Saturday 27 July 2013

The final post...

Hello everyone!

This will be the last post as we are flying home tomorrow evening.  We have had such a wonderful time and it has been a fantastic learning experience.  We are so grateful to the staff at Villa Maria Hospital and the guesthouse for making us feel so welcome.

Over the last few days, the students have been working hard finishing and submitting their projects.  We had a relaxing day at the beach today to celebrate. Last night we had a lovely meal at a restaurant called 'Plot 99' - cocktails and burgers were a real treat!

I've been to a few clinics over the last few days - both in the outpatient department and in the HIV clinic.  Many of us have had the dreaded lurgy so this has limited our activities somewhat!  We are all feeling much better now though.  On Thursday evening we had a netball match against the local primary school which I am ashamed to say we lost!  Clearly we let them win...

Yesterday, I went to Kitovu Hospital which I mentioned in a previous post.  I met my friend Sarah who works there and went to their CME (continuing medical education) meeting; the topic this week was communication.  I then met with the medical superintendent of the hospital, who is very keen for us to send another group of students to Kitovu next summer.  So next year we are hoping to have one group at Villa Maria and another at Kitovu, to give more students the opportunity to do this SSC.

Thank you so much to all of you who have been following our blog.  Finally a big thank you to all of the students for being such a delight to be with and for working so hard on their projects.

We are all keeping our fingers crossed for a smoother and speedier journey home!

All the very best,

Amy and the Uganda SSC students 2013

Tuesday 23 July 2013

Tuesday Update

Hello everyone,

I just thought I would send an update of today's activities.  The students have been struggling with writing their essays given the frequent powercuts, so today most of them went to a cafe in Masaka with free wifi.  This left Gemma, Rachel and I at Villa Maria!  This morning Gemma was sadly feeling unwell so stayed here to rest.  Rachel went to an outpatient clinic with Dr Alfred, and I went to the antiretroviral therapy (ART) clinic to spend some time with one of the counsellors.

I had a fascinating morning.  The counselling support for patients with HIV here is tremendous and the counsellor I was with (James) spoke excellent English and kindly translated for me throughout.  Each time a patient comes to the clinic, they see a doctor, a nurse to dispense their medications, and the counsellor.  There were a number of complex and troubling issues faced by the patients I saw today.  One of the patients was a young girl whose mother had died from AIDS so was being looked after by her father.  He has to work as a fisherman to provide for them, but consequently there are problems with the child taking the correct medications at the correct times (which is crucial for someone with HIV).  We saw a woman with HIV on ART whose husband refused to be tested; this is a common problem here.  The team run outreach education programmes but still there are those who prefer not to be tested to avoid the stigma of being diagnosed with HIV.

Another important role of the counsellors is to explain which medications to take, how to take them, when to take them and why they are important.  This ensures that the patients obtain the maximal benefit from the ARVs.  James discussed clean water safety with each patient, and distributed water purification tablets.  Although these do not produce entirely 'safe' water, many patients only have access to contaminated water from lakes and streams, so it is better than nothing...  He also discussed malaria prevention with many of the patients.  One woman told us that she did not like to sleep under a net because she felt hot and claustrophobic, even though she understood the risks.  This is a common view here.

During the clinic, James and I had an interesting conversation about the social, economic and political situation in our respective countries which was very enlightening.  He actually trained as a social worker, and we were discussing the differences in social support between the UK and Uganda.  My sister Lucy is a social worker so we had a good chat about the services available here and in the UK.  They have a large proportion of social workers for 'OVC' - orphans and vulnerable children, but there doesn't seem to be a formal infrastructure for adoption or fostering.  They have some social workers for patients with mental health problems, but mainly in the cities.  He said that the provision for people with disabilities is poor, and there are only a few social workers for those with physical disabilities.  They have some social workers for older adults, but their average life expectancy here is 64 (compared to 81 in the UK).  He was astonished to hear that I am interested in care of the elderly, or even that it exists as a speciality!

I explained about the free healthcare provided by the NHS and that education is free up to the age of 18 and left the clinic feeling very fortunate indeed.  James was asking about the prevalence of HIV in the UK and why I thought it was so much lower at home than in Uganda.  He also asked about which diseases were common in the UK.  I explained that many of our diseases are caused by smoking, alcohol and obesity.  I said that I had only seen one person smoking since I've been here, but he said that smoking is a problem, particularly in the big cities.  Advertising of cigarettes is still allowed and they are very cheap to buy.  I wasn't able to quote the price of a packet of cigarettes in England but explained that they are very expensive!  Apparently, alcohol excess is becoming increasingly problematic here as beer and spirits are cheap.  I wondered whether the strong influence of the Church in Uganda had any impact on reducing alcohol intake, but he didn't seem to think so.

