More from the crazy mzungu…

Beautiful Uganda


I had written another dispatch previously but I decided that it was too negative and so filed it away in my journal. I just started venting and decided that it wasn’t appropriate to send that all out. This has been a frustrating week though – probably one of the most frustrating of my life! I have switched over to ward 4A, which houses all the Gastroenterology as well as infectious diseases patients. Unlike all the other specialties, ID is split into two teams – male and female. For some reason, the female side tends to run at about 30-35 patients and the male side more like 20.

I guess I am enjoying ID as I am seeing plenty of pathology – most of it related to end-stage HIV. The stuff I saw on the HIV ward in St. Paul’s in Vancouver was nothing compared to this. It’s heart wrenching, I’m not used to losing so many patients. And I feel like what I can do to prevent it is very limited. I know what to do and I know what would make a difference - at least in some cases - but getting it done is another story. Inadequate numbers of nurses, inadequate nursing care, inconsistent (or nonexistent) access to medications or even basics like IV fluids, very little access to diagnostic services and my struggles with procedures all combine to make things difficult.

The worst was the LPs this week – I was so frustrated with myself. I basically HAVE to get the LP because it’s the only diagnostic test that’s possible or with in the means of the patients (i.e. it’s free) and when the interns can’t get it – I get called. Well, trying to do them on a concave bed with a confused patient, one set of sterile gloves, no drapes (I use the inner glove cover paper as a sterile sheet), sketchy chlorahexidine scrub solution on (maybe) sterile cotton and an IV catheter as my needle (the 18 gauge is just barely long enough in the slender Ugandans) is quite difficult. On top of that, the wind then comes in and starts blowing everything around (ie patient’s clothing/sheets, cotton, sterile piece of paper etc. Great. ….I made one girl move onto this flat gurney because her bed was positively a valley in permanent reverse trendelenberg and prayed really hard – miracle occurred, prayer answered – got the tap.

Actually I’m not sure what this experience would be like without the HIV. It’s so pervasive. They say the statistics are that the prevalence is 10% in Ugandans but it’s probably about 75% in the patients admitted to Mulago. I’d read about the effect of HIV in Sub-saharan Africa but you really don’t understand until you’re here and you see the absolute devastation this virus has caused. And it’s usually in people who don’t really have huge risk factors like we would twig onto in Canada, frightening.

I should say that there are positive things too. For the most part people are very kind too me and I have made more friends amongst the residents – it’s hard because their agenda is very much educational based (they don’t get paid to be on service) but I feel I can’t just leave the poor intern to run the ward herself so I spend much more time on the wards than the rest of the residents. Also, patients are always so grateful – even though I feel like I’ve done nothing for them.

Uganda is a beautiful place. It has rained a lot this week so it’s very green and humid. It rains very hard at night and I often will wake up and listen to it drumming down on the metal roof. The birds are nice too – although there is one black, iridescent species with a long curved beak that makes a terrible noise: a kind of cross between a frightened cat and an angry crow. And then there is the Maribou, a large stork. They are very ugly, large birds that all congregate in tall trees. If you’ve ever seen Walt Disney’s Jungle Book it totally reminds me of those vultures that sit in the dead tree and ask each other “So, what do you want to do?” “I don’t know, what do you want to do?” (Alita – I will try and send pictures so you can look them up in your book).

(This next paragraph is church/Mormon related so those of you not interested could skip it) It was a hard week for the church here too. As some of you may know, President Duke, the mission president for the Uganda mission was killed in a car accident on the Entebbe road early Thursday morning. His wife was injured but is recovering well, at least physically. I forgot to ask about the driver, but should have. They had a memorial service for President Duke so that all the members here could attend and it’s been very hard on all of them. So many of them are new and felt very bereft at his death. One of the other couples that are here (there are several couple missionaries) has been asked to step in for the interim until they call a new president. The missionaries are in shock but coping OK as well.

I have been working pretty much everyday but everyone keeps telling me that I need to see some of Uganda besides the 5 square kilometers that I pretty much have seen. I have been taking walks in an attempt to get more exercise and it’s pretty good as Kampala is basically built on a bunch of hills. The Ugandans think I’m crazy, why walk when you have money to ride somewhere? Whenever I go out walking I’m sure to get honked at every 30 metres or so by either a taxi driver or a boda boda driver (motorcycle for hire) checking to see if I want a ride. I guess most Mzungu (foreigners) are into conspicuous consumption here (at least it seems like it as they have the most gorgeous houses, SUVs and gardens ever) so it’s hard for others to see a Mzungu who’s on a bit of a budget. I don’t think it’s necessary to take a special hire (taxi) everywhere – especially when I want some exercise. Don’t worry though, I don’t go walking around after dusk.

