Uganda be kidding me (credit to Chelsea Handler)

This post is dedicated to reviewing my first few days at Mulago Hospital. The hospital itself is set up as a storied courtyard with outdoor hallways and staircases. The views are beautiful from every side and it really is surreal to walk out of a dark, damp room and see this beautiful scene. The hospital itself is run down with no air conditioning, minimal resources and an abundance of patients who need serious help. Patients line the halls in colorful clothing and wait for hours to be seen. Some patients even bring mats to lie on as they wait to be triaged.

They gynecology department, where I have spent my first week, consists of a hallway with several rooms and a parallel hallway branching off of it. Patients line the halls and are crowded into rooms, with 5-7 women in each one and sometimes women even have to lie on the floor with a mattress. Women bring their own bed sheets, have to retrieve their own water, food and prescriptions and have minimal family present as there really isn't that much room to accommodate visitors. The floor is "divided" (I use this term loosely as there are no real divisions) between annex (triage), benign gynecology, post-operative patients and most astonishing to me, a separate room for molar pregnancies.

Mulago Hospital Gyn Ward

My first day I rounded in the "molar room" with one of the OB/GYN residents. As I have very rarely seen a molar pregnancy in the US (honestly, I'm not sure I ever have, and certainly none that were this invasive), I appreciated the review of something I had only learned through a textbook. Over the next hour we examined these four patients and I was struck by a few things. First, these women were sick. I could see their pulses bounding in the carotid arteries, they had shockingly large and tender tumors in their abdomens and by any US standard would be rushed to the operating room ASAP. Instead, they had been waiting for at least a day and would likely be waiting for another day or two to be operated on. Second of all, I could not get over the sheer look of hopelessness, fatigue and resignation that they all shared. It was if they expected nothing more or nothing less than to lie on their bed for days until the physician had time for them. Third, I was shocked by how the physician patient relationship was much more abrasive, but more equal than it is in the US. Physicians talk in frank medical terms, tell patients to shut their phones off and show little emotion toward the seriousness of the patient's condition. Part of this is the stoic, lackadaisical temperament of  Ugandans, but part of it is because the physicians have such a large number of serious conditions on their hands that they cannot stop to coddle each and every patient. At the same time, patients are active and knowledgeable about the medical frenzy happening around them. They know exactly what labs they had drawn, they know exactly what x-ray is the newest one and they hold their charts until they show the physician which new results came in. It is a very different dynamic than the "gotta have it all", paternalistic, hurried, customer-service based relationship that physicians have with their patients in the US. At the same time, I do miss some of the humanistic,emotional interactions that often happen in the US.

These past two days I have participated and observed two surgeries I have never seen in the US. Now, a note about the ORs. In the gynecology theater (their word for operating room), the minute you step into the area you have to take your shoes off and walk in your socks to the back where someone will hand you *hopefully* clean scrubs and "gum" boots, which are white rain boots you wear in the theater. The first day, my scrubs had no tie and were 14 sizes to big for me so I had to wear two sets of scrubs. The theater is not air conditioned and sterile technique is merely a suggestion. Surgeons operate in minimal lighting, retrieve their own instruments, gown and glove themselves, and never yell or fuss about anything. Students crowd the room, nurses are in and out, people come in and out without masks or proper attire and the surgeons serves as his or her own scrub tech. Needless to say, this part has been the most shocking part of my journey thus far.

Super pumped about her new BP cuff. ; ) Her and the sisters were actually all ecstatic when I brought it as they had been sharing one between the entire floor. Thank you Dr. Duffy!

As far as the surgeries happening, first, I saw an "emergent" (emergent is really in the Ugandan vocabulary) ruptured ectopic pregnancy (a very emergent, life threatening condition)  my first day. This particular case was operated on a full 12 hours after being admitted because of all the other ruptured ectopic pregnancies that had come in that day. I then learned that this ward sees almost 10-12 ruptured ectopic pregnancies per week.

Today, another rare surgery occurred, this time it was even more crazy because it was only me and one resident at the operating table. Earlier in the morning, I had heard about a patient who had a uterine rupture (again, super rare) 4 weeks prior and had been readmitted 3 days ago to the ward due to a foul smelling discharge coming from her wound. The team had determined that she was septic, but because of the amount of ruptured ectopic pregnancies coming in, and the fact that only 1 operating room was available, she had waited three days to be operated on. As I waited for her to go back, the resident in charge of the surgery looked at me and said, "you assisting me?" "uh...yeah..." I stammered. For the next hour I tied knots in my scrubs to make sure I didn't look like an idiot (which of course happened anyway). I kept expecting another attending or resident to show up and take my spot across the table, however, that person never came. Instead, I was the first assist for a septic patient with a necrotic uterus that eventually had to be removed. At one point the resident realized the ureter had been damaged and torn from surgery, so eventually a specialist was called in for a few minutes. At the end of the day, the patient ended up with her bladder draining through a stent in her incision and an abdominal drain with another pending surgery in 4 weeks. However, she was alive and in stable condition. The entire ordeal was surreal and I learned more in one afternoon than I did on an entire month on some rotations. It is amazing what you can do when you are truly pushed to the brink of your capabilities, even when you are really, really, sweaty.