Hairstyles

So basically everyone has the same hairstyle. Men and women both have shaved heads or really short hair that they will shave in a little while. I heard that the school girls have to keep it short so that they will not be attractive to the boys. The only way to tell school girls from boys is that they wear dressed instead of shorts. But I also think they keep it short because it is more manageable and it is basically the accepted style here. Some women from higher than peasant class have hair a little longer or in braids. But most women wrap their heads in scarves or bandannas tied on the top.

Jerry keeps us working hard on the wards from 8 am to 7 pm every night with a rushed 1 hour lunch break. At least now on the male ward I have 2 med students working under me to help out. We are still getting very sick patients compared to the female ward. On Monday a patient rolled in who was emaciated breathing fast and barely responsive. He looked like he had some kind of chronic disease but we couldn't figure it out. Jerry with his master clinical skills carefully auscultated the lungs and found a small area of bronchial breath sounds underlying the right axilla signifying a consolidation. He guessed that this person probably has TB. We treated him for everything TB and pneumonia because he was so close to death we couldn't afford to be wrong. The next day we got a lab result back of a sputum sample the patient had given. It showed TB. Jerry was right. I mentioned to the med student, Tina, wow I didn't realize you already sent the sputum good job. She responded I didn't send it. No one knew who sent it. Then I noticed the date on the sample was February 18th!

This patient had been admitted one month ago and submitted a sputum sample then had been discharged before anyone bothered to check the results. He could have been started on treatment earlier. Now he is close to death and will most likely die. As of today he is hypothermic and can not swallow. If this happened in the US it would be called malpractice. It would also be a public health outrage letting someone with TB back into the community. The second the specimen was read as positive the patient should have been sought out both to start treatment and to isolate him from others.

In the hospital he is in a separate room but it does not have negative pressure ventilation so his breath can still go all over the hospital. Also we don't have masks to wear when we examine him so we are exposed on a daily basis. Also his family that stays in his room with him in the hospital is constantly exposed to him. Also the other patients in the isolation room isolation like the ones with dysentary are exposed to him too. But this is Africa and there are no means to take other precautions. A difficult situation.

Working hard is good and rewarding. However, it is frustrating sometimes that I am all the way here in Africa and I am just working all the time. Any free time is spent eating, bathing, and sleeping. I barely even have time to check the internet. Now we also have to work both days of the weekend so that we may not be able to go on long treks.

Rafi

The Muzungo Parade

So Saturday night another contingent of Muzungo's arrived from Montefiore. Five more medical students, in addition to the 3 who were already here who I haven't mentioned yet. Jerry Paccione who is one of the founders and leaders of the social medicine program at Montefiore for the past 25 years and Jerry's niece who is our age and also wanted to work in Uganda.

Jerry is a brilliant physician, a master of physical diagnosis, and very experienced working in developing countries. He also works very hard and is very demanding. So Sunday morning he wanted everyone to go in early to meet all the patients. So Sara and I led the med students to the wards and instead of 2 muzungos it was a group of 10 all walking together. People were just staring at us. As soon as we got there Sara went to check on her girl with status epilepticus and she was seizing again. Jerry walked in the room and in one second he said "this isn't a seizure it is hysteria". I guess it made sense since she wasn't dead yet and she had been in this condition for 3 days. Apparently hysteria is common here and we aren't used to seeing it. In the States it is something we would call conversion disorder.

There is a phenomenon of patients "escaping". That is leaving without being discharged. There was a very interesting patient I had admitted on Friday who I wanted to present who had escaped overnight Saturday night. He had developed swelling throughout his body over the past 2 weeks including his arms legs belly and face. After closely examining him and doing a urine dip stick I came to the conclusion that he had nephrotic syndrome. Patients escape once in a while in the States we call it eloping. But it happens here much more often. When a patient feels better he just leaves without a discharge or medications to take with him.

Sunday evening after the wards we went on a hike up a hill. It was just one hour up and one hour down. It was with all the new students who had come. We began hiking up the hill through all the hill side agriculture. Then we began to get a great view of the town from above and all the surrounding mountains. The village kids were chasing us as we climbed up and actually running circles around us and they were very cute. When we got to the top of the hill we could see the nearby Lake Mutanda and the sunset. It was beautiful and I got some good pictures. So our outpost of muzungos has grown and we would have a lot of extra help now on the wards for the upcoming weeks.

Rafi

here is a link to the pictures of the hike up the hillside: http://picasaweb.google.com/rafiki/UgandaHikeUpTheHillside

Gorilla Tracking

So we decided to take our first day off on Saturday after having an intense week of hard work. We left at 7 am from our house with a driver and took a road full of potholes 45 min (14 kilometers) to Mgahinga Gorilla National Park . We got there and there we 13 other Muzungo who also came to go Gorilla Tracking. The muzungos were broken into to 2 groups mine had 7 people. 2 other Americans, 2 people who were white but originally from Zimbabwe now living in London. And another British guy. We bought permits got a briefing and had the option to take a walking stick (I took one) and set off. One of the stipulations in buying the permit was that you must have proper rain attire to participate in the hike. I had a nylon jacket on which looked like it could protect you from rain so they let me go.

