August 21 - September 6, 2016
The memory and heartache of watching a husband cry in the corner looking on as his wife lay lifeless on the examination table, dead from severe malaria at 18 weeks pregnant, is seared onto my heart.
This 25 year old woman arrived only two hours prior with severe anemia, moaning and writhing in her altered mental status, foaming at the mouth, with the pulse oximeter showing 42% oxygenation due to her severe anemia and pulmonary edema. She had already received the recommended first line treatment at another facility, and all we could do was transfuse, start second line treatment, monitor glucose, and hope that she would turn the corner. There are oxygen tanks on the ward, but no regulator head in order to deliver the oxygen.
While precepting the medical students on the nearby patients who are moaning from an inevitable abortion*, bleeding profusely from an incomplete abortion, or shaking with rigors with a temperature of 41 degrees celsius and with a cord prolapsing out from another inevitable and now septic abortion, I'm called over for CPR as the patient with severe malaria no longer has a pulse and has only intermittent agonal breath sounds. There is no crash cart. There is no intubation, no respirator, no board with which to place under her back for adequate CPR. After it is clear that continuing further CPR attempts are futile, I call time of death.
As I console the patient's mother, while registering the grieving husband in the corner, I listen to her words as she is coping with the shock and yet states so calmly, "the Lord gave me my daughter, and now he has taken her away."
With this I am stunned, and can't begin to reconcile that half a world away, the taking away is so much less.
And this was the second death I attended to that day.
Fast forward to week two.
The inner surgeon in me arrives on the unit early to ensure that my post operative patients are doing well the following morning. While on the ward the nurse asks for my help with a patient who was restless overnight. I see a young 20 year old who delivered a 30 week stillbirth at home, then arrived the following day due to swelling. She is tired, breathing rapidly, edematous all over her entire body, with massive pulmonary edema, a blood pressure of 160/100, 3+ proteinuria, an oxygen saturation of 80% on room air, and a creatinine of 12.98. Severe pre-eclampsia with multi-organ involvement.
I have since discovered the one room in the hospital that has oxygen, giving around 2 liters by nasal cannula. With the help of another GHSP volunteer, we are able to coordinate patient care and get the patient to the casualty (British for emergency room) resuscitation room for oxygen and carefully balancing diuresis. With oxygen her saturation improves to 92%, not great but an improvement.
The following morning she is still alive, with stable vital signs from the day prior, however worsening creatinine status to 16 and hyperkalemia. She needs dialysis to remove the extra fluid and stabilize her electrolytes; the closest dialysis center is again Mulago National Referral Hospital in Kampala, 4 - 6 hours away. The cost of transport to the hospital and a few sessions of dialysis is 500,000 to 1,000,000 Ugandan shillings ($150 - $300). The family needs to raise the money to get her there.
When I am next able to check on her, the room is empty and I am told she was taken to Mulago. Whether she made it alive, and if so was she even able to be seen and treatment given, I'm not sure I'll ever know.
Week 3. A patient with cardiomyopathy and mitral valve involvement, had previously been stabilized on the unit, was doing well when I last saw her on Friday, excellent heart rate and 98% oxygen saturation on room air. Over the weekend she goes into spontaneous labor with a breech fetus, brewing pre-eclampsia. She is given a large fluid bolus and hydralazine to manage her blood pressure, with her heart rate sky rocketing, oxygen saturation to 80% upon entry into the theatre for her cesarean section. As I walk to work on Monday morning I receive a call from the anesthesiologist from overnight, asking me to check in on the patient as they were worried. I walk on to the ward to find a woman gasping like a fish out of water, heart rate 145, oxygen saturation 39% on the nasal cannula in the room. Ramping up the oxygen and with a face mask I can get her to 51% saturation. There is no beta blocker available in the hospital, or even in the entire town, to slow her heart rate down for adequate filling time or decrease her blood pressure. Her lungs are filled with fluid as her heart can't keep up. Intubation is not an option. There is no respirator.
12 hours after she delivered a healthy baby, she arrests. We perform 15 minutes of CPR while her newborn baby lies sleeping soundly in the cot close to hers. After calling time of death and informing the family, they are so accepting of death and the transient nature of life. They ask me what they should now do with the baby...
Fast forward to week two.
The inner surgeon in me arrives on the unit early to ensure that my post operative patients are doing well the following morning. While on the ward the nurse asks for my help with a patient who was restless overnight. I see a young 20 year old who delivered a 30 week stillbirth at home, then arrived the following day due to swelling. She is tired, breathing rapidly, edematous all over her entire body, with massive pulmonary edema, a blood pressure of 160/100, 3+ proteinuria, an oxygen saturation of 80% on room air, and a creatinine of 12.98. Severe pre-eclampsia with multi-organ involvement.
