The food

Above is my typical lunch from the hospital canteen.  That's chicken, rice, pumpkin, matooke (mashed green plantain) all for 7000 shillings ($2.80!!!!).  After a while, it has gotten a bit tired but it's cheap and keeps me full. 

A 4000 shilling snack (drink included, $1.60!!!)

It's no secret that I like to eat. I'm still navigating my way through the culinary landscape in Kampala. Thus far, it has been a mixed bag.  Sometimes, the restaurant menus are a wish list of suggestions.  Most things won't be available.  And you won't find this out until about 30 minutes after putting in your order.  It's never a good scene to let hungry Sheryl know 30 minutes after her order is placed that she won't be getting her food.

There are both some familiar and unfamiliar things.  Some of the foods (especially matooke), remind me of things from my Jamaican roots.  Indian restaurants abound, which is great for me.  I still, however, have not found anything that has blown me away.  Admittedly, I am a food snob, so that makes things difficult.  I will continue my quest to find fabulous dishes in Kampala.

She Survived!!

When I walked into the cancer ward this morning, I was elated to find the patient who yesterday vomited at least a half gallon of blood was alive. . . and smiling no less.  She said she felt much better and the vomiting completely stopped.  She still had not been seen by gastroenterology or received all of the medications that were prescribed but she was awake, in good spirits and able to sit up.  Miracles do happen.

Now I have seen it all (not for the faint of heart)

After taking a break to go to the outpatient Infectious Disease Institute Clinic, I returned to the inpatient cancer ward yesterday.  There was a 17 year old patient there who was being seen by the medical student.  I asked the medical student if he needed any assistance and he hesitated.  The patient promptly began to vomit bright red clot-filled blood into a bucket.  Now, I will fully admit that I can be squeamish but I was able to remain calm despite the fact that in all my years of training and practice I have NEVER seen this before.  I went through the assessment with him and told him what needed to be done and asked him to get everything started.  She stopped vomitting and layed back down. 

The oncology attending arrives and asks how far we have gotten on rounds.  As if on cue, the patient vomitted another round of bright red blood with gigantic chunks of clot which unfortunately landed on the floor.  "Ahhhhh, that is not nice", the attending replied and he commenced rounding.  Despite my previous experiences, I still had some expectation that the sight of bloody vomit would incite some panic or rapid and decisive action.  As we went through the chart, it was discovered that she had not gotten the medications that were recommended the day before when she first started vomitting blood.  Her personal attendant was no where to be found and the attending physician reminded me that when there is no attendant, the patient's care is compromised because there is no one to obtain and administer the medications that are prescribed. 

I asked how to get a GI consult.  Unfortunately, it seemed that of the two endoscopes available, neither one has the fully ability to band, sclerose, or biopsy.  We were, again, in Old Mulago.  Any scoping would need to be done in New Mulago which is about 1/4-1/3 of a mile away.  The GI attending would need to come up the hill to do the consult first and then decide what to do from there. There would be a delay in even getting the consult because we did not have our cell phones available to call.

I was amazed by the team's ability to continue rounds despite the 17 year old who had again vomitted blood for a 3rd time.  I was completely distracted but felt helpless. 

This morning, I am preparing to go back to the ward with the hope that she received at least some of the things that she needed and that she is still alive.

Ethical Dilemmas

She was a new admit to the cancer ward.  From the brief history I could get from the house officer, she had a history pancreatic cancer (not sure what stage, not sure what her DNR status would be) and was coming in for change in mental status.  "Change in mental status" was a bit of a euphemism.  She was actually completely obtunded, unresponsive with eyes open.  Her attendant could only tell us that the day previously she ate lunch without incident and then was no longer herself.  Her blood pressure and oxygen saturation were too low to be measured.  Her hands and feet were ice cold. When we initially examined her, she would swat our hands away.  And then she stopped breathing.  In any other setting, this would be reason to call a code.  She did resume some form of breathing on her own.  I asked the house officer about transferring her to a higher level of care/monitoring but was told that this patient would not meet criteria for being in the ICU (I'm still trying to figure out exactly how close to death you have to be to get into the Mulago ICU).  Besides, we were in Old Mulago and the ICU is in New Mulago which is about 1/4 of a mile away with no easy way of transporting her over there.

In that moment, perhaps the house officer saw what I could not.  I was looking at the immediate need:  If someone stops breathing or if they do not have the proper circulation, you FIX it.  Especially when the patient was doing 'well' and ate lunch with her family just yesterday.  But in looking at the 'long' term, you have a patient with a diagnosis that carries a poor prognosis AND she is in a resource deprived setting.  So do you try to make this person better or do you preserve the few resources that you have? In this particular case, the house officer gave her fluids and antibiotics.  She died that night.

In addition to allocation of resources, the other dilemma that arises frequently is the reluctance to have frank discussions with patients about their prognosis.  For example, a renal failure patient needed dialysis.  Dialysis is expensive.  The patient's family sold land, property and possessions to pay for 5 sessions of dialysis.  Since dialysis is a lifelong need, what do you do when it is time for sessions 6 through infinity? So how do you counsel the family who is selling all of their possessions for 5 sessions of dialysis?? 

