The UN, Statistics, and School Children

Hi there.

We can hardly believe that we’ve only got a couple of weeks left in Juba. I think we both have very mixed feelings about this. There’s a tension of not wanting to leave the people and the work we’re doing, but also missing home. It’ll be good to be back with family and friends for Christmas, but on the downside we haven’t had a day below 30 degrees* C for the past 4 months so we’re anticipating absolutely freezing back in the home-land.

*(can't do superscript in blogger)

It's pure coincidence I appear to be wearing the school uniform...

Yesterday we had the hilarious experience of being mobbed (in a nice way) by a group of school children on our walk into work. It was too good a photo opportunity to miss, which of course excited them further, so I’m sure their teacher wasn’t too pleased that morning. It’s funny how even at this stage amongst all the bad stuff we see this place can still surprise you completely out of the blue and bring a smile to your face.

Right – down to business. The Emergency Medical Ward is continuing to go very well. The nursing staff are just great (great fun and also great at nursing) which makes it a real pleasure to work on. The morning team of nurses actually volountarily stayed for a couple of hours after their shift this afternoon (for no extra money) because we'd had a busy morning with some sick patients and they wanted to make sure as much of their work was wrapped up as possible so the afternoon team didn't get lumped with it. I've never seen that in the UK. Also the junior doctors are unanimously in favour of the system, and the consultants are also very impressed. Sustainability is the name of the game at this stage, and we’re making good in-roads into this as well.

These visitors had banners which we never had. Oh well.

There's been a delegation of consultant surgeons, anaesthetists and nurses come over from Saudi Arabia here for the past week working and teaching in the hospital. It's been quite an insightful experience actually watching 'Juba newbies' come in and do similar things to what our link is doing. By all accounts they've been doing a good job.

We’re keeping a very close eye on mortality rates in the department, and at this juncture they are looking quite good. I think one of the things we feared was that we could cut down 24 hour mortality on our ward, but it would all shift to day 2 when they were transferred. However, this is just not happening at all, which vindicates our repeated emphasis that early recognition and intervention really does have a better overall outcome.

Ward shot. Notice the Oxygen concentrator we have full time now. Very important.

Patients are still dying on our ward of course (and we’re keeping a detailed log of who and why) but the key thing for us as doctors is that we know in good conscience that they probably would have died in a UK hospital. This is mainly down to the late presentation issue, which is somewhat outside of our influence. In other words, we’re (and by’ we’ I mean the whole team on the ward) are doing everything possible for them. Mortality in the department of medicine is hovering around 4% at present, from over 5% in July. This may not seem much, but it means that the new ward system is saving 1 life every 100 admissions, which is roughly every 4 days. (ie. the number needed to treat is 100 for those statistically minded.) It’s still early days but I know that anecdotally I’ve seen the nursing staff save the life of patients who would have otherwise died. It would be the icing on the cake (in a world of evidence based medicine) to demonstrate it formally, but we’ll see.

John Holmes shaking hands with Dr Magdi, the lead Consultant Physician in emergency medicine.

The UN arranged a flying visit by John Holmes, one of their top officials this afternoon who was looking into the state of healthcare in the Southern Sudan. He was only here for a day I think which was why he couldn’t get out into the rural areas where things are much more dire, so he came to the hospital here instead. The Jubans of course were only too delighted to proudly show the whole entourage round which included (unexpectedly I may add) a trip to our new emergency ward. Luckily it was tidy... The Minister of Health came visiting the other day (see photo in an earlier post) and was generally pleased with the clinical care, but thought that the place was looking a bit dirty and wanted more bed sheets etc. So we’ve been working on making the place look a bit prettier recently (blue sheets for the male bay and pink for the female no less!) which was convenient for this visit. Apparently he said to Dario afterwards that "Juba Teaching Hospital is one of the best hospitals in the developing world I've seen." High praise indeed.

Gratuitous cute photo from one of my favourite wards.
It's getting into mango season now as you can see.

OK, that will do for now.

Jem-ez & Daff-eed

For the people we leave behind

Hello everyone. I have been spending much time talking about our endeavours in JTH. It is true to say that the work of the St Mary’s Juba Link has had a huge impact in JTH. However, none of this work would be possible were it not for the kind efforts of our friends back in the UK. So for the friends and family members we leave behind, this blog post is for you.

