Ebola Outbreak Forces End to Visit

Matt did end up leaving due to the outbreak. I elected to stay but not to participate in treating patients. It is an awkard situation, to say the least. It's hard not to feel like an entitled Westerner. And, although everyone is being polite and understanding, I would like to know what they are really thinking about our seeming over reaction to this situation.

Elective Colorectal Surgery at Mulago #2

Ebola outbreak becoming more of a concern today. Although the actual outbreak is in Bundibugyo in the west, one of the treating physicians who contracted the virus was in Kampala when he developed symptoms. He was being treated in Mulago in isolation but died. We're having a lot of pressure from the UCSF Infectious Disease folks to stay out of the hospital, especially out of the operating room. It's a difficult situation, politically, given the fact that everyone else continues to work. Haven't yet decided what to do.

Elective Colorectal Surgery at Mulago

Participated in two exploratory laparotomies today with Dr. Masiira, the Colon and Rectal surgeon here at Mulago Hospital. The first patient was a man in his 70's with a palpable abdominal mass but no obstructive symptoms. Not being able to afford a CT scan preoperatively, there was no way to assess resectability until the patient had already been subjected to a large midline incision. Once this was done, we found the tumour to be a solid lesion approximately 18cm in diameter arising from the serosal side of the mid-sigmoid colon and replacing the mesentery. It was firmly adherent posteriorly, involving the left ilac vessels and extending up to the aortic bifurcation. The blood loss from just exposing the tumour was almost 1L. Thus, the decision was made not to resect.

The second patient was only in his mid-thirties. He had been having obstructive symptoms and frequent bloody stools. He also had a large palpable mass. Again, no money for a preoperative CT and no colonoscope in the hospital so no way to assess tumour preoperatively. The patient had a very difficult airway and there was no working suction (no money for disposable tubing) so a few tense moments for UCSF Anesthesiologist Matt Aldrich during induction. We found a 6 cm mass in the transverse colon extending into greater curvature of the stomach. No obvious liver lesions palpable. We performed an en-bloc transverse colectomy and partial gastric resection. Blood loss was still significant. No functioning electrocautery so the knife and scissors are used with lots of packing afterwards. Not enough suture available to clamp and tie small vessels. It's saved for the larger vessels that need to be ligated.

Air conditioning not working today and roof leaking from heavy rain so particularly heavy odor in the air. That on top of jet lag made for a few pre-syncopal moments in the middle of the cases. I haven't had that happen since I was a first year medical student!

Return to Uganda

Here are just a few scenarios from one day to illustrate some of the greatest problems:

- The first patient we saw was an 18-year-old woman, but she had died in the overflowing hospital lobby. She came in, alone, with abdominal pain. She died waiting for an X-ray. No other tests had been done. This was within the standard of care there, though it would be unacceptable in the United States.

Most patients with surgical problems in Uganda never even reach a medical facility. Those who do often have an unsalvageable, advanced state of disease for something that would be routinely treatable in the United States at an earlier stage.

Why? It's partly because tests, medications and all bedside care are paid by the patient - although technically, public hospital care is "free." A hospital stay is unaffordable on an average income of 80 cents a day.

- I later supervised two Ugandan medical students suturing a patient's wounds. The students there are an incredibly precious resource. Uganda has four doctors per 100,000 people (average for East Africa), compared with 260 per 100,000 in the United States. The injured man being treated went to a ward with 45 other patients, all cared for by one nurse. Africa is short an estimated 1 million health care workers, and training programs are critically important.

- Later, we saw a 7-year-old girl who had been struck by an auto several days earlier and had not been treated. On arrival, she was barely alive, with a chest full of blood. We struggled to find IV's and blood pressure cuffs, all routinely available here.

Fortunately, we were able to drain the blood, and she improved. Other patients could not have emergency surgery that night because the hospital ran out of blood and oxygen, not an uncommon occurrence.

As in most poor countries, Uganda has an epidemic of vehicle crashes with no emergency system or adequate facilities for injured patients. Injuries kill more African children over 5 than HIV, tuberculosis and malaria combined, and 90 percent of injury deaths globally are in low-income countries.

Later that day, I unexpectedly had my own surgical problem. While playing basketball after work, I tore a tendon in my knee. I knew immediately I would need surgery. Unfortunately, the resources to reliably take care of my injury did not exist there. Without the right operation, I would be unable to walk normally again.

Four days later, I was back in San Francisco, and the operation was completed at UCSF. After surgery, I had near one-on-one nursing care, and at my fingertips was a personal flat screen cable TV which probably cost several thousand dollars.

I struggle to see how these worlds co-exist.

The above was originally published as part of an editorial I wrote for the San Jose Mercury News.