THE CURSE OF NATURE

KAREN:

Nature can be so beautiful, nature can be so ugly. Nature can cause so much pleasure, nature can cause so much pain. On the evening of Monday 1st March 2010, tragedy struck Eastern Uganda when a landslide caused multiple deaths destroying four villages in the county of Bududa. Many people were buried alive as rocks, mud, stone, and water thundered down the foot hills of Mount Elgon submerging buildings, schools, health centres, and entire communities.

Stories and images of devastation dominate the news here in Uganda as a humanitarian emergency has been declared. Over 350 people are feared dead along with hundreds of livestock. Rescue efforts have been coordinated by the Uganda Government with the support of the military and humanitarian aid agencies. One week on and only 31 survivors have been rescued from the rubble and 89 bodies exhumed after disaster response teams and locals alike have been using hoes, pick axes, spades, and even their bare hands to dig in over 3.3 square kilometers of flattened terrain.

The 200m wide avalanche of mud and debris was triggered by endless days of downpours, more typical of the cool wet season, not the hot dry season that Uganda should be experiencing at this time of year. The affected villages of Nametsi, Kubehwo, Liira, and Matuwa have been declared disaster zones. Flooding due to the above average rain falls, is causing further problems in these regions of devastation. Over 1000 people in these villages have been made homeless. A total of 4000 people living in mud-slide prone areas have been advised and encouraged to evacuate their homes and seek refuge in temporary relief camps or in nearby villages. Oxfam, The World Food Programme, Save The Children, and UNICEF are amongst the aid agencies involved in distributing food, clean water, cooking utensils, blankets, and essential medical supplies to the people seeking refuge in the internally displaces peoples (IDP) camps. Medical teams have been flown in from Kampala, the country capital, reinforced by medical staff from nearby Mbale Hospital.

And with the flooding comes further misery in the form of water-borne infections and diseases from unearthed decomposing bodies. 80 cases of cholera have been confirmed in a neighbouring district - an acute intestinal disease caused by consumption of contaminated food and water which causes severe diarrhoea and dehydration. Minus prompt treatment, cholera can result in death. The concentration of people living in the IDP camps and temporary shelters can greatly increase the risk of disease exposure and transmission from over-crowding and utilisation of basic sanitation facilities. Aid organisations have been working hard to disseminate water purification packs in a bit to halt the introduction and spread of the disease and prevent the outbreak of an epidemic, with the International Committee of the Red Cross (ICRC) at the ready to treat 1000 cases should the need arise.

Although efforts to retrieve the bodies from the rubble continue, it is expected that President Museveni will declare an end to the search operation in the next day or two as chances of recovering bodies grows increasingly slim and excavation poses further public health risks. Not an easy decision when villagers so desperately want to provide the dead with a ceremonial and respectful burial.

Whilst response efforts are primarily focusing on immediate interventions in the aftermath of the landslide, longer term re-development planning is not being forgotten. In the proposed 5 year re-development programme buildings will be established to continue the education of the survivors of the 374 children in the affected areas. Homesteads will be constructed in safe locations. Land will be cultivated to replant the 792 hectares of damaged crops, predominantly consisting of maize, vegetables, cassava, banana and sweet potato, thereby contributing to future food security. Livestock will be replaced to compensate for the lost animals including 176 cows, 50 goats and 2000 chickens- essential sources of income and food for people in developing countries. Plumbing of water pipelines to the affected villages will be reconstructed, as well as sanitation and road infrastructures.

Living here in Uganda, it is difficult to know how far news of such a tragedy has spread to the outside world. And it is even more difficult to learn how such a tragedy has inflicted suffering in a country that has captured our hearts and that we have come to call "home" causing such loss to people and communities that already have so little.

Sadly the rain continues to fall...

Any one for a pint?

