Photos of the HDU so far are here and chimps are here
Thursday, 13 May 2010
Things have really picked up pace. With only 11 weeks left here I have so much to complete. I'm in that pre-amble phase of writing lots of lists and making pretty coloured timelines, which is somehow reminiscent of revising for any set of important exams. 'We need the induction of labour guideline urgently' and 'When can you set up the HDU? This weekend?' suggested to me that the head of department is also conscious of my nearing departure.
Induction of labour is at best haphazard here. We had a case of uterine rupture in a woman, who had an induction which had been carried out in line with FIGO recommendations, that made the department collectively twitchy about the induction process. There are no true written rules, and while everyone sort of does the same thing, it's not uncommon to come across women who seem to be undergoing an eternal induction. So rapid action was required and Prof Lule was quick out of the starting blocks to get something put together on induction , while I worked to pull together the evidence for use of Misoprostol throughout obstetrics and gynaecology, and summarise it in a presentation. We presented both pieces of work together in the morning meeting and there was a lot of debate and discussion about exactly what we should do here to induce labour. Different people have different opinions about what works, based on personal experience. The difficulty is consolidating that with what is in the literature and what is deemed to be safe. I think this will be one of the most difficult guidelines to ratify here - there are a lot of strong-willed people with differing opinions.
Big things have happened with HDU. I've mentioned it previously here, but there's a definite need for some sort of high dependency care. I have felt strongly about this since arriving at Mulago, having discussed it with my predecessor, and the idea gathered momentum after Mark Muyingo went to Liverpool and identified a need for a high dependency area for postnatal women. We unsuccessfully bid for funding to set it up, learning we had not won the money in early February. The idea for a 'shoestring' HDU has been floated around and I finished the first draft of the concept paper. The Friday before last the Head of Department, the Ugandan LMP team and I went to ward 5C and identified the latent phase room as the best place to put it. 'When can you start work? This weekend', was no joke, although it was too short notice to co-ordinate painting. 'Next weekend' was my reply.
Working on guidelines has allowed me to eat lunch away from the hospital with my housemates. I was sitting waiting for Adam, Avner and Phoebe to join me one afternoon. Adam came bouncing into the restaurant, clearly quite wound up. He had had an altercation with a taxi conductor over 400 shillings (about 12p), in which the conductor had snatched a packet of photos from Phoebe's hand as a way of forcing them to pay more than the usual fare because they were Mzungu. It seemed to get out of hand, and culminated in Adam slapping him, grabbing the photos back and running away. There's a degree of racism here, when it comes to paying for stuff, and the 'Mzungu price' often gets hiked way above the local cost. This gets very wearing at times, when you live here and you know what goods and services are supposed to cost. I guess Adam had reached the end of his tether. Time to leave the country - he's currently chilling in Zanzibar.
I joined my housemate Avner for a march on labour day (May 1st). We were marching against child labour. I was under the impression that this would be a huge organised thing. We turned up at the roundabout by the Northern bypass at 8.15 ready to march en masse. The few of us in our group were the only people there apart from a group of security guards. It turned out that the march had been cancelled, but that not everyone had been informed. All the other groups were already at the shcool where the march was supposed to conclude. So we walked for 5 km to get the, in the beating sun, to find that in fact, the majority of people that were there were from large corporate firms, present to keep the politicians happy. The only other group that was even vaguely similar to us was the Ugandan Nurses Union. So there was I, ready to chant and burn stuff in protest, only to find that I had to plod round the parade ground in front of the powers that be, and be on my best behaviour in front of the mayor and various other invited guests. We were on TV that evening, but I don't think we got our message across!
Phoebe and Mark left to go back home to Canada last week. Our small group of close friends is ever decreasing in size. We had a lot of fun with them, but apparently Sescatchewan was calling them. Great opportunity for a Canadian break though!
