Goodbye Kiboga!!

We were very sad to leave Kiboga and all our friends at the hospital this morning and head back to Kampala, where I am now. We took lots of pictures and forced everyone to hug us goodbye, even though it's not a Ugandan custom. We Americans like to hug!


I will be working at Mulago, the national hospital and the teaching school for the medical school, but not yet! Need some more vacay time first!

We head out early tomorrow morning to go to Jinja, the source of the Nile River, where we're going on a white water rafting trip down the Nile (up the Nile? the Nile is so backwards). I'm sure I will get soaked and burnt to a crisp, but I'm suuuuper excited!

We're spending the night in Jinja and then heading east to Sipi Falls, where we'll stay two nights before heading back to Kampala on Tuesday. Sipi is supposed to be ridiculously gorgeous (which must be impressive because almost everywhere we've been in Uganda is gorgeous), and we're going to attempt an all day hike on Monday. Shalina and I are still recovering from our Bunyonyi injuries--I think I now have the hip of a 65yr old woman--but we're pumped to be doing summery things!

We're not taking our computers so I'll be incommunicado til Tuesday night. Happy Birthday to all the birthdays I'm missing in the states!!

Dr. Mzungu, Surgeon!

I know I owe a million blog posts, but I have no time after yesterday's 14 hour day. It was our last real clinical day so we wanted to do everything, so we did!

Beyond seeing a million ridiculous cases in maternity like usual, a horrible preteen sexual assault case, watching two vaginal births, and watching two C-sections, we got to assist in surgery!

I was the first assist (and ONLY assistant for Dr. K) on an emergency Caesar that got much more complicated and tricky than had been planned, but despite the sweat rolling down my back the entire time apparently I did wonderfully! Both mom and baby survived, despite lots of bleeding and a long struggle to start breathing (respectively). I was responsible for basically everything during the surgery but cutting and suturing, which is a lot of crazy juggling. I even got to clamp off and cut the cord. It was so so awesome.

Shalina caught the baby on the first surgery, so she got to assist on the second one while I caught the baby. She of course got a nice quick clean case after my messy one, but that meant the baby was super healthy, which was more fun for me!

I held the wiggly screaming baby while they cut the cord, then took her over to the midwife and got to suck out all the goo and tie off the cord neatly, and weigh and APGAR score her. She was chubby and super healthy, but fussy and cold during the rest of the surgery despite the warming lamp. The midwife told me the baby's name was Maren now, so I should hold my namesake while I watched the rest of the surgery. So of course I did. And observing surgeries late at night is made more enjoyable by simultaneously snuggling newborn infants, in case you didn't know.

After the surgeries we were starving and ready to drop, but maternity was blowing up downstairs so we saw some crazy cases for another hour and a half before we escaped (leaving Dr. K still there) and got home at midnight.

A wonderful last clinical day!!

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!

Malaria in Pregnancy--A Case Study

I promised I'd post more about my project on malaria in pregnancy, so here is a case study I did of one women who came to Kiboga Hospital with malaria. Even if a woman has grown up in a malaria endemic region like Uganda, when she becomes pregnant the malarial parasites can hide in the placenta and cause severe disease. Severe anemia is the most common complication, which can lead to peripartum and postpartum hemorrhage, and malaria-induced anemia causes the most maternal deaths at Kiboga Hospital. Additionally the parasites in the placenta lead to miscarriages, still births, premature births, and low birth weights, and these infants that are born are at a much increased risk for contracting other diseases and dying in their first few years of life. Here is Juliet's story:
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When I first met Juliet during Monday morning rounds on the maternity ward she seemed like many other women in a similar condition: glad that she no longer felt ill, and very eager to leave the hospital. I learned that Juliet was 24 years old and six months pregnant with her third child, and had been admitted with severe malaria over the weekend. She had recovered well after several doses of IV quinine and was hoping to be discharged that day. I asked the doctor to ask her the questions I’ve been using to survey all pregnant women admitted with malaria, and among other things we learned that she doesn’t sleep under a bed net, did not have malaria in her previous pregnancies or as a child, and had recently emigrated from Rwanda. Her case piqued my interest.

