Mzungu bye-ee

“A mzungu bye-ee! A mzungu bye-ee! A mzungu bye-ee!”

I arrived in Uganda almost 7 months ago, and this rhythmical chant from the children of Kamuli has become the soundtrack to my life here.  Every day, unfailingly, they wave and chant as I pass by on my way to and from work or the market. Come rain or shine, their enthusiasm for the mzungu never wavers, and their infectious giggling when they receive a wave or hello in reply is enough to make anyone smile.   At first, the constant reference to my ‘mzungu’ status felt a bit odd, as if I was being singled out when I just wanted to blend in (which, obviously, is pretty tricky here), but I’ve come to appreciate it as one of the ways in which I have been made to feel special as a visitor to Kamuli.  And now, as I prepare to leave Uganda, it really is time for a mzungu goodbye.

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My final two weeks of work in Kamuli General Hospital were spent doing as many teaching sessions as possible, training staff in the use and maintenance of the newly donated equipment, and re-auditing the areas which we had been working on- namely triage and prescribing.  It was encouraging to see we had improved in both areas, and although there is still a long way to go, it has brought the staff and me satisfaction and motivation to see that we can improve care for the children in Kamuli.

The sickle cell clinic continues to run well, and it is exciting to see that we have now registered and treated over 100 children with sickle cell disease- a testament to the hard work of the clinic team here.  Through one nurse’s initiative we have also been able to begin screening for sickle cell disease- a test which was not previously available in the hospital. She saw the need for our patients and managed to link the sickle cell clinic with another service so that we can now send blood samples to Kampala for sickle cell diagnosis, and I am incredibly proud of her for enabling such a significant improvement to our services.  Our pharmacist has also brought initiative and organisation to our work by starting up a Drug Monitoring Committee, in order to continue and improve upon the work we have started with regards to the paediatric prescribing practice here.

It has been such a pleasure to work with motivated and dedicated staff such as these, and I am sad to be saying goodbye to many colleagues who have become friends over these past few months.  And what an experience those months have been. High and lows, many harrowing and devastatingly sad moments, but also moments of success, reward, surprise, pride, pleasure and even fun and laughter. There will certainly be fond memories to look back on from my time at the hospital, amongst the sad, shocking and frustrating ones, and I’m grateful to the staff who have supported me throughout them all.

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Final teaching session, with some mzungu goodbye cakes

The staff generously organised a leaving party for me, led by the wonderful Sister Prossy, which was a great evening of food, laughter, speeches and even an impression by the hospital administrator of “How fast Dr Kate walks”.  I was slightly concerned that my walking style may have been the only thing I’ve taught the staff, but it was hilarious to George striding rapidly across the room to cheers and laughter from us all.

Goodbyes with Sister Prossy and the hospital team

On my final day, I was invited to a celebration at a local primary school as their way of thanking the paediatric services at Kamuli General Hospital, after the principle’s nephew was treated on our ward.  The children were full of energy and excitement, and put on a wonderful performance of poems, singing and dancing to contemporary and traditional Ugandan music in their dusty school yard, despite the scorching afternoon sun.  Many had written letters to me in perfectly neat handwriting, about what they enjoy studying and what they aspire to be when they grow up, and I was impressed and humbled by their sincerity and motivation.  It was a very special occasion and I was grateful to be welcomed so warmly as a guest in their school.

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A visit to Kasambira Preparatory School

After many final goodbyes to my friends and colleagues, and a farewell dinner with my wonderful Ugandan family who have made me feel so welcome in their home and lives, it was time to say goodbye to Kamuli.  There wasn’t too much time to feel sad though, as the end of my work placement signified the beginning of my holiday with Joe and my friends Claire, Lizz, Matt and Stuart who have been volunteering in Uganda and Kenya.

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Farewell to Fred and Prossy, Sister Prossy, and my lovely home

We had a wonderful few weeks visiting beautiful places in Uganda and Rwanda, and managed to see and do so much in that time. We started with a trip to Ishasha in Queen Elizabeth National Park, where we were lucky enough to see the unique tree climbing lions, who escape the afternoon heat of the savannah by climbing into the shaded branches of huge fig trees.  Another real highlight was a visit to the mountain gorillas in Bwindi Impenetrable Forest- a truly incredible experience being so close to these fascinating animals.  The hour we spent in the forest with the Nkuringo gorilla family- a silverback male, a female, a younger male and two young babies who entertained us by swinging comically around the branches and practicing beating their chests- was an unforgettable experience.

We also hiked Mount Sabinyo, a volcano whose peak borders the Congo, Rwanda and Uganda.  It was a challenging climb to say the least, but we were rewarded with stunning views of valleys and forests, and the chance to eat our packed lunches in 3 countries at once.  This was followed by further hikes in Uganda, a sunset boat ride spotting birds and animals on the Kazinga channel, mountain biking in Rwanda, and canoeing across the beautiful Lake Bunyonyi,  before a final few days of rest in Entebbe.

The trip was an amazing opportunity to see so much of this beautiful country and its neighbour Rwanda, but it is not just the spectacular landscapes and abundant wildlife that I will miss when I leave Uganda. I will miss the everyday surroundings of Kamuli life that I have become so used to here.  The slow pedalling by of men in suits, carrying passengers on their bicycles along the dusty red roads in the midday sun, never without their shirt and suit jacket.  The colourful displays of neat shining rows of aubergines, tomatoes and peppers on the market stalls, with the friendly call of “Nangobi! Ovacados! They are ready!” to tell me she has ripe ones today. Children throwing sticks into mango trees and trying to catch the sweet rewards. Goats and chickens everywhere- on roads, in shops, on buses, even on the ward- and cows with ferocious looking horns who sit stubbornly in the road whilst everyone moves around them.  Children in bright pink or yellow school dresses and shirts, white socks pulled up to the knees, laughing and smiling on their way home from school.  And the waves and friendly smiles of neighbours and strangers who have welcomed me here to their town, and helped to make it my home. This is Kamuli to me, and I am sad to be saying goodbye.

A crested crane – the national bird of Uganda- and the lesser spotted three horned chameleon

But it’s time to move on. This has been an incredible experience, from which I’ve gained so much and hope to have given some back, and much as I will miss my Ugandan home, family, friends, colleagues and patients, I am ready to be reunited with those from England. It’s the people in your life that make it what it is, and it’s hard to describe how much I’ve missed them whilst I’ve been away. So I’m excited to be going back, sad to be leaving Kamuli, hopeful for the future of the children’s services here in Kamuli General Hospital, grateful for all the love and kindness I’ve experienced whilst working and living here, humbled by the people who have shown it to me and to others in need, and awed by the beauty of this land.  Kamuli will always hold a place close to my heart, and I know I’ll be back here one day.

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Thank you for reading about my time in Uganda. The support I have received from family, friends and colleagues has been much appreciated, and has helped me more than I can say. For those who have generously donated to Kamuli General Hospital to enable us to provide essential equipment for the paediatric and neonatal wards- thank you once again. You have made a real difference to the lives of children in Kamuli and your support is recognised and hugely appreciated by all the staff there.  They gratefully send their love to you all.

Thank you.

 

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Mpola mpola (slowly slowly)

I hear the slow rumble of a sugar cane truck as it trundles along the bumpy Kamuli roads, with its over-stacked load of cane, people, or sometimes both.  I see women bent low at the waist, faces almost touching the floor as they plant and dig, wash clothes, prepare food- slow and deliberate in their actions. I watch folk ambling slowly along the roads- for all I know they could be in a hurry. This is the Ugandan pace of life.

Those of you who know me will agree that I’m not one to do things slowly. Walking, talking, working- it’s all at a fast pace. In Lusogan, even my name sounds remarkably like the phrase “quick quick!” – “Kati Kati!” which brings great amusement to my Ugandan friends.

Adjusting to a different pace of life in Uganda has taken some time, and I’m definitely not there yet. This is evident by the children trying to imitate my fast paced walking by swinging their straight arms enthusiastically and giggling as they almost run to catch up (do I really walk like that?). A colleague who I met once on my way to work later told another nurse that she had walked with me, and commented “it was as if we were flying!”.

My tendency to rush from one thing to the next is matched by my expectations of what I feel I should be able to achieve in any given length of time. I’m sure I was too impatient here in Kamuli hospital to begin with, too easily disappointed by an apparent lack of progress with the initiatives we have begun. But I’m starting to realise that, slowly slowly, little by little, things are happening here. ‘Mpola mpola’, I’ve been told, and I’m trying to understand that this is how things take shape. It’s easy to miss the little changes, but every now and then I see them.

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I’ve been trying to introduce admission records and drug charts, treatment guidelines for our new noticeboards, and an increased sense of motivation and responsibility amongst my colleagues. One day, all of these things seemed to fall into place. We began with a clinical officer giving her first resuscitation teaching session to her colleagues, after having done some ‘train the trainer’ sessions over the past few weeks. She did it brilliantly and is clearly a natural teacher. A sick child was then admitted to the ward, complete with a neatly filled in admission record by the clinical officer in OPD which listed his diagnoses- severe malaria, severe anaemia, pneumonia, severe acute malnutrition, gastroenteritis.  I quickly reviewed the child, and agreed with the assessment, making just one change to the prescriptions. The ward in-charge took the child and started to give treatment. The nutritional nurse was just next door in the nutrition office (a relocation from OPD which has proved invaluable) and saw the patient with me immediately. She had a dilemma- we had run out of the start-up nutritional feed, F75. But we consulted our new guidelines on the wall and realised we could make it ourselves using a diluted version of the follow-on milk, F100, so she started calculating volumes to give.  Throughout the morning, student nurses had been working through the case load of patients on the ward, giving treatment in the newly designated treatment area and coming to me with questions and problems as they arose.  A diligent student nurse was looking after a young boy suffering from tetanus, and was trying his best to fill in the observation chart- the first time I have ever seen someone count and record a respiratory rate on the ward.   He had even phoned me at home the evening before to ask for help with the management of this child, and had carefully followed my advice and documented the treatment on his chart.

