Throughout the morning of scanning pre-op patients, I had scurried off to the obstetrics tent more than once, checking in to start our ultrasound teaching. At 845 they told me to come back at 9. At 9 they told me to come back at 915, and at 915 they told me to come back again. Finally, some time closer to 940, we had two pregnant women in the clinical space and around 8 or 9 midwives and medical officers ready to participate.

We started with some basics. I was cognizant of keeping things simple with an audience who had no experience with ultrasound. Everybody got to hold the probe. We identified where the uterus and the bladder ended, what position the babies were in (head down, breach, transverse), finding the heart rate, and locating the placenta. Easy peasy. One after another, we saw the staff get excited at pointing out different structures. They had a lot of questions about how else to use the device, fetal aging or determining the size of the babies.

‘First we just want everyone to feel comfortable holding the probe. We will get to using it clinically with time,’ we said.

We were probably an hour into the session when the midwives started swapping out our subjects for new ones, trying to get a view at babies of different sizes and placentas in different positions. Overall, it was refreshing to see the engagement. The obstetrician herself (again, not sure if she was a specialist or a medical officer although she was the one in charge) came over at one point and interrupted the session. Miriam was her name. Her ebony skin glowed against the stained concrete walls.

‘Hello Doctor, can you please help me to assess this lady?’ she said. She had a woman with her, wrapped in colourful cloth.

‘Certainly, what are we looking for?’ I asked.

‘I think she has had a missed abortion,’ she answered. ‘No fetal movements.’

‘Oh no,’ I said.

Abortions, the medical term for miscarriages, present in one of a few ways. The concern for a miscarriage comes first from the mother complaining of vaginal bleeding, clots, or expulsion of fetal parts. If a miscarriage is suspected, a pelvic exam can help. If the cervix is open, then a miscarriage is in process, nothing can be done to stop it. If the cervix is closed, one of two things is possible, either the bleeding was just bleeding and the baby isn’t necessarily lost, or the miscarriage happened already and the cervix closed after. We refer to closed cervix scenarios as a threatened abortion (baby still alive, cervix never opened), or a missed abortion (baby died and the cervix that was open has closed). If the miscarriage already happened, the question remains as to whether everything was expelled or not. It’s important to evaluate for this, because if the fetus or parts of it are still inside and the cervix is closed, there is a high risk for infection and toxic uterus, which can be life threatening. When fetal products remain after a missed abortion, the treatment is usually to give medication that helps to expel the contents fully.

‘Alright, Dr Miriam, please take the probe, and I will be your guide,’ I said. ‘So, what is the patient history? Passing blood and clots, now with the cervix closed and absent movements?’

‘Yes that’s right,’ she said, taking the probe and coating it with jelly.

Showing her how to orient the probe in space, we started the scan the same way I just taught the midwives, at the base of the uterus. By now the midwives scanning the other patient were watching us, invested in the case. The patient looked sick with anxiety, gloom written on her face as she turned her head away.

Starting at the bladder we fanned up, the uterus came into view slowly, followed by a big circle, the gestational sac. Dr Miriam now held the probe with intensity. Inside the sac was a fetus, wiggling around.

‘Looks alive to me,’ I said. ‘Let’s just be sure and find the heart rate. Let me guide your hand just like this… and…’

Dr Miriam’s eyes widened. Thumping away was the fetal heart, plainly in view. Jitters reverberated through the midwives behind us and the tension evaporated. She spoke to the patient in Swahili, and relief overcame her. Dr Miriam continued to scan the uterus, now excited by her findings. A grin spread across her face lighting up the whole room before she handed the probe back.

‘I have to show this to the rest,’ Dr Miriam said, and vanished behind the curtain. She came back with one of the medical officers. He was an older guy, with a bristly moustache. He took the probe for a spin as well, and several more took turns pointing out the structures. The patient herself was watching on the screen too.

‘You will come back tomorrow, yes?’ The medical officer said to us. His name was Ese, and he would go on to become one of our biggest champions for the ultrasound device in the camp.

‘We will gladly come back whenever you want us. Tomorrow we can go over some more advanced techniques.’

‘Good, good’ he said.

‘We have another!’ Dr Miriam said, bringing another patient out. ‘She is urine pregnancy test positive, and having pain in her right lower quadrant. Rule out ectopic.’

Alex scanned her, now with all eyes over his shoulder. Quickly he identified a normal pregnant uterus with a gestational sac in the right place, no ectopic. Another win for the midwives of Health Centre IV.

We couldn’t have arranged a better demonstration on the utility of the device. The morning quickly came to noon, and we agreed to come back the next day.

