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.