Photos: Birds

Photos: Sunsets (even more!)

Spot the odd one out!

Leaving time

We are sat in our room at the hospital, now mostly packed, having donated away most of our household goods [not mugs and kettle but tea! so no hot drinks tonight]. Yesterday was my last day at work, tomorrow we leave for Malawi on our way home. We will have a week relaxing in Malawi with Nat and Will then head home the week after [as my wife has already told you but I've been too busy to read what she put].

The last few weeks have gone very quickly, with the last couple of days being spent winding down. Yesterday our visiting plastic surgeon was operating, so I had very little to do. In fact, the only operation I carried out was the drainage of a chest wall abscess (slightly complicated by bleeding from one of the major local vessels). It almost felt like a bit of an anticlimax, after everything I have done!

We have had a fantastic experience, faced some novel challenges, had times when we have really enjoyed it, and others when we just wanted to pack it in and head home. If we have achieved nothing else, I have operated on 550 patients and looked after a sizeably larger number on the wards. I'm sure once we have unwound we will have some final thoughts to put on here. I will then be looking in earnest for a job back home!

In the meantime, enjoy the photos! [Patience and electricity in plentiful supply mean you now get photos until the 19th of Feb when we return]

So long, and thanks for all the fish

It seems strange to be sat here writing what will be (after lunch tomorrow) our final blog post from St Francis'. I say final but you will find a set of photos appear over the coming 8 days or so [depending how much electricity and patience I had after this]. I can remember very vividly writing the first blog post sat on a chair in our room in Lusaka on the first night. I was pleased that we'd mastered the internet so quickly because I thought it would come in handy for sanity preservation - and so it proved.

Today has been a sad day as both Geoff and I have been around the hospital trying to say goodbye to people. Inevitably some people haven't been around so some goodbyes have gone unspoken. We've both been touched by the genuine expressions of sadness and regret that we are leaving so soon. I've even mastered a diplomatic answer to the question 'When are you coming back?'. I haven't yet worked out the best reply to the men in Accounts who told me that if I couldn't stay in Africa forever because I'm too pale then they would happily find Geoff a black wife :)

On Sunday morning we will jump into the back of Will's car and the 4 of us will turn left at the end of the drive and onto a new adventure in Malawi for a week. They have luckily picked the week that includes our 11th anniversary (yes, he has really put up with me for that long) and Valentine's Day so it's going to be a nice romantic jaunt...

Our first stop will be Dedza, which is now well known for its pottery, but is of particular interest to me because it's where my Dad spent 9 months teaching in 1967. I'm going to see if it's changed. We've already noticed that the main road has moved so it might take a little investigating to find his old house (assuming it's still standing).

From there it's some pampering and relaxing in the tea plantations near Blantyre then the compulsory Lake Malawi stop - we already have the Praziquantel needed to make swimming safe!

We are both looking forward to getting back to Blighty, even if we omitted to pack coats in our haste in August. It will be interesting to see how we re-adjust and whether the changes that have undoubtedly happened to us out here will stay or whether we return to our old selves when we get back into a routine.

There is one thing I'm sure of though - I'm not going to take electricity and water for granted again. And as for my washing machine... I'm sure you're all bored of hearing about that!

So we'll see you all soon we hope!

Is it very rural? [+ return of the chickens]

Since we arrived I'd been hoping to spend a day with the HIV Outreach team. Four or so days a week a team of Nurses, Counsellors and Dispensers travels to different health centres around the district to enable HIV positive patients in the rural communities to receive free ARV treatment and check ups.

Some of these clinics are more urban than others (e.g. Katete Urban Health Centre - just down the road). Really I wanted to go to a Clinic further afield to see what the conditions were like. Ideally I would also love it if someone could show me around a typical village and explain how it worked and what all the different structures were used for.

As often happens, despite my 'best' efforts, the job was left until the last week of our stay. The only day that Natalie and I (accompanied by Will and Nat's Mum) could do was Wednesday (yesterday). I looked on the rota in the ARV Dispensary and asked 'Where is Kasenengwa? Is it very rural?'

My friend Jacob started to answer with a description of where it was but soon handed me over to a gentleman who had been waiting for a print out. I didn't know who he was but I was soon to find out.

