Thursday, 31 December 2009

2009... same difference?

What did 2009 bring? Indulge me here, while I get a bit deep and philosophical... I have had some time for reflection whilst I've been home over the Christmas period. I've been able to catch up with old friends and family and for the first time in ages, check my head. The nice thing about coming home after being away for 4 months is the realisation that despite the fact that many things have changed, everything's still the same.

2009 was the year when I grabbed the bull by the horns, bit the bullet and faced all sorts of other metaphorical perils and hazards face on. 2009 was the year that I decided to fulfill a life career ambition of doing obstetrics and gynaecology in Africa. The decision to take a year out of program to work in Uganda is probably the biggest and most uncertain that I have ever made. Having never travelled on the African continent, I was charting unknown territory, on my own. It still scares me if I think about it for very long! Having thought about it a lot over the last few weeks I have come to the conclusion that it is the hardest thing I have ever done, the most frustrating thing I have ever done, the most acute learning curve I have tackled, at times fantastically rewarding and an experience that has taught me more about myself than anything else ever has. It has made me realise just how many people touch your life, in so many different ways. Mulago has challenged me in more ways than I thought possible. It has tested my resilience both as a doctor and a human being, and will almost certainly continue to do so for the next 7 and a bit months.

Lots of things happened in 2009; people got married and engaged, some had children, some are still waiting to hatch, a lot of people loved and a lot of people lost. And me? Well, I just plodded on, business as usual until August 13th. And then I stepped into the (metaphorical) abyss. I remember someone once read a verse out at a conference, referring to uncertainty, written by Guillaume Apollinaire. I distinctly remember it because I had a stinking hangover after an evening of wine tasting and subsequent shenanigans in Melbourne that resulted in my laptop drinking a glass of wine and ending up in hospital. The quote was ;
'Come to the edge, he said. They said: We are afraid. Come to the edge, he said. They came. He pushed them and they flew.'

That quote rang very true to me as the time came to leave for Kampala, and it was my pride that did the pushing, because when it actually came down to it, I didn't feel brave enough. Sometimes being proud and stubborn can be a good thing. I'm pleased I went to the edge, and I'm pleased I was pushed, although I'm not sure that I am flying with any grace or finesse just yet.

So what have I learned?

I've learned that one person doesn't change things, but that little by little you can begin to change the way people think, and changing the way people think changes the way things get done. Changing the way things get done maybe, possibly might change the world. A little bit.

I've learned that one pair of hands can only do one thing at a time.

I've learned how to reflect. Not in the way that our portfolios do, but in the way you sit on the theatre floor, head in hands, crushed because you couldn't get hold of any blood, and that a unit of blood might just have made the difference. And the way you change how you do things because this time you were just lucky, the way you learn from not having stuff that you take for granted to hand, or not having a team of 6 people working and focusing on one problem together.

I have learned the importance of having colleagues that will go the extra mile, but also the importance of acknowledging those colleagues, and appreciating them. When the propellor and the proverbial are having a meeting, it's a lonely place to be on your own. So to all of you who go the extra mile on a daily basis, thank you, you're stars, whether you're in Mulago, Liverpool Women's, Arrowe Park or Leighton - and not in any particular order. That extra mile might be running to Nakasero Hospital just to see if they've got another unit of blood at 4am, or making a shift of knackered people a tray of much needed tea, or being kind to someone when inside you're broken and you don't feel like it any more. But the little things sometimes make as much difference as the big things, so please keep doing them , they are appreciated.

I've learned that we probably don't need all those shiny silver things with obscure archaic names that look a bit scary that live on the section tray in theatre... but they're nice to have! Sometimes you don't even need a blade handle.

I've learned what all the fuss is about catgut... 'If only I had a length of catgut...'

I've learned that I am stronger than I think I am, and yet I am more sensitive than ever before.

I've learned that the things you think will get to you don't at the time, but come back and hit you when you're least expecting it.

I've learned that we should all talk less and do more. In the words of the late, great Elvis Presley, 'A little less conversation, a little more action please'.

I've learned lots of other things too, so many that I'd bore you. I'm the same as I was when I left, but I'm different too.

What else? I know that being able to write this blog keeps me afloat, being able to email people and vent has kept me sane, and the support that I have received from friends and family has been immense. I was overwhelmed by the number of people I saw over Christmas, braving the snow and ice, before and after nightshifts and long days, operations and the dreaded lergy to come and say hi. I guess you don't really appreciate what you have until you leave it behind. Thank you to each and every one of you that has listened, advised, encouraged and pushed me. You know who you are, and if I try to mention you all by name I'll miss people out.

So, now I'm back in Kampala, and it's a new year. My New Year's resolution? To appreciate what I have more, to appreciate the people I love more.

Wednesday, 23 December 2009

Brrrrrrrrrrrrrr!

Well, I knew it would be cold back in Blighty, but snow?! A definite shock to the system. I was grateful for my big snuggly tracksuit bottoms, base layer and fleece, and even more grateful that I had taken them to Uganda with me despite cries of 'What do you need those for?' when I was packing them back in August. Coming through the arrivals door was the best feeling, three familiar faces beaming back at me, followed by 'You're not going out in public dressed like that!' It's good to know that nothing changes!

My last week at work felt very long and was a mixed bag of challenges. I didn't go in on Saturday, choosing to spend the day doing some Christmas shopping and chilling with Adam. He's been in Mbale for the last few weeks so it was good to catch up and pretend to be a tourist for the day, hitting the craft markets after breakfast and bargaining for tacky African Christmas presents. The best thing I found was a massive wall hanging of the late Michael Jackson, badly sketched and even more badly printed, featuring, in Luganda, the timeless slogan of 'We will never forget you'. At 22,000 USH (about £8) I thought this was a bargain, but Adam disagreed, so it will not be adorning our dining room wall in the near future. Perhaps it will be in the sale when I get back...

On Sunday I went to work, putting myself in theatre on labour ward. The washing machine in the hospital laundry was broken, and we had no sterile linen. One of the senior consultants managed to acquire some brand new linen from stores, but we were unable to use it until it had been labelled in gloss paint, allowed to dry and autoclaved. We started our list of 13 pending caesarean sections at 2pm, managing to do four and a normal delivery on the theatre table by 5.30. Linen continued to be a problem throughout the week, with the operating obstetrician going from labour suite theatre to gynae theatre, depending on where the current stock of linen was situated.

I spent Monday sorting out the Midwife of the Month award, packing my stuff to take home and tying up last minute loose ends. One of our senior anaesthetic officers sadly passed away on Monday, which had an impact on morale amongst the rest of the staff. Work continued, albeit at a slower and less enthusiastic pace.

Tuesday, Wednesday and Thursday were again spent on labour ward, in and out of theatre. I seem to be having a run of arm prolapses, badly impacted heads which I have needed to deliver by the breech and sub-total hysterectomies - the second one in a week was for a bad uterine rupture. We were due to present the Midwife of the Month award on Friday, however we lost a further 3 anaesthetic staff in a car accident on Thursday, ironically whilst they were travelling to their colleague's funeral. It was felt to be inappropriate to celebrate people's achievements while the department was in mourning and so it has been postponed.

We had some farewell house drinks on Friday evening. It felt a bit strange that the surrogate family were heading off in different directions for Christmas, but we are all badly in need of a break from Kampala. On Saturday, my regular Boda Boda guy Alan was a bit miffed that I hadn't asked him to take me to the airport, and couldn't really understand why, carrying 25 kilos of luggage, I didn't fancy taking the 45km journey on a motorbike, opting for the far more sensible car. I managed to sunburn my left arm by hanging it out of the window, and arrived home sporting two totally different coloured arms and a very attractive watch strap mark, which I have avoided for the last 4 months! The flights were unremarkable for the most part, although I had a very luxurious 8 hour sleepover on the floor at Dubai.

It's nice to be at home, nice to have the creature comforts that I have missed, nice not to have to sleep under a bed net and nice be with my family. But it's a bit of a shock to the system too, and I think that I am probably becoming more of a Muganda than I have realised. That said, you can't beat a pint of real ale in your favourtie pub in the world - The Crown Posada - and a kebab, which is exactly what we had last night. All I need now is some fish and chips, some pease pudding and a parmo...not necessarily at the same time either!

Thursday, 10 December 2009

So, a Hippo Walks Into a Bar...

So, it's been a while since I've blogged. I've been crazy busy here, I'm not even sure where to start!

Prior to the arrival of our colleagues from Liverpool I had a hectic few days on labour ward, spending a fair bit of time in theatre, delivering arm prolapses by the breech and other such exciting things. It has been a testing time for me recently with lots of difficult cases and difficult deliveries, not all ending in good outcomes. A lot of the time I feel very surreal and detached when they happen. I think this is a coping mechanism of sorts, but it's not something I'm comfortable with if I think about it too much. Many of the difficulties we experience here are due to resource constraints, meaning that it can sometimes be impossible to manage patients in a timely fashion, for example a woman waited for 24 hours to get to theatre for a third degree tear repair. We are extremely lucky in the UK to have the capacity to get women to theatre within 30 minutes of a decision to deliver.

