tag:blogger.com,1999:blog-75120022225200241802024-03-22T02:19:04.689+00:00Kate's Adventures in UgandaKeep up with my year out in Mulago Hospital, Kampala, Ugandakatealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.comBlogger43125tag:blogger.com,1999:blog-7512002222520024180.post-76209557592128233532010-08-25T15:55:00.001+01:002010-08-25T15:55:25.881+01:00Full Circle<div style="text-align: justify;">Since we were unable to get home from Rwanda in a timely fashion, I missed the first day of the neonatal resuscitation training. It felt right to be finishing off my year at Mulago in the same way that I'd started. Following our recent 3 day programme, we had cut the training down to 2 days. We planned to run 3 courses back to back. Domalie and Agnes were willing and eager as ever, and so my missing the first day was no great shakes, especially as only 7 candidates turned up for the training. The numbers on the first of the 3 sessions were very disappointing. Fortunately by the end of the week, they had picked up significantly, and we trained a total of 60 midwives in a week. Several midwives from outside of the hospital attended for training, and so hopefully this will help spread knowledge to other clinics and healthcare centres outside of Mulago. While Domalie and Agnes delivered lectures, practical demonstrations and critique, I had my head down, wading my way through the maternal death audit case files, determined to finish before leaving Kampala. It took a lot longer than anticipated, and I was still beavering away the morning that my flight was leaving Entebbe, but I managed to collect data from all of the files available. I felt guilty that I had not spent my last remaining weeks doing clinical work, but was also determined to tie up my loose ends and fulfill a numbers of pledges.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We had BP machines attached to the walls on Ward 14 and also ordered and took receipt of 17 mattresses, which were bought with money raised by Heather, Lorraine and Rebecca, and their friends and family. I met with the matron to discuss her vision for the future of the department from a midwifery perspective. I had a good nose around the new labour ward too, which is a fantastic use of the space available to put it in, and a much more pleasant environment than the current labour ward. The medical students finished off their SSM project. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I bought enough African souvenirs to sink a ship, and then realised that I might not be able to get them all home. I decided that I was going to sacrifice many of my clothes in order to get them home - I was prepared to abandon all of my possessions entirely to get a painting home which I had bought, by an artist named <a href="http://www.edisonmugalu.net/">Edison Mugalu</a>. It typefied for me everything about the year I had spent in Uganda, and more broadly East Africa. The easiest thing to do was to divvy up the spoils between Alan, the Boda guy, for his wife, and Doris. Now, I'm not a waif, but Doris is a tad larger than I am. She managed to wedge herself into one of my poisoned pink bras that had seen better days, and over the following few days turned up to work in a selection of my clothes. My possessions almost became a free-for-all, 'Your bag is nice, can I have it?'. Doris was fantastically happy. My Mum asked me to give Doris a small gift from her, to thank her for looking after me. She was overjoyed. When I asked her what she would spend it on, she exclaimed 'Laundry and shoes!' By that, I think she meant clothes. I hope that she enjoyed it.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I spent time with the boys in the house, chilling, eating, chatting - although not about our impending leaving dates. It felt strange that time had suddenly crept up and I was in my last week of being in Kampala. I caught up with friends and bid them farewell. Frequented my favourite haunts for the last time.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">My last day at Mulago was Tuesday July 28th. I took in a couple of cakes to the morning meeting, as is customary. I was unable to say very much to accompany the cake, other than thank you. There was too much to say to too many people, and I was choking the tears back before I'd even opened my mouth. But I think the sentiment was understood. I was then presented with a number of very unexpected gifts - baskets, bowls, pestles and mortars, straw mats and carvings. Having already packed my stuff, and with a modicum of concern about the weight I was already trying to take home, I had to pass them on to Shireen and Amelia, and Carol and Louise to take back for me. I said a lot of goodbyes. There were some people that I missed, that I really wanted to thank, and bid farewell to. But I also wanted to leave quietly.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I spent the next couple of days finishing off the audit. On the Wednesday, I was invited to the launch of the Ugandan Parliamentary Scorecard, the project that Adam had been working on throughout the year. There were rumours that the President would be there to launch it, however he was unavailable, and so the Prime Minister came instead. We sat through several lengthy presentations before Adam stood up and said his piece about what the scorecard actually means. Then followed another lengthy speech before the Prime Minister stood up to speak, prompting a fit of giggles from me as he attempted to clear his throat while shouting the word 'capture', at the same time. The presence of several TV cameras didn't do anything to help matters, and I was helpless for a good ten minutes. It is not uncommon for me to get a fit of giggles in inappropriate places -weddings, masses, first holy communions, funerals, formal dinners - but rarely have I done it on camera. We were on the news. I just hope that the Prime Minister didn't see me. My giggling was avenged by one of the heaviest rainstorms I've seen in Kampala, and the heavens opened, as if on cue, almost the second we left the hotel. By the time we got to Garden City, we looked like drowned rats. I was so cold I had a hot chocolate.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">The day I left was hard. I had some photos printed for Alan, who insisted on walking to the mall with us as it was our last day. I wandered through the go-down taking photos, trying to capture the place in all its glory, and not succeeding. Maureen came round to say goodbye. I showered and changed. James, the driver, arrived early, as predicted. I said goodbye to the dog, who put his head on his paws as we loaded the cases into the car, and he whined. I couldn't speak to Adam, we just hugged each other. We didn't need to say anything, it was hard enough already. I will always be grateful to Adam and Elizabeth for their unswerving friendship and support. Without them, I am sure that I wouldn't have lasted the year. They were my rocks. I said goodbye to James and Maureen, and George the guard, and after cuffing Pasha round his ears one last time, got in the car and headed to Entebbe...</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-87081461495715560692010-08-17T17:26:00.000+01:002010-08-17T17:26:16.292+01:00Um Bongo, Um Bongo, there is none in the Congo!<div style="text-align: justify;">The day after the girls left, I took Sunday to rest and recuperate. Elizabeth, Adam and I went off to the spa for an afternoon of pampering. Adam and I opted for the couple's massage, since it was cheaper, resulting in much hilarity as neither of us wanted to witness the other in the buff. There was much theatre with towels and sheets in order to avoid any unnecessary flesh exposure. It was much needed, and after the masseure let loose what felt like an elephant on my back, neck and shoulders, I felt significantly less tense than before I'd started. We finished off our girlie day by subjecting Adam to Sex and the City 2 at the cinema, which he endured without too much whinging. Meanwhile, Shireen and Amelia, medical students from Liverpool, who had an SSM project planned at Mulago, landed at Entebbe.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">On Monday morning, we began what was to become the very frustrating process of applying for ethics approval for the project. The project itself was a very simple straightforward proposal, which involved taking routine vital signs observations and equating them into an early warning score, which would trigger when patients were becoming ill. The plan was not to use these scores to guide care, but simply to see firstly whether it was feasible to collect such information, and secondly to use it as a pilot for a larger validation study to see whether the scoring system actually worked. The girls were not planning to take any measurements that the patients should not have had done already, and were not planning to use the information to alter patients care. It had been approved by the University of Liverpool's ethics committee, and so we were hoping for a straightforward process. Simples? Not so. The first time it was knocked back was because it was not in the standard format for the hospital's ethics committee. Frustrating because we had asked before we submitted it whether the format was acceptable, and the secretary had said yes. It was knocked back a second time because the information sheet was not in the local language, and various other spurious reasons. This wouldn't have been quite as annoying, had we not already questioned whether the information sheet needed to be in Luganda. The process dragged on for the whole time that the students were at Mulago, and so unfortunately we had to adapt the project and they ended up doing retrospective and prospective audits, looking at compliance with the current post-operative care protocol. This yielded interesting, if not surprising information about post-operative care in women who had had emergency caesarean sections at Mulago. The information will be shared with the department and hopefully this will provide evidence that will help to influence the care that the women receive. It's just as likely to sit in a filing cabinet and never see the light of day, which would be a shame. Louise Ackers and Carol Porter arrived on the Thursday to work on some stuff for the Liverpool Mulago Partnership and experienced similar frustrations with a project that they were trying to get off the ground. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Meanwhile I finally got round to wading through the patient case notes to complete the maternal death audit for 2009. I managed to get hold of 180 of the 186 sets of casenotes for women who died last year. It was much more difficult and took much longer than I had anticipated, but I was determined to complete it and get good information so that I had a fairly accurate picture of why the women that die at Mulago die. The causes of death range from women who have complications of induced abortion - sometimes performed by themselves - to women who die because there is no blood available. Eclampsia and hypertension, sepsis, complications of HIV, burst abdomens and obstructed labour were all culprits as well. I still need to process the database to write a report. For the first time ever I felt like I'd done a really useful audit that will be informative - I even enjoyed doing it! It took me the best part of 3 weeks solid work, but was worth it.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">The weekend was spent relaxing with friends, and on Sunday morning, Alan, my boda driver invited me to his house to meet his family. He lives with his wife Joyce, and their 3 children Sly, Lydia and Lilian in a small mud walled house about 7 feet wide by 10 feet long. It is divided by a piece of fabric and the walls lined with dismantled cardboard boxes. The bike is kept in the yard, where Joyce prepares and cooks the family's meals. I spent an hour or so playing with the kids and watching bad Ugandan music videos on TV. After having photos taken, which I printed out for Alan as a keepsake, I went back to the house to get ready for a poolside afternoon at the house Carol and Louise were staying in, a lasagne and way too much gin. Which turned out to be a pretty safe place to watch the world cup final.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We were totally oblivious to the fact that 3 bombs had exploded in public places where people had congregated to watch the match, until Alfred collected Amelia, Shireen and myself from the house shortly after midnight. The explosions happened at Kyadondo rugby club, which is less than a mile from our house in Naguru, and at the Ethiopian Village in Kabalagala. The morning after the bombings the roads were eerily quiet. On arrival at the hospital there were crowds of people outside, red cross workers everywhere and lists of the dead and injured posted on the walls outside of casulaty. The rest of the hospital seemed to operate as if it was business as usual. It was quite surreal really. Fortunately nobody I knew directly was in either of these places, but several people I work with lost friends or family. Suddenly Kampala was on alert, and armed guards, soldiers and police emerged outside every public place in the city, scanning machines installed and searches instituted. People were worried, and stopped going out to socialise. Somali Islamic Militants were swift to claim responsibility, which prompted something of a backlash by Ugandans in the city against Somali immigrants and refugees. With many Africn leaders due to descend on Kampala for the AU summit, the atmosphere was tense and nervous.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Three days after the bombing, I was sitting in the departmental library with Shireen and Amelia, working through our respective audits when pandemonium broke out outside. I went out to see throngs of people running and shouting to one end of the hospital, on each of the floors. The words 'Bomb scare' swiftly spread through the crowd like a wave. There we were, stood on the 5th floor, with the stairwells jammed with people panicking. It was the first time I had felt genuinely frightened in Uganda. And then, almost as quickly as it kicked off, it all settled. It turned out that someone was running amok, snatching mobile phones out of people's hands, and had grabbed the attention of several onlookers while being chased by security. I didn't want to be in the hospital. I realised how vulnerable we were, in such a large institution that lacked the capacity to properly screen every single person who walked through the door. I decided to get out of town for the weekend.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Adam, Elizabeth and I took a trip to Lake Kivu, Rwanda. Elizabeth was already in Kigali, so the gruesome twosome took the Jaguar night bus from Kampala to meet her there. We had been on the bus, sitting at the bus station, for about 5 minutes before a man stood up, puked in the aisle and behind one of the seats, and got off. The bus crew came on with a bucket of water to swill it around and a sheet of cardboard to cover it up and hide it, before the bus departed from the depot. Sleeping in moving vehicles is not my specialty, so I spent an uncomfortable, very cold night trying to rest my eyelids, lying across two seats, while Adam sprawled himself across the three seats in front of where sickyguts had let out his rainbow yawn. About 8 hours later we reached the Rwandan border where we were required to get off the bus and go through the necessary formalities. By this time, Adam is wearing a kagoul, shorts, beige trouser socks and brown flipflops, and looked like someone who should not be allowed contact with vulnerable people. After getting our stamps and having our luggage searched for contraband plastic bags, we were allowed back on the bus. As we were about to settle back into our spots, Adam discovered that he had spent much of the night lying in a small puddle of vomit. Much to my amusement.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We arrived in Kigali whortly afterwards, stopping for breakfast on the way to Elizabeth's where we had a shower and got changed. While Elizabeth went to a meeting, Adam and I went to the Kigali Genocide Memorial. I can't describe the impact that the museum has on you. It's almost impossible to comprehend the scale and brutality of the massacre that happened in 1994. The museum is divided into three parts, the first devoted to the Rwandan genocide, the second to other genocides that have happened and the last part of the museum is dedicated to children who were victims of the Rwandan genocide. There are a number of large photographs of happy, smiling girls and boys, many of them toddlers. Beneath each photo is a small plaque with information about their name, their favourite food, their best friend, their favourite toy, how they died and their last words. The effect that those little bits of information had on me was something I'll never forget. By the time we left the museum, the pair of us were snivelling, puffy eyed wrecks.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We took a bus to Gisenyi. More of a van with many seats in actually, and much difficulty was encountered trying to find the right place to get the bus from in the first place, but once we had a ticket secured, we had time for a cold beer before boarding. We left Adam to watch the bags, since he doesn't like beer, and when we returned he had stocked up on crap food from street vendors to help him survive the 3 hour journey. We took an unhealthy taxi from the bus stop to the hotel, which appeared to run out of petrol as we pulled up to the gates, checked in and ate some fish. I was absolutely exhausted, having had no sleep the night before and spending a ridiculous amount of time sitting on buses. My head hit the pillow and I was out like a light.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Lake Kivu is beautiful. Peaceful and quiet. We ate breakfast on the lakeshore and relaxed to the sound of nothing. I sat on the beach and read my book, enjoying a bit of downtime, and glad to be away from a city that had suddenly become a very stressful place to be. Beer o'clock came early - at around 3 - and went on until around midnight. Two friends of Elizabeth, Giorgio and Dudu came and met us at the hotel and tried to persuade us to cross the Congolese border for a night of partying in Goma, which we politely declined.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We headed to the border with the DRC the following morning. As usual the Rwandan side of the border was fast and efficient. It seemed that the boys had not made it back from the DRC until morning and we saw them having what looked to be a very fraught conversation with a number of official looking gentlemen. We elected not to try and find out what the problem was, hoping that they weren't on their way to a police cell. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">The bureaucracy on the Congolese side of the border was something else. We were standing in the queue, when the girl in front turned round, and I recognised her as a medical student from Kings who had been at Mulago almost a year ago on elective. It was a bizarre happening, of all the places in the world we could have both been. Once we eventually got to the front of the queue, our passports and money disappeared goodness knows where, which left us nervous for a good 10 minutes. Once we had our stamps we were ushered round the back of the building to have our yellow fever certificates checked. I have carried my yeallow fever certificate all over the world, and ordinarily it doesn't leave my passport wallet, but for some reason, I had taken it out and left it in my bag, which was 6 miles away back at the hotel. Elizabeth didn't have hers either, and she had a rapid, slightly heated conversation in French about how the certificate was elsewhere with the woman behind the desk. After much discussion, they demanded that we pay a $20 fine to compensate for our lack of a certificate. I couldn't help but point out to them that charging us $20 was not going to stop us spreading yellow fever, which in hindsight probaby didnt help. We refused to pay the bribe, at which point they said that we could try and cross the border. So we did...</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I have never experienced such a change of atmosphere between two places as between Rwanda and the DRC. Almost as soon as we crossed into Goma we received verbal abuse and unwanted attanetion from bike taxi drivers and random pedestrians on the street. There was a sinister atmosphere about the place, the streets were pretty empty and nowhere looked welcoming. We got as far as the roundabout in the centre of town, when a group of 4 men began to follow us. We decided to cut our losses and leave. We were in the Democratic Republic of Congo for exactly 58 minutes. I was glad it was no longer. It was the worst $35 I've ever spent. Nice stamp though!</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">That evening we headed back to Kigali, to discover that the night bus we were supposed to take back to Kampala was cancelled. We caught the early morning bus, and spent the journey sweating, being covered in dust that the bus kicked up as it screamed through Rwanda and Uganda, watching Ugandan and Tanzanian music videos, badly choreographed and danced by pelvis thrusting dwarves in ill-fitting velour tracksuits, interspersed with clips from a Westlife karaoke DVD. It was truly awful. 10 hours later, and looking more orange than we'd started, we were home.</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-39179183046325688342010-07-25T09:59:00.001+01:002010-07-25T11:32:10.147+01:00Misadventures in Mombasa and beyond<div style="text-align: justify;">The girls travelled off to Nairobi, the night we got back from Murchison, leaving Kampala at around 2.30am in order to catch the first flight to Nairobi. The plan was that they would follow the route we had taken when we went to Mombasa some time back. I received a text message to say that the night train to Mombasa wasn't running that night, and so I put my travel agent hat back on... After several hours of frantic phone calls to bus companies and airlines in Nairobi, and hotels in Mombasa, flying round Kampala on the back of a boda boda to the airline offices, the girls had tickets to Mombasa and an extra night's accommodation at the Castle Royal Hotel. When they arrived at the Castle Royal, it turned out that there had been no running water for 3 days, and their room was a dump. It also transpired that there was no other accommodation available in the city. Travel agent hat went on once more, and although they had to spend the night where they were, the Serena beckoned the next night. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I flew out to meet them, arriving at the hotel on Saturday morning. The Swahili coast was as breathtaking as I remember it being, the suntan lotion was slapped on and I thoroughly enjoyed soaking up the rays - it felt like I had been in the hospital for so long without having a weekend to properly relax. Heather and Rebecca took a ride on a camel, and I wandered along the beach, chatting to the touts. Miriam sells Kangas to tourists. It was the usual 'look at my stall' in the beginning. I rarely buy stuff when I'm away, I seem to get it home and it's never quite as nice as you thought it was when you bought it. And so I plugged my usual 'I've been here for a long time, I have a lot of this stuff and I don't need any more'. Then I got the 'I have to feed my family' line. I asked Miriam whether she was married... She said that her Kanga stall was her husband, 'Much less hassle than a human one, doesn't argue, answer back or drink my profits away'. I agreed to consider going back and having a closer look the next day. In the distance, somewhere in the direction of the camel, I could hear the girls, now with an entourage of beach boys, singing 'Jambo Jambo' and smiling to myself, I wandered and found a place to sit and breathe in the fresh sea air. