Helpful reminders.

It is quite easy to overlook or forget quite how much we have done and quite how far we have come. Today I was asked a question by one of our UK medical students that made me take a moment to consider such things. When I think back to what I came to in November, or even back to when I first came in July, things in Muheza have moved forward substantially.

Beyond the progress of the mesh hernia work (which features heavily throughout this blog) the beep, beep of the anaesthetic monitor brought by the Hereford team in July is now a familiar sound in theatres here. It is used all the time and we have gotten very used to it. In fact, when I think back to what was done before, it is a massive step forward (they might have used a pulse oximeter). But it is best not to think too much about such things, as when two theatres are running (as happens fairly often with emergency caesarean section) there is only one monitor. And thus one patient goes unmonitored. Even this situation is also potentially fragile when you consider that there is no backup currently if it were to break….

That can also be said for the diathermy machine we now use for almost every case (previously redundant except for occasional use by a visiting ENT surgeon doing tonsils and adenoids). The team are so familiar with its use now that they know to set it up for bipolar when we are doing paediatric cases. Today I looked over to see that the wires were in the right sockets, the bipolar selected and the other settings were correct (bipolar means that the electric current is not transmitted through the body, which in smaller people is safer).

The ‘WHO’ checks are now done as routine (even for cases overnight) and the swab count has become second nature. These are just a few of the things that immediately came to mind, and each of them make surgery safer and better quality. And there are many more things I could add to the list.

Furthermore, when we had a bit of ‘excitement’ whilst anaesthetising the child for the first case of the day, the problems were dealt with calmly and efficiently. It was a world away from some of the situations I have recounted previously, having unfortunately found myself part of during my time here.

But it is not all roses. Yesterday there was another neonatal death, this time due to a cord prolapse (the umbilical cord pops out before the baby and is compressed which cuts off the blood supply (and thus oxygen). Whilst I am not an obstetrician, I think I can remember some simple measures that might have resulted in a better outcome. Things like this remain pretty heart breaking. I am encouraging discussion around this case (and other adverse events) which I hope can maximise the learning and minimise the chance of them happening again. A cornerstone of the modern approach to healthcare perhaps, but this requires a cultural shift across many different staff groups, and it will always be a slow process.

On the home front, Kate went to Tanga to renew our visas. They were due to run out today, but I was told that many discussions had already taken place, everything was agreed and that I should remain in Muheza to continue to operate. So it should have been an easy process…. but of course it wasn’t. I am delighted that I am sitting at our desk this evening writing this and not driving madly to the Kenyan border or to Dar es Salaam to find a flight home. The renewal was indeed granted, but only for another month which means we will have to return to Tanga once again in the hope that they will allow us to stay for the final 8 days until we are due to depart! I guess life might be tedious without such excitement to keep us on our toes and it certainly seems that this might be considered another Authentic African Experience.   

Things are hotting up.

The temperature in the middle of the day is certainly becoming more oppressive. Even the locals complain of the heat. It is 33°C in the shade which BBC weather tells me is a real feel heat of 44°C! Pretty sticky at night too.

Delightful queue of 'taxis' at the

'front door' 

Today I travelled to Korogwe (just under an hour away) to visit another hospital where I had discovered they perform mesh hernia repairs. It was very interesting to visit another district hospital within our region. Whilst quite a large town, the hospital is smaller than that in Muheza. Their head of surgery is a Nun, a medical doctor and a trained specialist surgeon. Another amazing individual. It was such a pleasure to meet her and we happily talked for over an hour about things. She works with one other AMO surgeon on the General Surgical side.

Large numbers of diathermy 

handpieces!

They have been supported for many years by the charity Hernia International. They host about two ‘missions’ a year, each for about two weeks with hundreds of hernias repaired with mesh over the last decade. It was also great to hear that the missions have trained the local staff too. Between missions, they now continue to perform mesh repair (although the numbers are low given the uptake during the missions). Furthermore, with all these hernias repaired, the incidence of emergency presentations with complicated hernias has dropped considerably, a real testament to the project. It is fantastic to hear first-hand about the great work that this charity has done. I was very interested to hear about the finer details as well as take a tour of their hospital. One of the things that struck me the most was the plethora of equipment that they had. Numerous anaesthetic machines, diathermy machines and with loads of pencil handpieces accumulated over the years being left after each mission.

Very similar theatres, but more kit.

I was delighted to discover such a wealth of experience in mesh hernia repair locally. Even better news was that Sister was very keen on the idea of future collaboration both with Muheza and more widely. She was very encouraging about my vision for potentially sharing our experience and expertise more widely and I feel I have discovered a strong ally here. She was interested to hear about what we have been doing and was delighted to hear that we have managed to set up a viable ongoing service. She wants to support this, offering to visit Muheza in the future to work with the AMO surgeons here as required, until such as time as our Specialist Surgeon completes his training and returns at the end of the year. This was music to the ears of our Hospital Superintendent sitting next to me! Furthermore, it was clear that there are several aspects of what we are doing that are of particular interest, and as such she agreed to visit us next week. So on Wednesday I now have two specialist surgeons coming to humble Muheza. Things are certainly hotting up!

After such a rewarding day and on returning to Muheza, we have been treated to dinner at the convent of our lead nurse anesthetist (an unrelated event, although interestingly we learned that all the Nuns mentioned in today’s post know each other and are from the same church!). Up in the hills overlooking Muheza centre, there was a very pleasant breeze making it that little bit cooler. We had a tour of their shamba (farm) including cows, pigs and chicken which are of course universally appealing to children wherever you are in the world (adults too!). We were then treated to a Tanzanian feast which we all devoured. 2nds and 3rds were had by all the children which could not have been better compliments for the cooking. Delicious. The company was also delightful and it was certainly one of the highlights of our time here.

My ladies all sporting their newly made 'African Dresses'

Sustainable Progress

I have long believed that a powerful marker of a successful teacher is to make themselves redundant. Today, I have achieved such. The local team undertook two mesh hernia repairs completely independently, with me sitting and doing some admin in the surgeons’ room. I popped my head into theatre from time to time and what I saw was so very pleasing. It may have taken a long time (the first one took 2 hours!), but the quality of operating was extremely high and the end technical results excellent. I feel incredibly proud. It is such a pleasure to see them confidently using the diathermy, progressing through the various steps of the procedure correctly, handling the tissues with increased care and confidence and working well together. I am also certain that speed will come with time. By taking their time now to learn something well (doing is an important part of this), the natural progression is for the pace to quicken as experience and confidence grows.

