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