Goodbye Uganda, hello Tanzania!

Hello from Tanzania! We'd booked a direct flight from Entebbe to Kilimanjaro airport with Precision Air. Emma had warned me that her previous experience hadn't been good... We got a taxi to the airport and walked to departures to find a big crowd waiting outside and nobody allowed in. I still don't know why that was because I got slightly distracted by the departures board which didn't show any flights with Precision. Most of the flights it did show were cancelled! I left Emma with all the bags and went to find the airline offices, only to find Precision didn't have one! Eventually someone said to go to Air Uganda, who it turned out have taken over Precision's flights from Entebbe as they no longer fly that route. Not that we'd been told! Unfortunately, the bad news was that all Air Uganda's flights had been cancelled for a whole week. I begged and begged, and the staff were lovely and eventually found us two options. Both involved travelling with Kenyan Airways to Nairobi, then Nairobi to Dar es Salaam and then with Precision to Kili. The first option left in the evening and got into Kili the next morning, after our safari was meant to start. The second got in the same day but was fully booked so we had a very anxious wait to find out if anyone had cancelled. Eventually about 30 minutes before the flight we were told there was space so we ran through check-in and security! I have never known as many security gates as in Entebbe, I think I went through 5 metal detectors in total! Slightly stressful when you're running for a flight and have to take your walking boots on and off every time! Then suddenly we were on our way to Kenya!

After a very short flight on a very smart plane we arrived in Nairobi and waited in transit for our next flight. I got more and more stressed as our flight was half an hour late taking off and we only had 1 hour 5 minutes in Dar to change flighta. I spent the whole of the second flight bouncing up and down and willing the plane to fly quicker, as we really didn't want to spend a night in Dar! In the end we landed 30 minutes before our next flight. We ran through to immigration and pleaded for help. The visas took ages as they make it using the picture from your passport. We then had to queue again for passport control but a man took pity on us and waved us through! We then grabbed our bags and ran through a tiny corridor to departures which was totally empty. It was 10 minutes before our flight was meant to leave so obviously check-in had closed. We pleaded with some officials who phoned a lady who very reluctantly checked us in and then refused to give us our tickets until we gave her some money. We didn't really care at the time but are now feeling rather annoyed that we had to bribe her! We ran up the the gate to discover that, surprise surprise, they were running late and everyone was still waiting! Two men had been told to walk to the plane with our bags and we watched out the window to see if we could see them. Finally, 7 hours late, we arrived in Kili airport and were amazed and delighted to find our bags there waiting! Maybe bribery does help... So now we're in Tanzania! We stayed at an Ethiopian restaurant/guesthouse but arrived too late for food so we'll have to wait until after the safari. It was such a relief to have made it to Arusha, even if we did go a very long way round (have a look at a map to see how close Entebbe and Arusha are and how far away Dar is!) I love Africa but there are times that I'm glad that I'm European and don't have these problems every time I travel!

Entebbe and the Ssese Islands

We're on holiday! Our first stop was the town of Entebbe, near Kampala and on the banks of Lake Victoria. It used to be the capital and the airport's still there. It's joined to Kampala by a long road which is lined by a series of towns and villages so it feel like they merge into each other, but Entebbe is much smaller and quieter than Kampala, and in our opinion much nicer! When we were at the gorilla camp we got chatting to the boss who was visiting for a few days from their office in Entebbe. She said we should stay with her in Entebbe and we later found out she meant for free! It was so sweet of her and it was a lovely place to stay. In between her house and the company office there's a small annex with 2 bedrooms, a bathroom, kitchen and sitting room and we had it to ourselves the whole time. It even had a TV and games console and really comfy sofas and it felt so cosy and Western compared to our house in Kagando! The first night we stayed in the guesthouse and had a lovely meal cooked for us. We were very excited to discover BBC world and catch up on the world outside rural Uganda!

The next day was Emma's birthday. We walked into town, although every boda-boda (motorbike taxi) and matatu (minibus taxi) stopped by us asking if we wanted a lift. As usual when we are in a big town our first stop was a supermarket! We then went to the zoo, or offically the Ugandan Wildlife Education Centre. The animals there have all been rescued from poaching or other threats and they use it to educate people about the threats to wildlife in Uganda. It was really interesting and we saw lots of things that are hard to see in the wild like a leopard, white rhinos and chimpanzees. The chimpanzees were in a huge enclosure and we spent ages watching them climbing trees, play-fighting and swinging on the ropes. We met up with a friend from Liverpool, Jemma, who's been working on the paeds ward in Kagando's sister hospital further South. It was really fun to see her and exchange stories. I was a bit jealous as they had interns (first year doctors) and 2 consultants on paeds there and more resources. After the zoo the 3 of us went out for a birthday meal, its so nice to have a variety of food!

The next day was really hot so we met up with Jemma again and went to a posh hotel to spend the day by their pool. The pool was massive and had a 10 metre diving board. We spent a very lazy day reading books, swimming and sunbathing which was lovely. There were lots of tourists there, it's strange to see so many muzungus!

The next day we packed up and got the ferry to the Ssese Islands, which are in the North-West of Lake Victoria. The ferry took 3 hours. We splashed out on 'first class' (for £6 instead of £4) and were glad we did as it meant we had enough space to lie down on the sofas as the journey was very rough and we both felt very sea-sick! The Ssese islands used to be a popular tourist destination but the ferry stopped for a while and so people stopped going. Our hotel definitely felt rather derelict and past its hay-day! We'd paid for half-board which we later regretted as there was only one veggie option for Emma and the food wasn't great. The people were friendly though and the hotel was right on the beach with amazing views of the lake and other islands. The water level is much higher than it used to be and there was a jetty and a parasol about 20 metres out which used to be on the beach! At first we felt a bit deflated but it was nice to relax and have time to catch up on blogs and read. We stayed there 3 nights and then got the boat back. It was much less windy and a much nicer, less rough journey.

We had one more night back in our lovely accommodation in Entebbe before leaving Uganda. We had a fun day doing some shopping and eating nice food again! Our host Lydia, had had a baby in our absence which is exciting but she didn't manage to be discharged from hospital before we left so we left her a present in the house. Next stop Tanzania!

Lake bunyonyi

I've realised I haven't written about a trip we took ages ago, in May, to a place called Lake Bunyonyi. It's about a 6 hour drive from Kagando, quite near the border with Rwanda and the gorillas. There were 9 of us in total as 5 new medical student had arrived that week and Jess and Becky were still there. We left after ward round on the Friday and had a long and bumpy drive down on the nursing school minibus which we'd hired. The scenery was amazing though and we spent most of the journey gazing out the window. FIrst we went through Queen Elizabeth National Park, which is flat savannah. We then climbed up into some hills which were really green and lush, with lots of different plants growing. It was fun to see all the food we eat growing. Then we passed lots of tea plantations. Most of the road was paved but there was a stretch for about an hour which was really bumpy and dusty. Lake Bunyonyi is about 20 kilometres from Kabale but between them is a massive hill which the minibus struggled up and we saw lots of vehicles being pushed! We then went back down again with amazing views of the lake. It's said to be the most beautiful lake in Uganda and we were told that after you've seen it you realised God must exist. I'm still not sold but it was incredibly beautiful!

We were staying on an island so we got canoes there. It was pretty hard going against the wind and our group (3 girls and a guide) had only 2 pairs of oars so we were very slow. On the plus side we got to rest a lot whilst the others had to row the whole way! We passed lots of islands and eventually got to ours. We stayed in a place called Byoona Amagara which is an Eco Lodge. We stayed in their geodomes which were huts with open fronts with amazing views of the lake. The showers were heated by solar power and had amazing views too but the loos were compost toilets and less pleasant! They don't have a generator so all the power comes from solar panels. The lake it quite high (over 2000 metres) and it got pretty cold in the evenings.

I stayed in a room with Jess and Emma which was fun. It was nice to have a big group and lots of different people to talk to. On the Saturday we went on a guided walk on the mainland. It was a really steep climb up but then we were rewarded with gorgeous views of the lake. Our guide told us stories about the islands. There's one tiny one which used to be used as a prison for girls who became pregnant out of wedlock. They were sent there with no food and it was too far to swim. Their only hope was to be rescued by a man who was too poor to afford to pay for a wife! Luckily that doesn't happen any more! When we got back we went for a swim in the lake. It's one of the only places in Uganda with no hippos or crocodiles and (probably) no schistosomiasis (bilharzia) so it's safe to swim. That evening we had a late meal (as the food arrives about 3 hours after you order it) and then the staff all came out and started dancing so we all joined in. It was very spontaneous and great fun.

We swam again the next day before opting for the lazy option and getting a motorized canoe back before our long journey home. It was a great weekend through and probably one of my favourite places in Uganda.

