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Facing Africa needs volunteers!

Dates of upcoming surgical missions to Ethiopia:-

  • May 2021: 7th – 22nd 
  • October 2021: 8th-23rd

Facing Africa surgical missions are made up of unpaid volunteers who spend 2 weeks in Ethiopia during which time 25 – 35 facial reconstructions will be carried out, mainly on noma patients but may include facial tumours, severe animal bites and trauma.

Facing Africa can only consider volunteers who are willing and available for the entire two weeks.

  • Plastic surgeons (2 – 3)
  • Maxillo Facial surgeons (1)
  • Cranio Facial surgeons (1)
  • Anaesthetists (3)
  • Scrub nurses
  • Ward nurses
  • Junior Doctors (8 weeks at Facing Africa House) (1)
  • Wound care nurses (8 weeks at Facing Africa House) (2)


Surgeons and anaesthetists must be consultant level.

Ward nurses must have good and long experience in wound care and organisational skills.

Scrub nurses should ideally have experience in head and neck surgery.

In addition to the main surgical team, one junior doctor and two nurses with considerable wound care (ideally head and neck) are needed for the pre’ and post op’ care of our patients who will be based at Facing Africa House just outside Addis Ababa for 8 weeks (two weeks prior to the arrival of the team and a further 4 weeks after the departure of the surgical team. Their job is to prepare the patients for complex surgery and to ensure that all patients are free of any complications or infections after their operations. These 3 volunteers are assisted by 6 Ethiopian nurses throughout the 8 weeks and are expected to teach the local nurses new and better techniques and procedures in wound care. See full and detailed 8-week wound care nurses manual at the bottom of the page.

All reconstructive surgery is carried out at the Nordic Medical Centre ( which is an extremely well equipped hospital which we started to use in May 2018. Facing Africa takes the bulk of its own drugs, medications, antibiotics, consumables, disposables and  an excellent stock of our own surgical instruments that are stored in Ethiopia between missions. Accommodation is provided for all team members (rooms to be shared by 2 persons) at the Tizeze Hotel (  ) located 50 yards away form the hospital.

How to apply

  • Ward, scrub and Cheshire nurses download, fill in and return this application form

Other volunteers must send the following:-

  • Up to date CV with relevant registration number and personal indemnity covering work abroad.
  • Nationality
  • Personal profile (age / marital status / country of origin)
  • Details of any overseas missions
  • Contact details ( postal address, phone numbers and e-mail)
  • Facing AfricaAnaesthetic fellowship application details

Volunteers are expected to inform their friends, family and colleagues of their commitments to taking part in any Facing Africa surgical missions and try to generate donations and sponsorship for Facing Africa. Also informing local and national press for media coverage. Most hospitals have their own PR officer who can also help with publicity and fund raising.

Wherever and whenever possible, contacts with hospitals, pharmaceutical companies and manufacturers of surgical equipment and consumables should be used to acquire donated items for the mission. All products must be “in date” as Ethiopian rules forbid the importation of out of date products.

Teaching Ethiopians

Surgeons, anaesthetists and nurses are also expected to teach local staff with regular presentations (short lectures and power point presentations) on surgery, anaesthesia, nursing, hygiene.

English is spoken by Ethiopian doctors, anaesthetists and surgeons. Nurses mostly have limited linguistic skills and must be guided and taught using very simple and short sentences. Ethiopians are keen and willing to learn better skills and new techniques.

Over the years that Facing Africa has been sending teams, we have acquired an enviable array of  equipment including  2 drill/saw (B Braun), 2 diathermy machines (Valley Lab), 3 fiberoptic scopes (Olympus and Stortz), 2 Glide Scopes, plates and screws and a wide range of surgical instruments (mostly B Braun).  The Nordic Medical Centre has a CT scan and binocular surgical microscope.

Each team member will be expected to send a written report to Facing Africa within 4 weeks of their return from Ethiopia.

What is provided by Facing Africa

  • Return flights from London or other European airports to Addis Ababa with Ethiopian Airlines in economy class.
  • Ground transportation throughout the mission
  • Accommodation at the Tizeze Hotel ( 2 persons sharing )
  • All meals (but not drinks, tea or coffee except at meals when Facing Africa pays for non-alcoholic drinks)
  • Basic travel insurance (unless already held)
  • One suitcase baggage allowance , not more than 23 kg.

Not paid by Facing Africa

  • Travel to and from home to airport
  • Optional week-end excursions in Ethiopia. The middle week-end (Sat & Sun) are free days when team members can opt to spend 2 nights at a lodge or visiting the ancient underground churches at Lalibela
  • Laundry while in Ethiopia
  • Personal phone calls
  • Visa for entry into Ethiopia (about £ 30)
  • Excess baggage over 23 kg

Husbands, wives, girl/boy friends

We are unable to agree to team members travelling with their loved ones, even if they offer to pay their own way, so please don’t ask. However, if you want to invite someone to join you in Addis at the end of the mission and extend your stay for a few extra days to visit other parts of Ethiopia, Facing Africa can amend your return flight accordingly.

Volunteer medical students

Unfortunately we are unable to offer places on our teams to medical students


Each team will ALWAYS include at least one surgeon who has previous experience of noma missions in Africa. Volunteers are welcome to apply from any country in Europe. Volunteers from North and South America, Australia or New Zealand are also welcome but will have to pay their own fares to Ethiopia.

Our missions are very much based on ‘team spirit’, so it is extremely important that everyone enters with the ethos of a team and not as an individual. Close co-operation and discussion between team members is critical, especially after the trip if and when complications or infections arise and are notified by the post op’ team at facing Africa House.

Junior Doctor and 2 wound care nurses – 8 weeks

Each mission also includes a doctors, usually a junior doctor and 2 nurses who have exceptional experience in post op’ wound care, who are required to spend 8 weeks in Ethiopia. Their function is to prepare all the patients two weeks prior to the arrival of the surgical team, carrying out screening, teaching basic hygiene, taking patients to the hospital for X-rays, CT scans , blood tests, preparing medical notes and observations etc. During the 2-week surgical period they have to organise transfer of patients to the hospital for their operations and then remain for a further 4 weeks taking care of post op’ wounds, infections, feeding etc. A total of 8 weeks. After the surgical team has left Ethiopia, the doctor and 2 nurses must communicate (by phone, WhatsApp, e-mail, Skype etc) with the surgeons and anaesthetists in the event of any complications or infections. The doctor must not at any time leave the grounds of Facing Africa House unless a replacement doctor has been appointed.

The doctor and 2 nurses will be based at Facing Africa House which is in the grounds of the Cheshire Rehabilitation Centre, located about 20 miles outside Addis Ababa in a rural countryside setting . They will have opportunities to spend occasional days at the Hospital watching and possibly assisting during surgery, but it must be clearly understood that Facing Africa has made an undertaking to have at least one qualified doctor at all times at the Cheshire Rehab’ Centre. Accommodation and meals are provided at the guest house within the Cheshire Rehabilitation Centre throughout the 8 weeks. Facing Africa also arranges for an Ethiopian dentist to spend the first 2 weeks at Facing Africa House to carry out basic dental care, scaling etc.

Theatre nurses – job description – 2 weeks

application form

This is an exciting opportunity for a registered nurse to gain experience working with the Facing Africa team in Ethiopia.

As a theatre nurse working at MCM Hospital in Addis Ababa you will be required to scrub and circulate for a variety of plastic, maxillo-facial and reconstructive procedures whilst anticipating the needs of the patients and the surgical team. During the two week mission, Facing Africa run two theatres simultaneously. The procedures undertaken include but are not limited to local flaps, free flaps, release of Temporo-mandibular ankylosis. Due to the variety and varying complexity of the patients who present to Facing Africa for treatment, you will need to be flexible and adaptable. Your role will also include the washing, packing and sterilization of the instruments in the on site autoclave; monitoring and rotating stock levels and educating the Ethiopian nurses about the procedures, current ‘best’ practice and patient safety (WHO surgical checklist, theatre counts ect). The Facing Africa team work very closely together in the pre operative planning, intra operative care of the patients and supporting the staff in the post operative care of the patients. The MCM hospital continues normal service during the mission which may require you to recover our patients or assist the high dependency nurses. There may be a requirement for you to cover on calls dependent on the condition of the patients.

