Matthew Doe / General Surgery Registrar / South West Deanery
Surgical Registrar Mr Matthew Doe, on the challenges and rewards of an Out of Programme Experience (OOPE) in Mbale, Uganda. From orchidopexy to burr holes: Matthew tells us about a typical week, and some of his memorable cases. With the right training and preparation, the difference that one person can make in the lives of others is profound.
Its 5pm on a Friday and I’m called to see an 8-year-old girl with severe burns. Helping her older sister cook while her father slept, she had made the fatal error of mistaking kerosene for cooking oil. 24 hours of bouncing between small health clinics and a long, bumpy motorbike journey culminated at Mbale Regional Referral Hospital, a 470-bed government institution in Eastern Uganda.
Calling her unwell would be an understatement. There are more than 60% burns of mixed thickness. Her peripheries are cold, her lips swollen and eyes red. A hasty calculation reveals she is short of eight litres of fluid and she expresses her desperate need in the characteristically direct East African way: ‘you give me water’. It’s a desperate situation.
Let’s go back a step. How did we get here? What led my wife and I to put our training on hold and spend the best part of a year in a corner of East Africa?
An Interest in Global Surgery
As a general surgery trainee with an interest in travel and charity work, I have watched with great interest the growing field of global surgery.
The concept gained its name and widespread recognition in 2015 with the publication of the Lancet Commission on Global Surgery report.(1) Thanks to this landmark research, we now know that five billion people currently do not have access to safe and affordable surgery. Moreover, there are four times more preventable deaths worldwide from surgically treatable conditions than from HIV, TB and malaria combined.
While the statistics seem to illustrate an insurmountable need, the cost-effectiveness of treating surgical conditions provides room for optimism. Surprisingly, surgical services more than pay for themselves in saved disability adjusted life years and subsequent economic growth. We now know that operations like repair of hernia or cleft lip and palate are far more cost effective than public health initiatives such as seatbelt awareness campaigns or even direct treatment of communicable diseases like HIV.(2)
My interest in this topic led me on two occasions to the Global Surgery Frontiers conference at the Royal College of Surgeons in London. Inspired by the stories of consultants and trainees working in partnership with colleagues in low-income countries, I decided to arrange a placement of my own. That said, I chose to take my time and wait until I was a little later in my training and more comfortable with emergency operating. The truth is that any doctor at any grade can be immeasurably helpful in the right place, but I chose to ensure my surgical skills were up to scratch before leaving.
Preparing for Launch
Being a numbered trainee, the best way to take time was to arrange an Out Of Programme Experience year (OOPE). I arranged to spend the first two months of my year shadowing in plastics, paediatrics and obstetrics, as well as locum on-call shifts to help fund the trip. I also did Mr David Nott’s ‘Surgical Training for Austere Environments’ course, which was fantastic cadaveric training that I’d recommend to any surgeons considering similar experience.
Mbale Regional Referral Hospital
My wife and I spent a few months researching where best to work, getting in touch with various hospitals and charities in East and Central Africa. In the end we settled on Mbale, Uganda. Mbale is a small town with a population of around 90,000, but it serves a much wider region right from the Kenyan border in the South to Soroti in the North. The hospital is a 470 bed government regional referral unit, and with a catchment of 4.7 million, it is the busiest of its kind the in the country.
The hospital is big, but by no means big enough. There is a busy casualty, 6 operating theatres and access to sub-specialist care such as ophthalmology, ENT and endoscopy. More than 60,000 patients are seen each year, 5000 of which undergo major surgery. That said, the majority of the services we take for granted in the Western world are absent – notably there is no intensive care and no CT scanner. Major staffing issues mean patients on a 50-bed ward are often cared for by only one nurse. Porters, scrub nurses and health care assistants are non-existent.
Supplies of drugs and sundries are limited and, while healthcare provision is theoretically free, patients will often have to purchase their own antibiotics, sutures or surgical gloves. The wide catchment area combined with an ingrained hesitancy to seek medical care means that many patients present very sick indeed – sometimes several days into a life-threatening illness.
A Typical Week
The work was tiring but unquestionably rewarding. A typical week would start with a morning outpatient clinic where I would see 30-40 patients. Every Tuesday was a grand round of our 50-bed surgical ward, followed by up to 12 hours of elective operating on a Wednesday and endoscopy on Thursday. Emergency admissions were ever present and there would often be two or more theatre cases every afternoon.
Theatre was a challenging working environment. Quality instruments were limited and the autoclave was temperamental. Any overnight rainfall would inevitably delay our list as the linen failed to dry in time. During the three months of dry season there was no running water and the temperature was typically over 30 degrees in an operating room with little airflow. Cotton gowns quickly soaked through with blood or bowel content so a thick apron was essential, as were masks, goggles and double gloving given the risk of transmissible illness. Sweat would drip from my forehead down my nose, meaning I would need to entrust a watching medical student to catch drips in a swab before they fell into the patient.
But despite these challenges the work was incredibly worthwhile. Sadly, patient’s expectations were often low. ‘This is Uganda’ was a common expression used to apathetically explain away the string of disappointments associated with accessing quality healthcare. This made it all the more rewarding when things did go well, especially when the team performed life-saving care in austere circumstances. I remember vividly the power and water shutting off late one afternoon just as we were to start three emergency cases across two theatres. Any developed hospital would have quickly moved the patients elsewhere, but with no other option the team ploughed on by the light of smart phones and with the little instruments and linen available. All the patients did very well and even left hospital later that week.
