There was a Lizard in the Operating Room Today----Uganda Part 2

 "There was a Lizard in the Operating Room Today....and you know what we have instead in America?.... CDiff"

Giving tummy tickles to little Innocence

May 3rd

 Patients:  

•    A 19 year old with endometritis due to septic abortion. She had tried to go to Kenya to have an abortion. Septic abortion is a common issue here because women don’t have access to contraception. They become infected because they’ve tried inserting various sharp objects to stop their pregnancy.

•    Surgery on a young male whose brother had chopped his leg (on purpose) with a machete and cut his Achilles tendon

•    A boda boda accident: a young woman had her knee cut open down to the bone. A passing driver had pieces of wood resting across his boda boda/motorcycle that cut her.

•    A young man with HIV who had an open wound on his ankle down to the bone ...for the last nine years. He was walking with a stick for a cane.  It was not able to heal due to his immune system suppression. We offered him an amputation at the knee.

•    A woman with a breast abscess from breastfeeding. We thought she worked at the hospital because she had been translating for other patients to us, but then we realized she was just being very helpful and actually was a patient.

•    A C-section on a woman who had been struggling in obstructed labor for over 14 hours.

In the late afternoon, we went to visit the connecting school in order to give them the soccer balls, supplies, and other gifts we had brought. When we arrived the girls were singing and working in a line to pass roofing tiles for the next construction project.

The children were so excited to welcome us and all assembled to perform songs and dance.

While the last group of children were performing, they ran up to our table and grabbed us all by the hand to come dance with them. We all continued to sing and dance and they fought for the chance to be able to dance with a “Muzungu.”

We next went out to the field by the school and the children shouted with joy as we awarded the soccer balls- one for the boys and one for the girls.

 

We gave the albino boys each a hat and wrote their names in them this time for safe keeping.

Next, we all played games together. I realized it had been so long since I had played any games and struggled to think of things we could teach them. Previous groups have tried to teach games like kickball, but the concept of a “home base” or a “safe zone” is so foreign to them that it could never work.

I decided to try teaching them “duck, duck, goose” but realized that I would need to pick animals that were less foreign to them. I asked the girls what their favorite animals are and they said cat and rat…. So the game of “cat, cat, rat” was created.

Following a few rounds, our time with the children became us standing encircled by them while they examined us. The children petted my eyelashes, my hair, my skin, and my piercings and shrieked with laughter. They even smelled my skin and clothing.
Some of them had never seen ‘muzungus’ in person and had never been able to touch white skin. They were perplexed as to why I had long, curly hair but it didn’t feel coarse like theirs. They were confused by my freckles and light eyes and all of our different features.

Most girls in Uganda have their ears pierced at a very young age, because it is seen as good luck to add an imperfection to a baby when they are still innocent and perfect. The girls were perplexed as to why I had several piercings in my cartilage.

The girls kept saying to us “I wish I lived in America.” We tried to tell them that their country was beautiful too, saying that where we are from everything is really busy and sometimes the buildings in cities are so tall you can’t enjoy the sun and nature like here.

The girls said “I wish I had skin like yours”- I tried to explain to them that their skin was beautiful too, that they had superpowers to not become sunburnt which I could never have. This was so ironic because my classmates and I kept marveling at the beautiful skin of the African people. Additionally, many Caucasian skin tones are very similar to albino skin tones, yet albino people in Africa are typically seen as demons and shunned from their families, orphaned, or killed.

Here’s a 10 year old girl doing an amazing job dancing a traditional dance for us:

May 4th:

Each morning we would all eat breakfast together then go round on patients in the ward with the Ugandan doctors. This would help us to learn how medical treatment is in Uganda.

We would check on previous patients and their recovery from surgery and give newborn hats and baby blankets to the mothers who had delivered the day before.