OR at MCM Hospital

OR at MCM Hospital

IMG_6493 IMG_6739 IMG_8748 IMG_8906

Essential requirements:-

  • Registered Adult/ Paediatric nurse
  • Minimum 3 year post registration experience
  • Experienced in plastic surgery/maxillo-facial surgery/head and neck surgery although experienced nurses from other diciplines who feel they could transfer their skills will be considered
  • Up to date knowledge of Infection Control Practice
  • Good interpersonal skills with the ability to relate within the interdisciplinary team and across disciplines
  • Self motivated, uses own initiative and able to prioritise work
  • Ability to adapt to different hospital and country environment and be extremely flexible and reliable
  • Work well in stressful situations and able to respond effectively to challenging situations
  • Must be able to provide a Transcript of Qualification – this is a requirement of the Ethiopian Government (can be obtained from University or from NMC)
  • Physically fit – there will be an element of lifting/ moving heavy objects and long hours
  • Ability to teach good standards of nursing practice


  • Experience working in developing countries

Ward nurses – job description – 2 weeks

Application form

This is an exciting opportunity for a registered nurse to gain experience working with the Facing Africa team in Ethiopia.

As a ward nurse working at the Nordic Medical Centre in Addis Ababa you will be required to perform pre op’ assessments and post operative care to patients undergoing head and neck surgery. The types of surgery include submental flaps, free flaps, commisuroplasty and Abbe Estlanders.

The Nordic Medical Centre provides patient rooms with 2 or 3 beds during the 2 week Facing Africa mission. Your role will include educating the Ethiopian nurses about effective nursing care and the patients about the importance of good hygiene practice. Regular assessment of the post operative wounds and flap observations is essential. You will be required to provide clear instructions to the Ethiopian night nurses and ensure that the instruction are carried out efficiently. There may be a requirement for you to cover evening/ night shifts dependent on the condition of the patients. Each mission’s ward nurses are led by an experienced team leader.

Facing Africa is a non religious organisation which requires all volunteers to be open minded and not to try to involve patients or staff in religious activities, teaching or prayers.


  • Registered Adult/ Paediatric nurse
  • Minimum 3 year post registration experience
  • Experience in wound care (preferably head and neck)
  • Up to date knowledge of Infection Control Practice
  • Experienced in administration of intravenous medications and a good knowledge of post operative pain management
  • Good interpersonal skills with the ability to relate within the interdisciplinary team and across disciplines. This involves conveying instructions and teaching in simple English and questioning the Ethiopian Nurses to ensure they understand.
  • Self motivated, uses own initiative and able to prioritise work
  • Ability to adapt to different hospital and country environment and be extremely flexible and reliable
  • Work well in stressful situations and able to respond effectively to challenging situations
  • Must be able to work effectively as a member of a multi /national / cultural team
  • Physically fit – there will be an element of lifting/ moving heavy objects and often long hours
  • Ability to teach good standards of nursing practice
  • Computer literate
  • Must be able to provide a Transcript of Qualification – this is a requirement of the Ethiopian Government (can be obtained from University or from NMC)

Desirable but not essential:

  • Experience working in developing countries
  • Experience caring for patients post head and neck surgery

If you are interested, please send a copy of your CV including your NMC registration number, postal address, mobile/home/work phone numbers to:

20130206_100036-1 20130206_100036 20130211_103506 20130214_120344 IMG_4901 IMG_4944_2 IMG_9158


Ward nurse manual – 2 weeks

Facing Africa Staff in Ethiopia


  • Miss Selam Abera: FA Manager Co-ordinator
CT at MCM Hospital

CT at Nordic Medical Centre

IMG_0423 IMG_0477 IMG_0514 IMG_0547 IMG_0664 IMG_0704

The hospital is located in a relatively quiet part of Addis Ababa with easy access to many excellent restaurants. It is a privately run hospital and FA has exclusive use of  patient wards and two operating theatres during each of their missions.

Each patient should already be known to the hospital and have an NMC registration number. They should have a set of pre-op bloods and the patient’s infection status should be known prior to admission (Hepatitis B / Syphilis / HIV etc.) All X-Rays and CT’s should hopefully also be complete prior to your arrival.

Day 1 – The Big MDT (Saturday)

You will drive out to the Facing Africa House , Menagesha for a big MDT. The team that are already there (two British wound care nurses and a junior doctor) will present each case including history, previous surgeries, pre-op info, nutritional status and patient expectations. The surgeons will spend a couple of minutes with each patient deciding what operation they can do (if any) and whether they will operate this mission. Patients will also be reviewed by the anaesthetic team to assess airway management. Be prepared to see approximately 60 patients during the day.

IMG_4098 Surgeons selecting patients

Day 2 – Setting up (Sunday)

While the surgeons plan their operating lists you will be responsible for unpacking all the equipment at the Nordic Medical Centre. The theatre nurses will sort and prepare all the theatre equipment while you and the other nurses will prepare the ward for use. There should be a cupboard on the ward which you can lock medications in. All linen is sourced from the hospital.


Getting ready for Monday morning

A whiteboard will also be sourced from the hospital to write down bed numbers and patient’s names. The whiteboard is also a good place to document the following information as the ward staff do not have individual handover sheets:

Patient list on the ward at MCM

  • Nil by Mouth for Theatre
  • NG feeds
  • Fluids/soft diet
  • Removal of Drains
  • Any special post op instructions
  • Medication administration times
  • Discharge date

The use of the whiteboard can make it easier than having each nurse try and read through the patient records as the documentation is not overly user friendly and is quite repetitive.

Due to the Ethiopian calendar (see notes further on) previous trips have found it useful to document medications at the following times:

  • Paracetamol 6am, 12md, 6pm, 12mn
  • Diclofenac 8am, 2pm, 8pm
  • Augmentin 8am, 2pm, 8am

These times fit with both the Western and Ethiopian clock (minus the am/pm!) This regime also allows the majority of the medication to be given by the day staff, particularly the antibiotics and the anti-inflammatory drugs.

Patients do not tend to ask for pain relief (Ethiopians are very stoic) so it is good to encourage the Ethiopian Nurses to give analgesia regularly.

Day 3 onwards (Monday)

Theatre starts on the Monday and the first patients will have arrived on the Sunday afternoon. All pre-op patients arrive the day before due to heavy traffic in the city centre. The majority of the ward work will be:

  • Hygiene and cleanliness
  • Pre-op admission
  • Observing Vital Signs
  • Medication administration
  • NG feeding or encouraging of oral diet
  • Arranging meals for both patients and guardians of children
  • Wound care and drain removal
  • Some physiotherapy
  • Discharge

Oxygen can be sourced in the hospital for the ward.

All patients will arrive with a muslin provided by Facing Africa which they can wear to cover their faces. There will be a spare stock of muslins on the ward so that these can be changed every day and Terry will take the dirty muslins for washing.

New Admissions

As previously mentioned new admissions will arrive the day before surgery in the afternoon, after they have had lunch at the Cheshire.

  • Registration

Each patient will need to be registered and admitted to the ward (even if they have previously attended MCM). This can be done at MCM reception.

  • Consent

Each patient needs to be consented for theatre. The consent forms are written in Amharic and completed by the Ethiopian nurses, usually those working the night shift. It is important to note that the surgeons do speak to each patient about their operations via an interpreter, but this is not always at the same time the consent form is signed.

  • Baseline observations are taken


Each page needs to be headed with the patient’s name. The admission sheet should be filled out at this point and documentation should be started in the Nursing Record.

MCM Admission Paperwork:

  • Consent
  • Nurses Admission Data

With Nurses Discharge Summary on the reverse

  • Admission Summary

With Physical Examination on the reverse

  • Vital Signs
  • Medication
  • Nurses Record
  • Doctors Order


Complete the Nurses Discharge Summary with the following information:

  • Current medications (supply TTOs for the full course of antibiotics to be completed at the Cheshire)
  • Specify diet type e.g. soft diet
  • Any wound instructions e.g. when to remove sutures

Photocopy for the Cheshire:

  • Nurses Discharge Summary
  • Doctors Order (Post Operative Instructions)
  • Anaesthetic Chart
  • Operation note

A Ward Inventory will also need to be completed for each patient at the end of the mission stating what stock has been used to allow FA to bring in the number of supplies required through customs in future missions.

Wound Care

One of the most important aspects of the nursing role is the post operative wound care. Dressings will need changing on a daily basis, more frequently if high levels of wound exudate.

Wounds need to be cleansed with normal saline and a suitable wound disinfectant such as savlon or chlorhexadine.

All suture lines should have Chloramphenicol applied and then dressed with gauze as required.

Jelonet and other non-adherent dressings are available for more complex wounds such as graft and donor sites.


You should have 2 Ethiopian nurses during the day with you and 2 Ethiopian nurses will be on duty at night. During the day is a great time to share your skills and knowledge with the Ethiopian nurses who are generally enthusiastic and keen to learn.

The Ward Team Leader will arrange the nursing schedule dependent on the needs of the patients. You will need to be flexible as you may be required to work split shifts/ evenings and on occasions night shifts.


