All good things must come to an end.

It is with a heavy heart that I am writing my final post on this blog. But everything requires closure and the time is right to wrap this up.

Writing this has been a real pleasure. Whilst it has been quite a mission at times, I have genuinely enjoyed the process and have found it often therapeutic. Perhaps it is the opportunity to order my thoughts, perhaps it is the opportunity to offload. Regardless, there is also something very powerful about sharing experiences with others. Whilst my natural preference would be to talk about things over a cup of tea or a beer, I have surprised myself about how engaged with this ‘blogging thing’ I became.

There have also been several moments when it has been quite difficult to write about the things that I did write about. I have on more than one occasion felt quite vulnerable by what I was sharing. I have opened my heart and mind, which I hope has been interesting, insightful and valuable to those reading it. In doing so, my hope is that for some, reading this will inspire you to get involved in some way with Global Health. Whether it is to support projects financially, to influence policies and politics or even to go out to such places and give time / skills / education / support / care. It is so very much needed and, in my experience, welcomed. The gaps in Global Health are substantial and it is, I believe, everyone’s responsibility to help close them.

There is so much more that I could write about – things such as how LMICs are viewed and portrayed, how to best direct support for them, ways to cope doing work such as this, how to teach, how to learn, how to enjoy the time, what I have gotten out of it (loads!). But as I began to pen some of my final thoughts and conclusions to ‘paper’ I realised that I was in danger of slipping into longwinded rambling and also the potential imposition of my opinion on others. I wish to do neither. But perhaps the above ‘questions’ might be useful food for thought for all of us.

So finally, I want to say a few thank you’s. Firstly, to all of you who have taken the time to read this blog. Thanks also to those who have left comments or fed back through other media. It has meant a lot and lifted me through some of the more difficult periods.

I want to thank the Hereford Link for allowing us to piggyback on their incredible working relationship with Muheza Hospital – especially K&R without whose enthusiasm, encouragement and willingness to share, none of this would have happened. I also want to thank Hernia International, who were so very generous in sharing their incredible experience with me and enabling the development of the mesh hernia service that we did. I suspect that this project will remain one of the most personally rewarding things I will ever achieve.

I must mention the chidlers schools, who have supported them in coming and have managed to hold their places open for our return (which by all accounts has not been easy). Their UK school work kept them sane.

Clearly the staff of St Augustine’s Hospital Muheza need a huge thank you for inviting us to work with them and for being such incredible colleagues and now friends. They are such an inspiring and lovely group of people working in a very challenging environment. There is so much to admire, and I am just delighted that they were so receptive to working with us.

Thank you to all our colleagues who have supported us in a professional sense. There have been some invaluable conversations, emails and WhatsApp messaging that has supported us through some of the most challenging times.

There are many friends and members of our extended families that have offered us a tremendous amount of support. You all made this possible, so I hope that some of the pride and satisfaction that we feel in having done it can be shared by you too.

My wife is absolutely amazing and there is no doubt that I would not be where I am without her. I don’t think I can ever adequately put this into words, so for now will leave it at that. I must finally thank my children who had no choice in coming with us (and at times made this observation themselves in a very compelling fashion), who weathered the experience so very well, and I hope in time will ultimately look back on our Tanzania adventure fondly. It has been far from easy for them, but I am in no doubt though, that we have all gained from the experience considerably.

My mind is very much still processing my experience, and will I suspect for a long time to come. I am so pleased that we actually made it happen and went. It has been incredible. So very challenging, but incredible. I also believe I have become a far better surgeon for my time in Tanzania – who knew for example that I could work effectively for 5 months without ever seeing the renal function of one of my patients?!

For now we are home though and have, I think, successfully ‘plugged ourselves back into the Matrix’. There are many things to love about the UK, but many things that are worth carrying with us from Tanzania. I hope we can enjoy the best of both.

One of the real highlights of this time for me has been the extensive collaboration that I have enjoyed. It has been such a privilege to work with so many different people (many completely unexpectedly), across so many different contexts and localities. It has been truly fabulous and I look forward to all the future opportunities to continue this work and make a real difference to the lives of those who, purely by circumstance, find themselves in a less privileged position than many of us enjoy.   

Many thanks for reading.

Asante sana kwa kusoma. Nitarudi tena. 

It’s good to be back.

I am delighted to report that Fortune favoured me, and I got a seat on last night’s flight. The relief of pitching up at check in to be told that there was a seat for me was incredible. I was so ready to be going home. The 17 ½ hour, 14,500km non-stop flight got me into London Heathrow at just after 5am.

Whilst it would be fairly easy to dismiss my return journey as ‘just another flight’, I am once again slightly overawed by this remarkable feat of technological development – over a third of the Earth’s circumference non-stop. With the current climate change campaign raging (which I strongly support in principle), it was also great to read that this aircraft uses 25% less fuel per passenger and thus may be more environmentally friendly (although this claim gets a little more complicated as you have to factor in the additional fuel that is carried in order to make that long journey) – landing back in London I do feel very self-conscious of our recent airmiles. My family arrived two hours later, and it was both surreal and delightful to greet them at arrivals.

So we are home again in the UK as a family. We have had quite an adventure.

Stranded

I have come to the end of my two-week holiday in Australia. It has been a strange period of time for me. I have gone from the challenges of rural Africa to a week back in the UK that absolutely epitomises the intensity of Western Life, and then before that was even concluded; headed out on another marathon journey to end up here in Australia. My mind is somewhat confused not really knowing whether it is coming or going. That is probably in part exacerbated by the jet lag – an exhausting reality that I have never properly experienced or appreciated until now.

Signpost at the end of Busselton Jetty

It has been a lovely, albeit full-on (childers do that), two weeks though spent with friends. Australia is a beautiful country and the climate has been delicious – their autumn is very much a British ‘Indian Summer’. Having not seen even one of the ‘90% of the worlds most dangerous creatures’ that live here, it feels a lot safer too than one might playfully contrive. Although you do need to be sensible. I now completely understand why many Brits are emigrating here. With the current cultural climate in the UK so pressurised, it really does feel very different. It is difficult to be specific, but it is very apparent. 

We had many great adventures visiting caves, coastlines, beaches, jetties, aquariums, vineyards and breweries to name but a few things. I was also able to up my running and have really enjoyed exploring ‘on foot’. They have so many dedicated running and cycling paths here – it’s great!

My mind has never been very far from Tanzania though as I try to work out what my role in its future might be. Regularly in touch with my colleagues there, I have received a number of very encouraging messages and pictures giving me updates on the patients I left behind recovering (now outpatients, they are all doing really well). The team continues its efforts to consolidate the services we developed, and I am delighted to report that they have now done a further six mesh hernia repairs. They are also committed to the mesh registry we started, so hopefully we can continue to accrue meaningful and encouraging data.

But my mind is stranded in a place of confusion, not knowing exactly how to continue my global health interest for the future. My dreams are vast and ambitious. Although equally, from a clinical perspective, what I envisage could be done to rapidly raise the standard of healthcare, is actually quite straightforward. So my mind is awash with ideas of fundraising, setting up charities, developing networks of interested parties, raising the profile of Global Surgery and trying to campaign for a raised interest / agendas at national levels….. Not much then. Whilst I have made some tentative steps towards some of these things, I need to be clearer what I can and want to do.

