Moving is tiresome

Moving is indeed tiresome! I'm currently trying to move everything in my little apartment, which doesn't seem so little at the moment, to the upper level of a house. My apartment is currently a complete disaster.



I'm moving in with a friend and she agrees that the new place is way nicer than where I am now. I, personally, will be very happy to not be living behind a pub anymore (the starving student lifestyle is getting a little less than endearing after 12 years of post-secondary education). It's just going to be very tricky as I am supposed to be in Montreal at a conference the same day that I'm supposed to be moving, hmmmm. Will keep you posted.

Still alive in the frozen north

Actually, it's not really that frozen - we're having a really nice fall. I just like to say that so that people feel sorry for me because I live in Edmonton. By the way, Edmonton is a perfectly nice city, I'm just getting a little sick of it after 7.2 years (and counting) and I always feel waaay out of the loop. Hmmm, part of that could be what I do for a living and the fact that I'm apparently compulsively unable to keep up-to-date with people other than those I see every day despite having several email addresses, a facebook account and a great long-distance plan. It's really quite atrocious. Anyway, for all of you (and especially John - so I won't be at the bottom of his "People who haven't blogged recently" list - he's still my most irritating little brother) this entry is an attempt to make up for the last 4 1/2 months that aren't recorded on my blog.

After a fabulous trip through East Africa and Zanzibar (see some pictures below)...

Everyone at a village in Uganda



The central bus station in Kampala, Uganda


At the Equator (Uganda)



Eating lunch in shadow of Mt. Kilimanjaro (you can sort of see it in the background)





Maasai women

Alita and I in a Maasai mud hut

Real life on the Serengeti

Can you see the leopard?





The endless herds of zebra and wildebeest

The Guineafowl that stole Cathy's lunch

Pumbaa!!






The end of the safari


Zanzibar!!




I started my Infectious Diseases training on July 1. (By the way, NEVER get sick the first week of July in North America - all the doctors are completely new and haven't the slightest idea what they're doing.) I finished my 3 years of general internal medicine and so I'm now sub-specializing in Infectious Diseases (what we like to affectionately call "ID"). I started in the microbiology lab and learned all about what happens to your pee after you put that little container in that little cupboard in the wall and what happens to that big Q-tip thing after the doctor sticks it down your throat etc etc. It was kind of fun.

August was spent on the "ID consult service" which means that anytime anyone has a question about an infectious disease in the hospital they call us for advice. It gets really busy (ie. I worked about 80 hour weeks that month). It's everything from someone who had surgery who now has a wound infection to malaria in someone who was travelling to someone with a new HIV diagnosis to someone on chemotherapy who has a weird fever and rash and all sorts of other things. It's really interesting but tires me out.

(I unfortunately have no pictures of these two months - except for a bunch of weird rashes/wounds that I took pictures of to teach my med students and I don't think I'll post that!!)

September I was on the Pediatric ID consult service. Very much the same as August, but with kids and somewhat less busy but no less stressful because although kids are much healthier than adults in general, a much greater proportion of their illness is due to infectious causes AND because it's really much harder to see sick kids.

The best part of that month though was my trip to Chicago. It was my birthday gift to myself because I really wanted to see my little nephew David (and Scott and Sue Ann of course hee hee). Dang is he ever cute. We toured around, shopped, saw some fish in the aquarium, ate good food and generally had a great time. I was only gone for 5 days but it was a nice break.








The end of September I rotated back into the microbiology lab but can't say much about that because highlights were instead a trip to San Diego for the IDSA conference (Infectious Diseases Society of America) where I presented a poster and went to some great talks AND got to visit Rachel and Scott McKeon and their kids Audrey and Jonny!! It was great to see them and I had a blast playing with the kids - they were nice enough to let me stay for Scott's birthday!



Later in the month I also got to go to another conference - Alberta Society of Infectious Diseases Conference (bit of a wind fall lately by way of conferences) in Banff at a very nice hotel. It was fun - we climbed up Sulphur Mountain with Esther and Abdu, two residents I worked with in Uganda, who are now here doing an exchange in Edmonton. It was pretty cold so we got to ride the gondola back down the mountain (it was free for those who climbed up - pretty good deal!!).





