The good, the bad and the very ugly (as in absolutely shocking)

Welcome welcome one and all for a bit of a long (hopefully interesting) ranty one this time round I’m afraid!… Firstly I wanna congratulate all of the 2011 City University Speech and Language Graduates! (That isn’t meant to be a self-congratulatory pat on the back) Woo-Hooo :) and now onto the good, the bad and the very ugly (and by that I mean some pretty shocking things from this week).

The Good:
Last week I carried out 2 training sessions at 2 different hospitals - the 2 biggest in Kisumu, the Provincial (“Russia” where I have been working weekly) and the District. The turn-out was great - for Obama Children’s hospital (“part of Russia”) 28 Doctor’s and Nurses came along and at the District 37 staff members (mostly Doctor’s/Nurses but others from different areas of the hospital came too). On the whole they all seemed genuinely interested in what I had to say and had far too many questions to ask about all sorts which was brilliant if a little hard to answer well at times :S

It was the first time I’d been in the District hospital and there were some great things that arose which I wasn’t expecting at all - firstly I was taken around and introduced to EVERY SINGLE ward to introduce myself and explain why I was there and the types of difficulties people may have that I can possibly support. Although some units probably are not too relevant to me e.g: Maternity/New borns, Obs/Gyn it was still great that Boaz, the O.T showing me around realised that anyone can have an impairment in the area that Speech and Language Therapists work with and felt it was important to promote who we are/what we do to all J Whilst going around I noticed signs up for the meeting I had held in practically every department! I believe this is common practice here but compared to “Russia” where it seems to be done by word of mouth it was lovely to see such good communications/promotion of CME’s (Continuous Medical Education seminars).

The last great thing was at the psychiatric ward (only one in Kisumu I believe) where I was expecting a real horror show of people strapped to beds and staff members not really doing much. The guy in charge immediately mentioned a lady whose speech becomes unintelligible when she speaks quick/gets excited (“Cluttering”) which was great and then he took me inside the unit to meet her. Walking into the unit wasn’t scary per se but it did seem very reminiscent of a prison scene - all patients in Jail-esque outfits, one open air area in the middle with a few benches around and then dorms either side. The lady didn’t particularly seem “with it”, which may be the drugs which the patients are on or just her general being and did not speak to the guy in charge very much so couldn’t really see the impairment (as such). The rest of the patients (a mix of sexes, ages between teenage and 60’s) were a little overeager to touch me/say hello and for a split second I thought it was going to kick off a bit but everything turned out alright! I’m only at this hospital for 2 more times before I leave and there are a load of people to see in the surgical unit, male and female inpatient unit and paediatric unit so I’ll just return to give the head officer some written information on cluttering. I did ask a few questions about the unit and the 2 big things that stood out to me were that family members are the ones that choose to put people in the unit via a doctor's assessment (though considering money is a big factor here I assume a lot are willingly accepted purely on the basis of what the family report) and that to be "released" they have to pass a "mental exam". I asked about whether social skills were taken into account e.g: training to go back to the community. The head said that "Unfortunately due to lack of staff and safety concerns this is just not possible" which I can understand from one point of view - resources here aren't great - but from the other point of view releasing potentially dangerous people back into the community based solely on a "mental exam" seems more of a safety concern than being one staff member short for 10 minutes a day perhaps..?

