A bit of a sad week...

Debbie:

The last 2 weeks at work have been tough on Karen and I as we've been faced with many patients have been extremely sick and been forced into the realisation that we can't do as much as we would want to for them. We'd like to remember them:

The first patient was a female aged 25 who, when she was admitted last Monday, was septic with an unknown infection. I cannulated her, took blood tests and started the antibiotics that the Doctor had prescribed. The next day we went to Pabbo Camp to help with the HIV clinic. When we returned to work on Wednesday I was happy to see that she looked better and appeared to be improving. The Doctors came onto the ward and started their rounds and Karen and I began assessing our patients, sending off blood, sputum and urine tests and giving treatment. I went to see the lady just before midday to check her observations and found that her blood pressure was unrecordable and peripheral pulses could not be felt. The Doctor had seen her earlier in the day and stated that her chest x-ray was poor but she had been alert and orientated then. By this point the lady started becoming slightly agitated and had difficulty breathing. I called the Doctors over immediately after realising that she was haemodynamically unstable but there was nothing that we could do quickly enough to save her. She slipped away before our eyes. Her mother was present and began praying and was obviously very distressed. Karen and I stood with her and bowed our heads as a sign of respect. I sat with the lady and put my arm around her. The only word that I could say to her that she would understand was 'sorry' which made me feel so helpless. When I sat next to her she put her head on my shoulder and wept. The patients sister then arrived and was so distraught. The loss of this girls life was so sudden and unexpected that it had shocked both nurses and family. To make matters worse, it transpired that the family were far from home and to take her body home they would need close to 100 pounds which they did not have. I hope they found a way to take her home. May she rest in peace.

Our second patient was a lovely young girl aged only 15 who had such a sweet temperament. She was admitted a month ago and so Karen and I got to know her and her family quite well. She had complications related to Rheumatic Fever and had developed heart failure, admitted with difficulty breathing and chest pain. Although the Doctors prescribed all of the medication that they could for her she deteriorated and passed away over the weekend. In the UK we would have had the resources to give her so much more and such a better chance at life. May she rest in peace.

Our third patient was a 34 year old lady admitted with a swollen abdomen and reduced appetite. The Doctors ordered an ultrasound of her abdomen which found that she had cancer. With no treatment available at our hospital we were only able to give her end of life care as the cancer was quite advanced. She did not complain once even though her abdomen must have been so uncomfortable and she would have found it difficult to eat, walk and do other normal activities. She also passed away over the weekend. May she rest in peace.

Karen:

An early morning knock at our door and there stood our housekeeper in floods of tears. Her relative had just died. That relative being a 13 year old boy who we had been caring for on our ward for the past week and fighting so hard to save his life. Her news was utterly devastating for to both Debbie and I as we united in her grief.

This was perhaps the most devastating death since we arrived in Uganda 4 months ago. We first looked after this HIV positive boy back in November , along with our colleague Dr Sally, when he was exceptionally unwell and suffering from nose bleeds and vomiting blood. Against all the odds, he fought back and walked out of the hospital smiling. This gave us optimism when he presented once again with the same symptoms, but this time complicated further by a raging temperature with an infection of unknown origin. He was found to be severely anaemic and suffering from thrombocytopaenia - a low platelet count resulting in the bleeding.

Every day his temperature crept up until it hit 40.9 Degrees Celsius. He received a cocktail of intravenous antibiotics and medications with an unrelenting fever, eventually thought to be TB Meningitis. He received in total 7 units of transfused blood over the course of the week. Acquiring the blood was no easy task. The laboratory had no B+ blood in stock and so obtaining every single unit he required was an ongoing struggle. Urgency is non-existent in Uganda and so when I ran into the lab saying I needed blood urgently they failed to react until I was almost in tears of frustration! By the end of the week, I think they were getting increasingly familiar with the sight of this crazed 'muzungu' nurse and responded with a little more haste! It was from a contaminated blood transfusion for a childhood illness, likely malaria, that he developed HIV 6 years ago, ironically on this occasion it was a blood transfusion that would contribute to possible saving his life.

