Well it is my last day in Kisoro. Tomorrow morning at 4:30 I will take as bus trip to Kampala and then on to Entebbe to fly back to the US. I am sad it is over so quickly. I would have liked to stay and worked longer and gotten to know the community better and toured around more. I will miss the sounds of sunrise, the relaxed pace of life where no one pays attention to time besides for us, the stars at night and the waxing and waning of the moon, the wind and dampness in the air before a big rain, and the friendly people who I have gotten to know. I don't mind so much the cold showers, the lack of variety of food, the sluggishness of the internet, or the children asking us for pens every second. I hope to return to this place or someplace similar to it in the future to practice medicine the old-fashioned way without millions of expensive tests to distance you from the patient and provide easy answers but to solve the mysteries of the human body by speaking with the patients and carefully examining them.
Rafi
Saturday, March 29, 2008
Wednesday, March 26, 2008
The wards
So over Easter weekend the wards were relatively quiet but then we got a backlash of many admissions as the new week was starting. We saw some interesting cases including a once in a lifetime tricuspid stenosis. We also diagnosed an 8 year old girl with endomyocardial fibrosis. Then there was the patient who arrived without a brachial pulse, no blood pressure, and a heart rate of 180. We gave her lots of fluids, started broad spectrum antibiotics, stress dose steroids, and put in a foley. Her EKG showed SVT which turned into sinus tach after a few liters were in. I thought we had saved her but she developed flaccid paralysis and died 3 days later. That was the second death on the female ward in 2 days. At the beginning of the month the male side had more sick patients. We still have our share though. But most of our post-Easter admissions were lacerations and traumas after drunken fights or accidents.
One patient we had was stabbed in the chest with a machete. Through physical exam we diagnosed a hemothorax and then confirmed it on chest xray. Luckily he was stable enough and it was not large enough to require a chest tube. I have had to improvise in a few situations. First a man came in who was punched in the face and his mouth was bleeding. They sutured his bottom lip but his mouth continued to bleed overnight. By the time I arrived the next morning his clothes were drenched in blood and he was still bleeding from the mouth. When I explored his mouth I noticed he was bleeding from a crack in his upper gum. I held pressure for 15 min and he held pressure for another 30 min but it still would not stop. So I went to the pharmacy and asked for some adrenaline. I diluted the adrenaline and injected it around his gum which turned white and stopped bleeding. We observed him for another day and he had no more bleeding. And the gum also went back to normal color.
Another case was a boy who was beaten and had a dislocated shoulder. It had been out of the joint for 24 hours. I had never reduced a shoulder dislocation and didn’t really know how to do it. But I didn’t want the boy to have to wait for the orthopedic officer to come in the next day because it is very painful and the longer it is displaced the harder it is to reduce. I was looking for a book to tell me how to pop it back in which I had at home but not at the hospital. Then one of the med students said they might have a book in their backpack that said how to do it. It had less than half a page about this topic just one paragraph. But I read that paragraph and felt the boy’s anatomy. We gave him some diclofenac, codeine, and valium then I said here goes nothing and tried to reduce the dislocation. It worked! I fixed his shoulder! Everyday is an adventure here with its ups and downs.
Rafi
Here is a link to pictures of Kisoro hospital: http://picasaweb.google.com/rafiki/UgandaKisoroHospital
One patient we had was stabbed in the chest with a machete. Through physical exam we diagnosed a hemothorax and then confirmed it on chest xray. Luckily he was stable enough and it was not large enough to require a chest tube. I have had to improvise in a few situations. First a man came in who was punched in the face and his mouth was bleeding. They sutured his bottom lip but his mouth continued to bleed overnight. By the time I arrived the next morning his clothes were drenched in blood and he was still bleeding from the mouth. When I explored his mouth I noticed he was bleeding from a crack in his upper gum. I held pressure for 15 min and he held pressure for another 30 min but it still would not stop. So I went to the pharmacy and asked for some adrenaline. I diluted the adrenaline and injected it around his gum which turned white and stopped bleeding. We observed him for another day and he had no more bleeding. And the gum also went back to normal color.
Another case was a boy who was beaten and had a dislocated shoulder. It had been out of the joint for 24 hours. I had never reduced a shoulder dislocation and didn’t really know how to do it. But I didn’t want the boy to have to wait for the orthopedic officer to come in the next day because it is very painful and the longer it is displaced the harder it is to reduce. I was looking for a book to tell me how to pop it back in which I had at home but not at the hospital. Then one of the med students said they might have a book in their backpack that said how to do it. It had less than half a page about this topic just one paragraph. But I read that paragraph and felt the boy’s anatomy. We gave him some diclofenac, codeine, and valium then I said here goes nothing and tried to reduce the dislocation. It worked! I fixed his shoulder! Everyday is an adventure here with its ups and downs.
