Address...

CONFUSED ADDRESS:

we smiled when we read this address....

STAFF ADDRESS:

Dr. Francis Banya and Dr. Rachel Ion, our maternity hub registrar, together with Dr. Bruce, our obstetric intern, addressed the Staff yesterday for a Maternity teaching session on the management of severe bleeding.  This included a practical demonstration of a balloon device which can be assembled from cheap local materials and may save the lives of mothers with bleeding after delivery.






WHAT A DRESS!

Lovely as ever!

Work, rest and play...

WORK:

Hanna has been busy on Maternity, and delivered one lady who had had 11 previous pregnancies but only 3 surviving.  They had all been girls, but this time she had a boy who was healthy.  The mum went home very happy.

Other details of Hanna's work are not suitable for a general public audience but represent the aftermath of picking up the pieces where women have been inappropriately cared for in the community prior to coming to Kisiizi.

Hanna, conveniently for others being O Negative blood group, gave blood again recently and probably has the record for duration of a bruise which is still prominent over 2 weeks after the event!


We have had some challenging cases in the Children’s ward recently... as well as 3 children needing chest drains we have had a wide range of patients.   

Child with pneumothorax and right chest drain in situ

We have discharged one girl who had bad burns and has done well, but still have a young boy who has developed tetanus secondary to his burns and is quite unwell.  We have tried to access tetanus immunoglobulin [this is a preparation of body defence protein specifically against the toxins produced in tetanus] but it doesn’t appear to be available in Uganda and we are trying to access it from Nairobi...

Then a one month infant came in with a swollen everted lower eyelid related to infection... happily now responding to treatment.
 

We have had a few cases of dysentery all improving but tragically a little boy who had nephrotic syndrome [kidney problem with big loss of protein in the urine causing body swelling] and who had a background poor nutritional state died yesterday.  I had a day off so wasn’t there but he apparently collapsed having been out to a washroom.  It highlights how limited our resources are as we would have had a much greater insight into his diagnosis and guidance in how to manage him optimally if we had been in UK with all the tests available.  Having said that, we are much better off than many other places in Uganda having ultrasound, basic tests and specialists around.

We have a 9 year old admitted unconscious, it seems this is caused by very high blood pressure in turn due to kidney problems.... not very common fortunately.  I was pleased to hear today she has started eating and communicating.

Then we had a baby who had come in to the hospital at the age of two weeks with infection of the tibia [bone in the lower leg] sufficiently serious to expose the bone.  A couple of weeks later he had developed very unusual swellings of the ends of his collar bones [as shown in the photo] where they join the breast bone.  These were quite prominent and symmetrical.  I had never come across this before but one of our visitors from Chester told us she had seen it in older children at Alder Hey hospital in Liverpool.  It is due to an overgrowth  called hyperostosis.  A quick look at the literature has not turned up any cases younger than 3 years with this condition [Sapho syndrome] so we might write up the case...

REST AND PLAY

so at last due for some days off...

but had to go in the first day as the Primary School had arranged an end of year concert and I had to give a speech... 

then it turned out one of our medical officers had also arranged another meeting for in-charges of health centres that we are responsible for in our health sub-district so, yes you guessed, another speech... [fortunately I managed to avoid mixing up the speeches!]...

 ...then in the evening after having a couple of people for a meal we had a surprise birthday party here for Peter, one of our two Australian medical students who have been with us for about six weeks.  

 The guest house had produced a good cake and someone brought roasted g-nuts [ = ground nuts, the local name for peanuts which we more usually eat as g-nut sauce...] and Gloria Banya, aged 1, was of course present to share in the fun...

 

But yesterday was a proper day off, and we needed it.  Good to unwind a bit and Kisiizi is a beautiful place to do this.

  

 The sun was out, the sunbirds were out, the spray from the waterfall picked up by shafts of sunlight through the trees,

the hospital cows chewing the cud contentedly

[they provide milk for malnourished children on the ward and for Staff] 

 

and Hanna enjoying a break on the verandah. 

 

I had a short game of badminton and paid the price in the evening with stiff muscles not used often enough.

