A world without propofol: Looking beyond Western medicine

By David Sussman, PGY3, McMaster University

A glimpse into the practice of anesthesia in Uganda

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The familiar sound of the pulse oximeter provides comfort in an otherwise unfamiliar world. The patient: an 8-day-old female. The case: myelomeningocele repair. In the OR at McMaster University Medical Centre, the anesthetic procedure, while uncommon, is fairly straightforward: hook up the patient to appropriate monitors, induce with a dose of propofol, and connect to the ventilator. In the operating theatre in Uganda’s regional referral hospital: a nightmare. The anesthetic of choice: halothane and thiopental; two drugs I can only recall reading about once before. As I scan my monitors I realize I have no end tidal carbon dioxide or other gas analysis, nor do I have an EKG monitor, or other vital signs to suggest how my patient is doing. 72 hours prior to this moment, I had taken ignorant comfort in these tools.

My international elective in Uganda is one that brought me some 7200 kilometers away from home. I arrived at the international airport in Entebbe, before making the one-hour journey to Kampala where I would be spending the majority of my time. At first glance, Uganda appeared impoverished, overrun with people and animals. It was seemingly chaotic generally and medically. I couldn’t have been more wrong. 

Uganda, a country of 40 million, rivals the population of Canada. It’s riddled with pathology that I had only learned of in medical textbooks. While I had read about many of the drugs and anesthetic agents (albeit some in chapters on the history of anesthesia), I began my journey slowly attempting to find my bearings in unfamiliar territory. What I very quickly realized was that this was a beautiful country, full of people who are quick to embrace and take care of you.

Each day begins with a chaotic navigation through the streets of Kampala, Uganda, to Malaga hospital (the largest referral center in the country). I compete for space on the dusty sidewalks with people, budda budda (motorcycles), and bicycles. I love observing the details of this morning rush-hour. Ugandan men sport perfectly pressed shirts with French cuffs, regardless of where they are going. Ugandan women dress in the most colourful fashions.

The hospital building is a large, unassuming, well-manicured 1960s structure. Although the building leaves much of the chaos of the city streets behind, another sort of morning rush takes over. The halls are flooded by people in white coats eager to start their day. As I maneuver my way to the operating theatre, I pass through the neurosurgical ward. It’s filled with old steel beds, but is otherwise barren. Holes cut in the cement walls act as windows. I pass by rooms overrun with patients, and observe overworked nurses in perfectly pressed and starched white uniforms. I enter the operating theatre and change into my scrubs, wondering what the day will bring. 

As a third year anesthesia resident, this would be my first international elective; however McMaster has a longstanding history with Malago hospital and its Anesthesia program. I had heard from previous residents that my role would be that of part observer, part teacher, and part cultural ambassador. In private some had conveyed to me their sense of powerlessness, the hospital’s dearth of resources, and the overwhelming needs of hospitalized Ugandan patients. I didn’t know what to expect but decided to approach with as much of an open mind to the experience as I possibly could.

My international medical elective was an experience filled with excitement, nervousness, and at times sheer terror; feelings spanning the whole spectrum culminating in an indescribable cultural, medical, and overall life experience I wouldn’t trade for anything. I found myself participating in almost all aspects of patient care; from the ABCs of an acute resuscitation, to scrubbing into a cesarean section, to performing a rigid bronchoscopy for removal of a foreign object, to teaching other medical students and other residents.

The residents at Malago were extremely well versed in theoretical knowledge, and were even more gifted with the practical application of their skills. They were able to perform tasks flawlessly with equipment that would make any North American doctor cringe. The luxuries of being able to get intraoperative hemoglobin, or a blood gas in the ICU, or a chest X-ray for line placement simply did not exist.

One had to rely on clinical decision making purely at the bedside. I found the residents quoting medical literature and journal articles to support their management decisions. Furthermore the residents did not have the luxury of administering a pediatric stylet, or using the glidescope for a more challenging intubation. Working within their means (a meager selection of available equipment),

staff in the OR performed their tasks with ease. The effortlessness and confidence with which they performed these tasks nearly left me with a feeling of embarrassment.

While I would like to think I was assisting Ugandans with their day-to-day medical systems operations, I must admit that my motives were not entirely altruistic. While I was eager to assist fellow doctors, I was just as, if not more keen to learn from their experiences and practices. I teamed up with a resident at any available opportunity, discussing approaches to various diseases. What I found the most astonishing was how two countries set so far apart, both geographically and medically speaking, still shared the same fundamental principles and the same innate desire to help those in need.

I would be lying if I said that at times I wasn’t scared or frustrated, wishing that I could have the comforts of home with me.

Outside the walls of Mulago hospital I explored the country. I found myself travelling to the north to visit the source of the Nile is in Jinja, home of some of the best white water rafting in the world. Class 4-5 rapids that dwarfed the raging waters of the Ottawa River. As a natural thrill-seeker, I found myself at the front of a raft eight people, all of us being tossed about some of nature’s best and most beautiful white water.  To the west, at the Rwandan border, I came face-to-face, literally, with one of the world’s last remaining gorilla families, the Silverbacks. To the north, I found myself cruising through Murchison falls National Park on a safari, chasing down antelope, cautiously observing lions, and hiking to the top of one of the most spectacular waterfalls I have ever seen.

As I look back at my time in Uganda, my mind is full of memories and experiences I will never forget: the smell of burning garbage on the roadway, the sounds of horns blaring, the heat of the sun as it shines down on your face. But most of all I will remember the faces; the faces of the people I met and had the opportunity to work with, the animated laugh of the anesthesia staffer as he watched my face light up the first time I woke a patient up after delivering my first anesthetic, the serious expression on my fellow resident’s face as he translated for me on the wards, guiding my hand as I palpated a woman’s tumor, the tears in my friend’s eyes as she tells me how a patient of hers passed away because her hospital had run out of blood. Having learned so much from these people, I am left with the feeling of wishing there was more I could have done for them. My elective experience in Uganda took me out of my comfort zone and it is because of the challenges I experienced, that I’ve been left with one of the most medically, and culturally rewarding experiences of my career.

Although not all the outcomes were good, I think I learned more from the past four weeks, then the past four years of residency.

When I asked: “Is there anything I can do to help?” the residents at Malago just look at me and smiled. As I sit at home, I smile as I reminisce about my experience in Uganda. I find myself longing to go back. As I sit in the comfort of the operating room at Hamilton General and scan my monitors, my attention is drawn to that familiar hum of the pulse oximiter and the many stories it brings.

Dave can be reached at david.sussman@utoronto.ca.