Monday, November 2, 2009

Problems with Authority

Safely ensconced in the BOMA. For all that I have not been suffering any privation for the last four weeks, it is nice to be in a place with a nice hot shower and internet; the fact that it is close to the airport for my ride home tomorrow is no small thing, either…

Wasn’t sure I was going to make it to Entebbe today. My ride was supposed to arrive this morning at 10, by 10:30, still no cars. For whatever reason, there was a miscommunication and the driver did not know that the booking was confirmed. They were nice enough to send out the next person ASAP, and we got to leave at 11:30.

Many more police by the side of the roads today; I think since we were in a passenger car instead of a van we were preferentially waved over, since it happened several times on the way to Entebbe and hadn’t happened at all going to Mbarara. I think it must be the driver that looks shady, surely they don’t suspect little old me of anything untoward? I was very happy that I had a smart driver when the first two cops asked him to pop the trunk so they could look. He got out and went back to talk with them, apparently telling them that we were late in getting to the airport and that he was unable to open my luggage. They were requesting to search my luggage, not sure if that’s just a prelude. They then asked if he could have me open the luggage, to which he smartly replied that he would be happy to do so if the captain of the police force requested it. Since I’m not sure that they were actually supposed to be stopping and searching people, they quickly allowed us to be on our way.

It’s surprising how quickly you can get used to things. I remember on the way out to Mbarara that everything looked so different from what I’m used to seeing driving down the roads back home; on the way back, it was just more of the same old thing. It’s interesting that different regions of the country have different specialties and different emphases- soon after passing a papyrus swamp, the sides of the road were filled with people selling papyrus weavings. We passed through a watery area, and had people waving to get our attention trying to sell tilapia (a very tasty fish- common here). We had to detour through Kampala itself, since the road we were going to take to get to Entebbe by going around Kampala is not one you want to travel on without a four wheel drive after it rains. We passed through an impressive squall on the way to Kampala, inky black clouds and thick drops of rain.

It was nice that it was just the driver Herbert and myself; I got to pick his brain about life in Uganda and its recent history. Until now I have been hesitant to ask about the difficult years under Amin and what effect that had on the country, since I‘ve been unwilling to dredge up possibly painful memories. Luckily, he provided the segue into the conversation, and didn‘t seem to mind discussing politics and culture in Uganda. I also learned that he can apparently tell an Ankole from a Bugandan quite easily, and took delight in trying to explain the subtle differences to a clueless Mzungo.

I also got to learn how much a cow costs in Uganda, and how much a hectare (no clue how big that is) of land costs- apparently Herbert has quite the operation going, with 4 cows and 16 hectares, much of which is planted in a banana plantation. Food is certainly not the problem for his wife and 5 children, since they have so much planted land; paying for school is the issue. From what I understand primary school is covered, but the government run schools are seen as far inferior to private schools for which people have to pay. You can “freehold” here in Uganda, which means that, at least for now, after you pay for the land, surveyor, title, etc you own it free and clear without having to pay taxes yearly, which I find incredible. Not sure how that will fare after the future elections. The elections aren’t scheduled until 2011, and people are already talking about it quite a bit- should be interesting.

I will miss the food here- had a great dinner of tilapia fillet and chips (French fries), with the fish freshly pulled from Lake Victoria. Looking forward to sleeping tonight without being awoken by either the Imam or the trucks bouncing across speed bumps. Not looking forward to waiting until my flight leaves at 11:00 PM tomorrow night, the nine hour flight, 6 hour layover in Amsterdam, another 10 hour flight, nine hour layover in Minneapolis, and then only a short 4 hour flight into Portland. Hoping to catch something on standby….

Saturday, October 31, 2009


I get a little cranky when I don’t get enough sleep. I am very cranky today. For the last several days there has been an evangelical meeting/ concert/ lecture series happening in the park down from the guest house. As I was sitting around last night reading, it was remarkable that I could actually hear the preacher talking on the loudspeaker from so far away. At first it was interesting, hearing the praise songs and the rhythmic rise and fall of the preacher’s voice. Unfortunately, it went on and on. Eventually the one preacher must have tired, since they brought another out to substitute. They would alternate between singing, preaching and at times rhythmically chanting-- I swear at one time he was just yelling monosyllabically at the crowd and they repeatedly called back and forth. This went on until 6:00 this morning….

