Remember that three-part post about my Best Day in Uganda? Where we canoed to the island and made the kids spaghetti? And then afterwards the kids danced, to a beat that was eerily similar to one used by high school cheerleaders? Remember that?
I promised that we had made a video of the dance, and that I would post it here. It was only half a lie --- we did make the video, and then we lost it.
BUT
Theres another dancing-kid video, taken by the incredible Montefiore resident who first "discovered" this family several years ago.
It's in exactly the same location. And yes, it has exactly the same cheerleader beat.
Thursday, August 27, 2009
Thursday, August 20, 2009
Climbing the Muhavura volcano
Everything creaks. That’s the first thought in my head this morning. I can’t make a move, take a breath without it.
Yesterday [Editor's Note: no, not actually yesterday] we hiked the Muhavura volcano. It’s featured prominently in a few of the photos I’ve posted -- the tallest of the three large peaks behind my house.
These two fit Brits, Tommy and Andy, hiked Muhavura a few weeks ago. “Sure it’s a proper hike," they said. "Cost you four hours up, two on the go down.”
No prob, six hours.
The New Math: I was talking about hiking the volcano with one of the med students and the others who wanted to come along (total = 5 people). And then it got mentioned to a few of the translators (=8 people), who each wanted to bring a friend or partner (= 12 people). Oh, and then the three Scottish med students wanted to come. Grand total = 15 people. How did this happen?
At 6am I was at the hospital. Jen and Will and Ro were there, but Michal was sick. None of the Ugandans arrived. The Scots showed up. By 6:30 everyone but Maureen was there, so we drove and picked her up.
We arrived at the site about 7:15, walked ten minutes to base camp. A skinny young man in a military uniform was tasked with collecting our fees. His face was so smooth, you would swear stubble had never sullied it.
This took far too long. We each got jacked for fifty bucks, and the Ugandans were supposed to be free, but this went back and forth. The “official” price was 30k shillings, but someone had been to an office yesterday and got permission blah blah blah. We paid them 5k shillings for each Ugandan and took off hiking.
As usual, the Ugandan mountain guides have to give you a little speech to assert their authority. This speech tells you exactly what you already know: “The activity we are to engage in today,” said George haltingly, “is mountain hiking. Muhavura is four hundred thousand meters --- is four thousand one hundred meters above the sea.”
I knew our guide George for only one day, but the expression I heard him say more than any other was “We try again?” This was, you can guess, while we were sitting, drinking water or eating. I would reply with something like “Again? We just tried five minutes ago,” which got me a perplexed and hostile stare.
Five minutes into the hike, some higher-up in the UGA (ugandan wildlife authority) walkie-talkied George, and he sadly informed us that the Ugandans would have to pay the full fee. Everyone was incensed, but actually some of them were already feeling tired and they said Eff It we’re going home. We tried to argue with them, but since we didn’t actually have the cash to cover them it was all academic. The group was halved.
The terrain was beautiful and varied. Often it was very desert-like. The open slopes were covered with thick-leaved hardy fir bushes, or squat broad-spined plants resembling yucca. Then the trail would duck into a vertical fold in the mountain, a section where strands of cloud get caught, and it would suddenly be a rainforest, leaves dripping, tree trunks heavy with dark green shag. From every branch hung strands of pale green wisp moss, nature’s tinsel, with tiny drops of moisture in the lattice like flies in a web.
There’s nothing to be written about the walk itself, except that it was effing brutal. One foot after another. I’m a big fan of the walking stick after my time in Uganda.
They laid down bamboo where the walking was difficult. These were basically -- no, they were exactly -- bamboo ladders laid on the ground. You stepped on the rungs to get through a muddy patch.
I could be imagining this, but it seemed like as the hike progressed, the ladders increased in both length and degree of difficulty. They started out semi-necessary --- your shoes would get wet without the ladder. But then they started running the ladders across dips in the trail, so that if your foot slipped off the rung you were looking at a six-inch drop. Then it was an 18-inch drop, and then two feet. And the number of rungs went from four to six to ten. And then they started laying two ladders sequentially, so you’re teetering on these rungs for the better part of a minute.
And this is where the walking stick came in handy. I became a big fan of the walking stick yesterday. When you’re on a smooth flat trail the stick doesn’t add much, but when you’re losing your balance on a wet strip of bamboo stretched over a ravine, it’s nice to have an eight-foot appendage.
Half our group didn’t take walking sticks. George definitely did not make clear how helpful they would be. “Here are walking sticks if you want,” he nodded as he walked past the base camp hut. I almost didn’t take one, but I saw that George had a walking stick, and so did the guy carrying the rifle.
Did I not mention the guy with the rifle yet? Actually there were two. They came along to protect us from wild animals, buffalo apparently being the most common. George --- I could tell from his defensive tone that he’s been exposed to hand-wringing liberals like myself before --- assured us that the guns would be fired in the air only.
The hike destroyed us. One person got a severe leg cramp and had to stop. Another person got altitude sickness and started vomiting. Five people made it all the way to the top. (Plus George, who did I mention is about fifty years old? He wasn’t even breathing hard.)
Muhavura and the other two volcanoes are shared by the three countries: Uganda, Rwanda, and DR Congo. Our route led us up the Uganda-Rwanda border. Per standard tourist protocol and George’s suggestion, we got a photo of ourselves with one foot in each country.
We came to the summit and found a small crater pond. It was pristine, completely still, hiding in a slight hollow like the indentation a cherry makes on top of a sundae.
I walked to edge and saw ... algae. The dark water was filled with green growing things, slippery brown rocks, goo.
But Jamie (one of the Scottish med students, who is actually from Ireland originally) was committed to going in the water. And I was blazing hot by this point, so it didn’t take much convincing. We stripped to our skivvies (skivvies? Ach, do you see what spending twelve hours with Scots does?) and waited for Jen to get her camera ready. Then we counted off and jumped.
It was close to the coldest water I’ve ever been in. My chest tightened up, I couldn’t breathe. I tried to swim to the other side, and made it about halfway before turning around and giving up. The cold was like a vice grip on each large muscle group --- thighs, shoulders, stomach -- tightening down and converting active tissue into useless slabs of meat. In the last five strokes before I hauled myself onto shore, the thought “I don’t think I’m going to make it” went through my head.
