Blog9

New Year 2009 on the mighty Zambezi upstream of Mosi-oa-Tunya
“The smoke that Thunders”

Part of the road to Livingstone from Monze is now, after an excellent start to the wet season, almost impossible to navigate with a lacework of deep, wide and water filled potholes around which the 90-seater bus had to weave, sometimes almost at right angles to the direction of the road. One pothole we descended into scraped the base of the bus as we ascended out of it. Often the only way ahead was on a soft hard shoulder now also very muddy and on the verge of disintegration, which, when it happens will tip the bus even further into the roadside bush. The surrounding dry brown bush has been changed dramatically, by the heavy rains. Vigorous green “high as an elephant’s eye” grasses and other equally verdant growth line the road. The new sown lawn appearance of last time has been transformed into swathes of purpley-pink or soft flax blue flowered grasses

Overall we travelled for a third of the journey (one and a half hours) on this sort of road. The driver drove very skillfully and clearly enjoyed the challenge although he didn’t seem to always have his eye on the right bit of road or hard shoulder. We had excellent seats in an executive bus because we arrived early at the Golden Pillow bus station catching the late 11.30 instead of the 13.00. This bus allowed extra room and cushioning for the bumpy road ahead. It also meant we could arrive earlier to settle into the wonderful Tongabezi rondavel right on the edge of, and almost completely open to the mighty Zambezi.

Only an almost invisible fine mesh wire mosquito netting lay between all our rooms (including our bedroom and bathroom)and the warm air flowing from the river.

A family of monkeys was in the trees of the surrounding wood

and we could hear the grunts of a group of hippopotami in the river on the Zimbabwe side. They stand in groups on sandy banks in shallow parts of the river either completely submerged, which they can do for eight minutes at a time,or with their little round ears, eyes and noses just above the water. They spend all day in the very warm water of the Zambezi, much warmer than our pool at home and get out onto the banks to graze at night.

The hippos at a safe distance, yawning and already in the water early in the morning

They share the river with crocodiles, fishermen in traditional dug out boats and a few tourists. When they yawn their heads disappear to becomehuge, wide-open, pink, toothed mouths. They are amazingly large heavy creatures and live mostly in the river during the day grazing on land at night. The boats give them a very wide berth in the river.

We had 3 very expensive nights at resident’s rates with a $100 a night reduction each. It was our b’day/Xmas and anniversary presents rolled into one.

The food was great with amazing breakfasts overlooking the river

with its grunting hippopotamus’, gentle swirling currents and very lazy pace in the lovely warm sun. It’s the by far the best food we have had for breakfast and the South African dinner wine included in the

cost was very drinkable. They put on a special New Year’s Eve show with Zambian dancing in amazing costumes.

On two mornings and one evening, including 31/12, the last sunrise and sunset of 2008 was watched from a boat on the river. We drank Earl Grey tea in the morning

Early morning encounter with fishermen in a dugout on the Zambezi washing and phoning using a mobile in a plastic bag to keep it dry

Fish in one of the two wooden dugouts caught by the early morning fishermen

and a gin and tonic, ice and lemon in the evenings.

It was really quite magical, with tuneful birds, echoing grunts from the hippos, and the rush of water when we came across shallows. Each time we were alone with the boatman on this vast river.

We were taken to the David Livingstone Museum, which took a whole morning but was a fascinating and informative insight into his life. He was obviously a very successful fundraiser. Quite a different impression of him compared to Paul Theroux’s description of a strange depressive man who achieved almost nothing with a total number of converts to Christianity of one man who later relapsed!

We always managed to fit in swimming

before the excellent lunches with wine, reading and a sleep.

However the most exciting event was our visit to David Livingstone Island and a swim in Devil’s Pool right on the edge of Mosi-oa-Tunya “the smoke that thunders”. The Island goes right up to the edge of the Falls and is where the local people took David Livingstone for his first close up view. It was a sacred place when DL first visited which is easy to understand. There has now been enough rain since our last visit for the falls to smoke and thunder and the Island enabled us to go right up to its edge to see the rainbow at the bottom of the plunging water, and as shown in the to be soaked by the spray when the wind changes direction.

To get to Devil’s Pool now requires a walk across narrow rocks, swims across swift currents just above the hundred-metre drop

and a jump into a pool that seems to be continuous with the edge of the falls.

The pool is in fact like Blue Pool on Gower, a deep pot and if you keep your legs down it is difficult to be swept over the edge. Unlike Blue Pool the water is wonderfully warm, and it is the most exciting thing I (MRT) have ever done.

