Bickering and bracelets

Ruefully I admit that parental stress affects the children's behaviour....or is it the other way around?
We've all been more than a little snappy with a week of bickering. I wasn't even sure I wanted to embark on this weekend's proposed adventures, but with a rare pre-planned trip to Arusha we were all set to go.
And a good thing to. A remarkable peaceful & organised exit from Hillview yesterday to get the bus for the 7 hour journey to Moshi. The children don't bat an eyelid now at sitting for interminable periods of time. The passing African scenery is somehow soothing. And we have learnt to avoid looking at the tv screens which play endless violent boxing/shoot up movies on loop! Air-con luxury bus cost us £30 for all of us.... the extra pound for air con is completely worth it as we all wilted on our one bus journey without it. M even bought himself a fried plantain at the 1 pit stop en route, something he would never have done a few months ago.
A change of scene, a communal sense of journey and dynamics get a good shake up. So we had a lovely family evening in what is now our 'regular' restaurant in Moshi, along with all the other wazungu, in the 'IndoItalian'. An obvious menu of pasta or curry!! Funny how we are creatures of habit, liking the feeling of knowing which streets we are heading for rather than hesitating on each corner.
We have returned to the same hostel we used either side of our Safari, basic but clean with fabulous artwork on the walls and leopard print sheets. I have learnt to check the mosquito nets for large holes and make sure the fans work before accepting a room.
This morning we were greeted with delight by the Masai security guard (Masai's fearsome reputation means that is their commonest line of work). He, along with most people we meet, is so enthusiastic to be welcoming children who speak a little Kiswahili, most especially the smallest one. We had wanted to get a photo with B last time, but missed the moment. This time he was very keen, but she wasn't (never work with small children or animal). He obviously had her measure and returned with a small Masai bracelet as a gift, and hey presto, one happy child wanting photos!

We have an invitation to visit his village next week to see some traditional dancing and his goats. At least I think that's what he was asking, B seemed to think he was offering her a goat!
M has gone to visit the hospital as part of his expanding surgical network so  we are reliant on my Kiswahili which is a tenth of his.

So we are going to attempt some school work with the majestic Kilimanjaro in the background before making our way a further 2 hours to Arusha to visit the lovely French/English family we met at Christmas.
Best of all our tensions have evapourated and we are back to the happy, connected family from last weekend.

HALF WAY

One of those days where you'd rather hide from your children and forget you had them, than face the battle of chivvying out of bed and off too school. All too tired after a busy weekend (no I never do learn to leave enough down time). A sigh of relief when the hospital car toots it's horn to pick up those girls who are ready.

Two in today, the youngest having dabbled in pre primary is not to be swayed from her determination to stay safely at home. She at least set to writing out her proposed schedule for the day and resolutely made swift work of her maths and spellings for the day before I disappeared to fulfil my hospice commitments.

My flat state of mind was not helped by my first home visit, where for all my wealth of knowledge, I had no promise of any treatment to offer. He has Parkinson's, which in the UK is bad enough, but here with no medication available he is rapidly trapped in his ageing body. All very well being able to work out what's wrong with him, but I felt miserably inadequate without drugs to help. We at least gave his elderly wife a medical overhaul. She is caring for him alone, unusually their children (who live in the same village) do not offer any support.

The day was no more brighter with the last visit. A lady of indeterminate age, discharged a few days ago from the hospital. She is on treatment for HIV and TB but they had told her she probably has oesophageal cancer. Frankly it probably doesn't matter what cancer she has, she was a living skeleton and in terrible pain. I at least could offer comfort in knowing we could help ease her pain and support her and her family in what inevitably will be her last bit of time.

Back to review some of this week's clinic patients, a bit of teaching and then more home school. Slowly climbing back up from emotional depths of the morning.

B & I gorged on mini mangoes and felt very self satisfied with our work achievements for the day, before I collected the others from school.

And what a difference a day makes, the monsters returned as angels and we have merged into a serene evening. I have morphed from a gloomy fed up mother and doctor into a multitasking super mum. Yep, I can cook supper, make chocolate brownies (it's pudding night), help complete word problems on ratios and proportions, spell check middle child's emails and English homework, hopping over sharp pieces of playmobil and researching questions on the healthcare organisational setup in Tanzania (from a husband with an overflowing brain of blue sky thinking) all at the same time!

Back to earth with a crunch tomorrow morning no doubt.

