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).

Relaxing in Luangwa

This month’s update comes direct from the porch of the most luxurious tent I have ever had the pleasure to camp in. The soft background chirrup of grasshoppers contrasts strikingly with the violent snorting and splashing of hippos in the Luangwa river a stone’s throw away. A young impala has just wandered past the tent. A monkey scampers over the roof and swings off through the trees. I have escaped the hospital and am spending a long weekend with Gemma, my surgical consultant colleague, in the South Luangwa National Park, around 4 hours drive from Katete.

Groundnut (peanut) field

Everything is drying out now as the wet season comes to an end and the maize harvest is in full flow. There’s a lovely loop to run from the hospital along dirt tracks past fields – and usually past several heavily laden ox carts with a handful of children running along behind gathering up the maize that makes a bid for freedom at each pothole. Maize crops are heavily down this year though as the rains did not provide enough water – only 57% of the usual according to the local radio. This will have knock on effects later in the year, as one of the nurses said ‘the people will be hungry’.

Gemma, me, 'typhoid boy' and his aunty

I mentioned the boy with the abdominal fistulas and severe malnutrition – affectionately known as
‘typhoid boy’ amongst the doctors and medical students. (See pic above - with his aunty). We have been taking food in each evening for him for months, and a couple of weeks ago discovered to our extreme frustration that his bedsider was sharing the meat we took in for him with other patients, their bedsiders and eating some herself. This wasn’t malicious, she just didn’t understand how desperately he needed calories, perhaps she had become so used to how skeletal he looked that she didn’t see it anymore. Following some bedsider education we are now sure that the contributions from our mess dinners and various other baking efforts are getting to the right place. We have started to see an improvement in him over the last couple of weeks – to start with a flicker of a smile, the ability to hold his head up when carrying him onto the scales for weekly weigh-ins, then the strength to sit up in bed, sit in a wheelchair outside in the sun (for the first time in several months), a wave from his bed when we walk onto the ward, and for the first time last week the strength to walk a couple of metres from his bed and back holding two hands, then one, and then a couple of steps by himself. This was followed by what I thought initially was a fall from exhaustion, but then realised it was him bobbing down to rescue his shorts which had slid to his ankles having nothing to hold them up. (The next day I found a belt for him in Katete market!) It is so encouraging to see a patient like this gradually get better. That first smile was worth more than any box of chocolates or sentiment filled thank you card.

There has been a whole host of weird and wonderful cases in theatre recently, and my bosses are very good at letting me do the operating on some of these under their supervision. A couple of memorable cases include the lady with a tongue tumour the size of her tongue, attached by a small pedicle – when she initially stuck her ‘tongue’ out (just the tumour) it looked like a slightly lumpy but normal sized tongue, but then if she protruded it further you could really see the size of the problem. How she had let it grow so big I have no idea – speaking was difficult and although she did say she could eat she could only manage ‘pangono pangono’ (a little). We’ve also had a selection of foreign bodies to retrieve – a cockroach from an ear, a seed from a nose, a piece of broken wire from under the skin of an arm (present for 5 years but ‘migrating’ and causing the patient worry). Gemma also taught me to perform a bilateral orchidectomy on a lovely old man with metastatic prostate cancer – the medical equivalent that is offered in the UK is not available here and the surgical method does just as good a job. He was incredibly grateful, not quite what you’d expect given the nature of the operation, and wished ‘every blessing be upon you’ after we’d finished.

This lady couldn't stop smiling after this awful tumour was removed

I have inherited a bike from one of the doctors who left around a month ago and have discovered a new freedom as a result. Much as I enjoy the bike taxis into town, being able to get there under my own steam is even better. A few weekends ago a couple of us cycled out to a friend’s orange farm around the other side of the Katete hills – a beautiful ride, and only one minor over-the-handlebar incident that miraculously didn’t necessitate any first aid or hospital visits. If I was one of my patients I would have referred to myself as ‘at least’, the meaning of which is hard to explain but I think it is similar to ‘not bad’ or ‘ok’. I have also taken a leaf out of Prof’s book and now cycle into the hospital if I’m called overnight. Admittedly it is only a 5 minute walk but there’s something very satisfying about cycling along the empty hospital corridors and it means the escape back to bed is quicker once the problem has been sorted out. Also, cycling while wearing a white coat makes you feel a bit like superman as it flies out behind. Of course the illusion is shattered when you arrive on the ward and spend the next 15 minutes trying to solve a problem by creating something out of an empty vial of ketamine, the tubing from a catheter bag and some ‘strapping’ (incredibly sticky tape used for just about everything).

Herbert's orange farm

I have now migrated to a sun lounger overlooking the beautiful Luangwa river. On Monday I will become Dr Charrot (or Challot, or occasionally ‘Carrot’) once again (having an R and an L next to each other in the same word is a bit of a challenge when the letters are interchangeable), but for the next couple of days I will continue to eat my bodyweight in homemade eggybread and enjoy watching some of the most gracious and beautiful animals that roam in the national park. It's not all hard work!