Travel

Today we set off on our second Tanzanian mini-break! I think it is fair to say that we all are in need of such things. For this trip, we are combining some business and pleasure!

After our 7 hour bus journey north, today we have come to Moshi, the town that sits at the bottom of the impressive Mount Kilimanjaro. Tomorrow I am going to visit KCMC Hospital, our ‘local’ zonal hospital. I am really interested to see this institution for myself, one I have heard so much about.

Then we will be heading up to Arusha for the weekend to stay with some friends that we met on the coast. They are the anglo-franco-danish ex-pat family with children similar ages to ours. On Monday I am then to meet with the CEO of a massive company who amongst other things manufacture mosquito netting. It is the only potential way to source the hernia mesh from within Africa, but given how specific the requirements are, equally it might not work out.

Following that meeting, we will then return to Moshi on Monday afternoon. After climbing many proverbial mountains in Africa, it only seems appropriate to give the ‘real thing’ a go. So early on Tuesday, my eldest daughter (11) and I will be heading off to one of the Kilimanjaro National Park entry gates, from where we will attempt a 6 day excursion to scale the mountain. Exciting stuff!

A ‘normal’ day?!

The striking thing about today is that it has felt like one of the more ‘normal’ days I’ve had here. Whilst this leaves me a little stumped to know what to write about, it is perhaps, in itself notable. Maybe another step taken on the ‘settling in’ ladder.  

Before

(Suitable permissions granted)

Today we did four procedures on three patients. Firstly, a large paediatric umbilical hernia. Whilst only two years of age (quite young to repair such things) hers was large and it seemed prudent to get on with the repair. As it turned out the neck was certainly tight compared with the contents (caecum and appendix) and I am glad we repaired it. Then it was excision of a large groin lipoma in an older lady (the size of a standard UK mango [a mango of that size would be considered small here]), which I guided one of the local surgeon’s through. To finish, it was repair of an epigastric hernia and lower midline recurrent incisional hernia in the same patient, both with mesh. 

After

The cases today couldn’t have gone much better really, and I am enjoying where we have got to as a team. We are also now up to 22 cases with ‘mosquito’ mesh and approaching the sort of numbers that provides meaningful evidence that what we are doing is safe.  Fingers crossed that the current good run continues. (Proof reading this I think it is important to clarify that I do not use mesh in the children)

My efforts with the pencil diathermy (electrocautery – modern version of a red hot poker) have also had another breakthrough. We have three in circulation currently (with three spares I think), but after 16 cycles through the lower temperature autoclave, the buttons on ‘pencil 1’ are becoming temperamental. Especially the button we use the most (blue, coagulation). To be honest I am delighted that it has lasted so well. A single use instrument has been reused 16 times! But, desperate to extend the lifespan of these instruments even further, I had a moment that was either going to be genius or whimsical experimentation. I wondered if we could activate the pencil using the foot pedals usually used with the forceps diathermy instruments. It worked! Brilliant. So we have given these pencils yet another new lease of life. Perhaps dramatically.

On the home front, I’m sorry to report that things were a little tiring. For some reason, conflict was the mood of the day with lots of grievances from most parties about something. I have never been one to enjoy such things, and here most of the problems seemed very ‘western’ issues. No-one in the household had died or was in the process of doing so, no one was starving (literally) and most of the trouble seemed to be around invasion of territory or property (of which, in my opinion we all have too much). So, perhaps a very normal day by western standards then!

(For clarity, I think as a family we do pretty well. On the whole, we get on with each other as well as any family does, I believe. It’s just that being here, you see such a stark contrast to western reality. It is normal for children to grow up without one or both parents (many a child is attended in hospital by a grandparent or aunt/uncle), or to have siblings who have died, or for parents to have lost one or more children. HIV is also the reality for many. And some go hungry. Being immersed so richly in the reality of this by working in the hospital leaves me little sympathy for what can seem the triviality of ‘western complaints’. But of course, these complaints are the important reality of our lives and must be given the attention that they require. Perspective develops with time and experience. It is however a wearing journey as any parent will know. But on the other hand, how privileged we are to be in such a position.)

To do? Or, not to do? That has been my question.

Rightly or wrongly, today I did.

It would be fair to say that today has been a day of two halves. The ‘quick’ trip to Tanga early this morning to ‘just’ get our visas stamped, turned into a very unsettling process. Many things were explained to us, which in short were quite alarming. Essentially, it seems that we were issued with the wrong type of visa when we arrived at the airport (in good faith by both the immigration team and by us). Certainly, at the airport we reviewed in detail the large stack of documents we had brought to support and explain our visit. However, the bottom line is that the type of visa we have is not easy to extend. We have been granted a month to get matters in hand, but it is going to take quite a lot more effort on the part of many people to enable us to stay. I am very tired by this process and so will leave further details at that. It will either get sorted or it won’t. Everyone seems to want to help us to stay, acknowledging the work we are doing, but you have to have the right papers and THAT is the challenge. 

Improvised tourniquet.

It worked very well!

This afternoon however, represented the culmination of much thought and consideration. You may recall the young boy whose predicament I described in my blog post ‘Dilemmas’ (11^th December) with the large tumour on his foot. I had used whatsapp to ‘phone a few friends’ (well message actually) for advice about what to do and had a mixed response. Some encouraging, some very cautioning (the most frightening being that if it was a vascular malformation he could bleed to death). I was left with much still to consider. The local team remained very encouraging (I don’t want to call it pressure) but I was still unsure. There were some important unknowns remaining and I have used the time since December to try and fill the gaps as much as possible. For example, ‘Blue Peter skills’ have once again come into play, with a creative but effective (and reliable) solution for a tourniquet (to make surgery easier and minimise the risk of death by exsanguination).

However, the final catalyst in my decision making was seeing another patient with an advanced, obviously malignant tumour that I am sure could have been excised long before it had become cancerous. The reality hit me that if I did not operate, it is most likely that no-one would. On my departure, this young boy would be left with a disabling growth that would almost invariably develop into cancer in the future (although possibly malignant already, more likely not to be). So my decision was made and today was the day.