The team who had recently been to Liverpool presented their work, including a slide show of their touristic activities. A picture of Joy Acen freezing to death, wearing all of her clothes, standing on Crosby beach tipped me over the edge and I sat in the meeting blubbing away, feeling suddenly very homesick! Adam and I had a really nice Thanksgiving meal at a swanky restaurant, as Elizabeth abandoned us and went to Rwanda to celebrate. It was sedate but I was shattered so it was nice to chill out.

On the Saturday I did 6 sections, battling through 5 power cuts. I will never complain about the theatre lights at home again! Thank goodness for Ketamine! I met Adam afterwards to watch the rugby and walking towards a restaurant, I fell down a storm drain. One minute we were bounding down the street and the next I was flat on my face, one leg down a massive hole and the other flat on the pavement, with no idea what had just happened to me! A few cuts and bruises but nothing too exciting.

The team from Liverpool; Andrew Weeks, Carol Porter, Louise Ackers, Sarah Jarvis, Clare Fitzpatrick and Sarah Ryder arrived on 28th November. On the Sunday I excused myself from Labour ward to go to Mabira Forest with them for lunch. By the time we got there and ate, it was time to head back to Kampala, so we didn't get to appreciate the rainforest and wildlife. While there I got a phone call to say that someone had broken into my Mum's house and taken my car - he's currently missing in action. I'm gutted, but at the same time, it made me realise how much I have changed while I've been here. I think when you see as much severe disease and loss of life in difficult circumstances, material things become just things. More importantly, no-one was hurt.

We headed back to Kampala, and had a barbecue at my house. I asked our Ugandan colleagues to contribute typical Ugandan dishes to the otherwise Muzungu style barbecue. I was not expecting someone to bring a box of fried grasshoppers - and neither were the Liverpool lot! Still, they were certainly 'interesting' to eat, although I don't think they'll be stocking them in the international food aisle in Tesco any time soon. We had a great night and a beer or seven. Sarah had carried an SOS parcel for me containing new clothes, M and S goodies, wellies for theatre, Turkish Delights, more Marmite than you can shake a stick at and amongst other wicked things, a Rubik's cube! Louise brought me some face and foot goodies so I will pamper myself when I get a chance.

On Monday we hit the hospital, attending the morning meeting and the report from the Sunday which had been a bad day - including a woman jumping from the fifth floor window - and a shocking introduction to Mulago for our visitors. We then went on a tour of the hospital, starting with the main delivery suite. It's an overwhelming experience even just to be present there, and Clare and Sarah were no exceptions to the rule. They got a good overview of the hospital and by the time we finished the tour it was mid afternoon. We left for the evening and went out for dinner, while Andrew travelled off to Mbale on a bus.

On Tuesday, the two Sarahs went up to Ward 14 and Clare went off to theatre. I was covering labour ward off and on, and went up to check that all was well on 14. A patient was being transferred down to the main labour suite and the girls were following her down as the baby was undiagnosed breech. We got down to labour ward and were there for around 30 minutes before a woman on the floor began pushing.
How many Muzungus does it take to deliver a baby?

One to deliver (Sarah, medical student), one to direct the medical student (Sarah, Midwife), one to shout in broad scouse 'Go on sweetheart push down, right down in your bum, that's it, go on, go on' (Clare, Midwife) and one to translate the scouse into Luganda 'Sendike Nyabo, sendike!' (Me).
Anyway, the baby was delivered, followed by a swift flurry of three more deliveries on the floor in the corridor, and a quick round of neonatal resuscitation. On Tuesday evening we continued our culinary tour of Kampala, heading for Turkish washed down with a few more beers and a debrief. Wednesday morning was spent on labour ward again, and in theatre. In the afternoon we had a meeting to talk about the Liverpool Mulago Partnership and the way forward. I think it's a really worthwhile exchange and essential to drive initiatives and keep momentum, and change attitudes.

On Thursday morning we did emergency skills training for 19 midwives from labour ward, covering cord prolapse, PPH and neonatal resuscitation. The session was a bit disrupted by the lack of space but it was enjoyable and I think they learned some stuff. In the afternoon, we visited an orphanage for children whose lives have been affected by HIV/AIDS. It was a really humbling and emotional experience. The orphanage houses around 30 children, and also pays the school fees for a further 90 from surrounding villages. We had a great afternoon, Clare and Sarah brought bubbles, stickers, crayons, colouring books, felt tips and sweets. My SLR camera was kidnapped by one of the boys who had a great couple of hours wandering round taking pictures, with me following closely behind, petrified he was going to drop it, but he was so content I didn't have the heart to take it off him. By the end of the afternoon the kids all looked like they had some sort of pox, having put the stickers on their faces, the bubbles had been used up, with a few kids getting soap in their eyes, many having learned to say 'That's lush Clare' in a scouse accent and there was not a flat surface that hadn't been covered in crayon and felt tip! We decided to walk to the village to buy sodas for everyone, and Enid the orphanage manager said she was sending two strong kids with us to help carry the crates back with us. We ended up feeling like the Pied Piper, with about 15 kids in tow, and carried two of the babies who had fallen asleep on the journey! I did a couple of medical assessments, one on a child with asthma and another child with a possible appendicitis. All in all it was a really rewarding day. We had a big meal in the evening at Khana Khazana, where the curry was so hot that Clare said she was 'sweating like a glassblower's arse', which she then had to explain to Joy, the Ugandan midwife, eliciting loud cackles from their side of the table. Avner, who has recently moved into the house, and is a lawyer from New York came down and joined us with Elizabeth. A thoroughly good night all round, and the Ugandan midwives got a doggy bag - also an unfamiliar expression - to take home with them.

Myself, Clare and Sarah then went off to the Red Chilli Hideaway ready for our safari trip to Murchison Falls. We had a noisy night in the dorm there - with me apologising profusely for the budget accommodation - and an early start the next morning. Naturally we ended up on a truck with two Finnish women who talked literally non-stop for 7 hours all the way there, and one angry scouser with a migraine. After a long journey up there, we got to the top of the falls as the heavens opened, Claire having been eaten alive by mosquitoes. Walking up to the top of the falls was an awesome experience, the power of the water was immense. After taking some photos, and helping two stuck trucks out of the mud, we made it to the camp, where we stayed in semipermanent tents, falling asleep to the sound of scavenging warthogs.

We started the next morning with a game drive, crossing the river as the sun rose. We were greeted on the other side by a breakfast robbing baboon, before driving off through the bush in search of the big five. We found giraffes very quickly, then elephants. I will never forget the abundance of wildlife that live alongside each other in that space. We then happened upon a lioness who was sitting in a tree which seemed a bit bizarre, until we realised she was watching an Oribi - a small antelope. She climbed down from the tree, stalked across the grass, and in one swift stealth move, grabbed it by its throat and killed it. An incredible and rare thing to see, we felt blessed. After finding some more elephants, buffaloes, giraffes and crested cranes, we headed back to the lodge for lunch. In the afternoon we took a boat launch to the base of the falls, spotting hippos, crocodiles and kingfshers, drinking Nile on the Nile, catching some rays and chilling out. For three hours, Sarah didn't even have to evacuate her bowels! In the evening we sat in the bar, in a roaring thunderstorm, when in walked a hippo. Well, into the beer garden at least... incredible. It shuffled round a bit, sniffed the ground and then buggered off back to the river!

On Sunday, we went to Ziwa Rhino sanctuary, tracking the rhinos on foot and getting within 5 metres of a male and female. It was a gobsmacking, and slightly pant browning experience, but a real experience. We got back to Kampala, exhausted but really happy.

On Monday we threw our noses back onto the grindstone, working on adapting the Maternity Early Warning Score for Mulago. Amusingly, we're going to call it AMEWS. Using the magic whiteboard that Clare brought with her, we constructed charts using colour coded pens to stick on the wall in the recovery area. On Tuesday we bumbled round on labour ward, putting the AMEWS stuff up on the walls, creating a flurry of excitement. We then arranged to have two blood pressure machines which had been bought for the hospital by two friend mounted on the wall. I took a trip to the workshop, bracing myself for the long paper trail that's usually involved in these things, found a guy called Robert who came back up to labour ward with me. He drilled holes in the back of the machines that afternoon and mounted them onto the wall the next day. I was amazed! We put one up in the post-op recovery room and one in the admissions room.

Within around 30 minutes of Robert finishing the work, a woman came in with a massive antepartum haemorrhage and a stillbirth, bleeding profusely. We couldn't get her into theatre immediately and there was no blood available, so Sarah and Clare monitored and resuscitated her with fluids in our newly created room, using the AMEWS chart on the wall to keep track of her condition. We managed to get her into theatre and delivered the baby by caesarean, but unfortunately had to do a subtotal hysterectomy. She eventually got blood, and thanks to a good team effort is doing fine.

