A Flying Visit to Kalene Hospital…

 

The Bonnetts with pilot Bruce.

Taking off from the Kalene Hospital airstrip in the tiny 6-seater plane and watching the hospital and Kalene Hill disappear into the horizon I finally have a few moments to reflect on the last three weeks.  It was always a bit of a crazy plan; 4700 miles, one 3 year-old (Maddy) and a flying visit to the north-west corner of Zambia.  In 2011-2012 we spent a year working at Kalene Mission Hospital and earlier this year Rachel Reed, a midwife working at Kalene, invited us back for their ‘surgical camp’ in October.  We began to hatch this mad plan with our friends Emma and Chris Houlden, who were working at Kalene at the same time as us.  Emma is a nurse/midwife and Chris is a colorectal surgeon; they also have a little boy called Jack, aged two.  So would it be possible to combine all our medical roles with occupying two energetic toddlers??

Maddy and Jack

Phil flew out first, spending a week in Lusaka helping to run the Safe Obstetric Anaesthesia and Lifebox courses.  Phil has been involved with this since we left Zambia four years ago and travels to Zambia on a yearly basis to help facilitate the running of the courses in different locations around the country.  Back in 2012 Phil was involved in the MMed Anaesthesia programme, the first anaesthetic training programme for Zambian doctors.  A number of these doctors are now fully trained up anaesthetists and deliver a lot of the course teaching themselves.  This course targeted 80 student anaesthesia clinical officers, who will later be sent out to different hospitals throughout Zambia. There has been significant expansion in the number of anaesthetic student clinical officers recently recruited, demonstrating the government’s commitment to improving anaesthetic provision within the country.  It is hoped that the next course, which will take place next year, will be entirely run by Zambian staff.

Phil and the trainee anaesthetic clinical officers

Practising airway skills

A few days later Maddy and I flew out to Zambia with Emma, Chris and Jack.  Three planes, via Dubai and Lusaka, took us to Solwezi on the Copperbelt, a 6-hour drive from Kalene Hospital.  We were picked up from the airport by our friends Mel and Ross Ferguson, who run the Lunga Children’s Home near Nyangombe.  We first got to know them while they were running Hillwood Children’s Home near to Kalene.  They have brought the same incredible vision and compassion to this new project and we loved spending a couple of days with them, meeting the children and seeing progress with building of accommodation on the new site.  We even managed to squeeze in some canoeing on the allegedly crocodile inhabited Lunga river – this was the closest we got to exciting African wildlife, unfortunately for Maddy, who was expecting Zambia to be just like the Lion King!

With Mel, Ross, Anita, Hannah, Ben and the girls

After a bumpy 4 hour drive we finally reached the end of our journey and arrived at Kalene: it was good to be back!  We were joined there by Stan, an anaesthetic nurse from the USA, and also had visits from Dr Goran, plastic surgeon, and Dr Felicidad, a head and neck surgeon from the Congo, as well as surgical trainees Albert, Olga and Sarah.  Kalene had advertised the visiting doctors a number of months earlier so quite a number of patients had travelled from near and far, some from the Congo and Angola.  Day 1 we were in at the deep end with Chris and I seeing patients in outpatients whilst Phil and Stan went to set up the anaesthetic equipment in theatre.  Operating lists were drawn up and both theatres were running by Day 2.  Phil and Stan were kept on their toes with power cuts, hairy paediatric anaesthesia, airway challenges and lack of available drugs.  Phil really enjoyed working with Stan and was very grateful for the extra anaesthetic hands with two theatres running.  Emma set up a post-op recovery area and facilitated safe transfer back to the wards once patients were stablised.  Kalene Hospital has an excellent Zambian doctor, Dr Kahilhu, working there at present and he did an admirable job of keeping the hospital running whilst the surgery was taking place.

Stan and Phil at the ‘head end’

Tess and Chris at ‘the other end’

The surgical camp team

I must admit I felt pretty overwhelmed by the sheer volume of patients that turned up to see ‘The Tess Doctor’ as I am apparently known locally!  I saw between 60-70 patients with gynaecology problems or previous pregnancy problems during the first week.  Balancing childcare with work was a challenge: I was able to see some patients during the day but the rest had to be seen in the evening once Maddy was in bed!  Women came with menstruation problems, ovarian cysts, fibroids and a huge number with fertility problems which is so difficult to investigate and treat in this setting.  Some of my medical Lunda did came back but I was blessed with a brilliant translator in midwife Mary, who not only translated but also explained the nuances of local culture and customs.  She was also kind enough to tell me straight when I was asking ridiculous questions; for example “how many children are you planning to have?”  No women would ever answer this question, because they don’t feel they have any say in the decision.

Mary, midwife and brilliant translator

My heart really belongs in maternity more than gynaecology but the volume of women who turned up with gynae problems meant that I spent much less time on the maternity ward than I would have liked.  Emma did a great job of facilitating teaching sessions for the maternity staff on a variety of emergencies.  I did get a chance to spend some time doing ultrasound training with Grace, Kalene Hospital’s radiographer, as well as getting involved with some deliveries.  I was really pleased (and a little bit surprised) to find ‘obstetric ultrasound for midwives’ cribsheets still attached to the maternity ultrasound machine and the maternity guidelines I’d written four years earlier still in general use!  Thanks to all the Jessops midwives who collected delivery instruments for Kalene – it was great to see them in use on Maternity!