This poor child continued to vomit clots of blood and developed bloodied watery diarrhoea. Towards the end of the week he was becoming increasingly weak, and began convulsing - a serious sign of neurological deterioration. He was such a brave young boy with an incredibly caring family who sat with him night and day. Debbie and I left work on Friday willing him to make it through the weekend to stand a fighting chance. In my last words to him, I urged him to keep fighting and that we'd have a party the day he was well enough to once again leave the ward smiling. Sadly this was not to be the case.

I spent Saturday morning with his family at the hospital as they prepared to take his body back to his village 2 hours away for burial. His mother spoke of how the death of her son was 'God's Calling'. I found it comforting that despite the loss of her child, she found so much strength in her faith , something that no-one can ever take away from her. His mother thankfully spoke good English and so I was able to communicate with her. So often it is frustrating not to be able to communicate with relatives when their loved one dies due to the language barrier, only being able to say 'sorry'.

All day Saturday we felt in mourning and questioned if there was any more we could have done for him. What is difficult about times like this is that we are minus our usual support network that exists at home in the UK. While there are a few medical folk here with whom we can discuss cases and 'offload' it is not the same as being with your good friends and being able to distract yourself by watching television, or a film, and the ease of being able to put a pizza in the oven for dinner! Our feelings are often compounded by the frustrations that exist at the back of our minds when we know what care the patient would have received in a developed country. But those sorts of thoughts almost become a form of self torture because those treatments and interventions just don't exist here.

This last couple of weeks have proved very difficult as we have experienced so many deaths on the ward. Looking through the death register book I sadly realised that of all of the deaths the eldest had been a mere 50, with most aged between 20 and 30.

May their souls rest in peace.

HIV and Health

KAREN:

• An estimated 40million people worldwide are infected with HIV


• 60% of those living with HIV live in Sub-Saharan Africa


• 7% of Sub-Saharan African adults are infected with HIV


• 2.1 million children worldwide live with HIV, with 90% living in Sun-Saharan Africa


• Approximately 7500 people are infected daily by HIV


• It is currently estimated that in developing countries, 1600 children are infected daily with HIV


• Africa has over 14million AIDS orphans


• The clinical course of paediatric HIV is more than in adults


• In developing countries, 9.5 million people require life-saving HIV drugs - only 4million (42%) actually receive the medications

Yesterday we travelled to a place called Pabbo to an Internally Displaced Persons (IDP) camp to help at a HIV clinic run by our friend, Dr George.

In the height of the war in Northern Uganda, people were forced to leave their villages to live in these camps for their personal safety from rebel troops. The camps comprised of thousands of mud huts built in very close proximity to each other. Since the end of the war 3 years ago, many people have left the camps to resettle in their villages, however, it is estimated that to this day, many of the camps remain 20% occupied. Pabbo was one of the largest camps with a population of 90,000 occupants! Today it serves as a functional community comprising of a school, church, health centre, and farming land. It is not uncommon to be greeted by a cow or a chicken as you walk around the camp!

Pabbo is a fairly remote area with limited access to costly public transport. Consequently Dr George and his outreach team frequent the camp to run a HIV clinic for the local people. HIV is a huge problem here in Uganda. Sexual transmission is a significant mode of transmission as well as mother-to-child transmission. Culturally men are permitted to have many wives. Coupled with little use of condoms, spread of the disease is rife.

The clinic was previously held outside under a tree, but now the camp have allocated a small room where the patients can be seen, blood tests can be taken, and medications can be dispensed. It was a busy clinic yesterday attended by 60 patients in total, including both adults and children. At the clinic patients can be counselled and tested for HIV, medications can be reviewed and altered, patients conditions can be assessed, and any new problems can be treated. Many complications accompany HIV including the herpes simplex virus, anaemia, and weight loss to name but a few presenting complaints. HIV patients are also at risk of developing life-threatening opportunistic infections such as pneumonia, tuberculosis, and cryptococcal meningitis as a result of a weakened immune system.

