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.