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">That evening we had planned to revisit the Tamarind Dhow for a dinner cruise, but learned that both boats were in the work shop for repair. We settled for dinner at the Tamarind Restaurant instead, that was delicious, oysters, crab and prawns being the order of the day. Returning back to the hotel, sleepy and sated, I fell asleep swiftly and had the best night's sleep in ages. The girls had an early flight via Nairobi to Zanzibar, I had a direct flight mid-afternoon, and so took the opportunity of a lie in...</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Arriving at the airport in good time, excited about the prospect on being in the tin can for less than an hour, I walked up to the check in desk and presented my passport to receive the dreaded words 'Your flight has been cancelled'. 'What?!'. 'We can fly you to Nairobi tonight, there are no more flights to Zanzibar today'. 'You're going to fly me to Nairobi? I don't want to spend a night in Nairobi'. It seemed, however that I didn't have a choice. And so, off to Nairobi I went, on my own, feeling very pissed off and a little bit sorry for myself. I had been so excited at the prospect of sitting in the cliff top restaurant at Coral Rock in Jambiani, with a glass of Kilimanjaro as the sea breeze blew in through the open terrace. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Instead I found my self in the Panari Hotel, a gaudy business hotel with as much atmosphere as a vacuum and decor to match. I settled myself into a striped black and white faux leather chair and wept into my beer as Germany thrashed England in the football. Since Kenya Airways were footing the bill, I decided I wasn't going to pay extra for an a la carte meal, and settled for the buffet. Big mistake. I woke up at 3am with cramp. By the time the bus came to collect us and take us to the airport I had become very friendly with the hotel toilet. As I sat on the plane, I realised that it was not going to be a pleasant flight. Unable to stomach any food, I really fancied a sip of orange juice. As I took my second gulp, the captain pointed out Mount Kilimajaro on the right hand side, which I was unable to appreciate as I reached for the airsick bag and emptied my stomach of the previous night's meal. The woman sleeping next to me didn't even stir, and the stewards ignored the bell. I was grateful that the bag was wax lined as I carried it up the middle of the plane to dispose of it, chuckling at the message 'If this bag is used for airsickness purposes, please hand it to the steward'. For a minute, I had contemplated depositing it in the seat pocket. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">The girls came and met me at the airport, with a day of activities planned. Feeling slightly less peaky, we drove to a spice farm. Having no sense of smell, is a drawback on this sort of tour, but I was interested to see the processes involved, and what spices actually look like before someone dries, grinds, bottles them and ships them off to Tesco. Our guide showed us nutmeg, cinnamon, berries for making lipstick, hacking stuff down from trees and putting them into a banana leaf funnel to take home. We got to the cloves... 'These are cloves'. 'That's lovely, where's your toilet?', as I was gripped by the familiar rumble, accompanied by a profuse cold sweat. 'Now?'. 'Now, now!'. I was shown to the thatched toilet hut, knowing full well what was I was going to find inside.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">At the age of 9, we took a family holiday to Scotland. Having just left the castle that we had paid a fortune to get into, and entered the forest for a walk, I decided that I absolutely had to pee. So I was instructed to go behind a tree. As I squatted, my brother leaped out from behind said tree, scared the living daylights out of me, and I pissed all over my own trouser leg. Since then, I have had major issues with peeing outside, or in squat latrines. The words 'Asian toilet' send shivers down my spine. Try as I may, I just cannot master the art of piddling in a hole in the ground. And this time, I was not worried about urinating on myself. It was something far, far worse.<br />
</div><div style="text-align: justify;"></div><div style="text-align: justify;">I thought I was better, having relieved myself, and attempted to join in the rest of the spice tour, taking in one further spice - could have been bloody anything for all I know - before running back to the hut, making an executive decision to lose the trousers completely and whistle loudly to scare off other would be toilet users. 20 minutes later, I emerged and parked myself on a bench, lying still and wanting to die, while the rest of the group finished off the tour and had lunch. They were deposited in Stone Town and I went to the hotel.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">I was greeted by Pedro at Coral Rock, who gave me the option of 2 rooms. 'N2, that's the honeymoon suite right?'. 'Yes'. 'I'll take that'. 'Do you want to look at the rooms first?', 'No thank you, I'd like to go to the toilet, get into bed and feel sorry for myself', 'Oh, OK'. And that's precisely what I did. When Heather and Rebecca got back from their tour I joined them for a coke, skulking back to my room by 9 and stumbling back into bed. So much for Island Paradise. The next morning, I felt significantly better and we took a walk out to the channel to swim in the sea. I had forgotten how blindingly white the sand was and how warm the water was. Once more I really did feel like I'd found Heaven on Earth. A tentative bland lunch seemed to be the way forward, and the afternoon was spent chilling by the pool and reading. Remembering how good the food was the last time I was there, and craving some real sustenance, I opted for fish, which was delicious. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">My stomach begged to differ, and I was back to square one. Once more my Zanzibar odyssey becoming a bed bound adventure. Along with the bad weather, it served to sabotage our planned boat trip. I can think of worse places to have gastroenteritis, but it's a bloody expensive place to do it. Coke and water arrived at regular intervals, and by 4.30 I was feeling well enough to decamp to the pool for a quick dip in the water. I was not much of a fun travelling companion. Fortunately we rearranged the boat trip for the next day. Once more, however, stormy weather off the coast, was to meddle with our plans again. Instead, we headed back to Stone Town, this time I was feeling much better. We meandered through the maze of streets, stumbling across little boutique clothes and craft shops, enjoying the leisurely pace, bartering with shop keepers and soaking up the atmosphere. We found the Persian baths, a crumbling testament to former Stone Town days, stunning in their own way, but in need of a little TLC. We stopped for a coffee before plodding onwards past the markets in the hunt for 'Two Tables' restaurant. Down a back alley, this place is actually someone's house, that opens in the evening for dinner. Consisting of two tables in a conservatory of sorts, it's a gem. We rang the bell, and heard someone shout down from an upstairs window. We shouted up that we wanted 3 places for dinner, and were told to return for 7.30. We continued on to Africa House for a leisurely lunch on the terrace, overlooking the harbour, in the company of 3 menacing monkeys that were trashing the bar with the help of 3 unruly children.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We wandered and shopped a bit more, calling into the Old Fort, and unsuccessfully bartering for some bowls, our final stop of the day was the 'House of Wonders'. The first house in Zanzibar to have electricity and an elevator, it had clearly seen better days. The hand stitched Dhow was interesting, but in reality, the Museum is badly laid out and badly maintained. Which is a real shame, as it could be wonderful. We wandered into the night food market, sampling some sugar cane juice and grilled bread fruit, watching boys jump into the water from the harbour walls, with varying degrees of acrobatic skill. We stopped for a beer, before heading back to Two Tables.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">On arrival, we were greeted by the head of the household, and invited to take a seat downstairs, and a small living room full of bric-a-brac, that would give any British Antique shop a run for its money. After a short while, we were invited upstairs to the dining room. We were served soup, followed by lentil curry and the most delicious Mandazi I have ever eaten, a portion of vegetable croquettes witha spiced coconut dipping sauce, a small meat kebab, Marlin in coconut curry and fried Elephant bananas to finish. It was gut busting, delicious, a wonderful experience - the family sat and watched TV as we ate - and incerdible value for money at $15. Thorooughly recommended and worth hunting for. Stuffed, we found our driver and headed back to Coral Rock. We were greeted by a drunken Neil - the owner - who wanted to know what had happened to me since my last visit and why I wasn't being savage. I explained that I'd been unwell, whereupon he insisted on buying us a drink and made us do the pub quiz which we'd missed.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Suddenly it was our last Zanzibari day. The weather was dreadful, and plans to snorkel in the channel off the beach thwarted by torrential rain. No sooner had we set off for the airport at midday, than the skies cleared. It was a long day of travelling, arriving in Entebbe at around 8.45pm, as our plane was delayed. James dropped us at Emin Pasha, where we met back up with Lorraine to hear about her 2 weeks at fistula camp, and travelling around South West Uganda. We decided on a take out curry, which we ate in the hotel room on Emin Pasha's finest crockery, washed down with a few beers. It was a late night in the end, I got home at around 1. The following morning, Heather, Rebecca and Lorraine flew back to Blighty. Having them around for a month had been great fun, it had been fantastic to share Mulago and some experiences there, but also the things we had done together outside the hospital. I realised I was going to miss them all immensely, and that at the same time them leaving also indicated that with 4 weeks left in Uganda, my time was coming to a close too.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Photos are <a href="http://www.facebook.com/album.php?aid=445627&id=776350584&l=93c138a50f">here</a></div><div style="text-align: justify;"> </div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-17890444043888759882010-07-22T10:20:00.003+01:002010-07-25T08:42:21.973+01:00A Bad Case of the 51's<div style="text-align: justify;">Heather and Lorraine spent a further week at Mulago. On the Monday morning I learned that we would not be able to move the HDU project any further forward due to building works happening elsewhere on the ward. This was disappointing news as I had been reassured that the space we had created the HDU in was not going to be affected by the works, and a number of people had put a lot of time and effort into what we had managed to achieve already. This news has unfortunately dampened my enthusiasm to push the project forward - which is a real shame as I felt I was going to be able to leave some sort of lasting legacy. C'est la vie, as they say.<br />
<br />
We ran a skills training morning which we opened up to all staff. Disappointingly, only the midwives attended, but there were 15 in the group. We covered Eclampsia, PPH, shoulder dystocia, neonatal resuscitation and vaginal breech delivery. It was a really fun morning and I think that the staff enjoyed it as much as we did. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We spent a drunken night making a poster illustrating cervical dilatation and positions of the fetal head... I haven't had the guts to look at it again, as wielding a ruler, pencil and Pritt Stick after a third of a bottle of gin cannot possibly bode well for a professional looking product. We were mostly on labour ward - and for the most part it was reasonable, apart from one day when I had been to meet a friend for lunch, and arrived to find Heather and Lorraine muttering curses as they ran from patient to patient. The theatre was not up and running, the list was overspilling and there were several women who were causing concern. Finally we got moving, and stayed around until the last patient that we had been involved with had been delivered - baby and Mum both did well.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Rebecca Smyth joined us that Friday, and the girls all moved out of Mulago Guest House and into Emin Pasha - a far superior abode. I met them for dinner and drinks. We made the mistake of eating a salad...</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">On Saturday morning, we hired a driver for the day, for our grand tour of Kampala. Alfred collected Adam and I from the house, the three girls from the hotel and a radiotherapist called Kate from the guesthouse. We then travelled to the Kasubi tombs, and important historical site, which is the burial place of four Kabakas (Buganda Kings). The tombs were destroyed by fire back in March, but the site is still very interesting. The tombs are tended by the wives of the Kabaka and subsequently their descendants. Around the central building - ravaged by fire, covered in tarpaulin and a mess of mangled metal - are small thatched huts where the tomb attendants dwell. As we entered the complex, we met the Prime Minister of Buganda, and spoke to him about how work was going on to reconstruct the tombs. It turned out that there was a Buganda Princess with an entourage at the tombs that morning. We wandered round, receiving snippets of information from our guide and meeting various people. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We met an elderly lady who was responsible for looking after the tombs, sitting outside her hut wrapped in a large piece of barkcloth. Our guide introduced the ladies in the group to her, and we each greeted her. Because women are considered subservient, Adam was not permitted, due to custom, to greet her. However, she let him know, that even though she couldn't greet him because of tradition, she 'loved him just the same'. Our brief tour of the site concluded with our guide showing us a list of the different Buganda clans. Heather happened to notice that clan 51, known as the Ekitibwa, was translated in the list as 'Shit'. This obviously appealed to our inner schoolchild, especially since it is not permitted to eat the thing your clan is named after, and you're not allowed to marry a fellow clan member. In other words, if you're a member of the Ekitibwa clan, you can't eat shit, and you can't marry shit. I think I'd be ok with that.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">From here we travelled to the Kabaka's Palace, to visit one very specific part of the site. The Kabaka's palace itself, is not accessible, but the grounds contain an important and sinister piece of history. Idi Amin constructed a concrete bunker here, where he and his soldiers incarcerated people and tortured them. The chamber itself is accessed down a slope, flanked by imposing concrete walls. The doors of the bunker are no longer there, nor are the sliding doors covering each of the 4 large cells, but it's complete enough to give you a sense of what it must have looked like. The cells are raised up off the ground by about 3 feet, and the open part of the chamber was filled with water. On the walls are bloody handprints and smears, and graffiti, inscribed by prisoners, and latterly by family members who suspect their relatives were victims. It is a dark, dank, oppressive place. In the far corner is a cockroach nest, and there's a colony of bats that move from one chamber to the next to roost. I was glad to get back out into the fresh air, even though the heavens had just opened.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">After the oppression of the torture chambers, and lunch, we headed to the National Museum, to examine the dust coated relics, paying particular attention to the educational text accompanying the exhibits. For example, if you didn't know much about paleontology, a fossil is something which has been dug up. Thanks for that. I am now much wiser about what fossils are. We stopped for a drink and a spot of craft shopping before heading back to the hotel to meet Judith Ajeani for a farewell drink. Heather managed to miss the entire farewell session, in favour of spending time visiting the bathroom, and my stomach also decided that I couldn't participate for long. We both ended up with a severe attack of the '51's'. I headed home and spent the night burning up with fever, as the world fell out of my bottom.</div><div style="text-align: justify;"></div><div style="text-align: justify;">We were due to head to Murchison early the next morning. I felt like 51. I called the girls and by this point Rebecca was also unwell. And so instead of spending time journeying to visit the wildlife, the day was whiled away drinking flat coke and eating rich tea biscuits. Having been relatively fortunate in my time here, I realised that complacency had got the better of me, where food was concerned. Fortunately we were able to rearrange our Murchison trip, thanks to good old Fast Eddie. Taking Monday to fully recover - and utilising the time to take Rebecca round the hospital and buy some more Africrap (read: souvenirs), finishing with a barbecue and copious deviled eggs - we started our trip to Murchison bright and early on Tuesday morning.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Fast Eddie excelled himself - literally - by making it to Masindi in 3 hours flat. We ploughed on to the top of the Falls, where we took a leisurely stroll around. What initially started out as 'This is a pleasant walk' swiftly turned into 'Kate Alldred, when I get my hands on you...' as the heat and terrain took its toll on a certain group member (Smyth). Fast Eddie was on hand to help - thankfully - and everyone made it back to the car in one piece, nobody having been murdered, albeit sweatier and dustier than when we'd started out. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We moved on to the Red Chilli Camp, and the boat launch. Eddie had booked us onto a tiny boat, that carried no beer on board. Not what I had requested and I told him so, in a fit of childlike tantrum, demanding to go on 'the big boat with the cool box'. It worked. I think it was my outburst that caused karma to break my camera, just as I was about to get a National Geographic head on shot of an elephant by the water. The beer, however, was ice cold and delicious. The usual assortment of game were out playing, with a particular abundance of elephants this time, and a good trip was had by all. After a refreshing cold shower, dinner and a bottle of Nile, I was knackered and in bed by 9. The game drive the next morning was great, with a tentative sighting of a leopard - which was a black silhouette skulking between two bushes - and a shoebill stalk. There were dozens of giraffe out too, and a lot of the game was quite close to the track whereas previously ithe animals have usually kept their distance. On the way out of the park we had 15 minutes of being attacked by Tsetse flies in the car, and a mass execution of trapped flies - using a copy of the Bradt guide as a weapon - ensued. All flies out of the car we travelled to the Ziwa Rhino sanctuary, stopping for lunch in Masindi on the way.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">At the rhino sanctuary, we tracked a family of rhinos, Baby Obama, who is just a year old, was stomping around with Mum and dad keeping a close eye on him. We had a slightly hairy moment after Mum got annoyed with Dad and Obama's play fighting and charged him. Dad then contemplated charging us and stood pawing the ground, facing us, as the rangers talked him down. It was a privilege to see the family interaction and a worthwhile detour on the way back to Kampala. </div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-45081111394884949482010-07-14T15:23:00.001+01:002010-07-14T15:24:32.155+01:00Doris Days 2<div style="font-family: inherit;"><span style="font-size: small;">Two further conversations that have occurred with Doris in the past couple of weeks - slightly out of sync with the blog, but I have to write them down before I forget...</span></div><div style="font-family: inherit;"><span style="font-size: small;"><br />
</span></div><div style="font-family: inherit;"><span style="font-size: small;">Doris; <i>'James, I have been seeing on the television, the thing that picks the football, youu know, you eat it sometimes'</i></span></div><div style="font-family: inherit;"><span style="font-size: small;">James; <i>'What?' </i></span></div><div style="font-family: inherit;"><span style="font-size: small;">Doris; <i>'You know, the thing for dinner, that picks the winner'</i></span></div><div style="font-family: inherit;"><span style="font-size: small;">James; <i>'The what?!' </i></span></div><div style="font-family: inherit;"><span style="font-size: small;">Doris; <i>'On the television, the thing with the legs like the spider'</i></span></div><div style="font-family: inherit;"><span style="font-size: small;">James; <i>'Oh, the octopus!'</i></span></div><div style="font-family: inherit;"><span style="font-size: small;"><br />
</span></div><div style="font-family: inherit;"><span style="font-size: small;">And then last night...</span></div><div style="font-family: inherit;"><span style="font-size: small;"><br />
</span></div><div style="font-family: inherit;"><span style="font-size: small;">Doris; <i>'I saw it again, the thing like the flower, that lives in the water'</i></span></div><div style="font-family: inherit;"><span style="font-size: small;"><i><br />
</i></span></div><div style="font-family: inherit;"><span style="font-size: small;">Today, on returning from work...</span><span style="font-size: small;"><br />
<br />
Doris; <i>'Kate, is Adam around?'<br />
</i>Me; <i>'Not yet, he'll be back, but later'<br />
</i>Doris; <i>'You tell him he needs to pay the cabbage for 3 months'<br />
</i></span><span style="font-size: small;">Me;</span><span style="font-size: small;"><i> 'The what?'<br />
</i></span><span style="font-size: small;">Doris; </span><span style="font-size: small;"><i>'The cabbage people, they need the money for the cabbage for 3 months'<br />
</i></span><span style="font-size: small;">Me; </span><span style="font-size: small;"><i>'Cabbage?'<br />
</i></span><span style="font-size: small;">Doris; '</span><span style="font-size: small;"><i>Yes, you know that you put outside'<br />
</i></span><span style="font-size: small;">Me;</span><span style="font-size: small;"><i> 'Garbage?'<br />
</i></span><span style="font-size: small;">Doris; </span><span style="font-size: small;"><i>'Yes, cabbage'<br />
</i></span><span style="font-size: small;">Me;</span><span style="font-size: small;"><i> 'OK, I'll tell him. So what about the water, we were supposed to pay them weren't we'<br />
</i></span><span style="font-size: small;">Doris; </span><span style="font-size: small;"><i>'Ah, I don't know when they are coming back'<br />
</i></span><span style="font-size: small;">Me;</span><span style="font-size: small;"><i> 'You don't know when they're coming back?'<br />
</i></span><span style="font-size: small;">Doris; </span><span style="font-size: small;"><i>'No, it's because they're Indian'<br />
</i></span><span style="font-size: small;">Me;</span><span style="font-size: small;"><i> 'Right.'<br />
</i></span><span style="font-size: small;">Doris; </span><span style="font-size: small;"><i>'Also, the liquid soap. It is finished'</i><br />
<br />
