Shenanigans in Kampala

(dear blog,)

Physioing the last few days were great. Saw a lot of patients in pre-op/post-op orthopaedics again. Spent a lot of time on gait training and pre-op instructions for exercises. Some of these patients receive conservative care (leg in traction) or have external fixation (screws go in, and stabilizing plates are on the outside), so they are bedridden for up to eight weeks. For these patients, its a lot of isometric strengthening of the involved limb with some contralateral limb strengthening and strengthening for preparing to leave with an assistive device.

I got to measure for axillary crutches. As far as I know, this isn't really done in the states (US has metal adjustable ones, here they individually order wood ones).

I learned how to count to four, and used that with my instructions to a couple patients, and they liked it. Most patients speak decent English, but they get a kick out of a muzungu trying the local language.

I worked with two Ugandan physio students, David, and Kristen on Friday. The students saw a lot more patients to at least check up on them, so it was a good experience. I was impressed how much they knew their stuff, but if you look at their training background it makes sense. Physiotherapy is basically a three year bachelor program here, but they are thrown in the clinic starting in the second year. We tried to get a patient to use a walker after months of mostly bed rest, and it was impossible (to stand, she was essentially mod assist X 3-4). She was incredibly grateful for the attention though, as many patients generally are (we're often in a small group with them).

and on to other things...

We're staying on campus at Makerere University at a guest house called Nufu. Its a four bedroom, two-story house that exceeded my expectations greatly. We have decent internet, the electricity is usually on, and the water temperature/pressure is pretty good. There's a nice common room/kitchen, and we have a housekeeper that keeps things tidy and serves breakfast every morning (Juice! Coffee! African Tea! Toast! Eggs! Sausage!).

The University is an island within a pretty hectic part of town. Its mostly fenced in, and there is not much traffic, which makes walking around pretty easy. Its a large University complex with some student housing, soccer fields, restuarants/bars, etc. Walking to the hospital takes about twenty minutes.

Some things we've done:

Running!

• Not that bad here. I haven't noticed the pollution, and the mornings are pleasant (low 70s, humid), and afternoons are tolerable (80s and humid)
• Going off campus isn't practical, so I haven't really run more than 45'
• I have actually conned the other PT students to join me running, so I haven't been on my lonesome every run
• My marathoners have not been dry in a week
• I'm looking forward to running in Nkokenjero (rural)

African Dance Show

Lecture from Dean of Medicine about Ugandan culture

Playing cards/word games in the house

Beer selection isn't bad - there's actually five or six local beers available

Lunch with the UW Global Health Class#

Inservice from a pharmaceutical rep at the hospital

Inservice with Karen on treating cerebral palsy (felt like real live second years!)

I'm off to Nkokenjero now, working at a home with mostly orphans and kids with disabilities, run by nuns, and staffed with an OT and a few other assistants. Many of the children we will see have hydrocephalus or cerebral palsy. There is probably internet, but I doubt I'll be able to blag much while I'm there.

Good luck to all the physio students back home. Learn a lot!

Physiotherapy in Uganda

(dear diary,)

I'll start with a quick recap of arriving in Uganda, but I'm mostly going to talk about clinical from the last few days.

Our flights were awesome. Turkish airways took great care of us, we got socks, a sleeping mask, ear plugs, touch screen movie screens, and multiple meals and snacks. We had an 11 hour flight, a one hour layover in Istanbul, and a six hour flight to Entebbe. We were met by a guy in a Wisconsin shirt to take us to Kampaala. We finally arrived at our place at 3AM, and I ended up not sleeping at all.

The first day was mostly relaxing, going on a jog, walking through campus, got lunch and groceries, and ordered a pizza.

Physiotherapy in Mulago Hospital

First of all, physical therapy in the USA=physiotherapy everywhere else in the world. I prefer the international way.

We are working in the largest referral hospital in Uganda. Its about a mile from where we're staying. Our first day consisted of meeting the physical therapists and going on a tour of the hospital. It reminds me of the Ugandan version of UW-Hospital. Its gigantic - six floors in the main building, and a series of additional wards and medical school buildings on the campus.

