Lusaka? Can you spell that please?

Weather - Maximum temperature 37 degrees Celsius

- Rainfall zero

Highlight of the week

Bush brunch Robin Pope style

Lowlight of the week

Learning the hard way: Medical evacuation from the South Luangwa valley.

When we volunteered for this job, we were fully aware that we would always be on call. Twenty-four hours a day. 7 days a week. For 6 months. No slouching. No intoxication. No going AWOL. Our commitment is unstinting. We are not allowed to go away on holiday. Locked down. Sound familiar to any of you? A cross between COVID-19 style lockdown and a junior house job at Newcastle General Hospital.

We are expected to be within 1 hour of the main gate of South Luangwa National Park. At all times. We need to be able to react to emergencies as quickly as possible. The one in one rota might sound onerous, but the workload is not usually too intense. Drive five minutes from the park gate and you are instantly in the deepest darkest African bush. Leaving hyperbole aside: game viewing doesn’t come better than the South Luangwa Valley. So, it is easy to feel that you are not at work. Mobile phone coverage in the valley is reasonable. The doctor phone has 2 sim cards installed in it to minimise black spots. And the jungle telegraph has its way of getting urgent messages to us. Everyone knows where the valley doctor is.

Needless to say, we don’t often sit at home waiting for our phone to ring. We can’t go on walking safaris. We rarely get to the remote reaches of the park. But we do take advantage of living in the finest game reserve in Africa whenever possible. South Luangwa has been developed for tourism since the mid 1960s by pioneers including Norman Carr and Robin Pope. Norman Carr safaris evolved into Time and Tide. Both Time and Tide and Robin Pope know how to do safaris. We first stayed with Robin Pope safaris in 2013. We drove from Livingstone, through the most remote, tsetse fly infested bush to get here. Camping on the roof of our Land Rover Defender. Loving the freedom, but craving luxury. Our brief stays at Robin Pope’s Tena Tena and Nsefu camps showed us how safaris should really be done. We loved it so much that we dragged my parents, Pat and Peter, kicking and screaming I might add, here in 2016 to celebrate Keith and my combined 50th birthdays. Last weekend we leapt at the chance to stay for a weekend at Robin Pope’s Nkwali camp. It is 15 minutes from our house. Well within the rules.

Friday came. It was a particularly busy day and quite harrowing. I will revisit the details in another blog entry. With relief we arrived at Nkwali at 1500 hours. Our guide and host, Kiki, gave us a quick orientation to camp. A dip in the pool washed the memories of our morning away and reduced our body temperatures. We settled down on our idyllic veranda with our perfect river view. Escaped from the rigours of practicing medicine in resource poor, challenging Zambia. Or so we thought…..

Our work phone is also known as the bat phone. It summons us at short notice, so that the citizens of Gotham city can sleep easy in their beds. Safe in the knowledge that Batman and Robin are here to save them from the parasites and ills of the City. At 1700 hours, this Friday, the bat phone rang. Our urgent assistance was required. Max*, a guide from deep in the park, requested our assistance for a sick client. We agreed with Max to meet him at a riverside lodge near Kakumbi village within the hour. Quick Robin to the batmobile….

1800: We reach the riverside lodge. Just minutes before Max and his client. The lodge owners gave us a room for our assessment. At first glance, I wondered what all the fuss was about. Andrew*, the sick client, was walking around. From a distance he looked fine. However, it soon became clear that he was far from fine. He had been in Zambia for 5 days. His past medical history was unremarkable, aside from high blood pressure controlled on treatment. He told us that he had been vaccinated against COVID-19 and that he was taking Malarone to prevent malaria. Although he could walk, he was unsteady on his feet. Max had had to wrestle with Andrew to prevent him from jumping out of his Land Cruiser en-route. Fortunately, Andrew cooperated with us as we assessed him. We laid him down. He really was very unwell. He had a fast heart rate at 122, a raised respiratory rate at 32. His oxygen saturation was low at 88%. His temperature was mildly elevated at 37.6 Celsius. Andrew did not complain of any symptoms at all. He knew he was in Zambia, and could tell us the month and the year. But he had no idea what day or date it was. This alone would not concern me, for a holiday maker, but his thinking was definitely muddled. He told us about his past health and admitted that he felt foggy in the head. He initially could not remember his address back at home. And then he started to repeat himself. He was extremely confused. The doctors amongst you will agree his consciousness was clouded. To non-medics, he was as mad as a box of frogs at times. His neurological examination was otherwise totally normal. His chest seemed clear despite his raised respiratory rate and low oxygen saturations. His blood pressure was slightly raised at 160/100 and his heart sounds were normal.

For those medics amongst you, I am sure you will be shaking your heads at our ignorance. “Ginny and Keith it’s obviously… blah blah blah”. For us, nothing was obvious. We scratched our heads and plumbed the depths of our long and illustrious medical training and careers. Was there something in his story which might give us a clue? We re-took the history as far as we could. This revealed nothing new. Andrew was travelling alone, so there was no one to corroborate the story. Max told us that Andrew had been a bit confused when he arrived. Might that had been linked to jet lag? For 2 days he had seemed OK, but when Max and Andrew spoke the conversations seemed odd initially and then frankly bizarre. On Friday, he got a whole lot worse. During our assessment Max contacted Andrew’s sister back at home. “Had Andrew perhaps taken some sleeping tablets?” the sister asked, but she had not seen Andrew for 8 months. There’s a pandemic on, don’t you know? We authorised a search of his belongings - no contraband was found.

