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.