Christmas at the Equator...

...is only a little surreal! Here at Kiwoko Hospital in Uganda we had our Christmas Party yesterday. For someone coming from Scotland, its very difficult to get used to a mid-winter festival taking place in 28 degree heat, with burning sunshine, no rain or snow, and 12 hour days. Nevertheless, there are some wonderful aspects to a Ugandan Christmas – not least the fact that there is none of the commercialism that is seen in the UK anytime from August onwards!

Our party yesterday was superb. We had what would be known in the UK as an outdoor concert – lots of different sketches, songs, dramas and performances from different groups both within and without the hospital. At the last minute the doctors put on a small sketch of “A Greek Tragedy in Five Acts,” suitably adapted to Ugandan culture – which went down very well: I think as much because they got to see the doctors dressing up in silly clothes and performing as anything else! We had Christmas carols in English from the Nursing school choir, children’s games (enthusiastically played by the adults!), and several speeches about not leaving Christ out of Christmas – a message that probably should be heard more clearly in the UK!

And then of course was the barbeque – as is usual on these hospital occasions, a bull was roasted and cooked throughout the afternoon, ready for a feast of chapatti, BBQ-beef and sodas in the early evening… so far there’s not even a hint of a dodgy stomach!

I’ll be working on Christmas Day itself (I have no idea how busy it will be: I suspect, like in the UK there’ll be plenty of people with stomach/heart complaints later in the day!), so I’ll take this opportunity to wish everyone who’s been following my blog a very Happy Christmas, and to ask God to guide and bless all your hopes and plans for 2008.

Steve

The man with the key is gone...

...is a well-known Ugandan saying – often heard if visiting somewhere to get something done such as collect a repair, prospectively view a purchase, visit an official, etc. Usually there is only one key for the room/building you are trying to enter, and invariably that key is with someone who is not there. Ugandans are fairly laid back about this sort of thing – why get upset or annoyed when you can’t do anything about it? Muzungus on the other hand tend to get very frustrated by not being able to get something done in a hurry! “The Man With The Key Is Gone” is also the title of a book by Dr Ian Clarke telling the story of how Kiwoko Hospital, where I work, came to exist.

I found myself in the unusually position yesterday of being that Man With The Key! I had been doing some photocopying the previous evening, and had forgotten that I had the key to the room in my pocket… Of course Ugandans are far too polite to interrupt our doctors meeting, so they waited an hour until they could speak to me to get the key back! No hassle, no pressure or attempts to make me feel guilty – its just how life is here! I’m really going to miss it once I return to Edinburgh in a few weeks time.

Another thing I’m going to miss is the huge variety of the medical work here, although I’ll not miss busy nights on-call like last night – I’ve been unlucky to only get a couple of hours sleep on my last couple of calls. After a good surgical afternoon – a gastroscopy, a large abscess and a partially amputated finger to sort out – I started my call at 5pm, and had seen eight admissions before 7pm!

To give an example of the variety of work not normally seen by a General Surgeon, last night I saw: A man with a huge swelling in his armpit, likely to be an abscess or TB; A 13 yr old with severe heart failure who had come to Kiwoko because the treatment prescribed by the Kampala referral hospital wasn’t working and he was seriously ill; A man with HIV on antiretroviral medications who had developed a second bout of TB within a few months of completing treatment, likely therefore to be drug resistant; A child with severe malaria and secondary anaemia who died within minutes of arriving in hospital; Two babies with dehydration after two days of vomiting and diarrhoea; A young child with severe malnutrition secondary to Cerebral Palsy and poor home circumstances; Another baby with a distended abdomen, not moving it's bowels; Three triplets, five days old, delivered at a local health centre, one of whom was dehydrated, wasn’t feeding and had unrecordably low blood sugars; A postmenopausal woman with sudden onset of significant vaginal bleeding; A girl who was unconscious after being knocked off her bicycle by a car and sustaining a head injury with probably basal skull fracture; A young woman who had sepsis following an attempted abortion (illegal here in Uganda); A seriously ill pregnant mother with meningitis and a cerebral abscess who died later in the night; a second trimester mother with lower abdominal pain who may have appendicitis; Another young woman with end stage HIV, cerebral toxoplasmosis and giardia who also died through the night; and finally at 4am a mother with deep transverse arrest in second stage of labour requiring a difficult emergency Caesarean Section. I got to my bed at 5.30am!

Not every night is so busy, but when on-call I do cover seven wards with about 250 beds, as the only doctor available! In Edinburgh, that number of patients overnight would be a busy night – but I’d have a team of four or five junior doctors to help me look after half as many patients. Also all the patients would be likely to have similar conditions – various different types of abdominal pathology – with better facilities for investigation. My girl with the head injury, for example, would have gone straight to CT scanning, and probably rapidly onwards to specialist neurosurgeons, if not to ICU. Here I was examining her by paraffin lamp (no electricity overnight), was preparing to take to emergency theatre for blind burr holes to drain a blood clot, if she deteriorated, and today will just observe and support her as the family cannot afford to take her to Kampala for a CT scan costing only £15!

However, I’ve just over three weeks to go, and am starting to realise that I’ll be leaving soon. So many people have been very kind in their disappointment that I’m going away, all of them making me promise to visit again, and sincerely wanting me to come back and work here for longer. I’m committed to another three years of specialist surgical training in Edinburgh, but only God knows what I’ll be doing after that. Africa certainly has a very strong appeal!!!

Anyway, have a very Happy Christmas whether its in somewhere hot and sunny like Uganda, or dark, cold and wet like Scotland… In case you’re wondering, the picture is of a typical Ugandan meal – Matoke, groundnut sauce, Irish potatoes, eggplant and cabbage! Enjoy your own Christmas meal!

God bless,
Steve

Dr Bennett, I presume...

For the last two weeks my brother and sister-in-law have been visiting me here in Kiwoko Hospital, Uganda. They’re probably the last people I’ll have coming to stay, as I now have less than seven weeks until I’m back in the UK. Before heading on another grand tour of Uganda, we spent some time at the hospital – the first and probably the last time that Alan and I have worked together as doctors. It was actually quite fun: we were able to operate on a couple of patients together, and helped each other out doing an orthopaedic clinic when our visiting specialist failed to turn up. I introduced him to some of the more tropical aspects of orthopaedics, and he was able to help with some of our more complicated patients.

Life here seems to be getting ever busier as time goes on. I’d love to leave some of the surgical work to our Ugandan surgeons, and concentrate on finishing off a few of my projects, but complicated patients keep turning up, and I’ve found myself doing even more big surgery. The biggest miracle of the last few weeks was an elderly (well, forty-something is elderly here in Uganda) woman who was admitted with a large abdominal mass. An ultrasound scan by one of the other doctors suggested a fluid-filled structure in the upper left of the abdomen, probably the large bowel. In the absence of any further possible investigations, I took her for a laparotomy (opening the abdomen to see what is going on), operating with one of our Ugandan surgeons.

We were surprised to find that the mass was a huge distended, necrotic stomach, which had perforated leaking gastric contents into a swollen mass of inflamed tissue. Short of just closing back up and allowing her to die from sepsis, the only option was to remove as little as possible and join up what we could of her bowel. I ended up having to perform a total gastrectomy, joining part of her small bowel directly onto the end of her oesophagus, along with a little extra plumbing further down. I felt that was the minimum that could be done to give her a chance of surviving. I’ve certainly never done such an operation before, although I’ve probably assisted at one at some time. It was completely new to my Ugandan colleague!

Given the size of the operation, and her weakened pre-operative condition, she should have died before waking up from the anaesthetic. As we have no facility for ventilation or intensive care, she should have died shortly after the operation from lack of oxygenation. She did develop a very fast heart rate, Atrial Fibrillation at a rate of 250/minute, and without the ability to shock the heart back into the correct rhythm, or even give any suitable drugs other than some Digoxin to try to slow things down a little, she should have died that night. Over the next few days she should have developed major intra-abdominal infection, as a result of the perforated stomach, and died. At five days after her operation, she developed a fever, which should have been the result of a leak at the point of joining of the bowel, and she should have subsequently died.

However, God is good… It is now over two weeks since her operation, and she is going home tomorrow. She woke up without difficulty from her anaesthetic. Her heart rate slowed and went back to the correct rhythm with minimal assistance. She didn’t develop infection, or sepsis. An x-ray with contrast showed no leak from her joins. The malaria that had caused her fever was treated, and she has slowly recovered her strength. She is left without a stomach and will require frequent small meals plus Vitamin B12 injections for the rest of her life, but I feel another miracle has happened just with her surviving to leave hospital. It remains to be seen whether the tumour that caused the problem will recur… we will have to leave that in God’s hands, as there is no further treatment I can offer her here. Yet again, the hospital’s motto seems very appropriate – “We treat, Jesus heals”.

