House of Peace

It's been almost an entire week since my last post, and I am always amazed at how quickly time can fly by. Most of the week has been fairly relaxing, but I did have a few adventures, including a visit to the FoodStep home in Entebbe where the children from the prison stay, a long wait in really heavy jam (traffic), and yesterday's full day trip to House of Peace in Kayunga. 

Just a side note to start off about jam - I hate jam. In the mornings, I usually choose to walk 3 miles rather than risk sitting without moving in the back of a mtatu for about the same amount of time it takes to walk. On Monday, we were completely stuck. People do not follow any rules. The "best" intersection was the most frustrating. We were trying to go straight but every vehicle coming form the cross traffic decided it was time to go through the median. Instead of one car at a time and going through the paved median, the cars were at least 4 across and driving over the curb, across a few feet of grass, and over the other side's curb for at least 10 minutes. It was extremely frustrating to get through but hysterical at the same time. Everybody was yelling at somebody and honking a horn, and then eventually you would see the yellers laugh and smile at how ridiculous the whole thing was. This was probably about 10 minutes into our total of 3 hours to travel 5 miles so we were in more of of laughing mood than we were a while later. Also, earlier that day we caught site of three guys getting free rides on mtatu's - clearly a good way to travel if you are in a hurry, are lazy, and don't care if you get hit by a bike, boda, mtatu, or other piece of moving metal on wheels going down the street.

On a more serious note, we had a great day in Kayunga and Jinga. We, meaning Paul and Gunnar who are a future medical student and a future med-peds resident who are both from Minnesota and were willing to come out for the day. Paul is also going to be working with Medicine for Sick Children to help out with any projects we have during this trip. 

House of Peace is an orphanage we have been working with to provide medicine for the past 3 trips, so we have known about them for almost 4 years. Pastor Moses  has a small church outside of Jinga and started an orphanage project in his home village near Kayunga. Since the last time we were here 18 months ago there have been some changes. A health inspector came to see the home which is standard procedure for all children's homes that are registered in the country. There were some violations, including a toilet (outhouse) which is too close to the house and kitchen in addition to being full and needs to be re-dug. Prior to this trip, we knew about this problem and are planning to financially support getting a new one built because having proper disposal of waste is a great way to prevent disease.

It's always a warm welcome full of smiles, greetings, and prayers. It was good to see all of the kids, but they are all so big, I can hardly call them kids anymore. I think the youngest is 8 years old now! the kids are now staying in Jinga with random families and some are sleeping with 2 kids in a bed until they are able to fix the home at House of Peace so they can all move back. In total there are 44 children, but some have completed secondary school, some have stopped going to school because they couldn't pay school fees, and some are attending trade schools and are not staying at the home. There are quite a few older boys who still stay in Kayunga and are trying to make repairs as they are able.

The inside of the house needs some work. I wish I could say that it is the worst I have seen, but it actually doesn't look THAT bad. I do realize that after seeing as many orphanages as I have over the past 6 years, my expectations are sometimes a little lower than they used to be. The biggest problems are the lack of proper beds, walls that are slightly crumbling, no electricity, and a kitchen setting that does not meet sanitation standards because it is just a room without proper furniture or shelves to store things. We are waiting for the full report from the inspector to see exactly what needs to be done and if it is feasible.

The biggest problem now is sustainability. Even if we help with minor repairs, do major work building a latrine, and help bring the kids back together, there are still many things to be done to ensure they can continue to keep up the house. One idea that Pastor Moses has is to re-start farming on his land. He has over 10 acres to work with and could have enough food to feed all the kids and to sell in order to help with upkeep and to hopefully pay for school fees in the future. The question is whether the garden will continue to grow, or if it will suffer from drought and lack of working on it as it has the past couple of years. In addition, is there enough of a market to sell the things and make a profit? I know next to nothing about agriculture - and in fact, I generally can't keep a house plant alive, so I feel like I need an expert's opinion about it.

I guess when I think about it, I am hopeful that this is a good project and I can trust the people that we are helping to use the resources provided in a responsible way. However, I sometimes feel like I ask too many questions, bring up to many "what ifs", and put a lot of doubt in my own mind. If you would have asked me to take an amount of money that people donated 5 years ago when this type of undertaking was presented, I probably wouldn't have hesitated and said, "let's do it". After seeing projects come and go, learning a lot about trying to do the best work you can with international development, and thinking about the future and not just the present, I always hesitate just a little bit more. Medicine for Sick Children has a mission to fill in the gaps of providing health services to children. This is very important! There is also an importance of providing a healthy environment to keep kids from getting sick. This means a roof over their heads, mosquito nets, nutritious food, and a safe and loving environment. I keep trying to draw a line in my head of where medicine ends and other things begin, but it's the blurriest transition I can imagine. 

