Heartbreak High

This morning I woke up in the convent in Korogwe to the ringing of bells at 6am and the beautiful singing of the thirty or so nuns in the chapel opposite our dorm. It was a running day (I had even packed my kit) and so sneaked out of the room in the evolving light, leaving my eldest daughter sleeping (we had split into two rooms, one adult in each). I was greeted by a few of the nuns not in church (presumably catering for us) and they certainly had a smile of interested bemusement on their faces (I have long come to accept that my particularly white Mzungu legs attract such a reaction).

I set off in the relatively cool breeze (hot for the UK) and ran out into the country side then along the dust road into a village. This proved to be an excellent decision as I was clearly a delight to the local children all walking to school. Every day between about 06.15 and 06.45 there are droves of children all over the country walking to school on their own. Some are quite little (certainly smaller in stature than my nearly 6 year old). If they are lucky, they have an older sibling to walk with, but many do not. They are all beautifully dressed, looking very smart – white shirts, bright jumpers and usually dark skirts / shorts / trousers. Although on closer inspection you can see the holes and repairs in the uniforms or the very worn shoes that most of them wear. They often carry large containers of water or firewood or twig brushes for cleaning. Clearly education is highly valued, and the local environment considered safe. I cannot recall how many times I replied “marahaba” to their respectful greeting of “shikamoo” (accompanied by lots of giggles), but I certainly felt like a celebrity. For whatever reason, I have not attracted this much attention elsewhere when I have been out running. At one point I had collected a little flock of followers, all running behind me. In some ways, I wish I had had a camera. But equally you can never quite adequately capture such things on film. It is a delightful mental image to carry away with me. Another highlight of my time here.

I returned to the convent, a hot shower (ironic that for once I didn’t want it, cold was blissful), a delicious breakfast and then it was off back to Muheza.

Sometimes I feel that I am reliving the same emotionally draining experiences time and time again here. Today was another such episode.

Having seen all my pre and post-op patients for the week (all doing pleasingly well), I was asked to review another patient on the ward round. A man in his 70s, I was told he had ‘some itching around his bottom, then developed a wound’. Great I thought, this sounds like a colorectal theme (my area of specialist UK practice). I was however slightly bemused by the sparse account of the story, which to be honest shed very little light onto what we might find. It dramatically underplayed the situation. He laid on the bed to reveal an extensive perianal ulcer that could only be a squamous cell cancer. My mind was racing. This is an area of sub-specialist interest for me. In the UK centre that I worked before coming to Tanzania, we performed salvage surgery for such cases. These are big operations and we work closely with the plastic surgeons to reconstruct anatomy using clever flaps of tissue. However, I was getting ahead of myself, because even apparently extensive tumours like this can respond dramatically to targeted chemo-radiotherapy. In the UK the cure rate in such situations is surprisingly good.

But even as these thoughts were passing through my mind, accompanying them were the almost inevitable responses I knew I would hear. But I didn’t want to hear them.

The Specialist Surgeon Nun had returned with us to Muheza and she was also present on the rounds. This was particularly useful for me as she would be considered an expert in what was available for surgical diseases such as this in Tanzania. Unfortunately, she confirmed what I already suspected. Yes, the only centre that can offer chemo-radiotherapy would be Dar es Salaam. However, I established that it would be nothing like the service that I would take for granted in the UK. I tentatively asked if the patient could travel there. Everything was explained to him and his reply was quite clear.

No. That would not be an option for him.

I felt my heart sink once again. It is genuinely painful. I find myself again confronted with a situation where I have all the knowledge and skills to manage this difficult situation, but none of the support teams, drugs, nor equipment. I feel helpless. Whilst I can confidently diagnose and offer theoretical options for this poor man’s predicament, circumstance means that there is precious little I can do to actually help him. He might be cured in the UK. Here…..

