The Hair Issue, Part 2

After weeks of rocking the afro (something I have never done before this trip), I decided to do somethinig different.  Braids have not ever really been my thing but I figured when in Rome. . .

"I've killed patients during my internship. . .I'm Learning"

"I've killed patients during my internship. . .I'm learning".  Yes, that is a direct quote from the intern I have been working with. The statement is scary enough but when punctuated by an apathetic shoulder shrug and an air of indifference it was almost chilling. 

I had been working with this intern on the endocrine service at Mulago Hospital for at least week when she made this revelation.  She possessed what is perhaps the most dangerous combination of personality traits that a physician can have: apathy, lack of knowledge, disinterest in learning, dishonesty, emotional detachment, cockiness and poor work ethic.  It is just a recipe for disaster. 

When we first met, her lack of clinical knowledge, poor clinical judgement and laziness were obvious.  She would stroll in around 8:30 and not be prepared for rounds.  As an attending, I tried to coach her through history taking, physical exams, developing a differential diagnosis, and making treatment plans.  I was hoping to help her "look good" for her Mulago attendings.  She really was having none of it.  If she saw me examine a patient, she would ask for my findings instead of examining the patient herself, write them in her poorly constructed notes and look expectantly at me to feed her the plan.  If she did ever venture to develop a treatment plan, it was more often than not incorrect and thoughtless.  But I still encouraged her to try.   After about two days of this, I reminded her that at the end of this rotation, that she would be an independent medical officer who would have sole responsibility for the well being of her patients.  This was met with a blank stare.

With every day, I was losing patience with her and beginning to feel my efforts were futile.  I finally asked her why she became and doctor and why she was bothering to continue with her training.  Unfazed, she replied that as a child she watched ER and was fascinated by George Clooney.  Her parents "foolishly" encouraged her in her studies.  As she began her clinical studies, she would cry when a mother's life was lost labor but now if she saw a woman giving birth on the side of the street, she would "hurry up and pass".  Now, toward the end of her internship year, she feels that she is "numb, not even human".  If nothing else, at least she is honest about who she is.  When I asked her again why she would not consider going into another profession now, she said she thought this would be temporary and that once she finished internship and could practice in a better environment, things would be better. 

Teaching her was an arduous task.  She can quite delusional about medical information.  I actually had to show her in print that Hepatitis B is not routinely transmitted via kissing.  Even after this, she stated she would still go and "look it up on eMedicine". 

Her apathy is epic.  In reviewing a 30-somethinig year old patient who had cirrhosis and later developed a seizure while in the hospital followed by a new focal neurological deficit (which I discovered, since she had not bothered to examine the patient after his seizure), she could not understand why I would bother asking for neuro checks or a head CT because "hepatitis has a poor prognosis anyway".  At least she was willing to write the consult to have gastroenterology see him for the hepatitis.  She was actually proud as a peacock that she thought of that. 

She her work ethic is some of the worst I have seen. She did say that with being paid what she calls "pocket change" during her internship, she has decided that she is not going to let the patient load or work break her back. So she does "what I can" and will do no more.  On the weekend, she arrives at the hospital around midday.  She cringed when I suggested she get to the hospital earlier than 8 am.

She is a danger to patients. It is one thing if there were upper level residents to pick up her slack. They have all been absent because they have exams (which I find ludicrous, but that is a whole other story). It would also be different if there was consistent supervision from the hospital attendings. But she is there, alone, mostly unsupervised taking care of some of the sickest patients that I have ever seen. 

She has expressed a fear of needed to repeat this three month rotation in Mulago. She, however, has not yet made the connection that her actions (or lack thereof) are going to lead her right down that path. She is someone who I would fail without hesitation.  On my last day working with her, she decided that she was entitled to have a life and would be taking a three hour lunch. This despite the fact that the majority of the patients had not been seen. It was the last straw for me. I reported her to one of the attendings in the department of medicine.  I felt a bit of relief when it was revealed that her suboptimal behavior had been noted and that she was indeed in danger of needing to repeat the rotation. 
So in stepping back and looking at the entire situation, it is hard to know how much of this is due to intrinsic personality deficits and how much is the culmination of years of working in a medical system that does not work.

