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bath time in Kisiizi!

bath time in Kisiizi!
outside children's ward

Sunday, September 18, 2011

Never again...



As part of the follow up from last weekend’s mission, we have been running a series of short video clips from a dvd each looking at a different topic.  These have included “Trust” with a very amusing 2 year old learning to jump from the side of a pool into his father’s arms; “3 seconds” looking at the time to make a decision to do or not do, or say or not say, something.  This was illustrated by the author bungee jumping over the River Nile here in Uganda, something many of the audience had never seen. Will |I or won't I take the plunge?

On Thursday evening Herbert, one of our electricians, chose to do a poignant clip from Rwanda and the genocide memorial in Kigali which has the words “never again” on the structure.  It is hard to believe that such awful, terrible tragedies occurred so recently and only about 3 or 4 hours drive from here.  The message of the video was to live with forgiveness and love rather than revenge and hatred.  Challenging.

On Friday night I spoke at the final session to a full chapel all about our perspective on life – our “world view” - do we just see it as existence that eventually fizzles out and that’s it, or do we realise the eternal dimension that changes how we think about everything else?

I told a lot of stories including of the man who gets on the bus to Kampala and opens his bag and starts to wall paper the side of the coach, put up curtains and family photos to the amazement of the other passengers.  When asked what on earth he is doing he replies “setting up home”!  The others point out that this is just a bus on a journey, that he will be in Kampala this afternoon and he should focus on what he will do there rather than worry about the transient journey.  The story is of course a parable with life: we are just passing through this world with eternity ahead which changes our perspective entirely. But we should still enjoy the journey!
Finally, after stories, video clips, exuberant African rhythm singing and a bit of impromptu drama, the evening was over.

On Saturday we had a much appreciated lie-in to 8.30am then some domestic chores cleaning the house ready for 2 special visitors for a late lunch – Esther, our senior nursing officer, and Moses, our administrator. We have known and loved them both for many years so it was a special time for us to share together.  Esther is due to retire at the end of November which will be a huge change for her but also for Kisiizi.  I don’t think many people realise quite how much she has done / does to hold things together.  She has faithfully worked with a line of Medical Superintendents including myself over the years and has given wise counsel and support. 
I was interrupted to go and see a baby but the conversations continued whilst I was away and on my return.  Then, after quite a few enjoyable hours, we escorted our visitors home as befits local custom.

Today the English service at 9am included a sermon by Dr Gabriel, our excellent surgeon.  He spoke very well on the familiar story of the Good Samaritan but drew out some fresh points.

Afterwards passed via the baby unit then the hospital shop to get milk [bring your own jug] and home to read up some papers and prepare some talks, answer emails etc.

Then this evening a very nice meal with friends – Herbert [electrician] who did a lot of translating for me in the past week and was MC for the mission; his wife Sayuni, a nurse on children’s ward with their lovely tuneful little daughter Faith.  Joined by other members of their family for a lot of laughs and sharing of stories, mostly amusing, some sad, all memorable.

On the way back passed the wards [light on in Maternity theatre so probably doing a caesarean section] and enjoyed the stars which were clear.

Now it’s a bit late so the internet speeds up from tortoise speed to crab speed as less people are competing for the link and I am trying to finish this blog before crashing out for the night…

Thursday, September 15, 2011

oh happy day!

A very happy mum able to take home her little baby born at only 28 weeks and weighing just 1kg.

The baby had a number of problems and did require blood transfusion, iv antibiotics, oxygen etc but has done well and is breast feeding nicely.

Encouraging when sometimes we face the tragedies of losing babies due to limited resources such as the lack of surfactant, ability to monitor basic electrolytes etc.
what's all the fuss about?!

Wednesday, September 14, 2011

Crystal clear...


Our son Mark has just had some work published in the journal CrystEngComm – it is related to research he has participated in as part of his PhD course and concerns the laboratory powder X-ray diffraction data on an X-ray amorphous mixture of carbemazepine and indomethacin…  umm, makes my prescribing of good old gentian violet to put on wounds here seem rather tame!