We discussed a defuntioning colostomy (this means that the bowel is brought onto the skin and the effluent collected in a bag rather than passing through the anus). In situations such as this, it is a palliative procedure to try and improve his quality of life. Whilst currently he is just about managing to pass stool through his bottom, it is only a matter of time before such things become either unbearable or impossible. The local and visiting team both felt that this surgical procedure should happen. I was slightly reluctant given that currently his symptoms were manageable. But in no uncertain terms it was made quite clear to me that his best option would be for me to perform the procedure before I leave. But I have not much longer left now. The decision must always ultimately lie with the patient. I was certainly clear that I would not do it today. We are away next week, but should he want it, I could do it on my return in a fortnight.

He wants it.

The Elusive Appendicitis

It transpires that appendicitis in Africa is actually quite unusual. As a surgeon working in a District General Hospital (DGH) in the UK, we would expect to have several (perhaps 3-5) confirmed cases per week. It is certainly considered one of the most common surgical emergencies in the West. The population we serve in Muheza is comparable to that of a DGH back home, but I was yet to see a single confirmed case in my nearly 5 months here. Until today.

It would not be unreasonable to wonder if we were just missing them for one reason or another, but I now understand that this paucity of such pathology is entirely consistent with others experience. Furthermore, I had reluctantly taken on about 6 cases of ‘suspected’ appendicitis during my time here (whilst my scepticism was valid, to have a look was really the only ‘safe’ option), performing exploratory laparotomy. All had normal appendixes (although the local surgeons commented on how long the structures were).

And then today I was taken to see a 16 year old lad who was unwell. He had been admitted for a couple of days already, but for whatever reason, I had not been asked to see him until now. It did not take me long to establish that he was peritonitic (this means the findings of abdominal examination were very concerning). Whilst the signs were by no mean typical of appendicitis (his tenderness was in the ‘wrong’ place), he clearly warranted surgery. I probably ought to say that these decisions are entirely based on clinical judgement here, there are no other tests easily available. I had asked for an FBC (full blood count) as the machine is now fixed, but it was not forthcoming. I also probably ought to say that it would be easy to dismiss such symptoms and signs (perhaps why I had not been asked to review him sooner). The population here is incredibly stoical, and to complain of or show pain is quite a statement. But you cannot hide true involuntary guarding (this is when the abdominal muscles contract involuntarily to protect the abdomen from pain) and I was quite clear that he needed an operation. I was suspicious of what we might find, although there was some scepticism of this provisional diagnosis locally. I asked him to be prepared for theatre.

Unfortunately, it transpired that he had just eaten some porridge. Hmmm. Despite this being an emergency, I felt it was probably safer to wait the recommended 4-6hrs before putting him to sleep. He was on antibiotics and not systemically septic. Given all our anaesthetic challenges, I thought it would be prudent to minimise any additional risk.

Today, we had again been visited by the Surgeon Nun from Korogwe. Rather flatteringly, now that she knows I am here, is keen to capitalise on every possible opportunity to work with me.  We started the day’s operating list as planned. A 2-year 8-month old with a large inguinal hernia and a lady with an incisional hernia (lower midline from previous caesarean section) which we repaired with the ‘mosquito net’ mesh.  Both were quite challenging, but both operations went very well I am pleased to say. Sister was keen to stay for the emergency case too.

The young man arrived at theatre reception and I was asked to review him again by the local team – did I still want to operate? His signs were apparently quite changeable, which did not fit with my initial impression earlier. I approached him and in the better light of this atrium, could see even more clearly that he was not well (there is a certain subtle, almost waxy, look to the acutely unwell).  I laid a hand on his tummy and was left in no doubt. “Yes, he needs surgery”. For the first time since being here, I was also in the privileged position of having a second opinion to hand. Whilst I was clear as to the required decision, with my Surgeon Nun colleague standing next to me, such an opinion was invited and forthcoming. Thankfully, she was in complete agreement. I suspect this also reinforced some very useful learning for the local team.

Given that the diagnosis was not certain (and theoretically could have been any number of things), I elected for a midline incision (this way of opening the abdomen leaves all options open), rather than the classical appendix incision in the right lower tummy. It was a good decision as there was a lot of mischief inside. He did have appendicitis, which had perforated, and there was evidence of infection throughout his abdomen. We removed his appendix, with a gaping hole in the distal third. We broke up lots of adhesions and interloop abscesses; this is when pus collects between other loops of bowel – the body’s natural reaction is to wall this off and try to destroy the bugs. Then we thoroughly washed out his abdomen with warmed saline (salty water) adhering to the old adage ‘the solution to pollution is dilution’ learned early on in my surgical career (this holds true for the human body, if not the environment). Things went very well. The local team, the visiting team and the British team (that’s me) were all equally delighted with the case. I at least felt it would have been almost rude to come all the way to Tanzania, operate as a General Surgeon for five months and not take out an abnormal appendix. But I have also certainly learned that it is comparatively rare here.

