Geelong ED

C swears he doesn’t know who attacked him. He has a fairly dubious story that involves ‘minding his own business’ and ‘some guy I never even seen before’ that he relays to me as I am preparing to stitch up his face.

He is younger than me by a few years and full of the bravado of youth, testosterone and alcohol. He looks a bit nervous as I lay out my suturing gear and glove up, but he tries to act cool and talks to me about the various places I should go out while I am in Geelong. When he catches sight of the lignocaine, however, he falls silent and starts to look a little bit pale.

C has already lost a few teeth this morning and he has a face like Rocky at the end of the movie of the same name. Given how well he seems to have coped with what we can safely assume was a full-blown arse-kicking, his apparent needle-phobia is almost hilarious.

Mnazi Mmoja Hospital

Operation: thyroid liberation

I was supposed to go to Mbweni yesterday. Instead I stood in the ENT 'Sea View' theatre and watched people - happy looking people - heading out on snorkling trips or sailing past on traditional dhow, whilst I was left trying to dodge the fine sea-sprays of blood emanating from an obese woman's neck.

About five minutes into the operation I think we all realised it was going to be a marathon. The goitre was enormous and the woman was, what we in the industry like to call, a bit of a bleeder.

By the third hour, the usual theatre chit chat had died away and we worked in silence, save for the odd imperative ('suction', 'gauze', 'forceps') or exclamation from Dr Tao, a man with a knack for capturing the collective sentiment in a way that only someone with broken English can.

"Argh" he said as yet another geyser arced into the air, "too mucha blood. Want go home."

Having foolishly agreed to assist in the operation I felt a bit like an American soldier in Iraq - in the middle of a bloody battle I only half understood, with no exit strategy. So I stood there with sweat pooling in my gumboots and tried to concentrate on the various token tasks I was given (sucking up blood, cutting sutures, holding back neck fat) instead of staring out the window and thinking about my housemates who would probably be sitting next to a pool somewhere drinking colourful coctails with those little umbrellas in them.

Ultimately, the operation ran so far over time that the patient woke up and the generator packed it in and we had to complete part of the closure under torch light.

The ENT theatre

Around Stone Town

Thanks to Jenny for the photos!

Manny's

My favourite hangout in Stone town is Manny's coffee shop.

Its not actually called Manny's coffee shop. It's just a coffee shop run by a guy named Manny. Its also not really a shop. Its more of a wooden bench, but its a really nice place to sit and have a drink and I think Manny's coffee shop makes its sound more impressive than Manny's wooden bench. So that's why I call it Manny's coffee shop.

I'm not really sure if Manny's name is Manny, but he seems like a Manny. So I call him Manny. He hasn't corrected me yet.

You can find Manny's coffee shop in the heart of stone town in a place called Professor's Square. If you believe the signs, Professor's Square is actually called Jaw's Corner but I prefer to call it Professor's Square because it is squarish and there are lots of pictures - political campaign posters I think - of a man named Professor Lipumba. The posters don't say what he is a professor of but I think he is definitely a professor of either agriculture or macroeconomics.

Stone town, David Bowie, Communism

Stone town is a bit like the maze (or labyrinth if you will) that confronts a young Jennifer Connolley in the classic 1986 movie 'Labyrinth'. By which I in no way mean to suggest that the locals resemble Jim Henson creations* but rather that its narrow, winding alleys - which would be easy enough to get lost in - are very dynamic. Wooden shutters set into the stone walls of each street open and close throughout the day, meaning the shops inside can appear or vanish in about the same time it takes to realise a wrong turn and backtrack. My early attempts at constructing a mental map of the place... 'past the pharmacy,turn left at the tea shop...' were completely useless and I spent quite a bit of my first week wandering around lost and cursing David Bowie.

Still, its a very friendly and beautiful place to be lost in. You can walk down a tiny dingy alley, past the rusting carcass of a old car (how on earth did it get down such a narrow street?), climb over a pile of rubble and suddenly find yourself in front of a set of beautiful carved wooden doors opening into an immaculate marble-floored cafe. Which makes it a bit like going to most bars in Melbourne.

