Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (2 of 4)

Monday, November 7, 2011

In the morning, I toured the hospital with some of the visiting doctors. The hospital is addressing the medical needs of a large urban area (Mbarara has about 150,000 people) and of the surrounding rural areas, despite limited resources. It is basically a collection of low-rise buildings connected by pathways. The wards were built around 1950 and look as if they were meant to accommodate no more than 20 patients each, but at least 50-60 patients occupied each ward, many of them on the floor. There is an “ICU” that consists of 2 beds, with 1 working ventilator. A handwritten sign outside the OB ward listed supplies that were out of stock – sterile gloves, morphine, IV needles, and disinfectant. Care is supposedly free, but because of shortages of drugs and supplies, family members are often sent into town to purchase these items. Although there is activity everywhere – doctors, nurses, and students moving from place to place – there seems to be a lack of formal routine. Doctors are not checking on patients, and nurses are not taking vitals, nor do they appear to have blood pressure cuffs or stethoscopes for doing so.

Family members actually provide a lot of the care. Families cook for the patients and wash their clothes and linens, and often end up being the ones to notify the sisters (nurses) if there is a problem. When someone is in the hospital, families often travel hundreds of kilometers to care for them, losing valuable income.

I also learned that most of the surgeries performed at the hospital are emergent, not elective. However, most take place during the day (before 2pm), as staff are not always available to do procedures at night. In fact, much of the anesthesia is provided by “anesthetic officers,” who are technicians with variable training.

Finally, courtesy of Dr. Stephen Ttendo, an anesthesiologist who is our main contact in Mbarara, we get a tour of the new hospital building, which is under construction and should be finished by next summer. It will have more modern ORs, an 8-bed ICU, a CT and other imaging technology, and a chemistry lab. This expansion is greatly needed, and long overdue, since the hospital is already serving as a national referral center. I can already see that it is going to be a huge challenge to address the obvious needs related to head trauma. Without reliable ICU care, a way to monitor patients who are at high risk, or a social infrastructure to assist with aftercare for brain-injured patients, a surgeon can do only so much. I hope that the new facility can begin to address some of these challenges.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery