Prologue

Having returning safely, the first thing I noticed was how clear the air is here. Everything looked so..sharp. I'm still blowing charred debris out of my nose. The mission is over but I have a few final random thoughts on the trip. In no particular order.

 

Medicine:

The medical system is driven by the university, not a hospital department. This means that pay and promotion is based on academic status, not on one’s specific medical training. So a PhD will command a far greater salary than someone is more surgical training and experience. For this reason, pursuit of degrees take priority over fellowships and training. This cant be good for surgical skill development.

When Ugandans finish medical school, they intern for a year for which they are paid a small salary. However, should they decide to enter a residency program, such as plastic surgery, they are essentially doing a masters and do not get paid anything. NOTHING. In fact they have to pay tuition during their residency, though it is only three years, instead of five in Canada. This means either only those with money can pursue medicine or those without have to somehow fit another job into their life. Given how BC has almost tripled tuition and gutted the student loan system, I guess Uganda is the ideal goal for here at home, but at least residents still get paid, sort of. It is nice to have something to aim for I guess.

One of our secondary goals was local education. Unfortunately with pay so low, even for fully trained surgeons, it was rare to see them in the OR with us, their obligations split between the hospital and private endeavours. At $500 a month (rent costing about $200 for a modest place in the city) salary, it is hard to blame doctors for seeking other sources of income but it is clear that unless these staff are paid enough to make the hospital their only priority, patient care will never be improved.

Antibiotic resistance is always a big concern. Standard protocol is to use cheaper, less powerful antibiotics in healthy patients and step up to more powerful (and expensive) medications if no improvement occurs. As culture results come back from the lab, the choice can be modified to the best option. This keeps our big guns from getting prematurely used and developing resistance among those who are very sick. Unfortunately in Mulago, the first line is often a largest gun in the arsenal of options, namely Imipenum. This is sadly driven by aggressive marketing both inside and outside the hospital in the form of posters, presentations and lobbying. Even the nursing aprons sport the product’s label. Their slogan is “The first choice is the best choice”. Even worse, the microbiology department that processes the wound cultures, stack the report with a bias towards these antibiotics, again a product of aggressive pharmaceutical campaigning and outright bribery. In Canada, pharmaceutical companies have lost a lot of clout in their ability to lobby doctors. We no longer get free weekend ski trips at Whistler or free Hawaii “conferences”. I can see where they have shifted their attention and it will only lead to misery for patients as these vital antibiotics become resistance and useless.

Social:

North Americans are loud. I never realized this until spending time in Uganda. Ugandans speak in soft, steady tones, with a low pitched. I felt deaf half the time when talking, squinting my eyes and hold my hand up to my ear. It had nothing to do with accent; Ugandans speak excellent English for the most part, from doctors to street sweepers.

Christianity is the dominant religion in Uganda with a smaller minority of Islam (about 10%) but many other faiths exist, with relative freedom. Religious violence is an issue but not rampant in Uganda. Indigenous religion is fairly limited but many Ugandans loosely subscribe to practises such as making scarifies to ancestors.

Social issues have not progressed significantly; Homosexuality is considered a sickness even among some of the more educated and is a difficult topic to broach. Abortion is illegal, except in extreme circumstances where the life of the mother is threatened. Public perception is that any woman getting an abortion was unfaithful adding social stigma to criminalization. As is often the case in countries that ban abortion, the underground market for illegal abortions is huge as are the complications which end up in the hospital. It is not uncommon for these women to be charged while admitted in hospital if it is revealed they had under gone the procedure, revealing a less than rigorous patient confidentiality culture within the medical system.

Public sector has borne the brunt of Uganda’s financial woes (remind you of anywhere?). As mentioned previously, nurses have been unpaid for weeks while teachers had just recently gotten caught up on a portion of their back pay while I was in the country. This is a very common and seems like a national system of cheque kiting. The government holds pay from one group and dumps some money on another. This creates a situation where no one wants to protest, because previous attempts to strike typically result in that particular group getting punished with longer pay freezes. So everyone keeps their mouth shut and weathers the dry spells with the hope that they will get a reprieve at a given interval. God, I hope our government doesn’t figure this one out.

Diet:

While meat is a regular part of the Ugandan diet, its role is much less prominent. Consisting of maybe 10% of the total meal, most of the calories come from high carb sources including Irish potatoes, Yams, and a white grit like dish made from a variety of starches. Despite this heavy carb diet, the bane of the North American, you won’t find many overweight people here. This supports a dietary theory that it is less about what you eat, but eating what you genetically and geographically evolved with.

Candy and sweets in general are not a common snack in Uganda. For this reason kids went pretty nuts when it was available but I felt kind of guilty given they are likely better off without it. One surprise hit with the locals was Nutella, which I suggested as a logical combination with their local chapatti, similar to crepe and Nutella. To the Ugandans this seems like sacrilege at first until they try it. Needless to say, I had everyone eating this at the hospital break room and a jar of the stuff never lasted long. Too bad a jar is about 30,000 shillings (over 10 dollars). I’m going to miss those chapattis. 

Commerce:

There are metal workers in this country that can recreate almost any item you want providing it doesn’t have complex electronic components. This includes many firearms, so the number of fake weapons in circulation is very high. You can buy a Ugandan knock off AK47 for as low as 12 dollars American. I was very tempting to test out one, but it isn’t appropriate for a medical professional to associate with firearms in my opinion.

