The Money

22nd January 2007

Monday morning at the height of the rainy season, and I am just emerging children’s ward after a particularly challenging round. Malaria is rife at the moment, so it’s standing room only, and the febrile Mpanshya tots greet me with the usual chorus of screams. On this ward I am the bogeyman, and I have long since learned that no amount of gentle coaxing will persuade these children to sit nicely while being examined. But an hour of restraining protesting toddlers is not a good way to start the week.

I press on to female ward, but before I get there, I am intercepted by Emmanuel, who has come out of the labour room looking vaguely worried. Jenny has just been brought in by ambulance, and she gave birth on the way. The baby is fine, but forty-five minutes on, the placenta has yet to make an appearance. She is bleeding. And everyone is looking at me.

Usually, in these situations, I like to start off by bleating that I am not an obstetrician, before grudgingly doing something, but the gravity of Jenny’s condition precludes even the briefest protest. Ten, long minutes later, I am holding the recaltricant afterbirth in my hands. (I will spare you the details of how it got there.) The bleeding has stopped, but Jenny is still shocked, and needs a transfusion urgently. She is unconscious, so I inform the relatives, thus provoking a heated quarrel between her Catholic granny and her Jehovah’s Witness mother. I stand in the corner, watching despondently as the debate proceeds. My resuscitation efforts are about to be scuppered by some obscure piece of theological hokum. But luckily Rome wins. It usually does around here.

31st January 2007

Today, our CD4 counter is working for the first time. It arrived three months ago, and has been sitting in the corner of the lab, draped with a tea towel, unused. Our donors neglected to buy us a vortex mixer, so we had no way of processing our samples for analysis. During this time, we have been sending samples to Lusaka for testing, an unsatisfactory arrangement which generally yields about one result for every three samples dispatched. So most of our decisions we make about our HIV patients are based on educated guesswork, which has its limitations. But no more. The vortex mixer has arrived, and the tea towel has been cast aside. Flouting infection control regulations, and causing mild alarm to Mrs Mwale, I dance into the lab bearing the tray of blood samples. This is real progress, a good day for the ARV clinic.

1st February 2007

Last week, I admitted an elderly man by the name of Cement. He has a multiplicity of medical problems, including, I think, a collection of fluid at the base of his right lung. I asked Elias to X-ray him a couple of days ago to confirm this, but the film he produced only shows the top half of his chest so I am none the wiser. (This is not entirely the fault of Elias; for months now, we have only had comically undersized X-ray films in stock, so imaging an adult chest in its entirety is a tall order. I have protested about this to Sister Sabina, but she insists that these are the only ones available in Lusaka. So, for the time being, I am stuck with peering at tiny, smudgy X-rays, which more resemble Monet miniatures than anything to do with human anatomy.)

Rather than sending Cement back to X-ray for a complimentary film of his lower chest, I decide that I will confirm my suspicions by trying to draw some fluid off his lung with a needle and syringe. I am slightly disconcerted to find that only air is coming out. But there are many more patients to see that morning, and I move onto the next one without giving it much more thought.

Shortly afterwards, Mr Phiri comes rushing through to get me. He tells me that Cement is having an asthma attack. He is in a bad state when I go back to him, hunched over and gasping for air. I check his windpipe and, finding it deviated to the right side, I realise that I have given him a tension pneumothorax. This is a medical emergency, and I have only a vague recollection of the physiology involved. I know that I need to stick a wide bore needle into his chest to relieve his breathlessness, but in my panic, I can’t remember in which side it is meant to go. Eventually I decide on the right, and as I sink the needle in, there is a loud hiss of air, and he is breathing normally within ten seconds. Much relieved, I then set about making an improvised chest drain with a suction catheter and sticky tape. Throughout this debacle, Cement and his wife keep thanking me for all my attention, despite my attempts to explain that I actually caused the problem in the first place. It just proves that the second inverse care law is an international phenomenon: the more disastrous your interventions, the more paradoxically grateful patients tend to be, everywhere in the world.

2nd February 2007

Chas comes home from Lusaka late this evening. Joost and Bernadette are round at the house when he arrives, spilling out of the back of the overloaded ambulance like a veal calf escaping its crate. He had a meeting in town today with a representative from a medical charity to discuss his eye clinic proposal. We ask him how it went, he makes vaguely positive noises, and then we talk about something else.

Later, when J&B have gone home, I ask him again how the meeting was. He is much better at feigning nonchalance than me, but he can’t keep it going any longer. He fails to suppress an enormous grin. “They like it, and they’re going to fund it.” No polite refusal this time. This project, which Chas has spent more time on than anything else in the last year, is going to happen. It is too good for our own words, so we celebrate by reading aloud the new Oor Wullie annual (recently arrived, thanks Henry and Sheena) over large measures of whisky.