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I did it with four young Greeks their mother, but not father (he stayed on shore)

and three young very strong Zambian swimmers from Tongabezi,

After the swim we retraced our steps dried off and had a great lunch with white SA wine on the island, in a breeze cooled by spray of the falls. I was lucky to get the swim as the trip and swim to the pool is not usually possible after December because the currents get too strong and access to the pool is more difficult. The boat to and from the island was from the well-known 5 Star Royal Livingstone Hotel, luxery – international in style, and with Zambian staff dressed more like colonials – including khaki shorts and topees! Not a patch on Tongabezi.

In good spirits together with lots of indestructible memories and many pictures recording these events we braved the four and a half hour bus back to Monze, economy class but with front seats, excellent views of the potholes, and the driver’s skill in either avoiding them or going sufficiently fast to clear them. He had rare talent in deciding on which of the two strategies to adopt. Occasionally they were approached at 60mph, but he rarely made a mistake! The bus was clearly built of strong metal to cope with the occasional poor decisions.




Clinical Cases

A 23 hr call woke me up and was a request to see a 26 year old patient with possible bowel blockage. We had gone to bed at 21.30 partly because we were tired by the walking to and from work in 100 degrees of heat and partly because we were having difficulty reading by candlelight! In fact when I got out of bed the electricity had been restored, so Judy also got up, and did some ironing, not possible before she retired!

The hospital driver arrived ten minutes later and through the rain, and remembering my umbrella, we made our way to Monze Mission Hospital. As the patient was in Xray I put the umbrella up again and walked the short distance through the darkness to the Xray dept where the patient had been incontinent of faeces on the Xray table and was being cleaned up. This simple event strongly suggested he didn’t have a bowel blockage but he certainly looked very ill, was breathless with a very calm but worried Mother. She told me he had herpes zoster (shingles) three and a half months ago and had tested positive for HIV. He recovered from the zoster but refused anti-retro viral therapy. In December he began to lose weight, three days before this admission he had become breathless and for the last two days his abdomen had become distended and his bowels had stopped working hence the referral to me.

The X-rays,however showed he had an extensive infection in both lungs or pneumonia and the whole of his colon was distended with air reaching to the anal canal.I was grateful that the senior and very experienced but young non-medical radiologist confidently said there was no evidence of bowel blockage and that his primary problem was his chest. I then phoned Dr. Mvula the medical as opposed to surgical doctor on call. He quickly came in confirmed the diagnosis of AIDS related infections and suggested his gut problems were because of an associated fungal infection which can apparently cause gaseous distention. The patient was put on some powerful antibiotics, I was able to go home, again in hospital transport and was very pleased to get to bed at one am. All this was a consultant delivered service as the medical licentiates are still on strike!

The next morning he was, to our relief better and the following day, although he still looked very miserable, he was eating. If his improvement had continued he would have been started on ARV therapy for his HIV and could have lived virtually a normal life for several years with the virus kept at bay for many years. Such is the new aspect of AIDS now with ART. However unfortunately he collapsed and died soon after I saw him.

ART drugs reduce the viral load, so the patients are much less susceptible to infection and the bonus is that they are also less infective. The down side of all this is that people, knowing that HIV is less of a threat may not be so enthusiastic to change their risky behaviour.

Two cases that did have bowel obstruction.

These cases caused me a considerable amount of worry and demonstrate some of the additional problems associated with managing these sorts of cases in Africa. The first and probably the most important is that in almost all cases they have greatly delayed coming to hospital often because they initially try traditional treatments including “scarification”.

The first case was a 40+-year-old man who had extensive necrosis of the bowel, ileum to colon caused by a simple adhesion. As he was very ill I removed the dead bowel

and did an ileostomy. He then developed an extensive abscess in his pelvis and it was clear that he would not be able to manage his high output ileostomy/bag at home made worse by poor supply of appliances. A week after the 1st op we re-operated closed his bag and drained his abscess. He is now doing well but if he has any further complications he is unlikely to survive.

The second was an old lady who looked older than her years with necrosis of her bowel from a simple femoral hernia, which had been left too long.

She recovered very quickly was drinking the next day and in spite of being fully mobile, sitting under the tree outside the ward, disconnected from all her tubes remained very miserable. It was only after a few days I realized she wasn’t eating because her bowels hadn’t worked. After some laxatives, with a result she began to eat, was much happier and could have gone home but was then lodged on the ward for a further 4 days waiting for her son to pick her up from her remote village.

I last saw her looking very happy sitting on the dusty ground at the side of the road outside the hospital with her daughter waiting for her transport: 10 days post operatively, so much for enhanced recovery programmes and Henri Kehlett.