Farewell Katete

The past 5 months have flown by and I now find myself in Lusaka having bid farewell to St Francis’ Hospital. I arrived back at the hospital a couple of days ago having escaped to Malawi again for a much needed holiday. This time I spent 5 days in the Mulanje mountains, walking between small wooden mountain huts, cooking on wood fires, bathing in crystal clear springwater rivers and enjoying some solitude, seeing only one other mzungu in passing the whole time. Yesterday I dropped into theatres to say goodbye and was greeted very warmly, particularly because there were a few extra cases on the list and there was an empty theatre. It made a welcome break from packing to do some impromptu operating – making a skin graft for one of my old burns patients and incising an abscess in another. A great way to conclude one of the most valuable, challenging and eye opening experiences of my life. It is difficult to sum up the time I have spent here, but here are a few memories that will stay with me for a very long time:

Feeding ‘typhoid boy’ (he was finally discharged just before I went on holiday – a transformed child, smiling, running, cheeks filled out); weird and wonderful injuries secondary to ox-carts/stray piglets/cows/goats/drunk drivers; baobab trees; trying to have a shower in dry season (an oxymoron); ‘how are youuuu’s of children when cycling/running into town; daily inspection of veg for growth progress report; Zambian music – Organized Family especially the song ‘Potato Saladi’ in which the singer compares his relationship with his girlfriend to his love for potato salad; making a chitenga hammock using sign language and drawings in the sand to explain what I wanted to the tailor; the smell of the burns ward; ‘talktime’ – buying phone topup in 12p chunks and wondering why it runs out so often; public transport and the infinite patience required to survive it; extreme kindness shown to me when travelling alone; snake bites; ‘kulibe’ (‘we don’t have’) following a request at various times for strapping/sutures/sterile gloves/sterilising solution/gowns/insulin/ceftriaxone/catheters/gauze/any instrument you can think of especially the one that you really need for the current job etc etc. but notably when it came to patients (not patience!) ‘kulibe’ never applies; cockerels crowing; cycling through the hospital corridors when on-call at night; venous cutdowns; gin and tonic sundowners; happy pants; greetings; outdoor dinners (until it got too cold); house invasions by local children; cockroaches; stoical patients; laughter on ward rounds (directly proportionate to the amount of Chichewa I attempted to spseak)…

To all those who have encouraged me, emailed, texted, posted letters and parcels – thank you for your support. I am very much looking forward to seeing friends and family when I get home tomorrow afternoon. For now I will soak up the last of the Zambian sunshine and close this blog, at least until the next time…

(Photos to follow when I have a decent internet connection)

The Great Incident

It has been a busy few weeks since the last update, mainly due to The Great Incident (TGI) which was a lovely welcome-back present for myself and Gemma after our holiday. Gemma and I were happily returning to the hospital after a relaxing few days, planning a quiet evening and preparation for the week ahead. As we approached Katete we received a phone call from Prof asking for help quickly as there had been a big road traffic accident and first estimations were that 20 injured patients had arrived at the hospital. We hurried back as quickly as we could and raced into the hospital. The security guards at the front gate were all wearing disposable gloves, something I hadn’t seen before – this was an indicator of the severity of the situation.

A large flat bed truck had been carrying sacks of maize flour from a maize mill which the mill workers also use as their form of transport back to the village after work. It was the end of a long Sunday of work, the truck was stuffed full of sacks and 60+ people were squeezed in on top and in between. A cyclist had pulled out onto the dirt track and the truck swerved to avoid him, losing control and sliding from side to side across the road, spilling the passengers off the back at every turn, sending them flying headfirst onto the gravel and dust road. Once it gained control everyone (bodies and bodyparts included) was loaded back onto the truck which drove straight to St Francis’.

