Pride and Optimism

Reading over what I wrote yesterday feels very sobering. Yet it paints part of a very important picture of what reality is here. Whilst the events described are dreadful and terribly sad in many ways, my strongest reaction is one of injustice. How life for this truly beautiful community has so much more fragility to contend with than that which we enjoy back home. Regardless of the complexities that could be discussed in making sense of this situation, it simply is not ‘right’. However you look at it.

I am struck with an incredibly powerful sense of pride that we have come here. For us as a family, it has been far from easy. But it has also been such an amazing adventure and fulfilling experience already. It is an incredible privilege to live and work here. The culture is rich and incredibly friendly. Smiles are everywhere, warm and genuine. Even the common greeting etiquette encourages a sense of optimism (almost every greeting is met with “nsuri sana, asante” – “very good, thank you”). It certainly lifts you in a way that “fine, thanks” seems a little lacklustre.

A view of the hospital from the front gates.

This week, for all its challenge, has been full of very rewarding moments. The 1month old baby who we drained an arm full of infection a few days ago is doing very well and a relook today revealed a healthy wound. It was a ridiculous amount of pus to be drained from such a tiny limb. But her sepsis is settling and she was starting to use the arm again – an incredibly positive sign. The very challenging laparotomy from last week has improved day on day and will hopefully be ready to go home on Monday (with no detrimental effects from her dabble with asphyxiation either). We have successfully performed three mesh hernia repairs, all of whom have done very well and are going home today. Hopefully they will remain well until we see them again for follow up in a fortnight.

One of the hernia cases was undertaken with my colleague as primary surgeon. I took on the role of trainer, guiding him through the repair as well as the correct use of diathermy. As those that have worked with me know, I am particularly passionate about education and training, and for me this case was especially rewarding. It is one thing to do something yourself, it is quite something else to enable another to take the first steps towards being able to do it too. It is perhaps still very early days, but I am optimistic that the work we are doing here as not only valuable, but also sustainable.

Tomorrow we head off to Tanga again, and I am looking forward to another weekend by the sea to recharge the batteries. And, perhaps, we might get a new cooker too!

Death

A view from the hospital to the front gates

As a surgeon, I am no stranger to death. It is an unavoidable part of the choice you make when becoming a doctor. ‘Part of the Job’; albeit, perhaps, a very hard one. I have seen death in many guises throughout my career; old, young, some terribly sad, some heart-breaking, some anguished, some expected, some peaceful, some wanted, some lonely, and there are some that catch you completely unawares. It is not that you ever get used to death as such, but as a doctor you learn to develop a certain emotional detachment that allows you to perform your job (sometimes in very extreme circumstances), as well as to protect you from what would otherwise become overwhelming. And of course, one of the ultimate roles that we sometimes play as doctors is to help a patient’s course veer away from its clutches. A true privilege when it happens and goes well.

Death here seems much closer. Life hangs on a much more tender thread. Things that would rarely happen in the UK and seem tragic, are met with an almost acceptance, within the spectrum of ‘normality’. Maternal and infant death. Children. Young adults. Mothers. Fathers. Friends. Family members. It happens much more frequently here. And despite the herculean efforts of the staff, the simple fact is that much of what modern medicine can offer is just not available.

The four bedded ICU

Last night I was called into the hospital to see a man in his 40s. He’d been admitted for 2 days already and had been transferred to ICU (the Intensive Care Unit) as he was deteriorating. It is important to highlight what ICU means here – it is a 4 bedded ward with one trained nurse allocated exclusively to these four beds (although not always present). There is no monitoring as such, but it does house one of the hospitals saturation monitors, a blood pressure machine and one of the ECG machines (I think there are two in the hospital). There are a couple of oxygen concentrators available, although these seem to alarm incessantly; complaining that they are not delivering as much oxygen as they would like to. It is a world away from what we would consider an ICU at home.

As I laid eyes upon the man I had been asked to see, I knew his tender thread was desperately bare. Without some significant change to his current course, he was not long for this earth. He was barely conscious, his breathing ragged and looked ghastly. His wife was holding his hand, willing her strength upon him. He had IV fluids running,  a nasogastric tube and a catheter. A surgical review had been requested as somewhere along the line a working diagnosis of peptic ulcer had been made (and, if perforated, was something that an operation could potentially solve). My immediate thoughts as I approached the bed were that we would need to get him to theatre immediately if he was to stand any chance. I was slightly irritated that things had been left so late before involving us. However, as I assessed him, things did not add up. The history was confusing, albeit third hand – his wife talking to my colleague, talking to me. Yes abdominal pain had been a feature, but the sweats and rigors (uncontrollable shaking that occurs with certain infections) were far from typical. And as I laid a hand upon his belly I knew there was nothing I could do surgically. He was roasting, truly burning up in front of me. His body was gripped by some infection and his abdomen was not ‘a surgical one’. There are certain signs in patients with an ‘intraabdominal catastrophe’ (potentially salvageable with surgery) that could conceivably generate a similar clinical picture that guide you towards the belly as the cause. He had none. I would go so far as to say his abdomen was blameless. His saturations were dangerously low and he did have some signs in his chest (but it is difficult to know if these were cause or effect of his illness).

