Dysentery won't stop Dr Robert

,So the ... Frequent ..pooping recurred.

Q2h bathroom trips.

So at first I was gonna sleep it off and let my intestinal epithelium shed itself and miss clinic but I woke up with a renewed passion, showered and hopped on a bodaboda (motorcycle) to catch the gang at clinic. 

As usual, Dr Jan had procured business for me. 

Going through the patients

1. Following up my friend  with ISS/ AIDS with pyrexia of unknown origin ( like FUO) who's doing quite well. 

2. 60 something old female with new diagnosis if chf . Dr Jan asked me to appreciate her physical exam findings and wanted to know if I had additional questions. So I found out that someone had " given her medicine that made her pee more " which I interpreted as diuretics aka someone knew she was fluid overloaded. Then I examined her . Pertinent findings: JVD, cardiac wheeze, crackles to halfway up posterior lungs , irregular heart rate and rhythm , ascites, bilateral pitting leg edema , significant dyspnea while lying supine. So I theorized that she is in chf exacerbation with underlying afibb either from dilation or may have thrown her into chf. Interestingly , she did admit to occasional palpitations while at home.  So we managed her as best we could , uganda style. 80 ,g iv lasix, started aspirin/ digoxin / beta blocker / aspirin and hoped for the best . 

3. 60 something old male with cirrhosis/hepatomegaly of unclear etiology and possibly nephrotic syndrome . In short, he hasn't gotten better in 6 days and we don't know what he has. We reviewed years of his paper records and weird labs like an albumin of 0.7 in the past ( which dr jan thinks is lab error from shady reagents in Mbale ). So I proposed he gets a proper chemistry and liver function tests..which can only be done in Kampala , the capital . Given his age and proteinuria , he probably needs a kidney biopsy . And to add to the fun, he needs a liver biopsy for this "cirrhosis ". So...the family asked us for an estimate for these things and we guessed about 1 million shillings which is about   435 US dollars . This is a significant burden on a family and after a meeting realized we can't do this today. So I suggested we empirically treat with high dose steroids and told him there was maybe a 10% chance this work. My quick lit search showed that there is maybe a 50% remission rate . The morphology of nephrotic syndromes is so varied and relapse is relatively common. 

4.  Poor soul of a lady with cervical cancer with likely hips mets. She just came in for pain management and unfortunately lives by herself.

5.  My copd/asthmatic / interstitial lung dz lady returned with chest tightness. Kind of humorously , she appeared to be completely normal when nobody was watching her. 

6.  Last patient of the day, triaged from the front. A 40 something year old male with known cirrhosis comes in with massive ascites. He pretty much looked 9 months pregnant. In short, we found out that we had been a cirrhotic since 2007 and was previously well controlled on diuretics and abstaining from alcohol. However, as of 2011, he went back to alcohol, specifically waragi, which is a type of homemade gin. 

http://en.wikipedia.org/wiki/Waragi

So basically, Dr Jan asked me to set up another paracentesis and even better, walk the clinical officer through my custom setup. Here's some before and after pics with CAPUT MEDUSA!

So prior to me leaving, we were about 7 liters out. I knew we'd probably get close to 10 liters (pending by holding) given his 11kg weight increase from prior weights. 

All in a days work :).  And now the clinical officer is officially certified by yours truly , hahahaha

Last thing,  I wanted to know about the source of the loud dog barking next door to my hotel/casa and I spotted my new friend from across the balcony. 

Kinda reminded my of the beast from Sandlot.

http://villains.wikia.com/wiki/Beast_(The_Sandlot)

Islamic University of Uganda

So I'm starting this entry from within the mosque @ IU, waiting for the noon prayer .  

I made a promise to myself that I'd check out the Islamic University of Uganda for many reasons. One,  the main campus is in Mbale and it's a large and comprehensive University. Two , while I don't claim to be stellar example of a devout Muslim, I am one none the less and I view masjids/mosques as homes / places that ought to be visited abroad . I know Big K (my dad) would check it out as well and well this apple doesn't fall  too far from the tree. 