For now, I am just continuing to pray that we will make wise decisions about the things that we are involved in and that we will be led to make the best decisions we can about the things we have. Prayers and input are encouraged, especially as my mom will be coming in a couple of weeks and she will also be involved in figuring out what to do! These really are lovely people and the children and I want to help them. I just want to do it in a wise way! 

Let It Go

Today was one of those days that I just felt like not doing anything. Not because I felt like sleeping in or taking a day off for fun, but because I was just frustrated. I know days like this are bound to happen because I have been here many times before. There comes a point during every trip where I feel helpless to make a difference and start to wonder if anything I am doing is ACTUALLY making a difference or if I am am just doing what I am doing to make me feel good. During these low days, I tend to dislike being here and I wish that I was around people who understand me. This is really not fair of me to think, and I know it will pass. Nobody is deliberately trying to make me frustrated, but because the expectations in cultures are so different, there eventually is tension. Even though I should expect that people are never on time, give the wrong food when I order (sometimes if you ask for no meat, you get a giant pile of beef), or take over an hour to get fries from a pre-made pan and bring them to your table, after a while these things eventually frustrate me. Okay, sorry for the rant. I know it sounds horrible, but it's really not that bad. It's just a reality that catches up with me and then goes away after a couple of days and I go back to absolutely LOVING this place!

My real reason for the title, "let it go" has to do with my experience in the hospital the past few days. Like being at home, I am able to be "assigned" a patient for whom I check on every day, get lab tests, and then present their information to the attending (or boss) physician. I was assigned a patient called Innocent (I feel like I can say this without violating some confidentiality because there are 36 million people in this country and based on my own extrapolation of the number of people I have met with that name, there may be around 5 million Innocents). On Monday, I was assigned him as a new patient, mostly because he had caregivers who spoke English. From the start, he didn't look good and our clinical suspicion was that he has Tuberculosis that is in his lungs, abdomen, and probably hiding in other places, too. However, in order to start treatment for TB (which is 8 months long with lots of side effects and needs to be monitored daily) there needs to be a test proving the diagnosis.

Monday I spoke with the mother and father of this 30 year old man they were very helpful and grateful for me for taking over an hour to spend with them. I carefully examined Innocent and realized that he was having a difficult time communicating but he was able to follow along with requests I made. I was very thankful when I went to collect his blood samples that I was able to do it on the first try (at home we use fancy needles and usually phlebotomists or nurses do it so my skills have been tested here and they are finally getting better!) because it meant less pain for him. I felt like I had a pretty good plan for evaluating what was wrong, but knew that we were just confirming a very likely diagnosis.

On Tuesday, I decided to stop by the ward early on my way down to eat my usual monotonous breakfast of a Queen Cake and black tea. I didn't see too many new patients and I was ready to continue on my way but then I took one last glance down the hall which we keep our more sick patients (the ones that would be in the ICU at home with dozens of monitors and individual nursing care but here just have a bed closer to where the main office is) and was flagged down by the parents of my patient. The were distraught because he had more trouble breathing during the night and had appeared more disoriented to them. I took a look and realized the oxygen tank he was on wasn't actually working and so I got one of the interns to move him to another bed. He was hooked up to another tank with multiple other patients (we sometimes call it an "octopus" of oxygen because we have no idea how much of the 7-8 liters of oxygen are getting to which one of up to 8 patients one might be getting). I checked the results of his ultrasound and chest X-Ray and could confirm that he has a disseminated Tuberculosis infection. I informed the intern and we knew we could start his anti-TB medications that day, but that they weren't likely to take effect for at least a couple of weeks.

I left the family to grab breakfast and then check on a few other patients. By the time I got back, Innocent was still doing poorly and maybe was a little worse. The attending from the US who has been on the wards a lot lately saw myself and the intern at Innocent's bed as we were ordering his new drugs. At that time, the family couldn't find his file -  a pink folder made of folder construction paper and they frantically searched for it. In the commotion, the patient's mother accidentally had her finger stuck by a needle attached to an IV pole that was left by the last patient in that area. Of course, we had no idea which patient that was or why they were here but the chances of them having HIV or some other serious transmittable disease are very high so she needs to get tested and probably take PEP (post-exposure prophylaxis) drugs to make sure that if she was exposed, she will not actually develop an HIV infection.

