Blog 11

Another trip to Mosi-oa-Tunya and lots of visitors 1/3/09

Vicki and James arrive on Monday 23/2/09!

It had seemed a long wait for Vicki and James’ visit but suddenly after being in Zambia for almost 5 months there they were, in the arrival lounge at Lusaka International Airport.

They had had a fantastic time at a wedding in Kenya in a game reserve and had also been on a safari in the Masai Mara with all the guests.
As the bus we had booked to meet them would not have got us there in time M.B. had very kindly offered his dilapidated Japanese car, (reminiscent of ‘Dukes of Hazard’ meets ‘The Hill Billies’) in which we swept them off to Monze from the airport in the hope of showing them around the hospital and Monze town that afternoon, before going down to Livingstone the next day. The journey went relatively smoothly apart from paying K100,000 (about £16) to persuade a policeman to let us continue after stopping us. He wanted to fine us K180.000 for skidding dangerously to a stop when he flagged us down. He informed us we were not speeding but was fining us because of the way we stopped! I’m still not sure what all this was about but was glad to get away quickly although it cost £16. Needless to say we didn’t get a receipt.

We arrived home for lunch after a short shop in our nearest supermarket Shoprite in Mazabuka 40 miles from Monze. After a quick tour of our 4 rooms and some unpacking we took them for a whistle stop tour of truck stop Monze, its typical urban dusty open market and the Mission Hospital.

We introduced them to some of our colleagues in the hospital and to friendly Joyce from whom we buy a lot of our vegetables.


We had invited one of my surgical colleagues M.B. and our new VSO daughters to dinner. However Dhun couldn’t come as she was back in India following the death of her G’ma but Natasha came




and we had a lovely meal with interesting company and Vicki on very good form.

We were up early the next morning with a taxi booked with Proven to get to the Golden Pillow Mazhandu Family Bus station, for an early 10.30 bus for the bumpy four and a half hour drive to Livingstone. At 9.30 we were called to be told unless we were there at 10.00hrs for an earlier bus there were no spaces for the rest of the day! In a mild panic we were ready for Proven at 10.00hrs for the 5 minute trip but predictably Proven was late. He eventually turned up 20 mins later after a second phone call but we still managed to catch the earlier bus because it was late! A case of two lates make you early in Zambia. We had our lunch on the bus which required extraordinary skills and co-ordination to get our sandwiches and coleslaw to our mouths between the bumps without sharing it with the other passengers. We were in spectacular Tongabezi on the banks of the mighty (and mightier than our last visit) Zambezi, in time for tea.
We had a great time talking to Vicki and James, and again watching the sun rise

and set on the silently flowing Zambezi, apart from the birds, hippos and occasional rapids. Our thirsts were quenched once again with either Earl Grey tea on the early morning sun rise boat trip or a slightly dilute (for us!!) gin and tonic with ice and lemon watching the sun set on the Zambesi. The food was consistently superb for all meals, but particularly for lazy lunches with excellent wine, on a wooden platform almost hanging over the river looking across to the Zimbabwe side. We sat in the warmth under vast open skies of towering white clouds with a backdrop of deep blue.

This alone would have replenished us for another month or two in Monze but we also saw a much wetter Mosi-oa-Tunya both from the air in an unbelievably expensive, but probably worth, it thirty minute helicopter ride

This shows the wide meandering Zambezi above the falls, the long narrow gully it falls into and the previous gullies it previously created now in Zimbabwe

as well as from the end of David Livingstone Island and looking at the rainbows directly over the edge of the falls,

and getting absolutely drenched by the thundering spray while walking on the other side of the falls.
We dried out in the warm sun sufficient to burn MRT.’s bald patch while Judy, Vicki and James spent a long, long time bargaining to buy the right hippopotamus at the right price.


We also had one evening meal at Tongabezi on a floating platform lit only by candles ten yards from the bank, with food and wine ferried to us in a boat.






We were serenaded by some of the staff who came out to us in a boat and sang a welcome to us at Tongabezi. Some of us thought this was very romantic watching the electric storms lighting the sky on the Zimbabwe side but unfortunately the candles attracted tens if not hundreds (and thousands) of unwanted flying alternative guests of varying sizes so that at least one member of the party had difficulty in getting her food to her mouth through the small gap she had left between the edges of her scarf which otherwise completely covered her head and upper body.