Surgical work aside, I am making progress in finishing off some other projects. I’ve now managed to complete my trauma course for the doctors, so hopefully we’ll be better at looking after seriously injured patients. My Endoscopy room is almost fully equipped, and Dr James is rapidly learning how to perform the necessary Endoscopy procedures. I’ve two more lectures/talks to give to our nursing students over the coming fortnight, and hopefully there won’t be too much more to prepare for.

My thoughts have started turning towards preparations for returning to the UK – I suspect that one of the hardest parts will be getting used to the relative cheapness of things, and the relative cost of time. It seems to be the opposite here in Uganda. Still, that’s next year, and there’s Christmas to come first. Although Christmas is big here in Uganda, I’ve been pleasantly surprised to find that it hasn’t really been mentioned here yet… I suspect it’ll become more obvious through December. Apparently most people are fattening up a pig for their celebrations! Which reminds me, someone gave me a chicken a couple of weeks ago as a way of saying thank you. It was quite an experience watching one of the local boys cutting its head off for me and then plucking all the feathers off – still, it tasted good, and confirmed to me that I’m definitely not a vegetarian!

God bless,
Steve

Christmas has come early...

...here in Kiwoko Hospital, Uganda. Some visitors from Northern Ireland arrived today bringing with them three more endoscopes for us to use, including one designed for Gastroscopy. If you’ve been following my efforts this year, either through this blog or by newsletter, you’ll know that one of my projects has been to introduce endoscopy services to the hospital – the facility to examine the inside of the stomach or bowel using a flexible telescope.

Its been quite exciting putting together the equipment required from various kind donations of surplus or unused items by several UK hospitals. A doctor from Basingstoke visiting in February prompted the project by offering a fibre-optic scope from her hospital. A hospital in Northern Ireland donated a light and air source. My own hospital in Edinburgh donated some accessories and cleaning equipment, and I’ve bought a couple of extra things over the Internet. We got everything working a few weeks ago, and were able to examine the inside of a patient’s stomach for the first time in Kiwoko. However, the telescope was designed for looking in the other end of the bowel, and was therefore too short to see further than the stomach – the endoscope we received today was designed for the top end, and we have used it twice already to visualise the duodenum. We were able to tell one muse (older gentleman) that his upper abdominal discomfort and associated weight loss were not due to a stomach cancer, and advised a younger lady that she had inflammation of her stomach but no ulcers.

I’ve almost completed the plans for our Endoscopy Suite – a spare room attached to theatre where we’ll be setting up the equipment permanently, along with all the cleaning and disinfecting equipment. I need to get an oxygen concentrator from Kampala, which will hopefully come on Thursday, and then we’ll be in full swing. I’ve been teaching Dr James who performed his first examination today, and will hopefully build his confidence and experience, while also training some of the other doctors over the coming weeks.

We’ll be able to offer this investigation to the people of our local area who previously would probably have been unable to afford to get the test done in Kampala – the charge of the equivalent of £30 is more than a months income for most people here. It could literally make the difference between life and death – if we can diagnose a problem early it can sometimes be cured… Of particular note, we now offer a better service than the NHS in the UK! The waiting time for an endoscopy in Edinburgh can be several months – we will usually do it the same or the next day! There’s no such thing as a waiting list here.

Christmas has also come early with the news that our new theatre monitors are now available in the UK. I’d asked a company where I could get spares and accessories for our current obsolete monitor, and they told me I couldn’t – but they would be able to donate some more modern equipment. We’ll shortly be in possession of six new monitors able to monitor Pulse, Blood Pressure, Temperature, Oxygen saturation, and a heart tracing – one for each of our two theatres, another for our theatre recovery, and three more for our wards, in addition to several other machines able to measure Pulse and BP only. They’ll even work off internal batteries – which is essential when you may only have electrical power for a few hours each day! At present our sophisticated way of ensuring a patient having anaesthesia continues to have a regular heart beat is a stethoscope taped to the front of their chest, and we share a single oxygen saturation monitor between both theatres and wards!

So today is a very positive day. The last month here has been very tough, and I’d become fairly chronically overtired, and dispirited as a result. However, I had some time off last week and was able to relax while visiting the Eastern part of Uganda – a beautiful area called Sipi Falls where we stayed in a beautiful (and cheap) lodge right at the top of a 90-metre waterfall, serving fantastic four-course meals! It was a shame to come back to the hospital yesterday having seen another visitor off at the airport. However, I now have less than eleven weeks left before coming home to Edinburgh, and should get most of my projects completed by then – plus I get another tour around the West and South-West of Uganda in a couple of weeks time when my brother and sister-in-law visit… life is tough (but I am looking forward now to January 7th)!

So it’s good to be enthusiastic again – I hope that you’re also able to see the positive side of whatever situation you’re facing just now. Do please remember the hospital, staff and patients here in Kiwoko in your prayers.

Steve

Flying by the seat of your pants...

…is sometimes what practicing surgery in Kiwoko Hospital feels like. For someone brought up in the UK healthcare system, where almost any investigation can be carried out (albeit sometimes with a long wait – oh dear, I’m getting political!), the lack of facilities here in rural Uganda makes treating patients fairly interesting.

We can do basic laboratory investigations on blood, but each test costs the equivalent of £1 or $2 – which starts becoming unaffordable for our population if you suggest too many. So rather than getting routine haematology and biochemistry on every admission, we may request a Haemaglobin level to check for anaemia, a white cell count (done manually by microscope), to look for signs of infection and likely type of causative organism, and sometimes a Potassium level or renal function tests.

Our radiological investigations are similarly limited. We can do plain x-rays (of adequate quality) which cost about £1.50 each, and we have a portable Ultrasound machine – if you’re prepared to try and use it yourself: in the UK all ultrasound exams are done by radiologists, so I’ve had to learn on the job what I’m looking at! Other more complicated examinations such as dye-tests on the kidneys, contrast studies for bowels, and CT scans (3D x-rays), are available in Kampala – 2 hours away along a very bumpy road – but are usually too expensive for our patients, costing upwards of £20 a time (a CT scan is £15!!!). The other factor in our x-rays is that we have variable availability of electric power – if we have no mains electricity, urgent investigations have to wait until 10am the next day when the generator comes on for a few hours.

I’ve managed to improve our bowel investigations from non-existent, to now being able to visualise the inside of the stomach or lower colon. The equipment I’ve managed to acquire over the last six months has resulted in us having the facility for endoscopy – fibre-optic examination through a narrow tube, and this has been enthusiastically received by the local doctors who are very keen to be taught how to use it. We’re limited at present by the 60cm length of our endoscope, but would love to get hold of an actual gastroscope (90cm) to extend the amount we can see!

I’ve had three patients this week for which I would have loved to have had better facilities, but instead ended up going straight for an operation – well, operating is what us surgeons do best! The first was a 7 year old boy who came in with three days of bowel obstruction followed by the passage of a little bloody stool – classical signs of intussusception even if he was a little old for it. No x-rays were possible, but small bowel loops were visible through his abdominal wall, so he needed an urgent operation that night. I actually found he had a hernia of his large bowel through a defect in the right side of his diaphragm into his chest, which had blocked and become necrotic. Not something I’d ever even heard of before, but I was able to resect part of his bowel, close the hole in the muscle and place a chest drain. Would an x-ray or CT scan have helped? I might have known what to expect before I started, but I suspect I’d still have done the same operation.

Second was a 30-year-old man who had perforated an ulcer ten days earlier and had been operated on by one of my colleagues. He had developed pneumonia, had some fluid in his abdomen, and he was being very slow to progress. We sampled the fluid and it did not appear to be infected, but it would have been good to get either CT scan or contrast x-rays to see if his ulcer was still leaking. Going back for a look in theatre was not a good option because of his pneumonia. Unfortunately his wound burst open, necessitating a trip back to theatre where I carefully drained the fluid and confirmed that the patch on the ulcer was still in place. Again, this was a situation where more information might have helped with the decision of whether to operate again or not.

My third patient was an elderly lady admitted with bowel obstruction for the previous week who was very dehydrated. X-rays might have helped determine the level of the blockage, and a contrast enema might have shown whether it was constipation or a physical lesion. Without these confirmatory tests, the obstruction had to be relieved, so I operated. The actual obstruction was in the middle of the small bowel, which was full of constipated stool (usually only seen in the colon). The obstruction was not a physical lesion but a bolus of firm bowel material that was moving very slowly, but showing all the appearances of a blockage. I think this lady would still have needed an operation, as even with investigations it would have seemed to be a small bowel obstruction.

For all three patients, the decision to operate was made on the basis of the story and examination. Investigations would make the job easier, but ultimately I think all needed their procedures, and I am pleased to report are all well on the way to recovery. These sorts of decisions are the ones that cause the stress of being a surgeon here – who you operate on, who will get better without an operation, who will die if you do operate… It’s tough, but in the absence of any alternative, I hope that I can continue to try to do what is best for the patient. In many ways, it will actually be hard to go back to the defensive practice of over-investigating patients once I return to Scotland in January!

