Do you want to make God laugh?

Tell Him your plans! At least that was what my former minister said (Rev Dennis Lennon, who sadly died recently). I sometimes feel that God’s been able to laugh at me a lot. It’s now over three months since I returned to Scotland from Uganda, and I’m still finding it difficult to settle, workwise. Surgery at the Royal Infirmary Of Edinburgh is a very different work environment from surgery at Kiwoko Hospital in Uganda, but I think it’s more the type of surgery that I’m doing that is causing me difficulties.

I still have two and a half years of specialist surgical training to complete before I become a consultant. My plans had always been to specialise within General Surgery and become a Vascular Surgeon (arteries and veins outside of the heart) – the fine, technical nature of the operations was stimulating; the patients were generally in hospital for slightly longer than a lot of surgical patients, allowing for a better doctor-patient relationship; and the out of hours work is usually limited to exciting emergencies!

However, over the last two months I’ve come to realise that this doesn’t stimulate or interest me any longer. I crave the variety of operations the Generalist Surgeon is able to perform; I enjoy keyhole surgery which isn’t a feature of vascular surgery; I’m already bored of varicose veins; and there is much less of a sense of admitting a patient, diagnosing them, operating on them, getting them better, and discharging them – all too often our vascular patients have multiple medical problems that are difficult if not impossible to sort out, and frequently there is no treatment option other than amputation of a limb, often resulting in a patient who never recovers to get out of hospital.

Fortunately my director of training is very understanding, and has agreed without any problems to enable me to change the direction of my training. I’ll stay where I am for a total of six months, as there’s lots to learn here that will be useful for any type of surgery, but then I’ll continue training in a more General, Gastrointestinal Surgery. The choice then will become where to work as a consultant, and I’ve been finding out a bit about Remote and Rural Surgery in Scotland, which sounds very similar to what I was doing last year in Uganda.

I guess I’m waiting for God to make it clear to me that I’m to go back to Africa, something I’d love to do – but that will have to come from Him, as I’m sure I couldn’t cope if I didn’t have His complete help and support! Still, last year wasn’t my idea at all, and yet I’m sure it’s what He had in mind for me. As Proverbs 3v5 says, “Trust in the Lord with all your heart, and lean not on your own understanding. In all your ways acknowledge Him and He will direct your paths.”

Steve

Life in the UK doesn't completely suck!

I’ve been having a fairly depressing time since returning to Scotland from Uganda – the weather in January was miserable, it’s been a little overwhelming to reacquaint myself with old friends, life is very over-regulated, and returning to work in the NHS hasn’t been easy. However, on Saturday I found myself saying, for the first time in six weeks, “I’m glad to be here today!”

I was standing on top of a mountain at the time, Carn Gorm, north of Loch Tay and Ben Lawyers. The weather was fantastic – sunshine, crisp coldness, no wind – and as a bonus the only clouds were in the surrounding area, with temperature inversion causing only the tops of the other big mountains to show through. It was glorious, the early start totally worthwhile, and the prospect of three more mountains to climb during a circular walk turned the whole thing into a fantastic day out. This is definitely one of my favourite things about living in Scotland. On the right day, being able to get out of the city and up a big mountain within a couple of hours is unbeatable.

Rather than moaning about the last six weeks (which is also one reason why I haven’t posted recently), I’ll try to focus on the positives! I may have been less than enthusiastic about the weather, but the comparison between the constant dry, sunny, 28oC of the Ugandan dry season in December and early January, and the wet, cold, windy, darkness that greeted me for the whole of the rest of the month, was difficult to ignore. Fortunately February has been more than making up for it. It’s been mostly dry, cold but bright, and the days are noticeably getting longer. In fact this week I’ve been cycling to and from work in daylight.

It’s been good to get back together with friends, all of whom have been fabulously interested in what I’ve been doing over the last year. Kiwoko Hospital has been a great place to live and work, and the people there are frequently in my thoughts. It’s been superb to relive many memories of the year as I’ve had various dinner parties, short presentations and catch-up chats, often accompanied by brief photo-sessions. I hope that I’m opening people’s minds to how a good proportion of the world lives, something not often greatly realised by people in the West. I’ve also been very gratified by the number of Ugandans who have been in touch. A number of the nursing staff (male and female!) have been in touch by email and texts, and I’ve spoken with my former housekeepers several times, keeping in touch with what’s happening in their lives. I also have one former hospital staff member (currently studying in Belfast) coming to visit next month, which I’m looking forward to enormously.

