Thursday, June 24, 2010


One of the nurses on Female Ward wants me to see a friend of hers, who is having bleeding after delivering a baby recently. It sounds normal to me, but I tell her to send the woman to my clinic to see what is going on.

Later that day, the woman arrives in my clinic. She explains that she gave birth in March, and then in April, she had bleeding for about a week and a half, along with some right-sided abdominal pain. She was given antibiotics (as usual – they are given for everything here) and the bleeding stopped. She did not see bleeding again until just over a week ago, when she had bleeding for 1 week, which stopped on its own. The right-sided pain had never gone away; it was not associated with bleeding but did seem to be worse when she was bending over or lifting something.

It sounds to me like the woman is getting her period. I tell her this. She is surprised. She is breastfeeding, so she expected not to see her period. I tell her that she can have bleeding sometimes, even though she may not be ovulating and that, in fact, the bleeding can last longer than a usual period because the body doesn’t have its normal hormonal pattern, and so it doesn’t really tell the uterus when to stop bleeding.

As I am telling her this, I can feel the tension from the elephant in the room. The nurse who referred the woman had told me that the woman kept having babies with sickle cell disease. The woman looks profoundly sad – the kind of sad that is not just today, but that accumulates over years, until the person doesn’t even realize she is sad, because it feels normal.

I ask her about the sickle cell problem. She tells me that her three previous children were all born with sickle cell disease, but she has not yet tested the infant. Of the three, one died at age 6 – and before dying, that child had a major stroke, and then a second stroke with seizures that caused the death. Of the living children, her oldest, a 9-year-old girl, had a stroke a few years ago, and now can walk but has difficulty with speech, and her entire left side, including face, arm, hand and leg, are partially paralyzed. As she talks, I can see the weight of this burden emerging on her face. Her eyes become teary, but she keeps talking.

Finally, we get around to doing the physical exam. Although the bleeding sounds normal to me, I do an ultrasound to make sure there are no fibroids or other sources of abnormal bleeding. It is normal, and there is nothing on the right side where she notes her abdominal pain. I do a vaginal exam to make sure there is no palpable cervical cancer, but it is normal too. I explain that the bleeding is just her menses. The pain is in an odd location – far from the pelvis but not really near any specific organ, at the level of her umbilicus but far to the right. It is not tender. To check for a hernia, I have her sit up with her belly exposed. There is no hernia, but there is a large diastasis. During pregnancy, the abdomnal rectus muscles (in the front of the abdomen) can become very weak and separate to accommodate the enlarged uterus. After delivery, they remain weak and as a woman sits up, there is a visible bulge in the center of her abdomen where the muscles have separated.

My guess is that her pain (which she notes is worst when she is trying to use her abdominal muscles) is probably because she is compensating for the lack of midline abdominal strength by using her side abdominal muscles, and preferentially her right side. I can’t be sure that this is the case, but it is my best guess. I recommend a daily routine of increasing repetitions of sit-ups. I teach her how to do them. She can’t even do one without using her hands.

This leads us back to a discussion of her children. She tells me that caring for her disabled and ill children is very time-consuming and takes all of her energy. I can see it. “You look tired,” I say. She has no help other than a young housekeeper (a “house girl”). I tell her that she needs to take 15 minutes for herself every day to do these exercises so that her pain and strength will improve. In truth, the exercises are not life or death, but I sense that this woman needs 15 minutes to herself once a day. She gives the other 23 hours and 45 minutes to her children.

I ask her how many more children she wants. She doesn’t have an answer. I tell her about the statistics of sickle disease – that if both parents are carriers (and clearly she and her husband are), the chances are 1 in 4 that any one child will be born with sickle cell disease. She is very unlucky, having had at least 3 with the disease. I tell her that she needs to think about how big she wants her family to be. There is no way to predict whether her current infant, or future children, will have the disease, but that she should assume that any further children will also have it – because she has to be prepared for the burden that might come if they do.

She starts to tell me more detail about the sickle cell disease that afflicts her children. She tells me at what age each of them started having symptoms, and she tells me about the events that led to the death of the one child. She tells me about the difficulties of caring for the 9-year-old, who cannot attend school and probably will never care for herself. As she talks, tears start to roll down her face. She dabs at them with a handkerchief.

“What about your husband?” I ask.

“He is a teacher,” she says.

“Does he want more children?”

“We have not discussed it,” she admits.

“You need to discuss it. He needs to understand what it is like for you. Maybe he does understand, I don’t know. Because for a father it is also hard. But for a mother, it is even harder to see your children suffer. If your child suffers, the mother suffers 100 times.”

She nods and sobs. “You understand what it is like for mothers, doctor.”

Well, I can’t say that I understand from personal experience, but I have known enough suffering mothers that at least I can make that observation. But that’s all she wants from me – validation and understanding. I can give both.

I encourage her again to consider family planning. “You love your children, but I can see that you are tired. You need to take care of the ones you have, and you are a human, you can’t take care of 10 children when you already have ones who are very sick.”

She shakes her head and shudders at the thought of having 7 more children to take care of.

She promises me that she will discuss it with her husband. She agrees with me that she is too tired, and the burden is heavy. I have nothing to offer her in terms of help – no social services, no referrals, no therapy. I offer sympathy.

She wipes her tears, which have not finished coming. We both express our hope that her newborn infant does not have sickle cell disease. I tell her to come and find me if she needs anything else.

“You know where I stay now,” I tell her.

“Should I call through my friend, or I can come and disturb you?”

“I am here. You can disturb me anytime.”

After she leaves, I can’t get her out of my head - the sadness that emanated from her face. I hope I have helped by reassuring her that her bleeding is normal, but I couldn’t do anything about her real problem.

