Crash, Bang, Wallop!

Before I start I will say that the fact that I'm able to write this means I haven't lost the use of my arms, or hit my head so hard that all my food from now on has to come via a blender. For a brief moment yesterday this outcome was not a certainty.



The day had started regularly enough; I had packed my stuff into my rucksack and was trying to sort out various things in the clinic before flying out for my holiday. This involved sweeping my arms across the desk and depositing all the paperwork I still had to do into a large metal trunk. It can wait until the New Year…probably.



The roar of engines overhead indicated an immediate arrival and departure. The aeroplane thundered across the barren ground billowing sandy dust in its wake. Soon we were bumping along the runway before a roaring departure from terra firma and into the brilliant sun and bright blue sky. After a stop at another project to pick up some passengers we were skimming across the clouds to the missions base.Flying here is so standard it has become a little like a bus or a tube, I have become a bit blasé about the whole enterprise.



The plane slowed as we approached the tarmac of the airfield, the only place we land with tarmac. The flaps wirred into life, the ground rushed to meet us. I really wasn't paying attention. My book ('Rubbish' by Richard Girling) was very diverting and we would soon be on the ground and taxiing, and I would soon be off on holiday. So to summarise I really wasn't prepared for what happened next.



As the plane touched the ground there was a very loud bang. When I say loud, I think some of you in the UK might have heard it and wondered what it was. This was followed by an equally worrying 'wararah wararah wararah' noise. The plane shuddered violently and lurched across the tarmac. Up front, the pilot flicked a few switches and was engaged in a struggle with a plane intent on leaving the tarmac and becoming intimately acquainted with the airfields perimeter fence. As we careered onwards the aircraft adopted a sort of strange diagonal position, a bit like a bad skier trying to parallel turn.



Eventually, after a further loud bang, and more violent shuddering we began to slow down. By this point my skin that had turned the colour of Tip-ex and my eyes were the size of large frying pans. If I had had rosary beads (and, perhaps more importantly, been Catholic!) they would have been a pile of sawdust.



When a tire blows on a big plane like a jumbo jet you don't notice, there are loads of other wheels able to take the strain. Sadly I don't work in place that would accommodate your average 747. In small planes it is a big deal! We had lost one of the three wheels. As we got out of the plane, the damage was clear, a tyre, flat and shredded a landing gear that was sitting at an angle that made the plane look like it had been designed by a drunk four year old. There was also a very nasty new groove in the tarmac of the airfield. Nobody seemed to care about this.



My huge thanks, obviously, to the pilot whose skill prevented a much worse situation, but defiantly something I don't need to repeat.



Anyway, safe and sound, I'm off for a break until the 5th of January. I'm also having a holiday from blog. I'm sure you will all be too busy to read it anyway. Thanks for coming with me in 2006 and hopefully pick up where we left off in early 2007. Happy Christmas and New Year one and all.

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Triumph and Disaster

So a week at base camp, and the place that I would call ‘home’ out here.
With no outreach buddy anywhere to be seen I have been kept busy in the
inpatient department. A variety of staff holidays and, what in the business
is called a ‘high patient flow’ (i.e. clinic busting at the seams!) means I
haven’t exactly been idle. The basic figures are as follows. Discharge - 43,
died - 7, admitted - 58. Behind every number is a story, some tragic, some
remarkably uplifting; one of each to follow;

Yesterday we tried to resuscitate a twenty-eight year old man who had
advanced tuberculosis. He had been sick for some time. Sadly there was
‘something else going on’ which is what we term any condition that we cannot
diagnose due to a lack of facilities. Basically we went for hit and hope
treatment. Take an educated guess as to what it is and cross you fingers.
Inevitably we sometimes we get the calculation wrong.

The man was showing signs of acute liver failure and had begun bleeding
heavily internally. I managed to site an IV line and the blood that flowed
was very dark and thin, indicating he was not getting enough oxygen and the
iron level in his blood was dangerously low. A lab test confirmed as much
(Hb of 1.5, yes, I know, 1.5 for the medically minded).

Blood donors only come forward at the last moment and the only
people who donate are members of the immediate family. Sadly none of this
family matched the patients’ blood group. His condition nose-dived in the
mid morning. We struggled to rescue the situation, for every problem we
addressed another two would crop up. In the end the man became very
distressed and agitated, sensing, I think, that time was short. We gave him
a generous dose of diazepam and he gurgled, foamed and convulsed until he
was finally gone. Our national staff were magnificent, considering that the
patient was a personal friend of some of them. I can’t say it was anything
other than horrendous.

