I tried to compress six months of learning into one day. Some days are slow, but some days are like this:
I said goodbye to Derrick in the hematology lab and headed
up to the ward. Along the walkway that overlooked the courtyard 3 floors below,
I noticed people sleeping and washing clothes in the early morning. Most likely
family of patients, some getting fresh air from the normally stuffy wards,
others washing the patient’s clothes and bedding. The patient’s attendants are
crucial to ensuring a patient gets proper food, bedding, clothes, and bathing
while they are in the hospital. These tasks fall on the family members, as most
nurses and physicians have over 40 or 50 patients to attend to. Tree after tree
was eye level with me, until I glanced down at the two stumps of the trees that
used to be in the corner of the courtyard near the walkway. These stumps always
gave me a bit of an uneasy feeling, as Derrick told me that they had been cut
down because too many people were using them for cover as they jumped from a
high level of the walkway to commit suicide. Something, I unfortunately
witnessed just a few weeks ago. Derrick says they jump because they are
stricken with grief, whether it is an unexpected HIV or cancer diagnosis, or
one of their family members recently passed, it is very apparent Uganda, as
with many developing countries struggle greatly with mental health issues.
I continued to walk. “Yes, good morning, sir. Yes, how are
you? Fine, fine, thank you. Good day, too.”
I have met many local students, interns, and residents
during my time in Mulago, and I recognized someone nearly everywhere I went. I
got to ward 3C and turned to go up the stairs, smiling at the 30 or so people
that were waiting outside of the ward. More family and attendants of patients.
Only a certain number of people were allowed into the wards at a time. Some
smiled back, some just glared. They all noticed my long, white coat stocked
with gloves, syringes, and blood tubes ready to collect samples for the day.
I headed up the stairs, past security at the door, and
started down the long hallway. Straight ahead of me was the labor suite.
I greeted the in-charge nurse as I passed. “Good morning,
sister, how are you today? Yes, yes, I am fine. Well done, too. Thank you.”
I reached the end of the hallway and looked right to glance at
admissions. About fifteen pregnant women sat on a bench against the
wall, awaiting triage, to determine if they entered the labor suite or were
sent to antenatal care. At the admissions desk, I gave a “good morning wave” to
Eve, one of the friendliest and hardest working midwives I have met at Mulago.
Dang, I thought. Eve is on admissions today. I always liked when she was on the
labor suite. She is always very helpful and working hard.
I looked left to wear there were women sitting on mattresses
on the ground. Most were sleeping, nursing their babies, taking tea, etc. These
women delivered yesterday or last night and were awaiting discharge. Women are
kept at Mulago “overnight” after delivering, but what is meant by overnight
depends on when a women delivers. If she delivers at 9am, she is discharged at
8am the next day. If she delivers at 10pm, she also are discharged at 8am the
next day. I have been told that even if she delivers at 3am she is discharged
at 8am. The constant need for space requires high patient turnover.
I continued into the labor suite, and I passed through the
familiar “rubber ducky” sheets that hung in front of the entrance to block
others from looking in. I quickly became used to the familiar smell of bleach
mixed with blood that hit me every time I passed through the curtain. I swiftly
circled the room, looking to see if anyone delivered very recently. I noticed
all the beds were full with patients, as was the bench at the nurses desk, and
a few women on the floor. Today is going to be a busy day, I thought, as I
noticed one women in the back that just delivered and the placenta was still
there. I walked up to her and said, “Mamma, ozade omwanaki?”
“Omwalla,” she replied.
Ahh, a girl. Not of
interest to me, as I was just collecting blood samples from boys (As a
reminder, I am collecting the blood from the umbilical cord from male newborns
to study G6PD deficiency). I said congratulations to the new mother, smiled,
and walked to the nurses desk.
Here I noticed Joy, one of the oldest midwives who worked on
labor and delivery. Joy saw me, smiled, and walked over to me and said very
slowly, “Wasuzotya no Paul-o.”
“Bulungi, Joy. Wasuzotya no Joy.”
“Bulungi, Paul-o. Jabalayko”
“Kale, nawe jebaleko.”
“Kale, Paul-o.”