[If you are squeamish you might want to skip this part]. The floor of outpatients was covered with patients and a lot of blood (‘maningi magazi’ as one patient commented), with doctors quickly triaging and loading the sickest onto trolleys to be transferred to x-ray and theatres. All the staff that could be found were roped in to help – student nurses, medical doctors, surgeons, obstetricians, medical students. Theatres were opened and a conveyor belt of patients began with quick blood-stemming dressings being applied on the way to x-ray and then the worst off patients transferred to theatres for cleaning and repair of their wounds. There were some pretty horrific facial wounds – degloving of facial skin down to bone with nasty fractures underneath and gravel and sand embedded deep into the wounds. Two ladies suffered traumatic amputations of the arm – one very near the shoulder which had to be disarticulated and covered with a skin flap, the other at the wrist. Dr Jamie and I examined this second lady who had a makeshift splint of cardboard wrapped with a chitenga soaked in blood around her arm. We gingerly peeled it back to reveal the horror of the wound underneath, the hand dangling in the breeze with bone fragments exposed on either side and a gaping hole in between, with only a couple of bits of skin and tendon keeping the hand attached. All the injuries were confined to head and upper limbs, probably because of the way the passengers were propelled out of the truck, which was probably why there weren’t more deaths. Three passengers died at the scene – two adults and one baby, but everyone who made it alive to the hospital has survived. Everyone worked flat out from around 5pm to 2am when the last patient returned from theatre and an air of (relative) calm descended over the wards. There was a bed allocated to babies of unknown ownership, each with a set of notes where instead of a name a description was entered, my favourite being 'blue t-shirt, floral trousers'. Thankfully over the course of the next day all found their way back to relieved mums. The total admissions count came in at 62 - the first estimation of 20 was a little on the optimistic side. It is quite difficult to describe the scene that night, and I think it is one that will be etched in the memory of those involved for a long time.

A calming picture of a sunflower instead of one of the gory aftermath photos from TGI which would are not publishable here

Mukasa (female ward – my home turf) has been pretty busy since then although we have gradually discharged most of the victims we still have a handful remaining with external fixators and nasty wounds. Theatre lists were dominated for days after TGI by wound debridements with the occasional bit of gravel surfacing in yet another gammy wound. The burns wing has been filling up too as it gets colder and I have realised just how depressing it is to treat burns victims in a resource poor setting, although I get the impression that even with all the bells and whistles of hospitals at home the outcome is still often not great. One night I was on call and admitted three patients from the same incident – the father of the family was refilling their generator with petrol by the light of a candle when one of his children accidentally knocked it over, causing an explosion and petrol burns to the father, 5 year old son and 3 year old daughter. The father received the worst of it, sustaining 75% superficial burns, while his two children had 35% burns each. The son died on the second day of admission, the father on day 4, leaving the daughter who is actually doing ok, having avoided the overwhelming sepsis that caught the other two.

Note hammock in the background

My little house remains a happy place with the addition of a hammock to the garden, thanks to Nelson the genius gardener who followed my instructions without question to dig a very large hole and bury a pole deep into the ground, although I think he thought the whole idea of just lying around in a bit of fabric a little strange. To make the hammock I found a tailor in the market in town with a hand powered Singer sewing machine and through a mixture of sign language, my very broken Chichewa and drawings in the sand managed to get across what I was after. A bit of rope, two chitengas, some stitching and a pole (dead tree) later, the hammock was born. The garden is now home to more seedlings – pumpkins, basil, aubergine, carrots, coriander, cabbage and lots and lots of lettuce. The tomatoes are also starting to bear fruit which gives me great excitement, and there is even one flower on the decorative marigolds I planted in the first week.

A couple of patient updates: typhoid boy is doing well, he is slowly gaining weight and is now smiling all the time and wandering around the grassy area outside the ward by himself, getting stronger all the time. The man with the horrific dental abscess/chest wall necrosis came back to clinic last week - his skin graft of his chest wall has taken well, his tracheal fistula has healed and he looks great. The man from the RTA in my first week whose ear nearly came off but was saved by Gemma's plastic surgery skills has been back to clinic a couple of times and is also looking really good - his ear is very much attached, a little lumpy but much better than no ear at all, and his facial nerve palsy seems to have largely resolved.

I have another little holiday planned, this time to the Mulanje Massif, the mountains in SE Malawi to do some hut to hut walking. Alarmingly I won’t have very long left at St Francis’ when I come back – only a few weeks. But I'm trying not to think about that for now as life continues to be busy but very good here.

Best patient name so far

An actual snake (identified via google searching as a burrowing Asp, although if you know more about snakes than me feel free to put me right. It was about 20cm long and moved very quickly. Until it was beaten to a pulp by some small children from the village we were running through).

Waiting for patients in theatre (a common occurrence)

So for now, petani bwino (goodbye, or more literally, stay well).

Relaxing in Luangwa

This month’s update comes direct from the porch of the most luxurious tent I have ever had the pleasure to camp in. The soft background chirrup of grasshoppers contrasts strikingly with the violent snorting and splashing of hippos in the Luangwa river a stone’s throw away. A young impala has just wandered past the tent. A monkey scampers over the roof and swings off through the trees. I have escaped the hospital and am spending a long weekend with Gemma, my surgical consultant colleague, in the South Luangwa National Park, around 4 hours drive from Katete.

