Tizdaonana

Weather - Maximum temperature 28 degrees Celsius

- Weekly rainfall 42mm

Highlight of the week

Three leaving dos make us feel valued in the Valley.

Lowlight of the week

Rain stops play. We cut short a precious game drive because of Biblical rains.

In the immortal words of Shane MacGowan: Sad to say. I must be on my way.

Tizdaonona equates to au revoir. Nyanja allows us to side-step goodbye. We left the Valley this week. Booked to return as soon as political forces and competition from fellow volunteers will allow. South Luangwa Valley has captured our hearts. New friends. Dedicated work colleagues. Fascinating patients. Untamed wildlife. Stunning scenery. An Escher staircase of ever-increasing highlights. No one aspect the sole winner. A dead heat of equal firsts. The antithesis of lockdown. Our Valley is the equivalent of Conan Doyle’s Lost World. A place full of challenge and scary creatures. A place where adventure thrives.

Ousted from the Valley by government regulations that limit the maximum term of the Valley doctor to six months. We now join the carousel of doctors who choose to give their services to the Valley. The earliest opening in the rota is currently for April 2023. Our friend Dr Ellie is the first doctor to keep our seat warm. And then Dr Caroline has a second innings. But should any of their successors stumble, we will be back at the crease. Like a shot. Addicted to the Valley vibes.

Ellie deserves special mention in this blog. I shared our Zambian dream with her 3 years ago. We are going to work in Zambia in 2021. Our dream became her dream. But Ellie’s dream was in fact conceived when she left Zambia at the age of seven. As a child Ellie had seen the challenges of providing care in Zambia. She imagined that one day she would return to join the fray. This week we had the honour of passing the baton on to her. A week jam-packed with induction. Kakumbi clinic, the supporters of the Luangwa Safari Association, the ropes. A week barely scratches the surface. We craved more time to pass on the tips that six months experience have given us. But we knew that it was time to let our baby Ellie fledge. She jumped out of the nest and has been embraced by the Valley.

As we leave our Lost World, we cast our memories back over the last 27 weeks. Thirty blogs chronicle our so much more than hum drum lives, during our time served in Africa. I promise today to update you with progress reports from key characters that have featured on these pages. Before I do that though, I will share two more recent uplifting tales. You will be all ears and eyes as you hear, or read, about Solomon and Timothy.

Solomon teased me as he stuck his head into my consulting room last week. You don’t recognise me do you Dr Ginny? I didn’t. He insisted that I summon Keith before sharing his happy news. You have cured my deafness, doctors. He gratefully announced. Thirteen years ago, aged 10, Solomon had blocked his own left ear canal with a purple bead. He became deaf overnight in that ear. A month ago Keith performed a complex procedure on Solomon. Keith spent almost an hour fishing for Solomon’s purple bead. Syringe and soapy water. Suction device. Fibreoptic otoscope with attached Jobson Horne probe. Finally, the elusive bead was landed via a bog-standard otoscope with a not-so-fine pair of forceps.

When Keith joined us in my room, initially he did not recognise Solomon either. Nor did he recognise Solomon’s left ear canal. Devoid of its resident purple bead, Solomon’s ear drum had healed perfectly. Keith whispered to check Solomon’s claim of cure. If a pin had dropped Solomon would have clocked it. But Solomon had not been so wise in childhood. I was a very naughty boy. I hid the purple bead from my sister. He confided. My own sister, Sam, reminded me that we did something similar as children. Fortunately, our beads were readily removed from our noses with a swift sneeze.

Two weeks ago, we met Timothy. He is 9 years old. Timothy came to the clinic with his mum. As he walked through the door his ailment declared itself. He blinked compulsively. Eyes sore. Miserable, even in the dim light of my consulting room. What would you like to talk about today? I asked, through Joyce, my trusty interpreter. She looked at me incredulously. His eyes. She said without even bothering to translate. I bit my lip and asked Sherlock Holmes to stick to her brief: Thanks Joyce. I need to hear more of the story before we jump in with a rescue plan.