I could have come to Muheza and operated independently for five months and achieved a fair amount. Instead however, I came to Muheza with the hope of working towards something sustainable. I can now confidently say that I will be leaving behind a viable mesh hernia service for the future. As a team, they now have the equipment, knowledge and skills to prepare the mesh, perform the surgery to very high standard and also continue to follow up and audit their practice. Excellent. Furthermore, this model is now certainly something that could be shared and applied more widely throughout the region, country and perhaps even the continent. But let’s not get carried away.

For all the challenges we have faced in getting here, arriving is all the sweeter. I am chuffed to bits.

It travelled through Mumbai,

Dubai, Nairobi and 

Dar es Salaam to get to me!

As if to mark the occasion, the shipment that I have been awaiting of further supplies of mesh arrived from India. For that I have to thank the incredible generosity of the Indian Surgeon who has pioneered this technique, what he has achieved is mind-blowing. It is enough mesh to do several hundred, if not several thousand repairs and thus also opens the door for other centres to potentially start using it (we have already made some provisional steps on this journey).

Of course, there is always more to do, and we will spend the next few weeks reinforcing everything that we’ve learned together. But I’m going to enjoy a beer tonight and go to bed a very happy man.

Stunning sunsets

Today has been a thankfully gentle day clinically which was much appreciated after a rather turbulent start in getting the older two out of the door to school.

Rounds were very brief and we discharged the man on whom I did a limited caecal wedge resection during his strangulated hernia repair last week. I was also shown two legs with pretty horrendous ulcers. Middle aged men, one of whom was hit by a motorbike 5 weeks ago, the other developed the ulcers spontaneously 3 weeks ago. Whilst I am not a massive fan of managing such wounds, I am grateful for my vascular experience during the early years of my registrar training. Both these men face a very long road if their legs will be salvaged. Amputation is still very much on the cards. But I hope we can give them a ‘wash and brush up’ this week and then hopefully have some success with skin grafting – I brought a special machine to help with such things from the UK. It is VERY heavy and so putting it to use would at least partly justify its big dent in our baggage allowance.

Clinic was surprisingly pleasant as we ran two rooms. Our room still seemed to see the lions share, but then again that is hopefully very good experience for the AMO I was with (the more junior of the two). We saw quite a few children (I have certainly rediscovered my love of paediatrics) and a number of mesh follow up patients, all of whom are doing brilliantly. We finished at lunchtime for a change and it was very nice to get home to eat with my wife who also had just returned from Hospice home visits. We opened a tin of corned beef (something I have always loved) which felt like a real treat – however sad that sounds!

For all the difficulties we face of where we are living, one of the wonderful things about it is that we get a fantastic view of the Usambara Mountains. The sunsets tend to be beautiful most of the time, but this evening it was particularly stunning. A real marvel of mother nature. The photo definitely doesn’t do it justice, but its not bad.

Escapism

Certainly in contention

I think it is fair to say that as a family we might be reaching saturation point here in Tanzania. The chidlers certainly seem to have been worn down by the heat, lack of roaming space (it’s too hot to do very much outside most of the time), water shortages, regular power cuts and alternative schooling. We have struggled to establish any sort of consistent / acceptable routine for them, which as any parent will know is key to finding a steady path. It is also difficult as parents to challenge their complaints when they are completely reasonable! They have done brilliantly, but I think the next few weeks will require a superhuman effort from all of us to make it enjoyable. 

If we were to do this for longer, I am completely clear that we would do it differently. Certainly we would need to find a school that would be both comfortable and challenging for the children. The current arrangement has been neither and has relied heavily upon home supplementation. Far from ideal for any of us. A massively beneficial experience for them (life changing perhaps) but I think they have gotten all that they can from that for now. I think we would also need to emulate more of the ‘haven’ we found when visiting our friends in Arusha. Space and home comforts for the children would make a big difference to all of us. It is difficult to embrace the challenges of working here when you come home to a turbulent household.

Ironically, I find myself increasingly settled and comfortable in my work. Whilst a similarly experienced colleague would be extremely welcome (there is undoubtably quite a significant burden of responsibility, which although I embrace happily is also invariably quite draining), I have found my path and have created plenty of ongoing challenge to fuel my curiosity. I would be lying to say that I don’t miss my UK practice – there are many times when I long to enjoy being part of a truly world class treatment pathway (not to mention good kit!). But of course, on my return I will enjoy and appreciate such things all the more. And I hope that it is clearly apparent from my posts that I feel the work I am doing here is so very valuable. Genuinely, I think I have made more of a difference here in 5 months than I am likely ever to make in the rest of my UK career. Whilst I hope that I am good at what I do, the reality is that back in the UK if I didn’t do it, someone else equally qualified would. Here there was no one else.

So this weekend we have headed once again to The Tides in Pangani (where we spent Christmas), in the hope of recharging batteries (undoubtably escapism tactics). We managed to leave early on Friday afternoon and with the dirt roads evidently ‘serviced’ (some big machinery had restructured them, smoothed the surface and eliminated the vast majority of potholes) we made excellent time. It is beautiful here and we are very well looked after. The chidlers noticeably relax and of course the parents do to. I just hope that it is enough to see us through the next week. 

Dinner on the beach and incredible views from the bar

Perhaps we might heed the inspiration printed at the bottom of our Saturday night dinner menu:

'A winner is a dreamer who never gives up' 

My new favourite piece of art!

Barking up the wrong tree?

A new contender for outrageous bodaboda load award.

The Hospital Superintendent was very cross!

Today I went to Tanga to meet with the Regional Medical Officer. This meeting had been arranged at my request by the Hospital Superintendent. The RMO is the most senior doctor in charge of a Region and is quite high up in the hierarchy of Healthcare politics. I was keen to see if there might be any avenues to make the organisation of future trips easier and was also wondering if this meeting might be a bridge to meeting other more senior Tanzanian Healthcare policy makers (the Minister for Health?!).

I was asked to explain what I have been up to since being here and also why I wanted to meet with the RMO. I dutifully gave an account of our work, focussing mainly on the Mesh Hernia series as I feel this seems a tangible project to base future requests around. I then went on to explain the barriers we had faced in coming out and how I felt that these are a significant issue for future collaboration (it makes it very hard).

My hope was that the RMO would be enthusiastic about our work, see the potential for expansion of the mesh project (as well as others) and would be highly supportive of future collaboration. Naïve perhaps. All cards were kept very close to the chest.

