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.