For the evening, a rather impromptu invitation to visit the Convent in Korogwe was reiterated (it was mentioned briefly in passing last week). A moments hesitation soon gave way to a sense of adventure, even if it was a ‘school night’. How could we refuse. I quickly established that my wife and children were up for it too. I managed to secure the Hospice car and we made the 75-minute journey arriving in the dusk. It was so very worth it. We visited their health centre first (another interesting piece of the healthcare puzzle for me) and were then treated to the most delicious African meal. Hospitality here really is exceptional. Another delightful and memorable Tanzanian experience.

Facing daemons.

In contrast to the highs reported yesterday, comes the less pleasant task of living with your failings. Sometimes these are transient, or evident transiently at least. And sometimes they are not. Some you have to face almost every day.

As I walk into theatre to prepare for today’s operating list, I am once again reminded of one of mine. In the coffee room I am greeted by the broad but subtly asymmetric smile and slightly muffled words of the colleague I operated on back in December. You may recount the story described in the posts ‘Childs Play?’ and ‘Two sides to every story’. Unfortunately, the facial palsy following this parotid surgery persists, and I am reminded of this fact on an almost daily basis.

Over the past few months I have from time to time formally assessed the nerve’s function. With a Facial Nerve palsy, all the muscles of facial expression are paralysed leading to a drooping of one side of the face and the inability for that side to smile, raise the eyebrow and close the eye properly. Whilst the asymmetry is thankfully quite subtle to the untrained eye for this individual, it is very obvious when you look for it. Furthermore, formal testing leaves no doubt as to the problem, the now pencil-line scar over the angle of the mandible suggests the cause for those who know to look for it. Early on, there did seem to be some residual function (the eye can close almost normally) and I would be lying to deny that although I knew it unlikely, a part of me deep down was hoping dearly that a dramatic recovery would occur. But as the weeks and now almost 3 months have passed, I have had to accept that it is very unlikely that it ever will.

To say this remains gutting is an understatement. In the first few weeks after they returned to work, it was really quite hard to see such things every time I arrived to undertake another operation. A stark reminder of the stakes I would be facing as I approached the table, picked up the knife and made that first incision. It invoked that feeling of carrying a little daemon on your shoulder, baiting you to make a mistake and fail.

But I have certainly come to terms with it now. I have had to. All surgeons experience complications at one time or another, and no matter how hard it might be, you have to learn to manage your feelings about it. Thankfully, I have had precious few. For me, one of the harder things to come to terms with in this case was the fact that in the UK I would never have been in this situation. I would never be the one to perform such an operation. Yet here I was, having taken on a big parotid tumour, and, quite literally now, staring my failings in the face. In tackling this substantial tumour, it is entirely possible that injury to the nerve was inevitable, no matter whose hands the operation had been in. But such thinking is a dangerous road to pursue. Better to simply accept that it has happened and deal with it. Another patient helped me do that.

Suitable consent received
Sorry if its 'gory' but it
powerfully illustrates a point.

A few weeks ago, I was asked to see the relative of another staff member. When I was told about the problem (a good description of a parotid tumour), I was not sure how I would feel. But of course I agreed to see them. Brought to theatre reception (on a day I was operating), I saw this new patient between cases. As I walked towards them and held out my hand in greeting, their face turned slightly, and the scarf fell away a little from their face. There was no doubt what I was looking at. The huge ulcerated growth over their jaw and in front of their ear was clearly an advanced parotid cancer. It had destroyed many of the structures of the face, including the facial nerve. It was beyond any kind of help and as well as being disfiguring and miserable to live with, I was fairly sure that they would not be alive in three months.