I had a worm on me when I got out. I didn’t discover it for a few minutes, because we were all covered in sludge. As picked the winding strips of algae from the legs and stomach, I saw something moving. He was a tiny little guy, maybe one centimeter, and the width of an angel hair pasta. I could see his little nasty teeth on one end. Needless to say, this prompted a full-body search, focused especially on the inside of my underwear. I saw the movie Stand By Me, I’m no fool.
(As I revisit the subject in my head, I think I’m just going to give myself a deworming dose of albendazole just to be sure.)
Then we just cavorted and took silly pictures in our underwear next to the summit marker, until George came and told us we had to go down.
Yesterday [Editor's Note: no, not actually yesterday] we hiked the Muhavura volcano. It’s featured prominently in a few of the photos I’ve posted -- the tallest of the three large peaks behind my house.
These two fit Brits, Tommy and Andy, hiked Muhavura a few weeks ago. “Sure it’s a proper hike," they said. "Cost you four hours up, two on the go down.”
No prob, six hours.
The New Math: I was talking about hiking the volcano with one of the med students and the others who wanted to come along (total = 5 people). And then it got mentioned to a few of the translators (=8 people), who each wanted to bring a friend or partner (= 12 people). Oh, and then the three Scottish med students wanted to come. Grand total = 15 people. How did this happen?
At 6am I was at the hospital. Jen and Will and Ro were there, but Michal was sick. None of the Ugandans arrived. The Scots showed up. By 6:30 everyone but Maureen was there, so we drove and picked her up.
We arrived at the site about 7:15, walked ten minutes to base camp. A skinny young man in a military uniform was tasked with collecting our fees. His face was so smooth, you would swear stubble had never sullied it.
This took far too long. We each got jacked for fifty bucks, and the Ugandans were supposed to be free, but this went back and forth. The “official” price was 30k shillings, but someone had been to an office yesterday and got permission blah blah blah. We paid them 5k shillings for each Ugandan and took off hiking.
As usual, the Ugandan mountain guides have to give you a little speech to assert their authority. This speech tells you exactly what you already know: “The activity we are to engage in today,” said George haltingly, “is mountain hiking. Muhavura is four hundred thousand meters --- is four thousand one hundred meters above the sea.”
I knew our guide George for only one day, but the expression I heard him say more than any other was “We try again?” This was, you can guess, while we were sitting, drinking water or eating. I would reply with something like “Again? We just tried five minutes ago,” which got me a perplexed and hostile stare.
Five minutes into the hike, some higher-up in the UGA (ugandan wildlife authority) walkie-talkied George, and he sadly informed us that the Ugandans would have to pay the full fee. Everyone was incensed, but actually some of them were already feeling tired and they said Eff It we’re going home. We tried to argue with them, but since we didn’t actually have the cash to cover them it was all academic. The group was halved.
The terrain was beautiful and varied. Often it was very desert-like. The open slopes were covered with thick-leaved hardy fir bushes, or squat broad-spined plants resembling yucca. Then the trail would duck into a vertical fold in the mountain, a section where strands of cloud get caught, and it would suddenly be a rainforest, leaves dripping, tree trunks heavy with dark green shag. From every branch hung strands of pale green wisp moss, nature’s tinsel, with tiny drops of moisture in the lattice like flies in a web.
There’s nothing to be written about the walk itself, except that it was effing brutal. One foot after another. I’m a big fan of the walking stick after my time in Uganda.
They laid down bamboo where the walking was difficult. These were basically -- no, they were exactly -- bamboo ladders laid on the ground. You stepped on the rungs to get through a muddy patch.
I could be imagining this, but it seemed like as the hike progressed, the ladders increased in both length and degree of difficulty. They started out semi-necessary --- your shoes would get wet without the ladder. But then they started running the ladders across dips in the trail, so that if your foot slipped off the rung you were looking at a six-inch drop. Then it was an 18-inch drop, and then two feet. And the number of rungs went from four to six to ten. And then they started laying two ladders sequentially, so you’re teetering on these rungs for the better part of a minute.
And this is where the walking stick came in handy. I became a big fan of the walking stick yesterday. When you’re on a smooth flat trail the stick doesn’t add much, but when you’re losing your balance on a wet strip of bamboo stretched over a ravine, it’s nice to have an eight-foot appendage.
Half our group didn’t take walking sticks. George definitely did not make clear how helpful they would be. “Here are walking sticks if you want,” he nodded as he walked past the base camp hut. I almost didn’t take one, but I saw that George had a walking stick, and so did the guy carrying the rifle.
Did I not mention the guy with the rifle yet? Actually there were two. They came along to protect us from wild animals, buffalo apparently being the most common. George --- I could tell from his defensive tone that he’s been exposed to hand-wringing liberals like myself before --- assured us that the guns would be fired in the air only.
The hike destroyed us. One person got a severe leg cramp and had to stop. Another person got altitude sickness and started vomiting. Five people made it all the way to the top. (Plus George, who did I mention is about fifty years old? He wasn’t even breathing hard.)
Muhavura and the other two volcanoes are shared by the three countries: Uganda, Rwanda, and DR Congo. Our route led us up the Uganda-Rwanda border. Per standard tourist protocol and George’s suggestion, we got a photo of ourselves with one foot in each country.
We came to the summit and found a small crater pond. It was pristine, completely still, hiding in a slight hollow like the indentation a cherry makes on top of a sundae.
I walked to edge and saw ... algae. The dark water was filled with green growing things, slippery brown rocks, goo.
But Jamie (one of the Scottish med students, who is actually from Ireland originally) was committed to going in the water. And I was blazing hot by this point, so it didn’t take much convincing. We stripped to our skivvies (skivvies? Ach, do you see what spending twelve hours with Scots does?) and waited for Jen to get her camera ready. Then we counted off and jumped.
It was close to the coldest water I’ve ever been in. My chest tightened up, I couldn’t breathe. I tried to swim to the other side, and made it about halfway before turning around and giving up. The cold was like a vice grip on each large muscle group --- thighs, shoulders, stomach -- tightening down and converting active tissue into useless slabs of meat. In the last five strokes before I hauled myself onto shore, the thought “I don’t think I’m going to make it” went through my head.
