Why is Kili a Killer?

This weekend I was given the call to attend to a sick climber who was on his way down from summiting Mount Kilimanjaro. He seemed to be suffering badly from altitude sickness, but with no medical personnel on his trek it was difficult to get an idea of his severity. Given that these retrievals require a helicopter with extremely limited space and limited on weight, we can take very limited equipment. Also with it getting later in the day, we were getting extremely limited on time. As Tanzania warms up throughout the day, cloud tends to roll up Kili towards the afternoon and so the helicopters can’t get up there.

Kili has been getting a bad reputation in the last few years for climbers becoming extremely sick up there and a handful of deaths each year. I’ve never climbed it but I know that most people consider it a simple trek and therefore not worthy of the respect such an altitude deserves. It’s the kind of charity event that a city executive might jog around the park a couple of time to train for and then bumble his way up and down (with a small army of porters I might add). So why are people running into problems? I am told that the medic often doesn’t summit because they are looking after the clients who fall by the wayside. Having worked alongside a lot of expedition doctors who have done it, the problems are multifactorial:-

1)      The ascent is extremely quick. Most groups will dash for the summit from 4600m to 5895m in one day. The safe recommended ascent rate is only 300m per day in order to acclimatise. The route is fairly straightforward so it can be done pretty fast. My friends tell me to expect at least 80% of the clients to have signs of moderate altitude sickness by the summit.

2)      The group mentality. People always explain away their symptoms by dehydration, a change in diet, bright sunlight causing headaches etc etc. So they press on despite often quite severe symptoms. With mild symptoms you can stop and acclimatise and you will be fine. But if you ascend you could be in all sorts of problems. However we don’t want to look weak in front of the group, we don’t want to hold people up and the guides want to get you to the top.

3)       A lack of appreciation or understanding of the risks of altitude sickness. Most of the people I speak to

believe that if you are strong, fit and fast you are less likely to get AMS. Wrong. You are more likely to run into problems. Slow and steady types tend to fare much better. And probably more importantly, it can happen to anyone.

4)      Genetically, unlike the indigenous people of the Himalaya or the Andes, Africans are no better at coping with altitude than you or I. Also they cope poorly with the cold and are rarely equipped properly. If it weren’t for a load of strange white folks insistent on climbing up things, it’s rather unlikely they would have bothered. As Peter, my friend from South Sudan said at dinner “What is with you Mzungus (white guys)? Why climb to the top of mountains making your life difficult for no reason?” So the porters, keen to make money, push themselves extremely

hard and frequently run into problems, especially the new ones.

5)      Then there is the concurrent common issue of trauma. Kili is non-technical, i.e. ropes, crampons, harnesses etc not required but if you are staggering around with poor coordination due to a mix of fatigue, dehydration and AMS you can easily lose your footing and you can imagine the rest.

So what is Acute Mountain Sickness? I’ll be brief but it’s a fascinating subject. It’s basically a syndrome caused by prolonged exposure and physical activity in a low pressure atmosphere. At altitude there is less of all the atmospheric gases, not just oxygen but you feel the effects of the hypoxia (not enough oxygen) very quickly. To demonstrate, if I immediately took you to the top of Everest from sea level you would have a couple of minutes of useful consciousness then pass out and die if we didn’t get you some O2. Hence why airplane stewardesses say “In the event of cabin depressurisation, oxygen masks will fall from the panel above your heads. Make sure you put your own mask on before attending to your children.” (Children are basically rubbish in a crisis) But we climb mountains very slowly and acclimatise. Over minutes, we breathe faster. Over hours, our kidneys adjust things to cope with the changes in blood alkalinity. Over days our haemoglobin changes to deliver oxygen at lower atmospheric levels. Over weeks, we start producing more red blood cells to cope with less O2 and over generations we recruit/alter genes that allow this process to work more efficiently.

My own oxygen saturations were 77% at Everest BC

Most people will have some symptoms above 3500m and eventually be able to comfortably tolerate levels of hypoxia which would make them pass out at sea level. See picture right

. The symptoms include headaches, nausea, fatigue which are all pretty non-specific and common for lots of people who has just been a few days in new country, so they are easy to brush off. I’m not sure of what current research says but it used to be thought of as slight brain swelling and the direct precursor to its far uglier grown up sister, full blown cerebral oedema where the swelling gets out of control. These patients start stumbling about and becoming more and more confused until they slip into a coma.

Then there is ‘pulmonary oedema’ which is basically drowning in your own tissue fluid as it secretes out into your lungs. It’s not clear why one person develops this and the next doesn’t. The best way of understanding this is as having overly sensitive blood vessels in your lungs which constrict in response to the drop in oxygen. This isn’t weird, they are meant to do this. Sitting here writing this I use about 600ml per breath even though I have about a 7.5litre lung capacity. So the 7 litres of lung tissue I’m not using gets shut down (the vessels constrict) when I don’t need it. And it’s that reaction that is thought to go a bit haywire in reaction to the low O2 levels at altitude. Constricting your lung’s vessels is fine when you don’t need them, but when you do (like when you are starved of oxygen climbing a mountain for example) you become very short of breath, the right side of your heart gets strained and fluid and even blood starts getting forced out of your blood vessels into your lungs. Which then further reduces available oxygen making the problem worse and you spiral the plughole as your lungs fill up. Not a nice way to go. I remember evacuating a poor girl from Gokyo Ri in Nepal, who went from bounding up the rocks like a mountain goat and two days later couldn’t walk across the room.

