Matt Edwards Blog working in remote medicine
One of our locum doctors was on his way in to help out but was a little way off in the infamous Nairobi traffic. The tiny Cessna plane arrived from Lewa and taxied to us. The little girl had improved on the journey and was now wriggling away from stimulus. It was a good sign; lots of little kids respond like that after a significant head injury. I see mostly insignificant head injuries in children back home, and often I have to physically catch them from the play-area in the waiting room to assess them. We packaged her up while calming the parents and sent her off to the hospital for a scan of her head to exclude a neurosurgical issue. I am told she awoke fully on the way to the hospital and is doing fine.
It took about an hour to get to this gold-mining town in Kahama, Tanzania and on the way, while being bumped around by the thermals coming off the baked ground, we did our standard checks and discussed our plan. Given that we were expecting to be escorted to the patients bedside, we thought we would have a little time to assess and plan in the relatively safe and sheltered environment of the hospital. As we taxied around at the dusty runway, I noticed an ambulance sitting just outside the gates on the other side of the airstrip. I wandered off in the baking heat to have a pee (I am always totally convinced I am going to get bitten by a snake when I do this) and Kisito the flight nurse explained to the airstrip’s official that the ambulance needed clearance to enter. It seems no matter where you go in the world you will find irritating ‘jobsworths’. It’s just that in Africa they tend to back up their obstinate behaviour with an AK-47. Kisito gave up and beckoned the ambulance to bring some people to help us hump the equipment the 500m over to the gate. I lifted a few pieces of equipment out of the aircraft and then noticed he had started running towards them.
Unfortunately the relatives could only afford a flight with our caravan. We could have been there in 20 minutes in a jet. Two hours and a bumpy road journey later we were at the patient’s side to discover the doctors had intubated him despite the advice of the guys in the radio-room. They had intubated and sedated him but had no capacity to give him positive pressure ventilation. So he was basically in a worse state than if he had been left to his own devices. He was sedated, driving down his own appropriate urge to breathe rapidly and the tube was merely providing an extra long windpipe, like a rather thin snorkel, just making the work of breathing more difficult with the froth from his chest bubbling out the end periodically. I’ve never seen this done to a patient before. Without the benefit of assisted ventilation I simply don’t understand what they were hoping to achieve.
As I settled down to a well-earned sleep that night, little did I know that, across the other side of the country, something terrible had just happened. The storm was about to get worse…
Stay tuned for the next signal….
About; AMREF’s vision is for lasting health change in Africa: communities with the knowledge, skills and means to maintain their good health and break the cycle of poor health and poverty. We believe in the inherent power within African communities – that the power for lasting transformation of Africa’s health lies within its communities.
Interested in working in remote medicine? Courses of interest
The inverse Swiss cheese model of Success!
I have been shown the Swiss cheese model for error or disaster many times in my career. But I wonder if there is a Swiss cheese model for success? So instead of the multiple holes lining up to allow an environment for disaster, all the right holes line up allowing you to sail through against all the odds and come out the other side with a truly excellent result. If there is not such a model, I would like to propose it now and give you an example that happened just the other day.
I have written little about the staff and expertise that goes on behind the scenes allowing AMREF FD to do its job. They made those first layers of Swiss cheese line up, just in time.
Coming from a first world country and working at AMREF you become very acutely aware of the different medical capabilities in the third world and how incredibly remote (geographically and logistically) some of these places are. And that’s coming from someone who has worked in Antarctica! If taken ill in one of these places you had better cross your fingers and hope your own body can sort it out. While out here I have often thought about one of my medical school colleagues, who tragically succumbed to a severe illness in the bush of Africa on her elective. I wonder if she would still be with us if AMREF FD had been there and able to pick her up in time
We received word of a young man travelling in a remote area of Ethiopia who had become extremely sick. They thought it was probably malaria but could not confirm. He had had a pretty classic malarial course with a few days of very high fevers, rigors and then started to develop dark urine and jaundiced skin. He seemed to improve on a dose of artemether (administered by another member of the group he was with) and then during the night became drowsy, confused and convulsed. He had not regained consciousness since. The doctors in the small clinic there had neither the supply of medication, nor the facilities to treat such a severe illness. Their experience of severe malaria like that in their local population is that it is invariably fatal. They just expect to watch people pass away.
When a distress emergency call like this comes into AMREF a number of things need to happen before we can get going. One of the first things is getting confirmation from the insurance that they will pay and the patient is covered for what we propose to do. Then we need to get the guys at Phoenix to work out how to get us there. That requires knowledge of the airspace, the airstrips in the region and, crucially in this case, their opening hours. Our operations team need to get immigration to agree to let the patient into the country and get clearance for our aircraft to enter the countries airspace and land.
