of the bed and breadth of the living area.
Then, obviously, the lights went out.
After much cursing (although, notably, no blaming of Geoff who had put the bottle in that position) the situation seemed to be under control.
Half an hour later the sky cleared and the sun came out. Before long the ground looked dry. You'd never know there'd been a storm at all...
Sunday, 6 January 2013
The beginning of the end?
It might seem a long time until the beginning of March and our return to our jobs, or at least my return as Geoff is technically unemployed from the end of our contract here, but we don't have many weeks left in Katete.
We intend to go travelling in Malawi for a week with Nat and Will, have a brief stop off in London and then go skiing for a week after we leave, so our departure is about a month away.
It is really starting to hit home now. In the past month we've had 4 new medics arrive and it's interesting to see how like us at the beginning they are. But their different personalities bring a different atmosphere to the Mess, the wards and the hospital. It feels a bit like the changing of the guard.
This week we are losing Fi and Rory on Thursday. It's strange to think that we've had our last weekend together. They have been giving away their household items to the new people and talking of their plans in London next weekend.
Today we did a large barbecue as part of the goodbye celebrations and it was a good opportunity to reminisce about our group experiences. We bought Will a bbq fan for Christmas so there was no need for Rory to take his top off to fan the coals today. We realised that he will probably never have to fan a fire pit again either because all our wood is too wet to do one this week.
Wednesday is the proper goodbye dinner at Phoebe's. We've requested flying ants and Nshima but the rest will be more Western food. Then I think we have to play pool with Rory and potentially go to Drums...
Drums is the nightclub in Katete. Since Geoff and I and Nat and Will don't really do nightclubs (I'm sure you are shocked to discover this), we've been kicking the can down the road. We promised Rory we'd go once in our time here. And we haven't been.
I had been mildly enthusiastic at some point until they came back from their second visit and described the lavatorial situation. That being that any sane person would do their business outside rather than go in the designated building. In the bush I'm fine with that, I quite enjoy it. In the middle of Katete, at night, surrounded by drunk people, dressed in trousers [the ladies appear just to pee with their legs open stood up in Chitenges (even sober during the day) - I know, I know] I can't think of much worse.
I've said I'll go if they catheterise me first...
We intend to go travelling in Malawi for a week with Nat and Will, have a brief stop off in London and then go skiing for a week after we leave, so our departure is about a month away.
It is really starting to hit home now. In the past month we've had 4 new medics arrive and it's interesting to see how like us at the beginning they are. But their different personalities bring a different atmosphere to the Mess, the wards and the hospital. It feels a bit like the changing of the guard.
This week we are losing Fi and Rory on Thursday. It's strange to think that we've had our last weekend together. They have been giving away their household items to the new people and talking of their plans in London next weekend.
Today we did a large barbecue as part of the goodbye celebrations and it was a good opportunity to reminisce about our group experiences. We bought Will a bbq fan for Christmas so there was no need for Rory to take his top off to fan the coals today. We realised that he will probably never have to fan a fire pit again either because all our wood is too wet to do one this week.
Wednesday is the proper goodbye dinner at Phoebe's. We've requested flying ants and Nshima but the rest will be more Western food. Then I think we have to play pool with Rory and potentially go to Drums...
Drums is the nightclub in Katete. Since Geoff and I and Nat and Will don't really do nightclubs (I'm sure you are shocked to discover this), we've been kicking the can down the road. We promised Rory we'd go once in our time here. And we haven't been.
I had been mildly enthusiastic at some point until they came back from their second visit and described the lavatorial situation. That being that any sane person would do their business outside rather than go in the designated building. In the bush I'm fine with that, I quite enjoy it. In the middle of Katete, at night, surrounded by drunk people, dressed in trousers [the ladies appear just to pee with their legs open stood up in Chitenges (even sober during the day) - I know, I know] I can't think of much worse.
I've said I'll go if they catheterise me first...
Friday, 4 January 2013
The value of the Strategic Plan
As part of the Cost Effectiveness study that Geoff and I are
doing, we need to break down the cost of running the hospital to an operation
by operation level. This hasn’t been done before in published literature to the
degree that we would like to do it and I believe it’s because most surgeons
aren’t married to management consultants. However, we are here to break new
ground.
