From dying to smiling

I think a lot of you know about Scrat now, my ground squirrel. Let me tell you his story.

One Friday, a group of young boys turned up to the Lifeline clinic with a squirrel wrapped in newspaper. It looked like a taco so I called it a 'squirrel sandwich'. They wanted to sell it to us, but we refused, thinking they'd just let it go. We watched them walk off towards the shabeen (where Herero people make and sell their own alcohol) and thought nothing else of it.

The next day, I and a friend went for a walk and we had just reached the edge of the shabeen when 2 drunk women called us over. Now, they didn't speak English and we didn't speak their language but it's rude to walk on by, so we dutifully went over and listened for a while. I was just explaining that we were from the clinic and that I was sorry but I didn't understand what she was saying, when I noticed a bit of tail sticking out of her shawl. I asked her what it was and she got excited and pulled out a very dead looking squirrel. I asked her if it was dead, and made the 'cut the throat' sign, so she put it on the floor and it stood. I don't know how, but there's an unfortunate skill that medics learn in being able to tell when someone/something is hours away from dying. Anyway, I recognised this so rushed back home to get change and bought him for the equivalent of 60p, which she glady took and handed him over, wrapped in a piece of torn plastic.

Let's pause for a moment and think about this woman's perspective of how cheap this squirrely life is. How cheap is life to you? I didn't see the squirrel's life as cheap, but important. I'm glad he was cheap though, it made it easier!

So my friend and I rushed back and got a cup of water and a syringe. At this moment in time, the squirrel had 3 problems: (1) he wasn't very conscious, (2) he was going to die of dehydration soon, (3) he is only half grown and has a small stomach. Do you see a problem? Yes, firstly, if he isn't awake he could aspirate the water we give him and it could enter his lungs and cause pneumonia. Second, his small stomach capacity means that you won't be able to give him enough fluids to rehydrate him. It was a negotiation. I figured that since the dehydration was going to kill him before any pneumonia did, he got quite a lot of rehydration solution in that first hour, by syringe. Followed by honey+water to treat presumed hypogylcaemia and a hot water bottle for presumed hypothermia. That first afternoon I had to keep checking that he was still breathing..it was really his only sign of life! He needed fluids 2-hourly, but still he remained dehydrated.

On the second day he looked better - alive! His tail moved for the first time. I took him out in the 'garden'..i wasn't bothered if he 'ran away' or not. He could do what he fancied. The garden was open, and my only intention was to give him some exercise and stimulation. He definitely perked up outside, and I started walking backwards and he followed! So we did 3 good runs before I took him back for more fluids. He had quite a severe left-sided weakness, and would fall flat on his side 3 times on each run. I stewed some apples for him today, and tried to give him some by syringe but he didn't like it. He didn't like milk either.

Now that he was becoming more active, I started thinking more about Namibian ground squirrels and whether or not they bite! I was more careful with him. But it didn't take long to realise that he was an absolute sweetheart. When it was time to change his hot water bottle, if you put him on the table he would just get this drive to launch himself at you for cuddles, and if you didn't catch him he would launch himself off the table in your direction! All he wanted was to be put in your top and go to sleep on your warm skin - isn't that cute!

Let's pause for a minute and marvel. This is a little squirrel who was almost killed by people, right. They caught him, imprisoned him, starved him, dehydrated him, and would ultimately have killed him. How rubbish do you think he felt during that 24 hour period? Ok, now think about how he was with me. No hard feelings, he would want cuddles and followed me round everywhere, even though I, too, am a person. Am I the only one who marvels at this? I would imagine that if someone was an asshole to me and almost killed me, I'd have a few reservations about people after that. So either Scrat is very simple, or I'm missing something. If anyone sees it, let me know :)

When you see an animal which is terribly miserable and unwell, you easily notice when they are happier. Can I convince you that he's smiling in this picture?

