Intensive Care in Mbarara

ICU bed awaiting a patient

Maybe we were naive but we didn’t expect to find much in the way of Critical Care in Mbarara. Sure, maybe a close observation area for the sickest patients with monitoring and maybe some oxygen if available but not anything close to what we would expect at home.

 However we found a small intensive care unit (ICU) equipped with 2 beds with a ventilator each, all be archaic, and in theory a series of high dependency units (HDU) for each speciality. These functioned less well, largely as a result of the lack of equipment, staffing and spacial planning, but the idea is there. Nearing completion, but lying barren, is the new hospital furnished with an 8 bedded ICU that wouldn’t be hugely out of place from a design perspective in the UK.

The temporary unit...still under wraps

The current ICU is awaiting transfer to its temporary home (prior to the new hospital) a 4 bedded unit equipped with new ventilators and an air-conditioning unit that would keep an Eskimo cold! In the meantime it occupies what is mean to be the maternity HDU. The small unit is staffed by Ruth, the dedicated senior sister and several of her juniors. Patient reviews take place at the beginning of the anaesthetic working day and other problems are dealt with as they occur. Ruth has been working on the ICU for 10 years. She moves around the unit and organises it with quiet efficiency and looks after the patients and their families with professionalism and kindness. She seems happy at work but talking with her reveals the frustration and disappointed she deals regularly as she watches many of her wards die, even more difficult she mentions when they are staff members or children. I think the same applies for all of us in the medical world but we are very fortunate to not have to battle with the issues and subsequent mortality rates that Ruth and her team face on a daily basis. That being said everyone maintains and constant note of optimism whilst appreciating the hard reality that the odds are often stacked against them.

Patient in ICU

Hope, a small 13 year old girl, presented with osteomylitis of her lower leg, an infection of the bone. As is so often the case her family only brought her to hospital after several weeks of treatment in the village. This had involved applying herbal remedies to a wound on her foot, including the application of cow maneour, a popular remedy here. Her family are farmers from a local village and, as is usual, acted as her main careers helping bathe and dress her.

The infection had tracked up to the bone just below her knee. Having been to theatre to have her leg cleaned she came to ICU very unwell from this serious infection. This sort of infection requires high doses of antibiotics and ideally they should be directed specifically against the offending bacteria. A recent revelation has revealed that we have no idea how potent the antibiotics are and we can only get a broad idea of which bacterium might be causing the infection. Alongside this, the daily review and plan had to take into consideration the ability of the family to purchase the various tests and bits of equipment for their daughter. At home we take test results, bacterial identification and availability of drugs and equipment for granted and even then treating patients is a real challenge. How much more in the dark we found ourselves now. 

Hope was a young scared girl when she arrived but one who became more involved in the unit as the days passed and she improved. Everyone became very attached to her and her family. On one morning we found her taking an active interest in the resuscitation teaching that was being performed on the dummy on the floor by her bed. This is a novel idea, we thought, teaching the patients resus skills whilst treating them!

We are delighted to say that although Hope developed several complications whilst with us she made a good recovery and made it back home.

Hope’s case, although individual, was surrounded by the daily problems faced by doctors and nurses here. It is a perfect example of the need for public health education and timely presentation to hospital. It highlights the challenges of treating an infection whilst not knowing the exact cause and not being able to have faith in the dose of drugs you are using. It reminds us of the joy of free medical provision at the point of care and not having to balance the needs of the patient and those of the medical team against the financial position of the family.

As a side thought in the current times of financial constraint maybe we can learn a little from this. I wonder if the money we were spending was coming directly out of our, or the patient’s, pocket would we be quite so relaxed with ordering multiple tests and investigations that will do little to change our course of treatment. Would we look after that simple piece of equipment that bit more carefully....?

The events described in the blog are true although in the interest of confidentiality certain details and characteristics have been changed.