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!