Resident Travel Blog September 6, 2013

This blog documents the medical experiences of our residents as they travel abroad and experience healthcare in different parts of the world.

September 6, 2013 by Brigette Gleason

Gleason_Brigette_fcNearly 38% of Ugandans live below the extreme poverty line. There are about 25,000 people for every doctor (in contrast to about 400:1 in the U.S.). According to some of the faculty at Mulago, patients tend to present to the hospital at late stages of illness for numerous reasons, including lack of money or transportation, lack of health literacy, reliance on traditional healers, and fear of Western medicine. One woman on the hematology/oncology service initially refused a lymph node biopsy because people in her village told her that if something was removed, it would grow larger. She later agreed to it and was found to have lymphoma.

I’ve continued to work primarily with the heme/onc team at Mulago, although the spectrum of disease in those wards definitely extends beyond those fields. Patients often are triaged to a certain department based on a chief complaint or single physical sign, given that labs or imaging aren’t routinely performed in the ER. This is why a patient with a brain tumor may end up on the infectious disease ward.

uganda10_057 uganda10_060

Appropriate patients for the heme service are more obvious because the anemia is often quite severe, and patients frequently present with signs of anemia-induced heart failure. I am still learning so much because while I may know about a disease, in this setting there may be different risk factors for it, manifestations of it, techniques to diagnose it, or options to treat it. Malaria, TB, and HIV are on the differential for almost every patient on any ward, and I have thoroughly enjoyed the opportunity to treat patients with conditions rarely seen in the U.S.

Chemotherapy is frequently available and free but almost always palliative. In contrast to the U.S., cancer screening is rare, and as a result, cervical cancer is one of the most common cancers. I haven’t yet heard any discussions related to prognosis with patients or families. Some staff at Mulago explained that cancer is a presumed death sentence here, and most people would rather not talk about it. I also haven’t witnessed any conversations about end-of-life care, but have been told that it isn’t unusual for families to sell their house to provide treatment for a loved one that ultimately is futile.

There are no “code status” discussions either because codes aren't performed. I'm not sure that a defibrillator, other resources, or training are available to carry out a code. It is definitely a different mindset that I've had to adjust to, but it is part of being in a setting with limited means. Even less heroic measures are sometimes out of reach due to an inconsistent supply of medications. The CBC machine has been down for the last week, so patients now have to pay out-of-pocket if they need this done. And can you think of any patient in a hospital who hasn’t needed a CBC?

There have been more medical residents at Mulago this week because the Makerere University strike ended. (Professors had demanded a salary increase.) The new interns who started in August now have more assistance, and the patient load per intern is around 30 rather than 60—in part due to greater guidance in deciding whether to admit or discharge patients. Even with the extra help, patients are not monitored as closely as I’m accustomed to in U.S. hospitals. Vital signs are often limited to once a day, and even then may not include a blood pressure or oxygen saturation level. There aren’t enough oxygen tanks to provide oxygen to everyone who needs it, and there are only about six ventilators in the ICU for the entire hospital. I’m not sure how they managed there when the power went out one day last week.

Despite the constraints, there is no limit to the amount of good care that is provided, dedication to research, or effort to continue to work toward improving outcomes. I had the opportunity to round with a very impressive and compassionate palliative care team that tends to stay quite busy. Their needs assessment determined that 45% of the patients at Mulago would qualify for their services. I plan to spend more time rounding with that group as well as the very busy infectious disease ward in my remaining time here.

uganda10_051 uganda10_027