Hell Hath No Fury Like the Sun Scorned

Grant at last weekend's poker tournament. Easy way to earn a few hundred bucks.

Things have been going well since Ann posted last week. We've continued to work on the Cryptococcal Meningitis Immune Reconstitution Inflammatory Syndrome (CM IRIS) database at the IDI. The work is quite monotonous and mind numbing. It's especially a struggle after lunch, which always contains an abundance of carbohydrates, and I often find myself struggling to avoid dreamland. We are nearly done updating the database, so in a few days I will start tagging along with a Ugandan neurologist's team in the clinic to learn how they administer their neuro-cognitive testing. Once I figure out what this consists of, I will venture off into the world of the IDI and attempt doing them on my own. It'll be interesting at first, but I should improve with time. The plan is to be running on all cylinders come December/January when the new antiretroviral therapy timing trial (hopefully) begins.

Ann went to Tororo on Friday for an East African Scholars meeting put on by U. of California San Francisco. 4 hour drive there, 6 hour meeting and 4 hours back all in one day. Sounds brutal, but apparently the road is one of the better you'll find in the country. I spent the day at home doing laundry. Gotta love hand washing your dirty clothes. I literally skinned one of my fingers by scrubbing. I will say my socks get much cleaner by hand than with a machine, but the process is just so time consuming.

We went to the Kabira country club on Saturday morning to take part in a spin (intense exercise biking) class. I'm still feeling it today. Beautiful place and I'll need to spend the day there sometime hanging out at the pool. I've never been a huge pool guy, but when you can't escape the heat they're very enticing. Too bad my malaria prophylaxis (doxycycline) makes me burn quite easily. Every time I spend time in the sun I end up with a bit (or more) of a burn. Saturday night we actually stayed in for once. There are always things going on and sometimes I miss being able to just relax at home. Luckily we bought a (pirated) dvd of True Blood season 2 and had a marathon viewing session Saturday evening. I've gotten Ann hooked on the show while here as I had the first season on my computer. She's not so into the graphic vampire stuff (which is the best part), but she puts up with it. We'll have to find something a little more light hearted for our next series. It's quite annoying watching tv on my 12 inch laptop screen, but I guess it'll do.

Sunday we went to Munyonyo, which is essentially a suburb of Kampala on Lake Victoria. Went with our South African friends to a beautiful resort that had just hosted the presidents of the African Union. Security was pretty tight. Soldiers with AK 47s all over, and this was after the presidents had left! We hung out at the pool and did some boating/tubing on the lake. The South Africans are friends with the executive chef at the resort and he treated us to an amazing meal. He hung out for a good portion of the day as well. One of the funniest people I've met here. On the way back we bar hopped at a few local pubs ending up at Bubbles in Kampala. We usually get our interneting (is this a word? it should be) done here on Sunday nights.


Grant admiring his sweet farmer's tan.


Ann thinking "Lake Victoria ain't got sh*t on Lake Villard".


Awwwwwww.

So today I'm dealing with the pain of a new sunburn and trying to get into the whole database updating again. Kind of slow moving today. I'm excited that Halloween is coming up this weekend, however it's not a holiday they celebrate. There are usually parties going on amongst the ex-patriot community. I plan on playing in a poker tournament at the Pyramids Casino. This is assuming there is still space when I sign up tonight as it's only open to 30 people. First place is about $3000 or so as the casino is putting a bunch of money is the prize pool. If I do well, I'll likely miss the Halloween parties. I'll take the money, though.

BACK IN THE KLA

Back in Kampala and it feels like I never left. It has been great running into old friends and meeting new ones everyday. Back at Mulago and the IDI, things are still the same - for good and for bad. It is nice, though, to show up and know where to go and what to do and not having this awe-struck look on my face all the time. I know how to respond to the mzungu calls, negotiate a boda or taxi ride, and where to get the best Indian food. Grant is doing great, much better than I did on my first appearance in Africa! And he is doing a good job on keeping you all updated. But I thought I would give you my perspective too, whether you like it or not.