Due to some pressure from a few parents and the influential ASaLTEA conference last week, I quickly pieced together an Autism Support Group (Western Kenya’s first as far as I know!) which went much better than I expected with 13 mothers, 2 teachers and 1 nurse turning up. My aim was for 10 people to come so was dead chuffed but at the same time at least 3 parents and 3 teachers who were dead certs to come didn’t so hopefully next month’s one will be even bigger (I‘ve dragged in a few people to continue the group and will make sure David and/or Rach will be there too)! It was fairly hard to work out what to present as most of those who turned up I’ve done a basic Autism workshop with before, but the most difficult thing is the abilities of each child is sooo different that some information may not be suitable for some children and I don’t want the parents to zone out/go to sleep! I ended up going back over sensory needs (asking them to keep a diary and try to discover patterns around the times when the child calms down to use during those times of hyperactivity for example), the diet (there’s hardly any evidence!!) and showing how to make some basic AAC (Alternative and Augmentative Communication) devices such as “now and next” boards and basic picture communication boards/books. I also showed some videos of Intensive Interaction which was relevant for many of the parents. Overall, it was a success I think as the main reason for the meeting was to meet others, share information and experiences etc.. and almost an hour was spent with people introducing themselves and voicing their grievances with many of them vocally supporting the need to love your child no matter what :)

Bad:
Although over the moon with numbers who turned up for Autism Support Group, out of 16 hospital staff who were “interested” only 1 turned up and out of maybe 7 or 8 teachers/professionals who I was hoping/expecting to come only 2 did.

The more work I’m doing in hospitals, the more people there are who are seemingly beyond help - case in point being a 14 year old girl who is continuously having seizures, malnourished, on a Nasogastric Tube (NGT) for feeding as her swallow is poor and has a whole host of things going on affecting her brain (e.g: Sickle Cell, Malaria, TB) and a 72 year old man who had a right sided CVA (Cerebral vascular Accident) approximately 2 weeks ago. I’ll speak about both of them to varying degrees below, in the “ugly” section.

Oral Hygiene. That being the care of the oral area such as brushing, using medication to clear up infection and hydration. I’d always figured this was families responsibility (in fact I think I mentioned it in a past post) but low and behold when I brought it up at the training sessions they said it was the nurses responsibility. I therefore went off on a little telling off that sure it’s important for family members to be involved and know how to support this area but if it’s the nurses responsibility they should be carrying it out alongside the families or at the very least teach carers how to do so and check up on the client. None of this has ever really been done to my knowledge - definitely not with brushing of teeth etc.. and my gut feeling is any oral thrush medication is just given to the family and told how many drops/spoonfuls to give per day. A great example is the 72 year old I mentioned above - he has oral thrush and it looks like no-one has even looked in his mouth let alone brush his teeth in weeks (there are lots of bits of stuff stuck in between his teeth). On my next visit on Tuesday, I will show both the wife and staff how to apply oral medication safer (gel on gauze and dab rather than crushed pills in water) and how to clean his teeth (using water or toothpaste will create saliva and foam which the client is likely to aspirate on).


Ugly:
Client C, who I have spoken about a number of time previously  - 11 years old and has been in the ward for almost 3 months. He came in with meningioencephalitis (meningitis and inflammation of the brain) from which he has had several complications. He is on an NG tube, severely underweight, has very little movement, possibly blind, has some understanding of language but no way to communicate at the moment and does not have a safe swallow on any consistency.

The hospital tried to discharge him.

This makes me soooooo angry because not only is there NO WAY IN HELL this child should be discharged but additionally if mum is happy to be there supporting him, paying the fees etc (which is a BIG factor here) why should they try and turf him out because they “can’t do anything for him”. Firstly, there is ALWAYS something that can be done that is making his quality of life better than it would be at home (in this case he will almost certainly die if he went home) and secondly, you only have to look at client M who staff felt the same way about only a month ago and now she is doing unbelievable well. I’m not saying this will happen to C but if he goes home, the same as if M had, death is the likely consequence.


Back to the 2 patients I mentioned earlier:

Whilst reading through the notes of the 14 year old girl I noticed 2 glaring things - Firstly when she entered the hospital her age was marked as 14, then halfway through the notes suddenly she becomes 12. This doesn’t really have an affect on intervention but somehow something as simple as this has been miswritten - when I asked mum she immediately said 14 so it’s not like she doesn’t know/is unsure of date or birth which is pretty common here. Secondly, I noticed that the ideal liquid diet (through her NGT) for her weight is 2700ml according to the nutritionist. Her current feeding charts marks her as having on average 4 feeds of 300mls a day - 1200mls LESS THAN HALF WHAT SHE NEEDS. I approached the doctor’s about this who initially seemed taken aback by this fact and then proceeded to name 3 reasons this may be.

