some pictures from Mbale Trip

 An EMO vaporiser being used for administering Ether to maintain GA An endoscopic sinus surgery in progress.

Tympanoplasty being performed under microscope

Harsh

My first Excursion to Uganda, Sp. Mbale Hospital

My first thoughts!

I was fortunate enough to be picked up as one of the team member to visit Uganda representing Royal Surrey Hospital. It was indeed a moment of pride. A few meetings and emails and lot of jabs later we found ourselves in this lovely part of east Africa which is rather famous for its wild life safari. A very warm welcome awaited us on our arrival past midnight on Monday the 18th Feb. During the day, we paid our first visit to the Mulago teaching hospital in capital city of Kampala and met with the local ENT and anaesthetic teams and plans were made for rest of the week. There was also a scheduled visit to another remote hospital in Mbale about 250 kms away. The team was split and five of us were picked up for this challenge. 

Tuesday

Next day we found ourselves in the back of a private van and were blessed with a driver who was rather on the over cautious mode. Hence the journey took forever. Better late than never we told ourselves.

On arrival  we visited the hospital director, and were introduced to the ENT surgeon who helped us to find our hotel as well. Another warm welcome it felt like. We were made aware of the next 48 hrs of surgical activity planned. 

Wednesday 

Tympanoplasty under progress

Due to a very unfortunate domestic event, we couldn't meet the surgeon again for the next two days of our stay. Hence we visited the hospital on our own  Myself, Manohar (the ear surgeon), Carl  (sinus surgeon), Rupinder (scrub nurse) and Dagmar (audiologist) found our way to the ward and then operating rooms. We could identify two cases lined up for the day:

8 year old girl for drainage of Ethmoidal mucocele  and 65 year old woman for Tympanoplasty.

endoscopic procedure in paediatric patient

There was an anaesthetic officer present with whom I got myself oriented to the theatre and the anaesthetic equipment.  Once all the checks including availability of surgical instruments was carried out, we sent for the Tympanoplasty. The drugs available for me were Sodium Thiopentone for induction of anaesthesia, Suxamethonium for facilitating oro-tracheael intubation, Halothane for maintenance.  I went through with anaesthetist as to how to use Laryngeal mask and hypotensive anaesthesia for such cases. Then I lost him to emergency Caesarean section and hence had to do the endoscopic drainage of Ethmoidal cyst by myself. I was a bit nervous at the beginning having to use a very-very outdated anaesthetic machine and also using drugs which I had not touched for almost 15 years. It was fun. The day finished uneventfully and we retired to the hotel and treated ourselves to local food. 

EMO vaporiser being used for adminstering Ether for maintaining GA

Thursday

Arrived promptly to theatres after having identified the two patients planned for the day:

34 yrs old man for septoplasty who was also a member of staff and a 8 yr old boy for nasal endoscopy. Both were done avoiding endotracheal intubation. This was quite educational for the local anaesthetist. I also demonstrated the use of fibreoptic intubation kit which I had taken with me which I ultimately donated to the department. They seem to be much obliged with this gesture. This would hopefully help them in managing difficult airways in future. Then I had the opportunity to get involved with an emergency GA Caesarean section conducted by one of London deanery anaesthetic trainee called Jordie who is pursuing her out of programme experience in Uganda. This was quite an experience as I saw Ether being used via historic EMO vaporiser. Meeting her also enabled me to sort of pass the baton for continuing to reinforce the principles of induced hypotension and minimally invasive airway management with the anaesthetic staff.

All in all a very satisfying day at the office I'd say.

Then was the journey back to Kampala and this time we had exactly the other extreme kind of driver who was so good at ignoring the various potholes and speed breakers. Good workout for our backs but we reached our destination well within time. Phew! Reunited with the rest of the team.

I'd say it was rather short timeframe to make much sense of the place and make any robust plans to improve the services. 

But this changed my approach somewhat to how we complain about the lack of resources in NHS. You sometimes don't realise what you've been blessed with unless you see the other side of the globe. An eye opening experience for sure which has surely made me more content with what I have at the moment and also stimulated me enough to undertake such assignments in future and make a little difference in someone's life. A very small step taken.

Harsh Saxena

My thoughts on Uganda

This is the second time I have come out to Uganda as part of the Uganda ENT project. The Project started out over 10 years ago with a group of Canadian ENT surgeons. Up until the last few years, it has focused on patients with diseases of the ear and hearing loss.

We have now started a rhinology group, manned by UK doctors and nurses, and I'm very proud of the RSCH team for whom the experience was not an easy one.

There is no doubt that the Ugandan people are in dire need of improvements in healthcare, not just in ENT, but across other specialties too. The average life expectancy amongst Ugandans is 54 years (compared to 80 years in the UK). The bulk of their healthcare provision is from the main hospital in Kampala, its capital.

