Bad Idea

If you look closely, you can see that we already realize this....

Word of the Week

“Diarreted” (die-uh-RETT-ed)

Me: Did she have any diarrhea?

Moses (my translator): She says that she diarrheted once last night.

Belly Juice

A woman came in last week with a big distended belly. She had lots of ascites (fancy medical word for fluid that’s not pus or blood). At first I assumed she had cirrhosis, which is the most common cause in the U.S. But in her case it was heart failure so bad that the fluid had backed up through the liver into the abdomen.

She was in a lot of pain, and I considered doing a paracentesis immediately (draining fluid directly from the abdomen using a needle). But then she told me that she had stopped taking her meds two weeks ago. And that meant that I should try putting her back on her meds before poking around with sharp objects.

A day later I saw her again and she wasn’t better. Her big belly was firmer than before, meaning more fluid had collected inside. The hospital was out of IV lasix, which would be my medicine of choice, and the oral lasix wasn’t getting the job done. So I decided that a paracentesis was, after all, necessary. Plus she said she was having trouble breathing. (Any compromise of the vital signs seals the deal.)

In the U.S. we have these nice kits with the word “Saf-T-Centesis” printed in big letters on them. You tear the package open with a satisfying ‘rrrrrrrrrrrrtttttttch” and everything is nicely laid out inside. One of my many fears before coming to Uganda was having to do a procedure --- any procedure --- without the comfort of a kit.

Now, I don’t want to alarm anybody who’s coming to Uganda soon. But yes, the technology is different. They don’t have fancy sterile kits, and that means you have to learn how to use some new equipment. How are you going to learn this new equipment? By inserting it, your first time ever, into a real live human being (who by the way is very sick so you can’t screw it up).

So yes, you have to be willing to get your hands dirty. And by dirty, I mean literally. Like covered in amber belly juice.

But I’m getting ahead of myself.

It seemed so straightforward when I mapped it out in my mind: take an IV, stick it in the belly where the fluid was collecting, remove the needle, let the fluid drain through the catheter and tubing into the bucket. All I needed was an IV, some tubing, and some iodine to sterilize. Simple.

I found an IV in the nurses station and played with it for a few minutes. Needle. Catheter. Plastic bits. Cool.

Next I pulled out a length of IV tubing and inspected it. One end was easy, it was designed to attach to the IV. The other end was supposed to go into a bag of saline or Ringer’s, and had a sharp plastic prong on it for said purpose. I hunted for a pair of scissors for about three seconds, and then just yanked the prong off by hand.

I was ready to go. Or so I thought.

I had by now collected two medical students to assist, and they reminded me that we would need a place to put all the ascites. (Good job Jen, you are so getting honors.) I knew there would be a lot of fluid, so we needed a big container.

Of course the hospital had nothing useful, but the impoverished patient did. Like everyone admitted to Kisoro District Hospital, she’d brought a wide plastic basin with her.

(Why, you ask? Standard patient behavior at KDH is to keep one’s basin beside one’s bed, and lean over at intervals to spit into it. I never object to this behavior, because it eliminates the question “what color is the mucus you are spitting up?”)

We were ready to go. I sterilized the area, and inserted the needle using proper Z-technique (don’t worry, I just threw that in for medical-legal reasons.) Nothing came back through the IV. I pushed and pushed, until I started getting worried that I was going too deep. There was, after all, an intestine in there somewhere, with a thin wall easily punctured. On a whim, I pulled out the needle, leaving the catheter in place.

Suddenly clear amber fluid started spurting from the IV, dripping on the bedsheets and all over my fingers. I fumble with the tubing, trying to screw it onto the IV, but it won’t go. Why won’t it go? I stub them against each other, but they’re not designed to interlock. Oh shit! I’m trying to attach two female ends together. Stub stub stub. Everyone’s watching, shit!

Then I see it. There’s some kind of plastic doohickey attached to the IV, a tiny clear nub getting in the way. I twist at it, still under the wide-eyed gaze of the patient, her family members, all the patients in neighboring beds, and the two medical students. Everyone’s fascinated by this, it’s a flaming car wreck, they can’t turn away.

The nub is still there. Why is there a nub and why won’t it come off? Why would anyone design a product like this? Its sole purpose is to humiliate and destroy well-intentioned doctors like myself. The fluid keeps pouring out of the IV, and my hands are getting slippery. Do I deserve this? I came here to help people, for God’s sake, not cover myself in abdominal juices!

Finally the nub comes off, and now the tubing fits neatly onto the end of the IV. I screw them together tightly and watch the fluid drip down into the basin which is resting on the floor.

That’s it for the exciting part. We didn’t have vacuum bottles to suck the ascites forcefully from the abdomen, so we had to sit and let it trickle out by the force of gravity. Took about half an hour.

I squatted, holding the tubing and staring at the bottom of the patient’s basin. It was forest green, with a snowman pictured over the words Merry Christmas. I wondered, since most people in Kisoro have never seen snow, if my patient understood who this rotund white figure was, and what he represented.

We drained out about six liters of clear yellow fluid. The patient’s belly got less swollen and she felt better. That’s it.

Probably the grossest three seconds of my entire month in Uganda was when I had to carry the full basin of off-yellow fluid into the smelly squatter bathroom and dump it.

Please give thanks, to whatever Lords you may have, for the great great gift of Purell hand sanitizer.

more to come....

Haggling addendum

Last week I went to the massive, semi-weekly market in town. I bought a cabbage for 300 shillings, about 15 cents.

Then yesterday I was walking home from the hospital and I saw some ladies selling vegetables. I bought some tomatoes and onions, and I threw in a cabbage, what the hell.

When I paid them they said I was 200 shillings short. I counted up the items and couldn't figure out where the discrepancy was.

"It's 300 shillings for a cabbage, right?"

"No, five hundred," one lady said.

"Oh. In the market last week it was three hundred."

The lady was middle-aged, and her bright sarong was knotted at the shoulder. "Even us," she said, "we buy them three hundred in the market." A smile was creeping up her cheek.

"And then you charge me five hundred!" I returned the smile.

The lady, happy that I was taking this the right way, gave me the full toothiness of her smile. In what seemed a universal gesture, she raised her palm to shoulder height.

I slapped it. High five for capitalism.

Stolen Photos V

Here's Lake Mutanda, close to my hospital and home of my Best Day in Uganda. Finally got a clear shot of the island we canoed to, it's the tall one in the distance.

Bovine Intervention

A few night ago I was walking in pitch black down the craggy dirt road that leads to the med students’ house, when I was almost gored. I was lost in thought, not really looking at what was coming at me, when suddenly a horn passed six inches from my right breast. I looked up and saw eight bulls walking at me down the middle of the road.