Yikes, this is ridiculously long already so will sign off. Thanks for your letters and support! More next week.

Uganda Report 2: Ah….the starch

(Here's the second posting - I think from about May 4th.)

I may be belated in doing this but I should clarify for some people what exactly I’m doing. Some of you didn’t really know that I was even coming to Uganda. (Sorry, sometimes I’m not the greatest at keeping in touch with people…). I’m here for two months on what’s basically an exchange program between the division of internal medicine at my university (University of Alberta) and the university here (Makkerere University). I’m working as a senior resident here at Mulago Hospital, which is the referral centre for Uganda and some of the surrounding area. Having lived in developing countries before some things are not as shocking as they might be for someone experiencing all this for the first time but some things are eye opening, that’s for sure.

In keeping with family tradition, when living abroad I must make at least some detailed comment early on about the food. (Sorry – inside joke for immediate family members, if you’re not interested in food you can skip this paragraph). That is why the title of the email. I was never a fan of the low carb craze but after this trip I may decide to take it up as I feel like I have seriously overdosed on the starchy foods already. Let me explain what a daily diet is – at least for me. In the mornings, I eat a banana (if I’m lucky), which is great, some toast (on white bread – yep, jo eating white bread as that’s what there is) and sometimes an egg – although as mom could witness, I’ve never really loved eggs. At lunch time I usually eat at the “Doctor’s Canteen”, which is on the top floor of the hospital and as far as I can tell has the best food of all the places at the hospital – as is evidenced by the fact that a lot of the staff eat there and not just the doctors. This is good traditional Ugandan fare (i.e. starch-o-rama) you get “the mix” or selections from “the mix” plus “sauce”. The mix is a big huge plate of: white rice, posho (ground white corn flour made into a loaf-like texture), matooke (plantains boiled and mashed), sweet potato (more like our regular potato) and yams (purple and very starchy, not like North American yams). The “sauce” is brought in it’s own little bowl and can be beans (which I like and always get if available), groundnuts or g’nuts (actually peanuts ground up into a sauce – quite tasty), fish (always fried tilapia from Lake Victoria, with a tomato/oil sauce), or some kind of meat (chicken, beef or goat boiled in a tomato/oil sauce). The alternative is to get chips (i.e. French fries for you Americans) plus “sauce” or sausages. For supper I either eat out (vegetables preferably) or eat some fruit and crackers, as I’m not usually that hungry after such a big lunch. I haven’t solved the dairy deficiency problem yet but am working on it. I have made friends with the couple staying in the little apartment next to my room and they have a fridge that they say I can use.


Fruit Market


Lake Victoria







Whew, long section – as per usual, I got a little carried away when talking about food, my apologies. I am now well settled in at the guesthouse and am enjoying it. Kampala is a beautiful city (when you live up on one of the hills) and I have enjoyed walking around and exploring a bit. I haven’t been very far really as it isn’t wise to be out after dark but hope to do a little more exploring this weekend with some new friends. Two of the girls who work at the guesthouse and I are going shopping tomorrow. We’ll see how it goes.

I went to church last Sunday and enjoyed it. It was in English so that was really great. They were very kind and I made some friends who were so kind as to invite me over for dinner on Sunday afternoon. They live just on the other side of Mulago hill (Kampala is divided into neighborhoods that are roughly based on the hills). I also met a girl who is an intern at the hospital and lives just next door to me. I also met all the missionaries (who were the only other foreigners at church besides me) and actually took the two elders who work in this area out for dinner once this week. One is from Botswana and the other is a farm boy from, you guessed it, Idaho.

I haven’t mentioned much about the medicine this week. A few people said that my last posting was too medical. It’s kind of hard since that’s really what I’m here to do (and it’s taking a whole lot of my time!) but I’ll try not to make things too unintelligible for the civilians. I’m kind of a little frustrated actually. I feel like I’m not really contributing much. I’m not sure if it’s because I really don’t know very much or that I still sometimes can’t figure out what exactly is supposed to be happening and the language and culture are huge barriers. Maybe it’s a combination of everything.

Part of the problem is that cardiology was never one of my strengths – I’ve probably learned more in the past 2 weeks than I ever did in my 2 months of cardiology rotations at home. I realized how well I know my acute coronary syndrome stuff and what to do (I didn’t realize that I actually knew it so well) BUT how poorly I know the rest of cardiology. Who knew that dilated cardiomyopathy secondary to blown out hypertensive heart was so common? I am seeing a lot of rheumatic heart disease (with lovely mitral stenosis and regurg murmurs) as expected but there’s lots of other stuff. I’ve really had to study pulmonary hypertension and other valvular heart disease. I am looking forward to starting infectious diseases on Monday – although my knowledge will probably be sadly lacking there as well.

