Trauma

Photos to follow!

For a while I have been thinking of writing about ‘’tauma’’ – the name medics use of the mess that happens as a result of accidents and injuries. There is no shortage of trauma on the ward where I work. In fact, road traffic accidents are the largest cause of admissions to the in-patient ward here in the last three months. (I count such things – see ‘’Audits’’!)

The main means of motorised transport here is the boda-boda – the motorcycle taxi. Being a ‘Boda-Man’ is quiet a status symbol – picture a young gun, going fast, wind in the face, taking risks, feeling the adrenaline, with maybe a bit of alcohol inside to fuel the fire. Many of the larger vehicles on the road treat bodas as errant creatures, with as much right to be on the road as a goat, and expect the poor boda drivers (usually with no helmets, and certainly with no leathers) to take avoiding action whilst the big vehicles plough on in the middle of the road. The roads are rutted and potholed. On two wheels, coming off is almost inevitable. Every week, there are boda-related injuries to patch up, from simple wounds and soft tissue injures, to nasty fractures and major head injuries.

 

The other vehicles prone to accident are lorries with open backs, on which tea is carried from small growers to the processing place at Kayonza. The growers stand in the back of the trucks, hanging on to the metal railings or sitting on the crops. And when the lorries are emptied , they drivers race back home as quick as possible, haring it along with men hanging on to the back. Trucks topple and crash, or break suddenly, throwing their passengers off the back with horrible consequences.

 

Last Friday was particularly terrible. A truck toppled into a bend. Its cargo was secondary school children, returning from a football tournament. All the youngsters were flung out of the truck onto the road, or trapped underneath it. Miraculously no one died, and little by little, the 35 injured were transferred to the hospital for care. They arrived around midnight and my fabulous Ugandan colleagues set to work triaging the most badly injured, and taking them to theatre for life-saving surgery – amputations and the like. Beds were found for all the others, and by morning, (which was the first I heard about it,) there was an air of calm busyness about the hospital as the work of the daylight hours began. There were feet and limbs to clean and wash and bandage. There were dozens of Xrays to perform and hundreds of painkillers to be administered. There are normally only two nurses on the ward. We had thirty patients extra patients. Wonderfully, nursing students stepped in to help, administering tetanus toxoid to all those with dirty wounds to prevent infection, and bandaging and bed-bathing all day.

 

And it so happened that the day was a public holiday (‘’women’s day’’ – a day for older men to stand and make political statements about their commitment to women’s equality.) Relatives of all the injured were on the doorstep of the ward, asking for news. By mid afternoon these crowds were supplemented by onlookers and the curious. Every time we went in and out of the ward, we had to make our way through crowds.

 

It was exhausting. We learnt lots of lessons about managing mass casualty events.

 

Now, several days later, all but the most severely injured have gone home, none of the wounds have got infected and the injured have moved from shock to pain to boredom as they wait to be fit enough to be back on their feet and to go home.

 

I’m not a surgeon and I haven’t done much stitching in years. But I was glad to be involved in dealing with this event. It is a testament to a value driven institution that so many staff stepped in to help, and I found the sense of solidarity was very strong and carried us along.

 

What’s needed now is public health – work with boda drivers (like the ‘’Better Boda ‘’ project) to try and increase the safety of Boda drivers in their risky environment. Wearing helmets, using head-lamps, not driving when drinking – all simple interventions that could make a significant difference. But beyond even that, there are deeper issues about how risk is experienced here. There is so much risk in most people’s lives here, and that largely because there is no financial safety net. There’s the risk of being unsure if there is enough money for the next meal or for the next set of school books, or how to cover the cost of an unexpected event. And there is illness, accident, injury, death in a life that is physically hard and exposed. And if life is full of risk, then why not drive a boda ? – it will earn some money, and offer status. If life is full of risk, and you are a school administrator, why not rent a truck rather than a bus for a trip – the cost of hiring a bus may make the trip impossible….

 

I think it will take far more than any medical management to address the rates of trauma here.

An eleven-out-of-ten day

My girls have got into the habit of rating the day out of 10. Most days get at least an 8 1/2, so I count that as pretty reassuring, but Friday was extra-special. Friday got, from Miss A, ‘’eleven out of 10.’’

