Final tallies

From the past four months:

Flights: 14
Boat trips: 6
Dance parties: 2
Crossword puzzles completed: 41
Nile River water swallowed: approximately 1 liter
Casual walk-by mzungu fist bumps as only form of silent greeting: 5
Acai bowls consumed: Dozens
Out-of-pocket medical visits: 3 (thanks, UCSF insurance!)
Cameras destroyed: 1
Phones destroyed: 1
Pieces of clothing destroyed by (and left behind in) Uganda: 11
Motorbikes ridden: 8
Babies delivered on the (actual) floor: 2
Peeling sunburns obtained: 2
Birthdays: 1
Sea creature T-shirts acquired: 2
Parasols acquired: 2
Days away from San Francisco: 116

Time to get back. See you tomorrow, little Irving Street apartment. 

Ode to the nyabo

Not to culturally generalize, but Ugandan women are pretty much badasses.

I thought I'd write this post about my last day today in the hospital - the everyday chaos, tragedies, and swimming against the tide - but the more I thought about it, the more I decided I'd rather write about my growing admiration for the women I've met and treated and delivered and dined and danced with here.

You can guess at their badassness just by people-watching on the streets here. Whatever their income, Ugandan ladies dress just spectacularly. The wealthier young ones wear immaculately tailored dresses, modest in terms of shoulder and knee exposure but specifically cut to emphasize butt curvatures. Respect. Older women go for more coverage but still impressive, with blooms of perfectly matching bright fabric cut to form billowing sleeves and swishy skirts. Even the women patients of Mulago, who sleep on the floor and eat only rice for dinner, are still bringing their A-game. Their only skirt is colorful and as clean as possible, and occasionally you'll spot one sporting what is clearly a second (third?)-hand American prom dress, shiny and floor-length and all. No sweatpants or old Tshirts here. Personal standards to be upheld. And this is to say nothing of the amazing variations in, cost of, and time spent maintaining beautiful hairdos.

So they look good. But they're also constantly rising to the high (and unfair, I'd say) demands Ugandan culture puts on them. Family life is essentially entirely on their shoulders. I've met many women like Juliet (mentioned two posts below), who house/cook for/raise the children of a man who always has his foot halfway out the door. Many men here, especially those wanting a son, will openly father kids with other women; Juliet's husband has seven children, exactly one of which is hers also. She cooks for them all while he watches TV. And the more well-educated women - or at least the female faculty and house officers of Mulago I met - get no breaks. All of the childrearing and food preparation and hostessing duties go on unabated, just squeezed into smaller time frames. Dr. Namulindwa, one of the Mulago faculty training with Dr. Ueda, told me about one of her recent Fridays: she started doing hours of oral exams with medical students, followed by a complicated multi-hour surgery in the OR, then spent the night of running all over town preparing food for the 100 people who were coming for her husband's Catholic prayer group the next morning. (Dr. Namulwinda herself is Anglican.)

The pressure on Ugandan women to have children, preferably lots of children, sometimes looks crushingly intense. The stigma for infertile women here is dramatic. Until recently, though it's now officially discouraged, Ugandan women who died childless were actually buried in different, less respectful manner than mothers, carried out the back or side door rather than the front one. This manifests itself in different ways in womens' health care here: women often fear and avoid birth control, and medical professionals often contribute to that (I was looked at with amazement here when I asked if a patient having her fifth complicated C-section might be interested in having her tubes tied. The house officers thought it was crazy to even offer it after "only" five.) It's not necessarily true that the woman herself wants more children (we see plenty of complications of illegal abortions to attest to that), but rather seems to be a fear of being known to be sterile. Sadder still was a patient I met at Herbert's clinic, who'd lost six - six - pregnancies in the second trimester (even one loss at that stage is very rare), and just went right on getting pregnant again as soon as possible, desperate to have a child despite the mental and physical toll.

So out of all that background comes the scene at the Labour Ward itself. Sweet sassy molassy, these women are tough. Imagine 20-ish beds (cots, really) side by side, with thin curtains separating them, each occupied by a patient who brings her own plastic half-sheet on which to deliver her baby. No men are present, including fathers. No anesthesia whatsoever, including for stitching vaginal tears (ow).  An occasional yell or heavy fast breathing may come from one section of curtains, maybe right around the time of delivery, but mostly women labor stoically, gritting their teeth as contractions pass and then going about their business in between. Even if things eventually end up going towards a C-section, women obligingly fold up their plastic half-sheets and walk themselves to the OR, hopping up on the table despite being 9 months pregnant and actively laboring. Badasses. (I cringe a bit to think of coming back to UCSF and the American women who insist on their vision of a "natural" birth: surrounded by candles, a birth doula (or two), a whirlpool tub, a husband giving back massages, moaning for hours with soft Enya music in the background. I thought they were a little ridiculous before, honestly, and I'm really not going to be able to take them seriously now. I'll give you natural, lady.*)

So that all seems like the right thing to say, the right thing to write, as I wrap up here in Kampala. The systems that serve women here are often crazy and broken. But the women themselves are resilient to the point of awe. I hope that if they stick it out long enough, eventually the Ugandan systems will prove themselves a bit more worthy.




*I realize this statement may make me a big, bad, birth-medicalizing ObGyn. I respect the desire for minimal intervention, I do. But if you've seen patients die for lack of an intervention that a wealthy patient then actively chooses to decline, it rearranges your perspective.

Sunday scenery

A few shots from my Sunday stroll yesterday, just for a little sense of place:

The week's supply of plantains, deposited outside the Good Samaritan restaurant downstairs. Sarah looks on, wondering what the heck I am taking pictures of.

Resident chickens outside the breakfast house. Kampala is so hipster.

This curb is actually not on the grounds of ,or even that particularly close to, Mulago Hospital.

Red Dirt Sunday League game.

Happened across the National Library. 

Now that's a psalm I can get behind. Please note the SUV parked directly on the sidewalk.

No further museum explanation is offered. Please note the bodabodas driving on the sidewalk (to avoid the speedbump in the road, of course).

Kampala!

City of red dirt, crazy traffic, a president/dictator, and a partial king! But I didn't really know any of that until now! Since I've been staying at the Mulago Guest House, there's only about a ten minute walk between my room and the front door of the Labour Suite. It's easy to let your whole world (or weekday world, at least) be within a one-mile radius.

