Monthly Archives: September 2012

Animal attacks – week 4

The week here at AMREF Flying Doctors has seen a welcome respite from war and human conflict. However, human-animal conflict has taken its place, with cases including severe malaria, a hyena attack and a crocodile attack! Its been a busy and challenging week with flights to destinations including Cameroon, South Africa, South Sudan, Uganda and Tanzania.

Malaria remains a huge problem globally. In 2010 the WHO documented 216 million cases with over 600 thousand deaths. This is also likely to be a gross underestimate as many cases go unreported in very poor areas lacking in healthcare facilities. Malaria is caused by a micro-organism called Plasmodium which has several sub-species and is transmitted to humans by the female Anopheles mosquito (the more friendly males feed on plant nectar!). The disease can vary in severity from a relatively mild flu-like illness to severe cerebral malaria with complications including kidney failure (black water fever), convulsions and death.

I’ve seen the full range of severity in malaria this week. On a long flight to southern Tanzania with a mud-pack bush airstrip, we needed to use our Cessna Caravan aircraft which can land on almost anything. The aircraft however is relatively slow (130 knots or so) and has a non-pressurised cabin. Flying at 13,500 feet, I tested my own blood oxygen level at 88% which is low and not a level you would want to sustain without proper acclimatisation. After a 5 hour flight with a refueling stop in the Tanzanian capital Dodoma, the patient was able to walk onto the aircraft carrying his bag. He needed only oxygen, intravenous fluid and monitoring for the return trip.

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Two other cases of malaria however were at the opposite end of the spectrum. Both were cases of suspected severe cerebral malaria in Cameroon and South Sudan, requiring advanced ventilatory support. One involved a volunteer consultant paediatrician working for Medicines Sans Frontiers in a remote area. We evacuated both safely and they are making a good recovery here in Nairobi.

Road traffic accidents are a common occurrence in Kenya. During one of the malaria missions, a mini-van carrying 22 school children (capacity should be around 10) overturned on the highway right outside our office. Thankfully everyone escaped with cuts and bruises only. On my way back to the house at 1am from one of these flights I saw two cars in a ditch by the highway. We stopped and I looked for casualties – there seemed to be just two men involved, who were arguing by the roadside. Staggering around, they both stank of alcohol while I asked them in Kiswahili if they were ok. One of them looked at me and said in perfect English, ‘we are fine but please tell this man not to drink and drive!

Photo below is a cumulonimbus thunder cloud from close quarters…

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The mission to evacuate a man involved in a hyena attack was book-ended by two contrasting trips to Uganda. On the first, we evacuated a 49 year old woman with a brain haemorrhage from a district hospital lacking in facilities. She required intubation and mechanical ventilation which proved to be very difficult due to her condition and body shape. We got her safely to Nairobi but I worry that her outlook is bleak. The second Uganda mission involved evacuating a young man with a mental health disorder. He required constant gentle reassurance and his hand holding for the 2 hour trip.

The hyena attack was a sad story. A woman carrying a baby was attacked by a rabid hyena in northern Kenya. The animal had become rabid, we believe, after eating a dog with the condition. A man from the village went to help but sadly the woman and baby were both killed, the man sustaining very severe injuries to the face, head and both arms and hands. He had lost a lot of blood and needed extensive treatment when we arrived. I don’t want to elaborate more on his injuries here, suffice to say that he will be in hospital for a long time. I am hopeful however that he will survive with a decent quality of life. We evacuated him as part of our charity work and his hospital fees are being paid by the Kenya Wildlife Service.

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So ends another week and I am halfway through my time here… I’m continuing to love my work and feel very fortunate to have this opportunity. It’s hard work (I have flown over 20 missions and I am on-call 24/7) and can be emotionally draining sometimes, but I wouldn’t have it any other way.
Thanks everyone for your continued support – the blog is proving to be quite popular with over 500 visits. Please spread the word – AMREF needs all of the support they can get.

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Below: refuelling stop in South Sudan. The UN and World Food Programme have a major presence there.

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Wars, mountains and beer – week 3

The world can seem like a serene and beautiful place from 40,000 feet. On the Horn of Africa however, a different story unfolds on the ground. We flew north along the Somali coast, the tin roofs of the village sparkling like diamond dust in the sunlight, thousands of feet below. We descended steeply and banked out hard right over the Indian Ocean, swooping in low once again to the fiery furnace that is Mogadishu in the afternoon heat.

