ON THE ROAD AGAIN

Yesterday was mine and Julia’s last day at Clay House, so around 11, we found ourselves on the infamous mutatu to Mbarara.  I was in the back seat with a mother, her 3 children, and some other lady (surprisingly enough, not horribly uncomfortable).  Anyway, I’m sitting directly next to the mother who is carrying her ~10 month old baby on her lap.  Of course I start making playful faces to him and as he has probably never seen a white person before he originally just stares blankly at me.  However, ~an hour and a half into the journey, we have become a little more comfortable with each other.  It is around this time that mom decides it’s time to breast-feed.  This is not an irregular sight in Uganda, but what made this particular experience awesome was that this little kid turned, looked right at me with his big eyes as if to say “wish me luck”, grabbed that breast like a cheeseburger and dove right into it.  It was even better around the 3^rd feed, when he started to grab on with one hand, and hit me with his free hand until I would watch him eat.  TIA.

It’s funny that I was so nervous about coming and now I wish I could stay longer.  It was sad to leave everyone and it really sucks that most of the friends I made here don’t live on the same continent.  And those that do, will be living in the Midwest shortly.  I’m not good with goodbyes, so even though I just spent a month in an entirely different culture, these last few days have actually been the most emotionally draining.  Alas, all good things must come to an end.  Now I’m day 2 of the 6 day journey back to Philadelphia.  I’ll be stopping over in Georgia to debrief, after which I’ll probably write something meaningful and reflective.  As for now…I’m exhausted from today’s travels.  See you all soon.     

BREAKING BAD NEWS

The past few days, Dr. Tinkah (who I normally work with) has been out, so I’ve been working with another doctor who doesn’t have the best reputation and has been known to not show up on occasion.  I preface with this because I don't think I would've been put in this situation had Dr. T been around.  Anyway, about 4 days ago, we had a patient come in to the female medical ward with palpitations, headache, and dizziness.  When this 30 y/o lady came in, I was outside and saw the nurses wheel her in.  I thought they were horribly mistaken taking her into the female ward because she looked just like a man.  Strong jaw, muscular, t-shirt (i.e.-no obvious female characteristics visible). I literally waited for them to wheel her back out and take her to the men's ward…but they didn’t.  Instead, I ended up rounding on her.  One of the struggles with people out here is that there is a great deal of denial and so when there is a bad prognosis (usually cancer) they have been told about, they pretend they’ve never known anything and expect you to rediagnose them with something different.  So when this lady came in and refused to let us run any tests on her (looking for secondary causes of high blood pressure), we thought she was hiding something.  We had managed to look at her chest during her heart exam and noticed she had absolutely no breasts.  Trying to to an external genital exam was the biggest fiasco ever and never actually happened for reasons not worth going into.  Eventually, she let us do an abdominal U/S which showed that she had no uterus or ovaries.  For numerous reasons also not worth going into, I found myself in the position of having to break this news to her.  Alone.

I can’t even begin to explain how difficult it was to get the courage to do this and the circumstances that led to me finally being able to- were undoubtedly from God.  If I thought I could explain concisely, I would, but the timing of everything was just too perfect and far too intricate to do so.  If you remember when I get back though, I would love to share.

Anyway, the whole time I’m preparing to do this, I’m thinking of those “dumb at the time, but now are like the Holy Grail to me” doc.com videos we had to watch during intersession.  I didn’t have tissues (I have actually yet to find a paper product in all of Uganda), but I did manage to find a private room for us to use.  I was a little extra worried because I knew I would be working through a translator, but luckily the patient actually spoke a little bit of English.  I explained what we had found and the implications of it and how I thought it was related to her blood pressure.  Her reaction was actually kind of cool.  She got really quiet for a second then said “I always wondered why I hadn’t developed breasts like the other girls”.  That blew me away.  For at least 15 years, this lady wondered why she didn’t look like the other girls and had just accepted it.  I can’t even imagine the psychological damage that would’ve caused me and I can’t help thinking we offered her at least a little relief.    Here at Kagando, we don’t even have a way to measure electrolytes, so we will never be able to tell her why she doesn’t have female organs, but as is often the case….we do what we can.  For her, that means we are trying to control her BP and will start her on OCPs in hopes that the estrogen will help her at least a little physically.