Tuesday, June 15, 2010

Know Your Limits

One of the most important things any resident learns is to know their limits. Some people don’t learn that lesson, and they are scary. But most of us learn it.

First and foremost, we are taught that in an emergency, you need help. You can’t do it alone. Even if you know what you are doing, you need another pair of hands there, just in case. It is the first thing taught in CPR classes, and it is the first thing every intern should learn.

When I was an intern and working with a team I liked, my chief resident and attending challenged me with a hypothetical scenario one night on call. “Your attending and both senior residents are upstairs in the main OR, and you are on the labor floor alone. You are watching the fetal heart rate tracings, and you see a deceleration. You call us, but can’t each us. The deceleration goes on and on. You try to resuscitate but it doesn’t work. The baby is going to die. What do you do?”

I thought about it, slightly panicked, both over the hypothetical scary situation, and the desire to get the right answer in front of my chief resident and my attending.

As I thought it through, they pushed me more: “Do you go ahead and do the c-section? You have nurses here.”

Could I actually do that? I had only done a few c-sections, I really didn’t feel comfortable. I cringed and answered honestly: “No?” Were they going to laugh at me?

Both of them smiled. “Right. You don’t do it. Because you could kill the mother. That baby might die, but you have to keep trying to get us, even if you have to run upstairs to the main OR and drag us down.”

Later, when I was a chief resident, I designed a lecture for the incoming interns on how to handle obstetric emergencies. In order to help them remember what do to, I created the three C’s: Call for help, Call for help, Call for help. They laughed as we reviewed it on the powerpoint slide, but it stuck with them. (Laughter is the best mnemonic.) Later, when working with one of the interns, I was pimping her on the maneuvers to relieve a shoulder dystocia. “What’s the first thing you do?” I asked. I was looking for “Put the patient in McRobert’s position.” Instead, she smiled and said “Call for help, call for help, call for help.” (Excellent!)

Many times in Uganda I have been faced with situations in which I almost had to decide whether I would do something I am not comfortable with or experienced enough to do.

I have often written here about things I have done here that I had “never” done before – but in reality, they are variations on things I have done before. The cornual ectopic, the abdominal pregnancy – those are situations that I haven’t actually seen, but had been well-prepared for in my training. In fact, I had never even operated on an ectopic pregnancy through a laparotomy – only laparoscopically. But I had done ectopics, and I had done laparotomies, so it isn’t a far stretch to put those two things together into one surgery.

But then there were situations that were less clear. On occasion, I have suspected a patient might have appendicitis. Would I be able to do an appendectomy? I have done quite a number of appendectomies in patients with cancer and it was actually remarkably simple – but their appendices were normal. Would I be able to do the same in an infected, inflamed appendix? I don’t know. Fortunately, none of the patients ever turned out to have appendicitis.

One day, I walk into clinic and see a wheelchair in the hallway (those are rare around here), and a hospital nurse inside one of the patient rooms. There is a young boy lying on the exam table, and an anxious-looking man sitting on a chair – the boy’s father. P, one of the study doctors, is examining the young boy, and asks for my help.

He tells me the situation. The boy is 12 years old. Two days ago, he fell off a bicycle, and the pedal punctured his abdomen, and his intestines came out. He was taken to a Level 3 Health Center, where they pushed the intestines back in, and stitched the hole closed. Since then, he has not passed stool or flatus, and he has severe abdominal pain and fever.

On exam, the boy looks terrible. He looks weak and dry, his eyes are sunken and he is clearly in pain. On the left side of his abdomen, the skin over the injury had been bunched up and stitched with silk suture – which needs to be removed at some point. When I palpate his abdomen, it is obvious that he is extremely tender everywhere, although too weak to make a lot of noise despite excruciating pain. There is also the distinct crackling sound of crepitus when I press on his abdomen. I try to do an ultrasound, but I can’t see anything and it causes him even more pain.

P and I consider the situation. When an abdominal injury causes the bowel to come outside the body, it is called an evisceration. In that case, not only the skin has to be sewn closed, but the fascia (the firm white internal sheath that holds in the intestines and abdominal contents) also needs to be closed. Did they close the fascia? We don’t know. In addition, once the intestines are exposed to the outside, there is a high risk of infection. He is on antibiotics, but the coverage is insufficient (which is ironic, because usually they give extremely broad coverage for every non-bacterial ailment here).

P and I agree that the boy needs an exploratory laparotomy. But who is going to do it? Neither of us is comfortable with extensive bowel surgery. It is hard to know exactly what we will find once the abdomen is open. There is a strong chance that the boy might need part of his bowel resected and re-anastomosed (reattached), or even a colostomy.

At home, I would call general surgery to see the patient immediately. Even if I didn’t expect to find a bowel injury before operating, I could call an intraoperative general surgery consult, and they would be there within minutes.

There is a regional hospital an hour away in Mbale that is much better staffed and equipped, and even has specialists. But if we send him there, will he make it? He would have to go in a matatu – I cringe just thinking about this poor kid suffering through a matatu ride in his condition. I can barely tolerate them when healthy. In addition, if he makes it to Mbale, will they treat him, or will they ask for a bribe first? His father looks extremely poor. Will referring him there be a death sentence?

P and I discuss the options. It’s possible that one of the two doctors here is comfortable with bowel surgery; they have seen it all. I try to call both, but their phones are off.

Plan B: There is an orthopedic surgery camp taking place in the theatre all week. Some consultant orthopedic surgeons came from Mulago Hospital in Kampala to work on children with orthopedic deformities. Possibly one of them might be able to assist with bowel, even if we open up the abdomen first.