Another part of the problem is that the approach to things is quite a bit different here. They are interested in slightly different things and don’t get worried about the same things. Maybe it’s because they can’t do much about them so there’s no point. For instance, there was a gentleman today who’s oxygen sats were 75% (99-100% is normal expected) yesterday and it had been suggested that he move to where the oxygen tank is (there’s only one so all the people who need it have to be clustered around it) but it wasn’t done. Today his oxygen sats were 66% and he was very cyanotic looking and the comment kind of was: “well, when we finish rounds we’ll get the sisters (nurses) to move him to the oxygen.” It’s hard, because at home we’d have called the ICU long ago. I don’t know, the problem is that he’ll probably only get a maximum of 3L of oxygen /minute anyhow so I’m not sure how much the oxygen will help anyway.


Oxygen Tank

I also didn’t realize that all that “patient-centered” stuff in med school sunk in as well. I realized at home that I spend an awful lot of time explaining things to patients and their families. Here I can’t because I don’t speak the language (they laugh when I try to say things in Luganda). I don’t think it’s really done here either, mostly we just write in the chart and on the treatment order sheet and move on – except for telling the patient that they need to take more of that or this pill (Captopril, Furosemide, Propranolol, ASA, Spironolactone, Warfarin and Digoxin are pretty much the only drugs I’ve ordered this whole time). I think it’s a cultural thing – I’m still getting used to it.

I do enjoy the on-call nights (ha ha), mostly because I feel like I’m actually doing something. I don’t pick up on everything (apparently, despite much reading I know nothing about Sickle Cell anemia). I do know some things though and with help can manoeuvre through the intricacies of the system. It’s hard though. They expect me to be an expert on things like stroke and I have to really think. They ask, so, what would you do now and I think to myself: “ummm, page the Stroke Fellow…”. For instance, do I or do I not try to lower a blood pressure of 210/110 when I don’t know if it’s hemorrhagic or ischemic (no CT scan).

Anyway, this is ridiculously long and probably getting boring so I’ll stop. I wanted to talk about the animals - Maribou storks and the monkeys that live next door just for you Alita but I will save that for next time and maybe will be able to send pictures as well. Talk to you later.


Monkey!!


Maribou stork (eating garbage)

Uganda Report number one

As promised, here is the first installment of "The Uganda Report", I think I will try to stick in a picture here and there as well to illustrate it. I apologize to those of you who were not on my email list (part of the problem is that I'm not the greatest at keeping up with people and so didn't have some emails ready at hand....) Anyway, this was originally sent out on April 27, 2007.

Greetings all, I just thought I’d drop you a line to let you know how things are going here in Kampala, Uganda. I arrived 5 days ago and thus far am really enjoying myself and learning a lot at Mulago Hospital. I don’t feel like I’m contributing much yet so I hope that will come.

Getting here was a long flight but everything went so smoothly, it was a miracle – no lost luggage, no late flights, no visa troubles, nice shuttle bus drivers etc etc. BUT, of course, life is an adventure and I did have some troubles with accommodations when I first got here. There was some mix up at the Mulago Guest House where I was supposed to be staying. The hostess, Sara, had me down as coming this next weekend and not last Sunday so there was no room for me until this next Saturday. When I think about it, I’m not surprised, as every time I talked to her before coming the phone connection was absolutely terrible. All is well however. Sara is a very kind lady and she helped me find a hotel close by to the hospital (about a 10 – 12 minute walk) where I am staying this week until I can move into the guesthouse tomorrow. It’s been just fine, however there are two pubs/bars very near to right under my window and given that there is some East Africa International Football (Soccer) tournament going on this week – and Uganda has been doing quite well – things have been a little loud. Fortunately, I brought earplugs and now that the jet lag is subsiding I am sleeping quite well.



View from my window, overlooking the bars


My little room - pretty nice!!

Africa is as lovely as I remember from Madagascar. I sort of worried that I was remembering things with rose-tinted glasses but things are good. In fact, Uganda is much more prosperous with less overt poverty than Madagascar had – at least several years ago. Granted, I really was right in the middle of real life in Madagascar and haven’t been much around Kampala yet. I’m sure there are areas that can compare with the slums of Antananarivo. I had forgotten though, what it’s like to be completely visibly different from everyone else. I’d forgotten what it was like having all the kids yell “Vasa” (Madagascar) or “Mzungu” (Uganda) as I walk down the street. (i.e. “white person” or “foreigner”) and not understanding the intricacies of language – verbal and non-verbal.