Well the best treatment for all of them is descent, more oxygen or more pressure. Any of these will sort them out in the vast majority of cases. Other treatments can help, for example Diamox, steroids, nifedipine and even Viagra (yes Viagra, but an erection in a climbing harness is never fun). But what do you do if you are really sick and you can’t descend, you have no O2 bottles and no portable hyperbaric chamber? You are screwed frankly. Or someone comes along in a helicopter and saves you. Weather permitting of course.

So back to the evacuation. With this scanty information we set off across the stunning plains of southern Kenya towards Tanzania and the looming cone of Mount Kilimanjaro in the distance. As we bombed along at about 2000ft we passed over giraffes, ostriches, elephants and seemed to scare the crap out of a heard of wildebeest. In between the fauna sightings we discussed our plan for the evacuation. With the cloud thickening we decided the best plan was a ‘scoop and run’. Chuck him on the stretcher, fix the monitoring, get him on oxygen and get off the mountain. We were all agreed; whatever his status, he was far better off about 1000m further down.

 As we approached Kili we saw our window of opportunity was narrow if it hadn’t already passed. Kim our pilot skilfully wound his way around the clouds to the western slopes and climbed through above the clouds. More and more of the impressive peak loomed into view and we could soon see snow and the summit. We passed over one camp fairly low which raised a few cameras from the trekkers and headed higher towards the given coordinates.

The guides and patient were close to the helipad and Kim pointed out the cloud below us. He told us that “It’s marching up the hill pretty bloody quick. I can give you 2 minutes to assess the patient.” Unreasonable demands from the stressed; it was like being in the Emergency Department again! Luckily the patient had improved and could walk. We basically grabbed him with the blades roaring above our heads and chucked him on the stretcher. Monitoring and O2 on, all back in the helicopter (after I managed to sneak a quick shot) and we took off. We had to fly higher up the mountain and Kim displayed some nifty piloting around the slopes until we were above the cloud and looking for a gap to descend through.

The patient improved and we all enjoyed a beautiful flight back to Wilson with the gentle orange hue

from the low sun projecting long shadows across the plains. This really is a tough job.

Trips to the Moge - part 2 - For the love of Lasix

My first trip to Mogadishu (bless you) was to pick up a poor chap in his 30s who had gone into complete 

bowel obstruction. An abdomen full of trapped gas is not something you want when you are ascending in a plane as it expands. He needed a lot of fluid resuscitation and a nasogastric tube on the ground but apart from that transferred ok. As predicted the gas expansion caused cramps and a further reduction in his lung capacity so he needed O2, analgesia, buscopan and lots more fluid - something I’m discovering that health care providers in this area of the world are rather stingy with. But my oh my they love their Lasix (Frusemide, a diuretic – good if you are a boggy cardiac patient with fluid backing up everywhere, but a disaster if you are already a crisp.) In the end he had a ‘twisted sigmoid colon’ sorted laparoscopically. My referral from where he was treated in Mogadishu had as it’s top, and only, differential diagnosis ‘psychosomatic pseudo-obstruction’. Poor chap, unless he was able to twist his colon with the power of his mind that was a rather unfair call. He’s making a good recovery now in Nairobi.

Then the next day I had a far more complex situation. One transport, three patients; one a spinal fracture with unilateral leg weakness, one an epigastic pain of unclear origin and the third was one of the sickest conscious patients I’ve ever seen. A poor chap who had diabetes and had been on ARVs for about a decade presented with chest pain after a 11K run the morning previously. He had widespread changes on his ECG apparently (I did not get sent them so couldn’t see) possibly ischeamic, possibly a more suspicious cardiomyopathy with a large heart on CXR. It’s all a bit confusing but he got catheterised and was not passing urine. Someone, somewhere obviously told these guys ‘if the patient has a cardiac problem and doesn’t pee – he needs Lasix. Lots of Lasix.’ Which is exactly what they did. Regardless of the fact that he had just run 11K in the friggin desert! If you squeeze a dry sponge you will yield little water, but you may well tear the sponge to bits.

The airframe equivalent of his kidneys

So when got to him airside in Mogadishu (bless you) he was alert, breathing four times the normal rate, chest clear with good saturations, a crappy BP and a bizarre broad junctional bradycardia. Given our prior info about his renal failure, a stonking potassium was my first bet so we threw the kitchen sink at him. Atropine, bicarbonate, Calcium, insulin and filled up him with fluid as best we could. For the medics reading this, his pH was 6.8! I’ve only ever seen corpses with blood that acidic. His blood was so full of acid (probably a good mix of uraemia, ketones and lactate) as his kidneys had packed in that his lungs were the only thing keeping him alive by blowing off CO2. If he stopped breathing for a nanosecond he was highly likely to crash as the acid took over. I was asked about whether we needed to intubate and put him a ventilator.  While his lungs were working so well the resounding answer to that is ‘no’. If we stopped his breathing to get a tube down his throat and ventilate, his acidosis would worsen to a level incompatible with life. Patients like this have a cardiac arrest as you put them to sleep.

