School of hard knocks

A boda boda in a Kampala intersection

An ICU bed at Mulago

Crossing the street in Kampala is terrifying.   For the most part there are no lanes, stop signs, traffic lights, or speed limits, and the streets are riddled with giant potholes and swarming with boda bodas, which are motorcycle taxis.   The boda bodas are insane-- they weave through traffic and make reckless merges, and come flying out of nowhere when you are trying to cross. Needless to say, there are lots and lots of traffic accidents, many of them involving bodas. 

I rounded with the ICU team for two days during my last week and saw several unfortunate traffic trauma victims.  One young man had been crossing the street to get a chapati when he got "knocked" by a truck. (Knocked is an adorable way to say run over).  He happened to come in at the same time as another young man who also had a traffic accident but there was only one ventilator open so the ICU team had to choose whom to admit. The chapati seeker lost the coin toss, and stayed on the backup ventilator in the emergency room for several days, and was still there when I left.  The ICU attending estimated that about 75% of their patients at any given time were trauma patients.  Another statistic that I heard quoted frequently was that there were five boda boda deaths a day.  

In Liberia, the government just banned their motorcycle taxis, called pehn-pehns, in an attempt " to curb the ‘carnage and mayhem’ the pehn-pehn drivers cause," in the words of the police traffic chief.  In October, there were 1011 patients admitted to city hospitals in Monrovia for traffic related injuries.

When there are accidents in the street in Uganda, there is no good mechanism to get patients to the hospital.  Good Samaritans and police officers generally bring people in on the backs of bikes and in cars.  Ambulances are rare and the drivers are not trained paramedics so patients do not get any resuscitation or support prior to arriving at the hospital, if they make it to the hospital.   I met a surgeon named Peace who was trying to raise money to buy a used ambulance from Canada and had plans to train emergency responders to man it.  She was tired of receiving patients who had been "knocked" by boda bodas or taxis and came to the ED injured and without a story or early attention en route.

There was an op-ed in the New York Times recently that commented on the dearth of proper ambulances to deal with the traffic accidents in East Africa.  A follow-up letter to the editor argued that if roads were safer there would not be as many accidents in the first place.  I wondered often what it would take for that to happen, especially after particularly harrowing times crossing the street.  People take boda bodas because they get around the fastest-- when there are bad jams, private cars and buses along can stand still for hours.  There would need to be a metro, or buses plus roads that actually have traffic lights and lanes so that vehicles don't just cram themselves through the streets without any order.  There would need to be police to enforce rules like running red lights or speeding.  Of course it all requires money, but also attention and priority-- these are basic parts of a society, things the government ought to recognize as important and fix.  

Many people I talked to had the feeling that things like transportation, healthcare and education are not changing in Uganda any time soon, not with a president who has eradicated term limits and has been in power for twenty-odd years.   In the national Ugandan newspaper the Daily Monitor, the Former Minister of Ethics and Integrity, Miria Matembe, recently urged the educated youth of Uganda to demand better from their government.

“Youth, you have to wake up and take on the responsibility of stopping this government from stretching further. Because the more it stretches, the more you feel the pinch,” she said.

When I read this I had a hard time imagining young people rising up and organizing against the government, not because they are not motivated or aware or even unhappy with the status quo-- they are-- but because there is a deep current of respect for elders and a grim attitude of keeping one's chin up and soldiering on through hardship.

But I was wrong.  There's a limit, apparently.  Right now, the interns in Mulago and across Uganda are on strike because they haven't been paid since August.  As it is, their pay is meager and their hours are long and they get absolutely no vacation.  The senior house officers, the equivalent of senior residents, don't even get paid-- they pay tuition.  A university official had the audacity to explain to one of my friends that the gloves and supplies that the hospital provides and the experience of learning from patients is payment enough.  Right now, those unpaid senior house officers are manning the hospital while the interns are (appropriately) on strike to get their wages.  

I learned about the strike from my friend, and expressed worry for her and her patients.  She wrote back in agreement: "The patients are in trouble."