First the terrain hills with grass and trees and bushes. It started to drizzle a little. Then we reached a point where the bamboo forest started. It was like walking through a cave of bamboo shoots and very scenic. The way you track the gorillas is early in the morning the some guides set out and actually follow clues to find where the gorillas are. They have walkie talkies and tell the guides leading us where to hike in the park where to go to find the gorillas. After the bamboo forest we came to a clearing and the trail continued with grass and some trees and bushes. At this point it started raining harder then drizzling and everyone started to put their hoods on. I just had a hat. Not a rain hat but a regular hat. Also my jacket didn't zip up.

At this point we'd been hiking about an hour. The guide got a call on the walkie talkie from the other trackers telling him they found the gorillas and told us where to go. We had to go off the main trail through the brush. It was still kind of a smaller trail. You didn't have to use a machete but you did have to squeeze through pretty tight spaces. We went through tall grass then back into a bamboo forest. It was alternating from drizzling to raining really hard. Like tropical rainforest hard. Which is what we were in. I was getting pretty drenched. Plus there were some puddles and some mud and my boots were getting soggy.

So we trekked through the jungle through small trails with branches and vines hanging down for about 2 hours in the tropical rain and finally we met up with the other guides and we were very close to the gorillas. We left our walking sticks and the guides slowly led us to the gorillas. There instructions to use were do not use your flash on your camera, ,move slowly, if you have to sneeze or cough cover your mouth so you don't transmit disease to them, and if a gorilla charges you stand still don't run and don't make eye contact.

So we slowly crept up to a spot where we saw our first gorilla. It was a large male. It was like 15 feet away right in front of us. Sara took out her camera and her first shot the flash went of. The gorilla roared and charged us. Some people ran. I just stood watching kind of like it was in a cage and there was no possible way it could hurt me. After that I realized I was stupid and should have run. Any way right when it was like 5 feet away it turned and ran up the hill a bit and was like 15 feet away again. Later we joked how she was the stupid American. It was sitting huddled with its arms crossed too keep warm because it was raining and cold. We watched him for half and hour and took a lot of pictures and videos. There was also a female with an infant nursing it further away behind the trees and a 3 year old came out and walked around the male. Then we walked up the hill a little further and found 3 more gorillas females eating and playing.

We watched the gorillas for a total of an hour and it was time to head back. While I was hiking and drenched I was still creating heat I was a little cold but warm enough. But after sitting still soaking wet while it continued to rain I was freezing and starting to shiver. I was becoming hypothermic. I was really glad to start hiking back again. Basically it was raining so hard. The guide said it was raining so hard you would curse the day you were born. I was 100 percent soaking wet. You know on the way up I was trying to avoid stepping in puddles but now there was no point. 1. I was already wet 2. The trail was basically a stream. With each step your foot would sink into the mud up to the ankle with a huge slosh every step. Yes I was unprepared for the weather.

As I was walking back through the forest cold and wet I was thinking to myself. I thought Africa was supposed to be hot and dry. And here I find myself everyday cold and wet (like decompensated CHF). And hypothermic like every day. So I was quite uncomfortable on the way back down and praying to just be back. When we reached the part where we joined back up with the main trail it stopped raining and things started to dry off a little. When we got back to the bottom the sun actually came out and I was so happy. My passport and wallet which were in my pocket were totally drenched. Somehow magically my camera which was in the inside pocket of my jacket still worked. And I have amazing pictures and videos of the gorillas. My boots and pants were totally muddy and it will take my boots like a week to dry. Now I am wearing sandals on the wards.

Rafi

Here is a link to the videos of the gorillas:
http://www.youtube.com/watch?v=udDlJka9ZP0
Here is a link to pictures from that day:
http://picasaweb.google.com/rafiki/UgandaGorillaTracking

Muzungo

Muzungo is the Rufumbira (that is the language they speak here) word for white person. Or actually non-African black because they call Asians that too. That is what you hear everywhere you go. The children all follow you and yell MUZUNGO MUZUNGO. The most frequent thing the children say is "Muzungo give me a pen". Then sometimes you get "Muzungo give me money". Other times it is "Muzungo how are you" Pronounced "Howa you". It is really cute when all the dirty littles kiddies who can barely walk probably 2-3 years old all say "howa you, howa you, howa you" and wave to us. We wave back. I don't really get the thing with the pens. One time some white dude must have come to this town and given the kids a whole lot of pens.