During this time, we determined that Innocent was in Shock, likely Septic Shock from either the TB or another bad infection in his blood or organs. I think by that point the Ugandan intern and senior resident didn't really think there was much point in getting worked up about it, but the US doctor convinced them to stay a little longer. (At home this would probably be a time where somebody pushes one of the emergency call lights and a patient has a "code" with a team of doctors, nurses, and pharmacists rushing to his bedside) We gave him lots of fluids and some steroids and he was able to breath a little better, but still didn't look great by the time we left his bed. We decided on giving the strongest doses of antibiotics and then moved on to the next patient because there were really no other interventions we could do for him.

When we left his bedside, I was sure he wasn't going to live past this infection. We have had many cases like this the past 4 weeks and they don't end well. The mortality rate on the ward is about 30% and it is usually because of patients coming in very late in their infection, like Innocent. I think I still was holding out hope that maybe something we would do would change his outcome. Maybe if we give him just a little more attention and dedicated support, he would pull through miraculously. Maybe the steroids would help him and the new antibiotic would buy him some more time. I had been thinking and praying about being here this weekend and had decided I didn't want to unaffected by all of the death and suffering I have seen because most days when we find out patients have "passed" overnight, we just shrug our shoulders and move on. I think there comes a point, especially on this particular Infectious Disease Ward, when you can't get too attached because there are just so many very sick patients and losing them is a constant reality.

Before I left the ward after 1 pm, I checked on him and it seemed he was breathing just slightly better, but I informed his mother that he is very sick and it doesn't look good. Despite the poor prognosis, she was extremely grateful. She said, "please thank everybody on the team for taking time to be with him and trying to make him better." She went on to say that it was now in God's hands and all we can do is wait. I had a sinking feeling that when I showed up the next day, I would find a new patient in his bed, but I secretly hoped I was wrong.

This morning, I took a short stroll around the ward and didn't see Innocent's parents, which was not a good sign. I went from bed to bed to see if he had been moved, but as expected, he was gone. I went back to check the log book and sure enough, at 2:20 in the afternoon, he had passed away. He had been suffering and was hardly able to get oxygen into his extremely infected lungs, so it wasn't a surprise. I felt a little guilty that I had left the ward to meet with some other students and didn't stay until past 2, but part of me was glad I wasn't there when he passed because I felt attached to him and his family even though I had known them for only 24 hours. If I had been there, I probably would have been wishing for CPR or intubation or some last ditch effort at saving him. I felt worse that I hadn't been there to say anything to his family, especially his mom. Thankfully, his father and brother came in in the middle of the morning to pick up the death certificate before traveling 300 kilometers for his burial on Friday. I was able to chat with them and offer my condolences. They thanked me for helping to take care of him and taking time to talk to them.

 For some reason, the rest of the day I was just mad. Mad that patients, often young ones, suffer and die so often. I was mad that there is not a system in place to treat severely sick patients. I was mad that people don't come in early enough for us to do anything useful. I was mad that there wasn't more I could do, especially since I am often just learning what to do myself. In the end, I realized I just have to let it go. There isn't much I am able to change about how things work, at least not in the short time I am here. I can only do what I can with what I have and hope that it makes a difference. I prayed that I wouldn't be numb to the things I saw, and I guess something has changed in me. I
feel sad and frustrated but at least I am feeling emotions. I have to ask myself sometimes how the doctors are able to continue working at this hospital day after day, knowing that they are treating lots of patients, but that so many end up not making it. They continue working hard and intervening where they can, but face the reality of losing 3 out of every 10 patients that are admitted to the ward. I am amazed at how well some of them take it in stride and not surprised when others simple don't show up for work.

Overall, the week otherwise has been just fine so far. Angella's birthday was on Tuesday so we celebrated with a  cake for dinner and we will be going out on Saturday night to have a real celebration with some of her closest friends. Match day is tomorrow and I will find out where I will be training for the next 3 years, which is really exciting. I have gotten a few really nice runs in around our neighborhood and met some really great students that just arrived this week. I do love how things are different here and every day is a reminder that I'm not in Minnesota. Since I really don't have any pictures to go with today's post, I will end with this rooster. Every morning when I go to the canteen to get my Queen Cake and tea, I sit at a table and this guy is walking around the restaurant, making noise and getting to close to my feet. The past few days though, I don't think he's been around. They do serve a lot of chicken so I hope he didn't end up on a plate. Also, while I was walking to the ward this morning, I heard a loud rooster call and realized that there was a similar bird just sitting next to a suitcase in the triage area inside the hospital. I am sure he was somebody's purchase while they came in from the village, but it still always shocks me a little when I see them carried around like another piece of luggage.

