Friday, 25 May 2012

Moving forward...

I have been really impressed with the progress made at all three of the health centres I have been working at (Kawempe, Kabubbu and Kasangati). I visited Kawempe today to find the postnatal ward full of mothers who have had emergency caesarean sections! This is great for the local woman as they no longer have to make the difficult journey to Mulago and face the long waits to be seen by a doctor. Word is spreading that Kawempe is now doing caesarean sections and more women are attending for delivery. However Kawempe is still struggling, their budget has not been increased now that they are performing caesareans and shortages of drugs and equipment remains a daily challenge.
The new postnatal ward

The building of the new postnatal ward at Kasangati is now complete. However a walkway still needs to be built connecting the operating theatre to the ward and then hopefully caesarean sections will commence.

The number of deliveries at Kabubbu has more than doubled over the past 6 months and more women are continuing to attend for antenatal care.

The past week at Mulago has been hectic. The registrars have been away for their exams, so it leaves doctors very thin on the ground. On one occasion a woman had been found having an eclamptic seizure and was bought in by the police. She was very unwell, agitated and confused and her baby needed urgent delivery. The wait for theatre was too long so I had to deliver her baby by vacuum. It took heavy sedation and four nurses and doctors to restrain her. I can't imagine ever having to do this in the UK, but when the wait for theatre is hours you're often forced to make really difficult decisions.

I recently spent a week on the emergency gynaecology admissions ward. I had no idea of the scale of the problem caused by unsafe illegal abortions. These women are desperate and manage to buy misoprostol or use local herbs to induce an abortion. Women risk their lives trying to have abortions. I removed a stick from a woman's cervix, she was lucky that she hadn't perforated her uterus, haemorrhaged or developed sepsis. Unlike a young woman who was referred from a hospital in northern Uganda with septicaemia following an illegal abortion, who unfortunately died a few hours after admission. With no social welfare system or assistance for women who have large families, women simply cannot afford to look after the children they have let alone any more children. With additional barriers accessing contraception women will continue to have unwanted pregnancies and seek illegal abortions. This is a very sensitive political and religious issue with fierce condemnation of any woman who seeks an abortion. Unfortunately I'm not sure how this situation will change.

Monday, 23 April 2012

Renovating Kasangati Health Centre

Old delivery bed
Painting the maternity ward

The new delivery bed!
Kasangati Health Centre lies on the outskirts of Kampala and refers many women to Mulago. There are about 3,000 deliveries per year without a functional operating theatre to perform emergency obstetric surgery.  The LMP and the Ugandan Maternity and Newborn Partnership Hub decided to invest in Kasangati  primarily to improve the functionality of the operating theatre and thus reduce the number of caesareans being referred to Mulago. A team from the UK came over to refurbished the maternity unit and operating theatre. The generator was fixed and a new postnatal ward is currently under construction. The midwives and mothers were delighted and lots of local people came to offer their support and help. With the money I raised from the Kampala half marathon I bought Kasanagti a new delivery bed, so mothers no longer have to give birth on the old rusty one. We hope to start doing caesareans in the near future, I will keep you updated!

There is good news from Kawempe Health Centre in Kampala. The medical officer has returned because he heard that the operating theatre was now functional and they are currently doing both emergency and elective caesareans! A great success and a step towards our goal of reducing congestion at Mulago.

The screening team!
At the beginning of April I helped to organise a cervical cancer screening programme at Kabubbu Health Centre. We were able to screen 182 women over 4 days, all of which had had no previous screening. I would like to say a huge thank you to all of the midwives who helped in the screening, it wouldn't have been possible without their hard work.

Thursday, 8 March 2012

Family Planning Success!

Over the past few months I have been working closely with the nurses and midwives at Kabubbu Health Centre. A lot of my work has concentrated on providing health education to the local women, particularly about family planning. This has been a great success. So far we have held 4 sessions in the community, with 30-40 women attending each session. Our hard work paid off and on February 16 2012 we held a one day 'camp' for women to come and get the contraceptive method of their choice, free of charge. We inserted 38 implanons, which provide contraception for 3 years. (This photo shows myself and one of the midwives inserting implanons). Providing long term contraception allows women to space their children and have the opportunity to work thus reducing their levels of poverty. I provided training on the insertion of implanons for the nurses and midwives so they can continue to offer this service. As well as continuing to expand the family planning services at Kabubbu our next goal is to provide cervical cancer screening. The incidence of cervical cancer in Uganda is high and often presents with advanced disease when it is sadly too late for surgery.

A greater proportion of my work is currently focused on improving the functionality of health centres that provide maternity care. Essentially this means getting operating theatres up and running so caesarean sections can be performed without having to refer women to Mulago Hospital. If we can achieve our aim we hope to reduce congestion at Mulago and also prevent women from making long uncomfortable journeys when they are in labour. One such health centre, Kasangati (pictured) has a operating theatre which is not currently in use, however with a small amount of investment and a bit of rebuilding we are aiming to have the health centre functional in next couple of months (building is due to start next week). A Ugandan doctor has just been appointed to work at Kasangati during the week, which improves the long term sustainability of this project.

