Sunday, 20 June 2010

Doris Days

Wow, the weeks seem to go by more and more quickly.  And my blogging seems to get less frequent.

We successfully completed the neonatal resuscitation course, and trained 11 midwives - one suffered a bereavement mid-course and didn't complete - despite one of the instructors getting malaria.  It was generally well received, although there were complaints about the food.  People complain about the same things, wherever you are in the world.  The three day format worked very well, although for subsequent courses we plan to run it for 2 days to keep the group sizes down.

The SHOs had exams for 2 weeks, so I covered the labour ward.  The first week there was me, one specialist and 1 to 2 interns.  Despite being extremely short staffed we managed pretty well I think.  I spent the Monday and Tuesday on the shop floor, while the specialist was in theatre with the intern.  I sutured cervical tears using the light from my mobile phone, kneeling on the floor.  I did some manual removals under pethidine sedation.  I ran around struggling to get blood, and then having to decide which of the three moribund patients - one massive APH with a live baby, one massive PPH and one severe malaria in pregnancy - who were O +ve to give the single unit I could get hold of, to.  We gave it to the woman with the APH.  All three women and the baby survived, fortunately.  I also resuscitated babies, dealt with complications of HIV, severe malaria in pregnancy and severe PET.  

I spent 3 days in theatre, battling with the usual frustrations - no catheters, no cannulae, no gloves - the patients had to bring their own, which created its own set of disasters, since it seemed to be those most in need of an urgent section that didn't have money to buy the consumables we were lacking in or didn't have attendants to go to the pharmacy and buy them.  We had  a retained twin, delivered by CS, the mother had delivered twin 1 at 1am and rocked up to Mulago at 3pm, from less than a mile away.  Baby was fortunately OK.  My section mix consisted of 1 woman with 5 previous scars in labour, 4 genuinely obstructed labours - one of whom I had to deliver by the breech - an impending rupture, a cord presentation, 4 other women with previous scars, 1 HIV +ve woman with PROM, a PG with contracted pelvis and one severe PET.  Numbers wise it wasn't a huge amount of work, but when the list often doesn't start until at least 11am - sometimes later - and with all the other rate limiting factors, on a good day in one theatre most people don't get more than 7 sections done between 9 and 5.  I had the weekend off, which cover had been arranged for, and gathered my thoughts, relaxing in the garden with a good book and plenty of coffee.

The second week the staffing numbers were a little better, 3 SHOs - including me - and two interns. This meant that we were able to run 2 theatres.  We still had issues with gloves.  We had the added problem of the student anaesthetic officers being examined on the emergency list.  This meant that the choice of anaesthetic was dictated by what they needed to be examined on rather than the clinical indication for caesarean.  It also meant that the list shifted very slowly indeed.  I spent 2 days on the labour ward shopfloor, the highlight of which was an undiagnosed multiple pregnancy, twin 1 breech, twin 2 cephalic.  I was called to assist as the arm was not deliverable on twin 1 on account of it being extended above and behind the head.  After a lot of manouvreing, I managed to hook the arm down and deliver the baby, resuscitated it, only to find that twin 2 was a compound presentation.  I managed to push the hand back, rupture the membranes and she delivered vaginally, so all was well that ended well.  

I had a challenging few days in theatre.  The first day we had 3 sections for fetal distress, a transverse lie, back down, with a previous scar and oligohydramnios at 32 weeks, who I had to do an inverted T incision on, a badly obstructed labour and 2 women with 2 previous scars.  Aside from the glove issue, the list ran fairly smoothly.  The second day, I walked into labour ward, past the admission room and spotted a woman with 2 previous scars, behaving like she had an impending rupture.  We managed to prioritise her to go in first but the anaesthetic students refused to start the list as they were waiting for their examiner to arrive.  I ended up getting annoyed, since I had expressed my concern about the likelihood of this woman rupturing.  They brought her through, and put her on the table to start the spinal, and I knew from the change in her behaviour that the uterus had ruptured.  Fortunately the baby was still alive, and although the uterus had ruptured posteriorly,  managed to repair it.  She had a PPH and required blood but subsequently did OK.  