Needless to say we asked to be ferried back to the shore for coffee although some of us found our flying visitors seemed to be less of a nuisance as the wine rapidly evaporated in the wonderful warm air over the gentle waters of the Zambezi. We slept very contentedly to the music of the Zambezi. Next day after breakfast by the Zambezi

Vicki and James flew back to Lusaka, then to Nairobi and finally home. We treated ourselves to an extra night at Tongabezi before taking advantage of the Mazandu Family bus back to Monze.

Visit to Chikuni Village and Mission Community

We are still meeting new people, visiting new places and learning more about the country. We were offered a trip to see Chikuni Mission Hospital, and managed to arrange to go when we both had very little in the way of other commitments. Chikuni is about twenty kilometres south of Monze and about ten kilometres along a very rough road, off the main road from Chisekesi and across a river by means of a ford. It is run by Claudia an Italian doctor, who has been there for several years. She sometimes brings cases into Monze in a 4WD such as complicated obstetrics and car accident victims and so is quite well known by the medics in Monze. We approached the isolated village along the uneven road and saw several streets of well kept single storey modern dwellings with neat gardens. It was very different from Monze, Fratton to Hambledon in about the same distance! We were welcomed by Claudia and shown around the hospital. It has been built by the Roman Catholic Church and has quite a European feel to it. Everywhere was clean, light and well maintained. The wards, lab and x-ray department all open onto a large courtyard garden, with a huge majestic tree in its centre. The new HIV/AIDS centre was opened last year and even has a well-equipped waiting room for children. This area has the atmosphere of an open-air café with seats and tables under umbrellas. There is even a meeting room where an educational day conference was taking place. We were asked to introduce ourselves as we peeped in, and so discovered we were interrupting its recording. This was being done by the local radio for broadcasting later! Claudia also proudly showed the building extension to the existing operating theatre. The new complex is of considerable size and we could see quite a lot of equipment there waiting to be used.

The whole hospital appears to be run by Claudia. She is the doctor in charge with the help of two or three clinical officers. She organises the maintenance and building works as well as all other administration. She keeps meticulous records and seems to know most of the statistics off the top of her head. It is all incredibly impressive particularly the data about HIV. Accurate positive rates are very difficult to establish in well defined complete populations but in Chikuni in pregnant woman they seem, as in all rural areas to be lower at about 16%. When she finally goes she will probably be replaced by three other people. Her enthusiasm and energy is impressive but she did look tired and seems to have little support.

After this we were taken to the local radio station.

This is a state of the art broadcasting and recording building, set up by the Christian Brothers, who run the Catholic Church here. It is run by an Irish Brother who is self taught, with a back-



The Irish brother with Violaine and second son (right) and Claudia the very hard working doctor running Chickuni Hospital.

ground in electrical engineering. There are educational and public service broadcasts, used by the schools and quite an emphasis on music, as the radio organises a Tonga Pop Music Festival in August to which thousands of young people come. They also offer work experience to older school children. After this we had lunch with Claudia, who offered a pasta course as well as chicken and vegetables. There was chocolate mousse for pudding, and coffee – a sumptuous feast for lunchtime – or indeed anytime here! We were joined by a Cambridge medical student who is doing his elective with Claudia and cooked most of the lunch. If he only sees Chikuni he will probably never know what the real Zambia is like.

Our transport had to leave after this, so we lost the opportunity to visit the Cultural Centre and excellent bakery. The hospital seems to be funded by Christian charities and run by Claudia, and we wonder how long it will take for the local people to take it over and run it in such an effective way. We are sure the folk there appreciate and contribute to it all but when will they be able to run it themselves without all this input and financial support? The community, mostly the women I would guess, are also developing income generating schemes, selling packs of vegetables that they have produced having first dried them. But where will they be sold other than as currently in the Diocesan Centre and who will buy them other than ex pats and volunteers? Without vehicles it is a long trek to Chisekesi. There now seems to be more invested in education and health than in the past, but is it just a form of neo-colonialism? It is just by accident that Chikuni Hospital is so remote – as the local Chief had got muddled as to which religious group he had sold his land to.

