Week 4: Cases of the Week

Two hospital posts in a row--lucky you! Week 4 was very light on the clinical side, especially after week 3. We had to put in a lot of hours to finish the next step in our projects, and we left Wednesday afternoon for our safari, so we only spent two mornings in the clinic. Always great cases though!

***Bug of the week--Leaf bug!
There are always creepy crawlies about the hospital but they're usually gigantor moths and beetles, so it's exciting to see cooler bugs like the praying mantis last week and the leaf bug this week! This not-so-little guy was hanging out on one of the windows in the maternity ward, and after the furtive whispering and poking and pointing between Shalina and I Dr. K paused and asked us if we'd like to get a picture so we could move on with rounds. He knows us so well now!


***Burst Abdomen--Guts on the Outside: This case was as dramatic as it sounds. Remember the two C-sections from the Friday of the previous week, where nothing seemed to go right? Well this case was the second of those Caesars, the woman who was operated on around midnight by a different surgical team.

We rounded on her Monday morning and were pleased to see that she and her baby were alive and recovering well (her baby was very pale after the prolonged labor, so there were several jokes cracked that she had somehow given birth to a mzungu baby). She had developed a cough since the surgery, but since it was likely due to the anesthesia she was prescribed a cough syrup and we moved on.

A while later a sister (nurses=sisters here) discretely came up to us and said that the patient in Bed 6 needed help. When asked what's wrong the sister quietly said that the patient was...bleeding. When pressed for more information she just again quietly said "She is....bleeding....from her....wound," and said she should be seen by the doctor. Though confused, we went with Dr. K back to the front of the ward and had the patient uncover her abdomen. That's when we saw not blood seeping through her dressing, but a large softball-sized amount of bowel coming out of her abdomen! It was pretty shocking for all of us, since it was not what we'd been expecting. The woman was varying between staring at us and staring at her intestines, and Shalina and I could not believe that she wasn't going into shock.

The coughing would have had to rupture through at least three layers of stitches for her guts to come out, which seemed very unlikely for the mild cough the woman had. Dr. K demanded to see her chart again to see what doctor had operated on her, and immediately started calling people for an emergency surgery. Since we'd experienced "emergency surgeries" before I decided to look at my watch and decided to time how long it took to get this woman into the theater. It was 11:18am.

We finished rounds and came back to check on her before we left, around 12:30pm. No progress had been made on readying the OR, though sisters were still trying to track down theater staff while doing their other duties. The patient was trying to keep a gentle but firm hand on the sheet covering her extruded intestines, and trying really hard not to move or cough, but perfect immobility was impossible and more bowel had slipped out since we last saw her. Lots of other women in the ward were stopping by to encourage her and help her and her baby out, and hopefully that helped keep her somewhat calm.

Shalina and I left for lunch and to work on our projects around 2:30pm, and the woman was still nowhere close to getting into surgery. We had hoped to come back later for the surgery, but it wasn't until after 8:30pm --over 9 hours later--that she went into surgery, and Dr. K didn't have a moment to call us once he'd corralled everyone into the theater. Dr. K told us that by the time they started operating almost all of her large and small intestines were outside her body. Completely insane.

He did a thorough wash, sterilization, and repair, and miraculously the woman has not gotten sepsis. It's especially lucky considering her HIV+ status. Unfortunately her cough has gotten worse (don't worry! Dr. K used an extremely tough suture technique so nothing has come out again), and the sisters mistakenly cut her sutures after only 6 days instead of the 10-12 days Dr. K had ordered. Now we're waiting to see if she has tuberculosis (which is super great since she's been coughing around us for two weeks now), and Dr. K re-repaired her outside layer of stitches this past Wednesday.

We never found out if it was a medical error that cause the original 'burst abdomen', but some external sutures have blown on two other patients the same doctor has operated on... We wish Dr. K was available for every surgery!

Me and the most awesome peds nurse, Sister Grace!

***Convulsing Infant: As we were leaving the pediatric ward on Tuesday we were bombarded with several urgent cases. The first one was a day-old infant who had been fine until he was taken to the immunization clinic for his first round of shots. On the way back he started having full-body convulsions, so his mother brought him straight to us. Upon examination we saw that he was having convulsions predominantly on one side, and that they would last for a few minutes and fade away, and then another round would start. Disturbing him too much would set off rounds of convulsions, but they would also start without any stimulus at all. Additionally the baby had a large lesion the size of a quarter on the side of his scalp that was semi-crusty but would ooze fluid if it was poked or squeezed. The mother said he been born with it, and that it didn't seem to bother the baby.