I withdrew to the office to consider his predicament. I was sure that he had overwhelming sepsis of some sort, but the cause was far from clear and any number of sources could be harbouring his demise. Antibiotics were a must and we started them immediately. Fluids were running, but clearly they alone were not enough to support his failing organs. The inequality in healthcare was starkly apparent. This man in the UK would be on full monitoring including tubes into arteries to give beat by beat readings of his blood pressure. He would likely have his breathing supported and possibly be given medicine to improve the functioning of his heart and blood flow. He would be stabilised for special investigations (such as a CT among a myriad of potential others) to try to find the cause of his trouble. He would still be desperately sick, but he would have a chance. Here, the only tests available beyond clinical acumen are a haemoglobin (not even white cell count), bedside HIV and Malaria testing (both negative). We could not check his liver function, nor kidney function nor even do blood cultures to try and narrow down the source and target antibiotics appropriately. X-rays were not possible as earlier in the day the power was not sufficient and now he was too sick to be moved. So it was antibiotics, fluids and hope.

This morning he was worse.

Hospital Corridors

Around 12 midday a guttural, agonised cry ripped through the open-air corridor between theatres and ICU causing every head to turn. His death was announced by the grief of his departing wife.

This is healthcare in Africa.

The first mesh goes in.

Today has been a hugely significant moment in my time here. We performed the first mesh hernia repair.

Last night, I prepared some meshes ready to sterilise and freed myself of all other responsibility today to concentrate on the job in hand. Whilst a very routine procedure for me to do in the UK, here there were lots of things that I needed to ensure were done correctly. Today needed to go well. So, from the morning meeting I went straight to the theatre CSSD and took personal responsibility for the sterilisation process. During the 40min it took to ‘cook’ I made use of the time by writing up a guide for the process. I am confident that with the new miniature autoclave and the expertise within the department, the process is easily reproducible and thus sustainable for the future (which is so important to my work here).

We planned to do two hernia cases today before a couple of others. With the meshes ‘cooked’, the first patient was taken into the operating theatre ready to start the ‘spinal’. This is a form of anaesthetic whereby the lower body is numbed by putting medicine into the spine (similar to the epidurals used for c-sections). This is their routine practice here and something they do very well. Unfortunately, as the patient was ‘hooked up’ to the monitoring, it transpired that his blood pressure was unacceptably high. We had picked up on his hypertension a few weeks ago and had started treatment, but unfortunately he had not taken his medicine for the last two days. The only safe thing to do was to postpone his surgery.

The first mesh goes in!

(I have up till now resisted posting anything 'gory')

Suitable consent obtained.

The second case however went ahead. The patient had a recurrent hernia, his previous suture repair having failed after 4 years. This, in many ways, is a very fitting way to start our mesh efforts here; assuming recovery is uncomplicated… which is of course never guaranteed (writing those last few words causes a momentary pang of anxiety)! And we certainly had to work hard for the case today. It was a large hernia, heavily scarred with very distorted anatomy from his previous repair and plenty of potential pitfalls. However, we took our time and whilst challenging (a very common word in these blogs) the end result was technically very pleasing. The mesh performed brilliantly and now all he has to do is heal and recover without complication….

The beautiful chaos of Outpatients?

Today has been pretty full on. It started well with a fairly concise morning meeting, followed by surprisingly brief surgical rounds. And it was then to the outpatient department, for what I am starting to feel is the Monday onslaught! The clinic nurse clearly thought so too. 18 patients somehow turned into 35!

It is very different to how we typically practice in the UK where we tend to have ‘slots’ in a defined clinic list. And normally we have some sort of letter to guide why a patient is coming to see us (although the presence or quality of such documents is by no means guaranteed). However, here in Tanzania, there is usually very little documentation with most patients just turning up on the day and wait to be seen – Mondays are known to be surgical OPD. Even the follow-ups can be a bit sketchy with the documentation.

As I am sure is becoming clear with my posts, the practice of a General Surgeon here is VERY general. The broadest UK general surgical remit is joined by a significant amount of orthopaedics, urology and paediatrics, with a smattering of ophthalmology and ENT. Obstetrics and Gynaecology is conducted separately – although there is overlap (not least as ALL the doctors on call do caesarean sections – by this I mean every doctor be they medical, surgical, paediatric as there is only ever one on for the whole hospital!).

