Resident Travel Blog March 15, 2013

March 15, 2013 by Vijay Narendran


I've been on the wards at Mulago, and the 3rd year here was schooling me on finding murmurs tonight on the casualty rotation (kind of like ED but more just an IM 24 hour obs ward). Yes, Mulago has one, we don't. I rounded on Friday with an attending pulmonologist from South Korea named Dr. Yoo. He is awesome. He makes it a point to get everyone involved and really teach the students about each case. The first guy had a massive LUL pneumonia with textbook air bronchograms on XR, another one of our patients has a tracheo-esophageal fistula 2/2 esophageal ca beautifully captured on barium swallow, another with a Hgb of 2g/dl 2/2 HIV marrow supression. Everyone with a pneumonia and HIV has TB until proven otherwise, and like >50% of our 15-20 pt service had HIV, most on no meds.


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A very common complaint here is neck swelling. Lots of people come with large bilateral cervical lymphadenopathy. As soon as someone comes with neck selling, immediately an FNA is done bedside by the resident, smeared on a slide, those with more significant adenopathy, especially ones concerning for cancer, get a bed side neck dissection and LN biopsy, by the IM resident himself! They're trying to catch the obvious TB cases quickly with the FNA, to find the AFB on the slide smear and get them into the isolated TB ward. I was watching them do one (pictured below) initially started with at 2 cm incision, and by then end it was a 3-4 cm incision that they went about 2 cm deep to find this gigantic LN also pictured below, the patient received very little epi-lido, and they just went on digging until they got it, for like 20 minutes.

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Patients here have about a 30:1 patient to nurse ratio and the role of nursing in patient care is not well defined. Patients, if they get admitted, pretty much have to bring a "supporter" to sit next to their bed, act as transporter to various imaging tests around the hospital and take samples to labs to get the results. Patients and supporters are the keepers of their own medical record and thus take samples that are obtained by residents (LP samples, thoracentesis samples, etc) to pathology labs (sometimes the hospital's lab). Every day when the team rounds, it reviews all the info that the supporter and the patient keep in their possession including Xray and CT films (on old-school big plastic film paper.) along with lab printouts from various labs. Patients' supporters are required to obtain the various meds, PR/PO/IV/IM, from various pharmacies, especially if the pharmacy for the ward does not have the required drug. Dr. Yoo pointed out the "blanket" sign on my first day of rounds. If the family/supporter is able to provide nice blankets for the patient's hospital bed, then you know they can likely afford medication, if the blanket is threadbare (as it often is), the patient likely cannot afford anything.