'No! It is not VERY rural' [And so began a reasonably long description of what very rural constitutes in his mind. I knew I was being chastised for being sloppy with my language - I had been talking to friends originally. Before we came my father had suggested that people might find my description of Katete as 'the middle of nowhere' slightly offensive. Here I was demonstrating the point very nicely and justifiably getting my comeuppance. I listened attentively]. 'There are places that are very rural where the villages are cut off for 3 months of the year by the Luangwa river and they have to survive with no contact from the outside world and only a few radios. That is very rural. Kasenengwa is not.'

When the gentleman left my friends laughed. 'I'm sorry about him. He wanted to be MP for Kasenengwa but he wasn't chosen. He was quite rude to you... It is very rural!'

And so it turned out (apologies to the local aspiring MP). We drove halfway to Chipata and then turned off the road onto a dirt track for at least half an hour. We were well off the electricity by then, and, that's my definition of very rural!

The health centre looks reasonably newly built. It is large and well appointed. Actually we thought it might be a little better than the current OPD at St Francis'. The Clinical Officer was away so the Nurse gratefully took up Nat's offer to assist in seeing patients.

This left Will, Nat's Mum and I to entertain ourselves. We went for a little walk but, not knowing much Nyanja, we weren't able to discover much about how people lived. I made friends with some school children (standard) and we found ourselves sitting about.

I knew I needed to ask someone to take us around but people were still getting established and the clinic was busy. I've also learned that these things tend to sort themselves out one way or another and I shouldn't worry about them too much (something that the Healthcare Partner at work has tried to teach me in the past :) ). Eventually the others got restless so I approached Jacob. Shortly a man was found to take us around.

I was expecting a short trip to the nearest village and a cursory look at the living conditions. But after village 1 (where we'd got to go inside the cooking block, which was formerly a bedroom) we were taken to another small village then the largest nearby village. Everything was explained with great attention to detail and only a few men sat around a pool table had asked us for money.

I got to ask all the questions that I had! Which must have seemed many to the others, for Nat's Mum observed 'It's funny, Charlotte, you are interested in very different things from us' and 'You are very nosy, why are you asking what they are cooking for lunch?' Well, I wanted to know! I didn't want to come and live out here and spend 6 months in a brick building with a tin roof, running water, flush loo, electricity etc and not understand properly how the majority of the locals lived. So now I've seen it and asked about it and I can go home feeling that I have some reasonable understanding of what it is to be a poor Zambian.

Chickens

You might remember that we bought 2 live chickens for Christmas but ended up not using them. One was eaten a while ago as curry but the other has been waiting in the freezer for a prime moment. The freezer did look a little odd given that it contained a chicken, sliced bread, ice cubes and two different types of gin.

Last night it was my turn to turn the dressed chicken into lumps suitable for a chicken 'stew' [Nat's mum doesn't like curry]. We had tried to defrost it in the fridge but clearly there hadn't been any power cuts yesterday because it was still mostly frozen. I put it in the sink and took our little vegetable knife (the only sharp knife we have). Something wasn't quite right but Geoff was busy. I made a deep cut along the middle but then couldn't work out what to do from there. The legs also looked funny. Time to call in the back up...

'You've got it upside down' Rigghhtttt, that would do it. I turned it over - that looked better. I tried the same cut - 'No! you need to go to the side of the midline - that's just bone!' This was not going well. After a short while I revealed the breast but it took a long time to get the meat off and I wasn't sure I'd got down to the rib cage. I tried to remember what I'd been taught by Surgeons about considering the anatomy of the muscles and cutting sympathetically, but with a tiny knife and frozen meat it was harder than they made it sound. The leg in particular seemed to be mostly tendon. Eventually I finished side 1.

Emboldened I decided to be more decisive the second time. I cut down hard on the breast - there was a load bang sound and the knife jolted down. This time, it transpired, I had not only found the rib cage but cut through one of the ribs entirely. :) Oh well, at least I'd got all the meat off the breast. I have a new found admiration for butchers, although I think the chicken had mostly frozen my hands by this point!

Eventually enough meat was removed to feed us all. I was reminded of Abraham's comment that I should really have learnt how to do all things chicken in my time here. I think I'm happy to understand how Zambians kill chickens, how we kill chickens (in factories with machines), and what to do with prepared chicken. Chicken to eat comes from the supermarket... not the garden

Enhanced recovery?

Not infrequently, we lament the death of a post op patient and say "if only we had a ventilator/inotropes/parenteral nutrition/haemofiotration..." Indeed, comparing what is available here to what is done in England, I am regularly amazed at how many survive despite the lack of ITU facilities - a point floridly demonstrated by two cases from this week.

