Highway to……..

A final beer in Peponi yesterday evening

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

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

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

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

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

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

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

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

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

Unfinished business.

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

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

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

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

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

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

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

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

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

The Brennen Mesher

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

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

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

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

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

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

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

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

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

A final photo, the two local surgeons and myself

Left holding the Baby for the 50th Mesh Hernia Repair

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

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

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

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

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

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

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

Party!

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

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

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

Operating on a little person

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

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

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

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

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

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

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

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

Ha! No water….Let them eat cake.

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

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

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

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

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

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

Cake and presents!

A final flourish

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

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

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

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

Fan repaired, hole persists!

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

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

Zanzibar – A sobering exit.

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

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

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

Octopus in the boat and Moray Eel in the lagoon

Sailing back

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

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

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

Zanzibar – Watching the tide roll in….. then I watch it roll away again.

My body and mind are confused. I am in one of the most beautiful places on Earth, perfect for relaxing and chilling out (something I have always been very good at) but for some reason, I feel unsettled. My mind and spirit feel elsewhere. It is taking all of my practiced determination to let go of such debilitations and enjoy the time we have here.

Tucked away in the tropical garden

For the last few days of our stay on Zanzibar we have moved to a little self-catering cottage complex on the South of the island. A big step down in terms of ‘luxury’, this is certainly a good stepping stone to reclimatisation in Muheza. It has none of the opulence of our previous accommodations and its beauty lies in its simplicity and integration with the natural surroundings. It is a stunning and delightful place, set just back off the beach in a tropical garden designed for shade. It has many little pergolas and our favourite is up on stilts catching the full force of the sea breeze which certainly takes the edge off the heat. From here, you look down out over the sea and can watch the tide rolling in and out. Very calming.

Our favourite spot - lovely breeze, great views. and Morning Tea

The breeze also keeps the mosquitos away, of which there are plenty. On our arrival it was a bit of a shock to find our cottage with unnetted windows and teeming with the blighters – more mosquitos than I have seen since arriving in Tanzania. But Zanzibar has almost eliminated malaria and so it is more the irritation than a health risk as such. Closing the shutters and a quick fumigation of the entire building before we went out in search of supper was very effective. On our return it was ‘safe’, if not a little aromatous, with not a single biter in sight (except lying in state on the floor)! 

I think we will have a lovely few days here.

I have also received great news from Muheza. The two laparotomies from last week are recovering well and the service continues to thrive without me. Even in the face of staff bereavement and medical student examinations, they have managed to do a mesh hernia repair independently. Woohoo! I am chuffed to bits.

Zanzibar - Diving

Up on the north of the island, the focus of the last few days has been diving. Opposite the well known Mnemba island dive sites, it might have been considered rude not to go. On Monday afternoon we were picked up and taken by boat to the dive centre a little further up the coast for a pool session. Whilst my wife and I are PADI certified, it has been many years since either of us had dived (children do that to you) and we both felt that a refresher would be a good idea. Also, our eldest daughter was old enough to do an ‘Introduction to diving’ course which meant that after a short pool based tutorial she would be able to dive with us on the reef too! This is not a PADI certification as such and means that in the water she has to be buddied with a dive master or certified instructor and is limited to 12m in depth. Whilst technically this limited what we could do, neither of us minded as the opportunity for her seemed too good to miss (there can’t be many 11 year olds that have actually dived on a coral reef). 

Also, my brilliant wife had discovered that there is a diving taster that our middle daughter could do; “Bubble-blower” who knew there was such a thing. This meant that she had an hour in the pool learning to dive. Fantastic. The team there were very sweet and at the end of this pool session they put a child’s mouthpiece on my spare regulator and let our youngest daughter swim with me on the surface with her head in the water breathing through the regulator to get an experience too. All three of them were absolutely thrilled!

Middle daughter learning. Older two in the deep end playing with the instructor. Our youngest loving it too!

Our original plan had been to go diving together on the Tuesday, but both of us had independently woken up in the night and decided that we could not leave our younger two children in the care of the hotel staff. Whilst they were lovely, it just did not feel right to either of us. So on Tuesday my wife and eldest went off for an amazing diving experience together. I had a fun time with the younger two in the three hotel pools – tough I know!

