Saturday, October 27, 2007
We reviewed the statistics for the last week:
6 cesarean sections per day (average)
10 FSBs (Fresh Stillbirths)
4 MSBs (Macerated Stillbirths)
1 Maternal Mortality
At the end of the meeting, they let me take a picture:
These are some of the postgraduates and interns:
Dr. Mugyenyi and Dr. Wasswa:
Dr. Wasswa and Dr. Mukasa:
I am truly grateful to everyone in the department. The nurses and midwives who graciously helped me figure out how things worked, translated for me and tolerated my bumbling. The postgraduates who showed me everything, treated me as one of them, and were so considerate and wonderful despite their exhaustion. The consultants who treated me as a colleague, who were so receptive to my perspective and interests, and engaged in so many stimulating discussions with me about the state of women's health in Uganda. The patients who, although we did not speak the same language, communicated nonetheless, welcomed me with broad smiles, and taught me countless unforgettable lessons.
Friday, October 26, 2007
We planned to leave at 8 am. Which became 9am. So we left at 12pm.
On the way there, we stopped in an agricultural town where swarms of people came running up to the car bearing big bunches of onions. Occasionally someone had cauliflower or garlic, but it was a serious Onion Town. On the way back, we stopped in Carrot town – swarms of people ran to the car bearing trays of large, fresh, Bugs-Bunny-type carrots. The price was an entire tray (maybe 20 or 30 huge carrots) for 1500 Shillings – about 80 cents.
Lake Bunyoni was truly stunning. Supposedly, it is a very hilly/mountainous area that had a large river near it. Then a rock collapse or something created a natural dam in the river, and all the water flowed into this large valley and became Lake Bunyoni. That’s what Dr. Mugyenyi told me, anyway.
The Lake is quite large (and reputedly very deep), and winds around various islands. We stopped at a camping area, walked around the grounds and had lunch (chicken & chips). Then we hired a boat to take us around the lake. It had a motor, but we had fun pretending to row.
No one but me knew how to swim, so there was a lot of drama surrounding the life jackets before we took off. Dr. Mugyenyi just kept his close by, but his wife & sister wore them throughout the ride.
One of the very small islands is called Punishment Island. It was where unmarried pregnant women were taken as punishment for getting pregnant. It was a tiny, barren island with only one tree, and it was expected that the women would die of starvation. When they did die, it was usually drowning from trying to swim away. Dr. Mugyenyi told me that young men who were poor and couldn’t afford a dowry would wait until a girl was dropped off on Punishment Island, then would swing by in a boat, “rescue” her and take her as his free bride.
Wednesday, October 24, 2007
Crytpococcal meningitis is largely an illness of HIV/AIDS patients. Patients usually present with a headache of mental status changes, and the diagnosis is made through a lumbar puncture (LP) and staining of the cerebrospinal fluid with India Ink. Personally, I have seen it once - in medical school (Downstate, where else?). The Internal Medicine service here in Uganda sees it frequently - at least 1-2 per week. But the Obs/Gyn department rarely ever sees it.
This patient had been diagnosed as an outpatient by LP, and had been treated with fluconazole. She had stopped taking it - it is not clear why, although probably because she couldn't afford it. By the time she was admitted, she had not taken it for 2 weeks. Therefore, her risk of resistance was high.
The true treatment for Crytpococcal meningitis is Amphotericin (or, as it is often called, Amphoterrible, because of its awful side effects. Doctors shudder when discussing it.). It is contraindicated in pregnancy (as far as I know), and anyway it's not an option here, because it is too expensive. Instead, the hospital here is trying a regimen of high-dose fluconazole. Whereas the dose this patient was taking was 400mg once a day, the internal medicine service is treating patients with up to 1200mg per day. We don't know the effects of this in pregnancy.
On Friday, I rounded with Dr. Wasswa. I have come to appreciate his insights, as he has seen a lot and is quite detail-oriented. We reviewed the patient’s progress.
On admission, the patent had undergone another LP, which revealed elevated intracranial pressure and again a positive India Ink stain and CSF culture for cryptococcus. She was now taking 400mg of fluconazole daily by mouth, which her mother would crush up and dissolve into liquid for her. The patient was doing very poorly. She was conscious, but just barely, and was worsening daily. Her mother was her attendant, and we could see how caring and attentive she was. The patient said very little, except at one point she shouted "I can't see!" in Runyankole. The mother told us that her vision and hearing were going.
Dr. Wasswa decided to call the medicine consult again. Perhaps the patient needed another LP, or a different medication, or steroids? Neither of us was very familiar with the management of this complicated illness. We discussed whether or not to deliver her. We weren't sure of the gestational age. Was the pregnancy making her condition worse? No. Would she be helped by delivery? No, not like a pre-eclamptic would. Would delivery make her worse? Possibly. Probably. But it would also allow us to give aggressive medication without worrying about the fetus.
We were not sure of her gestational age. The absolute minimal gestational age for survival here is 28 weeks, and even then they rarely survive. Her LMP was very uncertain; we were estimating 30-33 weeks, but what if it was less? What if she had irregular menses from chronic disease? In the US, we would immediately do a bedside ultrasound to get a sense of the fetal measurements and weight. Here, there is one ultrasound (in fact, it’s the imaging modality. There is no X-ray, CT scan or MRI) and it is a tiny screen (barely bigger than an iPod) and can’t take any measurements. There is a better ultrasound machine in the MSF (Medecins Sans Frontiers) research center, and I could do fetal measurements there, but the patient would have to be moved way over to the center, and she was not stable or cooperative enough.
What would be the best mode of delivery? Vaginal delivery would be best for her, but an induction would be likely to fail at her gestational age, and a cesarean after failed induction has increased risks of infection, blood loss and essentially every complication. Plus, her HIV was probably advanced, and her viral load high (although she was on anti-retrovirals, Cryptococcal meningitis usually only happens when the immune system is severely compromised. In Mbarara, we can only check CD4 count, not viral load, but we didn't even have that for her.) . So then her likelihood of transmission to the fetus would be high in a vaginal delivery. So perhaps we should just do a cesarean section. But in that case, we would be performing an elective abdominal surgery on a severely ill woman - it could easily kill her.
With all these uncertainties, we decided it would be safer not to deliver her yet. We would call the medicine service and see what their recommendations were. If they felt we should deliver her and somehow we could get her Amphotericin, then that might be an indication.
