Today was our first day in the hospital!  Unfortunately due to that aforementioned speed bump, neither of us slept well enough to feel refreshed.  Nevertheless we headed out across busy Mbarara Road and made our way to the Emergency Wards for “post-take rounds”. 

The medical system here runs quite differently than ours, which may not be a bad thing.  Medical students pretty much run the show – making sure patients’ orders get completed, taking vitals, sometimes drawing labs, etc.  The intern stays around the clock and admits patients – alone – all night long.  They only call to report to their upper level resident if they have a question about management.  Then the upper level comes in the morning to do these “post-take rounds” to see the patients that came in overnight.  They may or may not agree with the intern’s management of the patient.  There may or may not be an attending present at rounds, so the resident advises the team and then calls the attending if he has a question.

Rounds in the Emergency Ward this morning were busy.  There were several new patients: a confused woman with a diabetic foot ulcer, a young lady with malaria, a young lady with HIV and sepsis, a young man with likely tuberculosis and sepsis, an 84 year old man with likely esophageal cancer, and a young lady with vomiting, found to have diabetes and pregnancy (surprise!).  There was also a middle-aged man with confusion, headache and neck stiffness for several months, and we think likely tuberculosis in his brain.  He unfortunately came to the hospital too late for any treatment to likely help him.

After seeing those patients, I and the upper level resident – Sam – moved on to the men’s and women’s wards to see the sickest patients and come up with their plans for the day.  One ward is probably a little less square footage than my apartment, is open-air, and contains 26 patient beds.  If there are more than 26 patients, the rest just place mats on the floor between the other beds and sleep there.  There is only 1 nurse for 26+ patients, so you can imagine it’s impossible for patients to get the attention they need.  There’s also absolutely no privacy, in stark contrast to our HIPAA-ruled western medical world.  Every patient knows what’s wrong with their neighbor, and care of the patient is discussed openly in the ward.  Since there’s so few nurses, patients generally have a family or friend “attendant” that stays with them around the clock.  The hospital doesn’t serve meals, so the attendant is responsible for cooking for the patient in the hospital’s yard, as well as sometimes administering their medicines and cleaning their wounds.  Patients without attendants get worse care, and unfortunately it seems the sickest patients don’t always have attendants.  Also unfortunately here, you have to pay up-front for your medical treatment, so oftentimes patients’ family will decline diagnostic work-up (chest x-ray, etc) because they can’t pay for it.  Supposedly sometimes patients will “disappear” in the middle of the night because their families are afraid of paying for their bills.  Because of this you’re often forced to guess at a diagnosis, and treat just based off the patient’s story and physical exam.  This is challenging and pretty refreshing compared to how just about everyone in an American hospital gets a CT scan.

Generally when I have patients on a general medicine service at UVA, about 1/3 to ½ of them are dangerously sick.  On this women’s ward, every person seemed dangerously sick.  Most were lying in motionless lumps under blankets on their cots with flies landing on them, occasionally you’d hear coughs and cries.  Some women had no one to care for their children while they were sick, so they had their babies in the bed with them.  There were several patients with presumed tuberculosis.  There was a 30 year old woman with kidney failure who couldn’t afford dialysis, so she was being discharged home with hospice.  There was a 15 year old girl with Kaposi’s Sarcoma in her mouth – that is a cancer that only AIDS patients get.  Another 13 year old refugee girl from a nearby camp presented with bloody diarrhea.  Her whole family had it as well after eating a meal, which reportedly was poisoned by someone else in the camp.  She is better now, but the only survivor, and I’m not sure where she will go when she’s released from the hospital.

There’s definitely a lot to be sad about in this hospital, but there’s also definitely a lot of people who can get better here too.  Young people come in with terrible infections, and with some simple antibiotics and IV fluids they are cured.  Others come in with terrible decompensated heart failure and get relief of their symptoms with a few IV medicines.  That’s really wonderful, and combined with racking your brain over diagnostic dilemmas without tons of CT scans and tests really is what I think I went to medical school for! 

Since there were a few depressing stories there, I’ll share some pictures that I didn’t get to put up yesterday.  There’s a few pictures of our house, the giant storks outside, and the busy road. Enjoy!