I dash over to theatre to ask them. They are very nice about it, and agree that the boy needs a laparotomy. Still they are vague about their exact comfort level, and how much they would be able to help. They tell me to bring the boy. I’m not sure about this, but it might be his only hope. I don’t know.

I head back to the clinic and tell P what they said. “Dr. Veronica, I am not in,” he says.

He is right. We have no sense of whether the orthopedists would be able to help us, we have no other backup, and none of us are comfortable doing this. If we open his abdomen, we could kill him.

On to Plan C: Transfer to Mbale. I know that the hospital has an ambulance, and there might even be fuel in it. If we can transfer the boy in the ambulance, that might increase his chances of making it there, and of getting treated. I call the Senior Hospital Administrator, but his phone is off. I walk to the administrative offices of the hospital to find him, but every door is closed. What’s going on? It’s a Wednesday. Then I realize that it’s a national holiday, and everyone is gone.

As a last resort, I call the Junior Hospital Administrator, a young man who has always been friendly and helpful. He answers. He is around the hospital grounds. I tell him that I need his help with an emergency. “I can be there in 20 minutes. Is it OK?” It will have to be.

10 minutes later, I go to check in on the boy, but the bed is empty. Where has he gone? I find P, and he tells me that Dr. W, one of the hospital doctors, showed up on the ward, so they took him back to the ward to be evaluated by Dr. W, and possibly operated on. I am greatly relieved. I like Dr. W very much, and if he is able to operate on the boy, then he will be OK. I try to call Dr. W’s phone, but it is still off.

The Junior Hospital Administrator finds me a few minutes later. I explain the situation and tell him that things are probably OK, but that if the boy needs to be transferred, I will call him again. He explains that the ambulance is available and has a driver, but no fuel. If we can provide the fuel, then we can send the boy.

Sigh. The usual. I know that if the boy needs transfer, we will find the money for fuel. Maybe we will use money from the poor patient fund, or my own money, or whatever, but I will not let this boy die for lack of fuel. I thank the JHA and tell him I will contact him if the boy needs to be transferred. I don’t hear anything that day, so I assume that Dr. W was able to operate on him.

The next day, I decide to find out what happened to the boy. Dr. W’s phone is still off. Since the boy is 12, he would not be in the pediatric ward. There are so many patients admitted aged 5 and under that the huge pediatric ward is filled with them alone. Children over 5 years are admitted to the adult wards (if they are still quite young, then they are admitted to the female ward with their mothers). He must be in male ward.

I go to male ward, and scrutinize every patient there. It isn’t very hard, because there are no young boys. I walk through the entire ward, but I don’t see him. I find two nurses and ask them for help. I explain the situation. One of them goes out to the ward to announce the type of patient we are looking for (which would have been kind of funny if I had not been really worried about this kid), while the other one helps me search each bed.

The boy is not there. Both nurses agree that they have never heard of such a child, but there is nowhere else he could have been admitted. Disappointment.

I go back to our clinic and mention this to P. He tells me that the boy is in Mbale. Apparently, one of the other study doctors has an aunt who is sick and admitted in Mbale, and he went to visit her there. While there, he happened to see the boy, who was waiting to go into surgery just then.

I am relieved to hear that he made it to Mbale. I know that we did the right thing – if we had operated, we could have killed him. In my desire to save the boy, I considered it briefly, but it would not have been the best thing for him. The study doctor who saw the boy knows the surgeon who was going to operate, and promised me that he would find out what happened. It was hard to let go of a patient not knowing whether someone else would be there to help him. I will feel much better once I know the outcome.

Thursday, June 10, 2010


I had stopped by the operating theatre to try and schedule a case. When I was there, the anesthetist asked me to see a patient he had in the waiting area.

The patient was a 9 month old baby girl, the daughter of a clinical officer at TDH. Both parents were there looking concerned. The problem, they reported, was that the baby's genitalia were abnormal.

They removed the baby's clothes so that I could look, and immediately I saw the problem. There was no vaginal opening. I could see the urethra (where the urine comes out) and the rectum was normal, but the labia were sealed shut, almost as if she had had a female circumcision.

It was unlikely. There is only 1 tribe in Uganda that does female circumcision, and although they are not far from Tororo, they would not do it in a child this young. I ask the parents, but they are not from that tribe, and they did not have any circumcision done to the child. They don't know how long the labia have been that way.

I am perplexed. I was expecting something more like ambiguous genitalia. But this is clearly a girl - there is no penis. Maybe it isn't a girl? Should I do an ultrasound and confirm the presence of a uterus and ovaries? Would I even be able to see them at this age? I can't think of anything else to do.

It could also be an imperforate hymen or a vaginal septum. But this appears to be the labia. An imperforate hymen would be inside the labia, and normal labia would still be visible. A vaginal septum would be even more internal.

Well, I don't know what it is, but would I need to do anything about it? The girl isn't going to menstruate for another 10-13 years or so, and operating on a small infant is more difficult than operating on a child or adolescent. The urethra appeared normal, so she can urinate without a problem.

The parents do report that the girl cries every time she urinates for the last 2 months or so. It's possible that this closure is causing some partial blockage of the uretral meatus, preventing the urine from exiting efficiently and allowing infection to build. If that is the case, she might then need surgical correction.

I decide to do some research and have them come back. I tell them to get a urinalysis to look for infection, and to return to me next Wednesday when I normally hold my clinic. They are grateful, and very worried that their little girl might need surgery - or worse, might have a permanent abnormality.

In the meantime, I call a trusted obstetrician in Kampala, Dr. O. I have enormous respect for this man. He is well-known in the field of global Obstetrics & Gynecology, and has made great efforts to reduce maternal mortality in Uganda. He is one of the investigators on my research projects. He is also an extraordinary clinician, a firm but patient teacher and unfailingly professional and polite, even when juggling multiple acute responsibilities. I have called him with questions many times, and he never fails to help me. When he comes to visit the study site, he is able to briefly tour the faciluty and then present a list of ideas for improvement and progress that are always perfectly on point.