Midwife Emma doing emergency drill training

Grace, Kaoline’s radiographer

The house we were staying in had a steady stream of visiting ‘wildlife.’ The dead scorpion count was 6 by the time we left!  I think we could have cooked a family meal out of the enormous spider we found in the bath!  Visiting creepy crawlies were dealt with using the time-honoured method of dropping a large surgical textbook on them.  Rachel and Richard Reed spent a lot of time making the house habitable before we arrived and Richard had found a snake living under the sink!  Said snake was residing in a bucket at the Reed household when we arrived and one of the kids favourite activities was visiting the (three) snakes living in Rachel’s kitchen!  We had to use our imagination to entertain Jack and Maddy; activities included recreating the children’s ward (with dolls) under one of our tables, baking, using the top of an old piano as a car ramp and hunting for lizards and butterflies outside the house.

Maddy and her ‘twins’

Jack and Maddy working on the ‘Children’s Ward’

 

It was so precious to catch up with our friends Bruce and Marilyn Poidevin, Peter Gill and Rachel and Richard Reed.  During our previous stint at Kalene we were always looking for an excuse for a celebration – with an international workforce we had a diverse list of national holidays and celebrations to ‘borrow’ for a get-together.  True to form Canadian Thanksgiving coincided with our stay, so we had fun observing it last Monday with our North American friends, complete with pumpkin pie and round table expressions of thankfulness.

Canadian Thanksgiving

Sometimes an odd sight catches your eye at Kalene.  Two of my favourites from this trip were a chicken wandering around the antenatal ward and a ring pessary sighted on the theatre emergency trolley!  In the ABC of emergency management (Airway, Breathing, Circulation), ‘P for Prolapse’ is a long way down the alphabet!

So what are my reflections?  I feel exhausted – the two weeks at Kalene have been full-on!  It’s been fantastic to spend time with old friends and colleagues, Zambian and ex-pat, and reconnect and catch-up.  I feel really encouraged to see the ways the hospital has developed since we left, in particular an increasing sense of Zambian ownership and leadership regarding the hospitals future direction.  The kids have been surprisingly adaptable – perhaps it’s us adults that find it harder to function in such a different environment with all our expectations and misconceptions?  As ever, the most we can do still feels like a drop in the ocean, and I really struggle with that.  We leave with questions and thoughts about the hows and whys and future of combining overseas obstetrics and anaesthetics with our work in Sheffield, but a determination to manage it somehow!  We would love to be back in Africa in the not-to-distant future.  And lastly I really wish I’d gone for a wee before I got into this tiny plane – still three hours to go!

Dr Phil and Dr Tessie Signing Off…

Greetings from South Africa!  It felt a bit strange to be travelling south when we left Zambia on our way home to the UK but we have so enjoyed our ‘limbo time’ in Cape Town – we’ve caught up on sleep, had a chance to see some of South Africa and valued some precious thinking time!  I’m writing this after just polishing off some fish and chips which is part of the ‘UK Reintegration Process’ along with being freezing cold and getting rained on!  We kind of forgot that it was the middle of winter in South Africa when we planned our visit and arrived from Zambia totally inappropriately dressed for South African midwinter – I have no shoes with me that aren’t sandals!  We’ve been up Table Mountain, been to see the penguins and visited the Cape of Good Hope – I’ve been so excited to see the sea again!

Our last few days in Lusaka passed without incident apart from the obligatory fruitless visit to Immigration!  I was full of hopeful (naive) anticipation that perhaps I would finally get my work permit after applying for it eighteen months ago, visiting Immigration a total of eight times, paying two million Kwacha, and being assured on my previous visit that it would be ready for collection!  Anyway, it turned out that the folder containing my application and all my documents has been lost or possibly doesn’t exist.  Either way, they stamped my passport with enough grace days to get out of the country and promised to look for it.  I’m coming to terms with the sad reality that I will never see my Zambian work permit!

We’re really missing Kalene and feel like we’ve left a little part of ourselves there!  Although the medical work was fairly relentless the patients were always so grateful which helped you keep going during a difficult day.  The patients would always say thank you when they were discharged from the ward and after a Caesarean section there would be a little crowd of relatives waiting outside theatre to give you a  round of applause (you say thank you in Lunda by clapping your hands).  It was very humbling when patients said thank you because so often you felt like the care you were giving was limited by lack of resources,  staff or your own energy.  After a while we got used to just trying to do the best we could we what we had but we had frequent days of wishing we had more drugs or investigations or x-ray films.  Away from the hospital there are many things I’ll miss about life at Kalene; pineapples, babies on mum’s back, little kids running to wave when you walk past their village, sun on your skin, the smells, the market, walking on the airstrip at sunset and living simply.

 

We’ll also really miss our friends and colleagues from Kalene; living and working in such a close-knit environment inevitably means that you get very close.  We’ve loved getting to know the long-termers at Kalene, the Reeds, Woodfields, Hannays, Gills, Alice Turner and the Poidevins, and have been inspired by their commitment and dedication.  We’re particularly grateful to John Woodfield who has patiently trained us to be ‘mission-hospital-ready’ over the last year – he’s taught us so much about medicine and surgery in Africa and we know it will come in useful in the future.  Over the last year our Zambian colleagues at the hospital have truly become our friends and we’ll miss working with them very much.

It has been such a privilege to meet so many lovely Lunda people: they have welcomed us so warmly into their community with much smiling and clapping of hands, not to mention widespread hilarity whenever we tried to speak any Lunda!  Two Lunda words have become thoroughly embedded in our vocabulary over the last year – the first is “chanti” which means ‘a bit’ and has all sorts of uses uses in normal conversation.  The second is “kwiji” which means ‘maybe’ or ‘perhaps’ but can also be used as ‘yeah right’ or ‘whatever’ so this also comes in useful!  I think we’ll be slotting these two Lunda words into our English sentences for years to come!

