Night at Mulago

My last entry, for this trip at least. I’ve had this one written for a while, but debating on the details and how to portray it. I’ve had some adventures in between, which are unfortunately a bit too complicated (and inflammatory!) to get into here, but please feel free to ask me and I will happily tell you the whole long, convoluted, and unfortunately very sad and frustrating story.

But before I sign off, for this trip, at least, here is one last short snapper of my last clinical experience here in Uganda. I spent one night of obstetrics call at Mulago, the national referral hospital and center for the nation’s biggest medical school, located in Kampala, Uganda’s capital city. It provides free, quality care to patients from across the country, who flock here for its free and specialized care.

More than a narrative experience, the night came to me in a series of sensory snapshots. I will try to capture some of them here. The images come in flashes, not a sensory coherent whole. There are no photos, as I did not have my camera, plus I’m not comfortable with the ethics of taking pictures of hospital wards filled with people. You will just have to use your imaginations!

*          *          *

Slop! It sounds and looks like someone has poured half a can of red paint over the floor beside one of the labour beds. Except instead of red paint, it is the lifeblood of a woman who has just given birth. Standing beside her bed, the gush comes suddenly and unexpectedly, making a bright splash on the greyish yellow floor. A spot of bright colour in this drab ward, atypical for Ugandan hospitals, normally characterized by the cheerful prints of various blankets, sheets, and nightgowns that patients bring with them to the hospital.

Another, slightly higher pitched slop  draws my attention, followed by a prolonged retch and more slops. A woman who has yet to receive a bed is kneeling quietly over a small green bucket, vomiting in the middle of the hall, for all to see. But I feel like none do, so wrapped up is everyone in their own world, the laboring mothers agonizing at their own bodies’ uncontrollable spasms, the midwives and doctors flitting like hummingbirds purposefully from one patient to the next.

One bed over is a twin bucket, this one cheerfully yellow. A pregnant woman sits on it, eyes squeezed shut, mouth a tight line. She is straining hard. I have no idea whether she is trying to push out a baby or a bowel movement.

*          *          *

Women here tend to shun clothing in labour, their dark bodies, gleaming with sweat, contrasting with the bland faded paint that coats the walls and floors.  They rock rhythmically to understated groans of pain, punctuacted by occasionally sudden stiffenings accompanied by bloodcurdling screams, throwing all those around into reminder of just where we are. A strange sight it is, all of them at once, up to 20 at a time. Beds so near to each other, with no curtains or privacy between. Yet each woman is involved in her own world, her own struggle to push forth new life into this world.

I’m sad that the mothers must be alone. Because of the already crowded chaos that seems to typify Mulago for me, women are not allowed anyone to accompany them into the labour ward. So they sit and lie and crawl and stand and kneel in pain, alone, some curled up quietly gently rocking or waving a hand to soothe themselves, while others keen and wail and scream out their fear and agony. The midwives and doctors are spread thin, so only the loudest, most desperate of screams “MUSAVO!!!!” (“doctor/nurse”) seems to garner attention. I sit there, often paralysed by my inability to communicate with most of these women. I am there, awkwardly at the doctors’ bench, watching women laboring in front of me, sitting patiently on the ground, waiting for a bed, or crawling up in utter agony to the bench in hopes of being told where to go and what to do. I review their charts, and tell them to wait until a bed is available. I wish I could help more.

*          *          *

A woman comes up to me, cramping lightly. “Please doctor, I want a cesarean”, she says. “What is your reason?” I ask, as I start to thumb through her chart. “With my first baby, I laboured so many hours, then had a cesarean, but she died anyway. I have no children. Please, I don’t want this one to die, too!” I can see tears in her eyes. I agree. But when will we schedule her in? Even though we have 2 C/S ORs running all night, we still have a back up of emergencies here on L+D that must go first---the laboring woman who’s had 3 previous scars and has been laboring for hours, the woman who is bleeding briskly and we’re concerned not only about her baby, but herself for going into DIC (severe bleeding that can easily be fatal), for the other woman whose labour is obstructed with signs of serious fetal distress. How do we choose who goes next? She sits patiently among the madness and waits.