When I try to explain to most people here what we are trying
to achieve a glazed expression comes over their eyes and they start to tell me
all the difficult calculations that have to be made, if they even know where to
begin. I’m not fazed from a theoretical standpoint – I’ve worked out the cost
of production of plastic sheet in North America to enough detail to prove to
the owner of the business that he was undercharging on some product lines. I am
confident I can tackle a hospital.
What I haven’t been confident about is getting the
information needed to do it. Hence I am writing about this element rather late
in our trip. I know from home that most organisations aren’t entirely keen on
having outsiders go through their books and here, where both me personally and
my career are unknown, I expected it to be even more tricky.
So I played the long game and waited until we had the Acting
Medical Superintendent on board and then explained to him the numbers that I
would need. At his request I made a document explaining all of these and he
signed it and sent me to the chap in accounts.
First it went to the Acting Accountant who seemed eager and
told me he could do all the numbers in two weeks. Personally, I thought it
would take a month to fill in what I’d asked for but I’m a sucker for
enthusiasm. After 6 weeks I still had nothing and he’d lost the form. No
problem, I put a soft copy on his desktop – you can’t lose that…
Then the Accountant came back. He wanted to see my request
so I was positioned on a chair outside his office (but not in view of the door)
whilst his Deputy took in a paper copy. I was there for half an hour. I was not
surprised and nor (because I’ve been here long enough) was I bored, annoyed by
the waste of my time or anything else. I occupied myself watching people coming
to pay bills or pick up their pay. Partly my relaxed approach is because I’ve
been here a long time but partly it was because I knew what the problem was…
The problem was that the 10 page document that I had written
was a wish list. At home over 75% of Financial Directors or CFOs would have
looked at it and sucked their teeth. Not because the information didn’t exist,
per se, but because I wanted it cut a particular way – and normally that’s not
how the business is separated, most commonly for legacy reasons. In this
instance I wanted costs allocated by department down to Repair and Maintenance.
I was pretty sure they wouldn’t have it! But it’s always better to ask.
Presently, I was called in to the office and the difficulty
of my document was explained to me. After a few moments the Accountant asked me
my background and, finding that I was both an Engineer and worked for an
Accountancy firm, promptly relaxed and advised his Deputy that they could speak
freely. I took this to mean that they could speak in Accounting jargon and
assume that I was keeping up ;)
A compromise was reached swiftly. There was just one
problem. Salaries. The Medical Superintendent told me these would be a problem
because most staff are paid directly by the Government and not the hospital, so
he believed their salaries would be unknown [We need them anyway because we
have to do the total cost]. This was not the problem – there is a large yellow
book with all the salaries in sat in Accounts. The problem was that they didn’t
know how many staff of each grade were in each department… So I set off to find
that out for them.
This was a little before Christmas and we have hit the
dreaded Year End so progress has been slightly hampered. In the interim, I have
been asking the Project Manager to work out how much it would cost to build the
hospital again from scratch. He mentioned that it would help if we had the
Strategic Plan.
There is a Strategic Plan?? This is gold dust to me. On
every project the acquisition of the Strategic Plan is the key first step. It
will solve all problems – everything will become clear, there will be no
confusion. In reality it’s often a bit of a let down but, you know, hope
springs eternal and all that.
The second it’s on my USB stick I feel invincible. It’s 102
pages long I discover, surely it contains everything I could possibly need and
more?! I begin to read, OK, so it’s not quite what I was expecting but there
are some snippets in here. Anyway, not to worry, the numbers in the back will
explain everything, I just need to get a quick idea of the big changes and then
open my Excel.
Copy pasting tables sat in the sunshine is not a chore – my
colleagues should work outside more in summer, honest. I have data from 2009-2011.
I have data from 2013-2015 and I have data for the current year, 2012. This is
perfect. I am sorted.
Except that they don’t match. The same sinking feeling I get
at home happens. Someone has changed the descriptions of some of the lines. All
of a sudden £40k has disappeared from one place and cropped up in another, but
I can’t see why. There are bizarre trends that I’m not sure about – is it real
or did something else change? Drugs funding is split out in some places but not
in others, my attempts to pro rata it don’t seem to make much sense. Capital
projects includes RMI, RMI includes new equipment purchase, somewhere there’s a
massive double count on new items.
