We arrived at our accommodation at KCMC late in the evening
Sunday, November 23, 2014
At the end of a long journey from the UK on Saturday, we arrived at our accommodation at KCMC late in the evening, and managed to get some rest despite the sounds of Africa – the thrumming of the cicadas, evening birdsong and the local cockerels, which begin to crow at 2am! With a clear blue sky, the team decided to walk into the hospital to distribute knitted gifts of jumpers and blankets for the new babies on the maternity ward. Whilst there, we bumped into Dr Pendo Mlay, a consultant obstetrician, who has worked with the team for many years on the Ultrasound Outreach Project. We were pleased to hear that everything was still going well with the services we had helped to set up in the Hai District, and offered to try and find a company who may be willing to repair an ultrasound machine damaged by power surges. On the wards there were over 70 mothers and new babies and the nursing staff helped identify the mothers who would most benefit from a new outfit for their babies to wear as they prepared to go home. We saw so many beautiful babies and were delighted to meet a Masaai mother with twins, only two days old. With deliveries done, the team of eight set off to walk into town a few kilometres away to stock up on provisions. This involves occasionally jumping into shallow ditches to avoid the speeding dalla dalla minibuses and passing rows of shops selling coffins and roadside vendors selling fruit and vegetables. When we got back to our accommodation that night, we finished sorting our teaching and training materials ready for an early start the next day.
Visiting Machame Village Primary School
Monday, November 24, 2014
An early start to meet with the hospital directors before leaving for Machame Village Primary School as part of the Burns Awareness Project. After an hour long drive we arrived at the school, located up a steep slope and across open fields, to be greeted by the teachers. In a rural Tanzanian home most cooking is done over open wood fires - a major hazard for all children who play in this area. Mothers with untreated epilepsy are also known to fall into the fires, often with their babies still strapped to their backs. Through playacting by strapping a doll to the back we taught the children how to avoid such injuries by always ensuring the child is cared for by someone while the mother is cooking. The children were really engaged- rushing forward with water bottles and bandaging the pretend injuries. They could list all of the main fire hazards in the home before we left and understood what to do if a burn injury happened and when they should go to hospital. Two of the team's nurses, Peter and Tony were rewarded by joining  the children for a game of  football after the lesson. We called into Machame Hospital where we had a tour of the facilities and met a four year old girl with severe burns to her arm which had been caused by hot tea. Thinking she could be a possible patient for plastic surgeon Jeremy when he arrived from Australia at the weekend, we requested a transfer to KCMC so that she had a better chance for treatment.  Following this we went to the school of nursing where team members could share their skills with nurse students. Vaseline and honey are needed to make special burns dressings and we find that whilst Vaseline is readily available, the honey would be supplied by patients from their local village hives. Our finance manager, Jo and I then met the finance team to develop a new project. It's difficult to imagine coming from a fully resourced NHS how KCMC can deliver a healthcare service when government funding is so limited and people cannot afford to pay for their treatment. Yet they find a way to do it.
Visiting intensive care
Tuesday, November 25, 2014
Another early start for the long drive through lush vegetation to Kibosho Village Primary School as the second part of the Burns Awareness Project. The playacting was even better this time, and with a little stage makeup to show blisters and burns it was very realistic. In the end, everyone was rushing forward with bottles of water to cool the burns. Over 50 children took part in the lesson and had great fun and were given pencils, stickers and sweets as prizes for the best suggestions for fire safety in the home. Back at KCMC, Catherine, Meg and I were in the intensive care unit to look at the more severe burns patients. As we arrived, the anaesthetist had just given an eight year old girl, burnt in a cooking fire, an injection so that she could be sedated while her dressings were changed for the new specialist dressings. The next patient was a two year old girl sitting on the bed with burns to her chest and legs. Despite a valiant effort by Catherine and her books, toys and finger puppets, this was not going to be easy. It is really hard to hear a child cry as she knows that treatment is going to hurt. Fortunately, some five minutes later, when everything was done and she was given a lollipop, all was forgiven. We soon find the patient with burns from electricity, agitated as the new treatment feels different to him. Once he understands why, he is happy for the dressings to stay in place. The other patients are comfortable so its job done on the ward for the day. Peter and Tony are in the casualty department checking on progress and find that a new purpose built accident and emergency department is under development. This is a far cry from the three cramped cubicles that the hospital currently has to cope with hundreds of patients each day. It’s good to see progress. Peter and Tony set off back to their accommodation to prepare their teaching plans for teaching that will be delivered to the nurses later in the week. There is no electricity today so work is undertaken by candlelight.
