Talc powder and pappadums

It has been officially 2 days with no diarrhea and counting.

Unfortunately the hot and humid weather has left me with what can only be called a moderate case of swamp crotch. That’s right everyone, this blog will tell both the good and the bad. The problem will only get worse I suspect and at least one pair of underwear have been lost at sea, presumed drowned.

But it isn’t all crossing your fingers every time you use the toilet and thoroughly powdering scrotums with talc. There is a bit of medicine going on here and today we got our first real taste. Today we ran the outpatient clinic.

The day started off productive enough. After a brief breakfast and the daily scramble to untangle our various electrical devices from a communal charging station, we crammed into a small vehicle; our regular van was unavailable for unknown reasons, heavy one extra passenger who crammed into the back. One would think that 20 seconds of exposure to traffic in Uganda would result in 100% seat belt compliance but it always seems to have the opposite effect overseas and I was mocked for suggesting their use. We arrived at Mulago hospital on time but were asked to meet with the head of the surgical department as a courtesy. The gentleman in question carried the presence of a politician, wearing a suit that was slightly too large. He spoke softly with large hand gestures, welcoming us to his facility and introducing us to various staff. The walls of the office were a patchwork of yellowed, curling papers tacked into particle board. A dusty, pale clock, built into the wall, stared out at the room with no motion, while a gaudy Pfizer clock a few feet away ticked along steadily. We were now over a half hour late when the meeting finished. Slowly, we were lead into an even more dilapidated room near the hospital’s burn ward by one of the senior plastic surgeons of the department. Stacks of old equipment balanced in the corners, while a plain clothed man washed dishware at the back. More conversation was had. No working clocks in here. Finally, over an hour late, we were lead to the clinic

The Main entrance of Mulago hospital, Families on the bench to the left sharing a meal as they wait to be processed.

Small and cramped, the hallways were lined with patients and their family, their heads snapping in our direction as we spun around the corner in our crisp white jackets, shirts and ties. A quick survey and I could see many burns and limb deformities. The issue with medicine here isn’t just that people get hurt in large numbers. What makes treatment a true challenge is the delay in their presentation to the medical system. Many households cannot sustain taking a family member to the hospital for multiple visits. Transportation limitations complicate this further as many of our patients come from rural areas. Many Ugandans seek out alternative treatment following an injury further delaying definitive treatment. At the very best these herbal remedies do no extra harm and in other cases can cause secondary infections.  The delay means a much worse injury state, which means more complex surgical management with less successful options to choose from. You may think it is presumptuous to assume traditional medicine will not work for these people but after seeing your 12^th burn contracture with a limb that will no longer move, essentially crippling the patient for life, you don’t have the luxury of being open minded about these things. No amounts of herbs are going to fix a face melted by acid or recreate the fingers on a child maimed by a machete.

Waiting patiently to be seen, patients cling tightly to the chart and xrays, there are no copies.

 

Splitting into two teams we worked straight through the morning into the afternoon. One by one patients quietly filed in. No one complained about the wait, some of whom had arrived before sunrise to ensure a spot in the clinic. Children with burns were common, a result of open cooking fires in homes. I had been aware of the phenomena of acid attacks in Uganda and surrounding countries. These injuries melt skin, bone and eyes equally making them one of the most complicated reconstruction procedures. Large awareness campaigns and restrictions on the sale of acids have likely reduced this bizarre area of trauma but it remains all too frequent. Congenital deformities, including a very rare cleft foot, and complicated muscle injuries to upper extremities made up much of the remainder. By the end of the clinic we had filled up over 70 hours of OR time to be done by our team of four over a 3 day period. This didn’t include any extra emergency procedures that may surface. It didn’t matter, everyone who we deemed needing surgery was put on the schedule. The real question is whether the hospital will pull together the anaesthesiologists, nurses and have the equipment sterilized.

This severe case of Filariasis, commonly but inaccurately known as elephantiasis, is common to the region and by late stage presentation only significant and massive debulking of the scarred lymphatic tissue can be done all while avoid disruption of the various nerves and vessels that run the length of the leg

Leaving the hospital, we planned to grab a very late lunch in the town at a well recommended India restaurant. Having been holding my bladder since morning, I went to find a washroom. My attempts to not elevate myself above the locals met with disaster when I went to use the common wash room next to the clinic. Despite stern warnings from the Ugandan doctor I confidently strode in to a 2cm river of brown muck covering the floor. A quick scan revealed refuse, used diapers and a pile of clothes that may have been a body. I bailed. Waiting for me was the doctor holding the staff washroom key.  I am such a hypocrite.

As we left the hospital, brightly coloured blankets and clothing hung from windows to dry. Day to day care of patients falls under the responsibility of family. They will bath, feed and change linens daily. These family members aren’t allowed to stay with the patient however; leaving them to camp out on the hospital grounds. When travelling home is either geographically or financially difficult they will stay for the duration of the admission. I have no idea what happens to those patients without any family.

The team coordinated prior to splitting off to see patients. Despite the concerns of patients eager to get  in, we assessed every patient who arrived.

A quick taxi ride back to the house to change and out again brought us to one of the larger malls in the downtown area. Security continued to ramp up with the impending celebrations the following day. A number of opposition leaders had been imprisoned by the incumbent party to ensure a smooth running event but surprise, surprise this seems to have had the opposite effect. On the top level an impressive open air restaurant commanded a 300 degree view of the city. Small rounded hills topped with mosques, cell towers and thick foliage surrounded the area in all directions. The meal was great, and the total for eight people came in under 200,000 Ugandan shillings. About $80 and that was with a lot of beer and about 300 papaddums. Of which I ate 150.

 

I didn't get many pictures today so here is a snail I saw on our front walk.

Following our meal, others in the party split off to browse various gift shops full of wooden spoons and weaved bowls. You know, crap. After picking up a few items from a supermarket; Mango juice for breakfast and talc powder for my groin, I walked over an ATM to withdrawal some spending money. I should have noticed something was wrong when one of the machines had a piece of re-bar shoved through its screen but I was determined to get some Shillings. A few moments after entering my PIN the machine decided that I didn’t need the card anymore and promptly swallowed it. A receipt was spit out stating "Card Capture: Reason Unspecified" (You lose!). I looked around for more re-bar. The bank, Barkley, was just on the other side and I quickly went around to the entrance. The door was locked. My repeated knocking was answered by a security guard with an ancient SKS Chinese rifle. Staff were still inside but the guard informed me they had closed at 6. It was 6:01. “Come back on Wednesday” (Tomorrow being a national holiday and all) he stated in a thick Ugandan accent and closed the door. I knocked again. Same guard, same rifle, which incidentally had a folding bayonet. I explained I was a traveler and couldn’t be without my card for two days. I could tell he wasn’t too worried about that. Fortunately an employee overheard my comments and intervened on my behalf. I didn’t get any cash but I did get my card back.

Tomorrow we return to the hospital to review and reassess the inpatients. Given how large the celebration is set to be, I’m not convinced there will be many staff available to work with. We always have the patient’s families I guess.

I’ll be in touch.