Number 1:
Doc: “You know sometimes it’s difficult for children to keep food down through the NG Tube”
Me: “She vomited twice on the first day she was in/on an NG tube, since then she has retained all feeds for the last 10 days”
Doc: “Oh”

Number 2: Families can not afford food. Understandable and fair point. I enquired with the nutritionist and basically they have NO funds to provide anything free nutrition wise (e.g: extra nutrition flour/special seed/nut paste sachets).

Number 3:
Doc: “You know sometimes mothers feed their children and don’t immediately report it to the nurses”

After chatting to mum and a few nurses who I dragged into it, I came up with a dietary timetable, exactly the same as the one in the notes which is to be stuck on the wall next to the bed so Mum can immediately mark down when she feeds. I feel it may also be good for her to have the exact amount written down and the amount of times she is meant to be feeding her child to get her to hopefully realise how underfed she is at the moment. I told Mum I realise how hard it is to feed every 3 hours all day/night and that money for food is an issue but that I was expecting the intake to be AT LEAST 6 feeds rather than her current 4. We will see on Tuesday how things are going..

The 72 year old has left-sided hemiplegic (paralysis of the left side), visual difficulties, doesn’t seem to be understanding any language and does not produce any spoken or body language to speak of according to wife/nurses. He does not have any swallow to speak of. They tried twice to put in a NGT (Nasogastric Tube - which allows feeding straight to the stomach whilst bypassing the throat and the risk of aspiration [food/drink going into the lungs]) but it failed. Why? The nurses could not tell me. So he has been fed porridge/liquids and been given crushed drugs mixed with water all whilst he has absolutely no swallow to speak of and is coughing (I.e. aspirating) anytime he is given anything orally (according to the wife). He desperately needs to be put on an NGT, which I spoke to the nurses about, who agreed with me.. AGAIN WHY ON EARTH HAVE THE STAFF ALLOWED ORAL FEEDING/MEDICATION TO CONTINUE???!! Don’t get me wrong - I realise we are in a 3rd world country and things are different to back home etc.. BUT these guys are trained doctors and nurses AND there are the facilities in place (I.e. NGT) to support this client but nothing has been done in 2 weeks or so.

Continuing on a similar vein - LACK OF KNOWLEDGE HERE IS UNBELIEVABLE (and I don‘t mean in terms of people don‘t understand or need to know more about certain areas). Some examples from training:

56 out of 69 hospital staff (vast majority of Doctors and nurses) thought cutting a tongue tie improves speech

Only around 50% could label more than 7/12 labels on a diagram of head and neck

When talking about swallowing difficulties, I asked a doctor to explain to me what aspiration was. He had no idea what the word meant. This is a word that is used here, there is no Kiswahili alternative used within the hospital and all discussions/notes are in English.

Can’t really put my feelings into words really - Sometimes things are the way they are because of lack of money, lack of general knowledge, common superstitutions/beliefs but as with feeding issues these are all things doctors and nurses are trained on. F*cking unbelievable.

Apologies for the bit of a rant today but I think it’s a fair reflection of some of the practices out here and if I don’t rant to someone than I’ll prob end up destroying some relationships I’ve built up with staff/friends out here!

Only a few more weeks left and only one and a bit of work so you only have to be bored by me a couple more times and I’m off!

J xxx

Top 3 songs played on Itunes shuffle whilst writing this:
1. FreeBird - Lynard Skynard
2. Everlong - Foo Fighters
3. Titus Andronicus- Titus Andronicus

Some pictures and a little bit of learning!

