2nd October 2014. The weekend and Kimilili sequel.

Kenya Electricity were doing work up the road from Dreamland on Sunday An electrical surge destroyed four computers, an autoclave and several surge protectors. We think twp phases came downline at >400V. Bang! Ouch! The company are not known for compensating for their mistakes!...

Tony had preached in the morning and we had our weekend snacks at Mount Crest Hotel; samosas +\_ two egg omelettes or chapati. Jomo did give us a Sunday evening meal, so we got up on Monday for breakfast. Food stocks were running out such as jam and cornflakes. Jomo works on contract for visitors, and Catherine has looked after the accommodation. She is due to get married soon. Today, Thursday we gave each of them 400KSh from each of us on Becky's suggestion.

Monday I read Philippians 2:13 and shared it with the team. Bjorn had received a similare message from Norway so we shared it with the theatre team. Despite my anxieties about caring for the tiniest babies, Monday's 5kg lips went so well we finished early and I walked home with Bjorn before the rain. Tuesdays lips (& non-operation palates) went almost as smoothly for the last 4kg children. The last one held me up on the intubation, but God's grace and Bjorn's assistance were great. We came in on Wednesday prepared to do surgery, but there were no new arrivals. 10/12 Belinda who weighed 4 kg at birth arrived at the w/e weighing 3.9kg with a jutting premaxilla with bilateral cleft lip and palate. Tony had a powerpoint lecture with him of a similar case, and it is far more complicated, so she has been left on a feeding programme. We are contemplating anothe visit next October if all is well, but the Pettersens hope to take their Norwegian church group to the Gambia in week 40 in October half-term.

Gile was off sick for our last three days. She had held the nursing team together so well. Simon & Jane Daniell who have worked here for seven years came back to see the work vision enacted out. Although a general surgeon and radiologist he oversaw the hospital expansion from a clinic in September 2012, when the first soil was turned. Having had their house built to their specification, Simon got good prices and quality workmanship for the three wards and theatre. It is a tribute to his oversight. Michael Nightingale put a funding request to Guernsey for the buildings, and to a company for the equipment for theatre which Tim of MedAid brought in; old reconditioned European stuff serviced by engineers and brought out by Operating Department Practitioners. I met him at Oak Hill College in July 2013 at their mission stand at the Developing Health course that I went on.

So Wednesday was the start of tidy up, locating my theatre scrubs which had been washed and ironed, and making sure I brought back stuff I didn't want to leave. Thursday I continued to assist Ann in cleaning the lips for final post-op photos which have to be full faceview with both ears visible, and the patient looking at the camera straight on! Difficult with the babies.  Don't let them fall asleep after the trauma of the clean up!

We had got to Hospital devotions on Wednesday since we didn't have operating. Bernard asked me to prepare a 10 minute talk for today. I titled it Questions that Jesus asks of us from Mark 8: 27-38. I gave my testimony and the effect of Mildred's question to me at my confirmation: "What does Jesus mean to you now?". Then the farewell started - and continued a long time with singing, dancing and garlands (Christmas decorations actually, returned to Becky's office later).

So the final clear up. Only four patients remain in the hospital, the last operated ones due to go home tomorrow. We got back to the guesthouse on the muddiest of roads after all night rain by 1045, and left after farewells to Solomon & Ruth, Becky and Jo. We loaded up the IcFEM van and Amos drove us through a busy Kimilili market, into Bungoma market. We filled up at a Total garage and got to the Kiboko Hotel at 1445. We passed Kisumu Yacht Club nearby where I took my first steps in June 1954 when I was 15 months old: late developer!

This place is beside Kisumu's inlet into Lake victoria, and comprises tents on short stilts with a concrete swish bathroom suite attached at the back. So you enter a door into a mosquito screened verandah. Inside is a zippable tent are with huge bed with mosquito net, kettle facilities for tea and coffee with a fridge, and the bathroom tiled behind! At 1850 it is almost dark and the crickets are chirping. Birds here are amazing. A brown crested heron, a nlue bird the size of a canary, and another bird with a bright yellow chest. I have my binoculars and a boat trip is a possibility tomorrow, anytime from 0600hrs! Taxi to the airport is booked for 1630 tomorrow. We passed the airport a half-hour drive away.

This is possibly good-bye from this kenya trip. Perhaps next year again?!