The St Mary’s Core Team have been working hard on the Isle to set up the St Mary’s Juba Link Bikeathon. The event took place last week and below is a glorious photo of the UK’s only Southern Sudanese Consultant on his bike:

Dr Hakim, Consultant and Medical Adviser to the St Mary's Juba Link

Continuing the biking theme in London, one of my good friends Richard (Edward Wilson Kattan has decided to “grab life by the bars” by growing his very own handlebar moustache for the entire month of November (aka Movember). This is Richard with his clean shaven baby face on November 1st:

Clean-shaven Richard

And this is Richard 3 weeks into his glorious facial hair growing extravanganza:

Richard "Hell's Angel" Kattan

Our blog will continue to update you of Richard's facial hair growing antics. Curently he has raised over £300 for the St Mary's Juba Link by ritualistically humiliating himself for one month. So if you feel like donating some money to this man for our benefit then please visit:

http://www.justgiving.com/richardkattansmovembermission

Dan (left) and Tom (right) taking a rest before cycling up another rancidly steep slope

Back in September some other good friends of mine, Sophie Quarterman, Dan Westlake and Tom Kenyan, decided to cycle the South Downs Way. for the St Mary's Juba Link They cycled solidly for two days covering 75 miles on the lumbering slopes. "Doing this was the hardest thing I have ever done for charity," Sophie said. "There were 20 miles of slopes that were too steep to cycle up and too steep to cycle down."

Sophie and Tom relaxing after the South Down's Way

A special mention should also go to Dan “The Man” Westlake who managed to do this herculean distance on a BMX!

Some of the beaut views on the South Downs Way. Dan's BMX is in the foreground

We would also like to thank everyone for their countless emails of encouragement and words of advice and support. In the days when smiling is difficult, a small email can make a huge difference.

So to my friends who have been supporting our efforts, I extend my thanks. Access to healthcare is the most basic of human rights and in a land recovering from 40 years of civil war, in a land where only 25% of the population have access to healthcare, the need to train healthcare professionals has never been more immediate and dire. Your kind words and novel approaches to fund-raising make us smile, keep us motivated, and will ultimately transform the healthcare given at JTH.

See you all soon,

David

Life

In a UK hospital, when a young patient dies, it is a huge deal. The general public do not realise how hard hospital staff fight to keep their patients alive. Sometimes, despite our best efforts, the illness claims our patients life. We then have to tell the patients relatives the bad news and they leave, crying. However, for the hospital staff that lose the battle, it is also devastating- a sombre air descends on the whole department as each person inwardly reflects on what happened and how unfair life can seem.

In the Southern Sudan life is cheap. Young patients die on our wards with an uncomfortable regularity and the staff seem detached and apathetic to it all. I am not surprised - after a war spanning three generations, where over 2 million people died and horrific atrocities were committed, hope remains a distant dream.

However, on Saturday, something special happened on our Emergency Ward. I was summoned by the nurses to assess a patient who was obviously very sick and we turned his bed into a high dependency bed. He received monitoring, suction, and oxygen. There were lines and tubes coming out from all parts of his body. I summoned my seniors. For two hours, myself, another SHO, a Consultant and two nurses fought desperately for the life of this 21 year old man. However, despite our best efforts, we were losing the battle.

One by one, his organs were shutting down. His kidneys were the first to go. His digestive system was next- we passed an tube into his stomach and blood was aspirated. Whilst trying to solve these problems, we noted the electrical readout to his heart was changing, a worrying sign that there was inflammation of the heart. His blood pressure then plummeted and his heart slowed. I looked at my Consultant and he shook his head. The family, who had been present throughout this, knew that there was nothing that could be done.

H.E The Minister of Health came on a visit to the ward last week

Our 21 year old patient died at 3.05 pm. I looked around at the nurses faces and in their eyes I beheld something that I had not seen since I started at JTH - they were devastated that a life had been lost. “Well done everybody.” I said. “We all did our very best. There is nothing further that we could have done. He would not have lived even if he was in the UK.”

In our ward, life has become precious.

David

Quick Follow-up

Very quick post:

1) The lady we transfused is alive and sporting some much more stable vital signs

2) A man who was admitted yesterday peri-arrest (with oxygen saturations of 67%) was sat up joking with his relatives this morning after receiving good supportive care

So it's nice to see some of the fruits of our labours. Nursing morale is also very high on the Emergency Ward as they are increasingly being recognised by all in the hospital as being very professionally competent and also from the satisfaction of seeing patients turn around as a result of the basic resuscitative measures they're practicing.