Camping, Murchison Falls and Chimp Trekking

This past weekend was a definitely a first for me. Though I strongly feel that I am not high maintenance (just maintained highly), there are certain things that I just don't do. Camping is one of them. I've NEVER been camping in my life. Bugs (many of which refuse to die if you just step on them), outdoor toilets, tents, no electricity, paying to rent a ratty towel, and cold water showers in an unspeakably filthy communal bathroom are just not my idea of a fun-filled weekend. But I am proud to say that I did it and survived.

Family of warthogs wandering the camp site

Red Chilli Rest Camp

So to go back to the beginning, this weekend was my second trip out of Kampala. A group of us ventured north to Murchison Falls.  The first stop on our journey was the Ziwa Rhino Sanctuary.  Though rhinos were once numerous in Uganda, they had been hunted and poached to near extinction by the 1980s with the last rhino seen in the wild in Uganda in 1983.  In 2004, Ziwa was established to help breed the rhinos with the hope of eventual repatriation to the wild.  The sanctuary allows pretty close contact with the rhinos.  It was a hot trek in the bush but so worth it. 

Rhino trekker and a pile of rhino poop

Baby and Mama Rhino

The following morning, we crossed the river Nile and went for a game drive in Murchison Falls National Park. There were legions of bird species, hippos, giraffes and 3 of the big 5.

Abyssinian Stork

Hippos in the background

Hippo footprint

That evening there was a trip to the top of Murchison Falls. At this spot, the massive Nile River converges and pushes through a narrow gap in the surrounding rocks making powerful rapids and mist.

sunset at Murchison Falls

Murchison Falls at a distance

The following morning was perhaps the highlight of the trip.  Entering the rainforest to trek for chimpanzees was both exciting and scary.  They went about their daily business without much regard for us.  They were fun to watch in their various modes of courting and play. 

Being a fashion designer vs. Being a Doctor in Uganda

A little known fact about me:  when I was deciding what I wanted to do following high school graduation, I had strongly considered applying to Parsons or FIT with the goal of going into the fashion industry.  Being practical, I decided to attend a regular 4 year college to keep my options open.  In addition to loving fashion and clothing construction, I also loved science and knew that medicine would not be feasible with only a Parsons or FIT background.  At some point in college, I finalized the plans to go to medical school.  I knew the training would be tough: four years of non-stop studying followed by slaving away as an intern and resident.

Though my journey to become a physician was by no means easy or without its challenges, I tip my hat to the Ugandan medical students and residents.  Why? Because if I had to do what they do to become a doctor and get paid the salary that Ugandan physicians get paid, you surely would be wearing the spring line from the Sheryl Natasha House of Fashion instead of reading a blog written by Sheryl Natasha Young, MD.

After secondary school (or the equivalent of high school in the U.S.), the Ugandan students who qualify will enter medical school.  There are some private as well as publicly funded spots for these schools.  After medical school, they enter internship year.   One intern can be responsible for twenty to thirty patients. An internal medicine intern training in the United States is limited to providing ongoing care to a maximum of TEN patients.    

The work of an intern involves evaluating patients, drawing blood, inserting tubes for feeding or urinating, communicating with families and a laundry list of other duties.  This makes for very long hours.  The days off are limited.  Per one intern with whom I recently worked, he had no days off in the preceding 7 weeks. They get paid the equivalent of $250 per month.  From my observations, the interns work and function without consistent supervision, education, or support.  

After internship year, the intern may go into general practice in the community or return to obtain more training as a Senior House Officer (the U.S. equivalent of a resident).  This involves working long hours supervising interns and providing care to a large number of patients.  Because this training is seen as Master’s level program, the Senior House Officer pays for his or her residency training.  This was astonishing to me as I could not ever fathom paying to do residency.  Though I did not get paid much during residency, the fact is that I got paid.  And my salary was sufficient for a decent standard of living. 

