Mulago Hospital Experience: Our First Week

Well, what should we say about our first week at Mulago? How about - oh my God! Although we've only been working 8a-6p with no call, we are completely exhausted. We're not sure if it is the jet lag, the heat, the humidity, the language difference, the culture shock, and the lack of knowledge of presenting conditions or the utter chaos of seeing a hospital attempt to work with limited staff, training, supplies, and facilities. Perhaps it is a little of all these factors that differentiates home from here. The next time we hear someone complain in Canada about healthcare, we'll simply tell them how patients at Mulago must provide their own linen, food, and WATER!

Mulago Hospital is the main referral centre for all of Uganda, but at the same time is dramatically underfunded. The complex comprises 6 levels each housing 4 wards, each containing up to 50 patients. So, what’s that? 1200 patients! Wow… Glenna and Sean’s experiences have been markedly different while at the same time sharing common themes. The physicians here are very knowledgeable, like those internal medicine types that know lots of book facts. But, due to limited supplies their procedural skills are quite limited. As for the nursing staff, it appears that they do not take the role of primary caregiver for the patients as this is left to the family. In fact, we are not really sure what they do as getting vitals is often a challenge. The supplies are dismal and usually consist of a mix of donated items not conforming to any standard making replenishment an absolute nightmare.

As for the differences, Sean will explain his first few days in the Casualty Unit:

I arrived at 10 am (ask us why we were late upon our return to Canada). The waiting room was full – I mean, people were sitting on the floor. Now, it is somewhat difficult to tell who patients were and who family was as I now realize that you

need your family to simply remain alive in the hospital. The Casualty Unit is split into a medical side and a surgical side. I decided to take the surgical side for the day. The 4-bed surgical evaluation area was staffed with one nurse and one first year, first !DAY! intern! There was supposed to be a Medical Officer (physician who has completed internship), but he was on AST, “African Standard Time”. The other three beds were filled with patients waiting to be seen. So, there I was – attending in a 1200 bed hospital ED-sort-of. I noticed the intern suturing some guy’s scalp laceration using some rusty instruments and no sterile towels. The suture material was dragging across the stretcher which doesn’t get cleaned between patients! Not knowing the patients HIV status I provided the intern with my goggles and then observed her suturing technique. Unfortunately, the combination of wrong needle type and tough skin made the task rather difficult. Suddenly, I was struck in the eye with blood – yes, I’d been there less than one hour! The patient did not know his HIV status and did not want to be tested. We tested him anyway (presumed consent, right). So for one agonizing hour I worried about HIV and the need for me to start anti-retroviral therapy. Thankfully, he was HIV negative and I dodged a bullet.

Next, two Harvard medical students arrived to experience the surgical casualty unit led by a Uganda Medical Officer. Well, this was good as I now had a team. So, I put them to work seeing the other patients and tried to learn the system of just how the casualty unit worked, admission procedures, triaging, cueing, patient transfers, blood work, x-ray, and a billion other procedural items I take for granted in London. As it turns-out, patients must pay for most investigations and Mulago being the only government-funded hospital in Kampala receives mostly those who can’t afford to pay. So, no tests, no xrays, no CTs … Well, we sometimes got tests if they were absolutely necessary or the patient was near death. Luckily while I was sorting this out, the Medical Officer arrived. Phew … I thought things would improve, but it just got more hairy as the day went on.

At one point, a distressed mother brought a 3 year old child wrapped in a blanket and urgently asked the medical officer to see her child. The officer, not even examining the child, sent her back to the waiting room to “wait her turn”. I was busy suturing a patient at this time and only noticed this encounter in my periphery. The mother than returned 10 minutes later and again asked the doctor to see her child. At this point, I lost track of the mother, child, and medical officer so I wandered over to our resuscitation room (more about this room later). There was the medical officer standing over the child with a facial expression absent of emotion. I approached and checked the child – she had an obviously distended abdomen that was firm and warm. She had no pulse. Her pupils were non-reactive. She was dead. She died in the waiting room and the medical officer was not even fazed… What the heck? This child might have been saved had the system been different, had the medical officer cared, had I been the one to greet the mother on her first entrance to the unit. I shed a tear and went back to work seeing patients.

To contrast this start, here is Glenna’s first-week experience (in mostly ICU):

Arrived late just like Sean... and also got the general tour. Morning started with an unstable trauma patient, who promptly got intubated and then we lost his pulse. Sean, me and the chief of dept. were all there. Tried to salvage the patient for 1 hour... all the while we couldn't get the blood pressure cuff to take an accurate pressure and the oxygen monitor kept beeping... finally noticed the patient had no heart sounds and gave up.

After that, I took off to the intensive care unit. We only had one patient so after a quick rounds, we had tea time and teaching with the local residents. Rounds start each day at "AST" of course, so i seem to always be the first one there. The residents are very eager to learn. So I started a series of teaching sessions each morning for the rest of the week following tea time. A few times Sean wandered by to take a break from the crazy casualty unit and kept finding us at tea time... i swear it was just his timing! :0) I did wander down one afternoon to help out in casualty too, it was wild there. I kept trying to get the nurse to draw a blood test for me but he couldn't understand me and kept calling in the patients family... i'm not sure why. I lasted about 2 hours, then had to go for a walk to set my head back on straight. Missed my tea time in ICU.

The rest of the week for me focused on resident teaching and academic rounds. Plus trying to teach the local doctors "my way" of rounding in ICU. Finally convinced them to try it. Blood work comes back after several hours in patients who are critically ill. By then, it's kind of pointless. So I've learned to treat them based on a sketchy clinical exam and a gut feeling. Families are asked to boil water and bring it in to put in the patients' feeding tubes. Oh, and I've spent a bit of time trying to convince the bed side nurses that when a monitor alarms they should probably check the patient and/or call a doctor... So I seem to be spending alot of my time teaching and giving advice. Then I would wander down and take action shots in the casualty unit. Must admit, I have had it alot nicer then Sean this week. The ICU even had it's on staff washroom that actually has a seat! Which turns out...is quite a luxury in the hospital.

We have settled-in to a Swiss Family Robinson routine around here. Glenna has well-adapted herself to the role of house-wife, sort of… She makes our lunches and prepares our powdered milk. I’ve accepted the role of water-boy, and garbage boy, and bug-killing boy. We seem to be sharing our duties on the dinner preparation. By the way, we have foregone meat for the time being on account of some absolutely rancid chicken we obtained on our first shopping trip. Now it is beans: beans and rice, beans and pasta, beans and beans, …

This Saturday, we took it easy as we have yet to relax since arriving. It was a day to walk downtown, get groceries, and book adventures for the remainder of our stay in Africa. – followed by a day trip to Entebbe, a suburb of Kampala on Lake Victoria. After our first crazy week... we really enjoyed a little rest time. And the outdoor pool has been quite nice to cool off after our hot, no A/C days...

Here a few photos from our walk-about:

Glenna standing amongst the sellers and buyers at Nakasero Market in the heart of Kampala

Yep, some streets do not have sidewalks so the pedestrians end-up walking on the road with the crazy car drivers and the drunk Boda Boda (motorcycles).