More on palliative care in Uganda

When I rotated with the inpatient Palliative Care service at Mulago last week, I was impressed by the multidisciplinary team and somewhat aware that the very existence of palliative care in the hospital reflected a culture shift, recently brought about by forward thinking and hard work.  But what I did not realize was that this service was just one part of a revolutionary effort in Uganda to bring palliation to dying patients throughout the country, including in rural areas, that dates back twenty years.  Nor did I realize that Uganda is far out at the head of the pack in this movement in sub-Saharan Africa, and that there are many places in Africa where terminally patients are completely cut off from medications like opioids that might ease their pain. 

The effort to bring palliative care to Uganda started in 1993, when a British physician named Anne Merriman was moved by the suffering she witnessed among cancer and HIV patients in Kenya and Africa to found Hospice Africa Uganda.   This organization established a national policy for palliative care delivery in Uganda, and worked with the government to ensure cheap and widespread access to morphine.  They also integrated palliative care education into the curricula of two of the major Ugandan medical schools, Makerere (the med school affiliated with Mulago) and Mbarara. 

Liquid morphine, and a poster in the cancer institute.

Today, morphine is free with a prescription in Uganda and can be prescribed by palliative care nurses in addition to doctors.  During rounds in the Cancer Institute this week I saw ubiquitous bottles of liquid morphine tucked into patients' bedclothes and the green elixir being tipped into patients' mouths from little cups.  The solution is mixed in Uganda, Breaking Bad-style, and comes in two strengths, 1mg/ml and 3mg/ml, distinguished by food coloring. It is packaged in somewhat sketchy looking water bottles, but this creativity is what has kept costs down and facilitated access.

Outside of the hospital, palliative care and basic aid is delivered to terminally ill patients by community health workers, trained volunteers who access patients in remote areas by bicycle.  Like expanded morphine prescribing privileges for nurses, the use of trained volunteers to deliver care is an example of "task shifting," the concept of delegating tasks to less specialized workers to ease the strain of worker shortages.  The World Health Organization recommends task shifting as a public health initiative, particularly in the delivery of HIV care in resource-poor settings. 

By contrast, I learned from a Human Rights Watch report this month that access to opioids in Senegal is extremely limited, and patients must travel from all over the country to Dakar for morphine, and even there can only get a one week supply.   Further, this limited access to palliative care is more the rule than the exception in Africa:

"According to the Worldwide Palliative Care Alliance (WPCA), half of sub-Saharan Africa’s countries have no known palliative care services. Only six sub-Saharan African countries—Kenya, Rwanda, South Africa, Swaziland, Tanzania, and Uganda—have integrated palliative care into their national health plans. Only four countries—Kenya, Malawi, South Africa, and Uganda—recognize palliative care as an examinable subject in medical schools and have it integrated in the curriculum of health professionals. Palliative care seems to be particularly poor in Francophone Africa, with 11 of 18 Francophone African countries having no known palliative care services.  Most palliative care on the continent is provided by non-governmental, faith, or community-based organizations with no guaranteed sustainability. In 2008, morphine consumption in Africa was almost 20 times lower than the global mean."

Kind of incredible that even as the FDA is tightening regulations on opioid prescribing in the US because of an epidemic of overuse and abuse, children with terminal cancer are dying in excruciating pain halfway around the world-- two ugly sides of the same coin.  If only there were the drug equivalent of those trendy canvas shoes Toms, so that every time a suburban kid in Connecticut bought oxycontin, a child suffering from cancer pain in a rural village in Senegal could get a free bottle of morphine?  You heard it here first...

Too much

People in Uganda love to use the adverb "too".  Where a Californian might say "I'm hella hungry," or a New Englander "I'm wicked thirsty," Ugandans say "I'm too tired" or "she's too weak!"   This kind of statement might be accompanied by a shake of the head, or a clucking noise, and does not need to be preceded by a question, like "Do you want another serving?"  "No, I'm too full."  It's not usually a response or a qualification of anything, rather a superlative adverb, used in place of "very," or "so."