Malnutrition

One of the saddest conditions we see here is malnutrition and this year has apparently been unusually bad. There are two types of malnutrition, oedematous and non-oedematous (also known as Kwashiorkor and Marasmus). Nobody really knows why some children develop one and some the other, but the oedema seems to be due to protein-deficiency. It causes the children's feet, abdomens and sometimes faces to swell and they also develop skin changes, curly, light hair and they become sullen and apathetic. The other type is due to lack of calories full-stop, and they are usually lighter (less than 60% of the expected weight for their height). Both groups of children are at risk of serious infections and because of the malnutrition they don't always have fevers, raised white cell counts or positive malaria tests, so we treat them empirically with the strongest antibiotics and with antimalarials. Then are started on milk called F-75 which is then changed to F-100 when the swelling is gone and they are more lively and seem hungry. Sometimes they respond really fast, one day they'll be lying still looking miserable, the next day you might get a smile and the next day they're playing! The tiny babies seem to take longer to respond. Once they've put on weight and are doing well they are started on a peanut-based food called RUTF which they go home on. This and the F-75 and F-100 are free. The F-75 and F-100 are made from milk from the hospital's farm (which I didn't know existed until two Brits came over to work on it a couple of weeks ago). The remaining milk is used to make tea for the staff! Water, oil and sugar are added to the milk using a recipe from the WHO. The hospital are trying to get ready-made sachets of the milks though because these contain other things like vitamins and minerals which they can't get separately. If anyone knows how they can get the ready-made milk please let me know!

Malnutrition affects many of the children we see to some extent, and malaria and other serious illnesses can trigger it, so it becomes a vicious cycle. The other children who are at high risk are those with HIV. On the last ja-ja day I was talking to the nurse who organises it, Laheri. She was getting worried about a couple of the children because they were looking sad and not playing. This withdrawal is often a sign of malnutrition and she says that's how they often lose the children. Many of them are looked after by grandparents who struggle to find food for all their grandchildren. During each ja-ja day they have 2 meals- firstly porridge and then a lunch which they call 'balanced-diet food' as it contains matoke (a type of green banana, mashed), rice, beans, meat and cabbage. I've never seen plates piled so high and even the smallest children ate about 3 times as much as I could and took the left-overs home for later. For most of them it's a once a month treat as they can't afford to eat that well normally. Ja-ja day ran out of money last year and they had to stop for 6 months and apparently quite a few children died of malnutrition during that time. It's tragic that children with HIV are on free treatment and so don't die of AIDS but instead of hunger.

The crazy thing is that Uganda is really lush, green and fertile. It rains a lot and they can grow so many crops. The farmers I mentioned above have said that the farming here could easily be productive enough to feed the population and stop malnutrition but so far it's hasn't worked. I don't know enough about farming or economics to comment but there definitely seems to be lots of food around, it just doesn't get to the people who need it.

Neonates

I promised ages ago to write about the neonatal ward and never did, so here goes. The ward is next to the main paeds ward and has two sections- the main room with cots, a resuscitaire (used in the UK to resuscitate babies but here as another incubator) and a few incubators, of which only one works. There's also a bed so one Mum can be there with her baby. The other room has 7 beds and is used for the stable babies on antibiotics to be with their Mums and also the preterm babies receiving Kangaroo care. The number of babies varies from about 3 to about 25, but there are usually 10-15. The unit looks after babies from birth to 1 month of age. Most come in straight from maternity or from the community on day 1 or 2 of life. Some have fevers or other signs of sepsis and are treated on a cocktail of antibiotics for 5-10 days. These babies usually do well. Another set of babies are suffering from birth asphyxia (basically lack of oxygen either because of a problem during the pregnancy, during labour or straight after labour). This is a lot more common here than back home, mostly I think because most births are in the community and problems aren't recognised until very late. Giving birth in hospital is expensive. The caesarian rate here is really high because only the most complicated cases come. These babies are often quite unwell and can have lots of seizures. Sometimes they respond well and recover quickly but others don't and you can tell from quite early on that they are likely to develop cerebral palsy or other long-term problems. It's really sad because if they survive they are much more likely to end up malnourished when they are older and are less likely to survive to adulthood.

There are also lots of premature babies. We don't usually know exactly how premature they are because most women aren't sure when they are due but some are very small. When they are first born they are put in the incubators if available and given oxygen and intravenous fluids. We use aminophylline to help prevent apnoeas (stopping breathing suddenly due to the immaturity of the brain). In the UK we use caffeine which is apparently a metabolite of aminophylline. They also all have antibiotics. Once their breathing settles they are started on feeds of expressed breast milk given via a naso-gastric tube. At this point they can usually start Kangaroo care. This is a great system that was started in Colombia and involves postioning the naked baby next to its Mum's bare chest and then wrapping them both in lots of layers. It's basically using the Mum as an incubator and is used a lot now in low-resource settings. The babies are discharged home once they have reached 1.5kg and continue Kangaroo at home. At this stage they are still too small and immature to breast-feed so the Mums continue nasogastric feeding or give them expressed milk using a spoon.

There are also a few babies with other problems, such as congenital problems or babies who came in from the community. One baby I saw had been burnt really badly because her older siblings had been playing with a candle near her. In the UK, a story like that would trigger at least a discussion with social services but here there's no child protection set-up. Another baby that stands out was a tiny little thing who was brought in at 2 weeks because she hadn't been feeding or crying. It was immediately obvious that she was very premature which was probably why she couldn't feed. She'd been born in a rural village and been taken to a traditional healer. She was extremely malnourished and really unwell. It broke my heart because she'd probably have done ok if she'd been brought in a birth but as it was we never managed to get her any stronger and she died after a couple of weeks. There are so many factors involved and it's stories like that that make you realised the importance of education, community health programmes and working with traditional healers to teach them how to recognise their limitations and when to refer to a hospital.

In my second week here I was by myself (except for a very helpful and very good medical student) and I was petrified at the idea of having to do the neonatal ward round. The ward was really busy and lots of the babies were very sick. I was right to be worried, and I almost left at the end of the week! There was a pair of twins, one of whom was very poorly but there was nothing else to do for her. She was on antibiotics and fluids and although she was jaundiced the only treatment for that here is sunbathing (!) and she wasn't stable enough for that. I worried about her all night and the next day saw her first on the ward round. I was just about to examine her when I realised she wasn't breathing. Luckily Emma was there and Jess, the student and together we started to resuscitate her. I'd never been at a full-blown neonatal resuscitation before and was very grateful I'd done the course as otherwise I'd have been totally overwhelmed. Even then though it was pretty stressful. We tried everything but never got a heart rate so after 25 minutes I decided we should stop. I spoke to the Dad (one of very few people in Kagando who spoke good English) and explained what had happened. It was awful, but it got worse because I suddenly realised the nurse had restarted resuscitating her, saying she thought she had a heartbeat. The Dad looked hopeful for a bit but we went over and listened and there wasn't one so I put my foot down and said we had to stop. I think the nurse was quite inexperienced but so am I and the whole situation was so awful. Thankfully the other twin did really well and the parents were so sweet and so in love with her! I really didn't want to go back the next day but I had to, because there was nobody else. A couple of days later we had another resuscitation of a very premature baby who'd come in after being born at home. Her twin had already died. Unfortunately the outcome was the same, but the nurses were much more helpful and supportive and it helped so much. I don't really feel ready to be making decisions about stopping resuscitation but here even the nurses sometimes have to, as there are so few doctors. Luckily it will be years before I'm in a similar position at home.

There are lots of neonatal deaths here, and I imagine we are only seeing the tip of the iceberg as many probably don't make it to hospital. It's really sad but it's also sad to see the ones who survive but you know will have developmental and health problems long term. On the other hand most get better and it's lovely when you see the premature babies coming back for review and they've put on loads of weight and are doing well. The 'kangaroo' room is also always really sociable and happy as all the women chat and help each other. If a mother's too ill to care for her baby or if she dies in labour everyone else works together to help and the babies are usually looked after by relatives or neighbours. Ugandans are such warm friendly people, almost always smiling!

Soon I'll be working in a big tertiary Neonatal Intensive Care Unit in the UK. It will be interesting to compare it to Kagando's NICU!

The last week

I wanted to write a bit about my last week in Kagando as I think it sums up a lot of aspects of hospital life. They've employed a new medical officer on paeds and it was his first week. A medical officer is similar to an SHO in the UK. When Ugandan doctors leave medical school they become an intern for one year, during which they rotate around medicine, surgery, paeds and obs and gynae. They then work as a medical officer for a few years after which they can do a masters to become a specialist. It's crazy though because they're not paid during their masters so they have to study fulltime and work in the evenings to earn money. Unless they are very well-off they also need to find a sponsor to pay their tuition fees. The masters take about 3 years and then they can work as a specialist. The new medical officer has just finised his intern year so is quite inexperienced. However he's expected to do ward-rounds by himself and learn on the job. I tried to teach him as much as I could before I left and I think he'll do well but it's definitely a lot of responsibility. I can't wait to be back in a team of doctors and have lots of people with more experience to ask for help!