No, what this man needed was to be attached to an artificial kidney in Nairobi and everything else we were doing was just temporising the situation but not for long. We managed to get him to call his wife for what I strongly suspected would be the last time.

With a lot of hard work we got a more normal looking ECG trace, a reasonable BP and his lungs kept doing a good job. We delivered him to the emergency department with a glimmer of a chance of survival. That’s when we had to leave him. Unfortunately getting a patient on a heamofiltration apparently requires a specialist nephrologist consult and in the delay his time ran out. He needed ventilation and had a cardiac arrest as they intubated. All for the love of Lasix. Stupid drug.

Trips to the Moge - part 1 - an inadequate history

My latest two medevacs have taken me into the famously unsettled city of Mogadishu in Somalia. Before I start I’ll just reassure my mother who will be reading this, that Mogadishu airport is probably the safest we fly into. The UN security is phenomenally tight now. It must be, the paperwork and checks to get in and out are extremely laborious and detailed. I’m sure these reports I heard about suicide bombers were actually people spontaneously combusting in frustration. Right well now I’m sure I have the CIA reading this, hi guys, keep up the good work.

My friend Abdi from Somalia tells me that, back in the early 80s Mogadishu was a stunning city, prosperous and cosmopolitan. Before the war it was even a great holiday destination. It has long beautiful beaches with a nice reliable wind, perfect for watersports. (I wouldn’t get your kitesurfers out just yet though. I’m told there’s still a large population of sharks that skulk about there ever since the war. They must have had a good supply of meat and are still wondering when the buffet is opening again.) There is a book written about the war-torn city called ‘The Lost Paradise’ and seeing the old photos and comparing with the shabby bullet pocked buildings left standing, I can understand the sentiment. However I probably shouldn't show my photos of the airport and UN presence in Mogadishu. I might get in a wee bit of trouble.

So my potted understanding of the conflict goes something like this. As most of the conflicts in Africa, it starts with clans and colonies. You may not know that Italy once had an empire, and I am not referring to the Romans. There was a time when our tiny island of Great Britain had a rather big empire and lots of European countries wanted a piece of world domination as well. Africa became a real game of ‘Risk’. 

Somalia was divided with the Italians in the north (now known as Somaliland) and with the British in the south. During WWII we captured Somaliland from the Italians and it stayed under British rule until independence in 1960. Then there was a bit of a problem as there often is in a power vacuum. The clans supposedly united under one flag even though apparently the British advised the Isaaq of Somaliland to stay a separate nation. But they were rather excited about re-uniting the ‘five stars of Somalia’ which are the Somali people of Djibouti, Ethiopia, Southcentral Somalia, Somaliland and Kenya. Uniting Somaliland and Somali seemed like a good start. There was peace until the early 1980s when the people of Somaliland started getting marginalised by the Somali government in Mogadishu, they started getting angry with the incumbent president Said Barre (who had ruled with an iron fist for about 20 years) and formed a separatist movement called Somali National Movement (in London interestingly) and that’s pretty much where the trouble started. The military wing of the SNM started attacking from Ethiopia but then as the President became more annoyed the Ethiopians officially withdrew their support (but they didn’t really). The SNM could support themselves by this point anyway and started an insurgency capturing cities in the north. Here’s where it gets complicated.

Do you remember the scene in The Life of Brian in which John Cleese’s rebel group can’t remember if they are the Judean People’s Front or the Judean Popular Front? Just before they agree to fight for the right for Eric Idle to have babies? Well the various clans and sub-clans in Somalia cottoned on to the SNMs successful campaign and wanted a piece of the action. From north to south the United Somali Front, the Somali Democratic Alliance, the Somali National Movement, the United Somali Party, the Somali Salvation Democratic Front, the United Somali Congress, the Somali African Muke Organisation, the Somali National Front, the Somali Manifesto Group, the Somali Democratic Movement and the Somali Patriotic Movement (breathe) all started kicking off to get rid of the President’s military dictatorship.

The result? The dictatorship crumbled leaving a wonderfully complex shifting series of clan/militia alliances, grudges and conflicts which have raged ever since. The US made a wonderful pigs-ear of trying to stabilise Mogadishu by capturing the warlord Aidid in 1993 (the film Black Hawk Down) and had to pull out in 1995. It was chaos. Every town had its warlord. Boys with guns everywhere. So two independent solutions to the problem emerged; an Islamic fundamentalist movement (the ICU) enforcing Sharia law in the South and the African Union (particularly the Ethiopian troops who were rather heavy handed by all accounts) the UN and the US backed Transitional Federal Government in Mogadishu. The Isaaq in Somaliland to the north were quite happy by this point and started working on distancing themselves from all the mess down south hence the continued drive to create an independent state now (just like we told them they should back in the 60s). 

