18/11/08 The rains begin with a vengeance and a mourner is struck and killed by lightening at a funeral!
The corrugated roof of our house, which is the standard covering for most Zambian dwellings, was strangely silent this morning. It normally expands and contracts with murmurings, grumbles and intermittent loud cracks twice a day as the unforgiving sun rises and sets, and even with the occasional passing cloud. However this morning we and the corrugated roof were protected by heavy cloud which has persisted most of the day and now at 13.30hrs the impressive thunder and lightening has released huge quantities of water creating a totally different deafening noise like trees in a gale as well as instant puddles streams and rivers.
It is amazing how quickly our moods swing at work, even changing within one day from resignation that we have very little to contribute to rising enthusiasm that we can. This is mostly related to our relationships to individuals rather than the overall objective. VSO did warn us about this.
So far his week I have done are two fistulas and two hernias apart from the rectal cancer, which was initially presented to me as a fistula and, then corrected to needing a sigmoidoscopy and examination of the back passage. This was difficult as there were no properly functioning biopsy instruments so I diagnosed a rectal cancer on simple examination with a finger, which could have been done in outpatients! I did eventually manage to take a biopsy blindly using a short scope and a torch only to be told that they had no formalin to preserve the specimen so all my efforts had been a waste of time. The diagnosis and treatment plan has to be based on a simple clinical examination. Dr. Ngulula did an orchidectomy or removal of testis in an older guy just to cure his rather large and probably long standing hernia!
Over to Judy.
At last I have been able to visit some of the rural communities with the outreach HIV/AIDS workers. The first time it was with the PMTCT (Prevention of Mother To Child Transmission) Group who are based in the Maternity Unit and encourage mothers to get tested so that they and their babies can get treated.
Burial Programme for the late Mrs. Lute Zulu Hamachila
Burial of the late Mrs. Lute Zulu Hamachila who died on 16th November 2008 will be on Wednesday 19th November at the farm.
09:00 HRS - Mourners assemble at the mortuary
09:30 HRS - Preparation of the body
09:50 HRS - Body viewing
10:00 HRS - Church Service (Hospital Chapel)
11:00 HRS - Departure to the farm
12:00 HRS - Body viewing
12:15 HRS – Commital – Prayer - Burial
12:40 HRS – Laying of wreaths
13:00 HRS – Life History by family representative
13:10 HRS – Speech from the council chairman
13:25 HRS – Speech from village headman
13:35 Hrs – Speech from the employers
13.50 HRS – Speech from the Royal Highness – Chief Monze
14.00 HRS – Speech from the District Commissioner – Monze
14.10 HRS – End of Programme
May her soul rest in eternal peace
We eventually arrived with over 200 others and the wailing began with close family “body viewing”. Most attendants were not family and stood a respectful short distance away. We stood all around the farm buildings, including the building that had been struck by lightning in the storm the previous day, killing one of the visitors. The walls were charred and all the grass and wood immediately around was burnt to charcoal. We wondered what the locals felt about this and whether they thought it was a portent from above.
We then moved off for the burial some 5 km away from the farm. This was the deceased’s family burial site, a small clearing on a slightly raised mound surrounded by a circle of bushes and small trees through which you could catch glimpses of the surrounding miles of flat empty plains and fields. It was very silent and peaceful apart from the occasional wail and bird flying high over us.
The corrugated roof of our house, which is the standard covering for most Zambian dwellings, was strangely silent this morning. It normally expands and contracts with murmurings, grumbles and intermittent loud cracks twice a day as the unforgiving sun rises and sets, and even with the occasional passing cloud. However this morning we and the corrugated roof were protected by heavy cloud which has persisted most of the day and now at 13.30hrs the impressive thunder and lightening has released huge quantities of water creating a totally different deafening noise like trees in a gale as well as instant puddles streams and rivers.
The house lights flash on and off with the lightening for some reason. I have changed over to the lap top battery, so that I can switch off and protect the surge protector! The storm has made it impossible to walk back to the hospital for the afternoon’s ward round and clinic. We would get soaked getting to the hospital transport just outside our bungalow if it was available which it isn’t!