When I reach him, I tell him about the problem.

"Oh yes," he says, "I have seen this before. The parents are not washing the baby properly. They are failing to wash the labia, and the baby develops a mild infection and inflamation of the skin, and the labia fuse together."

I am stunned. "Really? That's it? You have seen this before?"

"I have seen this many times. I have even had babies referred to me by urologists."

"What should I do?" I ask.

"It is very easy to manage. You just take a piece of gauze, and you pry open the labia manually. They will come open easily."

I am skeptical. "The labia looked really fused together. Do you really think it will come open, just like that? I am worried about hurting the child."

"You will be surprised, he says. "You will not hurt her. She will cry. You will have to have someone hold her down, and maybe have the parents wait outside the room because they will become upset. But you will not be hurting her very much, and she will stop crying when you are finished. I have done this many times, it is always fine."

I trust this man, but I am pretty nervous about this. "Ok, I will try it. Just in case, if I can't open it, can I take a photo and send it to you?"

"You can send me a photo if you need," he says. He sounds like he knows I won't need to.

The parents return and find me in the clinic. S, another clinic doctor who shares my office, is present. The little girl is as cute as ever. The parents report that the urine result was negative, and the symptoms have gone away.

I tell them what Dr. O has told me. I explain what I am going to do. I ask if they want to be in the room when I do it to hold her, or if they want to wait outside.

The husband turns to his wife. "Do you want to hold her?"

She looks unperturbed. "I can hold her."

"Ok," I say, "women are strong. They can push, and they can hold the crying baby. Men, they cry and they faint." We all laugh. Everyone here likes African-women-are-strong jokes.

I ask S to help me with this, just in case I need a hand. We take the baby into the other room. The mother undresses her. She leaves on the string of beads tied around the baby's waist. Many girls and women wear these beads. They have some kind of cultural significance that I'm not sure about, but they are very pretty. I almost want some.

We lie the baby on the bed and she is already crying. The mother bravely holds her legs. We look at the perineum. The labia look totally fused. There is a line of fusion, but it really doesn't look like it is going to come apart. I am nervous.

Gently, I take a piece of cotton and use light pressure to try to spread the labia. The baby is crying but the mother is holding her well. As I apply pressure, a small depression appears along the fusion line. S is surprised, as am I. He helps me to continue applying gentle pressure. Magically, the labia appear. There is a normal vaginal introitus. The labia have a tiny bit of blood on either side, but otherwise are fine. I can't believe it.

It takes me a few seconds of staring to realize that it actually worked. We instruct the mother on proper cleaning of the labia so that it does not happen again.

The baby is crying, but as soon as the mother picks her up, she stops. She even looks content. Amazing.

The mother is very grateful. I reinforce the cleaning procedure, and she leaves.

S and I are still quite surprised that it actually worked. Now I am even more in awe of Dr. O. Maybe this is something that pediatricians see all the time - I don't know - but I have never seen or even heard of it. S remarks to me that he knows of a 13-year-old girl who has to go for surgery soon to have the same thing fixed, but he didn't realize that a simple hygiene lapse was the cause of it. If the labia had stayed fused for years, this baby would later have required surgery because the fusion would have been too severe for manual separation.

Ten minutes later, my phone rings. Her husband is calling.

"Doctor, I am very grateful! I had to go back to work, so I have not seen her, but my wife has passed the message that she is fine and you have cured her. Thank you so much! I am very relieved and very grateful."

Wednesday, June 9, 2010


This week I have been alone in the house with Agnes, our cook/housekeeper. All of my roommates are away in Kampala taking exams for a masters degree program they are enrolled in. Our next-door neighbor, Beth, is also in Kampala for the weekend and her askari (guard), Fred, is taking care of her house. (Every house has to have a night guard. Fred is unarmed, as is our askari, Lazaro).

At 4am on Saturday morning, my phone is ringing. I see that it is Agnes calling me. She would never call me at that hour unless it was urgent.

ME: Hi Agnes. What’s wrong?

AGNES: Doctor Veronica, I am here with Fred. He is crying.

ME: What? Crying?

AGNES: These people, they came to Beth’s house to steal and Fred, he stopped them but they cut him.

ME: WHAT?? What happened? Robbers? Where are they?

AGNES: They have gone. Doctor Veronica, there is blood.

ME: He’s bleeding? Where is he injured?

AGNES: Blood is pouring. BLOOD.

ME: I’m coming.

I jump out of bed in a daze. I look around, grab my headlamp and put on shoes. What the hell is going on? Where is Fred injured? What if they cut open his abdomen or something? Can I repair that? He doesn’t even have a uterus. OK, stop thinking about that. What do I need? I have no idea. OK, go.

I get outside and Agnes is waiting for me. We approach the fence that separates our yard from Beth’s and call to Fred. When he comes to the fence, he is leaning forward. Blood is covering his shirt, his face, his head. What the hell?? Where is he injured?

I realize that the majority of the blood is on his forehead, and then I see a 4cm horizontal laceration on his frontal scalp that is actively bleeding. I tell him we need to go to the hospital now to stitch it, but he refuses to leave. He says we will go in the morning.

I try to ask what happened. Fred normally has a moderate stutter, but now he is completely shaken up and can barely get a word out. I decipher that they hit him with a panga (machete), but that’s all I can get. I decide to let him calm down – we can find out later. He shows me that during his fight with the robbers, he managed to get the guy’s shirt, his shoes, his keys and his panga (which is really a large knife rather than an actual panga). Pretty impressive.
(We have the same knife in our house. It barely cuts anything, lucky for Fred.)

