Working "up the hill"

     As a team member in 2009 I can second some of the comments already made, particularly regarding the contrasts between previous missions with the Uganda Heart Institute and our work this year in “peds acute”.  I had not visited any of the other pediatric areas scattered throughout the hospital and across the medical campus in 2009 so my adjustment to our new setting was almost as great as for the first timers.
     Working in peds acute meant a dramatic increase in the number of patients, the severity of illness and the types of illness at the same time that there was a decrease in the resources available in material, facilities and personnel.  Managing one’s own stress in this situation required a dramatic lowering of expectations and a focus on those goals that might be attainable in a short time frame.
     The successes we can claim are a result of hard work, a focus on physician and nurse education, modeling a systematic, problem solving approach and the readiness of our Ugandan colleagues to accept our contributions of energy, expertise and ideas, and to patiently decipher our American accented English, including one New York variation.
     If we helped bring the attention of administrators to this under-resourced area of the pediatric service more good may come.  The needs for both basic and advanced pediatric health care extend far beyond Mulago Hospital though, as the team that visited Mbarara can attest.
     My respect goes out to all of the Ugandan physicians and nurses, who work day in and day out under these difficult conditions, and to all of the volunteers, who contribute measures of time, concerted effort and resources at Mulago and elsewhere.
     The UNC team that made the trip this year was a combination of old and new members, including our first librarian, Mellanye Lackey.  It is incredible to work with such strong, positive, resourceful individuals.
     Each evening we processed the day behind us and planned for the day ahead.  The challenges we faced were difficult physically, mentally and emotionally.  It is a tribute to every member of the team that we engaged these challenges vigorously, constructively and supportively.  As a result we grew in our understanding of and appreciation for one another and left Uganda with a sense of accomplishment despite the failures we also witnessed.
     We are not under any illusions about the small scale of our contribution in the face of such great needs and deficiencies.  But any one of us could talk at length about what more we could do in partnership with many of the wonderful Ugandans we met.
     How this mission proceeds in the years ahead is an ongoing question.  The progress of the Uganda Heart Institute reflects what is possible when resources are available and applied to a complex but limited problem.  Working “up the hill” will require a longer time frame, a greater investment of resources and effective partners within the institution.  Like any project in a poor country, this is a great undertaking.

John Bryson

What a rude awakening!

I am a Ugandan born and raised in the "Pearl of Africa". The green grass, juicy fruits, beautiful clouds, raw nature, cloud formations and animals will take your breath away. I have always gone back to visit family and had good times at the beaches, resorts and parks. But nothing prepared me for a professional experience that I just had.

This was a different kind of Visit. One that made me hold my breath. Just never thought that the kind of experience I  had would be from a country I grew up in.

When I signed up for the mission, it was a lifetime opportunity. It never occurred to me that I would walk away feeling helpless, defeated, angry, and more appreciative of the life I have in the United States.

How could I be so helpless just like the children and parents I met at Mulago Hospital? After all, I was there to help!
Its amazing what happens when you are stuck in a situation where you have to work with what you are given. Unfortunately, the poor parents, children and health care providers are not just in a moments situation. It is their way of life.

With healthcare providers at Mulago Peds, Triage,  Rresuscitation, Acute and PICU stretched thin, lots of desperate children awaiting care could hardly get any services. When it came to respiratory distressed patients, limitations were endless, such as;

• All Peds areas used two pulse oximeters with the same probe moved from one patient to another
•  Masks and nasal cannulas were re-used
• No infection control between patients and providers whatsoever
• Could not determine how much oxygen was delivered later on liter flow per minute since a water bottle was attached to a flow meter on an H-cylinder and various needles and IV tubing were used to connect nasal cannulas.
• Masks were re-used for breathing treatments, Non-re breather masks had been used for God knows how long
• Resuscitation was more harmful than useful. Basic CPR skills were not practiced
• Parents were not part of their children's care and were actually afraid of their sick children
• Use of BiPAP was the most we attempted to non-invasively Ventilate. And the list is endless.