It’s an interesting contrast though.  Mark’s research will hopefully lead to better tools to evaluate new medicines.  Yet some research has led to useful treatments like gentian violet being phased out in the west so that painful conditions like herpes stomatitis [very sore mouth] have to be treated instead with expensive things like Difflam spray that don’t, in my experience, work half as well as what we have here!

Then there is the contrast in costs: in my department at home I would happily inject a dose of surfactant down an endotracheal tube of a premature baby with respiratrory distress that would cost a couple of hundred pounds - here that would be about 900,000 Uganda shillings which would pay a nurse for a few months…

Research in the past has made a huge impact here - the work on producing vaccines has changed the spectrum of diseases.  When we first came here over 24 years ago the most shocking thing was the "measles room" full of terribly sad cases of adults and children.  Many were seriously ill, some going blind, some with meningitis etc.  Now we don't see any cases at all as immunisation has prevented the spread of the disease.


Sunday, September 11, 2011

[very] long-term follow up!


 Some of you may recall seeing photos of a little girl we met right back in 1991.  She came from a poor family living in a remote village.  Sadly she was badly injured by a paraffin stove which caused serious burns on her right chest wall, right armpit and the inner aspect of her right upper arm.

She did not receive any proper treatment in the local town and the result was that extensive scar tissue formed and her right arm became adherent to her chest with severe limitation of her range of movement.

This situation lasted some months and then she developed some infection in the arm under an area of the scar tissue.

This time they came to Kisiizi, simply expecting some antibiotics etc to treat the infection.  I took the photo on the left when she presented to us.


Happily we were able to do more and under general anaesthesia released the scar tissue to allow her arm to be freed.  However, this left raw areas on her right chest and upper arm so we skin grafted these with donor skin from a thigh.

After a further “tidying up” procedure, I took the photo of her going home now able to carry a bucket on her head.  Without this surgical intervention she would have had a permanent disability that would have probably prevented her from getting married.

We did see her again once in her remote village when we had visited Kisiizi in 1995 but not since.

You can imagine then how touched we were to find that, having heard we were in Uganda again, she decided to travel down at once to see us.  This was a challenging 7 hour journey from Fort Portal where she now works for a bank.  She came with her fiancĂ©, Stuart, and they plan to marry next year.  They are both Christians and seem very happy with life.

It was wonderful to see how well Loyce has done and she was very happy to raise her arms high for the photo. 

When I asked her what she remembered of her time in Kisiizi having the treatment, she described something I had long since forgotten.  Of all the things that stood out to her was that the second time she was due to go to theatre, and was maybe a bit apprehensive, I apparently sat her up on my shoulders and she “rode” there, enjoying every minute!

So we rejoiced together and thanked God for how things have worked out.




Rise and shine!


The long-awaited mission weekend arrived… very last minute preparations as tents appeared and we set up the sound system with the new equipment, ready for the start at 6pm.  The chapel choir came, the band came, members of staff came, patients came, school kids came… and the rain came!  It poured, and though the tents proved waterproof, there were streams of water rushing along the ground producing a lot of mud and of course there were a lot of electrical cables, microphone leads and connections etc on the ground.  So it was a real challenge to keep things going.  But, all credit to them, the choir just got up and sang enthusiastically; the Bishop and team arrived and joined in and a good time was had by all in spite of it being cold and wet.  The theme for the mission was a verse from the book of Isaiah chapter 60 and verse 1 which says “Arise, shine, for your light has come, and the glory of the Lord rises upon you”.  So quite a contrast between the weather and the theme, and yet it all became a bit of a parable as Saturday was brighter and this morning, Sunday, was lovely and bright and warm. 
The lead singer of the music group

The programme included a music group from Mbarara, a city 80 miles away.  The group are often on the radio and seemed very popular.  I think they write their own songs which have a powerful message.  The main lead singer spoke a little of his own life where he had been an alcoholic with many problems but then “the light had come” and turned him around completely.  

A mini-drama had people in stitches especially the youngsters present.

