Coming home

BA flight 060 has left Nairobi and I’m once again in the African skies. But this time I am not in my own private jet and I will not be retrieving some unfortunate soul from the depths of the continent. My time with AMREF Flying Doctors has come to an end and I will soon be back on home soil in Heathrow. The time has streamed by in steady flow of little adventures that, no sooner had I started to reflect on one, I was whisked off on another. 

It was not all that long ago I was in a similar aircraft approaching Nairobi and, to be blunt, utterly bricking myself. Since then I relaxed into my role and was embraced into the AFD family. The variety and frequency of the strange situations flash through my mind like someone rapidly flicking through a comic book. It’s so difficult to pick them out from each other. I’m now so glad I started writing the blog so I can revive the memories for years to

come. I’ve thoroughly enjoyed writing the stories and I’m really chuffed so many of you have enjoyed reading them. To date over 7000 people have read these posts and I find it hard to believe my mother was responsible for all of them! I would love to continue writing them but life as an emergency physician in St Mary’s hospital is less conducive to attention grabbing headlines. ‘Woman gets offended when told her sore throat is not an emergency’ is just not as exciting as ‘Buffalo attack wake up call’.

The guys were able to summarise the work which I have done over the last three months and it has surprised even me: -

• Countries visited – Iraq, UAE, Sudan, South Sudan, Ethiopia, Djibouti, Somalia, DRCongo, Uganda, Rwanda, Burundi, Tanzania, Chad, Zanzibar, Madagascar, South Africa and all over Kenya.
• 73,000 miles flown, which is nearly three times around the world.
• My work as a volunteer has provided over $33,000 USD which has been saved by the charity.

It has been an exceptional time, providing me with some of the most heartwarming, bizarre, frustrating, terrifying and challenging medical experiences of my life. I’ve learnt a huge amount as a clinician. I’ve learnt about teamwork and timework, suffering and salvation, injustice and incompetence, African cultures and corruption. I’ve been so privileged to be involved in some of these stories and would urge any of you, who have the appropriate skills, to seriously think about taking this job on. I would imagine this is my last post for AMREF Flying Doctors and thanks again for following the blog. It’s been emotional.

Somalia, Kenya and the African Union

Having just been to pick up a few more sick and injured soldiers out of Somalia I thought I would reflect a little on the ongoing military situation in this troubled little corner of the world. I was involved in military casevacs very quick; in fact, my first medevac with AMREF FD was retrieving injured Kenyan soldiers out of Kismayo on the Southern coast of Somalia. It has been fascinating to watch the African Union, the Kenyan forces and the UN combining their efforts to bring something resembling stability to the region. I’ve seen the results of this conflict in many different spheres: -

 I’ve seen the vast refugee camps of Daadaab, retrieved injured Kenyans out of Kismayo, treated African Union troops in Liboi in North Kenya, visited the Somalian army training camps in Uganda, seen the aftermath of the UN compound bombing and a myriad of other terrorist attacks in Mogadishu, chased US drone aircraft along the coast and listened to friends recounting stories of terrifying hostage situations, piracy payoffs and a load more I shouldn’t probably know about. It’s phenomenally complex.

I didn’t realise how controversial the Kenyan presence in Kismayo actually is. The ruling on the African Union interventions is that only remote African nations can form part of the armed forces. Therefore it can’t be seen to be an invasion by a bordering country.  For example, the Ethiopian troops backing the Transitional Government, really shouldn’t be there under the rules of the AU and have only now pulled out completely. The occupation in the south was more of a unilateral decision by Kenya that the AU and the rest of the world chose to ignore (or actively assist in by levelling the Al Shabaab positions using remote drones). You couldn’t blame them for taking the matter into their own hands. The constant flow of refugees,

the insecurity along the border and piracy along the coast was really starting to piss the Kenyans off. No one was really doing much about it and then there was a high profile abduction from Lamu by Somali pirates which scared off the tourist trade. I’m told, that was it. Abducting people from within Kenya was simply not on and the army was mobilised and advanced into southern Somalia as far north as Kismayo (there may also be a lot of mineral wealth there too, how lucky!). For most of my time here it has been pretty stable but there has been more action recently.

I’m not a military doctor. I’ve never experienced anything like this before. But I’ve got more used to the accounts of IEDs, sniper fire and skirmishes. I’ve got more used to our crazy low level flights across the sea into ‘Moga-disco!’ I’ve developed a real affection these African troops. Whenever we arrive they are smiling and courteous and are doing the absolute best for their comrades, whether they be Ugandan, Burundian or Kenyan. And my word, they are tough cookies. It’s strange seeing these brave smiling faces with injuries that are causing severe pain, and then their relief when we get their pain under control and they know they are getting out. I know the medics are doing their best but from what I know of our capabilities in places like Camp Bastion, I know that these guys won’t have anywhere near the chance of survival after trauma that our troops can expect in places like Afghanistan.

