Hello again! I am sorry for the delay, but I have been unwell and the internet has not been cooperating with me to sustain connectivity in order to post something.
Today I am feeling a bit better, so Drs. Okello and Samuel traveled by transport van provided by Mulago Hospital to our new assignment at Kawempe Hospital, which is also a national referral hospital, located approximately 30 minutes from Mulago Hospital. We departed at 7:30 am and the next “free” van picks everyone up at 8:30 pm, which is often not enough time to handle all of the patients’ collective and individual needs.
The building is quite large compared to Mulago Hospital and is much less spread out horizontally, but has many floors vertically. The Acute Care Unit, which specializes in neonatal intensive care (NICU), accepts patients from all over the country by referral but receives most of its patients from within Kawempe Hospital which has an OB/GYN floor where many of the patients are delivered with severe medical problems or prematurity. Once again the ratio of physicians to patients is very low, two intern physicians and one or two attendings along with several nurses (aka “sisters”) for 40+ patients all of whom require a great deal of care and attention.
Family members are allowed to visit every two hours for approximately 30 minutes for the patient to be fed but are otherwise not present within the unit. As this is a referral hospital run by the government, family members are only responsible for purchasing drugs from the local pharmacy if they are not available on hand as they did at the Child Malnutrition Unit. The out-of-pocket cost seems to be much less in the way of prescription drug purchase than it was at CMU. They have more resources than the CMU when it comes to medications, resuscitative equipment, oxygen, and intensive care items that are necessary to maintain the wellbeing of the patients. I have never seen so many incubators in one place at one time. Some patients weigh less than a kilogram, which is shocking to see a child that is so small, yet still clinging to life. Day two will be interesting to see how the paradigm of the ward shifts overnight.
Boarding the bus at 7:30 this morning felt very early today and both Dr. Okello and Dr. Samuel overslept since they did not leave until nearly 22:00 last night from Kawempe. I am impressed with their ability to never have a day off apart from one week during their training and both of them have already taken their allotted time off already. The ride to Kawempe today was very backroads and so bumpy for the entire 30-minute duration of the trip. Those who know me well are aware that my left hip and bumpy roads do not get on well. We went a different route today to avoid traffic, but it was a bit unpleasant.
The hospital is already extremely busy with patients packing each of the floors, with the fifth floor, where acute pediatric care is located, swarming with a sea of mothers, a few fathers, and extended family members. The patient volume has nearly doubled overnight with each incubator being occupied by two or three very premature patients and the four adult-sized single beds lined all the way across with non-premature, but still sick patients, along with at least 16-bassinet type metal beds occupied by similar patients.
Dr. Samuel has taken on the numerous incubators on one side of the room, which is fairly small and very hot. Dr. Samuel stated that twins were extremely common in Uganda and there are at least 10 sets of twins, which I found shocking, as they do not seem very common in the U.S. Some mothers have even had two or three sets of twins. The mothers range in age from 12 to 40 years old, with many of them having at least two or three previous pregnancies.
One mother, who was 39 years old, died overnight as a result of complications from a cesarean section and her premature daughter will remain in the acute care unit until she is able to gain some weight. Just as the mothers were an integral part in the care of their child/children at the Child Malnutrition Unit, the mothers at the acute care unit are responsible for feeding the patients every two hours either via a feeding tube or breastfeeding. For the child whose mother passed away, a female family member has stepped in to help care for her.
Dr. Samuel takes the vitals of each patient and then writes a treatment plan for the day, which will be reviewed by one of the consultants later in the day. Some of the patients who are jaundiced are placed within an incubator that has “phototherapy,” an ultraviolet light that reverses the condition. A small eye mask is placed over the patients’ eyes to protect their vision, but Dr. Samuel stated that many children end up blind after phototherapy, as they constantly pull off the mask and if their eyes are exposed to the UV light it permanently damages their sight. I kept a close eye on the phototherapy patients and would replace their masks every time they moved around.
Dr. Okello has taken on the patients in the bassinets and the adult bed patients. He started with the patients on the adult beds who were more critical than those in the bassinets. Their medical issues were mainly attributed to birth hypoxia caused by prolonged labor, umbilical cord being wrapped around the neck or complications during a C-section. Several of the patients have been “sero-exposed” which means the mother has HIV and did not take antiretroviral medications (ARVs) during her pregnancy to prevent the transmission of the virus to the child or the mother continued to breastfeed the child even though she knew she should not.
Each patient is evaluated and a treatment plan for the day is generated. The patients in the bassinets are mostly ready for discharge and 12 of the patients are well enough to go home with their families today. Some of them have only been here for a few days, while others have been here for approximately a week, mostly for observation. I think that both of the doctors were happy to write so many discharge summaries since they did not write more than one or two while at the CMU.
There is much less interfacing between mothers/caregivers and the intern doctors given the every two-hour feeding schedule is like clockwork. The mothers come in, feed the children and then go back out into the large, overcrowded waiting area. A handful of nurses are responsible for speaking with the mothers/caregivers and are the conduit between the intern doctors and the mothers/caregivers. There are not enough interns to tend to all of the patients and speak with the mothers/caregivers and the system seems to work to the best of its ability.
Two consultants/attending physicians arrived to help out with the patient volume and all of the patients were evaluated by 15:00 today and I think this was a huge boost for morale in the intern doctors since they never seemed to be able to see all the patients at the CMU. They are both are thankful for their experience at the acute care ward but are looking forward to getting back to their main wards; Dr. Okello’s Stanfield Clinic where he is able to practice within the pediatric emergency ward and Dr. Samuel’s sickle cell disease section.
I am interested to see what both of these sections have to offer in the way of learning opportunities and areas of opportunity for improvement within an under-resourced area. We will be transferring back to Mulago Hospital on Wednesday, Dec. 21.
Laura Anne Salm is a Master of Public Health candidate in the global health leadership track at the Keck School of Medicine USC. She is spending the month doing a clerkship at Mulago Hospital, which is affiliated with Makerere University in Kampala, Uganda.