Also, the boy had six digits on each hand! He had extra fingers growing out of the middle of his pinky fingers, so while we were waiting to see if the seizures progressed or abated Dr. K tied off both digits tightly with sutures and said they would fall off in less than a week. He said this was decently common in Kiboga District (which was super surprising to us!), and then asked the mother if she had been born with extra digits. She held up her hands and we saw that she had small bumps of flesh on the outside of both pinkies--the remnants of her extra digits.

During all of this the side having most of the convulsions switched! Most of the diagnoses on our differential diagnosis didn't fit, and we were left with thinking it was a reaction to the immunizations (which had been our first suspicion anyway). The other option left was that the lesion was communicating through to his brain and allowing bacteria to enter. The boy was admitted for observation, but since we didn't return to the hospital this week we never found out what happened to him.

***Two tongues: One last weird case was a six-month old infant who appeared as we were walking out the door. The mother, nurse, and Dr. K got quite excited discussing the case in Luganda, and we could tell Dr. K was teasing the mother. When he finally turned to us he said that the boy was really a snake--he had two tongues! When we pried open his tiny mouth to examine him he did indeed appear to have two tongues. But unlike a snake's split tongue this boy had two tongues on top of each other--very bizarre! The mother said the boy had no problems swallowing or breathing, so while Dr. K wrote a referral to Mulago he told the mother not to take the boy until he was five years old or so, unless he developed problems before then.

With these two cases this week, the boy born with no arms the week before, and a couple other cases we feel like we've been seeing lots of weird birth defects. Dr. K says we've seen only a few, and that there are lots lots more. When we tried to press for more details about what he thinks is causing them he didn't really have an answer for us. More unsolved mysteries in Kiboga!

Safari Palm Tree says, "GO STANFORD!"

Week 3: Cases of the Week

Yes, yes, I know it's now week five, but such is life in Africa. Here's the long update from week 3!

This week was a doozy. We did four full clinical days, which lasted 10-12hrs each (with an hour break to escape and eat something...anything!) and included a trip to the OR every day. It was amazing, and soo exhausting. We also had meetings crammed in here and there and everywhere for our projects, but with long hospital days and no electricity at night, we didn’t get very far on actually writing our next assignment…oops! Luckily it got finished the next week so we didn’t have to feel guilty about our clinic time!

The post is long but hopefully not as graphic as the last one, though with medical cases and surgeries there will be some details that may make some squeamish, so again feel free to skip to the next post.

***Praying Mantis: Okay, so this more of a hospital story than a medical case, but there was a praying mantis on the door to the labor suite on Wednesday! It was giant! Shalina and I were shocked and amazed! The locals thought we were bananas, as usual, and found it hilarious that Americans bother to round up bugs and put them on display at zoos (we told the staff that’s the only place we’d seen them before). Later we learned that not only do mantises roam free here, they FLY, and it can be quite distracting when a giant green bug zooms past your head as you’re trying to focus on a woman in labor.

***Surgeries: This week we saw four surgeries—a hernia repair, a circumcision, and two Caesars.

The hernia repair was on a 20yr old man who’d had an indirect scrotal hernia for over 5 years. The man had spent 400,000 Ugandan Shillings on traditional herbal methods of healing with no luck (obviously—I’m not sure how herbs could push bowel back up inside your abdominal wall…) and so finally scheduled the surgery during his school break. Shalina and I thought the hernia was pretty big to leave unattended for so long as it was 6-7” long, but Dr. K said he’s seen indirect hernias the size of basketballs—insane! The hernia was completely manually reducible—you could push all of it back up into his abdominal cavity though his external inguinal ring, but it would all just slip back out again (this is all under his skin of course) after you removed your finger. Pretty crazy. The surgery was awesome to watch since the whole anatomy of the abdominal wall, inguinal canal, and spermatic cord was integral, and Shalina and I were sweating getting ‘pimped’ with all of the questions Dr. K threw our way.