The British built Mulago hospital shortly before independence in 1962, when the population of Kampala was around 150,000. The massive population explosion in Kampala since then (now estimated at 1.7 million people) has meant that that healthcare provision has not been able to keep up with the demand. Uganda is a poor country, and despite a large amount of overseas aid (£100 million from the UK in 2012 alone), the government appears not to have sufficient funding to improve or even maintain ENT services at Mulago.

Part of the problem lies in the fact that otology and rhinology are largely microscopic/endoscopic sub-specialties in the western world. Though the Ugandan surgeons are incredibly knowledgeable and hungry for experience in these more modern techniques, they are not able to acquire the specialised equipment required to perform these procedures. As much of an issue is the lack of expertise for maintaining and servicing such equipment even if it were available.

As a first time Project participant in 2011, that visit proved to be a frustrating experience in the clinical setting, albeit a fruitful and enjoyable one in the academic setting; the Sinus Surgery course that I ran during that time appears to have been well received.

The frustrations of that occasion were somewhat diminished this time, but sadly this was more to do with knowing what to expect, rather than any improvements in the running of services at Mulago. Disappointingly, politics plays a fiendish role and this is something that cannot easily be addressed by the Ugandan doctors, let alone by a group of naive ‘muzungus’ who go over once a year for a week or two.

I was pleased to have helped the local surgeons operate on 2 patients with sinonasal tumours, as well as seeing patients in clinic with other sinonasal pathology. I was less pleased about those patients with tumours that I did not have time to treat or the 3 day old baby that died overnight whilst waiting for us to operate on her the following day.

Having now returned to the UK, my feeling about my experiences, this time and last, is dichotomous.

On the one hand, the sense of frustration over a sloth-like system discourage me from giving my time, energy, and yes, not inconsiderable personal financial expenditure, to provide a hospital with a free health worker. I wouldn’t care, but the surgical skills I have been teaching are not being implemented by those that I am trying to train. The microdebrider that I wanted to use for the sinus surgery cases did not work. The last person to have used it was me. In 2011. No surprise that it had seized up whilst sat in a cabinet for 16 months!

But at the same time, a 5 minute walk around the hospital and its grounds reveals the huge numbers of patients who have ailments that we rarely see in the UK because they would be treated much earlier. I see their families camped out on the grass verges or balconies in make-shift tents in all weathers; for they are the ones who provide food for these patients, bathe and clean them in their beds, and tend to their wounds because there are inadequate nursing staff. At night, one nurse looks after the 30 patients on the ENT ward.

These patients are desperate.

So I have little doubt I will be returning to Uganda again. But our strategy needs a rethink. And I'm pleased that, with our Canadian friends, this process has already started.

San

Away from Mulago

Today we realised that Mulago is actually not too bad at all... Compared to some other areas of the city!

We went out to an orphanage run by the Missionaries of the Poor. It was shocking and heartbreaking but so pleasant and heart warming at the same time!

The orphanage caters for children of all ages up to 14-15 yrs, mostly girls. It also provides care for disabled children and adults! some of whom are severely disabled, including conditions like cerebral palsy, congenital deformities, amputees etc.

The orphanage is located in a slum, but the first thing which struck us on arrival was how pretty and lively the building looked! all the walls are painted in bright colours, with animals and Disney characters drawn over every single wall- really stimulating for the children!  Brother Horatius told us they were drawn by a friend, who is clearly very talented!! Brother Horatius is a young Haiitian chap who runs the orphanage. After a very warm welcome he took us for a tour around the orphanage... a really eye opening experience.

Several children with obvious physical/mental disabilities were sat in the yard, observing all the Muzungi around them and enjoying the the bubbles we were all blowing at them (provided by one of the American volunteers in our group) Most of all they seemed to enjoy and appreciate any form of human touch- from holding their hands to caressing their faces. It always strikes me how much these people must lack physical contact with other humans... They have no one to cuddle them or play with them and this must be like a big highlight in their lives! Just think of the times when you're down, lonely etc and long from a hug from someone- this is how these children/adults must feel all the time! Sad isn't it?

Another fairly impressive sight was a row of 4 or 5 children strapped in a line to some kind of whole body frames. Brother Horatio told us they were children with cerebral palsy who every morning are seen by physiotherapists for exercises and then strapped to the frames with the intention of straightening their contractures and enabling them to walk when they're older! We all looked pretty sceptical but Brother assured us he had seen a child who was having this therapy a few yrs ago and is now walking!

Next on our tour were the dormitories, which looked very tidy, again all painted in nice colours and animals (couldn't help asking Priyanka to pose beneath an arrow sign painted on the wall (next to a cow) saying 'THIS IS A COW' ! Cheeky!!! Had a similar shot myself and felt quite please when Mandy assured us we looked nothing like cows! THanks Mandy! ;))

The Kitchen was even more impressive! 2 huge pots stood at the side of the room, each around a metre in diameter! One was full of soup and the other with some kind of mushy rice! It wasn't difficult to understand the huge dimensions- Brother had already told us that they get over 600 children to feed from the school next door at lunchtime!! 