Quite reasonably perhaps, the RMO wanted to know more details about our work and of course has suggested that this be shared in the form of a written report. A googly that I had not expected was that there would be an expectation that the work should be ‘validated’ by Tanzanian Surgeons. Unfortunately (although predictably if the thought had ever occurred to me), the two ‘surgeons’ I am working with are AMOs (not medical doctors and not trained specialists). On the one hand this could be viewed as a big gold star for the viability of future expansion of our approach, on the other it turns out they do not hold the necessary kudos to endorse such things. Furthermore, the concerns that I raised regarding the procedures and costs associated with our presence here were met with knowing smiles and described as the necessary procedures to arrange such visits.

I perhaps slipped with etiquette and may have proffered a ‘faux pas’ when I allowed some of my irritation to bubble to the surface. When discussing the costs, the suggestion was that initially these should all be met by the hospital who makes the invitation for overseas assistance. Until such a time as there was a strong enough argument, backed by evidence, to justify starting the processes required to acquire exemption from such fees (a lengthy process). When I challenged this notion with the statement that the hospitals cannot afford such costs (as well as the fact that the costs were high for people to work for free), the response was that if the hospital required such arrangements to care for the patients then the patients should pay for such a privilege. That is after all the model that the Tanzanian healthcare system is based upon. I was perhaps a little too blunt in asking what the point was of taking money from those with little and putting it into the generic government’s accounts for such a purpose. I also highlighted the World Health Organisations agenda in Global Surgery to reduce the burden on those requiring costly intervention (too many people in low- and middle-income countries are crippled by the costs of surgery – they often have to sell animals, farms and possessions to pay for what they need, leaving them destitute). In retrospect, this may not have been the best time to raise such a point.

I am told by the Hospital Superintendent that the meeting went well. There were certainly times when the finer points we were both making did not translate brilliantly into the others ‘language’ leading to some miscommunication perhaps, but at the end of the conversation the RMO was happy to learn more and support the work if the reports were suitable. We certainly left with smiles and friendly farewells. I must confess that my take on things was less enthusiastic. I left feeling significantly deflated. It was certainly not the pat on the back and ‘let us know what we can do to help’ response that it perhaps could have been.

This experience completely validates all the concerns and frustrations I have heard vocalised by many of the volunteers / NGOs / charities we have met working here. The procedural climate in Tanzania has become significantly more challenging in recent years, and in some experiences prohibitive, leading to the collapse of organisations and exit of individuals. From my perspective specifically regarding healthcare workers, it is such a shame that it seems so hard for people to come. People who will willingly work for ‘free’, are happy to share their experience (currently absent within the country) and gladly support the development of expertise within the country for the future. But perhaps that statement is being overly simple. Or perhaps the simplicity is what makes it so powerful. Hmm.

So it seems any quick wins for the future that I was hoping might emerge from these tactical meetings whilst I am still here, may not be so easy to come by. They also seem to create more work for me. However, I am sure that there is certainly merit in making these contacts. A faceless name on a piece of paper is far less compelling than a name of someone you have physically met in the past….. I hope.

What a difference a day makes

It is fascinating how mood can change. Having been feeling distinctly blue (in a low-grade fashion) these last few days, something changed mid-morning and I found that I had very much recovered my ‘mojo’! Exactly what happened and why is unclear to me, but I suspect a combination of many factors including the insatiable warmth and kindness of the theatre staff. Or perhaps they had sneaked something extra into the cassava they fed me (an ordinarily very bland starchy root vegetable, that had been cooked in some way to be delicious). Afterall, they had noticed that I was feeling a little bit drained yesterday…. they were all eating it too.

Anyhow, today has been interesting, productive and enjoyable.

Interesting because I was asked to review a young six-year-old boy with sickle cell disease this morning. Examining his abdomen, he had the best example of splenomegaly (a big spleen) I have ever come across. Whilst perhaps not ideal for him, the medical curiosity of such things for an enthusiastic teacher such as myself is very exciting. Furthermore, having four UK elective medical students here to later share such a discovery with brought much joy for me. Sad perhaps, but I have always known I am a medical geek and at least I can confidently say I chose the right career!

Productive for several reasons. Firstly, we performed another two mesh hernia repairs (adding to our series). The first of these was a recurrent hernia in a battle-scarred abdomen which I was asked to start, but was so straight forward that I insisted my Tanzanian colleague completed it. This was great experience and confidence building for him. The second repair promised to be very straightforward and seemed the perfect opportunity to try and acquire some photographs I have been wanting for a guide that I am slowly putting together. The patient was delighted to be asked and the case proved to be perfect for the task. Not only did we get some great pictures, but performing the procedure in such a stepwise fashion turned the case into a teaching ‘masterclass’. This was very useful for the local surgeons (such tactics in a teaching programme should not be overlooked) and it was a delightful experience for me too. It’s always nice when you feel you have performed something really well.

Secondly, the medical students delivered the whiteboard I had bought to the surgical ward. Another one of my many service improvement ideas, it has been waiting for a couple of weeks to be marked up as a bed board for the ward. I must say that they had done a brilliant job, much better than my original idea. When I saw it, I was really chuffed, and the ward staff were delighted. Hopefully this will make locating patients on the ward much easier, as well as getting a snap shot feel of what is going on.

Enjoyable for all the above reasons, but also because I got round to distributing the four other holepunches I had bought (one I had already located in the theatre office). I had become very fed up with never being able to file papers in patient notes properly (yes, I am a surgeon. And yes, I can, and do, file notes). When it became clear that the hospital procuring some punches was not going to happen anytime soon (trivial perhaps, but money is that tight), I bought five myself. Cost me about £8. These ‘zawadi’ (presents) for the wards were received very warmly and I hope will make things that little bit easier and better. I only hope that they are not locked away in a cupboard, they had a feel of gold dust about them when I handed each over.

A final small victory for the day was the repair of my sandals. I had bought a pair of leather Massai sandals (very nice, environmentally friendly – no plastic –, and good for local trade) but the toe loop had broken. They were taken to one of the many shoe repair ‘shops’ and for the princely sum of 75p were not only repaired but given a substantial upgrade – he ran numerous new stitches through them.

As I write this, it is much cooler this evening having rained heavily in the middle of the day. It is blissful and I think I might treat myself to a quiet cold beer whilst the chidlers watch a movie on the laptop.

All in all, a great day.

Like learning to ride a bike.