My current work at Mulago has concentrated on patient monitoring. During my time at Mulago I have noticed that many women simply do not get their observations taken (blood pressure, heart rate, temperature and respiratory rate) and all too often I hear the words "woman found gasping" and then she dies before the doctor has had a chance to do anything. I believe that if these women are properly cared for and have their observations done regularly we can identify those women who are deteriorating and get help to them earlier. To try to assess the scale of this problem I have started an observational study that looks at the frequency of patient observations and any barriers to getting them done i.e lack of equipment and over crowding. Hopefully with the results in hand we can really try to improve patient monitoring, which is a step in the right direction to reduce maternal mortality.

Sunday, 12 February 2012

The first caesarean in 18 months!

After all of the hard work getting the operating theatre up and running at Kawempe health centre we finally did the first caesarean section in 18 months! This is a massive step forward. The theatre was tested to the max, firstly the theatre light broke so we had to turn the operating table towards the window so we could see what we were doing, then the power went! The midwife on duty didn't know how to turn the generator on, but she finally worked it out 30 minutes later, if this had been at night we really would have been in trouble. The mother and baby did really well and were discharged 2 days later!

Last week I went to join a team of British doctors, nurses and midwives who were volunteering at Hoima hospital (about 200km from Kampala). They set up project similar to the Liverpool-Mulago partnership 3 years ago and visit Hoima hospital several times a year. The hospital is much smaller than Mulago and therefore much more manageable. I visited the hospital for 2 days with one of the midwives from Mulago. The aim of our visit was to implement and train the midwives about patient observations and monitoring using a scoring system (MEWS). The visit was successful and we returned a week later to give the midwives their own 'kit' which has all of the equipment needed to perform basic observations.

I had a welcomed visit from Prof Louise Ackers last week. We had a busy week of meetings at the Ministry of Health and Kampala city council. We are really pushing the authorities to help to appoint medical officers (doctors) at the health centres that we are working at. It is impossible to recruit medical officers because of poor working conditions and low pay, it is much more attractive to them to work in the private sector or for NGO's who pay big bucks. The meetings were successful but I imagine it will take a while before we see any medical officers in these health centres.

Sunday, 29 January 2012

Much of the work I have been doing over the past few weeks has been concentrating on getting the operating theatre in Kawempe health centre up and running. This has been a slow and slightly frustrating process. The main problem has been with the generator. It hadn't been wired up to the theatre so in the case of a power cut (a daily occurrence) there was no alternative power source. It has taken about 8 weeks but the generator is finally wired up and the theatre is ready to go! As of yet there hasn't been any caesareans, mainly because of the lack of doctors at the clinic. I am currently spending one day a week there but this isn't enough, there really needs to be a doctor present 24 hours a day for the theatre to have the intended impact on Mulago. This has been the biggest challenge and is a problem reflected throughout all health centres in Uganda. The government is aware that there should be a doctor at Kawemepe and despite asking the health authority to help they still haven't appointed a medical officer.

I've been continuing with the community health education at Kabubbu health centre, concentrating on contraception and antenatal issues. We are currently planning a 'one stop shop' for women to have any gynaecological issues dealt with and to get the contraception of their choice. We have just appointed two new members of staff, a very experienced midwife and a nurse who will help push Kabubbu in the right direction. The number of women attending for antenatal care and the number of deliveries has started to increase, which means less women are delivering at home (either alone or with traditional birth attendants).

Work at Mulago goes on and I'm really enjoying it at the moment, partly because I am getting small breaks when I go to the other clinics. I've been splitting my time between the main labour ward, the admissions area and the high dependency unit. Post partum haemorrhage kills many women at Mulago. Partly because it isn't managed well. Slow decision making and the chronic shortage of blood means that these women often die. For example a woman had an emergency caesarean section because of a placenta praevia (low lying placenta), she started to bleed and was taken back to theatre. However the bleeding continued. She arrived in the high dependency unit but I couldn't control the bleeding and her condition was deteriorating. She needed to go back to theatre. Getting blood was a nightmare.The intern had to find the blood and cross match it herself because the lab technician was nowhere to be found!  The woman was taken to theatre for a second time and had a hysterectomy, fortunately for her she had completed her family.

Monday, 9 January 2012

Sorry it's been a while!

