The Child

During my shift at surgical casualty, I heard the intern calling the consultant with a case. “Her pupils dilated and non-reactive to light.” Who? Who had such severe head injury? The nursing student told me that the patient was in the resuscitation room. I ran over to try and help out. When I got there, I realized the patient was only a child, looking no older than 4 or 5. And there was no doctor present. One sister was trying to get IV access, and another one was taking the patient’s blood pressure. Nobody was in any hurry, there was no flurry of activity – nothing that I was used to on the site of an active resuscitation. A man was standing next to the little girl, manually bagging her. She had no spontaneous respirations. I checked the girl’s eyes – they were indeed fixed and dilated. The sister was having some trouble getting the BP, so I volunteered to try – 138/92. At this point, a consultant walked into the room. “She’s hypertensive, doctor. I think she has raised ICP. And her pupils are fixed and dilated.” “Ok,” he replied calmly, and started writing notes on the chart.

I ran to my intern and told him the situation. “Shouldn’t we start mannitol? Raise the head of the bed? Maybe hyperventilate her? Send her for a head CT? Give neurosurgery a heads-up?” “Aren’t they doing all that?” the intern asked me. “Not as far as I can tell.” “Well, you go make sure all that is done.” So I ran back to the resuscitation room, and repeated myself. “Should we start mannitol? Raise the head of the bed? Maybe hyperventilate her? Send her for a head CT? Give neurosurgery a heads-up?” “Just make sure her BP is ok before giving her mannitol,” the consultant replied. I stared at him. We had already wasted so much time. Every precious moment we gain could be life-saving. The sister went to reconfirm the BP that I had just gotten, moments ago. “Yep, her BP is good.” She started the mannitol drip while I raised the head of the bed. Then she called the radiographer manning the CT and informed him that we were coming. Then, with the help of another health personnel, we wheeled the patient to the CT unit, bagging her the whole time.

The brain CT was not promising – diffuse axonal injury with severe edema; no intracranial bleeding. There was nothing for neurosurgery to do at this point. I turned to the sister. “Do you think she’ll survive?” “No chance,” came the reply. “Not without a ventilator, and we don’t have any available vents.”

I later found out that the girl had been hit by a car, along with another child. The man with the child, whom I had assumed was a male relative, was just a passer-by who had witnessed the accident. He put both injured children into his car, and drove them to the hospital. The other child had been DOA. This child was barely hanging in there. Her parents had been contacted. We were probably going to keep bagging her until her parents arrived to say their goodbyes.

Surgical Casualty at Mulago

I woke up early, and decided to go into Mulago for half the day. I was supposed to start a new rotation on the surgical casualty service. When I arrived, Peter, the intern, was busy suturing up a head laceration – the result of a boda boda (the motorcycle-based passenger service in Uganda) accident. Most of the other patients that were waiting were all there because of boda boda accidents, or fist fights. And here I thought that there was no violent crime in Kampala. Who would get into a fist fight early on Saturday morning?

I introduced myself to the intern, and he asked me if I knew how to suture. Of course, I’d love to help you suture up some lacerations. Did they use Sub-cuticular stitches for facial lacs? You know, to optimize the cosmetic outcome? “I would if I had time,” the intern replied, “but I don’t. So no.” Ok then. He directed me to the patient waiting on the other bed. Apparently, my patient was the boda boda driver, and his patient was an unfortunate pedestrian who had been knocked over my patient. And they were both in the same room, lying next to each other, awaiting treatment.

My patient had a very deep and long laceration right underneath and along the length of his left eyebrow. The only syringes we had available to inject lidocaine with had needles so large, I wouldn’t want that thing going into my deltoid, much less close to my eye. But it was the only thing we had, so I used it to inject him with what I thought was an ample amount of lidocaine. However, I was really worried about poking his eye (I was working so close to his eyeball), and so proceeded very carefully and slowly. I tested his pain sensation with the tip of the needle, and he seemed to be fine. So I started. But as soon as I started my first stitch, he started pulling away in pain. And I had to follow his head movements with my suture and pickups. He kept fidgeting in pain. After a few painful stitches, he asked me why I couldn’t give him any anesthesia. “But I already gave you a lot,” I replied. I spoke to one of the sisters, who told me that he was probably an alcoholic, and alcoholics are insensitive towards lidocaine. It was true. His breath did reek of alcohol. So I gave him another hefty dose of lidocaine, and he behaved a lot better. I finished up and put a bandage over his wound. Then I asked him if he could move his eye from side and side, and up and down. “No,” he replied, and I felt a cold cold chill run down my spine. I had sutured his eyeball!! And I had been so careful!! But upon further inquiry, it turned out that he couldn’t move his eye because of all the swelling around his eye. If he tried very hard, he could move his eye any which way he pleased. Phew! What a massive relief!!