Since Juliet was told she need to wait for another blood smear before she could be discharged I asked the doctor to introduce me and my project and ask if I could come back and chat with her while she waited. She looked surprised and embarrassed as he translated, but shyly looked at me through her long lashes and agreed to the interview. When I found her later (with a nurse who could translate her tricky Rwandan dialect) I noticed that while she still seemed shy she had retied her hair into a beautiful scarf and had changed into a nicer dress; it seemed she was looking forward to the interview as well. Juliet was very quiet and succinct with the male doctor earlier, but once the nurse and I started talking with her she talked very animatedly and used her hands to mime out what she was describing so I could follow along.

I soon learned that Juliet was born and raised in Rwanda. She grew up in a village with her family where they raised cattle and relied on subsistence farming for food. She attended school for five years before school fees became too expensive for her family, so she dropped out and helped her family with “digging” instead. When Juliet was 18 years old she married a cattle farmer, and now she has two daughters ages six and three.

A few months ago a newly pregnant Juliet moved with her husband and her younger daughter to Kiboga District in Uganda to be near her husband’s family, who are cattle farmers in the town of Kiboga. Their oldest daughter is still in Rwanda; she is staying with Juliet’s mother and attending a new, free school mzungus have started in her old village. Juliet’s family is renting a room in a house shared with two other families that is located on the highway about 4 miles outside of Kiboga. Their family is quite poor, and while they eat three meals a day they cannot afford much else.

When Juliet was two months pregnant she fell ill quite suddenly. Juliet said she was shivering uncontrollably, her abdomen felt extremely hot on the inside, she was dizzy, and she had a horrible headache. She was scared and didn’t know what was wrong with her but when she went to Kiboga Hospital for treatment she learned that she had malaria. She had heard of malaria in Rwanda, and knew that people in her village had gotten it before, but neither she nor anyone in her family had ever had it. After getting several doses of IV medication she was discharged with oral medications to take, but since they made her nauseous and caused vomiting she stopped after taking only a few.

This past weekend Juliet, who is now six months pregnant, was digging in her family’s rented land when she started shivering and developed severe joint pain. She decided to stop digging and instead squatted down to begin collecting nuts, but she quickly lost all her energy and returned to the house. She was still shivering and achy and suspected she had malaria again, and so walked the four miles to the hospital for treatment.

I asked Juliet if she knew what malaria is, or what causes it. She is still unsure of what the disease entails since she has had different experiences with it, and had no guesses as to what could cause it. The nurse asked her if she had ever heard of a fever disease caused by mosquitoes, and while Juliet said she hadn’t her face lit up and she explained that she’d had lots of mosquito bites since moving to Kiboga, and asked if they were related to her sicknesses. She used to sleep under a mosquito net in Rwanda but her family cannot afford to buy them here, so she’s been bitten many times at night. She has been attending antenatal classes at the hospital, but doesn’t think they’ve ever mentioned malaria (although she has trouble understanding rapid Lugandan) and she was not given a free bed net. She knows she has been given lots of pills to swallow at antenatal, and thinks she may have received 3 pills to prevent malaria, but she was very unsure.

At the end of our chat I took time to talk with Juliet about malaria and what causes it and explain that her whole family is at risk because they’ve never been exposed to it before. I also explained that malaria can be harmful to her pregnancy, and told her to specifically ask for a bed net at her next antenatal appointment. Finally the nurse and I tried to convince her to complete her oral quinine treatment this time, and made sure she was prescribed an anti-nausea medication to take with it at home.

Juliet thanked us for helping her and her family, and I thanked her for sharing her story with me. As I walked out of the ward I looked back towards her bed to find her still watching me. She broke out in a huge grin—the first one I’d seen from her all day—and waved goodbye to me with both her arms. I waved enthusiastically back and felt lighthearted knowing we had both helped each other that day.

Week 2: Cases of the Week

Still playing catch up… Posts about Week 3 Cases and this weekend will hopefully happen before we leave town to go !!!SAFARI-ING!!! Wednesday afternoon. FYI this is a clinical post, so it's long and somewhat graphic, so be warned. I'm not offended if you skip this post and wait for more pics of kids and animals! Here's a zebra to tide you over. 

***First Ugandan Theater Experience: Every time Dr. K says “Shall we go to the theater?” I have to pause for a second to remember that he wants to go to the operating theater, not to see a Broadway show. Though we’ve seen quite a few operations now, my first back-to-back C-sections (or “Caesars” as they’re generally called here) will always be memorable.