I encourage him to clean off the blood and put some pressure with a cloth to stop the bleeding. The scalp can bleed profusely, even life-threateningly. He repeatedly refuses to leave his post to go to the hospital. The bleeding seems to improve over 15 minutes. I instruct him to have Agnes wake me up if the bleeding returns.

Agnes tells me that she originally woke up because she heard Fred yelling for Lazaro, our askari. She and I go looking for Lazaro but we can’t find him anywhere. He is supposed to sit in front of the house and guard all night. His bicycle is there, but he isn’t. We walk all over the yard calling his name, but he doesn’t answer.

Fabulous. Eventually, I go back to bed, but sleep isn’t an option. I am wide awake and full of adrenaline. Our guard is MIA, and the neighbor’s guard has just been attacked. What if the robbers had tried to come to our house? No one would have stopped them. The house is locked, but should I lock my bedroom door? What about Agnes, who stays in a separate little house?

I lie awake for a couple of hours and eventually doze off. Agnes wakes me at 7:30 from outside my window.

AGNES: Doctor Veronica!

ME: Yes?

AGNES: Those people, they have returned. Fred has caught them.

ME: What?? They came back?

AGNES: They have come back, and Fred has caught one. He has him there.

ME: I’m coming.

I get outside, and Agnes calls Fred to the fence again. He comes, and he has a cloth wrapped around his head to cover the laceration. He drags over the robber he has captured, and I realize it’s just a kid. He looks about 16, terrified and miserable.

What am I supposed to do now? I call people from work to try to get someone who can go to the police station and send the police here. I finally reach someone and we sit and wait. Interestingly, the kid doesn’t make any attempt to run away, even when Fred dashes off and leaves him alone for a while. Fred brings a mzee (old man) who knows everyone in town, thinking the mzee will know this kid. As they are talking, I turn to Agnes.

ME: So what happened before? How did Fred get cut?

AGNES: When those people came, Fred saw the first one, and he started to beat him. He was really beating him, and he was crying out “Stop beating me! I am going to die!” Then the second one came, and he had the knife and he cut Fred on his head with the knife.

ME: Does Fred recognize this boy? Was he one of them?

AGNES: Maybe.

ME: Did he see the robbers?

AGNES: The first one, he saw. He saw him very well, because he was beating him with the torch [flashlight].

I can’t help but laugh at this.

ME: So this isn’t the first one?

AGNES: No. But maybe he’s the one with the knife, I don’t know. Fred did not see that one.

I call my coworker, Jesse, to see where he is with the police.

JESSE: I am here with the police. But they want money for transport.

ME: They want money?? For transport?? But they’re the police.

JESSE: Yes, the police. They want money.

ME: ………

JESSE: How many suspects are there? Are they many?

ME: Just one.

JESSE: Just one? They thought there were many, and they didn’t have fuel for a vehicle. I think we can come on bodaboda.

The police finally arrive with Jesse. They inspect the yard, and Fred shows them what happened and where. The Detective introduces himself, gives me his phone number and tells me to call him directly if we ever have trouble again. I am relieved. They take the suspect and Fred to the police station. I tell Fred to come and get me once he is finished making a statement. I give a small amount of money to Jesse to pay for the bodabodas (whaddayagonnado).

When Fred gets back, I am starting to feel my lack of sleep. I have had 2 cups of coffee already, but they are fading. Fred has covered his wound with a cloth and a baseball cap. We take a bodaboda to the hospital.

At the hospital, I need to call for the anesthetist to help me open up the supplies I need to close the laceration. The last time I repaired a scalp was in medical school (Interestingly, that person had been whacked with a machete, too. Ah, Brooklyn.) The only thing guiding me is the fact that a year ago, a friend of mine split his head open in a Harry-Potter-style laceration in a Frisbee-induced collision with someone else’s face. I took him to the ER and had extensive discussions with the ER physician and an acquaintance who is a plastic surgeon regarding the proper technique for repair. That incident was not very lucky for my friend, but is quite lucky for Fred, because now I have some slight idea of what to do.

I put together everything I need, and get started. Immediately, I am cursing myself. It is really hard to inject lidocaine into the scalp, and Fred is not getting much pain relief in some areas. The needle I have on the suture is not ideal – it’s too big. The more I manipulate the scalp, the more it bleeds, which makes it difficult to see. For crying out loud, I’m a gynecologist, why am I stitching up someone’s head?

Because there is no one else, that’s why. Fred is really brave about the whole thing. I can see him cringe occasionally, but he tries not to complain. I tell him to complain because then I know where he needs more lidocaine.

The laceration is not very deep. I suture one layer closed, but the superficial part needs better closure. The other needle I have is even bigger, and hurts Fred way too much. I hunt down someone to open a smaller suture for me, and I find a nice tiny suture with a tiny needle. It doesn’t hurt Fred at all. I close the superficial part in interrupted sutures. By the time I am finished, it actually looks pretty good. Not bad for a vagina doctor. I hope it heals ok.

I am so impressed with Fred. All day, I am showering him with praise over how brave he is. He is so sweet and modest, he just smiles sheepishly. He reminds me that he needs a tetanus shot, and that is another herculean task.

It turns out that the tetanus vaccine is only kept in Antenatal Clinic, which is closed on weekends. I go to Labor Ward, where I start a phone chain of calling people to try and get the key for the clinic. I have Fred waiting there, and I imagine he must be hungry, so I buy him a mandazi (Ugandan doughnut).

