Mulago....Mulago.....Mulago
on Sam Elrick (Uganda), 06/Jun/2010 13:57, 34 days ago
It's not for the faint of heart that is for sure. It was with some trepidation that I arrived for my first shift at Mulago Accident and Emergency Department. In some strange twist of fate or lunacy it is a requirement of the Ugandan Nurses and Midwives Council that all foreign trained nurses should complete eight weeks of supervised practice at a major Kampala hospital in order to gain Ugandan Nurses Registration. Some aspects of this statement are a contradiction of terms of course. On my first day I didn't meet another nurse so I am not sure how the concept of 'supervised' practice is working here! In fact in the first month I have not seen the same nurse twice and if there is a nurse on duty she sometimes disappears for hours on end, after arriving somewhere between nine and ten for a shift that starts at eight!About an hour into my first shift I was suturing someone's head. Not something that I have ever done before or not something that I had ever imagined doing. I felt pretty nervous about suturing and felt sorry for the man whose head I sutured. This feeling however was short lived as I saw other people suturing and their techniques and standards left alot to be desired. Of course there are some differences between suturing in Mulago and suturing in Australia. In Mulago there is no light, often no sterile field, rusty equipment which often doesn't work, you don't have to spend much time selecting the sutures you just use what is available and usually that is several years out of date and completely inappropriate for the job at hand. So since that tentative first day there has been much suturing and I have got quite good at it although I am really just making it up as I go along. I am also now very adept at shooing away flies before they land on the wound, although I don't think many clinicians worry too much about that here.I have been working in the trauma room of the accident and emergency department. Most days are a blur of traffic accidents (mostly boda-boda or matatu), mob justice beatings, assaults, domestic violence, burns and bites (yes that is a combination of dog bites and strangely human bites). It is a strange world to exist in. The reality and prevalence of mob justice in Uganda has been a real eye opener. We all know it exists and I have seen it a few times in my neighborhood but to see the magnitude of it in society has been stunning to say the least. I am flabbergasted at the damage humans can do to another, and I am not sure if the punishment ever fits the crime. Mob justice seems to exist whether the crime is real or suspected and the victim has little or no chance to defend himself. Most mob justice victims are beaten with sticks, rocks, fists and feet and present covered in blood with multiple cuts, bruises and abraisions and usually some form of head trauma. More serious cases present with burns (ie beaten then set alight), fractures, sever head trauma, stabbings (eg cut throat) and the occasional gunshot wound. So I guess the motto is.....if your going to be a theif in Uganda make sure you are a really good one and never, never, ever get caught....The Mulago emergency room lacks the frenzied activity of many emergency rooms back home. This took me a while to work out, then it seemed to become clearer that although there were horrific injuries most patients were relatively stable. After careful thought and consideration and some discussion with my colleagues I discovered that patients in more critical conditions didn't make it to hospital. Many accident and trauma victims that make it to hospital in a critical condition in Australian die at the scene in Uganda. There is no public ambulance service in Uganda, and if there was it would be pretty hard to get through the traffic and the potholes anyway. So patients receive little or no first aid at the scene. The issue of life and death is somewhat random. Many patients arrive in hospital in the back of a police pick up truck after being bundled in there at the accident or incident scene, no first aid has been administered until they arrive in hospital and if they are lucky they may get treatment once they arrive. So there it is if you can somehow get to a hospital you could have a chance of survival, if you can't get to a hospital you will just die on a roadside somewhere and hopefully people will step over you......I am perplexed by the numbers of head injuries that present usually as a result of assault or traffic accident. Not once have I seen a patient properly assessed for neurological function or injury, occasionally patients are allocated a CT scan or Xray but many are sewn up, sent home without assessement or follow up. Next week I will start working on the Neuro ward so intend to follow up on these questions to find out just how brain injury is cared for in Uganda and what the impact is on the society. Of course the amount of brain injury here could potentially be reduced by the universal wearing of well fitting helmets by boda-boda drivers and passengers. The use of helmets is rare and most helmets are ill fitting.Working in Mulago is like stepping through a hole in the Universe and arriving in a place like no other that bares no resemblance to anything you have ever known. I have seen some of the most appalling clinical practice that I could ever hope to see. I have see Doctors slap patients, nurses verbally abuse patients and degrade and humiliate them. I see poor practice in terms of infection control. The trauma room is covered in blood which seems to end up on door handles and walls and ceilings, I am not sure how! It is only ever cleaned with water, so I am not sure what microbes and things may be lurking around. Drugs are never checked and vials may be used for multiple patients are often accessed with a dirty needle then used for different patients. IV lines that have been on the floor are connected to patients.....there are too many things to mention.....but it is interesting that this time of practice is to get Ugandan registration and I have only seen bad practice. I am not sure what we are supposed to be learning.Exsisting at Mulago makes you question the very core of health care and ever society here. It makes me question why I am here. I didn't come to Uganda to change the world (or Uganda) but I did hope to make some small amount of difference. Unfortunately it seems that a thousand lifetimes at Mulago may never make a difference. So the question extends, can I really make a difference when I return to my VSO assignment or should I just admit defeat and head home????? The answer of course isn't simple and perhaps doesn't exist yet. So what are aid workers and volunteers doing in Uganda? Can we help? Can we even comprehend what is going on here? Why in a country with 7% economic growth is there no money put into the health care system? Only questions I am afraid, I may attempt to answer them someday but at the moment I can only confuse myself (and probably you) with them.......