These may seem like simple, obvious things which you would expect to find in any hospital, but for me it felt like a big step forward from when I first arrived. Seeing clinical officers engaging with new initiatives and improving their decision making, a newly trained staff member training others, students asking for help, and nurses following guidelines made me proud of my colleagues, and I felt that we have moved forward a bit in terms of the care we offer to our patients. It doesn’t feel like that every day, but when it does, those are the moments to hold on to.

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Resuscitation training led by Sister Prossy
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Shiny new guidelines on the paediatrics ward

A theme throughout my blog so far has been the contrast between life in Uganda and life in the UK. I may have mentioned it a lot, but sometimes it’s too huge not to mention.

There is so much excess at home, compared to here. Common practice in the UK is to open up several cannulae into your sterile field in case you don’t get the first one in. Compare that to being given one precious cannula in a paper bag, bought by a child’s father, which he has been clutching whilst patiently waiting in line for his son or daughter to be seen and treated. Then the father must decide which of the 3 drugs you have prescribed he will buy. None are in stock, and he can only afford one. Which is most important doctor? The IV antibiotic? The salbutamol inhaler? Or the oral rehydration solution? The answer is all of them. But you can’t tell him that.

Even if we don’t have things in excess in the UK, we usually have enough. Like the blood we take for granted at home. How often have I not been able to urgently transfuse a patient in an emergency in the UK, because there is no blood in stock? Once. One single time in the last 5 years.  And that was because there was no blood in the fridge in that particular department. We got blood from somewhere else in the hospital within 30 minutes.

Here, a total lack of blood is a daily occurrence. Last week there were 3 children in front of me requiring urgent transfusions. For the medics out there, their haemoglobin levels were 4, 2 and 1.3. One was alert but very weak, one was fighting to remain conscious, the third was already unresponsive, hypothermic and in shock. We had no blood. We were not expecting to receive any that day. The nearest place with blood was at best 1.5 hours away. All patients were transferred- that means all parents were told to carry their child out of the ward and make their own way to the place with the blood. There is no ambulance here. They may have had a friend with a car, they may have gone on the back of a motorcycle, or maybe they waited for a public bus. We could not save them in Kamuli, but advising them to go may not have been the best thing to do either. In all likelihood, 2 of those 3 children did not survive the journey. A journey which will have created huge costs to the family, rising even more if the child dies en route- it costs more to transport a dead body than a living child, because of the superstitions of having the body on the transport. It is believed to bring misfortune to all those on board. A mother who suffers the loss of her child on public transport whilst trying to get them to hospital, suffers again with the blame of her fellow passengers for causing that bus to break down or be delayed.

And what of the other children, the siblings? Whilst precious money is spent on a futile attempt to save one child’s life, the others will suffer with less food to eat.

The nurses and I make these decisions, telling families they need to go to other health facilities, and the parents often listen to us, and do everything they can to raise the funds to follow our advice. Our responsibility is huge, and we can’t simply consider the life of the ill child in front of us- a luxury we usually have in the UK- we must think about the whole family and the impact of our actions. Perhaps sometimes the better thing to do is to say, stay here. Your child will not live, but he is unlikely to survive a transfer, and this option will cause less trauma to your family’s finances, and ultimately to the health of your surviving children.

Six months is not enough time to get used to this kind of responsibility or decision making. But it can open your eyes, make you appreciate the privileged world in which many of us live, and the crushing injustices of the world in which many, many more live.

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An emergency room with no blood

We’ve tried to address one particular injustice here in Kamuli, and that was the fact that children with sickle cell disease had no local clinic to attend, compared to those living near the regional referral hospital in Jinja. I’m pleased to say that we held Kamuli’s first ever Paediatric Sickle Cell Clinic a few weeks ago, and now after just 3 clinics we have treated over 60 local children with sickle cell disease.  All credit goes to the excellent team I have been privileged to work with- a dedicated nurse and clinical officer who begin the clinic with a group education session, teaching the parents and children about the condition, and then work steadily through every patient, registering them to the clinic, checking for complications of the disease, and prescribing their essential routine medications.

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Group education session in the sickle cell clinic

I had the interesting experience of travelling to Gulu in north Uganda last weekend, with fellow volunteers Lizz and Matt, to attend the Uganda Sickle Cell Rescue Foundation conference.  This took place on World Sickle Cell Awareness Day and was a fantastic event in raising awareness of the condition in the local population and providing free screening, food, clothes and medications. Thousands of people turned up, and we began with a rousing Awareness Walk through the town, led by an excellent brass band. I even got a chance to hold the banner!

We found ourselves getting quite involved- giving out free medications to a disorganised crowd of hundreds surrounding us on all sides, running a first aid tent (initially without a tent) with only a few bottles of ibuprofen to hand, and fielding a question and answer session when the local doctors had all mysteriously disappeared. Whilst we hadn’t quite anticipated this (not to mention the hasty exit we made from the town as a ‘security situation’ arose and they started bringing out the tear gas)  it was an eye opening experience, and has hopefully raised the profile of sickle cell disease in the area.

(We were all fine, by the way- the conclusion of the weekend was that perhaps all conferences should start with a marching band, although maybe not end with tear gas…)

 Crowding round for medication, and Matt keeping busy in the first aid tent

I’m delighted to say that the incredibly generous donations from those of you who have been supporting the hospital have now been spent, and the new equipment has finally arrived. The water filter is in place, providing safe drinking water on the paediatric ward. Digital weighing scales have been donated to the nutritional team- not just those for accurately monitoring the weights of our malnourished children, but also kitchen weighing scales to easily measure and make up the essential therapeutic feeds.  We have been able to finish kitting out our new emergency room in OPD, plus our paediatric and neonatal resuscitation areas, with a resuscitation table, two new oxygen concentrators, oxygen tubing, infant and child nasal prongs for delivering oxygen, and stethoscopes.

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Huge thank yous from the paediatric ward nurses and nutrition team for our wonderful new water filter

The staff and I can’t thank you enough for your generosity, and we want you to know that your efforts will make a huge difference to the care we can deliver to sick babies and children here. Thank you so much- we could not have done this without you, and there is no doubt that your support will save lives.

Thank you also to those who have pledged their support, this was taken into account when ordering the new equipment and we are so grateful for your ongoing help.

We’ve also been grateful to receive a substantial grant from ETAT and have put this money towards a power inverter, amongst other equipment, meaning that during power-cuts we will still be able to provide light and oxygen in the paediatric ward and neonatal room. So the new oxygen concentrators will be used to their full potential!

Neonatal resuscitation areas with new table and guidelines

The new emergency room in outpatients, complete with oxygen concentrator and resuscitation bucket

There continue to be challenges in my day to day life here- from frustrations and difficulties at work, to missing friends and family- and although in some ways my time in Kamuli has flown by, it still feels like a long time since I last saw those who are closest to me at home.  So I’ve been grateful, as always, for the friends I have made here and the fun we have together.  We had a mzungu get-together in Jinja a few weeks ago to say goodbye to some of the Kamuli Mission Hospital volunteers- it was great fun getting dressed up in our African print outfits and enjoying a delicious meal down by the Nile.

I also enjoyed an unexpected Ugandan feast when Sister Prossy came round to my little cottage one Sunday, complete with a crowd of new faces and enough food to feed them all. I was taught how to make matoke from scratch (steamed savoury bananas, pronounced mat-oh-key)- from peeling the matoke, breaking up the stalks to line the pan, wrapping it in banana leaves, building a fire in the garden to steam it over,  mashing it by hand through the leaves, and steaming some more. And after a mere 5 hours, it was ready! It was accompanied by delicious rice, potatoes (happily referred to as ‘Irish’ here), cabbage, beans and fish in ground nut sauce. The best part was probably the matoke speed-peeling competition between Sister Prossy and Jjajja,  the great grandmother of my Ugandan family!

The cottage and the garden were a wonderful setting for a feast, and we even had time for a girls versus boys football match whilst the matoke was steaming.

At the end of the garden are a few stone steps perfectly placed for watching the sunset. Sometimes I sit there in the evenings, watching as the sky changes colour, seeing the planets and stars come out one by one, marvelling in the bright glow of the moon.  I follow the bats as they swoop low for their evening meal, listen to an orchestra of crickets and frogs and the chatter of village life in the background, and see the wide expanse of green forests and plantations before me disappear into the night. What a pleasure to experience this right from my doorstep. As the sun goes down over Uganda, I feel like there’s nowhere I’d rather be.  With just two weeks left now, these are some of the moments I will miss the most.

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Thank you for reading 🙂

Losses and gains

 

My life in Uganda so far has been one of many contrasts.  When looking out of the window on a matatu journey, I see stunningly beautiful scenery, and burning piles of rubbish alongside the road.   I see acres of lush, healthy crops stretching as far as the eye can see, yet children with such severe malnutrition it is obvious they are starving.   I leave my lovely, secure, stone house with my bed, mosquito net, table and chair, and walk past families living in fragile mud houses, with the grandmother sitting outside on the floor because she has nowhere else to sit. Scenes of plenty, next to those of poverty.