Must not be neighborhood ordinances here, since I am sure I’m not the only one that was kept awake. For whatever reason they finally quieted down for a break around the time the Muslim call to prayer was announced at 6:00. I only thought about using my earplugs at 6:00 and while it didn’t eliminate the racket, it did lessen the intensity. I assume they stopped soon after 6, but was too tired to notice and slept until about 8:00.

Monday, October 26, 2009

Traveling in Uganda

Went to Lake Bunyonyi this weekend, a valley lake situated at 1600m above sea level in southern Uganda, close to Rwanda. The full crew from the guest house went, 7 people in all. Since there were so many, we hired a car instead of all trying to fit into a mutatu (minibus). Of course, there are several things to remember when traveling in Uganda:

1) Travel Time- Unlike the United States, where travel time is most directly proportional to distance, here the most important factor to how long it takes to get to your destination are the condition of the roads.

There were several stretches of road that were quite smooth, but once again large potholes are more the norm. At least much of the way there had the pretense of being paved. On several portions of highway outside of Mbarara they were working on patching the holes, having thoughtfully outlined in white dashes of paint the obstacles to avoid if you wanted to keep your engine block intact. Unfortunately this left little of the road surface unmarked with little white dashes and squares. They used tree branches and rocks as road cones to keep people from driving on the freshly patched asphalt, which was very effective. To control the drivers’ speed, they build monstrous speed bumps every 10 feet throughout the entire portions where fresh gravel had been laid, forcing the driver to weave on and off the shoulder to avoid them. Most other cars were doing the same thing, and we ended up weaving on and off the shoulder on both the right and left sides of the road; I think at one time we were passed on the left hand side by a car coming the other way (not unusual in America, but here they drive on the opposite sides of the road, so it meant that both cars were operating on the wrong side of the road).

After Kabale we turned off onto a dirt road to head up the mountain toward Lake Bunyonyi. When you are scrambling up dirt mountain roads, having to head to the shoulder to avoid oncoming buses hurtling down the mountain, it can take quite a bit longer than it seems like it should based on the distance on the map. The distance on the map from Mbarara to Bunyonyi was less than that from Mbarara to Queen Elizabeth, but it took us 5 hours just on the way there, whereas it took only 2 and a half to get to Queen Elizabeth. Of course there were several delays along the way, as I will explain later. Once again, they were working on the road leading up the mountain, having thoughtfully placed piles of dirt every 5 feet to be used in construction. The fact that this narrowed the already precipitously small road down to ½ lane just meant you had to be more creative when passing. Several times our driver pulled over to the valley-side shoulder to allow larger trucks to pass us coming down the mountain. The only gauge for deference of direction appeared to be the size of the vehicle, with pedestrians and bodas coming out on the losing end. I was able to look out the window and clearly see just how steep the mountainside was down to the valley floor, since I saw no shoulder underneath our van. After a while I just closed my eyes and hoped for the best.

2) Hydration- Ensure that your driver or the car has at least 20L of water on hand.
I was lucky enough to score sitting in the front seat of the minivan. What I didn’t know was that the engine lies directly below the passenger side. At least I didn’t know until I was sitting there and I suddenly felt steam rising up from below both sides of the front seat. I looked over to the temperature gauge on the driver’s panel, and noticed it creeping almost up to the top of the thermometer. Putting my hand down beside the seat, the heat washed over my hand like sticking it near a broiling oven. We were climbing altitude to get to the level of Lake Bunyonyi, and I had been wondering why the driver wasn’t going above 20km per hour. As I looked over, I found out; whenever he tried to push it harder, the temperature gauge would shoot up again. About halfway up the first pass, he stopped the van.

