Sunday, 28 March 2010

Fistula Outreach Camps

For the past two weeks I have been away from Kampala, working with some of Mulago's urogynaecology specialists who were conducting VVF outreach camps. The first of these was in a small town called Kiboga, which geographically is not far from Kampala, along a well paved road. In reality, there are many constraints faced by women afflicted with fistula - who will pay for transport and food, who will farm the land, who will care for the children - that prevent them from accessing definitive treatment at Mulago. The second camp was in a larger town called Mityana, along a rougher road but still within reasonable distance of the capital. The camps are endorsed by the Ministry of Health and funded in part by an organisation called AMREF.

We arrived in Kiboga, me, two specialists (Mwanje and Alia) and a scrub nurse (Alice), on a sunny Monday morning. Just before we entered the hospital grounds, Mwanje leaned out of the window to talk to someone coming out of the hospital.

'We're here to do a fistula camp'.
'Oh, er, do you have an anaesthetist with you, because we don't have one'.
'What are you talking about? You ARE an anaesthetist'.

And so we met 'Uncle' the resident anaesthetist, whose excuses as to why we couldn't work were many and varied and would be a constant theme over the next few days. 'We have no instruments', 'We have no linen', 'We have no linen', 'It's too much work', 'I worked all night, we did two sections' and so forth. Fortunately, our humour and patience were as limitless as his excuses and so we did manage to get some work done.

We spent the first afternoon screening patients. Radio announcements are made about the camps in advance. Almost everyone has a small wireless radio, or knows someone who has one, so this is the best way of achieving maximal publicity. Prospective patients turn up on the first day, and the plan for the rest of the week is made from there. We saw around 20 patients and operated on 13. While the majority of women attending do have a fistula, we also saw women with prolapse, stress incontinence and pelvic infection. One patient had lived with a vesico-vaginal fistula (communication between the bladder and vagina) for 24 years. It proved impossible to get theatre space the first day, Uncle was dodging us, there was an emergency case and then it was too late in the day to start.

On Tuesday and Wednesday, we managed to get through our 13 patients. We acquired a second theatre table, and after cleaning and oiling the table and topping up the hydraulic fluid it was semi-functional, despite one episode when the head of the table collapsed while the patient was being prepared for spinal anaesthesia - fortunately without the needle in her back, and with the gas man to catch her.

There were several very complex fistula cases which were repaired, third degree tears that had not been repaired which we operated on, ureteric implantations performed and an exploratory laparotomy and adhesiolysis. There was one emergency section performed while we were in theatre, resulting in a neonatal death due to severe hypoxia. I spent 45 minutes ventilating in vain. There is no special care baby unit in Kiboga, or indeed before Kampala, and so even if resuscitation is successful, there is no facility for supportive care. The hospital itself is a decent building, but it's not being used optimally. There was no running water during our stay and very few staff - 3 doctors in total. It was, however, fairly clean, all things considered.

At the end of Wednesday afternoon, our work in Kiboga was complete, and no new patients had attended, so we returned to Kampala with the aim of spending two days operating there, if we could get an anaesthetist to work with us. Unfortunately there was no-one available, and in fact there was no-one for the elective list in the fistula theatre that would normally be running until 3 in the afternoon. We repaired a fistula in a 4 year old who had fallen onto a tree branch some time back. The cause of the fistula was confirmed by the discovery and removal of two pieces of wood lodged within the tissue, one around 2cm long and the other about half a centimetre. We went from here down to the main gynae theatre to perform a bilateral ureteric re-implantation and bladder repair on a woman who had had a section 2 days previously and who had not passed urine since. It was a complete mess, but surgery was successful. Friday was a day of running around organising and doing admin.

I worked the night shift on labour ward on Saturday, spending the night in theatre, getting through 8 sections. The SHO on the shop floor managed to do 3 more sections in gynae theatre. The cases were varied. A woman had pushed for 12 hours before being referred from a clinic to the hospital with a stillborn baby and a difficult section due to severe impaction of the head in the pelvis. Three women had uterine scar dehiscence and all of their babies survived, simply due to us luckily eing able to move them through theatre fairly quickly and avoiding complete rupture. One woman had an undiagnosed placenta praevia. At 4am we ran out of fluids, had no catheters, no venflons and there was only AB +ve blood in the hospital. We had to stop theatre with 3 sections still pending. In that time we had a cervical tear which I repaired on the ward with no light and no sponge holders, kneeling on the floor. We had a number of severely anaemic women, and I spent a merry hour running around the various wards trying to find fluids and gear, with minimal success. All things considered, it was a fairly successful night shift. Sunday, naturally, was a write off.