These were the gorey kind of horns, too. Not the Mary Tyler Moore-style horns that Cape Buffalo have, or the purely decorative antelope horns. Ugandan bulls have some kind of Pamplona lineage in them, they sport serious impalers. The horns come out from the head at a forty-five degree angle, then curve gently forward so the sharpened tips are facing dead ahead. It’s a fiercesome look.

And here’s the topper: Taking up the rear of this deadly herd was a boy who could not have been more than seven years old. I’d say he was probably five. But it was pitch black, so hard to say for sure.

Stolen Photos IV

I know it looks like a river. But it's Lake Bunyoni, and it stretches 25 km. Also apparently the second deepest in the Africa...

a thousand words on why I don't care about this subject

I’ve noticed a change in myself recently, and I’m trying to figure out why. By "recently" I mean over the past ten years. And by "change" I mean fade away.

I'm talking about haggling. This is something that many of us who travel in poor countries engage in. Even though the real dollar amount is small, there's something bothersome about getting “the tourist price”. Everyone wants the local price, it’s a badge of honor, something you can tell your friends about when you get home.

Many of you have been on the receiving end of exactly these stories. The setting is a sophisticated dinner party in Manhattan or Washington DC. Someone remarks on the African (or Asian) piece of art (or sculpture) on the wall (or coffee table), and everyone stands around with their chablis admiring it. Eventually (inevitably), the story of its acquisition is told, and that story, quite frequently, involves a deep personal connection between buyer and seller, such that “he gave us the local price.”

There’s always a pause after that revelation, to give you a chance to be impressed. You didn’t know your host was such a friend of the downtrodden. You didn’t realize he had the ability to forge such deep personal connections with marketplace vendors --- and so quickly! after a ten minute chat! --- such that for the sake of friendship this vendor would forgo the need to earn profit and feed his eight children. Your host must be an incredible person, far more profound and spiritual than you’ve given him credit for. Funny, he seemed so ordinary on the outside.

I’m not judging. I mock because I care. I mock because I too was someone who needed to get the local price. I too have haggled over a five cent banana.

But I don’t anymore. And that’s my long-winded way of getting to the point: I don’t haggle anymore.

Okay, that’s not true. I haggle, but only in dollar terms. I will haggle over a ninety-dollar rug, if I think I can get it down to fifty. But I will not haggle over a fifty-cent cup of tea, even if my refusal to haggle costs me a thousand dong (official currency of Vietnam).

And why? Is it because I have more money now? I don't think so. As much as I like to romanticize my poverty-stricken college days --- and it's true I did hitchhike around Europe gnawing on day-old baguettes --- I don’t think there was ever a time when ten cents was a big deal to me.

Another possibility is that I'm getting older. I’m not as angry at the world. I no longer worry that everyone is trying to rip me off. Because I know everyone is trying to rip me off, and I have more important things to care about.

The third possibility is that it’s a confidence thing. I finally have nothing to prove. I only cared about getting tourist prices when I was worried I might actually be one.

This explanation makes sense. The more I think about it, what other weird behaviors accompanied my need to “get the local price”? Well, I was petrified of carrying a camera around my neck. I wanted photos, but struggled to take them because I hated having people see me with a camera in my hand. And never in a million years would I hang one in that neck position reserved for tourists.

I would never wear logos, or any clothing with too much of an American flavor. My reasoning at the time was that this would help me blend in. (Yes, that’s right, during a summer spent in the West African country of Mali, this white boy devoted serious mental energy to "the best way to blend in.")

Another eyebrow-raiser: I hated taking out maps in public. I would find a secluded corner, press my forehead into it, and then surreptitiously remove the map from my pocket and consult it in a tachycardic sweat, before shoving it back into my pocket and proceeding nonchalantly down the street.

My logic was that I was at greater risk of being mugged if I openly took out a map. I imagined the thieves in Kinshasa crouching in alleys, scanning fruitlessly for tourists, frustrated to tears.... and only when I slipped up and exposed my map did they cry A-ha!

Today, all the tourist-hating behaviors are gone. I take out maps and stare at them, and squint at the sky, and scratch my head. I wear stupid American clothing everywhere. (When we went gorilla tracking I wore my “I ♥ BX” T-shirt, and only realized it later when I saw the photos of myself.) And the only reason I don’t hang a camera around my neck is that I can’t keep one unbroken long enough to do so.

I guess for me haggling is like a fluffernutter: I remember the old appeal, and I can still enjoy it, but somewhere along the way it just stopped being a part of my life.

Office vs Lawn

I saw a patient in the Chronic Care Clinic today who I was sure had cirrhosis. Skinny guy, big tense belly. Spiders, caput...I was sure it was ascites. Still, you gotta do those maneuvers to confirm it: shifting dullness, fluid wave, you know the drill.

But clinic in Kisoro means lawn furniture. I’m sitting behind a desk, and this guy’s in one of those green plastic deck chairs in front of me. That's the entire room. It's not that I'm a bad writer and I can't think of other details. I can describe the dirt on the floor if you want: it's brown and powdery. But that's all, there's a desk and two chairs and some dirt. No crinkly roll of sterile paper to cover the examining table. No examining table at all.

The message to me is clear: don’t examine the patient unless they’re sick enough to be admitted to the hospital.

But I'm stubborn, and I cling to my antiquated ways.

So I made the guy lie on my desk.

Stolen Photos III

This church is just up the street from the hospital. But really I chose it for the majestic view of Muhavura volcano (which resides in three countries).

Don't Know What You've Got

When I first arrived in Kisoro, I had a translator named Bob.

Let’s all take a moment to giggle at his name.

Ready?

Bob is a skinny kid, probably about 20. He has a lopsided smile.

It always irked me that Bob seemed kind of bored doing translation. He would look off into the distance, play with the blood pressure cuff, always with a Why-am-I-here expression on his face.

Then two days ago Bob had to go home for a family emergency. Moses replaced him. Moses never acts bored. He never stares off into the distance, he’s always focused.

But Moses’s translations are nowhere near as good. Moses talks much slower, he often struggles to find the English words. The reason he's always focused and engaged because this is a difficult job for him. Bob was always bored because he was too smart for the job.

I would take Bob back in a second.

There's something else I only appreciated about Bob after I lost him. (no comments from the peanut gallery about that last sentence.) Bob quickly picked up on my insecurity: I wanted absolutely everything translated so I didn't feel like I was missing anything. Even when there were little insignificant exchanges (like “hold on, I’m going to translate that for the doctor”), Bob would then turn to me and say, “I just told her I’m going to translate for you.”

Why did he need to do that? Because I have some weird fear that in those little exchanges, Bob is saying “take six doses of lamivudine and then stop.” If I really trusted him, I wouldn’t need to know every last word.

But Bob didn’t try to challenge the irrationality of my obsession. He just accepted it and adapted to it.

Bob, I hardly knew ye.

Frustration III: Blocked in Translation

I still get frustrated on the ward. I guess it will never go away.

My frustration comes out in some particularly wince-worthy ways at the end of a long day.