But for now I shall enjoy my secret supply of fruit & nut chocolate and bask in the words I never thought I'd hear from L "Thank you for bringing me to Africa. I'm glad I have stayed and not made you take me back to England. I feel almost African now". Cue mental fireworks and fanfare.

Today is our official HALF WAY THERE, according to M's calculations, and for now at least it all feels worthwhile.

Karma Chameleon

Chameleons are my new favourite animal!

We have driven up a very long bumpy track into the Eastern Usambara mountains, which make up the view from our house.

Flashbacks to being forced out on fabulous adventures by my mother, with us all dragging our heels wanting just to stay at home and read. Total empathy....no interest from my passengers about all the information I wanted to share about the Amani Nature Reserve where we have woken up this morning (some of the best rainforest in the world, with hundreds of species not found anywhere else, home of the African violet, and an impressive old German medical research centre looking at the jungle plants). My sisters will all groan knowingly! 

I would love to be here with my grandfather Ioan for all his botanical knowledge. You could really get engrossed here.

Chameleons saved the day...the ultimate reason for trekking up here...and the lure to our little fish. A begrudging hike up to a view point...highlight being attacked by Safari ants....wow they really hurt.....especially when you're ignoring one in your bra to come to the aid of your shrieking daughter with one embedding itself in her finger! View point itself out over endless treetops, peaceful between the raucous cries of birds. 

The piece de resistance, our night walk to find the prized chameleon. Our guide thoughtfully tracked a few down for us in advance, saving us a longer hunt. The creatures themselves are so captivating: eyes that swivel independently, bodies that change shape to mimic the leaves around them, careful paws gripping so tightly to the thinnest of stems, and of course their colour changing ability. We all now envy Rapunzel in Tangled with her little friend Pascal.

We enjoyed our venture into the pitch black of the forest, busy with night noises. Our guide's headtorch picked out chameleons that I wouldn't have spotted if I stood there all night. We were mesmerized by a lone firefly, or perhaps a forest fairy tempting us to follow deeper into the trees.
I have woken before the girls, though the dawn chorus here is so much quieter than muheza. 

The day ahead promises butterflies, a waterfall and a tea plantation

Making the rounds

I took this to show how big Mango trees are (the big leafy one behind the rectangular water pump). If you have been reading M's blog you can see how far it is to fall. The little boy is walking home from school past the village water tap - the supply comes on once a week.

I have given up declining people carrying my bag, The relative of our patients will always insist on carrying all our bags.

Curious kids. They all come running to see the hospice car. Even more excitement when a mzungu doctor climbs out. We're here to visit their grandfather who has prostate cancer. 

What's a home visit without a bit more shopping -  coconuts today!

Power cuts and little mangoes

So, here I am dripping in sweat with the power off again and it hits me that what sent us into panic those first few weeks now barely raises a sigh.

Last night, with M in Dodoma, there were torrential rains and an almighty thunderstorm which predictably plunged us into darkness. We were having a cheeky 'movie and jelly baby' girls' night (courtesy of Christmas packages) so we were none too bothered.

More annoying was the power going just after I had put the kettle on for my dawn brew. Cereals with UHT milk is the least popular breakfast option here, but was the only thing on the menu having failed to locate any matches or firestarting equipment to light our gas hob (specially acquired for these precise moments). It was only once our housekeeper arrived later in the morning did we realise that yet again it was not a power cut but we had run out of electricity. Cue her going off to the electricity shop to buy some more. I then have to precariously balance on a stool, on top of a chair, outside the front door to enter a code into the electricity meter (a job usually delegated to the surgeon). I still half expect her to come back with a bag full of sparking blue electricity! Mental note to self; must develop habit of checking the meter regularly.

Power off again this evening as dusk falls. Gives more time to locate all the torches than if power goes once night has already come...having distributed them round everyone's bedsides last night we still had to hunt them down as inevitably they were part of B's afternoon game along with Gerry the giraffe. We do this now with a leisurely acceptance, one lonely candle lighting the sitting room. The girls have all mastered jug washing without assistance, my role just to direct the headtorch onto missed areas of red dirt.

Our night watchman turns up at 7.30 with a 'Hodi' (knock, knock) at the door. He accepts a cup of chai, and a plate of food if I have any extras. It is reassuring to know he's out there in the dark, or at least we think he is! But only on dry nights, on stormy nights like last he arrives to tell us he will not be sitting getting soaked; I don't blame him.