To start with , some pics from the clients I specifically mentioned last week - M and Mr Oteng and some before/after type of pictures! :)

M’s improvement, as mentioned, seemed to have nothing to do with a change in medication/care, just a good ol’ fashioned miracle - especially considering the diagnosis and her condition when I first saw her (see previous posts). I can honestly say that although I did my utmost to explain M’s eating and drinking difficulties and try to work on that aspect (again, see previous posts) , the reason why M is not only on the road to recovery but even alive is 100% down to mum. She was the one who decided not to be discharged, especially under duress by hospital staff to free up beds (f’n ridiculous if you’ll pardon my language) and did amazingly in carrying out oral care (the responsibility of the family not the medical staff out here) and following strict instructions regarding food/drink. A wonderful mother and a wonderful kid. I saw M today and she is already understanding “Wh” questions (What, Where etc..) and responding in beautiful sentences.

I would like to point out that in this picture
M is not smiling but clenching her teeth as
a result of a seizure that occured days previous.

A beautiful young girl hopefully on the road to full recovery

Mr O and his recovery is again a testament to not only his strength but also the support of his brother George. I have made a number of blog entries regarding the incredible support/work the duo have made and the steps George has taken to not only support his brother but also relay all information to other family members to carry out strategies based around word-finding difficulties, his dominant difficulty. Additionally, with the help of my Yellow House Colleague Rachael Gibson who I managed to drag down on a number of occasions to deliver oro-motor exercises, an area she is specially trained in, George and Mr O have been working tirelessly on continued home therapy in this area. I will see them for a follow-up on Friday morning to see if Mr O has done his homework ;)

Sooo - onto the main part of this week, the 4th East African Speech and Language Therapy Conference held in Kampala. As I don’t wanna bore non-SLT’s (and even SLT’s as well!) I’m gonna have a little write and then a list of ten things I learnt from the conference.

The conference was brilliant. It was the first conference I’ve ever really been to and I can confidently say it probably nothing like how a normal conference runs and even more confidently say that I hope to be back in 2 years for the next one. There were over 50 people who attended from 15 different countries - most working within or part of working wihin East African countries (lecturers, researchers, SLT’s and other professions) plus some amazing special guest speakers such as Cath Irvine (Intensive Interaction) and Lindy McAllister (Clinical Education). Rachael and Martin (O.T / Head of Mumias EARC) put on an excellent presentation of the Yellow House Team, who we are, the work we have done and the challenges we face and how we plan to overcome them. I joined them and David (O.T from Uganda who works alongside Rach) for the plenary session to answer questions. I didn't even know what the word plenary meant until the conference!

Things I learnt (among others!):

1. In 2005, the World Health Organisation (WHO) estimated 600 million people had hearing loss with 80% of cases in developing countries. The majority of these cases are preventable/treatable.

2. Currently in Kenya there is approximately one Speech therapist to every 4 million people.

3. A much nicer word for “Challenging behaviour” is “exotic behaviour” as coined by Cath Irvine (note - this is not a term that should be used in the professional world whilst writing case notes!)

4. Some traditional (still practiced) practices to eliminate a stammer are to throw a child into a river repeatedly and to eat peanuts that have been left by a parrot whilst talking.

5. Quibble seems like a fun party game

6. Research should be done into a link between SLT’s and dancing ability because on the whole people were throwing shapes on the Saturday night!

7. Intensive Interaction seems p-retty amazing.  It is aimed at children and adults who have severe learning difficulties and/or autism and who are still at an early stage of communication development however more research is coming up for other client groups it could be useful for. Check it out.

8. If interested in disability work/rights and what is happening all over the globe check out the following: “World report on disability”, “UN convention on rights of persons with Disability”, “Millenium Development Goals” and last but by no means least “Communication Therapy International.

9. Almost purely based on the conference and the speakers, many of whom talked about research, I am beginning to consider a Msc project, possibly within Kenya if at all possible. I am so easily influenced.

