To Zion

First, I want myloyal readers to get in the same vibe as I am as I write this blog.

Listen to this song: 

Delerium - Terra Firme 

http://youtu.be/LKUxE8UE7S0

-or-

Deadmau5 - Sofi Needs a Ladder 

http://youtu.be/gDndZn0YPdI

Welcome to my mind palace ;) 

Our destination today was to a rural clinic , in the mountains. 

Some background : http://ugandambale.help-international.org/blog/zion-medical-community-clinic

Interestingly , the co-directors for Help International in Uganda were actually staying in our same hotel/hostel. 

So getting to clinic turns out to be quite a journey . In short, our driver could get us only so far into town and we'd have to walk/hike the rest of the way.  So let's do this in pictures :

Car getting stuck, we get out to drop the weight.

Do not pass go. The car cannot go any further uphill.

So we begin .

Our goal is somewhere on that hill to the right .

After climbing uphill for a bit , burning some serious calories, some friendly neighbors told us we were going the wrong direction . We were actually going uphill as well. As such. We should go back downhill to the main path. Downhill = using trees / grass to grasp onto and rocks to anchor your feet so you don't slip. 

Here's Courtney getting help from the locals.

We make it up to clinic after about 1.5 hours of hiking. 

Now, you have to consider this in perspective . This clinic services a rural, mountain community. They don't have power or running water. The chlorinated water treatment areas may be empty. This clinic does antenatal, postnatal , pediatric and adult care. It is set up in stations so there is a triage area, counseling area, treatment area , dispensing area and lastly follow up/counseling area. 

We are greeted by people who work at Zion and the local pastor/church members. This takes place in ..what's best described as a roomy treehouse 

Up the steep stairs 

We are warmly greeted and welcomed as guests and people whose help is appreciated. The community members were so grateful for our help . They also voiced their concerns with their community. Things like needing transportation for sick patients from off the mountain to the main hospital, teacher salaries, medications ( as they keep running out) and housing for staff who can't get off the mountain on certain days. 

Here's a stretcher in my examination room . 

A guide to treatment.

The view from my window 

I saw a couple of pediatric patients : new diagnosis of malaria ( splenomegaly , pallor, jaundice , fevers ) , pneumonia , viral uri , blepharitis , contact dermatitis. 

Now to head back , down the mountain.

Uh oh, gloomy skies. Don't want to be going downhill ...in rain... On a mountain 

Downpour 

Ashley in a geico poncho, though she looks like she's in a kimono 

Pig.

Moo moo 

And the clogs came off .

My boots

Our collective feet/footwear 

The car ! Finally !

Dinner @ endiro , our new hipster locale.

Sketch path to endiro.

Food selfies!

Ashley got waffles !

Manafwa Clinic

So today we went to Manafwa for clinic. Manfwa is in a more part of town but ill get back to that.

First the morning routine. 

Obviously things are different in Africa . You adjust , you rest you expectations. 

Let me give you some examples. 

US/Uganda

1. Power goes out, people call LIPA. Lipa people get fired , company completely revamped and becomes PSEG/ Power goes out , you whip out a "torch" (flashlight) and maybe a generator provides some electricity for lighting. 

2. You order food , expect it in maybe 30 mins after appetizers. Pitch a fit if no delivery . / You order food 2-3 hours ahead of time and still give it another hour before asking when lunch will be ready . 

3. You need to take care of business aka number 2. You expect a toilet with toilet paper. / You need to do "long call" ( the word for pooping). You carry your own toilet paper / flashlight / hand sanitizer because you never know what you're gonna get.

4. We say " you're welcome " when someone says thank you. / people say "you're welcome or you're most welcome " when meeting you or welcoming you to a new place. * this is one of my favorite things to hear in Uganda 

So having said all of that. Our group has two vices / habits. Morning showers and coffee. We made arrangements for coffee but little did we know the water tanks would cleaned this very morning and possibly be down for "hours." Long story short , we got one shower working and all took a quick shower..but it's one of those less than subtle reminders of things we take for granted . 

So after figuring the shower business out, we packed into a land cruiser and headed to Manafwa. 

Low head clearance + dirt road = good times. 

