Malaria season and Continuity
In Uganda the wet season lasts most of the year. During the wet season it rained every single day, and everywhere you looked everything was green. Our garden overgrew and gave us many vegetables, and the weather was warm and pleasant. In the beginning of December the rain stopped and the dry season started, along with unbearable heat. A full blown Israeli summer, but without the air conditioning. Along with the dry season came the mosquitoes. The patient load in the hospital grew tremendously – up to 4-5 times more patients in any given time. Many malaria cases and complications, but also many other diseases. Apparently in the dry season, when people don't work in the fields, much more patients come to the hospital.
At the same time, in the beginning of December, the 'big switchover' took place. Many of the nursing staff was switched between the wards. During November we still had hope the change is going to be for the better. The hospital executives promised us to replace some problematic nurses and place dedicated ones instead. So they promised. The promises were lost in the local politics. The head nurse pulled a successful coup, The hospital’s director calmed he was tricked. And so, in the midst of the busiest season, we were each left with a smaller staff, compiled mostly of unmotivated nurses, that don't bother to give medications to patients, bring supplies from the hospital stores or show up to their shifts, and in general try to work as little as possible. Most of our favorite nurses, those that we could count on with our eyes closed, were transferred to various motivation-grinding placements, such as the operating theatre (where they are mostly in charge of sterilization of equipment) or the pharmacy (where you definitely need special skills to count medications).
The next two months were challenging. One doctor cannot effectively treat more than 40 hospitalized patients a day. It's impossible to do good medicine like this, especially if you don't have staff you can count on. So we worked ourselves to the ground. We came home later and later every day and Eyal forgot what we look like. We tried to focus on the difficult patients. We cut corners, we stopped documenting everything on each patient and wrote only the bottom lines. We started paying people to come and help us – we brought translators so we can do rounds, we brought nurses to give out medications or bandage wounds. Luckily at around the same time enforcement arrived - Ronen and Yahel (the new volunteers that came to replace us) jumped right into the deep water and helped tremendously with the crazy workload.
Finally this month the amount of patients reduced and the situation quieted down a bit (even pediatric ward returned to its regular work load…). We are still busy trying to make changes in the nursing staff placements, hoping to improve the situation a little. Wish us luck.
Our mobile outreach clinic in Kabuye is already up and running, and we decided to open another clinic. We found a new village named Degeye, who is located in an area known to be very poor. Many of the malnourished children that come to the hospital live in this village. We arranged with the village leaders and set on our way with our loyal staff, medication boxes, and Ronen and Yahel who joined the team.
We opened the clinic in a mud-hut set at the center of the village, which is used as the local church. In the new clinic we see many difficult cases. The people are very poor and can't manage to travel to the hospital even when they suffer from life-threatening medical conditions. We see many children suffering from malnutrition, or multiple convulsions that were never treated before, patients suffering from severe skin infections and ulcers, HIV and other sexually transmitted diseases, malaria, pneumonia, cancer and more.
Before we leave to go back home, we plan to open a third clinic and offer access to medical care to more people. Yahel and Ronen will continue to operate the clinics after we are gone.
At the same time we started conducting teaching sessions with the hospital's clinical officers and nurses. The clinical officers, who studied for three years, are the ones who manage most of the patients who come to the hospital. They see the patients in the emergency room / outpatient clinic and are supposed to (supposed…) to follow up on the ones they admit to the wards. Some of them are very professional, but many have only basic knowledge and skills and make many mistakes in diagnoses and care. We started gathering everyone for sessions on various subjects that we saw over time that needs strengthening (with drinks and a cake for extra motivation of course). With their help and cooperation, we write guidelines that are based on the government recommendations and are tailored to the local conditions and challenges. We hope to make a lasting change through the empowerment of the local staff.
Heart of a lion
On an innocent Wednesday morning Eitan arrives in the ward, expecting to see a few children with pneumonia, malaria, skin infections, and convulsions – a routine day's work. Little did he know. The nurse calls him to see a child breathing heavily. A quick peak in his throat reviles a big blocking mass – an infection or a tumor perhaps. Immediately Eitan begins to arrange for his transfer to Kampala, as our humble hospital is currently lacking an ENT and even a ventilator, and the kid is barely breathing. He manages to arrange for an ambulance, convince the hospital superintendent to pay for it and even finds a functioning oxygen tank. But the kid continues to deteriorate and every few minutes stops breathing for a short while. Eitan calls Dr. Peter, our favorite doctor and together they agree that the child needs a tracheostomy – which means inserting a tube through his neck (since hit throat is blocked) directly into his trachea so he can breathe through there. Anyone knows how to do that? Eitan did it once on a pig during his army training, Peter read about it, no need to say that there is no ENT around. Peter calls an ENT friend of his that gives them directions through the phone (find the place, watch out from blood vessels and nerves. Good luck!). The kid is dying in front of their eyes, and the decision is made – there is no choice. Using anesthesia medications is out, for two reasons. First – it might make the kid stop breathing completely. Secondly – there are none. So - physical anesthesia it is (which means 4 people grabbing the kid and pining him to the table). Peter bends towards the kid and before he cuts says the eternal words – 'to do this you need the heart of a lion'. And then, with unimaginable skill and serenity (and absolutely no previous experience), cuts into the kids neck, identifies the trachea, inserts the tube and stiches. In case we didn’t mention it before – Dr. Peter ‘Heart of a lion’ Isagara is the doctor we admire most in the entire world. These days we’re trying to arrange for him to come to Israel for a gynecology fellowship.
