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.

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