Doctors Doolittle

Weather - Maximum temperature – 40 degrees Celsius

- Rainfall – 4 hours of "2 drop" rain

Highlight of the week

We venture into exotic veterinary medicine

Lowlight of the week

Spoiler alert…… We lose our 5th patient

Photo caption competition winner: Ellie Bond – the honey badger.

Wednesdays have always been my favourite working day. Whilst I enjoy my work, in medicine it can be hard to achieve balance. Wednesday feels like a tipping point. There is often a lull. The ying comes up to meet the yang. Work suddenly seems manageable and another life is no longer out of reach. I differ from the average anaesthetist. Anaesthetists are said to dislike working Wednesdays. For them it seems a shame to break into both weekends.

This Wednesday began like many others. Instead of relying on our baboon alarm clock, Keith set his phone for gentle harp chords at 5:15. We whiled away two hours in South Luangwa National Park before work. A male giraffe worked his way around a sausage tree. Eating all the young pods and shoots. We sighted elephant. The mark of a good day. Furthermore, Jack could not be criticised for his dullness today. Play had already been ticked off from the to-do list. Work beckoned.

Did someone say sausages?

Our first two patients were thought to have asthma. Asthma is thankfully not common in Kakumbi. Particularly since we have few therapeutic options for true asthma. Keith saw a teenage girl with a strong family history of asthma, but her peak flow was normal, and anxiety seemed more likely. I treated a more obviously asthmatic, a 2-year-old child, with five puffs of salbutamol via a spacer and started her on a short course of oral prednisolone. Then I had to step up to the plate and cannulate a 14-month-old with sepsis. Again, amazingly we seemed to have all the necessary kit and medicines at hand. I am chuffed to say that my success rate with cannulas is still 100%.

Our conventional medical practice of the day was drying up by 12:30. The strumming guitar chords of the bat phone interrupted our last conversation. One of our nurse prescribers, Keith and I, were talking with a constipated patient. The patient was grumbling that elephants had eaten all of her garden fruit. Keith reckoned that she should at least be able to get hold of some pumpkin leaves, or cabbage, to get things moving along. He apologised that our pharmacy isn’t equipped with laxatives. Elephants causing constipation! Better than blaming the dog for not handing in your homework at least.

I peeled off to answer the bat phone. Anna from Chipembele wanted some help with an elephant. Are you constipated too? I almost quipped. But I held my tongue. I heard the anxiety in her voice.

Chipembele wildlife education trust is an incredible organisation started by Anna and her husband, Steve. Their mission is to teach Zambian children and communities the value of wildlife and their environment, to conserve them for present and future generations. Less poaching and habitat destruction. More community involvement in conservation and wildlife education. Chipembele of note, has an animal sanctuary where ill and injured animals are taken for rehab and potential release. These animals sometimes need the services of a vet.

The impact of the ethos propagated by Chipembele is self-evident in Mfuwe. Rumour has it that when a recent back-room deal was made to sell off Park buffalo to canned shoots in other Southern African countries: the inhabitants of Mfuwe did their best to prevent the hunt organisers accessing the park.

But I digress. It’s Wednesday. Anna shared her tale of woe with me on the phone: We have a very poorly elephant. The vet is committed elsewhere, deep in the bush. The Valley doctor is our only hope. The vet had suggested that you might carry IV fluids. Is there any chance that you could get here straight away?

Now Keith and I have a thing about elephants. As I mentioned earlier: A good day is defined by the mere sighting of an elephant. Anna wanted us to resuscitate an elephant! Wild elephants couldn’t keep us away. Quick Keith we have an emergency visit to make. He looked at me bewildered. I promised to fill him in in the car.

We learnt as junior doctors, before the beginning of time, that providing emergency care always came second to our stomachs. A bunch of bananas from Charity at the market resuscitated the newly appointed vets. Our vet-mobile (the honey badger) accelerated away toward Chipembele, half an hour down a dirt track.

Kakumbi, a 2-year-old male elephant, had been found the previous day. He was sick and alone. We can only guess what caused his isolation from his herd. Kakumbi was in dire straits. Well-meaning villagers felt they need to tie his feet together to transport him to Chipembele. He had arrived late the previous evening. Although emaciated, dehydrated and unwell, he was still relatively lively. The team immediately removed his bindings and fed him baby milk, hourly during the night, along with some oral rehydration salts. By Wednesday morning he looked more chipper. In fact, so much so, that Kakumbi chased the staff around his enclosure. He then took some pleasure in drinking from a pond and covering himself with mud. The vet popped in at 11:00. The prognosis seemed good, despite a multitude of ailments.

Kakumbi - a shadow of his former self

But 30 minutes later the pendulum swung. Kakumbi fell to the ground and the staff could not get him up. Somehow, they managed to carry him into a small shelter. This was no mean feat since he weighed about 200kg. They lay him on mattresses to protect him from further pressure sores. His breathing became erratic. The vet was by now deep in the park and not reachable. Anna spoke to the elephant orphanage in Lusaka. They suggested IV fluids. Perhaps you might know of a doctor who might help? Enter the newest vets in the Valley, stage right.