 

Sister Tiopista

 

I spent most of our working days in Magale in surgery. I’ve mentioned some of the major differences in surgery here, but the little things continued to shock me...
Our patients would never complain. Judy was teaching Ugandan doctors epidurals and sometimes the patients would have to  endure 5-6 sticks. They would sit there silently and only say thank you.

Following surgery, a patient’s family would come into the room, put the blankets they brought on a new stretcher, and roll them away from the operating theater. In terms of post-op medications… one small plastic bag with about 20 ibuprofen that Jim brought himself to give to patients. Otherwise, they wouldn’t have received anything.

Patients today:

-An umbilical hernia repair on a middle aged man.

-Emergency C section for a woman with pelvic contractures who would be physically unable to deliver vaginally but she had been in labor for at least 10 hours.  She was mentally delayed and had just delivered via C-section 13 months beforehand.

- Another C section for a woman at 44 weeks gestation who was failing to go into labor. Normal gestational age is 38-42 weeks, but in America women usually are induced to deliver by 40 weeks. Even 42 weeks would be considered very late-term in America.

The nuns make our meals and spend a good portion of each day cooking. Everything is done by hand and over a pot over coals. When we had 'ground nuts,' they had shucked each one by hand. Every bean we had they had harvested and then peeled individually. Every fruit we ate had been picked and peeled from the trees. Our passion fruit juice was strained and juiced by hand.

our little helpers

their kitchen

May 5

Today at breakfast I was trying to explain the obesity epidemic to Patrick, one of the Ugandan doctors. He mentioned wanting to move to the US to practice orthopedics, and so I thought it would be beneficial to tell him how different medicine is in the USA.
It was endearing to hear him try to think of solutions to our obesity 'epidemic'. The concept of rampant obesity is hard to explain to someone who lives in a society where no one has excess food, everyone is physically active by necessity, and there are abundant fruits and vegetables surrounding you in the forest.
I had to explain to him the excesses of my country. I tried explaining how people who are more overweight are usually less wealthy and the vicious cycle of lack of education, financial resources to afford healthier food, and access to obtain healthy food.

I tried to explain our necessary consent forms for every procedure and our intensive documentation processes with high risk of lawsuits.
I would worry about what people of Uganda would think coming to the US, particularly into the medical field. How could they understand the pages of consent forms for procedures, or the fact that we often spend more time sitting at computers charting on patients than we do actually treating them (to protect from lawsuits)? 

How can I explain that our healthcare system is set up to perform quick fixes of symptoms, but doesn’t actually treat the root cause of the chronic illness (usually illnesses that don't even exist in Uganda).

Patients today:

• A woman following hysterectomy for post menopausal bleeding. She had alopecia and was practically bald. When the Ugandan doctors asked us what alopecia could be caused by, and we all began listing the causes we see in America. They informed us that alopecia is a common sign of untreated syphilis. In the US, it is very rare to see untreated syphilis.
• We asked the woman if she had had any of the signs of syphilis in her life: deaths of her children at a young age, miscarriages, still-borns, etc. In Uganda, they treat syphilis with several smaller antibiotic doses, rather than one large penicillin injection like in the US.  Our patient said that she had, in fact, been treated for syphilis but never completed the antibiotic.
• An emergency C-section delivery.  I had the opportunity to take the baby out to meet her extended family following. The mother was stoic about the birth, as most mothers here are.   I brought the baby out to meet her extended family, who were all waiting outside of the surgical theater among the chickens and overjoyed with excitement. This was the only time I saw a reaction like this to a birth in Uganda.
• Surgical excision of a lipoma (from an older man’s chest) in the hallway next to the surgical theater. The operating room was occupied already, and it was the only available space. There was a lizard crawling on the ceiling above us and the door was partially open to the chickens and people walking around outside.
•  An inguinal hernia repair. I was with Jim and Patrick and we removed the testicle from the scrotum, in addition to some bowel, under an epidural. The young man told us that he could partially feel the procedure.