I am about to start on a very important stage in my professional life as a newly appointed consultant. Those responsibilities are substantial and I am completely committed to being the best that I can be in that regard. Indeed, part of my appointment was the opportunity to drive forward the development of an exciting new service at my NHS hospital. A project that will require a great deal of effort and time I am sure.  But I equally feel absolutely committed to the road I have started to tread, down the less developed paths, the muddy and dusty tracks, where I feel so much can be done to dramatically improve global health.

Clearly it will be about finding the right balance for me and collaborating as widely as possible to maximise those efforts. I really do believe that a little bit of effort, even from a few people, in the right direction and in a joined up fashion could have a huge impact. 

Perhaps it’s a good job then that I’ve got some unexpected extra thinking time; I am stranded at Perth Airport. Separated from my family once again, I have just waved off my wife and three daughters to board ‘our’ plane home. Unfortunately, in the shenanigans to reschedule flights to return to the UK for the interview, my homeward bound flights from Australia were somehow also cancelled. Clearly this was completely unknown to us until we got that look from the check in clerk. An absolutely delightful lady, her face however told the story. That look that tells you there’s a problem. That look that changes from ‘there’s a problem’ to there’s a major problem’. Was this really happening?! Could we not have one simple leg of our journey?! You couldn’t make it up. 

But remarkably, I remained calm. I was surprisingly unfazed about the situation. At least the girls could get home. Sorting out a flight for one is much simpler than for five. It turned out that I could get on the flight to Singapore, that would cost just $600Aus, but the problem was the connection to Heathrow. The onward Qantas flight is overbooked by 18 (some unhappy joining customers in Singapore I suspect) and the only other available BA flight would be $8,000Aus – clearly not an option then. So we looked to other options. It turns out that there are seats on the non-stop Dreamliner flight from Perth to London tomorrow. Whilst far from cheap, it was possible. I booked my seat. A credit card makes the pain of that transaction negligible. I completely ignored the money I’d just spent. We can sort that out next month!

Furthermore, I was also told that there was an outside chance I might be able to get a standby seat on tonight’s flight – apparently, although it’s fully booked there is a reasonable chance that someone won’t turn up. So, I am waiting for seven hours at Perth Airport to find out. It’s all very pleasant though (its cool, there’s no dust, there’s food and drink and a nice place to sit, read and think). Ironically, if I were to get a seat on tonight’s flight, I would arrive at Heathrow an hour before my wife and children.

Fingers crossed.

The next chapter

So I embarked on my mammoth journey to Perth in Australia to re-join my family. It would end up being well over 36 hours of travelling, I would be going from Heathrow to Singapore to Sydney to Perth (the logistics were complicated – flights at short notice and airmiles). I left our African crafts in the UK, left my car back at my parents-in-law and got a taxi to the airport, my bag much lighter this time. In some ways I was quite looking forward to my travels – I was released of all burdens. No work, no interview to prepare for and not even a family to manage for this long-haul marathon. For all my optimism, it was inevitably a bit tedious though.

Heathrow airport was quite an experience. I had been looking forward to my solo exploration of the airport, finding a nice place to eat lunch and peruse some shops (childer agendas usually offer a different dynamic to such time waiting to board planes). However, certainly conditioned by my time away, I was initially bemused then completely overwhelmed by the vast masses of rushing people, the oppressive advertising, the compulsory walk along the snaking path through almost a kilometre of various duty-free stalls. I have travelled fairly frequently over the years, but having been away, this almost violent and unavoidable immersion into the depths of Western Capitalism was an assault on the senses that had completely the opposite effect from what it is trying to achieve. Rather than being drawn into buying stuff (which I definitely didn’t need), I withdrew. I walked serenely, looking, but letting all this just wash over me. Completely put off by my environment, I found an inexpensive sandwich, an empty seat and sat down with my book to await my flight. My conclusion – it’s completely bonkers what we have created. And I’m sad to say that I really don’t like it. But there we go.

I was suitably awed by my plane however. I have never been on a double decker, nor seen one up close. It is quite an exceptional feat of human engineering. It even gets two jetways for passengers to board. Amazing that such a beast can fly too! Whilst being in ‘economy’ meant I was on the bottom tier, I must say that I felt very well looked after by Quantas. Although I did wonder if the portrayal of first class in the film ‘Crazy Rich Asians’, watched on my flight home last week, would be going on above my head. I quite fancied a double bed! I did manage to snatch a glimpse of the sheer internal volume of this craft, responding to a call for a doctor about 30min after I had gotten to sleep. I was in the middle of the plane, and it was quite a long walk to the back where I was guided up a staircase to where the unfortunate individual was located. A far cry from needing to perform an emergency tracheostomy or chest drain with a biro, it was much less exciting and when an enthusiastic Emergency Doctor joined us soon after my arrival, I was very happy to step back and return to my seat. No upgrade. I settled down to a fitful sleep. My mind trying to quiet, but in the slightly uncomfortable setting, it drifted back to the major question hanging over me.

I have come to realise over the weekend, just quite how much getting this job meant to me. Impossible to keep my mind away from such an important and interesting topic, I indulged my imagination, playing out so many different takes on the situation. Of course one of those options would be not getting the job, and whilst I quickly caught myself, pulling back from pointless speculation, that option left me feeling very empty. Using a surfing analogy, I felt like I had just paddled into the biggest wave of my life. The tremendous power of the ocean palpable. I had taken the drop (a bit wobbly, but fairly well) and was flying down the face, loving the experience, with the wave now forming a tube above my head. But then the pause button. The ‘Sliding Doors’ (film) moment. Would I be successful and come out of the tube victorious, whooping and smiling broadly. Or would it be one of the biggest and most painful wipe-outs of my life.

I slept, fitfully. No news as we transited through Singapore (although I wasn’t expecting it so soon). Those of us continuing to Sydney had to get off for a couple of hours then would re-board. The next leg was much the same. Plenty of time to think and I was running out of movies to watch. Whilst the staff were brilliant and food was pleasant enough, I am not a captive animal. Being confined to a seat on a plane for a long period of time is not my ideal. I slept and woke up for ‘breakfast’ as we approached Sydney. Another very smooth landing (which I was again totally impressed by when I remembered the sheer size of the machine I was on). It was 05:00 local time on Tuesday morning and I was in Australia (8pm Monday night in the UK).

I had a moment of nervous anticipation. This was it. If I turned my phone on and allowed it to roam, I would probably get the news. I was sitting in my seat as my fellow travellers were all busying themselves with their hand luggage. I did it and closed my eyes.

