A chain of unfortunate events

I arrived early in the morning and found Dr. Christopher on the surgical ward. We decided to quickly do some rounds. I told him to start with the female ward, since we had rounded on the male patients the day before, but I was fairly sure nobody had rounded on the female patients. Before we even got started, an emergency case had presented itself. A 9-year-old boy presented with fevers, abdominal pain with a distended abdomen; most likely diagnosis – intestinal perforation secondary to Typhoid. Dr. Christopher was thrown abruptly into a bad mood. “I’ve seen too many cases of this. Too many. There is some unsafe source of water around here, and we should figure out which pond or well it is, and seal it off. You know these children, we don’t always save them. We lost close to half of them. And it’s completely preventable.” I could see why he was angry. I was getting pretty angry myself. We took some blood from the boy, and sent it off for CBC and type and cross. The boy looked severely anemic, and would most definitely need blood before surgery.

Then, Dr. Christopher was called to a meeting with a public health official, and left me alone to start rounds with the nurse. Armed with my copy of the Uganda Clinical Guidelines in one pocket, and the Oxford Handbook of Tropical Medicine in my other pocket, as well as the extensive knowledge and experience of the nurse, we started rounds. Halfway through rounds, I realized that I was going to survive this. Surgical patients are not terribly different the world over – make sure that they’re wound is healing and not getting infected, they’re urinating well, passing flatus and stool, tolerating oral diets, ambulating, pain is controlled. I could actually do this! I could manage this ward. And I started to feel like I could possibly be close to something like a real doctor.

Towards the end of rounds, we saw a patient who was on the wards for diabetes. “Why is she on the surgical ward?” I asked the nurse. “She was admitted with a diabetic foot ulcer. Any type of wound, they end up on the surgical ward.” “But her ulcer is well-healed, and she’s mainly here for insulin management. We should transfer her to the medical ward.” “They won’t take her.” I sighed and moved onto the next patient. Exact same thing, except this patient looked sicker. She was sweating, shaking a little, hugging herself. I took her temperature – normal. Just then, Dr. Christopher came back from his meeting, and took me aside. “Doctor, I really must advise you not to touch the patients without wearing gloves.” “But I’m only taking her axillary temperature.” He came in closer and whispered, “With this Ebola outbreak, we all have to be more careful.” As it turned out, the meeting with the public health official had been about the recent Ebola outbreak in the neighboring Kibaale district. We had heard about a “mysterious disease” that had taken 16 lives in Kibaale district, but the news reports had been intentionally evasive about the exact nature of the disease, its symptoms, its speed of progression. After a few days of this “mysterious disease” business, the authorities finally confirmed it to be Ebola.

The tension and fear had spread to Mubende. Dr. Christopher’s fear was contagious. I looked at the diabetic patient whose temperature I had just taken. She looked sick, she had abdominal pain, she felt febrile even though my thermometer had informed me otherwise, but thermometers can be faulty after all. What if she had Ebola? It could be spread through any bodily fluid, including sweat, and this patient was sweating profusely! “Dr. Christopher, there’s something wrong with this patient. Doesn’t she look really really sick to you? As in really really sick?” I asked him in a panic. He glanced at her. “I think she’s in DKA.” Oh. Right. Of course. Diabetic patient with poor glucose control. What was more likely? Ebola or DKA? I felt ridiculous.

We quickly finished rounds, and I inquired what time we were going to operate on the boy with the intestinal perforation. “Oh him. His blood came back as O+, and we’re out of O+ blood, so we can’t transfuse him pre-op. We have to transfer him to Mulago.” “Do we have an ambulance?” I asked. “Yes, but I think it’s out of fuel. The boy’s family will have to buy the fuel.” “And if they can’t afford the fuel?” Dr. Christopher shrugged. It was just another one of the countless problems facing one of his countless patients. He couldn’t solve all the problems facing all his patients, so he was going to focus his efforts on the problems that he could solve and help the patients he could help. Unfortunately, this boy was not one of them.

Just then, I got a call from Robert. Tuesdays were circumcision days at Mubende Regional Referral Hospital, and I had mentioned to Robert that I wanted to learn how to do circumcisions. In the US, ObGyns are no longer trained in the technique of circumcision, and have to ask the pediatricians to do them. Personally, I would like to be able to deliver a baby and do the circumcision, if that is what the parents want for their baby boys. So I left Dr. Christopher, and went to find the circumcision room.

I found 2 clinical officers in the midst of speed-circumcision. They were each competing to see who could circumcise at a faster rate, with better cosmetic outcomes, etc. I learned that there were two main techniques of circumcision – the dorsal slit and the forceps-guided methods. I also learned that neither of the clinical officers were very good teachers. At the end of the day, I guess I could do a circumcision on my own in an emergency situation (but who really needs an emergency circumcision?), but otherwise, I would still not be comfortable doing the procedure without any supervision. And the last thing I learned – I never want to circumcise a young child without general anesthesia. The only form of anesthesia we had available was local. We received so many young boys brought in by their parents for circumcision. They started howling as soon as they were placed on the operating table. The boys cried and screamed the whole way through, looking at us like we were trying to murder them. And we could never tell whether they were actually feeling pain, or were just scared. This was another reminder of why I hated pediatrics so much. I walked away from the day knowing that I had deeply traumatized and psychologically scarred several young boys, possibly for life. Would they trust any doctor ever again?

Towards the end of the day, amidst the screams of the young boys undergoing torture/circumcision, we received some disturbing news. A patient suspected of having Ebola was brought to the hospital for treatment. A chill traveled up my spine. Ebola. The word struck fear into the very deepest part of my soul. I couldn’t think of a worse way to die. But what happened to helping people? What happened to taking care of the sick? If doctors run away from diseases, what will become of the patients?

That night, I did some soul-searching. What was I so scared of? Was I really that terrified of death? I could take the necessary precautions to give myself the best protection against the virus. I could wear goggles, gloves, a mask and gown, and wash my hands scrupulously. But what about all those healthcare professionals who were wearing personal protective equipment but still died during the Ebola outbreak in Gulu? How did they catch the virus? How did they die?

In the end, I realized one thing – I’m afraid of dying, I really am, but I’m even more afraid of not living fully. I cannot allow the fear of death to prevent me from fulfilling my duties as a doctor, from taking care of my patients, especially if I have a reasonable chance of survival. But I absolutely cannot die before my mother. I don’t think she would be able to stand that loss. The weight of all of her hopes and expectations, her happiness and sorrow, her life and death, they all rest on my shoulders and mine alone. We are two in the world, and I cannot leave her alone. I bear the burden of an only child of a divorced mother, and what an awful burden that is to bear. I owe my mother my life – from the moment of my birth till the second of my death. I live for me, but more than that, I must live for her. And the second issue that crossed my mind – I would never forgive myself if I brought the disease home to the people I stay with, and they died because of me. I would not be able to live with myself (provided that I actually ended up surviving). And so I decided to stay away from Mubende Regional Referral Hospital until further notice. I'm running away from my obligations as a doctor, I'm going back on my Hippocratic Oath, but it is the only choice I have. I am neither proud nor ashamed of my decision.