How different it would have been if they had been close to the main road instead of forty minutes by car down a rough track. Claudia’s dream of doing more than minor surgery in her new operating theatre will never come true unless it has the support of the Health Ministry, and patients with more than simple problems will have to continue to face a difficult transfer. We wouldn’t have missed the experience for the world, and it would be interesting to know how many of these small ideal enclaves there are scattered over Zambia.

The Holy Family looks up!

Another new person in our small world is Theresa, who has come to take charge of the Holy Family Centre, which is a rehabilitation centre, mainly for children, and focussing on physiotherapy, which is her background. Judy had met her when travelling back to the UK in December. She is very lively with a load of energy, and charged with updating the facilities at the centre as well as improving and expanding the services. Maggie, a friend, was with her for the first three weeks and it was very impressive to see how much was achieved. As well as discovering disused buildings that should be demolished, a container with sixty-five hospital beds (she plans to sell most of these), wheel chairs and bicycles, she also found two eighteen year old boys who had been abandoned by their families and were living with the young mothers when they brought their children in. She could see a scandal in the making. Like a whirling dervish - yes, she has lived in Egypt - she has sorted all this out, renovated and redecorated her own bungalow plus accommodation for volunteers and generally has an iron fist in a velvet glove. As Maggie left, Mo, Theresa’s husband arrived, plus two volunteers, Aidan and Maeve. Mo seems to be a displaced person of the first order, and has Irish, Canadian and Egyptian passports! He is Palestinian by birth – still has family in Gaza – but his immediate family has finally settled in Cairo. He met Theresa when they were both in Canada, where she first worked after qualifying. He is older than her, and her first home with him was with his family in Cairo, where she seems to have learned lots of skills for life here. They seem to have spent a lot of time in the Middle East and Mo has now retired, but still with some business interests. Theresa still has a lot of energy and is clearly not ready for retirement yet and we suspect she and Mo will greatly change things at the Holy Family. We have continued to be constantly entertained and informed by numerous visitors which seems to be so much an integral part of being an ex-pat in Africa. We mention Brad and Tom in the clinical part of the blog who have joined us at the parties, BBQs and swims with our new friends at the Holy Family, Theresa together with Mo, Maeve and Aidan, and Eric and Carol from the States who have been working with Natasha and Francis in sports for kids.


Brad on the right, Mo front central Tom and Michael between Mo and Brad. Thersa,Carol and Aidan facing out from the back. Judy front left with ? Maeve behind!

This weekend Tom has visited from Lusaka. He is doing VSO work coordinating NGO’s who are trying to mitigate the effects of HIV/AIDS in women, and is also the chairman for the VSO volunteers in Zambia at the moment. He travels around Zambia meeting the volunteers so gets a very good overview of what is going on. He met Jane L (volunteer in Livingstone), who, with her husband, had had dinner with the very young President of Rwanda, who persuaded them that they were now determined to put an end to the Hutu/Tutsi genocide war by peaceful means. Let's hope he is successful. We also talked a lot about how important it is to minimize the harm that can be done in trying to help Zambians move into the modern world, which is now so evident to all of them through all the new methods of communication including satellite TV. Satellite dishes are growing like maize in a good wet season.

Clinical Cases

I was hoping that after the busy weekend of the gunshot wounds that the next 2 would be quiet. This was not to be.

Sigmoid Volvulus: a twisting of the gut!

The following weekend I had to see 2 cases of sigmoid volvulus late on Friday evening and could not operate on either because we ran out of oxygen at 02.00hrs Saturday. One died on the table later on that afternoon because of bleeding from the spleen and because we had no blood for transfusion!
Both cases had extensive necrosis of the sigmoid colon but the second also had severe damage/ischaemia to the rest of the colon, which led down the path to attempts to remove it resulting in damage to the spleen. This was partially calcified and severely stuck to the diaphragm. Although we eventually controlled the bleeding from the diaphragm, (the splenic vessels weren’t a problem) he had probably bled down to 10% of his initial blood volume, which we could only replace with simple saline (no blood).
In retrospect I should have left the “bad” colon in and taken the risk of it making him very ill subsequently, rather than taking the risk of blood loss from removing the colon without blood for transfusion. These are new clinical scenarios for me and hopefully I will make the right decision next time. Fortunately I was joined by Mr. Banda to explain to the distraught relatives of this man that he had died inspite of all our best efforts. His bowel might have been in a better state and not needed removing if we could have operated on him 12hrs earlier, if oxygen had been available in the early hours of the morning.

