Mulanjie Mountain Rescue Team 21st - 24th July 2009

Last weekend I went up Mulanje to a hut called Tuchila on the Luchenya plateau. It was a lovely weekend with some folk who are leaving imminently. I had a bad case of ‘Mulanje legs’ on Monday i.e. very sore! However, my vision of a few days rest from exercise was dashed when one of the paediatricians asked me to join a mountain rescue team to find a missing climber. As the only anaesthetist who is not head of department in Blantyre I was free to go. So, 5 am on Tuesday morning found us back on the road to Mulanje. Now, I don’t think I have adequately communicated the scale of this rocky outcrop. The plateau itself is above 1000m (higher than any of the Munroes) and then our base for the rescue effort was at 2217m. The lost climber had set off up the highest peak on the Massif which is greater than 3000m. Because it is winter here the weather is very changeable and a bright morning can turn misty incredibly quickly, much like climbing in the Cullins. We got up to our base camp having seen nothing other than a few feet in front of us all the way. When we got there we dried off and waited for the search team to return. There were about 20 porters and guides in the team and that number grew throughout the week to about 40. We heard that this missing climber had initially tried to set out for Sapitwa (the name of the peak means ‘Don’t go there’) at 4 pm on the Thursday and was persuaded to wait until the next morning. He then left his rucksack with the hut watchman and set out on his own in a pair of sandals without a guide. As you will have guessed the mist came down and he never returned. Also, you will have noticed that we only got there on Tuesday. A couple climbed Sapitwa on the Saturday but found no trace of him. What do you bring up a mountain in terms of resuscitation equipment when someone has been missing for three days already? We didn’t know initially how badly prepared he was and had hoped that we might find him sheltering in a cave or having fallen but equipped for the cold. It became apparent that we were more useful running an aches and pains clinic for the porters, and prescribing metronidazole for a case of bloody diarrhoea.

We went out in three search parties for three days, searching rivers, caves and other peaks but didn’t find any evidence of his having been there. The Brazilian government got involved and scrambled a helicopter from Mozambique which accompanied us on Thursday and Friday, the weather having been too bad before that for it to fly. Nothing. It was perishingly cold at night, and every morning we woke to frost on the ground; the first night was minus 10. It was decided by Friday to scale the operation down and so we left, feeling uneasy but realising that to continue looking was futile. 

Four days of feeling cold, not washing and being covered in soot from the woodfire which was our only source of heat and light is quite a bonding experience and I am very glad that the guides and porters were good company and weren’t scornful of having a woman involved in the effort! One of the guides was 72, and had been climbing in Mulanjie since the 60s! He was short and wiry, walked with a staff, and bearing an uncanny resemblance to Yoda seemed to materialise out of the mist whenever anyone was in trouble. 

Every morning when we woke up we asked everyone else in the hut if they had woken well, (Madzuka blwanji?) which is the traditional morning greeting. The answer, of course, is I have woken well (Nadzuka bwino, zikomo). On Friday morning having gone through this ritual every day, I looked around at everyone’s bleary crumpled faces and said, “But we are all lying! We all ‘woke cold!” It just requires more vocabulary than I have to go off piste with traditional greetings!

It is a desperately sad reason to have been there and regrettable that we did not find him, but I don’t think we could have tried harder. I hope that no one I know ever goes climbing on their own. If you do, don’t tell me about it.

Chichewa Guide For Tourists 14th July 2009

Ask anyone who has been in Malawi for longer than a passing visit if they have seen the Chichewa guide for tourists and they will either laugh or start quoting the ‘useful’ phrases from the book that was originally printed in the 70s. Such useful phrases like, ‘Give me the gun’, and, ‘Don’t shoot until I tell you’, immediately followed by, ‘I have been wounded.’ and, ‘Where is the hospital?’. 

Under phrases useful for camping is the chat up line, ‘There is a fine moonlight’ = ‘Mwezi wawala bwino’, should you find yourself in a position to use it. I might try it this weekend.

And just when I am beginning to despair of ever grasping the language, gems of words present themselves: wilibara (wheelbarrow) and jekeseni (injection) and my favorite, tipoti (teapot).  