After more than an hour, a nurse finally arrives to give him a tetanus shot. I make arrangements for Fred to go home by motorcycle. By 3pm, I am completely exhausted and ready for a nap. After buying groceries, I head home, and Agnes and I recount the night, laughing at the insanity of it all.

Monday, June 7, 2010

Raising Money for TDH

Tororo District Hospital is missing a lot of things. I can't hire more staff or create a reliable supply of medicine, but I can try to help by purchasing essential, lifesaving equipment.

Blair Thedinger
, a family medicine resident from Oakland, CA, spent a month here. Blair and I decided to link up with a non-profit organization called World Altering Medicine that raises money for hospitals in developing countries to buy lifesaving equipment for hospitals.

Michelle Montandon, another family medicine resident from the same program, used our site to raise money before her recent trip to Tororo. Through generous donations, Michelle was able to bring $3000 when she came here.

Michelle bought some of the supplies when she first arrived in Uganda, but the oxygen concentrator wasn't available then. So Michelle and I took a trip to Kampala recently to buy the supplies.

First, we went whitewater rafting in Jinja. This was taken just after we survived the final rapid, appropriately named The Bad Place. We are exhausted and glad to be alive.

Then we headed to Joint Medical Store in Kampala to buy supplies. Supplies are subsidized there, and are often cheaper than bringing them all the way from the US.

Michelle is receiving the box of small supplies we bought, marked for Tororo.

I am waiting in the "Picking Area" - the man behind me is carrying our oxygen concentrator.

In order to get these 2 boxes to Tororo, we brought everything with us on a matatu. We had to pay for extra seats in order to fit the boxes. It was a ridiculously long and occasionally harrowing journey, and we were happy to get to Tororo safely and with all items intact.

We were able to buy a lot of great supplies with the money.

The midwives don't have adequate protective equipment for when they deliver patients. We bought gumboots and aprons.

The midwives modeled their aprons:

Hadija is demonstrating proper use of the gumboots while taking blood pressure:

Here, midwives don't have an electronic fetal monitor to listen to the fetus' heartbeat. They use a fetoscope, which is a cone-shaped metal instrument. It's quite hard to use and took me a few months to really learn. We didn't buy any fetoscopes, but Hadija really wanted me to take a photo of her using one:

We also didn't buy the weighing scale either, but Hadija was getting really into the photo shoot, and we were having fun:

The one blood pressure cuff on maternity ward was broken - the velcro is weak and so the cuff always falls off the arm while you are taking the blood pressure, and the patient has to hold it on. The accuracy of the readins is questionable. So we bought a new blood pressure cuff, which is more portable than the old one (the one Hadija was using) and doesn't have mercury.

Patricia was very happy with the blood pressure cuff.

We also bought some operating theatre equipment. Some of it seems small, but it can lead to a big improvement in efficiency.

Previously, instruments would be sterilized in one big tray, left inside the autoclave all the time, and pulled out one by one for any surgery when they are needed.

We bought autoclave cloths and autoclave tape. The instruments can then be wrapped and autoclaved, and then stored inside the cloth to maintain sterility until needed. The tape has temperature-sensitive stripes that turn black when autoclaved.

The instruments can be packaged together in sets for a particular surgery, like a D&C or a cesarean section. This allows the theatre staff to pull out an entire set all at once, which means it is much faster to get a patient to surgery. Below is a laparotomy set.

The sets or individually wrapped instruments can be placed in metal autoclave containers and sterilized within the container and left there until needed.

The operating theatre staff started using the autoclave almost immediately after we brought it. Wesonga, the anesthetist, demonstrates some autoclaved sets within a container.

Lastly, we unveiled the oxygen concentrator we had dragged all the way from Kampala. Wesonga (the anesthetist) and I were excited to open up the box with the oxygen concentrator.

Dr. Wabomba, one of the hospital doctors (left), turned up and was also excited about the oxygen concentrator.

Michelle and I were thrilled that we were able to buy it.

The hospital, prior to this, had only two oxygen concentrators. One was in maternity, and the other was in the operating theatre. Both are very old, and often broken. We brought this one to theatre, and are hoping to fix the old one and bring it to Pediatric ward, which currently has no oxygen at all. When a child in Pediatric ward needs oxygen, the nurses need to schlep the concentrator over from maternity. It is bulky and heavy, and by the time they actually get it moved, sometimes it is no longer needed.

There are more things I would like to buy for the hospital:
1. More oxygen concentrators
Optimally, I would like each ward to have an oxygen concentrator - there is plenty of need for it, and it is absurd for someone to die of respiratory distress for lack of oxygen.
2. More protective equipment for the midwives
We were only able to buy a few aprons and gumboots for the midwives, and I would like to buy more, especially so that they are protected when they deliver HIV-infected patients. They do so many deliveries every day that the few we bought will be destroyed quickly.
3. Autoclave containers
Especially one for the labor ward, where they have a very small autoclave but never bother to use it, so there are never any sterile instruments. When a woman needs a vaginal tear sewn, the midwives hold the needle in their gloved hands without an instrument. If I can buy a small container that would fit in the autoclave, they could sterilize instruments in advance and store them in the containers.
4. Speculums
When a woman has vaginal bleeding, she can't be examined because there are no speculums. So I would also like to buy some speculums that can be wrapped up, autoclaved and stored for use when needed.
5. Poor patient fund
I would like to have a flexible fund to pay for necessary tests and/or medicines for patients who absolutely can't afford it. I have been doing that casually at the moment, and it would be great to have a system in place.

As I come back and forth over the next couple of years, I hope to buy more supplies on each trip. I prefer not to buy anything that will be used up, like medicine or disposable things, but more permanent and reusable equipment that can have a big impact for a lot of patients.

I will be reporting on our future purchases here on my blog, and if you let me know that you donated, I will email you individually and let you know exactly what your donation paid for.