So Day 4 in the wards was pretty routine. The girl with the status epilepticus was seizing again when we went back in the next morning. And we went through the valium and phenobarbital via NG tube again. Her oxygen was 48% again but she was still alive and her seizures stopped. We performed another paracentesis that day also. Several of my patients develop delirium. I guess we see it in the States too as altered mental status but it is more pronounced here. They have high fevers then become confused and sometimes violent. After work Sara and I went into town for dinner and signed up for an adventure to go on the next day.

Rafi

Showering

I have found out the only thing you really need to shower is water an soap. Our first night in the hotel in Kampala that is all we had and I still took a shower by filling a bucket with freezing cold water and splashing it on me using soap. Other luxuries include 1. water pressure. and 2. warm water. In our house we actually have water pressure but not warm water. So every morning I get into a freezing cod shower and quickly wash my hair and body. Unfortunately I also develop hypothermia in the process. Another option is to boil water in a kettle and pour it into a bucket in the shower then add cold water to make it warm water and splash that on yourself. I have been too lazy to take that approach but maybe I should start to avoid becoming hypothermic.

The third day on the wards I was starting to get into the swing of things. Being able to recognize malaria in about seconds by the eyes, spleen, and complaints. We also performed a paracentesis (removing abdominal fluid) on a female patient. As we were finishing that the nurse told us there was a patient who's been waiting who is having "hysteria" so she saved her for us too see last. When we walked in she was convulsing and her eyes were rolled back in her head. She had been like this for the past 5 hours. She was in status epilepticus NOT "hysteria". Her oxygen was 80% by this point. The only oxygen available was in the maternity ward and is not portable. We put in an IV and and pushed valium 3 times and it did not break her seizures. That was the only IV medication that they had for seizures. They said they had oral phenobarbital and oral dilantin. But she was seizing and couldn't swallow anything.

At this point her oxygen sat was 48% (we brought a portable pulse ox from the States). Then I got the idea of putting in an NG tube and giving her the other medications that way. They didn't have any dilantin in the hospital so we gave her phenobarbital. At that point it seems like the valium kicked in because she broke. Her oxygen went up to 96% but she was unresponsive. We will see if she wakes up tomorrow. 5 hours of seizures fries the brain. So does 5 hours of not getting enough oxygen. I also had a girl who was 12 I was asked to see. It was obvious she had a fracture of her lower leg. I am not experienced in setting fractures so I splinted it and referred her to an orthopedic specialist who would be able to see her the next morning.

Rafi

The weather

The weather is pretty nice. The temperature ranges between 60 - 80 degrees. It is starting to be the rainy season so it rains in paroxysms from a 15 min - 3 hours heavily. Then stops and the sun comes back out. When it is raining and at night it is about 60. When the sun comes out it warms up. I usually wear long pants and a jacket. The buildings have concrete floors and no heat so it tends to feel cold even though it is only 60. At night I keep warm using 2 blankets.
The second day at the hospital I also had to run chronic care clinic as well as performing my ward duties. I saw about 30 patients one after the other most just had hypertension and diabetes. Only 1 out of 30 was obese. It took all day to see those patients and I missed lunch.

By the way I also came here with another resident who works at my hospital. Her name is Sara Doorley. She runs the female ward. We basically do everything together. Eat go to work go home go into town. She is very compassionate to the patients and has a lot of experience with global health in the past.

Rafi

I got here OK

Well It was a 6 hour flight from JFK to Amsterdam, an 8 hour flight from Amsterdam to Entebbe. A 1 hour drive from Entebbe to Kampala where we stayed overnight. Then we got on a bus at the central bus station at 8:30 am. It sat there till 10:15 am. We arrived in Kabale at 5 pm and It was a 2 1/2 hour car ride from there to our village called Kisoro. Impressions: the roads are horrible either paved with potholes or not paved with a lot of rocks. It is very green. There are a lot of people walking around balancing things on their heads. The internet is REALLY slow.

Today was my first day in the hospital on the wards. I am on the male ward. I had 25 new patients to meet and learn about. Ages 12-75. Some have malaria, some have pneumonia, some have had trauma. One 13 year old boy has burns all over his body. At around 12 pm they brought in a new patient. 24 yr old boy breathing very fast. His family said he was too weak to get out of bed and hadn't eaten or drinken for days. I couldn't get a blood pressure or feel a pulse. He was very cold. I could tell he was in shock. His eyes were yellow and by his finger tips and eyelids I could tell he was severly anemic. He was difficult to arouse and couldn't answer any questions. The nurse couldn't put an IV in and so I put one in his neck and we sent off a blood sample for hemoglobin and type and screen. I instructed them to keep giving him lots of fluids.

Two hours later he was still breathing fast and cold but was more arousable and I thought he might be getting better but I still couldn't get a blood pressure or feel his pulse. Basically he stopped breathing and died and there was nothing I could do. I would have had a lot more medications, equipment, and tests at my disposal if I were in the US and could have probably saved him.

Uploading pictures takes way too long so I am not able to do it. More blog to come. I will update this blog as frequently as I get a chance. So check every few days.

Rafi