The following morning, myself, Barageine and Sister Rose piled into another pick-up to venture to Mityana for the week. After a protracted departure, involving paperwork and diesel fuel, we bumped along the road to the hospital. The hospital is in fact best described as an assortment of shacks in varied states of dilapidation. Cows, dogs and ducks roamed the compound freely, whilst chickens strutted through the wards oblivious to anyone. Bags of blood hung from improvised drip stands made of branches. The theatre was small, filthy and clutteres, plants growing in through the windows and insects populated the inside of the semi functional theatre light. There were no overhead lights, no running water and no proper linen - drapes were made from ripped up scrub shirts. The patients were screened in an office, and listed for theatre. We saw a woman who had a catheter which had been in for over 6 months, having had her fistula operated on in a private clinic and then being discharged without follow-up or instruction, and another woman who was operated on at a previous camp and had gone home with the gauze pack still in-situ 4 months earlier. Many of the fistulas were extensive and complicated.

We worked on 27 women, over 4 days in theatre. At points we would be operating, while another patient has a section in the same theatre on a flat bench with no drapes and in the 'anaesthetic' room a child would be being circumcised or having a dental extraction without anaesthetic. The conditions were shocking. After 4 days of operating in the theatre, I was glad to be leaving, amazed that the staff can work week after week in such conditions, and yet dismayed that no-one pushed for change and improvement. I will be glad to get back to Mulago next week.

I took some photos, I don't think words can do justice to the conditions that patients and staff are existing in. You can find them here and will note the striking difference between the two hospitals.

Wednesday, 10 March 2010

Planes, Trains, Automobiles, Dhows, Boda Bodas and Tuk Tuks

Things at Mulago calmed down after surviving the week on labour ward. Urogynaecology is refreshingly quiet. The set up is very different. Mondays and Tuesdays are ward round days, and so, since most of the patients are electively admitted and for the most part relatively well, the round is usually finished by 11am. Wednesday and Thursday are theatre days and Friday is clinic. There is a dedicated fistula theatre, with the capacity to run 2 tables at a time. Most procedures are done under spinal anaesthetic. The week I started, there had been no list the previous week, and the specialists were upcountry on an outreach fistula repair camp. This meant that the ward was even quieter than usual, and so I had the opportunity to go to theatre for the family planning list, performing two sterilisations by mini-laparotomy, under local anaesthetic. This was a first for me, since the vast majority of elective female sterilisation is done laparoscopically at home.

Normally, the urogynaeology team perform 6-8 procedures a week, and about half of these will be fistula repairs, and the rest will be prolapse repairs, vaginal hysterectomies and sling procedures or Burch colposuspensions. The majority of fistulas here are obstetric in origin, since prolonged labour is common, and access to definitive care limited. There are also women who attend with pathology due to trauma, secondary to sexual assault, particularly in times of conflict. It is not uncommon to meet women who have been victims of rape at the hands of groups of soldiers.

Fistula is a taboo subject. There is difficulty in setting up functional fistula centres, as the perception is that to do so is to admit that fistula is a problem within the population. Until recent times at Mulago, less than 10 fistula repairs were being performed each year. Now the department repair several hundred annually. Women with vesico-vaginal fistula cannot control the passage of urine. They are constantly wet, which causes all sorts of issues with hygiene and tissue viability. They become social outcasts, marriages are destroyed, they are unable to have intercourse, being considered 'dirty'. In some places, women with fistula are shut up in small huts, like dog kennels, away from the family home, unable to stand up straight, clenching their legs together in an attempt to stay dry. They are not allowed to leave these huts, meals are passed in through small holes. These women develop disfiguring contractures of the limbs, necessitating surgery.