'A single man with a child is not natural'

One of the highlights of last week was visiting the Sanyu Babies Home.  It is an orphanage with the capacity to provide homes to about 50 children up to the age of 3.  We got a tour of the orphanage and learned a bit about their mission and the placement process for the children.  When adopting from Sanyu (and perhaps throughout the country), there is a specific hierarchy.  First priority goes to couples who are natives of Uganda.  Next on the list is single women.  After that they will consider foreigners who live in Uganda.  If all else fails, international adoption will be considered.  Being the curious one that I am, I asked where in the priority list do single men fall.  The orphanage administrator looked at me like I had three heads and said that it was not natural for a man to adopt a child and that a single man would never be considered in the adoption of a child.  At that point, I figured I would not bother asking about same sex adoption.  I thought it was shortsighted that no single man would ever be considered a candidate to adopt a child.  There is clearly a need for adoptive parents.  If there is a single man who has passed the same screening  process that the single woman has passed, why is he not worthy of adopting?  Any thoughts??

Anyway, next was playtime.  The children just needed and wanted lots of hugs.  I was happy to oblige.
The kids were playful, rambunctious and all around fun.  No pics because no cameras were allowed :-(

It's Saturday night, what's a girl to do????

Today was a fun filled day at the Ngamba Chimpanzee Sanctuary located on an island south of Kampala near another city named Entebbe.  It is a safe place for orphaned chimps who have been confiscated from people keeping them as pets or trying to sell them for various other reasons. The chimps were social and do display some human-like tendencies including males mating with multiple females, fighting over "politics" and working to overthrow the alpha male in charge.  It was alot of fun and very educational.    

I got back to my flat around 7 pm and made dinner (rosemary steak and cabbage with pepper/carrots/onions- Yummy!!).  And now I'm stuck.  One of the drawbacks of moving out of the shared flat is that it is a lot more difficult to hang out with the other program participants. The public transportation system is not well developed and getting to most places would require taking a "special hire" (a.k.a. a cab). And while I've been told it's safe to walk around Kampala at night, I'm not ready to do that.  

So instead of a night on the town, I'll be curled up with "The Girl Who Played with Fire" and watching Wolf Blitzer.  This is far from the excitement I was hoping for.  Next week will have to be better!

The St. Stephen's Experience: the cocky gunner medical intern, the seizure, and the home visit

Yesterday was a day spent away from the hustle and bustle of Mulago Hospital.  St. Stephen's is a smaller (much smaller) community hospital in the northern portion of Kampala.  It has an operating theatre, several wards and an outpatient clinic.

(St. Stephen's Hospital)

(empty ward at St. Stephens)

We started off rounding with with the medical officer and saw patients who were being treated for routine issues: malaria, tb, etc etc.  One of the visits was a post op follow up from a total abdominal hysterectomy about 3 days earlier.  When I reviewed her chart, I saw her anesthesia consisted of some lidocaine derivative and diazepam.  Meaning she was not asleep.  I hope to never have a hysterectomy, but if I do I will be knocked out with general anesthesia, none of this regional block with anti-anxiety medication business.

After rounds we headed to the room enclosed by a metal door with prison-like locks and pass through called the clinic.  Here is where I encountered the "cocky gunner medical intern".  Now this is a species that I thought only existed in halls and call rooms of hospitals in the United States.  Somehow, this breed has crossed the Atlantic and landed in Uganda. He sat at his desk, chest puffed out and condescendingly explained that pneumonia meant that the patient had an infection of the lungs.  I politely humored his lecture about how pneumonia is treated with some nods and smiles wondering when he would shut up. The smiles got a little tight when he repeatedly tried to pimp me on what burning with urination could mean.  The smile flatlined when he told me I needed to "open any book" and read about how hypertension causes peripheral neuropathy.  I shut him down when he tried to teach me how to do an abdominal exam.

In the midst of dealing the the cocky gunner medical intern, a woman brought in a 1 year old child who was actively convulsing with an oxygen saturation of 56% and poor respiratory effort.  Cocky gunner medical intern was still flapping at the gums, not taking decisive action.  Luckily the Yale med-peds resident stepped in.  Frankly, sick kids scare me and it has been so long since I have taken care of a child, that I would not have been able to handle this one on my own.  We managed to stabilize her with meds and no intubation!

During the afternoon, we had what was probably the best (and calmest part of the day).  We did two home visits in a more remote area.  Chickens, goats and cows were sharing the road with us as we drove to the first home visit.  I was amazed at how happy and grateful they were to see us. 

The Hair Issue

(Me in my new apartment. I moved out of the shared flat!)