As you may remember the hospital usually doesn’t have electricity or running water, and the same can be said of the operating theater. There are large tanks of sterilized water located throughout (they look like the Gatorade jugs you see on the side of football fields) for scrubbing in and other uses, and if you’re in the theater after dark—and do enough politicking for hours beforehand—there is sometimes a generator available to run lights and the oxygen machine for the anesthesiologist (BTW we’ve now done two surgeries completely without power, and one where it crapped out for 20 minutes in the middle). We wear the usual caps, masks, and scrubs—the hugest and holey-ist scrubs you can imagine—but also giant, white galoshes, the mandatory OR footwear. We’ll bring the camera to work soon so we can document the ridiculousness of our theater attire.

Our first Caesar was on a woman who had been in labor for 2-3 days by the time she arrived from her village, and though the baby was in the correct position the labor was obstructed. We got into our galoshes and into the OR and had no idea what to expect—neither Shalina nor I had seen a C-section before.

Dr. K made a few quick incisions to get down into things, and with the first touch of the scalpel to the uterus a giant spray of brown liquid erupted out, spraying several feet off the table and quickly sloshing all over the floor. We suddenly understood (and were thankful for) the galoshes. We were understandably distracted for a few seconds by the brown volcano coming from our patient’s abdomen, but Dr. K calmly fished around inside the patient and before I could register the appearance of two baby feet he pulled and twisted and tugged the baby completely free of the mother and had her dangling upside-down by her feet in the air. A nurse came and collected the baby and worked on her while Dr. K and another nurse worked on cleaning up and repairing the mom. All of this happened in the first 3 minutes of the surgery, and I think Shalina and I stared slack-jawed and rooted to the floor the entire time.

When things calmed down we learned the volcano was the result of the long obstructed labor. The placenta had already separated (Dr. K had tossed it out right before he grabbed the baby) and the baby had already had its first bowel movement, which is what tinted the color and caused the gas. The baby was not okay initially but resuscitated well, and although the mom developed sepsis a few days after the surgery both she and her baby are doing well now.

The second Ceaser seemed less dramatic, but it was nice to see a more typical case. This mom had also been in labor for over two days, and CPD (Cephalic-Pelvic Disproportion, or inadequate pelvis size) necessitated operative intervention. With very young and very skinny moms here this is a common cause for a trip to the theater (obstructed labor is the other big ticket item). The operation went smoothly and both mom and baby did well afterwards. We’ve had several less positive Caesar experiences this week, so it was a treat to have our first day in the theater result in two babies.

***The Morgue (WARNING: graphic): This week we learned that if anyone asks you if you want to see a postmortem on anyone in rural Africa, you say no thank you. Before we could start rounds Monday morning three detectives arrived from the police station to request a postmortem exam on a 6 year old girl who had died the day before. The parents said the girl died of malaria, but the neighbors suggested that the girl was beaten to death, so the police were investigating. We learned that beating children is common, culturally acceptable, and legal in Uganda—unless the child dies.

Shalina had never seen a postmortem or an autopsy before and was visibly nervous as we descended into the basement. Although I took the autopsy elective winter quarter, and was putting up a tough front as usual, I was still unsure about seeing a child abuse case. As it got darker and smellier I re-remembered that there’s no electricity at Kiboga (so no lights and no refrigeration), and started to think that this trip to the basement may be a mistake.

We were the last two to go through the double doors into the morgue and froze upon entering. There was a dead man lying on a table right inside the door, only partially covered by a sheet, and although it smelled (reeked) like he had been dead for quite a while his blood was running off the table and into a large, thick puddle on the floor. It was horrifying. Absolutely horrifying. The heat, the smell, and the scene in front of us compelled us to move quickly on, and we followed Dr. K and the detectives into the next room.

The little girl had been carefully wrapped in sheets and was still wearing her Sunday go-to-church dress before she was prepared for the exam. Dr. K was quick and thorough in his external examination while the detectives took photos. It couldn’t have been more than 5-10 minutes, but the smell coming from the next room made it feel at least 10 times as long. Shalina was on the verge of passing out—shaking, nauseous, sweating—waiting for the external exam to turn into an internal one. She was sure she would collapse if Dr. K picked up a scalpel, and so after a few minutes she fled for the sunny outdoors and fresh air (smart girl). Two detectives soon followed. For some reason I forced myself to stick it out (though I was also pretty sure I would lose it in the heat and the smell—the smell!—if Dr. K was going to open her up). When Dr. K explained that the exam was inconclusive and that if the detectives wanted a full autopsy they would have go to Mulago I almost fainted from relief. For some crazy reason I stayed while he filled out the paperwork before returning upstairs, and when we crossed through the outer room with the dead man I didn’t breathe and didn’t look anywhere except the exit.