It’s all seems to be getting interesting again. There was the fantastic news that the two Medicin San Frontieres aid workers have just been released after a couple of years held captive. The so-called father figure of the Al-Shabaab and jihadist ideology in Somalia, Hassan Dahir Aweys, the chap with the fetching bright ginger goatie, has recently surrendered himself. There is a lot of speculation as to why he has done this but the overriding theory seems to be that Al-Shabaab is becoming split in its ideology and Aweys is fearing for his life. He has been rather vocal denouncing many in Al-Shabaab

A bullet through the tibia and fibula, ouch.

for "acting in a manner unbecoming of upright jihadists". I am curious to know where ethics and a code of conduct comes in to it but such talk seems to have been his undoing. There seems to have been a hostile takeover by the Afghan-trained Ahmed Abdi Godane and there has been a string of assassinations from within. People are saying they may be on a course of self-destruction but that sounds rather optimistic to me. It sounds like just another tale of one warlord usurping another to me; same old same old. But stories filter through that the new wave are more interested in martyrdom than power or politics. Apparently foreign jihadists are being rejected, or being told to do' undesirable work' and going home. If that’s all true, then hopefully they will manage to extinguish themselves pretty soon. If that’s true, then those men seeking death and glory but with no strategy for seizing power, no interest in winning popular support, and fractionating themeslves from foreign supporters, will get their death wish and go out with a bang. Unfortunately the bang will involve more civilians and the peacekeepers with the AU, UN, Bancroft, RMSI, and AMREF FD picking up the pieces.

Tragedy in the Aberdare Mountains

Late Thursday night I received word that we would be part of a Search and Rescue team entering the Aberdare mountain range at first light. We would be searching for a small Cessna 206 '5Y-BUG' single engine plane which had not returned to Wilson airport after picking up two clients in the Laikipia region north west of Mount Kenya. 

The Aberdare range as the cloud broke up

There had been activation of the aircraft’s Emergency Locator Transmitter (ELT) which sends an automatic distress call out to South Africa, and meant it had definitely crashed. But the signal had stopped, presumably because of low battery, and getting a pinpoint on its location was proving very difficult. For one, the best estimate on its location was in a highly populated area to the west of the range, making the estimate from South Africa very unlikely. People tend to notice air crashes in their back gardens. So charting a path from the last known location to Wilson, the most likely location was within the dense forest of the Aberdare mountains.

There were three souls on board - an extremely experienced and well known pilot, and two female tourists. There had been no contact or distress calls indicating they had had trouble. Phone reception up in those hills would be poor. After my last plane crash experience I was cautiously optimistic we would find them alive, others were less so. There are tales of pilots walking out of that forest five days after the search had been abandoned, so while there was still hope of finding survivors, we were going along. We would also serve as an extra pair of eyes scouring the treetops.

Low cloud down to the inhabited areas

 Daylight came and the weather was not good. Dense cloud clung low to the hills and there was little hope of penetrating up to the summit. A couple of planes passed over and were unable to find the ELT signal but they reported the cloud was breaking up a little so we set off. We briefly went to look and confirmed that a crash over the far west side of the mountains would not have gone unnoticed, and then advanced up into the hills. Meanwhile, on ground, supposedly there was a search party which was entering the areas on the east side. Without a more accurate idea of where to look, they had little chance of finding anything. The forest is a vast area to search on foot. A British fighter plane was apparently accidentally found there 60 years after it had crashed.

Indeed the cloud began to lift and break but, as our pilot Chris expertly guided the chopper into the forest, my heart sank. It would be like looking for a needle in a haystack. The forest was so dense that, for the most part, all you could see was canopy. Subtle damage to the treetops would be very difficult to spot. Where there were no trees, it was dense bamboo. As I watched a group of elephants making their way through it, I could see that, if a plane went down there, the flexible bamboo would just close over and swallow them. 

We stopped off to ask a few National Park rangers whether they had heard a plane the day before but they said they hadn’t. They also told us that the cloud was very heavy and all over the hills. The idea of an engine failure was becoming more and more unlikely. No distress call implied a sudden event. An event like getting caught in low cloud among steep hills and having no instruments to guide you. That’s when small aircraft crash into the sides of mountains.

The pilots used their experience to guess where their colleague would have flown if he was in trouble and we searched for an hour or so. Anthony  (the AMREF flight nurse) and I hung out of the open helicopter doors in harnesses to get a good look below us but soon the fuel was running low. We all realised that without a better plan we had no chance of finding them and headed to Nanyuki to refuel and regroup with the rest of the search party.