 Our destination:

Now the views from this rural clinic are amazing . The air is fresh and foliage green and lush. Between seeing patients we enjoyed the following : 

And finally the clinic 

Clinic was decent paced. My chief complaints were all over the place:

Urinary changes, foot rash, dizziness, fever , leg numbness, leg pain, arthritis pain, worms

Diagnoses that I made : lady with potential hyperthyroidism (nodular thyroid , hypertension, palpitations, hyperreflexia) , older lady with with sbp in 170s who I found a systolic murmur of which I suspect is mild aortic stenosis , lady with hearing loss from hard, impacted cerumen and likely effusion given her uri symptoms 

Had a couple gu / pelvic / "gi" exams 

The rest of the cases weren't as clear cut with many chronic complaints. This coupled with all my information via translator made it a tougher day for me. However , I tried to do right by my patient, write good notes and tried to procure good follow up :) all in all, a productive day . One of my older patients ( the lady with a.s.) told me that if I manage to make her feel better, she hopes I'm blessed for my effort .

A solid end to my day :) 

Monday Clinic at Joy Hospice

So Monday Clinic.

Tidying up after the weekend. 

Time for Jan to minionize ( to make into a minion ) me.

So the wards , patients need to be seen, treated.

So recaps. 

My 60 yo gentleman with cryptogenic cirrhosis/hepatomegaly with nephrotic range proteinuria passed before receiving the first dose of high dose steroids . Apparently , he turned over in his bed that evening and passed . In some ways, perhaps it was for the best . He had been bounced around various clinics/hospitals with unclear diagnoses and finally came to us, a small clinic with limited resources. Perhaps we could get a diagnosis in Kampala , the Capitol. This may cost the famil millions of shillings. Even with a diagnosis , treatment may be a significant burden to the family or even feasible. This is a sad thing to realize , but humbling none the less. 

Today's patients 

Outpatient consultation

40 something year old lady with a massive goiter of at least 6 years . She initially presented in 2008 with a painless thyroid mass. This had become progressively larger and larger . In the most years after several pregnancies, it had become painful. Acutely, this lady is starting to have airway issues while sleeping . I managed to find myself a bruit hidden In her giant goiter. In short, I sent her to the Capitol for ENT evaluation , imaging and thyroid tests. 

After explaining this to her husband, he seemed confused on discharged and didn't understand why we didn't give her any "pills" for the goiter... So we sent her home with ibuprofen. 

Outpatient consultation 

40 something year old lady with two year history of burning chest pain , worsening with activity and feelings of "heaviness" at times . Basically, I worked my way through her long history. She had various diagnoses throughout her various other clinics : neuropathic pain, neuropsychological pain, thoracic spondylosis . At one point she had a sed rate of 95. At one point someone told her that she had peptic ulcer disease. In short, a tough one to figure out. I knew I could rule out h.pylori in clinic. If negative, I'd empirically treat with a ppi and Tramadol for musculoskeletal pain ( she had point tenderness over the sternum) .  Now, the kicker is if she truly has angina ...well what do I do? I can do a single lead ekg in the office (which I did , sinus tach, see below for what this device looks like) . What I can't do: stress test, lipid panel   And cardio referral may or may not be helpful . Jan asked me what I thought about an echo ... And I was like..well unless its crazy abnormal , it may not help and cost the patient . As such, we will work up what we can , follow up and move forward .

Outpatient consultation 

60s year female with valvular chf . She has mitral and aortic regurgitation . After digging, I found out she has significant pillow orthopnea. Basically we beta blocked, afterload reduced with an ace and fluid managed with diuretics. Of course ...even in the states, there's always a balance with valvular disease. Too little preload means no output. Too much equals overloaded lungs. So I told our team to do serial weights with her visits and try to find her euvolemic state and base our management on that and clinical appearance / functional status. 

Inpatient follow up 

60s something year old female who was admitted with acute malaria. Her history was a bit muddled and there was documented ccf history, history of malaria and copd possibly. So she comes in with uti symptoms an shortness of breath  and is found to be malaria positive . So in classic Joy Hospice style, I tell Dr Jan I'm going to reinvent the wheel and start from scratch . So what I get is a history of a lady with progressive shortness of breath and chronic hypoxia as documented in her chart. Her prior exams had mentioned digital clubbing . Previous imaging showed evidence of right hear failure/cor pulmonale.  So with this info, I examined this very spirited lady and appreciated dry,Velcro sounding crackles throughout her lung fields.  She had a slightly enlarged liver . Her legs were free of edema . Her nails showed significant clubbing and she had evidence of faint cyanosis to her lips/mouth. Sats on our pulse of we're around 80-85 . Despite all of this , she felt okay and wanted to go home. She ambulated without problem . I trailed her on o2 via our portable concentrator , to no avail or Improvement in sats or symptoms . Soooooo... In classic doctor rob uganda style fashion, I planned on sending her home on hi dose steroids. I theorized that she likely had right heart failure from chronic ILD  as evidenced by her compensated hypoxia and lung exam . Now with my history and exam, the patients daughter told me her brother was coming with some recent imaging. I get these results an hour later annnnddddd wait for it...