I breathed, looked, it was searching for a connection. I closed my eyes again, breathed. All the time I was surrounded by a lot of hustle and bustle. I sat quietly (to be honest I have never seen the point of rushing at such times). This time though, rather than watch in bemusement the inpatient activities of my fellow travellers, my reality compressed into a very small space. The noise disappeared. I was in the zone (to use a sporting analogy). The anticipation left my mouth dry (or was that the air conditioning). I opened them, saw the flashing green notification LED. This was probably it. The screen had timed out and I woke my phone up. There were quite a few WhatsApp messages (which is unusual for me). I breathed again and allowed my phone to show me them, I was back in the ocean. I was frozen surfing that massive wave. The play button was pressed and the wave was suddenly crashing all around me, I was searching for the right message to open. And then I flew out of the tube. All my suppressed emotions silently burst forth as I realised I’d got it! I had been offered the appointment! It was almost too much to process in my sleep deprived state. However, all the other messages were absolutely delightful and helped to cement my reality. Lots of ‘well done’s from all my future colleagues. I was soooooooooooo chuffed!

The sweetness of victory, if I can call it that, was just amazing. I was buzzing.

I was one of the last ones to get off the plane. It was 5am in Sydney Airport but given the time difference I had enjoyed a flurry of message chats with the UK – technology definitely has its advantages. However, my wife and children were still fast asleep in Perth (it was 3am there). I sent them a message to wake up to, but knew that I would be boarding another plane soon and would be once again airborne when they got it. I was a very surreal experience. But fabulous nevertheless.

I had left the plane and was walking along a link corridor when I passed some seats. I had to stop and sit down. I breathed, a broad smile across my face. I closed my eyes and savoured the moment. I was the cat that had got the cream. The last few passengers had overtaken me, and I found myself opening eyes to an empty corridor. If anyone was watching the CCTV footage, they would have been bemused I am sure but probably smiled. As I left those seats and walked alone down that now empty corridor the emotions burst through. I did a few arm-air-pumps and whoop, whoops. What an absolutely fantastic result.

I retrieved my bag, passed customs (despite the ingrained red dust), and walked the couple of kilometres to the domestic terminal. I embraced my now completely confused body clock and treated myself to a rather delicious breakfast bap and a cold beer. Whilst it was 6am in Sydney, I reasoned it was still 9pm in the UK and I had passed the offer of ‘complimentary’ alcohol on board. I thoroughly deserved it and it was fabulous.

I have two weeks in Australia now with friends and my family to unwind and process everything. This feels like quite a big moment of change in my life. I wonder what the next chapter will hold? Exciting stuff.

Cliffhanger

What a week. It has been both lovely and exhausting. Lovely to see my friends that I’m staying with along with a handful of others that I was able to sneak a few minutes with. Exhausting to be preparing for one of the biggest days of my professional life.

Whilst I have tried to remain relaxed about the whole experience – you can only do your best and prepare as well as you can – I think that my return to the hospital thoroughfare might have been viewed as a little shell-shocked by those I met up with. Only a few days out of rural Africa and I was walking into the hospital’s coffee shop where one drink costs the same as lunch for five in the hospital canteen in Muheza (and the food was great I hasten to add). But it was so much more than that. For not only was I visiting old colleagues (many of them I would consider friends), I was visiting them in an entirely different capacity.

I was there to sell myself as a credible future consultant within the department. I was there to glean any possible material that might be useful for the big day on Friday – recent developments, news and agendas. I was there to visit the senior hospital management and present myself as a ‘must have’ appointment. I have always felt very at home in this hospital, but for these few days, it was exhausting. I felt like a peacock trying to strut my stuff (probably trying to brush the insatiable red African dust off my feathers), except that I was rusty, wearing a borrowed suit (thankfully it fitted fairly well) and knew that the other four shortlisted candidates would also be visiting, immaculately presented and completely ‘on it’. And I could take absolutely nothing for granted. Being known in a hospital can be an advantage in these situations (assuming you are liked), but it can also present significant difficulty in that there are expectations that you really should know everything about it.

So it was a full on week. Lots of conversations, lots of reading, lots of preparation for possible questions or themes of questions and there was also a 10-minute presentation to prepare. Whilst advice on the importance of this was mixed, given it was the only thing you could actually guarantee (almost) would come up, getting it right was of course crucial. After much deliberation, I had a moment of genius (or so I thought – it felt right anyway) and decided to go completely left field with it. As the idea emerged, it felt very me. The compulsory slides would carry only pictures – no words, no facts, no numbers. Any detail that I wanted to convey, I would have to vocalise by mouth. There would be no reading off the slides. The first ‘content’ slide would feature Usain Bolt.

Risky? Probably. But hopefully it would go well and be different.

Every waking moment this week has been spent preparing or recovering (running and eating meals with my friends certainly got me through it). I prepared and practiced, practiced, practiced. Conscious not to let the topic of my interview dominate my friends’ week too (which of course it did), there was lots of talking to myself; in front of mirrors or the panel of Teddies (who were thankfully not too intimidating, and gentle in their style of questioning).

There is always so much more that can be done in these situations, but by Thursday night I felt that I had achieved a huge amount, my mind was back in the game it needed to be in, and I was as ready as I could be without having done it already.

Friday was interview day and a bizarre experience. I woke up in the morning feeling great and remarkably relaxed, but also very clear as to what was required of me today. I was facing a massive day in my professional life – arguably one of the biggest I would ever face. In this regard, I am very grateful for my sporting background which has taught me that to give it everything I would need to manage my ‘inner chimp’ well (reference to the Chimp Paradox if further explanation required) and stay relaxed. This helped so very much.

The day was to be in two halves, a morning panel followed by an afternoon panel. The expectation being that some candidates would be culled after the morning. I walked into the room on Friday morning feeling a strange combination of emotions; relaxed, excited, an undercurrent of inevitable anxiety, a self-imposed confidence, perhaps to compensate for a natural sense of doubt, happy (to be in this situation) and relieved (that it would soon be over and was all to play for). And then it started, a warm welcome and then…. a googly.

No gentle start for me. The first question threw me. Ahhh. Inner Chimp and entire body systems straight up to Defcon 1! I hope no-one noticed. I employed every tactical option I knew. Breathe…. Smile…. Look relaxed…. Think…. Look thoughtful….Think some more…. Quickly, but clearly. Try not to look like a rabbit in headlights or a naughty child caught red handed in the biscuit tin. An abbreviation had been used in the question that I knew I should know…… I did know…. But nope, it was not going to come to me for that moment. Could I ask for clarification? I probably should have but it was one of those momentary decisions driven by the desire to maintain ‘face’. I knew the ballpark and started to answer. How well I answered is anyone’s guess. To me it felt a bit rubbish. But the interview had started and knew that I would just have to keep chipping away and up my game.

45minutes later and it was all over. I went for a quiet cup of tea and waited for the phone call to tell me whether I had got through to the afternoon. It’s hard not to focus on that first question. The next one wasn’t that much better, but after that the rest of it had gone fairly well. Not a perfect performance by any means, but I had presented me. I would just have to wait.

Unusually, I met up with one of the other candidates whom had been in before me – a friend of mine who is excellent and who I thought would be a great appointment too (I would love to work with him). Rather than see him as competition, for some reason I just hoped that if I didn’t get it, he would. We both laughed at the ludicrous nature of sitting together chatting whilst trying to get the same job. He then went off for lunch with some other friends, I was left to my thoughts and sat quietly looking through my presentation.

