After an incredibly refreshing weekend on safari in the gorgeous Murchison Falls park (see giraffe and waterfall photos), I came back to work wondering why I had been so melodramatic about what I had seen to date in Mulago. It was culture shock and I had overreacted, I felt. At least there is a public hospital-- so many people would be so much worse off if there weren't, and they are doing the best with what they have.
The day started with a journal club that I co-led with a senior house officer in the internal medicine department. We talked about a cost effectiveness analysis of viral load and CD4 monitoring vs clinical monitoring to evaluate the effect of antiretroviral therapy in HIV+ patients in Cameroon, a similarly resource-poor setting to Uganda. Because viral load testing is so expensive, and it was a short study and thus did not see a big mortality difference between the groups, the upshot of the study was that viral load testing was not cost effective in that resource-poor setting. I am completely, 100% certain that viral load testing to monitor response to anti-retroviral therapy is beneficial and should be the gold standard (the WHO agrees), even though randomized clinical trials have not yet shown mortality benefit and this study and others have not shown cost effectiveness. One of the professors in the audience commented at the end, with frustration, "Why can't we have this kind of monitoring in Uganda? This study says it is not cost effective, but what does that even mean? The ethics committee said it was okay to not monitor one arm of the study even though we think it is better. What we need is some advocates, to get our patients the medicines and testing that they need. Just because this is Africa, just because resources are limited, why can't our patients get the care that we think is best?" I had answers for every other question that had been posed, but after this one I was silent.
After the journal club, I returned to the female ID ward to find many new patients. We rounded for hours, still going at 2pm when I felt faint and peeled off for lunch. When I returned, I decided to leapfrog to one of the patients we hadn't rounded on yet, to keep things moving. I checked her vitals -- because of course, these had not been checked since at least yesterday-- and found that she was completely toxic, somnolent, with blood pressure too low and heart and respiratory rate frighteningly fast. Her family was ardently religious, and wanted to take her to a religious healer. We urged them to keep her in the hospital and they relented, but were selective about which tests and treatments we could give her, because of fear and money constraints. I looked at this young woman and suddenly felt so angry. I knew that if we didn't act, she would be gone in the morning. Why didn't she have a nurse who could ensure that she received all of the fluids and medications she needs? Why couldn't the hospital just provide the medicine that would be appropriate for her-- what could possibly be more important to spend 40,000 Uganda shillings on (~15 US dollars) than a dose of antibiotics that could save a life? And how could her family have so little understanding about health and disease that they would refuse essential care in favor of faith healing?
Things went from bad to worse as three more patients rolled in, and I suddenly found myself alone-- the intern had "gone to the bank" and never come back. I checked the blood pressure on a patient who had been unceremoniously dumped by the gynecology service on our floor. HIV positive, septic for days without any antibiotics and with a bladder so full of urine she looked pregnant. Her eyes were rolled back and her blood pressure was too low to measure. As I examined her, her breathing became shallow and she would occasionally gasp and lurch and then go apneic. I was certain that at any minute she was going to be lost. I realized at that point that I had not yet been the last to leave the ward-- the intern was always still around when I left in the late afternoon, and I never had to choose a stopping point for when to walk away from patients I was worried about, the thing that always trips me up at home and keeps me in the hospital forever. Moreover, there was no one to hand off care to here. Patients and their families are essentially left to fend for themselves overnight.
I tried for a while to get a second IV in her collapsed veins and sent her husband to the pharmacy to get antibiotics. I finally corralled the only nurse in sight (she was tending to probably over fifty patients) and asked her to get an IV, give the meds that the husband brought back and help me get a foley in. As usual, I rattled off in my head all of the other things I would do for her at home. Transfer to ICU, place a central line, start pressors, broad spectrum antibiotics, copious fluids with frequent lab monitoring and give a detailed handoff to the next resident and nurse who would have responsibility for the patient for the night. Instead, I made sure her fifth bottle of fluid was hanging and left six more bottles on her bed with instruction to the family to keep changing them as they finished. She was still hypotensive and looked awful when I left, and probably won't be there when I go back tomorrow. But I could truly be there forever if I waited until everyone was fine before I left, so I went.
The anger welled up again as I walked out. It's not just the fancy lab testing that Mulago lacks, it's the basics. Nurses, monitoring, around the clock care. Also, I would certainly lose my mind if I did residency here, so I sympathize with the poor, overworked doctors and nurses, but it's hard to deny that there is a depressing human factor to the inefficiency of Mulago. The medical staff at times seems just plain defeated, and the sense of responsibility that it takes to see things through sometimes drops off (probably because it is so infrequently rewarded), and as a result things that ought to be pretty easy to fix, like UTI, turn into crises. And when the whole system feels broken, it's easy to feel broken too, and wonder where you could possibly start if you wanted to make things better.
Perhaps I should have realized that my sense of denial would be followed in true Kubler-Ross fashion by a faceplant of anger? I did see a hopeful note this week though, in an outpatient HIV clinic that had a giant stockpile of charity-funded antiretrovirals and an efficient, motivated team of nurses, doctors, peer educators and social workers to distribute them. And I saw an elephant!
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