We would love to work in Africa again in the future – at the moment only God knows when and where – but we’ve always felt that our year in Zambia was just the beginning.  For now we’ve got two more years of training to concentrate on in the UK but I’m already itching to get back and I only left Zambia two weeks ago!   Phil will be back in Zambia in November helping run an obstetric anaesthesia course for anaesthetic doctors training at the teaching hospital in Lusaka so he hasn’t said goodbye for long!  I think the last thing left to say is thank you so much for your support and for following the blog.  We’ve really enjoyed writing it and your comments, emails, prayers and post have encouraged us so much and truly kept us going!  Tunasikili mwani mwani mwani!!!  (Thank you very very much!)

Lots of love, Phil and Tessie xx

Leaving Kalene…

Our last week at Kalene has come round all too quickly.  We have very mixed feelings about leaving: on one hand we feel ready for a rest – we’re feeling pretty exhausted – but on the other hand we feel very sad to leave our Kalene friends and colleagues.  Kalene has really started to feel like home these last few months.

The new theatre block is nearing completion much to everyone’s excitement.  Paul Hannay and his team have been working hard to finish all the internal fittings.  The new block has three theatres and all of them need a working anaesthetic machine so last week Phil and visiting medical engineer, John Poidevin, set to work getting anaesthetic machines out of storage and into working order.  After much manual-reading, circuit-board twiddling, Anglo-Canadian amalgamation and a few tubes of glue all three machines were up and running!  In the course of the fixing ex-cornet player Phil discovered he could play a tune on the oxygen piping – a great party trick if he ever gets a bit bored in theatre!

Maternity recently received it’s tiniest premature baby ever, born nearby the hospital and brought in a few hours after delivery: we think she was probably around 28 weeks gestation when she was born.  When Mary arrived she weighed just 920g and this dropped to 740g as she adjusted to feeding.  She’s now making great progress and is putting on weight ‘chovu chovu’ (slowly slowly) and now weighs 970g – nearly as much as a bag of sugar!

We thought you might like an update on little Sparkle who’s Mum died shortly after she was born around three weeks ago.  The family returned after the burial and felt that they couldn’t look after her properly so she has gone to live at nearby Hillwood Children’s Home with her 4 year old sister, Maureen.  Anita, who helps run the children’s home, has volunteered raise her as her own.  Her name has been changed to Sarah as Lunda people find ‘Sparkle’ very difficult to say!  We saw her when we visited Hillwood a few days ago to say goodbye to the children: she is settling in well and getting bigger by the day!

Last week we received a tragic case of a patient who had 30% burns: he had been admitted to a nearby hospital and needed extensive skin grafting however the hospital had no skin graft knife blades.  This is a huge problem in Zambia as skin graft knife blades cannot be bought anywhere in the country.  Four weeks later he was finally referred to Kalene but by this time he was very ill.  Fortunately we have a small supply of graft blades, interestingly made at Swann-Morton in Sheffield, so he has finally been able to get the skin grafts he so desperately needs.  He’s had three procedures so far and is starting to look a lot better.

For the first half of our time at Kalene I was looking after a lady called Esther who was pregnant.  Esther had one of the biggest uterine fibroids I’ve ever seen (growth in the muscle of the womb) and it gradually got bigger throughout her pregnancy until it was like a rugby ball sticking out of the right side of her abdomen.  I was very concerned that she would go into premature labour but she eventually delivered a little boy at full term although she had a postpartum haemorrhage after delivery which is common with fibroids.  She came back last week for a myomectomy to remove the fibroid so that she doesn’t have the same problems in her next pregnancy.  Here are the before and after photos – she’s very pleased with her new flat stomach!  Apologies to the squeamish!

On the our last Saturday we had a joint celebration for a Birthday, an anniversary and our departure.  Hospital staff and friends from the mission and further afield gathered together for a warthog roast, sourced from nearby Nchila Park.  Many conflicting opinions were offered about the timing and manner of the roasting; starting roasting the night before, getting up at the crack of dawn, injecting the hog with fruit juice, stuffing it with pineapples etc!  Unfortunately Googling ‘spit-roast a warthog’ doesn’t yield that much information.  The warthog was delicious and we had a great time together.  Here’s a photo of us at the hog roast with Heather and Hayley, two medical students who have just arrived for their medical electives from the UK.  We’ve really enjoyed spending time with them and know they will be very useful to Kalene over the next few weeks.

By popular request, here’s some more of our favourite Zambian brands!

We’ve had a busy last week with anaesthetic machine fixing, guideline writing, goodbyes and lots of surgery to fit in before Phil’s departure including one twelve-hour thyroid operation!  Things were so busy that we didn’t start packing until 10pm the night before leaving!  We’re writing this on the road travelling overland back to Lusaka: this is a three day trip covering 1000km, although the roads gradually improve as you get further away from Kalene.  We’re stopping for a couple of nights at Lifesprings Farm on the Copperbelt, which is linked with our church in Sheffield, then we fly back to the UK via South Africa where we’re hoping for some ‘processing time.’  There’s so much to reflect on about our time at Kalene; questions to ponder and thoughts about the future, so we’re really looking forward to some thinking time before we re-enter our normal lives.

