Frustrations of follow up

Time to arrange the next visit. Pick up the book and open up the map. Spend a while letting our eyes focus on alien names and eventually resort to Google Earth. 0 results, remember that ‘R’s and ‘L’s are interchangeable and bingo next destination found. Time for the phone call...

Attempt 1) network busy, 2) the number you have dialled is not available on this network, 3) phone rings. Ringing rapidly changes into happy tune currently in the charts...

“Hello”

Hello how are you?

“Hello, I am fine, how are you?”

I am also fine.

“Good”.

My name is Hugo.

“Who?”

Hugo

“Who? Chigo?”

Yes, sigh, Chigo. I am an anaesthetic doctor in Mbarara.

“Ohh”

I work with Dr Ttendo – you know?

“Ey – I know”

I understand you were on the conference in July?

“Ey”

I am doing follow up from the conference.

“Ey”

Were you given a case report book?

“A what?”

A case report book?

“I am doing cases.”

Yes..ok..were you given a logbook?

“Yes I have a logbook”

Good, the blue one?

“Yes I have”

Do you have a white one?

“I have”

So you have 2 books from the conference

“No I have just 1”

OK – which colour?

“Blue”.

Not white.

“Yes white.”

Right, would it be possible to visit?

Very possible

 

And here in lies the first of our problems. Communication. Whilst face to face discussion on the whole is quite straight forward, over the phone many things are lost in translation. We have a list of 40 candidates. 20 of those have 2 report books. 1 book is blue the other is white. However as was pointed out to us on one visit, the blue one is white on the inside...fair enough.

Although the scenario is quite amusing over a beer at some removed point, travelling to the rural health centres takes a long time on bad roads. To find out hours later that the delegate doesn’t have the book becomes quite disheartening. It still is an invaluable eye opening experience and we have met lovely people along the way. 

More frustrating is when we double check arrangements and the person has gone on holiday, or the book is in the locker and there is a man with a key.....

When the drugs don't work

I’m sure from reading our blogs you have a fair impression of the issues facing the medical staff and patients here. Funding, staffing, availability of drugs including oxygen, reliable electricity supply are but a few. Thankfully Mbarara keeps the backup generator fuelled, not the same can be said of many of the more rural health centres. 

Micrbiology Labs

An issue that only came to light in the last few weeks is being able to know what quantity of antibiotic any particular patient needs at any one time. In the UK we trust in our quality control checks that the antibiotic strength is as it says on the tin. Antibiotics arrive mainly from India and China and undoubtly from the cheapest supplier. The end result is no quality control. This was recently demonstrated by a local pharmacy research student. Multiple vials of the same antibiotic of the supposed same strength were checked and their ability to treat a particular bacterium measured. Needless to say the results ranged hugely. This leaves all physicians in somewhat of a quandary. To little antibiotic and the infection won’t be treated and can actually worsen the situation, too much antibiotic and the side-effects of treatment can be harmful and even outweigh the seriousness of the original problem.

Anaesthetic Trolley with OMV

The anaesthetic officers face a similar dilemma with the drugs used to deliver general anaesthesia. Doses quoted to us for the use of Ketamine (a common anaesthetic agent) ranged from the usual 2mg/kg up to double the dose, with some reporting little effect even then. We found that the paralysing agent used, Suxamethonium, is often left out of the fridge which diminishes its effect. Errors like this can be corrected through education, but not when it is because there isn’t a working fridge in the hospital to start with.

Oxygen storage

One of the more frustrating factors we encounter is the lack of equipment and drugs. Although we have come to expect this at times there is a seemingly simple solution. A good example is when one hospital will have a set of spinal needles but no drugs to use in them, yet the neighbouring hospital will have spinal drugs but no needles. It seems difficult to produce effective communication between the 2. Politics and budgeting at a higher managerial level seems to get in the way.

Maybe it is more similar to home than we thought....

Intensive Care in Mbarara

ICU bed awaiting a patient

Maybe we were naive but we didn’t expect to find much in the way of Critical Care in Mbarara. Sure, maybe a close observation area for the sickest patients with monitoring and maybe some oxygen if available but not anything close to what we would expect at home.

 However we found a small intensive care unit (ICU) equipped with 2 beds with a ventilator each, all be archaic, and in theory a series of high dependency units (HDU) for each speciality. These functioned less well, largely as a result of the lack of equipment, staffing and spacial planning, but the idea is there. Nearing completion, but lying barren, is the new hospital furnished with an 8 bedded ICU that wouldn’t be hugely out of place from a design perspective in the UK.

