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The Automat - Palliative Care in Rural Uganda

8/31/2014

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Naggalama hospital is basically a compound of one story plastered brick buildings with corrugated roofs connected by covered sidewalks.  Walking around the grounds, it has a very open airiness, families sitting on the grass preparing meals or doing laundry in the troughs provided.  Children run everywhere, both pediatric patients and their supportive services of brothers, sisters, and cousins.  Patients languish in beds if they are too sick, but you may find them sitting on the curb outside their ward, heplock IV in place, as if this were a fresh air sanitarium from the early 20th century America.

Observing the care at Naggalama is feels very much like going back in time.  Limited technology, patchy knowledge, multi-bedded wards, and nurses in caps, it all seems so sepia toned.

In 1965, we drove our charcoal gray 1962 Rambler station wagon to “The World’s Fair” in New York City.  While I don’t remember much about the fair itself, except a telephone with a television screen and some giant plaster green dinosaurs courtesy of Sinclair Oil, I remember staying at the Ambassador Hotel [1] and not sleeping due to the noise of the street below.  But the highlight of the trip to me was a visit to “The Automat” where I put a nickel in the windowed wall and took out a slice of lemon meringue pie.  This was my first experience of the concept of “self-serve” and I thought it was just swell.

In Uganda they still may not have self-serve frozen yogurt stores, or self-serve Korean grocers’ salad bars, or do it yourself Kinkos office machines, but in Uganda they have something we don’t have in the West.  They have self-serve hospitals.

Controlled by the consumer, Ugandan hospitals have all the amenities of a US hospital without those bothersome labor costs.  Most hospitals in the U.S. don’t have 24 hour dining services.  Uganda does.  In order to understand this concept, you first have to know that hospitals in Uganda require that every patient must have an “attendant” that stays with them at all times.  In fact a patient will be refused admission if they can’t guarantee there will be someone to stay with them 24 hours a day during their hospitalization, not that there is a bed provided for your sitter.  Nor a recliner, not even a plastic chair, but the concrete floor next to the sick person’s bed will be your lodging for the duration. 

So you want your dinner at 2 a.m.?  No problem.  Your spouse or sister or auntie will prepare all your meals for you whenever you want, prepared on the floor just below the edge your bed so you can guarantee freshness.  What American hospital can advertise that I ask you?  Familiar foods served on your familiar plates from home, how comforting that must be. 

Or sleeping on your own bed linens, changed whenever your relative is available, the epitome of “home away from home.”  No need for a hospital laundry, or a costly hospital employee to make your bed.  Your attendant will change your linens when you soil them at any time without having to find the call bell no matter how critically ill you are.  

And medical care?  No problem.  Phototherapy is just a few steps away from your bed onto the lawn.  And it can be combined with respiratory therapy; nothing beats some fresh air for those nasty HIV lung infections than sitting on a bench watching the other patients cough and sputter. 

There’s even self-serve hygiene, with your very own wash basin brought from home from which to bathe, and a toilet only 65 feet down the hall.  For the less ambulatory, a bucket brought from home stashed under the bed to spare the walk to the WC, though no curtains for privacy.

Need an x-ray?  Just walk yourself over to the cashier, plunk down some Ugandan shillings and then walk over to radiology and get your x-ray handed to you in just a few minutes, after it has been hung out to dry in the sun first, of course. 

Medications? No problem.  Ugandan hospitals have figured that out as well.  The nurse just leaves your medications at the bedside in little manila envelopes, with handwritten instructions on the envelope such as 1 x 3, or as we so cryptically would write in the US, one tab TID.  And this includes pain pills for the patient to administer themselves prn, what we call Ugandan PCA. No need for those expensive pumps.

And let’s not forget your wake up call, the rooster standing next to your bed at 4:30 each morning.

Remember that the average hospitalization in the US is about $12,600, where the average bill, payable on receipt before they let you out the iron gate at Naggalama Hospital is about $16.  Next time you feel your blood pressure spike when you open your bill from your local hospital, remember that Uganda is only an airplane trip away and Naggalama Hospital is there for you. 



[1] The Ambassador Hotel was deservedly demolished the following year.


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Power Outage - Palliative Care in Rural Uganda

8/28/2014

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I wish I had “woke last night to the sound of thunder” but unfortunately at 4 am, at the sound of the first violent clap, I had yet to fall asleep in my hypobaric mosquito netting, thinking about the patients I had seen the days before and who repeatedly visited me throughout the night, each of them entering my tent, and shaking me awake with their withered hands every time I started to doze; one in particular.

