“We can’t let the perfect be the enemy of the good” or Stories of language and orange seeds in jam jars.

I have never noticed before how the patterns of the seasons in the UK help me orientate myself to the time of year and how time is passing. Since our arrival we have gone through the rainy season and we are now in the cold season. It seems that the cold season brings similar phenomenon across the world over – old people are coming in with hypothermia, babies all have bronchiolitis, people complain about the weather and don’t want to go outside. The confusing factor here is that it is still perpetually blue skyed, windswept and sunny and up to 30 degrees in the day and only down to 12 at worst at night. The words ‘March and April’ seems meaningless to me without connecting them with frosty mornings, wet shoes, grey skies, daffodils and scarf wearing. This means that we have sped through these months unaware and have now somehow arrived totally disorientated in May and over half way through our time here!

Life here is becoming more normal and so I forget which moments are ones to write down or try to remember. So just a few stories from the hospital. We had an experienced HIV consultant visit from the UK for a week who in one of his teaching sessions told us ‘We can’t let the perfect be the enemy of the good’. It has stuck with me as a way of expressing the balancing act of looking after this patient in front of you as best you can and at the same time trying to ensure that the children who come after this one can also have the best care possible. How long can I ventilate this baby for using a bag and mask only with 40 other children who I am also responsible for waiting to be seen? Can I put this 900gram baby on IV fluids for the 4th day running when I know there is only one nurse and having to do one and a half hourly fluid boluses will take her attention away from the 19 other small babies in the little hot incubator room? How much of our only Salbutamol inhaler should I use up on this 7 year old with an acute asthma attack? We are lucky in that these questions are not as loud for us as for some as we are working in a setting which in comparison to some other African contexts has relatively good staffing and resources but the questions are still there. To what extent do we focus on an individual or do we try to get the greatest good for the greatest number? In some ways a wider version of these questions have been in the back of my mind for years : is it better to have a doctor right here right now who isn’t from your country, doesn’t speak your language or wait and try to invest in building a stronger health service for the future. Is aid helpful? What problems does it cause in the long term? I still don’t know the answers. But I have noticed the value of being there for this person, in this place, in this time. For that person you can change something. Whether that is enough to justify the other unanswered questions I cannot say.

One night I found particularly difficult this month was an on call where I was in the hospital most of the night with a beautiful 2 year old who eventually died of croup. I had convinced this was the one child I was going to save – I had managed to track down and make up some nebulised adrenaline at 2am and gave her a lot of steroids- she had the most terrible stridor for hours I have ever heard but then she didn’t make it. The mother was distraught – screaming and wailing so I had to get a hospital guard to go and get her own mother from where she lived luckily nearby to take her home in the middle of the night and calm her down. I always feel extremely frustrated at my lack of language skills at times like this. I have to rely on the nurses to translate for me and they are often too busy or don’t see the point of explaining things in detail so I often have to try and sum up everything I want to say and how sorry I am just by saying “sorry” and standing there looking sad. So inadequate for what I want to express. Sorry we can’t intubate your child because there are no doctors trained and then no ventilator available. Sorry you child is being looked after by an English SHO when they deserve a full ITU and anaesthetist. Sorry you would get that if you were born in another country. Sorry you actually managed to get your child enough food and clothes and that they were growing well and walking and talking and you tried really hard with the little amount of things you have and still they died when you thought they had made it past the risky time. Sorry your child just died scared and probably in pain and I couldn’t stop it and I am getting in the way of you trying to grieve by coming along and listening to their chest and just writing a lot on my piece of paper with no explanation to you. Sorry.