26th September weekend

After two lip and palate procedures we had operated on 27 patients and completed 29 operations. We had to finish palate procedures before our last weekend to give time for healing before our departure. Tony & Ann came up to Dreamland with me on Saturday morning with 9 litres of porridge, did a wardround, and then cleaned up, photographed and discharged three more patients. We all had a quiet day reading, lunched at Mount Crest Hotel, and Bjorn was recovering from his cough. Tony & Ann busy themselves with photographs on their computers, so that Becky can forward the Smile Train papers ASAP for quick funding hopefully before the end of October.

Bjorn on Saturday night his pillow had eucalyptus oil sprayed liberally on it, and as he turned his face into it, he got an eyeful!

I was keeping touch with Sue & Naomi on their travels via LGW to Rome. Trevi fountain being hidden from view, and a boxroom for a bedroom. Fortunately they were upgraded!

Sunday was Tony's opportunity to preach at the Anglican church. Ann & Tony got them singing Alleluia, Praise the Lord with women taking Alleluia and standing, while the men sat, then the men stood for their Praise the Lord parts. I was more worried about them dropping the roving microphone on the tiled floor! Jo & Becky were in the back row with Simon (surgeon/radiologist) and his wife Jane (oncologist) who have built up this place. Simon has organised the building with generous donations from Guernsey and a family-linked business. They are back to see the results of their efforts. Mike Nightingale (Becky's husband) did a facebook comment on our work here. One of the mother's of the first three children put up a positive facebook comment on the IcFEM website, the day of her child's discharge. I look forward to reading it. The patients come from poor as well as educated families, but this Mount Elgon area is poorly served by Government health facilities. 

On Sunday, Bjorn & Anne-Marie did the porridge run, and checked on the patients. A ten-month old arrived with a cleft lip & palate weighing 3.9kg. We have agreed that the infant is not strong enough to have a good chance of benefitting from surgery now: A feeding programme is required first. An adult relative also has a cleft lip with two affected daughters. We have tried to make contact; we shall see the outcome. We could operate on Wednesday if we have cleft lips to do.

Monday's patients have all been on the feeding programme. Their ages go from 5 to 14 months, and their weights from 4.6 to 5.4 kg. Simon & Jane have been into theatre to see how their brainchild is working. They left a shell in December when they went back to the UK to move up to the Peak District village of Eame celebrating 350 years since the Plague. They are thrilled with Becky's management of the ward and theatre development.

Bjorn had shared with his Norwegian Church in Christiansand our need for prayer as we got to the tiny malnourished babies. One of the elders texted him at 0400 about God's good purpose veing fulfilled. If Sue is reading the same Encounter with God notes as me we were in Philippians chapter 2. Verse 13 stood out for me before Bjorn told of his text message. It talks of God's purpose being done in and through us. So when Bjorn And I started the walk home at 1500 in glorious sunshine, we chatted about how well the day had gone. Thirty minutes later as we approached the guesthouse dark clouds and long rumbles of thunder were heard. Fifteen minutes later the heavens opened.

14th September - Sunday

We had an early evening last night. Ann & Tony had sorted the suitcases, and we were chatting on the veranda when Catherine invited us to dinner. The dining room is large: it could seat 40, but there were the five of us. The lemon yellow walls decorated with a hand-painted flower motif; a pleasant room to enjoy a meal. Catherine served us chicken, roast potatoes, courgette and carrots, followed by topped and tailed bananas.

Becky came round to check we were OK and what our plans for today are; late breakfast at 0900 if that was alright with Jomo. Catherine checked that it was. At other times it will be 0645, so we can get to devotions at the hospital before work starts.

After dinner we chatted in the lounge area of the guesthouse, and I got Father's Daily Light out. The reading was on resurrection, which fitted well with the beautiful singing we had heard at Anne-Marie's 93-year old Dad's funeral three weeks earlier. Bjorn had shared it on his new Samsung Galaxy. Generations of family had sung a cappello with no rehearsal. A real worship service.

My room has twin beds with mosquito nets hooked on ceiling hooks. Decoration is blue with the description of purple room on the key. A small bedside table between the beds, a large wardrobe with two lockable drawers, and space for my suitcase on top. Bathroom en suite has a medicine cabinet, a sink that has no plug and my universal one hardly slows the drain off! There is a shower beside the toilet. There is an electrical heater for the shower; adjusting the heat is done from a long plastic lead connected to the showerhead. It looks like a broken system, but all the bathrooms have it. I have a shaving light and mirror above the sink. It was good to see two days of beard disappear with my battery razor.

