Shapiro In Bugobero

The following was written by Miriam Shapiro, 3rd year pediatric resident at University of Minnesota.



The rains have started here in eastern Uganda. The storms can be brief and, despite the significant amount of rain that comes down, the red dirt soaks it up in little time, leaving just a hint that it was here at all - the scent of dampness, a few puddles, a bit less dirt kicked up on the roads as we drive.

I am working at a rural health center in a village called Bugobero. It is about a 45-minute drive along these red dirt roads from Mbale, the largest city in the area. My primary task here is a clinical investigation of a syndrome of malaria, severe anemia and hematuria.

Though both severe anemia and hematuria are known complications of malaria, they were being seen at an increased frequency and with increased mortality in January and February of this year.

The health center in Bugobero is unique because it was adopted by an American health care NGO, which has partnered with the government to improve care delivery. Because of the extra funds provided through the NGO, the clinic is able to hire more staff and have a more reliable and wider supply of medications. The community has responded to the increase in services with a huge increase in patient visits.

The health center includes adult and pediatric inpatient wards, a
maternity ward, an operating theater and a steady stream of outpatients
seen daily on a first-come, first-served basis. It is now drawing
patients from all around the vicinity.

The health center has one doctor, who spends most of his time working on surgical cases, and is otherwise staffed by clinical officers, midwives, nurses and nursing assistants.

There is a laboratory here, which can do rapid HIV tests, thick blood smears for malaria, urine microscopy and urine dip stick. Usually they can do hemoglobin estimates, but of late have run out of the slides required to run the test. This limitation has required that I rely more heavily on history and physical exam findings than ever before. It also means there are several children here whose diseases fall outside the ability of the health center to diagnose or treat, even if they were diagnosed properly.

Our primary role here has been the malaria investigation, though we also see patients on the pediatric ward and outpatients, as time allows. Though the numbers of patients are not huge, the investigation is taking much of our time because, in addition to taking histories from the patients' parents and doing physical exams, we also draw the blood samples and prepare the thin smear slides. We also must leave from Bugobero early enough each day to deliver the samples to the research laboratory and have them run prior to its closing time. Because we are relying on an outside laboratory, we rarely get results back in time for them to be relevant to clinical care.

It is a stark contrast to the help we get in the hospitals in the U.S. - write an order and (usually) our work is done. Here, we rely heavily on the nurses and nursing assistants for aid in translation. Few of the villagers speak enough English to get through the detailed interview, and medical records as we know them do not exist. Each patient has a small notebook that is usually purchased upon arrival to the clinic, though occasionally is brought from home with information from previous clinic/hospital visits. When we are lucky, we can read about half of what is written in the notebook; generally the amount of clinical documentation is minimal.

Occasionally we are asked to see a child who is particularly sick. Last week, it was a 6 year-old boy with pneumonia who presented in severe respiratory distress. By the time we were called, they had already put him on supplemental oxygen via the one concentrator available. Despite the oxygen, he remained tachypneic and in significant distress, with an O2 saturation in the mid-80s. He was given a dose of ceftriaxone, which is sometimes present in small supply, and given fluids. The oxygen concentrator was then required in the operating theater, so he was taken off oxygen.

Given his persistent distress, the decision was made to transfer the child to the district hospital in Mbale, where hopefully more resources would be available. We made the 45-minute drive with him in the backseat, off oxygen; by the time we reached Mbale, his saturation was down to 59%. He was admitted in Mbale, placed on oxygen (delivered by an intranasal catheter, which was not very effective; at least at first, his O2 sat had only increased a small amount).

When we checked on him again later, it turned out that the hospital was out of the drugs that they had prescribed for him, so he wasn't actually getting them. We went to the pharmacy, purchased more ceftriaxone and paracetamol and brought it back. While we were there, the power went out, which meant that the oxygen also went off. In the end, this child was not getting much more at the district hospital than he was at the health center. Despite it all, he steadily improved, and a couple days later was asking for chapattis.

Sometimes these stories end well.

Miriam Shapiro poses with some children at the health center in Bugobero.