An exchange of “good mornings” and “well done’s” that I had
gotten very accustomed to during me time here. Joy always made an effort to
greet me in Lugandan, and as most Ugandans do, she adds an “O” to the end of my
name. She sometimes greets me with the Buganda tribe name the midwives have
given, “Kalule Paul.”
As the midwives attended to the immediate needs of the
patients, I waited for morning rounds to start with the doctors. On the labor
ward today was a resident and an intern from Uganda, as well as an OB/GYN
resident from the University of California-San Francisco. This was the fourth
resident that I had met from UCSF, and they were always very nice and helpful.
As rounds went on, I listened as the doctors discussed the progress of the
patients. I had begun to take for granted how much I had learned about labor
and delivery, and medicine in general, during my time here. Able to follow
along with the discussion, I mentioned I had a blood tube, and I could send to
get the woman’s complete blood count (CBC) test. This particular woman had a
fever and had other risk factors that made her a higher risk patient, and a CBC
is a great first test to help doctors understand what the possible source of
the problem could be. I gave the doctor one of the many tubes I had in my coat,
he drew the blood and filled out the paperwork, and I told him I should have
the results in a few minutes.
“A few minutes? Yeah, right,” he told me, as this would
usually take at least 2 hours.
I smiled and said, “The perks of working in the hematology
department. I know the staff and can run the machines. I will have this in 5-10
minutes.”
He gratefully thanked me as I went to run the test and
returned 10 minutes later with the results.
By this time the team had moved on to another patient. This
woman was young, 14 years old. She looked terrified, lying naked on the bed
with a team of Ugandan and Muzungu (white) doctors around her. During my time
in Uganda, I have probably learned more in the labor ward than any other place.
More than in the lab, and more than talking with other people in the community.
And after 6 months of working here, I still cannot imagine what is going
through that young woman’s mind as she looked up at us, the group standing over
her. When doctors are making their assessment, they speak and write their notes
in English. Usually, all women are told throughout the whole labor process is
where to go, were to sit, and to wait. Some doctors spend more time explaining
what is going on, but many don’t. Women are constantly crying for help, asking
for something to help with the pain (there is no pain medication on the ward), or asking to go to theater (for a
c-section). To all of these I am left to only try to console the woman, as I
cannot check her progress, give her pain meds, or move her to the theater. I
just tell her that she just needs more time, a response that often leaves her
discouraged.
As I was wondering this though, I heard Irene calling me.
“Paul! Paul…..prep the resuscitation area!”
Unfortunately, this was also something I was familiar with.
I hurried to the corner of the labor suite, stepping over patients on the floor
and a puddle of blood along the way, to where there was a small table, tubing
for oxygen, and resuscitation bags and masks. I put on gloves and hooked up
tubing to the resuscitation bag, attached a clean mask, and turned on the
oxygen. Irene rushed the baby over and laid it gently on the table. This baby
was pale, not breathing, and not moving.
Throughout my time on the labor suite, the midwives seemed
to come to the conclusion that I was one of the better people on the ward at
resuscitating babies. There are a lot of things to think about during the
process, from making sure there is a good seal on the mouth, to giving
consistent, controlled breaths. It is a high stress situation, but it is extremely
necessary to remain calm. If you get stressed and start to panic, the breaths
that you give through the bag will be too pressurized, causing air to escape
through a pressure release valve and not go into the lungs. I have seen many babies
die because of inadequate resuscitation skills, such as not giving good breaths
or mistaking the gasping reflex for breathing, causing the care providor to
stop giving forced breaths and proceeding to hook the baby up to nasal oxygen.
Over my time here, I have been taught proper techniques by both foreign and
Ugandan physicians, and since I am a constant foreigner on the ward, I have
been able to pass these skills down to other students. For many months on the
ward, I had refused to do anything “procedural,” such as starting IVs,
delivering babies, or helping with resuscitation. I am very aware of what I am
able to do, and I always try to think of the best thing for the patient before
agreeing to “help.”
