After two 8 hour flights and a 3 hour jaunt around Amsterdam, I got back home yesterday afternoon. It's nice to be back in a place where I can cross the street while talking on the phone because there are traffic laws that are respected and the general rule is for cars to yield to pedestrians. I still look both ways before crossing of course, but I can still do that while talking to someone on the cell phone.
Coming from one of the poorest countries in the world back to one of the wealthiest neighborhoods in the US emphasizes that a lot of the things we take for granted don't come out of nowhere. I've always been a little amazed at how our country, and many others, manage to pave so much land and build such huge buildings. Clearly that doesn't happen everywhere. People who know more about economics and business probably have a better
view of the flow of resources that allows all of this amazing
infrastructure to develop and facilitate our lives. My sense is that these great things are at built on the foundation of a strong social contract where people buy in to the idea that there are certain things that are in the common good, like education and clean water (and in some places health care) that lead to a better life for everyone in society. I'm sure there are plenty of big books that talk about this in a much more informed way though so I'll stop before I just start ranting with my uninformed opinions.
In any event, it's great to be back in the US. I hope I can visit Uganda again and spend more time with the great people of Mulago and also to see more of the country outside of Kampala. I hear the gorilla trekking is incredible and the pictures of the Rwenzori mountains look amazing, so there are plenty more reasons to go back.
Monday, November 26, 2012
Thursday, November 22, 2012
An uplifting one
Today I spent the morning with an oncologist in clinic, then went to the cardiology floor to see a patient with endomyocardial fibrosis (probably non-existent in the US and I would be surprised if it was ever mentioned in med school), then went to the solid tumor ward to do a history and physical on a patient with esophageal cancer.
In the morning, we saw patients with prostate cancer, ovarian cancer, colorectal cancer and a couple of leukemia cases. This whole week I was particularly curious about how chronic myelogenous leukemia (CML) is managed here because it's an example of a disease for which very effective, and typically expensive, targeted therapy exists in the form of tyrosine kinase inhibitors like imatinib and dasatinib. This morning we saw a patient with CML who had been diagnosed in 2005. He had been receiving imatinib since his diagnosis and was doing great. It's uplifting to see quite sophisticated medications making a major impact on people's lives in a place that's physically and economically so far away from where those advances were made. I think the company that made imatinib (Novartis) was initially quite reluctant to invest in the drug because they didn't think it would make any money. Fortunately the company succumbed to pressure to keep developing the drug.
During one discussion this morning, someone mentioned the acronym 'EMF'. I wasn't familiar with the term so I asked about it and the attending told the students that they had to take me to the cardiology ward to see a case because it's so common here.
After clinic, one of the students took me to the to see a 41 year old man with endomyocardial fibrosis (EMF). He had massive abdominal distension from ascites (fluid in the abdomen), but no leg swelling, which is "classically" how EMF presents. Apparently it's a common cause of heart failure here and typically affects relatively young patients (peaks of prevalence at 10 and 30 years of age according to my quick internet search). Patients with EMF are "classically" people who immigrate to the Luwero district of Uganda, which is just north of Kampala (it's the district where the current Ebola outbreak started). This district grows and consumes a lot of cassava, and one idea is that toxins from cassava cause EMF in people who have some susceptibility. The only "cure" is a heart transplant, but that's not really done here. It's been 3 years since our patient was diagnosed and he's being managed with periodic paracenteses (drainage of the abdominal fluid) and diuretics to try to slow down the rate at which the fluid builds up.
I'm off to Thanksgiving dinner with two Americans, one Swede, two Germans, and one Swiss. We're going to an Indian restaurant and then watching the new James Bond movie.
I hope everyone has a great Thanksgiving!
In the morning, we saw patients with prostate cancer, ovarian cancer, colorectal cancer and a couple of leukemia cases. This whole week I was particularly curious about how chronic myelogenous leukemia (CML) is managed here because it's an example of a disease for which very effective, and typically expensive, targeted therapy exists in the form of tyrosine kinase inhibitors like imatinib and dasatinib. This morning we saw a patient with CML who had been diagnosed in 2005. He had been receiving imatinib since his diagnosis and was doing great. It's uplifting to see quite sophisticated medications making a major impact on people's lives in a place that's physically and economically so far away from where those advances were made. I think the company that made imatinib (Novartis) was initially quite reluctant to invest in the drug because they didn't think it would make any money. Fortunately the company succumbed to pressure to keep developing the drug.
During one discussion this morning, someone mentioned the acronym 'EMF'. I wasn't familiar with the term so I asked about it and the attending told the students that they had to take me to the cardiology ward to see a case because it's so common here.
After clinic, one of the students took me to the to see a 41 year old man with endomyocardial fibrosis (EMF). He had massive abdominal distension from ascites (fluid in the abdomen), but no leg swelling, which is "classically" how EMF presents. Apparently it's a common cause of heart failure here and typically affects relatively young patients (peaks of prevalence at 10 and 30 years of age according to my quick internet search). Patients with EMF are "classically" people who immigrate to the Luwero district of Uganda, which is just north of Kampala (it's the district where the current Ebola outbreak started). This district grows and consumes a lot of cassava, and one idea is that toxins from cassava cause EMF in people who have some susceptibility. The only "cure" is a heart transplant, but that's not really done here. It's been 3 years since our patient was diagnosed and he's being managed with periodic paracenteses (drainage of the abdominal fluid) and diuretics to try to slow down the rate at which the fluid builds up.
I'm off to Thanksgiving dinner with two Americans, one Swede, two Germans, and one Swiss. We're going to an Indian restaurant and then watching the new James Bond movie.
I hope everyone has a great Thanksgiving!
Wednesday, November 21, 2012
The hospital bias
A few days ago I got an email from a friend who read my blog and he (or she) said "This place sounds scary and without your descriptions almost unimaginable coming from where we come from." This got me thinking about a few things that are either directly related or tangential to his (or her) comment.
I definitely agree that most of the stories I have written about are scary. I would be scared to be a patient at the hospital where I have been working. Just to be clear though, I certainly don't want my stories to be an indictment of the people who work there. There are many interns, residents, and some visiting expats who do amazing things with the resources that are available. And of course, like everywhere, including back home, there are people who under-perform and consequently make a negative impact on patient care.
On the pediatric oncology ward I've spent some time with a peds resident from Europe. She works from 7 AM to 1 AM and essential splits the ward of 30 patients with a medical officer (the term for someone who has finished internship but hasn't done residency), who is also very dedicated and talented. It's really amazing to see the dedication she has to her patients and to watch her advocate for her patients in a system where it's easier to just let things slide. Of course, often the battles are lost, but she keeps fighting when most people (myself included) would probably give in. Part of her work here involves trying to improve the organization and recording methods in the ward. She's made spreadsheets to make it easier to record chemotherapy doses and and other medications. Apparently it's quite popular among most people in the ward because it makes records much easier to decipher, but one of the directors has expressed some fairly strong disapproval, preferring to use the older system. Like everywhere, there are people who are constructive and those who aren't.
Which brings me the point I've wanted to make about how, from what I've seen, the students, interns, residents, and consultants (attendings) have been overwhelmingly welcoming of visitors. The team often asks the visiting residents what they think and, save for the example I mentioned in the previous paragraph, I really have only seen constructive camaraderie between the Ugandan team members and visitors. I would have expected at least some occasional hint of resentment or defensiveness on the part of the locals, but they really value and appreciate the help and input from the visiting residents I've worked with. The only hierarchical interaction I've seen is in the interaction between attending and resident or resident and student, but that's just normal for medical training.
Going back to my friend's comment, I should also point out that this blog reflects my experiences with a government-supported tertiary care hospital in a very poor country. Two nights ago a group of us talked about how our perspective of Uganda would be different if we had come here strictly for vacation. We probably would have spent a few total nights in hotels here in Kampala, but most of the time would be spent away from the city, on safari in the amazing national parks and seeing all of the wildlife and natural beauty this place has to offer. And we would have met the friendly, welcoming Ugandans as well as the few who aren't so nice. If we had gotten sick, we would have gone to the nice hospitals. I hear the International Hospital is quite upscale. All in all, it would be a great place to vacation. Certainly further from the comfort zone than more familiar vacation destinations, but it could be quite comfortable nonetheless.
In contrast, being in Mulago Hospital means we have a front and center view of the consequences of limited resources (eg clean water, vaccinations etc), and the political failures that lead to sub-maximal utilization of the limited resources. All of the human suffering that happens is concentrated in one place, providing no shortage of examples of the shortcomings of the system.
So, to wrap up, I would emphasize that the stories I mention here only describe one small part of Uganda. It's certainly an important part, but it doesn't reflect what it would be like to visit as a tourist. Imagine, if someone went to Chicago and worked on the Cook County trauma team, their blog might give on the impression of a society where violent crime is rampant.