It's still hard work but things are going pretty well.

James & Dave

More Emergency Anecdotes

Dr Magdi (Consultant Physician) and Sister Anna on Emergency Medical Ward

Hello again everyone.

Much has happened in the four days since the creation of the medical emergency ward and I thought it was about time to update you all. You will recall I predicted bedlam. My prediction was correct - the first four days have witnessed the chaotic birth pangs of a new system in evolution. Here are some highlights:

Friday: Day 2 of the Emergency Ward
Why Bed Managers Are Important

At 8 am I walked into a ward that was simply heaving. I have never seen anything like it- the patients were two to a bed, there were patients outside, patients on the floor, and in the corridors. The first order of the day was to move all relatives outside so that we could see who the patients were. Then we spent the morning with all nurses transferring patients.

At 10 am the male patients we were transferring started arriving back because there were no male beds (the wards are male medical or female medical). In fact there are about 70 female medical beds and 22 male medical beds. This problem was finally ironed out today when Matron Susan (the Head of Nursing, a good friend, a powerful ally and a Pastor for the Catholic Church) re-designated some of the wards.

Saturday: Day 3 of the Emergency Ward
The Nurses Show Their Worth

At 11 am I was dealing with a very unwell patient and saw the nurses taking the suction machine out of the Emergency Cupboard (for you non-medics this is not a good sign - it means there is a sick patient lurking on the wards).

At 11.05 am I was asked to see a patient by the nurses. The patient was unconscious and without any help they had done a full ABCDE assessment on the patient, which included:

1) Sucking secretions from the airway
2) Measuring observations (temp, respiratory rate, pulse, BP and conscious level)
3) Inserting a cannula and starting a drip
4) Taking basic bloods to the labs
5) Diagnosing low blood glucose levels

I want you to appreciate the magnitude of this in Juba Teaching Hospital. Three months ago, nurses couldn’t do ABCDE and were deemed too stupid to do observations. Three days ago, the nurses wouldn’t have had any life-saving equipment on the ward to help them. Today I walked in whilst they were giving the glucose to the patient and my heart melted as the patient woke up. Six hours later the patient was discharged. Four days ago that same patient would probably have died.

Sunday:

I took my first day off in four weeks

Monday:

Day 5 of the Emergency Ward- the birth of the “High Care Bed.”
We had a patient admitted who was horribly, horribly ill (to the medical folk out there, she was severely malnourished, septic and febrile, oedematous and had a BP of 50/23 with a Haemoglobin of 24g/L- and no this is not a misprint, it was actually 24g/L). However, our ward had a few tricks up it’s sleeve:

1) She received 1-2-1 nursing with 20 minutes observations, including hourly urines
2) She became the first patient to receive pulse oximetry and non-invasive automated BP monitoring on our funky monitor (and the first patient in a ward to receive this)
3) She had oxygen! (Nasal cannulae only but it’s a start)
4) Her family were too poor to buy any medical treatments so we opened the emergency drugs cabinet and gave her drugs that our hospital had run out of
5) We gave her some blood to increase her haemoglobin levels

This means that our “High Care Bed” was functioning almost to the standard of an ordinary UK hospital bed.

Now blood is in very short supply out here - if you need it the relatives have to donate it. The only person she had was her husband and a 12 year old granddaughter. So, as a doctor my duty of care went a little bit further:


Thanks to the screening, I also learned that I do not have malaria, hepatitis B or C, syphilis or HIV. When I left her, she had received the first pint of blood and had two units waiting for her. She seemed to be turning a corner- certainly the vital signs were looking better. The technician had a bit of trouble siting the (large) blood taking needle but luckily James was on hand and only too glad to ram it home, so all was good. Bearing in mind the important “3-1 rule” of replacing blood loss with fluids, we went to the pub on the way home to round things off.

So it’s all fun here in Juba!

David & James



PS:
In an unrelated note, this little monstrosity is what is often seen around the hospital cutting the grass. In a land where we've often witnessed car wheels come flying off their axels down the road, you can understand why being anywhere near one of these little bad boys in action makes us very nervous...

James

Progress

James has never been a fan of inserting exclamation marks into blog posts and I agree with this approach. However the next sentence warrants three...

