A Day in the Life

I am finding it very difficult to write about my project and medicine in general, thus the content of my posts have focused more on my free time than where I spend most of my time. What I want to say should be realistic yet not so disheartening, and optimistic but not so much as to glamorize the work. But honestly, it is very hard to not be cynical after two months of wards, clinics, and research.
After having worked at Hospital Jose Maria Velasco Ibarra in Ecuador, I thought I was prepared for what I would see at Mulago National Hospital. I believed I would be able to handle the inefficiency and lack of resources more than other mzungu professionals coming from their high-tech, westernized institutions. Part of the reason I want to work in developing countries is so that I never get so dependent on the technology we have at home that I am unable to practice medicine without it. What I have realized is that it isn't always the technology that is holding this hospital back, it is basic necessities that I HAVE become dependent on during the training I have had back home. IV fluids, antiseptic, clean gloves, soap, scissors, tape, paper. You should see me begging to get another pair of gloves, or some lab request forms, and then conniving to get it some other way when I am denied.
Mulago National Hospital and the Infectious Disease Institute are two distinctly separate yet intricately connected institutions here in Kampala. And it just so happens that IDI is Mulago's (and my own) saving grace. The IDI is a model institution that focuses on research, training, and HIV patient care. They see 400 AIDS patients a day in the clinic and are training physicians, scientists, laboratory technicians, and administration personnel in the art of caring for this challenging (medically, practically, emotionally) population. And they have what is lacking on the wards of Mulago - patient advocacy, efficacy, and efficiency.
The IDI is where my research project is based. There is a large cryptococcal meningitis (CCM) IRIS study run jointly by Ugandan physicians, University of Minnesota faculty, and others. The patients are recruited from the Infectious Disease ward at Mulago, and are followed at the IDI after discharge. The physicians here in Uganda have noticed that so many patients and their families refuse lumbar punctures (LPs aka spinal taps) that are important for diagnosis and treatment of meningitis. So my project is to interview patients, their families, and health professionals to find out why there is such resistance to this procedure, and then use their responses to develop patient educational materials for meningitis and lumbar puncture.
I have not yet been able to interview anyone because the project has not been approved by Makerere University after many months and resubmissions. And although I tried to keep my expectations low when I was planning this project, it is still a source of frustration. I have, however, been able to informally ask questions of patients' families who refuse LPs and get opinions from the doctors on the wards, and have been working on the educational materials as much as I can. Helping with the overarching study by recruiting patients, doing their LPs, and being the eyes and ears (and hands) on the ward keeps me pretty busy in the meantime. Along the way, I realize how much I have learned about AIDS, infectious diseases, resource-limited settings, Uganda, research, myself, and my capacity to adapt and change.
I will leave you with my activities from today...
I get up at 6:30 am and out the door at 6:45 when the sun comes up, so I can run around the golf course and still get to work by 8 am.
I get to the Infectious Disease Institute for our weekly "switch meeting." This is a case conference where counselors and physicians discuss patients who have "failed" their current anti-retroviral treatment regimen and determine what the way forward shall be.
After the meeting (which starts and ends on time!) I head over to ward 4A - Infectious Disease.
Rounds have not yet started, but the intern is performing a skin biopsy on a man with obvious Kaposi's Sarcoma. He uses lidocaine to anesthetize, although there is no lidocaine with epinephrine produced in the entire country, so he makes sure to have gauze available because it is never going to stop bleeding. He then takes a scalpel blade minus the handle and cuts out a wedge of skin from the patient's arm. He then takes out the suture, and when I am about to question the HUGE needle he is using, I realize he has no needle driver.
Although I would like to keep up on both sexes, it would be impossible for one person to round on both the male and female sides. So I go to the male side, 24 AIDS patients with varying opportunistic infections. The resident fills me in on who passed away the night before and how many patients are new. As we round, we discover many medications were never delivered or administered; the patient we wrote needed 4 liters of fluids got only 500 ml; the 15 year old whose potassium was 1.6, got only 2 ampules of KCl when we had the mother buy 5. But there are pleasant surprises; the man who came in with undetectable blood pressure is now awake and taking food. That is kind of the usual ratio though, for every 3 or 4 patients who need a lot of attention, the one that gets it might live.
A sampling of the patients...cryptococcal meningitis and CCM IRIS, tuberculosis (pulmonary, abdominal, meningitis, IRIS), Kaposi's Sarcoma (cutaneous, pulmonary, disseminated, IRIS), cerebral malaria, onchocerciasis, candidiasis, toxoplasmosis, snake bite, stroke, lymphoma.
As the staff (and med students) scatter, I stay to help the intern and house officer see the new patients and hustle to get all bloodwork and other samples in before the lab closes. I am putting in IV's, starting and changing fluids, drawing blood, making blood slides for malaria, and getting patients' urine and stool samples. We have a couple LPs to do before the end of the day and a resident from Canada stays to supervise me. We get one done, but are unable to do the other because there is no alcohol available on the ward to clean the site, so we will do it tomorrow before rounds (hopefully).
I go back to the IDI around 4:30, where there is wireless internet, to work on my research project. I get out late today, around 7:15 and head home, across the street, to grab some food and then socialize - my two favorite past times.