I'm taking doxycycline 100 in the mornings against malaria. This is a bad area, and Becky has had falciparum several times when tummy upsets have made the regular prophylaxis fail. You need to swallow it with lots of fluid and stay upright for some time. Stanley Parrick in the Gambia took 200mg in the evening without adequate water, and his oesophagus suffered for the next two weeks! And he had worked on the Mercy Ship so he might have known better!?

Landing in Nairobi didn't bring any memories back to me. I was born in this capial city over 60 years ago in one of the hospitals: I don't know which one! My Father worked in Kisumu, and I had no memories of that either apart from tiny old B&W photos of sailing on Lake Victoria, and a cine clip. My Father was a keen photographer. The rock formations on the hills around Kisumu are amazing. It reminded me of the Peak District Standing Edge, but much more random with boulders shaping the summits and balancing their substantial shapes on the steep hilsides, all the way to the plateau and beyond. The geograhy of the Rift Valley is fascinating.

My purple bedrom faces onto the verandah which is into a courtyard with the dining room on the far right. The window on the bathroom side looks out to the hills. There are lots of sounds around; children, cows, crickets and cockrels. Dogs had a short howling match last night.

I slept well under the net. The bed is probably 6'3", so I slept on the diagonal. I appreciated my bottled water in the night. I had a headlight, iPad and spectacles beside my pillow, and didn't get too disoriented on my excursions.

A Swahili word for welcome has been shared with us by the staff here. It is Karibu.

16th September 2014 First Surgery Day

The dogs barking last night gave me a disturbed night. Hearing the cockrels at 0530 meant I wasn't going back to sleep! But we retire to bed much earlier than in the UK, and last night the flying ants seemed to penetrate past our curtains. The guesthouse does not have mosquito screening, so from dusk to dawn you cover up.

In our introductions at devotions Tony & Ann mentioned their 6 children & 9 grandchildren, the Pettersens told of their 4 children & 8 grandchildren, so I spoke of Sue being so disappointed not to be here, and then of our three and our granddaughter. My voice was cracking up as I said it. It means alot to me for the home support, amd I miss you all.

Today went well. The first theatre case started at 0905, and the local & visiting team worked well together. We did our Team introductions, and the World Health Organisation Surgical Safety Checklist.

I was joined by Kaan a medical assistant anaesthetist based in the government centre where their anaesthetic machine is broken so he comes up to IcFEM's Dreamland hospital to do orthopaedic procedures, with the excellent equipment that we have to use. He is a Masai Catholic, married to a local Bukusa women, so his family are local to this Western State. He hopes to join us again, but he was called to do a Caesarean section under spinal.

We did three cleft lips, the youngest being four months old and 6.2kg. Our fourth we will do first tomorrow. We had a tea break after the first child was recovering, lunch was provided with bottles of fizzy, so we are well looked after and tonight at the guesthouse we had chicken with roast potatoes (thyme flavoured?) followed by mango crumble.

Three more planned for tomorrow; Tony is weary but coping. The rain started again at 1530 with thunder & lightning, and it is noisy in theatre. Along the road are the maize fields and sugar cane.

As we rest in the lounge, Ann is entering photos onto the laptop, so all the Smile Train records are complete. Three more patients arrived today. The wards are filling up.

20th September: Saturday to relax.

Tony, Ann & I had breakfast at 0730, and Becky took us to Dreamland Hospital shortly after 0800. Bjorn and Anne-Marie took a later breakfast, and we met up at 1130 after we had planned Monday's ops, cleaned up five faces, and discharged them. It was fascinating to help Ann as she Q-tipped the suture lines with saline then dried them clean. Although I have anaesthetised over 100 clefts for Tony, this was the first time to witness this discharge rite of passage. They have healed up faster and better than the RVTH, Gambia patients. Fucidin instead of metronidazole for antibiotic cream, clean mountain air to seashore dust in Banjul, clean theatre and wards in Kimilili in comparison to the Royal Victoria (or Edwin Frances Small Teaching Hospital 2013), and Mums sitting in the shade of a garden, rather than taking the newly operated babies into the market area! So we have discharged on 3rd and 4th day, when 5 days was the rule in Banjul. It's great to have some empty beds!

