Expedition & Wilderness Medicine » medicine

Volunteering in Zambia

Mark Hannaford — Fri, 24 Jul 2009 12:26:37 +0000

Life In Luangwa , Zambia

“Doctor Emergency”! I had seen the blood spattered wheelbarrow parked on the veranda that served as the waiting room and now the sign of the shuffling flip flops told me I was about to meet its occupant. He entered the room uncertainly, supported between his two inebriated friends. The blood soaked tea towel adorning his head giving a big clue as to his presenting complaint. Removal revealed a 7inch gash across his forehead down to the skull. His helpful friends informed me it had been inflicted by an axe, two nights ago, in a fight and they excitedly asked me to examine his leg which had been stabbed by a spear.

Welcome to life in Luangwa or more accurately the Kakumbi Rural Health Centre. I have just returned from my second three month stint as the South Luangwa Safaris Association Medical Fund doctor. The post provides the unique opportunity for doctors to practice in a developing country whilst enjoying some Western style comforts. South Luangwa is a place where two worlds collide. It is situated in the Eastern province of Zambia, one of the countries poorest provinces in one of the world’s poorest countries. It hosts some of the worlds most exclusive safari holidays and draws tourists from around the globe. The medical fund was formed by the safari lodges as a way of importing expatriate doctors to provide medical services for the staff and guests of the lodges whilst securing access to a doctor for the local population. Kakumbi Rural Health Centre is the only clinic in Zambia to have a doctor working in it.

Work at the clinic is challenging. There is a language barrier, a cultural gulf and very basic facilities. There is no access to investigations and so most diagnosis are made on clinical grounds. A limited number of drugs and dressings are available but supply is often interrupted. The local hospital is over an hours drive away along a very poor quality, heavily potholed road. It is manned by two doctors and has microbiology, some blood testing facilities, an x ray machine and an ultra sound scanner. There is no ambulance service and patients are responsible for finding and paying for their own transport.

The health needs of the local population are huge. HIV/Aids is rife and both it and its complications often present during surgery. Diseases now confined to the history books of the Western world make not uncommon appearances. I saw cases of Tuberculosis, Syphilis and Rheumatic Fever during my three months visit. Other more unusual cases include snake bites, crocodile attack and foot trauma due to entanglement in a bicycle wheel. Trauma is a frequent occurrence in the community: children fall in open fires; builders fall off roofs; fishermen get hooks in their eyes and people assault each other. My stay spanned the wet season and in early March the number of confirmed cases of malaria started to rise. By month end it became evident that a full blown epidemic was likely and by mid April we ran out of malaria rapid diagnostic test kits and Co-Artem, the first line drug treatment. A week later supplies of quinine were down to less than 10 adult doses. On most days the clinic resembled a hospital and resources and staff were stretched to the limit. Sadly deaths started to occur as more severe complications such as cerebral malaria started to appear in young children.

The doctor is constantly on-call for the safari lodges but the workload is carefully managed and fitted around work at the clinic. After hours call outs are minimal and luckily I did not have to deal with any major emergencies on this trip. Zambia lacks medical facilities of a standard suitable for most tourists and therefore any problems arising either have to be dealt with by the doctor or medivacced to South Africa. Thankfully most visits to the lodges for guests are for minor problems; diarrhoea, lost tablets etc but serious medical problems and major trauma have occurred in the past. There aren’t however many places in the world where when returning from a “ home visit” you can come across a sleepy pride of lions snoozing on the road or giraffe gracefully grazing in the bushes.

Life in Luangwa is far from all doom and gloom. The valley is stunningly beautiful and the National Park is alive with wildlife both big and small. The doctor has very graciously been granted free access to the park and after a testing day at work there is nothing better than spending a few hours unwinding with a cold beer watching elephants frolic in a mud bath or a spectacular African sunset across a Hippo filled lagoon. There is plenty of opportunity to really get to know and understand the wildlife of the area and local guides and residents are more than happy to help you make the most of the experience.

