Pushing the envelope of helicopter medevac…

kampala, looking east to lake victoria


Mbarara district referral hospital in the right lower corner.


Kampala's old taxi park (left lower corner), from the air


Dave flies the helicopter with a couple of patients lying next to him



February 21st

It’s Sunday afternoon and I’m visiting Guustaaf out in Ntiinda. I’ve decided to go climbing in the Rwenzoris next week and Guustaaf has been kind enough to lend me some of his gear.

(Just in case you get worried that postings here are drying up and I’ve disappeared or checked into detox or something—no, I’ll just be in the mountains for 8 or 9 days.)

Tom calls and asks if I want to fly to Mbarara. I say sure, but tell him I’m in Ntiinda (about 20 minutes by boda or 40 minutes by matatu from IHK). He says that they want to take off right away. I give him the option of sending Dr. Christine from OPD or waiting for me to boda over. He talks to Dr. Christine and tells me to get on a boda.

It is pretty clear my boda driver has no idea where IHK is. I have to turn him around after he makes a turn on Kira road towards town. So we’re headed down the Lugogo bypass (picture a big white guy sitting on the back of a small motorcycle wearing a backpack with an iceaxe attached to it…) and another bigger motorcycle goes by, slows, looks at me, looks at the iceaxe. Turns out its Dave, the helicopter pilot. I tell my driver to follow the guy with the yellow helmet and we make the illegal U-turn across Jinja road and scream through the industrial area. I show my driver the shortcut through the slum up onto Namuwongo road, so we beat Dave to the hospital by a good five seconds.

It turns out that a 4x4 full of evangelists blew a front tire about 9am outside of Ntungamo and rolled several times. An elderly couple from Tennessee were pretty banged up and couldn’t walk and a couple of other people were injured as well. They wanted to know if we could fly all four to Kampala—in a helicopter designed to carry 5 passengers seated. Typically, if we fly for a patient that needs to lie down, we take out the front passenger seat and fold up the back seats—which barely allows room for a stretcher to be strapped to the floor. Dave did the numbers, though, and figured we could carry 3 patients and me and my medical gear. We decided that instead of the stretcher, (or spine board, or any of that crap) we would just put a bunch of cushions down on the floor and squeeze the two supine patients in between the control column and the door…

While I was on the phone trying to track down the doctors in Mbarara, Dave was on the phone getting a guarantee of payment. (missionaries or no, the helicopter is a strictly mercenary business—Dave said he told the guy what the per hour charges were and how long the flight time, and the guy said okay, he’d pay for one hour of flight time, and Dave would just have to fly faster!) I managed to get one of the doctors at Mbarara district referral hospital on the phone. He said that he was taking one of the patients to the theatre. He said we should come and pick the patient in four hours. I told him that in four hours it would be dark. And we don’t fly in the dark. He said something to the effect that we had a big problem. And hung up on me. And didn’t answer his phone the next 4 times I called.

Fortunately the thunder storms from Friday night had abated and we have clear flying to the football pitch across the road from the hospital. Fortunately, as well, the field is surrounded by fencing which keeps most of the Mbararans from running into the area where helicopter blades are spinning (although later on we had to shout at the spectators snapping pictures of the injured patients with their cell-phones). Moving the patients to the helicopter proved problematic. Actually even moving them through hospital—strangely enough not equipped with ramps for wheelchairs or gurneys—was difficult. But we managed to get them slid onto the floor of the hospitals ambulance and over to the football field without damaging them any further.

Without being indiscreet, or violating patient confidentiality, let’s just say that our patients are not small people. And that getting them loaded into a space smaller than a twin mattress and getting the door shut took some doing.

The flight back to Kampala was relatively uneventful. Dave’s record of 9 years of flight time and never having an airsick passenger was interrupted as the third patient (sitting next to me) hurled into a plastic bag that later proved leaky. And the other two patients kept complaining of being hot. As I tried to explain to them that both the windows were open as far as they went and the helicopter didn’t come with A/C.

But we all survived the flight and managed to get them checked into the ICU without further drama or trauma and still able to move all their toes and fingers. Some where along the line, some perky 3rd year American internal medicine resident who somehow was related to the church sponsoring our patients showed up and started barking orders at the ICU nurses: ‘why haven’t the neck x-rays been done?’; ‘what are the CBC results?’; ‘what do you mean they haven’t had a CT scan done yet?’; etc., etc. I had to take him outside and explain to him that one (in case it wasn’t painfully obvious) IHK is not Mass General, and two, he didn’t have privileges work in Uganda, let alone IHK, and that he should just shut up and enjoy the ride.

