Ward Round

We arrive on the ward and there is anxiety in the air. The nurse calls me over, she looks quite flustered. There is a young woman, second trimester, gasping. She still has a pulse but clearly about to go into cardiac arrest. She needs to be ventilated so I ask for the usual bag-mask-valve combo we use to ventilate in the first instance. The nurse is frantically looking through a cardboard box and not winning so I go and help; a tangle of old tubes and oxygen masks, covered in dust, but not the one we need, and it’s not a great surprise. Back at the bedside, things have deteriorated and I ask the woman’s sister to step aside. I ask for a bag of fluids to get things going, but there is no stock. We have a look through the notes, not much is known yet, maybe meningitis, maybe malaria, maybe a blood clot to the lungs. No investigations back yet, the lab is not working and blood gets sent across town for analysis. Her breathing is worse, I consider mouth to mouth, but that’s for the movies, and this woman’s fate is sealed. The pulse weakens and stops. Another doctor has come and tries some chest compressions, and I ask him to stop. A moment for collection and the ward team start preparing the body. A bandage used to strap the mouth closed, the body covered in a sheet, and a cardboard tag with her details tied around her left big toe. Another maternal death, unknown cause. I offer my condolences to the sister who seems remarkably calm. She must be shocked. The death of her sibling won’t sink in until later. The patient in the adjacent bed looks terrified; they’re only a metre apart and there are no curtains. On with the ward round.

A few moments to settle the nerves of said terrified adjacent patient. She cries whilst I hold her hand, worried she’s in the same boat. Fortunately, she’s on a different journey. She suffered with severe pre-eclampsia, the high blood pressure disorder in pregnancy. Her baby was born early and died the previous day. She has three, but wants two more. Fluid has built up in all the wrong parts of her body from the inflammation of pre-eclampsia, but most importantly for her in the lungs. I can hear the two puddles of water in the base of her chest. The SHO (obstetrics and gynaecology trainee) has arrived now and says they have asked the cardiothoracic surgeons for an opinion. It’s a blessing that they won’t come anyway, the last thing she needs is a knife. Her body should pass the water naturally over the next few days. I counsel her that she may need blood pressure medication when she goes home, and her next pregnancy will be very high risk. She will need careful antenatal surveillance in case this happens again, a service she unfortunately will not get. She’s going to get stepped down to the general post-natal ward now, a room with 40 mothers and crying newborn babies, and she will feel her loss.

I notice the catheter bag of a lady in the corner is a brownish red and suggest we see her next. She’s not looking well. She presented yesterday from another health centre after a prolonged obstructed labour at term, her first pregnancy. The baby had already died, and the operation notes suggest a very difficult Caesarean section. She is now semi-conscious and breathing very quickly, heart rate too fast, oxygen sats low, blood pressure holding. She’s either bleeding, or there is infection. No investigations, the family can’t afford the blood tests. She’s on some nasal prongs with a futile amount of oxygen trickling through. We get her on a more appropriate mask, and get another cannula in her arm. She needs some fluids, then I realise we have none. The woman’s mother is buzzing around, so the nurse writes ‘normal saline’ on a scrappy piece of paper and sends her to the strip of private pharmacies that line the hospital fence. ‘Free healthcare for all women and children!’ the government announced some years ago… I ask if we can check her blood sugar, but there is no glucometer available. I have my own machine, and one last testing strip. It’s low at 2.1, we give her a push of IV glucose. I’m half hoping it really picks her up; she stirs a little, but not much more.

We need to see what’s happening down below, why there is blood in the urine. The specialist gynaecology consultant has arrived now, thank goodness, he knows exactly what to do. But it’s bad news for the woman; the wall between the vagina and the bladder has been completely destroyed, a large fistula. The end of the catheter has prolapsed into vagina, and is draining a mixture of urine and blood and infection. We clean the area and there is clearly rotting flesh. The woman is in septic shock. With some basic plumbing we manage to get the catheter to stay up in the bladder. Back to treating the whole patient. The woman’s mother has returned with the fluids and we are into the second bag. We get some stronger antibiotics into her. More cleaning down below. Then the gurgling that I recognise, some fluid in the chest, we need to slow down the fluids. Everyone is working well as a team, despite the difficulty of the case and the conditions. The oxygen levels have come up, the pulse reduced a little. It’s the basics of medical resuscitation, it’s exhilarating and shocking all at the same time. Then things change, the pulse suddenly races to 210 beats per minute, far too high, a sprint that the heart muscle will struggle to keep up with. The adrenaline from the pain of the internal examination has probably shocked the heart into a short circuit. We continue the resuscitation, I’m hoping the rate will revert spontaneously, but it’s not budging and the oxygen level is dipping a bit. It would really help to know what rhythm she is in, but there is no ECG machine in the hospital. I start weighing up the options – difficult without knowing the rhythm. Some beta blocker? Some amiodarone? Would it be safe without monitoring? First do no harm. No chance of a defibrillating shock if she crashes, no defibrillator! Her salts could be abnormal causing the rhythm, but no way of knowing as the lab is not working. Probably wise to give some potassium and magnesium in case, low potassium will kill quicker than high potassium. We manage to get an anaesthetist from downstairs. She agrees, chance of harm if we start giving other cardiac drugs blindly, let’s give her some time. On with the ward round. Another woman has had a stroke from the high pressure of pre-eclampsia, another is swollen with fluid as her kidneys have completely stopped working. She needs dialysis which the family can’t afford, and she too will die.