On Thursday morning we ran our second training session, this time on the midwifery led unit, Ward 14. 15 midwives attended, many coming in on their day off, and we trained them on cord prolapse, shoulder dystocia using a Pringles tube, neonatal resuscitation and postpartum haemorrhage. We had a great morning, the staff were really enthusiastic and asked lots of questions. It was good to try it out, with the midwives rotating around each skill and everyone having a go at hands-on. In the afternoon we went to the pub to work on some guidelines and stayed for the quiz, which we were dreadful at, but it was great to have an injection of scouse fun and humour into the evening, Clare at one point taking the mike from the MC and singing at the top of her lungs.

Yesterday morning I was in theatre, and in the afternoon after running a flat baby across to special care attended the Hospital Christmas party, a terribly formal affair to begin with. I was shattered and left early but I believe it turned into the usual drunken debauched evening that you would expect from a hospital bash. I left with a bag of goodies, including the stock of Peperami that Sarah had brought with her in case of famine... I think the dog will end up eating them. Gutted that the girls have left, it was great having them here to help keep me sane at the point where I was becoming more exasperated than I have ever been. Still, it's only a week until I head home for Christmas. I'm ready for a break.

Wednesday, 25 November 2009

The winds of change...

It's been a funny old week and a half. After the exhaustion of painting the labour ward, I was quite relieved that last week ended up being, for the most part an 'admin' week. That's not to say that I sat on my bum, in fact far from it. I spent time working on a funding proposal, attending a brainstorming session on how to improve the department so that it is more effective and efficient, with a direct impact on maternal and neonatal morbidity, doing a bit of teaching and helping to facilitate a course for midwifery staff aimed at empowerment, teambuilding and management of normal labour.

There's a huge amount of enthusiasm in the department at the moment, to change the way things are done. We're talking about everything from strategies for decongesting labour ward, setting up specific clinical areas and concepts to changing the way all staff work, initiatives to encourage teamwork and so on. A lot of it is a pipedream at the moment, but it's an achievable pipedream. I have no doubt about it. I can feel the process gathering momentum, and it feels like the winds of change are starting to blow the tumbleweed out of the department.

The other stuff I've been busy doing, is preparing for the invasion of Liverpool Women's Hospital - something I'm really looking forward to. There are 6 people coming out here next week. The group who have recently gone to Liverpool from Mulago had a great time, and have come back full of ideas and drive, to improve things on labour ward. The follow-up visit from Liverpool will add to these ideas. One of the things we're hoping to do while they're here is to set up a practical emergency skills training morning for the labour ward midwives. If this is successful, I hope that it can become a department wide, regular thing. It would be a fantastic opportunity to get doctors and midwives training alongside each other, and would help to foster the team approach to patient care that we badly need.

In between all of this I found myself on labour ward off and on, getting stuck into emergencies, while finalising timetables and the like.

Sunday was the Kampala Marathon. Since my good mates here are a bit weird, and like running for fun - I'm the kind of girl who would only run if I was being chased by something likely to kill me - I was duty bound to go and shout for them. On the face of it the Marathon seemed well organised. I decided to go to the finish line around the time I was expecting Elizabeth to finish the half marathon. Which was too bad, as it would seem that everyone running the half marathon went the wrong way and ran a route around 3 miles shorter than it was supposed to be. That coupled with the fact that competitors were hopping on the back of boda bodas to improve their times suggested that all was not as legitimate as you might expect. Justus - who lives in our compound - and I stood at the finishing strait. It was a brilliant people watching experience. The vast majority of people doing the half marathon and 10k, were evidently not serious runners, but people really doing something for themselves, for a sense of achievement. Some women ran in traditional dress and sandals, one guy ran it in socks, a number of people with significant disabilities, including one Batwa lady with severely bowed legs and another lady on crutches, competed. It was a truly inspiring morning, and for about 37 minutes I seriously contemplated taking it up as a hobby.

We were waiting for Adam to finish the marathon. They started to dismantle the barriers. And people started to walk across the finishing strait. And they opened the roads. And the cars came down the finishing strait. And there was still no sign of him. Or any other marathoners. Eventually in the distance, his lanky frame came lumbering towards us,, dodging pedestrians and traffic with a look of absolute exhaustion on his face, crossed the finish line - which by now we were standing ON, with the official photographers - and exclaimed that it was 'the most pain I've ever been in'. None of the proverbial there, Holmes. And then he got on a bus for 6 hours. Nutter.

On Monday I had a major victory at the passport office. Finally, I've been granted a work visa. That's not to say it was a stress free visit. Oh no. When you apply for your work visa, you have to go back after 7 days to see if your file number is in the book. What that essentially means is that it takes a week for your file to cross a corridor, and someone writes a (sequential) number on it and records it in a book. You then return and have to trawl through a list of numbers to find yours - which is not easy when they're all similar. You then cross the courtyard to 'room 2', where you are then advised to look for your number in another book. Unsurprisingly, your number will not be there. Nor will it be there the next 5 times you go back, even though each time you've been, you've asked the 'nice' lady behind the desk and she's told you 'next week'.

Needless to say that when I returned on Monday, my number still wasn't there, and decided to check with the 'nice' lady behind the desk, as I was concerned that the file may have been lost. The 'nice' lady behind the desk, must have gotten bored of being deliberately obstructive, told me there was no way it could be lost and sent me to speak to a man in 'room 10'. The man in 'room 10' then sent me back to the place where I'd originally picked up my file number, to find out what date the file had left this office, presumably in the direction of 'somewhere across the courtyard'. Once I had this, I went back to him. He looked through several lever arch files, several times, huffing and puffing. I was sitting there thinking about my next move and whether I was going to be looking for locum work back on sunny Merseyside in a few weeks. Eventually he located my file number, stated that the work visa had been granted and it was in the book. So I told him that it wasn't. At this point I was seriously getting worried. He wrote something illegible on a post-it note, to take back to the 'nice' lady behind the desk. She barked an order across to a man who fumbled through piles and piles of similar looking and chaotically organised files, and exclaimed that it wasn't there. The 'nice' lady looked at me, semi-sympathetically, and stated that my file 'must be lost'. She must have sensed my frustration and got someone else to double check, which was great, as the file had been there all along, and probably for the last 6 weeks. So I handed over my passport, and I have to go back next week. It feels like the kind of scenario Swann and Flanders would write a song about...

So far this week I've been on labour ward. Yesterday I kicked off my shift with a rapid forceps delivery in the admission room on a woman with a massive bleed, and a fetal bradycardia of 40 beats a minute. I realised I was doing something out of the ordinary when I asked the midwife to bring me a pair of forceps, to which the response was 'What, artery forceps?'. We shuffled the examination couch round, I ran and grabbed some stuff, and in the smallest space I've ever done an instrumental in (sitting on top of a dustbin), delivered the baby who came out screaming (thankfully). What I didn't realise until the patient stood up was that she was around 4 feet tall with a significant kyphosis. Forceps are not commonly used here, and when they are it tends to be by the old school consultants, but the vacuum extractors don't work. It's a skill I hope to pass on while I'm here. The range of pathology you see in one shift here is quite something, and no two shifts are ever the same. The rest of yesterday and today were surprisingly calm by Mulago's standards, and I spent quite a bit of time in the admission room teaching the interns. And I have finally mastered the trick of doing an ARM at 2cm with the plastic end of a needle!

Sunday, 15 November 2009

It's no Michaelangelo....

So it's been an industrious couple of weeks, where lots has been a achieved, decided and attempts have been made - although not necessarily successfully - to implement. Following fun times on Ssesse, my week was filled with ward cover on the antenatal ward, working very hard on the triage documents and getting them circulated onto the labour ward, trying to train the midwives in their philosophy and usage and then realising that without getting a critical mass of people on board, triage will not succeed. One of the problems is that where the midwives are using the instrument, the doctors sometimes aren't, the rooms are sometimes hijacked by patients who see an empty bed and want to lie on it, or there are simply not enough staff to run it. I've already had some decent feedback on the documents though, mostly positive, and we need to do a little bit of fine tuning and more intensive training and supervision.

Last Saturday, myself and some very generous volunteers trundled off to the labour ward armed with buckets, rollers and tins of paint to freshen up the high risk end, which was in desperate need of painting. It was an eye-opening experience for all of the people who volunteered. The labour ward was heaving, as ever. We decided to paint the smaller rooms first, as the large room was simply too full and the patients were too sick. Opting for an oppressive shade of forest green for one of the rooms, Adam, Jill, Julia, Maureen and I set to work masking the skirting boards and windows, mixing the paint in a futile attempt to make it lighter and the slapping the paint onto the wall. I say slapping as it had previously been painted with what looked suspiciously like gloss, making it difficult to get any purchase. Meanwhile, Elizabeth, Sungo, his girlfriend and their 8 month old daughter tackled the admission room and the neonatal resuscitation room painting it a slightly more pleasing shade of baby blue. In my journeys from the green room to the blue rooms, I got involved in more obstetrics than I'd planned to, resuscitating two babies and sending one woman to theatre. The experience, understandably, was a bit too much for some of our volunteers and by the end of the afternoon we were down to 4. We wrapped up around 6, went off and had a debrief involving some Mezze and wine, and went on 'debriefing' until shortly before 4am.

