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.