On our return with Becky, we changed to go trekking up towards Mount Elgon. Jo and Lambert guided us straight up the road, past the new waterworks, up to the Rock. Tony & I didn't go to the very top due to the height. From the Rock we could see the waterfall and a young lad led the way. Anne-Marie and I had thorns make holes in our trousers. There were three varieties of plants  at least with significant thorns! The waterfall was not huge, and it was muddy brown colour! It was about 40 foot high, and the spray and wind around its base was fun. We then were led by four boys back to the main road which circled round the Rock, back to the crossroad to Dreamland or Kimilili. We got back to the guesthouse after a walk from 1150-1520. At 1540 the rainstorm swept in with a lightning hit less than a mile away. Our electricity has failed, and Becky suggested the local transformer may have taken a hit!

After a shower during the storm, I have taken my Dad's Daily Light which he annotated with family events and started to date his travels. January 1951 he reconnoitred Western Kenya for a few days, taking in Eldoret, Kitale and Kisumu. March 1953, my brother Ian had measles, then I was born, and two days later Jill ( my sister, now known as Richenda) went down with measles, while we were all in Kenya. I don't know if they were in Kisumu while I was born in Nairobi.

Becky has been busy with the XRay machine; a Kenyan technician from Nairobi has come 8 hours journey from Nairobi, and hasn't managed to fix it yet. He needs to return back tomorrow, so Becky will be up at 0500 to take him back to Dreamland to see if he can fix it early in the morning!

With no electricity, folk are heading to bed early. This Morning I moved my bed so the mosquito net is better placed over the bed. I shall see if it works!

24th September. 20-22 ops.

Tony is doing an awkward palatal fistula in a 6 yr old girl who had lip and palate surgery elsewhere. Kaan, the Masai Clinical Officer for Anaesthetics in Kimilili has told me a disturbing story about Lifebox training in Eldoret in April/May this year. A colleague went to Eldoret for Lifebox training, with the promise of an oximeter to take away at the end of the course. In reality he came away with a Lifebox kit with self-inflating bag, laryngoscope and a selection of tubes, but no pulse oximeter. The boss in Eldoret with its excellent facilities had kept the oximeter. This is not the way that Lifebox set out its stall. It doesn't always work as planned. It's a new charity with a great purpose. How it achieves that purpose without intervening power-play by senior national doctors at the expense of the Medical and Clinical Officers ability to care safely for patients, is a matter that needs individual decisions, and international Standard Operating Procedures.

The afternoon list is in full swing; the third and last patient on the list. Another 6 year old girl. I wonder what schooling opportunities have been lost by her so far because of her facial disfigurement? "I'll be jiggered!" Is a phrase sometimes heard in the UK. This girl has jiggers. She obviously doesn't wear shoes, and the jiggers have caused eruptions on the soles of her feet. It is a significant cause of morbidity, and there was a UK student here last week doing a Masters dissertation on the Public Health response to jigger infestations. Eight schools in Bungoma province shut down last week because of jiggers. I remember going to a shoe shop in Covent Garden with Naomi and Sue, where each pair of shoes sold raised money for another foot problem common in Ethiopia caused by a particular crystal type of rock surface they walk on. And we take shoes for granted.

We plan three 7 kg children tomorrow, and then two double lip & palate patients on the Friday.. Those patients count as two operations each with Smile Train. The last week we won't do any more palates, so we start doing the 4+ kg patients with their lips at about three months of age for their cleft lip repairs. We could possibly take a couple more cleft lip patients if they arrive soon.

Last night after the afternoon rain, there was more rain at midnight and at 0600hrs. A tractor had broken down in Becky's lane when she returned home so she parked by the Guesthouse. Her Landrover front passenger door lock fails to function so the passenger has to hold the door shut! Maurice was filling the vehicle tank with petrol, so I set out early and walked a mile before I was picked up. It was muddy!

Ann and Anne-Marie busy themselves making up porridge to bring to the hospital for 0800 feeds. They have a blender in theatre to take out the lumps. It needs to boil for ten minutes before cooling down. It is popular with the patients and parents. The volume required as the palate operations have taken place has risen to 9 litres for today, which are brought here in recycled cooking oil 3litre plastic containers.

Kenya, kimilili: september 2014

13th arrival.

After a morning at the L&D, Sue drove us to Barton-le-Clay to collect Tony & Ann with six suitcases weighing over 20kg apiece. The Alhambra took the 4 of us to LHR 4 to rendez-vous with Bjorn & Anne-Marie who had refreshed themselves at Cafe Rouge after their arrival from Oslo. We had drinks together, and Sue shared wedding and engagement photos before driving home via Sainsburys.