Respect for patients 13th July 2009

This week at Queens there is a VVF workshop. Vesico-vaginal fistula (VVF) occurs when a woman has gone into labour but due to the baby not lying the right way, or the mother’s pelvis being too small; the baby can’t come out. If this happened in the UK or even in the city in Malawi, there would be a cesarean section. When it happens in the village here the woman remains in labour for days, the baby dies and eventually is stillborn. As a result of the prolonged pressure the women develop a false passage resulting in a constant leak of urine. Because of the still birth and the smell associated with the leaking urine the women are invariably quickly divorced and become ostracised in their communities. One woman on our list today was 17.  She had already been divorced by her husband simply because she had borne him a dead baby. She had no prospects of re-marriage, no prospects of work; she was destitute.

Sadly, this being treated like dirt sometimes continues in the hospital when they present for their operation. One woman was scolded by the clinical officer because she flinched when the spinal needle was introduced without local anaesthetic. We have local anaesthetic. It takes no time to draw it up. It is a mindset of not considering patient comfort not to use it (Where does patient comfort come in the scale of survival?). The woman didn’t expect to be treated any differently. She was poor. She was HIV positive. She was being treated like scum; she thought she deserved it.  

I felt ashamed that she should expect to be treated like this. But how can I comment? I don’t live here. It reminded me of an encounter the Bible says that Jesus had with a woman with a similar problem. She was being hassled by the crowd and didn’t dare to take Jesus‘ attention to ask for healing, so she just touched the hem of his garment and was healed. Jesus stopped and spoke to her as if she were valuable and she is amazed. 

Thankfully, when I went back to Queens on Wednesday, there are different clinical officers and they are kind and address the women as ‘a-Mai‘ which is the respectful term. Surgery for these women has the potential to be nothing short of life changing and it is a privilege to be able to treat them with respect as well as to be part of the process of healing.

Annoyance 13th July 2009

I was cross at work today. I rocked up to obstetric theatres and realised that one theatre was unstaffed by anaesthetists. After asking Beauty, one of the ACOs (anaesthetic clinical officers) about it we decided I should set up in theatre one, Rose would do theatre two and Beauty would do theatre three. So I got busy. Sometimes things wash over you, sometimes you let them wash over you. Today was neither of those days. The theatre was a pig sty. The pressure bag for fluid infusion still had blood on it. There were unsheathed needles on the floor and a discarded scalpel blade on the theatre trolley. The emergency drugs had been left out of the fridge over the weekend and in fact had been drawn up on the 6th of July. Some of them had been partially used, potentially between different patients. I went in a huff and tidied the place up and then asked where the list of patients was and if anyone had seen them pre-op for an anesthetic assessment. No, they hadn’t been seen. No, there was no intention of going to see them, we would just assess them in the corridor when they were taken to theatre. So, my first patient was sitting quietly wrapped in a torn sheet in the corridor on the narrow wooden bench that counts for a sorry reception area. I managed to appropriate a scrub nurse and asked him to translate for a quick history. He was irritated at having to help and in response to my enquiry, ‘Is she taking any medication?’ said, ‘Of course she is!’ I needed to know what that medication was. He said it’s in her notes. I asked if he could find it there because I couldn’t and patients never come with their drug charts. He couldn’t find it and just repeated ‘Of course she will be taking medication on the ward but she won’t know what it is’. 

I then asked if she had a cough or cold, and I caught snippets of the conversation between him and the patient which went something like, 

‘Do you have a cough?’ 

‘Yes’

‘Are you coughing a lot?’

Yes.’

‘REALLY? Surely you are not coughing all that much.’

‘Well, no, not that much.’

Then to me in English, ‘Of course she is coughing: it’s winter.’

He then let his annoyance get the better of him and said, ‘You must learn Chichewa’. I said ‘I am trying!’ but he cut me short and said, ‘No! You must not TRY, you must MEMORIZE! It is simple!’ 

I was hurt, he was annoyed, the patient embarrassed; not a good result.

The surgeon breezed in ten minutes later and informed me that we were not using theatre one today. 

Desflurane and other white elephants 8/7/9

Today I went into the store cupboard at CURE to find giving sets for the intravenous drips. I couldn’t find them so was having a good old rummage around the store cupboard which is an Aladdin's cave of equipment that has been donated from overseas. I had plenty of time so I thought I would have a nosey. In a box by the door I found 16 bottles of desflurane. Desflurane is the most expensive volatile anaesthetic, and we are ‘strongly encouraged’ not to use it back in my base hospitals in London. Not only that, but it needs a special vaporiser with a heating element and a computer chip to deliver it. Needless to say, we don’t have the vaporiser. 