The first was an 80 year old lady. It is fair to say that 80 is "a good innings" in this part of the world, and they will have been 80 hard years working the fields. I didn't ask how many children she had, but the average is something around 8, and it is probable she has outlived them all. She arrived on Monday afternoon, and the clinical officer was sufficiently worried about her that she called me out of theatre to see her. She had had bowel obstruction for 5 days, was peritonitic and shocked, but after a bit of fluid perked up and we took her to theatre. She had a compound sigmoid volvulus (small bowel wrapped around large bowel wrapped around itself) although it was not necrotic (dead) which seems par for the course for this problem. Anyway, we proceeded to resect the offending bowel, which proved tricky to get two healthy ends together, so it took just over an hour in total. For the majority of the hour, we could hear the pulse oximeter beeping away in atrial fibrillation, and the anaesthetist complaining about the blood pressure. Indeed, he turned the anaesthetic down so much we had almost no space in which to operate [This is because the patients muscles start to contract again, closing the gap in the abdominal wall]. Having finished, she looked dreadful. Her starting haemoglobin level had been half the norm and she had bled a bit. The single available unit of blood had already been given. We put her on oxygen and fluids, and hoped for the best. Even in England, I suspect she would have a high chance of dipping in the immediate post op period. However, within 36 hours she was sat up, eating and had opened her bowels. She is now home. Some people are just made of tough stuff!

The second was at the other end of the age spectrum. I was walking through Kizito on Thursday afternoon and the nurse asked me to look at an ultrasound report for a new admission. I was a little bemused, as I had been in clinic that morning and thought I'd seen all the new admissions. However, as happens quite frequently, the really sick patients are sent straight to the ward by the clinical officers, even when we sit in the room next to them, and we are not told! This 7 year old had been run over by an ox cart, with the wheel going across the middle of his abdomen. While he looked remarkably well and had a normal heart rate and blood pressure, he was peritonitic, indicating some form of abdominal catastrophe. He turned out to be even more anaemic than the previous patient, and had a belly full of blood and two sizeable liver lacerations. This was however a solitary injury and all was in control once we had packed the bleeding points. After a few sutures to repair the liver and examination of the rest of the abdomen we closed up, and within twelve hours he was sat up, looking well and eating. Again, a remarkably fast recovery from a major injury.

We are still here!

Apologies for the break in communications. Don't worry, we are still OK!

Both of us have been battling this week to try and close off the loose ends that we have with our various projects. Somehow whilst we were away I forgot that I can't expect to work as efficiently as I would at home, so I've been a little frustrated with progress this week.

Today is a case in point. On Wednesday afternoon a cable blew up outside the Accounts department - severing the electrical connection between the hospital and both Zesco and the back up generator. It was unfortunate that the Accountant and I had just spent an hour and a half working on various things without hitting Save. In the moments after the power went off I sat very still until I thought it was safe to speak. Rodgers (who like Abraham is in a wheelchair) was motionless until I'd finished - upon which he banged both fists on the desk and swore loudly. I'm going back on Monday to get the last few bits and pieces. After a few hours power was restored but there was a question about whether the generator would kick in as required in future.

Back to today - the power went off across the whole hospital at about 7am. This isn't that unusual but such an early start is suggestive of a fault rather than routine maintenance. We all carried on as if nothing had happened, although the back up generator did not power up (I can't hear this from the house so assumed that it had). By mid-morning the Surgeons had given up on operating for the day. The battery back up on the Surgical wards was beeping alarmingly when I passed (it normally only has to work for 10 mins before the genset starts) - without reconnection shortly the Oxygen concentrators would turn off and critically ill patients will suffer.

There was no point going to Medical Records to get the data I needed as the computers wouldn't be working. So, reluctantly, Geoff and I returned to the house.

Strangely, when we arrived the power was on and has remained on throughout but the hospital is still without power as I write. I don't know how they fed the patients at lunchtime without power. I don't know how they will cope this evening if it isn't fixed, when all the batteries will have run flat and the hospital could be in complete darkness. But what I do know from experience is that these things generally work out, perhaps that's why the Zambians were quite relaxed about the whole thing.

My only gripe is that the water pump for our area is clearly the other side of the fault. After exercising this morning I discovered no water anywhere (something that hasn't happened for months) and I found it no less upsetting to have to get dressed sweaty today than I did then! In fact it's got to the point that when it started to rain a few moments ago, I put out the laundry bowl to try and catch some water - I'm thirsty and would like to wash my hands! The rain has stopped and I only have enough water either to drink or wash my hands... now that's a dilemma!