We had organized the driver through Praise, a Ugandan who works with one of the volunteers at the guest house. She was nice enough to coordinate finding a competent driver and transportation. However, the driver did not speak English (I assume he spoke Ankole), so we relied upon Praise to communicate with him. Third hand, he requested that I get out of the car so he could add more radiator fluid. I did, much to the delight of all the pedestrians working their way up the pass; they could all point and call out “Mzungo.” After waiting approximately 20 minutes for the radiator to cool down enough to remove the cap, he poured in all the water that was in the back. Unfortunately, this did not sufficiently fill the coolant tank, and he ran off into the woods. I hoped he was going to come back, since I couldn’t understand what he was saying before he left and he had taken the keys. He eventually returned with two full jerry cans full of water, refilled the radiator, and disappeared again to top up the cans. We then resumed travel. We were still restricted to going 20-30 kilometers per hour, and it felt like we were inching our way up the pass. When we reached the top the driver put the car in neutral and proceeded to careen down the winding mountain road at the closest approximation he could make to terminal velocity, urgently beeping at the unlucky pedestrians and bike riders daring enough to get anywhere near our van.
That was not the only pass, unfortunately, and we had to repeat the water ritual at least once on the way there, and twice on the way back. I’m not sure if there was a leak in the radiator or if the water just boiled off too quickly. After several hours of sitting in the steam bath of the front seat, I felt a bit parboiled. On the way back from Bunyonyi during one of these delays, at least it had started raining buckets so I was able to cool off. I think one of the other riders in the van snapped a picture of me standing out in the rain during our stop- I can’t have looked too excited.

3) Spare Tire- Need to have at least one, preferably two.
I think our driver had an urgent appointment to get back to on Sunday. While going to Bunyonyi we had to inch our way up the pass, only to gain speed on the opposite side. Most of the travel was uphill. On the way back this was reversed, and we spent much more time using gravity to help us cool off the radiator. Once again I shut my eyes and tried not to look at the curves we were navigating, tires screeching on a road freshly covered with the daily rain. I guess he was inspired by the speeds he was able to reach going down the mountain passes, because when we got to the slalom course of potholes on the highway from Kabale to Mbarara he didn’t feel like slowing down, and we were jolted from side to side as he constantly sought the best or least dangerous path through the course of potholes. At times there was no optimal path available, and he would go flying over the pothole, hoping that our escape velocity would carry us over the gap. This worked for a while, at least until we got a flat tire. I forgot to mention that I think our driver was Christian, which doesn’t matter except that he had a liking for old time gospel music and had a tape in the tape deck with no more than three songs on a side. This tape was played at loud volume, repeating over and over in a loop. During one of our stops while the driver got out, I surreptitiously tried to reduce the volume on the tape deck, but it was stuck at 11. I still have one of the songs stuck in my head.

I would have thought we put on quite a show, rocketing back and forth between potholes screaming by pedestrians on the side of the road, gospel music blaring from the open windows with Mzungos staring out, wide-eyed. At least, it would have been a show if every other mutatu had not been doing the same thing…

For all my complaining, we reached Bunyonyi in acceptable condition. Our only concern is that we had planned to stay at Bushara Island out in the middle of Lake Bunyonyi, and the boat going there only operated from “dawn until dusk.” As we were inching up the mountainside, I watched the sun setting lower and lower and pondered the exact definition of ‘dusk.’ Whatever requirements they used, the boat was still there when we arrived, and we were able to shuttle ourselves out into the lake.

Lake Bunyonyi is not a national park, and is surrounded on all sides by settled farmland, with little native forest left. The lake itself is the result of a naturally dammed up valley, so it is very deep and closely follows the course of the land, undulating in and out of narrow bays with numerous small islands. The steep hillsides surrounding the lake have been terraced over the centuries, giving a distinctive appearance. Since the lake is so deep without an appreciable shoreline and lies at such a high altitude, there are no hippos, crocodiles or reported cases of schistosomiasis, making it an ideal swimming location as long as you can stand the chill.

We had decided to stay on Bushara Island since it was highly recommended by the other volunteers, and got out of the motorboat to trek up to the top of the island on 3 or 4 switchbacks. Luckily one of the guides carried John’s (Cameron’s dad) pack for him, since at 79 years of age after a cardiac bypass I don’t think he relishes a steep trek up a forested mountainside with a heavily-laden pack. Bushara Island Camp was incredible- there was a large lounge/ restaurant situated at the apex of the island, with the island itself forming a shallow curve to the north and east. Several cottages dotted the north and south side of the island, with a collection of roofed tents scattered along the spine of the island to the north. The eastern curve of the island was largely taken up by a newly built, solar-powered office and conference center as well as staff quarters. For the first night there was a large German group of travelers that had just finished seeing the gorillas in Bwindi, so all the tents were taken and we all piled into a cottage.

