Still playing catch up… Posts about Week 3 Cases and this weekend will hopefully happen before we leave town to go !!!SAFARI-ING!!! Wednesday afternoon. FYI this is a clinical post, so it's long and somewhat graphic, so be warned. I'm not offended if you skip this post and wait for more pics of kids and animals! Here's a zebra to tide you over.
***First Ugandan Theater Experience: Every time Dr. K says “Shall we go to the theater?” I have to pause for a second to remember that he wants to go to the operating theater, not to see a Broadway show. Though we’ve seen quite a few operations now, my first back-to-back C-sections (or “Caesars” as they’re generally called here) will always be memorable.
As you may remember the hospital usually doesn’t have electricity or running water, and the same can be said of the operating theater. There are large tanks of sterilized water located throughout (they look like the Gatorade jugs you see on the side of football fields) for scrubbing in and other uses, and if you’re in the theater after dark—and do enough politicking for hours beforehand—there is sometimes a generator available to run lights and the oxygen machine for the anesthesiologist (BTW we’ve now done two surgeries completely without power, and one where it crapped out for 20 minutes in the middle). We wear the usual caps, masks, and scrubs—the hugest and holey-ist scrubs you can imagine—but also giant, white galoshes, the mandatory OR footwear. We’ll bring the camera to work soon so we can document the ridiculousness of our theater attire.
Our first Caesar was on a woman who had been in labor for 2-3 days by the time she arrived from her village, and though the baby was in the correct position the labor was obstructed. We got into our galoshes and into the OR and had no idea what to expect—neither Shalina nor I had seen a C-section before.
Dr. K made a few quick incisions to get down into things, and with the first touch of the scalpel to the uterus a giant spray of brown liquid erupted out, spraying several feet off the table and quickly sloshing all over the floor. We suddenly understood (and were thankful for) the galoshes. We were understandably distracted for a few seconds by the brown volcano coming from our patient’s abdomen, but Dr. K calmly fished around inside the patient and before I could register the appearance of two baby feet he pulled and twisted and tugged the baby completely free of the mother and had her dangling upside-down by her feet in the air. A nurse came and collected the baby and worked on her while Dr. K and another nurse worked on cleaning up and repairing the mom. All of this happened in the first 3 minutes of the surgery, and I think Shalina and I stared slack-jawed and rooted to the floor the entire time.
When things calmed down we learned the volcano was the result of the long obstructed labor. The placenta had already separated (Dr. K had tossed it out right before he grabbed the baby) and the baby had already had its first bowel movement, which is what tinted the color and caused the gas. The baby was not okay initially but resuscitated well, and although the mom developed sepsis a few days after the surgery both she and her baby are doing well now.
The second Ceaser seemed less dramatic, but it was nice to see a more typical case. This mom had also been in labor for over two days, and CPD (Cephalic-Pelvic Disproportion, or inadequate pelvis size) necessitated operative intervention. With very young and very skinny moms here this is a common cause for a trip to the theater (obstructed labor is the other big ticket item). The operation went smoothly and both mom and baby did well afterwards. We’ve had several less positive Caesar experiences this week, so it was a treat to have our first day in the theater result in two babies.
***The Morgue (WARNING: graphic): This week we learned that if anyone asks you if you want to see a postmortem on anyone in rural Africa, you say no thank you. Before we could start rounds Monday morning three detectives arrived from the police station to request a postmortem exam on a 6 year old girl who had died the day before. The parents said the girl died of malaria, but the neighbors suggested that the girl was beaten to death, so the police were investigating. We learned that beating children is common, culturally acceptable, and legal in Uganda—unless the child dies.
Shalina had never seen a postmortem or an autopsy before and was visibly nervous as we descended into the basement. Although I took the autopsy elective winter quarter, and was putting up a tough front as usual, I was still unsure about seeing a child abuse case. As it got darker and smellier I re-remembered that there’s no electricity at Kiboga (so no lights and no refrigeration), and started to think that this trip to the basement may be a mistake.
We were the last two to go through the double doors into the morgue and froze upon entering. There was a dead man lying on a table right inside the door, only partially covered by a sheet, and although it smelled (reeked) like he had been dead for quite a while his blood was running off the table and into a large, thick puddle on the floor. It was horrifying. Absolutely horrifying. The heat, the smell, and the scene in front of us compelled us to move quickly on, and we followed Dr. K and the detectives into the next room.
The little girl had been carefully wrapped in sheets and was still wearing her Sunday go-to-church dress before she was prepared for the exam. Dr. K was quick and thorough in his external examination while the detectives took photos. It couldn’t have been more than 5-10 minutes, but the smell coming from the next room made it feel at least 10 times as long. Shalina was on the verge of passing out—shaking, nauseous, sweating—waiting for the external exam to turn into an internal one. She was sure she would collapse if Dr. K picked up a scalpel, and so after a few minutes she fled for the sunny outdoors and fresh air (smart girl). Two detectives soon followed. For some reason I forced myself to stick it out (though I was also pretty sure I would lose it in the heat and the smell—the smell!—if Dr. K was going to open her up). When Dr. K explained that the exam was inconclusive and that if the detectives wanted a full autopsy they would have go to Mulago I almost fainted from relief. For some crazy reason I stayed while he filled out the paperwork before returning upstairs, and when we crossed through the outer room with the dead man I didn’t breathe and didn’t look anywhere except the exit.
We went about the rest of our day and tried to shake off the horrifying experience, but the smells wafting up the staircase turned our stomachs and reminded us all day of the man in the basement. Above ground people ate lunch, babies were born, and chickens roamed the halls.
***Mycetoma foot: We didn’t see this case in the hospital, but randomly came across a man begging on the streets of Kampala with a pretty advanced, gnarly mycetoma foot. Thanks to microbiology last quarter this case was too exciting not to add to the end of the list! Mycetomas can have a bacterial or fungal origin, and end up causing the tree stump-looking feet you may have seen—feel free to google mycetoma or Madura foot if you care to see pics.
Overall it was a pretty grueling week. There were several other compelling, sad cases this week (that I’m not including here but may show up later) along with the huge daily dose of poverty and disease. In addition we worked like dogs to complete the first stage of our community health projects and choose our topics. I’m sure I’ll be writing lots more about this, but I’m going to focus on malaria in pregnant women, and Shalina is focusing on malnutrition in kids under five. They are both big issues here, and I really sincerely hope we can the community before we leave!
