GPAS Blog

Training Course Round #2

noreply@blogger.com (Michael Lipnick) — Sun, 06 Jul 2008 21:36:00 +0000

The second round of training courses for the Prehospital Lay First-Responder Project took place this summer. In addition to training new police and taxi drivers, the training courses were set up this time to also assess skills competency and retention by those trained previously in May 2008. Again the courses went very well and by report from GPAS members around town it is nice to see trainees wearing their badges and using their kits.

First-Responder Training Courses

noreply@blogger.com (Michael Lipnick) — Fri, 09 May 2008 12:37:00 +0000

For the past two months we have been planning for the trauma lay first-responder training courses that took place this week.

As discussed in a stakeholders meeting a month or so ago, we decided that since trainees are not being paid by their employers to take on this extra responsibility, that we should give each certified trainee a first-aid kit, ID card, course certificate, and reflective armband, in order to provide incentive and a sense of pride.

It seemed simple enough at the time.

Just to provide some perspective, here in Kampala even simple things like ordering at a restaurant or buying some groceries, are tasks which inevitably involve delay, detour, or debacle.

Having said that, one can imagine the comedy associated with bargaining at the local flea market for quantities of supplies that quite frankly would be difficult to obtain even at a Costco.

Kit assembly took about ten times longer than calculated, mostly because we decided to individually spray paint the course logo onto each kit ourselves. But after sorting forty-thousand pairs of gloves, individually diluting and pouring 350 one-liter bottles of bleach, cutting 700 square meters of tarp into 350 one by two meter stretchers, folding 350 pieces of cardboards for splinting, cutting 700 triangular bandages, and after folding 6000 pieces of gauze we can see that it was definitely worth it.

During the Uganda Taxi Operators and Drivers Association (UTODA) training days, we were joined Mr. Moses Dumba, UTODA Road Safety Officer, and Mr. John Ndyomugyenyi, UTODA National Chairman. Mr. Dumba provided an excellent talk on road safety that was well-received by the trainees and accessible via Prehospital Project web page. Numerous reporters from local TV, magazines and newspapers were present as well.

The trainees were exceptionally motivated and interactive throughout the training day.

After baseline surveys and a pre-test in the morning, Dr. Jackie Mabweijano, head of Mulago Casualty Department and GPAS Director, gave a 45-minute lecture on the course fundamentals (video accessible online). She eloquently gave and engaging lecture simultaneously in Luganda (the local dialect) and English.

The rest of the day was spent rotating in groups of 10 through each of 5 skills stations. The topics covered airway management (Dr. Cephas Mijumi – Mulago Anesthesia; Dr. Jim Suozzi - UCONN), hemorrhage control (Juliete Kiyimba, Yusuf Kimbowa – Kampala Red Cross, Dr. Michael Lipnick), fracture splinting (Daniel Nsubuga – Kampala Red Cross; Dr. Robert Wangoda, Consultant Surgeon Mulago Hospital), Scene Management (Dr. Jackie Mabweijano, Head of Mulago Casualty Department), and triage/transport (Robert Okuyat – Kampala Red Cross; Dr. Doruk Ozgediz, faculty surgeon UCSF).

Based on the enthusiasm of the trainees, we are optimistic and eager to begin the prospective phase of collecting data for this study.

We are hopeful that we will be able to obtain additional funding from local government and private donations to facilitate future courses.

Prehospital Study Planning

noreply@blogger.com (Michael Lipnick) — Sun, 20 Apr 2008 16:09:00 +0000

A glimpse into another side of healthcare in Kampala.

We are currently in the process of coordinating our prehospital study. You can read about it in detail on the "projects page." The general idea is that here in Kampala, there is no public ambulance system. There are a few private ambulances, but they are too expensive for the vast majority of the population to even think of using. As a result, most people with injuries are either not brought to the hospital at all, or are brought in by taxi drivers, police, or relatives... and no prehospital care is provided. We believe that as a consequence, many people with survivable injuries are dying because of a lack of extremely basic prehospital care (ie airway management – turning an unconscious patient on his side, or controlling bleeding before loading the patient into a taxi, just to name a couple). The other week I visited the city mortuary and not surprisingly of the ~1000 deaths that were brought there in the last 6 months, it seemed that about 90% were injury-related.

