When it rains it pours

For a country in its rainy season Uganda has been very dry. That changed early this morning when a massive thunderstorm shook the capital. Deafening thunder woke us up with sheet lightning strobing the room as if it was noon. Rain beat down and I could hear the staff scramble outside to gather furniture left outside the previous evening. It only lasted less than a hour but by then the red clay that covers most of the ground in Kampala (the capital of Uganda where I am working for those new to this) turns into a thick glue. Cars are trapped, shoes are lost, pant cuffs are ruined.

The trip into Mulago Hospital was the same series of 'go slows' but our driver seems to have found a convoluted course that minimizes the misery. Before heading to the ORs I went to check in on some of our post op patients from the previous days. No major problems existed. Splints were still on properly, wounds were clean, sort of. Our more complicated patient, the man with the tethered flap was doing well but having some problems adjusting to be welded to himself. I explained the dressing care to the orthopedic team, nurses and family. After a few minutes I wasn't convinced it was clear so I offered to demonstrate the technique. You wouldn't think a dressing change would garner that much attention but by the time the nurses had gathered the supplies I requested, about 20 people: staff, volunteers and even other patient families has gather around to watch the muzungo put on a dressing. Similar good news for the young child with the electrical injury who is showing no significant signs of cardiac failure or muscle death in her blood work, and whose wounds were clean and healthy this morning.

My attention was caught by the shirt on this young woman reading: "Too young to marry, end child marriage and teenage pregnancy". Early marriage and pregnancy ensure entire generations of Ugandan women have zero opportunity and in turn contribute to a cycle of poor health and early death.

Speaking of nurses, Ive been pretty hard on them in this blog and though I have enjoyed working with them and getting to know  them, I haven't been impressed by what I interpreted as a serious lack of work ethic. Well it turns out their work ethic is just fine. The nurses aren't being paid. The government has frozen their pay with the promise to come up with back pay plus some bonus in the future. These nurses are working for free and some for as much as three months.  I was surprised I hadn't heard of this until now but it was clear this was a source of embarrassment and hurt pride for these people and discussing it was not popular especially with a foreigner. The freeze on pay is apparently isolated to the nurses as they represent the biggest payroll group of the health ministry, thus the biggest opportunity to save. They continue to come to work because to leave will lose them their jobs and any chance getting their pending back pay. It is a terrible situation and I feel very poorly for judging them so harshly before. I certainly appreciate them more now but it may only be a matter of time before job action grinds Mulago to a halt.

Now that's not to say there isn't room for criticism. Some nurses are more a hindrance than help and actively try to sabotage the OR day to cut it short. Some just lay around doing nothing. One 300 pound nurse in particular who spends most of the day sprawled out on a sheet on the floor eating three times her share of lunches is one step away from having Carrie Fisher (Princess Leia) chained to her.

A common site during the day, families camped out on the floor while a member is in the hospital. The lack of adequate patient care resources means entire families lives are put on hold during the duration of the admission. As a doctor, I feel  pressure to discharge quickly but run the risk of prematurely sending a patient home only to have complications.

Fortunately the nurses continued to work today and we had a new set of patients for OR. This was varied and included a large venous malformation in a 40 year old woman who had tolerated this painful and disfiguring facial defect from birth. Venous malformations are abnormal growths of blood vessels that manifest as large swellings, often with discoloured skin in the surrounding area and a high tendency to bleed, sometimes with deadly consequences. Even when stable, These can be disfiguring, especially when on the face as was the case for this woman. We performed a resection and debulking procedure to thin out the malformation tissue and restore as much a normal contour to the face as possible.

Venous malformations are common in all parts of the world but in Canada it is rare for the disease to progress this many years and to this size. Note in addition to the massive low lip, which makes it difficult to eat and speak, a purple discolouration that shows the extent of the disease across the lower to mid face..

Extensive ligation of the proliferating blood vessels as well as debulking of the fibrotic tissue will hopefully restore a normal facial profile for a woman who has been hesitant to go out in public for years.

With the end of the first week here, I am really starting to find my groove in the hospital. I can navigate the maze-like corridors like a veteran, Have a saluting repore with the various soldiers stationed throughout the facility.  I'm on first name basis with everyone from the nurses (who we call sisters) to Tony, the guy who organizes the break room snacks (important guy to know) and I can breeze through the red line of death without having my pants confiscated.

One of the many squirrelly short cuts around the exterior of the hospital, this one being popular with medical students.

Typical lunch at the hospital with various starches and rice plus a tasty greens that is not unlike spinach along with rubbery beef my colleges hopelessly chew at before giving up.

Other cases today in our OR included a tendon transfer procedure to restore a functional thumb in a young man electrocuted when handling (stealing?) wiring, the release of fused fingers in a children burned badly several months ago and facial reconstruction from a acid burn injury. I've touched on acid injuries before but the incidence of them seems staggering. Acid attacks remains a disturbing trend in this population involving everything from spousal abuse, workplace violence and robbery with car batteries the primary source of the caustic substance. During one procedure, one of our surgeons was accidentally cut with a scalpel. It broken the skin. With a national rate of HIV of 7% and as high as 60% within the hospital population, sharp injuries are a serious concern among surgeons. Fortunately the risk of transmission is low, but a rapid antibody test was ordered regardless, the new tests taking less than 20 minutes to complete, coming back negative.

Patients are tracked by Village, District, County (Saza), Sub-country (Gombolola) and Tribe, where tribal rivalries continue to this day and are still a source of significant violence. Attempts are made to separate certain hot button tribes to avoid conflict between not only the patients but the care taker families as well.

The other ORs clipped along relatively well and we managed to finish up most of the planned cases by end of day around 7pm and headed home. When our driver is unavailable, we are reliant on taxis to ferry ourselves back to the guest house. While none of the taxi drivers ever seem to know how to get to our residence, tonight's was particularly hopeless to a point that he ran out of gas at one point. Stopping the car in the middle of a busy street with the blinkers on, our driver bailed out the door with a jerry can in one hand without a word when he was coming back. The three of us sat in the back staring blankly as cars honked and weaved around us.

Three members of our team enjoying beers we stole from the ortho team's fridge after a day's OR.

Finally we made it home and negotiated a discounted fare. A quick stop at the house, mainly consisting of people checking their emails and struggling with getting a decent Skype connection to their loved ones, was done before we decided to head out for dinner. We had decided earlier that day to give our resident cook a break as he had been slaving away for the last few nights. Dining out in Uganda is about what you might expect. A number of westernized restaurants full of staff and cooks who have zero idea what they are doing. Several restaurants are within close proximity and we decided to walk. The recent rainfall brought out the mosquitoes enforce but I was smart enough to wear pants and a long sleeve shirt dusted with a glaze of DEET. We opted for a greek restaruant, called Athins (yes, Athins not Athens). They seated us quickly in the open air layout and waited until after we had ordered drinks to inform us that the chef was gone and there was no Greek food, just some local food they had thrown together as a buffet. It looked about as appetizing as the cafeteria food at the hospital. Fortunately the steakhouse down the road was tolerable, even though the waiter asked the four people ordering dry martinis if they wanted four separate glasses.

One of the better toilets at Mulago hospital.

With no option to book OR time on weekends, some of our team organized a 2 day trip to a chimpanzee reserve, complete with accommodation for one night in a tree house canopy resort in the trees with the chimps. I keep thinking of the movie Congo but I'm sure it will be a good experience. In some ways I would rather stay here and help out at the hospital but there likely is not much I could do unless specific plastics emergencies happened to come in. So I'm am off for the weekend, apparently internet will be available so I will update the blog as possible but if not look for my next post in a few days.