I didn't really know what to expect at the hospital, but nothing really shocked me too much, but its significantly different from the states. There is little emphasis on hygiene (washing hands & hand sanitizer), patient overflow in the hallways, patient's families camped out on the floors, and the patients are dependent on their families for basic services. I have heard that patients are only provided two meals a week, and I have yet to see anybody addressing bed sore prevention, dietary needs, or providing water. Its not that they are ignoring these important things, its just the responsibility is put on the patient or family.

On the second day, David and I were matched with Richard, a physio that has worked at Mulago for twenty years. All my misconceptions about health care workers in Uganda were quickly changed. To an extent, I thought that physios in Uganda would not have the same skill set as those in the USA. I thought that their skill set would be tailored to the resources they have in Uganda. I never thought much about it, but once I was in clinic, I realized that they are very similar in skills as physios in the USA. There are significant constraints put on them, the patient's culture, environment, and often occupation, make their job more challenging, and they have to adjust their care. The hospital itself and lack of time also make their jobs much more difficult.

We were placed on ward seven, predominately pre-op/post-op orthopaedic care. There are forty patients in one long room, mostly suffering from fractures or dislocations. Many receive surgical care, hip replacement seem to be the most frequent. However, often the patients receive conservative care, which generally means being put into traction for 6+ weeks. The most frequent mechanism of injury is motor vehicle accidents, but we have seen falls, insufficiency fractures, and gun shot wounds.

We first started with doing rounds with the orthopaedic physicians, nurses, and a couple other Ugandan physios. We went through forty patients in a couple hours. The physician would quickly assess the patients for surgery or discharge, and we would often lag behind to work with patients. Some patients received not care from us, but many had a quick follow up or some form of treatment. Generally, our care consisted of bed exercises and some gait training. The focus in this ward is to maintain strength during immobilization and to prepare the patient for discharge.

Richard (our clinical instructor) is also a professor, so he does a great job at challenging us with asking questions.

The next day, David and I were again placed with Richard on ward seven. Instead of rounds, the five of us (two Ugandan PT students, David, myself, and our physio, Richard) went through the ward ourselves. I was thrown in the fire a bit on the seconds patient. Richard gave us the chart and plain films, and I was instructed to give treatment. My patient:

• L Hip Dislocation with SI joint involvement, 3 weeks post surgical correction
• R mid-femur fracture with pubic ramus fracture
• I may have mixed something up?
• They elected for conservative care (traction: patient's leg is immobilized using weights/jug of water hanging off the bed) for the R femur problems, but the L hip was surgically corrected
• MOI: MVA

I struggled a bit with patient instructions, and not choosing aggressive enough exercises, but it went good enough. It was difficult not knowing exactly how far out the patient was from surgery, but the charts are a bit disorganized, hard to read, and often unavailable.

Some musings:

• I wrote this while drinking some wine, so expect spellling errors
• Language barrier can be hard, many patients are more comfortable in Lugandan
• Saw a pt whose entire midsection of femur was removed due to a GSW
• Richard sometimes reminds me of Dr. Bill
• Got quizzed on a variety of things (DVT, traumatic fracture complications, ROM indications, MMT grades, etc.)
• The Ugandan students generally know their stuff pretty well(most are 3rd years)
• We looked at almost all of the patient's plain films (x-rays), always by holding up the plain film to a window. The PTs consult them frequently, as they are more available than a chart
• The patients hang on to their own plain films (often in a file kept under their pillow)
• The physios are stationed everywhere in the hospital (ICU, burns, ortho, outpatient gym, neuro, etc.)

I'll get to some of the other fun stuff later (volleyball, football with the random kids, our house, running at the university, Africa in general, etc.)

Uganda!

Mini blog post to preview the trip. Sentence fragments!

4 days and 3 finals left.

Excited for my pants!

Chicago (10pm 5/13)->Istanbul->Entebbe->Kampala (2am 5/15)

Return to Madison 6/12

Itinerary:

Mulago Hospital in Kampala

Providence Home in Nkokonjero

Safari in Queen Elizabeth National Park

Mulago Hospital again

Nile River Rafting

Bonus week of rambling about

More info later

-DW