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!