Monday, May 21, 2012

2 Weeks in Surgical Casualty

I spent the past two weeks at Mulago Hospital in the surgical side of the casualty ward. This is similar to the emergency department at home. It is separated into a medical side and a surgical side and is staffed by medicine doctors and surgeons, respectively. I had heard this was a great place to get some practical experience especially with suturing up lacerations. At first I was surprised at how small the ward was. It is made up of several rooms - one is the main treatment room where most of the patients are seen. There are only 4 beds in this room that is divided by a half wall. Then there is a room for ultrasound, a room for xray, a resuscitation room, a plaster room (for orthopedic cases), and an emergency operating theatre. Most of my time on this service I spent in the main treatment room seeing patients.

The casualty ward is a busy place - on some days around 500-600 patients might be seen. The "slower" days average about 300 patients in one day. Despite the small amount of space in the main treatment room, there are a lot of "staff" people crowded in there and unfortunately not many of them are consultant physicians. During my two weeks, I was the only international student on the ward except for one day when my roommate Nicole joined me. There were several paramedical students and nursing students who also often lacked supervision. I often found myself not only in a position where I was without supervision, but I was also the supervision for the paramedical and nursing students. As I had the most knowledge and experience of us students, I was the senior. As a medical student, that is a very terrifying and humbling position to be in. I am very aware of what I don't know and when I need help and to not have anyone to ask when in that position is a horrible feeling. I am getting ahead of myself...

My first day on the ward was quite atypical. It was quiet. I was disappointed because I had heard such great things, and my first day I didn't end up being able to do much. I learned how the paperwork was filled out for patients and was able to suture up one patient's laceration, but that was about it. The next couple of days picked up and soon I was seeing and managing a lot of patients on my own. During this time, there was always at least an intern present for me to ask questions and to have check over my assessment and plan. All this changed on Thursday during my first week. The morning was a typical morning - the usual variety of trauma (mostly motor vehicle accidents), acute abdomens, back pain, swallowed foreign bodies, abscesses - I had lunch and then went back for the afternoon. When I arrived, the only staff present was the intern. There were not many patients in the emergency department and I got started on a new one that had come in. Soon after, a child came in with a femur fracture from a boda boda (motorcycle taxi) accident. The intern glanced at the patient and while I was still in the middle of evaluating the patient I had started on, he said "I haven't had lunch yet. You are okay to handle this, right?" Before I had a chance to answer, he left and I was alone with a couple of paramedical and nursing students. No nurses, no consultants. I was the most senior person there and I was in charge. I finished up what I was doing and went to see the femur fracture child. As I started my evaluation of him, two more trauma patients came in - the father of the child with the femur fracture who also had injuries from the accident and a patient with head trauma, several lacerations on his face and scalp and bleeding from his ear and nose. I was in way over my head and I knew that and was completely uncomfortable. Morally, I couldn't leave. Even though I was being forced to manage things by myself without supervision, I felt a responsibility to be there for the patients and try to do what I could to make sure that no one died. That was my only goal during that 1-2 hours I was alone - to make sure no one died. The paramedical students and nursing students wanted to help, but unfortunately they had so little experience that they needed me to explicitly explain what I needed them to do. It was terrifying having that responsibility. Somehow I managed and no one died and finally after being left alone in charge for 1-2 hours, the intern and one consultant returned. I finished up with the patients that had come in and talked with the consultants about them. It was nearly 5 and since that is when the international office closes and because I was exhausted from the afternoon, I left. The worst part about it is that even though I told both the consultant and the assistant to the international coordinator that I was left alone in charge of the emergency ward, the only response I got was, "Well, that's great for your learning." No. No it is not great for my learning to basically be experimenting on patients. I did what I thought to do and yes, no one died and I think I probably did the right things for these patients, but I should not have been left without supervision. I do not have enough training and these patients deserve better. They deserve to have trained professionals managing their emergencies and not an international medical student on her fourth day on the emergency ward.

This is one of those kind of days that makes me really grateful for the friends that I have and the support network that I have developed while in Uganda. I told my housemates about what happened, and they were so supportive and reassuring and helped me wind down after such an intense experience so that I could face the next day.

On Friday, I made sure to bring my Emergency Medicine Manual in my pocket to the emergency ward. If I wasn't going to have supervision, then at least I would have a text to consult so I had some kind of a teacher. I was very glad that I brought that book and for the rest of my time in emergency, it was my closest friend. Friday morning when I arrived, there were no consultants in the emergency department again. Apparently they were all at a meeting. I walked into a room with a few paramedical and nursing students and three bloody messes. The students were focusing all their time on the least critical of the patients - they saw that patient as an opportunity to learn how to suture. As they approached me to ask if I could supervise them, I asked if they had looked at any of the other patients. They had not. I told them that before I could supervise suturing, I needed to assess and triage the other patients that were there. The patient they were focusing on was stable - no bleeding, okay vitals, although he had amnesia for the event that lead to his coming to the hospital - concerning. The other two were in worse shape. One had several lacerations on his face and scalp and had lost consciousness after he had been in a motor vehicle accident. He had bleeding from his nose and ear and a huge hematoma forming underneath his scalp. The other was the most concerning of all. He had a laceration on his head and an open wound on his ankle and was actively vomiting - a sign of increasing intracranial pressure. Thankfully I was not alone for long before the consultants returned from their meeting and I could relax a little and just focus on one patient instead of three.