Work has consisted of doing some training in what my new job will be as study coordinator of a large clinical trial. I will be in charge of some of the accountability and quality management, so basically making sure the protocol is followed, everything gets documented, and regularly reporting to the organization funding the project (National Institute of Health, Division of AIDS). We are going to apply this process to a current study and hopefully it will be a well-oiled machine by the time this trial starts.

At the IDI, where we work, there are journal clubs, research meetings, and clinical conferences that give us some structure to our day. Our first day we showed up and it was nice to have a welcome from Andrew Kambugu, and entertaining to see all the mzungus start whispering when we walked into Monday morning journal club. They were warned of our coming by various sources (Katie P and Kristina) and we all became fast friends. Soon enough our social calendar was full.

This week we went out for pork, were part of a winning quiz night team, went to watch some intense Uganda basketball, spun at Kabira (me), took 3rd in a poker tourney and won $300 (Grant), and we went to a braai hosted by new South African friends.

I am grateful for all of our friends here, Ugandan and expat, new and old. Looking forward to more adventures to come!

But also missing our friends and family back home. We love you.

Pictures!

Man delivering bags of charcoal in Jinja...not a desirable job.


We stayed at Gately on the Nile. An old colonial mansion refurbished into a hotel in Jinja.


Breakfast at Gately (from L to R Elena, Grant, Ann, Sheida).


Dinner at Haandi (Indian Restaurant in Kampala) for Elena's 30th birthday (L to R Veronica, Kieran, Sheida, Peter, Grant, Ann, Michael).


Elena, Sheida, Ann and Grant towering above the Nile.


Part of the Adrift (rafting company) campsite on the Nile River...it is here that I saw my first wild monkeys. And they were fighting! Hilarious...


Grant at the Adrift campsite overlooking the Nile River.


Some buildings in Jinja. It's probably hard to tell in the small picture, but the sidewalk is in some serious need of repair. Those repairs don't really occur here. Potholes don't get fixed...instead cars swerve all over the road to avoid them.


Street scene in Jinja. Notice the matatus (van-like vehicles). These essentially take the place of city buses...they'll cram up to 20 people in them!


Fisherman on Lake Victoria in Jinja.


Grant and Ann at Lake Victoria.



The view from our kitchen and off our deck/porch in Kampala.

Jinja

We went to Jinja on Lake Victoria this weekend. This is the source of the Nile River. I went white water rafting with our friend Elena, a medical student from Penn, while Ann explored town with our roommate Sheida, another medical student from Penn. It was my first time rafting, and I have to say it was quite an experience. Drifting 31km down the Nile was pretty amazing. The rapids were quite intense, with the majority of them ranking class 3 to 5. We spent some time swimming in the river when it was calm, so I'm looking forward to taking some medication for the likely schistosomiasis that I now have. We saw a lot of interesting wildlife including a monitor lizard, a baby crocodile, an otter, and all kinds of birds. It's the rainy season and of course it started raining after lunch. At first it was fine, but then it turned into a torrential downpour with strong winds. Honestly felt like a hail storm. We couldn't even see the other rafts in the river for a while. We ended up making our way to some rocks on shore and propping up our raft while we huddled underneath. Our Ugandan guide, Roberto, was quite freezing. I'm used to worse. When the other rafts caught up to us we ventured back out as the wind had died down soon followed by the rain. The ride back to Jinja was pretty bumpy and slow. We had an altercation in the middle of a small village's marketplace where there was only room for one lane and another car wasn't going to move out of our way. It took like the entire village yelling at him (as well as a "bump" from our truck) to get him to move. Quite a scene. I nearly ruptured my bladder, but luckily a few people begged enough for the driver to pull over allowing nearly the entire truck of people (30?) an opportunity to pee in the ditch and/or bushes. Ann spent money in town...she'll have to post to let you know about her experience.