I had a worm on me when I got out. I didn’t discover it for a few minutes, because we were all covered in sludge. As picked the winding strips of algae from the legs and stomach, I saw something moving. He was a tiny little guy, maybe one centimeter, and the width of an angel hair pasta. I could see his little nasty teeth on one end. Needless to say, this prompted a full-body search, focused especially on the inside of my underwear. I saw the movie Stand By Me, I’m no fool.
(As I revisit the subject in my head, I think I’m just going to give myself a deworming dose of albendazole just to be sure.)
Then we just cavorted and took silly pictures in our underwear next to the summit marker, until George came and told us we had to go down.
Wednesday, August 19, 2009
Closing Up Shop
Okay kiddies, that ridiculous post was the last one I think. Everything else on my hard drive is even more farcical, and of even lower quality.
But now that I'm back on domestic soil again I'm going to reengage with the healthcare debate. Please check out my intermittent bloggings there:
www.whyitstime.blogspot.com
But now that I'm back on domestic soil again I'm going to reengage with the healthcare debate. Please check out my intermittent bloggings there:
www.whyitstime.blogspot.com
Tuesday, August 11, 2009
a conversation about bribery
During my latest 13-hour bus ride, I sat down for lunch with some Kenyans who have lived in Nairobi their entire lives.
We started talking politics: corruption is the biggest problem, we have to get rid of it. All those government people who steal money. Nepotism, favors, embezzling, etc.
Then our meal finished, and they lit cigarettes. We started talking about smoking: yes, I said, it’s illegal in many places in the U.S.
“Even here,” one of them said. “Even in Kenya. There are some places around in Nairobi where you cannot smoke.”
The other jumped in. “And they can fine you. They have a fine whereby they can take from you fifty thousand shillings for smoking in the wrong place.”
The other shook his head. “Even me they fined me for that one.”
“They caught you?” The first nodded. His friend shook his head sadly.
“How much did you had to give him?”
“Three thousand shillings.”
The listener nodded, sympathetic but somehow approving. It was appropriate to pay a three thousand shilling bribe to avoid a fine of fifty thousand. Sad but expected, like hearing that a smooth-talking politician you like has been caught in a sex scandal. So it shall always be. Within the tragedy there is comfort in knowing that the world will continue to revolve as it always has.
What struck me in this conversation was the unconscious assumption that bribery was a part of life. There was no irony noted in the fact that we’d been bemoaning the existence of corruption only five minutes earlier. That in fact we’d identified corruption specifically as the single greatest obstacle to Kenyan prosperity.
High-level corruption, that's a problem. But my bribes, those are okay.
We started talking politics: corruption is the biggest problem, we have to get rid of it. All those government people who steal money. Nepotism, favors, embezzling, etc.
Then our meal finished, and they lit cigarettes. We started talking about smoking: yes, I said, it’s illegal in many places in the U.S.
“Even here,” one of them said. “Even in Kenya. There are some places around in Nairobi where you cannot smoke.”
The other jumped in. “And they can fine you. They have a fine whereby they can take from you fifty thousand shillings for smoking in the wrong place.”
The other shook his head. “Even me they fined me for that one.”
“They caught you?” The first nodded. His friend shook his head sadly.
“How much did you had to give him?”
“Three thousand shillings.”
The listener nodded, sympathetic but somehow approving. It was appropriate to pay a three thousand shilling bribe to avoid a fine of fifty thousand. Sad but expected, like hearing that a smooth-talking politician you like has been caught in a sex scandal. So it shall always be. Within the tragedy there is comfort in knowing that the world will continue to revolve as it always has.
What struck me in this conversation was the unconscious assumption that bribery was a part of life. There was no irony noted in the fact that we’d been bemoaning the existence of corruption only five minutes earlier. That in fact we’d identified corruption specifically as the single greatest obstacle to Kenyan prosperity.
High-level corruption, that's a problem. But my bribes, those are okay.
Saturday, August 8, 2009
Manipulation
Ways that your style of questioning can affect the answers you get:
Well done, doctor. You’ve trapped your patient. You got them to say they’re not hungry, they’re not eating at all, and then you spring the weight loss question. How can they answer “No, I haven’t lost any weight” without looking a liar?
So you’re likely to get a “Yeah, I think maybe I have lost a little weight,” even though that thought never entered their head until you planted it.
I did this accidentally in Kisoro recently, so i had to discount the response and ask it later. But I know that there are some doctors do this intentionally, when they have an particular outcome they want to attain. If, for example, you have to document that the patient has been having weight loss so you can send him to medicine rather than surgery (or the other way around), this line of questioning is a great way to get there.
How is your appetite?
Terrible. I’m not hungry at all.
So if your appetite’s not good, you’ve been eating less?
Yes, much less.
Have you lost any weight?
Well done, doctor. You’ve trapped your patient. You got them to say they’re not hungry, they’re not eating at all, and then you spring the weight loss question. How can they answer “No, I haven’t lost any weight” without looking a liar?
So you’re likely to get a “Yeah, I think maybe I have lost a little weight,” even though that thought never entered their head until you planted it.
I did this accidentally in Kisoro recently, so i had to discount the response and ask it later. But I know that there are some doctors do this intentionally, when they have an particular outcome they want to attain. If, for example, you have to document that the patient has been having weight loss so you can send him to medicine rather than surgery (or the other way around), this line of questioning is a great way to get there.
Friday, August 7, 2009
God Slaps part deux
Holy jeez was there a lot of fluid in there. I probably drained off 2 liters today, which is several 7-11 Big Gulps more than you are supposed to. (I will address the logic behind my uncharacteristic deviation from S.O.P. in a moment.)
The gentleman arrived early in the morning, excited about having this pain taken away. I have to admit my heart started beating faster when I saw him. But not in the good way.
I took him into the empty "isolation room," which in theory is supposed to house TB patients but somehow never does. The guy took off his shirt and sat on the edge of the bed facing the wall. I went to the other side of the bed with all my equipment. I examined his back and percussed between every rib again, for the fourteen millionth time.
I've already given a pretty intricate description of sticking needles in body cavities in a prior post, so I won't repeat all of that.