Groundnut (peanut) field

Everything is drying out now as the wet season comes to an end and the maize harvest is in full flow. There’s a lovely loop to run from the hospital along dirt tracks past fields – and usually past several heavily laden ox carts with a handful of children running along behind gathering up the maize that makes a bid for freedom at each pothole. Maize crops are heavily down this year though as the rains did not provide enough water – only 57% of the usual according to the local radio. This will have knock on effects later in the year, as one of the nurses said ‘the people will be hungry’.

Gemma, me, 'typhoid boy' and his aunty

I mentioned the boy with the abdominal fistulas and severe malnutrition – affectionately known as
‘typhoid boy’ amongst the doctors and medical students. (See pic above - with his aunty). We have been taking food in each evening for him for months, and a couple of weeks ago discovered to our extreme frustration that his bedsider was sharing the meat we took in for him with other patients, their bedsiders and eating some herself. This wasn’t malicious, she just didn’t understand how desperately he needed calories, perhaps she had become so used to how skeletal he looked that she didn’t see it anymore. Following some bedsider education we are now sure that the contributions from our mess dinners and various other baking efforts are getting to the right place. We have started to see an improvement in him over the last couple of weeks – to start with a flicker of a smile, the ability to hold his head up when carrying him onto the scales for weekly weigh-ins, then the strength to sit up in bed, sit in a wheelchair outside in the sun (for the first time in several months), a wave from his bed when we walk onto the ward, and for the first time last week the strength to walk a couple of metres from his bed and back holding two hands, then one, and then a couple of steps by himself. This was followed by what I thought initially was a fall from exhaustion, but then realised it was him bobbing down to rescue his shorts which had slid to his ankles having nothing to hold them up. (The next day I found a belt for him in Katete market!) It is so encouraging to see a patient like this gradually get better. That first smile was worth more than any box of chocolates or sentiment filled thank you card.

There has been a whole host of weird and wonderful cases in theatre recently, and my bosses are very good at letting me do the operating on some of these under their supervision. A couple of memorable cases include the lady with a tongue tumour the size of her tongue, attached by a small pedicle – when she initially stuck her ‘tongue’ out (just the tumour) it looked like a slightly lumpy but normal sized tongue, but then if she protruded it further you could really see the size of the problem. How she had let it grow so big I have no idea – speaking was difficult and although she did say she could eat she could only manage ‘pangono pangono’ (a little). We’ve also had a selection of foreign bodies to retrieve – a cockroach from an ear, a seed from a nose, a piece of broken wire from under the skin of an arm (present for 5 years but ‘migrating’ and causing the patient worry). Gemma also taught me to perform a bilateral orchidectomy on a lovely old man with metastatic prostate cancer – the medical equivalent that is offered in the UK is not available here and the surgical method does just as good a job. He was incredibly grateful, not quite what you’d expect given the nature of the operation, and wished ‘every blessing be upon you’ after we’d finished.

This lady couldn't stop smiling after this awful tumour was removed

I have inherited a bike from one of the doctors who left around a month ago and have discovered a new freedom as a result. Much as I enjoy the bike taxis into town, being able to get there under my own steam is even better. A few weekends ago a couple of us cycled out to a friend’s orange farm around the other side of the Katete hills – a beautiful ride, and only one minor over-the-handlebar incident that miraculously didn’t necessitate any first aid or hospital visits. If I was one of my patients I would have referred to myself as ‘at least’, the meaning of which is hard to explain but I think it is similar to ‘not bad’ or ‘ok’. I have also taken a leaf out of Prof’s book and now cycle into the hospital if I’m called overnight. Admittedly it is only a 5 minute walk but there’s something very satisfying about cycling along the empty hospital corridors and it means the escape back to bed is quicker once the problem has been sorted out. Also, cycling while wearing a white coat makes you feel a bit like superman as it flies out behind. Of course the illusion is shattered when you arrive on the ward and spend the next 15 minutes trying to solve a problem by creating something out of an empty vial of ketamine, the tubing from a catheter bag and some ‘strapping’ (incredibly sticky tape used for just about everything).