The call came and a wave of relief and joy accompanied the news that I had gotten through to the afternoon. I had just over two hours to wait until my next appointment. Two hours to do something with. The gaps and waiting on days like this are the worst thing I think. I had lunch and tried to look some things up online that had popped into my head. The phone reception was rubbish and a broad,  ironic smile crossed my face. The mobile internet service where I was sitting in this modern hospital (I was near a window) was considerably worse than that I enjoyed sitting in the canteen or theatre coffee room in Tanzania! Very bizarre.

The time came to head up to the afternoon’s venue. I was in plenty of time and sat outside the room and waited. It felt like an age and I was twiddling my thumbs, craving distraction. I walked around a bit, shut my eyes and relaxed for a while, and then I looked at my phone – clearly I’m a victim of the digital era. Or perhaps in this case I was a beneficiary. I noticed that there were some WhatsApp messages from my colleagues in Tanzania. I was immediately immersed back into that very different world, almost bodily. It was lovely respite from the moment that I was in. Whilst I was sitting in my suit, tie, shiny (ish) shoes (the red dust was determined but hidden I think) waiting to be grilled, my mind raced away for some light relief in Tanzania – how very ironic given how challenging my time was over there!

The dressings had been taken down from the skin grafting patient and they had sent me photos of the wounds. I studied the pictures closely. They made me smile. Broadly. A genuine happy smile. A tonic for the situation I was in. Certainly early days, but it looked like a substantial proportion of the grafts had taken despite my concerns about low grade infection at the grafting site. One area on one photo looked doubtful, but the rest were great. I tapped my thoughts and response back into my phone. It was very therapeutic and a great reminder of where I had come from. Perhaps this man would keep his leg after all. What a great result. I on the other hand, just had to endure another interview.

The afternoon interview went in a whirlwind. There, I was essentially pitching myself to some of the most senior people in the Trust and two of whom would be working colleagues. I was bidding to be appointed to a job that would hopefully last for the next twenty plus years of my career. The presentation went as well as it could have done and seemed to be well received. Although, were they smiles of encouragement or bemusement – perhaps a mixture of both? The numerous questions were all fair and I think I gave answers that reflected me, even if they weren’t always that polished. They were certainly honest. I walked out feeling like I had given it my best and confident that I had been true to myself.

Then what to do? I was in limbo. Do I wait, or should I go home? I phoned a friend and met for coffee. I was told that the etiquette was that I should wait, as usually a decision would be made on the day, and either way a face to face delivery of that would be preferable.

I sat drinking my hot chocolate (I’ve never been able to get on with coffee) waiting for a call. After a while it became apparent that things were not straight forward. No decision had yet been made. I was told to go home and await a call. I left a little bemused, completely unsure what that meant. Had I flunked it? Had I done well but someone else had aced it? Or was it something else entirely? So many possibilities.

I was in the carpark paying for my ticket when I took a call explaining the situation further. For a variety of reasons, a final decision would not be made until next week. Gulp! I would have to wait over the weekend. I was thrown a lifeline and informed that I was still in the running for appointment. I took a moment, gathered my thoughts and at that moment I was strangely ok with it all. ‘It is what it is’, I told myself. However, things were slightly more complicated as it transpired that I would be in the air on my way to Australia at the time they would want to call me. Hmmm.

I knew immediately that I would not want to be awaiting news of a decision that had already been made. Whilst far removed from normal procedures I am sure, I asked if possible (and deemed acceptable) that an email or WhatsApp message be sent with the result, regardless of the outcome. All things being equal, this would be sent whilst I was airborne and I would get the result when I landed in Sydney.

It was going to be a long weekend. In many ways.

It’s like I’ve never left

Beauty comes in many guises;

The stunning night-time approach to

my brief transfer through Doha

Arriving back in the UK was a strange experience. The first thing that I noticed was that it was really very cold! Despite the very mild spring weather (I am told), arriving at Gatwick felt to me like stepping out into a fridge! But there was a certain appeal to that given how hot I had been for most of the last 5 months. Thankfully, I had a jumper to hand and enjoyed enormously the pleasure of burrowing my chin into its fleecy warmth.

The second thing I noticed were the cars. Blimey! So many. So new. And all driving so fast. Having been picked up from the airport by a taxi (a very nice Mercedes), being driven back to my car at my parents-in-law’s house was like being thrown into a whirlpool. You join the insatiable rushing of traffic and in doing so, you find yourself thrust into the collective ‘stress’ of this perpetual beast. Having been away, it's notably palpable. 

But for all of those observations, it almost felt like I had not been away. My mind switched straight back into UK mode and my Africa experience seemed to be becoming a rapidly distant experience. After five months away, in many ways nothing seemed to have changed as I stepped straight back into my old life. Yet I know, deep down on some level, everything has. Explaining this will take me a long time to unpick I suspect.

A brief cup of tea and snack at my parents-in-law's (they were away but had kindly made my life very easy) and I climbed into my seven-year-old turbo diesel estate. It felt like I was driving a Ferrari on a race track (not that I drive fast, I hasten to mention). But the roads are so smooth and the driving experience was so far removed from that which I had gotten used to in Tanzania. I headed off down the motorway to stay with my friends who are very kindly putting me up this week.

I have applied for a job, my dream job to be honest and have been shortlisted. I now need to get my head back into NHS mode. It’s not the clinical side of things that I think will be a struggle – I have worked hard to keep my mind in that place throughout my time in Tanzania – but all the ‘other stuff’. Rotas, politics, research, white papers, NHS policy, what the right thing to say is when saying ‘I would do the right thing’ just isn’t enough. Why do you want this job? Why here? What qualities do you possess……. My mind is suddenly overwhelmed by what is waiting for me. 

A consultant interview is a massive deal and right now I feel like I have volunteered to be thrown to the lions and torn apart as a fraud who has been off on a jolly for 5 months, but has the audacity to apply for one of the best jobs in the region (clearly if you have been following my blogs this last statement couldn't be further from the truth, but it's funny the games the mind can play). I have never been very good at self-promotion, it is not something I’ve ever really enjoyed. But I do dearly want this job. 

I know the department and they know me. I know that I would be great for the role and I know that the role would be good for me. I know I am a little unusual (perhaps not a stereotypical surgeon - if ever there is such a thing) and whilst I do sometimes feel like a round peg trying to fit into a square hole, this job feels very right for me. I would be part of a fantastic team that would allow me to be me (maybe rounding the edges of that square hole a little) and enable me to practice the way I want to in the NHS. I think any clinician strives to be in an environment that allows them to provide the best possible care for their patients, and for me this role would give me that. I know I would be happy. Isn’t that what any clinician wants? 

Ha! Perhaps that last paragraph is an evolving answer to an interview question I wonder….