So then guess what, the Islamic Courts Union along with an aggressively militant splinter group called Al

Shabaab (the Youth) drove out the largely Ethiopian military force from Mogadishu. The TFG had lost their force and the whole place fell into chaos again. By this time the whole world and particularly Kenya were getting pretty tired of all this insecurity and lawlessness and by the end of 2011 the Kenyan forces had driven Al Shabaab out of the south up to Kismaayo stabilising their border and the UN/government forces had driven Al Shabaab out of Mogadishu.

So now we have the UN and the AU keeping things stable in Mogadishu, the US keeping an eye on the pirates from Djibouti to the north and the Kenyan forces (praying for the day the nation is stable enough that the hundreds of thousands of refugees can go home) fighting with Al Shabaab periodically in Kismaayo in the far south. And then there’s me, flying around them all, picking up their patients and wondering what the hell is going on.

Fledgling Paramedics

It’s been a remarkably varied week. I’ve popped about on a couple of interesting retrievals, my favourite being for a poor sick young girl needing medevac out of Arusha in Tanzania next to Mt Kilimanjaro. We flew in the unpressurised Caravan plane and stayed low under the air traffic. I had stunning views across to the Rift Valley and the landscape was laid out like an incredibly detailed model. The tiny farms and homesteads could easily be made out with tiny people fussing around their tiny livestock (just to clarify, they aren’t actually tiny, they were just very far away) and I got a few good snaps from above.

I also had a late night retrieval into Addis Ababa in Ethiopia which was horrendous and I won’t go into. Maybe I’ll tell you over a beer someday (or more likely while lying on a therapist couch) but suffice to say it all turned out ok in the end.

Through our mutual friend Dr Stevan Bruijns I met up with one of the senior Emergency Physicains at Aga Khan Hospital Nairobi, Benjamin Wachira and he asked if I would represent AMREF and help out

with a teaching conference for the Kenyan Council of Emergency Medical Technicians (ambulance paramedics to you and I) as he was the Medical Director for the fledgling organisation. It has been largely funded through the John Hopkins University in the USA.

Kenya has had it’s fair share of major incidents in the last couple of decades. To name a few – the US embassy bombing in 1998 and the civil violence in 2007, not to mention the thousands of able-bodied and

The scenario set up by KC-EMT - remarkably realistic!

productive members of Kenyan society who die on the roads every year. There has always been one thing missing from the response capabilities and that has been the lack of a recognised ambulance service. Currently there are only a few agencies which train and deck out their own ambulances. There is no 999 you can call. They are a bit like the A-team ‘If you have a problem, if no one else can help, and if you can find them....maybe you can hire The Ambulance-Team’.

 Following the disaster in 1998, a group of people came together to train and become Emergency Medical Technicians and last week I was privileged to watch them hand over the accepted ‘standards’ for ambulance equipment and personnel to the government. It will mean very little until the government actually fund ambulances and recognise EMTs as skilled health workers. But Rome wasn’t built in a day.

The event was well attended by passionate EMTs, all hungry to learn and it was a pleasure to be involved as the AMREF Flying Doctors representative. The first day was spent in talks and teaching clinical skills stations then the second day was the competition. The KCEMT put a great effort into producing a realistic Road Traffic Accident scenario simulation for each of the teams to demonstrate their skills. I was really impressed! The winners of the competition could not have been faster at assessing and stabilising the scene. They rapidly had the patients strapped up, as stable as they were going to get and whisked off to the fake hospital.

The prize giving had typical African flare with lots of speeches of thanks and some of the biggest trophies

I’ve ever seen. Then just as I had escaped for lunch, the DJ got going and while I was discussing the future of Emergency Medicine in Kenya with the member from the MoH, everyone started to dance apparently. It was certainly more fun than being an ALS instructor!

I hope that the enthusiasm of the fledgling society continues and gains momentum. One day soon, I hope that people in Kenya will come to expect an Ambulance to come and rescue them in their hour of need. A robust Emergency Medical Service simply cannot exist without skilled paramedics to bring patients to us in their ambulances. It’s still a long way from Ben’s vision of Emergency Care in Kenya but, as above, it’s the first steps and it’s a very exciting future.

Djibouti onto Dubai

The valleys of North Kenya

I’ve spent the last few days at AMREF flying around over the desert of the horn of Africa and into the Middle East. A chap working in the tiny but strategically significant country of Djibouti had suffered an MI, been thrombolysed (given ‘clot-busters’) and needed medevac to Dubai. This was going to require an overnight stay in Dubai so I selflessly volunteered. Soon we were tearing across the sky in our very cool Cessna citation Bravo Jet approaching Djibouti. On the way I was informed that Djibouti has, in its interior, one of the hottest places on the planet. And not 'hot' in a hip and groovy kind of way, more of a 'leave an egg out for

The coastal city of Djibouti

10 mins and it’ll be hard boiled' kind of way. As I stepped out the plane I believed it. It was certainly around 45.