I was also really not feeling well this day, and at one point I had to bolt out of the theater, strip off my sterile layers and galoshes, find my shoes, and rush/stumble to the toilet to puke. When I was finished I chugged some water and wondered if it would be a poor medical decision to return, but I could hear Dr. K calling for me so I got back into all my layers of gear and entered the OR to find everyone staring at me silently. Dr. K calmly called me over to the patient’s side and asked me to describe and identify the different pieces of the spermatic cord he’d just un-entangled from the intestine. The surgery continued on like nothing had happened…

The circumcision on another 20-something year old man was also very interesting. Typically only Muslim men are circumcised in Uganda, and men in a few tribes in Eastern Uganda (in a crazy, painful, un-sterile, HIV-spreading ritual---yeesh), but with the advent of HIV and the studies proving efficacy more men are choosing to have elective circumcision to reduce their risk of contracting and spreading HIV. Though all the men in the room teased the patient that he was “Hadj” now (the Ugandan nickname for all Muslims, whether they’ve made the pilgrimage or not), the patient stood up to it and recovered well.

The first C-section we saw was a sad case. A woman came to the hospital early in the morning  after laboring for 48hrs under the care of a traditional birth attendant in her village. Upon examination it was discovered that the baby was lying obliquely in the abdomen, and so the forearm was being delivered first out of the cervix, wrapped and tangled in the umbilical cord (which was what was causing the obstruction). When Dr. K examined her at 9am there was no umbilical pulse; the baby had already died. He told us it was a "forearm prolapse" but when we saw her in the OR at 1pm (the quickest the OR could be prepped and the staff recruited) the entire arm was out of the woman's body, along with a foot or so of umbilical cord. It was very disturbing-looking and much more extreme than we'd expected. The surgery went well considering the murky state of things inside the uterus, and miraculously the woman recovered without developing sepsis (several women in the maternity ward did not receive their prescribed antibiotics this week, and two did develop sepsis likely because of it, but this woman at least had some small good fortune).

The second C-section we saw was one of two women who needed Caesars on Friday. Both women had arrived early in the morning after laboring for several days in their villages—the woman we operated on had been in labor since Monday! Horrible. Both women were spiking very high blood pressures (understandably—their bodies were not handling the stress of labor well after so many days) and so could not be operated on until they were lowered. Many doses of bp-lowering drugs were given before the anesthesiologist would accept either woman, and by the time our first woman’s came down and the OR was prepped her baby had died. The woman had developed a very high fever and she was heading for septicemia and a coma or death, so she was operated on first around 6pm. Her surgery did not go well; the woman bled too much and petocin, a drug to stop peri- and post-partum hemorrhage was mistakenly not given until the very end of the surgery when the bleeding could not be stopped (it should have been given as soon as the baby was delivered). Additionally the scrub nurse assisting Dr. K was sick, and she couldn’t even stand to complete the surgery. Tempers were running very high in the room.

After the surgery, even though the second obstructed labor patient was waiting, the electricity was cut, it was now completely dark, and the scrub nurse refused to do another surgery. Then the anesthesiologist left to get dinner and would only return if all of the problems were resolved. Dr. K was in a very dark mood, and after ranting about how screwed up the system at the hospital was (totally understandable) he tried to convince me to scrub in on the next surgery and assist so the woman could be delivered as soon as possible. There were a million reasons why this was a bad idea, and luckily Shalina and I had already discussed them during the previous surgery. I was torn--what if I agreed to help on the surgery but made a mistake or acted too slowly and the woman died on the table? Or worse, what if I refused to help and just let the woman and her baby die downstairs while waiting for surgery? The woman was also HIV+ and the OR was short on protective equipment; another factor to consider. Additionally the woman's family was too poor to afford a transfer to another hospital, so it was here or nowhere. I was basically ready to cave in despite all the arguments against it, but since there was no electricity, not enough sterile equipment, and no anesthesiologist Shalina and I just went home. We later learned that Dr. K spent several more hours fighting the system to get this woman her operation, and she was finally operated on by another doctor and team around midnight. She and her baby both survived, but she became a case of the week the following week, so stay tuned…

Don't fret! We're still cheerful at the hospital!

***87yr old mystery man: It’s extremely rare to see someone over the age of 60 in Uganda (the mean age of the population is 14yrs, and the life expectancy is around 50), so when we were called into the male ward to see an 87yr old we had to ask if we heard the age correctly. The man came in with his granddaughters who explained he’d been feeling poorly for a while but had staunchly refused medical care all his life. Now he was too weak to resist, though he still had some fire in his eyes even has he remained silent in protest during the whole exam. There were very cool physical exam findings, so we got to use all our new skills! There was crepitus across his right rib cage—air bubbles trapped under the skin that feel totally crazy, kind of like popping tiny bubble wrap. There was also fluid in his belly that was only present right below his rib cage (our mad percussing skills narrowed down the area). His lungs sounded funny as well, but we knew he had emphysema among other problems there. Lots more positives were found throughout the exam, as would be expected in an elderly man (it was much more exciting than doing full exams on healthy medical students!)