Last Friday I did one of the most rewarding things of my nursing career to date that perhaps directly saved a life...I donated blood to my patient. Returning empty handed from yet another trip to the hospital lab trying to acquire blood for transfusion for our patients, I felt compelled to help. Blood supplies are always in short supply in Gulu. Many patients here suffer with anaemia as a complication of malaria, and secondary to HIV anti retroviral medications. And when I say anaemia – I mean seriously low blood iron level. To any non-medical folk, a normal haemoglobin (HB) level is over 12.0, with UK patients receiving a blood transfusion at 8.0 or under. In Northern Uganda, patients are not transfused until they have a haemoglobin level of 5 or under – and it’s not uncommon to see levels at two or three!

My patient needed blood type A negative - a rare commodity at the best of times let alone from a blood bank with almost vacant supplies. Being a blood donor back in the UK, I was keen to offer a unit of my best claret to help my patient who was admitted with a HB of 4. Calling on my trusted side-kick Debbie, our interrogation of the Blood Bank staff began with us thoroughly investigating the Ugandan process of blood donation, and rigorously examining the blood collection equipment and ensuring the needles were indeed SINGLE USE! Assured by our findings we both decided to go ahead and donate! Before we knew it we had both donated 450ml of British blood to add to the dwindling supplies at the hospital. And just like home, the reward for your contribution...a sugary drink and biscuits – complete with smiley faces none the less!

We returned to the hospital ward with a standing ovation and a round of applause from our colleagues! And two hours later, after my blood had been screened and prepared, I was connecting it to my patient! Such a surreal feeling to know that it really could make a difference to the ultimate outcome of my patient! His family became so excited that they whipped out a camera and began snapping away as I went about connecting my bag of donated blood to the drip port cited in the arm of their relative. I was completely taken aback by this as I’ve never before seen a Ugandan with a camera!

And Im pleased to report that by today the patient was looking much better and has greatly improved. For once a success story where I feel incredibly proud to have played a significant role! Now we are keeping our eyes peeled to see if we are able to identify, by donor number, the recipient of Debbie’s kind contribution.

As the nurse in the blood bank said to us post donation “thank you for helping to save lives!”

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!

Gulu Celebrates!

KAREN:

HOME COMING

I'm pleased to report that I'm now feeling much better and travelled from the UK back to Gulu a few days ago. I'm now feeling back to my old self, full of energy, and raring to get back to work! Watch out Gulu here I come!!!

GULU GRADUATION

Saturday saw the whole town come alive with celebrations as the students graduated from Gulu University. Unlike formal graduation ceremonies in the UK, there was a true colourful carnival atmosphere with music, singing, traditional dancing, and a marching band. Ugandans certainly know how to enjoy themselves.

For the medical students, it was a particularly momentous day as they are the first medical students to graduate from Gulu University. Five years of training and they are now fully fledged qualified doctors. Graduation is a proud day for any student, but what really stood out is that these students in particular, began their studies when the area was still at war with an uncertain future. To now see Northern Uganda at peace must be such a heartening feeling and further add to their pride. Debbie and I felt very happy to see our ward doctors, who have become our good friends, celebrate their achievements!

The day began bright and early, and surprisingly on time at 8am with the inauguration of the newly built medical faculty building, adorned with banners and decorated with flags and flowers. I must say that the sweeping countryside views from the classrooms would certainly distract me if I was sat in a lecture! We then moved to the university campus where the endless speeches began - something Ugandans do so well no matter what the occasion! And believe me there were many speeches throughout the day! Acknowledgements and thanks take an eternity before the speech even begins!

The university campus was truly alive and vibrant with colour for the outdoor ceremony. It was highly amusing to see the university officials call for solitude and calm from the accompanying family members as they danced around and the women made their traditional guttural calls in chorus at the top of their voices as they rejoiced at the achievements of the students!

To be invited to join the events of the day was a real privilege, especially as we were joined by our Manchester colleagues Marian Surgenor and Mr Ged Byrne, and Marian's husband Tom. We were even mentioned in the University Professors' speech and referred to as his 'additional family members!'

