Sunday, February 21, 2010
Monday and Tuesday on the female ward were pretty hectic. A young woman in her 20’s was admitted who was unresponsive and was having seizures every 15-30 minutes. Her attendants had only known her for a short time and knew very little about her history other than that she had regular headaches. The sedative diazepam was not working no matter how many times it was administered. Babak the resident wanted to give the medication via a slow drip. In the US if we were to use this medication via IV drip the patient would be in the ICU with one nurse monitoring her closely for respiratory depression. The anti-seizure drugs Phenytoin and Phenobarbital were only available in pill form. This meant we had to place a nasogastric tube into someone who was actively seizing in order to give the medications that would hopefully save her life.
After well over 24 hours of seizures the young woman came out of it. Amazingly she had no apparent brain damage. We learned that she had been having seizures since she was in grade school and her father was only willing to treat her with herbal remedies believing that she was bewitched. As a young adult she was told that she likely has a brain tumor. Unfortunately, her parents came and pressured her to be discharged prematurely. Although it is difficult to say whether there was much more we could do for her given our limited resources.
This week was otherwise uneventful. The ward had the usual Typhoid, TB, HIV, and Malaria patients. I am learning the different presentations of Typhoid fever versus Malaria fever. With Typhoid, (a life-threatening bacterial infection spread through fecal or urine contamination in food or water) the fever gradually goes up each day. Most fevers cause increased heart rate, but with Typhoid fever the pulse remains slow. Another unique symptom is extreme apathy.
In contrast malaria related fevers rise and fall regularly, and are followed by shivering and sweating. Anyone with these symptoms is empirically treated with Co-artem. If symptoms are persistent then a blood test will be taken to determine if the more aggressive treatment of IV Quinine should be given. This drug often causes temporary loss of hearing, and it is no longer given in the US due to its harmful side effects. Given that tonic water has Quinine in it, drinking gin and tonics in malaria infested areas has been said to be useful as a malaria prophylaxis.
On Saturday I accompanied Morgen to the Village Mugwata. Morgen and Jay make regular visits to various villages to evaluate the Village Health Workers. They also go along for some of their home visits. Getting to a home involves walking through garden pathways that are all interconnected in a winding maze of foliage. When you pass someone working in their garden it is customary to say, “Wakoze.” This is saying thank-you to the person who is working hard digging and producing food.
Sorghum is being harvested right now and it is a grain that grows as tall as corn and has a beautiful red flower at its tip. It is used to produce local liquor as well as the commonly consumed breakfast porridge. The villager’s houses are more like compounds, usually with bamboo fences. Enclosed are several mud huts with grass roofs. There are always goats lounging about, and there was a chicken laying eggs in the living room of one of the homes. The wallpaper in another room was newspaper, one of which was announcing Arnold Schwarzenegger as governor of California.
We visited a pregnant woman’s home and made sure she was going to the antenatal clinic. After looking at her clinic papers we learned that her baby is in breech position. This was an opportunity to reiterate the importance of having a birth plan, which means a way to get to a hospital once labor starts. This can be difficult especially if they go into labor during the night. The woman reported that she WALKED to the hospital when she went into labor with her previous child. It had to have taken her at least a couple of hours to get there! I just cannot even imagine.
The next home we visited was a villager who was suspected to have hypertension. Her blood pressure turned out to be normal. Since next month the teaching topic for the VHW’s is sanitation we asked if we could look around the family’s house to see if the compound had good sanitation. There were several issues that are common in the villages. First, the latrine was not enclosed allowing flies and rodents to get in. It is not ingrained in the villagers mind how common it is that flies and rodents spread disease. Next, when we asked where the animals sleep at night, we were not surprised to hear that they sleep in the kitchen. It was explained that having animals where the food is cooked can contaminate the food. Finally, the kitchen had no windows, so when they are cooking over the fire there is very little ventilation. Apparently the wife had asked her husband to put in a window but he didn’t see the point. Of course this is the case since he never cooks in the kitchen.