Speakers included a young man from Kabale, a head-mistress of a secondary school, Dr Ian from Kisiizi and the Bishop himself.  I spoke on the Saturday morning with a very good translator called Herbert who really entered into the spirit of whatever I said.  So for example, when describing a memory of patients who had had cataract surgery sitting on a bench and watching the nurse come along the line and put a pair of thick lens glasses on each one [this was the days before we had intra-ocular implants] I remember how they one by one started clapping, singing, dancing with huge joy as they had been resigned to never seeing clearly again and now “the light had come”.  So when I illustrated the scene by clapping and jumping for joy Herbert joined me. 

The programme was full with the introductory evening session on Friday, then from 10am to 10pm Saturday quite a lot of activities, and today from 10 – 2 then lunch.  Thanks again to members of our church in Macclesfield who have helped with the costs of the PA system which coped very well considering the weather.

 Hanna found herself unexpectedly busy with a lot of babies deciding to arrive this weekend.

So we are ready to rest after a full and encouraging time.

Tuesday, September 6, 2011

A few excerpts from Tuesday:


06:30   Making breakfast:  tap water [from Kisiizi’s natural spring, flowing by gravity to the storage tanks] boiled in a small kettle with electricity [from Kisiizi hydro-generator] with Uganda tea leaves [tea grows not far from here in plantations on hill sides] and milk [purchased from the Kisiizi “canteen”, in plastic bags, then boiled as not pasteurised].  Bread [home made] with Blue Band margarine [from a tin] and [if Ian is lucky] marmalade from a tin originating from Kenya.  Through the window can hear the beautiful pure sound of a robinchat.

Dr Francis speaking on infection control
 08:00   After a shortened morning prayers we had a Continual Professional Development session for all staff in the Chapel.  This focussed on Infection Control and was led by Dr Francis Banya and Sister Maureen, Kisiizi Infection Control Nurse.

It proved a useful time with some amusing interchanges towards the end and will hopefully have significantly raised awareness of infection control principles.  We still have some medical staff wearing white coats and not always rolling up their sleeves when examining patients so the “naked below the elbow” principle is not yet fully operational…

09:00   Ian chatted with Reverend Patrick, Hospital Chaplain, re the use of a DVD next week in staff prayers.  Hanna on Maternity in Labour ward supervising deliveries and teaching student nurses.

800 gram preterm baby transferred from a government hospital
09:20   Ian did a ward round of the neonates – this has been a very busy area this week with a succession of small preterm babies.  Happily today they all seem to be behaving.  Accompanied by Kate, a doctor from UK here for 5 months, and a couple of medical students plus a school leaver in Kisiizi for only a day who is going to study history at University so not the sort of morning he is used to!  Then on to Children’s Ward.

11:45   Staff coffee in the staff room – this is for senior staff, Ugandan tea in thermos flasks is available together with a couple of small sweet bananas – tasty!  A good chance to meet up with colleagues, interchange varies from football teams, to national news, to discussing patients, often a useful liaison time.

13:30  Lunch – cooked this time by Peace [one of our housegirls when we lived here years ago].  Matoke [steamed green bananas which are peeled with a knife and cooked in banana leaves for a couple of hours] with dodo [no, not fossils but a form of spinach]  and groundnut sauce [un-roasted peanuts ground then boiled to produce a purple coloured sauce – delicious]. 

13:50   Knock on the door, someone arrived to collect some money we were forwarding for orphans’ school fees

14:00   Hanna spent a couple of enjoyable hours teaching student nurses this afternoon on the delights of fallopian tubes and placentae… ummm.  Came home in a major rainstorm soaked and weary but then still found the energy to cut my hair [ok, so there’s nothing like as much as there used to be…]

Meanwhile Ian spent some time  working on a strategy document which involved reading a number of other papers first and still needs more work.

18:30   Knock on the door – visit from Nancy, bringing a gift for Hanna.  Long chat and a few laughs remembering Nancy’s UK visit last November including various memorable encounters e.g. with an escalator…

20:30   Fellowship meeting in the Chapel, mainly to pray for the forthcoming mission this weekend.  One interesting challenge is that one of the speakers booked is a Head Teacher but as there is currently a national strike of teachers in government schools an edict has been issued that all Head Teachers must remain at their schools so she may not be able to come.