We arrived at 13:15. Anna called out to us as we approached Kakumbi’s enclosure: Hurry, I think he might be breathing his last. Anna sat on a mattress next to Kakumbi. His breathing was in the form of intermittent deep sighs. Sadly, the type that humans often make as they are in the process of dying. Cheyne-Stoke breathing in geriatric circles. Agonal gasps for those, like me, with a paediatric bent. But his heart was still beating strongly, and he was still blinking his eyes. Kakumbi’s eyes appeared to be looking around as if he was aware of our concern for him. We felt there was nothing to lose by giving a fluid bolus intravenously. If Kakumbi was dehydrated, he would need 10 to 20 ml per kg. We eyeballed his weight. For a 200 kg child, Kakumbi would need 2-4 litres as a bolus. We had 4 litres in our medical bag of tricks and another litre in our car.

We fished out a nice big cannula. Elephants have fabulous veins in their ears. All the better to cool them down on hot days. Gentle flaps of elephantine ears set up great convection currents and that, combined with massive direct radiated heat loss, helps them to tolerate the ridiculous heat that we have been suffering recently. Sometimes 2-year-olds can be tricky to cannulate. Not this one. Kakumbi had veins like motorways. No danger of me losing my immaculate cannulation record here. Whilst the team fashioned a hook to hang the fluids from, Keith and Richard squeezed fluid into Kakumbi. 5 litres of IV fluids went in so quickly that we dispensed with the idea of using the hook.

The five litres had gone in within 30 minutes. We paused to take stock. Kakumbi seemed hot. Anna bravely dodged Kakumbi’s productive bowels and inserted a thermometer into where the sun don’t shine. 38.6 degrees Celsius. We continued to improve the heat exchange taking place from Kakumbi’s right ear. Cool water. Taking care not to compromise the cannula.

Pushing in fluids fast

Kakumbi’s excrement was staring us right in the face. Jam packed with parasitic worms. His conjunctivae were pale. Our minds cast back to our experiences in Zanzibar. Parasites, mostly malaria and hookworm were responsible for anaemia there. The record low for a child’s haemoglobin in Zanzibar was 2.7 g/dl. Most of those extremely anaemic children came back from the brink with a transfusion. Unfortunately, there was no prospect of giving Kakumbi a transfusion. Perhaps the vet might sort out some iron and treat the parasites should Kakumbi survive the day?

The ambient daytime temperature was in excess of 40 degrees Celsius. In addition, the radiant sun on Kakumbi’s dark body were likely to have caused heat stroke. Could his fever be compounded by an infection? What would Mr Herriot do? With our newly framed veterinary degrees we decided, supported by Anna, that antibiotics were worth a bash. After losing an adult patient to sepsis a fortnight ago, we decided to throw the kitchen sink at Kakumbi. The British National Formulary was vaguely helpful when it came to working out doses. But should we go by age or weight? Weight seemed more appropriate. Desperate we brought out some 50% glucose from our bag. Not my favourite concentration of glucose. It’s prone to making veins angry. We decided that Kakumbi had plenty more veins to spare if this one went south.

Kakumbi stirred. His eyes opened and he became more aware of his surroundings. His breathing became regular and settled. He passed urine and opened his bowels again. Might it be possible that he could pull through. Kids tend to do, or not to do. He teetered on a knife edge. Thin and wasted. Badly affected by pressure sores. Kakumbi was still not able to take fluids by mouth. I tried to give him milk using a large syringe. Fluid pooled in his mouth and drained out. Oral paracetamol was not possible. We briefly considered administering paracetamol rectally, but Kakumbi’s bowels seemed too active for that. In fact, our medical kit looked seriously depleted. We had no more intravenous fluids and no magic tricks left.

As time wore on, Kakumbi’s breathing again became more erratic. But somehow, he appeared more peaceful. Perhaps he was sleeping now? We made a plan to prioritise Kakumbi’s comfort. Crossing everything, we dreamt that the real vet could use a magic trick or two the following day. Resigned to more realistic probabilities, we packed up our bags and started to head home.

In the car, we reflected on our experience. It had been a privilege to have been so close to a baby elephant. Perhaps we had made a difference? We certainly had not added to Kakumbi’s suffering. We had a further 20 minutes of blissful ignorance. The inevitable phone call heralded predictable news. Before we could get home, Anna shared the difficult tidings. Kakumbi had died peacefully. His breathing had slowed, and he gradually drifted off.

Had we been writing fiction: we would have given you a tonic to finish this tale. It shouldn’t happen to a vet, or a doctor. Losing a patient sucks. But to lose a precious, mysterious, wee beast like a baby elephant has left us heartbroken. We knew Kakumbi was perilously ill. He was the first baby elephant that we have been up close and personal with. We cared for him, God damn it. Professionally and emotionally.

Kakumbi was too far gone before we arrived. A cascade of ailments had affected him before his arrival at Chipembele. The final coup de gras may have been heat stroke. We have seen severe malnutrition in Africa before. It often travels with parasites and infections. Caring for patients with severe malnutrition requires fastidious attention to detail and a modicum of good fortune. The good fortune was not with us on this occasion. But Kakumbi did not die alone. He died surrounded by his adoptive family. We had an outstanding team with us to provide care for Kakumbi at the end. We all grieve, with his mother and his herd. In the bush they will not forget him. We never will either.

Photo of the week - caption competition