As of this morning, the patients were doing well and getting ready to leave the ICU.

For a very unflattering picture of me (that’s me bending over, stabilizing the patient’s head and neck as he vomits next to the helicopter) in one of Uganda’s national newspapers.

trauma update

Trauma Update: 12 February 2010

I’ve been having weekly sessions with our A&E (accident and emergency) nurses for almost a half a year now. We talk about trauma, and emergency medicine, and ambulance transport (most ambulance calls here go out with a non-medical driver and a nurse—there are no paramedics here, although I’ve been agitating to hire some clinical officers and train them to be paramedics), and other topics. Most days I think we’ve come a long way. At least they’ve started to laugh at my jokes.

Last Friday afternoon I was looking forward to the quickly approaching weekend and a cold beer at Fuego when Justine, senior sister (compare to nurse manager) in charge of OPD (outpatient dept.) and Linda, my emergency team leader, come and grab me to come see a RTA (road traffic accident—UK medical lingo). I’m a little disappointed that Linda feels it necessary to come with Justine as opposed to taking charge of her team, but I smile and head to the trauma room. Which is empty. (not a huge deal, since I’ve come to accept the fact that the trauma room is really a place to store obsolete, broken and esoteric unusable equipment) The patient is in one of the unmonitored beds in main 5 bed casualty ward. There are 3 nurses standing around him, none of them touching him, all of them watching as one after the other pushes the button for the automatic blood pressure cuff, which won’t seem to give a blood pressure value.

The patient was in a car crash earlier in the day in Masindi (about 3-4 hours north of Kampala by car—I've visited Masindi district hospital, see the Sept. 2009 post, it might explain why he didn’t seek care in Masindi). His coworkers tied a big piece of wood to his obviously fractured leg, threw him in the back to truck, and drove him to Kampala where, reportedly his health scheme covered his care at Kampala International Hospital.

It didn’t take much clinical prowess to see why they couldn’t get his blood pressure. He didn’t have one. He was cold, sweaty, pale (after 8 months, I am finally starting to get the nuances of just how pale a black man can be and what it means) and has no peripheral pulses. One hand on his left upper quadrant tells me that his spleen has ruptured, and the majority of his blood is now pooling inside his peritoneal cavity.

By this time there are now 5 nurses around the patient, still none of them touching him. Both the medical officers assigned to casualty have disappeared without a trace.

I try to nudge Linda into taking charge by reminding her of the ABCs (airway, breathing, circulation) and asking her what should we be doing first. ‘Well, we need to get the vital signs first.’ Sigh.

I coax the nurses into putting down the automatic blood pressure cuff and starting an IV line on our man (they look at me like I’m mad when I ask for a second line—‘can’t you see we just started one?’ I make a generally hopeless request for oxygen and a cervical collar. I track down one of our surgeons who agrees with me that the man needs to go to the theatre for a laparotomy.

And then the reception staff take over the casualty unit and everybody starts talking very fast in Lugandan. There’s been a slight misunderstanding. The patient’s health scheme pays for care at Kampala Hospital, not International Hospital of Kampala.

Suddenly my nurses, who have mostly been milling about for twenty minutes, leap into action and get the man loaded back up into the truck. The surgeon shrugs and says something to the effect that there is nothing we can do. This feeling is echoed by Justine. ‘What can we do?’
I feel like screaming, but I keep my voice well modulated. ‘We can do the right thing, and operate on him and possibly save his life.’
‘But he will have to pay cash for it.’
‘Can’t we worry about the money later?’

Apparently not. I tried to explain to the patient and his coworkers that he could easily die in the 20 minutes it was going to take for him to get across town. But they were having none of it.

I called over to Kampala Hospital and, after a number of transfers, spoke to their surgeon. He listened to my story, seemed surprised that I had taken the time to call, and thanked me for the heads up. Understand that in the US, making a call to say that you had just transferred a patient without a blood pressure in need of an emergent laparotomy (not even to mention in the back of a freakin’ truck) would basically be like begging to have your license to practice medicine revoked and all of your personal assets taken from you.

The patient survived his surgery.

He left the hospital 3 days later. The nurse I spoke with was unable to confirm if he was alive upon discharge.

