Successful Wrap-up for Uganda Study!
I am writing while in Brussels Airport, on my way home just in time to fly to San Diego for graduation from medical school. I seriously considered skipping graduation to head with the second team to scout out new clinic sites in Bwindi, Western Uganda, but fear of my mother's wrath was too great to go through with that plan. Gone only 9 hours from Uganda, I am already anxious to return. The last week was so busy that I haven't had time to post updates of the tremendous successes ITW has enjoyed. But now that I have a three-hour layover, here is a rundown of the happenings since the last post.
The study trainees learned extremely fast, and after only a day and a half of training in the thyroid, gallbladder, kidney, and pelvis protocols, we were confident that they were ready to begin the study. It took us a few hours, but by 11 am on Wednesday the study kicked off. While we had trained eight people, only 6 were actually called for in the study design. The remaining two helped coordinate the complex gymnastics required by the randomized study design, ferrying models and trainees from scanner to scanner to perform scans that will be used to (hopefully) prove that our protocols are of diagnostic value. Their leadership was uncanny, and by the end of the day Wednesday, we had completed 24 of the 54 non-obstetric scan-sets called for in the study design. On Tuesday, we were worried that we wouldn't be able to complete the study by Saturday when travel plans dictated we leave Kamuli. After Wednesday's success, there was cautious optimism that we would be able to complete the entire study by Friday, a fully day ahead of schedule.
Thursday morning arrived, and the morning was supposed to be used teaching the trainees the obstetric protocol. Unfortunately, only 5 of the expected 10 mothers had arrived at Kamuli Mission Hospital that morning, so we had to scramble to find an additional 5 pregnant mothers to reach the 10 that we had hoped for (one to demonstrate the protocol on, and 9 that would serve as models for the study). Luckily, there were many willing mothers-to-be in the hospital's maternity ward, and after a few hours, we had 10 pregnant models. We quickly measured their height, weight, and sonographic gestational age so that we could properly set up the day's study. We had told the trainees that learning the obstetric protocol would be easy once they had gotten a good understanding of the pelvic protocol, and the quickness with which they gained proficiency in obstetric scanning proved us correct. By 11:30 the models were smiling as they saw their babies appear on the monitors by way of scans done by our newly trained ultrasound operators. By 4 pm, we had completed all the obstetric scans needed for the study, and were even able to complete 4 more non-obstetric sets, leaving us with only 26 sets to complete Friday...and by a combination of efficient management by our student coordinators and good luck, we were now confident we would finish Friday.
In addition to serving as pregnant models for the study on Thursday, each of the 10 pregnant women also received diagnostic reads from Brian ensuring that their pregnancy and baby were okay. Erin (a sonographer from Austin who was volunteering as a trainer) and I had already noticed two heads on one of the scans done during the study, and after her diagnostic scan, Brian informed the mother, in her third trimester, that she was going to be having twins. This was especially important, as one of the babies was lying transverse and she would have most likely tried to deliver at home. She will certainly now be delivering at Kamuli Mission Hospital under Dr. Alphons's close observation. The final diagnostic scan of the day was of the pregnant model used to teach the models the obstetric protocol. As she was not used for the study, the machine was actually not ever turned on during the training. Serendipitously, she stayed around for her diagnostic scan, and again, two heads were immediately evident on the monitor. Out of 10 pregnant women that day, two previously unidentified sets of twins were found with ultrasound scans. If this doesn't illustrate the value of ITW’s program, I'm not sure what will!
