Sunday, December 28, 2014

Building Surgical Partnerships in Uganda

Uganda Blog

It is my first day in Uganda.

I spent the last week in Dubai working on the Lancet Commission on Global Surgery.  It was a wonderful week.  I got to meet some of the leaders in global surgery, many of them my heroes in this new field we are trying to define.  We spent every day going over the reviewers comments on our commission report and discussing how to address those comments.  Every evening was a chance to meet and talk with the commissioners and every evening was spent soaking up the many distractions Dubai has to offer.  It was a full and exhausting week.

At the conclusion of this exhausting week I got on a plane for Entebbe, and the next phase of my global surgery journey.  I arrived in Entebbe and was immediately reminded on the biggest issue in health on this continent – Ebola.  As we entered the airport we were immediately greeted by nurses in masks and thermometers checking us for signs or symptoms of infection.  Even here in Uganda, thousands of miles from the nearest cases in West Africa, the fear is present.  Perhaps it is not without some merit.  Uganda has had several small outbreaks of Ebola over the last few decades and just a few weeks ago a case of Marburg was discovered not far from here.  Still, the scene at the airport seems more of a show of force than an actual public health measure.  I’m not sure how well the thermometers work and the questions are rudimentary at best.

From Entebbe our group will head to the Mbarara, the largest town in Southwest Uganda.  My companions on this trip include Dr Jim Cusack and his wife.  Dr Cusack is a surgical Oncologist at MGH and the faculty leader of our Global Surgical Iniitiative.  Tiffany Chao is a 4th year surgical resident how is very experienced in global health and will spend a month in Uganda on a clinical rotation.  Charles Liu is an HMS student who is taking a year off to do work on a surgical database in Mbarara.  Charles has already been in Uganda for 5 months and just left for the week to attend the conference in Dubai.  Finally, there is Liz, a medical oncologist from Boston who spends much of her time in Botswana.  She is traveling to Mbarara to help us with discussions about starting a cancer center in the town.

On our car ride to Mbarara we stop at the equator.  I realize that this is my first time crossing the equator on land.  If I were in the navy we would have a line crossing ceremony and I would now be a shellback and no longer a pollywog.  From what I have heard of those ceremonies I am glad I am not in the Navy.

Today we arrived in Mbarara and had quite the welcome at the MGH guest house.  There is a reasonably large number of ex patriots in town this week and we arrived just in time for a dinner party.  There were about 25 ex-pats in attendance and we had beer, corn hole, several people broke out guitars and we feasted on steaks and bananas foster.  This was not the type of food I was expecting in Uganda.  I’m a little concerned it will be all down hill from here!

Today we start the process of partnership building.  This will be a large part of my mission here on this trip and will be the focus of our first few days.  We started our meetings with the leadership of the hospital.  I have learned that this type of partnership, especially in Ugandan culture, mandates many formal meetings with all the key people, and many of those who will only pay a peripheral role.  The meetings went fairly well today and we will have another full day of meetings tomorrow.  The goal of these meetings is to establish a formal partnership between the departments of surgery at MGH and at Mbarara University of Science and Technology (MUST). There is actually a slightly complex leadership structure here because the hospital – Mbarara Regional Referral Hospital (MRRH) and MUST have separate leadership structures, separate employees and separate pay structures within the same hospital.  This exists because MRRH is under the Ministry of Health (MoH) and MUST is under the Ministry of Education (MoE).  I will have to learn to navigate this complex arrangement if I am going to be effective here.

Our second evening in Mbarara was just as fun as our first.  Tonight we attended an “aerobics” class, my first ever.   It was in a nightclub, the class was full of overweight, middle aged Uganda’s in all ranges of dress.  The class started with “Call me Maybe” and the music just got better from there.  We did all kinds crazy exercises including arm swinging, back arches and running in a circle.  It was amazing.

Today I attended morning rounds in the Accident and Emergency (A&E) department prior to our meetings.  It was an insightful glimpse into the type of pathology I can expect to see while working here.  There were several patients that needed to go to the OR.  Unfortunately, for the third time in five days the OR’s were canceled for all but the most emergent cases as the hospital had no power.  Over the past several months this canceling of OR cases has been a common occurance.  Even if the hospital has power it frequently runs out of oxygen or halothane or other items essential for surgery.  I have learned that even though most cases here are done under spinal anesthesia, and therefore require no oxygen, the anesthesiologist will not do a case unless there is oxygen as back up in case the case can’t be done with just a spinal.