Last night we had a very enjoyable meal with Dr. Gabriel and his wife Sister Maureen and their 3 children, followed by a look at the night sky through a telescope... the moons of Jupiter were like tiny pinpricks next to the planet, the Seven Sisters beautifully clustered, and the almost full moon breathtaking.  Today Herbert, one of our electricians, spoke in chapel for advent Sunday and, having been sidetracked to see review the child with tetanus, we had a number of friends for coffee...  and later an enjoyable lunch with another group... so we thank God for the variety that is Kisiizi.

staff walking down towards chapel

999

ok, so we don't have 999 calls here, and no national ambulance service... though Ian was in Kampala recently and one set of meetings he attended was to do with setting up a Uganda:UK health alliance to co-ordinate projects.  Some of the people he met were from London Ambulance service scoping out the possibility of starting an ambulance service in Kampala....

But we still get emergencies...this child has come in the evening extremely anaemic and shocked and Ian has just put a needle into the child's tibia bone to give an urgent blood transfusion.
Note the wooden drip stand on the left, the angle-poise lamp for illumination.... the doctor on the right is our paediatric intern.

This child also arrived around midnight extremely unwell breathing at an extraordinary rate of 120 breaths per minute!  The child had pneumonia that had been treated in the community using traditional methods which involve making small incisions in the child's chest wall.  This may be done using a sharpened bicycle spoke and are usually superficial but it seems in this child that the right lung was punctured so when we examined her there was no air entry at all on the right lung which had collapsed.  The air leaking out from the lung then builds up in pressure causing a so-called tension  pneumothorax which not only compresses the affected lung further but also pushes the heart across onto the other good lung further compromising the child's respiration.

The treatment is insertion of a chest drain to relieve the pressure.

Another child also required a chest drain but this time for a huge collection of pus following complications of pneumonia.

Here are the two children happily playing together, each with their drains in place... the one facing us is the first little girl with the pneumothorax.

VHF

Viral haemorrhagic fever - this group includes Ebola and Marburg viruses.  We had a patient recently who was admitted to us from Kabale and died shortly afterwards and was a possible Marburg case but we have had confirmation today that his blood tests for Marburg are negative.

We are hopeful that the Marburg epidemic which started quite close to Kabale, about 90 minutes drive away, is now fading away as there have not been any confirmed new cases for some time.

However, Ebola has appeared again in Uganda nearer to Kampala [which is about 7-8 hours drive from Kisiizi]. It seems it is a different strain from the one in Kiballe forest in western Uganda a couple of months ago.
We are so grateful that we have not had any VHF cases here and continue to pray this will remain the case.  Hanna had helped to nurse the recent suspect case when I was in Kampala and we recognise that even with all the protective clothing these are very dangerous viruses.

yes, we're still here...

Augustine Tusingwire, driver, with Rev. and Mrs. Katombozi

sorry for the delay in posting, we have had a lot of downtime on the internet connections and then I have been away in Kampala for 3 days having some fruitful meetings with partner organisations and catching up with members of the wider Kisiizi family.  These included Reverend and Mrs. Katombozi at their home near Mbarara.  Rev. Katombozi was our hospital chaplain when we first went to Kisiizi 25 years ago!

Life remains full... we had a Board of Governors meeting which went very well, and a lot of sick children coming into the ward including two with advanced kidney tumours.  One was affecting both kidneys and had already spread on ultrasound assessment, the other child was less severe and had a successful operation two days ago by Dr. Gabriel. 

Myra & John Sloan

He was assisted by Dr. John Sloan, a Consultant from Chester, who has helped us together with his wife Myra who is a General Practitioner.  It has been a joy to have them here and has coincided with other visitors on Chester teams supporting our Imaging department and Pharmacy and Patient Safety / Infection Control programmes.

CPD...

keeping up to date with Continual Professional Development is important and here we have some photos of a multi-disciplinary seminar on Children's ward.  A different topic is focused on each week, this time it was Anaemia. 

The "muzungu" on the right is one of our two Australian medical students.

Sister Ann Moore, centre below, has served faithfully in Kisiizi for many years as a nurse and midwife, particularly caring for neonates and children suffering from malnutrition.  She also works as Deputy Principal Nursing Officer.

Set 7...

it's exam time for Set 7 who will then complete their 2 year 6 month course as certificate comprehensive nurses.  We had a good service in chapel this morning to dedicate their future careers and the coming week's exams.  The speaker was a nursing officer from Kampala who was very good.

After the service there was much laughter and the obligatory photo shoot!

A few days earlier we had a farewell tea for Allen, the warden, who is leaving after 5  years service to join her husband who has a job in eastern Uganda.