Even before coming to Uganda, Brian and Miss A particularly (and me if I have the time to think about it, and little Roo by default) are all quite obsessed with living creatures. For Brian it is insects, for Little Roo it is anything fluffy. For me – I don’t mind really. For Miss A, the answer is without doubt, reptiles. Whilst the rest of us are watching the monkeys play in the trees, she’s focussing on the nearest lizard, or gecko (and if there isn’t one, then a mole rat, or millipede.) Top of her list, best above everything is the chameleon.

Just as it was getting to dusk on Friday, I took a phone call from Flaviah, the wonderful lady who helps get our clothes washed and keeps our house clean. She was in her village but was coming ‘’now, now.’’ She had something that ‘’Tata-Brian’’ would be really keen to see. (Brian was already in England, but she thought I could take some photos and send them.)

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Flaviah and the box of surprises

 

I rounded up the children, just as Flaviah arrived with a cardboard box, tied with banana leaves. She opened it gingerly and stepped back. Tucked into a corner was a rather cross Johnston’s three horned chameleon, (Triceros johnstonii.) It showed its dissatisfaction at being moved from a bush in a field, by opening its mouth wide and rasping at us in an airy, crispy way, then proceeding to scurry as fast as possible away from the gathered children and adults. Not fast enough. He was picked up and admired for the next hour, as he tried in vain to climb every one to reach the highest vantage point and regain his composure.

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Johnston-in-a-box

He was three horned, with jowls like a lazy publican, skin the texture of a pan scourer and revolving bulging eyes that really could look in two directions at once. His skin was greeny-grey with a flash of rust-coloured orange across his back. He went darker, with time ( I suspect this reflected his mood.) Unlike the other chameleons we have found – generally small and dainty, and delicate of foot, – this one clambered with feet that pinched like pegs, and with an energy that was admirable, if misguided.

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Chameleon-fascination is quite infectious. Soon there were at least 12 gathered around this remarkable creature, taking photos, trying to touch it. Wondering at just what an amazing invention nature could come up with.

We asked Flaviah if she might take it home with her. After all these creatures are rare, and would be happier in the environment they had chosen, but she had used all her courage to bring him here. People here are in general uncomfortable about chameleons. There seem to be as many reasons as there are individuals to have them, but the general feeling is that they bring misfortune.

So our Mr Johnston was taken to the nearest patch of forested land by the children – carrying him as if he were the most precious treasure and placing him carefully onto a high branch. He settled himself and his black cloud-of-thunder skin returned to its green-and-rust pattern as he made his way close to the top of his new home.

Miss A was in raptures. Surely the best day EVER.

Here is the whatsapp message I got from Brian on sending him the pictures: –

‘’Oh my goodness! Where did she find it? Where is it? When can I see it?’  

 Then later

 ‘’Are those the only photos you got?’’

 Flaviah was right!

Salt – lake town

We are on ‘’off-days’’ so have taken the opportunity to go a little further north in the country for some exploring. We’ve had a wonderful few days of seeing wildlife in planned and unexpected ways, listening to hippos grunting at night, and walking in the forest. But today was an altogether different experience which I am still trying to understand and reflect on.

 

In this area (Kasese), we are in the heart of the Rift valley, full of extinct volcanoes. The area is studded with crater lakes, and one of these, at the village of Katwe, is an open cast salt mine. We went to visit. It was an un-preposessing, drizzly and chilly morning as the rainy season is about to start. We weren’t sure if we wanted to go, but we are so glad we did. The town of Katwe has a run-down, forgotten air about it. There are lots of buildings slowly crumbling into the surrounding dust and being invaded by plants. The town is on the lake shore. Hippos meander across the scrub-land adjacent to the village. No-one reacts much. It is as if not much disturbs this town.

 

In this area the soil is very alkaline, with abundant salt rock containing sodium chloride and sodium sulphide. This means that crops can’t grow, (and if they did, the many elephants and hippos would destroy the crops) so instead they ‘farm’ salt from the lake. The process of salt mining is all done by hand. 70% of the population of about 9000 in Katwe makes its living from salt. It is a seasonal activity, of the dry season, so they need to make enough money from half the year to last the whole year around. Salt is sold, and vegetables and carbohydrates are bought in the market. Some of the population turn their hand to fishing in the wet season on the adjacent Lake Edward. Each family has a salt pond which is the equivalent to an allotment plot in other parts of the country. These can be inherited or passed on but remain in local hands. Each pond must be about 20 metres by ten and shallow – maybe 50cm. When the sun shines on the water of the ponds it evaporates and the salt precipitates forming a scum on top of the water. This grows over 24 hours, and then the salt farmer uses the water from the salt pond to splash over the salt scum and make it sink to the bottom of the pond, by sedimentation. This forms a first layer. The process is repeated every day for 10 days or so until there is a thick layer of layers at the bottom of the pond. Then the owner of the pond uses a curved piece of metal called a peg to ‘’sweep’’ the salt into a pile and then heap them out onto the edge of the pond. It can take a single person the whole day of back-breaking bending and scooping in the hot sun to move the salt into a pile. The piles have to be covered in plastic and then in grasses to protect from the rain otherwise all that hard-gained salt will dissolve away.