Remember that we are practising medicine in the bush here. We have little in the way of investigations or treatment options. We did what we could do. We did a rapid antigen test for malaria and a lateral flow test for COVID-19. The results were available within 20 minutes. Negative on both counts. We checked Andrew’s urine with a multistix dip test for blood, nitrites, white blood cells, glucose, protein and ketones. Andrew had no idea how to pee in a cup without support, so Keith deftly caught the sample as Andrew swayed precariously. All the urine results were negative. That is our full laboratory repertoire. No clues from the laboratory. We needed to focus all of our clinical skills and acumen. Miraculously an oxygen concentrator appeared. The bush telegraph operating again. The resourcefulness of the combined valley populations at play. Andrew’s saturations nudged up to 94% as we provided him with 7 litres/minute of oxygen via nasal prongs. We decided that medical evacuation to hospital was the priority.

1845: I spoke to Andrew’s insurance company overseas. I was eventually put through to a medic who took down all the details. It felt good to share our uncertainties. I explained our working diagnosis. Acute confusional state, cause unknown. Did they have any bright ideas? They were surprised that we had not done many basic tests. Where was the full blood work up, the chest X-ray result and result of the MRI scan of his brain? I explained our predicament. We have the bare necessities here. Bush medicine. Even Baloo would be disappointed. No scans, no tests. I urged them to get moving on the medical evacuation process. They promised to call me back.

At this point, I kept the mantra “It is Africa” going in my head. In Africa we have low expectations. Any achievement is progress. Don’t expect what you want to happen to happen, you’ll only be disappointed. Even though I was dealing with a developed world insurance company I kept my expectations low. Surprise, surprise, I heard nothing back.

2030: Andrew was getting worse. He spiked a fever at 38.6 Celsius. His heart rate was fast and his respiratory rate was fast. His blood pressure was also higher than usual. We re-examined him from head to toe. He now had a pleural rub on the left. This might suggest pneumonia, or a pulmonary embolus. These possibilities did not explain everything though. We inserted an IV cannula and gave him 2g of ceftriaxone. AKA Domestos. We called the insurance company again.

I spoke to a whole new team. They wanted me to tell the whole story again. I added our suspicion of pneumonia or a pulmonary embolus. They told me they were working on approval for a medical evacuation. They agreed with our assessment. They agreed that medical evacuation was needed. I gave them all the details of our location, our local airfield, recommended options of hospitals within striking distance, the phone number of the flying medics service in Lusaka. And we waited….

2145: The insurance company called us back. They gave us approval for medical evacuation. But where were we? What country is Mfuwe in? What city does he need to go to? I spelt L-U-S-A-K-A to them 3 times. I was beginning to despair.

2245: The insurance company asked us if we could arrange the evacuation! Four hours had passed since our first conversation. We immediately phoned the medical evacuation company in Lusaka. Within 15 minutes the medical evacuation was all teed up. But the airports were now closed. Why didn’t we arrange this 4 hours ago? We had tried to, we explained. The soonest they could retrieve Andrew would be 0500. Saturday morning.

2345: Andrew was stable. Very unwell, but not deteriorating. We showed Max, and his able side-kick Tom, how to check oxygen levels and pulse rates, and how to count the respiratory rate. We gave them clear parameters of what might worry us. Max and Tom were happy for us to leave them to monitor Andrew, knowing to call us back if things changed. Medical input overnight would hopefully be minimal. We left the riverside lodge and headed off back to our weekend retreat at Nkwali.

0030: Finally, we climb into bed. The phone stayed silent overnight. The drums beat in Nkwali camp at 0530, in advance of a 0545 breakfast and an 0600 hour game drive. Andrew was evacuated at 0830 on Saturday morning. The treating hospital have scanned his head and investigated him thoroughly. Lyme disease seems a strong contender. Imported from home and affecting the heart and elsewhere. I imagine that Andrew is likely to be further evacuated to his home country this week. We wish him all the best for a full and speedy recovery.

There are clearly lessons from Friday night’s experiences. Keith and I work well together and are able to draw on each other’s strengths when times are tough. We live in the middle of nowhere in a very resource-poor setting. Serious illness here is a scary prospect. Oxygen is available when really needed. Cogs can turn very slowly here in Africa. But bureaucracy in developed countries seems just as bad and compounds our isolation. The South Luangwa Valley is very fortunate. The Luangwa Safari Association (LSA) Medical Fund is the charity that we work through. Without the charity, and our presence in the valley, Andrew might not have survived Friday night. His sepsis and hypoxia might have finished him off. We learnt last week of a psychotic young lady jumping out of a plane to her death in Madagascar 2 years ago. Might Andrew have also met a similar fate in Zambia this weekend without us and the LSA medical fund?

Settling in to Nkwali before the bat-phone rang

I can make a trunk call for you? - Local help arrived during our resuscitation.

Bush breakfast Robin Pope style.

Now this is what we came for. A fantastic game drive with amazing spots. Kiki was our guide.

*Names have been changed to protect anonymity