There is little supervision on the ward, and doctors and midwives
are quick to shift responsibilities to foreign students. As a foreigner, local
staff will ask you if you are able do a vaginal exam, start an IV, delivery a
baby, repair a vaginal tear or episiotomy, etc. If you were to agree, you are
often not supervised, unless you ask for supervision. This places a great
ethical responsibility on visiting medical students to not practice over their
training level when on the wards of Mulago. I have seen many visiting medical
students get very close to the “ethical line” on the labor ward by stretching
their limitations, but I have also seen a great number be very aware of their
limitations. As I have said before but will repeat again, I am not yet a
medical student. Because of this, I have been very cautious about what I do while I am on the ward. For the first
few months I set the line at getting supplies, weighing and wrapping healthy
babies, and cleaning. I was constantly turning down offers from midwives to
deliver babies and start IV lines. It was only recently, after many, many times
observing the starting of an IV did I agree to do it with proper supervision. I
still will not deliver babies. I started helping with resuscitations after I
had spent time working with some doctors from the United Kingdom, and they explained
the process and things to look for. They eased me into helping, under their
supervision. While working with them, I learned what to do, but I still
wouldn’t do it alone; I left it to the midwives. That was until I witnessed
midwives giving improper care when the UK doctors were not around.
“The breaths aren’t going in.”
“The mask isn’t properly sealed”
“That baby still needs to be bagged; you can’t just leave it
on oxygen; he’s not breathing.”
Often but in a place between continuing to help the baby or
attending to another mother, resources were stretched thin. Reminder after
reminder, until I just needed to demonstrate.
“Like this. You see how the chin is tilted back and by
fingers make a ‘C’ around the mask? Do you see the chest rising? What is the heart
rate? 120. So does that me we need to give chest compressions? No, that’s
right, we don’t…only if the heart rate is under 60. We just keep bagging like
this: slow and controlled with a good seal.”
At any rate, I help with resuscitations when staff support
is low and I am available. As Irene placed the baby on the table, I checked the
normal signs: heart rate, color, and tone. The tone and color were not good (no
reflexes and bluish), and the heart rate was 80 beats per minute. Anything
below 60 beats per minute would require chest compressions as well as breaths.
As I tilted the baby’s head back to open the airway, I ensured a good seal
around the mouth. I started giving breaths as I instructed another student to
monitor the heart rate. As I saw the chest rising, the heart rate started to
pick up to 120 beats per minute, which is desired for a newborn. Over the next
5-10 minutes of giving breaths, the baby’s color started to improve from bluish
to pink, and the heart rate stayed around 120. I talked through what I was
doing so that the student was learning, too.
The baby coughed up a little mucous, which I cleared with a
bulb sucker, and then he started to cry weakly. I patted his back to encourage
more crying. The student helping me looked up and smiled. We monitored the baby
for another 5-10 minutes as we hooked up nasal oxygen, also making sure he
properly wrapped to keep him warm. This baby would need to be transferred to
special care for additional monitoring, but he was breathing and his signs were
good. The student and I labeled and weighed the baby as the midwife filled out
the special care form.
I wish this was the case for all the resuscitations I see,
but it is not. I relatively large amount babies need resuscitation assistance
when they are born, and many do not make it. This is due to the large amount of
women who are experience prolonged or obstructed labor, causing a higher amount
of fetal distress. Women coming from far away may experience more difficulties
due to delayed medical care. Most frequently these babies will have a good
heart rate after giving breaths, but will not start breathing on their own.
Standard protocol at Mulago is 30 minutes of bagging before you are told to
stop. It is an extremely hard feeling to watch a midwife or physician (or
myself) stop bagging a baby with a good heart rate, only to have the heart rate
slow, and then stop. Knowing that things would be different in the United
States with proper respiration equipment makes it harder still.
As this baby was transferred to special care, I checked the
room for women close to delivering. The rest of the day went relatively
normally for a busy day. I collected samples and helped where I was instructed.
As I was about to head back down to the hematology lab at
4:30, I checked with the doctor who was making afternoon rounds. By this time,
the ward had quieted down a little bit, and I had collected 5 samples, which is
a relatively good day. The resident was examining a patient, and I just wanted
to check to see if I should wait for her to deliver before I headed down to the
lab. The doctor was working with an intern, and the intern and I stood opposite
the doctor around the bed.
“How far along is she, doctor?”