Plight of the Bodas

one last boda ride?
(photo credit: Irene Curley)


boda boys out of gulu

obeying the helmet law
(photo credit: kampala fan facebook page)



February 19th

Boda Boda Crackdown

I’m sure my previous posts have given the pros and cons of the Boda Boda, Kampala’s ubiquitous motorcycle taxis.

The daily carnage of the bodas is well documented and, now that I’m spending some time at the public hospital, has been presented to me on a personal level as well. But I don’t have a car here in Kampala (and even if I did, wouldn’t have a place to park it anywhere near Mulago) and it’s a long walk between IHK and Mulago and the trip in a matatu (2 minivan taxis, one from Namuwongo to the taxi park and the other from the park to Mulago) takes over an hour in good traffic and a third of a lifetime in the jam. So I have been forced to rely more and more on the bodas.

In my post from August 13th, I marveled at how the bota drivers in Kigali, Rwanda (they’re called motos there) all wear helmets (and carry one for their passenger). I mentioned to a Ugandan surgeon how this might help diminish the high rate of head injuries from boda accidents. He smiled. As it turns out, Uganda passed a law several years ago requiring boda drivers to wear helmets, reflective vests, and to carry a helmet for their single passenger (it’s not uncommon to see bodas with 2 or 3 passengers—plus a toddler sitting on the handlebars).

And, surprisingly enough, just in the last two weeks, the police in Kampala have started enforcing this law. News reports focus on the police jumping out of bushes and whacking the drivers over the head with clubs and confiscating their bikes if they don’t have the required permit, helmets and vest.

At the beginning of the crackdown, Friday before last, things were oddly amiss at Reste corner (the center of the south Kampala, vso volunteer universe—the Italian market, Palm café pizza, the wine garage and fuego cocktails all being within a stone’s throw). It took a while for it to sink in. There was not a single boda to be seen on a corner where usually you have to beat them off with a stick. That turned out to be because down the road in Kabalagala the police were actually beating them off their bikes with sticks. (the last time they had a boda crackdown, I’m told, there were riots in the downtown area, so this time the police have come with bigger forces and concentrated on one neighborhood at a time)

Two weeks later, there are still noticeably fewer bodas on the road. And many (but by no means all, or even the majority) have the vests and helmets. Although that doesn’t necessarily mean they have permits as a friend of mine found out the other day when his boda was stopped. He figured, since he’d only gotten half way, that he would only pay the driver for half the ride, but the police officer yelled at him and told him to give the driver full fare (so that the boda boy would have more extortable cash on him).

The boda drivers that hang in the lot across the street from the hospital know that I want to go across town to Mulago (going out of Namuwongo to town increases the risk of police apprehension), so they ignore my wave, unless they have the helmets. And the drivers with helmets have suddenly raised their fares 500 or even a 1000 shillings (25-50 cents—outrageous). And the helmets they are wearing range from the comical to the downright nasty. I was issued a helmet by VSO, but, I confess, had become a little lackadaisical in its use—until one of the drivers handed me this strapless bucket of a helmet smelling strongly of mildew and month-old perspiration. Now, the helmet travels with me.

I tried to get one of the residents in casualty excited about doing a study to compare pre and post crackdown head injury rates. He just gave me a wan smile as if to say, ‘silly mzungu, things here will never change…’

Rafting the Nile

(didn't take my camera rafting, this picture shamelessly stolen off the Adrift website)

Rafting the Nile (or LSU medical students gone wild in Africa)

February 16th

I’m riding the shuttle bus to go rafting. In addition to being the world’s longest river, the Nile also has some kickass whitewater, and I’ve been meaning to check it out for a while. I had to get up early to catch the bus, so I’m hoping to snooze a little on the 2 hour trip to Jinja, but I happen to overhear a young man’s voice bragging: “…well, all of us know CPR and a third of us know how to do a crike.” I open my eyes. A group of young people has just boarded. Medical students, I think. Then the same dark haired, thick-browed young man goes on, “Yeah, I could do a crike with my swiss army knife. No problem.” Pure, unadulterated hubris. Definitely a fourth year med student.

A crike, for the uninitiated, would be a crichothyroidotomy, an emergency surgical procedure that involves cutting a hole in someone’s neck and inserting a breathing tube. I can think of a lot of scary things to do at work, and a crichothyroidotomy would top the list every time.