Bushara Island Camp is organized around the community and sustainability- the island supports some 44 employees both on the island and in the surrounding communities, providing food for the guests staying there. Within the lodge itself there is a display of handicrafts, with local women placing items on consignment at extremely reasonable prices. The Camp organizes various community activities such as scholarships for community children, an orphanage fund, HIV counseling and testing, and a yearly pig raffle, where people can sign up to win a pair of piglets with the understanding that they have to donate some of the offspring back to the community. The goal is to provide jobs with a good income and help bring up the communities surrounding the lake.

It may sound like I’m advertising for Bushara Island Camp but there is a reason- I think that if you do happen to visit Uganda, you would be very well served by relaxing for a day or two on Bushara. There is no electricity, so the lounge at night is lit by candles, lanterns, and firelight. There are several swimming docks, many different available hikes and canoe trips, and even a small sailboat. Cameron was brave enough to take the sailboat for a skim around the lake. I deferred, since my only knowledge of ship-lore is being able to talk like a pirate when I’m inebriated; I don’t think telling people to walk the plank would quite get me back to the island if I was stuck out in the middle of the lake. I’m sure I could have jibbed the mainsail or something, but oh well.

Bunyonyi is known as the lake of the little birds, and on Bushara it was clear why. In the morning and at dusk the air was filled with birdcalls of dizzying variety, in fact making it a little difficult to sleep in. Several of them sounded computer generated, so alien and tonally pure were the calls. The north side of the island, being the shadier side, also supports a healthy population of gnats and small bugs, on which I assume the birds subsist. The south side, where our tents were located the second night, is much clearer with panoramic views of the lake and islands, including a view of ‘punishment island.’

Among the uses of the various islands dotting Bunyonyi lake in the past have included a leper colony, church, and the appropriately-named punishment island, where by lore women that were pregnant and unmarried would be exiled to suffer an untimely death unless a man daring enough (and poor enough that he could not afford a bride price) would come over in a canoe and take her away. Not an equitable system, but long-gone now.

I went out for a morning walk the day after we arrived to explore the island for a while, and ended up sitting on one of the benches on the dock overlooking the lake. Since it was still early, the lake was still quite smooth, at least until the rain started. Soon after that, I was drenched and ran for the shelter of the cottage. After drying off and putting on my rain jacket that I should have taken with me in the first place, I headed up to the lounge for an exhausting morning of reading, drinking coffee and listening to the birds and the rain.

I have spent a lot of time in my journal writing about my weekend excursions, but there is a reason. The weeks spent in the hospital are difficult. It’s good to look forward to and plan the weekend excursions, since that prepares me for another week on the wards. I have to give a lot of credit to the PGY’s and doctors that live here for learning to cope. I think the most frustrating thing is feeling helpless when patients come in so desperately ill, knowing that there are resources that could help them if they were only available. Combined with a dearth of diagnostic tests this makes for an endless source of frustration. “Mrs so and so is a 38 year old NYY (HIV+) patient on septrin prophylaxis with evening fevers, a month of severe weight loss and pallor.” The usual course of treatment is to try and get sputum for a TB test, see if they can afford or are stable enough to go into town for a chest xray, and transfuse them. Most people are extremely anemic, so that even if you don’t have a blood count the PGY’s can reliably assume that their palmar pallor portends a significant anemia. If they have a lobar consolidation they will often be started on penicillin with or without chloramphenicol. On certain days the hospital also has ceftriaxone. If they do not get better after several days and the sputum comes back negative for TB, they are often started on tuberculosis therapy regardless given the prevalence. Of course there are many variations on this theme, but you get the idea. The other typical presenting complaints include ‘body swelling’ and abdominal pain. Pretty much every differential begins with TB, since it can mimic or produce symptoms anywhere….

Tuesday, October 20, 2009

Whole Lotta Shaking Going On

Went to Lake Mburo this weekend with Cameron Cover, the other physician here from Providence, and his father John. Combining Lake Mburo with Queen Elizabeth National Park means that you see more of a variety of animals, since there they have zebra and several varieties of antelope not found in QENP. They also have impala, for which the capital here, Kampala, is named. On the drive into the park we were fortunate enough to see an enormous herd of Eland, the largest variety of antelope. We had to stop for several minutes and allow the herd to pass in front of us, leaping across the road.

