TIA: This Is Africa

It is with a heavy heart that I write this month’s blog. As of last week, I have been banned from working at the hospital as a nurse / midwife.

The General Nursing Council of Zambia allow foreign-trained nurses to register temporarily for 6 months. In order to renew your registration, you must sit an exam. In June, 3 of us from Kalene travelled to Lusaka for the exam. It was difficult to prepare as we really had no idea what we might be examined in. The paper was rather random to say the least. Questions included ‘what is the name of the bed you make up for an amputee?’* The exam contained multiple choice, short answer and essay questions. I managed to write quite a bit (or so I thought) about the indications for and management of patients with a tracheostomy, while wandering how many hospitals in Zambia have the facilities to care for such patients. I also answered questions about neonatal tetanus and the causes, management and complications of patients with acute renal failure. There were no questions on what one might expect to see on a paper for foreign trained nurses working in rural Africa – topics such as malaria, HIV, TB and malnutrition were not included, which was a shame, as these were the subjects I had spent a lot of time revising. The 3 of us all failed the exam, along with about 90% of the others who sat. The cost of travelling to Lusaka and the exam fees totalled over $1000.

We are hoping that when the provincial medical officer visits next week, he will allow me to continue to work. If he does agree, this will entail another trip to Lusaka to re-register and the re-sit is in November. In the meantime, Fisher Ward is being run by unqualified, unregistered staff. Although I feel that the standard of care has improved recently, attention to detail and use of initiative are still lacking and I know patient care will suffer as a result.

It is difficult not to feel insulted, frustrated, demoralised and bemused. It is easy to be cynical and to see this as a money spinner for the GNC. Systems and processes here seem to be designed to cause the most inconvenience for those who have come to help – 9 years nursing experience, nursing and midwifery UK registration, 2 British university degrees and a diploma in tropical nursing is not evidence enough of qualification or competence for the GNC. We realised that we first made contact with Kalene in 2007. Since qualifying in 2002, most of my decisions regarding jobs and training have been based around my desire to work in the developing world. This kind of bureaucracy in Africa is surely fuelling the cycle of inefficiency, corruption and dependence. This is precisely why so much help is required.

Christine

I have so far been kept busy, despite my loss of role. It has been nice to devote all my time to Christine. She has been an absolute delight and we have felt so privileged to have had her over the past 3 months. Her mother Maria, died at the beginning of September and her grandmother returned to Angola for 3 weeks while Christine remained here. It was quite a challenge to look after her and Fisher Ward! At times, I would just strap her on me and go off on the ward round, much to the amusement of the patients! He grandmother returned last week and she has been coming over to our house so I can show her how to bath her, care for her bad ear, change her and give her her bottle. She is now nearly 3 months old, 4.1kg (she was 1.4kg when arrived!) and smiling lots. We have had some fun times – we even found the most miniature swimming costume for her! We were sad to say goodbye yesterday as she and her granny left for their new home at Hillwood. Still, it is good to know they have each other and that they will be supported there.

I am trusting God to show me how I can serve Him here at Kalene in other ways. There is plenty to do – I just need to try and get over the frustration of being unable to use what I would perceive to be my most useful skills! I have been helping with the pharmacy stock take. I have also used the opportunity to spring clean Bamboo Cottage, which has been timely as my in-laws arrive in two days time ekkkk! Thankfully, I know my identity is secure in God and not in my job and I know He doesn’t ever make mistakes.

Hydro

We’ve had 4 days without power or hot water here which has proved a bit of a challenge! We take it so much for granted! I joked with Mama Kafweku that we’d be coming to her house every night for nshima as we weren’t accustomed to cooking without power! We were lent a camping stove thankfully so we could heat water for Christine’s bottles and baths and make some basic meals. We had to be very organised and ensure we boiled enough water for drinking each night.

