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!

ROSE

Thanks to everybody who has commented and showed compassion for the children in the prison! It really was a good thing to see and experience but every time I think of it, my heart breaks a little. Since Saturday, I feel like a lot has been done, although it really has been only three days. I have been at the hospital working on the Infectious Disease Ward on Monday and today, but I will write more about that tomorrow or the next day. For now, I think it is important to talk a little about Rose, and think about the world through her eyes for a bit.

Saturday night was seemingly a pretty expected night, given that this was Rose's first time in a bed. She and Zefanya were sharing the bed and unfortunately for him, Rose is very sick. She had diarrhea - foul smelling, large amounts of diarrhea - that filled her diaper, the bed, and trailed her all the way to the bathroom. By the time Renske heard her crying, the mess was all over and Rose was just sitting in a pile of crap.

The first time I saw her for the day, Rose was standing with no clothes on in the hallway outside of the bathroom. She looked and me, then looked away, and proceeded to use the floor as her personal toilet. Renske calmly cleaned up the mess and we both assumed she was done. Just as she finished using soap to disinfect the floor, Rose squatted down for another go. If you ready about diarrhea in a medical textbook they will tell you that it is technically 250 grams or more per day of stool. I don't ever measure amounts nor do I ask patients, but when I saw what was coming out, I knew that this girl was well above the necessary number for diagnosis. She continued to make messes all day and we got to the point where we just sat her on the toilet every hour or two to hopefully prevent more overflowing diapers. Maybe all of you moms out there can relate to having a sick kid, but for me, this is a lot of new messes. In addition to feeling not so good, this girl is malnourished and not accustomed to functioning in a house. If she were back at the prison, she would probably not be wearing any clothes below the waist and if she had an episode of losing stool in an odd place, one of the older kids would likely beat her up for it. At least here, she can be sick and we are trying to lovingly correct her.

When it comes to emotions, Rose shows next to none. When food shows up, she perks up quite a bit and positions herself as close as she can to it. Even though she is not feeling well, she wants to eat. When I got home from my run in the evening, she was making little happy cooing noises, which I quickly learned were because she saw Angella cutting a mango and was trying to ask for some.

On Monday morning, after another long night of diarrhea, crying, and adding to it a bit of vomit, Renske was prepared to take her to the clinic that they usually take kids to. On our drive in to drop Zefanya and for me to get to a good place to walk to the hospital from, we heard noises from the back seat and turned to see Rose regurgitate all the mango and whatever liquids she had gotten last night. Renske later informed me that she threw up for the entire hour long ride to Entebbe and made a huge mess in the car. That night, I was happy to learn that Rose has Malaria and probably some sort of intestinal infection, which is nice to know because they can be treated!! She was started on IV antibiotics (which they allow you to administer at home if you are able) and antimaliarial treatment. We have been giving Oral Rehydration liquid as well, and last night there was no vomiting or diarrhea - just crying because of hunger!

Although physically there is a lot of improvement, I am still quite sad about the way that Rose has developed so far in life. She has probably lived on the street (nobody can tell us because there is nobody that brought her in, she was just collected with a bunch of other kids), she might have been abused in some way, she probably went long periods without eating, and she probably never had anybody to just hold her and show her she is loved. She is like a little rag doll that you can shape any way you want. If you sit her down, she stays sitting until you pick her up. If you stand her up, she won't sit down. The only time she moves is if you tell her to come and show her food or maybe a ball to play with. Today, she looks much better, but she still doesn't smile. She reminds me a little bit of our dog, Rocky, who is inspired by any food we are preparing. I was making juice and she didn't leave my side, but just stared up at me with these beautiful dark eyes. We we sit down for dinner, she gets up to the table and wants to be as close as she can to the food. I am just praying that over time, Rose will grow to experience love in a way that doesn't involve a reward system with food. It is likely that she will go back to the orphanage that takes kids from Kampiringisa later this week not that she is not acutely sick.

With Rose, I feel like I have to realize what happens when I child is really sick and malnourished. Having her at home reminds me of all the hard work there is to rehabilitate a child after so long without living in a home environment. As a physician/medical student, we often just see a very small glimpse of what recovering from illness can be as we examine and tell people how to treat. With Rose being here, I have seen some of the daily struggles of helping a little girl like her. I know there are thousands of other children like her, without a supportive family or feeling loved by anybody. It makes me so grateful to have grown up where I did with the family and friends I have around me. I really can't relate at all to what it would be like to grow up without that support. I am trying to show compassion and love to her and hope that she will slow start to feel something.