Herbert's orange farm

I have now migrated to a sun lounger overlooking the beautiful Luangwa river. On Monday I will become Dr Charrot (or Challot, or occasionally ‘Carrot’) once again (having an R and an L next to each other in the same word is a bit of a challenge when the letters are interchangeable), but for the next couple of days I will continue to eat my bodyweight in homemade eggybread and enjoy watching some of the most gracious and beautiful animals that roam in the national park. It's not all hard work!

Snake bites, pus and leggae leggae music.

St Francis' Hospital

It's been a while since I last posted so it's about time I filled you in on some more details of life in Zambia. I am now feeling very settled and at home here. I’ve just about adapted to the heat and continue in my attempts to speak Chewa, the local dialect with mixed results.

The regimented garden

 

My little house is now very much feeling like home. The veggie patch is coming on nicely, the rocket is almost ready for the first harvest and the tomato seedlings are thriving despite my lack of watering. Having paid a visit to the permaculture project over the other side of the Great East Road a few weeks ago I feel rather ashamed of the regimented angular layout of my garden (although the beds were already rectangular when I arrived), having admired their spiral beds of mixed vegetables, the nitrogen fixers complementing the non-leguminous plants. The window ledges are decorated with yoghurt pots and milk cartons planted up with seeds harvested from the abundance of vegetables available for pennies at the chadda, the market outside the hospital. Amongst the hopefuls are watermelon, pumpkin, cucumber, aubergine, groundnut (peanut), lemon, orange, papaya, mango and avocado. Some are starting to sprout, others are growing only a nice film of mould. I’ve been experimenting with baking using ingredients available at the chadda – banana loaf and pumpkin cake have both proved successful and the surgical team has started to complain that they are all getting fat as a result. Tidiness has never been my particular strong point, and although the Sahara is a very long way away from Zambia it seems to be making its best efforts to set up shop in my living room. Sweeping up the sand is an endless task, especially when half of the dust pile crawls away when my back is turned.

Kizito (male surgical) ward

Towards the end of my second week at St Francis’ I succumbed to the almost inevitable d+v which lurks in the wings waiting for susceptible foreigners with naïve stomachs. I was treated to the luxury of ‘hospital at home’ by my kind medical colleagues and made a full recovery, sped up by a few bags of IV fluid strung up to my mosquito net. Once back at work I have been able to get fully stuck in to life in the surgical department. With three theatre lists a week there is plenty of opportunity to operate – I tend to work in theatre 3 where we do minor procedures – lesion removals, lipomas, insertion of suprapubic catheters, sequestrectomies for osteomyelitis, desloughing of dirty wounds and lots and lots of incision and drainage of abscesses. The word ‘mufima’ meaning pus was one of the first I learnt!

A standard theatre 3 case - this one was a very dense sebaceous cyst

On a theme of pus: we have a patient on the ward at the moment who came in with ‘toothache’ which ended up being a bit of an understatement – he had a huge dental abscess which tracked down under his chin to his chest wall. Despite the heaviest duty antibiotics we have here he ended up with gas gangrene and necrosis of most of his anterior chest wall, leaving him with all his muscles exposed and a tracheal fistula which bubbles pus every time he takes a breath. Fortunately he seems to have turned a corner and the spread of infection has halted, but it will take a long time for everything to heal and he will require extensive skin grafting. An extreme example of the dangers of poor dental hygiene.

Purple market

Red market

 We hold twice weekly surgical outpatient clinics where we see a whole assortment of cases, some straightforward, some more complex. Over the last few weeks we have seen patients who have been bitten by an assortment of creatures, varying from dogs to crocodiles, snakes and on occasion their own wives. We have also had a recent flurry of patients falling from motorbikes when trying (and failing) to avoid a pig. A significant number of the casualties from road traffic accidents have been driving when intoxicated, and although they often deny it the overpowering stench of Shakeshake, the local maize beer, gives the game away. We also see a fair number of injuries as a result of ox carts – either people being mowed down by bolting oxen trundling the hefty sized carts behind them, or passengers falling out of the cart. A couple of weeks ago (and before I’d seen any ox cart related injuries) a group of us took an ox cart to a nearby village to watch a traditional women’s dance – a lovely evening and all survived the journey, although I’m not sure I’d be so keen to go again having seen so many injuries in recent weeks!

