An ivory gift

Maximum temperature: 29 degrees Celsius

Rainfall: Zero

Highlight of the week: Ellie our medical elective student arrives on schedule. We celebrate together her finals success and our 30th wedding anniversary.

Lowlight of the week: The valley cold strikes us down. More fool us for going mask-free in clinic.

What have the Romans ever done for us? Well, how long have you got? Aside from seeing Brian off in 1979: they kicked off the whole anniversary gift thing about two thousand years earlier. Silver and gold wreaths for 25th and 50th anniversaries were the thin end of the wedge. Sometime after the Romans had moved on, sharp entrepreneurs got the ball rolling again for every possible year of incarceration. Paper, cotton, leather. Cheap and cheerful to hook you in. The bait is set. Then the snag and the reel. Silver, ruby, gold. The net lands you. But who ever thought up ivory as a gift?

Thirty years ago, Keith and I hooked up and made a pledge. We became united if you will. Consequently, Keith may now have bought me 29 anniversary gifts. I may even have a spare room full of trinkets and artefacts. So, what type of gift might I expect to receive this Monday? Professor Google, at first, opined pearls. But next in the pecking order was ivory.

Back in the day, ivory was quite de rigueur,

non dentists would pay a fee quite dear,

an old fellow, long in the tooth, quite the prey,

their harvest of teeth had a role quite unclear,

so, a merchant chatted with a quiet cashier

And now we have a gift for our 30th matrimonial year.

Our garden here is often adorned with ivory. Au naturel, of course. Our gardeners use them as nature intended. They dig. They lift. They dominate. They defend. So, Keith wakes me on Monday to share the joy of seeing our gardeners, au naturel. Their teeth unpulled. As nature intended. On elephants. Alive, beautiful, magical, intelligent, gentle. Beguiling and worthy of respect and distance.

Bones. Keith tells me that Star Trek’s doc is called Bones. Keith has always aspired to owning a tricorder. A magical scanning device that tells Bones what ails his patients. Surely that takes all the fun out of medicine? I prefer the thrill of the chase.

Keith and I have a long history of fixing bones. We first met at Ashington General Hospital, 32 years ago. Keith was an Accident and Emergency doctor. And I was doing a combined surgical and orthopaedic house job. Three months older than me, Keith showed me the ropes. We reduced old ladies’ Colles fractures together as a starter for ten. Our record was 13 forearm fractures on one particularly icy day. A long queue of broken ladies snaked along the corridor outside our operating suite. We did one together and then divided to conquer. There was no hint of romance that day. Honest.

Fifteen years later, I emerged, Ursula Andress style from the Pacific Ocean, white bikini hiding nothing, to distract a broken park warden whilst Keith and Steve pulled his Colles fracture straight. The anaesthetic was rather Heath Robinson that day. But the result was unimpeachable.

But I digress. Let’s jump forward to 2023. Keith and I sit surrounded by children and ducks. Our first tree clinic of the season. Chikuzi. A quiet village. A steady, slow trickle of mums and little tots. Nothing too taxing. Perhaps we see sixty kids. The trickle peters to a drip. Our minds turn to lunch at Project Luangwa with our friend Anna. But the idea of an early lunch evaporates with the gentle but insistent melody of the doc phone.

Mfuwe Lodge request that we visit. A lady has fallen whilst out on a walk. She has a sore shoulder. How is she looking? Do you think her shoulder might be dislocated or broken? Keith enquires. He is keen to figure out whether this is an emergency. He recommends the only option of pain relief available at the lodge and promises to be with the patient at the earliest opportunity. When will that be? They ask. The drip stops. In about 20 minutes I expect. It is 10.30. We hustle our colleagues into the Blue Beast, bid farewell to the villagers, and set off to rescue a damsel in distress.

Time is of the essence. There is still a hint of being able to meet Anna for lunch. And paracetamol is not going to deal with a nasty shoulder. Perhaps it’s all a storm in a teacup? Keith and I talk through the possibilities and our approach in the car. We have a limited repertoire of medical tricks here. The bare necessities. Might we be able to reduce a dislocated shoulder in the Valley?

Mfuwe lodge barely had a chance to change our bedding in Leopard chalet when Britta* moved in. She shares the chalet with her daughter Hanna*. They are here for a special birthday celebration. We bustle back into Leopard chalet carrying our cases, feeling totally at home. Lodge staff don’t flinch at the double booking. They exhale. The Valley docs take away their angst. Shoulders drop with relief. Except for one.

Britta, a stoical Swedish lady sits holding court. Hanna greets us and relates the story. Mum fell onto her shoulder. A trip over a branch. She hasn’t been able to move the shoulder since. Britta wears a fleece formed resourcefully as a sling. At first the contour of the shoulder is hidden.

We gently unfasten the fleece. Bad humour enters the fray. Our lunch date vanishes. Britta has a dislocated humerus. Nothing funny about that.

Nothing looks like a dislocated humerus. But this is not nothing to Britta, Hanna, nor the 2 barefoot doctors in the bush. We hesitate for a second or two. How would you both feel about seeing if we can pop that shoulder back into joint for you? We venture. Our latter-time mentors whisper gently in our ears: First do no harm

We aren’t planning to stick a foot in Britta’s armpit without X-ray input. Why don’t we give you a bit of pain relief? And something to relax those painful shoulder muscles of yours? Then you can have a gentle snooze on your belly. There’s a good chance that your shoulder will just pop right back in.