As we were leaving this house one of the young women slyly reached out and brushed her hand against my arm and then jumped back and laughed. The interpreter relayed to me that she wanted to discover if my skin felt the same as hers. I asked the young woman if it felt different and she replied, “No.” It was one of those magical moments where we all jabbered and marveled at how much the same we really are. This is aside from the glaring fact that the countries that we each happened to be born in allow us an inequitable difference in opportunity.
As we were walking back to the van, we peered into a compound where the people were working hard at what looked like beating grass with a stick. Morgen stepped inside the compound and inquired as to what they were doing, and asked if we could try. I soon found myself beating what turned out to be beans from their pods. It was super fun and tiring participating, for a short time, in the daily activities of a villager. Of course the families loved watching the Mazungus try and do their work.
As we headed back to the trading center, (small business center of the village) we were summoned by another VHW to go and visit a home. Apparently a woman had given birth at home to her 6th child a few weeks prior. It broke my heart to hear that a few minutes after the baby made its first cry it died. If that wasn’t enough the mother began to hemorrhage and was taken to the hospital after she became unconscious. We were asked to visit this woman because, after being discharged from the hospital, she was continuing to have dizziness, weakness, and lower extremity edema. There was not much we could do for her but to encourage her to eat iron-rich food such as millet and greens for her anemia, and to elevate her legs for her edema. Although it wasn’t an appropriate time to mention it, this was an unfortunate example of the potential dangers of having too many births, and also why it is so important for women to have a birth plan in order to give birth in the hospital.
Last Sunday was the day I attempted to climb Mt. Sabinyo, (Old Man’s Teeth) which is a 3 peak climb that begins at 2364 meters and ends at 3635 meters. The final peak you are on the border of Rwanda, Congo, and Uganda at the same time. You are not allowed to hike in Mgahinga National Park without at least two guides, one of which totes an AK47. We were told it was to protect us from the dangerous water buffalo, but we couldn’t help but wonder if it was because we were going to be on the border of the Democratic Republic of Congo
The beginning of the hike was a beautiful walk through bamboo forests. Along the way we discovered wild pumpkins, also known as “elephant beer” due to the fact that it makes elephants intoxicated. As we began our steep ascent into the magical draping moss forest land, I began to experience symptoms of acute mountain sickness due to the rapid elevation gain. The nausea, dizziness, and shortness of breath were unlike anything I have ever experienced on a hike. After climbing many ladders and stopping to rest way too frequently, I managed to make it to the first peak. It was a gorgeous misty mountain view. Suddenly all of our cell phones began to beep at different intervals. It was a text message from Rwanda, welcoming us to the country! I took a nap in the sun on the first peak, while the others continued on, except for Julius, the gun toting guide, who was there to protect me from I don’t know what.
After about an hour we began to hear the rumble of thunder and see the clouds rolling in. I texted the group that I was descending early to avoid the rain. This was at the recommendation of a Polish mountaineer who had been climbing peaks in the rain for the past two weeks. He explained that it was treacherous. Sure enough it began to rain, no actually hail. It was a muddy slippery climb down, and I fell countless times. I don’t know how my guide managed with his rain boots that had absolutely no traction at all. At one point I landed on some stinging nettles. After Julius picked the nettles out of my hand he told me how they usually whip thieves with these painful little plants.
The rain eventually stopped, and I was completely soaked. As we neared the trailhead, I saw two people and a dog run away into the bushes. It was poachers! Apparently they were illegally hunting the water buffalo. I was sure my guide was going to run off and chase them or shoot his gun. Fortunately, he stayed with me.
While I waited for the others to return at a small canteen outside of the park, I ran into Sandra. Sandra is from the UK and has been in Uganda for the last 7 years studying the endangered Golden Monkey. She has been spending the last 5 months attempting to habituate the monkeys. This means getting the monkeys used to humans so they don’t run away, making it possible to study them. She had a successful day in the jungle, where she was able to sit and watch the primates for over an hour without minding her presence. If anyone ever wants to hang out with these cute little guys, Sandra is always looking for volunteers.
That’s it for another great week in Uganda! Now I am off to lunch at my interpreter Penninah’s house.