One final thought was something that Natalie told me on Saturday that really stuck and maybe will leave you with something to think about. "Kids like her don't feel hopeless. They can't feel hopeless because they have never understood what it means to have hope."

Prison Party! - Parting Gift = 2 year old

Today was an awesome day……an extremely long and dirty day, but amazing still the same. We left the house at 6:30 am and got home after 7:30 pm. Renske has been working with a group called Foodstep for the past year or so. The organization was founded by a Belgian couple about 6 years ago. They are pretty amazing and the work they do is not easy. They started out on a completely different project in Northern Uganda but when they found out about a "rehabilitation project" sponsored by the government that is essentially a children's prison, they invested all of their efforts to this project.

The prison is called Kampiringisa and is a place where children from the streets end up if they are caught by the police. There are frequently "round-ups" of street children where up to 300 at a time are put into huge trucks and driven an hour and a half (or a 3 day walk) outside of the city to a place where they can't run away back to the city. Although, hundreds escape every year and find their way back to the streets - begging, stealing, or doing whatever they need to survive. The conditions in the prison are not great, and when Nathalie and Werner started out, they were apparently much worse. There is so much I could do to explain the living conditions today, but I am going to stick to the big points and if you want more details you can ask me the specifics. The NGO also has a website http://www.kampiringisa.org

First of all, the only real adults in the prison are the guards, who don't do much except for count to make sure the children are where they are supposed to be and punish them by beating if they are disobeying or if they try to run. There is a social worker employed by Foodsteps that helps with minor things, but not the day to day tasks. This means that the children learn to fend for themselves. They do the cooking, the washing, the cleaning and caring for younger children. There are children as young as 1 year old in Kampiringisa - how a child could end up there is sad. Sometimes a parent simply abandons them to the prison, sometimes they are caught by the police on the streets, and sometimes the parents are in prison so the children are sent to Kampiringisa. The worst is that the government is supposed to be providing the funding to support the rehabilitation of the children, yet little has been done beyond a very minimal amount for food and guards to be paid. NGO's such as Foodsteps have built new buildings, starting a woodworking and leather work shop to make furniture and shoes, built gardens, and provides medical care weekly to the children. They visit every Thursday and every 2nd Saturday have a party with good food including meat and vegetables instead of rice, beans and porridge. The kids trust the Foodsteps volunteers because they are a consistent presence in their lives, which most of these kids have never had.

In addition to the work in the prison, Foodsteps attempts to locate families and permanent homes for children through social workers. If no family can be found, they offer to take the child to the Foodstep home where they have a real bed, clothes to call their own, consistent meals, school support, and basically a loving family environment. The have helped so many children, but the numbers of children never seem to get lower. They have been working so hard and continue to have a positive attitude about their work and their mission. They are truly an inspiration and I hope I get to see more of what they do.

As for our day, we were helping with a group of dentists who came to provide care for all of the children. They yanked quite a few rotten teeth today an did some basic cleaning and preventive care for the kiddos. In the meantime, the rest of us spent time with the kids, helped them eat lunch and dinner, and played games with them. In addition, Renske has been providing basic medical care and supplies to the kids so we help a little with cleaning some wounds and applying some ointments to faces. These are the days that I love in Uganda. I come home and all I want to do is shower because I am full of food, feces, sweat, dirt, and probably lots of other things. Showering is amazing because you wash off a film of red dirt and usually reveal a bit of sunburn and some new scratches and bruises. It's totally worth it to be helping to make an impact in these kids' lives, knowing that the project is very well managed and has been a consistent presence for the kids.

I have a hard time putting into words all the thoughts that were running through my head today. The biggest thing is that I can't imagine these kids are just completely abandoned. They have no family, no community, not even an orphanage that has taken them in. There aren't foster homes waiting for them, there are not other alternatives. It is literally a dumping ground to get them off the streets. If they try to leave, they are tracked down and brought back. Some of the young ones are bullied by the older ones rather than being taken care of by them.

Today Renske was able to get permission to take a 2 year old girl, Rose out of the prison to be eventually placed into Foodsteps. Since they have never had a child as young as 2 and she is basically about as developed as my 8 month old nephew, Renske took her in for at least the weekend to get her cleaned up, checked out by a doctor and hopefully ready to live in a stable, but busy environment. Can you imagine what is going through her head? She doesn't speak any language we understand because she comes from a tribe that doesn't speak Luganda or English. She has only known the streets and Kampiringisa. Now she rode in a private car, had dinner sitting at the table, took a bath (and cried the whole time), and is going to sleep in a bed for the first time ever……ever! That's over 2 years sleeping on the ground or a floor.

