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