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Medical Thursday Doors Zambia

Monday Morning Meeting

The only door in this post, sadly. It is the door to the admin section of the health centre. Note the height chart written on the wall to the left.

7:30 am start, prompt. Most of the health centre staff who should be here are wearing masks and waiting for the opening prayer. The nurse in charge asks the most timid, quiet staff member to lead the prayers. We all bow our heads while she mumbles into her mask. I can’t understand a word of what she is saying, but I “amen” along with the rest of the team when she stops.

Her next task is to take the minutes book and read out what we decided last Monday. Again, her voice is very quiet but her English is halting as she tries to read the handwriting of the previous scribe. We get the drift.

It is important to adjust your ears so you can detect sounds of danger from all angles

What is on the agenda? The malaria sensitisation campaign is underway. I find this rather strange as the peak months for malaria are April – June. Perhaps now we are less busy treating malaria we can find the time to educate the population about how to prevent it. We are recruiting insecticide sprayers for next month. Unfortunately, we don’t have the capacity to spray all the surrounding villages, but some are complaining that they missed out last year on both spraying and free mosquito nets. I must admit to having seen mosquito nets being used in the gardens to protect crops against birds. And some say they have also been used as fishing nets.

One good idea is for the health inspector to alert community health volunteers when someone tests positive for malaria from their village. They have rapid diagnostic kits and will test people living near the “index case” to snuff out an outbreak. Test, treat and track. Where have I heard that before?

The nurse in charge is a very experienced midwife, but he made a plea for other midwives (and any assisting nurses) to remain calm when there is an emergency. “Don’t panic,” he said. “Don’t run around looking for things to do. Just calmly assess the situation. The women are not going to expire immediately. You have got time to make an assessment.” I find this is usually true, but when obstetric calamities occur, things can go bad very quickly. However, I agree with his sentiment and nod sagely. I wonder what catastrophe happened last week that I was not aware of?

This male kudu has the curly-wurly horns of a mature bull. 360 degrees of antler twist per year

The lab technician seems to be working much better now she is alone in the laboratory. Last year, there were three technicians. Too many cooks spoiling the agar broth, I suppose. She informs us about all the tests which are available, but some we can’t use, because they are reserved for certain patients, people living with HIV or pregnant women. It’s a shame I can’t order a haemoglobin estimation for “ordinary patients”, especially as the local hospital won’t transfuse blood unless I know the patient is very anaemic (5g/dl or less than half the normal amount).

Later this week, we will be visited by the Regional ICAP (“International Center for AIDS Care and Treatment Programs”) Team to support our work with patients living with HIV. Perhaps this is a reward for the excellent care provided here, which has improved drastically over the past five years (since my first tour of duty here). The clinic provides anti-retroviral drugs for over a thousand patients in Mfuwe. The vast majority are compliant, their disease is suppressed. The last baby to have been infected by their mother during pregnancy was in October 2019. I find it rather odd that they are paying attention to such a small centre, even if we are doing such great work.

Lion cub hanging out with the pride.

What makes me uneasy is the contrast between excellent HIV care and the poor care for diabetes, hypertension, asthma, epilepsy and other chronic diseases. The difference is, of course, that HIV care gets massive funding from the Global Programme for HIV AIDS.

The nurse in charge issues every staff member with a paper mask which must last them for a week. In the UK, these masks are discarded after four hours as they become damp and less protective after being in contact with moisture in our breath. I am pleased to see everyone keeps their nose covered. In a comment aimed at me, the nurse says, “We are forced to make compromises.” Indeed.

The Human Papilloma Virus (HPV) vaccination programme is stalled. Girls who are 14 – 15 years of age are eligible for two jabs, a year apart, to protect them from cervical cancer. It began nationwide last year and Kakumbi Rural Health Centre staff gave 269 girls their first HPV shot. We don’t know for sure, but we estimate that 90% of this cohort of girls go to school. Schools are the obvious location to round up and vaccinate the girls. But with the Covid-19 situation, all schools are closed apart from “examination year classes”. Unlike last year, we cannot just tell the teachers to line up eligible students for vaccination. Our problem is not just the girls waiting for their second shot, but another 270 girls now aged 14 who need their first shot.

