Ian McDaniels ‘16, is a medical student from Thetford, Vt., completing a one-year Pathology Student Fellowship between his third and fourth years of medical school. He recently finished a seven-week elective at Mulago Hospital and Makerere University College of Health Sciences in Kampala, Uganda, through the global health program sponsored by the UVM College of Medicine/Western Connecticut Health Network/Danbury Hospital. He spent four weeks in the pathology department, conducting interviews and participating directly in autopsy and surgical pathology, as well as three weeks rotating through obstetrics, pediatrics, and infectious diseases. The following post includes reflections he wrote during his time in Uganda.
I arrived in Kampala, Uganda, at 11 p.m. last Tuesday night after departing from Hanover, N.H., at 6:30 a.m. on Monday. It’s amazing how a few hours in time difference and multiple layovers will evaporate days. My travels were smooth, except for trying to navigate the NYC subway system with two massive suitcases, as well as two smaller bags. After the embarrassing and frustrating experience of getting stuck in a malicious turnstile (whose grasp I required assistance freeing myself from), I gave up and took a taxi to the airport. Traveling with so much cargo is not my style, but my payload included about 60 lbs. worth of textbooks: Rosai Surgical Pathology volumes 1&2, Sternberg’s Diagnostic Surgical Pathology, volumes 1&2, Rosen’s Breast Pathology, and Breast Pathology by O’Malley, generously donated by Dr. Ambaye of the UVM Department of Pathology for use by the pathology residents at Makerere University in Kampala. To add to the bulk were two boxes of N95 masks, , which I do not regret packing given the fact that on the morning of my first day at Mulago Hospital, I attended a series of forensic autopsies, the first of which was a death due to tuberculosis. Most of the deaths were due to traffic accidents, which is no surprise for anyone who has ever seen a road in Kampala. During the afternoon I assisted with the gross examination and processing of three Wilms tumors, a relatively rare malignancy of childhood.
Pathologists at Makerere University and in Uganda (the distinction is hardly necessary given that Mulago employs nearly all of the pathologists in the country) are generalists, responsible for surgical pathology, cytology, and for doing forensic and medical autopsies. They do a good job, but are limited by paucity of resources as are other departments in Mulago. For example, they lack ink in the grossing room, which limits the pathologists’ ability to assess surgical margins, a task critical in determining the efficacy of a surgical resection. During examination of the Wilms tumors my advisor, Dr. Kalungi, pointed out the constant need to improvise and work with the resources that are available, even if they are not ideal.
This week was busy and productive. My days have been steadily growing longer; I now leave before sunrise and return shortly before sunset. I have started doing my own post-mortem exams including the initial evisceration step (removal of the internal organs). I started doing cases on Wednesday, and I’ve done seven so far. We’ve had a steady stream of first-year medical students in the mornings, about 12 to 15 per day. The students look very young, which makes sense considering most are fresh out of high school. They have already taken basic anatomy and physiology courses, however, so they’re not totally new to the body, although they are new to the morgue (earlier this week, one of the students collapsed in dramatic fashion). On Thursday I did some teaching with them and on Friday I was the dedicated educator, largely due to the high volume of cases we had. I kept the students occupied while the pathologists and the resident worked on the remainder of the cases. We cut cases short if we’re suspecting TB because of the health risks. In fact, one of the autopsy technicians was recently diagnosed with TB pericarditis, a very rare entity in the U.S. Dr. Kalungi is keeping me busy outside of the hospital as well. I’ll be working on writing a case report on an aorto-esophageal fistula I discovered in one of my cases.
In addition to having a productive time at Makerere, the host stay is proving very home-like, with wonderful hospitality. I feel very comfortable here and I am immensely enjoying the interactions with my host family. Nyce, my host sister, is my friend as well as cultural and logistical advisor. She has helped me navigate the Matatu (a 14-person van/bus) commute to Mulago and other matters of daily life in Kampala. There is a happy bustle about the Luboga household, with equal parts regimented routine and meaningful social interaction. I feel both cared for and free to do what I want. Because school is not in session yet, the house is full of young, lively individuals whom I am getting to know well. I’ve been slowly recruiting two of the young men in the house, David and Sam, to do workouts with me. Sam also took me to a church-league football match in the neighborhood on Sunday.
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Two weeks ago, I spent a week working on the low-risk labor and delivery unit. Ward 14, as it is also called, is staffed completely my midwives. The resources are minimal. Patients bring changes of clothes, blankets for the baby, a plastic sheet to labor and give birth on, and whatever else they need in a suitcase. There is no continual fetal heart rate monitoring system. Instead they use fetoscopes, which are cone-shaped devises used like a stethoscope to hear the fetal heart. There are no clamps for the umbilical cord and no scissors to cut the cord. Instead we break off the cuffs of surgical gloves to tie the cord and cut the cord with a scalpel blade. Vaginal repairs are frequently done without needle drivers, often without proper local anesthesia, and in poor light. Still, without the resources of a western labor suite, the job gets done. The midwives are extremely proficient and are happy to teach medical students. I went into the week never having done a cervical exam on a laboring woman or having delivered a baby. At the end of the week, I was proficient at cervical exams, had delivered three babies, and was also developing some skill at Leopold maneuvers.
Before I left for Kampala, I met with Barry Finette, a pediatrician with a wealth of experience working abroad, including at Mulago. He told me it would take me two full weeks to acclimate to Kampala. After one week I thought I would forever be only semi-acclimated but indeed, after two weeks I discovered that he was right. I have fallen into the rhythm of the city. My threshold for excitement has changed. No longer are the yells of matatu conductors or boda-boda men (motorcycle taxi drivers) distracting, no longer do I get upset about the anarchist sub-culture that is Kampala traffic, no longer am I shocked by the smell of dust and burning garbage, or men carrying live chickens on the sidewalks downtown.
Wow, it sounds like an incredibly unique experience. It seems like you’ve learned so much, so quickly. Thank you for helping me to remeber that it’s so easy to take things for granted. As a pathology resident in the US, I have never once thought about how lucky I am to have ink to evaluate margins, until now that is. Best of luck. Can’t wait to hear more.