21:40   Review on the Special Care Baby Unit – happily all still doing well, able to increase the feeds on three babies and reduce their iv fluids. Hopefully I won't get called out of bed tonight as happened yesterday.

22:30   Walking home hearing the thunderous sound of a very full waterfall after the earlier rains.  Some cloud cover so haven’t yet had the chance to look for the “new” supernova which lies near the Plough [ a constellation we sometimes see near our northern horizon as compared to being overhead in UK] [we also can see the Southern Cross on the other horizon if you are interested!]…

Right, mozzie net down, time for bed…

Linguistic Perm^u*ta@tio~n#s...


Yesterday the labour ward was rather busy and towards the end of the afternoon we were out of delivery packs.  An urgent trip to the sterilising room by one of the students did not produce fresh supplies as the autoclave cycle still had about 20 minutes to go.
Chloe, one of the elective medical students from the UK, was hoping to “catch” her first delivery.  However, the mother-to-be was not progressing as well as one might want, and when the foetal heart rate dropped to undesirable levels – the following conversation ensued…

Me:  “we need some instruments and especially some scissors…”
Midwife:  “Sister, we don’t have – there is no ‘seesar’ at all”
Intern:  (rather worried) “Why are you looking for a Caesar?”
Me:  “I don’t need a Caesar – I need a scissor for doing an episiotomy – and all she may need is a ventouse, not a Caesar at this point!”
Midwife:  “But Sister – there is no Caesar!”
Me:  (suddenly inspired!) – Please go to theatre and get a scissor from the Caesar pack!”
Midwife:  “But Sister – there is no ‘seesar’!!!”

Somehow – a few minutes later – the caesarean section instrument pack was produced and a pair of  scissors retrieved… just in time – a few minutes later another little Ugandan girl safely entered the world.  Afterwards, on reflection, we finally understood that my “scissor”,  the Midwife’s “seesar”  and the Intern’s “Caesar” were all different interpretations of the same sound!…

Hanna

Sunday, September 4, 2011

All change...

Having looked forward to a quiet weekend to focus on some strategic planning and to think about my talk next Saturday at the mission, all was changed… 
yes, started off well, peaceful enough as we had breakfast [happily Hanna is definitely now improving though still not fully back to normal] and I simply planned to review the neonates as we have quite a few small preterm babies.

My intended half an hour review session ended up hours later.  One baby aged 6 weeks, born at 28 weeks gestation, and previously doing well had an apnoeic episode and was anaemic so had to have a top up blood transfusion and start on iv antibiotics. 
30 week twins, each weighing about 1.3kg, had been born the previous day; one doing very well but the other had a chest deformity and severe distress and possibly an abnormal heart. He deteriorated on nasal oxygen with continuous positive pressure and we tried a period of hand ventilation to see if he would pick up.  No ventilators here of course and no investigations such as blood gases.  We had the father hand ventilating him for a while.  However sadly he failed to improve and died.
Meanwhile a 1kg preterm baby doing quite well but needed a cannula - no luxury of having registrars here to do the tricky practical procedures though the baby nursery nursing team are quite good at putting in iv drips in the bigger babies.

Just when I though I could leave, a woman arrived carrying a bundle of cloths.  When these were opened up, there inside was a tiny 800gram baby, very cold.  He had been born the afternoon before at a government hospital called Kambuga about 80 minute drive from here to the north-west.  They had told the mother they had no facilities to care for the baby so to they should go to Kisiizi.  This is an example of how the real healthcare is provided by the church hospitals.  The baby had not even been assessed by a doctor, probably none on site on a Saturday.  The baby's temperature must have been around 30 degrees only as after a couple of hours in a very warm incubator it was still only 32.5!  I put in a cannula and gave him some saline and dextrose and covered him with iv antibiotics.  Today he is doing quite well and has started on tube feeds which he seems to be tolerating.
So in the evening I went back to review the above and things seemed to be more stable.  Then this morning the note arrived [see photo] and I reviewed the baby whom I suspect has Down's syndrome and perhaps Hirschsprung’s disease with marked abdominal distension.

