Kibale National Park and Chimp trekking

As our lodging’s name suggests Chimpanzees are rather a draw here. Kibale Forrest is home to a family of 120 individuals who often split themselves into ever smaller groups depending on the availability of food. When its plenty everyone’s happy, when its scarce individuals break off.

The area isn’t really designed for the ‘independent’ traveller with most people arriving as part of a tour completing the Ugandan circuit. Our only option was to take a boda-boda down the 10k dirt road to the trail head. Now we’ve not been granted the upmost faith in boda-boda’s, small 125cc motorbikes that swerve around traffic picking up passengers with nothing short but a blatant disregard of the law of the road and for the drivers own health. We unfortunately had also seen far to many people on our trauma list as a result of this lawlessness. However there is little traffic here and we had little option, so at 0700 Hugo found himself clinging onto a boda driver in a bright pink mac and wellies whilst Katie found herself desperately trying not to slide off the end. Either he was very calm or our combined weights made it tough for the 125cc engine but at least the up hills were slow, downhill was a slightly different story as we gathered pace and momentum to conquer the next hill. Being on a motorbike did however give us a unique view of the forest and its wildlife. The family of baboons with some very little ones didn’t seem perturbed by our arrival.

Having tucked our trousers into socks, the safari ants like to climb legs before choosing to bite, we set off in search of our close primate relatives. Even without our main goal in sight the forrest was beautiful. Saved from logging in the 30’s a lot was young rainforest but some of the old giants live on. Huge roots at their base formed partitions on the forrest floor – almost inviting you to sit down and stare up the towering height of the tree. Vines draped themselves across the plants twisting into uniquely beautiful shapes and all around was the constant chatter of bird life. Our guide, Bosco, and our protector, Ferida with the AK47, where extremely adept at mimicking bird calls and naming them. They were also highly skilled at pointing out the marching lines of safari ants that would quickly envelope any object in their path and take a nip if fleshy enough. Imagine my joy later at having to fish out the camera’s lens cap from one such congo line....

Not to much later we caught our first site of our ancestral cousins. High up in the tree tops a Chimpanzee mother was building a nest for herself and her youngling. The night before we had been entertained by a dramatic thunder and lightning storm and the rain had continued into the morning. The upside was a cooler trek, the downside we were warned was the the chimps tend to curl up in the tree tops in the cold. We walked on but an hour later had not stumbled on any more chimpanzees. Just as we were reconciling ourselves to the fact that the distant glimpse we had caught earlier would be our lot, huge cries echoed out across the forrest. As the calling increased into a deafening crescendo we caught site of a male chimp in the tree above. The males are a lot bolder and he happily continued his foraging with only the occasional glimpse in our direction. We spent a good amount of time watching him swing above us no more than 5m above our heads. He quite happily showering us with the standing water from the trees, making us duck the odd stray leaf and branch. The Wildlife Authority rules meant we couldn’t stay any longer than an hour but we left, muddy, tired, wet with the odd ant bite but very satisfied.

An uneventful boda ride and some lunch later saw us sitting outside our room looking over the tea plantations writing the blog in the company of Spot the dog. Our new companion whilst staying here has kept us company during the day and been an impromptu guard at night. We also met Agnus N. the daughter of an Englishmen who after his RAF days worked as a commissioner in Uganda eventually retiring to the region after his final placement in Fort Portal. His untimely death when she was young saw her being looked after by their family friends, the original owners of this property and has seen it blossom into the business it is today. Old ordinance and mining survey maps line the old house and the shelves are filled with old books that would have been read by some of the initial colonial settlers, their version of the Bradt and Lonely Planet guides.

The guest feedback form asks if we would stay here again on a return to the region. No need to think about that one-we’d be back like a shot.