The next patient that came in was transferred from another unit, severely anaemic, having been delivered by section the day before in another unit. I was dealing with the PPH on the corridor, so one of the other SHOs went in to start the laparotomy, finding that the bladder had been sutured to the upper lip of the uterine incision, and she had bled from the lower lip and into the broad ligament.  Again, there was no need to do a hysterectomy.  Unfortunately, because of this referral taking priority over other cases, the next woman with a severely obstructed labour ruptured anteriorly, and the baby was stillborn.  I managed again, to repair the uterus and she did OK.  We then managed to get through two more sections - 2 and 3 previous scars in labour - before finishing for the day and handing over to the night team.

The next morning I walked into theatre to an almost identical scenario - students awaiting examiners, another impending rupture - who again, ruptured on the table, with a live baby.  Unfortunately the rupture also involved the bladder and I couldn't confidently find the apex or the ureters, so I called the specialist in.  That day we also had 2 undiagnosed praevias, a breech with a cord prolapse, one CPD and a severe PET.  It was nice to hand the house over on the last evening, knowing that I wouldn't be taking it back again the next morning.

The next week was dedicated to finalising some stuff for the upcoming Liverpool Mulago exchange, putting the finishing touches to the HDU paintwork and completing some of the paperwork that we need in order to get the HDU running.

Being so busy at work meant that I wasn't at home very often, and had particularly missed relaxing in my own space, and also spending time with my housemates.  Doris, our housekeeper has been a constant source of interesting conversation recently.  She's a formidable woman with a hatred of men - for reasons we are not sure of - and is inherently suspicious when new people, particularly of male gender, move into the house.  She collared me in the living room when I got home while she was still at the house...

Doris; 'Who has been feeding the bones of fish to her?'
Me; 'Who has been feeding the bones of fish to who?'
Doris; 'Someone has been feeding the bones of fish to Pasha'
Pasha is a male dog.  Doris is forever confusing gender, and will refer to Adam, Pasha, Justus and George as she or her, while referring to me and Elizabeth as he or him.

Me; 'I don't know who has been feeding fish bones to Pasha'
Doris (accusingly); 'It must have been Justins [Justus] or George.'
Me; 'I doubt it was Justus, it may have been George'
Doris; 'You need to speak to her, in my country when they are trying to kill a dog, they feed her the bones of fish'

Or another conversation a matter of days later

Doris; 'She has been stealing plates and bowls and knives and forks'
Me; 'Who has been stealing?'
Doris; 'Justins [Justus].  And she stole my pegs'

When Doris settles her mind on something, it can be impossible to change it.  We have a new housemate, Chi, a Tropical Medicine SpR from London. 

Chi; 'Hi Doris, my name's Chi'
Doris; 'Cheese?'
Chi; 'No, C-H-I. Chi.'
Doris; 'Yes, Cheese.  Welcome'

Doris recently found 70,000USh in my trouser pockets, which I'd abandoned in the washing basket.  She is a woman of the utmost honesty and integrity.  Having discovered the money she spoke to Adam who was the only one home...

Doris; 'Whose are these trousers?'
Adam; 'I don't know'
Doris; 'I think they are for Kate sometimes'
Adam; 'I don't know Doris'
Doris; 'Yes, they belong to Kate sometimes.' (Long pause, Adam looks around room uncomfortably) 'I found this money in them'.

I don't know who my trousers belong to the rest of the time, if they're only mine sometimes, but hey ho.  I admire Doris.  She grafts to school her kids, as a single mother, strong, stubborn and doesn't take any sh*t from anyone.  I will miss her when it is finally time to leave.


  1. Fantastic that was!
    Cheese is featuring a lot in this final trimester for you is'nt It?
    How does a women with an impending rupture behave, ive no idea?

  2. I just love your chapter titles, feel sure they will appear in a publication one day xx


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