Mary Duke Biddle Reflection Essay - Adam Was
Seven years ago I found myself in South Africa’s Johannesburg International Airport, sitting alone in a restaurant and fighting back tears. I had spent the previous two years working throughout Africa for the Clinton Foundation Health Access Initiative. This incredible chapter in my life was at an end: I was returning to the United States to begin medical school. I felt thrilled about becoming a doctor yet devastated to be leaving my work and life in Africa. As I gathered my things and walked onto the plane, I promised myself that I would return as soon as possible.
In March 2015 I boarded a plane to Uganda practically giddy with excitement. I had kept my promise. Thanks to generous support from Stanford and the AAP, I was traveling to Kampala, Uganda to work at the Mulago National Referral Hospital. I was scheduled to spend six weeks working in the Acute Care Unit (ACU), a pediatrics high-acuity facility comprised of a PICU, NICU, step-down unit, and resuscitation room. I couldn’t wait to begin.
I spent most of my time in the ACU’s resuscitation room, which treated the sickest of the sick children. Our small team of pediatric residents, nurses and students treated dozens of critically ill children every day. At Mulago I learned how to use limited resources to manage a myriad of pathology. I saw more cases of neonatal sepsis, severe respiratory infection and malaria than I could count. I learned how to treat diseases I had previously only read about in books: tetanus, severe acute malnutrition, toxic epidermal necrolysis and snake bites. I went home every day in awe of what I saw and learned.
At Mulago I learned how to use limited resources to manage a myriad of pathology... I went home every day in awe of what I saw and learned.
This is a truth of global health: no matter how much you teach, you always end up learning more. Indeed, I had ambitious plans for teaching and quality improvement. For example, I had hoped to leverage my background in anesthesia by teaching pediatric airway management and respiratory support. However, respiratory management is different when there’s no BIPAP, no ventilator available for patients with respiratory failure, no true capacity for intubation or intense long-term respiratory support. This became an excellent lesson in context-sensitive clinical practice.
Our formal teaching lessons were certainly helpful, but I found that most of our team’s education happened in piecemeal fashion while working long hours side-by-side. I taught medical students how to systematically approach a new patient when they burst through the doors of the resuscitation room. I learned how to manage a sick, anemic patient from start to finish: I would run a hemogram, place an IV, draw labs, confirm the anemia, go to the lab, type the child’s blood, crossmatch a unit, withdraw an aliquot of PRBCs, administer antibiotics or antimalarials if indicated, slowly transfuse the blood, then admit to the ward. I showed residents how to optimize their bag-valve-mask ventilation technique. We taught each other hundreds of small such lessons.
I was also reminded that most quality improvement successes happen not through large, effortless leaps but through small, deliberate steps. I began to create makeshift IV kits during our breaks, and I showed a curious nurse how to do the same. I explained how it keeps all the supplies readily at hand and saves a few seconds during an emergent resuscitation, which could make all the difference. A few days later I noticed the nurse teaching her students how to make the kits. After a few weeks I arrived every morning to find a bucket of kits already made.
Lastly, I spent every day admiring the Ugandan patients, parents and clinicians around me. The children repeatedly astounded me with their resilience and spirit. We had no local anesthetic for IV placement, which made the process unpleasant for everyone involved. Still, I watched with incredulity as 7-year-olds calmly offered their arms for us to poke. More often we had to hold the patient down, but even then I would check on the child 15 minutes later and find her with a smile on her tear-stained face, waving at me happily and asking for a high-five. The mothers were similarly incredible. When a new patient got admitted, the experienced mothers would take the patient’s mother under their wing, give her food, show her around, and even guide her on how to breastfeed her baby. They endured long waits, multiple IV attempts on their children, and system challenges with a stoicism I couldn’t have imagined, and then they thanked us just for trying to help. My fellow clinicians were inspiring as well. I learned that in Uganda, the pediatrics residents pay the hospital, not the other way around. Many of them work separate jobs in addition to the long hours of residency. Despite these pressures, I began to notice them quietly slipping money to parents whose children needed an ultrasound or medication that they couldn’t afford. Suffice to say, I spent most of my time in a state of amazement at all the people surrounding me: Ugandan patients, parents and residents alike.
I spent most of my time in a state of amazement at all the people surrounding me: Ugandan patients, parents and residents alike.
These are the things I remember most from my six weeks at Mulago Hospital in Kampala. I learned more than I could have imagined about pediatric healthcare delivery in Uganda. But the lessons that really stick with me were how lucky I am to be a doctor in the US, how many resources my patients and I have at our disposal in our hospitals, and how it’s a privilege and a joy to treat children, whether in California or Kampala.
This experience has been the highlight of my residency. Tomorrow, sadly, I’m leaving Uganda and boarding a plane back to the US. But I promise I’ll be back.
Adam traveled to Uganda as a Mary Duke Biddle Scholar, supported by the Stanford Center for Innovation in Global Health, as well as an International Elective Award from the American Academy of Pediatrics Section on International Child Health.