I drive out of the hospital with that familiar feeling, a bit disconnected, a little overwhelmed, but knowing it will pass soon. Everyone getting on with life as usual out here. Those women are out of sight and out of mind. Maybe it would be different if we were at the heart of a humanitarian crisis, but this is a capital city in 2018. 2018! Do you remember how futuristic 2018 sounded? Hover boards? A meal in a pill? In 2018 a pregnant woman teetering on that fine line between life and death can’t get a bag of fluids and a basic blood test, whilst all the world carries on. One assumes that the health system they are working in is on an upward trajectory but a longitudinal view over some years makes me wonder otherwise. The funding and systems in place are deficient, creating a demoralising environment for the doctors and nurses that work tirelessly to make things better, indeed they are the strongest cog in the wheel. Families are not shocked, because this stagnation is an accepted part of life. The problems are systematic, and they come from the top. Whilst I stand by the philosophy of singing the good news stories, sometimes one feels the need to lay out the truth of what is really happening on the ground. It can’t be right. What on earth are you meant to do about it? Who does one shout at when we all know that method doesn’t work? Surely it’s wrong that we let pregnant women die of preventable causes well into the 21st century. Frustration and anger, probably not constructive, but important emotions, to write down and perhaps to share.

The woman in the photo is a generic image pulled from the internet.

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The tightrope of pregnancy in Uganda

Pregnancy is an uncomplicated business (in the medical sense at least..) for most women, most of the time. But when things go wrong, the situation can rapidly deteriorate putting both the mother and baby’s lives at risk; babies get stuck, mothers bleed both prior and after delivery, and many suffer a serious disorder of blood pressure called pre-eclampsia which can lead to fits and strokes. The avoidance of such grave consequences requires a tight system of antenatal surveillance and rapid sequence of action when complications arise. Whilst the health system in Uganda has the potential to supply each of the component parts of this system, they are weakly tied together, and elements of the chain may break due to basic inadequacies in infrastructure such as electricity and surgical supplies.

Each year we teach a two week of module of maternal, neonatal and child health which forms part of the East African Diploma in tropical medicine and hygiene (DTM&H). Seventy-two post-graduate doctors from both East Africa and around the world pass through and will expect an introduction to the practicalities of clinical medicine and research in sub-Saharan Africa. Each afternoon we take groups to meet women and hear stories which exemplify both the public health and obstetric challenges a woman may meet along the tortuous journey of pregnancy in Uganda. We make an effort to celebrate good maternal and neonatal care, as well as pick up on shortfalls. The cross-cutting themes include the impact of gender inequalities, educational background, and socio-economic components of care-seeking behaviour. Here are some of their stories. Names have been changed.

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A group of students on the 2017 course

Respectful care

Robhina is a 26-year-old lady, with a good educational background. Her first baby was born by Caesarean section due to obstructed labour; the baby’s head was simply too big for the mother’s pelvis, a common problem worldwide but even more prevalent where woman’s growth is stunted due to malnutrition in childhood. A vaginal birth is possible after Caesarean section, but must be done in a very supportive environment, and probably avoided in the context of pelvic insufficiency. Robhina laboured at home for a considerable time before going to a health centre IV, which should be able to provide blood products and a Caesarean section if needed. She continued to labour there overnight in considerable pain before it was clear she would need an operation. Unfortunately no doctor was there to do the operation and was transferred an hour across town to our facility which was overflowing. She was received in a very poor state and in agony. After another hour she was in theatre; her uterus had ruptured along the previous Caesarean scar and the baby was found floating free in the abdomen and already dead. She got the blood transfusion she needed and the surgeons managed to repair the uterus and avoid a hysterectomy (removal of the uterus). The team did a great job saving the woman’s life, but it was too little too late for the baby. We see around 4 of these ‘fresh’ stillbirths every day. Rhobina told her story totally matter of fact; she clearly had no idea that this was an avoidable outcome. So common are such stories amongst women that they are normalised. I asked her why she hadn’t come to the hospital sooner to deliver. It came down to the way she had been treated previously; talked down to, no privacy, scorned for complaining. Why not have a go at home with loved ones around? Explanations like these remind us that the respectful care of women is an integral part of future health system reform.

