Asante Daktari *

One month with AMREF Flying Doctors, working as an aero-medical retrieval doctor, transferring patients from across Africa and the Middle East.

 

AMREF Flying Doctors HQ, Nairobi

"What are these people doing?!," Victor leans on the horn of the land cruiser. We grind to a halt behind two cars blocking the road, while the drivers ponder how to get into / out of the same gated entrance. "They have no idea of other road users!" he continues. "Road users" comes out as "rrroad uzAS" it's emphatic, and matter of fact, rather than angry. 

He swerves right to overtake the obstruction, very nearly inadvertently wiping out a motorbike taxi rider and his un-helmeted passenger, who have sped between us and an oncoming estate car.

Welcome to Nairobi! The chaotic occasional diving excursions are now routine. AMREF has, to it's credit, a selection of very good drivers, who can weave a car or ambulance deftly through the down town traffic, and leave you feeling relatively safe as a passenger.

There are rules of the road, it's just you or I don't know them. Everyone else appears to, which is why road rage is very uncommon. Undertaking, cutting up other drivers, forcing your way into and out of a 3 lane roundabout, are all legitimate manoeuvres, met largely with a placid acceptance by other motorists.

I avoid being in a vehicle where possible. The job itself involves sometimes long plane flights, so opportunities to stretch my legs and keep fit are precious.

Nairobi West is bustling and dirty, with children happily walking to school alongside commuters heading to work, passing by the stalls of roast yam, fried breads and random clothes for sale spread along the grassy verge. It's only a short distance from Kibera, one of the largest slums / shanty towns in Africa, the proximity to extreme poverty is pretty obvious, but the vibe is friendly and upbeat.

It's a 20 minute walk to Wilson Airport from the accommodation, and I enjoy the immersion in friendly chaos, dodging traffic with the other commuters. During daylight hours I walk to the AMREF offices, where I meet the medical coordinator in the "radio room". Here I get the (sometimes very limited) medical brief. 

 

 - 9 year old, fall, head injury, Rwanda. 

- 42 year old, cerebral malaria, low gcs, Congo. 

- 32 year old, gunshot wound to abdomen, Ethiopia 

 

Best efforts are made to get more information about the patients: more clinical details, when was the initial problem, how stable are they etc. Often this is not fruitful. Language barriers, remote medical clinics with limited communication, and miscommunication from messages passing sometimes through an insurance intermediary arranging the evacuation, all compound the issue.

Ultimately you have to prepare for the worst case scenario, based on minimal information. Usually it's less serious. Sometimes is definitely not.

Downstairs the biometric security lock recognises my fingerprint and pings as the gate to the hanger opens. 

Inside, in the store I help my flight nurse pack up all the equipment and drugs we might need. Often it's the same list, based on Murphy's law (anything that can go wrong, will go wrong) and Gump's law (... "you never know what you gonna get"). 

Ok, so I made up Gump's law, but you get the idea.

The Thomas Pack, contains all the airway kit, most drugs, chest tubes, catheters, cannula syringes, in fact most of the consumables.

Ventilators; usually a Hamilton T1 and an Oxylog as a back up. 

Syringes drivers, infusion pump, suction. 

Oxygen cylinders, each containing 600L of gas, are taken to supplement the 2000 to 4000 litres on board the aircraft, depending on what we are flying in. If the patient is likely to be oxygen, the journey time and likely requirements need to be calculated - some trips are the length of Africa and beyond.

Fridge drugs are transported in a cool box. We load everything into the aging steel trolley, and help the ground crew push it out onto the runway.

Loaded and ready to go

 

None of the aircraft were bespoke made for medical transfers, so the space has to be used efficiently. Inside, seats have been removed from the right side, and replaced with a stretcher conversion (or 2 in the case of the larger Citation Sovereign jet) on top of which, monitor and large bags can be strapped securely. Other items are stowed in a rear compartment and cupboard. 

We say hi to both pilots, give them a heads up about how much time we are likely to need with the patient before loading. They let us know about any weather or other concerns from their side - flights to some areas have security risks, ongoing fighting or political instability in the region mean a quick turn around is needed.

Challenged locations

 

Finally we take off. It could be 45 minutes to 9 hours before we reach the patient.

Citation Jet

 

AMREF Flying Doctors started in the 1950s with 3 pioneering surgeons literally turning up in their light aircraft, on a dirt runway in the bush, and delivering life changing surgery across East Africa. It has grown into a pan-Africa, and now global aeromedical transfer and retrieval service, with a small fleet of 5 aircraft and about 100 staff. 

Mt Kilimanjaro and Meru

 

Some patients are international travellers, covered by their health insurance. For many of the African residents who cannot afford this kind of cover, there is an AMREF policy available which costs £15 approximately for a year for Kenyan residents, and even the most expensive policy (pan Africa cover) is around £200 for a year, making it affordable for many working people within Africa. 

AMREF Flying Doctors also do free charity transfers, for people within Kenya who cannot afford the costs of cover. I am one of many volunteer physicians who work for a month gaining unique experience as a flight retrieval doctor. By doing this, we save the company a month of Doctors fees that can then be funneled into the mother AMREF charity. This provides essential health care services throughout Africa: vaccination programmes, health clinics, sanitation programmes, surgery provision, medical training and more. 

What do I get out of it? Travelling to new places and cultures has always been a love of mine, and this has been an opportunity to meet a huge diversity of people including patients from a wealth of cultures. I have learnt from my from my highly experienced colleagues who have many stories to tell, from war zones to ebola outbreaks. Applying my skills and knowledge in new and sometimes challenging situations, forces me to think on my feet and develop as an independent clinician.