I definitely agree that most of the stories I have written about are scary. I would be scared to be a patient at the hospital where I have been working. Just to be clear though, I certainly don't want my stories to be an indictment of the people who work there. There are many interns, residents, and some visiting expats who do amazing things with the resources that are available. And of course, like everywhere, including back home, there are people who under-perform and consequently make a negative impact on patient care.
On the pediatric oncology ward I've spent some time with a peds resident from Europe. She works from 7 AM to 1 AM and essential splits the ward of 30 patients with a medical officer (the term for someone who has finished internship but hasn't done residency), who is also very dedicated and talented. It's really amazing to see the dedication she has to her patients and to watch her advocate for her patients in a system where it's easier to just let things slide. Of course, often the battles are lost, but she keeps fighting when most people (myself included) would probably give in. Part of her work here involves trying to improve the organization and recording methods in the ward. She's made spreadsheets to make it easier to record chemotherapy doses and and other medications. Apparently it's quite popular among most people in the ward because it makes records much easier to decipher, but one of the directors has expressed some fairly strong disapproval, preferring to use the older system. Like everywhere, there are people who are constructive and those who aren't.
Which brings me the point I've wanted to make about how, from what I've seen, the students, interns, residents, and consultants (attendings) have been overwhelmingly welcoming of visitors. The team often asks the visiting residents what they think and, save for the example I mentioned in the previous paragraph, I really have only seen constructive camaraderie between the Ugandan team members and visitors. I would have expected at least some occasional hint of resentment or defensiveness on the part of the locals, but they really value and appreciate the help and input from the visiting residents I've worked with. The only hierarchical interaction I've seen is in the interaction between attending and resident or resident and student, but that's just normal for medical training.
Going back to my friend's comment, I should also point out that this blog reflects my experiences with a government-supported tertiary care hospital in a very poor country. Two nights ago a group of us talked about how our perspective of Uganda would be different if we had come here strictly for vacation. We probably would have spent a few total nights in hotels here in Kampala, but most of the time would be spent away from the city, on safari in the amazing national parks and seeing all of the wildlife and natural beauty this place has to offer. And we would have met the friendly, welcoming Ugandans as well as the few who aren't so nice. If we had gotten sick, we would have gone to the nice hospitals. I hear the International Hospital is quite upscale. All in all, it would be a great place to vacation. Certainly further from the comfort zone than more familiar vacation destinations, but it could be quite comfortable nonetheless.
In contrast, being in Mulago Hospital means we have a front and center view of the consequences of limited resources (eg clean water, vaccinations etc), and the political failures that lead to sub-maximal utilization of the limited resources. All of the human suffering that happens is concentrated in one place, providing no shortage of examples of the shortcomings of the system.
So, to wrap up, I would emphasize that the stories I mention here only describe one small part of Uganda. It's certainly an important part, but it doesn't reflect what it would be like to visit as a tourist. Imagine, if someone went to Chicago and worked on the Cook County trauma team, their blog might give on the impression of a society where violent crime is rampant.
Tuesday, November 20, 2012
No clinda part 2
Yesterday was my first day on the oncology (cancer) ward. I did pediatric oncology yesterday and today and then I'll do adult oncology for the rest of the week.
The first patient I saw yesterday was an 9 year old girl who had a right above the knee amputation for a rhabdomyosarcoma (cancer of muscle cells). After the amputation she developed osteomyelitis (infection of the bone) at the site of the amputation and improved on the antibiotic clindamycin, the same antibiotic that was out of stock on Friday when I was on the adult ID ward. The same shortage of clindamycin hit the pediatric oncology floor and the girl couldn't get her clindamycin doses. I didn't round on her today to find out if clindamycin was now available or if they had started an alternative antibiotic. Tomorrow I'm going to get an update.
Today, like yesterday, I rounded on kids with various types of cancer like Hodgkins lymphoma, non-Hodgkins lymphoma, acute lymphoblastic lymphoma etc. One kid, a 12 year old boy, has refractory Hodgkins lymphoma and needed to have fluid from his chest drained because it had accumulated to the point that it was making it hard for him to breathe. The general surgeon and a visiting student came to place the chest tube early in the afternoon. Curtains were placed around the bed so that they blocked the view from the foot of the bed but kids and parents in the same row as out patient had a front and center view. Outside the window, people were having lunch and occasionally looked in to see the procedure. While the people outside seemed generally unflustered by the boy's screams, some of the kids inside looked pretty uncomfortable to horrified.
During the procedure, the mother of the boy sat at the foot of the bed, trying to comfort her son. Aside from screaming during the entire procedure, he bravely kept his body steady, not once flinching at the pain. Once the tube was placed, the surgery resident realized that he had forgotten a suture to tie the tube to the chest wall to keep it from slipping out. One person went looking for a suture in the building and I went to try to find some in the orthopedic surgery ward. After walking to a few buildings in the general vicinity of where I was told the orthopedic department is located, I found someone to help me. Unfortunately, the person who had the key to get into the area where the sutures are stored had gone home for the day and the only suture available otherwise was the wrong kind. So I walked back to the pediatric oncology ward, the boys screams leading me in the right direction, hoping that someone else had found the right suture. Fortunately I found the surgeon in the process of tying the tube in place, even if it was resorbable (wrong kind) of suture.
The first patient I saw yesterday was an 9 year old girl who had a right above the knee amputation for a rhabdomyosarcoma (cancer of muscle cells). After the amputation she developed osteomyelitis (infection of the bone) at the site of the amputation and improved on the antibiotic clindamycin, the same antibiotic that was out of stock on Friday when I was on the adult ID ward. The same shortage of clindamycin hit the pediatric oncology floor and the girl couldn't get her clindamycin doses. I didn't round on her today to find out if clindamycin was now available or if they had started an alternative antibiotic. Tomorrow I'm going to get an update.
Today, like yesterday, I rounded on kids with various types of cancer like Hodgkins lymphoma, non-Hodgkins lymphoma, acute lymphoblastic lymphoma etc. One kid, a 12 year old boy, has refractory Hodgkins lymphoma and needed to have fluid from his chest drained because it had accumulated to the point that it was making it hard for him to breathe. The general surgeon and a visiting student came to place the chest tube early in the afternoon. Curtains were placed around the bed so that they blocked the view from the foot of the bed but kids and parents in the same row as out patient had a front and center view. Outside the window, people were having lunch and occasionally looked in to see the procedure. While the people outside seemed generally unflustered by the boy's screams, some of the kids inside looked pretty uncomfortable to horrified.
During the procedure, the mother of the boy sat at the foot of the bed, trying to comfort her son. Aside from screaming during the entire procedure, he bravely kept his body steady, not once flinching at the pain. Once the tube was placed, the surgery resident realized that he had forgotten a suture to tie the tube to the chest wall to keep it from slipping out. One person went looking for a suture in the building and I went to try to find some in the orthopedic surgery ward. After walking to a few buildings in the general vicinity of where I was told the orthopedic department is located, I found someone to help me. Unfortunately, the person who had the key to get into the area where the sutures are stored had gone home for the day and the only suture available otherwise was the wrong kind. So I walked back to the pediatric oncology ward, the boys screams leading me in the right direction, hoping that someone else had found the right suture. Fortunately I found the surgeon in the process of tying the tube in place, even if it was resorbable (wrong kind) of suture.
Monday, November 19, 2012
No clinda
It's been hard to get a computer and internet service that loads up blogger, hence the lack of posts in the past few days.
Friday was my last day on the adult infectious disease ward. It was yet another reminder of the lack of resources here. The 30 year old woman I wrote about last week, the one I said would probably not make it until the morning, was still hanging on on Thursday. She was still just lying in bed with her eyes open and a frightened expression on her face, but her blood pressure was up to 110/70 (from 75/55 on Wednesday) and she was getting the antibiotics she needed. On Friday morning we checked up on her and her blood pressure was down to 85/55. Apparently she hadn't gotten any doses of clindamycin or IV fluids since 6 PM the night before. Clindamycin, we found out, is out of stock. The lack of IV fluids can just be attributed to insufficient nursing coverage overnight, or poor communication to the night staff of the precarious condition of this particular patient, who can't drink or eat on her own and is entirely dependent on IV fluids to keep her hydrated and for treatment of sepsis.
Though I was uncomfortable with the fact that she didn't get her doses of clindamycin overnight, I could understand that it simply wasn't available, and therefore beyond the power of the night staff or the patient's attendants to administer the antibiotic. Of course it would have been good to start treating with an alternative antibiotic, but that decision could arguably wait until the morning. But the lack of IV fluids didn't sit well with me. It just highlighted the fact that the system could so easily lead to the neglect of a patient that requires one of the simplest and oldest medical interventions available. The bottles of normal saline, D5half etc were all just a few meters away in another room, but no one bothered, or to be more fair, no one was available or informed, that this patient needed to be on maintenance IV fluids overnight.
On Friday there was some discussion about how patient care is handed off to the night team. Apparently, for some patients, the transfer is done by word of mouth, but for most patients, the night team just reads the notes in the patient's charts, which sit on the patient's beds. That means the night intern(s) have to go around the ward and decipher what is going on with each patient based on the notes. And it's not like back home where vitals are obtained every few hours, which at a minimum would give the night intern some indication about whether a patient requires some urgent attention.