The group was tired, really tired. Anthony and I had been up since 5 but many of these guys, particularly Rob Link, had been up all night trying to get more information about what had happened to their friend and his clients. It was heartening to work alongside these guys, obviously upset, stressed and exhausted, but all the while able to create a dynamic and sensible strategy to continue the search. There was now more information allowing us to triangulate a smaller area of the western side of the hills. We had the last signal from the ELT, which we had already established was probably a couple of miles off and we had the last radar point in which the aircraft was being tracked by Jomo Kenyatta airport. Now, in addition the telephone company was able to give us an approximate location on one of the women’s cell phone. It had been ringing and ringing but no answer. It was also a very bad sign and fitted with our growing fear of a sudden lethal event up there. My optimism of finding anyone alive was fading.

As I listened to Rob and the others drawing up a plan, a series of promising reports started coming in. The wreckage had been spotted and the police were walking on foot towards it! We got the location and headed out immediately. As we moved up the hills again, it became clear that this was all unsubstantiated rumour and hearsay. On the move, Rob and Chris managed to work out, it had been heard from someone, who heard it from someone else, and the trail ran dry. The head of the land-based police search had no idea what we were talking about. What amazed me was that the rumour had such detail and it obviously infuriated us all because we had been led on another wild-goose chase and wasted more time and another tank of fuel.

So we went back to the original plan and divided the area into grids and using three helicopters scoured the area. I have no idea about what was going on down on the ground (I certainly saw no evidence of a ground search from the sky) but I’ve since seen some footage on youtube (see below) indicating they were probably making little progress. But as the hours ticked by, and we scrutinised each suspicious patch of foliage, it became obvious neither were we. The cloud rolled in, obscuring the hills, it started to rain and the light began to fade. We had to give up. We had been searching for 9 hours straight.

I was called on Saturday morning to let me know a pilot from the Kenyan Wildlife Service had found the wreckage. There were no survivors. My biggest fear had been that we had been flying over the site and they had still been alive, able to hear us but unable to show us where they were. We had to terminate our search imagining that we had looked but not seen. But my colleagues tell me, from the look of the wreckage and the bodies, they all died on impact. Frustratingly the wreckage was in plain view on the very top of the hills that we couldn’t get to in the cloud, about 2 miles from where we were searching.

Unsurprisingly this story has been across the news here in Kenya. Rob Link and the guys from Yellow Wings really led this SAR exercise. Without their tireless efforts the wreckage never would have been found. The wildlife service never would have known where to look. Rob, who flew with me all Friday, was also giving press statements as events unfolded. The impressive government/police effort can be seen on this news report as well.

http://www.youtube.com/watch?v=fgRM2VO8L4k

The bodies were brought back to Wilson Airport today and the whole place became subdued in the morning drizzle. The pilot (whose name has been officially announced) Harro Trempaneu is a well-known and well-loved figure at Wilson Airport and was the chairman of the Aeroclub of East Africa. It is a tight-knit group of aviators here and they have all been shocked by these events.

Harro Trempaneu

"Harro, an aviator through and through and a larger than life personality, was one of the industry's prime sources of information, combative, eloquent and never shy to call a spade a spade, which earned him the admiration of most within the aviation fraternity"

 I understand the relatives of the two women in the crash have now arrived as well. It is extremely sad and reminds us all that even the best can be caught out by bad weather and bad luck in the sky. Rest in peace.

Buffalo attack wake up call

(warning - there is a gruesome picture)

“Daktari… …immediately… …Buffalo attack… …Magadi.” That’s about as much information as filtered through into my brain as I answered the bleeting phone at 05:00 this morning. Before I was really aware I was not dreaming I had my trousers on inside out and was ineffectually attempting to fight my way out of my mosquito net in the darkness.

About 03:30 in the morning, a park ranger in a reserve close to Magadi, about 75km South West of Nairobi was on patrol when a buffalo attacked him. I am now reliably informed by my friends here that ‘Don’t worry about lions and snakes.  Buffalo are one of the only beasts around here that will attack you for no reason.’ And they can cause some nasty damage. They are not as invariably lethal as the elephants but they will charge and impale you with their horns. This poor chap in question was charged before any shots could be fired. Apparently it dragged and threw him before attacking him on the ground and ran off into the night.

He was rushed back to the camp where the nurse there tried her best to stem the bleeding from the huge wounds in his shoulder, his thigh and his head. She did a good job with little equipment and established IV access and gave him painkillers and a tetanus shot. Throughout the ordeal he never lost consciousness.