The most reliable source of daily wince-fodder is the interaction between myself and my translator. Here’s a scene from the bedside:

Patient: Uga n'da uga n’da. Uga n’da uga n’da.

[pause]

Me: (to Moses, who is looking at the patient) What’d she say?

Moses: (faltering) She didn’t say anything.

Me: Yes she did, she just said something. She just said a whole lot of things!

Moses: (flustered) Yes, but she is saying. . . she is....

Patient: Uga n’da uga---

[I turn to the patient and hold up a finger to silence her.]

Me: (to Moses) Please just translate what the patient says.

Moses: She is saying, there is some important thing for me to translate to you, and this is what it is.

Me: Yeah, okay, what?

Moses: That is what she said to me. She said there is something important for me to tell you.

And then I cut her off just as she was starting to tell it.

Yes, that’s a little embarrassing. A good lesson in trusting your translator. And trying to chill out a little bit.

Stolen Photos II

I'm pretty sure this is where we shouted to the island on My Best Day Ever. Note that you cannot see the island in question.

Stolen Photos I

Since I have a crappy camera phone, and I can't seem to make the USB cord do its job and transfer the photos off it, I am initiating a new series (in my final week here).

There are 1377 photos stored on the computer that I often use to upload to this blog. Let's have a taste, shall we?



I know this view well. It's from the hill that overlooks the hospital. Those blue roofs are the hospital.

The internet is in high demand tonight. More soon....

Messing with the mzungu

Word is out that I’m learning Rufumbira. Twice yesterday someone greeted me using the local language. The first was Peace, the lady who owns the shop where I buy tomatoes; I noticed a sly smile on her face as she did it.

The second was a group of teenage girls. We were walking the same direction on the road from my house to the hospital, on opposite sides of the street. “Warai?” one of them called. I knew what was coming. I called back “E’go” and they erupted into peals laughter.

They laughed so loud I saw a goat lift its head.

Trade offs

The dry season here is dusty. The Mack trucks roll past --- building a road to Congo -- and send the dust hundreds of feet into the air. It's like a fine brown talcum powder, it gets in your eyes, your hair, the keys of your laptop.

But the late afternoon sunset is a crisp circle of orange, like the sky has been hole-punched with fire. It almost makes it worthwhile.

My Best Day in Uganda, Part III

(We're in the courtyard of a little village on Mutanda Island, surrounded by children.)

After everyone was done with spaghetti, I plucked the tiny container of honey from my satchel. It held maybe a quarter cup of honey. Originally my plan had been to spoon a little onto a piece of bread for each child, but it was clear now that bread would not be forthcoming.

I went over to the 4 to 10 year-old group. All twelve of them were still clustered tightly on the woven mat. I took out the little container and peeled the top off. They marveled at the little golden stalactite that hung from the cap. I dipped my finger in the honey, put it in my mouth, and made Yummy Yummy noises. I offered the honey to one girl and got her to dip her dainty finger in and taste it too. Another girl followed, but both of their reactions were more bemused than excited. The other children watched closely, unsure about whether to taste. I thought the whole thing might flop right there.

Then suddenly, from the back of this tight mass of children that had twenty arms and hands going in every direction, one adventurous girl leaned forward and jabbed her finger deep into the honeypot. Everyone laughed. The ice was broken, and now everyone wanted some.

Honey is not the cleanest of substances to distribute. When the girl from the back brought her finger to her mouth, she dragged a line of honey across three other girls. This was nothing short of hilarious, of course. I glanced at the adults to see if there was disapproval for what I’d begun, but they all seemed to find it a gas too. So we kept it up: finger dip, retrieve, drag honey across the dress of your neighbor, laugh hysterically. If this were a comedy routine, I would say that I killed.

I offered the honey to Kabunga, the twelve year-old head of household. Rather than just dipping his finger, he paused and took the container from me with a stern dignity. He looked at it for a moment. He probed with his finger like a surgeon exploring a wound, and brought it cautiously to his mouth.

No one turned down the honey. The old ladies. The too-cool teenagers by the banana trees. Everyone had to have a taste. There was still an eighth of a cup when I finished, so I presented it, publicly and formally, to Kabunga, for him to dispense later as he saw fit.

Eleanor and I sat against the wall of the mud hut to digest. The 4 to 10 crowd suddenly got an idea, and two girls ran off behind the hut. A few others whispered to each other and followed. Soon the entire bunch of youngsters had disappeared. The teenagers continued to watch us sullenly. All was normal in the world.

And then the children were back. And Kabunga’s sister was banging a blue jerry can with a length of sugarcane, while the kids jumped and stamped and swung their arms behind them. The rhythm on the jerry can was this (in an eight count for you musicians):

1. Tap-[pause]
2. Tap-[pause]
3. Tap-Tap
4. Tap-[pause]
5. Tap-Tap
6. Tap-Tap
7. [pause]-Tap
8. Tap!

It’s a cheer. I don’t know the words to it, but I know that those last two taps are accompanied by a spirited “Let’s Go!” and a flail of the pom-pom.

Then they asked us to dance for them. And as much as I love to dance, the packed dirt courtyard isn’t my usual venue. But we’d had such a lovely afternoon, I was high on the connection we’d formed, plus I was probably suffering a little heatstroke, so I pulled out my crappy camera phone, which had a few MP3s on it. I scrolled past “Heart Shaped Box” and “Gouge Away” and stopped on “She Loves Me Like a Rock” by Paul Simon. I pushed play, and a thin reedy sound emerged from my phone.

And then Eleanor and I got up and danced. We danced our freaking hearts out there on the packed dirt, on the island, in the lake, in southwestern Uganda, just a few miles from the border of Rwanda and Congo.

The children stood motionless and expressionless while we danced. I like to think their small minds were expanding. I like to think we widened their horizons, stretched the scope of their understanding of the universe forever.

Eleanor had a different opinion. “I think we traumatized them,” she muttered.

An awkward pause ensued, and then someone started banging on the jerry can again. Everyone preferred this, and we all just jumped around together for a few minutes.

The sun was dropping, and the honey high was fading. We tramped back down the path, just as sunset reached its Point of Maximal Impressiveness.

The ride back from the island was a luxury: two canoes. I guess we’d done something right. When we arrived on the opposite shore I paid the boy who’d rowed us both ways the equivalent of 25 cents, and Willbroad said that was too much.

Just before the boy pushed off to go back to the island, a second boy ran down and jumped in the canoe. “Wait, who’s that kid?” I said.

Eleanor got it. “Oh my God, remember when the canoe first came to pick us up? There were two kids in it, and one of them stayed here. That boy’s just been sitting here the whole time...”

I won’t try to make a profound point. I won’t try to spin this into some fluffy cotton candy about how every time you try to help one person you end up hurting someone else. I think the point is this: Not everyone gets to eat spaghetti every day.