Rafi
Here is a link to pictures of Kisoro hospital: http://picasaweb.google.com/rafiki/UgandaKisoroHospital
Mount Mahavura
Mahavura is the big dormant volcano overlooking Kisoro. I stare at it everyday wherever I go. Mahavura means “guide”, so named because it is such a huge landmark everyone uses when traveling in East Africa. So I decided to spend my second and last day off from the hospital climbing Mahavura. The only other person adventurous and crazy enough to go with me was Rebecca the med student who went with me the week before to Lake Mutunda. When we were trying to make arrangements to climb the mountain every step of the way people were like it is too hard, don’t do it. “It is rainy season and will be miserable”. Roland the hotel manager from Traveller’s who set up our hike for us told us that 80% of people don’t make it to the top and tried to convince us not to do it. Sam one of the staff members at the hospital also told us not to do it this time of year. But I didn’t have a choice this was my only day off the rest of the time in Uganda.
The night before we set out I couldn’t fall asleep. I just lay there in bed awake anticipating the hike the next day. Maybe I couldn’t sleep because I was so excited. Maybe I couldn’t sleep because I was nervous thinking about all the warnings. Maybe I couldn’t sleep because I was afraid I would sleep through my alarm since we had to leave so early at 6 am. I was also thinking about the Montefiore resident who had broken her ankle at the top of the mountain and had to be carried down on a stretcher by 6 men just a few months prior. In the end I realized I couldn’t sleep because I had had 3 cokes during dinner that night.
It was Easter Sunday. At 6 am we were ready waiting for our driver who didn’t arrive till 6:15, which was not a big surprise. We set out on a horribly bumpy half hour drive to the base of the mountain. This time I was prepared. I had learned from my gorilla rain blunder and purchased a poncho. It was a cheap one that I could have bought in a dollar store in the US but here they charged me 36,000 schillings about $20 but I didn’t care I was gonna stay dry this time. I also brought a sweater and a jacket to keep warm on the hike. As we pulled up you couldn’t see the top of the mountain due to the clouds.
We paid the entrance fee to the park and set off around 7:52 am. The 2 of us with 1 guide and one rifle carrier dude. The base was 2381m about 7,857 ft. The hike would be a 6 km trail up and the same trail back. The peak was 4137 m (13,652 ft) a vertical gain of about 1756 m (5794 ft). Usually the hike takes 8-10 hrs about 5 hrs up and 3 hours back down. They gave us walking sticks to use for the hike.
The first terrain we encountered was forest that had been farmland until 1990. During the 70’s farmers had encroached upon the mountain and been doing hillside agriculture. But in 1990 the government took the land back and compensated the people living there so a national park and nature conservatory could be established. It was typical tropical forest terrain with big leaves, different trees, tall grass and ferns, and the noises of birds and insects. White butterflies were flying around across our path. The incline was challenging but enjoyable. It was lightly drizzling but the rain was keeping the air cool. I didn’t even need my poncho yet I just had a t-shirt and a long sleeve shirt over it. We hike for about 40 minutes till we reached the next section of terrain: virgin forest.
It was similar difficulty and along the trail there were steps built into the ground made from logs laid horizontally. We were moving at a good pace, not taking any breaks, enjoying nature, and getting a little exercise. I was still wondering when a torrential downpour was gonna start so I could pull out my poncho. We continued in the virgin forest for about an hour till we hit a sign that said Ericaceous zone 3116 m.
The trees changed to shorter spooky trees with low hanging vines and moss. Another change was that the trail was getting a little steeper and instead of the logs being steps in the ground they were ladders every so often scaling a steeper incline. The dirt trail became mostly stone and much narrower as well. If you turned around and looked down the mountain you could see the surrounding valleys far in the distance even though it was pretty foggy. We were starting to get a little tired and a little cold with the higher altitude and the persistent light drizzle. Not poncho time yet though. The parts which weren’t stone were slick mud. If you stepped incorrectly you would slip and fall. We had to take cautious steps to avoid this but everyone slid a little here ad there. I found that putting my foot flat with the heel down gave me more friction even though instinct is to just put your toe down on a steep uphill grade. It was still fun making our way up. But I kinda hoped we would reach the top soon. It had been about 3 1/2 hours and I was getting hungry.