I pray life may be fairly stress-free for you wherever you are just now!

Steve

Miracles do happen today...

I was especially struck by this amazing fact earlier this week. At the beginning of last week, I was on-call for Kiwoko Hospital, here in Uganda, covering all seven wards rather than just the surgical wards that I work on day-to-day. At 6am a small child was admitted, very sick, with a fever and difficulty breathing. The diagnosis of chest infection was fairly straightforward, and the treatment we are able to give, namely oxygen and intravenous antibiotics, was started immediately. Something about this six-month old made me wait to ensure that he responded – and five minutes later she stopped breathing completely.

We have limited options here in our rural hospital for any form of life support. Our oxygen supply comes from oxygen concentrators rather than gas cylinders, or pipes through the wall as in UK hospitals. We have no facility for assisted ventilation, other than by hand using a bag and mask. We have no blood gas analyser to assess how well oxygenated a patients blood is. We have no defibrillator to restart a heart that has stopped beating.

For this young child, I had to do what I could. After the IV antibiotics came some IV steroids in case there was an asthmatic component to the breathing problem, then some IV aminophyline, a respiratory stimulant. When breathing stopped, I had to stand there and ventilate by hand. After a few minutes breathing restarted again, and then after another few minutes stopped.

In the absence of any other facilities, all I was able to do was breath for this child using the bag and mask. After 30 minutes, the paediatric doctor arrived to start the day, but had no other suggestions, so we continued. After an hour of ventilating, it became apparent that we were not going to have a successful outcome. We took the difficult decision to stop ventilation.

However, the baby had other ideas, and slowly started breathing for itself again. I returned to the ward a few hours later to find to my surprise that she was still alive – albeit looking very sick and barely breathing at all. Our expectation was that she still wouldn’t last the course of the morning.

I was therefore very shocked a week later when Dr James mentioned that he was discharging the child that morning. Not only had she not died, she had made a full recovery, and had no evidence of any residual problems as a result of her lack of breathing. Miracles happen today – this child had no hope of survival, and yet did, against all the odds and medical explanation! I am extremely privileged to be part of the amazing work that God is doing here in the middle of rural Africa, and very grateful for the opportunity to witness Him at work as seriously ill patients receive the limited treatment we can offer, and recover against every expectation.

This particular patient made a huge difference to this week for me. Its been very busy as we’re a little short of medical staff at the moment, so I’m looking after surgery on my own, and was on-call for the whole hospital four nights in eleven. I’ve also had to book my flights home for the beginning of January, which releases a very different set of thoughts, as I’ve realised that I have less than four months before I have to leave to return to Edinburgh. The last eight months have gone by very quickly.

Still I have a few more things to look forward to. I have a couple more sets of visitors in the next two months, so I’ve some travelling planned, including visiting the Mountain Gorillas in the South West of the country, and a relaxing weekend on the “chilled-out” Ssese Islands. The Queen visits Uganda at the end of November for the Commonwealth Heads Of Government Meeting (or CHOGM as its called here), which will make the country pretty busy for a while. I still have several things to finish here in the hospital, not least my Endoscopy training, and my Trauma training, both of which are progressing well.

We have some more doctors arriving in the next couple of weeks, which should allow some relief from the current busy spell. In the meantime, apologies for not posting more frequently – I’m sure you understand!

Steve

Buy a man a fish...

…and you feed him for a day, buy him a rod and teach him how to use it, and you feed him for life.

Last week I witnessed Kiwoko Hospital’s own particular way of following this advice! For many years the hospital has had it’s own training school for nurses and laboratory technicians – I think initially set up to help train staff for the hospital, but now recognised as a good institution throughout Uganda. Friday was Graduation Day, and we saw all the trainees from the last two years come together to get their certificates. I guess it was much like a UK graduation ceremony – plenty of speeches, all extolling using God’s gifts wisely in serving others; a couple of songs/poems from some of the students; the handing out of certificates; etc.

Although the training school is separate from the hospital, we work very closely together, and I frequently find myself teaching the students when they are on the wards. This can be from informal anatomy, physiology, and clinical lessons, to describing different parts of a complex operation! The students (or their families) all pay to be here – a year’s tuition including food and accommodation runs to 1.6 million Shillings (about £500) which is a significant outlay – but this shows itself in their keen-ness and interest and desire to learn. I think the students here put UK students to shame – often they will have lectures/tutorials every morning, be on the wards for a full eight hour back-shift five days a week, and have all day teaching on the other two days. They’ll often study on top of this gruelling schedule, and still be keen for more!

It’s also been said that if you educate a woman, the whole community benefits. Certainly more than half of our students are female, and I think it’s very good to be helping women in Uganda find employment. Women are often treated as second class here, and there’s currently a media campaign trying to advise younger women from becoming subservient to older men, “Say No To Sugar Daddies”! This is also an important message in helping stop the spread of HIV/AIDS. If we can get women into employment after training them, they’re unlikely to find themselves in the position of only being able to survive by finding a man to support them.

I think that investing in people and helping them to help themselves has to be the best form of aid that the developed world can offer countries like Uganda. The actual cost of training is very little in UK monetary terms, and the benefits are huge. I’m very excited about starting to do some more training of my own. Our Endoscopy system is now up and running, so we’ll be actively looking for patients so I can teach Dr James & Dr Peter how to use it! Lots to do, but the normal hospital workload is quite intense at the moment with several doctors away, so the next few weeks will be busy. I’m on call tonight, and it’s been pretty non-stop, so I’ll keep this blog short, and hope to get some sleep later.

The only other thing I’ll mention, that will amuse everyone back home, is that I met my housekeeper’s sister this weekend – Helen is leaving me at the end of September to go to college to do a social work diploma, but she’s arranged for her sister who is just finishing school to come and replace her. There’ll be a few weeks gap before she starts, so I’m going to have to cope without a housekeeper during October! It’s going to be tough… although I’d better get used to it for my return to the UK in January!

Steve

Is that poop on my shoes?

I’d like to update this blog every week with more news of what I’ve been doing here at Kiwoko Hospital, Uganda, but the last two weeks hasn’t really produced much that is exciting enough to mention. We have had a number of staff changes – doctors coming and going – and that has meant a period of adjustment. At present we have three surgeons (myself, Dr Peter, and Dr James – a doctor previously at Kiwoko who has just completed three years of surgical training in Kampala), one community doctor (Dr Raul, who also helps with covering surgical on-call as he is a paediatric surgeon from Germany), and three other doctors (Dr Rory, Irish GP and Medical Superintendent; Dr John, Ugandan physician; and Dr Darius, a brand new Ugandan doc who is in between university and internship). As usual, there are other medical folk around: We have one UK elective student, and two Ugandan medical students at present (sometimes there is a short gap between UK elective students – normally we are oversubscribed and have a maximum of five at a time), and we also have another Ugandan doc doing some refresher training after several years away from clinical work.

As there are more surgeons, the workload has been slightly diluted, but we have had to cover more areas of the hospital as a result – I’ve spent slightly more time helping with obstetrics, and Caesarean section is almost certainly the most common operation I’ve done recently. I had a good experience on Sunday afternoon – I was called urgently to the labour ward to see a woman with delayed second stage of labour. The baby had started coming but had then stopped. As I could see the head, I thought of doing a vacuum assisted delivery and got the equipment ready, but the midwives couldn’t find the valve that regulates suction pressure! The baby seemed to be ready to come, so I encouraged the woman some more, and with her very next contraction I was able to deliver a healthy baby girl – my second normal delivery since I’ve been here, and my second since finishing fourth year of university twelve years ago! It was quite nice to feel a little superior to the midwives – normally I recognise my lack of experience and defer to their judgement most of the time… however, you’ll be pleased to hear that I got my just rewards for my pride: I stopped to talk with Dr Rory on the way back from the ward, and he pointed out that I had dirt on my shoes – in the process of pushing the baby out, the woman had pooped on me! Mmm, lovely!

We have a large number of children here with cancers. Lymphoma is relatively common, but we often find other large masses in young children’s abdomens. One such case was this morning. A 2 year old had a four-month story of an abdominal swelling. An ultrasound had suggested a solid mass, and he was admitted with malaria in the meantime. This morning he had fully recovered from his illness, and so we took him to theatre to try to remove the mass, or at least biopsy it. When we got inside his abdomen, he turned out to have a large tumour arising from his liver (not suspected from the scan). While I’m happy to attempt many more operations here that I would be back home (usually there’s no option but to do your best), I decided I had to draw the line at partial liver resections. Livers tend to bleed heavily, and without diathermy (electrical coagulation), I didn’t rate my chances! Unfortunately a biopsy was likely to bleed heavily too! Fortunately I was able to call Dr Raul, who had at least done partial liver resections on children before. It was very interesting to see his technique, which resulted in almost no blood loss – the next time I’m faced with the same situation, I’ll know what to do….