Djibouti has an intimidating US military presence with all sorts of impressive hardware lining the runway. I thought best not to put a load of photos of it up here. I’ve already been arrested by the Egyptian military for taking photos (accidentally) of a military installation and it is not an experience I wish to repeat. (It’s a long embarrassing story.)

Downtown Djibouti

Anyway the US have obviously invested heavily in combating 

the scourge of Somalian pirates along the coast of the horn of Africa. I was lucky enough to watch a few of their fighter jets take off. I stood next to a massive American soldier with a ridiculous trucker style moustache as these planes roared into the sky and I exclaimed “Yeehaw Jester’s dead!” (a very famous victory call from Top Gun – if you don’t know that, be ashamed) which was greeted by a slow head turn in my direction, an expressionless stare from behind mirrored shades then a slow head turn back towards the planes. I decided I would shut up and go sort out the patient.

Expecting a stable patient I was surprised as the ambulance doors opened and I saw the poor chap looking dreadful. He was gasping, sweaty and pale. Fortunately it was just because they had just had a problem with the air conditioning so he was just being cooked alive. He was actually fine, just a little toasty. So we popped him in the jet, cooled him off and blasted off north into the Middle East.

The lush hills and towering cumulus congestus clouds of East Africa had been left long behind us. The ripples of

dunes spread out below us with occasional lines of low small cumulus humilis following each other across the sand. A sand storm far below soon obscured everything from view and eventually merged with the dust that frequently blankets the wealthy city of Dubai. Visibility was poor and the new Al Maktoum airport of Dubai was far too far away to see its formidable spiked skyline. I had been looking forward to seeing the Burj Khalifa building from the sky.

Notes about Dubai,

“We have delivered the patient to a private hospital in the middle of Dubai. I’ve never seen so many expensive cars on our way into the city. This hospital’s lobby and reception is more like a five star hotel!”

The emergency department was quiet, spacious, immaculate and well-staffed. Within minutes of our arrival a full clinical team with two nurses, an emergency doctor and soon after, a cardiology consultant, came to take our handover. Apparently they are always on the lookout for Emergency Physicians (isn’t everyone?) and offering very handsome payscales. The region's attendances at Emergency Departments is rising and the escalating burden of obesity, diabetes, hypertension and inactivity is thought to be to blame.

My Somalian friend (I will explain about my new house mates in my next update) explained to me: -

“It is Arabic culture. If you have money then you eat all day, you don’t move, you grow fat. If you see a skinny rich man, everyone will think he is a miser.”

 I remember my time dealing with the children from rich Arabic families when I worked in Paddington and it really does seem to be an issue. Especially among the young lads. Take a wander around Harrods and you will see what I mean.

 “I wonder, would I take a job in the wealthy spacious hospitals of Dubai in the middle of the desert? I doubt you could pay me enough to work at the beckoned call of a load of demanding millionaires who take no interest or responsibility for their own health.”

But maybe I got the wrong end of the stick.

Hospital Rwanda

I managed to spend all Monday in Rwanda, stuck as the piggy in the middle between the local medical team and the patient on one side, the parents and the insurance company on the other side. It was a convoluted drawn out affair that is still ongoing as I write. I obviously can go into no details but I learnt a great deal about African medical rivalries and politics. I also learnt a huge amount about medical travel insurance. All I will say is this - read your policy carefully. Depending on the very particular wording of your policy will depend on where you can be transferred to. There is a big difference between paying to repatriate you once you have been treated where you are (have a think about what that might entail i.e. where are you going?) and paying to air ambulance transfer by private jet to whatever country you desire. A lot of people will be under the impression that if they get sick/injured they will just get a medevac back home. Not necessarily I'm afraid...

To cut a long story short, Morris and I spent 14 hours in Kigali waiting for a final decision and were eventually pulled out as the costs of having the pilots and the plane just sitting there at the airport was escalating beyond reasonable. We lost our ambulance and so had to get a pick up to take us back to the airport and then check in all our medical equipment through standard airport security. Explaining to the Rwandan airport security (both sets of them! - how exactly anyone is supposed to be able to generate any dangerous or illegal materials in the 250m between the two checks is beyond me) that we had delicate medical equipment that might damage the X-ray machine or explode was rather tricky. Note to self - don't make the universal sign language for explosion at Rwandan airport security again. Or tell them you have drugs.

Two hours getting grilled in Kigali International Airport and we were free to go air-side. We had to carry all the stuff to a crowded shuttle bus, squeeze on and got driven from plane to plane until he made a detour for us to where the jet with the two very bored looking pilots Peter and Rob were distinctly unimpressed. I was also to learn that I missed a charity case evacuation of a 2 day old child with sepsis and a complex congenital colo-vesical abnormality. So not one of us was in a great mood.











The day did, however, have some positive aspects. I did get a good chance to get driven around Kigali which is a beautiful city if you ever get the chance to visit. Lush green hills, well made buildings along the hills and valleys, the roads and landscaping are immaculate. In fact there was hardly any refuse to see. Apparently the president of Rwanda has banned plastic bags. An interesting initiative, and as Peter the pilot said, "They don't have the Nairobi flower here." The Nairobi flower is the common site of a black thin plastic bag stuck flapping on a post or a wire. There were billboards up with interesting slogans such as 'CORRUPTION. It demeans us all. Sweep it away." It was a surprise to feel so safe and so impressed with a city that so recently was the site of so much horror.