The conduct of the clinics themselves is taking some getting used to. Firstly it is noisy, really noisy.  With well over 100 people milling around outside the rooms waiting for their various appointments. Most patients arrive early at about 8am, pay their fees to secure an ‘appointment’ and wait patiently to be seen – our last patient today was at 3pm (that’s a 7hour wait)! So there is a lot of hubbub (although it is all very good natured). And little ‘insultation’ from it. The windows are of the slatted type and of course are open (for the heat) assuming they are not missing the pane of glass.

Our clinic room, looking in from the window!

There is also an organised chaos in the rooms (which I am sure would make more sense if my Swahili was better). Patients will often just come in to drop in notes or the results of a test they’ve just had done, ask a question or request a ‘slip’ of one sort or another. Or hospital staff may sometimes come in to be seen or to wait in the room for a relative to be seen. That, together with the curtain-less windows does mean that privacy is far from ideal. However, there is a definite pragmatism within the hospital in this regard. Although on the streets shoulders and knees are generally covered, there is no hesitation for a patient to whip out a boob or drop their trousers to show what the problem is. I hasten to say that we do have a curtained area (with a new couch today!) which we encourage them to use. Patients are called in for their 'appointment' by shouting their name inside the room (quite loudly) or asking the departing patient to call the name. You then hear an echo of this name being passed around outside until the correct individual is found and enters – it is surprisingly efficient.

And then there are the consultations themselves. I have long been a strong proponent of the importance of the history - the subtleties of the story that patient tells can more often than not tell you what the diagnosis is. My Swahili currently is nowhere close to being able to take a decent history on my own, so I am working closely with my Tanzanian colleagues. And this dialogue with them, is of course one of the main reasons why I am here, it is very educational for us all.

It was an exhausting day and I do wonder about my tactics / approach to Mondays (and perhaps more generally). The need is great which is very difficult to ‘shy’ away from when you are actually here. And it is also important to me to be part of the team and throw myself in to it all (not least to build up the crucial relationships that will enable maximal development of the surgical team). But it does take a lot out of me and I am not sure it is necessarily the best use of my time / energy. A certain amount of involvement with this OPD work is essential to help them develop their thinking, but there are other things I believe are important for me to focus on too (for example procedures within the operating department). Food for thought.

Anyhow, we have found 4 hernias to do and tomorrow, we are going to try them with mesh.

Paradigm Shifts

It is surprising how quickly you get used to a new environment, at some point the strangeness of a new place seems to become your new ‘normal’. This afternoon, whilst driving back to Muheza, I was struck by such a realisation. Whilst the scenery was no less breath taking at times, I had come to consider the very different buildings, endless speed bumps, roadside stalls, tropical fruit, lorries, overladen motorcycles (to name but a few things) all part of my new normal. I was even starting to recognise the route to and from Tanga. Fascinating.  

A weekend in Peponi (“Paradise”)

This is going to be a very brief post with a few photos that say it all. It is truly stunning here and has been everything that we could have needed to recharge our batteries. Amazing food. Stunning scenery. Beautiful buildings. Sun, sea and plenty of shade. A cooling breeze. A swimming pool. Friendly and attentive staff. And some much-needed intensive family time. Truly divine.

Our Accommodation for the weekend

Stunning Views

Lovely places to relax and enjoy!

Amazing food.

Colour changing Gecko and Stunning Night-time vistas

The Sweetness of Victory

There have been a number of moments on this trip when I have considered the line to be particularly fine between ‘being up for it’ and ‘madness’. And at 6pm today as I entered the second hour of my journey, I was questioning which side of this line I had found myself! I was driving on my own, now down what was beginning to seem like an endless rutted mud track through the African wilderness, in the rapidly failing light (we had been strongly advised against driving after dark) in a borrowed 4x4 (that has over 300k on the clock and just had a puncture repaired – the reason why I left late) to join Kate and the girls for a weekend away – they had left this morning as it was a school off day. However, as I pulled up to the gates of the Peponi beach resort (literal translation – paradise or heaven), I breathed a proverbial sigh of relief and confirmed that what I had in fact done was an incredible mini-adventure driving through absolutely stunning scenery (and, perhaps, got away with it!). From the messages I have had throughout the day from Kate and the girls, a much-needed weekend escape to paradise awaits.