On Sunday I attended a wedding introduction, where I was required to wear traditional dress in the form of a hot pink Gomesi, complete with huge shoulders. Apparently I was 'very smart', although I'm not entirely sure about that, especially as my housemate's Ugandan girlfriend was nearly sick laughing when she saw me in it. It was a privilege to be invited and I was made to feel very welcome, given heaps of food and had the whole thing explained to me as it was happening.

Returning to work on Monday, our Forest Green was looking a bit patchy, and whilst we weren't aiming for a decorative masterpiece, we were still aiming for something to be proud of. The day on labour ward was consumed with seeing and assessing admissions and heading into theatre. We had a lot of sections pending when we arrived, and so managed to get the Oncology list halted so that we could utilise the gynae theatre. There is only one theatre on labour ward itself, so getting theatre space is often at the expense of the elective lists. Got home exhausted around 8, ate and crashed. Spent all day in theatre on Tuesday, this time entirely in gynae theatre as the anaesthetic machine in labour ward theatre was not functioning. We managed to get 5 sections done, including an impending rupture - an impressively oedematous bladder and a tight Bandl's ring were found, but fortunately no hole! Babies all did well, fortunately. On the ward round later one of the patients who didn't like the idea of being examined and wasn't getting a response from the Ugandan doctors looked me in the eye and wailed 'Muzunguuuuuuuuu'. The response from the team was that, 'You're clearly closer to God than we are'.

Wednesday I devoted to spending on the high risk side and just moved from patient to patient, pushing in fluids, dealing with PPH's and unrecordable blood pressures, doing assessments and running round organising. The highlight of the day was doing a breech extraction on an undiagnosed premature breech presentation, undergoing induction. I listened in and heard a bradycardia, found an unmistakeable set of testes coming out first and proceeded to deliver the baby according to what I'd learned on the ALSO course and from reading the MOET manual. Baby came out in poor condition, but picked with a few cycles of bag and mask ventilation and is happily screaming away on SCBU. My final patient of the day came up to me as I was leaving labour suite, grabbed hold of me with a vice-like grip around my hip, stated 'My baby is coming now, now', to which I responded 'What, now, now'? as she dropped to the floor next to the admission desk and pushed the baby out before I could get a pair of gloves. After yet another journey to special care I got home buzzing, for the first time in a while with a wonderful feeling of achievement knowing that I had directly saved three lives. Not often I ever got to say that back in the NHS.

Thursday was a day of admin and teaching, meeting Samir who was over from Liverpool on a cricket coaching trip, followed by the pub quiz, and Friday I was spent helping fill out a grant application for money to set up an obstetric HDU, which is badly needed. On Friday evening, walking through the go down with Adam to buy Avocadoes, he was on one side of the open drain inspecting the produce and I was on the other. He didn't think the avocadoes were quite ripe enough, but the stall holder was insistent 'THEY ARE READY!'. Minding my own business a well dressed woman came up to me and said 'Do you love Jesus?'. Taken aback somewhat at the lack of introduction before such a personal question I responded 'Everyone loves Jesus', in a 'What a ridiculous question' tone, whereupon she said good, and strutted off. I have no idea what her reaction would have been if I'd said something else!

Yesterday the surviving awesome foursome went back to labour suite to complete our stealth painting operation. We actually achieved a hell of a lot, completing the green room and then the larger room. We were painting around 8 women in various stages of labour and states of health and also happily plastered the walls with blue paint while the ward round, including women brought in from the corridor was conducted beneath us. We spent a large proportion of our day moving women from one corner of the room to another, but we managed to get two coats of decent looking paint on the walls. Our only casualty of the day was when Adam fell off the stool he was standing on the reach the ceiling, and painted a patient's forehead blue. I don't think she knew what had hit her. The midwives were great at shepherding women into 'safe zones' to prevent them being splattered. Some of the less uncomfortable patients also mucked in helping us to move bags, bedpans and all sorts. We had a really satisfying day! One more room to go... Any volunteers?!

Friday, 6 November 2009

Fathoming Facts and Figures

Today I went to the launch of the White Ribbon Alliance for Safe Motherhood in Uganda. I want to share some numbers with you, quoted to us at the meeting, that might give you an idea of the scale of the problem health care providers are facing here...

Worldwide
Every one minute

380
women become pregnant

190
women face unplanned or unwanted pregnancies

110
women experience pregnancy related complications

40
women have unsafe abortions

1
woman dies

In Uganda

435/100,000
is the maternal mortality ratio

76/1000
is the infant mortality ratio

29/1000
is the neonatal mortality ratio

38%
of infant deaths occur within one month of life and most of these will occur within the first 24 hours

1.2 million
pregnancies occur per year

6.7
children are born per mother

5.1
is the number of children that women, on average, would prefer

23%
of pregnancies in Uganda are in women between the ages of 15 and 19

5.5
months is the median gestational age for initial antenatal visit

$39
is the amount per capita spent on healthcare in Uganda

$2434
is the amount per capita spent on healthcare in the UK

The leading causes of maternal mortality in Uganda are haemorrhage (26%), sepsis (22%), obstructed labour (13%) and unsafe abortion (8%). The leading causes of neonatal mortality are birth asphyxia (27%), low birth weight <1000g (25%), respiratory distress (17%) and prematurity (14%). I think that the numbers speak for themselves.

I urge you all to consider joining the White Ribbon Alliance to help lobby for change by working with grassroots people, communities and healthcare workers. You don't need to make any monetary donation. This organisation has already made a huge impact in other developing countries, and really could make a difference here in Uganda... I've put a link in the essential info section.

Monday, 2 November 2009

Paradise Lost

They say that no man is an island. Well I met someone this weekend, who is his island. Lives, breathes and sleeps it.

Elizabeth and I decided that it was high time we got out of Kampala. Banda Island, and the king of its castle, Dom Symes had been recommended to me by several people. It's the stuff of legends, the kind of place that people go to for three days and end up staying for three months. Banda is one of the smallest of the Ssesse Islands and 36 km off the coast of Entebbe as the crow flies. Or as the fishing boat chugs. There was an immense amount (read, a text message was sent) of planning involved, Dom sent us a shopping list for 2 loaves of bread, a kilo of green beans, some bacon and a tin of blue gloss paint. I knew from the outset that we were not in for an average weekend desert island break.

We set off from Kampala on Friday afternoon, and arrived at Kasenyi fishing village with instructions on who to speak to, and advice on avoiding the hooligans. We found our boat, with reassurances of 'It's leaving now, now', and were whisked on board. By this I mean that we were swept up off the beach, into the arms of our respective porters who waded through the water and dumped us in the boat. Along with 30 other people. We got a prime seat on top of the vessel, so it was just as well that the water was calm. Fortunately we had come prepared with essential provisions... a 3 litre box of wine (when empty I believe the bag makes an excellent flotation device) and an empty water bottle, just in case the wine fired off our bladders' parasympathetic nerve supply! 'Now, now' is a phrase that is best interpreted with caution. In this instance 'Now, now' meant in 90 minutes. But still, we at least got a good seat. Sitting in the port was a feast for the camera, men carrying extraordinary loads through the water, impossibly loaded boats, masses of birdlife. Eventually we up-anchored, cast off and were sailing. No sooner were we away from shore than the wine was opened. We chugged along for 3 happy hours, towards an island adjacent to Banda. As land came into view Elizabeth insisted that a 'short call' (guess what that is) was necessary, much to the amusement of our other, mostly male, passengers. Hangin' on until Banda, was not an option. Little did we know we would be required to change boats - hilarious in itself, given that I'm a natural gymnast... I spilled some wine in the bottom of the boat to cries of 'Eh! Muzungu, what is that?', 'Er, it's Blackcurrant Mirinda, obviously'.

So on transfer to the smaller boat, with its sputtering engine, we cut the top off the bottle. Elizabeth upset the other passengers by trying to move to the front of the boat to do her 'short call' in private, to cries of 'Muzungu, are you trying to drown us?!'... It turns out that none of our fellow passengers could swim, and didn't appreciate a rocking boat.

At last, we spotted Dom on the beach, with his seven fostered dogs, beer in hand, awaiting our arrival. Land was a welcome sight. 'Beer anybody?', were welcome words. The rest of our evening was spent round a beach bonfire, drinking beer and overindulging in Dom's unique way. The food was great, a tasty paella. Tasted even better on the way back up. Not one to let the side down however, after 30 minutes of island air, I was ready to start again. We moved to Dom's castle, a feat of civil engineering that would baffle that bloke off 'Grand Designs'. By rights, it shouldn't be standing. I asked Dom whether he had experience of architecture. His answer was 'No, I sat in my chair, got stoned and it sort of came from there. I built whatever came into my head, what didn't work fell down, and I bought more cement and tried again. I used my knowledge of the stars from sailing and some of my mining experience, but most of it came from inside my head'. Astonishing. Dom is an eloquent, intelligent bloke, who loves winding people up and is therefore deliberately on the other side of the debate, almost always. After discussing the finer points of his recent brush with the law, how many children he may or may not have and his views on the 'African problem' we decided to retire to our cottage. This coincided with the point at which Dom was unable to stand from his chair, and then unable to sit back down in it unaided. Which I guess is always a risk of drinking home made Waragi from a plastic green and white striped kettle.