It was a frustrating week as the machine to do CBCs (full blood counts, including a haemoglobin, white cell count and platelet count) was broken and, for 2 days, so was the other machine that only does haemoglobins. As so many of our patients are anaemic this meant we couldn't quantify the degree of anaemia so we had to just decide clinically whether to give them blood transfusions and how many. Some of the sickest children need lots of transfusions as the malaria breaks down their red blood cells. Luckily the blood here is all screened for diseases like HIV and hepatitis so it's relatively safe but we quite often ran out of some blood groups. We also couldn't test blood glucose as they'd run out of the test strips. This was difficult because we had 3 unconcious children who were having seizures. Low blood sugar levels can be the cause of seizures and they can also be the result of being very unwell and not having any nutrition other than intravenous fluids. I therefore decided to give a couple of the children intravenous glucose empirically just to be safe.

Two children died one night and both had been in for a couple of days on treatment so it was really upsetting and frustrating that we hadn't managed to save them. We don't even know what was wrong with them because we couldn't do many tests, but neither had clear-cut malaria. They both deteriorated during the night and the nurses resuscitated them without any doctors there so we couldn't even get a clear picture of what happened. Normally the children who die do so in the first few hours in hospital before the treatment's had time to work. It still seems crazy to me that a child can die without a doctor being called and without knowing what the cause was. In the UK it's such a rare event now that there's an investigation into every child death and it's just so sad to think that here and in so many places it happens so often. 

One of the biggest challenges here has been working with the staff and trying to get the right balance between being assertive but also not feeling like the Western doctor coming in and telling them what to do. I have met some amazing and very dedicated nurses who have taught me so much and made my job so much easier and more fun. Unfortunately there were also some who were less good and I can't remember how many times I stamped my foot because none of the children had had any observations done! In the UK every patient has a heart rate, respiratory rate, oxygen saturations and temperature at least twice a day and sometimes up to every 30 minutes or hour if they need it. If anything changes they call the doctor on-call. We'd be lucky to get one temperature measured a day, even on the children in high-care. I tried everything I could think of to persuade them to do more observations but it never seemed to make any difference. There was a particular low point when I'd been away for a weekend and on the ward round on Monday noticed that hardly any children had had their medications over the weekend. Often this means the parents had taken their children outside so weren't there during the drug rounds but this time it included some of the really ill children who couldn't have gone outside. You realise how well the drugs work when you see how ill the children are without them! Luckily none had died but it meant lots of children had to stay in longer which increased the cost for their parents. I've never been so cross at work but the senior nurses (who don't work weekends) were great and got really cross too. The next day things weren't much better but the following day they'd really improved and they never got so bad again. I think the senior nurses threatened to take the money it would cost the patients to stay longer out of the pay of the nurses who'd been at work!

It feels strange to have left Kagando. By the end I was starting to feel quite confident with most things I was doing, although I still much preferred the days when my consultant was there than when I was alone and had nobody to ask for advice. I've looked after lots of very sick children and almost all of them have got better which is great. I've done ward rounds of sometimes 60-70 children and neonates and had to decide what treatment they need and way up the benefits of investigations and treatments against the cost to the families. It's hard not knowing what you are treating always or if you are doing the right thing but I think my clinical skills and decision making have improved massively. I do feel that I've helped and made some difference but with that comes a feeling of guilt for having left, especially as we're now having a holiday before we go back. However it's been hard work and emotionally draining and we both feel we need a break. I'm really excited about working in a lovely NHS hospital again with lots of nurses and doctors and never needing to worry about running out of drugs or not being able to do the investigations the patient needs. I hope to come back though, with a bit more experience under my belt!

Our little house

I wrote this blog about 2 weeks ago but my (usually very good and user-friendly) blogger app had a bit of a strop and it’s stuck in the process of publishing it, so I’ve had to re-write it. Now I back everything up before I press ‘publish’!

I feel it’s about time I described where we live a bit better. We are staying in a big compound across the road from the hospital. The compound is massive and we’ve only seen a tiny bit of it. It houses the nursing school and their accommodation and also most of the staff of the hospital and their families. It’s on a hill so the walk to work is downhill all the way but it’s a very steep trudge back home! The compound has locked gates with a security guard. Apparently there’s a curfew in this part of the country of 10 o’clock and I met a student who’d got back from playing badminton too late and spent the night in a police cell! It’s strange because we’re basically in the middle of nowhere apart from one village so it doesn’t feel very dangerous but I guess it’s nice to know we’re safe.

They gave us a choice of living in the doctor’s guesthouse or a house. It’s so nice to have a house. It’s basically a bungalow in a little garden just off the main path through the compound. Rita’s house is next door. There’s a concrete area between the 2 houses and the side doors come off this so there’s about 2 metres between our door and Rita’s. The main door is round the front with a covered porch. The garden has a few plants, a hedge, a lawn and a big coconut tree, as well as a washing line. We used to have 2 but random people have been chopping down one of our trees for wood and they broke one. We don’t really sit outside much because the lawn is on a steep slope and there are lots of things that bite in the grass!

The main room at the front has a sofa, 2 armchairs and a rocking chair and some pretty hangings on the walls. We spend almost all our time in here, reading books, sewing, writing blogs etc. I don’t think either of us have read so many books in such a short time before, I must be on over 30! Off the sitting room is a dining area and then off this to the right is the kitchen. We have a fridge-freezer, 2 hobs, a sink and a big dresser. The kitchen’s very well-equipped thanks to the many people who have lived here over the years. The bathroom’s small. We’re meant to have hot water but it’s broken and it’s hard enough to get the engineers to sort out the big problems so we’ve decided it’s not a battle worth fighting! In a country where lots of people walk for miles to collect water, our running water is enough of a luxury. After a big rainstorm the water sometimes turns a nasty brown colour because it picks up mud. It’s ok to shower in but slightly disconcerting for washing clothes or when we boil it for drinking water! Emma’s bedroom is off the same corridor and mine is off the sitting room. I have a queen-size bed which is nice but the mattress is broken down the middle so I have to sleep diagonally. My room has a washing line too so we can dry our clothes there when it rains. I often have puddles on the concrete floor afterwards and you can see which way it slopes!

The ‘rubbish bin’ is a hole in the ground just up the path from our garden. Apparently they burn the rubbish when it gets full but it never seems to get any fuller because the birds and animals get in and spread the rubbish around. It definitely doesn’t feel like the tidiest or most hygienic solution but I guess it’s hard without rubbish collectors. People burn stuff a lot here on bonfires. They always smell awful and we can’t close our windows so the smoke sometimes gets in  the house.

Our electricity comes from a company in Kasese and we have a card which we have to top up in town and then we put into a little box outside our house to get more power. It’s usually pretty cheap but we’ve had a problem with ours and it uses way more than normal (like 5 times more). We think it’s either the fridge or a loose connection but the electricians came and didn’t get anywhere. It’s still only about £5 a week but it does mean we have to plan ahead so we don’t run out! We have a lot of power-cuts here, at the moment there seems to be about one a day. There’s a generator we can use when the power goes off. We turn a handle in our house and then wait until the generator has been started. It runs on oil and apparently once during an operation there was a power-cut and they were out of oil so they had to send someone to buy some whilst keeping the patient breathing manually without the usual machines! Sometimes it takes a while for the generator to be turned on so candles and head-torches come in useful. Because of our electricity problems though we quite like being on the generator because it’s free. We also have a special box which we use to charge tablets and laptops so they don’t get fried by the power surge when the electricity comes back on!

As I mentioned before, most of our cooking is done on gas and a few weeks ago we ran out and had a tough couple of days before we got more. All these things make you realise how easy life is back home, although we’re very aware that our lives here are much easier than most people’s in Africa. Our house definitely has its quirks though. The other day after a power-cut, the power came on but not enough for any of the lights except the bathroom light. Now they’re all working again but the bathroom light has stopped working, so we have to shower by the light of a head-torch!