I think about engaging him in conversation… ‘So, buddy, assuming you’ve been very lucky and you’ve managed to get your ballpoint pen into the patient’s trachea (as opposed to the carotid artery or the esophagus), and you are now blowing air into a small tube in a poorly sealed hemorrhaging wound in some poor bastard’s throat, what are your gonna do next? Call 911?’ But, nah, I was him once. I turn up my iPod and tune him out.

The source of the Nile has been the subject of controversy for a number of years. In 1858, John Speke was the first to suggest that the Nile originated from the lake he named Lake Victoria. His travel partner, Richard Burton (get the 1990 movie Mountains of the Moon on netflix), called this a bunch of rubbish. Even now, the purists will tell you that the waters of Lake Victoria (and hence the Nile) come from many sources, the most remote being the Akagera river, which starts as the Rukarara River in the Nyungwe rainforest of Rwanda.

For rafting purposes, however, the Nile starts somewhere below the Owen Falls Dam in Jinja. (Although a new dam currently under construction at Bujagali Falls will eventually submerge most of the rapids we'll raft over). Unlike most of the canyon whitewater I’ve been exposed to in the US (certainly not an exhaustive survey, mind you) which is more narrow, rocky and continuous, the Nile is big and wide and has long stretches of flat water punctuated by high volume, waterfall-like rapids perfect for flipping rafts in. Fortunately, the water is warm, and the rapids spaced far enough apart to allow you time to find your paddle and get back into the boat.

Prior to the first big rapid, we practiced flipping the raft. Tutu, our guide wanted us to hang onto our paddles with one hand and the safety rope of the raft with the other. As we were flopping into the water with the raft on top of us, I felt an unnatural torquing sensation in my shoulder and thought, this would be the perfect way to dislocate a shoulder.

And sure enough, on the last rapids before lunch, the raft in front of us was tossed and one of the rafters was floating at an odd angle in the water holding his right arm against his lifevest. We pulled him along side and headed for shore. About this time the boat with the med students shows up and my buddy starts barking out orders about bed sheets and traction and makes the poor guy with a dislocated shoulder take his wet shirt off (next time you dislocate your shoulder, try taking your shirt off). The med student wants to use the traction/counter-traction method of reducing the dislocation—probably the most painful way ever devised to put a shoulder back in.

Lee, the lead guide, has been given the impression that the med students are doctors. Upon questioning, however, the young man has to sheepishly admit that no, he doesn’t graduate from medical school until June, and, no, he’s never reduced a shoulder dislocation in his life. But he points to one of his fellow med students and says that she is going to be an orthopedist and that she’s ‘put in hundreds of shoulders.’ (Turns out that she’s only a 3rd year student and, although, she would like to be an orthopedist when she grows up, she hasn’t even done her orthopedic rotation yet.)

Before the 4th year can do any more damage, we gingerly load the patient into our raft. On the flat stretch of river before the lunch island, I talk the man into extending his arm out to about ninety degrees and the shoulder pops back into place. At lunchtime, the man is ignoring the sling I put him in and is eating with both hands. The raft company pulls him from the trip, however, to go get an x-ray in Jinja.

We flip our boat in the rapids below the ‘Bad Place.’ I don’t hang onto the rope, or my paddle. I float the whitewater feet first and wait for Tutu to get the raft turned over.

another short, sweet trip to the Sudan

in the cabin of the 206
Torit International Airport
Torit, South Sudan, from the air
The Irmatong mountains
Over Lake Kyoga


February 10th

Monday’s hash was in Bugolobi, or Mbuya, or somewhere toward the southeast outskirts of town. We got lost trying to find the starting point at Daytona Bar, so I was playing catch up from the get go. My phone kept going off. I know, you say, how stupid to run with a phone, but on the Kampala Hash getting lost is such a frequent occurrence you never know when you’re going to need to call a friend. On the hash, answering a mobile phone is a punishable offense (punishable by the threat of having to drink extra free beer at the finish…), so naturally I answered it.
Tom from transport was looking for a doctor to fly to Arua about seven in the morning to help transfer a patient down to Kampala.

So I said sure.

Modified phone log:

1900hr: Call from Tom. He has just texted me the phone number for the Doctor at the hospital in Arua.

1905hr: Call the doctor in Arua. No Answer.

1915hr: Call the doctor in Arua. No Answer.

1930hr: Call the doctor in Arua. Very bad connection. He’s in the theatre (that means the operating room here, not the cinema) can I call him back in a half an hour.