Can I bring her home with me?</span></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-2929792232717127622010-07-06T18:13:00.001+01:002010-07-06T18:14:05.260+01:00How Many Ugandans Does It Take To Get a Midwife Down a Mountain?<div style="text-align: justify;">Heather Nunnen and Lorraine Dinardo arrived from Liverpool one drizzly Saturday afternoon at the beginning of June, which seems such a long time ago. I was excited about them arriving and about working with them at Mulago, but also nervous about what they would think of Mulago, and also about how I have adapted to the environment here and how that reflects in my clinical practice. We had a very action packed 2 weeks at the hospital, and an equally action packed social calendar. Which started almost immediately on arrival, with several beers and a curry, and confirmed my suspicion that we would be working hard, and playing hard too.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">We spent Sunday doing the leisurely tourist intro to Kampala, including an obligatory trip to the craft shop 'Banana Boat' and met up with Alice Alum, who is the manager of the midwifery led labour ward here at the hospital. Sunday evening kicked off with 7 of us piling into a car made for far fewer people, and as the resident hobbit, I drew the short straw, sprawling myself across the girls in the back seat, wedging my head up against the window and bracing myself for the potholes. We arrived at the Ndere Cultural centre for a night of traditional dancing and entertainment. We went on a cultural journey around Uganda, with most areas being represented in varying forms of colourful hip shaking, bum wiggling dance. A number of staff from Mulago joined us, as well as a team from Canada and my housemates. It was a fantastic show.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Monday started in earnest with the morning meeting, introductions to notable people within the department and a tour of the hospital. The labour ward was fortunately quite quiet, although at the end of our tour round, we came across a flat baby that needed quite a lot of resuscitation, taking him to special care and commencing CPAP. He recovered reasonably well, but it highlighted some of the problems that we face here. We debriefed over a few beers and an Ethiopian in the evening.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Tuesday was a day of bureaucracy, and Heather and I trudged to the Nursing and Midwifery Council in the searing heat, to collect her registration certificate. And got sunburnt. We wandered back to Mulago, stopping to buy grilled sweet potatoes, and taking in the scenery of Wandegeya - coffin makers, cabinet makers, stalls selling everything from shoes to bath taps - before returning to the hospital. I hosted a barbecue in the evening for everyone involved in the partnership, which went down well. The star of the evening, however, was Alice's one-year-old daughter Anneke, who caught and held Heather and Lorraine's attention for much of the night.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Wednesday was a national holiday - Heroes Day - and so after some craft shopping at the National Theatre we went out to visit Enid at the orphanage in Buddo. It's some time since I visited Enid last so it was nice to go back there and see how she and the children are doing. Enid prepared a simple lunch of matoke with g-nut sauce, greens and beans, which we ate in her home with her mother. At Enid'e request, Agnostic Alldred, managed to stumble through something resembling a prayer, dragged from the back of my catholic educated mind, and we were then able to share our meal. It was delicious.</div><div style="text-align: justify;"></div><div style="text-align: justify;">After lunch we met the children, and Heather and Lorraine gave the stickers, books, pens, crayons, balls, parachuting men and a whole other selection of goodies to Enid for the children. It was less of a free-for-all than the last time we went. Enid told us a bit about her life, and how she got to where she is now, what life at the orphanage means to her and about her family. We mucked around with the kids for a while before they migrated to their rooms, or towards the TV, and after a farewell prayer we headed back to Kampala and settled down for a Ghanaian meal. It had been an emotional afternoon, which manifested itself as a need to have 'just one more beer'. And for once, it was not me doing the encouraging! We met my housemates at the casino - Avner was due to leave town and was having a blow out - which made for a late night.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">On Thursday I pottered onto labour ward at precisely the wrong moment. In the space of an hour we delivered 3 stillborn babies and dealt with a woman who had what we thought to be an eclamptic fit. It was total chaos and by the time it started to settle we were knackered! The day continued in the same sort of vein. On Thursday, Norfolk Enchants hosted the best/worst pub quiz (delete as appropriate) ever conducted in the history of the world, at Bubbles O'Leary. The major advantage to having to write and present the quiz is a free bar all night. Which we took advantage of, since it would have been rude not to. Friday was an admin (hangover) day for me, Lorraine stayed on labour ward and Heather went up to ward 14 for the day. I arranged for the carpenter to return to measure up for the mosquito grilles on HDU. On Friday night, we had a leaving party for Avner, who has finished his time in Uganda. Was gutting to see him leave, but we have many fond memories of the hairy Mexican/Egyptian/Israeli/Khazakstani Jew wandering round the house in nothing but pornographis moustache and a small towel. I can hear him say 'Antisemite' at that sentence. It was drunken, and ended at some ungodly hour of the morning. And then we got up to drive to Sipi Falls the next morning.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">Fast Eddie arrived at the house at some horrifically early time after the party. Chi had slept in so we were a bit late staring out but Adam, Chi, Mbarara Mike and I piled into the van and picked up Heather, Lorraine and a random dude called Jason, from the guest house. Eddie lived up to his name and before we knew it we were in Jinja, eating rolex for breakfast. On the road out of Jinja, we were leafleted through the van window, much to Adam's annoyance. The leaflets were advertising a Dr Brown and Professor JK, and claimed to be able to cure diabetes, improve your sex drive and get rid of the <a href="http://en.wikipedia.org/wiki/Tikoloshe">Tokoloshe</a> (a dwarf-like water sprite or zombie), amongst 26 other wild claims. I kept the phone number, just in case... The journey was otherwise uneventful, apart from a torrential rain storm breaking just as the mountains came over the horizon. We reached the Sipi River Lodge at around 2pm, and had lunch of sandwiches and locally grown, roasted and ground coffee. After sorting out who was sleeping in which banda, we decided to go for a hike to the top two falls out of the three that make up Sipi Falls.<br />
<br />
And so the fun began. It was steep and it was slippy, and our guide didn't quite know what he'd let himself in for. We got to the top of the first waterfall, before we started collecting people. A number of children began to crowd around Heather, one or two at first and then a whole throng. We heard lots of giggling, and at each corner when she caught up with us, she had more flowers about her person - in her hair, shirt, behind her ears - than before, and seemingly more kids. We were almost stampeded by a crazed cow that came hurtling down the track, but veered off into a field and crashed through a farmer's fence instead. We reached the base of the second fall, by now with around 12 children in tow. We spent a few minutes taking photos in ridiculous poses before starting the trek down hill. It turns out that our newly found troupe of children came in handy for steadying 'Grandma' as they had affectionately named H, on her descent, as the track was slippy. Ahead of the group this time, slips were usually preceded and followed by a loud 'AaaghAAAghArgh!', from Heather, and the accompanying infectious cackle of one of the kids, with or without a crash through the undergrowth. Naturally this set the rest of us off laughing and in some instances a domino of slips too. We made it down from the mountain as night fell, covered in mud and soaked through from falling. A welcome beer and a home cooked meal awaited us, and after a hearty feed and more coffee, we stumbled back to our banda and fell asleep to the sound of rushing water from the falls, and the creaks of the bunk beds as people shifted around.<br />
<br />
The next morning we had a leisurely breakfast and then set off to tackle the lowest and largest of the three falls. Heather elected to stay behind at the lodge and write postcards. She definitely chose the sensible option, and I envied her choice as we slipped and slid down to the bottom of the falls only to get absolutley soaked on the way back up. The views were spectacular though, and it was a great way to work off the previous night's dinner. We had lunch before departing, getting 5 minutes down the road before Mike declared he had left his watch in the dorm. We turned back to pick it up, I got paranoid and decided I had left my ipod - which I hadn't, it was in my bag all along - so frantically rummaged through my bags and the dorm only to find it in the last place I could possibloy have looked. Chi jumped out of the van declaring that she had left her brain behind, at which point we realised we were all being ridiculous, and we set off back to Kampala for the second time.<br />
<br />
We reached Kampala late, had dinner and headed home, ready for another week at Mulago, refreshed after a fantastic weekend in the great outdoors...<br />
<br />
Photos are <a href="http://www.facebook.com/photo.php?pid=6462635&id=559716153#%21/album.php?aid=445627&id=776350584">here</a></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-64971792271159938522010-06-20T10:48:00.001+01:002010-06-20T10:55:57.343+01:00Doris Days<div style="text-align: justify;"><span style="font-size: small;">Wow, the weeks seem to go by more and more quickly. And my blogging seems to get less frequent.</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><span style="font-size: small;">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.</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><span style="font-size: small;">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. </span></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><span style="font-size: small;">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.<br />
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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. </span></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><span style="font-size: small;">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. </span></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><span style="font-size: small;">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.<br />
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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.</span></div><div style="text-align: justify;"><span style="font-size: small;"></span></div><div style="text-align: justify;"><span style="font-size: small;"></span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
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.</span></div><div style="text-align: justify;"><span style="font-size: small;"></span></div><div style="text-align: justify;"><span style="font-size: small;"></span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
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...</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Who has been feeding the bones of fish to her?'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Me; 'Who has been feeding the bones of fish to who?'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Someone has been feeding the bones of fish to Pasha'</span></i></div><div style="text-align: justify;"><span style="font-size: small;"> </span></div><div style="text-align: justify;"><span style="font-size: small;">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.</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><i><span style="font-size: small;">Me; 'I don't know who has been feeding fish bones to Pasha'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris (accusingly); 'It must have been Justins [Justus] or George.'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Me; 'I doubt it was Justus, it may have been George'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">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'</span></i></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><span style="font-size: small;">Or another conversation a matter of days later</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'She has been stealing plates and bowls and knives and forks'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Me; 'Who has been stealing?'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Justins [Justus]. And she stole my pegs'</span></i></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><span style="font-size: small;">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. </span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><i><span style="font-size: small;">Chi; 'Hi Doris, my name's Chi'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Cheese?'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Chi; 'No, C-H-I. Chi.'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Yes, Cheese. Welcome'</span></i></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><span style="font-size: small;">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</span><i><span style="font-size: small;"> </span></i><span style="font-size: small;">integrity. Having discovered the money she spoke to Adam who was the only one home...</span></div><div style="text-align: justify;"><span style="font-size: small;"><br />
</span></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Whose are these trousers?'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Adam; 'I don't know'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'I think they are for Kate sometimes'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Adam; 'I don't know Doris'</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;">Doris; 'Yes, they belong to Kate sometimes.' (Long pause, Adam looks around room uncomfortably) 'I found this money in them'.</span></i></div><div style="text-align: justify;"><i><span style="font-size: small;"><br />
</span></i></div><div style="text-align: justify;"><span style="font-size: small;">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.</span></div><div style="text-align: justify;"><span style="font-size: small;"></span><i><span style="font-size: small;"><br />
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</span></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com2tag:blogger.com,1999:blog-7512002222520024180.post-64716477085865389942010-05-13T11:46:00.001+01:002010-05-13T14:22:01.556+01:00A Chimp Off the Old Block<div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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! </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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!</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.<br />
</div><div style="text-align: justify;"></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;">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.</div><br />
Photos of the HDU so far are <a href="http://www.facebook.com/album.php?aid=429225&id=776350584&l=22417f0eb2">here</a> and chimps are <a href="http://www.facebook.com/album.php?aid=428810&id=776350584&l=d97cc42e89">here</a>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com2tag:blogger.com,1999:blog-7512002222520024180.post-2265748421117626162010-04-24T13:45:00.002+01:002010-04-24T13:46:40.929+01:00Chicken Run<div style="text-align: justify;">We travelled to Arua the day before the outreach camp was due to start. Arua is in the far north west corner of Uganda, near the border with the DRC and Sudan. We knew we had a long day ahead of us, and so we set off at 9.25am - not bad considering we planned to leave at 9. Armed with the Sunday papers, myself, Barageine, Alia and Rose set off with our driver in a Landcruiser. Once we escaped the clutches of the jam - even on a Sunday morning - we made a fairly good pace. We stopped along the road to buy skewers of beef muchomo, barbecued plantain and maize from the throng of vendors at the turn off for Masindi. Not a bad breakfast, and much cheaper than chips! We continued along the road, skirting along the edges of Murchison Falls National Park. We spotted baboons patrolling the roadside, donating the remains of breakfast - at high speed I might add - to them. We crossed the Nile - awesome as always - and carried on west through Pakwach and beyond.<br /><br />Not far out of Pakwach, the car suddenly veered to the right side of the road, into the path of an oncoming bus, which was screaming down the road like something possessed. The driver managed to get the car back across to the other side of the road before we were hit, but it was a little hairy. We came to a halt, and got out to check the cause of the problem... a punctured back tyre. Which would have been fine, except that the jack for the car wasn't big enough, and while we could get the wheel off, we couldn't get the spare on. And so ensued the search for a flat rock, to place under the jack, and a series of improvisational measures were employed to keep the car elevated enough for us to take the jack out from under it, and place a sturdy and big enough rock under the jack, so that we could lift the car high enough to get the wheel on, in the baking heat, with no drinking water between us, on a deserted road, in lion country. We succeeded in completing the task at hand, and piled back in the car, a tad sweatier and dustier than we'd been when we got out.<br /><br />We stopped in Nebbi to visit Rose's family and to drop off some bread which we had bought in Kampala - bread's very expensive in the north, so it's a rare treat shortly before stopping for lunch, which after the tyre fiasco was welcome. We travelled for around another hour, passing IDP camps made up of round huts of mud and straw. Some of the buildings were pockmarked with bulletholes - evidence of the still relatively recent struggle with the LRA. We hit Arua, a big, bustling market town, full of pedestrians and cyclists. We checked into the Hotel Pacific - which, in a landlocked country is surprisingly nowhere near the pacific, nor did it seem to have any features to suggest a tie with the pacific ocean. Either way if was fine, comfortable enough, apart from the howling scrapping dogs in the alley behind the rooms and the roosters that crowed incessantly from 4am, in a manner suggesting that they were being skinned alive. We settled down in the hotel for a beer or 2, and had a bite to eat.<br /><br />Alia wanted to go to his Dad's village to pick up some chicken that had been killed and cooked for us, but there was an issue with taking the Landcruiser. The chicken arrived, by boda boda, with a pan of matoke and some sugar cane, right after we had finished eating dinner, so we loosened our belts and tucked in.<br /><br />Next morning, we got to the hospital. The patients had been screened by Alia and Barageine shortly after we arrived in town. We got to theatre around 9, and I was pleasantly surprised by the theatre, which was a far, far cry from Mityana's. The first patient was waiting, drip in hand. The day got off to a flying start. The staff were motivated, and apart from the anaesthetist who repeated the phrase, 'That's next to impossible' regarding our request for a fan to help survive the heat were very positive. We got our fan - which was just as well, or else I'd have melted. We got through all 5 scheduled patients by 4pm and screened the new arrivals. We headed off for a well earned drink - which swiftly turned into 6, plus fish and chips, Alia insistent on 'just one more beer' for all of us - makes a change from me saying it anyway!<br /><br />This camp turned out to be the best so far, everything ran like clockwork, we had good light, running water, instruments and proper linen, a motivated team, the hospital's own doctors got involved and there were even medical students around! The fistulas were among some of the most complicated I've seen so far, which was interesting to see. In the end, however, we only operated on 13 women. This was a question of people not coming to the camp to be treated - everyone we saw that needed surgery got it. We left Arua on the Wednesday afternoon. Prior to leaving, Alia went off to collect a chicken from the village, which was bundled into the car, clucking manically.<br /><br />We hit the road on what was to be a long drive. We stopped not too far outside of Arua to buy Mangoes from kids on the roadside, prompting stories from the guys about how they used to scrump for mangoes. They had kids running up and down the road buying plastic bags. Fruit purchased, we continued on our journey. We stopped at Rose's village to collect another Chicken to keep the one we already had company, which doubled the noise asince they decided to peck at each other. Loading the car up with more mangoes we set off again. In Pakwach, we stopped again, this time to invest in wooden milking stools with phrases etched into them. My particular favourite was 'Remember Pakwach'. What?! After politely explaining to the 20 people flocking around the 4x4 that I didn't need any wooden crocodiles, cars, crested cranes, innominate birds, balancing objects, bows and arrows or drums, and everyone else satisfied with their purchases we drove across the Nile. On the other side were tens and tens of Elephants. Alia hypothesised that they were all going down to the river to drink. Barageine disagreed, stating that they had almost certainly already drunk from the river and were heading in the opposite direction. Rose and I looked at each other and burst out laughing, suggesting that since they were all facing in different directions it was difficult to tell what they were doing or where they were going, and either of them could be right, but that they were arguing for the sake of it. After an hour we stopped again. Alia bought 4 more chickens and Barageine bought 6, bringing the total to 12, making for a bloody noisy car, and reminding me why sometimes having no sense of smell has its advantages. The rest of the journey was relatively uneventful, apart from a heavy downpour. Getting the chickens out at the other end proved to be a challenge and I finally got through the front door at 10.30.<br /><br />Since arriving back from Arua, I've spent a lot of time doing project work. I've spent time preparing and co-ordinating stuff for the next exchange visitors from Liverpool Women's - registration, accommodation etc - and also trying to sort out visas for the Ugandans who are hoping to visit LWH. I've been working on a detailed proposal for a shoestring HDU, and have made the final arrangements for a neonatal resuscitation course. Many of you have donated generously, and so far I've collected almost £1000 in donations - THANK YOU! We're also hoping to present on a few new guidelines for the unit next week and so have been putting the finishing touches to these. From here until I leave things are going to be fairly intense, with 3 separate groups of visitors coming who are working on fairly different things, we'll be physically setting up the HDU at some point in the next 6 weeks and there are post-graduate exams, so I'll cover labour ward for 2 solid weeks.<br /><br />Thursday was pub quiz, the first one we've been to in a while. We had some new additions to the team, Anna, a medical student, and Whiteney and Lisa, 2 nursing students, plus Phoebe and Mark joined us for the first time. We came 2nd. Slowly we're improving - perhaps next time we might win. From here we visited Elizabeth, who has just taken a job in Rwanda - we had left her earlier in a packing frenzy - to sit and drink wine on the porch one last time before she left yesterday.<br /><br />Yesterday was also Adam's birthday. Phoebe and I went to pick up his birthday cake. I had explained the order, with the appropriate illustration to the lady at New York Kitchen. Rather than a whole cake, I asked if it was possible for them to give me half a chocolate cake and half a carrot cake but to put them in the same box. At some point between me explaining what we wanted and the cake arriving in the shop, somebody interpreted the order as, chocolate cake on the bottom, carrot cake on top with a layer of chocolate fondant between them, iced entirely in chocolate. What part of that combination would be normal in anyone's frame of reference.? So I waited for 25 minutes while they deconstructed the cake - since we needed it within the hour , and there wasn't time to start again from scratch - stripped off the icing, re-iced the chocolate cake and put the carrot cake in a separate box. Armed with our 2 cakes, party hat and candles, we jumped in Alfred's car. And sat in the jam. For 2 hours. School's out. We had forgotten. We got to the Italian Restaurant later than expected but had a lovely evening, and the cake, in the end, was delicious.