This is the most important lesson I have learned in my first week of work at Mbarara Hospital, and one that I suspect will cause me strife throughout my time here. It's really unnerving to be making important clinical decisions about a patient's care with virtually no hard information outside of my clincal exam. In the US, I frequently didn't even meet my patient until after I had the results of a complete blood count, a renal panel, a liver panel, an Xray, often a CT scan and sometimes an MRI. Things are different here. But let me start at the beginning, by describing the hospital...
Mbarara Hospital is a public hospital, meaning it is funded by the Ugandan Ministry of Health and general care in the hospital is free. It is affiliated with the medical school (MUST), one of only 2 med schools in the country, and so the hospital is staffed by med students and residents. The med students are good, and the residents are really excellent.
There are a few different wards in the hospital: a pediatric ward, an OB ward, an emergency ward, a surgical ward, and our medical ward. The medical ward is split into a men's and women's side and there are a total of 56 beds that lie in 2 rows about 2 feet from each other. Despite there being 56 beds, the ward is usually over capacity with many patients in spaces on the floor. There are 2 nurses for the whole ward, and very few other staff.
One of the most unique aspects of the hospital that struck me on my first day and continues to astonish me as I go to work everyday, is the presence of "attendants". Every patient is expected to have family tend to ALL their non-medical needs. This includes feeding, toileting, laundry, providing bedding. Everything! As you can imagine, a hospital full of patients creates the need for many, many attendants, and so the grass outside the ward is filled with women doing laundry or preparing food, other family members sleeping, and many just sitting. Waiting.
As a place to work, the hospital is great, but this is in part due to the rather sad dichotomy between the well-read, very intelligent, hard-working med students, interns and residents and the stark lack of resources, medications, and investigative abilities of the hospital. For my purposes of trying to gain broader clinical experience, my past 2 weeks have been the richest of my short career, but the tragic disparity between the impressive brain-power that you find in a good clinical training program such as this and the lack of tools available is apparent everyday, with almost every case. Having said that, no one here sits around complaining! They are creative, resourceful and able to provide impressive quality of care to the whole ward for the cost of a single ER visit in the US...
So what do I actually do? I am formally a volunteer teaching attending in the department of medicine (Yes- I actually have my Ugandan Medical License- can't wait to put that on a CV!), and am assigned to one of the 4 medical teams. It is surprisingly like any other residency program in the US or the UK, in that we have post-call intake rounds every morning, and I lead a combination of bedside teaching rounds with medical students and work rounds with the whole team when we see every patient together. The resident I work with is wonderful, and steers me back to Uganda when I fly off on a diagnostic tangent that is feasibly impossible.
As I said, you just have to be comfortable not knowing exactly what the diagnosis is. Be thorough. Make your best guess. Then treat, treat, treat!