Now as surgeons, when presented with the prospect of a difficult case, we usually try to make our other activities leading up to the time of surgery as easy as possible. So, it was an ideal morning’s preparation then, I can hear you thinking. Hmmmm.

However, perhaps because of the ‘laws’ of ying and yang, pleasure and pain, his surgery couldn’t have gone any better. The tourniquet worked brilliantly (the cuff holding its pressure for the 25 minutes it was up without any mischief) and the tumour shelled out beautifully. This means that once the dissection was started, the planes between the tumour and the ‘normal’ tissue were very well defined. An excellent prognostic indicator (much less likely to be something nasty) and made the surgery a real pleasure. It was actually very straight forward in the end. Deflation of the cuff revealed a healthy skin flap (the danger is that you can devascularise such tissue during the dissection). Then, my only remaining challenge was how to cobble it all back together giving him the best possible reconstruction and wound (the sole of the foot is a functionally a very important structure and wounds on the surface are far from ideal). The problem I faced was a large excess of skin – imagine a deflated football when all I wanted was the semicircle itself and not the wrinkly dome. I toyed with many ideas, including trying to work out some complex flap that would keep all the wound off the sole, but in the end, decided that a small wound off the pressure area would give the best possible outcome. I hope I am right.

Dressed with extra padding for

protection / fill the redundant space

Technically, I am delighted and really hope that it will heal well. The chances of keeping a 6 year old off the wound is difficult at the best of times. Here there are no such things as crutches! It is all wrapped up and I am hopeful it will heal. We will resist the urge to look at it for at least 5 days (and as I will be away, these instructions will hopefully be followed). Fingers and toes crossed again please.

(Once again I have many fantastic 'gory' photos which I will resist posting. All clinical photographs that I do post are with the explicit consent of the patients / families for such purpose).

We've still got some learning to do with histology!

At least we have formalin.

Barriers, it’s definitely more red tape than carpet.

Coming to work in Tanzania on a voluntary basis has proved to be considerably more challenging logistically than we had first expected. A surgeon and a GP offering to come and work for free? You would have thought that the process would be made as easy as possible, that a ‘red carpet’ might even be rolled out to welcome and lure us into staying for as long as possible. Ha! It sometimes seems that the opposite approach has been taken. The processes are complicated. And expensive (for example I have subsequently found out that we have had to pay fifteen times that of a local doctor in professional registration fees – and we’re not even earning any money here!). The red tape is prohibitive and I worry greatly that it will (and probably does) put off other people from doing the same sort of things as us. 

But we made it here and are so glad that we persevered. Today we had to go to Tanga to get our Visas extended. I won’t bore with the details, but this has been on the agenda since we arrived. All in hand I was informed. But of course the expiry date crept closer and closer and my enquires became more persistent. They expire next week and I finally persuaded the team to take us to get them renewed. I was assured that it was a simple process and a formality, but I was very right to be sceptical. Those looks that you get from officials sometimes say so much more than words ever could. There have been many changes to the processes and laws here over the last few years I am told, which has made what we are doing harder to achieve. There was a lot of waiting around, but the local immigration officer was sympathetic to our cause and supports our extension. Unfortunately, this can only be for one month at a time (so we will have to return twice more) and today the person that we would need to actually complete the paperwork was absent. So we will return tomorrow. Fingers crossed it works out, otherwise we will be leaving in a hurry!

My reaction to all this is threefold. Firstly, whilst it seems bonkers, there is absolutely no point in letting it ‘get to you’. We took some good books to read and just went with the flow. I predicted it would be far from straight forward, so we were somewhat prepared at least. Secondly, it is actually quite an interesting insight into things. The complexities and detail of the various visas available is eye-opening (or perhaps it was the exemptions available for visas, I got quite confused). The rquired documents was mindboggling. Certainly, I feel that we have had another authentic African experience – and one that we’ve paid quite a lot of money for so perhaps we should enjoy it?! Finally however, I am even more resolute to try and meet with some of the leading stakeholders in such processes. I feel it is absolutely crazy to actively discourage (for that is what it overwhelmingly feels like) highly skilled visitors who wish to help train the local workforce in such a way that could rapidly raise the quality of healthcare. I absolutely support that comprehensive processes are in place to regulate such activity, but perhaps not like this.

Just give up and come home I hear you say? Certainly an option, but at the end of the day it is the patients that will suffer the most. So we will persevere and hope that we can adequately jump through the hoops to emerge successful.

We arrived back in Muheza late in the afternoon. To my delight (that might be said slightly tongue in cheek) there were a handful of patients that had been saved for my special review in outpatients. A victim of my own success?!

Weekend Musings: African Critters

I have always found little insects incredibly annoying. When holidaying in France, the small flying things that land on you and itch usually drive me into cover, exacerbating my pasty complexion. Even in the UK, I would find flies and insects a great way to spoil an otherwise idyllic spot. Here, whilst insects are aplenty, surprisingly I find myself far more accepting of such things, even admiring their audacity and resourcefulness.

Sometimes they indicate their

affection!

There are ‘ants’ aplenty. From the large termites building architectural wonders, the rainforest Soldiers / Fire (advise to avoid being bitten) to the tiny little critters that are everywhere. And I mean everywhere. Whilst they are ‘harmless’ they’re ability to crop up at any location is a little taxing at times. Any food source left without impenetrable covering will be found and, if exciting enough, swarmed upon. Needless to say, we live in resigned acceptance that these are our inevitable house guests. There is a longstanding conflict which neither side is ever likely to win!

Even as I am writing this, I see the occasional scout whizzing along the desk. Sometimes, they find you unawares and explore you too. They are so small and quick that when you do notice, they are very difficult to find and remove. And of course, an itch is never just an itch here. A compulsory body inspection is required to rule out / destroy personal invaders.

I am less affectionate of their utilisation of the theatre suite though. I described a few days ago how fortunately they stop moving when the hot water is added to the leaves and sugar that goes into making African tea. Extra protein?! But intraoperatively, I confess, they do cross a line that I cannot accept. Sometimes I see one running across the drapes through the ‘sterile’ field. I am pretty sure that they have come from the patient (the team does a good job of keeping their obvious presence in the operating rooms at bay). I am afraid that when they present themselves in such a fashion, they get an extra helping of surgical spirit.