The MCM guest house is situated within the hospital grounds and a few members (if not all) of the team stay here. The apartments have small kitchens and some have laundry facilities which you can access. There is a communal dining room where you can get a Korean style breakfast each morning. If you prefer you can buy your own bread and cereals from local stores to have in your apartment. If, as has happened on the last few missions, the MCM guesthouse cannot accommodate the team, then you will be accommodated at a nearby hotel.

Lunch is provided in the hospital. Theatre staff have a buffet style lunch in the Theatre coffee room, ward staff can either share this food or go separately to the canteen with meal vouchers.

All meals are provided by Facing Africa. In the evenings the team goes out to dinner at a variety of different restaurants (Italian, Indian, Chinese, French, Greek, Turkish and Ethiopian). This is a chance to wind down from the day and get to know the other members of the team. If you are feeling tired at any point during the two weeks a take-away can be arranged!

Bring some warm clothes as it does get chilly at night due to the high altitude!

Things to bring:

  • Laptop (not essential but you can connect to Wi-Fi  at MCM Hospital and email home more easily)
  • Photos of home and family – it’s a great way to overcome communication barriers with patients.
  • Colouring books and crayons for the patients (young and old!)
  • Pen Torch (for examine inside the mouth)
  • Book (for the odd quieter moments if you get any!)
  • Torch (for power-cuts)
  • Swimming Costume (you can swim at some of the hotels in Addis)
  • Alcohol gel
  • Towel (local towels are usually threadbare)
  • Duty free booze if you enjoy an occasional tipple
  • Mobile phone for texting home (international phone calls are expensive from Ethiopia).
  • Camera

The Bigger Picture:

Facing Africa in Menagesha

The patients will spend at least 8 weeks under the care of Facing Africa each mission. They spend the majority of their time at the Facing Africa House on the site of the Cheshire services in Menagesha.

A brief overview of the patient journey is as follows:

  • Week 1 & 8
  • Patients arrive at FA House, Menagesha for pre-op screening, dentist review & nutritional build up
  • You and the surgical team arrive, assess patients and construct an operating list
  • Patients attend MCM hospital for surgery and immediate post op care
  • Patients return to FA House, Menagesha for further wound care and nutritional input until their wounds are fully healed, free of infection and complications. 

Cheshire Services

The Menagesha Rehabilitation Centre is Cheshire Services’ largest centre. Here up to 70 children under the age of 16 who have suffered from Polio undergo residential orthopaedic and social rehabilitation. The home also has an outpatient’s centre for adult patients and a workshop where orthopaedic shoes, leg braces and prosthetics are produced on site for patients by skilled staff.

Ethiopian Time/Date/Year

Please be aware that Ethiopia has its own separate calendar, date and time. The year is 8 years behind ours (so 2019 is 2011 in the Ethiopian Calendar). There are 13 months running from September to August with the thirteenth month having just 5 days. Finally, each day starts at 6am rather than midnight. Therefore 8am is actually 2 a.m. and 6 a.m. is 12 . The nurses can struggle with documenting dates and time because they are more accustomed to their own time and calendar; hence the suggested medication times.


There are over 80 different languages in Ethiopia. The most common 2 you are likely to come across are:

  • Amharic
  • Orimifa

You will need to pick your nurses for translation carefully as not all of them can speak Orimifa. Often other patients will help out (this is not seen as a breach of confidentiality here and most patients do not mind being open about their health status). However these communication barriers can be challenging.

When speaking to Ethiopian nurses, it is essential that you speak slowly, clearly and refrain from using English colloquialisms. Only use simple words and always look at their eyes when speaking to them as you will see from the look in their eyes whether they have understood or not. It is often worth repeating what you have said using different words just to ensure that they have understood. They will often nod their heads or say yes, yes , yes…when in fact they have not understood, so please make a big effort to communicate in ways that you are sure they have understood. Misunderstandings can lead to serious problems and complications.

Previous missions have been known to have patients who originate from Somalia. This can prove a bit challenge with language.

Working with the Ethiopian Nurses

The Ethiopian nurses are really friendly and keen to learn. They will need plenty of encouragement and guidance to ensure the FA patients receive the best care that you would expect from the UK. They work well when given instructions as it can take time for them to do a task without being asked. They are not used to using a great deal of initiative and tend to wait to be told what to do.

Post-Operative Care

The types of surgery you may see are:

Plastic Surgery

  • Radial Forearm Free Flaps
  • ALT (Anterior Lateral Thigh) Flaps
  • Submental Flaps
  • Turnover Flaps
  • Abbe-Estlander Flaps
  • Modified McGregor flaps
  • Commissuroplasty
  • Nose reconstruction (using cartilage / bone)
  • Genioplasty
  • Debulking of neurofibromatosis

Ankylosis Release:

  • Coronoidectomy
  • Condylectomy
  • Costochondral graft


At present there are no current guidelines or protocols with regard to physiotherapy following trismus release. There is however a physiotherapy department at MCM which can be accessed for advice and a treatment plan if needed.

Dr Einar Erikson

After you and the surgeons leave for the UK, the patients remain at the Facing Africa House for up to 4 weeks and receive daily post-operative wound care. Although the surgeons can be contacted by email, phone, WhatsApp or Skype at any time, Dr Kjell (CEO and Medical Director the Nordic Medical Centre)  is the main link that patients will be referred to if any concerns arise. Dr Kjell is a very experienced and skilled surgeon and has worked with Facing Africa and the UK surgeons for several years. He will gladly see any patients whom there are concerns about and he also performs minor secondary procedures as required.

Nurse Report

You will be expected to produce a report outlining the running of the ward during your stay and the work that you have done. The report is also an opportunity to state any problems you have experienced, how they have been resolved and any suggestions you have for the future. These reports should be sent to Chris Lawrence ( ) soon after you get home.

Packing Away

The ward will need to be packed away at the end of the mission and left in the condition that you found it in. Please take the time to make any suggestions to Chris and Terry for extra equipment that would be beneficial to future missions.

We hope that you have found this manual useful when working for Facing Africa. Please update this manual at the end of your stay with any additional information or changes to help the next team. Thank you.

Finally….always remember that you are in Africa where bureaucracy rules, where standards are different from those at home, where culture is very different, communication is often difficult, superstition is rife (some of the patients you will see will have been treated at some stage by traditional healers in their villages using very unorthodox healing methods), traffic is confusing, animals are treated badly, eating habits are unfamiliar, poverty is extreme and you will see this every time you step out of the hospital, begging is common, life is hard….few Ethiopians know what the word holiday means (other than religious holidays). But in spite of all the hardship most of them endure, Ethiopians are warm and friendly, their smiles are infectious and incredibly warm, they speak in hushed tones and you will rarely hear an Ethiopian shouting. They tend to be shy and show little curiosity in anything other than what to tell them. They dont probe or ask awkward questions.

Ethiopia and especially Addis Ababa is a safe country. In spite of what you may read on the internet about political troubles, there is no kidnapping or terrorism in the capital (that only occurs hundreds of miles away near Somalia and Eritrea). It is safe to walk in the streets, though at night we go out as a group and generally go by taxi or mini-bus. Pickpocketing exists in crowded places, as it does in London, New York, Paris or any other major city, so beware. Do not lean out of a car window with your mobile phone or camera as this can lead to it being snatched.



8 week Voluntary Nursing Project

Application form



Introduction:                                                                                                        p. 3

Staff, location & facilities                                                                               p. 4

The Mission

Stage 1: Patient Admission, Assessment and Screening              p. 6

Team working

(Onsite, Offsite & Inpatients)

Promoting Health: medical assessment and screening                              P. 8

(Admission, Assessment & Clinical investigations)

Personal & oral hygiene                                                        p.10

(Hand washing & Health Promotion)

Nutrition                                                                              p.12

Organization and Play

(Administration, Bed management,

Communication & Safety, Stock control,

Laundry and cleaning)

Stage 2:  Selection at Presentation Day                                               p.15

Stage 3: Surgery                                                                                              P.17 

Stage 4: Post Operative care                                                                   p.18

Pain Control:

Prevention of post-operative infection

Wound healing

(Preparation, Assessment, Teaching, Treatment &


Oral hygiene and mouth exercises


Discharge Planning                                                                                            p.23

Further Reading                                                                                             p. 26


Introduction: What’s involved 

 This manual is a developmental document. It builds on the experiences of nurse volunteers who have been involved in Facing Africa (FA) in Addis Ababa over recent years.  It is written to consolidate their participation as members of the Facing Africa team, in achieving positive surgical intervention for Noma survivors who present for facial reconstructive surgery.  It functions as guidance to assist both

  • An enquiring nurse to decide if they are a suitable volunteer with the required skills and commitment to support a Facing Africa mission
  • The selected nurse understand their role and prepare for the mission

From Decision to Action:

Once you decide to apply to Facing Africa, if shortlisted, you will be invited to talk to a nurse who has previously participated in a mission. The nurse will assist you with any further questions you may have.