The next morning, I woke up to the sound of the water lapping on the shore, sat on the beach front porch and read my book. At what we figured was probably a reasonable hour, we stumbled across to the castle for a simple but tasty breakfast of coffee, Marmite on toast and fresh pineapple from the island plantation. Once this had been polished off, Dom announced that it was Beer o' Clock and that there were to be no exceptions to this rule, especially since we had had no Waragi in our coffee. Beer o' Clock was swiftly followed by lunch of freshly caught Tilapia, the green beans and bacon we had carried, a delicious fresh salad and the obligatory Ugandan stewed beans. And more beer. Then it was siesta time, which for me meant going out for a walk with the dogs, who accompanied me around the island checking for snakes and the presence of Herbert, the solitary resident hippo. Banda is literally teeming with life, every inch of it moves. I spotted the only Paradise Fly Catcher on the island, and had a thoroughly pleasant afternoon pottering, chilling, reading a book and listening to music. We had a brief boat trip round to see the island's monitor lizards and then went back home to catch the sunset from the castle roof. Wearing our minging Hallowe'en dresses from Owino Market.

We were treated to a stunning sunset, good conversation, luke warm beer etc. Dom regaled us of the time when he first arrived on the island, sampling every hallucinogenic plant in his new domain, and lost several weeks. We talked about travel, life, you name it (especially if it's controversial). Climbing down from the roof before it got dark, we headed for dinner on the beach, equipped with a kettle full of Waragi. We sat and drank, and drank, and drank. At one point Dom sneezed, so drunk that he fell off his chair, couldn't get up off the floor and we couldn't help him for laughing. Eventually he rolled over and crawled back to his perch. At this point in the proceedings he announced we should go and find the hippo. When we asked Dom how we were going to find him, he licked his right index finger, thrust it in the air, determined the direction of the wind and proclaimed that since he couldn't smell Herbert, he must be 'over there' pointing in the vague direction of the centre of the island. 'I'm in the perfect state for tracking the hippo'. I felt that I was in the perfect state to avoid being trampled to death and suggested another glass of Waragi. So the hippo was allowed to sleep undisturbed. We headed to bed around 4.15am. It took Dom 45 minutes to get home, which was all of 25 metres away. A testament to the potency of his home distilled poison, and the difficulties of walking in sand.

The next morning, the weather had turned, and it had evidently rained very heavily, since we were greeted by a slightly soggy Dom, who had missed his mattress, and slept on his bedroom floor with the windows wide open. Breakfast was eaten, and there was a point at which it looked like we'd be staying another night as the heavens opened again, and the thunder crashed across the water. We sat in the dining room with the bats - yes bats - waiting for a sign. The only sign we received was that the boat was coming to get us, regardless of the lashing downpour. No point being a fair weather sailor... This small boat took us to... the other end of Banda. We were offloaded, parked on a bench and left there, unable to communicate with any of the local populus and with no sign of the weather improving. After an hour and a half, and a slightly unnerving encounter with the village madman who sat and shouted at us to a soundtrack provided by the local churches cacophonic choir, our bags were picked up to a grunt of 'Tugende', just at the point where the rain reached its heaviest. Our boat, essentially looked like a floating rubbish tip, and the reality was not much different. We were thrown on the boat, left to find a sheltered position amongst crates of empty soda bottle, jerry cans, bags of flour and sugar, crawling beasts and fellow passengers. It was not a happy passage. The lake was choppy, several times we listed just a little bit too far starboard and I spent a significant amount of time trying to decide which of the random items I was sitting amongst would make the best float. The sun eventually came out and by the time we reached the mainland we were dry. I have never been so glad to get on a Matatu.

So was Banda paradise? If paradise consists of a mixture of beauty and eccentricity, beasts large and small, and a plastic kettle full of Waragi, then yes.

Wednesday, 28 October 2009

Uncomfortably Numb

I really wanted to update the blog this weekend. I couldn't do it. Not because I didn't have anything to write, in fact quite the opposite. I couldn't find the words.

Last week I spent a bit more time on Oncology. Again, there was a lot of advanced cervical cancer. I'm beginning to really get to grips with examination under anaesthesia and am trusting my hands more and more. There was no theatre list this week, as we didn't have a specialist available to cover. This was a shame as I have not yet seen any oncology surgery done here.

So why the difficulty in writing? I want to describe to you what I am experiencing, to present the bare facts, but I don't want either myself, or more importantly the unit to be misrepresented. Mulago is probably the biggest maternity unit in the world. The unit delivers more than 30,000 babies every year. The hospital was built in the 1960's, and the labour ward was designed to take 20 women at a time. There is a miwife led unit on site, which delivers around 8,000 babies, but even so, if you do the maths you can see that the numbers don't add up. Women are referred from clinics on the outskirts of Kampala, and from farther afield. They can be in labour for several days before they are referred to, or reach Mulago. Women who have had caesareans in previous pregnancies often don't attend hospital soon enough, coming in when the pain is too much to bear with an inevitable uterine rupture. Mulago labour suite deals with whatever comes through the door, just like any other labour suite. The difference here is that often, by the time these women arrive, the outcome is inevitable and beyond prevention. This is frustrating for all involved. The midwives and doctors are phenomenally skilled, resourceful and innovative people, who work bloody hard in extremely difficult conditions with limited resources. I admire and respect each and every one of them.

I spent Friday night on the labour ward. It was, without doubt the hardest shift I have ever done. I witnessed a huge variety of pathology that I have not seen before. The volume of work was overwhelming, even with two theatres running simultaneously. We walked the length and breadth of the hospital looking for blood. The house was heaving. By Saturday morning we were beat. Totally beat. I couldn't have slept even if I had wanted to. My head was full of mixed emotions, disbelief, anger, frustration, sadness, and a very uncomfortable and unfamiliar feeling of numbness and I suppose relative immunity to what I had been involved in. For the first time in my professional life I was acutely aware that I had deliberately emotionally distanced myself from something that would most certainly devastate me at home. Why? If I'm very honest, if I hadn't, I could well have been on a plane back home on Saturday.

Already I have learned so much, not only about obstetrics and gynaecology, but about myself, about what kind of person I am. I know that by the end of this year, I will have changed, both as a doctor, but also as a human being. Being here is a privelige and a humbling experience, and I'm so, so pleased that I came. And by next July, I really think that there'll be very little that scares me. Although I'm not sure I'll ever get used to cockroaches.

Monday, 19 October 2009

Treble Trouble

Hi peeps. Another week of wonder in Uganda! It was a week of undiagnosed multiple pregnancy last week, which is a recurring problem here as significant majority of women do not have a scan in pregnancy. On Tuesday I diagnosed a set of twins at full dilatation who had not delivered after a significant period of time and the history didn't fit. I'm really beginning to trust my hands to tell me what I need to know. Abdominally it was not that obvious, but I could feel two distinctly separate amniotic sacs, one containing feet and the other empty. Alarm bells went off as this was a multiparous woman who really should have delivered by that point, with the leading twin a footling breech and the second twin probably cephalic... I had visions of locked twins. She was delivered by section and essentially neither twin was in the pelvis. It was liberating to not run to the cupboard and grab the scanner!

A bit later on after spending the morning in the admissions room having limited success with my appalling Luganda, I went back to the high risk side where I found the specialist delivering what was thought to be another set of undiagnosed twins. Between us, we delivered and sorted no fewer than 3 healthy babies, and I felt pretty comical walking with 3 children in my arms to the scales, trying to remember according to the pattern on each blanket, which triplet was which. It was a little bit like pulling rabbits out of a hat! And of course it hammered home why all the manuals for resource poor obstetrics bang on about checking for a second and third baby before giving oxytocin. The patient was expecting one baby, and the look on her face was one of sheer bemusement.

We had a big discussion on Thursday about triage on labour ward, which is not a concept that exists here, but is desperately needed. A lot of people in the meeting got quite excited, and myself and one of the specialists went to the labour ward, moved some equipment around and created a new admission room. This will hopefully pave the way for the triage system, which will in turn empower the midwives to see and treat straightforward cases, referring only women who really need to be seen by a doctor, and categorising those women so that the most urgent or complicated cases are prioritised. Hopefully this will lead to a more streamlined service ensuring that haemorrhoids and haemorrhage are not treated with the same level of urgency. It will be a simple system of traffic lights, as is pretty standard, utilising coloured boxes for the notes to be placed in. We are also going to look into acquiring a whiteboard to help prioritise theatre cases and stay up to date with each case that is awaiting intervention. These are simple systems that I hope will be effective. Implementing them will require a lot of energy and input but I think a lot of people feel very strongly about this project and I really think they could improve the patient's experience.