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Hearing personal stories provides context and a deeper level of learning (East African DTM&H 2016)

A new wave of medical disorders in pregnancy

Urban Africa is not only about empty plates. There is a rapidly expanding middle class with a taste for refined sugar, and a culture which associates large abdominal girth with higher social class. As a result we are beginning to see a rise in cases of diabetes in pregnancy. Doreen is 31 and has just had her third child. The first was delivered normally and weighed a decent 4.2kg. The second was even bigger at 4.8kg and needed to be delivered by Caesarean due to obstructed labour. Big babies are the hallmark of untreated diabetes in pregnancy; the high sugar level means the baby lays down more fat around the shoulders and abdomen raising the likelihood of complications at delivery. They also get so used to the high sugar and produce so much insulin that when they are born into the world their sugar level plummets which can kill. There is no screening for diabetes in pregnancy in Uganda. We do not yet even know which screening test would be best, or even what we would do if it was picked up as management is not straightforward and beyond the present antenatal system. As I spoke to Doreen the story of diabetes in her case was clear. This recent baby needed a Caesarean as there was not enough fluid around the baby (diabetes causes both too much or too little fluid). Her baby was wrapped up in sheets beside her and I see a tiny area of the sheet flickering over and over again in a repetitive way. I ask to see her 2-day old baby and sure enough the tiny girl was having a seizure, repetitively jerking her left arm up in the air. Doreen has no idea, and no doctor has been around that day. One junior doctor usually has to cast an eye over around 80 women and their new babies in the course of a morning. Few get a thorough check, and besides Doreen has no diagnosis. We take her baby to the special care unit for anti-convulsants; perhaps a low sugar level soon after birth could explain the fits, or infection, or low oxygen levels, we don’t know. Fortunately both are discharged a few days later, but the impact of the seizures and damage to the brain may not be realised until months later.

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The Maternal HDU (High Dependency Unit) during clinical rounds with Dr Anita Makins

Living with fistula

Ruth is 43 and has travelled from a very rural farming community. She has a coy smile and has the air of a once confident person who has suffered too much hardship in her life. She came to the hospital after hearing a radio advertisement. She had been leaking urine for twenty years having developed a vesico-vaginal fistula (abnormal connection between the bladder and vagina) after the birth of her third child. She laboured at home for three days before giving birth to a baby who had already died; she had been unable to afford the transport to get to the nearest hospital 7 miles away, a mere £3. The pressure of the baby’s head, stuck in the pelvis, caused damage to the tissues leading to abnormal tract formation. It’s a condition very rarely seen in the West, but still common in areas without accessible and affordable health services. Since that time she withdrew from village life, and farmed alone, hiding her shame from the community. Fortunately a supportive husband stayed with her, though many are not so lucky. Ruth has had decades to contemplate her fate, has come to terms with her condition, and is now happy that something may finally be done about it – surgical repair. Opposite Ruth sits another girl, with the same condition, but at the start of her story. She is very small, and looks incredibly shy. She is only 16 years old, but as I gain her confidence she tells me her story. Her first statement says so much; her family was not able to pay for her to go to school, so she stayed at home and became pregnant, totally matter of fact about the inevitability of such a chain of events. Again she laboured at home and got to the hospital too late. A dead baby was delivered using a suction cup in what sounded like an extremely traumatic series of events. She started leaking urine 6 weeks later, again due to injuries from a prolonged obstructed labour. She looked very vulnerable and alone, in a room full of women with totally avoidable internal injuries, victims of a world that still fails to recognise the equitable status of women in society.

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With Dr Ed MacLaren, my tutoring partner for the module, and one of the HDU nurses

The antenatal visit

Annett is a 24-year-old lady, a bubbly character with a broad smile across her face. She had given birth to a baby boy the week before and is overjoyed. Her first pregnancy had not been so successful; she had suffered high blood pressure which hadn’t been picked up in her antenatal visits. They didn’t have the basic testing strips for analysis of the urine, and blood pressure had not always been measured. She lost her first baby at 34 weeks of pregnancy. The staff encouraged her to get to antenatal visits early in subsequent pregnancies. Annett had the confidence and educational ability to speak up at her antenatal visits and demand the basics were done. She also had some money to get an antenatal scan – less than £10 which is far more than many can afford. As often happens she suffered with high blood pressure again. She came into the hospital at 26 weeks and was managed with medication for another 5 weeks to give her baby the chance to mature. At 31 weeks her condition was so severe that her baby had to be delivered, since the placenta is the cause of the blood pressure disorder. Her baby boy was taken to special care unit. On the first day Annett showed me pictures on her phone, but the next day took me to see him in the neonatal unit. Seventy similar babies were lined up, many with NG tubes in their noses, their mothers expressing milk and pushing it down the tube with a syringe. One doctor has the job of looking after all these delicate beings. Annett tells me all about what she does several times per day for her baby, and in immense detail. This is a mother’s love and casts out the common attitude of ‘just another stillbirth, or just another neonatal death.’ Annett and her baby had received great care, using basic principles of medicine. But she only got there because she had the educational and financial means to transcend the gaps in the chain, a privilege of few. Four young women, one just 19 years old, died of this high blood pressure disorder in our two weeks on the unit this year.