Fort Portal follow ups

Once again we set out from Mbarara this time heading north to past Queen Elizabeth National Park to Fort Portal a town sat at the edge of Kibale National Park. The route of Mbarara is particularly scenic. Not long after leaving the town we are driving past farmland, standing out of the usual fields of maize or millet is a small piece of land dedicated to lemongrass. A funded farming project that unfortunately came to no fruition when it was deemed to be economically unviable, however there it remains, now a field of wild lemongrass. A short drive later our eyes are drawn to a large cement memorial on the road side. Our driver explains that this was the sight of a schoolbus accident many years ago. All the children, 70 from the same village, died. This sobering sight on our latest adventure reminded us of the perils faced on the roads here and the tragedies many of the familes have known.

Soon the regular fields give way to the banana plantations that populate much of the country. Bananas in their various species and guises form a large part of the local diet here. There are bananas for cooking (matoke), bananas as we know them, including the tiny really sweet ones and even bananas for beer and whiskey brewing (not gone down that road yet)! We can see the fruits of their labours piled onto the back of pick up trucks to an unimaginable height, and just when you thought no more could be put on you notice the people sat on top of this precarious pile.

As we continue north the land becomes increasingly hilly and much of our journey is framed be the domineering presence of the Rwenzori’s. This large mountain range borders Uganda with the DRC and also helped form the landscape of our destination – the crater lakes. By know we are looking out over a bright green felt, carpeted landscape. The region is famous for its tea plantations and was a popular retirement area for a few of the past British commissioners during Uganda’s time as a protectorate. A quick look at the map told us we could short cut our journey and have a chance to drive through the crater lakes – however this meant forsaking the comfort of a tarmac road and hitting the dirt track once again. A few quick enquiries later established that the road should be drivable and off we set.

In between the tea leaves and banana trees we could catch glimpses at first of the lakes. Soon we were spoilt with stunning views of deep blue lakes surrounded by cliff edges, a result of the massive volcanic activity that helped form this land. Oded, our driver, had never been here before and was wide eyed with the view as well. “Surely these people are blessed with the lakes they have been given” he exclaimed. While I have to agree they do live in a beautiful part of Uganda and have a supply of water from the lakes there are no fish in them and they create an existence through some back breaking work.

This brings us back to our follow up. Our next stop on the SAFE follow up was KIU (Kampala International University) hospital. This relatively newly build hospital sprawls across the hillside looking down over Ishaka town. The hospital attracts students from across Uganada and neighbouring countries. The impressive building supports an A&E department with two ambulances waiting outside. This made it all the more curious that as we entered the main door and approached the receptionist there was no one to be seen. Something else bothered our subconscious but it took a while to place it – it was the abscence of sound. The hospital had patients, indeed the person we had come to meet was currently in theatre but for a building of its size it was eerily quiet.

After a short wait we were enthusiastically greeted by the anaesthetic officer. She quickly ushered us across the compound, threw some theatre greens at us and before we knew it we were in theatre with an emergency caesarean section on the table. The spinal had just been sited and the staff were waiting for the surgeons to arrive. We were impressed with the standard of theatres. A huge room housed 2 operating theatres each overseen by an anaesthetic machine with a reasonably equipped anaesthetic trolley next to it. The hospital had power and a back up generator (which we had the joy to see in action when the power went part way through) and prior to surgery the WHO safe surgical checklist was completed. Accurate records and full observations were taken. With all this it still seemed strange that the entire hospital, including ICU and theatres, had one saturation probe – the one we were looking at on the patient’s finger. Issues between clinicians and managers exist here to when it comes to deciding where the money goes to. For the record the mother and baby did very well and as always there was an inner sigh of relief when the little boy let us know of his arrival into the world with a full set of lungs.

Kitagata town

It took us a while to work out where all the patients were. After all here is a brand new big hospital near a pretty sizeable town with easy road access. The answer lay not far down the road. 

Kitagata springs - with the locals

After leaving Ishaka we reached a fork in the red dirt road; left to Kitagata and right to Mitooma and between the two all the patients we expected to see in KIU. Kitagata (literally hot springs, they have natural hot pools here with proposed medicinal purposes) serves as the larger of the 2 hospitals with an impressive theatre record book of cases. Mitooma is a health care 4 centre. It is served by one dedicated anaesthetic officer who comissioned, designed, oversaw the building of and runs theatres. This means personal care and stock taking of all the equipment, drugs, water and power supply. Ingeniously a solar power back up system, on top of the back-up generator, has been installed providing light to theatres at all times. Feeling slightly foolish we hadn't thought of this before, we wonder why more places don't have this.