We’ve had various house-guests/pets whilst we’ve been here. We always have a few geckoes, 3 of whom we named Tom, Dick and Harry but we’ve forgotten which ones they were! For a while we had a praying mantus who lived on our door called Rupert but he’s long gone. One night when I was ill Emma woke me up asking for help because she’d seen the biggest spider. It was literally the size of our fists and was very hairy. We’d heard strange noises earlier in the evening and I’d searched my room before I went to bed thinking it was coming from there. I definitely think an added bonus of a mosquito net is to keep out other bigger wildlife too! Emma tried to pick the spider up using a cup but it reared up at her so she swept it out with the broom. We’ve also had to sweep out frogs, cockroaches, loads of beetles and worms and other creepy-crawlies we can’t identify! The most dangerous animal in Africa is definitely the mosquito and all our windows are covered in netting so most of the time they don’t get into the house. Lots of people keep chickens and goats in the compound and there are quite a few cats that wander around and fight at night. In the evening the crickets all come out and make a racket so all in all it can get quite noisy! The other day there was a swarm of grasshoppers that arrived in a rather biblical fashion overnight and the next day all the Ugandans were frying and eating them. Apparently they’re a delicacy and normally quite expensive but I chickened out of trying one.

We’ve been very lucky to have had such a nice place to live and I’ll definitely miss it. However I don’t think I could live in a compound like this for a long time and daily life is definitely easier (and quieter) in the UK.

How to save a life

The hospital here is a missionary hospital and money is in short supply. When we arrived they said they were so grateful to have us because they'd run out of money and they couldn't afford to pay a new doctor until the new financial year, which starts at the beginning of July. The hospital doesn't have a lot of the basic equipment that we take for granted in the UK. For example, we only have 2 oxygen machine on the paeds ward, whilst neonates has 3. I'm very excited because at my Mum's work they have been raising money for the hospital whilst I've been here, and that plus the money I have saved should be enough for a new oxygen machine. It's so nice to be able to tell the doctors and nurses that we'll be able to buy them something so essential and I wanted to write a bit to explain what benefit it will have.

Anyone who has done basic first aid will remember the acronym ABC for how to care for a patient in an emergency. The same applies in hospital. A stands for airway and you decide whether the patient can maintain their own airway or needs help. In the UK, this means an anaesthetist gets called and any patient who cannot keep their airway open is sedated and a tube is placed into their windpipe so that their breathing can be controlled by a machine in the Intensive Care Unit (called being intubated and ventilated). All patients who are unconscious or semi-conscious come into this category. Here, we regularly have children who this applies to, but there are no intensive care facilities and only one patient in the whole hospital can be intubated at a time, as there is only one ventilator, so it is usually reserved for the operating theatre. This means that we basically skip A and move onto B, which stands for breathing.

To assess breathing you need to count the respiratory rate, look at, feel and listen to the chest and measure the oxygen saturations. This is done by using a pulse oximeter, a hand-held machine that clips onto a finger or toe and tells you the saturation of oxygen in the patient's blood and their heartrate. It's actually amazing technology but it's also something we take for granted in the UK. Here, they have a monitor in neonates but not on the paeds ward, and it's almost unheard of for a child to have their saturations checked unless we explicitly ask a nurse to go to the neonatal ward and get the machine and check the sats whilst we are with the patient.

The main treatment for breathing problems is, of course, oxygen. As I have said, we have 2 oxygen machines on the main paeds ward. Ideally, any child with low saturations should be on oxygen, as should any child who is unconscious or very unwell. Unfortunately there are often way too many children who need oxygen and if the neonatal machines are all being used only 2 children can have it (they have them on the adult wards but there are never enough there for all their patients either). I've had to decide which of two unconscious children with severe malaria to leave without oxygen when another needs it more. Since I've been here we've had about 10 children die (excluding neonates). I'm not sure if any would have survived with oxygen but it's not inconceivable. Furthermore, the children take longer to recover without oxygen and we have had a number of older children become very confused and agitated for a long while after recovering from a severe illness, be it cerebral malaria, meningitis or encephalitis, and I imagine that these children might have done better with oxygen therapy. It's frustrating and upsetting as in the Uk we  have oxygen supplies by almost every bedspace and all patients have their saturation levels recorded regularly so they can be started on oxygen as soon as it's needed.

The machines they use here are concentrators, so are able to create air with added oxygen. This is really useful as it means they can be used time after time and not have to be re-filled like the canisters back home do. Therefore, one oxygen machine can be used for a long time. My aim is to collect enough money to buy an oxygen machine, one or two sats machines and some resuscitation bags and masks. These are used for patient's who aren't breathing and basically involve a mask that goes over the nose and mouth and a bag that attaches to the mask which you squeeze to force air into the lungs. There's an attachment for oxygen. As I mentioned in a previous blog, we had a horrible resuscitation attempt when nobody could find a mask that fitted and so I had to start giving mouth to mouth before we got one. Even then it barely fitted and 2 of us had to hold it still onto his face. Resuscitating a child is  awful enough without these problems. I tried to order some here but it's proved very complicated so I'm going to buy some and send them over.

I'm sorry this hasn't been the cheeriest blog but I wanted to write it to says thanks and explain where the money's going and I guess  to say to anyone else that if you have any spare money you want to give I'd be very grateful. I'm going to collect it and donate it to the UK charity Friends of Kagando because that way we can get gift aid. I'm liasing with the staff here to make sure the money goes to the right place. I promise it will help enormously, and I hope it might save some children's lives.

Rain, rain go away.

As they say, you can take the girl out of Britain, but you can't take Britain out of the girl, so I'm going to write about the weather! Most of the tropical countries I've been to have had similar weather most days but here it's almost as unpredictable as back home.

Traditionally, there are two wet seasons a year and 2 dry seasons. One wet season is from March until the end of May. True to form, it's rained a lot since we've been here and everything is pretty lush and green. Apparently though in recent years the seasons have been less clear-cut and this year has been particularly strange. December is always dry and sunny but this year it rained quite a lot we've been told. Meanwhile, during the last few weeks everyone was warning us that come June it would be sweltering and very dry. The first week of June it was hot but since then we've barely seen the sun. It's slightly worrying and you can't help wondering if global warming is to blame. I guess we'll see...

When it rains here you know about it! We also get loads of storms. They can be really impressive, with massive sheet-lightening over the mountains. The weather changes quickly too. Often we'll be sitting in our house and it will be sunny outside and then suddenly the wind picks up and within a few minutes the sky's dark and there's a tropical storm. I think the weather here is particularly dramatic because we're so near the Rwenzori mountains, which are very high and on the other side of them, in the DRC, is a massive rainforest. To be honest though, whilst we're working it's nice to have cool weather as it gets ridiculously hot down in the hospital when it's sunny. Fingers crossed for sun when we're on the beach though!

Food, glorious food

Having just finished the best meal we've had yet in Kagando, I figured it was about time I wrote about our food here. We had the option of eating in the guesthouse or having a cook but we decided not to, not least because the 2 main vegetarian meals they cook are beans and rice (and Emma hates beans) and omelette (and I hate omelette!). Most of our shopping is done in the local village which is about a 5 minute walk away. In the village there are loads of stalls, almost all selling the same things. We still have no idea how it works when 10 people in a row are all selling tomatoes but they seem happy enough and they man each others stalls when needed and give each other change. The main vegetables are tomatoes, avocadoes, aubergines and potatoes and often green peppers and cabbages. One day there were carrots which was very exciting but they haven't reappeared! At first, the only fruit available were pineapples, passionfruit, lemons and bananas of varying sizes but since we've been here the mango season has started to our great delight (although the first ones were tiny and were almost all stone!). Oh and watermelons are appearing too. The food is very cheap- about 5p for an avacado twice the size of one at home. I think the people in the village know us now but they still seem to find us hilarious! There's also an `African and English supermarket' or as we call in the `muzungo shop' as we are the only people who seems to use it! It's much more expensive and sells store cupboard ingredients like tomato puree, jam, pasta, rice and milk, juice and eggs. They used to have porridge oats (all out of date) but we bought them all and I don't think things get replaced very often...

We have now been to Kasese, the big town 45 minutes away, 3 times to do a big shop in the supermarket there (actually the size of a corner-shop). They sell the most exciting thing of all- cheese! It's a big round gouda cheese that costs about 6 pounds and would taste pretty bland in the UK but here is's made so much difference to our meals! They also have heinz ketchup and kidney beans, low-fat milk and other delights.

For breakfast we either have toast or porridge, depending on when we wake up and whether we can find oats. The bread here is white and very sweet. It's really not very nice! They produce lots of honey here so that's easy to get and we've found jam and peanut butter. Toast has got much better though since my lovely Mum sent us a parcel containing mini, hotel style, sachets of marmite, nutella, jam and honey. Equally excitingly, we also managed to buy some 'salty' (i.e. normal, not sweet) brown bread on the way home from Rwanda. We're having to ration our second loaf though! At weekends when we're here we sometimes cook pancakes. Lunch is usually bread-related and has got much better since we bought cheese. Our ktichen is amazingly well-equipped and even has a toastie-maker!