I arrived for dinner - it was stunning

For me, today has been great. The morning meeting was livelier than normal as the challenges of the case from yesterday were recounted at length. It was fascinating to sit in on the animated discussions that switched from English to Swahili and back again. Comments about me were generous and it is always nice to feel appreciated. It was then on to an eclectic ward round of the female ward, children’s ward and male ward. My practice here in Tanzania, whilst very different from the relatively specialist practice I have in the UK, is very interesting (and challenging, in a mostly pleasing way). On our ‘travels’ round the hospital, we found a strangulated femoral hernia that needed surgery and this was to be the case for the day. As it turned out, a fantastic case for the team, with the best example of a Richter’s hernia I have ever seen (a fairly rare variant of a complicated hernia). This was especially pleasing as it really consolidated the material we had covered in our meeting yesterday. And the team delighted in doing another bowel resection (albeit a very limited one). They were also very open with the fact that had I not been here, this probably would have been operated on as ‘an enlarged lymph node’ and I suspect that the patient may well have become very poorly when that tiny knuckle of bowel that would have been very easy to miss, perforated and caused peritonitis. 

You can see the needle at the start of the green

But the highlight of the day for me was to be found in an autoclave (a ‘cooker’ to sterilise surgical instruments). And that statement is something I would never have been able to even dream of saying before this trip. In trying to find a solution to the mesh problem, I had been taken to the stores two days ago to see if there might be a ‘Little Sister’ (type of autoclave) hiding in one of the containers that had come from Hereford years back. Instead however, we found a brand-new ‘pressure cooker’ type one that had been sent from India for a research project at some point in the past. I had done my research with Professors ‘Google’ and ‘Youtube’ as well as having had some very helpful feedback in response to an earlier blog post (technical things about pressures and indicative temperatures). So after the hernia case, we set it up and gave it a go. The first challenge was that the plug was Indian (of a type I have never seen before). Remarkably, a suitable adaptor was found! Then there was a little trouble in actually getting the other end of the cable to fit in the machine, but we managed and turned it on. It seemed to work. I had prepared another sample mesh and we stuck a piece of indicator tape to the envelope (black stripes appear if sterilisation is adequate). I then sat very patiently as it started to boil. Waiting, watching and waiting for the pressure needle to begin to rise. And then after about five minutes it did. Great. Slowly it crept up the gauge over another five or so minutes until it hit the start of the green zone. Now I needed the needle to stay at the start of the green zone (equivalent to 121°C) and not drift any higher as the mesh would melt. The steam started venting and it seems that this particular model had been set to run at 121°C. The temperature was holding. The 20minute timer was started and I began to feel optimistic that this might actually work. And then there was a power cut (of course there would be) – gulp – the needle started to drift just a touch but held in the green zone… and then the power returned. Phew. And then a few minutes later, the power went again…. but again returned. We reached the end of the cycle and vented the machine (extreme care required, I did not need a third degree burn, but all went smoothly). And then we opened. I could see immediately that the indicator tape had done what it was supposed to. And within the envelope… the mesh… was perfect! It was just as I had hoped and had shrunk the 10-20% or so that I was told it would (reassuring me further that the sterilisation process was indeed acceptable). I can not quite express how happy this made me feel. 

Sometimes, to really appreciate something, the struggle makes the ‘victory’ that little bit sweeter. Mesh hernia repair is a go.

1. Lifting the lid, you can just see the lines on the indicator tape. 2. The successful mesh below the three previously overcooked ones.

Complicated complications.

Setting up for the surgical meeting

Today is Thursday, and unique to Thursdays is that there is no Hospital Morning Meeting. Instead, there are supposed to be departmental meetings – although the surgical ones seem to have slipped a little. This morning however, I had been ‘volunteered’ to lead a session on hernias – it did not require much persuasion given my interest in education and my primary aim of being here to help the department move forward. This took place in theatres and it seemed to be very well received. I was also delighted with the performance of the mini-projector that I had indulged in buying before leaving the UK (everyone likes a good gadget – it’s not much bigger than a phone!). As things came to a close, I was mentally relaxing into a catch up day (as there didn’t seem to be much on surgically)… but perhaps not….

At the end of the meeting, one of the O&G surgeons asked for my help with a patient who had returned to the hospital following a laparotomy 6 days ago for a difficult (massive) uterine ‘myoma’. There was green discharge from the midline wound – clearly enteral (bowel) contents. Whilst I was in no doubt that this was likely to be challenging, a relook laparotomy was required and so the arrangements were made. It took a bit of time to get the patient into theatre, but then we were on.

