Climate change...

hailstones!

Well, we are located about 5,500 feet above sea level in the Kigezi highlands so I suppose it's not too surprising that we get covererd in cloud and have some thunderstorms at times... recently the rainy season has commenced and the rains can be quite intense at times which may make a conversation difficult when in a building with a tin roof.


Recently we actually had hail stones which is not too common, and you will see on the picture the change in the amount of flow over our waterfall after the rains....

Saturday morning ward round...

Dr. Josephine is having a well-earned rest so Ian is covering paediatrics and neonates.  Happily we now have an intern so that is a great help.

I started in our special care baby unit where most babies were improving.  One infant had come to Kisiizi a few days old with a major problem called a sacro-coccygeal teratoma.  This is a form of tumour that causes a large mass over the lower spine.  Dr. Gabriel, our surgeon, had operated to remove the lesion, no mean feat as quite large and even involved the caecum and appendix anteriorly!  Happily the baby now looks really well and is thriving.

Dr Johnson, intern, and Sister Jane on Children's Ward

Then we have the usual mix of premature babies including one born weighing around 900 grams who has now doubled in weight and will be heading for home in the not too distant future.

One baby had been born on the way to hospital and had arrived very cold but is now improving.  Another was born here by a difficult breech delivery and needed resuscitation at birth.

The saddest case is a baby who was born some distance from us in the community, apparently in a house belonging to a nurse who is not a midwife.  The baby had problems and was seen in a village clinic who only referred her on after a couple of days.  She arrived in poor condition and needed urgent blood transfusion and had some initial fits which we were able to control.  Today she is much improved but we are guarded about her longer term neurological outcome.

I have just removed an umbilical vein catheter and put in a peripheral cannula on a baby who had a degree of birth asphyxia and still has abnormal tone.  It's sad to see such cases born in other places.  However, on a positive note, our own maternity and obstetric service is developing.  In addition to Dr. Helen Smith, Consultant Obstetrician, visiting again recently to support Dr. Francis Banya, our own Consultant Obstetrician and Gynaecologist, we now have Dr. Rachel with us for a few months as the first "Maternity Hub" registrar.  She will help Dr. Francis and the midwifery team in various ways as we seek to improve further the quality of care.

he ain't heavy... he's my brother!

After the babies down to Children's ward.  One lad is recovering from a laparotomy [surgical exploration of the abdomen] yesterday.  He had had features suggesting peritonitis after a preceding history of fever and abdominal pain and we suspected typhoid and a perforation of the gut which is a well recognised complication.  However it turned out that he had a ruptured gall bladder!  This is an unusual event in a child of 10 and there were no stones present.  It must have been linked to the direct effect of infection causing inflammation of the gall bladder plus or minus an effect of pressure on the drainage duct due to enlarged lymph nodes which we had noted on ultrasound and confirmed at surgery.  He seems to be reasonably well this morning considering how sick he was.














Another child aged 20 months came in with a long history of cough and a recent swelling over his thoracic spine.  I think he probably has TB and has some damage to one of the vertebral bodies causing some collapse and angulation.  Happily he doesn't appear to have any damage to his spinal cord.


So that's just a taster of some of our patients, and of course the usual mix of children with pneumonia, gastroenteritis etc as well.

Then a quick diversion to the hospital "canteen"  shop to get some milk as my dear wife is back in UK and the girl who helps run our household is off this weekend.  Back home for a coffee and to boil up the milk [it comes direct to the canteen in a metal container and isn't pasteurised] and time to update this blog and to thank you all for the messages of support and encouragement and your prayers that sustain us in this work.

Here is a photo of a child we admitted about 3 weeks ago - the child had a form of neonatal hepatitis that had caused her to remain jaundiced but the prognosis was good.  However, the family, advised by the mother-in-law, had taken her to a local traditional healer who had performed "ebiino".  This practice involves digging around in the infant's gum and pulling out an un-errupted  milk tooth.  The practice is usually used in infants with diarrhoea and, as this is usually self-limiting, it perpetuates the myth.  However the practice may result in severe infection including septicaemia or, as in this case, bleeding, probably exacerbated by the underlying liver problem affecting clotting.