Experiencing one of the less safe modes of Zambian transport

One patient in particular has begun to tug at the heart strings of the surgical team – a 9 year old boy who has been in hospital for the past 8 weeks, originally with a bowel perforation secondary to typhoid and a string of subsequent problems with a faecal abdominal collection which discharges through four separate openings in his abdominal wall. He is horribly malnourished, weighing just 18kg, some of which is oedema from protein malnutrition. He is too weak to stand and can barely even hold his head off the pillow. The staple food, inshima and rape, is very low in protein and not particularly calorific and the hospital kitchen only provides meat once a week. His family cannot afford to buy meat or beans to supplement his diet and the only hospital nutritional supplement in stock, F100, a high protein milk-based drink is not enough to fulfil his requirements. As a team we have taken to bringing in extra bits of food for him, saving meat from dinner in the mess, baking calorific cakes and buying him full fat yoghurts and nutty chocolate bars. Over the past few weeks we have begun to see a gradual change in him, his mood seems brighter and his ribs are not looking quite so prominent. He is still very unwell but we remain hopeful that with a focus on his nutrition he will become stronger and some of his wounds will heal, aiming to provide reconstructive bowel surgery in 6 months time.

Look at me, my eyes move independently from one another!

Last weekend four of the students and I travelled to Lake Malawi for a relaxing few days. As we had been assured it was well worth the long (16+ hours) bus journey and we spent the weekend snorkelling in the crystal clear water, enjoying non-hospital food and drink and generally enjoying ourselves. We attempted to paddle dug-out canoes which are the standard boats for local fishermen – it turns out they make it look much easier than it is and there were many, many capsizes. We enjoyed some live ‘leggae leggae’ music at a local ‘crub’ – after initial confusion we worked out the interchangeability of the letters L and R. We returned refreshed and very well fed (and feeling a need to up the pace of evening runs to offset the overindulgence!).

Snorkelling, good food and drink, this view...not a bad holiday all told

Thank you to everyone who has been in touch, I really enjoy hearing your news. Apologies it has taken a while to update the blog, I’ll try and do another before too long.

First impressions

“Welcome Dr Ghana” was the sign that greeted me, held by Isaac from the Zambian Anglican Council on my arrival in Lusaka airport 10 days ago. A good guess - I worked out it was me he was waiting for! After a day in Lusaka I made my way to St Francis’ Hospital after sweating my way through the bustle of the bus park and the 7 hour bus journey to Katete – unfortunately my arrival had slipped the memory of the administration staff and the usual hospital transport had not been arranged. The journey was relatively uneventful and I arrived in one piece, complete with luggage, including the sacred 500 pairs of sterile surgical gloves which had arrived nail-bitingly last minute, the night before I left the UK, which will see me through the next 5 months in the surgical department here.

St Francis’ Hospital is a rural District General Hospital funded by a combination of the Government and the Anglican and Catholic Councils. Care is provided to patients entirely free of charge, provided they fall within the hospital’s catchment area. It has around 350 beds but this number varies depending on how many patients there are in each!

Catho 2: a semi detached property with a convenient location

A little electrical experimenting

So far so good – I’m settling in to life in Zambia, adjusting to the heat (having failed to mend my fan which, despite a new plug still does nothing), gradually making my little house, Catho 2, more homely and meeting lots of very friendly and accommodating people. The surgical team consists of two consultant surgeons, Prof Robert from the Netherlands and Gemma from the UK, a Zambian doctor, Victor, and two licenciates – Geoffrey and Jane – who have undergone basic medical training and rotate through surgery, medicine, paediatrics and obs and gynae. There are also 6 doctors from the UK here who are running the medical wards, 3 of whom I already know from the Diploma in Tropical Medicine, and an ever changing group of medical students who are mainly based in medicine and paediatrics (we have only recruited one to surgery so far!). The set up is basic but much less so than I was expecting – I have a small but comfy studio house with bed area off the end, kitchen with slightly eclectic array of crockery and a bathroom, complete with a family of cockroaches which continue to reproduce despite my best efforts and catch me off guard, usually when I’m in the shower. To my delight I have a decent bit of garden complete with veggie patch which I have started to cultivate – this morning I sowed mixed lettuces, rocket, basil, thyme and tomatoes, accompanied by beautiful singing floating across from the Zambian service at the nursing school opposite. I have yet to make it to the English service as it starts antisocially early although one day I will drag myself out of bed for it.