I've been kicking around Kampala this weekend, sampling some more of its fabulous restaurants. We went 'over the tracks' to the South of the city centre on Friday for Ethiopian food, but the restaurant we were hoping to eat at had finished serving food - at 745pm! We stumbled across a 'local' Ethiopian restaurant where we were told that we would be eating the mixed platter and that we could have beer but they'd have to go out and get it. Either way, the food was great, and we paid 19000 shillings for all 4 of use to eat and drink beer - which is basically £6 for the lot! Will we ever find it again? I doubt it very much... Saturday was spent chilling with housemates and Sunday was spent writing the triage proforma and cooking meat on coal!

This week I'm back on Oncology, and am looking forward to getting into theatre tomorrow.

Monday, 12 October 2009

Stubbly Citrus Sojourn


So, I've had another really interesting week here in Uganda. I spent some time on the gynaecology oncology wards. There is a big problem with cervical cancer here in Uganda. There is no screening service to speak of, other than opportunistic visual inspection if women attend the gynaecology outpatients department. Women present, often with advanced disease. Diagnosis is made by examination under anaesthetic and biopsy. Seven women had an EUA on this week's list and all but one had stage 2b disease or worse. It's something that's really made me appreciate just how good the NHS is, and certainly is something that should encourage all women to be screened where screening is available. So that's my soapbox issue for this blog entry. Girls, go and have your smear done if you're due...

I spent Tuesday night on labour ward with one of the SHOs, to cut my teeth properly in theatre. I've had to learn, pretty quickly, how to do a section using only one large swab and 2 lengths of suture material for the whole thing. For the old fashioned obstetricians who might be reading, I now understand the virtues of catgut as a suture. I'm going to be one of those people who whinges when I'm in theatre in the UK, 'if only I had a bit of catgut...' Anyway, we had a relatively quiet night for Mulago, 9 sections done, 3 pending when we finished the ward round at 11.30 the next morning. No such thing as the EWTD here! Wednesday was spent in a bit of a general daze, wandering round Kampala, drinking coffee at various points on my amble. Too awake to sleep, too tired to function.

Thursday is the 'Major Ward Round' in Oncology. I've never seen so many consultants on a ward at the same time! Ward rounds are done the traditional way. There's a lot of really interesting pathology to be seen. I'm hitting the books again, going back to stuff I've not read since med school - tuberculosis, malaria etc etc.

Thursday afternoon was a wash out in many sense, the rain hammered down like all the water in the world was falling out of the sky in one go. Cracking thunder and blisterung lightning everywhere. It did affect the teaching session, with only a few people attending to go through shoulder dystocia. Managed to get some mannequins, and whilst not ideal they helped people to really get some hands on and practice entry manouvres, and also to understand the underlying principles of each one. Which was great until one of the dolls' heads fell off... so much for gentle traction. It was fun though, and I'm really looking forward to teaching vaginal breech delivery!

After the teaching, I attempted to tear arse across Kampala, to catch a lift to the Hairy Lemon Island in New Jinja. I say attempted, since due to the rain, the jam was worse than ever. Of course, when you're relying on your driver to be late, sod's law dictates that for once, he'll be operating on British ti9me, and not Uganda time. So I had to dive out of the matatu, against my better judgement and hop a boda, since we needed to catch the last 'ferry' - read wooden dug-out canoe-esque boat - to the Island with a two hour drive to get there. Of course, the boda driver thought the best plan would be to race his friend down the pavement, dodging pedestrians and bollards, while I'm hanging on for dear life, soaked, muddy and cold, wind lashing in my face, while he aquaplaned to our destination. Of course, in true 'scream-if-you-wanna-go-faster' style, suggesting that I really wasn't in THAT much of a hurry only encouraged him to speed up even more.

Anyways, Elizabeth, Adam, Pierre and I made it to Hairy Lemon, all limbs and senses intact. What a cool place. It's a small Island in the Nile, cheap as chips, all meals included, beers for peanuts, a couple of wicked Island dogs, wildlife galore and no hassle. We stayed in a hut called the 'Sugar Shack' - not as seedy as it sounds - and really chilled out for three days. Arrived back in Kampala Saturday night, relaxed and refreshed for the week ahead...

Sunday, 4 October 2009

Breech Baha'i Butterfly Barbecue Bonanza AKA a summary of the last few weeks

Well I've been a busy bear these past few weeks. Lots of stuff going on, so much achieved, seemingly so little time.

I have started the teaching sessions for the midwives. The first session was last Thursday, talking about Antepartum haemorrhage, which was not so well attended - they are optional sessions - as the hospital was ridiculously busy (even by Mulago's standards) and it was difficult for the staff to get away from their clinical committments. This week we did postpartum haemorrhage, 17 midwives attended and we talked for around 3 hours about issues surrounding PPH and its management. I really felt like people went away from the session having had the opportunity to ask questions and clear up confusion about such an important obstetric emergency. Some of them now want to look at a better system of measuring blood loss so that they can pick up PPH and manage it earlier. We're going to explore the idea in a bit more detail and maybe get a small study going. Next week we're going to try and run a practical drills session on shoulder dystocia.

I've been spending more time on labour ward, starting to get directly involved in patient management. In one afternoon in the admission room alone I saw so much; an eclamptic fit, 2 women with severe PET, footling breech in labour at term (NVD), 2 women with HIV and ruptured membranes, an acute severe exacerbation of asthma, twins, a handful of women in latent labour, 2 women who delivered in the admission room and also got involved in a PPH. I didn't even set foot into the labour ward proper. Buzzing - and knackered - when I left. There's so much other stuff that I'm witnessing, and I'm really beginning to see things that you tend to only read about, for example, breech delivery with entrapped head. I also spent a bit of time in the general gynaecology ward.

We're trying to set up an audit looking at stillbirth rates at Mulago, to try and see if there are any preventable factors that we can identify and work to improve. It will hopefully be a useful and fruitful exercise.

We had midwife of the month again this week, which was a resounding success. We have begun to rotate it around the wards, so that all the staff have a chance of becoming the midwife of the month, and hopefully this recognition will help to improve morale.

I've spent some time this week working with one of our specialists and two midwives who are going to Liverpool Women's as part of the Liverpool Mulago Partnership programme. They're really excited and now they have their visas are raring to go. One of the midwives who was due to go in June, but had visa problems, tells me she can't believe it's real, and won't until she actually arrives. Let's hope there are no other hitches. I'm really looking forward to wroking on the ideas that they bring back from Liverpool with them, I think they're people who have an immense amount of drive and energy to push things forward here.

Socially, still having a ball. Two of our housemates have gone back to Germany and the States, and a new guy, Michael has moved in. Seems like a nice guy. Met up with a couple of lads from the UK, friends of a friend, Elliott and Jake. Went out for a fab curry at Khana Khazana in Kampala, and a few beers, but we were too full to go dancing. Our now weekly Muzungu Barbecue party the following day was fun, although Sunday was wiped out, although I spent a bit of time at the hospital working on a guideline for normal labour.

This week was occupied by coming fourth in the pub quiz, more grilling stuff on coals and then yesterday visiting the Baha'i Temple in Kampala. It's a really pretty, simple temple set in stunning ground on one of Kampala's hills. The butterflies are stunning and there are hundreds of them - of many different species. Learned a bit about the religion and then wandered through the gardens for a bit.

Had a slightly unnerving boda ride where a taxi driver leaned out of the window of his cab, looked me square in the face and shouted
"Muzungu, they are going to kill you!"
Not really sure what that was all about, and who 'they' are... Any ideas?

We're going to organise a big house adventure to the Ssesse Islands next weekend to relax a bit. Going to spend this week on gynae oncology, which will be interesting as there's a high incidence of cervical cancer here in Uganda.

Sorry about the technical, businesslike entry - feel like 10 days is too long to leave between one entry and the next, must update more often!

Happy 26th Birthday to Ben - hope you enjoyed your surprise party!

I'm off for a pedicure - feet are trashed!

Wednesday, 23 September 2009

Zen and the art of motorcycle maintenance... or bodaism and how it misaligned my chakras

Oh yes, there is a revolving restaurant in Kampala! So last Thursday Elizabeth, Pete and I decided that for kicks and giggles it was a must visit... Apparently it's only one of three revolving restaurants in Africa. Personally I don't understand why every town doesn't have one. Got some excellent views over the (pitch black) golf course. Actually we got some good views of the 7 hills of Kampala, and the food wasn't bad at all. 10 out of 10 for novelty value I say!

So what else have I been up to this week... Well all seems to have calmed down on the political front for now, although I'm not sure how long that will last for, and will be keeping my ear to the ground - my nose is fairly useless for this kind of thing, being anosmic and all.

I spent some time in theatre last week learning a little bit about how things get done here, how to book cases and so on. I spent the day wearing two right footed surgical wellies, one size 9 and one size 11. It was a special look and one I shall spend the rest of the year trying to perfect. If anyone wants to send me a pair of wellies the next time people come to Kampala, I'd appreciate it, size 5, the louder the better!