For interest you need to be aware Ethiopia has its own separate calendar, date and time. The year is 8 years behind ours. There are 13 months running from September to August with the thirteenth month having just 5 days. Finally, each day starts at 6am rather than midnight (8am is actually 2am.) For the purposes of the mission and administration, the world time zone is accepted and used respecting that at times there may be some confusion and it’s often best to use events rather than time to detail expected activity e.g. before or after breakfast, mid morning snack time etc.

Should you want to learn about some national vocabulary you can download free

FSI Amharic: Amharic Basic Course Student test units Vol. 1& 2

Amharic Basic course audio

Remember to seek your own health advice and travel insurance. Book an appointment with your travel nurse. There is no malaria in the region however there are a lot of mosquitoes so remember insect repellent.

If accepted you will need to send your passport details (scanned copy) to the Facing Africa office so they can book your flights. All flights are from London Heathrow.

A letter of invitation will be sent to you so you can apply for a 3 month visa. This usually takes approx. 7 – 10 days and will be your responsibility & at your own cost:

Staff, Location and Facilities

Facing Africa Staff UK

  • Chris Lawrence: Chairman/Trustee
  • Terry Lawrence
  • Dalia Kuoraite
  • Angus Mack

Facing Africa Staff (Ethiopia)

Administrators based in Addis Ababa:

  • Selam: FA Country Representative
  • Wassi: FA Patient co-ordinator & translator
  •  Facing Africa Nurses (on site at Facing Africa House):
  • 5 or 6 Ethiopian Nurses

The nurses work as follows:

  • 2 nurses during the day (including weekends)
  • 1 nurses at night

Generally, the Ethiopian nurses work 2 or 3 night shifts in a row and aim to have their days off in a row as well, but this can be altered to meet individual circumstances.


Facing Africa House is based at:

Cheshire Services Ethiopia

PO Box 3427,



Facing Africa House is situated in the 30-acre grounds of the Cheshire Services, which is located in beautiful countryside surroundings just outside the town of Menagesha, approximately 45 minutes drive from Addis Ababa. The Cheshire grounds are within a very secure and peaceful enclosure that has it’s own security guards. There are footpaths and cultivated flowerbeds, open grass play areas as well as meadowland and forest. You will get used to seeing the monkeys, deer, giant tortoise, donkeys and cattle onsite, and at night hearing the hyenas.

Find out more at

You will be invited to meet the Cheshire Staff and be encouraged to integrate Facing Africa and Cheshire patients in play and educational facilities offered on site.

Cheshire staff

Gebramedhin Bekele: Executive Director

Mr Kedir:  Manager (who you are more likely to correspond with)

Feleku: Manages the Cheshire Kitchens and Housekeeping

Facing Africa Facilities

Facing Africa House comprises 4 main building.

  1. A kitchen/dining area with adjacent toilet and hand washing facilities.
  2. An 18-bed building comprising two 9 bed dormitories and shower and toilet facilities either side of a central Dr/medical room
  3. A new 24-bed building comprising two 12-bed dormitories and adjacent shower, toilet and open sink area.
  4. A building that has a storeroom, treatment room (dental treatment and wound care dressings) and a new laundry.

The dining room and dormitories are all ramped with open verandas and face a central lawn play area

Any extra patients/relatives can be housed in various other buildings either in or around the Cheshire site.


The guesthouse is situated a 3 minute walk away from the Facing Africa House, within the Cheshire grounds. There are three single rooms each with en-suite toilet/ shower and a kitchen/dining/lounge room where a dedicated member of Cheshire staff prepares all your meals. You will have your own individual key to your room and shared access to the kitchen/dining/lounge area. Bottled water is available and we learned that patients really appreciate your empty bottles.

It is important to bring plenty of warm clothes and a hot water bottle, as it does get cold at night due to the high altitude! You will be provided with fleece blankets. It is also advisable to bring a torch as there are frequent power cuts.

You will be given an Ethiopian mobile phone to use during your stay . There is a Facing Africa desktop computer available or you can use your own laptop. This enables you to keep in regular contact with Terry and Chris by either email or phone. They will always phone you straight back if you send them a text. You can also keep in touch with your families.

There is a television and DVD player in the dining room and a selection of books left by previous volunteers.

Staff guest wing at Cheshire Home

Staff guest wing at Cheshire Home

IMG_3819 IMG_3825

The Mission

The mission is eight weeks and divided into four stages:

  1. Admission, pre-assessment and screening: Day 1-14
  2. Selection: Presentation day 15
  3. Surgery: Day 16-28
  4. Post- operative care. Day 18 – end of mission day 54.

Stage 1: Patient Admission Pre-Assessment and Screening:

Prior to your departure at Heathrow you will be met by Chris and briefed about the mission. You will be given details as to the category and number of patients you will be expecting on arrival. Facing Africa House officially opens on the day of your arrival however the Ethiopian nurses will already have opened the house and patients will have arrived or be arriving. The first two weeks of your stay is devoted to patient pre-operative assessment. While the overriding aim of the assessment is to prepare a PowerPoint presentation for the acute surgical team that will be arriving in two weeks time to select patients for surgery: It is equally important to focus on the sub-components parts that are required to achieve this. We identified these to be

  1. Team working:
  2. Promoting Health: medical assessment and screening.
  3. Personal & oral hygiene:
  4. Nutrition:
  5. Organization and Play:
  6. Teaching for Ethiopian nurses on hygiene and wound care and management to prepare them for the weeks post op.

The main purpose of the pre-assessment phase is to settle the patients and work effectively together to promote their personal health, hygiene and nutritional status and exclude or treat any underlying medical conditions that may compromise an effective surgical outcome.

A. Team Working:

Everyone involved with Facing Africa House have an important role to play to achieve a positive outcome for the mission. The larger team includes the visiting surgical, anaesthetic and ward nursing teams that are based in Addis. We will discuss their role further in the Patient selection phase.

On-site team

The onsite team involved in patient assessment in the initial two weeks are

  • Ethiopian Nurses
  • 2 nurse volunteers
  • Ethiopian Dr
  • Ethiopian dentists

Off-site team

Between missions patients are primarily found by Gez, who travels out into rural communities with posters to try and raise awareness of the condition amongst Ethiopian communities. These communities can then lead him to affected individuals who can be offered assessment for treatment.  The FA Coordinators are there at all times to support the mission and resolve any problems prior to the surgical team arriving. They will meet you at the airport and take you to Facing Africa House.


The patients admitted are classified by clinical presentation and supporting organization

  • Returning Noma FA patients
  • Returning Project Harar patients
  • Returning other FA patients
  • Returning other Project Harar patients
  • New Noma FA patients
  • New Noma Project Harar patients

Patient ages may range from 4-75 but age is not a reliable indicator, as date of birth is rarely known.  Regional location and language is more often attached to identify patients. As Ethiopia has around 84 languages, facilitating translation with staff and patients is a priority and it is common practice for patients themselves to act as translators. Most patient, are Christian orthodox, protestant, or Muslims and all integrate together. It is important to distinguish anyone choosing to cover their face for religious rather than stigma reasons. During the October mission it is good to be aware of the dates of Eid al-Hada, a Muslim religious holiday.

Many patients may not be used to exposing their faces but at facing Africa House they are encouraged to integrate together and support one another. However, when they travel into Addis Ababa for clinical tests you will find they cover themselves up and can be stared at so it is important to find them discreet locations e.g. there is an enclosed courtyard within the grounds of the Korean Hospital (MCM) where they can feel comfortable rather than placing them in main public waiting area. We have muslins and hats for the patients to wear for hygiene purposes and for protecting their dignity and privacy.

As there are both returning patients and new patients you will find that they naturally make friends and support one another. They also assist each other with the routine and translation so that everyone knows what is happening.  We found the patients very compliant and also not afraid to tell you of any concerns they may have.  Much can be communicated in gesture and there is usually someone available to translate. Should there be no-one available, everyone in the team will be aware of this and a translator or member of the family located to assist.  You will need to respect a communal/cultural element regarding confidentially as part of your working day. However, issues of informed consent are taken individually and if there are any concerns in this respect, operations will be deferred.

All children and young people under the age of 18 are legally required to have a parent, guardian or responsible adult to sign their consent form on the day of surgery.  For some patients, whose relatives were unable to come, Gez was able to sign the form as their responsible adult.