Working in the NHS again hasn’t been the most pleasurable experience, although things are getting better as I settle in. From being my own boss, solely responsible for my own patients, I now have to work for five different consultant surgeons, sharing responsibility with four other middle grade doctors, and supervising a number of more junior doctors. It isn’t helped by the type of surgery I’m doing just now – there was hardly any need for vascular surgery (arteries & veins) in Uganda, and I haven’t worked in the specialty for several years. It’s an odd experience from being the most experienced General Surgeon in a hospital to being unsure of how to manage most things because my knowledge is a few years out of date and from a different hospital setting. Add to that the fact that most of my patients are old with multiple other illnesses to manage (almost none of them encountered in the last year!), and I’ve been feeling a bit like a fish out of water. Still, a fortnight in, I’m starting to understand the system, and am trying hard not to harbour thoughts of putting most of my patients out to pasture!

One thing that has been good is the amount of surplus equipment and consumables that I’ve been able to collect – things that can’t be used in the NHS for whatever reason, but that can be used time and time again in a Developing World hospital – and which I’m hoping to take out to Kiwoko when I next visit, possibly at some point in the next few months.

Anyway, if I haven’t managed to catch up with you personally yet, get in touch – what are you waiting for? If you think you might be able to help Kiwoko Hospital in any way, get in touch! If I can offer any assistance to anyone thinking of going to Uganda, get in touch! I’m told that the real depression is going to hit about three months after getting back here... that means I’ve about six weeks to go!

God bless,
Steve

Out of Africa...

...and back home in Edinburgh! My year’s adventure in Uganda has come to an end, and I have safely returned, although I’m aware that a large part of me has been left behind and is still in Kiwoko Hospital. In many ways it’s a miracle to have made it home (there seemed to be a conspiracy to keep me at the hospital!). First off was the planned UK airports strikes, cunningly designed to impact my planned date of flying! These were fortunately called off well in advance.

Then came the situation in Kenya. Although obviously devastating for that country, the violence that has erupted there in the wake of the disputed elections has a much wider impact on the whole region. Most of Uganda’s imports come through the port of Mombasa, passing through Nairobi on the way to the border. This trade route was effectively closed, with the result that Uganda rapidly ran out of fuel. Unlike a western country where there would be reserves and a control on prices, in Uganda the few stations still able to sell fuel were able to inflate the price enormously. I’ve heard complaints from the UK about petrol reaching £1/litre, but in the space of a couple of days after New Year, people were paying £5/litre. In a country where a large part of the population earn less than £1 a day, this is obviously unaffordable, and resulted in most transport ceasing. My planned route to the airport – a public share-taxi, usually costing a couple of pounds at most – would have had to charge four or five times as much to cover its costs, which no locals could afford, and so wasn’t running. Fortunately I was able to get a lift with Dr Rory, who was heading to Kampala for the weekend, but meaning I left a day early and spent time in hotels in the capital and Entebbe instead.

The send-off I got from the people in Kiwoko was a bit overwhelming. We held a ceilidh (Scottish dancing) on my last night, following which several people were in tears as they said goodbye. The Ugandan locals had obviously welcomed me completely into their community over the last year, and were very sad I was leaving. For my part, I have made many good friends who I will miss terribly, both among hospital staff and locals, and will definitely return to visit soon.

And so I’m now back in a very cold, wet, windy, dark and miserable Scotland - just my luck to return in the middle of a few days of appalling weather. It’s been good to spend time with my family, and good to start catching up with friends again. In many ways it feels like I haven’t been away, with so much just the same as before I left, but I’m also aware that a year has gone by in everyone’s life here, just as it has for me. It’s going to take a while to settle back into life.

I have managed to get things fairly well sorted out in my flat; I have so much stuff here compared with in Africa. Now I’m here, there are various talks I’ll have to prepare for various groups that have supported me this year, and then various admin jobs to complete, such as my tax return, and sorting out a parking fine dispute from November which actually concerns a white van which has cloned my car’s numberplate while I’ve been away! Unbelievable! Then comes the challenge of reintegrating myself into the UK health system, when I start work again at the beginning of February. I'm still not sure what job I’ll be doing…

Anyway, to all those who have been following my adventures this year, I hope that this blog has given a good idea of what life is like in one part of the Developing World. It’s been a fantastic experience for me, and one that will stay with me for the rest of my life. Please do continue praying for the work of Kiwoko Hospital, and the staff and patients there, as they show a practical expression of God’s love for all people, in an area of great need. Check out www.fokh.org.uk for more information about the hospital and how to support it.

God bless,
Steve

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