I have since discovered the one room in the hospital that has oxygen, giving around 2 liters by nasal cannula. With the help of another GHSP volunteer, we are able to coordinate patient care and get the patient to the casualty (British for emergency room) resuscitation room for oxygen and carefully balancing diuresis. With oxygen her saturation improves to 92%, not great but an improvement.
The following morning she is still alive, with stable vital signs from the day prior, however worsening creatinine status to 16 and hyperkalemia. She needs dialysis to remove the extra fluid and stabilize her electrolytes; the closest dialysis center is again Mulago National Referral Hospital in Kampala, 4 - 6 hours away. The cost of transport to the hospital and a few sessions of dialysis is 500,000 to 1,000,000 Ugandan shillings ($150 - $300). The family needs to raise the money to get her there.
When I am next able to check on her, the room is empty and I am told she was taken to Mulago. Whether she made it alive, and if so was she even able to be seen and treatment given, I'm not sure I'll ever know.
Week 3. A patient with cardiomyopathy and mitral valve involvement, had previously been stabilized on the unit, was doing well when I last saw her on Friday, excellent heart rate and 98% oxygen saturation on room air. Over the weekend she goes into spontaneous labor with a breech fetus, brewing pre-eclampsia. She is given a large fluid bolus and hydralazine to manage her blood pressure, with her heart rate sky rocketing, oxygen saturation to 80% upon entry into the theatre for her cesarean section. As I walk to work on Monday morning I receive a call from the anesthesiologist from overnight, asking me to check in on the patient as they were worried. I walk on to the ward to find a woman gasping like a fish out of water, heart rate 145, oxygen saturation 39% on the nasal cannula in the room. Ramping up the oxygen and with a face mask I can get her to 51% saturation. There is no beta blocker available in the hospital, or even in the entire town, to slow her heart rate down for adequate filling time or decrease her blood pressure. Her lungs are filled with fluid as her heart can't keep up. Intubation is not an option. There is no respirator.
12 hours after she delivered a healthy baby, she arrests. We perform 15 minutes of CPR while her newborn baby lies sleeping soundly in the cot close to hers. After calling time of death and informing the family, they are so accepting of death and the transient nature of life. They ask me what they should now do with the baby...
**************
To compare the drastic change in environment, the US is currently grappling with the maternal mortality rate increase to 23.8 deaths per 100,000 live births, while according to the UN Population Fund Uganda has a maternal death rate of 343 per 100,000 live births. A presentation by a local epidemiologist sites the Mbale maternal mortality at 680 per 100,000 live births. This does not begin to touch on the number of stillbirths.
Mornings start with a report that takes place every weekday at 8:30am. Every meeting begins with an opening prayer. Nurses, midwives, and a smattering of physicians then discuss the events occurring on labor, postnatal, gyn, operating theatre, and neonatal wards over the past 24 hours, or 72 hours if it is Monday morning. Reported numbers include admissions, discharges, runaways, SVDs, cesarean sections, maternal deaths, fresh stillbirths, macerated stillbirths, abortions (*for non-medical personnel - this is a medical term for various types of miscarriage), UTI in pregnancy, malaria in pregnancy, pre-eclampsia, and blood transfusions, to name a few. This is followed by challenges the different wards are facing.
Challenges noted over the past two weeks:
-Lack on running water on the unit
-No urinary catheters
-Fetoscope is missing from the ward (that's right - fetoscope. No electronic fetal monitoring here)
-One curette available for D&C or D&E
-Pitocin is out of stock (leaving only misoprostol for postpartum hemorrhage - methergine and hemabate don't exist as they need refrigeration)
-IV Metronidazole is out of stock
-Bleach is out of stock
-Lack of sutures (5 boxes of 12 sutures is given for a 3 month supply)
-No oxygen on the unit
-Lack of manpower on the unit***
The lack of manpower is a crisis across the entire country of Uganda. This has to do with a nation wide discrepancy between students emerging from their medical training, the number of internship positions across the country, and the compensation the interns receive.
The typical regional referral hospital includes the following personnel:
-Nursing, midwife, clinical officer, and medical students
-Nurses (usually one per unit)
-Midwives (one on duty at a time)
-Interns
-Medical officers
-Consultants
The medical education system is more British-style. After completion of A-level (US: high school), students can go on to receive a diploma (US: associate degree) to become a nurse, midwife, or clinical officer (likened to a physician assistant), or head to nursing or medical school to receive a diploma (US: bachelor's degree). The medical students receive an MBChB (Medicinae Baccalaureus, Chirurgiae Baccalaureus in Latin) similar to a combined undergraduate and medical school in the US. After five years of training at their home institution, the sixth year is completed through an internship at various government hospitals around the country. The Ministry of Education oversees the medical schools, while the Ministry of Health is responsible for the internship positions. Completion of an intern year is required to obtain your degree, however there are currently more graduates from medical school than there are internship positions. Not to mention that the interns are paid through the Ministry of Finance, which often does not pay interns for 3 - 4 months at a time. A disconnect between the ministries. Thank you, ACGME, for making sure I was able to work AND receive a paycheck every month.