A much regarded 48 year old nurse with bad hypertension has suddenly died and for the last three days most of the hospital employees have been ferried to and from the “funeral” which takes much time and is a Zambian cultural tradition with a significant cost to the economy and the individuals involved. For the three days before the actual ceremony people visit the home. This has to be done properly both out of respect for the deceased and also to make sure her spirit is appeased and put safely to rest. We were warned about this and it is impolite for even quite distant aquaintances of the deceased not to pay their respects at the wake and close relatives may have several days off work to attend the funeral travelling long distances occasionally on foot.
A much regarded 48 year old nurse with bad hypertension has suddenly died and for the last three days most of the hospital employees have been ferried to and from the “funeral” which takes much time and is a Zambian cultural tradition with a significant cost to the economy and the individuals involved. For the three days before the actual ceremony people visit the home. This has to be done properly both out of respect for the deceased and also to make sure her spirit is appeased and put safely to rest. We were warned about this and it is impolite for even quite distant aquaintances of the deceased not to pay their respects at the wake and close relatives may have several days off work to attend the funeral travelling long distances occasionally on foot.
Later on in the day when I eventually get to the hospital we hear that a mourner was struck and killed by the lightning while visiting the deceased's farm. This means the hospital transport will probably be in short supply for another week!
It is now 15.00hrs, the roar has decreased and the rain after 90 minutes may be slowing although it is still very dark. We have had quite a bit of rain intermittently over the last few days but never as continuous as this, with such determination, dark skies, thunder and cool air.
It is now 15.00hrs, the roar has decreased and the rain after 90 minutes may be slowing although it is still very dark. We have had quite a bit of rain intermittently over the last few days but never as continuous as this, with such determination, dark skies, thunder and cool air.
It’s difficult to believe that the sun and heat are so completely obliterated by the cloud, that it is still up there and will probably be out before the close of the day. At least it has allowed me to start our next blog!
The grey skies over the Lusaka to Livingstone railway and the road crossing close to our home across which we walked across most mornings. The trains were so slow and long it could be a long wait to cross the lines on occasion.
We may have to make a dash for it to the hospital if it stops, especially as it is the orthopaedic surgeons’ monthly visit and I will be sorry to miss them.
It is amazing how quickly our moods swing at work, even changing within one day from resignation that we have very little to contribute to rising enthusiasm that we can. This is mostly related to our relationships to individuals rather than the overall objective. VSO did warn us about this.
Arranging post graduate teaching and more clinical cases
We have religiously attended a Thursday morning 7.30am post graduate meeting set up by Tom Lavender which is very popular and well attended.
We have religiously attended a Thursday morning 7.30am post graduate meeting set up by Tom Lavender which is very popular and well attended.
Unfortunately it eventually petered out during the medical licentiates strike shortly before we left. However this morning I was disappointed that two of the trainees only saw difficulties in setting up some extra teaching sessions. They couldn’t make a session over lunch because they have to go home to eat nshima and they weren’t keen on a session immediately after the ward round in the afternoons. Nshima is rather like mashed potatoes but made with ground maize or “mealie-meal”. It is used as a mop or is molded to scoop up fish or meat, usually with their fingers; it has more stickiness than mashed potato. Later on that morning I had another talk with the Congolese Consultant surgical colleague Dr Ngulula who was interested in getting some teaching going and seemed keen to learn new techniques, which raised my mood again.
Later on mainly with the encouragement of Michael Breen who put the materials together we had two basic surgical training sessions to teach the medical licentiates how to do anastomoses using pig/cow bowel. These were very popular and well attended.
The general surgery consists mainly of small operations. Most of the major surgery is either obstetrics and gynecology which is well covered by Michael Breen or major orthopaedic procedures on failed conservative treatment of fractures which is done by the monthly visiting orthopaedic surgeons from Lusaka. Other cases, right outside my expertise are also done by visiting surgeons such as hare lip and prostatectomies which I would probably do if there was no alternative. However we may have a rectal cancer to do and we have at least interesting general surgical emergencies including 'intestinal obstructions' once a week.
So far his week I have done are two fistulas and two hernias apart from the rectal cancer, which was initially presented to me as a fistula and, then corrected to needing a sigmoidoscopy and examination of the back passage. This was difficult as there were no properly functioning biopsy instruments so I diagnosed a rectal cancer on simple examination with a finger, which could have been done in outpatients! I did eventually manage to take a biopsy blindly using a short scope and a torch only to be told that they had no formalin to preserve the specimen so all my efforts had been a waste of time. The diagnosis and treatment plan has to be based on a simple clinical examination. Dr. Ngulula did an orchidectomy or removal of testis in an older guy just to cure his rather large and probably long standing hernia!
