Low Hanging Fruit

Photo of the week: No excuse for another leopard needed - so photogenic. A new female for us just outside Mfuwe Lodge

Highlight of the week: Our paper "Can a lifestyle-centred, low-dose model improve hypertension and diabetes care in low and middle-income countries?" is accepted for publication

Lowlight of the week: A loose screw in Mzungu's tyre deflates us

Maximum temperature: 34 degrees Celsius

Rainfall: Not on your Nelly

The awakening is in no way rude. A soft knock on the door, brings us both back into consciousness. Keith’s personal phone is softly purring. The screen facing down brings no insult to our eyes. Doctor Keith we need your help urgently. I’m just outside your door. Keith’s naked body only visible to mosquitoes. Modesty quickly achieved. Our uninvited guest vague with the nature of our emergency. She is bleeding badly. We can’t stop the bleeding.

I begin this story in the middle of the night. But the beginning of the story precedes this polite awakening. Let’s rewind the clock a little: It’s Monday night. 20:30. Late for us. Our first night call this year. A reluctant patient. But reasonably straightforward. Probable heat-stroke. Reassurance. Explanation. A safety net and guidance on sucking eggs.

A tasty slice of key-lime pie kicks our blood glucose levels into the air. Our drive home offers 4 more sweet treats. Four bushy-tailed mongoose cross our path. We smile, enjoying the feast. This drive home always offers something. It’s been pretty quiet. I reflect. No real emergencies yet. The Q word has been uttered. In code. Research about how saying the word quiet can bring on medical misery, painstakingly undertaken.  It’s a silly medical superstition, the papers conclusion Broadcast in a learned scientific journal. The Christmas BMJ. 2019. 

Welcome back to the middle of our quiet night. It’s 22:40. A noise outside. A voice. A gentle, but persistent, knocking at the door stirs us both from our reverie. At the same time Keith’s personal phone hums. The doc phone most definitely quiet. Keith’s phone invites regular traffic. A hot line with boundaries. 20:00 the Rubicon.

Andrew calm and polite waits for us to rouse. We couldn’t reach you by phone. I’ve come to find you. We have a client who seems to be bleeding from the vagina.

Within 5 minutes we are fully dressed and on the road. Mouths doubtless offensive. No time to freshen up. Blasphemy also possible. I don’t wake up full of cheer. Keith negotiates the familiar bumpy dusty tracks. We leave Andrew to eat our dust. A dip. A jink. An elephant! A huge grumpy bull elephant shakes his ears. Threatens to charge. But sees the steely determination in Keith’s eyes and backs off. Keith swerves past him and floors the accelerator. Keith silent. I process our limited triage information. Out loud. Andrew, not medically trained, has left us in the dark. Bleeding crivens. I swear. Vaginal bleeding is not our core area. Pregnancy always possible. Vaginal injury normally comes with a lot of drama. We stay in the dark, but rehearse our options. Gloves. IV lines. Tranexamic acid. Resuscitation.

We reach camp. Staff relief is palpable. Tense shoulders drop. Thank goodness you are here. We walk towards the client’s  room, gathering information. Not vaginal bleeding, it transpires. Rectal bleeding. With massive haemorrhoids. Hanging out. We are warned: There is blood everywhere!

Inside the dimly lit room. White floors and walls smeared with red. Sheets and blankets covering the worst of it. On the bed, lying face down, is our patient. *Pereina. 57 years old. A towel preserves Pereina’s dignity. Her backside under wraps. Pereina tells us that she has been struggling with grapes issuing from her backside. Piles have been troublesome for years. Thank God you are here.

Pereina lies prone. The towel drawn back reveals the low hanging fruit. But the expected grapes are replaced with a large fleshy grapefruit. The whole of Pereina’s rectum lies ripe for inspection. No proctoscope required here. A healthy rectum, bright and beautiful. But totally inside out. Prolapsed and sitting neatly between Pereina’s buttocks.

Fortunately, Pereina is no longer bleeding. The red paint, so liberally anointed over bathroom and bedroom is a mere cupful. Not enough to threaten life. Her pulse, a jaunty 125, betrays her emotion, rather than a perilous blood loss. Our focus is drawn away from her veins back to a huge grapefruit in the room. Keith is going to need those gloves after all.

Now, imagine that you are about to pass a large grapefruit. Per rectum. I imagine that you are all now averting your eyes, or leaving the room. Imagining that you can decline what needs to now happen! The camel needs to pass through the eye of a needle. Pereina’s tears soak my hands. I take the head end. Keith takes the tail end.

Let’s slow your breathing down Pereina. Keith has done this plenty of times before. The kind lie. Jelly covers the grapefruit, and Keith’s hands envelope the fruit. Gentle pressure persuades the fruit to change. A metamorphosis. Fruit becomes: fruit of the sea. An octopus in Keith’s hands invaginates. An amoeboid arm enters the anus and reaches the pelvis. Body follows arm. Arm follows body. The octopus gains entry leg by leg. Fifteen slow minutes test Pereina’s belief in God and in Keith. You can do it. Can’t you Doctor Keith? Keith cautiously plays with the conditional tense. Yes, I can. But the future is less certain. For a full, slow, 15 minutes. Until the last octopus leg chooses to enter the dark recess.