Such things are incredibly sad to see. They once again highlight the healthcare inequality that faces much of the world’s population. There are many cases like this, and they are all equally heart-breaking.

But perhaps operating on my colleague was the right thing after all…..

The rest of the day was slightly odd. For the first time since arriving here, I was the sole provider of the service, something I have tried to avoid (I am very focussed on sustainability and training). However, the senior AMO was still running examinations and the other AMO remains unwell. It was quite fun to be honest. Working with one of the senior theatre nurses, we were able to crack on through the cases at a rate of knots and enjoy my efforts at Swahili ‘small talk’. I’m improving apparently.

This is why we do it.

It was back into the thick of things today, with another very busy outpatient clinic. I quite enjoyed myself, which might seem surprising in many ways not least because the senior surgical AMO had been seconded to running examinations for the week (an interesting decision from my perspective) and the other one was feeling distinctly under par – a high fever, but malaria test negative. Like so many healthcare workers all over the world, he came to work and we just got on with it. The week would have been decimated without him, as I really do not have the depth of Swahili language to run an outpatient clinic effectively on my own. It was another hot day here and as I walked through the door of the clinic room, I looked up hopefully at the ceiling fan. Have you been fixed? I thought to myself. It stared back at me lifeless. No amount of fiddling with the switch could persuade it stutter into life. Clinic was to be another stuffy affair. I have gotten rather used to sweating.

Once again, an interesting and eclectic mix of patients came to see us today, which I really do rather like. It is a very different practice to that which I enjoy back in the UK; where, driven by the complexities of specialist practice, we see a much more selected group of patients. It is certainly challenging, but refreshing in many ways too. Furthermore, I have definitely rediscovered my love of paediatrics and if nothing else, the opportunity to provide such a service here has been a real pleasure for me (albeit a slightly stressful one anaesthetically).

However, the real highlight of the day came when a certain familiar face walked through the clinic door. She was smiling from ear to ear and brought the ‘sunshine’ in with her (but without the heat I hasten to add). Blimey she looked well. This was the 49 year old lady I described in ‘complicated complications’ back in November. She had had more than one close shave with death and with inevitable wound complications (and lack of community support or clever wound management systems) had been an inpatient in Muheza for over two months, including Christmas and New Year. She was finally discharged about 6 weeks ago.

If you had met her for the first time today, you would have had no idea what she had been through. There was not even a subtle hint that she had been ill (nor newly diagnosed with HIV). And further good news was to come when I inspected her abdomen. Her scars bore testament to her ordeal, but the wounds had completely healed. The sinus that I was suspicious might have become a long-term issue, had dried up. What an absolutely fantastic result. For me this was a really special moment. Here sitting before me, was a lady we had rescued from the very brink of disaster. She was alive, well and thriving. As we talked about how she had been getting on, she then wanted to hear about news of my littlest daughter (who had taken her sweets just before we went away for Christmas). It was a delightful conversation. She was patient with my Swahili, but sometimes the words don’t matter all that much. As I discharged her from clinic giving her a ‘clean bill of health’, I couldn’t help but think she was starting another chapter of her life that she very nearly did not have.

It is cases like this that make all the years of hard work and toil as a surgeon worth it. Investing so personally in the outcomes of our patients does carry a significant burden when things don’t go so well. But the flip side is that moments such as this are that little bit sweeter. They are that little bit more powerful. And seeing such a person thriving brings with it a certain special sense of deep satisfaction that we have used our skills well. The attention to detail, the perseverance. All worth it. I blink and my mind momentarily flashes back 3 ½ months to the chaos I found when operating; the torn bowel, the hole in the colon, the enteral contents. My lids open; and walking out of the door is a beautiful healthy human being.

Weekend exploring.

It has been an absolute privilege to come to Tanzania. Fuelled by my wife’s attention to such things, we have made the most of our opportunity to explore our novel surroundings. It is such a beautiful and friendly country.