A visitor in the decorative but non-functioning bathroom sink

Hospital days start at 7.30am with meetings or ward rounds. I’m based on Mukasa, the female surgical ward which has around 40 beds but usually sleeps more than this, with patients sleeping on mats on the floor of the entrance corridor and treatment room. It’s been particularly busy recently as a visiting fistula surgeon operated on around 40 women the week before I arrived, and they have been gradually recuperating on the ward. Mukasa is a standard Nightingale ward with a side room for burns patients (stiflingly hot in here to prevent burns related hypothermia) and an ‘ITU’ – the closest 6 beds to the nursing station, identical in everything other than location to all the others.

The moth eaten appearance of osteomyelitis

Elective operations are performed on Mondays, Wednesdays and Fridays, with only emergency ops the rest of the week. There is a huge variety of cases from broken bones (children falling out of trees trying to get to juicy mangos) to hernias, perforations from typhoid, volvulus (twisted loop of bowel), road traffic accidents and assaults. I have been spending my time in theatre debriding wounds/burns/ulcers, doing sequestrectomies (using a hammer and chisel to chip off dead bone due to osteomyelitis), incising abscesses, removing foreign bodies from hands and feet (eg. the broken off needle from a sewing machine, buried deep next the bone), inserting suprapubic catheters (under local, using open dissection as there are no Bonano catheters here) suturing lacerations and assisting in laparotomies, under the supervision and with the assistance of Prof, Gemma or one of the licenciates.

Happy customer - my first open suprapubic catheter patient, relieved of two days of urinary obstruction

On Friday I was called from theatre by a student nurse from Kizito, the male ward who came with the message that ‘there is an emergency, you must come quickly, there has been a road traffic accident’. I found the patient, a man in his 40s, lying in bed on the ward in an expanding pool of blood, his head wrapped in a blood soaked chitenga (traditional patterned African cloth, used for everything from carrying babies to sanitary towels) surrounded by a crowd of nurses, students, relatives and interested onlookers. After a rapid assessment, and some hefty fluid resuscitation we whisked him along to theatre leaving a trail of blood behind us, sending a nurse running ahead (well, quick walking – no-one runs here, not even in an emergency!) to alert the theatre staff. Removal of the chitenga exposed an arterial bleeder from a scalp wound and a deep laceration filled with shards of glass from his chin to his ear, which was hanging off by the lobe. We set about suturing everything back together and Gemma did a very neat job of reattaching the ear, with fingers crossed that there was enough tissue attached to prevent it becoming necrotic. Fortunately for the patient his only other injuries were minor scrapes – I have heard many stories of others who have come off much worse.

Theatre 1: the aftermath

Investigations are relatively limited – the lab can provide a haemoglobin level but not a full blood count at the moment (equipment problems), some liver and kidney function tests but no electrolytes which makes potassium replacement a bit of a guessing game. The radiology department can provide x-rays which are usually of pretty good quality and ultrasound scans which are less reliable. Prof has been known to announce ‘we will take this patient for a CT’ which means we will open them up in theatre and see what the problem is. There is one CT scanner in Zambia which is in the University Teaching Hospital in Lusaka and at a cost to the patient of £100 per scan and a 7 hour bus journey away it is out of the question for most patients.

Not a bad view for washing up

There are ongoing financial problems at St Francis’ – this month the government has not paid the hospital which has had a knock on effect. There have been daily power cuts and by the end of the week there was no fuel to run the hospital generator – an emergency operation was delayed by 4 hours while a driver was sent to Chipata to buy more as the closer petrol station in Katete had also run out. We also had a suture crisis with only enough remaining to schedule operations that didn’t require sutures, allowing some to be held aside for emergencies. In addition the hospital staff have not been paid but are still expected to work, and many support large families, relying on their monthly salary. Although a relatively politically stable country, Zambia still has its problems, not to mention the immense poverty that is seen every day here and the high HIV positive rate (14% at the last count).

Sundown

It’s not all doom and gloom and hard work though – there is a great social side to life here, with everyone living on site in little houses, and evening meals for doctors and medical students provided by the doctors’ mess. The weather is fantastic, although it is currently the rainy season it is mostly hot (~30degrees) and sunny, with a downpour every few days. I have been eased into hospital life gently, without any overnight on-calls this week, and only a ward round to run on Saturday morning but the rest of the weekend off. I have thoroughly enjoyed my first week and I’m sure the next few months will fly by. Internet access is pretty good and I have already heard from a few of you – it is lovely to hear how everyone is getting on, whether at home or abroad, so please keep in touch. If you don’t already have it my email address is charlottegunner@gmail.com – I would love to hear from you.

Sunday afternoon barbecue under the shade of a mango tree