I've had to combine yesterday and today's blog as the internet died on me last night, along with it being quite busy in terms of preparing to travel back. As most of the team begin our journey back to the UK today, leaving only 5 of the English team behind, it was our last big follow up and teaching clinic. We still saw 85 new and about 130 follow ups however!
Amongst those seen in Nakaseke were only one child with malaria compared to many in our Bombo clinics, Elvis (in the photo below - a gorgeous boy with cerebral palsy who always runs up to us for a hug, giggling, grinning and celebrating) and Baby Sarah. If you read my blog when i came to Uganda in the Summer, you might remember me describing a baby who was severely malnourished and who's life the team valiantly saved by rushing her to hospital this time last year. When we saw her in the Summer, she seemed to be growing well but, now 14months old, she appears to be significantly malnourished, with poor head control. Therefore, we are sending her to Kiwoko Hospital for nutritional enhancement.
Hadija is Baby Sarah's 14 year old half sister and she has had an incredibly traumatic past 4 months due to a multitude of problems. I was able to spend time with her yesterday and she bravely described the horrors that she had experienced. Despite her incredible resilience, understandably, these experiences have taken their toll on her so I will refer her to a Child and Adolescent Psychiatrist in Kampala with whom I am in contact.
During the clinic, Meg and Mike were able to visit Evelyn at home. She is a girl that the January medical team in 2017 found face down in dirt, in a shed that her family had locked her in. She has learning disabilities so her parents locked her away due to her being so vulnerable. Yesterday however, when Meg and Mike visited, she was being locked up for far less time, sat up and even walked around the house, beaming! The team continue to work with the family regarding Evelyn's safety and isolation but unfortunately this takes time. There was however a significant improvement in Evelyn's presentation since last year.
Another home visit was to a woman with a complex HIV related skin condition and contractures to both her feet, which meant that she could only crawl. We are doing all we can as a team to ensure that she receives the most appropriate treatment.
I saw a few people with epilepsy yesterday, including my lady who had been treated horrendously by her step mother. She had returned to the clinic as i asked her to in order to review her medications and notes. It appears that, although she hears screaming auditory hallucinations, she only takes anticonvulsants and has never been diagnosed with psychosis. I have referred her back to Butabika in order for them to investigate this further and hopefully to treat her. They were struggling with the funds for transport to this hospital so we will ensure that we help here as much as possible.
In psychiatry, our examination is the mental state exam, an assessment that can only be completed by taking a thorough history from the patient. Although I have been to uganda 4 times previously, I don't think I had previously realised quite how hard it was to conduct a Mental State Examination through translators who are not trained in psychiatry. The Mental State exam includes reporting how the person speaks, their subjective and objective mood, and any psychotic symptoms. This is incredibly difficult to ascertain when you don't know their language and i had to ask the interpreters to give me their own report, which they were very helpful with but, as they are untrained in psychiatry, this was still difficult. An example of this is that one of the team triaged someone and thought that they needed to see me due to hearing voices. When i asked the patient what their problem was however, this was translated as epilepsy, for which they had been started on medication previously. Another example is my lady who heard screaming: she and her mother would say "when she could feel it coming on, she would pray to stop it". It took me a large amount of time and repetitive questioning to find out that "it" was hearing screaming voices and not having a seizure. I presume that this is partly why epileptic patients are treated by psychiatrists here in Uganda, as the fits seem to be thought of as similar to psychosis.
In addition to this, you have to have ask personal and difficult questions that are phrased carefully, along with reflecting statements back to patients, in order to show them you understand/ have listened to them, along with sometimes highlighting things that they may not have noticed otherwise. This is very difficult again through a translator who is not trained psychiatrically and also must be very difficult for the translator to ask such difficult questions eg about suicidal thoughts, when they have never done this before. One tried so hard to keep the patient positive that he laughed and joked throughout but this can sometimes minimise symptoms. I have to emphasise however that all the translators who I've worked with have been incredible, compassionate and very knowledgeable, and i do not expect them to be trained psychiatrically, but i feel it is important to reflect on such challenges.
In the afternoon yesterday, we held the final women's and mental health teaching sessions. Around 25 attended the womens health group and many asked questions, about similar myths. The women's health teaching overall appeared to be very helpful and important, uncovering so many myths about contraception, sex and the menstrual cycle. Meg and Kirsten should be very proud of their incredible work.
Only 2 attended our mental health group but it was the most intense session of all! One young teen appeared to cry throughout the session but stated that this was due to her "flu" (meaning watery eyes and blocked nose in Uganda). The other lady of a similar age had a baby with her but seemed to focus on the teaching well despite the baby fidgeting. When i asked the girls to try to breathe quickly with me in order to demonstrate the physical effects of low carbon dioxide and how it can make people worry more, the young mum only took 4 quick breaths before going into a type of pseudo seizure/ panic attack. Tony grabbed her baby to keep him safe and i just held her, telling her to slow her breathing down. Unfortunately, the translator was panicking and thought she could not hear me due to thinking she was having a true seizure (however she was responsive so i was not tkk concerned). After reassuring both the translator and then the young mum, we were able to contain her high emotions and calm her down! Although i did not want to frighten her as i did, we were able to explain about panic attacks and anxiety, along with how to control them very clearly through this experience which was great as this young woman had suffered many similar episodes before. Tony and Sarah again taught and spoke brilliantly and passionately and i think that, although there were only 2 people who came to it, the teaching felt really worthwhile.
I have been writing this blog intermittently on the journey back today! I started writing it on Wednesday night, then continued it at a beautiful hotel by Lake Victoria and near the airport where we had a wonderfully relaxing day in and out of a swimming pool and soaking up some last few rays while we still could!
I have then continued this blog writing at the hectic and stressful Entebbe Airport. Here, we had to go through 2 sets of security scanners, 2 passport checks and a check-in desk where the system wasn't working so the poor staff had to write everything down! At each point we had to queue for a very long time, sweating and batting off mosquitoes as we waited, before finally being shepherded into a stuffy gate area with no toilets unless you went back through security! Even the incredibly positive Peter Gregson struggled to find any positives in this airport!
We are now in Brussels Airport which is an all together different experience! Unfortunately however, after a few hours of broken sleep on our overnight flight from Uganda, we've just found out that our flight is delayed with no reason given and the time keeps increasing... We're so close to home.... Almost there!!!
Thank you so much for reading through my daily wittering! If I've sparked your interest or you have any questions, please get in touch with me! Who knows, you could even come with me next time!