Part of my role here in Uganda is to help train local doctors and improve the facilities of the hospital. This has taken large steps forward in the last few weeks. I’ve started a weekly tutorial for the doctors in the management of trauma. Over the coming weeks I hope to teach many of the different skills required to manage a seriously injured person, with a combination of lectures and practical sessions. Ultimately I’d like this to culminate in the equipping of a “resus” room in our Outpatients Department (A&E/GP equivalent), so that rather than dumping an injured patient straight into a ward, where the nurses then have to find appropriate equipment, the doctor would go to the patient in a room where all the equipment was available – the patient can then be moved once stable.

I’m very excited about getting to do some Endoscopy in the near future too! We have received a donation of a fibre-optic sigmoidoscope, and a light/air source arrived last week. There are a couple of other things to sort out (not least getting the cleaning/disinfection process organised correctly), but hopefully we’ll be up and running in the next couple of weeks. Dr James & Dr Peter especially are looking forward to learning how to use the equipment. At present, Endoscopy (looking at the inside of the bowel with a flexible tube) can only be done in Kampala, and costs more than most people here earn in a month. If the doctors here can be trained successfully, we may get many more patients coming for the test, and it could even turn into a money-earner for the hospital, thus freeing funds for other types of treatment.

I’m also very pleased and encouraged by the amount of support the hospital and I have been receiving from home in the UK. Various people at my parent’s church have kindly given small donations, and they are holding a fund-raising auction soon: hopefully they’ll be able to use the money to sponsor a nurse’s training, as well as some of the other equipment that might be needed. My old hospital in Edinburgh has kindly donated some old Endoscopy accessories, and some drug prescribing manuals that should arrive later this week. And of course the emails and letters that arrive with news from home always encourage me. My Dad comes to visit in a couple of day’s time, the first of my family to do so, and I’m looking forward to a few other visitors later in the year too.

So all continues to go well here. Please remember the hospital, staff and patients in your prayers, as we seek to help those who would otherwise have no access to healthcare.

Steve

It never rains but it pours...

I’m sitting in my house watching a completely tropical downpour here at Kiwoko Hospital in Uganda. Although there hasn’t been too much of a wet season, and we’re now supposed to be in the dry season again, when it does rain it can be spectacular. So water is currently flooding over the deep gutters, and there’s a river running through my garden! I’m told that there’s been flooding throughout the UK this summer – perhaps things here aren’t so bad: I suspect in another hour or so it’ll be bright sunshine again! Everything stops when it rains here – so it’s a good thing that I’m having a quiet day today… it was a different story last week.

I must have operated on about twenty patients between Wednesday and Friday. There wasn’t a huge variety, but the majority of cases were quite big surgery. For some reason I had about six women all with some form of pelvic abscess requiring drainage. Two of these required their appendix removed at the same time (primary cause – not able to distinguish between appendicitis and salpingitis, but appendicitis is pretty rare here). There was also at least one large ovarian cyst.

So on Wednesday I managed to see all my patients before 8am, and was able to get started in theatre early with two laparotomies and a large hernia before lunch. Then there was a broken elbow to put in plaster, a deep wound in a heel to debride and resuture, and finally some skin grafting in the afternoon. I was especially pleased with the result of my skin grafting, as I haven’t done this operation in the eight years since I was a junior plastic surgeon, and even then it was under very close consultant supervision. My patient on this occasion was an elderly lady who had lost a large area of skin over her left shin as a result of chronic osteomyelitis, which had now been treated well. I’ll be taking the dressings off in a couple of days to see how well the skin has taken, but I’m very hopeful of a good result.

If Wednesday wasn’t busy enough, I had another three laparotomies on Thursday morning. We were just about to head for lunch when Dr Louis (a new Ugandan doctor) told us we had an emergency Caesarean Section – he isn’t able to do them without supervision – so I stayed and helped him with a woman who had had a significant pre-delivery bleed, and whose baby was showing signs of distress in the womb. He did a good job, and we were reasonably quick, but then there was another woman who was in labour and had had two previous Caesareans, so things would burst if we didn’t operate again. I did this one myself, and unfortunately reached inside the abdomen to find a free-floating dead baby and placenta with a uterine rupture. This woman was very lucky to survive, and it became apparent that she’d ignored the advice to have her baby by Caesarean in hospital and had instead been labouring for three days in an attempt to save money. Tragic.

Then there were three women who had had early miscarriages and required evacuation of blood and products from their uterus, and a huge neck abscess to drain. Later in the evening (I was on-call for the hospital on Thursday night), I also had another laparotomy for a woman to wash out and drain widespread peritonitis (pus in the abdomen) probably as a result of PID. So Thursday had about six major and four minor cases – and Dr Peter was away in Kampala, so there really was just me to do it all!

My biggest case of the week took place on Friday (fortunately the on-call was not too busy overnight, so I had managed a few hours of sleep). For once I was doing an operation within my normal specialty – a cholecystectomy and bile duct exploration for obstructive jaundice. Ultrasound scan had shown two large gallstones wedged in the bottom of his bile duct resulting in back pressure into the liver and making him yellow. Without laparoscopy (keyhole surgery), I had to remove his gallbladder through a large abdominal incision, and then I opened his bile duct to try to remove the stones. We don’t even have x-ray available in theatre, so I wasn’t able to see exactly how stuck they were, but I was unable to move them or even bypass them with a fine catheter. Back home in the UK we’d have closed up after leaving a drain for the bile, and tried to retrieve the stones by ERCP – getting them out through the stomach with a fancy endoscope – but I don’t think this is available even in Kampala. I decided I had to do a definitive procedure to relieve his jaundice, so I brought up a bit of bowel and joined it to his bile duct to bypass the obstruction. He seems to be doing well, so I hope my improvisation should work – I’ve never before even seen the procedure I attempted, but the principle seemed to be correct. I’m sure if any of my bosses back home are reading this they’ll be horrified!

So as you can see, I’ve done very little this week except operate – thus the fairly surgical slant to this blog. I know some of you were missing the medical instalments of life as a surgeon in rural Africa! For those who prefer slightly less gory detail, I apologise, and would like to say that I managed to get away to Kampala on Friday evening for a great Thai meal, a good night’s sleep in a decent hotel, followed by a successful shop on Saturday, and even the latest Harry Potter film in the cinema on Saturday afternoon! It’s not all work and no play, although the balance could be better sometimes!

Anyway, the rain is abating, so I’d best go and see what new patients we’ve acquired since this morning.

Steve

Africa is BIG!

Everything here in Africa seems to be a size bigger than in the UK. I’ve noticed this especially over the last couple of weeks during my short holiday from work here at Kiwoko Hospital in Uganda. Distances, heights and depths, animals, thrills and spills… I’m still trying to process a few of the things that I was able to experience, but I’ll share a few of the bigger ones here!

I guess the one of the first things noticeable about Africa, and Uganda in particular, is the huge sense of space. Uganda is unique in East Africa in that it has lots and lots of vegetation – it is a very green country, and most of what I’ve seen has been rolling countryside stretching off for miles in every direction. In actual size, Uganda is not much bigger than the UK in terms of area, but as it has about a quarter of the population, there is no sense in which the various towns and villages run into each other. It’s much more like rural Scotland in that sense. Even along the main road to the North of the country, there are places where you can see the road stretching off into the distance for miles, with no evidence of human settlement to be seen – and this is in a country where bypasses are not seen: roads bring people and help the local economy, so each town wants the road to go through it.

It takes a lot longer to get anywhere too. A lot of this is due to the state of the roads: serious potholes slow a journey down considerably, and it’s not sensible to go much above 50km/hr on any of the dirt roads, even a recently graded one. And of course the rain is much bigger here – when it rains, it really pours with huge rain drops that are much wetter than rain in the UK (?!) – but this means that dirt roads become quagmires and have to be crawled along, while potholes on surfaced roads become harder to see, both slowing down your progress.

The animals are bigger. We visited Ziwa Rhino Sanctuary on our tour. Uganda only has eight rhinos, two in Entebbe zoo and the other six in a sanctuary – basically a massive park with a boundary to keep poachers out. The plan is to re-introduce them to the National Parks in the country once they get a little older and have started breeding. For now, it is possible to track them, and even get to within ten metres of them on foot in the company of the rangers (who stay with them during daylight each day for their protection). Rhinos are huge! They really are graceful, majestic animals, even if they do look a little silly – but of course I wouldn’t say that to their face, not with the size of their horns!

