On the wards of Mulago Hospital

It was another hot, muggy day in Kampala, the capital of Uganda. As we walked through the doors of the pediatric acute-care ward, we were overcome with the multi-sensory experience of Mulago Hospital. The sounds of screaming babies assailed our ears before the swinging doors were fully opened. Inside, with no relief from the heat, we had a full view of a burgeoning population of patients and their families in the hallways. As always, our nostrils immediately registered the unmistakable smell from the overcrowded, disordered conditions. It was all still hard to comprehend for us, two Canadian medical students, even one week into our elective.Angling our way toward the intensive care unit, we dodged mothers’ legs that spilled into the halls as they sat patiently waiting for their children to be seen. Their eyes would continually meet ours, with a blank helpless stare. We probably had the same look on our faces. One thing the hospital had in short supply was pulse oximeters. As a result, oxygen saturations could rarely be monitored. Children who came to the emergency department were often extremely hypoxic but neglected until their oxygen-depleted state became glaringly obvious. Hypoxic rounds involved going up to any random child, hidden among the ever-increasing hallway crowds, and checking their oxygen saturations. When we found hypoxic children we hoped we would be able to treat them.The first baby we walked up to was lying in a crib, still. Placing the pulse oximeter on his tiny finger, our supervisor noted that the oxygen level was only 67%. The baby’s breaths were rapid and shallow. As we examined him closer, we were shocked to find his abdomen was badly distended. All three of us laid our hands on his belly, and felt it was rock hard. We had found our first hypoxic patient on our first try. It was difficult to think of all the other hundreds of children who were in similar states in the same ward.The mother of the boy looked up at us, wondering in perfect English what was going on with him. We explained to her that we needed to bring the baby to the ICU, as there was no oxygen in the ward. Quickly, we picked him up and carried him into the ICU, gave him oxygen and began to monitor his vitals. In our preceptor’s words, this was no doubt “a surgical abdomen,” an absolute emergency, and we knew without surgery his odds were dire. The only problem was we had no idea where to take him for further treatment.Scarcity of suppliesWe turned to other team members, including the hospital’s pediatric staff, but they were not sure how to arrange a surgical consult. After 15 minutes of no answers, we picked him up and carried him to the main hospital, where we hoped to get him an X-ray and into surgery. Upon arriving there and asking for directions to the radiology department, we were sent to the emergency department that was down a long corridor lined with trauma patients. There, we found a large, yellow door, which was closed. A posted sign read: “Attention: There is no X-ray film available today. Sorry for the inconvenience.”We had no idea what to do. We were informed that there might be plain films available at the other end of the hospital. We ran to our next destination, but the staff there turned us back to the place from which we had come. Bouncing back like ping-pong balls, we dashed back to the other end of the hospital again. The baby was using every muscle to draw in as much air as he possibly could. Time was limited.Upon arriving back at the original X-ray room, we were greeted by a radiologist who tried to accommodate us. We explained our case and asked for an abdominal X-ray.It was impossible to imagine what this radiologist goes through. Hundreds of emergent cases were presented to him daily, and given his limited supplies of film, he had to make extraordinarily difficult decisions regarding who was able to get imaging and who was not. He quickly examined the baby and agreed with our clinical suspicion. After some tense moments, we received an X-ray that clearly showed multiple air-fluid levels along with free air. Surgery was our only option, but we still had no consult.The first OR that we entered was small, cramped and devoid of surgeons. When we finally were able to talk to someone from the surgical team, he told us they could not do the baby’s operation that day; it would have to wait. He explained how the hospital had a huge shortage of surgeons. Almost every surgery here was an emergent case. Surgeons were booked solid from morning to night. He recommended trying the other OR suites to see if anyone was available.Again we raced from one end of the hospital to another. At one point, we had to stop to find the closest available oxygen to give to the baby. One rejection after another finally led us back to our starting surgical ward, where we were told to leave the baby and he would be taken care of. At this point, it had been five hours since we had found him that morning. We were relieved. We finally felt like we had accomplished something.Later that afternoon, we went to check that the baby had been brought into surgery. We tracked down his mother, who informed us that they would not do the surgery that day. We were desperate for answers, and asked the nurse why this baby had not been operated on yet. She explained that we were in the wrong place, and the baby needed to go to the emergency department. The baby was then carried to the emergency department, where we waited an hour for a surgical consult.Finally a surgical resident walked into the room, conceded that it was, in fact, a surgical emergency, and promised to schedule the baby for surgery as soon as possible. We left, hoping our actions would not be futile, thinking that this little boy may survive.More delaysFour hours later, before going home for the night, we decided to check in to see how the surgery had gone. We were dumbstruck to find the mother still waiting for him to get his life-saving operation. Throughout all this, she never complained, and always thanked us from the bottom of her heart for our help. She tried to never let her exhaustion show, and always managed a smile each time we came for an update.The next morning, we arrived at the hospital hoping that we would find out that his surgery went well. Unfortunately, we were stunned to hear that he had died. The surgical resident on call the night before did not have experience in pediatric surgery; however, due to the baby’s worsening clinical condition, the operation had to be done immediately, and he was the only person available. While in surgery, he accidentally nicked the child’s liver, causing fatal damage.Out of all the things we learned while on an overseas elective, the one lesson that constantly repeated itself was that life is not always fair.Kathleen Quinn and Holden Sheffield are medical students at McMaster University in Hamilton.

On the wards of Mulago Hospital

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