This is one of the many challenges that we face with regards to maximising the sterility (or rather cleanliness) of our procedures – of paramount importance when considered in the context of the mesh surgery. Mesh is an implant which harbours potential disaster if infection should manage to find its way to it. When I compare and contrast the almost space age like approach that is now commonplace for orthopaedic theatres in the UK with what we have here, I sometimes think that we must be walking a very tight line. But what we are doing seems safe in the twenty patients who have undergone mesh surgery so far.

However, I cringe at the unmistakeable grey / brown that tinges even the third set of swabs we use to prep the patient (clean the surgical field before the ‘sterile’ drapes are lain), a clear indication of the ingrained dirt most of the population wear (3 washings with Savlon, 2 of spirit if you’re interested). My dissatisfaction regarding the flies in the operating room has become increasingly vocalised (gently and politely of course). Something we must eliminate. When they land on the instruments, your ear or the back of your neck toying with you, I can barely contain my frustration though. Equally, the staff’s efforts to swat the blighters is almost as bad, the sterile field sometimes forgotten in attempts to placate me! The canvas drapes also seem a fairly flimsy barrier (they soak up the smallest amount of liquid and I am sure that more than just a single celled organism could quickly find its way through the weave.

But for all that, we are doing well with all our operations. There are a number of steps that we have included to optimise the cleanliness of things, particularly for the mesh surgery. The hernia patients also all stay for two days postoperatively, receiving IV antibiotics for this time (first dose on induction) and then 3 days of oral to go home with. I have recounted the UK day case mesh hernia practice a number of times with one single dose of IV antibiotics on induction. But that was met with a knowing smile. It’s not quite the same when a patient returns home to a hot and dusty mud hut that they share with chicken and might not wash for…. for… a while. That said, this schedule is the same as they employed for their sutured hernia repairs before I came, and we have in fact reduced postoperative infection rates.

Perhaps, if we can get things firmly established, we can try pushing the boundaries out again in the future. But ‘polepole, polepole’, slowly, slowly.

The blood brain barrier

I continue to be impressed by the commitment and innovation that I find here in Tanzania. Perhaps, it should come as no surprise to me that such traits would flourish. But it certainly brightens up my day when I see another small step moving things forward. Today it came from a trainee Nurse Anaesthetist. She is away studying this year at the Zonal Hospital in Moshi, but is currently on her 4-week block of holiday. So, of course, she comes in every day of her holiday to work for free in the hospital ‘to gain a little bit more experience’. She is very good and works very hard.

The 'blood brain barrier' seen at the top of the photo.

Today I noticed that the ‘blood brain barrier’ had been erected. This is the affectionate term used by theatre teams to describe when part of the surgical drape is used to shield the head end of the patient from the surgical site and vice versa. Blood being the realm of the surgeon, brains to describe the anaesthetist (I think we can guess who coined that phrase!). I had not seen it used here…. and I am not too sure why I hadn’t asked for it (perhaps trying to explain such a concept was too daunting as being scrubbed I would desterilise myself if I tried to erect it). Nevertheless, I was delighted when it was put up today. It was immediately apparent how greatly it improves the quality of the sterile field here (the drapes are quite small and basic). For the hernias it will add another layer of cleanliness to the cases (less likely for the patient to cough over the mesh or an accidental stray hand desterilising the field unnoticed). It is also low enough, I am pleased to report, that I can still clearly see and communicate with the head end (the importance of this will be evident from previous posts).

Perhaps a small thing, certainly something I would take for granted at home, but it is just another example of how things in Tanzania are moving forward fuelled from within the country. Experience being shared and disseminated. It is great to see and be part of, and again adds to my belief that all the time and effort we are investing here is both worthwhile and sustainable.

Unfortunately, the case itself was less pleasing. I had anticipated it would be challenging (I refused to start it before the blood crisis had resolved – temporary fix now in place), but was hopeful we could achieve a good result. She was a lady in her 40s who I had been asked to take to theatre before Christmas for appendicectomy – the ultrasound scan report had strongly suggested such a course of action. But when I saw her, she clearly had a mass and of the like which I could easily make things considerably worse by rushing in to surgery. I cautioned patience (to the disappointment of the local surgeon, I had to explain that a good surgeon knows when not to operate) and we treated her for two weeks with IV antibiotics. She improved and was discharged. I committed to surgery on a semi-elective basis if things did not completely settle down. To my mind, she either had an appendix abscess or a perforated cancer. I remind you that CT is not an easy option (patients have to travel a very long way and is prohibitively expensive).

Intraoperatively, I found myself looking into an abdomen I would never have entered in the UK. A CT would have told all. As she was put to sleep, I had increasing concerns (an anesthetised patient is relaxed and subtleties in the abdomen can become more apparent). Her entire right flank was rigid and the mass felt more extensive and very fixed. Hmmm. We opened. Sadly, the intra-abdominal compartment was pretty blameless, but there was an extensive mass palpable in the right retroperitoneum. It is either a posteriorly perforated and extensively locally advanced colorectal cancer, or a tumour arising in the retroperitoneum (like a big renal tumour). There was nothing I could do. We closed. It is always disappointing when you commit so personally to try and help someone, to be faced with something beyond such measures. I will see if she can travel for a CT to at least help inform her prognosis. But realistically, the sort of chemo-radiotherapy that we can offer in the UK is not available here and so, in some ways, a scan could be viewed as an expensive academic exercise. Hmmm. Very sad. I did not become a cancer surgeon to be faced with such situations. We do get late presentations of cancer in the UK, but we are able to perform extensive diagnostic tests (down to millimetres of tissue planes on special scans) that gives us a much clearer idea of what is and isn’t possible. Whilst the boundaries of cancer care are being pushed all the time in the West, I’m pretty certain this would be beyond even anything we could offer there. However, more information would allow an informed discussion with the patient, and palliative (life prolonging) treatments would be available to try. Here none of that is available and it often feels like guesswork (or is that clinical acumen).

The X-ray machine in pieces. It's looking terminal.