Perhaps the Strategic Plan isn’t going to be the Holy Grail
this time either. Maybe it never is. I’ve decided to wait for the Accountant –
it might be taking a while but at least he’s telling me that the problem is he
didn’t believe his first set of numbers! And at home, that’s almost invariably
a good sign (in the end).
Wednesday, 2 January 2013
The meeting of European and Zambian medicine 2
Looking back, I have already discussed the difficulties I faced dealing with the wide difference between my training in burns care in Chelmsford, textbook care and the reality on the ground here. In fact, we have made big strides, with most patients now being resuscitated better, much faster turnaround and decision making for conservative versus surgical treatment and the consequent reduction in bed time and blood usage. We have however started the more difficult task of modernising the care of patients following major abdominal surgery.
There is now good evidence that feeding people immediately after major surgery reduces the catabolic physiological response to trauma and improves their recovery. The evidence also supports early feeding even when there is a bowel anastomosis, with some exceptions (generally when the patient is critically ill or has been obstructed for a prolonged time). British practice, and my training, has moved away from the previous theory that a patient should not be fed until they open their bowels post-op, to reflect this new evidence. Indeed, I was at a national conference last year where someone suggested it would be negligent not to adhere to enhanced recovery protocols following colorectal surgery, a large part of which centres around early post-op feeding. To this it can be added that the patient population here is already malnourished pre-presentation, and a further week of starvation is a huge physiological challenge on top of a laparotomy.
The current practice at SFH, which has been the international norm for a very long time, is to keep a nasogastric tube in situ and the patient nil by mouth until they open their bowels. This is irrespective of whether they have had an open and shut exploratory laparotomy, a major bowel resection or surgery to another abdominal organ. Three examples from this week best illustrate things:
1. 18 year old boy with traumatic bladder rupture, repaired and catheter left in. Bowel not injured. Should be fed immediately post-op.
2. 56 year old man, HIV positive, small bowel intususseption reduced but not resected at laparotomy (CD4 count unavailable so we were unsure how an anastomosis would fare). Patient had been obstructed for over a week and was left with a bowel full of fluid, so best left with a NG tube, but would rapidly recover and feed on day 1 or 2.
3. 30 year old lady with recurrent sigmoid volvulus, underwent a semi-elective sigmoid colectomy once volvulus reduced. Should be fed immediately post-op.
On each of these patients, we have clearly indicated the feeding instructions on the post-op plan. For each of them, the recovery nurse has (sometimes aggressively) questioned us and told us we were wrong, and the ward nurse has ignored the instructions. I am not being critical - the staff are adhering to the standard of care that is the norm here, and are being true to their training. I also appreciate the need to be sensitive to the fact that we are new faces and are transient members of staff, and so people need time to adjust to us and our ideas. It is however challenging to reconcile that with our desire to provide care that we know to be first rate.
At the moment we are working hard, on a case-by-case basis, to convert nurses and licentiates to our way of thinking. We remove the NG tubes ourselves and directly communicate to the patients and relatives about feeding. We also, every day, discuss the reasons for our approach with the nurses on duty. It is feeling a little easier than with the burns changes, and I suspect that is because I have been around longer, and that the nurses have seen the benefits of my burns changes. We shall have to wait and see how long it takes to make these changes stick!
There is now good evidence that feeding people immediately after major surgery reduces the catabolic physiological response to trauma and improves their recovery. The evidence also supports early feeding even when there is a bowel anastomosis, with some exceptions (generally when the patient is critically ill or has been obstructed for a prolonged time). British practice, and my training, has moved away from the previous theory that a patient should not be fed until they open their bowels post-op, to reflect this new evidence. Indeed, I was at a national conference last year where someone suggested it would be negligent not to adhere to enhanced recovery protocols following colorectal surgery, a large part of which centres around early post-op feeding. To this it can be added that the patient population here is already malnourished pre-presentation, and a further week of starvation is a huge physiological challenge on top of a laparotomy.