Monday, February 15, 2010
This week I spent 3 days on the female ward, 1 day in bed hoping I wasn’t getting sick, and 2 days doing Village Health Worker Training. I am beginning to find a rhythm on the female ward. I could have never imagined that I would be able to know the status of 24 patients in 1 shift. That is not without the help of the other nurse on the ward. It is working out well that I am acting as the lead nurse, assessing the Patients, documenting, and when possible making sure all of the doctor’s orders are getting done. The other nurse distributes medications, places IV cannulas, and wanders off from time to time.
All of the nurses have been great. There was one exception when one day the nurse assigned to the ward showed up for only about 20 minutes during the morning, and when it came time to give medications, she told me she was leaving. This was after I told her I did not feel comfortable passing the medications alone. I tried not to panic or be too upset at how seemingly uncaring this nurse was. There were 24 Patients, 7 that needed to be discharged, 2 new admissions, a demanding family, and an unstable elderly woman. I needed to keep it together. Fortunately, my interpreter Penninah helped me fill out the discharge paperwork, and the nurse from another ward assisted with the medications. The day ended on a sad note as an elderly women with malaria, who seemed to be improving passed away.
Village Health Worker Training:
The Village Health Worker training was a lot of fun. The topic I taught was on Diabetes. I am finding that I love preparing lesson plans. When I am in front of a group instructing, I really enjoy trying to get everyone engaged in learning. Diabetes is not an easy illness to understand, but I think that the Village Health Workers walked away with an understanding of what diabetes is.
I used a display of local foods to demonstrate the foods that a diabetic should and shouldn’t eat. The Village Health Workers loved it when I attempted to get an idea of how much beans they eat in one meal. I started by setting a small handful of beans on the table. They kept saying, “More, more, more,” giggling the whole time. It took awhile but I think they were finally able to grasp how their favorite food, the Irish potato, can raise a diabetic’s blood sugar.
The seriousness of diabetes was really driven home, when I asked leading questions that led them to figure out how a diabetic may require an amputation that begins from a small wound on the foot. I have a feeling that from now on the Village Health Workers will be checking the diabetic villager’s feet, and encouraging them to wear shoes. I also took these classes as an opportunity to promote and encourage them to send diabetics to the Chronic Care Clinic that the Doctors for Global Health residents set up a year ago. This clinic has been very successful, and diabetics could really benefit from the monitoring that the clinic provides. After the lesson I feel confident that most of them now know how to detect the signs and symptoms of diabetes, (including high and low blood sugar) and what they can do to help a diabetic who is unstable.
I took a walk to Lake Motunda with Babak last Sunday. It is about a 90 minute walk, in the direction of the Democratic Republic of Congo, whose border is about 8km from where I am living. On the way to the lake we walked at a leisurely pace taking in all of the sights and sounds of nature. I finally got some good photographs of the large and lovely trumpet flowers. The bird watching was awesome and really slowed me down. Stopping to pull out my binoculars and identify the elegant Sacred Ibis is when I first noticed Livingston.
Livingston is a 13 year old boy, and a fellow wildlife enthusiast. Together we walked along and used my bird book and binocs to discover the names of the birds we saw. Impressively, Livingston already knew many names of the birds and I was also able to teach him some bird names he didn’t know. We really got into it together as he told me stories about animals, of his daily life, and his dreams for the future. His understanding of my English was by far the best of any African I have met so far. I learned that Livingston wants to study wildlife, and his favorite types of animals are “flesh eaters.” He seemed to know more names of “birds of prey” than any other. He told me this detailed story about how eagles take tortoises from the lake and fly them up to the hilltops and drop them on the rocks to break their shell. When he finished the story he paused and softly said, “It is not very sensitive of the eagle.” My heart melted.
Arriving to the lake was beautiful but anticlimactic after all of the birds we saw on the way there. My favorite on this trip was the curious-looking Great Spotted Cuckoo. They have long tails, and hang off branches side-ways. Livingston and friends accompanied us much of the way back. This is when I learned that Livingston goes to school in Kampala and he was waiting for his Dad to send him a ride to return to school. His Dad is late though, because all Ugandan schools have resumed session from the holiday. When I inquired further, I realized that his Dad may not be able to afford his school fees. This is not an uncommon thing to hear about in Africa.
