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?
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?
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