Burns Unit at Mulago Hospital

I found a picture of the halls of Mulago hospital. Here family members are lined up with their suitcases. They basically live at Mulago. They bring straw mats to sit on, buckets to wash the clothes in and for their family members to go to the bathroom in and throw up in, thermoses... etc.


BURNS UNIT

I had heard rumors of a burn unit at Mulago. There was, there wasnt..... Finally I stumbled upon the very well established burns unit of Mulago hospital. The ICU required and entire changing of clothing and shoes to protect patients from outside bacteria. I wore a hair net and Burn unit cover all. This is the same as I would at MGH. I had once read a book on the history of burn care and basically it hasn't really advanced since the turn of the last century. For this reason, I found the practice of burn care at Mulago very similar to MGH. My day started with washing the patience and soaking the tub in alcohol between. We would wash and hold down screaming children and then bring them to the dressing room where we would hold down screaming children once again. They don't give pain medication unless the case is severe (which there were some very very severe cases so I don't know what it really takes to be considered severe). "It causes addiction" said one nurse. So dressing changes are done without any analgesia. It took 3 people to hold down one nine year old boy. He was fighting us, begging us, losing his mind. So the nurse smacked him in the face. I'm not trying to say these nurses aren't compassionate but the approach is different. Some of the kids were so tough, just taking the pain. Some were so tired of the dressing changes and begging for us to stop. Here the dressings are changed every 2-3 days as opposed to every day like what I'm used to in the States. And the wounds really do look good. I didn't even see any that were infected. I did see one man with exposed bone and no dressing but he was headed for surgery to fix it. In the ICU there were 2 patients: one 45% burn and one 70% burn. In the back room I found a heating lamp, an oxygen tank, a ventilator from 1920, and a couple other machines they must use when the big burns first arrive. "They usually don't make it" the nurse told me. But obviously some did. 70% is a big burn to be able to manage. They get all their supplies donated. They use cardboard from boxes for splints to prevent contractures. They use silver cream and iodine which is very inexpensive. I was impressed by how well managed the burns were, aside from lack of pain medication. It was definatley one of the nicer units at Mulago.

Casualty Ward

Casualty Ward is the equivalent of the ER in the states. It is a dark lobby with where motorbikes and cars constantly arrive carrying bodies. There are ambulances here- usually an old small toyota truck with a siren on top. The medics sit on the sides of the truck- but they do any interventions till the patient gets to the hospital. Even then the doctors yell at us white girls constantly "leave him", "let her rest".... then maybe we can treat the bleeding, painful, complete femur fracture in like an hour. That didn't happen once- it has now happened 4 times. It's Africa- things are done "slowly slowly" or else people feel uncomfortable. I've also seen matatus crammed full of people and one half dead. Sometimes there is nothing but public transport.
Anyway- the casualty ward is F*****!.
Day one begins like this... I walk into a room with 3 men all on old rickety metal gurnies crying out. One has obviously fractured both femurs and they have been dressed but there is still about 1 liter of blood on the floor and that is a conservative explanation. This blood remains there for the next 3 hours till someone mops it away- no disinfectant. The man is obviously loosing too much blood. I mean obvious. It is not until we suggest that the man get some blood that they take some blood to then crossmatch for a unit for him. For example: in the states. The second a trauma comes in vitals are taken, a monitor is hooked up, lines are placed for ressusitation, blood is taken for crossmatching, .......... and also- pain is managed. Here we give a strong NSAID (the equivalent of 4 ibuprofens) as an IM injection in the ass after your fracture has been reset. I have seen so many open fractures from Boda Boda accidents in the past few days it's crazy. There is no morphine in the ED. The Ugandans just grin and bear it like soldiers. I am positive I would be swinging if someone did the things they do without explanation. The orthopedist walks in tosses a piece of cardboard (a splint) on the patient, lifts the leg, sets it- done. He does this with the same facial expression of someone tying their shoe. I got to do some stitches on a man beat by the police. Stitching the scalp takes a lot of muscle. That's the other one I see a lot- people beat by the police.
BUT here's the best one.
I could smell him the minute I walked on the ward. When he opened his jacket I saw a growth like a hollowed out mushroom cloud on his chest. The center was necrotic and inside - what is that crawling all around? magots.
I have also seen a penis that is unrecognizable due to genital warts.
A nose that is necrotic to the bone.
Text book things in my face, so much blood on the floor, and doctors that say "this man is giving me a headache with all this carrying on" and "leave him". (not that they aren't compassionate.. it's just very different).