This afternoon, Gemma and I went to the maternity unit, and she undertook some qualitative research with the midwives relating to her project which was really interesting to observe.  She was asking them about the importance of ante-natal care in preventing neonatal sepsis, and the barriers to accessing ante-natal care here.

The weather remains warm and sunny here as it seems to be at home too - I can't believe the heatwave is still continuing!  The news of the royal baby has even reached us here - one of the teachers at the school yesterday asked me 'how is Kate?' and it took me a few moments to work out who he was talking about!

The students are all working hard on their projects ready to submit them this weekend.  The incentive is that we can all go to the beach on Saturday if they are complete!

Tomorrow I am planning to go back to the ART clinic to spend some time with one of the doctors there (they have a special day for adolescents with HIV tomorrow).  I will also be doing a video interview with Dr Moses (the medical superintendent) - I have my list of questions prepared!  I am putting together a video diary of the trip so am making sure I have all the footage I need this week.  I did an interview with our new friend Jacintah who works in medical records today (she is also joining the netball team for Thursday!).

More to follow in the next day or so,

Amy

Monday 22 July 2013

The final week...

Hi everyone,

Apologies for the delay in another post - I did write it in full but lost everything in another powercut; a daily occurrence here!

Here is our latest update:

Kitovu Hospital
On Thursday I went to Kitovu Hospital (approx 15km away) where my friend Sarah from England is working.  She is a GP who has been in Uganda for approximately 2 years, and has just recently returned having had a baby in England.  It was really interesting to see this hospital and compare it to Villa Maria.  It is approximately twice the size and has a specialist vesico-vaginal fistula (VVF) unit.  I sat in on one of Sarah's teaching sessions with the nurses and spent some time on the new baby unit which is fantastic.  She then took me round Masaka in the afternoon and we had lasagne for dinner which provided a welcome change from rice and beans!

The Ssese Islands
On Friday morning, we left for the Ssese Islands in Lake Victoria.  We arrived on time ready to get the 2pm ferry, only to find that it did not leave until 5pm!  We are getting used to Uganda time...  We had a lovely relaxing weekend by the beach.  I even had a warm shower on one of the evenings which was real luxury!  Yesterday, we came back to Villa Maria via Masaka, and had lunch in a lovely cafe run by a Belgian HIV charity.  We then had a wander round town, and I did some successful bartering (much to my surprise!) in some fabric shops.

The Ssese Islands:



The paediatric ward round
This morning, Felix, Emma, Rachel and I did the paediatrics ward round with Dr Alfred.  There were many children with malaria and respiratory tract infections.  The child with the wound on her head following a road accident had gone home which I was very pleased to see!  Sadly, the little boy with tetanus has yet to receive any antitoxin, nearly 2 weeks later...  It seems unlikely that the hospital will be able to source it, and even if they do the family are very poor and would not be able to afford the costs.

Another sad story is of the 2.5 year old girl I mentioned in a previous post who was originally diagnosed with croup.  She was later found to have TB and was started on quadruple therapy.  She has now developed frequent partial seizures, and was found to be HIV positive over the weekend.  She has been started on carbemazepine (an anticonvulsant) and her CD4 count is awaited.  Dr Alfred has suggested that she may have cerebral toxoplasmosis or cryptococcal meningitis.  Neither of her parents were known to have HIV, and have not yet been informed of her diagnosis...

Emma, Rachel and I on the children's ward:


The adult male ward
Rachel and I then went on the male ward round.  There were only 5 patients on the ward.  The medical and surgical patients are all together on one ward.  The first patient we saw was admitted with suspected colitis, although they do not have access to endoscopy at Villa Maria.  We then saw another gentleman who had undergone a laparotomy a week ago and was found to have a sigmoid volvulus (twisted bowel).  One week is approximately the amount of time patients here will remain in hospital after an operation.

We then saw a patient admitted with jaundice.He did not want to stay in the hospital for investigation and treatment, so self-discharged against medical advice.  The next patient had initially been admitted with abdominal pain, but then developed a flaccid paralysis.  Dr Alfred suspected Guillain-Barre syndrome, however the treatments (immunoglobulin and plasma exchange) are not available here.  The personal tragedy of illness and disability is compounded by the social and economic implications - there is no welfare system here, no state pension, and family members are usually called upon to care for their relatives.  The final patient was a 62 year old gentleman diagnosed with TB.  He had an HIV test on admission which was negative, but was found on subsequent testing to be HIV positive.  Here, he will be treated for his TB first before starting anti-retroviral therapy, to avoid the risk of immune reconstitution inflammatory syndrome.