With the scanty information of ‘buffalo attack, head injury, severe bleeding’ we prepared for the worst (always a good bet for AMREF FD as I have said

before). As we took off into the dawn, Phyllis and I drew up basic drugs ready for a critically ill patient and very soon we were circling over the remote little airstrip in the Rift Valley. On ground we were greeted by a group of concerned looking rangers and staff from the park. Some of them obviously very shook up by the nights events. Others less so. I suppose, in general, there isn’t much to be worried about when you are carrying an absurdly massive gun.

We were all driven with our equipment through the bush to their camp and we were relieved to find a young man, in pain and bleeding admittedly, but conscious and orientated. The buffalo had managed to leave him without critical head, spinal, chest, abdominal or pelvic injuries. He had a few minor head wounds and a large thigh wound without underlying fracture. It had stopped bleeding and exposing it showed how very close the buffalo’s horn had come to tearing open his femoral artery. I doubt he would be alive if it had.

His biggest problems was a horrendous right shoulder injury. The animal’s horn had punctured through one side of the shoulder, shattering the proximal humerus bone as it went and torn through to the other side. Unfortunately he is right hand dominant. His pulse at the elbow was pretty weak but, amazingly, he had preserved sensation to his fingers and upper arm. The wounds were still oozing profusely and the arm was at a horrible angle. It was time to introduce him to my good friend Ketamine.

Ketamine is a fantastic drug for the pre-hospital environment and I think it would be one of your ‘must have’ drugs for remote medicine. It is ‘remarkably safe and is certainly the safest anaesthetic if you are inexperienced’ as, one of my old bosses Dr Sinclair wrote in his book on basic bush anaesthesia for AMREF ‘Ketamine is particularly useful in developing countries’. It’s a potent sedative, analgesic, bronchodilator and best thing about it is that you can give it to patients who had lost a lot of blood without their blood pressure plummeting. Most of the other strong analgesics and anaesthetics will do that, so you run a tightrope of cardiovascular instability if you use them in trauma.

It has its side effects of course. Some of you may know it as Special K for its exciting hallucinatory effects that probably make clubbing vaguely interesting. Those waking from the sedative effects of high dose ketamine often have crazy ‘emergence phenomenon’ which effect different people very differently. Last chap I gave it to, to extricate him out the back of landrover, stared at me and asked ‘Are you God? I am dead. You are angels’. Kids often have fun with their hallucinations but adults have a greater tendency to freak out. Children generally have an overactive imagination anyway, meaning that

seeing a dragon at the end of your bed is quite cool, but as an adult you might start climbing the wall.

The other stumbling block for using ketamine in trauma is that the majority of the medical world thinks it will make patients’ heads explode. If you have sustained a head injury, due to a couple of case series written up in the 70s, ketamine is strictly not allowed as it was thought to detrimentally increase the pressure in the head. Making them explode! I’m not sure how many more review papers, head-to-head comparisons (excuse the pun) or research papers into its potential neuroprotective qualities in head injury need to be performed to revise the dogma. Doctors across the world are still far happier using drugs which dangerously drop blood pressure, an effect shown definitely to worsen outcomes in head injury, than use evil ketamine. It is so engrained into medical culture that I still feel uneasy about giving it. Not because I think it’s going to cause harm but more because of the stern criticism I can expect from other colleagues, utterly convinced I have made the patient’s HEAD EXPLODE!

We popped in another IV line, attached him to monitoring and I gave a mild dose of sedative in the vain hope that we wouldn’t get emergence issues. Then something a bit weird happened...

There is an old medical proverb that ‘if you hear hoofs coming down the corridor, don’t assume it is a zebra’. Which basically means, think of the common stuff first before rushing to weird and wonderful diagnoses. Real medicine is not like House MD, more’s the pity. So imagine my surprise as, having just administered the ketamine, I heard hoofs, turned round and was face to face with a curious zebra. It was watching me work as I knelt beside the patient. I had a double take, making sure I hadn’t inadvertently given the hallucinogenic drug to myself. ‘Nope, that’s a zebra alright.’ Now none of my medical mentors ever told me what to do if there is actually a zebra in the corridor. I pondered this for a second as the zebra and I stared back at each other. The surreal but beautiful little moment was broken as he was shooed away by one the rangers and we carried on.

I gave traction to the horribly crunchy upper arm as Phyllis applied a battlefield style dressing, splintage and a sling. The patient didn’t even flinch but I think his colleagues were slightly concerned by his fixed disembodied gaze at the sky. They do that. Soon we had control of the haemorrhage and the patient was packaged up and ready to move. We rang ahead to warn the receiving hospital that we had a limb threatening injury and to let their surgical teams know. With a 30 minute flight time we were in their emergency room in about an hour. The patient was taken for imaging and I understand he is now in theatre. Neither I nor the orthopaedic surgeon were particularly optimistic about the future function of that arm but, after all, stranger things have happened. Like zebras watching you at work for example.