Fortunately the second case did very well and went home a week later. I did a temporary colostomy that we can close in 6 weeks time.

I tried to deflate both cases from the lower end but the twist was too tight in both and at any event it was clear the colon’s blood supply had been compromised as shown by bloody mucous in the lumen of the bowel. It is said that it is possible to decompress the majority of these and avoid major surgery but I have succeeded in only 1:4 probably because they mostly present much later in Zambia.

Although I had a very quiet week, the weekend was again busy just before Vicki and James arrival on Monday for our week’s holiday!

First of all I was called in early on Saturday morning before breakfast while we were doing some gardening before it was too hot. I quickly shaved and had breakfast and as the hospital transport had still not turned up in-spite of two phone calls I walked in under the now burning sun. I arrived drenched in sweat to find M.B. had already removed another necrotic sigmoid volvulus in a 41-year-old 29-week pregnant woman. The problem was that she also had dead and twisted 60cms of terminal ileum and ascending colon. Around the very large uterus we removed the dead part of the bowel joined it back up and also joined the 2 open ends of the colon left after removal of the twisted sigmoid. We decided not to do a stoma, as it would have been very difficult to site it. The next day she was looking very well, was eating and drinking very quickly and although she went into labour a week later and had a healthy live baby who is doing well it means so far, 200% survival.

A 12 year old with possible re-perforation of small bowel typhoid ulcers.

MB and I were looking at this woman in ITU on Sunday morning after mass and congratulating ourselves on her excellent progress following resection of small and large bowel, when we noticed a very sick 12 year old boy who had had surgery for a double perforation of his small bowel, probably secondary to typhoid 3-4 days previously. He had green intestinal contents coming from his wound and as he had had a join (anastomosis) in his bowel we thought it must have been leaking. I phoned the surgeon who had done the previous operation and together we did further surgery after persuading a very reluctant anaethetist to put him to sleep, especially because he had already had a cardiac arrest during his previous surgery. In fact at operation we found he had not leaked from the join in the bowel but had a further perforation beyond the sutured join in his bowel. His tummy was full of intestinal contents with severe peritonitis for the second time, his blood pressure was very low 50/20 but he rallied quickly after washing him out. We did a further resection of his bowel and then brought an end out as a stoma as we didn’t think it was safe to join him up again. We will be using stoma bags supplied by Carol Sturgess given to Vicki by Emma to be delivered the day after the operation!! Great timing! Thank you Carol and Emma. He has survived the week and I will be seeing again him tomorrow.

Simon under the watchful care of his grandma

10/3/09 The boy continues slow improvement although the whole of his wound has fallen open,

there is little healing and he remains very weak. It’s a good job no further anastomosis was done. I am encouraging him, with the help of his grandmother his only visitor who always greats me with a short bow and speaks no English, to eat his nshima including salt and “porridge”. Porridge is simply dilute ground maize compared with thicker stickier nshima. However as with the malnourished babies the nutritional nurse from the paediatric ward is arranging for his 10.00 hrs feed it to be supplemented with soya bean milk. I have also bought him a bottle of golden syrup to put on the porridge at which his very large and at the moment sunken brown eyes lit up with a smile for the first time.

His best hope for survival is being able to eat as we have no other forms of nutrition available like intra-venous feeding or even an elemental diet. He and we live in hope and I suspect a considerable amount of trust. His ileostomy is difficult for him to accept and the nurses to manage but at least we have a great supply of ileostomy bags, which are keeping most of his bowel contents out of his wound. We are now encouraging the ward staff and his grandma to take him out into the sun in a wheel chair. He still cannot walk or stand, that is the next step and then will come the difficult decision of when we should close his stoma, a smaller operation but still not without risk if we close it too early. The problem is that if we send him home with an ileostomy we may create even bigger problems. He may live in a rondavel in a hamlet, several hours from the hospital with no running water, a lot of dust and no support. I will let you know how he gets on in future blogs.