I'm now back on the adult ID consult service, this time at a different hospital - our "inner-city" hospital - at least as close as you get to inner-city in Edmonton (population ~1 million) and so am seeing lots of weird and wonderful stuff. I also got to go down to Calgary last weekend for my mom's birthday (I'm trying to help her with the cleaning incident to all the renovations my parents are doing) and luckily enough got to go to Ross Blaszczyk's mission farewell talk. That was really neat!

Whew!! That's really a long blog, if you lasted this long, you're amazing and you deserve to win a prize. I'll try and be better but my life is not as exciting as all my siblings/cousins lives seem to be (or at least I don't have any kids so I can't fill up my blog with cute pictures...maybe I should get a fish or something...)
Hmmm, have to think about that.

Clinics and cakes

Last report - sent June 10th, 2007

Greetings all! I hope this find you well and enjoying spring (…or summer for some of you further south). It still seems to be the rainy season here as we’ve had several heavy rains here this week. Everyone here thinks that the seasons are changing – the rains are more erratic than previously - and they blame it all on global warming. I understand that Calgary had a huge rainstorm last week and unfortunately they’re not as well equipped to deal with it. (In Kampala there are no basements to flood, the roads have specific run-off gutters and there aren’t nearly as many large auditorium-like buildings with roofs that can collapse) I hope that everyone is coping OK with things. Dang global warming.

This may be my last “Uganda report” as I start my last week of work tomorrow and it depends on how ambitious I feel when I start vacation the week after. Last week and this coming week I have been and will be doing some outpatient clinics at the IDI (Infectious Disease Institute) that is just across the way from Mulago Hospital. In a sense “IDI” is a bit of a misnomer because it’s pretty much all HIV – at least the clinical side is. (Although, really, the same could be said for the “ID” wards at Mulago, and for that matter, many of the other medical wards). I really wanted to get a sense of outpatient management of HIV because most of what I’ve been seeing has been what happens when HIV is NOT managed in outpatient. (For the non-medics: outpatient = basically, people not in the hospital – they can still be quite sick though).

There are numerous HIV and other clinics that I could have gone to but I chose the IDI for a few reasons, not the least of which is the proximity to Mulago so I can go back and forth. Several people I have come to know also work there as well and finally, I am still trying to figure out just exactly what I want to do/be when I grow up (I know, it’s pathetic at my age…) and the IDI is sort of one model of a very long term collaboration/organization between resource wealthy (mostly U.S.) countries and a resource poor country that I was looking at to evaluate the setting I want to work in. I’m still not sure exactly what I want to do but I am enjoying my time in clinic. It is more of a primary care type clinic. The care is free there and therefore the patients very seldom would see any other doctor. There are lots and lots of patients (called “friends” at the IDI) to see, although not as many as at the free Mulago clinics where the stack of charts seem endless, and one has to be very efficient.


The IDI


Dr. Kalule and I at the IDI
Overall I have really enjoyed my time here in Kampala and I can’t believe it’s almost over! Time flies when you’re learning lots and having fun. Yesterday afternoon I went with some of my friends to an “Introduction”. It is the first stage of the traditional Ugandan wedding ceremony. It was quite fascinating although given that it was all in the tribal language (which happened to not be Luganda) I really didn’t understand much. They tried to translate for me but it’s hard and given I was the only foreigner there I already stuck out so tried to create as little ruckus as possible.

My friends (5 sisters) are close friends with the bride and her sister and one of the 5 was a bridesmaid so they wanted me to come. The day was very long and I was quite tired by the end of it. I had gone into the hospital in the morning for awhile and then went over to my friends’ house at around 1pm. I’m not sure why 1pm since we didn’t end up leaving until just after 3pm so that gave them plenty of time to dress me up in traditional clothing for the wedding. I seem to attract this wherever I go – I’m not sure why as I generally look kind of funny (hmmm, maybe that’s the reason): this tall awkward white girl (made taller by the heels that I’m inevitably given to wear) with traditional clothes that don’t quite fit properly and that I’m always tripping on and adjusting because traditional clothes in the places I’ve traveled tend to involve long flowing/draping styles. Ah well, at least it provides entertainment. Maybe I’ll show you the pictures at home.


