Finding Nemo and the Real Pain in the Neck

          Finding Nemo. A masterpiece if I may say so myself.      

I’ve realised this week that I need to start sleeping in the ICU to see the real action because all the crazy, exciting and scary things happen at night! On Friday morning I came in and met the patient we have now affectionately dubbed ‘The Fisherman’. He is a 25 year old who was out fishing on Thursday evening with friends and caught a wee fish. He put the live fish in his mouth between his teeth (God only knows why) but somehow took a big breath in and managed to inhale the fish into his lung. He started choking and his friends brought him to a village hospital, where they quickly identified he wasn’t able to breathe. That hospital didn’t have any pulse oximeters to measure the oxygen levels but he was going a bit blue, so they put a big needle in the neck to create a passage for air. Unfortunately that didn’t help much, and as said in my last post the vast majority of hospitals here don’t even have access to oxygen, so they sent him to Lacor hospital for further management. When he arrived he had oxygen saturations of 72%, and he was obviously pretty sick (as anyone with a live fish flapping around in his lung would be!). Ray and Francis took him straight to theatre, where it took two hours for the oromaxillofacial surgeon to remove the little fish piece by piece using a bronchoscope (lung camera) and a forceps. It was stuck headfirst between the right main bronchus and carina (see very detailed diagram attached). The next day when I saw him, he was talking to his friends, looking a bit worse-for-wear but thankfully (and rather miraculously) alive.

Francis (white coat) and the patient doing well two days post-op.

On Tuesday night a lady who had just had thyroid surgery earlier that day complained of pain in her neck, and the nurse Albert quickly realised she was bleeding. Bleeding like this can cause big problems in the neck as it can compress the airway and the vessels supplying the brain with blood. Her oxygen saturations dropped to only 70% and she quickly started slipping into unconsciousness. The fast acting nurse contacted the anaesthetist Francis and anaesthesiologist Ray who woke up the surgeon in the middle of the night to take the patient back to surgery straight away. There was a huge amount of swelling around the trachea (airway) but Francis managed to intubate, and after an hour of surgery stabilized the patient enough to put in a tracheostomy (semi-permanent airway in the neck which we will remove in a few days). I tottered in the next morning blissfully unaware of all this commotion overnight. I found her sitting up, breathing a bit of extra oxygen through the tracheostomy, but alive. Bleeding thyroids, although rare, are one of those situations that make anaesthetists and surgeons alike involuntarily shudder because they can go so horribly wrong and have a high mortality if rapid action is not taken. There is no doubt that Francis, Ray and the nurse Albert saved that lady’s life.

As you can probably deduce, I am massively impressed by the skills and knowledge of the people around me here, particularly Ray and Francis who have really welcomed me and have taught me so much. These are just two examples this week of lives saved at Lacor hospital where otherwise and elsewhere would have meant certain death for the patients. I feel like I am gaining so much more than I could possibly hope to give back to this place, between learning new skills, knowledge and experience and I am so happy to be here. Although I can take no credit for helping in these cases, it definitely makes the tough and sad cases easier knowing that Lacor Hospital and its skilled staff tipped the balance in favour of these two patients at least, and kept the greedy Grim Reaper at bay.

*More Good News*

Ray with a 24 year old who was in a road-traffic accident (* very common here - do not get me started on Ugandan drivers) : several broken ribs on the left and a collapsed right lung, successfully resuscitated and treated - discharged to the general surgical ward. 

45 year old man with air under the diaphragm from a perforated duodenal ulcer. This was repaired in surgery and he was discharged a few days later to the ward.

14 year old girl who fell from a mango tree three days before coming to hospital with shortness of breath and pain. XRay shows left haemothorax (blood in the lung space). She had a chest drain put in and was discharged to the surgical ward a few days later. 