 

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Salt ponds. There are little mud paths between, and wooden posts to stop the paths washing away.

 

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Salt ‘harvesting’ with her ‘peg’ to make a pile of unwashed grade 2 salt
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Grade 2 washed salt for human consumption

Various grades of salt are produced – ‘’animal salt’’ – which is dirty and lumpy and which is given as a supplement to herd animals. Then there is grade 2 unwashed salt used for curing hides, then grade 2 washed salt which is used for human consumption. There used to be grade 1 salt (the most refined) but this was overexploited and has all been used up. And then there is rock salt – extracting it is high risk, high gain work and only open to men. The men walk out into the main body of the lake which isn’t deep; less than a metre. They reach into the water, being careful to avoid getting the salty water into eyes or lips and lift out slabs of rock salt as large as they can handle from under the water. They use metal rods that have been planted in the lake to break up the slabs, and simple rafts to float the rock salt to shore. The rock salt is sold to Rwanda and Congo where there is no local salt mining. It is high in iodine so very much in demand in those areas which are low in naturally occuring iodine.

 

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The rafts used for stacking the rock salt slabs and pushing them to shore
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blocks of rock salt

 

The salt miners work as individuals or families. Apparently there are no problems with stealing. The work is ‘co-operatised’- there is a collective that sets the price for the salt and does the bargaining with the buyers. When a lorry comes to pick rock salt, it takes, for example, two sacks from each salt miner until the lorry is filled, so that revenue is shared equitably. The cooperative oversees other activities such as a savings scheme. Apparently Idi Amin set up a salt factory in the town in the 70s, sucking up the salt water in metal pipes, heating the water and extracting the salt. It didn’t last long – the pipes were made of metal that corroded with the exposure to salt. It’s probably a good thing. I can only imagine that the income from salt mining in those days went to line the pockets of the elite, rather that generating wealth for the local community. The remains of the factory sit on the lake shore like some out-of-place white elephant, reminding the town of the country’s complex past.

 

It is quite something to watch this gruelling work of salt-extraction. It feels like being a spectator somewhere on the border between purgatory and hell, with the heavenly peaks of the Ruwenzori mountains just emerging through the clouds on the horizon. People are lifting and carrying on an empty stomach, sack after sack of 100 kg of rock salt. Bare foot, over tiny narrow paths between the ponds. Miners sustain injuries from the slabs of rock salt and the metal poles as they work without protective gear other than gum-boots. The sulphur in the water causes skin rashes and long term damage.

 

Around the mine ponds, there is a lot of noise and banter and back-chat. Miss A and Little Roo were the sources of much fascination. Even more curiosity was evoked when they  were able to make greetings and simple statements in the local language. Are they twins? Is little Roo a boy or a girl? Our guide, Henry, was a very interesting young man. Orphaned in early childhood, he was excelling at school, working in the salt mine in all his spare hours. But he started to develop strange and medically unexplained symptoms in his final A level year, and didn’t finish is exams. His illness was eventually diagnosed as depression. He didn’t receive any explanation about it, only pills which he took once then abandoned as they made him feel so bad. He has had no counselling or talking therapy. Instead he has read on the internet and in newspapers finding things out about depression and slowly working his way back to good health. His depression was triggered by the dislocation between his ambition for his future, and the actual prospects of a future mining salt in the lake. Slowly he is emerging, working as a guide for visitors like ourselves, earning his way out of the salt-saturated future that faces so many of his community.

 

 

Batwa

I’ve had cause to reflect this week, about whether I did the right thing, and also about the challenge of looking after people whose culture and life experience is so far removed from my own.

A Batwa lady came to hospital. Her admission note described her as ‘elderly,’ though it also noted that she was 55. She was very small with an active and expressive face. She was short of breath. (for Batwa, see another entry about Kids – I’ll post this soon – the Batwa are original indigenous forest dwelling pygmy population locally – they are disposessed and even more disadvantaged than the local population.)