We are planning to train taxi drivers, police, and local council members in basic first-responder skills (~300 in the initial training courses in May 2008). We will also provide them with a basic first aid kit. This study is based on similar efforts in other countries. We hope to measure its impact in a small area of Kampala over the next year.

In order to collect some data for the study we have been traveling to the health clinics in Kampala. This has been an interesting and informative experience.

We have visited five health centers around Kampala that we hope to designate as potential health facilities for our first-responders. Most of our trips have involved a few common themes:

1. Traffic
A near accident or pedestrian collision seems to occur almost every few minutes. After each of these we look at each other and repeat the comment,"I hope the data collection doesn't start on this fieldtrip." Long-lasting "jams" are everywhere, and can occur at anytime of day. The few traffic lights around the city are rarely working and as for the condition of the roads - red dirt and gravel that is broken up by pothole-strewn, paved portions.

2. Understaffing/waiting
Despite appointments, the clinics are so badly understaffed that they understandably have trouble meeting with us – so far most of the clinicians we have talked to, report seeing about 150-300 patients between 8AM-5PM, as there is only one doctor, a few nurses and medical assistants in each clinic.

3. Inadequate facilities
Though many of these clinics, by definition of the ministry of health, are supposed to have basic instruments and supplies for first aid, we have found that many do not. Some do not have even gauze, more or less suturing instruments. And those with suturing instruments may not have a sterilizer... etc.

4. Traffic
Worthy one more mention.

5. Optimism
Despite the discouraging conditions that we found in the health clinics, we were consistently greeted with optimism by the health clinic staff. All have been in agreement that it is time to at least try for a change or attempt to learn what may or may not work for prehospital care in Kampala. We have been invited back to the clinics to provide a basic orientation course to the staff regarding the study forms – but per their request, we are using this opportunity to provide a brief course on basic first aid and the approach to an injured patient.

WHO - Workforce Conference - Kampala

noreply@blogger.com (Doruk Ozgediz) — Sat, 22 Mar 2008 12:06:00 +0000

GPAS participated in the WHO "Global Health Workforce" conference right here in Kampala March 2-6, 2008. It was run by the "Global Health Workforce Alliance" of the WHO and is demonstrative of the increasing emphasis being paid to the health workforce shortage in developing countries—it has definitely been a neglected part of global health. Lots of ministers prominent members of the major international organizations, universities, civil society etc. More than 1000 people attended this conference.

The massive scale-up attempts of the HIV and infectious disease programs have really stressed that "human resources" and "health systems" are the major limiting factors to their success. The first day was highlighted by sessions on leadership, training, and management. I think everyone wanted a bit more animation from the conference.

Indeed it is hard to think of a more pressing issue facing the global surgical community, or the global health community…there is a global shortage of 4.2 million health workers and one million in Africa; and Africa bears 25% of the global burden of disease with only 2% of the world's workforce...for surgery the numbers are also quite extreme but poorly understood due to a lack of research. The problem isn't just shortages of surgeons, but also nurses, anesthetists, and overall neglected health infrastructure.

Nonetheless...several issues predictably came up repeatedly…organizations focusing exclusively on infectious diseases (primarily HIV) pointed out that all the resources for these specific initiatives would improve health systems, while others questioned whether more benefit may be gained by allocating more from these vertical initiatives to health systems…the head of the Global Fund for AIDS TB and malaria indicated that in this next round of the fund for HIV TB and malaria they really want proposals to strengthen health systems. I think for those of us working on other aspects of health systems it would be good to see evidence for the impact of these funds and programs on health systems more broadly—that evidence currently seems lacking. Being biased on the surgical-essential health services sides its hard to appreciate these effects in the hospitals and clinics we have been working in here.