On Sunday I gave him a real chance to go back to the 'wild'. I found a beautiful, very secluded spot, with about 4 ground squirrel dens, and I set him down at the entrance to one of them and then ran behind a thorny bush. He ran after me. 3 times I did this! So the 4th time, I put him just inside the den and watched him walk into it and disappear. Then I ran about 15m away and sat and watched. I wanted to know if the current residents would like him, or if he'd come out being chased, and so on. I sat there for about 15 minutes, hearing nothing. Then I saw some movement and saw him wonder around and disappear again. I waited 10 more minutes then went to investigate. He was sitting, like a lemon, at the den entrance, getting cold. 'Go and find a squirrely to snuggle up to!' but I don't think he understand English. I left again and waited until it started getting dark and went to investigate again. he was still sitting there, shivering now. he was obviously going to die of cold or get eaten that night. So I picked him up, told him he was a lemon, tucked him in my top and took him home with me.

The only thing to do on the Monday was to bring him with me to the Naankuse Wildlife Sanctury, where I was headed for the last week. Well, I had a 3-day safari in the dunes midweek, and I would leave Scrat at the farm, as we call it.

Now, medics, listen carefully. I don't know if the solution to Scrat's first presentation occurred to you (it hadn't to me), but of course, the answer was subcutaneous fluids!! For non-medics, this is injecting fluid under the skin, and above the muscle. it's largely not used for adults as adults either drink orally or are given fluids into their bloodstream..although I've since learnt that in Canada they use this method for elderly patients. Anyway, so a good dose of warm subcutaneous fluids and he was doing much better!

The rest is history. He was much loved on the farm..had a baby mongoose friend of about the same size to play with...his left sided weakness was doing MUCH better. I don't know why he didn't take his freedom. Maybe he felt too unwell. Maybe he knew that, as a young squirrel who didn't have a mum, he wouldn't do well in a new crowd. Who knows. And I don't know why he likes people! But he really does, he really, really does, he is the sweetest sweetie.

This is his 'superman' pose. If he's asleep, and you wake him up to feed him, he'll stretch...but it won't stop! He's just loving life in this moment, a permanent delicious stretch. The camera hasn't captured his legs yet, but take it from me they're also stretched out fully. I was composed for this photo, but trust me, his superman pose always had me in stiches. I am most fond of this, of all the funny things he does.

On reflection, in Amsterdam airport, I thought about all the bags, shoes, clothes, jewellery, etc I've bought, and how working with this little squirrel was, somehow, so much more fulfilling and satisfying than anything the material world has provided me with.

If you liked this blog, please consider reading/donating to my fundraising page for the work at the Lifeline Clinic http://gogetfunding.com/project/neonate-paediatric-oximeter#.VBs11y3s2bE.facebook

Thank you!

This past week

We went to a town called Skoonheid about 30mins away from our Pos 3 town. We held a clinic there, although there weren't many patients. Saw interesting cases of suspected herpes simplex, and a facial fungal infection. The cows there were well behaved, for once. So were the dogs. The local community were working on their crafts, which they sell in Windhoek.

We also visited a small settlement of 4 rubbish-bin huts on a farm, in a place called Hinda. This place is suspected for MDR TB. We had to screen all the inhabitants (about 30 of them in these 4 huts). One 7month old was moderately-severely malnourished and had a cough - we are suspecting TB. Some days later, two visitors to this settlement turned up at the Pos 3 clinic with haemoptysis - ie coughing up blood. They come from another settlement..also TB suspects. You need to send 2 sputum samples/patient before the hospital will take them and start treatment. Or a good going chest xray. They need to be in hospital for the first 2 weeks, then are discharged and continue treatment via clinics.