Given the high rate of communication errors back home, despite verbal signouts on every patient and the help of electronic medical records (with all its benefits and drawbacks), I think it's a safe assumption that the rate of errors that happen here is significantly higher.
Today was my first day on the pediatric oncology service. I write about that next time.
Friday was my last day on the adult infectious disease ward. It was yet another reminder of the lack of resources here. The 30 year old woman I wrote about last week, the one I said would probably not make it until the morning, was still hanging on on Thursday. She was still just lying in bed with her eyes open and a frightened expression on her face, but her blood pressure was up to 110/70 (from 75/55 on Wednesday) and she was getting the antibiotics she needed. On Friday morning we checked up on her and her blood pressure was down to 85/55. Apparently she hadn't gotten any doses of clindamycin or IV fluids since 6 PM the night before. Clindamycin, we found out, is out of stock. The lack of IV fluids can just be attributed to insufficient nursing coverage overnight, or poor communication to the night staff of the precarious condition of this particular patient, who can't drink or eat on her own and is entirely dependent on IV fluids to keep her hydrated and for treatment of sepsis.
Though I was uncomfortable with the fact that she didn't get her doses of clindamycin overnight, I could understand that it simply wasn't available, and therefore beyond the power of the night staff or the patient's attendants to administer the antibiotic. Of course it would have been good to start treating with an alternative antibiotic, but that decision could arguably wait until the morning. But the lack of IV fluids didn't sit well with me. It just highlighted the fact that the system could so easily lead to the neglect of a patient that requires one of the simplest and oldest medical interventions available. The bottles of normal saline, D5half etc were all just a few meters away in another room, but no one bothered, or to be more fair, no one was available or informed, that this patient needed to be on maintenance IV fluids overnight.
On Friday there was some discussion about how patient care is handed off to the night team. Apparently, for some patients, the transfer is done by word of mouth, but for most patients, the night team just reads the notes in the patient's charts, which sit on the patient's beds. That means the night intern(s) have to go around the ward and decipher what is going on with each patient based on the notes. And it's not like back home where vitals are obtained every few hours, which at a minimum would give the night intern some indication about whether a patient requires some urgent attention.
Given the high rate of communication errors back home, despite verbal signouts on every patient and the help of electronic medical records (with all its benefits and drawbacks), I think it's a safe assumption that the rate of errors that happen here is significantly higher.
Today was my first day on the pediatric oncology service. I write about that next time.
Thursday, November 15, 2012
First code
Today was another busy day on the adult ID ward. I started off helping out the interns by doing a couple of lumbar punctures and some blood draws and then the team rounded on all the patients. Rounds here are a little different than back home. We start off by seeing the new patients or the ones on the high dependency area. Also, during rounds the team takes vitals and starts IV fluids if indicated.
Other than the patient with hyperactive delirium who kept saying that the American resident was telling her lies and that I was her white father, the most memorable event of the day was being involved in a code for the first time. I was just about to draw blood on a patient when an attendant said to me, without any apparent concern in her voice, "She has arrested." At first I just looked up and asked "She's arrested? What do you mean? Who?" The attendant pointed at a patient three or four beds down the row from where I was standing and I looked and tried to make out what was going on. I couldn't really see the patient breathing so I went over and checked and her chest wasn't rising and she didn't seem to be moving air. Her hands were cold and I couldn't feel a pulse.
I told the nearest doctor I could find, who was the American resident on the team and he came over and started chest compressions and told me to get the other resident. Because there was an infant, probably a 1-2 year old, playing on the floor next to the patient, right behind the resident who was doing chest compressions, the first thing I did was try to find a place for her where she wouldn't get stepped on or have body fluids or a needle land on her. The mother didn't want her on the bed, probably out of fear of getting her daughter sick, so I looked around and thought of putting her on an empty bed but no one was there to make sure she wouldn't fall off. Finally someone in the room realized that I needed someone to take the infant.
Finally I found the senior house officer and the intern and we all started running a code. For about 25 minutes we did chest compressions and bag ventilated the patient and that whole time we tried to get IV access and failed until we finally got a femoral IV line and gave epinephrine at about 20 minutes. After 25 minutes without any sign of a pulse or heart sounds, it was pretty clear that continuing was futile, but we moved the bed to another room that had suction to get rid of some of the gastric contents that had come up.
All of this happened in a room full of other patients and the family members watching. As I was doing chest compressions, I was using the song "Stayin' alive" to keep the right rhythm because I've heard that it's a song that plays at the ideal beat for chest compressions. It seemed to keep me at the right rhythm, but having an upbeat song running in my head while running my first code seemed to make for a strange combination emotions.
The American resident, who had rounded on the patient earlier, said that the patient had been responsive earlier in the day. She was in her 20s and had known ISS (immunosuppression syndrome = AIDS) and had come in with abdominal swelling. She was in kidney failure and she was acidotic (bicarbonate of 11) so it seems like she likely had a pulseless electrical activity (PEA) arrest due to acidosis. But, given that there was no EKG, we have no idea what sort of heart rhythm she had.
Other than the patient with hyperactive delirium who kept saying that the American resident was telling her lies and that I was her white father, the most memorable event of the day was being involved in a code for the first time. I was just about to draw blood on a patient when an attendant said to me, without any apparent concern in her voice, "She has arrested." At first I just looked up and asked "She's arrested? What do you mean? Who?" The attendant pointed at a patient three or four beds down the row from where I was standing and I looked and tried to make out what was going on. I couldn't really see the patient breathing so I went over and checked and her chest wasn't rising and she didn't seem to be moving air. Her hands were cold and I couldn't feel a pulse.
I told the nearest doctor I could find, who was the American resident on the team and he came over and started chest compressions and told me to get the other resident. Because there was an infant, probably a 1-2 year old, playing on the floor next to the patient, right behind the resident who was doing chest compressions, the first thing I did was try to find a place for her where she wouldn't get stepped on or have body fluids or a needle land on her. The mother didn't want her on the bed, probably out of fear of getting her daughter sick, so I looked around and thought of putting her on an empty bed but no one was there to make sure she wouldn't fall off. Finally someone in the room realized that I needed someone to take the infant.
Finally I found the senior house officer and the intern and we all started running a code. For about 25 minutes we did chest compressions and bag ventilated the patient and that whole time we tried to get IV access and failed until we finally got a femoral IV line and gave epinephrine at about 20 minutes. After 25 minutes without any sign of a pulse or heart sounds, it was pretty clear that continuing was futile, but we moved the bed to another room that had suction to get rid of some of the gastric contents that had come up.
All of this happened in a room full of other patients and the family members watching. As I was doing chest compressions, I was using the song "Stayin' alive" to keep the right rhythm because I've heard that it's a song that plays at the ideal beat for chest compressions. It seemed to keep me at the right rhythm, but having an upbeat song running in my head while running my first code seemed to make for a strange combination emotions.
The American resident, who had rounded on the patient earlier, said that the patient had been responsive earlier in the day. She was in her 20s and had known ISS (immunosuppression syndrome = AIDS) and had come in with abdominal swelling. She was in kidney failure and she was acidotic (bicarbonate of 11) so it seems like she likely had a pulseless electrical activity (PEA) arrest due to acidosis. But, given that there was no EKG, we have no idea what sort of heart rhythm she had.
Wednesday, November 14, 2012
Adult Infectious Diseases
This week I've been on the adult ID ward. Overall, my time here has been an incredible learning experience, but this week I really felt like I've been able to contribute to the team in a significant way.
The team I'm working with, which is responsible for about 40 patients, has two interns and, like the rest of the hospital, severely lacks enough nursing staff. Because of the lack of nursing staff, dosing decisions for medications are adjusted under the assumption that doses of medications will be missed. For example, for treatment of presumed or confirmed bacterial meningitis, which is probably 25-50% of the patients, they give double the normal dose (2 grams, twice a day) so that if the patients only get one dose they still get the "full" recommended dose.
The severe shortage of interns and nursing staff means that visiting students, residents and nurses can really be a significant help in taking care of the patients. Yesterday I did several blood draws (including my first femoral), 4 lumbar punctures (only 1 successful), hung bottles of IV fluids and placed urinary catheters from 8 AM to 7 PM. It was really the first time since I've been here that I appreciated how much anyone with some fundamental skills can help out here. And because the patients here are often very sick (to the point where in the US they would be in the ICU), getting things done in an expedient manner feels like it might make a difference.
This morning, one patient, who is HIV positive (like most of the patients) with a CD4 count of 10 who is essentially not responsive (likely due to meningitis suspected tuberculosis, cryptococcal meningitis, syphilis etc) had a blood pressure of 75/55, heart rate of 130, a respiratory rate of >30 and a sodium of 168. This patient would likely be in the intensive care unit in the US but here that's not an option so we just hung a bottle of IV fluids, which even with the line fully open was not going fast enough to catch up. We tried to put in another IV line but failed and the team went on to the next patient. I would be surprised if she's still in the ward tomorrow as she looks sicker than a lot of the patients that I saw one day and were gone the next.