This is all to complete your basic MBChB degree. The positions are infinitely smaller for specialty masters degrees (US: residency), therefore most physicians practice as medical officers with internship level training in their field, while a select few become consultants (US: attendings) in internal medicine, surgery, obstetrics and gynecology, orthopedic surgery, anesthesiology, etc. Consultants become available to answer any questions and weigh in on tough cases that the interns and medical officers need assistance with, however don't typically see patients in the government facilities unless they are teaching the students.
And for all of you MFM, Gyn Onc, MIS gods and goddesses out there, you are earning/have earned the equivalent of a PhD in sub-specialization.
To make matters worse, the interns were supposed to start working on August 15th. However the institutions did not choose their interns until well after this date. And now the interns are striking as the government proposes that only students on a government scholarship will receive a stipend - to be compensated by 2 years of compensatory service in a government hospital, while those students not on a government scholarship will fund themselves through internship.
The lack of interns means that the medical officers are shouldering all of the inpatient clinical responsibility. There are three medical officers employed by Mbale Regional Referral Hospital in obstetrics and gynecology. Two medical officers show up to work; the third is mostly MIA.
And the ward is busy, delivering 35 babies a day, 1,000 a month.
As a physician educator/lecturer and consultant with Busitema University Faculty of Health Science (BUFHS), I am just beginning to learn my role in university and in the hospital setting. My first obligation is to teaching the medical students, with the first class currently entering their fourth year since BUFHS opened in 2013. We teach them in ward rounds every Monday and Thursday, theatre (operating room) on Tuesday, Antenatal clinic every Wednesday, GYN clinic Friday, and a smattering of classroom and patient bedside presentations on the other days. In the first few weeks, I've discovered that showing up really is half the battle. Oftentimes consultants will no-show, arrive late, or leave early for various personal reasons (again when you are paid every 3-4 months and aren't sure when the next paycheck will arrive, you can't blame anyone for having a second job). By just being in the place that I am supposed to be at the given time, I am able to give my group of 13 students so much on their 5 week OB/GYN rotation. Never mind that I have to modify my thick American accent, or pick up new phrases or acronyms to adequately convey what I am trying to teach. I am there for them to learn.
When teaching in the hospital, I am learning to treat malaria in pregnancy, postoperative management of patients with obstructed labor (obstructed for days - when I mentioned the Zhang curve of no cervical change for 6 hours then proceeding to cesarean, my supervisor and counterpart laughed), as well as performing a hysterectomy with 2 sutures of 2 Vicryl (not 2-0 Vicryl) skin-to-skin. Outpatient I am wrapping by brain around the routine intermittent preventative treatment of malaria in pregnancy, diagnosing fistulas, relying on LNMP and fundal height for the estimated due date without any first, second, or third trimester ultrasound to confirm dating, and auscultating fetal heart tones through a fetoscope. When explaining why I didn't know how to use their fetoscope, the staff thought it was because I was used to using the fetoscope with with ear pieces like a stethoscope, rather than the megaphone-like fetoscope that is used both outpatient and on the ward. Nope, its just that I'm spoiled with electronic doppler and external fetal monitoring (AND tocometry).
Plus sides: there is a blood bank. Fitz, I might not have methergine, hemabate, or a Bakri balloon (though I've been told how to make one out of a sturdy Peace Corps dispensed condom and a foley catheter), but I DO have a blood bank.
A huge thank you to Dennis who is always there to hold my hand, and to Drs. Bonaventure Ahaisibwe and Maureen Ries from SEED for being amazing sounding boards as I discover my role and continue to listen and absorb what the school and hospital need most.
Up next - the fun experiences with fellow GHSPers and making Mbale home.
**************
Mornings start with a report that takes place every weekday at 8:30am. Every meeting begins with an opening prayer. Nurses, midwives, and a smattering of physicians then discuss the events occurring on labor, postnatal, gyn, operating theatre, and neonatal wards over the past 24 hours, or 72 hours if it is Monday morning. Reported numbers include admissions, discharges, runaways, SVDs, cesarean sections, maternal deaths, fresh stillbirths, macerated stillbirths, abortions (*for non-medical personnel - this is a medical term for various types of miscarriage), UTI in pregnancy, malaria in pregnancy, pre-eclampsia, and blood transfusions, to name a few. This is followed by challenges the different wards are facing.