Today we had power, oxygen and halothane!  Tiffany was able to do several cases.  She did 2 craniectomies with one of the surgeons here that has had extra training in neurosurgery.  There is a huge need for neurosurgery here.  Much of this need is driven by the huge burden of motorcycle trauma.  The majority of the vehicles on the road are motorcycles, or Boda Bodas.  These are invariably used as taxis, always without helmets and driven on poor roads without traffic rules.  The result of this is numerous closed head injuries and the need for neurosurgeons.  This is further complicated by the problems with the CT scanner.  MRRH has a CT scanner but it has been down for the last several months.  Even when it is running there is often no IV contrast.  So now, if a patient needs a CT of their head after getting in a Boda Boda accident their family needs to go sell some possessions, carry their loved one into town, get a private CT scan and bring back the patient and the films to be reviewed in the hospital.

We left to head back to Kampala today.  We are attempting to establish a Cancer Center in Mbarara.  Currently, there is only one center in the country, the Ugandan Cancer Institute (UCI) in Kampala.  The Ugandan government is interested in establishing several regional cancer centers and they want the first one to be in Mbarara.  We met with leadership from the MoH and the UCI to work on plans for this center.

Today we went to the national referral hospital in Kampala.  This is the largest and best-equipped hospital in the country.  It is also associated with a medical school – Makerere.  This school and hospital has established partnerships with several US academic centers including UCSF and Yale.  We met with the leadership of the Department of Surgery there to learn more about their partnerships and also to see how we could work together on a more national scale.  In particular, we are interested in trauma education.  The surgeons at MUST told us that it is their number one priority and asked us for help.  We met with the surgeons at Makerere and they would also like help in training their trainers for the trauma and critical care course they have developed for their surgical residents.

I said good-bye to Dr Cusack, his wife and Liz yesterday as they departed to head back to Boston.  Today I will journey back to Mbarara.

Most of our meetings are now complete and today I transitioned my focus to clinical and research work.  On rounds we found a man that had fallen off a ladder two weeks ago.  Since then he has had a swelling in the left upper quadrant of his abdomen that has gotten larger and larger and was associated with pain an bruising of his abdomen.  It is clear, even without the aid of modern imaging technology, that this man has a splenic injury and a dangerously enlarging hematoma.  He taken to the OR later that day for a splenectomy.  The hematoma ruptured intra-op which made the operation more challenging especially since they had no suction in the OR.

On rounds we also found 3 Boda Boda accident victims, a man with penile cancer, a man who was attacked by someone throwing acid on his face, a perforated gastric ulcer that also went to the OR and a child with septic arthritis of his hip.

After rounds Tiffany went to the OR and I went to ward rounds to help out the intern.  Every morning after A&E rounds the interns are divided up to help in the various areas of the hospital.  This was our first morning with interns as they have been on strike for the past month.  It is the end of November and the interns have not received a pay check since they started in July.  After a month of strikes the government finally agreed to pay at least two months of the interns salary.  This was enough to end the strike and today we have 6 interns on our team. 

These are not surgical interns.  In Uganda, after medical school a new doctor does a rotating internship spending several months on medicine, surgery, OBGYN and pediatrics.  After one year they are then sent to a district hospital to work for one to two years before they can go to residency.  Residency is typically three years, no matter what specialty you choose.  Further, fellowship level training, often requires leaving Uganda to places like Ethiopia, Nigeria, South Africa or Europe.  Few doctors get this level of training and of the ones that leave for this training even fewer return to serve in Uganda.

Today I helped one of the interns again on ward rounds.  One intern helps in the clinic, one in the OR, two stay in A&E and the last two go to the ward.  One rounds alone on the male ward and the other on the female ward.  Despite there only being 20 beds there are typically 30-40 patients on each ward.  Patients can be found in beds, behind beds, on the floor and every other place they can find a spot to lay down.  There is also only one nurse for each ward.  These nurses do not do the typical work we associate with nursing care in the US.  Rather, they function more as ward managers.  The families are the ones who walk the patients, help with their dressings and feed them.  If a patient needs a medication the family gets a prescription and then goes to town to buy the medication.  The role of the family, or “attendant,” is so important that often a patient will not be allowed to be admitted without one.