Over to Judy.
At last I have been able to visit some of the rural communities with the outreach HIV/AIDS workers. The first time it was with the PMTCT (Prevention of Mother To Child Transmission) Group who are based in the Maternity Unit and encourage mothers to get tested so that they and their babies can get treated.
Sister Hangoma co-ordinates all of this and took a group of four other women with her including a nurse. The three lay women were all HIV positive mothers who she is training to do outreach care. At the risk of sounding boring and repetitive we were late starting, gave two hospital workers a lift home, filled the Land cruiser with diesel and stopped yet again to buy lunch (e.g. chicken and chips!) for anyone going who wanted it.
There is only one main road through Monze, north -south from Lusaka to Livingstone and we set off north and turned west just outside Monze. Of course, it would be correct to say that the north south road was built by the British for taking products from the Copper Belt and agricultural areas of the north to what was then Southern Rhodesia and S. Africa, as was the now almost defunct railway
There is only one main road through Monze, north -south from Lusaka to Livingstone and we set off north and turned west just outside Monze. Of course, it would be correct to say that the north south road was built by the British for taking products from the Copper Belt and agricultural areas of the north to what was then Southern Rhodesia and S. Africa, as was the now almost defunct railway
but which still runs but at snail’s pace. The British were very good at organizing the transport of exports for a colony but road building elsewhere was not a priority.
Fairly quickly we were on a wide dirt track, not too pot-holed but very dusty, so that we left a red “vapour trail” behind us and became choked if a vehicle came the other way.
The rains haven't yet dispensed with the dust! Soon we turned off this onto a much narrower and rougher surfaced road which in parts was just sand. As we got deeper into the bush, tracks joined and left us apparently randomly. It would have been impossible to give anyone directions. There were also footpaths leading in all directions but not many dwellings to be seen. Signs pointed to schools, just about visible, and goats and a few cows moved out of our way. When we did see a small homestead it consisted of what are called rondavels, which are the typical round mud huts
(though now sometimes concrete blocks or large bricks are used) with fine grass thatch. There are often small round woven enclosures which are on stilts and which are used to keep the chickens and goats safe from snakes and other predators.
The village pump is always surrounded by a fence of tree trunks and has a
convoluted entrance, possibly to try and deter animals. Eventually after about 20 km in total we arrived at our rural clinic.
These places are very impressive. They are single storey concrete buildings with solar panels, which the government was obviously keen on at one time, almost certainly from overseas funding. One long building had three doors from the outside and these were labeled antenatal, labour ward and post-natal. Each was a small clean room with one bed. There was also another building with male and female wards in a similar vein (two beds each) and attached was the medical officer’s room and a pharmacy. This was really quite well stocked with basic medication, which the medic can prescribe after 3 years training. In this community it is a husband and wife team and she is the midwife.
Some local pregnant women had been gathered together. It seemed they were HIV positive and were being trained to talk to other women in the area to encourage VCT – Voluntary Counselling and Testing. They all seemed enthusiastic in spite of their situation and it really is encouraging to see the interest in a plan that is sustainable. The remains of lunch and some drinks were shared around and promises made to return at a later date.
We travelled on to one more village with similar infrastructure but the women we had hoped to meet were not there, possibly as our schedule was running very late. It was a hot bumpy journey home but a fascinating insight into their work, life and society.
Some local pregnant women had been gathered together. It seemed they were HIV positive and were being trained to talk to other women in the area to encourage VCT – Voluntary Counselling and Testing. They all seemed enthusiastic in spite of their situation and it really is encouraging to see the interest in a plan that is sustainable. The remains of lunch and some drinks were shared around and promises made to return at a later date.
We travelled on to one more village with similar infrastructure but the women we had hoped to meet were not there, possibly as our schedule was running very late. It was a hot bumpy journey home but a fascinating insight into their work, life and society.
My second trip out was in a large pick-up/open truck with the VCT team and also the Peer Educators.