This weekend we made our way up into the West Usambara Mountains (the ‘second half’ of the mountain range that we look out over as you travel up towards Moshi / Arusha). We left a very hot Muheza mid-afternoon on Friday in the hospice car, taking the solo New Zealand / Singaporean medical student with us. Thank goodness for air conditioning, it was wonderful to just be in the car and be a bit cooler! We headed up towards Lushoto and Irente Farm Lodge (2 ½ hr drive). The roads were surprisingly good almost all the way. As we wound our way up the mountains, the scenery was stunning, and the environment slowly changed to more of an alpine feel. The road became not dissimilar to some you might find in the Alps – steep drop offs (although no barriers here which is a little disconcerting) and very sharp u-bend corners (along with some alarmingly fast-moving vehicles, so very similar in fact!). 

Not a bad view for breakfast!

Irente Farm Lodge

Stepping out of the car when we arrived was delicious. It was cool! Such a contrast to what we have gotten used to. The farm is wonderful too. A working farm that has its own herd of cows (a Friesian cross which would not be out of place grazing in many a British field), pigs, bees, ducks, a fish pond as well as several crops to keep everything fed. The mountain-side setting is stunning, with space for the children to roam, animals for them to visit and homemade breads, cheeses and jams (the best we’ve found in Tanzania) to eat. We were very well looked after.

'Not sure who is more content!' and 'cheese making tour'

On Saturday afternoon, we made our way deeper into the mountain range to Mambo View Point Lodge. It was a bit of a mission to get there in all honesty. A further two hours on roads that were now dusty and often bumpy tracks, winding through the valleys and around the beautiful peaks, hundreds of terraced shambas (farms) almost impossibly sited on the slopes. We had one close call as we turned a tight left-hand corner (you drive on the left here like the UK) to find another 4x4 coming the other way on our side of the road at speed and almost upon us. Fortunately, I was driving at a gentle pace, slammed the breaks on and tucked into the cliff face. It swerved, missed us (just) and also managed to stay on the road. Hmmm. We have been well aware of the burden of traffic accidents in Africa. But up until now, we have not really had any personal experience of such things beyond the regular limb and head injuries presenting to the Hospital associated with BodaBoda (motorcycle) use. This was a near miss we would rather not repeat.

Apart from that, the other striking thing about our journey was the vast array of road improvements going on. There were many lorries dumping huge piles of stones and earth ready for making the roads more resistant to the rapidly approaching wet season (many of the road networks become impassable at that time). And there were many ‘bridges’ being made – drains for the many streams that form. The particularly interesting thing about these ‘bridgeworks’ I have discovered, is that they are often undertaken by the local villagers. They get together when problems emerge and try to tackle them, often commissioned / in conjunction with local government. The work is usually all done by hand, with no special equipment or machines. A lot of hard work, sweat and toil. Image that system in the UK! It is impressive, and epitomises the character and strength of community you find here.  

Mambo View Point Lodge is one of those little gems that you sometimes find and well worth the effort of getting there. At 1800m on the very edge of the mountain range, the views are stunning and the environment delightful. As the sun went down, we even needed jumpers! In the evening, they placed a brazier of hot coals under each communal dining table to take away the chill, and a stunning meal was taken chatting to the other guests and some of the staff. It is another establishment built by overseas entrepreneurs, but the owners of this one live here. Talking to them over a glass of wine struck a chord with me as they recounted their philosophy of ‘trade, not aid’. 

Our Luxury Banda and walking out to a view point - vertiginous!

Saturday night was the first time since being here in Tanzania that I have slept in a bed without a mosquito net (too high and cold for them – I was in a tent up Kilimanjaro). In the morning, we awoke to a stunning view, looking down upon the clouds. In the far distance you could just make out the two peaks of Mount Kilimanjaro. 

It was a fabulous weekend and another opportunity to recharge the batteries ready for the next week of work.

Another contender on our journey home.

Yes that is a massive satellite disk on the back of a motorcycle!

Decompensation

Today I ‘decompensated’ in theatre. Today it was one time too many, and I found my frustration bubble over. I did not shout, but perhaps raised my voice a touch. I vocalised the words “this is completely unacceptable” and was very blunt with my other comments. I even said that I was cross. I am not a shouty person (and hope I never will be). For me, this was a big deal. And clearly it had an impact. Whether this episode will ultimately be a good thing, or not, only time will tell. It will either be a catalyst to help drive improvement, or it will damage my relationships with the team. I really hope it is the former. I am only human after all.