I like working on projects like this, and seeing what people really go through in Uganda, but it is so hard to see. Even visiting the country, it is easy to separate yourself from what is really going on if you aren't paying attention to the realities. There are still children abandoned, there are still witchdoctors casting spells, there is female circumcision, there are child sacrifices, and there are kids suffering without anybody in the world to stand up for them. Although I now know many Ugandans who have a pretty good chance in life, with parents, an education, and opportunities, I sometimes forget what happens those that are the worst off. The most promising thing is that Nathalie and Werner along with Renske are showing these kids that people love and believe in them through persistent involvement in their lives and teaching them about Jesus. A favorite part of almost any day trip is the singing. The kids got together with drums, dancing and singing to praise God through music. They get truly excited and are given an opportunity through Foodsteps for a better chance in life.

Okay, that is a long rant, and there is so much more I could say about the day and about the project, but I can only say so much and you probably are having a hard enough time reading through this long length of writing. I didn't take pictures today because it is frowned upon by the guards and I don't like to overstep any boundaries. It's basically a bunch of big buildings without any real private space for anybody. Oh yeah, and there are locks on all of the sleeping rooms so that the kids can't get out in the middle of the night. I think I still need to fully process the entire concept of this place and all of the things that went through my head as I heard stories and saw the children living at Kampiringisa.

Every Day Life

The past few days have been full of a whole lot of random things that I would probably be doing if I were at home, such as cooking dinner, running errands, playing games, knitting, running, and reading books. The only difference is everything takes just a little more effort. I have to keep reminding myself I have only been here a few days because it already feels like I am just doing normal tasks. I hope that once I start in the hospital next week things still feel relatively "normal". I guess I can comment a little on a few of the things I have been doing….

Cooking & Eating
There are three foods that I look forward to more than anything when I get here - Pineapple, mangoes, and avacodos. I have so far eaten two pineapples and 3 mangoes, and am just waiting for my avacados to ripen. I can't wait much longer! Also, I do appreciate passion juice and Angella suggested that I make my own, so last night I cut up a bunch of those little golf ball sized fruits, blended them together and added a little sugar and oranges (which are more like limes) to make my own juice! It was so satisfying to know we made it ourselves and it was delicious! Renske and I also made lasagna from scratch yesterday with a bunch of fresh vegetables from the market. I am not used to having people to cook for and since in the house it is Angella, Renske, and her 6 year old son, Zefanya, we can cook complete meals and eat together each night. It kinda feels like a family and I love it!

Errands:

Running to the store to get a few items is nothing like taking a Target run to University Ave. back home. You have to know what  you are looking for and even then you don't usually know where you can find the things you want. The downtown area of Kampala is the "real Kampala" with hundreds of little shops selling anything and everything you can think of, except for the one thing you are looking for when you need it. We had a list including ink cartridges, pillow cases, and a door bell. Easy at target, right? It is about a 2 hour endeavor in Kampala! The only advantage is that if you go to a store and ask about a doorbell, they might not have it, but usually a guy called a "broker" overhears you asking and tells you they know where to go. You can then weave through the streets and follow them to some obscure shop tucked in a corner. If it's not there, you can usually just take a seat and they will run around looking for what you need. The only downfall is that they usually add to the price as a "finder's fee". Plus, as a mzungu, we know we are already getting a horrible price for the things and we have to haggle hard to get things down. So our doorbell was found after visiting 3 different shops, following a broker, then waiting for 20 minutes for him to run back and forth to find one. In the end we got the price down from 95,000 shillings to 55,000 ($22). We also stopped by the fresh food market, which has just about anything you can grow or catch. From eggs to live chickens, to fresh fruits and herbs, and grilled whole fish (or just a head), it is all there. We settled on a few things for dinner and snacks including my three favorites. One guy wanted 2,500 for one mango but instead we walked 20 feet and got 4 for 5,000. Probably still over what we should pay, but still made me feel like a got a deal!