Where I Live Now

Rwanda Genocide Memorial

Such a great memorial. Really lays it all out clearly, tastefully, and powerfully.

I actually found this much more moving than the holocaust museum. (Is it uncouth to compare genocide memorials?)

Among the hundreds of photos of dead bodies there's one that really grabbed me. It's of a man stuffed through the side window of his truck. His body is bent in an L-shape, his head against the seat. He didn't die this way, the indignity was put upon him after his death.

The main section of the memorial moves chronologically, and is beautifully done. By the end of it, I was pretty much spent. I'd gotten a little teary and figured it was time to leave. I walked back into the lobby, stumbling toward the bright sunlight, when a quiet-voiced young woman gently touched my elbow. “There is one more section upstairs,” she said.

I asked her what the other section was. “The children,” she replied.

Oh Jesus. Just put an icepick in my heart.

But when someone says that you can't just wave and say "No thanks, maybe next time." So I walked up the stairs.

On each wall was a giant over-sized photo of an adorable little kid. In front of each photo was a placard with a few headings: Favorite food, Favorite sport, Best friend. Some of the placards had Last Words.

And that was it. I lost it. I didn’t try to hold back the blubbering, I just kind of stumbled from photo to photo, tripping over my own feet. I was even doing those quick sharp intakes of breath. A total mess, I can’t even remember if there were other people in the room.

I finally got outside and figured this would be my chance to collect myself. I looked over a railing into a courtyard, and saw a group of Rwandans in formal wear carrying massive baskets of flowers. One man led them down a set of stairs and beneath a garden trellise.

I followed the group at a respectful distance, wondering what the official criteria for being a masochist were.

They carried their flowers and laid them on a flat concrete section of the ground. I could figure what this was. The preacher gave a short sermon/eulogy in Kinyarwanda, and they all walked back. I went over and looked. Like I said, these were some massive bouquets. Like six or seven of them. With names markered in capital letters on wide swaths of ribbon around the bouquets.

After that I just wandered around Kigali and smiled at every child I could see, and gave out way too much money.

Things I Didn't Know About the Rwandan Genocide

*This has been going on a long time. There was a genocide of Tutsis in 1959, just before independence. Then in 1973 there was a coup, also followed by violence. Then there were small bouts of ethnic killings all through the early 1990s --- at least SEVEN different episodes.

*In 1994, there was a major contingent of Tutsis who fought back. This seems obvious once you hear it, but we are so accustomed to thinking of the Tutsis as powerless victims. Basesero was the region, it was mountainous, they hid and fought guerilla style with bows and arrows and rocks. When the French forces arrived they came out of the mountains, but the French didn't protect them and many were slaughtered by Hutus.

*Rwanda was the most rapid mass death since since Nagasaki.

*300,000 orphans created.

*A priest drove a bulldozer into his own church to collapse it and kill 2,000 Tutsis hiding there.

*The manager of the Hotel Milles Collines (Hotel Rwanda) was not the only hero. Many, many Hutus protected Tutsis at great risk to themselves. One farmer laid them in a ditch, covered them with planks, then put dirt on the planks and planted sweet potatoes on it. Each Tutsi had a food/air hole, to which his daughter would deliver food disguised in a trash can.

A moment

Walking behind a woman late at night. Her infant son, wrapped tightly against her lower back, was giving out a faint wail of protest. The sound he made bounced in time with her steps: “Wahhh-AH-ahhhh-AH-ahhhhh-AH-ahhhhhh”

I think the little guy was kind of enjoying it.

Why Auscultate?

This blog has been very observational and analytical. And maybe a little sarcastic, big surprise. So let me just put a little sincerity on the record: I love this work. Seriously.

It just feels important. The day-to-day tasks, all the mundane details, they really matter. When I take a history, I actually care about getting every fact right. When I listen to a lung, I actually listen for crackles, like really listen. Hard. When someone has a heart murmur (and there are lots), I actually do those maneuvers like having them bear down, or lie in lateral decubitus.

I have to tread carefully here: I’m not saying I don’t do my job at home. I do listen to the heart and lungs on all my U.S. patients. And if one of my CHF patients in the U.S. has massive wet crackles at the bases, I’ll pick that up. But do we really base our treatment decisions on it? Rarely. Let’s say I’m trying to decide whether I should change the lasix dose. If the crackles sound the same, but the chart says he put out 4 liters of urine, which one are you going to trust?

When I do a heart exam, my opinion about whether it’s a late-peaking murmur radiating to the carotids don’t mean diddly. We’re gonna get an echo to find out if there’s stenosis. And all treatment decisions will be based on that. The heart exam is irrelevant.

Here in Uganda, the physical exam matters. Here, my physical exam is the final word. And I’ve discovered that when my physical exam is the final word, I actually care about doing it right.

Let’s be clear: I’m not saying that in the U.S. there’s no need for smart people to make diagnostic and therapeutic decisions. There’s plenty of brain work available. It’s just the physical exam that’s useless. And for a good reason: technology is better.

But patients want to be examined when they get seen by a doctor. So what’s the result? Doctors waste a lot of time doing physical exams that won’t really affect their treatment decisions. They’re disengaged from their work. Lower job satisfaction.

Me on the other hand? Here in Uganda? Every moment that I’m with a patient I’m engaged. Because I’m actually paying close attention to every lung I auscultate and every abdomen I palpate.

Is there grey area here? Obviously. There are plenty of examples in the U.S. of times when the physical exam does matter. And of course, when you’re unsure, you always go back to the patient.

But my “job satisfaction” here in Uganda has been strikingly high, and I think one reason is the real importance of ordinary tasks like the physical exam.

The other reason is lakes with islands in them.

My Best Day in Uganda, Part II

(When we last heard from our hero, he was in a canoe heading toward Mutanda Island.)

We pulled up to the island and the boy jammed the canoe hard into the reeds. “Wakozi,” we said to him as we hopped out. Thank You. “Shouldn’t we pay him something,” I said to Willbroad. “He is from the family,” Will replied. “This is like something that he does for the family.” “Like chores,” I offered. “Yes, that,” he said. Will wasn’t really listening. There was something up ahead of us.

The island’s residents had gathered along the path leading up from the lakeside. Almost all of them were women, and they were in their best Sunday getups. Purples and blues and oranges and greens, all of them bright and flashy, none subdued or muted. Not a pastel in sight.

We shook hands reverently with each old lady while the children screamed for attention. The kids grabbed at our hands, they stared, they stood in front of us and stuffed fingers in their mouths and pushed out their protruding bellies.

We visited the grandmother of the island first, which Willbroad stated was proper island protocol. On arrival there was another round of handshaking, bowing, nodding, smiling. I began using the few Rufumbira words I knew --- “Hello” “How are you?” “Thank You” --- and each attempt was greeted with general laughter.

I wanted to convey my enjoyment, and so I thought for a moment. “Will, could you tell them I think this is one of the most beautiful places I’ve been in my entire life?”