Today feels like another landmark in the mesh hernia work. The first case of the day was a pretty straight forward inguinal hernia repair and I informed the two local surgeons that I would not be scrubbing. It felt a little bit like the moment when you first take the stabilisers off your child’s bike hold their saddle to get them going then let go! It is a moment of deep pride mixed with inevitable anxiety. I sat on a stool in theatre watching them work together, resisting the urge to look too much or make ‘helpful’ suggestions. But I made plenty of encouraging noises when required. They needed a little bit of advice here and there and some gentle reminders about the details of some of the steps. But they did brilliantly. Until they ‘fell off’. Whilst skeletalising the cord (the life line to the testis), they had been a little overzealous and had caused one of the cord vessels to bleed. Their efforts to correct this was making things worse and there comes a point when the only ‘right’ thing to do is to intervene. I dutifully scrubbed, took control, explained the problem and demonstrated what I would do, whilst making it clear that the best strategy is to avoid being in this position at all. Fortunately, the cord was salvaged (which means the lifeline to the testicle remained functioning adequately) and the end result was a good learning experience. Having helped them ‘back up’, ‘brushed off their knees’ and got them going again, I once more ‘let go of the saddle’. And off they went. A wobble here and there but they finished the repair without further intervention and I must say that the end technical result was very pleasing.

Almost as reward for my efforts with the first case in the morning, they had booked the repair of a re-recurrent hernia as last case of the day for me. This means that it had been repaired twice before and failed. It was always going to be difficult and indeed it was. With the normal anatomy completely disrupted, it was quite remarkable that we managed to make any sense of it at all. However, we managed to find the spermatic cord, preserve it, carve out and suture together something to reconstruct a vague resemblance to what it should look like, as well as finding somewhere suitable to locate the mesh. In the end it came together well, but I couldn’t help myself from thinking about the laparoscopic approach we would have used in the UK in such a scenario. However, with a mesh now in situ, hopefully this will be the final time he needs this hernia repairing….

So another long, but good, day ‘in the saddle’.

Hitting the wall

For some reason today I have felt incredibly weary. Perhaps it is the stifling heat. Perhaps I am a little under the weather (two of the childers have had ‘head colds’ and I’m a bit snuffly) although I felt great on my run this morning. Or perhaps I am just fatigued by what we are doing here – have I finally ‘hit the wall’ of this ‘endurance event’? Regardless, it is draining, not least because by being aware of such things you work especially hard to ‘keep going’ and ‘put on a brave face’. Which of course is all the more tiring. 

Theatres seemed to be on a go slow today and we only managed to get three of the four cases done that we had intended to. It was originally only going to be three planned cases, but an emergency needed doing (strangulated hernia) and it seemed very realistic to fit this in as well. Evidently not. I waited patiently as the clock ticked by and whilst I drank some tea and caught up with some admin, I also listened to the somewhat concerning noises that accompanied the installation of a white board that I had bought for the department. What I thought was a fairly simple job requiring a drill and a couple of screws, the approach employed seemed to include quite a lot of loud hitting of the wall – I could feel the vibrations of each blow where I was sitting. Quite alarming. The analogy involving a sledgehammer and a nut came to mind... It is up though and seems to be fairly secure. The wall also looks to have survived. 

We did not start our first case until 10am, a 4 ½ year old child with what was either a lipoma (fatty lump) of his lateral abdominal wall or an unusual hernia. I have become so sceptical about the quality of our ultrasound imaging here that surgical exploration was the only way forward. I dutifully waited until he had been intubated before scrubbing (ready to provide back up if required) but all went smoothly and so off I went. However, on my return to the room (the scrub sinks are outside) somehow the ET tube (breathing tube) had come out (a medical student told me it had fallen out whilst other things were being done) and I saw the disastrous scenarios of the past flashing before my eyes. Not again?! Fortunately, a little calm authoritative support / direction was all that was required and the situation was promptly resolved. Not wanting to be blazé about his worrying desaturation, it was not for long and I’m sure he will be ok. The surgery went well, although it was bit of a fiddle as I was trying to keep his incision (scar) as small as possible and the lipoma (as it turned out to be) was extensive.

I had wanted to let the two local surgeons ‘sweat’ their way through the emergency case together. I say ‘sweat’ metaphorically because the A/C in theatre was working very well today. However, I wanted to give them an opportunity to work together as a team and get through this difficult case without me. It proved to be a step too far. In fairness to them, until the specialist surgeon returns from training in November, they would refer such a case on to the regional hospital. They managed the approach, but the hernia itself was troublesome and on reducing the scrotal contents into the wound the extent of the trouble became apparent. This was a genuine strangulated hernia and part of the wall of the caecum (first part of the colon) had infarcted (died) and was starting to perforate. I quickly deployed some damage limitation measures and got control of the situation. I managed to perform a wedge resection of the caecum which ended up looking very pleasing. Let’s hope it heals. In this context, repairing the hernia with mesh felt unwise. We thus performed a suture repair which I hope will be sufficient. Interestingly, the scarring that often accompanies a low grade infection (inevitable with such a case) will often result in a very sound long term repair. 

With all of that, we had to cancel the next elective hernia, but we agreed that the planned re-look of the scrotal abscess should be done. This was very pleasing and we were able to close most of it today. 

It was quite a relief to finish for the day and get home. Fortunately the power is on and the fans take the edge off the heat. The Chidlers are all on good form and really enjoying our new batch of elective UK medical students. Hopefully a good night's sleep will revive me, and tomorrow I can once again step up to the challenges of the day with a relaxed smile on my face. 

Is it possible to cheat the incoming tide?

For much of the day, my mind has drifted back to a young lady I saw this morning. It is most troubling. Between cases in the outpatients, I have been desperately trying to somehow magic up a solution for her. It is beyond frustration. If I saw her in the UK, her pathway would be very different from what she faces here. I have all the knowledge and skills to offer her a world class treatment pathway, but none of the tests, equipment nor ancillary / support services I need to do so. In the UK, such a discovery would be devastating, here it feels like a death sentence. And my efforts feel like those of a child trying to build a trench to protect my sandcastle from the inevitable destruction of the incoming tide. With my hands tied behind my back.

She is just 29. I had been asked to see her on Friday by one of the other doctors. She has had altered bowels and has been bleeding with the passage of stool. When I went to see her on Friday, there was no KY jelly available anywhere in the hospital (imagine that in the UK) and I wasn’t going to examine her without it. Unfortunately, todays examination could not have been much worse. Of all the possible diagnoses, she has a fairly low rectal cancer. Whilst certainty in such situations invariably comes with definitive histology (tissue samples) sometimes there is no doubt.