I have thoroughly enjoyed both of my visits to the South Luangwa valley. I have immensely enjoyed working alongside the local staff and have learned a lot from the nurses. I have re-honed my clinical skills and revelled in the freedom of the autonomy of working in a very different health system. “Life in Luangwa” gives you a fascinating insight into the challenges that face rural Sub Saharan Africa in the 21st Centaury and I would highly recommend the experience to any doctor who is looking for a clinical challenge: who is willing to adapt to an unfamiliar environment and who has the relevant skills and experience to be able to feel comfortable in such a remote but awesomely beautiful place.

Dr Rhona Whiston May 2009

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The Life-Line Clinic, Namibia | Job Oppurtunity

Mark Hannaford — Fri, 24 Jul 2009 12:20:58 +0000

Namibia Medical volunteer
This challenging programme offers you a unique opportunity to work at a small, rural Bushman clinic in Africa and make a difference to the lives of those in most need.
N/a’an ku sê is a unique and special place in the heart of Namibia which is committed to conserving wildlife and improving the lives of the Bushman community. Live your African dream and help make a difference by volunteering at our Lifeline Clinic.

About N/a’an ku sê’s Lifeline Clinic
• Bushman are treated as third class citizens and live in extreme poverty
• Adult onset diabetes, cardiovascular disease and cancer are sharply increasing in Bushmen and alcoholism has become prevalent
• Many Bushman children suffer from malnutrition, disease, discrimination and abuse

The N/a’an ku sê Lifeline Clinic was set up in 2003 to address the needs of the rural indigenous communities in Epukiro, a remote part of Namibia. The demand for a basic but comprehensive health service became apparent to medical professionals working in the area when they witnessed the tragic and unnecessary death of a young child due to the failure of ambulance service and hospital staff, largely due to the fact that the child was a Bushman. This vital service relies upon the time and dedication of volunteers and donations from supporters to continue to run and serve the communities in need.

About the role
• Improving Health: The clinic is dedicated to the health and welfare of the Bushman community.
• Making a real difference: The clinic has treated nearly 3000 patients over the past year.
• Free treatments: Over 2200 (72%) of the patients were Bushman who were treated for free.

The clinic aims to help marginalized local people and provide accessible affordable primary healthcare to those living in the area. By joining this project you will experience the harsh realities faced by Africa’s Bushmen communities and have the chance to make a difference to their lives. You will be immersed in the health and development programme while providing care to patients living in extreme poverty.

During your time at the Lifeline Clinic you will work with Sister Anna and assistant Natalia seeing and treating patients from the local Bushman and Herero community. Your daily schedule will be varied and you will carry out duties such as making and recording medical observations, keeping medical records, monitoring the progress of pregnant women, helping with wound dressings and working in the pharmacy. You will also visit an outer community or farm to do general health check ups and any treatments as required.
As part of your time at the clinic you will undertake an assignment such as looking into drivers of disease such as alcoholism to find out more about the health needs of this marginalized society.

You will also assist with community projects such as planting and cultivating vegetable gardens to help encourage good nutrition. You will spend time with the local Bushman community to understand how they live as well as going on a walk with them to look for bush food or medical plants.

You can also choose to experience the rare and exciting opportunity to work and care for the animals of Africa, assisting in their rehabilitation as part of our wildlife volunteering program.

Take part now! To take part in this project or find out more please email bookingsnaankuse@iway.na or visit www.ecotourism-namibia.com.

Make a donation –We rely on voluntary donations and the time and support of volunteers such as you to continue to help the Bushman people in need. If you are interested in supporting the clinic and the patients who need our help please email donationsnaankuse@iway.na to find out how you can help. We urgently need funding to continue to run this service, buy medicines and pay for our one full time Nurse who runs the clinic.