“Just 5 centimeters,” he said, as he took off his gloves and
I was simultaneously hit with liquid in my face. The doctor carelessly took off
his gloves, snapping the latex a bit too much, and as a result, I got several
small drops of the blood and meconium from the vaginal exam on my face.
I froze immediately, almost like I had just been shot.
“What’s her status?”
The intern seemed confused. “Her what?”
“WHAT is her STATUS?”
The intern flipped to the cover of the patient's file, which read TRR. My stomach sank.
TRR stood for tested, results given, reactive. This women was HIV positive.
My first thought was water; I need water. I rushed to the
employee break room. (All the other sinks on the floor were broken). I
thoroughly washed my face, and returned to talk to the physician. I was
extremely upset to say the least. After the initial discussion of how he should
never snap his gloves when taking them off, we talked about where the drops
landed. I said I felt several over my face, some close to my eyes. I told him I
didn’t think any got in my eyes, but I wasn’t 100% sure. Through the eyes is
really the only risk for an exposure to the face. The doctor assured me that I
would “probably be fine,” which is actually very true. Even if a drop of blood
entered my eye, infection rate of HIV is extremely low, well below 1%. I don’t
even know if any got into me. You can’t get HIV through the skin, only through
cuts, open wounds, and mucus membranes.
This experience for sure ended my day on the ward. I headed
down to the hematology lab to talk to Derrick, as the physician’s mild
reassurance was not enough to comfort me. In the lab, Derrick explained to me
that unless I felt it get into my eye there was “virtually no way I could be
infected.”
With his reassurance, I decided I was fine. I finished my
lab work and headed home, still in a moderate daze. It was hard to put on a
smile for the usual neighbor kids that greeted me along the way.
I must have recreated the scenario over 50 times that night
in my head. “Did it get into my eye? Did
it get into one of my pimples? Did it get into my mouth?” I replied to all
these questions in my mind, “No, I would
have felt it…..wouldn’t I?”
I didn’t sleep well that night, and when I woke the next
morning, I knew that I had made my decision. I had to take the anti-retroviral
drug post exposure prophylaxis (PEP) treatment. This was something that I
wasn’t looking forward to, but well worth the cost of putting my mind at ease.
PEP is free to all workers of Mulago, and is nearly 100% effective at
preventing an HIV infection if taken within 72 hours of an exposure. The
initial reason for my hesitation was that I had heard the side effects of the
drugs are really bad: overwhelming fatigue, nausea, headache, night terrors.
Not things that I would not to put up with for 28 days (length of time you need
to take the drug) if I wasn’t even sure if I was exposed in the first place.
When I got to the lab, Derrick tried to assure me again,
“Paul, the chances that you could get it based on what you told me is less than
1 in a 1,000,000.”
To which I replied, “People win the lottery all the time. To
me, the side effects are worth it for me to have my peace of mind.”
So Derrick worked with me that morning to get the drugs from
Mulago (which was quite the process). I can say that I probably was not
directly exposed, but I did not want to take any chances. I have been on the
PEP for about 3 weeks now, and the side effects are actually negligible. The
drug I am on (atripla) is one of the better drugs on the market, and was
recently upgraded (from combavir) to be stocked in Mulago.
So to my friends and family out their reading this, rest
assured that I am fine. Just wanted to share what a “day in the life” might
entail. It has been a long time since I posted my last blog, but I have been
learning a lot and staying busy. Outside of the hospital, my other main accomplishment
is climbing to the peak of the Rwenzori Mountains in late April. This was by
far the physically hardest, yet coolest thing that I have ever done. The
Rwenzori mountains are the highest mountains in Uganda, and the third highest
peak in Africa. It might not get the big name recognition like Mount
Kilimanjaro, but I would trade the surreal feeling of being the only group on
the mountain, following a scenic river the entire way up, needing gum boots for
2 of the days to hike through a bog/swamp, and crampons, pick axes, and
ropes/harness to make sure we didn’t fall of the snow covered glacier for
height every time! (selected pictures below).
I leave Uganda in two weeks on July 8th. My time in the lab
is going smooth, and I am going to finish my lab tasks on schedule early next
week. I am getting excited to come home and see my friends and family
(especially Kara! J
).