Today we are taking a teenager back to the Naankuse farm with us in Windhoek. Im spending the weekend there - whoopee!! She's coming back with us because she was hospitalised for nonaccidental injuries and this isn't the first time..she's also got cognitive impairment, so she's vulnerable and naankuse is hopefully going to get her a job on the farm so she hasn't got to go back to her stepmother. she has an aunt..which we are trying to contact to see if she'd take her. problem is, the aunt isn't far from the stepomother. In the UK, I always wonder why paediatricians spend so much time on the social history..making sure the presenting complaint adds up, that the stories add up, and so on. I didn't really like this aspect of the job. I thought it could be left to other professionals, after all, doctors just treat medical conditons right? Well..im learning that doctors are often the first port of call, and its that lovely word signposting! Signpost to different services. You need to pick things up if you need to signpost them. So this girl and I will travel in the back of the ambulance (its our only means of transport!) back to the farm. Im going to have a VERY chilled, VERY lazy weekend. reading, drinking tea, hopefully some football with the locals on Saturday.

Oh, we had a 'mother and baby' project yesterday, where we show films, then have meal, then play. One volunteer here had brought a parachute game with her - the one where you hold the handles in a big circle. The kids LOVED it! We played that a lot. I had to go back to the house to take some stuff to the kitchen and all the kids came running after me! I thought that was sweet. group trip back to the house, and then back to the parachute! They kept asking for the paddling pool, so we're going to bring that out for them next time. They love dancing here, so we put some music on for them and they dragged me up with them so that was fun! The teenage boys looked like they really wanted to join in with parachute, but you know theyre too 'cool' for that I suppose. I haven't yet spent much time talking to them, or to the teenage girls They always seem a little awkward and I don't want to make that worse for them. but now they know us a bit, ill try and chat to them next time. what do cool young Namibians chat about?! ill start off with music. or dance. they're well segregated in the courtyard. the mothers all on one side, the children all on another, and then the teenage girls hovering by the gate, and the teenage boys hovering by the wall. and the volunteers just wonder around!

I love mother and baby project because it gives us a chance to socialise properly with the locals. Getting to know the people here is what makes this whole experience more worthwhile.

Right, better go and get in that ambulance! Off for a 'weekend away' :)

Wildfires, thorns and evil cows

I went on a 3hr walk from the clinic today.