We had to resuscitate the child, give oxygen and fluids iv and vitamin K and then Hanna, my faithful wife and O Negative universal blood donor, gave some fresh blood to help control the problem with good results.

This case highlights the need for health education and promotion to try and avoid such cases in the future and we hope to develop our community programmes in the coming months to pursue this goal.

Beautiful Lake Bunyonyi...

As Hanna is travelling back to UK for 7 weeks today, we "escaped" for a weekend away at Bushara Island, a lovely spot on Lake Bunyonyi [= the lake of little birds].  It was very peaceful and good to have some breathing space after a frenetic few months.

Mark and Ruth had given me a telescope for Christmas and it was put to good use enjoying the magnificent birds and scenery.  Unfortunately the sky wasn't clear enough for any good star gazing this time and the backdrop of the volcanoes which are sometimes seen was stubbornly covered in cloud so we'll just have to go back another time.

no, not an exotic insect!  A seed designed to be carried on the wind...

We travelled on from Kabale up to Mbarara and had a lovely stay with Esther Kobusingye, previously Sister in Charge at Kisiizi.  It was good to spend some time with her and catch up with each other.  Hanna stayed a further night there and then went on to Kampala and Entebbe yesterday whilst I drove back the 80 miles to Kisiizi, the last 18 miles being on murram gravel road.

We are so grateful for the beauty of this region of Uganda and the chance to enjoy this short break... now back to the mix of admin and clinical work that makes each day different....

Kisiizi tapestry...

Life in Kisiizi is very varied - with the Hospital, School of Nursing, Primary School and Hydro-electric power company there is a wide range of activity both clinical and non-clinical.  And then there is always the wild life to enjoy...

Malcolm Crawford, Rev Patrick and Justine auditing accounts

Malcolm Crawford, a CMS mission partner in Kisoro, kindly helps us with end of year accounting reviews.  Rev Patrick is our hospital Chaplain but has also been serving as acting Finance Manager, whilst Justine is our accountant. 

Building and maintenance work is often seen, the photo shows the use of banana leaves to protect a newly laid concrete slab for a septic tank.

Every weekday Staff meet in Chapel at 8am and sometimes the Chapel Choir will sing.  The "adult mission" has been postponed as, due to the scare about Ebola, it was clear that turnout would be low and the government had recommended the avoidance of large public gatherings. 

Happily no new cases of ebola have been confirmed in Uganda for some time.  There have recently been cases from neighbouring Congo but interestingly these are apparently a different strain of virus so not part of the outbreak affecting Uganda a month or so ago.

a small gheko finding a warm place to rest!

sport focus...

We have limited internet at times here but have managed to follow the Olympic headlines and to hear reports on the local BBC station based in Mbarara 80 miles away.

People here are generally much more interested in football, especially the Premier League, than in the Olympics though perhaps today's Uganda gold in the marathon may change perceptions!




People will crowd to watch a very small TV screen when the football season is underway, and many will play sports including football, badminton and volley ball when they get the chance.

Quote time...

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and science. He to whom this emotion is a stranger, who can no longer pause to wonder and stand rapt in awe, is as good as dead: his eyes are closed."

ALBERT EINSTEIN

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"Endless invention, endless experiment,
Brings knowledge of motion, but not of stillness....
Where is the Life we have lost in the living?
Where is the wisdom we have lost in the knowledge?"


T.S.ELIOT

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"Every ant knows the formula of its ant-hill,
every bee knows the formula of its beehive.
They know it in their own way, not in our way.
Only humankind does not know its own formula."

FYODOR DOSTOYEVSKY

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

"We see either the dust on the window
or the view beyond the window,
but never the window itself."

SIMONE WEIL

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

"So now, from this mad passion
Which made me take art for an idol and a king
I have learnt the burden of error that it bore
And what misfortune springs from man's desire...
The world's frivolities have robbed me of the time
That I was given for reflecting upon God."