But let me just say that these two procedures (draining fluid from the belly and from the lung) should be more different than they are in Kisoro. In the U.S. they have entirely different kits, but here I basically did the same procedure.
They don’t have the superfine needles we would use to give anesthetic, so I had to numb him up with a big ole 18 gauge. Stuck it right on the periosteum of the rib --- forgot how close beneath the surface that is. Then I shifted the needle up, no tilting, just lifted it and kept it horizontal. I pulled back and injected, pulled back and injected. Once I was over the rib I literally pushed the needle forward in millimeter increments.
Why so cautious? Lung + needle = puncture. Pull back, inject. Pull back, inject. Pull back, and suddenly there's yellow fluid in the syringe.
I squirted a little lidocaine into the pleural space, and then slowly removed the needle, keeping my thumb on the spot where the needle had gone in deepest. I compared the depth of the needle to the length of the longest IV catheter I had. It was about 1.5 inches, just barely long enough.
So then I inserted my IV catheter in exactly the same position as the lidocaine injection. And I repeated exactly the same process, except without injecting anything. I just pulled back on the catheter at each step of the way, and when I got the yellow flashback I removed the needle and screwed the syringe directly onto the catheter.
The dangerous part was over. There was a soft plastic tube in his lung, no sharp needles, no risk at all of a puncture.
But here was a problem: there were no large syringes in Kisoro hospital. Literally none larger than 5 mL. So I had to keep sucking out fluid in little 5mL increments, and in case you’re not so good with the metric system that’s about a tablespoon each time. They finally found me a 10mL syringe, and then things went a little faster.
But that was a minor issue. The real trouble was something I hadn't thought of: air. When you do a thoracentesis with one of those fancy American kits, the fluid goes straight from the lung, through the tube, into a bag. The entire system is sealed, air can’t leak in anywhere. But with my hodge-podge arrangement, every time I unscrewed the syringe I let air in.
When I started the procedure air wasn’t a problem. He had buckets of fluid packed inside his chest, so the pressure was pushing out, not in. When I unscrewed the syringe the fluid kept flowing out briskly.
Then I heard a weird noise. It was after I'd drained over a liter of fluid from his back (again, this is not what you're supposed to do, and I promise I'm going to explain why, just be patient for a second), and suddenly there was this scratchy sound, kind of clicky.
At first I didn’t think it could be coming from the catheter because it sounded too mechanical. Then I noticed that fluid wasn’t dripping out anymore. In fact, when I looked at the place where the fluid had been flowing out, it was completely empty. Not even a little drop sitting at the opening. And when I listened to the sound again, I realized it was similar to what you hear when you finish a milkshake with a straw.
So something was sucking the fluid back into his pleural cavity. I had to stop and think for a minute about why that might be happening.
I had drained out nearly 2 liters of fluid (for a good reason, wait for it now), and what was filling the space where the fluid had been? Ideally, his lung. And eventually, one day soon, it would be his lung, but right at this moment --- not his lung. He’d had this effusion for months. His lung was squashed down small, and it would take a while to expand.
Which meant that when I drained out 2 liters of fluid, I was creating a 2 liter vacuum inside his chest. And now, every time I unscrewed the syringe, that vacuum sucked a little bit of air into his pleural space.
So I started covering the IV catheter with my thumb. But even in the half second between taking off the syringe and sticking on my thumb, the fluid was getting drawn quickly back into his chest.
This was a little scary. Because I wasn’t going to stand around all day covering this hole. Eventually I was going to take the catheter out, leaving a hole directly from his pleural space to the outside world. This guy was a set-up for a pneumothorax (fancy word for air in the pleural space).
So why was I doing all this? Why was I removing 2 liters of fluid when the guidelines suggested a maximum of 400 to 500 mL? You've been waiting patiently for the answer, and here it is.
This gentleman was not staying. He didn't live near Kisoro, and he had to go home. If I could take away some pain he'd be grateful, but he had a life to live. He wasn't sitting around in the hospital for two weeks while I removed a little mayonnaise jar of fluid each day. He'd stated clearly he was leaving tomorrow.
Which meant that this was my only shot.
There was another reason to do this all at once. Under these conditions the procedure is not all that sterile. Every time you stick a guy with a needle you're risking giving him an infection. And this is a patient with HIV, so reducing the risk of infection is pretty important. Even if I could do six taps in six days, that would not be best thing for him.
(BTW, this is the same reason we usually give 2 units of blood when we transfuse someone. Why give one unit and then a second unit the next day? It's double the risk of a lab error.)
So there I was, torn between two competing instincts. On the one hand, drain as much fluid as possible since this was the only chance. On the other hand, the more you drain out, the higher the chance of a pneumothorax.
I ended up sitting around for a while, shooting the shit with the med students with my thumb on the syringe. I thought maybe that would give the lung a chance to expand. Sure enough, fifteen minutes later when I unscrewed the syringe, the fluid just sat where it was, it didn’t trickle out or get sucked back in.
So that was it. I pulled the needle out and held some pressure on the area for a few minutes. It didn't bleed, and he wasn't coughing or short of breath. I knocked on wood a few times and sent him to the Male Medical Ward for the night. I can assure you he'll be the first patient I check on in the morning....
(update several weeks later: next morning he was fine. The pain was better but not gone, and since I'd actually done him some good he agreed to stick around for another day. I did another tap and took out 1.5 liters. Yes, that's a total of 3.5 liters -- sitting in his chest. If your jaw hasn't dropped yet, picture it in Coke bottles. He went home very happy with no pain. I gave him oral antibiotics which he probably didn't take and saved to give his children the next time they get sick.)
The gentleman arrived early in the morning, excited about having this pain taken away. I have to admit my heart started beating faster when I saw him. But not in the good way.
I took him into the empty "isolation room," which in theory is supposed to house TB patients but somehow never does. The guy took off his shirt and sat on the edge of the bed facing the wall. I went to the other side of the bed with all my equipment. I examined his back and percussed between every rib again, for the fourteen millionth time.
I've already given a pretty intricate description of sticking needles in body cavities in a prior post, so I won't repeat all of that.
But let me just say that these two procedures (draining fluid from the belly and from the lung) should be more different than they are in Kisoro. In the U.S. they have entirely different kits, but here I basically did the same procedure.
