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.