The terminal 1-3 luggage handlers strike had only been for postal services, but the Norwegian SAS had allowed their main cases as cabin luggage, but all sharp items were lost at security.

Check-in and security went OK: Tony had a random thorough search, which he said was usual for him! We then found an enjoyable Lebanese cafe to get some food before boarding.

KQ101 to Nairobi boarded from gate 8, and i exchanged messages with Naomi & Sue before boarding. Right hand side over the wings in a 727; The Pettersens to my right, and the Giles behind. The Master & Commander movie stopped half-way, so I gave up on in-flight entertainment after seing a little of Entrapment. Sleep was fitful with walks up the aisle more for stretching and comfort. Having left LHR at 2000, we landed in Nairobi at 0630. (0430 UK). Altitude about 5,200ft. Visa queue took close to 90 minutes; we should have got the paperwork and queued rather than written everything first. It was slow as they fingerprinted right and left hand! We could see our colourful cases on the carousel for an hour before reaching them.

Ann led us out to the Orange & Airtel kiosks and we got SIM cards for our phones, before wheeling our luggage trolleys to Domestic Terminal for KQ654 to Kisumu at 1020. We had all taken our doxycycline by then. There was just time for a catnap and a snack and we were landing at Kisumu at 1100. The rock formations on the hills around lake Victoria are amazing. Massive boulders strewn across the landscape near the hills, but rich green vegetation elsewhere except for maize (corn on the cob) crops that looked as if they had not had enough water when needed. This dry season has been wet. Becky met us in a Pajero, and Amos took the luggage in the IcFEM van with Ann & I. It was about 2 hrs at up to 50mph on mainly good roads, and we could see mount Elgon's foothills as we got to Kimilili, the IcFEM Hospital and guesthouse. Jomo & Mary will look after us for meals, but Becky gave us a bread, cheese and ham salad feast with some welcome drinks. At 1500 after 15 minutes of T&L, the predicted rain came! We ran back through the new puddles to the guesthouse to unpack and rest before supper at 1830.

We have arrived safely; Tony has had significant side-effects from his medication for repeat thyrotoxicosis; anne-Marie has a crooked finger after a recent cycle accident in Norway, and Bjorn has had a redo TURP correction this week! My bent thumb is minor!

18th September . Third day for surgeries.

I don't know what happened to y'day's blog; it's in the ether somewhere! We had done three cleft palates, amounting to about 4 hours of surgical time, ad an easier day for Tony. When you add in anaesthetic time, recovery , tea breaks, lunch and post-op visits and pre-op planning it remains a full day. A lift in the long Landrover, picking up hospital staff over the first two kilometres, so 13 by unloading. Today we had 14. The summit of Mount Elgon was clear this morning. Y'day it threatened a storm, that passed us by. Today we had a torrential hailstorm that started on the dot of 1530. You cannot be heard speaking in the theatre environment! We did a palate in the morning followed by more challenging cleft lips. So we finished later and got the lift home as the vehicle slithered past huge mud puddles.

Anne Marie planned to go to the market with Jo Finlay this morning, but she is still recovering from concussion after her bike acident in Norway when she dislocated an index finger. We didn't see her all day, but on our return we found she had severe vomiting, probaly from sorting out a patient a day or two before. One senior member of Dreamland hospital was admitted with malaria today. It's too soon for that for Anne-Marie, but she will be more prone to malaria since her doxycycline today will not be taken. We pray her recovery is swift and that Bjorn and the rest of us avoid it!

After three days we have done nine patients. We are hitting the target set in the planning of the project, and more patients keep turning up. How we decide who to do, and who can't be done will be difficult if it comes to that.

22nd September 2014. Start of second week in Kimilili.

Monday morning, and the whole team were up at Dreamland. We started shortly after 0830! And the first patient was shorter than expected, so we had done three by the time we took a late lunch. Then the delays started as a media team arrived to interview the patients' mums and some staff. We waited for them to take photos of theatre when we weren't working.

Agnes, the lead nurse in theatre, was down with malaria over the weekend, so Matron Gile scrubbed for the first two. Agnes did make a show since she lives on site. Matron is a spinster. Evelyn had transport problems and worked on the wards when she arrived. So Matron also did recovery, a real multitasking leader! We finished at 1630, and then the pre-op visits for the next day and the post-op visits too. The rain started at 1450 with thunder & lightning ten minutes after Anne-Marie set off walking  back; her plan was to go to the market, but she relinquished that idea! We bumped back in the Landrover; just eleven of us today.