He translated it. One of the more spirited old ladies pumped her fist in the air and shouted a few words in Rufumbira. Everyone laughed.

“She says, ‘Oh, the mzungus, they all like islands, why do mzungus all like islands and water?’”

And I thought, Doesn’t everyone like islands and water?

We walked back down the hill to the home of Kabunga, the orphaned boy that we’d come to see. This boy had been discovered when a previous Montefiore resident in Kisoro had taken care of his mother, while she was dying of cancer. The resident was concerned about the woman’s children, and first came to visit the boy in 2006. Since then there have been regular trips, by many different people. Spaghetti-making is a frequent activity.

Kabunga (not his real name) is a quiet, upright boy. He seems older than his twelve years. He is the man of the family, and wears this title sternly. An attempt was made to pay for him to go to boarding school, but he quit and came back to the island. He said that as the man of the family, he had responsibilities and could not go to school.

Kabunga’s house is a simple mud hut. There are several rooms, including a kitchen, bedroom, and living room. When we first walked inside I made the mistake of taking a normal lungful of air, and I nearly asphyxiated. There was so much smoke that I could barely see to the other side of the room. Kabunga was casually dusting off a bench for us to sit on, and he seemed to be taking full breaths with no respiratory distress, which boggled my mind. I politely asked if we could move the bench outside.

The packed dirt courtyard was filled with two groups: children between about 4 and 10 who clustered on a woven mat next to the fire, and older kids from 12 to 17 or so, who hung out in back by the banana trees. Plus two or three old ladies. I was the only human being between 30 and 60. The gender breakdown was still 90% girls and women.

After another round of formalities, we started meal preparations. Wood was collected from whatever was in sight. A teenage girl brought a flaming fist of corn husks from inside the home and lit our pile of twigs. We moved some rocks into place and set a big metal pot of water over the stick fire.

One of my accomplishments for the day was impressing everyone by using a fresh green banana leaf as a lid for the pot of water. The fire burned the outside of the leaf, where it hung over the edge of the pot. But the rest of the leaf stayed intact and worked perfectly well as a lid.

(Of course, the point of putting a lid on a pot water is to make it boil faster. And I have a feeling the question “Aren't you happy you can boil your water faster?” would be greeted with a skeptical eyebrow and a “Why would we care about that?”)

I squatted over the fire for much too long, in the blazing direct sunlight, and when I stood up I nearly passed out. My vision closed down circularly from the outside in. For a brief, scary second, I was blind. I willed myself to stay standing. It would not do to fall on my side, especially if that side was toward the fire. I managed to stay upright, but when my vision slowly crept back I found I was staring into the face of an old Ugandan woman, a wizened, craggy lady squatting against Kabunga’s house with a stick of sugarcane in her bony hand. She cackled and showed me the few teeth in her mouth. She knew exactly what had just happened to me.

We dropped two packs of spaghetti in the nearly boiling water and stirred it with a one utensil we had: a large knife, the same one we were using to chop the tomatoes.

I had to catch my tongue so many times while we were cooking: Do you have plates for all these kids? (No.) Are there enough forks? (Actually, there are no forks.) Is there a spaghetti strainer? (Now you’re just being an idiot.)

Once the spaghetti was precisely al dente (because hell, if you’re going to do it, do it right) we drained the water out using that large knife. Do you have a dish towel to hold the hot metal pot? (No, we have calluses.) Then we chucked the tomatoes in the pot, added some lard, added some salt, and stirred. When it was “ready”, we transferred it salad-fork-style, using the knife and a borrowed tablespoon, to the four available plates, and passed them around.

Taken out of context, this moment could be hell on earth: sitting in the dirt; sharing a plate with two other people; shoveling the food into your mouth with your fingers; washing it down with warm water, with the sun pounding on you and no shade anywhere.

But you’re watching fifteen children stuff their faces with a food they only get a few times a year. Which you just cooked for them.

And the pleasures of the day are not over yet. Not nearly.

What I Do Each Day

I realize that I’ve been blogging for a couple weeks now, and I haven’t really explained what I do every day. So a little on that.

When I get to the hospital in the morning, I go straight to the Female Medical Ward. This is a gigantic room (Monte peeps, think of the Moses ER) with beds separated by curtains. It holds about thirty beds. No sheets on the bed unless the patient brings one. There are anywhere between eight and thirty patients in the room on a given day.

First I check the nurses’ register and see if new patients came in overnight. About half the time, the register says no one came in. And about half the time the register is correct. The other half we just stumble across a new person sleeping in our ward, like Goldilocks.

I usually do the new admissions first, devoting an hour or more to each (translations take time). By the end of each patient I usually have about 500 things in my mind that I think this disease could be. So I go back to the nurses station (out of sight of the patients) and quickly consult my cheat sheets and handbooks. I decide what medicines to give and tests to order, and I write it down and tell the nurse. Then I put my confident game face back on, and walk back out to do it all again.

After the new patients are done, I go around and see all the “old” patients, i.e. the ones who are already here. I carry my stethoscope, my penlight, the stack of charts, a blood pressure cuff, and a plastic cup with a thermometer in it.

You may find it odd that I can carry these things all by myself. One little weakling balancing 30 charts? Yes, it is strange, and so I will address this point because I know it is tormenting you.

A chart (or “chart” if I’m in a cynical mood) means a plastic slipcover between which 3.5 loose sheets of paper are slid (or slided perhaps. slidden?) The sheets are not stapled, not three-hole punched, not attached in any way. One piece of paper is the Clinical Officer’s note, which got them into the hospital. A second piece is the note I write when I see them. And the third is the piece of paper that the nurses use to document when she gives meds. The half sheet (winner of the Most Likely to Get Lost award) is where they write blood test results.

Not everyone gets blood tests, or X-rays, or any of the other stuff that is practically required for admission to a U.S. hospital. I've gotten good at asking myself "would the results of this test change the decisions I make for this patient?" If not, I don't order it. I don't get a CBC just because someone's been bleeding a little. If the conjuctiva aren’t pale they're not anemic enough for me to care.

If I want someone to get an X-ray, my first question to the patient is “Do you have a family member who can push you in the wheelchair?” Except when we don’t have a wheelchair. In that case my first question is “Do you think you’re strong enough to walk two hundred yards?”

For lunch, sometimes I spend fifty cents on a big bowl of matoke (mashed plaintains) with beans at the local bean shack, eating with other Ugandans on wooden benches and dirt floors. If I have leftovers, I'll retreat to my little apartment, a five minute walk away.

In some ways it's similar to the Montefiore. Rounds are in the morning, and in the afternoon I do procedures and follow-up test results, have conversations with the patient and families. Same general structure as an inpatient month at a U.S. hospital.

When someone is ready to go home, I scribble “D/C today” on whatever page is up front, that way the nurse is guaranteed to see it.

