Doctor's Review: Medicine on the Move

October 18, 2017
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Ugandan grandeur

An MD returns to her father's homeland as a volunteer and finds it's as beautiful as she imagined

The vivid emerald greens and rusty reds of the Ugandan landscape greeted my arrival as the plane approached the airport in Entebbe. The sun shone brilliantly and the sky was clear — a welcome sight for the first day of January. I was on my way to a one-month teaching assignment at Mulago Hospital in the capital of Kampala, and this was my first view of Uganda, a place that has many familial ties.

My father's family moved from India to Uganda in the late 1940s. He grew up in a rural town in the southwest called Mbarara. However, in the 1960s, predicting troubles under Idi Amin's regime, his family emigrated to England. I had heard many tales of this country, often affectionately referred to as "back home," and I wanted to see it for myself.

In the stories told by my grandmother and father, life seemed simpler — the goal was to educate the children and try to improve the quality of life for the family. It was a time of struggle, but also a happy period with a close-knit family and small, supportive community. This month-long volunteer stint was an opportunity to combine my wish to see the country with my desire to share my pediatric expertise.

I travelled under the auspices of a wonderful organization called Health Volunteers Overseas. HVO is a private, non-profit, non-sectarian voluntary organization created in 1986, which has its headquarters in the United States. Its mission is to improve the quality and availability of health care in developing countries through training and education, with the ultimate goal of enabling local personnel to continue the educational process.

HVO coordinates programs in 11 specialty areas including pediatrics, orthopedics, dermatology, and anesthesia and has programs in 25 developing countries. It operates five pediatric sites including St. Lucia, Cambodia and Uganda. Most programs require a one-month commitment although some are only two weeks long. Volunteers pay for their own flights from home, however many sites provide room, board and daily transportation. Travel and room expenses are tax deductible for volunteers.

First Rounds
My first day in Uganda was spent sleeping and recovering from jet lag, before exploring the hospital in search of the Acute Care Unit (the equivalent of their pediatric emergency department) among the maze of bright blue outbuildings surrounding the 1960s-era hospital building.

I spent the first few days in the Acute Care Unit, familiarizing myself with the style of practice and facilities. It was a difficult place to work. Rows of mothers sat with young children on wooden benches in the waiting room, waiting to be triaged. There were only two physicians working at any given time: the senior pediatric resident and a junior intern. Dr Kiguli, the sole emergency staff member, was usually busy teaching or involved in administrative duties, and was rarely available.

The majority of children seen were under the age of five, and many were less than a year old. Many older children are seen in doctor's offices and, unfortunately, a large proportion of families are sent to the emergency department when money has run out and they can no longer afford the physician fees. Unlike North American emergency departments, services are divided into medical and surgical. Only medical problems are seen in the pediatric emergency unit. All traumas and potential surgical problems are sent to the adult emergency ward, a confusing place with crowds of adults sitting around, patiently waiting their turn.

The sickest children are put into the resuscitation room — a large sterile space which has two stretchers with torn covers showing their rubber padding. A sheet was sporadically placed on the stretchers which were rarely cleaned. On one day there were five patients in the room: three infants on one stretcher and two on another, with the mothers quietly standing next to their children.

A single oxygen tank, looking like it came from another era, graced the head of the room. Tubing was connected from the tank to nasal cannula, which appeared to be the only means of providing oxygen. The more patients required oxygen, the more connections were made to the tank, so each patient received less when the demand was high.

Resuscitating the Residents
The residents are well trained and work very hard. I admired their calm management of patients. A resident would start the IV, set up the drip, take blood work, administer antibiotics and connect the patient to oxygen. Nurses hold a severely limited role compared to their Canadian counterparts, and it was frustrating to see the line of patients continue to grow as residents performed time-consuming tasks which would be considered nursing responsibilities here.

 

Equipment issues are a major source of difficulty for staff. A cardiac monitor was found detached from its leads and it took our collective brains over 20 minutes to figure out how it worked! I discovered a defibrillator which was not charged, and it took me another hour to find the battery charger, charge it, and connect the defibrillator.