Traditional clothes

We arrived at the venue by around 3:30 pm and it was good that we hadn’t gone sooner as nothing started until around 4:30. It was at the bride’s family home and they (excluding the bride and her attendants) all sat on one side of the yard waiting until the groom and his entourage (mostly family members and close friends – all male) arrived seeking entrance. Female family members of the bride and her brothers meet them at the gate and the groom’s side have to “negotiate” to come in. Once they do they sit down on the opposite side of the yard and the ceremony begins. They are served some sort of traditional drink – no one could really explain what it is (some sort of fermented sorghum drink?) and a whole bunch of speeches welcoming and receiving welcome occur. One uncle of the bride and one uncle of the groom do most of the talking (the bride and groom and their immediate family say very little the whole day) and those who are funny and good at speeches seem to be preferred. (Hmm, I’m not sure who I would choose of my uncles – it has to be one of your father’s brothers so couldn’t be Uncle DeLoss – he’d be good but then, so would all Dad’s brothers too, I think they’d get into it).

Once it’s been established that the groom’s family came seeking a wife for one of their members (more speeches), girls start coming out. First they send out a bunch of young girl cousins between 10 and 14 years and the groom’s uncle makes a big deal of the fact that these are too young. Then some of the bridesmaids are brought out and the uncle make another big deal comparing them to a picture he has of the girl and deeming them not right. Finally another group of bridesmaids come out this time with the bride and her aunt (mother’s sister) and the groom’s uncle proclaims that he’s finally found her. At that point they have to “find” the groom so the aunt and the sister (sort of like the maid of honor) go over to the groom’s side and “identify” the groom. He then comes and they are “introduced” and he gives her a small gift (necklace in this case). I guess traditionally these would have been arranged marriages made by your aunts and uncles and you wouldn’t meet until the actual day, hence “introduction”.

The next part was…interesting: the negotiation of the bride price. They finally settled on 6 cows, which is apparently quite a lot. It kind of gets my feminist ire up a little bit (I was never a great fan of “Johnny Lingo” like many were – sorry, inside joke for those of you who didn’t understand that). One of my friends was sitting beside me and explained that it is still traditional, especially amongst this tribe, although many feel it’s quite archaic and should be done away with. (Mormon comment here sorry) She told me they’ve been very strongly counseled by Pres. Hinckley and other leaders to celebrate as much of their culture as possible that is positive but to not participate in things that denigrate people and the bride price is a commonly cited example. It equates woman to property and encourages a negative unequal marriage partnership.
Anyway, after that, more celebratory speeches and a tradition that I think we should emulate. A cake was brought in to celebrate (not a true wedding cake as I guess that’s for the next ceremony) and the bride and groom cut it along with the aunts and uncles. Then the bride, groom, bridesmaids and groomsmen handed out cake to everyone. Great tradition I thought! Not only do they get to move around and quickly greet people that they might not otherwise, they also get rid of the wedding cake. Not that they would have had troubles getting rid of it – it was very good chocolate cake! It just seems like most North American weddings have massive amounts of excess cake left over which wouldn’t happen if you actually brought it around to people.

There were more speeches of celebration at this point and then introduction of the family members (although only the males on the groom’s side as the females don’t participate in this part I guess). I didn’t really understand much of this and I was getting quite tired by this time. It was about 8pm by the time they finished all the speeches. Then we got to eat (Hurray!!) traditional food, which I have come to really like. The “give away” is the next ceremony, in a couple of months I guess, which is the actual traditional wedding and nowadays is usually accompanied by a church wedding the same weekend.

I had brought my camera and had taken a few subtle pictures prior to this but then took a whole bunch of all the bridesmaids and my friends, which they were very excited about – very few people have cameras here. In fact, I burned them a CD of all of the pictures and gave it to them today because they were so keen on having them. We came home late and I was very tired but it was a really great day.






Once again I’ve blathered on a long time so will sign off. I hope you are all doing well and I’m looking forward to seeing you soon.

