November 2013 archive

D84 Wednesday 23rd October, Haydom to Mwanza.

Fortunata, one of the midwifery sisters, collected me for ‘morning devotion’ at 8am. All hospital staff except those dealing acutely with patients were asked to attend this prayer meeting everyday. Announcements for the day were made there too!

From there to the labour ward and maternity block:

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It was great to see simulation equipment set up and ready to use on a regular basis:

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The labour ward had 5 rooms with the midwifery station in the middle, catering for about 400 deliveries per month.

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There was also an assessment room with a scanning machine! I was asked to do two scans during the morning!

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Donation, donations:

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I did the antenatal ward round with the intern doctor.

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The ward was over full, with at least half of the beds having double occupancy. There were patients with a whole range of problems including premature rupture of membranes, early labour, urinary tract infection and antepartum haemorrhage. There was also one patient who, with a previous caesarean section and a breech presentation at 32 weeks, had been told to stay in hospital until she delivered (likely 6 weeks time).She was so desperate to go home, but lived 800km away!! Yes, that’s right – she had travelled 800km to get to the hospital! Inpatient care was free.

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I spent a little more time on the labour ward. One tribal lady with numerous metal bangles on her wrists and ankles came in in labour having been trying for days at home deliver her baby. She had given up and put her trust in the labour ward team.

All too soon it was time to rush off for my next destination. I was disappointed that there had been no time for training – the labour ward had been too busy during the morning!

I had a quick bite to eat while sorting the accommodation bill (there is always a bill of some sort or another to pay!) and before long we had said our goodbyes and were back at the airstrip. It took a bit of convincing because no one had heard a plane arrive!

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We taxied to the other end of the strip and took off for Mwanza:

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The areas that we flew West over were some of the most desolate that I had seen so far on the FEM journey.How on earth would you manage to get to hospital if you were a pregnant woman here?

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There were some more urban areas too during the 2 hour flight to Mwanza:

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As we approached Lake Victoria, the ground was becoming greener:

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We caught our first glimpse of the magnificent Lake:

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Mwanza was in the distance and we set up on a long final approach:

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The landing was a great one!

As soon as practical, I phoned Derrick, our anaesthetist contact at Bugando Medical Centre. He would be our host for the next 2 days. As the working day was drawing to a close, he suggested we head straight home:

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Derrick’s wife Susan was waiting to welcome us. We gratefully ate some snacks and drank some juice! Hungry and thirsty as ever!

And then time for a quick snooze before we headed out for dinner! Flying days are always tiring and perhaps increasingly so!!

D83, Tuesday 22nd October, Arusha to Haydom.

Another early start from the Mission to Mount Meru Hospital in order to give a lecture to the medical staff following morning handover: Maternal Collapse and Obstetric Haemorrhage. Lots of healthy discussion was generated, but I was concerned about the comment that the use of bimanual compression in Obstetrics may lead to transmission of the HIV virus and therefore shouldn’t be performed in the case of an atonic postpartum haemorrhage (where the womb doesn’t contract well after delivery of the baby and afterbirth). This suggestion was simply wrong – health care workers are well versed in how to protect themselves against blood borne viruses (gowns, gloves, eye-protection etc). No needles or blades are involved. Bimanual compression is a simple, effective and life saving technique!

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After the lecture, I went to the Obstetric department where we had planned to carry out some practical training with the labour ward midwives and doctors. And I waited and waited. Firstly the floors were being cleaned, then it was was the ward round….and I waited. After a couple of hours I left to find some food…I would try later in the day! But on my return the story was the same! I guess no one was keen for teaching today!

Ross and I were keen to fly on to our next destination of Haydom before 3pm and so I hurried back to the Mission to pick up Ross. Ben (one of the Flying Medial Service pilots) kindly drove us to Arusha Airport. The direct road was pretty bumpy, although beautiful with Jacaranda trees lining it:

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After a debate in the payment office about whether we should pay in Tanzanian Shillings or dollars (as a foreign-registered aircraft the request was for dollars but we were kind of running out!) we left for Haydom!