They are morbid stories in themselves, but more frightening is the sheer number of similar stories that are told every day, even in this one hospital. An old friend presented me with an audit of the women’s health service in the same hospital from 50 years ago, 1967-1968. Each maternal death is detailed and the stories are hauntingly similar. However much we try to champion good progress in sub-Saharan Africa, with health statistics improving year on year, it’s hard not to feel like the two worlds in which I spend my time are moving further apart. Whilst total average worldwide wealth improves, the inequities both within and between nations are worsening. It’s easy to be paralysed by the enormity of the problem, but inertia is far from an effective solution. Sharing stories like this will not change the world, but the least one can do is advocate for those without a voice. It may at least help in appreciating the excellent standards that our National Health Service affords our women and mothers.

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The 2017 contingent graduating in the gardens of Mulago Hospital

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Tutor group on the 2017 course

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A group on the 2016 course

Lifebox

I first met Nick about a month ago. He’s an anesthetist from the UK working in Hoima in northern Uganda. He has been part of a project that donated some anaesthetic equipment to rural hospitals in Uganda about 3 years ago, and was about to embark on a journey around the south west to follow them up. He needed an assistant and extended the invitation my way. He said it was going to be a great adventure. I trusted him and so with very little information to hand I said yes, a habit that has taken to me to some extraordinary places in my life, both good and bad, but always interesting.

A pulse oximeter measures the heart rate and the amount of oxygen in a person’s blood. It’s a routine piece of equipment used in the west and you’ll know it by the painless finger clip. Rural hospitals in Uganda rarely have this technology where anesthetics and surgery are regularly performed with no monitoring equipment at all. This is a dangerous business with little way of telling if a patient’s condition in deteriorating. The charity with which we are working, called Lifebox, saw this gap and have produced robust and simple to use oximeters – themselves called a Lifebox. They were given out with training to the anaesthetic officers in 80 rural hospitals 3 years ago. Follow up at 6 months suggested that they were being put to good use, but the real test was whether the improvements to patient safety have been sustainable and the project should be extended to other parts of the world. Nick and I were to find out just that; Were the Lifeboxes still working? Were they still being used? Had the project made any difference? Here are the notes from out trip.

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(Anaesthetic officers: Uganda has a population of 35 million but is home to only 30 aneasthetists. The majority of the anaesthesia is provided by the 300 anaesthetic officers who don’t have a medical degree but have attended a 2 year diploma. They would be the source of all the information we needed.)

Day 1

An early start to begin our journey south. 3 hours drive to Masaka to visit our first hospital, the non-governmental catholic-run St Peter’s Kitovu hospital. As we drove through the main gates the difference from a government establishment was palpable – pristine gardens and a sense of order and calm. The anaesthetic officer we are to meet was called Sister Mary Prospero. She appeared in her brilliant blue habit and was all smiles. She took us into the convent quarters where we interviewed her about the use of her 3 Lifeboxes since she received them in 2011. She’s thrilled to tell us all were in working order, used regularly, and made a great difference to the care she could offer her patients. Her equipment was in a similar condition to her veil – immaculate. We were shown around the theatres and admired the old ether drawover machines that they still use, real antiques. I was pleased to see they have a special VVF theatre for fistula camps. I hear that my old friend Andrew Browning will be coming here to operate in August. Great to see that fistula camps are being run in the same way in Uganda as in Sierra Leone. Tea and chapatis were laid on for us and Sister Prospero asked if we would like to stay the night their with them, an offer we couldn’t refuse.

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Nick with Sister Mary Prospero

After a fill of oily pancakes we were back in the car and made our way about half an hour further south to the second site, government run Kalisizo health centre IV, to meet the anaesthetic officer Rosemary. Again we were welcomed with open arms and shown around her theatre. Her original Lifebox was working well and again she had no problems with its use. She had a brand new GE 9100 anaesthetic machine but unfortunately there was one missing filter and her oxygen supply was inadequate. This is often the case with expensive donated equipment. Again a lovely atmosphere in this hospital with birds in the trees and children playing below the great jacarandas. We drove Rosemary home and made our way back to Kitovu. Nick headed down into town to meet another anesthetic officer at Masaka referral hospital and I took a couple of hours to explore the compound. We saw many of Uganda’s great birds on the journey down – the long-crested eagle, great blue turaco, and black and white casqued hornbill. This walk was notable for it’s butterflies who were congregating at the top of a cliff. They must have chosen this spot for the fine sunset over the maize fields to the west and the views down into the lush green valleys to the East. A fine supper with Sister Prospero and an evening visit to the paediatrics wards to blow up some balloons for the kids. We met some wonderful people in Kitovu.