Despite dozens of vendors selling rolls of it by the road side to drivers caught in traffic jams, here is no toilet paper anywhere to be found in this country. There are a lot of smears on the bathroom walls though.

Shopping is much like other developing nations. Bartering is considered a given though my enthusiasm for beating locals down on their prices was limited. I have no issue with hammering vendors in Mexico into the ground so I guess that makes me a hypocrite. A careful eye is needed if you are looking for authentic Ugandan, “locally made” products, as most items in the country come from the same place everything else comes from: China. One item I was continually impressed by was batik painting, which uses wax and dyed canvas. I managed to pick one up for about ten dollars and it is beautiful.

Grocery stores carry many of the items one would find in North America but at higher prices compared to the average income (but still relatively cheap by a westerners perspective). Security checks are everywhere, even these supermarkets and getting pat down for weapons is common.

Final words:

Some have asked if I’ll be continuing my blog based on my experiences in medicine at home. My gut is to say no, mostly because it is a significant chunk of work and I’ll probably get fired if I start speaking frankly about my patients. I do appreciate the comments and emails. Thanks to everyone for reading and tolerating the typos including those readers in Russia, Australia and Germany (the blog website tracks country of visitor in addition to other stats), I have zero idea who the heck you are but welcome all the same. This isn’t the last overseas mission I plan on; in fact it is just the beginning, so maybe I’ll be back with another blog at some time in the future.

I’ll be in touch…later.

The last day in Scotland

They say to go out with a bang. In my case, more of a whimper.

I returned to Mulago hospital for the last time packing the final boxes of supplies we had brought with us leave for them to use as needed. There wasn't much of a team to meet with. The new interns were not entirely as enthusiastic as the last, with one AWOL and another last seen eating and reading an old magazine in the OR breakroom. The staff surgeons were no where to be found. Fortunately a frazzled resident was around to review new patients that had come in over night which included some large burns and an traumatic amputation (you guessed it: those damn bodabodas). We had a busy slate booked in the OR but there was a problem. They were out of oxygen. Low oxygen had been an issue all week. No one had gotten around to ordering more, likely budget issues or maybe good old fashion laziness. No oxygen, no operating on our patients. We scrambled to see what our options were but it was too late. The OR personnel had smelled opportunity and jumped ship. Anaethesiaologists, nurses, cleaners all fled out the back. There were literally sheets of paper blown about from the mass migration. "Don't worry!" I was told, they'll be back for the lunch you guys are supplying so at least that won't go to waste. Son of a ....

I'll miss the  OR at Mulago along with the sterile drapes with huge holes you can peer through. That's quality.

We checked on all the patients still admitted as well as some that had been discharged already, some days ago, but still hanging out in what ever corner would fit them. It wasn't uncommon for patients to stay due to financial issues or long travel distance, waiting for an opportunity to catch a ride with a relative or friend at some point in the future. Some would create jobs for themselves, like door guard to the ward in an effort to stay. The little boy with the head injury was holding on and back on a oxygen tank on the plastics ward where he belonged. I don't think  he is going to make it though. His breathing has continued to become more laboured. He will eventually fatigue from the muscle excursion and go into respiratory failure. Normally we would put such a patient on a ventilator to relieve the patient of this work load but there are no pediatric ventilators available and the adult ones are on a private ward, costing half a million shillings a day ($200). It is this reason that when seriously injured patients come into causality, it is rare to intubate (place a breathing tube). While short term a person can manually breath for these patients using a squeeze bag, the lack of ventilators means eventually they have to give up. This puts families into situations where they desperately hand pump the respirator for their love ones in shifts until exhaustion and inability to remain at the hospital constantly force them to stop. It is a horrendous situation that is best avoided.

The electrical injury is improving, but like all electrical injuries, the damage is much worse than it first seemed. It is clear she is suffering from some psychological issues sounding the trauma but the resources for this are almost non-existent. She will need further surgeries to remove the devitalized tissue and regular wound care but should recover if they stay on top of things.  It is diffiult leaving and not being able to finish these patient's treatment but they have surgeons here at Mulago and they can continue plan. Arrangements have also been made to follow up by email with updates and pictures.

Of course getting paid might help with the appreciation part.

With no OR to work in, I spent the rest of the morning wandering around the various wards checking out all the hidden areas of the hospital. I had a tonne of candy and little toy lights that clip onto your finger I had picked up before I left and the various children I came across children seemed to get a big kick out of these little gifts. The candy is eaten immediately and the finger lights will keep them entertained until the batteries die or they break but none of it will last for ever. Sort of like Humanitarian aid on retrospect.

Children are particularly taken with us Muzungo (white) doctors and commonly reach out to touch you as you walk past them. These little guys are all smiles after receiving their sweets and toy lights. One of my colleagues wanted the photo to include me handing them the items but I declined on the basis it was already a bit too colonial.

While trying to catch a photo of the UN craft in the back ground, this Russian made MIG 29 landed out of now where. The Ugandan government acquired 5 of these planes which were shown off extensively during the independence day celebrations.

There appears to be no limit to the carrying capacity of the bodabodas (local motorcycles)

It felt strange being back at the guest house during the day. It is usually pitch dark by the time I arrive back. I spent the afternoon relaxing in a chair under a small gazebo and even had short nap. I declined to participate in the evening activities and just continued to unwind.