The Aviators

http://www.youtube.com/watch?v=c0995Pok7l0

I've put together a little film about flying with AMREF FD set to the wonderful piece 'The Aviators' by Helen Jane Long. I'm sure anyone who loves flying will enjoy it. Click the link above.

The hinterland between stratus and altostratus

The Kisii Bus Crash - Sample of the Twitter conversations

In addition, the kind of contemporaneous response we had on twitter from the families and friends was heart-warming:-

“Girl still bad state. Neurosurgeon needed to clear blood clot in the head. Evacuation only solution to KNH”

“The police aircraft couldn't manage this delicate transfer, now we can fully appreciate!”

“Ready for airport transfer. The AMREF doctor has briefed us well.”

“AMREF doctors are just awesome. Tears of Joy. RT get well soon!”

“A 24/7 Working control centre, prompt Twitter Handle to all emergencies. That's AMREF Flying Doctors.” Sir Maseme Machuka

I just hope that next time something like this happens (it is only a matter of time I’m afraid) AMREF Flying Doctors is involved immediately. Then we can do what we do best, for the best possible results.

The Calm Before the Storm - Part 2

About 1900 in a place called Kisii, close to Kisumu on Lake Victoria, an over laden bus full of about 70 teenagers attending a sporting event had crashed at high speed. There were about 8 dead at the scene including the teachers and 10 or so critically injured and the other 50 with an assortment of walking wounded. The local population had mobilised and were dragging the casualties to the local hospitals including to the larger nearby town of Kisumu. The pictures and footage at the scene depict what you would expect: people running about haphazardly carrying people in bedsheets, rushing off with them in the back of pick ups and taxis, a couple of local policemen completely overwhelmed and no sign of a fire service or any ambulances. Mass casualty disasters like that must be terrifying, especially if you know that no help is coming. When you know there will be no flashing lights, no big boys in uniform telling you what to do and no one to assess and triage the injured. As I slept peacefully, Kisii had turned to complete chaos.

The local hospitals did their best but the majority of the critically injured succumbed to their injuries overnight. With current advances in trauma care I can reasonably claim that most of the critical initial survivors would not had died if there was an early, coordinated Emergency Medical Service, Fire and Police response taking them to a well-resourced major trauma centre. In the same week there has been two similarly horrific events occur in the first world – a train crash in France and an oil tanker explosion in Canada. I have watched those stories unfold on the BBC World News, CNN and Al Jezeera.  I bet you didn’t even know about this tragic loss of life in Kenya though, despite it being officially declared a ‘national disaster’ by the Government or the fact that there was a worse crash back in February killing 35. The tragic thing is that Kenya has enthusiastic people with the skills and the resources to provide a better response. This is the kind of horror story that my new friends at KCEMT (the Kenyan Council of Emergency Medical Technicians), the CDC and John Hopkins University are working so hard to make a thing of the past.

This should be the part of the story in which I explain how we were mobilised and ready at first light with two planes fully equipped to go and stabilise and retrieve the most critical from the disaster. Unfortunately we had no idea of the scale of the tragedy that morning and I was sent off early to Kismayo to pick up a load of injured but stable soldiers. It was only as we were setting off back to Nairobi that we learned that the regional governor for Kisii had informed the Government’s ‘disaster control centre’. The reason for the delay is unclear. Then this plea for help was escalated to the President himself who officially declared it a disaster. 

It still took a while for AMREF FD to be authorised to send a caravan plane out to Kisii, along with a few police helicopters and bring the patients back to Nairobi. Kenya’s Red Cross ambulance service were also heavily involved but they could not cope with the situation on their own. They are a paramedic staffed ambulance provider and are simply not geared up for the safe transfer of severely injured patients. AMREF FD is the only certified air ambulance in East Africa that can do the kind of highly skilled rapid triage, treatment and evacuation of the most critical casualties. I hope that the Kenyan people are starting to recognise this. I do hope that the government can now understand that AMREF FD is a specialist resource that can be used to save lives if they are allowed to be involved early enough.

