Fifty-six to go

Saturday 7 July 2012

Location: Kalene Hill, Northwestern Province, Zambia

1315hrs local time

Dear friend,

It’s been two days since my arrival into Kalene -- and what a full-on two days it’s been! I’ve been having real issues accessing the wireless internet on my Mac so have had to lump quite a lot of excitement into one entry and use my flatmate's laptop to upload. Cup of tea in hand advised (i.e. very long entry ahead!).

I spent my second day in Lusaka visiting Immigration and spending 1.6million kwacha (=local currency) at the grocery store, buying enough to last the entirety of my two months at Kalene. Lusaka is surprisingly developed. They have shopping centres and strip malls reminiscent of home, with even a Subways, KFC and a café with a pretty decent Hazelnut Latte.

The next day (Thursday) I met up with a few missionaries returning to Kalene after a furlough home to Canada. The group of us headed out to the airport together to meet up with the missionary pilot. It’s an incredible work they do here, having developed a small independent flight service in the early 90s for transporting staff, supplies, visitors to the relatively inaccessible rural missionary sites. It would otherwise have been a two to three day journey by (undeveloped) road! We embarked on the three-hour flight in our tiny five-seater plane. Before we took off the pilot asked if I was prone to motion sickness – which I wasn’t – but told me there were sickness bags next to my seat, “just in case.” And boy, did I get close to needing it!

Looking over the landscape I realized I had never been completely landlocked before. Growing up in New Zealand, Korea, Seattle, there has always been a body of water if not in direct view then just a drive away. With that, being here kind of feels… suffocating, like geographical claustrophobia. Maybe this is why I don’t like the idea of being on a cruise with nothing but endless ocean in view.

Dry, red-brown earth dominates the landscape here and the horizon is dusted with a haze of dirt – stark contrast to the deep blues and greens of home. Taking in the view as we made our ascent I couldn’t help but wonder, is it possible to have beauty in barrenness? … yes.

Upon landing at the dirt airstrip at Kalene Hill I was greeted by some of the missionaries, as well as two UK medical students I would be living with. The mission compound is made up of the hospital, a nursing school and various small houses/flats for staff and visitors. The small two-bedroom flat we are in is exactly what one might expect in rural Africa – concrete slab floors, small screened windows, a bathroom and kitchen that has just survived the test of time, and furnishings you might see in a museum about life in the early 1900s. But it has everything one might need, even a breadmaker (the only way of being able to have bread out here in the whops).

The hospital is currently at a transition period with one long-term doctor (kiwi surgeon) currently sick in South Africa, leaving the other senior (Zambian) doctor managing the hospital on his own. Yesterday (Friday) saw the arrival of not just myself but also a new Zambian medical doctor who is here for at least one year. No one was quite sure who would be there that day, if they would even have one doctor, and at the end there were three!

There is no need to go on about the amount of disease and pathology I have already seen in just a day and a half, because that is (sadly) what you’d expect. Having made my peace last time around with the complexity of the issues regarding access and quality of healthcare in Africa, I came out this time to do what I can, when I can, acknowledging that so much of “it” is beyond my control.

But it still breaks your heart.

Day 1, Case 1

A small boy (?age, maybe two) was brought to hospital last week with vomiting and bloody diarrhea. The impression at that stage was dysentery so supportive management was started. A few days later his abdomen started to distend and rather than diarrhea he developed constipation. On the morning of my first day at work he was clinically obstructed, his abdomen so distended it looked like it was just about to burst open and having passed no bowel motions or flatus for days. He was sick. 

Most Zambian doctors have some basic surgical knowledge and experience, including Caesareans, hernia repairs, simple grafts, appendectomies and laparotomies.  With the kiwi surgeon for the hospital out of action, the operating doctor was the senior Zambian doctor covering the hospital. There is currently no specialist anaesthetist, only a local whom the hospital has trained in-house to do some basic procedures.

It is in this context this very sick little boy went for a major paediatric operation. As soon as the incision was made and the abdominal cavity opened, loops of small bowel filled with gas tumbled out under the pressure of the obstruction. It didn’t turn out to be worms, but rather, the results of typhoid – something I have been vaccinated against without a second’s thought. 

 

The little boy was under for more than three hours and likely had a few apneic episodes while they were trying to intubate as well as during the surgery itself.

One hour post-op he spiked a fever to 40degrees Celcius. Everyone watched, metaphorically holding our breath, and waited.

My flatmate, the medical student, takes shifts as being the senior nurse on-call (there is a senior nurse on-call and a doctor on-call after hours). At ten that evening she was called to certify the little boy. As she had never walked over to the hospital in the dark alone we decided to go together; as she had never certified a dead body before (senior nurses can do this in Zambia), we decided I would this time around.

I’ve written about this before, on my FirstYear blog about intern year, but the part about certification that really gets to me, the part that is so unsettling, is staring into their huge, dilated pupils that seem to have a streaky haze of white, like you’re staring out at the universe that just goes on… and on.

Back home after a death in hospital one must examine the events leading up to it, to try to figure out why it occurred and whether or not it could have been prevented.

Simply said, this death would not have occurred had this precious little boy had been born in many other parts of the world. Is there someone or something to blame? It would be misguided and ignorant to think it’s that simple. Was it the surgery? The post-op care? Could this have been picked up earlier, before the boy became so acutely unwell and there was no other option but to operate? Could the typhoid have been prevented? Why wasn’t he, and all those other children, vaccinated? Something so accessible to those in other parts of the world.

There are no simple answers…

So that was my first day of work. My flatmate was again called around midnight. As she is a very sound sleeper, I ended up answering the phone in our flat. 

“I am calling from Mens’ Ward. Is this nurse on-call?”

“No, but I am a doctor and I live with her. What’s the problem?”

“There is a man here who has amputated middle finger. Human. Human bite.”

[Pause]

“Okay, we’re on our way.”

All that, in one day. Fifty-six to go.