Sadly, this happens all over the developing world. Even sadder, is the fact that while fistula is operable - and when performed by someone with significant experience can be extremely successful, and life transforming - access to such surgery is difficult. Whether this is a question of geography, finance, stigma or a combination of all these factors and more, I don't know. The good news is that the team at Mulago are running fistula camps at hospitals in more rural areas of Uganda, each lasting a week. They are running one every two weeks for the next 6 months. Hopefully taking experienced surgeons into these areas for intensive periods, will help to tackle some of the issues, and ultimately transform the lives of these women.

After two weeks on urogynaecology, I was feeling much happier with being out here. The job seems to swing through extremes of nice highs and horrific lows. The other thing about urogynaecology and the way the job is set up affords me time to work on other things. I had run some really good teaching sessions with the midwives, interactive tutorials where we all learned new things. I also spent some time thinking about how to take some of the projects forward that have stalled or have not worked as well as we would have liked. It's a happy medium for now, but I'm sure that in a couple of weeks I'll be bursting for some more labour ward action.

Last weekend was a long weekend, for International Women's Day, which is a national holiday in Uganda. As a spur of the moment thing, we decided to fly to Nairobi and travel to Mombasa, Kenya. The idea was conceived and flights booked quickly, to depart the following morning. Elizabeth, Adam and I headed bleary eyed, to Entebbe airport at 4am. We arrived in Nairobi around 7.40am and after battling to get through immigration, 'You can't pay with this $100 note, it was printed in 1999', we met Moses, who was our driver for the day. Having agreed our price, we headed to Nairobi railway station, where we bought 4 second class tickets for the night train to Mombasa, for the three of us and our imaginary friend 'Boris'. So far, so good. From here we went to the National Museum, which was fab. It was an eclectic collection of natural history, cultural artifacts and good art. We whiled away 3 happy hours here - stopping for obligatory coffee and cake at the museum cafe. Nairobi has a reputation for being extremely dangerous. We were expecting seedy run down streets, but what we saw and experience couldn't have been further removed. Our experience of Nairobi was one of a cosmopolitan city, a city on the up, and quite different from Kampala. We decided to attempt to get to the giraffe sanctuary, in the northwest part of the city. Moses said he knew where it was. We stopped to get fuel. It seemed to take us an age to get there. And then, on a random road, seemingly in the middle of nowhere, the car cut out. 'They didn't put the fuel in'. And so we found ourselves attempting to push the car along this random road, in the searing heat, the boot so hot you couldn't push for long without burning your hands. Moses spent some time on his cell phone, trying to arrange a rescue plan. We had no water, were ridiculously thirsty and had no sunscreen on. We decided to walk to the nearest watering hole, which thankfully wasn't far. We thought we might get some lunch there while waiting for Moses to sort out the transport situation. 'We have chicken, goat or beef'. 'OK, how long will it take?'. 'Probably about 40 minutes'. So we were stuck in a local bar, with no immediate chances of escape, with a train to catch, a broken car, somewhere on the outskirts of Nairobi. But the beer was cold.

About 30 minutes later, Moses rocked up in the car, engine running, and we decided to cut our losses and get back to the area near the station, so that if the car died again, we'd still catch the train. The giraffes would have to wait. The restaurant we chose to eat in was closed. By now it was late afternoon, we were hungry and becoming grumpy. We took our chances on a restaurant called Berber's. It became clear that this wasn't a restaurant travellers stumbled upon very often, apparently it was 'an honour' for us to be there. And we would have felt honoured to be there if the food hadn't been so terrible. But it was all part and parcel of the experience and we were just glad that we weren't still pushing a car along the road in 30 degree heat. After 15 minutes of panicking, trying to get hold of Moses on the phone - who was driving around Nairobi with all our stuff in his car while we ate at the restaurant - who had gone AWOL, thinking that all our worldly possessions had been pilfered, we located him, got back in the car and went to the station.

Nairobi railway station was like something out of a black and white film, except the steam trains of yesteryear had been replaced with spluttering, wheezing diesel engines. We waited on the platform, people watching, until the train drew into the station an hour before scheduled departure. We located our cabin, threw our stuff in and made ourselves at home. We were pleased to have somewhere to lay our heads, and pleased that we had survived the day. The train pulled away from the station bang on time, and we cracked open some Tuskers and watched the outskirts of the city speeding past the window as the sun began to set. The train manager paid us a visit to welcome us on board, informing us about meals and arrival times, and to check we were happy. Good old British Rail could learn a thing or two! The bell rang for dinner and we headed to the dining car where we had stew and rice, washed down with some red wine.