*          *          *

I wander to the pre-eclampsia ward. We go through 3 blood pressure cuffs before we find one that works. The beds here have even less space between them than on labour and delivery (“L+D”)—not even an arm’s length from one bed to the next. The women who aren’t fortunate enough to have a bed are seated on the floor, on a thin bamboo mat or cloth they’ve brought from home.  These are long-term patients, confined to a small space on the floor with minimal padding for days or weeks on end. There are also two laboring women here—both are inductions; one who due to her severe pre-eclampsia, the other because her baby died inside and it needs to come out. The woman with the dead baby just lies on the side of her bed, eyes and mind blankly staring somewhere else. She absently strokes her stomach tenderly. The woman with the live baby is writhing in pain and screaming loudly, back arching in agony. When I asked if perhaps it was time for her to go to L+D, I was informed that the pre-eclamptics have to labour in the pre-eclampsia ward to keep a closer eye on them. Hard to believe that there is less privacy here than L+D, but there is. Not only are the beds practically touching, but no one else has any distraction other than her, and it is not a self-contained or closed ward—anyone walking by to the bathroom from any of the other wards or just wandering the halls, will definitely hear and probably also see her bare dark body spasm in agony.

*          *          *

Mulago is an overload for the senses. Visual, auditory, olfactory. First of all is the ever-present scent of body-odour. Many Africans don’t wear deodorant. However, that is the least of my concern as I walk by certain other areas, where there is an overwhelmingly foul odour so potent I have to make a conscious effort not to retch as I walk by. My efforts to keep my face neutral fails as I wrinkle my nose in protest. The source of the offending odour? There is only one functioning bathroom for all the antenatal and post-natal mothers and attendants—about 100 mothers in all.  I haven’t had the courage to see if there is a sink and soap or alcohol to wash hands. I really hope so, but given the paucity of sinks and places to clean your hands in general, I’m not so sure.

Ironically the woman with the closest bed to the bathroom (even if you didn’t know it by sight , you would definitely know by smell) has an open infected wound growing ultra-resistant bacteria to everything except meropenem, one of the most expensive antibiotics. She certainly can’t afford it. I wonder what will happen to her. Her next door bedmate has active TB and is coughing everywhere. She is so skinny, between her HIV and TB, she is literally wasting away in front of me, her upper arms skinnier than my wrist. There are also plenty of women with malaria in pregnancy. Fortunately, easily to test for and treat. Not so fortunate: there are no mosquito nets and lots of mosquitos flying around spreading the disease from patient to patient (yes, even in the OR, I had to bat a few mozzies and flies away).

*          *          *

Getting to the C-section OR involves walking through a small foyer. I literally have to pick my way through a maze of people who have basically set up camp in the corridors. I’m not exactly sure who these people are, whether they are family members and friends of the women in labour, women waiting to be assessed/placed, or the post-partum mothers who aren’t keen on staying in their “room”. Not that I can blame them if they’re the latter. Women who’ve had a normal vaginal delivery are crammed together like cattle into a small, windowless room with no furniture (there is no room.) The floor is mostly covered in mats, cloths, and bamboo mats. The women sit crammed, side by side by side, cross legged (there’s no room to stretch out), holding their babies. It is literally just a holding area for post-partum mothers.

*          *          *

Like everything else at Mulago, the OR is a bit of a culture shock. Once I successfully weave through the masses of bodies to get here, I am given a dirty looking (but I’m assuming sterilized/clean?) large piece of square cloth to tie back my hair. There are 2 residents on tonight plus an intern just dedicating to doing Cesareans. Two rooms are going at once, non-stop. I figured out from first glance that these were not originally designed to be ORs. More than anything they remind me of a concrete one-car garage. The ORs are not closed off, even from each other; from the OR hallway, you can look into all 3 ORs at once. Set up is basic: anesthetic machine, OR light, instrument tray, which had a variety of instruments, sometimes what you needed and sometimes not. Even very basic, essential instruments, like needle drivers (used to hold the sutures that sew people together) aren’t guaranteed-for one case I have to use a hemostat instead. They have run out of catheters, making surgery more difficult and dangerous as we try to avoid the bladders that puff up like balloons. There are no mattresses on the stretchers, and neither the OR beds nor stretchers change height, so transferring patients always involves a rather uncomfortable yank-and-plunk (about 30-40cm down) onto the metal stretcher.

There is no particular waiting area for patients waiting for C-section. When their turn is coming, up, women are shown the door to the OR. They then sit on the floor in the corner, clutching their papers and their sarong, laboring, cramping, crying, until the room is ready and they can find a bed to crawl on. I feel sorry for them, if I am a bit confused and intimidated and overwhelmed, how much more their fear and anxiety!  But once again, my very limited Luganda prevents me from comforting them and explaining the situation.

*          *          *

Somehow the night passes by and it is time for morning rounds. Good thing it isn’t just me rounding, or I would miss chunks of patients. I didn’t realize that at Mulago you don’t just look for full beds and people on the floor, but there are also frequently patients under the beds!! Probably so that they don’t get stepped on by being between beds.