With that said,  the minimal impact we made, doctors, nurses and technicians were all eager to learn and were very gratefull for the education we provided. Parents were also grateful for our presence and some attributed survival of their children to our presence there. And as much frustrated as I felt during my experience at Mulago, the connection I made with the people I met was rewarding. Visits by relatives at the guest House were a great distraction from a day's frustration.  Palm sunday with Donna, Kristi and Sue was a distraction as well.  And with much more needed work, there is a light at the end of the tunnel which requires a lot more than mere words can say.

Judith Phillips.




The pretty green and clouds



A refreshing moment with a healthy child



 

A refreshing moment with a healthy child




Palm Sunday at Lubaga Cathedral





Judith with Prima at the Guest House yard .
 Prima is in desperate need for surgical removal of
her enlarged tonsils and adenoids.

Our reasons for being so quiet....

Hi All,
Now that we arrived home safely, I did want to explain to those following us why we could not be more outspoken and communicative and why we could not send more pictures until now...Well the story begins months ago when we were forced to change our travel dates to avoid an always controversial Presidential Election. This finally occurred in February and so our trip was rescheduled to commenced in April. Of course, the world became aware of all of the neighboring countries, particularly those in the Arab World, who were undergoing revolutionary change in their governments. If one looks at a map of Uganda, you can see ALL the neighboring countries in conflict. Thus for the safety of our team, we kept our travel dates secret and posts/broadcasts quiet. We arrived in Uganda with news of local and limited protests and conflicts in the capital, Kampala. Our US Embassy kept our team informed by sending email alerts and in speaking to us nearly daily throughout stay.

Warden Message

Kampala, Uganda
April 14, 2011
Opposition Walk-to-Work Protest Turns Violent
Opposition party-led demonstrations over rising costs of living reportedly are turning violent. Witnesses indicate that police are firing into the air and using tear gas to disperse the crowds. Injuries have been reported. American citizens are advised to exercise caution and avoid any large gatherings. Areas currently affected include Gayaza Road, Jinja Road, Kalerwe, and Bwayise (all in greater Kampala).


U.S. citizens are strongly encouraged to enroll in the Smart Traveler Enrollment Program (STEP) to receive the latest security information. You should keep all of your information in STEP up-to-date, including your current phone number and a current email address where you can be reached in case of an emergency.
U.S. citizens should also consult the Country Specific Information Sheet for Uganda and the Worldwide Caution, both located on the Department of State’s web site. Up-to-date information on safety and security is available toll-free at 1-888-407-4747 from within the United States and Canada, or at regular toll rates at 1-202-501-4444 for callers from outside the United States and Canada, from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Friday (except U.S. federal holidays).


Our friends and partners at Samaritan's Purse had a network of individuals on the ground throughout the country with their ears to the ground sharing real time information with us. SP provided us with multiple local phones that were essential in communicating as we had GREAT difficulty in using our Sprint or Blackberry phones in country. It took a week to establish voice communications though we were severely limited in text and data services.  We could receive but not send text messages. Our friends in Uganda and back home had other important information and daily updates for us (THANKS SUE B). We felt quiet safe and secure in the country, though we had daily security updates and discussions with the team while creating a series of contigency plans "just in case." As it turns out,we ended up being in the middle of escalating protests which turned violent.  One summary of the conflicts lead by President's opposition leader, Dr Besigye (the former physician of President Museveni) is described below.
http://www.newsfromafrica.org/newsfromafrica/articles/art_12482.html
Mulago Hospital, where we were working, received many patients who suffered from a variety of injuries including gunshot wounds and the ill effects of tear gas. We saw innocent babies and children in the Peds Acute who were caught up in the protests. Sadly, on the day we left, we read that a 2 year old was shot in the head and chest and killed, reportedly by the police supressing protests. This year, unlike years in past, there was a constant wailing of the sirens of ambulances, day and night. While receiving a security update from Samaritan's Purse, I saw a protestor being chased by numerous policemen in camaflouge and carrying machine guns through the edge of the hospital complex into town. The police presence throughout Kampala was obvious and dense. We were stopped by a policeman as we departed the city, who detained us briefly because he saw us take a picture of him and he wanted to be certain we were not foreign journalists. It was unclear what his intentions were, though he did state that he could arrest us for taking the photo. Our internet access was severely limited this year. It was unclear if this was intentional stemming from the protests or from fiscal constraints that shut down access from the ISP's. We were able to obtain a satellite modem that allowed us to send and receive email, though pictures could not be sent. News reports over the TV and in print varied widely, though apparently none reached major news outlets like CNN. This was good from our vantage point as we wished not to distress our family and friends. We all cheered as we landed in Atlanta and went through US Customs and Boarder Patrol where we were greeted by the kind officers "WELCOME HOME!" This year these two words were even more salient and comforting. We are so blessed and privileged....

