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!

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.