GPAS Blog

Trauma in Lira and Kampala

2008-01-31T00:00:00.000-08:00

It has been nice to be back here working with colleagues. There has been as usual, a fair bit of trauma that we have been dealing with. A day or two after I arrived, there was a large bus accident in the West in Kasese with about 40-50 injured patients, who came to Mulago in waves. There were some 6-10 deaths in this crash. Many of those who were injured had soft tissue, orthopedic, and head injuries. We cared for a patient who unfortunately suffered a low cervical spine injury with resulting paraplegia, then progressive quadriplegia, and she was unable to be supported through the week. Cervical collars are very hard to find and prohibitively expensive for most families. Many of the families involved in the crash had multiple victims within their families. Just the next week, there was another major bus crash in Lira in the north. An overloaded truck with about 130 people overturned with 6-8 casualties on the scene. Those who survived showed up in waves at the two main hospitals in the region, one the regional hospital in Lira, and a private mission hospital. The Ministry of Health was asked to send a team with extra supplies to care for the injured, to help evaluate critically ill or multiply injured patients, and to evacuate those who needed a higher level of care. A team led by Dr. Jackie Mabweijano went to Lira on January 16th with assistance from a medical helicopter provided by the military. The team also comprised Dr. Waiswa of the Department of Orthopedics, a physician from the Ministry of Health, and I also joined on this trip. We first picked up supplies requested by the Lira Hospital from the Joint Medical Stores in Entebbe before heading to Lira by helicopter, about a one hour and a half ride. We were greeted by a group of local government and hospital officials who were clearly still reeling from the incident. They were tremendously thankful for the support. Apparently all 130 casualties showed up in waves at the hospitals. The truck had been headed back from a very large (20,000+ persons) church gathering. The Lira Hospital had two specialist surgeons and several medical officers to deal with the injuries. The hospital staff were exhausted having worked continuously since the crash. We were generally impressed with the attention and triage the patients had received given the environment of limited resources (ie one operating room, one X ray machine). They unfortunately lost a patient just before our arrival who suffered a cervical spine injury. Many of the patients had severe soft-tissue injuries. We took five patients back to Kampala by helicopter ranging in age from one to forty. There were several patients with combinations of longbone fractures and head injuries, along with severe soft tissue injuries. The crash highlights the carnage on the roads that continues to be a major neglected epidemic in the developing world, with many unsafe vehicles overloaded with passengers contributing to the problem. Many of these incidents don't make the news or are buried and forgotten, especially compared to the international attention provided to infectious diseases. Then a few days later seven Ugandan patients were burned in Juba, southern Sudan, in a housefire, and evacuated to Mulago Hospital for further care. Unfortunately, one patient with 100% burns could not be resuscitated on arrival due to severity of injury. Two patients arrived with no cutaneous burns but had signs of severe inhalation injury and required immediate intubation. They were subsequently sedated and ventilated in the ICU and fortunately have been recently extubated and are generally revering well. It seems this may be the first time that patients that suffered from such severe airway injuries from burns were able to survive due to effective critical care. Patients were initially sedated with propofol then on a midazolam drip as the propofol supply was exhausted. They were able to be nutritionally supported through soft food through an NG Tube. It is a testament to the ICU and critical care-anesthesia staff that these patients have done as well as they have. Especially given the great shortage of personnel in the country trained in anesthesia and critical care.

OR Shut-downs

2008-01-21T03:55:00.000-08:00

A major problem in the hospital has been that the main operating room has been shut down for the last month due to leaks, and subsequently positive microbiological cultures from the theaters. This has obviously compromised the ability to do any surgery and is very frustrating to surgeons, hospital staff, and patients. It highlights, in general, the difficulty in maintaining theaters at minimum standards and the general neglect of support to basic health services such as surgery. The fact that the main theater has been closed in the country's main referral hospital is very distressing to all. It is currently unclear when the problem might be resolved. As a result, mostly only emergency cases are being done in the OR in the emergency room, which has extremely limited resources and poorly functioning equipment to take care of frankly the sickest patients in the hospital. There are, of course, fortunately, other private hospitals in the city that also provide surgical services, however they are more expensive. Many of those patients who have elective surgical problems have been discharged. On the surgical oncology ward the most striking observation is that all of the patients with cancer on the ward have locally advanced or widely metastatic incurable cancers of the breast, liver, soft tissue, and esophagus--ie, none are curable and the majority of the patients are most in need of palliative care. Any operation would be palliative. A number of these patients have been or are being evaluated by hospice care which has been a critically important service. Many other patients on the ward are still hospitalized with various stages of severe surgical infections and chronic wounds, recovering from trauma, or from operations for abdominal emergencies such as bowel obstruction and perforated ulcer. The hospital and wards are still limited by supplies, with limited consumables such as gauze and suture, as well as basic equipment such as blood pressure cuffs. All vital signs are taken manually. The last night on call there was no functioning manual blood pressure cuff for the ward holding the 40 surgical inpatients. A hospitalization can cause financial ruin for an often already impoverished family and this, along with the actual resource limitations, really limit the studies and services that can be provided. It seems there really needs to be greater research on the economic burden and contribution to poverty of health care costs—and especially for surgical problems.

Ebola Outbreak Forces End to Visit

2007-12-12T12:00:00.000-08:00

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

2007-12-11T23:00:00.000-08:00

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

2007-12-10T22:00:00.000-08:00

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

2007-12-06T03:21:00.000-08:00

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.