Fighting fires

Weather - Maximum temperature 39 degrees Celsius

Weekly rainfall 3mm in places, up to 15mm in others.

Highlight of the week

Ellie arrives in the Valley to replace us.

We find 4 wild dogs hunting wart hog within 30 minutes. (It took us 2 months to find wild dogs.)

Lowlight of the week

Ellie arrives in the Valley to replace us.

We will be homesick for the Valley within a week. We leave in a week.

Emergencies are my bread and butter. They’ve always stimulated me. Adrenaline surges through me as a sick child teeters on the brink. Yet I gravitate to it. Teach it. Thrive on it. Well trained colleagues, teamwork, effective resuscitation protocols, comprehensive equipment and drugs, control the controllable. But here in Zambia we have few fully trained or experienced staff. Equipment and drugs are patchy at best and often safely locked away. Inaccessible. Dramas become crises.

Contrast this instinct that I have to fight fires with Keith’s drive to stop the rot. His bread and butter is prevention and early diagnosis. He continues to find challenge in the complexities that are woven into how key ailments affect peoples lives. In Zanzibar, primary care, early diagnosis and preventative work left me cold. Unstimulated, even though I know that it is as important as firefighting. Community care in Northern Zanzibar was not my bag. Despite this, I have enjoyed the process of childcare clinics in Zambia. Churned my way through hordes of sniffling and pyrexial children at Kakumbi. Both of us know that we cannot have any lasting impact here without understanding the job at hand. Educating staff and community members our unwritten role here.

We now have six months of work at Kakumbi Rural Health Clinic under our belts. Our rapport with colleagues is good. The clinic is leaps and bounds ahead of anything that we experienced in Zanzibar in the 1990s. But our colleagues face unimaginable challenges. The lack of basic equipment and drugs is part of it. Highly motivated and caring. Many of them are working as volunteers. They have been to college. Passed all their exams. Now they want to work. But paid jobs are scarce. We only have eight full time, paid nurses or clinical officers. To cover a service 24/7. With an average of 40 to 50 patients per day. Everyone has high expectations of our new president. HH, Hakainde Hichilema. Staff wait in limbo. Hoping for deployment in this New Year. Work will be where it will be. No choice of posting. Bags packed. Waiting. It is our good fortune that they plug our gaps in Kakumbi as they wait. Our most able staff.

Wednesday started like any other day. Mercy, a 15-year-old girl occupied one of our beds. Suffering with a swollen leg after a snake bite. She was gladly not especially unwell. Just in agony. Painkillers would help. But ibuprofen was not safe due to the risk of bleeding with some snakebites. Other strong painkillers elusive. Paracetamol and time would have to see her through. We let her go home with a plan. No weight bearing on the foot. No household duties. Rest. Analgesia. Fluids. Follow up if required. The elusive snake may have been another stiletto snake. Mercy reckoned that there was a single puncture mark. The wound had been treated with herbal medicine before resorting to modern medicine. The waters were muddy, we couldn’t see a distinct puncture mark, never mind two. Already experienced with stiletto bites we knew the drill. Pain and possible local tissue necrosis the issues. Luckily for Mercy, and for us, the mambas and boomslangs remain undisturbed for now.

Mercy limped home and we settled down to work through the hum drum. A pile of record books on my desk, but nothing pressing. Might it be a slow day? Not a chance. Drama unfolded rapidly. A mother was immediately ushered in, holding her 2-year-old daughter. She has stopped talking was all the history I could get. I took one look at Dorica and knew that she was in trouble. Barely breathing. Secretions bubbled around her mouth. She felt hot. She was very stiff. It looked like a febrile convulsion. But not a simple one. I needed to assess her without delay. The treatment room was already busy with an immobile patient. So, we used a less suitable room. I called for help. The nurse looked at me. I asked if we had any diazepam to administer, to stop the fit. No, the unwanted answer. My oxygen saturation monitor, always at hand, found a home on her thumb. Dorica’s heart rate was 180 beats per minute and her saturations 60% in air. Not good. Keith appeared. Aware of the commotion. What do you need? He offered. Go and find me some of the good staff. Fetch the oxygen concentrator. I need an Ambu bag to ventilate her. Diazepam would be lovely too. Keith went running off. The nurse just stood there paralysed, untrained for a crisis. Now my oxygen saturation monitor predicted doom. 30 percent. What could I do? Dorica was about to die.

Then the cavalry appeared. Snatching victory from the jaws of defeat. I seized an Ambu bag and began to ventilate Dorica. An oxygen concentrator, miraculously found, chugged into action. Given, one of our clinical officers, got a cannula into her hand ready for diazepam. The fitting fortunately stopped. Dorica’s heart rate quickly came down to 144 beats per minute. Her oxygen levels rose to 95%. My own heart rate started to fall. Dorica became more conscious. She started to fight us off. Pulling her arms and legs from our grasp. Phew. The fit had stopped even before we had a chance to give her the diazepam. Dorica’s mother reappeared. Tears of relief streamed down her cheeks. Dorica death had been averted. Close call. Emergency over.

But I was seething. Mostly angry with myself. Why had I not set in place some teaching about emergencies? I already knew that the staff do not manage acute incidents well. I had seen this over the previous 5 months. Nobody knew where basic equipment was kept. The clinic Ambu bag was not where it was meant to be. A lifesaving piece of kit. The sort of kit that when you need it, you need it now. Locked away for safekeeping. Many staff did not even know that we have an oxygen concentrator. Emergency drugs and cannulas were locked away in the pharmacy store. With the keys in someone’s pocket. Someone elusive.