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Bellenois creona – The African White

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The children’s ward – the burden of malaria ever present

Day 2

We started the day with mass in the chapel. Lovely hymns in African voices accompanied not by the organ but by the drum. After breakfast we headed an hour further SW to a small referral hospital called Lyantonde. There we were welcomed by Agnes who has been the only anaesthetic officer on call for the last 20 years. Lyantonde was an example of the most basic anaesthetic set-up we had seen so far. Whilst they do about 40 operations per month she has no anaesthetic machine and sedates all of her patients with a continuous infusion of ketamine. She has no way of protecting the airway with a tube. Again we found one of new 9100 machines but they don’t work without a good supply of oxygen, which was the case again here, and in most facilities we were to visit, a massive oversight. We were shocked in two ways really – that a hospital on a main road can be left with such basic equipment, but also how one woman can do such much with so little. We were charmed by Agnes. She is a great example of human endeavour overcoming the challenges in the resource-poor setting. We were so pleased to see he still has her Lifebox in fine working order, a monitor that she treasures. We were shown around the hospital by one of the four medical officers and even had time to pop into the laboratory, look under the microscope at some malaria parasites, and teach Nick some tropical medicine.

We kept moving and headed another hour south to Mbarara. Great laughs as Nick struggled through another difficult phone conversation, talking very slowly and very loudly, to arrange visits for tomorrow. In Mbarara we met Charles at Ruharo hospital, another church run establishment. Again the difference in organisation is clear. He was very eloquent in describing the benefits he derives from the two Lifeboxes that were still in working order. Like all the other anaesthetic officers he seemed very happy to give up his time and talk to us. It really felt as though they were enjoying someone taking an interest in their work. We headed into town and had a great time catching up with my old friend Dr Amir over a soda. We didn’t stop for too long as we had to head another hour and a half further SW to Itojo hospital, a rather dilapidated district hospital.

As we travel further along this road the hills began to form around us and the landscape was becoming more and more spectacular. We drove down that familiar scene, the red snake of road, lined with children, slicing through the lush green countryside. In Itojo we met Angelo, a great tall man. He took us to the theatre where a man was having his testicle operated on. He was awake with a local anaesthetic and neither he nor the surgeon seemed to mind our invasion. I know I certainly wouldn’t have wanted anything to distract the surgeon… We found the Lifebox, but unfortunately it was no longer working due to a blown plug and battery, probably from a power surge. We asked all of our questions and replaced the device with a brand new one with some training. The anaesthetic officer who was originally trained was off duty so we would drive to her village the next morning. Again the new anaesthetic machine was present, but never been plugged in due to the lack of oxygen. It was dark by the time we finished but we managed to find a place for the night at a nearby community centre, fairly basic but provided chips and beans and a bed. And the Brazil Vs Chile game.

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Nick with Agnes outside her operating theatre

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The hills beginning to rise

Day 3

An early start with a boiled egg and coffee. The AO from Itojo that had originally attended the Mbarara course was off duty and at home so we drove 30km or so off the main road and up into the plantain covered hills to her home in the village. It was well worth the trip and we learnt a lot from her about the challenges she faces in the hospital and in her career. Anaesthetic officers earn a maximum wage of £150 per month. This does not increase with the number of years of experience or the extra hours worked. On top of this the government will not pay for extra training or refresher courses which are about £100 per go. They say they are trained enough, whilst the AOs know they need further skills. There is a severe shortage of anaesthetic providers. Surgeons country wide are available but unable to operate due to the lack of AOs. I have been in the same position waiting for three hours with a woman who had a ruptured uterus by the time we operated. She probably ruptured whilst I was sitting with her like a lemon. Like other AOs she has four children and can’t afford to send them to school. Unless the government gets to grip with the fundamental principle of providing a sensible wage, the shortage will continue.