Home Safely! Our inspiring and humbling journey concludes....for now...

Hi All,
We all arrived home safely on Saturday night at 8pm, greeted by all our loved ones we left behind for the past 2 weeks. We have so many stories to share, many of contradictions. Life and death; health and sickness; new and old friends; hope and despair; accomplishing so much and doing so little; beauty and ugliness; exotic scents and disgusting smells; and the list goes on.... Once again our team was spectacular in all of our endeavours:  healing, caring, teaching, empathizing, and being FLEXIBLE (like Gumby)! We have all been transformed in our individual and collective ways...Thanks to all for your love and support..

Rude Awakening

Our mission is coming to a close.  The experiences will never be forgotten.  From lost baggage for 5 days to being locked out of my sleeping quarters for 24hrs. Then my entire team drove off without me at the Mall. Its a good thing I have a little sense of humor.  Overall its been a journy of sorts.  Trying to keep kids alive long enough to get them over the hump using Bipap to the realization that some were not going to saved, the long hours are worth it wihen you see those faces a few days later.  The first missions trip I went on in 2009 was well planned but also gave me a false sense of hope. On this current trip would be the same.  Instead it was like a peditric MASH unit.  The more we tried to help the more the news got out and this brought even more patients.  We covered peds ed, triage, acute care, 28 day and greater neonatl unit and of cousre the PICU and we still had patients lined up from the wards that needed PICU.  In the mornings 75% of the beds in acute care are empty the patients are discharged overnight.  By 11am there is no room in the inn, by 4pm its overwhelming it seems there is no end in site  Every child admitted was started on oxygen and had an IV placed.  Not sure of the reason behind this.  Because there is a shortage of flowmeters, pulse ox's its difficult to determine who needed what until you wlak by and notice a child struggling to breath. Up to five child at a time will be place on one flowmeter using a water bottle with needles stuck in it to bleed oxygen to who ever needs.  In the end it does not matter as long as evrey pattients needs were meet.

Sheila White RRT.

Oh what a difference....

While this is my third trip to Uganda with the team, so many things differ this time.  Without being able to find a heart surgeon, the mission took on a new life by focusing on the Peds Acute/PICU areas, teaching a structured course for all of the staff, and meeting up with the heart and peds surgeons here to see if we could operate with them or help in whatever way they needed. 

The start of the day Monday, differed only in the area where we were unpacking supplies, and of course the lack of drinks and lunch until late in the afternoon.  Other than that, business as usual....separate the supplies for different areas, take them there and put them away.  As I trucked my supplies "down the hill" to the Heart Institute however, the differences came to light.  Our home away from home here in Kampala, was full of the usual hustle and bustle of patients waiting for care, but the actual ICU that we had established had no patients, and there were only a few staff around, caring for the patients in the adult ICU.  Though I brought supplies down for "possible" cases, we had no set time to operate, no patients designated to operate on, and no connection at this point, to the pediatric general surgeons here at Mulago.  The simple atmosphere, smell, number of patients and supplies & equipment that surround us in the heart institute, after coming for several years, is worlds away from what my colleagues are facing "up the hill."  It is not easy either, to take what you need from one area,  to serve another, simply  because you need it...despite the fact that we've brought most of those supplies, and there were patients dying "up the hill" without them.  As is the case in the US, the Heart institute is looked at as the spoiled child, who is getting funding and support from many sources, while other areas of the hospital go neglected with DRAMATICALLY less.  Lets be clear though, they don't have state of the art equipment and endless supplies......but, they are able to take vital signs because they have the equipment to do so, weigh a patient for appropriate medication dosing because they have a scale, and actually care for the patients because they have staff there.  The care is documented so everyone knows what has been occurring with the patient, and the nurses are well educated through great collaborative efforts, to understand how to provide that care.