By the afternoon, no one had called medicine. I ran into Jane, a British internist working for a year as a consultant in Mbarara, and told her about the patient’s worsening status. Immediately concerned, she went straight to the ward with me to evaluate her.
With her hearing and vision loss, the patient probably had high intracranial pressure. She needed an emergent LP, and probably daily LPs until her pressures improved. She should be transferred to the cryptococcal service on the medicine ward, where the fluconazole is provided free of charge (the patient’s mother had been purchasing it herself, and it was difficult for them), and would get better monitoring. We spoke to Tony, a senior consultant and an expert in HIV neurology. He agreed with the plan. We discussed whether to increase the dose of fluconazole to 1200mg. Fluconazole is avoided in pregnancy, mostly because its effects are not well known, and 1200mg is a very high dose. On the other hand, this woman was going to die without it. Even with it, Tony estimated her chances of survival at about 50%. She was now in the third trimester, so anomalies are not a concern, and regardless: no mother, no baby. We agreed to increase the dose.
There were no beds on the medicine ward, and the patient would have had to sleep on the floor, so we left her on the antepartum ward, but Jane said they would round on her in the morning. The next morning, the patient had still not gotten the higher dose of fluconazole; Jane gave it herself.
Later that evening, she developed intractable seizures (here, they call them “fits,” or they say “the patient was fitting”) and went into cardiopulmonary arrest. Jane was there. They tried to rescusitate, but couldn’t, and postmortem cesareans are rare here. Mother and fetus died.
Tuesday, October 23, 2007
Monday, October 22, 2007
I was glad to see that they took lemons and made lemonade:
Thursday, October 18, 2007
Last week, when I attended Dr. Mugyeni’s clinic, we saw a woman who has had vesicovaginal fistula for the last ten years, and who presented only now for help because she never had the money for transportation.
She had six normal deliveries, followed by a seventh pregnancy that was complicated by a long obstructed labor, which resulted, eventually, in an emergency cesarean. The baby was stillborn, and she is not sure what was done in the surgery. Since then she has had very light menses and she continually leaks urine.
She is now 37 years old, and a widow; her husband died in 2004.
We admitted her to the hospital from clinic in preparation for surgery, but were only able to get her into theatre today, one week later.
We did the repair under spinal anesthesia. Her spinal was difficult, and it was the first time I realized that they do them without numbing the area first; the women invariably tolerate the spinal without a peep. I couldn’t imagine that in the United States.
Intraoperatively, we found no cervix – probably at the time of cesarean she had had a uterine rupture and a total cesarean hysterectomy. The fistula was easy to see – it was a vertical slit-like hole, just less than one centimeter, somewhat near the apex of the vaginal vault. You could see the urine leaking from it.
Conceptually, the repair is not hard. It is the reality of it that makes it difficult. You incise the surrounding vaginal mucosa, dissect the vaginal mucosa off the bladder, close the bladder defect (we did it with a pursestring suture) and then close the vaginal mucosa. But visualization is hard, since, after all, you are operating inside a vagina. And you have to be careful about the ureters, which in her case was difficult because the cervix is usually a valuable landmark.
But this year I have found that I really enjoy vaginal surgery, largely under the tutelage of Dr. Banks and Dr. Wieland at home. This surgery in particular was quite fun, and incredibly satisfying. If it works (and I really hope it does) it will make an immeasurable difference in this woman’s life. I can’t imagine what it must be like to leak urine every minute of every day, to smell of urine constantly, to have an irritated, blistered perineum because good hygiene is impossible. And all because of one tiny little hole, less than once centimeter.
The surgery is only the first half of the fistula repair. The integrity of the repair depends deeply on the quality of the nursing care. The patient has to have a catheter in her bladder for an extended period of time, and one has to insure that the catheter does not become blocked, because overdistension of the bladder could destroy the repair. There are very few nurses here, and they cannot provide the kind of care required to repair fistulas often like this. So the patient herself will have to be vigilant about her catheter. I am going back to the ward now to check on her.
In developing countries the most common clinical scenario for uterine rupture is a woman with several prior vaginal deliveries and an unscarred uterus, and it is not a rare event. In Mbarara, they see at least 1 or 2 per week. There hadn’t been any since I arrived, and someone joked that I was a good luck charm.
Today I was in the Operating Theatre watching Dr. Mayanja and Dora repair a previously unrepaired fourth degree laceration, when one of the other interns arrived to say that there was a suspected uterine rupture who needed to come to the OR. She had been laboring since 11am yesterday (it was now 5pm), her contractions had stopped, and her abdomen was abnormally distended. She had 3 prior vaginal deliveries, and 2 living children (one died at 2 months).
There was a woman waiting in the holding area for a cesarean, but she was not the uterine rupture. It was an obstructed labor. Curiously, they did her cesarean before the uterine rupture. It was a long time before the fourth degree repair was done and the room was ready for the uterine rupture, who had by now arrived in the holding area. She was in pain, but she was not contracting, and the upper part of her abdomen was rock hard, like a skull, and there was a strange tympanic bulge on the left side. She was stable.
As we started to wheel her into the Theatre, Liz, an intern, came by to say that there was a cord prolapse on the ward, and they needed to bring her now. I said “Whose hand is in the vagina?” and Liz said “No one’s.” I wondered if it was a true cord prolapse, and if so, whether the baby was alive. Still, now we had to choose between the cord prolapse and the uterine rupture.
The cord prolapse didn’t arrive. So we moved the uterine rupture into the theatre. We overheard that the cord prolapse delivered spontaneously. The anesthetist told me to scrub. Then a midwife came in with the cord prolapse baby, who was doing poorly. He was blue, limp and gasping for air. Now the uterine rupture had to wait while the anesthetist rescusitated the baby. He tried to intubate, unsuccessfully, and left on a nasal cannula and went back to the theatre.
Dr. Mukasa came in to perform the cesarean with me. By this time, it was 7pm. When we opened, we found a seemingly intact uterus, but a huge abnormal bulge in the lower uterine segment with the bladder overlying it. I wondered if she had ruptured into the bladder.
We got the baby out, and it seemed ENORMOUS. I would have guessed 6kg, although when they weighed it, it was only 4.5kg. Not surprisingly, the baby was dead, and there was a foul odor. When we evaluated the uterus, it looked ugly. The lower segment was attenuated and necrotic-appearing. It could not be repaired, so we did a hysterectomy.
