Uganda Day 9 - Part of my heart..

 Today was our last full day here as our original flight had been cancelled so we were now flying out late friday night instead of Saturday.

We woke up early and I for one felt a bit of sadness that it was our last day here. We had the staff teaching again today and weren't sure whether it would be the same set of staff as Monday or a different set. Which meant we weren't sure what our teaching plan for the day would be.

We also wanted to hand out the rest of the gifts that we had brought... more hats and blankets, we had presents for Grace's children and some of the staff's children. We wanted to take some blankets and hats to the woman we had met in the mud huts near the hospital who had not long ago had a baby, who we had met earlier in the week... so much still to do... so little time. I also wanted to check on the cleft baby that had come in the other day and had not looked well.

We headed back up to the classroom with no windows at the front of the hospital and set up some kit. Bit by bit, staff drifted in, Ugamda time. Many of them had been here on Monday so we decided to teach the class as a whole and perhaps do a bit more in depth.

I started and went through the resus and then explaoned in more detail and with some badly drawn pictures, about why we follow the WHO recommendations for 5 inflation breaths. I also talked a bit more about preterm lungs. They are unable to give surfactant here and only have one CPAP machine which is dependant on electric being available, so they have limited resources to deal with the preterm baby or babies with breathing difficulties (or as Grace would say, breathing challenges). They do a remarkable job in such challenging circumstances.

I talked a bit about surfactant, and then segwayed a bit into neonatal feeding with nasogastric tubes and answered some questions they had. It was interesting as whenever they asked a question, I checked with them what they would do, or what resources they had, before answering as the way we do things are often not possible out here. I can't emphasise enough what an excellent job they do!

Once I had finished, Gillian and then Sam did their adult, midwifery bit. I sat on the wall with the listening kids. The staff here clearly knew their stuff where delivering babies was concerned and Gillian and Sam had to answer some very intuitive questions. Sam told me that their approach to shoulder dystocia is a lot different and often results in breaking the baby's clavicle in order to deliver the baby.  They were delighted when Sam showed them manoeuvres they could do to avoid that. Sometimes it's the simpler things that help most.

Claire then did her feeding talk... knitted boob out again! Lots of questions for her about breastfeeding, despite them being very breastfeeding savvy here. Many of the questions were about what happens if the mum dies or if her milk runs out. Anectodally it seems as though a friend or family. member would take over breastfeeding the child but this is discouraged because of the prevalence of HIV out here, but the formula available is expensive and not within the means of many people here. We tried to stress that the baby should be brought to the hospital where they could provide help but whether that happens in practice, it was difficult to tell. 

Gillian did a bit about maternal maleria and then I did a bit about recognising an unwell child. With more bad chalkboard drawings, we went through observations on a well child and then the differences on an unwell child. I tried to stress the importance of close observation and actually looking at the child, something I also stress back home! Here many of the babies are covered up and being held by the mothers, which is great if they are well, but not so good if they are becoming or are unwell, as it is harder to see what they are doing and closer observation difficult as was seen with the twin that died yesterday. I wondered whether a more strict regime of observation for these babies would be possible here, it would be beneficial for the smaller or sicker babies but with only one incubator that was currently out of commission, and a culture whereby all babies are swaddled with their mothers for a good portion of the day, and no nurses dedicated to the neonatal section only, it may not be possible to introduce a more intensive observation regime. 

Perhaps when there is a dedicated neonatal unit, it might be something for the future.

With us all having done our bit we decided to go pretty much straight through. Gillian bought some more drinks for the staff and Sam had a great idea of doing stations... one for PPH, one for difficult birthing situations, one for resus and one for expressing and infant feeding. Myself and Claire went back out under the trees and we split the group into 4, with 20 minutes for each station. 

In my station, I went through the full resuscitation process as a demonstration and recap from Monday and then got up 2 volunteers to start. I then pretty much sat back and let them get on with it... providing information about the baby's condition when asked... what is the heart rate? is baby breathing? what is baby's colour? what is baby's tone? 

I also encouraged them to ask for more help if baby wasn't picking up, provided feedback on their performance and highlighted areas they could improve. It became an organic thing, with the more confident, experienced members of the group, helping the more junior members of the team, leading the resus and the teamwork of Freda Carr shone through brightly. It was a proud moment for me. The little extra I had given them this week, in terms of updated practice, was nothing compared to what they have given me. Not for the first time in this trip, I felt close to tears. 

We switched round and again and again the staff demonstrated what they had learnt this week. We also had fun, with me scampering off with the baby doll to 'give birth' in the bushes and the staff chasing after me to rescue the baby and take it back to the resuscitation area before going through the resuscitation steps woth the rest of the group joining in counting breaths and helping if the others were unsure, providing extra hands if required and interacting with the process wholeheartedly. 

When all 4 groups had been through each station, we gathered them all together. We all gave a little speech. I started mine with a few words of Ateso, which always is well received and basically thanked them for welcoming us and being so fantastic. 

They got paid for their participation and we got asked for photos and our numbers and emails so we could all keep in touch. I think I speak for myself, Claire and Sam when I say that Freda Carr and its people have stolen a little bit of our hearts and if we can continue to support them in any way, we will. 

Gillian asked if there was anything they particularly enjoyed about the training... one girl stood up. She worked at the district health centre across the road (we did not have time to visit them) and had also come for the training the day before. We had given her a bag and mask and a stethoscope or two to take back to there. She sounded close to tears when she told us that she was so grateful we had given her these things as they had had none over there and now they had the equipment to be able to do their job. It was very heart warming. Such a small thing for us (via the rotary club's generosity in paying for these items of equipment.), made such a massive difference to her work. 