Rachel and Dr Alfred on the ward round:


St Cecilia's Primary School
This afternoon we went to St Cecilia's primary school just up the road from the hospital.

From left to right - myself, Felix, Rachel, Cate, Flo and Gemma:


We had been invited by some of the teachers we met locally, and they were very pleased to see us!  There were approximately 200 children (all girls) in a barn with all the school teachers, and the children put on a range of traditional tribal dances and songs for us which were wonderful.  At this school there are 52 pupils per teacher!  They had all gone to so much effort and were so welcoming:



The headteacher then give a speech, and then turned to me and asked me to do the same!  I didn't really know what to say and was pretty embarrassed...!  I just explained who were were, where we were from and what we were doing at Villa Maria.  I wanted to emphasise that we are keen to build a sustainable long-term link here.  We then had a 'Q&A' session where the children asked us lots of questions including whether we had children(!), who was the country's leader and what we like to eat in England.  

We then had a tour, and watched the girls playing netball.  We have managed to talk ourselves into playing a match against the children on Thursday!  I will let you know the outcome...! 

Another update to follow soon,

Amy

Wednesday 17 July 2013

Mid-week update

Hi all, 

This morning, Sarah-Jane and I went on the maternity ward round with Dr Moses, the medical superintendent.  This was a really interesting learning experience for both of us; here are a few of my reflections:

-The first woman we saw was in active labour, delivering her 10th child at the age of 29!  This is not uncommon here - women have so many babies and have very little choice with regards to family planning.  It strikes me that until effective contraception is widely available here, the status and opportunities for women here are unlikely to improve.  As I mentioned in a previous post, the Catholic attitude towards only 'natural contraceptive methods' only here is pervasive...

-Whilst reviewing this patient there was a commotion in the courtyard outside, and half the midwives and nurses ran out.  Sarah-Jane and I followed to see a woman on the back of a moped who had just that minute delivered her baby!  There was absolute chaos as people gathered closer to see what had happened.  The nurses brought around green screens in an attempt to cover her, and the cord was clamped.  The baby and mother were well and were taken in to the ward to recover from their ordeal!

-The ante-natal, post-natal and gynaecology wards are all mixed.  This means that women who have had miscarriages (called 'abortions' here as what we refer to as an abortion is illegal) are in beds next to mothers with newborn babies.  The attitude to miscarriage here is very matter-of-fact and it is accepted as a fact of life.

-Here, once the babies are born they sleep in bed with their mothers, and lie covered in 4-5 blankets from head to toe so you wouldn't even know there was a baby in there (see pictures below!).  I asked Dr Moses if he was concerned by this but he stated that it is a cultural practice and they haven't had any neonatal deaths from this here...  This is in stark contrast to the advice in the UK and 'back to sleep' campaign to reduce rates of cot death. 


Above: this 2 day old baby was hidden under 5 blankets.

-Obstructed labour is a terrible problem here.  We saw one 18 year old woman who had an obstructed labour and sadly her baby died.  She has now developed a vesico-vaginal fistula, so that she is constantly leaking urine.  As well as being desperately unpleasant for her, there is a significant social stigma for these women.  Apparently, at Kitovu hospital approx 17km away there is a programme for fistula repair, but I'm not sure what the cost to the women would be.  

-The majority of the caesarean sections in patients here are done using longitudinal scars (much more visible than the usual low transverse scar seen in the UK as the incision goes up above the belly-button).  Dr Moses said that the transverse incisions have only been practised here for about 4 years, and many of the women have had previous c-sections using the longitudinal scars so they use the same scar again.  Women are kept in for 7 days after a c-section here (in contrast to the UK!)

-Interestingly, we saw a baby who had been born yesterday weighing just 1.4kg (approx 4.5 pounds).  The age of the baby was approx 28-29 weeks (there are no routine dating scans here so it is difficult to assess the gestation of the baby accurately).  I was amazed that this baby would survive here (at home, babies can survive from as little as 23-24 weeks, but we have all the invasive technology, monitoring, breathing support etc).  Dr Moses explained that as long as the babies can suckle and reach >1.5kg they can be discharged home.

-Affordability of medical care is a big problem here, as I mentioned in a previous post.  We saw one woman who was thought to have had a miscarriage, but the team were uncertain as to whether the miscarriage had been complete or if there were any retained products in the uterus.  She could not afford an ultrasound scan so was taken to theatre for a vacuum evacuation, a potentially unnecessary procedure...