And I left my shift a little bit early to go buy a helmet. No facial lacs for me please, thank you very much.

Last day on ID

Early in the morning, I called Sanyu, a medical student from Mbarara who was spending her vacation working at Mulago hospital. What diligence! She was Cliff’s friend, and had brought digital copies of a variety of Oxford handbooks for me. I had found my medical education thus far quite lacking in terms of preparing me for Mulago, and wanted to read up on tropical medicine. The Oxford handbook of tropical medicine came highly recommended for this purpose. Long story short, I called Cliff, he called Sanyu, and I had my book!

So I ended up arriving a little late for rounds. But we still finished up rounds quite early. We were fast and efficient, working together like a well-oiled machine. Then, we sat in the nurse station finishing up the paperwork. Many of the attendants of patients on the GI ward came by asking us to discharge them. Apparently, the patients on the GI ward had not been seen by any doctor in days. The intern on the ward had not come to work ever since the interns had switched services, and the previous intern had rotated off the service. “You should call that intern up and tell him to get his ass over here,” I told Dr. Wilson. “No worries.” I went over to Dennis and asked him for the GI intern’s phone number. I gave it to Dr. Wilson, who proceeded to call the intern. “Yes, sir, I will be right over,” the intern responded when Dr. Wilson told him that his patients were asking for him. We left the wards at 7.30pm that night. There was still no sight of the GI intern.

A special occasion

Today, the interns all rotated to new services, and we got a new intern – Dennis. He was a nice young doctor with a can-do attitude and a very friendly disposition. I took a liking to him immediately. Another new event – an internist from Manitoba came to round with us and attend on our service. Since we had an attending with us, Dr. Wilson was eager to put our best foot forward. So when we had patients with Cryptococcal meningitis vs. TB meningitis, and Dennis had failed to procure the lab results, including our CSF analysis, Dr. Wilson dispatched me to go get them. Since I was down on the third floor anyway, I went and got all the lab results from the different departments – Microbiology, Clinical Chemistry, Immunology. I even went to Haematology to pick up the packs of whole blood we had ordered to transfuse our severely anaemic patients, including one with a Hgb of 2.0. Oh, the wonders of the body’s ability to adapt, even to such low levels of Hgb that should be incompatible with life!

Rounds are so much less efficient when you have someone new who isn’t familiar with the patients. We had to present every patient in a fair bit of detail, and have our clinical decisions questioned. The attending was very cost-conscious, and reprimanded the team for ordering new tests instead of trying to track down records from outside hospitals. He also questioned our decision to prescribe a very expensive drug instead of a cheaper alternative for one of our patients with neuropathic pain. Slowly, throughout our rounds, I came to understand one thing. Dr. Wilson believes in providing the best care to his patients. He never settles for anything less – no cheap alternative for his patients; they only get the best available service, medication, everything that our team can offer up. It’s one thing if the hospital is out of a certain drug or a service is unavailable (which happens more often than not) but if that is not the case, then why should his patients get anything less than the best treatments available? Our attending was approaching the issue in a system-based way – save money for the system, and more services to go around for everyone. Dr. Wilson was approaching the issue in a patient-based manner – give each and every patient the best possible care. I certainly can’t argue with either point of view.

Rounding with the consultant

An unusual thing happened today – the consultant came to round with us. She rushed through the critical cases (the patients crowded around the one oxygen tank) and then “had to leave”. But we had one more not-quite-usual case that our SHO wanted her to round on to give the team some advice. Dr. Wilson had just started presenting this case when the consultant turned to me, and asked me for the time. It was 10.05am. “Oh no, I have to leave for a very important meeting. So sorry.” And she left, right in the middle of the patient presentation. Even the patient was shocked by this incident. “Where is that doctor going in such a hurry?” I had come to understand that here, nobody rushed to anything; they only rushed away from something. But I just smiled and repeated what the consultant said. “She has an uber-important meeting that requires her presence – STAT.”