High res ct shows diffuse reticulonodular changes and honeycombing c/w interstitial lung disease . 

Take that ct scan.....diagnosis purely based on history and physical . 

No hilariously, or just classic Joy Hospice style. My lady wanted to go home . So despite her sats of 80-85 and no way of doing home o2 plus her malaria, we sent her home on azithro/pred 60/ malaria treatment with follow up in a week with a goal of tapering her steroids based on her clinical appearance and functional status. 

....and so ends another day at Joy Hospice . 

To Baduda

So this weekend , we set out to visit a host family , the Zaales. They are a very special family, but i'll detour for now and talk about bullfighting .

En route with Sula ( short for Sulaiman I learned today ) we stopped our car because we saw some bullfighting in Bududa. 

Apparently, this is a relatively common activity in the village. Young men bring out their bulls and basically prod them to fight / butt heads . There are no set arenas or frankly and barrier between this ornery bulls and spectators. Now, in classic Muzunga (Muzunga is the word used for foreign person in Uganda) form, we apparently were just as interesting as the bulls. In short , we probably got way top close to the bulls, as demonstrated by our frantic running from two ... Fighting bulls that made their way towards us.

Now, we got Bududa .

Bududa is rural and beautiful. 

We arrived around noon and was greeted by our host family , the Zaales. It's difficult to sum up the Zaales in a few lines of prose. This is a family who struggled for the first part of their lives and basically vested a lot of time in their family and the education of this family . We spent a good amount of time with their daughter , Annette who explained some of this motivation. In short , the Zaales have wanted education for their family. They view it as a means to better themselves . Pa Zaale / David himself was a teacher and all his children are educated. Am Zaale herself finished up to about seventh grade but is a community leader, role model and sharp in her own right . Now, these are amazing people who have started several initiatives in their community . 

Please take some time to check this site out :

http://pdiuganda.org/

Pa and Ma Zaale are warm, loving, Godly people. They treat you as esteemed guests. I felt like I was one of the family. Little comments like Pa Zaale asking me about Georgia and Ma Zaale told me she was concerned about my ability to hike. Their home/compound/farm is in the middle of several mountains . Pa Zaale also harvests cow poo for methane , to power his stove. He does it via this pit kinda of system with an exhaust vent for the methane , that runs to the stove inside = biofuel. 

Photos from around town : 

Hiker, the family dog

Our celebrity , David

Rain

The Longdrop , this is where you poo. There's also a Muzunga altered one where there's a fake toilet bowl on top..leading to a long drop. 

The Hike

No as part of PDI, they are trying to create hiking trails using locals as guides. Given this information, we decided we'd hike one of the nearby mountains . So we had our breakfast and waited for our guides. Two young men from the surrounding village joined us and our hike began. Now as to the the length/intensity of the hike. Mr Zaale described the hike as "needing boots" and "not for him." He said, maybe 2 hours. Our guides didn't really give us a time or destination but whether we near the top, maybe. So our hiked ended up being about 4.5 hours. The path was narrow to nonexistent at points. I slipped many times, thankfully not off the mountain .  We almost lost our attending ( as in her almost falling off the mountain) at one point. Halfway into our hike , we all ran out of water . On the way back to home base, I almost crumped. Legs killing me, tachpneic , chest tightness, lightheadedness ...I lay straight down on a relatively flat part and prayed I wasn't supposed to die.  Now the kicker was ...maybe 1.5 hours away from being at the base... The clouds started to loom. Now, picture this scenario . Steep downhill climb, unclear paths , dirt plus water = slipping down and ... Probably dying. Or somehow camping in the mountain until the rain dried up . Soooo... We kinda hustled ... And made it. 

Mountain hike, accomplished. 

Baduda , I will miss you . 

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