The big picture

The clinic is this really weird mix of lethargic routine and quick bursts of excitement. The patient load trends HUGELY towards children between 6 months and 5 years old, with some combination of cough, temperature, and upset stomach. Within these there is obviously some variation, flu, malaria, cholic, but it tends to be the same series of questions, the same quick physical exam (check the eyes, palpate the stomach, listen to the lungs) and the some variation of the same series of drugs. Occasionally though weird or random things come in that get everyone excited. We had a case today of a man complaining of testicular pain without any acute cause, and minor pain in his sides. Without access to any of the tests required to rule out things like kidney stones or varicose infections we kind of had to guess. The only test we could run was a urine test, which showed us that there was a bit of blood present, which totally threw off what we were thinking. Four of us (Viola- the clinical officer, Rogers –the do-everything patient care guy, Irene- the junior nurse and I) spent nearly half an hour digging through books and speaking to COs at other med-centers in the area and performing a testicular exam (Rogers and I took that one. There are not lots of stigmas here when it comes to medical care, but gender issues definitely come into play at times). Ultimately we still had no way to reach a definitive diagnosis, but we went with our best guess for a course of treatment (so mid-level kidney infection) and we are hoping that does the trick.

 

I spent my morning touring the other medical facilities in the area. We are in Bududa district (basically Uganda breaks down as nation-county-subcounty-district-parish-village. There are 10 or so parishes in a district, 20-40 villages in a parish, 10-40 families in a village). Medical facilities are designated within these areas based upon two factors: there service types and the area they service. In Bududa district there are 4 other medical facilities. Busanza med center (a level 3), which is very small and primarily does vaccinations and child-births , with limited out-patient care and no long-term care.(it’s only about a km up the road from our house, I ran there this morning). Bukigai, which is also a level 3 but along with vaccinations and maternity has a large out-patient area, a small long-term stay facility and a cholera ward (Bukigai is the only 24 hr med-center in the district that is lower than a level 4). There is a small Christian missionary clinic that really only does for profit medication dispensation (they would be a level 1 if they were public). The only other facility is Bududa hospital. Bududa is a level 4, and along with having out patient care has 4 long-term wards (male, female, pediatric, and maternity), a dental clinic (open 2 days a week), and OR, and a Casualty (equivalent to an ER). All of these things are staffed by 4 doctors and two surgeons (total. Not at a time. Total). Each ward (which can have up to 60 patients at a time) is managed by one nurse. Deliveries are handles by midwives, with doctor’s only being called upon if a C-Section is needed. Bududa also has an X-ray machine and a very old, extremely decrepit ultra-sound (made in 1987). The Casualty has one ambulance, an old jeep, that is not actually an ambulance, it is just a jeep with a siren. The drivers have no medical training, they just do patient transport (apparently they often don’t use it because most situations where an ambulance is needed the person would die in the back without care). There are 3 more med-center levels, level 5 being county hospitals (there is one in Mbale, 2 hours away over unpaved roads), level 6 being regional hospitals (8 in the whole country…I think, not sure about that number) and level 7 being national facilities (Kampala International may be the only one- 8 hours away). The clinic is a Level 2 facility. We get that designation for two reasons. While we see a comparable number of patients as Busanza or Bukigai, we only do emergency child-births (as in, someone walks through the door with a baby falling out of them). We also don’t have the refrigeration facilities to do vaccines or many forms of lab testing. And when I say refrigeration facilities I simply mean a refrigerator. But we see patients from a larger area than Busanza and similarly sized area to Bukigai, so we are often lumped into the same category as those two, even though we are at a different classification level. Geographically speaking Busanza is very close to us (maybe a 25 minute walk). Bukigai is on the opposite side of the Bududa loop (the main district road is a big loop at the end of the long stretch from Mbale. It’s about 12 km total to go all the way around.) This is really the only road in the district that can be driven on. The road leading to the clinic will occasionally get travelled by boda-bodas (motorcycles), but only the boldest of drivers are willing to do so. Bududa Hospital is about equi-distant between Busanza and Bukigai (Busanza is right on the loop, we are about a km out off it). What seems like happens is that Busanza handles most of the maternity cases on this side of the loop and we get most of the rest. That is just my observation though, I have no data to back that up. There are so many people out here it seems like nearly everyone we see is a new patient (of 53 patients today, only 7 were repeats). A lot of this has to do with the birthrate. A huge part of Ugandan public health work has to do with family planning, and all public med-centers are required to offer free family planning services. Eventually I will get around to some background on the clinic and its sister program (the Arlington Academy of Hope –which is astounding actually, it’s an incredible example of what can happen when schools in this area are done right) and maybe get into the people at the clinic some. There are a lot of great characters.

 

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