Mulago Slog Continues

Our afternoon lecture started with a prayer and ended with a prayer. "God- give us the ability to learn and work together as a team. .......". First topic of conversation: a gift for sister Annett (nurse) - a bag of 10 digital thermometers - which she then handed out to the med students because we have one digital thermometer for the whole floor. That is 1 thermometer shared amongst 150 people on the infectious disease unit where we don't have enough sanitizer to spare to wash it. So, everyone gets axillary temps- but that still is crappy infection control. Most of the time they don't even bother with vital signs anyway- I mean what can they do about whatever they find anyway? Second topic of conversation: there is no paper for patient records. There are no file folders left because they were used when the paper ran out. "This is not a problem" announces the Chief doctor on the unit "we just ask the families to buy notebooks". We then discuss a couple cases of death. "If God wants to take a life there is not much we can do"- this is said a few times by different African doctors. The cases are so rudimentary I could treat these patients- scary.
Yesterday at the hospital 6 died- I wheeled beds with dead bodies into the back room as family members hung onto the bed and cried. We start med administration at one end of the floor and work our way through 150 patients to the other end. I get yelled at everytime I go back to hang a second med for someone. I am used to keeping track of people- I remember what I've left unfinished. The nurses at Mulago have no idea what is going on with people they just give meds and keep going. Nothing is explained. If you are a family member, you are the nurse. You must remind the nurse of everything that needs to be done. News has traveled that I will come and help and so people are constantly tapping me on the shoulder. The nurses here could do so much more if they weren't so lazy and the attitude is "it's in god's hands anyway" .. "there's not much we can do". The patients also ask me to buy medications for them because they are poor and I want to sooo so badly. I just know the minute I start that- 150 people are going to be asking me.
Today there were IV fluids finally but no IV tubing. That made it hard to give people their IV antibiotics. There was also no blood for blood transfusions- not that they would waste that on a lot of people anyway.
My little soldier (who is 26- my age- I don't know why I call him little) with the upper GI bleed is still alive. Not exactly conscious, but still alive. Everyone is teetering on death there. Everyone. I don't know why I like him so much- because he's young and his soldier friend spends countless hours cleaning his bloody stool, bloody vomit. I want so badly to seem him monday when I come back but I'm really afraid I won't. With the ones who could use it and get better, I hand them out IV fluids and tell them to save them for later. I know I shouldn't but I can't help it. The young ones- are too young. Death is just a fact of life here. Most women have lost children and it is interesting to see how detached they are. There is nothing I can do about the lack of nutrition. We have feeding tubes but no tube feed. I just instruct people to force feed their loved ones. They all line up for porridge, which is the only food the hospital provides. Porridge here is some white, nutritionless, grain in milk. They get one mug per person. And that is if you have a family member to go and get it. People that don't have family go unwashed, unmedicated, unfed, no sheets, ..... Often another person, a stranger, will help them. But they won't buy things for them. Yesterday I found more than one person lying in their own shit and by the looks of things had been for days. There are no sheets so I couldnt change them. Today- I'm going to the market to get some. Here if you are strong enough to walk- you can walk home.

On a lighter note: went to the R Kelly concert last night which was the concert of the year. Thousands of people just lovin R Kelly. Remix to Ignition.. I believe I can FLy. It was just as entertaining as it sounds. Getting in was scary though. The line broke and everyone ran for the gate. As we started to get crushed (and I started to get the "shit shit shit"feeling), the crowd erupted as police started hiting people with sticks and firing into the air in front of me. I mean literally 2 people away from me. The color of my skin saved me from being hit. Nobody cares about the black man- not even Africans. We ducked and ran in. Then in the crowd to see R Kelly I was pushed into the middle of 2 fights. Then when we left, we hoped on the back of a motor bike. We are zooming between cars with the traffic and I here the screech of tires to look back and see a car loose control and hit the median like 10 feet away from me. My whole pack of guardian angels is still hard at work- even at 3am. We danced all night... again. I really love Kampala.

Day 2

Today we had no IV fluid so we couldnt even give meds till 1pm because we had nothing to mix them with. I only wrapped one body today- but two died over night. Families watched in amazement as I helped a woman dress. That just isnt done by the nurse. They were like this girl's got a Florence Nightingale complex. What else- I saved a life.. of that I am sure. And my little honey better be waiting for me in the morning cause I worked really hard to jerry rig oxygen and catheters and fluids. And it's hopeless really. 27 with upper GI bleed. For the most part, at Mulago, if someone has a something actually life threatening you just watch them die to save the supplies for someone who will most likely make it. I organize family members to help me carry the beds because none of the wheels work. O2 tubing is IV tubing cut and taped together. There are 2 IV poles and they are both missing all the wheels...hanging off to the side. There's so much left over supplies in the states that could help these people. I don't even know why they come. A lot of families say "let us go. we think he's gonna die".