On a lighter note, the teaching on the adult ID service has been excellent. The SHO (senior house officer) that I've been working with constantly elicits the students' opinions both to teach but also to guide treatment.
That's all for now.
The team I'm working with, which is responsible for about 40 patients, has two interns and, like the rest of the hospital, severely lacks enough nursing staff. Because of the lack of nursing staff, dosing decisions for medications are adjusted under the assumption that doses of medications will be missed. For example, for treatment of presumed or confirmed bacterial meningitis, which is probably 25-50% of the patients, they give double the normal dose (2 grams, twice a day) so that if the patients only get one dose they still get the "full" recommended dose.
The severe shortage of interns and nursing staff means that visiting students, residents and nurses can really be a significant help in taking care of the patients. Yesterday I did several blood draws (including my first femoral), 4 lumbar punctures (only 1 successful), hung bottles of IV fluids and placed urinary catheters from 8 AM to 7 PM. It was really the first time since I've been here that I appreciated how much anyone with some fundamental skills can help out here. And because the patients here are often very sick (to the point where in the US they would be in the ICU), getting things done in an expedient manner feels like it might make a difference.
This morning, one patient, who is HIV positive (like most of the patients) with a CD4 count of 10 who is essentially not responsive (likely due to meningitis suspected tuberculosis, cryptococcal meningitis, syphilis etc) had a blood pressure of 75/55, heart rate of 130, a respiratory rate of >30 and a sodium of 168. This patient would likely be in the intensive care unit in the US but here that's not an option so we just hung a bottle of IV fluids, which even with the line fully open was not going fast enough to catch up. We tried to put in another IV line but failed and the team went on to the next patient. I would be surprised if she's still in the ward tomorrow as she looks sicker than a lot of the patients that I saw one day and were gone the next.
On a lighter note, the teaching on the adult ID service has been excellent. The SHO (senior house officer) that I've been working with constantly elicits the students' opinions both to teach but also to guide treatment.
That's all for now.
Monday, November 12, 2012
The Odwalla Superfood bar that failed to bring peace
On Friday, after a day in the neonate ward, four of us headed out to Sipi Falls for the weekend. The falls are a beautiful series of drop offs that are each about 100 meters high set in the foothills of Mt. Elgon where coffee, bananas, avocado, and passion fruit, among other crops, are grown for sustenance and income. We stayed at a lodge owned by a Brit and run by locals. But probably the most memorable aspect of the weekend was the transportation to and from Sipi Falls.
In the week before our trip, we called several drivers that either we had hired previously to drive here in the city or had been recommended to us. We received quotes ranging from 400,000 Ugandan Shillings ($160 US) to a few million shillings and so naturally we opted for the 400,000 USH option, which, you can judge for yourself, might have been unwise.
On Friday after work, we waited at the Guest House as the driver, 'Don', showed up 30 minutes late. He pulled up in a Toyota station wagon of some sort and began to explain that for our comfort, he borrowed a larger car Because the care was larger, the fuel cost would be more expensive that he had originally estimated and thus he said that he needed to charge us more, specifically 25,000 more for each person, bringing the cost to a total of 500,000 round trip. We voiced our resistance to spending more considering we had agreed upon a price beforehand. We had also specifically told him that we only wanted a larger car if the price would still be 400,000 USH. After some discussion we agreed to the new price and he also explained that he needed money up front to pay for gas. Reluctantly, we paid Don 300,000 and got into the care and began our journey to to Sipi Falls.
About five minutes into our trip, we pulled into a gas station to fill up gas (180,000), and apparently to top off the oil, hydraulic fluid and to replace the spare (60,000) that none of had realized was in the left rear of the car. Don also ran across the street holding the money in his hand and went into what appeared to be an auto parts store. After all of the necessary maintenance and repairs, we set off again.
About twenty minutes into our journey, after talking with Don about Uganda, his family etc, we pulled over for Don to give 60,000 to his fiance and child. At this point, Don has spent the 300,000 that we have given him, 240,000 in overhead and 60,000 for his family (ie profit).
We continued on our way and we asked Don to stop somewhere to get some 'Rolexes', which are chapati's (kind of like naan flatbread) with fried egg on top that are then rolled together. He told us that he would take us to a rolex stand that he knows and trust. Because traffic was absolutely awful, he drove us on a shortcut that seemed to be quite effective, bypassing the rush hour traffic entirely. Finally we got to his neighborhood, Seeta, and parked across the street from a rolex stand. We ordered three chapatis and Don ordered himself some food and put it on our tab. As we walked back to the car, Don explained to me that he needed 30,000 more right now. So I gave him 30,000 and told the rest of the group that we had now paid a total of 330,000. We got into the car and Don held out the 30,000 out of the window and, without a word, handed the money to a woman that had been quietly standing about 20 meters from the car.
About 45 minutes into the drive, Don pulled into a gas station and said that he was going to get water. As he was parking, he asked if we wanted water and we said that we didn't need any, at which point he started driving again. We were all puzzled and then explained that it was entirely fine for him to get water for himself. He drove back around, parked and went to get water. It seemed to us that he was expecting us to buy water for him, but there was never any direct communication, so we remained a little confused, but Don got his water and we continued our trek.
Don communicated to us that he would be stopping at his "mom's" or "auntie's" (in quotation marks simply because I wasn't totally clear on the relationships despite Don's explanations) house on the way to pick up food, a request that we were fully supportive of.
At one point we were driving along the Ugandan countryside and he quickly slowed down and pulled onto the side of the road, did a U-turn and greeted his mom and another woman. We drove back about 100 meters and turned into a fairly hidden grass drive way. Don's auntie came out of the home with a black plastic bag and gave it to Don, who gave his auntie 7,000.
Don kindly offered us the roasted corn and sweet potato that his auntie had packed for him, but we declined, explaining that we were planning on eating dinner at the lodge.
Shortly after the stop for food, we were caught in a major downpour. Visibility was about 1 meter and the windshield was fogging up. We asked Don if he wanted to stop and wait out the storm and he chuckled, saying that he could see and that there was no problem. At one point, I saw how the distance between us and the side of the road was increasing and I reached over to the steering wheel and considered nudging it back but saw that Don steered us back on course.
After what seemed to be about 15 or 20 minutes of torrential rain, the weather cleared and Don pointed out that he hadn't needed to stop.
As we approached our destination, along winding mountain roads in the dark of night, Don stopped a couple of times for directions. At one turn, I had to warn him that he was headed for a median.
As he didn't convince us that he was totally clear on the route, we called the lodge and asked Don to talk with them for clarification. Despite his protestations that he didn't have to stop to talk on the phone, we forced Don to pull over.
We continued along the winding road and started slowing down to see the signs advertising accommodations. At one point, we pulled off the road to shine the headlights on a sign and as Don was trying to read the sign, the car was rolling forward and I saw that we were just a few feet from a 10 foot deep ditch. With visions of having to climb out of the car as it sits vertically in a ditch, I said "Do not move forward!" Fortunately, Don stopped at the last minute.
When finally made it to the lodge, Don seemed to indicate that maybe he could stay with us because his dad, with whom he said he was going to stay, was too far away and would cost too much in gas money. As our agreement, which we had made abundantly clear just involved him getting us to and from Sipi Falls, we said that that would not work, and Don was able to arrange to stay with someone down the road from our hotel. We agreed that we would see Don back in the lodge at 1 PM on Sunday and we parted ways.
On Sunday at about 12:20 PM, we had just sat down for lunch when, to our delight, Don arrived. We finished our lunch and as I walked to the car, Don started mentioning something about miscalculation. I just kept walking and said that we would talk about this in Kampala. We loaded our bags in the car and started getting in as Don says "As I was trying to explain to you, I miscalculated..." He went on to explain that he had been planning on staying at his dad's home but that it would have cost too much money in fuel so he stayed with a neighbor of the lodge and owed them money, that he had spent money on food, that the car would need oil, hydraulic fluid etc etc.
He said that he needed 10,000 to pay the two gentlemen that were hovering near us. So we gave them 10,000 to cover his lodging, saying that it was coming out of what we owed him. We said to him that we would pay for the gas to get to Kampala and that any money left over from the 500,000 that we had agreed on in Kampala would be his. We made this offer several times, and Don seemed to repeatedly indicate that he didn't find those terms agreeable. I told him that he wouldn't be holding us hostage in Sipi Falls and that if he didn't accept our agreement within the 8 minutes remaining until 1:00 PM, we would take a bus back to Kampala.
When the discussions appeared to be going nowhere, I went in to the lodge, got some toilet paper to check the oil and asked about the buses to get back to Kampala. I came back out to the car and told Don to open the hood. I checked the oil and it was full, which made sense because he had filled it when we first left Kampala. Then he said that the hydraulic fluid was low. To me, it looked like there was enough liquid.