The etiquette here is for the surgeon to be scrubbed and preparing the instruments, before anaesthesia is commenced. The lead nurse anaesthetist was away, but her able deputy seemed happy to undertake the GA involving intubation and muscle relaxation. However, as I was gowning up I was aware that securing the airway (getting the breathing tube into the right place) was proving difficult. Now I am surgeon, but I have a massive respect for what my anaesthetic colleagues do both here and in the UK. Anaesthesia is one of those specialties that goes smoothly the vast majority of the time…. but when it goes wrong, it goes very wrong… and quickly. The patient had desaturated (was running out of oxygen) and as I looked on it was apparent that the difficult intubation had successfully intubated the stomach (this is bad). The saturations were now unrecordable. This is very very bad. I offered to help and somewhere inside me I remembered some of what I was taught in my early SHO years in A&E and on ICU. A number of key principles also came strongly to mind (I suspect as a result of the crossover meetings / dialogue in theatre that we have with our anaesthetic colleagues). I pulled out the tube and managed to ventilate the patient. Times goes painfully slowly as you wait for some positive signs that what you are doing is working (and patience may not be prudent either), but as the seconds felt like minutes, slowly the saturations came back 50s (very bad), 60s (still very bad), 70s (still very bad, but we’re making progress), 80s…. 90s (thank *&%£ for that) and finally up to 100. Whew. We were safe. I re-preoxygenated the patient (anaesthetic readers are probably horrified by this tale, but will be proud that I did this) and then tried to intubate the patient. Now, whilst I am rusty, I know what I am supposed to see – not least because I get an excellent view of the anatomy every-time I do an OGD (flexible camera test of the stomach) back in the UK. I was definitely not seeing what I was supposed to. It took three patient attempts (calm in the face of adversity is a good thing here), trying different positions and also the use of a boogey (a guide wire). In the end, it was definitely a ‘blind’ intubation (there is a technical term for this, grade something or other), but it was successful. To say this was stressful, underplays how I felt a little (like massively). This  definitely ranks close to the top of my all-time most difficult clinical moments. Now I just had to do the laparotomy.

Instruments from the UK

Somehow, I composed myself and got back into my 'A game' for the operating. The abdomen was a car crash – technical term for a mess – and as it turns out, also one of the most difficult operations I have ever had to do. The anatomy was hugely distorted with the residual cavity of this ‘myoma’ occupying the entire lower abdomen, displacing everything else above the umbilicus. It had been extensively stuck to multiple loops of bowel and so there was a significant ‘rind’ left in-situ. The residual cavity was full of clotted blood and there was a large hole in a densely adherent loop of small bowel. I also found a tiny perforation in the colon. A lot of careful dissection (only made possible using some of the instruments I brought from the UK), patience and perseverance actually resulted in a technically very satisfying end result. Now all the patient needs to do is wake up…. and heal….

….fingers and toes crossed.

On arriving home, and recounting the events of my day in explaining why I missed lunch and was home so late, a very pertinent question was asked by my amazing wife: “When exactly was the last time you intubated a patient?”…..

Illness

It was inevitable that at some point there would be illness (in the UK I am sure we would have had a plethora of winter colds from school by now). But having illness in the family here is slightly trickier given that the mind will always drift to the possibility of tropical disease. Ruth has been under-the-weather now for a couple of days and when the headaches and nausea began, we started to wonder if we were being foolish adopting our usual relaxed approach (like many children-of-doctors, our kids have to be really ill to get much attention). Ruth had also been a little bit cavalier in her approach to preventing insect bites and she had had more than the rest of us put together. So, although unlikely (given the timescale) a malaria test seemed like a good idea. This was to prove to be another step in my topical disease education as I was shown the bedside testing kit and how to use it – remarkable.

Delighted to report that it was clear.

This is to be a short post today as I’m trying to become an overnight expert in portable autoclaves (more to follow on this topic in due course).

Cultural Harmony

Today is a national holiday – Maulid Day – an Islamic festival and a very welcome ‘bonus’ rest-day for us all. One of the notable things about Tanzania is its cultural diversity and harmony. Practicing Christians (about 60% of the population), Muslims (about 35% of the population) and traditional tribal people, live closely together within the community respecting / sharing / enjoying each other’s holidays. It is a rich community and one that I think perhaps many places in the ‘Western’ world could learn a lot from.

After a morning run, I briefly popped into the hospital to see my post op patients. They are all doing very well I am delighted to say. Otherwise, it was a very enjoyable day catching up on some admin, sorting the house out a little bit more, and playing with the children. We also all very much enjoyed watching our house being insect proofed as the Veranda and back bedroom windows were re-netted and meshed. It is certainly starting to feel like home.

Another eventful day!

It was a difficult morning getting the girls out of the door, with school refusal from one and a general lack of engagement from another. I was surprised by quite how much it drained from me here! Such a normal part of parenthood, yet with everything else, almost enough to tip you over the edge! Then as I sat in the morning meeting, my day was completely turned around as I was humbled by the thanks given for ‘saving the life’ of the laparotomy patient. I had been so focussed on the clinical challenge that he had presented, I don’t think I had really thought through what would have happened to him if I had not been here. The stark reality is that in all probability he would have died, incorrectly treated for severe malaria or at best transferred to another hospital too late. Considerable food for thought.

