First Impressions of Mulago
on Random Uganda (Uganda), 08/Feb/2010 07:37, 34 days ago
5 Feb 2010First Impressions of MulagoMulago Hospital is Uganda’s National Referral Hospital. Theoretically, Mulago would be the shining jewel in the crown of the Ugandan public health system. It would be the showcase hospital where the best minds and the best technology came together to tackle the really tough cases referred in from the outlying ministry of health hospitals. The equivalent hospital in the US might be Walter Reed, or maybe Massachusetts General Hospital (that is, of course, if the US actually had a health care system to take care of all of our citizens).Mulago was founded by a British missionary doctor, Dr. Albert Cook (OBE), in 1913 as a clinic for venereal diseases and sleeping sickness. The current 1500 bed incarnation of the hospital on Mulago Hill was built in 1962 by the British as a parting gift to a soon to be independent state.The Casualty Ward at Mulago occupies much of the 3rd floor of the hospital’s main wing (the hospital is built into a hill side, so that the 3rd floor is on the uphill side and ambulances and police trucks can drive up to deposit their patients). The main entrance to Casualty is guarded by its own police barracks. Once you make it by the police you enter a darkened waiting area reminiscent of a bus station in the deep south. There is a cage near the entrance for registration, and a small area cordoned off with 5 foot high portable blue-curtained partitions for the triage nurse amid a sea of waiting patients. The triage nurse will write your name and complaint and vitals on a small slip of paper. She will arbitrarily decide if your complaint is medical or surgical, and she will make a swipe with a colored magic marker on the chit—red means you get seen soon, orange means you may get seen, yellow means you will be waiting a long, long time.The Medicine side of the ward operates out of a tiny 3 room cluster off the main hallway. When I visited last week, Edith, a recent graduate from what we would call an internal medicine residency, but now the clinical director of the Casualty ward, was explaining to an intern on her first day:‘don’t clerk the patient (clerking is what we would call doing a workup and writing the patient up), just decide if they are sick or not.’ If they aren’t sick, in the eyes of a brand new intern, they go home. If they are sick they go to Ward 3BM which is a holding area. In Ward 3BM (for ward 3 area B, medicine, not that you’re going to have 3 bowel movements while waiting to see the doctor) the patient’s are seen by another intern with a little bit more time. This intern may order what few lab tests are available (a CBC, a blood smear and a fingerstick glucose, if they aren’tout of strips), maybe an x-ray, and then will decide what service in the hospital will admit you. Then they will tuck you in (I mean this metaphorically, as the only way you will get tucked in at Mulago is if you remember to bring your own sheets) and hope you are alive in the morning to go to your respective ward.Last September I had my 3 month meeting with Sarah, VSO Uganda’s Health Program Manger. Sarah is one of many bright, well-trained young Ugandan doctors who have found it much more pleasant (not to mention lucrative) to avoid the actual practice of medicine and work for an NGO. (there is some irony in the fact that the NGOs set up to improve global health can actually worsen it by hiring away the best of the local doctors).I had confessed to Sarah that the acuity of emergency medicine at IHK was, on average, fairly minimal. She had suggested that maybe I could do some work at Mulago as well. She had thrown this out there almost like a challenge—I don’t remember her actual words, but I do remember the tone in which it was made: ‘so you think you’re ready for Mulago white boy?’So I said,‘sure.’And every few weeks afterwards I would send her an email, or query her as I wandered through the VSO offices, about how she was coming at getting me some work in Mulago. And she would respond that she was working on it. That they wanted this paper, or that paper, or somebody to sign off, or the department of surgery had to be approached, or the department of medicine…Finally, upon my return after Christmas, her response was that‘IHK has a MOU’ with Mulago, and so Kevin (IHK’s recently promoted CEO) should be the one to establish my relationship with Mulago.MOU stands for memorandum of understanding (I had to ask). It’s going to take one hell of a memorandum to improve the understanding around here…And Kevin is so far over his head trying to parlay a career in insurance sales into CEO of a private health care system in a foreign land in the developing world, that he would be the last person to arrange me work at Mulago.So I called my friend Conrad, a Ugandan doctor who studied with me at the Liverpool school and trained at Mulago. He gave me the phone number of one of his classmates, an endocrinologist who finds himself in charge of the casualty ward. A day later I met with him. He wanted copies of my Ugandan medical license and my US registrations. I knew that VSO Uganda had copies of these on file, so I sent an email to Sarah asking if they could make me a set of copies for Mulago. I was informed that, no, I would have to pick up the paperwork and make the copies myself. (VSO Uganda has a photocopy machine and a fax machine that also makes copies)But by the next Tuesday I had gotten the documents to Dr. Fred. And on Wednesday I had the approval of the Executive Director, the Deputy Director (who basically said, in so many words, what took you so long?), and the Chairman of the Department of Medicine to work and teach in the Casualty Ward.And later on Wednesday I was standing on the endocrine ward with Dr. Fred and four fresh interns looking at a man who was dying from multi-organ failure. It appeared to me that the man’s liver and kidneys had shut down (it would have been hard to tell for sure since the only laboratory test the patient had had completed in his nearly 24 hours in the hospital was a fingerstick glucose which was mildly high—hence his admission to the endocrine ward). I talked about trying to rehydrate him without putting him into heart failure, and then, when asked, about some of the more invasive options available ‘in my country.’ After which Dr. Fred said wryly, ‘okay guys, get him on hemodialysis and sign him up for a liver transplant… but in the meantime, see if you can gethim transferred to the Renal ward.’I don’t know. Maybe Sarah, by her inactivity, was trying to save me from myself.