Fortunes and Misfortunes

It was a sad day today in Lacor. I came in to find a 27 year-old mother of five had passed away in the ICU. She came in on Saturday night with a placental abruption, had a stillbirth, and followed by massive postpartum haemorrhage and consumptive coagulopathy. Despite best efforts over the weekend with surgery, 4 units of red cells and 2 units of fresh blood (donated by student nurses on site) she died overnight. 

Then at 1PM today I reviewed a new patient we received from the emergency department - a two year-old girl who became unwell five days ago with bloody diarrhoea. She went to her local hospital where she was treated for dysentery with antibiotics and fluid. When she failed to get better, spiked a fever and started vomiting after three days, she was transferred to another hospital in the region. There she rapidly deteriorated and lost consciousness on Saturday. She was transferred to our care this morning. Unfortunately she was in florid septic shock and had not regained consciousness since Saturday with a Glasgow Coma Scale of 4/15.

At 3.05PM I went to check on her again – I found she had no pulse and she wasn’t breathing but she was still warm. There are no monitors or alarms in the ICU to have alerted us sooner. I did 15 minutes of CPR and gave adrenaline boluses but I knew my efforts were futile. Even if we got her circulation back, after three days without oxygen in a village hospital and three days in a comatose state from septic shock her outcome was always going to be dismal. We called her time of death at 3.20PM.

Unfortunately resources are very limited in African hospitals. I consider myself very fortunate to be working in the only hospital outside the capital city in Uganda to have access to oxygen, working ventilators, and a formal intensive care unit staffed by trained nurses. I am also very fortunate to find myself under the mentorship of a UK anaesthetist who set up this ICU over ten years ago and who has personally overseen its growth and development. With over twenty years of experience working in Africa, he has been teaching me a huge amount about medicine, anaesthesia and intensive care in the resource-limited setting. In Ireland oxygen is our very first intervention in almost every single sick patient – completely taken for granted at home, yet a pure life-saving luxury here in Uganda. What an oxymoron.

I consider that little girl today very unfortunate that she had to go to two hospitals before Lacor – hospitals that are so under-resourced they couldn’t possibly have the means to save her life, but which are tragically considered the standard of care here.  In 2013 under-5s childhood mortality in Uganda was 66/1000 compared with 4/1000 in Ireland.

Finally, not forgetting the 27 year old girl who passed away last night, the maternal mortality ratio is forty times higher in Uganda than it is in Ireland (360 vs 9 deaths per 100,000 live births respectively). Although I was not directly involved in her care, I find it hard to accept the loss of a mother who is less than two years older than me, with five children who will literally wait forever for their mother to come home.

Particularly considering what I have seen today, I have never felt as fortunate and as privileged to be Irish as on this St Patrick’s Day 2015. 

GuluLife: Chatting and Chickens

There is so much to talk about when it comes to traditional African culture and it has taken some adjustment for me! They are a nation of tradition, family and religion - and nothing is more important than the people in their lives.

I had such an amazing first week staying in my friend Prossy’s house with her family. She lives across the main road from the hospital, behind the market in a lovely cosy home with her son Kaka and housemaid Claudia. The house has four cement walls with two bedrooms and a bathroom so it was sheer luxury compared to the standard home here! Most families in Gulu live in small round one-roomed homes made from home-made clay bricks and a thatched roof.  They build these mud houses in clusters, close to other family members, and women often spend the day sitting out in the sun or shade preparing food or opening up groundnuts watching the children playing. There could easily be four generations living in one cluster, with dozens of children around. 

They have such a strong sense of family, that a girl told me she would be very offended if her cousin called her ‘cousin’ instead of  ‘sister’. There is no distinction between siblings, cousins and second cousins, and children and young adults pay utmost respect to their elders, whether it be their parent or not. When Prossy’s sister was in her later stages of pregnancy, a younger cousin came to stay with her from Kampala to help out for a few months – this is a closely observed tradition and although she was happy to go, it was certainly an expectation that the cousin would dedicate these few months to family, because quite simply family is more important than anything else. 