The Thermometer

It sits with three of its brothers, upright, in white plastic cup. At the bottom of the cup is spread an orange stringy material, which is almost identical in appearance to pumpkin innards. The orange, I am told, is a disinfectant.

We carry the cup from bed to bed. I pick up the thermometer and give it two jabs: first into the orange stuff, and then into the patient. I tell myself, as I do this, that I am practicing good hygiene.

Elevating my Blood Pressure

I just arrived in Kisoro. I have no idea how sick people in this hospital are. I check blood pressures on all my patients, and I’ve been getting a lot of them in the 80s over 40s.

“Damn,” I thought, “these Ugandans are a sick bunch!”

But they never seemed to have any symptoms. Most of them were getting up and walking to the bathroom.

One woman looked dehydrated, said she was dizzy, and her BP was 68/38. I freaked out and ran over to the nurse. I practically shouted that I needed stat IV fluids, NS wide open, large bore IV blah blah blah. Ten minutes later I saw the patient out on the lawn, squatting down and scrubbing her clothes in an orange plastic basin.

“Damn,” I thought again, “these Ugandans are a sick bunch AND tough as nails!”

But I was missing some diagnosis, and I knew it. I just couldn't put the pieces of the puzzle together.

Then today in clinic, the culprit was outed.

At the chronic care clinic, the nurse checks in my patients with a different blood pressure cuff, and then writes the BP on a piece of paper, which the patient brings me. If I have time I recheck the blood pressure. And my pressures are always 20-30 points lower than the nurse's. Today it finally clicked: my cuff is broken.

I confirmed this by testing my cuff on one of the local experimental animals (his name is Will, he’s a med student). He states that his BP is “always 120/80”. Mine gave him a reading of 95/65.

The real joke is that I was actually starting to toy with ways to investigate this. Seriously, I was pondering a research project into the low blood pressure “phenomenon”: A case-control study, or cross-sectional design? Could I get grant funding for this?

Geez....

Resident Report Addendum

I don’t know how many people read the first “Resident Report” I posted, in which I gushed praise for the basin shower. I would like to state that upon revisiting the subject, I my feelings are more complicated.

Don't get me wrong, I still love the basin shower. But scrubbing hard against one’s face, with one’s eyes closed, while one is squatting naked on a slippery concrete floor, can be dangerous. It can upset one’s vestibular balancing apparatus.

My Best Day in Uganda, part I

Okay, so I just had the most incredible day. And I came back and wrote it all down so I wouldn’t forget it.

I’m still kind of giddy, so I’m completely incapable of judging whether this is an interesting read or not. And I don’t really care. As I’ve stated before, this blog is for me, to record my thoughts and experiences so I don’t forget them. You have a scroll bar there, use it.

The way Eleanor described the trip, I almost didn’t come. “We’re going to deliver some stuff to these kids. It might be hard to get there, it's on this island,” she said. I pictured a long dusty car ride, followed by unloading boxes onto a ferry. Maybe I’ll stay home and read.

But it was sunny and 60 degrees, and everyone was out wearing their beautiful Sunday getups. So I met Eleanor and Willbroad outside his church at 11:30.

Willbroad is a dentist at Kisoro hospital. He’s tall thin man. I will not comment on his name. He wore a Nike Swim T-shirt, which turned out to be ironic: before we left he went and fetched his personal lifejacket from his apartment. “I am very afraid of water,” he said.

I got more details on the project: Hike to Lake Mutanda, take a canoe to the island, and make spaghetti for an orphan boy. This was starting to sound more interesting...but I had no idea what was in store for me.

The market we stopped at had no spaghetti, so I made a trip into town. Eleanor bought tomatoes and Karimbo (i.e. lard). While I was buying the spaghetti, I saw a little packet of honey for 600 shillings (25 cents) and stuffed that in my pack too.

It was a goddamn rough walk. More than two hours over very hilly countryside. We rose and fell through multiple small villages, always greeted by the chorus of “How are you?” “Give me my money” “Give me my pen” “What is your name”.

I’m always struck by how much you can learn about a child by that simple first interaction. Some of them come at you with open hearts, calling out “how are you?” like they really deeply want to know. Others jump straight to the material requests, standing directly in your path and daring you to go around them. Their eyes rove covetously over the laces in your shoes and the zipper on your backpack. You can see the resentment and anger already starting to boil up in their little chests.

There are other variations of child too. Today we passed a ten year-old boy wearing a spotless electric blue button-down shirt that was ironed to perfection. The shirt was fashionably untucked, and as he greeted us he pushed one side back to stick a hand in the pocket of his snug-fitting jeans. The Fonz, I thought. He yanked up a corner of his mouth in a sly smile as he spoke. “How you?” he said, tipping his head back. Damn, this kid is cooler at ten years old than I’ll ever be.

We reached the edge of Lake Mutanda and Willbroad asked if we had sharpened our voices. “What do you mean?” I asked. Apparently Kabunga (the orphaned boy we’d come to visit) and his siblings lived on the island where all the canoes were. They had no phone, and they didn’t know we were coming.

So there was only one way to let them know we were here: screaming across the water at the top of our lungs. Willbroad suggested we all shout at once. He counted off One, Two, Three, and we all screamed “KABUNGA WEH!” We repeated this over and over for ten minutes and there were still no canoes on the horizon. “What if they’re not there?” I asked. “Eh!” Will replied. “Where will they be?”

As we waited, we chatted with an older man by the lakeside who was braiding papyrus. He had a few beautiful cone-shaped baskets already completed, which Willbroad told us were used by the fishermen to catch mudfish. Apparently mudfish are so plentiful that you just sling one of these cone baskets through the mud, and when the silt drains out you find yourself with a little wriggling thing inside.

The old man reached into a dirty tin can and came out with a fish stuffed in his fist. Dirty brown, the length of a twinkie, with whiskers on its nose, it resembled a mini-catfish.

After shouting a few more times we finally saw a canoe leave the island. When it arrived I discovered it was a hollowed out log with two young boys paddling. One of them ran into the reeds and started plucking spongy leaves. “Seats,” Willbroad said.

I examined the canoe. It seemed to be literally a log with the inside scooped out. The front and back were blunt cylinders. The sides weren’t straight up and down, they curved inward toward the passenger, as a tree trunk would. We three climbed in, and one of the boys paddled us to the island.

It’s hard to describe the beauty of this place. And since it’s the same day all this happened and I’m exhausted, I won’t try too hard. Hopefully the crappy camera phone shots survived the wet boat ride, and my photos will give me a thousand words of credit.

We made it. We were heading for the island. And I have to say, when you’re canoeing through a mountain lake, toward a lush green island with the broad banana leaves flapping in the wind; to your left is the sharp majesty of a tall volcano topped with fluffy clouds; to your right are a series of uninhabited islands, small humps of land like the backs of whales; a coastline of reeds all around; other canoes in the distance, men casting nets, women collecting water; well, the tension just drains from your face and neck and chest, and you hang your arm over the edge of the boat and watch your hand dip in and out of the water as the canoe rocks back and forth with each stroke of the boy’s paddle.

