Broken Back Mountain

Altitude sickness, Diamox overdose, vasovagal syncope, two extremely sore backs and the kind of sunburn only possible if you were born north of Hadrian's Wall were the physical rewards of a week spent slogging up the Machame route of Mount Kilimanjaro in northern Tanzania. Thankfully, our efforts were not in vain as we managed to raise £1,166 for Mbarara Regional Referral Hospital. 

Thanks to everybody who sponsored us - every penny of the money will be spent improving the quality of maternal and child health here in south-western Uganda. We've already had sinks and hand gel dispensers installed on the wards in an effort to create a culture of hand hygiene (in line with WHO guidelines) and we are aiming to improve the availability of bednets, bedside privacy curtains and other basic medical supplies.

We've posted some photos below to prove that we made it, though God knows how we did. There's still time to donate (via this link) if you'd like to add to the total.

The Start - only 27 hours and 62 miles of walking to go...

The raven of death.

Day 2 - Shira 2 Camp at 3,810m above sea level.

Day 3 - Walking above the clouds and through the alpine desert at 4,000m

Day 4 - Barranco Camp at 3,976m

Rorschach, from The Watchmen, turned up on Day 5 at 4,673m 

The White-eyed Slaty Flycatcher remained sceptical that we could do it.

But we did - summiting at 5,895m on Day 6

The view from the top, looking into the volcanic crater and over the clouds towards Kenya.

Altitude, sickness.

Please give generously to our Kilimanjaro Climbing Appeal!

I have now been working in Mbarara Regional Referral Hospital (MRRH) for just over 5 months.  My primary aim is to improve maternal services in Mbarara and this is a brief update on what I have achieved so far and my plan for the future.

The organisation of the unit has frequently been chaotic, particularly on the antenatal ward where 25 admissions a day is commonplace. For its size, the unit also has an extremely high number of deliveries per year (around 9,000).  I have introduced a white board to facilitate order, to enable better quality handover and to act as a reminder to perform timely examinations. Although there was initial resistance (and for the first 2 weeks there was only myself and one of the fourteen residents updating it regularly) it is now being used effectively. 

Kilimanjaro, elephant.

There are no curtains and very little privacy for those patients who require intimate examination on the antenatal ward. There is also a lack of bed nets to protect patients from mosquitoes and subsequent malaria.  With money raised from the Global Gateway Challenge I have ordered bed nets and curtains to improve patient care on the antenatal ward so we are excitedly awaiting delivery.

One of my main roles in MRRH is teaching, which can sometimes prove difficult, partly due to the lack of available space close to the clinical areas.  I am pleased to report we were recently granted permission to renovate a storage room adjacent to the ward area.  This renovation was only made possible by funds raised from generous fellows and members of the RCOG. The room is a more appropriate teaching environment and makes it easier for staff to attend sessions whilst remaining easily accessible in the event of an emergency. This area has already been used by midwives, medical students and doctors. 

Before...

...after

Along with this refurbishment, and with the collaboration of my Ugandan colleagues, I have managed to pilot a cervical cancer screening project for HIV-positive patients using visual inspection with acetic acid (VIA).  This has now been running for 10 weeks and we have already screened 350 women. We hope to expand this programme through collaboration with Mulago-Mbarara Teaching Hospitals’ Joint AIDS Program, who are instrumental in the funding and functionality of the HIV clinic in Mbarara, and who we hope will provide the means to train more nurses in VIA technique.

I currently sit on a maternal mortality committee. We have identified one of the main problems, namely that a significant contributor to maternal death is the lack of appropriate antenatal care women are receiving in this region. In the future, along with help from other committee members, I hope to improve these services by providing necessary equipment to establish a high risk antenatal clinic and by producing referral criteria for distribution among other health units to improve antenatal care.

Although these changes are small, change in Uganda begins and is sustained by changes in attitude. I hope that by taking an interest in teaching and by providing dedicated teaching areas, residents’ enthusiasm for post-graduate learning will increase.  Although our HIV / cervical cancer screening programme is in its infancy, I hope that the number of screened patients will continue to rise. Single lifetime screening has been associated with reductions in cervical cancer of as much as 31%.  Furthermore, if we can improve our antenatal care, there may be a subsequent fall in maternal and perinatal mortality.  I believe that these small changes can make a big difference to the health of women and babies in Mbarara.

Kim has promised to do it without legs (surgically removed by Dave) if anyone is willing to donate £10,000.