Britta is slight and naïve to tramadol. Fifty milligrams seems reasonable to start with. But we want her really relaxed. A double check in the British National Formulary reckons that 10 mg of diazepam, taken by mouth, is needed. Relax and Obliviate. Win win.

We lie her down and within minutes she drifts off. Her left arm dangling over the bedside. Still curiously contoured. She purrs gently. Have we over-sedated her? The pulse oximeter goes on and I scuttle off to grab a bag, valve and mask. Barefoot, but not totally without resource.

Gravity seems inadequate. Half an hour has passed. Britta’s purring continues. Gladly her oxygen numbers stay North of ninety. It’s time to weigh in with orthopaedic brute force. We give the nod to Hanna and warn Britta that she might feel a tweak. Keith grasps the lower portion of Britta’s upper arm and applies downward pressure. I push the scapula away from the offending shoulder. Grind. Groan. Britta protests. We rest. Already her arm is bruised from Keith’s firm but gentle grip. Her platelets disabled by her medicine for atrial fibrillation.

A short rest. Gravity with diazepam was at least doing no harm. How would you feel about us putting the air-conditioning on Britta? We propose. Sweat drips down the inside of our designer scrubs. Our proposal is denied. The patient knows best. We sweat on. OK, another gentle stretch. Warns Keith. We resume our exertions.

Keith pulls the upper arm downwards and gently rotates the whole arm. A grating. Something shifts. Almost imperceptible. Certainly not a satisfying clunk. Britta, I think we may have sorted out your dislocation. Keith declares. Would you like to sit up so that we can check it?

Britta’s distal upper arm is florid. Bruising in the skin. All Keith’s own work. Oh my. We point it out to Britta and Hanna and apologise. Keith again expresses that the dislocation has relocated. The shoulder has certainly regressed towards the mean. But the girth of Britta’s upper arm is still twice her mean. A bit of longitudinal pressure suggests a fracture.

After our impressive medical intervention our nursing skills let us down. A comedy of errors. The ingenious fleecy sling previously disassembled lies to one side, mocking us. We struggle to arrange Britta’s new sling with more conventional materials. We almost resort to YouTube. Eventually our inner nurse gives us inspiration and Britta’s arm sits true.

Keith yearns for Star Trek technology. Bones reaches for the tricorder. A quick scan. Bones and Keith agree. We’re pretty sure that your upper arm is broken Britta. But with any luck you might get away without an operation. I’d like to recommend a transfer to Lusaka to get your shoulder x-rayed. Britta, stoic and thinking of others, declines. She’s here for the sake of her daughter. A special trip.

We pause to let our secret weapon operate. Time. Mfuwe lodge kindly lay on a scrumptious lunch for two somewhat hypoglycaemic, over-heated Valley doctors. Spot hit. The dining area at Mfuwe lodge is light and breezy. A favourite throughfare for elephants when the winterthorn trees are in fruit.

Meanwhile, Bwana Andy is working magic: I’ve managed to secure 2 places on a charter flight to Lusaka today. Do you think Britta should go now or later? Keith and I jinx each other with a double now! Britta’s medical history and her fracture mean that a delay could be risky. She might well need surgery. I call the Medland hospital in Lusaka and speak to a charming orthopaedic surgeon who is keen to get Britta on board the next possible flight.

A quick chat with Hanna cements our resolve. Hanna would be unable to enjoy game drives knowing that her mum needs urgent medical care. The only nay-sayer is Britta. Evacuation is a no brainer. A delay puts her at risk of complications. We have stopped her anticoagulant and her possible operation is safer to be done sooner rather than later. We conspire.

The conspiracy pays off. Britta folds and agrees to the combined medical opinions of two Valley docs, a Consultant Orthopod in Lusaka and a worried daughter. We cautiously hug Britta and Hanna farewell. Hanna’s shoulders are noticeably relaxed. Not to mention Britta’s.

Keith, the human gannet, secures two chocolate brownies from the afternoon tea offerings at the lodge and we head back to Kapani. Home from home.

Spock decides to use the shuttlecraft rather than the transporter. Britta is a little ginger after her manipulation. A private charter is a fitting way to round off her adventure in our Valley. Six pm sees the shuttlecraft dock in Lusaka.

Within 24 hours Britta’s shoulder X-ray pictures pop into our WhatsApp inbox. Bones’ tricorder had been spot-on. A beautifully relocated shoulder sporting two fractures. Properly broken. But not needing further manipulation, nor heroic surgery. Definitive management in the bush.

No writers block. Our blog writes itself. So much omitted. Alice’s evacuation from the Valley last year not quite making the final cut. Her fractured hip not recognised by her insurance company. What does the X-ray show? The heroics and creative necessities. The medicine and the logistics. Alice’s pictures now emerge.

Generalists. Pragmatists. But not really budding trauma docs. Alone we might be all at sea. Here in the back of beyond. At the end of a road, we offer a two for one deal. Two Valley doctors. In synergy. We salute our adventurous single-handed colleagues and friends. Ellie. Ian. Nina. Leopold. We pay you homage.

*Names have been changed to protect confidentiality. Permission was granted to publish the Xray picture.

Photo of the week

Ivory au naturel

A new Ellie in the valley

Properly broken

Alice arrives at the airport

Alice's handover

Sundowners at Wildlife