B. Promoting Health:  Admission/Assessment and Clinical Investigations

Every patient has both a Facing Africa number and an MCM number. The Facing Africa numbers are presently being replaced by a new system as a computer database is in development.

We found on site it was very important from the beginning to develop a system of filing so that you and any member of the team can locate the file of every patient and how they are progressing through their assessment and treatment. It is very difficult to find patients previous files and some patients may have more than one.


You will find approximately 70 admission packs already prepared for your arrival and you will need to replace these admission packs at the end of the mission so they are ready for the next team.

Within the admission packs there are the following forms,

  • Nursing Registration form that includes patient identifiers, personal information along with baseline observations and personal processions on arrival.
  • Medical Examination form includes full medical assessment and examination, NOITULP (this is no longer used by the surgeons), functional and psychosocial assessment and plan for laboratory testing.
  • Dental examination and treatment form
  • Consent for photography form (every patient needs to sign one of these so that Facing Africa can use the photos)

You will be able to incorporate the new admission notes into the old files of returning patients. It is also advisable to number each patient file according to an agreed order so that files can be located throughout the entire 2-week pre-assessment phase until the PowerPoint presentation is made. We chose to do this according to the briefing order we were given at Heathrow


We found the most effective approach to assessment was to divide each of the three component parts of the admission assessment between each responsible professional.

The Volunteer nurses worked with the Ethiopian nurses to collect the personal information and record the following:

  • Vital signs: TPR & BP, Height/weight and BMI
    • Urinalysis & Pregnancy tests for all women
    • Take photo’s: Profile and side +/- Trismus

To do this you need the following equipment: Tape measure, scales, BMI chart (adult and child) sphygmomanometer including adult and child cuff, stethoscope, thermometer and cleaning agent, urinalysis and pregnancy tests, tongue depressors, pen-torches and a camera.

We found the best location for this was the dining room with a separate outdoor area outside on the veranda near the toilets to test the urine.

Patients are then directed to the Doctor room for their medical assessments and then to the treatment room to be assessed by the dentist. At the end of these 3 assessments it is known what medical investigations and dental treatment will be required for each patient.

Clinical investigations:

Pre-assessment clinical investigations are usually carried out at the MyungSung Christian Medical Centre (MCM) Korean Hospital, a private healthcare organisation, in Addis Ababa used by Facing Africa for surgical procedures. There are frequent problems with x-ray or CT not working at MCM so we used the Wudassie Centre which gave a very efficient service. If you need to a centre other than MCM for investigations please liaise with the Project Coordinator to arrange payment.

Routine blood tests requested are for every patient are CBC, Blood Group, INR, HBsAG & RIV (HIV).

Further urinalysis is required for positive samples.

Chest X-rays and CT are individually requested.

(ECG & Cytology is available but we did no use this)

Returning patients will have already been registered, some may have a registration card but if not, their personal number will be available on their old records or on your brief. New patients will need to be registered. We would recommend that you meet with or contact the MCM Facing Africa coordinators before starting to formulate plans to visit MCM. They are based in the Chief of Nursing Services office and by keeping in touch with them you will ensure your requests can be facilitated. You will need to give them a list of the patients, their MCM number and the tests they are having. They will register the patients on the system and provide ID numbers for new patients. To register a new patient they will need the following information:

  • Name,
  • Gender
  • Age
  • Contact telephone number

Bills will be generated for you to sign that can be paid directly by facing Africa. Gez will collect results for you during the week. It is important these are collected and incorporated into the presentation before it goes out to print.

The Laboratory and radiology facilities are in close proximity to the Nursing office and the dining room where you can purchase breakfast for the patients.  There is also an enclosed courtyard with tables and chairs where the patients can eat in private. It is essential to leave early for MCM to avoid delays in traffic. It is also important to remember water bottles and tissues in case patients drool.  We found that on all these visits to MCM, also for post op reviews, taking along a laptop on which to watch movies was very useful as often you could end up waiting several hours to be seen.

C. Personal hygiene:

On admission all patients participate in a clothing exchange whereby their personal clothing is exchanged for Facing Africa clothing. This consists of clothing items e.g. tracksuit and T-shirt with additional jumpers for the cold evenings. Shoes, underwear and pyjamas are also issued along with personal toiletries. Muslins (cotton replacement headscarf) are also available for patients who choose to cover their faces and hats for them to wear when it gets chilly. A registration checklist of all items issued to each patient is placed in the patient notes. This details, orientation, Patient ID, and provision of:

Bowl, pants, t-shirt, jumper, trousers, pyjamas, socks, shoes, towel, bathing soap, tissue paper, nail clipper, nail brush, slippers, toothbrush, toothpaste and sanitary towels. Shampoo and hair oil is shared between small groups and washing powder for personal clothing to be washed before being put away.

Patient’s personal clothing is bagged and labelled and placed in the storeroom out of the way. Valuables can also be locked away here and a receipt given by Kessmie. Facing Africa patient clothing is washed daily by Cheshire staff and organised by size on the shelves in the laundry room to be re-issued as required by the Ethiopian nurses.

The purpose of the bowls is to place all the issued personal items and store them under the bed neatly in the dormitories. Clean sheets, pillowcases, and bedspreads are also provided and changed regularly which will be monitored by the Ethiopian nurse on duty. We found that beds often were not being changed as regularly as they should, so instigated a system for male and female bed sheets to be changed on alternate days. A thick blanket is also provided for each bed. Bed spreads to be changed only when dirty. This does need to be checked up on, to make sure it is actually happening.

It may seem institutionalised to issue what appears to be a uniform to the patients but it enables them to integrate equally with each other and develop good hygiene habits from admission. These hygiene habits are essential to enable them to cope with their post-operative wounds and prevent infection.

Oral hygiene:

During the first few weeks the patients have dental assessments and treatment. The dentists also start giving daily mouthwashes after the evening meal. Mouthwash is difficult to obtain in large quantities in Addis. Soluble tablets are the most efficient and cost effective form but may not be as therapeutic.

The aim at this stage is education and discipline in relation oral hygiene and teeth cleaning. A course of prophylactic antibiotics will be given to patients that have dental extraction to prevent infection prior to surgery.

Hand washing and health promotion

The importance of personal and oral hygiene can be reinforced at a health promotion talk that all patients attend during the first few days of admission. During our mission this talk was cascaded to all patients with the Ethiopian staff and in-patients themselves acting as a translator to ensure everyone was included.  We got them to draw posters of how and when to wash their hands and then displayed them in the dining room. One of the tasks of the Ethiopian nurses is to check all the sinks every day to make sure there is soap and clean towels.

4. Nutrition


One of the Aims of facing Africa is to build patients up nutritionally.

Patient’s meals are prepared in the main kitchens over at the Cheshire and are carried over to serve from Facing Africa kitchen at breakfast, lunch and dinner. Cheshire staff prepare and serve this food.

Facing Africa nursing staff provide additional snacks during the day to help increase oral intake. A rough guide to snacks is:

  • 10:00 Bread and peanut butter with fortified milk
  • 15:00 Banana’s with tea
  • 20:00 Biscuits with milk

Biscuits as the last snack of the day as they do not involve any preparation as there is only one nurse in the evenings. Gez buys and delivers fresh bread and bananas on his daily run to Africa House from the Facing Africa budget. The patients often decline the peanut butter, so this is something that needs to be encouraged. For those patients with low BMI’s we introduced banana milkshakes (made with milk, bananas and honey) which we gave in addition to their other snacks, twice a day.

Breakfast can be bought at MCM for patients who will miss this due to leaving the site early for blood tests, x-ray or CT. Patients also have preferences and after a week you may need to review their diet and times of food. Any concerns can be shared and resolved with the providers at Cheshire.

Dietary intake is also supplemented throughout the 8 weeks by daily multi-vitamin tablets given at Lunchtime. All patients are given Anthelmintic medication.  Albendazole, 400mg as a single dose (This can only be administered to females after a confirming a negative pregnancy test.) As everyone receives these two medications and they are dispensed by the Ethiopian nurses they are not documented on a drug chart but recorded on their own in-house records.

5. Organization and play:

Staff organization and patient play is  vital to an effective mission. The more organized and prepared you are the more you can relax with and enjoy spending time with the patients so winning their confidence in you.


Administration can take the form of paper records, electronic records, information boards, diaries, notes, verbal handovers, team meetings, reports etc. At present there is no consistent collation of information that is shared between the Ethiopian staff, volunteer staff and Facing Africa. To resolve this we are going to try and introduce a handover sheet for use on every shift.