Several of us went to the breakout session on training. A major focus that is relevant to surgery and anesthesia is the role of "task shifting." Its exact definition even, and role are really still being defined...the WHO even now has new policies and programs around this. There was quite a bit of debate about the term "mid-level provider" and "non-physician clinician"...some felt that this term was quite derogatory and pointed to excessive hierarchy when we should all be working as a "team" in health care...others pointed out that plain and simple, some people train longer and have a more specialized set of skills, and that’s the frank reality…

Whatever term you decide you want to use, the "mid-level provider" or "non-physician clinican" is being used quite extensively across sub-Saharan Africa (see Mullan et al Lancet for a review in 47 countries)...one presentation from Malawi echoed their recent publication basically saying that non-physicians are doing C Sections and even more complex obstetric procedures and that their outcomes are similar to physicians. In India there has been a new cadre created to train “rural doctors” in emergency surgery and other essential skills. This presenter stressed that doctors wont work in rural areas and people die as a result.

Others were concerned about quality of care that would be provided by these cadres, and the real need for them. Some argued that in their countries, rather than creating new cadres, what is needed is more effort to appropriate incentives for rural service delivery, and focusing on recruitment and retention...or, in addition, a major problem is that there are many trained personnel who surprisingly are not absorbed into the system—ie they cannot be hired or have "jobs" created for them, so this should be the focus. Surveys in Ethiopia have shown that with salary increases and improved accommodation, a much larger number of doctors would be willing to serve in rural areas.

10 key facts reviewed at the Forum were:

Fact 1 - Health workers work

Health workers are people whose main activities enhance health. They include health care providers and people who manage and support delivery systems. Worldwide, there are 59.8 million health workers. Without them, prevention and treatment of disease and advances in health care would not reach those in need.

Fact 2 - Shortage of health workers

In 2006, WHO stated that a country with less than 2.3 doctors, nurses and midwives per 100,000 people is undergoing a critical health worker shortage. This is the case in 57 countries (36 of which are in sub-Saharan Africa).

Fact 3

One million health workers missing in Africa The global health worker shortfall is over 4.2 million, with 1 million health workers needed for Africa alone.

Fact 4

Sub-Saharan Africa has 25% of the global disease burden Sub-Saharan Africa faces the greatest challenges. It has 11% of the world's population and carries 25% of the global disease burden. Yet the region has only 3% of the global health workforce and accounts for less than 1% of health expenditures worldwide.

Fact 5

Americas have 10% of the global disease burden In comparison, North America and South America, which together have 14% of the world's population but only 10% of the global disease burden, employ 37% of the global health workforce and are responsible for over 50% of the global health expenditure.

Fact 6 - Pandemics

Many factors have led to the health workforce crisis, including growing economic disparities between countries and upsurges in new and old pandemics. Such pandemics pose special challenges to workers; for example, HIV/AIDS is a 'triple threat' to health workers, causing far bigger workloads, psychological stress, and the daily risk of HIV infection.

Fact 7 - Innovative trainings

Training a nurse takes at least three years; training a doctor can take more than six. If action to expand the health workforce is taken now, effects will only begin to be felt years later. Innovative methods (distance learning, task shifting or community health worker programmes) can shorten this delay effect, but there is no "quick fix" to this problem.

Fact 8 - Migration

Health worker migration is increasing due to disparities in working conditions, wages and career opportunities. One in four doctors and one in 20 nurses trained in Africa later migrate to work in more developed countries. In Africa and some Asian countries, a public sector physician's monthly wage can be less than US$ 100; in higher resource countries, monthly salaries can exceed US$ 14 000.

Fact 9 - Funding

WHO estimates that a rapid health workforce scale-up by 2015 would cost US$ 447 million on average per country per year. WHO advocates for 25% of the US$ 12 billion (2004 figure) devoted to international health aid to be spent on the health workforce.

Fact 10

Global Health Workforce Alliance The health workforce issue crosses many sectors - no single entity can successfully address it on its own. The Global Health Workforce Alliance has brought together a coalition of health leaders, civil society and workers to explore solutions to this crisis at the first Global Forum on Human Resources for Health in Kampala, Uganda in March 2008.

At the conclusion of the conference, the "Kampala Declaration" was adopted…it can be viewed at http://www.who.int/workforcealliance/forum/2_declaration_final.pdf

It is good to see more attention paid to the needs of health workers and the workforce worldwide...the goals are very much in line with everything we are trying to do. It was refreshing at the meeting to meet many people who are working on so many other conditions besides the infectious diseases that have been the focus of most international donor efforts---there is such a need for greater coordination, and we are working on that.