On Friday morning, UVM medical student volunteer (and future superstar outreach general surgeon) Asha, photographer Alec, and I walked from the guesthouse to the hospital to meet Dr. Alphons for his daily rounds. I had done this multiple times last year, but this was a first for Asha and Alec, and I think they were shocked at both the slim resources of the hospital and the incredible workload Alphons’s shoulders 365 days a year. Early on in our rounds of the maternity and surgical wards, Alec became faint and had to head back to the study room...seeing a hospital such as Kamuli Mission can be that overwhelming. As Asha and I continued rounds, we were amazed at the diversity of cases Alphons treats by all by himself. In the maternity ward he introduced us to patients who had come in with incomplete abortions, missed abortions, ruptured uteruses (where he had done emergency cesarian sections, saving the lives of the mother and the child), and eclamptic seizures (for which he gave diazepam, as they were without magnesium and then delivered a healthy baby, again saving the mother's life). If that was not enough, in the surgical ward, we met patients with all kinds of conditions requiring Alphons's surgical intervention. One man needed multiple septic wounds debrided after being attacked by a bull. 3 women with cervical cancer were waiting for Alphons to do curative hysterectomies, which he could not do until he could secure blood from either Kampala or Jinja. Possibly most impressive, was a man who had fallen off of a motorcycle taxi (boda boda) and shattered all three bones in his leg. The hospital has no access to orthopedic hardware, so Alphons informed us that he has drilled small holes in each of the bone fragments, reconstructing the bones by tying the fragments together using surgical sutures. He says this with a calmness and matter of factness that is beyond my comprehension given the incredible challenges he faces, clearly having learned to adapt his surgical skills in such unacceptable conditions. Alphons is the only doctor at this 180 bed hospital, assisted by a staff of midwives and comprehensive nurses. He operates most days, and often nights, 7 days a week, year round. Rarely, he has foreign doctors around to help him. Asha and I made a pact at the end of those rounds to try and get him more help. He has plenty of beds for visitors, and would welcome any help he can get. If anyone reading this is interested in helping Dr. Alphons with this remarkable responsibility, please email me at firstname.lastname@example.org.
After rounds, Asha and I rejoined the rest of the team who had just arrived at the hospital excited to try and complete the study. Finishing early became even more important when Erin discovered that her flight was actually leaving Saturday morning instead of Sunday, when she originally thought she would be flying out. Luckily for us, Betty, our nursing student trainee-turned study coordinator quickly had combinations of models and ultrasound operators in rooms and we got started immediately. By lunch we only had 6 protocol sets left to complete! We learned so much from our last attempt at this study, but there is no way we could have predicted this much success. As I mentioned before, luck played a part in our success. Last year, we ran a generator everyday because of constant power outages. We did not have to fire it up even once this year. Last year, there were issues with models being unable to be there everyday, this time around our models and operators graciously arrived on time each day ready to work. Also, last year, working on different machines presented a number of technical problems that we didn't have to deal with this year, working on four modern, Terason portable ultrasound units. We enjoyed a leisurely lunch of matoke, g-nut sauce, beef stew, greens and rice before getting back to work on the last 6 studies.
We completed the study just before 3 pm on Friday, exceeding even the most optimistic predictions. We made sure to make 3 backups of the data, complementing the original copies on the machine hard drives. With such redundant backups, we hoped to avoid any loss of images that could force another repeat of this extensive study. It took us about an hour to pack and clean up. After taking tea with chapatis and mandazis, we presented the operators newly trained in ITW protocols with certificates, handed out gifts, and said our goodbyes. We all climbed in the new ITW ride, and with the fearless Picho behind the wheel (his favorite phrase is "I ain't never scared"), we set off down the pothole covered Kamuli road hoping to avoid the inevitable traffic jam that awaited us on Jinja road. In an attempt to delay the inevitable jam, we stopped 20 minutes south of Kamuli, paying an unexpected visit to Sister Angela at the Nawanyago Clinic, the first ITW ultrasound equipped health center in the world. After greeting us with giant smiles and hugs, Sister Angela escorted me to the scanning room that I had become too familiar with the following summer when I had spent hours troubleshooting the network. I was amazed to see how great the room looked, freshly painted, very organized, and clearly well used. Angela informed me that since we left her alone with the machine last July she had completed hundreds of studies (mostly obstetric, with some pelvic). While she wouldn't admit it, Allan explained that she has become quite a folk hero around Kamuli and Jinja district, with women coming from far, far away to the clinic that they heard had a machine that could tell them that everything with their pregnancy was okay. With each passing month, the number of pregnant women coming was increasing, as was the number of repeat women receiving antenatal checkups and the number of women delivering at the clinic. Sister Angela was beaming when she told me that husbands were practically dragging their wives to the clinic, anxious to get an early peek at their unborn child. There was definitely a different, powerful vibe at the Nawanyago Health center, a transformation that I hope can be replicated by providing other clinics with the power of imaging, not only in Uganda but worldwide.
After leaving Nawanyago, we headed back to Kampala, moving at a snails pace, arriving around 9 pm with stomachs growling. Picho drove us to Nakumatt for a western meal, as Gail was ready for something other than matoke! Dinner was a great time to celebrate and reflect on the success of the training and study. We all agreed that our training methods have continued to improve, and will surely become more refined as the project continues. On Saturday, I said goodbye to Erin, Brian, Gail, and Asha, which left Alec and I in Kampala awaiting the arrival of Frank and his son who would be leading the site evaluations in Bwindi. And after more than a week of early mornings and long days of work...I took a nap.