Uganda doesn’t have quite the same level of game animals that you might see in the parks of Kenya or Tanzania, but levels are gradually recovering since the civil war 20 years ago that saw most of them killed by soldiers and poachers. I’m told that you can see herds of elephants containing more than 100 animals – but due to serious rain we stuck to a boat trip on the Nile (a seriously big river: the longest in the world at over 4000km!). So rather than lions and leopards, we saw huge numbers of hippos and crocodiles, plus water buffalo and a wide variety of birds. I’m also told that East Africa has about eight times as many bird species as the UK!

Murchison Falls is a huge waterfall. The whole volume of the Nile passes through a five-metre gap, falling 45 metres to continue its journey towards Sudan and Egypt. The power of the water moving so quickly and with such fury through such a small gap is quite awe-inspiring. I must say that I have a bit of a thing for waterfalls, but Murchison has to be the most dramatic I’ve seen for sheer power – bettering even Niagara (although admittedly I’ve not been there for about 18 years!). We got to visit the top of the falls (where there isn’t even a guard rail to protect you from getting too close to the water), where the sound of the water and the touch of the spray demonstrates exactly how powerful the combination of water and gravity can be – and we also saw the Falls from below on our boat trip.

From Murchison we visited Lake Albert, the second largest lake in Uganda, forming part of the border with the Democratic Republic of Congo. I was looking forward to seeing the famed Blue Mountains and the Mountains of the Moon (as the Rwenzoris are called), but it was unfortunately a bit too hazy to see to the other side. Lake Albert is big enough, probably as wide as the English Channel but long and thin, while the largest lake in Africa, Lake Victoria, apparently is big enough to lose nine times as much water from its surface in evaporation as flows out down the Nile towards the Mediterranean.

Lake Albert is near the top of the Rift Valley, the great chasm in the surface of the east side of Africa that in several million years may split off to form another tectonic plate. There’s also a huge oil field deep underneath which is just starting to be explored. Apparently there’s fifty billion barrels of oil just waiting to be extracted. I’m a little intrigued as to how they’ll manage to pipe that out, as the Rift Valley is an area of seismic activity – I’ve experienced two fairly major earthquakes here in the last six months: a very unusual experience!

And then of course there’s Kampala, the capital, home to only two million people, but always busy and full of life. The roads are crowded with minibus-taxis, and the main taxi park is an experience in chaos in itself! There are crowds and crowds of people covering the streets – everyone always seems to be busy buying, selling or just walking, walking, walking! It has a unique charm as despite all these people, the city feels very safe – it has very little crime, and has a friendly welcoming feel in complete contrast to other African capitals such as Nairobi (or Nairobbery as it’s known).

But that’s really the biggest thing about this country – the people. They may be small in stature, but they offer the biggest welcome that is possible. Everyone is genuinely pleased to see you, to stop and talk to you, to walk with you, to help you out if they can. This is despite their own poverty and lack of material things. Everyone wears the biggest smile you can see, all the time, white teeth standing out in the middle of a dark-faced grin! I’ve been reading Michael Buerk’s autobiography recently, and he mentions the contrast between the people of Africa, and the dull, dreary people of the UK when he returned from being African Correspondent for the BBC, based in Johannesburg. I’ve been told people here in Uganda are much happier than those in the West – “in the West you have things and God, here in Uganda we just have God” – and so they get on with life. Perhaps there’s a message here for those of us who grow up and live in the materialistic West.

Steve

The sounds of Africa

(Guest blog by Lizzie Stewart, visitor to Kiwoko)

Crickets, drying their wings
Cries of, ‘Hello, how are you?’ as you walk past people
Cries of, ‘Oli otya?’ as you cycle past people
Cries of, ‘A Mzungu’ as people notice you in car
The squeak, squeak, creak of the 4x4 after the wheel fell off
The other noises in the world you can hear once you’ve bent the brake drum back to the right shape!
Birds that tweet, sing and hoot
Birds that sound like mobile phones, alarm clocks, reversing trucks, dogs…
People praising God to prepare for the their day of work at the hospital at morning chapel
Intense roar of the waterfall at Murchison Falls, as the Nile forces itself through a 5m gap.
Shouts of joy and cheers as we navigated some more white water successfully on the Nile
Shouts of joy and cheers as we capsized through some white water on the Nile
Space, miles away from anywhere on the banks of Lake Albert
Crack of sticks as you creep around the jungle looking for the chimps
Gentle snoring of a sleeping rhino
Sharp intake of breath as the rhino, only 5m away, stands up
Even bigger intake of breath from the majesty of the rhino towering in the shade of the trees
Bang, bang, shoo of the keeper sending the rhino he loves off into the bush
Chatter and clatter of people milling around in the village, all going about their business
Broom, brum of the boda bodas taking people where they want to go.
Kampala, Jinja, Kiwoko, Luwero calls of the conductors touting for business at the taxi park.
Hiss and Crackle of the fires of the chapati makers and maize barbecuers beside the road
Rumble of thunder and the crack of the dry lightning flashing across the sky
Spit, spot of a wee rain shower
Spit, spot, sput of middle sized rain shower,
Plunk, plunk splash of an African rainstorm, run for cover under the nearest tree or veranda
Flick, rattle, fizz opening a bottle of soda.
‘Look over there’ calls of a game drive
Vroom of camera lens and Clunk click of a crocodile or hippo photographed whilst floating gently on a Nile launch boat
Crunch of tyres on murrum as the driver steers round the potholes
Thud of tyres on murrum as the driver drops the car into a pothole
Hum of the fridge now the power is on
Snap of the inverter when the power goes off
Hiss of the stereo when Uganda electricity load-sharing programme does not quite give 240V
Buzz of mosquitoes and the scratching of itches evidence of their last meal
Cock o doodle do of the cockerel – at almost anytime, day or night
Thud of avocados on the corrugated roof as they fall from the tree
Thud, thud, thud, thud of avocados on the roof as Steve shakes them from the tree
‘Well Done’ infested speech of Steve turning into a Ugandan
Satisfied licking of lips munching on the sweetest, yummiest pineapple you could ever eat
Creak, thud of fly screens shutting as you go through outside doors

Surreal transportation...

I’ve just started back doing surgery at Kiwoko Hospital today, after having a fantastic holiday for the last couple of weeks. It was really great to take some time off and rest, but I also managed an amazing trip around the Ugandan countryside! I could probably write a novel about all the different experiences, but I’ll try and sort out a few thoughts into more manageable chunks of blog! My first thought is to try and explain some of the many ways I’ve found of getting around Uganda!

First off must come what Ugandans call a taxi (Kenyans call it a Matatu – it is probably best described as a share-taxi/minibus). I’ve mentioned a few of my taxi journeys in previous blogs, and after six months in Uganda I’m getting fairly used to the joys of this particular form of public transport. The taxi-parks in Uganda look like complete chaos at first glance, but there’s always a helpful Ugandan to point you in the direction of the minibus going to where you want to go. Then it’s a simple matter of squeezing in with whatever bags you have, and waiting until it’s full. Of course full is a relative term, but in Uganda it’s actually supposed to be illegal to have more than people on board than there are seats! A lot of the time, this is a fairly loose concept, and especially in rural areas where there are no police checks its really a factor of how many can possibly fit. I’ve had 27 people including the driver in one minibus with seats for 14 before!

However, we actually hired a small 4x4 for our week of travelling around the country, and this proved to be a very sensible idea. It meant we could go where we wanted, when we wanted, and therefore enabled quite a creative tour to be created. The 4x4 was very necessary after it had rained almost non-stop for two days, as the dirt road between Murchison Falls National Park resembled a mud-wrestling pit for much of its length. In fact, the most extreme driving conditions were actually found in Kampala at the start and end of our journeys! Driving in Kampala is really just a giant game of chicken… The person with right of way at any junction or roundabout (or even just pulling off from the side of the road) is the person who looks least likely to stop for anything! After carefully negotiating a couple of roundabouts at the start of my driving experience, I must have started getting a slightly crazed look about me – very few other vehicles got in my way, and we were able to get about in a reasonably civilised manner!

I’m sure I’ve mentioned the state of the roads in Uganda before. The main road to the North of the country is supposedly surfaced, but is covered in some of the deepest potholes I’ve seen. I think some of them would swallow a whole lorry if they got the chance. Driving is therefore a case of finding the safest route through/around/over them, usually by weaving all over the road and the verges, while simultaneously watching for on-coming traffic doing the same and keeping out of the way of the taxis or buses coming from behind on either side (I think taxis are much like company cars in the UK – able to drive through potholes/up kerbs without any apparent modification!). The road to Kiwoko Hospital has become very potholed itself, and could do with a re-grading of the murram surface, but is negotiable at a slow speed. The World Bank is financing a resurfacing of the Luwero-Gulu road which made our journey north a little slow as they seem to just plough whole of the previous surface up before attempting any levelling or tarmac, but I was surprised to find the main road to Masindi was mostly newly surfaced.