Another favorite thing to do is to interject the word "what?" into sentences for rhetorical emphasis.  "The patient presented with thrush, evidence of clinical failure, and that is why we decided to change the what? the anti-retroviral regimen."   The first few times I heard this on rounds I thought it was pimping, or maybe someone forgot the word they needed, but it's neither-- you are not meant to actually answer.   The "what?" is meant to slow the conversation down and call attention to an idea.

As I've alluded to before, I have yet to figure out what warrants ICU admission in Mulago hospital.   I have seen many critically ill patients die on the ward, usually because there was "no space" in the ICU.  But I've also heard of patients who were transferred that surprised me, most recently a patient on the neuro floor who was pronounced braindead, but the family could not understand this since he was still breathing.  A visiting American neurologist explained that he was effectively dead, and refused their request to transfer the patient to the ICU for mechanical ventilation.  Then, the American left for the day and the Ugandan doctors transferred the patient and intubated him.  The mzungu would be gone next week, they justified, but they would still be here, and feared that the family would tell their community that they brought their loved one in to the hospital and the doctors did nothing to help.  I have heard this same rationale for prescribing antibiotics for the slightest cough or diarrhea, and steroids for just about everything else (malignant bowel obstruction?)

Dangerous consequences of this mindset abound.  Excessive antibiotic use leads to widespread resistance.  Overzealous steroid use leads to adrenal insufficiency, immunosuppression, diabetes and ulcers.  Both doctors and families place a huge emphasis on feeding patients, and aspiration pneumonias pick off vulnerable, delirious patients after oral feeding goes down the wrong pipe.  I also learned today that the concept of using performance status prior to deciding who gets chemotherapy is not popular, and incredibly weak, frail patients with poor nutritional status get chemotherapy right up to their last days.

"She's too frail for chemotherapy," we tried to advise the oncologist today, about a young woman with metastatic cancer who weighed about sixty pounds and was bedbound.  He agreed, she's very frail-- let's feed her!  He assured us that he would drop a nasogastric tube and get started with feeding her right away.  We shook our heads no, it's too late.   She's dying.  We should focus on her symptoms.  He stood his ground: "But we can't do nothing!"

The first thing that impressed me about medicine in Mulago was the under-treatment-- insufficiently broad antibiotics, infrequent labs, poor access to imaging and specialists.  But I'm starting to notice that sometimes, the problem is the what? the over-treatment of patients, in order to do something, anything-- even when it's too much.

Palliative care at Mulago

After another glorious weekend away (see photos of the idyllic Kyaninga Lodge), I started a new rotation on the Palliative Care service this Monday.

The Center to Advance Palliative Care defines palliative care as "specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.  Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment."

An inpatient ward at Mulago

In Mulago, palliative care is provided by a consult service that started in 2006 as a nursing-led initiative, then included doctors in 2008.   Apparently they considered creating an entire palliative care ward, but calculated that about 40% of the 1500 patients in the hospital would qualify for the ward, so they stuck to consults.  The current list is about twenty patients, mostly cancer patients.   Despite the fact that the infectious disease and pulmonary services have the highest inpatient mortality rates (a whopping 30% each), neither of these wards ever consult palliative care.  From my extremely limited experience, this is likely because patients die abruptly on these wards, whereas the cancer patients and end stage renal patients who can't afford dialysis have more advance notice of the terminal nature of their illness.  Like in the US, the palliative care team both helps patients manage their symptoms while in the hospital and helps them transition to hospice upon discharge.

There is no such thing as "comfort care," or changing the focus from curative intent to symptom-driven management for inpatients at the end of life, in Mulago.  Again, my experience is very limited, but I speculate that the incredible dearth of nurses and also a cultural resistance to acknowledging impending death might be barriers to adoption of this concept.  I have seen very little shared decision making in Kampala-- generally decisions flow in a paternalistic doctor to patient direction-- and therefore the evaluation of patient goals and preferences at the end of life that usually precipitates a transition to comfort care would be new and unusual.   Which is not to say that it can't happen, but it might look different and need a little creativity to take hold. 