A final blow for the day is that the X-ray machine seems to have given up. It has been coughing and wheezing for about two months now, but I understand that last week it had ‘retired hurt’. It has seemed fragile ever since my arrival here last November, but every time I enquired about its health I had been told that it was all to do with power outings and taking a long time to warm back up. Hmmm. Its persistent illness resulted in a visit from the national technicians yesterday. It seems that unfortunately, the retirement may be a more permanent one. Everything that could be tested has been and is fine, but it still doesn’t work. Hmmm. This is a massive blow. Massive. For the patients and the hospital. I am not sure how a replacement can be organised, but I fear that even if possible, it will take months.

Just as progress seems to be gaining momentum, an important string to the bow snaps. Can a hospital function effectively without an X-Ray machine? We will find out I guess.

Wild goose chase?

Today is Thursday and I have been trying to ingrain the habit of the Surgical Department Meeting actually happening every week. Unfortunately, this has resulted in me having to prepare and provide most of the material and drive. I am keen to engage the wider team in facilitating these sessions, but currently they are steadfastly resolute that I have too much to offer. This morning I was unusually completely unprepared – things have been pretty full on – and after briefly toying with the idea of just winging it (I am usually pretty good at doing such things now) I decided on my walk into the hospital that actually I was too tired and today we would just give it all a miss.

But sometimes you can be a victim of your own success.

Innovation?!

Whilst much to my relief, no one was present at 8am (the expected start time), just as I was preparing to sit down and have a cup of tea instead, one of the senior O&G surgeons arrived and started to arrange the furniture ready for the meeting. He was closely followed by the Hospital Superintendent who had come to find me to discuss the quote for renovating the theatre complex which somehow I had apparently requested (spare £1,900 anyone?!). After a very quick walk around to appraise the proposed work, the room had filled. Even three medical students had turned up. The hospital superintendent also decided to stay. I was cornered! When about twenty people are looking up to you in anticipation, there is really only one thing you can do…. Just get on with it. Thinking on my feet, I found a large cardboard box to use as a white board (I am working on finding one of those currently) and began to explore acute abdominal pain (a request at a previous meeting). Catering to an audience that includes theatre porters through to senior doctors is quite a challenge for such a topic. I think I managed to pull it off and make it relevant and interesting for all. It was certainly the most interactive session we have had to date (perhaps my efforts to encourage such interaction is finally paying off). I got the customary round of applause at the end (hands are rubbed together in a circular fashion and then three synchronised claps are sort of thrown at you) which always makes me smile.

The local team finishing off a hernia

together. I still scrub, but we're making 

great progress.

It was then mainly a day of operating, waiting to operate whilst emergency C-sections were fitted in, and having very entertaining impromptu Swahili lessons whilst eating Mandazi (a sort of unfilled Tanzanian donut). The main question I had today was why there were so many words for ‘this’ (hii, hiki, hili, huu, huyu). Whilst everyone (except for me) was completely clear when each version should be used – we had very amusing rounds of naming games – no-one could tell me any sort of rule which would help me know when to use each one (with the exception of ‘huyu’ which is used for people and animals). I am having such fun learning Swahili and my efforts clearly delight and amuse the staff in equal portions!

As well as these immersion language lessons, another real bonus of living and working in a community such as this is that I am being exposed to a fairly unique culinary journey. I have long since got past my paranoia of not eating or drinking anything that I hadn’t personally prepared or cooked myself (although I am still pedantic about drying my crockery and not eating dodgy street food). I can now even cope with the hundreds of tiny ants that get over anything even vaguely representing food or water. Black tea (leaves in the bottom of the mug) with a touch of sugar (I would never normally dream of touching the stuff) accompanied by several of these little critters (stop moving once the boiling water goes in) is something I actually look forward to! The staff have been expanding my palate by bringing me in more and more things to try; plantain (a cooked green banana that is delicious), breads, donuts, roasted peanuts, root vegetables to name but a few. It is a fantastic insight into their real-life, every day, culture. And it is generally delicious (and healthy!).

My schedule for the day was slightly derailed by the addition of a strangulated hernia at the end of the list (mesh case number 20). But after a quick team appraisal, we decided to pursue my slightly crazy proposed activity, albeit a little later than planned. The three of us (both the local surgeons came) jumped into the hospital car and went off in search of some missing data. It is at this point that I should probably state that I did wonder if you can be too committed to a cause. I am still mulling this question over. But two of the hernia patients had failed to return to clinic (over a month overdue) and I was disappointed about this. Firstly, I thought they still had sutures to remove (we have now developed or technique to include completely absorbable skin closure) and secondly, being a little OCD (more nodding heads reading that I know) I wanted to do everything I could to maximise the outcome data we were collecting from the mesh procedures. Unfortunately, the demographic data that is held in the patient records is very limited which had made contacting them impossible (we are now collecting telephone numbers). I had slightly tongue in cheek suggested that we could drive out to the villages to ask after them, and when this idea was not dismissed immediately it evolved into reality. So this evening, off we went.

The first village we went to firmly kicked this idea into touch as the ridiculous idea that perhaps it was. We went to the very plush health centre located there and even spoke to the village chairman (who would usually know of most people) but to no avail. Frustrating. Albeit predictable perhaps. But at least I could say that we had done everything we could have. Off we went, back down the bumpy dust road to Muheza and then out in another direction for the other village. The title of this post pays homage to how I was feeling as we made the turn to head back out of Muheza. 15 minutes later, I pulled off the main road and parked up. My colleague jumped out to ask around after our second patient. I was just in the middle of sending my wife a message to explain why I was so late home (it would be 7pm before I made it through the door) when he knocked on the window, beaming, with a slightly dishevelled and dusty man in hand. It was our missing patient! I was absolutely delighted! We had actually found him! Furthermore, he was doing brilliantly. An impromptu outpatient consultation ensued and we could fill some of the gaps in the mesh database. I was super stoked. What a great result. What good fortune. A totally bonkers idea, but it had worked. He might even come back to the special follow up clinic I’ve got planned for April before we leave (we did take his phone number though!).