Mummy school today; all the basics like fractions into decimals, prefixes, counting in 10s and then some interesting research into ants, today's chosen topic from B. We learn that the poor Queen is more like a slave than a tyrant ruler. She stays deep in the middle of the ant nest for her entire life laying eggs every few seconds. So she might have a million worker ants finding food, digging tunnels, keeping her clean but it doesn't sound much like a life of luxury keeping the entire ant colony in babies. We drifted into termite mounds....even more fascinating with the air tunnels. I do enjoy this looking up of things we don't know the answer to. I just need to get better at finding time to look up my medical questions. #

We popped in to the hospice for me to do a bit of paperwork; I'm auditing the drug usage to see if the palliative care side can liase better with the funding for the HIV side of things. B enjoys the swings out the back of the building which are used by the HIV kids club on Saturdays and got treated to a lesson on eating little mangoes by our palliative care nurse. Has opened up a whole new area of mango enjoyment for us!

Mango lessons in my clinic room

Back to school

I have half an hour of interrupted peace before heading into work.
Day 2 of the back to school campaign. Huge success yesterday with smiles all round and an acknowledgement that the thought of school was actually far worse than the reality. Today, predictably 'I don't want to go to school' was the first sentence uttered...but L has found her confidence and shot in without a backward glance. B on the other hand, having had attention lavished by her own personal nuns yesterday is still not so sure. She announced she would like to try pre - primary, which is the right age for her, but also means English speaking in the children is virually nil. But they do a lot more fun stuff and don't sit in rows chanting/copying from the board for quite so many hours. A few tears shed this morning but hoping will be all smiles on my return. My new revised game plan is school for the first 3 days of the week (half days for B) and then Mummy school for Thursday & Fridays. As always, I do love making plans/lists, but they are so frequently revised!
M set off at dawn this morning for a 10 hour bus journey to the capital Dodoma. He has gone to meet the upcoming surgeon for whom Muheza has high hopes, but is currently the equivalent of an SHO in the UK. So just us girls for the next 3 days...we will miss him, not just for his porridge making, water filtering, water pumping and all round sorter outer of things that go wrong skills!
I am in full flow planning the remaining schedule. We have a trip to Arusha to visit our Christmas friends (and the hospital & mosquito net factory), a mountain climb, a visit from my uncle R ( with requisite safari/Zanzibar outing), another 2 rounds of medical students, a surgical colleague of Mark's and another anaesthetic team visit from Hereford to factor in, without forgetting a bit more Peponi and some highland explorations here in Amani and up in Lushoto (where we will be treated to fires and hot water bottles!). Suddenly not enough time left!!!

Visiting day

 

Home visits again today. My favourite activity really, for the insight I get into local life. A long drive again, almost to Korogwe, the neighbouring town. We almost always seem to incorporate shopping into the road trips, with the palliative nurse making the most of local produce en route. Today we stopped in to another convent who deal in dairy & chickens. We came away with eggs, fresh milk and an enormous chicken ( already plucked I hasten to add).

Another wonderful example of what the palliative team offer to this community. I admit I was somewhat sceptical before we set off, on what would be almost a 2hr round trip, to visit a lady who has been on the books for 9 years with 'liver cirrhosis'. No identifiable cause, and other than a massive build up of ascites (fluid in the tummy due to a failing liver) every few months doing remarkably well. The palliative nurse got a dr to teach her how to do an ascitic tap and has been doing it every few months since then when the pressure build up becomes unbearable. I was hugely relieve she wasn't expecting me to do this - I've only assisted a long time ago as a medical SHO. This procedure in the UK is usually done under sterile conditions by a specialist doctor in hospital. Here our nurse made things as aseptic as possible in a small mud hut with chickens flapping in through the window. One large cannula, a bit of tubing and an old cooking oil container later and we had a huge amount of fluid draining. We waited an hour, sucking on oranges which her husband proffered for our refreshment. Her abdomen deflated from that of a lady looking like she was about to go into labour, to one ready to leave the maternity unit. Her relief was palpable and we left a very happy customer to rest.

The nurse told me that most patients with ascites will be refused the same procedure at the hospital as it is not curative and the fluid will only reaccumulate. She is doing it purely for symptom relief, and I suspect without this input today's patient would not still be around, let alone enjoying her life between times.