This last week I have not been able to forget about Livingston. He was so intelligent and one of the few Africans I had met so far who was able to look far ahead into the future and have a dream, not just for livelihood, but for personal fulfillment. It was apparent that Livingston realized the importance of education, yet his future was hanging in the balance. I hear that foreigners often sponsor education for people they meet in Africa. I hope I can find Livingston again and see what I can do to help him fulfill his dreams; otherwise it will haunt me forever.
Bugs are fine, but I prefer bugs outside rather than inside. Babak and I can’t figure out how the bugs find their way into our cement house. Okay there are screens above each window, (the windows also have bars across them, and are covered with cheap shower curtains) but the only break in the screen we already covered with duct tape. Thank goodness Babak thought to bring duct tape. These one bugs, I call them the “Fighter Pilots.” They are like GIANT maggots with wings. They graze our faces at lighting speed, with an amplified BUUUUZZZZ……..BUUUUUZZZZ, but much more aggressive than the buzz of a bee. In fact right now I can hear them banging on my bedroom window trying to get in. When you see one you know that there will be more coming as long as you keep the light on. They like to chase us out of the common area. In the evening we are often forced to lock ourselves in our rooms.
Funny, I saw a medium sized cockroach running across the kitchen counter this morning and it didn’t even phase me. The troupe of roaches that found their way into my bag of honey really grossed me out though. Philip made me feel guilty when I told him I threw the honey away. He said, “You should give the honey to someone who wouldn’t mind the roaches.” That thought never even crossed my mind.
I cannot get used to the spiders. There are at least 20 different kinds of spiders that I have seen so far. For some reason it’s okay if they have long legs, but god-forbid their bodies are big and hairy. I lose all sense of reason. Hiring a spider killer seems like a good idea, although I really shouldn’t be killing the spiders. The reason is that one morning in the shower I found a “Fighter Pilot” hanging limp in a spider web. I was very proud of that spider and his dainty web.
Babak casually asked me this morning if I had been getting bitten by many bed bugs. Panic seized my body. If he is getting them, won’t they be coming after me soon? He nonchalantly said, “I thought everyone here had bed bugs.” That was news to me. I’ve only had one bug bite so far, and I suspect it was a spider. My only relief in my current life with bugs was when I learned that the fat jumping spiders that visited me in the shower every night were actually crickets. I can handle crickets.
There is one main road to town, which is about a 15-20 minute walk from where I live. It is a rocky 2 lane road that is part dirt, and part paved. This TWO lane road needs to accommodate 2 lanes for pedestrians, 2 lanes for bicyclists, and 2 lanes for buses, cars, and trucks. Walking this road feels like Russian roulette. The giant buses cannot be bothered with pedestrians as the drivers lean on their horns, going 50 miles per hour, warning the mothers, children, and people on bicycles to move out of the way…...or else. I usually find myself forced to walk in the muddy, cow pie filled ditch.
As I walk, I pass by many people on the road and rarely do I see a fellow Mazungu, (white person), but everyone always says, “Hi, how are you?” or “Omezute?” I am always amazed at how many people have hoes slung over their shoulder, off to go digging somewhere. Yesterday I didn’t feel like walking to town because it was too hot. I asked one of the leering boda bodas if he would give me a ride on his motorcycle. “1000 shillings!” he barked at me. Now I know that it is only 50 cents, but that is the Mazungu price, and normally it costs only 25 cents for the 3 minute ride. He wouldn’t give me a ride, and I wouldn’t budge on the price. As I continued walking I wondered if arguing over 25 cents is really worth it.
The reliable fresh food source any day of the week is from the ladies and children selling avocados and yellow bananas from their hand woven baskets on the side of the road. The school children are always happy when someone is selling the 7 foot tall stalks of sugar cane. It’s cute to watch them skip along in their red and white checkered uniforms sucking on the juicy sweet stalks. Not so cute when they look at me and demand that I give them money. This doesn’t happen all of the time though. I can’t fathom how the men balance a stack of sugar cane lengthwise on the back of their bicycles on the bumpy road.
