Sunday, 28 February 2010

Hard Labour

Mum and I had a few days together in Kampala. She wanted to go and visit the hospital, so we went. I showed her around the midwifery led unit, ward 14 first. A woman had just given birth in the corridor, but the ward was otherwise fairly quiet. Still she was a little shocked at what she saw. We then went to the main labour ward, chaotic and overrun as usual, women in various stages of labour strewn about the place, on mats on the floor, some in beds, some on benches. I don't think she really knew what to make of it, and I don't think it reassured her about the decision I had made to come here. But I think that when I return in August, with tales to tell, she will at least understand them better than most people, for having witnessed the hospital first hand. Our time in Kampala was otherwise spent with friends, barbecuing, eating and drinking good food and wine and doing very little else. We spent an afternoon exploring Owino market and the new bus park, but after the time we spent on the road, we were both tired, and fed up of being 'tourists'. And so much of the day was spent hanging out in the garden being tormented by the dog, and chatting with Doris, our housekeeper, who took a special shine to Mum, probably because they both had motherhood in common. She left in the early hours of Saturday, and I felt a little bit empty after her departure, having been constant companions for 3 weeks.

We had decided as a house, that since most of the 'original' housemates had left, it was time to upgrade the chipped and cracked plates, bent cutlery and plastic tumblers with stuff to make the house more homely. We also decided it was time to upgrade the cleaning stuff for the house too, much to Doris's delight. She admitted to us that nothing had been replaced in the 6 years she has worked at the house. Doris is much happier and upbeat, with a new enthusiasm for her work. And we felt good for doing something seemingly small and routine, that it some way showed that we value Doris and her work. So, we're a happy house! Of course, on our spending spree it was also deemed necessary to buy some 'fun' house stuff. We returned from our shopping spree laden with a volleyball, basketball, 4 badminton racquets and shuttles and a universal net. Ravi and Adam spent a bit of time putting the net up, and the following afternoon, the Inaugural Naguru Lawn Sports Society Meeting was held. Of course, no sports day is complete without a bit of beer and a barbecue, and it seems that our weekends have taken on a whole new meaning.

My first proper week back at work was taken up with meetings, teaching and administrative tasks. I spent time making edits to some of the documents I produced prior to going on holiday. I walked around the department, to see what was happening in the various different areas, saying hello to people and conscious that I hadn't been visibly present there for a number of weeks. I decided to follow-up on some of the things we put in place right before I went off travelling - I had put whiteboards up, providing pens and a small amount of money for replacement pens, and had given brief instructions on their use. It was a small experiment on my part, as I was curious to know whether even something as simple as replacing a sheet of paper with a board to write the theatre list on, giving a static point that would help improve prioritisation, would be implemented without me having to push it. Similarly, having given a tutorial on the whiteboard on 14 as a tool and having seen the initial enthusiasm of the staff, I had been hopeful that they would get it off the ground off their own backs. I was dismayed to see that the examples I had used to demonstrate how to fill the board in, were still there, and it was clear to me that the boards hadn't been touched. But I wasn't really surprised, and a little redeemed from my own cynicism. It led me once more, to question the sustainability of the work I have done here so far. And I now need to think about maybe taking a different approach to the projects I have been trying to get going. We have had a change of guard, so to speak, with staff - particularly effective senior midwives - being rotated. This will hopefully bring an injection of renewed enthusiasm to many of the clinical areas which will hopefully translate into improvements in patient care.

The weekend came round quickly, good old St Valentines day looming, Avner and Ravi were both out of town and myself, Adam and Elizabeth needed some down time together to catch up on each others' lives. We decided to treat ourselves and spend some time at a hotel on Lake Victoria's shores, taking advantage of their weekend Valentines special offer that sounded too good to be true... and was. We arrived to discover that it wasn't as cheap as the flier had suggested. But it was a bloody nice place, so we decided to stay anyway. We persuaded them to put an extra bed in our twin room, and managed to obtain a corporate rate for it too. We then settled into the terrace bar and had a long deep and meaningful while gazing out at Lake Victoria as the sun set. We spent the night under duvets in our air conditioned room - extremely decadent and a real treat by our standards!