Rafiki

Sad children all getting in to bed tonight as they bid farewell to their adopted Aunty S. She has been such a lovely unexpected addition to this adventure and they all feel bereft that she flies back to the UK tomorrow. She has medical school interviews to get back for so lots of excitement in store but we shall miss all her hours of playing with the children and the lovely feeling of having someone for them to escape to when the company of sisters become too much.
It is one of the great joys of this trip, all the new friends we are making, some just to enjoy for the here and now, others to stay in touch with. The family we met over Christmas, whom we are going to visit in Arusha, another who we met at Peponi who are linking us in to the expat community in Tanga, the medical students coming for electives here in Muheza.
It certainly makes such a difference as a parent to have another adult to distract/cajole/entertain when you yourself have run out of patience/trying to cook supper/mediate sibling bickerings.
The Australian students leave too this week, and though we were away for 2 of their 4 week stay we have loved more playmates, and the impetus that others exploring, what are now familiar surrounds, brings. We have had a fun weekend, with 2 days in Tanga checking out a new swimming pool we had been recommended at the Tanga Beach Resort (although no beach). A far more enticing pool than the tired Mkonge Hotel with plenty of shady surrounds for us to spread out across. We discovered a whole row of scantily clad wazungu girls being admired by the pool attendants, whom on further enquiry turned out to be nursing students from Norway. We also tried out the spa - why would you not when there are 3 lovely Australians babysitting in the pool! Best pedicure I've ever had (totally self indulgent) - I am contemplating booking all the children in the week of our departure and asking the lady to apply the same level of scrubbing all over - my feet have never been so clean!
We started the weekend off with the hospital party. Official invitations were issued the day before and we were all included in the celebrations for the results of the recent hospital inspection (for which they received 5*). Everyone, from the hospital car drivers and mortuary boys up to the hospital superintendent were resplendent in their finest clothes (I was resoundingly underdressed). They certainly know how to party, with almost the complete reverse of the typical schedule we would expect at a works party from home. We were issued our drinks tokens, with which everyone collects their entire allocation of drinks for the evening. The dancing then immediately kicked off, interspersed with speeches and awards and then finally dinner (at about 11pm), after which there is a mass exodus. The girls initially eyed the large hall filled with tables and grown ups with despair, but we were all soon enjoying our attempts to join the group dancing.
I feel like the fast forward button has been pressed, and I am whizzing through the full range of emotions that every day here brings. From calm conclusion that I would happily home school 2 children, between tending to the dying and training the junior doctors; through frustration at said children refusing to do any of the work I had carefully planned and inevitably requiring completely different input at the same time; deciding that I shall go mad if they are at home all day every day, disappointment with the girl suggested for home tutoring; trauma at trying to get them to have another go at school...………..at least the trials and tribulations of daily life at home in the UK will feel less insurmountable.
We will be half way through next week. Wondering if I will achieve Nirvana on the schooling front before we leave. Need to catch up on all my photos: a few highlights from the last few weeks below...

Our new Tanga swimming pool discovery

Hanging out at the Yacht Club

The usual back seat scene at the end of a weekend

Wish you were here Monty dog

B and her gardening team

Hands free

Our new routine of a morning walk, before the heat of the day kicks in, has even more of a 'hakuna matata' pace to it. B has announced she is now progressing to walking outside with her load on her head. Apparently the next stage will be to add contents to the bowl. The stick is in case she encounters any snakes!

Put life into their days, not just days into their life

Yesterday the current palliative care doctor at the hospice handed in her notice. Today she is gone. Apparently that's just what happens here - no working out a 3 month notice period. Here today, gone tomorrow!! It leaves the palliative care team with 2 nurses and the hospice administrator. There is one other doctor and the clinical officer but they are employed for the HIV care & treatment and not the remaining palliative work.
I am still trying to piece together how the hospice runs, how it is funded, how it integrates with the hospital but this news has put me on fast track. I hadn't until now given the time to read the hospice website (I have put the link on this blog). I am humbled by just how much Dr K achieved in setting us this place and the whole embryo ethos of palliative care in Tanzania, her MBE undoubtedly well earnt.
It is unlikely that Dr H will be replaced (employment arrangements are too complicated for me to explain) but I do hope this doesn't mean the hospices drive to improve palliative care access regionally and nationally doesn't suffer. I had a meeting with the hospice director today and we will meet with the hospital medical superintendent tomorrow to devise a plan.