*          *          *

And thus was my night at Mulago. One one hand, enough to bring me to my knees in tears at the state of the national referral hospital, the country’s largest teaching center. Lacking basic necessities such as water, toilets, beds, it can be overwhelming. Yet, despite the chaos, I continue to be awed and amazed by the staff who work there. They are uniformly committed to their jobs and to their patients, whatever the work environment and terrible wages. Their knowledge and skills are certainly up to any resident or doctor I know back home, and more advanced in areas that we rarely see at home, such as management of multiple co-infections, such as TB, HIV, and malaria. After just one night, I’m not sure I could survive, let alone thrive in the chaos and madness that is Mulago. Yet the residents and doctors and midwives and nurses here do. I definitely have a thing or two to learn from them. And next time I’m back at home complaining about something like the difficulty of getting after-hours ultrasounds, or that lab results are taking a while to show up on the computer, I’ll think again, recalling the patience and cheerfulness of my colleagues in Uganda and other parts of the world who work in infinitely more difficult circumstances, and remind myself how fortunate I truly am to live and work in Canada.

The Mighty Nile and the Mystery of Hotel "Jekyll and Hyde"

Everyone who has been to Uganda told me to go to Jinja and go whitewater rafting. I was a little anxious about whitewater rafting, for while I had a most excellent and enjoyable experience with my sister rafting down the Colorado River in the Grand Canyon this spring for 2 weeks, my last experience rafting overseas was in Thailand years ago, and during one particularly scary capsize, I became doubtful for my ability to come through alive. (Those of you who’ve been on this email list long enough will remember that entry!!)

I later found out from one of the American guides (though most were Ugandan) that of the 20 rivers he’s rafted on, the Nile (this stretch) is the safest because it’s so large volume there’s little chance of smashing yourself against a rock, and the rapids are short followed by long stretches of flat water. I did learn, however, that while it is generally crocodile-free since the villagers kill any spare crocs, there was a 15 footer that was captured and killed a few months ago here. Yikes! Maybe this is the reason I had that song “Never Smile at a Crocodile” inexplicably stuck in my head most of the way down…

Luckily for us, no crocs on this trip. Lots of capsizing, though! Out of 8 rapids, we flipped on 4, and I fell out on an additional one. At first it was terrifying, being washing-machined around in the spinning water, bumping up against the raft, being sucked back under, and, luckily for me, the second time popping up was never back under the raft. But by the end, flipping was almost blasé, (but not quite). I was pretty much expecting it. Especially when you see a huge standing wave that is twice as high as your boat, with lapping foam coming down  generously over the crest, just begging to flip you over (which it inevitably did.) Luckily the water was 28C, as was the air, so it was just a refreshing little swim to get capsized. Sometimes in the flats we would just jump out and swim for the heck of it.

Jinja is located at the source of the White Nile, as it leaves Lake Victoria. I found what at first seemed to be a too-good-to-be-true budget hotel, right on Lake Victoria at the Nile Headwaters! How awesome is that?! Really awesome. The views were incredible, in the morning mist, watching the sun set, just so gorgeous and peaceful. A kind and gentle Dr Jekyll. Except at night. Night was an entirely other entity here at the Hotel Triangle. It’s when it’s evil Mr Hyde side came out. It’s when the lake flies came out. They are kind of like mayflies back home-big, but harmless. At least, that’s what I had to keep telling myself, as I tried not to panic walking back that first night after supper (in the dark) walking along the outdoor balcony to my place, the crunch crunch crunch over hundreds of lakefly bodies, the walls looked black and alive and swarming rather than the painted white I knew them to be. I swatted at my face as they kept entangling themselves in my hair and flying into my eyes, nose, and mouth.

See how beautiful the headwaters of the Nile are in daytime! 

Still glorious at sunset! Little did I expect what was coming!

No I did not get any night photos. Sorry. The less time being mauled by bugs the better. Plus there was NO WAY I was getting out from under that mosquito net, no matter how tempting the photo....you'll just have to imagine.

I stepped into my room, turned on the light, and closed the door, relieved to be out of the madness. WRONG ORDER. In the microseconds between turning on the light and then shutting the door, I’d been invaded. Hundreds, if not thousands, of flies were now in my room. I was starting to get demoralized. I quickly let down my mosquito net, but to little avail, for there were almost as many bugs inside the net as out. I put the net down anyhow and went on about a 20 minute killing spree making my white sheets black with polka-dotted black bug bodies. I then covered the sheet tightly over me to prevent me from feeling any more creepy-crawlies (which worked except when they crawled on my face, or up from under the sheets).