I am a specialist colorectal cancer surgeon and as my examination revealed the pathology, my subconscious mind was immediately gathering all the information that I would need to properly counsel and treat her. It was posteriorly sited, big, its lower border at about 6cm, but it was just too high to fully assess whether it was fixed or not (if so that would be a bad prognostic indicator). But as I thought through how we could treat her, all my ‘expertise’ seemed wasted. All that information I was subconsciously processing is inadequate on its own. For beyond that information there are major gaps that need filling before I can treat her effectively. As a surgeon, it is fantastic that ‘we carry’ many of the resources we need within us. Just a few simple instruments and we can actually do quite a lot. However in cases such as this, knowing what I know, without more information, I am pretty helpless.

I had a couple of UK medical students with me today and we took some time after seeing her to discuss the implications of her diagnosis. For me this proved to be an opportunity to vocalise the stark reality of the healthcare ‘injustice’ she faces. In the UK I would call in one of our specialist nurses to help support her through the information that I would need to explain to her. She would have time and support. We would perform a colonoscopy and acquire the definitive tissue diagnosis I described. She would also have a special CT scan and a very special MRI scan to help define the cancer and give us as much information about it as possible. That would all happen within about 2 weeks and we would then meet again to plan either primary surgery (keyhole surgery with the intention of maintaining her ‘normal’ plumbing [ie being able to poo through her bottom]) or if the cancer was too advanced, explanation and referral on to one of our specialist colleagues for consideration of chemoradiotherapy. This can then sometimes be a stepping stone to conventional curative surgery but if that has not done enough, we can then consider employing the skills of some very specialist surgeons who are pushing the boundaries of what is possible (and a lady of her age would be a very suitable potential candidate). Furthermore, if the cancer has already spread, that is not necessarily an end game scenario in a lady of her age, as we now have options to chop out other sites of cancer with the help of other specialist colleagues and within the framework of our extensive (and to me sitting here in Africa, frankly mind-blowing) extended MDT – multidisciplinary team. Oh, and not to mention the fact that as she is young, we would also certainly consider a genetic anomaly contributing to things, which would lead to her assessment within a specialist genetics service too.

Here….. yes, here…… Today I can offer her none of this. We can certainly try to refer her to the national hospital for a CT scan and whilst MRI is available, I am not sure that it would be of the sort I would require. If she is deemed suitable for surgery, the practice in Tanzania would be to perform an AP resection for such a cancer (that would mean removing her bottom and leaving her with a permanent stoma) and my understanding is that the mortality (risk of death) and morbidity (risk of other problems) from such surgery is very high here. And that of course assumes that she has the means and support to travel for such things. The last lady I sent for a CT scan has not returned for follow up and being known to one of the clinical officers here, I now know that she has turned to traditional healers (or witchcraft to use the words spoke to me).

In the UK, whilst these sorts of cases don’t come around very often, they always hit you hard as a clinician. They are like a bucket of cold water thrown over you, waking you up to the reality of life. I am sure different people will do different things with such experience. For me they help to remind me to appreciate what I have. I always return home, that little bit more humble. I hold my hugs with the children and wife that moment longer, and I give thanks for our current deal of the cards. That is in the UK. Here…. Here…. I am a little lost to be honest. I don’t know what to feel. I am powerless and feel woefully inadequate. Surely I can do something? Yet however ambitious I am in my thinking about what I could possibly do…….

The reality is that I will almost certainly just have to accept her fate. However painful and wrong that might feel. She is just 29, so young. And a mother too. I will try my best, but I strongly suspect that she won’t be alive in 12 months’ time.

So sad.

Weekend Musings – Dreams.

Martin Luther King very famously coined the phrase ‘I have a dream’. He was referring to his vision for equal rights in relation to race, skin colour, creed.

Over the weekend we have returned to Peponi for some much-needed R&R. It is so beautiful here and the sea breeze certainly takes the edge off the heat. We are well looked after and the chidlers have a wonderful ‘playground’ to entertain them. As well as resting and learning a bit more Swahili, my mind always seems to drift into thinking mode. Many reading this may smile wryly at that statement – I am well known for being a thinker!

Time certainly flies, and it seems that our time here is rapidly accelerating. It is now little more than 6 weeks until we will be leaving. Blimey. I could self-indulgently review all the things we have already done, all the things we have achieved, and sit here with a sense of deep satisfaction. However, whilst I will certainly take all those things and enjoy them, I cannot help but think towards the future. We have come as one family and without any doubt we have made a difference to the care provided in Muheza, both during our time here and (I believe) after we have gone. But we are just one family, I am just one surgeon. And, as will be so very apparent to anyone who has followed my writings regularly, there is SO much more that could (and indeed should) be done.

Furthermore, as my naturally inquisitive nature has led me on my journey (both physical and intellectual) to unpick the healthcare system more widely here in Tanzania, the more I learn, the more I see. And the more I see, the huge potential for further work becomes quickly apparent. I confess I have dreams. I have a dream that healthcare here in Tanzania could one day be much closer to that provided in the West. And in my dream, that day is not just some abstract point in the distant future, but that it might be soon and certainly within my lifetime. It would be amazing to think that improving healthcare in countries like Tanzania could become a catalyst for healthcare improvement more widely in Africa, and indeed the rest of the world. But that is getting carried away. My dream has had to ground itself on something tangible. Certainly ambitious, but tangible.

I have met so many amazing doctors, nurses and other healthcare workers here. What they do with what they have is absolutely incredible. But they are lacking so much. So very much. They need financial support, intellectual support, educational support, moral support. They need equipment, skills and enthusiasm. They need to see a vision for the future begin to unravel and then the progress will snowball. But my dream is that they are the ones to drive the healthcare revolution in Tanzania. What I have seen in my time here is that there are many strategic initiatives from NGOs that undoubtedly improve the system, but the impact on the ground is less apparent. I have also seen lots of individuals and organisations working here, some beavering away for years, some parachuting in and out. My dream is about supporting the local teams to do it themselves, to drive this healthcare revolution forward. Sure, they will need lots of support to do this. But that is my dream.

I have given much thought to all this. My mind is awash with ideas. I find myself in a raging torrent of possibilities struggling to make sense of it all and to keep my ‘head above the water’, to keep myself breathing the air of realism. But perhaps all ‘great things’ (dare I suggest that these ideas might become such) have to start somewhere. Fortunately, I have an amazing wife who is an incredible sounding board, tempers my enthusiasm and helps direct my energies into something productive.