Stella and her equipment

Vaccination day at Mitooma

Mitooma is a basic health centre from a surgical/anaesthetic point of view. All we could do is take our hat off to Stella the anaesthetic officer for putting it all in place. She works here on her own and has spent years bringing people back from the private clinics in town (private means expensive but not necesarily better) to her theatre complex. The downside is that if she ever tries to have a day off, attend a course or go on annual leave she is surrounded by angry villagers demanding she works. An sort of training involves slipping away unnoticed - and we thought getting leave at home was difficult! The bottom line is that no one trusts the big new place and want to continue to use the place they know. Also as ever KIU might be quite a journey for the villagers and this is expensive. Far better and cheaper to stay close to home.

Circumstances put a few of our plans on hold and stalled us from visiting some of the other units. However we managed to conduct  rewarding telephone interviews in their place and gleamed a lot of useful information and feedback. I’m sure you’re getting the picture but when we asked one officer about the main issues he faces at work he declared there are just 3 “lack of equipment, lack of drugs (including oxygen at times) and lack of power” oh well just those then we thought!

Back at our new base camp, the beautiful Chimpanzee Guest House, we had been greeted by extremely friendly staff and just to ensure we would completely fall in love with the place a fire had been lit to heat the water tank to our room...yes this potentially would mean a truely hot shower. Having had a few disappointments along the way and having spent the last week washing out of a bucket in our bath we didn’t get our hopes up to high. We are not ashamed to admit however that it was amazing to stand under running, hot water and properly wash. We spoilt ourselves at dinner with a cold beer (Hugo found another new Ugandan brand-Moonberg) and meat- chicken stew and roast goat.

Official Ugandan anaesthetist ...Dr Webster

Logistics of medical care

One over whelming problem that we have faced is lack of funds for medical care. The patient’s families have to pay for a varying proportion of their care. Sometimes if they can’t afford to pay for the blood tests then we have to operate without the results which causes tremendous problems as you are in the dark about many things.

Blood is never usually available at the beginning of the case, however it seems to magically appear half way through – from where I have no idea. I might have thought some unsuspecting passerby might have been the donor however, looking at the bleed dates I can assure you all this doesn’t happen. Well, as far as we can tell. 

Lower theatre

There has been no X-ray film in hospital since February so excellent clinical skills examination skills have been brushed up in the last few weeks. For now the patients have to go to Good Will Radiology centre in Mbarara town. The names do make you laugh sometimes. There is the Homely Medical centre down the road and the Honest laboratories, who are anything but honest. Stories have been told of imposters on the ward posing as medical students who later approach the patients, some of whom may not need blood tests, and direct them to their own labs rather than the hospital ones which are free.

Difficult airway....!

This is for all the anaesthetists I'm afraid. This lady gave her consent to be put in our blog with her photo. Awake intubation was performed, not quite as we'd expect from our western practice however. A gargle of 2% lidocaine and direct laryngoscopy was performed, awake. Seemed to work well actually...

Photographed with the patients permission

Krazy Ketamine

Well, one of the skills we both wanted was to be happy with administering ketamine anaesthesia and we have certainly attained this! Every case usually has ketamine in the mix! It seems to be used as an anaesthetic agent for induction but also to bring the blood pressure up in difficult hypotensive episodes. The general rule for hypotension is – turn the halothane off. If it still goes down or the patient moves give ketamine. If it still goes down grab a 1mg of adrenaline and whack it in your IV bag. It works a treat although I think the ODPS at home might think we have gone crazy if we took this practice back home.

First week of work

The hospital shares its ground with Mbarara University of Science and Technology (MUST) and is a regional referral centre. In the hierarchy of health infrastructure it is a tertiary referral centre with patients being sent here from the entire south west region. In some cases the national referral centre in Mulago also sends patients here particularly when they have no equipment. 