We then drove a further two hours south to Kabale where landscape changes from rolling pastures to steep terraced cultivated hills. Here we visited two hospitals. The first was the large regional referral hospital where we met Harriet in the well groomed lawns. We are welcomed into the theatres and were amazed to see the first working 9100 continuous flow anaesthetic machine, filled with not just isofluorane but sevofluorane too. We ask the AO how this had come about and she told us it was all down to good communication with their procurement manager. She says the equipment was there if you shout loud enough. Their Lifebox had begun to play up so we replaced some of the parts. They do a huge number of operations there, up to 140 Caesarians per month for instance, so we provided them with another Lifebox pulse oximeter and a paediatric probe. She then took us down to nearby Rugarama mission hospital to meet the AO Alex. They do far fewer operations there and rely on an ether drawover machine. Again there were some issues with the Lifebox so we replaced the necessary parts and did some training on the setup. Like all of the AOs we had met, these two harbour a huge amount of knowledge and take on staggering responsibilities. They clearly understand the benefits of measuring oxygen concentrations in the blood and provided beautiful examples of where the Lifebox had saved lives. After chapati and beans with Harriet we headed further SW. We took the scenic road along the Western edge of Lake Bunyoni and were afforded spectacular views. The children were beside themselves with excitement as we drove past. The winding road then took us over the col and through dense rainforest until the great Virunga volcano range came into view before us. From the top we could see across the borders into Rwanda and the DRC. We truly were in the heart of Africa. The political significance of such an area was brought home as we drove past the large, now redundant, UNHCR refugee camps. We drove down into the small town of Kisoro as the sun set and quickly found a bed for the night.

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Lake Bunyoni

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The Virunga volcano range comes into view

Day 4

A fresh morning in Kisoro. Nick visited two local hospitals during the course of the morning whilst I caught up with some other work. 3 Lifeboxes, 2 working well and another needing replacement. Again Nick found very basic equipment. In Kisoro hospital there was just one classic Ether drawover machine for three busy theatres. There were recurring themes – lack of oxygen supply, and issues surrounding limited career progression as an anaesthetic officer. By midday we were back on the road towards Kabale to meet another AO, winding our way through the green terraced hills, on the tail of a vehicle carrying three men armed with oozis and draped in ammunition. Innocence, the AO, usually works up in the hills but bought his Lifebox down to us. He was most complimentary about the use of the box, but again it needed replacing after three years of daily use. After another lunch of beans we broke off the main road and starting climbing a dusty track high into the Kisezi highlands. The next couple of days we would be out in the sticks. Locals were all smiles and cheering as we drove past and gave them the customary dust storm. Much of the hills are wooded with pine. We were amazed to see the men working in the valleys, 2 to each of the 9 foot saws, cutting straight planks from the round trunks. We were heading towards Kisizi hospital, a well known church of Uganda establishment. We could appreciate the influence of the place as we met women with their babies, on their way back from antenatal clinic, 20km by foot. We met men packing huge bags bulging with fresh tea leaves on our approach through the valleys. Kisizi is a very small and isolated town, dominated by the large hospital, which is renowned for it’s community health insurance scheme, which keeps the local population in fine health at little cost. We were met at the guesthouse by 2 medical students, beaming with the idea of some fresh faces. The isolation had been catching up with them and they were pleased to be taken out for a couple of Nile Specials. I had deserved a beer after a metaphorical undressing by the locals on the football field.

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Taking a break from chopping wood

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Packing tea

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Returning from antenatal clinic

Day 5

After 4 full days we decided to slow down for day 5 as we weren’t able to organise any appointments. We started the day with a walk up to Kisizi falls, 30m high and the pride of the town. The previous night I had committed to taking a swim in the icy waters. There was no way I was going to lose face so I took the plunge and pretended to enjoy it. Nick was very impressed. We then walked up to the top to admire the hydroelectric engineering and put forth various theories based on an elementary knowledge of physics. What seems probable is that the 30m vertical column drives a turbine which then supplies the entire town with electricity, another of the hospital’s famous local initiatives. After our walk we visited Kisizi hospital. Moses, the principle hospital administrator, gave us a warm welcome, and I was shown around by a lady called Confidence and a man called Happy. Whilst I visited the various wards, I left Nick in theatre to talk about his favourite subject – pulse oximetry. All the wards were busy with patients and staff, a working atmosphere that I have not grown to associate with healthcare in Uganda, and quite particular to private and missionary establishments. There was a lot of tricky medicine around. I met a 23 year old girl with HIV and TB going into liver failure as an adverse reaction to her TB medications. Conditions like these are difficult for even very experienced physicians so I had utmost respect for those junior doctors whose care she was under. The theatres had three full lists for the day and we were happy to supply them with another Lifebox in light of their heavy workload. We were most impressed by Kisizi hospital. It was by far the most organised and hardest working hospital that we had found that caters for the general public who have little or no money. We said our goodbyes and were back on the road after lunch, dropping from the cool forest and heading north into the warmer rolling hills of Bushenyi district. We dropped in on one further site, the government run Kitagata hospital. The feel was instantly different as the sleeping guard failed to get his shoes on to open the gate. The theatre staff were just about to do a Caesarian section and the AO we were looking for was not around. We found the Lifebox, replaced the sensor, and made our way. After another 30km we arrived in Ishaka where we stopped for the night. I took a sunset run around the local area, getting lost in the fields of matoke, exciting and scaring the local children in equal measure. After talapia and gin we were ready for bed.