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We had decided to make a slight detour to overfly the Ngorongoro Crater – a great decision as the views were amazing:

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After a 360 degree of the Crater, we headed South along the eastern Rift Valley:

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A town sprung up in an otherwise desolate area – Haydom!

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We overflew the airfield to check its condition prior to making our final approach:

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What a nice feeling to shut down the engine and not to have to report any airport authorities!

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Before long a hospital car arrived to drive us the short distance to the Lutheran Hospital. We were welcomed by the nursing team. It would be an early start tomorrow!

D82, Monday 21st October, Arusha, Tanzania

First stop of the day was Mount Meru Hospital to visit the District Medical Officer and plan my visit to Arusha.

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Dr Maliki was one busy lady! All of her staff gathered around at 8am each day before dispersing to their various areas.

I was taken under the wing of the Medical Director of the hospital Dr Mlay, with whom I visited the Obstetric department – a new wing to the North side of the hospital:

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The department sees 30-40 deliveries per month; in September there were a total of 819 babies born and of those 164 caesarean sections (20%) with no instrumental deliveries (vacuum or forceps). There was a vacuum machine (metal cup) but it wasn’t functioning.

I had a quick tour of the labour ward:

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and the antenatal and postnatal wards of which this was one:

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The matron uploaded the ‘Safe Motherhood’ section from the Global Library of Women’s Medicine (http://www.glowm.com/) onto her computer from the memory stick I had been carrying. I’ve been giving the data to as many institutions as possible and especially in areas where the internet is not readily available, courtesy of Mr David Bloomer.

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And then there were my donations:

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I’ve really been very happy with the choice of blood pressure monitors as donations; they have for the most part been in very short supply wherever I have been travelling!

The senior staff from Mount Meru were going to be in a meeting for the rest of the day, and so, with the agreement of returning the following day to deliver a lecture, I jumped in a taxi to visit Mr Andrew Browning MRCOG
at the Selian Lutheran Mission Hospital. I had met Andrew in Liverpool last summer at an RCOG conference and promised to visit!

My taxi driver Festus needed to stop by his son’s primary school on the way:

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I took the opportunity to ask the headteacher if I could talk to some of the older girls about learning:

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There were many budding doctors, teachers and pilots!

I found Mr Andrew Browning him in the operating theatre of Selian Lutheran Hospital, and so I got changed:

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He has almost finished his list when called to the labour ward – a Masai patient with eclampsia (fitting with very high blood pressure and protein in the urine) had come from home after apparently fitting 4 times. She was semi-conscious and her baby had died as a consequence. Her blood pressure was difficult to control and her kidneys were failing. She was in labour but would she deliver naturally, and quickly?

Andrew finished his list and then delivered the eclamptic patient by caesarean section as labour was not progressing well and delivery was not imminent. The blood pressure monitor in theatre wasn’t functioning so well and so I handed over my donation a little early:

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She went to high care post operatively and luckily, given timely intervention, her outcome was good and her kidneys recovered (I checked the next day).

We had a look around the other parts of the hospital, in particular the fistula ward. And I spoke about Early Warning Charts (‘usual’ for me, by now!)

The working day was drawing to a close, and I headed back to the Flying Medical Service Mission where dinner had been prepared! How lovely – so nice to have home cooked food when you have been travelling for so long!

I wandered around the Mission:

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and appreciated the garden, together with the wonderful view of Mount Meru from the back:

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Pat was off on an emergency evacuation flight; vaccines were being prepared for use at rural, fly-in clinics the following day. It was all go at the Mission!

D81, Sunday 20th October, Malindi to Arusha, Tanzania

And we were finally off! After 12 nights in Kenya!

We were very grateful to the Davies for helping us (especially me) relax!

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Malindi Airport was relatively straightforward in terms of payments and flight plans. They even called the immigration officer so that would could fly directly to Tanzania without stopping at Mombasa.

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We flew South along the coast and in particular low level past Watamu!

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After the Creek (where we had done much of our swimming) we turned inland to follow our route to Kilimanjaro International, where we would stop to clear immigration and customs before flying on to Arusha.