I think there’ll be one more blog post before we get home with some final reflections about our year at Kalene.  Thanks so much for reading,

Love Tess & Phil xx

Cleft lips, cucumber sandwiches and the Commonwealth Games…

From reading the newspaper on the internet it seemed as if Britain was in the grip of Jubilee fever last weekend!  I do love a good old British knees-up so we couldn’t possibly let the Diamond Jubilee pass without marking it in our own Kalene way!  Celebrations kicked off with ‘The Commonwealth Games’ with representatives from Britain, Zambia, Australia, New Zealand and Canada.  In contrast to the Jubilee celebrations back home we were able to arrange an outdoor event with guaranteed blue skies and sunshine!  Events included welly throwing, national anthem renditions, tug-o-war, egg-and-spoon, three-legged, wheelbarrow and sack races.  Britain emerged victorious despite me letting the side down and throwing the welly into a mango tree twice!

Afterwards we had a royal tea-party with cucumber sandwiches, Coronation chicken, trifle, scones and Union Jack cake!  People had sent us some brilliantly British decorations including bunting, Union Jack plates and serviettes, crown table confetti and corgi cupcake decorations!  You wouldn’t believe how much old china we found around the place when we started poking around in the back of cupboards! Our friend Jill unearthed an original framed black and white photo of the Queen’s wedding from nearby Sakeji School.  Next door’s dog, Rafiki, stood in as an honourary Corgi.

You might remember me telling you about Mukanda, the little boy who was very ill after a bowel operation for a condition called Hirschsprungs Disease.  His abdominal wound kept breaking down leaving his bowels exposed and he had a really bad infection.  He has improved in leaps and bounds over the last couple of weeks and was discharged earlier this week after his abdomen finally healed!  He’ll be returning in a month or two to have his stoma reversed.  It’s so good to see him looking so well: there were many times we thought he wasn’t going to survive.

*Squeamish Alert*  I love being in theatre and operating but the thing that I really can’t stand is PUS!  A large part of our surgical workload here at Kalene involves draining pus from various bodily locations.  I never cease to be amazed at some of the strange places that people develop abscesses here.  Real surgeons LOVE squeezing pus out of abscesses but my deep hatred of pus makes me think I’m not cut out for tropical surgery!  Phil caught me unawares and took this highly unflattering photo of me draining a pelvic abscess – eeeugh!

It’s always very sad when a baby dies in the womb (stillbirth) and the biggest challenge is offering support to the mother who, understandably, will be devastated.  Earlier this week we had a patient called Loveness who came to Maternity to report that she couldn’t feel her baby moving.  Unfortunately when we scanned her there was no heartbeat and the baby had died.  This was Loveness’s seventh pregnancy; she had already had three stillborn babies as well as three live babies.  She was obviously very upset  but the first thing she said was “What are my family going to do to me?”  After a bit more probing it turned out that her family hold her personally responsible for the previous three stillbirths and keep telling her that it’s all her own fault because she’s ‘not good at pushing.’  I had to hold a conference with four of the men from her family to explain that it’s likely that she has a medical condition causing these stillbirths and they shouldn’t blame her.  The whole episode made me feel very angry – you really shouldn’t have to defend a women from her relatives when her baby has just died.

We had a busy few days last week when we were visited by Goran Jovic, Zambia’s only plastic surgeon!  He flew in last Thursday and managed fifteen operations in just 48 hours so the theatre team were on a tight schedule!  He specialises in cleft lip and palate operations.  Phil’s gassing skills were tested to the maximum as cleft palate surgery requires a ‘shared airway.’   This means that the tube being used by Phil to ventilate the patient is in very close proximity to the surgery taking place.  We had two children who travelled from the Congo to have their cleft lips repaired.  Many such children ‘disappear’ soon after birth in the Congo such is the stigma attached to cleft lips and palates: the grandmother takes the baby away, never to be seen again.  More and more patients have been arriving from the Congo over the last few years as word spread has that the condition can be treated.

Sandwiched in between all these cleft palate operations was a challenging obstetric case.  A lady arrived from Angola with a referral letter in Portuguese.  My Portuguese isn’t up to much but the gist was that she’d been bleeding for a week and had a low lying placenta.  The lady was around 32 weeks pregnant but unfortunately by the time she had reached us the baby was dead.  Her haemoglobin level was 4.1 (should be >11.0) and she was still bleeding.  When I scanned her the placenta was completely covering the cervix making a normal delivery impossible: to add further complication she’d previously had two Caesarean sections.  We took her to theatre for a Caesarean and on opening the uterus it became apparent that the situation was even worse than expected because she had a placenta accreta which means that the placenta had invaded the muscle of the womb, making removing it particularly difficult.  She ended up with a Caesarean hysterectomy and a six unit blood transfusion.  She already had three children so she was fairly philosophical about her hysterectomy and was mostly just glad to be alive!

Do you remember me telling you in the last blog about the six thyroid patients that Dr John had saved up by the time we got back from our holiday?  We’ve done five and there’s one more to do next week!  Thyroid operations take hours and the big neck lump is right next to the patient’s airway making anaesthetising these patients quite tricky for Phil.  Here’s a before and after photo of Grace who won the ‘biggest thyroid lump’ competition!

Time is flying and we’ve reached our last few weeks at Kalene.  There’s not many spare moments for reflection here at Kalene but we both feel that we have a lot of think about and process in relation to our time here.  Sometimes you end up with more questions than answers!  We’ll certainly feel sad to leave this little community of friends and colleagues and it feels like there is still so much work to be done!  Nearly time to start packing!

Lots of love, Tess & Phil xx

Back to work…

We felt glad to get back to Kalene after our trip away.  It felt a bit like ‘coming home’ when we touched down on the airstrip!  The hospital has been pretty busy while we we’ve been away and Dr John had saved up six patients with massive thyroid lumps that needed removing as a special ‘welcome back’ (four down, two to go!).