Fortunately I was in the cabin with one of the co-odinators! We were off in a different direction but with the same backcloth. We arrived at the same type of pristine rural clinic where the nurse was doing her ante-natal clinic outside in the sunshine. More of a chat than a check as we know it. The group of women and men in the Peer Educators group with us had announced our progress along the track with drum beating and singing. Finally as we got nearer a megaphone was used to attract attention and encourage folk to come.
The Peer Educators are again a voluntary group who may go from door to door and meet with groups of families, or may go out in a large group and try and attract attention.
The Peer Educators are again a voluntary group who may go from door to door and meet with groups of families, or may go out in a large group and try and attract attention.
They tackle many issues apart from HIV/AIDS. A lot are to do with gender issues such as “widow cleansing”, the tradition of having sex with a male relative of their dead husband, inheritance by the husband’s family rather than his wife and children, which many widows are frightened to challenge, early marriage and disclosure of “reactivity” or having a positive HIV test to a husband or wife. They convey all of this in songs and small plays. They are naturally good actors and very confident, so that watching them is very entertaining. A good trip overall, though the community should have been forewarned, and only four came for VCT, all negative.
We were back later than planned, but the rain came on time, so those in the back of the truck were probably well washed of the red dust by the time we were back in Monze. They continued singing and drumming right to the end.
The rain didn’t stop and it went straight from being dark to night and the rain continues now 9 hrs later.
We were back later than planned, but the rain came on time, so those in the back of the truck were probably well washed of the red dust by the time we were back in Monze. They continued singing and drumming right to the end.
The rain didn’t stop and it went straight from being dark to night and the rain continues now 9 hrs later.
Clinical Cases
I (Mike) eventually got to the hospital through the rain in hospital transport, Jasper in the Land Cruiser, and met the orthopaedic surgeon called Alan Norrish about 40+ very confident trained in Cambridge, hadn’t met Scott and brought with him 2 Americans. He works from The Beit Cure Hospital in Lusaka, which is funded by an international Christian charity with headquarters in America. He is currently away for two weeks visiting and operating in rural hospitals. We had two patients for him, both very expertly dealt with. The first had a bad compound fracture, which had pushed through the skin of the ankle. The foot was displaced inwards with a fragment of bone, the medial malleolus floating free. He had brought with him an extensive collection of heavy black metal external splints some of which were selected to be fixed to the outside of the ankle using four needle like pins two through the bones in his ankle and two through his shin bone.
I (Mike) eventually got to the hospital through the rain in hospital transport, Jasper in the Land Cruiser, and met the orthopaedic surgeon called Alan Norrish about 40+ very confident trained in Cambridge, hadn’t met Scott and brought with him 2 Americans. He works from The Beit Cure Hospital in Lusaka, which is funded by an international Christian charity with headquarters in America. He is currently away for two weeks visiting and operating in rural hospitals. We had two patients for him, both very expertly dealt with. The first had a bad compound fracture, which had pushed through the skin of the ankle. The foot was displaced inwards with a fragment of bone, the medial malleolus floating free. He had brought with him an extensive collection of heavy black metal external splints some of which were selected to be fixed to the outside of the ankle using four needle like pins two through the bones in his ankle and two through his shin bone.
The granulations in the open wound were removed, a few stitches inserted where the medial malleolus had floated free and the wound left open. It was remarkably successful in spite of the medical staff being worried about infection through the pins. Re-aasurance for this was via texts by mobile phones to Alan Norrish. The wound cleaned up very quickly after spending 3-4 weeks on the ward going nowhere and eventually the pins were removed and replaced with a POP cast.
During the operation there was raging thunder and lightning, the lights went out as the electricity failed and for a full five minutes the operation continued with poor illumination from a torch, with hardly a hesitation and absolutely no complaints. Tony Brand’s gaunt face appeared at the darkened theatre windows on one occasion to check that his diesel generators had once again saved the day. Public electricity wasn’t restored until after the operation had finished. The other patient was an ancient crone who had severe shortening of her leg after a bad fracture of her hip at the inter-trochanteric level. Norrish put a Denham pin through her tibia just below the knee with a plaster over it both to get the leg stretched and the plaster to stop the pin rocking and working loose. Apparently this idea was given to Norrish by a retired Professor Jellis aged 70 who still does charity work by flying himself all over Zambia where he has worked all his life. He takes passengers in his plane and is a very good pilot. He is an old colonial, owns a large farm and is very sociable.