Our first day in theatre was an interesting one which took us on a steep learning curve of Ugandan anaesthesia. We are obviously not going to talk about the specifics of cases on this blog but in our first week we had power failure, a young child with sats in the fifties whilst enduring a period with no available oxygen and total blood volume loss so great it covered the theatre floor and started flowing out the door within a couple of minutes, all this coupled with no vasopressors or inotropes. All patients survived and did well. Made us realise we might be overdoing things in the UK sometimes. 

Operating theatre

In the case of no oxygen there wasn’t much we could do. The only place in Mbarara hospital that is supplied with oxygen is theatres so we were lucky to have any to start with. It is piped from large cylinders that sit the other side of the theatre wall. When they are depleted the anaesthetist simply has to wait until the cylinder is changed by someone on the outside, which involves a quick phone call. Apart from continued ventilation of this child, we simply had to wait until someone came to the rescue. Fortunately they did and with the oxygen replenished the child improved and did very well. 

Hospital grounds

Theatres here are a juxtaposition of western practice and limited resources. Depending on availability patients pay for sundries such as gauze, gloves, venflons and syringes. All other equipment and drugs are paid for by the government but most is in short supply. The anaesthetic department is well run with 3 anaesthetic consultants, 3 registrar equivalents and anaesthetic officers comprising a very experienced department. There are two theatre complexes, upper and lower. Most general surgery and elective cases take place in the upper theatre which was built as a short term solution whilst the new hospital is being built. The lower theatre is mostly gynae and obs. 

Walking into theatre and looking at the anaesthetic machine you could be forgiven for thinking we were back home. Modern anaesthetic machines with ECG, SpO2, EtCO2, FiO2 and NIBP monitoing.  Vapours available are Halothane with Isoflurane sometimes. So not much different from home after a quick introduction and learning curve on the use of Halothane.

There is a small emergency ward which is run by an intern in the first year post grad. It gets very crowded and busy with emergency surgical referrals and patients are kept here if they are on the emergency list. Elective patients go to the surgical ward which is split into male and female sides in a Nightingale fashion with parallel beds in a rectangular ward. The nurses are exceptionally busy sometimes caring for over 30 patients. They administer medications and take observations. All other nursing care that we would expect at home is provided by relatives, called attendants here. They wash, dress, change, feed and care for the patients. Hospital care is expensive for them, especially if they have travelled away from home. The family will not only have to cover the patient’s costs (when we say feed that also means buying the food) but also their own – for many nearly an unaffordable trip. It’s very easy to presume that the late presentation of many patients is down to either poor public health knowledge or the belief in traditional medicines but there are so many more factors – as always money and daily survival being one of them.

For the anaesthetists reading this - the head of the anaesthesia department has recently purchased a very good ultrasound machine so we have started a weekly tutorial session in the basics of ultrasound guided regional anaesthesia. Pain relief is limited to morphine 3 mg every 3 hours and pethidine. Paracetamol can be given PO or PR but if the patient is NBM post op then analgesia is a real problem. There are no epidurals or indwelling LA infusions for major cases, saying that none of the patients complain. Adding in local nerve blocks would really help this situation as local anaesthetic is very cheap and available. All the residents seem very keen to learn so we have started with axillary and lower arm isolated nerve blocks to get them use to the machine and in plane needle technique. Once they are up and running it would be good to collect some data and the plan is for a record book to be kept alongside the machine

The intensive care department is being housed temporarily next to the post delivery ward. It currently has 2 beds although there is a building with 4 beds in the hospital but it isn’t working due to lack in equipment and nurses. Mostly post op surgical patients occupy the beds, not many medical beds as they have a high observation section which is run separately. Inotropes such as adrenaline, noradrenaline, dopamine and dobutamine are given, they are diluted into 500mls and run through an infusion. The BP is recorded non-invasively and we have seen no arterial or central lines so far (although we did see one Picc line randomly - the system is well adapted to use whatever it can get its hands on..). Ventilated patients are usually spontaneously breathing on a ventilator and oxygen is humidified and available, again via cylinders with piping run through a water trap.

