Monday, November 28, 2011

Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara, Uganda

(2 of 3)

It has been a busy week in Mbarara.  Much of the first day in town was spent with introductions, meeting clinical faculty at Mbarara Hospital and academic administrators at Mbarara University (MUST) who help coordinate post-graduate training and the relationship between MGH and MUST.  The short meetings made me not only feel welcome but also gave me a better idea of the structure of collaboration here.  It is nice to witness the outstanding relationship that has been established between MUST and MGH by dedicated individuals from both sides.

On the first day in clinic, starting around 8 AM, the line of patients had already stretched a good distance outside the one-room clinic that has handwritten letters "ENT" on the door.  Multiple patients are seen in different corners of the room at the same time by the resident, attending, and clinical officer.  There is a nurse who directs traffic, calling in new patients when a seat opens up, handing charts or referral notes to free clinicians, recording all patient visits in the master log, translating when necessary, and seeing to it treatment plans are completed.  Patients carry in their own medical records, records that consists of a soft notebook in which clinicians have documented past illnesses and treatment plans.  The majority of patients have no records.  

The clinic flow is steady and efficient.  On a small table in the center of the room sit an assortment of medical instruments that are constantly being reached for; sometimes the absence of something needed is quite noticeable to me but quickly improvised.  When the power goes out, the head-mirrors used to look in mouths, throats, and ears can no longer be used.  I'm glad I brought several battery-powered headlamps so that the exams can continue.  

Most of the patients present with problems I've seen before; hearing loss, cerumen impaction, ear pain, foreign bodies in the ears or nose, hoarseness, trouble swallowing, tonsillitis.  Several patients are seen with more complex, less common issues, like a new presentation of laryngeal tuberculosis and several advanced head and neck lesions/cancers not yet fully diagnosed.  When clinic ends, I'm am eager to find Internet access to do some reading.  I have no idea how I would treat a suspected enlarging nasal dermoid cyst in a 4-year-old seen that day (a cyst that has about a 30% chance of intracranial connection) without access to MRI or a CT-scan, tests that would normally be used to exclude or delineate this possible central nervous system connection prior to surgical removal.  I am told that there is a CT scanner in the capital city of Kampala, a 5-hour drive away, but no one I ask seems too sure of the cost or wait time for a scan.  I am certainly, and perhaps predictably, being challenged to think in different ways some of the time here.

When I look back at the past week, I feel very grateful to my Ugandan colleagues for allowing me the opportunity to work with them.  As a junior resident in otolaryngology, I find no shortage of learning opportunities in Mbarara.  I also see opportunities to build surgical capacity in several areas related to otolaryngology here and am beginning to brainstorm the creation a few small projects with the outstanding MUST resident.  I hope to touch on these projects the next time I write.  

Kyle Chambers, MD - PGY-2
Harvard Combined Program in Otolaryngology-Head & Neck Surgery

Wednesday, November 23, 2011

Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara (1 of 3)

As travel goes, the trip to Mbarara, Uganda, had a bit of everything. There was delay in Kigali due to an airplane crash on the Entebbe runway, failure of my hotel shuttle to pick me up (with several taxi drivers unexpectedly unwilling to take me), and the theft of some of my medical equipment out of my checked luggage somewhere in-transit. But there was also the stunning 5-hour drive from Entebbe to Mbarara and conversations with the driver about traditional medicine in Uganda, the role of foreign mzungu doctors, and the Ugandan soccer team that barely lost a birth to the Africa Cup by 1 point to rival Kenya. The drive also gave me a chance to take in the warm, visibly tropical environment of southern Unganda as we crossed the equator and catch a glimpse of Zebras as we passed close to Lake Mburo National Park.

