April 26, 2016
Last night we all slept really well because the rains came and it cooled down nicely. But the difficult part was getting up and getting ready for another day of work at MKMC this morning. It was still raining and the kind of day in which you just wish you could pull the covers over your head and go back to sleep. Also, the power was out so it was pitch black in the room. I bring a little flashlight lantern with me so I groped around but couldn’t find it. I usually leave it on the bed at close reach since the power often goes out at night, but apparently I kicked it off and it was under the bed. Once found, I had some light to start running through my normal routine, but when I set the small lantern on the desk or toilet seat, it really didn’t light up the room- the light went down towards the floor. I finally found a way to hang the light from a cord that was strung across my room- the cord to which the mosquito net was attached and that made a significant difference. Finally I was ready to go to breakfast. Soon I was drinking delicious hot Ugandan coffee and munching on a fruit plate that begins every breakfast. There seems to always be fresh pineapple, a banana, and a slice of watermelon but today we had a bonus- MANGO! I love MANGO!
After we all ate, Sam, our driver, came to pick us up to go to the Masindi-Kitara Medical Center (MKMC). We are taking 2 trips this week since there are now 6 of us. Sam has a small sedan and all 4 students have been cramming into the back seat while I sit in the front, but with Dr. Melanie Nicol joining us, our number is too big for 1 trip. Since MKMC is only 1-2 miles away, it isn’t a problem for Sam to make 2 trips.
Our normal routine at the clinic is for some of us to go on morning ward rounds to see the inpatients and some stay in the outpatient clinic to help out in the pharmacy or see patients with the Clinical Officers. After rounds we go back to visit the patients and review the charts more in-depth and meet with the patients with a translator, when needed, to ask more questions about their drug therapy prior to admission and to provide education about their disease states and medications. Today, though, in addition, the students got a chance to watch 2 procedures in the surgical theater. One was a small child of about 3 years old who had a severe laceration of his tongue due to trauma. Normally a tongue wouldn’t need to be sutured but the bleeding was great and so Dr. Godson decided to repair it. The other surgical patient was about 1.5 years old. She came to the clinic about a month ago with severe malnutrition and sores and rashes all over her body. She also had a deep skin infection in her buttocks. She needed IV antibiotics, better nutrition and medications for the rashes for almost a month as in inpatient. Initially she was so sick they weren’t sure she would survive. But, MKMC has a competent and caring staff and sometimes it seems like Dr. Godson works miracles with his surgical procedures. The child eventually improved and today returned to have the large buttock wound finally closed so complete healing can take place. I think the outlook for long-term survival for this child is good, as long as the circumstances that caused the child to initially be malnourished are alleviated. None of the healthcare workers nor my pharmacy team were able to ever figure out exactly why the child was malnourished. The mother seemed caring and was well-fed herself. I just hope she will be able to maintain a healthy diet from now on for this child.
At lunchtime, which is usually around 12:30 or 1pm, we return to the New Court View Hotel for lunch. By that time we are “starving”- OK, not seriously “starving”, but our hunger has gained most of our attention. The food here is delicious and made to order so as we wait, we often debrief the day and figure out what to do for the rest of the day. In the afternoons, if there is nothing pressing at the clinic, we remain at New Court View and work on projects, such as the CME talks we will be giving tomorrow. We also look up the answers to all of the medical questions that have come to us on rounds. We have learned about many disease states that pharmacists don’t often get to see in the States such as the complications of pregnancy. We have seen a few pregnant women who have had pre-term premature rupture of membranes (PPROM). This is a condition where the woman starts leaking amniotic fluid before the onset of normal labor and the “pre-term” part, means this happens prior to the 36th week of pregnancy at a time when you would prefer not to have the baby delivered because it is too small. This can happen for no particular reason but it can also occur when the Mom gets an infection during pregnancy, such as a Urinary Tract Infection or a vaginal infection. On our first day at MKMC we were introduced to a Mom who had PPROM and delivered a 32 week old baby who was immediately placed in an incubator- he was only 1.7 kg (3.7lb). In the USA, there would be no question of the viability of a newborn this age and weight, unless there were other medical problems besides prematurity, but here in Uganda, the odds of survival are much lower. I was so pleased to see that MKMC had an incubator to help maintain appropriate body temperature and a sterile environment. Although the large national referral hospital, Mulago, in Kampala has incubators, the Masindi District hospital only has 1 and if it is in use, then it is not available for other premies. There was a happy ending for this Mom and her infant as they were discharged home at the end of last week. We’ve seen 2 more similar patients, both with PPROM and babies born at 32 weeks. Unfortunately, one of the babies only survived less than 2 days. This Mom had delivered the baby at another facility and when the baby was so small and not doing well, they came to MKMC. Unfortunately, the birth occurred before any steroids could be given. Steroids given the Mom prior to a pre-term birth are a safe and effective way to help the babies lungs mature in-utero, when he/she doesn’t have enough time for this process to occur naturally. The other 32 week old is currently still in an incubator but doing well. The Mom of this baby, though, is very anxious to leave the hospital with her child. She has been at MKMC for about a week now because she came in with PPROM and we were able to complete the steroids prior to the baby’s birth, but this has cost the family a lot of money. Now, she thinks her baby is fine and wants to take him home. We all worry, though, that the Mom doesn’t realize how fragile this child still is and can not be treated like a regular baby. If he doesn’t nurse well, he can get dehydrated really fast and this will predispose him to infections or death from dehydration. Hopefully, the family will find the funds to have her and the baby stay in the hospital awhile longer.
So, as you can read, our time in Masindi has been a great learning experience. Each day brings something new. As we are learning, we are also trying to help the Clinicians by making sure the drug doses are appropriate and looking up the answers to all of their questions. Tomorrow we will present a CME on Antibiotics, Antenatal Hemorrhage, and Urinary Tract Infections- these were topics they asked us to talk about.