So, I have 4 days now to get myself back up to my A-Game. I have 4 days to woo the senior management in the trust, explain what I have been up to and give them a taste of who I am ahead of the interview on Friday. It is a massive ask to be ready on Friday. But ready I will be in one way or another. If I learned anything from my years of elite sport (that’s another story), focus on your strengths and look for solutions to your weaknesses. And remember, in many ways I have been preparing for this moment my whole life.

First I need a haircut though.

Highway to……..

A final beer in Peponi yesterday evening

It was with a heavy heart that I climbed into my taxi this morning. In the breaking pre-dawn light and to the sounds of gentle waves lapping the beach, I walked from our banda (hut) in Peponi down the fine sandy paths to the car. Met by the warm greeting of our ‘taxi-driver’ friend, we loaded up my bags, and set off.

I left my sleeping children and sleepy wife to head back to the UK. They will be heading off to Australia in four days’ time (brought forward) for our original planned holiday ‘on the way back’ to the UK. Perhaps slightly inconveniently, I now have to ‘pop back’ to the UK first, to address my future career prospects. I will be flying out to re-join them in Australia in a week’s time. Life is never dull.

It is a long drive to the airport, the first hour of which was on dusty bumpy tracks, before joining the main tarmacked road from Tanga to Dar es Salaam. Half-way there (about 4 hours in), the unusually late  rainy season (by a good 3 weeks) finally declared its intention to begin. Nothing too exciting fortunately, but some heavy intermittent rain showers hammered upon the roof and windscreen. It was deafening and made driving all the more exciting – more ‘excitement’ is definitely not required. We passed several crashed vehicles (including a lorry that had gone off the side of the road), but fortunately, our driver is excellent and I felt very safe in his hands. Interestingly, the temperature on the car thermometer dropped from 35°C to a mere 24°C – and I certainly noticed that I was probably more comfortable than I had been for the vast majority of our time here. What a pleasure not to be hot and sticky!

We passed the time with a healthy conversation of mixed Swahili and English (his English being far better than my Swahili, but it is fun nevertheless). We were pulled over by the Police a few times (such things seem an almost compulsory part of any long journey) and documents and licences were dutifully checked. Apart from that, the journey was otherwise fairly uneventful until we were about 40min from the airport….

We encountered the most enormous traffic jam, joining the back of what would turn out to be a monster. The sort of which I just don’t think happens in Europe. With only a few of the most major routes across the country tarmacked, and then only as single carriageway, when disaster strikes, it is carnage. Later, we would learn that it was over 20km long. Odds on caused by some form of traffic accident exacerbated by the rains. Road etiquette is pretty crazy. Once the traffic had been stationary for a while, options started to emerge. Firstly, we followed a number of other cars driving down the opposite side of the road – whilst slow, this was still fairly exciting as it was often up blind summitted hills. Then when the occasional car came the other way, we would drive up the opposite hard shoulder. This worked well until we then encountered a major road improvement project (they are making part of this road into a dual carriageway) where the hard shoulder tapered out. This was about the same time that more frequent vehicles started coming in the opposite direction, including some massive lorries. I was bemused to see some of the ‘Bunge’ (covered three wheel motorbikes – ‘rickshaws’) as well as a few cars electing to use the ‘under construction’ portion of the road. Surprisingly, they did not just sink into the sand, but I was relieved that we did not follow. Something you just would never see in Europe.

We were in trouble though. Already 45min had passed and progress was minimal, a few kilometres at best. I had had plenty of time to get to the airport, but having felt completely laid back about things, was now starting to wonder if we would make it in time. Every hill we climbed revealed a huge line of stationary traffic snaking into the distance. As luck would have it, as we ground to a halt yet again, a local indicated an ‘off-piste’ alternative. This diversion was risky given the rains, but the car managed the muddy tracks well and we started to make significant progress towards our next goal – the split in the highway that turns off towards the airport.

We were within spitting distance of the split, less that 1km away, but unfortunately we had reached the end of this rat run. We had been deposited in a rather large lorry park. The back routes could take us no further and we sat waiting with the other ‘ratrunners’ to re-join the main road. The minutes ticked by and it was becoming painful. Time was getting tight. It was only 1km to the turnoff and the ‘word on the ground’ was that the route to the airport was clear, if only we could get there. But we were going nowhere. Eventually, my driver suggested that we hire a Bunge (rickshaw) as it could squeeze past the traffic – he could park up and we would go together. More waiting and just as we were about to change vehicles, things started to move. We re-joined the carriageway and could see the turning up ahead. There was hope! Some further creative driving got us to the junction, and we were free.

I made it to the airport in ample time, checked in, sent my hold baggage now crammed with souvenirs up the belt (the surgical instruments had been replaced by African crafts) and headed to security.

I write this in the airport restaurant waiting to board my plane. This is it. I am done. I really am leaving Tanzania.

Unfinished business.

I woke up this morning with a strange feeling. It would be my last day in Muheza. A surreal realisation that this ‘adventure’ is coming to a close. 

My wife, chidlers and our visiting friends would be setting off midmorning for a final weekend in Peponi, a last dip into paradise. The plan was that I would join them later, but I had many a loose end to tie up first. I had a lot to do today!

The whole day would be a very bizarre experience for me as the realisation struck home that each activity of the day was to be my last here. Sitting through the morning meeting, I made a special point of breathing the whole experience in, trying to ensure I had some mental souvenirs to carry away with me. I was sitting amongst my colleagues, many of them now friends, an almost daily routine that was soon to end for me. The clinical officer report, the nursing report then the death report (four this morning). There were the usual discussions surrounding such things, notably for me was that the clinical officer got a hard time for prescribing steroids to a snake bite (a quick check of Dr Google confirmed that this is not ideal). Once again my educational hat was immediately wondering whether this important discussion would be disseminated. Would there be learning and change? Would my consistent contribution to encourage such things begin to reap rewards? This morning it felt unlikely for this particular case, but seeds have been sewn and perhaps they just need time to germinate. The meeting closed with a reminder by the hospital superintendent of my departure. The reaction was generous; nobody wanted me to go but of course everyone wished us well!

I had an agenda today and for once I was assertive in dictating it. I needed to be super-efficient with my time to get everything done and get away at a reasonable time. There was one final operation to do, I needed to pack, and I was desperate to finish my present for the team.

I explained my time pressure to the local surgeons and we agreed that they would call me when the patient was ready in theatre. It was then back to the house to get on with my other tasks.

Firstly, I gave my attention to the present I was making, a photo-board (mugshots of the team) for the department. A familiar site on most NHS walls, I felt it would be both nice and valuable here. It had taken a long time to get done and I had been working on it in one way or another since before Christmas. However, as often seems to happen when an absolute deadline looms, a flourish of activity can bring it all together. My friends had been amazing in printing out quality photographs for me in the UK (I had struggled to easily find anywhere to do this locally), and my wife had managed to find a good quality pin board in Tanga yesterday (blimey, I completely forgot to mention in yesterday’s post that she had to go for round three of our visa saga – success I am delighted to report). But I got it finished just as the team called me to theatres.

Whilst Fridays are usually reserved for emergencies, we had been given the go ahead to do one of the two skin grafts still outstanding. Hoping to get them both done this week, for various reasons we had managed neither. Although disappointing, it was great that we would at least get one done. 