Little bee-eaters sharing a perch. I particularly like the blue eye-shadow

Regular readers will have read my previous blog article about my misgivings with a vaccination programme which should have been given to 10 – 11 year olds, before they have become infected with the oncogenic strains of HPV. Once a girl starts having periods, boys consider her ready to have sex. A significant percentage of 14 year olds are not only sexually active, but are already young mothers.

I must have been daydreaming/brainstorming how to solve this problem when the quiet nurse in the corner started talking softly into her mask. “She’s leading the prayers,” I thought, dropping my chin onto my chest and clasping my hands. A few seconds later, I squint up at everyone else; no one is praying. She is actually reading out her minutes for us to approve. Nonchalantly, I try to adjust my posture to disguise the fact that I wasn’t really praying. I couldn’t tell if the other health workers had noticed and were smirking behind their masks. But I am used to making mistakes and they are used to my strange ways.

We finish at 8:15 am, ready to start the busiest day of the week at the health centre.

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Zambia

Leopards and other dangerous creatures

The general manager of one of the nearby safari lodges decided to have a team-building, morale-boosting trip to the National Park for sundowners on Sunday. (It is traditional to find a pleasant spot to watch the sunset while enjoying a drink, hence the term sundowners.) Seven of us drove into the park at 4.30pm, planning to meet up with friends at 5pm on the open plain of WaMilombe.

I really enjoy being driven in an open, high vehicle. The view is so much better than the view from the driver’s seat in the doctor’s car and I can concentrate of seeing animals, instead of trying to avoid potholes. The Luangwa River spills over into WaMilombe during the rainy season, creating a vast, shallow lake. Mud from the river fertilises the soil, creating rich grassland, perfect for herbivores. The floods recede, draining away into streams which carve deeply into the muddy soil, creating excellent cover for carnivores hunting the herbivores. This makes WaMilombe popular with leopards, and people who want to view leopards in action.

The plain is bordered by ridges on two sides, the Luangwa River and its dried-up tributary, the Mushilashi River. Leopards like to rest in trees on the ridges, while they look out for their next meal. Normally, the plain is dotted with antelope, puku and impala, but this evening it was empty. A solitary game drive vehicle was stationary under a tree close to the Luangwa. Game vehicles only stop for refreshments, toilet breaks and when there is something interesting to see. We decided to take a look.

Leopard 1
Leopard 2
Leopard 3

Stretched out in the shade was a beautiful young leopard. We stopped ten metres away and took photographs. The leopard wasn’t interested in our interest. Its belly looked full. The driver of the other game vehicle said that there were two other leopards over by the ridge. As we crossed a deep dried out stream bed, we disturbed another leopard, who trotted away from us, towards the trees. Our driver could see another leopard hiding below the ridge, so we went to get a closer look. As soon as we began to observe leopard 3, leopard 2 sauntered over to leopard 1. As it approached the shady tree, the leopard speeded up, and ran up the tree trunk.

Leopard 2 crossing open ground in WaMilombe, going for second helpings

We realised that there was something attracting leopard 2 to the tree, so we returned and parked under the branches. We could seen the fresh corpse of an impala, draped over a thick branch. Leopard 2 was partially hidden by leaves, but we could see and hear it eating. I wasn’t expecting a sac of antelope intestines to plummet from the tree, just missing by inches the only vegetarian in our vehicle. Partially digested grass and manure splattered against the side of the truck. Leopard 1 decided to capitalise on this good fortune by picking up the guts and returning to its favoured position by the trunk of the tree.

Leopard 1 likes tripe
Leopard 2

Both leopards gorged on the remains of the impala while we watched. The sun began to set so we left the feast and drove to the bank of the Luangwa River, where we could safely get out and have a drink. The sunset was magnificent, but not as impressive as the afterglow which lingered in the sky for twenty minutes, getting deeper and deeper red. I took a selection of photographs of the sky reflected in the river as the light faded. Hippos started leaving the river to eat grass during the night. We could hear baboons giving alarm calls on the other side of the river, but we couldn’t spot another leopard in the gloaming.