My friend and O&G colleague, Anna, travelled back to Kalene with us and has been living and working with us for two weeks getting a taste of life at Kalene.  She arrived with bags of energy and enthusiasm which has been a real boost for us!  She’s been busy training the midwives to scan, writing protocols and running maternity emergency training scenarios.

The cases of clothes and toys collected for Hillwood Children’s Home arrived a few days ago.  We unpacked them at our house before taking them to Hillwood and were so overwhelmed by your generosity!  The kids helped us carry the cases in and also helped with the unpacking!  Mel and Anita, who run the children’s home, were just so delighted with all the clothes, toys and other very useful things which had so generously been packed up in the UK!

We’ve had another week of both tears and rejoicing on the Maternity Ward.  The tears were for a lady called Reeness who sadly died this morning.  I first came across her when she was 28 weeks pregnant and attended Maternity with severe heart failure secondary to a heart valve problem.  We managed to get her symptoms under control and performed a Caesarean under general anaesthetic yesterday to avoid the extra strain on the heart that a normal delivery causes.  Reeness seemed to be doing well at first but got very sick very quickly this morning, probably due to all the redistribution of fluid in the body that happens soon after delivery.  It’s always such a tragedy when a baby loses it’s mother and we all feel very sad, especially when we look at this beautiful little girl.  We know that we gave her the best care we could and the outcome may still have been the same even if she’d had her baby in UK, but it’s still very hard to accept.  In this situation the family usually go to bury the mother and then return to pick up the baby in a few days so we spent this evening looking after her.  One of the children thought she should be called ‘Sparkle’ so that’s her name until her family return and give her a proper name.

In contrast there was much rejoicing in Maternity on Tuesday when Marjorie (below) delivered her first live baby.  This was her fifth pregnancy: she’s had two stillbirths followed by a late miscarriage of twins and then another miscarriage.  As if she needed any more stress her placenta was completely covering the cervix (placenta praevia) and she’d had bleeding on and off throughout her pregnancy.  She had a Caesarean on Tuesday and is delighted with her little boy!

We hear that the UK is going Jubilee-Crazy!  You know I can’t resist an excuse for a         party so we’ve been planning our own Zambian Jubilee celebration including ‘The Commonwealth Games’ and a royal teaparty!  We also think we should be entitled to a  four-day weekend – we’ll keep you posted!!

Lots of love, Tess & Phil xx

A bird in the hand is worth two in the taxi?

We’ve so enjoyed having our parents to stay these last three weeks and have showed them the sights and sounds of Kalene, both the hospital and the surrounding area.  There aren’t many tourist attractions in these parts but we’ve used our imagination and walked to the top of Kalene Hill, visited the hydroelectric dam and the source of the Zambezi River and spent an afternoon at nearby Hillwood Farm visiting the children’s home.

Hillwood Children’s Home are just delighted about all the clothes, toys and other things donated by Brabourne and New Brighton Baptist Churches, APH Occupational Therapy Dept and Sharon Payne – thanks so much!  More about that in the next blog!  Mum and Dad x 2 loved meeting the kids and were mobbed the moment they arrived!

Since then we’ve had a great two weeks holiday and started off by travelling to South Luangwa to see some amazing animals and birds.

Next was the ‘Doug Haynes Malawi Roadtrip Experience’!  Dad worked as a teacher with VSO in a school in northern Malawi back in the 1970s and wanted to return to see how much had changed.  We were warmly welcomed by the headteacher, the deputy and one of Dad’s original pupils – now forty years older!  We were asked to speak at a special assembly with about thirty seconds notice!  Towards the end of the day we had a small communication mix-up.  Dad’s old pupil asked me if he could give me a Coke.  I said “Ooh yes please!”  He disappeared and turned up around twenty minutes later with a live COCK (cockerel) and a guineafowl!  It was so kind of him to give us a present so of course we had to accept but keeping a cockerel and a guineafowl under control in the taxi on the way back to our lodge was quite a challenge!

Meanwhile Phil’s parents, Dave and Sylvia, were exploring Lake Malawi’s south shore.  We all met up again at the end to visit the mighty Victoria Falls.  We were joined there by my good friend Anna who is one of my O&G colleagues from Sheffield.  She’ll be travelling back to Kalene with us and spending two weeks at the hospital.  The Zambezi river was certainly a lot bigger than the tiny spring we saw when we visited the source of the river two weeks earlier.  Perhaps a geographer or a mathematician could work out whether the water we saw at the source of the Zambezi reached Victoria Falls before or after we did two weeks later?  Answers on a postcard please!  It was an awesome sight and we got pretty wet from all the spray.

I got attacked by a very cheeky baboon while we were there.  It decided it wanted my bag and jumped onto my back from behind.  Phil and my dad gallently chased it away!  You can see my battle wounds on the photo below!  At least I’ve got a wild animal story to tell the grandkids now!

We waved our parents off to the UK on Saturday.  We’re now on the final leg and travelling back to Kalene on Monday 21st.  More soon!

Lots of love, Tess & Phil xx

The Coca-Cola Test…

In his book about the Congo, Blood River, author Tim Butcher proposes the ‘Coca-Cola Test’ to measure how remote a place is.  It’s very simple: can you buy a Coke?  Kalene is failing the ‘Coca-Cola Test’ at the moment – we haven’t been able to buy a Coke in our local village Nkemba for about six months now.  Our nearest Coke-purchasing opportunities are over the Angolan border or in our nearest town Ikelenge, one hour’s bumpy drive away.  I’m not really sure why I’m suddenly so interested in buying Coke – I don’t even drink it at home!  Our nearest supermarket ‘Shoprite’ is a six hour drive away: this is the nearest place to buy dairy, like cheese or butter, hence both are carefully rationed!  We’ve just about got used to powdered milk now: I think I’ll keep some in when I get back to the UK to avoid those late-night dashes to the cornershop in my slippers!