Around here, there's just deserty plants and gravel roads. No sign posts. So my plan of action was to take a phone and a piece of paper and draw a map as I go! So this started off very well, until my pen stopped working about 1.5hrs into my walk, leaving me stuck on the main gravel road. This was fine, lost of cars would stop and ask me if I was OK. I think its unusual for westerners to be seen travelling around on foot. Many locals just hitch rides. But i hadn't come out with any cash, obviously thats far too organised for me. Anyway, so in the end i just started hiding behind bushes when cars came down, to avoid the 20 questions. It felt a bit odd! Then life was good, and i noticed that my road was leading me towards the wild fires, but this was fine as the road is gravel and so i assumed it would be safe to travel through them. They were only small. I passed 2 cows. Now, let me tell you about cows. They're evil. That's all. So, I passed the cows and they seemed placid. Then they started following me. The brown one was evil. Shed follow me from one side of the road to the other (i was testing this out!). Then it started trotting. Now, when you're on a solitary, empty gravel road and there's nothing on either side but burnt out thorny deserty bushes and wild fires, you're pretty screwed. So I jumped into a burnt out thorny bush and got tons of them in my arms and legs, but at least the cow left me alone and eventually moved off. So, a little shaken up, I carried on down this solitary gravel road..the wild fires became closer to the road. I wanted to go home but twice we've had fires in our kitchen at uni, and i hate fire now so i thought it would be useful to keep going to get over this! So i was walking on, and there was quite a lot of smoke coming from the right side, and then this big bush just bursts into flames! i carried on..i could see a family further down the road. one person was on a horse, there was a donkey cart, and some people hanging around. Now, when you're in the middle of nowehere and Namibians are on the path, it's more useful to go and meet them and see they're safe than to run off home. So i persevered, and they were pleasant enough. They told me I was in Pos 2 (the next twn along from Pos 3 where i live), and they asked me if i was afraid of the fire. I said no. I asked them if they were, and they said no. So, i don't get that question. They told me the fire had jumped across the road, because the wind had blown over burning embers. I was a little freaked out by this stage..should i be afraid of the fire? Is Pos 2 too far away from home? Are there more mental cows around? I continued for 10mins then turned around and walked back. When i walked past them the second time, the women asked me 'are you not scared of the people around here?'. A car full of wierdo men had just driven past, but i had ignored them. They pointed to them and said 'are you not scared of the people around here? the tribes, the san tribe?' I said 'no'. The san are the people we treat at the clinic! I asked them why, should i be scared? They said that those kind of people chase women. They said they had been chased and had run all the way back to Pos 3. I asked why they had been chased, why they are chasing them. I asked this because if you dont know then you always assume the worst, and i was hoping the worst wouldnt be the case. 'Because they want to rape you, to steal all of your things' she said looking directly at me. Well, thats a lovely thing to be told when you're 1.5hrs away from home, in the middle of nowehere, alone. She asked me if she could escort me back to Pos 3. I saw she had a child on her back. I said no thank you, its far for her. But really, i just didnt want to expose her and her kid to more risk, if there really was a risk. So i set off back home, alone, on this road, trying not to freak out. I picked up a big rock. If any cows pissed me off or cars pissed me off maybe i could use this? I didn't like cars anymore. I hid when the next car came along! But then i rationalised..as a tourist, im probably safe. So i stopped hiding and 3 cars went past without a problem. Then i was almost back at Pos 3 and this bitch cow wouldnt let me go past her on the road. Even 2 cars had to manoeuvre around her because she was staring at me, unmoving. I waited 30mins next to the solitary big-thorned tree, then she eventually moved off and i could tiptoe past her. Got home and had a shower, tended my wounds, and am definitely staying AT HOME tomorrow!! Namibia is not Uganda. That's for sure. Evil thorny bushes, evil wildfires, evil cows. But, whatever those women said, i have only experienced positive conversations and experiences with Namibians here, and I'm not going to let their experiences freak me. Think about london. So much crime goes on right, doesn't mean you stop going and having a great time. You just mind your buisiness, they mind theirs, and everythings cool.

Saturday
went for another walk today. still ended up in a tree! angry dog this time, don't want rabies. I walked past the shabeens - where they make their own alcohol - and walked up a sandy path. very quickly it became fairly isolated, with a couple of houses ringed with wooden fencing. they looked a bit bemused to see me there. one guy taught me how to greet in africaans. I walked past the last house and was about to go into an area of bushy countryside where they graze their goats, but then the dog started up and I just ended up in the tree. after the dog pissed off, I wondered down another path and found some really lovely small (still spikey) bluish bushes with a single flower. it looked quite nice against the background of dry deserty plants. but then a herd of cattle came along, so I sprinted down the path and went home! I really want a Doberman. or a bloody Rottweiler. all these animals need to fuck the hell off!

Outreach and dancing

03-09-14

Today we left Pos 3 area, and travelled to a day/boarding primary school about 45 minutes away for outreach. Armed with boxes full of antibiotics, dressings, creams, etc etc. There were 5 of us. 1 person triaged the list of excitable kids waiting outside the classroom, 2 of us were on the wounds station, and 2 were on the 'other' station. I was on wound station to start with. I don't know how these kids spend days and weeks with the wounds they have. Some were infected, many painful. Thorns, gravel, rocks. I was less successful at triage! Took about 10mins to get them under some sort of order. I spent some time walking around the grounds and getting to know the kids. There's quite a lot of politics going on among them, or you could call it a hierarchy. The easiest way to talk to kids here is to ask them about what lessons they learn at school (always animals!) and then about their favourite animals. Zebra, monkey, lion.