Mulago Hospital, Kampala Uganda

So after networking for a week and doing things Pole Pole (slowly slowly) African style, I get us into Mulago Hospital- the national hospital of Uganda. We enter right into the heart of the beast- infectious disease ward.
There are not rooms. One big room with beds lined up. If there isn't a bed, your family buys you a mattress to sleep on. There are 2 nurses and 2 student nurses to 75 patients. Because of this, your family comes and stays with you. It's required really- if there isnt anyone, the nurse will ask "where are your attendents?". Your family buys you all your medical supplies from a store, all your drugs from a pharmacy, all your food from home, all your bedding from home, your clothing, your diapers, your bucket to puke in. Provided by the hospital is: bed if lucky, IV fluids - which were not available today ("we will probably loose a few to dehydration today" a doc says casually at lunch) , and IVs... oh and medical tape. The nursing team starts at 10am and begins administering medications to all the patients. This continues till 4pm. Family does bed baths, walks you to the bathroom, ties you to the bed when you are thrashing, etc.. The nurse only has time for meds and if you die. I started my shift with wrapping a body and ended it with wrapping a body.
"Come someone has died" he says with a smile on his face. I walk into the room to find a man lying on the floor in all his clothes: pulseless, cold, pupils fixed and dilated. Everyone- family members and patients- are just watching me as I wrap the man in a sheet and find some people to carry him to the "treatment room". No one is sad, no one is scared, no one even cares.... in fact someone cracks a joke.
Medication Administration:
There is a sheet at the end of the bed where the doctor writes what should be prescribed. The family takes the sheet to the pharmacy. The nurse takes the medications from the family and administers them and writes it down on the paper. I administered meds all day and I don't actually know what were any of the diseases I was treating.
I thought we would just be a nuisance but the nurses welcomed us. Just started telling us what to do. In nursing, your senior knows more- just listen to them. At Mulago- they were so nice, never judging our qualifications, just teaching us what they do so that we can help. I understand- because they need it. I taught how to properly drop NG tubes today and they listened... weren't annoyed with me at all. At the end of the day they said "thank you" all smiles....
In the midst of all the problems there are here, there are some things I would like to learn from Africa:
-how to laugh when you are scared
-how to laugh when you are mad
-how to laugh when everything is shit
-how to be patient
-how to be quiet when you don't trust a situation
-how go pole pole and hakuna matata
-how to drive a boda boda

Kampala, Uganda

When Chimp trekking falls through, we hitch a ride with a tour group back to Kampala. We shop in the market all day- something that never gets old for me.... and then out at night. We spend the weekend dancing and making new friends in our new home. When we arrive at our new house, things are mmm... not what expected. We are 30 min out of the city, working in a clinic- not a hospital- and staying with a family who eats at 1030 at night, doesn't want us out past 9pm and lives in a locked compound, and we are sleeping in a room filled with mosquitoes and no place to hang a net. Not pleased. But on the bright side I have not paid and my friends are coming in handy- picking me up and hopefully finding me work elsewhere. I really don't care how nice she is- just doesn't work for me. So today we are going to sort it out.

Murchison Falls, Uganda

It occurs to me that I may sound a little insensitive to the poverty in Africa. I'm not. My point is only that things are different here and I see positives with the negative. Positives that Africans don't articulate to me because they have nothing but America on the TV to compare their country to. I'm reading The Sum of Our Days by Isabel Allende and she so eloquently puts what Ive been noticing around me:
"At first it was difficult for Willie to understand my obsession with gathering my children around me, to live as close to them as possible and to add others to that small base to form a large, united family I had always dreamed of. Willie considered it a romantic fantasy, impossible to carry out on the practical level, but in the years we've lived together not only has he realized that this is the way that people live in most parts of the world, but also that he likes it. A tribe has its inconveniences, but also its advantages. I prefer it a thousand times to the American dream of absolute freedom, which, though it may help in getting ahead in this world, brings with it alienation and loneliness."

I'm currently in Murchison Falls, Uganda which in its day was one of the premier game parks. Poachers killed most of the wildlife but today Rhinos have been reintroduced and most of the other wildlife present has returned to normal numbers.
To get here we leave at 7am - sick again from something we ate haha. Get on the bus with shit tummies and proceed to travel from Rhuengeri, Rwanda to Murchison Falls, Uganda. This is a 48 hour journey. 14hr Bus, 4 hours sleep, 5hour bus, 3 hour matatu of death (breaks down twice, nearly kills 2 separate bicycles and when the African's scream you know it was serious. Even if they are still laughing. We skid all over the road in the van-with all 25 passengers braced for impact... and it is clear to me that I have a guardian angel- a team of guardian angels ;)), 1 hour ride in a mattress truck, half an hour motorbike with full pack= future back surgery. My boda boda driver's name is "trust" -right- which I find ironic for a number of reasons. He guesses that I'm 16 years old- as most people do. My little blonde friend is usually presumed to be 30 because they think her hair is white. This is funny for a few reasons: 1- this is not the first blonde they've ever seen surely because Africa isn't that isolated, 2- because people don't grey at 30 here, 3- because her hair is clearly yellow not white, and 4- because she's 23...... oh and finally because it really pisses her off. She's a diamond though and we wander around this part of Africa together- laughing and taking care of each other. Plus she knows all the songs from Mary Poppins- she's British.. not her fault, but me- I have no excuses.
We take a boat along the Nile- which is filled with hippos, elephants, crocs, and birds along the banks. We are riding up to the falls. It's "one of the most spectacular things to happen to the Nile" according to Lonely Planet: East Africa 2003- which, in our experience, is FOS (full of shit). But in this case, the falls are TREMENDOUS. They fill the word to it's full extent. We are blown away by its obvious power. We also go on a game drive which is beautiful but not all that impressive as far as animals go- giraffe, buffalo, elephant- no lions ;) Luckily we pay 1/4 price.