Challenges noted over the past two weeks:
-Lack on running water on the unit
-No urinary catheters
-Fetoscope is missing from the ward (that's right - fetoscope. No electronic fetal monitoring here)
-One curette available for D&C or D&E
-Pitocin is out of stock (leaving only misoprostol for postpartum hemorrhage - methergine and hemabate don't exist as they need refrigeration)
-IV Metronidazole is out of stock
-Bleach is out of stock
-Lack of sutures (5 boxes of 12 sutures is given for a 3 month supply)
-No oxygen on the unit
-Lack of manpower on the unit***
The lack of manpower is a crisis across the entire country of Uganda. This has to do with a nation wide discrepancy between students emerging from their medical training, the number of internship positions across the country, and the compensation the interns receive.
The typical regional referral hospital includes the following personnel:
-Nursing, midwife, clinical officer, and medical students
-Nurses (usually one per unit)
-Midwives (one on duty at a time)
-Interns
-Medical officers
-Consultants
The medical education system is more British-style. After completion of A-level (US: high school), students can go on to receive a diploma (US: associate degree) to become a nurse, midwife, or clinical officer (likened to a physician assistant), or head to nursing or medical school to receive a diploma (US: bachelor's degree). The medical students receive an MBChB (Medicinae Baccalaureus, Chirurgiae Baccalaureus in Latin) similar to a combined undergraduate and medical school in the US. After five years of training at their home institution, the sixth year is completed through an internship at various government hospitals around the country. The Ministry of Education oversees the medical schools, while the Ministry of Health is responsible for the internship positions. Completion of an intern year is required to obtain your degree, however there are currently more graduates from medical school than there are internship positions. Not to mention that the interns are paid through the Ministry of Finance, which often does not pay interns for 3 - 4 months at a time. A disconnect between the ministries. Thank you, ACGME, for making sure I was able to work AND receive a paycheck every month.
This is all to complete your basic MBChB degree. The positions are infinitely smaller for specialty masters degrees (US: residency), therefore most physicians practice as medical officers with internship level training in their field, while a select few become consultants (US: attendings) in internal medicine, surgery, obstetrics and gynecology, orthopedic surgery, anesthesiology, etc. Consultants become available to answer any questions and weigh in on tough cases that the interns and medical officers need assistance with, however don't typically see patients in the government facilities unless they are teaching the students.
And for all of you MFM, Gyn Onc, MIS gods and goddesses out there, you are earning/have earned the equivalent of a PhD in sub-specialization.
To make matters worse, the interns were supposed to start working on August 15th. However the institutions did not choose their interns until well after this date. And now the interns are striking as the government proposes that only students on a government scholarship will receive a stipend - to be compensated by 2 years of compensatory service in a government hospital, while those students not on a government scholarship will fund themselves through internship. The lack of interns means that the medical officers are shouldering all of the inpatient clinical responsibility. There are three medical officers employed by Mbale Regional Referral Hospital in obstetrics and gynecology. Two medical officers show up to work; the third is mostly MIA.
And the ward is busy, delivering 35 babies a day, 1,000 a month.
 |
| WHO Partogram on L&D |
As a physician educator/lecturer and consultant with Busitema University Faculty of Health Science (BUFHS), I am just beginning to learn my role in university and in the hospital setting. My first obligation is to teaching the medical students, with the first class currently entering their fourth year since BUFHS opened in 2013. We teach them in ward rounds every Monday and Thursday, theatre (operating room) on Tuesday, Antenatal clinic every Wednesday, GYN clinic Friday, and a smattering of classroom and patient bedside presentations on the other days. In the first few weeks, I've discovered that showing up really is half the battle. Oftentimes consultants will no-show, arrive late, or leave early for various personal reasons (again when you are paid every 3-4 months and aren't sure when the next paycheck will arrive, you can't blame anyone for having a second job). By just being in the place that I am supposed to be at the given time, I am able to give my group of 13 students so much on their 5 week OB/GYN rotation. Never mind that I have to modify my thick American accent, or pick up new phrases or acronyms to adequately convey what I am trying to teach. I am there for them to learn. |
| Casuality Resuscitation Room - the only room with oxygen in the entire hospital |
Plus sides: there is a blood bank. Fitz, I might not have methergine, hemabate, or a Bakri balloon (though I've been told how to make one out of a sturdy Peace Corps dispensed condom and a foley catheter), but I DO have a blood bank.
A huge thank you to Dennis who is always there to hold my hand, and to Drs. Bonaventure Ahaisibwe and Maureen Ries from SEED for being amazing sounding boards as I discover my role and continue to listen and absorb what the school and hospital need most.
Up next - the fun experiences with fellow GHSPers and making Mbale home.
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