The Caravan Plane used in the evacuation

Personally I found all this out after we had handed over our soldiers in Nairobi and one of our caravans had already headed out for Kisii. Frustrated I had missed the action, I was put on standby in case they needed another team. Our guys had already made it the hospital to find that ‘most of the local population seemed to have taken up residence in the hospital’. People from all over the region rushed there after the accident to look after their relatives or probably just to have a good look at the tragic story. The ambulance was unable to even get to the entrance of the hospital because the main road had become a car park with empty vehicles. Then inside the hospital there was barely room to assess and transfer the patients along the corridors, it was so packed with people. It was a perfect example of why the police are so vital to control the crowds and ensure access and egress from the scenes of major incidents. In the end they managed to get in and triage the 53 patients concluding that only 4 needed to be airlifted to Nairobi. The rest could be safely treated where they were.

As we waited at Wilson by our hanger it became busier and busier. Soon there was a massive crowd of news media, the Red Cross chaps, members of parliament and the Kenyan police. I thought it was a rather big turnout for just four patients. Then someone explained to me that nearly 20 injured patients were being airlifted because the President had declared a disaster. Therefore all the injured must come to the Government hospital in Nairobi.

As the cameras clicked away Charles and I took the first multi trauma case (head and chest injuries) to Kenyatta hospital. I had never been there before and we greeted by even more media. We were soon joined by more and more ambulances dropping off their patients and the already stretched A+E was suddenly swamped. Our staff and the Red Cross paramedics were impressed by how many staff had been diverted to come and take their patients. It’s true, we did not need to hang around. The patients from the incident were all seen very quickly. But I saw how busy the A+E Department was before we arrived and I wonder how the other patients fared while this influx inundated the hospital.

As I returned to Wilson airport, we were asked to head straight out to Kisumu (not far from Kisii) where one of the young girls involved in the crash had been taken. Strangely, we were stood down at the last minute. Apparently new arrangements had been made. I was surprised and assumed that she must have passed away. I was even more surprised when, the next day, Kizito and I were instructed to retrieve the poor girl again. What had happened became clear when we arrived. We were told by the staff at Kisumu that a police helicopter had turned up instead of AMREF FD with just a mattress in the back and no medical personnel. Thankfully the medical staff at Kisumu stood their ground and refused to allow such a critically ill young girl to get airlifted like that. Again I have to emphasise that when there is a resource like AMREF FD, capable of stabilising and safely transporting such a patient, sitting on your doorstep, ready to go at a moment’s notice, then it must be used. Unfortunately another 24 hours had been wasted.

By the time we were at her bedside, her conscious level had deteriorated further. She was now only responding to painful stimuli by inwardly twisting and extending her arms, which is a sign of quite considerable neurological impairment. She was certainly not protecting her own airway so, yet again, Kisito and I set to intubating, sedating and ventilating her and trying to protect her brain as best we could. I think we were reasonably successful as the high spikes in pulse, respiratory rate and blood pressure she was having on the ward, settled with us and she was nice and easy to manage on transfer.

Upon arrival we were met by the CEO of Kenyatta hospital who was extremely grateful for the safe transfer. I think that he clearly understands that now, when the police or Nairobi’s ambulance services can’t handle it, he knows who to call. 

The Calm Before the Storm - Part 1

The past week at AMREF has been one of strange contrasts. There were no flights at all for three days and it was making the staff twitchy. It just doesn’t feel right to have nothing going on. In actual fact there was quite a bit going on at AMREF FD headquarters, just no flying. We had the official launch of the new Beechcraft King Air air ambulance on Monday. It was an impressive event with the dignitaries and guests sitting in the hanger alongside the beautiful new plane. Proudly I watched as my

film was being shown on repeat in the background. Dr Bettina Vadera, a representative from AMREF and the visiting MP all made speeches with a compare from Nairobi radio. She did a fantastic job of helping market the Maisha cover plan. It is the AMREF FD new insurance policy which is affordable to a large proportion of Kenyans and they then can get rescued from wherever they are in East Africa.

But after the banners and tables were cleared we sat around twiddling our thumbs for the rest of Monday and then Tuesday. Then suddenly on Wednesday morning, we had three urgent medevac flights requests simultaneously. Then during the next two days AMREF FD would take on 9 flights, many of them extremely sick patients.

As I entered the office I was ushered to the waiting Cessna Caravan to do our checks as we had to fly out to

Lewa (north of Mt Kenya) where an 8 year old girl had fallen from her horse and was unconscious. There really is nothing like paediatric trauma to brush off the morning cobwebs. Far more effective than coffee.

As I was busy agonising over whether I should be using the (A+4)x2 or the (Ax3)+7 calculation for her weight and the plane was about to start up, we were suddenly stood down. We were informed the girl was being brought straight to Wilson in a small plane with the parents. But we waited to recieve to resuscitate as required and pop her in our ambulance to take her straight to hospital. But I was now needed on another urgent flight into Tanzania. The storm was looming.