When it was clear that we were making no progress with Don, we took our bags out of the car and told him that we would take the bus. He then explained that we were abandoning him and the car and he asked "How am I going to get to Kampala?" We reiterated our offer to get the car and all 5 of us to Kampala, but he still wouldn't agree. We walked the 30 yards out of the lodge and stood at the bus stop. Several kids offered us a ride to Mbale to catch the bus and said, referring to Don "You shouldn't go with him. He may leave you stranded".
As we waited for the matatu to Mbale, one of the lodge employees came out, apparently as a mediator sent by Don because he informed us that Don accepted our offer. I told the employee that it was too late, and that if he accepted, he should speak to us himself.
A few minutes after the lodge employee walked away, Don slowly pulled out of the lodge and just looked at us out of the car. He asked me to come over and told me that he accepted our offer. I responded that we had decided to take the bus back and I walked back to the group, where we deliberated whether to take the bus or go with Don. Despite our reservations, we decided to go with Don, partly out of convenience, but also because we didn't necessarily want to leave Don stranded.
So we got in the car, drove down the mountainside and into the first town. There we passed a large mob of people that were partaking in a circumcision ceremony that is traditional in that region of Uganda. As the crowd passed, some of them gave us the peace sign with there fingers, to which I reciprocated, drawing elated cheers from the crowd. Don explained that that is the symbol of the opposition party, while the thumbs up is a symbol of Museveni's party.
We drove out of town on the main road and suddenly Don turned right on a dirt road, explaining that it was a shortcut to avoid the 'fake' (meaning potholed) road we had taking previously. We vociferously vetoed that option so he looped around and got back on the main road.
The road came to a T, where we turned left and filled up gas. Here, we agreed to pay 80,000 in gas and 15,000 for hydraulic fluid. We paid it directly to the gas station attendant and got back in the car.
As Don pulled out of the station, he started turning in the opposition direction in which we were originally headed. Again, we protested and said that we wanted to take the same route we had taken on the way there. He explained that he wanted to stop by his dad's home to get food. We strongly opposed this, mostly because we weren't sure if he had some ulterior plans and we figured that he had either eaten breakfast or he could stop at his auntie's again for food.
Don's reaction to our demands included claims that we were treating him like an animal by ordering him to drive and not letting him eat. He also complained that we hadn't invited him for lunch. At one point in the discussion, we offered him an Odwalla Superfood bar. This just offended him more and he continued to say that we were treating him like an animal and expecting him to eat chocolate (referring to the bar) when we had eating a nice meal. We failed to point out that 1) the Superfood bar costs about $2.50 US, 2) that it traveled from the US in a suitcase, 3) that two members of the group had brought large stores of these bars and were eating them every day, and 4) that it might represent the absolute pinnacle of the science of nutrition.
Finally, we agreed that as long as this would be the last stop to Kampala, we were fine with him stopping.
We drove a few minutes on the road and then, to our surprise, turned on to a dirt walking path, aka singletrack. In other words, where full sized, four wheel vehicles don't drive. This path meandered through crops and forest. We drove on this singletrack for probably about 3-5 kilometers. Finally we got to Don's old home. He said that it would be a quick stop. We debated whether to get out to go to the bathroom and finally opted to just use the facilities, which consisted of a cylinder of bricks about 4 or 5 feet high for privacy.
After Don spent about 10-15 minutes chatting and eating with family members, he took a large bag of nuts and put them in the trunk of the car. We got in the car, drove on the walking path for another few kilometers and got back on the highway.
The rest of the trip went smoothly and we made just one more stop on the way back to Kampala for Don to pick up a large bag of rice. When we got to the guest house, we gave Don the remainder of what we owed him (15,000).
The whole ordeal was quite memorable. My sense is that Don, who claimed to have worked as a driver for a touring company, either doesn't have a sense about how to estimate overhead, which in my mind includes housing and food for his weekend, or that he planned on having us cover his overhead without telling us in advance. I'm not sure if this has worked for him in the past or if it works for other drivers, but it didn't really work this time. I understand that his life doesn't even fit the saying "living paycheck to paycheck", but in the end, if he's trying to run his own business, he's not winning himself any referrals with his business plan.
As for his profit over the weekend, we know he made the 60,000 that he gave his fiance and son, the 30,000 that he gave to the mysterious lady, and then 15,000 that we gave him in the end. Interestingly, at one point in one of our several discussions, he indicated that the 60,000 that he gave his fiance and son were part of the trip expenses. We pointed out that one works in order to feed their family and that the payment to his family constitutes profit. Overall, his total profit was at least about 105,000 for 2.5 days. He might even get some reimbursement from whoever lent him the car for fixing the flat tire. We're told that police officers here make 150,000 ($50) a month, which isn't enough to support a family so they supplement their income with bribes. If Don makes 105,000 every 3 days, in one month he would make 1,050,000. So, in my mind, I don't think Don actually made off too badly even if he didn't make as much as he had hoped.
In the week before our trip, we called several drivers that either we had hired previously to drive here in the city or had been recommended to us. We received quotes ranging from 400,000 Ugandan Shillings ($160 US) to a few million shillings and so naturally we opted for the 400,000 USH option, which, you can judge for yourself, might have been unwise.
On Friday after work, we waited at the Guest House as the driver, 'Don', showed up 30 minutes late. He pulled up in a Toyota station wagon of some sort and began to explain that for our comfort, he borrowed a larger car Because the care was larger, the fuel cost would be more expensive that he had originally estimated and thus he said that he needed to charge us more, specifically 25,000 more for each person, bringing the cost to a total of 500,000 round trip. We voiced our resistance to spending more considering we had agreed upon a price beforehand. We had also specifically told him that we only wanted a larger car if the price would still be 400,000 USH. After some discussion we agreed to the new price and he also explained that he needed money up front to pay for gas. Reluctantly, we paid Don 300,000 and got into the care and began our journey to to Sipi Falls.
About five minutes into our trip, we pulled into a gas station to fill up gas (180,000), and apparently to top off the oil, hydraulic fluid and to replace the spare (60,000) that none of had realized was in the left rear of the car. Don also ran across the street holding the money in his hand and went into what appeared to be an auto parts store. After all of the necessary maintenance and repairs, we set off again.
About twenty minutes into our journey, after talking with Don about Uganda, his family etc, we pulled over for Don to give 60,000 to his fiance and child. At this point, Don has spent the 300,000 that we have given him, 240,000 in overhead and 60,000 for his family (ie profit).
We continued on our way and we asked Don to stop somewhere to get some 'Rolexes', which are chapati's (kind of like naan flatbread) with fried egg on top that are then rolled together. He told us that he would take us to a rolex stand that he knows and trust. Because traffic was absolutely awful, he drove us on a shortcut that seemed to be quite effective, bypassing the rush hour traffic entirely. Finally we got to his neighborhood, Seeta, and parked across the street from a rolex stand. We ordered three chapatis and Don ordered himself some food and put it on our tab. As we walked back to the car, Don explained to me that he needed 30,000 more right now. So I gave him 30,000 and told the rest of the group that we had now paid a total of 330,000. We got into the car and Don held out the 30,000 out of the window and, without a word, handed the money to a woman that had been quietly standing about 20 meters from the car.
About 45 minutes into the drive, Don pulled into a gas station and said that he was going to get water. As he was parking, he asked if we wanted water and we said that we didn't need any, at which point he started driving again. We were all puzzled and then explained that it was entirely fine for him to get water for himself. He drove back around, parked and went to get water. It seemed to us that he was expecting us to buy water for him, but there was never any direct communication, so we remained a little confused, but Don got his water and we continued our trek.
Don communicated to us that he would be stopping at his "mom's" or "auntie's" (in quotation marks simply because I wasn't totally clear on the relationships despite Don's explanations) house on the way to pick up food, a request that we were fully supportive of.
At one point we were driving along the Ugandan countryside and he quickly slowed down and pulled onto the side of the road, did a U-turn and greeted his mom and another woman. We drove back about 100 meters and turned into a fairly hidden grass drive way. Don's auntie came out of the home with a black plastic bag and gave it to Don, who gave his auntie 7,000.
Don kindly offered us the roasted corn and sweet potato that his auntie had packed for him, but we declined, explaining that we were planning on eating dinner at the lodge.
Shortly after the stop for food, we were caught in a major downpour. Visibility was about 1 meter and the windshield was fogging up. We asked Don if he wanted to stop and wait out the storm and he chuckled, saying that he could see and that there was no problem. At one point, I saw how the distance between us and the side of the road was increasing and I reached over to the steering wheel and considered nudging it back but saw that Don steered us back on course.
After what seemed to be about 15 or 20 minutes of torrential rain, the weather cleared and Don pointed out that he hadn't needed to stop.
As we approached our destination, along winding mountain roads in the dark of night, Don stopped a couple of times for directions. At one turn, I had to warn him that he was headed for a median.