Elizabeth and Nelson, awesome Mulago senior house officers

Opportunities like this month are a such a gift and opportunity for reflection and growth.  I have experienced many ups and downs over the few weeks that I have been here, and am learning so much.  I have been frustrated with the system and with individuals, and then frustrated with myself, for being at turns too critical and too sensitive, focusing inordinately on the negative.  There are many sources of inspiration at Mulago, most notably the patients themselves, who often travel long distances to seek care and endure their illnesses and the abysmal hospital conditions with stoicism and grace.  Many of the doctors are an inspiration too, tending to far too many patients with very little support and extremely limited resources.  They find creative ways to work with what they have and are always wondering what they can do to make things better. 

My friends Ari and Kelly, who are members of the first installment of the US Global Health Service Partnership, a new healthcare specific branch of the Peace Corps, are another source of inspiration and hope.  They are working in a hospital in Mbarara, a town in western Uganda about 180 miles from Kampala, where they have even more limited resources than at the big tertiary care center Mulago.   I highly recommend checking out their account of their experiences living, teaching and caring for patients in Mbarara on their moving blog, here.  Rather than just bitching about what they see, as I'm doing, Ari and Kelly are trying to build the educational system in Mbarara and inspire the next generation of physician and nurse leaders in Uganda. 

As always, Pema Chodron has something to offer, a balm as I set myself in a little spin. This is from her seven step practice of feeling compassion for others:

"If someone is dying or someone is very ill and I think of them and I wish them to be free of suffering and the root of suffering….  I really want them to be free of fear, fear of the pain, fear of all the spinoff from the illness. I want them to be free and I want myself to be free of all this spinoff…

"Somehow the root of suffering is how we escalate the suffering, how we make the suffering more intense by going on and on and on about it with our habitual reactiveness. In some sense, not to get too complicated or psychological, but often what we're wishing for people is that they be free of their fear of what's happening to them, or their depression about what's happening to them, or their bitterness and anger about what's happening to them.  Because sometimes what's happening to them, we actually can't, it can't be changed. We might wish that it could be changed, but we're not trying to do this practice to get into kind of wishful thinking or, like, if we just aspire enough that everything is going to be all right. Because in life there's so much not everything being alright, you know. 

"There's this old adage that it isn't so much what happens to us, but how we react to what happens to us, that we're working with with a spiritual path. When we wish for people to be free of suffering and the root of suffering, at some level we're wishing them to be free of all the spinoff."

Falls, and a little tripping

Something snapped today. 

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!

Disappearing

In Uganda, when someone dies they sometimes say that person "disappeared."   Given the perilous state of health that many of the patients are in, I was not surprised to see my first deaths only three days into working in Mulago hospital.   There are only six ICU beds (and two are now closed) for the 1500 bed hospital, so many of the patients on the ID ward would certainly meet ICU admission criteria by our standards but are not transferred off the ward because their conditions are rarely reversible and ICU beds are so scarce. 

The first young woman I saw "disappear" was in her 20's and had come in altered and febrile, with a non-focal but grossly abnormal neuro exam, stiff neck and toxic appearance.  Her eyes were open with a vacant gaze, she grimaced and made slight movements to pain and was completely nonverbal.   She had HIV with an unknown CD4 count and was not on anti-retrovirals.  Bacterial, cryptococcal and TB meningitis were all possible causes of her presentation, and though her immunocompromised status and altered mental status would have bought her a head CT in the US, the team proceeded to lumbar puncture without the cautionary step because it was too expensive.  The patient's husband helped her onto the basin on the floor before the procedure.  She was limp as a rag doll as he lifted her back up to the bed.  I held her legs in place as she squirmed slightly when the senior house officer, Elizabeth, expertly passed an ordinary 18 gauge needle into her subarachnoid space.  The clear cerebrospinal fluid gushed initially, then tapered off to a few drops.  She withdrew the needle and we repositioned the patient and walked away, she to send the CSF to the lab and I to retrieve an NG tube so we could feed her while she was too altered to take food by mouth.  When we returned to the bedside, we immediately noticed that she was no longer moving, and did not even have the usual rise and fall of her chest.  Her pupils were fixed and dilated.  Her carotid pulse was present under my fingertips at first, but drifted away after a few moments.  The intern did a pantomime of compressions over her chest, then shut her eyelids and declared her dead.   Her husband shook his head and let out an angry sigh. 