We went about the rest of our day and tried to shake off the horrifying experience, but the smells wafting up the staircase turned our stomachs and reminded us all day of the man in the basement. Above ground people ate lunch, babies were born, and chickens roamed the halls.

***Mycetoma foot: We didn’t see this case in the hospital, but randomly came across a man begging on the streets of Kampala with a pretty advanced, gnarly mycetoma foot. Thanks to microbiology last quarter this case was too exciting not to add to the end of the list! Mycetomas can have a bacterial or fungal origin, and end up causing the tree stump-looking feet you may have seen—feel free to google mycetoma or Madura foot if you care to see pics.

Overall it was a pretty grueling week. There were several other compelling, sad cases this week (that I’m not including here but may show up later) along with the huge daily dose of poverty and disease. In addition we worked like dogs to complete the first stage of our community health projects and choose our topics. I’m sure I’ll be writing lots more about this, but I’m going to focus on malaria in pregnant women, and Shalina is focusing on malnutrition in kids under five. They are both big issues here, and I really sincerely hope we can the community before we leave!

Elusive Electricity

Sorry for the lack of follow through on the promise of more posts...we've had little to no electricity this week, and then the generator at our guest house blew so we've had no opportunity to charge things! Having one candle to light the room (and flashlights to read by) makes us sleepy, so we've been turning in at 9pm the last two days and getting no work done on our projects.

Now we're off to Kampala for the weekend to meet up with some other UW girls--HOORAY! :)

Cases of the Week….from Week 1!

I’m dreadfully behind on sharing my hospital experiences. This is mostly because every day is so eventful I could write a novel about it, and I barely take time to jot bullet points down in a word file before falling asleep in bed each night. So my new hope is that I can do a cases of the week post and share the weirdest/rarest/most troubling cases of the past week, or at least from Monday-Wednesday, when we do most of our clinical hours. If I’m a good girl I can get Week 1 done today, Week 2 done tomorrow, and do this week’s post on schedule!

As a reminder, most of the cases we see are in maternity or peds, where we do rounds with Dr. K (by the way, he’s the only doctor who does rounds at Kiboga, and getting them done is often like pulling teeth from the staff). He does get pulled to look at mysterious or urgent cases in the men’s and women’s wards (since there never seem to be ANY other doctors around outside of the outpatient department) so we get to see those cases too.

Most cases we see are already becoming weirdly too common—severe malaria, anemia, upper and lower respiratory infections (pneumonia, bronchitis), and dehydration or malnutrition cases in peds; severe malaria, anemia, obstructed labor and other complications, and patients waiting to deliver or be operated on in maternity. While the severity of these cases were staggering at first I’ve quickly learned they’re the norm at the hospital, so unless one of those kinds of cases has extra complications or is more compelling, I’m leaving them as the background filler that make the days long and the hospitals overflow.

Here's a couple of pretty butterflies in case things get too real :)

Week 1: Cases of the Week

   • Full Blown Tetanus: Even after studying the biochemistry and physiology of tetanus this year I never expected to see such an extreme case of tetanus, and especially not on my first day at Kiboga. The patient was a 13 year old boy who had deeply cut his foot one week before (the wound still looked horrible—the cut between two of his toes was so deep you could see through the subcutaneous tissue to fat pad and bone). He had all of the classic signs: trismus (lockjaw), risus sardonicus (grimacy facial spasms), and opisthotonous (full body rigor with the backbend into a U-shape). Spasms were triggered by any minor stimulation. It was painful to watch. Tears quietly leaked down his face the whole time we were in the room. He was given some antibiotics and transferred to Mulago for IVIG to counteract the toxin, but since his case was so advanced and had progressed so quickly, his prognosis was poor.

