Time critical

Photo of the week

Highlight of the week: Our first high blood pressure and diabetes clinic in Kakumbi kicks into action. 24 patients. 4 clinicians. Inertia overcome. Newton’s second law in tatters.

Lowlight of the week: 4 late night calls leave us feeling knackered.

Maximum temperature: 37 degrees Celsius

Rainfall: No

Four hours. A not unreasonable expectation. 21^st Century England. From the first signs of a stroke to definitive treatment. Morbidity minimised. Lives saved. Specialist hospitals. Super-specialist doctors. Doctors who only deal with strokes. Rapid transport. A system that works. Much of the time. Remind me not to complain about the NHS in November.

Some calls sound innocuous. But some have a nasty sting in the tail. For once, I’m not talking about scorpions. On Thursday we had a request to follow up a lady after a bout of D&V. We naively suspected an easy ride. So much so, that we packed an extra bag with chocolate and whisky. With the expectation that we would make sundowners at Rob and Emily’s house. An opportunity to catch up with old friends. We anticipated enjoying good company and the setting sun. And an unbeatable view over the Luangwa River.

It was a request to see Mary. An indomitable tourist. A long-time safari addict. Could we review her on her way to the airport? To confirm she is fit to fly? Straightforward enough. On the way, we divided roles: I would do observations. Pulse. Oxygen Saturations. Temperature. Blood Pressure. Keith would talk and examine. Nothing too taxing. The Birrell team at work. Organised. Professional. Competent.

At 15:30, 2 hours before sunset, we pulled up to the clinic. Our meeting point. The safari vehicle lay in wait. Mary’s daughter, Hayley, stood beside the car. Looking worried. Mary invisible. But a shape on the back seat emerged. Slouched to one side. Mum is not feeling too good. She suddenly became sleepy. Just as we arrived in town. She wanted to lie down.

My gut constricted. This does not sound good. An unspoken thought. We glanced at Mary. Face asymmetrical. The left cheek drooping. I can’t move my arm. Mary mumbled. It’s like a useless flipper.

Mary was having a stroke. Yikes. Keith’s, and my, dilated pupils met. The stakes had just been raised. This was happening right before our eyes. Things were evolving as the cogs in our minds connected. We sprang into action. Observations. Talking. Assessing. We kissed goodbye to sundowners. In Zambia we have no realistic chance of meeting the 4-hour window for stroke treatment.

But now what? There were immediate decisions to be made. Mary needed somewhere to lie down. To be properly assessed. A holding bay. Until transport could be summoned. What better place than our brand-new hospital? 30 minutes up the road. Right next to the airport. With the possibility of a CT scan to boot. We spoke to their driver. Keith hopped into the car with Mary and Hayley. I followed in Mzungu. Soon their car was out of sight. Max Verstappen at the wheel. Keith feared for both his life, and the lives of the Mfuwe valley residents. Please slow down. It’s not that urgent.

Mfuwe district hospital was expecting us. Keith had called ahead. Not exactly a welcoming committee. But at least a room was made available to us. A bed. A generator. Even air conditioning. I chatted to the staff. Any chance of a CT scan? I was met with smiling faces. Hopeful….. But, I was given a long-winded reply: We have a CT scanner. It’s down the corridor here. I am the radiographer. I looked at him expectantly. And? I urged.  Ah madam. We have a problem. It is off-line. Not working this week.

Saying no is not the thing here. Part of the culture. They would rather give a qualified “yes”. No matter. No CT scanner would save us time, pre-transfer. Mary was already on aspirin and a statin. We should crack on with calling the flying squad. Mary needed to be in a proper hospital. One with doctors and specialists. With nursing staff. With intensive care support if necessary. With appropriate drugs and equipment. Our lovely new hospital building has none of these things as yet. It is a beautiful building. Well designed. Well built. But currently it is just a holding bay. Somewhere to prevaricate. To wait. A hotel.

A flying squad was just what Mary needed. But more of that later.