The current practice at SFH, which has been the international norm for a very long time, is to keep a nasogastric tube in situ and the patient nil by mouth until they open their bowels. This is irrespective of whether they have had an open and shut exploratory laparotomy, a major bowel resection or surgery to another abdominal organ. Three examples from this week best illustrate things:
1. 18 year old boy with traumatic bladder rupture, repaired and catheter left in. Bowel not injured. Should be fed immediately post-op.
2. 56 year old man, HIV positive, small bowel intususseption reduced but not resected at laparotomy (CD4 count unavailable so we were unsure how an anastomosis would fare). Patient had been obstructed for over a week and was left with a bowel full of fluid, so best left with a NG tube, but would rapidly recover and feed on day 1 or 2.
3. 30 year old lady with recurrent sigmoid volvulus, underwent a semi-elective sigmoid colectomy once volvulus reduced. Should be fed immediately post-op.
On each of these patients, we have clearly indicated the feeding instructions on the post-op plan. For each of them, the recovery nurse has (sometimes aggressively) questioned us and told us we were wrong, and the ward nurse has ignored the instructions. I am not being critical - the staff are adhering to the standard of care that is the norm here, and are being true to their training. I also appreciate the need to be sensitive to the fact that we are new faces and are transient members of staff, and so people need time to adjust to us and our ideas. It is however challenging to reconcile that with our desire to provide care that we know to be first rate.
At the moment we are working hard, on a case-by-case basis, to convert nurses and licentiates to our way of thinking. We remove the NG tubes ourselves and directly communicate to the patients and relatives about feeding. We also, every day, discuss the reasons for our approach with the nurses on duty. It is feeling a little easier than with the burns changes, and I suspect that is because I have been around longer, and that the nurses have seen the benefits of my burns changes. We shall have to wait and see how long it takes to make these changes stick!
Tuesday, 1 January 2013
Our Christmas day activities...
[I've put photos at the bottom because I'm too frustrated with the Blogger software to try and weave them in today]
Geoff has already written about the impact of Christmas on the busyness of the hospital and I was tasked with writing about what we did on the day. I was going to do it a few days ago but my present from Geoff this year was a hideous case of man flu - I could have died.
Thankfully I pulled through, with some assistance from Dr Rory who informed me last night "This is the first time I've ever had to prescribe someone drugs for a cold...". Probably so and it's the first time I've not been able to go to the Chemist to buy them myself :p
Anyway, on Christmas morning Geoff got up as usual and headed into the hospital to do his ward round. That done, he and Gemma came back for a short while to get all Christmassed up. This involved putting on the hats that Geoff's parents had sent over and collecting the gifts for the children. I was in charge of photography.
We started on Mukasa - the female and child surgical ward - things did not begin as expected. Gemma approached the first child who promptly burst into tears and grabbed onto its mum to hide its face. This was repeated a lot. Tigger is very scary, apparently, and colouring books are confusing. Not a single child smiled on receipt of the gift, although the parents invariably looked pleased!
However, after a time, when they thought we weren't looking anymore, we could see them starting to play with the toys, even Tigger. The ones that went down best were the small cuddly toys for the two toddlers in traction (see the photo). They were busy throwing their toys around and generally having as much fun as you can when you are suspended by your legs :)
The older children on Kizito (so, boys) were a little more responsive but it struck me that perhaps colouring books and crayons aren't common around here and many weren't sure why they were being given what they were. The little toy cars with internal mechanisms were easier to understand.
Once all the surgical children had been seen to, we moved to the Paediatrics ward with the remainder of the presents. It was a similar experience with the mums and children eyeing us with some suspicion. I made a little crown out of pipe cleaners, which I put on the head of the first child that came within reach - his face was a picture "What on earth has the silly woman done to me?"
We soon returned to Kizito to serve the lunch of chicken and rice. Each patient was also given a bar of soap, some salt and some sugar. I asked the Social Worker about the salt and sugar and she just said it had been like that when she took over. Our best guess is that these are things the patients will actually use and therefore they make good presents - the African equivalent of socks!!!
That done we headed home for a break to grab a small snack and chat to people on Skype. All hands were needed on deck from about 4pm to prepare the Christmas meal in the Mess. When I told one of the current students that we were cooking in the Mess her only response was "You know that it's filthy, right?". Yes, I did - see previous posts on the subject.