In addition to the Arabic, Indian and Portugese influences around there are still little reminders of the islands 1964 revolution and its communist sympathies, from the Childrens playground at the waterfront that plays Chinese nursery rhymes throughout the day to the Mao Tse-tung Football Field (Mao being a well known soccer afficionado). I even had a young guy ask me yesterday why I would choose to come to Zanzibar instead of pursuing my medical training in the USSR. (I didn't have the heart to tell him that the place no longer exists).

I was reminded of these ties again yesterday when a group of Cuban doctors and medical educators arrived at the opthalmology department as part of their hospital tour (Cuba is responsible for much of the undergraduate training here). Unfortunately, at that precise moment, Dr Ji was in a back room underneath a desk trying to fix his computer. This left me as

the only person in a busy clinic sporting a white coat. Naturally the Cubans took me for the man in charge and lined up to shake my hand and ask me questions about the facilities. I was so confused, I went with it.

*What are you, some sort of racist?

Opthalmology

Its the simplest things that bring the department to a standstill.

Its not a lack of qualified staff. The head opthalmologist, Dr Ji, is a highly qualified Chinese doctor on loan to Mnasi Mmoja for the next two years.

Its not a lack of equipment. They they have a whole lot of, as my inner-bogan might say, 'shit-hot' ophtalmology gear which was donated by the Chinese government along with Dr Ji.

Its not the three-years-out-of-date eye drops, which noone seems to have a problem with.

Every day the opthalmology outpatient clinic grinds to a halt due to a lack of glue-sticks. Not some sort of special eye-glue either. Just the regular paper kind which is used to stick intra-occular pressure printouts into the patient notes.

Every day we run out of glue. Dr Ji gets angry. And nothing much happens until an assistant manages to go and borrow some from another department.

Cool bananas

Solomon, the twenty year old son of our host, dropped round to say hi to everyone the other night, and we had a very frank discussion about my poor use of his native tongue.

I can always tell when Solomon is over because the girls in the house suddenly become scarce / overdressed. This particular time I saw Em in the living room wrapped in a blanket despite the thirty-plus-degree heat. I found Solomon in the kitchen playing with his mobile phone.

'Mambo?' he asked me (how are you?)

'Poa' i said 'kachisi kama ndisi' (I am cool like a banana)

Solomon then very ernestly explained to me that it would be very uncool for me to talk like this.

'No, do not say this. I have not heard this since I am a child. You must never say this.'

101 uses for a kanga

Em bought a book yesterday called 101 uses for a kanga (the large scarves worn by woman around the island). The book includes folding instructions for making a dress, a bikini, a papoose etc. Today I learnt of another use: tying patients with cerebral malaria to the bed.

"Sometimes I just wish they would admit them to the downstairs ward" Dr Habdi told me.

"The malaria ward?"

"There is no such place."

"Oh, you mean so they don't..." I gestured towards the window

"Yes, you would be surprised how many try to jump."

Zanzibar

Zanzibar could be considered paradise were it not for three small facts. The first, which was to be expected, is that it is very hot here. The second, equally well advertised is that it is a predominantly conservative muslim culture which requires that we wear a little more clothing than we might have chosen given fact number one. The third crucial fact, and very well kept secret, is that Zanzibar currently has no electricity. This means no fans, no airconditioning, no refrigeration, and no cold drinks at the end of a long day. Now and for the foreseable future.

People do talk about a time when airconditioning will again return to Zanzibar. It is said that there is a man from a far away land who will one day come and bring us back our electricity. The prophesised one is in fact a Dutch engineer who has gone home to spend time with his family until February. In his absence, the mainland government has basically said to Zanzibar, 'well, you wanted to be an independant state... so suck it up'

Despite the lack of response to my emails prior to departure from Australia, it seems that we were expected at the hospital. We have been given a room on the second floor of a large old stone house a few minutes walk away (which is a rather redundant description as every house is large, old and made of stone) which we share with some other students.

The house is owned by a rather schrewd and wealthy electronics/ whitegoods dealer named Mr Habib who lives with his family on the floor above. The running joke in the house is that no matter what you need, Mr Habib has a friend who knows a guy who can get it for next to nothing. His family seem nice except for the Nana who tends to wander in from time to time and scold us in Swahili for wearing shorts or being infidels.