<br /><br />This weekend is my last free weekend for some time. I intend to do absolutely nothing.</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com1tag:blogger.com,1999:blog-7512002222520024180.post-68354736291111578972010-04-06T19:50:00.010+01:002010-04-10T10:29:04.740+01:00It's Chilling in Kigali...<div style="text-align: justify;">Returning from fistula camp, I had a mountain of stuff to catch up on. Many of the staff commented on my being 'lost' - read, not around - some thinking that I had abandoned Mulago forever. Not so. I did spend much of the week trying to pin people down to make progress on various things - arranging for the next wave of exchanges, getting protocols moving again and trying to work out how to take the HDU project forward without any formal funding. I managed to meet with the head of department to discuss these and more and feel that we've taken a big step closer to realising some of our ideas. We have enough basic equipment to set up an HDU if we can acquire the physical space and I'll drag my trusty band of painters back to the hospital - possibly kicking and screaming - to spruce it up. We're hoping to acquire a six bedded bay with dedicated staff. I feel perhaps that I spend a lot of time expressing 'hope' on this blog. Speaking of which, we're going to give triage another bash, this time I have permission to get the whole department involved, mobilise the doctors as well as the midwives, who we had focused all of our efforts on the last time we piloted. I'm still hopeful that we can get it working. See, there it is again... hope.<br /><br />I did a bit of teaching, more interactive which seemed to be well received, and some practical refresher training on vaginal breech delivery and neonatal resuscitation. We definitely need to run another formal course. We have identified over 30 midwives who need to be retrained or trained. Initially we were looking to run a series of one day courses, but having met with Agnes, one of our in-house trainers and talked a bit more, she feels that we should run a more intensive 3 day course so that we can really drive the message about resuscitation home. I've set up a charitable donation page <a href="http://www.mycharitypage.com/katealldred">here</a>, and if you're feeling generous, money is accepted in all forms... I'll even take beans if you've got 'em. We're going to do it during the first week of May. Although I didn't do any clinical work, I did achieve a lot in terms of igniting or re-igniting project work that had gone off the boil a bit.<br /><br />For Easter, the three amigos - Adam, Elizabeth and myself - decided to take a road trip down to Rwanda and back to Kampala via Lake Bunyonyi. We arranged a driver for the weekend, and asked for a 4x4 vehicle. Alfred rocked up the night before departure with what looked like a clapped out Matatu (minibus taxi) and a grin on his face. Fortunately it was fairly plush inside, and since it was the 11th hour and we had no choice paid the deposit. The next morning, bleary eyed at 5.30am Alfred turns up with Dan, and the bombshell that Alfred is in fact not going to be driving us after all. Thanks for the notice, mate. We piled in, and Elizabeth and Adam were asleep before we'd even reached the outskirts of Kampala. Given that I cannot sleep in a moving vehicle of any description I was glad I had brought a stack of books with me and began to devour the first with absolute delight - I don't get to be much of a bookworm these days. We stopped on the Equator for the compulsory naff photo, a coffee and the biggest muffin in the world before continuing through Mbarara - where Dan, not being one to leave things til the last minute, had to stop to buy insurance. We ploughed on to Kabale - Uganda's highest town - where we stopped for lunch. We were pleasantly surprised when the food that we had ordered from the fairly dubious looking menu arrived, and particularly impressed by the avocado and banana milkshake. We ate our fill - eyes bigger than bellies - and proceeded to tackle the border.<br /><br />I hate crossing borders by land. The process is always ludicrously bureaucratic and a total waste of ink. The Uganda-Rwanda border was no exception. The concept of queuing was non-existent and it was pouring down. Despite the seemingly tight control I am fairly certain that you could easily pass freely from one country to the other without anyone noticing - as one crazy gentleman appeared to be able to do, while muttering to himself and flailing his arms in the air. Having added a new stamp to my East African collection at the much more organised Rwandan side of the border, I got back in the car along with the others and we set off once more. There was a minor moment of panic, when Dan decided after driving for about 70 km that he should probably stop and ask someone if we were heading in the right direction, since I, who had never set foot in the country before, didn't know. We were heading in the right direction, thankfully, and I managed to stop myself from suggesting to the driver that following a random truck from the border in the hope that it was heading to the same place as us was, to my mind at least, a foolish plan. We drove past acres and acres of tea plantation in the flat bottomed valleys. Every inch of the land is seemingly given over to farming, with agricultural terraces tumbling down the hills like a patchwork quilt of every shade of green imaginable.<br /><br />Eventually we hit Kigali, driving past the taxi park and heading up the hill. The striking thing about Kigali is how well looked after it is - it's clean, there's no rubbish, the roads are paved, it's organised and the traffic's not mental. The perfect city antidote to Kampala in fact. It unsurprisingly transpired that Dan didn't know Kigali at all, and we didn't have a map. So we were driving randomly around hoping to spot a landmark that looked familiar to Elizabeth, who had lived there in a former life. We eventually made it to the Hotel Chez Lando a mere 14 hours after we had left Kampala, and I was wishing we'd climbed aboard a plane and arrived 15 minutes before we'd set off. Elizabeth headed out for a business dinner and Adam and I amused ourselves trying to translate the French menu, with no success, only to find the English version at the bottom of the page.<br /><br />Elizabeth spent the next day in meetings, and Adam and I decided to see the sights of Kigali. Brandishing our faithful, if not trustworthy Lonely Planet and a map from the local rag which had the landmarks in all the wrong places, we got into Dan's van. We'd furnished him with a wishlist of places we hoped to go. We were not expecting much, as on getting to the carpark, we found Dan awaking from his slumber in the back of the van where he had spent the night. Give him his due, he'd done his homework and had developed a remarkable knowledge of the city's geography.<br /><br />We arrived at the Kigali Memorial Centre, to be greeted by a firmly shut iron gate and a guard making X-factor signs at us, demonstrating that the centre was closed, rather than displaying his affection for Simon Cowell. We were informed that it would be open the next day, since Easter Saturday generally isn't a public holiday. We decided to visit a couple of churches outside of Kigali, 25 and 30 km south of the city. En route we stopped at a memorial garden, where the grass was being cut by people brandishing machetes, which had an uncanny irony to it. The remains of over 600 genocide victims were buried here, some identified by their first names only, and some simply identified as 'boy'.<br /><br />Along the roadside, heading out of town were bands of men working on roads or in gardens or on construction sites wearing pink tabards. These uniforms identify them as prisoners suspected of having been involved in genocide on some level - most of whom killed or looted - awaiting trial. They work on civic projects, a useful form of community service. The prisons are overrun with genocide suspects with little hope of a trial in the near future.<br /><br />We arrived at Ntarama Church in a downpour. Around 5000 people were killed here by Interahamwe militia using grenades and machetes. Most people were sheltering in the church itself when the grenades were thrown in. The church is a humble brick building with rows and rows of simple benches. At one end of the church are shelves containing the skulls and femurs of the dead, many showing evidence of how brutally they were massacred, clean lines sliced through the bone by the soldiers blades. Around the church, hanging on the walls are the victims' clothes, cooking utensils and whatever possessions people brought from home in the few days they took refuge before a neighbour told soldiers of their whereabouts. Outside you could see where the grenades had entered the building, blasting through walls that are 18 inches thick. The steel window frames were twisted and bent where the people trapped in side had tried desperately to escape. The place felt desolate and abandoned. It didn't feel like a church. It was deathly quiet.<br /><br />We got into the car, feeling sombre. We drove another 5km to the next church at Nyamata. We met Steven, now 24, at the entrance, who was 8 when the killings started. Above the entrance to the church, there is a banner which reads,<br /><blockquote><br />"Iyo uza kwimenya nanje ukamenya ntuba waranyishe"</blockquote><br />I asked Steven what this meant. He said that it was far more philosophical than the translation<br /><br /><blockquote>"If you had known me, and if you had known yourself, you would not have killed me"<br /></blockquote><br />While waiting to be shown around inside the church, Steven told us his story. They heard the soldiers coming, they were beating drums as they advanced towards the village. Steven fled the village with friends and neighbours. His Mother and Father, Uncles, Grandmother and brothers remained behind. After the genocide was over, Steven was adopted by one of the adults that he had fled with. This man spent 4 years trying to trace survivors from Steven's family. He eventually managed to track down his grandmother, and Steven and his sister were reunited with her. The rest of his family had been slaughtered. The man who had killed his father and 2 uncles turned up at Steven's house in 2003 begging for forgiveness. Steven told us that his grandmother refused to let him in the house. His sister couldn't speak to him. Steven went outside and asked him to leave, and if he felt the same way in a week to come back and ask again, this time bringing details of where the remains of his family were buried. The man returned the following Sunday. He took them to a pentecostal church. During the service, there was a period for free speech, where people took to the altar and spoke to the congregation. The man stood on the altar and asked the deputy pastor and a number of others in the congregation, men and women, to stand. He identified these people as being complicit in the hiding of 32 bodies in a disused latrine. 9 years later, the bodies were still there. Those involved were arrested. The man, along with Steven and others, removed the bodies from the latrine. Steven told us that they were in varying states of decay, the ones in the middle still had flesh and skin. They brought the bodies to Nyamata to rest. Steven told us that he has forgiven the man who killed his family. They drink beers together these days. He's a stronger person than I think I could ever be.<br /><br />He took us into the church, much bigger than Ntarama. It seemed a lot more peaceful, but I think that was the light. There were piles of clothes on every single pew and the altar. The altar and font were pockmarked with bullet holes, and light peeked in through tiny shrapnel holes in the tin roof, created by grenade explosions. There was an eerie sense of oppression. 10000 lives extinguished. We were told that the Hutu soldiers tied people to the pillars and amputated their limbs one by one, often hours apart. They used the dismembered arms to wave at other Tutsis imprisoned in the church as a warning of what was about to happen to them. Those who had money, paid the soldiers to shoot them dead, to avoid suffering. We went down into the basement of the church where there was a coffin and hundreds of skulls. He told us that in the coffin were the remains of a mother and her baby. Hutu soldiers had sharpened two wooden poles and driven one through the woman's chest and through the baby that was strapped to her back, and a second pole through her abdomen and out through the back of her neck. They were buried as they were found. Out the back of the church were two large tombs. Inside the tombs were stacked coffinsm 5 or 6 high, each containing 35-40 skulls. It is estimated that the remains of 40,000 people are buried at the church.<br /><br />Returning back to the church entrance we met Charles. He was also 8 when the genocide happened. He was in the church when the Interahamwe arrived, along with his brothers and sister. Charles, one of his brothers and his sister were still alive after the first wave of mass execution at the church. His brother knew that the soldiers were coming back. He Charles that he needed to hide and pretend he was dead. He covered him in blood, told him to lie with his head inside a small hole in the bottom of one of the walls - we were standing next to where Charles had lain while he was recounting his experience - and then piled dead bodies on top of him. His brother told him he was going to check on the rest of his family, but that he would be back. He never came. The soldiers returned to the church and executed more people. When it was quiet and they had gone, Charles came out of his hole. His brother was dead, his sister seriously injured. She asked him to find water. He brought some to her, but while he was fetching it he heard the soldiers returning a third time. He went back to his hiding place. The soldiers moved amongst the bodies, jabbing at them with spears to see whether there were any survivors. One of them put a spear in Charles' leg. There was a pile of bodies between him and the rest of the military. Charles looked him in the face. The soldier asked him if he was still alive. Charles answered 'Yes, please forgive me'. The soldier told him that he didn't want to kill him, and sparing him, went to join the rest of his group. There were 7 survivors from the church. They fled and hid in a nearby swamp. Soldiers came to the swamp looking for survivors. 2 of the 7 died from hunger. It was harrowing to hear his story first hand.<br /><br />We left the church and headed to Hotel Milles Collines - better known as Hotel Rwanda. If you hadn't read about it, or seen the film, you wouldn't know what had happened there in 1994, it feels like any other business hotel. But it seemed like a fitting place to have a drink and take stock of the places we had been and the stories we had been told. The rest of our day was spend mooching around, most places of interest being closed due to the public holiday. <br /><br />The next morning, we headed back to the memorial, only to discover that it was still closed. I was sorely disappointed to be leaving Kigali without getting to see it, but c'est la vie. We spent the morning at a craft village, piled high with what I now consider to be the generic East African souvenir tat, although I did buy a wooden statue of a pregnant woman that seems to resonate with my purpose here. We then set off on the brief journey back to Uganda and onto Lake Bunyonyi.<br /><br />I loved Bunyonyi the first time I went, and I loved being back there. We stayed at Bushara Island camp, a 10 minute motorboat ride from the main land. It's a beautiful, peaceful place with abundant birdlife. We slept in a huge furnished safari tent with views of the lake. We spent two days relaxing, swimming and walking. We spent a merry afternoon attempting to circumnavigate the island in a dug out canoe, failing miserably and wasting a lot of time spinning the canoe around in circles. It was true downtime.<br /><br />This week was spent doing a variety of things - the usual mixed bag. I had a couple of days on labour ward, we tried to relaunch triage, I did some teaching. Tomorrow I travel to Arua, in the far north-west of the country, 10 miles from the border with the DRC. It will be my last fistula camp during my time here. I'm looking forward to it.<br /><br />Photos of the trip are <a href="http://www.facebook.com/album.php?aid=412128&id=776350584&l=4f4f2aa444">here</a><br /><br /><br /><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-69952745133691797512010-03-28T07:48:00.005+01:002010-03-28T13:14:39.982+01:00Fistula Outreach Camps<div style="text-align: justify;">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.<br /><br />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.<br /><br />'We're here to do a fistula camp'.<br />'Oh, er, do you have an anaesthetist with you, because we don't have one'.<br />'What are you talking about? You ARE an anaesthetist'. <br /><br />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.<br /><br />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. <br /><br />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.<br /><br />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.<br /><br />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. <br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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 <a href="http://www.facebook.com/album.php?aid=404811&id=776350584&l=763f732c59">here</a> and will note the striking difference between the two hospitals.<br /><br /><br /><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-14223838364132532922010-03-10T13:53:00.012+00:002010-03-14T10:44:47.539+00:00Planes, Trains, Automobiles, Dhows, Boda Bodas and Tuk Tuks<div style="text-align: justify;">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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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!<br /><br />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.<br /><br />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.<br /><br />Photos can be seen <a href="http://www.facebook.com/album.php?aid=399626&id=776350584&l=ad73e4b630">here</a></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com1tag:blogger.com,1999:blog-7512002222520024180.post-44247091824748164852010-02-28T15:06:00.007+00:002010-02-28T16:57:28.138+00:00Hard Labour<div style="text-align: justify;">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.<br /><br />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.<br /><br />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.<br /><br />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! <br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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!<br /><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-24351987215526375982010-02-22T09:58:00.003+00:002010-02-22T14:51:24.872+00:00January...Part 4 - Hippos and dirtroads and birds, oh my!<div style="text-align: justify;"><span style="font-family:trebuchet ms;">The morning after we had been tracking the gorillas, the world started falling out of my bottom. So it was a good thing that we hadn’t planned on doing anything for the day, as I quite literally couldn’t have left the lodge. We spent the day watching the birds in the valley – sunbirds, sparrows and the like – brightly coloured on a backdrop of blue sky. After lunch we decided to try and get an idea of the size of our hotel bill, and it was at that point the lodge manager announced that it wasn’t possible to pay by credit card, despite being reassured by the office in Kampala that we would be able to. We had a minor panic at this point, having literally just enough cash to cover the bill with none left over for emergencies. We spent around an hour unsuccessfully trying to work out a solution. The nearest ATM was more than an hour’s drive away. We called Eddie, who had disappeared up a mountain somewhere, to take us to the ATM. When he arrived an hour later, he reminded us that it was a public holiday, and should the ATM be empty, we were stuck. We decided it was probably most sensible to take our chances with no rainy day fund to speak of. It was a day of doing absolutely nothing, that turned out to be fairly stressful. All in all, the ‘splurge’ turned out to be a true disappointment.</span><br /><br /><span style="font-family:trebuchet ms;">The next morning, we left at around 8, driving to the next decent sized town, where the cash machine decided that it initially wasn’t going to dispense any money for us, and then 5 minutes later after having no success inside the bank, decided that actually it would give us some funds after all. We were relieved. We then set off for Ishasha. Arriving at around 10, we hoped to catch a glimpse of the tree-climbing lions. As it turned out, the lions were not feeling particularly tourist friendly and had abandoned the branches of their fig trees. We didn’t spot a single one. Disappointed that nature had won the game that day we carried on through the park in the direction of the Kichembwa Lodge, which was to be home for two nights.</span><br /><br /><span style="font-family:trebuchet ms;">Queen Elizabeth National Park is very different to Murchison Falls. The hot, dry savannah continues as far as the eye can see, with bits of scrub here and there, and the occasional damaged tree, providing evidence of the presence of elephants. We saw hundreds of Ugandan kob, a sort of antelope, and numerous elephants on the horizon as we drove along the dusty dirt track, baking in the blistering sun. The lack of game meant that the drive was fairly dull, with little to grab our attention or capture the imagination. As we got out of the park and onto slightly better roads, Eddie picked up the pace. Along the way were brightly coloured butterflies. Wherever there was a puddle, the butterflies congregated and as we drove past, they fluttered up from the ground like handfuls of wedding confetti, streaming out from underneath the back of the car. Beautiful. We arrived at the lodge, which was a series of round thatch-roofed huts, reminiscent of Hobbiton. We got to our hut and were greeted by a breathtaking view of the plains below, reaching what seemed to be the edge of the world. It was a really special place. We reflected on the day’s game drive and the arid landscape that we had seen, and decided to change our plans. We’d originally decided not to go up to Murchison Falls, but Mum wanted to see giraffes, and we figured that we would probably have more luck seeing big game up at Murchison. We decided to spend one night at the lodge, game drive the next morning, head to Fort Portal for 2 nights and then spend 2 nights at Murchison.</span><br /><br /><span style="font-family:trebuchet ms;">Our game drive the next morning was again, fairly fruitless, save for watching male kob sparring with each other at dawn, and group of mongooses/mongeese/mongice/mongoose (exactly what is the plural of mongoose?!). There was a disappointing lack of most of the big 5. We were out in the park before the sun came up, but as it rose it was seemingly too hot and dry for the animals. I was glad that we had changed our plans. After eating a breakfast of fruit, bread and eggs while gazing at some salt flats, we began our journey to Fort Portal, and I started a series of phone calls to rearrange our accommodation. Unfortunately the guest house we had already made a reservation at was unable to accommodate us a night earlier, and so referencing our ‘trusty’ lonely planet, settled for a place called the Y.E.S. Hostel. We drove round some of the crater lakes which sit outside Fort Portal proper. on the way there We saw endless numbers of men pushing bikes impossibly laden with bunches of green matoke, up dirt tracks in the midday sun, and women and children tilling and farming the land. We were in very fertile country, on account of previous volcanic activity in the area. The fields were full of coffee, tea, matoke, papyrus and other crops.