We were allocated to the largest and most modern theatre with good air conditioning and 2 dedicated Orthopaedic scrub staff. Janet was again invaluable organising the equipment and often double scrubbing to teach the staff what to do.

We brought much more equipment with us and yet still it was not enough.

Last year there were plenty of sutures but even they were running low this year with the government reducing the budget for the hospital significantly.

Next time I plan to take with me anything I think I might need to use. This includes retractors, sutures implants etc. This will make teaching easier and more effective and allow more cases to be performed.

I have had some specific shoulder retractors made which will be left behind for the local team to use.

The clinic contained patients with shoulder, knee and elbow problems only. Several of the fractures were several weeks old, making their treatment very challenging. The elective cases ranged from recurrent shoulder dislocation to ACL tears and the trauma from fracture dislocations of the shoulder to a paediatric radial head malunion from an elbow dislocation.

Most patients had either interscalene, supraclavicular or axillary brachial plexus blocks with their general anaesthesia for post-operative analgesia.

We were short of prep, had no sterile plastics and every third case had to use a hand drill while the power drills were being sterilised. Having said that the staff were well trained, friendly and worked very hard.

The surgical wards are of the older style open plan type. Nurse to patient ratio is high, with one nurse allocated to thirty patients on a night shift.

Pain control is poorly attended to, as there is a general reticence to administer opioids on the ward for fear of addiction. It was disappointing to find not even any paracetamol administered despite it being charted. It may be that as the patients were pain free on return to the ward they were deemed low priority, even though pain after regional block dissipation can be quite severe.

As I said previously the registrars were much more interested in learning this year. I gave a total of 6 hours of lectures at various times, 1 of which was attended by Eddie McCaig who participated in the teaching. The topics were mainly basic joint examination, particularly of the shoulder and elbow, as well as injections and aspiration and techniques for diagnosis of septic arthritis.

There was coverage in the press regarding drug and equipment shortages affecting CWMH. These included bladder catheters and basic antibiotics. All elective surgery was cancelled for the 2 weeks after we left and no end was in sight for the problem.

The arthroscopic gear was not working so we did open ACL reconstruction instead but still achieved excellent results.

Our team was warm and welcoming and honoured us with a farewell dinner and night out. The experience, needless to say, was unforgettable.