It’s amazing how time slips away when doing this blog. It is still pouring with rain and Judy has resorted to playing patience after losing at Canasta, again!! It is now 23.20 hours and we have to get up tomorrow at 6.30hrs so off to bed after a bath.
In fact it rained most of the night. In the morning there were puddles and mud everywhere, it was still cloudy but much lighter and had stopped raining. During the day there was very little sunshine and just a little rain.
A wake or traditional Zambian Funeral. Wednesday 19/11/08
We arrived at the hospital to find most people were being mobilized for the burial of the much beloved and revered ITU nurse who had died suddenly on the 16th. We had met her only briefly but Mrs. Yamba felt it was appropriate for us to take part. This meant leaving our clinics, which would be run on skeleton staff but only after the communion service in the hospital from 10 to 11am. I would guess about 30% of the hospital staff were then transported out to the husband’s farm. The deceased hadn’t lived at the farm during the week, but in the centre of town, probably because the farm was through the market and down 15 km of unmade roads. The final cortege of trucks, buses, 4WDs, cars and motor bikes, about 20 in all, that finally went to the farm
During the operation there was raging thunder and lightning, the lights went out as the electricity failed and for a full five minutes the operation continued with poor illumination from a torch, with hardly a hesitation and absolutely no complaints. Tony Brand’s gaunt face appeared at the darkened theatre windows on one occasion to check that his diesel generators had once again saved the day. Public electricity wasn’t restored until after the operation had finished. The other patient was an ancient crone who had severe shortening of her leg after a bad fracture of her hip at the inter-trochanteric level. Norrish put a Denham pin through her tibia just below the knee with a plaster over it both to get the leg stretched and the plaster to stop the pin rocking and working loose. Apparently this idea was given to Norrish by a retired Professor Jellis aged 70 who still does charity work by flying himself all over Zambia where he has worked all his life. He takes passengers in his plane and is a very good pilot. He is an old colonial, owns a large farm and is very sociable.
It’s amazing how time slips away when doing this blog. It is still pouring with rain and Judy has resorted to playing patience after losing at Canasta, again!! It is now 23.20 hours and we have to get up tomorrow at 6.30hrs so off to bed after a bath.
In fact it rained most of the night. In the morning there were puddles and mud everywhere, it was still cloudy but much lighter and had stopped raining. During the day there was very little sunshine and just a little rain.
A wake or traditional Zambian Funeral. Wednesday 19/11/08
We arrived at the hospital to find most people were being mobilized for the burial of the much beloved and revered ITU nurse who had died suddenly on the 16th. We had met her only briefly but Mrs. Yamba felt it was appropriate for us to take part. This meant leaving our clinics, which would be run on skeleton staff but only after the communion service in the hospital from 10 to 11am. I would guess about 30% of the hospital staff were then transported out to the husband’s farm. The deceased hadn’t lived at the farm during the week, but in the centre of town, probably because the farm was through the market and down 15 km of unmade roads. The final cortege of trucks, buses, 4WDs, cars and motor bikes, about 20 in all, that finally went to the farm
was quite impressive snaking across an otherwise relatively deserted, wide open, very flat brown going green countryside with a few spectacular trees under threatening skies.
Multiple footpaths lead off from the “main” track as Judy has described and as we got closer to the farm long lines of people emerged from small hamlets and single homesteads. We were given a lift in a lorry but were allowed to travel in the cabin, which was fortunate as it rained quite heavily on the way home 4hrs later.
You can see Judy's leg and arm still in the cabin! There was standing room only on the back!
The hospital employees travelling in the back of the lorry, including Sister Juunza pronounced Joansa, sang quiet subdued tunes not quite a dirge but not the cheerful songs they normally sing.
There was a published timetable for the day:
There was a published timetable for the day:
Burial Programme for the late Mrs. Lute Zulu Hamachila
Burial of the late Mrs. Lute Zulu Hamachila who died on 16th November 2008 will be on Wednesday 19th November at the farm.