There is a memorial museum about the genocide and the pilots told me it is difficult not to leave in tears. The biggest question people always leave with is 'How?' How can such extraordinary numbers of good people do such horrendous things to each other? From Milgram's electroshock experiment to Zimbardo's prison experiment, as unpalatable as they are, we know that unfortunately we all have such potential. It doesn't seem to take long or much prodding to influence it out of us either. As we waited by the plane and mused on the issues of moral relativism and the collective intentionality of something as horrific as genocide, I think I said something stupid like "Hopefully we can all learn from such events to stop them from happening again." to which one of the pilots said, "You mean like in Syria just last week." "Oh yeah." We stood there in silence for a bit, looking out across the mist rolling into the surrounding valleys of Kigali and then we flew back to Nairobi.

A quiet weekend

This weekend on-call has yielded only one flight. Interesting that it still had a theme.

I've managed to catch up on some work, do some more reading and prepare some lectures and training scenarios for the flight nurses. As I've beavered away at the guest house (until now I was the only guest) Jane the hostess, busied herself about the place or watched some television. I've noticed that whenever the television is on it features back to back Christian programming. I wasn't really paying attention initially but I've never seen anything like it! Cartoons of the early life of Christ, adverts for a new game Bible Bingo and a energizing American preacher in a glittering yet rather over-the-top stage setup, bombarding his audience with the easy answers to the difficulties in the world. I am learning that Christianity is strong and vibrant in Kenya. My secular and atheist ways are, I've realised, rather odd around here. Jane asked me if I would be joining her at church on Sunday. I politely refused and explained I had no religion. She thought this very strange. In fact, as I explained my secular upbringing and my mistrust of the man-made imposition that is organised religion (things I have no problem explaining normally) it was rather distressing to see the look on her face. She clasped my hand and told me that what I was saying was causing her physical pain, in her heart. She has resolved to teach me what I missing. I think, in retrospect, I should have kept my big mouth shut. (Note to self - don't talk about religion again. Now look what you've done.)

It is funny that the next medevac I was called for was to assess and retrieve an elderly American-born Catholic priest from the town of Musoma in Tanzania on the bank of the massive Lake Victoria. He was a member of the Flying Doctors of East Africa (now the scheme known as Maisha) and so was eligible for transfer in the event of a life-threatening emergency. He had collapsed while giving morning mass after a week of non-specific ill health. He was confused and the mission nuns/nurses were concerned he had suffered a stroke. When we got the call I did point out that the differential for an elderly man with progressive confusion for a week, syncope and no focal neurology was unlikely to include a CVE so again (as they always do) we prepared for the worst.

Again time had been a healer and we were greeted at the runway by an extremely healthy looking octogenarian accompanied by a few concerned nuns. He walked out to the plane (albeit a little unsteadily) warmly greeted me and even scaled the steps into the plane unaided. This amazing man I was to learn, had lived in Tanzania for 57 years! He came out with a small group of missionaries in the 60s and just never left. So on assessment his observations were fine, his examination unremarkable and his ECG, blood glucose and venous blood gas were all unexciting. For a man who was supposedly confused he got 10/10 on the minimental test, admittedly I did have to change the questions about the Queen and WW2, to the president of Tanzania and the date of Kenyan independence. It's very important these questions are culturally relevant to the patient. The nuns thought he must have malaria. "It's not malaria I told them. I've had it six times!" I discovered that he had been struggling to remember things over the past week and struggled to give his sermon in Swahili so had to revert back to English. I wish I had longer to speak to him about his incredible life but I'd probably end up talking about religion which I had decided not to do again. I do hope that, after his recent lapse in mental functioning and the little scare he gave his congregation, he turns out to have a mild infection and he is back preaching in Swahili again soon.

Back to back retrievals

I had been taken to Wilson airport the day previously and shown around. I also had a chance to review all the various bits of kit they use. It's a pretty impressive set up actually.

"I feel strangely at home in this small airport. It's slightly larger than Kemble where I've been learning to fly myself and I find myself surrounded by twin otters and Dash planes. It's like being back at Rothera Antarctica."

I was barely able to get a quick introduction to the various members of the AMREF team when I was asked to fly out to pick up two sick Kenyan soldiers from south Somalia. I did a slight double take as you might imagine. "Don't worry from the medical report they are both very stable." Yes the medical issues were not what concerned me. Last thing I watched about Somalia was Black Hawk Down! "We just ask a doctor to go along just in case there are issues." Issues that have arisen before have included a nearby mortar attack which meant a sicker trauma patient bumped the original patient they were originally going for.
The medevac went very smoothly actually but I'll admit I was nervous as we flew over the deserted south Somalian coastline.