Their website: http://www.iuiu.ac.ug/

First, getting there. I spoke with one of our Casa friends , James who told me that its not really a practical hike. Im used  to 30-40 minute walks to most places i needed to be, so I asked him what he suggested. He told me to take a bodaboda (motorcycle)  and pay 1000shillings (4 bucks) one way and 500 on the return. Now, I've avoided bodabodas as our attending, dr jan told us a horror story of a staff member who fell off one and sustain a head bleed plus one of ashleys friends also sustained a nasty burn to one of her legs getting ofd a bodaboda so with all this in mind i was hesitant. So i walked a little way into town and i spotted a muslim bodaboda driver (could tell by his hat/garb) . Now, i figure (logically or illogically, take your pick) that if i were to perish on a bodaboda , best to do it on one driven by a Muslim guy on the way to an Islamic University ;)

So I made it in one piece. Who knows what i looked like on that bodaboda . This brown mazunga boy with one hand clutching the back of his seat and my Kenneth Cole messenger bag slung around my neck speeding across town.

No matter.

The University is quite expansive and nice . There are schools of law,  nursing , science. I basically walked around for a bit looking at buildings, computer labs, biology labs, dorms , etc.  Students are all around campus, sitting under trees, desks , benches. There's many clubs and notices throughout the campus. At one part, they had laid out many photographs on some mats , I'm guessing from an event ? The student body is very diverse. The women wear the traditional hijab . The men wear anything from traditional long gown-type clothing / kurtas or jubbas or long pants and a shirt/ t shirt of some sort. While predominately African, there are many different shades of skin and shapes of faces but most everyone I observed were happy and busy about their day. 

A very nice experience , stayed for noon prayers and took a bodaboda back to down.

Had coffee @ Cafe Arabica 

Then the GI distress began and lasted the night :(

The boot

Boots come in pairs. This is a functional and as I've learned an emotional pairing. 

The weekend's  plan was safari-ing at Murchison Falls . We'd get picked up at Casa and head to Murchison via Lira in a counterclockwise loop around Uganda . Now as we stopped in Lira for a bit , I had taken my boots off to air out feet ...and boot number 1 fell out.... This realization did not occur until many miles later ... Let me show you 

So I get out the van...and my shoe is missing ..

I have no backup shoes. 

So we go into a nearby hotel,http://www.paraalodge.com/, and buy myself some African sandals 

So I'll get back to the shoes. 

We stayed at http://redchillihideaway.com/hideaways/red-chilli-rest-camp-murchison/

Not a bad place buuuuut. ... Bugs galore....and then after live managed to settle in your bed..put your mosquito net down...fan on the highest setting

It starts raining ..and the power cuts off...no biggie.im used to it...and the waiting begins. I wait for the power to come back on. I wait for my fan to cool me down as I start to perspire ...profusely ..

And .... 

It...

Never..

Comes ..

On..

And the night was...sweaty..

So we got up at dawn ..to get on the ferry (across the Nile) to start safari-ing 

We get on first...and then the ferry breaks ...a few feet away from the dock...

For several hours...

People who had to use the bathroom on shore ( ill find pictures later with the decent gap between shore/ferry) had to have someone paddle a small boat to the ferry then paddle them back :) 

And then there was talk about the safari not happening..given there's no other ferry ... 

But we made it across.

- safari pics to follows (there's lots)

Highlights: lion sleeping after a kill ( we drove up to it) , lion cubs , tons of giraffes,tons of buffalo, fair number of elephants , antelope

Then we took the Nile safari ...while it rained . The rain was less than ideal but it made for more hippo action as the hippos spent more time out of the water. We saw two crocs as well. We then made our way up to Murchison Falls, the waterfall . At this point, our guide said that those of us who are hiking...will get off the ferry...on the river...on to this kinda sketchy little land piece leading immediately to the trail. 

Our hiking mates from Sweden were decked out in fleeces, hiking boots, ready for action. I'm wearing a shirt and jeans (poorly flexible jeans) and flat bottomed sandals. These are less than ideal ....wear for a hike.  The hike was about 45 mins -1 hour. It was steep at points, precarious with slippery rocks and a steep drop off into the waterfall ...and at the end...you had to clutch the wall. At one point the guide told us that if you stray too far from the wall, you're likely to fall into the falls. However not to worry, we would be quickly consumed by the waterfall and die. So my hiking experience was punctuated by slips ,tachycardia , wobbly legs and diaphoresis . Genuinely I thought it was at least 10% possible that I may..uh..slip off ..to my death...which thankfully I didn't.

So some tips for any Murchison Falls Hikers

Awesome idea as the views are amazing from the hike.

Use boots.

Hydrate.

Flexible pants/ shorts.

Keep your hands free.