I have become accustomed to these contrasts over the past 4 months, and thought that I was learning to cope with the emotional contrasts that come with the work here, but in these last 2 weeks this has become my biggest challenge yet.

I left Uganda for a week to attend the Kenyan Paediatric Association conference in Eldoret, where Claire and I were privileged to be able present some work we have done on sickle cell disease in Uganda.  We were able to highlight the contrasts in care received by children attending a specialist sickle cell clinic in a regional referral hospital compared with those in district hospitals (such as the ones we work in) where they have no access to a specialist clinic.  Unsurprisingly, the children attending the regional hospital clinic receive much better care, and those in the district hospital areas are more likely to end up in hospital with potentially life threatening complications of sickle cell disease.  This data has spurred us on to recommend the establishment of sickle cell clinics at district hospital level, and in Kamuli we are now in the process of starting up a paediatric sickle cell clinic.  Although this seems quite a daunting project to undertake for a paediatric SHO, I feel excited by the prospect of being able to improve care for our many patients with sickle cell disease, and have been working with the pharmacy, lab and outpatients department to try to make to make this a reality.IMG_4622

I was also inspired at the conference by a session on paediatric rheumatology, led by esteemed consultants from South Africa and Kenya who re-kindled my interest in this fascinating specialty of paediatrics.  It was sobering to realise that Kenya has just 7 rheumatologists, one of whom is a paediatrician, and Uganda has none– in contrast with services in the UK where there are four paediatric rheumatologists in Bristol alone. Rheumatological conditions, such as juvenile arthritis and lupus, cause a great deal of suffering to those who are affected, and require long term specialist care. There is clearly a huge gap in training in this area for Ugandan doctors, and those throughout Africa.  I had previously enjoyed working with the rheumatology team in Bristol and knew it was an area I wanted to be more involved in in the future, so now I am excited to see how an interest in rheumatology and global child health could go together, and am thinking about how to involve both in my future career plans.

The Kenyan experience ended with a lovely weekend retreat in the beautiful Kakamega rainforest with the other Global Links volunteers, and then it was an early 2am start for the long bus journey back to Uganda. When I finally reached Kamuli, my fatigue was replaced by the comforting feeling of being home.  Walking through familiar lanes, smiling and waving at neighbours, and feeling the warmth of the evening sun, I felt so happy to be back.

 

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Climbing above the canopy at Kakamega

I returned as Kamuli was undertaking a second week of ETAT+ training.  During Kamuli’s first ETAT+ training week in February, I was faced with an incredibly busy children’s ward and all the challenges of being the new doctor, and barely had time to join the training at all, so this time I was looking forward to being much more involved – given my position as the “ETAT+ volunteer” here.  Things did not quite go to plan.

On my first day back, I arrived at 8am ready for training to start at 9. The majority of the candidates finally turned up at around midday.  There was general disinterest and no enthusiasm for learning. The main objective of the candidates seemed to be to receive their allowance for travel and attendance, despite the fact it was being held in their normal place of work, the training was free and they were being given breakfast, a hearty cooked lunch and tea.  It was very disheartening to see such a lack of engagement, especially as several staff members had complained that they hadn’t been invited to ETAT training the first time around.

I was called out of training at least 4 times for emergencies.  I had no objection to seeing these children, but was puzzled as to why none had been seen by the clinical officer as per the usual process in outpatients.  I then discovered that the clinical officer had not turned up to work that day, and no-one had reported this or tried to get another one to cover. Instead, the nurses (some of whom were also supposed to be in the ETAT+ training) were valiantly attempting to assess and treat the children themselves, even though this is not their responsibility and they do not have the necessary level of training.  The students were attempting to triage, but there was no-one to see the urgent or priority cases once they were identified, let alone the many others. The place was heaving with children and parents, many of whom had been waiting for hours, and everything just felt chaotic.

I went to the ward with one of the emergency cases, and the child couldn’t be cannulated because the nurses had no gloves.  The child needed ORS and zinc tablets, but they were out of stock and the mother had no money to buy them. There was another child lying semi-conscious in the emergency room receiving no treatment, and no-one I asked seemed to know what was wrong with him.  A student nurse who had been left unsupervised told me that he had had a convulsion and been given medication, but nothing was documented in the notes.  There was no way of knowing what medication and dose this child had received, and whether it was safe to give any more.  The mattresses stank of stale urine and none of the surfaces were clean, including where the drugs are prepared.  I was called by a mother to review her child who was screaming in pain and distress, who had no clear history, diagnosis or plan in the notes and had not been seen by anyone since admission the previous day.  He also hadn’t eaten or drunk anything that day- not because he couldn’t, but because the mother had no money to buy food or water.  A severely anaemic girl was having a blood transfusion- a risky procedure requiring regular monitoring- yet there wasn’t a nurse in sight.

I felt like after being away for one week I was seeing everything for the first time- an outpatient department where no-one reports a major staffing issue which is having a dangerous impact on patients.  A dirty, disorganised ward full of suffering children with no appropriate plans for their care and no-one checking to see if they were getting better or worse.  A major lack of basic medical supplies such as gloves, syringes and cannulas, which I had initially thought was due to poor government organisation of hospital deliveries but have now found out is because no-one from the ward had ordered them from the hospital’s stores. The supplies were there, but due to an inefficient system, lack of organisation, overwhelming workload in an understaffed department and, sadly, unmotivated staff, no-one was ensuring that they reached the ward.  Since the day I arrived we have had no soap on the ward.

I had asked about soap and other supplies several times but had always been told they were unavailable. Now I find out that every ward is allocated a jerry can full of liquid soap, it’s just that the paediatric ward hadn’t requested theirs. Why didn’t I investigate further? Why didn’t I push the issue? Because I was new, I was the foreigner, I didn’t want to cause problems, I didn’t understand the system and so I believed what I was told. I can’t bear to think about the number of sick children who have had their treatment delayed in the past few weeks because their parents (who are often living in poverty) have had to go and buy their cannula and syringe first, when it’s possible that those things were available for free in the hospital all along.  The number of times I should have washed my hands properly between patients but haven’t, because there was no soap, and have risked transmitting disease from one patient to the next.

I also found out that several staff members have not been turning up for work and others are having to cover for them, without informing those in charge of their reasons for absence, meaning the nurses who are working are exhausted and are stretched even more thinly, and there are seemingly no consequences for those neglecting their duties.

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I felt overwhelmed with sadness and despair and felt that my last 4 months of doing daily ward rounds and trying to improve the organisation of the ward had been a waste, as none of that continues when I’m away.  I began to realise that my work so far had been largely unsustainable, and my efforts felt futile.  Why set up a triage system, if no-one turns up to work to see the triaged children? Why re-arrange the ward into emergency areas and treatment areas and create more efficient ward rounds, if there’s no-one to do the ward-rounds when I’m not there, everyone just piles into one tiny room and the nurses don’t seem to know which child needs treatment? Why promote and deliver a training course to teach people to look after sick children properly, if no-one wants to attend or learn?

It was my lowest point yet, and I was wondering what on earth I was going to do.  How could I possibly help this situation, this multitude of problems which all stem back to a root cause of poverty and poor national infrastructure?  I had lost hope. I’d lost my enthusiasm, and my confidence. I’d lost faith in the system and, worst of all, in people.

It took all my willpower to turn up to work the next day- I cried at the thought of going into the hospital where I feel such overwhelming responsibility yet seem to be doing nothing to help. I have never wanted to give up on something as much as I did right then.

But I turned up. And most importantly, over the next few days I got some sleep. I hadn’t realised quite how exhausted I was, and it was only after catching up on some sleep that I began to realise how much tiredness and sadness can impair my judgement and rational thinking. Don’t get me wrong- there are a lot of things that need improving here. But I was only seeing the problems, not the successes or the potential solutions. I began to realise that I can’t be the only person to fix things, I certainly can’t fix everything, and ‘fixing’ is probably the wrong word to use anyway, but there are things that I can do. I just needed to gain some perspective and work out how to approach things in a more sustainable way.

We persevered with the ETAT training, and thankfully things got a lot better as the week went on.  People really started to engage and by the final day many candidates were able to successfully demonstrate how to manage a sick child. We even had one who was recognised as having ‘instructor potential’, a fantastic achievement.  This was largely down to her dedication to learning, which she displayed admirably when she continued to attend the course despite a significant personal loss during the week.  I was inspired by her not to give up on things, and by another staff member who went above and beyond his duties that week to care for a critically sick child, and I realised I had been too quick to judge when it came to the many problems I felt we were facing in Kamuli.   There are many people here who are working their hardest and who really do engage with plans to improve things, and it is these people who are keeping me going, and most importantly, will keep the hospital going.

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ETAT+ training, Kamuli

I took time to rethink how best to concentrate my efforts in the hospital, and discussed my concerns with the senior management team. It turns out I was not alone- they were also experiencing the same shock and disappointment as me with regards to the state of the paediatrics ward. There was a lot of despair.  Suddenly I had to be the positive one again, encouraging the team that we can change things for the better, and it doesn’t have to be this bad for our patients.

I have now decided to draw back from the paediatric ward and spend more time in outpatients working with the clinical officers, who are the ones that admit children to the ward. It was not an easy decision to make- I feel compelled to do daily ward rounds and spend all my time on the ward, as I know that if I don’t review the kids, potentially no-one will.  But that is not a sustainable way to help the hospital, as when I leave in July there is no-one to take my place. It makes sense to focus my efforts at the beginning of the patient’s journey, in outpatients, in the hope that with teaching and training the clinical officers will be able to make more accurate assessments, more correct diagnoses and more appropriate management plans to see these patients through their admission.  I was trying to do some teaching before, but now I am taking a more focused approach, and I hope to get a lot more teaching sessions done.