I like the autonomy I’ve had out here with this other physician in so far as I have quickly learned to trust myself a little more and feel able to manage things without always running to an attending, but I’m really looking forward to the guidance I’m going to have as an intern- just someone to make sure I’m not making huge mistakes.  Get excited. :)

ELEPHANTS!!!

It’s Wednesday and it’s already been quite an eventful week, and I think the most important lesson I’ve learned is the importance of trusting your own clinical judgment. 

Monday, there was a lot of praying, as I started rounding by myself.  It turns out, I actually made a lot of good decisions and correct diagnoses based mostly on Physical exams.  My big win was this lady who came in with fever and abdominal pain and the admitting nurse (who is actually usually very good) had thought the patient had severe typhoid.  Let me tell you how much I know about typhoid and how willing I am to say someone doesn’t have it….yeah, not at all.

Anyway, after examining her, I really thought she had PID.  Not having very good ways of culturing here (and because there’s a huge amount of perforated gut from typhoid and they really take abdominal pain seriously here), I started her on Antibiotics for PID and I ordered an abdominal U/S, which showed…endometritis! I was kind of proud.  :)

Of course, I made my fair share of mistakes as well, but luckily nothing that made anyone sick/die.

I’m also surprised by how many common things people have here as well.  We always tend to want to diagnose crazy tropical diseases, but this week we’ve diagnosed a trochanteric bursitis, DKA, CHF, migraines, epilepsy, etc.  (Still no nodding disease). It’s funny because we have some sick students here who we’ve decided had cholera, some sort of worm, and TB.  In hindsight, it’s probably traveler’s diarrhea, lack of sleep, and the common cold.  Who knows?

Non medical things: Eric (a medical student from Temple, actually) left today, so Julia and I went with him on Safari yesterday.  We saw so many animals and we were very blessed that it didn’t rain like it has been all week.  No lions, but at the end, we saw this huge herd of elephants, just hanging out in the road.  It was awesome.  Our driver was also kind enough to take us by one of the many explosion craters here as well as by the equator!  It was a great way to spend a last day, if I do say so myself.  It was sad to say bye to him today, but I’m happy that he lives in Philly and we’re going to get to hang out when I get back. :)

 

There were 11 elephants!

 

 

Julia and I at the crater lake.  Then Eric, in a picture he doesn't know I'm posting. :)

RAINBOW ROOM

I know I posted yesterday, but this was really exciting for me.

 

So, at Kagando, there is a rule that every patient has to have an “attendant”; a family member who bathes the patient, feeds the patient, is there to watch over and provide history for the patient, etc.   However, only one attendant is allowed to be in the room with the patient.  As a result, there are a lot of people who have to bring their children and leave them outside to roam around/do nothing.  Side note:  it is a cultural norm to let children wander- there is a big emphasis on community and it is expected that the whole community care for the children, so it’s not dangerous to do this.   Anyway, there is also a very active Pediatrics ward with children who just sit around.  I live with some student teachers from Belgium who decided that they wanted the children here to have more of an actual childhood so they created the Rainbow Room, which if you’ve ever worked at St. Chris, is kind of the equivalent of Childlife. 

The seven colors of the rainbow represent 7 areas of focus: Pastoral, Health, Music, Art, Play, Movement, and Learning.  As the end goal, we are trying to get activities for all 7 areas set up so the children around Kagando can learn and have fun.  Today, we intended just to have a planning meeting, but when we went over to the newly erected tent, we brought some toys and started to play with a child.  Before we knew it, children were coming from all over to play!  Even the parents were intrigued by what we were doing and came to watch. 

The first child we played with is one who is near and dear to Kagando.  He is ~10 years old and a leper.  As a result, his father abandoned him here at Kagando and he’s lived here for ~6 months.  I’m told that he has the desire to go back home to his father even though he beats him.  A while back, people eventually conceded to letting him go back home and a ride was set up to take him there.  However, the ride dropped him off in the middle of nowhere and the boy walked himself back to Kagando.  He’s been here since.  For us, it was so rewarding to see him come play because it allows him to regain some of the childhood innocence that was taken from him.  