We had two casualties on this occasion. Their contrasting injuries, for me, illustrating something of the lives of the AMISOM troops in Somalia. The first patient was suffering from multiple gun shot wounds and was in a bad way. The second patient had a fractured patella from playing volleyball. The gunshot wounds had been inflicted in a so called ‘friendly fire’ incident and although I cant really elaborate more on that here, it didn’t seem very friendly to me. The bullets had caused compound fractures to both arms, the right arm having no blood flow now at the wrist and the hand was contracted into the claw of an ulnar nerve injury. I suspect he will later loose the arm. The small, clean entry hole of the bullet just below the rib cage on the right was in contrast to the much larger exit wound a few inches around the side. The bullet seemed to have just missed the liver, lung and diaphragm.

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I have long been a proponent of non-violence and nowhere do I feel that conviction more strongly than I do here. To my mind, its time that we learn from our many mistakes and make a greater effort to settle our differences through negotiation and mutual understanding; rather than through killing and wounding one another. The end does not justify the means. War begets more war. As Mahatma Gandhi said, ‘the means are like a seed, the end is like a tree.’ Maybe I am a hopeless idealist, I don’t know. What I do know is that AMREF Flying Doctors make a contribution in picking up the pieces of the shattered lives of war and I’m glad to play a small part in that.

Its not been all war, doom and gloom. As a flying doctor, I’m privileged to witness some incredible scenery and experiences. As we flew south on another mission yesterday, Mounts Kilimanjaro and Meru were standing proud ahead of us, like sentinels at the gates of Tanzania. These are Tanzania’s two highest peaks (Kili being the highest in Africa) and I had climbed both seven years earlier on a trip with Jagged Globe Mountaineering. We landed at Kilimanjaro Airport to be met by welcoming, friendly locals, grateful for our evacuation of a young man who had literally fallen off a cliff. He was fortunate and got away with lung and kidney contusions only.

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This week I’ve also had the opportunity to give some teaching to the AMREF nurses, help with the preparation of a conference presentation and spent some time relaxing with a Tusker beer at the Aero Flying Club of East Africa. Life is good.

http://www.flydoc.org http://www.AMREF.org twitter: @siforrington

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Necks, burns and malaria – week 2

Last week proved to be a gentle introduction. At least least from a clinical perspective. The majority of my patients required simple interventions to be safely evacuated.They certainly didn’t require critical care. Medicine works differently out here and evacuation by air ambulance can serve other purposes from back home.

The temptation is to think that it was not worthwhile flying five hours to Cameroon; to evacuate a man with a stroke from a remote area – for the one hour flight to hospital in the country’s capital. But you realise that the 400km distance would have taken several days by road and the lack of resources would have meant a medically-accompanied escort would have been unlikely. Distances by road in Africa are measured more realistically in time, rather than by miles. Air remains the most sensible form of medical transport in many areas.

This week however, our work has increased markedly in complexity and clinical severity. Cases have included spinal injuries – one from a gunshot wound, severe, life-threatening burns and cerebral malaria. Its been a busy and challenging week.

A suspected spinal injury was sustained by a Kenyan man in a motorcycle accident in Shimba Hills National Reserve. They were a long way from a landing strip and so we had a 4 hour round-trip in a helicopter in order to safely evacuate him. Flying low over Kenyan Game Reserves, spotting zebras and gazelles on route was a great experience. We had a large audience when we touched down at the village. In stifling heat, I assessed the mans injuries, immobilised his spine, gave him pain relief and awkwardly loaded him into the cramped helicopter. He was discharged from hospital the following day.

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Another incident involved evacuating a man from Mogadishu who was injured during the suicide attack last week. Somalia is just beginning to emerge from being a failed state for over 20 years. It has had no functioning government for that length of time and has been one of the most dangerous, turbulent places in the world. However, AMISOM (African Union Mission In Somalia) has been trying to establish peace for some time now. A new president has recently been elected and it was he who was targeted in the attack last week.

Mogadishu lies on the indian ocean coast and the on-going security situation demands that we approach the airport low and fast over the sea, rather than flying over the city. Taking off, we also fly out to sea. The man we evacuated had been shot in the neck, he was paralysed and was breathing with his diaphragm only – as his other breathing muscles were also paralysed. We stabilised him on the ground and evacuated him to Nairobi. Sadly, he passed away in hospital a few days later. War is such a futile business and wrecks so many young lives.

The photographs below show AMISOM soldiers at Mogadishu airport and loading the patient into the aircraft.

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Unfortunately, the burns patient is also in a bad way. He was the sole survivor of 4 in an air crash, shortly after take off. He sustained very serious burns (around 60-70% body surface area), fractures and lacerations. We evacuated him to intensive care in Nairobi and he remains very poorly. His chances are not high, but there is always hope.