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The ground quickly became more barren as we climbed to 8500 feet:

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But as we saw wildlife we descended a little to have a closer look!

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Were they buck or were they buffalo? They certainly were moving at quite some speed!

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There was no doubt about the elephants though!

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Or about the fact that this was the famous Kilimanjaro:

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albeit it covered by cloud at the top!

Soon after we could see Kilimanjaro International:

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I had expected it to be busier than it was! But there was one plane taking off as we turned onto the base leg prior to final approach.

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And we landed!

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We quickly checked immigration, re-entered the airport and paid our (extortionate) fees and settled down for cheese sandwiches before our next departure. I was still trying to get rid of a fair degree of nausea that had developed during the last flight!

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The flight to Arusha was incredibly short! Only 90km separate the two towns.

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As we approached we were excited to see evidence of a great deal of general aviation activity:

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And as we landed wondered where we would park!

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On shutting down, we pretty immediately bumped into Ben – a pilot from the Tanzanian Flying Medical Service – and his boss Pat. Would we like to come and stay? You bet!

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Pat had some work to do on his Cessna 206 and so we waited and helped a little before heading to their Mission a little outside of Arusha.

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We chatted over dinner about our journey and motivations. And became excited to learn more about the Flying Medical Service in the days ahead.

D80, Saturday 19th October, Malindi, Kenya

Ross and I decided to leave on Sunday for Tanzania, given that it was the weekend and that he needed some downtime following a hectic week co-ordinating the fixing of the aeroplane in Nairobi!

And so we swam and chatted, ate and drank, recharged both of our batteries, and I rearranged next week’s medical itinerary in Tanzania.

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Topped off by a moonlit Douw Boat meal!

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D79, Friday 18th October, Mombasa, Kenya.

It was an early drive South to Cape Provincial General Hospital on this rainy morning! First stop in Mombasa was the airport, to follow up on an email I had had from Kenya Airways the previous day. Somehow I had managed to leave my passport on my seat on my flight from Nairobi and they had contacted me to let me know that they had it – before I actually appreciated that it was missing! So a big thumbs up to Kenya Airways who couldn’t have been more helpful!

Next the hospital:

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where I met Joyce, head of Maternity, and Zainab, head of Labour Ward.

They were extremely pleased with my donations to the department:

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Cape Provincial is a referral hospital which covers a large geographical area along the coast, with some patients travelling as far as I had that morning in search of specialist care. In addition, Mombasa is built on an island, and although there are road bridges to the North and West, a ferry service connects the Southern side. Zainab told me the sad story of a maternal death just the week before, of a lady who arrived moribund. She had delivered in a clinic to the South of the city and been referred with a postpartum haemorrhage. The ambulance that brought her had been delayed at the ferry terminal because a large cargo ship was entering the the port. The delay undoubtedly contributed to her death. Very sad.

The walls of the labour wall were covered with guidelines and posters:

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This was the first hospital on my journey in which responsibilities and accountability were so openly on display.

The maternity building itself had been recently extended with funding from Japan and the layout was sound with an assessment area, a lower risk labour area:

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and a high risk area with 6 bays such as this one where the patients with severe pre-eclampsia or eclampsia were cared for:

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The midwifery station was central and there was ease of access to each of the areas.

Zainab and I talked about the Liverpool School of Tropical Medicine’s clinical skills training course in Obstetrics (http://www.mnhu.org/) which has been rolled out in many of Kenya’s provinces. She had been on the course and found it extremely empowering, especially in optimising the labour ward team’s management of patients presenting with postpartum haemorrhage, and with the skill of vacuum delivery, which she was now practising regularly. She was also able to mentor more junior and less confident midwives with such skills. ‘Let’s do more in-service practical training for midwives!’ she requested with passion!

As we were chatting, there was a request for help from one of the midwives. How brilliant – no hesitancy is asking for help, a sure sign of a well functioning labour ward team. A patient had arrived post delivery with heavy bleeding. She already had a drip and fast running fluids and been started on an observation chart for pulse and blood pressure.

We had a short training session on the Obstetric Early Warning Chart (previously described on my blog). It was received with much enthusiasm. There was a great keenness around to keep driving up standards of maternity care.