MICHAELANGELO

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

Accountability...

It was apt that one of our current visitors, a Ugandan medical student who has previously worked with us as a Clinical Officer, spoke on the topic of accountability in Chapel last week.  He took the well-known parable of the Talents and the fact that we are all responsible to use our natural gifts and talents, and all that we have and are, to the full.
For, on Thursday, we had a visit from the District Health Officer [DHO] and his team to look at the Hospital and to inspect our record books.  It seems Kisiizi has sometimes been slow in sending in data to the district and at times it has been incomplete.  Walking around with the team affirmed many areas of practice but also highlighted some improvements needed and was a very helpful exercise that we hope to see repeated regularly.

DHO and team talk with a patient in Rehabilitation

The DHO visited the new operating theatres, built with support from St Paul's Church in Dublin under the supervision of our builder David Barratt, and was impressed at what he saw.  We then toured Maternity, Neonates and Rehabilitation unit having already seen out-patients including the dental, HIV and ophthalmology areas.

We look forward to working more closely with the DHO and his team in the future and share some important goals regarding Community and Public health.

Ebola update

We are happy to report that Ian phoned the Uganda Viral Institute this morning and they confirm that both our patients in high-level isolation are negative for Ebola.

This is good news and a real answer to prayer. We continue to be vigilant with a triage desk next to our main entrance to screen all patients as soon as they arrive.

Ian in protective clothing

The contingency planning has taken quite a lot of time to set up but now seems to be running well. It has been encouraging that a number of Staff have volunteered to help with the high-risk patients which has included night duties.  Dr Gabriel Okumu, our Consultant Surgeon, is Infection Control Officer and has led the team well setting a good example in dealing with our first high-risk patient.

The care of patients in high-isolation is also time consuming and quite uncomfortable as the protective clothing is very hot and it is not too easy to breath.  We found also that the protective visors/eye shields tend to fog up making procedures more challenging.

 But happily all has gone well.  Hanna has done a lot of nursing care for the two patients as has Sister Kate, our Acting Principal Nursing Officer and Ian had to do their blood samples, clearly a high-risk task, but thankfully it went smoothly.

Ian diagnosed another possible case picked up on triage on Wednesday as in fact having pulmonary tuberculosis.

Apparently a case has been confirmed on the Tanzania / Uganda border, again not very near to us but suggesting that there may have been some spread of the condition.

Mental Health service plans...

We greatly appreciated Ann visiting for a week to advise on our planning for a new Mental Health Unit.  We are the only non-government hospital to run a mental health service, treating patients who are often marginalized and in desperate need.   

Management have identified a site for the new Unit.  Nancy, who heads up the service here, together with Ann and others in the team spent time hearing the views of patient groups, relatives and Staff as to what was going to be important in the new Unit.  We have drawn up some initial provisional plans and Ann will work on these with architect colleagues and fee back ideas to us.  It is special to have a “blank canvas” rather than having to convert an exisiting building.

Many of you who followed our blog last year will recall the tragic story of the death of Jamie, the son of Avril and Jim who had come to Kisiizi to raise support for our psychiatric service.  Ann is the sister of Avril so it was really special to have her here particularly as it coincided with the first anniversary of Jamie’s death and we were able to go and pray together next to the site of the new Unit.  Avril and Jim have wonderfully worked to set up a fund in memory of Jamie and will be establishing a formal charity.  They have already raised support for a mental health vehicle which will allow more trips into the community to provide support to these patients, and now are focusing on the funding for the new Unit. You can read more about this by following the link below:

 http://www.justgiving.com/James-Jamie-Devaney/

We are excited to see psychiatry, often the "Cinderella" specialty, getting this focus and support  and we anticipate that it will lead to something very special indeed.

"Fear not, for I am with you..."

It’s easy to preach such texts in theory but times come when we are put to the test.   