As he didn't convince us that he was totally clear on the route, we called the lodge and asked Don to talk with them for clarification. Despite his protestations that he didn't have to stop to talk on the phone, we forced Don to pull over.
We continued along the winding road and started slowing down to see the signs advertising accommodations. At one point, we pulled off the road to shine the headlights on a sign and as Don was trying to read the sign, the car was rolling forward and I saw that we were just a few feet from a 10 foot deep ditch. With visions of having to climb out of the car as it sits vertically in a ditch, I said "Do not move forward!" Fortunately, Don stopped at the last minute.
When finally made it to the lodge, Don seemed to indicate that maybe he could stay with us because his dad, with whom he said he was going to stay, was too far away and would cost too much in gas money. As our agreement, which we had made abundantly clear just involved him getting us to and from Sipi Falls, we said that that would not work, and Don was able to arrange to stay with someone down the road from our hotel. We agreed that we would see Don back in the lodge at 1 PM on Sunday and we parted ways.
On Sunday at about 12:20 PM, we had just sat down for lunch when, to our delight, Don arrived. We finished our lunch and as I walked to the car, Don started mentioning something about miscalculation. I just kept walking and said that we would talk about this in Kampala. We loaded our bags in the car and started getting in as Don says "As I was trying to explain to you, I miscalculated..." He went on to explain that he had been planning on staying at his dad's home but that it would have cost too much money in fuel so he stayed with a neighbor of the lodge and owed them money, that he had spent money on food, that the car would need oil, hydraulic fluid etc etc.
He said that he needed 10,000 to pay the two gentlemen that were hovering near us. So we gave them 10,000 to cover his lodging, saying that it was coming out of what we owed him. We said to him that we would pay for the gas to get to Kampala and that any money left over from the 500,000 that we had agreed on in Kampala would be his. We made this offer several times, and Don seemed to repeatedly indicate that he didn't find those terms agreeable. I told him that he wouldn't be holding us hostage in Sipi Falls and that if he didn't accept our agreement within the 8 minutes remaining until 1:00 PM, we would take a bus back to Kampala.
When the discussions appeared to be going nowhere, I went in to the lodge, got some toilet paper to check the oil and asked about the buses to get back to Kampala. I came back out to the car and told Don to open the hood. I checked the oil and it was full, which made sense because he had filled it when we first left Kampala. Then he said that the hydraulic fluid was low. To me, it looked like there was enough liquid.
When it was clear that we were making no progress with Don, we took our bags out of the car and told him that we would take the bus. He then explained that we were abandoning him and the car and he asked "How am I going to get to Kampala?" We reiterated our offer to get the car and all 5 of us to Kampala, but he still wouldn't agree. We walked the 30 yards out of the lodge and stood at the bus stop. Several kids offered us a ride to Mbale to catch the bus and said, referring to Don "You shouldn't go with him. He may leave you stranded".
As we waited for the matatu to Mbale, one of the lodge employees came out, apparently as a mediator sent by Don because he informed us that Don accepted our offer. I told the employee that it was too late, and that if he accepted, he should speak to us himself.
A few minutes after the lodge employee walked away, Don slowly pulled out of the lodge and just looked at us out of the car. He asked me to come over and told me that he accepted our offer. I responded that we had decided to take the bus back and I walked back to the group, where we deliberated whether to take the bus or go with Don. Despite our reservations, we decided to go with Don, partly out of convenience, but also because we didn't necessarily want to leave Don stranded.
So we got in the car, drove down the mountainside and into the first town. There we passed a large mob of people that were partaking in a circumcision ceremony that is traditional in that region of Uganda. As the crowd passed, some of them gave us the peace sign with there fingers, to which I reciprocated, drawing elated cheers from the crowd. Don explained that that is the symbol of the opposition party, while the thumbs up is a symbol of Museveni's party.
We drove out of town on the main road and suddenly Don turned right on a dirt road, explaining that it was a shortcut to avoid the 'fake' (meaning potholed) road we had taking previously. We vociferously vetoed that option so he looped around and got back on the main road.
The road came to a T, where we turned left and filled up gas. Here, we agreed to pay 80,000 in gas and 15,000 for hydraulic fluid. We paid it directly to the gas station attendant and got back in the car.
As Don pulled out of the station, he started turning in the opposition direction in which we were originally headed. Again, we protested and said that we wanted to take the same route we had taken on the way there. He explained that he wanted to stop by his dad's home to get food. We strongly opposed this, mostly because we weren't sure if he had some ulterior plans and we figured that he had either eaten breakfast or he could stop at his auntie's again for food.
Don's reaction to our demands included claims that we were treating him like an animal by ordering him to drive and not letting him eat. He also complained that we hadn't invited him for lunch. At one point in the discussion, we offered him an Odwalla Superfood bar. This just offended him more and he continued to say that we were treating him like an animal and expecting him to eat chocolate (referring to the bar) when we had eating a nice meal. We failed to point out that 1) the Superfood bar costs about $2.50 US, 2) that it traveled from the US in a suitcase, 3) that two members of the group had brought large stores of these bars and were eating them every day, and 4) that it might represent the absolute pinnacle of the science of nutrition.
Finally, we agreed that as long as this would be the last stop to Kampala, we were fine with him stopping.
We drove a few minutes on the road and then, to our surprise, turned on to a dirt walking path, aka singletrack. In other words, where full sized, four wheel vehicles don't drive. This path meandered through crops and forest. We drove on this singletrack for probably about 3-5 kilometers. Finally we got to Don's old home. He said that it would be a quick stop. We debated whether to get out to go to the bathroom and finally opted to just use the facilities, which consisted of a cylinder of bricks about 4 or 5 feet high for privacy.
After Don spent about 10-15 minutes chatting and eating with family members, he took a large bag of nuts and put them in the trunk of the car. We got in the car, drove on the walking path for another few kilometers and got back on the highway.
The rest of the trip went smoothly and we made just one more stop on the way back to Kampala for Don to pick up a large bag of rice. When we got to the guest house, we gave Don the remainder of what we owed him (15,000).
The whole ordeal was quite memorable. My sense is that Don, who claimed to have worked as a driver for a touring company, either doesn't have a sense about how to estimate overhead, which in my mind includes housing and food for his weekend, or that he planned on having us cover his overhead without telling us in advance. I'm not sure if this has worked for him in the past or if it works for other drivers, but it didn't really work this time. I understand that his life doesn't even fit the saying "living paycheck to paycheck", but in the end, if he's trying to run his own business, he's not winning himself any referrals with his business plan.
As for his profit over the weekend, we know he made the 60,000 that he gave his fiance and son, the 30,000 that he gave to the mysterious lady, and then 15,000 that we gave him in the end. Interestingly, at one point in one of our several discussions, he indicated that the 60,000 that he gave his fiance and son were part of the trip expenses. We pointed out that one works in order to feed their family and that the payment to his family constitutes profit. Overall, his total profit was at least about 105,000 for 2.5 days. He might even get some reimbursement from whoever lent him the car for fixing the flat tire. We're told that police officers here make 150,000 ($50) a month, which isn't enough to support a family so they supplement their income with bribes. If Don makes 105,000 every 3 days, in one month he would make 1,050,000. So, in my mind, I don't think Don actually made off too badly even if he didn't make as much as he had hoped.
Thursday, November 8, 2012
Here's a quick report about today.
Two of my colleagues and I went to a clinic called Alive Medical Services. It's supported by a variety of sources including the Ugandan government and Alicia Keyes. It's in a neighborhood where the main road has about 5% of its original pavement and some of the the biggest washed out potholes I've seen in a residential area. Three blocks away are the slums that are ubiquitous here in Kampala. To compare the slums here with my only other reference point for slums, the slums of Buenos Aires ('villas de emergencia' or just 'villas') take up relatively small pockets of the city. In Kampala, the majority of the land is taken up by slums.
The facility is quite nice in absolute terms, even upscale by Ugandan standards, and the surrounding neighborhood has what I would qualify as upper class homes. There are about 10 consultation rooms for outpatients and about 5 inpatient beds. Patients can present to the clinic 24 hours a day. By far the main focus of the clinic is management of HIV and its associated complications. To give you an idea, I saw two kids, 5 and 8 year old boys, and their father who are all HIV positive. The mother is also HIV positive and had active tuberculosis recently and now the 5 year old has a cough and junky-sounding lungs (or crackles and rhonchi to be precise). According to the doctor I was working with, he should have been on isoniazid prophylaxis as soon as the mother was diagnosed.
One interest thing to note is that here the HIV serostatus is always mentions in the opening line of the history of presenting illness. And they often refer to HIV as ISS, a euphemism that stands for immunosuppressed syndrome.
Probably the most memorable event of the day was the trip to the neighboring slums. Two women who work for the clinic and live in the slums took us there to show us the "neighborhood". As we walked, the kids often smiled and waved at us and came to shake our hands. Occasionally we heard the word Mzungo, which referred to us. We visited a hairdresser's home and got to see firsthand what it's like in one of these homes. This particular one was made of wood rods tied together with mud or stones filling in the spaces. Some walls were sheet metal.