One more cleft lip arrived during the day. We could do with another three or more now that Meshack has returned. Meshack's Dad wants the surgery for his child, but his Mum didn't. That is both a cleft lip and palate which can be done together in Meshack's age, so counts as two ops for Smile Train.

Two more patients have gone home today, a day earlier than the equivalent patients in the Gambia. There, many got infections; at Dreamland they have all kept clean. It is a tribute to the way the staff take pride in keeping Kimilili's Christian Hospial clean. Their commitment to the patients is so different.

I'm struggling with these blogs. I seem to have lost two in the last three days, but i'm sure I saved them!

Sunday included A.C.K. anglican church with Anne Lipson, with a 60-strong Sunday school that led the singing with three African drums alone. A message onhow fearfully and wonderfully made we are, and an opportunity to introduce ourselves.

Lunch was at the Mount Crest Hotel, but it was samosas again. Dinner was at Becky & Jo's, with a shepherd's pie with Mike's lime and chilli homemade sauce from two years ago. Lorraine, a Canadian primary school teacher, hrlped prepare the meal since Becky had been up from 0500 sorting out the charge on the XRay machine which is now working! It had to be up to 112-113 KV but it had gone to 114.5, so she wheeled the machine up & down the top corridor till the charge had settled. And she wore a lead apron for eleven hours, such is her dedication to the hospital, as sh and the engineer followed telephoned instructions from the UK.

Hannah phoned at the end of dinner, but rang off quickly when she heard I was dining out! Pity! Sue phoned at about 2130hrs having put out the rubbish having driven home non-stop from Bristol.

Today our laundry has benn done by Catherine. It's 50 Kenyan shillings per item, so I clocked up £10 of laundry bill.

Tony had his thyroid function test repeat today, and he remains hyperthyroid on his unpleasant treatment, but his shakes have settled and his energy levels are picking up. And he is working at his compter as it approaches 2000hrs. He has usually been in bed by now!

25th September 2014. Thursday; ops 23-25.

Becky called in at breakfast and said she was at Dreamland ASAP, then driving to Bungoma for another couple of bottles of halothane anaesthetic for my general anaesthetics. Maurice was going to drive us again. I set off walking at 0725, and Mount Elgon was the clearest I had seen it. The walk was muddy, and I was picked up fifteen minutes later. The Landrover was full, bar the front seat. The passenger door is now fixed with string, so Maurice had to let me clamber across!

At the hospital Gile, the Matron was telling Becky how tired she was, but she gives her all to this work. The staff and patients are used to our routine. Many are sitting on benches under the trees, and wave to us as we approach the wards. When it's not raining, they like their fresh air!

Our three patients today range between 7.5 to 7.8kg; their ages between 10 months and four years! The 4 year old is handicapped, and resists feeding and medications. Anne-Marie brings him in, and he is holding her lips and throat gently as she cradles him and speaks. We think he is deaf too. He can feel her voicebox vibrate as she speaks and sings.

Lunch is as good as usual, but we hurry through it because the four year old is distraught and tries to pull out IV and nasogastric feeding tube. I resedate him with diazepam and ketamine and give some more paracetamol; he had only half of his premedication earlier of paracetamol, and refused any oral rehydration solution. Having sedated him we have to watch him through our lunch break in shifts. Most patients are awake and wanting Mum within 15 minutes. But he is different. Mum, aunt and nurses will have a busy time in the next few days with him. Our afternoon patient's start is delayed by a quarter of an hour. This is the small young one, and things appear to go smoothly until Tony puts in the throat pack, when my monitors imply my tube has been kinked or displaced. So the surgical team step back as I contaminate their sterile field and secure the airway again. All well. Tony predicts the duration of the operations in quarter-hour segments, and his surgical time is usually an over-estimate. My anaesthetic and recovery time can almost double the length of a procedure. We work together as a team very well, both in theatre and on the wards, as well as back at the guesthouse.

My CO2 monitor got messed up at the end of today's first case. I thought I had sorted it, but it wasn't working during case two. Fortunately the three-lead ECG has a program that allows it to act as a respiratory counter and alert; a nice consideration which our monitors in the UK don't seem to have often.

The heavy rain started around 1530. I won't be walking home today since I need to check on the four year old and how staff manage him tonight. These palate operations need much more care which includes porridge and medications going down the nasogastric tubes for up to 5 days. I noticed the four year old also wanted to suck his thumb. Not a good idea with a load of stitches there in the mouth!