For my last weekend here, I'd been considering some sort of day trip out of Kampala - rainforest ziplines? chimpanzee islands? the usual - but in the end I ended up staying in town. And it was actually really fun. I felt quite a bit more...socially embedded, I guess, than I have during the previous three weeks. Kind of found my stride a little bit - though right at the end of the trip, of course.

Friday night, the Mulago Guest House lawn was host to a rather fabulous barbecue, thrown by the Mulago Anesthesia department and deejayed at maximum volume by one of the house officers. Featured such excellent touches as a grill obviously custom-welded out of an old oil drum as well as a dance party dominated by completely uninhibited Ugandan men. Killin' it. I joined in on the outskirts but couldn't hold a candle to Erasmus, anesthesiologist by day and possibly Beyonce backup dancer by night. (Many men here have wonderful first names, not heard in the US for the past 200+ years: Erasmus, Gideon, Godfrey, Pius. It's lovely.) Good time had by all, with the possible exception of the goat who provided the main dish.

Managed to somehow avoid a Ugandan-gin-associated hangover and rally in time for...a bodaboda tour! An enterprising group of young guys in Kampala are out to convince visitors that not all bodabodas (small zippy motorcycles) are death machines. I'd been warned off/outright threatened by my residency director not to ride a single bodaboda during my time here, but another Dutch ObGyn visiting Mulago was dead set on doing the door. (I suspect Karoline is a adrenaline junkie.) And you know the East African motto: Doing anything with someone is almost always better than doing some preferred thing alone. And I'm pleased to say I am NOT dead or maimed, and actually had a great time. The guides took us all around the city - Baha'i temple, downtown matatu station (amazing chaos), highest minaret in the city, Bugandan king's palace - and in three hours I rather felt way better oriented in terms of geography and history. Kind of wish I'd done it on Day One. Don't tell Dr. Autry.

In the evening, a bit of a different direction. I'd met a young woman named Juliet outside the Guest House a week or so ago who cheerfully chatted me up for a little bit. She dropped by my door twice more, once to offer a small mango as a gift, and then a day later to invite me out dancing on Saturday night. Having warmed up with Erasmus, I was ready. But it turned out Juliet's favorite club was only playing soccer games last night, so we (she, really) decided to head to her place for a drink. Turns out that Juliet and her family live in a pretty poor part of town; not quite a slum, exactly, but only by virtue of a little more space between walls. We wound our way by backdoors, streambeds filled with trash, little kids running around happily in the dark, before stopping at her one-room concrete home. She shares it with six others that make up three generations; only one is employed. Everyone was friendly and gracious, delighted to have an interesting visitor, offering me the only seat in the home and sending the kids out for a single Nile Special beer and a serving of fried chicken for me. I haven't quite learned how to gracefully navigate these kind of guest-fêteing situations; I know that it's meant as the proper welcoming gesture, but I also know that this family should not be spending money to buy me beer and chicken. (Especially true for me since I don't particularly like beer and actively avoid chicken.) I settled for sharing the beer with Juliet and the chicken with the kids while we all watched Ugandan music videos together on a tiny jerryrigged TV, hosting a string of curious neighbors who wanted to say hi. Juliet eventually sent me home with her trusted bodaboda friend (OMG terrifying - I made so many promises with the traffic gods on the back of that bike if they would only spare me) with promises to come visit me in San Francisco soon. 

And so in 36 hours I somehow saw more of Kampala than I had in the previous three weeks. It's not going to be on any architecture list of beautiful cities, but it definitely qualifies as a fine bustling African metropolis. Next time: urban adventuring earlier the game.

Irony

Of all the threats to my physical well-being in Uganda - malaria, scalpel injuries, bilharzia, crazy motorcyclists driving on the sidewalks - it seems ridiculous that the one most likely to actually kill me is this stupid peanut allergy. Ach. One minute you're ordering a nice eggplant curry and the next you're madly itching and wheezing and wondering whether you need to go bother the anesthesiologists staying next door. Who puts peanuts in curry? Honestly. Stupid delicious Indian food. Stupid overactive immune system.

Seems like this happens about once every one of these trips, just as a little reminder that I can't rely on my body as much as I pretend I can. Luckily it passes quickly - after an extremely unpleasant evening after dinner last night, I woke up this morning with only a residual scratch in my throat and some rather remarkable eyelid swelling. Very Betty Friedan. Can't wear my contacts yet but grateful it wasn't worse.

FYI, there is now an employment opportunity available for any readers who wish to be my Personal Taster on future journeys. 

A Day at the Theatre

Another day in the Labour Suite, this time spent C-sectioning, reminds that I still haven't written much about the culture here in the OR - or, as the Ugandans call it, the theatre. Which is a grave blog omission! It's actually probably one of the most jarring aspects of working here. Operating at Mulago compared to operating in a resource-rich hospital makes you feel (and look) like you've never performed a surgery. It's a whole different animal. And that animal might be an evil pied crow.

Probably the only sensible way to begin to describe the experience is to go through chronologically. How does one do a surgery at Mulago?

1) Gather what you need.

It's kind of remarkable anyone ever actually gets to the OR table here. The delays are myriad, and the first case of the day in the Gyn theatre rarely gets going before 10am.

Some delays are secondary to resources. The suture shortage goes on here, daily; it seems like new shipments of surgical stitches won't be arriving until July. In the meantime, patients (who expect free care) are asked, quietly, to either buy their own or to wait longer for their surgeries. You find yourself trying to count out the bare minimum of sutures necessary to do surgery on a patient who doesn't have the money to buy any stitches, let alone extra. The blood supply on a given day is also anyone's guess; last week we had to delay surgeries for cancer patients who were type O+, since the blood bank was out of stock. Gauze, drapes, sets of sterile instruments - anything you might need to perform surgery can and will run out. You don't even think about these things in the US (we've operated to the point where we're out of drapes?), but it's a frequent issue here.

Then there's the human resources. Did the floor nurse actually wheel the cancer patient to the OR from the temporary ward across campus? Did the anesthesiologist wander away for tea (usually happens around 9:30, 9:45)? Are there OR nurses (all called "sister") around who can bring you things when you're supposed to be maintaining sterility mid-surgery, or are they also at tea?