We have previously described our interactions with insurance companies. On Thursday, we crazily hoped that in 2024, liaison with an American insurance company would be easier. We know the mechanics of medical evacuation. Slightly complicated by the need to med-evac Mary to a decent stroke unit in Johannesburg. Not Lusaka. We knew that Lusaka did not have all the know-how that Mary needed. And so the process began. But we were in the middle of a power cut. Load shedding, as they call it here. Rubbish internet signal. Poor telephone reception. No such thing as a landline. Calls went through and dropped out. Information given over and over. The search for a hospital in Jo’burg. Bounced from pillar to post. Reminding me of a skit performed by the class of ‘88 in our annual medical review.

The skit was based in a courtroom. Two opposing sides. A judge in the middle. Each side trying to make their case. Each side trying to shirk responsibility for the care of a patient. The patient had a nasty bleed from a stomach ulcer. Was this a medical problem? Or a surgical problem? Remember that I trained in the days of yore. Well before a specialist Gastrointestinal team had been conceived of. Each side argued their case. Sloping shoulders. Nobody responsible. The judge decided who made the best case back in ‘88. In 2024 our friend Gid helped me to find a possible hospital. Their website looked good. I lost count of the number of dropped receivers and dropped calls. After an age, I finally spoke to an emergency doctor. He told me I needed a neurologist. The neurologist told me I needed a physician. The physician told me their hospital was not the best for Mary’s problem. She suggested somewhere else. Repeat. Ad nauseam.

In the meantime, I briefed the insurance company. And I informed the evacuation company. All we needed was for the dots to be joined. To create the image we were after. Of a flying squad. An aeroplane. With a skilled transfer team. By now its 18:00. How time flies. I called the airport manager. What time does the airport close? Mr Sidecki told me we had 30 minutes before the runway lights went off. And the staff went home. Negotiations started. I told him of our predicament. He promised to keep the airport open a little longer. Until we had a plan. And then a plan seemed to come together.

The transfer will be in the morning. We do not have an aircraft today.

 So much for a time-critical problem. Now we needed to get tough. Why should we accept second rate care? Why settle for a bad decision? Back to the insurance company. They told us they had approved the transfer tonight. Back to the transfer company. They wanted cold hard cash. A previous sour deal with an insurance company Is the client able to pay direct to us? And then claim back from the insurance company? Who would say no to this?

Hayley was aware of how critical things were. And money really does talk. At 20:00 Hayley’s bank account was emptied. At 20:00 everything was in motion. A plane scrambled from Lusaka. Another coming from Jo'burg. A wing-to-wing transfer, planned on the apron in Lusaka. Not in the air, thankfully. And the evacuation team finally found us a decent hospital in Jo’burg. A doctor willing to say yes. I give Hayley and Mary a thumbs up. It is happening tonight.

And then at 21:30, one of the most unusual calls of them all. From the Zambian air force. Do we have a medical evacuation? Where is the plane now? I reply that it is somewhere between Lusaka and Mfuwe. Surely they have radar, and surely they should know better than I! And then the penny drops. They are asking about the South African plane. Heading for a Lusaka rendezvous. They had spotted an unusual pattern of flying. A small plane coming from Jo’burg to Lusaka in the middle of the night. They wanted to check that the flight was legit. Not a drug smuggler. No illegal activity.

Reassured, the air force let the flight through. No need to scramble the jets. No need to shoot it down. But it led me to the question. Does the Zambian air force even have any fighter jets? Or missiles for that matter?

The next leg of Mary’s evening was less fraught. A 5-minute ride to the airport. Kept open at great expense. US$ 500 per hour. We counted 15 members of staff. Security. An ambulance with blue flashing lights. Driven on to the apron, for effect, rather than function. Keith rode with Mary in the safari vehicle, to bypass security, and meet the flying squad. A nurse showed her face. Managers met and gret (sic). Our personal belongings were scanned. The plane descended from the sky. On time. A pilot. 2 paramedics. We helped to load Mary onto the flight. And bade our farewells.

No records were set. 7 hours from start to finish. As usual, bureaucracy tied us down. Treacle. Red tape versus money. A predictable battle. Expensive insurance policies not worth their salt. False reassurances from overseas. We did what had to be done. Conducted an orchestra of dissolute players. Finally making fine music. The dots joined together. Our patient dispatched. The best of Zambian care.

I'm stumped

The arrival of the Flying Squad