</span><br /><br /><span style="font-family:trebuchet ms;">We stopped for lunch where we got rid of the packaging from breakfast. My Swiss Army knife was wrapped up with them, and was inadvertently disposed of, without either of us realising until the next day and by which time it was too late. From here we continued to the sparse, prison like hostel. We were the only guests. Mum was incensed, ‘I stayed in a place like this in Afghanistan in the ‘70s, and there was shit up the toilet walls there too’, I suggested that our options were limited but we could check out the posher – and even more soulless – hotel just up the road. On balance, we decided to stay put and grit our teeth for 3 dollars a night. On walking to the posher hotel we became surrogate parents of a random dog, who followed us all the way there, entered the ground with us and sat next to us while we drank cold beers in the shade. The dog found the rest of the customers fascinating and whiled away a few hours making a nuisance of itself. At one point the bar manager came and asked us if the dog was ours, and we quickly denied having any connection with it. As we left, the dog decided it had probably best go home and followed us back to where we had found it. We had concluded quite quickly that Fort Portal itself was a place to pass through and use as a base for exploring the area, rather than a place to have a holiday. </span><br /><br /><span style="font-family:trebuchet ms;">We went back to prisoner cell block H, spending a bit of time playing table tennis, without actually using the table at all. In a desperate attempt to make our evening into something we went to a nearby guest house with a roof bar, containing a pool table, a couple of TVs showing football and a noisy parrot. One beer and we decided the best thing we could do was go back to our room and try and get our heads down. This was delayed by Mum's discovery of the lonely hearts page in The Red Pepper, Uganda's quality rag. 'Married man seeks woman for fun times' and ' Man seeks woman from North for marriage, must have untilled land upcountry'.</span><br /><br /><span style="font-family:trebuchet ms;">The following morning, we couldn’t have escaped faster than we did and checked in to Rwenzori View, which was lovely. We headed off to Amabere Cave, just outside of Fort Portal. We met Robert who was to be our guide for the morning, and set off, first on a ridiculously steep hike through burned fields to a vista point from which we could see three crater lakes. He pointed out birds and plants on the way and we had some interesting discussions about religion and politics. Like most Ugandans I have met, Robert talked around the subject matter, including the Anti-Homosexuality Bill of 2009, without actually giving us his personal opinion on any of it. On the way back down towards the falls themselves we met a couple of girls, who can't have been any older than 10, one carrying a bunch of matoke and the other carrying a pumpkin and a machete. Child labour is all too evident outside of Kampala, where less than 60% of kids attend school. We headed to the cave from here, fighting through sinewy forest to reach it. Here, stalactites and stalagmites continue to form, supplied with minerals by the milky coloured water dripping from the cave roof. Robert regaled us with the legend of the cave - full name Amabere ge Nyinamwiru, meaning Breasts of Nyinamwiru. Nyinamweru was the King's daughter, the most beautiful woman in the land, constantly plagued by budding suitors - a feeling I know only too well ;). The king had heard prophesy that he would be killed by his Grandson. The King had no grandson, but the attention of suitors towards his daughter now worried him. In an effort to reduce her beauty and hence the attention of menfolk, the king chopped off her breasts - and in Robert's version of the tale, poked out one of her eyes too - to reduce the chances of her becoming pregnant. This still had no effect on her charms, and so the King threw her into a tower - Robert's version - or into the caves - Bradt Guide version. Either way, she was impregnated and gave birth to a son. In Robert's version, word reaches the King that Nyinamwiru has produced a son, and the King takes the child and throws him into the cave, where he manages to survive by drinking the milky water running from the cave, grows up, learns of the events surrounding his birth and abandonment, meets the King out on a hunting trip and avenges his misfortune by killing him. The guidebook version is not so elaborate, basically stating that the child and his mother took shelter in the caves, and she, having no breasts, replaced the milk with the water dripping from the caves. I know which version I like better. We spent a happy hour scrambling round the caves and behind the waterfall there, and on the way back to the car, Robert pointed out a bald cow, born with no hair, which has to be one of the strangest freaks of nature I've ever seen.</span><br /><br /><span style="font-family:trebuchet ms;">Adam, my housemate, met us in Fort Portal that afternoon, and we went back to the guesthouse to shoot the breeze on the porch with a few beers. We met a Dutch surgeon and his wife, who had trained one of the guys I work with at Mulago, and it was interesting to talk about the differences between Mulago and Kisoro hospitals. We shared a communal dinner around a large family table at the guesthouse, with about 15 other people. </span><br /><br /><span style="font-family:trebuchet ms;">The following morning, we embarked on the long drive from Fort Portal to Murchison Falls. The day was scorching hot and the roads incredibly dusty. We sped along the dirt roads, kicking up the dust that flew through the car and covered us in a thin film of orange particles. I looked like a Scouser with a bad St Tropez tan. As we drove along, the scenery was similar the whole stretch, fields of Matoke, coffee and tea plantations, papyrus springing up from the marshes. Most of the vegetation was also covered in orange dust. Each village we hit was a collection of similar looking huts and shops, some painted with the colours of mobile phone companies, others displaying signs such as 'God is Able Grinders', 'Second Chance Salon', 'The Breath of God Ministries', 'God is Good Barbers' and so on. We saw a man wobble along the road on his bike, so drunk that when he eventually fell sideways into the ditch, he just went to sleep there. There was a brief moment of excitement when a wasp entered the car and Mum nearly had a fit of hysteria, demonstrating the 'Dinsley Wasp Dance' to Eddie and Adam with a modicum of style and finesse. After 8 hours on the road we stopped in Masindi for lunch. They had nothing on the menu we asked for 'It is finished', 'It is over', 'We don't have', so we settled for Chapatti and avocado salad. We were caked in orange dirt and must have looked stunning.</span><br /><br /><span style="font-family:trebuchet ms;">Eddie bundled us back in the car, and drove into Murchison Falls National Park. The scrub had been destroyed by wild fires, sparked by poachers or carelessness. Much of the vegetation along the main road in was blackened, the trees stripped of leaves, their bark scorched, looking eerie in the smoky air. We couldn't get a space at the backpackers campsite and had booked a banda in a lodge. It was more gross than the hostel in Fort Portal and at least 20 times the price. We decided to upgrade to a cottage, which wasn't much better but at least had a shower in it with hot running water. It had been a long and tiring day, and having to spend much more money to get a decent bed made me grumpy for the first time on the trip. We did get a good night's sleep, but I reflected on how the best places we had stayed had been some of the cheaper places.</span><br /><br /><span style="font-family:trebuchet ms;">Eddie collected us at around 6.30 ready to pick Adam up from his campsite and catch the Paraa ferry across into the park proper. The sun was rising over the misty Nile, hippos wallowing in the water like giant rocks with ears. On the other side, we didn't have to drive for long before finding an abundance of giraffes, buffaloes, kob, hartebeest, oribi, warthogs, baboons and hippos. Eddie managed to spot a shoebill stork on the far side of the river, one of the rarer birds here, with a face that looks literally like someone stuck a clog on the front of it. We went to the hippo mating ground, and if hippo foreplay is anything to judge by, all I can say is that I'm glad I'm not a hippo. We saw a solitary lion and a few elephants too. On the way back to the ferry, Adam spotted an upturned, decomposing hippo, a fair distance from the water. Not something the UWA mentioned we were likely to see in the brochure. Quite how it ended up on it's back, all four legs up in the air is beyond me. Perhaps it fell out of a tree.</span><br /><br /><span style="font-family:trebuchet ms;">We spent lunchtime at the Red Chilli Hideaway, kicking back with our books. The tranquility was only disturbed by an octogenerian canadian man using a chair to fend off a warthog that was just standing on the opposite side of a ditch minding its own business. His shouts of 'You might just get more than you bargained for, sonny!' while thrusting the chair towards the hairy pig had us sniggering into our plates, and when he turned to address the rest of his group after the warthog got bored and walked off, with the line 'You just need to make a threatening gesture', I had to leave the table for fear I might embarass myself. After lunch we took a boat trip to the bottom of the falls, watching the hippos pop up from underneath the water with a look of surprise that seemed to say 'Oh 'ello!', and spotting all sorts of colourful birds. There were many more elephants around compared to the last time I was here. It was a really lovely afternoon. We got back to the banda, and helped Adam to pitch his tent outside. We headed over for dinner, and despite us all having headtorches on, Adam still managed to trip over a sleeping warthog. I'm not sure which of them was more surprised.</span><br /><br /><span style="font-family:trebuchet ms;">The next morning we took a hike to the top of the falls, the last leg of our adventure before heading back to Kampala, and again were blown away by the sheer power of the water. We got back to Kampala mid afternoon, and after showering, throwing the dirty washing in the laundry and finally properly unpacking, caught up with the gang. It had been an amazing journey.</span><br /><span style="font-family:trebuchet ms;"><br />Photos can be seen <a href="http://www.facebook.com/album.php?aid=382550&id=776350584&l=8eef66311b">here</a><br /></span></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-34174495231743424182010-02-05T12:50:00.001+00:002010-02-05T12:54:45.282+00:00January...Part 3 - Gorillas, in the midst<p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">Part 3 of a 4 part summary of January...<br /></span></p><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">Our road trip around Uganda began with an early start and frantic unpacking and repacking of bags after our Zanzi trip. Fast Eddie arrived early in his Landcruiser, and we sped off through the go-down away from an overcast, drizzly Kampala. We stopped en route at a place called Mpambire, where the Royal Drum Makers make and sell African drums. When we asked Richard, the craftsman, exactly what they were called, he replied 'Drums'. So that was us told! A beautifully crafted large cowskin drum can be had for sixty thousand shillings - approximately £20. We elected to consider going back following our return to Kampala, as the idea of transporting one round the whole south west of the country didn't seem sensible. We continued from here to the Equator, for cheesy tourist photos, coffee and breakfast before plodding on down the Masaka road, passing through Masaka, past Lake Mburo to Mbarara, where we broke the journey with lunch. From here we continued to Lake Bunyoni. Arriving at around 5, we checked into our treehouse safari tent on stilts, overlooking the lake. The sun was beginning to go down by the time we got ourselves square, so after a cup of tea and a quick walk we decided to relax at the camp. After eating the worst pizza I have ever encountered, we decided to get into the tent and read to the chorus of frogs and insects that was coming from the waters edge. After deciding on an early night, I was woken by the loudest clap of thunder I think I've ever heard, and a heavy shower of rain. In a tent, in a treehouse on stilts, in a thunder storm... Safe. I decided I was too warm where I was, and being struck by lightning is one of the more exciting ways to go, so I stayed put. The next morning the entire lake was shrouded in mist. Eddie picked us up at 10, ready for the long slog to Buhoma, in Bwindi Impenetrable Forest. We wound around the lake's shores, high up on the hills, affording spectacular views of the mirror-like water. Soon after leaving Bunyoni, we hit bumpy dirt track, which continued through the hills. Looming ahead in the distance was Bwindi, noticeable because of the sudden density of the forest canopy. We drove through the forest for around 3 hours before arriving at the lodge, with its spectacular view of the forest. The lodge was comfortable, although not as nice as we had expected it to be, given that it was our splurge on the trip, but nevertheless, we made ourselves at home with a couple of beers and chilled out watching the valley and the birdlife. We were looking forward to gorilla tracking so much that I don't think at that point we'd have cared where we slept.<br /></span></p><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">We woke at 6am the next morning, excited, full of trepidation about the unexpected.<span style=""> </span>We would have to trek through Bwindi ‘impenetrable’ forest, were warned that it would be strenuous, that we might not find the gorillas, but that it was ok, because if we didn’t, we’d be entitled to a 50% refund on the tracking fee.<span style=""> </span>We arrived at the UWA headquarters at 7.30 after a slightly hairy moment where it seemed that perhaps our driver had slept in/was still out drinking and shooting pool/had decided he just couldn’t be bothered.<span style=""> </span>Fast Eddie tore up the drive in a billow of dust at 7.25.<span style=""> </span>Phew.</span></p><div style="text-align: justify;"> </div><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">After being shown two interestingly produced videos about the gorillas , dubbed with a commentary in the Queen’s English, we met our guide, Kathy, outside.<span style=""> </span>We counted two of us in our group – me and Mum.<span style=""> </span>Assuming there must be more to come we waited for around 10 minutes before Kathy said it was time to go and that she’d brief us once we got closer to the gorillas.<span style=""> </span>We were to track Habinyanja group at Buhoma, a group that now contains 18 mountain gorillas since the young Silverback overpowered the older silver back, who had left the group taking 3 females with him.</span></p><div style="text-align: justify;"> </div><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">We drove for 45 minutes to the trailhead, where we picked up two porters, Moses and Wilson.<span style=""> </span>These guys turned out to be fantastic help, not because the bags were heavy, but because we’d have struggled to keep balance carrying a load – I struggled enough with my camera – and pick our way through the steep, thick, slippery forest.</span></p><div style="text-align: justify;"> </div><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">We walked for around 40 minutes through farmland, taking in the vast valley view, teeming with tea plantations, banana trees, terraces and children vying for a ‘How are you?!’ from the two Mzungus in silly hats with walking poles.<span style=""> </span>The pace was slow and steady, and we had regular radio contact with the two advance trackers, who had gone ahead of us to find the gorillas, based on where they had left them the day before.</span></p><div style="text-align: justify;"> </div><p style="text-align: justify;" class="MsoNormal"><span style="font-size:100%;">The forest edge loomed ahead, an abrupt border to the farm terrain.<span style=""> </span>We entered, and suddenly the ground was soft underfoot, nervously stepping and unsure as to where the true forest floor lay.<span style=""> </span>Impenetrable.<span style=""> </span>We thrashed our way through branches, ferns, thistles, nettles, webs and goodness knows what else.<span style=""> </span>The forest, a thicket of every shade of green and brown imaginable, pierced every now and the by the occasional shaft of bright sunlight, as the weather had deigned to be kind to us.<span style=""> </span>We slipped and slid down through the trees, zigzagging round obstacles, with the help of the porters holding back and snapping branches as we moved.<span style=""> </span>After 50 minutes of battling with the forest, hands and bums muddied from falling over, we met the advance trackers.<span style=""> </span>Kathy then said to us ‘There are no gorillas in the forest today’… WHAT?! ‘Just kidding’, she said, beaming.<span style=""> </span>We were briefed on the rules – ‘No flash photography, no food or drinks, no sudden moves or pointing, no spitting, farting, swearing or petting in front of the gorillas’ and we were off.<span style=""> </span>We traversed down the slope, and up ahead, just visible through the trunks and branches, lay a black back, keeping watch over the other gorillas, amassing 13 in number, just a bit further down under the forest canopy.</span></p><div style="text-align: justify;"><span style="font-size:100%;">They were grooming, swinging from branches, the small ones beating their chests at each other in an effort to prove their strength while the adults cuffed them round the head when they got too boisterous. It may sound like a cliche to say that we felt privileged to be there, observing them in their natural habitat, such gentle giants. There was a real sense of family and community. The silverback was separate from the group initially, being groomed by two of the ladies. One adolescent female was crouched about 10 metres from where we were. As I crouched to take a photo, she stared directly at the camera lens, and I realised that she was going to charge. I stepped back at the guide's instruction and she galumphed past us, grabbing the back of my left calf as she went, reminding me of exactly who was in charge. I know that if I had been any closer, the force would have knocked me over. Awesome. </span><br /><br /><span style="font-size:100%;">The silverback joined the rest of the pack, who were now basking in sunlight, eating leaves, nesting in trees and rough and tumbling, taking branches down as they went. They moved down the hill and we followed them to their next nest site where they continued with their antics. It was amazing watching the interaction between the group members. They moved off again, this time through the trees rather than on the ground, at an astonishing pace. We reached a dip in the forest, needing to climb uphill to get to the next area of flat groud from which we could leave the forest relatively easily, rather than trying to negotiate our way back along the route we had come. Moving uphill was tricky, with very little to grasp, the ground wet and slippy. </span>We reached the top of the hill and the porters moved from where they had been waiting with water. William, one of the advanced trackers, suggested we continue down the next hill into a clearing in the forest canopy, which would allow us to leave the forest through terraced farmland. We followed him through a dense growth of thistles, nettles and other spiky plants, tearing at our feet and clothes and tripping us over. We were sweaty, knackered and covered in thorns. As we started to climb through the farmland, Kathy pointed out a black back down the hill, separate from the rest of the group. We waited amongst the vegetation for him to move, out into bright sunshine, and he lumbered past us up the hill to join the group, providing the best photos of the day.<br /><br />We plodded back out of the forest, in awe of what we had just experienced. Something that was really special, truly magical. I don't have the words to describe how it felt at the time, but it was definitely up in there with the top 10 things I've ever done in my life. Worth coming to Uganda for on its own.<br /><br />Moses took us to his house on the way back down the hill, a mud hut with three rooms, sparse with no furniture to speak of apart from a mattress. It was very humbling, especially to know that here was a man doing a job that pays him relatively well by Ugandan standards, that had very little in the way of material possessions. It was another raincheck on just how much we overvalue possessions. We were greeted at the end of the trail by a group of children from an orphanage project who performed some songs and dances, tapping into the tourist trade in their own way. We swiftly ran out of shillings.<br /><br />We headed back to the lodge for a well earned beer, to reflect on what we had just seen, exhausted but elated.<br /><br />Photos can be seen <a href="http://www.facebook.com/album.php?aid=380197&id=776350584&l=8cf2e3c333">here</a></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-37810876505065543672010-02-03T06:11:00.017+00:002010-02-04T07:17:54.187+00:00January... Part 2 - On Earth as it is in Heaven<div style="text-align: justify;">Mum arrived on January 17th. It felt strange meeting her at an airport in a hot country - normally I'll collect her from the perpetually freezing arrivals terminal in Manchester, on a dreary, drizzly day. We had an overnight stay in a motel in Entebbe, since we were leaving early the next morning for Zanzibar, and after introducing her to the local beer we hit the hay. Fearing being bumped off the flight - flights to Zanzibar are routinely overbooked - we decided to head to the airport early, only to find that we couldn't check in until an hour before the flight. This meant we had to settle for 'coffee' - lukewarm brown liquid with no flavour - and a 'croissant' - stale butter infested bread - in the only cafe before the departure lounge. Not the ideal introduction to the culinary delights Uganda has to offer, but we were hungry. Check in was smooth in the end, and we began an epic 9 hour journey, flying to Nairobi, then to Dar es Salaam passing Mount Kilimanjaro en route, and finally making a 30 minute leap across the ocean in yet another plane to Zanzibar itself. The airport at Dar provided a few comedy moments, since we had to check in again here. After having our passports and $100 taken from us by a man in uniform who then disappeared into a throng of people, we were a little bit concerned we would be stranded in no-man's land, however they were returned pretty swiftly. We then spent 15 minutes being passed from one person to the next to try and get our boarding passes. After confirming 4 times that our luggage definitely hadn't come off the carousel, we were shepherded down a narrow corridor to a desk where we were presented with boarding passes, only to be shepherded back the same way, bypassing security altogether. When we finally made it to the gate, they scanned our bags, producing a few suspicious looks from the woman operating the x-ray machine. It turns out that Mum had a cigarette lighter in her bag. What was amusing about this, was that the bag had been scanned at Newcastle, Amsterdam, Entebbe (twice) and Nairobi, and no-one spotted it. What was even more amusing, was that when we finally arrived at the hotel, she found another one in the same bag!