Today however a busy day care awaited (the usual role for Dr H) so instead of mentoring the clinical officer I waded in to run things myself. The hospice runs weekly day care clinics for all the palliative patients on the books, helping with transport and providing refreshments for the day. A chance for people to come together with others going through similar situations and have a regular contact with the hospice team. This itself an invaluable support. One of my favourite quotes from the founder of the palliative care movement is "You matter because you are. You matter to the last moment of your life and we will do all we can, not only to help you die peacefully, but also to live until you die". I think the hospice day care encompasses this beautifully.

I was happily in my comfort zone as it is similar to a gp clinic, dealing with any problems patients brought up, a lot of which are unrelated to their underlying cancer/HIV illness. And of course the problems related to their life limiting illness are also things I can help with. At times I almost forgot where I was, others frustratingly handicapped by the language barrier. Plenty of moments completely stumped by my bread and butter clinical situations which here I stumble on knowing what treatments or tests are available. I add trip to pharmacy and laboratory to my long to do list.

Who sticks in my mind today; the youngest and the eldest:
The 26yr old beautiful girl, HIV +ve who is wheeled in and peels back her skirt to reveal a hideously deformed and elephant like leg with Kaposi's sarcoma (an HIV related skin cancer).
The 96 yr old chirpy, toothless lady who whips out a distorted breast which looks like it encloses a hard edged boulder. She's remarkably well, and thanks to the palliative team has not spent her family's fortunes chasing surgery and chemotherapy. She would rather enjoy her days amongst her children, grandchildren and greatgrandchildren and as and when she becomes more unwell is reassured to know the support is there.

In between a likely DVT, housemaids knee, angina, rectal bleeding, infected eczema amongst others and the largest abdomen I've ever seen in a non pregnant lady, full with a huge dermoid cyst.

School went back today: one child went. One I'm going to homeschool (in between stretching my brain), the other we are still negotiating over.....

African dada

L & B spend a lot of time practising to be African dada (which means sister/miss in Kiswahili).
B has charmingly talked her new tutor into carrying things on your head lessons (I have yet to catch this on camera). I keep finding her wandering the corridor with whatever she needs balanced on a tea towel on the top of her head. I suspect she'll be an expert before long.

Today they had a long await lesson from our 2nd housekeeper on chapati making. Supper was chapati & beans (superceded pesto pasta in Beth's favourite foods). It was obviously a day for chapatis as I also finally discovered where the hospital canteen is, as well as the med students showing us a chapati stall we hadn't know existed. Turns out if you walk past the house selling water on the other side of the road and ask at the door of the next house they will serve you freshly cooked chapati.

I was also badgered into a trip to the local hair salon. The Australian med students have been busy getting their hair braided with amazing extensions, and L has been eyeing up hairstyles since we got here. My eyes watered just watching the experience. B stoically made it through half a head before suggesting that perhaps she would finish it off tomorrow! L was still there 2.5hrs later and delighted with the results.

R is still debating the merits of braiding and is rather wishing she'd gone short before we left. A thick head of hair is SO hot.

Tropical medicine

A busy week of brainwork for me so far.

Today palliative review of a lady on Wallace ward (the gynaecology ward). Another late stage cervical cancer. She was brought in last week, barely able to sit up, let alone stand. 55yrs and her face is resigned, no glimmer of hope from a body that wants this all to be over.
She came in before Christmas and was given a blood transfusion, this time her haemoglobin is 5.9, not low enough to warrant a transfusion here. There is nothing else the gynae team can offer.
I can tell from the smell that she likely has a colovaginal fistula (the cancer has made a hole through from her cervix to the bowel). She is leaking faeces vaginally, the odour pervading through the ward. Her family's main concern is the swelling in her groin, and the fact that she is barely eating. The gynae team wonder if the swelling is an abscess and contributing to her tummy pain, but it is rock hard and craggy, so I suspect more likely to be the cancer which has spread to the lymph nodes. She winces just to move on the bed and any more invasive examination would be unbearable. I had asked for M to give his surgical opinion on the query about it being an abscess for draining, but he concludes that although they could examine her under anaesthetic she is unlikely to gain anything from this process. The palliative nurse H has explained this to her and her family and we agree that she would be better off being cared for at home by her family.
H has explained one of her frustrations in trying to improve palliative care on the wards is the actual administration of analgesia. She all too frequently writes it up, gets the liquid morphine from pharmacy and gives the first dose herself, only to find no further doses get given. She is at a loss knowing how to change this. It does feel that once the patient has been referred to palliative care, that the rest of the hospital staff shrug off any responsibility. It is something I am discussing with Dr A, the medical superintendent, whether any nursing palliative care training sessions would be useful.