They don’t have the superfine needles we would use to give anesthetic, so I had to numb him up with a big ole 18 gauge. Stuck it right on the periosteum of the rib --- forgot how close beneath the surface that is. Then I shifted the needle up, no tilting, just lifted it and kept it horizontal. I pulled back and injected, pulled back and injected. Once I was over the rib I literally pushed the needle forward in millimeter increments.
Why so cautious? Lung + needle = puncture. Pull back, inject. Pull back, inject. Pull back, and suddenly there's yellow fluid in the syringe.
I squirted a little lidocaine into the pleural space, and then slowly removed the needle, keeping my thumb on the spot where the needle had gone in deepest. I compared the depth of the needle to the length of the longest IV catheter I had. It was about 1.5 inches, just barely long enough.
So then I inserted my IV catheter in exactly the same position as the lidocaine injection. And I repeated exactly the same process, except without injecting anything. I just pulled back on the catheter at each step of the way, and when I got the yellow flashback I removed the needle and screwed the syringe directly onto the catheter.
The dangerous part was over. There was a soft plastic tube in his lung, no sharp needles, no risk at all of a puncture.
But here was a problem: there were no large syringes in Kisoro hospital. Literally none larger than 5 mL. So I had to keep sucking out fluid in little 5mL increments, and in case you’re not so good with the metric system that’s about a tablespoon each time. They finally found me a 10mL syringe, and then things went a little faster.
But that was a minor issue. The real trouble was something I hadn't thought of: air. When you do a thoracentesis with one of those fancy American kits, the fluid goes straight from the lung, through the tube, into a bag. The entire system is sealed, air can’t leak in anywhere. But with my hodge-podge arrangement, every time I unscrewed the syringe I let air in.
When I started the procedure air wasn’t a problem. He had buckets of fluid packed inside his chest, so the pressure was pushing out, not in. When I unscrewed the syringe the fluid kept flowing out briskly.
Then I heard a weird noise. It was after I'd drained over a liter of fluid from his back (again, this is not what you're supposed to do, and I promise I'm going to explain why, just be patient for a second), and suddenly there was this scratchy sound, kind of clicky.
At first I didn’t think it could be coming from the catheter because it sounded too mechanical. Then I noticed that fluid wasn’t dripping out anymore. In fact, when I looked at the place where the fluid had been flowing out, it was completely empty. Not even a little drop sitting at the opening. And when I listened to the sound again, I realized it was similar to what you hear when you finish a milkshake with a straw.
So something was sucking the fluid back into his pleural cavity. I had to stop and think for a minute about why that might be happening.
I had drained out nearly 2 liters of fluid (for a good reason, wait for it now), and what was filling the space where the fluid had been? Ideally, his lung. And eventually, one day soon, it would be his lung, but right at this moment --- not his lung. He’d had this effusion for months. His lung was squashed down small, and it would take a while to expand.
Which meant that when I drained out 2 liters of fluid, I was creating a 2 liter vacuum inside his chest. And now, every time I unscrewed the syringe, that vacuum sucked a little bit of air into his pleural space.
So I started covering the IV catheter with my thumb. But even in the half second between taking off the syringe and sticking on my thumb, the fluid was getting drawn quickly back into his chest.
This was a little scary. Because I wasn’t going to stand around all day covering this hole. Eventually I was going to take the catheter out, leaving a hole directly from his pleural space to the outside world. This guy was a set-up for a pneumothorax (fancy word for air in the pleural space).
So why was I doing all this? Why was I removing 2 liters of fluid when the guidelines suggested a maximum of 400 to 500 mL? You've been waiting patiently for the answer, and here it is.
This gentleman was not staying. He didn't live near Kisoro, and he had to go home. If I could take away some pain he'd be grateful, but he had a life to live. He wasn't sitting around in the hospital for two weeks while I removed a little mayonnaise jar of fluid each day. He'd stated clearly he was leaving tomorrow.
Which meant that this was my only shot.
There was another reason to do this all at once. Under these conditions the procedure is not all that sterile. Every time you stick a guy with a needle you're risking giving him an infection. And this is a patient with HIV, so reducing the risk of infection is pretty important. Even if I could do six taps in six days, that would not be best thing for him.
(BTW, this is the same reason we usually give 2 units of blood when we transfuse someone. Why give one unit and then a second unit the next day? It's double the risk of a lab error.)
So there I was, torn between two competing instincts. On the one hand, drain as much fluid as possible since this was the only chance. On the other hand, the more you drain out, the higher the chance of a pneumothorax.
I ended up sitting around for a while, shooting the shit with the med students with my thumb on the syringe. I thought maybe that would give the lung a chance to expand. Sure enough, fifteen minutes later when I unscrewed the syringe, the fluid just sat where it was, it didn’t trickle out or get sucked back in.
So that was it. I pulled the needle out and held some pressure on the area for a few minutes. It didn't bleed, and he wasn't coughing or short of breath. I knocked on wood a few times and sent him to the Male Medical Ward for the night. I can assure you he'll be the first patient I check on in the morning....
(update several weeks later: next morning he was fine. The pain was better but not gone, and since I'd actually done him some good he agreed to stick around for another day. I did another tap and took out 1.5 liters. Yes, that's a total of 3.5 liters -- sitting in his chest. If your jaw hasn't dropped yet, picture it in Coke bottles. He went home very happy with no pain. I gave him oral antibiotics which he probably didn't take and saved to give his children the next time they get sick.)
Thursday, August 6, 2009
Vacation
I'm sitting in the Amsterdam airport now after a week seeing old friends and familiar places in Kenya. In case you weren't jealous yet (although with those descriptions of getting covered in body fluids, how could you NOT be?) I'll do what I can to stir up that emotion.
Kilifi is a lovely little town on the north coast of Kenya, where the Kilifi River enters the Indian Ocean. There's a marina where rich yachters refuel, and it's the perfect spot to have lunch and do some writing. Which I did.
These are more or less the same photo, taken from my laptop. Between them you get the whole panorama.
Kilifi is a lovely little town on the north coast of Kenya, where the Kilifi River enters the Indian Ocean. There's a marina where rich yachters refuel, and it's the perfect spot to have lunch and do some writing. Which I did.