The highlights on A&E rounds today included a child with a perforated terminal ileum.  He was our third patient with this problem this week!  I have never seen this in the US except in cancer patients on chemotherapy.  After discussing this with the surgeons here in Uganda and doing a little reading I have learned that this is an incredibly common problem.  It is one of the most common reasons for a patient in Uganda to present with an acute abdomen.  The cause in most cases is presumed to be typhoid ileitis.  This is a condition leads to terrible morbidity and is associated with a 30% mortality.  This is such a big problem with so much room for improvement in management that it has been highlighted as an area for research by the surgeons here in Mbarara.  They want to start a randomized controlled trial to compare different surgical techniques for managing this disease.  They have asked for help from some of the surgeons and residents at MGH with the design and conduction of this trial.  I am very excited to be part of this project.  Often research work in the US means changing a wound infection rate from 3.2% to 2.9%.  But here in Africa we have the chance to make a difference in serious morbidity and mortality.  This trial will certainly have challenges – it will involve two IRB’s on different contenents, we will have to consent patients in their own language (and Uganda has many), we will need someone available at all hours to help with the study protocols and we will have to get the surgeons to agree to take this extra step in patient management.  This is not a small task for a system and surgeons that are already heavily over burdened by just the usual patient care.

            Today was a busy one for A&E rounds.  We saw a perforated gastric ulcer, an adhesive SBO, a closed head injury (CHI) after a car accident, a patient with a CHI after falling off the back of a truck, a young woman with gastric CA, a man with ascities from metastic cancer of some type, two Boda Boda accident victims with CHI and one with a femur fracture, and urinary retention from benign prostatic hyperplasia (BPH).  This last gentleman received a suprapubic catheter to drain his urine.  There are almost no urologists in the country and patients with BPH have no surgical options.  Their prostate has grown so large that it has completely blocked off their urethra and they are unable to urinate.  The bladder swells causing pain and urine back up can lead to serious kidney damage.  In this resource constrained setting these patients are treated by inserting a catheter directly through their abdominal wall into the bladder.  For these patients this catheter becomes a permanent part of their abdominal wall.

            Today was another busy one in the OR.  There was another child with a perforated terminal ileum. He was taken to the OR for a bowel resection and a temporary ileostomy.  After the OR he was taken back to A&E.  There is no post operative anesthesia unit (PACU) and patients on the ward receive so little care that it is only suitable for the most stable patients.  All but the most stable post operative patients go back to A&E for monitoring for one to two days.  Sick patients that are discovered on the ward are also transferred back to A&E.  This is the only place in the hospital with a doctor and a nurse available around the clock.

            It is another weekend and this time I head with a group from the MGH guesthouse to the impenetrable forrest to trek for Gorillas.  The forest was never reached by the last ice age and is therefore one of the oldest in the world.  After hiking with a park ranger for about three or four hours through dense forest we find a family of gorillias.  The family is 10 gorillas headed by a dominant male “silver back.”  There are only 900 mountain gorillas left in the world.  Almost all of these are in this region of Africa in the mountains of Uganda, Rwanda and Democratic Republic of Congo.  We got within five meters of these massive animals.  It was an amazing experience.

            After returning from the trek we made it back just in time for the huge Thanksgiving celebration.  We invited all the ex-pats in Mbarara over to the guesthouse for a huge dinner.  About 40 people showed up for a pot-luck style dinner.  Good food, drinks and friends.  If you can’t have thanksgiving with your family back in the US, surely this is the next best thing.

            Sunday’s highlight was a game of Frisbee in the afternoon. 

            Tiffany went back to Boston over the weekend so I am the sole MGH surgical representative left in Mbarara.  We had another patient on A&E rounds with “peritonitis.”  Here in Mbarara imaging is often not an option so a patient that presents with peritonitis often gets a trop to the OR.  This surprised me and thought there would be a significant number of negative explorations but serious pathology is almost always found.  This is not universal; I did witness an exploration for pancreatitis last week.  But that is the only negative exploration I have seen so far. 
            I helped one of the Ugandan surgeons in the OR with the patient with peritonitis.  After opening we found a sigmoid volvulus with necrotic colon and feculent ascites.  We performed a Hartman’s procedure and then transferred the patient back to A&E.