So, one of the most frequent questions I got asked about this trip was "What are you going to do with your hair???"  Well, I had planned a weave because I was just tired of dealing with the time consuming bantu-knotting and flexi rods. That didn't work out so I'm left to deal with it on my own.  This week, I am rocking the unstyled fro.  Not my favorite but it will do for now.  I'm sure that someone in Uganda has seen hair like this and be able to do something with it ;-)

My first few days on the wards

Being a foreigner in a completely different medical system has been a challenge.  I'm still learning what my role will be on the wards and in the education of the med students and residents. 

Even still, the first few days have been eye opening:
In the hospital, attendings do not round or go over the patients with their teams on a daily basis.  Rounds start haphazardly and with no specific schedule.  For someone who thrives on order and routine, this has been difficult for me.

My first rounding experience was with the resident who is on heme/onc.  We made our way through the open ward and she made her notes in the paper charts and provided the patients with order slips to carry out the orders for their medications and workups.  The cases were varied but almost always something end stage.  There was one young woman with nasopharyngeal cancer who had the matted, immobile lymph nodes that I have read about but have never seen or felt to such an extreme.  The lymph nodes in her axilla were about the size of lemons.  There two women in her 60s or 70s who looked about 8 months pregnant who without much guesswork you could tell had stage 4 ovarian cancer. 

My next rounding experience was on the Pulmonary ward.  Here, the most striking (and sad) case was a young man in his 20s or 30s who had been admitted on April 10th with known HIV who had a cough, fever, weight loss and complaint of dysuria.  The plan at that time was to treat him for pneumonia with ceftriaxone and do a number of diagnostic tests.  I saw him with the team consisting of the Makerere University Intern and medical students and Stanford resident on April 13th.  He was cachectic, obtunded, obviously tachypneic, had pale conjunctiva, had two unopened vials of ceftriaxone on his bed but NO IV access.  He was breathing at 48 breaths per minute, with a heart rate in the 130s, oxygen saturation of 93% on room air.  His xray had complete opacification of the right upper lobe with an accompanying effusion and reticular infiltrate throughout the rest of the lungs (my interpretation, there was no report). I'm thinking this could definitely be TB or PCP or a number of other things.  
Off to the ICU?  No.  In the hospital there are 4 ventilators and per the staff, it is unclear that they are all functional. As such, very few people get intubated.
EKG and monitoring?  No.
Oxygen?  The intern protested a bit stating there was no room on the ward that had oxygen available. I asked them to move him anyway.
Transfusion?  I had no cbc to back me up but we all agreed that with conjunctiva that pale, he was anemic.  No type and screen done yet but that and the cbc were requested 
Fluids?  Finally, this was something that could be done for him.  The nurses got to work on establishing access and hung the fluids and hung 500cc of normal saline.   
There was so much to be done regarding stabilization that the diagnostics had to take a back seat.  It was incredibly disheartening to see someone so sick, know what he needed but not be able to provide it.

We moved on to seeing the other patients.  About 10 feet away was a young man who was admitted with pneumonia and pancytopenia.  His white count was 1.6, hgb was 4.2 (yes FOUR point TWO) and a platelet count of 40.  He was right next to a man with pleural TB, 5 feet across from a man with an active productive cough and about 10 feet from the patient who needed to be in the ICU.  Isolation? No.
My solution?  Put a mask on him and hope that no one touches him or breathes directly on him.  Since there are very few areas to thoroughly wash hands, sanitation is definitely an issue.

Mulago Hospital

This is me outside of the Mulago Hospital entrance gate.  Mulago hospital is a 1500 bed hospital that is the major referral hospital of Uganda.  It consists of the very large "New" Mulago as well as a network of buildings on the other side of campus called "Old" Mulago. 

To say the hospital is resource deprived is an understatement.  The wards are dimly lit, rundown, large open rooms with no air conditioning or window screens.  There are no walls, so there is no privacy and definitely no concept of HIPAA. Nurses are few and the patients rely on their "attendants" for alot of their care.  Attendants are usually a family member and they are there to provide what we usually expect of nurses.  For example, if a patient requires morphine every 4 hours it is the attendant's duty to go to the pharmacy/dispensary, PURCHASE the morphine and ensure that the patient takes it every four hours.  The attendants are also in charge of bringing food and water to the patients and making sure they have bed linens.

While labs are available at the hospital, phlebotomy comes around twice per week.  In between those times, the patients would need to travel down to the lab to have their blood drawn.  Complete blood counts and chemistries are free.  The remainder of tests ordered need to be paid for out of pocket.

Once the patient has been seen by the medical team that day (IF they are seen by the medical team that day), it is their responsibility to ensure that the plan is carried out.  Need an ultrasound?  You as the patient need to make sure that you make your way down to radiology to get it done.

Welcome!!

Welcome to my blog!!! This is the first time I have ever blogged about anything, so I am still getting the hang of it.  When I was accepted to participate in the Yale/Stanford/Johnson and Johnson, I was incredibly excited to have the opportunity to live and work abroad for the very first time.  Now I'm here living Uganda and adjusting to day to day life.  It has only been a week since I left the States but I have already seen and experienced so much both in and out of the hospital.  I'll be posting as much as time/electricity/internet access will allow, so stay tuned!