The most dramatic part of our drive occurred on the very good dirt road into Murchison Falls National park – 20 minutes in and I suddenly lost control of the car, swerving violently into the ditch on the left, then the ditch on the right before managing to come to a stop in the middle of the road. It’s only by the grace of God that the car didn’t overturn, and other than a small bruise on an elbow, nobody was injured! Imagine my surprise when I went to check on the car and found that one of the rear wheels was missing! The nuts securing the brake drum to the axel must have been loose, and had shaken off during the bumpy journey. The wheel was attached to the drum, and was fortunately retrieved from the middle of a field of maize by a couple of helpful locals. I managed to get everything back together as by taking the nuts attaching the spare wheel to the back of the vehicle we had almost enough to secure both brake drum and wheel to the axel! Fortunately the brakes themselves were undamaged.

In the same week we had a superb boat trip up the Nile to view lots of wildlife and the amazing Murchison Falls waterfall, and then at the end of the trip we went white water rafting near the source of the Nile, which turned out to be exhilarating, great fun, and not particularly scary at all! Its just as well that there are no crocs in that part of the Nile, as our guide took great pleasure in allowing us to tip upside down in several of the rapids!

No tour around Uganda would be complete without a game drive – and we managed a sunset trip around the new Kabwoya Wildlife Reserve in the company of the owner of the Lake Albert Safari Lodge who also runs the reserve itself. To complete our set of motorised transport in one week, there was the obligatory Boda-boda ride between the Bujugali Falls on the Nile and The Source of the Nile at Jinja. This is basically a back-seat ride on a 50cc motorbike, often reaching terrifying speeds and winding in and out of traffic and potholes with abandon!

Our list of crazy transport isn’t quite finished, as in the second week of holiday we managed a couple of bike rides in the area around Kiwoko Hospital. A trip to the local town and back was a bit of a warm up for the hot weather and dusty road conditions, and getting three pineapples at the market for the equivalent of 30p was a definite bonus! We also managed a two-hour ride into the unknown to visit some of our students who were on community placement. This involved mostly recently graded dirt roads, but included a couple of sections where the roads were being improved by having mounds of clay dumped on them randomly. I hope they’ll be graded at some point, but it was great fun hurtling downhill at high speed over the bumps!

The most surreal (although seemingly completely safe) journey was also by bike. We visited our friendly Ugandan family at their homestead and after much fun, hot tea and games, ended up cycling back to Kiwoko in the dark. It was interesting to be cycling along pitch-black roads, passing people and other bikes without any lights, and being overtaken by a couple of vehicles and boda-bodas, especially when we had only two lights among three of us! It was completely crazy really, but at the same time actually surprisingly straightforward.

Who would think so much fun could be have just by travelling?!!

Steve

So what does it for you?

I know many people turn to alcohol or drugs, or adventure sports, to get that elusive feel-good factor in their lives, but I’m fortunate enough to be able to get it from my job. Working as a surgeon here at Kiwoko Hospital, Uganda, provides many opportunities for frustration and tiredness, but at the same time, there are often priceless moments when you know you’ve done a good job, and someone’s life has been changed as a result! What a privilege.

Two patients over the last couple of days have delighted me in this way. The first was on Friday afternoon - a Musee (Elderly Gentleman) was admitted with a story of two weeks of a tender swelling in his abdomen next to his liver. He had been seen the previous weekend and ultrasound by one of my colleagues had suggested a liver abscess, for which he had had some pus removed with a syringe, and had been placed on antibiotics. He had not improved, and had come back. I decided to operate so that I could drain the abscess and place a drain for irrigation, but when I opened his abdomen I found that the problem was actually a very inflamed gallbladder, with an adjacent abscess. It was a simple matter to remove the problem gallbladder and wash everything out, and I expect that he will be on his way home in a couple of days. It was great to do an old-fashioned general surgical operation, and the procedure was quick and straightforward. I removed over 130 gallbladders last year, but this was my first in Africa, and the theatre staff had not seen such an operation before.

The second patient was this lunchtime. A Ssebo (man) was admitted with half of his lower lip missing – his “friend” had bitten it off while both were drunk last night! I wasn’t sure how to replace the missing tissue, but hoped to be able to make a skin flap of some description. I was pleased to discover that he had such large lips (common in Ugandans!), that I was able to trim the edges of the defect and close the gap without difficulty. The end result was a neat line of sutures below the lower lip, and he was able to go home later this afternoon.

I’m sure that the feeling of taking a patient with an illness or injury, being able to do something to help in a practical way, and ending with a successful, aesthetic result, is one of the main reasons that I’m a surgeon. If you could bottle the sense of achievement gained, I’m sure I’d be a millionaire by now. Its funny – I’ve often said, ever since I started working as a doctor, that I enjoyed what I do day to day so much that getting paid for doing it was a bonus! Well, I’m putting it to the test this year – I don’t get paid a salary for working here in Uganda!

Having said that, I had a nice weekend away from Kiwoko last weekend. I ended up in Jinja at the Source of the Nile on Lake Victoria for the night on Saturday before dropping a visitor back to the airport on Sunday night. It was relaxing to go to a really decent, and cheap, restaurant, have a couple of nights sleep away from the possibility of being called to operate, and enjoy both the company of friends and some peace and quiet! Its important to remember to take time out to rest, and that can be forgotten easily when you live and work in the same place. I’m looking forward now to the beginning of July – I’m taking a couple of weeks holiday to go on safari, see various parts of the Ugandan countryside, and catch some adrenaline going white water rafting on the Nile. I think I’m about due a break!

No gross medical pictures this week. The child above is one of our adoptive Ugandan family who came to lunch with Rory and myself last Saturday. I don’t know what he was meaning by this pose, but it’s a cute photo!

Steve

What an exciting week...

Several fantastic things have happened this week. It’s often the small things in life that can make the biggest difference, and that sense is sometimes magnified a little here at Kiwoko Hospital, as surgery and life in rural Uganda is a long way from my previous life in Scotland!

The first bit of great news was at the end of last week. I have a young patient who was admitted with a fractured femur (thigh bone) and which the x-ray suggested had an underlying disease that we thought was probably a bone cancer. The combined experience of my cousin and brother (two orthopaedic doctors in Scotland) who gave me some great advice based on an emailed photo of the x-ray, was very helpful in deciding that it was probably an underlying infection rather than cancer, and this probability was confirmed by our visiting specialist from Kampala. Instead of an amputation, the girl faces several weeks of traction and antibiotics, and hopefully the bone will heal given time. She is a really friendly nine-year-old, who is stuck in a bed in female ward, so I took my laptop to the ward on Saturday evening and watched “Finding Nemo” with her – one of the few child-suitable DVDs I have with me in Uganda! She was so excited and enthusiastic about it (even though she speaks very little English) that every time I’m on the ward she asks when I’m bringing my computer again! I may have to do the same for a younger child on Paeds ward who is lying with her feet in the air for the next few weeks in order to get her femur fracture to heal (Picture above).

The next bit of amazing news came later in the week. Two endoscopes arrived at Kiwoko, having been donated as surplus to modern requirements by a hospital in Basingstoke. The possibility of starting to provide a diagnostic and therapeutic endoscopy service was one of my wish-list aims of the year here - one which I never suspected might be possible. We have been given two fibre optic scopes which will allow visualisation of the bowel from within – these are used with an eyepiece, which is perfect for Uganda, whereas the remote TV picture scopes used in most UK hospitals now rely too heavily on electricity for us here! I do still have to source a suitable light/air source in order to start using the equipment, but if none of my contacts in the UK are able to help, there is always eBay! I’m just really excited at the prospect of training the Ugandan doctors over the next six months, and leaving behind a new service that will really make a difference.

I got a call later that evening to let me know that Ethicon (Johnson & Johnson) have donated several boxes of sutures, which have finally arrived in Kampala. They very kindly offered to give me some sutures with blunt needles for use here in Uganda – this will help protect me against needlestick injuries, which is especially important given the HIV rate of about 9% in our local population. The sutures the hospital buys are sourced from India, China and Hong Kong, and are much cheaper than would be bought in the UK, but are not so good. Getting some sutures that I am used to will be great, and much safer for me to use.

The best news of all came with a phone call from my brother this evening! The government has been messing around with medical employment in the UK, and the end result has been that 30,000 junior doctors have been applying for 20,000 jobs to start in August. The whole thing has been a real mess, and many thousand of trained young doctors in the first few years of their careers are finding themselves unemployed. It’s a complete waste, and a political mess that I won’t bore you with – suffice to say that I’m very pleased that I have a job to go back to in Edinburgh at the end of the year, and have been able to watch the disaster unfold from a difference.