Having returned extolling the amazing experience that they’d had (including two dolphins that came to them underwater), it was arranged that I should go on Wednesday. I was not to be disappointed. I was treated to an amazing array of fish (lion, angel, stone, puffer, moray, flat and a host of others that I cannot name – including some incredible camouflage experts) as well as some pretty good coral (it was good to see the reef alive, if not thriving). Somehow, in all of that, my eldest daughter managed to negotiate a second day of diving, which meant that she spent nearly 4 hours underwater in total. 

Eldest daughter in the Indian Ocean

Very well disguised flat fish - its most of the top of the rock

I remembered we should pose for a photo!

Moray eel

Zanzibar – Expanding Horizons

Zanzibar is every bit as idyllic as it promised to be. Exploring Stone Town at the weekend was fascinating, not least because a visit to the slave museum provided a gripping insight into the far from idyllic history of the island. One of the main ports for slave export from the continent of Africa, the museum holds a harrowing account of what humans are capable of doing to one another. It is remarkable to think that the tail end of this industry continued into the 1920s.

One of the three pools

After lunch, we said goodbye to my wife’s uncle – his schedule only allowed a very brief visit – and we set off for our hotel on the northern tip of the island. The SeVi Boutique Hotel is truly magnificent. It overlooks a beach which has sand of the most remarkable quality. It is so white and so fine, it is almost like walking upon flour. The hotel ‘complex’ is extensive with three pools and the modern twist on traditional bandas (thatched huts) is delightful. We have our own family house (complete with a personal plunge pool) and are being treated to genuine luxury for a few days. As almost the only guests here (we are very close to the start of the rainy season and so most hotels start to close down for a couple of months) it is also delightfully quiet. All the hustle, bustle and constant ‘best price, very good price, cheapest taxi’ of Stone Town thankfully behind us. 

Our beach cottage - the whole thing! and The bed greeting us!

Over the past few days, I have also had some space and time to think about and discuss a number of ideas that have been evolving over these past few months. I am immensely proud of the work we have done in Muheza and do believe that many of the developments we have worked upon are sustainable. Furthermore, the new local links and commitment for ongoing collaboration that emerged will be invaluable for the hospital. All these things will make a big difference to the quality and safety of the surgical service provided in Muheza. So in many ways, I could walk away in a couple of weeks’ time and justifiably feel that not only has our time here been worthwhile, but that we are leaving behind a valuable legacy too.

However, these five months have opened my eyes and given me a much deeper understanding of global healthcare. This experience has ignited within me a fascination and passion to do more. I have learned so much during my time here and my unexpected travels within Tanzania have further uncovered abundant potential opportunity. There is much that Western practice (and life in general) can learn from countries such as Tanzania, and there is of course so much more that can be done here to ‘raise the bar’ and narrow the gap in global healthcare provision. Having dipped my toes in the water (and perhaps immersed myself in the depths for a short while) I would like to continue to be involved.

When I return to the UK in a few weeks’ time I hope to continue to support and expand the work we have started here. Through my eyes as a surgeon, clinically such things seem eminently possible. Of course this may be ambitious, expansion will require many different resources and also greatly increases complexity. It will be challenging. But many steps have already been made towards such an endeavour and my network of contacts and willing help is growing. Through sustained and co-ordinated collaboration, I believe we can continue to help the productive development of surgical services here. Now, I just need to lay out my proposals in a more formal fashion and to begin to find ways to fund all this future work.

Best not to get bored on holiday!

Zanzibar - Reverse Culture Shock

My wife’s Uncle arrived safe and sound very late on Friday night and it was an absolute delight to welcome him to our home. Although our original plans were for a traditional Tanzanian supper with all the family (cooked by our house keepers), the childlers were long fast asleep by the time he arrived. We had saved him a plate of food; pilau, goat stew and a spinach like vegetable dish. It may not sound it, but it really was delicious. We enjoyed a beer and lots of conversation, clearly there was so much to talk about. I think it was the latest night we’ve had here!

After a breakfast of fruits, pancakes and Tanzanian coffee; on Saturday morning he was ‘treated’ to an immersive African experience. The children had given a lot of thought to what to show him for the morning we had in Muheza. They took him on a guided walk through the fields and local shambas (mini-farms), then into town to see the market and finally I would take him round the hospital.