And at that moment, all your gripes with the world seem so small. You can’t even remember what they are.

The Dry Season

It is 6:37pm, on my thirteenth day in Uganda, and it is raining for the first time.

The fat drops are smacking into the dust, raising tiny swirls.

The smell is incredible.

(my Macbook dashboard correctly predicted this.)

HIV and gender

There are four Einstein medical students here for the summer. They travel to villages each day to do health worker training. They have the privilege of walking that delicate line between medical necessity and cultural acceptability. As a result, they end up in long conversations about cultural norms and behaviors, and they learn things about this society that I would never find out from my lonely hospital post.

Michal, one of the med students, recently told me a few things about gender relations in Uganda that left an impression. If a woman says she has HIV, that's taken as an implication against the husband. The assumption (usually correct) is that he has been sleeping around, he gave it to her, and that he has HIV too. So if a wife is publicly known to have HIV, the husband's response will be to condemn her. He will say that she is one sleeping around, and kick her out of the house.

So fine. Your husband's been cheating on you, and he gave you HIV. Maybe you’re better off without him right? Except that when a wife is kicked out she leaves with nothing. She takes no money, no property, no children. Let me repeat that last one: she can't take her children with her. She knows her husband will do nothing to care for the children, and his other wives certainly won’t. It's basically a death sentence for her children.

A woman who reveals she has HIV destroys not only her own life but that of all her children. Any wonder no one is willing to admit it?

(p.s. maybe I shouldn't be so angry at that patient last week who didn't disclose her diagnosis.)

Smackdown

I got into an argument in Rufumbira with some kids today. And won.

It’s not so hard to learn the basics of a new language. One of the words I’ve noticed my translator Bob using is ‘weh’. As far as I can tell, it means “Hey!” or “You there!” Bob shouts it at people. When I’m trying to talk to a patient but they’re not paying attention, Bob says “Weh!” and when they look up he translates my question.

I was walking back from the hospital when a group of kids passed me on the road. They chattered in Rufumbira, and I could tell they were talking about me. I looked over at them, to let them know I wasn’t an idiot. Apparently this was a provocation.

One of the kids stopped in his tracks. “Mzungu,” he said, which means white person. Then he said something in Rufumbira, I still don’t know what. But I reacted immediately.

“Weh!” I said, pointing my finger.

The kid was taken aback. He hesitated, and then a few words spilled warily out of his mouth.

I was at the end of my rope, vocabulary-wise. I stood there, a wanna-be stern authority figure facing a group of junior high schoolers, trying to lay down the law in a language I knew five words of.

But maybe the fact that I only knew five words was an unexpected boon. I was about to turn tail and run, but the Rufumbira word for “No” popped into my head. On an impulse I decided to deploy it.

“AH-ah!” I said. (Not ah-hah. Ah-ah.)

I repeat: I have no idea what this kid said to me. From start to finish, the only word I understood was “white man”.

But for some reason, me saying ‘No!’ was received by these kids like I had just laid down the baddest Momma joke in the history of the world. “Oooooooh!” “Awwwwww!” “Ohhhhhhh!” the boy’s peers cooed.

I knew enough to quit when I was ahead. I turned sharply and kept walking down the road. The boys’ jeering melded back into smooth babble of chatter. The entire experience was probably forgotten before I was out of earshot.

Frustration II

I was called away from clinic for an urgent admission. I arrived at the Female Ward and found a thin woman in her 50s, dressed in swaths of colorful fabric. She was carrying one of the little black plastic bags that people use to bring vegetables home from market. Before I could ask her anything she coughed, hard and wet. Then she spit a mouthful of bright red blood into the bag. She had a fever of 101F and had a big right side infiltrate. I didn’t need a laboratory to tell me this woman had TB.

This woman is a cardiac patient in the chronic care clinic. There are several pages of notes documenting her heart condition, which is known as endomycocardial fibrosis. She’s been seen by the legendary Jerry Paccione, who politely rebutted the previous resident’s opinion of hypertension with a “not likely” scribbled in the margin.

We talked for a while, and eventually I thought I had a pretty complete history. I started to finish up, and sent my mind back across the most likely diagnosis. Why did this woman get TB?

“Have you ever been tested for HIV?” I asked her.

The way her eyes went left and right, scanning for nosy ears, immediately told me the answer. I stepped forward so she could whisper, and motioned my translator to do the same. The words she muttered were barely audible.

“She has HIV,” my translator said.

I looked down at the five pages of “Chronic Care Management” notes I was holding. They went back as far as 2006, and she’d never mentioned the fact that she had HIV.

“Do you have a doctor taking care of your HIV?” I asked. She said she went to the HIV clinic in this hospital for her care.

So she wasn’t telling her heart doctor that she had HIV. And she wasn’t telling her HIV doctor that she had a heart condition. The two sets of doctors were a hundred yards away from each other, and for three years this duplicity had been maintained.

It makes me angry. I can’t help it. You don’t want to talk about HIV? You don’t want to bring it into the open? Fine. But other societies have been down this road before. I was just a kid when the HIV epidemic started in the U.S., but even I remember that Silence = Death.

Luggage update III

Dr. Michael called on Thursday night and said that my bag had arrived in Kisoro. Deo would bring it to my apartment.

This was the bag that should have arrived with me on the plane ten days ago. The bag that finally did arrive in Uganda last Friday. The bag that supposedly was being driven by DHL to Kisoro on Monday. The bag, containing all my underwear and socks, that kept not showing up on Tuesday and Wednesday and Thursday.

This bag needed a week to make a 9-hour drive.

So when Deo pulled up in the van I was bouncing on my tiptoes. I shook his hand vigorously and thanked him for coming. He clicked the back door of the van open and revealed: a cardboard box.

“Where’s my bag?”

Deo looked puzzled. “This is what DHL delivered.”

The phrase ‘my heart sank’ does not begin to describe the despair I lapsed into then. “This cannot--- this cannot, no. No!” I remember hunting around the van, behind the other seats. I was kind of delirious.

When I finally tore open the cardboard box, it wasn’t a rational strategy. It was a fit of vengeance against the parcel that had usurped my precious underwear and socks.

But the strategy worked. (If you’re clever you’ll have figured this out already.) Turns out DHL had smashed my bag into a cardboard box to protect it. Bastards.

And so happiness, peace, and clean underwear reigns once again.

In Defense of My Frustration

It’s a been a rough week. I found myself getting very frustrated last week, even angry at my patients. Not pretty. But the second week is much better.

Part of my frustration comes from feeling overwhelmed and underprepared. But there's more to it than that. I’m going to transcribe as closely as possible an interview I did today, and maybe you’ll see what I mean.

So, what brought you into the hospital?