The day started powerless, the electrical supply to the guest house, not my self-confidence, so in the dawn’s light I donned a clean shirt and pants in anticipation of my first day on the palliative care team with Professor Randi at the helm. After swallowing my daily meds, daily bread, and daily eggs, I grabbed my stethoscope and set off with the Professor to find the Palliative Care team at the hospital. 

Nervous we would be late for our 9 am pre-arranged rendezvous, I pressed hurriedly forward, bristling  that Randi was sauntering casually well behind me.  Despite my urging, she wouldn’t speed up.  At 9:45 we were still waiting for the team as Randi sat smugly on a bench, having learned about African punctuality last year. 

By the next day we had seen 12 patients, our pickup truck having bounced through cratered dirt paths to a mud hut or to the backroom of a storefront selling faded plastic chairs, or to a homemade brick house (and I mean both homemade bricks as well as a homemade house.)  The travel and the visits were at times disorienting, and usually nauseating.  Breasts that had been replaced with lumpy creased spackle of tumor, a leg mordantly altered by elephantiasis, pocked with a leg ulcer swarming with flies desperately fighting with each other for the meal of pus, or an epileptic girl that had seized herself into the cooking fire after running out of her medications.  My stomach retched and my heart ached for the nearly living and the barely living, bargaining with their bad fate with an Ibuprofen here, an antibiotic there.  

It was on that second day that we were brought to a clearing, a young boy lying on a reed mat on the dirt outside a small mud cooking hut.   He lay in fetal position on his right side, mouth agape to catch air between the smothers of smoke from the cooking fire a few feet away.  The only sound was chickens scratching at dead leaves nearby. 

Upon hearing our truck, his mother appeared in the doorway of the larger living hut across the small dirt yard. We had been told by the Palliative Care team leader, Prose, that this was a boy they had first seen last week for congestive cardiac failure and had advised a low salt diet.  As I stood back as the documentary picture taker, the team approached the boy.  Randi took the camera from my hands and told me, “This one is yours.”  I weakly protested as I pulled the stethoscope draped over my neck and knelt over him.  Congestive heart failure in a child? What do I know of CHF in anyone under the age of 70?  I know they should have edema – None.  I know they should not being able to lie flat – but here was this 10 year old horizontal in the dirt.  I moved to listen to his heart, and anticipating, the mother dragged the boy to a sitting position to obviate the need for me to bend over him.  I listened to his lungs (clear) and for a murmur (none.)  And then it occurred to me.  The mother had had to drag the boy to sit up.  He didn’t do it himself.  My thoughts stepped back, no longer seeing him as just a kid with a heart problem.  I looked at him lying, slumped in his mother’s arms, and now saw his right arm lying limp, his right leg contorted in a position I would not tolerate if it were my leg.  I reached for him again, with my hands, not my stethoscope, and examined him fully, now seeing a boy paralyzed on half his body, unable to sit up without his mother holding him, unable to straighten that twisted leg, unable to grasp my finger.  I straightened his leg and my own leg felt relief, although the child’s expression never changed, mouth gulping for air, a white coated tongue protruding, eyes wide open and unblinking. 

At some point, old records were produced from a brown envelope the mother: 

2011: Mulago Hospital in Kampala.  A normal echocardiogram.  An abdominal ultrasound: portal hypertension, an enlarged liver and spleen.  A CT scan: ring enhancing lesions in his brain consistent with a fungal infection, “probable toxoplasmosis.”  One of the reports listed him as HIV positive, that crossed out and hand written above it, NEG. A prescription for sulfadiazine and pyrimethamine. 

How long had he not been able to move his arm and leg? About two weeks.  Would she let him be admitted to Naggalama hospital now?  I have no money.  Randi and I look at each other.  It will not cost you money.  Please not today?  Tomorrow we will bring the ambulance. 

As we drove away I wondered what we would do tomorrow with no echocardiogram, no CAT scanner, no neurologist, no infectious disease specialist, no blood tests beyond a CBC, HIV, LFTs.   Shifting uncomfortably, I felt powerless.

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    Author

    Howard Eison MD is an internist who follows his wife Randi Diamond MD to the ends of the earth and becomes a better person because of it.

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