<br /></div><br /><div style="text-align: justify;">Having left our hotel at 7am we finally arrived at Coral Rock Hotel in Jambiani, Zanzibar, following a hard sell 'I'm a tour guide too' taxi ride across the island, at 7pm. It had been a long day. And what a wonderful place to end it. The evening was warm, the sun had set and there were a pleasant breeze wafting from the ocean, towards our beach front cottage. We met Daniel, a South African who had gone travelling, and never quite managed to leave Zanzibar behind, who showed us around. Mum and I ended up in the honey moon suite - a little incestuous, I know - but it was nice. We headed to the restaurant, desperate for a proper meal, after our last in flight gourmet offering of Spam and mustard in a flat bread. The fish, bought on the beach that morning, and served up with a Zanzibari sauce, was phenomenal, and the atmosphere great - the sea lapping onto the rocks below and that warm sea breeze blowing in through the window. I felt like I had died and gone to heaven. I sort of hoped I had! After dinner we were invited to join a group who were embarking on a drinking game - flipping a coin into a glass. It's not often that you meet hotel staff that truly interact with their customers, but Neil, Daniel and Sibs were up there heading the stakes. It was a late night.<br /><br />We decided on a chilled out beach day for the next morning. I love arriving somewhere after dark, so that the next morning, after you've rested and you can take everything in, you really appreciate what is in front of you properly. We opened the cottage door to the most stunning view. Crystal clear sea, with every shade of blue, turquoise and green imaginable, on a bed of white rock and sand, as far as the eye could see, punctuated occasionally by a Dhow, or a fisherman wading out with his sails and nets on his back, or a woman going to check her seaweed harvest. We spent a number of hours sitting by the pool, absorbing this view, reading, relaxing and in traditional Alldred style, getting sunburned - despite the factor 40, I hasten to add!<br /><br />After more fish for lunch, we decided to walk down onto the beach, and out for a kilometre or two to the channel which had revealed itself at low tide, protected from the ocean proper by a coral reef. The sand was blindingly white, the landscape surreal in its piercing clarity, and vast. Absolutely colossal. There were shallow pools of water, heated by the sun, and small plots where women had set up seaweed farms made of sticks and twine. It was almost lunar. As the sun beat down we eventually found the water's edge, and had to wade a further 200 metres until it was deep enough to swim. The sea was beautifully warm, but the current too strong without fins, so after a very quick dip we beat a retreat back to the hotel, followed by the rapidly advancing tide.<br /><br />The next day we went on a boat trip. After all, what is a holiday without a boat trip? We drove to Fumba, a group of 12 people in the bus, armed with snorkels and fins, high factor sunscreen and plenty of water. Told we would arrive at the beach at high tide so the boat would be almost on the shore, it seemed that there had been some mistake, and we waded out for about 400 metres across sharp bits of dead coral, navigating round jelly fish and all manner of other plants and creatures, to the boat. We cut through the water for around an hour before stopping to snorkel. There were shoals of hundreds of brightly coloured fish - black and white striped, electric blues, yellows and oranges - with a wall of several thousand sheltering behind a huge hunk of coral, avoiding being washed towards the shore by the tide. There were huge urchins, anemones and brightly coloured coral. The visibility was perfect. And of course after an hour of snorkelling, I had gained a branded back.<br /></div><div style="text-align: justify;"><br />We continued our journey around the bay, stopping on a sand bar in the middle of the water for fruit and beer, where we got chatting to a South African couple, Jen and Alan. It turns out that Jen was bridesmaid for the sister of a guy we know in Hartlepool. As they say, it's a small world. We sat and watched crabs dig sand out of holes, got back on the boat to the next island where we ate yet more seafood, climbed a Baobab tree and then got the boat back to Fumba. Back at the hotel, the party was just warming up as we arrived, and many shooters, including the local spirit, made for a bunch of merry travellers who danced until the small hours.<br /><br />The next day we had opted to take a guided tour of Stone Town. Normally we'd explore a city with the help of a map, but given the state of the pair of us, hungover and sleep deprived, it was better to do it this way. We drove to Stone Town and were met by Abdul, the most acharismatic tour guide I have ever met. It was going to be a long afternoon. We wandered through the narrow streets and passageways, lined with crumbling whitewashed buildings, and weathered ornately carved Arabic and Indian doors. Women in headscarves and kids in Kaftans weaved through the streets, while guys on bikes and scooters dodged pedestrians around blind corners. The sheltered maze provided welcome relief from the baking sun. We visited the local produce and fish markets, seafood festering in the heat of the mid-afternoon sun while locals bid for it at auction. The spice market was a bit disappointing, everything having been pre-packaged for tourists, and I suspect not where Zanzibaris buy their spices from.<br /><br />From here we went to site of the old slave market, functional right up the abolition of slavery was effective here in 1873 - although there was continued illegal trade from the island after this time. We visited two small holding cells, the cell for women and children having a capacity of 50-70 people, in what must have been a 15 by 10 feet in maximum dimension, with two small slits allowing in tiny shafts of daylight. It was harrowing. In the old marketplace itself there now stands a statue to commemorate those sold into slavery, next to the site of the old whipping post, where slaves were flogged to determine their worth. The thought that this barbaric practice had ever been acceptable is sickening. From here we visited the Fort, and stopped for a drink at Africa House, which had been the British Club in colonial times. It made the visit to the slave market all the more sobering, to think that we had probably followed in the direct footsteps of British perpetrators of slavery - from the market to the bar.<br /><br />The evening was spent watching the sun go down, and sampling the wares of street hawkers selling barbecued seafood at the night market, while watching kids pull somersaults off the seafront into the water. Stone Town had been interesting, but there wasn't anything that made me think 'Wow!'. Perhaps if we had had the time to explore it at our own leisure, I would feel differently about it. Our final morning on Zanzibar felt a bit strange, we said our goodbyes to the staff who felt almost like new friends and headed off to the airport to make our way back to Uganda for the next leg of our journey...<br /><br />(Photos can be seen <a href="http://www.facebook.com/album.php?aid=382514&id=776350584&l=f7602ab10d">here...</a>)</div><div style="text-align: justify;"><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-70683869637406699632010-02-03T05:33:00.003+00:002010-02-03T06:06:27.246+00:00January...Part 1 - Back to the grind<div style="text-align: justify;">January has proved to be a whirlwind month. This posting has the potential to be very long so I will probably split it into several smaller postings for ease of digestion.<br /><br />Having arrived back from a bitterly cold Christmas break, I struggled to get back into work, knowing that I would be on the road in another 2 weeks. I had a lot of loose ends to tie up on some projects that I didn't manage to finish/polish before I went home, and focused my energy on these. Administrative tasks seem to take a lot longer here in Uganda, and it's very possible that you might manage to achieve one or two things in a day that would take an hour or two in the UK, but you literally don't stop running round sorting for a full 8 hours.<br /><br />It was nice to see friends and colleagues at Mulago, the midwife in charge of Ward 14, Sarah, greeted me with a hug, and the exclamation of 'You look well, you've gone all pale and you've put on weight'. This, I think, was meant as a compliment! Others seemed to think that I had run off and left them forever without so much as a goodbye 'You are lost! Eh!'.<br /><br />My industrious fortnight consisted of arranging the printing and laminating of posters, which I spectacularly failed to achieve while in the UK, completing the first draft of the normal labour guideline, completing the work on the AMEWS charts and policies, advertising for the next round of applicants to go to Liverpool in April and making printed flowcharts for ward 14. I did a midwife teaching session on Eclampsia and Premature Rupture of Membranes, and while on ward 14 mid-tutorial got involved in some neonatal resuscitation that involved a fairly swift and extremely bump 4x4 ambulance journey down the hill to SCBU. Trying to perform bag and mask in such a situation is no easy feat, especially when you're sitting sideways on a makeshift bench, and sprinting up 3 flights of stairs - especially when running is against your religion - makes for a very sweaty Mzungu. <br /><br />We used some of the Magic Whiteboard that Clare Fitzpatrick brought over in December to make a prioritisation whiteboard for the emergency caesarean section list, which went up and was being used the same day, with much excitement from the SHOs. I made a decision to appear not to have any involvement in the implementation of this, to see if the acceptability and uptake is any different. I have been reading a lot about volunteer involvement in Africa and the lack of sustainability once volunteers leave. I'm concerned that much of what I may start here will not continue once I leave, and after my recent break am also aware of the importance of conserving my own energy and sanity levels and spending a little bit more time focusing on gaining personal clinical experience - particularly in theatre. Mark Muyingo, who has recently been in Liverpool, put the whiteboard up and announced it, so I hope that he will continue to drive it.<br /><br />I'm keen to get whiteboards up on the central delivery suite, but I'm not sure how easy they will be to implement. There are times when patients go missing, as we don't have a way of keeping tabs on who's present on the labour ward. They may sit outside with their attendants while waiting to go to theatre, get missed, and end up being found the next day with a more significant problem than they started with. A geographical whiteboard would help to improve patient monitoring, and ultimately might help everyone manage the women better. It may also improve partograph usage. The number of patients and the current lay out of the labour ward would not be easy to manage even with a whiteboard system, but it would be a step in the right direction. <br /><br />By contrast, ward 14 deliver around 20-25 women a day, and it is a much more ordered place. We put a huge whiteboard up there, the staff numbered the beds and we then laid the board out methodically, with an example patient in the far corner. We're hoping that this whiteboard will improve the pick up of women heading for an obstructed labour or who are failing to progress and facilitate earlier transfer, hopefully resulting in better outcomes - fewer sections, stillbirths etc. The staff seemed very enthusiastic, and after putting a couple of women's details on the board we had a Post Partum Haemorrhage on the ward. I put all the details on the board, real time, including drugs given, estimated blood loss and the time the ambulance was called to transfer her, to illustrate just how useful the board can be. I left it in the hands of the co-ordinator, along with some money for extra pens, and departed the hospital, ready to disappear off travelling for a few weeks with my Mum...<br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-74136329640466457562009-12-31T19:35:00.005+00:002010-01-05T14:46:07.010+00:002009... same difference?<div style="text-align: justify;"><span style="font-size:100%;">What did 2009 bring? Indulge me here, while I get a bit deep and philosophical... I have had some time for reflection whilst I've been home over the Christmas period. I've been able to catch up with old friends and family and for the first time in ages, check my head.</span> The nice thing about coming home after being away for 4 months is the realisation that despite the fact that many things have changed, everything's still the same.<br /><br />2009 was the year when I grabbed the bull by the horns, bit the bullet and faced all sorts of other metaphorical perils and hazards face on. 2009 was the year that I decided to fulfill a life career ambition of doing obstetrics and gynaecology in Africa. The decision to take a year out of program to work in Uganda is probably the biggest and most uncertain that I have ever made. Having never travelled on the African continent, I was charting unknown territory, on my own. It still scares me if I think about it for very long! Having thought about it a lot over the last few weeks I have come to the conclusion that it is the hardest thing I have ever done, the most frustrating thing I have ever done, the most acute learning curve I have tackled, at times fantastically rewarding and an experience that has taught me more about myself than anything else ever has. It has made me realise just how many people touch your life, in so many different ways. Mulago has challenged me in more ways than I thought possible. It has tested my resilience both as a doctor and a human being, and will almost certainly continue to do so for the next 7 and a bit months.<br /><br />Lots of things happened in 2009; people got married and engaged, some had children, some are still waiting to hatch, a lot of people loved and a lot of people lost. And me? Well, I just plodded on, business as usual until August 13th. And then I stepped into the (metaphorical) abyss. I remember someone once read a verse out at a conference, referring to uncertainty, written by Guillaume Apollinaire. I distinctly remember it because I had a stinking hangover after an evening of wine tasting and subsequent shenanigans in Melbourne that resulted in my laptop drinking a glass of wine and ending up in hospital. The quote was ;<br /><blockquote style="font-weight: bold;">'Come to the edge, he said. They said: We are afraid. Come to the edge, he said. They came. He pushed them and they flew.' </blockquote><br />That quote rang very true to me as the time came to leave for Kampala, and it was my pride that did the pushing, because when it actually came down to it, I didn't feel brave enough. Sometimes being proud and stubborn can be a good thing. I'm pleased I went to the edge, and I'm pleased I was pushed, although I'm not sure that I am flying with any grace or finesse just yet.<br /><br />So what have I learned?<br /><br />I've learned that one person doesn't change things, but that little by little you can begin to change the way people think, and changing the way people think changes the way things get done. Changing the way things get done maybe, possibly might change the world. A little bit. <br /><br />I've learned that one pair of hands can only do one thing at a time.<br /><br />I've learned how to reflect. Not in the way that our portfolios do, but in the way you sit on the theatre floor, head in hands, crushed because you couldn't get hold of any blood, and that a unit of blood might just have made the difference. And the way you change how you do things because this time you were just lucky, the way you learn from not having stuff that you take for granted to hand, or not having a team of 6 people working and focusing on one problem together.<br /><br />I have learned the importance of having colleagues that will go the extra mile, but also the importance of acknowledging those colleagues, and appreciating them. When the propellor and the proverbial are having a meeting, it's a lonely place to be on your own. So to all of you who go the extra mile on a daily basis, thank you, you're stars, whether you're in Mulago, Liverpool Women's, Arrowe Park or Leighton - and not in any particular order. That extra mile might be running to Nakasero Hospital just to see if they've got another unit of blood at 4am, or making a shift of knackered people a tray of much needed tea, or being kind to someone when inside you're broken and you don't feel like it any more. But the little things sometimes make as much difference as the big things, so please keep doing them , they are appreciated.<br /><br />I've learned that we probably don't need all those shiny silver things with obscure archaic names that look a bit scary that live on the section tray in theatre... but they're nice to have! Sometimes you don't even need a blade handle.<br /><br />I've learned what all the fuss is about catgut... 'If only I had a length of catgut...'<br /><br />I've learned that I am stronger than I think I am, and yet I am more sensitive than ever before.<br /><br />I've learned that the things you think will get to you don't at the time, but come back and hit you when you're least expecting it.<br /><br />I've learned that we should all talk less and do more. In the words of the late, great Elvis Presley, 'A little less conversation, a little more action please'.<br /><br />I've learned lots of other things too, so many that I'd bore you. I'm the same as I was when I left, but I'm different too.<br /><br />What else? I know that being able to write this blog keeps me afloat, being able to email people and vent has kept me sane, and the support that I have received from friends and family has been immense. I was overwhelmed by the number of people I saw over Christmas, braving the snow and ice, before and after nightshifts and long days, operations and the dreaded lergy to come and say hi. I guess you don't really appreciate what you have until you leave it behind. Thank you to each and every one of you that has listened, advised, encouraged and pushed me. You know who you are, and if I try to mention you all by name I'll miss people out. <br /><br />So, now I'm back in Kampala, and it's a new year. My New Year's resolution? To appreciate what I have more, to appreciate the people I love more.<br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-38053159507552796562009-12-23T09:54:00.004+00:002009-12-23T10:33:26.229+00:00Brrrrrrrrrrrrrr!<div style="text-align: justify;">Well, I knew it would be cold back in Blighty, but snow?! A definite shock to the system. I was grateful for my big snuggly tracksuit bottoms, base layer and fleece, and even more grateful that I had taken them to Uganda with me despite cries of 'What do you need those for?' when I was packing them back in August. Coming through the arrivals door was the best feeling, three familiar faces beaming back at me, followed by 'You're not going out in public dressed like that!' It's good to know that nothing changes!<br /><br />My last week at work felt very long and was a mixed bag of challenges. I didn't go in on Saturday, choosing to spend the day doing some Christmas shopping and chilling with Adam. He's been in Mbale for the last few weeks so it was good to catch up and pretend to be a tourist for the day, hitting the craft markets after breakfast and bargaining for tacky African Christmas presents. The best thing I found was a massive wall hanging of the late Michael Jackson, badly sketched and even more badly printed, featuring, in Luganda, the timeless slogan of 'We will never forget you'. At 22,000 USH (about £8) I thought this was a bargain, but Adam disagreed, so it will not be adorning our dining room wall in the near future. Perhaps it will be in the sale when I get back...<br /><br />On Sunday I went to work, putting myself in theatre on labour ward. The washing machine in the hospital laundry was broken, and we had no sterile linen. One of the senior consultants managed to acquire some brand new linen from stores, but we were unable to use it until it had been labelled in gloss paint, allowed to dry and autoclaved. We started our list of 13 pending caesarean sections at 2pm, managing to do four and a normal delivery on the theatre table by 5.30. Linen continued to be a problem throughout the week, with the operating obstetrician going from labour suite theatre to gynae theatre, depending on where the current stock of linen was situated.<br /><br />I spent Monday sorting out the Midwife of the Month award, packing my stuff to take home and tying up last minute loose ends. One of our senior anaesthetic officers sadly passed away on Monday, which had an impact on morale amongst the rest of the staff. Work continued, albeit at a slower and less enthusiastic pace.<br /><br />Tuesday, Wednesday and Thursday were again spent on labour ward, in and out of theatre. I seem to be having a run of arm prolapses, badly impacted heads which I have needed to deliver by the breech and sub-total hysterectomies - the second one in a week was for a bad uterine rupture. We were due to present the Midwife of the Month award on Friday, however we lost a further 3 anaesthetic staff in a car accident on Thursday, ironically whilst they were travelling to their colleague's funeral. It was felt to be inappropriate to celebrate people's achievements while the department was in mourning and so it has been postponed.<br /><br />We had some farewell house drinks on Friday evening. It felt a bit strange that the surrogate family were heading off in different directions for Christmas, but we are all badly in need of a break from Kampala. On Saturday, my regular Boda Boda guy Alan was a bit miffed that I hadn't asked him to take me to the airport, and couldn't really understand why, carrying 25 kilos of luggage, I didn't fancy taking the 45km journey on a motorbike, opting for the far more sensible car. I managed to sunburn my left arm by hanging it out of the window, and arrived home sporting two totally different coloured arms and a very attractive watch strap mark, which I have avoided for the last 4 months! The flights were unremarkable for the most part, although I had a very luxurious 8 hour sleepover on the floor at Dubai.<br /><br />It's nice to be at home, nice to have the creature comforts that I have missed, nice not to have to sleep under a bed net and nice be with my family. But it's a bit of a shock to the system too, and I think that I am probably becoming more of a Muganda than I have realised. That said, you can't beat a pint of real ale in your favourtie pub in the world - The Crown Posada - and a kebab, which is exactly what we had last night. All I need now is some fish and chips, some pease pudding and a parmo...not necessarily at the same time either!</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-20070063581144085672009-12-10T14:28:00.014+00:002009-12-12T09:43:17.944+00:00So, a Hippo Walks Into a Bar...<div style="text-align: justify;">So, it's been a while since I've blogged. I've been crazy busy here, I'm not even sure where to start!<br /><br />Prior to the arrival of our colleagues from Liverpool I had a hectic few days on labour ward, spending a fair bit of time in theatre, delivering arm prolapses by the breech and other such exciting things. It has been a testing time for me recently with lots of difficult cases and difficult deliveries, not all ending in good outcomes. A lot of the time I feel very surreal and detached when they happen. I think this is a coping mechanism of sorts, but it's not something I'm comfortable with if I think about it too much. Many of the difficulties we experience here are due to resource constraints, meaning that it can sometimes be impossible to manage patients in a timely fashion, for example a woman waited for 24 hours to get to theatre for a third degree tear repair. We are extremely lucky in the UK to have the capacity to get women to theatre within 30 minutes of a decision to deliver.<br /><br />The team who had recently been to Liverpool presented their work, including a slide show of their touristic activities. A picture of Joy Acen freezing to death, wearing all of her clothes, standing on Crosby beach tipped me over the edge and I sat in the meeting blubbing away, feeling suddenly very homesick! Adam and I had a really nice Thanksgiving meal at a swanky restaurant, as Elizabeth abandoned us and went to Rwanda to celebrate. It was sedate but I was shattered so it was nice to chill out.