After 8 weeks of preparation, training, enlisting support, and a few courtesy steps backwards, we have done it:

The new emergency ward is up and running!!!

We have a dream team of nurses and they seem to be loving it. The work is hard but one of them said to me today "I do not mind hard work if we are making a difference."

James ducked out of surgery today to help in medicine

The impact has been immediate and absolute. In the past, there would have been no in-ward medical cover from the time the patient was admitted until the next day. The mortality figures amply demonstrated this with >50% of all medical mortalities occurring during this time.

Now there is medical cover and most importantly, nurses trained in the basics of acute care. Today was a first for many things:
1) The first time an emergency cupboard was opened to save a patients life
2) The first time a ward performed obs on all patient admissions
3) The first time a prescription chart, fluid chart, observation chart and acute care pathway were used
4) The first time that the doctors and nurses were working together as a team

Today was another first for me- it was the first time I saved an asthmatic patients life with the power of creative thought. We had a very unwell asthmatic (who was also very dehydrated and had a chest infection) brought in today. We had no medicine for this at JTH so I sent his grandson who was only about 10 to the Pharmacy to buy some asthma medicines (I needed 3) and some antibiotics. He had spent what little money he had- he could only afford a salbutamol inhaler and the antibiotic. He looked at me with tears in his eyes.

An idea dawned. A salbutamol inhaler can be made more effective if you attach something called a "spacer" which a well made static-free container (we don't have these either). In fact it is as good as a machine that we use in the UK for our severe asthmatics (called a nebuliser). So I took a large mineral water bottle, cut out a hole in the bottom and covered it with tape. Then I made a smaller hole in the tape and put the inhaler in that end. I got the patient to put their mouth at the other end and breath. After 10 puffs on this, 3 litres of fluid and some antibiotics, there was a massive improvement. This chap would have almost certainly died if it was not for this new ward.

The improvised salbutamol spacer

At 5 pm, one of the patients relatives came to me. "Khwaja (means white man), I want to thank you for the work you are doing. That child was crying because he thought his grandfather would die. I have just left the man- he is sat up and talking to my husband."

The nurses were amazing. They seemed to be enjoying themselves and (with the exception of a few minor hiccups) they slotted into the new system like a glove. The day was much less chaotic than I anticipated and I left at 6pm physically exhausted but mentally exhilarated. I am certain that two people would have needlessly died today if it was not for the nurses and the New Emergency Ward. However, anecdotal evidence in Medicine is of no value, which is why we are going to monitor all deaths and see if there is a noticeable reduction.

See you all soon,

David

Emergency Medical Unit

The enthusiasic new EMU staff

Two steps back...

“Your teaching has been cancelled today,” said William the Director of Admin and Finance “ We have an Indian delegation arriving with the Undersecretary for the Ministry of Health.” We are very good friends and he didn’t mean it to sound rude. It’s just he doesn’t speak English very well so it comes out rather brusquely.

I had planned this teaching for three weeks and it was designed specifically for nurses who would be working in the Emergency Ward. However, in Africa you have to adapt. We moved the teaching to the next day and moved back the opening of the ward. It now opens on Thursday (assuming there are no further delegations.)

...and one priceless step forward

Today, however, we took the necessary step forward. They learnt the principles and delivery of oxygen, how to write in prescription charts, how to write in fluid charts, and how to work medical machinery like nebulisers and suction machines. What they loved most was a special present I saved for them- a monitor that shows oxygen concentration in the blood (oxygen saturations), pulse, and blood pressure. All they had to do was press a button and the blood pressure cuff inflates and deflates automatically and gives you a reading.

Dr Magdi, Lead Consultant in Emergency Medicine demonstrating and teaching the monitor

We have 8 of these monitors and they are in storage because no trained in their operation. Today was:

1. The first time this was brought out of its (rather dusty) box
2. The first time certificate nurses in JTH were trained in its use

And they absolutely loved it! They were amazed that it cost $6,000 and were more amazed that one of the adaptors alone cost $400. For me, I see these things on the wards in NHS hospitals all the times. The ability to measure the concentration of oxygen in your blood (and indeed have oxygen therapy to give at every bed) is second nature in our hospitals. I found myself thinking fondly of the NHS, then feeling gutted that these people had so little to work with when we have so much, then thinking “Stop thinking useless thoughts and do something productive like training these nurses. Come on boy!” This cycle all took place within 10 seconds.