It is easy to forget you are in the tropics working 12-14 hours a day. This quiet spot in the yard was only just noticed on my last day.

I fly out tomorrow. I'll spare everyone a painful rendition of my inner thoughts as I think about the last few weeks. The mission went largely as expected and we didn't kill any of our patients, in fact no complications, even minor ones, occurred. For this reason I would call our time here a success but it is just a drop in the ocean at the end of the day. I'd like to come back though even if it is just another drop. My final words of this blog will not be to encourage all you reading to open your wallets. The problem's here can't be spent away though If you really want to contribute, supporting an organization like MSF (Doctors without borders) ensures your money will largely go to good use. No, I would instead urge us to lift our heads and look around us once in a while and appreciate what we have at home and more importantly stand against those trying to take it away

I'll see many of you soon.

Private enterprise

I think it says a lot about a city when all the stores from large to little holes in the dirt, prominently sell door locks, door gates and bars. Crime is high in Kampala but we have been relatively sheltered from it with our electrified walled residence, private driver and manned security gate. The signs are every where though, police, who can be seen wearing four different uniforms patrol the streets and operated checkpoints. Soldiers add to this, though their presence is less now that the independence day jubilee is over. We keep hearing from the locals how dangerous it is but every time I've gone out, there have been no issues.

Today I had a change of venue and worked at CoRSU, Comprehensive Rehabilitation Services in Uganda, as there was no slate available at Mulago hospital. The hospital is about a 45 minute drive outside of the capital and near Entebbe airport. Funded by the CMB (Christian Blind Mission) this facility has a focus on reconstructive services, rather than acute trauma, with a paediatric focus. I have always had reservations about mixing religion and medicine and that hasn't changed. What this facility does have is the capacity to do microsurgery on patients where no other option is available. Microsurgery is a unique field unique of plastic surgery and involves the complete removable of "flaps" or segments of tissue based on specific neurovascular anatomy and transplanting them to a different part of the body. The flaps are then reconnected using high powered microscopes (10x to 20x power), the big crane style ones, not the science lab ones, to the neurovascular vessels in the new area. It requires expensive equipment but more importantly, high quality 24 hour nursing care to monitor vascular status of the flaps for any signs of compromises, at which time we would have a small window to return to the OR and salvage the flap. This window before the flap dies is about 6 hours maximum, therefore vigilant nurses are needed to watch the patient. Unfortunately while Mulago hospital may have a rickety microscope that might be up for the task, its nursing care  is no were near at the level required.

Not surprisingly, the beds and layout are much more spaced out at CoRSU hospital compared to Mulago.

So while moving local flaps from one area to a wound right next to it is an easy task even in the simplest of facilities, because we don't have to disconnect it surgically from its original blood supply. Moving tissue from that same arm to the foot or face, where local flap options are very limited, requires a significant jump in technology, expertise, and post op care. This is were CoRSU comes in useful as it allows us to treat patients that otherwise would have no options at Mulago or most other public hospitals in the country. Obviously the solution is the provide a better funded health care system, pay and train nurses appropriately and equip hospitals accordingly, but that isn't going to happen, in fact it will likely only get worse. Even in my own country, our health care is slowly being eroded in the name of financial dogma. Just ask Uganda how much cash you save when your population doesn't get the health care it needs.

This young man was discussed yesterday and had this large lymphangioma tumour  of his tongue removed and the resulting defect reconstructed

Today he is doing well with no signs of bleeding or breathing problems. Unfortunately his jaw has been warped by the tumour over time and will need further surgery before he can properly close his mouth. This is the challenge of medicine in this part of the world, delayed presentation means more complications in an area with limited resources to begin with.

Leaving my unnecessary social rant for the moment, our day was an exciting one from a surgical point of view. A woman with a severe recurrence of breast cancer needed a massive chest wall resection to clear the tumour. After removing all the cancer, her pericardium (that's the heart) was exposed along with about a square foot of chest cavity and bone. We harvested a latisimus dorsi muscle free flap, a large flat muscle of the back, along with overlying skin plus additional skin grafting to fill the chest defect and close the wound. The defect left on the back is then closed with a long incision. The nursing staff will watch for signs that the muscle/skin flap is not getting blood flow by checking its colour, temperature and using a doppler, similar to an ultrasound, to evaluate blood flow across the micro-surgical connection.

Another case, which is now the absolute worst hand contracture injury I have ever seen after claiming the one yesterday was the worst, took a number of hours and is best described by the pictures below. The rest of the day included syndactyly, fused fingers, and more and more burn contractures of the extremities and face.

If you are thinking: "what is that??" you are not alone. This teenager suffered a hideous machete injury to his arm at a very young age. As he grew his hand was contracted back by scarring until his hand was flipped 180 degrees the wrong direction. It now lays hyper extended and grown into the top of his forearm pointing at his elbow. Despite all this, his tendons are reasonable in working order.

After releasing the tissue and skin grafting the resulting defect, tendons were lengthened, nerves moved and bones removed or fixated with wires to create a relatively normal hand. He was beside himself when he woke. He had never seen his hand in a normal position since he could remember. however, months of healing and physio remain before he gets back to using this new hand.

Syndactyly, a congenital condition where the fingers develop in a fused state, is one of the more common pediatric deformities and even more so in Africa and the middle east. This child has both hands the same, with all 5 digits, including bone, fused into one non-functional mitt.

