Necessity is the mother of medication
by Lorien E. Menhennett
In the United States, we’re used to any medications or supplies being available at any time in any dose: ask and ye shall receive. In Uganda, that’s not the case. Only certain drugs are available through Naggalama Hospital. For example, morphine is the only opioid. Even medications that should be available often run out (and morphine did run out while we were there). For those medications that are actually present, the pharmacy might only carry one dose — a dose that’s certainly not appropriate for every patient. With all of these constraints, palliative care (and any care, really) becomes a challenge unfamiliar to visitors. You learn to make due, and to get creative. Here are a couple of examples of how that played out while I was there.
One day, we visited the home of a patient with horrible spinal stenosis. Her lower limbs were essentially paralyzed. She was unable to walk or even stand. Her upper limbs had become extremely weak too. She could no longer raise her arms above shoulder height, and grasping anything in her hands had become impossible. To help treat her neuropathic pain and her depression, the palliative care team decided to use a drug called amitriptyline. But the only dose available, 25 mg, was far too high for this situation. The round, bright pink pills were coated, so couldn’t be broken easily by hand. Thankfully, though, they were scored in the middle. So we asked for a knife. What we got looked like a small rusty machete, but it did the trick, and now she has a more appropriate dose.
Zofran is a great drug to treat nausea after chemotherapy. But it’s expensive, and therefore not available at Naggalama. So for a woman who’d had a mastectomy, and is now undergoing chemotherapy, the team decided to try a drug called haldol. A dose of 0.5 mg or 1.0 mg is where we would start in the United States for a case like this. But the only dose available was 10 mg — enough to completely knock her out. So as we sat talking to the woman in her home, Dr. Randi Diamond broke the round, white pills into halves, and then quarters, to get a 2.5 mg dose (roughly). It’s something. And hopefully it will control her nausea and vomiting without making her too tired.
Getting patients their medications is a start, but just like in the United States, medication compliance is another issue — though perhaps for different reasons. The woman with spinal stenosis, for example, was afraid to take her morphine (and other medications) without a family member around because she gets dizzy. And no one is around on weekdays. So she’d only been treating her excruciating pain on the weekends. The palliative care outreach team from Naggalama Hospital does supply its patients with needed drugs like morphine and amitriptyline. But for many other people, the cost of medication — priced in Uganda at pennies a pill — is simply too expensive.
I can identify! We use haldol for nausea–can be very effective! Haven’t had to cut a tab into teensy pieces–but have had to get creative in the home to change a tab to liquid form when a pt couldn’t swallow and the concentrated liquid wasn’t there.
Being in Uganda definitely taught me how important creativity in medicine is — it’s good to know that skill will come in handy here in the United States, too!