Experience your African dream at N/a’an ku sê
N/a’an ku sê is a unique and special place in the heart of Namibia which is committed to conserving wildlife and improving the lives of the Bushman community. Live your African dream and help make a difference by taking part on one of our exciting and rewarding volunteer programmes:

Volunteer at our Lifeline Clinic – located in a remote part of Namibia, this vital clinic is dedicated to the health & welfare of the Bushman community. By volunteering at the clinic, you will be immersed in the health and development programme while providing care to patients living in extreme poverty.
Contact: bookingsnaankuse@iway.na

Volunteer with wildlife – you can choose to combine your time at the clinic with the rare and exciting opportunity to work and care for the animals of Africa, assisting in their rehabilitation as part of our wildlife volunteering program.
Contact: bookingsnaankuse@iway.na

Experience our Lodge – start or finish your trip to Namibia with a stay at our beautiful lodge in the heart of Namibia’s bush land. Here, you can enjoy sumptuous meals, take a dip in our beautiful pool, experience unforgettable carnivore feeding tours and enjoy magnificent African sunsets.
Contact: naankuselodge@iway.na

Make a donation – sadly N/a’an ku sê does not receive any government funding and we rely solely on voluntary donations and the time of our volunteers to keep our vital projects running. By adopting an animal, sponsoring a child or treating a patient you can ensure we can continue to make a difference in the lives of the people and animals who need it most.
Contact: donationsnaankuse@iway.na

Making a difference
By visiting our unique lodge, volunteering at one of our projects or making a donation you can make a real difference to the animals and people we strive to help. All profits from our Lodge and volunteering activities go directly to benefit our work with wildlife conservation, our Lifeline Clinic for Bushman in Epukiro and the people from the Bushman community we employ.

Take part now by emailing bookingsnaankuse@iway.na or visit www.ecotourism-nambia.com to find out more about the work of N/a’an ku sê.

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Essential Healthcare in Ethiopia

Mark Hannaford — Fri, 24 Jul 2009 12:10:33 +0000

Essential Healthcare Amid Dust and Desolation in Southeast Ethiopia
MSF doctor Anna Greenham describes work and life in the Somali region of Ethiopia

“Life in the Somali region of Ethiopia is tough. The rains have failed, food is running out and even the camels are dying of thirst. Add to this a complex armed conflict and you have a recipe for disaster. Nomadic people can’t find water or grazing for their livestock and are forced to travel huge distances to survive. Many have lost everything. Without a livelihood they move to the edge of towns where they live in squalid conditions in very basic shelters, unable to access clean water or food. It is in one of these small rural towns, Wardher, that MSF provides the only reliable health care for a dispersed population of about 40,000 people.

Wardher town is a dusty, bleak place. Most people live in tin roofed shacks or mud huts. There are only dirt roads, no running water and electricity only works for a few hours a day. There is a market but hardly any fresh food is available.

You would probably be shocked if I gave you a tour of our clinic. Things are very basic. Crowds of anxious patients wait outside on benches for consultations. Some have walked for days to reach us. Many have tried traditional therapies first and only access the clinic when they are critically sick. The sickest patients are referred to our inpatient department where two large tents with mats on the floor function as wards. It may look chaotic but it is amazing what we can achieve with so little. As well as primary and secondary health care we support a TB program, feed around 100 malnourished children, provide routine antenatal care, vaccinations and even mobile clinics to isolated villages. By training local staff we hope to leave something behind when MSF eventually leaves the area.

Most of the children are dying from simple illnesses- diarrhea, chest infections, preventable childhood illnesses such as measles and malnutrition. We use IV fluids, antibiotics and nutritional support to nurse these children back to health. Amazingly, most of our patients do recover, despite the limitations of what we have to offer. Some are not so lucky. It is so sad watching a baby die from pneumonia, when in a more advanced setting they would easily survive. The nearest proper hospital is 2 days drive away so this is rarely an option.

When I am not volunteering as a medical doctor for MSF I work as a General Practitioner in the NE of England. Next time anyone complains about the National Health Service there I suggest they put themselves in the shoes of a typical nomad like Fatima*, who walked for 4 days with no food or water to reach the clinic with her 4 month old baby. She was so exhausted that her breast milk had dried up. Her baby weighed only 2.5kg and was close to death. We were able to admit them both to our inpatient ward and the child is slowly improving with intensive nutritional support. She is one of the lucky ones. Many others are not strong enough to make the journey.

Work can be very frustrating. I am so busy during the day that I never have time to finish anything properly! I juggle ward rounds, reviewing complicated cases in our out patient department, admitting emergency cases, doing minor surgery in our small dressing room and assisting difficult deliveries. Add to this training local staff, sorting out human resource problems and trying to chase goats out of my ward, I hardly know whether I am coming or going. It can also be stressful living and working in an area of armed conflict, with severe restrictions on any form of social life.