Advanced Trauma Care Course

noreply@blogger.com (Doruk Ozgediz) — Tue, 18 Mar 2008 14:32:00 +0000

Reflecting on my call nights in the casualty (emergency) department of Mulago over the past four years I can recall countless times I ran through the ABCs of resuscitation or followed through an ATLS algorithm in my head. During most of these occasions I was simultaneously reviewing the approach with Ugandan residents and students and realizing the lack of a more organized trauma training and certification here is a significant but addressable problem.

The residents here at Makerere are the frontlines for trauma care not only at Mulago but in the community as well. As enhancing workforce training is a primary goal of GPAS, we have just completed a pilot course in advanced trauma care here at Mulago.

Injury and trauma contribute to a huge burden of disease here and in other developing countries. The development of trauma systems has been shown to decrease medically preventable deaths in injured patients by as much as 50%. One of the essential elements of trauma systems is the capacity of providers to approach injured patients with the required skills to evaluate and treat these patients.

In collaboration with GPAS, the departments of Surgery, Orthopedics, and Anesthesia here at Makerere University offered an “Advanced Trauma Care” course on February 28 and 29th, 2008. The topics and content were adapted from the similar ATLS course offered by the American College of Surgeons. The faculty here had not previously run a similar course themselves, and it was quite well received by the students, all residents in orthopedics, general surgery, and anesthesia—25 in total. Materials provided by GPAS as well as by www.trauma.org proved to be very helpful in course design and evaluation.

The formal ATLS course includes quite a few algorithms that require technology simply not available here. Therefore the faculty here modified most of the basic ATLS course to fit the context that is readily available in Uganda. The introduction of the ATLS course proper in developing countries has been previously studied—though quite some time ago—and showed a 50% decline in mortality after the introduction of the course (Ali et al. 1993 in Trinidad). A number of modified ATLS courses are available, one that is being used in more rural areas and district hospitals in Africa is the Primary Trauma Care course (see Wilkinson et al. Anesthesia 2006). After discussing with faculty leadership here and reviewing content and materials from all these courses, we came up with the course offered last week for Mulago. In the meantime, in collaboration with GPAS, the surgeons here are planning to formally apply to the ACS Committee on Trauma to support trauma training here through ATLS.

We started very early both days, and went quite late! Lectures were mixed in with practical skills sessions. Presentations were quite animated at times and refreshingly the presenters modified the “accepted doctrine of the west” to tailor to the conditions here, where every form of resource is just more scarce. One of the highlights was having such close collaboration between all the departments of surgery, anesthesia, orthopedics, and obstetrics. Despite resource limitations, the basic approach and principles to identifying and treating life-threatening injuries was stressed.

We are in the process of conducting formal evaluations of the course as well as assessing its impact on patient care. The hospital leadership is making a commitment to ensuring the provision of essential supplies and equipment so that the skills gained by the students can be maximized in patient care.

We hope this course can lay the foundation for other similar courses that can be run here locally—but will need more resources to do so! It cost about $1500 to run, so we will be trying to procure resources to keep it going. Hopefully we can raise independent funding with matching or partial support from the hospital. In the coming weeks we are planning to create an online teaching module containing resources used by GPAS at Mulago as well as resources used by other organizations for similar initiatives worldwide.

Prehospital study kicks off!

noreply@blogger.com (Michael Lipnick) — Tue, 18 Mar 2008 14:19:00 +0000

GPAS has kicked off plans for a model prehospital trauma care initiative that utilizes current informal systems already in place in Uganda and hopes to build upon previously established recommendations by the WHO and other studies.

Currently there is no public ambulance system in Kampala, so injured patients are most often brought in by police, other local government employees, or bystanders. These first-responders have no medical training and no system exists to provide them with much needed preparation.

The aims of our prehospital initiative include:
-to create an open dialogue between the relevant government and civilian organizations critical for establishing an effective prehospital system

-to provide pilot, first-responder training courses, and distribute cost-effective, practical first aid kits to participants

-to monitor outcomes through emergency admission logs, discharge records, and field surveys

-to tailor the training courses as needed for expansion

-to encourage allocation of resources by local government and to devise novel incentive tools such as certification placards for taxi drivers

On March 11, we helped coordinate a stakeholders meeting between the Injury Center Uganda, the police, the Taxi Drivers Association, Makerere Medical School, Mulago hospital, and representatives from the City Council Health Department in Kampala.

