Hospital madness - A magician at work

Photo of the week: Elephant family come for a drink as we commute home from work

Highlight of the week: Close ups with elephants, with no fear

Lowlight of the week: A sick boy with a life sentence

Maximum temperature: 33 Degrees Celsius

Rainfall: Rather dry

The witching hour. Strange medical things that go bump in the night. 02:00 - 04:00. A time best left to the fairies. Not a time for us mere mortals to be troubled. Bizarrely, I have never seen, or been seen, at this time. For the entirety of my career…. So far…. My juniors never needed to call me…..

Evenings in South Luangwa are typically quiet. Gone are our days of raving. Partying ‘til dawn. Going to work on a hangover. Thinking that sleep is for softies. Our middle names are now Responsible. The irrational vigour of youth spent. We crave our due ration of sleep. Downtime part of the mix. Occasional nights out remind us of the heady days of our youth. Yet even those nights fizzle by 21:00. Especially on a school night.

It's 19:30. We have eaten. Taken our antimalarials. Cleared up. Prepared our bags for the morning. It’s wind-down time. I prepare for bed. Crawl under the mosquito net. Read. Chill. The lights should go out at 21:00. But Keith calls out: Don’t get undressed yet. We have work to do.

I’m tired. Bummer. I groan. It has already been a long day. Nowhere near the witching hour. But still, my relaxation plans have been destroyed. Grumpily, I emerge from the bedroom. We steel ourselves for the next bout.

Jack is having some kind of mental health crisis. Can we help? We try to gather more information. We are told that Jack is staying in a camp up the road. He was due to fly out today. But he was too distressed to get on the plane. Could you see Jack? He might need sedation. We do a quick stock check. Oral and intramuscular magic. Cushions for the mind. Medicines that calm and protect. We hop into Mzungu. Our white Hilux. And head toward the camp. Thinking aloud.

Thinking is allowed. Although many clinicians seem to fire from the hip, way too often. A great joy of medicine is the challenge that it offers. No two patients are truly alike. Our shared job as Valley Doc a precious thing. For each conundrum we see things with different eyes. We bring differing views. Approaches. Spin things different ways. Synergistically, not oppositionally. Problems halved or at least shared.

Our journey to see a patient is a crucial phase. Thoughts collected. Approach negotiated. Tasks apportioned. A flexible plan, mapped out. A goal at least. In this way, we arrive with purpose. Our clients see confidence. To inspire confidence. Part of the battle. Anxiety muddies the water. Clarity is needed.

Jack sounds agitated. Clouded thoughts. The product of medical, chemical or psychiatric forces. But we must not jump to false conclusions. Run before we can walk. My task will be to gather information from those around Jack. Keith will aim to engage with Jack.

The phone rings again. There is confusion. Jack is on the move. No longer at camp. His colleagues have taken him to a clinic. But which one? Kakumbi? Or Velos? We stop on the road. Ten minutes triangulating. Velos the new plan. Our drive resumes. Velos is a short schlep. 30 minutes under Mzungu steam.

It’s 21:00. We arrive at Velos hospital in synch’ with Jack. He is sat in the front passenger seat of an open game viewer. Held fast in a caring embrace by a young lady. Settled? We rashly venture. But as we approach, it becomes clear that all is not well.

A flash of anger. Menace. Fearful eyes. Words betray his paranoid state. The car door thrown open. A stare, insistent that Keith should not approach.

Jack’s agitation propels him away from us. Fortunately, the hospital parking lot is a safe space. Well lit. Fenced off and elephant-free. He mutters at nobody in particular. Pacing. His girlfriend heads his way. To shepherd him. At least there is no suggestion of any getaway plan. But Jack’s inner turmoil, and our challenge, won’t be resolved anytime soon.

Whilst our patient mutters and paces, I peel off to focus on my preassigned task. To seek further information from Jack’s colleagues and his partner Lucy. Keith phones a friend. Jack’s best friend. Jack’s brother. Rudi.

No history of fever. No rash. No unusual insect bites. No illness. A four week steady decline in work ability. Change of attitude. Reports of being confrontational. No history of alcohol abuse. No drug use. He hasn’t slept well for the last week. Not at all for the last 24 hours.

Keith speaks to Rudi, one thousand kilometres away. Rudi and Keith share their intel. And then Keith begs a favour: A reference from Rudi that will likely help Keith gain Jack’s trust.

Nothing in the gathered stories suggests an acute medical illness. Nor a toxic response to chemicals. That leaves a psychiatric issue. Acute paranoia. Disturbed thinking, without a physical or so-called organic cause.

The phone is spirited to Jack. Opening an intracontinental dialogue. Initially, Jack’s paranoia puts the kybosh on our preferred way to Jack’s heart and mind. The phone is thrust away. The tarmac impacted by the phone’s resilient case. Strike one. The use of someone else’s phone is eschewed. Not to be trusted. Try harder Doc.

Reaching the end of the opening salvo of our plan: Keith and I reconvene. The plan needs some refinements. Some detail. Some contingencies. Trust is key. A shared plan with patient and docs might involve sleep and calm. Chemically induced calm, for a troubled mind, is best taken by choice. But how do we help Jack to realise that our choice can also be his choice? A photo of Jack’s chosen medicines give Keith an in. Sleepers seem to be an acceptable option. Lucy is tasked to ask Jack if he would like a sleeping tablet. A chill pill. A rest.