The celebrations continued until way after dark as we joined the West Nile Graduates for an evening of more speeches, music, food, and dancing. A fun day and night were had by all!

It's back to work I go!

I must say that the first few days back at work without Karen have been quite strange! We're always a great support for each other and when things get a bit frustrating or upsetting we cope with it together. So, first day back I was slightly apprehensive about what the day would hold. However, I soon found that there was nothing for me to be concerned about because when I entered the ward I was greeted by numerous staff welcoming me back and asking after Karen (or 'Lamara' her Acholi name meaning loves her work/hard worker!)

Unfortunately, on friday, I sustained a small needlestick injury after inserting an IV cannula (the needle pierced my skin after being in contact with a patient). This is never an easy experience as you go through a range of emotions and worry about what might happen. Straight after the incident I followed the protocol that we are taught back at home and then I informed the Sister-in-Charge who was very apologetic and went to ask the Consultant for advice. The patient then consented to having a HIV test and I went home to get our emergency antiretroviral pack. On my return, feeling quite shaken and worried, the nurses on the ward were extremely supportive. They said that 'God would protect me' and that I shouldn't worry. The HIV result came back negative shortly afterwards which was a huge relief. The Consultant advised me that I should continue to take the antiretroviral drugs just in case the patient was in the window period where HIV cannot be detected. The Intern Doctor relayed how he'd had two incidences where he had needed to take the antiretrovirals and that everything would be ok. The Sister at the HIV clinic was very supportive and helped me to get the full course of medication from their pharmacy.
It just goes to show that, even when you might feel a million miles away from home, there are always friendly faces to offer help and support. I was really impressed with all of the staff at Gulu Regional Referral Hospital in this situation and, without my Acholi sister Karen with me, I was glad that I was surrounded by Gulu friends!

Today I went onto the ward to find two patients who were unconscious, one who could hardly breathe and then not long into the shift another patient started having an asthma attack. Now on days like these it's difficult to know where to begin and, with only one other nurse on the ward for 45 patients, I realised that we were in for a busy day!!
I started work going to look at our unconscious patients who both appeared to be surprisingly quite stable and not requiring anything urgently. I then went to a very unwell looking lady who was gasping for breath! After recording her observations and finding them to be extremely unsatisfactory I put up the fluids that were prescribed and went off to A and E to find the Oxygen Saturations machine (to measure her oxygen levels) and a Doctor as our Medical Intern Doctor has unfortunately gone on leave this week, leaving one Intern working between A and E and the Medical Ward. I luckily found the Sats machine easily but then two barriers stood in my way - one was the A and E Sister who wasn't very keen to lend it to me at first (I promised I'd bring it straight back!) and the other was that there were no batteries in it. So, having signed to say I'd return it, I went off in search of batteries. These purchased from a local kiosk, I went back to my patient and found that her oxygen levels were very low. I trundled back to A and E and presented the case to the Doctor who said that he'd come straight away.
We decided to put the patient on oxygen so we had to borrow the oxygen concentrator from A and E - the Sister said that she'd come and arrest me if I didn't return it!!(I can understand her worries as things go missing very easily around the hospital because it's so under resourced that every piece of equipment is in great demand!I think that it worked in my favour that I had just brought back the Sats machine complete with batteries!) So the Doctor came up and reviewed the lady and decided that she probably has TB...he asked for some further investigations and we are now giving her the maximum treatment that we can from the medical ward: 2 litres of oxygen (a very small amount by UK standards), IV antibiotics and TB treatment if her sample results come back positive. I hope she pulls through...

Another patient today was very quietly lying on her bed under a sheet and when I asked her name it transpired that she was having an asthma attack! She was very wheezy and really struggling for breath. Just as I was going to find a Doctor the Intern walked onto the ward and he reviewed her immediately. I cannulated her and gave her some IV aminophylline and within 15 minutes she was sat up chatting and giggling with her son and daughter. When I went back to see her she gave me a big grin and said Apwoyo Matek! (Thank you very much!)