Other merchants on the side of the road sell used clothes. I’ve learned that these clothes are considered good quality because they are clothes donated from the US or UK. These clothes are apparently of higher quality than the new “made in China” clothes that are sold in the local stores. When I explained that most of our clothes are made in China too, I was told that the cheapest “made in China” clothes get sent to Africa. I guess Chinese clothes sent to Africa fall apart after one washing rather than after three washings in the US. I am curious. How do the DONATED used clothes from the US and UK become goods for sale though?
I love the sign that I always pass while walking. It is a picture of a gorilla that says, “I want to be your new best friend.” It reminds me that somewhere only ½ hour drive away there are fuzzy gorillas chomping on bamboo. Sometimes I meet Morgen at her favorite tea shop for African tea. For 15 cents a piece we sit on a rickety bench and enjoy a steaming mug of sweetened black tea spiced with ginger and cardamom.
One of the first stores I pass when I get to town is the Indian Supermarket. Not really a supermarket as much as a dark and dusty store where I can get my fix of processed foods. The local crackers are usually mushy and stale, but fortunately, or maybe unfortunately they have Pringles. The Indian community in Kisoro is small and they stay to themselves. In Africa, Indians are known as the shrewd and wealthy business people. They have always been very kind and helpful to me. I’d like to think it’s not just because they know I can afford to buy Pringles.
My new shopping addiction is down a muddy side street in town. Rose’s shop sells cheap vinyl handbags, hair products, other random toiletries, and what are considered the highest quality textiles in town. It is a cramped non-descript shop that has colorful fabric stacked high. Rose has a good connection for these sought after wares from the Democratic Republic of Congo. You may wonder what I do with all this fabric. Well you can’t walk far without seeing someone sitting in front of an old fashioned sewing machine, mending clothes or making elaborate African outfits. Laurence, my new tailor is making me a dress for only $10.00. I hope that when I pick up the dress it isn’t in the popular African style, which is floor length with giant puffed sleeves, and a matching head scarf. I don’t think I can pull off that look.
Further down the way is the market which is on Mondays and Thursdays. I love market day. Everyone is dressed up in their finest clothes on a mission to sell and socialize. At the market there is a passion fruit section, a pineapple section, a bean section, a dried fish section, and so on and so forth. I already have my favorite woman that I buy carrots and green peppers from. She always helps scatter the young boys who try and sell me plastic grocery bags for 10 cents. Apparently only city folk and Mazungus eat peppers and carrots. Villagers prefer Irish potatoes, cabbage, and tomatoes. All of the ladies that sell vegetables are super sweet. I can only imagine how far from their village they had to walk, carrying the heavy produce stacked high on their head.
At dusk families begin to gather. The Reggae-like African music gets turned up louder, and the smell of stewed beans, fried matoke, and fresh chapatti wafts about. It never fails that I get caught walking home in the dark. When I say dark I mean you cannot see your hand in front of your face, yet every star in the sky is visible. Reaching my “home away from home,” I rinse my dusty feet and feel content that after only one month I already feel a sense of community here in Kisoro.
Saturday, February 6, 2010
A day in the life of Nurse Julie at a government run hospital in the USA:
I arrive to work and print out a list of the patients I will be caring for. The list will include; diagnosis, allergies, latest recorded vital signs, the medical specialty the patient is under, and space to write my notes for the day. There will be as little as 5 and no more than 10 patients that I am assigned to. On the worst day I will have 10 patients, but I will have someone on my team to assist with giving medications, checking blood sugars, documenting intake and output, and taking vital signs.
After getting a thorough report from the nurse on the previous shift I look up each patient in their electronic medical record to check for new orders. If a patient needs an intravenous (IV) cannula placed, I inform the IV team and expect it will be done within 1 hour or sooner if it is urgent. When I see that a lab needs to be drawn, I print out a request and send it to the lab, and anticipate that the phlebotomist will come to draw blood. I will see the results in the computer within my shift. Chest x-rays are easily obtained with a portable x-ray machine brought to the ward soon after the order is put in. Sometimes a medication is not available, so I phone the pharmacy and they will have it sent up. The amount of time I have to wait for these things when I have an unstable patient can seem like an eternity.