Amongst our contingencies is the nuclear option. If anxiety, anger and agitation make it impossible to play the softly-softy approach, our plan B is an injectable chemical cocktail. Designed to go into a big muscle and to work fast. But fast is a relative term. Intramuscular injections take several minutes to down an angry bull. We just can’t fire from a safe distance. We need to be up close and personal. Jab into a held thigh. Hold the anger and the power of the challenged creature. We have a collection of burly security officers and clinicians on hand, ready to hold limbs. To take the strain.

We touch base again with Rudi. Jack’s brother is resigned to a compulsory detainment approach. His words consent to the use of necessary force. Rudi is in the loop. He knows of the need to protect the safety of Jack’s carers. He recognises the therapeutic properties of the proposed sedatives. Keith arms himself. With a mixture of drugs that he is familiar with. Just the right blend of anxiolysis and counter-paranoia. A syringe of the possibilities lies up his sleeve. Yet Keith bides his time. Seeking even now, to find a key to Jack’s heart. A key to Jack’s mind.

The prospect of a scrum, centred on Jack is not relished. It would take away Jack’s dignity and his free will. It’s rarely therapeutic to act in this way. Occasionally a necessary evil. A route toward mutual safety. But it is also a retrograde step. A step backward from trust. After forceable detainment and chemical assault, it’s an uphill battle to re-establish trust. Keith later tells me: that in 24 years as a GP he had never sectioned a patient. Not a single patient, sad, mad or bad, had needed treatment, against their will, in 24 years. I suspect witchcraft. Why else would all of his patients follow the party line, pied piper of Hamlyn style, for all of that time? But I had never seen this wizard casting spells before now.

Jack and Keith dance. Not the traditional steps. But they size each other up. From a distance, at first. Jack brushes Keith off. You are using the wrong words Doc. He chides. Keith takes the verbal punch. But he now knows that he is inside Jack’s armour. Somehow, they end up physically closer. On the floor. Keith ventures an arm. Holds Jack’s back. Physically and figuratively. Keith offers Jack medicines to allow him to rest. To calm his over paranoid mind. They joke about the phone holding Jack no ill will. Keith’s sleeved arm hidden from view. Just because you’re paranoid, doesn’t mean that nobody is out to stab you. Keith laments inwardly.

Keith borrows Jack’s phone to call Rudi. Rudi’s voice calm and measured. Rudi and Keith wrap Jack in emotional cotton wool. They talk of common passions and pet hates. They guide him back to what usually makes him tick. And how to put his tick back.

Keith turns to me, and in semaphore, he asks if now is the time for the jab. But both of us know that Jack is under Keith’s spell. No need to use skulduggery. Keith softly suggests that Jack might accept a sleeping tablet. You look tired my friend. The friendship is accepted. And Jack opens his mouth. Why don’t you lie down Jack? Would it be OK for me to give you another medicine? A medicine that will cushion you from your paranoia. And allow you to be yourself again? Assent. The rabbit in the headlights, closes his eyes and nods meekly. Wanting to feel better.

The hospital security team stand down. The duty clinicians drop their shoulders. Relax. We shepherd the informal patient to a private room. Jack volunteers to swap white linen for polished hospital floor. He gains comfort from medicinal cushions and a hospital mattress. It’s 01:00. The witching hour is not yet upon us. But Keith already knows that no magic will be required tomorrow. He bids Jack goodnight and promises to call by in the afternoon.

We procure Jack some food. But he is already gone. Off with the fairies. Sleep and reality envelope him.

We climb wearily into the car for the drive home. I am full of awe at Keith’s abilities. I have always known about his patience. But to watch him in action was quite something. His calm demeanour. Gentle voice. Kindness. Care. Patience. Knowledge of the right thing to do. And how to do it.

Our bed at home welcomes us. Our deep sleep matches Jack’s. A traditional alarm clock, set for a later start, our offset. Morning exercise omitted. Sleep too precious.

By chance, we are due at the district hospital the following afternoon. An educational talk from a visiting surgeon. Keith breaks off to see Jack. I follow him after the talk. I am greeted by a lucid Jack. Smiling but sheepish. Worry and sadness in his eyes. Full of apologies for his behaviour last night. He gives me a hug as he cries softly. The hospital psychiatry team and Keith agree. Jack is safe to leave Velos today. His colleagues will keep tabs on him. He flies to be with his brother, care and comfort within 2 days. Regular sleep a key part of his prescription.

Our district hospital has played another blinder. The right environment for an ideal outcome. Seized from an inauspicious set of circumstances. A rabbit caught in the glare of oh-so-bright headlights, is somehow pulled to safety. As if from a hat. By a magician. By my husband Keith. That makes me so, so proud. To be half of this Valley doctor team.

Web cam picture of the week - the elusive Kapani leopard. At 1900. Not the dead of night!

A noisy night-time visit - right outside our bedroom window. Protected by some bricks and glass I feel strangely safe. 

More webcam footage. Baboon mayhem

Sorry we will be late for work today. An early morning visitation

An unwelcome visitor. Keith saw him before any damage could be done