It was really brilliant to show him where we have been working these last few months. I felt a strong sense of attachment and pride as we walked round. I talked him through the layout and organisation of the hospital as well as describing the day to day activities. Although it was Saturday, there were plenty of people around. It was also Kids Club at the Hospice which was great for him to see. This is an amazing weekend initiative that offers children with HIV breakfast and lunch as well as lots of games, whilst squeezing in their regular clinic appointment. It has provided an incredible support network for them and encourages compliance with treatment. Despite their diagnosis, these are now ‘healthy’ children which is quite amazing really.

I realised as we walked around, quite how much a part of Muheza hospital we have become in our time here. I introduced the various staff working and many others who were passing through the grounds (all in Swahili I am proud to say). I have become very fond of this place and am so pleased that we came to work here. We have achieved a lot. However, guiding a new pair of eyes around also reaffirms just quite how much more there is that could be done. The rusty and wonky beds, the dubious mattresses, the collapsing bedside tables, the tired paint, the building works in progress (not to mention the lack of ITU and anaesthetic equipment, the very tired x-ray machine and a host of other things). The tour concluded and I think we both had much to think about. It was a very informative experience for all. Hopefully, we can continue to support the growth and development of healthcare services here. I pointed the ‘tour group’ in the direction of home, whilst I briefly returned to the wards to see my post op patients.

It was then an early lunch and off to the airport in Tanga. We had a 14.15 flight to Zanzibar! This was a trip that I have been so looking forward to – an anticipated escape and reward that has enabled me to knuckle down and get on with things these last few weeks.

The flight itself was delightful. We walked out of the small terminal onto the runway to be greeted by our small single prop plane that could carry 12 passengers. The Top-Gun-esque Indian pilot dressed in pristine whites and golden epaulettes (with the compulsory shades of course) spoke the Queen’s English and took very good care of us. It was amazing to see the region from the air and to fly over our regular weekend beachside retreats.

We had arranged to stay one night in Stone Town before moving on to two ‘beach resorts’ at either end of the Island. Treated to this holiday, we would be staying in some very nice hotels and would see another very different side to Tanzania. Arriving at our hotel in Stone Town was a slightly strange and surreal experience for me. 

The Tembo Hotel oozes Afro-Indian style opulence. I smiled broadly as we walked through the large, dark wooden, brass studded doors, to a foyer housing reception. This led straight out to a courtyard with a pristine marble fountain, luscious plants and that very inviting and soothing sound of trickling water. But then as I walked through the hotel, past the swimming pool and bar to the beach, I found myself quite overwhelmed. I had stepped into another world and was surrounded by affluent and scantily clad Wazungu (not all of them could carry it off), who were lounging in the sun sipping various cocktails. 

I suddenly felt very uncomfortable being immersed into such an environment. So many white people! All clearly having an excellent time. But their time seemed such a world away from what our lives have been these last few months. It was surprisingly difficult, and I now understand the meaning of ‘reverse culture shock’.

But this is all part of the rich experiences of life. Whilst on the one hand you could spend hours unpicking the social injustice of it all, such an approach is often not very productive and certainly wouldn’t help me to enjoy the holiday I was going to be having regardless of how I was feeling. The girls were all beside themselves with delight I am pleased to say. I took a deep breath, took a brief time out by walking along the beach and threw myself into the fun that I knew we all needed.

A beer also helped.

Whilst the hotel did not serve alcohol, there was a bar 10m down the beach that did. I enjoyed a cold bottle of Kilimanjaro and relaxed into my surroundings whilst the children were making the most of the hotel pool. When it came to paying the bill, the 6,000TZS price tag made me stutter. Whilst just a little over £2, it was 3x the price of what you would pay in Muheza. I found myself playfully commenting in Swahili how expensive the beer was, which delighted the waitress (clearly very, very few Wazungu ever even try to speak the native tongue). She empathised, and this led to a short conversation. I surprised myself by my near fluency in understanding the fact that this was a tourist bar, not a local bar (where beer was much cheaper), and then by explaining where we had come from and what we have been doing in Tanzania. This impromptu dip back into my Tanzanian reality was in fact extremely therapeutic for me and I walked back to the hotel ready to embrace the next few days and enjoy them.

Pound of Flesh

Today is Friday, a day we try to reserve for emergency operating only. Recently, our elective work has spilled into Fridays, but having been very efficient this week I was looking forward to an easier day. We had no planned cases. The morning meeting was uneventful and walking to the wards, I was thinking that it might be a fairly quick round and then an early lunch. I was planning to head to Tanga in the afternoon to do some shopping before picking up my wife’s uncle from the airport who was coming to visit us. All the arrangements to borrow the Hospice car had been made.