Small changes still require funds.  Dave and I are climbing Kilimanjaro on the 28^th June and we would appreciate any support you can give us.  Your donations will be used to improve the care of mothers and their babies in Mbarara Regional Referral Hospital.

Truck travel

In preparation for Kilimanjaro we decided that organising a 5 day trek would test our fitness whilst enabling us to explore the more rural bits of Uganda.  I must admit I did not think the most gruelling part of our adventure would be getting there.

We had to travel to the village of Buhoma where our walk was due to start.  Although the village is only 176km from Mbarara, the roads are fairly bad so we knew it would take a while.  We planned to get a catch a bus to Kihihi then take a taxi to Buhoma, which we thought would be straightforward.  Famous last words.  Our first mistake was missing the bus, not exactly our fault as we did turn up to the bus station at the time designated, however we should know by now that in Uganda designated times mean nothing.  After this initial hiccough, a very friendly Ugandan kindly offered to help us get a matatu (an overcrowded minibus where the passengers are packed in like sardines) to Kihihi. 

Truck taxi

Once we set off (6 people tightly squeezed into the three seats in our row) we expected a 6-7 hour drive before reaching our destination.  What the kind Ugandan had not mentioned was the fact that half way through our journey, the matatu could no longer continue due to the road surface and we had to switch vehicles into an open truck shared with about 30 people, their luggage and a live chicken.  The truck was definitely an experience, it was amazing to see the camaraderie that develops when you are holding onto one another for dear life in an attempt not to fall out.  I also now realise that no vehicle really needs a roof, just a large tarpaulin for when it rains.  As a female mazungu I was pleased to be given one of the better seats at the back on a pile of large bags of flour, unfortunately Dave got the slightly worse end of the stick.  He had to balance on the side of the truck, which was about 5 inches wide.  This may have been manageable however he made friends with a Ugandan toddler who proceeded to sit/sleep/generally move about on his knee for the five hour trip.  That we both arrived in one piece was a shock in itself.

Despite the seemingly difficult journey, it was actually a very enjoyable experience (most of the time).  In the UK, you could imagine the complaining and arguing likely to ensue in this situation however what really struck me about the travelling was the way everyone was very relaxed, happy and chatty.  We had interesting conversations about Ugandan politics and met a member of the town council who gave us invaluable insights into the area, there was the irritating football banter but I can’t stop Dave doing this in the UK so what chance do I have in Uganda?

When we arrived in Kihini we shared a ride with two of the Ugandans we had met on the truck and even though we were 3 hours late when we eventually got to Buhoma we were greeted by a warm smile and fortunately even warmer food despite the hour. 

It is very easy, particularly when coming to Uganda on holiday, to have a car and driver meet you at the airport, stay in luxurious lodges and see incredible animals and birds, however I think experiencing the culture and the people has been the best part of our trip.  We have never felt so welcome, safe and included. Sometimes at home, people can be reluctant to help each other out, but here it is more important for people to do so and, in our experience, much more likely.

Glastonbury 2012 To Go Ahead After All

The similarities between the world's greatest music festival and a provincial Ugandan town don't seem to be immediately obvious, but here's ten reasons why they are more alike than you think:

1. The Weather

Despite Glastonbury falling around midsummer the weather always conspires to transform the entire site into a mudbath within 24 hours of the gates opening. You can enjoy similar scenes of rain-based chaos here in Mbarara, as epic thunderstorms turn the murram roads into boggy rivers. However, whereas 'revellers' in Somerset will stand in the pouring rain watching a barely audible Get Cape, Wear Cape, Fly set in stoic misery, the Ugandans head undercover and sensibly wait for the sun to re-emerge before continuing with the normal activities of daily life.

Party on!!!

2. The Food

Barbecued meat, warm flat beer, bread that tastes three days old and has bits of earth in it, melted chocolate and a reliance on bananas as the major energy source - again, the similarities are clear.

3. Music

Wherever you go, whatever time it is, whatever day it is, it will be unusual to enjoy silence in either place. In a similar way to Glastonbury, we often feel the music before we hear it (as I type this on a normal Monday lunchtime, a marching band is parading up and down the road, apropos of nothing). Young men set up enormous sound systems in the back of empty banana trucks, turn up the bass and turn down the treble, and then spend all day driving up and down Mbarara high street playing hip-hop at gut-rumbling volumes. Even the churches turn it up to 11, with one recent evangelical shindig keeping us awake until 4.30am on a Sunday morning.