We ligated the round and uterovarian ligaments on both sides. We ligated the uterine arteries on both sides. There was some bleeding on the left. And then the power went out. Dr. Mukasa said “Get a torch, quickly!” The anesthetist shone his mobile phone (seriously), which didn’t do much. Then he used the laryngoscope light, which gave us enough light to just see exactly where we were sewing. Finally, they came with a battery-powered bright light (it looked like a bug zapper).
The anesthesiologist, who was watching us, said “Do you know what TIA is? This Is Africa.” Eventually the lights came back on, and we finished the cesarean hysterectomy. The mother was OK.
After that, I did 2 cesareans with Liz. By then we had run out of masks, so Liz tied a piece of gauze around her face. We had run out of knife handles, so we used a small clamp to grasp a surgical blade, and we cut with that. All the while, Liz kept saying, “This is Africa. We improvise.”
The medical students had their exams this week. The written exam was on Friday. On Monday, the third-year students took their clinical exams, and on Tuesday it was the fifth-year students.
The clinical exam consists of three parts:
- The Long Case: The student is assigned to a patient in a ward bed. She or he is given 1 hour to take the history and perform a basic physical exam, and compile a differential diagnosis. Then the examiner, one of the consultants, approaches the student at the patient’s bedside, and the student presents the patient. The consultant questions the student throughout – either to clarify a statement, or to ask for more detail, or to simply quiz on that particular topic. Then the student does a complete physical exam in front of the examiner, stating the relevant findings. At the end, the student is asked for the diagnosis, and then the differential diagnosis. The examiner has 30 minutes for this portion.
- The Short Case: After the Long Case, the student moves onto the next patient to which she or he is assigned, where the consultant is waiting, having finished the Long Case with the prior student. The consultant tells this student the basic details of the patient’s history, and then asks the student to do a complete physical exam. At the end, again the student has to state the diagnosis and the differential diagnosis. This is 20 minutes.
- The Viva (pronounced Vye-vah): A large tray of many medical instruments and tools are present on the table, such as a speculum, an IV cannula, a bottle of normal saline, Oxytocin, oral contraceptives, a ring forceps, et cetera. The examiner chooses (or has the student choose) an item, then asks the student “What is it, and how is it used?” As the student speaks, the examiner asks more details, and can go in any direction with it, and eventually the instrument itself can become irrelevant. The discussion may focus on only one instrument, or may incorporate several instruments. The Viva lasts 20 minutes.
It was very interesting to watch the exams. I have particularly enjoyed here how the physical exam becomes so much more important in the absence of basic diagnostic tests (eg. diagnosing anemia based on pallor in the conjunctivae and palms, palpating hepatomegaly and splenomegaly).
My favorite part of the exam was the viva. I thought it was very creative, and a very nice way to quiz students. There was such a wide range of questions that could be asked, and all were clinically relevant, and could have been learned on the wards.
Dr. Mugyeni conducted the Viva for the third-year students. He is a sympathetic man who smiles often, although he can be firm when teaching. He encouraged me and Joseph, the postgraduate who was there, to chime in with questions. He usually used the instrument to start, and then asked several questions surrounding the subject. Sometimes his question was confusing in the wording, and I could see the student hesitate. He wouldn’t realize the confusion, but sometimes Joseph or I could clarify.
For the fifth-year students, Dr. Wasswa conducted the Viva. He is an operatic man, with a definite stage presence and a lot of drama in his speaking. He punctuates his sentences with volume and by bulging his eyes out. It is quite funny when you are watching, but surely quite scary when you are the anxious medical student in the spotlight.
For Dr. Wasswa, the tray of medical instruments was a mere table adornment. I saw him use it only once, when he handed a student a vial of Depo-Provera. The rest of the time, he picked a topic and just started asking questions.
The questions were often vague, and sometimes designed to have only a wrong answer. For example, if he asked a student what he might find in a clinical scenario, and the student said something like “The patient might have ruptured membranes, or vaginal bleeding,” Dr Wasswa would bellow “Doctor! You want the patient to have ruptured membranes or vaginal bleeding! That is terrible! You are a truly bad doctor!” He also had a tendency to close his eyes as the student spoke, so that you might think he had fallen asleep, then suddenly he would bulge his eyes and shout “CORRECT!!”
Martin, the postgraduate who was with Dr. Wasswa, is a very nice, empathetic soul. Sometimes when a student could not get an answer, Dr. Wasswa would sit there and just stare at the poor thing, and you could cut the tension with a knife. At one point, Martin couldn’t handle the tension anymore and just burst out with an answer.
The funniest part was when he was asking a student about gestational diabetes, and the answer was “Insulin”. The student could get it. Dr. Wasswa picked up a pack of syringes with needles off the tray, tore one away from the pack, and began to fiddle with it. He tapped himself on the cheek, twirled it in from of his face and held it straight up. Still, the student could not get it. Dr. Wasswa finally gave up.
As a side note, the women who participate in the Long and Short Cases are all real patients in the wards. They are approached and asked to participate, and they invariably agree. The women are astoundingly tolerant of all of this, sitting through each extended review of their personal medical history, complaints, and descriptions of their bodies (“The abdomen is distended and uneven. It moves with respiration. There are striae and a linea nigra.”) with patience and a bemused expression. At the end, snacks and sodas are purchased for them. Also, in order to prepare the ward for exams, the patients who are not chosen to participate (and who are not so sick) are cleared out of the postpartum ward and wait outside all day. I found it remarkable.
Why would a boy spend his Saturday preaching to women in the maternity ward of a hospital? And why would the women want it? Maybe they just tolerate it because he’s so young and cute.
But no, then I see that he is standing above one woman, he reaches his hands up and lowers them over her body until he is touching her. He continues to shout in Runyankole, with his eyes closed and his face pointed to the ceiling. She has her eyes closed in order to be healed by him. This is not merely bemused tolerance of a silly child.
He has been talking so loudly and for so long that we can’t help but hear it from where we are in admissions. Moses, one of the postgraduates, is now getting distracted; a couple of times he looks over at the boy, chuckles and shakes his head.
When I look again he is on to another woman, who is standing with her eyes closed. He puts one hand on her forehead and waves the other hand up and down in the air, shouting all the while in his growly tone.
So it’s definitely religious, but I’m still confused. Why would this boy spend his time doing this?