In the next bed was a patient I had expected to pass much sooner than she, another woman in her 20's with HIV who had come in altered, her pathology likely immune reactivation syndrome of tuberculosis meningitis.   She had become progressively obtunded over the past night and was visibly aspirating while we were at her bedside, as she likely had been doing for hours.  Her breathing was fast, shallow and coarse.  She looked terrible.  On rounds we discussed what we could do for this septic patient in acute respiratory distress.   We gave her a few liters of fluid, "broadened" her antibiotics from ceftriaxone to ceftriaxone/flagyl to cover anaerobes, left the suction machine at her bedside to manage her secretions, and kept her on oxygen.  It was not enough.   Later in the afternoon she looked worse, her eyes rolled back in her head, her breathing ominously loud.  I suctioned her, and felt increasingly helpless knowing that this woman was so close to the end and there was nothing more we could do.  Finally, I took her chart, a pile of papers fastened together, and walked over to the pharmacy.  

"What opioids do you have on formulary?" I asked the young man sitting in the closet sized space.  Morphine, he told me.  IV?  Of course not.  But they might have some in the Palliative Care office, he suggested.  My eyebrows shot up.  He walked me down the hall to another closet sized room with a half dozen people inside.  An elderly nurse in crisp whites with an enormous bosom introduced herself as Florence.  

"There's a patient who's dying on the ID floor," I began, after introducing myself.  "What can we do?  I heard you have morphine." 

Apparently, Florence had never been consulted from the ID ward.  Her patients were almost exclusively oncology patients, though she also had some end-stage renal patients.  She came with me to the bedside and nodded.  "We have liquid morphine," she said, then told the family where to go to get it and when they returned with the bottle, she poured a little into an empty water bottle and gently instructed them how to measure the medicine into a thimble sized cup and deliver it with a  syringe through the patient's NG tube.  She described how to read the patient's expressions and noises even if she couldn't tell them about her pain.  They nodded in understanding, and appeared afraid but grateful to have something to do rather than just watch their loved one slip away. 

When I returned the next day, the young woman's bed, and she, had vanished.  I realized then that every day there were actually fewer beds than the day before, that the first death that I witnessed was just the first one that happened during the day while I was here.  It was easier to think of those patients as disappearing, though I still felt a knot of frustration in my throat thinking how little we did for those two patients.  Elizabeth, the senior house officer took the post-LP death particularly hard.  I learned later that she and her family had buried her little brother, only 22, over the weekend after he died of TB meningitis.  Elizabeth is a smartly dressed, bright young woman about my age.  I can relate to her so much more than to the patients in Mulago, most of whom are incredibly poor and chronically ill, with limited access to healthcare.   Yet her family was also vulnerable to preventable illness and loss that is hard to imagine at home.  I don't know how she came back to work, and continued to practice medicine immediately after her brother died.   She carried herself with professionalism and grace, but it was clear in her eyes that no one really "disappears" to their loved ones.

And until everyone can afford better public heath and greater access to healthcare, it is encouraging that there are people like Florence.  I am certain that the proportion of patients near the end of life far exceeds her capacity to care for them, and the ability to identify an appropriate point for shifting focus from "aggressive" measures to palliation is as much of a problem here as it is anywhere.   It is so easy to feel overwhelmed thinking of all of the suffering.   But each life is unique and precious, and worthy of care and attention right until the end.  And any dose of Florence TLC is better than none.