There is such a relaxed pace of life here, it is as if someone actually removed the accelerator gene from the population. There is never any urgency or rush. I have no idea what time work actually starts at in the hospital and I don’t think anyone else does either... I haven’t seen too many emergency situations yet but I can’t imagine anyone breaking a sweat at any point. In some ways maybe they have the right mentality – the work gets done eventually but I find it really hard to justify delays when it can end in a worse patient outcome. This is something I am beginning to accept because I know my powers of persuasion definitely will not stretch to changing a lifelong culture! In the village, the housewives will spend all day pottering around doing a bit of cleaning and cooking, chatting together and maybe popping up to the market to get a few things. The trip to the market could take an hour or two despite the short distance, because you’re likely to meet several people you know and will stop and chat for a while. Most of the time it doesn’t matter what time of the day it is, because there are rarely specific engagements at specific times (except mass!) so nobody really wears a watch and I have rarely seen a clock. Most women who work outside the home will have a maid to do the cooking and cleaning – usually a young girl from a neighbouring village who lives in-house. It is actually your duty and responsibility to the community to employ a maid/security if you have the means, and to not do so would be incredibly stingy.

There is also a great culture of visiting here in Uganda. Neighbours, family and friends will stop by unannounced and may sit for hours talking and catching up. There is particularly a strong culture of visiting elderly people, who are greatly respected in the community. I had such a great day last Saturday when Prossy’s mum and I went to visit her grandmother, and she was so welcoming she even gave me a live chicken to take home! (Eaten for dinner on Sunday!) It really reminds me of the way neighbours used to call in on my grandparents every day in Tipperary just for a chat and a cup of tea, and there are many ways the culture in Uganda today bears some resemblance to old Ireland - the religion, the big families, the strong sense of community, tradition and stories. They also have great superstitions and a pretty strong pagan culture here, which isn’t a million miles from stories of Banshees and devils of Irish folklore. Village people, especially older people often still choose the witch doctor before the hospital, and though I haven’t had the pleasure yet I am dying to meet a witch doctor and see what they do. From what I’ve heard they wear the traditional garb with feathers and facepaint and the works and there is a lot of chanting and shouting!

One great aspect of this close-knit community culture is that there is never anyone complaining of loneliness. Interestingly despite this, Uganda still has reportedly high levels of depression, maybe more of a reflection of the particularly tragic and violent history here over the last fifty years. Personal space really doesn’t exist much here - people honestly find it so strange when I choose to do go to town alone or do anything at all by myself. Someone will happily sit beside you for hours in silence while you read or listen to music – and lots of people simply cannot believe I’ve come halfway across the world on my own. Prossy’s mum is very keen to find a Ugandan husband for me so I can stay here forever – I have explained to her that the culture of polygamy, which is commonplace here could be a major problem for me but she seems undeterred. For the moment my priority is to make the most of my time here so I’m going to try to slow my walking pace so I fit in a bit easier, enjoy the company of friends and take off my watch.

Winner winner chicken dinner!

First Impressions

Dear Internet,

I have arrived safely in the pearl of Africa, Uganda! I flew into Entebbe airport on Sunday/Monday, arriving at around 5AM (which actually looks remarkably like the last scene in the Last King of Scotland now that I think about it)... The first nice surprise was the fact that everyone else in the passport queue had to pay $50 for a visa, but I didn’t because there’s no visa charge for the Irish, thanks to all the foreign aid we give every year! So nobody has any excuse not to visit me really.

I was picked up by a lovely 24 year old Ugandan who brought me to Lacor House in Kampala where I stayed overnight. I was awoken at 10AM with the plan to leave at 11AM – properly African-time-shtyle we didn’t end up hitting the road until 5PM. And hitting the road is rather literal – serious potholes up the north of Uganda, mostly a dirt road, but I had great company with an American clinical officer, two Italian technicians who have come to set up a new XRay machine, a Ugandan XRay technician and our driver. The landscape was a lot greener than I had imagined it to be, we had several drive-thrus (ie. where traders approach with pineapples and bananas on their heads when you’re stopped in traffic), which had a plentiful supply of fruit and nuts. I also crossed both the equator and the Nile, but it was too dark to see anything so I'll keep my eyes peeled the next time I head to Kampala!