Mulago is the National Referral Hospital and so cases from all over the country are brought here when they have surpassed the expertise or resources of the smaller district and regional hospitals. It also is the regional hospital for Kampala and so a wide variety of pathology is seen on the wards. Although the surgical casualty wards tends to see a lot of trauma patients, a fair number of other interesting things walk through the door as well. I saw one woman who had a suspected meningioma for the past ten years. One entire side of her face was puffed out from the tumor. Because they don't have any treatment available for her, her tumor just keeps growing. It seems we get a lot of late presentations of cancers. The patients don't seem to come in until something has really advanced and so we see some huge masses or patients who are wasted away from throat cancers who haven't been able to eat for months. We also see a lot of bread and butter emergency room problems as well - I saw many young children who had swallowed coins or batteries or some other object and acute abdomens. The trauma patients often seem to involve boda boda accidents. The worst of these involved three people on the same boda - the driver, an older woman, and her grandchild. All three of the boda riders had right sided mid shaft femur fractures. The older woman also had a right sided humerus fracture. Both the driver and the grandchild had open fractures - the driver's fracture had a huge piece of skin missing and a large hematoma had already formed above the fracture site. All of the fractures are set in the casualty ward before they are moved to the wards. Depending on who is working in the plaster (ortho) room, the patients get varying amounts of analgesic relief before manipulation of their fractures. One orthopedist was really great and made sure all patients had morphine on board before reducing and setting the fractures. Others will do the manipulation when the patient has only received diclofenac (an NSAID like ibuprofen) - you know when these patients are being reduced because their screams reverberate throughout the entire third floor of Mulago.

It isn't just with ortho manipulations that pain management often seems a bit lacking. I saw one woman with a peritonsillar abscess. The casualty physician stuck a scalpel blade on the end of a clamp and was poking at the abscess at the back of her throat to try and drain it. I have seen a lot of kids with abscesses. It doesn't seem to matter how old the child is or where the abscess is located, they are all drained in the emergency ward without any sedation and sometimes not even local anesthesia. It's also hard to watch the parents have to pin their children down in order to keep them still so that their abscesses can be drained.

The other difficult thing about having so much responsibility for making treatment and management decisions is that I am not really sure what resources are available. Many of my boda accident patients, I have wanted to get a head CT on because I was concerned about intracranial hemorrhages. Of the several that I ordered, I don't really know how many of them were actually done. I found out that there is only one neurosurgeon at Mulago Hospital so even if there was a CT done and it showed a hemorrhage, there isn't a guarantee that a patient would be able to have burr holes drilled in the event of increased intracranial pressure anyway.

The lack of readily available CT is also a problem for other patients. I spent one morning/afternoon in the resuscitation room where a man was brought in. His initial complaint was an acute abdomen and he soon became non-responsive. Initially the physicians taking care of him thought that he had a ruptured spleen - there was some story about an accident/fall and after an ultrasound, there was free fluid seen in the peritoneum and so splenic rupture was suspected. We started rapid resuscitation measures but his blood pressure just wouldn't pick up. He was taken to surgery (relatively quickly - maybe an hour or two after being in the resuscitation room) for an emergency laparotomy. When the abdomen was opened up, the surgeons were surprised to find not blood but intestinal fluid filling up the abdominal cavity. The patient had a perforated ulcer, not a ruptured spleen and was likely in septic, not hemorrhagic, shock. Looking at the records after this discovery, we saw that this accident had happened over a week ago. The patient survived the surgery but died later that night. Had the diagnoses been known (better imaging would have helped improve the odds of making a correct diagnosis), the patient would have not had surgery immediately, but would have been treated more conservatively with antibiotics and measures to increase his blood pressure before being taken to surgery to repair the hole in his stomach.

Despite the challenges and difficulties of working in casualty, I have become even more sure that emergency medicine is the right field for me. I enjoy the fast pace and the variety of patients that I see. I enjoy the hands on aspect - I have lost count of the number of patients I have sutured. I also think it is a great opportunity to do teaching to improve the care that people get when they come to the casualty ward and therefore improve their outcomes. It's the kind of teaching that you can do to enable the people already here to help make the hospitals less dependent on foreign aid.

Location:Kampala, Uganda

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