We have a place to start. Right here, right now, in Muheza we have a working model for mesh hernia surgery that could transform care throughout the country. It is a small cohort perhaps, for now. But hernia repair is the most common general surgical procedure carried out in Tanzania and indeed worldwide. If we can share this experience more widely in Tanzania and support the evolution from suture repair to mesh repair, then that would be a massive step forward. I have made many contacts and I have ideas. So much more work to do and I will certainly need help. But we have made a start.

“Human progress is neither automatic nor inevitable… Every step towards the goal of justice requires sacrifice, suffering, and struggle; the tireless exertions and passionate concern of dedicated individuals.“

February 10^th 1961, Martin Luther King, Jnr.

It can’t go too smoothly.

The focus of my day today has been resuscitation of the mesh autoclave. Last night, I was shown that the adaptor plug had burnt out. You may recall that the native plug for it is an Indian plug (I think) and so the adaptor plug is essential. The plastic around one of the pins had melted. It was definitely kaput! 

Of course alarm bells should have rung at this point, but it was not until today when I was looking for a solution to get it back up and running that the true extent of the issue transpired. Having been told that a suitable adaptor plug would not be available until a trip to Tanga was organised (likely next week), I reasoned that it would make more sense anyway to rewire it with a UK plug (most sockets here in Tanzania are UK). The plug into the wall was a sealed unit and it would require cutting the wire (and completely sacrificing the plug) to work this solution. I had a look at the plug into the autoclave and saw that it could be opened and thus rewired that way. So off I went looking for a suitable plug and cable – such as from the kettle or microwave that had broken at home. 

After a bit of toing and froing, I was taken into the store room that can only be adequately described as an ‘expired goods mortuary’ and felt a little like a Harry Potter 'Room of Requirement'. Anything that was broken, but potentially worth keeping for spares, was in here. It was a masterclass in hoarding (possibly also reflecting the challenge of disposal that a country like Tanzania faces). A bit of rummaging and I found our old microwave – its plug and socket were perfect, so I removed them. Back to theatres to rewire it. Should be simple. Although it wasn’t. And I discovered the true reason why the adaptor plug had burned out. Evidently, after our last issue when the element was left to boil dry, the plug into the autoclave took some damage too. Things had obviously reached a point of criticality and a short within the plug into the autoclave had resulted in it welding itself together. Today, I have painstakingly taken this apart, cleaned it and I think definitively fixed it. I hope.

Cleaned up and rewired

A nice distraction from these shenanigans was the operating for the day; two mesh hernia repairs. These both went very well and were both done by one of the local surgeons. One was even a tricky recurrent hernia. It was a real pleasure for me today. I can see the confidence of the local surgeons growing and I really do believe that, when I leave, they will be able to not only carry on such surgery, but carry on doing it well. I have seen them grow in confidence and also in their technical expertise and approach to operating over the time that I have spent with them. When I leave, what they do and how they do it will definitely be better. And this is exactly why we came.

Unfortunately, on the home front, the power has been out for the last 6 hours. It has been a sticky evening and, as I think about heading to bed, it looks like it will be a restless night. The electricity company is apparently on the case. But who knows? I could really do with the fan to take the edge off the heat to help me get a good nights sleep….

Freestylie

It is particularly hot at the moment in Muheza which, I must say, is particularly draining. Today was interesting surgically with the first case of the day something again I’ve never seen before. It was an older chap who supposedly had particularly large bilateral hydroceles (balloons of fluid around the testes). However, on opening his scrotum, we were confronted with lashings of pus from the first side. A careful and sequential drainage and debridement of dead tissue ensued and despite my initial hopes that we might preserve the testis, it was gone. So a formal orchidectomy was performed. The cord was divided through a second incision in the groin as on exploration the nastiness had tracked up towards the inguinal canal. I wanted to be sure that it hadn’t in fact tracked down from within the abdomen. Thankfully not. My fears of some bizarre intrabdominal abscess / cancer driving this process were fortunately not to be realised. All very odd though. I did not touch the other side, and we left things open in the hope that the now apparently healthy remaining tissue might heal. We will inspect again in due course.

The next two cases of the day were to try me, both inguinal hernia repairs. The first was a recurrent hernia following previous suture repair. These are always tricky as whatever technique has been used has invariably completely destroyed the ‘normal’ anatomy making dissection difficult and creation of a suitable space for the mesh challenging. However, it went really well and I was feeling very pleased with how things had gone. And then we opened the mesh. The first inkling that something was up was when we opened the ‘green’ wrap to find not an envelope, but a folded and taped piece of paper. Ok. Not in itself a problem. On the one hand creative / resourceful. On the other it was not what I had demonstrated, and I had provided an ample supply of envelopes. Hmmm. (you may also recall my comments yesterday about the anxieties associated with handing over this final piece of the process). But the real trouble was when I opened this paper to find a somewhat undersized piece of mesh. To say it was tiny is only overexaggerating a little. Grrrr. At this I was annoyed. I ‘gently’ enquired about why this was the case, given that I had provided clear instructions, a demonstration and even a template for cutting the mesh. I am pleased to say that outwardly I remained completely calm, smiling and constructive (explaining and demonstrating why this was a problem) whilst inwardly being distinctly peeved – freestyling on the first one!?! Really? The response of course was all smiles and with much laughter and banter from within theatre (the head of CSSD got a good ribbing – all in Swahili of course, but I followed most and had the rest translated). He wanted to save the envelopes for some reason and had lost the template so ‘made it up’ (I think using an envelope). Somehow (by using the diagonal of the piece), I managed to make it work acceptably (if it was too small I would have used another) and the end result was absolutely fine. So another colourful step on our journey.

The final case was another large hernia and with complete loss of domain of the back wall of the inguinal canal. What this means is that an already tired me, had to sweat my way through an operation that would normal be ‘quick and easy’. Head down, plod through. Be creative. Reconstruct the ‘normal’ anatomy as much as possible. And the end result. Well very pleasing actually. The mesh? Well it was as it should have been – it was one I had prepared previously.

Oh, and happy commercial love day!

Letting Go

It certainly was back to Muheza with a bang yesterday. Getting off the bus, the temperature was noticeably warmer and we will once again have to get used to sweat trickling down our backs as routine (although with the arrival of the new medical students, we realise quite how well we have adapted to this). We also have another water shortage. Evidently no water came last week or this one. We have just a tiny amount left in the tank. Back to the stark reality of living here then!