My final mission from last week was to evacuate a young Kenyan lady with very severe cerebral malaria (P. Falciparam) from South Sudan. She required some resuscitation at the airport as she was in a poor state, but we safely evacuated her to Nairobi where she is still being treated in hospital. Her chances are good.

I had time to relax at the weekend on a hike up a local mountain with some of the staff from the office and a trip to the cinema yesterday afternoon. Thanks for reading. Live updates (Twitter) on @siforrington and @AMREFflyingdocs

www. flydoc.org http://www.AMREF.org

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AMREF Flying Doctors – week 1

Its been an eventful week at AMREF Flying Doctors. My own contribution has included 6 flights, treating and evacuating 9 patients across 5 countries, ranging in age from 11 months to 72 years. I’m beginning to wish I was accumulating air miles…

The staff here have been friendly and welcoming – I feel very much part of the team and It feels more like a month than the 7 days since I started. It’s been a tiring week at times, but never less than very satisfying.

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Cameroon is a long way from Nairobi. On the other side of the continent, in fact. It was a 10 hour round trip to evacuate a patient from a very remote area in the north of the country, with limited health care facilities – to Yaounde, the capital. The patient had suffered from a stroke, was unable to move the left side of his body and was unable to communicate verbally. I knew my main challenge was to prevent further damage to already injured brain cells from the relatively low-oxygen environment present when in flight.

The airport at Garoua was like a relic from a bygone age. Once, it may have been an impressive sight, with a large terminal building and expansive apron. The buildings now though, were in a state of crumbling disrepair. The rusting covered walkways protruding from the terminal, with no aircraft attached, like partially amputated limbs. Inside, the abandoned luggage carousels eerily quiet and motionless with a solitary person, listlessly mopping the floor in a comically futile gesture.

The only aircraft present was our small jet. The entire airport staff seemed to number about half a dozen. I struggled to communicate and remember the rudimentary French that I regretted having given up learning years before. We got by with a combination of broken French, broken English and hand gestures. It seems that kindness, openness and a smile can achieve a lot in these situations.

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When the patient arrived, he was quite stable and although my spoken French was limited, he did not speak English, and could not verbalise, we communicated well enough. Following initial assessment, we carefully loaded him into the aircraft, attached monitoring and sufficient oxygen and transferred him uneventfully to Yaounde.

At the most basic human level, I believe we are all very much the same. To me, our core motivating factors are to be happy and to avoid suffering. This is never more apparent than working as a doctor – especially in the ‘developing’ world. When someone is ill, all of those layers of wealth, status, race, religion, gender, politics, language etc are stripped away. Communication is often at that very basic level and simple empathy and compassion can go a long way

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The previous day, we had a call to evacuate an 11 month old baby girl with severe bronchiolitis from Addis Ababa in Ethiopia. Small children in this kind of situation are prone to deteriorate very quickly. The condition often causes breathing difficulties and can result in dangerously low-levels of blood-oxygen. I was apprehensive, having not treated children this small for some time. We had some time while awaiting flight clearance and I was glad of the opportunity to fully prepare.

I downloaded the most current clinical guidelines from SIGN (Scottish Intercollegiate Guidelines Network) and calculated all of the drug doses I might need, (from the Royal Manchester Children’s Hospital utility crashcall.net) based on the weight of the baby which the doctor in Ethiopia had provided. I knew also that the baby’s oxygen saturations, without supplemental oxygen were around 80%, which is very low.

Ethiopia is a country with proud traditions and a proud population, being pretty much the only African state not colonised during the imperial times of the past. I remember clearly the devastating scenes of famine and hunger from the 6 o’clock news of my childhood. As we waited on the apron, parked next to a UN World Food Aircraft, those memories were fresh in my mind.

During my preparation, I had discovered that Addis lies at an altitude of 2350m. This is quite similar to the altitude present in the pressurised cabin of our jet, so I knew the baby’s oxygenation should not deteriorate during transfer.

When she arrived, the baby’s condition was better than I had anticipated. On oxygen, she was able to breast feed and was not in any respiratory distress. After initial assessment, it was important to have the baby (and mother) as calm as possible so as to reduce the baby’s demand for oxygen. We got them settled on the aircraft, the baby was comfortable and feeding with oxygen via nasal cannulae and we transferred them safely back Nairobi.