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 run and 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.

Kahama, Tanzania

So as we popped her in the ambulance the King Air was brought around and had been loaded ready for us to head into Tanzania straight away. A young girl of 15 had been involved in a nasty car accident and was critically ill. She had been unrestrained in the back seat of her father’s car as they hit a pot hole, breaking the axle and the car rolled several times. The father was fine but his daughter had been ejected though the front window and was lay unconscious on the road. Once they got to the local hospital, we were contacted. As far as they could tell she only had a head injury (always a dangerous assumption) and she was still unconscious. All they could do was wait for us and give her strong medication to suck fluid out of the cells in her brain and halt the swelling going on inside.

 It took about an hour to get to this gold-mining town of Kahama and 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 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 Kizito 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. Kizito 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.

It took me a little while to work out what the problem was through the heat haze. Then I could make out a little group of people hurriedly carrying a small body on a stretcher. ‘Oh bugg*r’ I thought and quickly followed Kisito.

A rapid sequence induction on a critical patient in the pre-hospital environment can be one of the most stressful situations you can encounter as a doctor. But it still needs to be calm, clear and systematic process with good communication between the intubator and the assistant. So many things can go wrong; the powerful drugs you use to render the patient amnesic and unaware of the whole process, to reduce the stress response to having the breathing tube put down their throat and to paralyse their muscles, can easily put them into cardiac arrest. And if you can’t get the tube down and can’t breathe for them then they will asphyxiate. In a critically ill patient the time you have to get a breath into the patient can be only seconds before the oxygen in their blood is used up. The pre-hospital environment makes this procedure even more difficult especially in injured patients with potentially broken necks, damaged lungs and occult internal blood loss.

From one look at this girl, you did not need to be a doctor to see she was in a bad way. She was unresponsive with a partially obstructed airway, breathing extremely fast with a pulse rate of 170. Her blood pressure was actually slightly elevated, as young people often do before it starts dropping. Her head was bandaged and she had signs of a facial fracture. Kizito and I did not need to spend long deciding what we needed to do and we placed the patient in the shade under the wing of the aircraft. Soon Kizito had established a large IV line and was getting one of the crowd (of course there was a crowd) to squeeze a bag of fluid into her, while I drew up the necessary drugs. Soon we had her assessed, oxygenated and her pulse rate was sensible. I was prepared for it all going horribly wrong but the tube passed simply and she did not respond adversely to the medication. We continued to optimise her chances of neurological recovery as best we could on our way back to Nairobi but I’m afraid the prognosis for such injuries is not very good.

Mount Kili on our back

Just as we were handing over in Nairobi we were instructed to return urgently as we were needed in Kisumu next to Lake Victoria. A normally sprightly elderly man had had a heart attack the day before and was not doing well. We had had a non-urgent enquiry about a transfer for him to have cardiac catheterisation earlier in the day. The clot busting and cardiac support drugs he had been given had seemed to be working. But then as his heart started to fail and the pressure started backing up, he had started to drown in his own fluid. This is not an uncommon occurrence for us in the emergency department and we deal with ‘crashing pulmonary oedema’ pretty regularly. Nitrates and ‘non-invasive assisted ventilation’ works pretty well. Obviously this was not available in Kisumu hospital. They also couldn’t do an echocardiogram because the machine is owned by one of the other physicians and apparently it can only be used on his patients. 

Our radio room informed us that the patient was deteriorating and we needed to get a move on.

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.

For the second time in the day Kizito and I exchanged glances, shrugged and got to work. Thirty minutes later we had this chap settled on the vent and his chest was already improving. We had to contend with his heart doing some weird things as we ascended but with a little tweaking and strong cardiac drugs we had them solved by the time we handed him over back in Nairobi to go have his angiogram.

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…

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.

The landscape of northern Ethiopia

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.

From Wiki - a monolithic rock-hewn church in Lalibela

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.

The carcass of a DC3 plane at Addis Ababa Airport

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.

A deep canyon under the clouds

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.

The Lewa Downs Safaricom Marathon

Last weekend I was lucky enough to be part of the team giving medical support to the Lewa Downs Safaricom Marathon. This marathon has been placed among the 10 ‘must-do marathons’ in the world. It has a cap of 1000 runners and it is an extremely popular yet formidable challenge. A marathon distance is difficult enough for most people but this particular jog through the bush also involves the dry heat, high altitude, tough terrain and a host of local beasts trying their best to interfere with the curious long line of humans running through their home.

I have been involved in medical support for a few endurance events and I would like to start by congratulating the organisers on a slick and effective job. I would urge anyone reading this blog – if you are looking for a unique endurance event with stunning scenery and a great party atmosphere, not to mention the opportunity to see some of the fastest long distance runners in the world disappear into the distance, this is the race for you.

