A very un-African New Year

I still find myself thinking of Kiwoko Hospital in Uganda frequently, recalling the life that I lived there over two years ago with fondness. One obvious and major difference between Edinburgh and Uganda this New Year has been the weather – for once the UK has had a proper cold spell with winter weather that has now lasted over two weeks! I suspect my friends at the Equator have been suffering with the beginning of the dry season, temperatures of 28-30 degrees (Celcius), and a distinct lack of water. Here we’ve had more snow than I’ve seen in Edinburgh in over 15 years, repeated snow-falls, temperatures dropping to -14, and plenty of ice. It makes a nice change from the usual dark, wet, windy pseudo-winter that we usually suffer each year, and I’m all in favour of it, especially as it happened over Christmas.

New Year was spent in the middle of Edinburgh’s Hogmanay Street Party for the first time this century! We wrapped up well, took a hip flask of a rather nice Tobermory 10 year old, and joined the crowd for some live music, dance and banter. In fact midnight itself was seen in with a rather flamboyant Cuban band and some Latino music. And the fireworks were magnificent. It turned into a late night as we went on to another friend’s party, very handy at a flat overlooking Edinburgh Castle. I’ve had much quieter New Years in the recent past, so it’s good to remind myself that I can still enjoy myself even as I get older!!!

My friend Mark from Uganda wouldn’t have coped with the cold. I Kiwoko hospital again in October, and brought him back for a few weeks to the UK, which was a fantastic experience for both of us. It’s surprising how much you can squeeze into a short space of time. I had only ten days in Uganda on this occasion, but found myself working (Dr Peter tends to take some time off if he knows I’m visiting!), and it was good to find a couple of patients specifically attending to see me. One was a lady with intermittent jaundice due to gallstones and I was able to unblock her bile duct and remove her gallbladder – an operation the local surgeons wouldn’t have been comfortable doing. The other was a patient with swallowing difficulties. I was able to use the Endoscopy facilities that were still working well (see previous notes for details of setting up an Endoscopy Unit in 2007), and unfortunately found he had a large obstructing oesophageal tumour. Here in the UK we would have seen if the tumour had spread by means of a CT scan before deciding on surgical or oncological treatment. However, this man couldn’t afford the cost of a bus to Kampala, let alone the CT scan (albeit only costing £15), and I didn’t think that taking on such a major operation as an oesophagectomy without the back-up of an intensive care bed was very sensible. The best I could offer was a plastic stent to allow him to swallow food again – fortunately I had brought one of these out with me previously, and this was successfully put in place. It’s certainly not a cure, but hopefully he’ll at least have some quality of life over the next six months before the tumour spreads further.

Back in the UK with Mark, we found all sorts of things to amaze a person from Uganda who’s never travelled outside of his country before! I think the whole experience was a little overwhelming, but he went home with lots of photographs and a better understanding of our part of the world – people in Uganda get many visitors from the West, but have a number of inaccurate preconceptions of how life is here. Hopefully Mark will be able to address this. He was particularly impressed at our street-lighting and the orderly nature of the traffic on our roads, and amazed at the cost of living.

We managed a few days sightseeing in Edinburgh and nearby Scotland, a few days in London, a week at my UK hospital, and finally meeting up with several UK friends who managed to visit while he was here. Particular highlights included staying next-door to the Queen (a hotel near Buckingham Palace), taking in a show (Grease seemed to be fairly straightforward to follow), and of course tube and train travel. The main reason for his visit was to get some experience of Theatre Nursing in a UK hospital, and my colleagues at Edinburgh Royal Infirmary were very friendly and willing to show him how we do things here – hopefully he’ll have several thoughts that may be helpful back at Kiwoko. The main surgical difference he noticed – laparoscopic (or keyhole) surgery, which he found very exciting as its not seen in the hospitals he’s been in in Uganda.

But here I am at the beginning of 2010, with my final Surgical Exams in less than six weeks. After that I plan to get out and enjoy myself a bit more with skiing trips, mountaineering trips and social outings planned! I’ll need to focus then on what I do when my contract here ends in October – the options probably being to find a Consultant Surgeon job here in Scotland, or to head back out to work in Uganda again... not an easy decision – I’ll let you know how it works out!

Steve

I left my heart in Uganda...

It’s been far too long since I last posted, but this blog was really supposed to be a record of what I was up to in 2007 when I was working as a Surgeon in Kiwoko Hospital, Uganda. I returned for a visit recently, and realised just how much I missed working there, and just how unsatisfying I am finding my current UK life. I think there are a number of reasons for this, and I probably need to sort out a few of my issues here in Scotland before making definite plans to return long-term – although this is a definite possibility!

Living in community is a big feature of Ugandan life, and something we don’t do particularly well in this country. There’s something very wonderful about living as part of a Mission Hospital community. Although living in my own small house, my immediate neighbours included several other ex-pats, and most of the Ugandan staff lived on site too. There’s always other people around, and Ugandan’s are the most friendly, genuine, respectful and welcoming people I’ve met. Starting each day with your colleagues in a short service of worship, teaching and prayer before heading off to live out your faith together in all that you do at work is an amazing and energising way of life!

At present I’m working a couple of hours away from home, so I live in the hospital during the week and only get back at weekends, so I’m completely missing any sense of community at present. It’s difficult not to feel very isolated, and it’s hard to meet up with friends when you only have limited time in the same city. I’m also studying for more professional exams, further keeping me away from being sociable! Hopefully these things will improve when I move back to my local hospital in August, and get the exam out of the way.

Working as a doctor in Uganda is also incredibly rewarding. If you read some of the other posts below, you’ll realise just how obviously worthwhile is everything you do there. Patients only come to hospital when they have something reasonably seriously wrong, and often they can’t afford to go anywhere else for help. The buck stops with you, and you do the best you can to help, knowing that there’s no alternative. The vast majority of patients recover well from their operations or other treatment, and are very grateful for all you have done (and I must give a lot of credit to God for many miraculous events I’ve seen along the way!). The work is hard, time consuming, and thoroughly satisfying!

A lot of the time work in the UK seems much less satisfying. Patients are much more demanding, they expect to have perfect health and often blame the doctor when this isn’t the case. Work time is limited by European Working Time, and so work-patterns involve a series of shifts and handovers of patients – there is less of a relationship with patients and less continuity of care, which ends up being demoralising. The emphasis is on patient throughput, and often you don’t again get to see patients you’ve admitted or even operated on! I’m envious of the surgeons of 30 years ago who enjoyed much more autonomy, and were able to practise in a more holistic way. Perhaps this side of things will improve once I complete my specialist training and become a consultant next year.

Spiritually things are harder here in the UK too – it somehow seems easier to totally depend on God for everything when you’re in an environment where there is little else. As one Ugandan said to me, “In the West you have God and things, here we just have God!” There is a definite tendency when one has much to depend more on yourself and what you have rather than surrendering everything to God’s care. That’s another challenge for me here in the UK.

Meanwhile I continue to enjoy great friendships with many Ugandans who stay in touch through the occasional email or phone call. It was fantastic on my recent visit to be welcomed back in such a loving way, and it’s very encouraging to feel so obviously wanted and loved. I’m surprised I’ve still not settled back into the UK after well over a year... perhaps Developing World medicine really is my calling!

Steve

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