I am getting there with communication slowly though. Last week a little girl went home after being with us for almost 3 weeks. She is a very elegant, thin and self-contained 9 year old who came in actually the same night as my croup child with her intelligent and kind Grandmother who always wears a head scarf and a yellow chitenje, with a month of shortness of breath, weight loss and night sweats. We initially thought she had TB until we sent her for an ECHO (an ultra-sound scan of the heart) in the hospital Chipata –an hour away- which demonstrated a very severe dilated cardiomyopathy- her heart now so floppy that it was only pumping a fraction of the normal amount of blood around her body with every beat. We are not really sure what caused it but possible a viral myocarditis – an infection of the muscle of the heart. Since then we have been trying to get her better on medication here but with very little success and the only option really in any country would be a heart transplant. (which on an incidental note is a very interesting thing to try to explain to Zambian nursing staff who slightly concerningly believed that in the UK robbers just took hearts from people they caught in the street and then we as doctors would transplant them for a fee) Both her and her Grandmother were so patient and uncomplaining and little A. even got to the point where she would answer my stilted Chechewa questions on my ward round with her whispered answers: ‘how is the cough?’ ‘a little better doctor’. I am very attached to her. A few days ago the Grandmother asked me if she could go home seeing that A. wasn’t getting any better and from what she understood there wasn’t anything else we could add. With a nurse we managed to have a half an hour conversation about where would be best for this little girl to be and how we could achieve that and in the end decided that going home was the best decision. Although a very sad situation I felt we were able to give the family the power to make a decision which would hopefully result in the most dignity and least suffering for this lovely little girl.

One of the Scottish doctors working with me on Paediatrics for the last 3 months has now switched to medicine. The nurses had noticed our style of working which was basically just affirmation of each other at all points or trying to hug cute children and one of them commented when L. left ‘I wonder how you will cope Dr Rachel without her – I notice you two love each other so much’. Instead I have been joined by H. who is also from Scotland and is here for a year and lives next door to us in the square. She is wonderfully kind, genuine and straightforward, and likes (amongst other things) ants, knitting and talking about Shetland. The other doctor with us is a brilliantly eccentric Ukranian doctor, new to the hospital, who is employed by the government and has worked in Zambia in various hospitals for over 20 years. She has a slightly different approach to patients than our very British one and the other day to see if someone was breastfeeding she without warning picked up their breast and squirted the nurses and the mother with milk whilst shouting at them in a mixture of English/Ukranian and Chichewa. No one seemed to bat an eyelid but I thought it was hilarious and couldn’t stop laughing in the corner. So we are quite a mismatched team but get on well.

Outside of the hospital I am enjoying how life is simpler here. There are less things to do so I end up having time for things I always wanted to do at home but felt I never had time for – like reading books with cups of tea, planting orange seeds in jam-jars, trying to make sloe gin from an unidentified berry I was sold at the side of the road (I haven’t sampled this yet so will have to keep you updated on it’s success) and enjoying things like eating chips made by a 10 year old boy running his own chip stall and buying tomatoes from the market. We have been befriended by a beautiful nurse C. who works in SCBU (special care baby unit) with me. Her and her 5 children, Esther, Tony, twin 3 year olds with spaghetti-like hair – Gloria and Patience and 6 months old Hastings came round for pancakes, painting, guava tree climbing and football with ‘Uncle Doctor David’ last Saturday and this weekend we were invited round to their wonderfully slightly ramshackle house and fed eggs and chips in one of their 2 rooms and given gifts of orange lemons. The children were excited to show us all the best parts of their garden – my favourite of which consisted of Tony’s (8 years old) little garden patch which was completely empty so far but apparently growing lemon seeds, T proudly explained ‘I think this is the best part because it’s got lots of soil in it’. I had been off work for a few days with a bad cold (I told you – it’s the ‘cold season’ I was just getting in the spirit !) so had knitted Hastings a little stripey jumper (whilst using precious internet to live stream one hour of radio 4 as a treat) and C is making D and I matching chitenje outfits. It was lovely to spend time with people outside our little circle of doctors and feel like we are making some Zambian friends here. D and I borrowed two old mountain bikes a few weekends ago and we went cycling along red dust tracks past sunflower fields under wide blue skies and through little villages consisting of round thatched huts and wandering pigs where children scrambled to the edges of the path to wave frantically at us and call out the infamous cry of ‘Mzungu how are you ?’ I commented to D that I felt like we were in the Tour de France because of how celebrated we were as we reached every village. That was probably where the similarity ended.

This has already got too long so will have to write more next time. We are happy and enjoying life. Thinking of our favourite doctor friends in the UK a lot with all the strikes and pressures there. We have been looking at old photos of everyone so now feel very nostalgic and missing friends and family at home. We think of you often and love hearing from you.

Orange lemons!
David and the twins
Outside the Paediatric ward
Me and our new breakfast club friends
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Jumper for Hastings!
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Most recent garden triumph. Seeds from Lidl.



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