It doesn't look like much now, but for our first stage we have separated and reconstructed the hands into 3 digits, including the thumb. Once this heals, final division of the remaining 2 can proceed, but to rush this can cause vascular compromise and dead fingers.

The new thumb not only needs separation but construction of a web space to allow it the range to oppose and grasp.

Unfortunately CoRSU has even worse administrative red tape than Mulago. At one point our two occupational therapists, who had been working and teaching all morning with the local physio team, were detained by security and ejected from the facility for not having the proper paperwork. Even us surgeons, despite having arranged medical licenses beforehand, were cautioned about not coming to the hospital in numbers greater than 2. We were running 3 ORs that day so it is unclear what logic they were operating from. This malicious bureaucracy seems to go hand in hand with health care around the world but it was particularly mean spirited and self-destructive in Uganda.


After a forgiving ride back home that evening free of go slows and excessive diesel fumes, we decided to push our luck and travel out again for dinner, this time at a well known Indian restaurant, Kana Khazera. It is hard to present oneself as a hardworking, in the trenches surgical team when you keep going to nice restaurants, but its one way to survive the hard hours and dammit I was hunger. I never would have thought I would find so many good restaurants in Uganda. This was likely the best Indian food I had ever had. Palak Paneer, Mushroom Marsala, Vegetable kebobs, all excellent and for less than 70$ for the 6 of us. We did have a server with the worse body odour known to man, but we have to rough it a bit I suppose. It probably didn't help that members of our group kept asking him to answer questions just to get him near one of us at the table. We are pretty terrible people. Don't worry though, we tipped him about 3 months salary. On the way home, I got dragged into a popular night club, Big Mikes, where they play live blues music with way too much reverb. It may have also bee the site of a previous car bombing a few years ago but the only bomb tonight was the singing.

Tomorrow we have our last day in the hospital and I'm looking forward to returning to Mulago one last time. It may be run down, ill equipped and poorly organized but...well anyhow I return tomorrow.


I'll be in touch.

Ugandan ATMs suck

This blog must be getting repetitive. Days blend into each other and I'm often off by a day at any given time. The second day of our 4 day OR marathon is over and the hours and lack of sleep are starting to wear on me. A few updates that I know you are dying to know. Still no diarrhea, for me anyhow, can't say the same for the more delicate members of my team. White people continue to be mind bogglingly ugly. ATMs still rip you off, charging a fortune in fees and limiting how much you can withdrawal forcing you to do multiple transactions to generate enough cash to buy a meal. No wonder people in this country are constantly stealing them. All I can do is beat the machine up a bit when the guards aren't looking. Traffic is still complete death on wheels. The swamp crotch continues though I would describe it as stabilized for now though the more alarming swamp ass is becoming a bit of an issue.

Safety first. This barred and padlocked fire exit pretty much sums up Ugandan safety protocols. Uganda: You're gonna die here.

The day was the same as before. Our driver continues to be useless and drove us right into the same traffic jam despite assuring us he would take a new route. I'm getting to be on a first name basis with the vendors at the side of the road who sell their wares to trapped drivers and it is pissing me off. The post ops were doing well with one exception. A woman, 18 weeks pregnant, with a large but stable burn injury, died for no apparent reason. I can only guess some sort of cardiac or stroke but it was shocking given how well she had been doing. I just had a conversation with her the other day. I have never lost a patient with child, it is all I could think about all day. I asked when the autopsy would be done and got blank looks. I was in no mood for the usual slack attitude to protocol and in short time the necropsy was scheduled for the next day. I can't say it is unique to Africa but people here just aren't phased by sudden disaster. No doubt this is protective behavior and it is surprising how quickly it rubs of on you. Our little burn with the head injury continued to stay alive. At first I couldn't find him or his family until someone pointed to another very crowded ward where I located them all crushed into the space between two stretchers on a mat. The stink of urine and rotting wounds was everywhere. His oxygen tank had run out over night and no replacement was provided so the mother wandered around and plugged him into whatever tank she could find. At least three other patients had patched into the same large rusty cylinder like fish crowding into the bottom of a leaking aquarium. In any case, I think I've ended the witch hunt against the mother. The hospital seems much more inclined to kill him than she is. I complained that keeping oxygen tasks supplied was not exactly a task that could be pushed to the morning. Being oxygen and all. Our electrical injury was also no where to be found, taken for an EKG I had ordered LAST WEEK. Better late than never I guess.

Patient consent is an important part of surgical care, even in Uganda. With low literacy rates, thumb prints are the signature of choice for many that get treated at Mulago Hospital. Much more effective than an "x".

The OR slate was more of the same with some twists. One young girl with what has only been described recently in the medical community as Nodding disease, though documented as far back as the 60s. The predominate symptom is severe seizure activity with a 'nodding' pattern as well as mental dsyfunction, not unlike autism. This illness has surfaced in about 2000 children in very specific areas of Uganda as well as surrounding countries and this type of pattern suggests something environmental. Theories included high level of silica in crops to Vitamin b deficiencies to parasitic infection. I suspect lead poisoning as this region is well know for strip mining and lead is a common component of the process to isolate precious metals in an industry that poisons thousands every year. Our girl fell hard during a seizure and split her chin and lip down to the bone. Over the weeks that followed she healed with poor scaring and the lower lip was now severely retracted making it impossible for her to close her mouth. As well as a chronic fistula (open tract) from her chin to her mouth constantly leaked drool. She was so passive and non-interactive, not even flinching when the IV needle was placed. We might have fixed her face, excising the fistula and closing the wound as well as reconstructing her lower lip with a special flap from her tongue, but the behavioral issues would last her entire life in a country where even the healthiest have a difficult time surviving.