            We rounded on the volvulus patient from yesterday in A&E.  He was doing well and appeared very stoic.  I asked about his post operative pain regimen.  I was again surprise to learn that the typical regimen for patients is rectal Paracetemol.  And that’s it!  Opiates are hard to find and when they can be given they usually are not because patients cannot be monitored closely.  All of these patients who get large open operations for severely painful conditions suffer soundlessly with just Tylenol to ease the pain.

            All the OR cases were canceled again today because the hospital was out of oxygen.  Since I couldn’t help in the OR I went to ward rounds.  I met one of the interns who had just admitted a patient to the ward from clinic who had a large inguinal hernia.  I asked why he was being admitted instead of being scheduled for an elective operation, as we would do in the US.  The inconsistencies with power, oxygen and Halothane make it incredibly difficult to schedule elective cases.  It is often easier to admit the patient to the ward and have the patient wait, often for many days, until OR space opens up and they can get their operation.

            After rounds this morning I went across the street to a coffee shop and restaurant known as the Ark.  This is one of the few places with free wifi and good food and is therefore tremendously popular with the ex-pat community.  I was able to skype into my weekly meeting with the Program for Global Surgery and Social Change in Boston.  The connection was choppy but got the job done.

            For dinner I met with some of the leadership in the department of surgery here to discuss the development of an annual membership agreement.  We drew up the draft of a document that would lay out the plans for the partnership between MGH and MUST over the next year.  This is a non-binding document that will allow us to put our goals down on paper and then have a benchmark that we can use at the end of the year to evaluate how the partnership has progressed.  I will bring this draft back to Boston with me and we hope to have a final copy signed by both departments by year’s end.

            I was helping the pediatric surgeon and a visiting pediatric surgeon from Candada with a recto-vaginal fistula case.  This condition can occur in children infected with HIV.  Towards the end of the case one of the interns came up to the OR for help.  There was a patient down in A&E in respiratory distress.  This patient also had HIV and had a massive purulent pleural effusion.  The intern needed help placing a tube into the patient’s chest to drain the build up of pus that was making it difficult for the patient to breath.  I scrubbed out of the case and left to help the intern.  On the way down to A&E the intern informed me that the hospital was out of chest tubes.  We put our heads together for a few minutes and came up with the idea of using an endotracheal tube as a substitute.  This is a tube typically placed down a patients throat to help with breathing.  I had never improvised a chest tube like this but after finding a large endotracheal tube I thought it was worth a try.  We found the man in significant respiratory distress.  He was emaciated and covered in Kaposi’s sarcoma lesions, another visible hallmark of late stage AIDS.  I was surpised to see how well the endotracheal tube worked as a chest tube.  Almost immediately the tube drained several hundred millileters of pus from the man’s chest.  His breathing improved instantly.  The next issue was no pleuravac (a chamber used to collect the pus and as a one-way valve for the chest tube).  Using some suction tubing, tape and a couple of water bottles we were also able to improvise a container for the chest tube.  Amazingly, the whole contraption worked remarkably well.

            My time in Mbarara is almost over.  I spent the morning packing and played another game of Frisbee in the afternoon.  This evening I went out for a drink with one of the Ugandan surgical residents.  We discussed the challenges of practicing medicine in this setting.  I learned that he is very interested in research and we discussed how we could work together on projects in the future.  He seemed very interested in collaboration.

            I drove back to Kampala today.  I got there in time to meet up with Lisa, an infectious disease and critical care resident at MGH who was spending the year in Mbarara.  She had been in the US for Thanksgiving and was on her way back.  We had dinner and discussed the challenges with doing research projects in Mbarara.  She gave me some excellent tips on getting grants and working with the Ugandans on research.

            I had went back to Mulago, the National Hospital in Kampala.  I met with the surgeons again to discuss plans for our trauma team visit next year.  In the afternoon I drove on to Entebbe.


            This morning I got on a Rwanda Air flight to Accra and the next step of my global surgery journey.  There I will interview surgeons and educators in Ghana about their efforts to establish the Ghana college of Physicians and Surgeons.  They have had remarkable success in stemming the “brain drain” of physicians out of Ghana.  My goal is to learn how they were able to accomplish this and to write a case study about it.