First World Body in a Third World Country - Uganda Part 3

6 May

• We couldn’t believe it, patient M was alive this morning.  Somehow, she improved slightly with the little blood we could give her. Because her body couldn’t handle anesthesia or even an epidural, she only received a little ketamine for her exploratory surgery to save her life. Her surgery involved removing all of her abdominal organs, while she was awake and screaming, to do a flush of her peritoneum (which was filled with abscesses). 
  • Judy learned later that the reason she was near death was that the Ugandan doctor who performed her C-section had decided to leave all the bloodclots inside of her instead of removing them during surgery.

• A patient today tried to attempt suicide by phosphate ingestion (insect poison) and arrived at the clinic with his family. Knowing there was an extremely high likelihood that he would die, we gave him atropine for his symptoms and comfort… but overall there is little that you can do here in Uganda. 

I spoke with the PA here, Daniel (who is Ugandan), about how people rarely commit suicide compared to the United States.  He said that it’s rare here, and almost always happens with insect poison (never llicit or prescription drugs like in the US). 

The people here are accustomed to living a life of hardship, and consequently learn to be more resilient and are more appreciative of what they do have.

We discussed the irony of how people in the US have everything they could possibly need or want, but do not develop the same emotional resilience or grit. We concluded that this environment of excess and skewed outlook breeds constant feelings of dissatisfaction and a lack of a sense of individual fulfillment.

 We then went to the Magale church service to support our program's connection with the community. There were hundreds of people singing in the local language. 

We were to stand in front of the whole church (of 300+ people) and introduce ourselves and greet the community. The offering procession included two girls doing traditional African dance and carrying bananas, instead of bread, down the aisle for communion.

The entrance to the convent and school on the way to the local church

so beautiful

          A friend of the hospital named Gerald said that he would like to take our group for a hike to “a beautiful garden with a swimming hole.” Wilton told us to grab a copy of our passport and prepare for anything because he didn't know what this hike would be like. 

We decided that we wouldn’t be going swimming… whatever the swimming hole was like, the water was either going to make us very sick or was full of creatures. 

We were only on schedule for emergency surgeries for the rest of the day. 

The girls and I prepared for an ultimate jungle excursion. We were dressed in workout clothes and hiking shoes and covered in deet bug spray and sunscreen. We had broken our attempt to wear long skirts (no pants) to assimilate with the local culture, thinking that it wouldn’t matter if we were “out in the trees somewhere.” 

.....Gerald met us at the convent gates wearing a button up shirt, dress pants, and dress shoes and then informed us that our hike would be through ‘downtown’ Magale and then a few kilometers to his workplace.

Gerald,Wilton, and sugar cane

Walking through town was quite an experience. 

Now, we turned heads not only because we were the only "Mzungus" around, but we were dressed in pants and neon 'hiking' through the center of town.

            We hiked to other smaller villages nearby, past homes with goats, cows, pigs, and chickens roaming in front of them and children yelling and running behind us because they haven’t seen “Mzungus." The scenery was beautiful:

 Children Eating Sugarcane: Notice the Babies with Machetes in their Hands.

 After several miles, we arrived at the "beautiful garden" Gerald had talked about. It was a place called the Pine Garden- which is actually a Ugandan 'club' to party.

The pine trees were planted here to be exotic and different.
The “swimming hole” Gerald was talking about was a small swimming pool of stagnant water surrounded by bizarre  sculptures. We all had a warm beer and sat at a table while numerous onlookers came and took pictures of the Mzungus who were visiting.
Wilton joked that we’d probably be on the brochure.

 

7 May

            Today started with our usual hospital rounds to hand out new mother kits, baby blankets/hats, and to see the patients of the hospital. Jamie and I were to be working in the delivery room, which I was excited about because there were 6 women actively in labor and I knew it would be a day full of labor experience.

            We started by learning the Ugandan style midwife exam, which was a great learning experience.  With no Doppler or ultrasound to check on a baby, it is critical for a midwife to be able to manage the whole process successfully without technology, fetal monitoring, or medications we have available abundantly in the US. 

Sister Tiopista taught us how to estimate whether a mother would have a successful vaginal birth using just our hands.
She taught us how to feel the inside of a patient’s pelvis and to estimate the distances of the bony limitations of the birth canal.  

She taught us how to feel a mother’s abdomen for the baby’s lie and head presentation (something that is never a mystery in the US and we always have confirmed consistently with ultrasound prior to labor).

            Labor in Uganda is highly different from in the US. Instead of independent rooms and birthing suites with the whole family waiting nearby, women here give birth alone (maybe with a mother or sister) and their husbands do not come.