10. The amount of people (as mentioned) who attended, plus the types of people and guest speakers has really shown (I’ve been told by those who attended previous year/s) how much speech therapy and the understanding/awareness of communication difficulties in Eastern Africa has grown. Long may it continue.

Turns out I have less than a month left before I return! Additionalyl I’m hoping to finish up with a week spare to make sure I leave everything in a good place before heading to Nairobi a little early to have a bit of a shop and to be lucky enough to observe an experienced therapist who has been living here since 1999 :) (Thanks Emma!)

A last quick plug for a Speech and Language E-Book project I’m trying to get off the ground -  It is an E-book project whereby the aim is to create an easy to read, informative book of short stories based on Speech and Language Therapists and Service Users experiences. The idea is to promote the role of a Speech and Language Therapist, the work we do and the people we do it with. Essentially, the E-publication (through Amazon) is designed to get a greater number of people to understand what we do!

Please e-mail me if interested at jonathanmlfagan@gmail.com and/or join the facebook group cleverly entitled “SLT E-book project”

Hope all’s well with everyone wherever you may reside in the world,

Big hugs,

Jon x

Top 3 songs played on Itunes shuffle whilst writing this:

1. Small Town Girl - Good Shoes
2. To Whom It May Concern - The Civil Wars
3. Emergency - The Answering Machine

Life and Death Pt.2

I officially decided to re-start at work on January 3rd and things have been right back to usual and pretty hectic. Personally, I’m always very torn by this as I love working with both my clients as well as other members of the Multi-Disciplinary Team (all those who work with/around the client e.g: parents, teachers, hospital staff etc.) but equally part of me wishes that it wasn’t so busy and there were not nearly as many children in need.
I’m going to concentrate on 3 clients for this entry - 2 great stories of rehabilitation and the unfortunate passing away of a new client.

M is a Christmas/New Year miracle. Period.
To re-cap on the info I gave in a previous blog after I initially saw her a month ago -
M is 6 years old and has been in hospital for almost 2 months. She has had multiple cerebral infarcts (stroke) is sickle cell anaemic and is severely malnourished. The day before I saw her she had a convulsion (which are said to not be common for her) and her NG tube removed (why, I have no idea - I’ll get to that in a mo)… she is not particularly alert, has difficulties with mouth control (M has clenched teeth the majority of the time), cannot support herself at all physically and seems to have little to no understanding of spoken language…M was not safe on any liquid - not only does she have very limited movement creating difficulty to give her anything orally, she had no swallow on a small amount of water and one day I came in her mum had just given her a small spoon of very thick medicine (like a gel) which is for her oral infection - she had an incredibly delayed swallow with very gurgly, heavy breathing ( a sign things are trapped/going down the wrong way) and the majority of the medicine seeping out of her mouth over the next 10 minutes or so.

Come January the 4th and I can hardly recognise the child sat independently in front of me. I’m actually so blown away I almost immediately cry. I reach out my hand and say “habari” (how are you?) and M moves her hand towards me slowly and responds “mzuri” (fine). Not only is she independently supporting herself and beginning to move her limbs but her understanding and spoken language is coming back with mum reporting she verbally requests toilet, water, food amongst others. One of the most noticeable things about M is she has put on weight and is looking much healthier - she was taken off an NG tube when her condition was getting better and I assume they trialled feeding her and all was well and she continued to improve. Watching her eat and drink without any difficulties, a strong prompt swallow present on all textures and Mum indicating that she has none of the difficulties of which I previously explained lead me to tell a very happy mum that I could now leave them alone! I went through M’s records as well as asked mum/staff if anything was changed whilst I was away - maybe different drugs for example - NOTHING. She has literally miraculously gotten better without any change to treatment, which in essence was palliative care. I couldn’t be happier for a beautiful little girl and a very hard-working mummy.
(I should have some pics to put up next week)

Mr O is reaching for the stars
Another previous client re-cap -
Mr O is a lovely young man (32) who approximately 6 weeks ago had a stroke. He is exhibiting global aphasia (difficulties with both receptive and productive language) with very common characteristics such as word-finding difficulties (causing non-fluent speech) and some fluent unintelligible jargon-like speech. He has an unbelievable brother who is looking after him and takes notes at all meetings.

