Dear All,

Since I last wrote, I spent three weeks in the south-western hill town of Kisii, travelling around banana and tea plantations to do my visits, and I am now at the end of two weeks at Kisumu, Kenya's third largest conurbation (behind Nairobi and Mombasa). I will be sorry to leave this afternoon as there has been a lot to keep me entertained. The local doctors in the city itself have been very welcoming and I have had a bit more of a social life, visiting the banks of Lake Victoria, which has amazing sunsets and lovely fish!

My visits continue and I have now visited 42 anaesthetists in 30 different hospitals. I am desperately trying to keep up to date with all the paperwork (failing miserably) by visiting hospitals four days a week and doing one day of admin. I will have to do some serious report writing when I get a long weekend in Nairobi at the end of the month. As time goes on however, I am more and more keen to get around as many centres as I can because I feel that participants appreciate that someone is travelling to see them and follow up on the course. Also I must admit, I get passionate about helping as much as I can when asked a question or for advice, and really must stop when I see people glaze over with saturation!

My lessons on neonatal resuscitation with my "baby in a box" resuscitation doll, which goes with me everywhere (including the supermarket which always gives the security guy checking my bag a shock), have been enthusiastically received. If there are no theatre cases, we set up in there and/or in the labour ward, and I do an open session for whoever is around: midwives, nurses, students and medical officers. I have now taught the neonatal life support algorithm so many times I am starting to dream about it.

My sense of humour seems to be understood here, and it is great to see how much people enjoy the training, and how much laughter there is in the sessions. "Simulation training" - taking a mannequin and making people actually practice as if for real - is a relatively new concept in Kenya, so I am throwing people in at the deep end. It was so wonderful to see some student nurses continuing to practice and go through the algorithm as I left to get a matatu this week.

I am trying to visit hospitals on days when doctors are operating an elective list, so that we can do "on the job" mentoring. It is always easier to evaluate someone when you see them in action, and provide hints and tips along the way. I am learning so much too - who knew you could give Misoprostil sublingually? You can when you have very limited access to uterotonics (drugs to help the uterus contract and limit blood loss)!

I need to extend a big thank you to the folk at Essex and Herts Air Ambulance who have trained me so well in the use of Ketamine - it is coming in very handy out here as one of the few drugs that everyone has access to. I am sharing the dosing regime I have on my flight board quite a lot, as it would appear many haven’t been trained to dose appropriately.

I have enjoyed mentoring anaesthetic officers through cases, convincing them to use a small analgesic dose, and see them realise how well it can work in much smaller amounts. In centres without formal post-operative recovery units, it is so much safer to see women going back to the wards conscious and talking rather than over-sedated. A favourite moment from this week was seeing a woman who was given Ketamine for an ovarian cystectomy, where the spinal hadn't worked, recover her faculties and point at the clinical officer, calling his name, before pointing at me and saying "muzungu!"

In doing my day to day work, the difficulty is I have a tendency at times to feel very stupid, gullible and then very guilty that I can't find a faster way of getting to the hospitals so I can maximise teaching and mentoring time there. My natural work ethic tells me I am failing and could do better, work harder and achieve more, but my rational brain appreciates hiring a private vehicle costs upwards of 10 times more than public transport and would explode my bursary.

I am getting very used to it now, but the first time I squeezed myself into the 6 inches of space allowed in a matatu, sharing the front passenger seat with another lady and my kit bags, I was surprised to find out the guy I thought was driving was actually another passenger- so there were 4 of us in front! I looked behind and saw 6 people in the back seat and some more in the boot, all smiling at me. My face must have been a picture because the driver smiled at me and said "don't worry", (when did telling someone in a crazy situation not to worry, ever cause them not to worry?) and then drove amazingly well for someone sharing the driver's seat, across a road surface that resembles the moon. Discussing this experience with my supervisor on the phone, she chuckled and added "wait until someone puts their goat on too!"

In that same car, I had difficulty getting to a particular hospital, the woman next to me asked where I was going and happened to know where the hospital was. She said it was "not far" and on arrival she battled the hassling boda-boda drivers and walked me along the high street, directing me up the road to the hospital. We parted at the junction and I walked the final half kilometre with the perfect directions she had given me. Wherever I find myself, I am always humbled by how many people will walk out of their way to show me the right alleyway or get me into the right vehicle, or at least one that claims to be so! It does make me wonder how welcoming or helpful I am to lost-looking tourists in London...

Next I will be moving on to Eldoret, and apparently it is going to be cold as it is at altitude. Still, less mosquitoes. So if you have read this far, thank you. I am sorry I get type-happy…I should be writing my reports!

Until next time,
Naomi