Despite all the difficulties and challenges, I do love my work. It is so satisfying seeing critically sick children recover, when without the efforts of the MSF team they would certainly perish. MSF is not only providing health care, our presence in Wardher also gives hope to what is a very neglected population”.

Note
MSF has delivered vital healthcare to communities in the Somali region of Ethiopia, on and off as necessary and where possible, since the 1990’s; where the population struggle to survive amid numerous challenges, not least an ongoing conflict between governmental and rebel forces.

*False name to protect anonymity

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How do I use a hyperbaric chamber? What are the alternatives?

Mark Hannaford — Thu, 10 Apr 2008 19:46:37 +0000

Hyperbaric Chamber

The concept behind the 3 main portable hyperbaric chambers is they effect a physiological descent by inflating the air impermeable bags above ambient atmospheric pressure. The extent of the descent is dependent on the altitude at which the bag is used and the pressure to which they can be pumped. The patient is placed in the bag lying down (which can be claustrophobic), there is a window for the patient to look through, the fabric of the bag is thick but a conversation can be undertaken. If the patient has difficulty lying flat put the bag on a slope.

Oxygen can be placed inside the bag with the patient. It is worth ensuring the patient has something comfortable to lie on and has a sleeping bag if they get cold. Conversely if its day time the bag needs to be in the shade to avoid ‘boil in a bag’. The bag is zipped up and the bag inflated slowly using a foot pump until the pop-off valve hisses (at around 2 psi). The pressure then has to be maintained by continuing to pump but at a slower rate.

The patient is normally kept in the bag for about an hour, as long as they remain stable in the bag. As pressure increases, the patient needs to be warned to equalise if they are able. It may be worth giving the patient a bag to vomit in if required. Occasionally the zips burst, leading to rapid depressurization and the risk of barotrauma. When reducing the pressure to get the patient out do it slowly, the zip can normally be opened slowly when the side of the bag dimples on pressure.

What are the advantages and disadvantages of this piece of equipment?

Advantages: Lightweight well tested, robust. All the equipment weighs aproximately 7kg. Fast to use, inexpensive in comparison to the others.

Disadvantages: Still costs £1500 or so, the zip can breakdown and is the weak point. No carrying handles if you wanted to physiologically and geographically descend simultaneously.

Who makes hyperbaric chambers?
The Gamow bag is the oldest design. The other bags are the PAC and the Certec. Both as good and lighter. The Certec uses a different pumping system, which can be tiring.

Gamow Bag. The Gamow does not have handles but can be carried on a stretcher if absolutely necessary. You can read more about Gammow Bags and their inventor, Igor Gamow, scientist, classicist, professor, adventurer, at web.mit.edu/invent. Gamow is the son of the famed physicist George Gamow, a co-author of the Big Bang Theory and the first to propose the genetic code.

Where can I hire a Gamow Bag?
They can be hired from Expedition and Wilderness Medicine see our Media Support Page for more details.

More About CERTEC Bags. The present CERTEC hyperbaric chamber is an improved version of a hyperbaric chamber that was originally designed in 1989 by a French and German team.

The color of the new CERTEC hyperbaric chamber is not orange but yellow and blue.

Its design is different from all other pressure bags (Gamow, PAC, etc.) since it is comprised of two bags in one:

An outside envelope made of very strong material (to withstand tension) and good friction (for stability on any surface) , an inside envelope made of polyurethane (for airtightness)

Advantages of this double envelope design are:
it is rugged and durable
good protection of the airtight inner envelope

All air valve systems are doubled for security:
two inflation valves
two automatically opening preset valves (220 mB)

A very large window allows contact with the person in the bag.

Two full length zippers (inside and outside bags) allow easy in- and egress.

The inflation pressure is 220 mB, corresponding to a virtual descent of about 2500 m (depending on the actual altitude).

Total weight of the CERTEC Hyperbaric Chamber is 4,8 kg (carry bag and pump included).