4. Fires

Ugandans like to start fires. As you fly into Entebbe Airport, vast plumes of smoke can be seen all over the surrounding villages. We have twice been smoked out of our flat as a result of our neighbours deciding to burn their rubbish ten metres from our (glassless) windows. Like at Glastonbury, the smell of burning is constant and inescapable, and results in a permanent cough which only a rigorous course of physiotherapy will cure.

5. The Power Supply

It's usually around day 3 of the festival that iPhones and Blackberries start to run out of battery, and a general sense of panic begins to develop as access to Facebook and Words With Friends is rendered impossible. In a similar way the power supply here is often unreliable, though the consequences of this are perhaps more serious when it cuts out half way through a night-time emergency laparotomy. The blackouts are described euphemistically as periods of 'load shedding' which, to me, appears to imply that there is simply too much energy for the system to cope with, and it must be thrown overboard for the ship to remain afloat. The only benefit of the outages is the brief respite it can give from the nocturnal evangelists, as they scrabble in the dark for the key to their diesel generators.

6. The Toilets

There are public toilets in Mbarara, but they tend to be entrepreneurial ventures set up by individuals, who charge a 200 shilling fee (5p) for the opportunity to make a 'short call' or a 'long call' (you work it out). Anecdotal evidence from Ugandan colleagues at the hospital suggests that they are best avoided, and that pharmaceutical measures should be taken to avoid their emergency use. Anyone who has visited the pit latrines on day 5 of Glastonbury and regretted their failure to pack a box of Imodium tablets will sympathise.

7. The Hippy Vibe

The Mbararans are an extremely friendly people, and will take a keen interest in anything that you are doing. Thus mundane activities like opening a parcel in the post office, going for a run or performing an intimate examination on a patient will all draw a crowd keen to know exactly what is going on, and offering helpful comments on how you can do it better. You only realise how unsociable most British people are when Ugandans will approach you in the street and tell you their life story and demand you share yours with them. Similar behaviour in the UK would probably have you interred for harassing passers-by, except at Glastonbury where people rely on artificial stimulants to enable this social interaction with strangers. The average Mbarara resident needs no such device for their innate and routine friendliness.

A reveller.

8. Public Transport

Anyone who has spent an unpleasant 5 hours at Castle Cary railway station waiting to be herded back to their hometown will have some insight into Ugandan intercity travel. Recent experiences on a bus trip from Kampala to Mbarara (bus packed to the brim, no air conditioning, overpriced ticket, tyre blowout whilst doing 80mph on a bend, arriving two hours late) led to memories of cattle-class transport services away from the festival.

9. Bono

10. The Inevitable Return

Every year, 160,000 physically exhausted, emotionally demoralised people flee from Pilton vowing never to put themselves through such a period of intense sensory overload ever again, yet every year they block phone lines and websites in their desperation to get a ticket for the next festival. Likewise, although Uganda can be equally as frustrating, noisy, challenging, smelly, hot and wet as Glastonbury, it's hard not to love it, and to want to spend more time here, bathed in mud, listening to evangelical rock at 4am, drunk on warm lager and ready to do it all over again.

Birdblog #3: Grey crowned crane

Grey crowned crane - featuring reverse knees.

This young punk is the national bird of Uganda, though it appears more often on coins and flags (and as the door handles of the Ugandan Embassy in Trafalgar Square) than in real life.

There is a family of three that we've spotted over the hill from our flat, but when I went for a run yesterday one of them was lying dead in a farmer's field whilst the other two conducted a rudimentary post-mortem.

Grey crowned crane door handles - just visible behind ardent fans of The Seahorses

No-one seems sure why it was chosen as the national bird, but it definitely is one of the more spectacular species, particularly with its red wattle that has evolved to resemble a mad, screaming, bloodied mouth.

When a few of them get together they sound a bit like the Scousers from the Fast Show - the third sample down via this link gives the best example.

If the Grey crowned crane were a celebrity it would be: Johnny Rotten

The Great Partogram Robbery

We thought we’d better provide a hospital update, if only to reassure you that we are doing some work amongst the Michael Bolton tribute parties, clothes shopping and birdwatching.