Also found were arterial cannulas (we don’t have the capacity to monitor blood pressure invasively and there is no blood gas analyzer in Blantyre, let alone our hospital); six anaesthetic monitors that we can’t fix because there are no spare parts; and a rather retro square stainless steel unit with a drawer in it that looks like it was used in an American hospital in the 1950s. I have my eye on that wee trolley for a storage unit for my bathroom, but I’m pretty sure leaving the hospital with equipment is not conveying the right impression. So it stays in the store cupboard, next to the relics of anaesthetic memorabilia, taking up room and making no one happy.

Independence day celebrations 6/7/9

So, Monday the 6th of July is Independence day in Malawi. the slogan is “from poverty to prosperity”. I’m not sure it has been that straight a road. The first president was a dictator and people who disagreed with him disappeared. He ruled for 20 odd years but in the way that history gets rewritten by the strong, he is somehow remembered as a good man. The Independence day celebrations were held in a 68,000 capacity stadium named after him (Kamuzu Banda). Some friends from the UK tried to go but the gates had already been closed by 9 am because it had reached capacity. Several Malawians suggested they could easily bribe the police officials to get in, but they thought that was surely the kind of double standard that the independence day was trying to disband! Apparently, from work colleagues who did get in (didn’t ask if they paid a bribe but one of them is related to a police official), it was a brilliant spectacle, slightly tarnished by the presence of a Robert Mugabe. Allegedly, Bingu’s first wife was a cousin of Mugabe and therefore that entitles Bob to guest appearances and even a major highway in Malawi named after him. In return it meant that Bingu’s wife was gifted a farm in Zimbabwe when it was taken off the white farmers. What a disappointment to hear that Bingu is involved in anything to do with Mugabe’s regime. I went to a play by a local theatre group a week after the independence day celebrations and they were very vocal in their distain for Mugabe. And also, even more daringly, challenging Bingu not to be like him. So, at least Bingu allows freedom of speech. I hope that doesn’t change.    

Singing in the church at Mbame 5/7/9

Well, there was a big party out at a village called Mbame on Saturday for a few of the doctors who are leaving. It was an all day and most of the night affair. Some of the people from the village started up a sing song which snowballed into a practice session for church the next day. One of the doctors who is leaving had always wanted to sing with one of the choirs so she volunteered us to join a group of 5 who regularly sing at the local church. Only problem was, this was Saturday night, and they take their singing fairly seriously which means turning up for at least two choir practices a week. So we were cutting it fine, but what could we sing? I’m still not quite sure how it happened but Sunday morning found us taking our turn and singing Joy to the World.  In July. And only two verses. Even then we didn’t get the words right (can you remember the words to the second verse? Exactly: which one is the second verse?) I don’t think the congregation laughed at any of the other choirs. Its not just one church choir at Mbame. There are several groups and each takes a turn at singing a wonderfully harmonised medley of three or four well rehearsed songs. So we slotted ourselves in and sang just the one unseasonal, badly rehearsed song and then skipped back to our seats in a short lived daze induced by lack of insight. The minister then welcomed the visitors ( about 7 stragglers from the party the night before) and then casually suggested that the visitors sing a song all together. Once we recovered from our impressions of zebras pretending that the lions can’t see us if we stay very still, we had a short con-flab and three of us girls got up to sing a song called ‘Father God I wonder...’ which, in retrospect, was quite appropriate. i.e. Father God I wonder how I ever got myself into this / how I can get myself out of this / what possessed the minister to ask us to sing, AGAIN. And I never realised that the key to that song was so tricky. As we sat down, not yet having processed the full embarrassment of our (entire) performance the minister announced that the reason why the church was so full today was because there was a choir festival on after the service. Strangely, we were invited to join as a late entry. Insight having just set in, we declined.

I think we should have given our choir the name, ‘it seemed like a good idea at the time...’.