2030hr: Call the doctor (Patrick) in Arua. Ask about the patient. ‘Oh, he’s fine.’ Okayyy. He (the patient) just has end-stage liver disease with cirrhosis, portal hypertension and bleeding esophageal varices. He just had an upper GI bleed the other morning with a blood pressure of 70 and required a blood transfusion. I ask him what the patient’s hemoglobin level is now. He says he doesn’t know, but ‘clinically’ the patient is not anemic. I ask about when the last time Dr. Patrick saw the patient was. ‘Oh. I haven’t seen him all day, I’ve been in the Theatre.’ I ask him to go check on the patient and call me with his current status. (no further contact with Patrick.)

2045hr: Call our hematology lab to see if we have any O negative (free of the major blood antigens, so you can give it to anyone) they could pack up for me to take on the flight with me. ‘No.’ We have no blood, let alone Oneg.

2355hr: Tom calls to let me know the time of the flight has been pushed earlier. Can I be at the hospital at 5:30? A.M.? I tell him at 0530 he’s going to have to send a driver to pick me up. He agrees.

0500hr: Safari James from transport calls. ‘Did Tom tell you about the medevac to Arua?’
‘Uhhh… Yes, he did. He said you’d come pick me up at five-thirty.’
‘Are you ready to go yet?’
‘Is it five-thirty yet?’
‘Oh.’

0515hr: Safari James calls. ‘Can I come pick you now?’
‘Is it five-thirty yet?’
‘Oh.’
‘Come pick me up at five-thirty. I’ll be standing on Kironde Road.’

0540hr: (because the accepted behavior here for arriving at a closed gate is to lay on your horn until someone opens it, I have chosen to exit the gate and save my housemates from awakening to the sound of the ambulance horn. I have now been standing in the rain for 10 minutes.) Safari James calls. ‘I am leaving now. Are you ready to go?’

0620hr: We arrive at the Kajjansi Airfield. Aside from the night watchman that we wake up with our horn, we are the only people there.

About 0700hr a couple of people with luggage wander in. I’m thinking, ‘hmmm… what exactly has Tom signed me up for this time.’ Then the guy with the uniform wants to inspect the medical kit.
‘Do you have anything dangerous in there?’
‘No.’ Unless you consider an oxygen cylinder, a scalpel, and enough diclofenac (an injectable relative of advil that seems to be the preferred pain-killer and anti-pyretic in Uganda) to put the pilot into renal failure. I don’t bother to explain to him that if I was going to hijack anybody anywhere it would be back to my bed…

Then Dave, the pilot for MAF, comes in and explains our flight plan. First we’re going to fly to Entebbe to pick up two more passengers and clear immigration (Immigration? I thought Arua was in Uganda?). And then we’re going to fly to Torit. Torit? Torit, as it turns out, is in South Sudan… (you know that imaginary line that VSO has asked us not to cross? Torit is way across the line.) And then we’ll fly to Arua to pick up the guy who’s bleeding from his gut. So much for being back in Kampala for lunch. And I don’t have my passport. (VSO still has my passport—almost 8 month in and no work permit yet). Dave says he’s going to list me as crew, so I won’t need a passport.

At Entebbe, Dave checks the fuel to make sure it hasn’t been watered down, loads the luggage of the additional passengers, gives us a safety briefing, and says a prayer. (MAF stands for Missionary Aviation Fellowship) If the only guy standing between me and crash-landing somewhere out in the African bush where the chances of rescue are next to nothing wants to pray, then by god, let him pray. I say a little prayer for Dave’s continued health as he prays for the success of my mission to Arua.

We fly north over Lake Kyoga at 10000 feet. The dry season is in full effect up North and the sky is thick with dust and smoke from burning fields. Below, the land is a parched yellow brown. In the haze on the horizon sits the purple line of mountains just north of the Sudanese border.

Dave picks out a low point between peaks in the Irmatong mountains to pilot his Cessna 206 through. The mountains are free of trails and cell towers. Red rock with sparse green scrub.

A few more nautical miles (why do airplanes measure distance in nautical miles?) and the mountains subside, we cross a dry river bed, a few tracks appear on the plain, and Torit comes into view.