I arrived in Gulu at 1AM. Managed to terrorise some poor English volunteer in the hospital guesthouse by barging accidentally into his room in the middle of the night, but managed to get a few hours sleep before waking to the sound of a cock crowing. Incessantly. At the crack of dawn.

There are such stark contrasts between the hospital here and what I’m used to at home, I’m not sure where to even start.

Firstly, the heat. It is like 27 degrees or more everyday, with no air conditioning or fans. The hospital itself has almost 500 beds, split into medical, surgical, obstetrics, gynaecology and paediatric wards, as well as a 10 bed ICU and the capacity for six operating theatres. So there is a huge number of staff, all of whom so far have been so friendly to me. People tend to stare and children shout ‘Muzungu’ (which means white person) when they see me and my pashty complexion, but it’s very inoffensive and I’ve been told the best thing to do is wave and say hello. So I more or less feel like somewhat of a celebrity.

Bottle of local brew, 5.9%. Yeoooow.

I’ve spent my first four days in operating theatre. It is totally different to home. As there is a shortage of doctors in general in Uganda and a large requirement for trained anaesthetists, they run a two-year anaesthesia training programme for non-physicians (ie. Nurses or clinical officers). After this they are fully trained in anaesthesia and intensive care and may end up as the only anaesthetist in a rural hospital. As far as I know, the medically trained anaesthetists are known as anaesthesiologists. It does make me feel like a bit of a shmuck embarking on a six year training programme... They actually have something similar for medical doctors here too – called a ‘medical officer’ or ‘clinical officer’ where they don’t have a medical degree but can perform most of the duties of the doctor.  With such a large population and so few trained doctors it seems to be the only and best solution here. There is also extremely limited radiology – only XRay and ultrasound (and occasionally a small bit of fluoroscopy). There is no CT or MRI.

Most of the operations I’ve seen are general surgery and obstetrics/gynaecology. For almost all procedures (90% according to the anaesthesiologists) they do not use general anaesthesia, opting instead for spinal blocks. This seemed absolutely bizarre to me initially, to have women fully awake during a hysterectomy or a toe amputation it works very well as there is a shorter recovery time and less requirement for intubation and ventilation (there are only 3 ventilators available). What I’m beginning to understand about working with limited resources is that you reuse and recycle as much as possible without endangering the patient. A spinal only needs a few syringes and needles, but general anesthesia requires a sterilized laryngoscope, an endotracheal tube, possibly a sterile mask, a ventilator, oxygen and an inhalational agent (normally halothane) which are both very limited. There is no waste here – all drapes, gowns, hats, masks, tubing, and all equipment are sterilized and reused as much as possible. Sure half the time, instead of using a blanket for the patient going to recovery, the surgeon will give you his gown to cover the patient. And here there is nothing wrong with that!

I’m living with the nicest Ugandan woman across the road from the hospital and really enjoying it so far. Her sister had a baby the other day by C-section and I was there with her for the procedure so it’s a very exciting time and there’s loads of their family about. I’m loving the African food and learning a few odd phrases of the tribal Acholi language but mostly everyone speaks a bit of English. I actually cannot even begin to explain how friendly everyone here is, every five seconds someone welcomes me and shakes my hand! 

Final tot from the fundraising was €3750 – half of which will go to St Judes and half toward medical supplies for St Mary’s Hospital. Thank you all so much for your generosity, it will really go far here!

 

I’m a bit overwhelmed at the moment and there is so much to say about this place but I’ll continue to update the blog when I’ve access to wifi and/or when I’ve formulated some coherent thoughts about life here!

Wee shnake on the road to Gulu today (Friday)... It might have been dead but I didn't get too close to check..!