Luckily Keith had grabbed our own Ambu bag and diazepam from our car. Experienced and well trained, Keith and I had done checks and drills on arrival in the Valley. Equipment and drugs had been made ready for the worst. More about me spitting tacks later.

Whilst my drama had been unfurling into a crisis, Keith had already started to spin other plates. The immobile patient told a woeful tale. Mikul had been paralysed in an awful road traffic accident several years ago. He had been plagued by hideous, cavernous, pressure sores in his buttocks. Mikul lay immobile in the treatment room as Dorica had attempted to breathe her last breath. Keith had apologised to Mikul and his patient father as he abandoned them to run for emergency support and supplies. Concurrently, Keith was confronted by another frustrated relative, anxious that his wife had been waiting too long. Keith triaged rapidly. Checking oxygen saturation, pulse and temperature. Let’s give Poona some paracetamol now and get a malaria test and a COVID test done. Then I can see her with the results. Another plate needed a gentle spin: Keith asked 15-year-old Thandi to come back after an hour, so that Dr Ginny could give her a second opinion on her leg swelling and to go through the options to manage her heavy painful periods.

The dust settled. Lunch had been missed. Thandi wanted the pill, but her mother had vexed about how that would go down at school. We found a way forward. Next door Keith found Poona’s record book on his desk. He had recalled asking her to sit next to his consulting room for just a little longer. Eventually the family had lost patience, telling Yollam our clinical officer, that they would come back later to see Dr Keith. Keith read her results. Her rapid diagnostic test for malaria was negative. So was her lateral flow test for COVID-19. But Keith was unhappy. Poona’s symptoms had only started the day before. Lateral flow tests perform particularly poorly on day 1 of symptoms. Even after that, lateral flow tests only show positive 65% of the time. False negatives are rife. Poona might become the next Typhoid Mary. The index case for our next wave of COVID in the Valley. Keith would not rest easy until he had contacted Poona.

Back to me and my tacks. Those tacks I was planning to spit earlier. Something had to be done about emergency equipment and drugs. Once Dorica was settled on the ward, I went off to find the nurse in charge. I wanted to be subtle. The staff here see new a new doctor arrive every 3, 4 or 6 months. The staff do not need every new doctor to come in and to criticise their methods. Well-meaning protocols and recommendations have no legs without planning and consensus. Memories are short. Once we are out of sight, we will be forgotten. The guard changes. The agenda changes. But I have a bee in my bonnet. I’ve bitten my tongue for 6 months already. I agreed with the nurse in charge to have a staff meeting. The time for action has come.

Half elated, half knackered, we left clinic and sat in the Honey Badger. Air conditioning was needed and quickly. But chaos theory had taken over. The key would not turn in the ignition. Not for love. Not for money. The Honey Badger was stranded. Rather like Katy in Ice Cold in Alex. Immobile and unbearably hot. Our prospects of getting lunch evaporated in the haze. Mirage gone. Our chances of getting an ice-cold beer in Alex were about the same. We ran through our options. Knights in shining armour were in short supply. The fifth day of Christmas had seen to that. It took 3 phone calls to find a good Samaritan. Cold milkshake from Mayana counted as lunch as I took refuge in the lab. The air-conditioned lab is where we usually find avoidant staff. Now I discovered the attraction for myself.

Whilst my blood sugar and body temperature were regressing back to the mean, Keith nipped onto the ward. He did a double take when he saw Dorica sat up, smiling. He raised his thumb to her and she reciprocated. Keith ever quick with his phone camera tried to capture that magical moment. He asked mum for permission for a photo but Dorica declined to raise the thumb again and the smile reverted to the mean. Still, more than ample reward for a tough day at the office. I choked back a tear when Keith showed me the picture.

Reviving the Honey Badger seemed to be thwarted at every step. African-ness seemed to affect every option considered. The WD40 was back at the workshop, but then failed to resuscitate the Badger. Our mechanic wanted to hotwire the ignition but had no wire. Another trip back to the workshop. After an age the Badger choked back into life. We took her pulse, checked her oxygen saturation and drove straight to the workshop. The temporary hotwire fell apart just as we got home at 16:15. By now we had the Blue Beast back in our possession. Our car resuscitation protocols would need reviewing too.

Poona proved difficult to track down. The address on her record book was vague. She was happy to hear Dr Keith’s voice but was blissfully unaware that a negative lateral flow test meant little on day one. She promised to take precautions to avoid becoming the index case and to test again the following day. Typhoid Mary neutralised, Keith went off for a sundowner and I collapsed in a heap. All in a day’s work.

My period of waiting was over: Imagine me biting my tongue for 6 months! Wednesday was finally the time for action. The staff met at midday. We played hunt the emergency kit. It took 2 minutes to find, but only because experienced nurses were at hand. Oxygen, and the Ambu bag materialised. Diazepam remained elusive on the Wednesday. Kept in the room of requirement, diazepam appeared on the following day when another child was fitting. Resuscitation training is usually my baby, so-to-speak. It has taken a gargantuan effort for me to resist the impulse to fix our Kakumbi clinic quickly. Resuscitation training will be the first item on my new agenda when we return to the Valley for Into Africa, the sequel.

Dorica rallies.

Ellie's first tree clinic

Getting to know the locals

Our gardener pops in to say goodbye

For a limited time, 3 valley doctors