There were three patients on the ward who had been admitted over a month ago with horrendous leg ulcers. All young men (one in his 20s, one 30s, one 40s), two had sustained traumatic injuries and in the other they had emerged spontaneously (some infective cause I suspect). All three were substantial, encompassing most of the gaiter area (calf / ankle). Presenting late, all the wounds were infected had required extensive debridement, surgical toilet and dressings to try and salvage the legs. With such nasty wounds and extensive skin loss, these three men were flirting with the need for lifechanging amputation. However, some excellent basic work in both theatres and on the wards had gone a long way to salvage the situation. Two were now suitable to attempt grafting.

I had been really keen to get this done before I left as I had brought out a very heavy but brilliant bit of kit with me. If I could get the local team trained up in its correct use, it could transform their ability to manage these wounds. To put it bluntly, it might make life changing amputations unnecessary.

The Brennen Mesher

A Brennen Mesher took up a massive 6kg of our baggage allowance, but it is a beautifully machined tool that dramatically improves both the success of and scope of skin grafting. After taking a donor of skin (usually from the thigh with a special knife), you run it through the device and it creates fenestrations. This does two things, firstly it allows fluid out from underneath the graft when you lay it (blood, exudate, bugs) and fluid under the graft can prevent it from healing (it needs direct contact with tissue to get the nutrients it needs and to grow the tiny blood vessels that will allow it to live). Secondly these fenestrations allow it to cover a much wider area. The one I had brought out doubles the size of the graft.

With the patient on the table, I took down his dressings. The wounds were granulating well (this means trying to heal, creating a bed of tissue that the graft can sit on and grow onto). But there was a slight suggestion of low grade infection. This is not ideal as it reduces the chances of it healing, or ‘taking’ as we tend to say. Simply put, infection can kill the fragile graft. But it was now or not at all and I felt it was worth a try. This is not an easy decision as if the graft fails, you have created another ulcer on the thigh for no benefit. And these donor sites are not without potential complication, and they do scar. For a grafting of this size the donor site would be large.

I have done several skin grafts in my time, but on a smaller scale and I had not used the Brennen Mesher before (I had used other systems that require expensive disposables). However, the instructions that I had received before leaving the UK (and my experiments with paper) meant things went very well. My only quibble with myself was that the donor harvests with the Humby Knife were a bit ragged. You have to use this special guarded blade to regulate the thickness of the slices you take – too thin and the graft falls apart, too thick and the wound you create doesn’t heal - the donor site relies on the skin regenerating from the skin follicles that lie deeper than the slice taken.

My comment about this ‘unsightly’ work was met with a wry smile and utter bemusement. If not for my self-appraisal, neither the patients nor the staff would have even registered that there might be a cosmetic consideration. However, my professional pride was a little dissatisfied, which I think is important. I mention this because I believe it is the expectations that I have of myself that has driven me to strive for UK standards whilst working here. By doing this, remarkably perhaps, we have managed to achieve surprisingly good outcomes on the whole during my time here.

Nevertheless, the skin grafts were laid upon the gaiter wound, looked very satisfactory and were dressed. I can now only cross my fingers that they will take. They will remain untouched for 7 days before they are inspected. Too soon and you risk peeling the graft off with the dressing and ruining it. He will be on bed rest and antibiotics.

I will of course, be back in the UK for the moment of reckoning. Far from ideal but I have confidence in the team. There is also a distinct deja-vu about this situation. During my brief previous visit in July, we did a smaller skin grafting on a foot on my last day. That time the take was 90%. If we can get anything close to that it would be amazing and limb saving for this man.  

And that was it. My last operation in Muheza. I walked away from the operating room with a jovial exterior but a heavy heart. I was very sad to be leaving. All that was left to do was to present them with the gift I had made and say my final goodbyes. I don’t think my departure had really sunk in for any of us.

I left behind my scrubs, theatre shoes, headlight and a few other bits. But most of all, I hope I have left behind a legacy that will enable this surgical department to continue to grow. Turning away and walking out of the hospital gates was really hard. In my heart, I know that there is more unfinished business here than just the skin grafts and I hope that it will not be long before I can return, if even for just a short time.

I walked home and packed. At 3pm I climbed into the Hospital Car and drove down the dusty, bumpy road away from the hospital then out of town for the very last time. I had one last night in Peponi and would be leaving at the crack of dawn tomorrow to fly home.

A final photo, the two local surgeons and myself

Left holding the Baby for the 50th Mesh Hernia Repair

My first port of call this morning was to review the young lad with the abdominal pain. Expecting to have to persuade his mother to allow us to take him to theatre, I was surprised to find his bed empty. Just as I was fearing that he had been taken home, he walked through the other door to the ward. Coming in from outside, he spritely walked to his bed with a big, slightly coy, smile on his face. Even in the context of abdominal pain in childhood (it can be a tricky beast at times), this was all very bizarre. I examined his abdomen and it was blameless again. There was only one thing to do, I sent him home.

Today we would reach the landmark of fifty mesh hernia repairs. I am absolutely delighted, not least because the number has a significant feel about it. With the redecoration of the main theatre suite ongoing, we are still located over the way in the obstetric ward theatre. At one point, I found myself left ‘holding the baby’.

Our start to the day’s operating was far from smooth. There was quite a period of delay as the first patient to arrive was very hypertensive and had to be cancelled. He may have genuinely fallen foul of the phenomenon ‘white coat hypertension’ (this means that the blood pressure goes up disproportionately in the presence of medical stress and isn’t actually a problem), given that the previous three readings in clinic and on the ward had been normal. However, I have been very careful to support safe practice here, and was thus very happy to endorse the anaesthetic decision to postpone the surgery. The second patient required quite a lot of ‘pre-optimisation’ as well (an issue not dissimilar to the previous case, but not so severe) and, not unreasonably, the local surgeons had disappeared to use their time productively. However, after a short while I was summoned to the operating theatre from the coffee room. I walked in to be told that the spinal had been put in and the patient was ready on the table. I was the only surgeon present. Hmmm. No-one was answering their phones. Hmmm.

I had had no intention of performing this final mesh procedure myself (it would be the local teams final opportunity to perform this procedure with my supervision), but you really can’t leave a patient waiting on the operating table. I did not rush, but I dutifully scrubbed and prepared the operative field. The local surgeons were still yet to arrive despite my encouragement to locate them. Much to my dissatisfaction, I had to continue. I made the skin incision. However, with the knife barely leaving the patients skin, they bundled through the door much to my relief. They got scrubbed and I welcomed them warmly to the operating table. They took over the case at my request, I de-scrubbed and stepped back to watch them at work. It was a tricky case and would take them a long time (over two hours in the end). But the quality of the operating was very good and I know that speed will come with more experience. I sat in the corner pretending to get on with some admin, all the time slyly watching them work. It was a real delight for me to hear how they coached each other through the procedure, recounting the steps I had taught them. I knew it was going to be a challenge, and it was particularly pleasing to observe how carefully they operated. They recognised the difficulties, each time pausing and slowing until they had made sense of things and knew they could move forward again safely. 