I’ve also started ‘Training the trainer’- teaching permanent staff how to teach skills such as resuscitation and managing a sick child, so that they can work with me in delivering the teaching and eventually continue to deliver teaching to their staff after I leave.  The medical superintendent has agreed to review the current doctor’s duties and see if there can be a greater focus of care on the paediatric ward- it is after all our busiest ward, with currently over 60 patients, and has the greatest mortality rate of any department in the hospital. The senior nursing officer has also agreed to address some of the more ingrained issues on the ward and is starting weekly supervision to support the nurses there.

Training the trainer

Finally, we are hoping to introduce new documentation aids which we hope will make things safer and more efficient on the paediatric ward. Currently, there are no admission sheets, drug charts or monitoring charts in use in the hospital- it’s no wonder we have so many drug errors when there is nothing to prescribe on (my audit so far has shown wrong drugs, wrong doses, wrong timings, drugs being changed for no documented reason, drugs not being given at all). I hope with the use of simple drug charts we can improve this situation, but this requires training on how to use them, and of course money to photocopy them, which needs to be sourced somewhere in the hospital budget.  It seems after many weeks of discussions between me, the management team, hospital administrator and accountant we may have finally found the funds, so I’m keeping my fingers crossed for the first batch of new documentation any time soon.

So after a difficult week, I started to experience another contrast of emotions- the satisfaction of teaching people and seeing them learn how to teach others; the admiration of people working their hardest even when they are feeling their worst; the reassurance that others share my concerns and want to improve things too; the relief that all is not lost and I can do something to help. The many losses have led to many gains- I’ve gained perspective again, I’ve gained some rest, and I’ve gained a wealth of experience in dealing with set-backs, uncomfortable revelations and disappointment, and learning how to move forward from those things. And I’m relieved to say I have regained hope.

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Student nurse giving an inhaler to a child using a spacer- a skill I’m trying to teach to all the paediatric ward staff

Of course, change does not happen overnight.  This week has not been easy, with the surge of admissions related to the rainy season which brings a wave of infections and incredibly sick children to our ward.  When desperately pleading with the staff to order supplies from the stores, I found out yesterday that there really were none this time. Not a single drug on the ward. Not even paracetamol. We had no power all day, and therefore no oxygen. We had children whose parents had no money to buy water, and no power meant we couldn’t even boil the tap water in the kettle for them. And the tap had broken anyway. As is often the case, there was no blood in the blood bank. Children died yesterday because of lack of oxygen, water and blood.  Some teaching sessions have happened this week, but others have not as staff did not turn up. There may have been very good reasons for this in a hospital as stretched to the limit as it is.  At times like this it is hard to remain focused and to see the potential for change, but I hope that it is still there.

I would not have made it through this tough patch without the support and kind words from friends and family, for which I am very grateful.  A bundle of post arrived at just the right time- some of it was sent 8 weeks ago, but it made it here eventually and must have been fate that it came just when I needed it most.

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All you need is tea- this cuppa with a real English teabag was gratefully received  in a lovely parcel from a friend

I am also incredibly humbled by the continued generosity from donors who are supporting the fundraising efforts for the paediatric and neonatal services in Kamuli. You have now raised enough money for the paediatric ward to have a water filter and an oxygen concentrator, meaning we can give safe water to all children, and oxygen to more of those who need it. Basic life necessities, which we couldn’t have provided without your help, and which will save lives.  We have also purchased noticeboards to display essential treatment guidelines and a new resuscitation table for the maternity ward, and I hope with continued support we may even be able to buy a second oxygen concentrator for our new emergency room in paediatric outpatients.  Most of the equipment isn’t here yet- these things take some time to organise- but the water filter is on its way from Kenya and I promise to send photos when it arrives! So thank you so very much once again to everyone who has helped the hospital, and to others who have pledged their support. For more information on how to support Kamuli, please follow this link:

https://www.gofundme.com/67wbtqdw

 

Just arrived- new noticeboards and resuscitation table, with proud carpenters

 

Kamuli itself remains a reassuring constant- hot and humid, with spectacular storms and sunsets- and my relatively simple life here is a relief to come home to every evening.  I have an abundance of fresh avocados, tomatoes and now mangoes (the season has arrived!) at my fingertips.  I live next to a hen coop and some bee hives, meaning my fresh local eggs and honey have a food mileage of around 20 metres. I never have to queue at a supermarket.  The other day my young neighbours congregated on my porch in the rain and we attempt to play cards, but mainly ate bananas and biscuits. When we play ‘running and jumping’ our backdrop is an endless expanse of banana trees and a sunset sky of pink and blue. My nearby friends in Kamuli and Kayunga are hugely important and I rely on them daily- for hospital debriefing, for words of wisdom from my excellent senior paediatric colleague and friend, for pest-control discussions, for silly card games, for weekends away, for beer and delicious food.   A lovely lady in town has made me a beautiful Ugandan dress- I may have got stuck in it when trying it on, but once rescued (they had to rip the zip off and my dignity was less than preserved) it has been adjusted and now I feel the part- all I need is a party to go to!

I know this kind of life is a luxury to experience and I’m sure I’ll miss it as soon as I leave.  It provides a much needed balance from the demands of the hospital, and its simplicity makes me appreciate all the more the things that I have which others do not.

I now have two months left here in Kamuli to dedicate to the hospital. There is a lot to be achieved, but it is a privilege to be trusted with the responsibility of trying to achieve it.

I’ll keep you posted.

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My home in a stormy sunset 

 

P.s. Thank you so much for reading this monstrously long blog (I wouldn’t blame you if you skipped out stuff in the middle!).  I know this was a heavily medical post, but part of my reason for blogging is also to maintain my professional development as a paediatric trainee, to reflect on my experiences here and to show how the challenges I am facing are enabling me to improve my skills as a doctor.  Already I can see how it has helped me with leadership, problem solving and team work (and I hope I am making some progress with resilience too!) and I know these will help me as I continue my career in the UK. So thank you for supporting me by showing an interest, and making it to the end!

Drip Drip Drop (little) April Showers

The rains have come. I don my waterproof coat, trekking trousers and walking boots, and set off for work. The dusty red roads have turned to muddy streams, and I draw even more looks than usual in my wet weather gear. On my way, I decline many offers of lifts from the boda boda drivers.

“Madam! Up to where? I take you!”

“No thank you”

Incredulous look. “You are footing?!”

“Yes”

A pause. “Oh”. Apparently lost for words.

Why would someone “use the foot”, in the rain, when they could hop on the back of a motorbike? I walk onwards. Most people avoid the rain, so the roads are quiet, but there are enough people sheltered in shop doorways to laugh at my attempts to leap over ankle-deep puddles.  Others continue as normal- children splash past in flip flops, or no shoes at all, clutching wet school books. Millions of tadpoles have appeared as if from nowhere to fill the new roadside pools. Kamuli feels different in the rain. I arrive at the hospital, soaked and muddy, and change into my smart clothes and white coat. And the day has begun.

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Between the rains

The rains affect my work in a way I hadn’t expected. Firstly, I was anticipating huge crowds of sick children pouring in as the rains pour down, due to the associated increase in malaria that occurs with the wet season. This hasn’t happened yet (although I’m sure it will)- in fact, quite the opposite. The ward has been much emptier, as people are making the most of the opportunity to dig and plant whilst the ground is soft, so they are out in the gardens and fields, and fewer children are being brought to hospital. I’m sure there will be consequences to this delay in seeking healthcare, and I am bracing myself for the repercussions.

Secondly, it affects my teaching.  I’ve managed a few more resuscitation training sessions in the past few weeks which have gone well- the staff are slowly getting used to using a manikin to practice on, which is very out of keeping with the kind of lecture-based teaching they have received before- and it is fun and satisfying to see people learning new skills.  Recently, however, I’ve had to postpone training twice due to staff simply not arriving- I was informed by the students that they were ‘delayed by rain’.  They seemed almost surprised at the arrival of the downpours, despite the fact that I’ve been warned about the coming rainy season for months. Perhaps it’s a bit like snow in England- it happens every year, everyone knows it’s coming, you have plenty of warning, and yet when it arrives everything grinds to a halt.

Thankfully, the rain is far from constant, and there are still many hot and dry days in between the showers which I hope to use to make up for lost time.

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Coming home through this gate each day, from dusty farmyard into lush green jungle, feels like stepping into a summer version of Narnia

A few changes have taken place in the hospital since my last blog, and others are in progress, most of which have been made possible by the incredibly generous donations from friends and family who have been supporting Kamuli General Hospital. I have been overwhelmed by your kindness and willingness to help, and the staff are hugely appreciative of your support. We now have two new sets of weighing scales which are being used in our triage area (which I am happy to stay is still running fairly smoothly, most of the time!) and in our nutrition office. The nutrition team are now based on the paediatric ward, much to the benefit of our many malnourished patients, and the weighing scales alone are making a difference to the way we care for our patients. The donations have also been used to buy measuring jugs for making up the therapeutic feeds, and to provide Resuscitation Buckets and more resuscitation equipment for the wards and outpatient area.