There's much more to say, but I'm out of time so I'll have to fill in details later.
Two of my colleagues and I went to a clinic called Alive Medical Services. It's supported by a variety of sources including the Ugandan government and Alicia Keyes. It's in a neighborhood where the main road has about 5% of its original pavement and some of the the biggest washed out potholes I've seen in a residential area. Three blocks away are the slums that are ubiquitous here in Kampala. To compare the slums here with my only other reference point for slums, the slums of Buenos Aires ('villas de emergencia' or just 'villas') take up relatively small pockets of the city. In Kampala, the majority of the land is taken up by slums.
The facility is quite nice in absolute terms, even upscale by Ugandan standards, and the surrounding neighborhood has what I would qualify as upper class homes. There are about 10 consultation rooms for outpatients and about 5 inpatient beds. Patients can present to the clinic 24 hours a day. By far the main focus of the clinic is management of HIV and its associated complications. To give you an idea, I saw two kids, 5 and 8 year old boys, and their father who are all HIV positive. The mother is also HIV positive and had active tuberculosis recently and now the 5 year old has a cough and junky-sounding lungs (or crackles and rhonchi to be precise). According to the doctor I was working with, he should have been on isoniazid prophylaxis as soon as the mother was diagnosed.
One interest thing to note is that here the HIV serostatus is always mentions in the opening line of the history of presenting illness. And they often refer to HIV as ISS, a euphemism that stands for immunosuppressed syndrome.
Probably the most memorable event of the day was the trip to the neighboring slums. Two women who work for the clinic and live in the slums took us there to show us the "neighborhood". As we walked, the kids often smiled and waved at us and came to shake our hands. Occasionally we heard the word Mzungo, which referred to us. We visited a hairdresser's home and got to see firsthand what it's like in one of these homes. This particular one was made of wood rods tied together with mud or stones filling in the spaces. Some walls were sheet metal.
There's much more to say, but I'm out of time so I'll have to fill in details later.
Wednesday, November 7, 2012
The past few days I've been working on the pediatric infectious disease ward. Not surprisingly, I've seen a lot of things that I suspect are pretty rare in the States. And the senior house officers (ie residents) are great at teaching, just like the peds ID service back home. It must be something about the peds ID culture.
On my first day, I got a tour of the facility. It's a one floor unit with two larger wings and a couple of smaller rooms for very ill neonates and one for patients with tetanus. The room for the tetanus patients is dimly lit to minimize stimuli that might precipitate spasms. I've only been in their briefly, but from talking with the residents, they are mostly managed with anti-toxin and benzodiazepines. During rounds on my first day I was in the neonate room when I started hearing the deeply pained cries of a mother who had just lost her son to tetanus. The body, wrapped in sheets, was carried past us into another room. We heard the mother's cries for the next few hours and one of the residents told us of a few other cases of kids that died because from tetanus and pointed out how awful it is that kids die from a disease that's preventable with just a 'jab' as she put it.
The main things I've seen here are septicemia, malaria, meningitis. The main test that is done early on in the workup of most patients is a blood smear (B/S) to rule out malaria and evaluate for sickle cell anemia when appropriate. Another test that gets ordered often is a hemoglobin level. It's not uncommon to see hemoglobin levels of 2.0 to 5.0. The liver function and renal function panel interestingly (to me) has gamma-glutamyl transferase instead of alkaline phosphatase, which I'm guessing is due to the better specificity of the GGT but maybe it's a cost thing. I'll have to ask or look that up when I get a chance. Then the complete bood count is done pretty commonly followed by hemoglobin electrophoresis (which costs about $7-8 US).
Many kids are on antibiotics for septicemia (ceftriaxone mostly) and quinine (for 3 days and then 3 days of artemisin combination therapy) for malaria. The artemether (an antimalarial) is often given intramuscularly in a childs gluteus muscles. One kid today was having some right leg weakness that was likely due to administration of the artermether dose too close to the sciatic or other nerve in that area. The resident said that it's not uncommon for this to happen and that he's seen many cases of patients that have long term neuropathies (like a foot drop).
Today I saw a child with a diagnosis of post-measles encephalitis who presented with fevers and convulsions about 1 week after recovering from measles (a vaccine-preventable disease).
Yesterday I saw a patient with hepatitis B (another vaccine-preventable disease) who presented with fever, vomiting and diarrhea (no tender hepatomegaly). The patient's sister was in the bed next to him and might also have hep B though the differential currently includes abdominal tuberculosis and typhoid fever.
Today we saw a patient who has had jaundice for several months that we suspect is hepatitis A (again, vaccine-preventable). For the patient with hep A, we ordered a PT (prothrombin time to assess the liver's ability to synthesize proteins) to get an idea of whether the patient was at risk for hepatic failure. Because the patient doesn't have the means to pay, we took the order to the appropriate office to get the 20,000 USH ($8 US dollars) for the test. Unfortunately the secretary in charge of distributing the funds was out sick so the team decided to front the money. We went to the lab to place the order and get the appropriate tube, but apparently the lab is out of the reagents necessary to perform the test. Tomorrow we're going to decide whether it's necessary for one of the patient's family to go to another lab in town to get the test.
After finishing on the ID ward on Monday, I headed to the pediatric acute care service. This is where parents bring their kids where they are initially triaged. There was a kid having a sickle cell crisis who was having decreased movement/strength of his right arm, likely due to a stroke. He was getting transfused and hopefully his right arm weakness improves.
For another patient who needed an urgent transfusion, the resident took a sample of the patient's blood for ABO typing and did the agglutination tests on a broken tile.
I also helped one of the residents do a lumbar puncture for a patient with suspected meningitis. It's actually fairly common for patients' parents to decline a lumbar puncture so often the kids are empirically treated with antimalarials and antibiotics.
In other news, my camera was stolen from my room so my posts are going to be lighter on the pictures.
Sunday, November 4, 2012
Excursion to Murchison Falls National Park
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| Murchison Falls is the yellow area to the right of the "Democratic Republic of Congo" label. |
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| We had beautiful weather the entire trip. |
I decided to join some fellow Americans in the form of a couple of residents and a fellow fourth year medical student for a trip to Murchison Falls National Park on the west side of the country, near the border with the Democratic Republic of Congo. I absconded from work on Thursday and we drove about 4 hours to see the falls and go on a few game drives and a boat tour. The park is no doubt one of the most special places I've visited. The sheer number of animals was incredible. I was expecting to drive for hours and see a few antelope-like animals, maybe an elephant, a giraffe and some water buffalo but we literally saw hundreds of animals. We saw them in droves populating the big rolling hills of more open areas as well as more forested land that take up the huge expanse of the park. And that's after some significant poaching that happened in the past here. To give you a sense of how this region was a hiding ground for the Lords Resistance Army, in 2002 a guide for the company that took us on the trip was in the far remote north area of the park and was shot and killed by members of the LRA. Fortunately it seems as if the LRA has been significantly weakened since then.
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| The Toyota Hi-Ace 4 wheel drive van that to my surprise rolled over every obstacle we encountered. |
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| One of the few nicely paved and marked highways on the trek from Kampala to Murchison Falls National Park. |
Getting back to the animals, our first encounter with wildlife was after driving for a while on the last stretch of dirt road before reaching the campground when we saw several groups of baboons. They seemed to be drawn to the road and one member of the group, probably the alpha male, always lingered in the road the longest and casually made way as we passed by. They are apparently only dangerous if you have food that they want. Otherwise they don't bother people.
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| These were baboons we saw on the road on the way in to camp. |
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| One of several baboons that greeted us on the drive in to camp. |
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| Murchison Falls. Here the Nile River flows through a narrow section of rocks. Two days later we took a boat tour upstream and saw the falls from the bottom. |
Our next encounter with wildlife was with the camp warthogs. They didn't seem to mind all of the people walking near them.
When we arrived to camp, the guides gave us an overview of the facilities and some safety issues regarding the wildlife. They said that the warthogs don't bother anyone and aren't a danger unless provoked. More worrisome are hippos. They said that 'if' a hippo comes into camp, it will come at night and will only get angry if someone shines a light in its eyes or otherwise provokes it. And to keep hippos or other animals from coming near the tents, the staff would light kerosene lamps in front of each tent that would last until daylight.
The first night, I had gone to my tent after having seen the enormous hippo for the first time. I fell asleep at around 8:30 and at about 9:30 I woke up to what sounded like large stamping feet a little distance from my tent. I listened, trying to figure out what the sound was and if it meant the hippo was angry and about to charge my tent. The sound got closer and closer, and I started ruminating over whether I needed to scream, turn on a light to scare the hippo or to be prepared to roll in between the two wooden bed frames in my tent and get into the fetal position. The sound kept getting closer and closer and I peered over the canvas to look through the netting and saw the hippo right outside my tent. It slowly moved forward and made several chomping sounds with each step, at which point I realized that the sound was actually the hippo pulling out chunks of grass as it fed. I lied there in bed as motionless as possible as it seemed to circle my tent and then slowly get further away. After about 10-15 minutes of feeding, all of a sudden the hippo decided it was time to leave because I heard it gallop off at what sounded like a fairly rapid clip.