Visits yesterday were bittersweet. Beautiful scenery, mango stalls and sheet upon sheet of drying peppercorns adorn our hours drive out into the foothills of the Usambara Mountains to review the lady I had seen before Christmas with what we think is cerebral toxoplasmosis (an infection of the brain caused by a protozoa). You may have heard of toxoplasmosis from the advice we give during pregnancy to avoid cat litter. An infection could harm the baby, though unlikely to cause serious illness in a healthy grownup. In someone with HIV the effects have been devastating. However, this time we are greeted with smiles all round and our patient is already sat in the living room awaiting us. Last time she could barely be assisted out of bed. Her mother beams saying she is eating well, feeding herself and growing steadily stronger. She can answer our questions directly today, her speech almost back to normal. It seems the medication started by Dr K back in October has helped significantly. My research leads me to advise that we continue treatment for another 6 months. We shall check her CD4 count at our next visit (a marker of how her HIV control is).
Our return journey leads us to drop in on another home bound patient. The hospital discharged him last summer following a stroke. He is only 46, and when his family describe the story of sudden onset of severe headache for 3 days, followed by loss of vision and paralysis on one side I assume a diagnosis of a brain haemorrhage (bleed). He is still unable to speak, 8 months later, and cannot move without help. He is incontinent and they have to wash, dress and feed him. They say his communication is very limited; he responds to his name but often appears to have no understanding of what his family are saying to him. They were advised to seek physiotherapy for him but cannot afford it. The burden on his family is huge, his quality of life negligible. The palliative team have been dropping in to offer the family support and a listening ear. The stark and sobering contrast with the stroke rehab on offer in the UK.

Out on Home Visits

Peppercorns drying in the sun

Another clinic patient testing my realms of knowledge is a 36yr old lady, referred to the palliative care team after coming to hospital after 3 weeks of excruciating epigastric pain (the tummy area just below your ribs), loss of appetite & weight loss. She has been seen by a clinical officer who has done a blood test for hepatitis and arranged an ultrasound scan which shows a large liver with multiple nodules. They have written a diagnosis of hepatoma (liver cancer) but have not told her anything more than to now attend the hospice. She is deeply anxious, her husband sitting on the edge of his seat....they fear the worse...I do too.
It takes a while to start from scratch, I am thrown by the certainty by which they have formed a diagnosis. I ask her when she first noticed she was jaundiced - she said no one had remarked on this, though the whites of her eyes are bright yellow, but it started 1 week ago. By brain is whirring through causes of jaundice & hepatomegaly (an enlarged liver) & liver nodules. They have not established her HIV status, though she tested negative during pregnancy with her youngest child, now aged 5yrs. We arrange a quick test which is also negative.
I take a detailed history, examine her and then talk it through aloud to the room now full with the hospice clinical officer, the palliative care nurse and a visiting Australian medical student who this week is shadowing the hospice. The med student's previous degree in environmental health proves invaluable as we work our way through possible unusual infective causes such as brucellosis, leptospirosis, q fever. Could she have amoebic cysts, though I'm sure these are more likely to be singular lesions. I am not clear as to which hepatitis strains they test for here at the hospital. I am also not sure if I can trust the ultrasound report - are there really nodules? Her liver is certainly enlarged, I can feel it myself. She looks very unwell, her pulse is racing and she is painfully thin. I fear a cancer diagnosis may be likely, whether primary liver cancer which I now know is far more prevalent in sub-Saharan Africa than in the UK, or from metastasis (spread from another cancer).
I decided to start her on antibiotics which cover the possibility of  a few unusual infections and give myself time for some homework. We also sorted out some decent pain relief for her. She'll be back in a few days time. Regardless of diagnosis or no diagnosis, she will certainly need the input of the palliative team over the next few weeks. If it is primary liver cancer she won't have long. I deeply miss the ability to talk directly to her, so much is lost in translation. Her 3 children are the same ages as mine.
I ask the clinical officer what he would've done without me....this is the kind of patient he gets sent all the time.... I get whisked off before he can answer. We have so many topics for our tutorials now!