By the time you've herded all these cats, you've wasted a few hours. It's rare to do more that two Gyn surgeries in a day, even ones when the actual operating time should only be two hours.

2) Get dressed.

This part is kind of fun. Mulago surgeons dress...well, a bit like butchers. Size XXXL thick cotton scrubs, with rubber knee-high boots, a full-length mackintosh apron, and then another thick cotton sterile gown over top that tends to have hilariously short sleeves. I feel like Clive Owen in the The Knick, though obviously not as good-looking. It gets wicked hot under all that, but the time you skip the mackintosh apron will inevitably be the time you end up soaked in the patient's questionable body fluids.

3) Get clean.

All hand scrubbing here is done not with soap, but with iodine, giving your clean hands a weird yellow sheen. (I've asked a few times what happens if someone has an iodine allergy and haven't ever really gotten a good answer.)

The surgical sterility of the OR itself is also a bit more....lax, to say the least. Staff regularly wander through open surgical theatres with their face masks around their chins, patients' bare feet occasionally stick out from under drapes, anesthesiologists drink soda during cases, the windows are opened to the outside world if it gets too hot (which it always does), etc. For those of you not in medicine, just know that any of those things would be an enormous honking deal in the US, incident-report worthy. It's not all terrible - the staff is good about keeping the incision area clean, using gloves regularly, and sterilizing the OR table itself. But the sterility of the surrounding environment is not a priority.

I will admit that there's something rather pleasing about operating while watching a thunderstorm pour down outside an open window...but this is more than counterbalanced by the dismay of watching a fly come buzzing through that same window.

4) Operate.

Actually performing surgery feels a bit like one big improv game, though bleedy-er. The anatomy is the same, of course, but the tools you have to access that anatomy are like a surgical grab bag. No two sets of sterile instruments is exactly the same, many of them don't work that well (some scissors don't actually cut anything thicker than floss), and virtually none of them are the ones we'd use in the same surgery in the US.

In some sense, it's a nice exercise in thinking about what you really need to do to execute a given action. What do I need to grab this piece of tissue? A Kocher clamp! Don't have that. An allis clamp? Nope. Well...what do we have that's medium-length, pointy, and ratchets down?

You will also be looking for this instrument yourself, on a large tray piled haphazardly with sterile instruments. While in the US, there's a dedicated nurse to hand you what you need while you operate (the person who hands over the knife when the TV doctor yells "scalpel!"), you're on your own in Mulago. You root around until you find your own dang scalpel.

Other fun twists: you might have a random and extremely ill-timed power outage, give the aforementioned thunderstorms. It SEEMS like the machine keeping the patient breathing isn't affected by these outages, but your electricity-requiring surgical tools are out of commission at least until the generator starts up.

You're also trying to save suture, of course, so you end up typing the world's tiniest knots. Ugandan surgery will make me blind.

5) Watch your patient carefully afterwards.

Patients tend to stay at Mulago quite long after their surgeries, often because they often live far away and the local docs wouldn't know what to do about any post-operative complications. And they do get more complications afterwards, including infections and the dreaded diagnosis of "burst abdomen" (internal sutures coming undone, for reasons of either poor surgical technique or internal infections). Recovering for up to two weeks after a visit to Mulago's theatre is not unusual.


There are another dozen new things that give me pause every time I'm in the OR here, but those are the highlights. Really, surgery was one of the most terrifying aspects about working here when I first arrived, but I realized today that much of it doesn't really even catch my attention anymore. Turns out you can get used to anything. I think I'll be in for a rude awakening once I get back to UCSF. What do you mean, I can't delay a surgery to take tea?

Mulago Safari Guide

You may have heard about Uganda's famous gorillas. I'm sure they're very nice and all. But after the past few weeks here, I really can't imagine those silverbacks are able to hold a candle to the fabulous fauna strolling around the Mulago campus and Kampala generally. (That, and there's no way I can afford a solo gorilla trek while I'm here. Sour grapes.)

So! I hereby present possibly the world's first safari guide for the Mulago Hospital campus. Not complete by any means, but a few of the must-see highlights:

Green Snipey Guys (aka Hadada Ibis)



These guys! So fancy. They're about Canadian goose-sized and always seem to be hovering around in pairs. Skittish fellows, they tend to freak out and fly away with a really loud panicky call. They have mousy brown base feathers, but with a very stylish green streak over the wing and a pleasingly curved beak. I've been calling them green snipey guys, for no particular reason other than I like the word "snipe", but a quick internet search ("uganda bird green") reveals that they're Hadada Ibises. Apparently the name comes from a transliteration of their panic call; I'll have to listen more carefully next time. Here they are in my backyard, looking wary.

Evil Crows (aka Pied Crows)



These guys terrify me. They give a bad name to pies everywhere. They are aggressive, loud, and a bit too clever for their own good. Also, absolutely everywhere. They freaked me out in Tanzania and they freak me out here. Let us say no more about them.

Marabou Storks



The sleeper hit of Mulago! The offspring of an egret and a vulture, but somehow way bigger than both. These guys stroll around the Mulago campus, approximately four feet tall, totally silent and spectacularly ugly. Some of the bigger ones sport these giant waddle/goiters that really push the ugliness factor to the next level. And they fly! Definitely the largest flighted bird I've ever seen. They must have at least a six-foot wing span. It's like watching gliders go past the window. They like to sit creepily on the hospital roof, almost motionless, standing guard over the chaos below. Dr. Ueda, who is only about 4.5 feet tall herself and prefers her animals good-looking, dislikes them very strongly. Perhaps needless to say, I love them. I've taken quite a lot of pictures of them. Here they are being creepy on the roof across from the Labour Suite OR windows.

Put these guys on the national flag, I say.

Monkeys! (aka Monkeys)

It's a very "Africa!" moment when you head out your door in the morning and discover that the lawn is full of about a dozen small monkeys, eating bugs and grooming each other and doing other monkey things. The Mulago Guest House, where I stay, has a resident herd of monkeys that shows up maybe every other day. None of the Ugandans ever feed them or coddle them in any way, so there's no primate-on-primate harassment; they mostly ignore the humans eating lunch in front of the canteen, though will bolt if any mzungu with a camera gets too close. It's a little like a herd of feral cats, though much more charming.