The drive to Jinja was interesting. It is about 1.5 hours from Kampala on a good day going through rural Uganda and a rainforest. Driving here is crazy and It definitely requires your full attention (if you're the driver). People just kind of do whatever they want and people on the road usually accomodate you.
Friday was Ugandan Independence day, so a lot of people are on holiday this weekend. We had Friday off and spent it celebrating Elena's 30th birthday. Ate dinner at a very tasty Indian restuarant with some local Ugandans that we have met. Later drank wine and socialized at Elena's place, which is a beautiful house with a huge veranda (porch?) up on one of the hills in town. She's staying with an expat family that owns a gold mine in Uganda, or something like that. Pretty different than some of the slums near wear Ann and I live. The poverty here is very eye-opening. I'm thankful for how lucky we are in the US.

We're still working on internet and photos. I feel like we're back on dial-up in the early days of the internet. I promise we'll get photos soon. Probably a post with entirely photos from everything so far...

We Have Arrived

Well, Ann and I have finally gotten (somewhat) settled in Kampala. After a brutal day of travel involving canceled flights, hours spent in the Mpls and Amsterdam airports, long waits in the immigration line and one lost bag (Ann's) we finally were on our way from Entebbe airport to Kampala. It was around 10:30pm local time, so it was difficult to see much beside the Friday night life along the road. Those of you who have trouble with Minneapolis or Chicago traffic have no idea. Try driving down a dimly lit "highway" sharing the road with bikes, motorbikes and pedestrians walking along the side. Luckily the speed limit was fairly slow...I can't imagine if the speed limit were the equivalent of 55mph. We were probably about 1-2 feet from killing some guy who thought it a good idea to stroll across the highway at a nice leisurely pace...if our driver hadn't seen him at the last second and swerved out of the way it would have been a much more interesting introduction to Africa (for me...this is second nature for Ann).

Once we got to the city, we had a ways to go to reach our apartment. Ann was able to point out some things to me along the way. It was quite a relief to get to our apartment. We got all of our bags inside and fell asleep immediately. Our apartment is relatively nice. I don't have much to compare it to, but I can't complain considering we're in Africa. I've killed two cockroaches, apparently they enjoy my room the most. We have running water, a small water heater for showers, a portable gas range, and a small fridge. It's a three bedroom apartment, two of which are taken by Ann and I. The third is a medical student from Penn who is here for 2 months. Sleeping under mosquito nets is a new experience for me and I have to say it's pretty annoying. No air conditioning, but at least we have a fan...could be worse.

So far we've done a lot of walking around the city, visiting the supermarket, eating at some restaurants, checking out the ex-pat bar scene and going to the "mall". The scenery is beautiful from afar, but up close can be a different story depending on where you're at. I can say it's unlike anywhere I've ever been. We're in a somewhat poorer part of town, but it's pretty safe. We take the same precautions as we would in Minneapolis. I've yet to see much wildlife, but we do have neighbors with chickens in their yard complete with a rooster that makes sure we're up every morning.

Tomorrow we start work at Mulago Hospital and the Infectious Disease Institute. Probably will involve meeting lots of people, getting computer access, and getting used to everything. Not sure what to expect, but it will be interesting.

We'll try to post as much as possible, at least once a week. I'll get some pictures posted, hopefully in the next few days. Internet access is somewhat limited, but we're working on getting our own at the apartment. I hope everyone is doing well...I'm finally starting to realize how long 8 months is. I already miss Hunter...and I suppose everyone else too.

New posts coming...

I apologize for not keeping up on weekly posts, like I had originally intended. The internet here is very sporadic and unreliable, so much so that sometimes creating and publishing a post, with pictures, will take me hours.
But there is so much I would like to share with you...so I plan on catching up in the next week or so and getting more pictures and thoughts up for you to enjoy.
As I leave for the airport in a couple hours, I am contemplating all of the people I have met, the adventures I have had, and the skills I have learned. So much to think about...and talk about if you ever have interest.
I am so excited to see my friends and family. Grant will be picking me up at the airport on Saturday and I will head home on Sunday to visit my family and celebrate Grandma's 90th birthday.
See you all soon...

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.