Buluba - Living Like a Real Rural Doctor

I realized I haven't done any updating in pretty much two weeks. The biggest reason is that for 5 days I was in a rural area called Buluba working at real village hospital. I could have had internet access, but I chose to leave my technology behind and read a lot of books every night instead.

Buluba hospital was founded in 1934 and originally served as a Leprosy hospital until 2003. During that time any patient diagnosed with Leprosy in the central and eastern part of the country were sent for support and treatment (when it eventually became available). Similar to the United States, before there was treatment for Leprosy, patients were isolated in "colonies" in order to prevent the spread of disease.  The hospital compound covers pretty much the entire village, located along the shore of Lake Victoria. At its prime, Buluba Hospital had dozens of homes, a church, a farm, and pretty much everything that people need to survive. Patients would be treated and then were allowed to stay and have a job and a place to live for as long as they wished. Any prosthetic limbs, special shoes, wheelchairs, or special tools were made there. In fact, today they still make anything that patients need in workshops, but there are far few patients. In this shop, they make special shoes that don't have any points that rub and if a patient has an ulcer, they cut them in special ways to decrease pressure on that part of the foot so they heal better.

If all you know about Leprosy (Or Hansen's Disease) is that they were shunned in the Bible, I will give you a little idea of what happens to people with the infection. The organism that causes Leprosy is related to Tuberculosis (so the hospital also did a lot of research and treatment of TB - which is much more common). The infection is surprisingly difficult to get because it requires that the person has the genetic make-up that doesn't carry a lot of immunity to getting an active infection. For those that do get infected, the symptoms can range from small discolorations in the skin which lose all sensation to pain and touch all the way to damage of limbs which eventually leads to the person's body basically self-amputating the limb. Many patients have facial deformities or require amputation because of trauma to their feet and legs. I had never really seen patients with this disease before, but I now have now seen dozens of them and they are really able to live normal lives except when they damage extremities that they can't feel. Overall, I picture support as being similar to patients with diabetes who have trouble with ulcers and decreased pain sensation in their feet. The treatment is up to 2 years long, but most of the symptoms resolve if it is caught early. I came very close to posting some pictures of some of the patents, but out of respect for them, and for those of you that don't want to see some severe ulcers, I decided against it.

As far as the hospital itself, there are nuns that run most of the wards - who are also trained nurses. I think there is a total of 5 doctors who basically do whatever they can. That means if a woman comes in and needs a C-section, they do it. If there is a fatty tumor on somebody's back, they become the surgeon. If a child was burned, they do all the dressings. They do what they can with very little choice of medications and limited laboratory tests. In fact, I think that they only have certain scans 3 days per week. I am excited to be a Family Practice Physician, and maybe be working in a rural place, but these rural doctors are incredible. They have to know a lot and be confident in so many skills.

Because there aren't always a lot of patients, the team of 2 medical students and 4 nursing students were able to basically see every patient by 1 or 2 pm and then maybe stick around to see patients that walked in later (which could be zero or 20, but usually it was on the low side). This meant that we got to enjoy some relaxing time sitting by the lake. I woke up early every morning for gorgeous sunrises and watched as the fishing village woke up and men went out in their small boats to see what they could catch. It was a very welcome change from the busy-ness of Mulago Hospital and Kampala.

There were also some pretty dramatic medicine moments that will stick with me for quite some time, but I don't want to get into too many of the details. If you want to some day, I can share them personally with whoever asks. I guess I am just not used to the rapidity of how things work. We had a patient pass away from what with think was DKA, basically an emergent situation caused by poorly controlled diabetes. In a matter of 30 minutes, the family had their dramatic goodbye, we transported the body onto a boda boda, and they were gone to bury their father, husband, and brother. As I watched them drive away I felt like I had to be dreaming because it was so different from the way I know things work back home.

I think I sometimes forget what happens after we are with patients. So often there are other people assigned to every job that doesn't include assessing and deciding on treatment, that we forget what really goes on. In Buluba, and in most of Uganda, there are not such defined roles in health care and nurses and doctors are responsible for most tasks. There are not often social workers, there definitely aren't nurses' aides, and lab technicians never collect blood samples. You really have to learn how to be a self-sufficient doctor. I am very thankful that I am learning skills that I don't get to do enough at home, but it can be extremely intimidating when I realize how skilled the physicians are here, simply out of necessity. I just hope that I can learn in a way that is respectful for the care of the patients but will also provide a solid foundation for being a rural doctor in a slightly less resource limiting setting in the future. I don't really love being in an operating room, but I apparently looked like I was having fun with the other students in the OR!