The next time I turn back, I get it. He has just finished his healing with a woman close to the door; she reaches out a hand, and he takes the money in her hand and puts it in his pocket.
Later I see him outside the building. He looks like any other little kid, there to visit his mother or something.
Monday, October 15, 2007
This is why I heart the Lancet.
The Lancet published research article last Friday that showed that abortions are not less common in countries where it is illegal, only less safe. Here is the New York Times article about it:
In a discussion today among the consultants (attendings), it was noted that MVAs are often unavailable, and are being discouraged by health authorities because they assume that they will then be used by healthcare providers for illegal abortions. For the same reason, misoprostol is not approved (it can only be purchased on the black market for about $2 per 200mcg pill), even for postpartum hemorrhage.
Therefore, two methods which are known to be extremely effective in the treatment of pregnancy-associated hemorrhage - one of the biggest killers of pregnant women - are discouraged or prohibited because of a fear that they will be used to perform safe, illegal abortion.
Now, a multiple choice quiz:
1. Women are dying in droves every day of hemorrhage and septic abortion. This is:
2. A woman dying of hemmorhage should die because the method that would save her life could possibly be used for an illegal abortion.
As one of the consultants said in the discussion today, almost anything can be used for illegal abortion if the desire is there. Maybe we should make cassava illegal.
Date of death: Hospital Day #2
EDD: Post-delivery (abortion at 4 months induced 4 weeks prior)
Death d uring delivery: No
- Arrives complaining of lower abdominal pains following induced abortion four weeks prior (cassava stem inserted vaginally)
- Second pregnancy, first child is alive
- Feverish, vomiting, moderate pallor, no jaundice, fully conscious but weak, in shock
- Foul-smelling discharge
- Impression: post-abortion sepsis
- Peritonitis secondary to septic abortion
- Find perforated uterus
- Declines quickly following surgery
- IV antibiotics
- IV fluids
- Exploratory laparotomy and total hysterectomy
- Taken to ICU following surgery
Cause of death: Septic abortion
Date of death: Hospital day #1 (9 hours after admission)
Death during delivery: Yes
- Arrives after convulsion at home, had previously been well
- High blood pressure
- Deteriorates quickly, unable to talk, unconscious, more convulsions
- Blood clots from the mouth,bleeding from the mouth and blood in urine
- Impression: at first head injury, then complication of eclampsia and hypoxia
- Labor induced
- Magnesium sulfate
- Patient was intubated and started on mechanical ventilation, arrested after three minutes of ventilation
- Rescusitation started, doctor decides not to do CPR
- Mother dies during delivery – baby extracted due to shoulder dystocia
Cause of death: Dissemintated intravascular coagulopathy with widespread haemorrhage into all tissues due to eclampsia
Date of death: Hospital day #3, Postpartum day #6
Death during delivery: No
- Fever, severe headache, abdominal pain, vomiting (history of fever for past three months)
- Wasn’t feeling well, treated herself for malaria, started contractions, had spontaneous abortion at 16 weeks (due to fever?)
- Went to HC III, where she as treated and discharged
- Discharge from vagina, had herbal treatment
- Poorly treated malaria and incomplete septic abortion
- Disoriented and generalized convulsions, but GCS is 15/15
- HIV negative
- Evacuation performed – resulted in significant bleeding
- IV fluids
- IV quinine
- Blood smear requested, but no result listed
Cause of death: Sepsis? Cerebral malaria?
Date of death: Hospital Day #5
Death during delivery: No
- Induced abortion one week before
- Incomplete septic abortion
- Foul smelling discharge
- Significant blood loss
- Developing fever
- Perforation in posterior wall of uterus
- IV antibiotics
- IV fluids
- Blood transfusion
- Surgery to repair perforated uterus and gut (colostomy) and hysterectomy
Thursday, October 11, 2007
She is now 43 weeks and 1 day today. She has 1 prior cesarean section, resulting in a living child, followed by three VBACs, all of which died. The first died at 1 month of life, the second two were fresh stillbirths (FSBs). She desperately wants a living child.
She was admitted with severe anemia three weeks ago. At that time, her hemoglobin was 5, and her platelets were 68. In addition, the fundus seems small and intrauterine growth restriction is suspected (although biometry cannot be done). Adding to her dilemma, her spleen was enormous. Absolutely massive. It is bigger than her uterus. It was measured to be 26cm. It is so big that it hangs down her abdomen, creates a pannus, and pushes the uterus downward.
On admission she received 2 units of blood, and has basically been waiting since then. On the day I saw her, it was Ugandan Independence Day (Oct 9), a holiday, so no consultants were around, only the interns and postgraduates. Plus, the lab was closed.
I felt she needed to be delivered, but how? She has one prior scar; she cannot be induced here (there is no fetal monitoring). But with the levels of hemoglobin and platelets that she arrived with, a cesarean could kill her. Only packed cells are available from the blood bank; platelets have to be ordered 1 day in advance from Kampala, and not on a holiday. Plus, she would have to undergo general anesthesia because a spinal with platelets that low is too dangerous. Furthermore, the last time she had labs was 3 weeks ago – the hemoglobin went to 7 the day after the transfusion. But what were they now? Whatever had caused her anemia could be getting worse.
Her blood pressure had been measured twice over her stay (seriously). Both times, it was 140/80. We took it again – 145/88. Did she have HELLP syndrome? It would go along with the labs and the fetal growth restriction. Or did she have severe hepatosplenomegaly syndrome from chronic repetitive malaria, causing hemolysis and platelet sequestration?
We reviewed her differential diagnoses; no matter what, she needed to be delivered. If it was pregnancy related (eg. preeclampsia), then she would improve after delivery. If it was unrelated, then it would still be there after she delivered, and she had plenty of indication for delivery, given her postdates and growth restriction. The medicine service had been consulted, and they agreed. But how can we do a cesarean when we don’t know her hematologic status? She can’t pay for labs, and the lab refused to do it for free. The medicine consult offered to contribute some of their Poor Patient Fund toward drawing labs for her. (The Obstetric Service needs to establish a Poor Patient Fund.)
The labs did not get drawn that night. They waited until the next day, and then took her blood to the MSF Epicentre, where the labs were tested free. Her hemoglobin is 6.6, and the platelets 87.
She is still pregnant. She was seen by the anesthesiologist, who recommended transfusion and delivery tomorrow under general anesthesia. That is the current plan.