Really a step up from squirrels.

The Front Line

This week marks my return to L&D (or as Mulago calls it, the "Labour Suite". So fancy). After spending a single day on the Suite during my first week, when all the house officers were gone, I was sort of dreading going back. It felt like so much chaos, so many patients I was losing track of and offering only substandard care, so many seemingly inefficient systems I just didn't understand.

But you know? Today wasn't that bad. I ended up manning the Admissions room with two other house officers, seeing an endless line of patients with aggressively pregnant bellies, and I actually felt like I was helpful. It definitely helps to have the house officers back. And it also turns out that Obstetrics everywhere is kind of the same, no matter the surrounding chaos. There are only so many pregnancy-related medical problems, and there are even fewer potential treatments (to wit: deliver vaginally, deliver via C-section, or watch longer). At this point in my training, I've seen enough folks that I can at least confidently funnel patients into "concerning" and "unconcerning" categories. And that's enough to be useful in triaging.

And sometimes, when a true, true zebra comes in, house officer knowledge and UCSF resident knowledge can be quite complementary. Around noon today, the Admissions door slammed open and two terrified young men appeared pushing a barely conscious, gasping woman with a giant distended belly. The rest of her, however, was completely emaciated, and the intern and I were able to hoist her easily onto an exam bed. Her wide-eyed relatives were able to tell us only that she'd had a baby the day before, at home, and had suddenly taken a turn for the worst that morning.

Our first thought: she was having a postpartum hemorrhage and bleeding to death. The intern confirmed anemia just by looking at her eye sockets. (They're masters of physical exams here, not having easy access to blood tests.) And her belly looked huge, suggesting that her uterus might be distended and hemorrhage-y. But her current bleeding didn't really seem that bad, and her belly, though huge, felt strangely squishy - not uterus-like at all. Weird. After getting her some oxygen and some IV fluid, we decided to roll over the ancient ultrasound machine, and I took a peek inside her belly. (Bedside ultrasound seems to be a relatively new addition to the Mulago house officer repertoire - most of the house officers rely on formal ultrasounds for managing patients but don't get any consistent training in using them.)

Inside her belly was a tiny, well-behaving postpartum uterus, and...fluid. Liters and liters of clear fluid filling her abdominal cavity, something you'd expect to see more with patients with heart or liver problems. And then one of the house officers asked the right question to her relatives: Had she been tested for HIV? She had, in fact, just two months ago, and was found to be positive. Furthermore, her immune system was suppressed to the point that she'd been recently started on medicine, which they don't do for just all HIV+ patients in Uganda; you've got to be in a pretty bad spot to merit meds.

So all of a sudden it turned out that our postpartum hemorrhage was actually more likely an AIDS-related complication - it just happened in a patient who'd recently delivered a baby, which brought her to us. Definitely not your typical US triage patient. But I was proud of us, really. We figured out (generally) what was going on, stabilized her, and started the process of getting her into the right hands; I hope the Infectious Disease people tell us what's up.

And then, of course, another five laboring women piled in the door and our marathon continued for a few more hours. But with those little satisfying bursts just often enough. Looking more forward to getting back into the fray tomorrow.

[While writing this, a woman I chatted with over the weekend knocked on my door and gave me a teeny perfect homegrown mango! Huzzah! Excellent gift.]

Perfect Attendants

In the US, staying at a hospital is in many ways like staying at a hotel. You get meals, clean sheets, clean floors, entertainment, wall art, the works. Our new UCSF hospital is like an upscale Sheraton, though with more IV poles. This means a host of American "hospital" employees actually have no medical knowledge but are crucial to day-to-day functioning of the place.

You may be shocked to learn that Mulago Hospital does not offer psuedo-hotelier services. Mulago offers its admitted patients 1) medical assessment, 2) some medicine, and 3) space under a hospital-built roof (bed and indoor location not guaranteed). But of course these patients still need meals, clean sheets, help to the bathroom, etc., all of which they are usually too sick to manage themselves. Who does this?

Your attendant, of course! All admitted patients at Mulago are required to have a attendant with them during their whole hospital stay, and this person is in charge of feeding, clothing, cleaning, and making occasional runs to the medical supply store when Mulago runs out of something it's officially supposed to provide (certain antibiotics, surgical suture, etc.). The ward floors are crowded with attendants napping on thin woven mats, plastic food containers, and piles of colorful clean sheets that patients' families bring in from home. A fairly representative photo from the interwebs:



Your attendant can be your sister, your cousin-in-law, your buddy, your 12-year old daughter - anyone who's willing to stay and help. And it seems like this person can occasionally make or break your hospital stay. An alert, persistent attendant, especially one that seeks out a doctor rather than waiting for one to come by, can secure better care and faster healing for a patient; it's a like having a personal patient advocate. But the converse is also true - one of our patients on on the Gyn Onc floor last week had an often-absent attendant, and she essentially languished in the corner, trying to recover from high-dose radiation therapy without anyone to bring her basic things like water.

So now, as I wander around Mulago, I've started to think about who my attendant would be. It's a big responsibility! It seems like the only way to decide fairly would be to establish an Attendant Point System, which I have done, because I need hobbies. Points are assigned in terms of likelihood of your leaving the hospital healthier than when you arrived.

Attendant Point System (APS):

Loves you: +1 point
Good cook: +1
Willing to Sleep on the Floor: +1 point
Not squeamish: +2 points
Loud/Assertive on your behalf: +2 points
Any medical knowledge whatsover: +5 points
Male: +10 points
Personal friend of someone high up in the hospital administration: +50 points

So by this algorithm, I think my attendant might have to be...Clif Brock, perhaps? A charmingly abrasive medical school friend? I'll have to see if he's doing anything important next time I get really sick.

Quote of the Week

Buying a soda at the local gas station after work, I hear a tiny voice yell "Mzungu!" ("White person!") I look up and see a very small, very excited little girl rushing into the store with a huge smile on her face. She comes right up to me, beaming, and extends her hand confidently. I say "Hello! How are you?" and extend my hand. She grabs my hand in a death grip, swirls back to look at her mom, and announces across the store in perfect English, "This is my mzungu!"

Always good to feel wanted.

A Day in the Life of Herbert

Dr. Herbert Kayiga, everyone.