Earlier in the week we had seen a child with cerebral malaria.
He was very lethargic and didn’t flinch when we put IV lines into him, which
is never a very good sign. Round the clock observation and high doses of
antimalarials seemed to be getting us nowhere. I decided to have what is
referred to as ‘the chat’ with mum and dad. The chat can basically be
paraphrased, as ‘unless there is some sort of miracle your relative is not
going to survive this’. It is useful in preparing the family for, what is
often, the inevitable demise of a loved one, but it is not exactly easy.

Slowly, very slowly, the little boy began to show signs of
improvement. He began by moving an arm and sighing (as if he found the whole
thing a bit boring). By the next day he had opened his eyes and rolled over
onto his side. Today he was playing with his siblings, and grinning from ear
to ear, my whole year is worth it just for that.

Whilst the individual success stories are, personally, the most
rewarding many more lives are saved by prevention. This week there has been
a much-needed push to improve the care we give to pregnant women. The
newborn fatality rate here is astronomically high. Pregnancy and childbirth
are a leading cause of death in women. It is not difficult to see why. Most
babies are born at home with only a village wise woman (without any training
but lots of experience) in attendance. The babies are delivered onto a muddy
floor, they often aren’t kept warm enough, they may be two days walk from a
health centre should problems develop. The vast majority of mothers have
received no antenatal care whatsoever, and are very anaemic. A consequence
of this is that they bleed heavily and often die.

This situation is compounded by some damaging health beliefs that are
commonly held here. The babies’ umbilical corn is cut with a rusty blade and
the stump is often smeared in cow dung, leading to tetanus and infection.
For the first three days the baby is fed on goats milk, as it is believed
that colostrums is bad for the child. Establishing breast-feeding after this
is very difficult.

We only see deliveries in the clinic when all other avenues have been
attempted. The traditional healer, the old ladies and a multitude of wise
women have had a go at getting baby out and failed.

By this time the mother is often tired, the baby more often than not is dead
and there is precious little we can do about it. Destructive delivery is
often the only feasible option, and I can’t begin to describe what an
unpleasant business that is.

As an attempt to stem this lethal tide we have been constructing and
improving home delivery kits. These are kits given to pregnant mothers for
use in delivering their child. They consist of string to tie off the
umbilical cord, a razor for cutting the umbilical cord, soap for mum and
baby, cloth and blanket to wrap the baby in, gloves for whoever is helping
in the procedure and a large plastic sheet in preference to a muddy floor.
Simple but, all the research indicates, very effective

Their construction rivals Wembley stadium in terms of length and problems! A
committee of a few of us (being the only children’s nurse got me mired in
this particular adventure!) have met to discuss various aspects of the kit.
What do we include, what not to include, how to train mothers and so on. The
‘do we need a plastic bag for the placenta’ argument dragged on for weeks.
Finally resolved we began to give out the kits this week.

Obviously first on our hit list was the clinics staff. I held a large
teaching session for all the staff that wanted to come. I proceeded to open
up a kit, mime having a shave with the razor, I blew up one of gloves like a
balloon bouncing it up and down and took a bite out of the soap (which was
stupid).

My point being that if we don’t teach mothers how to use the kit we may as
well not give them out. It at least got a laugh and hopefully made the
point. I finished by telling them that as there were twenty of them there if
they each told five pregnant women to come and collect a kit that would help
to save the lives of one hundred babies and one hundred women. Back to
numbers again

So health interventions in there mega and nano versions this week, what will
happen next? Your guess is as good as mine.

All change please, all change

To grossly misquote Wilde 'to lose one outreach partner could be seen as a
misfortune, to lose another smacks of carelessness'. Of carelessness I am
clearly guilty. The revolving door that is the outreach nursing team has
sprung suddenly into life again! Francis has decided outreach really isn't
where he wants to be. This coupled with a very attractive masters degree
offer has led to him beat a hasty retreat. From resignation to departing
took less then ten hours.

It's obviously very disappointing but this isn't the sort of work you can do
if you aren't fully committed. In honesty he wasn't happy about the set up
here from the moment he stepped off the plane. And towards the end of our
time together it began to show. It has been a bit difficult, but everyone
has been really supportive and reassured me that it isn't my fault I was
beginning to wonder!

I've been keeping myself busy by helping out in the base clinic which is
starting to resemble an Accident and Emergency waiting room with patients
almost sitting on each others laps! The edited highlights of my week to
follow in the next few days.

