Elective Report – Kiwoko Hospital, Uganda
John Hutchinson, 2006
Kiwoko Hospital
PO Box 149
Luwero
Uganda
I spent an amazing 6 weeks at Kiwoko Hospital, Uganda. I wanted to do my elective in Sub-Saharan Africa, and narrowed it down to Uganda, Malawi or Zambia. I chose Kiwoko based on a number of positive reports from previous Nottingham students, and had a fantastic experience, both in terms of the medicine, the hospital community, and the country and its people as a whole. Hopefully this report will give some insight into the hospital and my time there, and why the experience was so beneficial.
Background
Kiwoko Hospital is a mission hospital in central Uganda, around 2 hours north of Kampala, the capital. The village of Kiwoko is located 14 km from the main road, and the hospital is a significant presence there. It was founded in the late 80s by a Northern-Irish GP, who came to the area in the aftermath of the civil war that raged in the country, and particularly the Luwero region, during the mid-eighties. Since then the hospital has expanded significantly, from original clinics held beneath a tree to a 220-bedded hospital with a strong reputation in the country, attracting patients from a vast area.
The hospital is classed as private-not-for-profit, meaning that patients pay more than they would at a government hospital, although fees are heavily donor-subsidised, and the care received is generally perceived to be of higher quality. The hospital has four main wards: male, female, paediatrics and maternity, plus an impressive neonatal intensive care unit (one of the best in the country), 2 theatres, two non-acute wards (nutrition and TB), a busy outpatients department, a well-stocked laboratory, and wide-ranging community programmes. These facilities are spread out over an attractive site that also features staff accommodation (including the guesthouse used by medical students) and a nursing and laboratory assistant training school.
The hospital staffing obviously varies, but during my stay there were four doctors: a GP from Northern Ireland, a Paediatric Surgeon from Germany, and two Ugandan doctors. An SHO from the UK was also present, doing a 3 month post, and several other temporary foreign staff were scheduled to come for periods during the rest of the year. Four ‘clinical officers’ (almost doctors and generally fairly impressive in terms of their knowledge) manned the outpatient department (OPD). There were a few other non-doctor ex-pat staff members, notably the programmes manager and his wife (from the UK), who were the main people looking after us on arrival and during off-the-ward times. Nurses on the wards were ably supported by students from the nursing school and patients’ ‘attendants’ (a friend or relative) who would do most of the personal care role taken by nurses and health care assistants in the UK.
Kiwoko was set up by a missionary doctor, and is run by the Church of Uganda, so there is a strong Christian element to the hospital. I was advised on applying that ‘while the ethos of the hospital is Christian, students can be of any faith or none’. There is, however, an understandable expectation that students respect the beliefs held by those at the hospital, and the majority of staff are fairly devoted Christians. Practically this means students are expected to attend ‘Morning Prayers’, a daily session of Christian-based speaking, and no alcohol is allowed on the hospital site.
Medicine at Kiwoko
There were 3-4 medical students present at any one time when I was at Kiwoko. We would generally decide on the Monday which ward we would spend time on for that week, and rotate around the various wards during our stay. However, it was fairly flexible in terms of what you wanted to do, and generally all staff (except a couple of scary Sisters) were very welcoming.
The day would start at 8:15 with ‘Morning Prayers’, a 45-minute ‘assembly’ of the majority of hospital staff, featuring singing, notices and a sermon-type address on a Christian issue. Following this, the medical staff would get together for the Doctors’ meeting, featuring a review of the night’s on-call, discussion of interesting or difficult cases, and presentations on educational topics. Students were invited to do brief presentations during my time there, which was a good way to get involved and learn about a new subject – I did neurological complications of HIV/AIDS, someone else did snake bites, and so on. After the meeting we’d have some drink and snacks, before heading to the wards for the rounds. Previous to my time at the hospital, ward rounds had started at 7:30, with the sickest patients being reviewed in the first 45 minutes – this still happened on one of the wards and may start up over the whole hospital again in future. Ward rounds would often last most of the morning, before a leisurely lunch between 1 and 2. We would then return to the wards to clerk any new patients, review those from earlier, and do anything else that needed doing.
Generally the morning round would be with the doctor covering that ward, with the afternoon alone unless you needed to call the doctor for anything serious. Given that all ward patients had been seen in OPD by one of the clinical officers, there was always at least a potential diagnosis to get you started, and usually a basic management plan suggested. This helped a lot in the early days with weird symptoms and no knowledge of local treatments. The nurses were also very helpful in advising on usual drug doses and routine treatments, and there were old BNFs lying around everywhere. Occasionally there would be no new patients, and you could either spend the afternoon in the guesthouse with the nurses calling you if anything came in, just chill on the ward chatting to the nurses, or go somewhere else to see what was going on.
Clerking patients was generally fairly simple. Although the official language in Uganda is English, local languages are the mother tongue. At Kiwoko this is Luganda, the largest and most widely-spoken of the tribal languages (and so useful for weekends at Kampala, where using the basics will impress people). Surprisingly few patients spoke English, so the nurses would translate. There were the occasional long debates followed by one word translated answers, but generally nurses were incredibly patient and helpful, even if you obviously had no idea what was going on. After getting a history and doing an examination, you would write up the notes, give your impression, and suggest management and write up drugs. Initially I was wary of doing this without getting my suggestions reviewed, but later became happier giving some basic meds and ensuring the patient got seen later if needed.