I could not have been more proud. I sat there silently, soaking up those moments, savouring them. There I was, thousands of miles away from home, sitting in an operating theatre in the heart of rural Africa, witness to something very special for me. We really had done it.

In the face of so much challenge, in an environment so far removed from what I would take for granted in the NHS, we had never-the-less established a service that is remarkably close in quality to what you might expect to find in the UK. Whilst I would be leaving in just a few days’ time, I would be going content in the knowledge that the local team are safe, thorough and understand what they are trying to achieve. I felt genuinely confident leaving this new service in their hands. What a great result. What a fantastic step forward in the provision of healthcare for this population.

It also brought me much satisfaction and pleasure to have shared this moment with our visiting friends. Their complimentary comments and approval of the service we had developed was fantastic to hear. Perhaps it was more than that though. Their professional opinion was important to me. It was validation for what we had worked so hard to achieve, feeling almost like a stamp of approval. On what will become a very memorable moment in my time here I am sure, it felt a very fitting way to be ending this chapter of the project.  

Party!

My time here is rapidly ticking away. The morning started with a presentation at the hospital meeting. I had volunteered to share the experience of the Surgical Department activity during my time here. It was a really nice thing to do, summarising what we have achieved these last five months. Whilst I ensured that it was a balanced report ‘warts and all’, these were thankfully very few and it was certainly a report that I was proud to be sharing.

As I neared the end, I had a moment of hesitation. Caught completely of guard, my throat tightened as I praised the work of the local team and started to suggest some things to encourage a vision for the future. A slightly awkward period of silence ensued.  Evidently, I am very proud of what they have achieved. It will be hard to leave. It felt like an age to me (silently berating myself and imploring self-control and composure), but I managed to do so and finish strongly. I was rewarded with the most delightful applause – the hand rubbing, followed by some synchronised quick claps, building up to two large claps that they ‘throw’ at you. I smiled broadly.

After the meeting it was back to reality. The surgeon nun was visiting once again from Korogwe and we went to review the boy from yesterday. Disappointingly, he was more sore and we agreed to return later to decide if surgery was indeed required.

Operating on a little person

The operating list was in the obstetric ward theatre, which despite my initial reservations was a perfectly acceptable venue and actually worked out very well. We had an unexpectedly challenging paediatric hernia, which turned out to be a combination of hernia, maldescended testis and hydrocele (this means that the testicle had not migrated correctly into the scrotum on that side and was surrounded by a balloon of fluid). Far from the slick masterclass I had hoped, it was however perhaps excellent learning for all of us and went very well (herniotomy plus orchidopexy [fixation of testis in the scrotum]).

Further progress to our planned schedule was trumped by a C-section. My visiting friend was keen to get involved and I found myself happy to add to my experience of two.  We cracked on. It was a difficult procedure with the baby’s head wedged deep in the pelvis. It was also a hot and sweaty affair; the older air-conditioning was significantly less effective and we were both cursing the mandatory plastic aprons (without them we would have been soaked through with almost every body fluid though). One thing I won’t miss leaving Africa is the sweat pouring down my back and dripping off my forehead in such cases.  However, for all such things I am pleased to report that the baby came out safely and crying albeit with a funny shaped head (this is normal and resolves) – I am not sure if I will ever get used to obstetrics.

With that interlude completed, we were once again able to continue with our list. It was an exploratory laparotomy in a middle-aged man with chronic right lower tummy pain and an USS that suggested appendicitis! I was extremely sceptical, but like the handful of other such cases I have faced, the only option left available is to have a look inside the abdomen. Whilst certainly an invasive procedure, there is the potential to miss important mischief and no-one is yet to decline despite my cautionary counselling. Interestingly, all the previous cases (normal findings with routine appendicectomy) have remarkably reported full resolution of their symptoms.

Having successfully embraced the local teams request in the past, and despite my ongoing reservations, we conducted the procedure under spinal anaesthesia alone. In the UK this would be unheard of as we normally insist on general anaesthetic with full muscle relaxation to improve our access. Once again, embracing their practice was successful and it is certainly something that I might consider for very selected cases back in the UK in the future. After a brief flirtation with the ascending colon (initially we thought that there was a stricturing tumour – I initially got excited, but it turned out to be unusually pronounced muscle spasm of the colonic wall) it was indeed normal and we performed a routine appendicectomy before closing. Once again I smiled at the enthusiastic comments about the length of this worm like structure, but when you have seen over 500 of these things, I could confidently say it was within the normal spectrum.

On completion of that case, we had run out of time and concluded our operating for the day. We returned to see the young boy and all of us agreed that he needed surgery which we would schedule for the following morning. However, his mother was very reluctant to let us proceed despite gentle encouragement by the visiting surgeon nun. I cursed my decision to cancel him on the table yesterday. A most unsatisfactory situation, I hoped that things would be easier in the morning.

The evening was a fine affair. We had arranged and financed a party for 60 of the hospital staff that had worked most closely with us. Every single one came. Free drinks and a free meal were evidently ample encouragement. It was truly delightful and towards the end there were a few speeches followed by some gifts for us. They had had a dress made for my wife and a shirt for me. So lovely. And to compliment those, we were also given a few reams of beautiful African material which they paraded to us under the accompaniment of music and dancing and then wrapped these around our whole family. Twice – they are huge! There was a requirement for a vast number of photos and it felt like our wedding day, standing on show with various different combinations of the staff. The children were fantastic about it all, despite being tired and I am so glad because it clearly meant a lot to the staff.

It was then a very late night for a very tired Family Shim.

This picture is with the entre theatre department staff 22 in total

Ha! No water….Let them eat cake.

With all the terrible flooding wreaking havoc and causing death and destruction just a little south of us, it seems slightly bizarre to be commenting on our lack of water. The rainy season is still yet to start here, and it is now very notably late I am told. Apparently, we are having an unprecedented period of drought and the piped water supply to the whole of Muheza has been dry for the last three weeks. Unfortunately, that means that our water tanks are now almost empty again and we are back to rationing. I am hoping that I will be able to squeeze out another couple of quick showers in the mornings after my runs. But I won’t hold out too much hope.

I guess this is living the reality of climate change. Genuinely quite scary. Perhaps it is time for such things to register as a wakeup call on a global level and that we can start to try and make amends before it is too late.

So that, together with the recent nightly power cuts, certainly seem to be gentle reminders to appreciate reliable utilities when we return to the UK.

Today has been a funny day. Major theatres are still out of action with the refurbishment in full swing. Despite many assurances to the contrary, I just can’t see it being ready to use again this week. Whilst frustrating in many ways (being both predictable and avoidable perhaps), they are doing an excellent job and I am keen that they are allowed time to finish it properly. The theatre team have settled very well into our alternative venue in the obstetric ward and I think we will manage some elective work there after all.