Next on tour was the clinic. ( By this time Priyanka had adopted a cute little 2 year old dressed in a starched white frock and fancy shoes, who wouldn't let go of her!! Quite impressed by the sign on the clinic entrance which read 'IMMUNISATION EVERY THURSDAY'! Inside was a clinician and a whole stock of medicines and supplies, including bedside malaria testing kits.

Our tour ended with a tour of the school, a few metres away. Pretty impressive to see around 30 kids in one class, chanting along to the teacher's prompts of 'legs', 'haiiir' etc. The older kids were even smarter- they knew about Canada, the weather there and snow! :)

 I spotted a sweet albino girl but was extremely shocked to learn that in this country albinos are usually sold to witch doctors for body parts to experiment on!!!! In 2013?!?!

On returning back to the orphanage it was time to hand out all our little gifts to Brother Horatio- spanning from a vast collection of barely used children's shoes, which Mandy collected from children's schools, sport kits in fancy luggages which the Americans brought along and colouring books, pencils etc which Priyanka put together nicely with sweets. He was really appreciative!

Didn't really do much to help out there but we were all inspired to do some kind of fund raising/collections once back home, which we are planning to ship over to the orphanage in the near future...

If you were also touched and would be interested in helping out in our little mission, more details about how you can do this will follow later...


Stephanie

Internet fail

Apologies to all. Thunderstorms have meant that Internet access has been pretty much non-existent. Lots to update you on though so please bear with us.

Pictures tell more than words

Reality

The hospital was built by the British for a population of 6 million, it now serves 34 million. There are patients literally lying outside the wards, waiting for a bed to be vacant. As they can't afford the hospital canteen, there are lots of picnics going on...

I visited ICU, they have 4 ventilated beds. (We have >12 at RSCH, with more to follow very soon). The ENT list didn't start till 11am today - the hospital water supply didn't work, a frequent problem. No morphine, nitrous oxide or air gases in theatre either, short supply. Everything is recycled, they always have to make to do with what they have. Mandy & Janet are trying to introduce the concept of a WHO check and educate the theatre staff basic surgical safety, they have a long way to go...

San has listed 6 patients tomorrow, I don't think we will get through them, the first one is 3 days old. It just takes forever to get anything done in theatre...


Bhav

Day One

Our eyes have been well and truly opened!!!!!

After our very late/early arrival and very little sleep, we headed off to Mulago Hospital. 
We were greeted very warmly by the local staff, and they then gave us a guided tour of their hospital including the ENT ward and clinic. 
We also had a tour of the operating theatres. 
We were then split into groups where Mr Sunkaraneni, Dr Hili and Dr Joshi went off to clinic to assess some patients that could require surgical intervention whilst the ENT team were in Uganda.
Dr Patel and Mandy Vincent went off to the paediatric theatre to observe a laparotomy and bowel resection on a child of 6 days old,whilst Dr Saxena and Janet Maloney went to observe a depressed skull fracture.
 We also went into the anaesthetic department and have arranged with the head of anaesthesia to participate in an educational day to run interactive workshops.
To be continued......

The team gets split tomorrow, with Hersh going to Mbale Hospital for 4 days, with the rest of the team staying in Kampala.

The night before......

Last night before the trip. Had a minor panic over my yellow fever certificate - found it eventually. Surprising how much stuff one can put in one's suitcase for only a week's trip. Just need to find my headphones for the in-flight movies.
Passport - check.
Currency - check.
Underwear - check
Laptop with lectures - check.
Poor Mrs S having to get up early to drop me at the airport!
Look forward to seeing the rest of the team in the morning.

San

One week to go...

This week our trip has gone 'viral'... we have been mentioned on Facebook, Twitter and the Surrey Advertiser!

The severe weather on the east coast of N. America has led to flights being cancelled for several of the Canadian medics who were due to go a week earlier to start outpatients, etc...some won't get to Uganda till Thursday 14th Feb now. No doubt the English weather will try it's best to wreak havoc when we leave next Sunday morning.

Uganda population 34 million, average life expectancy 54 years (80 years for UK)

Bhav

Final pre-trip meeting and the media

We had our last evening meeting last Monday to tie up loose ends and ask/answer last minute questions. Pretty much everyone is now vaccinated. Conversation centred around the merits of different anti-malarials, along with a little too much discussion about potential unpleasant side-effects!
We also had a meeting with a journalist from the Surrey Advertiser yesterday, who was very interested in our trip; the who, what and whys. The answers to the 'whys' from my future travelling companions were very pleasing.
We are all very interested in helping people in the developing world, whose access to the sort of healthcare we take for granted in the UK is very limited.
We all want to try and do our bit, not only for the patients, but also for the doctors/nurses/clinical officers, who also do not have access to the level of training that we UK doctors and nurses have had the privilege of experiencing.
T -15days and counting......


San