It was then to theatre to ‘tee up’ the young boy for removal of the coin – a novel technique of a bladder catheter to try and hook it out was to be employed. I was umming and ahhing about repeating the X-ray, but I’m glad I did. It had indeed migrated below the diaphragm into the intestines. It also transpired that it had not been 3 days ago he had swallowed it, but yesterday. I just hope it passes all the way through now, otherwise he will need a laparotomy if it gets stuck.

On the ward round there were two patients that needed suprapubic catheters. We would do this in theatre before the Outpatients and an experience this was to be for me. None of the special kits we have in the UK. Simply some local anaesthetic, a knife, a clip and the catheter. A procedure I did not enjoy at all not least because in the first patient who’d had an open prostatectomy, my first pass of the pilot needle encountered air (meaning I’d found some bowel). But both went well in the end, with the patients much relieved. I accept that it was absolutely the right thing to do for these two men who had been in urinary retention for 3 days, just very uncomfortable for me!

And then it was to clinic, starting very late and with 24 patients to see. Unfortunately, an additional dynamic today was that I had to pop back to the house a number of times to check up on the progress of the water and window netting. The water situation has become very complicated (two sources, low pressures, bore hole renovation) but was getting the close attention of the hospital superintendent and two engineers. The window netting issue transpired last night as we were assaulted by a deluge of massive flying termites in the house (body 3cm long, 4 wings each 4cm long. Massive! And horrible! I spent quite a lot of time ‘splatting’ them). I thought I had checked all the windows thoroughly, but the chidlers had spotted some large gaps in the veranda behind the blinds when they were playing. Well done them!

I was caught by a clinical officer on my way back to clinic to look at the XR of a child – who was being carried on his father’s hip looking only slightly sorry for himself – pretty astonishing given that his left leg was snapped in two (he had a nasty displaced spiral fracture midshaft of his femur). The attitude, approach and stoicism of the African people is really astonishing. Something for us all to learn from perhaps?

It was another busy OPD clinic with lots of orthopaedics and congenital paediatrics. A 1week old with bilateral polydactyly (an extra stump of finger growing on the little finger) was sent to major theatre where the theatre manager (not a surgeon) just cuts them off! Another 4month old with syndactaly (two of the fingers fused together). And it seems I have already become a sports injury specialist with a 24yo keen footballer attending with pain in his knee post injury two years ago. I was quite proud of my efforts at a knee examination, but unless he can travel to somewhere like South Africa or the UK for an MRI and arthroscopy, there is little that can be done for his probable meniscal tear. One highlight of the day was conducting my own consultation in Swahili – the doctor I work with needed to leave for a few minutes. Whilst only a very, very basic level of communication was required today I will write more about this aspect of practice in the future. The end of a very long day at work concluded with review of my young laparotomy. He is doing brilliantly. It is quite remarkable that regardless of the fact we have limited vocabulary in common, how emphatically patients can universally impart upon you their desire to have an NG tube removed (a tube through the nose and into the stomach). And remove it we could.

I returned home to a delightful household with a buzz of activity as the visiting students (UK nursing and laboratory) entertained the children – or was it the other way round! We also have a small amount of water in the tank (probably not enough to last the week though) and there are a number of materials in the veranda to fix the windows tomorrow.

Weekend trip to Tanga.

Friday night treated us to our first tropical thunderstorm (this season is known as the ‘little rains’!). Wow, quite an experience! It felt like we were on a battlefield with the large raindrops hammering the roof like machine-gun fire, the lightning flashes momentarily illuminating the rooms like daylight and the thunder so loud that it literally shook us in our beds. And inevitably, as the light bulbs warily flickered before we turned in for the night, the power was completely out by morning. Hopefully it will be back when we return from Tanga.

We have been gifted the use of the hospice car at the weekends, which is both a massive privilege and absolutely fantastic. It gives us some independence to explore as a family in a very exciting way adding a hugely positive dimension to our time here. So after popping in to the hospital to see the young laparotomy who is doing well (and inevitably being asked to review a couple of others too), I eventually located the car (more could be said here) and climbed behind the wheel of this large Toyota 4x4. Great! I do love driving ‘new’ cars (this one has 350,000km on the clock) and a big smile crossed my face as I managed to start it without too much trouble – all cars have little idiosyncrasies. I delighted in driving it to the hospital gates, which were duly opened, and pulling up to our house (the first challenge as it is quite a steep ‘drive’ and the rains had made the mud very slippery). We all piled in and off we went. Driving in Tanzania is quite an experience – there are countless pedestrians walking on the roads, bicycles and motor bikes (that generally go quite slowly, but often laden with frankly ridiculous loads) not to mention the numerous lorries (that almost always only just get over the hill – often creeping the last few meters at under 5km/hr), other cars and busses (some slow, some fast with very questionable overtaking etiquette – would you overtake three lorries into the path of multiple on coming motorbikes, cars and even lorries?). 