 

The majority of the donated money will be spent on a water filter for the ward, which I am in the process of ordering.  This will enable us to provide up to 75 litres of safe drinking water per day for our inpatients and their carers. It struck me how much we take water for granted when the other day I was treating a little girl with rigors (uncontrollable shivering due to an extremely high fever) who we needed to give paracetamol to, and the mother couldn’t give it to her because she had no water to swallow it with. Thankfully I always carry a bottle of water around with me, so she used that, but I wondered how often drugs are delayed for the simple lack of water.  When we have our water filter it will at least solve this one problem, and hopefully many more.

So thank you, thank you, THANK YOU for your generosity and support with these projects- it really is making a difference to the children of Kamuli. Sister Prossy, the senior nursing officer, and my mentor and friend, would also like to pass on her sincere and heartfelt thanks to you. These are her words:

“Please express our deepest gratitude to these people who are helping us; we are so thankful, and we love them. Thank you so much”.

To find out more about supporting the hospital please follow the link below- your help is greatly appreciated.

https://www.gofundme.com/67wbtqdw

We have also been fortunate enough to receive even more donations from the UK- these ones delivered by hand! My family came to Uganda for a visit a few weeks ago, and brought a suitcase full of goodies. Admittedly, some of these were treats for me, such as shampoo, biscuits, pesto, oxo cubes, minstrels and mini eggs (excellent choices for transportable chocolate that won’t melt) but there was a generous pile for the Ugandans too from my family in England, Wales and Ireland- colouring books, crayons and toys for the children’s ward, and presents for the family I live with.  The biggest treat of course was seeing my family, and we had a wonderful time together exploring Murchison National Park and spotting elephants, giraffe, hippos, warthogs and hundreds of beautiful birds on safari, as well as the almighty Murchison falls- a place where the power of the Nile really comes into play as it thunders through a gorge just six metres wide.

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Mageeans on safari

Toy box gratefully received by the paediatric  nurses and nutrition team

We then treated the people of Kamuli to a Mageean Safari- all five were spotted walking through the town together, a rare sight indeed.  It was lovely showing them my new home, and they were treated as very special guests by Fred and Prossy, our perfect hosts. We ate traditional Ugandan food together, shared gifts and laughter, and drank tea with Sister Prossy whilst sheltering from a downpour under the thatched roof of my porch.  Apparently it is good luck if it rains when you have visitors here, so I took that to be a good sign!

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Lunch with both families- English and Ugandan 

 

We also visited the children’s home and school that Fred and Prossy set up when they first moved to Kamuli.  The work they have done for the vulnerable children here is heart-warming and humbling, and they are truly generous, loving and hard-working people. We were all overwhelmed by the welcoming nature of the children as they sang to us and showed us their home, and were impressed by their aspirations as they told us what they want to be when they grow up- engineers, pilots, doctors, teachers, nurses and bank managers. I’m sure with the nurture and support they receive from Fred and Prossy, and the Mothers in the home, these children will go far beyond what may have been expected of them.

 

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Laundry time with the girls at the school

 

In a country where fifty percent of the population is under the age of 15, the young people of Uganda face challenges that are hard to bear.  Access to education, healthcare, jobs, and even a social security system for those without families, is hindered by poverty and a lack of infrastructure to cope with the needs of such a youthful and rapidly growing population.  Locals like my Ugandan family live simple lives themselves, but they are doing what they can to improve the lives of young people in their town. I am grateful that my work as a paediatric doctor enables me to contribute in some small way to the lives of children in Kamuli, and I am glad that it has brought me to Uganda.

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My family and neighbours

I can’t go before sharing with you just a few updates on Ugandan life in general.  Last weekend I enjoyed a Liverpool reunion with fellow volunteers in Uganda- Emma, Sarah Beth and Claire- and we took on the challenge of the Mpanga Forest trail run. It might only have been 5k, but it was very, very muddy, and we had great fun wading through knee-deep puddles and leaping over fallen trees whilst gasping in the humidity of the forest.  Unfortunately none of us won, so we did not go home clutching the coveted prize of a round of cheese (this is not a joke- we really miss cheese) but it was lovely to catch up over a head-torch lit pasta supper in the forest.  It did mean braving the matatu park of Kampala on the way back- the picture speaks for itself- and I felt proud that we all managed to get on the right bus home.

Finally, my blogging has been delayed today by the new arrival of a red and wriggly infestation in my water pipes- I spotted hundreds of tiny red worms coming out of my shower and bathroom taps this morning. Unfortunately, I noticed them after I had showered, washed my hair, and washed my dishes and clothes in this water. Needless to say, I’m feeling rather wriggly now myself. But all is well, it turns out they are the harmless larvae of a non-biting fly, so I won’t be taking any exciting tropical medicines this time. I have now created my own larvae-trap by attaching a fine-mesh sieve to my shower head with duct tape, and am awaiting the magic of chlorination by ‘the water man’. This is Africa!

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Thanks for reading, please keep in touch with all your news (pest-related or otherwise!), and I hope your April showers are lighter than mine 🙂

Nearly half way- and the glass is still half full

“Nangobi! Nangobi!” I smile and wave, and am greeted with the biggest of smiles in return. This is the name I have got used to being called as I walk to work every day. In Lusoga it refers to a particular tribe, meaning something like “Daughter of the royal clan” – I’m not sure I deserve such an esteemed title, but I’ll accept it gratefully- and it does makes a change from “mzungu!!”. I’ve also been given a new Lusogan name at work – Mudesi- meaning ‘one who is respected by the elders’. Needless to say, I feel rather over-titled. Luckily, they just stick to Dr Kate most of the time (there seems to be a struggle to grasp the ‘–ie’).

I’m settling into something of a routine at work, although no day is the same as the one before.  Some things are becoming second nature, like treating malaria, seeing children with severe anaemia and writing “needs oxygen- currently unavailable due to powercut” in the notes.

I’ve learnt that drugs and equipment are ordered quarterly, and once they’ve run out, there’s nothing to do but wait for the next quarter’s delivery. So when I began, we had a reasonably well stocked ward. Now, as we wait for the April delivery, we have run out of nearly everything. We have no antibiotics, no oral rehydration solution (essential for children with acute diarrhoea, which affects at least half of my patients) no cannulas, no needles, no syringes, no gloves. If a sick child comes into the ward, they have to wait for a relative to buy these essential things before any treatment can be given. Seeing a baby with meningitis, having a seizure, who hasn’t fed for days so probably has dangerously low blood sugar levels, with no intravenous access and no nasogastric tube, and trying to decide how best to use the one syringe you have on the ward, is a very difficult situation to deal with. At times like this, I rely heavily on the nurses’ experience to guide me and support me, and I am so grateful for their unflappable nature in the face of an emergency.

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Entrance to the paediatric ward

When we are fortunate enough to have blood, we can’t accurately measure the volume we are transfusing – usually we rely on an estimated line drawn on the bag in biro, and hope that a nurse will glance at the bag and stop the transfusion at the right time.  The children with malnutrition are a particular worry for me, as they need feeding every three hours, day and night, in order to recover.  This is challenging as it relies solely on the carer to give the feeds at the right time, as there is no capacity for the nurses to feed the children or remind the mothers- but how do you know when three hours has gone by when you don’t have a watch or clock, or can’t read the time?  Soon I hope things will improve on this front, as the nutritionist is due to move into the paediatric ward. It will be of immense benefit to the children to have a nutritionist on hand during the day, who can safely prepare the therapeutic feeds, teach the mothers, and document the feeding progress.  Of course, these special feeds must be made up with clean water, so there is a kettle provided for boiling water, but sometimes there is no power and so it can’t be boiled, and other times the mothers use the water when it is still too hot, which denatures the precious vitamins in the feeds.  I am trying to find a sustainable solution for this problem, and if I am able to raise some funds I feel that a water filter for safe drinking water on the ward would be an appropriate investment (see later for ways in which you can help!).

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The ward- where are the patients? Under the mango tree

 

Amongst the many children with malaria, pneumonia and gastroenteritis, the cases I am treating here can be extremely interesting and varied.  I have seen a young boy with a huge abscess taking up most of his thigh, which was so severe it had led to a fracture of his femur, and was probably due to tuberculosis. We will never know for sure, as our lab cannot process samples for microscopy and culture to identify the causative organism.  Some major causes of illness in our children are related to the dangerous environment they live in.  I’ve treated several children with paraffin poisoning- it is used at home for cooking, but unfortunately as a clear liquid kept in old water bottles around the home, it makes for a tempting drink for little ones, with potentially fatal consequences.  Open fires are commonplace, either for cooking or for burning rubbish, and pose a serious hazard to young children playing nearby.  Children carry and play with pangas (huge wide knives) and run across roads where boda-bodas (motorcycle taxis) speed up and down.  A ten year old girl was carried into the ward by strangers one evening after being hit by a boda-boda. She was semi-conscious and had multiple, dirt-filled head injuries. In the UK, there would be a trauma call and many members of highly trained staff would come running. Here, the trauma team was Esther, the one nurse for that shift, and me. The child needed oxygen, blood, antibiotics, a tetanus booster, and ultimately a CT scan to check for intracranial injuries. We had only nasal cannulae to give oxygen, but as she was bleeding from both nostrils we couldn’t use it. We had no oxygen mask. We had no bottles for a blood count or blood grouping, so couldn’t cross-match any blood for her. In fact, there was no blood in the bank anyway. We had only one antibiotic- ampicillin. There were no x-ray facilities to exclude severe chest trauma. She had signs of raised intracranial pressure, but we had no access to mannitol, the drug used for this kind of emergency- apparently it was locked safely in a cupboard on the adult ward, but the person with the key had gone home. We couldn’t even transfer this poor girl to a hospital with better facilities as she had no-one to take her- on-lookers had kindly brought her in, but her family did not know she was there.  I felt out of my depth, and largely helpless. In the midst of this panic, I started to feel quite dizzy, and it was then that I realised it was 6.30pm, I hadn’t eaten since breakfast, I had no water left and it was still swelteringly hot.  It was also the eve of the general election, which we had been building up to for weeks, and everyone was concerned about safety- I had been advised to be home by 4pm, but the sick patients just kept on coming and I felt I couldn’t leave. In danger of fainting onto the poor girl, I had to step outside, remove my white coat (smartness is a priority here, and there is apparently no acceptable level of heat that allows you to go without the coat) and stick my head between my knees. Buying water would mean leaving the hospital premises, and I didn’t want to be seen walking away from the emergency.  It probably didn’t help that I was faced with a situation that I knew would be managed entirely differently at home, just due to the simple fact that at home we have life saving resources, and here we often do not. The overwhelming unfairness of this situation just hits you sometimes. Fortunately, I was able to pull myself together, extra staff did turn up to help, we stabilised her as best we could, and eventually her family arrived and were able to transfer her out.  I made it home just before dark, and luckily Kamuli did not experience any election trouble. We rarely receive any follow-up on our patients, so I am still unaware of the final outcome for that young girl.

