A Day in the Life

I am finding it very difficult to write about my project and medicine in general, thus the content of my posts have focused more on my free time than where I spend most of my time. What I want to say should be realistic yet not so disheartening, and optimistic but not so much as to glamorize the work. But honestly, it is very hard to not be cynical after two months of wards, clinics, and research.
After having worked at Hospital Jose Maria Velasco Ibarra in Ecuador, I thought I was prepared for what I would see at Mulago National Hospital. I believed I would be able to handle the inefficiency and lack of resources more than other mzungu professionals coming from their high-tech, westernized institutions. Part of the reason I want to work in developing countries is so that I never get so dependent on the technology we have at home that I am unable to practice medicine without it. What I have realized is that it isn't always the technology that is holding this hospital back, it is basic necessities that I HAVE become dependent on during the training I have had back home. IV fluids, antiseptic, clean gloves, soap, scissors, tape, paper. You should see me begging to get another pair of gloves, or some lab request forms, and then conniving to get it some other way when I am denied.
Mulago National Hospital and the Infectious Disease Institute are two distinctly separate yet intricately connected institutions here in Kampala. And it just so happens that IDI is Mulago's (and my own) saving grace. The IDI is a model institution that focuses on research, training, and HIV patient care. They see 400 AIDS patients a day in the clinic and are training physicians, scientists, laboratory technicians, and administration personnel in the art of caring for this challenging (medically, practically, emotionally) population. And they have what is lacking on the wards of Mulago - patient advocacy, efficacy, and efficiency.
The IDI is where my research project is based. There is a large cryptococcal meningitis (CCM) IRIS study run jointly by Ugandan physicians, University of Minnesota faculty, and others. The patients are recruited from the Infectious Disease ward at Mulago, and are followed at the IDI after discharge. The physicians here in Uganda have noticed that so many patients and their families refuse lumbar punctures (LPs aka spinal taps) that are important for diagnosis and treatment of meningitis. So my project is to interview patients, their families, and health professionals to find out why there is such resistance to this procedure, and then use their responses to develop patient educational materials for meningitis and lumbar puncture.
I have not yet been able to interview anyone because the project has not been approved by Makerere University after many months and resubmissions. And although I tried to keep my expectations low when I was planning this project, it is still a source of frustration. I have, however, been able to informally ask questions of patients' families who refuse LPs and get opinions from the doctors on the wards, and have been working on the educational materials as much as I can. Helping with the overarching study by recruiting patients, doing their LPs, and being the eyes and ears (and hands) on the ward keeps me pretty busy in the meantime. Along the way, I realize how much I have learned about AIDS, infectious diseases, resource-limited settings, Uganda, research, myself, and my capacity to adapt and change.
I will leave you with my activities from today...
I get up at 6:30 am and out the door at 6:45 when the sun comes up, so I can run around the golf course and still get to work by 8 am.
I get to the Infectious Disease Institute for our weekly "switch meeting." This is a case conference where counselors and physicians discuss patients who have "failed" their current anti-retroviral treatment regimen and determine what the way forward shall be.
After the meeting (which starts and ends on time!) I head over to ward 4A - Infectious Disease.
Rounds have not yet started, but the intern is performing a skin biopsy on a man with obvious Kaposi's Sarcoma. He uses lidocaine to anesthetize, although there is no lidocaine with epinephrine produced in the entire country, so he makes sure to have gauze available because it is never going to stop bleeding. He then takes a scalpel blade minus the handle and cuts out a wedge of skin from the patient's arm. He then takes out the suture, and when I am about to question the HUGE needle he is using, I realize he has no needle driver.
Although I would like to keep up on both sexes, it would be impossible for one person to round on both the male and female sides. So I go to the male side, 24 AIDS patients with varying opportunistic infections. The resident fills me in on who passed away the night before and how many patients are new. As we round, we discover many medications were never delivered or administered; the patient we wrote needed 4 liters of fluids got only 500 ml; the 15 year old whose potassium was 1.6, got only 2 ampules of KCl when we had the mother buy 5. But there are pleasant surprises; the man who came in with undetectable blood pressure is now awake and taking food. That is kind of the usual ratio though, for every 3 or 4 patients who need a lot of attention, the one that gets it might live.
A sampling of the patients...cryptococcal meningitis and CCM IRIS, tuberculosis (pulmonary, abdominal, meningitis, IRIS), Kaposi's Sarcoma (cutaneous, pulmonary, disseminated, IRIS), cerebral malaria, onchocerciasis, candidiasis, toxoplasmosis, snake bite, stroke, lymphoma.
As the staff (and med students) scatter, I stay to help the intern and house officer see the new patients and hustle to get all bloodwork and other samples in before the lab closes. I am putting in IV's, starting and changing fluids, drawing blood, making blood slides for malaria, and getting patients' urine and stool samples. We have a couple LPs to do before the end of the day and a resident from Canada stays to supervise me. We get one done, but are unable to do the other because there is no alcohol available on the ward to clean the site, so we will do it tomorrow before rounds (hopefully).
I go back to the IDI around 4:30, where there is wireless internet, to work on my research project. I get out late today, around 7:15 and head home, across the street, to grab some food and then socialize - my two favorite past times.

One picture...every day

January 21 - The 1.5 hour flight turned into 8 hours of traveling, after our layover in Dar Es Salaam. We finally made it to Kilimanjaro airport, where my mom was waiting for us. The power
went out while we were retrieving our bags, but we made it out and into Moshi intact.


