It was an early morning and the leaves were gilt with the first golden light when I received the call. A hasty drive through grasslands dotted with various large impediments, including several stationary and lugubrious giraffe, brought me to a boat idling on the Luangwa. Several large and weighty cases were piled into the boat, and across the river, unmolested by hippo or crocodile, we sped. A further winding drive from riverbed through ebony grove brought me to the room and instantly I smelt the dark cloying smell of digested blood, as if lions had killed nearby and after their first gorging, passed tarry faeces all over the place. The bed was covered in dark shadows, coffee grounds the classical description, and indeed, it was exactly as if there had been a fairly explosive incident with a cafetière. In the bed lay a man, waxy and tense with incomprehension. He had been vomiting blood since the early hours of the morning and, even more sinister, passing black bloody faeces. Climbing out of his huge bed, he had collapsed, and upon resuming consciousness, called for help.
He needed to get out of there, that much was immediately clear, and so, having set the wheels in motion for this, I bustled around checking blood pressures and heart rates and getting some IV fluids sorted. Having strung these up with the aid of a torn piece of cloth tied to the mosquito net frame, the fluids started running in at pace to replace some of the blood he had lost through the night. It was a constant battle to maintain a balance between giving him sufficient fluid to maintain some kind of circulating volume, and overloading him, flooding his lungs, and so killing him. It seemed every few minutes he veered one way or the other. The numbers were dreadful.
At least five times that day I was certain that he was about to die, beyond a continual pervasive pessimism about the likely result. Nevertheless, on went the routine, fluids, check heart rate, check blood pressure, slow down, speed up, listen to the chest. The gurgling would get worse and then better, and occasionally he would wake up and say a few words, before slumping back into his pillows. He took what drugs I had; some anti acid medication, and some pain relief, and somehow carried on. At one point he got up to have another bout of bloody faeces and leaning on me with his bag of normal saline held over my shoulder, he wobbled to the toilet only to collapse unconscious on the floor, chin bleeding. I was unable to lift him, and the maintenance worker who was my assistant had briefly left to run some errand.
The time dragged by with every minute bringing us closer to his death. I sat outside the open door on the veranda in the ebony glade and listened to breath after breath bubbling up and cursed myself for giving too much fluid, the next minute checking his blood pressure and finding him to be barely maintaining enough circulating volume to keep his organs alive. So up and down with the infusion- faster and slower and faster and slower ad infinitum. Meanwhile he passed two more large bloody faeces and grew steadily paler and waxier until even his conjunctiva had no apparent colour and his face seemed no longer animated by any life force.
My only hope was that we would get him on a plane and so to Johannesburg where he could get blood and have an endoscopy to find the bleeding source. The time continued to pass. There was no information; the lodge staff were continually engaged on the phone speaking to this or that insurer. Vital signs were emailed across continents repeatedly, the numbers of a vanishing life. The plane was still not authorised. It later emerged that the two insurance companies involved spent the day arguing over who should pay for the flight that would wing him to safely, neither one willing to accept responsibility and authorise the plane. By now five hours had gone by since I had arrived, and we were only closer to a horrible death. I knelt outside, lost in despair at my inability to do anything, and overwhelming anger at the insurance companies, who by their fractious squabbling over money were allowing a man’s life to seep away.
He started groaning and moving wildly, grasping at the air, at someone who was not there and could not provide solace. I stood beside him, convinced this was it, brought him painkillers in the hope that perhaps they would provide comfort, and again, he slumped and continued, despite the odds, to live.
Word came, finally, that a plane was authorised and was coming with a medical team to evacuate him. Finally some hope, and the fear that perhaps when in sight of redemption, he would fail at last. But no, he continued gurgling and I continued in my post, now outside for a little respite from the desperate noise, now back, unrelieved. The plane proved a false dawn, some paltry excuse about not being able to carry bleeding patients. A few more hours of anxiety and fading hope and another beacon, another plane, with a doctor on board. So, into the back of a car by stretcher and over potholed road and river, bag of fluid swinging wildly from the roof, bucket strategically situated by the man into which he soon vomited a further litre of blood. Crouched beside him in the back I started a further bag of fluid; slicing the melted plastic open with a knife and tying it to the roof to swing there for a further few bumpy kilometres.
On our arrival to the airport we were greeted by the district medical officer, an august and elderly personage who failed to live up to the usual Zambian standards of politeness by refusing to shake my hand. Rather puzzled by this I took in his cohort of masked colleagues and it suddenly dawned on me that the lapse of manners and the undercurrent of bumptiously enthusiastic officialdom was due to the suspicion that I was bringing in a case of Ebola. An ungainly journey through various halls of bureaucracy later we ended up in the quarantine room- all neatly kitted out with hospital beds which had obviously not seen use in many moons, where we were subject to a long and repetitive inquisition. Finally, having been convinced by dint of repetition that this was not a haemorrhagic fever, the district medical officer deigned to give a nod of approval to my treatment plan, and seconds later, we were alone again, deep in the dusty halls of Mfuwe airport, still awaiting the ever-delaying arrival of the plane. Several false alarms later, the plane finally arrived, and with a certain amount of manhandling, the patient was loaded on the plane accompanied by a Zimbabwean doctor and nurse, still waxy skinned and shocked, but somehow hanging on to the threads of life. They took off as the sun disappeared, just as the airport closed for business, almost 12 hours after I had entered that bloodstained room.
It is not often that we as doctors spend a whole day in the company of a patient who is dying. In fact, we rarely spend a long time with a single patient under any circumstances. This enforced captivity with all the vicarious distress of the constant struggle for life, the gurgling and rattling and the silences which haunted my day, all of it was awful. What if I am killing him, what if I am not doing enough, what else can I do? There is no other who walks beside you, would that there were! The helplessness of having no solution but to keep attempting to prolong a guttering life was hard to face. And then, after having had the first plane and salvation rudely dragged away from under our feet, it suddenly seemed that perhaps we had done the wrong thing by trying to trust to the medical evacuation services, perhaps we should have just treated him as a local and shipped him to the nearest hospital, but then, they so rarely have blood. Perhaps we should have borrowed one of the light aircraft in the valley and flown him out ourselves to Lusaka. It was hard to see the right path. In the end it seemed that we did right, the next day the news that he was in the intensive care unit in Johannesburg, awaiting surgery. Yet there were a thousand endings to that day, and most of them would have taken place in a morgue in Chipata. The day ends, as it started, with hope.