The view from the Yacht Club and the Lutheran Hostel monkeys

But we made our way safely to Tanga and really enjoyed exploring by car. We found the supermarkets and bank then made our way to the Yacht Club (recommendation) to enjoy an idealic afternoon of beach and swimming and a superb lunch. As the day drew to a close we tried our luck at a Lutheran Hostel which was great. Not least because it has lots of ‘wild’ monkeys which absolutely delighted the girls. And whilst our food took a while to come out (and we had to risk being out in the open to the peril of the mbu – mosquitoes) we had a lovely time talking to the hostels manager and playing cards with her. The Tanzanian people really are so very friendly.

A lovely breakfast awaited us on Sunday morning – we feel like we have eaten like royalty this weekend – which was devoured by all. We popped to the market to do a bit of food shopping and then managed to get directions to the area where we might be able to buy a mosquito net to replace one that had ‘sprung a few leaks’. A truly authentic Tanzanian experience as we drove through the narrow streets bursting with shops (they are all little and really eclectic in what they sell) getting more and more specific directions as we closed in on our goal. And yes, we somehow managed to find exactly what we wanted. It was then off to check out a swimming pool at a posh hotel that had been recommended and enjoyed a very ‘normal’ few hours for us as a family messing about in the water. As we headed back to Muheza after lunch it was very apparent that we had achieved a much needed recharge of all our batteries. A most excellent outing.

When we got back and as I was about to settle down to a cup of tea, I was called in to do an appendicectomy. All went well and as I was leaving to get home just before dark, I was presented with a child who had swallowed a coin  a few days ago (it is stuck mid-oesophagus) – that requires sorting tomorrow, but what to do without any form of endoscopic equipment….  

And that’s just the end of week 1….

This is why I’m here.

Today was pretty full on. Exhausting to be honest. But ultimately immensely satisfying.

The morning was dominated by difficult cases (all of which I had been asked to review after the morning meeting). Firstly, a man with possible oesophageal cancer, unable to swallow and coughing up very offensive sputum – to be honest, this was fairly straight forward from a decision-making perspective – he was sadly clearly heading down a palliative pathway (going to die).

Then a man who had developed progressive hoarseness of voice over two months; I’ve never heard stridor like it (stridor is a hugely concerning clinical sign that implies the airway is soon to occlude, sounds a little bit like Darth Vader). But what to do? With limited tests and no fibreoptic laryngoscope, it was best guesses. He had slightly improved with antibiotics, but to my mind, clinically he either had a laryngeal lesion (throat cancer) or a laryngeal nerve palsy from something like anaplastic thyroid cancer (a type of thyroid cancer that can destroy the nerves that supply - and keep open - the voice box). Either-which-way, with no ENT services available to him (travel to the capitol was not an option - money) it was a case of some adrenaline nebs, steroids and see what happens. Whilst technically, I could do a tracheostomy, it did not seem like the ‘right’ thing to do. Not least as I am lacking the required ancillaries and there is no specialist aftercare. My gut feeling is he is probably not going to do well.

Next a lady I’d seen the day before with a probable appendix mass – I’m treating her with antibiotics. But without a CT scan, I can’t do much more than hope that it is not in fact a caecal cancer. If she doesn’t improve by next week then perhaps a laparotomy…. Finger crossed because I predict that that would be a mess (“mess” is a ‘technical’ term for a very challenging operation!).

Then a Masai tribal boy (so neither he nor the family spoke Swahili) referred to this hospital to see me (within a week I have become a specialist orthopaedic opinion apparently) whose history said progressive swelling, pain and reduced function of the left leg over two months (but without trauma). He had an incredibly tender, deformed and obviously fractured femur to me (the XR later confirmed this). But might it be pathological? Probably. He has been referred.

And then a 14yo boy admitted the day before with abdominal pain but testing positive for malaria. When I examined him, he was overtly peritonitic to my mind. But tricky. Very tricky. And I found myself in a very difficult place clinically. It felt very, very uncomfortable. Is this malaria, or is that just a ‘red herring’? And with no other tests available (no WBC, no CRP, no CT, no specialist USS) it was all down to my clinical judgement. I needed to decide whether to watch and wait or perform a laparotomy (laparoscopy – key hole surgery – is not available here). A big call and no one here to share it with or ask for advice. I decided to give myself some thinking space and headed home for lunch (our house is literally at the hospital gates). Dr Google was very informative and Dr Karylin and Richard responded to my Whatsapp message with a phone call. Cant quite put into words how amazing that conversation felt, not just clinically but emotionally as well – at times it can feel quite isolated here estranged from our usual clinical support network. It also filled lots of gaps in my knowledge about malaria – apparently 25% of the population test positive for the parasites but most are asymptomaitc. So, when I went back to review, and he was clearly not better, he went to theatre. I will describe the theatre experience in more detail another time, but on table he seemed to have a central mass, so I elected for a limited lower midline laparotomy. I can honestly say that I internally breathed a huge sigh of relief when I discovered the cause of his troubles and that a laparotomy was absolutely the right decision. Always a big call in a child, but the right one. He had a small bowel intussusception (when the small bowel telescopes in itself – quite rare) and when I tried to reduce it, the interssuscipiens had clearly infarcted (that bit of bowel was dead). It may be surprising to read that at this point I felt very relaxed, I could almost have been back in the UK, and eased into performing the small bowel resection that was an absolute delight to the theatre staff. They have not tackled pathology like this for several years. The case went well and as I left for home, rather exhausted to be honest, it felt like an important moment in my time here. 

