Mulago patients die waiting for surgery
ON one hand, hundreds of desperate patients are waiting for life-saving surgeries that can only be done in Mulago Hospital. On the other, dozens of specialised surgeons at the hospital are yearning to put their skills to use. But there is simply no theatr
BY LYDIA NAMUBIRU
ON one hand, hundreds of desperate patients are waiting for life-saving surgeries that can only be done in Mulago Hospital. On the other, dozens of specialised surgeons at the hospital are yearning to put their skills to use. But there is simply no theatre space for the two to meet for the operations. Saturday Vision has established that the hospital has only five major theatres. All its surgical units have to share these few theatres, except for gynaecological, casualty and private patients units which have their own.
While patients wait in pain, highly qualified doctors are busying themselves with nursing duties as they wait for their turn in theatre. The results – surgical wards have accumulated waiting lists so long that they may never get to operate upon even half of their patients.
“It is very hard. Two theatre days is not enough. We get four or six patients needing major surgeries but we can only operate two a week. There will be a deficit of four and yet more keeping coming each week,†laments Michael Muhumuza, the head of the neurosurgery unit at the hospital.
Muhumuza’s unit shares one theatre with the Uganda Heart Institute. The heart surgeons use the theatre on Mondays and Wednesdays, while the neurosurgeons use it on Tuesdays and Thursdays. The two units then share out the Fridays alternately. The other surgical units follow a similar model. Urology shares with the Ear, Nose and Throat unit. General surgery splits theatre days with plastic surgery unit, the orthopaedic unit shares with the oral surgery unit and the paediatric surgeons share with the general surgeons who have the biggest workload. With only two theatre days per week, each unit on average can only operate two to four patients, although each one ward has 30 - 40 patients at any one time. A patient spends two to three weeks admitted at the ward before they go to theatre.
The heart institute has more than 400 patients waiting for surgery. The majority have cardiac diseases and about a dozen suffer from other chest diseases, like cancer of the oesophagus. Although the cancer patients are fewer, they take one of the institute’s two theatre days because many are very sick. As such, the list of heart patients continues to grow. Not that this saves the non-cardiac patients. “Even those ones are too many. They die off as we wait for theatre space. It is useless to keep a list,†Omagino resignedly says.
Although Omagino usually has about 12 patients at the ward, at best, only four will be operated upon. Even these very ill patients will wait three or four weeks to be operated upon if they survive.
The situation is not any different in the other surgical units that share the few theatres. Waiting times for patients continue to grow longer while the surgeons are getting more and more frustrated.
Yet, lack of theatre space is not the only thing that is frustrating the surgeons. “The workload is too much, we do not have specialised support staff like neuro-nurses and we have to share space in the intensive care unit. Sometimes you cannot operate because you cannot get a bed in the intensive care unit,†Muhumuza said, describing but a few of the reasons waiting lines continue to grow. He is afraid that the idea of building more theatres would be hard since the anaesthesiologists are too few.
To compound the surgical crisis, surgeons often fail to use even the few allocated theatre days because they lack surgical sundry supplies like drugs and tubes. “We are surgeons. We want to be in the theatre doing surgery every day, but that does not happen. It is demoralising,†one surgeon laments. The heart institute, for example, has the capacity to do regular open heart surgeries but it does not do any except during surgical camps by foreign experts. According to Omagino, their major deterrent is that they do not have the specialised surgical sundries that they need.
Ironically, the hospital staff and mangement sweeps the problem under the carpet. Off-record, surgeons express frustration with the system, but refuse to be quoted by the media, citing political reasons.
In the spirit of political correctness, the hospital has also restricted the number of patients who can be recorded as pending surgeries and how far into the future they can be booked. “We were told to book only three patients a week,†says a sister at one of the surgical wards. Another confirms this by saying she too can only record patients whose operation date can be fixed in the near future. “I cannot give a patient a booking seven months away. That will have bad political implications,†a surgeon says. As a result, patients are left without any information on when they might get surgery.
Asked about the theatre crisis, the director of the hospital had only one comment. “We know that very many patients are waiting for operations and we are aware of the limitations,†Dr. Edward Ddumba said. He is not indifferent. He is frustrated according to his juniors who readily defend him. The hospital is given only a quarter of the money it needs to run. “If there are limited funds and people are dying of malaria while others need surgery, I will not be thinking straight if I put surgery first,†one surgeon reasons on behalf of his boss.
WHAT CAN BE DONE
According to the World Bank and contrary to popular opinion, access to surgical services is not too expensive for poor countries. It can be provided at a cost that is comparable to providing immunisation services.  A World Bank book titled Disease Control Priorities in Developing Countries says, “surgical intervention can be cost–effective and serve priority public health goals, instead of being traditionally considered as the extreme end of the curative medical model.†The book says for developing countries, providing these services at district level may be the most cost effective option.
Muhumuza believes that the district level approach would go a long way in solving Mulago’s long waiting list problems. “We are suggesting there be a neurosurgeon in every regional referral hospital. A patient from Arua would not have to be referred to Mulago,†he explains. Currently, Mulago is in most cases the only public hospital where one can get specialised surgical services.
Building the capacity of lower level hospitals to offer after operation care will also decongest Mulago. Patients spend months at the surgical wards after operation while undergoing rehabilitation. “We should be doing surgery and then sending the patients to rehabilitation centres elsewhere to create space for new ones,†another surgeon at the hospital said.
The public is also unaware of Mulago’s role as a referral hospital. Many patients with simple illnesses that could be treated elsewhere continue crowding it. Educating the public would help.
Building departmental theatres is what surgeons are asking for first. They say that even minor theatres would be of significant impact helping them to do the routine minor surgeries quickly. This would make waiting times shorter for major surgeries.