My first flight was to a gentleman with suspected bleeding from benign tumours within the liver.  I talked through a plan with my flight nurse as we flew to Zambia. She, like the rest of the AMREF nurses, is an experienced intensive care nurse, who has done many of these retrieval. Not much fazes her. We don't carry blood products, so actively bleeding patients need to be stabilised in the local hospital before transfer. We discussed the need to turn him around and return to the hospital if he was not fit to fly when we arrived, but once we landed it was clear he was actually as stable as promised. 

The AMREF golfing umbrella was handed to a family member, who kept the sun off the patient while we secured him safely, before lifting into the aircraft. I was not familiar with the stretcher loading, so I observed and kept an eye on the patient, while the pilots and nurse coordinated getting him into the tight space of the doorway and clipped in securely. The patient was a gently spoken man in his sixties, grateful for all we did. He was stoic, but in pain, so I replaced the old now failing cannula in his arm, and gave some fentanyl during the flight. 

Vibration and interference from the aircraft in flight means that certain monitoring is not as accurate. ECG traces would routinely become erratic if we encountered a bit of turbulence, and the sats trace would sometimes disappear completely, or under read. In this case however, the combination of the relatively low cabin pressure (an equivalent altitude of approximately 2500m, and the patient lying flat, not taking particularly large breaths, led to a genuine desaturation into the high 80s, so we applied some nasal cannulae to provide a little oxygen during the flight.

Other patients could simply walk onto the aircraft, sometimes needing a little assistance, but otherwise requiring little management during the flight.

A construction worker with cerebral malaria, having been treated, and recovered from the worst of the disease, was still unsteady on his feet and intermittently confused, but once on board he mainly slept until Nairobi.

Another man with pneumonia was able to chat to me about his work as a humanitarian aid worker in some of the most challenging parts of Africa. It was inspiring and humbling, and a pleasure to be able to help.

From Sierra Leone to South Sudan, Congo to Zambia, we collected patients with typhoid, mental health crises, appendicitis and trauma, from gunshot wounds to motorbike accidents. Many were stable, some required continuation of their hospital treatment (antibiotics, pain relief, etc.). 

One man had been a passenger on a motorbike taxi which lost control, sending him flying into a ditch. He broke a vertebra in his neck, which was compressing his spinal cord giving symptoms, so he required a vacuum mattress and care to transfer him from the hospital, to a local ambulance which was driven over enthusiastically to the airport. 

Dodging potholes and other equally enthusiastic drivers, we bounced and juddered in the back of the vehicle. I pointed out to our driver we were not a time critical emergency, so please could he slow down and chill out, which he obligingly did. The patient was entirely sanguine about the whole experience, being previously from Europe, and cheerfully chatted about living in central Africa which he much preferred.

Another man with terrible leg injuries from another motorbike crash, who was almost certainly going to lose his leg. Gangrene had set in and he required major surgery.

South Sudan

 

A young child, ventilated, with a tracheostomy required transfer to a larger ITU for ongoing care.

An overseas traveller developed Guillain Barre syndrome a week after having malaria, so was now unable to walk. We chatted about where she had been on her trip so far, enjoying her retirement, and her plans after recovery.

The sickest patient we cared for, was known to have a pneumonia and other medical complications, but we were expecting him to be relatively stable. Once we arrived that night, it was clear that he was not as stable as we thought. As the ambulance, a converted jeep-style 4x4, arrived on the runway, we could see two men standing on the rear step of the vehicle balancing a 1.5m tall oxygen cylinder between them. The patient was breathing 100% oxygen and needing a significant amount of respiratory support from a nurse. Every time the facemask was removed his oxygen saturations plummeted rapidly. There was no way we could safely transfer him like this, so I decided with my flight nurse we would intubate to maintain stability during the flight.

Improvised oxygen transport

 

It was dark, he was very odematous, and had only a small single cannula in his arm. A brief look, even with ultrasound, showed no real hope of getting a second access at this time, and the pilots were starting to look at their watches, we were limited as to how long we could wait on the runway. We had to commit and then deal with more venous access later. We drew up drugs, prepared kit and used the environment to make this as safe as possible. Going through my checklist, I realised that the trolley he was on was too high for my position and ideally I needed a step. One of the pilots thought for a minute, then removed the rubber chocks from behind one of the aircraft wheels. He laid them together making a platform for me to stand on, which worked a treat.

Using the lights from the back of the 4x4, and the floor of it as a makeshift equipment and drugs dump, we went through the pre-procedure brief and commenced the rapid sequence induction. Predictably, despite a lot of pre-oxygenation, his saturations started to fall rapidly, but intubation was straightforward and I was able to bag him back up to normal oxygen levels. The escorting doctor (also an anaesthetist) and nurse were excellent support team, and between us and the various ground crew, we carefully packaged our patient onto the aircraft stretcher, and slid him up the ramp into the aircraft.

Loading at night

 

The rest of the journey back to Nairobi was spent managing blood pressure, replacing electrolytes and getting a second cannula, but the satisfaction of handing over our patient in a better state at the end of the flight was enormous.

I exchanged grins with Jacob my flight nurse as we wearily left the hospital.

“That was good Doc” he smiled.

 

 

* “Asante Daktari” means “thank you doctor” in Swahili.

All of the cases described are genuine, but locations, and patient details have been changed / removed to maintain confidentiality. 

All names have been changed for the same reason. 

Except mine. 

That would be silly.