Things are going well at the obstetric unit; I’ve acclimatized to the mayhem and even managed to reduce it (sort of) by introducing whiteboards outlining the essential details of all the labouring patients. This is designed to improve the organisation of the ward and to make sure everyone is aware of the patients who need particular attention.  I will admit that there was initial resistance, and for the first 2 weeks there was only me and one of the fourteen residents updating it regularly, however it is now up and running successfully!  I even had a resident come up to me after his weekend shift to apologise for sticking paper on the board after the marker pen ran out.  We now have more marker pens, unfortunately they still need to be tied to the wall to stop people ‘borrowing’ them but small steps are being taken in a (generally) forward direction.

In a similar vein, it is amazing what people ‘borrow’ if they find it lying around the ward. My favourite thing to go missing so far has to be a massive (3ft by 5ft!)  laminated partogram (in this case, by ‘left lying around’ I mean ‘stuck so firmly to the wall that its removal has left the wall paintless’).  On a positive note it gave me the opportunity to discuss why the use of a partogram was so important in the morning meetings and we’ve now organised a partogram teaching session, so every cloud…

Another reason for my work-related blog is to post some of my favourite theatre photos, when things are going less-than-swimmingly in the operating theatre, you just need to walk into the recovery area to find instant amusement.  We have ‘The Dangerous Drug Cupboard’, which I think has a much better ring to it than ‘Controlled Drugs Cupboard’.

The Dangerous Drugs Cupboard

There is also the store of endotracheal tubes with the mysterious empty box – if like me you thought there must be something secret and wonderful inside that is kept safe from all the staff, you may be a little disappointed but I was still amused that it was actually an empty box (modelled by Julia one of the UCLA residents who came over for a recent 3-week placement).

Julia - with empty box

Is it really an empty box?

Also, if you are looking for another way to use tape, here’s your answer.  There is no end to the ingenuity; some of you may have noticed the lack of a cord clamp replaced by the sleeve of a disposable glove which works surprisingly well.

Babies

On a more serious note, our projects are going well, and with the collaboration of my Ugandan colleagues I have managed to pilot a cervical cancer screening project for our HIV-positive patients using visual inspection with acetic acid.  I am also starting a quality improvement project aimed at reducing the very high rate of stillbirth here, so I’ll let you know how that goes.  We are also planning to introduce improved infection control measures, focussing on hand hygiene. This has been proven to reduce rates of sepsis in other Ugandan hospitals, and we’re hopeful that similar results can be achieved in Mbarara.

Thomas a Becket, Michael Owen and other Mbarara Residents

Having been born in the early 1980's, we thought our chances of meeting Thomas a Becket would be slim, given that he was famously murdered in 1170 on the altar steps of Canterbury Cathedral.

Imagine our surprise, therefore, to be introduced to him by a colleague at a recent social event. Regrettably, as huge fans of beatified 12th Century martyrs, we were disappointed to hear that the man before us was born in northern Uganda in 1978 and was therefore almost certainly not the original version.

A contemporaneous photograph of Thomas Becket's murder.

It transpired that his parents were keen admirers of the deceased Archbishop and had decided to name their first-born son in his honour. This doesn't seem to be unusual practice in Uganda, where most people have entirely different forenames and surnames to their parents', opening up the possibility of becoming a namesake. As such, as well as Thomas a Becket, we've also met Michael Owen and Michael Jackson, which would make for an entertaining, if morbid, episode of Celebrity Come Dine With Me. 

Michael Owen - ex-footballer

To add to the variety, most people here tend to structure their names with a Ugandan-style name first, followed by a European-style name.

This also leads to confusion when we introduce ourselves, as people assume that our working, hospital names are Dr David and Dr Kim, but informally they will call us 'Riding' (pronounced 'Rayding', which I prefer) and 'MacLeod' (variations in pronunciation infinite, even in the UK).

The second names also tend to be very traditional, as this list of some of our hospital colleagues reveals:

Dr Mutiibwe David, Dr Kayondo Stanley, Dr Rwambuka Godfrey, Dr Kanyago Samuel, Dr Ngozi Joseph etc.

It's also usual to meet people called Herbert, Moses, Gerald, Ronald, Gertrude, Beatrice, Henry, Isaac, Ernest and Albert, names which somehow give immediate authority. This is in contrast to Kim's experience in Liverpool where Nevaeh is a popular girls name ('Heaven' spelt backwards), and Chantelle, Britney and Beyonce all keep the taste police busy. Worryingly, American colleagues confirm a rash of unfortunate children called 'Lady' in tribute to The Gaga.

Whether the Ugandan names provide inspiration for any possible future offspring is still under discussion, but don't be surprised if you are introduced to Master Riding Agamemnon at some point in the future.