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Taking a morning shower in Kisizi falls

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Nick doing some first class birding

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Day 6

I awoke to see the valley shrouded in mist. By the time we had eaten our bright orange toast and purple sausages the sun had burned it off and we made the 5 minute drive up to KIU hospital (Kampala International University). Here we were meeting two AOs who work either at KIU, in Katagata, and in Bushenyi. The KIU building was by far the most impressive we had seen, almost looking like the outbuildings of a French chateau. This is a private hospital which offers private medical education. A total of 1000 students pay fees of $4,000 per year, making up a hefty income ($4 million per year!), allowing the patient fees to be subsidised. The hospital houses impressive equipment and a large number of specialists. The only thing it was missing was any patients! We visited the ICU where an anaesthesiologist looked after 5 beds with ventilators (that’s more than Mulago…), but no-one using them. We were never to find out why, but apparently the impressive architecture intimidated the locals. We visited the theatres and tracked down the Lifeboxes. One was working well and the other needed replacing. The AOs were happy as always to spend time with us and answer our barrage of questions. One had travelled 5 hours to see us, and was then traveling 5 hours back later in the day.

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We then headed an hour north and stopped for lunch on the escarpment overlooking Queen Elizabeth National park. The view that unfolds is a true spectacle, an expanse of safari savannah, with Lake Edward in the distance, topped off with the 5,000m tall Rwenzori mountains as the backdrop. We even had time to slap on some suncream and have a swim. After lunch we dropped down into the park. We were immediately met with two large African elephants by the roadside and herds of grazing Kob antelope. We cut straight across the park, crossing the Kazinga channel, and then drove NW to a small predominantly muslim town called Bwera, 5km from the border with DR Congo. We were met by the AO John at the hospital perched on top of a hill, again with good views over the park. We looked around the hospital and then were welcomed into theatre. Nick put on his scrubs and joined the team to prepare a lady for Caesarian section whilst I sat with John and got a good idea of his work in the hospital. He had cherished his Lifebox until it had gone missing 6 months ago. The importance of the equipment was all to evident, his face lighting up as I offered him a new pack. This was clearly a hard working hospital, and all the staff we met were very enthusiastic to tell us what they were up to.

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Hillsides covered in tea

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Taking a break overlooking Queen Elizabeth national park

We wished to stay longer but had to find somewhere for the night. We had heard a rumour of a small hotel on the banks of Lake Edward, off the beaten track, and we went for it. After 8km down a dirt track we found Kayanja, a small fishing village which was clearly untouched by tourists at the park. The hippo lodge was quite clearly still under construction but the manager, my Congolese namesake Jacques, assured us that they had officially opened a couple of days before and welcomed us in. The fuss they made confirmed we must be amongst their first guests. The sun was coming down over the mountains of DRC. We made our way straight into the village to meet the locals around the fishing boats. The children were uncharacteristically terrified, and it took a fair while until they plucked up the courage to take a closer look at the funny looking people. Some of the younger ones just burst into tears at first sight. Before we knew it we had an entourage of 15 or so kids who escorted us around. The sunset was magnificent and gave way to a clear starry night over the lake to a chorus of frogs.

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Looking over the lake to the mountains of the DR Congo

Day 7

We woke up to the calm of the lake and took half an hour to visit the boats coming in after a night of talapia fishing. We said our goodbyes to Jacques and headed north to our first stop of the day, a mission hospital called Kagando, tucked up in the foothills of the Rwenzori mountains. Another fine welcome by another Moses, and a good look around the theatres. There seemed to be some good funding from somewhere in the UK, and we even found a ventilator in the paediatric ICU, a piece of equipment not even enjoyed by the national referral hospital. The AOs Richard and Felesta told us great stories of how the Lifebox had changed the way they practice. Richard showed us the precordial stethoscope with the long tube he used to use to constantly listen to the heart of a patient under anaesthetic. He said that thanks to the Lifebox this ungainly piece of equipment now lives in the museum. After our goodbyes we drove another 80km north to another mission hospital called Kalimbe. Again this hospital was tucked into the spectacular setting of the foothills, surrounded by green and lush interlocking spurs with a river running through. We had a really good laugh with the two AOs and the three surgeons there. The atmosphere and team spirit was the most energetic and good humoured we had come across. They were really pleased to have us there and were keen to establish a more permanent link. We gave them a new paediatric probe and joined them in theatre to see it put to good use as they repaired a bowel perforation on a 5 year old caused by typhoid fever. They were most grateful for the equipment. We heard a story of the Lifebox being used to transit a woman with cardiac arrest from Kalimbe to Mbarara, with a good result. We also heard of the recent floods which forced the surgeon to use three broad stitches midway through a laparotomy and swing the patient over his shoulder to take them to safety and complete the operation. TIA. After high spirited goodbyes we drove a little further uphill to see the old copper mines which have fallen into disrepair before moving back to the main road.