My frustration was simply that we are better than this. The team here is better than this. But why are we making the same mistakes? I found myself watching an adult patient having an unnecessarily long period of hypoxia (time without oxygen). Once again, the same issues emerge. A lack of situational awareness perhaps. A lack of communication. A lack of preparedness (the CO₂ monitor was not connected, the new suction catheters I had had sent over from the UK were not ready, the bougie was in the store room). When things go well, they are very slick. But when things are tricky, the situation seems to escalate. Problems will always emerge in healthcare, but rather than the brakes going on and returning to a place of safety, somehow things seem to spiral and become unnecessarily hazardous. I seem to have been the brakes more often than I would have liked.

Today the patient was a difficult intubation (this means it is difficult to get the breathing tube into the right place) and we did not have our lead anaesthetist present. Things were taking longer than ‘normal’. Equipment was not ready. The clock ticked on. All this time the patient was without oxygen. The pressure to secure the airway increased. But it was not forthcoming. At this point, the team should have stopped. Reset. Reoxygenated the patient and tried again. Up until this point, whilst not ideal, everything was safe. And such things happen in theatres across the world. Not uncommonly even. However here, things ploughed on. In what looked like a last ditched effort, the tube was sited. Unfortunately, it transpired, this was in the oesophagus (food pipe, the wrong place). But it would take time to establish this fact (longer because the CO₂ monitoring wasn’t attached). It was around this time that I spoke up. The operating room was noisy, and I asked for quiet. The saturations were unrecordable. We needed to try and rescue what was rapidly heading towards a disastrous situation. I just hoped it would be in time. The tube was taken out. Thankfully, a bag and mask (a technique used in resuscitation) was very effective and the saturations climbed. Soon we had returned to a place of safety. Hopefully there would be no long-term damage.

I was encouraged to take over. But this time I refused. I knew the team was better than the last few minutes. Having vocalised my frustration, I now voiced an air of calm (far from how I was feeling, but the team didn’t need to know that). “Take a deep breath. The patient is safe. Now what do you need to do this properly?”. I stood behind the nurse anaesthetist and took on the role of their ODP (a crucial person in the UK who helps make sure everything is ready, acts as an extra pair of hands, a second pair of eyes and is a supporting role not be underestimated). I attached the CO₂ monitor. We got the boogie. We set up the suction properly. We were ready. The patient had been well re-preoxygenated. I said “You do this. You can do this. You have plenty of time now. Relax”. I could see that he did. I could tell it was not easy, but he was calm. He used the boogie and intubated the patient. Fantastic. “Well done” I said.

I washed my hands and did his surgery.

There was definitely an air of ‘walking on eggshells’ in theatre for a short time after that. But this slowly dissipated, and we returned to our normal happy place. At the end of the case I said thank you and well done to the whole team as I usually do, but this time apologised for ‘getting cross’. “I was frustrated. You are better than that”, I said. They smiled and nodded. I went to write the operation note. I was distracted though. What am I missing? Why do these things happen? What don’t I understand? Clearly things here are very different to the UK. Clearly a consultant anaesthetist in the UK has substantially more experience and training than the staff here. But I genuinely rate the staff that I work with in Muheza. For what they are, for what they have, they are excellent. But it occurred to me that I did not understand the whole picture. They were not me, and I was not them. And so I walked to the coffee room. It was a jovial place and I was reluctant to drag us back to a less happy place. But I did. I asked my Tanzanian colleague (the senior surgeon); “Do you want to talk about what happened? Ask the team. If you do, come and get me.”

What happened next, was fantastic. I was both humbled and delighted. He came to get me and when I walked back, the whole team were lined up on chairs sitting in front of the whiteboard I had bought. We had not used it yet. What a way to start. We spent the next 30 minutes unpicking what had happened. A classical ‘simulation debrief’ if you like. Except of course it wasn’t a simulation. No punches pulled and no stones left unturned. It was incredibly honest and incredibly insightful. Together we identified the problems, why they were an issue and, perhaps most importantly, what we could do to change our practice.

Perhaps today was a good day.

When I visited the ward later, the patient was awake and talking. Another close shave, but I think we got away with it.