Bed management:

We maintained two white boards in the Dr’s office to demonstrate where patients were located.  These white boards updated daily were useful reference and guide for both volunteer nurses and Ethiopian staff. Personal details e.g. date of admission or post-operative day and type of surgery, date of return to Cheshire, and other comments can be appended to each individual listed. As patients are admitted to MCM remaining patients can be relocated to create post-operative bays, near the Doctors office so as to be nearer to the nurses at night. In future it would be hoped that Facing Africa moved towards an integrated system of administration and bed Management.

Communication & Safety:

Teamwork depends on an open honest communication between colleagues to establish trust. It is important to discuss how misunderstandings will be resolved at the beginning of the mission and also to identify that language limitation and cultural values of different staff may create misunderstandings.  Only issues that have been raised with colleagues and unresolved on the ground floor should be taken higher unless of course an injustice has occurred or there is an imminent threat to the wellbeing of a patient or member of staff.

All staff members have mobile phones. However there is often a poor signal and at night it is not safe to walk unescorted onsite. Establishing a landline or using walkie-talkies between Africa House and the Guesthouse has been recommended so that in the event of an emergency staff can remain in contact during the night. It is also very important to carry a torch in the event of power failure. Each team can establish its own on-call response.

Stock control:

Facing Africa House has a large storeroom that stocks everything required for the mission and stores everything left between missions. There are lots of bags/ boxes in the storeroom ready to go to MCM to be used by the surgical team. Up until these bags are removed your ability to organize the storeroom will be compromised. These bags are usually black and are taken to MCM prior to the arrival of the surgical team leaving you time to organize your working space.

Be aware that any excess items not required at MCM will be returned to the storeroom. It is helpful to check this stock so that there is no unnecessary duplication of stock and replacement items can be requested. Do not pack away anything brought to you in green bags. The green bags are returned to the UK to be filled with surgical supplies for the next mission. As the storeroom is also used to stock items by Project Harar who use Africa House between the January and October Facing Africa Missions, it is helpful to keep their items separate. Only Kessmie and the volunteer nurses have a key to the storeroom throughout the mission. The surgical team will return all unused stock on the review day before departure. At the end of the mission you will need to pack away all facing Africa equipment into the storeroom. There are filing cabinets available to lock away Drugs and the keys can be returned with you to the UK to be give to the nurses leaving on the next mission

Laundry and cleaning

Currently FA employs one lady to do all the washing which is now done in the new laundry room where there is now a fully installed, functioning washing machine and dryer. The power supply has been upgraded so these machines can be operated at the same time, except when there is a power cut, which often happens in the afternoon. Cheshire staff clean the dormitories, toilet and shower areas and dining room. The Ethiopian staff and the patients are all involved in maintaining the dormitories. You will find the returning patients support the new patients integrate and the dormitories are very clean and generally uncluttered pre-operatively. Post operatively patient need more support from the Ethiopian nurses to maintain environmental and personal cleanliness.

Disposal of rubbish: All clinical waste must be bagged and placed in the rubbish bin, and Cheshire staff will take this rubbish away to be burned. Please check that the rubbish is not being dumped behind the buildings and left to collect, but is burned promptly.


Play is a very important part of a patient’s day. Games can be played on the lawn e.g. football, volleyball, tennis, badminton and Frisbee. Table tennis can also be set up. Cards games are very popular as are crayons, drawing books, plasticine and playdough. Children may not know how to take care of items as some may not have experienced using them before so it is important to help them put them away. Soft toys can be a comfort to all ages. The patients enjoy music and demonstrating their traditional dance.

Play can be staged according to the patient progress through the stages of the mission. There is a TV and DVD player in the dining room. Patients enjoy you taking photographs so long as they can see the photographs you have taken of them. The patients will explore the site and integrate with the Cheshire children and their activities.

Coffee Ceremony:

This is a traditional gesture of welcome that everyone can participate in. An area surrounding an open lit stove is decorated with flowers. Coffee beans are roasted and ground to make a fresh brew that is distributed black and sweetened in small cups.

Stage 2: Selection at Presentation Day

This stage is a culmination of all the work that you have done in Stage 1: Admission, pre-assessment and screening. In the preceding week you will have collated all your information onto a PowerPoint presentation that can be both printed and projected on presentation day. The purpose of presentation day is patient selection for surgery. It is carried out in the round meeting room at the Cheshire site on the day the surgical and anaesthetic teams arrive in Addis.

A PowerPoint template is available to you so all you have to do is prepare the required information and then present the patient for assessment and selection. This is a team effort.

The presentation details some general information and then has a slide for each individual patient. The slides are presented in a pre-numbered order that will become their operating number if they are selected. The presentation reviews returning Noma patients (both Facing Africa and Project Harar) returning other patients (both Facing Africa and Project Harar) followed by New Noma Patients  (both facing Africa and Project Harar)

An individual slide per patient will contain the following information:

  • Disease e.g. Noma + age of onset
  • History
  • Details and date of previous surgery
  • Problems with eating/drinking/speech
  • Any Patient concerns
  • BMI
  • Blood results
  • X-Ray/CT/ECG
  • Dental Information
  • Pre-op photographs

For the presentation and selection to proceed swiftly it is useful to have the following items available:

  • Alcohol gel
    • Box of non-sterile glove
    • Tongue depressors
    • Pen torch
    • Cm measure for Trismus

This is not a formal event and in fact can appear chaotic. The PowerPoint presentation can be shown on the screen while the patients are being examined.  Nobody is required to talk through the presentation. Provide printed copies of the presentation as well, so that members of the team can take notes about individual patients. During our presentation day the team divided into two, one a group of surgeons who assessed if they could operate, the second a group of anaesthetists who assess for anaesthetists and started considering intubation techniques.

There will also be patients who will arrive on the day, some for review and others simply because they have heard that the doctors have arrived. Often those expected to come on the day, do not arrive but many others will. It is helpful if a coordinator can summarize and disseminate the team conclusion in respect of each individual.  Patients can be classified as following:

  • Listed for operation
  • Discuss prior to decision
  • Discharge post review
  • Defer to another mission
  • Dental only
  • Refer to another service

Presentation day can be very stressful for the patients. They are exposed to many faces looking, photographing and examining them. As assessment proceeds very rapidly it is helpful if patients can be prepared for different options in respect of possible surgery. Support from the on-site Dr and Nurses assisted by translators is very helpful in this respect to clarify why a decision was made not to operate or defer to another mission.  This translation should be done on the day by the doctor and Ethiopian nurses. Again this support can also assist with any compliance issues to support an optimal surgical outcome. If a patient wants further information from the surgeons directly they can also be followed up at MCM. However, it is our experience that with careful briefing a patient will make their own decisions and during our mission several inpatients did not proceed to presentation because they were happy with the way they were or accepted they were not medically fit for surgery at that time. Facing Africa will not operate on anyone who cannot give consent or does not have an appropriate person to act on their behalf e.g. a relative or guardian for children under 14.

At the end of the day a list of patients that the surgical team feel appropriate for surgery will be agreed. The following day the surgical team will meet at MCM to discuss all the patients and plan the operating timetable.

All the new patients that arrived on the presentation day will need to be admitted and get settled in after the team leave and their paperwork completed if not already done so. Some of the new patients made need tests pre surgery, that have been specifically requested by the surgeons. They can have these done on the Sunday at Wudassie Clinic if necessary.

 Stage 3: Surgery

Patients are admitted to the hospital the day before their surgery.

They will need:

  • Notes & Patient ID band  (Name/MCM number)
  • To have showered and be wearing clean clothes
  • Towel, soap, toothbrush & toothpaste
  • Clean Muslin

Linen bags are available that can be labelled with the patient’s name and taken in with them.

All patients under the age of 18 years need to have a “Responsible Adult” with them at the time of admission to hospital to sign the consent form for surgery. This can be organised by Gez or Betty.

The types of plastics surgery you may see are:

  • Radial Forearm Free Flaps
  • ALT (Anterior Lateral Thigh) Flaps
  • Submental Flaps
  • Turnover Flaps
  • Abbe-Estlander Flaps
  • Modified McGregor flaps
  • Karapandisz flap
  • Commissuroplasty
  • Z-plasty
  • Nose reconstruction (using cartilage / bone)
  • Genioplasty
  • Debulking of neurofibromatosis
  • Ankylosis Release:
    • Coronoidectomy
    • Condylectomy
    • Costochondral graft

Some patients may also have had additional procedures at the time of their surgery e.g. dental extraction and enucleation.

Stage 4: Post Operative Care.