My time in Torit didn’t include the city tour, so my impressions were mostly from the air: a large sprawling village with a few rectangular single level buildings, but mostly round huts arrayed in packed dirt compounds set haphazardly on an irregular street grid. A creek or small river meanders southwest of town giving life to a winding swath of greenery and trees. The runway angles away from the east end of town. When the UPDF (Ugandan Peoples Defense Force—the army) chased the LRA (Lord’s Resistance Army) out of Uganda, the LRA hid in the Irmatong mountains and wreaked havoc on the people of the Torit district. At some point in the conflict, the LRA was reportedly receiving military assistance from the Sudanese government as payback for the Ugandan government’s support of the South Sudanese Liberation Army…

A WFP (world food program) plane is getting ready to take off as we land, and the crowd of people surrounding it moves to encircle ours. But we haven’t brought any food, only missionaries. Francis shakes my hand, ‘God bless you Dr. Riley.’ Motorcycles and bicycles criss-cross the runway as a herd of emaciated cattle stagger by in the dusty heat. There are no Sudanese immigration officials checking passports, so I go looking for a tree to pee against (the Torit International airport lacks a tower, terminal, even a latrine). I have to walk quite a ways. The huts line both sides of the runway. Their roofs are more peaked than in the north of Uganda, but otherwise similar.

We flew another hour or so west (and a little south) to get to Arua. Arua sits at the northwest corner of Uganda. Supporting aid delivery for a large refugee population from Sudan and the DRC (Democratic Republic of Congo), as well supplies being shipped by road into South Sudan, has made the Arua Airport the second busiest airport in Uganda next to Entebbe. When we land, however, aside from an Eagle Air LET-410 taxing out, the only other plane at the airport is an Antonov AN-2, a 1940s Russian biplane that the UPDF uses to drop paratroopers.

I was expecting an ambulance. But I have learned never to expect too much. I called the contact number for his employer at the UNDP and was told that the patient was at the airport. I notice a sick looking, emaciated man lying by himself on a bench by the small terminal building. Sure enough, that’s my patient. Fortunately, he still has a blood pressure. Fortunately, he was kind enough not to throw up blood all over the back of the Cessna, and we had an uneventful flight home. Naturally we had to drive at breakneck speed back into Kampala with the lights flashing and the sirens blaring.

On arrival at Kampala Hospital by the golf course (the patient’s doctor doesn’t come to IHK) we wheeled the patient onto the ward. The nurse asked, ‘Where’s the patient’s family.’ The ambulance driver said the patient was alone. ‘Well. Who is going to make the patients bed?’ Who indeed. I was carrying the patient’s suitcase. I asked him if he had sheets in there. He did. I put the sheets on the bed. And the transfer was completed.

for more pictures of the flight

Updates on previous postings

Updates

February 7th

Re: It’s so hot.
It rained most of the day yesterday. We had planned to find a pool to sit by. We went bowling and to the movies instead. I woke up shivering cold in the middle of the night.

Re: Eviction notice.
Prashandan, the Indian Cardiac Anesthetist, had been housed in Sally’s spare bedroom pending our eviction. Prashandan’s wife got wind of the arrangement and raised a little hell. Prashandan is now living in one of Ian’s guest houses up on the hill. I let Dorothy in HR that I was expecting the same level of comfort in my new housing as I had in my old. This led to a flurry of emails between IHK and VSO. It now looks like they may rent a house for Richard and Pat (Richard’s a doctor from the UK who was working here, but went home in September, but are coming back for a short project) and give me a room in it.

Re: Another weekend in Wakiso
Bebe Cool was shot in the legs in a gun battle between the Special Police Constabulary Unit and his body guards that happened either at Centenary Park, the Nakumatt parking lot or the Lugogo Mall (depending on which paper you picked up the day after the much awaited but generally dissed R. Kelly concert in which Bebe was an opening act). Details of the shooting are blurry as well, but seem to hinge on a police unit interrupting a couple having sex in a parked car. Bebe was initially reported in ‘critical condition’ with ‘both of his legs shattered,’ but, after a visit from President Museveni, he was able to walk out of the hospital a few days later.

for more info on the shooting

First Impressions of Mulago

5 Feb 2010

First Impressions of Mulago

Mulago Hospital is Uganda’s National Referral Hospital. Theoretically, Mulago would be the shining jewel in the crown of the Ugandan public health system. It would be the showcase hospital where the best minds and the best technology came together to tackle the really tough cases referred in from the outlying ministry of health hospitals. The equivalent hospital in the US might be Walter Reed, or maybe Massachusetts General Hospital (that is, of course, if the US actually had a health care system to take care of all of our citizens).