Predictably though, as often happens in surgery, things would not be anything like so straight forward. Perhaps I jinxed it as I headed to the wards, noting that we had not had any big cases recently. No laparotomies for a while. Today we would end up with two!

I walked onto the female ward and met up with one of the local surgeons (they tend to split the wards between the two of them). I saw our post-ops who were all doing really well. Great. I was about to leave when he said “Dr Mak (their take on my name)…. I want you to see this mama” (‘mama’ is the Swahili word for ‘mother’, but also the way to describe or address any ‘middle-aged’ woman). I smiled and turned around. I was taken to see one of the few obese Tanzanians I have been asked to review during my time here. She was being quite vocal about her pain (I had noted this when I entered the ward earlier) and was rolling around on her bed. In my experience as a surgeon in the UK, you have to be quite careful with such patients, some might simply be a little histrionic and it is best to be cautious about proceeding with potentially life changing decisions such as surgery. However, I have also learned to remain very open minded.

On my review, I could see that she was uncomfortable. Assessment of her abdomen was tricky given her ample covering (obesity does genuinely make the clinical assessment of the abdomen difficult). However, I could feel a large epigastric hernia which was slightly tender. Putting everything together, felt she warranted surgery. I did not make this decision lightly (to be honest I didn’t really want to operate today, and certainly not on what was likely to be a difficult case (obesity also makes the technical aspect of our job more challenging). But it was the right thing to do. In the UK I would have put her through a CT scan first (which interestingly would have been very helpful as will become apparent later) but that was not an option, so we booked her for theatre.

As I walked to the male ward, I gave myself a little pep talk. Whilst my day had become more complicated, the operation was very necessary and I reasoned that I could get it done and still get away at a reasonable time if we were efficient.

Pleasingly, all our post-ops on the male ward were also doing great and I discharged a few. The discharge paperwork is so much easier here, an A5 piece of paper with only the essential information. Beautifully informative by being succinct, and in my opinion, much better than the now onerous systems we have in the UK. Just as I completed the final instructions outlining the requirement to return to the outpatients for follow up, the other local surgeon spoke up. “Dr Mak. I want you to see one patient”. I looked up and again I smiled. What would this be.

It turned out that the patient was about to be transferred from another ward. We walked out of the door to go there, but pushed by a nurse they met us weaving precariously on one of our hospital wheelchairs. On the positive, we do have a few wheelchairs. Unfortunately, they are all a bit tired and tend to behave like mischievous shopping trolleys.

The fact that this 36 year old man was transferred in a chair was a useful clinical sign in its own right, it implied that he was definitely not well. The transfer from chair to bed was also clearly a trial for him, but a certain pride here often prohibits the acceptance of any help. We read the notes and the suspicion of the doctor who reviewed him this morning was that he had bowel obstruction. A brief history certainly suggested this too. I examined his abdomen and it was tense like a drum. He was also tender (a bad sign suggesting pending, if not already occurred, catastrophe). Inwardly, I confess, I sighed as I vocalised what I knew was my duty to this man. He also needed a laparotomy. My day was becoming very complicated.

An x-ray would have been useful, but the machine was out of action being treated to a refurbishment of the ‘suite’ that houses it (perhaps a little encouragement for it to stay alive). This absolutely epitomises my experience here. Devoid of the many investigative comforts that I enjoy in the UK, I have learned to confidently work as a clinician in the truest sense. All the sophisticated tests to which I might normally turn to add another piece to the diagnostic puzzle are absent. I pretty much rely upon only those which I can perform with my own hands. Surprisingly, I have been very comfortable with this. Certainly experience counts for a lot, and I also suspect that having had access to such tests in the past, I have learned so much from them and am now able to almost predict and visualise what they might show. Undoubtedly, modern sophisticated investigations might have changed many a patient’s pathway in some way, but I have also learned that you can do a huge amount without them. He too was readied for theatre.

The first lady was on the operating table at 11am. My clinical findings on the ward were sound as I dissected and defined a rather large epigastric hernia (this means the hernia originated between her belly button and breastbone). It was about the size of a large grapefruit. It contained a bruised loop of transverse colon, which I concluded could probably account for her symptoms. However, I was clear in my mind before the operation that I would want a proper look at the inside of her peritoneal cavity (in other words get a really good look inside her tummy) to be sure that there was no other mischief. The neck of the hernia was tight (this means that the hole in the abdominal wall was small compared with what had come through it) in keeping with the bruising to the bowel, and I had to enlarge it to get the bowel back inside safely. This also meant that I had a good ‘window’ to inspect what I needed to. I could see no other obvious issues.