This was the first time these key players had come together to address this issue.

Recognizing the impossibility of creating a de novo prehospital system without a significant if not primary role being played by the local government, everyone was extremely pleased by the attendance and enthusiastic dialog at the stakeholders meeting.

Establishing this open communication and coordination was the first step of our intiative, for which GPAS has received preliminary funding to pursue.

The next phase of the study will be training courses offered in May 2008 that will train ~150 police officers, 50 taxi operators, and 50 local government officials. The pilot course will be offered in select areas of Kampala in order to facilitate timely outcome measurements and monitoring during the study period.

In the coming months we have a lot of preparation to do, but are encouraged not only by the local support here but also by interest expressed by numerous medical/public health professionals around the world.

If you are interested in contributing time or other resources to this GPAS initiative, then please contact us at partners@globalpas.org

Surgical Outreach to Kapchorwa, Uganda

noreply@blogger.com (Alexander Ayzengart) — Wed, 12 Mar 2008 02:23:00 +0000

On Feb 18th, 2008, a group of surgeons from UCSF, including Dr. Doruk Ozgediz (Asst. Adjunct Professor of Surgery), Dr. Alexander Ayzengart (PGY4 in General Surgery), and Paul Shen (MS IV), embarked on a surgical outreach visit organized by the African Medical and Research Foundation (AMREF). The initial invitation came courtesy of Dr. Jane Fualal, a consultant faculty general surgeon and endocrine surgery specialist at the Mulago Hospital in Kampala, Uganda. We were to accompany Dr. Fualal to the district hospital of Kapchorwa, located in a small village in the valley of Mt. Elgon on the eastern border of Uganda. Dr Fualal had made multiple prior visits to this remote hospital and had excellent working relationships with the hospital staff.

---

At the time of this invitation, our group was actively involved in teaching, patient care, and collaborative research projects with the Department of Surgery at the Mulago Hospital. Due to the gradually strengthening bond between the faculty and residents from our two departments, the degree of our involvement went far beyond mere short medical volunteerism and, over time, has developed into a long-term collaboration. Needless to say, we were happy to contribute to this growing relationship in yet another way.

---

On the day of our departure to Kapchorwa, and not knowing what to expect on site, we collected a few boxes of medical and surgical supplies, piled everything into a large mini-van, and headed out to meet Dr. Fualal at the district hospital. After 6 hours of bouncing around on the rural roads of Uganda (imagine potholes sprouting bigger potholes!), we were being greeted by dozens of patients, curious on-lookers, and members of the operating theater staff. However, our meet and greet was short lived, as we were scrubbing on our first case within an hour of arrival. Dr. Fualal, who arrived in Kapchorwa by plane a few hours ahead of us, has been busy evaluating and triaging many patients lining the halls of the hospital, in order to create a manageable operating plan.

Within the span of 2.5 days, we performed close to 25 operations - all under the conditions rivaling the most hardened of any surgical field hospital, where the lack of running water, working surgical lights, and functioning instruments created an additional element of difficulty. Most of the procedures consisted of subtotal and partial thyroidectomies, aimed at providing relief to the patients with gigantic goiters that developed due to widespread iodine deficiency. However, since surgical care has always been hard to come by in many district hospitals of Uganda, and Kapchorwa was no exception to this rule, our operative log covered a multitude of problems that required surgical intervention (anything from large salivary gland tumors to chronic appendicitis).

---

True to the surgical etiquette practiced worldwide, we made it a point to see all of our patients after each operative day. Despite all of the challenges mentioned above, most operations went as smoothly as expected, with all patients doing well on their 1st postoperative day. Just imagine stepping into a large room full of people that are gingerly nursing their neck dressings and actively sharing their experiences and worries with any neighbor willing to listen! This was one of the many cultural differences that stirred and shocked our senses on the daily basis while in Uganda.

---

So, was it all work and no fun, all the time? Of course not! At the end of our stay in Kapchorwa, we found a little free time to visit the valley of Mt. Elgon and to track on foot to the top of Sipi falls. It is difficult to do justice to the beauty of Uganda's countryside in mere words... let me direct you to our photo section, so you can judge for yourself!

