After a six hour road trip from Entebbe Airport, the gates of Nyakibale Hospital opened and welcomed me. I was immediately led to the ED (Emergency Department) where I was greeted by Dr Mark and his clinical officers. Within one hour after settling in I was overseeing some of the clinical officers in their patient care duties. The Emergency Department is the only one within the district. It is the dream come true of Dr William Walsh MD and Dr Mark Bisanzo MD who originated the project and made it a reality.
The Emergency Department is open from 8am to 8pm everyday. It is staffed by clinical officers who are comparable to physician’s assistants in the US. They provide comprehensive patient assessments, emergency procedures and appropriate admission triaging. With each visit of Dr Mark Bisanzo, who is a Harvard trained Board Certified Emergency Physician, they learn new clinical skills. This month they learned lumbar puncture, chest tube insertion and respiratory management. The clinical officers are baked up by the on-call medical physician. The emergency department has been extremely busy this month as word of mouth amongst the patients has triggered demand for these medical services. Most of the supplies and medications have been donated by mission organizations.
After my ER shift, I was ushered into a very comfortable guest house. There were electric lights, western toilets and showers and a refrigerator .All of the beds were draped with mosquito netting. It was a clear reminder to take our prophylactic antimalarials in this very endemic area. The following day was a Sunday so we attended Mass in the local church. It was a 90 minute celebration of the liturgy in song and dance. Everyone was happy to be there and lifted up their voices to praise God. After Mass, I was fortunate to meet the Caiola Family. They are Lay Mission Helpers who have live in Nyakibale with their three children for the past three years. Originally from North Carolina they have acclimated well to the salubrious equatorial mountain climate. Jeff Caiola is the Hospital Administrator. With his diligent bookkeeping and agreeable personality he has managed to keep the hospital running in the black. One of his passions is running the trails around Nyakibale and he will be participating in the Kampala marathon next month. Cortney Caiola is an RN who also teaches art in the local schools as well as being a fulltime MOM for her children Ellis, Marie, and Gabby. The children all attend the local school system. The class size is over one hundred and they are fluent in the local language as well as English.
On Monday the regular medical routine began with morning report. All of the physicians and night nurses gather in the Administration Building to discuss the admissions of the previous day and night. Nyakibale is a 164 bed hospital which is currently being covered by 4 physicians. The hospital provides all primary care services including high risk obstetrics and Caesarian sections, orthopedics, pediatrics, general surgery and general medical. There are specialty clinic days for HIV, diabetes, and hypertension.
After morning report each physician makes rounds on their assigned wards. They rotate services every three months. When they are on call they are available for the emergency room, surgical theater and for C-sections. Most nights they are called for one of these medical issues.
The patterns of illness at the hospital reflect changes in society and in the weather. At this time in the rainy season we are seeing many malaria cases. While visitors often take prophylactic medication, the residents do not and build some immunity from multiple exposures to the parasite. While Many patients who are HIV positive are living asymptomatically , those that enter a more advanced stage have complications both from the illness and the antiretrovirals. We see many patients who are anemic and require transfusion. In addition, patients are more susceptible to opportunistic infections such as TB and cryptococcal meningitis so we must treat a broad spectrum of illnesses at Nyakibale.
The surge of helmetless motorcycle transporters on crowded roads has led to a great number of motor vehicle pedestrian crashes. Many of the injured are the young and the elderly who are unable to avoid the oncoming vehicle. Their injuries include pelvic fractures, femoral and tibial fractures and intraabdomial lacerations. These injuries were not seen 20 years ago and are solely the result of uncontrolled technical advance.
Another area where we are seeing an increase in the ED is domestic violence. Every day, I hear that a patient was assaulted. The causes include alcohol induced rage, unemployment, depression, and resentment. Most of the injuries are by hand or by ‘panga’(machete). Fortunately the number of civilian weapons is limited or outcomes would be much worse. It is hopeful that the Ugandan Public Health will address some of these problems which may be prevented.
Most patients leave Nyakibale with a smile. I am reminded of 13 year old Moses who had pathologic fracture of his right femur one year ago. He stumbled 2 weeks ago and it fractured again. Dr Mark and Dr Julius drilled into the bone suspecting osteomyelitis. He never complained during any of the anaesthesia or the drilling. He was placed on the ward for 10 days without improvement. The fracture is still not healing. He will be transferred to Mbarra Hospital. He may have osteogenic sarcoma. He definitely has a strong spirit and a winning smile. He has never complained on the ward, but looks forward to healing and returning to playing football. As I said goodbye to him, he smiled and wished me well. He will be in my prayers daily.
During my stay I was able to meet Dr Rob de Vos from Holland. He worked as medical superintendent for 5 years in the nineties. At that time he was the only physician and with a limited staff they cared for a 200 bed hospital. Since returning to Holland he has made two haypicking visits, whereby he critically evaluates the improvements that have occurred as a result of his fundraising efforts. His foundation supported by the Dutch people accounts for over 30% of all mission donations. His foundation money has built a new canteen, new hospital wings, generators and has sponsored students for specialty study.
In one month it is difficult to get to know the patients, the routines and the names of the staff. I have learned a lot from all of them and I am happy to know that they will keep Nyakibale moving forward. In addition to visiting we can help them by donating medical supplies, money and most of all by prayer.
Stephen P Kelly MD