Basically I had the role of a house officer – a second doctor on ward rounds, and ward doctor in the afternoon. I found this to be a perfect level of responsibility for me, as I was able to do lots but still had the support of other doctors to back up my inexperience. I was able to develop basic skills, become more confident in my role as a doctor (nurses basically see you and treat you as a doctor) and get fully involved in the cases on the ward. In terms of practical procedures, nurses do all cannulas, catheters and so on, but I did several ascitic and pleural taps, and would have easily been able to do lumbar punctures. Due to not being Hep B immune, the med school advised me to avoid invasive procedures and theatre, so I didn’t spend much time there. However, another student who was a keen surgeon spent every afternoon scrubbed up, so there was the opportunity to do this if you wanted to.
I spent my first week on Female Ward, the busier of the two adult wards. The caseload here was a mixture of HIV cases (referred to as ‘ISS’ – for immunosuppressed state/syndrome), TB, pneumonias, familiar things like diabetes, heart failure and hypertension, and a strange tropical condition called endomyocardial fibrosis (EMF) which results in recurrent gross ascites that requires tapping. Often we had a collection of symptoms that never got a diagnosis, due to limitations in investigations and occasional spontaneous improvement. We were able to do a surprising number of basic tests, but as patients pay for each test, you couldn’t just order them with the frequency you would in the UK. A fair number got an Hb, WCC + differential, and B/S (blood slide) for malaria parasites, but others were rarer. I had one woman with abdo pain and considered LFTs, but these cost the equivalent of £1 for each individual component (a significant amount), so I spent a long time debating the worth before settling on just AST, Alk Phos and Bilirubin. X-rays and Ultrasound were available, but CT, echos and so on would require a referral to Kampala and often be too expensive.
The most difficult cases on Female were ISS patients that came in very ill, often with decreased conscious level, dodgy respiratory signs and numerous other symptoms. The differential included bacterial meningitis, but also the HIV-associated neurological complications such as TB meningitis, toxoplasmosis and cryptococcal meningitis. While we would get in there with oxygen (usually worked OK) and iv antibiotics, lumbar puncture would often be difficult or non-contributory, and in several cases during my time at Kiwoko, these patients would pass away soon after admission. I was originally surprised to be nonchalantly told by a nurse one day that a patient like this had died, but we grew to realise that the staff must have seen so many HIV patients come in and die that while not ‘normal’ it was certainly not an unusual occurrence.
My second week at the hospital was on Paediatrics. This was by far the busiest ward – cots lined up in three columns across the ward, with the vast majority of cases having malaria +/- anaemia. Paeds admitted patients aged 5 and under, with older children going to Male or Female wards. I soon got used to the clerking routine (having not done paeds since early 4th year) and by day two I was confidently writing up quinine doses and making management plans. The ward round took ages on Paeds due to the huge number of cases, and initially I was simply the scribe for the doctor, but later took patients on my own. It was a bit weird reviewing random kids that I wasn’t familiar with, but generally it followed a pattern. There were also cases of gastroenteritis and malnutrition, and several interesting surgical presentations of large lumps that had been steadily increasing in size for some months before the child was finally brought to medical attention. These were generally given an ultrasound, before biopsy, and either referral to Kampala or resection at Kiwoko.
My third week was on Male Ward, which was initially fairly quiet, perhaps due to the reluctance of men to want hospital admission. However, numbers increased during the week. On the medical side, there was a mixture of HIV/AIDS, TB, malaria, and respiratory and gastro infections, and on surgical side, there were some older guys with hernias, several abscesses, and a regular supply of trauma due to road traffic accidents. Clinical signs were impressive: big spleens, widespread crackles, dodgy chest X-rays and so on. One patient had a blatant pneumothorax – it later turned out this had been diagnosed several months earlier at another hospital, but he had been unable to pay for the chest drain, and so had to leave without treatment – he had since returned due to the breathlessness getting worse. Another patient had an abscess over his right biceps – when aspiration was attempted, it was found that this was overlying an arterial aneurysm – he was keen for surgery and eventually underwent a 9 hour operation to repair this, but sadly died of complications several days later.
Kiwoko has a strong community programme, and they encourage students to spend some time exploring this during one week, which I did in week 4. This is all donor-funded, and includes several projects centring around HIV/AIDS, including a weekly clinic, home visits to follow-up non-attenders and deliver antiretrovirals, and work with orphans. Other parts of the community work include immunization visits to rural villages, and a Youth Friendly Centre, a facility in Kiwoko town that works with adolescents to address health promotion issues alongside usual youth centre type activities. A weekly clinic with a doctor and nurse allowed people to receive drop-in advice, diagnosis and treatment regarding STDs. Apart from the fun of riding on a motorbike down random paths through the bush and meeting crowds of excited kids, the community work was a great way to experience the local community beyond the confines of the hospital site, and also showed how much need there was among the population, and the benefits that health promotion could achieve. I spent some time discussing Uganda’s progress in tackling HIV/AIDS with one of the community workers, and it was reassuring to see the passion the staff had for their work.
I spent most of week five on the Neonatal Intensive Care Unit. This was a valuable experience that I had not obtained back in Nottingham, and I was able to practice my neonatal examination skills, see the sorts of conditions common in neonates, and get an overview of management plans. I was fortunate to have the tuition of a British SHO for most of my time, and it was clear that she would be missed after her departure. During my week she was called numerous times to emergency C-sections late at night, and I would arrive in the morning to find a resus going on, or a detailed discussion with the Sister concerning treatment options. Many of our discussions in Doctors meeting concerned neonates: how to continue treatment when no venous access could be obtained, the best way to treat severe jaundice given concerns over our phototherapy lights, and so on. Despite the numerous sad stories that emerged from the neonatal unit, it was also a place where those babies who would not have had a chance elsewhere could receive excellent treatment and later went home with delighted, thankful mothers. Due to Kiwoko’s facilities and reputation, difficult obstetric cases would come from far afield, and so theatre and the NICU were constantly busy.