Love Jo

Uganda Report 5: Gorillas in the Mist

Next update: originally sent out May 31

I apologize for sort of being missing in action the last few days. I actually took a spur of the moment trip to Rwanda to go gorilla trekking and also have had some internet connection troubles. It seems to go down with unpredictable but frequent regularity. I wonder if it’s like the electricity problem where I think that too many people are trying to use it. I’m not very technologically savvy and don’t really understand internet access all that well. I’m just happy when I can get on. (It’s frightening how accustomed and even dependant I’ve become to my luxurious cable-line access at home).
Things are going along as usual on the ID female floor. I am trying to learn as much as I can and to help as much as I can without getting too upset about the inadequacy of the care we are able to give most of the patients. I think one of the reasons a lot of the staff people are just not around on the ward is that they realize this as well and probably get burnt out dealing with it so just don’t. Somehow ID female has also been saddled with the next rounds (next Tuesday), which happen to be the last rounds of the semester as exams start the next week. No one wants to have anything to do with them of course because of all their exams and trying to finish up work. We also can’t find a good case on a topic that someone hasn’t recently just done a presentation on. I think we are going to actually revamp my old Primary CNS Lymphoma talk as an “Approach to CNS lesions in HIV” as 75% of the work is already done. I hope it turns out OK as they tend to be a very hard crowd and like to nit-pick even more than some of the more famous nit-pickers in our program.

Speaking of nit picking, that reminds me of the gorillas last weekend and their grooming habits. I was feeling very burnt out and frustrated and after having worked everyday since I came here I was encouraged by numerous people (including many of you) to take a weekend off and do something. The opportunity came up to go gorilla trekking in Rwanda so I took it and loved it – despite the 10 hour bus ride each way (yuck – I won’t dwell on that much, only to say that loperamide is a good drug in a desperate situation), and the very random border crossing procedure which involves all passengers signing out of one country and trekking 500 metres through the mud to sign into the other country. I went with Victoria, a recently graduated medical student from the US. She is a very interesting girl.
Kigali (the capital of Rwanda) is absolutely beautiful (more beautiful than Kampala actually). All of Rwanda that I saw is really beautiful, it’s hard to believe that the genocide could have happened in such a beautiful place with such nice people. It’s such a small country that all of it has to be under cultivation so you see all these fields straight up all these very steep hills. I took a million pictures of it because I thought it was so nice.
We arrived in Kigali at about 1pm and were met by Isaac, the brother of a travel agent that we’d been in contact with. He was very nice and drove us around Kigali quite a bit. Nothing was open until 2pm as it was the last Saturday of the month (and that’s national clean up day in Rwanda so everything is closed while everyone cleans the country – great custom) so we ended up going to the nice mall and eating lunch in a coffee shop there. So, after lunch we went and picked up our gorilla tracking permits and then we went to the genocide memorial. It’s a lovely building and tells the story of how the genocide actually happened and some reasons why. It is very well done and completely heart wrenching. I was quite upset at some parts and I think Isaac felt bad for me. The only place I’ve been like that before is Yad Vashem in Jerusalem. There were two particularly bad parts, one was some commemorative biographies of children that were massacred in the conflict and the other one was in the clothing room. They’d saved some of the clothing that was found on some of the corpses and one was a little boy’s t-shirt that said “Ottawa, Canada” on it. It made me feel awful, we could send all our used clothes over to Africa but somehow none of us could do anything to stop the horror of the genocide from happening. Outside the building there is actually graves of victims and beautiful grounds. I guess whenever they find a mass grave (and there are lots) the bodies are coffined and brought there for formal burial services. It’s a peaceful place with lovely gardens.



Kigali, from grounds of genocide memorial


Anything after that is a bit anticlimactic but I must say the ride up to Ruhengeri (the town close to the Parc National des Volcans – where the gorillas are and where Dian Fossey did her work) was stunningly beautiful although a bit frightening because of the drop off. It was akin to the “Going to the Sun” highway between Waterton and Glacier National Parks but obviously more tropical. We got up early the next day in order to get to the local park office and there we were split up into groups of 8 (the maximum number of people they allow to visit each family group of gorillas). We had a bit of orientation with our guide, Placide, who told us about things and then we got to know each other a bit.