These are more or less the same photo, taken from my laptop. Between them you get the whole panorama.
God Slaps
(N.B. This post should in no way be construed to endorse a belief in imaginary beings)
There was a guy who came in last Friday with right-sided chest pain. He had HIV. He had normal breath sounds on the left side, but none at all on the right side where the pain was. When I percussed his chest I could feel/hear exactly where it shifted from tympanic (air-filled) to dull (pus-filled). This was a pleural effusion.
If I was confident in my history and physical, I could have put a needle in and drained the fluid out. But that idea made my palms sweat. Stick a needle in someone’s lung? I’d only done one thoracentesis in my whole life, and it was under close supervision of a pulmonologist.
Instead, I got a chest X-ray. It showed a massive opacity at the right base, just where I suspected the effusion was. Still, I convinced myself as I looked at the X-ray that it could be a pneumonia. Hard to tell. I wouldn’t want to stick a needle in if there was no fluid there.
God was already slapping me in the face here, though. The guy had a written note from another hospital, documenting clearly that he had been treated for pneumonia less than a week ago. I asked him if he had taken the medicines, secretly hoping that he hadn’t.
Yes, he said, I took every pill. When was the last dose? Two days ago, he replied.
So we have an infection that is not responding to oral medicines. Why not? Because there’s a huge collection of pus in the lung, and the antibiotics can’t penetrate it. He has a pleural effusion, and the fluid needs to come out.
Still, I hedged. I told myself that I should be a good doctor and play it safe. There’s a small chance that this is just a pneumonia, so why don’t you go to ultrasound tomorrow and have them take a look? He came back the next day with the hand-written ultrasound report in his hand: “Massive fluid collection in the right supradiaphragmatic space.”
At this point God has moved on from slaps to punches. What are you gonna do, He’s saying? It’s right there, you got it in writing now. Are you gonna drain it?
So I ask the guy more questions. How bad is the pain in his chest? Can he live with it? Because, you know, maybe the best thing would be to just continue those antibiotics for a while longer. I mean, maybe they’re just taking a while to work, and we should give them a chance. And hey, if that means the resident who comes after me does the thoracentesis --- well, I can handle the disappointment. What’s most important is the best interests of the patient.
The guy answers me: he’s having fever and he’s having trouble breathing. I measure his respirations and sure enough they’re up.
God is now holding me by my lapels and punching me in the nose while calling me a sissy little girl. How many reasons, He is saying as He does this, do I have to give you, before you drain this guy’s effusion? How obvious do I have to make it?
Look, He says, I know you’ve only done one of these procedures, and you’re not very confident with it. That’s why this is a test. It wouldn’t mean anything if you were completely comfortable with it.
The reason I had this patient present in such an unambiguous way (still God talking --- I’m incoherently blubbering) is because I knew that you would try to wuss out of it. But guess what: you’re out of excuses! So get it in gear, chickenshit! We don’t always have the luxury of a hundred hours in the batting cage before getting called up to the Majors. Step up to the plate! Step up, you whiny bitch!
(I guess you can tell I’m an Old Testament kind of guy.)
So I explain to the guy that I’m going to take some fluid from his lung. Like I’m taking some milk from the refrigerated case in the deli. Just gonna pick up a liter or two of clear yellow fluid. Transudate, exudate, whatever’s in there.
I look at my watch casually. It’s getting late, I say. Why don’t we do it tomorrow? He nods and leaves.
And I go home to the textbooks and spend the next three hours reminding myself how to do a thoracentesis.
There was a guy who came in last Friday with right-sided chest pain. He had HIV. He had normal breath sounds on the left side, but none at all on the right side where the pain was. When I percussed his chest I could feel/hear exactly where it shifted from tympanic (air-filled) to dull (pus-filled). This was a pleural effusion.
If I was confident in my history and physical, I could have put a needle in and drained the fluid out. But that idea made my palms sweat. Stick a needle in someone’s lung? I’d only done one thoracentesis in my whole life, and it was under close supervision of a pulmonologist.
Instead, I got a chest X-ray. It showed a massive opacity at the right base, just where I suspected the effusion was. Still, I convinced myself as I looked at the X-ray that it could be a pneumonia. Hard to tell. I wouldn’t want to stick a needle in if there was no fluid there.
God was already slapping me in the face here, though. The guy had a written note from another hospital, documenting clearly that he had been treated for pneumonia less than a week ago. I asked him if he had taken the medicines, secretly hoping that he hadn’t.
Yes, he said, I took every pill. When was the last dose? Two days ago, he replied.
So we have an infection that is not responding to oral medicines. Why not? Because there’s a huge collection of pus in the lung, and the antibiotics can’t penetrate it. He has a pleural effusion, and the fluid needs to come out.
Still, I hedged. I told myself that I should be a good doctor and play it safe. There’s a small chance that this is just a pneumonia, so why don’t you go to ultrasound tomorrow and have them take a look? He came back the next day with the hand-written ultrasound report in his hand: “Massive fluid collection in the right supradiaphragmatic space.”
At this point God has moved on from slaps to punches. What are you gonna do, He’s saying? It’s right there, you got it in writing now. Are you gonna drain it?
So I ask the guy more questions. How bad is the pain in his chest? Can he live with it? Because, you know, maybe the best thing would be to just continue those antibiotics for a while longer. I mean, maybe they’re just taking a while to work, and we should give them a chance. And hey, if that means the resident who comes after me does the thoracentesis --- well, I can handle the disappointment. What’s most important is the best interests of the patient.
The guy answers me: he’s having fever and he’s having trouble breathing. I measure his respirations and sure enough they’re up.
God is now holding me by my lapels and punching me in the nose while calling me a sissy little girl. How many reasons, He is saying as He does this, do I have to give you, before you drain this guy’s effusion? How obvious do I have to make it?
Look, He says, I know you’ve only done one of these procedures, and you’re not very confident with it. That’s why this is a test. It wouldn’t mean anything if you were completely comfortable with it.
The reason I had this patient present in such an unambiguous way (still God talking --- I’m incoherently blubbering) is because I knew that you would try to wuss out of it. But guess what: you’re out of excuses! So get it in gear, chickenshit! We don’t always have the luxury of a hundred hours in the batting cage before getting called up to the Majors. Step up to the plate! Step up, you whiny bitch!