The temporary unit...still under wraps

The current ICU is awaiting transfer to its temporary home (prior to the new hospital) a 4 bedded unit equipped with new ventilators and an air-conditioning unit that would keep an Eskimo cold! In the meantime it occupies what is mean to be the maternity HDU. The small unit is staffed by Ruth, the dedicated senior sister and several of her juniors. Patient reviews take place at the beginning of the anaesthetic working day and other problems are dealt with as they occur. Ruth has been working on the ICU for 10 years. She moves around the unit and organises it with quiet efficiency and looks after the patients and their families with professionalism and kindness. She seems happy at work but talking with her reveals the frustration and disappointed she deals regularly as she watches many of her wards die, even more difficult she mentions when they are staff members or children. I think the same applies for all of us in the medical world but we are very fortunate to not have to battle with the issues and subsequent mortality rates that Ruth and her team face on a daily basis. That being said everyone maintains and constant note of optimism whilst appreciating the hard reality that the odds are often stacked against them.

Patient in ICU

Hope, a small 13 year old girl, presented with osteomylitis of her lower leg, an infection of the bone. As is so often the case her family only brought her to hospital after several weeks of treatment in the village. This had involved applying herbal remedies to a wound on her foot, including the application of cow maneour, a popular remedy here. Her family are farmers from a local village and, as is usual, acted as her main careers helping bathe and dress her.

The infection had tracked up to the bone just below her knee. Having been to theatre to have her leg cleaned she came to ICU very unwell from this serious infection. This sort of infection requires high doses of antibiotics and ideally they should be directed specifically against the offending bacteria. A recent revelation has revealed that we have no idea how potent the antibiotics are and we can only get a broad idea of which bacterium might be causing the infection. Alongside this, the daily review and plan had to take into consideration the ability of the family to purchase the various tests and bits of equipment for their daughter. At home we take test results, bacterial identification and availability of drugs and equipment for granted and even then treating patients is a real challenge. How much more in the dark we found ourselves now. 

Hope was a young scared girl when she arrived but one who became more involved in the unit as the days passed and she improved. Everyone became very attached to her and her family. On one morning we found her taking an active interest in the resuscitation teaching that was being performed on the dummy on the floor by her bed. This is a novel idea, we thought, teaching the patients resus skills whilst treating them!

We are delighted to say that although Hope developed several complications whilst with us she made a good recovery and made it back home.

Hope’s case, although individual, was surrounded by the daily problems faced by doctors and nurses here. It is a perfect example of the need for public health education and timely presentation to hospital. It highlights the challenges of treating an infection whilst not knowing the exact cause and not being able to have faith in the dose of drugs you are using. It reminds us of the joy of free medical provision at the point of care and not having to balance the needs of the patient and those of the medical team against the financial position of the family.

As a side thought in the current times of financial constraint maybe we can learn a little from this. I wonder if the money we were spending was coming directly out of our, or the patient’s, pocket would we be quite so relaxed with ordering multiple tests and investigations that will do little to change our course of treatment. Would we look after that simple piece of equipment that bit more carefully....?

The events described in the blog are true although in the interest of confidentiality certain details and characteristics have been changed.

First ultrasound guided regional nerve block in Mbarara, maybe in all of Uganda!

Recovery trolley in theatre

So the precious elixir of oxygen still hadn’t arrived. Many phone calls are followed by promises that the cylinders will arrive in the afternoon. Some paediatric elective theatre work resumes – ENT, not a time when you want to run out of oxygen. Something we wouldn’t have worried much about in the past except for the fact that we’ve now seen that red alarm on the ventilator more than once! Not good for one’s own heart. As we took the 3 year old off the table and placed him in the corridor the anaesthetic officer from next door wandered out and kindly informed us that the ventilator had started alarming and all dials were in the red...although not good news we had a big inward sigh of relief as we looked at the boy sleeping off his ketamine/halothane anaesthetic in the corridor. Only a few minutes before he had been obstructing his airway and needing supplemental oxygen.

The emergency list was long as always with plenty of lower limb work. In theory the patients could receive a spinal anaesthetic and stay awake for the procedure hopefully not needing to be converted to a general. However crossing fingers isn’t enough and a ‘spare’ O2 cylinder was found that would be enough for any emergency situation requiring someone to be ventilated. Therefore work re-commenced.

Over the last few weeks we have been teaching ultra-sound guided regional anaesthesia (USSRA). Right – not what we expected either. A brand new, high spec ultra-sound machine had been obtained by the anaesthetic department. At first we thought the same as I am sure many of you. Surely this money could have been put towards more essential things. It certainly was not what we envisaged our teaching sessions would be on before we arrived. However having spent a few weeks in theatre we could actually see its potential benefit. Upper limb work could be carried out without the risk of a general anaesthetic. Post-operative pain relief, which is poor here, could be vastly improved, especially post laparotomy with TAP blocks. And at times like this when there was enough O2 for an emergency but not enough to run GAs lists, work could carry on. 