In this particular case, the challenge was that the call came through about lunchtime and the airstrip we were flying to could not support night flights. Lalibela is a site of considerable beauty and cultural heritage in Ethiopia attracting a large amount of pilgrims and tourists alike, so the runway is tarmac and well maintained, allowing us to get there is a jet. But immigration dictates we cannot go straight there; we use first stop in the capital Addis Ababa to process the paperwork. Only in extremely rare circumstances is that wavered in any country, not just Ethiopia. (For example, because of a prior agreement, we can fly straight to any airstrip in Tanzania without going to Dar Es Salaam). So given that it’s two hours from Nairobi to Addis Ababa, then about 30 mins until we can set off to Lalibela which takes 45minutes and shuts at 18:00, we were looking at a cut-off time of 14:30. If we missed it we would have to wait until morning. The medical report strongly suggested that the patient would not survive such a delay.
As our Operations staff battled with Ethiopian immigration and badgered to gain clearance for the flight, our radio room in desperation tried to charter a flight in Ethiopia to go get the patient and bring him to Addis (which is open 24 hrs) then we could pick him up there, but we couldn’t get a doctor or nurse to do the escort. At 13:45 it was looking like this young man’s life was slipping through our fingers. All we could do as the medical team was sit with our equipment, ready to go and hoping the operations team could pull it off in time. It just seemed crazy to me that this red tape can’t be sorted out while we are on our way or even once we had picked him up, but that just isn’t the way it works.
At 14:10 we got the call the clearance had been granted, the insurance had confirmed they were happy, the patient’s travel documents had been found and we started up the jet. It was still going to be tight. It was entirely dependent on the immigration officials at Addis Ababa. Airport officials here seem to behave a little like ‘Rheopectic liquids’ i.e. they become ‘slower and thicker over time when shaken, agitated, or otherwise stressed’. Utter deference to their lofty status and prostrated begging normally works better for the fluid dynamics of the situation.
In Addis we were able to speak to the doctor treating this chap. He was worried. Really worried. He said his respiratory pattern was changing indicating he was not long for this world. This news came as the pilot did his calculations and worked out we would have about 30 minutes on ground. We told the doctor to him to get him to the airstrip, we couldn’t come to him. He was reluctant but it was the only way.
The flight into Lalibela was about 45 minutes. As Clement the flight nurse and I drew up drugs and set up the ventilator I caught glimpses out the window of an incredible landscape. If the only pictures of Ethiopia you have ever seen have been from Oxfam adverts, the country has been rather misrepresented. This particular region is breath-taking, with vast undulating valleys, deep canyons and lush green cultivated fields. From that elevation I missed any of the famous temples carved out of the ground and canyon walls but I could see the scattered village buildings resembling little mushroom plantations. Soon we were banking hard around a valley rim and on finals into Lalibela.
The patient had been brought to the airstrip and he looked worse than I imagined. His travelling companions were obviously incredibly worried and glad to see us. Like any of these situations a little crowd of locals had gathered to watch. It’s annoying and intrusive but you get used to it. There simply is no point telling them it isn’t a spectator sport. Because it is really. You just have to get on with it and they can be useful on occasions as another pair of hands to help lift things.
Clement and I set to our resuscitation (being given our absolute max time of 45 minutes) and the pilots were incredibly helpful and just became members of the medical team. When rushed in a situation like this where there is no one to bail you out like in hospital, it is even more critical you keep your head, calm down and go through your checklists. Communication is key and despite not having worked with Clement for long (he is one of our newest flight nurses) we gelled and did a bloody good job if I do say so myself. Within our allotted 45 minutes we had more IV lines in him with improving oxygenation, a blood pressure, and had established him on the ventilator without any complications. We settled him into the plane with all our pumps, drips and machines and were taking off from the beautiful Lalibela just as the light was fading.
With all our kit we were able to invasively monitor his progress as we treated and correct his various issues. As he improved he started to require more sedation to help him cope with the ventilator which is a promising sign that his brain was coming back on line. By the time we arrived in the hospital in Nairobi we performed a blood gas test which showed he had massively improved and was even breathing for himself. I am told he is now stable and improving in intensive care and the doctors are very positive about his prognosis. Discussing the case, we all agree that had it not been for the actions of our dedicated operations team busting through that red-tape and our pilots ‘pushing the envelope’, the story would have been very different. But for this lucky young man, all the holes in the Swiss cheese lined up just in time.
Having recovered from travelling the length and breadth of the the continent last week, I’ve been doing a few shorter retrievals into the wild expanses of Kenya’s neighbor to the south – Tanzania. I’ve done a few medevacs from there in the last month but haven’t written much about it. But as I seemed to be spending more and more time buzzing around it’s vast landscapes in the co-pilot seat of a Cessna caravan, I thought I’d expand on my experiences there.
I was first called out to a young man stuck in the middle of the game reserve of Katavi, the other side of Tanzania and close to Lake Tanganyika, with resistant malaria. Now if I’ve learnt to respect one thing out here it’s malaria. I suppose I am exposed to a pretty severe case-mix to be fair. If the local treatment isn’t working or they are in a collapsed state we get involved. Some of these guys are impressively sick and I suppose, now I reflect on it, I think what is actually affecting me about this is the number of young people with critical illness I’m seeing on this placement. Working in the UK I’m so used to critically unwell elderly patients but I’ve just not been asked to manage many elderly patients here. Well apart from the minister in Musoma and the jogging octogenarian rose farmer who had broken his hip in Kampala but they don’t count as really ill. They could both beat your average middle aged Brit in a race, even with a fractured neck of femur.
