My love affair with rubber

“It’s only flat at the bottom part”

This began in July 2014, when I had three flat tyres in a week, just before I was due to leave after my first tour in Kakumbi Rural Health Centre. There was speculation that a sangoma, or witch doctor, had cursed my vehicle in an attempt to stop me from leaving.

This morning, I drove to the clinic for our 7am meeting and when this concluded, I returned to my vehicle to collect my medical kit. My front driver’s side tyre was flat. As one joker said, “It is only flat on the bottom side, not the top.”

I unloaded my emergency medical gear from the rear of the Toyota Prado and liberated the tyre wrench and jack. The first problem was that the tyre wrench was a very snug fit onto the wheel nuts, which made it difficult to get a good grip. When I managed to get a good fit, I couldn’t shift the nuts, partly because they had been tightened by Superman and partly because of the friction between the tyre wrench and the metal surrounding the nuts.

“Give me a long enough lever & a place to stand and I will move the earth,” said Archimedes. So Aaron, the clinic volunteer, went off to find a length of steel tubing which would fit over the end of the tyre wrench. This did the trick, but we couldn’t fit the jack under the designated points on the chassis without digging a small hole in the ground.

I removed the spare from the back door of the Toyota while Aaron removed the front wheel. After attaching the spare, I noticed it was a bit soft but thought that it was normal for long-term spares to lose a bit of pressure. I went back to my patients, but after an hour, Aaron came in to tell me that the spare we had fitted was getting softer. I didn’t want to be stuck at the clinic, so I decided to drive to the filling station in the village where there was a compressed air hose. Unfortunately, it was not functioning, so I telephoned Greg at Kapani and asked him if I could get the tyres sorted at his workshop.

I drove gingerly to the workshop and dropped off the flat tyre. I could see there was a plug on the shoulder of the tubeless tyre which looked dodgy. The lads soaped the tyre, filled it with air and diagnosed two leaks. But they had no repair kit for tubeless tyres, so I had to source one from Flat Dogs. In the meantime, the pressure in the spare tyre on the front driver’s side had fallen to less than 10 whatsits per thingumy, when it should have been 30. I pointed out that the rear passenger side tyre looked soft, too. The mechanic pumped both tyres up and I said a little prayer, before setting off for Flat Dogs Workshop. I went on to the clinic and finished seeing patients just after 1:30pm and drove back to Kapani with the puncture repair kit.

The mechanics were putting a tractor engine back together again. This involved a JCB, thick nylon rope, a heavy duty car jack, and several wooden blocks. They manoeuvred the two parts of the engine casing into alignment, then pushed them together with manpower and bolted it into position. I was exhausted just watching them do it.

Dodgy tread

I drove the vehicle around to the workshop to pick up the mended tyre and I felt the rear driver’s side tyre was deflating. The lads had trouble getting the nuts off that wheel also. They used a different tyre wrench and ground down a bit of my tyre wrench so it would fit in future. Strangely enough, they could not find a puncture in this tyre. “We will keep it under observation,” said the chief mechanic, “as it is a spare.” I was not impressed by this logic. However, when they tried to fit this wheel onto the back door mounting of the Toyota, the washers on the wheel nuts would not fit into the holes in the wheel. By now it was knocking off time, so they asked me to return tomorrow when they would switch the original spare tyre onto the back door and the “under observation” tyre onto the front driver’s side.

After thanking the mechanics for their help, I mentioned that I thought it could be the work of a sangoma again. They considered this but were not sure. Then I told them that I had seen a new oil patch at the front of my carport…

Medical Zambia

Dead Drunk

Half a dozen men carried the unconscious man into the health centre and laid him on a bed in the male ward. The clinical officer felt she needed a bit of support, so she asked me to see him with her. I asked if anyone knew what had happened.

“He was drinking cane spirit last night and passed out. We couldn’t wake him up this morning to go to work.”

No one knew if he had any significant past history. He was a regular drinker but had never been like this before. He was well before he got drunk and he didn’t appear to have hit his head.

My initial assessment began with calculating his Glasgow Coma Scale (GCS). I asked the clinical officer to speak to him in Nyanja but he was oblivious. He wasn’t even moaning. Score one. I tried to get some response to painful stimuli, pinching his earlobe or rubbing my knuckle up and down his breast bone. There was no reaction so he scored one. His eyes were closed but when I opened pulled his eyelids apart, his pupils were small and sluggishly responsive to light. Again, he scored one. His GCS score was 3/15 which is pretty dire.

While I examined him further, I asked the clinical officer to get some 10% dextrose for intravenous infusion. Alcohol can cause hypoglycaemia, and although we don’t have any blood glucose testing strips, it seemed a reasonable course of action. I have a pulse oximeter which showed his blood was 93% saturated with oxygen. His blood pressure was 108/76 and pulse 96/minute, thready with low volume. His temperature was 35.8C, slightly low but not enough to be hypothermic. He was breathing shallowly and rapidly at 22 breaths per minute, but his lungs sounded clear. There were no heart murmurs. His abdomen was soft with no masses, enlarged organs or fluid. His arms were floppy but his legs were stiff. His breath gave no clues (kidney or hepatic failure, diabetes); it did not even smell of alcohol. I tried to check his fundi but the batteries in my fancy ophthalmoscope were flat.

I asked the clinical officer to do a rapid diagnostic test for malaria, an HIV test and a test for syphilis. Our laboratory has a limited number of tests on offer. All investigations were negative.

“Are we missing anything?” I asked myself. “Could it be methanol poisoning?” The men who brought him to the clinic said that they had drunk the same spirit as our patient, albeit not as much, with no ill effects.

“Or sleeping sickness?” I wondered. Zambia has only 50 cases per year, so that would be very rare.

“Maybe he has had a stroke or a cerebral event?” If this was the case, there would be little we could offer.

The clinic doesn’t have an ambulance, so we have to telephone the district hospital to send their vehicle. But we know that they don’t have any fuel. And it takes an hour for the vehicle to get to the clinic.

I decided on a course of masterly inactivity while the 10% dextrose corrected any alcoholic hypoglycaemia. Well, that isn’t exactly true. I went back to the consulting room and continued to see patients.

After half an hour, one of the drunk’s pals told us that he had woken up and wanted to go home. I was happily surprised; I have never seen anyone with a GCS of 3 who recovered so quickly.

This is not a rare event. On Monday afternoon at 1pm we had another unresponsive drunk in the clinic who had finished three small bottles of 47% cane spirit during the morning. Perhaps he was a Boomtown Rats fan (“I don’t like Mondays), but that’s a hellish way to start the week.

Egyptian goslings on a pond near Mbomboza

Post Script: Last Christmas, someone was brought to the clinic dead from alcohol poisoning. There were also cases of children aged 10 and 12 who were brought to the clinic the worse for wear. Each small bottle of spirit costs just 40 pence.