Now , you have to appreciate how Uganda's health care system is set up. Ideally, there is a tiered approach with health care centers. The smallest centers would be closest to the village but have the narrowest spectrum of clinical services. As you move up to regional hospitals, they offer more services but are further away from rural patients. For example, if a health center 2 ( which joy hospice technically falls under) needs to refer a gi bleeder , they would move up the system and refer to somewhere like regional hospital, for a scope .
There's a good article explaining this for another town:
The highest referral would be to Kampala for the national hospital.
The sort of kink in this system is that while the regional hospital certainly has more staff and government support , it doesn't mean the care is necessarily better or focused. This is not to slight them, but it's a matter of staffing/ patient volume/ acuity and resources. This speaks to Dr Jan's patient centered care and a great staff at Joy Hospice. The fact that I may be able to manage chf in a ten bed unit at hospice better than a district hospital ...is crazy. It's also humbling and sad.
So we all headed to the regional hospital ,after procuring permission from the hospital director , to shadow / observe the pediatric units. The permission was vital, as we found out that some visiting person had been arrested for taking pictures / touring with consent/permission .
The pediatric units at regional include a general unit, an HDU (high dependence unit ) and a ward split by age groups .
We showed up a few minutes before 8am to catch ward rounds. Now, factor in the Uganda / Africa time factor and we finally saw some house officers by 9am. In the meanwhile I'm going to switch to stream of conscience mode ( as I couldn't take pictures ) so ill try to paint on with my words / awkward writing.
-begin-
So we take our usual back path / dirt road with signs that warn about a fee for public trash and/or urination. People are cooking on the side streets. We pass a sign for public restrooms . Every once in a while, we pass a stray dog, usually sleeping in the sun which is starting to warm up. As we reach the regional hospital, we can see the bodaboda drivers arriving with patients/ employees and waiting for people leaving .
The hospital itself consists of many wings / buildings. There are names like ENT/orthopedic wing, Masaba wing, casualty wing. The wings are connected , more or less, by a walkway . The walkways are constructed of pipe, aluminum siding and some wood. There is a series of drains running parallel to the walkways. There's occasionally some fencing, presumably to keep chickens/ dogs away from patients? The buildings themselves are okay. Quite a few of the have at least one broken window.
Now what about the patients and their families? They are scattered throughout the hospital walkways. In the morning, many of them are preparing / eating breakfast. People have bins of boiled eggs. Some have porridge. Their linens/clothes is laid out on the sun covered grass for drying . Lines start to build as a queue forms. Mothers hold their children close to them. The hungry or irritable child is quickly placated with an exposed breast. Now, being my third week in Uganda , this doesn't startle me quite as much. At one point, Ashley told me she happened to walk past me while I was interviewing a patient and this lady who had lifted up her shirt for the exam stayed uncovered for the duration of the interview. She didn't seemed bothered In the slightest , with "everything all hanging out."
So anyway, breast is best and be it far from me to suggest any sort of breast feeding impeding behavior. Not like in the us where you see this :
Yeah , that doesn't exist here.
So as we wait for house officers , several hilarious things happen. The first, a chicken kind of strolls into the waiting area for pediatrics and clucks around for a bit then disappears. Now something about random chicken appearances and chickens general behavior is very amusing to me . The second thing that happens involves a ginormous moth creature . Apparently, unbeknownst to me, a large (maybe 2/3 the size of my hand) moth had attached itself to my black backpack, camouflaging itself . Dr downs drew attention to this ... By standing up and pointing and saying "WHAT IS THAT?!" While my first inclination would be to say my backpack ( a slightly sarcastic reply), I lowered my gaze and saw this moth thing whose size may rival some small birds. I walked over to the fence with my backpack and dislodged this behemoth. It landed on the ground and fluttered a bit with its wing things. At this point I left to sit back down. Our friend Eric continued to watch the bug who started to fly off. Simultaneously a surveilling bird spotted the insect and swooped down to eat it. After one failed attempt, he caught his prey and ... Finished him. It was national geographic worthy. Eric was astounded , as were.