Joyce relented and translated my words. Timothy’s eyes had been a bother for 4 months. In fact, he had been seen in September. Without a definitive diagnosis, he had been dispatched with some tetracycline eye ointment. A treatment more irritating than water boarding. I speak from bitter experience. Keith and I were both afflicted by macho in Zanzibar. No, we are not reminiscing on our East African aggressive achievements. Macho merely means eyes or conjunctivitis in Swahili. I was far from macho when Keith held me down twice a day and instilled tetracycline ointment into my eyes. Tetracycline works for bacterial infection but was about as useful as water boarding for poor Timothy.

Keith, can I have your opinion please? I shouted through the clinic wall. Keith appeared. There was no gunge in Timothy’s eyes. Bacterial conjunctivitis seemed unlikely. His visual acuity was mildly impaired. Light stung his eyes. Both eyes were red, especially next to the irises. With a handheld ophthalmoscope Timothy’s anterior chambers appeared clear. His eyes were both red. Keith stained Timothy’s eyes with orange fluorescein dye. His corneas were in good nick. Might this be a drastic, potentially blinding condition like iritis? We pondered. Or just a nasty variant of allergic conjunctivitis? We decided to phone a friend. Two or three friends in fact.

Friend number one is a chap called Crosberry. A dab hand with eyes, based at Kamoto Hospital, an hour down the road. Crosberry kindly agreed to see Timothy the following day. That evening, as we waited impatiently for Crosberry’s opinion, we tapped into the jungle telegraph with buddies Alan and Karen. WhatsApp has superseded the jungle telegraph of late. So, we opted for the upgrade. No drums required. Alan and Karen have also done time in Africa. Alan is currently an ophthalmologist in Glasgow. We mentioned Timothy and discussed our concerns. Alan nodded sagely. Perhaps it’s just severe allergic conjunctivitis he opined. Hay fever. Surely not. I ventured. It looked far more serious than that.

Timothy bounced back from Kamoto with a firm diagnosis two days later. Hay fever. Deepest darkest Africa matched perfectly with the jungle telegraph opinion from Alan. Crosberry had apologised to Timothy, and to us: His pharmacy, unfortunately, had no medicine for him. Perhaps you might be able to help? Keith rummaged in our own room of requirement. Magic drops would save Timothy’s eyesight. I exaggerate of course. But Timothy’s smile is tattooed onto the inside of my eyelids to this day. His image makes for photo of the week.

Alan and Crosberry’s expert input allowed us to place the final piece into our Zambian clinical jigsaw. The picture has been detailed and varied. As a child my older siblings had first dibs when we shared a jigsaw. I relished the challenge of making sense of the minimal clues that blue skies or seas offered. In Kakumbi, I have sifted through a sea of colds and fevers to pick out key patients with tell-tale detail in their stories. Our British friends and colleagues have willingly checked these details against their own original jigsaw box. The results have almost always been fruitful. We have continued to learn, from those experts and from each other. We have continued to practice.

Let me now stand back and look at some of our clinical vignettes with you. Extra pieces of jigsaw have now been added:

I still have no firm diagnosis for Precious. Her cardiac condition remains something of a mystery. My ultrasound scanning skills don’t appear to have been up to the mark. Just finding the heart on a scanner is not good enough. I have struggled to get good images of my wriggling baby’s heart. The doppler function has remained elusive to me. Jonathan and I can’t quite predict Precious’ future through those hazy, crystal ball images, without doppler.

At 9 months of age, Precious only weighs 4.5 kg. She has cardiac cachexia. Her heart is so weak, that all of her nutritional energy is used up with breathing. She has no spare energy to build muscle or to lay down fat stores despite supplementation. Skin and bones. Diuretics bail out the sinking ship. Too slowly. Precious’ engine room is overwhelmed. Palliation now the best that we can offer. Dr Ellie steps in at an appropriate juncture. A GP and an expert in end-of-life care for both children and adults. She is the perfect person to ensure Precious does not suffer. Dr Ellie will be able to support and guide both Precious ,and her mother Harmony, through the difficult times ahead.