   • Boda Boda Accident: We have been avoiding boda bodas (the motorcycles/dirt bikes so ubiquitous here) since we arrived, and this case highlighted why. This man had been “knocked” by a boda boda while walking down the road, and had been brought to the hospital the day before in a coma. Kiboga is not well equipped for emergencies, but Dr. K had tried to piece him back together. When we saw him his coma had improved, but he still looked horrible to us. Besides the many abrasions and cuts that had been neatly stitched back together, he had multiple depressed skull fractures that had just been superficially repaired, and they were now oozing pus. I mean oozing. Dripping off the mattress onto the floor oozing. Dr. K reopened, drained, and repacked the head wound (all with minimal equipment), and Shalina almost lost her breakfast. It was bad. The man also had not been cathetered as requested so he and his bed were a mess, and as his bed was in the sun all the smells were extra pungent. Dr. K explained that a lack of nursing care would be what prevents this man from recovering—at the hospital there is only one nurse per ward (maybe two), and so most nursing responsibilities like cleaning, dressing, feeding, and checking on the patient regularly are the family’s responsibility. It works well for most patients, but when a patient comes in alone they do not receive adequate care, and so become septic and die. You can’t even transfer the patient to Mulago for surgery when he’s alone; he needs attendants to watch him in the ambulance. Dr. K was still optimistic about getting his family to come and getting him transferred to Mulago once he was conscious, but we learned today (6/27) that he died that weekend still waiting for care.

   • Sickle Cell Pregnancy: Sickle cell was another disease we studied the minutia of this year, but I’ve never seen such an advanced case. The woman, who was in labor, and on her way to obstruction, had bossing (big square forehead), very long long-bones, and widely different lengths of fingers—all consequences of her blood cells forming weird shapes. The woman had been told the day before to go to another hospital to deliver since Kiboga didn’t have any blood in her type (a common, almost daily problem) and she would likely need some on hand for her high-risk delivery. She didn’t go, and showed up in advanced labor at Kiboga instead. She labored for another day before being transferred to Hoima with another delivering woman, where there was blood and staff available.

   • Septic infections: The two saddest cases of the week (which is a hard prize to claim) were two women who had long, obstructed labors and didn’t make it to the OR in time to save their babies. We saw them on the wards during rounds, and they both had developed sepsis around their surgical wounds. The wounds looked awful—deep, raw, and so full of pus—and the only way to drain them is open back up the top layer of stitches and squeeze these poor women’s sore, cut up abdomens. It was extremely painful to watch. These women were just heartbroken, and so sick. They had really long labors, and then C-sections, and then had not been eating or drinking properly (if at all) in the days since then; all of these factors lead to increased risk of septic infections. The women slowly got better, and went home after another week or so of staying on the ward with all the excited expectant mothers and just-delivered happy moms and babies—not the most restful place for women who had lost their pregnancies.

Those were the most notable cases of week one--I tried to walk the line of being honest without being too graphic, so let me know how I did. Week 2 cases soon!

Weekend in Entebbe

This weekend we made our first real Trip to See Uganda, and trekked back down through Kampala to Entebbe. Entebbe is just 45 minutes south of Kampala located on the shores of Lake Victoria, and was the British headquarters during their stay in Uganda ("entebbe" means headquarters!).

We traveled to Kampala Friday afternoon after working in the hospital in the morning, so we could spend the night there before heading to Entebbe with other friends Saturday morning. We surveyed everyone in Kiboga who speaks English about the best way to get to Kampala, and decided we should get on a bus (like a big charter bus or greyhound) that runs from Hoima to Kampala rather than take a mutatu (oversized vans than serve as the main form of "public" transportation here, both in the country and in the city. They have loose routes, and don't run them until they're crammed beyond capacity). We asked when these buses run, and where they stop in Kiboga, and could not get a definitive answer. So after we left the hospital and ate lunch we decided to go ask at the nearby police station because if anyone knows of an actual bus schedule, it would be them.

Side note: we're a wee bit afraid of police. They walk around with AK-47's or sawed off automatic weapons, we've heard countless stories of corruption, and we've been asked for bribes at multiple traffic stops.

At the police station a very nice police lady told us to just go sit under this tree with some 'boys' (men of 30-40), and they would wave down a bus for us. We tried multiple times to explain we wanted to ride the 2 o'clock bus, and would love to go to a bus stop if they told us where one was, but she insisted a bus was coming now that we should get on. We told her we had to at least change and get our things, so we ran back to our place to change and quickly pack for the weekend.