The day was a good one. They were all excited about being the first nurses to work in a ward with basic life-saving equipment and medicines (something completely taken for granted in the UK). However, today I saw something else. They were actually proud of themselves. In a land where nursing is the most downtrodden profession and the nurses self-esteem esteem is low, seeing this was a priceless experience.

The ward opens on Thursday - I shall keep you informed but my prediction is one of chaos that turns to order as the dust settles over the first week. The long term strategy for acute care is very much a step-wise one. We're aiming to get medicine running first, and then the model can be rolled out to Paeds and the other specialities. It's tempting to do try and do everything at once (particularly as time is running short) but we feel the wisest thing is to just get a small(ish) thing right first and then leave the Jubans with the tools to press ahead with the rest.

Ta for now,

David & James

Acute Care

Hello

I justed wanted mention a few points of progress regarding the improvement of acute care services in Juba. There's been some good consequences from my presentation to the Ministry of Health at GOSSHA2 (see previous blog entry) recently. Amongst other things, we clearly demonstrated in a mortality distribution study that 60% of inpatient mortalities (and 70% of paediatric mortalities) in JTH occur within the first 24 hours of admission. We concluded from this that in order to reduce hospital mortality, attention would be best spent on improving the acute care delivery services.

What's been really great is that people are actually taking this seriously. Dr Dario (my Consultant and Director General of JTH) has created a new permanent post in Juba: Director of Emergency Services, and appointed Dr Thomas to the task to coordinate it all. This is really encouraging and improving acute care is now high on the hospital's agenda.

Another good outcome from GOSSHA2 has been that Dr Dario managed to put forward as an official recommendation to the ministry that the current procurement system for hospital supply should be revised. Consistent supply of life-saving drugs and equipment, whilst we take it for granted back at home, is a huge issue here. There's few things more frustrating and upsetting as a clinician than seeing delays in, or worse still no treatment at all for a sick patient because there just are no, for example, venflons in the hospital. So in the old system we got what we were given by MoH rather than what we said we needed. Hopefully this will change and the hospital will have more autonomy in procuring supplies.

Enough from me - a few words from David now.


James

The new emergency drugs cupboard on the Emergency Medical Ward.
It may not look much but you wouldn't believe the amount of effort required...

“How was your day?” the Comboni’s often ask me at supper.
“Same as usual,” I often reply “Everyday we move two steps forward, one step backward and one step sideways. But always, we move one step forward!”

Yesterday we took three huge strides:

The purpose of the cupboard is to provide medicines at night time when there are no pharmacists and to allow access to life-saving medicines that you need within seconds. Currently, if a patient needed urgent treatment I would have to send a nurse to pharmacy. More likely than not the nurse would get side-tracked in vigorous hand-shaking and salutations, the Pharmacy would probably be shut, the Pharmacist would be out, or there would be no drugs. This lamentably slow process would take 15 minutes at best. At worst the word “Bukra,” would be given which is a word I hear rather frequently (it means “tomorrow”).

We have selected the Male Emergency Ward as our new Emergency Ward because it has two separate wings. One wing can be for females, the other for males. Handover and the drugs cupboard is in the middle. Today we have been moving the patients out of the Male Emergency Ward and redistributing them.

I am holding out high hopes. We have enough staff, they are all trained, we have the medicines and equipment we need. In the future, we will see if it impacts on mortality.

David

Sunday Ramblings

Well it's a hot Sunday today, a day of rest, so I thought I'd just write briefly about some non-clinical things. We'll follow it up with more work-related content soon as things are moving along nicely...

Part of Father Luciano's vegetable garden at Comboni.
(A favourite spot of mine for sitting etc.)

I haven't been feeling so recently so I've had the past couple of days off from the hospital to rest up a bit. This has been a very good thing. Comboni House is a very restful and peaceful place to be and sit and play guitar around. The chapel is also very nice.

The ferry over to the island

We took a little trip out onto the Nile with some Combonis the other day to go walking on an island. (There's quite a big island in the middle which I hadn't quite appreciated before. See for example Google Earth 4°51'48.49"N by 31°37'38.58"E). It's very green and lush. A little bit like our Island back home. Come to think of it, a lot of Southern Sudan is actually very green. I was quite ignorant about Africa before coming here and tended to think Africa = arid and generally beige but the countryside around is really quite lush and rather pleasant.