Altitude 3855 m (12,721 ft) sub-alpine belt. Again, a terrain change occured. There were just short shrubs, short bushes and grass. Since there were no trees blocking the light drizzle I started to get wet so I busted out my poncho. There were a few small holes in it. So much for my 20 dollars. I kind of felt like Moses climbing the mountain with the wind blowing rain into my face, cautiously moving step by step using my staff, struggling with the elements, and my poncho flapping in the breeze.
Next, I started to notice that in addition to not enough oxygen being there for larger trees to grow, there also wasn’t enough oxygen for me. I started breathing fast just from walking at a normal pace. Soon, I was totally hyperventilating. Also, the mountain was getting steeper. I started to feel nauseous. I started walking really slowly. Instead of using my walking stick as a walking stick, I was using it as a crutch. I was going really slowly. First I was thinking one two, one two, for every two steps. Then I was thinking one, one, one, for each step. Then I was stopping for a few seconds after each step. We still had to climb ladders and negotiate a steep muddy trail. We stopped cause I was so tired and I realized that I was also freezing cold. At this altitude the temperature had dropped significantly. So I put on my sweater and my jacket underneath my poncho.
We moved on slowly. Again I was breathing so fast and I realized that I must be in respiratory alkalosis. I really wanted to check an ABG to see my pH. The other people with me were breathing a little fast but were definitely handling it better than me. I would take few steps and then stand there for a minute or 2 breathing really fast. I thought we were nearing the top then I saw that the fog blocking the top had fooled me and we still had further to go. I closed my eyes and I almost blacked out. But I didn’t and we kept inching up the mountain. I pushed my limits. I went way beyond what my limits were. Finally, we reached the summit. It had taken 5 hours and 10 minutes since we began. I was feeling so horrible I couldn’t even talk or smile.
At the summit there is a lake in a crater. It is 36 meters across. It was so foggy though you couldn’t even see the water in the lake. We walked around the lake and sat down to eat some food. I had some avocado some chapatti some peanut butter and a passion fruit. Even stopping breathing to chew and swallow put me back into breathing really fast. It was like cheyne-stokes breathing. Sitting still and eating at the top made Rebecca and I freezing despite our layers of gear to keep us warm. We were both shivering and cold and hypoxic. I was glad when we set out to go back down.
As we started to descend I began to feel so much better. It was less cold, more oxygen, less energy expenditure, less oxygen demand. I was actually starting to enjoy myself again. I was appreciating the beautiful views with the clearing fog and tapering drizzle. I was having fun jumping down the muddy slick ledges and rocks. If I was the one who had the most trouble going up, Rebecca had the most trouble getting down. She has bad knees and it was tough on her descending the steep and very slippery mud and rocks. I could see how the Montefiore resident broke her ankle a few months prior on this same mountain. The guides were very good about helping her on the ladders and mud. While they were helping her out I was able to go ahead and just be alone hiking down taking in my surroundings: the smells, the sounds, the colors, the peacefulness. It ended up taking another 5 hours to get back down but I was having much more fun than on the way up. Rebecca made it ok too.
Our boots and pants were plastered with mud ad we were dirty hungry and tired. The locals who we tell about our feat can’t believe we actually made it all the way up and down. It was a tremendous challenge but was definitely worth it even if I have to wear sandals for 3 days while my boots dry and even if I will be sore for the next week. I got some good pictures out of it too.
Rafi
Here is the link to pictures of the hike: http://picasaweb.google.com/rafiki/UgandaHarMahavura
Friday, March 21, 2008
Lake Mutunda
So I decided to take advantage this past Sunday of my half day off for the whole week. Instead of resting after working 6 ½ long days I decided to try to see some of the surrounding territory and went on a little excursion. I went with Rebecca, one of the med students I work with. There is a lake called
We rode there on boda-bodas (motorcycles). It was a half hour bouncy and fun ride through some surrounding villages and banana fields to get there. Then a 10 minute hike to get to the lake’s shore. It was such a beautiful scene with the lake, surrounding mountains, and agriculture on the hills. When we got to the lake there were some kids swimming and a herd of cattle, goats and lambs drinking from the lake. Once at the lake we hired canoes carved out of wood to take us around on a 2 hour boat ride. We mostly just sat back and relaxed and enjoyed the peacefulness and the view. We saw a few cool birds like a kingfisher and a sea eagle. While we were on the canoes our guide was telling us about the local brew here. Banana beer. When we said we had never had it he said we should try it sometime. It was a great way to relax on our half day off and unwind. We even got some sun to give us color to our muzungo skin.