Sickness.

What were you feeling?

Malaria.

What symptoms were you having?

Chest pain, headache, stomach ache.

For how long?

Since yesterday.

Did you have any symptoms before yesterday?

No.

You were totally fine two days ago?

Yes.

Have you been coughing?

Yes.

For how long?

Three days.

So you weren’t totally fine two days ago, you had a cough.

I was fine, but I had a cough.

Were you coughing anything up?

Yes.

Did it have any blood in it?

A little.

So you were totally fine, but you were coughing up blood?

Yes.

Of course, now that I think about it, this interview could just as easily have taken place in the Montefiore Emergency Dept.

Factoid

The word for No in the local language and the word for sharp spiky lava in Hawaiian are the same word: a-a. Pronounced AH-ah.

?ufumbira

I saw several signs in town today with the word 'Bufumbira' on them. This is disturbingly close to what I thought was the word for the local language, Rufumbira. Am I just being paranoid? I've gotten things like this wrong before, for a lot longer then 5 days.

Presumably there might some interesting explanation here. Like maybe R is the language and B is the ethnicity? Or you use R when speaking and B when writing? Hopefully

If someone out there has the answer to this question, please edjimicate me. I'm happy to complete a standard 7-10 day course of self-embarrassment, but would rather not develop a chronic condition.

lugagge update II

still no bag. supposedly it will come wednesday. I may break down and buy a toothbrush.

(so far i've been getting by on the courtesy mini-toothy from KLM)

Resident Report

Dear Montefiore Residents Coming After Me,

The apartment you will be staying in is simple and spare. All the floors are concrete. The small living room has a couch and two chairs, none of which are “comfortable” by our double-stuffed double-padded extra-plush American standards. Padding here means a hint of dry beige sponge. A Ugandan couch is essentially a bench with a thin layer of foam wrapped around it. And by the way, your bed is a double thick slab of that same beige foam.

There’s a little gas two-burner stove in the kitchen, attached to a propane tank. I connected the stove to the tank without incident, but halfway through my meal heard a hissing sound. Because of a loose connection, the propane was leaking from the tank. And yes, this was while the burner was lit. No adverse events occurred. Just something to be aware of...

There’s a sink, obviously. But very little counter space to prepare food. But you’re probably not going to be cooking gourmet three-course meals anyway, so it all works out.

I’m not saying there’s no food around, because there is. There’s just not much variety. If it’s grown on the hillsides, you can buy it in the market: tomatoes, onions, bananas, potatoes. All the little shops along the main road sell exactly the same thing: soap, cooking oil, matches, plastic basins. Everything you need to survive.

(survival: It reminds you how in the U.S. that little detail gets swept aside. We’re so far beyond it. When you stroll through Whole Foods glancing at little packages of organic artichoke hearts for nine dollars, you can forget that the reason we started cultivating them to begin with was to keep us alive.)

There’s no hot water. But this gives you the opportunity to experience the joys of the basin shower. I’m serious, actually. I realize that 99% of what I’ve written so far has been smarmy and sarcastic, but go with me on this: I love the basin shower.

Here’s how you have a basin shower:
1) You boil up a big pot of hot water.
2) You split the hot water between the two wide plastic basins in the bathroom.
3) You add enough cold water from the bathroom tap to make the water just right.
4) You squat. Naked.
5) Before doing #4, make sure all the curtains are closed.
6) You splash hot water all over yourself.
7) You designate one basin soapy and one clear.
8) You soap yourself up from the soapy basin
9) You rinse yourself down from the clear basin.

You have to keep your hands as unsoapy as possible when you put them in the clear basin, which can be hard. But if you fail, you’ll be left with two basins of soapy water and nothing to rinse off with. Which means you’ll have to turn on the cold shower. I’ve been there, and I’m sorry in advance if it happens to you.

Why is the basin shower so great? One word: mess. Sure, when you take a normal shower there’s water splashing everywhere. In theory that’s messy. But it doesn’t feel messy. When you take a basin shower in your apartment in Kisoro, you’re squatting on the floor of your bathroom. With the door open. You’re scooping water up in your palms and throwing it all over the place. I threw water into the kitchen during my last basin shower. My towel got wet. Give yourself over to the reckless abandon, that’s my advice. Have fun.

In the OR

Yesterday I saw a young man who came in drunk with a nasty cut on his head. HE said he was robbed, which I might also if I just got drunk and fell down. Today I went with Dr. Charles to the minor operating theater to suture it up.

First difference between the US and here: the patient walked from his bed to the OR. He got slapped on the shoulder by Dr. Charles for walking into the sterile area with his boots on. He laid himself down on the operating table.

Dr. Charles is the equivalent of a fourth-year medical student. But since he's sutured over 30 scalp lacs in the past few months, i didn't try to pretend like i knew more than him.

The sterile towels weren't ready. So the nurse took a pair of sterile gloves (the same kind we use in our ORs) and opened it up. The inside was sterile, and she opened a few packs side-by-side and called that a sterile field.

Yes, there are all kinds of problems with this. Not the least of which is, what a waste of expensive sterile gloves. In some ways it's a metaphor for the problems of poor countries in general: you don't have enough resources to develop efficient infrastructure, so when something needs to be done urgently you end up spending a lot more than you would have.

Charles and I got to work debriding the wound. When we looked up to get more gauze, the nurses were gone. We were both sterile and couldn't touch anything, and they had the radio playing loud in the next room. After a few shrill blood-curdling screams from me, we got a nurse's attention. She walked in with a one year-old baby on her hip and grabbed the orange biotidine cannister from the windowsill, sloshing it into a metal emesis basin. Then she grabbed the sterile tongs (still carrying the baby, who was rightly fascinated by all this) and plucked out a lump of gauze to dunk in the antiseptic.

Then the nurse sat down against the wall and started breastfeeding. I could tell she was kind of annoyed by having to wait around for us.

Let's be clear: the same kind of thing happens in our ORs in the U.S. It just typically involves talking on cell phones, and playing the radio, rather than suckling an infant. And which is more practical?

lugagge

my bag is supposed to be delivered here today. i'm going on 5 days now, with one change of clothes. even for me that's pushing it.

Will the dark continent never learn?

There are a number of reasons why I'm starting this blog. First, I want to give my fellow Montefiore residents a sense of what they'll be plunging into when they arrive in Kisoro. Second, I want to remember my experiences here and don't have a camera. Third, I'm a desperate attention whore who craves constant approval. I'll let you decide which of three was most important.

I actually do have a crappy camera phone, so hopefully this blog won't be 100% text. But don't get your hopes too high.

The title of this blog is a word I heard a nine-year use this afternoon, while he was paddling me across Lake Madara. All I know is that it's some kind of passionate exclamation. Neither the boy nor any of his friends could translate it, and for all I know it's some kind of racial slur. If anyone out there speaks Rufumbira, feel free to educate me.