It was back to work today, and I was greeted so very warmly. I am delighted to say that it really is nice to be back, even though I already knew we had a big list of patients waiting for theatre. These are mostly hernia patients suitable for mesh, which is great for the project.

Today I took things another step forward in the mesh hernia work and have offloaded the initial preparation of the mesh to the head of CSSD. Up till now, I have been cutting the mesh to size off the bolt myself, and then placing in an envelope before handing it over ready to be wrapped and sterilised. This may seem like no big deal, but I have handed over all the remaining mesh I have for now (a new consignment has been ordered) and with that gesture, I feel I am very definitely handing on responsibility for more of the project to the local team. I feel a mixture of pride in how far we have come as well as the inevitable anxiety that someone like myself will feel with such a step (most surgeons have an element of OCD). Over the next few weeks, it is my intention for the team to become increasingly independent with these operations. After all, I now only have a couple of months left.

Some more great news for the hospital is that the X-ray machine has been fixed. It does feel a bit like a successful resuscitation on an elderly care ward though – how well it will perform from now and how much longer it will last is a huge uncertainty. Of course, nothing will be done to replace it now until it does finally expire, unless someone can happen to find a retiring machine in the UK and have it shipped out?!

The hospital superintendent specifically sort me out this morning to tell me a second piece of good news – the full blood count machine that has been away in Dar es Salaam for fixing is now ready and should be back in the next few weeks. Clearly this is great news, but I confess I did not know we ever had one. I have had to be content with just a simple Hb level since arriving. But just like on the Mountain, every step forward is another step to where we want to get to. Certainty one thing that I find hugely inspiring about being here is the whole team’s constant drive to improve – sometimes they just need a little nudge, a different perspective or a some kind of ‘validation’ that it is right that they should expect more.

So in the words of the Coldplay song that has been spinning round my head for the last few days; ‘Up and up and up’! (Have a listen…..!).

Kili Day 7 – Homeward bound.

Distance Travelled: 21.3km down (Total: 31.2km up 37km down + 10km acclimatisation)

Altitude Gained: 0m (Total: 3390m + 660m acclimatisation) Highest point: 5895m.

The 'blood wagon', the quick way down!

Today was our ‘walk out of the park’. It is easy to overlook the beauty of such a leg, particularly when you start at 6am and only want to sleep! Whilst we had done what we came to do, it really was a fantastic walk through the lower 3 of the 5 tiers of the Mountain. It certainly lives up to its claim to be a wonder of the natural world in my opinion. My only one quibble with that statement is one of rubbish. It is such a great shame, but Mount Kilimanjaro, one of the most beautiful places on the planet, has become yet another human rubbish tip. Litter is strewn across the mountain and when you start looking for it you see it everywhere. Plastic, cigarette buts, juice cartons, even at the top there are disposed of hand warmers aplenty. It is such a shame. And it is also something that I think should be urgently addressed. Perhaps an extra $10 per person on the entry fee (already very high, an extra $10 would not be noticed) for environmental management would be money well spent. For the first few years it could fund a huge number of jobs for the clean-up programme (even ‘good’ wages are tiny here). Then after that time, additional rangers could inspect campsites and encourage a culture of taking all rubbish off the mountain (including any extra you might find).

Unique tree / shrub things!

We descended the mountain via a different route, and it was fabulous. On the lower tiers we were treated to a number of close encounters with monkeys and some of the very unusual vegetation unique to Mount Kilimanjaro was fascinating. Today we walked 21.3km and as I write this, I am again blown away by the efforts of my 11 year old. 23.3Km! Yes it was downhill, but 23.3km and the paths were often very challenging. We chatted constantly for the entire descent (mainly about her proposed bantam rare-breeds chicken breeding business!). Such a fantastic way to spend time. The main low point of the day for me came with the requirement for ‘tips’. I absolutely hate this culture, whereby you pay a huge amount of money for your trip, but are then expected to effectively pay the team that takes you (they only receive a very rudimentary salary) on top of it. We are far from plush with cash and this makes the process all the harder. I gave them what I felt I could (and by the salaries paid in Muheza, a vast sum for 7 days) but I knew it would be disappointing. On the way down, I did remember my ‘emergency dollars’ and decided that it was only right to give each of our guides some of those funds – they did after all get me to the top and also carry my daughter down from the ridge to base camp.

Blue monkey (?s)!

And then that is it. We arrived at the main entrance to the mountain and were treated to a fantastic lunch of ‘chipsy mayai’ (chip omelette – it really is delicious). The van was packed and off we went. An absolutely amazing adventure. Not least because I realised I had switched off from everything else for the last 7 days.

We stopped to buy some t-shirts and a round of beers for the team (most don’t drink so its was mainly soda, I however enjoyed enormously my bottle of Kilimanjaro – how very appropriate and a truly fantastic lager).

I write this at the ‘hotel’ we are staying at. The Honey Badger Lodge, a brilliant find by my wife and I would highly recommend it. Whilst outside of the centre of Moshi, it has a lovely swimming pool and the best showers I have found so far in Tanzania, and I certainly needed one! Although we were dedicated in our daily flannel wash in our tent, actually feeling clean is delightful!

So tomorrow, it is the bus back to Muheza and I suspect it will be back to work with a bang on Wednesday. I know the team are waiting for me. It has been such a great break and an incredible adventure.

A well deserved way to finish!

Kili Day 6 – On the top of Africa.

Distance Travelled: 6.2km up, 6.2+9.5km down (Total: 31.2km up 15.7 down + 10km acclimatisation)

Altitude Gained: 1175m (Total: 3390m + 660m acclimatisation) Highest point: 5895m.

Setting off at midnight!

We were woken at 23.20 (although I might have already been awake) and we made our preparations for the summit. We had slept in most of our clothes and it was just a case of pulling on our overclothes and putting on our boots. It was then a quick cup of tea and some biscuits before our midnight departure. Thankfully, I felt so much better.

It was quite a magical experience. The sky was clear and the stars / Milky Way stunning once again. We made our way to the start to join the procession of torches heading up the mountain. There were about 10 other groups I think, some pairs (plus two guides) including an older American couple we had met at the bottom. One of them was using Altox, which I was intrigued to know was now on offer here. There was one very big group with the guides all singing and chanting them up the mountain. Everyone goes ‘polepole’ but clearly there are different paces of ‘polepole’. We started strong and it felt like we were going to fly up (slowly) the mountain.

Childer1, you can see the 

cloud base far below in 

the distance.