We also saw quite a few Topi, Bushbuck and Impala, several other varieties of antelope. We stayed in the Arcadia Cottages above the lake itself, and I got an entire cottage to myself. The cottage itself was framed on the outside in concrete, with painted burlap and wood trim on the inside. Add in a separate bathroom and it was a welcome luxury compared to some of the places I’ve been staying. Walked out my front door to sit on the veranda and startled a vervet monkey that had come to investigate the noise of my unpacking and rustling about the cottage. The mud surrounding the cottage was filled with tracks of every shape and size, from pronged antelope tracks to the three clubbed fingers of hippopotamus.

Took a boat tour that afternoon around the lake. I am still not used to being such an oddity here (sarcastic comments aside). John, Cameron and I headed down to the lake shore to take the boat launch around the lake, and there were a group of primary school students from a town nearby on a field trip to the lake. While we were settling ourselves on a lakeside bench to await the boat, all 60 of them lined up in rows next to us, giggling and pointing at the Mzungos. John was very friendly and went over to them and started having pictures taken of him and the students- they loved to have their picture taken and then see themselves on the small camera screen. He took down the address of the school in order to send the copies of the pictures to them after we get back.
Lake Mburo houses large varieties of bids, groups of hippos and several crocodiles. Unfortunately we only were able to see the adult crocodiles as their heads stuck out of the water, since they rarely went out on land. We did see several baby crocodiles on the bank, ranging from 6 inches to 2 feet in length. While we were out in the middle of the lake the rain started, cascading down in sheets of water. I felt bad for the people up front, since they took the brunt of it- sitting in the middle we were protected by people in front and back of us and the roof overhead. I wasn’t quite sure that the outboard motor would make it back to the dock- on the way back it sputtered in gasps and starts but luckily kept going until we made it to shore.

The rain continued overnight, drumming on the corrugated tin roof loudly enough to wake me up several times. The cottages themselves had no electricity or lighting; we were provided with lanterns to use if needed during the night. Combined with my headlamp and flashlight, it made for quite a cheery setting. When it gets dark out in the African savannah, it gets VERY dark…
I woke up one time at night at about 3:00 with the bed shaking and thumping; having been used to nightly visitations by hippos I assumed that one had decided to rub against the outside of the cottage vigorously. This wasn’t too concerning to me since the cottage was framed in concrete and it would have taken a bull elephant (I think) to do any damage. This happened one additional time, but in my sleep addled brain I didn’t think too much of it. The next morning John and Cameron asked me if I felt the earthquake, to which I sleepily replied “wha?” I guess in retrospect I shouldn’t expect a hippo to be able to shake the entire cottage, but there was apparently a small earthquake that night- not surprising since both the East and West Rift Valleys frame Uganda on either side. No harm, no foul. It was a very minor earthquake, and no damage was done. From talking with the staff at the lodge, they have one or two each year.

Friday, October 16, 2009

HIPAA and You

I went through the ward census the other day writing down information to present. I was anticipating doing case vignettes to give people a sense of what kind of patients I am seeing everyday. However, on reflection, I don’t think that it is fair to post peoples information up for grabs on the internet. I could change the age and sex of the patients, but I think that part of the learning and novelty of the cases here is that people are so young when they present. Also, since I am based on the female side of the ward, it would be a bit transparent to change the sex of the patient. I am starting to think of 65 as old aged. I have heard that the average life expectancy here is 45, which is not surprising given the infant mortality rate and the lack of elderly people that I have been seeing. Eddie, a British registrar volunteer, has a background in geriatrics and hopes to work on outlining an educational curriculum for the PGY’s about geriatrics, but I think he’ll have to adjust his usual age range down, since we have patients who present with end of life issues in their 50’s- 60’s. We still get our share of the 80 year little old ladies that keep falling, but much less frequently than in the states. Admissions for placement are unheard of, since there are no real other options than at home with family.

I have already seen two cases of Stevens Johnson Syndrome, a condition usually caused by medications that causes your skin to ulcerate and fall off; if severe enough, it progresses to Toxic Epidermal Necrolysis. NYY (or HIV+) patients are 40x more likely to get this syndrome. In the states, if they are severe enough or enough of the body is involved, these people would be sent to a burn ward. Even if they weren’t, you would take extreme caution to place them in a safe, sterile environment, since with so much skin loss, they are exceptionally prone to infection and dehydration. Unfortunately here we don’t have those resources; they are kept on the same wards with everyone else, with the septic pneumonia patients, malaria patients, and the lady with that nasty productive cough that makes you very concerned for tuberculosis and wish they would put more masks on people who come in hacking up blood.