Thankfully, amongst these many challenges, there have been some great moments of success and progress.  Kamuli hospital had the ETAT training course in my second week here (see blog post 2 for more info!) and part of my role here is to help the hospital to establish regular ETAT-style teaching and make this education ongoing for the staff.  I delivered my first teaching session on newborn resuscitation to the midwives a few weeks ago, and we enjoyed using the brand new resuscitation doll to practice our skills. Happily, this took place on International Women’s Day, and although these nine female staff should have been off (the day is recognised as a public holiday in Uganda) they were all hard at work, and it felt significant to spend my morning educating women.

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My best day so far has been the initiation of triage in our out-patient department last week.  Previously there was no system for seeing the patients, except first come first serve, and this poses a real risk of sick patients deteriorating, or even dying, whilst waiting in the queue. Now the staff are practising triage so that the sickest patients can be seen first, and we hope this will improve care for all our patients.  We were so lucky to have the help of Will, a volunteer nurse working in Kamuli Mission Hospital, who has great experience in outpatients and childrens A&E, and kindly gave up his time to work with our staff in establishing a triage system. I can’t explain the excitement I felt in seeing it take shape, and how proud I was of our staff for their motivation and willingness to try something new, and their great enthusiasm for wanting to improve their practice. It really felt like a triumph! I’m sure there will be teething problems as we get things going, but it certainly feels like a great start.

Triage in action, and our brand new stamps to help prioritise the patients

Of course there are day to day successes too- just seeing a child with severe asthma receiving their salbutamol inhaler via a spacer from a student nurse who has learnt how to use this equipment the day before, and who then teaches the mother how to use it, is very gratifying.  And playing high five with that child before they go home looking well is a moment to hold onto on the days when things are bit tougher.

We are in the process of establishing an emergency room in our outpatient department (it’s not quite Bristol Children’s A&E, but it will be something!) and have benefited from some generous donations of resuscitation equipment from friends in the UK (you know who you are- THANK YOU).  We now also have a Resuscitation Bucket on the ward- it’s simple, but it will hopefully be an easy way to keep the essential equipment on hand in case of any emergency.

Donations being gratefully received by Sister Prossy and Dr Charles

In terms of further donations- I know many of you are keen to help, and I am so grateful for your support. I have decided to set up a Go Fund Me page (see link below) so that if anyone feels they would like to do a little fundraising, it can be donated via there. I will give details for the things I would like to raise money for, but at the moment I am considering some scales for the triage area so children can be weighed and medications prescribed accurately, and a water filter for the ward so that all the inpatients can have access to safe drinking water.  There may be other pieces of equipment that I can aim for too, and I will keep the page updated.  I want to be sure that any impact made is appropriate and sustainable, and will benefit the ward after I have left, so thank you for bearing with me as I take my time over this.

https://www.gofundme.com/67wbtqdw

So what else is there to say, aside from my work at the hospital? Well, there’s plenty! I realise this blog is becoming as long, if not longer, than the previous ones, so feel free to take a tea break if it’s all getting too much!

I am really enjoying my home life in Kamuli. Cooking on my outdoor gas ring under the thatched roof of my porch, with the sun going down behind me, is a daily moment of happiness (that’s when I manage to make it home from work before dark- on a busy day it’s a race against the sun as I hurry through the red dust). Sometimes, during the big storms, I cook by the light of my head-torch, and sit outside watching the torrential rain and lightning, seeing the sky lit up pink.  I’ve also discovered something you can ‘bake’ on a gas hob – Welsh Cakes! It’s been great fun trying to make them without any measuring equipment (amazing what you can do with a beaker and spoon, plus a water bottle as a rolling pin, and a friend in the UK measuring things out for you in tablespoons and texting you how many to use!). My neighbours, who I actually refer to more often as my Ugandan Family, loved them too, and insisted on a Welsh cake lesson. I was slightly nervous when they all turned up with their chairs and made themselves comfortable around my hob, and wondered if I was setting mysefl up as some kind of wannabe Delia, but it went well.  Any further stove-top baking recipe ideas will be gratefully received 🙂

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The result of the Welsh Cake lesson

There has recently been a new addition to my Ugandan family, in the form of the beautiful baby Daniellah Kwagala Gift.  After a worrying few days when her mother, Liz, contracted malaria, and they had to resort to an emergency c-section to deliver Daniellah safely, both mum and baby are doing well, and the family are currently staying in the other half of the lovely cottage I live in. So I have the privilege of being their paediatrician-next-door, and Daniellah’s mzungu aunty!

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The lovely Daniellah

I’ve had a lot of fun with my nearby friends at the Mission Hospital, and in the last few weeks Alice, Gideon, Will and I have enjoyed dinners, BBQs, weekend trips to Jinja, and a sunrise climb of Kagulu rocks for breath-taking views of the sun coming up over Mount Elgon. Sadly, we have had to say goodbye to Gideon, as he moves onto the next stage of his overseas adventures, but we are lucky to welcome Sarah Beth, another friend from the Liverpool diploma, and some more students and volunteers will be coming and going over the next few months.

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Sunrise at Kagulu rocks (Mum, I promise this was safer than it looks)

I had a wonderful week away with Joe when he visited in February, and we enjoyed hiking around waterfalls in Sipi, visiting a coffee plantation (and even learning how to make our own from scratch) and relaxing by Lake Victoria in Jinja.  I’ve also had a chance to catch up with my fellow Global Links volunteers, Claire, Lizz and Matt, who travelled from Lira and Kayunga this week to meet in Kampala for our big ETAT meeting. Pete Nash, director of Global Links, joined us from the UK and we had an opportunity to reflect on our progress so far and focus our minds on what we would like to, and need to, achieve over the remaining few months. There is certainly a LOT to be done, but I feel confident that we can make some headway despite the challenges we are all facing.  We timed our reunion well to include a trip to Hairy Lemon Island over Easter weekend- an idyllic retreat on the Nile, where we spent the days swinging in hammocks, relaxing in natural jacuzzis, laughing at the cheeky monkeys leaping around above our heads, and enjoying many games of bananagrams.  Watching the sunrise over the Nile on Easter Sunday was a particular highlight of the weekend.

So I feel I’m making the most of enjoying what Uganda has to offer, and certainly feel fortunate to be living and working with such lovely people. Every little trip brings me some much appreciated down-time, and renewed enthusiasm for the next few weeks in the hospital.

For now though, it’s back to work. I hope you’ve all had a very Happy Easter and I look forward to hearing all your news and updates whenever you get a chance 🙂

Thanks again for reading my ramblings!

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You can’t complain about leaving work late when you get to see this on your way home

PO BOX 359, Kamuli, Uganda

p.s. if there are any other budding future volunteers reading this, please feel free to get in touch if you have any comments or questions- I’d be glad to share more of my experiences with you.

Kamuli at last

I have finally arrived in Kamuli, and have had time to reflect on my first week here- and what a week it has been.

I arrived to the welcoming hug and smile of Sister Prossy, the senior nurse in charge at Kamuli District government hospital.  She has kindly taken me under her wing and has spent the week helping me to settle in in the hospital, introducing me to seemingly every member of staff (how will I ever remember all their names?!) and helping me to find accommodation for the next 6 months.

I was invited to join Prossy at her Pentecostal church on my first day here, and experienced a very lively and vibrant service, unlike any church I have been to before. As it was their Family Sunday, the service was extra special, and I was asked to stand up in front of the several hundred-strong congregation and ‘greet the church’. It was a little nerve wracking and I felt very self-conscious, but it was nice of them to welcome me in this way. We then all ate a hearty portion of typical Ugandan food for lunch, which was much appreciated after the four hour long service.  It turns out that I am living in a little cottage on the land owned by the pastor of the church, so I’m sure I will get to know many of the congregation well.

The cottage is a lovely little round house with a thatched roof, split into two rooms. My semi-circular room is simply furnished with a bed and table and has a little bathroom, and my kitchen is an outdoor gas hob under the thatched eaves. There is another cottage where the pastor’s son and wife live in one room, and two other daughters in the other room, and they are set in a beautiful green garden overlooking an endless expanse of jungle-like foliage.  There is a pig farm just down the slope, and several chickens, dogs and cats running around near the pastor’s house, not to mention the endless stream of children playing and doing chores here and there.  The place has a very welcoming, family-feel to it and I’m already starting to feel at home here.