I will definitely enjoy a beer tonight!

All the best plans….

….need perseverance!

When I came to Muheza in July, one of the things they were keen for me to establish on my return is mesh inguinal hernia repair. Currently a suture repair is performed here, a technique we rarely use now in the UK. Unfortunately, whilst the benefits are very well described, the cost of the mesh is prohibitive in low resource environments. Quite remarkably, a clever technique emerged in India a few years ago using sterilised mosquito net as a surrogate implant. I heard about this at a conference a while back when the results of Project Hernia (a UK charity that sends regular surgical missions to Africa) was presented. Over the last few months I had made contact with Project Hernia who were incredibly helpful, sending me supporting literature, protocols for sterilisation as well as a consignment of net (mesh)!

Keen to get things going, I had prepared some samples to autoclave one evening. I took them to theatres in their suggested postal envelopes, explained the precise protocol and went for lunch whilst they ‘cooked’….. on my return they were waiting and I opened them up eagerly….

The top is the original size, the three samples (bottom) have horribly shrivelled.

…disaster. They had melted, coming out like little shrunken crisp packets that had been cooked in the oven as part of a Blue Peter Badge project.

The mesh has a melting point of 122°C and so it is crucial that the machine is set to 121°C to ensure sterilisation whilst maintain the integrity (it is supposed to shrink a little). It turns out that the autoclave machine here only runs at 135°C and they only have one machine (the other is broken) – this is a major issue. Gutting. Almost heart-breaking to be honest. All that preparation….We have agreed to ask the hospital engineer whether we can adjust the machine easily, but I suspect not and that another solution will be required…..hmmm....

Back home, Kate went in with Beth to school today for the morning which was a genius move by my amazing wife. She helped Beth to interact with the other children and from the big smile on little Beth’s face today, it is a massive step in the right direction.

Settling in....

Although there were plenty more challenges, today feels as though we might be settling in. It was a relatively light day at work for me with just some brief rounds and one operation to do – an orchidectomy in a young man with an atrophic and maldescended testis.

Yesterday, there were some questions about how to sterilise the diathermy implements (electrocautery – the modern equivalent of a hot poker to stop bleeding) and these had been left very much unanswered. When I walked through the door into theatres this morning the chief of CSSD (clinical sterilisation services department) was there to greet me with the sort of smile that lights up anyone’s day. This might be somewhat surprising, given that it transpired he had been recalled from his holidays! Whilst I was so delighted to see him again, I was also somewhat horrified to be the unequivocal ‘cause’ of such things. He seemed to be very ok with it however.  

He is a fantastic example of the many exceptional individuals here in Muheza. One of those people who really gets ‘it’ and can’t do enough to help anyone, inspiring all those around him. Having come to the UK on one of the Hereford Link programmes a few years ago, he is working so hard to emulate in principle here what is done back home. The work of CSSD is definitely something that I would ordinarily take for granted. But here, particularly being so involved with it all, it becomes so starkly apparent just how crucial their work is to the care provided. The care that as a surgeon you feel ultimately responsible for and the work that you will be certainly judged by. Having this kind of support definitely makes things significantly less worrisome. The diathermy protocol was clarified and he briefed his deputy on the complex process involved using chorine, soap and surgical spirit (the plastic of the handpieces melts in the normal autoclave – at home they are disposable).

On the home front, whilst the older two are thriving at school, unfortunately it is proving just too much for Beth. Today Kate picked her up at morning break and we have agreed to try a few half days. She is very willing to go and likes the idea in principle, but when there just finds it overwhelming; bless her. Fortunately, we brought some materials which we can use for ‘home tuition’ which she loves (at an age when it is all fun), so some reading, writing, drawing and maths this afternoon. She then played after school with some of the immediate neighbours’ children. Fingers crossed we can get her settled.

And I thought I would share the sunset we get to watch most days from our window. The sun goes down very quickly here and the views are stunning.