After another hour north we drove for half an hour up a dirt road to find Rwasende HC IV. Although only 12km off the main road it felt very rural. The kids in the school went berserk as we drove past and our car was surrounded by their raucous chanting. We finally met Dr Seth, the only doctor working there. He doesn’t have an AO but does the anesthetic himself whilst he operates, perhaps 10 spinals and 4 general anaesthetics with ketamine every month. He was also grateful for the Lifebox which again we found in good working order. By late afternoon we were done and drove another hour north to the pretty town of Fort Portal where we had supper with some colleagues and put up for the night. It had been a great couple of days tracking the Western edge of the majestic Rwenzoris.

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Bringing in the night’s catch of talapia

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Recent floods around the copper mines of Kalimbe

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Arriving in Rwasende

Day 8

The last day of hospital visits. Nick went off to visit Fort Portal regional referral hospital whilst I hung back and got on with my own business. He was pleased to see the Lifebox in good use, and impressed with the team of 5 AOs, many of whom came in on their day off to meet him. We couldn’t believe how generous they were all being with their time, it really made us think they truly value this equipment. After a quick lunch we drove around the northern apex of the Rwenzoris, off the rift, and down into the true lowlands on the Congolese side. The climate was very different, hot and humid, as the expanse of the DRC’s rainforest began. We drove up to Bundobugyo district hospital 5kms from the border on an unannounced visit. We had no number for any AO there, but had information they had received an Lifebox 3 years ago. Despite the lack of warning we were welcomed by the medical superintendent who was the same age as me having graduated in 2010. He is the only doctor there, whilst 10 other posts for doctors remained unfilled. He deals with every speciality, does all the surgery, and even performs the post-mortems. Anyone medical will understand this is an unheard of amount of responsibility. There was no AO there as such, and they had never received an Lifebox, but we found Mary who was an anesthetic assistant and delivers the anaesthesia hospital wide. Although they do around 30 Caesarians per month she is not comfortable with spinal anaesthesia and so gives a general anaesthetic in the form of ketamine or ether to everyone. She is not comfortable with intubation and has not provided such airway support for over 10 years. The other anaesthetic provider has never intubated anyone in her life and never had any formal training. The look on Nick’s face… This really is basic rural medicine. We don’t enquire about their safety record, but we suspect it is probably not as shocking as we would expect. Again with very little at their fingertips these anaesthetic providers are doing amazing work against the odds. They have very rudimentary equipment but know how to work it, and Nick admits probably better than himself. In the corner of their theatre is one of the new $15,000 GE 9100 machines that have been handed around. No one knew how to use it and Nick suggested they continue to avoid its use until they have had proper training. This really was a situation where new technology can be dangerous. Nick arranged for another UK anaesthetist to visit them in September and support them with some more training, as well as a Lifebox.

We 30km back down the road to the park gate of Semliki national park, Uganda’s premiere birding spot. There they have some relatively basic bandas where we settled in for the evening. We were the only ones in the area, our only company the piping hornbills and black and white colobus monkeys swinging through the trees.

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The lush surroundings of Fort Portal

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Talking about pulse oximetry. As usual.

Day 9

We were up before sunrise to take a walk through the park with our guide (called Moses of course). As the light grew the forest came alive. Moses knew all the bird calls and we encountered no less than 5 different species of monkey including the particularly shy De Brazza’s monkey. He led us to the natural hot water springs, where super-heated sulfurous water boils up through the ground depositing minerals as it cools. It was great to interact with the landscape rather than being restricted to tourist walking boards. We cooked eggs in the water for our breakfast and walked perhaps for 4 hours. The sun breaking over the mountains was a real highlight as all the wildlife celebrated the new day. We spent a decent amount of time identifying the huge array of butterflies with the use of a new field guide (thank you Ellie!), you start seeing so much more when you get your eye in. We felt very lucky to take in the experience of Semliki, a park rarely visited.

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The hot springs of Semliki

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A spectacular sunrise over the Rwenzoris, alone in the national park

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After lunch in Fort Portal it was time to catch the bus back to Kampala and say goodbye to Nick. A week ago we hardly knew each other, but through the course of our adventures we had become great friends. I had great admiration in the way that he conducted the study, taking a real interest in the people behind the equipment, and extending genuine offers of support. There is no doubt that we had collected some very powerful data which is down to the organisation and planning that went into this trip. Foreigners don’t always get it right in Africa, but Nick was an example of how to conduct great research in this part of the world. We had learnt a great amount about the state of healthcare in rural SW Uganda, been inspired by the people that work for humanity against all the odds, and taken in a lifetime’s worth of spectacular natural beauty. It had been a truly incredible week in the office, deep in the heart of Africa.

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Here are a few inferior photos of butterflies, just a handful of the incredible array of species we came across:

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Actinote bonasia

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Bellenois raffrayi

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Bicyclus safitza – male

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Charaxes varanes – the mimic of an autumnal leaf