Hyena in the headlights

When it was pitch black, we drove back to the leopard tree. A hyena was lolloping about, hoping for some titbits to fall from above. I got a poor photograph using the headlights to illuminate the scene. We were a mile from the park gate when a large grey shape appeared in front of us. I could pick out four elephants, munching away on trees. We drove carefully past and joined the main dirt road leading to the gate. The driver slammed on his brakes, creating a cloud of dust. “There was a puff adder in the middle of the road back there. I’m going to reverse, let me know I am not going to run it over.”

Puff adder

The lighting conditions were very poor, but the puff adder was clearly recognisable, as a short, fat snake, with a triangular head and typical diamond markings on its back. It might look fat and sleepy, but that’s its modus operandi. It stays still, waiting to attack with one of the most rapid strikes of any snake. Its venom causes massive tissue damage. Not the sort of snake you want to step on during a walking safari in the bush.

About a kilometre from my house, we stopped again to allow a lion to cross the road. Bush highway code: animals have priority on these tracks. As we waited for a second lion to emerge from the bush to join its sister, I reflected on how fortunate it was to be able to see these savage beasts in their natural environment. And we had just popped out for a couple of hours on a Sunday evening for a social drink with friends.  

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Medical Thursday Doors Zambia

Could this be Covid?

This is the Valley Doctor’s car, being protected by a large baboon on the roof. The car door is the only portal in Thursday Doors this week.

She was gasping for breath as they brought her into the consulting room, never mind the patient who was already there telling me about his piles. The nurse ushered the man with piles outside, but the lady was so distressed, she could not sit in the vacated chair.

“Let…me…go…down,” she wheezed and sat on the floor, back against the wall.

My first thought was: could this be covid-19? If it was, it would be the first case we have had in the clinic. My second thought was, this looks like asthma. Experienced clinicians know that “common things are common,” or if you hear hoofbeats, don’t think of zebras – unless you are working next to South Luangwa National Park, as I am. I quickly established that there was a history of asthma and I set to work examining her.

Crawshay’s Zebra. It has intensely black stripes with no faint grey line between.

It is always important to stand back during emergencies and calmly assess the situation. I took my time counting the respiratory rate, observing her use of accessory muscles of respiration, checking she was not cyanosed. She was clearly very unwell. “I…can’t…breathe,” she managed to say. OK, enough masterly inactivity, “Let’s try her on a nebuliser,” I said.

The nurse retrieved the nebuliser from a cardboard box under the sink. It was dusty and battered, but there was a power cable, tubing, a mask and a chamber for the drug. All we needed now was a salbutamol nebule. “Out of stock,” said the nurse. “They never were in stock,” I replied. “The only nebules we have ever had were donated from overseas or brought by muzungu doctors.”

We moved her out of the consulting room to the female ward, but it was full, so she took a bed in the empty male ward. Despite sitting propped up, she became more distressed and said that she felt tired with the excessive effort of breathing. I checked the medical cases in the back of my car but could find neither my nebuliser, nor any nebules. But I did find a salbutamol multi-dose inhaler which I brought back to the ward.

“Do you know what this is?” She nodded yes. “Breathe in the gas from this inhaler.” She put the inhaler in front of her mouth and tried to activate it. No gas came out. “Press harder,” I said. A cloud of salbutamol came out of her mouth as she hadn’t breathed in. “Never mind, try again.”

Big cat in a tree, stretching after a heavy meal of impala in South Luangwa National Park

“I…want…an…injection,” she managed to say. The nurse went off and came back with a syringe and aminophylline. Now, aminophylline works extremely well, but it has a narrow therapeutic window. Give too little, it has no effect; give too much and the heart stops. I wasn’t ready to use this drug just yet, so I used my calming voice to try to reassure her that the inhaler would start to work quickly, just relax, don’t worry, this is going to improve very soon. I gave her a few more squirts from the inhaler, this time ensuring most went into her lungs. “It will just take a few more minutes to work,” I told her. I bought some time by feeling the pulse and checking her arterial oxygen saturation. The pulse was fast, but not tachycardic and her saturation was 99%, which was better than mine.