After the canoe ride we returned to the boda-bodas for the ride back. On the ride back the drivers pulled off into a village to a dark shack. We were like why the hell are we stopping and what is here? The guide walks in a comes out with a bowl of yellow nasty smelling liquid. He takes a few sips and hands it to us. It was the banana beer. All the village people were gathering around us to watch us. We each ended up taking a sip of the nasty yellow liquid. It actually tasted pretty good. Like one might imagine banana beer would taste like. We hoped we wouldn’t catch a disease either from drinking out of that bowl that has never been washed and the whole village uses to drink out of or from any microbes in that concoction they made up. Luckily neither of us ended up puking that night. When we got back to our town we joined a couple of other med students and hospital staff taking the same sunset hike up the hill that we had taken the weekend before overlooking Lake Mutunda which we had relaxed on earlier that day and watched the African sun set over the lake.
Rafi
Here is a link to pictures of our day at Lake Mutanda:http://picasaweb.google.com/rafiki/UgandaLakeMutunda
The Food
The Food
So the foods easily available around here are bananas, avocados, potatoes, beans, and tomatoes. You can buy those pretty much anywhere at anytime. Most of the people here just live off of beans and potatoes sometimes with peas or cabbage. There is also maize and sugar cane. People just walk around biting chunks off a long 5 foot long stick of sugar cane and chewing it and spitting it out. All over the road there is chewed up sugar cane. On market day, which is every Monday and Thursday, you can find other delicacies such as pineapples, mangos, passion fruits, and carrots.
The bakeries also make chapatti. It is flat fried dough. It is an Indian food, but is all over the place here. I pretty much live off chapatti. For breakfast I have chapatti with bananas and peanut butter. For lunch I have the same or chapatti with avocados. Also for lunch I stop off at the local shack and order a coca cola. For dinner I usually go to a restaurant but always order chapatti on the side. Other things the bakeries make are samosas which are fried dough stuffed with peas. It is also an Indian food but for some reason all over the place here. The bakeries also make what we call dough balls, which is a huge ball of fried dough sweetened with some honey.
There are like 5 different restaurant/lodges that we usually go out to for dinner. I pretty much get the same thing at each place. That is vegetable curry (another Indian dish) with chapatti and chips (fries) or rice on the side. Also, of course a coca-cola. Countryside is the restaurant/lodge closest to our house but their service is slow and their food is mediocre.
One of the cell phone companies here, Telecom, has signs everywhere. Their logo is a smiley face and the smile looks like a U. From far away the U blends in with the eyes and it looks like and O-U the symbol for kosher foods in
Agriculture is the main source of income here. Tourism is another but most of the population is peasants who work in agriculture. The biggest crop is Irish potatoes. When you ask someone their job they say digging. That is all they do all day. Dig to plant or harvest or take care of the potatoes. Beans, maize, and bananas are other crops too. If you can’t dig you can’t make money. If a woman is a good digger she gets a large dowry. So we usually keep well fed all be it with tons of starch from chapatti and potatoes.
Rafi
Wednesday, March 19, 2008
Sunrise
Every morning at sunrise a huge round ball of sun peaks over the horizon as a loud music plays AAAAAAAAAAAAAAAAASAWENIAAAAAAAAAAAA bagithiti Baba!!!!! straight out of the Lion King. I don’t know where they hide those speakers but it is really dramatic. No, actually I haven’t been up in time for sunrise yet. But every morning a million birds chirping do wake me up. It is a constant potpourri of different sounds. My favorite bird call that I have never heard before I call the harmonica bird. It plays 3 scales sounding like a harmonica decreasing in pitch. There are roosters in the distance but they are not dominant. Actually the sound that is most dominant even over the birds are the goats baaaing.
Man there are goats everywhere. They pretty much replace dogs and cats. I have only seen one dog here my entire time. But everyone has goats roaming around their yard. Some are on leashes. Some are big some are small. There are white, brown, and black. Kids lead them around on a leash and the goats also play with each other. Sometimes I do a double take because I think it is a dog but it is actually a goat. For some reason though people here don’t drink goats milk. It would be a useful source of milk though.