Later on today I went to the paediatrics ward to check on the young girl I mentioned in an earlier post.  She had been in a road traffic accident and had extensive wounds on her head that need daily dressings.  On Monday, we witnessed the dressings being pulled off and she was clearly in extreme discomfort, crying and calling out.  I went to the ward and again saw this awful process of the bandages being taken off whilst she cried in agony.  I went and spoke to the nurse and asked about whether she had been given analgesia beforehand and whether this was routinely done.  She stated that it wasn't, so I decided to talk to Dr Alfred, the paediatrics doctor.

I was concerned that it might seem as though I was interfering, but I tried to say things in a tactful way and he was happy to talk to me about it.  I said that in England we often give analgesia approx 1/2 hour or so before a procedure, to make it more comfortable for the patient.  They have paracetamol and morphine readily available here, so this would be entirely manageable.  He asked me, "are you afraid of pain?", and stated that he thought the child "could probably tolerate it".  This is reminiscent of the conversation I had with the midwives about analgesia in labour that I mentioned in a previous post.  I agreed with him that she probably could tolerate it, but that I didn't think she needed to given there is plenty of analgesia available here and it would alleviate her suffering.  He has promised me that he will "think about it" which I hope he will.  

In many ways, resources are scarce here and this limits the services and care that can be provided to patients.  However it is so frustrating when simple things can be done and resources are available but they just aren't used...    

This afternoon we went to a local school for the students to ask their questionnaires; this was really fun and we were so impressed by the students' knowledge.  

Tomorrow I am going to Kitovu hospital (17km away) to visit my friend Sarah from England and see the hospital's facilities.  I am intrigued to see what the hospital will be like and meet the staff to see whether next year we might be able to expand the SSC programme to include both Kitovu and Villa Maria hospitals.  I will keep you posted!

Anyway, it is getting dark so I had better go inside to escape the mosquitoes!

Here is a photo of us from this morning on the hospital site at Villa Maria: 



Another update to follow soon,

Amy 

Tuesday 16 July 2013

A few of my favourite photos so far...

Above: stranded in Amsterdam but making the best of things!












HIV outreach clinic

Today Flo and I visited a community clinic with the HIV outreach team from Villa Maria.  We travelled by jeep to Buyoga, approximately one hour's bumpy drive from Villa Maria.

There were approximately 60 patients at the clinic, ranging in age from babies to adults of 62 years.  The patients arrived at the clinic to collect their notes, and pay a small fee (1000 Ugandan Shillings which is approx 25p).  The medications are free and provided by the government but this covers some of the costs of the clinic.  They then queue up to see the doctor.  Today's doctor was Denis, a newly qualified, wonderful junior doctor who Flo and I both spent some time with.  We worked together in the clinic and at times he asked my advice on a few things (although when it comes to HIV he was definitely the expert!).

Patients visit the clinic every 2 months, so at the appointment discuss any recent symptoms and how they are coping.  We saw a range of drug side effects including rashes and peripheral neuropathy.  I saw several patients with oral thrush, a range of skin conditions including eczema and shingles, aches and pains, gastro-oesophageal reflux ('heartburn'), and many patients with concurrent TB infection.  Treatment for TB here uses the same drugs as in the UK and all patients with HIV are routinely screened.  Interestingly, we saw a few patients with a high fever who were treated empirically for malaria (there is no facility to diagnose malaria in these peripheral clinics).  I was also surprised to see that hypertension (high blood pressure) is a relatively big problem here as well as in the UK.  Flo spent some time with a number of mothers who were breast-feeding to collect some data for her project.

All patients with CD4 counts <350 are started on antiretroviral therapy (ART).  Most of the patients at the clinic have been coming there for years - the clinics were first established in 2004.  Once the patients have seen the doctor they go to the dispensing desk.  Here, the nurses dispense the medications the doctors have prescribed - this includes the ART, as well as co-trimoxazole prophylaxis which all patients receive, along with a range of antibiotics, mebendazole, ointments and anti-hypertensives depending on the particular patients.  Flo and I took it in turns to record the drugs dispensed and distribute them to the relevant patients (the language barrier was an issue at times!).

After this, all patients go to see a counsellor to discuss any personal issues or concerns they have about their HIV or treatment.  The stigma surrounding HIV is a massive issue here.  Many patients discontinue their treatment as they don't want their partner to find the drugs and discover that they have HIV...

Whilst at the clinic, I distributed some clothes and toys that my sister Lucy had given me to take - Luce you can see here how they have been put to good use!







Another update to follow soon!

All the best,

Amy

Monday 15 July 2013