I was lucky enough to be allowed to sit in the co-pilot seat for the trip there. It was a long journey in the caravan but you simply couldn’t get bored with that view. We flew past the famous Ngorongoro crater into the wide open plains of the Serengeti. I was told on the way that the crater is an incredible, almost ‘locked-in’ ecosystem of a huge variety of animals. Even though Sir Arthur Conan Doyle’s Lost World was based in South America, it’s tempting to believe the crater could have been an inspiration for the tale. It is truly vast and few animals, especially the lions, seem to see the need to cross the rim. As we made our way into the Serengeti plains I could not stop humming Toto’s rock ballad ‘Africa’ – it drove me mad.
Soon we were landing in Tabora for a fuel stop and then continued south west towards Lake Tanganyika. The landscape became relatively featureless and it reminded me of flying in Antarctica. The huge marshlands of the Katavi National Park came into view – the home of a huge number of hippos and billions of bloody tsetse flies unfortunately. At least when you went to see Antarctic wildlife you didn’t have to cope with their irritating, disease-spreading, insect entourage.
We managed to find the secluded airstrip and did a dummy run to clear it of about five impala. No wonder cheetahs struggle to catch those things – they move incredibly fast. At most of the Tanzanian airstrips we have to get rid of a number of large animals standing in the way. Not something most pilots normally need to worry about. There are certain interesting considerations to this animal clearing such as; if you are going to land between two herd animals, bail out and climb. If it is just one, it will run away so you can land. The instinct to herd is so strong when they are threatened, that they will run together. So if the plane is landing between them, the likelihood is that one of them will run into the path of the plane and that would be sub-optimal for a landing.
Our patient was not too bad so was quickly popped into the plane and connected up to some fluids etc. I am told he has been treated for recurrent malaria and is recovering well.
This was a shorter journey and the route was thronged with wildebeest (with a couple happily grazing on the airstrip). When we arrived on the beautifully secluded airstrip we found our patient, who was alive, cheerful and looked pretty chipper! We examined the circumstances surrounding this cardiac arrest and it was very short, while he was witnessed drifting off to sleep. It is possible that someone’s heart can stop due to an abnormal heart rhythm briefly and then it reverts to normal when someone starts thumping on their chest. It’s possible. If that was the case, then he is one lucky guy. For our years and years of research into the outcomes of out-of-hospital cardiac arrest, we know that the only people who have a reasonable chance of walking out of hospital with an intact brain are those who are witnessed to collapse and have good early bystander CPR. Just look at the survival outcomes they acheived in Las Vegas! (Valenzuela, NEJM 2000) The situation is slightly different in the middle of the Serengeti I’m afraid. There are many different explanations to what happened to this chap, including the fact he might have just been asleep, but the key fact was that someone was at his side and and started life saving actions immediately. I can only hope that, in the event of a sudden collapse for myself or my loved ones, someone close-by acts as promptly.
Who are AMREF?
In 1956, three doctors – Michael Wood, Archibald McIndoe and Tom Rees – drew up a groundbreaking plan to provide medical assistance to remote regions of East Africa, where they had all worked for many years as reconstructive surgeons.
Spurred by what they had seen of the combined effects of poverty, tropical disease and a lack of adequate health services in East Africa, their collective vision was born in the foothills Mt Kilimanjaro.
At that time, there was one doctor to every 30,000 people in East Africa – in Britain it was 1:1,000. Medical facilities were sparse, with rough terrain and often impassable roads making access to medical care difficult for people in rural and remote areas. As this was where the majority of the population lived, Archie, Tom and Michael saw an air-based service as the only way to get health care to remote communities.
AMREF Flying Doctors provides air evacuation services in medical emergencies across East Africa, as well as air ambulance transfers between medical facilities.
We are Africa’s leading provider of air ambulance services and operate across many East African countries including Uganda, Kenya and Tanzania and, when clearance can be obtained, most neighbouring countries including the Democratic Republic of Congo, Eritrea, Somalia, Ethiopia, Rwanda and Burundi. Subject to flight clearances, AMREF Flying Doctors will carry out evacuations from anywhere on the African continent.
In addition, patients can be repatriated via an AMREF Flying Doctors aircraft to Europe, Asia and North America or a medical escort can be provided on commercial carriers. AMREF Flying Doctors operates 24 hours a day, 365 days a year. As a vital link between remote areas and AMREF’s Control Centre at Wilson Airport in Nairobi, AMREF has established a radio network that comprises over 100 HF radio stations across East Africa, making it the largest two-way radio network in Africa.
As well as emergency evacuations, AMREF Flying Doctors provides a medial outreach programme, taking essential health care to some of the most impoverished and remote areas of Africa. AMREF Flying Doctors, part of the African Medical and Research Foundation, is based in Nairobi, Kenya and has been delivering health care to some of the most remote areas of east Africa since its formation in 1957 by Sir Michael Wood.
AMREF Flying Doctors is committed to providing world-class medical services to the people of Africa.