So the debate began: is this a lung problem or a liver problem? Pneumothorax? Liver abcess that had ruptured? Obstructed/perforated bowel? Without more certainty Dr. K didn’t want to push a needle into the man’s side to see what came out, and with no imaging options available we had to transfer him to Mulago, the national hospital in Kampala. It was so frustrating not to be able to just send this guy down for a chest and abdominal CT scan and get the answer within a few hours. The radiologist had gotten married the previous weekend so there weren’t even ultrasound or chest x-rays available. Now we’ll never know what was wrong with this man (sigh).

***Pediatrics: Though we only spent one day in peds this week there were still too many notable cases to talk about. Cerebral palsy, severe malnutrition, a possible thalidomide case in a boy born with no arms… One case in particular though stands out in my mind.

There were two adorable toddlers who seemed well recovered from their bouts of malaria and kept escaping from their moms to come play with us as we progressed around the ward doing rounds. We saw them eventually, and both were due to be discharged later that day. One of the moms came back to us half an hour or so later and said her boy was convulsing. We went to go look at him and indeed he was having small tremors all over his body. The staff didn’t seem too concerned, and Dr. K suggested an anti-seizure drug. Half an hour later Shalina and I wanted to check on him on our way out since we felt uneasy with the previous visit; the boy had come in for malaria, which can cause both high fevers and hypoglycemia, both of which cause convulsions in toddlers. We saw he was still convulsing--more severely now--and he hadn't even received the previously stat-ordered meds. So we bullied and nagged Dr. K until he spent time to re-examine him and ordered more appropriate treatment, which quickly stopped the convulsions. Though the case was minor Shalina and I both felt like the boy may never had received correct meds and wouldn’t have stopped convulsing for hours unless we’d intervened. This case made me apprehensive of how many other cases on the busy, overcrowded ward were being overlooked due to harried staff and soft-spoken young mothers…If this kid hadn’t been totally adorable and charming before I might not even have noticed his rapid decline and fought for him to receive appropriate treatment, and who knows what damage would have been done.

***Mulluscum contagiosum or Varicella?: A women in her second trimester of pregnancy was in an isolated room off the labor suite when we stopped by to visit her with no inkling of why she’d been admitted. We walked in the door and saw a women covered from head to toe in pox. Shalina and I have both had chicken pox, but we’re in the middle of nowhere in Africa, and we both took three steps backwards to flatten ourselves against the wall as soon as we saw her. Not super proud of that, but the pox looked extensive and weird. We were laughed at by the staff who assured us it was probably chicken pox. We crept a little closer to examine the woman and noticed that many of the pox were umbillicated (look like cheerios) across her abdomen, so we threw out Mulluscum contagiosum for the differential diagnosis, and asked about her HIV status. Dr. K was pretty sure it was chicken pox, despite the weird presentation, and was pretty unconcerned with any dangers to the fetus, though we were told in detail about the dangers of varicella to the fetus in microbiology class. She was treated with calamine lotion and antibiotics and while she remained the only person in her room she wasn’t in isolation and wandered out around the other pregnant women quite frequently. We haven’t seen an epidemic break out since then, but we still were uneasy with this whole pox case….

***Leprosy: We didn’t see this in the hospital, but like the mycetoma foot the week before we saw a man with very advanced lepromatous leprosy begging in Kampala. It didn’t look like he’d been receiving treatment, so we were glad we were just passing by in a mutatu (though you need a lot of contact to catch the bacteria). It was pretty crazy to see such an advanced case--it looked just like the textbooks!

You made it to the end! Giraffes say thanks!

Murchison Falls Safari & Nile Cruise

I think Shalina and I took 500 photos between the two of us over the few days were were gone, all of which are amazing (of course), but I'll try and put of some of the best ones here. I need to start a site to share all my photos, but we'll see if that happens before I'm state-side again...

We left Wednesday afternoon from Kiboga to head to Kampala, where we feasted on coffee treats and had dinner with friends. The safari company we used, Red Chilli's, has a compound outside of Kampala and so we stayed there Wednesday night before leaving early in the morning to start the drive up to Murchison Falls National Park. We got there kind of late and there weren't enough beds for our group so we got a free upgrade to this huge fancy house! It was wonderful, and we had lovely hot showers. Perfect start to the trip.