Active resuscitation is rarely performed. Residents do not have the opportunity to work with a staff person to learn resuscitation skills for critically ill children. Equipment is difficult to obtain and often not working. There is no ventilator for intubated patients. In essence, respiratory failure means a death sentence.

The residents have excellent clinical skills with diagnostic skills that are finely honed, particularly because of the lack of available ancillary tests. However, this did not always translate into resuscitation and emergency management. Dr Kiguli, the lone physician pioneer in emergency, was eager for the residents to obtain some emergency training and improve in this area.

After observing the practice in the ACU, I designed a modified pediatric advanced life support (PALS) course to teach some practical management and essential algorithms to the residents. We decided to also offer the program to all nurses who were interested.

Setting up the course was not an easy task. I was fortunate to discover that mannequins and many teaching tools had been left by previous volunteers. I had ample resources at my disposal.

It was challenging to advertise the program to all wards but I was pleasantly surprised to find both nurses and residents at all sessions. We decided to hold the two-hour course in the morning and afternoon, to try to accommodate different schedules. I kept track of who attended, the ward they represented, and an evaluation form was completed by all.

The residents attended in groups of six or seven. Initially I could see the reticence on their faces and their doubts as to the usefulness of the exercise. I felt that I had to win them over! But once a team began to practise a mock code scenario, the energy level picked up and I could sense the satisfaction that came with a successful resuscitation.

It was interesting to see residents who were exceedingly bright and "book smart" falter over basic resuscitation, but they picked up the skills very rapidly and eagerly took turns acting as team leaders. It was particularly useful to have nurses and residents in the same group and I tried to encourage the resident to stand back and allow the nurse to perform many of the tasks while the resident directed the efforts.

Dr Kiguli kindly supplied oranges so that we could make cuts in the skin and practise suturing! For many of the residents, this was their first exposure to this procedure and they were happy to be able to take the time to learn in an unhurried manner.

It was very gratifying to hear the residents' and nurses' positive response to the course. I was particularly happy to have an advanced nurse attend. She expressed interest in teaching the course on an ongoing basis and I reviewed all of the materials with her so that it can easily be set up again.

Matoke and Matatu
One of the pleasures of volunteer work is meeting other volunteers engaged in interesting teaching and research. During my stay, two Canadian and two British volunteers were at the hospital and we spent many evenings exploring parts of the city centre, going for dinner, and sharing stories and experiences.

Accommodations for volunteers were comfortable. The guesthouse had a central living room with sofas to relax on at the end of the day. I had my own bedroom with the requisite mosquito netting around the bed and monkeys that scampered across the roof, waking me up every morning! There were plenty of small cafés nearby serving the staple Ugandan diet of matoke (plantain), millet bread, cassava and different grains.

During my stay I was able to explore the capital of Kampala and many of the surrounding cities of this small country. Travelling by matatu (minibus) is a popular means of getting around — and an experience in itself, as they often travel at breakneck speeds. I felt safe travelling on my own during daylight hours, but tried to ensure that I was home before nightfall.

I travelled to Mbarara, my father's hometown, and retraced some of the journeys of his youth.

In Masaka, I visited my father's sister who returned to Uganda 10 years ago and reclaimed a tea plantation the family had been forced to give up during the exodus.

I also took two weekend trips to some of the national parks for mini-safaris. These were fabulous experiences. The country has a wealth of natural beauty, such as the stunning Murchison Falls, where the wide Nile River is forced through a seven-metre cleft in the rocks towards a 43-metre drop. The abundance of wildlife is another highlight of travel in the country, and it is small wonder that tourism is steadily increasing.

Uganda is a wonderful country to explore. Some areas in the northeast are still unsafe due to civil war, but the majority of the country is accessible to tourists and very beautiful. It was a privilege to work with the pediatric department at Mulago Hospital and I hope to return one day to see their progress.

 

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