There was a first for me today; I cancelled a patient on the table. I had been asked to see an 11 year old boy at the end of morning rounds. Although the history was a little confused and the findings far from classical, at that stage he seemed to have a peritonitic abdomen. A decision to operate was made and arrangements began. However, a little while later I watched him walk very happily towards the obstetric theatre. Alarm bells ringing, I re-examined him ‘on the table’ before he was put to sleep. The clinical picture was now completely different. His abdomen almost blameless. Never one to allow pride to overcome making the right decision, I sent him back to the ward for further observation. I suspect that he will go home tomorrow. I felt slightly bad for our visiting friends as their first few days have been a little bizarre I expect. Things have been far from the normal for here, and this normal being very far removed from the UK anyway. However, they seemed to take it all happily in their stride and we had an early finish to the day.

This was excellent news as it is our littlest daughter’s 6^th birthday today. We returned for birthday lunch and of course birthday cake and tea a little later. A huge effort had been made by my wife and other daughters to give her the best possible day. They had created a wonderful chameleon cake and she had plenty of presents with those sent out or bought here. She had an excellent day, with lots of whatsapp video chats and things to do and enjoy. She did say at bedtime though that she missed seeing her friends and the rest of our families in person – it was one of those incredibly sincere and mature moments that children sometimes throw at you. It made me both smile and feel a little sad for her. She is a very happy and content little lady though and I’m sure stories of her African Birthday will be told for years to come.

Cake and presents!

A final flourish

Today is my last Monday in Tanzania and it has been pretty full on. The hospital is a hive of activity and it has been an eventful and pleasing day.

Yesterday we were delighted to welcome some friends from the UK; a Surgeon / Anaesthetist couple who brought their 15month old daughter with them. Having been involved with lots of work in Africa in the past, they are both midway through training in their chosen specialties and were keen to try out the reality of Africa with a child! They had somehow managed to co-ordinate their on-call rotas and leave requests, managing to make it out here. It’s a big thumbs up so far. Their daughter seems to love it. And she certainly likes the new big friends she has found in our chidlers. For us it has been really nice to share some of our time here with such people.

Somehow, a few weeks ago I had agreed to pay for the redecoration of theatres. Expecting it to require just a modest amount of funding, the quote turned into something more substantial. £1,500 might not sound a lot, but here that’s a massive amount of money. Hesitation to commit to such expense personally (given that we are scraping the bottom of our barrel currently) was soon to be overcome by the generous offer from family to make contributions as a birthday gift. Before I knew it, the whole thing was financed, and the work was commissioned. I was genuinely delighted. One of the best birthday presents I think I have ever received.

I had hoped the work might have been completed during our stay in Zanzibar. Unfortunately, whilst it was started at the weekend it is now midway through and walking into the theatre complex today made me rethink the reality of the weeks operating schedule. Dust, plaster and paint everywhere. Operating this week might be a little lighter than I had anticipated! But I am absolutely delighted that this work is underway. It will make a massive difference to the department. Not only will it make it easier to keep clean (improving sterility), it should reduce the likelihood of flies in theatre and will certainly have a nicer feel for the staff who work there. Another small but significant step to raising the bar of surgical care here. A herculean effort is underway to get things finished….I am being open minded…. (rest assured, we have moved emergency work into the previously dormant theatre in the obstetric ward, but we really do need to reserve that for unplanned work only).

Fan repaired, hole persists!

And so on to the main event for the day – outpatients. I knew it was going to be a huge clinic as I had integrated a special mesh follow-up clinic for the majority of those in our series. I felt it was important to encourage a robust system of feedback for the local surgeons, as well as capturing important data to validate what we have done here. As I walked through the door, I immediately noticed the now working ceiling fan – what a great omen for the day – it would be a comfortable marathon at least. Whilst a mammoth 44 patients were seen, the majority were follow-ups and doing brilliantly.

If ever I needed a final reminder that what I have undertaken here has been worthwhile, this was it. It felt a little like an indulgent success parade, with patients modelling beautiful scars and a significant number regaling delight in the outcome of their surgery. Whilst all the mesh patients were fantastic to see, the highlight for me was a couple of the children who I had brought back to review before I left. To see them thriving was such a pleasure. The little boy who had had a big recurrent hernia was particularly special for me. Motherless, his grandmother smiled broadly as she showed me his now near normal inguinal region (groin). Whilst the original broad scar was a clear indictor that he had had surgery, our little fading pencil line was only a hint that we had ventured back in. All the inevitable post-operative swelling had disappeared and I felt an enormous wave of satisfaction that my work here has been done well. Such things will probably make a real difference to this child. I feel he could certainly do with a few better deals of the cards.

Zanzibar – A sobering exit.

We have had a lovely final 24hrs on Zanzibar. The beach we look out over is quite remarkable. The gradient is extremely gentle and the reef encircling this part of the island is about 1500m off shore. This creates the most incredible tidal variations. At high tide, it laps the ramp up to ‘our’ garden. At low tide there is a 750m walk out to the remaining lagoon beyond which lies the reef. The water is the most stunning blue and has a swift current as the vast volume of water tries to exit through a gap in the reef somewhere distant.

The beach and lagoon are places of much activity at low tide. There are numerous seaweed farms tended by local women. Our understanding is that these are a recent initiative to create an industry for the ladies here, with the plants being sold as a food item or as an ingredient in beauty products. 
There are also numerous local fishing activities as you might expect and for us the lagoon current was to be an excellent playground. We walked upstream then waded in and allowed ourselves to be swept back downstream in the warm water. It was excellent family fun – we are all water babies at heart.

We also went out on a boat trip with our host to visit a snorkelling spot. Wanting to offer our younger two children the opportunity to see coral and reef fish we were not to be disappointed. Predictably, close to land the coral was very limited, but the fish were plentiful and our littlest even spotted a most beautiful moray eel. The local crew also took full advantage of the paid trip, and found an octopus that they deposited in the bottom of the boat – interesting for us, sad for the octopus as it was heading for the cooking pot!

Octopus in the boat and Moray Eel in the lagoon

Sailing back

Our departure from Zanzibar later that day though offered a more sobering perspective. Amongst all the thriving tourist business, local life still remains challenging. Our taxi driver stopped to speak to a lady sitting by two children. They must have been about 8 and 12. It transpired that they had just lost their mother. Their father had already died 3 years ago. Our driver had stopped to offer his condolences as is the custom here. My conversations with him suggest that these deaths are probably HIV related. Regardless, for us all sitting in the car it was a fairly stark reminder of the challenges faced here. The children we saw sitting outside, stoical but clearly grieving their loss, were essentially the same age as our older two sitting next to us. An extremely sobering thought. The extended family network here is incredibly strong, so they will have somewhere to live and will be cared for. But what an extremely difficult way to start out in the world. My wife and I exchanged a look that clearly said we were feeling the same thing – heartbroken.

We left Zanzibar on another delightful flight, this time with an all-female (and equally glamourous) flight crew, arriving safely home in Muheza late in the evening. I must say walking through the door was a real pleasure for me. It was that very pleasant feeling of returning home.

And so we enter my final week here. Slightly earlier than originally planned, I have got to fly back to the UK next weekend before then heading back out to re-join my family in Australia for our planned holiday on our ‘return’ leg. I think it likely to be an eventful final few days.