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.