I even helped choose some new delivery beds which were to be ordered!

As I left, we stopped by the office of the head of nursing and midwifery for a cup of tea and samosa! They all couldn’t believe the story of my journey!

It was a long, hot ride back to Watamu. I was thinking all the way about what it must be like to be transferred all that way in labour, or when recently delivered.

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Although the road is for the most part tarred and in good condition, it is single carriageway with many trucks and other obstacles around. Hard times for a woman in labour.

When I arrived back, Ross had already arrived from Nairobi with a fixed plane! Time for a mini-celebration!

D78, Thursday October 17th, Malindi, Kenya.

I took advantage of being at the coast by doing a scuba dive first thing. No better way to clear one’s head! So as opposed to my usual 10000 feet in the air, I was now 100 feet under! We even saw a blue spotted ray – one of my favourite fish!

Joyce, the sister in charge of Maternity at Coast Provincial District Hospital, and I spoke further. We postponed my visit until tomorrow first thing, especially now that I had had word from Ross that although the alternator had definitely arrived, it would likely only be fitted Friday. Fingers crossed it would be Friday!!

So further relaxing and reading and swimming was on the cards for me; ‘downtime’ had been rather unchartered territory on this journey and i could feel it was doing me good!

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D77, Wednesday October 17th, Malindi, Kenya

I had a bit of a dash to my early morning flight at Kenyatta National on account of the traffic! In the end we made use of the ‘bypass’ which cuts around the edge of the National Park and is still being constructed (creating a lot of dust when driven on!!)

And so, still wondering if this was a good decision, I was off!

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There were wonderful views of Kilimanjaro from my side of the plane:

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On arrival, I called Joyce the Head of Maternity at Coast Provincial General Hospital, hoping to make a teaching visit over the next day or so! She said tomorrow was better, and so I headed straight to Watamu – about 2 hours North of Mombassa:

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I would be staying with Damian, Sue and their son Joshua for what was originally planned for 2 nights! This turned out to be somewhat of an underestimate!

A quick swim before dinner and then it was time to relax with a gin and tonic!!

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All just what the doctor ordered!

D76, Tuesday October 16th, Nairobi

Today my parents left for a short safari trip before going back to the UK, and Ross and I plodded on with logistical issues surrounding the aeroplane, and writing our blogs of course! The never-ending blogs!

By now we were expecting the alternator to arrive on Thursday morning and hopefully be fitted the same day. Expecting…but there was still a large degree of uncertainty surrounding that! We’d been disappointed before.

I also started postponing our arrangements with the Tanzanian Ministry of Health (Tanzania being our next country visit) and with my contacts in Malawi. Given all of the time spent making arrangements this felt very disappointing! Luckily there was plenty of understanding given the nature of our delay!

In terms of Nairobi, and of Kenya, it was difficult to arrange any further activities – hard to be proactive and busy when the mind is elsewhere and worried about the continuation of the journey!

With all this I was getting rather stressed, so when the invitation came up to visit the coast, I um-ed and ah-ed but in the end accepted. Ross said he would wait for the repairs and then pick me up from Malindi, North of Mobassa.

And so my flight was booked for the following day!

D75, Monday October 14th, Nairobi

The day started with a breakfast meeting with Mr Jeremiah Mainah, the President of the National Nurses Association of Kenya and his team.

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We had lots of stimulating discussion around the maternal health equation including in particular the attitudes of healthcare workers and factors affecting attitudes. ‘What a shame you’re not staying longer, to visit the rural areas in the Western area near Lake Victoria.’

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Maybe I would be staying longer! The alternator was still to be shipped and Rick the engineer was going home this afternoon…

Ross, dad and I spent all afternoon trying to find an economical way to get the alternator to us, and to find a suitable mechanic to fit it. Very stressful times indeed – dealing with such uncertainty that has huge influence on the execution of the project. Should we choose DHL and risk customs problems? Pay for someone to bring it? Ask another airline company to carry (for example AMREF). Really difficult.

In the end solutions for both were found. At least we hoped they were. Fingers crossed from here on!

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