The last time I saw Mr O, at the beginning of Dec, he had come along great guns in the month or so since I first saw him and around 10 weeks since his stroke. Alongside strategies that I had provided and discussed with him and his brother Rachael came down to do some oro-motor exercise work with him to create more muscle strength and control in the right-hand side of his face which had been affected by the stroke. Before Christmas I re-did an informal assessment similar to that of my original one and he performed far better, making fewer mistakes, having more consistency within these errors - e.g: semantic errors only (using an incorrect word that is linked in meaning to the target word such as using cat instead of dog) and having clearer speech sounds. He was still using a wheelchair at this point.

Fast forward less than a month and I greet a very healthy looking Mr O sans wheelchair chewing away on a piece of gum with very little obvious difference between the two sides of his face. For the entirety of the session Mr O rarely looked towards his brother for help (which he previously did on many occasions) due to his reduced word finding difficulties. After asking both Mr O and his brother of how things are going, areas of difficulty etc.. the main area of functional difficulty seemed to lie with Mr O’s reduced ability to ask new people/strangers things. Upon discussion the crux of the matter is that Mr O is worried what people will think of him if he takes time to speak/cannot retrieve words etc. Therefore after discussing it his “homework” for the next week is to come up with a sentence that is easy for him to remember and produce accurately which explains his difficulty - an example might be “I have had an accident and need some time to speak please”. And then use this sentence with 3 people in his local community who he sees regularly but who are not friends/family - maybe shopkeepers/bus drivers etc.. I’m very interested to see whether he managed it and what the responses were!


Client M
M was a child of 3:6 with a diagnosis of Cerebral Palsy who had come into hospital a few days before I saw him (Thursday) with severe pneumonia. Before I suffered from pneumonia myself a few years back, I always associated it with chest infection due to coldness however it is an inflammatory condition of the lungs that can have a number of causes, one of which is chest infection through aspiration (food/drink going into the lungs instead of the stomach due to eating and drinking difficulties).

On first sight M was hooked up to oxygen to aid his breathing and was coughing away for the majority of the 30 minutes or so as I explained my job, swallowing difficulties and the plan (Mum had confirmed he coughs during feeding, has a chest infection and has lost weight - all signs of aspiration). I organised to come in the following morning to do a swallow assessment / observe mum’s feeding if it was feasible and safe. I trialled M on 2 teaspoons of water (the safest substance to trial on as it is ph neutral and less likely to cause infections) and he produced a delayed but strong swallow with a few small coughs afterward (a sign some may have gone down “the wrong way” into the lungs). I followed this with a small teaspoon of mashed banana to see if his oral movement/swallow was different on a different texture however there was very little oral reaction at all and I manually took out all of the banana from his mouth. Explaining to mum that he is not safe on anything at the current time it would be advisable for an NG tube to be placed with M to keep his nutrition up whilst bypassing his swallow, giving his chest a few days to heal up hopefully without anything going in. At the same time “rounds” where happening and I gave a very brief presentation to the Dr and the 15 of so students who surrounded M’s bed. Immediately after I explained all the Dr exclaimed out loud “Why isn’t this child already on an NG?” before shaking his head vigorously. Which immediately made me appreciate and think that this Dr knew what he was talking about, however whilst listening to him discuss medication options with the students TWICE I had to butt in when he prescribed “oral tablets/capsules” after I specifically said that this child was not safe on anything oral.

Just writing this is making me infuriated beyond belief as this is the SECOND time I have had to tell Dr’s to place a child on an NG tube. This was also the second time I have lost a patient out here.

I received a text message 4am on Sunday morning from M’s mother simply saying: “Hi Jonathan, your friend M has just died, L.”