It was a glorious sunset as we drove back to Muheza. I was in that slightly tired state of elation that can only come when a distinctly questionable idea turns out well. What’s more, whilst en route we got a phone call from the nurse at the health centre to say that remarkably she’d managed to track down the first patient we had gone looking for. Hopefully he’ll come to clinic on Monday.

The challenge of acceptance

For some reason (perhaps the planets have aligned in a unique way – more likely not), I have found myself challenging the same issue a number of times today. I am not sure that today is particularly special in fact, rather perhaps that my exposure to this recurrent issue has finally reached a critical mass and (rightly or wrongly) I have felt compelled to make some efforts to redress it. Or perhaps I have reached a place of confidence in my presence here and feel able to. Or perhaps I am just exasperated. Regardless, it is endemic to this part of the world.

It is the matter of acceptance.

It is not, I believe, that people here are indifferent to the huge problems that they face. Far from it in fact. Rather, I believe that things like death, inadequate resources, interrupted supply chains and poverty have become so familiar that they are ingrained into the culture as ‘just the way it is’. People are extremely grateful for what they have, and, accept what they do not. In many ways this is a hugely admirable perspective to possess. Many a book that I have read about mindfulness extol the importance of such an approach to life. To reach this place of universal acceptance is to find a sense of supreme satisfaction that enables you to live a life of genuine happiness. Whatever ‘deal of the cards’, ‘role of the dice’ or ‘twist of fate’ you find yourself with, you are content. Somewhere within this paradigm probably lies the secret to why Tanzania is such a beautiful place to be, and why, perhaps, people here are so happy. It is also possibly something that we, in the West, could do with a healthy dose of reminding about.

However, acceptance can easily roll into indifference (it is a very fine line I think) and it is certainly very easy for this to also drift into a closed, fixed mindset (simply, this limits significantly what can be achieved). Whilst I could give you countless examples of a closed, fixed mindset back home in the UK, here I believe it is particularly problematic. Furthermore, I believe perhaps somewhere within this complicated matter, lies one of the greatest challenges that faces a country like Tanzania.

(I have probably very inadequately addressed what I am trying to write here and completely accept that ‘musings’ this time might in fact be ‘ramblings’. However, to continue…)

Now that I know what I am looking at, I see it all around me. There have been clues everywhere.  This morning there was another child death. A three year old diagnosed with severe malaria. They attended the hospital and were treated for severe malaria. They died from severe malaria within 12 hours of arrival. Except that they might well not have had “severe malaria”. They essentially presented with a clinical picture of severe sepsis (I think most will understand such terms). This is bad and in the UK the patient’s care would be rapidly escalated. The child would almost certainly receive a dose of strong IV antibiotics within the first 20, possibly even 10 minutes of arrival. Here they did not get any. Blinkered by the finger prick malaria test (which I am told is positive in up to 80% of the population – it indicates exposure, not necessarily active infection) the course of management was decided. Perhaps sealing the child’s fate. I may be being unfair, the child may have had severe malaria and despite the best possible care, died because of a late presentation. But they might not.

I have listened to several such stories (and you might recall the dilemmas I faced in the older child I ultimately performed a laparotomy on towards the beginning of my time here). Perhaps they did all indeed have severe malaria, with parasites overwhelming their immune systems and ability to survive, but I am suspicious that several of these cases did not. Today, as we were moving on to the next death, I questioned the diagnosis. I asked what the parasite count was (which we can do here and would provide definitive diagnosis) and also when the child received the first dose of antibiotics. There was silence. Then some discussion. Cats and pigeons come to mind. I think there was some useful discussion. Certainly, there was very positive support for what I was suggesting from the senior medical staff. Perhaps it is a small step towards broadening clinical thinking.

Exploring this matter of acceptance further, I have come to recognise that there is a reluctance here to question what is suggested or presented as fact (for example by a positive MRDT result (malarial finger prick test). It is very apparent when talking to medical students. You can also easily uncover this in any clinical situation if you adopt an educational role and try to encourage clinicians to broaden their differential diagnosis. It is particularly problematic if a patient has already been assessed by another clinician of the same level.

As an individual who has never been shy to ask questions (many a raised eyebrow and nodding head reading these words perhaps), I find this particularly interesting.

The next death was no less harrowing. A maternal death following emergency caesarean section with heavy blood loss. There were warning signs post op. Why didn’t they take the patient back to theatre?

Rounds were brief and we had managed to salvage a few cases for theatre today (the blood crisis persists).  However, we were bounced. Our access to theatre was denied. Once, twice, thrice and then a fourth time by emergency caesarean sections. I did ask whether we could run parallel theatres, but when I discovered that one of the cases had progressed to an emergency hysterectomy for a ruptured uterus. I found myself just accepting. The baby had died. Sometimes, it is definitely better to just go with the flow. I occupied myself admirably whilst waiting – home for a cup of tea and paperwork, I even squeezed in a bit of DIY (fitting a wall fan that we had been waiting to be replaced for over a month – when it didn’t work, I quickly uncovered that the previous ‘faulty’ fan had been wired live to earth. Hmmm. Well at least it is all sorted now).

On my way back to the hospital I crossed paths with the pharmacist. Disappointingly, all the time I had spent trying to understand the logistics and supply chains seems to have been in vain. We were apparently no closer to being able to stock the drugs for BPH or new sutures that I had requested over a month ago. Why not? Great question? Quite a long discussion ensued. The long and the short of it was that I have encouraged some lateral thinking, perhaps asking other departments how they manage to get such things. Again, perhaps we have made some progress.

We eventually got into theatre, overlapping with the final C-section. Unfortunately, the air-conditioning unit in theatre two was broken. To say I sweated my way through a difficult inguino-scrotal hernia repair is an understatement. I think I would have been drier if I had lain down in a bath. Sweat dripping down my back as I operate is definitely something I have had to get used to here. But today, with the air-conditioning out, it was a particularly special experience. Although I did have to smile as the very considerate theatre team started to fan me with papers in a very ‘emperorial’ way. Unprompted, they then then proceeded to mop my brow and neck. Ha! They should see me after my morning run!

