By Dan Denniss, Queen Elizabeth Hospital, King's Lynn.
I completed my PgD in medical ultrasound last year. Towards the end of my training I decided it might be useful to do a month long elective in a developing country to observe the use of radiography and specifically ultrasound in this setting.
I contacted a small hospital in rural Uganda that I had heard about through some friends who had visited for their medical electives. They said that they would be delighted to have an ultrasound ‘expert’ visit as they had recently acquired an ATL 5000 machine but did not have a member of staff qualified to operate it. This was obviously unnerving, but I decided that I should give it go.
Kiwoko hospital is situated about two hours from Kampala, the capital of Uganda, in a very remote region of the country surrounded by banana tees, elephant grass and mud huts.
The area that the hospital serves is desperately poor. Life expectancy is only 43 years old and more than 40% of people do not have access to safe drinking water. HIV prevalence and maternal mortality remain high.
The hospital is a non-profit charity hospital and has only five doctors for 222 beds. Approximately 32,000 outpatients and 7,000 inpatients are served by the hospital each year.
I found working in the hospital extremely challenging and quite heartbreaking at times. In only one month I saw more ultrasound pathology than in 18 months of ultrasound training in the UK – in general patients didn't arrive at the hospital until they were at death's door.
Many of the patients I scanned were in end-stage phases of their illnesses and were often full of free fluid and non-functioning organs. Death was a regular occurrence.
I saw several cases of end stage hepatitis B with chronic liver failure as well as a number of end stage renal-failure cases and some severe cholangitis. Many patients had advanced AIDS and associated pathology.
I certainly felt quite out of my depth in my first week but since they had no qualified sonographer the doctors were relying on my opinions quite a bit.
Although English is the official language of the country, most patients spoke only their native language therefore communication was often extremely difficult.
One patient came into the hospital complaining of an abdominal mass and when I scanned her I discovered an 18 week live foetus. She did not understand this and claimed that she was a virgin and it was not possible. When I fetched one of the Ugandan doctors to explain in her native tongue she still wouldn't accept. The doctor explained to me that it is a sad fact that many young girls are sexually abused by family members and often don't understand what is happening to them.
The suffering caused by the Ugandan civil war is also still evident today. One patient I met was blind after having his eyes removed as a form of torture and was left caring for his two small grandchildren after the death of their parents.
Only one doctor and one midwife at the hospital had some basic ultrasound knowledge and much of my time was occupied with teaching them how to get the best out of the equipment and how to make accurate measurements.
As a newly qualified sonographer, teaching was a completely new area for me however I saw significant improvements in ultrasound practice particularly by the midwife in a relatively short time.
The x-ray department was definitely the most basic I have ever seen. The x-ray unit was more than 30 years old and when I arrived they were using wet developing.
Having only used CR for most of my time as a radiographer I was unable to help the two x-ray technicians improve their radiographic technique as they were already working to a high standard with the limited resources available to them (despite having no formal radiography training).
The majority of the x-ray workload was surprisingly from RTAs, most commonly motorcycle accidents. The poor quality of the roads and lack of protective clothing or helmets meant horrific injuries were a daily occurrence.
Several weeks before my arrival, the hospital had received an Agfa Curix automatic x-ray processor and a Philips BV25 image intensifier from Northern Ireland.
Image intensifiers are few and far between in Uganda. There are eight in the entire country with a population of 25 million. There was therefore considerable excitement concerning the use of the machine.
Fortunately I had previously had plenty of experience using a similar image intensifier in the UK and was able to get it up and running fairly easily. I taught two of the staff how to use it and wrote them an instruction guide and a diagram of how the buttons work.
We managed to perform retrograde pyelography and a micturating cystogram under fluoroscopy control. Perhaps the greatest difficulty was trying to emphasise the ALARA principle and the importance of radiation protection as the technicians were fairly ‘trigger happy’ with the exposure button!
The staff at the hospital had also anticipated that I would be able to install the x-ray processor. This was also well out of my comfort zone, however after some internet research and several long and expensive phone calls to Agfa and one of my x-ray engineer friends in the UK, I managed to get the processor working in the tiny darkroom.
It was very humbling to hear the two x-ray technicians saying that they had seen such things in books but had only dreamt of using one.
One of the greatest frustrations in both x-ray and ultrasound was the lack of reliable electricity. While the hospital had it’s own generator, this was only turned on for several hours each day and the rest of the time we relied on the national grid. There would often be no electricity at all from 4pm until 9am the following morning.
While my accommodation was of a high standard for this area of Uganda, it took a while to get used to using an outdoor latrine for a toilet and sharing a bedroom with a host of cockroaches and mosquitoes!
Overall, although I was faced with many challenges, I found my experience in Uganda invaluable and would recommend an elective like this to any student or qualified radiographer.
• SoR membership entitles you to professional indemnity insurance for your elective placement abroad. Indemnity cover is worldwide with the exception of work in the USA and Canada. For more information contact Cherie Slate in the membership department.
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