There's something very soporific about the sounds and motion of a train. Leaning out of the window, string at the stars and watching the lightning cracking across the horizon, I felt overwhelmingly content. Around 10pm I clambered up into my bunk, and fell asleep to the clickety clack of the train thundering through the Kenyan countryside.

The bell for breakfast at 6.45 was a rude awakening. We stumbled through the train for a serving of fry-up, and a much needed cup of coffee. At 9.30, right on schedule, we arrived in a very hot and very humid Mombasa. We took a tuk-tuk to the hotel, checking in early for much needed showers and then headed to a beach just outside of town for an afternoon of kicking back in the shade a palm trees, looking out across the white sand at the azure and topaz sea. It reminded me of Zanzibar although the colours were different. Elizabeth took a camel ride, on a majestic beast called Charlie Brown. Adam and I plodded through our books, keen to avoid becoming sunburned. We headed back after a few hours, changing for dinner. We were picked up from the hotel and transferred to the other side of the bay, to the Tamarind Dhow, a traditional Mombasan boat, for a dinner cruise. We ate lobster, while drinking nice wine and listening to the sounds of the band, knocking popular classics with an African twist. There's nothing like eating a good meal with friends, in the open air, floating past the world. It was fab.

The following morning we walked to the Old Town, exploring Fort Jesus, a semi-derelict Portuguese fort, unfortunately badly maintained. We then meandered through Old Town's streets. Since it was Sunday, most things were closed, but it had a lovely feel to it, similar to Stone Town, but not quite as nice. After a leisurely lunch back at the Tamarind - this time on land - it was time to head back to the station. The train back, this time with an imaginary child called 'Prunella' sharing our cabin, who was in absentia due to 'sickness' necessitating an imaginary hospital admission, was just as much fun as the first time. A little drunker and a bit more balmy, dinner was spent being childish and messing around, pretending to be 'Cousin it', for reasons I can't remember. After another sound night's slumber in the sleeper car, we spotted zebra and giraffes from the window of the train. Having not yet seen zebra in the wild, I was over the moon!

We arrived later than expected in Nairobi. We were collected by a different driver, Steve. We visited an art centre, and this time actually made it to the giraffe sanctuary, where we got up close and personal with Laura, a female giraffe. Kissing a giraffe is one of those life experiences that I will always remember, but have no desire to repeat! After a bit more craft shopping we went back to the museum so that Elizabeth could buy a painting she had fallen in love with at the beginning of the trip.

We had a few hours to kill - or so we thought - and after consulting the driver about how much time it would take us to get to the airport, we went to do a spot of shopping. All was well until Steve went missing in the car park, with a mobile phone that didn't work. And so for the second time on the trip we began to panic, knowing we had a plane to catch. We eventually found him, by now all of us a bit agitated. But we were reassured that it was only going to take around 40 minutes to get to the airport. 3 hours later, with 50 minutes to the departure of our flight, we were still stuck in a traffic jam, with what seemed like the rest of the population of Nairobi. Adam got out of the car to try and find out if we could get motorbikes to the airport - 'They are banned in the city centre'. The crowning moment in that increasingly tense journey was when Steve read the number of the radio station as the time, rather than the clock, and then suggested we could 'just get the next flight'. When we explained the cost implication of 'just catching the next flight' I think it dawned on him that we really did need to get to the airport. Creeping out of the congestion, Steve floored the car, in one of the most dangerous journeys I have ever been on. Elizabeth's suggestion of 'At least if we crash, at this speed we'll be killed outright' did nothing to reassure me. We arrived at the airport 29 minutes before take off, to be told that we could probably check in, but at that point there were not enough seats on the plane. The next anxious 10 minutes were spent standing at the check in desk, drawing effigies of the driver on the back of a departure card. Bob, the desk steward then announced that there were seats, and so we tore through the airport, skipping and dodging other passengers to the gate, where we were escorted onto the plane, people staring at us for being 'the ones that held the flight up'. I have never been so glad to put on my seat belt and be subjected to the safety talk. The weekend had been fantastic, but in a way, I was glad to be heading back to Kampala.

Photos can be seen here