Saturday was spent visiting the black and white colobus monkeys in Entebbe Botanical gardens and generally kicking back away from Kampala. Sunday was spent visiting Owino market where you can buy ANYTHING you need. You can get adapter plugs from egg shops, mops from shoe shops and oven gloves from the shoe shine man. Immense. We then had a house barbecue which was really nice, met some mangey puppies and generally had a fun and frivolous time. Monday was spent going up and down Kampala Road trying to sort out my visa...

I went to collect my passport to check it wasn't missing, was told that yes, I could have a special pass and to speak to the cashier. You would think that a cashier is someone who takes cash from you, but oh no... the cashier tells you how much it is, gives you an invoice and sends you to the bank... three miles away. At the bank, you queue - and if you're me discover that you spent 20 minutes waiting in the wrong place - and eventually pay the fee. You need a receipt, which you can't pick up FOR AT LEAST TWO HOURS. So I smiled and nodded, ran a few more errands - booked gorilla tracking permits YAY! - and went back around 4, waited for another half an hour in a queue got my receipt and decided that I couldn't bear to go back again.

Tuesday was spent back at the passport office, where I was told that I have to go back again to pick it up today. I'll go when I have sorted the rest of my paperwork and there is not a document that they could possibly ask me for that I don't have - ahem.

Today, we presented our Malaria in pregnancy guideline. I've made flowcharts for the others we've produced and I need to get them printed as A2 posters. This is prohibitively expensive in Kampala. If anyone at home knows of somewhere they can be printed relatively cheaply, I'd appreciate it if you could get in touch. We're going to need at least 5 of each poster and potentially we could be looking at 100 posters in total once all of the guidelines are written. I can arrange for them to be brought out to Kampala from the UK by hand so that's not an issue.

I'm restarting the midwife teaching sessions tomorrow, and I'm surprisingly nervous about how it will go down. One of the midwives has asked specifically for a problem based learning approach! I knew PBL would take over the world eventually!

Had my first Luganda lesson last night, and it will come as no shock to most people that I'm crap at Luganda....

Wasuze Ottya Nnyabo... How are you madam?
Sula Bulunge... Goodnight
Embwa si nungi... the dog is not fine (no it's not it's still being a menace)

And what else has happened? Ah yes, it's been a week of Boda Boda dramas... Almost fell off a boda on Monday going to meet a friend who I used to play rugby at med school with, then yesterday, we followed some kind of presidential convoy on the boda which meant we got through the jam without any dramas, but then the boda guy drove straight into the side of a cyclist, who retaliated to being driven into by poking the boda guy in the arm. The boda guy tried to justify what had happened, even though before the impact I was screaming Ssebo at him like a woman possessed to warn him, denying blame, and then just drove away! Today, I saw a guy leaving the hospital with a coffin balanced sideways on the back of his motorbike. Wonders never cease.

Anyway, back to the grind... got a section proforma to produce and another guideline to write and I want to get them finished this afternoon... Stay in touch people, missing you guys and all the gossip!

Tuesday, 15 September 2009

Interpolantics

Had a really interesting few days at work. I'm spending the week in the materno-fetal department, which covers all the high risk obstetrics. What is most interesting is that the majority of the stuff on the wards is the same as at home. The difference is that geography, and to a lesser extent social status, determine which women are admitted. Women often travel huge distances to get here or in some instances getting back to the hospital can be impossible due to money etc. The wards were relatively quiet, probably due to the riots more than anything else, so there were a significant number of women in the latent phase, false labour or women who had had previous sections awaiting elective caesarean. Other cases included HIV with extensive genital warts (by far the worst I've ever seen), malaria in pregnancy and a severe exacerbation of asthma.

I slept really badly on account of my sunburn (I know, I know) and then couldn't get a minibus so had to catch a boda-boda to work, which I despise because the guys are crazy and I hate motorbikes at the best of times. Too much excitement before work is more than the average girl needs, and boda-boda hair is not a good look!

Today I spent the morning in antenatal clinic. There is no true appointment system. Women turn up first thing in the morning and wiat their turn. The system actually runs fairly efficiently. They attend, their files are pulled, they have HIV screening if it has not already been done, they are then seen by a midwife or a doctor depending on whether they are high or low risk. Bloods and scans are arranged where appropriate. I saw a good case mix of twins, HIV in pregnancy, follow-up of women who have had malaria, cervical carcinoma and cervical incompetence. It's certainly a more interesting case mix than at home! The challenge of the language barrier is massive. Already I'm adapting my English to the African syntax, even down to how I ask people what time it is ('how do you make it?'). I am also trying to adapt my practice to the population. In Mulago women are admitted for things that aren't an issue at home, simply because of the difficulties with accessing healthcare, concerns for example about obstructed labour, that would potentially result in a disastrous outcome. I know that my mindset is beginning to change, but also that now my face is becoming familiar to the doctors and midwives here we can discuss things more easily. When I am asked about how we do things at home, this is sometimes a good springboard to talk about differences in management, and explore the evidence base. I am already questioning my own practice more than ever, I realise that some things are just taken for granted in Western obstetrics and that we don't always question the minutiae of what we do.

This afternoon I had a successful meeting with Interpol, got my letter of good conduct, so I'm ready for round 3 of the Immigration Title Match. I've also made enquiries about gorilla tracking in January when my Mam is coming over to visit! I'm SO excited! Tonight, I'll be working on a guideline, having a glass of wine and getting some sleep.

Sunday, 13 September 2009

All quiet on the Eastern [African] Front


Things in Kampala appear to have calmed down a fair bit. There was a small amount of trouble reported yesterday in some of the suburbs, but not to the level of Thursday and Friday. We barricaded ourselves in the house and played Scrabble and watched Men in Black, because we're so grown up. We had a brief interlude when cabin fever very much got the better of us and we had to go outside into the real world... to the shopping mall... where we bought junk food. We had a small altercation with a local vendor in the godown when we tried to buy 6 chapattis... although I suspect it was because of the 'fat b@stard' element to two of us asking for that many!

Today I went to Entebbe for a day trip with Kate, Jamie and a guy called Tom where we lazed around a swimming pool for the afternoon, ate Tilapia and got sunburnt. Was nice to get out of the city after the last few days.

Back to work and hopefully normal. Will post again later in the week and let you know what transpires...

Friday, 11 September 2009

Watching the people get lairy...

It's not very pretty, I tell thee, walking through town is quite scary, and not very sensible either....

The Kaiser Chiefs could well have been writing about Kampala yesterday and today. There have been big clashes in the city between the police and Baganda protesters. At least 7 people have been killed and many others injured. There was a steady stream of ambulances to and from Mulago yesterday and volleys of bullets and sirens were clearly audible from the hospital site. Protesters burned through the city centre and Wandegeya (where the hospital is), setting alight anything they could, throwing stones at police who returned the assault with gun fire and tear gas. Essentially the protest is against the government banning the King of Buganda from visiting an area just north of Kampala, called kayunga. It is populated by a break away group called the Banyala who have seceded from the Baganda tribe and are apparently not happy about the visit, hence the ban.

Needless to say that I didn't go to the hospital today, since I didn't bring my flak jacket with me. We are barricading ourselves in the house with our evil dog that we hate and hoping that it will burn itself out (both the riot and the dog), so long to a weekend of partying.

Other things happening in the news this week...

Dong.... Kate has surrendered her passport to immigration (before the riots), which happens to be on the main road into the city, for a visa extension... will she ever see it again?

Dong... Kate had to pay a visit to Interpol for fingerprinting to get a certificate of good conduct so she can apply for a working visa...

Dong... Kate would have spent more time on emergency gynae had the above political crises not occured...

Dong... APH guideline has been produced and accepted...

Dong... the fridge broke...

Dong... the dog is suffering from a borderline personality disorder...

Nothing else really exciting has happened. Loving the new house, housemates are cool, found myself a drinking buddy, it's a bit like being a student again! Will keep you guys updated over the weekend about what's happening in this crazy place!

Saturday, 5 September 2009

Mulago musings

Well, it's been a week and a bit. Have been able to focus a bit more on the clinical side of things, although I still have a couple of guidelines to write, which are a bit distracting. Started getting my hands dirty, even though I have been trying to 'observe' and get some idea how things run at Mulago, and also how specific conditions are managed. Delivered a set of twins with forceps, not commonly done here as few people are trained to use them, because there was no other equipment. Feel like I'm beginning to settle as I'm getting to know the doctors and midwives, and getting the opportunity to show people what skills I have. We had the midwife of the month award on Friday, which is a brilliant initivative, set up by the previous fellow. It's an award involving a sizeable amount of money and offers a massive incentive for improving morale and practice. The press came, so I'll be scouting for clippings and posting them here if I can.

Moving into my new house this weekend, when I think it will suddenly sink in that I'm not actually on holiday! This week I will be mostly registering with the medical council and trying to sort out a work visa, which I am led to believe is a challenge at the best of times.

Haven't done much else since I last updated you, but I do feel much more at home here. The mosquitoes are biting... I was winning before. Thanks goodeness for nets and Lariam! No other huge news at this point. Please stay in touch with all your news.... A couple of personal messages...