We hustled back to the police station within 20 minutes, and are again told the bus is coming any minute and to go sit with the boys. So we sit down, panting and sweaty, on the stools the men have evacuated for us, and end up waiting for almost 2hrs before a bus comes. Being told every 15 minutes or so that one is imminently arriving. Of course. We ended up talking to lots of police officers and police-associated people (detectives? accountants? no idea) which was interesting, and out of respect for us they changed the music they were blasting from their cell phones to dated American pop, so at least Britney, Shania, and the Backstreet Boys helped us wait.

It was good we'd waited at the police station, since when the bus rolled by it was full to capacity already. But since a policewoman waved the bus down it HAD to stop, and she intimidated the conductors into giving up their seats for us, so we got on! And paid the correct price! (Which did not happen on the way home :( :( despite our hardest attempt at bargaining they would not let us on the bus for less than 1.5x the price everyone else was paying...ugh. Mzungu tax sucks).

Anyways, all we did in Kampala was sleep and  stuff our faces with mzungu food, which was wonderful!

And Entebbe was gorgeous--look at the view from our hotel room! We stayed at a place outside of the main downtown area and north of the Botanical Gardens, so it was secluded and peaceful.

It was just across the road from the beach, which had several restaurants on it (that we of course stuffed our faces at later). Don't worry, we didn't go swimming--the facts about schistosomiasis were still too fresh in our minds.

We did LOTS of walking in Entebbe (probably a billion kilometers, however far that is...), and at first it was a million degrees and we were sweating buckets. Then it decided to rain buckets after lunch, but we walked on to the Wildlife Education Center, which is a combo zoo-rehab center. We are going on a safari in two weeks, but we've been in Africa for several weeks and we wanted to see some animals!

There were lots of beasties at the park, and they aren't as concerned with tall fences or trenches or anything, so we could get as close as we dared to most animals. Ostriches are big! And kinda ugly. I didn't get too cozy with him.

This nile crocodile was also pretty sweet (as were his friends). Thankfully we were up above them...on a rickety wooden bridge!

You know how at most zoos the wild animals are in enclosures, and then local animals like squirrels and seagulls roam freely looking for french fries and ice cream cones? Well this is Africa, so the local animals are monkeys. Tons of monkeys. Running around the park, hanging out in enclosures, hanging out outside of enclosures, having personal grooming sessions (or GYN appointments?) on every patch of lawn. We were careful to steer as clear of them as best we could, but local kids would run away screaming when they got chased or dive-bombed by monkeys jumping out of trees.

And even with all the lions and chimps around I still was one of the most interesting creatures at the park. A group of young kids followed us around for awhile until I stopped and talked with them and let them pet my arms and feel my freckles and arm hair (and laugh uproariously of course).

Other tourists wanted to take pictures of me and/or with me, because I'm soo exotic (this didn't happen to the other Americans with me). I told them all no, but I'm sure they snapped pics when I wasn't looking. Sigh. I wasn't even doing anything weird at the time, like hugging the GINORMOUS Elder Tree!

Since I can never get enough of lovely giant trees, we took the 2km route through the Botanical Gardens on the way back to the hotel, and got to see lots of awesome plantlife (that were labeled!) and more monkeys that would harass tourists and try to steal food. It's not totally their fault, since we saw some dumb mzungus feeding them out of their hands--we left before we were called in to treat monkey bites...

Back at the hotel we learned we were sunburned (especially me) since we forgot to reapply sunscreen after the rainstorm. It wasn't too bad (I'm already better!) and we went out for pizza dinner on the beach. We managed to eat two large pizzas and a garlic bread between the three of us, so clearly we were starving/really love and miss pizza. Mmmmmmm...

Sunday was mostly a fail day. Shalina and I tried and failed to find coffee in Entebbe (REAL coffee, not tinned coffee. We wanted cappuccinos!!) and so went back to Kampala to get breakfast. We went to a place we KNEW served espresso, but their machine was broken! Heartbreak. So we ate brunch and headed to the bus terminal to figure out when buses leave, which is when we got crowded by a million men yelling at us and got screwed on our bus tickets home. And since they lied to us about when the bus was leaving we sat on the sweltering bus for 90 minutes and were both pretty ill by the time it left. But we made it home safely in the afternoon, and took showers and naps instead of doing any work, so the day wasn't completely yuck.