Herbert is a kind of a big deal. He's a former Chief Resident from the Mulago ObGyn program, a UCSF Senior Scholar, and always gets a personal mention among the UCSF residents as a truly lovely human being.

And so, even knowing that Herbert often gets officially charged with helping UCSF residents find their footing around Mulago, I still felt rather special to be asked to come join him for a day at his new, post-residency job: Case Medical, a small private hospital complex in Kampala, where he's a full-fledged "consultant" (we'd call them "attendings" in the US - a fully trained, independent physician). I headed out this morning in my snazziest work dress, excited to do a little reconnaissance work on the local healthcare options to figure out which aspects were unique just to Mulago and which were just standard Kampala.

And seeing the differences between a private hospital for insured/cash-paying patients versus Mulago was interesting; Ugandan OR style really merits its own special post one of these days. But what actually caught my attention today was Herbert's career path itself - or maybe just the paths of all Ugandan ObGyns. Jesus, what a hard road. I'd gotten a little flash of the struggles that the Mulago house officers face, just in chatting with the young doctors on the wards this week, but Herbert really fleshed it out for me. Generally, Ugandan medical training seems to be generally modeled on the British system, but with less financial support, fewer job opportunities, and a government that fails to make adequate use of the few highly trained physicians it has. Seems like a crazy eye poke of a system.

From what I've gathered, Ugandans who want to be doctors start out with four years of medical school, for which they pay tuition. Fine. Tuition for school seems reasonable enough. They then do a single year of post-graduate training called an Internship, which trains them to be General Practitioners. This, theoretically, is a paid year - but as I mentioned a few posts ago, none of the Mulago interns have been paid in months and are currently striking. Still, at least the goal is to pay them.

General Practitioners can then take their year of training and go practice wherever they want in the country. Herbert stayed in Kampala, starting work at his current Case Medical hospital, but other graduated interns go way up country, serving as the only doc around for miles, doing all the C-sections, pediatric care, appendectomies, blood pressure monitoring, everything. After one year of training. Seems intense.

Then things start to get weirder. If you decide to become a "specialist" in Uganda (anything other than a General Practitioner), you have to have more training. But the Ugandan system doesn't pay its residents; instead, they pay to be trained. That's right - for three years, the house officers who keep Mulago running actually lose money to the government. Most residents I've met at Mulago actually have part- or even full-time jobs elsewhere in the city, just to keep financially afloat. And this at an age when Ugandan culture expects them to be providing at least for a spouse and young kids, if not an even larger dependent extended family.

So then, how's Herbert now? Done with residency, finally reaping the benefits? Sure doesn't look like it. Like many of the permanent Mulago faculty, his appointment as Mulago staff pays laughably little: less than $300/month. So he has to continue full-time with the private hospital that actually pays him. This, probably more than anything else, seems to contribute to the common situation at Mulago where there are simply no supervising senior staff on the hospital premises - they're all out at their private clinics, paying the bills.

Is private hospital work easy? It is not. Unlike in the US, where most hospitals have a system of rotating call among the staff doctors, or at least a call center, Ugandan private doctors are expected to be available essentially 24/7 for their patients. Herbert's phone rings approximately every three minutes during the day, to the point where his ring tone got stuck in my head today. Patients call him, family members of patients call him, patients text him questions about their family members' health problems ("doctor i think my husband has a uti what would recommend thx"). It looks exhausting.

The worst part? Herbert is lucky to even have a job - he estimates that of his cohort of ObGyn residents, only about 30% found jobs after residency. Even outside of Kampala, the government has created very few positions for ObGyns in rural areas, despite the need for them there. After three years of debt-creating ObGyn training, many of these former residents are now scrambling for jobs even just as General Practitioners, even as women die while waiting for C-sections at Mulago. The system looks pretty darn broken.

Residency in the US is annoying and hard and long, and we feel pretty sorry for ourselves most of the time. But you know? We get paid, we don't to work second jobs during residency, and we'll probably all find reasonable jobs afterwards. And no patient ever expects to receive my personal cell phone number, thank goodness. It's all about expectations setting.

Despite this, Herbert continues to be an excellent human being. We even had time for a selfie.

ObGyns, always at your cervix

Today was a good day. First! Breakfast with no hog. Second! Actual feelings of accomplishment and usefulness, with maybe even a hint of job satisfaction. Rare last week, but definitely buoying me up as I walked home today.

Somewhat unexpectedly, this comes after two days of working with Mulago's gynecology cancer patients. As an ObGyn resident, our Gyn Oncology blocks tend to be a bit of bummer. Unlike our young healthy pregnant patients, who bounce right back to 100% even after the worst possible birth experience, our cancer patients are....well, sick. Their illness tends to put them at risk for all kinds of other medical complications, and all too often, they never get better. Caring for patients who are facing an unbeatable diagnosis is emotionally draining in a way that few of our other residency rotations are. I have great respect for Oncologists and Palliative Care folks who do this year-round; six weeks at a time in SF is enough to wear me out. 

But I happen to be here with a UCSF Gyn Oncologist, Dr. Ueda, who's been coming here 3-4 times a year for the last three years or so. When she's here, she gathers the Mulago faculty with a particular interest in Gyn Onc and tries to do as much teaching, rounding, and operating as she can cram into a two-week period. And so this week, now that some of the house officers (Mulago hospital residents) are back on the floor and rounds are happening regularly again, I've decided to attach myself to her.

This turns out to be incredibly satisfying. The Gyn Oncology ward at Mulago is literally overflowing these days; as the old hospital undergoes very slow renovations, the department and its patients have been forced into an old Pediatrics outbuilding with far too few beds (and cartoon characters painted on the walls - feels a little incongruous). So patients line the sidewalk, waiting for someone to make a plan for them. And the patients who end up herded into the Gyn Onc ward may or may not actually HAVE cancer; more often than not, some other health care provider saw something he or she deemed suspicious (a pelvic mass, unusual vaginal bleeding, etc), decided it was probably cancer, and sent her over to wait.