We're quite proud of our reportoire of evening meals using the basic ingredients. We started with pasta with tomato and aubergine sauce. Everything takes a long time to prepare as we peel all the vegetables, including the tomatoes before we cook. It is fun thought to know that every meal is made from scratch and the ingredients are definitely local and in season! Once we found curry powder we started making the same sauce but with rice and calling it curry. The cabbage inspired bubble and squeak which we usualy have with guacamole and fried eggs. We've also mastered chips and have eggs, chips and guacamole or, most excitingly of all, bean burgers and chips. We cook on 2 gas hobs. They are adjustable but only really from hot to very hot so when we cook rice we have to keep turning the gas on and off to keep it at a simmer! Just before we went away for a week our gas ran out. Luckily we'd just finished cooking but we had to wait a couple of days until someone was going to Kasese and was able to take our gas canister and fill it up at the petrol station. We managed to cook pasta salad by soaking the pasta in boiled water for a while and then adding cold vegetables, but we left it rather too long so it was a bit of a soppy mess, not our best meal!

About halfway through our time here we found an oven which is basically a small glass bowel with a lid that has a fan in it, so it becomes a fan oven. We've now made 3 cakes, pizzas, oven-chips and today we made bread rolls. We started making the dough using some brown bread flour but I realised that the wholegrain seeds I'd seen were moving and were actually weevils! So we tried again using normal white flour and they worked perfectly. We've just eaten an amazing meal of kidney bean burgers in rolls, oven-cooked chips, guacamole and left-over curry as a relish. Only the tomato ketchup wasn't homemade.

We're feeling pretty spoilt now thanks to the parcels from mum as we have a house full of real English chocolate, tea-bags, sweet, cereal bars etc. African chocolate is made to not melt in the hot weather, but it therefore doesn't melt in your mouth either!

For drinking we mostly boil water and then filter it through my scarf! We sometimes have passionfruit squash and for a treat we buy sodas from the hospital squash. They have coke, fanta, bitter lemon or stoneys (ginger beer). They come in glass bottles and you are exepcted to take the bottles back as the shops have to give them back or they get fined. They are the re-used which seems like a much more sensible idea that recycling the glass. Alcohol is banned at the compound, but we really haven't missed it and it makes being away more of a treat if we can have a cocktail or glass of wine. Another one of our luxury buys (at about 3 pounds for a big jar) is Cadbury's hot chocolate powder, simple pleasures!

I think our time here has made us both better cooks and it's been fun but I think we are both still dreaming of supermarkets full or every food you can imagine, and bakeries full of salty bread!

Kigali

Hello from Kigali, the capital of Rwanda. We had a very comfortable bus journey listening to French music and with amazing views of mountains and valleys. The buses here leave on time, on the dot, even if they aren't full. In contrast, in Uganda they wait until they can't squeeze any more people on! Kigali is also very hilly but luckily we are staying right near the centre, in a lovely place called Heaven Inn. It's run by an American couple who have trained lots of Rwandan people and set up a restaurant with 3 rooms. The night we arrived they were also having an art exhibition and so the building is full of very nice (but very expensive) art! It's very classy and a world away from our little village in rural Uganda! The first night we ate in the restaurant. It was really busy because of the art show and full of ex-pats. There are no tourists in our part of Uganda, only people working in the hospital so it's been strange to see so many "muzungu" (white people). 

The next day we had a lazy morning and then went to the Genocide Memorial Centre. As you can imagine this was probably the most harrowing thing I'd ever been to. It was very well done and felt just like a museum back home. The main exhibition was on the Rwandan genocide and then they had one on other genocides across the world and a final tragic room with photos and information about some of the children who had died. Outside there were mass graves for lots of the victims. The genocide started on 6/4/94 and lasted for 100 days, which is almost exactly the same dates as our trip, but 20 years ago. I can't pretend to understand enough about it to say anything very intelligent but as you can imagine we left the memorial feeling thoroughly depressed about the human race and how people can be so terrible to each other and never seem to learn. Each of the stories, be they in Africa, Europe or Asia were just the same. On the other hand, seeing Rwanda today it's hard to imagine that it ever happened and it's really encouraging to see how well the country is doing and all the work that is going on at the memorial centre to educate people and try to prevent anything similar happening again.

In the evening we met up with a friend of mine from Canada called Jon. I last saw him years ago but thanks to facebook we managed to work out we were in the same country. He's been living here for 2 years and works as a psychotherapist with genocide survivors. It's very impressive work and he's been trying to teach Rwandans to help others. People both here and in Uganda (and most of Africa I think) are very reluctant to admit to psychological problems and it was interesting hearing how he's managed to get people involved. It was also fun to have an insider's perspective on the country and compare it to our view of Uganda. There's something very fun about seeing people you met in one country on the opposite side of the world and comparing stories!

Today we wandered around town and explored the craft markets and hung out in the mall. They have a very Western supermarket full of everything an expat might be craving for ridiculous amounts of money- i.e. marmite for £10, ultra-posh "superfood" juices and, best of all, Dorset cereals- from a factory 5 minutes away from my flat last year! We didn't buy any of it though. We then went to the Hotel Mille Collines for tea. It's the hotel that Hotel Rwanda was about. It's got a massive swimming pool and apparently the people who hid there drank the water from the pool to stay alive. Sitting there watching all the rich people swanning about it really didn't feel like Africa. The place where we're staying is in a very posh part of the city with lots of embassies and all the houses are gated with guards and barbed wire. It must be strange living in that sort of world.

This evening we're ate in the inn again. There was a band playing which was fun and once again it was very busy and full of ex-pats! Tomorrow we have an early start and a long bus journey back to to Kagando and back to work. It's going to be a culture-shock again and we'll miss hot showers, coffee, varied food and all the other luxuries!

Into Rwanda

After leaving the gorilla camp we headed to Rwanda! We decided to take a week's holiday and it's come just at the right time- after my malaria and Emma's stressful last week where she was the only person covering surgery, plus having to look after me! We got a lift from the camp to the border and the lovely driver helped us with the immigration. British people don't need a visa to go to Rwanda which is nice, I think it's because they've just joined the commonwealth so are feeling friendly towards us! It always seems strange how informal land border crossings are and how quick it is to change country. On the other side we got a minibus to the first town, Musanze. I hate mini-buses and we've so far avoided them on this trip (and plan to not get any more!). They are small and cramped and go so fast. I was too tall to sit upright so my back was killing by the end. Luckily it only took an hour and then in Musanze we changed onto a bus which was much bigger and felt much safer! Rwanda is very hilly and very pretty. It's more arid than Uganda but also seems very fertile. Rwanda seems richer that Uganda too. Most of the houses seem properly built rather than made from mud and straw and the country is really clean. Plastic bags are even banned and you can get fined for bringing them into the country (although nobody checked!). On the way we passed a concentration camp (and we'd seen one in Uganda too), presumably for refugees from the DRC but they both looked pretty empty. Our first stop was a place called Gisenyi on the banks of Lake Kivu, a lake bordering Rwanda and the DRC. We stayed on a peninsula 7 km out of town. It was absolutely beautiful. The hotel was right on the water's edge and we could hear waves lapping from our beds. We barely left the hotel and spent 3 days reading, catching up with the news on the internet and eating different food from the 5 meals we cook at home in Kagando. I finally feel normal again and almost back to full strength! Every evening we'd see the fishing boats heading out for the night. They would row in groups of 3 with long poles sticking out and you could hear the men singing. I spent ages trying to get a good photo but I think I failed! From the beach we could hear music from the local village. Sometimes it was gospel music from the church, sometimes traditional local songs and sometimes Western pop music- a strange combination. Everywhere you go in this part of the world people are singing or dancing and there's music playing.

Across the lake you could see the mountains of the DRC, it looks so peaceful and it's so sad to think of the constant fighting and problems there. Meanwhile, Rwanda is now one of the safest countries in Africa and certainly feels very unthreatening.

It's been nice to speak a bit of French too. Interestingly, however, the Rwandan government is trying to change the country over to speak English instead. A few years ago the schools were forced to start teaching in English instead of French and quite a lot of signs are in English. Most people speal Kinyarwanda as their first language and then the more educated speak French, but also English is definitely seeping in. I find it pretty hard to understand the French here as it's structured differently and accented but it's fun to try!

So after 3 lovely days we got on another bus and headed to Kigali, the capital for 3 nights of city life. It was hard to tear ourselves away from the lake but we have Zanzibar to look forward to in a few weeks!

Gorillas!

