Mentors from Across the World: Pediatric Surgery in Uganda
Finishing my second year of medical school and being interested in global surgery, I wanted to spend my summer abroad before entering clinical rotations. As a recipient of the McGill Global Scholars Program, I traveled to Uganda to undertake research at Mbarara Regional Referral Hospital (MRRH) in pediatric surgery. After a five-hour taxi ride from Kampala, the capital of Uganda, I arrived in Mbarara jetlagged and uncertain of this adventure I had just embarked on.
On my first day at the MRRH, a tertiary level hospital in western Uganda, I met my colleagues in the emergency department at morning rounds. There were more than ten of us, students, residents, and staff. Reviewing the surgical patients that had arrived overnight to the emergency department (ED), I was shocked by the mere number of patients/cases. Squeezing between patients and struggling to hear in the commotion of the ED, I tried to follow as we moved from patient to patient, from children to the elderly, and from the sick to the dying. I knew that the conditions of hospitals in low-resource settings were far different from what I was used to back home. Even as a second-year medical student I had seen patients suffer from terminal illness and watched as families sobbed over the death of a loved one, yet nothing could have prepared me for the impact Uganda was to have on me. It was not the severity of patient injuries nor the lack of resources that really affected me in the beginning: It was all of it at once. It was the 16-year-old boy with the open femur fracture. The battered and bleeding man lying on the floor, resting his fractured face on the bottom of a scale for comfort. The small child with a chest wound draining into an empty coke bottle. The little boy with a mangled arm sharing his bed with another child suffering from burn wounds. I witnessed many sights that would have been considered heartbreaking in Montreal, but sights that were all too common in Uganda to be labelled as such. As the days went on these sights became more familiar, and the medical system back home all the more fictional.
I spent the majority of my time with the pediatric surgery team, including Dr. Anne Wesonga, the clinical fellow in pediatric surgery. During my time in the operating room, I saw multiple anorectal malformation repairs, colon resections, hernia repairs, circumcisions, and orchiopexies. I watched the surgeons, anesthetists and nurses function with limited resources, including The electrocautery machine that would intermittently function, the needle driver that would not hold needles, gloves two sizes too big, power outages and much more. Despite these inconveniences, the team did their best to provide the highest quality surgical care possible.
As someone who wants to pursue a career in surgery, I did not expect my most meaningful experience to take place outside of the operating room. It was a Wednesday afternoon impromptu clinic. We saw patient after patient, some booked for elective surgery the following day, while others were referred directly to the pediatric surgical ward for emergent conditions. Many patients had traveled hours , even days, to see a doctor. Dr. Wesonga’s phone rang: it was a nurse from the ward saying a baby had arrived with gastroschisis.
Gastroschisis is a rare condition where a baby is born with their intestines outside the abdomen through a defect in the abdominal wall. Incidence in North America is estimated to be 4-4.9/10,000 live births. However, there is a lack of epidemiological studies in sub-Saharan Africa and therefore the exact incidence of gastroschisis is unknown.
A specialty-made Silastic silo bag is placed over the bowel to facilitate/ensure gradual reduction of the bowel into the abdominal cavity over several days. In Uganda, there are no special silo bags, so urine catheter bags are sutured to the abdominal wall instead.
The outcomes of gastroschisis infants are generally poor in low-resourced settings. These neonates lose fluids and heat from the exposed bowel and are at high risk for infection. They require resuscitation with strict fluid management, warming isolettes, and broad-spectrum antibiotics. While survival in high-resource settings is usually above 95%, mortality in sub-Saharan Africa is almost 75-100% in most centers 2. This dramatic difference is due in large part to keeping the neonates hydrated, nourished and infection-free while their bowel is outside their abdomen. Many suffer from intestinal dysmotility and therefore require nutritional supplement, such as total parenteral nutrition (TPN), either through a tube directly into the gastrointestinal tract or via the vein for short or long periods of time. However, TPN is not available in most public or private hospitals due to high cost and lack of availability. Dr. Wesonga explained to me that as a result, many infants with this condition die at home, during transport to the hospital, or are left to die in hospitals as many centers feel unequipped to handle these cases. She expressed her frustrations with the system and seeing gastroschisis neonates die all too frequently.
Responding to the call, we entered a room occupied by four incubators, only two of which were functional. I saw a young mother standing over the incubator staring at her crying newborn. The baby was tiny, wrapped in a fleece blanket, his eyes sunken and skin dry from dehydration. Less than 24-hours-old, he had already embarked a five-hour journey to the nearest hospital in critical condition. The mother was not crying: with a flat affect she simply stated that that she knew her baby would die soon. After seeing how fragile life is in such settings, I could see how circumstances like this become understandable, as they are all too common. Even so, Dr. Wesonga reassured the mother that she would do her best to save the child. She began resuscitating the newborn with fluids and placing a nasogastric tube. She created a makeshift silo bag using a sterile urine bag, which she sutured to the abdominal wall of the child. The mother was instructed to aspirate the nasogastric contents every few hours and slowly feed her baby small amounts of breast milk via a piece of gauze, in lieu of TPN. Despite the odds, The baby ultimately survived.
With minimal resources but intense persistence, Dr. Wesonga has now been able to save several infants with gastroschisis using these simple measures. During medical training, you meet many individuals who influence your clinical perspective: Individuals who provide you with insight and change your views in regards to patient care. Although I may never see Dr. Wesonga again, I am grateful to have met her, a mentor who has influenced my future career as a surgeon halfway across the world.
Tiffany Paradis is a third-year medical student at McGill University. Prior to medical school, she completed a B.Sc. in Anatomy and Cell Biology and worked as a research assistant for the Department of Pharmacology and Therapeutics at McGill. Tiffany has had a longstanding interest in surgery and global health. She has worked extensively with the Centre for Global Surgery under the supervision of Dr. Dan Deckelbaum on her work involving postoperative mortality rates. She has also worked with the Global Initiative for Children’s Surgery on the development of pediatric bellwether procedures under the supervision of Dr. Dan Poenaru. Tiffany’s research interests include the use of health metrics in the developing world and their impact on strengthening health care systems. Aside from medical school, Tiffany has done extensive work as a public speaker and mentor for disadvantaged youth within her community.