Alex and I walked out from the obstetrics ward with a rediscovered faith in our presence here. We decided to shift our focus for the rest of the week towards the midwives, who clearly had interest, and could use it to make important clinical decisions in real-time instead of waiting for scans with the sonographer that had a long turnaround. Ironically, the new generation of ultrasound programs is to demonstrate the utility of this device for everything except obstetrics. Ultrasound has been useful in obstetrics for decades, we weren’t reinventing the wheel here. Guess we should have never tried to. With no clinical duties left for us at Health Centre IV, Alex and I packed the ultrasounds and got ready for pickup heading for the local school.

Kyangwali had a fairly robust charity-run primary school, spearheaded by a group called Planning for Tomorrow. Despite bringing mainly medical personnel on the mission, Tayseer and his donors spent more funds on the education and community development projects through Planning for Tomorrow than they did with the medical services. Over the last several years, their contributions had built new infrastructure for the primary school, a computer lab, and sponsored several of the graduating kids for boarding school in nearby Hoima. This year, Planning for Tomorrow’s big project was the construction of a new secondary school within the community, aimed at making higher education and vocational training accessible to students without having to rely on sponsorships to leave for school in Hoima. These projects were not without their obstacles, both administrative and practical, as the secondary school’s construction had stagnated and they struggled to find qualified teachers.

One of our group’s projects was to generate a healthcare database, the brainchild of our two European-based researchers in humanitarian aid, Hamdi and Nikos. Together, they were collecting health data from all the kids including height, weight, nutrition status, dental problems, and any other medical conditions. This database would then remain alive for the school and local health services to use for intervention design. Alex and I were asked to help.

We sat behind two plastic tables in the school hall, a warehouse-appearing building with clean cement floors. Over the next few hours, classes of 30 kids at a time came in one after the other. Alex and I examined all of them, measuring limbs, looking into mouths, listening to lungs, and feeling pulses.

‘Sit,’ I would gesture. Taking their papers, I would open my mouth, directing them to do the same, before wrapping a nutritional assessment band over their arms (this was a WHO tool for malnutrition). In silence against the backdrop of howling rain, I would then lead them towards the scale, indicating to remove their shoes before stepping on. Finally, I’d lead them back to their seat and listen to their heart and lungs before giving them a sticker and saying goodbye. It wasn’t aggressive or inspiring medical work, but it was soothing in its simplicity. Inputting the data into laptops, I recorded a handful of children with fungal infections of the scalp or other benign hygiene-related issues, as well as a half dozen with dental issues. If anything, it served a symbolic purpose of letting the children know that somebody out here cared about their health.

Thankfully we found very few patients with clinical malnutrition. Overall, I was impressed at the general health of the kids I saw, but I did wonder if I was only seeing the more privileged kids in the community. Not everyone has the means to travel large distances by motorbike to school, and on days of significant rain, attendance drops due to the floods. Reminiscent of my time in Panama, in an instant, a seemingly calm gathering in the hall became rattled by blankets of rain colliding with the sheet metal roofing. Conversations became moot against the noise, and all I could do was communicate in gestures. How many were out there helping to farm, tending to sick family, or stuck at home with the floods?

That evening, the surgical team again arrived later than expected, due to another full day’s worth of cases. Not only that, but I got the feeling that frustrations were beginning to mount due to friction with the local surgeons. Susana and Pradeep both voiced their thoughts at the feedback session, with much to say about deficiencies in cooperation. Our team was doing surgical evaluations in the morning on their assigned cases and regularly finding patients booked for unnecessary procedures, or cases unsuitable to be done with our limited resources like spleen removals or laparoscopic surgeries. I cannot speak more to the subcontexts of this discordance, whether it was borne out of cultural differences in practice, personal dislike, disagreeableness (deliberate or accidental), sexism, arrogance on the part of one or many, or something else. What I can say though, is that the focus from the local partners during feedback revolved mainly around the number of cases completed that day, with an ever present need to hit a quota hanging overhead, whereas our team’s comments seemed to revolve more around the nature and quality of cases. The cynic within me wondered if this quota came from somewhere higher up, either from the UN or Medical Teams International, and if the need to produce numbers was the motivation for welcoming our surgeons here even if we thought we were signing up for something different. I would never know.

When time came for Alex and I, The Butterfly Boys, as we came to be known, our feedback was a sharp turn from the night previous. We had such a rewarding encounter with the midwives, it invigorated us with new hope. As I shared the anecdote of the patient with a potential fetal loss that was found to have a normal pregnancy, sighs of amazement percolated through the group. We looked forward to making more progress, and I was firm in my advocacy on behalf of the midwives for the ultrasound device to remain with them instead of the inpatient ward deep in an untouched closet.