In order to supplement my pitiable cooking abilities, I eat one meal per day in the Intern’s House. It is usually classic Ugandan food.
What is classic Ugandan food? Apparently, starch, starch, and starchy starch, with starch on the side. Also with a little meat. There is Ugali, which I have not yet tried, but I am told is akin to eating cement and could actually be considered the opposite of flavor; antiflavor, if you will. There is matoke, which is a thick mush of plantain, only less sweet. White rice is in abundance. There is a white mushy thing made of maize that I kind of like- it has the consistency of thick, solidified cream of wheat. There is ground nuts (I think that’s what they’re saying) which is literally purple, and looks like babaghanoush (only purple), and tastes, well, nutty. There are also potatoes, of the “Irish” variety, or sweet potato (which is yellow, not our usual orange). And today, to spice it up, there were some noodles. You usually have at least 3 or 4 of these starches in one meal. All of the starch dishes require a sauce, which here is called “soup” (confusing, as they tell you it’s soup, but then they pour it all over your plate), and is usually a thin meat-based broth. Then there is meat, which can be beef, goat, pork, chicken or fish.
Personally, I like this meal option. It's much better than anything I can cook, and starch is delicious (if there's soup). Once, also, there was an eggplant dish that was nicely salted and really, really good. I have been waiting for it to come back again.
The Ob/Gyn department has its own small OR, which is called the Gynae Operating Theatre (OT). It is a short distance from the obstetrics ward, and both the Caesars and the Gyn surgeries are done here, which means that the elective Gyn surgeries are usually bumped for the emergent cesarean sections. Today we were lucky in that Sarah, the anesthetist, was willing to run two rooms simultaneously.
The OT is a freestanding structure, and as soon as you enter the outer door, you remove your shoes and put on clogs that remain in the OT. There is a small foyer with a desk for writing operative notes. Through a second doorway is the central area. There is a small changing room, with scrubs available, and you leave your clothes in there (but not the valuables). You then change from the clogs into big rubber boots.
The central area is where the patients are wheeled after the surgery to recover for half an hour (or less). There are 2 stretchers there. The two theatres open off of that area, equipped with an operating table, low-tech monitors (blood pressure, pulse, oxygen saturation). I’m not sure if they are equipped for general anesthesia.
Scrubbing involves taking a piece of apricot-colored hand soap, soaping up all the way to your elbows, and then rinsing off. Sometimes you drop the slippery soap into the drain, so you pick it up and keep scrubbing.
Gowns, caps and masks are all cloth and reused. You gown and glove yourself – there is no scrub nurse or tech. You set up the instruments on the mayo stand, prep the patient with Chlorhexidine solution, and drape with a large cloth drape.
There is no such thing as staples. For closure, you use chromic catgut on the uterus and the peritoneum, then Nylon on the fascia (here it is called the “rectus” which is really confusing) and interrupted vertical mattress sutures of Nylon on the skin. You can do an entire cesarean with only 2 sutures. The Nylon, I am told, doesn’t dissolve. You remove it from the skin, of course, but it stays in the fascia, and often women have pain and irritation for a long time postoperatively from the Nylon in the fascia. They used to use chromic, but had too many incisional hernias, and Vicryl is just too expensive.
Wednesday, October 10, 2007
Uptake of family planning is very poor here. (Amusingly, the Runyankole word for family planning is family planning.) It is available; there are IUDs sitting unused, there are pills, condoms, whatever. But the women don’t accept contraception, and I am very curious as to why. Malaria is a huge and deadly problem; is is that the women assume that they will lose half of their children to malaria, so they have more than they want? Or do they want huge families? Or do they want to stop having children, but they are afraid of family planning because of rumors and misconceptions (we have enough of those in the Bronx, too)?
The last patient of the day in the HIV clinic is a 32-year-old woman with three living children. She is HIV-positive and 25 weeks pregnant. She is a gaunt, timid woman wearing a large red blouse that hangs off her – if it doesn’t have shoulder pads, then it looks like it does because she is so skinny. She is the only patient I saw who didn’t bring a plastic bag or colorful cloth to lie on the examining table.
Again, Dr. Mugyeni is ranting to me in English over why did she get pregnant. She doesn’t know what he is saying. I ask him “How many does she want?”
He translates my question into Runyankole, and to our surprise, she doesn’t answer, but pulls the collar of her red blouse over her face. I look at Dr. Mugyeni, but he is also clueless. Her chest starts to heave, and we realize she is sobbing. She sobs and sobs and sobs, and she can’t stop. She sits up to sob some more, curls herself toward the wall; whatever it is, she is already breaking my heart.
Finally, after looking at her card and asking her questions, we piece it together. She is a widow; her husband died three years ago of AIDS. She did not want more children, and was abstinent, but in April she was raped, and the pregnancy is a consequence of the rape.
We don’t know what to say. She is still sobbing. And sobbing and sobbing. Dr. Mugyeni rubs her back, I put a hand on her leg, trying to comfort her. “Do you have a social worker? Or maybe can we send her to psychiatry?” I ask. He says “Usually they are very connected to social work through the ISS clinic. Here we just do the family support group.” She keeps sobbing and sobbing. Finally he says “Yes, I think she needs the social worker.” He calls in a nurse, who embraces the patient and speaks gently to her in Runyankole while we quietly exit the room.
The clinic is on the campus of the hospital, less that 5 minutes walk from the obstetric ward, near a bustling market road (really a collection of shacks selling stuff). There is a large main waiting room with many rows of benches. Patients are cramped onto benches, sitting literally shoulder to shoulder, waiting to be seen. Nurses in pink uniform with white trim and little nurses caps register the patients, and some with special training run the family support group.
A very narrow hallway leads to the very tiny examination rooms, and this hallway is also lined with benches, stuffed with patients. Dr. Mugyeni’s tiny examination room is closed off from the hallway by a curtain that is just barely big enough for the entryway. No door. And the patient on the end of the bench is just outside that entryway. So much for privacy.
We are handed a few pink obstetric record cards – these are the first patients to be seen. Through the hours that we are in that room seeing patients, the nurses continue to come in and hand us more and more pink cards or green booklets (these are for the gynecology patients). Eventually my eyes start to bulge at the stack of patients waiting to be seen.