Two months ago a woman in her forties called Agnes arrived on female ward. For a year now she is unable to walk, and the situation is deteriorating. We give her a neurological exam, film and consult with doctors from Israel. We come to the conclusion she is suffering from a neurological condition called ‘sensory ataxia’, who can be caused by a long list of conditions.
As we already mentioned – the hospital doesn’t have many options for a proper medical investigation. We make do with what we have, send some blood and stool tests, preform a lumbar puncture and badger the lab until they look at the films, managing to rule out a few of the possible causes. We start to suspect that she suffers from a severe lack of vitamin B12, but what is the cause? Someone (to this day there is an argument who it was) – suggests the woman suffers from a massive parasitic infestation that can cause the vitamin deficiency. We are talking about a hypothesis based on a guess based on another hypothesis, but if it’s treatable – we have (almost) nothing to lose. We give the woman broad spectrum treatment against the possible parasites, but we are then faced with a problem –the hospital and the private pharmacies in town hold vitamin B12 shots. We set off on a search and finally manage to find and bring the drug from Kampala, and start giving her the shots. Two months later Agnes comes in for her weekly shot and walks into female ward walking on her own two feet… Little miracles.
Acquisitions and repairs
Supplies and maintenance is an ever present problem in the hospital. At any given time much of the equipment and machines are broken or not functioning and many things are out of stock. At times it’s an essential drug – ‘out of stock, maybe next week’, oxygen tanks are finished, the US machine brakes down, the lab reagents are finished and lab tests can’t be performed, or the lights in the operation room go out and surgeries are performed with dimed lights or flashlights. At times we find that all at once - half of the medications are out of stock and none of the hospital machines are operating. Money for repairs is always missing and shipments from the government stores are ever late. In the meantime, we can’t offer our patients decent care. The hospital goes on ‘guessing mode’ – lets guess what the patient is suffering from and treat him with the medications that are left (which are not even good for what we guess he has). Just to remind you we are talking about the only hospital in the District. Bravely serving a population of 400,000 people…
Frustration mounted as all the promises for things ‘arriving tomorrow’ failed to realize. We set off trying to solve some the problems ourselves. We fixed the ultrasound machine, bought films for the x-ray machine, fixed the lights in the operation theater, started buying essential drugs for patients and resuscitation equipment. We didn’t come to be the hospitals acquisitions department or to replace the ministry of health, and we certainly don’t want the hospital depending on us in this area. But we are tired of feeling that our hands are tied. We felt that in order to be able to give basic and proper care to our patients, those who don’t have any money at all (anyone who has even the least bit of money goes to private facilities), we need to maintain the equipment. It dug into our budget, but improved the care we are able to give. And who knows, maybe one day the truck with all the missing supplies will arrive. Maybe it took a wrong turn, maybe a flat tire.
Back when Africa was only a faraway fantasy, before we set on our way, we spent a lot of time thinking about what kind of project we would like to be a part of. We knew our first goal is to volunteer for a year in place where our work will be beneficial and meaningful. Making this happen was not an easy task, so we didn’t know upfront if we will be able to ensure continuity of the project. It’s hard to raise funds and not at all easy to find volunteers. But we hoped. During the past year we tried to spread the word about this project, and worked hand in hand with Brit Olam to make plans for the future and secure donors and funds. On Novemeber we got good news – first – we have a two new doctors coming to volunteer and replace us, and another couple coming after them – at least another 8 months ahead there will be 2 volunteer doctors working at the hospital (Just to remind you that without this the hospital has only one doctor on 120 beds…). Secondly, Solel Bone Company (SBI) is willing to continue and support the project for another year (and hopfully for many more thereafter) in an amount that will allow us to continue the work.
In December Ronen and Yahel, the new volunteers landed, straight from Jerusalem. They arrived fresh and energetic (still smelling of soap) and immediately started working where they were most needed. Ronen in the male department and Yahel in the packed female ward together with Reut, also running around the hospital and helping anywhere she can – getting things done in the lab, HIV clinic and other places. After two months experience replaced the freshness and smell of soap, but the energy remained… It’s great to have someone else to consult with, to carry the burden, someone to talk with in Hebrew (even Eyal suddenly started talking because he hears a lot more Hebrew around him). The need for good and enthusiastic medical staff is vast and we feel their positive contribution everywhere.
We are very happy to know that the project will continue after we leave. It would have been heartbreaking to leave the staff and patients here knowing there is no one to carry on the work. We continue to look for replacements to the replacements and hope the project will go on for many years to come.