However, I have been taught to be thorough and I used my hands to assess by feel what I couldn’t see. Just as was about to affirm ‘the all clear’, I checked the anterior abdominal wall. My fingers found what I immediately knew to be a second hernia at her belly button, about 4cm below where the bottom of the current hernia defect ended. This is interesting, as it is actually quite unusual to have two separate significant problems at such an operation. Furthermore, given her ample covering, this hernia was completely hidden from clinical examination – genuinely, I still could not feel it even when I knew it was there. However, the compressed sausage like contents that I could assess between my fingers were undoubtably a loop of small bowel entering this second abnormality. And they were very stuck. If I had just pulled harder, the bowel would have torn spilling its contents all over the abdomen which would have been disastrous. I explored this second area, dissecting it out and opening up the ring of tissue that was like a noose around this loop of bowel (this hernia turned out to be a little smaller than a golf ball). Unfortunately, it had been strangulating that knuckle of bowel for too long and it was dead. It needed to be resected (chopped out). I removed it, joining the two healthy cut ends of bowel back together with lots of individual stitches (an end to end, interrupted, handsewn anastomosis). It would have been so easy to miss this second problem and I am very glad that I didn’t. I suspect if I had, she probably would have died. As it is, she still needs to heal the join in the bowel that I have made and recover from this ordeal.

One down, one to go.

The second case was no less challenging than the first. On opening this man’s abdomen, an enormous loop of colon burst forth explaining the drum like quality that his abdomen presented on the ward. It was like an unwieldy python, about the diameter of a saucer and close to bursting. Massive. A sigmoid volvulus is where part of the colon twists upon itself causing what we call a ‘closed loop’ obstruction (both ends are blocked off, in this case by the twist). This is a big issue as the bowel will continue to distend (as it continues to produce mucus and gas) until it ruptures. I was not surprised to find such a problem, it was one of the more likely differential diagnoses I had considered. Fortunately, whilst impressive, it had not yet perforated which meant that the situation was potentially much more salvageable than if it had. Whilst in the UK I would have managed such a case very differently (using options such as endoscopy), with my hand somewhat forced, we performed a sigmoid colectomy.

Thankfully, it went very well. I decompressed the bowel first and untwisted the 360° rotation, but it was still an impressive loop of colon that I needed to resect. Once again I joined the two cut ends of bowel back together. It was not an easy join as there was a size discrepancy between these ends (I could go into a lot more technical detail here, but will resist). But the ends were healthy and taking a lot of care to produce the best possible anastomosis, the result was very pleasing.

With any bowel anastomosis (join), there is always a risk that it might not heal properly. If this occurs the bowel effluent leaks into the abdominal cavity and can make the patient very sick. Here I suspect if such a thing were to occur they would be extremely unlikely to survive.  No matter how good it looks at the time, this risk is ever present. Classically, problems arise around day five post-operatively, so it is always a slightly anxious period whilst the patients recover. However, I had done all that I could and just hope that they will recover smoothly.

During this last case my phone rang. It is always slightly surreal to dip back into another area of your life when you are elbow deep inside someone’s abdomen. I was halfway through making the join and I paused whilst my phone was answered and then held to my ear. Unfortunately, my wife’s uncle had missed his connecting flight as customs had been busy and would now be travelling by taxi from Dar es Salaam. This is far from ideal as he would be on the roads late at night, but with very tight schedules, it was necessary. It however also removed any possible time pressure from me as I would not need to travel to Tanga now after all.

As I walked home at about 5pm, I reflected on what had been a challenging, albeit very satisfying day. The team had performed brilliantly in difficult circumstances and I felt that we had ‘played our A-game’ today. A most satisfying culmination of all my time here perhaps. Feeling now very tired, I also came to the conclusion that I have very definitely given my ‘pound of flesh’ to Africa. We have done some great work, many fantastic cases, but it has been very tiring too. I have invested a lot of me here during our time here. 

I breathed a massive sigh of relief-mixed-satisfaction for my work and turned my attention to the coming week. With the arrival of my wife’s Uncle, comes a very special treat for us. We are off to Zanzibar for our final ‘holiday’ before we leave.