I did manage to get to the end of the morning service in the chapel and greeted some new visitors from Chester with whom Kisiizi has a formal link.  They are here for 2 weeks, a group of 6 of whom 2 have been before I think. 

We had a really nice lunch with Esther and a good chat then later I went back to talk with the parents of the above neonate as the father had meanwhile arrived.  We remember him from our time here decades ago so it was good to meet up again.  

Then back home, and now, on the fourth attempt, managed to get internet access to update this blog.
Thanks to all of you who have sent encouraging feedback.
Ian and Hanna


Thursday, September 1, 2011

Rain and shine...

This week has been a mix - Hanna has not felt well with a flu-like illness, cough and nasal congestion and, very unusually, has not been to work.  She is gradually improving but still not back to normal.

Kisiizi Falls after rain
The weather is variable with some beautiful days and then occasional outbursts of very heavy rains.  Sadly some people's fields in a nearby valley have been flooded with loss of some crops which in our situation here is very serious.  The waterfall is impressive after the rains.

Inflation is causing a lot of concern to people though in some cases, such as the price of sugar, there seems to be a political element as the sugar cane growing companies are putting pressure on the government to allow them to clear some areas of forest to plant more.

Maternity [upstairs] & Children's ward at night
Ian was called at 3.30am to maternity for a baby who was thought to have meconium-aspiration syndrome.  Unfortunately the baby was in-extremis and died.  So sad.  Yet on the other hand we have seen some very small babies doing surprisingly well.

On children's ward a real mix.  One child brought in found abandoned, a lad of about 5, cold and semi-conscious.  Made a good recovery, very apprehensive waking up in a strange place but taken in by the family of our surgeon Dr Gabriel who has children of a similar age and he settled in wonderfully.  Now the mother has been traced and the police involved to try and work out what had happened.

A 12 year old came in with fever and abdominal pain and then yesterday became quite jaundiced with a hepatitis picture.  Seems to be a lot of typhoid around, we have two children on the round this am who have had laparotomies for perforations that may then in turn cause adhesions with some secondary bowel obstruction.  Happily they seem to be doing well.

Thankfully we don't have too many in the malnutrition end of the ward at present.  One good thing to see is the introduction of "ready to use therapeutic foods".  We have one called "plumpy nut" that comes in sachets [made in France] and provided by a donor.  They have the advantage that they can go home with these and they store well as compared to trying to use milk feeds which are difficult to keep sterile.

The hospital will be hosting a "mission" the weekend after next so, in true Kisiizi style, there are a whole range of sub-committees established to try and organise everything.  The new Bishop will be opening the weekend on the Friday, there will be visiting choirs and speakers.  Ian is speaking on the Saturday morning - just an hour slot!  Will be translated so that helps, and an opportunity to tell lots of stories and illustrations.

Meanwhile we continue to work on some other areas including contacts re the possible bakery which is looking promising.  We are looking at some strategic management issues and there will be a special Board meeting to which we have been invited on 20th September so that is a really important session to prepare for.

thanks to all who have been in touch and for your prayers and encouragement.

Ian and Hanna

Case study: Baby "Twinamasiko"

This little baby came to us aged 2 weeks with a history of vomiting since birth.  The vomit was yellow suggesting it contained bile which implies a serious obstruction.  The baby was very dehydrated and had lost a significant amount of weight and required resuscitation with intra-venous fluids.

The parents are educated and very caring of their baby but nevertheless had first sought help from traditional healers who had performed "ebiino".  This involves digging in the gum for an un-erupted tooth which of course looks very odd and is then said to be the cause of the problem.

The x-ray showed significant obstruction and the baby went to theatre.  Anaesthesia was performed by one of our Anaesthetic Officers using ketamine.
Dr Gabriel, our Surgeon, found the baby had malrotation with a band causing the obstruction near the duodenum which he divided.


The baby was able to restart oral fluids after a day or two and made a good recovery.



Parents were very anxious during the initial post-operative phase but it was lovely to see how delighted they were when they were able to take him home.

Congenital abnormalities such as malrotation may present significant challenges to medical services.  In UK he would have had specialist paediatric surgery unit care in a regional unit with specialist anaesthetists, constant monitoring etc.