We made a diagnosis of pneumonia and settled her into a bed on the ward, with an oxygen mask on her face to help her breathing and a drip for her antibiotics.

By the next morning, she was lying still as a stone, curled up on the bed, hunched under a blanket. Her daughter was with her. ‘’We want to take her home’’ the daughter told us. But she had an eminently curable condition. A few days of antibiotics and a little bit of oxygen would turn things round and she would be well enough to go home. The nurses prompted the daughter to give her some bananas. ‘’Look, we just need to make sure she has enough to eat and she can get better. Let’s keep her here on the ward,’’ we said. The daughter acquiesced.

 

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By the next morning, the patient was refusing to take treatment, and refusing to speak. Her daughter was in tears. ‘’We want to take her home. She is already dead.’’ Once again, we explained that she was not at all dead, and that treatment would improve matters. Taking her home would likely result in her dying as her oxygen levels were too low to be sustainable without oxygen.

Her daughter said she would consult with her brother about what should happen. And they agreed that the patient should stay in hospital.

Meanwhile, the patient appeared to deteriorate. I arranged some tests. Nothing very abnormal.

When I came to the ward this morning, I was told that the lady had died in the night. Her daughter had been at her bedside.

What a sadness.

This was a lady of the forest, and she died with a roof over her head, away from her home.

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According to the nurses, the Batwa always want to take their family members home if they are dying. And this time, it hadn’t happened.

I felt as if I missed something important. The lady had died, had given up trying to live. Her family had seen this, and I hadn’t. Perhaps I should have listened better when they told me that she was ‘’already dead.’’

When I look at the forest, I try and imagine what It feels like to have this disorientating tangle of lush vegetation as your home, to understand its rules and know its reference points as the Batwa do (or did}. I find it almost impossible to connect with how that might be. And so, it feels as if this community lives by rules and experiences that are so far outside my own that I lack the usual reference points I use to help me think about the needs of my patients.

There is so much still to learn.

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Tour de Buhoma

For the first time in my life, I took part in an international sporting event a few weeks ago. One with Ugandan, American and British participation; the Buhoma Bike Ride.

This fantastic event was organised by Dan who runs the hospital guest house, and who is a fanatically keen mountain – biker. His children are too, and his wife Rachel has also got the bug. There are wonderful trails all around us, through the plantations, into the hills. The countryside is so beautiful, and undulating. Just asking to be explored by bike.

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A beautiful, bike-able track

And there are some nice bikes. There is a social enterprise project called the Bwindi Women’s bike project which has made bikes much more readily available locally. https://web.facebook.com/pages/category/Non-Governmental-Organization–NGO-/Bwindi-Women-Bicycle-Project-215104825711522/?_rdc=1&_rdr. The project is funded by one of the tourist lodges. The project received several container fulls of bicycles which local women have been trained to do up and to maintain. The bikes are loaned to tourists , and some are sold locally. And kids have bikes, usually too big for them, but the road near the guest house is usually fully of nine -to twelve year old boys messing about on bikes.

 

So the rule was to sign up, pay the entry fee and bring a bike and a helmet to the starting line in front of the church on Saturday afternoon. And there I found myself, not having ridden on a bike for some months, not off road for years, and not in a race, well…. for ever.

 

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The Men’s race…. at the starting line

It was wonderful. The route started at the village church and went up through the banana plantations along tiny muddy footpaths between the plots. It went through brooks and past a little valley, up to a road parallel to, and higher than the village, with a view out over the village to the hills on the opposite flank and away down the valley. A sweaty, white, unfit forty-something was the source of much hilarity as I puffed my way past. Children called out at me, and women carrying firewood on their heads moved gracefully out of the way of my clanking, wonky ride. I only came off once. Ungracefully, in a gulley in the track, with my legs in a ditch and my head in a tea bush.

And I made it around the course. Splash through the river, and over the finish line marked on the grass with red paint. Twice. I came forth out of four in the ladies race, but as they say, it was the taking part that counts, and the exhilaration and freedom of cycling in such beautiful countryside has stayed with me.

 

 

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The finishers, and the unfinished church

I now make a habit of Sunday morning rides before the heat fills the day and whilst the routes are quiet. I still prefer to fall off without an audience!

