June 17th, 2018 by pamelaparker
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My time in Kiwoko is finished, much too quickly. I have posted some photos to give you the feeling of day-to-day work. You may laugh when you think of scrub sinks with bars of soap held up by bottle caps.

Soap is attached to the sink by a soda bottle cap embedded in the bar of soap

But apparently studies showed there was less microbial growth than in bottles of liquid soap that we have in the ORs here at home.  The white Wellie boots were a bit overwhelming the first time I wore them, especially if I had on a pair that was 2 sizes too big. But when blood is splashing out from a surgery, they are fantastic at protecting your feet. What I could not capture, because it is not something you can get from a photo, is the spirit of the people with whom I worked. People were so generous with their time and suggestions. They are aware how visitors from affluent countries will have difficulty with the limited resources at Kiwoko. And yet, with what they have, they are doing amazing work, saving more lives than they lose. The NICU houses babies from 28 weeks gestation on. While they may not have the flashiest techno-equipment, they are making a difference for the premies and the babies who might otherwise not survive a difficult birth. Trainees just out of medical school perform cesareans at night, while covering multiple other units including Paeds, Men’s and Women’s ward, Labour and Delivery and NICU. Each day in morning report I would marvel at how much they did overnight, and how I, a seasoned physician, could not have done so well. Their leaders and advisors at the hospital constantly strive to not just get the job done, but to continually improve the processes along the way.

I am sorry that my time is over. But I will never forget my glimpse into the culture and practices at Kiwoko. I wish them well. And perhaps we shall meet again.

June 13th, 2018 by pamelaparker
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What do you do if you are on the labour ward, you have no way to continuously monitor a baby unless someone stands there holding a Doppler for hours (not going to happen) and you have no way of tracing uterine contractions? It is not that Kiwoko wasn’t given 10 lovely machines do to all that. BUT, they have no paper, the parts are obsolete, and cords don’t fit and cannot be replaced…..I felt very sad looking at these useless monitors sitting high on a shelf, never to be used. HOW are we ever going to know the difference between accelerations and deceleration and what KIND of deceleration, AND how is the variability? FEAR NOT. Dr. Bravado to the rescue. You might be thinking of a hunky physician that looks like someone from Gray’s Anatomy TV series. But alas, “he” is only a mnemonic but a very useful one for answering these questions. What does it mean?

DR: define risk – is this someone with a prior cesarean scar, twins, vaginal bleeding, history of fetal demise, etc.

BR: what is the baseline fetal heart rate (110-160 is acceptable)

A: are there accelerations in response to vaginal exams or fetal movement? If so then baby is most likely ok.

VA: What is the variability? There should be at least 5 beats per minute of variability (you can hear it and the Doppler will record this). If less than 5 bpm over 30 minutes, the baby is NOT ok – flat tracing.

D: If there are deceleration, where do they fall? For this, one must palpate the abdomen during uterine contractions AND measure FHT simultaneously. If the deceleration is congruent with the contraction, it is probably an early deceleration or even a variable. If it follows the contraction it is a late deceleration. Early is good; Variable bears watching depending on how low the HR goes and Late is bad.

O: Overall assessment? Very simply, fine or not fine. If not fine the midwife will call the house officer and most likely proceed to cesaer.

All labors are attended and monitored by the midwives for the most part, including twins and breech presentation. I have been continually amazed at the assessment skills of the people who work here. House officers are doing cesareans despite no specific OB training. They are tapping joints and chests and have to have stellar diagnostic skills since the MRI and CT scanner are nowhere near, and not available because of cost and distance. I think in the USA we become lazy since there are check sheets, and multiple layers of people overseeing medical diagnostic activities. I feel humbled in their presence. And I am very happy to make the acquaintance of Dr. Bravado! ???? Namaste

June 11th, 2018 by pamelaparker
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If you do obstetrics, you know at some point someone will not survive – the premature baby, the woman so ill she should have never been pregnant. Some things you expect, though never get used to. Last Friday a term baby was delivered, lifeless and not resuscitatable. His mother is only 17 and hated every minute of labor. Here there are no epidurals and rarely any pain medications to ease the process. She had her mother and grandmother with her, trying their best to help her labor, and at the same time teaching her HOW to labor (which means no screaming).  She progressed to 9 cms and then got stuck….we took her to theatre and delivered a limp blue baby with no reason to be dead – and yet he was. The team worked on him (3-1 compressions to ventilation; oxygen). There is no high tech team to swoop in, place umbilical lines, incubate and get him “going” again. He was just gone. And his mother was inconsolable. I was told when I arrived in Kiwoko that if a woman has enough pregnancies, she will absolutely have lost one or more. Somehow that statistic isn’t comforting to me or that lost 17 year old girl who now has a Pfannenstiel incision on her uterus and nothing to show for her efforts. The bad luck returned for the call team last night. A women at 22 weeks gestation arrived with a severe asthma exacerbation. They were able to provide medical intervention to improve her oxygen status. Suddenly with no warning, she arrested and could not be resuscitated. At the request of the family, a hysterotomy was performed and the dead fetus was removed so it could be buried separately. Not everyone agrees this should be done, but this is where culture and reality collided. This family is now minus two of its members, and must go on in whatever way they can. Most of the time doing obstetrics is a thing of joy, until it is not.