So, therefore, dear readers, friends, family and compassionate strangers, I ask for your donations in order to help me help TDH. You would be surprised how far a small amount of money goes - even $5 would buy an apron for a midwife.

The link to our Tororo page through WAM is here.
The donation page of the website is here.
I will also put a link on the sidebar of my blog so you can donate any time you feel so moved.

There are 3 ways to donate:
1. Paypal - This will deduct 3% from the total donation for Paypal fees. You can't specify which program you want to donate to, so if you use Paypal, you should email both me and to WAM to let us know that you want to donate to the Tororo project.

2. Network for Good - This will also deduct 3%, but you have the option of adding the 3% to your total so that the full amount will go to the project. You can designate the Tororo project. Network for Good also accepts credit cards.

3. Personal check - You can mail a personal check to the address on the website. The total amount will then go toward the project.

Saturday, June 5, 2010

Vacation Over

Remember how in Peter Pan, every time a person says “I don’t believe in fairies,” a fairy dies? I have a similar power. Every time I say “I think I’ll go home early today,” someone in Tororo immediately starts hemorrhaging.

I go to Nairobi for a long weekend, and getting back to Tororo requires an epic journey. My flight is cancelled without my being notified and I am forced to stick around another night (not a terrible development, as I get to spend more time with friends). I use 6 different forms of transportation (taxi, plane, matatu, walking, bicycle bodaboda and motorcycle bodaboda). I have to politely reject a man trying to hit on me in a matatu, then use the same man to protect myself from a drunk bodaboda driver yelling “MZUNGU LET ME TAKE YOU TO THE BORDER!” I cramp my legs trying to fit in the oddly shaped matatu, feeling whiny and wimpy as none of the Kenyans and Ugandans on the same matatu seem at all uncomfortable or fidgety.

By the time I make it to Tororo, I am sticky and dusty and exhausted, and my hair resembles a bird’s nest. Still, it’s only 1pm, so I head straight to the hospital to get some work done. I'm exhausted, but I figure I can just round on a few patients, check my email and go home around 3 or 4.

Soon after arriving, I get a phone call from a nurse on the Female Surgical ward. She asks me to come and see patients. There were some patients I knew were waiting for me from last week, needing ultrasounds. I grab the scanner and head over.

The ones I know about are in Beds 2, 5 and 7. I had taken notes on them before, and I am ready to scan them. There is also someone I had scheduled for a hysterectomy in Bed 9, who is admitted in preparation for surgery. Then the nurse points out that she would also like me to see Bed 6, Bed 8 and Bed 12. A clinical officer asks me to see a patient he admitted in Bed 10. As I start to see people, the nurse says “You know, there are also 2 people here who I was going to send home. I think they have cysts or something. Let me send them away, you have too many to see.” I stop her and promise to see them too. They are in Bed 3 and Bed 4. So I need to see Beds 2-10 and Bed 12.

I start scanning. Bed 5 has some kind of huge abdominopelvic mass. It looks most likely ovarian, but I can’t tell exactly. It’s more than 15cm. I am thinking ovarian cancer, but it’s hard to be sure. She will need it removed. I tell the nurse we will schedule her for surgery. When she translates, the patient reaches out for me as I am about to walk away. She grabs my hand and gives me the triple handshake, smiling and thanking me in Japadhola. “She is very happy. She is tired of that mass paining her,” translates the nurse.

Bed 6 is easy – she had a miscarriage earlier today, her bleeding is better, and her uterus is empty on ultrasound. Done, sent home.

Bed 7 has been in menopause for 20 years, but has been bleeding for 1 year now. Highly suspicious for uterine cancer. Another doctor attempted a D&C but her cervix was too stenotic. I scan the uterus – it has a large mass in it that looks like a fibroid, but she shouldn’t have a bleeding fibroid at her age. I contemplate my options – should I give her misoprostol to soften her cervix and repeat her D&C, or just go ahead and do a hysterectomy? I would prefer to do the D&C to check for cancer, but will I find a pathologist to give me an answer? I am still waiting on another patient’s path from 2 months ago. And if they do read it, will I still be here to do her hysterectomy? I am leaving in a month. Lastly, will it change my management? I am not a Gynecologic Oncologist, at most I can remove her pelvic organs, bu I can’t do node dissections, nor would it be useful without a pathologist to examine the nodes (and chemo/radiation). I can’t decide – I will think about it later and get back to the patient with my plan.

Beds 8, 9, 10 and 12 are still waiting for me. Bed 12 needs a pregnancy test, but the hospital doesn’t have any test strips right now. Bed 9 is for surgery tomorrow, and looks ok. Bed 10 is a young girl with a right-sided pelvic mass – probably a dermoid cyst (although she has gotten loads and loads of unnecessary antibiotics already). But first, I turn my attention to Beds 3 and 4, who are looking more urgent.

We start with Bed 4. She is visibly in pain, she looks like she is having episodes of cramping pain. She complains of heavy vaginal bleeding. Her last period was 6 months ago. I scan her and find a lot in her uterus. Looks like liquid plus some solid. I think it is probably an old pregnancy that died a while ago, and is just now coming out. The liquid is probably blood. I can’t see an actual fetus shape, but maybe it has degenerated. I decide to do a vaginal exam to see if she is dilated – and that changes my diagnosis. When I feel her cervix, it is rock hard, bulky and immobile – especially inside the canal. My guess is cervical cancer. The stuff in her uterus is not a pregnancy, but probably liquid and clotted blood. Her cervix has closed off from the tumor, and blood is collecting inside. She will need an exam under anesthesia, biopsies and a D&C to confirm.