HIV delays the growth and development of children. This was our second visit to Pabbo camp. On our first visit we met two children living with their grandmother following the death of their mother to AIDS. The children were aged 5 and 7 years yet both looked about 3 years younger. Dr George explained that the youngest child had not long learnt to walk - at 5 years of age! Here in Uganda children are quite advanced in terms of development and are usually walking by the age of 10 months!

Antiretroviral (ARV) medications are a life line to a person infected with HIV. Minus these drugs, the average time from acquisition of HIV to an AIDS-defining opportunistic infection is approximately 10 years, with survival then averaging 1-2 years. Whilst the medications initially often have many side effects, it is vital to persevere to live as full and healthy life as possible.

Yet some people do not wish to know their sero-status and prefer not to know if they have the disease or otherwise, and subsequently decline testing. Despite the high prevalence of the disease here in Uganda, it is still associated with a certain degree of social stigma. Discovering you are HIV positive can often sadly lead to the breakdown of a relationship, and family isolation.

Only this week we nursed a 24year old man on our ward who had previously declined HIV testing, not wanting to know his status despite that his wife was HIV positive and on ARV therapy. He was exceptionally unwell and had a decreased level of consciousness. For many weeks he had been experiencing a fever, body weakness, weight loss, a decreased appetite, and a persistent cough. Sadly he began convulsing, and stopped breathing and died a short time afterwards. His blood tested positive for HIV. Had this young man been tested for HIV and commenced on appropriate medications, the story could have been different. The same day, I took the blood of another patient who was also found to be HIV positive. I felt devastated on his behalf and accompanied the ward Sister to inform him of his result. I was pleasantly surprised by the mans positive response. He said he had been previously tested by the results had never been bought to his attention. He informed us that he was glad of a diagnosis so that he could begin treatment! I was amazed at his upbeat spirit! Hopefully his story will have a happier ending.

Back to the classroom...

KAREN - TUESDAY

Today Debbie and I sponsored a 12 year old local girl to go to school for a year. It was an incredibly humbling experience when we learnt that it would cost a mere £70 for a child to be given the opportunity to be educated. The young girl, Brenda, is an orphan. We know no details of her father, but our friend Dr George cared for her mother up until her death through HIV at Christmas time. She is now looked after by her extended family members. As well as covering our school fees, our money also makes a contribution to the school of a sack of rice, and pays towards her uniforms, text books, stationary, toilet paper (yes indeed the kids must supply their own loo roll!)...and a broom! We are not kidding, apparently the children have to sweep their own classroom every morning!

We learnt that Brenda is a clever young girl, coming second in her class in Science, Maths, and English. The report however did say she must be less playful in class - glad to hear she has brains as well as a sense of mischief! The school year started here in Uganda this week. We were motivated to help her when we learnt that she attended for school last Monday and was sent home by the caretaker as no one had paid her fees. This is a little girl with a passion to learn - how can you deny a child the opportunity to go to school? In a developed society we would automatically attend school without question of funding. We see it as our human right to be educated and even have the privilege of which schools we choose to apply! In fact, parents are prosecuted if children play truant! It is often difficult for a child to attend school here in Uganda because family sizes are so large, often with 5 or more children. Parents struggle to feed and clothe all their kids let alone afford to educate them as well. Consequently, children grown up working from a very early age, and learn a skill such as tailoring, carpentry, cooking, metal work and farming.

We are meeting our young friend on Thursday. Debbie and I are excited to meet her and to visit her at school!

DEBBIE - FRIDAY

After meeting our young friend Brenda yesterday we learnt of another child in need of sponsorship named Mercy. Her mother was abducted at the age of 9 on her way home from school by the Lords Resistance Army (LRA) and was held in captivity for approximately 5 years. During this time, she was given as a 'wife' to two Commanders and subsequently gave birth to a daughter - Mercy. After a failed attempt to escape she was badly beaten but thankfully succeeded on her second attempt. Now she and her daughter are rebuilding their lives. Mother managed to finish the schooling she missed out on thanks to the help of a local organisation, and 6 year old Mercy is top of the class and wants to be a lawyer!!!

This term however, Mercy was to be removed from school as no funding was available for her fees. We could not resist helping, and so now have two sponsors that we will enjoy seeing through their school years!