After finishing residency, Ugandan physicians then go out into the world to make $700 per month.  That’s less than what I made as a resident and less than what a moonlighting hospitalist in the U.S. can make in one 12 hour shift. Many Ugandan trained physicians will leave the country and go to places such as Rwanda, where they can make $2000 per month.  Those that stay hold more than one job to support themselves or go into research. 

The collision of a harsh training environment, brain drain, and poor compensation results in a milieu in which patient care can get lost in the crossfire.  In realizing this, I now have a better understanding of some of the things I have seen in the hospital.

Today Was a Good Day

Today is Labour Day in Uganda meaning that there was no laboring today.  I started my day off at about 9:30 or 10 with a transfer from the bed to the couch. I enjoyed a hot breakfast which I usually don't get on the days that I work.

Around midday, trekked to the mall, had the ice cream that I had been craving for three weeks and did a bit of grocery shopping.  In the afternoon I  engaged in one of my favorite indulgences and got a massage at Emin Pasha (50 minutes for 50000 shillings aka $20!!).  I followed this up with one of the best meals I have had since I have been here- chicken and spinach with fried plantain at a West African restaurant named Mama Ashanti. 

In all of this, I racked up 4.86 miles of walking.  Now I'm resting my weary legs and getting ready to go to HIV clinic tomorrow.

The food

Above is my typical lunch from the hospital canteen.  That's chicken, rice, pumpkin, matooke (mashed green plantain) all for 7000 shillings ($2.80!!!!).  After a while, it has gotten a bit tired but it's cheap and keeps me full. 

A 4000 shilling snack (drink included, $1.60!!!)

It's no secret that I like to eat. I'm still navigating my way through the culinary landscape in Kampala. Thus far, it has been a mixed bag.  Sometimes, the restaurant menus are a wish list of suggestions.  Most things won't be available.  And you won't find this out until about 30 minutes after putting in your order.  It's never a good scene to let hungry Sheryl know 30 minutes after her order is placed that she won't be getting her food.

There are both some familiar and unfamiliar things.  Some of the foods (especially matooke), remind me of things from my Jamaican roots.  Indian restaurants abound, which is great for me.  I still, however, have not found anything that has blown me away.  Admittedly, I am a food snob, so that makes things difficult.  I will continue my quest to find fabulous dishes in Kampala.

She Survived!!

When I walked into the cancer ward this morning, I was elated to find the patient who yesterday vomited at least a half gallon of blood was alive. . . and smiling no less.  She said she felt much better and the vomiting completely stopped.  She still had not been seen by gastroenterology or received all of the medications that were prescribed but she was awake, in good spirits and able to sit up.  Miracles do happen.

Now I have seen it all (not for the faint of heart)

After taking a break to go to the outpatient Infectious Disease Institute Clinic, I returned to the inpatient cancer ward yesterday.  There was a 17 year old patient there who was being seen by the medical student.  I asked the medical student if he needed any assistance and he hesitated.  The patient promptly began to vomit bright red clot-filled blood into a bucket.  Now, I will fully admit that I can be squeamish but I was able to remain calm despite the fact that in all my years of training and practice I have NEVER seen this before.  I went through the assessment with him and told him what needed to be done and asked him to get everything started.  She stopped vomitting and layed back down. 

The oncology attending arrives and asks how far we have gotten on rounds.  As if on cue, the patient vomitted another round of bright red blood with gigantic chunks of clot which unfortunately landed on the floor.  "Ahhhhh, that is not nice", the attending replied and he commenced rounding.  Despite my previous experiences, I still had some expectation that the sight of bloody vomit would incite some panic or rapid and decisive action.  As we went through the chart, it was discovered that she had not gotten the medications that were recommended the day before when she first started vomitting blood.  Her personal attendant was no where to be found and the attending physician reminded me that when there is no attendant, the patient's care is compromised because there is no one to obtain and administer the medications that are prescribed. 