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My new home

Whilst some renovations were being done to the room during the week I have been staying in a hotel in town, and I must say that when I arrived and suddenly found myself alone in a new town, with the daunting prospect of my work here ahead of me, I did feel a bit homesick. Thankfully, I have been able to keep in touch with friends and family at home via Whats App, and enjoyed re-reading the lovely cards I received before I left, which helped to cheer me up. What’s more, I am lucky enough to have a friend also living in Kamuli! I met Gideon when studying in Liverpool, and he is volunteering at the other hospital here, Kamuli Mission Hospital, so it has been lovely catching up with him in the evenings. He is staying at a very nice guesthouse complete with a lovely housekeeper, Goretti, whose cooking I have already enjoyed a few times this week.  So it has certainly helped to have familiar face nearby during this first week.

Life in Kamuli town is very different to Bristol (who’d have thought?). For a start, I stand out. A lot. A mzungo (white person) is very much a novelty around here, and wherever I walk I am surrounded by shouts of “Mzungu! Mzungu! Give me sweets! Bye!!” from the local kids. They also love to run and shake your hand, touching your skin to see what it feels like, and follow you around. It’s quite sweet, but makes for slow progress- especially when you are desperately trying to make it to the next patch of shade (it is very warm here). I also get lots of stares and calls from the older locals, which can be quite unnerving and uncomfortable, but I’m hoping that the more they see of me the less interesting I’ll become. I’m looking forward to going to the market and trying out my bartering skills with the locals, whilst bracing myself for the inevitable attention I will receive.

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The pastor’s house and chicken coops- behind which lies my lovely cottage

And now on to the hospital.  Kamuli District hospital lies just north of the town centre and is a complex of one-storey red roofed buildings with outdoor walkways in between. On my tour on the first day I was pleasantly surprised by what seemed like a fairly well organised, spacious and clean hospital.  There is an outpatients department, psychiatric nurse-led clinic, mother and baby clinic for HIV, eye clinic, dental clinic, pharmacy, lab and then the theatre and wards- male, female, maternity and paediatric.  I also saw the caregivers quarters- every patient has a caregiver, who stays with them throughout their admission and does most of the care that a nurse would usually do (this is commonplace throughout Africa, and I have learnt from the blogs of my friends working in Zambia that there they are referred to as Bedsiders).  They stay in the hospital grounds, where there is a covered area for them to cook and some basic sanitation facilities.

On arriving at the paediatric ward, I was shown a fairly large ward, with around 30 beds and an isolation room, plus a pleasing row of four sinks (unfortunately it turns out that none of these work).  What was most surprising though was that it was completely empty.  This was a stark contrast to the wards I had seen in the last 3 weeks, and I wondered naively if perhaps there were no inpatients currently.  I soon found out where they all were.  The patients and their families spend all day outside, mostly sitting in the shade of a huge mango tree, or in the cooking area, although some wander off into town.  They only come inside to sleep at night.  This means that my ‘ward-round’ consists of me sitting in the staff room behind a desk, with the patients crowding into the corridor and coming in one by one to be reviewed.

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My red and dusty route to work

 

On my first day I was in at the deep end doing my first solo ward round.  I had no overview of the patients, as you would if they were all on the ward together, so I had no idea how many there were, or who was the sickest and needed seeing first.  Instead I relied on the nurses having a vague idea of priority and calling those patients to the front of the line.  I quickly came to realise that this was not a very organised system.

Patients have a little exercise book which consists of their notes, and there are no drug charts- instead the drug prescriptions are written amongst the daily reviews. When the mother remembers to bring her child into the ward for treatment, the nurses flick through the book, try to work out where the last ‘prescription’ was and administer that drug. That’s if they have it in stock. On countless occasions this week I have seen children receiving a different antibiotic every day, according to what is in stock.  If you prescribe oral treatment only, the families will not stay on the ward or come in for treatment or reviews- they simply leave.  So the only way to keep a child in hospital seems to be to give IV treatment, often unnecessarily.  I found it frustrating to see a dehydrated child in the morning, advise treatment with oral rehydration solution and make a time to review the child several hours later, only for them to be nowhere to be found.

It turns out there are around 40 paediatric inpatients at the moment, but by around 1pm everyone has disappeared, so if I haven’t managed to see them all by then (which I inevitably have not) then they don’t get seen that day.  What’s more, the paediatric ward only takes children up to five years old- above that they go to the adult ward, which is covered by one doctor who works a 24 hour shift (often several in a row) and is responsible for all seeing all the other patients in the hospital whilst doing emergency surgery and caesarean sections.  This doctor is so over-stretched that they rarely make it to the paediatric ward- before I arrived, they had not seen a doctor on the paeds ward for weeks. They were mightily disappointed when they found out I was not surgically trained (as all doctors in Uganda have to be able to do ‘basic’ surgery as well as medicine)- their surprised response was “What, no surgery? Not even a simple laparotomy?”.  So I’ll have to work twice as hard at the medicine here to make up for it!

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This mantis was happily praying on my hob one evening

 

I am trying to get to grips with treating unfamiliar conditions whilst working out the systems for blood tests, scans, x-rays etc- it seems simple tests and in-stock medications are free of charge, but anything else has to be paid for by the family.   This often involves a trip to town or to the mission hospital, as we have no x-ray or ultrasound facilities here.  In fact, all the x-ray machines in Kamuli district have been shut down due to non-compliance with safety standards, so there is nowhere in the region to get an x-ray.

Another challenge is the language- although I have picked up a few words in Lusoga, the local language, it is not sufficient for history taking yet.  Thankfully I have been working with some very helpful nurses and clinical officer students, who have been translating for me.  I feel this slows things down considerably, but it’s the only way to do it, and at least by working closely with another healthcare professional I can simultaneously learn from them about the way things are done here, and teach them about best management for the children.

 

There have been quite a few difficult moments this week, as we have had lots of emergencies, and I am experiencing the true challenge of working in a low resource setting. We have one oxygen concentrator, so can deliver oxygen to one child at any one time.  We have a blood bank which fluctuates between being stocked or empty.  We frequently only have one antibiotic on the ward, and consequently antibiotic guidelines go out of the window- you give what you have. One day we had admitted two children with severe pneumonia, and whilst I tried to decide who to give the oxygen to and who to try to transfer to the nearest hospital that could provide oxygen, one child stopped breathing.  They do not keep resuscitation equipment on the ward, and by the time I ran across the hospital to find some on the maternity ward, it was too late to save her, although we tried our best. Another day we had three children all with severe malaria and severe anaemia, causing them to struggle to breathe, and thankfully we had blood, yet the day before we had a similar situation with no blood in the blood bank.  The emergency room can be chaotic, noisy and dirty, and we often run of IV dextrose- essential, life-saving fluid to give to a child with low blood sugar.

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Light relief- playing cards on my doorstep with my new neighbours

I am struggling at times with my role as the only paediatrician in the hospital, and although I am sometimes able to get through to doctors in other hospitals to get their advice over the phone, I am mainly working alone.  It is a big responsibility, and I rely heavily on the nurses and clinical officer students (who work tirelessly and without complaint, despite not being paid) to support me.  I know things will get easier as I get more used to the setting, and I hope I will be able to use my training to give useful teaching sessions to the staff whilst I’m here, and do what I can to improve the outcomes for the children of Kamuli. It will be difficult, but I am here now and at least I have begun.

Meanwhile, I look forward to settling into my new home, making friends with my neighbours, and enjoying the wonderful African sunsets which never fail to lift your spirit at the end of the day.

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Thank you again for reading and showing an interest in my Ugandan antics. It’s lovely hearing all your news from home – I’m sending especially big congratulations to the proud parents of all the new arrivals (babies Oliver, Aubrey, Archie and Darcy!) and lots of support to my UK junior doctor colleagues in the difficult situations you are all facing at the moment. I’m very proud of my Liverpool friends who are also working hard in Europe, Africa and further afield- Kenya, Uganda, Zambia, Malawi, South Sudan, South Africa, Yemen, Borneo, Calais- I love reading your blogs and look forward to hearing more!

I can’t explain how much a little What’s App message means, so do keep in touch (or even send me a postcard of rainy/windy/chilly England- PO Box 359, Kamuli, Uganda!).

For now, I’ll leave you with the view from my new front door 🙂

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Many patients, few doctors, little money

Time has flown since writing my first post, and it’s hard to believe I’ve now been in Uganda for one month. When I last wrote, I had just arrived in Jinja, and Claire and I spent a week in the regional referral hospital there.

Jinja is lively town and a tourist hot spot with its offers of white water rafting, beautiful sunsets over Lake Victoria, bird watching, and of course its biggest attraction- the source of the river Nile. Before getting stuck into work in the hospital we felt obliged to enjoy a few of Jinja’s best features, and spent a lovely day relaxing by the lake, walking to see the source of the Nile as it emerges from lake Victoria, and spotting storks, egrets, pelicans, bats, and even a beautiful brightly coloured little bee-eater.  The wildlife highlight was the family of monkeys we saw leaping around in the trees as we strolled into town.  We drank sweet and spicy African tea on the shores of the lake and soaked up the peaceful atmosphere, almost forgetting that we are here to work…

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Tea by the Nile
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The way to the source of the Nile

 

 

But then it was on to the reality of Nalufenya Children’s hospital.  It seemed to have a good structure of triage, outpatients, an emergency room, two medical wards and a malnutrition unit, but as always too few doctors- there were only two interns looking after the wards (approximately 80 – 100 patients) and one covering the special care baby unit on another hospital site.  One poor intern had been on 24 hour shifts for the past four days and said he’d had one hours sleep the night before- his name was Lazarus, and he looked like he needed raising from the dead.  There was a covered outdoor area (blissfully cool compared to the stifling heat of the wards) which housed the immunisation clinic, triage, HIV counselling and testing station, and drug dispensing area (I’d like to say pharmacy, but I’m not sure you can call it that when there is no pharmacist?).  I spent a morning working with Grace, a student nurse, in the triage area, and we saw some very sick patients coming through including a quiet, stiff-necked, starey-eyed preterm baby who could not feed and clearly had signs of neonatal sepsis and meningitis, and an excruciatingly malnourished 8 year old weighing only 11.4kg (roughly the weight of a healthy one year old) who was too weak to stand, had a swollen stomach and legs, and sores all over his skin.  Both patients were triaged as Emergency and were hurried off to the emergency room for urgent treatment.