January 22 - Our introduction to Tanzania, safari, and Swahili. We oohed and ahhed through Lake Manyara National Park, wanting to take so many pictures and receiving assurances we would see so much more in the coming days. We stayed at my overall favorite, a beautiful tented lodge camp called Migunga Forest outside the town of Mto Wam Bu.

January 23 - We made our way over the Rift Valley Wall and caught a glimpse of the Ngorongoro Crater from the rim. Our stop at a Maasai village made me sad at how they are selling their culture to tourists and upset at how conniving they are, leading to Ruy's mantra "Watch out for the Maasai." Lunch was eaten at Olduvai Gorge while getting an earful of its archaeologic importance, then finally on to the Serengeti - a truly remarkable experience!

January 24 - It just gets better! Today we were surrounded by herds of animals, hundreds of zebras and wildebeest. I could have sat there all day watching the graceful giraffes, moving as if in slow motion. Then on to playful baby babboons and a hippo pond (loved it!). In the evening we watched the sunset from the park, with the shadow of a leopard hanging from a tree branch...


January 25 - We left the Seronera Wildlife Lodge and spent our last morning in the Serengeti before descending into the spectacle that is the Ngorongoro Crater. Here there is a tremendous concentration of wildlife, as we saw 4 of the big 5 - rhino(!), lion, elephant, and buffalo - in the first few hours of our arrival. Midday was an adventure where we had sandwiches stolen out of our hands from swooping birds, an elephant joined us for lunch, and then ran into friends from Minnesota, Ann and Libby. Phil got his wish for a lion hunt while we were chilling with the lions and a zebra wandered away from the herd looking for water, it all unfolded in front of our eyes...


January 26 - Since we decided to take our Ngorongoro game drive yesterday afternoon, we had the morning to relax on the rim of the crater, drink tea, and reflect on the amazing things we have now seen. Something I was able to share with my mother...things I will never forget.


January 27 - Unpack, repack, back on the road; and a very bumpy one at that, for 4 hours, to the Rongai gate. We had chosen a less-traveled route on the Eastern slope of Mount Kilimanjaro, meaning there should be less people, more animals, and little rain. We saw black and white calabus monkeys playing in the trees, but it rained all day and we made it to Simba camp after dark. Thank goodness for giant Ziploc bags.

January 28 - We left Simba camp at 2600 meters and hiked 7 hours (pole pole - slow) to Kikalero camp at 3600 meters. Tonight they began the ritual of checking our oxygen saturation and pulse to make sure we could handle the altitude. We had decided on a longer, more interesting route via Mawenzi Tarn and from now on we would see no other hikers until summit day.

January 29 - At some point during our 3 hour hike to 4300 meters, I looked up and was awed by the snow-covered jagged rock that erupted from the clouds directly in front of us. This was Mawenzi Peak , where the second of 3 eruptions occurred 60,000 years ago, and to which no one reaches the peak as it is far too dangerous. We arrived at camp walking through the clouds, where we would sleep at the foot of Mawenzi.


January 30 - Everything was covered in snow as we peaked out of our tents this morning. Ellie, my Catalon-speaking, Barcelona-living Portuguese tentmate, and I were the only women on this trip. So...in the midst of drinking a lot of water and taking Diamox, we also tried to avoid trekking outside into the sleet and snow to make short call; an adventure in itself. The day included a 4 hour hike to Kibo Hut at 4700 meters and attempting to rest up before our midnight departure.

January 31 - What an amazing and exhausting day! I put on my entire wardrobe - 5 layers on top, 4 layers on bottom, and 2 pair of smart wool socks - to start the trek. I felt like I was on empty just a few hours into the early morning hike, but Milky Ways, Gummy Bears, and 5-hour Energy Drink got us all to Gilman's Peak at sunrise. We walked around the edge of the crater to Uhuru Peak at 5895 meters (19,340 feet) above sea level!


February 1 - After yesterday's 17 hours of hiking, you would think 6 hours wouldn't be this bad, but my knees and feet ached from the previous day's 8 hours of hiking DOWN to Harambo camp at 3720 meters. We took a different route down the mountain - the Marangu Route - and were able to see completely different scenery. This day was all about haraka haraka (fast) for me, because my mom was waiting for me at the gate and I desperately wanted/needed a shower. We made it back to Moshi, got our certificates, and had some Kilimanjaro beer to celebrate. Congratulations to my fellow trekkers - Ellie, Phil, and Dan; and thanks for accompanying me on this amazing journey!

East African Adventures

I apologize for the delay in posting...but really I am not sorry as I just had the most amazing 2 week adventure ever! My mom flew into Tanzania and we spent some quality time with the Barbosa family - Ruy, Daniel, and Phil - while we were chasing wild animals in our Land Cruiser with our trusty guide Wambura behind the wheel. After our safari, we picked up another world traveler, Ellie, and she joined Phil, Dan and I as we started trekking up Mount Kilimanjaro. In the meantime, my mom had an incredible experience at an orphanage in Marangu and Ruy spent his time cogitating, losing bets, and surviving in Moshi. After a brilliant but exhausting hike, it took all we (Ellie, Dan, Phil, and I) had to walk to dinner. Ruy and my mom had to stop and wait for us while we struggled stepping down from curbs and had no qualms making fun of our physical condition. We said our goodbyes as Ellie started her safari adventure, the Barbosas headed back to Kampala, and "Mama Sally" and I got on the bus to Nairobi. After a couple days in Nairobi, my mom started a 2 week trip through Kenya and Uganda and I enjoyed yet another long, hot, bumpy , dusty bus ride back to Kampala. I am now back to work (as you can see) and surprisingly, halfway through my time here in East Africa.