Then we reach Bed 3, who supposedly has ovarian cysts. She insists she is not pregnant, although she last took Depo Provera over 1 year ago. She looks pretty good, not in visible pain. That changes when I touch her abdomen – she cringes and recoils. Hmmm. I do an ultrasound. Immediately, I see a small live fetus inside her uterus, measuring 9 weeks and 5 days. It has a visible heartbeat. It’s inside her uterus, so this is not an ectopic pregnancy. I notice that the fetus is in the upper part of her uterus (fundus) and she seems to have a round structure, maybe a fibroid, in the lower part of the uterus. Maybe her pain is from a degenerating fibroid? The pain seems excessive for just a fibroid, though.

Then I look outside her uterus. Behind it, there is a lot of black, representing fluid. What is all that fluid doing in her abdomen? And there also appears to be something more solid floating in the fluid. Is it a clot? What is going on? Did she rupture an ovarian cyst that is now bleeding? I can’t even find her ovaries. She has an intrauterine pregnancy. Could she have a heterotopic pregnancy, where one twin is inside the uterus and the second is in the tube? That is exceedingly rare – I have already seen it once in my life and don’t expect to see it again. I ask if she has a history of twins, but she doesn’t. She has 6 children, all born singletons.

As I am trying to figure out what is going on, I realize that she is becoming increasingly uncomfortable as I press on her abdomen for the scan. I ask the nurse to get her some pain medicine. As soon as I do, the woman suddenly closes her eyes and seems to lose consciousness. The nurse immediately goes to get an IV to insert and hang fluid. The woman looks pale and sweaty. I take her pulse – it is normal. What is going on? I notice her move her arms toward her face with purposeful movements; she is not unconscious. Is she just being melodramatic about the pain, or is the pain just incredibly severe and she can’t help but close her eyes? She opens her eyes again and the nurse gives morphine. A second nurse puts in the IV.

I need to figure this out fast. I know that scanning is creating pain, but if that is really blood in her abdomen, then I need to take her to the OR immediately. I review the chart. As it turns out, the woman just had an ultrasound at the TDH department. It is not a great report, and the person seems as confused as I am. Eventually, the sonographer concludes, the patient should be admitted and “we should reevaluate with a clear mind.”

What? No idea what that means. Then I realize what I am looking at. I re-scan the pregnancy. It is not exactly in the uterus, but along the upper border. What if it is a cornual ectopic –located in the corner of the uterus, which is a thin wall, and bursting through the wall? It would explain why the pregnancy is bigger than a normal ectopic (in the tube they tend to rupture around 7 weeks, this is almost 10). Still, cornual ectopics are rare, and a tubal pregnancy is statistically much more likely in this case.

Regardless, she needs to go to the OR now. It’s almost 5pm. Will I be able to get an anesthetist and theatre nurse at this hour? This is life or death.

“And I was going to send them away!” marvels the nurse. One has a probably ruptured ectopic, and one has probable cervical cancer. Good thing she didn’t.

I call the anesthetist, and to my great relief, he agrees to come immediately. I write notes on the other patients while I wait for him to come. When he arrives, we move the patient quickly to the OR.

I open her abdomen urgently. As soon as I open the peritoneum, blood comes pouring out. Blood, blood, blood, more blood. Liquid, rapid, bright red blood. It is everywhere. I scoop it out with my hands (there is no suction). The anesthetist puts a big plastic garbage pail at the end of the table, and the blood runs down off the drape, between the patient’s legs, into the pail. It also pours all over our feet as we operate, soaks the drapes and the patient’s abdomen.

I can’t see anything because of all the blood, but it seems like the bleeding is still active. I stick my hand in to see if I can feel what is going on, and maybe pull the aberrant ruptured tube (or whatever) out of the incision. I pull out clots, and reach back in. I feel something different, mushy and textured. I pull out an intact placenta and fetus in a sac. Holy moly. Where the hell did that come from?

I scoop out more blood, and sop it up with mops (large squares of gauzy cloth). I pull up the right tube, and it is intact. I pull up the left, tube, and it is intact. Finally, I find the uterus. More mopping, and I realize that there is a 2cm hole, about 3cm deep, in the right corner of the uterus. It really is a ruptured cornual ectopic.

And it is still bleeding like stink. I need to close the defect. I have never actually operated on a cornual ectopic before. I heard about other people doing them in residency, listened intently to other residents’ accounts of them in case I ever encountered one, but I never saw one. They are relatively rare.

But here I am, and she is bleeding. I figure the best thing to do is pretend it’s a myomectomy. This defect is similar to the hole that is left after you remove a small fibroid. I close the defect in layers, with tight locking sutures to stop the bleeding. After 2 layers, it has improved, and after the 3rd layer, it is hemostatic. Phew. Meanwhile, more blood has collected and I need to mop it out. There is so much that I worry that something else is bleeding. My kingdom for a suction.

I finally get all the blood cleaned up, inspect the pelvis carefully, and discover that everything else is intact. There is no bleeding. I close the abdomen.

When I step away from the table, I realize it looks like the scene of a massacre. There is blood everywhere, and the pail has a scary amount of blood in it. I have no idea what her blood level is – the lab can’t do that test right now. She was extremely pale before the surgery, but most of the blood loss was already in her abdomen before we started. Still, she might need a transfusion.

At 7pm, as the dark is falling and the last bodaboda is available at the hospital gate, I finally head home. I look in the mirror, and something is crusted on my forehead – is it dirt from my long journey or blood from my crazy surgery? I take a shower, and when I wash my hair, the white conditioner turns brown from all the dirt in my hair. Finally clean, I lie down on my bed, exhausted. Tomorrow, I will go and see all the patients I didn’t see after I discovered the ruptured ectopic.