These, the stakeholders say will help in the short term but for the long haul, major hospitals like Mulago need to be built countrywide to cater for the expanding populations.
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ON one hand, hundreds of desperate patients are waiting for life-saving surgeries that can only be done in Mulago Hospital. On the other, dozens of specialised surgeons at the hospital are yearning to put their skills to use. But there is simply no theatre space for the two to meet for the operations. Saturday Vision has established that the hospital has only five major theatres. All its surgical units have to share these few theatres, except for gynaecological, casualty and private patients units which have their own.
While patients wait in pain, highly qualified doctors are busying themselves with nursing duties as they wait for their turn in theatre. The results – surgical wards have accumulated waiting lists so long that they may never get to operate upon even half of their patients.
“It is very hard. Two theatre days is not enough. We get four or six patients needing major surgeries but we can only operate two a week. There will be a deficit of four and yet more keeping coming each week,†laments Michael Muhumuza, the head of the neurosurgery unit at the hospital.
Muhumuza’s unit shares one theatre with the Uganda Heart Institute. The heart surgeons use the theatre on Mondays and Wednesdays, while the neurosurgeons use it on Tuesdays and Thursdays. The two units then share out the Fridays alternately. The other surgical units follow a similar model. Urology shares with the Ear, Nose and Throat unit. General surgery splits theatre days with plastic surgery unit, the orthopaedic unit shares with the oral surgery unit and the paediatric surgeons share with the general surgeons who have the biggest workload. With only two theatre days per week, each unit on average can only operate two to four patients, although each one ward has 30 - 40 patients at any one time. A patient spends two to three weeks admitted at the ward before they go to theatre.
The heart institute has more than 400 patients waiting for surgery. The majority have cardiac diseases and about a dozen suffer from other chest diseases, like cancer of the oesophagus. Although the cancer patients are fewer, they take one of the institute’s two theatre days because many are very sick. As such, the list of heart patients continues to grow. Not that this saves the non-cardiac patients. “Even those ones are too many. They die off as we wait for theatre space. It is useless to keep a list,†Omagino resignedly says.
Although Omagino usually has about 12 patients at the ward, at best, only four will be operated upon. Even these very ill patients will wait three or four weeks to be operated upon if they survive.
The situation is not any different in the other surgical units that share the few theatres. Waiting times for patients continue to grow longer while the surgeons are getting more and more frustrated.
Yet, lack of theatre space is not the only thing that is frustrating the surgeons. “The workload is too much, we do not have specialised support staff like neuro-nurses and we have to share space in the intensive care unit. Sometimes you cannot operate because you cannot get a bed in the intensive care unit,†Muhumuza said, describing but a few of the reasons waiting lines continue to grow. He is afraid that the idea of building more theatres would be hard since the anaesthesiologists are too few.
To compound the surgical crisis, surgeons often fail to use even the few allocated theatre days because they lack surgical sundry supplies like drugs and tubes. “We are surgeons. We want to be in the theatre doing surgery every day, but that does not happen. It is demoralising,†one surgeon laments. The heart institute, for example, has the capacity to do regular open heart surgeries but it does not do any except during surgical camps by foreign experts. According to Omagino, their major deterrent is that they do not have the specialised surgical sundries that they need.
Ironically, the hospital staff and mangement sweeps the problem under the carpet. Off-record, surgeons express frustration with the system, but refuse to be quoted by the media, citing political reasons.
In the spirit of political correctness, the hospital has also restricted the number of patients who can be recorded as pending surgeries and how far into the future they can be booked. “We were told to book only three patients a week,†says a sister at one of the surgical wards. Another confirms this by saying she too can only record patients whose operation date can be fixed in the near future. “I cannot give a patient a booking seven months away. That will have bad political implications,†a surgeon says. As a result, patients are left without any information on when they might get surgery.
Asked about the theatre crisis, the director of the hospital had only one comment. “We know that very many patients are waiting for operations and we are aware of the limitations,†Dr. Edward Ddumba said. He is not indifferent. He is frustrated according to his juniors who readily defend him. The hospital is given only a quarter of the money it needs to run. “If there are limited funds and people are dying of malaria while others need surgery, I will not be thinking straight if I put surgery first,†one surgeon reasons on behalf of his boss.
WHAT CAN BE DONE
According to the World Bank and contrary to popular opinion, access to surgical services is not too expensive for poor countries. It can be provided at a cost that is comparable to providing immunisation services.  A World Bank book titled Disease Control Priorities in Developing Countries says, “surgical intervention can be cost–effective and serve priority public health goals, instead of being traditionally considered as the extreme end of the curative medical model.†The book says for developing countries, providing these services at district level may be the most cost effective option.
Muhumuza believes that the district level approach would go a long way in solving Mulago’s long waiting list problems. “We are suggesting there be a neurosurgeon in every regional referral hospital. A patient from Arua would not have to be referred to Mulago,†he explains. Currently, Mulago is in most cases the only public hospital where one can get specialised surgical services.
Building the capacity of lower level hospitals to offer after operation care will also decongest Mulago. Patients spend months at the surgical wards after operation while undergoing rehabilitation. “We should be doing surgery and then sending the patients to rehabilitation centres elsewhere to create space for new ones,†another surgeon at the hospital said.
The public is also unaware of Mulago’s role as a referral hospital. Many patients with simple illnesses that could be treated elsewhere continue crowding it. Educating the public would help.
Building departmental theatres is what surgeons are asking for first. They say that even minor theatres would be of significant impact helping them to do the routine minor surgeries quickly. This would make waiting times shorter for major surgeries.
These, the stakeholders say will help in the short term but for the long haul, major hospitals like Mulago need to be built countrywide to cater for the expanding populations.
/