A difficult day

A few weeks ago, the maternity ward rang to ask if a 2 week old baby with measles could be isolated in my side room. They brought her down to the ward. I took one look at her and thought she looked dreadful. I went about trying to sort her out, getting IV antibiotics and fluid into her and helping the mother to express milk. I went home at lunch with a screaming Christine to find someone trying to sell me potatoes (usually VERY exciting as they are rare) and that Andrew, our worker had eaten all of the meal I had prepared for us (knowing I was on call and C was in theatre all day!) and the phone was ringing - it was the ward asking me to come back and see someone with a possible bowel obstruction! I went back but before I got to the bowel obstruction, I checked the baby and she looked worse (and I was wishing I'd paid more attention on my SCBU placement) so I decided she needed a nasogatric tube. Thankfully, Kirsty, our paediatric nurse was there to help me. She was just commenting that the baby was very tachypnoeic (breathing fast). I looked at the baby and said, 'Or...apnoeic' - she'd stopped breathing. So we started trying to resuscitate her – we were in the worse place as we had no suction / equipment so we moved her to maternity but after half an hour, there were no signs of response so we stopped. I hate the injustice of situations like this - knowing that a baby would never die from measles or its complications at home. It is a comfort to read God’s promise for the new heaven and new earth: ‘The sound of weeping and of crying will be heard no more. Never again will there be in it an infant who lives but a few days…my chosen ones…will not bear children doomed to misfortune: for they will be a people blessed by the Lord, they and their descendants with them.’ (Isaiah 65:19, 20, 22, 23).

Doctors
The biggest change to Chris’ working life has been the addition of two more doctors. Tess and Phil are a couple from Sheffield, UK. Phil is an anaesthetic registrar and Tess an Obs and Gynae registrar. We have divided the work load so that each doctor nominally looks after one ward each; Tess – Maternity, Chris – Female ward, John – Male ward and Phil – Children’s Ward. The on-call burden has gone from one in two to one in four allowing for much more sleep! The surgical work load has also been divided and having a ‘proper’ anaesthetist around has made operating days less tiring. This is a rough tally of the operating for September to give an idea of the ‘average’ surgery going on here:

Caesarean section 16

Thyroidectomy 4

Tubal ligation 23

Paediatric hernia 4

Adult hernia 4

Skin graft 7

Laparotomy and appendicectomy 1 (very unusual here)

Abdominal-peroneal resection of rectal cancer 1

Hydrocoele 2

Internal fixation fracture humerus 1

Varicose veins 1 (very rare –first at kalene for years!)

Cervical Schroeder suture 1

Omphalocoele repair 1

Hysterectomy 1

Amputation toes 4

Colonoscopy 1

OGD 11

Revision orchidopexy 1

MUA 4

Wound or burn debridement 11

Lateral internal anal sphincterotomy 1 (anal fissure is very rare here, but no medical therapy available)

Abscess 4

Lymph node excision biopsy 5

Lumps and bumps 8

D&C 2

Urethral dilatation 4

Banding of piles 2 (again very rare here)

Cystoscopy 2

Also at the end of August we did a nephrectomy for a kidney tumour

Another interesting case was Clivious, a 6 year old boy who presented with an eye ‘infection.’ Within a matter of days, his whole eye globe was protruding massively. We made a clinical diagnosis of Burkitt’s lymphoma and started a fairly prolonged course of intravenous and intra-thecal chemotherapy and all be it early days, he seems to be cured, despite a couple of hiccups with neutropaenic sepsis and parents threatening to remove their child because we weren’t operating on his eye ‘abscess!’

Celebrations

It’s great to be able to have times of celebration out here in the bush. We celebrated 4 years of marriage and 33 years of Christopher’s life! We had a Mexican themed night (well, to an extent! Basically, this just meant that I made some fahitas!) It was also lovely to have our first visitor from home as well. John Perkins from Newtown, made a special effort to come and see. It was a difficult time for travel due to the fact that election fever had seized the nation! He made it here and he was able to experience Kalene life firsthand and we were encouraged to see a friend from home.

On Tuesday, we will welcome Christopher’s mum and dad to Kalene, so I hope the house is up to scratch by then!! We are looking forward to spending time with them and showing them what we have been involved with here so far.

With our love, Emma and Christopher x

* In case you are wandering, it’s called a divided bed. I was indeed grateful that my students were able to introduce me to the different types of bed that can be prepared for patients, as this was clearly a gap in my nursing education!