One of the most noticeable differences in the Ugandan cancer patients versus American cancer patients is the dramatically different incidence of cervical cancer. It's more than five times as common among women here compared to American women, and it's also significantly more likely to kill patients here. Why? Pap smears! Hurray for Pap smears! One of the great medical inventions of the 20th century, I'm gonna say. Cervical cancer is a super-slow growing cancer, with many years passing between when a routine Pap might pick up something abnormal and when a patient might actually develop cancer; there's lots of time in a wealthy country to get a complete cure. But Pap smears are thin on the ground in Uganda. So patients here often present for care for the first time with cervical cancer that's already pretty advanced by US standards. 

But the satisfying thing is that even when our patients have established cancer, we have tools that can help. Quite a bit, actually. Especially for patients who haven't tried any treatment at all so far - which is virtually all of them. Depending on how advanced their cancer is, there's only really two basic treatments: radiation or surgery. And it turns out you can get patients going towards one of those treatments in just a single visit. All patients need is a single good physical exam, a few basic labs, and maybe a chest X-ray for good measure - all of which is entirely feasible at Mulago under the auspices of Sister Eunice, Gyn Onc Charge Nurse. 

So we the Onc team spent the day yesterday systematically making our way through seeing these women, bringing patients into our basic (read: a bit grim) exam room, checking their labs, deciding on a treatment plan under the guidance of Dr. Ueda, and making some moves. If you were a patient who needed radiation, you got a referral that very moment and could go start treatment in a week. If you were a patient who needed surgery - shoot, we could do it tomorrow if they were down. 

And we did, today! From clinic to surgery in 24 hours! Fantastic turn around time. And one of our OR patients today was particularly satisfying for me. We'd found her in the chaotic Gyn ward last week, a 46 year old woman who appeared to be 9 months pregnant but was skeletally thin and malnourished - the hard mass filling her pelvis and abdomen had made it impossible to eat. We managed to get her out to our Gyn Onc ward and to find her later among the crowds of patients waiting on the sidewalk (luckily she always wears the same Boston shirt). And today, by golly, we took that mass out. I think it probably made up about a fourth of her total body weight. Crazy. And while we won't know if that mass is cancer or not for a week or two, I feel extremely pleased about the prospect of her eating an actual meal again without feeling too sick.

And I think that's Mulago Gyn Onc in a nutshell. You're seeing so many new patients, patients that no one has offered treatment to before, so you can give them the very best the field has to offer. And even in a poorer country, the field offers some decent stuff. If you're a lucky patient, you may get a complete cure. If you're an unlucky patient, you still may get a lot of good, pain-free years that you wouldn't have gotten otherwise. No small thing.

It won't make an Oncologist of me, but I can see the appeal. Looking forward to more this week.

Riparian Ricochet

On the momentous occasion of her 32nd birthday, Colleen set off down the Nile.

After the week below, I understand a little better why everyone who rotates through Mulago makes a point of planning many small weekend adventures. It's exciting, of course, but it's also mind-clearing; we spend so much time and emotional energy on the floors of the hospital that it quickly begins to feel like that's the whole Ugandan world. Sometimes you have to look up, smell the milk tea, and launch down a hippo-filled river in a boat full of complete strangers.

All Annapolis kids are river rats to some extent, even those of us who lived on the non-sailboat-having side of the creek. I've become increasingly grateful that we were dumped into water early and often growing up; it makes water a source of fun and relaxation as an adult, rather than a hazard. Dunk your children well.

So off to Jinja! The self-proclaimed source of the Nile, though sticklers (ahemDADahem) may wonder about the Blue Nile; this issue is entirely ignored in the Ugandan brochures. Regardless - the Nile! A sturdy little bus went zooming around Kampala in the early morning on Saturday, picking up our ragtag bunch of rafters: we two Mulago docs, some Pakistani UN workers, four Chinese men with minimal to no English, and six incredibly burly Egyptian men who looked like the Cairo National Rugby team or something. Arms like tree trunks, all of them.

We bounced out of the city through increasingly gorgeous green countryside, littered with red mud brick houses and scrappy-looking goats. Kampala is dry, dusty, and built without any thought to preserving green space in the city; it's eye-opening and rather refreshing to be among lush rolling hills after only 20km or so.

Our rafting guides gave us bananas, stripped us of our shoes and sunglasses ("the Nile takes a tax"), and divided us quickly into three boats. In what later seemed to be slightly ill-conceived, the rugby team paired up with one or two other strong young men to form one boat, while the three women (including Dr. Ueda, who weighs all of 90 lbs) were teamed with the Chinese gentlemen. The language barrier became clear rather quickly ("paddle forward" is actually a pretty advanced English phrase, when you think about it), but the paddling skills barrier took us by surprise. Turns out it's quite tricky to explain to someone in their non-native tongue that dipping the paddle only 2 cm into the water is not effective, no matter how quickly it's done.

But it turns out that none of that really matters anyway. Everything in the river flows downstream eventually, paddling properly or not, so off we went, bouncing backwards over a few rapids, flipping once (!), and generally having a fine time in between rapids drifting through spectacular scenery. My left arm is quite sore and I think I swallowed about a liter of rather questionable river water, but a fine birthday indeed. Feeling ready to face the Oncology ward tomorrow.

Scenes of a Mulago morning

Today's post was supposed to be a lighthearted one, I promise. I'm well aware that no one likes to read a string of downer posts all in a row. Sometimes you've gotta cut the preachy stories with goofy pictures of lizards (or giant storks! Coming soon), or by golly everyone just gets sad.

But there has to be just one more I-can't-believe-that-just-happened Mulago story from this morning, mostly because I can't stop replaying it in my head. About 9 AM, I strolled into the Gyn Triage Area, well-rested and ready to tackle the patient crowd, and stepped into the little curtained-off exam room. There are two basic beds there, and it seems that before the doctors officially arrive in the morning, the nurses often eyeball the crowd and put the two sickest-looking patients in first. Today, coming in to put down my backpack, I saw that one exam bed held an extremely uncomfortable-looking woman, lying on her plastic sheet, wide-eyed and totally alone. As I walked up, I noticed that she 1) seemed to have a 6 month-pregnant belly, and 2) upon closer inspection, was actively delivering a breech baby on the gyn exam table. 

Note please that this is not the Labor and Delivery area - there's nothing in the Gyn triage area along the lines of, say, baby warmers or post-delivery bleeding medicines. But here we were. I snagged some gloves, got down beside her, and delivered a very small baby girl within about 30 seconds of walking into the room. 