Specialist nurses Meg and Catherine go to the burns ward
Wednesday, November 26, 2014
Specialist nurses Meg and Catherine went up to the burns ward to meet the nursing staff and the patients that they would be helping to treat. The families told us their financial worries - treatment for burns is so expensive and it can involve months in hospital. Before we came, we had received lots of donations of specialist dressings which we were keen to use to help quicken the patient’s recovery. Catherine and Meg help dress the burns of a young male patient. Despite sustaining terrible injuries following an accident with an electricity cable, and pain relief in short supply, they quickly discovered a lively personality which had not been dampened by his injuries. Many other patients had injuries caused by hot liquid and exploding gas cylinders and petrol cans. Specialist nurse Sue, Tony and Peter set off for the theatres to make plans for the triage of burns patients later in the week following a public broadcast across north Tanzania asking for burns patients to come forward for life changing plastic surgery. Dr Kondo, Head of Surgery had made detailed plans to ensure that everything was ready.
Preparing for plastic surgery patients
Thursday, November 27, 2014
I’m meeting with Redempta, the Head of the community health department, to discuss the team’s participation in an outreach project. Redempta had spent three months at Northumbria studying operational management and is now a member of the Tanzania Nursing and Midwifery Council. She is keen to develop a burns outreach project involving community health workers. There is a high number of motorcycle injuries in the area and we discussed how the team could perhaps support an information event, organised by the traffic commissioner and local police, to address road traffic safety issues. This is particularly important as Tanzania does not have an ambulance service and first aid knowledge would be very valuable. High visibility vests could also come in handy, especially as some motorcycles on the roads at night don’t seem to have lights. In the theatre department everything is set up to triage the patients who are hoping to have plastic surgery. A small room is cramped with people waiting to be seen while Sue, Peter, Catherine and Meg work in teams to take down their details and assess their injuries. Peter works hard to photograph each patient’s burn injury, so that when Jeremy (the plastic surgeon) arrives on Saturday, he will be able to view the notes and photographs to decide which patients will receive treatment. It’s going to be hard to choose from so many. Just as the teams think they are completing their work they find that more patients have been waiting patiently on seats along a separate corridor. This is only day one of assessment and more people are expected to arrive tomorrow. We receive a call from Machame Hospital to expect the arrival of the 4 year old girl with the arm injury. Peter meets her at the casualty entrance and she is admitted to the burns ward. Jerome, the clinical psychologist, arrives from South Africa and the team is beginning to build for the arrival of the surgeon at the weekend. 
Making progress
Friday, November 28, 2014
The surgical corridor is more congested today and there are now camp beds full of patients up and down all the hospital corridors. Once again the team assess the patients, write down their details and take photographs. Sister Angel, the lead nurse on duty, Meg and Catherine look at the patient with electricity burns. To everyone’s relief, he had a good night’s rest after using the new dressings and they remove easily. This is great progress for burns treatment when compared to the usual method of having to remove gauze by soaking it. However, the team are still concerned that the patient’s injuries are too severe for surgery. Passing casualty, Peter, spots a young tourist being wheeled into the resuscitation area with oxygen attached, it seems he has taken ill on Mount Kilimanjaro and has been brought down from the summit to a lower level too quickly. The group are anxious about their friend being treated in a foreign hospital but Peter stays with them and explains the severity of the patient’s condition and the risks that could occur if he doesn’t comply with hospital treatment. In a different part of the hospital, Jo spent the day with the finance team and I met with the hospital directors. We found out from the supplies department that our shipment of donated dressings had still not been cleared by customs so this means we will have to complete more paperwork.
The team is complete
Saturday, November 29, 2014
The weekend arrives and it’s time to catch up with old friends. I’m heading off to Bomong’ombe which is an hour’s drive from Moshi to say hello to the family of Dr Kimaro, a close friend of our link with KCMC. Dr Kimaro sadly passed away from renal failure five years ago - such a tragic loss as Tanzania does not offer dialysis treatment. This reminds me of just how lucky we are to have so many healthcare services in the UK.  Dr Kimaro had led a project to develop a modern accident and emergency department at KCMC. It was great to come back this year and see building underway to bring his vision into practice. This would mean lots of planning around training plans to support the launch of this new service. It was really good to know that things are moving along. Sue and Tony set off to meet one of the medical students to provide some support for his studies and others set off to explore the local safari parks. Jeremy, the plastic surgeon, finally arrives from Australia and has spent a couple of hours going through the patient notes with Sue to understand the challenges ahead. With so many patients it was going to be really difficult to choose who would be selected for life changing surgery.  The decision was postponed until the following day when Jeremy would meet the patients face to face. Late at night the final member of the team, Keith the anaesthetist, arrived so now our team is complete.