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Triage and ‘pharmacy’

I then moved to the outpatient department to work with Joseph and another Grace (this time male- it’s both a common male and female name in Uganda) who were the clinical officers seeing the patients triaged as Priority and Queue. Clinical officers have 3 years of medical training and do much of the work that a junior doctor would do in the UK. They are good at the common things such as malaria and pneumonia, but I noticed that most children seemed to go home with antibiotics that didn’t seem to be necessary and many were admitted for IV treatment of ‘severe malaria’ when oral treatment would have been adequate.  This leads to a knock-on effect on the ward, as patients remain in hospital for several days on IV Artesunate (the best treatment for severe malaria) plus IV ceftriaxone thrown in for good measure (a broad spectrum antibiotic that should only be reserved for the sickest of children; over-use will almost certainly lead to huge problems with resistance in the near future) and not only are they taking up vital bed space in a ward where there are two children to a bed when they could be taking oral medications at home, but it also leads to ‘stock-outs’ where the ward runs out of IV artesunate. Then when the really sick kids come in, they have nothing to give them.  This is something that could be addressed through teaching and training, but the clinical officers and interns are overworked with little time to learn, and are doing their best with what they’ve learnt from others practicing in this way.

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Immunisation clinic corner

To my horror, whilst in the outpatient department, we saw the very sick premature baby that I had seen being triaged as an Emergency over an hour before- she had not been taken to the emergency room after all, and had sat in the queue waiting to be seen. Claire swung into action and admitted her and we followed her through, trying to instigate management as quickly as possible, but everything we needed to do (put in a cannula, tape it down, give a bolus of IV dextrose, give antibiotics, insert an NG tube) was slowed down by the fact that the mum had to go and buy each piece of equipment first, including the gloves for us to wear.  I couldn’t believe that we weren’t allowed to just get equipment from a store and ask the family to buy replacements afterwards, when the baby was more stable, but that is the system there, and I was told that if it didn’t work like that then they’d run out of everything in a matter of days and would have the rest of the week without supplies.  This was hard to stomach.  All in all, it took two hours from her being recognised as an emergency patient to receiving her first, vital step in treatment. Even the blood sample that was taken to check for severe anaemia had to be taken by the mother to a lab in another hospital, as the lab at the children’s hospital could only do a few basic tests.

The emergency room itself felt completely chaotic, with children and parents and needles and empty glass vials everywhere, and patients with diarrhoea sharing beds with those who were possibly immunocompromised because the room for diarrhoea cases was full.  They did have two oxygen concentrators, which run off electricity and are able to give a supply of oxygen by concentrating it from the room air (useful when there are no oxygen cylinders available), although one seemed to be faulty.  The wards were similarly crowded and busy, and I struggled in the oppressive heat (having to wear a lab coat doesn’t help) and narrowly avoided fainting whilst trying to review the babies in the little neonatal room.  Luckily I was revived with a carton of mango juice, and resolved to toughen up!  There was also a quiet, dark room for patients with tetanus, and we saw the agony of this condition in a poor child having constant, painful spasms, his jaw clenched, back arched, arms outstretched and unable to move. The horrendous thing about tetanus is that the child is fully conscious throughout, and it is of course preventable by vaccine.  He was treated with sedatives to try to ease the spasms, and should have received anti-tetanus serum, but it was out of stock.

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The emergency room

One day we had the privilege of meeting Dr Emmanuel Tenywa, a paediatric doctor from Kampala specialising in cardiology, who comes to Jinja once a week to review the most unwell patients and to run a cardiology clinic.  He did an excellent teaching ward round with us, the interns and the nursing students, and then we joined him in his clinic where he reviewed patients with chronic heart conditions, many of whom have been waiting for surgery for years and sadly may never receive it due to lack of funding.  He had a great rapport with staff and parents, and congratulated the father of one of his long-term patients for taking such good care of his son, promising to reward him by buying him “the thigh of a grasshopper” next time he saw him.  This brought smiles and laughter to everyone in the clinic.

Another highlight from the childrens hospital was meeting Geofrey, a lab technician who enthusiastically displayed his ‘best malaria slides’ for us and let us use his microscope to see the parasites we had become so familiar with when studying in Liverpool. It was a strangely comforting feeling to be back in the lab, but it certainly made me miss my lab bench cronies! He insisted on giving the slides to us, although we explained we had no microscopes of our own to look at them with, so I am now carefully carrying several slides of malaria around with me, tucked into the pages of my journal….

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Geofrey and the lab techs

As our week in Jinja came to an end we enjoyed walking down the quiet, dusty red roads around our beautiful guesthouse, surrounded by lush palms and vegetation.  Whilst walking alongside a golf course and lovely big hotels, we saw a man stop along the road to fill up his water bottle from a muddy puddle, and then proceed to drink the brown water.  To see such desperation, poverty and probably lack of good health education, amidst the riches on either side of the road, was sobering and incredibly sad.  It also made me think about the patients I am likely to encounter here with diarrhoea and dehydration and how sending them home with oral rehydration solution may not be as simple as it sounds, if they don’t even have access to clean water to make it up with.

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With barely time to let everything I had seen in Jinja sink in, we were on the move again- this time to Kiboga, a town west of Kampala. We were reunited with our friends Matt and Lizz, and stopped in Kampala en route for a short stay in a beautiful, quiet guest house in the suburbs. Quiet, that is, until the morning was enthusiastically heralded by the resident cockerel, who we nicknamed Kellogg. There were no cornflakes for breakfast, but we were looked after well.

We travelled to Kiboga in a very full, very bumpy matatu- a little minibus that bravely tackles the incredible potholes that the Ugandan roads provide, whilst feeling like any moment it could fall to pieces.  This time we were attending the hospital for a week of learning whilst undertaking the ETAT+ course. This course teaches the Emergency Triage Assessment and Treatment Plus aftercare of sick children, and has been successful in improving health outcomes in Rwanda and Kenya. It is now being rolled out across Uganda, and is one of the reasons I will be working in Kamuli, to help instigate the ETAT+ teaching there.  We met the friendly faculty, and checked into our very simple guesthouse, complete with a fair few creepy crawlies. Luckily, we have discovered Doom- the finest insect spray in town. Its friendly moto is “nothing kills faster and keeps killing for longer”. It works.

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Besides us four, the course candidates comprised a mixture of doctors, clinical officers, nurses, midwives and students.  Although at first they were all very unfamiliar with the teaching style of using manikins and practice scenarios (this hands-on teaching is rare in Uganda) they embraced it and many made huge progress throughout the week, learning how to resuscitate babies and children, and to assess and manage children with severe illnesses.  We even learnt how to insert intra-osseous needles (a life-saving technique of inserting a needle into the bone to give urgent treatment when intravenous access can’t be gained) by practicing on chicken legs, which everyone was very enthusiastic about.  However, after handling raw chicken, it did raise the question of hand washing which was difficult given than Kiboga hospital has no running water. No running water. In a hospital. It’s hard to imagine. We were fortunate to have a bucket and bar of soap brought to us, and I had alcohol hand gel to use after the non-flushable hospital drop-toilets, but never mind us on our lovely ETAT course- what about the patients? And their caregivers? And all the doctors, nurses and midwives who work here? Every dressing changed, every bed pan emptied, every patient fed, every baby delivered- relying on there being a recently-filled bucket of water in the room, and if you are lucky, a bar of soap.  How can you hope to fight infection without even the most basic of provisions? It is so unfair for my colleagues and their patients here.

This issue was brought to the attention of the hospital director whilst we were there, who promised that progress was being made with the laying of pipes to a nearby reservoir, but as the hospital has been in this state for years I am dubious about how quickly it will be resolved.

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Kiboga hospitals water supply for the day

 

Whilst on the course, we were lucky enough to meet a wonderful Israeli and Polish couple, Ami and Maria, who were volunteer doctors at the hospital.  Unfortunately their time in Uganda is coming to an end, but we enjoyed spending an evening chatting over a few beers and picking their brains about their experiences of all things medical and non-medical in Uganda.

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New friends Ami and Marie

 

Then it was time for another goodbye, this time to each other as the four of us head to our separate, final destinations- our district hospitals.  It has been wonderful spending these first three weeks together as we have tried to adjust to the way of life here, and I do think this introductory period has been invaluable in helping me to understand the Ugandan healthcare system better- the management of malaria and malnutrition in particular, and of course the cultural adjustments to life in a Ugandan hospital. So I am very grateful for that, and I’m sure it will help me when I start work properly in Kamuli.  There are many challenges and surprises ahead, but at least I am partly prepared for them.

 

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A sunrise goodbye

 

Well done for making it to the end of this mammoth post. Please keep in touch!