The medical support came from multiple different groups, local ambulance providers, local hospitals and even a couple of medics from the British Army (I never got a chance to say thanks to those guys, but they were brilliant the whole day) coming together to provide excellent care for anything from muscle sprains to head injuries.

I had the opportunity to fly around the race course in a helicopter looking for collapsed runners. As you

probably imagine from the description of the race above, there are generally quite a few to scoop up. The same problems keep cropping up but there are a few unique hazards on this race. We had to spend the first hour of the race scaring off elephants, buffalo and rhinos from the course. Some of these runners are fast but I guarantee none can outrun an angry bull elephant. I’ve learned that they can be horrible creatures when they want to be. Apparently they will smash your body against a tree or the ground, then grind you into the dust with their back legs. There is often little left that is recognizable human anatomy after a fatal encounter with an elephant. So Pooh was right to be scared of heffalumps. He wouldn't have been quite as anxious if he and Piglet had been shooing them off in an awesome helicopter.

It was not long before we were called to one runner after the next. One poor chap had collapsed unconscious into some bushes with his neck flexed partially obstructing his airway. We got to him in minutes and he looked terrible. He had that horrible see-saw breathing showing not a lot was getting past his pharynx. It’s a shame to think that bystanders hadn’t cottoned to the fact that all he needed was a minor shift in the position of his head and he would probably have come round. His blood oxygen saturations were only 65% (they should be 95%) and he was deeply unconscious. We sorted his

airway quickly and put him on oxygen fully expecting him to need further resuscitation back at the finish tent. Wonderfully he gradually regained consciousness as we landed and I left him trying to work out where on earth he was. He genuinely had no idea he hadn’t crossed the finish line. 

The next patient was a classic heat-stroke, staggering about, confused with skin as dry as parchment and a temperature of about 40. Just like in extreme cold you will lose the ability to shiver, in extreme heat you can lose the ability to sweat. Just when you need to the most! He did well after we liberally coated him with water and then blasted along the bush with him in the helicopter. One of the best

ways to prepare for such a race is to acclimatise for a couple of weeks and build up your tolerance to exercising in the heat. But people rarely do this. I can see why. I’m not going off running in the bush when I might get mashed by an elephant, gored by wildebeest, torn to bits by hyenas, bitten by snakes or robbed by bandits. No thanks.

When we arrived at the resuscitation tent I was greeted to find a patient who had been brought by land ambulance in a collapsed state. He had regained consciousness only to go completely ballistic, screaming the place down. It had taken a large dose of sedative to control him. My best guess diagnosis on this chap, was of brain swelling secondary to low sodium, however that is yet to be

confirmed. The safest thing for this chap was to sedate, paralyse and transfer him back to Nairobi in the Caravan air plane. The team worked brilliantly together including our exceptional pilot Emmanuel for whom nothing was too much trouble. 

It difficult to confirm if low sodium was his particular problem. Low sodium or hyponatraemia in marathon runners is caused by them drinking too much water. Check out Dr Tim Noakes book ‘Waterlogged’ if you are a runner and want to know more about this, but the dogma that sports drink manufacturers would love you to believe about fluid replacement is pretty much garbage. Imagine our ancestors, cultural endurance athletes, I very much doubt they drank 3 litres of fluid when covering the same distances. Dehydration maybe a matter of performance but rarely a matter of life and death. Your sensation of thirst is a pretty good driver of behaviour to top yourself up just like your drive to get warm when it is cold. Unfortunately the strange sensations associated with water excess, make people believe they must be dehydrated and so they drink even more! In a study of Boston marathon runners in the NEJM (http://www.ed.bmc.org/library/core-curriculum/NEJMhyponatremia.pdf) 13% had moderate hyponatremia, with 0.6 percent had critical hyponatraemia which could easily cause seizures, coma and death. Nearly every year I hear about a London marathon runner dying from this entirely preventable cause. The anti-ecstasy drug campaigners would also love you to believe that these high profile tragic deaths of teenagers in night clubs was down to the drugs when it was actually due to harmless old H20. Occasionally I even see someone, who in the midst of a bizarre psychosis, has taken it upon themselves to drink gallons of water with the same dire consequences. Who would have thought water could be so dangerous.

So if you want to give this marathon a try, and I thoroughly recommend it, take my advice: - train hard, acclimatise somehow, keep your airway patent, drink when you are thirsty and bring a camera!

(and for those who enjoyed the last little film, I have put together another 5 min long one, purely about the marathon)

http://www.youtube.com/watch?v=N-ompKAWivc