Megan Hilger's Reflections on Her Experience at Mulago

 Posted on behalf of Megan Hilgers, Pediatric 2nd Year Resident

Hello from Kampala, Uganda!

As my time here is nearing the end, I am thankful for the experiences I've had, relationships I've formed and vast amount of knowledge I've obtained. I spent my first week working on research in the hematology lab with Dr Troy Lund looking at markers of oxidative stress in G6PD deficiency. My remaining time was spent doing clinical work. 

Megan Hilgers with Derrick, the Hematology Lab Tech

Most of my clinical time was spent in the resuscitation room of the Acute Care Unit.  This unit is where the Pediatric ED, PICU and a transition ward are located.  I worked alongside the Ugandan residents, interns and medical students. As you would expect from the name, the patients brought into the resuscitation room are critically ill and require rapid interventions.  After patients are stabilized they are transferred to the PICU or ward where we continue to follow them with the team. The most frequent conditions we care for are sepsis, respiratory failure from pneumonia, severe acute malnutrition, hyperbilirubinemia and severe anemia. Oftentimes, these are in the setting of sickle cell anemia, TB, HIV or chronic malnutrition. Not only have I gained knowledge of these diseases and complications but I've improved my exam skills, procedure skills and even my ability to read blood smears. As a resident in the resuscitation room, I provided full spectrum care and I can now draw blood, place IVs, place I/O's, reconstitute and draw up meds, mix IV fluids and run a code with a lot more confidence.  I greatly enjoyed the mutual collaboration with the Ugandan residents as we discussed various patients and how management differs in the US. 

Ugandan residents with Megan Hilgers and a visiting Anesthesia resident from Stanford

Resources and healthcare staff are stretched thin in the hospital and posed many challenges that often fell to the parents/caregivers. Parents are relied on to monitor their child at bedside, administer medications, purchase certain medical supplies- such as blood culture bottles, pick up test results from the lab and even go to a nearby pharmacy to purchase inpatient medications when the unit is out of stock. Parents form a supporting community together within the unit and I often witnessed mothers teach each other how to express breast milk, use NG tubes, share meals with those in need and care for abandoned or orphaned children.

This is a great setting for residents interested in learning about management of critically ill patients in a hospital setting with limited resources.  There were a lot of opportunities for hands on management and teaching students and other residents.  It was very humbling and I cannot express strongly enough how grateful I am for this experience.

Observations from the Special Care Nursery at Mulago

Posted on behalf of Sarah McIntire, MedPeds 4th year resident

Eighty. That’s probably a good estimate of the average census in the Special Care Nursery at Mulago Hospital in Kampala, Uganda. On busy days, the number of infants can rise over 100. Clearly, there’s no such thing as a cap on the number of admissions we can take in one day, let alone a couple of hours. Here, the babies are divided into two rooms: preterm and term. Preterm infants can be anywhere from roughly 26-28 weeks (here, viability is typically considered 28 weeks), and often come in multiples – twins, triplets, even one set of quadruplets! Term infants can present with problems ranging from low Apgars at birth or respiratory distress, to asphyxia, seizures, or severe sepsis. As Mulago is a major referral center and a government run hospital, many infants are transferred in for complex management or simply because their parents cannot afford step-down nursery care at a private hospital.

The Special Care Nursery, where I work is quite different from the NICU I have become accustomed. There are no ventilators, only CPAP. There are very few continuous infusion pumps. Phototherapy is limited, and labs take about a day to turn around, so if an infant appears jaundiced, they are often just brought to a separate isolette and squeezed together under the lights. 

On my first day in the SCN, I felt overwhelmed by the sheer number of patients, and the limitation of resources. I could only think of what I wouldn’t give for a ventilator, or even just a quick CBC. At first, it was so hard to see past the differences between NICUs in the United States and here in Uganda. But, just like any new rotation back home, I waded right in, and started to realize that just because the care of newborns here is different, that doesn’t make it bad. It’s more about realizing how to make use of the tools you have available. 

Sarah and Kendahl with the Special Care Nursery Nurses

I learned to rely on mothers, who act as bedside nurses, and who don’t need a nursing degree to tell you that their child is too warm, or is breathing funny, or has a distended abdomen. I diagnosed a trachoesophageal fistula on my third day, after learning to place nasogastric tubes and having one that just wouldn’t go into the belly. Chest X-ray confirmed the TE fistula, and surgery was there the next day and ultimately took the child to the OR for repair. Just like back home (although perhaps without a CT scan or prenatal ultrasound).

But the most amazing thing to me about the Special Care Nursery goes beyond the medicine. My contribution of prescribing antibiotics or advancing feeds paled in comparison to the absolute love and devotion of the parents and families caring for these infants. I saw a mother, after breastfeeding her own child, pick up an abandoned infant awaiting placement, and, gently holding him, feed him formula from a syringe. She could have (and should have) been resting, but to her it was more important to care for this child who had been left behind. Another infant, whose mother died in child birth, was cared for lovingly not by his parents, or grandparents, but by his paternal aunt who gladly purchased formula to feed him, and stayed for days in the hospital until he was ready to discharge.

Special Care Nursery Nurses with Kendahl and Sarah

In a place where there can be so much tragedy (on reading the death log, it appears that about two or three infants die daily in SCN), it’s easy to feel disheartened. But on the eve of leaving, I can only say that I’m overwhelmed be the love and gratitude of the families and nursing staff here. It’s been an experience I’ve been lucky to have, and I look forward to more to come in the years ahead.

Nate Herr (PL2) on Rafting and Brainstorming Implementation Research on the Nile

Posted on behalf of Nate Herr (PL2)

Beth Thielen invited me to try rafting with her this past weekend. (Beth is in the UMN Med-Peds program and is here working on the adult side of Mulago hospital on the ASTRO-CM trial with Dr. Boulware).  

With a few recommendations we decided to go with Nile River Explorers, an established rafting company here in Uganda.  Our raft guides, safety kayakers, etc, were all Ugandan, who have grown up into and thrived in the development of adventure tourism and sports.  Several of them, including our raft guide Juma, have competed at the international level in whitewater kayaking-- representing Uganda and Africa all through the energy of waterfalls and rapids in the backyard of their home village.

The fun and adventure of rafting with excellent guides

By the end of the day we were exhausted, sun burnt, and winded from the three times our raft flipped in the rapids. But, all-in-all we were glad to be able to experience the thrill of the Nile river rapids.  These rapids have been sequentially disappearing with each installment of hydro-electric dams on the Nile, built to fill the need of reliable electricity in a developing country. A third dam is currently being proposed and depending on the height, additional habitat, communities, rapids, and tourism economies will be displaced or eliminated.  A petition is circulating both in hard copy in communities and online internationally to encourage the building of a smaller hydro-dam that would preserve the remaining falls and rapids on the river.

Flat stretches of water were time for discussion and brainstorming

On the flat stretches between the rapids, we talked these issues of the Nile and more.  I also found out that it's hard to escape healthcare all together, even on your weekend off.  The two guys in the front of the boat were logisticians with MSF, in Uganda for a 2-week training session.  On the water and in the rafting truck we were discussing the challenges behind ensuring a cold-chain to deliver vaccines and the future promises of mHealth, the later which got me thinking-- a lot. mHealth is a broad term to describe mobile phone technology interfaced with healthcare and I see great potential for it here and elsewhere around the world.  If anyone has any experience or ideas on mHealth, please email me. It's hard to imagine future implementation research without it.

Getting a bit wet after one of those flat stretches