Rollercoaster Fatigue

Today has been somewhat more stressful than yesterday. The first case of the day was the 8 month old baby boy that we had to postpone from Tuesday. He had an inguinoscrotal hernia with palpable bowel in (so a particularly big hernia for a child of his age) that needed repair. The risk of strangulation (it getting stuck and bowel dying is high (up to about 30%)) and so it needed doing. Whilst I was not especially keen to be undertaking that here, there was not really any other option unfortunately (many reasons discussed over the course of previous posts). My main concern was not so much the surgery, but the anaesthetic side. I had discussed all this carefully in advance with our anaesthetic team and we decided to proceed. I was told that it was possible to do any child above 6 months old here (they are expected to do such for an ENT list). In the UK, all children are only anaesthetised and operated on by experienced specialists. A limited number of routine operations are performed in most DGHs on children over the age of five. But any complex procedure, or children below that age, would be sent to a tertiary referral centre (usually a big teaching hospital). 

My apprehension was entirely justified, and a stormy anaesthetic induction ensued. There came a point when, once again, I found myself at ‘the head end’ trying desperately to help keep this baby alive and safe. The trouble with such small people is that they are so small! They have almost no reserve, desaturate and decompensate very quickly. Their anatomy is also tiny and so securing an airway is extremely challenging. Whilst I have become accustomed to a bit of excitement here, this was without doubt the most stressful 30 minutes of my time so far. At one point he went a very worrying colour (albeit for a very short time). After several attempted intubations, the final one by me (you don’t get long and have to bail out back to a bag and mask quickly), and a number of times when he was fighting the anaesthetic (we want to breathe for him, but the drugs are wearing off and he is trying to breathe for himself), eventually we got an LMA (a special tube that sits above the vocal cords which you can place almost blindly) in a good position to rescue the situation and managed to get him settled. At this point, we had all had enough and were about to call it a day and allow him to wake up. It was all feeling very uncomfortable (that is an understatement). However, he did not just settle, but he seemed to thrive. His numbers on the monitor were perfect and he became very stable. After such a difficult process, I reluctantly realised it would be madness to let him wake up now. To do that would mean that he would either have to live with the risk of no surgery or head to a distant centre and go through the same process again. We went ahead and repaired his hernias. I must say that I felt a little bit ‘under the cosh’ whilst operating, almost waiting for him to destabilise at any moment. Thankfully he remained very stable and the surgery all went well. The inguinal hernia was very large and whilst the defect was fairly tight (the reason why there is a high risk of strangulation) it was big enough that a simple herniotomy did not seem adequate. I reconstructed his deep inguinal ring with some absorbable sutures and I hope that this will reduce his risk of recurrence. We also repaired his large umbilical hernia.

The second child (nearly 4) almost seemed to know what had happened with the first case and was very unhappy about coming to theatre. But there is no such messing about tolerated in Tanzania and he was quickly bundled into the operating room for his surgery. Perhaps not the tactics we would usually use in the UK, it was nevertheless very efficient! In contrast to the first case, the anaesthetic was very slick (and I wish to emphasise such things to highlight the quality of the team that we have here). His procedures (inguinal herniotomy and umbilical hernia) also went very smoothly which I think we all needed.

The final case of the day was a big inguinoscrotal hernia in an older man. I knew it was going to be difficult (he’d had it for years), but I wanted to give the two local surgeons an opportunity to try without me. They did very well, but inevitably I was called to scrub in. It was most pleasing to see how far they had gotten, and their difficulty was entirely understandable. The scarring was dense and the anatomy not clear. It was back to basic principles with careful dissection and discovery of the expected anatomy. I helped them past the hurdle and then left them to finish off. Whilst they wont intentionally take on such cases on their own when I leave, excellent experience nevertheless.

So, I must say that I am feeling a little jaded this evening. Our time here has definitely been much more of a rollercoaster than we are all used to. The highs have been exceptional, the lows testing to say the least. It has certainly been one of the richest periods of our lives experientially, but I think it is fair to say that we could all do with a bit of stability and, dare I say it, ‘routine’ for a while. I certainly feel like I could do with a bit of a rest!