On a different note, I have a regular boda boda driver who brings me to work in the morning. Alan is dependable, obliging and above all, a safe driver. We don't talk about much, but I like him. He had come to the house one afternoon, with a problem. Driving a boda boda is a way of making ends meet. Most of these guys don't own their bikes, but rent them from shrewd characters who know how to snare people into a rental agreement that is difficult to break away from due to financial constraints. On average, Alan earns 80k per week (about £25). He rents his bike for 50k a week, and puts around 20k worth of fuel in on top of this. He therefore has a take home of 10k per week, and this has to pay his rent and feed his wife and 3 kids. He has rented his bike for 18 month, having previously worked in a photography studio. He gave this job up because he wasn't paid for 4 months and driving a boda boda was the only option available to him. The guy he rents the bike from announced that he had sold the bike, and had bought a matatu, and that the bike would no longer be available to rent, but he could buy it for 1.8 million shillings. Alan's livelihood was at risk, and he was asking us to help him out with a loan. None of us had the capital sitting round to do this. I went to the bank with Alan, but the loan situation was impossible, and microfinance companies wouldn't make a loan big enough to cover the cost of a bike. Alan had decided that rental was a mugs game and that buying a bike was a way of sealing a future, with his goal of being able to buy land to farm and to school his kids. I really wanted to help him out. Then my housemate Avner mentioned a hire purchase scheme set up by an American journalist. The boda driver gets a brand new bike, he pays back over a period of 17 months with interest, but the papers are in his name and he walks away at the end of it with a good bike and 50k extra a week in his back pocket. I made some calls, arranged for Alan to meet the scheme manager and I put the deposit up for him, which he'll pay me back by bringing me to work for free. He turned up at the house with his brand new bike, beaming, ready to start a new chapter in his life, that will enable him to make a better future for him and his family.
Louise Ackers and Carol Porter arrived from Liverpool last week to present the findings of the evaluation they have done on the Liverpool Mulago Partnership. They have done some awesome work looking at patterns and trends in morbidity and mortality, including some really interesting work mapping out where the women that die at Mulago come from. This will perhaps allow us to address some of the logistical issues that contribute to maternal mortality here, such as transportation, referrals, functionality of referring hospitals and clinics and so forth. There is more data to collect and add to what has been done so far, but it's incredible to see everything collated and analysed in one place. I'm excited to read the final version. We attended a grant proposal writing workshop together with Judith Ajeani, one of the specialists here, for another funding bid to help in setting up the HDU, but more importantly to evaluate the impact that it has on care here. If we can get this funding, it will be a huge milestone for the partnership, and will strengthen the links that the team have worked so hard to forge. It will allow us to see whether what is actually a relatively simple intervention does make a difference in this environment. I'm keeping my fingers very tightly crossed. It was great to spend time working with them. I met a Liverpool palliative care consultant at the workshop, Dr Merriman, who had been a care of the elderly consultant at Whiston Hospital back in the day, and who set up Hospice Africa. It's a frighteningly small world.
We have finally unravelled what was happening with the maternal death audit data, which we need as a detailed baseline from which to measure the impact that various initiatives are having here. The data has simply disappeared. So I have 184 files to audit from 2009. They also brought a heap of donated equipment for the department. We had a nice meal with the Ugandan members of the exchange on the Friday evening.
On Saturday we travelled to Ngamba Island chimpanzee sanctuary. I had forgotten how rough Lake Victoria gets, and by the time we had made the 45 minute speedboat crossing in the lashing rain we were soaked to the skin. We spent a happy hour watching the chimps at play, socialising, chasing each other and interacting. We share 98.7% of a chimpanzee's DNA. The resemblance is scary. The chimps are all orphaned or rescued from injury, or from being kept as pets. We got back slightly less damp than we arrived.
On Sunday we deep cleaned the HDU and painted it. 7 of us - me, Louise, Carol, Mark Muyingo from Mulago, and my housemates Av, Eric and Carine - set to it with wire scourers and brushes, tackling all the surfaces and washing off years of grime. We the covered the room in soft white, managing to get three coats on before we ran out of energy. We need to go back and put the finishing touches to it, but it does actually look like we mean business. Once the painting's finished, we'll get mosquito grilles up and start to put the equipment in.
Andrew Weeks arrived on Monday morning, so we had a few drinks and dinner on Monday night. We'll spend a bit of time working on the HDU proposal while he's here. Carol and Louise left on Monday afternoon. The rest of the week will be spent training the midwives in neonatal resuscitation. We have 12 candidates this time, due to problems with staffing and rotas. The good news is that I have enough money to run a further three 3 day courses in July. It will be my swansong before heading back to Blighty.
Photos of the HDU so far are here and chimps are here