We’ve had a busy couple of weeks as Dr John has been away.  We had an eventful Saturday evening when a lady was brought in the from the Congo very unwell with a high temperature and severe abdominal pain.  We stuck a needle into her abdomen and aspirated pus and thought ‘Hmmm, not a good sign!’  She had ruptured her appendix and formed a big abscess in her abdomen.  We opened her up and Dr Gill, the visiting orthopaedic surgeon came to help.  The orthopaedic/gynaecological approach to a ruptured appendix is probably a little different to a bowel surgeon’s approach but we managed and she’s now looking much better!  Towards the end of the operation Phil’s anaesthetic machine started alarming as it had a leak.  If there’s a problem with the anaesthetic machine back in the UK Phil usually tells the theatre staff, the machine gets taken to the Medical Engineering Department to get fixed and the spare anaesthetic machine gets wheeled in.  Unfortunately at Kalene the Medical Engineering Department is non-existent so Phil spent an afternoon with Paul Hannay (in charge of hospital maintenance) opening up the anaesthetic machine and grappling with its insides!  I’m pleased to report it’s now in good working order and is ready for the next general anaesthetic!

Before John left he and Phil had a challenging moonlight theatre case!  A two year old boy came in to the hospital with his bowels hanging out of his abdomen through a stab wound where he’d apparently fallen onto a knife he was carrying.  It was an odd explanation and we were sure we weren’t getting the full story.  There was also an eight hour delay before the boy was brought to hospital.  The words ‘Social’ and ‘Services’ sprang to mind but, alas, there is no such thing here in Zambia.  There was a five year old boy a week or two earlier who’d cut his foot badly when his friend dropped an axe on it.  There are so many possible dangers for small children out in the villages; burns from cooking fires are another common problem.  I guess the moral of the story is don’t let your five year old play with a knife or an axe!

I told you about Mukanda in our last blog, the nine month old baby who had bowel surgery a few weeks ago.  Unfortunately his wound came apart on Monday because he’s had a bad infection and his nutritional status is so poor that his skin isn’t healing properly so we had to take him back to theatre again to put in some tension sutures to try to keep the wound closed – his abdomen is held together by PDS and prayer at the moment.  We’re really hoping that his wound will start to improve this week.

Another one of my surgical challenges this week has been a lady called Ruth who presented twelve weeks pregnant with abdominal pain.  On ultrasound her womb was empty and there was an odd looking area behind her womb.  We’ve been working hard to get the laparoscopic (keyhole surgery) equipment up and running over the last few weeks and were able to have a look inside Ruth’s abdomen with the camera through her belly button which confirmed the appearance of an ectopic pregnancy.  It turned out to be an ovarian ectopic – this is when the ectopic pregnancy implants itself onto the ovary – so we needed to do a laparotomy and remove the ovary and the Fallopian tube on that side as well as all the blood clots that were surrounding the ovary.  In Lunda culture if you want to say thankyou you crouch down onto the floor and clap your hands.  This is what Ruth did when I went to see her on the first day after her operation – it was nice of her to say thankyou but I was pretty alarmed about her crouching on the floor on the first day after a big operation!!

Yesterday I was asked to see a young boy who couldn’t open his eyes: a spitting cobra had spat in his eyes.  I looked it up in a big book and apparently cobra spit is fairly harmless: you’re only in trouble if the cobra actually bites you!  We washed his eyes out with copious amounts of saltwater which he wasn’t the least bit impressed about.  All in a day’s work at Kalene!

We’ve had a few more orthopaedic ‘Congo Specials’ over the last few weeks! One of them, Cathereen, underwent an operation on her hip in the Congo and they’d left a swab inside and the bone had got infected.  Another man had fractured his femur and had a pin put in with a less than successful outcome (see xray!)  Dr John has a brilliant quote which I think is highly appropriate here: ‘There is no medical condition that a poorly conceived and badly executed operation can’t make worse.’  I’m sure the intentions were noble but the Hippocratic Oath tells us ‘First, do no harm’!

We are so excited about our parents arriving today and even more excited about all the chocolate they have brought!  We went down to the airstrip to meet them when they landed this morning in the tiny plane and it is so good to see them!  Thanks so much to everyone who has so kindly donated things for Hillwood Children’s Home and also for all the lovely letters and packages given to our parents to pass on to us – we are so grateful!

Lots of love, Tess & Phil xx

Happy Easter from Kalene!

I’m missing the UK springtime with lambs and daffodils but the season is changing here and the rain is finally giving way to some sunshine!  I couldn’t resist some Easter baking to make me feel springy – who knew that hot cross buns take four hours to make from scratch!!  It usually takes me about five seconds to take them off the supermarket shelf!  We helped host an ‘Easter Party’ for the nursing students featuring various games including a variation on the hat-scarf-gloves-chocolate game where students had to don surgical wear and pick up Minstrels with a surgical instrument!  We had a lovely Easter Day and our friends, the Hannays and Poidevins, came over for a roast dinner!

