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.
Wednesday, July 29, 2009
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.
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.
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.
Tuesday, July 28, 2009
Sunday, July 26, 2009
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.
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.
Saturday, July 25, 2009
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.
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.
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.
Friday, July 24, 2009
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.
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).
Thursday, July 23, 2009
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.
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:
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.
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.
Wednesday, July 22, 2009
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....
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.
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.
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.
Tuesday, July 21, 2009
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.
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.
Monday, July 20, 2009
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.
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.
*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.
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.
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.
Sunday, July 19, 2009
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.
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.
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.
Friday, July 17, 2009
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.
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....
“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.
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.
Thursday, July 16, 2009
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.
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.
Wednesday, July 15, 2009
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.)
The fat drops are smacking into the dust, raising tiny swirls.
The smell is incredible.
(my Macbook dashboard correctly predicted this.)
Tuesday, July 14, 2009
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.)
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.)
Sunday, July 12, 2009
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.
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.
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.
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