Joshua came back to see me 4 weeks ago. He had managed 6 weeks off steroids before his nephrotic syndrome relapsed. Yincent, my nephrology expert recommended some options to push him safely back into remission. Our donated supply of prednisolone exhausted. Joshua’s parents are skint. So, I broke my pledge to avoid unsustainable personal donations. And bought enough steroids to get Joshua back into remission. Luckily, Ellie came with a new stash of steroids. She is now monitoring him and slowly reducing his dose. Yincent and I have left Ellie with a recipe. With licence to season according to personal taste. Ingredient supplies are subject to availability in the Valley.

Our final tree clinic reminded us that the best laid plans often go awry. Thomas approached us unabashed. He smiled and punched Keith playfully. Keith winced. Thomas, learning disabled, does not know his own strength. Thomas showed Keith a bruise on his head and another on his arm. Someone else was not pulling punches either. Thomas appeared to have a tormentor.

Keith and Thomas walked off together to find Aunt Joyce, his guardian. Joyce and Thomas thought that Thomas should have another injection to calm him. Water would be fine Joyce ventured. He likes the injections. They make him feel calm. He got one in Chipata a week earlier. Keith checked Thomas’ records. Fluphenazine. A risky option. Much stronger than water. Keith dug a little deeper: Thomas was not really having any trouble with his own anger. But had been bullied. That was where his bruises had come from. Stocky and muscular, Thomas gave as good as he got. He hadn’t been troubled since. With a little shared decision-making, Joyce stuck to her guns. Dr Ellie will give Thomas a placebo injection next month. But Joyce did agree to take another leaflet reminding the family how Thomas’ anger can best be managed. Written in Nyanja to maximise the scope for it’s appropriate use. But local literacy is patchy at best. Joyce says that she can read. But toilet paper is in short supply. I’m just saying….

We do have some good news stories though:

Fortune gave us the finger. Pictorially. Not a rude gesture. His finger mended. No suggestion of apoptosis. It has full function. No pain. It even looks good cosmetically. It bears no resemblance to the pulverised mess Keith first saw 4 months ago. In time the nail may even rise from its bed.

Geoffrey remains in remission from both his type 2 diabetes and his hypertension. He has maintained his healthy lifestyle. COVID-19 and TB almost stole him from his devoted wife Martha. Martha is delighted that Geoffrey has a new lease on life. Trim and active, Geoffrey is sticking religiously to his low GI diet.

Sara smiled. Happy and confident. But not overconfident. Sara knew it was her last meeting with Dr Keith. For the time being at least. Keith was handing over key patients to Dr Ellie. Sara’s dose of haloperidol now almost homeopathic. Time will only tell if carbamazepine will keep her mood stable, as life hands out its random cards. Perhaps more important is that carbamazepine is safe and available. Part of a safety net that Keith and Ellie hold under her as she balances on the high wire of life.

Alice is no longer stuck in the revolving door of the clinic. Her quest to understand her symptoms finally at an end. A tiny dose of amitriptyline ensures that she sleeps well. It also modifies her widespread pain to make it tolerable. Alice chose not to meet Dr Ellie. Conscious that shopping for opinions and tests is unproductive. Result. Alice has finally seen the bigger picture in her looking glass.

Into Africa is almost at a natural end. There are no prizes for guessing what our next episode will be titled, as we leave the dark continent. Doubtless Mozart’s clarinet concerto will play as we fly over the endless herds of wildebeest. We leave to a new beginning: We have a barn in Yorkshire. At the foot of the Howardian Hills…..

Not so wise Solomon with his hidden bead

Timothy - photo of the week

Fortune shows us the finger

The dedicated staff of Kakumbi

Lucy and Linus

Linus waits to pounce.