Wounds such as this are common and are easily fixed with the right knowledge. The trick is to understand one must reconstruct both the outside and inside components of the wound or it will recur.

Another interesting case was another young (14 year old) girl. Her story was familiar, severe burns (again seizure related, fell right into a cooking fire, twice) with poor or no treatment. She was left with contractions from the scars, deforming her right hand into a flexed claw and her right knee, making it impossible to walk. Similar to the case I described yesterday, we lengthened the tendons and excised the tight scar tissue but in this patient, we performed a special flap in our armament where by a  paddle of skin from her forearm was brought into a large defect on her hand tethered and fed by her radial artery, the well known radial forearm flap. The leg was released as well and the resulting defect filled with a leg muscle flap before a skin graft was placed over the exposed area. I expect she will be walking again in a week but her right hand will likely need further reconstruction before she can use it fully.

One of the worst flexion contracture injuries I have seen, this patient requires a much more complicated management than is typical. At the end of it and with good physiotherapy follow up she should regain a significant portion of her arm's function.

The wrist is now able to straighten after lengthening the tendons and removing the scar tissue. Note the triangular tissue that doesn't quite match the surrounding skin on the wrist and the hole in the forearm that it came from, now covered with a skin graft. We call this principal of moving tissue from healthy areas to defects: 'Borrowing from Peter to pay Paul' and it works extremely well.

A colleague (right), a local resident (centre) and myself  trying to control severe bleeding with an intermittently working cautery device. The local staff keep reminding me "This is Africa". I know and it really bites sometimes.

The general surgery team called me over to see a patient of theirs about to go into surgery for excision of a 'bump' on his arm. "What do you think it is?" they asked. "You're about to cut it off, don't you know, didn't you get a biopsy??" I replied. "Nope" they responded. Well it ain't a rash. I was fairly sure it was a sarcoma, a potentially malignant and invasive tumour. Poor management will mean this patient's death.

Stumbling out of Mulago hospital later that evening, soaked and sticky from hours in stifling OR gowns, we decided to get something good for dinner to make up for the less than spectacular Ugandan food court experience, which stands as our stupidest decision of the trip, superseding the previous winner, namely the river rafting/drowning tour. Though amusing at first, members of our group running repeated into the washroom holding their ass cheeks tightly together is becoming old. Nah, who am I kidding, it is freaking hilarious. A quick stop at home, we dumped off our filthy clothes and I had a shower. We went back to the scene of the crime, namely that Thai restaurant that was closed the previous night. It was great. I couldn't help but feel guilty as we were lead through the beautiful open seating areas past a large statue of an elephant with garden and waterfall to a spacious table with a couch and soft chairs. We ordered all the classics, Tom Yum soup, papaya salad, Pad Thai and various curries, and every dish was fantastic. I even had desert, date sultana with ice cream, before the bill arrived (half a million shillings, about 200 dollars or a poorer Ugandan's wage for over 6 months). It was a nice rest despite the obvious decadence and we walked back to our home almost forgetting the food court.

The restaurant was lovely except for the crushing realization that the money would feed a family in Uganda for months. It didn't help that pretty much every customer was white. I'm not sure anything has changed in this region of the world. At least the spring rolls were good.

Tomorrow I am not at Mulago but CoRSU hospital instead. I wasn't initially interested in coming here as I preferred to stay in the public hospital. However, while this NGO funded facility does provides private care, it uses this money to fund and provide free health care. Im not sure if I approve of this model but I can't deny it is a reasonable option for a country with such a challenged health care system. It is almost an hour's drive away so I'll be sure to sit far those with any ongoing bowel issues.

I'll be in touch.

Mini panhandlers

The four day OR marathon began this morning with torrential rains filling the deep potholes that litter the streets like mines. Our driver was not on his game and drove us right into a go slow (traffic jam) delaying our arrival to Mulago. For a moment I was jealous of the bodabodas zipping along the sidewalks and between cars but it passed instantly as the non-helmeted driver of one sped past with 2 passengers holding on behind and a huge bundle of supplies tethered to the sides.

A quick check on our patients was uneventful. The small boy with the burns and suspected head injury was showing signs of neurological improvement. Murmuring and concerns voiced by the hospital staff continued as to the safety of the child with his mother. I remarked that the mother hadn't finished off her young child yet. She was young, maybe 20, clearly out of her element and already caring for other children. Most parents have dropped their child once or twice in their lives, and given her circumstances, she was probably ahead of the curve. We would continue to evaluate but I was more concerned about the hostile rumor mongering and infection. Our near death experience child from the previous day was doing fine. Due to halothane's toxicity it should not be re-administered for 3 months after use. Here they wait only 6 weeks. Regardless, it was 6 weeks the child wouldn't be in the danger again. Some new admissions had arrived the previous night and I went to quickly assess them before our OR started. I wasn't worried, the OR hadn't started on time once during our trip. Beds are always at a premium in Mulago. Many of the new admissions, a collection of different service's patients, had been sitting or lying on the floor in the outer hallways of the wards all night. One elderly man sat on the hard, dirty floor gingerly wrapping dirty rags around his rotting feet. Most likely diabetic ulcers or trench foot from poor footwear and long hours in the mud. The stench told me all I needed to know: Gangrene and imminent amputation. Gunshot victims held pressure dressings onto their wounds, one woman the only survivor where two of her family had been executed by thieves. We triaged the list and made the necessary changes to the OR slates.

