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.