We see pregnant women with HIV, interspersed with largely HIV-negative gynecology patients. For HIV-positive patients, antiretroviral medications are provided free by the Ugandan government. Depending on the clinical situation, the women receive either Nevirapine + 3TC, or AZT alone, or they are not on anything, but get single dose Nevirapine (it is one pill to be taken at the onset of labor, plus a dose for the baby after delivery). The women also attend the adult HIV clinic through the Internal Medcine department (called the ISS clinic), and usually the decision to start antiretrovirals is made by them, as well as prophylaxis for opportunistic infections. Dr. Mugyeni reviews their regimen and handles the obstetric component of care.
Around 2 o’clock, just when I think I’m getting woozy with hunger (actually it’s staring at that pile of cards that makes me woozy; it’s all very fascinating, but when does it end?), Dr. Mugyeni sends a nurse to buy us some lunch. He shows me how to wrap a samosa in chapati (he calls it “Ugandan pizza”) and we have orange Fanta.
Rejuvenated, we continue. He did most of the obstetric patients first so that they could be sent to the family support group, and we finish with those, then move onto the Gyn patients. A woman with fibroids we schedule for a hysterectomy for tomorrow – maybe even a vaginal hysterectomy! A 48-year old woman with primary infertility for 8 years – not so mysterious. A 63-year-old woman sent by the General Surgeon for “postmenopausal symptoms” – actually what she has is an extremely tender inguinal hernia; we send her to the emergency ward. And a woman with vesicovaginal fistula for the last 10 years. She had seven children; three are living. The first six were vaginal deliveries, the last was a cesarean section after a long, difficult labor, and she developed the fistula after the cesarean (the baby was stillborn). We examine her, and the fistula appears small and simple. I ask Dr. Mugyeni why she has waited ten years to have it evaluated. He asks her in Runyankole, and translates for me: “She did not have the transport fare to come to the hospital.”
Tuesday, October 9, 2007
She had come in overnight, seven days after delivering a stillborn fetus at 36 weeks. She was extremely jaundiced, weak, and nearly comatose.
There is no glucometer, so comatose patients are usually given some IV glucose as protocol. She responded to glucose pushes, but repeatedly became comatose. Her eyes were yellow.
The suspected diagnosis from the on call team was hepatitis or malaria. Her blood pressure had not been measured. No labs had been checked, because labs are billed to the patient and the patient is poor (a routine lab, like a CBC or a chemistry, is about 14,000 shillings, or about $8.).
On rounds we checked her blood pressure - it was 160/105. Magnesium was ordered, and labs were requested.
Over the course of the day, she became comatose more than 10 times, but responded to glucose pushes. Eventually, they ran out of D50 to push or even to make a D10 infusion. They checked medical ward and pediatric ward - none. They gave Ringer's Lactate, which was all that was left, but the patient deteriorated. Imam, the postgraduate on call, asked the husband to go with him to a store to buy some IV glucose solution, but the husband refused. He told Imam that he was saving the money to transport her body home; he could not spend it on medicines.
This morning, the interns and Imam tell me the whole story. The bed was empty this morning, and they thought the patient had died. But on inquiry, the patient disappeared sometime after 10pm last night. They tell me that probably the family wanted to transport her home before she died, because transporting a corpse is much more expensive than transporting a live person.
Several minutes later, we go back to check on her; she is having a reaction to the blood. The unit has just finished, and she is covered in hives, her face has become swollen, and she is wheezing. Joseph, the postgraduate, calls for hydrocortisone, but there is none, so Liz, the intern, runs to the medicine ward. All she can get is dexamethasone, so I give it intramuscularly. The woman thrashes and tries to bat away the injections, but her attendants immobilize her. The hives are all over her face, shoulders, arms, abdomen.
When I step outside of triage there is a sick-looking woman in a wheelchair in the hallway. She is twisted in the chair, almost like severe CP, her head turned to one side like torticollis, her eyes rolled upward and a huge gash tearing into the muscles of her right foot. “This woman has been in a motorcycle accident,” someone tells me. But no one can tell me if she was on the motorcycle, or hit by it. And why is she rigid and twisted? Does she have a CNS injury?
We move her quickly into the other bed in triage. She is supposed to be 8 months pregnant, but her belly looks small. Her attendants tell us that she started having fever and convulsions at home, so they put her on a motorbike to come here, but she seized while on it and fell off. I try to get her blood pressure, but I can’t with the rigidity. She seems to still be seizing, so Liz gives her an injection of diazepam. We put in an IV and hang glucose, as she is severely diaphoretic with cold extremities. She softens a little but is still unconscious and twisted. I test her pupils; at first they seem fixed and dilated, but then we manage to elicit a tiny amount of constriction.
I check on the woman with the transfusion reaction again. She is slightly calmer, and the hives on her face have improved a little, but are still present everywhere else. I can’t tell if she is wheezing because she moans a little with each breath. One of her attendants, an old man with a large suit jacket and a fedora, tries to ask me questions in Runyankole, but I can’t understand.
We turn back to the woman from the motorcycle accident. We cannot hear a fetal heartbeat with the fetoscope, nor with a stethoscope (my kingdom for an ultrasound…). We try her blood pressure again, and I get a systolic of 110, but can’t get a diastolic. Joseph and I try several times, but it’s the same reading. It is a hard maneuver, because she is still twisted and trying to flex her arm.
We make plans for both women –labs when possible, antimalarials, ultrasound and monitoring. Liz draws a smear for the motorcycle accident patient. They are both as stable as we can get them right now. We leave the ward for dinner.
When I come back at 9:30p, I head to triage to see both patients. The bed on the left, where the motorcycle accident patient was, is empty. I had just seen Liz and Gerald, and they had no updates, so where could she be? I checked antepartum but no one there looked that sick. The ICU? No, they are reluctant to take patients who are not postoperative. And besides, the interns would have known. I find Sister Judith, one of the nurses, who says “I don’t know of her. There has just been a maternal death. Maybe it is her?” We ask the midwife, who is busy clamping the cord of a baby she has just delivered. They talk in Runyankole. Finally Sister Judith turns to me: “It is her. She has died.” She died at 8:30p.
I check on the other patient, who is still in triage. She is calm now, sleeping soundly. Her hives are almost entirely gone. Her face is smooth, and not swollen. She is not wheezing. Her family is still crowded around her, but slightly less anxious now. At the time, I thought she was close to death, but she has come through.