(I guess you can tell I’m an Old Testament kind of guy.)
So I explain to the guy that I’m going to take some fluid from his lung. Like I’m taking some milk from the refrigerated case in the deli. Just gonna pick up a liter or two of clear yellow fluid. Transudate, exudate, whatever’s in there.
I look at my watch casually. It’s getting late, I say. Why don’t we do it tomorrow? He nods and leaves.
And I go home to the textbooks and spend the next three hours reminding myself how to do a thoracentesis.
Tuesday, August 4, 2009
Vacation
I'm having a lovely time in Kenya. Will pots some wrap-up thoughts in a few days when I get back to the U.S.
thanks for reading!
thanks for reading!
Monday, August 3, 2009
A few gorillas
Some of the best photos got lost, unfortunately. More details on the trip coming, but here are a few to whet the appetite.
Reactions of Children to Me II
Outside of a church, I found a girl of eight or nine who laughed hysterically when I spoke. All kids laugh a little when I talk, but this one found my voice deeply hilarious. It wasn't my presence alone that was funny: when I wasn’t speaking she would stand and watch me silently. But after she’d prompted me with a “How are you?” she would lean in, up on her toes, rigid with anticipation. When she heard my voice, her laugh would explode out, uncontrollable. Genuine delight, waves of it rippling off her. The kind of laugh that makes other people laugh without knowing why. The force of it would push her backwards, turning away from me. A self-sustaining chain reaction.
Saying Goodbye
I’ve always wanted to be a regular. I don’t mean sitting in a bar for hours with the same five drunk guys. I’m talking about the kind of ritual that you do regularly, that involves people in your neighborhood and connects you with your community.
So when I stumbled into being a regular in Kisoro, it was a pleasant surprise. Here’s how it happened: there’s a little shop (i.e. rickety wooden shack that sells whatever they can get their hands on) directly across the tarmac road from where I was living, and during my first week I stopped in to get a soda on my lunch hour.
I leaned my head in hesitantly and found five women, all my age or younger: two working foot-pumped sewing machines, one managing a phone charging station (a power strip of twelve outlets, with every phone charger known to Uganda plugged into it), and two just hanging out.
(I later deduced that these were not fixed but fluid assignments, rotating on some secret schedule. I never found them in the same places twice.)
Not surprisingly, I was a novelty item. They giggled at my attempts to speak Rufumbira, and at each other’s attempts to speak English. My solitary request was for a single glass bottle of soda, but since the brand varied day by day we always had a conversation topic.
(Perhaps “conversation” is too generous a word: when two year-olds babble at each other, do you call that a conversation? One day one of the ladies tried to offer to sew me a shirt. It took twelve minutes of pointing at my chest and the sewing machine for her to communicate that.)
But it was fine, we didn’t need to speak much. We had a simple interaction, some harmless flirtation. It was a ritual we all looked forward to. When they handed me the soda I would say “wakozi” --- thank you --- and as I walked out of the shop I said “n’gaho” --- goodbye.
On my last day in Kisoro I went over and purchased my customary soda. After our normal banter it occurred to me that I should let them know this would be my last day.
“So, um, this is my last day,” I said in English, not knowing any of the words of that sentence in Rufumbira. “So...ngaho.”
They smiled. “Ngaho!”
“No, I mean... like, ngaho for real. Ngaho forever.”
They stared at me. Why was I saying goodbye so many times?
I added a gesture, the motion that football referees make when ruling a first down. “Ngaho!” I said again, sending my arm out straight and trying to face roughly West as I did it.
This did not do the job. From the ladies' perspective, I kept saying goodbye but not leaving. Their smiles had already moved through frozen and were now awkward headed for uncomfortable. All right, we get it, goodbye, get the fuck out already.
So this is actually a sad story, because that’s how it ends. I was making things worse by persisting, so I just left. It was one of the most frustrating parts of my departure from Kisoro.
Maybe in a few days when I stop showing up they’ll have a little chat, and one of them will recall my strange behavior, and they’ll figure it out. That would be nice, then at least they’d know I’d tried.
So when I stumbled into being a regular in Kisoro, it was a pleasant surprise. Here’s how it happened: there’s a little shop (i.e. rickety wooden shack that sells whatever they can get their hands on) directly across the tarmac road from where I was living, and during my first week I stopped in to get a soda on my lunch hour.
I leaned my head in hesitantly and found five women, all my age or younger: two working foot-pumped sewing machines, one managing a phone charging station (a power strip of twelve outlets, with every phone charger known to Uganda plugged into it), and two just hanging out.
(I later deduced that these were not fixed but fluid assignments, rotating on some secret schedule. I never found them in the same places twice.)
Not surprisingly, I was a novelty item. They giggled at my attempts to speak Rufumbira, and at each other’s attempts to speak English. My solitary request was for a single glass bottle of soda, but since the brand varied day by day we always had a conversation topic.
(Perhaps “conversation” is too generous a word: when two year-olds babble at each other, do you call that a conversation? One day one of the ladies tried to offer to sew me a shirt. It took twelve minutes of pointing at my chest and the sewing machine for her to communicate that.)
But it was fine, we didn’t need to speak much. We had a simple interaction, some harmless flirtation. It was a ritual we all looked forward to. When they handed me the soda I would say “wakozi” --- thank you --- and as I walked out of the shop I said “n’gaho” --- goodbye.
On my last day in Kisoro I went over and purchased my customary soda. After our normal banter it occurred to me that I should let them know this would be my last day.
“So, um, this is my last day,” I said in English, not knowing any of the words of that sentence in Rufumbira. “So...ngaho.”
They smiled. “Ngaho!”
“No, I mean... like, ngaho for real. Ngaho forever.”
They stared at me. Why was I saying goodbye so many times?
I added a gesture, the motion that football referees make when ruling a first down. “Ngaho!” I said again, sending my arm out straight and trying to face roughly West as I did it.
This did not do the job. From the ladies' perspective, I kept saying goodbye but not leaving. Their smiles had already moved through frozen and were now awkward headed for uncomfortable. All right, we get it, goodbye, get the fuck out already.