Toolbox anaesthesia

I have officially arrived as an anaesthetist at Queens, which is to say, I am now the proud owner of a baby blue toolbox. All of the clinical officers carry around a toolbox with their basic drugs and equipment in it and I finally got mine last week which was pretty special. I was also presented with my very own laryngoscope (without the batteries) and allowed to do a pretty tricky case all on my own (with a borrowed laryngoscope). Patient and I are both doing fine. 

  

Communication 1/7/9

Today I’m at Queens. One of the clinical officers has left for the morning and so I’m left to anesthetise a cesarean section on my own. I ask the obstetric registrar to translate and ask the woman a quick history and explain what I need to do (a spinal). Then the obstetric reg has to go and we are left waiting for over 3/4 of an hour for someone else to come and do the case. Its only me and the woman in theatre and my chichewa phrases are not sufficient for more than a few seconds worth of conversation (Good morning. Are you cold? Do you want a blanket?) and so she lies with her face to the wall just waiting patiently for whatever to happen. She is  a little sparrow of a 23 year old and she looks frightened but I can’t do anything other than smile and look like an idiot when I can’t understand her. So much of my job in the UK is calming people down when they are worried about the surgery or the anaesthetic, but I am powerless here, in fact I probably compound the issue because she is worried I won’t understand if she says she is in pain. Eventually a lovely Kenyan trainee clinical officer turns up and says all the reassuring things I should have said if only my brain worked in Chichewa. 

I just mention it for anyone who thinks that anaesthetists don’t have to speak to patients!

My route to work 30/6/9

So, now I have officially started training for the 1/2. Or rather, I have had to give the car I borrowed back and now I have no other way of getting to work which is about 4 and a 1/2 km away. So I run to work a couple days a week. To get to work I turn out of my road onto a main road and then turn down a dirt track that goes past a school. Lots of kids walking to school (which starts at 7:30!) who want a high five and lots of “Chap!” which is kind of a Chichewa version of “Whatz up!”. I then turn down a road which turns into a bit of a hill until a junction right in the centre of town where the traffic lights never work. After dodging the lorries, and Toyota 4x4s, and the women carrying random objects on their heads, I drop down into a bit of a valley where the Blantyre market sits either side of a pretty sludged up stream. During the day you can hardly drive through here in anything above first gear for the crush of people but early in the morning its just people trying to get a lift to work on one of the minibuses. A couple other people are also running to work, but they are all men and none of them have the luxuries of running shoes or music. Its not a game for them, but they wish me good morning in return for my wheezed greeting. Then there is a very long up hill where the minibuses packed to overflowing grind their gears and belch out black smoke. I wonder if it is feasible to walk this bit? The last bit involves a turn off past some nice houses, through the gates to the college of medicine and I duck into CURE using the back entrance which is just as well. I pass the children’s ward on the way to the theatre changing rooms and a few of the kids stare - they tend to stare anyway at any white people who come onto the ward but I am quite sure they have never seen a purple person before.

Victoria Falls Half Marathon 23/6/9

A friend of mine who some of you will know, Beth Capper, is working in Zambia, next door to Malawi. We have been trying to arrange a suitable time and place to meet up but so far have been unsuccessful. Beth emailed the other day and suggested we meet by doing the Victoria Falls Half Marathon in Zimbabwe at the end of August. In my head I said, ‘no way’, but for some reason I emailed back saying, ‘Vic Falls - sounds superb - count me in’. So I now have less than two months to train for a half marathon when the last time I did one it was all down hill and I still promised myself I’d never do one again. The blurb about the race on the web says something rather vague about running through national game reserves but not to worry, they know about the lions. Im not sure if that means they will be keeping the lions away or using them as an incentive for us stragglers at the back.

Moving house 24/6/9

So! I have finally left the guest house and moved into a house vacated by the last orthopaedic registrar. Its in a district called Namiwawa on the other side of Blantyre to the hospitals. I have a little verandah out the back which looks onto a garden of frangipani trees (my favorite!), borganvillia, poinsettia and hibiscus. Oh, and did I mention the mango and papaya trees? I have the house to myself for a few weeks until the new orthopaedic registrar and his wife arrive. It has got bitterly cold over the last week, though, so I am not getting the benefit of a house made to lose heat! I was out watching wimbledon last night with my beanie hat on and seeing the cloudless blue sky in London and feeling very jealous. Its not supposed to be that way round!