Just as the nurse drew up the aminophylline into the syringe, the patient became calmer. Sometimes this is bad news, as hypoxia causes sedation and she might be going into respiratory failure. But I knew this lady was well oxygenated, so we waited and her breathing became easier. Everyone smiled as she slowly recovered. After five more minutes she felt comfortable and was able to provide me with more history.

She said that she had been wheezy for about six hours. The night had been cold and windy, stirring up the dust in the village. She thought that this might have been the trigger for the attack.

She had been diagnosed with asthma ten years ago and had been prescribed inhalers in the past by muzungu doctors. But the clinic only stocks salbutamol tablets and inhalers are expensive if bought from the local chemist, so she discontinued therapy.

“So when was your last attack, before this one?” I asked.

“It was when I got tear gassed by the police,” she replied. I had a sudden vision of my patient attending a political demonstration in Mfuwe.

The nurse explained that there had been a disturbance some months ago, when a horde of villagers descended on a dying elephant with machetes to chop themselves a hunk of uber-fresh meat. To restore public order, the police had to fire tear gas into the crowd. Or perhaps it was to allow the elephant to die in peace.

I will have to add tear gas to my list of possible provoking factors for asthma.

At the local chemist, I bought a course of prednisolone and a replacement inhaler for the patient and returned to the ward. She was fast asleep as she had been struggling to breathe since midnight. When she awoke, I asked her to come for review in two weeks at the clinic.

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Life Zambia

Journey to Zambia

In autumn 1978, before my first medical job overseas, Dr John Seaman, chief medical officer of Save the Children Fund UK, advised me to invest in a proper, sturdy suitcase, a Globe-Trotter. “Go to Harrods and ask the assistant to jump onto the case from a chair to demonstrate how tough it is,” he said. I went to Harrods but the eye-watering price of the Globe-Trotter deterred me from asking for a demonstration. As a result, I have bought a succession of cheap pieces of luggage ever since; false economy. The zip holders on my grey Samsonite case have been replaced twice, and one of its wheels is wonky, but it is fairly secure. The soft-walled Delsey Sidewalk can carry more supplies, but both its wheels have fragmented; I will leave it behind in Zambia.

Even with a generous luggage allowance of two suitcases each weighing 23kg, I couldn’t pack all the medical equipment and supplies I had collected. I packed the cases equally, the more valuable items in the more secure case. I guessed that each weighed about 20kg, but I needed to check. The cases were too big to fit onto a set of bathroom scales, so I stepped onto the scales carrying a case, noted the weight, then put the case down and subtracted my weight from the total. 25kg and 23kg. Perhaps Ethiopian Airlines will allow some leeway for a medical volunteer, I thought.

I packed my iPad, Kindle e-reader, laptop, binoculars, camera and long lens into my secure backpack. It weighed almost 10kg against the allowance of 7kg, but I could justify needing to keep expensive stuff with me on board. Thank goodness this airline allows carry on luggage, unlike some others who fear it will increase the risk of Coronavirus infection.

The only way I could carry both cases was by dragging them behind me. They were so wide that it was an effective way of keeping a social distance from others. Heaving them up and off the train to London St Pancras was trickier. The underground was quiet, even at “rush hour”, though I did struggle to get the cases down a few short flights of stairs, huffing and puffing behind a mask.

I found the check-in desk at Heathrow Terminal 2 and had more difficulty manoeuvring the cases around the maze of narrow, roped-off paths. The first attendant scrutinised my passport and documents before telling me that I had to see her supervisor at the end of the row. I dragged my cases past other check-in desks and smiled sweetly at the supervisor. She told me that she would have to call the station manager for the flight, could I wait a few minutes.

She took photographs of all my supporting documents, visa and passport to email to the manager. Five minutes later, she called the manager again and I was granted permission to fly. I heaved my cases onto the weighing scales while she was tapping on her computer keyboard, hoping she wouldn’t notice the excess. She tagged the cases and attached “heavy” labels to them before asking me where I wanted to sit. I said, “Away from everyone else, please.” She assigned me three seats in a middle row at the back of the plane.