Before I enter a room to check on a patient I look at the flow sheet outside the room to see if the vital signs are stable. Any abnormal vital signs will give me clues on how to assess the patient. I may be exasperated if I see that there are no size small gloves for me to use outside the room, but I will go to the supply room down the hall and grab a box from the huge stack that are available. When I return to do a full head to toe examination, I first clean my stethoscope with an alcohol swab. If a patient has an issue, such as uncontrolled pain, I will page the doctor on-call. The doctor will return my phone call within 10 minutes, and a new order will be activated in the computer within minutes. When I sign out the medication electronically, I can check to see when the medication was last given, the dosage, and how much pain the patient was in at the time. If I need to give insulin for a diabetic, I can check in the computer to see what the latest blood sugar was. Of course, syringes and insulin are always readily available.
Antibiotics are premixed by the pharmacy in bags with carefully cross-checked patient information printed on them. I retrieve IV tubing from a giant bin and set up the antibiotic by programming into the electric infusion pump how many milliliters/hour it should run. I walk away and expect the machine to alarm when it is finished. When I return with a premixed 10ml normal saline syringe, (found by the hundreds in the supply room) I push normal saline into the patient’s vein, so that the IV line will remain patent. At this point I may notice that a patient needs a dressing change. If I go to the supply room and I can’t find what I need, I call the supply department and they bring me anything I request. On any given shift I will use approximately 100 pairs of gloves, 50 alcohol swabs, and 25 normal saline syringes. It is very rare that a medical supply cannot be obtained.
During my shift, I carefully document everything that has been done with the patient including the results of the head to toe assessment and how a patient responded to treatments. Then I pass the information on to the next shift. I am busy during the entire 8.5 hour shift, and barely have time to take a ½ hour break. Of course there are many variations to each day, but most days I can go home knowing I worked hard and my patients were well cared for.
A day in the life of Nurse Julie at a government run hospital in Uganda:
I arrive to the female ward at 8:30 in the morning and put the handwritten patient charts in the order of the bed numbers. The ward has no privacy, with all of the patients in one room together. The night shift nurse, who signs off to me, tells me very basic information about a select few patients such as the new admissions, who is on IV medication, and when their next dose is due. There will be 1 nurse caring for the entire ward, with no assistance. There are usually no less than 24 patients. Fortunately, on the female ward a lot of the patients are stable enough that they don’t need to be closely monitored. The common illnesses that I have seen so far are malaria, typhoid, random parasitic induced infections, ulcers, bowel obstruction of unknown etiology, newly diagnosed HIV/AIDS, tuberculosis, pneumonia, heart failure, uncontrolled diabetes, post-partum depression with psychosis, and osteoarthritis in the elderly.
The tricky part to the beginning of the shift is figuring out which patients need to be closely monitored. It is not protocol for a nurse to take a patient’s vital signs or document their intake and output. Not knowing this information negates important clues as to which patients are the most critical. The best I can do is to go and look at each patient, and try and prioritize/triage that way. First, though I flip through the charts and try to decipher the messy handwritten diagnosis and orders on random pieces of paper in each chart. I admit that I am not very good at it yet, as the types of illnesses and medications are much different than the ones I am used to at home. Not to mention I am accustomed to neatly type-written orders. It is a relief when my interpreter Peninah arrives and she helps me read through charts and then we go and do rounds together.
In Africa, it is customary for a patient to bring an attendant to the hospital with them, and it is usually a family member. The attendant is responsible for feeding, bathing, and laundering the patient’s linens. Washing linens is done by hand out on the hospital lawn. If the patient even has linens it is usually just a wrap they have brought with them, otherwise they are lying on the plastic mattress. The cleaning of each bed after a patient leaves is the responsibility of the attendant and usually does not get done. The patient and attendants are often from far away and therefore the attendant is forced to sleep on the floor under the patient’s bed. When a patient has a baby, (which is often) and the attendant is away, babies are found crawling around the ward. The attendants are a valuable and crucial resource, not only in caring for the patient’s basic needs, but also in providing important patient information to the health care providers.