Thursday we met our safari group (in total there were 7 of us Americans and 1 Welsh guy) and then spent most of the day driving. We got to the park around 4pm, and to the basecamp in the park near the Nile around 5pm. Even though most of the wildlife lives across the Nile we started seeing animals as soon as we entered the park! Warthogs, baboons, and various antelopey creatures were pretty brave and barely moved out of the way for our vehicle. This family of warthogs lives at the basecamp and searches for any food left out or ventures inside tents for snacks...

We wanted to stretch our legs before dinner so five of us hiked down the short hill to the Nile (and were told we shouldn't be wandering around without guns...eek) to see our first hippos!! We saw millions more the next day (only a slight exaggeration), but it was very fun to start the safari early.

We also saw more hippos late that night--outside our tent! The hippos come out of the water at night to feed, and apparently the grass at the basecamp is super delicious. They warned all of us extensively to steer very clear of camp hippos, so it's pretty unnerving when they are close enough to touch through your tent wall. They are also SO. LOUD. when munching on grass two feet away from you!

The next morning we were up before sunrise to hop in our sweet pop-top mutatu to get on a ferry across the Nile and start our safari! We had a ranger join us to help us spot and ID the animals, and also carry a terrifying automatic weapon "just in case" (BTW, not the weapon I was imagining when they said he'd have an "elephant gun"...)



So safariing we went! Like I said it was the best time I've ever had before 8:30am--we'd seen at least one group of every animal by then. And by group, I often mean animals dotting the landscape as far as the eye can see--it was totally unreal.

Here are some of my favorites, like Uganda's national animal--the kob!

Lion! Eating a warthog!

Me and some giraffes! There were soooo many giraffes!

And we were so close to them! And all the animals really--almost uncomfortably close sometimes.

Elephants! This guy was super handsome, and I got my wish to see some baby elephants before we left the park--sooo cute.

Many more animals, and many more pictures--too many to post. After the game drive in the morning, we went back to camp for lunch and a quick nap in the scorching heat, then boarded a double-decker boat to cruise up the Nile to Murchison falls.

The breeze on the boat was lovely, and we got to see most of the animals again as well as new water animals and tons of birds!




Here's me and a family of elephants!

Zoom in on the elephants

Nile crocodile! They were very hard to get a good pic of since they'd dive under water when we got too close, but were so huge and were awesomely green and black. So sweet.

Soooo many hippos. I didn't know there were so many hippos! They dig tunnels in the shallows so it looks like they're all floating in deep water, but when one stands up you can see that the water is barely up to their chubby hippo knees. I really enjoyed talking about hippo tunnels the entire trip--don't they sound like fun places?

We got to climb out of the boat near the falls and take photos on rocks before cruising back down to base camp. A lovely lovely afternoon.

We paid a little extra to do a wine and cheese sunset tour of the Nile, which was a wonderful $20 spent. We got waaaay too close to all the animals in our tiny boat with our brave captain who liked to bellow back at the male hippos who tried to warn us off from their 'schools' of females.

The next morning before we did the long drive back to Kampala (on which we got two different flat tires) we got to hike up to a view point of Murchison Falls and it's sister waterfall Independence Falls (it appeared in 1962 after a flood and is only around certain times of the year, so we were very fortunate to get to see both of them in all their glory!

We then hiked down some cliffs to visit the top of the falls. Me being me, I managed to jump down hard on a clump of soft dirt that was posing as a rock and starting sliding down the cliff! I tried to get my footing but just kept finding dirt and sliding further. Luckily I found a teeny tree root to grab, and pulled myself back up before anyone else had reacted to what had happened. The dirt is super soft and rich in mica, so while I was covered in it after my little fall I wasn't scratched at all, and I glittered the rest of the day! (My shoes are still filled with sparkly mica, so all my socks will get sparkly too...)

I have a billion gorgeous photos of the falls that I am pretty sure I could sell as postcards. Here's me at the end of a rainbow leaning on what used to be a precarious footpath across the falls.

The trip was AMAZING AMAZING even though we didn't pay extra (and spend two more days) to see the rhinos and the chimps. It was a wonderful break from work and worth every cent we spent! :)

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Just got back from surgery at the hospital so you only get a teaser safari photo...

A really fat baboon! He lives with his extended family all around the camp we stayed at in the park, and despite what the park rangers kept telling us was NOT afraid of humans...I was swarmed when they discovered I was eating a banana one morning!

Sweet sweet safari

THE SAFARI WAS AMAZING!!!!!

This face sums up the entire trip.

I'll do a full post with some (better) pics soon, but Shalina and I are exhausted and have to be awake for the hospital tomorrow morning.

Rawr!