The hallway of our plastics ward as they wait to be assessed and sorted. Limited space and long waits make keeping patient in this hospital difficult, often resulting in the patient returning weeks later with a much more severe problem.

Our slate today included the 8th of a series of surgeries for on going reconstruction of a man's face post acid burn attack from last year. His engagement party was approaching and he was eager to make what ever improvements could be done. His expectations were wildly unrealistic and the language barrier made it difficult to caution him about this. The orthopedics team tried to steal the anesthetic machine from one of our rooms but we chased them off. It was every surgeon for themselves and they gave up and went to prey on general surgery. One of our anesthetists, a Russian named Vladamir (who I very quietly renamed Vladamir the Inhaler much to the giggling of my colleges), abused each patient with impressive consistency. Too bad the ex-soviet decided he didn't want to work past 3 and effectively shut that room down ahead of schedule and forcing us to divert patients to the remaining OR rooms. Thanks for nothing Boris. A large disfiguring facial nevus (think huge mole) in a young woman was removed and reconstructed in four parts to recreate the cheek, side of nose, lower lid and forehead. An eleven year old boy with a lymphatic tumor of his tongue, was swollen so large and for so long his jaw had grown around it and his teeth were pointing almost 90 degrees forward. We removed the tumour and reconstructed what was left of the tongue but he will need extensive facial surgery from us on a future mission as well as orthodontics to eat normally. A young woman was treated for a tight flexion contracture (stuck in a flexed position) of the wrist for over ten years, making the hand essentially useless, which was the result of a complication with an injection to the arm. She had been contemplating amputation but fortunately found her way to our clinic the previous week.After exploring the wrist, the scar tissue was identified and released, tendons lengthened to allow the hand to extend and the wound closed and put in a splint. She will likely regain 95% normal function.

As with all my patients, this man graciously agreed to having his photo displayed. He suffered an acid attack last year after an argument with a neighbor. In addition to many other problems, he suffers from ectropion, when the eyelids are retracted and don't close properly. This can cause rapid degeneration of the eye and vision.

Giant congenital lesions such as this nevus would usually be treated at a young age. Not so in Uganda. I was too busy to get post op photos but will try to catch her at a follow up later this week.

This tight contracture makes it impossible to drive, hold a phone and perform two handed tasks.

The wrist was opened and tight, scarred down tendons, some seen here, were released and in most cases lengthened.

Though still somewhat tight, our patient will have no problems except for certain yoga postures. The next important step is aggressive physio to stretch the shortened tendon.

The  day ended in the evening as usual. Our driver returned us home and we decided to go out for dinner. We had heard of a new and good Thai restaurant about 15 minute walk away and braved the unlit streets and potholes. Walled compounds bordered the way there. Shards of broken glass and Concertina wire stood watch for anyone trying to hop over. Police gave us looks, considering if it was worth the effort to check our papers and extort a bit of money. Taxis honked for our attention. The six of us dodged across busy streets where car don't even slow down. Our Intel was poor, it was almost a 30 minute walk. And the restaurant wasn't open. We asked were another place nearby was and got even worse intel. 45 minutes later we were in downtown Kampala with only a vague idea where to go. We finally came across a mall we recognized and ended up eating in a food court out of desperation. A UGANDAN food court. Could we be making a sketchier decision? Unfortunately the long, exhausting walk had some of us a bit frayed so I opted to not voice concerns. Staff from the different kiosks out right fought and argued with each other for our business. I ended up ordering from the largest guy, figuring he could shield me from a hail of bullets when I turned down the others. Ironically most of us had Thai. It was mostly awful but not as awful as the toilet running some of them had to make a few hours later. Fortunately my meal was reasonably tasty except for some burnt tofu and the vegetarian diet gave me some protection in my biased mind

Razor sharp glass has been cemented to the surface of this wall. It looks almost pretty in the daylight.

Night life in Kampala is even busier than the day. The high volume of vehicles and limited street lights lower the life expectancy of pedestrians considerably. People work late in this city so evening rush hour goes well into the evening past dark which falls around 7. Women wearing impeccable office attire ride side saddle on those death trap bodabodas, the red dust swirling around them. Crowds of people of all types converged on taxi bus drop points. These small vans can cram in about 14 people, and are a much cheaper form (25 to 50 cents) of transpiration for the locals. They blast over speed bumps and side walks all over the city. I haven't road in one yet, but I suspect their seat belts are not up to code. As we walked I noticed small lumps sitting on the poorly lit sidewalks, not moving. They were children. Small children. I mean one or two year old at most, sitting, some in a puddle of their own urine, with their hands cupped staring silently at passersby. There were no adults or obvious care givers any where to be seen. But they are out there, waiting to collect the coins these mini panhandlers gather. It was difficult to process and members of our group wanted to bring them to the police or hospital. They say no one ever changed anything without doing something about it but this was not something for us to fix. I learned later that occasionally the police do drive around and scoop up these children and place them in what can only be described as a child prison. The children stay in this holding area for a 30 days with minimal care before they are transferred to government or NGO operated orphanages. Is that better? Worse? I wasn't sure and dropped some cash into the little hands with the hope something of it would go to the child. Maybe I'm wrong. Probably am. It started to rain again.

