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

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