Here are the first few kids playing with us and the parachute. :)

 

Everyone was really encouraged by the turnout, that we hurried home to make more activities for the children.  Although we didn’t intend on really launching this until next week, I think we might go back tomorrow. :)

HAPPY EASTER

Easter is a 4 day public holiday here in Uganda…especially when you’re working for a missionary hospital.  Finding ourselves with some free time; Julia, Eric, and I went to Lake Bunyonyi, which is a lake enveloping several islands near the Rwanda border, where we met up with some of Julia’s friends.  The lake was beautiful and Eric was particularly pleased to have some non-Ugandan food options.  Mostly, we lounged around and played games, but we also took some to go trail running and take advantage of the rope swing.  There is a group of Belgians who live with us at Kagando and we ran into them there, even though we didn’t know they were headed to the same island as us! 

On Sunday, it was awesome because Julia’s friends are all missionaries and we had our own “church” service on the island.  It’s pretty awesome that even across the ocean, you can still worship with complete strangers.  :)

Anyway, work started back up today.  We have a guy with tetanus right now, heavily sedated on Diazepam because he can’t afford to travel the 5 hours to a bigger hospital and get anti-toxin.  Third world problems.  Actually, on our muttato (public transportation here) ride back from the lake, one of the passengers was someone who was ill and needed to travel 3 hours to get to the nearest hospital.  Muttatos are vans that have seats for 14 people, but they always overstuff and there were probably 20 on when she was there.  Not really the most comfortable way travel when you’re healthy…much less when you’re sick.  That’s really the most distressing part about Ugandan medicine.  It’s not that people don’t know what to do…it’s just that technologies to diagnose and medications to treat are scarce. 

Anyway, here are some pics from the weekend.  I’m going to try to covertly take hospital pics throughout the week so you can all see where I work.

 The lake was absolutely beautiful!!!

 It took me over five minutes to actually jump. Eric has the whole 5 minutes on video. :P

 Sunday morning Easter worship time by the tent. :)

FOUND SOME INTERNET :)

I finally made it to Kagando, and it is way more rural than I expected.  I am wondering how I'm going to get the required paperwork to Drexel as fax/scanner aren't really accessible.  Praying they still let me graduate one time.  Eek.

It feels like I’ve been here forever, and we've done a lot (although I've only spent two days at the hospital).  So, now that I'm here, i can better explain the hospital:

Kagando Hospital is a 250 bed missionary hospital, where I am working as a medical student.  Eventually (by the end of the week), they expect me to be able to round on my own patients, which will be challenging as sometimes interpreters are hard to find and 80% of the population only speaks Lukonjo.  

So far, things are interesting, to say the least.  Medicine is different here.  There are "strange" medical decisions made here (ie.. adding on metronidazole for a UTI) and almost everyone gets treated for Malaria.  As often as this is done, however, and as often as I question their judgement, the patients get better, so I am practicing humility and spending a lot of time observing and trying to get my bearings.  I don't consider myself to know more than these physicians, especially considering there's a great deal of pathology I've never seen.  No nodding disease yet, though there appears to be a cholera outbreak right now.

My very first patient on Friday died in front of me.  She was suffering from cerebral malaria and was having a really hard time breathing.  Because she was so obtunded, the doctor told the nurse to place her on her side, so she wouldn’t aspirate.  As the nurse was doing so, the pt. stopped breathing.  The doctor came back and within 10 seconds (after not finding a pulse) said “we lost her”. And then went to the next patient.  Just like that.  ~30 seconds later, the patient started moving her arm, and only then did they decide to try to resuscitate.  (And by resuscitate, I mean give her bag O2 and chest compress for another 30 seconds.)  Meanwhile, the father has already left the room and started crying.  Showing grief is important to do here, so within seconds, you could hear people outside (I assumed family) wailing, and continued to do so for quite a while.  It was all very strange, especially since there are ~15 patients all in one room and they all lay there and watched this.  There was no stopping, and we continued rounding, and never spoke of our patient again.  It was a weird experience and though it has been 4 days and I'm still not sure I've processed it.

That is all for now.  I have much learning to do.  Pray I can absorb as much as possible now, as I'm not sure I'm ready to start rounding on my own later this week.  :)