Handover to the nurse and clinical officer took place at 1700. I decanted the diazepam into single dose syringes, and threw the rest of the ketamine away. He is the only patient in the 3-bedded HDU, so the nurse will have Mum and aunt to help. Hopefully he wil begin to take some nutrition through the nasogastric tube before it comes out.

Jomo, the cook at the guesthouse gives us wonderful flavours with all his meals. Tonight we finished off with pineapple fritters.

I've now read two books which we purchased at New Wine in July. One more to go.

15th september Monday Screening

HThe work has begun. We didn't know what to expect. One Landrover and one driver, both were sick. So Becky acted as chauffeur to hospital staff first, followed by us Mzunga, and another staff member in the short wheel base Landrover, through the mud and puddles. Becky is the hospital director, and as we joined devotions she had been asked to lead it. She chose the 1 Corinthians 12 passage on the members of the body each with a part to play. Bernard started a song in Swahili, and the staff joined in a capello. Gile, the Matron clarified each persons' duties on this day. Some of the first arrivals sat in on the staff devotions. We then started the screening with the first three patients who were registered. Registration was followed by Tony checking what the operation might be. Then we would weigh and measure, then Bjorn would check the patient's general health & fitness for surgery. Ann & Anne-Marie would take them off for photography for Smile Train requirements, and catalogue the photo to the patient. Tony compiled a list of operations and likely durations, and we had identified the malnourished or ill. Two of the sixteen today have malaria. We have listed four for tomorrow, but may only manage three. At lunchtime, there were none waiting to be seen so after rice and beans I spent an hour in theatre with Agnes helping me find things I needed. Saline, IV drip tubing, connections for the blood pressure cuffs, and a metal cutter for a coat hanger I was cutting up to stiffen my tubes with shortened lengths of malleable steel. The BP Cuff connectors were the most difficult to source. I think I am ready to go. Bjorn arrived to help me man-handle a 100 litre vat of water from one side of theatre to the autoclave area. I also got a scrubbing brush to clean my equipment between cases. By this time the patients were allocated to two wards, filling one and overflowing to another next door. We did a ward round, making sure those for tomorrow would be fasted and given medications at set times. And then we walked home. No rain today though it thundered just after 1800 a few times. It took me 30 minutes to walk on the rough road, so it's not far short of two miles back to the guesthouse.

After a short period of loosening up exercises on the verandah, dinner was lentil soup with chapatis and cabbage, followed by fruit salad.

Solomon came in to greet us this evening. He has been preparing with a lawyer for a courtcase over a sacked hospital driver. The hearing is in Kisumu tomorrow.

Surgery starts tomorrow. The plan is for an 0830 start in theatre... We shall see!

19th September: end of first week of surgeries

The last three nights have been much quieter in terms of dogs barking etc. Retiring to bed before 2100, and getting up before 0600hrs, means I am resting well. Dusk and dawn are at 1830 and 0630, and happen very quickly. The photo of the team at the Equator ball was an hour's drive away from here in the Rift Valley, so day length varies little from month to month.

Each day we have done three patients, so we have completed twelve patients at the end of our first week of operating. We have taken the longest surgical ones first, rather than the youngest to suit Tony's strength. Our list-planning the day before means we keep fasting from food and drink to an absolute minimum for the babies and older patients, so the babies can be done later in the day. We are pleased with what has been achieved by God's grace this week. Tony does struggle in the afternoons with failing energy levels, but daily he seems to have more endurance.

Anne-Marie stayed back at the guesthouse and has not been sick today, though she has a headache still. It's good that she is sitting up with us at the end of the day. The Landrover brought us home since the rainstorm hit at 1510hrs so walking back through the mud would have been unpleasant. 12 in the vehicle on the way up and 12 back with various pick-ups and drop-offs of hospital staff.

Gladys is the hospital cook and produced rice, beans, chapati, cabbage and chicken stew for lunch for the staff, and other good stuff during the week. The Kenyan staff wait for the white mzunga to eat and drink first, and then they enjoy it after us. They are wonderful people to work with in this Christian Hospital. Jomo, back at the guesthouse has given us chapati, beans and cabbage; it's all locally produced food. We had a chicken wander into our dining room at breakfast! And out again!

The shock of the afternoon was news of a massacre in Guinea of staff from the Hope Clinic and journalists who went into a village to teach about Ebola. Our on-line access is poor as we digest this news. The four others on the team have all worked there, and I have turned Tony's requests down for me to work there too. The mission leader is in the USA with his wife because of Ebola, and he has lost his close brother in the Lord. We gather that the government took the team and all were turned upon. We don't know if there were survivors.