A, now much needed, holiday is fast approaching. I actually escape next
Friday for a few weeks, though plans are a little fluid at present.

Are You Chicken?

I want to honour a food that I’ve grown to loath. It’s the perfect fodder
for aid workers toiling in war torn areas, such as this one. Arriving in its
own bulletproof vest, know commonly as a tin. It has tried to make its mark
on the culinary landscape of many a project.

In fact there is only one thing holding this great food back from global
domination, at least when it comes to feeding those who have little option.
It is practically inedible. I refer to chicken luncheon meat.

Even the name is misleading. Luncheon is the term that, the queen and
well-to-do pearl encrusted Daily Mail readers use to describe the meal in
the middle of the day.

This food would not exactly be on the menu at Buckingham palace. It would
struggle to get a look in at the workhouse in Oliver Twist. Certainly if it
was, Dickens great masterpiece would have taken a very different direction.
Young Oliver, carted off, lethargic, green and vomiting, to hospital after
managing to finish a portion of the offending item. ‘Please sir, can I have
a stomach pump?’

Created by Regal of Mauritius it is 260g of pure bile. It arrives in a
cylindrical tin an inch tall and two inches in diameter. If I had my way it
would go straight from factory to landfill without ever being offered for
human consumption.

The picture on the front of the tin displays what appears to be a large,
pinky-orange, sliced sausage surrounded by, rather tired, looking lettuce
and tomatoes. It even has the audacity to site this as a ‘serving suggestion
’. What exactly are the manufactures suggesting? Remove from tin, cut into
bits and put with fresh food in an effort to make it look appealing, not
exactly Jamie-flippin’-Oliver is it?

The ingredients listed, thankfully, include chicken meat, which I must say
came as a bit of a shock. Red rice and phosphate E451 are present which I
would feel happier about, if I knew what they were. Finally, in this
concoction, is the sinister sounding MSG E21, which sounds like the sort of
thing used to kill off dissident Russians.

I made the mistake of bringing a tin to outreach with me. By the end of the
week we were running a little short of grub and I decided to try an
incorporate it into a lunch (eon). I felt this was particularly important,
as I had just had a bit of a go at the clinics pharmacist for letting a few
boxes of drugs expire and the luncheon meat was a month of expiry.

I broke the tin open with a rusty opener and dug in with a spoon in the way
a normal person might eat yoghurt. I could just about see the rings of the
base of the tin when I began to feel very sick. Even as a student I was
never driven to try cat food, however chicken luncheon meat is as near as I
ever want to get. I fed the rest of the tin to an emaciated passing dog, who
didn’t finish it.

The fact that a poor animal has had to sacrifice its life in the creation of
this product makes even this carnivorous bloke come over all Linda
McCartney. I’m sitting with a tin in front of me as I type this; (funnily
enough we have stacks of the stuff in the store!) and I’ve just noticed one
slightly redeeming feature. The product claims to be Halaal, meaning that a
huge portion of the world’s population is able to see exactly what I’m
talking about for themselves, multi faith excrement indeed.

So here's to you Regal, creators of a food that even people who are really
hungry would rather chew on broken glass than eat. Chicken luncheon meat I
salute you!

Ten Things I’ve learnt Since Being Here.

I’m nearly at the halfway mark and I’m in retrospective mood. So I thought I
’d write down a few truths that have become apparent since my arrival. In no
particular order here we go……..

1) The notion of ‘sterile’ is a relative concept.

2) Any medical device, including IV lines, Naso-gastric tubes,
catheters etc can be made to attach any other medical device if you push the
two ends together with enough vigour!

3) Any food in a tin (cheese, mackerel, peaches etc) can become
strangely addictive.

4) Chicken farming is much more complicated than it would first appear.

5) People will work through the most extraordinarily difficult
circumstances with, almost nothing, to keep a clinic open. And save hundreds
of lives in the process.

6) How the western/‘developed’ world deals with the African ‘problem’
leaves an awful lot to be desired.

7) Having said that foreign aid CAN make a difference if (and it’s an
oft forgotten ‘if’) it is directed in the right way. When this does not
happen it often does more harm than positive good.

8) The IPOD solar charger is beyond criticism.

9) Sometimes even the simplest improvement in practice can yield
fantastically impressive results.

10) The world isn’t fair. I think I knew this already, but the last few
months have confirmed it.

Cometh The Hour, Cometh The Man.