I think I might have fallen asleep, but woke up in what I first thought was a panic attack. I felt like I couldn’t breathe. And of course I hadn’t brought my inhalers with me on this short weekend trip. I just wanted fresh air, but there was NO WAY I was going to open that door outside again, and the windows had no screens, so that was out, too. I decided to just blast the fan and try to lay outside of my sheets and calm myself. But my lungs were still feeling really tight. Finally I found a Benadryl which I took for sleep more than anything.

Somehow I fell asleep and in the morning it was almost like nothing happened. Most of the bugs had disappeared in my room, some of their bodies were littered on the floors. Same with outside. No indication of last night’s infestation, except for the crunch crunch crunch over the thousands of bodies that littered the ground, but were already being swept away by hotel staff.

Next night I was prepared. Before I went out for dinner, I tucked my net down. Coming back, I opened and shut my door lightening-quick, not turning on the light. Still a disappointing amount of bugs, but hey, at least there weren’t many in my bed! Still had that tight, uncomfortable panicked feeling though, like I couldn’t breathe. But it didn’t feel like anxiety tonight…again, I took a Benadryl and eventually fell asleep.

The mystery of the tight lungs was solved the next day. I forgot something in my room after breakfast, and when I went back to get it, I could barely enter the room, so strong was the stench of insecticide. I had to go back a few doors, take a gulp of air, hold my breath, run inside, grab my stuff, and back out before I breathed again. I tried to open the windows for some aeration, but got scolded by the maid who told me it would let bugs in. Good to know. Very good that I didn’t have some even more asthmatic friends of mine stay with me! I left the next day.

But on a good note, Dr Jean had recommended a local Jinja artist to me. I instantly fell in love with Angelo's work and got him to commission a piece for me! So exciting! I've never commissioned anyone for anything. Sadly, my camera was out of batteries they day it was ready for pick-up but you'll be able to see it displayed in my condo soon :)

Angelo working hard on his paintings

Harrowing stories from the OR

I am in the doc’s waiting room in the OR waiting to do a C-section. Reading my JOGC that I am planning on leaving here when I finish reading it (a medical journal--yes I'm a nerd!). Topic is peripartum hysterectomies in developing countries. Apparently the number one cause is uterine rupture, unlike at home where it’s PPH/placental abnormalities like accreta. Interesting. We get called that the OR, the patient is ready. I put down the journal. Little do I realize how topical it would be.

In the charting room

It’s a routine section, woman in labour with a previous section and failure to progress, and some signs the fetal distress. I open up and groan silently to myself. Nothing but thick, thick adhesions. The bladder is scarred halfway up the uterus. I can do it, I can do it, I tell myself. Slow and steady. Nice and methodical. Yes, here comes an adhesion down. And another one. Progress is slow. Painfully so. But it is still progress!

All of a sudden that changes. I see some strange filmy layer on the uterus, brownish in colour. I touch it gently to see if I can get a better idea of what it is. But even a light prod is enough to burst the sac, and fluid that looks ominously like stool starts to pour out. After a moment of deliberation, Dr Paul decides that it’s meconium (baby stool), and that this poor woman’s uterus has ruptured. We incise just above and pull out the baby, who is grey, oh so grey, and limp. I have no idea if it is alive or dead. But can’t focus on that. We need to figure out if we can save this woman’s uterus. We feel down to see if we can reach the bottom part of the tear, sew it together, make it possible for this woman to have another baby. But feeling down down down, all I can feel is friable tissue that would never hold together. Getting a better view of things, we can see that almost a quarter of the uterine circumference has been torn. It is not salvageable. So we have to take it out. “Please save the baby”, we announce to the nurse. “It is this woman’s last baby”. Miraculously, the baby survives. The mother barely does. We have no blood in the hospital for the last few days. We’ve asked someone to go to Kampala, at least an hour away, to get some blood. We get called to the patient's bedside later in the afternoon. She is still breathing, but has no palpable pulse and no readable blood pressure. Her breathing is slow and labored, her heart pounding at a pace I know is unsustainable. We’ve already given her a lot of fluid. In fact she probably has more saline flowing through her vessels than actual blood. I call for some epinephrine, the only pressor they have here. It doesn’t do much. Blood pressure still not readable. What she needs is blood. Dr Agnes has the same blood type. We are getting ready to take some whole blood from Agnes and transfuse it into this woman, when the ambulance arrives from Kampala with that precious blood. We run out and hang it. And wait. And hope. And pray. Miraculously, this woman has been brought back from the brink of death. Another few hours, and she would not have been so lucky. I saw them just yesterday, and they looked fine, both mother and babe. I wonder if the mother realizes how lucky she is to have a live baby, how incredibly fortunate she is to be alive herself. 