Being one of a handful of general surgeons serving five million people exposed me to a huge range of pathology. Common cases included gastric perforation, sigmoid volvulus, obstructed hernia and intususseption. Interestingly, tropical surgical complaints such as abdominal TB or typhoid perforation did occur, but were few and far between. General surgery in Uganda really is general and I quickly learnt to perform previously unfamiliar procedures such as split skin grafting, paediatric orchidopexy and burr holes for intracranial haematomas.
Quite often the small health centres in rural areas will have one or two medical officers assigned there. The work for them quickly becomes overwhelming, so it’s not uncommon for the poorer or less vociferous families to be ignored. One 7-year-old boy came to Mbale having been neglected at one of these centres an hour away. The puncture mark from a snake bite on his ankle 6 weeks previously had turned to an ulcer and by the time he’d reached us the leg was gangrenous and the thigh full of pus. He was cachectic, conscious, moribund. We performed an emergency high above-knee amputation, but had to leave the stump open, such was the extent of the infection. Amazingly, the child survived and it was joyous to see him return to clinic two months on, smiling, laughing and very confident on his new crutches.
Another success story came in the form of a six-month old baby with intususseption. At 10pm, after a long day’s elective operating, the baby was brought to the doors of theatre septic and distended. Uncomfortably fresh in the memory were our last two cases of infant intususseption, both ileo-rectal, both died the night following surgery. With no access to higher dependency care, the postoperative monitoring and attentive nursing care we need simply wasn’t available. That said, there was no option but to operate, it was their only chance. Once again the intususseption reached the rectum and once again the patient required a subtotal colectomy. Towards the end of the operation access was lost and we hastily fashioned an ileostomy as the baby came round. The baby was handed over the ward staff and I expected the worst. A feeling of dread came over me as I walked into the ward the next day, but miraculously found a crying baby with a functioning ileostomy. The baby was discharged a week later and is still going strong several months on!
Endoscopy, endoscopy, endoscopy
Thursday mornings were always spent in endoscopy. I initially worked alongside a gastroenterologist who was very proficient in upper GI procedures. This meant we could perform up to 16 tests each week, many of which would sadly reveal obstructing oesophageal cancer. However, my colleague was offered a promotion as part of a move to another hospital leaving me to run the department (!) It became clear that no one else in the region was trained to perform endoscopy so we were faced with the possibility of closing the only unit of its kind in the whole Eastern region once I left.
Fortunately the charity PONT that had set up the unit 10 years previously wouldn’t let this happen and they funded an endoscopy ‘camp’, which allowed us to perform 148 upper GI endoscopy procedures over seven days. Crucially, one of my colleagues was able to join in and he quickly became proficient. Since I’ve left he’s been in regular contact and the weekly list has been allowed to go on, saving hundreds of patients from a six hour journey to Kampala or, more likely, no test at all.
The First Surgical High Dependency Unit in Eastern Uganda
Working as a volunteer provided me with the freedom to make my own timetable and I spent my last three months focusing on development projects. Without any higher level of care we would often grit our teeth with anxiety as we handed over a very sick patient to the ward post operatively. A lone nurse on a 50-bed ward is never enough to safely care for these sick patients. The statistics back up our concerns too – an audit (4) carried out before I arrived in Mbale showed that 22.4% of patients (average age 25 years) were dying after laparotomy – twice as many than in the U.K. where the patients are typically older (average age 67 years) and 55% of high-risk patients are admitted to HDU.(5)
For this reason, it was a pleasure to co-lead a project fundraising and preparing the first surgical high dependency unit in Eastern Uganda. The idea had long pre-dated my time in Uganda but as an extra pair of hands I was able to help secure funding from the Royal College of Surgeons of England Christmas Appeal, procure specialist equipment and facilitate training. The whole project was incredibly rewarding and it was a special pleasure to attend the opening ceremony on my very last day in Uganda.
‘You Give Me Water’ continued…
But what of our 8 year old? Well we managed to get access via a neck-line and rapidly poured in fluid to replace her considerable losses. A slug of ketamine anaesthesia allowed us to clean and dress her wounds. She gradually came round in the arms of her mother who was able to finally to give her a drink and a cuddle. She was transferred to the specialist burns unit in Kampala and as far as I know, has survived the ordeal. Her sister was not so lucky and sadly passed away in the night. Such is the grim reality of this setting.
As I write these words I feel a familiar lump in my throat return. Working in Africa is a rollercoaster of emotions; I have never experienced such despair, but equally never experienced such hope. I would strongly recommend a similar trip to anyone considering it. I assure you that the difference you can make is far beyond what you can imagine. Anyone of any grade can be useful providing you choose the right placement. Please feel free to get in touch with me if you’re interested, I would also recommend linking up with the Global Anaesthetic, Surgical and Obstetric Collaboration, a group of trainees passionate about global surgery.
If you’d like to financially support the day-to-day work of the incredible team in Mbale RRH then please do donate to PONT or Born on the Edge, any donation large or small will go a long way to support a people in desperate need. You can get in touch with Matthew via Twitter: @drmatthewdoe.
Photos: Matthew Doe, Vanessa Champion, Christopher Mullen.