A Somerset GP in Malawi

Guest blog by Dr James Hickman

One of the joys about General Practice is the ability to use the wide breadth of your clinical knowledge yet also develop a special interest within or alongside it.

I have been a partner in a small rural Somerset Practice for nearly 30 years and value the continuity of care and relationships with my patients and team. However, alongside this I have developed a special interest in pre-hospital emergency medicine responding for SAVES (our local BASICS Scheme) and have become increasingly involved with organisation, teaching and examining on a local and national level. As a result of this, in 2009, I was recruited to be part of the small medical team that supports UK International Search and Rescue. This is the UK’s national, UN-accredited search and rescue team that is comprised of teams from fire services across the UK, together with a medical support team, a vet, dog handler and structural engineers. It is funded by the Foreign, Commonwealth and Development Office and can respond to disasters around the world.

The Medical Support Team is a group of 10 volunteers. We are a mixed group of doctors, specialist paramedics and a nurse – all with experience in primary care, pre-hospital emergency medicine and remote or expedition medicine. We train alongside the Fire Service and usually a group of 4 to 6 will deploy with the team to a disaster. In the past I have deployed to an earthquake in Sumatra and the 2011 Japanese earthquake and tsunami.

With an eye on global warming and changing weather patterns the team are increasingly developing our Flood Rescue capability. I have spent several enjoyable days in very cold, fast-flowing Welsh rivers in December learning swift-water rescue techniques…

In February and early March 2023, almost unnoticed by the World’s media, Cyclone Freddy hit Southern Africa. Freddy was both the longest-lasting and highest-energy tropical cyclone ever recorded worldwide. It was the third-deadliest tropical cyclone ever recorded in the Southern Hemisphere. Southern Malawi was badly affected with over 1000 deaths and a huge lowland basin becoming an inland sea, displacing and isolating thousands of people.

On Wednesday 15th March, I got the call that a 22-man rescue team was to be put on standby. I made hurried arrangements with work. Fortunately, deployments are rarely more than 10 days and the team provides some backfill funding for cover. Finally, on the 17th, mobilisation was confirmed and the team rendezvoused in Birmingham before boarding a charter flight bound for Lilongwe, together with several tons of rescue equipment, including inflatable rescue boats.

After arrival in Lilongwe we started the 5-hour minibus journey south to Blantyre. Here we liaised with a team from the Tanzanian Army loading our equipment and most of the team onto Puma helicopters, which ferried them south to Bangula, a settlement on the edge of the inundated flood plain. A small team of us stayed in the provincial capital of Blantyre to liaise with the emergency operations centre and the World Food Programme Team based there, before driving south to Bangula the next day.

Bangula is normally a bustling dusty town at the bottom of an escarpment, but was cut off as several of the bridges on the main road had been destroyed by the cyclone and although some could be forded by 4×4 the final river had to be waded in dry suits. A large reception centre on the edge of town had been set up along the lines of a refugee camp and here we joined up with the rest of the team at the “BOO” (Base of Operations); set up adjacent to the camp. Normally, on a deployment, we sleep in tents but, on this occasion, we had the luxury of a converted hangar used for relief workers, with small cubicles with actual beds in them and a block of flushing toilets! Catering is a diet of boil-in-the-bag meals. The team makes a point of being self-sufficient without relying on scarce local resources.

There followed five days of intensive work in rotating small teams, travelling by boat, out on the flood waters to isolated settlements and rescuing people to bring them back to the reception centre, as well as delivering maize to settlements that could manage with some support. The local population struck me as remarkably resilient – particularly the women who could nonchalantly walk with a 50kg bag of maize on their heads (considered a “two-man lift” by British firefighters).

Most of those rescued were uninjured but hungry and tired. However, several had significant injuries, including a disrupted knee joint and a nasty infected hand injury caused by a cut on corrugated iron.

One patient is particularly memorable. On our last evening we heard that Médecins Sans Frontieres had been told of a 90-year-old stranded in an isolated marooned village with a leg injury. The next morning a small team of me, the other team doctor, and two others set out by boat to find her. She had been moved from her last known location and we eventually find her curled up in a small local boat at one of the outlying “islands”, accompanied by her daughter. She is tiny, but has somehow survived 10 days in primitive conditions after her house fell on her in the cyclone. She has a compound fracture of the femur with the bone end protruding through the clearly-infected wound.

We are able to provide some potent IV analgesia and antibiotics and establish monitoring, before reducing the fracture with a traction splint and transferring her on to a stretcher. There is then a long extrication process. Initially we go by boat back to Bangula, then (after hopes of a helicopter transfer fail to materialise) we call for a local ambulance. When this arrives, it is a 4x 4 pick-up with 7 patients already on board. We decline their services and carefully package the patient, her daughter and two doctors in a conventional 4×4 with the back seats down for a long transfer back to the government hospital at Blantyre.

The team returned home (via Mozambique and Addis Ababa) arriving on Sunday 26th March ready for me to return to work (I took the Monday off!). Reacclimatising to UK General Practice is always a bit of a culture shock after a deployment. It definitively alters your perspective and always makes me realise how lucky we (and most of our patients) are!

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