Saturday was a pool day, catching rays, reading and messing about in the water. It felt a million miles away from Kampala, a holiday to recover from my recent holiday. Avner and Ravi's plans for the weekend had changed, and we persuaded them to come and join us. Av arrived first with supplies for Bloody Marys, took a shower and shaved his face, leaving a moustache that wouldn't have been out of place in a top shelf movie, and proceeded to prance around in a towel for a bit. We then went for dinner - Av had dressed by now, thanks goodness - and Ravi came from the airport to meet us shortly after we finished eating.

We had to walk past the pool to get back to the room, where there would now be 5 of us staying in 3 beds. It seemed only natural to swim, in the dark. I dived in in my dress - I suspect that a full day of imbibing alcohol may have been responsible for my behaviour - swiftly followed by the rest of the gang, wearing various amounts of inappropriate swimming attire. It was fun, childish, but fun. We went back to the room, threw some drinks together and chilled on the balcony into the small hours. Sunday, we travelled back to Kampala, feeling relaxed and refreshed, and not too hungover, all things considered.

Back at work, I was still feeling a little bit out of the swing of things, and the familiar feeling of dread and paralysis that affected me when I first arrived was washing over me again, less intense, but still palpable. I realised that I needed to face it head on, and really throw myself back in. And so began my week on labour ward, which was to be challenging and at times surreal. Throughout my time here so far, I have tried to write the blog as diplomatically as possible. I apologise if this is not the case with this posting.

I spent the Monday in theatre, tackling the emergency section list. We had a woman with a bad uterine rupture that had gone right through the back of the bladder. I managed to repair the uterus, but struggled to deal with the damage to the bladder and called the specialist in, who in turn called in the urogynaecologist. Uterine ruptures are common here, some much worse than others, but I am still not at the point where I am confident enough to 'just get on with it', as I don't feel that I have the experience of repairing a uterine rupture, or performing caesarean hysterectomy to do it independently and safely. This is considered an alien concept by some of my colleagues here, having been indoctrinated in a different system, but I can't subscribe to the 'see one, do one, teach one' philosophy. While I came to Uganda to gain experience of these types of things, I refuse to approach my patients any differently to what would be expected of me in the UK. It might hold me back a little, but I can sleep at night.

On Tuesday, I met with the head of department and two of the specialists to work through the applications for the exchange programme that runs between Mulago and Liverpool Women's. We spent several hours poring over the applications and discussing them. We selected two midwives to go. I returned to labour ward around 1pm, and was told that there was a destructive delivery happening. I have seen one before, quite early on in this job, and while they are brutal and unpleasant, they still have their place, especially in this setting. It was thought the the baby was in a face presentation, badly impacted and no longer alive. In this situation sometimes a destructive delivery and achieving a vaginal delivery rather than performing a caesarean delivery is a safer option for the woman, if not an especially pleasant one. The specialist was struggling to come to a decision about how to proceed, the landmarks being difficult to determine. The patient was pushing well. An episiotomy was performed. At this point it was noted that the breech (bum) was presenting. A breech extraction was performed, legs then trunk then arms. The head was stuck. Fast. What happened next will stay with me for the rest of my life. as the specialist tried to deliver the rest of the baby the head separated from the body. We had to take the patient to theatre to deliver the baby's head by caesarean section, the thing we had been trying to avoid in the first place. It was one of the most traumatic things I have ever experienced. The rest of the week on labour ward was busy, the usual mixed bag of eclampsia, massive bleeds from undiagnosed major placenta praevias, uterine ruptures, hysterectomies, severe malaria, severely hypoxic babies and so forth. Everything else that happened that week was eclipsed by Tuesday's horrific experience. But I managed to complete the week on labour ward, and I was proud of myself for managing to do that, but also astounded with myself for being able to compartmentalise my experience in order to function.

The Friday of that week, Ravi left us, his 6 week placement at Mulago finished, ready to go back to the States, graduate from medical school and take up his residency post. We had a big barbecue send off, which was a welcome antidote after the week's events. And we packed him off in a taxi a 3 in the morning, bound for Entebbe airport. One of the nicest people I have ever met, and someone I feel privileged to have spent time with, I know he will be a superb doctor, and I wish him well.

Sunday evening, walking away from the labour ward felt like a release from incarceration. I'm pleased to have finished there for a few weeks, but glad that I'm back in the swing of things once more. I am reminded, once again of how lucky we are to have the NHS, how lucky we are to be born where we are born, and how that affects our destiny. I also think this is the first time I've looked forward to doing a block of urogynaecology too!

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