Moses (of bible fame) was a very interesting bloke. His ability to cast
asunder large bodies of water would be particularly useful to many an
outreach expedition. Whilst his namesake, as far as I’m aware, is unable to
do this he did manage to save both the clinic and my frayed nerves!

One of the staff, David, had mentioned that there was a health worker who
lived not far from the clinic. He hadn’t worked for a few years and had been
doing other things (attending theological college for one) but he was
currently not working. David hadn’t finished his sentence by the time I had
written the letter to this man inviting him for an informal chat.

Moses, the health worker (Not the bible bloke, otherwise I really would have
something to write about!) strode through the early morning mist. He greeted
me with a bone-crushing handshake. He was a tall man, with a short beard and
voice ten octaves below baritone. It wasn’t so much as voice as a low
rumble. The sort of tone that could really put fire and brimstone into any
sermon.

As we spoke the sun broke through the clouds and cast the clinic in a
brilliant white light. A heavenly sign? I hoped so. A few moments later all
was well, the clinic had a new supervisor and I had stopped at least some of
my hair turning charcoal grey. We had been eight hours from closure. I never
want to be that close again.

Moses started the next day and whilst there were a few bits that had lodged
somewhere near the back of his brain they seemed to jump easily enough into
his working memory. I am sure he will be fine.

Very pleased with ourselves we half walked half skipped back to base, where
I am now, chilling. The next few weeks’ movements are a little up in the
air, but a holiday is defiantly on the agenda.

Spot The Healthworker

Regular readers of my musings on this blog will be aware that about a month
ago I had an outreach visit that involved a human resources nightmare. I had
hoped that the whole thing had rather blown over and I wouldn’t need to
discuss it again. It didn’t so much blow over and blow up!

Our outreach clinics are overseen by a supervisor who has been given nine
months training in all things medical and sent out to run the clinic and
treat whatever falls though the door. The rest of the staff effectively
operate in support of him, doing malaria tests, giving out medicines,
fetching water etc etc. Anyway, to say this member is crucial to the clinics
survival is to say money is reasonably important to Donald Trump. Without
this health worker the clinic does not open. Full stop.

A short version (the long version might put me in therapy) is that the
supervisor of this particular clinic managed the following during the last
visit;

He picked an argument with us for absolutely no reason at all. Then, when
informed in the most reasonable voice I could muster, that this was
unacceptable and that he should consider his behaviour in future he walked
out in an overly dramatic, eye-rolling strop. Walked out, I might add
straight into the arms of another NGO and a near tripling of his salary.
Just be glad there weren’t any large or sharp objects in the immediate
vicinity. I was a tad peeved.

So this left two outreach nurses playing an increasingly frantic game of
spot the health worker. Initially we solved the problem by dragging a
substitute on from another clinic. The problems really started when he also
(for valid enough reasons) had to leave very quickly too.

We found ourselves hot footing it back from one outreach site and straight
onto a plane to rescue another. Things didn’t go quite according to plan
from the outset when the pilot keyed the wrong coordinates into his GPS and
flew us in totally the wrong direction. Thankfully Francis was much more
awake than I was and pointed this out. 12,000 feet is not the sort of
environment that facilitates easily stopping to ask for directions. After
scrambling around with maps we resorted to flying to somewhere near it
(which we had the coordinates for) and circling until we spotted the
village. This accomplished the plane was onto the dusty savannah in a matter
of minutes.

The first thing to do was to hold a staff meeting. We informed all the staff
that we would be seeing the patients ourselves for the week and sorting out
the health worker vacancy at the same time. In truth it had all gone (to use
the south London vernacular) pear shaped. We hadn’t a clue where we were
going to find someone. The situation was looking bleak. Clinic closure and
redundancy loomed large. I don’t think either of us slept very well.

Some very sick patients compounded this state of affairs. The worst was a
two-week-old baby who attended the clinic and had been seen by both of us.
He looked very well, he was feeding well and mother had few concerns. She
had actually attended with her other child, for her to be seen. The next day
the mother came back, this time with just the baby in a basket. As I took
the covering off the basket it was obvious that things were very serious. A
confirmatory listen with the stethoscope was the evidence. The babies’ heart
rate was extremely slow and the breathing was shallow and gasping. Fifteen
minutes of frantic efforts were not enough and, sadly, the baby passed away
as I held him.

There was no temperature and the child seemed well nourished and cared for,
I have absolutely no idea why the baby died. Infant mortality statistics
look a whole load different when you see them in flesh and blood. The
parents took the child home in the same basket that they brought him in.
Another Tuesday morning in Africa.