After rounds, we handed out newborn hats and blankets to the new mothers, which was honestly one of my favorite experiences in Africa and  my favorite daily task we did.
 I was so happy putting the hats on the newborns & seeing the mothers so happy to receive this gift. My parents’ church had members knit upwards of 50 baby hats to take with us… all with beautiful patterns or made to look like fruits.

My favorites were the eggplant and the strawberry hats:

A little eggplant

The babies were so adorable and I was so happy to see the little monkeys in their hats!

Oftentimes, the mothers in Uganda will not have the resources, or not know how, to keep their infant warm at night. Their fabrics here are very thin and the baby can sometimes freeze at nighttime and die.

One major difference of Uganda vs. America is the care for babies after they are born. The mothers lay in their cot with the baby from the time they’re born.
There is no NICU or nursery; the baby isn't sent to have repeat diagnostic tests.
There are no long speeches to mothers about the risks for SIDS or how to breastfeed.
 Of course, it’s nice to have the technology, but its also nice to see a much more natural childbirth process. It was nice to remember that this process can happen on its own, and doesn’t have to be so drastically shifted away from what's natural.
I find it ironic that, in America, we’ve initiating protocols for “skin to skin contact” for a certain amount of time following childbirth. These protocols have followed numerous studies of how births have better outcomes when a baby has contact with its mother. 

This afternoon, the girls/my classmates and I had our World Health Organization presentations to the midwives in the area about protocols to improve the safety of the childbirth process. We made diagrams and flowchart breakdowns of the steps to make them easier to understand for those who couldn’t read or for easy reference.
We spoke about having clean materials (umbilical cord clamps, ambu bags, blankets, etc) around for the birth. We lectured about what to do with pre- and post- labor birth vaginal bleeding for the mother and what to do when a baby’s vital signs are dropping.

The midwives travel from far and wide to make it to this lecture. Judy informed us that it would probably take hours. “Hours?!” we said ”….but we only have to do our presentations?”
Judy laughed and told us that this would be an African style meeting, meaning that you don’t just arrive and expect the intended guests to arrive on time as well. We are on Africa time, which means that you meet “in the morning” and people show up anywhere from noon to that night (or the next day…or not at all).
When they arrived, everyone in the room took turns to stand up and say his/her name, and spoke about how glad they are to be there. The last person then introduced Judy, who introduced Wilton, who introduced Jim, who introduced my classmates and myself. This was followed by prayers and more speeches. People arrived slowly and in no specific time frame. Many people were extremely excited to receive a warm coca cola and the “glucose biscuits” given to them for coming.

Many of the things we were telling them suddenly seemed so impossible once we were  in Uganda. For example, my classmates and me telling them to have all birth materials clean and available at the bed (including an ambu bag in case the baby is struggling to breathe), seemed reasonable initially.
But, to ask them to hold all post-delivery patients with a pulse over 110 or less-responsive newborns with signs of failure to thrive for ‘additional monitoring’ and possible treatment with antibiotics is so far outside the realm of their capabilities. Where would they have the extra hospital beds for ‘monitoring’? Where would we get the antibiotics? Who would be around to monitor the patients anyway?

After a long day of presentations and surgery, I returned to the convent and cleaned up for dinner.
We were then notified that a 17year old woman, five days post C-section, had arrived at the hospital in sepsis (we’ll call her M). She was so sick that there was no detectable diastolic blood pressure, her heart rate was 140, and her fever was 104F.
She had severe peripheral edema, hematuria, and metabolic derangement… in addition to a bounding, forceful, heartbeat like I’ve never heard before.
Her incision from her C-section was draining pus and highly infected.  We were at a loss of what to do… there are only two choices of antibiotics in the hospital, both of which would further damage her struggling kidneys. We had no x-ray or CT scan to find the source of the infection, nor would she have survived active sedation or an epidural for an exploratory surgery.
There was no lab around to tell us her blood type or to provide blood… just one 200ml bag of O-negative available. The Ugandan doctors thought she would make it through the night with the blood, we were highly doubtful….