Visitors...

Life here is enriched by visitors from all corners of the world.  We currently have two medical students, Peter and Angus from Australia who, sadly, had an upsetting time in Tanzania prior to coming here when they were robbed.  But now safely in Kisiizi and enjoying settling in...

Moses Mugume with Jenny Tustian & Liz Traill

Jenny Tustian, previously Sister in Charge, and Liz Traill, who had worked in Kabale, visited Kisiizi recently and enjoyed seeing some changes.  

Alan & Tricia Bapty with Ezra Mugenyi

Alan Bapty had served here in 1961 and then again worked here for a few months with his wife Tricia in 1993, living in the same house we now occupy.  So a lot of memories as they looked around....

 

d

Dr. Robert

Dr Robert has one year to go in his specialist training as a general surgeon in Mbarara and is due to join us again in September 2013 to work with Dr. Gabriel.  He came to visit us for a day to see developments in Kisiizi including the new operating theatres.

The latest team from Chester have just arrived to support our imaging service with training in x-ray and ultrasound.  We were really pleased to hear that we may be able to start doing echocardiograms to diagnose congenital heart disease more accurately than is possible at present...

John and Myra Sloane have arrived today, John will cover Dr. Gabriel's fortnight away on leave so we are grateful for the locum support.  Myra is hoping to work on the medical wards and HIV clinic partly to prepare for a few months helping in a hospital in Congo early next year.

One other visitor was a mother and baby who came back to thank Staff - the mother had been extremely unwell so it was good to see her and her baby doing well and one of our interns, Dr. Henry, took the opportunity for a well-deserved cuddle!

Marburg outbreak update

for those of you following the details of the Marburg viral haemorrhagic fever outbreak here is the most recent Minister of Health press release from 29th October.  Note that there have been a couple of cases in Mbarara, our regional town about 80 miles away to the north-east, as well as the index cases south of Kabale, in our neighbouring district.  Thankfully we have not had any cases here so far and do not currently have anyone under high-barrier isolation....
PRESS STATEMENT ON THE UPDATE OF MARBURG OUTBREAK 

Today on behalf of the Ministry of Health, I take this opportunity to welcome you all to this press briefing organized to update you on the outbreak of Marburg in the country. You will recall that we declared an outbreak of this highly infectious disease on October 19th and since then the Ministry of Health and its partners have undertaken a number of interventions to control the spread of the disease. 
I wish to inform you that cases are now reported in the neighbouring districts of Ibanda and Mbarara. However, I want to assure you that the Ministry of Health and its partners are on the ground in the mentioned districts to contain the spread and manage the identified cases. 
To date, the death toll of both the probable and confirmed cases stands at eight, with the latest being a case that died at the isolation facility at Rushoroza Health Centre III on October 27th (Saturday). The case that was referred from Ibanda Hospital – Ibanda to Mbarara Regional Referral Hospital died on October 24th
I wish to clarify that since the onset of the outbreak, we have collected a total of 45 samples of which nine were confirmed positive; five in Kabale, two in Kampala and two from Ibanda. 
Working closely with the US Center for Disease Control and Prevention (CDC), we have set up a field diagnostic laboratory at Kabale Regional Referral Hospital. All samples from the affected neighbouring districts will hence be taken to this laboratory for quick diagnostics. This will shorten the time when we get results to three hours from the original 24 hours due to distance. Further serological testing will be undertaken at the Uganda Virus Research Institute (UVRI).
Due to the presence of cases in other districts, we have established temporary isolation facilities to accommodate the suspected and confirmed cases. In Ibanda, a temporary isolation ward has been created at Ibanda Hospital, while plans are underway to set up a proper isolation facility by tomorrow.
At Mbarara Regional Referral Hospital, a separate temporary has been designated for the suspect Marburg cases. A triage has also been set up at the causality ward. 
We have assembled a team of experts to work in the newly established isolation facilities and they are expected in these districts today.  We also plan to undertake infection control procedures in these facilities as safety measures for the workers and the admitted patients. 
Today, the total number of cases admitted is 12. Eight are currently admitted at Rushoroza Health Center III in Kabale. Two confirmed cases, a couple (husband and wife) still remain admitted at Mulago National Referral Hospital. Another two suspect cases are currently admitted at Mayanja Memorial Hospital in Mbarara. 
There are seven suspect cases (student nurses) quarantined at Ibanda. These cases attended to the confirmed case that later died at Mbarara Regional Referral Hospital on October 24th. Other health workers who attended to the patient are closely being monitored. 
We have line-listed a total of 436 contacts for close observation in four districts of  Kabale, Kam-pala, Ibanda, Mbarara, Fort Portal and Rukungiri. Those being monitored got into contact with either the dead or confirmed cases. The team continues to monitor them on a daily basis for possible signs and symptoms of this highly infectious disease until they have completed 21 days without showing any signs and symptoms. 
We have completed an orientation of the Kabale district taskforce on Marburg case presentation and prevention, barrier nursing and infection control. Plans are underway to conduct the orien-tation at Ibanda and at Mbarara Regional Referral Hospital. 
We have trained a total of 42 volunteers from the Uganda Red Cross Society and deployed them to conduct house to house community sensitization and active case tracing. 
We plan to set up burial committees in Ibanda district to manage burials of people suspected to have died of the disease. The committee will be oriented on burial procedures and infection prevention and control. This is one of the control measures to curb the spread of the highly con-tiguous disease. 
The Ministry of Health would also wish to clarify on media reports that one of its officers, Dr. Sheila Ndyanabangi, the head of the Mental Health Unit Division, had contracted Marburg and had been isolated. Dr. Ndyanabangi has not been isolated but has been advised to exercise social distancing. She is one of the contacts who are being monitored. She has not developed any signs or symptoms of the disease and therefore cannot be isolated from the community. She is due to complete the 21 days of observation. 
I once again urge the public to take the following measures to avert the spread of the disease. 
•    Report immediately any suspected patient to a nearby health unit 
•    Avoid direct contact with body fluids of a person suspected to be suffering from Marburg by using protective materials like gloves and masks 
•    Persons who have died of Marburg must be handled with strong protective wear and buried immediately
•    Avoid eating dead animals 
•    Avoid unnecessary public gathering especially in the affected district 
•    Burial of suspicious community deaths should be done under close supervision of well trained burial teams   
•    Report all suspicious deaths to a nearby health facility  