Unfortunately my brother has been caught in the middle of the scramble for jobs, and had three interviews recently, finally finding out at the weekend that he had been unsuccessful in getting a job for August. The whole saga has been very drawn out and confusing, and actually he was very positive about the possibilities of a year of locum work interspersed with other non-medical activities such as building a house. However, he heard this evening that there is a job for him for the next six years after all, and not only that, but he’s able to stay in Glasgow where he’s currently settled. What an answer to prayer! As he’ll continue to live fairly near to our parents, it means that there’s less family pressure on me to return to Scotland, as at least one of us will be within an hour’s distance from the parental home… Only joking Mum, I’ll be coming home at the end of the year as planned!

So plenty to be upbeat about this week – both within Uganda, and from back home in the UK. I’m on-call again for the hospital tonight (its been a busy couple of weeks), but its relatively quiet so far. I had an unusual experience earlier though. We had a mother who had been in labour for 24 hours, and was not progressing despite medicinal help with her contractions. There had been no change in the lie of the baby for four hours, and the cervix was no more dilated, so I decided that the baby was stuck above the pelvis and prepared theatre for a Caesarean Section. We had five 1st year nursing students in maternity all of which wanted to see their first operation, so theatre was full of excitement with many people around when the mother arrived in reception. I was just discussing with the anaesthetic nurse what anaesthetic technique we would use when I was called urgently. I arrived in the reception to find three theatre staff and five nursing students standing around a woman on a trolley who had decided that she didn’t need an operation after all, and was delivering her baby there and then! I was handed a pair of gloves, and then performed my first normal delivery in twelve years! I’ve delivered several dozen by C-section and one by vacuum since I’ve been here, but this was the first normal delivery since I was a medical student. The midwife arrived a few minutes later and was surprised to be faced with a healthy baby boy! I guess the bumping around getting the mother onto first one trolley to get from Maternity to Theatre, and then another in theatre itself must have jolted the baby from its position. However it happened, we were delighted with the outcome, and the students were able to witness only their second delivery.

So, there has been much joy and excitement here this week. I hope life is just as interesting wherever you live and work. God bless,

Steve.

They didn't put this in the job description...

Aside from some very busy weekends and nights of operating, the last few weeks have been relatively quiet at Kiwoko Hospital, Uganda. There hasn’t been a large amount of day-to-day surgery (possibly because I’ve done it all at the weekends!), and it’s been good to relax a little, catch up on sleep and enjoy being in the middle of rural Africa.

This weekend I was hugely reminded that our nice rural setting is actually the middle of wild Africa – courtesy of a gigantic 4 metre long snake! I was out with Dr Rory on one of our cycling expeditions into the local countryside, and about 40 minutes out, we stopped to visit a small homestead where Rory had met several football-mad boys on a previous occasion. They were very excited to show us their evening’s entertainment from a couple of nights earlier – a huge snake had made its way into their front yard, and was recognised as one who had eaten a whole calf earlier in the month! Around nine small boys had attacked it with sticks and panga knives, and had succeeded in killing it without getting injured themselves in the process! The boys proudly took us to where they had buried their snake, and dug it up for us to see! The monster pictured above was the result!

Its very easy to assume that things are very safe here at Kiwoko – the main annoyance is the insects and mosquitoes, with the occasional small rat or grass snake seen escaping into the bushes, and the only really scary animal being one of the many long-horned cattle that graze freely in the area. However, there is a lot of African wildlife around, as demonstrated by the size of that snake… And I’m aware of people being brought to the hospital with injuries sustained from crocodile bites, and even a leopard mauling, sustained only 15 miles away! However, we have good security guards on the hospital site, even if it is slightly scary seeing them patrolling at night with a homemade bow and arrow!

Sunday afternoon’s cycle ride was great for more than just the snake. The family we visited were rural subsistence farmers, with ten girls, nine boys, three mothers and a father all living in five mud huts surrounded by a boundary hedge – a really beautiful little compound. The boys would go out and look after the cattle, the girls would help with digging the ground for their crops, and they seemed to survive very well, if very basically. Being out in the middle of nowhere, two Muzungus on bicycles were the centre of attention for a couple of hours! The bicycles were rapidly borrowed (along with the excitement of a pair of Oakley sunglasses), and great fun was had! We were welcomed to Chai (hot milky tea), pineapples, bananas, and an impromptu Ugandan music and dancing display, followed by a photo-opportunity for their milk-jug collection (!!). Rory was lucky to escape getting married off to one of the twenty-something daughters, and two of the nine-year old girls seemed to be getting promised to me, so we stopped the chat and played football with the boys for a while!

Ugandan people are so welcoming and hospitable; it is sometimes difficult to know how to respond to their generosity, especially when it is obvious how poor they are. There is a danger in insulting them by refusing what they offer, and you want to respond in kind without being seen as a rich condescending westerner. In the end, we escaped without any extra gifts, and left behind a small plastic football, with promises to return again soon.

The social side of life here at the hospital has picked up a little recently as well. I’ve been getting involved with playing some volleyball with the some of the students, and have enjoyed various times of music with others. I have a number of budding guitarists who are very keen for me to improve their knowledge of different chords and rhythms, which is also great fun. I have another visitor from Scotland arriving on Sunday, so it may well be time to arrange another ceilidh (Scottish country dancing) in the next couple of weeks.

Thanks again for all the emails, letters and comments I’ve received over the last few weeks. Its quite exciting to get random messages from people I’ve never met who have been reading this blog – isn’t the internet an amazing thing! Everyone’s prayers, support and encouragement are most appreciated. God bless, whatever part of the world (safe or unsafe) you may be in at the moment!

Steve

Money Makes The World Go Round...

I’ve been struck again this week at just how much poverty affects people in Africa. I know that I live and work in a rural area of Uganda – Kiwoko Hospital is in the Luwero Triangle, the area previously torn apart by the civil war twenty years ago. That’s the reason the hospital is here – An Irish GP came here just after the war finished, when there was no healthcare available for the people living here, and started seeing patients using the shade of a tree as his clinic! Its testament to God’s grace and provision that in merely 20 years the place has progressed to a 250 bed hospital offering some of the best healthcare in the country.

Its very difficult to see patients on the ward who can’t afford the cost of a matatu (public transport, and very cheap really) to get to Kampala, let alone the £15 that a proper Ultrasound scan or Contrast X-ray would cost. We end up providing care based purely on the clinical skills of the doctors with a few limited laboratory tests that may not be particularly reliable. We often even have patients’ attendants asking for money to provide food for themselves and their patient (basic personal care and food is provided by relatives who stay with the patient, often sleeping underneath their bed at night). We are able to help in a number of cases, due to our Good Samaritan Fund, money kindly donated from overseas, which should mean that no-one is turned away from the hospital because of lack of money.

However, Muzungus (white people) are seen as having lots of money… I guess, compared with the local people, we are pretty well off. I’m fortunate enough to be supported while I’m working here by Skillshare International, who give me a small monthly allowance – which in UK terms is next to nothing, but compared with salaries here is possibly four times as much as our nurses get paid each month. The perception is that we have much more, and earlier this week I was asked by one of our students if I could help sponsor her studies. Tuition Fees are about £400 a year, which includes accommodation and food as well as the studies. Often women in this culture take second place to men, and this particular student is facing not being able to complete her course because her brother has now got a place at university, and the family only have money for one child to be able to study. Somehow, the ability to buy CDs and DVDs each month back home seems less important in comparison to helping someone train to get a good job and help to support a family in the future. In one way, its difficult to help one person, rather than all the others who are often in similar circumstances, but at the same time every little helps.

Meanwhile, Surgery here at Kiwoko hasn’t got any quieter. I was on-call this weekend again, and ended up performing 17 operations in addition to reviewing all the medical and surgical patients each day (fortunately someone else saw the paediatric and neonatal patients), and seeing the new admissions. I’d thought that Saturday was busy enough, but Sunday was again the busier day, and I was up from 0345 operating on two emergency Caesarean Sections. Then later in the day, another emergency section – this time the baby unfortunately didn’t survive due to the length of time it had taken for the woman to get to hospital, and in the evening four more operations including two laparotomies for peritonitis and another section. Not such dramatic pathology as the previous weekend, but still quite a variety – draining bones for osteomyelitis, opening abdomens to remove appendices and wash out pelvic abscesses, along with delivering babies with varying degrees of difficulty. I was again completely exhausted on Monday and was fortunately allowed the afternoon off to rest!

Somehow the workload, although tiring, doesn’t seem so much of a trauma as busy weeks back in the UK. Being on your own, making important decisions at all times of the day or night, performing surgery without trained assistants, should make things much harder than back home where there are always other people around to help share the work. However, when you recognise that you are doing what you love doing (Surgery rocks!), for a people who really need your help, and when there’s nobody else to do it, small things like being barely able to stand up due to exhaustion don’t matter so much! It’s going to be difficult to leave at the end of the year!