Ben, get well soon, hope you're better in time for Barcelona
Vicky, happy 21st!
Gran and Grandad, HELLOOOO!!!! Missing you and love you millions, hope the knee operation goes well

xxxx

Sunday, 30 August 2009

103 Midwives!


That's how many people we've trained this week. I'm knackered! Dhomalie and Agnes, our midwife trainers did a brilliant job, and worked like Trojans, and Kate's work to set the whole thing up really paid off. I felt privileged to be involved and it was great to see so many people leave with new found confidence and self belief. I hope it translates into clinical practice, but at least I can try and help with that by encouraging people when the situation arises. I even have the confidence to do it myself now! No more being elbowed out by the midwives ;) (Love you all!)

Now that I'm starting to get to know the staff, I'm feeling more settled. The hospital seems less daunting somehow, but I need to get stuck in properly now.

In terms of Kampala life, I've found a shared house with 5 other people who do a variety of things - journalism, politics, PhDs etc - from the States and Germany, and will be moving in next weekend. I think it'll be a brilliant place to live, and it's quite close to work, probably about 30 minutes by foot and minibus.

I still feel a little bit like I'm on holiday... not sure when that will wear off, but I'll let you know! Need to buy a jar of Marmite, and soon, I'm craving....

Please email me and tell me your news! I will try and email everyone who I have addresses for in the next few days

Wednesday, 26 August 2009

One crocodile, two crocodiles...

Well, what a hectic time I've had. Can't really remember when I last wrote, it's been a bit of a blur really. Went out on Friday for my birthday with my flat mates, got a little drunk (obviously). Felt dreadful the next morning, rising at 6 to go rafting. Had a fab scenic drive to Jinja, although was tired. Arrived, was kitted out, put on a raft and then thrown out of the raft several times on purpose, which served as an excellent hangover cure! Did 7 rapids in the morning and 4 in the afternoon. AWESOME! Was so knackered and sunburnt I was in bed by 9!

Sunday (my birthday) was spent at the source of the Nile, marked by a concrete block no less. Lots of amazing wildfowl along the banks of the Nile though. Managed to catch a lift with some American NGO workers back to Kampala, which beats travelling in a Matatu for 90km.

Neonatal resuscitation course started on Monday. There's been a brilliant turn out and the midwives are really keen to learn. Hopefully it will boost confidence and empower them to recognise and manage neonates who need resuscitating. My predecessor Kate raised the money to run it so it was offered to the staff for free. I will be running it again for the junior doctors and then in 6 months for the midwives. I'll give you advance warning that I'll be asking for your spare coppers.

Really enjoying life in Kampala. Settling in, and now Kate's back it's easier to meet the staff and explain who I am and why I'm here. The rainy season has arrived... and it rains Lions and Hyenas here!

To everyone at Leighton, believe it or not I have yet to swear at work!!! Told you I could do it! Anyway, the sun's going down and I need to get home before dark!

Laters xxx

Friday, 21 August 2009

'I hope it rains down in Aaaaaafricaaa'

Actually, I wouldn't mind if it stopped now, just for half an hour so I can get back to the hospital! But for now, I'm trapped and using my time wisely...

I've started work, and am slowly beginning to get into the swing of things. Everything is SO different here, that for the first few weeks I'll be 'observing' and learning about how things are done here. Starting to get to know some of the midwives and doctors. I've dabbled in labour ward, spending yesterday afternoon in theatre. Most of this week has been spent finalising arrangements for a neonatal resuscitation course which my predecessor and I are running next week for all the midwives. It's been an interesting week as I begin to learn how to approach people here and how to get things done. There's a definite etiquette that I don't yet fully understand, in terms of how to get things done.

The other thing I've done this week is write a guideline on multiple pregnancy with Anna, the Italian doctor who's here for a short while, and a specialist, Sarah. I presented it at the departmental meeting, and it seems to have been well received, and I hope, achievable... No difficult questions from the floor.

Play wise, I've moved into a house, which is great except that we have had no power for 3 days! This has unfortunately meant eating out rather than in, but I can tell you that the restaurants and bars here are really good, including the Irish bar with free wifi - where we wrote the bulk of the guideline. I have made it my personal mission to try them all!

The house is a minibus trip from the hospital, which is quick and easy. Haven't plucked up the courage to ride on a boda-boda yet... I think I'll avoid it for as long as possible.

This weekend, I'm heading off to Jinja to go rafting and visit the source of the Nile, a birthday treat to myself. I'll try and post some photos on here once I get back, decent internet connection pending!

Hope you're all well. Massive congratulations to Anna and Sam on the arrival of Poppy, and to Becca and Ted on the arrival of Thomas. Hope you're getting to know each other and the sleepless nights are bearable!

Sunday, 16 August 2009

Despatches from Kampala

Well, I've arrived safely with all of my luggage. Getting through the airport was easy enough, but my visa doesn't seem to have an expiry date, which means that at some point in the next week I'll be spending a bit of time at the high commission and the immigration office!

The journey through Entebbe to Kampala in a taxi was just like I expected it to be. Red soil and dust, fruit and vegetable vendors, advertising billboards promoting HIV testing and treatment, drum shops, massive marabou storks everywhere, boda-boda drivers swerving all over the place. Magic.

I arrived at Mulago guesthouse which is directly over the road from the hospital, and it appears that I have the whole place to myself, although there are three people staying in the adjacent house, Anna, and Italian doctor, aspiring to be an obstetrician and working in the department for 6 weeks, Songi who is a German social anthropologist and Assaye who is a paediatrician working on an Africa wide guideline for UNICEF. The guesthouse is basic but clean. I have discovered where the supermarket ism which is just as well as I have left my toothpaste behind. Couldn't find the Marmite though, so I'll have to go on a hunting trip.

Went into the hospital on Friday for a quick look around. The Friday morning handover meeting, a formal occasion, was a hotbed of lively discussion and debate, with lots of discussion about evidence, or lack of. Some of my previous consultants would have been given a run for their money! Everyone is expected to attend, and the nursing staff also give a summary of admissions and outcomes. There is a lot of stuff that I am going to see and experience that I won't be writing on here, as I think it will be too sensitive to be published in the public domain.

Met the low risk labour ward manager, the postnatal ward sister and the VVF theatre sister. They're very friendly and welcoming and I think that once I get over the initial shock of such a massive change I think I'm going to enjoy the challenges the year will bring. I'm certainly going to have to find a novel way of doing an ARM without and amnihook!

I've spent a bit of time exploring the city itself, with the other people that are staying here in the hostel. I looked at a house that wasn't suitable, but will be looking for a place more seriously once I get all the initial paperwork sorted out.

Friday night was spent eating Ethiopian food Alfresco, and then dancin until the wee small hours, and there's definitely a vibrant social life here which I'm obviously looking forward to exploring in more depth!

So, tomorrow I start work properly. Am I nervous? Obviously. Am I excited? Definitely!

Thursday, 13 August 2009

Airport chairs...


Well I'm halfway there, having set up camp on a recliner in Dubai airport which is unfortunately not conducive to sleep... And so far nothing too exciting has happened apart from frantically unpacking and offloading my excess five kilos of luggage in Newcastle! So I'm down from two white coats to one and have had to ration myself re textbooks... Eek! It all feels very surreal so far, not sure quite when it will all hit me. Many tears and stuff over the past few days, missed deadlines and the proverbial and the fan have had a couple of meetings too... But I'm on my way now and everything's pointing forwards, onwards and upwards!

Sunday, 9 August 2009

Three more sleeps...


Is the flat packed away? Is the damp wall sorted? Have I finished my Cochrane review? Do pigs fly?

Actually have got more chance of seeing a flying pig than being ready to get on the plane on Wednesday!

Have had a wonderful past few weeks catching up with friends and family, a number of send offs, some of which have made me a little worse for wear. I'm certainly going to miss Cain's beer!

Tuesday, 4 August 2009

Goodbye Leighton

Well, I've almost finished work! Just under two hours to go, and the midwives haven't thrown me in the bath...yet! Lots of lovely cards and pressies, all of which are very thoughtful. Thank you especially to the labour ward staff for the silver St Christopher, which I'll wear and will refer to when necessary! 8 sleeps to go!

Monday, 27 July 2009

Farewell party

The Safari themed farewell party was fantastic. Thank you to everyone who came and played, dressed up as animals and hunters, Gorillas and missionaries, ate, drank, danced and were merry. Thank you for the gifts, cards and good wishes. I'm going to miss you guys immensely. Started packing yesterday. Things look a little strange in the flat, similar to when I first moved in and had nothing. It's beginning to feel a little more real now, and in all honesty I'm getting very nervous. I have absolutely no idea what to expect!

Photos will be going up shortly from the party. Stay in touch people! xxx

Tuesday, 9 June 2009

Well, the flights are booked - departing from Newcastle on August 12th! The big farewell party is on Saturday July 25th - SAFARI THEMED FANCY DRESS - at the flat. Would love to see you all there!

Monday, 11 May 2009

This is where I'll be posting up to date information on what I'm up to in Uganda. I anticipate that this will allow people to find out what I'm experiencing and also to stay in touch, without me bombarding their inbox! Will be heading out there in August 2009.