Monday, February 17, 2014

Collaboration in Pediatric Medical Education and Clinical Care in Mbarara, Uganda

I walk into the admissions room for the “Toto” Pediatric Ward at Mbarara Regional Referral Hospital in Uganda and the intern on-call looks up at me with an anxious smile.  In this room there is a small bench, where two mothers sit with their toddlers, prostrate on their laps, one tachypneic, the other pale with visible scleral icterus.  The intern is admitting both children - checking vitals, writing admission notes, placing orders, inserting IV catheters, and ensuring these two patients receive their medications promptly.  I glance over at the single exam table where there is a small bundle – I lift the blanket and find two premature twins, each less than 1kg, swaddled together under a bare bulb for warmth.

As I begin to help him assess the needs of these tiny twins in respiratory distress, a nurse walks in carrying another bundle.  Lifting the cloth we find another set of premature twins.  These are larger and breathing on their own, so while they will need IVs placed, infusions to prevent hypoglycemia, antibiotics, and a full assessment in time, for now we re-wrap them and place them next to the first set of twins.  The intern returns to rapidly completing his assessment of his other patients, but only a few moments pass before a mother brings her child over from the ward – she is a toddler with cerebral palsy, severe acute malnutrition, and now a rash that appears to be disseminated varicella.  She is concerned and there is nowhere else for her to go, so she places her crying child in the last few inches of space on the exam table.  Just outside the room, caregivers sit patiently on a bench with their children, many of whom appear quite ill and have travelled a great distance to seek medical care, awaiting a doctor’s attention so their child may be triaged and treated as well.

Admissions Room in Pediatrics Ward at MRRH

This is a fairly typical day at Mbarara Regional Referral Hospital (MRRH), a governmental district referral hospital in Southwestern Uganda affiliated with the Mbarara University of Science and Technology (MUST).  Many departments from MGH have well established partnerships with our colleagues here with ongoing research, education, and patient care collaborations.  Given the partnership between the Pediatrics Department at MRRH/MUST and MGH is newer and continuing to grow, I feel fortunate as a resident in the MGH combined Internal Medicine-Pediatrics residency program to have the opportunity to work and participate in medical education initiatives here. The majority of my time thus far has been spent working in the Pediatrics ward, specifically the acute inpatient and malnutrition wards alongside the Ugandan post-graduates (residents), interns, and medical students.  My mornings consist of rounding with the team and co-teaching with the post-graduate, and the remainder of my time is focused on medical education.  Practically speaking, the greatest need has been in precepting the medical students on their presentation skills, reviewing case write ups, teaching physical exam skills, reviewing the approach to generating a differential diagnoses, and discussing management strategies for the myriad diseases being treated on the ward.  Additionally, I have been assisting the interns, who have just started their pediatrics rotation, with developing their skills in performing assessments and determining initial management of critically ill children newly admitted to the wards. 
View of the Mbarara Regional Referral Hospital on arriving in the morning

The pressures placed upon this already resource limited system are unbelievably high.  The “Toto” Pediatrics ward functions as the pediatric emergency room as well as the inpatient ward for all medically ill neonates and children at MRRH.  They admit anywhere from 15-25 children daily, many of whom are critically ill with conditions including cerebral malaria, severe sepsis, cyanotic congenital heart disease, severe acute malnutrition, ingestions, HIV/AIDS, and complex rheumatologic and oncologic conditions.  Each morning the interns report on whether or not supplies were adequate to provide care to the patients.  It is not infrequent that they report inadequate antibiotic coverage due to the hospital supply being depleted, lack of oxygen when the power driving the concentrators shuts off, shortage of forms for documentation and lab requests, inavailability of blood for transfusion, or absence of proper tubes needed for lab specimen collection. Many sub-specialty services or supplies not available at MRRH are accessible privately in town or in Kampala, however, this oftentimes is not an option financially or logistically for many families. 
Room for care of premature infants - currently empty for cleaning, the infants were waiting outside with their caregivers.

I cannot overstate how devastating it is to watch children die from diseases you know could have been prevented with earlier evaluation or treated with increased access to resources.  You can’t help but be struck by the inequity in the disease burden here – a mortality rate of 90/1,000 for children under 5, 76% of which has been estimated to be caused by preventable or treatable infections (WHO, Uganda ICCM Implementation Guidelines 2010).  But in truth, the most prominent thought I have on a daily basis is how smart, resourceful, and resilient my Ugandan colleagues are.  Despite being faced with a healthcare system that can be so complex and unpredictable, each day the post-graduates arrive smiling, inquisitive, and enthusiastic (albeit fatigued at times) about teaching, learning, and caring for an endless flow of patients.  Each day on rounds the post-graduates relentlessly push the medical students to definitively characterize an abdominal mass on palpation, rate the severity of digital clubbing, or outline the WHO algorithm for the inpatient management of malnutrition.  Modern medical advances and technology have certainly revolutionized the way we care for people to tremendous benefit, but I can’t help but wonder whether in more financially resourced settings we underestimate the power of our human resources.  There are limitations and frustrations encountered daily here, but the vast majority of the providers I have worked with find a way to maintain perspective, care for each child to the best of their capacity, and try to learn from the adverse outcomes.  These resilient, dedicated individuals are invaluable, and certainly have all the skills to be the leaders of future systems improvement. 

Outside the Toto Ward, caregivers have washed and are drying clothes.
Many caregivers will sleep out here at night, or on a mat on the ground near their child's bed.
I have only been here a few weeks and have just two weeks remaining, but even in this short period of time it has been a privilege to have the opportunity to support my colleagues here in Pediatrics.  I will have the opportunity next week to travel to Bugoye and work in a rural level three healthcare center where I will be able to learn more about the work of the clinical officers and village health workers, who are the backbone of the healthcare network for so many Ugandans.  As much as I spend my time teaching and sharing whatever I may have to offer, I hope my Ugandan colleagues have learned half as much from me as I have learned from them and am very thankful to the Partners Center of Expertise, MGH, and MRRH/MUST for providing me with this incredible opportunity.  

Meredith Eicken MD
Internal Medicine-Pediatrics, PGY-3
Massachusetts General Hospital

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