I found Sampson, the ambulance driver and our interpreter the other day. He had really impressed me on the resus stations and I wanted to find out if there was any way he could train as a nurse. He told me that he did not yet have the qualifications to apply for training, his childhood was spent hiding from rebels in the bush. His plan was to study for his high school certificate next year and then try and apply for nurse training. I was so pleased and wish that he will be successful in chasing his dreams. 

Training done, we then had a short amount of time before our train the trainer session. During the week we had identified staff who had shown promise in teaching others and selected them for further training so that they could then continue training other staff. 

In this short break there was much to be done. We took the rest of the equipment that we had brought out to Grace's office to be handed out to the areas with most need. Myself and Claire ran over to the village we had visited before to give hats and blankets to the mother with the new baby. When we got there, the father was sweeping the dirt floor with a broom made of twigs. It looked immaculate, the mud huts standing on the outside of the clearing, the whole place looking almost idyllic, the pride in their homes apparent. 

They were incredibly grateful for the presents and we took photos of the family and wished them well for the future. 

We then dived back to where we were training the staff and we quickly went to see the cleft lip and palate baby with Dr Moses. When we got there, she had just had an apnoic episode (stopped breathing) and had to be resuscitated. She looked pale again and was working hard with her breathing again. Her tummy was slightly distended and her mouth was full of gunk... secretions which had congealed. They don't have the same suction that we have so I showed them how they can use a bit of gauze and saline to clean her mouth and do some mouth care to keep ot moist and not dry out. We cleaned out the gunk and increased the CPAP and oxygen a bit. 

Here they don't use NGT tubes much so I showed them how they could aspirate the air out of her tummy using the tube. It was a new concept to them and now i have shown them, I hope they will continue to do that as it makes it more comfortable for the baby and stops the distension pushing up the diaphagm, making it easier for baby to breathe. There wasn't much else to suggest, given the limitations of their equipment and I left, thinking that maybe this baby would not survive. 

Whilst I had been looking at the cleft baby, the girls had gone back to the paediatric wards and handed over some more toys and blankets to the kids and the parents. We then reconvened back for the Train the Trainer session. 

We ran through our respective bits with more emphasis on how to do the teaching bit and giving feedback to the people they are teaching. At the end of the sessions we asnswered more questions and then handed out some gifts for their children and gave Grace some more stuff for her 2 boys. 

At some point we also handed out the rest of the toys and pencils to the kids. I stood outside our accomodation trying to control a bunch of excited children, eager to grab what they could. I tried to make sure every kid had something but the older boys kept snatching stuff out of the younger ones hands and there was a bit of a fight for it all. several times I tried to get them to sit down and give stuff to them but they sat, hands in the sir, shuffling forward and forward and grabbing stuff out of my hands. It was all a bit crazy... for a few pens. 

Once that was done, we were informed that we were being taken out for a dinner by the hospital senior staff. So we rushed back to our accomodation. Grace changed speedily and met us at our house, with her boys and a cake for us that her home helper and the boys had baked for us. James came and picked us all up in the minibus and we were whisked away to the hotel, where an inside table had been set up for us all. 

Myself, Sam and Claire had discussed how best we could help the hospital. We had decided that mending the ambulance would mean that once again, sick mothers and babies could be transferred in to Freda Carr for higher level medical care, potentially having the biggest impact on a short term basis. We had each donated some money and we gave it to Dr Amos, Stella (hospital administrator) and Grace with a note thanking them for welcoming us and asking that the money be used to mend the ambulance. It was a small thing but hopefully will make a big difference. 

We ate a fantastic meal with the senior staff of the hospital and the principal of the nursing and midwifery school, a very lovely, interesting lady, who unfortunately we had not got to spend much time with. Stella announced that after our plastic collection and concerns around the amount of rubbish and lack of recycling facilities, that one of their initiatives this coming year would be to look into whether they could set up some sort of collection point and work with the district on  regular collection. 

It was a lovely evening and I felt once again that I had made friends for life here. I will definately come back and see how they are getting on and pledged to myself that I would support them in building up their hospital and the neonatal side of it, in any way I could. 

We said our goodbyes and headed back to the accomodation. 

Myself and Sam then went for a last night walk, me hoping that this would be the night to see a cobra (it was not) and Sam hoping to find the bat tree where they all settled for the night. We did find a wierd spider that was almost flat and very well camouflaged and gave me a bit of a scare when I almost put my hand on it. I also got bitten by  a cheeky spider on my ankle... no damage done! 

We didn't find the bat tree but we could hear them chattering away... it sounded like they were laughing at us... silly muzungos (white women) can't find us! 

We went back after not too long.. on the way bumping into two women who asked us what we were doing, having been a little surprised that we said hello in Ateso. We told them, which made them laugh and then asked where they were going. They were taking some oranges to a market on a overnight bus. There didn't seem to be many oranges and I did wonder whether it would be worth the journey. We said goodbye and went to pack up our bags... we were going to have a shower but the water wasn't working. Such is life in Africa! 

Bags packed and settled in our respective rooms, I lay on the bed and contemplated my time here. So much had happened in a short space of time. It would take time to order my thoughts and work through all the experiences from the week. Overwhelmingly though, I felt grateful. Grateful that I had the opportunity, grateful to have met these people and be welcomed, grateful that I lived in a country where I had the opportunities that I have and the resources I have. Grateful that back home I had water and electricity when required. Grateful to have had choices in my life that weren't dependant on circumstance or custom. 

Tomorrow we were heading home.. but part of my heart will stay here. I will not forget