At the end of March a paediatric surgeon from Australia visited with his wife for two weeks.  Dr John had gathered quite a few children who needed different operations from hernias to hypospadias to Hirschsprung’s and including one little boy who was born without a bottom (anal atresia).  The children ranged in age from a few months to six years old so Phil was kept on his toes with some challenging anaesthetics.  Some of the children have been quite sick post-operatively but are slowly getting better now.  One little boy called Mukanda has been really unwell and has had to go back to theatre two times.  He now has a stoma and a really bad wound infection so please pray for him.

Phil has found a new chess partner!  Robbie is 15 and comes round to play chess once a week.  One of the previous doctors gave him a chess set last year and he’s eager to learn some new tactics!

The new theatre block is nearly finished!  Different teams have been working on the building for a few years now and it’s great to see it nearly ready to use!  There will be three new theatres with a proper recovery area and a high dependency unit as well as some theatre storage space and a lecture room.  Here you can see the ‘Express Route’ from Maternity to the new theatre block for emergency Caesareans – I just about resisted the temptation to write ‘Shinjika’ (Push!) in the concrete!!  We introduced you to Josiah a few months ago – he sees it as his job to ensure that the new block is kept clean and tidy and can often be spotted sweeping away!

One of the teachers from nearby Sakaji School came to Kalene to have her baby earlier this week.  We set up one of the houses as the ‘Kalene Low-Risk Birth Unit’ and Phil and I had to pretend to be midwives because the real midwife, Rachel, was away in Lusaka.  They arrived in the pouring rain during a power cut so at least we were able to create an ambient atmosphere with low lighting and candles!!  Gwen had a beautiful little boy and here’s a photo of me having a cuddle!

We’re so excited because our parents are coming to visit at the end of April.  They’ll be staying with us for a week at Kalene and then we’ll all be travelling back to Lusaka for a couple of weeks holiday together.  On the itinerary is a visit to South Lwanga National Park to see some of Zambia’s wild animals, a road-trip through Malawi back to the school where my dad taught with VSO and finally a visit to Victoria Falls where my good friend Anna will be meeting us before she comes to spend some time at Kalene.  We’re so looking forward to some time off as we’re feeling pretty tired.  There’s three doctors here and we’re two of them which means that the Bonnetts are on-call 48 hours out of every 72!  We work shifts back in the UK and we’ve never had to do 24-hour-plus on-calls before (older doctors who used to work really long hours would probably consider us complete lightweights!!) so adjusting to the ‘African Working Time Directive’ has taken a bit of getting used to!

We told you about some the wildlife in our house last blog.  I was sitting in our living room last week when the tiniest frog I have ever seen hopped past!  Here you can see how small it is in comparison to a pen!  We’ve also recently discovered a tarantula ‘nest’ in the garden to my great horror.  The gardener was quite excited and called me over to ask “What do you call these animals in English?” to which my answer was “TARANTULAS!!!!  AAAAAAAAH!!!!”

More soon!  Thanks for reading!

Love Tess & Phil xx

Ants in Your Pants…

Phil and I have discovered the true origin of this phrase after a recent encounter with some Kalene ‘red ants.’  These ants silently climb up your leg under your trousers and then all of a sudden start biting when they reach your pants.  You have to simultaneously drop your trousers (hoping that you’re not in a public place) and detach each individual ant from your skin at the same time as trying to run away from any other ants ready to try their luck!

Our work permits have still not been issued (despite paying two million Kwacha and making seven trips to the Lusaka Immigration Department!) so Phil and I have to present ourselves to an immigration officer every month in order to remain ‘legal residents.’  Last week our local immigration officer was on leave so we travelled to the immigration office at Jimbe on the border with Angola – an hour long drive along the most ridiculous ‘road’ I have ever seen.  We borrowed a hospital vehicle and Phil did a great job of negotiating various bumps, broken down lorries, ravines and small lakes: we arrived to discover that the Jimbe Immigration Officer was actually in Kalene, where we’d just travelled from!  By the time we had driven back to Kalene he was back in Jimbe!!  Imagine our joy at having to repeat the entire journey the next morning!  Check out the Trans-National Highway to Angola!

Mango Season is officially over but the local kids have found a new way to break bones!  We had four fractures in one afternoon earlier this week – the kids had been climbing trees to catch edible caterpillars!

On Thursday two patients presented with ruptured ectopic pregnancies within a couple of hours of each other.  An ectopic pregnancy occurs when a pregnancy implants into the Fallopian tube instead of the womb; as the pregnancy grows the Fallopian tube can rupture causing life-threatening bleeding.  The first patient had so much blood in her abdomen that I had to wash it out from between my toes at the end of the operation!  We only had one unit of blood left so one of the nursing students donated an extra pint.  Both patients are doing well and looking a lot better than when they came in!

One of the things I find most difficult at Kalene is helping patients with infertility.  Word seems to have spread that a ‘women’s doctor’ has arrived and loads of women have turned up over the last few months desperate to get pregnant.  Investigation and treatment options are very limited here at Kalene but childlessness has huge social implications.  I’ve met quite a few women who have been divorced by their husbands because they haven’t been able to have children.  We’ve devised a way use the portable Xray machine (C-arm) in theatre to check whether a women’s Fallopian tubes are open or blocked.  I’ve done around fifteen of these tests so far and the majority of patients have blocked tubes which is very difficult to treat.

The practice of men having two or more wives makes sexual health very complicated: four wives is the most I’ve come across so far.  Gentlemen – can you imagine how complicated your life would be with four wives??  If you diagnose a sexually transmitted infection in a women you also have to treat the husband and the other wives – but often the other wives may refuse treatment if they feel fine.  It’s like a Lunda version of the Jeremy Kyle Show!  I know that it’s important to respect cultural differences but I really believe that polygamy is a great injustice against women, demoting them to readily replaceable child-producers!