I'll describe more of my surgical experience at a later time, but my job here this trip was much shorter and much less involved than years past.  I've tried more, to help the rest of the team cope with the disparity they are seeing.  Many, including some who have gone on missions before, were having a really hard time knowing where to begin and why we were here, when all of the expertise we bring with us gets lost in the fact that there aren't any nurses or doctors available to take care of those in the greatest need.  The shock has stabilized over the first week, and I've been able to watch my colleagues go back day after day with the attitude that today they will make, if nothing else, a small difference.  They are simply amazing.

"Down-time"

It's Sunday and most of us are only working 1/2 day or have the day off.  I went to the pediatric Acute care unit that exists next to the Pediatric ICU to check on our patients (they had been moved from the PICU to the acute ward due to the fire yesterday).  I went with mixed feelings.  It's all a double-edged sword - I am well meaning - but I went hesitantly, because I knew that I could easily be sucked into the unending whirl of need and patient care (and though eager to work, ... I have limited energy also).  The most frustrating thing was and is and continues to be:  LIMITED SUPPORT.  Limited supplies, suboptimal education, overwhelmed and overworked staff, limited access to clean water, virtually no infectious disease precautions, cultural beliefs that hinder delivery of "western medical care" (be it treatment of hydration or infection), care delivered by a combination and mix of spotty staff and a variety of family members (making continuity and consistency a HUGE problem), language barrier, and inability to assess and address basic patient needs (such as hydration or fever), lack of follow-through and the seemingly un-ending number of very sick kids are enough to make anyone just stop and cry.
Never-the-less . . . you try to make a difference.  One baby at a time - just one
Parvin

It's okay to shout FIRE in a crowded PICU

Our Saturday came to a dramatic ending yesterday when an electrical fire broke out from the air conditioner box right as we were preparing to leave.  First, it helps to know a few things about the picu at Mulago.  It's required to take your shoes off prior to entering the very narrow door into the unit.  So, more often than not, I have to climb over a pile of shoes to get through the door.  Once in the picu, you are standing in small square room with 5 beds (maybe 6, if you have a couple of infants) lining 3 of the 4 walls.  There are windows, so the light is good, but they don't open, so ventilation is poor.  A table sits against the 4th wall, and is usually covered with so much stuff that is hard to tell what's what.  Above the table sits 2 wall electrical boxes, one with switches to the lights, and one with a switch to the AC.  One of our goals this week has been to help the Ugandan staff organize what limited resources they do have in a way to be efficient, and for them to be able to see the supplies that they do have.  However, with the overwhelming patient load, and critically ill and dying patients just appearing in the unit, organizing supplies has fallen down on the priority list.  But, on this morning, there was some time, so I spent about an hour creating a "code cart" for the unit and cleaning off the table.

All of that was destroyed however, when smoke started emerging from the electrical AC box, and sparks started flying.  I immediately thought, "fire extinguisher"....... and then quickly realized there is none.  So, we turned off the power, and quickly turned off all the oxygen to the patients, and removed the patients from the unit, and ushered everyone in the acute care area (which is adjacent to the PICU) outside.  Then I began assessing the patients out on the sidewalk to make sure that when we could return, the sickest were let back in first.

Maybe not surprisingly, the patients and their families did not seem that alarmed or frightened by the whole event.  They calmly went outside and waited.  There was no yelling, no crying, no running.  When I asked one of the matrons (that's what they call their nurses) if this kind of thing happens often, she said "No, this has never happened".   So, why was I the only one who's heart was racing?  Struggle and calamity...... death and tragedy are an every day way of life for the people here.  Yet, there is a resilience and hope and light that can be seen in the eyes of the people.  They find joy in the simple pleasures of life -- a song or  a nap on the grass in the sun.  I am humbled to be witness to the rawness and purity of humanity in this place.