The Nile is pretty swollen at the moment due to the recent rainfall. We had to take a little boat over which was punted by a sudanese chap. His pole was really a little too short for the task and we drifted downstream quite a bit and had to work our way back up the reed-beds in the shallows but we got there all ok. So we just went walking around really for an afternoon. It's good to get out of Juba actually (even if not very far.)

Mangos ripening at Comboni

A large beetle I found

Limes at Comboni. We drink these in our water every day. Delicious.

So that's me for now. Back to hospital tomorrow...

James

Cows, Birthdays etc.

Hello again everybody,

Apologies for the lack of blogging but time is rapidly running out and we are working around the clock in a bid to make all the good things we have achieved continue in our absence. We have 39 days left and are trying to achieve the following:

1. Organising trainers to continue teaching
2. Re-opening a new Medical Emergency Ward, stocked with drugs and well trained nurses
3. Training people to implement triage
4. Organising ceremonies for all nurses who have received certificates with us (should be around 200)
5. Travel to another hospital 500 km away to conduct a fact finding visit for another potential link
6. Practice medicine

It is safe to say that we have never been busier...

Yesterday I celebrated my 30th birthday in Juba. The morning routine began much the same as any day; on arrival at the main entrance, there is the exchange of many greetings which involve more than a modicum of vigorous hand-shaking, shoulder patting, and hand-holding (I can now say I am used to holding a man’s hand).

However, my birthday also started on a bit of a low. The evening before, I admitted a 25 year old woman with acute diarrhoes who was very unwell on arrival. This is potentially a nasty illness but thoroughly treatable - they just need good rehydration and close monitoring with hourly checks of vital signs (pulse BP, respiratory rate).

Sister Anna teaching nurses

Sadly, there were no nurses on duty that day and there would be none in the night either. There is a high level of absenteeism amongst the profession - a salary of £50 a month is not enough to feed their families and they need to do other jobs to supplement their income. I did the best for my patient- I gave her 2 litres of fluid and hoped. Sadly it was not enough. She passed away in the small hours of the night, leaving behind a two and a half month old baby whom she was breast-feeding. I don’t hold out much hope for the child; the family will not be able to afford the formula feeds. God bless the NHS - I swear I will never complain about it again.

However, as is typical in Southern Sudan, there were many highs; two drugs cupboards have been completed for our new Emergency Ward. This is the first time a ward in Juba Teaching Hospital will stock life-saving medications and fluids and in a land where minutes literally count, this will save untold lives. The Ward will be re-opened on Tuesday and all the nurses staffing it will have received training on managing medical emergencies. I am holding out high hopes.

I will be working on this ward with sister Anna, one of the brightest ward sisters in this hospital and she also does the nurses training with me. I mentioned to her that I was getting married next year and she asked “How much is the wedding?” I went on to tell her that a typical British wedding costed £15,000.

“Ah but this is not much though,” She replied.
“Not much?” I asked, slightly bemused. This is a massive amount in the Southern Sudan.
“My bridal price will be 200 cows. This is about 1,000 Sudanese pounds a cow so that is about... 200,000 Sudanese pounds (£50,000).”

I asked what made her so expensive as a bride and she told me. “It is because I am tall and I have black gums and white teeth. This means I will give birth to tall, strong, fighting men!”
I asked her how much my future wife would be worth in cows.
“What colour are her teeth?” I answered they were white.
“What colour are her gums?”
“Pink.” She tutted at this.
“And how tall is she?” I judged that my fiancé came upto my shoulders.
Anna shook her head. “She is not tall so all your children will not be strong. She is worth one... maybe two cows at the most. And a few goats.”

At 5pm we enjoyed a beer with some friends we have made in the NGO (non-government organisation) community, whereupon I was handed a selection of fine cheeses, including a particularly strong smelling stilton - you can’t even begin to imagine what a luxury this is out here.

Dave's second party of the night at Comboni

The evening ended on a high in Comboni, where we drank and feasted on various Italian delights that had been prepared by the priests for my birthday which was very kind of them.
On days such as these, I think of previous birthdays I spent with family, friends, and fiancé that are left behind in England. I smile when I think of these times gone by because I would never have guessed back then that I would be celebrating my 30th in a monastery.

Anyway, I had better go. I shall see you all before the new year is out. Take care everyone,

David