Mulago was founded by a British missionary doctor, Dr. Albert Cook (OBE), in 1913 as a clinic for venereal diseases and sleeping sickness. The current 1500 bed incarnation of the hospital on Mulago Hill was built in 1962 by the British as a parting gift to a soon to be independent state.

The Casualty Ward at Mulago occupies much of the 3rd floor of the hospital’s main wing (the hospital is built into a hill side, so that the 3rd floor is on the uphill side and ambulances and police trucks can drive up to deposit their patients). The main entrance to Casualty is guarded by its own police barracks. Once you make it by the police you enter a darkened waiting area reminiscent of a bus station in the deep south. There is a cage near the entrance for registration, and a small area cordoned off with 5 foot high portable blue-curtained partitions for the triage nurse amid a sea of waiting patients. The triage nurse will write your name and complaint and vitals on a small slip of paper. She will arbitrarily decide if your complaint is medical or surgical, and she will make a swipe with a colored magic marker on the chit—red means you get seen soon, orange means you may get seen, yellow means you will be waiting a long, long time.

The Medicine side of the ward operates out of a tiny 3 room cluster off the main hallway. When I visited last week, Edith, a recent graduate from what we would call an internal medicine residency, but now the clinical director of the Casualty ward, was explaining to an intern on her first day: ‘don’t clerk the patient (clerking is what we would call doing a workup and writing the patient up), just decide if they are sick or not.’ If they aren’t sick, in the eyes of a brand new intern, they go home. If they are sick they go to Ward 3BM which is a holding area. In Ward 3BM (for ward 3 area B, medicine, not that you’re going to have 3 bowel movements while waiting to see the doctor) the patient’s are seen by another intern with a little bit more time. This intern may order what few lab tests are available (a CBC, a blood smear and a fingerstick glucose, if they aren’t out of strips), maybe an x-ray, and then will decide what service in the hospital will admit you. Then they will tuck you in (I mean this metaphorically, as the only way you will get tucked in at Mulago is if you remember to bring your own sheets) and hope you are alive in the morning to go to your respective ward.

Last September I had my 3 month meeting with Sarah, VSO Uganda’s Health Program Manger. Sarah is one of many bright, well-trained young Ugandan doctors who have found it much more pleasant (not to mention lucrative) to avoid the actual practice of medicine and work for an NGO. (there is some irony in the fact that the NGOs set up to improve global health can actually worsen it by hiring away the best of the local doctors).

I had confessed to Sarah that the acuity of emergency medicine at IHK was, on average, fairly minimal. She had suggested that maybe I could do some work at Mulago as well. She had thrown this out there almost like a challenge—I don’t remember her actual words, but I do remember the tone in which it was made: ‘so you think you’re ready for Mulago white boy?’

So I said, ‘sure.’

And every few weeks afterwards I would send her an email, or query her as I wandered through the VSO offices, about how she was coming at getting me some work in Mulago. And she would respond that she was working on it. That they wanted this paper, or that paper, or somebody to sign off, or the department of surgery had to be approached, or the department of medicine…
Finally, upon my return after Christmas, her response was that ‘IHK has a MOU’ with Mulago, and so Kevin (IHK’s recently promoted CEO) should be the one to establish my relationship with Mulago.

MOU stands for memorandum of understanding (I had to ask). It’s going to take one hell of a memorandum to improve the understanding around here…

And Kevin is so far over his head trying to parlay a career in insurance sales into CEO of a private health care system in a foreign land in the developing world, that he would be the last person to arrange me work at Mulago.

So I called my friend Conrad, a Ugandan doctor who studied with me at the Liverpool school and trained at Mulago. He gave me the phone number of one of his classmates, an endocrinologist who finds himself in charge of the casualty ward. A day later I met with him. He wanted copies of my Ugandan medical license and my US registrations. I knew that VSO Uganda had copies of these on file, so I sent an email to Sarah asking if they could make me a set of copies for Mulago. I was informed that, no, I would have to pick up the paperwork and make the copies myself. (VSO Uganda has a photocopy machine and a fax machine that also makes copies)

But by the next Tuesday I had gotten the documents to Dr. Fred. And on Wednesday I had the approval of the Executive Director, the Deputy Director (who basically said, in so many words, what took you so long?), and the Chairman of the Department of Medicine to work and teach in the Casualty Ward.