<br /><br />On the Saturday I did 6 sections, battling through 5 power cuts. I will never complain about the theatre lights at home again! Thank goodness for Ketamine! I met Adam afterwards to watch the rugby and walking towards a restaurant, I fell down a storm drain. One minute we were bounding down the street and the next I was flat on my face, one leg down a massive hole and the other flat on the pavement, with no idea what had just happened to me! A few cuts and bruises but nothing too exciting.<br /><br />The team from Liverpool; Andrew Weeks, Carol Porter, Louise Ackers, Sarah Jarvis, Clare Fitzpatrick and Sarah Ryder arrived on 28th November. On the Sunday I excused myself from Labour ward to go to Mabira Forest with them for lunch. By the time we got there and ate, it was time to head back to Kampala, so we didn't get to appreciate the rainforest and wildlife. While there I got a phone call to say that someone had broken into my Mum's house and taken my car - he's currently missing in action. I'm gutted, but at the same time, it made me realise how much I have changed while I've been here. I think when you see as much severe disease and loss of life in difficult circumstances, material things become just things. More importantly, no-one was hurt.<br /><br />We headed back to Kampala, and had a barbecue at my house. I asked our Ugandan colleagues to contribute typical Ugandan dishes to the otherwise Muzungu style barbecue. I was not expecting someone to bring a box of fried grasshoppers - and neither were the Liverpool lot! Still, they were certainly 'interesting' to eat, although I don't think they'll be stocking them in the international food aisle in Tesco any time soon. We had a great night and a beer or seven. Sarah had carried an SOS parcel for me containing new clothes, M and S goodies, wellies for theatre, Turkish Delights, more Marmite than you can shake a stick at and amongst other wicked things, a Rubik's cube! Louise brought me some face and foot goodies so I will pamper myself when I get a chance.<br /><br />On Monday we hit the hospital, attending the morning meeting and the report from the Sunday which had been a bad day - including a woman jumping from the fifth floor window - and a shocking introduction to Mulago for our visitors. We then went on a tour of the hospital, starting with the main delivery suite. It's an overwhelming experience even just to be present there, and Clare and Sarah were no exceptions to the rule. They got a good overview of the hospital and by the time we finished the tour it was mid afternoon. We left for the evening and went out for dinner, while Andrew travelled off to Mbale on a bus.<br /><br />On Tuesday, the two Sarahs went up to Ward 14 and Clare went off to theatre. I was covering labour ward off and on, and went up to check that all was well on 14. A patient was being transferred down to the main labour suite and the girls were following her down as the baby was undiagnosed breech. We got down to labour ward and were there for around 30 minutes before a woman on the floor began pushing. <blockquote><span style="font-weight: bold;">How many Muzungus does it take to deliver a baby? </span><br /><br /><span style="font-style: italic;">One to deli</span><span style="font-style: italic;">ver (Sarah, medical student), one to direct the medical student (Sarah, Midwife), one to shout in broad scouse 'Go on sweetheart push down, right down in your bum, that's it, go</span><span style="font-style: italic;"> on, go on' (Clare, Midwife) and one to translate the scouse into Luganda 'Sendike Nyabo, se</span><span style="font-style: italic;">ndike!' (Me).</span> </blockquote>Anyway, the baby was delivered, followed by a swift flurry of three more deliveries on the floor in the corridor, and a quick round of neonatal resuscitation. On Tuesday evening we continued our culinary tour of Kampala, heading for Turkish washed down with a few more beers and a debrief. Wednesday morning was spent on labour ward again, and in theatre. In the afternoon we had a meeting to talk about the Liverpool Mulago Partnership and the way forward. I think it's a really worthwhile exchange and essential to drive initiatives and keep momentum, and change attitudes.<br /><br />On Thursday morning we did emergency skills training for 19 midwives from labour ward, covering cord prolapse, PPH and neonatal resuscitation. The session was a bit disrupted by the lack of space but it was enjoyable and I think they learned some stuff. In the afternoon, we visited an orphanage for children whose lives have been affected by HIV/AIDS. It was a really humbling and emotional experience. The orphanage houses around 30 children, and also pays the school fees for a further 90 from surrounding villages. We had a great afternoon, Clare and Sarah brought bubbles, sticke<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_3Vn9jxeZfD1Y3WahteVXS7eEfgQyt_Swqr_BrJjURnfNKKqEvml5bc0NvAod4lnXs51siv-aQ-1qIfesQXW5Fa2DF3vGVBQfT1vEOUNFonlXL-HK9K1FnuHmkCMRwNmYGQivAXV990U/s1600-h/DSC_0014.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 200px; height: 132px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_3Vn9jxeZfD1Y3WahteVXS7eEfgQyt_Swqr_BrJjURnfNKKqEvml5bc0NvAod4lnXs51siv-aQ-1qIfesQXW5Fa2DF3vGVBQfT1vEOUNFonlXL-HK9K1FnuHmkCMRwNmYGQivAXV990U/s200/DSC_0014.jpg" alt="" id="BLOGGER_PHOTO_ID_5414280651526307346" border="0" /></a>rs, cray<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqXZIT0f_CEbb1lrvRQlU89eu-nRzYFqTDxlFv2BxAzxL_Zw6Puhkg4ayLGp-yueN1xkiI0qwBF14AdZVic7yJ5wD2yweZ42e2Hs8fb-Zl4CZ60xGG6qS1gdbSOSTL-FFgy_cW_TGXK7k/s1600-h/DSC_0060.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 200px; height: 132px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqXZIT0f_CEbb1lrvRQlU89eu-nRzYFqTDxlFv2BxAzxL_Zw6Puhkg4ayLGp-yueN1xkiI0qwBF14AdZVic7yJ5wD2yweZ42e2Hs8fb-Zl4CZ60xGG6qS1gdbSOSTL-FFgy_cW_TGXK7k/s200/DSC_0060.jpg" alt="" id="BLOGGER_PHOTO_ID_5414280668269212754" border="0" /></a>ons, colouring books, felt tips and sweets. My SLR <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT4bjZsqkYpfnRDUv2h9tkofPL9-UCeOCxr0CPf2B5xc_ADkEaNkAKa8IZyom2t0yJh3bTFSCq-6WUV7ty9nKWEXsCt8YB5HD4RD58RlzQiHofhau9CvhLe0qyhAVX-xbSIil7taDiyv0/s1600-h/DSC_0032.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 200px; height: 132px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT4bjZsqkYpfnRDUv2h9tkofPL9-UCeOCxr0CPf2B5xc_ADkEaNkAKa8IZyom2t0yJh3bTFSCq-6WUV7ty9nKWEXsCt8YB5HD4RD58RlzQiHofhau9CvhLe0qyhAVX-xbSIil7taDiyv0/s200/DSC_0032.jpg" alt="" id="BLOGGER_PHOTO_ID_5414280656250601058" border="0" /></a>camera was kidnapped by one of the boys who had a great couple of hours wandering round taking pictures, with me following closely behind, petrified he was going to drop it, but he was so content I didn't have the heart to take it off him. By the end of the afternoon the kids all looked like they had some sort of pox, having put the stickers on their faces, the bubbles had been used up, with a few kids getting soap in their eyes, many having learned to say 'That's lush Clare' in a scouse accent and there was not a flat surface that hadn't been covered in crayon and felt tip! We decided to walk to the village to buy sodas for everyone, and Enid the orphanage manager said she was sending two strong kids with us to help carry the crates back with us. We ended up feeling like the Pied Piper, with about 15 kids in tow, and carried two of the babies who had fallen asleep on the journey! I did a couple of medical assessments, one on a child with asthma and another child with a possible appendicitis. All in all it was a really rewarding day. We had a big meal in the evening at Khana Khazana, where the curry was so hot that Clare said she was 'sweating like a glassblower's arse', which she then had to explain to Joy, the Ugandan midwife, eliciting loud cackles from their side of the table. Avner, who has recently moved into the house, and is a lawyer from New York came down and joined us with Elizabeth. A thoroughly good night all round, and the Ugandan midwives got a doggy bag - also an unfamiliar expression - to take home with them.<br /><br />Myself, Clare and Sarah then went off to the Red Chilli Hideaway ready for our safari trip to Murchison Falls. We had a noisy night in the dorm there - with me apologising profusely for the budget accommodation - and an early start the next morning. Naturally we ended up on a truck with two Finnish women who talked literally non-stop for 7 hours all the way there, and one angry scouser with a migraine. After a long journey up there, we got to the top of the falls as the heavens opened, Claire having been eaten alive by mosquitoes. Walking up to the top of the falls was an awesome experience, the power of the water was immense. After taking some photos, and helping two stuck trucks out of the mud, we made it to the camp, where we stayed in semipermanent tents, falling asleep to the sound of scavenging warthogs.<br /><br />We started the next morning with a game drive, crossing the river as the sun rose. We were greeted on the other side by a breakfast robbing baboon, before driving off through the bush in search of the big five. We found giraffes very quickly, then elephants. I will never forget the abundance of wildlife that live alongside each other in that space. We then happened upon a lioness who was sitting in a tree which seemed a bit bizarre, until we realised she was watching an Oribi - a small antelope. She climbed down from the tree, stalked across the grass, and in one swift stealth move, grabbed it by its throat and killed it. An incredible and rare thing to see, we felt blessed. After finding some more elephants, buffaloes, giraffes and crested cranes, we headed back to the lodge for lunch. In the afternoon we took a boat launch to the base of the falls, spotting hippos, crocodiles and kingfshers, drinking Nile on the Nile, catching some rays and chilling out. For three hours, Sarah didn't even have to evacuate her bowels! In the evening we sat in the bar, in a roaring thunderstorm, when in walked a hippo. Well, into the beer garden at least... incredible. It shuffled round a bit, sniffed the ground and then buggered off back to the river!<br /><br />On Sunday, we went to Ziwa Rhino sanctuary, tracking the rhinos on foot and getting within 5 metres of a male and female. It was a gobsmacking, and slightly pant browning experience, but a real experience. We got back to Kampala, exhausted but really happy.<br /><br />On Monday we threw our noses back onto the grindstone, working on adapting the Maternity Early Warning Score for Mulago. Amusingly, we're going to call it AMEWS. Using the magic whiteboard that Clare brought with her, we constructed charts using colour coded pens to stick on the wall in the recovery area. On Tuesday we bumbled round on labour ward, putting the AMEWS stuff up on the walls, creating a flurry of excitement. We then arranged to have two blood pressure machines which had been bought for the hospital by two friend mounted on the wall. I took a trip to the workshop, bracing myself for the long paper trail that's usually involved in these things, found a guy called Robert who came back up to labour ward with me. He drilled holes in the back of the machines that afternoon and mounted them onto the wall the next day. I was amazed! We put one up in the post-op recovery room and one in the admissions room.<br /><br />Within around 30 minutes of Robert finishing the work, a woman came in with a massive antepartum haemorrhage and a stillbirth, bleeding profusely. We couldn't get her into theatre immediately and there was no blood available, so Sarah and Clare monitored and resuscitated her with fluids in our newly created room, using the AMEWS chart on the wall to keep track of her condition. We managed to get her into theatre and delivered the baby by caesarean, but unfortunately had to do a subtotal hysterectomy. She eventually got blood, and thanks to a good team effort is doing fine.<br /><br />On Thursday morning we ran our second training session, this time on the midwifery led unit, Ward 14. 15 midwives attended, many coming in on their day off, and we trained them on cord prolapse, shoulder dystocia using a Pringles tube, neonatal resuscitation and postpartum haemorrhage. We had a great morning, the staff were really enthusiastic and asked lots of questions. It was good to try it out, with the midwives rotating around each skill and everyone having a go at hands-on. In the afternoon we went to the pub to work on some guidelines and stayed for the quiz, which we were dreadful at, but it was great to have an injection of scouse fun and humour into the evening, Clare at one point taking the mike from the MC and singing at the top of her lungs.<br /><br />Yesterday morning I was in theatre, and in the afternoon after running a flat baby across to special care attended the Hospital Christmas party, a terribly formal affair to begin with. I was shattered and left early but I believe it turned into the usual drunken debauched evening that you would expect from a hospital bash. I left with a bag of goodies, including the stock of Peperami that Sarah had brought with her in case of famine... I think the dog will end up eating them. Gutted that the girls have left, it was great having them here to help keep me sane at the point where I was becoming more exasperated than I have ever been. Still, it's only a week until I head home for Christmas. I'm ready for a break.<br /><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-15421336717302699332009-11-25T18:17:00.004+00:002009-11-25T19:53:55.984+00:00The winds of change...<div style="text-align: justify;">It's been a funny old week and a half. After the exhaustion of painting the labour ward, I was quite relieved that last week ended up being, for the most part an 'admin' week. That's not to say that I sat on my bum, in fact far from it. I spent time working on a funding proposal, attending a brainstorming session on how to improve the department so that it is more effective and efficient, with a direct impact on maternal and neonatal morbidity, doing a bit of teaching and helping to facilitate a course for midwifery staff aimed at empowerment, <span class="blsp-spelling-error" id="SPELLING_ERROR_0">teambuilding</span> and management of normal labour.<br /><br />There's a huge amount of enthusiasm in the department at the moment, to change the way things are done. We're talking about everything from strategies for <span class="blsp-spelling-error" id="SPELLING_ERROR_1">decongesting</span> labour ward, setting up specific clinical areas and concepts to changing the way all staff work, initiatives to encourage teamwork and so on. A lot of it is a <span class="blsp-spelling-error" id="SPELLING_ERROR_2">pipedream</span> at the moment, but it's an achievable <span class="blsp-spelling-error" id="SPELLING_ERROR_3">pipedream</span>. I have no doubt about it. I can feel the process gathering momentum, and it feels like the winds of change are starting to blow the tumbleweed out of the department.<br /><br />The other stuff I've been busy doing, is preparing for the invasion of Liverpool Women's Hospital - something I'm really looking forward to. There are 6 people coming out here next week. The group who have recently gone to Liverpool from <span class="blsp-spelling-error" id="SPELLING_ERROR_4">Mulago</span> had a great time, and have come back full of ideas and drive, to improve things on labour ward. The follow-up visit from Liverpool will add to these ideas. One of the things we're hoping to do while they're here is to set up a practical emergency skills training morning for the labour ward midwives. If this is successful, I hope that it can become a department wide, regular thing. It would be a fantastic opportunity to get doctors and midwives training alongside each other, and would help to foster the team approach to patient care that we badly need.<br /><br />In between all of this I found myself on labour ward off and on, getting stuck into emergencies, while finalising timetables and the like.<br /><br />Sunday was the Kampala Marathon. Since my good mates here are a bit weird, and like running for fun - I'm the kind of girl who would only run if I was being chased by something likely to kill me - I was duty bound to go and shout for them. On the face of it the Marathon seemed well organised. I decided to go to the finish line around the time I was expecting Elizabeth to finish the half marathon. Which was too bad, as it would seem that everyone running the half marathon went the wrong way and ran a route around 3 miles shorter than it was supposed to be. That coupled with the fact that competitors were hopping on the back of <span class="blsp-spelling-error" id="SPELLING_ERROR_5">boda</span> <span class="blsp-spelling-error" id="SPELLING_ERROR_6">bodas</span> to improve their times suggested that all was not as legitimate as you might expect. Justus - who lives in our compound - and I stood at the finishing strait. It was a brilliant people watching experience. The vast majority of people doing the half marathon and 10k, were evidently not serious runners, but people really doing something for themselves, for a sense of achievement. Some women ran in traditional dress and sandals, one guy ran it in socks, a number of people with significant disabilities, including one <span class="blsp-spelling-error" id="SPELLING_ERROR_7">Batwa</span> lady with severely bowed legs and another lady on crutches, competed. It was a truly inspiring morning, and for about 37 minutes I seriously contemplated taking it up as a hobby.<br /><br />We were waiting for Adam to finish the marathon. They started to dismantle the barriers. And people started to walk across the finishing strait. And they opened the roads. And the cars came down the finishing strait. And there was still no sign of him. Or any other marathoners. Eventually in the distance, his lanky frame came lumbering towards us,, dodging pedestrians and traffic with a look of absolute exhaustion on his face, crossed the finish line - which by now we were standing ON, with the official photographers - and exclaimed that it was 'the most pain I've ever been in'. None of the proverbial there, Holmes. And then he got on a bus for 6 hours. Nutter.<br /><br />On Monday I had a major victory at the passport office. Finally, I've been granted a work visa. That's not to say it was a stress free visit. Oh no. When you apply for your work visa, you have to go back after 7 days to see if your file number is in the book. What that essentially means is that it takes a week for your file to cross a corridor, and someone writes a (sequential) number on it and records it in a book. You then return and have to trawl through a list of numbers to find yours - which is not easy when they're all similar. You then cross the courtyard to 'room 2', where you are then advised to look for your number in another book. Unsurprisingly, your number will not be there. Nor will it be there the next 5 times you go back, even though each time you've been, you've asked the 'nice' lady behind the desk and she's told you 'next week'. <br /><br />Needless to say that when I returned on Monday, my number still wasn't there, and decided to check with the 'nice' lady behind the desk, as I was concerned that the file may have been lost. The 'nice' lady behind the desk, must have gotten bored of being deliberately obstructive, told me there was no way it could be lost and sent me to speak to a man in 'room 10'. The man in 'room 10' then sent me back to the place where I'd originally picked up my file number, to find out what date the file had left this office, presumably in the direction of 'somewhere across the courtyard'. Once I had this, I went back to him. He looked through several lever arch files, several times, huffing and puffing. I was sitting there thinking about my next move and whether I was going to be looking for locum work back on sunny <span class="blsp-spelling-error" id="SPELLING_ERROR_8">Merseyside</span> in a few weeks. Eventually he located my file number, stated that the work visa had been granted and it was in the book. So I told him that it wasn't. At this point I was seriously getting worried. He wrote something illegible on a post-it note, to take back to the 'nice' lady behind the desk. She barked an order across to a man who fumbled through piles and piles of similar looking and chaotically organised files, and exclaimed that it wasn't there. The 'nice' lady looked at me, semi-sympathetically, and stated that my file 'must be lost'. She must have sensed my frustration and got someone else to double check, which was great, as the file had been there all along, and probably for the last 6 weeks. So I handed over my passport, and I have to go back next week. It feels like the kind of scenario <span class="blsp-spelling-error" id="SPELLING_ERROR_9">Swann</span> and Flanders would write a song about...<br /><br />So far this week I've been on labour ward. Yesterday I kicked off my shift with a rapid forceps delivery in the admission room on a woman with a massive bleed, and a fetal <span class="blsp-spelling-error" id="SPELLING_ERROR_10">bradycardia</span> of 40 beats a minute. I realised I was doing something out of the ordinary when I asked the midwife to bring me a pair of forceps, to which the response was 'What, artery forceps?'. We shuffled the examination couch round, I ran and grabbed some stuff, and in the smallest space I've ever done an instrumental in (sitting on top of a dustbin), delivered the baby who came out screaming (thankfully). What I didn't realise until the patient stood up was that she was around 4 feet tall with a significant <span class="blsp-spelling-error" id="SPELLING_ERROR_11">kyphosis</span>. Forceps are not commonly used here, and when they are it tends to be by the old school consultants, but the vacuum extractors don't work. It's a skill I hope to pass on while I'm here. The range of pathology you see in one shift here is quite something, and no two shifts are ever the same. The rest of yesterday and today were surprisingly calm by <span class="blsp-spelling-error" id="SPELLING_ERROR_12">Mulago's</span> standards, and I spent quite a bit of time in the admission room teaching the interns. And I have finally mastered the trick of doing an ARM at 2cm with the plastic end of a needle!<br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-54382819869619396202009-11-15T13:29:00.010+00:002009-11-15T20:50:13.761+00:00It's no Michaelangelo....<div style="text-align: justify;">So it's been an industrious couple of weeks, where lots has been a achieved, decided and attempts have been made - although not necessarily successfully - to implement. Following fun times on Ssesse, my week was filled with ward cover on the antenatal ward, working very hard on the triage documents and getting them circulated onto the labour ward, trying to train the midwives in their philosophy and usage and then realising that without getting a critical mass of people on board, triage will not succeed. One of the problems is that where the midwives are using the instrument, the doctors sometimes aren't, the rooms are sometimes hijacked by patients who see an empty bed and want to lie on it, or there are simply not enough staff to run it. I've already had some decent feedback on the documents though, mostly positive, and we need to do a little bit of fine tuning and more intensive training and supervision.