This is the only stage that starts as the surgical stage is in progress. At the beginning of this stage you may have three types of Inpatients:

  • Non-operative patients awaiting discharge
  • Pre-operative patient awaiting surgery
  • Post operative patients requiring wound care:

Patients may be ready for discharge from MCM Post-Op Day 1 onwards and a nurse on the surgical ward team will inform you every morning of pending discharges, confirming what time they will be discharged so that food can be ordered. MCM usually aims to discharge about 11am so that patients can have their lunch at Africa House on discharge and planned admissions can return with Gez having had their lunch before departure. The ward nurse confirms post-operative care on a discharge summary and details of surgery can be confirmed on the operation report. MCM notes are not available but copies should be sent with the discharge instructions. Patients are usually very tired on discharge and want to rest in bed. Post- operative bays can be created (by the Doctors office) and heaters are available to keep the rooms warm.

Most post-operative patients have the following post-operative instructions

  • Analgesia e.g. Paracetamol, diclofenac dosed to weight.
  • Oral antibiotic’s e.g. Co-amoxiclav (individually dosed) prescribed for 5 days, standardisation of antibiotic protocol is needed.
  • Wound care e.g. Chloramphenicol ointment topically BD to sutures lines. Suture removal in 7-10 days. You may need to check for graft sites or donor sites for each individual.

Pain control:

We found Ethiopian medical and nursing staff have no understanding of the western assessment of pain or of the analgesic ladder in relation to prevention and treatment of pain.  A prescription chart is now available and both soluble tablet and syrup paracetamol on site. Mission 12 operated on 15 new Noma cases and 15 follow up Noma cases, the largest number to date. Our concern is that the first operations are usually the most traumatic and as patients will need follow-up operations it is essential for both Ethiopian Medical and nursing staff to embrace a commitment to pain control from the beginning even if culturally they are estranged from this notion. There are pain charts with a pain scale translated into Amharic which can also be used and patients can point to the scale to describe their level of pain. Try to encourage REGULAR administration of analgesia, at mealtimes and also at night.

Paracetamol is generally used in Ethiopia for headaches and fever so is not considered to be useful for any other types of pain. There are cultural reasons for not using suppositories and it can be considered disrespectful to suggest them to patients.

Prevention and Treatment of post-operative infections:

All patients are discharged from MCM on oral antibiotics if they have not completed their course post-operatively. These can be prescribed and administered using the Drug charts available.

Antibiotic medication is available in different dosages in Ethiopia. You need to be aware of this should you run out of stock. Ethiopian practice is to treat early and aggressively e.g. the common cold may be treated the same as a failed infected skin graft. There is no antibiotic regulation and some antibiotics available in Ethiopia would not be considered safe or appropriate in Europe.

Wound healing

Wound care is probably the major part of your contribution to the mission. In the immediate post-operative phased return of patients from MCM you will become increasingly busy. In fact you will be at your most busy the day the surgeons come to review the patients on site before they depart on day 28. It is important to create post-operative bays that are clean and warm for the patients on return.

In our experience wound care can be best divided into

  1. Preparation
  2. Assessment
  3. Teaching
  4. Treatment
  5. Evaluation

a. Preparation:

Preparation involves the following:

  • A shared understanding of practice between staff
  • An environment to deliver the care
  • The equipment to deliver the care.
  • Knowing who you are going to assess

Before discharges begin it is helpful to discuss with Ethiopian staff your approach to wound care.

The treatment room can be prepared in advance for wound care. The treatment room is spacious with fluorescent lighting, a sink and an autoclave.[1] It can be adapted as required to hold 2 beds and dressing trolleys, so that there can be 2 wound care stations. There is a screen to give privacy and chairs so for waiting patients to rest. The trolleys are not height adjustable.

While basic wound care equipment is available, we found it helpful to identify what you need in advance to ensure optimal practice. Donations of equipment from companies are valuable and you should determine with Facing Africa what you need and what you are taking so that you have clearance through customs on arrival.

We would recommend you ensured you had the following:

  • 12 boxes of 100 powder free gloves
  • Disposable Aprons
  • 200 irripods (saline for wound irrigation) or 500 ml bags of saline with spikes or giving sets.
  • 50 dressing packs for complex dressings or suture removal ? more
  • Sterile surgical gloves
  • Sterile gauze
  • Box of 100 sterile suture removers
  • 24 pen torches
  • 6 Boxes of 100 tongue depressors
  • 5 clip-removers.
  • Soap that is kind to your skin.
  • Alcohol Hand gel
  • Assorted topical dressing & occlusive dressings such
  • Assorted tape and Steri-strips.

Ethiopian staff like to know in advance what is happening so they can assist in the most helpful way. We found initially a diary was helpful to indicate day of suture removal. However on a daily basis a white board was utilized to let the Ethiopian nurse know planned wound care activity for each individual patient: e.g. those for wound cleaning, wound dressings, suture removal could be listed and ticked off as the day progressed.

b.  Assessment

Good preparation allows daily wound care to be pre-planned and proceed both orderly and carefully allowing you time to assess the wounds with care.  Assessment involves both the skill of observation and the ability to make a decision on how to treat.

As a guide we divided the wound care into three stages of the day:

  • AM (after breakfast): Wound cleaning and treatments/dressings
  • AM: suture removal to allow time to observe wound.
  • PM: Dressing
  • PM (after dinner): wound cleaning and treatments

This regime had the 4 main advantages of

  • Involving Ethiopian staff across am and pm shift.
  • Allowing for wound cleaning after meals and mouth wash.
  • Ensuring snack time was not missed..
  • Giving adequate time for suture removal and dressings.

c. Teaching

While it is important to involve Ethiopian staff in wound care, they are also very busy with general care activities in relation to environmental cleanliness, patient hygiene and nutrition. We concentrated on teaching them to assess post operative wound e.g. The location, post operative day, pain experience, colour, perfusion, temperature, increased swelling, hardness, graft corners, mouth ulceration, scab stability, type of sutures and method of stitching, indications for topical treatment, indications for dressings etc.  Our teaching aimed to be empowering them in making a clinical assessment rather than them assisting us. It is advisable to do one to one teaching and observation of wound care at first, until sure of the individual nurses competence as some are better or more experienced than others.

d. Treatments:

Most patients are treated with chloramphenicol topically to their suture lines for first 5 days post op prior to suture removal. We found the climate did not dry this out and could make wounds soggy, so recommend it be applied following cleaning at the discretion of the nurse. Chloramphenicol could be applied for longer in areas of infection. The corners of wounds flaps were particularly susceptible to small wounds, some requiring dressings to prevent infection e.g. lateral underside of chin in a sub-mental flap.

Suture removal was often progressive over several days to ensure that the wounds remained intact and patients were not unduly distressed. Sutures should be left for 10 days if possible, to ensure closure. There are many different types of sutures and styles of suturing used and they are located in very sensitive area e.g. eyes and nose. As a guide: If a suture appears solid and plastic it is likely to be removable suture. If a suture appeared woolly with multi-fibre ends it was likely to be soluble.  We found many soluble sutures did not dissolve and had to be removed at the request of patients or because they were causing a localised infection and abscess. Donor sites were dressed with jelonet or wet gauze while graft sites protected with NA, gauze and bandage to prevent adhesion. Failed graft sites after dehiscence or debridement were dressed with wet/dry gauze until review. A variety of topical dressings can be used to assist open wounds persisting post suture removal eg. ugotulle, aquacel, urgocell silver etc but for the most part, you will only need to use jelonet or wet/dry gauze dressings.. The most important part of the dressing experience is the provision of clean muslin on leaving the treatment room. Any leaking wounds or infected wounds require prompting to change their clothing and bed linen.

e. Evaluation

At the end of the surgical stage the surgeons will come to Cheshire to review each patient individually. This takes place in the clinical room and it is useful to have gloves and dressings available. Assessment is this time focused on discharge planning, and listing for further review or admission at the next mission.  Like presentation day, review proceeds very quickly and can be very stressful for the patients because once again they are exposed to many faces looking, photographing and examining them and discussing them in a different language.  While Surgeons are careful to ask how the patient feels and what he or she want in future, it is important that patient’s are informed of their plan. As the Facing Africa team leave MCM on this day, most patients will be discharged on the previous day. Their review will take place at MCM prior to discharge.

After the surgeons leave you will be on your own at the Cheshire dealing with the post-operative wound care. The surgeons can be contacted by email at any time and sending photos of patient concerns to the UK can be helpful. If you have any patients who need any extra surgical attention they can be referred to Dr Einar Erikson, a burns and plastics consultant at the MCM hospital who has worked with Facing Africa for several years. He will gladly see any patients you have concerns about.


Phone: 0911220984

One of the UK surgeons will be appointed to be responsible for all correspondence and will forward to other members of the team if necessary.

Observing post-operative complications can be very upsetting and distressing. You may question if surgery is the right answer especially if graft fails and further grafts are required. It is for this reason that so much of our efforts were spent educating the nurses in wound observation so they could make decisions on treatment and evaluate outcome.