I am still trying to figure out the best way to conduct my day, but so far I have chosen to attend primarily to the patients whom I think to be the most sick. I start by asking them what their primary complaint is, then ask if and how much they have been eating, drinking, peeing, and pooping, and then I take their vital signs. At home blood pressure, heart rate, and oxygen levels can be determined quickly using a battery powered machine. Here I take blood pressures using a manual blood pressure cuff and stethoscope. Checking their heart rate requires finding the radial pulse and timing it with a watch. At Kisoro Hospital there is only one oxygen tank for the maternity ward, so we do not check oxygen levels. A thermometer is usually hard to find, so I began to bring my own. To obtain a blood glucose level requires going to the male ward and borrowing their machine. These processes can be time consuming, which gives me some indication as to why they are not done routinely by the other nurses.
Sometime during the period where I am assessing the most sick, and passing by the least sick as they look expectantly at me, the 1 doctor on duty may request a lab to be drawn, an IV cannula to be inserted, IV antibiotic or fluids to be started, or an x-ray to be done. This is where it gets interesting. To draw a lab or insert an IV cannula first I have to find gloves. During the 5 days I’ve been on the ward, there was only 1 day where there was one box of gloves on the ward. Fortunately, I brought gloves with me, and I am not sure what I will do when I run out. I also brought alcohol wipes to clean my thermometer, BP cuff, and stethoscope between patients, but that supply is limited as well. Besides the gloves, the most useful thing I brought with me is hand sanitizer. There is only one sink with a bar of soap and often no hand towel. There are certainly no electric paper towel dispensers here.
Drawing blood and inserting IV cannulas is something I know how to do, but have practiced very little. So usually I have another nurse come to assist me. One always hopes when inserting an IV cannula you will be successful on the first try so as not to cause the patient any extra discomfort. Another thing that has to be considered here is that many times there have been no IV cannulas available at the hospital and the patient’s family had to spend what precious little money they have to buy one. It is therefore important to use such medical supplies sparingly and carefully. Once the IV is placed there is usually not enough syringes around to flush the line to maintain the patency, which makes the IV not last as long. The other problem with starting IV fluids and antibiotics is that there are rarely enough “giving sets,” (IV tubing) which forces the attendant to go buy that supply as well. More than once I have seen a patient or attendant unable to afford these supplies and despite the fact that the patient is very sick we are unable to administer the necessary fluids or antibiotics. Sadly, last week a patient on the male ward with cerebral malaria died because the patient’s attendant was unable to return fast enough with a “giving set” to give the antibiotic that would have easily saved his life.
The most common labs that are taken are for malaria, HIV/AIDs, and tuberculosis. The other lab values are either not available, inaccurate, or take such a long time to process, that it is often not worth it. An ethical issue here is that sometimes they draw a lab which is called a “blind serum.” It is an HIV/AIDs test taken without first getting the patient’s consent. Even more odd, is that the patient will often not be informed if the results are positive. This is at the discretion of the local health care providers, due to the fact that the patient may become depressed or they are not ready to hear the results. The point is that the health care provider will better be able to diagnose the patient. Interestingly, the patient cannot be put on an anti-retroviral treatment without first consenting.
Getting an x-ray has been near impossible since I have been here. The two reasons I have heard are the radiologist is not around or they were out of film. The residents are often frustrated that they do not have access to a CT scan which would, in many cases, make diagnosing a patient much more definitive.
When it comes time to pass medications a cart is rolled out to the middle of the ward and each patients name is called out. The attendant comes to pick up the medication to give to the patient unless it is an IV medication. The IV antibiotics are diluted by the nurse and the rate is set manually. There is no electric pump to program the rate. The oral medications have only the name and sometimes the dosage of the medication handwritten on the bottle. This fact and the fact that the medication orders that are handwritten in the chart are often unclear, leaves a lot of room for medication errors. It is common for a medication bottle to be empty and in that case, we document that the medication was not given and write instructions for the attendant to go buy it at an outside pharmacy. In the 3 weeks that I have been here the hospital has been out of insulin, and often they are out of other important medications, such as the diuretic lasix.
