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...

Every one minute

women become pregnant

women face unplanned or unwanted pregnancies

women experience pregnancy related complications

women have unsafe abortions

woman dies

In Uganda

is the maternal mortality ratio

is the infant mortality ratio

is the neonatal mortality ratio

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

children are born per mother

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

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

months is the median gestational age for initial antenatal visit

is the amount per capita spent on healthcare in Uganda

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.