Mnasi Mmoja (literally 'one coconut' - I kid you not) is the largest hospital in Zanzibar with around 440 beds. The fact that it serves a catchment area of nearly one million people explains why it appears to be bursting at the seams most days. It has basic medical, surgical, paediatric and obstetric facilities (with the emphasis on basic) as well as some ENT and opthalmology.

For my first week I have been assigned to the women's general medical ward which occupies the third floor of the hospital across two large open plan rooms (divided into mainly malaria and mainly gastroenteritis). Large doors and windows open out on to balconies which are occupied by patient families and let in a sea breeze which is more or less the only respite from the heat (the overhead fans work only intermittently due to the power outage)

(Photo not mine. I felt a bit uneasy about taking a camera on the ward so I've just stolen a pic from a previous student)

This morning we saw around ten cases of malaria, one pneumonia (which turned out to be malaria) and three diagnositic dilemmas (presumed malaria). There was also a lot of cholera - despite what the travel medicine doctors had advised - a few admissions for HIV complications and a few undifferentiated 'cardiac' patients. A few times during the morning a patient was carried in and left on the ward floor until a bed could be allocated.

History taking is difficult, due to the language barrier, but the medical notes are all kept in English so most of the time I know what is going on. Investigations are very limited and paid for by the patients themselves so the aim of the game seems to be to keep them to a minimum.

Probably the best aspect of the teaching here is the willingness of staff to help us learn procedures. I performed my first ascitic tap on an elderly lady with portal hypertension yesterday. (Albeit without any local anaesthetic and, because blood products are basically unheard of, with raw eggs used as a substitute for replacement albumin).

Unfortunately, when I emailed the hospital superintendent earlier in the year and asked 'do I need to bring anything?' his response of 'no' actually meant 'no, except for a white coat, two sets of scrubs and a $300 US cash donation for the hospital, and of course we don't have basic supplies or equipment like gloves, antimicrobial handwash, working sphygmonometers or stethoscopes so any donations you can get would be appreciated'.... so I did feel a bit frustrated and poorly equipt when I arrived. On the whole though its been a positive first few days and people have been very welcoming.

Ngorogoro crater

The hunt

Em thought the elephants were pretty awesome

MCs aint ready to take it to the Serengeti

Nairobi airport / Purgatory

So Em & I were about to disembark from our overnight flight into Nairobe when a particularly lovely air hostess came up to us with a carry bag full of left over plane snacks. 'You might need these' she said.

Puzzled, we thanked her, took the snacks and headed off to the terminal. Here we were promptly herded towards a transfer desk where they told us we had missed our connection, and were now on the afternoon flight.

One by one, we (and the other stranded passengers) were offered the use of a broken phone with which to notify hotels or family that we would be arriving late. In each case this was followed by a discussion with the desk clerk in which he insisted that it was our phone numbers, not the phone, that were the problem. Being about the fifth person to have this discussion with him, I was a bit sceptical.

Em and I wandered around the airport for most of the morning as all the seats in the transit lounge were being used as beds.

By one pm our new flight had still not appeared on the departures board so we returned to the transit desk to find out which gate we should wait at. The young woman at the counter looked quite confused as I handed over my boarding pass. "No sir, this flight has been cancelled."

Having been up for most of the night, I suspect the disappointment on my face would have been pretty obvious. "Don't worry sir, we can put you on to the evening service" she said smiling and gesturing towards the phone, "perhaps you would like to call someone?"

Em and I sat on the floor for a few hours and looked at the defeated travellers slumped on their bags, and the lines of African businessmen down the corridor, sleeping with heads on their briefcases. No one, it seemed, was going anywhere.

At around three pm I noticed a flight on the departures board direct to Kilimanjaro - near where we had planned to head by bus the following day - with a different airline.

I approached the transit desk for the third time with greater resolve. Yes, I explained, I know our tickets are non-refundable. I know I cannot by a new ticket without clearing customs and I know I can't clear customs without a Kenyan visa. But we have missed our airport transfer and we will miss our bus and we are tired and we just want to get out of here.

This angel of a woman took pity on us, took our credit card and went and bought two tickets from the rival airline. And ten hours after we arrived in Nairobe, we raced past the crowds waiting for their connection to Dar es Salaam, and got on a tiny twin prop plane and from 17,000 feet watched the sun set over Kilimanjaro.