I asked how to get a GI consult.  Unfortunately, it seemed that of the two endoscopes available, neither one has the fully ability to band, sclerose, or biopsy.  We were, again, in Old Mulago.  Any scoping would need to be done in New Mulago which is about 1/4-1/3 of a mile away.  The GI attending would need to come up the hill to do the consult first and then decide what to do from there. There would be a delay in even getting the consult because we did not have our cell phones available to call.

I was amazed by the team's ability to continue rounds despite the 17 year old who had again vomitted blood for a 3rd time.  I was completely distracted but felt helpless. 

This morning, I am preparing to go back to the ward with the hope that she received at least some of the things that she needed and that she is still alive.

Ethical Dilemmas

She was a new admit to the cancer ward.  From the brief history I could get from the house officer, she had a history pancreatic cancer (not sure what stage, not sure what her DNR status would be) and was coming in for change in mental status.  "Change in mental status" was a bit of a euphemism.  She was actually completely obtunded, unresponsive with eyes open.  Her attendant could only tell us that the day previously she ate lunch without incident and then was no longer herself.  Her blood pressure and oxygen saturation were too low to be measured.  Her hands and feet were ice cold. When we initially examined her, she would swat our hands away.  And then she stopped breathing.  In any other setting, this would be reason to call a code.  She did resume some form of breathing on her own.  I asked the house officer about transferring her to a higher level of care/monitoring but was told that this patient would not meet criteria for being in the ICU (I'm still trying to figure out exactly how close to death you have to be to get into the Mulago ICU).  Besides, we were in Old Mulago and the ICU is in New Mulago which is about 1/4 of a mile away with no easy way of transporting her over there.

In that moment, perhaps the house officer saw what I could not.  I was looking at the immediate need:  If someone stops breathing or if they do not have the proper circulation, you FIX it.  Especially when the patient was doing 'well' and ate lunch with her family just yesterday.  But in looking at the 'long' term, you have a patient with a diagnosis that carries a poor prognosis AND she is in a resource deprived setting.  So do you try to make this person better or do you preserve the few resources that you have? In this particular case, the house officer gave her fluids and antibiotics.  She died that night.

In addition to allocation of resources, the other dilemma that arises frequently is the reluctance to have frank discussions with patients about their prognosis.  For example, a renal failure patient needed dialysis.  Dialysis is expensive.  The patient's family sold land, property and possessions to pay for 5 sessions of dialysis.  Since dialysis is a lifelong need, what do you do when it is time for sessions 6 through infinity? So how do you counsel the family who is selling all of their possessions for 5 sessions of dialysis?? 

'A single man with a child is not natural'

One of the highlights of last week was visiting the Sanyu Babies Home.  It is an orphanage with the capacity to provide homes to about 50 children up to the age of 3.  We got a tour of the orphanage and learned a bit about their mission and the placement process for the children.  When adopting from Sanyu (and perhaps throughout the country), there is a specific hierarchy.  First priority goes to couples who are natives of Uganda.  Next on the list is single women.  After that they will consider foreigners who live in Uganda.  If all else fails, international adoption will be considered.  Being the curious one that I am, I asked where in the priority list do single men fall.  The orphanage administrator looked at me like I had three heads and said that it was not natural for a man to adopt a child and that a single man would never be considered in the adoption of a child.  At that point, I figured I would not bother asking about same sex adoption.  I thought it was shortsighted that no single man would ever be considered a candidate to adopt a child.  There is clearly a need for adoptive parents.  If there is a single man who has passed the same screening  process that the single woman has passed, why is he not worthy of adopting?  Any thoughts??

Anyway, next was playtime.  The children just needed and wanted lots of hugs.  I was happy to oblige.
The kids were playful, rambunctious and all around fun.  No pics because no cameras were allowed :-(