We had completed 2 weeks of teaching with some ‘willing’ volunteers, Hugo included, acting as maniquins as the trainees attempted to visualise the nerves. No needles allowed! Ground rules were established that everyone’s anatomy had to be up to speed (tested –Katie’s a tough examiner), everyone knew how to treat the complications and it was only carried out in theatre with full resuscitation equipment. A logbook would accompany the machine so a record of cases, practioner and success would be kept.

As if by design there on the emergency list was a young man injured from a machete attack. He had a wound to the palm of his hand that needed urgent repairing. Perfect example of how, if successful, a block could be used to facilitate awake surgery thus sparing the O2 and allowing this time critical surgery to take place.

Katie proceeded to perfectly demonstrate Mbarara’s first USS guided supra-clavicular block. The man successfully had his hand operated on. Although without going into too much detail we might not have been quite as confident about the possibility of carrying this out awake if we had actually seen his wounds prior to theatre...

There is always a lot of pressure when demonstrating a new technique. We were delighted it went well and with a lot of interest from our colleagues, medical students, nurses and passers by..

Next week TAP blocks....

The events described in the blog are true although in the interest of confidentiality certain details and characteristics have been changed.

Obstetric theatres and the twin theory

So our daily routine is falling into a fixed pattern as we find ourselves increasingly part of the anaesthetic/hospital team. 0800 meet on the ICU with the daily review followed by theatre work. The term lunch is used loosely. Yes it is the second meal of the day, but no, that does not necessarily mean in between the hours of 12 and 1400. We have learnt to pack our bag with some bananas and water.

This week has seen our first proper encounter with obstetric theatres. Slightly intrepid as a result of some of the tales we had heard and remembering our earliest encounters in upper theatres we entered with fingers crossed and breathe held. We found a busy couple of theatres. All electives had been cancelled due to a shortage of oxygen in the hospital. Not many places have oxygen and many of those that do have misfitting cylinder heads that either don’t work at all or deliver half of the supply to the general atmosphere of the ward. Cylinders are refilled and supplied from Kampala and we were awaiting our promised delivery. In the meantime we only had one full cylinder but with plenty of emergency caesareans on the list it was decided to limit the precious supply for these true life or death cases.

First Obs theatre

Working in obstetric theatres has been enlightening. The theatres although old are light and airy. The anaesthetic machines have their quirks (the Halothane vapouriser needs a bang before it kicks into life) but again, work fine. The surgical and theatre team are all very friendly. Swab, instrument and needle counts are carried out before the case and woe behold the surgeon who tries to close before the final count – all documented. All this with some of the neatest surgery we’ve seen yet. The WHO surgical safety checklist has taken a bit of a nosedive in the last few months but there is a big drive taking place to re-establish its importance this month. All a go for the group hug.

Aside from all this it’s a great opportunity to talk to patients and staff about issues surrounding health care in Uganda and general life. Most cases (>90%) are performed under spinal anaesthesia allowing us to talk in broken English but of a standard that far surpasses our limited Runyankole (a source of much amusement whenever we begin to speak).

Our latest topic of conversation has been surrounding twins. The conversation started after our first case of the morning. The surgeon happily presented the newly delivered baby to the theatre and into the arms of the waiting midwife. Just as we put the drugs into the infusion bag to help contract the uterus we heard the surprised surgeon exclaim ‘ah there are two’! “Number two?” we thought as we quickly stopped the drip – feeling foolish we re-checked the notes but there was no mention of twins there. Ah yes undiagnosed twins are very common we were told by our wiser and older anaesthetic colleague. Late emergency presentations and no routine USS mean undiagnosed twins are not an infrequent occurrence here. Once bitten twice shy. This was not to be our last case of twins for the day.

Twins have not had the best deal in Ugandan history. Their arrival has always been significant, but where some tribes perceive them as a blessing, others regard them with a wary eye. There have been reports in the history books of twins being drowned for fear of a curse on the village and to prevent drought and famine. In this region there is a strong belief that it is bad luck to not have any more children after twins. This was explained to us after we had delivered twins during an emergency caesarean for what would be the woman’s 7^th and 8^th children. As the obstetrician spoke he explained how he had tried to convince the lady to have a sterilisation during the operation. As he talked and the midwife laughed the realisation of this futile conversation dawned on him. He left exasperated at his wasted efforts that morning!

The events described in the blog are true although in the interest of confidentiality certain details and characteristics have been changed.