The CT Scan Part 2

In the waiting area, I told Mrs. M the news. P. would need a CT but we would need to venture outside the hospital to find a machine that could work. It would also cost 180,000 Schillings (about $90, and insane amount of money for a population that mostly lives on less than $1 a day). Mrs. M immediately responded that there would be no problem getting the money or transportation necessary for a CT, she just needed advise on the nearest place to go. I hurried back into the casualty room, where P. was still lying on the exam table knocked out from the Diazepam, and the Germans were attending to another patient. They advised me to talk to the senior house officer (SHO), a second year resident, working in the neighboring cell for suggestions on where to get a scan.

On the other side of a cement wall, I found the young SHO talking with a frail elderly man who had collapsed on the street. He stopped his conversation with the patient to field my questions about finding a CT for P. He initially dismissed my inquiry as the result of a classic mzungu mistake; “Don’t worry about it, he can’t afford a scan.” Trying to be sympathetic to his intuition, I kindly explained that despite the patient’s appearance, money would not be a problem for this one. He gave a few names for diagnostic imaging centers in the area, but didn’t know where they were located. Beseeching the nursing staff seated in the corner, they recalled some of the roads and neighborhoods where I could find them. And just as I thought we had a green light, the SHO informed me that the patient still needed a CT request form filled out before he could leave. The hitch, the ward doesn’t have any forms, and the SHO doesn’t have any idea of where to find one. After apologizing that he was new to the ward, the young doctor returned to his interview with the elderly patient, now hunched over the side of the exam table.

Realizing there were no more teeth to pull on this side of the wall, I crossed back over to P.’s cell. I again turned to my new German friends for help. Maybe it was the rare chance to see their triage efforts carryover into definitive care, or the thrill of possibly uncovering a neurosurgical emergency that could save a man’s life, either way the medical students were excited to help P. a scan scan. Thomas went off on a mission throughout the hospital to find a CT request form, and Marcus and I began orchestrating how to transport P. to Mrs. M’s minivan waiting under the main entrance of the hospital.

After about 20 minutes, we acquired one of the few gurneys on the ward, and Thomas returned empty handed. The radiology department had informed him that the hospital was out of forms, but helped dictate one that he could handwrite on a blank piece of paper. With our quasi-document in hand, we started a mannitol drip (a medication that helps reduce pressure around the brain while increasing a patient’s need to urinate, which can be quite an inconvenience when no catheter kits are available), and then transferred P. to a gurney. As we struggled to steer through the throng of urgent care seekers, the stretcher’s wheels squealed incessantly, giving the patients an advanced notice to totter out of the way. When we reached the van, the mannitol had already begun to work its inconvenient magic; we gathered him up in our arms, his jeans sopping wet. We laid him across the two rows of seats folded down in Mrs. M’s minivan, and informed P.’s wife to keep his head elevated in her lap, as her feet dangled into the trunk space. After closing the back door, I turned around to see a large gathering of spectators made up of both staff and patients.

Inside the van, I scrunched up with my back pressed against the rear side of the front passenger seat where Thomas was sitting. With my right arm raised and elbow dangling outside the open car window, I held the mannitol bottle above my head. Our first stop was an imaging center in the neighborhood around Makerere University, which was only a 5 minute drive despite heavy traffic. The center’s machine was down too, so we hopped back into the van drove into the city center. After 30 minutes of getting mixed directions from pedestrians on the street, we arrived at a polished, modern multi-story building near the police headquarters. But again, luck wasn’t with us yet. This center didn’t do CT, their sister branch on the other side of the city had the scanner. So once more, we got back in the van and made our way across Kampala.

As a result of the morning’s non-stop hustle and bustle, I had almost completely forgotten about my inflamed esophagus. But as our make-shift ambulance trotted through the bumper-to-bumper traffic, speckling each other in red dust, I became very aware that my throat was still pissed off at me for the poor choice of taking my Doxy without water. I strangely began craving lidocaine, but found white coat pocket empty, having left the bottle behind for the casualty ward. With some effort, I ingested a handful of antacids and a few painkillers, and then tried to distract myself by naming all the neighborhoods we passed through. Thomas would periodically check-in to see if P. was waking up too much or required any more of the Diazepam that he had packed for the journey. But after an hour from when we had set out from the hospital, we finally found a functioning CT scanner without having to tackle too much restlessness from P.

The imaging center was located in the Beverly Hills of Kampala, known as Kololo. The center kept itself as polished as the homes around it. We were forced to take off our shoes when we entered the scanning room, and the staff was resistant to having P.’s gurney wheeled too close to the machine’s bed. So we again had to get creative transferring P., this time with a bed sheet sopping from Mannitol’s charm. The staff was just as guarded about their work as they were of their scanner. The technician was uneasy about letting us take a copy of the scan to the hospital until after the center’s radiologist gave her reading of it first. In the end, it took another hour and a half for the CT results to arrive at Mulago.

P. had two small isolated bleeds in the front of his brain (right and left frontal lobes) and one in the back (right parietal lobe), as well as a small fracture in his skull and a clear increase in pressure around his brain. He didn’t require emergent surgery, but it took us 7 hours from the time he first arrived in the hospital to figure this out. Compared to the rest of the patients coming into the casualty ward, P.’s is a success story. Back on the wards, he received a protocol of medications that would help prevent seizures, decrease the swelling around his brain, and prophylactically treat a possible infection.

That evening, I learned the fully story of what happened to P. Mr. M, who was needed out of town that day for his work, received a phone call from a relative just before breakfast. The relative had learned by word of mouth that a pedestrian had witnessed P. get hit in the head by the side-view mirror of a taxi van while he was walking on the side of a road on the east end of Kampala. The pedestrian had found P. struggling to standup after being struck to the ground, and then wandering into traffic. The good samaritan had lead him to a nearby health center, but the relative was unable to determine which one. So while I was chewing around the crusts of my margarine sandwich that morning, Mr. M was taking in the news that a relative had heard in rumor fashion that his brother was seriously injured and lost somewhere in the outskirts of the city.

A few days later, Mr. M cited the events of that morning to me as an example of the power of word-of-mouth news in Uganda. I had become frustrated with P.’s wife for repeatedly trying to feed him orally while he was still unconscious (before we could place an NG tube, a story that could take pages to write on its own). Every time I stopped by to see P., I would ask his wife if she tried feeding him again, and she would say yes, prompting me to warn her again of the dangers of aspiration. After days of this happening, I asked Mr. M why she keeps doing this when all the staff, not just me, tells her not to do it. “Doesn’t she get that she could seriously hurt him, if not kill him?” To which Mr. M simply replied, “she’s only doing what her mother tells her, which she learned from her mother, and so-on.”


Notes:
Lots of stories about P.’s stay in the hospital could be written, but so much is happening so quickly here that I don’t have the time to write it all down at the moment, so will try to stay on top of the highlights of current events.

-P is recovering well now, discharged from the hospital yesterday, walking, still some confusion, but very impressive for how he started.
-He did require another CT outside the hospital during his stay, with which John Binford helped me orchestrate
-Hit and run accidents are common practice in Kampala, so strangely, it’s not strange that the driver didn’t stop to help P. after hitting him
-The esophageal ulcer stopped ruining my life after 10 days
-Now in Gulu, stories from the final days in Kampala and travels North will come shortly