09:00 HRS - Mourners assemble at the mortuary
09:30 HRS - Preparation of the body
09:50 HRS - Body viewing
10:00 HRS - Church Service (Hospital Chapel)
11:00 HRS - Departure to the farm
12:00 HRS - Body viewing
12:15 HRS – Commital – Prayer - Burial
12:40 HRS – Laying of wreaths
13:00 HRS – Life History by family representative
13:10 HRS – Speech from the council chairman
13:25 HRS – Speech from village headman
13:35 Hrs – Speech from the employers
13.50 HRS – Speech from the Royal Highness – Chief Monze
14.00 HRS – Speech from the District Commissioner – Monze
14.10 HRS – End of Programme
May her soul rest in eternal peace
We eventually arrived with over 200 others and the wailing began with close family “body viewing”. Most attendants were not family and stood a respectful short distance away. We stood all around the farm buildings, including the building that had been struck by lightning in the storm the previous day, killing one of the visitors. The walls were charred and all the grass and wood immediately around was burnt to charcoal. We wondered what the locals felt about this and whether they thought it was a portent from above.
The effects of the lightning strike the previous day.
The commital was in a small area surrounded by trees and was just for the burying of family members.
The ceremony started in a quiet and restrained fashion although the youngest son seemed angry and had to be ushered away. However after the lowering of the coffin in the previously dug 6 foot deep trench and packing the soil on top things became more relaxed with one of the main funeral directors rubbing talcum powder on to mainly men’s heads and faces as they came forwards to plant cut flowers (mainly plastic) over the burial mound. This caused much merriment. The main culprits were a formidable woman Mrs. Sikopo the wife of one of our senior anaethetists, who sported a full beard and moustache, and I think her much younger and prettier sister. The prank with the talcum powder was not completely without reason. It is traditional for close male relatives to rub white powdered maize in their faces as a sign of respect.
As always none of the deadlines were met and it wasn’t until 16.00 hrs that people started drifting back to the vehicles. The journey back to Monze was slow as we kept stopping, first to secure people on the back of the truck from falling off and then to drop them off in a planned way as we passed close to their villages.
Another amazing experience, again restricting our work to less than 90 minutes for the day but well worth it for ourselves at least.
As always none of the deadlines were met and it wasn’t until 16.00 hrs that people started drifting back to the vehicles. The journey back to Monze was slow as we kept stopping, first to secure people on the back of the truck from falling off and then to drop them off in a planned way as we passed close to their villages.
Another amazing experience, again restricting our work to less than 90 minutes for the day but well worth it for ourselves at least.
As the funeral progressed the sun was seen intermittently and the day warmed, although tonight it is again almost cold enough to require woolly cardigans. The variation in temperature in the last 48hrs is remarkable and probably simply because we are living at 3,000 feet and when the sun goes so does the heat.
Clincal Cases
Finally for this blog two more patients; one a more serious “mango tree injury” in a 13 yr old boy who fractured his spine at the chest level and is at the moment paralyzed from the mid trunk downwards.
He has an indwelling urinary catheter and has to be turned every few hours to prevent pressure sores. His chance of recovery is small; a big price to pay for a mango.
The other, a baby of 10 months who hasn’t really eaten properly since birth had a complete obstruction to the outlet of the stomach. She was just skin and bones. I operated to widen the outlet to the stomach. It is called a pyloroplasty.
Mother with baby waiting in the entrance to theatres with tubes to drain her stomach.
Mike operating with Dr Engulula
Mother with baby waiting in the entrance to theatres with tubes to drain her stomach. 
Mike operating with Dr Engulula
Widening the outlet from her stomach
Three weeks later eating normally and putting on weight fast!
We are off to Livingstone tomorrow Friday at 11.00 by courtesy of the Mazhandu Family Bus Service, big blue luxurious coaches.
The view from the bus at a stop on the way to Livingstone.
We will be getting our first look at the mighty Mosi-oa-Tunya, smoke that thunders or the Victoria Falls in the relative dry season and will be staying at the Wasawange Lodge one of the most expensive hotels in Livingstone with a good restaurant so we will be probably having our first bottle of wine since we left England. The bus fare for the 4hr journey one way is expensive, K70,000 or just over £10. The hotel is also expensive at K470,000 or just over £75 per night for a double room including breakfast. It will be an expensive weekend on a VSO salary! Our next blog will therefore all about our adventure getting to and back from Livingstone and if we are lucky our first look at one of the Seven Natural Wonders of the World. 
Judy editing the blog during a power cut!
Judy editing the blog during a power cut!
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