Blood Crisis

At this morning’s meeting, I asked about the availability of blood. I am glad that I did. Normally it is discussed every day. Today it was not (or perhaps I missed it, I am still struggling to follow many of the conversations that occur in swift Swahili). Whilst my need for blood during surgery here has been minimal (very much in line with my practice in the UK, diathermy clearly helps), we had two cases planned for this week that would be foolish to start without such a possible back up. It transpired that there was a problem. And a big one at that.

We frequently have problems with the availability of blood. The first common problem is donation. We are always walking a tightrope with our stocks. Usually for a patient to receive blood, the widely understood agreement is that it requires a relative to donate a replacement unit (imagine that in the UK!). The next common problem is that whilst there might be blood in the fridge, there might not be any that is a correct match for the patient requiring it (look up blood groups on google if you want to learn more – really very interesting). The third issue is that whilst we might have the bags of blood in the fridge, and of the correct Blood Type, the screening process might not have been completed to ensure that the blood would be ‘damu salama’, safe blood. With the rates of HIV in the population in the order of 2.5-4% and the rates of Hepatitis B as high as 9%, this is a crucial step in the process. A few years ago, a programme was set up to improve the safety of blood transfusion in Tanzania by taking the screening process away from local hospitals and establishing centralised screening centres at the ‘zonal’ hospitals. A sample of blood is taken with the donation and sent away for comprehensive screening. Whilst this has been a big step forward in improving healthcare here in Tanzania, today it was this step that had faltered. Big style.

The blood fridge.

Literally a domestic fridge with blood.

Today, we physically had bags of blood in the fridge, but the central screening process had a problem. Our zonal hospital in Moshi, it transpired, had run out of the required reagents to carry out some of the screening tests (this means that the machines won’t work because they are short of the required chemicals). As this issue was recounted to me, I was stunned. And my first reaction was that I must have misheard or misunderstood what I was being told. Nope. I had indeed heard and understood correctly. I was stunned. How could such a situation have been allowed to evolve? Furthermore, as the cogs in my head began to turn once again, I started to think through the full implications of what I was being told. Massive. This meant that every hospital in our zone (most of the north of Tanzania) had a major issue if they needed to give a patient a blood transfusion. Basically, they couldn’t. We, indeed, had none. Gulp. The same would be true for even the major centres, although they might have slightly bigger reserves.

There was no doubt in my mind that we would be postponing all the elective or expedited cases that could potentially require transfusion. But I was left with two further questions. When would the problem be sorted? And what about emergency cases? My first question could not be answered – to me such a lack of information is not acceptable, and I pushed the hospital a little on this. I was told that the issue had been escalated to the highest levels (ministry for health), but still no timescale offered. I got the impression that it might not even be a matter of just a few days….. I was left with a sense of deep unease, but some reassurance that the main players here in Muheza would give the issue their fullest attentions. The second response was as bad as I could have feared. Should it be a dire emergency and a patient absolutely required blood…. well they would have to be given unscreened blood. Gulp. This blow was slightly softened by the fact that we would undertake the few major screening tests that we could here…. but it would still be pretty risky.

Having been a blood donor as a medical student (I am no longer permitted as a surgeon, it is considered an exposure prone profession), I know a little about the blood transfusion service in the UK. The demographic screening that takes place before you are even allowed to offer your arm for letting is extensive. Furthermore, the screening process before the blood products are released for use is comprehensive. Yet we are also all probably aware of the well-publicised historical mishaps. Some of the stories are pretty harrowing. Blood transfusion is a big deal, albeit one that healthcare in the UK now rather takes for granted. Even in the face of the occasional national shortages that make the major news, we are so very well served and catered for. Yet here I am in the middle of a major blood crisis. It’s best not to think too much about it….. if you do lapse and let your mind wonder into the graphic possibilities, it is frankly terrifying.

I am left with the conclusion that all we can do is practice responsibly, take no risks and cross every finger and toe that a disaster doesn’t happen on our doorstep.

Spare reagents anyone?!

Halfway to….

We have been in Tanzania now for 75 days. We have another 75 days to go. Blimey!

The malarone calendar!

Today, I will start with some news on the home front first. For it is hugely important news indeed! Our most sceptical child, who has had many a tear at being here (bless her), has this evening declared that she actually now quite likes it in Africa and is indeed pleased we have come! Two excellent days at school have definitely settled her. Whilst I suspect we are far from being ‘home and dry’, both parents agree that we will bank it! Sometimes my heart wants to explode with pride. Our children have weathered this demanding adventure so very well. It has been far from easy for them, but we are optimistic that it will, in the long run, be hugely beneficial to them. Of course, there is also the possibility that it might in fact scar them for life…. only time will tell (joking aside, for anyone who would consider doing such as thing as this, it is definitely worth it).

On the work front, today I have concluded that there is only one of me.

Morning rounds were brief (I delighted in discharging the perforated gastric ulcer laparotomy) and then I escaped to the home ‘office’ before clinic to pursue the increasingly demanding clerical / logistical work facing me. I was corresponding with the UK, India and distant parts of Tanzania in my pursuit of ensuring sustainability of the mesh project. We are so close to a viable model that I have become increasingly aware could be rolled out throughout the country. So far, every hospital that I have visited have been extremely interested in this endeavour. It is a project gaining unexpected momentum and whilst this substantially increases the workload and ‘stakes’ of such work, I am increasingly excited by the potential of it too. The reality is, that if the momentum continues, it could rapidly transform hernia surgery throughout Tanzania over the next couple of years. But I resist getting carried away with such things. Every little step.

When I arrived in clinic, we were midway through another marathon. We topped 40 today. Bonkers. Whilst very demanding, the flip side is that the opportunity for learning for the local team (as well as me) is huge. A great example was the older lady with a multiply recurrent incisional hernia for which a mesh repair would be ideal. She had been seen a number of times and brought back specifically to see me. However, her symptomatology did not fit with the clinical findings. I concluded that we needed to consider other possibilities (like rectal cancer). Indeed, clinical examination revealed exactly that. So, hernia repair off, she needs a CT, MRI and colonoscopy. Except that we’re not in the UK. It is nothing like that simple here. Where as in the UK, these tests would all be done in most local general hospitals, here…. We have referred her to the National Hospital in Dar es Salaam in the hope that she will be able to get there (we established she has family in the city) and be able to afford and have these tests (I think an MRI is unlikely). Hmmm.