The inflight entertainment system was not working, but I didn’t mind. I was able to scrunch down into three seats, wrapped myself in a blanket, extended the middle seatbelt as much as possible so I could lie on my side and fasten myself in. I pulled up my mask so it covered my eyes as well as my nose and mouth and managed four hours of fitful sleep.

Being seated at the back of the plane meant there were fewer passengers around me, but I didn’t get a choice of meal and there was no coffee left. We landed in Addis during a thunderstorm and had to stay on board for 20 minutes until the tropical rain eased off. After waiting for a couple of hours in Bole International Airport, I boarded the flight to Lusaka. I had three seats to myself at the front of the plane, perfect for a quick disembarkation. I had heard that it could take three hours to get through immigration and health checks, so I was perfectly positioned.

At Kenneth Kaunda International Airport, all passengers fill out three similar forms, declaring their lack of covid-19 symptoms and how they can be contacted if their test, or the test of a nearby passenger, turns out to be positive. One health worker noted my temperature and collected one of my health declarations. An immigration officer asked for my papers. Her raised eyebrows indicated that she was impressed I had managed to obtain a visa. “Go to the diplomatic channel,” she ordered. The next immigration officer in the kiosk was confused by my supporting documents. He saw that I had been in Zambia last year and asked his boss what to do. The boss nodded his head and the officer started typing my details into the computer using two forefingers. On the narrow desk there was not enough room for the keyboard, so half of it was unsupported. Each prodded keystroke risked it falling off the table.

I was disappointed not to get a pretty page stuck in my passport. The immigration officer just stamped my entry onto a cluttered page and waved me through to the health desk. The health clerk misspelled my name on the request form and swab container and handed it back to me. I said, “I have proof of a negative test from four days ago, done by the NHS.” She wasn’t interested and waved me over to the swabbing team.

Two nurses in full “Ebola-style” personal protection suits, hoods, visors, masks, wellington boots and double gloves took nasal swabs from all the passengers. I asked if I needed to quarantine, and she said, “No, but we will contact you if we need to in the next 14 days.” I thanked her and collected my luggage from the conveyor belt. A customs officer inspected the baggage tags and waved me through. My taxi driver, Friday, was waiting for me outside. He said that he remembered me from my first visit, six years ago. He had parked his taxi 400 metres away, across the official car park, in the apron of a petrol station, probably to avoid exorbitant airport parking fees.

During the journey to the hotel, I looked out for familiar landmarks, but could not see anything I recognised. There were lots of new buildings and shopping malls, but the streets were eerily quiet. There was a statue of a giant chicken commanding a roundabout near the city centre. It is probably called ZamChick. I would have remembered that, I’m sure.

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Life Thursday Doors

Thursday Doors Old Hunstanton 2

If you are inspired by my photographs of beach hut doors in Norfolk, I would recommend that you pay a visit to two other places. Go to the Sandringham Estate, to walk in the wonderful woods, and have a meal in the visitor centre (roast dinners on Sundays). Then call in at Snettisham on the coast, where the Royal Society for the Protection of Birds has some hides on brackish lagoons and overlooking the Wash. Check the tide tables so you can time your visit to see the waders being pushed into the muddy shoreline by the incoming tide.

The beach hut tradition is not dying. There are new huts being built and old huts being repaired.

I like watching police dramas on TV, so I was interested in this pistol found at the base of the stairs, obviously a “throw down” – an untraceable gun, dropped at the crime scene by an officer who needs to justify a “bad squirting”.

And I was caught in the act, too

Categories
Life

Thursday Doors in Old Hunstanton

In the 9th Century, St Edmund landed on the Norfolk coast at Hunstanton; I drove there on 29th July. It was blowing a gale, with low grey clouds scudding across the sky.

There is a standard “Atlantic” lifeboat and a hovercraft stationed here

There are lots of beach huts among the sand dunes. Perhaps not as quirky as the huts in Cromer, most are painted in blue and white or pastel shades.

A few huts are higher up the beach, close to the trees.