I'll just let the pictures tell the rest of the story.
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| A water buffalo. These are actually some of the most dangerous animals in the area. The older males eventually get pushed out from the rest of the group and live out the rest of their life alone. They are sadly referred to as 'losers'. |
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| Jackson's Hartebeests (Jacksons) have really long narrow heads and gold-colored eyes. |
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| Elephants |
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| Elephant eating |
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| Elephant along the Nile |
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| We saw these types of dwellings frequently on the drive to and from Kampala. |
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| Giraffes |
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| I'm not sure what kind of bird this is but I'll take credit for the timing on this shot. One out of a thousand probably isn't a rate to go gloating about but I'll take it. |
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| These baboons were at the entrance to the camp area. |
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| This hippo let us know we were getting too close by charging out of the water. Imagine that thing outside of your tent sounding like it's trying to chew its way into your tent to eat you. |
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| Even with that generous belly and those stubby legs hippos can run up to 40 km/hr. |
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| On the boat tour of the Nile there were hippos everywhere. During the day they hang out in the water and at night they go feed on land. |
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| A dead hippo with a crocodile peering its head out of the water on the left. |
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| Murchison Falls from below |
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| Sunrise from camp |
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| This was by far the most dangerous stretch of road on the way back to Kampala. The road didn't have two full lanes and trucks that seem much larger than the ones in the US forced the driver to constantly gauge whether to slow down or stop before the next hole on the side of the road or go into the dirt or to accelerate. |
Life in Kampala
The most salient feature of Kampala is that it is crowded. There are people everywhere. And the same could be true of big cities anywhere in the world, but maybe I'm just struck by the extremely crowded feel of this place because there really is much less order to the movement of people here. Pedestrians walk on sidewalks that are dirt and are used like a passing lane for the boda bodas (motorcycle taxis). The cars and motorcycle traffic can be awful and crossing the street as a pedestrian is like a game of Frogger, which means you have to get your timing a speed right every time. Though many of my fellow visitors here have progressed to walking casually through an intersection, I'm still at the stage of running across and I'm not sure I'm going to change my strategy anytime soon.
A Swedish medical student mentioned today that he hasn't gotten used to how the cars here change lanes. I mentioned that maybe there are no lanes, kind of like the spoon-bending kid in Matrix who said that the trick is to realize that there is no spoon.
Compared to Kampala, the streets of Boston seem like a perfect grid. There are major arteries of paved roads, some with names and some without, and I have yet to see a street sign. Most of the roads are red dirt paths through shanties or slums and on the one street map I saw, they form a maze of paths without any names.
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| Storefronts like these line every paved street in Kampala. The motorcycles out front are the boda bodas (motorcycle taxis). |
Another striking aspect of Kampala, related to the crowdedness, is the commerce here. After being here for a few days, it really hit me that the shops and markets that line every single street here are indeed the shops where people purchase their essential goods. I thought that maybe like in other places I've been these were the stores where tourists bought their souvenirs and trinkets. But there really aren't many tourists here that I can tell. These stores seem to be by far the largest form of trade of everyday goods. Shanties made of sheet metal and wood boards might have a sign out front that says they are an official dealer for one of the major cell phone providers here.
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| Another "typical" street in Kampala. |
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| More stores in Kampala. |
The other thing that's striking about Kampala is the pollution. The first day I was here I asked another student here if there was a fire somewhere because there was a haze over part of the city. After a few days, I realized that the haze over the city is just the normal smog, no doubt a consequence of the cars and motorcycles and trucks that pump out black exhaust. Which probably explains the color of my mucus when I blow my nose here.
I also get the impression that food here in the city doesn't seem to be lacking in any great degree. I'm only basing that on what appears to be abundant food on the city streets and that most people here appear to be well nourished. Chicken is huge here and there are street vendors that have no shortage of chicken grilled and ready to sell.
I have to say that I have not felt unsafe at any point since I've been here. People tend to be quite respectful in general. With few exceptions, anyone who has tried to get my business, has accepted my apologetic decline without further questions.
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| One of the side streets in Kampala. |
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| Same side street as above. |
Mulago Hospital: Thoughts after 2 days
I've only been working in the hospital for two days now, in the pulmonary department, because I took the opportunity to go to Murchison Falls National Park from Thursday to Saturday with a group of fellow American medical trainees. I'll try to post some pictures of Murchison Falls in the next post. Uploading pictures to Blogger is a little slow here so the posts might be a little light on images but I know I can't use that as an excuse for not writing about the trip so here's an update.
On my first Monday, Stella, a second year medical student at Mulago Hospital took me around Mulago Hospital and the neighborhoods surrounding Makarere University and Mulago. Here are some pictures of some of the halls in the hospital. I was actually trying to capture the view of the city, which clearly didn't quite happen, but you can see that the halls are open air.
It's actually kind of nice to get to walk around in the open air when you're moving from place to place. I'll get some pictures of the the front of the hospital later, but I'll describe the wards to give you a sense of what it's like to be a patient here.
The patients are all in their own beds that, estimating from the paucity of paint and abundant rust, are probably decades old and are paired with matching mattresses. These beds are arranged one next to the other, with just enough space for a family member or 'attendant' to place a mat and belongings on the floor. Patients with HIV and low CD4 counts (one patient I saw had 6, normal is 500-1000 cells/ul) are right next to patients with tuberculosis.
Some of the beds are capable of raising the patient's head with the turn of a crank. One patient last week was having trouble breathing when lying flat (orthopnea) so we moved her to one where we could keep her head raised. You might assume that there's someone with the specialized task of moving the patient from one bed to another. Actually it was her husband, dressed in a worn suit jacket, and me who pulled the sheets (sheets that patients provide) off her bed and moved them over to the other bed. Most patients have one to one personalized attention from at least one family member or friend. These are referred to as 'attendants'. The attendants don't just provide emotional support, encouragement and someone with whom to spend the time. They actually play an essential role by being the ones who physically push the patient's bed to get the required studies. If an X-ray is ordered, the husband, wife or friend pushes the bed out of the ward and to the appropriate destination and then brings them back, with an envelope containing the requested study. Which in the case of an X-ray is often extremely underpenetrated, but I suppose adequate enough to tell if there an obvious pneumonia or effusion or cavitation. Or at least adequate enough to forgo the ordeal of getting another X-ray that will take a few hours and be equally underpenetrated. The attendants also go to the pharmacy themselves to purchase the prescribed medications. And they bring them food, which actually might be the envy of our system because some of the food smells delicious.
It's actually moving to see how people spend their time caring for their loved one in the hospital. When I helped the patient's husband move the bed sheets and belongings to a new bed as the patient stood by, disabled by her lung disease and severe osteoarthritis of the hips and without a place to sit, it seemed to me that the man, dressed in a worn (to put it mildly) suit jacket, attended to his wife's needs with only worry on his face when others might reasonably feel some burden.
As for medical 'records', the patients are the sole possessors of all of their medical records. Any past medical records are brought by the patient or their family or they're just not available. And all of the medical records, past or current, including imaging studies, are 'stored' on the patients' beds.
All of this is happening is a room where the walls are made from 'bricks' that form a repeating pattern of shapes where those shapes provide clear views of the outside. This keeps the ward fully exposed to any breeze from outside, which is actually the cheap version of a negative flow room because it keeps the air fresh and flushes out germs (like tuberculosis) that would otherwise spread better in an enclosed area with poor circulation.
One thing you might have read about in the news is the Marburg virus outbreak here. I knew that there were some cases in the west of the country, but I found out that there are 2 cases here at Mulago, which is a, or the, major referral hospital in Uganda. I found out when I noticed for the first time a box of latex glove on one patient's bed. I thought maybe this patient had something particularly contagious or the patient brought the gloves with them. I asked the the senior house officer (or 'SHO', who are the people who really run the service, with minimal oversight from the attending physician or 'consultant', which is a more apt term because they really don't play as much of a role as attendings in the US) if this patient had something contagious and he responded, "We have a visitor to Mulago. A visitor named Marburg (Mahbeg as it's pronounced here). Have you heard of him?"
Just so no one is too freaked out, I've been wearing an N95 mask everywhere on the wards and I bought a box of gloves and I have hand-sanitizer I use everywhere. And more importantly, the suspected cases of Marburg are sent to an isolation area and from what I've read in the news the CDC and other agencies are coming and they are going to start using a new test that can rule out Marburg in 3 days instead of a week or so.
So that's the update so far. This week I'm going to try to work in the pediatric infectious disease department. I haven't seen any cases of malaria, which is one of the main reasons I made this trip, and the pediatric ID department is the place that likely has the highest amount of malaria.
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