The usual patient mix is anything from maternity cases (usually sepsis from uterine ruptures), general surgical laparotomies ranging from perforations to ischaemic bowel and lots and lots of head injuries. Road accidents are prolific in Uganda and the outcome is pretty poor due to the lack of specialised neurosurgical services anywhere. The only neurosurgery under taken is Burr holes or cranial lifts. There is a mix of paediatric and adult patients and sadly the overall outcome is poor across the board, a problem the nursing staff find understandably difficult.

Bashara Island

Large drops of rain broke the smooth platinum surface of the lake. The mist clung to the lakeside as the dusk drew in and gave the Bushara an eerie feel. We were unsure at first quite what to make of our cottage. It had our first en-suite bathroom but we are still not convinced when this is combined with an indoor long drop!

We woke up to the rain that had threatened our crossing the day before. At a slightly higher altitude it became surprisingly chilly with the sun gone. However our surroundings were beautiful.

Hugo writing the blog

 

Translated the lake’s name means place of little birds and our aviary friends didn’t disappoint. We even caught a glimpse of the very rare long tailed starling. Some of our fellow guests took this to the extreme and our peaceful time curled up next to the fire with our books would be punctuated with a variety of bird cries. We would look up to see one of the slightly strange Swiss family practising bird calls and eagerly demonstrating in the book which one it was...all was forgiven when the later gave us some Swiss chocolate cake, our over eager bird imitator had recently been married on one of the neighbouring islands and was no on honeymoon with all the in-laws.

An uneventful return trip had us visit the last hospital in the loop for this journey and feeling very positive about our work to come. Hopefully on Monday work permits will be sorted and we will be allowed into our theatres.

Golden Monkeys and Lake Bunyonyi

Carrying the shopping home

Volcano peaks on our way to the Mgahinga National Park

Elias our ranger for the trek

Another early start saw us driving towards the 3 huge volcanoes that dominate the sky line around Kisoro. They are three of the towering peaks that make up the Virunga range across SW Uganda, sharing their slopes with Rwanda and the DRC. Finally breaking out of the valley allowed us to see how magnificently tall they are (highest peak 4300m). Thankful that it has been quite some time since lava has touched Ugandan soil we set off up the slopes with an American couple in search of the world’s last remaining Golden Monkeys.

Some tired legs later we stood amongst the bamboo watching them chew and play their way through the rooftop of the forest.

Golden monkey

Soon it was time to head back, the guide pointing out some of the various floras and fauna the forest has to offer its inhabitants. Elephant beer being a personal favourite..yep after a tough day in the rain forest there’s nothing more they like to do but have a beer and get a little tipsy – our genes are obviously not that far apart.

Sweaty Irish monkey

Elephant Beer

Worrying about making it back towards Mbarara over some tricky road services we struck gold (pardon the pun) with our American honeymooning golden monkey companions. They offered us a lift to Lake Bunyonyi, about half way back to Mbarara. One of the larger Ugandan lakes famed for its beauty and safe swimming conditions, Lake Bunyonyi is a popular retreat for the Mbarara crew so we gladly tagged along planning a night on Bashara Island.

The driver decided we had to take the scenic lakeside route although our nerves and buttocks cried out for one of the few stretches of tarmac road here. Rutinda harbour, the gateway to the islands was busier than expected. Lots of local people with their wares perched precariously in dug-out canoes. We gave a slight shiver as we remembered the vast majority would not know how to swim, and certainly no life jackets around.

Rutinda Jetty

A swifter but only slightly more stable motor boat trip across the lake passed some of the many islands we had read about. Of note were Sharp’s island (the previous site of a leper colony set up by an missionary doctor and now a secondary boarding school, Punishment island (where unmarried pregnant women would be abandoned in days gone by) and Upside down island (a curse on a group of drunkards saw this island tip upside down drowning all in the lake – or maybe the local brew is very strong!).

We were shown to our little cottage and headed to the bar to warm up in front of the blazing fire.