So Monday a week ago on the wards a really sick looking patient rolled in. His pulse was 140, his blood pressure was 65 and he was breathing 50 breaths per minute. His oxygen saturation was 65%. His lungs had crackles everywhere. In the States we would have intubated him immediately. Here we don't have that option. So I got an IV line and started giving him some fluids to raise his blood pressure. Our differential diagnosis was PCP from AIDS, advanced TB, or severe pneumonia or sepsis with ARDS. Since we didn't really have a way of knowing we treated him for everything. We also really wanted to at least give him some supplemental oxygen. Again we were told the only place with oxygen is the maternity ward and we are not allowed to take it from there. We went to check that out and got the hospital superintendent to give us permission to move it for the night. I got a 100% non-rebreather mask that I had brought from the states and we put the oxygen on him. His blood pressure came up with fluids and he was still breathing really fast. I was watching the machine making oxygen and I noticed there was a light that said oxygen concentration. And it had 3 color lights. Red yellow and green. Most of the time the light was red. THen for a few seconds it would change to yellow then go back to red. it never made it to green. So I don;t think the oxygen was that much greater than room air anyway. Then next morning the oxygen machine was off and I wondered why. I guess because it was noisy and the nurse turned it off. They just didn't get it was keeping him alive. Later that day it was off again. I tried to turn it back on then I realized the power had gone out. A few hours later the machine was taken back to the female ward. His oxygen saturation was still 65% and he was still breathing like 35 but he looked much more comfortable. Over the next few days he improved even more and now he wants to leave the hospital. His oxygen is still 75% but he is living like that. Crazy times here.
Rafi
Man there are goats everywhere. They pretty much replace dogs and cats. I have only seen one dog here my entire time. But everyone has goats roaming around their yard. Some are on leashes. Some are big some are small. There are white, brown, and black. Kids lead them around on a leash and the goats also play with each other. Sometimes I do a double take because I think it is a dog but it is actually a goat. For some reason though people here don’t drink goats milk. It would be a useful source of milk though.
So Monday a week ago on the wards a really sick looking patient rolled in. His pulse was 140, his blood pressure was 65 and he was breathing 50 breaths per minute. His oxygen saturation was 65%. His lungs had crackles everywhere. In the States we would have intubated him immediately. Here we don't have that option. So I got an IV line and started giving him some fluids to raise his blood pressure. Our differential diagnosis was PCP from AIDS, advanced TB, or severe pneumonia or sepsis with ARDS. Since we didn't really have a way of knowing we treated him for everything. We also really wanted to at least give him some supplemental oxygen. Again we were told the only place with oxygen is the maternity ward and we are not allowed to take it from there. We went to check that out and got the hospital superintendent to give us permission to move it for the night. I got a 100% non-rebreather mask that I had brought from the states and we put the oxygen on him. His blood pressure came up with fluids and he was still breathing really fast. I was watching the machine making oxygen and I noticed there was a light that said oxygen concentration. And it had 3 color lights. Red yellow and green. Most of the time the light was red. THen for a few seconds it would change to yellow then go back to red. it never made it to green. So I don;t think the oxygen was that much greater than room air anyway. Then next morning the oxygen machine was off and I wondered why. I guess because it was noisy and the nurse turned it off. They just didn't get it was keeping him alive. Later that day it was off again. I tried to turn it back on then I realized the power had gone out. A few hours later the machine was taken back to the female ward. His oxygen saturation was still 65% and he was still breathing like 35 but he looked much more comfortable. Over the next few days he improved even more and now he wants to leave the hospital. His oxygen is still 75% but he is living like that. Crazy times here.
Rafi
Monday, March 17, 2008
Night
So there are no street lights in Kisoro so at sundown around 7-7:30 it becomes pitch black. That doesn’t stop people on bikes and motorcycles speeding down the road. We usually use flashlights when walking at night. We work until 7 so we are walking around in the dark every night. The stars are so bright and numerous and beautiful. I had forgotten that they exist living in NYC. Then there are the noises of the night. There are 3 different frog sounds. One low corkscrew type bull frog. One high pitch chirping tree frog. And one frog that makes a noise like water dripping into a full sink. I call it the “water dripping into a full sink frog”.
Jerry continues to work us hard and astound us at the same time. We have had many interesting cases including 3 cases of impressive mitral regurgitation. Rheumatic fever is common here. Also 3 cases of endomyocardial fibrosis causing massive ascites. We also had a case of constrictive pericarditis. Remember all these are diagnoses soley by physical exam. No blood tests, no echos, no imaging. Some other fascinating things we have seen are a buruli ulcer and superficial spreading malignant melanoma. The only other death we have had is the guy with TB passed away last night. We have saved several people who have presented either in septic shock or hypovolemic shock and brought them back from the brink.
Rafi
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