"15:00 I've just been struck with bizarre nature of my current situation. I'm flying along the coast of East Africa with two Kenyan Soldiers (both requiring hospital admission but mercifully stable) having just evacuated them from a military base in one of the most politically unstable countries in the world. It's a funny old game. Just days ago I was having a beer on the King's Road. I guess that's what makes for a rich life; a bit of variety."

The base consisted of shelters in between low shrubs and a few more robust but hastily erected buildings around the runway. There were customary bits of tanks and heavy artillery sitting about in the dust.  An ambulance was waiting along the runway. We had a

 warm reception and, after a quick review and friendly chit-chat with the officers, the two sick privates were loaded on board. One poor lad had a nasty hand infection which needed theatre and a good wash out. And the other had what sounded very much like hepatitis A. Given the conditions the soldiers live in it was the most likely diagnosis. Not long ago a group of soldiers gradually became unwell and oedematous, stumping the medics on their base until they realised it was their diet and there was a combination of vitamin B deficiency and low protein. I'm rapidly learning each case I go to has a fascinating cultural aspect all of its own.

I suppose what was most surprising for me was how cheerful both these young men were. At first I thought it was because they were getting out of there. Being stationed in the middle of nowhere, constantly under threat of Al Shabaab doesn't really sound like much fun. But apparently they were having a great time! Genuine sentiment or a gagging clause from their seniors, who knows. Soon we were back at Wilson and I was greeted with news that they needed me for another evacuation. "What now?" "Yes, now."

So off we flew(I managed to get myself into the copilot seat for the ride) into north east Kenya where there was a young aid worker who had a high fever without a clear source and looked pretty sick according to the report. Malaria was obviously top of the differential. Malaria has a famous reputation for killing young people extremely quickly sometimes so we prepared (as they always are) for the worst.

A cumulonimbus cloud yielding a rainbow in its downpour

 The skies over the plain was beautiful, full of fluffy bright cumulus sitting with their flat bottoms at only 3000 ft. As we approached the refugee camp I was amazed by the expanse of featureless landscape. There were genuinely no bumps or undulations in it for as far as the eye could see. In a way it reminded me of flying around Antarctica!

My stress levels settled with the dust blown up from the prop as I could make out the patient standing holding her own fluids by the runway. It appeared she had got much better in the few hours since we got the call on merely IV fluids and paracetamol. Her fever had broken and her worrying vital signs (that would have got her triaged straight into the resuscitation room in my Emergency Department) had all normalised. In fact she was fairly cheerful. There were no facilities to diagnose or treat malaria where she was so she still needed evacuation. She again was rather sorry to have to go.

As I handed over her case in Nairobi to the nurse the phone went again! Did I have the energy to squeeze in one more flight? There was a little girl in Tanzania who they were concerned had meningitis. The report did not suggest a critical patient at all but the doctors there were very worried about her due to the onset of an odd rash and a headache.

So off we flew just as Wilson Airport closed and headed south east into the dark. Approaching Dar es Salaam I was enthralled by the lights of the city. It sparkled. Each light blinking at its own rate. It was stunning to watch. I don't know for sure, I tried to work it out as we descended, but I think there must be loads of short and leafless trees in between the single story buildings.

We waited in the claustrophobic stickiness of the evening watching the airport floodlights swarm with mosquitoes, massive bugs, bats and large cranes swooping back and forth out of the dark. A bird strike with one of those big birds would definitely down a small aircraft like ours. Luckily they were far too interested in the temporary floodlight ecosystem to bother with the gloomy runway.

Again we were greeted by a patient who was in considerably better shape than we had been led to believe. It seemed that during the course of the day the high dose of IV antibiotics, antipyretics, fluids and  antiemetics had really turned her clinical state around. The rash was an innocent speckling of pink fading  macules. Either the drugs had performed a miracle or this little girl did not have meningitis or any evidence of an serious bacterial infection. In fact she chatted with me and her mother the whole journey. It was difficult to get a word in edge-ways or write my notes she had so many questions! I trust she will now be doing just fine. After handing her case over at the children's hospital we took the ambulance back towards Wilson Airport and I reflected on my first day at work. Three transfers, four stable patients with little medical intervention required and visits to another two countries was not a bad initiation. I settled down to sleep at about 02:00 tired but buzzing. Or was that the anopheles mosquito that snuck into my room?

Images from the first week

The vast flat featureless land around Dadaab in north east Kenya.
(A comment from Kirk Watson, the great Antarctic and African explorer and film maker
"Aah the African plains and fair weather cumulus. Masuri sana.")

One of the many AMREF aircraft, flown and owned by Pheonix Air

The runway at Wilson Airport

Flight nurse Festas and I wait for a patient at Dar es Salaam Tanzania

BA Flight 0065 direct from LHR to Nairobi - notebook entries

 "Given my destination and my complete lack of exposure to African culture, it is unsurprising that my last few days have been unsettled and virtually sleepless. I am somewhat happier now I am on the plane. It's a bit trickier to bail on this now. I have only a vague idea of what to expect and, I suppose, that makes it all the more exciting...    ...So I must settle to my reading in prehospital horror stories, aeromedical physiology and basic Swahili to pass the hours flying south towards Kenya."

