Beth Runcie is one of four DMU osteopathic medical students who in May and June are on a four-week rotation at Mulago Hospital in Kampala, Uganda. The rotation is part of DMU’s partnership with Uganda’s Makerere University College of Health Sciences.
Today is day four of working in the operating theater for labor and delivery. We’ve averaged six cesarean sections per day while we’ve been on the floor, but there are actually 15-20 per day and this is usually with two obstetricians (one early shift, one late) doing the surgeries. In Uganda, it is culturally favorable to have a normal vaginal delivery and to my knowledge they don’t induce, so each c-section – or Caesar as they’re called here – is an emergency. The need is so great and resources are so limited that moms could wait for their turn as much as 18 hours or longer.
Mulago is a tertiary referral hospital and, while there is a private pay floor, the majority of the hospital services including the theatre that I’m working in are government-supported so supplies are limited. For example, there is a set amount of suture that can be used, so surgeons improvise and close the abdominal incision in three layers versus six, doubling the number of Caesars that can be performed with what’s available. The hospital can’t provide bedding so mothers bring their own bed sheets, cotton wool, nursery sheets and receiving blankets. Monitors are non-existent and IV flow rates are a guesstimate controlled with a clamp and by poking hollow needles through the top of the saline bottle to relieve pressure and increase flow.
This part of the rotation I’m working with a classmate, Susan Slycord, and today there were two surgeons working with the support staff sufficient for one OR, so we received babies. This includes brief exams (APGAR scores, weight, gender and time of birth); showing mom the baby, being sure to show its gender, cord trimming and identity labeling of each baby. Today was a little tougher than earlier in the week. We really have had pretty healthy babies for most of the week yet today we did three (successful) resuscitations. Overall, two-thirds of our babies delivered cesarean survived. Pathology and complications that I saw here in one day I would imagine that obstetricians might practice for 20 years in the States before they see each once. I was ready to receive one of our babies and the doctor told me it might not survive. I asked how I would I know if resuscitation should be attempted and she said, “Well, if you think it will survive.” For me, that was actually a little ambiguous and I really don’t think that I should be the one making that call, but we did. Fortunately for me, the decision whether or not to do each resuscitation was very obvious so I didn’t have to navigate the grey zone – it very black and white. At one point, both Susan and I were performing separate resuscitations. When my baby was stable, I went to see how her baby was doing and she was very calmly performing CPR on a baby boy. Nothing was sweeter than watching the pink color come into his face and hearing him cry. A baby crying in the operating theatre is a welcomed sound! Cry, babies, cry!!
After the day in the theater, we had our second Luganda language lesson. This has been very helpful because almost none of our patients speak English. Can you imagine waiting 18 hours for a caesar, being in excruciating pain, and having to interpret sign language and trust the mzungo* in the room? Thus, I pay attention and ask questions in Luganda class. After work, Susan and I walked to take care of some errands and had rolex sandwiches** from a street vendor on the way home. We also probably needed to get out and see some life in Uganda. That’s what the pictures are from – my walk home every day. I think you can see that there is much poverty here. It’s so honest and constantly present here, whereas in America (my frame of reference is middle-class Des Moines), it seems you have to make a special trip to be visually aware of it. But I want to make sure that I’m clear, this isn’t all of Kampala – it’s a developing country and there are growing businesses and there are people that have wealth. But here, it’s just all twisted together. Here you can’t get away from it – it’s right in front of you.
*mzungo = anyone with white or light skin
**the BEST and probably healthiest fast food I know. For 50 cents you get chipati bread and a two-egg omelet with onion and tomato. The chipati and omelet are plate-sized, shaped like pancakes and rolled up wrap-style.