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.