Road to Ruhengheri





We drove on abominably bad roads for a while out to a little village nearest to where our trek would start and then walked through fields for about 40 minutes to the edge of the park. Then it was pretty much straight uphill, although after about 10 minutes we had to stop, turn around and go back down and around to another point as the gorillas had moved. We went uphill then for another 30 minutes or so and then, all of a sudden, there they were, sitting contentedly and resting. It was an amazing experience! You understand while people get into studying fascinating animals in the field for years on end although at the same time you wonder how appropriate it is to sit there and stare at them – although they often stare right back, probably wondering why in the world there is an odd group of awkward, funny-looking animals that come to look back at them for awhile everyday.
The group we went to see has 9 members. The silverback was the first one I saw, just sitting and leaning over. I didn’t realize how big he was until he got up and started to move towards me – yikes. Then there were three females (although I think we only saw two), one blackback (a male, not yet mature), a juvenile female who sat grooming her mother the whole time, two young ones (a year or two) who were hilarious and very active – rolling around, climbing and falling out of trees, and rough-housing with one another. The last one was a very cute little baby that is apparently only 1 month old. She (they know it’s a female) sat in her mother’s arms the whole time, every so often peering out at us. I probably took about 100 pictures. You’re not allowed to use the flash so some of them didn’t work that well but I think I’ll save all of them to show to Alita – she’ll be really jealous as she really wants to see gorillas – maybe we’ll see some chimpanzees instead.





Gorillas


Mist

Anyway, it was a great experience but we eventually had to leave and walk back down the slippery, wet mountain (yep, everyone landed on their bum at least once) - it was fun. We then drove back to the main park centre – or I should say, we attempted to drive back to the main park centre but had a bit of trouble i.e. running out of gas. (I wonder if that terrible road we’d been on put a hole in the tank – I wouldn’t be surprised). All’s well that end’s well though and we made it. Two of our group members actually offered us a ride back to Kigali with them as they were going anyway and as we were nervous about the mini-van we’d been in (that had run out of gas) we paid off the driver and took them up on their offer.
Well, this posting has not been much about Mulago or the ID service but as it’s getting pretty long I’ll stop now and write more next week. I’m looking forward to seeing those who are coming in a couple of weeks!!

Uganda report 4: HIV is a bad disease!!

(Next update - originally posted May 22, 2007)

Yep, HIV is a really, really, really bad disease – most especially if you’re poor and you live in Africa (or probably anywhere in the world besides North America, Western Europe, Japan or Australia/New Zealand – i.e. anywhere there is high or soon-to-be high rates). Despite improvements in the educational aspects as well as treatment aspects there is still horrible outcomes here, everyday in fact. I’ve been on the ID female ward now for 2 weeks and I think we are unfortunately averaging about 2 deaths a day. The vast majority of them are patients with neurological complications of HIV. (Most often proven or presumptive cryptococcal meningitis, followed closely by proven or presumptive cerebral toxoplasmosis for you medical types). I think in saying that I’m a bit biased because most of them with respiratory complications (probably the next most common) go to either the pulmonary ward or the TB ward. I was concerned that it was me (as I’ve been the most senior person around the vast majority of the time) but when I expressed that concern all the rest of the house staff started laughing hysterically. I guess it’s always this bad.


What end stage HIV/TB looks like (permission granted to take picture)

Anyway, we do have successes, ones we do catch in time and ones that make a stunning recovery – it’s just hard to see the ones that don’t. TB is the other thing. Right at the moment several of our patients are on dual treatment for TB/HIV and we are not able to monitor them nearly as well as I’d like. For those of you non-medical types - TB is a bad disease but TB on underlying HIV is a terrible disease, it may present differently and be difficult to diagnose and it’s hard to treat. Maybe this isn’t quite so bad in Canada where we have access to much better diagnostic measures but it’s a problem here.

Actually I must say one of the most frustrating things here is the inadequacy of the ability to appropriately diagnose. I do think that my clinical diagnosis skills have improved greatly – not as good as some of the others here but much better – but still, you can only get so far with your ears, eyes, hands, stethoscope, reflex hammer and penlight (especially since my penlight has vanished). We end up treating empirically a lot of the time and that’s frustrating.