I've arrived in Mbarara as an otolaryngology resident given the opportunity to spend 2 weeks learning about ENT Surgery in Uganda and also with hopes of exploring possible future research and educational collaborations with Mbarara Univerisity of Sciences and Technology (MUST) and the affiliated Mbarara Regional Referral Hospital. Mbarara is home to approximately 150,000 residents with 500,000 people in the surrounding area. Mbarara Hospital serves as a major referral hospital for all of southern Uganda with an even larger catchment of unknown numbers that at times includes patients from northern Rwanda, Tanzania, and the Congo. As a hospital, it offers two operative theaters, two-four ICU beds, multiple over-crowded adult wards (by most accounts), and roughly 6000-7000 pediatric admissions to the pediatric ward each year. There are currently plans in place to build/open a new hospital that will reportedly offer 8 ORs and greatly improve the capacity to accommodate the large inpatient volume, expected to be completed next year.

By the numbers, otolaryngology in Mbarara is easily considered a needed specialty. Mbarara Hospital has 1 staff otolaryngologist, who has been a different cuban otolaryngologist every 2 years for some time now. This makes the ratio of ENT surgeons to population in Mbarara is very similar to that of the national average in Uganda of 0.06 ENT surgeons per 100,000 people (based on a 2009 study), which is remarkably lower than the 1:100,000 ration in the UK and the approximately 3:100,000 ration in the US.
Over the past several years, however, MUST has been trying to alter this deficit in ENT surgeons by starting a residency program with the goal of training and retaining otolaryngologists to serve southern Uganda. There is currently one resident in her post-graduate year three of four years with hope of bringing in a second resident soon.

Having arrived in Mbarara, with this background in mind, I am very excited about the days ahead.

Kyle Chambers, MD - PGY-2
Harvard Combined Program in Otolaryngology-Head & Neck Surgery

Wednesday, November 2, 2011

Ethiopia, the land of thirteen months of sunshine

Project: Surgical Capacity Assessment in Ethiopia
Partners: Harvard Humanitarian Initiative, MGH Department of Surgery, Harvard Program in Global Surgery and Social Change, Global Surgical Consortium

Ethiopia, the land of thirteen months of sunshine, is big.  Huge, in fact.  I spent this past October in  Ethiopia, crossing huge distances in planes, cars, and buses, visiting hospitals to administer a surgical capacity survey with the Harvard Humanitarian Initiative.

Visiting one of the hospitals in Debark with one of my co-researchers
After spending a couple days at the Ministry of Health and at Black Lion Hospital, working with the MoH Medical Director, Mr. Abebaw, and our local author, a pediatric surgeon named Dr. Miliard Derbew, we plotted out a rough idea of our country tour and then set about figuring out what combination of plane, bus, and car would get us where we needed to go.  It turns out that we needed to fly a LOT; I ended up taking eight domestic flights this month!  Fortunately, Ethiopian Airlines is quite good and, more importantly, inexpensive.

One of our many domestic flights required to reach hospitals around the country,
which is over one million square kilometers!
What we discovered through our travels is that hospitals in Ethiopia are distributed unevenly throughout the regions and city-states, with resultant disparities in physician:patient ratios in different areas.  Unfortunately, this limits the ability of many patients to access hospitals, particularly hospitals where surgery was available.  Though they frequently had access to primary care, the limited availability of surgical capacity translated into huge problems regarding obstetric care and trauma emergencies.  When patients are traveling by foot and camelback, the huge distances prove a problem.

Camelback is an acceptable alternative to an ambulance
While we also discovered infrastructure deficits, we were impressed by the creative workarounds that were developed.  Not only did we find the typical adaptations like electric generators and headlamps in areas without electricity, but we found air conditioners used to refrigerate medications, or living blood banks in areas without blood banking ability.  The ingenuity of the doctors and hospital administrators certainly was to be applauded.

Other than that, the country was a great pleasure to travel around.  We were able to experience a lot of wonderful things in Ethiopia, notably the wonderful coffee ceremonies.
Coffee ceremonies involve roasting green coffee beans, grinding them, and then cooking them over coals
Of course, no story would be complete without mentioning the incredible hospitality of the Ethiopian people we met, particularly the families, patients, and all the medical personnel we were able to meet with!

A gift from an Ethiopian family to keep warm; Ethiopia was surprisingly temperate!
Now that I'm back in Boston, I'll be taking some time to reflect on our experiences, but I will never forget this incredible month I spent in Ethiopia.

Tiffany E. Chao, MD, MPH
MGH Dept of Surgery PGY3