I think we shocked the whole town of Kiboga last night though--it was POURING down rain from 5-730 here, and at 630 we were so starving we knew we just had to go out in it. So we put on rain coats, running shorts, and flip flops and ran through ankle deep mud and up and down the main road (surprising everyone out or on their porches) until we finally found a place that was serving food on a dark, stormy, electricity-less Sunday night. We are definitely the crazy mzungus in town!

Epic long blog post...that's what you get from a full fun weekend!

Kiboga Hospital

Sorry for the lack of posting--I promise I'm alive! I've just been working really long hours at the hospital, cramming interviews in at all times of day, and desperately trying to finish the first assignment in the project I'm doing this summer. Plus I caught a cold so I'm a gross drippy ball of virus. :/

Here's a general post about the hospital I started on Sunday night (AGES ago!), and I promise more details soon!

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What’s more surprising at a large, busy hospital—two chickens strolling through the waiting room and coming up to the triage desk, or a gecko slipping into the operating theater and sneaking around the walls until he’s peering down at the just-delivered neonate?


The answer is neither here at Kiboga Hospital!

I find it hard not to stare and/or crack up at all the unexpected interruptions that happen daily at the hospital, but patients and staff alike never seem to bat an eye when crazy things happen in front of them. Chickens and cows roam the hospital grounds, people cook and do laundry outside the wards on the lawn, there's rarely electricity and never running water available...all a typical day at the hospital.




Kiboga is a Level 4 hospital, which means it’s a pretty big medical center, and only has two levels above it: the regional referral site in Hoima, and the national referral site in Kampala (Mulago Hospital, where I’ll be working shifts at the end of my trip). People come from several nearby districts (the Ugandan equivalent of states) to seek medical attention and to give birth where there are skilled birthing attendants (docs and midwives). There are four wards (male, female, pediatrics, and maternity), one operating theater, an outpatient department (that screens all patients, whether they’re outpatient cases, headed for inpatient wards, or are emergency case), a large HIV clinic, a couple big health education rooms (for antenatal classes, etc), and tons of administrative offices attached to the hospital and scattered around the hill the hospital is perched on.

The hospital from the road, and the side-trail we take up to it

Despite this impressive sounding status, the hospital looks nothing like anything you’d see in America. Beyond the madness outside the hospital walls, inside it's generally dark, dirty, and pretty smelly. The hospital is horribly understaffed and under-equipped, from lab equipment to medications to gloves to blood. The wards are crammed with people--each ward is supposed to have 24 beds or cribs, but most have around 30 beds, plus mats on the floor in every available space, bringing the total to 45 on the busier wards (like maternity).

Try to image doing rounds--the morning review of all of the patients on the ward with the sole doctor and the "sisters" (nurses). We're in our white coats, trying to look like legit doctors, helping to attend to patients, listening carefully to decipher the heavy L'Ugandan accents, and desperately attempting to answer the questions the doctor is "pimping" us with. Add to this skirting around a woman completely passed out on a mat who is 8 months pregnant and has severe malaria and anemia and is hooked up to a precarious IV stand, and making sure not to step too far back to avoid squishing the 2 day old infant sleeping under a blanket with his mother (who is recovering from an emergency c-section), to retake the blood pressure on a woman with preeclampsia who lost her previous pregnancy due to the same condition. Also I'm usually sweating, have a grumbling tummy, and my back and my feet are screaming from standing for hours on concrete floors every day.

Waiting room early in the morning, before it overflows...

Yep, it's rough. It's hard physically to keep up with our clinical mentor, the Ugandan Dr. K who never seems to eat or sleep, and thinks we're weird when we insist on going to get lunch at 4:30pm (after being at the hospital by 9) before returning to the hospital for back-to-back c-sections. It's hard to see the condition of the hospital, knowing what pristine, efficient, well-stocked, well-lit hospitals in America look like. But most of all it's hard to see the burden of disease and the great need of the people in the hospital. So many of the cases break my heart, because the diseases are largely preventable and the consequences of having them needn't be so disastrous to the patients and their families. And I feel largely useless, unable to understand their stories without translation, unable to get them the packed blood or medications they need to survive, unable to hurry the process along to see more patients each day so not only the very sickest get seen.