My hands full of very premature baby, I called for help, for tools, for someone to just hold the baby so I could check on the mom's bleeding; no one came, including the faculty doctor I had just walked by on my way in. The baby gasped a few times; I tried to dry and stimulate her, while becoming increasingly aware that this wasn't a place she could survive. (She almost certainly would in the US, or at least would've gotten a shot.) I briefly imagined somehow running with her across the open air courtyard to the NICU, trying to find a baby warmer or a tiny oxygen mask or just a pediatrician of some sort, and knew as soon as I had the thought that it was a non-starter - even if I somehow managed to detach the baby (still no one had arrived with anything to cut the cord), I've seen the Labor and Delivery staff here give up on babies much larger than this one.

This was all interrupted by the mom starting to bleed quite heavily. It probably only lasted a minute or two, and resolved with some basic Ob tricks, but I will say - hemorrhage without a way to give medicines through an IV is a scary thing, but hemorrhage when you don't even have any meds to give is a little heart-stopping. 

At this point, there were no more gasps. On the patient's request, I showed her her now-still baby girl; she seemed calm, practical, probably mostly glad not to be in labor any more. The faculty doctor strolled in at this point, surveyed the scene, and helpfully told me that I had gotten blood on the sleeve of my white coat. And by the time I came back from bleaching my sleeves outside the OR, the patient was gone, moved out so that another woman could hop up on the exam bed.

What kind of place is this? How can a patient like that not merit the tiniest bit of extra fuss or attention? Does this just happen all the time, and is shocking only to me? 

The Sea

Was that really only my third day? Lordy.

This time of the year turns out to be a particularly weird time for a foreign resident like myself to visit Mulago - the house officers (Ugandan equivalent of resident physicians) are all out of the hospital for two weeks, taking their yearly exams that excuse them from all clinical responsibilities. Furthermore, the interns (first-year residents) are on strike, as they haven't been paid for several months. (Fair.) This means that the whole of the ObGyn floor, including Labor and Delivery, the inpatient wards, and the Gyn emergency triage area are all being run with a super-skeleton crew of senior faculty members. I'd heard many times in other UCSF residents' descriptions of Mulago that these faculty members often peace out early or simply don't show up on their assigned days, leaving the house officers to run the show; it turns out that their patterns don't change even when the house officers aren't present.

This means that my introduction to Mulago's "workflow" (imagine my quotey fingers there) must be even more chaotic than usual. It also means that all of the Gyn emergency triage area might be manned by, say, myself and a "pre-intern" named Steven. Which it was, this very afternoon. During the morning, we at least had  the somewhat questionable guidance of a faculty member; even if I didn't agree with all of her management decisions, at least she's officially in charge. But once 2 PM rolled around, she simply left the floor; no other replacement faculty ever came.

I didn't feel like I could in good conscience see patients without oversight, but leaving the less-experienced pre-intern to manage the triage queue alone also seemed wrong. I eventually settled for seeing those patients that had already made their way onto exam beds but asking the others to wait until a new faculty member (supposedly) arrived in a few hours. Wrong? Right? Dunno.

It's difficult to express how overwhelming this triage area truly is. Everywhere you turn, there's a sea of sick women staring back at you, hoping you're coming to see and help them. There are dozens of admitted patients filling the beds (occasionally sharing), sleeping on mattresses on the floor, or piled into the hallway. There is no central list or census of who these patients are, or why they're admitted to the hospital; we pick our way around the floor mattresses every morning to try to review all of their individual paper charts, and there's often some terrible discovery of a patient languishing in the corner with, say, a worsening pelvic infection that hasn't been checked in on in three days.

There is also a queue of patients waiting to be seen that trails out the ward entrance door and never seems to shorten. Some of the queue have mild yeast infections; some are dying of malaria; some of them are actively bleeding internally from ruptured ectopic pregnancies. (The central hospital admitting staff do not attempt to separate gradations of "female problems".) So you try to sift through this queue while helping the admitted patients get blood transfusions or emergency surgeries or quinine medicine, all the while feeling like you're going increasingly underwater.

In the US, one of the most satisfying job feelings in running a busy medical service is figuring out what patients need at the beginning of the day and then getting it accomplished, tucking them in before you head home at night, watching them get well again over a few days. As far as I can tell, there is absolutely none of that in the Mulago Gyn triage area. It's all of the work and chaos and none of the satisfying endings. You put out fires all day and not much else. The work never really ends, in the sense of meeting all the patients' needs for the night. Mulago Gyn work simply ends when all the physicians get so exhausted they walk away. And then the patients just wait.

I wonder how the house officers can do it. Guess I'll find out in week #3.

On the upside, Steven the Pre-Intern is awesome. I'm promoting him to Pro-Intern.

Scenes of a Kampala morning

[cue Pastoral Symphony theme]

Drifted slowly towards consciousness this morning in the early dawn and became increasingly aware of a sort of loud, rhythmic whopping noise (a helicopter in my dream). My first interpretation was that my fan had broken (not my precious, precious fan!), but I eventually figured out a much more obvious explanation: it was raining. Turns out that a decent rainstorm on a corrugated tin roof is hella loud. But still kind of pleasant, the way it always is to know that it's raining outside and you don't yet have to get out of bed.

It's particularly interesting to listen to rain pour and simultaneously smell a woodfire; I live right above a little hospital canteen (the "Good Samaritan Restaurant"), and the chefs were already firing up for the morning rush of people needing their tea and breakfast samosas.

Also, spied this little guy smushed up against my bathroom window this morning. Creeper.

I consider bathroom lizards auspicious, I think. To the day!

Pocket full o' ultrasound gel

Back, exhausted, from the Mulago Labour Suite. Today was a day of feeling - pretty much simultaneously - that everything was crazy and different but somehow quite familiar. Not quite deja vu, exactly, but more like the sense of looking at the same scene from the other side of the room. Many things I'd forgotten about the world of East African health care came rushing right back, this time filtered through the lens of three years of wealthy-country medical training.