Once again the Ministry of Health calls upon the public to stay calm as all possible measures are being undertaken to control the situation.  

Hon. Dr. Christine Ondoa 
Minister of Health 

Ministry of Health update on Marburg 25th October

 Many of you are asking us about the current situation re the Marburg virus outbreak.  Here is today's Ministry press release re the national situation.  We have not had any cases in Kisiizi so far but are vigilant as we receive some patients from Kabale.  The index cases are from an area to the south of Kabale on the way towards the border with Rwanda at Katuna so not on this side of Kabale but nevertheless we clearly need to be very cautious as we don't know how far it may have spread...
==================================================================

October 25th 2012
                                    MINISTRY OF HEALTH
                                    P. O.  BOX 7272,
                                    KAMPALA - UGANDA

PRESS STATEMENT ON THE UPDATE OF MARBURG OUTBREAK

The Ministry of Health declared an outbreak of Marburg in Kabale district on October 19th 2012 after receiving laboratory results from the Uganda Virus Research Institute (UVRI) confirming that two family members had died of the highly infectious viral hemorrhagic fever.  Three other members of the same family had earlier died of a strange disease in a period of one month.
The death of these people prompted the District Health Office to undertake further investigations of this strange disease that had ravaged Kitumba parish in Kitumba sub-county, Kabale district.
According to the reports, the patients presented with symptoms of diarrhoea, vomiting, fever, headache, dizziness and generalized convulsions. Initial samples of blood and cerebral spiral fluid taken from the sick people ruled out Malaria and Meningitis. The family then invited a cult leader, a retired Reverend from Rukungiri, district to visit their household and pray for the sick.
The index case is believed to have been a member of a family in Rwabirondo village, Kitumba parish in Kitumba sub-county which occurred on 20th September 2012.  After the death of the index case, two other people, a sister and mother reportedly got sick and died.
This outbreak comes barely two weeks after the Ministry declared an end to another viral Hemorrhagic Fever (Ebola) on October 4th 2012. The last Marburg outbreak was witnessed in October 2007in Kamwenge district.
Marburg is a highly infectious viral hemorrhagic fever which kills in a short time but can be prevented. Marburg is spread through direct contact with, body fluids like blood, saliva, vomitus, stool and urine of an infected person.
A person suffering from Marburg presents with sudden onset of high fever with any of the following; headache, vomiting blood, joint and muscle pains and bleeding through the body openings, i.e. eyes (red eyes), nose, gums, ears, anus and the skin.
How is Marburg Spread?
It is spread through;
•    Direct contact with wounds, body fluids like blood, saliva, vomitus, droplets, stool and urine of a person suffering from Marburg.
•    Unsterilised injections, contaminated linen, beddings and clothes.
•    Using skin piercing instruments that have been used by an infected person.
•    Direct physical handling of persons who have died of Marburg