As a UK primary care doc Keith has comfort zones. Those zones, when crossed in England, have predictable outcomes. He can spin the ball gently out to the scrum half. A whole team of skilled professionals wait for his delivery. The paramedic deftly passes the ball onto the surgical team. Keith’s role as a gatekeeper has well defined edges.

In Zambia we are not only the scrum, but also the whole first 15. There is no one else on the pitch. Pereina’s phantom pregnancy, and imagined vaginal bleed, fails to give birth to a tiny individual, needing my normal services. But I know what I don’t know. And I make an executive decision to involve the off pitch substitutes.

Fida is on-call. In a paid capacity. His colorectal skills in great demand. He is barely home after a super busy day at Darlington Memorial Hospital. He picks up my WhatsApp video call immediately and smiles. Genuinely happy to see my smiling face. Knowing instantly that this is not a social call. I pass the phone to Keith, who now has clean hands.

Fida and Keith begin to hatch a plan. With all of the options that we have in the bush considered. 24 hours of bed rest with the bed-foot raised. Laxatives to avoid straining. A reasonable chance of a game drive on Wednesday. A protective hand to keep the octopus holed up during defecation.

It's 01:30. We head home. Weary. Memories of the key-lime pie sugar spike distant. Instead healthy fruit occupy our thoughts. Our grapefruit appropriately squared away. Our mission, accepted but unexpected, to keep the octopus at bay. We chew over the flesh of our next day’s play. Hoping that Pereina can keep her buttocks clenched for a while. At home our alarm clock gets a nudge. Sleep takes us and keeps us. Early exercise not an option for Tuesday.

Tuesday. 12:30. We are at our most distal tree clinic. Mothers, babies and staff on a go slow. No rush. They don’t know that we need to review Pereina this lunchtime. Clinic one in the bag. Clinic two is done at snail’s pace. The doc phone trills. A summons. Urgent and insistent. The grapefruit is back. Thankfully, there is no blood this time, but our instructions for rectal first aid are not received with confidence.

Our tree clinic staff have a stark choice. Pack up within 2 minutes, or take a long walk back to clinic. Instantly, a means to an end is discovered. Photos of cards. Registers shelved for later. Jabs and polio drops in double quick time. Mzungu fills as part of an emergency drill. In town we off load our staff with their heavy boxes and kit. Their walk back to clinic short now, at least.

Our drive to camp is rapid and elephant free. Somehow rectal first aid training has resulted in a tameable octopus. Pereina is smiling with relief and her freshly trained and accomplished zookeeper hugs Keith. Keith admires her work. A fruitless bottom.

Keith and Fida’s first plan has unravelled. No game drive tomorrow then. A different game plan will be needed. Pereina is going on a rather longer journey. Her operation has just been brought forward. A stitch in time and all that….

Pereina despite her confinement to bed jumps into action. Her insurance company is given a nasty bite in the backside. And within a couple of hours we have permission to evacuate. Meanwhile the camp team also step up to the plate and book her onto the next commercial flight to Lusaka. A plan is taking shape. All we need now is some nappies or panty liners and some Bridget Jones knickers.

Now being camp doctors has some fringe benefits. And when the sh*t is hitting the fan, or even the pan, we usually have access to 5 star food. Not exactly a free lunch. But gratefully received nonetheless. We peel off to a tasty plate of food. 

The spell is broken by a WhatsApp call from Pereina. Could you come now Doctor Keith? Thankfully there is no video. Our lunch at least is neither grapefruit nor octopus. Keith hot foots back to Pereina’s chalet and asks her to adopt the position. The octopus goes quietly back into its lair.

Evacuating Pereina is not what you think. Yes, of course we are giving her Movicol to keep her poo soft. Not in bowel prep doses. But she also needs a hop, a skip and a jump to get her back to a land where laparoscopic witchcraft can be performed. To hold her rectum permanently inside her bottom.

The hop is a quick flight to Lusaka. Pereina checks into Lusaka’s finest hospital. Under the care of a fine surgeon. She will not need to go under the knife just yet. We need the skills of the wider medical team. Pereina needs upskilling. She receives a rapid course in octopus entrapment. Keith’s hands operating remotely. Through clinicians somewhat familiar with this uncommon procedure.

The power of positive thought is key. Fida tells Keith that no medical escort is needed for her long double flight home. Keith tells Pereina that she is up to the job. That whilst on the job: she must guard her octopus lair. Not let grapes become a grapefruit. And so it comes to pass. Pereina becomes the guardian of the octopus lair. Ready for a skip and a jump.

*Names have been changed to protect identity. "Pereina" has read the full blog and given us permission to publish it

Bush-cam photo of the week

It's thirsty work being a lion

A giraffe sticking its neck out

The bush school entertain us with a concert from around the world