Many hands make light work and things were well on their way in under an hour. This gave me a chance to boil all the cloths available (which we'd had to pin down with knives given their propensity to move of their own accord) and spray the entire place with fly spray (it felt like genocide). I regretted the decision to Dettol the metal counter top when I saw how black the previously white cloth became! After the meal the game switched to trying to kill the massive cockroaches that were now crawling over everything.
We did our best to make the meal as traditional as possible - there were crackers and hats, mulled wine (even though it was a hot night) and enough leftovers to feed the students for lunch the next day. Everyone seemed to have a really good time.
That said, I'm already looking forward to the Christmas lunch that my Mum is going to prepare for us when we get back....... mmmmmmm yummy and no food hygiene concerns either!
Geoff has already written about the impact of Christmas on the busyness of the hospital and I was tasked with writing about what we did on the day. I was going to do it a few days ago but my present from Geoff this year was a hideous case of man flu - I could have died.
Thankfully I pulled through, with some assistance from Dr Rory who informed me last night "This is the first time I've ever had to prescribe someone drugs for a cold...". Probably so and it's the first time I've not been able to go to the Chemist to buy them myself :p
Anyway, on Christmas morning Geoff got up as usual and headed into the hospital to do his ward round. That done, he and Gemma came back for a short while to get all Christmassed up. This involved putting on the hats that Geoff's parents had sent over and collecting the gifts for the children. I was in charge of photography.
We started on Mukasa - the female and child surgical ward - things did not begin as expected. Gemma approached the first child who promptly burst into tears and grabbed onto its mum to hide its face. This was repeated a lot. Tigger is very scary, apparently, and colouring books are confusing. Not a single child smiled on receipt of the gift, although the parents invariably looked pleased!
However, after a time, when they thought we weren't looking anymore, we could see them starting to play with the toys, even Tigger. The ones that went down best were the small cuddly toys for the two toddlers in traction (see the photo). They were busy throwing their toys around and generally having as much fun as you can when you are suspended by your legs :)
The older children on Kizito (so, boys) were a little more responsive but it struck me that perhaps colouring books and crayons aren't common around here and many weren't sure why they were being given what they were. The little toy cars with internal mechanisms were easier to understand.
Once all the surgical children had been seen to, we moved to the Paediatrics ward with the remainder of the presents. It was a similar experience with the mums and children eyeing us with some suspicion. I made a little crown out of pipe cleaners, which I put on the head of the first child that came within reach - his face was a picture "What on earth has the silly woman done to me?"
We soon returned to Kizito to serve the lunch of chicken and rice. Each patient was also given a bar of soap, some salt and some sugar. I asked the Social Worker about the salt and sugar and she just said it had been like that when she took over. Our best guess is that these are things the patients will actually use and therefore they make good presents - the African equivalent of socks!!!
That done we headed home for a break to grab a small snack and chat to people on Skype. All hands were needed on deck from about 4pm to prepare the Christmas meal in the Mess. When I told one of the current students that we were cooking in the Mess her only response was "You know that it's filthy, right?". Yes, I did - see previous posts on the subject.
Many hands make light work and things were well on their way in under an hour. This gave me a chance to boil all the cloths available (which we'd had to pin down with knives given their propensity to move of their own accord) and spray the entire place with fly spray (it felt like genocide). I regretted the decision to Dettol the metal counter top when I saw how black the previously white cloth became! After the meal the game switched to trying to kill the massive cockroaches that were now crawling over everything.
We did our best to make the meal as traditional as possible - there were crackers and hats, mulled wine (even though it was a hot night) and enough leftovers to feed the students for lunch the next day. Everyone seemed to have a really good time.
That said, I'm already looking forward to the Christmas lunch that my Mum is going to prepare for us when we get back....... mmmmmmm yummy and no food hygiene concerns either!
 |
| The surgical team on Kizito |
 |
| Geoff gives a present to a toddler in traction |
 |
| Geoff and Kalynda serve lunch under supervision |
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| Picture of me just to prove that I haven't changed :) You must be so glad!! |
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