Unfortunately, it was a gruelling route. Underfoot it was at best slippy, at worst frank scree. And it was steep with the path zigzagging up the mountain. After about 3 hours, it started to take its toll. With about only 200m of altitude left to go until we hit the ridge (we had done 800m), my daughter really started to struggle. The pace became glacial and we were stopping more and more frequently. She had just run out of fuel. Chivvied along, she put in an almighty effort to continue. But we had barely made 100m in the last 2hs. She pushed and pushed, determined to at least reach the ridge, but she was clearly flagging. Then she stopped, vomited, pushed on another couple of times and then all but collapsed. I pulled her onto my knees and gave her a massive cuddle. She had reached her limit. She just could not go on. She had made it to the rock that the guides considered the start of Gilman’s point and in doing so gets rewarded with a certificate. She has climbed Mount Kilimanjaro! I was flooded with a mix of deep pride and concern for how she was feeling. We sat for a while, sharing the moment. Dawn broke and we enjoyed some stunning views. I found her some snow to hold – one of her priorities was to build a snowman in Africa.

Watching the sunrise over Mawenzi peak,

we are above the cloud base in the distance.

We had discussed what we would do if faced with this situation on the mountain, but of course the reality is always so much harder. The guides expected that I would carry on up with one and the other would take her back down to rest. I hesitated, not wanting to carry on without her, nor leave her alone feeling rubbish. However, the lead guide explained that if he took her back down it would be much quicker than if we descended as a group. It would be the quickest and best way to get her back to base camp to sleep (and easiest for her). Having rested with me for 15min, she was feeling better but very relieved to be heading back down. She had given it her all and certainly had nothing left. She urged me to continue, to make it to the ‘very top’ and get her ‘some good pictures of African snow’ for her friends. I was still understandably hesitant. But with the encouragement and reassurance of both her and the guides, I agreed to continue. The guides are incredible people, we had already built a bond of friendship and had learned to trust and respect their counsel.

My daughter was lifted on to the back of our lead guide and I watched in awe as he began a rapid, skilled and surefooted descent. It was a real-life superman moment (she tells me he carried her most of the way back to base camp, over 900m of altitude descent – astonishing, bear in mind it had taken us 6hrs to get up here).

So up I went. I would be lying if I said that my mind was not preoccupied with my daughter. I knew that she was alright and it was what she wanted me to do, but it was still far from easy. Her encouragement chivvied me up and I had to moderate my pace to ensure I did not get too tired too quickly. However, having made that commitment to her, there was now no question that I wouldn’t make it. However hard it would be.

The extraordinary glaciers seen at the top.

We ended up with both the day sacks (the guides were carrying them originally, the norm for the vast majority of those attempting a summit attempt) and so I carried one. However, I realised as we made the last few meters to Gilman's Point that I needed to offload it, at this altitude it felt like it was doubling my body weight. So, my guide took them both. It was only as we descended (I took it back for that) that I realised quite how remarkable these guides are. I am considered fit in the UK, but one had just piggybacked my daughter down over 900m of altitude descent required back to base camp and the other carried two daysacks to the summit!

The top of Africa; 5,895m up.

So what was the final bit like? It certainly rates as one of the hardest things I’ve ever done physically. Probably because it is something you just cannot prepare for (although I think if I was to do it again, I would take a much longer time over it and acclimatise better). Whilst the actual distance to be covered is quite limited up on the ridge, I felt very lightheaded. And the closer we got to the summit the more profound this became. The physical exertion is difficult, not because it hurts (like when you push yourself in training), but because of the difficulty in recruiting oxygen into the body (I believe that there is just 40% of the oxygen available at sea level at the summit). Altitude is really tough. Muscles just don’t work and get tired very quickly. Breathing is obviously heavy, and HR is sky high. The combination of an almost ethereal experience with the physical restriction, really did make it extremely challenging. And all of that was on the background of feeling under-par to start with. But I made it, and in good time. The last 250m (lateral distance) was particularly tough though, I needed to stop several times. As I paused, I noticed the slightly strange sight of several ‘summiteers’ being lead arm in arm by their guide. A testament to how tough it is perhaps. But I got there and have the photos to show for it. I enjoyed a few minutes looking out over beautifully clear skies from the highest point in Africa. It is a truly astonishing place to be. But my mind quickly returned to base camp and my daughter. 

I am not sure if there is a record for a non-guide’s descent from the summit to Kibo huts base camp. But I must have been in the running. I donned the smaller day sack and pretty much jogged back along the ridge – how I manged this I am not too sure. It certainly surprised my guide. And then on the final descent, it was a most pleasant surprise (I normally hate going downhill – my knees complain). After the initial scramble over rocks it was onto a scree slope and I flew down – it is a combination of surfing, snowboarding a skiing (three of my favourite activities). It was fantastic. And to top it all off, two of the porters were halfway down waiting for us; to congratulate me and take our bags. It was a lovely touch. And I got back to camp to find a very ok daughter who was absolutely delighted with my reported summit. I felt quite emotional (tired thing again) and extremely proud of her. We had a lovely cuddle. 

I then had just an hour to rest before lunch. Having got my appetite back, the hearty soup with lumps of root vegetables was just perfect for me. And the reward for our gruelling ordeal? We then had a 3 hour trek to our camp for tonight. Fortunately, it was fairly flat, and it was stunning walking over the Saddle between the two peaks of the mountain – actually, we both agreed it was our favourite leg.

So back to the question; "Ridiculous or brilliant?" Knowing what I know now, I think I can answer. My daughter quite clearly could not have made it to the very top on the schedule / route we had planned (even with the adaptation). She is a fit and active 11 year old and gave it her all – I am so proud – but the undertaking was huge. Perhaps the tummy bug we both had didn’t help (interestingly our ‘waiter’ was sent home today with the same – did he give it to us, or us to him?). But at the start of the summit climb, I think she was actually in fairly good form. It was just a massive ask. The route of 1000m of climbing up steep slippery scree was just too much. On my descent from the ridge, the Base Camp looking so small in the far distance (I wish I’d taken a photo), the magnitude of what she achieved really hit home. It was incredible. So I think it was both ridiculous and brilliant. The idea ridiculous, her performance brilliant. 

To put this into perspective for the UK – Scafell Pike is 978m high, Snowdon is 1,085m and Ben Nevis is 1,345m. Kilimanjaro is 5,895m high.

It has been a great experience for us both. I am so pleased we did it. We have grown as individuals and together, which is after all what these things are all about. We chatted constantly and I think I held my daughter’s hand more in the last few days (we walked hand in hand for most of it) than I have in the last year. And that is very special.