Current Status (Update)
The Ministry of Health has developed a response plan and budget for the Marburg control amounting to sh2.3b of which sh1.75 is for central level activities including Ministry of Health, six general hospitals and Kampala Capital City Authority. This will be majorly for case management, surveillance, research and social mobilisation and procurement of protective gears. The district budget totals 651,047,576 and it covers case management, surveillance, research and social mobilisation.
•    Out of the six people who have died so far, only three were confirmed positive for Marburg.
•    Currently, there is only one confirmed case admitted in our isolation facility at Mulago National Referral Hospital. One convalescent case is detained at  Rushoroza Health Center III while five suspect cases linked to the initial cases  are admitted there awaiting blood results.  Special teams of doctors and nurses have been assigned to attend to the patients in both the isolation facilities. The patient admitted at Mulago National Referral Hospital is from Kitumba sub-county and is a relative of the index case.
•    The Ministry of Health surveillance team has listed up a total of 196 contacts for close monitoring. These contacts are mainly in Kabale, Rukungiri and Ibanda districts while 29 are from Kampala. Those being monitored reportedly got into contact with either the dead or confirmed cases. The team continues to monitor them on a daily basis for possible signs and symptoms of this highly infectious disease until they have completed 10 days without showing any signs and symptoms.
•    A team of experts from the Ministry of Health, U.S Center for Disease Control and Prevention and World Health Organization have so far collected a total of 18 n   samples from suspected cases for further investigations. The samples are being analyzed at the Uganda Virus Research Institute, Entebbe.
•    The Ministry is conducting an orientation of local healthcare workers in Kabale Regional Referral Hospital and in the other peripheral health facilities on infection prevention and control, barrier nursing, surveillance and clinical case management. This is being done to build health workers’ capacity to handle such cases. 
•    In Rushoroza Health Centre, a burial committee has  been set up to manage burials of people suspected to have died of Marburg. The committee has been oriented on burial procedures and infection prevention and control. This is one of the control measures to curb the spread of the highly contiguous disease. The committee has so far supervised two burials.
•    A team from the Centers for Disease Control (CDC) is expected in the country to undertake anthropological studies.
The Ministry of Health once again urges the public to take the following measures to avert the spread of the disease.
•    Report immediately any suspected patient to a nearby health unit
•    Avoid direct contact with body fluids of a person suspected to be suffering from Marburg by using protective materials like gloves and masks
•    Persons who have died of Marburg must be handled with strong protective wear and buried immediately
•    Avoid eating dead animals
•    Avoid unnecessary public gathering especially in the affected district
•    Burial of suspicious community deaths should be done under close supervision of well trained burial teams  
•    Report all suspicious deaths to a nearby health facility 

Once again the Ministry of Health calls upon the public to stay calm as all possible measures are being undertaken to control the situation. 

Hon. Dr. Christine Ondoa
Minister of Health 

birthdays...

Dr. Francis Banya, our Obstetrician, came in from a game of badminton to find a surprise birthday party producing what must surely be the smile of the year!  The photo on the right shows him with his 1 year old daughter Gloria, and his wife Confidence.

 Ian, being a fair bit older, was dubious when asked to come urgently for “an emergency in the staff room” on his birthday and so he nipped around the back of  the building and popped his head through the window to catch out the waiting party! 

Great laughter resulted followed by sharing the largest cake he has had for a birthday! [thanks Hanna!]

 

 Birthdays come and birthdays go... and its amazing how time flies.  

Whilst reviewing a preterm baby recently Ian said, as a throwaway comment to Damari, one of our nursing team, " You probably weren't even born when I first came to Kisiizi in 1987!"

He was rather shocked when she replied that her mum had told her that he was the one who had delivered her!

Damari