I decide to make a trip into town. I am supposed to take a bodaboda (motorbike), but I don’t even know in what direction is town. On the road outside the University, there is an approachable-looking young woman selling mobile phone airtime in a small wooden booth. I ask her how to get a bodaboda, and which way to go. She shows me, then she says “500 shillings.” She purses her lips and jerks her head toward the bodaboda drivers she has just pointed at, as if to say “Watch out, they will try to rip you off.”
In town, I find a supermarket, of which there are several. Super they are not. They are more like convenience stores with a bit more variety. There’s not much inspiration for me there, as I don’t know how to actually use “ingredients.” Where’s the prepared food section? The Asparagus risotto, BBQ chicken pizza, Gnocchi alla sorrentina?
At home, I find it too taxing to buy pasta and pasta sauce separately – the sauce always goes bad, then you have pasta with no sauce. Or then you buy sauce, not realizing that you’re out of pasta. Here, in No-Trader-Joe-Land, they don’t even have pasta sauce. But they have plenty of pasta. What am I supposed to do, buy tomatoes and make it? Are you out of your mind? That involves all kinds of things, like salt, and garlic and, like, onions.
Forget it. I buy a can of tuna, a can of baked beans and a can of red plum jam. I also buy a thick wheel of Gouda cheese (the only kind in the store), to make my beloved avocado and cheese sandwiches. Avocados here are about 6 cents. That one fact alone may save my life.
While I am paying for my pathetic groceries, I run into Dora, one of the interns who I like very much. She has her daughter with her, who is 1 year and 8 months. The baby lets me hold her calmly, but then she stares at me dumbfounded. I think the only reason she accepts me is that she can’t even figure out if I am human. Dora shows me her mother’s shop, where they rent videos and make photocopies and things. Then she points me toward the bakery, so I can buy bread for my avocado and cheese, red plum jam, or anything else I can think of that one can do with bread.
I want to check out the shops around and explore, but it’s getting dark. I happen upon City Top, a restaurant recommended by the mzungus I met. The sign says they specialize in African and Indian dishes. The owner seems to be the man at the front, a nice Indian man with streaks of white in his short, groomed beard. He helps me choose Chicken Punjab and some parotta (I think), which turns out to be delicious, and not spicy.
Satisfied at having deliciously avoided cooking for one more night, I catch a bodaboda back to the University.
Monday, October 8, 2007
Eve is doing a retrospective and prospective analysis of maternal mortality at Mbarara Hospital. She showed me some of the case notes.
I noticed that a lot of them, at least half, receive the postmortem diagnosis of severe malaria, although almost no workup has been completed. Blood smears are usually requested, but no results are ever recorded; I saw only 2 that had blood smear results. Eve records this as “diagnosis based on clinical criteria.” I wonder how many of them really die of malaria. The lack of availability of laboratory diagnostics (the patients have to pay for them and often can’t afford them) and the poor record keeping make this sort of research difficult.
With Eve’s permission, I’m posting some of them, with some details removed.
This is one:
Date of death: Hospital Day #12
EGA: 32 weeks
Death during delivery: No
- Arrives complaining of two days of fevers, chills/rigors, severe lower abdominal pain, no history of neck stiffness of convulsions or bleeding
- Was given injections at clinic with minimal improvement
- Weak, difficulty speaking, severe pallor of mucous membranes, feverish, some dehydration
- Reports cough with white sputum
- Fetal heartbeat present
- Impression: malaria in pregnancy
- Blood smear requested, no results on file
- IV quinine
- IV fluids
- Delivers in hospital (stillbirth) with minimal blood loss
- Given oxytocics
- Blood transfusion requested but no blood available for four days. Patient died four minutes after blood arrived.
Cause of death: Severe anemia from clinical diagnosis of severe malaria.
The hospital is a series of small cement buildings connected by dirt paths and some covered cement paths. Most of the buildings are off-white or yellow, and the metal roof could use a paint job.
There is a front security gate (which was behind me when I took the above picture) with a 24-hour security guard. There is the intern house, where the interns all live, and where we can get lunch or dinner.
It's hard to get photos of the campus because there are people (mostly women) everywhere, sitting along the paths and outside the buildings, and I don't want to scare them by taking photos without their permission. The women are also in the grassy areas, washing clothing and hanging it on lines (I think they are the attendants of the hospitalized patients. Each patient has an "attendant" staying with them, bringing them food and caring for them, as there is not enough nursing staff to do so.)
The obstetrical unit is one building - to the right is triage, the delivery area and the antepartum area. To the right is the postpartum unit.
The gynecology unit is in the next building, connected by a covered path. It is one room with about 14 beds.
This is Eve standing under the trees. On the other side of the gate is the obstetrics building. There is laundry hanging on the fence behind her.
The operating theatre is about 50 meters from the obstetrical unit. You change your shoes as soon as you enter - you put on clogs that are left always in the theatre. Scrubs are provided, and you change in a small changing room. There are two theatres adjacent to one another. Only one surgery can proceed at a time, but one patient can be prepared while another case is finished if needed. To operate, you put on large rubber boots and a plastic apron. Gowns are cloth, and after the Caesar is done, you take off your gown and place it on the stretcher, where it becomes the sheet for the patient to lie on. The other person's gown becomes the sheet to cover the patient (and yes, they are usually covered in blood and gook).
The ICU, from what I saw, is a tiny room that looks like a storage closet. There is a cardiac monitor and a ventilator. The cardiac monitor is one that we would use as a portable monitor - to place on the bed while transporting a critical patient.
There is a nice library, with large windows, ample seating and a computer room with about 10 computers wired for internet access. Internet is slow-ish, but better than other places I've been.
This is the view from outside the library. The library would be to your right.
And there is some kind of crazy-looking bird that hangs out on the campus lawn. Two of them, actually, and one has big jowls. I wonder if they are what makes that nasal HAAA HAAA HAAAAAAA sound I hear every morning. I used to hear that in Kenya, too.
We walked through some beautiful hills nearby and then lunched on fried goat, chips and avocado at the Pan African Hotel. The hike was good, but the conversation was better.
I got the Stupidity Sunburn – forgot to put sunblock on my chest. You can see the diagonal mark of my bag cutting right across. But at least I didn’t burn the tops of my feet.
Sunday, October 7, 2007
Sunday morning, I am on call. There are 2 “Caesars” to go.