In amongst many other interesting patients (you are certainly never bored in these clinics), I received a call from one of the surgeons I had met last week in Dodoma. They asked if I could return to perform three laparoscopic cholecystectomies with them next week. Gosh. My mind was already spinning from trying to work out how we were going to get all the cases planned for this week done. It was already spilling into next week and after that, we are planning another little adventure… But what an opportunity. Wouldn’t it be fantastic to help them start their laparoscopic journey in General Surgery. So much to consider, so much to think through. Next week would be seriously pushing it though. There is only one of me…..

Karma, bump, karma, bump, Karma Chameleon…..

I have had my fill of bumpy roads and driving a 4x4 this weekend! Many an exhausting hour behind the wheel. We went to the Amani Nature Reserve in the Usambara Mountains for the weekend – the ones we look out over from our house. It is an incredibly interesting place, having been saved from complete deforestation in the early 1890s by a German research camp (malaria and other vector-borne diseases). It has a lot of very interesting history (I will save you the lesson here, you can look it up if you are interested) and is home to several trees, plants and animals unique to the reserve. Much to my delight it is also home to a tea plantation (visiting one has always been on my ‘bucket list’, I drink so much of the stuff) and much to the chidlers delight (and ours, if I am being completely honest) it is one of the best places in the world to see chameleons (cue recurrent ‘Karma Chameleon’ by Culture Club renditions to the delight of the parents and the embarrassment of the Chidlers [well the oldest one anyway] – we may have just hit an important parenting landmark… are we now officially old?).

Incredible views

A selection of chameleons, they come and go..... they come and go...o...oh!

Enraptured chidlers (and parents TBH)

Tea Plantation

Beautiful waterfall and perhaps one of the first hydroelectric power stations in Africa? Now disused.

A typical African village 'mud brick house'

Swallows and Africans

I am not sure whether I should share such things, but I have always had an emotional vulnerability when I am tired. Many I am sure would read this as a weakness. Others might be touched by the humanity of it. I think the only person who is really aware of its existence is my wonderful wife who has of course seen me through most of the highs and lows in my life. Although I suspect there have been times even in my professional life when there have been glimpses of it. Perhaps towards the end of a particularly long day at work, or an all-nighter or one of those occasional brutal 36 hour marathons, when my eyes have misted in the face of some pretty tough situations. I’m fairly sure some of my colleagues over the years have noticed. Those moments that catch you – the arrival of a family member to the bedside of a very sick or dying relative, breaking bad news, the beauty of an elderly couple sharing their last moments together, the agony of an unexpected death….. As a doctor, your patients and their families need an empathic professional, not a blubbering wreck, so you learn to manage such things, a professional front that is as much a shield for you as it is important for them.

Out of the window

This morning, having got up at 04.30 to catch the bus, I was tired. And as I left Dodoma, watching the scenery change, I had a lot to think about. Perhaps listening to Coldplay’s ‘A head full of dreams’ didn’t help. As I stared out of the window, a solitary Mzungu in a bus full of local Africans, I looked out over the beautiful scenery (savannah with occasional iconic baobab trees rolling into the mountains in the distance), breath-taking as it was slowly illuminated by the breaking dawn. And then there were the villages, just a few kilometres out of the capital, mud huts. Beautiful in their simplicity of creation and closeness to the natural, yet also a stark reminder of the reality of life for much of the population. I was, for some reason, caught completely off guard. A wave of powerful emotions crashed over me. I found tears trickling down my face. I felt completely overwhelmed by the multitude of thoughts racing through my head. The enormity of the situation I find myself. The stark reality perhaps getting a rare outing in my tired state (we humans are, I think, very good at managing or perhaps disguising such things).

Such a beautiful country. Such a beautiful people. We have been so very warmly welcomed into the lives of those we are working with. It has been such an incredible experience. Such an amazing adventure. Such a privilege. And for all its challenge, I am so glad we came. And yet, having started to meet more and more amazing individuals and seen the highs (as well as the lows) of healthcare in Tanzania I was struck by how fleeting our visit here is. And, whilst on the one hand I have bold visions of an evolving period of amazing transformational change in healthcare here, I was also struck by the limitations, perhaps, of what we are doing. One family. Two Mzungu doctors and three young children. A speck in a vast ocean of people. Like swallows, we have come to Africa for just a short ‘season’ and then will be off again, back to our comforts in the West. Leaving behind the lives of those people who live here. Many new friends among them. The tender thread they live on, no less tender really for our time here. We have been a pleasant distraction perhaps, but has our visit really been anything more than that? Sure, we have certainly made a difference to a number of lives here, undoubtedly saved a few even, and that in itself is of course fantastic. But are we just a transient novelty, an eddy of breeze on a hot day, a glimmer of hope soon to be gone? What happens when we leave?

I completely accept that I am a dreamer, but it strikes me so very powerfully right now that so much more could be done. But how? Ideas are just ideas. Dreams are just dreams. Words just words. Aspirations just aspirations. Of course there is value in the little (I have always been a strong advocate of such notions, there is value to every action). But I have also seen glimpses of how much more could be done helping to transform lives across this country, not just in one small pocket. Collaboration is a word I have used a lot in recent weeks. Perhaps, with the right interest, enthusiasm, passion and support from both within Tanzania and without, perhaps these dreams, these glimpses of a better future might just become reality in a timely fashion. Perhaps….

….Every little helps…..

Swallows are annual migrators, right?!

Teased with a laparoscope.

Wow. Today has been so very interesting and insightful. I visited one of the big hospitals in Dodoma to see the Muheza Doctor currently ‘Resident’ for his Specialist Surgical Training. I found a completely different perspective of healthcare in Tanzania. 