My thoughts are with you little man.

I asked the hospital what the eventual cause of death was and that is still pending. I suspect it may have just been too little too late for the child due to his numerous difficulties on top of his severe pneumonia and poor breathing. However, if he had been put onto an NG tube when first admitted as he should have done would things have been different?

Almost as a direct consequence of this, I have decided to spend the majority of my last month in hospitals providing as much dysphasia training as I can, as well as working with those in need. Next week I have already booked training for the paediatric hospital staff where M passed away as well as with O.T/E.N.T/Paediatric staff at the other main hospital in Kisumu.

I’ll try not to end on a somber note - tomorrow, along with other speech therapists from Kenya, I shall be heading to Uganda for a 4-day conference - the East African Speech and Language Therapy Conference 2012. It will hopefully be a great meet where there will be guest speakers famous in the world of Speech Therapy but more importantly it will give the platform for the SLT’s in Uganda and Kenya to voice the work we are doing, difficulties we are faced with and hopefully have some good discussions about the future.

Lots of love,

Jon x

Top 3 songs played on Itunes shuffle whilst writing this:

1. The Weight - The Band
2. The Great Beyond - R.E.M
2. Suspicious Eyes - The Rakes

Christmas Catch-up

 HAPPY NEW YEAR EVERYONE!!!

As part of my extremely flexible new year’s resolutions I’m vowing to be a little more succinct and concise with my writing and as such am doing a quick holiday catch-up in the much favoured  written form of the slacker - the list!

As a pre-cursor to my next blog update I’m gonna try and get something off on Tuesday as I’m off to Uganda for the East African Speech and Language Conference 2012 (fancy sounding I know!) from Wednesday through to Monday. It’ll have some info of a proper Christmas/New Year miracle, a project I’m trying to get going and my plans for my last month here (time flies!).

Soooo here’s my last 3 weeks or so bundled into one easy package:

Highlights

1. Safari - Saw everything could’ve asked for and more! Plus camping out was lovely.

2. Wasabi - Weird eclectic reestaurant in Moshi (near Kilimanjaro) did Japanese food!

3. Feeling of sand under foot / Being submerged in water

4. Stone Town - Lovely rustic seaside town where you can lose yourself in the back alleys shopping around. Like Mombasa but nicer for my money

5. Breeze - Not commonly seen in Kisumu!

6. Stars - With no pollution across most of the locations on holiday (Safari, Zanzibar beaches) the stars were simply beautiful

7. Seafood - Makes a lovely change from the one and only fish available in Kisumu.

8. Learning to relax - I find it pretty hard to switch off and managed it a fair bit during beach time in Zanzibar. Mission success.

Lowlights

1. Long journeys being sat on my arse (24 hours on 2 buses in 36 hours for example)

2. Crazy expensive compared to Kenya

3. Hotel shower -  pretty laughable how little pressure there was and we ended up sitting on the floor underneath the tap doing some form of new fangled shower yoga

4. Vomiting; Other people - on the ferries and on the buses. Top prize goes to the elderly lady who vomited every 30 minutes or so non-stop for an entire 11 hour bus journey into a carrier bag and refused to get off the bus at the break stop to change her bag.

5. Tsetse/spider bite -  Itchy hot swollen foot for days and $80 doctor’s bill

6. Missing my family for Christmas

7. An alternative Christmas - was lovely being in the sun on a beach having BBQ etc.. but wasn’t exactly “Christmassy” for me!

I know I’ve said it a lot but a million thanks for all those who have supported me, sent me some kind words or visited my blog to read up on what I’m up to here and in general what’s happening SLT-wise in Kenya. 

Huge hugs,

Jon x

jonathanmlfagan@gmail.com

Top 3 songs played on Itunes shuffle whilst writing this:

1. Walk on the wild side - Lou Reed

2. Dragging me down - Inspiral Carpets

2. Bliss - Muse