I'll be in touch.

No Choice

I think it was when the 4 year old's oxygenation dropped below 60% (normal being above 90%) when the panic started to grip me. Her pulse was dangerously high and erratic...I recognized the impending cardiac shock as her body fought for oxygen. Today I came face to face with my worst fear and my heart rate still hasn't settled...

I expected chaos when we arrived at the hospital, only two of us along with our two occupational therapists (who make splints and manage the patients physiotherapy) were present, the other two surgeons divided our efforts and went to CoRSU hospital, a private, NGO funded facility about an hour away. A lot can happen in any hospital over the two days while we were gone, and Mulago is no exception. Surprisingly there were no major admissions over the weekend. I guess all the broken legs and half amputated arms were at home getting traditional medicine for now. You have to take your breathers where you can get them. I can't say we were well rested after the weekend of hiking and long car travel but we were determined to make the most of this last week. We met with our plastics team, a volunteer general surgery resident from Boston, living off her savings with a strong interest in burns and two Ugandan interns, doctors in their 1st year general practice residency. The more senior local staff were rarely present, typically relegating morning rounds to their juniors, which is common practice in most hospitals. Unfortunately their involvement throughout the day was not always much different.

A common flyer posted throughout the hospital, these on a piece of plywood blocking a open elevator shaft. I'm not sure which is worse, having to pay to have a nurse care for you in hospital or the parasitic loan sharks that prey on the employees when they are short on cash.

Our post ops from the previous week were doing well. Some had been discharged home over the weekend, others remained, usually because of the long distance they had to travel or concerns about wound care. Our lower lip/face recon was doing well and embarrassingly grateful. She was still quite swollen but I expected a fantastic result over the next few weeks. Her fevers had settled but the malaria medication would continue and she could go home today. Many people in the region suffer from malaria and certain forms of this disease can flare up and resolve and then flare up again months or even years later as the relatively impervious cysts in their blood stream hatch and reestablish themselves. This makes curing the disease extremely challenging and is why Malaria accounts for a significant chunk of the morbidity and mortality of the African population.

This burn scar had not only caused contracture of the knee, preventing flexion but also developed into a form of cancer, a known but rare condition called a Marjolin's ulcer. Complete and immediate excision is critical to prevent metastasis. Unfortunately large blood vessels and nerves travel along this course in the leg turning the surgical site into a minefield.

5 days post op, the bubbling scar and cancer is gone, note the "Z-plasty" styled incision which takes tension off this new incision as it heals.

Hand to crotch guy was doing well (yup, that's his name now), the dressing teaching I had done previously was clearly well heeded. His neighbor, also in the same crash, suffered crush and amputation of 2 fingers and a thumb. We discussed the possibility of doing a toe to thumb transfer, transplanting the big toe to the hand as a new thumb, to give this hand more function, but it would have to wait until next year after his current wounds healed fully.

Our gunshot victim was showing signs of improvement and sensation was slowly returning to her arm and hand. It remained to be seen if motor function would return but as long as improvement was happening we would hold off on any invasive surgery.

The rest of the patients had similar updates with a few exceptions. A young child, about one and a half years old, who had suffered superficial but extensive burns long before our arrival had deteriorated over the past week due to an unknown infection. Barely able to lift his head, we had tinkered with various antibiotic and antifungal combinations. The blood cultures we ordered to elucidate this bug, originally returned as negative (meaning no infection) but today it was revealed those culture bottles had been expired, making our results worthless and left us flying blind. Over the weekend the child had become less responsive with a fixed gaze, where the eyes don't move normally, indicating a possible brain dysfunction. I suggested an infarct, or stroke, rare in a healthy child but a potential complication of one so sick. It was then the nurses whispered that the mother had in fact dropped the child on its head, twice, over the weekend. The team looked at each other and then the mother. A quick inspection showed no obvious contusion or swelling on the head. I encouraged caution to jumping to conclusions, but it was not unheard of for parents to attempt to speed along a sick child's demise. Ultimately it was decided to leave the child in the care of the mother, what choice did we really have? I hope I don't regret this.


Monday was clinic day. We still had a handful of patients from the previous week that needed surgery but more were needed to fill our OR space from Tuesday to Friday. The Ugandan plastic surgeon informed us that he had some administration to take care of for an hour and asked if we could run the clinic ourselves for this period. It wasn't appropriate to have foreign visitors leading a clinic but we agreed. Again, what choice did we have. The bastard didn't come back until the afternoon, about 30 seconds after we finished. Word must have gotten out quickly that the Muzungos (white people) were in charge. There was very little order and there was no semblance of a line or patient list. The calm and serenity of last week's clinic gave way to frenzy. I clearly had no appreciation for the control the local doctors maintained over these clinics. Patients and parents would push their way past each other to the door, displaying their or their children's injury, arguing with the nurse if she wouldn't let them in. Often patients wouldn't wait and charge in while we were still seeing the previous person, hovering over them menacingly to get them out. Charts appeared and disappeared. Nurses scolded patients for complaining about pain, or anything for that matter, which we could seriously use back home. It was madness. Benign presentations were ejected on sight and we focused our time on pediatric congenital defects or acute hand, face or other soft tissue injuries.