:) 

wonderful experience, wouldn't trade it...not sure if I'd do it again under the same circumstances :/

So the only thing left to do was Rhino Trekking 

In short, we basically paid to get into the sanctuary . Then we had a guide drive with us part way and then after donning wading boots, walked into the areas where the rhinos were. Basically we walked up to about 40 yards (or less) and take photos of these wild rhinos . 

*Amazing photos to follow 

Highlight : Ashley getting within 20 feet of the dominant male rhino , inadvertently. 

So really the rest of the day was on the road , heading back from Masindi to Mbale. 

The most remarkable thing that happened on our way back would be seeing a special ceremony.

It's called Imbalu and it marks the circumcision ritual of teenage boys in Uganda.

http://friendsnaturesafaris.com/nature-blog/item/1-imbalu-ritual-bamasaba-tradition-of-circumcision/1-imbalu-ritual-bamasaba-tradition-of-circumcision

The young boys dress in traditional garb and go around collecting money for their post-circ recovery. They spend time visiting relatives. Usually these rituals are performed in longer school holidays like Easter weekend and later in fall. 

My Pics 

Then home , sweet home to Casa del Turista

Oh, and the boot. So boot number 1 was located by our guide's contacts in Lira. Somehow they made calls and pulled strings to get my boot on a bus to Mbale. By a miracle, my boot made it back to Mbale before I myself made it back. Now my shoes are whole again and the circle is closed. :)

Monday, not too much happened. The girls headed to clinic in Manfwa (rural clinic) and I rounded with Dr Jan/ myself and saw a few patients : gentleman with AIDS, gentleman with metastatic prostate cancer ( previously had needed narcan in office b/c family had been giving capfuls of oral morphine ...the red one ( see previous post) , gentleman with some sort of chf , cirrhosis/ hepatomegaly (unknown etiology .... And no, getting a biopsy is not feasible) with what seems like urethritis , kiddo with dysentery , kiddo with quinine resistant p.falciparum malaria ( persistent fevers and parasitemia despite quinine treatment ) , and my poor soul of a lady with mt. Ovarian ca with malignant ascites who I tapped again. In case you were wondering how my setup looked ( see below). Basically I put a iv cath in my ascetic fluid...plugged iv drip tubing and cut off the tubing, secured it to the bed so the fluid could drain to gravity , into a collection container. Being the procedure master I am ( sarcasm ) , my attending asked me to teach the clinical officer how to do this tap. So the Robert Abdullah tap in uganda procedure.

Premedicate with oral morphine if needed .

Patient in LLD position.

Prep site with gauze / iodine .

Sterile gloves on.

Have assistant have iv tubing / "giving set" ready as you'll need the tubing to hook up to cath 

Use biggest needle (In my case 18)

z line technique 

Insert iv As far as possible with flashback of ascetic fluid

Remove needle..secure cath as best as possible

Set up drain ( cleverness encouraged )

:) all in a good day's work 

And lastly , Happy Birthday to my girlfriend of 2 Years, 4 Months , 2 days :) 

- Rob 

Montezuma's Revenge

Day 6

So I had chills on my 5th night and woke up feeling horrible ...weak...aches but I brushed it off to an unusually cold night and maybe some dehydration. 

Me and the girls headed out to clinic , hopeful that our three sickest patients made the night .

However , we all had reservations regarding our chef lady with gi bleed.

Needless to say I headed straight to her bed....and I saw a body covered by a blanket. 

...my heart sank

How naive was I to think my one day of interventions would save this medically complex and ill lady. I found out that despite having the blood , our iv access didn't work so by 6am , she had no blood and she passed . Our attending reassured us that we did our best and frankly they thought she'd have passed on her last admission for chf. 

May God rest her soul.

Our 30 yo metastatic ovarian ca lady felt a little better after our tap and started to eat some. However she has been anuric, without stool/flatus and remains sig. Anemic .....so we theorized she may have a bowel obstruction related to her huge solid mass cancer . Our attending said there's not a whole lot to do..she's not a surgical candidate ..that we can offer hospice at the clinic or home.... I will say that her pain was better controlled ....

So back to me...abdominal cramps and epigastric burning with aches throughout clinic. I took the free uganda govt rapid malaria test...negative . The techs ran my smear to be sure ..negative . So not feeling much better ...I walked the 30 minute walk home. I grabbed some carbonated drinks and buns as I'd been losing my appetite . Then it started . Politely..I was ...losing bicarbonate and intestinal epithelium via my gi tract . I crumpled over in abdominal cramps.... So..I probably have .... Diagnosis is what? 

http://en.wikipedia.org/wiki/Traveler's_diarrhea

So after some cipro and sleep... 24 hours after onset..feeling slightly better .