Take care, Alex Ayzengart.

Advanced Trauma Course in Uganda, surgical outreach and new publications

noreply@blogger.com (Laura Goetz) — Fri, 29 Feb 2008 22:24:00 +0000

Update from Doruk...

I spoke with Doruk yesterday about his recent activities at Mulago and in the district hospitals. He is in the midst of running an ATLS-like (Advanced Trauma Life Support) course for the residents and medical students. He organized the two-day course and recruited Makerere Faculty to teach. The first day went well and ran from 815 am (only 15 minutes behind schedule!) until 7pm. It was scheduled to end earlier but there were so many questions and so much enthusiasm from the residents and medical students, many stayed late to continue teaching. Pretty good indicator of the quality of the course, I'd say.

Earlier in the month, Doruk and 4th year resident Alex Ayzengartwent on an outreach trip to one of the district hospitals. More on that to come from both of them, but here's a brief note from Alex..

'things here are going well - we went on a surgical outreach trip to Kapchorwa (on the border of Kenya, way east) - and that was amazing! we did 25 cases or so in 2 days!! most of that time, there was no running water and we had to use sunlight as our only illuminating aid!'

Also of note, the February 23rd issue of The Lancet published a comment written by Makerere Faculty and UCSF faculty entitled 'Africa's neglected surgical workforce crisis' (see link: doi:10.1016/S0140-6736(08)60279-2 ) This was followed by the February 26th issue of World Journal of Surgery entitled 'The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda '
(see link: doi:10.1007/s00268-008-9473-4)

Kudos to all involved!!!!

Photo Comment - Surgical Workforce

noreply@blogger.com (Michael Lipnick) — Fri, 22 Feb 2008 23:24:00 +0000

Surgery at a district hospital in the north of Uganda. Anesthesia is provided by anesthetic officer, the patient is hand-ventilated though the operation, the primary cardiac monitoring is by precordial stethoscope. Surgical personnel work with limited instruments, protective wear, and draping is limited compromising sterility.

During a mini surgical camp at a district hospital, multiple patients must undergo surgery in one room to accommodate the need.

The numbers of nurses and equipment is limited, meaning that for patients such as this one who just underwent a laparotomy for a liver laceration sustained during a road traffic crash, post-operative monitoring is very limited or absent.

The limited surgical and anesthesia workforce is one of multiple reasons why patients access care with already very advanced disease that requires more complex surgery or would be potentially curable at an earlier stage of disease. These pictures depict a patient with a massive goiter (first pic) causing airway obstruction, an advanced tumor of the distal femur (second pic) that had already spread to metastatic sites.

Many injured patients do not have expeditious care of fractures and emergency trauma care, leading to complications such as this non-union of a femur fracture (now undergoing correction) (first pic); and this gangrene of the forearm and hand (second pic) in a child who had a distal radius fracture after a fall; this family first went to a traditional bone-setter, a common practice.

There is a limited supply of physicians in Uganda, and most do not choose a career in surgical and peri-operative disciplines, for a multitude of reasons. Dr. Jane Fualal (right), a senior faculty general and endocrine surgeon at Makerere University, teaches senior medical students in the outpatient surgical clinic. The two medical schools in Uganda produce a combined 140 medical students/year.

Photos by Dr. Cephas Mijumbi, and Dr. Doruk Ozgediz

Consent was obtained from patients prior to any photographs and none of the patients in the photos are identifiable.

Trauma in Lira and Kampala

noreply@blogger.com (Doruk Ozgediz) — Thu, 31 Jan 2008 08:00:00 +0000

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

noreply@blogger.com (Doruk Ozgediz) — Mon, 21 Jan 2008 11:55:00 +0000

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

noreply@blogger.com (Laura Goetz) — Wed, 12 Dec 2007 20:00:00 +0000

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

noreply@blogger.com (Laura Goetz) — Wed, 12 Dec 2007 07:00:00 +0000

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

noreply@blogger.com (Laura Goetz) — Tue, 11 Dec 2007 06:00:00 +0000

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

noreply@blogger.com (Doruk Ozgediz) — Thu, 06 Dec 2007 11:21:00 +0000

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.