Most patient are clinically well on discharge from MCM so routine vital signs are not indicated. However, it is good to alert staff if you observe complications so that TPR/BP can be recorded. Some needed recording of vitals for the first 24 hours back at Cheshire.

If there are complications post op such as infections or failed flaps, these patients will need further surgery either under GA or local anaesthetic in the 4 weeks post op. Arrangements should be made with Dr Einar who will either advise you to bring the patient’s in to MCM or he will come to Cheshire to review them if he is free.

Admission & Discharge at MCM after the FA team leave

Should you need to admit or discharge a patient at MCM after the FA team have left you need to arrange this with Dr Einar, the Ward Sister and Gez.  You will need to take the patient’s MCM number to the window signed Admissions/ Discharges in the Hospital Reception area and tell them it is a Facing Africa patient.

If you are admitting the patient please remind the person at the desk to send the patient’s file to the ward.

If you are discharging the patient you will be given a discharge slip which needs to be handed as you leave the hospital (there is usually someone sitting at the bottom of the stairs to the ward that will check this). You should also ask to be to photocopy the medical notes.

Admitting and discharging patients with the office is the responsibility of the FA staff not the ward staff.

The patient does not need to be with you during this process so can wait on the ward.

Oral Hygiene and mouth exercises

Oral hygiene is an integral part of facial wound care practice. Prior to dressing changes and after food patient can have their mouths assessed, cleaned with sponges if necessary, receive mouthwash and be encouraged to do exercises.

Mouth ulceration is a commonly seen post-operatively.


The Nursing discharge summary from MCM will indicate what type of diet the patient can have.  A few will be normal, most will be soft and some may be restricted to a liquid diet as they may be unable to open their mouths or advised not to chew.

Some patients will need to continue on a high calorie diet post operatively in order to have a speedy and successful recovery period. They can have milkshakes or supplement drinks twice a day.

Several patients on return from MCM reported diarrhoea and were treated with Tindizole. As all case of diarrhoea immediately resolved it maybe that cases were linked to the diet received at MCM during the immediate post-operative phase, although side effects from antibiotic medication cannot be excluded. In order to ensure safe administration of medication it may be necessary to remind the doctor to document all medication to the patient’s and the reasons for them, as this is not usual practice.

We found that many patients experienced symptoms of heart burn which was treated by famotidine. This is apparently a very common complaint throughout Ethiopia and is thought to be associated with the diet, particularly Injura (Ethiopian bread).

Discharge Home

The best policy for discharges from the Cheshire is to wait until the patient is better, and then add 2 days. Plans for discharge must be agreed between the volunteer nurses and the on-site doctor. As you start to plan your expected discharge dates it is a good idea to liaise with Gez, as some patients will need to travel together. Also Project Harar (PH) has their own mini bus so if you can discharge most of the PH patients together that would be helpful

You will be expected to produce at patient report at the end of the mission. This can be based on the presentation you have already created for the day the surgeons arrived. Simply insert a second slide for each person explaining the post-op evaluation of follow-up. Evaluation slides should include:

  • Operation, including date
  • Any post-operative complications +/- treatments
  • How happy the patient is regarding surgical outcome
  • Discharge Plan
  • Post op profile photos

This can be a very emotional time for all concerned. Don’t be surprised if some of the patients not yet discharged get upset seeing others leave.

Packing Up

As the mission starts to draw down it will be time to start repacking the remaining equipment, clothes and linen. At this stage it is helpful to label all the bags/ boxes and create a list of the contents. During this phase a list of things that you think is needed for the next mission can be drawn up which can be then forwarded to Chris.

The Ethiopian nurses will assist you to pack up and they will take responsibility for counting and packing all the patient clothing. Kessmie will then liaise directly with Chris/ Terry about what clothing is available and what clothing is needed.

Cultural consideration

It is important to remember that you are working in a different country and that there are many cultural variances. Ethiopians are generally very tactile and often hug, hold hands or stroke your arm/ back when talking to you. If this makes you feel uncomfortable then politely tell the person and they will stop.

There are also vast differences in medical practice. Ethiopian nurses are taught to do as the doctors tell them without question. Ethiopian doctors are not used to western nurses who can practice independently and frequently question orders. It is important to remember that it is difficult for all concerned to work with people from different backgrounds.

Visitors to Cheshire & Facing Africa House

During your stay at Cheshire you may find meet several groups of visitors to the project.

These visitors are potential supporters so it is important to welcome them and be prepared to talk to them about the condition of NOMA and about the Facing Africa projects.


During the mission you will need to take some days off to relax. During the surgical period it is possible to spend a day & night with the team at MCM. This is a good chance to see how the ward runs and watch some surgery. In the evening you can then go out for dinner with the team. Terry will arrange somewhere for you to stay.

After the surgical team have left it is up to you to decide when it is appropriate to take time off. According to the agreement between Cheshire and Facing Africa there must always be a doctor on site.

If you have a chance to go into Addis Ababa you may wish to visit either the Sheriden Hotel or the Hilton Hotel to relax. The foremost is the most impressive and a bit more up-market but at both you can use the pool facilities for under £10. So don’t forget your swimming costume.

If you decide to visit other areas of Ethiopia, Gez and Betty can advise you on where to go and help you with arrangements.

Further reading:

 Barmes, D. E., Enwonwu, C. O., Leclercq, M. H., Bourgeois, D. & Falkler, W. A. (1997) ‘Editorial: The need for action against oro-facial gangrene (noma)’ Tropical Medicine and International Health 2 (12) pp: 1111-1114

 Castillo-Carniglia, A., Weisstaub, S. G., Aguirre, P., Ahuillar, A. M. & Araya, M. (2010) ‘Identifying Cultural Representations of Families and the Health Team to Improve the Management of Severe Malnutrition in Childhood’ Qualitative Health Research 20 (4) pp: 524-530

 Coupe, M., Johnson, D. & Seigne, P. (2013) ‘Airway Managementin Reconstructive Surgery for Noma (Cancrum Oris)’

Anaesthesia-Amalgesia 117 (1) pp; 210-217

Enwonwu, C. O. (2006) ‘Noma – The Ulcer of Extreme Poverty’ The New England Journal of Medicine 354 (3) pp: 221-224

Enwonwu, C. O., Falker, W. A. & Idigbe, E. O. (2000) ‘Oro-Facial Gangrene (noma/ Cancrum Oris): Pathogenetic Mechanisms’ Critical Reviews in Oral Biology & Medicine 11 (2) pp: 159-171 [Online] Available at:

Enwonwu, C. O., Falker, W. A.,  Idigbe, E. O. & Savage, K. O. (1999) ‘Noma (cancrum oris): questions and answers’ Oral Diseases 5 pp: 144-149

Enwonwu, C. O., Falker, W. A. & Philips, R. S. (2006) ‘Noma (cancrum oris)’ The Lancet 368 pp: 147-156

Enwonwu, C. O., Philips, R. S. & Ferrell, C. D. (2005) ‘Temporal relationship between the occurance of fresh noma and the timing of linear growth retardation in Nigerian children’ Tropical Medicine and International Health 10 (1) pp: 65-73

Fieger, A., Marck, K. W., Busch, R. & Schmidt, A. (2003) ‘An estimation of the incidence of noma in north-west Nigeria’ Tropical Medicine and International Health 8 (5) pp: 402-407

Gollogly, J. G. & Mussomeli, I. (2007) ‘Noma in Cambodia: scars from the past’ Asian Biomedicine 1 (4) pp: 377-381

Johnson, N. W., Scully, C., Warnakulasuriya, K. A. A. S. & Mori, M. (1999) ‘Editorial. The horros of noma (cancrum oris)’ Oral Diseases 5 pp 91

Obiechina, A. E., Arotiba, J. T. & Fasola, A. O. (2000) ‘CANCRUM ORIS (NOMA): Level of education and occupation of parents of affected children in Nigeria’ Tropical Dental Journal [Online] Available at:

Ogbureke, K. U. E. & Ogbureke, E. I. (2010) ‘NOMA: A Preventable “Scourge”of African Children’ Open Dentistry Journal Volume 4 pp: 201-206

 Contributors to this manual:

Sarah Reavenall

Fiona Jackson

Leonie-Ann Munday

Clare O’Brien

Nicola Heath

Susanna Kiederling


[1] Full instructions for using the autoclave are available.

[1] Full instructions for using the autoclave are available.

More information

If you feel that this is a worthwhile and interesting opportunity that you would like to take part in, please let me have the required information and state clearly which role you are applying for. Please feel free to phone or e-mail Chris Lawrence with any questions you may have.

Chris Lawrence
Chairman & Trustee
Tel: 01380 827038
Mobile: 07748 180700

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