This is Ndongo.  She had a Caesarean section for a stillborn baby two years ago but unfortunately had already developed a vesico-vaginal fistula.  As it was a ‘Congo Special’ Caesarean her right ureter was also damaged (the tube that carries urine from the kidney to the bladder).

 

 

 

 

 

Ndongo has been to theatre four times so far.  The first time we identified a large fistula, the second time we tried to fix it but had to abandon the procedure as we couldn’t find the end of the right ureter (we didn’t know that it had been damaged at this stage).  The third time we downloaded an idiots guide to performing an intravenous pyelogram off the internet and used the portable Xray machine in theatre to diagnose that her right ureter was damaged.  The fourth time John and I were eventually able to repair the fistula.  She had her catheter and ureteric stent removed two days ago and is now not leaking urine!  We got there eventually!

A visiting paediatric surgeon has just arrived from Australia so Phil is set for a busy fortnight anaesthetising children of all ages for different operations.  We’ll tell you more about it in our next blog!

Lots of love, Tess & Phil xx

Lost in Translation…

Welcome to ‘Consulting’!  Around one hundred patients attend Kalene Hospital every day; they are screened by the Outpatients Department and then the ones that need to see a doctor are sent to ‘Consulting’ which is basically like a GP surgery.  Neither Phil or I have ever fancied being GPs, this is why we trained in hospital medicine, so we find Consulting the hardest part of our work here at Kalene – Phil prefers his patients asleep!  It has definitely given me a new found respect for GPs.  You just never know what will come through the door, from poor vision to broken bones to ‘whole body pain’ through to a referral letter from the chief asking me to arbitrate in a witchcraft case (“Can you give a medical explanation for this patients symptoms?”).  Kalene patients describe their illnesses very differently to UK patients which adds to the challenge.  You often feel as if you are missing something in the translation, especially when the description is accompanied by sound effects and enthusiastic gesticulations.  Patients find pain particularly difficult to describe: the question “What’s the pain like?” frequently elicits the response “It is painful!”

I'm an anaesthetist - get me out of here!

This last week I’ve had a few ‘I want to go home’ moments, probably a combination of feeling tired after some middle-of-the-night Caesareans and also relating to the frustration of not having the basic things we need to treat the patients properly.  The hospital receives supplies from the government but what you order is very different to what you get so we have a kind of ‘shortage rotation.’  When I arrived there was no blood, no theatre gloves in my size or asthma inhalers.  Now we have enough theatre gloves and inhalers but no Xray films, blood tubes, laxatives, stomach medications or HIV tests.  I find healthcare rationing very difficult but inevitably you do have to make decisions about which of your patients most needs your last unit of blood.

We’ve had some visitors in our house recently.  There’s a bat called Barney who lives in the porch.  We have a family of mice who are now mostly dead; Phil has tried various methods of catching them but the most effective is borrowing next door’s dog, Rafiki!  A few weeks ago I was in the bathroom and looked down to find this tarantula standing next to my foot. It was gallantly slain by Phil who then flushed it down the toilet: one of its hairy legs came off and wouldn’t flush for nearly a week making every visit to the toilet a terrifying ordeal!

I thought I’d show you around Maternity this week as this is where I spend most of my time.  I’ll start with the ‘Ladies in Waiting.’  Many women in the surrounding area deliver their babies in the village with a traditional birth attendant or at a rural health clinic.  We ask all ‘high risk’ pregnant ladies to deliver at Kalene so that any help they may need is easily available.  This includes first time mums (high risk because they may have CPD – see previous blog), women who have had more than five babies (they have a greater risk of bleeding after delivery), previous stillbirth deliveries, twins and any other factors which makes labour more risky.  These women often have to travel long distances to get to the hospital so they’d arrive a bit late if they set off from the Congo when their waters broke!  They turn up at the hospital between 34-36 weeks pregnant and just wait until they go into labour.  If you think you had to wait a long time when you visited Antenatal Clinic (seems to be two hours minimum at the Jessops Antenatal Clinic!) just imagine waiting for eight weeks!!  The women stay in rooms next to Maternity and sit around chatting and plaiting each others hair – it’s particularly amusing when one of them goes into labour slightly earlier than they were expecting and comes to the delivery room with one half of their hair plaited and the other half standing on end!

In Maternity we have an antenatal bay, a postnatal ward, a room for women in the first stage of labour, a delivery room and an office (which doubles as the makeshift Special Care Baby Unit).  Here you can see two of our staff in the delivery room; this is Brighton, a nurse, and Maria, a health care assistant.

Let me introduce the two Alices; they are pillars of the Maternity unit having both worked here for over thirty years. They have no formal training but they have seen everything – I’ve certainly learnt a lot from these two amazing ladies. On the right is Rachel Reed, midwife extraordinaire and part-time hospital administrator. Rachel runs the Maternity unit along with Grace, another excellent midwife.

Last but not least here’s a taste of what you can expect if you break any of the Maternity rules! At first I was a bit taken aback by the ‘fine system’ but having seen the tragic effects that ‘village medicine’ can have on a women and her baby I now think a deterrent is entirely justified. I do think the fine for wrong visiting hours is a bit harsh – how can you blame a person for their relatives!?

A big thank you to Class 3/4 M at St Peter & Paul’s Primary School in Wallasey and their teacher Miss Mulcahy who are collecting coins to go towards Kalene medical supplies and to all who contributed to the amazingly well-timed package of gloves, tape and syringes which arrived last week – we are really grateful!

More soon! Lots of love, Tess & Phil