Jenny Boyd

Mosquito repellent is the new Chanel no. 5

An easy conversation opener for any traveler to SSA (Sub Saharan Africa) is anything having to do with mosquitoes. How bad they are this trip compared to the last? Does your bednet fit? How did any mosquitoes get inside the bednet? and maybe there are more inside than out? We're comparing notes on which anti-malarial is better, and where it's cheapest to buy at home. Mostly, we reassure ourselves that getting bitten is really okay, because not all mosquitoes carry malaria anyway.

Parvin kindly schooled me on all the details of bednets, bednets, bednets. My first lesson in how to use a bednet was that they should not rest on the floor, rather they should gather on the top of the bed to form a tighter seal. This means that you brush up against them at night, which feels weird on my skin. Also, it means that the size of my bed is now smaller than before. My second lesson was a much needed safety pin to close the gap in the front of my netting. My amateur status shone like a new sheriff's badge! The first night, I felt a bit like a princess in a canopy bed or a really tall tent. The next morning, I wondered if I could get away with not using it at all. My mind quickly changed when the buzzing in my ears started.

I've asked several of the Ugandans I've met if they use bednets. A few yes, a few no. One said, "No, because it [malaria] affects children much more, besides, our blood is strong." Okay, I thought, but I've heard it does a number on adults, too. Another person told me it's just too hot to use them and he doesn't have a fan. Fans cost money to buy, and electricity is expensive. Also, this is a tropical climate, so the fan would be running all year, every day.

In another nod to public health interventions that prevent clinical situations, my Health Behavior Health Education (HBHE) training kicked in, and I wondered how to convince someone to change their sleep environment. Are you willing to give up your bed, your comfy sanctuary, your place of rest to live under a dome of netting for the rest of your nights, every night? Maybe it's an economic decision. Maybe it's just really hard to change habits. The bednets themselves are low hanging fruit, but the willingness to adopt is that last puzzle piece that's hiding under the table.

I remember growing up reading recommendations on how to not get bitten by mosquitos. This advice included a) don't wear light colors b) stay indoors at dusk and dawn and c) don't wear perfume. These recommendations were written by people who were not living out of a suitcase and had plenty of air conditioning. They had the choice to be inside our outdoors, with vented stoves and clothes dryers. The reality is that you wear what you have; here it's cooler to be outside than in and the heavy fragrance additives in most spray repellants would induce nausea if mixed with other scents.

And, with that, I wind this post down. I think there are one or two of the little skeeters in my net tonight. Hopefully they'll find their ways out just like they found a way in - without tasting this mzungu juice.

oh boda boda

Wearing helmets while riding a boda boda (a motorcycle named because it used to rocket from border to border) would do much to prevent head injuries after collisions. Here's some bkgd on the issue.  Helmet laws are fairly easy to enforce. Tickets, fines, confiscations all do the job. But, health behaviors are really hard. Convincing people to break out of their habits is one of the toughest jobs I know. Women object because it messes their hair. Helmets heavy and bulky when you're walking around during the day. Helmets aren't free, and Ugandans aren't rich. Excuses all, but just one more challenge for health educators. I heard a rumor that the president stepped in and halted the program, that it oppressed his people.

Only having one or two people on each boda boda would also improve the accident situation. We've seen boda bodas carrying three people, plus children and bags. On our way to Kampala from the airport, an accident between a boda boda and a full taxi happened right beside our moving bus. No helmets on any of the drivers, of course.

Also, talking on a mobile phone usually requires one hand to hold the phone, which means that only one hand is steering the boda boda. Add in that the potholes on these roads eat tires for breakfast plus, well, staying in one's own lane is just so restrictive! 

Unfortunately, boda boda's are an economic necessity for many. Cheaper than a car to buy, to fuel and to repair, they meet the needs of many in a tight economy.


Mellanye