I am loving being here, doing this job. Thanks everyone for your kind comments and encouragement. I will send another blog next week. You can also follow me on Twitter for live updates on @siforrington or @AMREFFlyingDocs. If you are interested please also check out http://www.flydoc.org and http://www.AMREF.org

First trip report 2012 – a holiday and my first day with AMREF

It was great to finally return to East Africa after months of hammering the locum shifts. I’m here in Kenya for 10 weeks, primarily to volunteer for AMREF Flying Doctors; more on that later. The never-ending locums before coming out were to pay the mortgage while I’m away… travel is not quite as care-free as it used to be when I was a student, it seems.

AMREF (African Medical Research Foundation) is a large NGO based in Nairobi which provides a range of health initiatives across Africa. They were originally founded back in the 50’s by 3 western doctors and have since won many awards. The Flying Doctors Service is based at Wilson Airport in Nairobi and will be my home until November.

We provide aeromedical evacuation services across East Africa and beyond, with transfers to the modern hospitals in Nairobi or occasionally, repatriations across the world. We run a combination of flights funded by an insurance scheme (in the region of $20US per year for local people, more for foreigners) and charity flights for Kenyans who cannot afford to pay. Any surplus from the insurance scheme is put back into AMREF’s public health work. I am the medical cover here for 8 weeks and will, in theory, be on-call 24/7 for that time. If there are concurrent flights (or on the occasions when I might need some sleep!) then local doctors are employed as locums, but this is very expensive for the organisation.

I needed a short holiday before starting work and really made the most of my couple of weeks off… the first for a long time. On a trip to the Massai Mara National Reserve, I saw some of the annual migration of the 1.5 million wildebeest and took an incredible hot air balloon ride.. drifting 500 feet above the savannah at dawn, gazing down on a herd of elephants was an experience I’ll never forget. After the Massai Mara, I did some mountain biking through Hells Gate National Park in the company of giraffe and zebra. I’ve spent the last few days on the Indian Ocean coast enjoying the diamond white beaches and snorkelling in the clear blue sea.

Yesterday (01/09) was my first day here at AMREF. I was picked up from the Wildebeest Eco Camp; which is a great place and my Nairobi base for the last 2 weeks, at 9am. Amazingly, I was in the air, zooming through the clouds above central Kenya by 10.15! The Beechcraft 200, one of AMREF’s medium-range aircraft had enough room for, in addition to our medical kit, 2 pilots, the AMREF employed Kenyan nurse and myself. We were heading for Juba, the capital of the world’s newest independent state – South Sudan. All we knew of what to expect at the other end was ‘a 67 year old patient, fluctuating conscious level, possibly unconscious).

South Sudan gained its independence from Sudan last summer, following the ‘end’ of Africa’s longest running civil war. It remains one of the poorest countries in the world. Most of the population are subsistence farmers and have a difficult life, contending with regular drought and shortages of basic care. Sudan’s chief export is oil and 75% of the reserves lie in South Sudan. However, the oil pipelines all run north and conflict on this issue persists.

Flying over the East African plains towards South Sudan, I felt totally elated… it felt like the culmination of 12 years of work. I had decided to study medicine at the age of 27 while cycling around South Asia. Now here I was.. I am a Flying Doctor in Africa – and I knew I had to deal with whatever awaited me in 2 hours time. I felt nervous, but mostly just excited about the challenges ahead.

We had quickly checked all of the kit before departure and did so again now. We skimmed over the Blue Nile before touching down at Juma airport, two and half hours after leaving Nairobi. An ambulance arrived on the apron but unfortunately they were expecting us to deliver them a patient! Welcome to African healthcare.

Eventually a second ambulance arrived, this time with our patient. It turns out (as is often the case) that the triage information was totally misleading. The patient was fully conscious but suffering from acute liver failure. I carried out my initial assessment, gained intravenous access and took some blood for analysis. We moved him with some difficulty into the aircraft, commenced some IV fluid and pain relief. Full monitoring was attached and my blood sample analysed. We took off again, needing to give oxygen for the drop in air pressure and monitored the patient closely. In the end, it was a fairly uneventful transfer and we got him safely to the High Dependency Unit at one of Nairobi’s hospitals.

I am staying in a small house near the airport and went back there to unpack my things, eat and get some sleep. Today is Sunday and all is quiet so far… I feel privileged to be here and I’m very much looking forwards to what the next 8 weeks has in store…

Thanks for taking the time to read this – hope you enjoyed it, there’ll be more to come..

simon

PS if you are interested in donating to AMREF or just want to find out more: AMREFhttp://www.amref.org

The photos below show:

1. Wildebeest Eco Camp
2. Ballooning at dawn over the Mara
3. Diani Beach
4. En-route to Nairobi from Juba
5. Transfer in Nairobi

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