Needless to say...my mum was in a state of fright but I shall call her when its a reasonable stateside time :) 

That's all for today .

The day we ran the clinic

So I think it's important to appreciate who's on my trip and our situation. 

Dr Jan is at home recovering from a fracture or rather a compression fracture and trochanter injury.

So basically Joy Hospice is being run by the clinical officers an nurses. Clinical officers are sort of like pa/midlevels in the u.s. this is usually not a problem at a level two health center buuuuuut here's our census :

40s yo guy with recently dx aids , with night sweats and poor po despite being on art and broad spectrum abx.

80s yo lady with severe asthma on 30 mg of prednisone , oral salmuterol , and nebs spaced anywhere from q 11 to q4. This morning she was newly hypoxia to high 80s, auto peeping and tachypneic to 30s.

80s yo lady with ccf ( congestive cardiac failure ), kaposis sarcoma ( non HIV), hx of pud. P/w weakness and fatigue . She was found to have a high of 6.6 yesterday with black stool but doing okay. We had started a ppi and hoped for the best today. However, she was looking shocks with cool extremities , white conjunctiva and looking horrible. Our c.o. Told us her o2 sats were 60s before we rushed in to assess her. In short , her poor perfusion gave a poor pulse of read but my main concern was a gi bleed as she had inc stools overnight that were loose and black with left sided abdominal pain. 

30 yo f with metastatic ovarian cancer with malignant ascites and multiple implant sites in adores was referred to us by the bigger hospital " for morphine " and evaluation with very little explanation of her disease. 

50 yo f with metastic breast cancer who ran out of her pain meds and was constipated along with Complaints of leg parasthesias .

Solo that's our ward. Day 3 on the job and we were left to run this ward and make decisions. Let me first say that I am working with two amazing residents, almost attendings ash and court who basically helped me run this semi adult icu service from a small clinic in Mbale , uganda . We rounded , did our own vitals , made plans then met dr jan at home for lunch and to discuss cases. Dr jan basically agreed with our management which follows:

1.Gentleman with aids , I was concerned for a tb coinfection thought he had no cough. However he had no sputum so we couldn't do an afb and ironically to run the free gene test at the  regional hospital we'd need sputum . The other differential would be an IRIS type reaction .

2. Lady with asthma . We basically made her q3 nebs , adjusted her steroids to adult dose and give iv aminophylline with great improvement . Hypoxia had resolved by end of day. 

3. 80 yo lady with ccf/ pud hx. On my way to dr jan...I smell and saw the malena personally. After going back and forth wi the staff because her hgb was 6.6 (from 9s one month prior)apparently the hospital will usually send blood only if <5 . We basically got blood sent , obtained an iv , started 2 units prbc with lasix between and prayed for the best . ; TLDR: I managed a gi bleed in outpatient clinic. 

4. 30 yo female wi met ovarian can Er. Basically I had to discuss her whole case with her . I had to explain how bad her cancer was and that she would die from it. I explained her ascites would keep coming  back  with this cancer . I explained that we should focus on treating her pain and letting her be as functional as possible . We even assessed her home situation which we realized she lives with her husband who works most days and can't tend to her ..as a terminally ill patient . So after discussing the case with dr jan   , she told me to tap the ascites if I felt like it . No , this isn't stony brook. I don't have a sonosite, I don't even have a paracentesis or thoracentesis kit. In short dr jan told me to sort of make an iv / tubing / bucket work for me . So with the help of Ashley , sweating my --- off I attempted to canulate her abdomen with an 18 gauge needle. Then I would hook it up to an iv set and basically reverse a traditional iv drip to drain this to gravity. Long story short, after much anxiety and a bent catheter on the first try I was able to drain 2 liters of straw colored ascites to the relief of the patient . Sadly   , after get distended and Tympanic abdomen went down, we were able to see the large left sided abdominal mass ....the source of her terminal illness. Sad. 

Fun fact   , oral  morphine is provided free by the govt for palliative care. It comes in three concentrations that are color coded/dyed. 

Green (5mg/ml)  Red (50mg/ml) Blue (100mg/ml)

All in all , one of the most memorable days of my life.

