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


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.