"Interesting, as I pass over the Nile at about 40,000 feet, the temperature is minus 50degrees C and if we depressurised we would have 60 seconds  of useful consciousness before the oxygen was literally sucked out of us."

"Nairobi has emerged from the dark. It is a smudge of dull light in a scattering of pinpoints and no hint there is anything else out there. After the endless sprawl of London it is another world. Outside temp 19 degrees C. Local time 21:00"

The Origins

My name is Dr Matt Alwyn Edwards and I'm an emergency medicine registrar from London. I have been encouraged to start this blog to keep a record of this unique life experience - I am the current volunteer physician working for the AMREF (African Medical and Research Foundation) Flying Doctors based out of Wilson Airport, Nairobi, Kenya. It feels terribly presumptuous to believe anyone will want to read my musings along the way but if you are interested and you find yourself here, 'Karibu' or welcome in Swahili.

Archie McIndoe

A Bit of History...
    The story behind the origins and the inception of AMREF is truly inspirational and I encourage you to look online for further details. Back in the 1950s, three surgeons who had either fallen in love with Africa or flying or both, decided that they would try to find a way of providing much needed medical care to sporadic and disparate groups of people scattered around East Africa. These three men, Sir Archie McIndoe (yes, of the McIndoe forceps) Sir Micheal Wood and Dr Thomas Rees are really worth looking up and having a look at their respective stories.

"Sir Micheal Wood consulted the famous Dr Albert Schweitzer at his Leprosy Mission Hospital in Lambarene, West Africa. How, he asked, can we serve the 80% of rural Africans who live beyond the reach of urban medical fascilities? "Use the tools of our time," was his answer. Aeroplanes and radios were the tools of that time and became the framework of AMREF."

So in the foothills of Mount Kilimanjaro they began gathering support and flying out into the bush and hosting clinics and performing simple and lifechanging operations on cleft lip and palette, clubbed foot and even opthamological surgery for trachomas. In an interesting talk he gave about the history of AMREF Sir Wood said they knew that curative medicine was going to be of limited use in the bigger picture and that preventative medicine was the key. However few Africans at that time would see a doctor unless something was already causing a problem and by then it was probably too late, too expensive or too technically difficult to do much about it. So he started to see these outreach clinics (which people flocked to) as an opportunity to drive the bigger picture of public health and preventative medicine. A pretty clever concept and it started to work. Soon they were joined by an exceptional character, Dr Anne Spoerry or 'Mama Daktari' (mother doctor), who flew around the bush in her own little plane treating ailments such as gonorrhoea and administering vaccinations.

Dr Anne Spoerry

From there AMREF has gone from strength to strength with offices around the world and helping the people of Africa prevent and treat the diseases for which we in the developed world have probably forgotten even exist. (So when parents in the UK say 'I'm not vaccinating my child, I don't believe in it.' Come to a country where you cannot depend on the herd immunity of those around you and we will see

what you believe in then. Or 'I don't believe in modern medicine interfering in the natural process of childbirth.' Don't make me laugh. Sorry I digress slightly...) It was not long before the potential for medical evacuation became a clear and real possibility. So AMREF Flying Doctors Air Ambulance became a splinter-group  if you will, and starting bringing patients, often in critical condition, from politically unstable corners of Africa, back to Nairobi for specialist treatment. Dr Bettina Vedera took over as CEO and the Air Ambulance now operates as a company in its own right. It's 'not-for-profit' because the money it makes in profit from insurance, private companies and government organisations goes back into the AMREF charity itself. So in a way, a bit like using the 'bait' of the travelling clinics to actually get some larger scale preventative medicine done, the Air Ambulance organisation manages to help AMREF's bigger picture by demonstrating to the world how good a pre-hospital and retrieval service can be. Plus the planes are really cool.

Dr Bettina Vedera

Where do I fit in to all this...

   I've been interested in pre-hospital and remote medicine since I worked with the British Antarctic Survey back in 2008-2010 and since have become more heavily involved in expedition medicine while continuing my Emergency Medicine training. Along the way I've been lucky enough to work in the Amazon, the Himalayas and up in the Norwegian Arctic. I had never set foot on the African continent. Far too hot, far too many bugs.

Then one day an old colleague of mine (Dr Richard Crosthwaite-Eyre) said to me as we mused over a blood gas at the foot of a patient's bed, "Matt, how would you like to go flying around Africa picking up sick patients for a couple of months?" Then he told me about AMREF, outlined the story above (don't worry we had finished with the patient by then) and told me that they run a 'volunteer physician' program. He had secured a position with them but had had a slight complication. His wife had become pregnant and he could no longer go. His position was open and knowing I had a tendency to wander off and take opportunities when they arise (recently that has led me to be recruited as the physician for the first British Microlight Expedition to the South Pole in 2014. Weird how these things work out) he thought I might be interested.
To cut a long story short I took it and now I'm here, in Nairobi and I've started work. As a summary of the last few days - it's brilliant. I will share more in due course *

*obviously in the nature of medical confidentiality I will be very scant with much of the detail.