The Work of the Day

My day here in Uganda usually starts around 6, when I am woken up by the call to prayer from across the street. I usually lie in bed for 10-15 minutes bitterly cursing before I get up and try to write a journal entry, shower and make breakfast. I’m usually the first one up in the guest house, with the others not getting up until 7, so I try not to bang the pots and pans too loudly.

At 8, Angus and the medical students staying in the guest house leave for lecture- since Angus is only here for 2 weeks he has been doing most of the didactic lectures for the residents at 8 and 3. Usually Cameron and I around that time are looking up cases on the wards or preparing things for teaching. We head across the road at nine dressed in full slacks, button up shirt, tie and white coat in the full African sun, provided it’s not raining buckets, in which case we run.

Post-take rounds start around 9. There is a strong connection here at Mbarara with the Bristol medical school in England for some reason, with alternating rounds of specialists coming out frequently to teach and help on the wards. Also, Dr Wilson is British and is responsible for much of the program. Post-take rounds, which is a British term, are somewhat like our night float accept, except that we all go around in a group, usually the attending, me and the interns, and see all the patients admitted overnight. While one intern is presenting the case in front of the team and the patient, one of the others repeats the examination. After the presenting intern is finished, the examining intern steps up and either confirms or corrects portions of the physical exam. We discuss management and try to make a few teaching points about each case, then move on. The post-take number is variable, from 2 to 5.

After post-take rounds are ward rounds. We have all been divided into ‘firms,’ the equivalent of our ward teams. A firm consists of two PGY’s, an intern and 4-5 medical students. Each firm is responsible for one side of the ward, and the census is entirely made up of patients based on their location; either male or female side of the hospital, and either towards the road (road side) or river (river side). I am currently on the female river side firm.

Ward rounds usually last 1-2 hours, where we go from patient to patient depending on acuity. On Monday, Wednesday and Thursday we have an attending present, but on the other days it’s just the residents and students, which is quite different from the states in that there is no staffing on that day.

We have new medical students that started yesterday, third years. This means that this rotation is only their second clinical rotation, having done pediatrics as their first. Subsequently, they have a lot to learn. Their book knowledge is excellent- when asked about antimicrobial locations of action, they were able to pull out the ribosomal subunit that is acted upon by chloramphenicol without breaking a sweat. I was glad that they didn’t ask me the question, since I would not have remembered. They were also able to rattle off the 5 different organisms to which people without spleens are susceptible. However, their fund of clinical knowledge is, as you would expect, pretty poor. They were unable to take a blood pressure on one patient, and did not know the basic scheme for physical examination. I had been hoping to discuss various articles that I brought with me about heart failure, heart attacks and high blood pressure, but I think that the first week or two will be just focused on teaching basic physical examination skills and presentation skills. I had my first scheduled teaching session yesterday- I had only told the students on my firm about it, but when I got in the room there were 12-14 medical students piled around. It was a little daunting, and more than a little cumbersome, to walk them all around the wards to demonstrate the neurologic exam.

One of our first patients on posttake that morning was an 80ish year old woman (no one knows how old she really is, which is not uncommon) with progressive right sided weakness over the past 2 weeks and a syncopal event where she passed out. Her only real known medical history was hypertension, and when we saw her she was largely non-verbal, unable to adequately communicate, and entirely not moving her right side both on upper arms and lower legs. She was able to move her left side, but wasn’t able to reliably follow commands. Luckily we have Dr Wilson as a resource, since he was doing posttake rounds that morning. Dr Wilson worked for many years in London as the head of neurology and was quickly able to walk us through the Ugandan differential for her presentation. The current working diagnosis is a possible subdural hematoma versus space occupying lesion, both of which are largely not able to be confirmed because they would require a CT scan, not available here in Mbarara. There was talk about sending her to Kampala for consideration of a CT scan, but it isn’t clear that that the family could afford the scan itself even if we were able to transport her to Kampala. Furthermore, it’s not clear whether any treatment beyond that which we are doing could be offered- neurosurgery to drain a blood collection would not be available, and any treatment of a space occupying lesion such as a tumor would not be available. If she had an abscess, or focus of infection causing it we could treat with antibiotics, but she had no other clinical signs of infection. After discussing her case, the most that we could offer her was IV steroids in an effort to reduce any brain swelling she may be experiencing. Regardless of the reason for her illness, her prognosis is quite poor- there are limited to no nursing facilities or programs for physical rehabilitation here, and it is likely that despite her family’s attempted care she will progress to develop complications like bed sores or aspiration pneumonia. We will try to prevent this by talking with the family about her care, but we’ll see. The family or other attendants here are crucial, since they feed the patient, care for them and administer their medications many times- without attendants many patients do not do as well.

Back to the schedule of the day- after ward rounds, we usually head down to the canteen for lunch, a plate full of rice with a side of protein such as fish or chicken, a quarter of an avocado and g-nut sauce, something like a peanut sauce. This mounding plate of food, along with a coke, only runs about 5000 shillings, or $2.50. Usually we discuss the various cases we’ve been seeing in the morning on our different firms, or debate the relative merits of the British versus American medical education system, or medical systems in general (final result, neither are perfect). After lunch, I usually run into town to get errands done, which takes about 45 minutes. Then I come back to the guest house to prepare lecture materials for the students, and head over to the hospital to lecture at about 3 until 4:30. Walking over in the afternoon with slacks, button shirt, tie and white coat is quite a bit more uncomfortable than the morning, unless it has already rained and cooled things down.

Posttake rounds are at 5 PM, with the interns presenting the patients that they have admitted throughout the day. In the early evening, I head back to the guest house and get some reading done. Dinner is alternately eating out or having one of us in the guest house prepare something, taking turns so as not to get too bored with the selection. Then, it’s more reading and preparing at night until I turn in at 10 or so.