Last weekend we went to Bwindi Impenetrable Forest and saw the gorillas. It's expensive to get a permit (although a lot cheaper in May than in June because it's the low season) and a lot of faff  and I was so worried all week that I wouldn't be able to go because of the malaria. Every day I was a bit stronger but the wardround 2 days before had left me exhausted so I wasn't very confident! On the Saturday we got Suboni to drive us down to a town called Kisoro where a driver from our camp met us and took us up to the camp. The camp was right in the mountains and the journey up was on a very bumpy dusty road. It was beautiful though with amazing views of the nearby volcanoes and the forest. The volcanoes were all distinct peaks but Bwindi forest is also very mountaineous and the road climbed up to 2200m where the lodge was on the top of a ridge. On the drive with Suboni we saw lots of baboons on the road and he said he once saw a gorilla by the road!

The camp was lovely. It was called Nkuringo Gorilla Camp and was quite small with about 10 other guests. They were so friendly and welcoming. Because we were in the middle of nowhere everyone stayed fullboard and they cooked amazing meals in a very small kitchen. In the evenings it got pretty cold so they made a campfire and they put a bucket full of hot coals in the dining area to warm it. They also put hot water bottles in our beds in the evenings which was amazing! We stayed 2 nights and each day got a packed lunch to take with  us. The boss was visiting from Entebbe and she was lovely. She was 8 months pregnant and petrified that she might go into labour up there. She told us about the problems they have with water and electricity. They have a tank for water but it's about to run out as the wet season is ending and then won't refill until September so they'll have to bring water up from the town 1 1/2 hours away. They had generator for electricity but they only produced a limited amount so they used gas lamps for lighting. It was a really special place to stay and the views were incredible- of the volcanoes, mountains, forest and across into the DRC, plus so many stars at night.

On the Sunday we got up early and went to the office to start our trek. There were 2 other men in our group- French men in their 50s plus a guide, 2 officials with guns and a porter we hired to carry our bag and help me with the walking! I told the guide I'd been ill and he was very kind and said we could go as slowly as I needed to. There are 5 areas Bwindi where you can trek gorillas, and you can trek them in the Virunga National Park too, from the Ugandan side or the Rwandan or Congo sides. There are now about 880 mountain gorillas in total, of which about 400 are in Bwindi. In 2006 there were 700 in total so they've obviously done a good job increasing numbers. Basically the gorillas you can see are conditioned to be used to humans. It takes about 3 years to get them ready and the trackers visit them everyday during that time and copy their actions etc until they are used to their presence. Once they are ready they are visited every day for 1 hour at a time but they are still wild and there's still a chance they might runaway or charge at you! The trackers go out first each day and follow the trail they leave from where they were seen the previous day until they find them, when they radio to the guide. You're not allowed to trek if you are ill as they are able to get human colds etc and can get very ill.

I've since found out that the area we were in is meant to be the hardest walk, glad I didn't know that beforehand! You start at the top of the ridge so it's a long walk down on a small path to the bottom. The path was good in places but sometimes got quite steep and rocky. It passed through a village and we saw lots of people walking up and down the path bare-foot to collect water from the river in the valley. It must be such a hard life. At the bottom we then climbed up a bit and walked along through the rainforest. It was hard-going and I kept forgetting to duck and hitting my head/ getting caught in branches. It was also getting quite hot. I was so glad we had a porter as he carried our bag and also helped us with the difficult bits where the path was slippery. The gorillas move about 1 km an hour as they stop to eat lots but they can be quite far away and I was really hoping they'd be close! We were lucky and had only walked for just over an hour when we got to them. We had to leave our walking poles and bags and we clambered down to where they were, but at first it was hard as they kept moving and we were no longer on a path, just a steep slope with dense forest. After a bit we got to a clearing where there were 2 massive silverbacks- the big males. One was the boss and the other the second in command. There were also 2 teenagers and we caught glimpses of others including a mother and tiny baby. We stayed there for an hour and it was incredible! The silverbacks were huge and the bigger one was very entertaining. He would eat and then lie down ad stretch, with the biggest beer belly ever visible! I don't know how they get so fat eating only leaves and berries! The teenagers were play-fighting for ages and then one camp really close to us (about 50cm away) and looked at us weirdly before climbing the tree we were standing next to. It was so cool, they look very human and their eyes in particular look very wise and intense. The other teenager then started doing yoga-type poses holding his feet before just sitting and staring at us. I was so excited that I'd made it and it was definitely worth all the money and stress!

The hour went really quickly and then we started the walk back. I'd been dreading it as I was already quite tired and it was very steep uphill. Malaria makes you feel so weak- like your batteries are just running out! I took it really slowly but still got very tired. I used my poles at first but then my arms started hurting (apparently arms usually hurt most in malaria) and the guide carried them and the porter pulled me up the steep bits by hand! It was also very hot which made it worse but Emma was very encouraging and patient. I was so happy to get to the top! I spent most of the afternoon in bed sleeping it off but I was very proud of myself!

Malaria

As I've mentioned before, the most common condition on the paediatric ward is malaria. Almost every child who comes in is tested for it and most are treated for it, even if they also have other problems as it often goes hand in hand with infections such as pneumonia or malnutrition. The sickest children are unconscious, fitting and often severely anaemic and 2 children have died of it during my time here. Both came in very late and died of anaemia before the blood arrived. The lowest haemoglobin level I've seen is 1.6. To put that into context the normal is about 12 or so, in the UK we give transfusions below 8 and in Uganda we transfuse below 5 or 6. Before I came here I didn't realise it was possible to have such a low count and still be alive!

We test for malaria using an RDT and a blood film. The RDT (rapid diagnostic test) takes about 2 minutes and is a bit like a pregnancy test but using blood instead of urine. 1 line is negative, 2 is positive. They are pretty sensitive but occassionally you get false negatives. They are also pretty specific but with really sick children you don't know if they are sick because of the malaria or whether they have malaria but also have meningitis or something else (as malaria is so common here) so we usually treat for both. We then send a slide of blood to the lab where they look for parasites. The highest I've seen was over 5000 prasites for every 100 white blood cells- that's a lot of malaria!

Luckily malaria is very treatable. We use quinine here for most cases or co-artem in the less severe cases. Quinine is quite a dangerous drug and in the UK it's almost always given in Intensive Care with the patient on a heart monitor but here it's just given slowly and in a bag with sugar so it doesn't lower the patient's blood sugar too much. Apparently it makes you feel rubbish but it definitely works! So many times I've started a child on it in the afternoon who looks awful- unconscious, fitting etc and worries overnight about them and then turned up the next morning and not been able to find them. I always worry they've died but usually they are just so much better they are unrecognisable! It's one of the best things about paeds here.

So one day a week and a half ago I woke up and really couldn't face getting up. Eventually I did but I skipped chapel and it took ages to get ready as my arms were feeling very weak and I felt a bit rubbish. I went down and started the ward round and my lovely medical student Tom carried a stool around so I could sit down with every patient as I didn't feel like standing up. I saw about 6 patients and then Dr Mary, the consultant turned up and I decided to go and have a rest in the staff room. A tiny little voice in my head said that I was feeling similar to last time I had malaria in Ghana but it's so hard when you first feel ill to know if it's real or you're just tired, and it was a Friday and the end of a long week. I went to speak to Dr Mary and she said I had to do an RDT and it was positive! Luckily my blood film showed no parasites, which suggests that the doxycycine I'm taking as prophylaxis had worked a bit but the RDT is enough to show it was malaria. I begged not to be admitted so she gave me some coartem and I spent the next few days in bed. For the next couple of days I got more achy and my arms really hurt but then I started feeling better and was just really weak. Emma was a star and looked after me, cooking all my meals and even offering to wash my hair. Dr Mary and one of the nurses came to check up on me a couple of times which was sweet. After 5 days I was able to get up and go for a little walk and the day after I went to the ward for an hour and a half (and then slept for the rest of the day!). The day after (last friday) Mary was away so I did a full 4 hour ward round which I was very proud of. And last Sunday, 9 days after the malaria I trekked to see gorillas, but that's for another blog.

This experience had taught me lots. Firstly, no antimalarial is 100% effective but now I've had malaria whilst talking doxy twice I've decided to give up on it! I'm going to try to buy another one in Kigali and if so will swap over. Secondly, I've now had it twice and both times at first dismissed it as feeling tired and maybe early flu. Thanks to Dr Mary I was diagnosed and treated really fast and I think that's why it ended up being so mild. So basically I urge anyone who is in Africa, or another malaria area to assume that any fever, or feeling weak and achy is malaria and get tested. Emma and I are going to carry RDT packets and coartem around with us for the rest of our trip just in case!

Possibly the best birthday ever.