As an aside , we also had a janitor incident. So while waiting for the house officers, a gentleman was cleaning the floors. He pragmatically cleaned each segmented. Having spotted us, he politely motioned for us to reposition to the other side while he mopped which we obliged. During this time, some moms(and their respective kiddos) started to line up. However, their passage into the ward would violate / trespass the newly wiped floors mr. Janitor would not tolerate such a thing. He went as far as to physically scoot a bench and block off the corridor , right in front of this lady. It was hilarious, if only you could hear Ashley tell the story.
Shortly after this Darwinian drama, we met the house officers who'd be rounding .
We split into two groups , one would go to general ward and the other to the HDU (sort of a picu).
HDU was intense, depressing, humbling all at the same time.
Our first patient was a newborn with resp distress. Imagine a small child who frankly is ashen in color , slightly cyanosis and limp. What appeared to be an NG tube in his left nare was actually his oxygen support. I asked our house officer about this and he explained that they've managed to an oxygen concentrator to an empty dextrose container via iv tubing. Coming off this dextrose container is feeding tubes arranged almost like an octopus. Each of these tubes can be used for different patients. Since they lack nasal canula, they simply place the Ng tubes into the nare. There's no pulse ox, I looked . The only sign that this child was doing any different was that his breast feeding had apparently picked up. :(
Several other patients were in the HDU. Mostly resp distress of unclear etiology. Later , I'd find out they can't do blood cultures at certain times . After abx, they don't ever do cultures .
One kid that stuck out was a young girl with resp distress and significant syndromic features. He had displaced / dysplastic ears , jaw changes . Apparently she was admitted for this and a cardio eval. When I inquired as to whether she had a murmur, the house officer said not one that was mentioned. As such, I asked to listen and appreciated a loud 4-6/6 systolic murmur . Given the kids liver and resp symptoms , I figured it was probably a vsd.... But nothing to do...
We then visited the general ward, not too much to say there . Our last stop at regional was to the general ward which was short lived given how busy it was . The interns/house officers were stretched and had little time to devote to visitors , which we could appreciate given the acuity and numbers.
So, prior to concluding our visit at regional , I had stepped out of the wards for air and to purchase a water. En route , I happened upon a crowd staring at a lady in a ditch who appeared to be in distress. I weighed my options at this point : keep walking orrrr...remember that you're a doctor ..so I stopped. I inquired as to the situation and found out this poor soul had just lost her husband. In the midst of this she was alternating between hysterics and near syncope. At one point she passed out. I tried to get a gentleman who was standing by to help me to lift her to safety, to no avail. As such, I resolved to get my bottle of water out and instruct the ladies closest to her to give her the water to drink and splash her face. I was concerned shed eventually have a heat stroke in the sun. At that point, she looked a little more alert and I rejoined the gang.
-never a dull moment-
So then we stopped by Joy Hospice for a bit, to help out a little. I decided to finish up inpatient rounds as the clinic officers got busy with outpatients. The most interesting patient I saw was a 16 yo girl newly diagnosed with HIV. Based on her parents premature death , it was assumed to be vertical transmission ( from mom to child). However, in true art of medicine / old school for , I retook bits of the history and realized she had prior partners of unclear hiv status and inconsistent barrier protection so this very well could be acquired from such. So, I proceeded to explain hiv as a virus and how this virus attacks the cells of the immune system over time . When this overwhelms the cells , you can get symptoms like other illnesses,fevers, weird rashes, loss of appetite . I explained that we have to treat these infections and then begin attacking the virus with meds. Once the virus goes down and the immune cells return, she should feel better. The last thing I mentioned to this poor girl was making she informs these men about her status when she can safely do so.
This was one of the sadder cases I've dealt with. I had to counsel her via translator and reassure her that we value her confidentiality and want her to get better and strive to do that.
One of my concerns was this diffuse skin rash all over her body. My first thought was to r/o syphilis . Rpr nonreactive, thank goodness.
And so ends the day. There's a sharp contrast between a very unique care at joy hospice and the over stretched / taxed regional hospital.
All I can say is that I was humbled and grateful for what we have at home, be it flawed and imperfect.
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