Day 4 - Meeting Dr Jan

So today was the first day of our rotation. We set out to find Joy Hospice and our attending , Dr Jan.
http://www.mbalehospice.org.uk/
Read through the website, it's pretty amazing stuff.
So of course we got lost en route. We tried to cut through the regional hospital as opposed to turning right at the little clock / turnaround .

* will include day 4/5 stuff *

Joy Hospice is a special kind of place . It's a mixture of a mini hospital with ten "ward beds " and outpatient clinic . The kinds of patients I've seen in clinic this far :

Ward

Infant with diarrhea illness treated with ORS and zinc 

Older lady with spondylosis and uncontrolled htn 

Young gentleman with wasting / fatigue found to have AIDS, cd4 count in 100s. He's been having some hypotension . He's also complaining of nausea and weakness  . My theory was that he could have an element of adrenal insufficiency but without a Chemistry / cosyntropin/ cortisol level, it's hard to prove . My c.o. Was amenable to trying steroids though :) labs cost money to patients in clinic   . HIV testing is free when available but we have to pick the best test for the money so this far he's only had a cd4 count .

2 different ladies wi asthma exacerbations. One lady came in with hypoxia and severe distress , was given steroids and only two salmuterol treatments which ....blows my mind. Needless to say I requested at least q4 treatments , with Ashley and Courtney in agreement .

Outpatient 

Young girl with fever / abdominal pain = typhoid and uti ( cipro for both)

Older gentleman with tendon pain and early satiety = hpylori positive / pud and partially torn tendon ( a good find on me and Ashley's behalf with a bunched up tendon and obvious deformities when patient lay prone comparing the two tendons 

Young girl with follow up , she had previously presented with significant weight loss / night sweats / nocturnal fevers  / anorexia and had been treated several times for "malaria " without improvement . The person at joy hospice took a thorough history and realized there was a sister with newly dx tb and patients afb came back +++ = newly dx tb. On follow up , two weeks into treatment she looked happy and alert . She thanked the clinical officer for saving her life :) 

So that was clinic so far . I feel very fortunate to be helping and learning . People are referred to joy hospice in times of desperation when other doctors can't help them.  I feel very fortunate to help in my little way and learn from the Ugandan people and our fellow healthcare workers.

I will blog about our clinic staff and dr jan later, since there is so much to share. 

Uganda Trip!

Days 1-3

Day 1
Left Lake Grove at noon. We quickly found out our driver was a conspiracy theorists . His theories included jet fuel as a coverup to distribute an agent orange kind of agent to the atmosphere , that politicians are trying to revert us to feudalism with a ruling class and peasant class ,etc. Good Times.

Flying
Flying and traveling was ...lengthy
Brussels was 6-7 hours / layover then "chilled on runway for an hour " / Brussels --> Rwanda  7hours / layover ( people get off , bug sprays gets sprayed , potties get used approx 1h) then land in Entebbe around 10ish. We stayed at Entebbe Backpackers (http://www.entebbebackpackers.com/) which was a nice little place . Cheap / mosquito nets/ your own shower

We slept over from midnight to 530a then started our journey once again, to our final destination of Mbale , Uganda . We drove in a van half-awake / jet lagged until about noon. Stopped in Jinja (popular tourist stop , site of rafting ) for breakfast @ http://www.enjoyflavours.com/  . Here I learned some rules for traveling abroad from Ashley :

Rules for traveling abroad
1. Eat what the locals eat , which is usually veggie unless you're in a touristy area . Street meats are usually out all day and likely to give you the diarrhea ,etc.
2. Don't order ice , usually . Unless you know the water us treated / filtered (that makes the ice ) .
3. The children will call you Mzungu (http://en.wikipedia.org/wiki/Mzungu) which means white person / with the undertone of meaning someone with wealth / foreigner .
...more to come ...

We finally arrived at our new home around  noon  on Sunday , Palm Sunday .  Since we travelled so early , we got to appreciate Ugandans dressed in their Sunday best carrying palms as they made their way to church. ( kinda looked like below ( from google images ))

Casa del Turista
http://www.tripadvisor.co.uk/Hotel_Review-g668276-d4367873-Reviews-Casa_Del_Turista-Mbale_Eastern_Region.html#

We were greeted by the owner and wonderful host at casa , Baker . Casa is  nice little dorm kinda of setup. Our rooms have beds/nets/ standing showers/ western toilets . We can actually see mount Elgon from the rooftop at casa. Baker is a wonderful host and helped us build a dinner menu and let us know about all the outreach casa takes part in from supporting two high schools to recycling straws to make purses which can be resold.