One day, I was reading a bit in the surgery textbook that sits in the OR charting room. It’s basically simplified surgery for non-surgeons who must operate. The typical scenario they open with strikes terror into my heart:

“you have just arrived at your new post. As you are unpacking your things, a nurse runs up to you and yells, ‘Doctor, Doctor! There is someone who has just arrived after a motorcycle accident. We fear his spleen has ruptured, he will need emergency surgery.’ You have never done one of these surgeries. You assisted on a few as an intern, but the senior you were working with never let you operate, except to sometimes close skin. You are the only doctor currently on site. The nearest referral center is 3 hours away and you know that if you refer this young man, he will die on the way.” 

YIKES!!!!! They have something in the textbook I think called “Bewes Rule” (or something). If you are really stuck, have an assistant press a gauze firmly against the source of bleeding. Unscrub, have a cup of tea, and look at this book. After 10 minutes you will be much refreshed and more confident.” I ask Dr Matov and Dr Agnes if they've ever used this "rule". "Many times!" they both chime in. While it has clearly been helpful in saving patients' lives here, I somehow doubt it would be acceptable for a Canadian surgeon to try that...

One of the OR sinks. The soap dispenser is out of soap. The remaining bit is in that blue plastic container. To scrub we just have to fish it out with our fingers. At least the water works.

Again, my reading proves to be somewhat topical. Later that evening, I get called to see if I want to see a splenectomy. Of course! Drs Matov and Agnes are doing it. I ask Matov how many he’s done. 3. One for each of the months that he’s been here. They have all been unsupervised. He had assisted on a few as an intern before being thrown into the situation of being the sole doctor on call in the whole hospital in a rural area, where patient transport is slow and prohibitively expensive. So the buck stops at him. Little matter if he’s inexperienced. Either he operates or the patient dies. Matov says a prayer before we start. Unexpected, but I like it. As soon as the peritoneum is incised, burgundy blood flows out. And keeps flowing out. With each breath of the patient, another gush. I wonder when it is going to stop. If it is going to stop. We fill up a suction canister and there is little sign of slowing. I am starting to get worried. Finally the flow slows enough (it never really stops) for Matov to reach a hand in. Out comes what looks like a giant clot. Oh, nevermind, it’s what remains of the spleen of this poor young many hit by a boda boda, a motorcycle taxi. The surgery goes well, and we are actually out pretty quickly with good hemostasis. Good job Matov. Maybe I should take to praying before my operations, too.

 Drs Paul, Matov and Agnes in the OR charting room

Another evening, unstable bleeding patients seem to be the theme. This time it’s a woman with an ectopic pregnancy. I get called to the OR. I get there and it’s locked. When I call Dr Paul, he says in a very frustrated voice that the woman is refusing to consent to surgery until she talks to her husband, who has been unreachable for the last hour while they have been negotiating. I walk back to the guesthouse, feeling sick. This woman is already very unstable with tanking blood pressures. But there is nothing we can do. What about when she goes unconscious? Is that implied consent? Or will we have to watch her die? 

Luckily we don’t get to that point. About 30 minutes later, Dr Paul calls me again and tells me they finally reached the husband and he talked his wife into consenting.  When we open her up, it’s blood again. So much blood. When we finally clear things enough to see the tube, it’s hard to believe this tiny little tube with the steadily oozing blood could be responsible for this much havoc. Blood is everywhere, clots soaking through the OR drapes, through my gown and into my plastic apron that we wear since the OR gowns are just cotton and not fluid resisitant.  The white rubber boots we wear are stained deep red, and I’m standing in a puddle. When I start to suction her belly clean, Dr Paul tells me to hold off and leave it. We leave the blood in her pelvis because there is no more blood in the hospital. They ran out yesterday. And this woman has lost at least 2L. Apparently it will reabsorb through her peritoneum, like peritoneal dialysis of sorts. A few days later, we get some blood from Kampala, and we give her one unit. But despite the fact that her hemoglobin was only 39 (!!) pre-transfusion and likely now only sitting at about 50, and her heart is racing and she’s dizzy, we dare not give her any more. She looks and feels better than when her hemoglobin was 39 (how can you not!)  and her heart rate, although still high, has come down. We dare not transfuse her, for we won’t get another shipment of blood for at least a week, and the weekend is coming up. If we give another unit to her, it could cost the life of another. She has enough to survive, for now.