And later on Wednesday I was standing on the endocrine ward with Dr. Fred and four fresh interns looking at a man who was dying from multi-organ failure. It appeared to me that the man’s liver and kidneys had shut down (it would have been hard to tell for sure since the only laboratory test the patient had had completed in his nearly 24 hours in the hospital was a fingerstick glucose which was mildly high—hence his admission to the endocrine ward). I talked about trying to rehydrate him without putting him into heart failure, and then, when asked, about some of the more invasive options available ‘in my country.’ After which Dr. Fred said wryly, ‘okay guys, get him on hemodialysis and sign him up for a liver transplant… but in the meantime, see if you can get him transferred to the Renal ward.’

I don’t know. Maybe Sarah, by her inactivity, was trying to save me from myself.

It's so hot...

4 February

It has been hot this week.

I can hear you chuckling to yourself. ‘Doh. You’re in Africa.’

But even my Ugandan colleagues are complaining about the heat. They sit in their offices and fan themselves, still looking cool and crisp in a shirt and a tie and polyblend slacks, while I’m standing in a puddle of sweat and my rumpled cotton aloha shirt is clinging to my chest. Complaining about the weather, it would seem, is a universal pastime. For months we’ve been whinging about how long and wet the rainy season has been (as you, back home, have been complaining about how cold, or damp, or snowy it has been), and, now that the rains have relented, we can only complain about the heat.

Generally any complaint about the heat (or the rain, or the recent unpredictability of the seasons) will be followed by a gentle jibe about how the excesses of the developed world (me) is ruining the lives of the people in the developing world (them). And it is pretty hard to put up much of a defense. Even though I walk and take shared minivan transport for the bulk of my travel here (okay, the occasional bota bota… but I don’t have my own official white Land Rover with NGO insignia and driver), I think just the number of intercontinental flights I have made in the past year alone means that I am still, even here, perched on an untenable carbon footprint. And, of course, that footprint over the course of my 48 years… well… It would be pretty mean of me to point out that the goal of just about every man, woman or child I have met here in Uganda is to have a carbon footprint exactly this size or larger, so I just nod my head and mumble what passes for apology and commiseration.

Foam rubber mattresses don’t breathe. Just in case you were wondering. So for us mzungus over a certain age and body mass this means waking up in a pool of sweat about 3 or 4 in the morning and gaining appreciation for the morning sounds—the sounds that come even before the roosters and the call to prayer from the Kibuli mosque: the clicking and cawing of the night birds (Roger assures me that some birds sing at night—despite the training I received in my youth from a Daniel Boone episode—Fess Parker is explaining to a soldier how to signal by using a bird call. The soldier asks how he will know if it is the signal or just a bird. Mingo (Ed Ames) gives the soldier a withering look, ‘birds don’t sing at night…’), the gecko hunting on my screens (and occasionally on my mosquito net), the dogs prowling and yowling on the perimeter…

And so I drag myself from sodden sheets and wander around the house waiting for it to get light. I have some granola and head off down Kuta road toward the hospital. The other morning I heard singing, chanting, and the thumping of feet and sticks. I thought it a bit early for the church. Especially with not one hallelujah. Around the corner came a group of Tiger Security recruits (I’m assuming this since the man drilling them was wearing the paramilitary uniform and insignia of the Tiger Guard, and if they were full fledged guards, they would be hard at work behind the gates in kampala) jogging barefoot in formation carrying fenceposts. They were stripped to the waste and smeared in mud. They must have been running up from the Namuwongo swamp, as most of the mud in our neighborhood dried up weeks ago. The instructor barked a command and they all made their best menacing warrior face and raised their sticks overhead—ready to bash me 20 times over as they flowed around me on both sides. The kid at the back of the company gave me a sheepish smile and a nod.

The toilet turkey is back. (I saw a young boy kick him on thanksgiving day near a row of pit toilets on my way to work) He had been missing upon my return in January, so I had assumed he had wound up on someone’s Christmas platter. But the other morning he was there, tail feathers fully arrayed, patrolling the latrines.
The toilet turkey’s neighbors squat in the courtyard washing themselves with clothes and small buckets of water. I can only imagine how hot it gets inside the plastered brick huts with the metal roofs.

I cross the street and nod to Patrick at the hospital gate. Moses and Setchay(sp) are standing by the ambulances.

Moses looks to the sky and nods. ‘It’s going to be hot today.’