I hope everyone had a great Christmas. It’s been a while since I wrote my last blog, so it’s going to be a long one!
The 2 weeks leading up to Christmas were perhaps the most intense two weeks that I’ve had at Mulago. Over these two weeks all of the SHOs were on exam leave and to make matters worse the interns were on strike because they hadn’t been paid. During this period I was the only junior doctor on the rota to cover labour ward, theatre and admissions (there would normally be 3-4 SHO’s and 4 interns)! Two seniors were supposed to be covering labour ward during the exam period, however often only one would turn up and would go to theatre leaving me alone. On one day no specialists turned up at all, so I wasn’t able to open theatre when there were 8 women waiting for caesareans. A woman presented with cord prolapse so I had to take her to theatre but she was the only caesarean that got done. We had 2 days with no IV fluids in the whole department, this meant no caesareans, and keeping fingers crossed that no women had a PPH. To say I felt vulnerable would be an understatement, and in true Mulago style everything you could imagine happened: Eclampsia, twins, breech deliveries, abruptions, ruptured uteri. One particular incident happened when I was alone in admissions. A woman arrived in a semi-conscious state following an eclamptic seizure, and was now having an abruption (premature separation of the placenta leading to heavy vaginal bleeding). It was very hard to auscultate a fetal heart beat and I feared the baby was dead, after delivering the baby with a vacuum it needed urgent resuscitation. I attempted to resuscitate the baby but it was futile, I didn’t have a towel to dry the baby and the resuscitation equipment was broken. A very frustrating and upsetting day.
Another incident that I believe could have been prevented represents some of the struggles we have at Mulago. A woman with obstructed labour had a caesarean section during the night and was found to be bleeding in recovery. She was not taken back to theatre, but instead admitted to the high dependency unit (HDU) where she continued to bleed. In the morning meeting she was reported as a maternal death until one of the nurses informed us that she was still alive! I went to HDU to find her in a peri-arrest condition. Two units of blood were rapidly transfused while I tried to locate the specialist who could take her back to theatre. She was eventually taken back to theatre for a hysterectomy but desperately needed more blood. After madly running around the hospital I was able to get another 2 units of blood but unfortunately she died a few hours later. If there had been more staff and no shortage of blood this woman’s life could have been saved.
In my last entry I mentioned a health centre called Kawempe and I’m pleased to report that the operating theatre will be up and running at the end of the week, ready to start doing caesareans! And hopefully start to reduce the burden on Mulago.
The other health centre I have been working at is Kabubbu. I have been really trying to promote health education and improve access to family planning, and this week I had a session with 30 local women about contraception. It is unbelievable how many myths there are about contraception such as causing cancer, birth defects and infertility. It was brilliant to be able to dispel these myths and give the women more options. Hopefully we’ll be expanding the contraception provided at Kabubbu to include the IUD and implanon, which the women seemed really keen on. Just a small step in the right direction!
Finally I would like to say a BIG thank you to everybody who sponsored me to run the Kampala half marathon. I have raised over £600 for the Liverpool Mulago partnership. We are still deciding how to best spend the money but I will keep you all informed.

Friday, 25 November 2011

With a recent visit from a surgeon and nurse from Liverpool, we evaluated the gynaecology services at Mulago. Surprisingly over half of the maternal deaths are happening on the Gynae wards. With over 40% of these deaths occurring as a result of sepsis. Mainly septic abortions (complications from illegal abortion including perforated uteri from instrumentation of the uterus with sticks) and puerperal sepsis (postpartum infections). I assisted in a case of a 16 year old girl, who presented 10 days after a caesarean section for obstructed labour in which her baby died. She had severe peritonitis and at laparotomy we discovered her whole uterus to be extremely necrotic and full of pus. Simple measures such as providing safe abortions to mothers would significantly reduce maternal mortality, and would save many children the pain and hardship of loosing their mothers.

I spent a week at a fistula 'camp' in Mulago. Fistula's as a result of obstructed labour do not occur in the UK, so this was a fantastic opportunity for me to see how they are repaired.  Women were initially screened to stage their fistulas, and sadly the women would often be standing in a pool of their own urine. The majority of women had fistulas between their bladder and vagina. Some of the fistula's were massive and a finger could easily pass straight into the bladder. Some women had no urethra at all and a small amount  had recto-vaginal fistula. These poor women suffer in silence, and are often ostracised from society.  I was amazed at how easily the fistula's could be repaired and at the skill of some of the surgeons. They were able to refashion urethra's and use the rectus sheath as a sling to correct stress incontinence.

I had a visit from the Liverpool Mulago team, which was great. We concentrated on some of the 'smaller' health centres (which in fact deliver 8,000+ babies a year). Many of these health centres have theatres for caesarean sections, however they are not functioning. Mainly because the doctors don't turn up and a lack of funding means that the theatres run out of supplies. Approximately 60% of maternal deaths at Mulago occur in women who have been referred from these health centres. It is vital to get these theatres up and running in order to reduce the congestion and number of maternal deaths at Mulago. I am quite excited at the prospect of working in some of these smaller health centres.  The photo below shows a fully equipped theatre at Kewempi health centre, but it has not been used in 18 months!

I've also spent some much needed time out exploring Fort Portal in western Uganda. It's a beautiful spot, in the foot hills of the Rwenzori Mountains. The area is dotted with amazing crater lakes, formed centuries ago by volcanic activity, leaving stunning lakes surrounded by rain forest.