Patients assessed for surgery
Sunday, November 30, 2014
Early in the morning the team set off for the hospital to meet the patients. With photos and patient notes in hand, they go around all of the patients who had been triaged on Thursday and Friday, as well as the existing burns patients on the ward. Jeremy and Dr Kondo, head of surgery, discussed each case in turn and Keith the anaesthetist assessed fitness for surgery, including possible obstructions to airways. There were concerns that the electrical burn patient would not be able to open his mouth sufficiently to have the anaesthetic tube safely inserted. However despite his severe injuries he was passed as fit for surgery. His case would be very challenging but it was unlikely that he would survive without surgical intervention. Some children were also assessed and soon a surgical list was drawn up for the week ahead. In the afternoon we visited an old friend, Amina, who runs a local orphan charity and school. After a delicious lunch of rice, cabbage and vegetable stew, all grown in her garden (shamba) we bought some of the crafts and items of clothing made by the charity to support their work. The previous day some of the team had been treated to a visit to the classroom with lots of singing and dancing to welcome them. There is something quite special about 50 schoolchildren throwing themselves enthusiastically into the Macarena, complete with dance moves!
Surgery begins
Monday, December 1, 2014
The big day had arrived – the first day of surgery. Having been selected for surgery, the electrical burn patient was the first to be taken to theatre. It was amazing to see so many students eager to witness really challenging plastic surgery. The scrub nurse, Sue, worked closely with the Tanzanian theatre nurses to co-ordinate and support activities. Everyone was aware that this was a particularly challenging case and Jeremy the surgeon had a lot of work to do with a six hour procedure. What a relief when the operation went well and he was wheeled back to intensive care all bandaged up ready for a good night’s sleep. The rest of the team set off to do teaching in the school of nursing. Jerome found the students very lively and enjoyed answering their questions about multi-disciplinary working. Peter and Catherine delivered training on first aid for burns to the final year BSc nursing students. The heavens opened that night and the rains beat against the roof of the accommodation with rivers running down the windows. However not even the constant rain stopped the dogs from barking and the cockerels from crowing!
Achieving great results and setting budgets
Tuesday, December 2, 2014
The team set off for the hospital trudging through the mud caused by last night’s rains. Catherine and Meg call in to see the electric burns patient in intensive care and were pleased to find his cheeky sense of humour still intact. Once his pain medication had been adjusted and dressings checked it was clear that he was very comfortable. Over to his right it was lovely to see the little girl with the tummy burn sitting smiling on her bed. Quite a different child to the last time when we had tried everything to distract her when changing her dressings. Now, one week later, she was ready to be discharged home. A great result! First on the theatre list was a man who had been knocked over by a car and suffered friction burns causing damage to his left hand and right elbow. It took some time in theatre to free up the elbow and apply skin grafts so that he could fully extend his arm. This would make such a difference to his mobility, enabling him to return to work and earn a living to support his family. The second case was a five year old girl who had suffered injuries from the open cooking fire. Although some of her injuries had healed well, her left arm was bent at the elbow by scar tissue and needed releasing. Once recovered from the operation she would be able to go out to play with her friends and once again hold a pencil to do her homework. It is amazing how surgery can transform lives. With the others in theatre, Catherine and Peter returned to the school of nursing to deliver training about emergency management of burns to the nurse students. Meanwhile Jo is also at the school of nursing delivering teaching in financial management. The students were broken up into groups to consider preparing a treatment plan and costing for three separate fictitious patients. They each had to prepare a budget for approval by one of the group members who was nominated to be the director of finance- much to their surprise. With funding so limited for the hospital often difficult decisions would have to be taken. The electricity was still off which made it difficult to prepare teaching for the day ahead. It seems as though we have to go back to a whiteboard and pens!  We have a long night ahead of us to transfer lecture notes onto flip charts.