Another common chief complaint is ‘body swelling.’ This could mean edema, weight gain, or anasarca depending on who is presenting. Underlying causes, as near as I have come to figuring out, can include heart failure, malnutrition, cirrhosis, or extreme kidney failure. The kidney failure patients are the hardest- we have several that are in their 20’s and are looking like end-stage renal disease, which is unfortunate in that there are no facilities for dialysis outside Kampala, and limited access there. One of the final year PGY’s, John, is interested in nephrology and hopes to expand their ability to care for patients that are end-stage, but it likely won’t come soon enough for the 20 something with diabetes that I am seeing with oliguria (decreased urination) and edema. It could still be schistosomiasis, a form of parasite, so hopefully we’ll actually be able to get some tests to try and figure it out. For body imaging we have an ultrasound available, unless they can pay for an ambulance over to Kampala 5 hours away and afford a CT scan. In the time I have been here I have only seen one CT scan done for a mediastinal mass. Unfortunately that patient could not afford to have a biopsy, so we still don’t know what kind of mass it is. An abdominal ultrasound is quite helpful when you are looking for abdominal lymph nodes, important here because extra-pulmonary tuberculosis is in the differential for most presenting complaints. It seems to be the favorite medical student differential diagnosis, since it can present as just about anything: anemia- could be TB, abdominal pain- could be TB, cough- could be TB, meningitis- could be TB…..Added to this that the diagnostic accuracy of the ZN stain or sputum samples is not great, and we end up treating many people for TB that never have had confirmation of infection, just a sufficiently concerning clinical picture.

Other complaints include palpitations- common since most people here are anemic to one degree or another and I have become blasé about seeing people with hemoglobins of 5 (less than about 13 is abnormal). The residents here are able to tell if people are anemic just by looking at their conjunctiva and comparing their palm color to the patient’s, which doesn’t work as well when you are Caucasian looking at an African’s skin tone… Of course, when the hemoglobin is less than 4 it is pretty clear to look at them and see that they are anemic. We still struggle to make sure patients actually have a blood count drawn before they are transfused, which I would estimate only occurs 70% of the time. Many times, I come in the next morning to see blood hanging and ask the intern what the hemoglobin was, only to be told that the family could not afford the diagnostic tests. In the states, whenever you see someone with iron deficiency anemia you usually make sure that they have had a colonoscopy to look for colonic malignancy- here you deworm them with mebendazole, since hookworm is so commonly the cause for iron deficiency anemia. Of course, we don’t confirm that a low MCV indicates iron deficiency, since we cannot send for iron or ferritin levels easily, but unless they have another clear clinical reason for it you assume that they may have hookworm infection.

Many people also present with fevers of one sort or another; evening fevers, daytime fevers or combinations of both. The differential changes slightly if they have recurrent fevers at one particular time of day. The correlation between fever curve and diagnosis is not exact, to be sure, but there are certain things in the history that make you more suspicious- evening fevers for malaria if the infection is established and the parasites release from the red blood cells in sync, evening fevers for lymphoma, multiple daily fevers for the endocarditis patients, and daily escalating fevers for typhoid (typically described as also having a pulse/ temperature disassociation, with high fevers but a relatively normal pulse). Of course, often we only have suspicion to go on, since many of the tests are not reliably sensitive or specific. Many people have low positive titers for brucellosis, 1+ smears for malaria and oocysts in their stool, but may not have active infections causing their current presentation. Added to the fact that many conformational tests are not available or not affordable for patients makes the practice of medicine here quite challenging.

Thursday, October 15, 2009

Wasn't Aware that I Needed to Know Chinese

One of the things that I like about being here is that you get to use all of your skills. When working on the wards, you have to think creatively to try and figure out a way that you can come to the diagnosis with the limited resources and investigations that you have at hand. Computer skills apparently also come in handy.

The University at Mbarara is actively trying to increase the scope of its practice and its ability to care for patients, as evidenced by the efforts that they take to bring doctors from all over to come and help with teaching. As part of his rotation here the British cardiologist Angus is trying to set up an exercise treadmill machine that patients will be able to run on and determine if they have underlying heart disease. The machine measures their heart’s electrical activity while people are stressed by running on a treadmill. He was able to have a machine and computer shipped here from China for exclusive use by the cardiology department (one local physician with an interest in cardiology). Unfortunately, the treadmill arrived in a large packing crate with Chinese only instructions. From what Angus was saying, it was a little like putting something together from Ikea, but with the instructions in an entirely different language, it was a bit more challenging.