There is currently an outbreak of Ebola Virus infection in western Uganda.  Cases have been mainly in Kibaale forest, some distance to the north of Kisiizi, but we are taking it seriously as we know a lot of people from our catchment area travel up to Kibaale to work in the timber industry.  It is likely that if they become unwell they may return home, and then  if they deteriorate they may come to us.  We have therefore had to spend a lot of time putting contingency plans in place including introducing a new patient triage near our main gate to try and pick out any cases before they mix in the out-patient queue.  We have set up the old operating theatre as a high-dependency area should it be required with barrier nursing facilities and we have partitioned our Isolation Ward to give more control of patient and visitor access.   

We hope we don’t get any cases as it is one of the viral haemorrhagic fever conditions that is extremely infectious.  We have had a number of volunteers from our Staff to help should we have any cases and will do further training this week.

Some medical students from UK have been advised to cancel or conclude their electives here because of the outbreak and potential risk.

Measles rash

A lot of our work is to do with infectious diseases, especially pneumonia, malaria, typhoid, TB, HIV and, occasionally, measles.  The immunisation rates here are quite good but still we see some cases slip through.

Rotas and Rotors...

We are really pleased that the Ministry of Health has approved Kisiizi to have a Paediatric Intern to join  our surgery and obstetric interns, rotating with 3 months in each specialty.  In fact, the Ministry would like us to take two interns in each specialty and our Management team have approved this goal.  Longer term,  if we can recruit an Adult Physician, we will then be able to have a medical intern also and the rotation would be a full year.   

This is a significant development with the prospect of improving patient care and also of making it much easier in future to recruit Medical Officers.  We will have a big change over this week as the new interns join us and we welcome new Medical Officers.  This is all moving towards a departmental structure and we hope will improve our clinical governance and allow better medical cover especially supporting out-patients.

Centre of attention...

One major excitement recently was the arrival of a helicopter from Kampala to transfer a patient who needed further investigations and support.  Many people had never seen a helicopter before, and as it landed on the primary school playing field a large crowd gathered including quite a number of patients who left the wards to witness the event!

Overwhelmed...

The Mills family with the Kisiizi waterfall behind

After the usual long drive from Kampala, stopping en route to say a quick hello to Esther in Mbarara, we arrived in Kisiizi in the dark.  Accompanying us we had Natalie, a medical student coming on her elective, and Ann who had come to help  advise us about plans for our new Mental Health Unit.   

We drove up to our new home, the Medical Superintendent house, which was in darkness, but when Hanna popped her head around the door a great burst of singing erupted and we found a surprise party in our lounge with perhaps 60 or so people gathered… it was an opportunity to say goodbye to the Mills family who had been in Kisiizi for 3 weeks as well as to welcome us, and it was such a special time to see the house full of people from many parts of the hospital community having fun together – drivers, nurses, teachers, secretaries, chaplains, medics, visitors etc…. so a real treat and a great encouragement for the future following what has been a difficult time for the Kisiizi community in the past few months. We felt overwhelmed by the love and warmth of the welcome.

Our new home is lovely with a view from the verandah towards the waterfall.  We have split the house into two areas as we don’t need such a big place.  We have a bedroom, shower, kitchen and the lovely large lounge.  The rear of the house with a bathroom and bedrooms has been allocated as an extension of the hospital Guest House as we have been in need of more space and it has already been well used.

Down, down.... up, up and away...

Normal descent into Entebbe, familiar sight of Lake Victoria out of the window, then all the engines increase power and we are going up again… fly on for 20 miles, turn and, after an impromptu over-flight of the Ssese Islands, we head back and land in the opposite direction.   

Apparently the reason was that we had a full aircraft and a significant tail-wind… but we actually wondered if perhaps the co-pilot was having a go and the Captain took over!

 Reminds us of a number of times taking over medically from junior colleagues also about to hit a heavy landing!  

So we don’t just take travel for granted, we had had a similar experience years ago coming into Nairobi on a Kenya Airways airbus… that episode was more dramatic with the plane lurching up having been almost at touch-down.  It turned out that a Air France plane had pulled onto the runway ahead and we would have collided.  So we are grateful to arrive here safely once again…