He was eventually transferred to the Holy Family for convalescence and feeding up! He really rapidly improved, gained strength, his wound healed with the careful care of one of the nursing brothers and was eventually re-admitted and had an uneventful closure of his ileostomy putting him back to normal. The Holy Family bought him a bike, paid for him to go to a local school and arranged for him to live with his uncle in Monze closer to the school. Over all a great success and it was a privilege to be able to help him. I hope the medical staff understod what can be achieved by persistence, good surgery at the right time and the importance of nutrition.

I hope the next few w/ends will be little quieter. (They have been so far!! 10/3)

Two Cases of imperforate anus (IA) repaired at Monze Mission Hospital (MMH)

In a previous blog I recorded I did a trephine colostomy in a newborn girl with imperforate anus( IA) and MB had a previous case now 3 years old also with a colostomy waiting for definitive surgery. MB had told the mother to bring the child back on the first of March 2009 for surgery and had written this on a torn piece of brown cardboard paper. He was worried when she didn’t turn up on the first but his delight was clear when she did arrive on his doorstep one early morning a week later clutching the piece of cardboard with a small baby on her back and the patient walking at her side. She had not knocked on the door just waited anxiously until he emerged, said not a word, presented the piece of cardboard and watched MB as in his delight he checked the child’s tummy for a stoma. She never spoke and I suspect she couldn’t either speak nor understand English. MB immediately organized her accommodation.

Imperforate anus is when children are born with no opening at their lower end and have a complete bowel blockage. They have to have emergency surgery at birth to relieve the blockage with a colostomy or they would die.

One of MB’s many talents is to arrange for a stream of various specialists to visit MMH. This time it was Brad F. a very experienced paediatric surgeon from Minnesota, who is a colleague of Stanley Goldberg and David Rothenberger.



He was visiting Zambia with a church group, including a young Welshman called Tom from Swansea. The group was seeing patients in clinics in Lusaka and Tom was introduced as a pharmacist, as he helped distribute drugs at the clinics. MB had arranged for Brad to come to Monze to do the I.A. cases, of which he had great experience, doing around eight to ten a year in the States

The first case, in the baby I had done a colostomy at birth went well.





The second unfortunately died on the ward less than 24 hours post operatively.

Both cases were relatively straight forward although in the second we had great difficulty in catheterizing the baby pre-operatively because of the recto-uretheral fistula

Repair of IAs are now done by exposing the rectum through a long mid-line incision in the perineum and completely dividing all the sphincters and the ano-coccygeal raphe. An amazingly bold approach but much simpler than I remembered from many years ago. The first case we also dissected the rectum off the posterior wall of the vagina and in the second a recto-uretheral fistula had to be divided with repair of the resulting defects in both tubes.

The pelvic floor muscles or cone, including a very dispersed stretched out external sphincter is then snuggly re-constructed around the lower rectum/anal canal. The rectal mucosa is sutured to the buttock/anal skin at a site identified before an incision is made. In the second case the area where the anal opening should have been had the appearance of a splayed out anus with the anal ruggae still just discernable.

Apparently reasonable continence is achieved in the majority of cases in-spite of any really obvious external anal sphincter and anal canal. However, although the first case seemed to have reasonably good muscle and will probably have a good functional result when the colostomy/stoma is closed in 2 months time, the boy in the second case had a much less chance of being continent although it is difficult to know without closing the stoma.

The second patient never fully woke up after surgery and MB first learnt of his death when the patient’s mother again turned up on the doorstep of his house early the next day, in tears with another torn off piece of cardboard with a very different cryptic message. It simply gave the number of the child’s place in the mortuary.

She had no where else to go before going home so she sat down outside the house silently weeping intermittently breast feeding her new baby still wrapped closely to her.

Well that’s all for the moment. We are almost half way through if we allow for our accumulated leave. We are beginning to yearn for a bit of snow and our two weeks skiing (at least) with the Penns next year and to see you all again.

We are expert canasta players and Judy wins almost as often as I do so it was just the cards before or has she just learnt to play like me!!??

However we are not missing the weather and may be going to a meeting in southern India in February next year so hopefully skiing trips can be either side of this.

We remain well and happy.

See you all in June.