It comes with a very efficient double effect pump (i.e. that pumps during up and downstroke) has a volume displacement of 3,7 liters for each pump cycle.

Only 4 pump cycles per minute are necessary to keep the CO2 in the bag at acceptable levels.

The price of the CERTEC Hyperbaric Chamber is $2300. It can also be rented.

Advantages: Higher pressures, though it isn’t known how clinically important/useful this is. The bag is lighter than the Gamow. The double-wall system should provide more durability.

Disadvantages: Similar to the Gamow bag, the Certec is expensive, around $2300. I have not seen the newer Certec bag, and my comments are based on the older orange model. I found the (old) pump to be quite difficult to use as it required bending over at the waist (see photo at top of page); it was very fatiguing. As in the Gamow® Bag, fresh air must be regularly pumped into the bag to prevent CO2 buildup.

More about The PAC® (Portable Altitude Chamber)
Dr. Jim Duff, an experienced climber and expedition physician, has developed a nice alternative to the Gamow® and Certec® bags. The PAC (a coated fabric bag) is about the same size and weight as the Gamow, but more of a mummy shape, so there is more room around the head and shoulders. It also develops a 2 psi pressure, equivalent to the Gamow bag. The PAC is much cheaper than the Gamow bag and is probably the most sturdiest of the three hyperbaric bags on the market.

The main design difference, however, is in the radial zipper at the head end. This opens the whole head end and makes access far easier than either the Gamow or Certec bags. This is especially important with large and/or comatose patients (ask anyone who has tried to stuff such a patient into the Gamow bag!). There is no pressure gauge, instead there is a clear pocket on the inside of the window, so you can insert an altimeter and watch it from outside.

The external, dangling pressure gauge on the Gamow Bag is vulnerable to wear/damage and subsequent leakage, something avoided in the Certec by having the pressure gauge set flush into the bag. I should note that the presence or absence of a gauge does not affect treatment; the pressure gauge or altimeter is merely a reassurance that the equipment is functional, something that is easy to ascertain in straightforward ways, ie, the bag inflates and the pop-off pressure control valves hiss.

Note that with the PAC the maximum pressure is limited by the pop-off valves to 2 psi, but you can adjust the valves to a lower pressure to accomodate patients who have trouble clearing their ears. Instructions for using the PAC are printed right on the side of the bag, as is a table showing the equivalent descent at various altitudes, a nice touch. This bag has recently been used in the HRA Pheriche clinic and seems to be durable.

Advantages: The shorter zipper and simplicity of design has resulted in a bag that is far cheaper than the other available alternatives: US$1,200 including delivery almost anywhere in the world. The end-opening design is a major advance in terms of ease of getting patients in and out

Disadvantages: No significant disadvantages.

Web Resources
High Altitude Medicine Guide
Gamov’s entry in Wikipedia
Climbing High
Interview with Igor Gamow
PAC Technology

About the author
Dr. Sean Hudson is a Fellow of the Royal Geographical Society and on the expeditionary advisory board for Summit. Sean has been involved in a wide array of expeditions over the last 18 years. During this time he has trekked across the Darien Gap, The Thar Desert, worked as a trekking guide and Chief Medic for Raleigh International in Namibia and Zimbabwe, a trauma medic in Columbia and ski field doctor in New Zealand. Since 1998 he has worked for Across the Divide Expeditions as medic and expedition medicine advisor, providing medical cover on expeditions in 21 different countries. Dogsledding to Desert trekking in Namibia. In 2002, he and his wife, expedition medic Dr. Caroline Knox, helped to established Expedition and Wilderness Medicine, which seeks to provide comprehensive training for medical professionals working as expedition medical officers in a variety extreme and remote environments.

Luanne Freer joins the Expedition Medicine team.

Mark Hannaford — Fri, 25 Jan 2008 10:08:35 +0000

We where privileged at EML to have the Everest Base Camp MD Luanne Freer join our lecture team in the Lake District during here recent visit to the UK

She has a great website for those of you interested in altitude medicine and the video below illustrates the difficulties of operating at this height

Visit her Everest MD website here

The BBC trailor for the documentary about her.