June 7th, 2018 by pamelaparker
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This is the epitome of a tweet-like blog. Like, who really might care. But anyone reading this who want to know what a typical day is like – here you go. Alarm goes off at 0650. Crawl out from under the mosquito netting, morning ablutions, breakfast (with fresh milk delivered by a milk man on a motorcycle) and then off to pre-round on the L&D unit. If nothing is going on, at 0810 to 0900 is morning prayers. Each day is different, and each day is the same. We start with a number of songs/hymns. I don’t know any of them, but if they ever decide to sing Amazing Grace I will be all over that one. There is someone leading the song, and either someone playing the guitar or an electric keyboard. Most of the songs are in English or part English part Lungandan. Then there is a homily that can be given by nearly anyone, including the pastor of the hospital or one of the doctors. It usually has something to do with uplifting everyone in preparation for the coming day. At 0900 we head back to the Women’s section and do postop or antenatal rounds. If there are surgeries cesareans, D&C, we divide and conquer. The midwives take the laboring patients but when anything needs higher level of care it comes to the docs. Wednesday is clinic day. The hours are supposed to be in the morning but if there has been rain the night before and the roads are bad, the women may show up at any time. Lunch is around 1300. A delicious lunch is prepared by Winnie and/or Rose. Talk about being spoiled. We then return to the Wards to see if there is anything going on. The call team takes over at 1700. The folks on call are interns or residents but are expected to cover the whole hospital, so there may be an intern expected to do a cesarean!! And then admit a baby and then someone with cancer, burns or malaria.They are really multi-talented. Sometime in the evening it is dinner – usually warm up whatever was for lunch, shower (don’t forget, always cold water), Blog/journal/reading time, and then back under the net. We hope each night that megaphone man doesn’t decide to start hollering too late or too early AND most importantly we hope the annoying loud base from wherever is not on that night. Sleep and then start again in the morning….

Milk delivery & a warning

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Mosquito net – Anopheles mosquitoes be deterred!!

June 6th, 2018 by pamelaparker
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The answer to that is, she has thrown off all her clothes…hardly anyone makes a sound so being naked is a big hint. If you peak into the Labour suite and the women are all dressed, you know the time to delivery is at a distance.

Labour and Delivery Unit – Kiwoko

How sanitary napkins are made – rip off what you need.

Pessary – we use the term for a rubber device of various shapes placed in the vagina to correct prolapse. Here you can order a clotrimazole pessary which is basically a vaginal suppository. I think that is a UK “thing”. Some of the cases we saw in gyne clinic included two little girls with vaginal discharge – one is coming back on Friday for an exam under anesthesia, presumptive diagnosis of foreign body in the vagina. A woman who had a “caesar” over a year ago with inadvertent injury to BOTH ureters, had utereral stenting and then disappeared for a year with the stents still in place in the ureters. She had no urinary symptoms until the stents were removed a year later. Now she has continuous leaking of urine – probably from a ureterovaginal fistula. This is going to be a difficult case from the standpoint of getting imaging (which is expensive) and figuring out who might do the surgery – nobody at Kiwoko. A couple came in with c/o infertility X 4 years. Bottom line, HSG for her and semen analysis for him. No resources for lots of specialty lab testing to be done for infertility. I assisted at a cesarean today for a woman who failed induction. The whole setup is very different including NO CAUTERY, scissors that don’t cut, Wellie white boots for foot cover and cloth gowns.  I was in charge of the trolley (table) that held sponges – we only started with 5 plus a rag of some sort. It was interesting to be an assistant in this OR since in USA I would have been doing it myself. I could have today other than the fact that we are just learning to work together and I would have been lost regarding the procedure. But not tomorrow!

These are the foot covers we wear when operating. Got to love Wellies!

Time to go wash “unmentionables”. The housekeepers Winnie and Rose wash everything but underwear (taboo) so we do it ourselves…boiled water on the stove after the power came back on (electric starter to the gas stove doesn’t work with no power). Then I hang them out, and iron them (if they have been outside where mango flies may have lay eggs). I might iron them just because they dry faster. It’s hard to iron underwear!! Peace.