Chief among them: how hard it is to do....well, anything. Jeez o' pete, it's like wading through Jell-O. I do have the distinct benefit of working in a field where patients sometimes benefit from benign neglect; if you leave a laboring woman alone long enough, odds are she'll often just have a baby. This is not true of fields like oncology, where patients rarely administer their own chemotherapy (the slackers). But for those obstetrical patients who actually do need some active medical intervention, getting it to them can feel Sisyphean. If Sisyphus was forced to wear medical clogs. 

Part of it's just a sheer and constant scramble for basic necessary resources. We had a steady stream of people heading to the OR for C-sections today...until we ran out of suture stitches. Difficult to sew people back together without suture. So all C-sections stopped for several hours while patient families went to buy sutures out-of-pocket at medical supply stores. There's often half days when the Mulago Hospital blood bank is entirely empty. Patients, who bring their own packs of sterile gloves for doctors to use on them, may buy too few; no more exams for her for a little while. You find yourself hoarding a half-empty tube of ultrasound gel in your pocket, because Lord knows when you'll happen across another one. 

But part of it's also the culture of practicing medicine in resource-poor areas. I remember, now, how different this always felt from the US system; shoot, I think I even wrote a previous blog post about it. At home, no matter where you learn obstetrical care, there's a culture of hypervigilance on labor and delivery. Obstetrics is a field of rare but devastating outcomes, and your job as a good obstetrician is to see those potential outcomes coming and do everything you can think of to either avoid them or resolve them with incredible speed. And the amazing thing is that you can. At my US hospitals, I take definite comfort in the fact that in the worst-case scenario, we can get any baby out from inside mom and into the pediatricians' arms in less than ten minutes. The system has many flaws, but that part works.

This is not at all the culture at Mulago. The staff, physicians and nurses alike, move at a relatively sedate pace. I spent a good portion of the my day trying to cajole the nurse midwives to actually, say, connect a patient's IV tubing to the medicine she's supposed to be receiving, or to help me in an easy bedside procedure that can be done in 30 seconds but simply requires two sets of hands (this ends up taking about 30 minutes at Mulago when the RN heads to the breakroom for tea). Every C-section is labeled an "emergency" C-section in the handwritten notes, but essentially none of them are; the ORs only get cleaned at one pace, and trying to move a patient into the OR cannot be hurried.

It's one of the most frustrating things for many UCSF residents here, and I understand why. And it also feels almost unloyal to think it - that the problems for patients at Mulago aren't just because of the lack of resources, but the seemingly apathetic attitude among providers. But in a more nuanced sense, it's just what working in a resource-poor system teaches these providers.You can only respond to the incentives put in front of you. In the US, if you push harder, stay vigilant, you might just save an extra life. But if the patient who gets to the OR two minutes faster still ends up dead because the blood bank is closed, why bother? It must be hard to see the point of killing yourself to work harder when the patient's outcome won't change anyway. And culture change of any kind is always slow.

But who knows? I also believe firmly in the power of a few motivated leaders to change work culture - a few senior physicians who demand a higher level of baseline patient care can often pull a system in a more efficient direction, resource shortages be damned. It gives me hope about all the work UCSF does in training and working alongside local Mulago residents and physicians; changing their own internal expectations about what consists of good patient care seems like the first potential step in creating a sea change.

So wish me luck, again, as I try to hold all those thoughts in my head concurrently this week. We respond to what our environment teaches us, but hey - I'm part of that environment now, too.

Older, Wiser...Still coming to East Africa

And here we are, ol' blog o' mine, back in action after an almost four year hiatus. I've been preparing for a few years (since starting residency at UCSF, really) for this clinical rotation at Mulago Hospital in Kampala, Uganda. But it wasn't until last week that it occurred to me to reboot this little blog. (Actually, it didn't occur to me at all - credit for that goes to Dad, who noted proudly that it was the only blog he'd actually ever read.) It's a little disorienting to read my last blog posts from my medical student self below, writing as she finishes up in Malawi. She sounds so perky and enthusiastic, cheerfully unaware of the Indiana-Jones-type boulder of residency training that is coming at her. We'll see if these new posts can live up to Dad's exacting standards.

The trip to Uganda was surprisingly smooth, capping off a crazy week of eight flights in seven days, starting in Honolulu, adventuring through Burma, then sailing into Entebbe airport around noon today. Easy peasy. It's an unexpectedly odd experience to come to Uganda from a relatively poorer country (which Burma/Myanmar definitely is). Turns out it's all about expectation-setting. Compared to their Yangon counterparts, Kampalans look pretty well to-do, really. Most of the street signs here are legible, some of the children are chubby, and there's not a single lizard in my bathroom! Though, of course, that may all be a glossy coat on a shaky foundation - it's hard to tell how much is true, up-and-coming African metropolis prosperity and how much is just shooing the sidewalk fruit and used shoe vendors off the main streets.

Luckily, there's no better way to learn about the true socioeconomic heart of a city than to visit its public hospital. True in United States cities, and undoubtedly true here. We'll see in the morning. I have a hard time putting my feelings about working at Mulago into words. It feels cowardly, somehow, to admit that I have a little bit of pit-of-the-stomach anxiety about walking in tomorrow. Some of it is the usual discomfort I have whenever I start a new rotation in residency; I hate the feeling of not being efficient because I don't know the system yet, and that'll be compounded in a place where I won't really even be able to guess at that system.

But I think part of that anxiety also comes from the expectation that I'll be asked to work further outside my comfort zone than I ever have before, and my ambivalence about how to respond to that. And it's a much more active choice, too; before, I was a student, but now, I'll be the surgeon. Mulago is huge, with endless need and drastically limited resources compared to US hospitals. I know from my predecessors here that UCSF residents may be asked to operate alone and unsupervised, to suture without proper instruments, to take patients to the OR without the safety net of a possible blood transfusion (when the blood bank runs out). Some residents oblige, others decline. The official residency line of advice is not to do anything "that you're not comfortable with".

This is not particularly helpful. Of course I'm not comfortable with any of that. I want these patients to have the care that I know has the best chance of keeping them safe. But what I AM comfortable giving to the patient, I won't be able to give her. Off the table. So then what? What am I comfortable with? What is fair, or ethical, or merciful? Am I just supposed to expect to know it when I see it? Hard for my little Type A personality to be walking in without a game plan.

So that, and possibly the weird Indian food I had for dinner, are making me sleep a little uneasy tonight. Wish me luck tomorrow.