Thanksgiving everyone for the birthday wishes and sorry for the delay in publishing this, I wrote it last week but the internest has been a bit rubbish! I had a brilliant birthday weekend. It started on the Friday night when we had a little party. After a busy day at work I got home and Emma and Becky had decorated the house with some decorations that Ann had given us. Emma had been really stressed getting it ready in time and it looked lovely. We had Becky, Jess, Rita and a Ugandan doctor called Naomi over for supper. We made tapas- guacamole, salad, tomato and aubergine, home-made chips, eggs and cheese. We also dug out an oven from the stores and made birthday cake which was exciting! The oven's odd as it has a fan at the top and so the top cooked (and then burnt) really quickly whilst the middle took ages to cook, partly because it was full of chunks of pineapple. Emma decorated it with passionfruit buttercream and candles, again thanks to Ann! I was so touched and it was amazing to have cake! Rita gave me a card and a lovely bracelet, made out of rolls of paper formed into tiny diamond shapes, which is a traditional technique in this part of Africa.

The next day we got up early and left at 6 ready for our safari in Queen Elizabeth National Park (about 20 minutes drive from the hospital!). The driver, Suboni, took us. There were 5 of us, Emma, Becky, Jess and I and a British engineer called Paul. It got light about 7 and we spent 3-4 hours on safari. We saw loads of Ugandan cob, buffalo and lots of different types of birds. At one point we went to a village which is in the national park. Usually people aren't allowed to live in them but this is a fishing village on the shore of Lake George. We saw about 10-15 hippos there, all lying on top of eachother to keep warm as it was quite cold. People were collecting water a few metres away from them and riding past them in canoes to go fishing. It's so dangerous, but I guess they have to live with the risk. The week before we came a man died in the hopsital after being attacked by a hippo. We carried on and headed West towards Lake Edward and the lodge where we were staying. On the way we saw a big family of elephants right by the side of the road. We stayed there for ages and watched them. The babies were playing, the teenagers fighting and the matriarch and other adults eating and trying to get them all to keep moving. It was so entertaining and amazing to be so near them and watch them getting on with their lives! We were desperate to see a lion but the grass is very long because of the wet season so I think they were all hiding! We  saw lots more elephants as we drove on, one with a very mishapen skull, probably from a fight. Suboni was great and told us lots about the animals. The buffalo usually live in big herds but occasionally you see one or a small group alone. They are called the losers, because they are males who fought the head of their herd and lost, and they are banished for the rest of their lives.

We arrived at Mweya about 11. It's a big lodge on a peninsula, surrounded by Lake Edward and the Kazinga channel which joins the two lakes. Emma and I were staying there as a special treat and the other girls were staying in a nearby hospital. We spent a lovely couple of hours sitting in the bar drinking a teapot of coffee and I opened some presents that my family had given me. I was so touched I kept almost crying! We then had our first meal of the 3 included in our full-board- a 4 course lunch! Afterwards we met up with the others and went on a boat ride along the channel to the edge of Lake Edward. The boat was really quiet and so we were able to follow the shore and get really close to the animals. We saw lots of buffalo, hippos, crocodiles and birds. The crocodiles were often sunbathing but as the boat got closer they would suddenly jump into the water, apparently because they are weak on the land and much stronger under water. We saw lots of baby hippos which were funny. They are such odd looking animals, so fat and ungainly but so powerful and dangerous. The birds were lovely too, some of them are so strange looking, like one we saw in the morning with bright orange legs and beak but black elsewhere. There's a village near the end of the channel and right afterwards we saw an elephant by the shore. I've taken almost all my photos with the camers fully zoomed in but we got so close to him and he was so big that I had to zoom out! It was great to watch him.

We headed back to the lodge and spent some time in our room. We chose a tent, which was the poshest tent ever. The sides were canvas but the back part with the ensuite was brick and the roof was thatched. In the front was a wooden balcony with a sofa, table end massive rocking-chairs. The biggest excitement was a hot shower- so nice to feel really clean! I sat and read on the balcony, with a brilliant view across the channel to the hippos and buffalo on the far shore. I could hear a hippo far below us on the shore as I read. Suddenly I looked up and saw a warthog looking at me from across the fence. He then disappeared under the balcony and later 3 other joined him. I could see the floorboards moving as they moved! Paul had headed back to Kagando with Suboni but the girls met us at the lodge and we sat and watched an amazing sunset. We then had another 4 course meal and cocktails- the first alcohol since we arrived as it's not allowed in Kagando. The girls had made me a lovely card. Then Emma gave me some gorgeous elephant earrings. I'd seen them at a place called Kingfisher lodge where we'd spent the previous Sunday and meant to buy them and then when I went back they'd gone. I was so chuffed that Emma had got them for me! All in all it was a brilliant birthday and I was very spoilt.

The next day we spent by the pool at the lodge, again with the same views over the channel to the animals on the other side. At one point a whole herd of elephants arrived, including some babies and they went swimming. It was a hot sunny day and I imagined they'd planned a day at the beach! We swam, sunbathed and used the internet to cath up with the world. It was really relaxing and fun. On the way back Suboni took us to the "buffalo hospital"- a salt lake where injured buffalo go to heal their wounds. We then stopped off at the equator for cheesy photos. All in all a very memorable birthday!

Tb or not Tb?

Sorry for the bad pun, but I just thought I'd write a bit about the challenges of working without being able to do many investigations. There aren't many tests available here- we can check the blood count and do tests for malaria and HIV and sickle cell etc but when it comes to other diseases we get a bit stuck. TB is a good example of a condition that can be very hard to diagnose as it has similar symptoms to lots of other conditions. There are more and more fancy investigations available but unfortunately we don't have them here. In adults the definitive test is to look at the patient's sputum for the distinctive bacteria but kids don't cough anything up! To complicate things further, the treatment is a minimum of 6 months long with patients needing to take 4 drugs for the first 2 months and then 2 for the rest of the time. If they miss doses they risk creating a drug-resistant strain, which is obviously bad news. So basically we rely on the history, examination and then look for patterns on their blood count and chest X-ray which make TB more likely.

Another difficult problem is the very anaemic children. We have had a few quite old children come in with really severe anaemia that stays low even after a number of blood transfusions. This is often triggered by malaria but it's important to know whether they might have an underlying abnormality, such as sickle cell disease, which makes them more likely to get severely anaemic. The problem is that by the time we see them they've often already had a blood transfusion, at which point any blood tests we do will be analysing the donor's blood instead! The soultion is to get them to come back in 3 months when all the donated blood cells have gone but many don't come back, or alternatively get ill during those 3 months and have more transfusions.

We very rarely find out for sure what our patients have, except when it's clear cut malaria. It can be frustrating as it's always nice to get an answer and be confident that you are giving people the right treatment. The good news is that most of the children get better anyway!

Ups and downs

I realise I haven't really written about the hospital much. I promise I've been working! To be honest it's been hard at times and I didn't really want to write about it but now I feel more settled. There are very few doctors here at Kagando. On paeds there is one consultant who is here 3 out of 4 weeks. Then there's me, a Ugandan final year student who leaves tomorrow and British medical students as and when they come. They are usually encouraged to start on paeds as adult medicine doesn't have a consultant. So for my first week Becky was with me and for the last 2 Jess has been with me. Next week there are 3-5 new British students coming so some of them might come along. The first week Mary, the consultant, was here most days and she and Becky showed me the ropes. There are 32 beds on paeds plus 2 side rooms for the children of hospital staff. However they often put 2 children in one bed and last week there were 37-40 every day. There's also a NICU (neonatal intensive care unit) which usually has about 8-10 babies and then in another room the premature babies who are off antibiotics stay until they weigh 1.5kg, when they are discharged home. They do Kangaroo care here, which means the babies lie naked next to their Mum's bare chest and then are wrapped up in blankets and they are fed by nasogastric tube or spoon. This is instead of being in incubators the whole time, and it seems to work really well.

The children mostly have malaria, severe bacterial infections, pneumonia or diarrhoea. We've also had a few malnourished children and some other random things. A lot of the children come in late and very unwell but it's amazing how quickly they turn around. I've seen lots of fitting, unconscious children who in the UK would be in PICU (paediatric intensive care) and here are sharing a bed with another child but with basic treatment they are often sitting up eating the next day! It's very dramatic and rewarding.