Women have to wait in the common area of the clinic ward or outside while they are in labor, until we called for them to come to have the dilation of their cervix checked. While in active labor, these women would bring their plastic tarp (the one they have to bring to the hospital) and put it on top of the examination table, climb up onto the table on their own, and hop off once we finished checking them for the next mother to climb up.

            The ventilator for the premature babies was padded with an old puffy orange eddie bauer winter jacket and in a side room that tends to stay warmer throughout the day. Notice ventilator was not plural- there’s only one and it’s basically a clear plastic box because there’s no oxygen/electricity hooked up to it.

When Jamie and I asked what they do when there is more than one premature newborn, sister Tiopista told us they just put multiple babies inside.

Women in Uganda have no prenatal care or education and almost every single laboring mother had symptoms of an untreated fungal, bacterial, or sexually transmitted infection. There was neither Doppler nor fetal monitoring, so we had to use a plastic cone to listen for the baby’s heart rate instead. One mother came in and we were unsure as to whether she had twins or not. She, too, was unsure as a first time mother.

Jamie and I, thankfully, had brought our own gloves because the labor room was running out of them and we were doing repeat cervical and pelvic checks. 

A mother would climb up on the table and, if she was ready, we could rupture her amniotic sac onto her plastic tarp. The amniotic fluid would then be poured into a large bucket in the corner of the room. There was no place to wash our hands with soap, no paper drapes or separate room for a woman to be checked.

women outside the clinic

             When a mother came in in premature labor at 24 weeks, I drew up an injection of decadron (a steroid) as a last-ditch effort to help the baby’s lungs develop prior to birth. Once I was done using the needle, I disposed of it in the plastic container for sharps….. but Jamie and I realized that we had upset the people working at the hospital because they wanted to keep it to reuse it.

            Jamie and I eventually ran out of soap for performing sterile cervical exams on laboring mothers. There was no more, so we had nothing to keep the area sterile and to protect baby from the germs of the external world during cervical exam.

            During our exams of all the laboring patients, a woman brought her 5 day old baby into the hospital with severe jaundice. She had given birth at home, like most Ugandan women do, and they had cut the umbilical cord with something that was unclean and tied it off with a piece of string. The infection from the umbilical cord had spread to the baby’s liver and he had the worst jaundice I’ve ever seen. I thought, at first glance, that the baby had already died because he was so unresponsive. 

We had to turn this woman away and send her to the nearest big city because there was nothing we could do to treat him here. His family either won’t have the resources to make it there, or they won’t make it there in time.

            Next, one of the mothers was ready to start pushing. Jamie and I got the tools ready for her delivery, and realized that the tools available in the delivery room were rusted instruments, an old and dirty ambu bag, and a cord clamp. 

The moment the baby came out, my heart sank. The baby was probably only 2 pounds, blue, and had a terrible cleft palate. While using the ambu bag on the baby, I had to be careful not to over-inflate its little lungs. 

The baby began to gasp for air and was dying. Although there was nothing we could’ve done differently, it was hard not to think of how this situation would be different in America. This baby would've been given medications to help its growth and development, given operations to fix defects, and put in an incubator to be saved (one that wouldn’t be padded by an old winter coat).
The whole time Jamie and I were using the ambu bag on the baby, the new mother’s mother and grandmother were standing behind her and watching the baby fail to breathe. I could feel her struggle and there was no way she'd make it.  Eventually, sister Tiopista wrapped the baby in the blankets the family had brought and put her in the corner to continue to gasp for air as she passed. I could see the blankets on the shelf move slightly from time to time as we continued to work with the other laboring mothers in the delivery room.

           Soon after, a woman arrived at the hospital soaking wet from the afternoon downpour of the rainy season. She had been physically assaulted by a stranger and the police sent her in for a medical evaluation in order to add it to her case (which would likely never be solved and the man would not be identified). 

She was sobbing and shaking and held up by two of her very young sons. I carried her over to another ward and she climbed onto an open bed drenched. There was nothing I could give her to dry off, no blankets, no towel, no bed sheets. I called Judy and Wilton to see if there were any disposable paper materials from the supplies we brought for the operating room to give her, but we had nothing.

Jamie and I, at this point, needed a break. Teary-eyed, we both walked outside and caught some fresh air and talked about the irony and difficulty of all the things we’d been seeing. Reusing gloves...reusing needles...no more soap available for sterile exams...the winter jacket padding the incubator for premature babies… it his us hard in contrast to America.

Worn out