Joseph, the intern, and I scrub for the first – a Para 4 (four prior deliveries) with obstructed labor – she has been 9 cm dilated since 3am, and it is now 8am.
There is routine blood loss with no complications, but as we are closing, the anesthetist, Sarah, starts to talk in Runyankole with English words thrown in.
“Runyankolerunyankolerunyankole she is anemic! Runyankolerunyankole probably malaria.”
I look at the monitor. Her blood pressure is 74/25, heart rate 125.
“Runyankole she will need blood. Runyankolerunyankole take some blood.”
She hands Joseph a syringe and a needle. He takes it and puts it down, continues to sew.
Blood pressure 44/22, heart rate 119.
Nothing seems to be happening, no one running for blood, but I can’t tell. Sarah is still talking in Runyankole, so maybe some one has been called to bring blood, who knows.
I ask Joseph if the patient is going to get blood. He says she is.
“Runyankolerunyankole take some blood! Runyankole I thought you were drawing blood and I am standing here runyankolerunyankolerunyankole. Do you want a postmortem?!”
Joseph stops suturing, puts down the needle and picks up the syringe. He exposes the patient’s right groin and palpates the femoral artery. He sticks in the needle, draws 1cc of blood, and hands it off to the circulator.
Sarah is still talking. She says something to the patient, who sticks out her tongue. It is white as a lab coat.
Blood pressure 64/27, heart rate 128
We finish suturing, and we clean and move the patient to recovery. As we are writing the operative note, a man arrives with 2 units of blood. 10 minutes later, we are ready for the next Caesar, and I check on the first patient. The two units of blood have been placed on her lap, but have not been hung.
I ask the circulator if they are going to give the two units. She says that they will give one unit. “She does not need two units, she needs only one.” I think again of her white tongue. I ask what will happen with the second unit. She says it will be brought back to the blood bank. She is sitting on a stool in the recovery area. No one seems to be moving to either hang the blood, or to return the other unit. I wonder if the second unit will make it back to the blood bank.
After the second Caesar, I come back to check on the first patient. She is gone, she has been moved to the ward already. I ask Sarah if she got the blood before she left. “No, not yet. They will give it in the ward.”
Friday, October 5, 2007
A 24yo P1 HIV+ with psychosis and possibly PID or cervical cancer, refusing exam.
I try to assess her mental status.
Hello, how are you?
I am fine, thank you.
Are you in pain?
No pain, I am fine, thank you.
Do you know where you are?
I am here!
Where is here?
Is this home?
No. Home is there!
So where are we?
In the store?
In the hospital?
Do you know what year it is?
Do you know who the preseident is?
But he is dead. [He’s not.]
Yes. He fell in the river. [He didn’t.]
Do you know who I am?
Who am I?
You are mzungu!
I had to give her that one.
Department meeting at 8:30am, where the previous 24 hours are reviewed.
The postgraduate (resident) who was on call summarizes.
Afterward, we see the sick patients.
I spend that day getting organized and getting to know the wards. Also getting lost.
In 24 hours, this is what I saw:
- Eclamptic, now POD#1
- Pus-filled abdomen from D&E at 24w with RPOC. Now POD#1 s/p ELAP.
- DIC/HELLP/Eclampsia – in ICU
- Severe PEC on methyldopa awaiting repeat c/s
- 33w HIV+ with cryptococcal meningitis and malaria
- Precocious puberty at 5yo with left adnexal mass
- Maternal death from severe postpartum hemorrhage at home. Para 12.
- Renal failure with global pitting edema and severe anemia at 12 weeks. Hgb=2.4 (!!)
- Uterine rupture with 2 prior c/s in labor
- Postdates at 45 weeks (LMP 11/21) – not in labor.
- Eclampsia at 8cm, arrived seizing.
- Full term IUFD with postpartum hemorrhage.
In the morning, Joseph, the postgraduate on call with me, reviewed the nights stats:
24 Vaginal deliveries
9 Cesarean sections
1 Maternal mortality
Really, the gods must be crazy.
Wednesday, October 3, 2007
The woman who was in the ICU when she left, after 4 weeks with a fetal demise arriving in DIC and who was probably going to die
The things that surprised Amy and Deidre when they visited
Tthe long bus ride ahead of us
HIV rates in Ugandan fisherman
The difficulty of obtaining a visa to do an elective in Canada
“Four doctors in one cesarean section? Impossible! In Uganda, the interns do them alone!”
Tuesday, October 2, 2007
But here in this Entebbe motel, I take my shower with shower gel and conditioner, I swallow various antimalarial and other medications with bottled water, I clean my face with antibiotic-infused towelettes, I smush gel into my hair, I spray DEET-containing bug spray on my exposed skin and coat my lips with SPF 15 chapstick.
Then I program my travel clock, reset my watch, check my Ugandan cell phone and open up my laptop.
In The Gods Must Be Crazy, a single Coca-Cola bottle brings a Pandora’s box of humanity’s worst impulses to a formerly happy tribe.
Maybe someday I will get rid of everything and see if I get any happier.
5 hours in Amsterdam, on a pleasant recliner chair in the very pleasant airport.
8 hours from Amsterdam to Entebbe
At the front receiving line is Eve, or Dr. Eve, bearing a handwritten sign that said “Dr. Veronica”. She is tiny, but warm and welcoming. The greeting is awkward; a handshake is too formal, a hug too intimate, so I do a little of both and then it's just weird.
I meet her two sisters, Grace and Betty, and either Betty’s two daughters, 2 and 3 years old, in dresses with close-cropped hair, wide-eyed and fascinated by the mzungu. The older one stares and stares at me, and is pleased to sit next to me in the car. The younger falls asleep immediately on the drive, but in a peculiar way, reaches her hand behind her sister to rest it on my arm in her sleep.
According to Eve, the older girl will have exciting stories to tell at school tomorrow. If only everyone found me this riveting.
Monday, October 1, 2007
I will be living and working in Mbarara, in southern Uganda:
This whole blog thing is strange to me, but I figure it's the best way to transmit my stories to the people who feel like reading them, without clogging your inbox with photo-laden messages. And if you find me boring, you don't have to read it. So that's nice.
If you do read it, and you feel like writing to me or leaving comments, please do so.
And if I get bored or don't feel like writing a blog anymore, I will stop without warning. And then you can complain via email to show that you care. Or you may not care, in which case that will work out nicely as well.