<br /><br />Last Saturday, myself and some very generous volunteers trundled off to the labour ward armed with buckets, rollers and tins of paint to freshen up the high risk end, which was in desperate need of painting. It was an eye-opening experience for all of the people who volunteered. The labour ward was heaving, as ever. We decided to paint the smaller rooms first, as the large room was simply too full and the patients were too sick. Opting for an oppressive shade of forest green for one of the rooms, Adam, Jill, Julia, Maureen and I set to work masking the skirting boards and windows, mixing the paint in a futile attempt to make it lighter and the slapping the paint onto the wall. I say slapping as it had previously been painted with what looked suspiciously like gloss, making it difficult to get any purchase. Meanwhile, Elizabeth, Sungo, his girlfriend and their 8 month old daughter tackled the admission room and the neonatal resuscitation room painting it a slightly more pleasing shade of baby blue. In my journeys from the green room to the blue rooms, I got involved in more obstetrics than I'd planned to, resuscitating two babies and sending one woman to theatre. The experience, understandably, was a bit too much for some of our volunteers and by the end of the afternoon we were down to 4. We wrapped up around 6, went off and had a debrief involving some Mezze and wine, and went on 'debriefing' until shortly before 4am.<br /><br />On Sunday I attended a wedding introduction, where I was required to wear traditional dress in the form of a hot pink Gomesi, complete with huge shoulders. Apparently I was 'very smart', although I'm not entirely sure about that, especially as my housemate's Ugandan girlfriend was nearly sick laughing when she saw me in it. It was a privilege to be invited and I was made to feel very welcome, given heaps of food and had the whole thing explained to me as it was happening.<br /><br />Returning to work on Monday, our Forest Green was looking a bit patchy, and whilst we weren't aiming for a decorative masterpiece, we were still aiming for something to be proud of. The day on labour ward was consumed with seeing and assessing admissions and heading into theatre. We had a lot of sections pending when we arrived, and so managed to get the Oncology list halted so that we could utilise the gynae theatre. There is only one theatre on labour ward itself, so getting theatre space is often at the expense of the elective lists. Got home exhausted around 8, ate and crashed. Spent all day in theatre on Tuesday, this time entirely in gynae theatre as the anaesthetic machine in labour ward theatre was not functioning. We managed to get 5 sections done, including an impending rupture - an impressively oedematous bladder and a tight Bandl's ring were found, but fortunately no hole! Babies all did well, fortunately. On the ward round later one of the patients who didn't like the idea of being examined and wasn't getting a response from the Ugandan doctors looked me in the eye and wailed 'Muzunguuuuuuuuu'. The response from the team was that, 'You're clearly closer to God than we are'.<br /><br />Wednesday I devoted to spending on the high risk side and just moved from patient to patient, pushing in fluids, dealing with PPH's and unrecordable blood pressures, doing assessments and running round organising. The highlight of the day was doing a breech extraction on an undiagnosed premature breech presentation, undergoing induction. I listened in and heard a bradycardia, found an unmistakeable set of testes coming out first and proceeded to deliver the baby according to what I'd learned on the ALSO course and from reading the MOET manual. Baby came out in poor condition, but picked with a few cycles of bag and mask ventilation and is happily screaming away on SCBU. My final patient of the day came up to me as I was leaving labour suite, grabbed hold of me with a vice-like grip around my hip, stated 'My baby is coming now, now', to which I responded 'What, now, now'? as she dropped to the floor next to the admission desk and pushed the baby out before I could get a pair of gloves. After yet another journey to special care I got home buzzing, for the first time in a while with a wonderful feeling of achievement knowing that I had directly saved three lives. Not often I ever got to say that back in the NHS.<br /><br />Thursday was a day of admin and teaching, meeting Samir who was over from Liverpool on a cricket coaching trip, followed by the pub quiz, and Friday I was spent helping fill out a grant application for money to set up an obstetric HDU, which is badly needed. On Friday evening, walking through the go down with Adam to buy Avocadoes, he was on one side of the open drain inspecting the produce and I was on the other. He didn't think the avocadoes were quite ripe enough, but the stall holder was insistent 'THEY ARE READY!'. Minding my own business a well dressed woman came up to me and said 'Do you love Jesus?'. Taken aback somewhat at the lack of introduction before such a personal question I responded 'Everyone loves Jesus', in a 'What a ridiculous question' tone, whereupon she said good, and strutted off. I have no idea what her reaction would have been if I'd said something else!<br /><br />Yesterday the surviving awesome foursome went back to labour suite to complete our stealth painting operation. We actually achieved a hell of a lot, completing the green room and then the larger room. We were painting around 8 women in various stages of labour and states of health and also happily plastered the walls with blue paint while the ward round, including women brought in from the corridor was conducted beneath us. We spent a large proportion of our day moving women from one corner of the room to another, but we managed to get two coats of decent looking paint on the walls. Our only casualty of the day was when Adam fell off the stool he was standing on the reach the ceiling, and painted a patient's forehead blue. I don't think she knew what had hit her. The midwives were great at shepherding women into 'safe zones' to prevent them being splattered. Some of the less uncomfortable patients also mucked in helping us to move bags, bedpans and all sorts. We had a really satisfying day! One more room to go... Any volunteers?!</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-27842762460484756692009-11-06T17:27:00.008+00:002009-11-06T22:56:13.386+00:00Fathoming Facts and Figures<div style="text-align: justify;">Today I went to the launch of the White Ribbon Alliance for Safe Motherhood in Uganda. I want to share some numbers with you, quoted to us at the meeting, that might give you an idea of the scale of the problem health care providers are facing here...<br /></div><br /><div style="text-align: center;"><span style="font-size:180%;">Worldwide</span><br /><span style="font-size:180%;">Every one minute</span><br /><br /><span style="font-size:180%;">380 </span><br />women become pregnant<br /><br /><span style="font-size:180%;">190</span><br />women face unplanned or unwanted pregnancies<br /><br /><span style="font-size:180%;">110 </span><br />women experience pregnancy related complications<br /><br /><span style="font-size:180%;">40</span><br />women have unsafe abortions<br /><br /><span style="font-size:180%;">1</span><br />woman dies<br /><br /><span style="font-size:180%;">In Uganda</span><br /><br /><span style="font-size:180%;">435/100,000</span><br />is the maternal mortality ratio<br /><br /><span style="font-size:180%;">76/1000</span><br />is the infant mortality ratio<br /><br /><span style="font-size:180%;">29/1000</span><br />is the neonatal mortality ratio<br /><br /><span style="font-size:180%;">38% </span><br />of infant deaths occur within one month of life and most of these will occur within the first 24 hours<br /><br /><span style="font-size:180%;">1.2 million</span><br />pregnancies occur per year<br /><br /><span style="font-size:180%;">6.7</span><br />children are born per mother<br /><br /><span style="font-size:180%;">5.1</span><br />is the number of children that women, on average, would prefer<br /><br /><span style="font-size:180%;">23%</span><br />of pregnancies in Uganda are in women between the ages of 15 and 19<br /><br /><span style="font-size:180%;">5.5</span><br />months is the median gestational age for initial antenatal visit<br /><br /><span style="font-size:180%;">$39</span><br />is the amount per capita spent on healthcare in Uganda<br /><br /><span style="font-size:180%;">$2434</span><br />is the amount per capita spent on healthcare in the UK<br /><br /><div style="text-align: justify;">The leading causes of maternal mortality in Uganda are haemorrhage (26%), sepsis (22%), obstructed labour (13%) and unsafe abortion (8%). The leading causes of neonatal mortality are birth asphyxia (27%), low birth weight <1000g (25%), respiratory distress (17%) and prematurity (14%). I think that the numbers speak for themselves.<br /><br />I urge you all to consider joining the White Ribbon Alliance to help lobby for change by working with grassroots people, communities and healthcare workers. You don't need to make any monetary donation. This organisation has already made a huge impact in other developing countries, and really could make a difference here in Uganda... I've put a link in the essential info section. </div><br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com0tag:blogger.com,1999:blog-7512002222520024180.post-26666782810398224522009-11-02T17:50:00.017+00:002009-11-05T14:52:53.205+00:00Paradise LostThey say that no man is an island. Well I met someone this weekend, who is his island. Lives, breathes and sleeps it.<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzYwuRJHfKtc3SPCP_TvKwT7VQgMMPFuvPn8sQvujedSa7sNkK6C0lTLBsKKIYzgJedWHPalc7Yxg8mLDrGEWAUkukNys3fDJR-lHLmR4lTR7BSXkEMetFgTD1fVtn1O6stbJN4US7GAk/s1600-h/DSC_0010.jpg"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 132px; height: 200px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzYwuRJHfKtc3SPCP_TvKwT7VQgMMPFuvPn8sQvujedSa7sNkK6C0lTLBsKKIYzgJedWHPalc7Yxg8mLDrGEWAUkukNys3fDJR-lHLmR4lTR7BSXkEMetFgTD1fVtn1O6stbJN4US7GAk/s200/DSC_0010.jpg" alt="" id="BLOGGER_PHOTO_ID_5400205429979357586" border="0" /></a><br /><div style="text-align: justify;"><br />Elizabeth and I decided that it was high time we got out of Kampala. Banda Island, and the king of its castle, Dom Symes had been recommended to me by several people. It's the stuff of legends, the kind of place that people go to for three days and end up staying for three months. Banda is one of the smallest of the Ssesse Islands and 36 km off the coast of Entebbe as the crow flies. Or as the fishing boat chugs. There was an immense amount (read, a text message was sent) of planning involved, Dom sent us a shopping list for 2 loaves of bread, a kilo of green beans, some bacon and a tin of blue gloss paint. I knew from the outset that we were not in for an average weekend desert island break.<br /><br />We set off from Kampala on Friday afternoon, and arrived at Kasenyi fishing village with instructions on who to speak to, and advice on avoiding the hooligans. We found our boat, with reassurances of 'It's leaving now, now', and were whisked on board. By this I mean that we were swept up off the beach, into the arms of our respective porters who waded through the water and dumped us in the boat. Along with 30 other people. We got a prime seat on top of the vessel, so it was just as well that the water was calm. Fortunately we had come prepa<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLSMdRxJNKuDz4oIsq5s1FkZIm28gQlVr-soQK6JOsLiBkx46jemeEhtOaNEwP5LuUdhAUlukb-dt2Ptc4hyphenhyphenVa8asVx-hgeLb3gugxeKnk9WQ5Q0XxswG3zzAzRG38sVUXEi3X-gRykNU/s1600-h/DSC_0021.jpg"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 200px; height: 140px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLSMdRxJNKuDz4oIsq5s1FkZIm28gQlVr-soQK6JOsLiBkx46jemeEhtOaNEwP5LuUdhAUlukb-dt2Ptc4hyphenhyphenVa8asVx-hgeLb3gugxeKnk9WQ5Q0XxswG3zzAzRG38sVUXEi3X-gRykNU/s200/DSC_0021.jpg" alt="" id="BLOGGER_PHOTO_ID_5400205437719605554" border="0" /></a>red with essential provisions... a 3 litre box of wine (when empty I believe the bag makes an excellent flotation device) and an empty water bottle, just in case the wine fired off our bladders' parasympathetic nerve supply! 'Now, now' is a phrase that is best interpreted with caution. In this instance 'Now, now' meant in 90 minutes. But still, we at least got a good seat. Sitting in the port was a feast for the camera, men carrying extraordinary loads through the water, impossibly loaded boats, masses of birdlife. Eventually we up-anchored, cast off and were sailing. No sooner were we away from shore than th<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5kXADj3TirewFLffLlKm1Z8VHK_Ex6LbUCsXkOuWZeuNbs_gmaaW-if8lhnn0-y9rLkt_M23C1ST6OEz24BymIPzHxf_Z_NiR871hkTGoZnSKPwsSNqdHnu7ODvT643KNPu9ldRwo5VU/s1600-h/DSC_0051.jpg"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 200px; height: 132px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5kXADj3TirewFLffLlKm1Z8VHK_Ex6LbUCsXkOuWZeuNbs_gmaaW-if8lhnn0-y9rLkt_M23C1ST6OEz24BymIPzHxf_Z_NiR871hkTGoZnSKPwsSNqdHnu7ODvT643KNPu9ldRwo5VU/s200/DSC_0051.jpg" alt="" id="BLOGGER_PHOTO_ID_5400205439964881378" border="0" /></a>e wine was opened. We chugged along for 3 happy hours, towards an island adjacent to Banda. As land came into view Elizabeth insisted that a 'short call' (guess what that is) was necessary, much to the amusement of our other, mostly male, passengers. Hangin' on until Banda, was not an option. Little did we know we would be required to change boats - hilarious in itself, given that I'm a natural gymnast... I spilled some wine in the bottom of the boat to cries of 'Eh! Muzungu, what is that?', 'Er, it's Blackcurrant Mirinda, obviously'.<br /><br />So on transfer to the smaller boat, with its sputtering engine, we cut the top off the bottle. Elizabeth upset the other passengers by trying to move to the front of the boat to do her 'short call' in private, to cries of 'Muzungu, are you trying to drown us?!'... It turns out that none of our fellow passengers could swim, and didn't appreciate a rocking boat.<br /><br />At last, we spotted Dom on the beach, with his seven fostered dogs, beer in hand, awaiting our arrival. Land was a welcome sight. 'Beer anybody?', were welcome words. The rest of our evening was spent round a beach bonfire, drinking beer and overindulging in Dom's unique way. The food was great, a tasty paella. Tasted even better on the way back up. Not one to let the side down however, after 30 minutes of island air, I was ready to start again. We moved to Dom's castle, a feat of civil engineering that would baffle that bloke off 'Grand Designs'. By rights, it shouldn't be standing. I asked Dom whether he had experience of architecture. His answer was 'No, I sat in my chair, got stoned and it sort of came from there. I built whatever came into my head, what didn't work fell down, and I bought more cement and tried again. I used my knowledge of the stars from sailing and some of my mining experience, but most of it came from inside my head'. Astonishing. Dom is an eloquent, intelligent bloke, who loves winding people up and is therefore deliberately on the other side of the debate, almost always. After discussing the finer points of his recent brush with the law, how many children he may or may not have and his views on the 'African problem' we decided to retire to our cottage. This coincided with the point at which Dom was unable to stand from his chair, and then unable to sit back down in it unaided. Which I guess is always a risk of drinking home made Waragi from a plastic green and white striped kettle.<br /><br />The next morning, I woke up to the sound of the water lapping on the shore, sat on the beach front porch and read my book. At what we figured was probably a reasonable hour, we stumbled across to the castle for a simple but tasty breakfast of coffee, Marmite on toast and fresh pineapple from the island plantation. Once this had been polished off, Dom announced that it was Beer o' Clock and that there were to be no exceptions to this rule, especially since we had had no Waragi in our coffee. Beer o' Clock was swiftly followed by lunch of freshly caught Tilapia, the green beans and bacon we had carried, a delicious fresh salad and the obligatory Ugandan stewed beans. And more beer. Then it was siesta time, which for me meant going out for a walk with the dogs, who accompanied me around the island checking for snakes and the presence of Herbert, the solitary resident hippo. Banda is literally teeming with life, every inch of it moves. I spotted the only Paradise Fly Catcher on the island, and had a thoroughly pleasant afternoon pottering, chilling, reading a book and listening to music. We had a brief boat trip round to see the island's monitor lizards and then went back home to catch the sunset from the castle roof. Wearing our minging Hallowe'en dresses from Owino Market.<br /><br />We were treated to a stunning sunset, good conversation, luke warm beer etc. Dom regaled us of the time when he first arrived on the island, sampling every hallucinogenic plant in his new domain, and lost several weeks. We talked about travel, life, you name it (especially if it's controversial). Clim<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixjhmqocDJDne9CNra2PbyQUsSPOk0WSl5Ce6d2ONigfKin908QUBuj2QFwYIoSNJVVqPalipT33xuKB2rI0yFOxRw3HrpfpYbcFeri-gvUmW4jMe2A08v-myyHBauLHHhQYZLMH9LWRA/s1600-h/DSC_0186.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 200px; height: 132px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixjhmqocDJDne9CNra2PbyQUsSPOk0WSl5Ce6d2ONigfKin908QUBuj2QFwYIoSNJVVqPalipT33xuKB2rI0yFOxRw3HrpfpYbcFeri-gvUmW4jMe2A08v-myyHBauLHHhQYZLMH9LWRA/s200/DSC_0186.jpg" alt="" id="BLOGGER_PHOTO_ID_5400207065178879666" border="0" /></a>bing down from the roof before it got dark, we headed for dinner on the beach, equipped with a kettle full of Waragi. We sat and drank, and drank, and drank. At one point Dom sneezed, so drunk that he fell off his chair, couldn't get up off the floor and we couldn't help him for laughing. Eventually he rolled over and crawled back to his perch. At this point in the proceedings he announced we should go and find the hippo. When we asked Dom how we were going to find him, he licked his right index finger, thrust it in the air, determined the direction of the wind and proclaimed that since he couldn't smell Herbert, he must be 'over there' pointing in the vague direction of the centre of the island. 'I'm in the perfect state for tracking the hippo'. I felt that I was in the perfect state to avoid being trampled to death and suggested another glass of Waragi. So the hippo was allowed to sleep undisturbed. We headed to bed around 4.15am. It took Dom 45 minutes to get home, which was all of 25 metres away. A testament to the potency of his home distilled poison, and the difficulties of walking in sand.<br /><br />The next morning, the weather had turned, and it had evidently rained very heavily, since we were greeted by a slightly soggy Dom, who had missed his mattress, and slept on his bedroom floor with the windows wide open. Breakfast was eaten, and there was a point at which it looked like we'd be staying another night as the heavens opened again, and the thunder crashed across the water. We sat in the dining room with the bats - yes bats - waiting for a sign. The only sign we received was that the boat was coming to get us, regardless of the lashing downpour. No point being a fair weather sailor... This small boat took us to... the other end of Banda. We were offloaded, <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqdbMS7bntkdmTHqz7kuCWwkBPPx_qY3HyowhlPTRtkTXCTOuap-6rXnNu_EqrUlnumPdgkBiZHK9X07ep2xdSiuG1RDEEIb28jPSZ6UFXQypY8cGrAPiNhNr6Il_-CG3vrQG-q6EQuSA/s1600-h/P1030243.JPG"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 150px; height: 200px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqdbMS7bntkdmTHqz7kuCWwkBPPx_qY3HyowhlPTRtkTXCTOuap-6rXnNu_EqrUlnumPdgkBiZHK9X07ep2xdSiuG1RDEEIb28jPSZ6UFXQypY8cGrAPiNhNr6Il_-CG3vrQG-q6EQuSA/s200/P1030243.JPG" alt="" id="BLOGGER_PHOTO_ID_5400205455187789874" border="0" /></a>parked on a bench and left there, unable to communicate with any of the local populus and with no sign of the weather improving. After an hour and a half, and a slightly unnerving encounter with the village madman who sat and shouted at us to a soundtrack provided by the local churches cacophonic choir, our bags were picked up to a grunt of 'Tugende', just at the point where the rain reached its heaviest. Our boat, essentially looked like a floating rubbish tip, and the reality was not much different. We were thrown on the boat, left to find a sheltered position amongst crates of empty soda bottle, jerry cans, bags of flour and sugar, crawling beasts and fellow passengers. It was not a happy passage. The lake was choppy, several times we listed just a little bit too far starboard and I spent a significant amount of time trying to decide which of the random items I was sitting amongst would make the best float. The sun eventually came out and by the time we reached the mainland we were dry. I have never been so glad to get on a Matatu.<br /><br />So was Banda paradise? If paradise consists of a mixture of beauty and eccentricity, beasts large and small, and a plastic kettle full of Waragi, then yes.<br /></div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com1tag:blogger.com,1999:blog-7512002222520024180.post-58324133003690512802009-10-28T13:39:00.009+00:002009-10-28T14:18:33.404+00:00Uncomfortably Numb<div style="text-align: justify;">I really wanted to update the blog this weekend. I couldn't do it. Not because I didn't have anything to write, in fact quite the opposite. I couldn't find the words.<br /><br />Last week I spent a bit more time on Oncology. Again, there was a lot of advanced cervical cancer. I'm beginning to really get to grips with examination under anaesthesia and am trusting my hands more and more. There was no theatre list this week, as we didn't have a specialist available to cover. This was a shame as I have not yet seen any oncology surgery done here.<br /><br />So why the difficulty in writing? I want to describe to you what I am experiencing, to present the bare facts, but I don't want either myself, or more importantly the unit to be misrepresented. Mulago is probably the biggest maternity unit in the world. The unit delivers more than 30,000 babies every year. The hospital was built in the 1960's, and the labour ward was designed to take 20 women at a time. There is a miwife led unit on site, which delivers around 8,000 babies, but even so, if you do the maths you can see that the numbers don't add up. Women are referred from clinics on the outskirts of Kampala, and from farther afield. They can be in labour for several days before they are referred to, or reach Mulago. Women who have had caesareans in previous pregnancies often don't attend hospital soon enough, coming in when the pain is too much to bear with an inevitable uterine rupture. Mulago labour suite deals with whatever comes through the door, just like any other labour suite. The difference here is that often, by the time these women arrive, the outcome is inevitable and beyond prevention. This is frustrating for all involved. The midwives and doctors are phenomenally skilled, resourceful and innovative people, who work bloody hard in extremely difficult conditions with limited resources. I admire and respect each and every one of them.<br /><br />I spent Friday night on the labour ward. It was, without doubt the hardest shift I have ever done. I witnessed a huge variety of pathology that I have not seen before. The volume of work was overwhelming, even with two theatres running simultaneously. We walked the length and breadth of the hospital looking for blood. The house was heaving. By Saturday morning we were beat. Totally beat. I couldn't have slept even if I had wanted to. My head was full of mixed emotions, disbelief, anger, frustration, sadness, and a very uncomfortable and unfamiliar feeling of numbness and I suppose relative immunity to what I had been involved in. For the first time in my professional life I was acutely aware that I had deliberately emotionally distanced myself from something that would most certainly devastate me at home. Why? If I'm very honest, if I hadn't, I could well have been on a plane back home on Saturday.<br /><br />Already I have learned so much, not only about obstetrics and gynaecology, but about myself, about what kind of person I am. I know that by the end of this year, I will have changed, both as a doctor, but also as a human being. Being here is a privelige and a humbling experience, and I'm so, so pleased that I came. And by next July, I really think that there'll be very little that scares me. Although I'm not sure I'll ever get used to cockroaches.</div>katealldredhttp://www.blogger.com/profile/08000932104200009769noreply@blogger.com1