Beautiful Africa

I think I may be a bit odd, even for a “mzungu” though, as it doesn’t seem like very many other foreigners walk as much as I do. I never see any other foreigners walking anywhere – although, come to think of it, this being Africa, you really have to watch where you’re walking, especially in the rainy season as the potholes, puddles, mud and rough patches can jump out and grab you. So maybe, I’m watching where I’m walking and not everyone else. Another thing – pedestrians DO NOT have right of way. This is fairly obvious on crossing main roads but sometimes I forget when crossing driveways (or when I cross a patch of sidewalk some one has decided looks like a promising spot to park a taxi or a boda-boda). I nearly got run over by a very large SUV and boda-boda at the same time because I looked the wrong way (they drive on the left side of the street). For those of you who haven’t been to Uganda, boda-bodas are motorcycles, you can hire one of the drivers to ride you around (if you have a death wish) and they are EVERYWHERE. They swoop in and out of traffic and as far as I can tell, are the leading cause of non-infectious disease related morbidity and mortality in East Africa (I have no evidence to back that up however, just observational data)

Mulago hospital is a neat place. It’s a sad place though, because the people who work there are great and the building itself looks like it was stunning at one point (and the grounds still are beautiful) but there are very few resources. People in Canada should stop complaining about the gurneys in Emerg (almost all my patients in Canada do that – except the unconscious ones), as the vast majority of the so-called beds at Mulago are not as nice as those gurneys. Every time we want to order a test or give a drug we have to consider very carefully cost and availability. An example for you medical types: I’d never really used captopril before I came here (most of the teaching I got in Canada was: why go with a multiple dose drug when you can take a once a day one) but the cost of the other ACE inhibitors is prohibitive.


Mulago Hospital


gurneys on one shocking day when this ward was empty

I should explain why I’m talking about ACE inhibitors. It turns out that there was some sort of problem on the ID ward (too many learners (elective students from Germany) / grumpy staff etc etc – I’m not clear and I didn’t press the issue) so they wanted me to go on to the Cardiology service for my first two weeks and then go onto the ID ward after that. Please note, there is NO general medicine ward – only specialty wards and they all share things – it actually seems like a pretty good system overall. (I won’t pontificate here about it but could go on for a long time about pros and cons of our system compared to theirs.) It does mean that the ID service gets a little overworked as they take at least 25-30% of the admissions but given that this is a relatively new system for them they are still working out the kinks.


A cool echocardiogram - any guesses?

Anyway, I am on the Cardiology ward (or firm as they call it here) and am really enjoying it. Shocking – I can’t believe I wrote that given my feelings about cardiology at home. (Sorry Jon). The range of admissions is very broad and very interesting AND the teaching has been phenomenal. As I said, I don’t feel like I’m contributing much yet so I hope that will improve. In fact, most of this week has been spent with me running around asking everyone questions (probably stupid ones) about where I should be, when I should be there and what I should be doing while I’m there.

Apologies

Greetings all,

I apologize to those of you who have been looking at this site in the hopes that I would post something. OOOPs. I actually have been sending out email updates to various people but couldn't ever get the photo side of things to work. For my last blog it took around 25 minutes to upload those four pictures so I decided it wasn't going to work, given that I have tons and tons of pictures to post. I think what I will do as soon as I get home is to post copies of those email updates EXCEPT with illustrations/photos. So check back here in July.

Jo

I tried to send you an email yesterday but it didn't work. I think pictures are just a little too much data for the strained connections over here to transfer so we'll try this. I have sort of figured out spots where I can get free wireless internet access (is this honest??) on my little laptop (boy am I ever glad I brought this thing - I've used it tons already).
I was looking at all your blogs yesterday as I hadn't been able to before given the time limitations on me at the internet cafes and a few of the kids that live around the guesthouse where I'm staying got very intrigued. They were totally in awe of the pictures of Enoch wearing so many clothes to go outside. They never have to do that here. I took a picture of them to send to "all the children in Canada and the US" and I told them I'd tell them what you all thought. So we'll see if this works. The three boys are named Titus (tall one in the middle), Edd (one on the right) and Calvin (cute little guy in the crazy sunglasses on the left).
They were actually out "hunting" the monkeys that live around the trees nearby. They have a dog named "Police" - who looks like your standard developing country mutt - but well taken care of. Police chases the monkeys around and around and barks like crazy but they just tease him mercilessly and never let him get too close. I'm not sure what the boys would do if they caught a monkey - they say that some people eat them (yuck!) but THEY don't. Anyway, I am also sending some pictures of the monkeys - one on top of the roof, right above my window!!

Love Jo

Hurray Hurray

This is just my introductory posting. I am hoping to use this when I'm in Uganda to report on things to various people so I thought I should check it out. My siblings all have their own blogs as well so I thought I'd jump on the bandwagon. We'll see - I'm not good at keeping up with things so we'll see how it goes.
Jo