The Great Incident

It has been a busy few weeks since the last update, mainly due to The Great Incident (TGI) which was a lovely welcome-back present for myself and Gemma after our holiday. Gemma and I were happily returning to the hospital after a relaxing few days, planning a quiet evening and preparation for the week ahead. As we approached Katete we received a phone call from Prof asking for help quickly as there had been a big road traffic accident and first estimations were that 20 injured patients had arrived at the hospital. We hurried back as quickly as we could and raced into the hospital. The security guards at the front gate were all wearing disposable gloves, something I hadn’t seen before – this was an indicator of the severity of the situation.

A large flat bed truck had been carrying sacks of maize flour from a maize mill which the mill workers also use as their form of transport back to the village after work. It was the end of a long Sunday of work, the truck was stuffed full of sacks and 60+ people were squeezed in on top and in between. A cyclist had pulled out onto the dirt track and the truck swerved to avoid him, losing control and sliding from side to side across the road, spilling the passengers off the back at every turn, sending them flying headfirst onto the gravel and dust road. Once it gained control everyone (bodies and bodyparts included) was loaded back onto the truck which drove straight to St Francis’.

[If you are squeamish you might want to skip this part]. The floor of outpatients was covered with patients and a lot of blood (‘maningi magazi’ as one patient commented), with doctors quickly triaging and loading the sickest onto trolleys to be transferred to x-ray and theatres. All the staff that could be found were roped in to help – student nurses, medical doctors, surgeons, obstetricians, medical students. Theatres were opened and a conveyor belt of patients began with quick blood-stemming dressings being applied on the way to x-ray and then the worst off patients transferred to theatres for cleaning and repair of their wounds. There were some pretty horrific facial wounds – degloving of facial skin down to bone with nasty fractures underneath and gravel and sand embedded deep into the wounds. Two ladies suffered traumatic amputations of the arm – one very near the shoulder which had to be disarticulated and covered with a skin flap, the other at the wrist. Dr Jamie and I examined this second lady who had a makeshift splint of cardboard wrapped with a chitenga soaked in blood around her arm. We gingerly peeled it back to reveal the horror of the wound underneath, the hand dangling in the breeze with bone fragments exposed on either side and a gaping hole in between, with only a couple of bits of skin and tendon keeping the hand attached. All the injuries were confined to head and upper limbs, probably because of the way the passengers were propelled out of the truck, which was probably why there weren’t more deaths. Three passengers died at the scene – two adults and one baby, but everyone who made it alive to the hospital has survived. Everyone worked flat out from around 5pm to 2am when the last patient returned from theatre and an air of (relative) calm descended over the wards. There was a bed allocated to babies of unknown ownership, each with a set of notes where instead of a name a description was entered, my favourite being 'blue t-shirt, floral trousers'. Thankfully over the course of the next day all found their way back to relieved mums. The total admissions count came in at 62 - the first estimation of 20 was a little on the optimistic side. It is quite difficult to describe the scene that night, and I think it is one that will be etched in the memory of those involved for a long time.

A calming picture of a sunflower instead of one of the gory aftermath photos from TGI which would are not publishable here

Mukasa (female ward – my home turf) has been pretty busy since then although we have gradually discharged most of the victims we still have a handful remaining with external fixators and nasty wounds. Theatre lists were dominated for days after TGI by wound debridements with the occasional bit of gravel surfacing in yet another gammy wound. The burns wing has been filling up too as it gets colder and I have realised just how depressing it is to treat burns victims in a resource poor setting, although I get the impression that even with all the bells and whistles of hospitals at home the outcome is still often not great. One night I was on call and admitted three patients from the same incident – the father of the family was refilling their generator with petrol by the light of a candle when one of his children accidentally knocked it over, causing an explosion and petrol burns to the father, 5 year old son and 3 year old daughter. The father received the worst of it, sustaining 75% superficial burns, while his two children had 35% burns each. The son died on the second day of admission, the father on day 4, leaving the daughter who is actually doing ok, having avoided the overwhelming sepsis that caught the other two.

Note hammock in the background

My little house remains a happy place with the addition of a hammock to the garden, thanks to Nelson the genius gardener who followed my instructions without question to dig a very large hole and bury a pole deep into the ground, although I think he thought the whole idea of just lying around in a bit of fabric a little strange. To make the hammock I found a tailor in the market in town with a hand powered Singer sewing machine and through a mixture of sign language, my very broken Chichewa and drawings in the sand managed to get across what I was after. A bit of rope, two chitengas, some stitching and a pole (dead tree) later, the hammock was born. The garden is now home to more seedlings – pumpkins, basil, aubergine, carrots, coriander, cabbage and lots and lots of lettuce. The tomatoes are also starting to bear fruit which gives me great excitement, and there is even one flower on the decorative marigolds I planted in the first week.

A couple of patient updates: typhoid boy is doing well, he is slowly gaining weight and is now smiling all the time and wandering around the grassy area outside the ward by himself, getting stronger all the time. The man with the horrific dental abscess/chest wall necrosis came back to clinic last week - his skin graft of his chest wall has taken well, his tracheal fistula has healed and he looks great. The man from the RTA in my first week whose ear nearly came off but was saved by Gemma's plastic surgery skills has been back to clinic a couple of times and is also looking really good - his ear is very much attached, a little lumpy but much better than no ear at all, and his facial nerve palsy seems to have largely resolved.

I have another little holiday planned, this time to the Mulanje Massif, the mountains in SE Malawi to do some hut to hut walking. Alarmingly I won’t have very long left at St Francis’ when I come back – only a few weeks. But I'm trying not to think about that for now as life continues to be busy but very good here.

Best patient name so far

An actual snake (identified via google searching as a burrowing Asp, although if you know more about snakes than me feel free to put me right. It was about 20cm long and moved very quickly. Until it was beaten to a pulp by some small children from the village we were running through).

Waiting for patients in theatre (a common occurrence)

So for now, petani bwino (goodbye, or more literally, stay well).