Bob Goodman, an orthopedic surgeon, served from 2014 to 2015 as a Global Health Service Partnership (GHSP) volunteer educator in Uganda. Bob reflects on the difficulty and heartbreak of trying to provide the best surgical care possible in a setting where resources are unavailable for timely, safe and effective surgery.
A 23 year old young woman, Angela, presented to the orthopedic clinic with a swollen left thigh and an ulcerating lesion of the bone below her knee. Her symptoms had begun many months before, and multiple tiny laceration scars on her leg were evidence of the unsuccessful treatment she had received from a traditional healer.
Angela was admitted to the orthopedic service at Mbarara Regional Referral Hospital. The x-rays showed destruction in her tibia and a calcified tumor on her left femur. Cultures of her wound grew Staphylococcus. The available free antibiotics – all she could afford – were prescribed to help her.
Surgery was postponed several times for the usual reasons: shortage of surgical supplies; lack of oxygen in the operating theater; delays in surgery requiring cancellation of later scheduled cases; preemption by life-threatening head injuries or fetal distress. When Angela was finally brought to surgery, weeks after admission, a biopsy of the lesion was performed and the specimen was sent to pathology. The infected tibia was treated, but while recovering from the surgery and waiting for the oncology consultation, Angela’s condition deteriorated.
Angela would always have a bright smile and wave for me when I made ward rounds, although the language barrier between us prevented more significant communication. In the meantime, Angela’s family had become increasingly distressed by her physical decline and the care she was provided. They had even brought her back to the traditional healer a few days prior to the official diagnosis: osteosarcoma, a bone tumor.
Angela returned several months later. Because of the steady advance of the tumor, surgical treatment would require removing her entire left leg and the left side of her pelvis. It was doubtful Angela could survive such an extensive procedure in her present state. At any rate, it could not be performed in Mbarara and Angela’s family could not afford to bring her to the capital city, Kampala. Our inability to provide timely, modern care to most of our patients with complicated problems made rounds distressing – but it became particularly difficult for me to watch Angela deteriorate. I prescribed morphine for her pain but there was little else that could be done at this hospital. When I did visit her, she still managed a feeble smile.
Angela died among her family the day after her parents brought her home.
My hope is that this narrative illustrates the difficulties routinely faced by GHSP doctors and nurses. We will carry the burden of accountability the rest of our lives. Maybe the training we provide to future health care professionals will germinate a demand for a better future for their patients and their country.