The case also demonstrates the challenge of health education once again, with even educated parents delaying bringing very sick children to hospital.

It is a credit to Dr Gabriel and all the theatre and support staff as well as the nurses on the special care baby unit that baby "Twinamasiko" went home well.  Support from friends of Kisiizi such as the syringe pump for iv fluids and oxygen monitor all helped in his care.

ready to go home with Dad...

Monday, August 29, 2011

back to work...

After yesterday’s frivolity, back to ward work today – the babies generally doing well in maternity including a couple born at 28 weeks gestation each weighing about 1 kg both progressing well.

Children’s ward not too full which is encouraging but found a new admission – a girl of 12 who back in February had developed some pain and swelling above her right knee.  This progressed and later some pus was discharged.  She received “treatment” in the village which included cutting the skin around her right knee.  She was at some stage taken to another hospital but it doesn’t seem much was done.

The following month she had a pathological fracture through the infected lower right femur.  No effective treatment was received.  This may be partly due to poverty and the family being unable to afford either the cost of treatment or transport to a hospital.

She presents with a small sinus discharging on her right thigh, which is markedly swollen and angulated.  The result of her untreated fracture healing incorrectly aligned is that she has shortening of the right leg [a 6.5cm difference].

She is not in a lot of pain as the fracture has healed and is stable but she has marked deformity and would limp if she tried to walk.  She is now on intravenous antibiotics and will need these for some time to try and clear the infection which is deep seated. 

All this would have been avoided if she had been treated correctly in the first instance and it’s really sad to see such cases.  Once again there is a challenge of health education…

On a happier note, the photo of the two boys shows them enjoying lunch – a mixture of pototoes, avocado and beans!  They both have fractured femurs from falls and are being treated with skin traction using stones in an old paint tin as the weight and other paint tins utilised to tip up the foot of the bed.

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Hanna has unfortunately picked up some sort of cold and, very unusually for her, has spent the day in bed…   hopefully she’ll feel better tomorrow.

Sunday, August 28, 2011

Draft Manuscript for a comedy drama


Location:  a remote part of a small central African country

Background:  tired group returning home late in the evening after a long trip to the capital, have sat down for a cup of tea at about 11pm and chatted for a few minutes…

Dramatis personae:  [names have been slightly changed to protect the innocent, any connection with persons living is purely coincidental…]

*   Kluless                         a housegirl
*   Eenkredulus                a matron who could not believe what she was hearing
*   Sheik Inwiv Lafter       a beautiful Dutch lady
*   Twitov Thed-Ecade     husband of the above
                                            ==================

ACT 1                          at the home of Sister Eenkredulus

Twitov Thed-Ecade:                Where is the key to our house?
Sheik Inwiv Lafter:                  I gave it to Kluless when we were leaving and she was to leave it here…
Eenkredulus:                           Well, it doesn’t seem to be here
[summons Kluless who is in a backroom sleeping]
                                                Do you know where the house key is?

Kluless [softly]:                        I lost it…
Eenkredulus [loudly]:              lost it!  What happened?
Kluless [very softly]:                it fell down the long-drop*...                 [* = pit latrine]
Eenkredulus [steam coming from ears]:       Lost down the long-drop!!!  what did you do about it?

[meanwhile Sheik Inwiv Lafter is living up to her name]

Kluless [very, very softly]:       I told my mum…

[loud explosions from Sister Eenkredulus mix with the whole room swaying caused by Sheikh Inwiv Lafter…]


ACT 2              Outside the home of Sheikh Inwiv Lafter and Twitov Thed-Ecade, about midnight, very dark all around

Twitov has managed to just slightly open a window.  By a combination of very sophisticated keyhole surgical technique principles and a metal coat-hanger obtained from Sister Eenkredulus, the latch is lifted and he is seen to clamber into the house then opening the back door and saving the day. 

The sight of this manoeuvre has set off Sheikh Inwiv Lafter, joined by Sister Eenkredulus who can now see the funny side of the whole story and with great hilarity they say goodnight, leaving the rest of the community wondering what on earth was going on.

====================

Of course, such a ridiculous story could never happen in real life…
 

could it?
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