While hardly life threatening, the stigma of duplicate digits is high. Simple deformities such as this can prevent an individual from getting work, or being accepted by their partner's family.

This procedure was done last week: The duplicate thumb is removed, the errant neurovascular  bundle resected to avoid chronic pain and the thumb joint reconstructed to correct the laxity that arises on the duplicate thumb side. No, it isn't just a matter of snipping it off. No one will ever know this girl even had this condition.

A number of post ops were present as well. Our cleft  foot was healing well and could now fit into normal shoes. A child with a volkman contracture, leaving his hand in a tight claw, was treated with tendon lengthening and transfer and now was extending his fingers for the first time in months. The young man with the disfiguring leg growth the size of a melon was walking after the excision and able to sit without pain and wear normal pants. It was pretty satisfying and most importantly no major complications had occurred. My less harm than good plan was working. So far.

With clinic finished, the team was asked to reassess our young four year old electrical injury we had treated the previous week (and discussed in a previous post). She had a fever and her vitals had been soft and suggested the possibility of early sepsis, blood poisoning, likely from necrotic tissue in her arm wound seeding bacteria into her bloodstream. Though her wounds had looked reasonable at the last dressing change on Friday, clearly something had  changed. The special antimicrobial silver dressing I had placed on the open wound had been taken off on Saturday for no clear reason (families would sometimes do this randomly). Operative exploration and further debridement of the dead and toxic tissue was the only option to prevent the child from getting sicker. Just one problem: We had no anesthetists. One of the anesthetist's children had died on the weekend. The funeral was today and EVERY anesthetist in Mulago hospital took the day off to attend. The Orthopedics had already suffered complete cancellation of their OR slate as a result but our patient couldn't wait for tomorrow.

A quick discussion and it was decided to perform a conscious sedation, which is the use of oral or intravenous drugs to make a patient dopey enough to do minor procedures but awake enough that they breath well on their own. It takes some skill to manage but the Ugandan team felt up for it. I recommended oral midazolam. They pointed to the halothane. I must have looked concerned, maybe horrified, because they quickly informed me they use it all the time. Halothane is an ancient anesthetic gas that NO ONE uses anymore but remains popular in the developing world . We don't even use it on rats in the laboratory. Though less of an issue with children, it can induce a form of hepatitis, with high mortality rates and has some unpleasant respiratory side effects. It was also meant for general anesthetics, not the much less involved conscious sedation and a quick scan showed no anesthetists in the room, just a trainee in anesthesia, not even a resident yet having just graduated medical school. I deferred to their judgement, trying to avoid being judgmental about practices that are outside the boundary of our own. Maybe I should have stopped things then and there but the child needed treatment, what choice did I have?

The majority of the case went smoothly. The arm and its fasciotomy site, where we had previously released the swollen muscle, tendons and nerves, was exposed revealing a large patch of necrotic muscle that would have to go. Several tendons were already frail and failing as well as the median nerve being exposed. We did our best to partially close the wound without subjecting the contents of the forearm to high compressive pressures.

Myself controlling unexpected bleeding during the case with an electrocautery tool.

It was as we put the dressings on that I could hear the oxygenation monitor signal slow in pace and drop in pitch. I glanced over at the O2 sat monitor, which measures the amount of oxygen in the blood via a small scanning device on a finger tip. Anesthesiology is a bit like flying a plane. Usually it is pretty easy and runs on auto pilot but can turn into a compete nightmare if something goes wrong. The oxygen levels fell quickly from 98% (good) to 82% (not good, but not too worried). The pitch dropped further, now to 73% (uh oh) and then to 65% (officially worried). I stopped everyone and focused on the respiratory issues. The trainee struggled with the face mask trying to get a good seal, as they dropped the halothane concentration and pushed up the oxygen. Again, like flying a plane, when something is going wrong in anesthesia, you need to run a check list in your mind to ensure you aren't missing something critical. Is the oxygen tank running? Are any of the connections loose or disconnected? What does the chest sound like, has a lung collapsed? Now 50% (sweat forming),  the trainee wasn't coping, so I stepped in. Turning the oxygen to 100%, I asked for suction to clear the airway. People started to yell instructions before I quickly ask everyone to be quiet and let one person speak (me). 42% (underwear is now wet). 35% (make that wet and brown). We were losing this child. At these low levels, brain damage would soon occur and the heart would go into arrhythmia. I wont lie, as worried as I was for this patient, my thoughts focused on a doctor who was charged and sentenced in abstentia in the middle east for an OR case where a patient died, through no direct fault of his own. He didn't even realize he had even been charged and sentenced until a year or two later when he was pulled off a plane connecting through Dubai and imprisoned.  The heart rate was severely rapid and irregular. I asked the team to recheck the ventilator and repositioned the patient to maximize his airway. We fired a dose of epinephrine in to treat what could have been a spasm in the lung. I got ready to begin chest compressions and called for the crash cart. 29% (Doom). 34% (what?) 41% (I'm keeping my license!) and steadily up to 98%.

The child woke up after the gases had fully cleared form her system. She was well. I  said very little as we placed the dressing over the arm. I must have been white as a sheet because the staff surgeon I was with saw me later and asked what happened. I said we had had a rough case. We were coming back tomorrow. What choice did we have?

I'll be in touch.