So this is actually a sad story, because that’s how it ends. I was making things worse by persisting, so I just left. It was one of the most frustrating parts of my departure from Kisoro.
Maybe in a few days when I stop showing up they’ll have a little chat, and one of them will recall my strange behavior, and they’ll figure it out. That would be nice, then at least they’d know I’d tried.
Saturday, August 1, 2009
Breaking Stereotypes: Scrabble
Avid readers of this blog (hi mom!) will recall the dentist who accompanied me on my Best Day in Uganda. His name is Willbroad, in case that triggers any memories. I assumed the shortened version was Will, but I am wrong. His friends call him Broad.
After our island adventure, Broad invited me to play Scrabble with him and his friends. He said they meet at a bar. I pictured a lot of drinking with a small dose of wordplay.
I was very wrong. When I arrived at Ebenezer Bar there was a game already in full swing. They sat around a card table on the concrete patio in front of the bar: four skinny Ugandans staring in silence at the board. There were two dictionaries in evidence, the official Scrabble dictionary for standard challenges, and a heftier one for challenges of THAT dictionary. One man sat aside and kept score, so that none of the players were disadvantaged by distracting externalities like adding numbers.
And I was the only one who ordered a beer. Like a rank amateur, they no doubt thought.
When the first game ended, all the standard courtesies resumed. Hands were shaken, introductions performed. Laughing, smiling, slapping arms and backs. The players once again became that most warm and affectionate of all social units --- a circle of African men after a day’s work.
I joined in game two. My guard was up after watching the intensity of the first game, but I figured I would be able to hold my own.
Nope. I was schooled. In my defense, I did try to lay down words that were clever and interesting, which was a big mistake. Broad and his buddies know how to maximize the power of the two-letter word.
“Eh?” I said at one point. “You think ‘Eh’ is a word? I think I might have to challenge that.”
He crossed his arms confidently in front of him. “It is a word.”
He was right. So then I mistakenly deduced that this meant other exclamations were in the dictionary. I tried to play “Oy,” and Broad shook his head disdainfully. “It’s not a word,” he said. “Of course it is,” I shot back. “If ‘Eh’ is a word, then ‘Oy’ is too.”
We looked it up, and again he was right: no Oy in either the little or the big dictionary. I sulked into my beer for a few minutes. Oy is a Yiddish word, I realized, while Eh --- whatever you think of it --- is full-blooded English.
(Wait, I should have challenged that it’s not English, it’s actually a Canadian word! Opportunity missed...)
Here’s a sampling of the many, many two-letter words that were played that night.
Ho
Ug
Ma
Fa
Eh
Fe
Et
Those are just the ones I remember. I did a lot of challenging, and not once did I catch them playing a word that wasn't in the dictionary.
Now, I don’t want to read too much into a tiny ancedote, but this two-letter obsession fits exactly with what I observed during my previous year in Kenya. It absolutely typifies the African work ethic.
Contrary to the beliefs of everyone outside the continent, Africans are the hardest-working people in the world. If they set themselves a task they will complete it. But they prefer working harder to working smarter. It is, unbelievably to me, somehow gratifying to memorize every two-letter word in the Scrabble dictionary.
Even the thought of attempting such a thing makes me reach for the remote. Or it would if I had a TV here.
After our island adventure, Broad invited me to play Scrabble with him and his friends. He said they meet at a bar. I pictured a lot of drinking with a small dose of wordplay.
I was very wrong. When I arrived at Ebenezer Bar there was a game already in full swing. They sat around a card table on the concrete patio in front of the bar: four skinny Ugandans staring in silence at the board. There were two dictionaries in evidence, the official Scrabble dictionary for standard challenges, and a heftier one for challenges of THAT dictionary. One man sat aside and kept score, so that none of the players were disadvantaged by distracting externalities like adding numbers.
And I was the only one who ordered a beer. Like a rank amateur, they no doubt thought.
When the first game ended, all the standard courtesies resumed. Hands were shaken, introductions performed. Laughing, smiling, slapping arms and backs. The players once again became that most warm and affectionate of all social units --- a circle of African men after a day’s work.
I joined in game two. My guard was up after watching the intensity of the first game, but I figured I would be able to hold my own.
Nope. I was schooled. In my defense, I did try to lay down words that were clever and interesting, which was a big mistake. Broad and his buddies know how to maximize the power of the two-letter word.
“Eh?” I said at one point. “You think ‘Eh’ is a word? I think I might have to challenge that.”
He crossed his arms confidently in front of him. “It is a word.”
He was right. So then I mistakenly deduced that this meant other exclamations were in the dictionary. I tried to play “Oy,” and Broad shook his head disdainfully. “It’s not a word,” he said. “Of course it is,” I shot back. “If ‘Eh’ is a word, then ‘Oy’ is too.”
We looked it up, and again he was right: no Oy in either the little or the big dictionary. I sulked into my beer for a few minutes. Oy is a Yiddish word, I realized, while Eh --- whatever you think of it --- is full-blooded English.
(Wait, I should have challenged that it’s not English, it’s actually a Canadian word! Opportunity missed...)
Here’s a sampling of the many, many two-letter words that were played that night.
Ho
Ug
Ma
Fa
Eh
Fe
Et
Those are just the ones I remember. I did a lot of challenging, and not once did I catch them playing a word that wasn't in the dictionary.
Now, I don’t want to read too much into a tiny ancedote, but this two-letter obsession fits exactly with what I observed during my previous year in Kenya. It absolutely typifies the African work ethic.
Contrary to the beliefs of everyone outside the continent, Africans are the hardest-working people in the world. If they set themselves a task they will complete it. But they prefer working harder to working smarter. It is, unbelievably to me, somehow gratifying to memorize every two-letter word in the Scrabble dictionary.
Even the thought of attempting such a thing makes me reach for the remote. Or it would if I had a TV here.
Reactions of Children to Me
I was walking alone down a deserted dirt road. There were no other people in sight. I came around a bend to find a small boy of five or six. He was about a hundred yards from me, carrying two jerry cans for water. When he saw he me stopped dead in his tracks. After two seconds frozen, he turned and started running as fast as he could back the way he'd come. Every ten steps he would look back to see if I was chasing him. He kept up this way, hauling full-tilt ass, until he was out of sight around the bend. I never saw him again.
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