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Quality

 

Sorry if this sounds like a rather dry topic – in fact it isn’t at all. I’m writing about this because it is so interesting (to me, at least.)

 

One of the things that is unusual about this hospital is its particular focus on quality improvement – the process of looking at what you do, and seeing if it is working, reviewing it, making changes, looking again. It really is part of the institutional culture. This is quite unusual for any organisation, and strikingly so for a remote, rural health care organisation. Every department is expected to audit its activity monthly, and submit the data for collective scrutiny once a month. The hospital has an overall five year strategic plan and within this, each department has an annual work-plan.

 

Today was the day when the audits and workplan for the second quarter were reviewed. For the last few days, we have been gathering our audits together in my department (the adult in patient ward) and reviewing them as a team. Each nurse is assigned an area of work to audit ;- questions such as; Do we screen patients for HIV within 24 hours of admission? Do new patients receive an orientation when they arrive on the ward? Do we screen people for unmet contraceptive need? Is our antibiotic prescribing rational? What is the rate of post operative wound infection? and so on. In a way that I am beginning to get used to, there were an awful lot of loose ends to tie up,  and reassurances that things would all be OK, and then some last minute fixes for everything to be ready on the day. There’s been excel spread-sheeting, and graph making and data transfer in a frenzy.

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checking our data before the meeting 

Our team had a meeting with the hospital’s executive director to go through our audits and our performance. We were really rigorously scrutinised. Questions like ‘’ you said your target was about proportions, why are you giving us a percentage?’’ ‘’ Are you clear about your numerator?’’ It was a really detailed and exacting process. And it makes a difference, because the outcome was a really useful discussion of how we can build on what we do to make changes and improve services. For example, now that we screen all our patients about their contraceptive choices, what can we do to encourage people to take up long acting contraceptive methods? Another audit shows that we don’t prescribe antibiotics according to guidelines because we don’t have guidelines for certain conditions – we could write them. It is stuff like this that really can bring about change and can be really inspiring.

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The path between the hospital and home

In other news, somewhere in the day, there was a ward full of patients to review, and it was Miss A’s birthday today, so we ended the day with presents and ……chocolate cake.

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Too late for a photo of the cake… only crumbs left!

 

Happy Christmas

( I wrote this on Christmas Day, but haven’t been able to upload till now.)

So we made it to Christmas day. The last few days, maybe a week, have been tiring. I realise just how exhausted I have been, with the energy spent settling us in, learning all that is new, and working six days a week, negotiating boundaries when there is so much need, all around us. I felt a bit homesick and melancholy for a few days and it was a difficult feeling to shake off.

But today has been wonderful. Such a happy Christmas, and a perfect mixture of holding on to family tradition, and finding new ways just fitting for today. So without any deep analysis or reflection, here is an account of our lovely day.

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It turns out that Father Christmas can still reach an area that is ‘hard to reach’’ – the girls were optimistic he would manage, and relieved to find that he had made the journey by night. He delivered some lovely bags, filled with goodies and unusual treats (including a Mars bar.) It turns out that his policy these days is to locally source presents for stockings as part of his commitment to a greener environment.

We spent a lovely slow few hours giving and receiving gifts. We closed our front door (something that is almost never done here) so we had some family time and we listened to the choir of Clare College sing haunting songs. The girls got dresses, made by local tailors and books found in the fantastic bookshop in Kampala (A critique of international trade arrangements for Brian and a book about Reptiles and Amphibians for Miss A.)

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Then our neighbours told us that it was time for the children’s party at the river. Children of hospital staff were invited. It was hot, so we carried chipatis, sodas, roasted potatoes, popcorn, floor mats and an inflatable dinghy along the river to the swimming place and set up a picnic, as our little neighbour cried excitedly ‘’ We are at the beach, we are at the beach.’’ Even Miss A, usually a bit hesitant about cold water, flung herself in with much happiness, and little Roo – well, she was in splashing heaven.

 

 

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We left the party just before the heavens opened, so we scampered back along the river bank, through the tea plantation and across the wooden bridge as the rain pelted on us and made us laugh.

 

Dry and rested, we made our way to supper with our American friends, who had invited all those far from home for a Christmas evening meal. There was abundant food, and wonderful company, and even, Christmas crackers. These had been carefully made by the children with old toilet rolls wrapped in beautiful paper and ribbons, and filled with trinkets and jokes about snow and snowmen.

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A lovely end to a very happy day. I hope yours was too.