Don't get me wrong--I love it here. It's great to do what I can, and I'm learning so so much. Perhaps my biggest skill is clowning around with the kids in peds (who love to giggle at Dr. Mzungu's funny faces), but hey--being sick and scared sucks and laughter is (almost) the best medicine, right? And already Dr. K is having us do more, so hopefully I'll be actually helpful by the end of the summer. And hopefully my project (which I'll post about soon!) will help lots of people in the community, possibly for years to come!

Email me if you want some crazy/gory details of the cases we've been seeing, otherwise I'll try to post a PG-list soon!

Life in Kiboga so far

So after three days in Kiboga we're pretty settled in; we know our way around and are starting to get braver and so are using goat/cow paths as short cuts and are slightly exploring the town more, even though the language barrier makes it a bit hard.

(We decided to try a restaurant nearer the hospital today since we had to go back after lunch, and even though there was no one inside it looked very clean so we went in. They were EXTREMELY excited to have us, and the food was pretty good (best chapati in town!! and also cleanest bathrooms!!). However, once they discovered we were Americans they found an ancient tape of Celine Dion music videos to BLAST for us while we waited for and ate our meal. It was both awful and hilarious. Have you seen her videos? They're very much synopses of bad romance novels. And since this place was not the fastest, we were brainwashed by the end of the hour we spent there. We also might have PTSD because when were heard a neighbor blasting music this evening we both cringed and paled, fearing it was more Celine following us around town...)

Here's a view from the porch of the "best restaurant in town" which we eat at once or twice a day (yes, we're already tired of the very limited menu). There are big gorgeous green hills all around town, with banana and mango trees everywhere! The air is soooo much cleaner than Kampala, and so far it has rained a bit every day except today (and by rain I mean THUNDER-ELECTRICAL STORM-A-PALOOZA! they're pretty dramatic, but don't last more than an hour). The main highway through town is paved, but all the other roads are red dirt and extremely rutted.

There are farm animals all over everywhere. Most of them (except the chickens) seem to get tied up somewhere new every day, so we meet different animal friends on our walks to and from work (besides all the children who love to stare before eventually smiling and waving excitedly. We're also pretty concerned we'll cause an accident from people turning around on their motorcycles or turning and hanging out their car windows to stare and/or honk). There are tons of goats (and a family of cute triplet kids), a family of pigs that lives across the street from us, and lots of cows. Cows with MONDO horns! The horns are generally thicker and longer than my arms, so we keep away from the cows that aren't babies and lying directly in our pathway.

Here's a piglet we scared by sneaking up on it. Most of the buildings in town are brick, and there are piles of drying bricks everywhere. At least the red dirt that gets all over us and our stuff is useful!

While we have running water at the fancy guest house we're staying at (for $7 a day that includes a delicious breakfast-our favorite meal every day!) this is one of several water depots in town for the local residents. I'll try to snap a pic of the precarious ways people transport water to their homes...seeing a 10yr old on a giant bicycle with 6 gallons of water is both scary and impressive!

Our guest house is great--we're sharing a room and a bed, but as you can see it's pretty giant and has a super mosquito net.

The room has no furniture except for the small table (we had to ask for a second chair) but at least we have somewhere to work on our computers, and so all of our stuff is in piles on the floor around the room, and we're still mostly living out of our duffels.

The bathroom is funny, since it's just a suuuper tall shower head over the floor (and toilet), with a drain in the corner. But there's a hot water heater that gives you 2-4 minutes of hot water at a time, and it's nice to be able to shower standing up. The water goes out less often than the electricity, so we almost always have running water.



We've mostly just been having meetings to get introduced to all the VIP's at the hospital before we start on our projects, but since everything runs on Africa time it's been slow going. We got our first few interviews done with the HIV team today, which was wonderful--we don't feel like we've done nothing since getting here now.

We've also spent a couple hours each day shadowing in the wards. We've already seen some crazy stuff, and I'll do a hospital post soon to give you medically-interested peeps some more details.

Luckily the beginning of our stay here coincides with 7 Ugandan medical students' rotation here, so we've been getting to know them and they've been extremely helpful in getting us settled and introducing us to people in the hospital. We have a date to hang out with them Sunday night so I'm excited to chat with them more!

Off to bed for me--more meetings and hopefully time on the maternity ward tomorrow!