Hopefully things will be a little easier soon. There’s a doctor from Edinburgh coming out to help for a couple of weeks, who could make my workload easier for the next time I’m on call for the week! Also I have a holiday to look forward to at the beginning of July. The plan is for a bit of a safari in the North west of the country, followed by a bit of white water rafting on the Nile, and a few days of rest and relaxation. It’ll be good to recharge the batteries!

I hope that you are able to see yourself making a difference in the lives of others wherever you are just now too.

Steve

Too Much Talk...

I’ve found myself speaking a lot in public recently. Apparently the locals don’t mind this, as I seem to have a clear British accent which they mostly have no problem in understanding. Some of these occasions have been fairly straight-forward, such as leading the music & singing at our daily morning devotional meeting. As Kiwoko is a Christian Hospital, we have a daily meeting with some sung praise and worship, a short talk, and some prayers, which is a great way of starting the day.

On Friday afternoon, I was faced with a more involved talk – I discovered that I was on the rota to preach at the local church on Sunday morning. Nobody had bothered to tell me, and the fact that I’ve been going to one of the other local churches, rather than the one attached to the hospital, didn’t seem to matter. At least the service is in English rather than Luganda, and at least I wasn’t planning to be away this weekend, as I had to spend Saturday morning putting together a sermon!

Tomorrow is another talk – medical this time – at another of our Hospital Grand Rounds. This one is on Burns, so I’ve just finished putting together a short talk on “Ongoing management of Burn patients” dealing with things like dressings, skin grafting, surgery, complications, etc. I’ve managed to take a few pictures of various patients we’ve had here over the past weeks, and will hopefully keep it short and simple to cater for the various grades of staff who will attend to be educated. I think its mainly aimed at nurses and nursing students, although the whole hospital is invited.

We’ve actually had quite a number of patients with burns recently. There has been a bit of an epidemic of men getting set alight after being dowsed in petrol (a common form of punishment here!!!), young women getting boiling water thrown over them by neighbours, and children pulling hot food onto themselves or crawling into fires. Sometimes it takes a long time for patients to get here, and we’ve had a couple of kids die shortly after admission as they had lost too much fluid before we could get to treat them. Its tragic, and the majority of childrens burns are due to the cooking method’s in this part of Uganda – most food is cooked on a small charcoal stove sitting on the floor, which is usually fairly unstable and easily pulled/knocked over. The sad fact is that gas and electricity, which would both be safer, are financially out of reach of almost all of the people in this part of the world.

Its also difficult to treat burns here. A number of local remedies applied before attending hospital (including such superb treatments as rolling in ash and animal hair) make infections much more common. Dressings are expensive and we don’t have the number of nurses required to change dressings well regularly. For what we can do - which is usually resuscitation, exposure, keeping flies off, and skin grafting when needed - we actually do pretty well for most of our patients.

The next medical talks I’ll be doing is for our doctors and clinical officers – namely a series of tutorials on surgical topics for those who don’t specialise in surgery. I’ll be doing some stuff on Ano-rectal conditions (not particularly well managed here, yet!) and Trauma Management. I’ve also found a patient with varicose veins (not common here, but one of my specialist operations), and have both of our other surgeons and a number of theatre staff requesting to be present to watch what I do!

And then I’ve also been asked to preach a series of three talks at our morning meetings. We’re doing a series looking at some of the kings of Israel from the Old Testament, looking at what we can learn from their characters, their strengths and weaknesses. We’ve had King Saul and King David already. King Solomon is next week, and then I’ve got three talks on… King Manasseh. Hmm, very well known as the son of Hezekiah. There are 23 verses in the book of 2 Kings about him, rather than the chapters available on the other kings we’ve looked at. Oh well, I guess my evenings will be fairly full for the next couple of weeks as I sort all of these things out.

So as you can see, there’s a lot more to being a Surgeon in Uganda than just operating. You also have to be a Teacher and a Preacher among other things! Still you can’t do Brain Surgery every day…

Thanks for all the comments, and personal emails I’ve been receiving. Support and interest from overseas is incredibly welcome and appreciated. The hospital is also very grateful for some of the equipment that has recently been donated, with some to arrive later in the year. We now have a Sigmoidoscope, and will shortly be receiving a couple of flexible endoscopes. A hospital has also kindly donated their old image intensifier (theatre x-ray machine) which will improve our orthopaedic management considerably, and which should arrive before the end of the year. Thanks also for praying about our staffing situation. Our two local junior doctors have decided to remain with us for the time being rather than moving on elsewhere, which is a considerable blessing.

I hope life is as interesting and varied wherever you may be at the moment.
Steve

The Natives Are Restless...

I made the mistake last weekend of thinking that surgery here at Kiwoko Hospital, Uganda, was becoming somewhat routine. However I’m not sure if it was because of a full moon, but I was on-call all weekend and admitted three different people who had been attacked by their fellow-Ugandans wielding pangas (a large jungle knife). I’m fairly used to seeing the results of human disagreements, with plenty of stab wounds of various degrees occurring most weekends back in Edinburgh, and I’ve even had to take someone to theatre with lead in their abdomen after being shot with a sawn-off shotgun. I’ve even seen the results of panga-injuries before, having put back together half a face that had been taken off.

The weekend’s collection involved head injuries. The first on Friday evening, someone who had managed to open the front of their skull into the sinuses causing significant bleeding; he had been out drinking the night before, and by the next evening managed to get himself to hospital, unsure of what had happened! Then I was woken at 5.30 am on Sunday morning with a teenager who had been attacked by her husband the previous evening – she had deep injuries to the muscles of her back and forearm, a near-complete amputation of half of her hand, and a slash to her scalp which had managed to slice open the top of her skull like a tin. I was able to close all her wounds, but unfortunately the hand could not be saved, other than her thumb.

In the early afternoon, panga-casualty number three arrived having been attacked by his friend on the way back from the pub the night before. He had attended a local health centre who had noticed a large slab of bone sticking through his scalp and referred him for further management. I ended up doing open brain surgery as I removed blood clot and traumatised grey matter from where the panga had sliced straight into his frontal lobe, before stitching the edges of his dura (the brain’s cover) back together, replacing some bone, and closing his scalp! I’m not sure I recall ever before even seeing the inside of someone’s skull while they were alive, let alone performing brain surgery, but the patient made a great recovery and went home two days later! Whether his personality is changed at all by the loss of some of his frontal lobe will probably never be known by anyone here at the hospital!

These two patients on Sunday proved to be only a part of a full day in theatre which saw me operating on various emergency patients almost constantly between 8am and 2.30 the following morning. There was a baby with a neck abscess, a 3yr old with an open finger tip fracture and nail bed injury, a man with necrotic small bowel and sigmoid colon following an internal hernia who required two resections and bowel anastomoses, a Caesarean section for obstructed labour in a poor teenager who had been raped nine months earlier, an obstructed groin hernia, and a foot which had been injured with an axe. Then I was up again with an ectopic pregnancy early the next morning. All in a day’s work – neurosurgery, orthopaedics, paediatric surgery, plastic surgery, obstetrics, general surgery, colorectal surgery and gynaecology, in most of which I have limited training if any! But then that’s why I’m here – helping those who would otherwise not have any access to healthcare.

On Thursday afternoon, there was another major injury – this time accidental as a woman who had dropped a mirror attended with a laceration to her forearm. On closer examination in theatre it became apparent that she had sliced the entire contents of the palm side of her arm. I ended up rejoining three nerves, two arteries and about eleven tendons in a three and a half hour operation. I had concerns that the blood supply wouldn’t be good enough, but the next morning she had a warm pink hand, so what I repaired had obviously worked. The challenge for this patient is getting the hand moving again over the next few months. I put the arm in a plaster splint to limit finger extension, and made some cunningly-placed rubber bands passively flex her fingers, allowing my repaired tendons to move without tension. She came back for review again today, and I hope will return for regular physiotherapy. Unfortunately the aftercare of patients is very haphazard here, and we regularly see patients returning pieces of metal such as external-fixators which they have removed themselves, and they often ignore advice about the length of time a plaster cast should remain in place. We’ll have to see how this lady allows us to help with her hand.

After all that, I needed to get away for the weekend – so I went to Jinja, the source of the Nile, and spent Saturday white-water kayaking on Grade 2 rapids. As I’ve not canoed for years, that was quite scary enough for me, and great fun. The major coincidence of the day was meeting the person in charge of the kayaking operation, and discovering he was the younger brother of someone I was at medical school with! It’s a small world. I can heartily recommend “Kayak-The-Nile” to anyone interested in a great day out, run by Jamie Simpson, brother of fellow doctor, Gavin!

And so it’s been back to work again today – with some mostly straightforward stuff to counteract the adrenaline-inducing activities of the last two weekends. But still the memory and story to dine-out on for a while yet – I’ve been doing Open Brain Surgery!

Steve