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
Friday 25 May 2007
Wednesday 16 May 2007
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
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
Tuesday 8 May 2007
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
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
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