Running

I have been a lot more diligent lately about running, especially since I got a Nike+ watch with GPS to map where I go and how fast I get there. Uganda is full of hills and dead ends. I started out going at a decent pace and soon realized it wouldn't last with a hill every quarter mile no matter which way you go. I think I passed the same cow 4 times as I tried to find my way home on my first run a couple mornings ago. I was always able to see the apartment building no matter where I was but I could never find a road that actually connected me to it. It was more than a little frustrating. Tonight, I took Zefanya out on his bike as I jogged. (note to anybody that hangs out with six year olds - they will ride in front and not wait for you but as soon as they need to stop or slow down they will yell for you to "STOP, WAIT FOR ME"). Only in Uganda have I used the phrases, "stop for the car", "stay to the right for the boda", "keep your eyes on the potholes", "stop chasing the chickens" and "look out for the cow" on a run. Even though I waited until the latest possible time tonight so it was cooled off, I still came back drenched in sweat and extremely hot. This swing in temperature is almost 100 degrees and I think will still take some time to get used to. My favorite part of the run is a road with really fine dust that reminds me of footprints in the snow. My shoes from running and my chacos (and my feet) are never going to be the same color again!) I am sorry about the foot of snow you all got back in MN…..can't say I miss it! 

This is the view of our apartment building from down the hill. It's still under construction, but it is very nice inside. I will have to post some pictures later. Out of all the places we have stayed so far this is probably one of the best, and most home-like of them all.

Tomorrow I am going with Renske to a children's prison - yes that's the correct term. I have been hearing a lot about it from her all week and I think it may be a little intense, but important that I learn about what happens to a lot of children who end up on the streets for various reasons. I may have something more interesting to say than stories about eating, shopping, and running tomorrow!

Home Again

I really can't believe that I am back in Uganda again!! I mean, I have been planning this since I left in August 2012, but it feels like it came up really quick. I knew that with the cost of a trip and the amount of time in my school schedule, I wouldn't be able to be back in 2013. It was the first calendar year in 5 years that I didn't go to Uganda, which was really, really sad. Instead I planned my schedule so that I finished the majority of my credits in the U.S. by February and then come here for the last 12 weeks of medical school to finish my electives, enjoy time with my Ugandan friends, and experience a longer time in this country that I love and hope to continue to work in. Prior to this, the longest I have been is 6 weeks. 3 months seems like an overwhelmingly long time, but I know it will be over before I know it!

I don't have a whole lot to say yet, as I have only been in the country for about 12 hours. The trip was uneventful and kind of tiresome. Although it is sometimes nice to travel alone, it can be lonely to not talk to anybody for 26 hours worth of flying and walking around airports. I had a few conversations with seat mates but I think I was so exhausted from the last four weeks of staying up late with friends and planning and packing that I just wanted to sleep. Let's be honest, airplanes do not make for good sleeping so I was anything but rested by the time I got here.

It wasn't until we landed in Entebbe that reality set in and excitement welled up. I felt like I had superhuman strength as I lifted my carry on (which is probably 50 lbs) form the overhead bin. It was the first time it felt easy to lift since the trip started over a day ago. Thanks to wanting to bring medical textbooks to give away along with the heavy electronics and some equipment, I had to overload my tiny bag to a weight nearly equal to my checked luggage. I always try to be inconspicuous about how heavy it actually is, but it is hard to hide a grimace and the struggle of lifting that thing above my head and getting it tucked away. Also, my struggling reminded me how nice it is to have a travel partner to help with all the lifting, but I will have those later on during this journey.

The next week I get to just relax and enjoy being here. Hopefully will be able to catch up with some old friends, maybe visit at least one of the orphanages, and meet some new people. There are many students and faculty from the University of Minnesota working at Mulago and I hope to spend some time learning from them as well. My official rotation will start Monday in Infectious Disease for 2 weeks. I don't know where I will end up after that. It's a bit of a mystery, but I know I will end up getting lots of good experience.

For now, I am just praying for guidance on where to go and what to do. It is nice, in a way, to have no real plans, but at the same time I like to have some things to do. I need to adjust to the heat a bit. I think the swing is about 100 degrees if you consider we had multiple days below zero and now the high's are 85 or greater. This Minnesotan will need to take some time to feel like the heat isn't going to make me pass out!

I will be staying with Angella, her friend and her son for at least the next 3 weeks and then possibly going to a more rural site in Kayunga. I will find out more of the details later. For now, the view is great. We are a little further outside the city so it is much calmer and quieter than where I have stayed before, but it is nice to leave the snow and wake up 30 hours later to this!

I will make updates as things happen. I can't promise it's always going to be exciting, but there is usually at least one or two things you might find interesting! I can't say I am going to miss the snow, but I will miss all the people back home for the next three months! Hope you all are enjoying the latest big snowfall!