Winnie, daughter Isabellah, and Rose

June 5th, 2018 by pamelaparker
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Liquor – it isn’t what you are thinking and it isn’t even pronounced like you think if you are from the USA. Here in Kiwoko it is call Lie’ Core and refers to the amniotic fluid.  Caesars isn’t just a palace but it is what we call a cesarean section. And gossipyboma which I previously called a textilloma and is a cotton item (generally a sponge) that is inadvertently left inside of someone at the time of surgery or a vaginal delivery. A woman came in with a malodorous thick vaginal discharge after delivering elsewhere about a month ago. Surprise when an overripe “sponge” was removed from her vagina. We had a good slide presentation about retained sponges and instruments and how this MIGHT be avoided. They do not have enough individuals in the OR so the assistant is the scrub tech also, and it is not unusual for the circulator and even the anesthetic attendant (not doctor) to wander out of the OR in the middle of a case. That happened yesterday during a cesarean hysterectomy for atony. Needless to say the surgeon was not happy. It did result in a lively conversation today.

“Loo” in theatre (OR) – a bit challenging when you are wearing a long skirt or scrub dress.

Other new concepts: All newborns here have the “flu”. They don’t actually but the moms think the babies do because they snuffle trying to clear their airways after birth. Mostly all newborns are given BCG and polio vaccines before discharge. All abdominal wounds are painted with Gentian Violet once the dressing comes off. Blood is not typed and crossed but it is “booked”. And it is high demand with short supply. And the operating room is the “theatre”. I realize anyone reading this from the UK may not find these words unusual. But for me coming here, understanding the British based terms, and the very soft-spoken locals who sometimes speak English and sometimes Lugandan – I feel like I have truly landed in a land of many new languages.

One last thought. Not only do mango flies lay eggs that hatch in larva that will stay in clothing that is hung on a line outside (no dryers here). The larva hatch, can burrow in your skin and stay there until they are ready to hatch from YOUR arm or leg (or elsewhere).  The other stunning thing about mangos is too many mangoes can cause constipation or obstipation or even bowel blockage – especially in young children. I may never learn to like mangoes.

The megaphone man is speaking….someone who hollers through a megaphone at various hours of the day (and night), mostly in language I cannot understand. From what I hear, the locals cannot tolerate his noisy rantings either.  When they complained to the police, they were told nothing could be done since the man also makes important announcements for the police (like avoid Road X because there is an accident there). Between him and the person who blares the booming base on the weekend at least from around 2200 until 0400, noise control is nonexistent. Thankfully last night, no base, no Megaphone. Until the next time….

June 3rd, 2018 by pamelaparker
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At least for me it has been. No thumping base all night long but whatever time zone I am on, I slept again until nearly noon. Tomorrow will be shocking when I actually have to be up and about for 0800 prayer and doctors meeting. It is very humid and warm today, adding to my jet lag lethargy. Yesterday morning there was a cute little ???? running on the wall of our Guest house. Today outside there was a much bigger Monitor Lizard – very shy around us humans though. The sugar ants ???? also decided to have a bit of a convention inside the door of the house. Not certain what drew them in, but Stephen helped dispatch them with some chemical I would rather not think about. There have been millipedes inside the house as well. I knew I would become educated about flora and fauna and “critters” of Uganda, but some of these would be best if they stayed OUT of the Guest House. My housemates have returned from their overnight visit to a rhino ???? sanctuary. They had a great time though one of them has been a bit under the weather for the past 5 days. New phrase…my LL Bean head lamp is a head torch! No more slacking off after today. I am hoping the jet lag brain is resolved by morning rounds.

June 2nd, 2018 by pamelaparker
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After 2 days, 28 hours in 4 planes (give or take ) and a ten hour time difference I am Kiwoko Uganda. Some things are the same – traffic, crowds, need for internet connectivity and some are very different – first night under a mosquito net (no problem); showers that never have warm water (refreshing); warnings about not drying clothes outside and wearing them without ironing first (charming to think of mango flies laying eggs in my clothes which can then hatch and burrow into my skin). I have had a quick tour of the hospital compound and hope to remember everything and everyone soon – but not today. Medicine here is different in some ways of convenience, and very much more complex in terms of the infectious disease burden and ability to do so much with much less than we have in the states. I look forward to seeing it in action on Monday. For now, I am dealing with jet lag by vegetating and wandering around aimlessly….

May 21st, 2018 by INMED
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Hello! My name is Pamela Parker. I am a Practicing Professional at California Polytechnic State University, and I’m starting my INMED service-learning experience at Kiwoko Hospital in Uganda beginning in June 2018.