Green fingers

Back on an even keel for emotions as we head into the weekend. A lot of brainstorming has gone on the last few days, the most substantial of which was how do we increase our outside time.
This family thrives on the outside world; many a parent will know that if their children come to play at our house they will usually be sent home with grubby knees and the 'dragged through a bush backwards' look. We are missing that here, mainly with the heat, but also with limited 'roaming' space. The girls still understandably don't feel at ease with many eyes looking on and their initial games of football out the front have diminished.
So with great determination, and more than a little help from the hospital gardening team we have tamed the garden behind the house, which to our delight looks all set to provide a shady afternoon play place. Indeed, we reaped the rewards this afternoon with a satisfying round of hide and seek.
Our biggest delight in the midst of all this was Mama Africa's revelation (on requesting some small trees in the 'field' beyond the house to be lopped). Turns out the 'garden' runs down the hill to an area of maize she has planted. We have been vaguely aware of next doors' housegirl disappearing through a gap in the hedge to fetch water from somewhere (mental note; must ask for carrying bucket on head lessons). This morning us shim girls set out to follow the trail down through the wilds of our 'garden' and then onwards through small, carefully kept vegetable patches or farms down to a substantial stream. Suddenly we have an 'easy' area for walking away from the hustle of the town roads. Although we have been advised to be careful of snakes - nothing B likes more than the chance to stomp along banging with a big stick to scare them away. We did also wonder about the likelihood of crocs in the stream...we have yet to establish the whereabouts of the attack on the poor girl M operated on in July.
My 'office' in the hospice has been cleared for me in anticipation and visits lined up for next week. The town is heaving with back to school supplies; R delighted to have purchased new school shoes from a pile on the street (no doubt shipped in from a child labour factory in china) and a mound of exercise books. We did wonder if there would be enough children in the whole of muheza to buy the inordinate number of books on offer.

The hospice car, having gone to Tanga to get new tyres and a jack that works (following our 2nd flat tyre in a week), unfortunately has ended up in the garage after an incident with a boda boda (though I can't help but feel concern for the motorbike which surely will be the worse off for hitting a 4WD).

Hillview: our house is aptly named

Morning walk down to the river

So a fresh start beckons all round....

PDP

Whimsical musings aside...now down to the practicalities of how to make the most of what is essentially now 3 months left.

Today we trialled out our home tutor/babysitter and I slipped into the hospice for the morning. I left her braiding the girls hair so all was calm. 

My biggest question after a full clinic and review of palliative inpatients is will this blog count as enough reflection for my GP appraisal learning diary? Or do I dutifully fill in my learning diary? Inevitably I always leave my annual paperwork to the last minute...tempting this year just to write ‘see blog’ in every section. My PDP for this year was pretty simple.....arrange our adventure to Tanzania and then do it!

I have a natural tendency to self doubt, and even now, many years down this medical road I often feel like I’m just pretending to be a doctor. There are so many things I feel I don’t know enough about and there’s a large part of me wondering what the hospice team here will think of me and what I can possibly offer them. And then I remember that this year I will have been a doctor for 16 years and a GP for half of that. 

Mentoring in clinic today knocked that doubt firmly out the window and boomeranged right back with the knowledge that I am overflowing with offerings....where to begin; teaching, questioning, reflecting, challenging. I have been tentative in wondering about presumed diagnosis.....there is a strong habit here of trying to make a round peg fit a square whole. I shall stop worrying about my scanty knowledge of antiretrovirals!

So many differences; introductions between doctor and patient are presumed (perhaps because the usual round of greetings can take some time!);as is the use of mobile phones, people thinking nothing of breaking off midsentence to reply to a WhatsApp or take a call, both dr and patient alike ; the consulting door left wide open throughout with a shared ownership of the running of the clinic with the next patient being called in by the one who is leaving. On the wards there is limited scope for privacy, but the ladies respect each other’s space, moving away from neighbouring beds if needed, and there is a small side room for more intimate examinations (albeit with clear glass windows at just the wrong height). Could they find me a speculum on the gynae ward, no....though I’m sure M had some in the stuff we brought out. It is stiflingly hot on the wards, the smells that go with cervical cancer require a stiff constitution. Cervical cancer is the commonest cancer in women in sub Saharan Africa......and it is certainly a miserable fate. How fortunate we are for our screening program in the U.K. I have established that they do the vinegar cervical screening here both in the HIV clinic and the family planning clinic, but still so many women only come forward with their symptoms once it is too late. 

I think it will prove satisfying to be working on a more regular basis over the next few months. The time so far has already yielded so much, but it will be far less confusing for all concerned if I have a pattern to when I am available.