04-09-14
Clinic this morning. 'Mother and baby' project this afternoon. I gave a 5 minute teach on infant feeding guidelines. In Uganda exclusive breastfeeding is uncommon, but here among the San  population, many mothers are still only exclusively breastfeeding their child at 1 year, rather than introducing other food at 6 months as is recommended. Patient came in late with a temp of 39.9 and a diagnosis of chicken pox. paracetamol and sleep sorted her temperature out, but shes spending the night in the state clinic next door. the main concern is herpes zoster peunomia. theres a lot of fungal infection here..scalp fungal infection. require ketoconazole shampoo and theyre sorted.

i met the San community chief today! Had to give him skins so that they can make traditional dancing clothes. the clinic acquired them. so, that was good. I just imagined he was a senior consultant, but in the end he was far more easy going than any of them. he still lives in a rubbish bin house.

Wildlife and patients

You read about Namibia being a desert, on the whole. It doesn't prepare you for your namibian plane neighbour welcoming you to the capital, windhoek, as you approach the airport and seeing nothing but rough shrub until the horizon. The runway was a strip in the middle of shrubland, with about 5 small planes on it. You're in the southern district of windhoek, the capital, and theres nothing but shrubland! the sun sets at 5.30pm..the days are very short.

I spent the first 2 nights on the Naankuse wildlife farm about 45mins from the airport. I stayed in a great big tent, which was lovely and the stars are just as famous as they said they were - absolutely beautiful, the milky way is in plain view each night. but it was freezing! and so basic. ive lived in basic accomodation but nothing comes close to this.  my first day was enjoyable - fed the lions, cheetahs, leopard, wild dogs, and we happened across a giraffe and a bunch of zebra, my first ever sighting of wild zebra! the lions were huge, much larger than i expected. massive beasts. you heard them at night, so close. that was cool. the second day i prepared the food for the domestic animals on the farm - chicken, geese, meerkats, deer, sheep, goats, etc. the meerkats are super cute. but i love the sheep. the volunteers were from new zealand/UK/switzerland/argentina/all over, and great fun. we spent our evenings around the fire pit, sharing stories or playing games. on the second day we played footy with the local bushmen's kids, that was great fun. in Uganda it was so easy to meet locals, but here, there is literally no-one around for miles! its hard to find any locals, let alone meet them.

The third day i left the farm for the Naankuse Lifeline clinic, where i will be for 4 weeks. It's about 4 hours east, near Gobabis, in an area called Pos 3, ie area 3. There are Heraro and San people living here. In a nutshell, going back hundreds of years the San community originate from the Khosian people, originally in southern Africa. The Heraro population originate from the Bantu people, who originate from northern Africa. So they look different and have a different language - the San have fair skin, high cheekbones and have a clicking language, the Harero are darker and have fewer clicks. Anyway the ethnicity of the Namibian population is fascinating, as is its history. its only recently become independent.

The scenery in namibia is underwhelming, on the whole. shrubland for ever. deserty sand with thorny bushes. the sunsets are spectacular though. Pos 3 is a very small settlement, probably about 200-300 people, mainly living in tin/rubbish bag huts. we live inside the compound with the clinic, in a separate house. work is from 8-5pm but its been incredibly quiet this week. school has started and so the patient numbers have dropped. i havent even done much exploring, we get home quite tired, and the sun sets 30mins after work ends. we cook dinner together then go to bed by 10! this weekend i look forward to exploring and getting to know the locals. as in uganda, making 'home brew' ie home made vodka, is an issue here. its made in places called shabeens. there are 2 in Pos 3. the harero are the more well off population, they make it and sell it to the San, who cant afford to buy shop-stocked alcohol.

Patients - TB, burns, STIs, contraception so far. MSK problems, rashes. The local state clinic and us lot work together well. Patients of note - one man came in, having been found from our TB screening from a settlement 2-3 hours away, with no breath sounds from the right lung. Xray showed pneumothorax and pneumomediastinum. when i walked around Uganda i sometimes wondered, what would you find if you clerked and investigated the average ugandan. well, i cant believe this patient was just walking around namibia. His 02 sats were 87% on air and he was about 30 years old. he has suspected TB, probably long standing. there is a settlement about an hour away called hinda, with 5 plastic bag huts. they reckon the majority of the 30ish residents there have multi-drug resistent TB. sputum samples dont always come back positive, but the clinic diagnosis is one of TB, and culture takes about 6 weeks so what do you do in the meantime? its tricky. opiates are generally not legally prescribed in namibia, so patients with cardiovascular risk factors demand high strength NSAIDs and without anything else to give them stronger than paracetamol you advise them of the risks and they make the decision.