Updates

I can't believe how quickly the days can go by without me posting anything! So sorry for the delay. I really get exhausted by the time I get home from the hospital, even if it is a "short" day,  meaning we start by 9:30 and get done by 2:00 or so. The problem is, getting to and from the hospital takes a lot of energy, and standing and walking around the wards wearing a white coat stuffed with 3 books, thermometers, a pulse oximeter, stethoscope, and a bunch of random other things takes more energy than I realize. I mean, we do similar things at home, but we have air conditioning, places to sit down in patient rooms (or talk about patients in a room with a table before we actually go to see them as a group), and an unlimited number of computers to look things up on at any time so real books in white coats are nearly unheard of. I still want to talk a lot about working on the Infectious Disease ward, but every time I sit down to write about it, I get overwhelmed because in a day we see a lot of things that are intense and I am not quite sure how to summarize it all in a way that is respectful to patients, Ugandan physicians, and we "Westerners" here for our medical school rotations or staff doctors offering their "expertise" for the patients. Pretty soon I will try to get at least a few of my thoughts and stories down for you.

As for Rose, she is doing a whole lot better! She was gone at the FoodSteps home from Thursday until Monday, but since she had malaria, needed to be evaluated for malnutrition, and has to be watched a little closer than she could be at the home for the time being, Renske brought her back here. I have to say, it was quiet over the weekend without her. I mean, no, I didn't miss her peeing or having diarrheal episodes on the hallway floor or crying all night long, or her staring longingly at my mangoes every time I tried to eat, but it was nice to have the little lady wandering around.

Since she came back, she has made drastic improvements. I think she gained at least a pound in the first 3 days and since then has probably put on at least one more. Her cheeks (both on her face and buttocks!) are filling out. Her belly is still big, but much softer than before. The best part is that she is a lot more interactive than she was when she was initially here. She still gets extremely excited about food and has a temper when she doesn't get what she wants. For being so little, she can pack quite a slap when you don't give her the Plumpy Nut right away. By the way, Plumpy Nut is an amazing invention in the world of malnutrition. It is a high calorie paste-like peanut substance that kids generally tolerate really well. It comes in individual packets and caregivers are instructed to give a certain number per day in addition to eating normal foods as they are able. For those of you worried about peanut allergies, there is surprisingly very little evidence that the millions of kids that have gotten it to treat malnutrition have had adverse reactions, so we can be thankful for that! Lots of kids around the world have benefited from getting this awesome stuff when they are severely malnourished and have very little chance of getting access to high calorie food.

Renske does an amazing job with Rose, being patient with her messes and not tolerating any of the attitude that Rose throws her way. I am generally a sucker for big watery eyes, and Rose likes to stare until you feel sorry for her and give her what she wants. Renske has taught me that you don't give in to that and even though she is sick and in need of a lot of rehabilitation, that doesn't mean she can get away with bad manners.

Today, I woke up to a little hand opening my door and a giggling voice as she looked at me sitting up in my bed. She came in just to say hello - and she was SMILING! A week ago she would usually come if you waved your arm to call her over, but she was expressionless. She has made a game of finding random objects to hand to me and then I thank her for bringing me something. It makes me happy to see her smile and laugh.

Rose still does have some problems. For instance, she eats well but still has diarrhea, but it is confined to the times she is actually brought to the toilet rather than on the floor. Vomiting can still be an issue. When Renske pulled up to get me today, she turned around to look at Rose who had just vomited all over the back seat of the car (I think for people that have raised children, vomiting in the car is probably more common than I assume it is, so I guess that wasn't that big of a deal). Also, she sweats, A LOT! Anybody that knows the Perko family knows that sweating is genetic for us. My brother left every basketball game with a puddle on the court. When I come back from running here, it looks like I took a shower. When Rose does ANYTHING, she is drenched. It doesn't matter if she is sleeping at night when it is cool, riding next the the air conditioning vent in the car, or just sitting at the table. She ends up dripping sweat from her face. It might be from simply being weak and it being hot, but we still think she needs testing for TB and maybe some other things even though she was treated for malaria and dysentery. Hopefully she will get a check on Friday and we will find a reason for her continued sweating.

For now, we can rest assured that she is generally getting better. I have a couple of pictures from last week. I will maybe take some tomorrow to show you all how she is a lot happier and excited that she had been before. It's great to see the turnaround. As for her emotional health, I don't know how much we will know until she gets older. For now, we are just trying to give her a lot of love and pay attention to her, which seems to be bringing out more personality in her….and we have decided that she can be really stubborn!