The people here accept child death as a norm, of course losing a child is
unimaginably painful, and I know they feel grief just as acutely as anyone,
but
children dying here is also greeted with a sad resignation, rather than
surprise.

A deeply depressing few days indeed, to depress myself further I looked
through the clinic records and found that many of the patients lived hours
walk away from the clinic and that its closure would cut a swathe of them
off from any healthcare at all. Furthermore the clinic was seeing patients
who were critically ill. I estimated that closure could cost 150 lives a
month.

The land where 'yes' is 'no' and 'no' is ......um...

“Yes” he said, “no, lets just get this clear, you are saying the pump is
fixed and working well,” I said “yes, yes” he said, “new pump, put in by
UNICEF. very good”. These words were still ringing in my ears as Francis and
I stood by what was a very new but (as might have been guessed) very broken
water pump.

The meeting with the tribal chief had been a useful one in that none of what
he had told us about the outreach clinic accurate. In fact in almost every
case the reverse was true. The people weren’t getting sick from drinking
dirty water (they were), the clinic fence had been repaired (it hadn’t) and
there were no military forces in the area (again, a bare faced lie!!).

The walk to the outreach site was uneventful, gone is the mud, replaced by
rutted tracks and smooth sandy paths. The sun is burning the vegetation away
from around us, with all the delicacy of a blowtorch. Not much has remained
unaffected and everywhere is yellow and dying.

As we walked along we passed though a village where the population seemed
very pleased to see us. Laughing could be heard in various houses and from
behind trees and bushes. In the distance men danced around and fell over. It
became obvious; as we got closer that everyone in the entire village, over
the age of four, was drunk.

The harvest season has just finished and the people here are able to make a
sort of wine homebrew. Clearly this village had enjoyed a bumper crop. Even
more impressive that they had managed to reach this level of alcoholic
stupor by nine thirty in the morning. It was like Liverpool on a Saturday
night. In some ways it might have been fun to stay and see what happened
when the party really got going! Another time.

The outreach clinic was running very well despite numerous problems. The
most comical was a difficulty experienced with weighing the children. In
order to do this we use a pair of dungaree shorts hung from what looks like
a butchers scales, suspended from the branch of a tree. Unfortunately the
bloke
doing this had a nasty habit of hanging the scales upside down. This led to
some babies weighing in at a stonking 25 kilos. A marker pen and a ‘this way
up ‘arrow soon solved the problem.

Statistics will, if you believe them, tell you anything and in this case I
can tell you exactly what date the pump broke (Wednesday November 3rd just
in case you’re interested). Why can I tell you this? Because three days
later we had an 67% upsurge in cases of gastroenteritis, we saw 33% more
wounds that week, caused by having to walk through a swamp to get to the
deeper drinking water, and a whooping 56% increase in eye infections, from
washing with, yes, you guessed it…filthy water.

The patients were drinking their medicine in the clinic with water that
looked like the sort of stuff found at the bottom of the sink after washing
up (for those of you who’ve lived with me, yes I am aware of what washing up
water looks like!). Putrid is the only way I can describe it. What is
particularly ironic is that we are giving them medicine to treat, amongst
other things, diarrhoea. And then we get them to knock it back with water
that you wouldn’t wash your car with in the west. I’m beginning to bore
myself about the water so I’ll stop now. Point, exhaustively, made.

The saddest case we saw involved a little girl who had been shot in the hand
during fighting four days earlier. The bullet had taken away a chunk of skin
at the base of her thumb and blown one of her fingers clean off. She wore an
expression of confused bewilderment, too young to understand the nature of
what had happened to her. As I lay awake that night listening to the
sinister rattle of machine gunfire I wondered what would turn up at the
clinic the next morning. Nothing did arrive, the optimist in me would like
to think that’s because no one got hurt. The realist thinks it’s probably
because they were beyond our help.

The staff themselves were all doing various jobs with an impressive degree
of efficiency, which considering we hadn’t visited in months, leads me to
think that actually it would be better if we just stayed at home and stopped
interfering. We were even able to promote a few which was fantastic for
them, and, I hope the clinic.

The high moral was shattered with dreadful Mozart cover version - the ring
tone on the satellite phone, which I can’t manage to change.“Hi Marcus, it’s
me (the boss). Listen there’s a bit of a problem, we’ve had to close one of
the clinics, the supervisor has resigned” “Resigned? You’re kidding.” “No”
she said. And, she meant it.