“We are at the ass end.” With that colorful phrase (and an apology for his language), the senior obstetrician who welcomed us back to the Department of Obstetrics and Gynecology at Makerere University explained the place of Mulago National Referral Hospital in the Ugandan health care system. Mulago, where we are both working and sleeping this trip, is the “flagship” hospital for the country’s struggling public medical system. Opened around 1960, at the very end of the colonial era, the six-story, blue and grey antiquated facility (featured in several scenes in the movie, “The Last King of Scotland”) sits on the western slope of one of Kampala’s seven hills, attempting to serve the sub-specialty referral needs of Uganda’s 30+ million people, while having been built in anticipation of a population of 3-5 million (or so we were told by our host). As the government’s largest and best tertiary care facility, the hospital should, and does in many ways, occupy the “head” position in the medical education and health care communities. However, since most of the really difficult cases – often advanced beyond a stage where meaningful recovery is possible – find their way to Mulago, where resources and expertise are often limited, our engaging host, with a sly smile and a hint of a shoulder shrug, placed Mulago at the other end of the body, so to speak.
We arrived late Monday night and, thanks to the university’s driver and van, moved safely and quickly through the heavy late night traffic on the road between the airport in Entebbe and our guest house on the hospital campus in Kampala. After a day to recover from travel fatigue, change money, buy a small wireless modem, and top-off our phone cards, we entered the hospital on Wednesday morning ready to begin our three-week sojourn in the “obstetric operating theater” in Ward 5C. Susan, the delightful and very helpful international coordinator for Makerere University, gave us our name badges and advised us that our presence was requested that night for the cultural event – an evening of music and dance at the Ndere Center, where they are succeeding in preserving the richness of the Ugandan tribal heritage. Recalling from the January visit how much harder our JPS team works than most groups of US and European medical students and residents visiting Mulago (who tend to work 8-5 Monday to Friday), Susan insisted that we have our “cultural night” at the start of the month saying, “I know that when you enter the wards, I will lose you. So, please do this for me.” We did … and most of us have seen little else of Kampala in the four days since.
We were pleased that many of the faculty, residents, and nursing staff remembered us from our visit in January. As a result, we were welcomed quickly back into the flow (perhaps not the most accurate description of the way things work here!) of the labor ward and operating room, scrubbing on (participating in) a total of ten cesareans in the first six hours or so after entering the hospital. We have split into two teams to take advantage of both day and night shifts, and I have tried to be present for much of both in order to get everyone acclimated to the very different way things are done here and to provide the necessary supervision as we get settled and they renew their confidence in us. I won’t be able to keep up the pace of successive 15-20 hour days much longer. After ending our Saturday night shift at 6:00 a.m. this morning, a long “Sunday nap” from 9 am to 3 pm, as the heavy rains fell, has renewed my energy to face the night shift again with Stephen and Ian. (Heather and Leah are working “days” right now.) Last night, they served as primary surgeon on a total of 5 cesareans, with Ian also assisting on two laparotomies for ectopic pregnancies and Stephen doing a vacuum-assisted vaginal delivery in the OR on a patient with two prior cesareans and a “contracted pelvis”. Her baby weighed 8 1Ž2 pounds and delivered with relative ease, much to the surprise of our Ugandan colleagues and the extreme delight of the patient, who avoided having a third cesarean.
We brought a portable ultrasound machine this trip (on loan from the SonoSite global health program) and have put it to good use. Despite having the busiest maternity unit in the world (with over 30,000 births per year), Mulago does not have an ultrasound unit in the labor and delivery suite. Women in labor are monitored (on a rather infrequent basis) with fetoscopes (wooden or plastic cones placed against the mother’s abdomen and the examiner’s ear). When the baby’s heart beat cannot be heard in this manner, they will attempt to hear it with a small, handheld electronic “Doppler” unit. If this is not successful, they must proceed with management plans not knowing if the baby is alive or dead. We have used our ultrasound machine on several occasions to confirm viability or to diagnose demise, to locate an abnormally positioned placenta prior to surgery, to estimate the age and size of an unborn baby whose mother had severe preeclampsia, and for “show and tell”. The Ugandan residents are eager to learn ultrasound techniques (One said enthusiastically, “I have fallen in love with this machine!”) and the staff and patients are fascinated with the images. I have been asked to conduct a workshop for the residents during our visit, and we hope to find the funding to donate a similar unit to Mulago in time for our next trip in February.
As was true this past January, we see more dead newborns in a week (the first delivery we witnessed last Wednesday morning was a fetal demise) than most of us will see in a career back home. The suffering and heartache remain pervasive and intense; the surgeries challenging, yet rewarding. Thankfully the weather is a bit cooler than in January, due to the start of the rainy season this month. However, with the rain and cool breezes come the mosquitoes. (I am frequently swatting them in the doctor’s sitting room as I type and in the OR as the residents operate!)
We are well and working very hard. At times, we struggle to see how Uganda earned the distinction of being the “pearl of Africa”, but we look forward to getting out of the city in a couple of weeks to explore one of the national parks on what will be a much-needed two-day break.
Thanks to everyone covering for us back at JPS!