The hospital was stunning, absolutely beautiful. Big, newly built and, I believe, with the vision of becoming another National Hospital (the main one is in Dar es Salaam). I visited the ENT department, where they are having a new Stortz outpatient endoscopic system installed in two rooms (complete with blue lights on the coving, very snazzy) – this is better than most hospitals in the UK have. Theatres where they have two OR1 type set ups (state of the art theatre lights with built in camera that shows the surgery on a TV screen on the wall, full laparoscopic stack, modern anaesthetic machine, very new diathermy system – to be honest better than most theatres in the UK). ITU with 6 fully kitted out bed spaces to a level you would genuinely be happy to find in any UK hospital. A laboratory with new machines in multiple rooms also to rival anything that you might find in the UK. Very, very impressive. The only slightly sad thing was that it was fairly empty. It was a world away from the hustle and bustle familiar to any UK NHS hospital. There were very few patients using these services. The huge potential capacity was very underutilised. Large pristine waiting rooms in each department (with very comfortable chairs) were empty, the ITU had no patients – we earlier had seen one recently discharged being wheeled down the corridor. Oh, how I long for some of that kit in Muheza. It felt a little bit like an ultra modern ghost ship as we walked down empty corridors, empty offices, few patients….

ENT set up

Main theatres

Panoramic of ITU

Pristine but empty corridors

This is of course a project in progress, with many staff out of the country for training I am told (for example a new cardiac cath lab is looking to be the first such facility in Tanzania). It is also a referral hospital (there are two other lower level hospitals also in Dodoma), but I also suspect one of the issues is one of cost for the patients. Unfortunately, for most, treatment at such a facility is just prohibitively expensive. Even traveling to Dodoma for much of the population is, I suspect, beyond their means. Not least because there would be no family to help them (food and basic needs care is still provided by family even here). However, I did meet another group of very inspiring individuals. Doctors with a vision for what healthcare can become in Tanzania (the hierarchy here apparently leans very heavily towards the medically qualified). It seems that the main barriers at present are training of staff in specialist services together with patients who can pay for such things. For example, they have laparoscopic kit, but the only person who can currently use it in the hospital is the head of surgical services (an O&G surgeon). They all were keen to secure my return….

Selfie with the students.

(Permission to take and post)

I had come today as a curious visitor, with no intention or expectation of getting my hands dirty. However, as I was in theatre spending time with the general surgical team, it was almost inevitable perhaps that they would ask me to get involved. There was an appendicectomy on the list and they had already established that in the UK we would perform such a case laparoscopically. Of course they asked. I was a little hesitant (not knowing the team, or the kit they had) but following a visit from the head of service approving and encouraging such things as well as establishing that they had everything I would need (I vocalised a long mental list), I dutifully agreed. I feel that I have taken several such ‘jumps’ since arriving in Tanzania. Good or bad, adventurous or reckless, altruistic or insane, I am not entirely sure. But so far, they have gone well. I found myself both excited and hesitant. Could this be the start of a new laparoscopic journey in Tanzania? It was all arranged. As we waited for the patient to arrive, I was asked to take a tutorial on hernias for the medical students. How very appropriate. For anyone that knows me, I of course loved it!

And then, just as I had got my head around this exciting endeavour, it transpired that the kit was not ready and it would be 2hours from SSD. Hmmm. The patient had arrived and adopted the standard naked crucifix position on the table (she was however covered with a sheet). I examined her and was sceptical about appendicitis (despite the investigations [USS &MRI – yes they have MRI]). She was the classical RIF pain, of the like we see frequently in the UK, in whom a diagnostic laparoscopy would be perfect. Shame. Inevitably, I was asked to perform the appendicectomy. I quickly negotiated this to evolve into a diagnostic limited laparotomy (of the sort I have done in Muheza). I did not want to leave behind any diagnostic uncertainty that would invariably arise if the appendix was normal (“that Mzungu surgeon…..”).  There were some shenanigans with the anaesthetic (an initial oesophageal intubation), but with no detriment to the patient, and I (thankfully) did not need to get involved. All very routine then. The surgery went very well (normal appendix) and whilst some of the more reserved members of the team gave nothing away, I feel like bridges are being built.

I am afraid that my blue-sky thinking has gone into overload on the back of this visit. As I sit in my hotel room (very nice it is too – hot shower [cleanest I’ve felt], nice food, comfy bed with duvet [it is deliciously cooler here]) my mind is in overdrive. So much could be quickly achieved in Tanzania with a bit of collaboration and support from willing trained professionals. A laparoscopic programme could be very quickly established, all it needs is the right sort of trainers. Practice could significantly evolve. For example in my chosen subspecialty field, currently any patient with rectal cancer here gets an APER. This means that anyone with a bowel cancer within 12cm or so of the anal verge gets their entire rectum and anus removed and a permanent colostomy fashioned. This is a big deal as rectal cancer a common site for colorectal carcinoma. In the UK if you can get just 1cm clearance from the anus (some centres go lower), most people would be offered restorative surgery (ie they can still poo through their bottom)…..

….I am getting carried away with the technical (but I am excited by such things). What I am seeing, is the potential for rapid progress in healthcare in Tanzania. And for such things, you need the bar to be raised at the top end as well as at the bottom. It is the only way to generate sustainable progress. Whilst it might be easy (perhaps obvious) to say that such substantial investment could make a massive difference in the poorest and more rural areas, I actually believe that raising the top end is important too. For people to see what is possible, gives them something to emulate. Every student, trainee, or other staff member passing through such an institution would know that such things can be achieved in their country. And this is powerful. Very powerful. For me, I have quite clearly seen that there is no reason why healthcare in Tanzania cannot equal that of the west, if only it can find the right resources – financial, vision, expertise to train, logistics…. 

On the back of this trip, the hernia mesh project is also rapidly escalating…. Crumbs….

And perhaps most importantly, I have met one of the key team players for the future of Muheza. I could not have asked for more. What an incredibly kind, gentle, intelligent and inspiring individual. Whilst we did not get a chance to operate together, for some reason I know he is very good.

In his mid 40s and a trained doctor, why did he leave his family behind (wife and two children in their early teens) to spend three years as an unpaid student (he gets just a block of 28 days holiday each year to return home), working incredibly hard, living in a shared room at the university complex and paying a huge amount of money out of his own pocket for the privilege? “Because the people of Muheza need me to. They need a local specialist surgeon.”

And THAT is Tanzania.