They were able to get the treadmill up and running, and got the computer set up to install the programs. Unfortunately, when the computer started up, all of the menus and dialog boxes were, you guessed it, written in Chinese. Angus asked me to have a look at it, hoping that I could change the menu options around. I was able to change the keyboard settings to type in English, I was able to change the currency and date formats for some programs to English, but apparently to change the menu and dialog boxes to English you need a special “multilingual user interface pack.” I searched on my netbook for ways to fix this, and it helpfully suggested in the help section contacting my nearest Microsoft office location….. Might not work when that could be on another continent.

The computer also needed an extra card installed to accept the serial connections from the EKG machine and the monitor. Having built my own computer at home, I figured this would be a simple task- open up the side, pop in the card, done. However, the Chinese apparently do not use phillips head screwdrivers to assemble their cases, they use torq heads. For those that don’t know, a torq head is a 6 headed star bit, similar to (once again) the hex wrenches used to put together furniture from Ikea. Since I only had a phillips head, I had to improvise a little, using one of my keys to wedge inside the screws and haltingly unfasten the case. 30 minutes later, I had the cover off and was able to pop in the card. Of course, I couldn’t find a driver for it, since all the options were in Chinese, so back to square one.

I was able to find a visiting IT professor from England who has a copy of windows xp, and this afternoon after rounds and teaching the goal is to wipe the computer completely and reinstall a copy of windows that we can actually read. One of the last things I expected to be doing while I was here was trying to fix a computer.

Wednesday, October 14, 2009

Dying on Rounds

It’s frustrating to have a patient die while under your care and know that there was more you could do.

We had a 27 year old female come in the day before for hypertension with a history of chronic kidney disease. There was no known cause of either her hypertension or her chronic kidney disease, and no way of knowing if one led to the other based on the tests we had available. For whatever reason, even though she had been admitted there had been no baseline labs drawn (you can get a creatinine level, an indication of kidney function, for free) since admission. Unfortunately, since Monday night at 6:00 PM she stopped making urine, a bad sign that the kidneys are failing. Also unfortunately, despite an attempted trial of lasix, a medication used to make the kidneys produce more urine, she was still anuric (without urine output), and no one acted on this until this morning. When I arrived for early morning rounds yesterday, I went over to talk with the medical student caring for her and noticed that while her eyes were open, she was clearly not awake and not interactive, breathing in large gusts of air and occasionally twitching her arms and legs. Her facial muscles were also fasciculating, clenching and unclenching spasmodically. Her eyes were open and dry, occasionally rolling back into her head. She was not responding to me, even with the painful stimulation of pressing her fingernails. When listening to her heart I now clearly heard a pericardial rub, a sound of friction between the two layers of tissue surrounding the heart. These findings, in combination with her known kidney disease made concerned that her renal failure had worsened. Since there is no way to scan her bladder to see if she is indeed making any urine, we decided to place a catheter and drain her bladder. There was only a minimal amount of urine after we placed the catheter. She had no intravenous access, and when I checked her blood pressure it was in the 90’s systolic- very low. I called over the other residents on the team and we started working on her, attempting to place intravenous access and getting medications like insulin, dextrose and calcium drawn up. The calcium gluconate in the drug closet had expired in December 2007, so I wasn’t sure if it would do more harm than good by administering it. We had no access to an EKG machine to check to see whether her kidney failure had caused her potassium levels in her blood to build to dangerous levels, but her heart rate was quite slow at 50 beats per minute. Despite our efforts, her breathing and heartbeat swiftly ceased. The family and the attendants were by her side for the entire time, and were surprisingly accepting when we discussed with them how sick she was.

One of the things that I like about being a doctor is seeing when something is going wrong and knowing and being able to intervene. It’s frustrating to know that in the US we would have done things very differently, and she might have survived. Now, whether that survival is to a life of dialysis isn’t clear. Furthermore, long term hem dialysis is difficult in Uganda, and there are no options in Mbarara yet. I enjoy the role of being the one that knows what to do when patients are getting ill. I forget sometimes that my other role is to be there for and with the patient and family, even and especially if there isn’t much we can do medically. All too important here, where patients are all quite ill and it’s not always clear what illness they have.