Blanket sign

The first lesson I learned on rounds on the infectious disease service in Mulago hospital, the university hospital in Kampala, Uganda, where I'll be spending the month, was the "blanket sign."  In Mulago, the family members of inpatients sleep on the floor next to their loved ones' beds and serve as their "attendants" while they are in the hospital:  they feed and clean and turn them, and are responsible for giving them their meds, and often leave the hospital to fetch meds at the pharmacy or results from the lab.  There are no hospital issued gowns, no hospital bedding, hot hospital meals, or for that matter, monitors or even really any nurses.  The floor is comprised of several rows of beds with nary a curtain to separate the patients.   The patients who have a family member to attend to them generally also have a positive "blanket sign," meaning they have a blanket and bedding from home, indicating resources and therefore an ability to pay.   This influences how decisions are made about a patient's care:  patients with a positive blanket sign are more likely to be able to afford a head CT, or vancomycin in a suspected staph infection.  The others get empiric or abbreviated therapies.  Even the positive blanket sign patients are subject to the severe rationing of resources:  very infrequent labs, a limited formulary, and a blood bank and oxygen tanks that available to the nearly dead only.

All of this makes the practice of medicine like a high stakes jenga game-- how many blocks can you pull out until the whole tower comes tumbling down?  It makes me realize how many things I take for granted in our incredibly rich system at home.  Starting with the basics of how a hospital works, as a huge team with many players doing specialized jobs to contribute to patient care.  The lack of nurses is the most stark.   The interns and medical students here start all of the IVs, draw blood, administer IV medications and perform basic vital sign monitoring, in addition to carrying out "investigations," procedures like drawing labs and performing lumbar punctures, para- and thoracenteses.  The medical staff do not carry pagers, because there are no nurses or techs monitoring patients or receiving orders that need clarification.  If doctors want to communicate with other doctors, they physically walk to another ward to find the consultant and talk face to face.  If they want a lab result, they draw the blood, bring it down to the lab, and then return later to pick up the piece of paper with the result and put it in the chart.  Or if it's a urinalysis or smear, they run it themselves. 

Needless to say, things don't happen quickly, and vital signs are rarely monitored.  The responsibility of gathering and synthesizing data for the daily ritual of morning rounds falls to the intern and medical students, though the data collection is not always done on the same day as the rounds presentation.   It is not an uncommon occurrence to discover a fever or hypotension on rounds, sometimes on a patient who was "admitted" the day before but was not formally seen until the morning and may have been languishing without any medical attention in the interim.   The intern and medical students will attempt to give a history, and an assessment and plan, and along the way they generally include key pieces of information, like the CD4 count for an HIV positive patient, but the emphasis on data in these presentations is limited.  Instead, empiric decision making prevails and the medical team relies heavily on clinical diagnosis, even when lab or pathologic diagnostics exist.  Incredibly, on the ID ward, it is rare to get simple cultures-- blood, urine, CSF.  They are considered a luxury, to be ordered if people can pay.  It doesn't matter all that much that there are no culture data to use to narrow antibiotics because everyone gets ceftriaxone for bacterial infections anyway (and all hell will break loose when the inevitable resistant bacteria strains emerge, as they're starting to do), but it still feels wrong.    Sometimes, when I feel overwhelmed by this seemingly haphazard decision making based on incomplete data, I remember that the alternative is doing nothing and more people would die than already do, and sooner.   Life expectancy in Uganda is 53.

All of the patients on the ID ward in Mulago are vulnerable, but especially the negative blanket sign patients.  They are utterly alone, without anyone to support them through the horrifying experience of being sick in a limited resource environment, emotionally or in the very literal sense of supporting them to the toilet or helping them to eat.  No one dashes out to get fluconazole for their thrush from the outside pharmacy when Mulago runs out, and during the night, a time I shudder to imagine, if anything happens to them there is no family member by their side to aid or soothe them.  

My friend Alicia told me that she thinks she ran the first ever code blue in Mulago, when a patient was unresponsive, she couldn't find a pulse, and she tried to create a sense of urgency around the patient's impending death and mobilize other people to carry out cardiac life support.  She was somehow able to find a nurse, and somehow able to get the patient connected to oxygen (though this was delivered by blowing the nasal cannula in the patient's face, rather than bag-mask ventilation).  She took turns with others doing chest compressions until they realized it was over, and that even if they could get a pulse back, their efforts were a bridge to nowhere.   There is no code button, no code pager and no code team in Mulago, not only because there are no nurses to monitor to raise the alarm in the first place, nor respiratory therapists or epinephrine or defibrillators, but because when patients die in Mulago, no one is surprised.