CA-3 residents Sam Hong, MD, and Sophia Poorsattar, MD, with faculty member Aviva Regev MD, MBA, boarded flights last fall on a long journey to Mbarara, a city of 195,000 in southwest Uganda, for a two-week rotation caring for women at the Centre for Gynecologic and Fistula Care at Mbarara Hospital.
The trio made the trip under the auspices of Medicine for Humanity (MFH), a nonprofit medical care and teaching organization dedicated to improving the health of women in underserved communities, and training local physicians so that women can have access to specialty care year-round. Its work represents an educational partnership between UCLA Health and Mbarara University of Science and Technology (MUST).
“The cases we did were predominantly urogynecological surgeries with the majority being various types of fistula repairs,” says Dr. Poorsattar. With little obstetric help available in most African villages, many women who experience obstructed labor suffer from obstetric fistula afterward, a vaginal tear between the bladder and/or rectum that results in constant leakage of urine, stool, or both, and often turns sufferers into outcasts. (Nicholas Kristof of the New York Times has written memorably about the thousands of women who endure obstetric fistula, calling them “the world’s modern-day lepers”.)
In the year leading up to their annual visit, MFH recruits women from all over the region to come to the university in the fall while the multidisciplinary team is there, Dr. Poorsattar reports. The patients undergo an evaluation process headed by Musa Kayondo, MD, who chairs the Department of Obstetrics and Gynecology at MUST, with his team of residents. The chief surgeon from UCLA is Christopher Tarnay, MD, a urogynecologist who leads UCLA’s Division of Female Pelvic Medicine and Reconstructive Surgery. Dr. Tarnay is now MFH President and Medical Director.
“Our surgical camp had two rooms running each day, with Sam and I each performing the anesthesia for one room and Dr. Regev supervising,” Dr. Poorsattar recalls. Usually Dr. Tarnay and his fellow would operate in one room, while Dr. Kayondo operated in the other. Local surgical residents were always present in both rooms and were actively involved in patient care throughout recovery.
“It’s a big adjustment,” Dr. Regev says. “You need to make a big mental shift in how you approach your practice. There’s no other option. You have fewer monitors, and less choice in your drugs. It’s a very unfamiliar situation that takes you out of your comfort zone.”
From the faculty viewpoint, Dr. Regev says, she learned along with the residents. There was no EKG or end-tidal CO2 monitoring capability in the operating rooms, and most operations were performed under spinal anesthesia. Most patients were very stoic, and didn’t expect or need sedation.
“There was no reliable oxygen supply,” Dr. Regev recalls, and most cases were done on room air. “It just gets tricky if the case goes long or the block isn’t great.” She missed having propofol and phenylephrine most, and ephedrine was only on hand some of the time. The only IV sedatives readily available were diazepam and ketamine.
“It was definitely a valuable experience for the residents,” Dr. Regev says, as they had the opportunity to become very proficient at performing spinal anesthetics. The team also learned from the challenge of providing anesthesia care in a setting of far fewer resources than they usually enjoy at UCLA.
Most memorable experiences?
Dr. Hong recalls his most memorable case. “We had a case of a failed spinal anesthetic that we had to convert to general anesthesia,” he says. “We used a Benson anesthesia machine with no ventilator, no ventilation monitoring parameters, and no end-tidal gas measurements. To top it off, the only available volatile agent was halothane.”
“We were also frequently recruited to assist in emergent situations with patients who were decompensating,” Dr. Poorsattar remembers. These cases occurred sometimes in the recovery areas and sometimes during emergency cesarean sections for placental abruption or uterine perforation. The team also helped on occasion with neonatal resuscitation attempts.
Off duty, Dr. Hong was especially impressed during his interactions with the local people “whether on the street, in a restaurant, or on safari,” he says. The entire MFH team had the opportunity to travel to the famous Queen Elizabeth National Park, several hours away, for an overnight safari tour. The park is adjacent to two game reserves and is known for its wildlife including the African bush elephant, hippopotamus, Nile crocodile, Cape buffalo, leopard, lion, chimpanzee, and hyena.
Judi Turner, MD, PhD, residency program director, reports that our residents will receive ABA training credit for their two weeks in Uganda, and that we plan to send two residents each year.
Dr. Poorsattar feels that the rotation was “one of the most significant moments of growth I have had during my anesthesia training.” Thinking back to all the patients, trainees, physicians and staff they worked with in Mbarara, she says, “I am so grateful for my experience and hopeful for the lasting positive impact on their lives.”
The history of Medicine for Humanity
Leo Lagasse, MD, Professor Emeritus of Obstetrics and Gynecology at UCLA, was inspired to found MFH during a safari visit to Kenya in 1995, where he was moved by the plight of many women who lacked healthcare. For years, he led international teams in annual visits to provide gynecologic care in underserved areas and to train local surgeons and nurses in their specialized work. Dr. Tarnay made his first visit in 2009, and when Dr. Lagasse retired, he took on the leadership role.
Dr. Regev explains that the teaching and training mission, in addition to delivering high-quality care, differentiates MFH from other humanitarian organizations. This was her second trip to Uganda with MFH, and she hopes to return. “It’s what makes me so proud to be a part of the work this group is doing,” she says.
Donations to MFH have funded construction of the new 50-bed Centre for Gynecologic and Fistula Care, where our anesthesia team worked during their rotation. Before it was built, patients sometimes had to sleep on floors and in corridors, as the existing ward had only six beds. To learn more about UCLA’s collaboration with Medicine for Humanity, or to donate, please visit the MFH website.
Photographs courtesy of Molly Marker and Medicine for Humanity