Case in point: 37 year old lady, known HIV positive comes in with right sided weakness and confusion. She’s not on anti-retrovirals (anti-HIV medications) and there’s some question about TMP-SMX prophylaxis. Probably cerebral toxoplasmosis but could be any number of things. The family cannot afford any investigations (they finally scraped enough together for a blood count, CT Scan? ha ha ha ha ha) and so we’ve been treating empirically with high dose TMP-SMX (forget Pyrimethamine etc – although, there is one study that shows high dose septra may be a good alternative…). I could and have been very, very tempted several times to pay for investigations myself. I haven’t yet because I don’t think it’s really fair. None of the people I’m treating have much money (that’s one reason they end up in Mulago Hospital) and to be fair I’d have to pay for all – how could I choose? We’ll see – I know that if it’s one of the young ones (the adult ward starts at age 13 here) I’ll probably not be able to resist the temptation to help out but thus far on our ward we haven’t had any of the really young ones that have been acutely unwell.
Hmmm, ethical dilemmas all the time.
OK, I know the last bit was super medicalized and I apologize to those of you who couldn’t follow it. On the lighter side of things – I have noticed that I am starting to talk Ugandan English. There are some definite differences and some figures of speech that are creeping in. One example: Somebody drops something, bangs their head, tells a story about not being able to sleep well the night before etc etc: Ugandan English: “Sorry!!” They say “Sorry” in a very sympathetic way when anything bad happens, all the way from a family member dying to me accidentally drawing on my lab coat. (Yes Martina, I will probably come home apologizing more than I already do hee hee).

Another example: Someone needs to use the washroom (toilet for you Americans): Ugandan English: “I am going for a short pass” or “I need to take a minute for a short pass.”

Another example: Someone is explaining something and trying to emphasize a point – Ugandan English: “He was very sick and we took him to the what?..To the hospital” or “She had meningitis and we gave her what?...the Ceftriaxone” or “She is losing her place to stay so she talked to who?...to the Branch President.” This one is my favourite and almost any conversation longer than about 30 seconds contains at least one example of this. I totally love it actually.

My Luganda (the most commonly spoken language in the Kampala District I think) is not coming along as well as I would like. Although today in fact there was a moment when we were asking about somebody’s pain (Kalooma) and I totally understood: it was very bad (nya nya nya) when she coughed (koloofa). I also can understand words like bowel motion (afluma) and breathing (sanyo) and ask about them. (NB I’m not sure of the spelling of these words). I also know the standard greetings and thanks etc but that’s about the extent of it. I’m not sure if my accent is terrible either because sometimes when I say what I think is the correct word they just look at me funny and my intern has to repeat it. Sigh, the one book I have does explain some things but it doesn’t really help in the medical setting (“that is the goat of my sister” and “please pass me the posho” aren’t terribly useful unfortunately.)

Uganda is a great place. Some of you have expressed concern that I am working too hard and I may be. I have worked every day since I’ve come and I’ve decided to try and take one short trip to at least see a little of the country. My social life has been extended slightly. There haven’t really been many people at the guesthouse at all so I’ve had to find people to do stuff from work. There was a visiting resident here from Yale University and his girlfriend was also here volunteering so I went with them to this orphanage one evening last week and played with the kids for a little while. We were supposed to be helping but I think we pretty much just got them all riled up. We had a fun time though!!


Fun at the orphanage


Some of the girls took me out last Friday night as well (other residents) and I have now confirmed my suspicions that most of the restaurants that the mzungu (foreigners) frequent are highly overpriced. We had a huge meal including soda for 3500 USh each and they thought that was a little on the pricey side. We had fun though and played snooker/billiards.


Billiards (bad picture of my friend though, she's much prettier in real life)


I also went to the Uganda Museum on Saturday after work. The people that were supposed to go with me bailed so I went by myself and spent about an hour and a half (and saw the museum extensively – it’s not an extensive museum). Highlights included the bark cloth exhibit and the traditional musical instruments with someone to play them for you. I actually bought a CD of traditional music for a souvenir because it seemed kind of more original than the other stuff (although I was slightly tempted by the T-Shirt that said: “Mzungu”).



Musical instruments in the museum





(Next paragraph is Mormon stuff) I really enjoy church here immensely, it’s a nice branch. I also went to institute class last week and enjoyed that. It turned out to be the last class of the semester but they will start up again in two weeks as well. I thought it would be fun and it’s nice to go mid-week sometimes to get a different perspective on life. Anyway, I’ve been so impressed with people here, they’re mostly very young – but very devoted. The District President has moved into the branch I go to so he spoke last Sunday. Fabulous talk about respect and reverence – I kind of wish my ward back home could have heard it. Great guy with a great little family.

Anyway, I need to go and this is getting very, very long – the longest yet! You all keep telling me it’s fine though…and I guess if you don’t want to read it you can delete. Keep well!

Love Jo