On the whole, underwhelming scenery, limited opportunity for exploration of the area and interaction with locals, but good company and good work experience! food is great. chicken casserole yesterday. soon we'll try springbock!

i got pictures but it will take an age to upload them and im tired and its late soo..another day!

Preparation!

Six days until I fly off to Namibia and I'm terribly disorganised and am only just trying to figure out what I need to bring with me! Namibia is both freezing cold and relatively warm at this time of year - rather unhelpfully. I could talk about how I still feel so out of touch with clinical medicine, how it's taking a LONG time to return to the level of knowledge and skills I had prior to my essay-laden year out of medicine, and how I would love to be going to Namibia with my brain stuffed full of everything I'd need, how it would challenge me more, how I'd feel more confident, less out of my depth. But I'd rather focus on other things. Let's talk about beauty. Or sand. I'm going to be living in a desert for a month! First times for everything. Apparently it has internet access, good, as I'm applying for jobs in early October and the best thing about applications is you get to rank them in return. So I'm going to take my time nit picking exactly what I want. How am I already back talking about work, I thought I was talking about the desert? Ok, work. I loved the idea of being in a clinic in the desert, a clinic which serves the original bushmen of Namibia, the San Community, a marginalised and fairly deprived population. I chose this clinic because it incorporates the work I've done in international health - I'll be able to apply all those juicy nuggets of knowledge about determinants of health, the 6 components of the health system, etc etc. The risk of not using knowledge is that you lose it (don't I know it!). But also, it's a huge clinical challenge for a medical student. Patients may walk in with anything commonly found in the UK, or a tropical disease which, although common, is rare for me. So here, the mind maps you need to create in your head when you take a history need to grow larger, you need to be aware of a greater list of differentials, or at least an alternative list, probably, to the ones you'd have for a patient in a GP surgery in Devon. You probably need to grow comfortable with thinking 'oh ... I have no idea what's going on here', and here you have an excellent opportunity to rely on your management plan (optimism to the end!), which will include finding out what is wrong, or just asking the doctor...Patient examination will need adjusting to meet the social customs of the country..I'm guessing. And communication. Diagnosis is all about communication. Patients give you the information to give the diagnosis. A wise doctor, Lord Ian McColl in fact, once told me this before I went to med school 'listen to your patient. they are giving you the diagnosis' - I thought it was rubbish to be honest, how can they when they haven't gone to medical school?! Is what I thought when I was 18. No, no, the wise doctor was right! I've eventually learnt this, 5 years later. You need to ask the right questions, but you need to ask them in a way which is understood, and you need to listen to what they say. Listening consists of two things. Firstly, hearing the sounds that someone makes. Secondly, hearing the meaning in their words. Take the phrase 'the light is bright'. This could mean both photophobia, where external light hurts your eyes, OR it could mean a patient's retina is producing spots of bright light, caused by a number of conditions (or even normal). Trust me, when you're tired, hungry and thirsty you may not care to delve much into the meaning of this phrase, which could take a number of questions and MUCH patience. But you do, always. So you see, it's tricky enough when two UK nationals talk to each other, how is it going to be taking a history from a Namibian? Phrases have different meaning even if said the same way. I learnt this from carrying out focus groups in Uganda. So I expect I will be having to pick up the lingo quite quicky to help with history taking. To be honest, now I'm talking about medic stuff, I'm getting nerdily excited. It's always good to rely on nerdiness to push you along to face challenges. It might be hard, it might be scary, it might be tricky..but fulfilling, it will always be fulfilling.