I received a text before lunch to say that the "No" vote had about 10% more of the vote in an 84% turnout in the Scottish vote for independence. It will be interesting to see if politicians can keep their promises now!

Tomorrow we need to spend one or two hours at the hospial to check on the patients and see that the nutrition programme is working out. Ann made porridge to go down narrow bore nasogastric tubes for the palate patients. It is thinner than the pre-op porridge that is even more nutritious as we optimise the malnourished young ones before their ops. As we drove away from the hospital today a young boy came up on the back of a motorbike with Bernard, the chaplain, and it looks like he has both a cleft lip and palate that we can fix. If we can do 36 operations on these cleft lip & palate patients, it will help the hospital develop further. It is already a great place serving this Western Kenya state on the slopes of Mount Elgon.

Ann, Tony and I hope to walk from the hospital up to a waterfall about 4 miles away, and return the same way. It is unlikely that Anne-Marie and Bjorn will come after her sickness for the last 48hrs. I think we will have a guide for the trek. If we get back before 1500, we hope to avoid showers - and they are heavy and are more likely to have hail as we climb up towards the mountain's extinct crater at 12,000feet.

 

23rd September: 6th operation day; 17-19th patients

I had my best sleep so far and awoke to my 0615 alarm, sleeping through dogs and cockrels etc... Anne-Marie had a bad night because she is used to 4 hours of physical activity daily as she coaches old folk through exercises, or has long walks at the weekend. She got the only exercise today as she left at 1430 to pay the tailor. The rain started an hour later, so she may have just avoided getting wet.

Theatre sister Agnes was admitted to Dreamland with her malaria, having scrubbed for the last two cases yesterday. Matron Gile spent today in theatre with us, doing the "running", and recovery. Evelyn and Sally scrubbed for the three ops. Bjorn assists Tony for each op having helped me with induction, intubation and cannulation. Usually he does he World Health Organisatoon Surgical Safety Checklist, Sign-in, before he scrubs, then the Sign-out at the end as he watches over the extubation and transfer to recovery. And at key moments he is also praying, when he sees me struggling with tiny veins or difficult airways. He and Anne-Marie are key members of this team. The wards run smoothly with Ann's organisation, which includes porridge-making for the naso-gastric-fed patients at 0630, the premedication and fasting times in co-ordination with me, and the pre and post-op photo taking which are essential for the Smile Train funding. We have heard that the first six patients' details have been accepted by Smile Train so that funding will come to Dreamland to help pay the October salary cheques.

We plan to do the longest case first, and have a tea/coffee break. Then the second patient and take lunch. Today, Gladys, the cook, has malaria, but she still came in to work! Lunch was served a little late, so I visited the wards to time the fasting and premeds for tomorrow. Lunch was in full swing in the theatre vestibule when I returned. Just as tasty and filling as usual!

The rain started close to 1530 so at 1645 the Landrover left with 14 adults and a 1-year old cadging a lift. There was no electricity at the guesthouse, and it was fairly overcast so I showered and changed, and came out to the verandah to read and then to write my blog. It will be dusk at 1830 when supper is served, and dark when we come out. Ann is sorting photos on her computer by candlelight, taking three or four different photo SD cards from their camera to transfer the images for Tony to compile the discharge papers, for Becky to submit to Smile Train. Two more discharged yesterday and a further two today, so our first ten have gone home, and we have done 19 ops so far. The turnover is faster than the Gambia because they are healing better in this better-run hospital and climate -despite the malaria! The fields are so fertile; on Saturdays walk, the maize was still on the stems, and the new bean plants were flourishing betwee the maize plants in the rich brown and well-watered fields. I am surprised that the two hailstorms haven't done more damage though!

We are doing at least one palate each day this week and moving into the younger more-malnourished babies for their lip repairs. So the last one today was 4.9kg. So we hope the feeding programme is making a difference for the smaller ones, who are only just over two months old.

Sue's text came through last night with two others. A couple who are planning to move from Eaton Bray to Swanage took the opportunity to give Sue a meal out after work. Today Sue is Granny in St Albans, enjoying Josie's company, and a 12-hour plus day from leaving at 0700 and getting home at 2100hrs. The things we do for love! This mini-iPad has a wonderful store of family pictures going back thirty or more years, so it helps me think of those at hone.