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!