So the first couple of weeks haven’t been the easiest. The house is amazing, my housemates are awesome, my colleagues are welcoming, Gulu town itself has loads going on. But work has caused a fair few sleepless nights.
I’ve said this already but I’ve come at a perfect time. An infectious disease doctor from Canada called Jan is acting as a visiting consultant for the coming month. The usual medical ward consultant is around but she’s also deputy director of the hospital which makes her a tricky woman to pin down. Therefore, Jan’s presence is gratefully welcomed. He’s also a fantastic teacher so for me, it’s a great learning experience.
First day on the ward: it’s boiling hot and packed full of people. And I don’t mean patients. There are only about 50 medical beds, most of which are unfilled. But there are up to 60 medical and clinical officer students. They all join the ward round trying to observe but when the crowd is 7,8,9 people deep, only half can actually follow what’s going on. The students are forced to just meander about as if their only aim was to check ‘today’s ward round’ off as ‘completed’.
The personal care is completely different too. There are only a maximum of 2-3 nurses on the ward at a time, their role limited to administering medications, doing infrequent observations (such as heart rate, blood pressure, etc) and paperwork. The family of the patients provide food and basic personal needs such as washing. They call them “caretakers”. However, you can imagine if you don’t have any ‘caretakers’ to look after you then things could be pretty bleak.
Our first ward round, we came across a woman in her twenties with HIV wasting syndrome. Her family hadn’t visited since admission and as such, she effectively had no caretakers. She hadn’t been fed for two weeks.
I’ve never seen someone so emaciated before. Her cheekbones stuck out so much they looked like they were about to pierce though her skin. Her eyelids were stretched over her eyeballs so far it was as if she’d been frightened awake. I wished she was asleep so she didn’t have to remember this. Jan and I fed her half a cup of juice and when the father turned up, asked one of the sixty students to help teach him how to feed her. It took a lot of convincing – I had to ask this student about three times, pleading with him that this was a treatment crucial to saving her life. I think the students and doctors here see themselves as having less of a pastoral role and more as academics. It was a frustrating day.
I didn’t stop thinking about that woman all evening; that she’d been left starving for weeks. It seemed obvious thinking about it, that patients would have to sort out food for themselves but it was still so shocking. I felt like kicking myself for being so surprised – what did I expect? That a Sodexo lady would do the rounds providing mushy peas and plastic-like chicken to everyone, finishing the day with a hot cup of bovril? The ward sometimes doesn’t have running water sometimes, why would it have a canteen? I felt frustrated with my own naivety. I told the girls about my day at dinner while tucking into a large quesadilla from the local cafe. It felt more distasteful than tasty. I didn’t sleep well that night.
The next day while doing the rounds in A&E, a motorcycle drove up to the department screeching to a stop inches before sending its front through the double doors. The two American elective medical students pulled a girl, probably around twelve, off the back and laid her on a bed. She had no heart beat so they started doing CPR. Jan was quick to stop them. In the western world, if someone turned up to A&E pulseless, of course we’d start CPR. We’d intubate, give adrenaline, send to ICU. But what’s the end goal here in Gulu? There’s no ICU, no intubation kits, no cardiac monitoring. We couldn’t even find a basic bag-valve-mask. I knew as soon as they started chest compressions that it would be completely futile. I admired their hopefulness but the sound of that child’s ribcage being smashed to bits was too deafening to take anything positive from the situation.
Most of the medicine I’ve learned up until this point feels completely futile too. I’ve just sat my post grad exams, reluctantly learning about the bizillion causes of kidney failure. There are a group of patients with kidney failure on the ward but does having knowledge of the underlying pathology really matter? An adolescent with HIV presenting with gross oedema and a raised creatinine. I begin working through differentials in my head. Focal segmental glomerulosclerosis? Minimal change disease? I quickly realise it’s not relevant. They will never have a renal biopsy to confirm. They can’t even afford regular renal function blood tests. We gave them diuretics and steroids, and hoped for the best.
I finished the first week feeling pretty demoralised. I knew it wouldn’t be easy working here but I’m struggling to get on with it being this difficult. The majority of my medical knowledge isn’t applicable, I have next to no resources and the patients I’m looking after are far, far sicker than the ones at home. I never thought I’d say this but I miss medically fit old grannies and falls reviews.
Finishing on a positive note, we reviewed the woman who hadn’t been fed on Monday and she was doing loads better. Her family had been visiting every day to feed her and it was obvious that she’d gained weight. She can now even raise her arms to feed herself. And give us the occasional wave. That felt like a win.
Getting on in Gulu 