With only 75 specially trained general surgeons for a population of 30 million, it is unsurprising that there are considerable challenges facing clinicians in Uganda. In this article the author describes his experiences working in the A&E department of a busy teaching hospital in Uganda’s capital Kampala. He describes the day-to-day routine of the unit and explores the unique problems facing the country’s health service.

INTRODUCTION
Uganda has a population of approximately 30 million, a gross national income per capita of $880 dollars (compared to the UK's $33,650) and a life expectancy of 49 years for males and 51 years for females. The incidence of deaths in those under five years of age is 134 per 1,000 and $143 is spent on health per capita, a sum dwarfed by the UK's $2,784 [1].

During the spring of 2010, the first author (from here on referred to as YZ) had the opportunity to carry out a medical elective in Uganda. He was based at the Mulago National Referral Hospital (a tertiary referral centre for the whole of Uganda), a government-run 1,500 bedded hospital in the capital Kampala [Fig 1]. Mulago Hospital is the primary teaching hospital for the Health Sciences department in Makere University. It has an average of 120,000 inpatient admissions and sees 480,000 outpatients annually.

YZ spent eight weeks in Mulago Hospital. Although this is a short time to fully appreciate the complexities of how such a centre operates, it was enough to glean an idea of how some of the departments operated. Of the eight weeks, four were spent on the surgical side of the accident and emergency department (A&E).

THE DEPARTMENT
The A&E is split into surgery and medicine. Patients are triaged in the waiting area by a staff nurse, and patients who require surgical assistance are sent to the four-bedded casualty room [Fig 2]. This is staffed by one senior doctor and often only one senior house officer (SHO) junior-grade doctor, two nursing staff, two porters, two or three medical students and two or three elective medical students. The room next door [Fig 3] contains resuscitation medication and a defibrillation machine, but electricity is only available intermittently. Patients often have to lie in the corridor waiting for one of the four beds to become available. Patients were assessed in A&E and are either admitted or referred as an outpatient after investigations, treatment or medication have been prescribed. In this confined space, turnover is quick and patients are often treated and moved within an hour or two.

The most common surgical cases in this region of Africa are caused by injuries, obstetric emergencies and malignancies[2]. Conditions such as rectal prolapse [Fig 4] are also known to present to the emergency department.