Yesterday was a sad day as we lost 2 children, the first non-neonates who have died in my 3 weeks here. One of them died when I wasn't there but for the other one I was. He came in semi-conscious, jaundiced, anaemic and febrile and deteriorated in front of our eyes. We gave him dextrose (sugar) as his blood sugar was dangerously low and fluids and had ordered blood for a transfusion. He had malaria and we started treatment for it just before he stopped breathing. Luckily my consultant was there and came to help. It was really stressful because we needed to breathe for him using a bag-valve-mask - basically a mask that seals over the face attached to a big bag, you squeeze the bag to give them a breathe and then it re-fills. The nurses couldn't find one of the right size and when they did it didn't seal well so it took 2 of us to hold it onto his face. Before they found one I had to give him mouth-to-mouth which was a new experience for me. It's frustrating but I'm planning to buy some masks whilst I'm here. The poor kid's parents weren't there as they'd gone away to work and he was with some of their friends. Everything here happens in public in front of an audience and all the other children and parents were watching. All in all it was a very sad day.

A big problem for many of our patients is that they cannot afford the treatment. The prices have apparently gone up a lot recently and the hospital is less busy because of it. Often we discharge children and then they stay here for a few days because they do not have the money to pay. It just makes me so grateful for the NHS. The saddest thing is when babies die and their parents have to go straight to the cash-office and pay the bill. I'm learning to make decisions based on price to the patients. For example a full blood count is more expensive than just checking a patient's haemoglobin, so we usually just do that. If children are very anaemic we sometimes don't even check it and just give them blood. One of the children at the moment is a gorgeous 7 month old from the local orphanage. The carer today said that she could stay as long as he needed. I asked where the money came from and the nurses said it come from foreign people who sponsor the children.

Last week Mary was away and I was therefore the most senior paediatrician here, which was very frightening! The neonates were the most difficult, but I will write about that in another blog! Even when she is here she only sees the neonates and the children we are worried about, so most of them will only have been seen by me during their stay. It's a million miles from back home where they are all seen daily by consultants but it's toughening me up and I guess I'm better than the alternative, which is no doctor. The nurses often have to manage alone and one of my aims here is to do some teaching to help them manage when they don't have a doctor.

Anyway sorry for the long blog and all the medical terms. One more day to go before the weekend and my birthday! We're going on safari on Saturday and then a river safari and we're staying at a posh lodge as a special birthday treat. Thanks for the birthday money Mum, Jo, Tom and Caro. I will send you postcards!

Ja ja home day

Today (Saturday 26th) was Ja Ja home day. Jaja means grandparents in the local language and it's a day when all the HIV positive children from a few local villages are invited to the community hall next to the hospital. The name comes because lots of them are cared for by their grandparents because their parents have died. The two medical students, Becky and Jess, and Emma and I helped Rita organise it. We made name badges for the children by plaiting ribbon and sticking the ribbon to pieces of card. They then wrote their names and stuck stickers on the cards.

The children arrive in the morning and have porridge for breakfast. They then play games and run around for a few hours and then have lunch before they go home. I spoke to a couple of local volunteers and they said how much the children like being around other children with the same health condition. Because all these children are on the register they all get ART (anti-HIV medication) and they mostly looked quite well nourished and healthy.  I imagine there are loads of other children in remote villages that haven't been diagnosed though.

It was a very tiring but really fun morning. As usual we were one of the main attractions, and they spent hours following us around and poking our skin, but they also played with toys, stickers and balloons. Like with everything here though, funding is a problem. Rita and her team do a brilliant job organising everything and I hope we can help out in the next couple of months when she's gone.

A Ugandan Easter

Sorry not to have posted for a while. The internet stopped working for a week and it's been a busy and stressful few days. I thought I should write a bit about Easter here. They have a tradition in the hospital chapel of celebrating both Easter and Christmas on the Thursday beforehand, as lots of the staff go home for Easter. They call it carols, even at Easter. There's a nursing and midwifery school on the hospital site and all the first year nursing students put on a play of the Easter story. The morning service lasted about  3 hours, including the play. They acted out everything, including whipping Jesus and putting him on a cross. It was a slightly bizarre, rather dramatic performance but more entertaining than the usual chapel services! They sang lots of songs too. Afterwards we had the more formal service.  I have to admit I struggle sometimes sitting on the hard benches but it's noticed if the Muzungos (white people) don't go to chapel and most days the service is only 30 minutes long.

On Easter day itself Emma and I had pancakes and coffee for breakfast (thanks Ann Smith!). We then got invited over to Olga, a German girl's house for more pancakes! There were about 10 of us there, us two, Olga, Rita and 6 Ugandas, mostly doctors or nurses at the hospital. It was really fun and rather indulgent to eat pancakes twice in one day. I took the last bag of little eggs Mum gave me when I left and everyone was very excited! That's all the chocolate gone now though, unless anyone wants to send a parcel...

Home sweet home!

We moved into our house today! It's a lovely little bungalow with 2 bedrooms, a bathroom, kitchen and big living room and garden. For the last 2 days we've been staying in the doctors' guesthouse and having meals cooked for us which was nice but it's lovely to have moved in and been able to finally unpack and stop living out of a rucksack! We went shopping and have a fridge full of giant avocadoes and passion-fruit which cost 3p!

The last two days have been hectic and exhausting. Everyone is really friendly though and very pleased to have 2 extra doctors to help out. I'm relieved to be on paeds rather than adults! The day starts at 8 with a 30 minute service/meeting in the hospital chapel. They understand that we're not Christians but it's polite to attend and it's an interesting cultura experience. Then we go to the ward and do a ward round of the children and then the newborn babies. At the moment there are between 20 and 30 children and about 10-15 neonates. The round takes all morning and we see most of the children alone, with the consultant seeing the sick ones and any others she wants to. She's very nice and I think I'll learn lots from her.  I'll write another post soon with more details of the hospital and the things we see on the ward. Lots of the children are really poorly when they come in but most get better, I'm very relieved that our 2 sickest both started opening their eyes today. The newborns have a more turbulent course and 2 have died in the last 24 hours which is horrible. It's quite harrowing but it's also lovely when they improve.

We have lunch around 1.30 and then have a nice lazy afternoon until we go back in at 4 to see any that the nurses are worried about and review the new admissions. The nurses on paeds are great and quite independent. I felt bad about having this time off at first and then I realised it's the time that in the UK I'd spend writing discharge summaries and doing other paperwork- there's much less of it here! The nurses do all the bloods and cannulas and sort out discharges. At the moment there is a British medical student, Becky, and a Ugandan student, Charity, on paeds too so we share the work but Becky's changing to surgery next week and Charity is moving hospital so it might just be me and Dr Mary, the consultant. I will let you know!

Arrived!

Hello everyone, I am writing this from Kagando hospital, using the internet from the nursing school here. I'm exhausted after an early start and a long journey. The journey was lovely though- the countryside is gorgeous and got nicer and nicer as we got closer to here. We are right near the Rwenzori and can see the mountains from the accommodation. We are also only a few miles from the Queen Elizabeth National Park and drove through a bit of it and saw an elephant! It was from very far away but I was still very excited! We also saw antelopes and water buck and earlier in the journey we say baboons. We are staying in a gest house for the first couple of nights and then moving into our house. Anyway I'm shattered so going to go to bed. Will write properly in the next couple of days.

Hello from Kampala!

So we have arrived in Uganda after years of dreaming and months of planning. We're staying in Kampala, the capital, for a few days and then will get a lift to the hospital on Monday morning. We got here on thursday after a very smart but very long journey with Emirates, via Dubai.The views from the plan as we landed were amazing. The international airport is in Entebbe, which is a city about an hour's drive from Kampala and it is on a penisula on the edge of  Lake Victoria, a massive lake bordering Uganda, Tanzania and Kenya. It's the wet season here at the moment so everything is very green and lush, not sure if it's always like it!
We're staying in a lovely little hotel in quite a quiet and smart part of the city. It's like a little oasis of calm in the mad bustle! I feel very grown-up staying a hotel rather than a busy hostel with 20-bed rooms like I'm used to! Everyone is so friendly and kind here. We spent the first day and a half being lazy and resting in the hotel with the odd walk in the local area. Yesterday there was a massive thunderstorm and it poured with rain in the way it only does in the tropics- like someone is emptying a massive bucket! We were very pleased to be inside! The rest of the time it's been sunny and hot though. We're both re-adapting to the  sticky feeling of wearing high-factor sun-screen and deet all the time!

This morning we went to the National Ugandan Museum which is about a 15 minute walk from here. Walking is interesting as the pavements are quite pot-holed and the motorcycles often decide to drive on them instead of the road! The museum was realy interesting and about the history of Uganda from prehistoric times and the animals and geography of the area. My favourite facts were tt chimpanzees eat special leaves to treat themselves for malaria and worms and that all the water in Uganda used to drain from East to West into the Atlantic until the plates moved thousands of years ago and suddenly they changed direction! There were loads of school kids there and I think they were more interested in us than the exhibitions! We had loads of conversations along the lines of "Hello, how are you, I'm fine, how are you" The brave would try to touch us or hold our hands! Ugandas are known for being really friendly though and they definitely have been so far.