Ethics of the Theater: Ophthalmology in Uganda

uvmmedicine blogger Julia Shatten '18
uvmmedicine blogger Julia Shatten ’18

7:30 a.m. – Weaving through traffic by foot to get to Beseda Medical Center.

8:00 a.m. – They take off the bandages of 90 post cataract patients, with an assembly line at expert speed from bandage removal, eye drops, vision test, pressure reading, slit lamp. I helped them to their stools, their vision is still blurry.

9:00 a.m. – Weaving through traffic by foot to get to Mulago Hospital for a day in the theater with oculoplastics.

9:30 a.m. – We wait for clean linens for surgery.

10:00 a.m. – We wait for clean linens.

11:00 a.m. – We wait for linens.

Noon – Linens arrive, we wait for the anesthesiologist.

1:00 p.m. – The first case. A one year old boy with suspected burkitts lymphoma is scheduled for a biopsy. His parents did not bring his medical records, but they had a photo of him with a large mass in his cheek. Based on the history, the team suspected Burkitt’s. The boy was so small. We try to get an IV.

1:30 p.m. – We try to get an IV, the residents, anesthesiologist, and medical students are all trying at the same time.

1:45 p.m. – The senior doctor shaves the scalp, and we put in an IV.

2:00 p.m. – The baby is having labored breathing, the oxygen is off. We wait for someone to bring more oxygen. “This child does not want us to take this biopsy,” the surgeon says. The calm in the room is disturbing to me. The lack of urgency as we watch this child in respiratory distress in painful for me. I try to take the same demeanor as the others in the room, but I cringe and feel weak—having been in this room since 9 a.m. The boy is extubated, and we wait.

3:00 p.m. – We begin the operation. We only use iodine on the eye, because it doesn’t sting as much, and never use gauze, only cotton. The dark iodine is applied by the resident while the surgeon scrubs in the tiny sink nearby, using her elbows to turn off the water and avoiding all obstacles in her path. She wipes her sterile hands on her gown and then puts it on herself, slipping into gloves. I tie her in the back. She begins the surgery. When she asks for cautery I hear the sound of a match and watch her heat the tiny instrument in the open flame. Seeing the open flame so near to all of the medical students, and the patient, and the oxygen tank, I feel myself again feeling immense tension amidst the calm in the room. Swiftly poking the conjunctival edema with a needle, and closing the wound with invisible stiches and no microscope she works like a magician, bringing skin together with slide of hand. OINTMENT! The signal that the surgery is done, a hand reaches over the surgeons shoulder to squeeze ramen noodle goop onto the wound, then it is quickly bandaged. Not over the nose, not too much pressure. The young boy is extubated, and the intern just pics him to bring him to a crib outside of the theater to recover.

4:00 p.m. – We flip the sheet over that we used for this patient in preparation for the next, a five year -old boy with a foreign body in the eye. He is too scared to lay down, so he sits playing with a toy piano on the operating table as the anesthesiologist administers the anesthesia. She catches him just in time, and lays him back. The rest of the operations that day were a blur. An evisceration under local anesthesia, where they scoop out the contents of the eyeball and leave the sclera, while the residents slap back the hands of the patient as they reach up in discomfort. A burn patient with a tiny, tiny eye comes in for enucleation, the removal of an unsightly eye. But the surgery is too difficult and the eyelids are sewn shut over the tiny eye. An intralesional bleomycin injection follows. The day closes out with a Hugh Flap surgery, a difficult three step plastic surgery with skin grafts to reconstruct the eyelid of a patient who was in a boda boda accident. There were three more patients scheduled that we could not operate on today. Although I was able to sneak out for food and water, I couldn’t ever quite regain my strength that day in the Theater. Were patients getting quality care? Was this version of sterility enough to prevent infection? And if these patients got an infection, would they be able to follow up? Was my presence in the theater preventing the Makerere students from learning? Was I scaring the kids?

8:30 p.m. – The surgeon drove me home. She was happy and light despite operating with no breaks and encountering so many boulders in the road. As we slowed for the speed bumps, and narrowly avoided pedestrians, bicycles, and boda bodas I thought about the calm in the operating room. It’s the same calm that people have crossing the street here. Where I flip my head back and forth so many times I am almost dizzy before darting across. Is the calm just a function of adaptation to environment? Or is there some deeper resignation to poor outcomes? I am beginning to this it is the former. There is an element of self-preservation in medicine everywhere and when the outside stresses are even higher, the defense must grow to match it. As I wait on the patio roof for dinner looking out at the constant stream of bobbing lights, still gathering water in the dark it is clear that the answer to improvements in healthcare cannot be singularly focused to increasing resources and training. The economics of poverty and the politics, infrastructure, and all of the other jargon that goes into social well-being in society must all shift together.

I can’t help but think about the theory behind Teach For America (TFA). The poor public education system that we have in the U.S. is, at its root, a function of institutionalized racism. We have to address the racism to change education. However, shifting the culture is a slow process. The idea of TFA is that we start in the trenches of education. Train teachers to have high expectation, and who will work relentlessly and outside of the box to change the life trajectory of their students. We were taught to “teach like your hair is on fire.” This is obviously not sustainable for a career – eventually, you will burn out. So those teachers either find a way to make it sustainable, having already set the bar high for their students, or they go into another sector of the system to bring about change. Of my five closest friends from TFA, one is still teaching middle school science, one is a principal of a school, one is a social worker, one is getting a Ph.D. in education, and I am going into medicine with an eye for social justice. The hope is that as the alumni movement builds, and more and more people have experience and exposure to the system first hand that there will be a tipping point for change, where alumni are working at all levels and we have teachers in the classroom with high expectations. It all has to happen at once.

When I was teaching I used to sit in my classroom after the bell rang, lock the door, and cry at my desk. I cried from exhaustion. I cried for all of my students, their families, their lives, and all of the ridiculous barriers they had to surmount to get an education. Since I started medical school, I have not once had that experience. The hardest day in medical school is still ten times easier than the easiest day teaching. My experience here has changed that. I feel the power structures, the hopelessness, and my privilege.  In TFA, when I felt these things, it was fuel to the fire. To work harder, plan better lessons, call more parents, make more home visits, and be better. Here, my struggle is that I do not have the luxury of “working harder.” I am an observer and a learner, and my inability to expand my locus of control is hard. All I can do is continue to show up.

10:00 p.m. – We pray and eat dinner as a family.

11:00 p.m. – I go to sleep in preparation for another day in the ophthalmology theater, I dream about children getting water from the stream.

Julia Shatten’s essay won the Best Reflection Award at the recent Global Health Celebration hosted by the UVM Larner College of Medicine and Western Connecticut Health Network.

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