Monday, March 6, 2017

Resiliency

Scott Nabity, MD, MPH
Resident in Medicine-Pediatrics at MGH
Pediatric Hospital Care in Uganda
PGY 4

January 24, 2017

This trip makes the third month-long tours at the teaching hospital of the Mbarara University of Science and Technology (MUST), including one adult and two pediatric ward rotations. A recurring theme of respect that I reflect upon with each visit is the resiliency of the patients, their families, and the hospital staff in the persistent effort to get sick patients, particularly the children, well again.

“Rosy” is one such patient. She is approximately 12 years old and, like too many adolescents in Africa, suffers the effects of rheumatic heart disease. Her disease is severe and local doctors are working to arrange a valve repair internationally. I first met Rosy exactly one year ago when she was previously admitted for decompensated heart failure. It was a surprise to see her again this year, her planned surgery delayed by complications of coordinating a transnational care plan. In the crowded space of the pediatric ward, I found Rosy again in decompensated failure. She lay even more wasted, unable to sit upright, working to breathe with taut ascites. She and her family spent day after day waiting for the diuretics to take effect. We gave her oxygen but mostly she found respite by assuming a prone position with her knees tucked tightly beneath her and her forehead pressed into her palms resting on the bed. This was the position I typically found Rosy morning after morning, with parents and little brother at the bedside, until she slowly experienced some improvement. Her parents never complained, and neither did Rosy. Their only immediate request was to have a photo of Rosy to share her progress with villagers, the feasibility of any surgical intervention uncertain.


Families preparing meals and washing clothes on the hospital grounds, which also serve as sleeping spaces. Caregivers are responsible for providing food, bedding, and many medications/medical supplies for patients.

While the stamina patients like Rosy exhibit is incredible, perhaps I can more realistically appreciate the resiliency of the resident doctors. For those of us fortunate enough to train in the bounty of a Boston hospital, facing the quotidian diagnostic and therapeutic limitations of the Ugandan public hospital can be paralyzing. Much of our training simply doesn’t translate, particularly when diagnostics are not available. Further, the volume and acuity of pediatric patients at home pales in comparison to that in the Ugandan context. In fact, a substantial proportion of the daily admissions would be triaged to an intensive care unit in the US, an extremely thin resource in Uganda. Many of the severely ill children we could easily support to wellness in the US just do not survive at this hospital. Childhood death, while never unremarkable, is not a rare event.

This reality is seated in stark contrast to my pediatric exposure back home. The frequency of child deaths I’ve experienced at my hospital over nearly 4 years of training was generously exceeded by fatalities in a 4-week period in Mbarara. When children die, the volume dictates that residents move on to the next sick patient, which seemingly takes its toll. Deaths are reviewed and prevention strategies are discussed. However there are no vigils, no special forums, and there are no psychosocial rounds. The work simply continues. And I presume at the end of the day, the doctors in training hug their own children extra tightly.

Pediatric residents and medical students providing post resuscitation care to a child who developed hypoxemic cardiac arrest during morning rounds. The boy eventually died.


My training programs have implemented a number of measures to retain humanity and resilience in medicine, going so far as to periodically insert group meditation sessions in place of the traditional learning conference. Physician trainee burnout in the US is a serious and growing concern, and our leadership is attempting innovative means to combat it. Indeed, our training is rigorous but our experience with dying children is unequal. I admire the work of our Ugandan colleagues. And with each visit I appreciate more the relative luxury we have in keeping most children healthy in Boston, as well as the system of buffers in place to keep each other going when things fall apart.
 


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