As soon as the medications are given it is around 2:30pm and the day shift is essentially over after the nurse jots a few notes in the log book. I’ve learned that only the bare necessities can get done in the allotted 4-6 hour shift, which depends on when a nurse arrives and how long they take for a break. By then I also am mentally drained and ready to go home. In a way the frustration nurses have cross borders. Things such as under-staffing and systemic issues continue to make nursing a profession that has a low retention rate and a high level of burnout. The nursing and medical administration here would like me to implement some new processes. One of the difficulties is that nurses rightfully may not trust me and may be resistant to change. We will see what I can do given the limited amount of time and resources I have.
My main activity this week was taking a two hour hike up Nyagashinge Hill right in front of my house. I went with Morgen and the new resident and my new housemate Baback. It was a short and steep walk up the hill, where we had a sad little boy named Gillard who decided to lead us the entire way, on his own volition, without a request for payment. At the top of the hill we found smoke rising, and discovered a boy, about 5 years old, roasting maize in the ground, and tending goats. As we meandered down the other side of the hill, we heard the loud call of dozens of weaver birds. I found the source of the calls in a tree full of nests dangling like ornaments. This is where we passed through a small village and collected an entourage of children. When we took pictures of them and showed them on our cameras they would scream with glee. One little girl name Rosette took my hand and held it until we reached town.
After our hike we stopped for dinner at the Golden Monkey where Morgen and Jay are well known. We were invited into the kitchen to hang out and watch our meal being prepared as everyone chomped on roasted maize. Tomorrow if it doesn't rain I may go with my new colleagues and attempt to climb the jagged Sabinyo volcano, a rugged 3669 meter hike. Now I’m off to popcorn and beer gathering at Peggy’s house.
Tuesday, February 2, 2010
To ensure mothers bring their babies into the clinic for regular check-ups and vaccinations, Sister Marie thinks that providing incentives for mothers would increase compliance. If the funding were available she would like to provide mosquito nets at birth, cups/bowels for 6 month old babies as a reminder to begin supplementing the baby’s nutrition with solids, and a toy at 9 months old. Although there is a high risk for contracting malaria, many people do not use mosquito nets because they do not think there is a risk or they simply can’t afford them. At 6 months old many babies become malnourished, because mothers are unaware that breast milk is not enough at this age. The toys would be used to evaluate whether a child is reaching their developmental milestones. There are only two toys at the Childhood Wellness Clinic that the nurses use. It is difficult for me to watch as the toys are passed from baby to baby, coming into contact with every draining orifice without being sterilized. The lack of resources forces issues like this to be ignored.
Sister Marie would also like to begin providing care specifically for the elders of the community. It was explained to me that in this community elders often feel that they are a burden because they can no longer work. Sister Marie thinks that if she first organized a time and place for seniors to gather for tea and socialization every month, it would create a great venue for health screenings. Screenings could include blood pressure checks, and assessments of each elder's capacity to perform normal activities of daily living. In addition, she would like to provide safe assistive devices such as canes and walkers that are more stable than the thin bamboo walking sticks that are normally used. As far as I know there are currently no services focusing on the elders in the community. The difficulty here is the lack of availability of health care workers to provide this type of care.
Another public health goal on Sister Maria's agenda includes outreach to the women in the local prison. Next week there is a focus group for the women at the prison. This will be an opportunity to assess the women for abuse and to see whether personal hygiene and other health needs are being met.
Finally, Sister Marie makes monthly visits to various secondary schools in the area giving health education. It is her idea that rather than just talking at the young people she would like to initiate a program where the youth form committees and give health education presentations themselves on topics such as HIV/AIDS, nutrition, malaria, drugs, alcohol, smoking, and any other issues that the youth might find relevant. In this way they are learning from their peers and getting more routine health education. All of Sister Marie’s visions are possible, but difficult to initiate, considering that she is the only public health nurse for the entire district.
I spent Monday with infants and their mothers at the Childhood Wellness Clinic. The clinic was packed. Here babies are weighed to ensure they are meeting their weight for age goals. It is quite a site to see the naked babies hanging from the rafters to be weighed, urinating at any given moment, with no one else noticing but me. Next, they are vaccinated by the very busy nursing assistants, Sarah and Panina, who are identifiable by their purple dresses. Finally, the babies are plopped down on a mat on the floor and are given a mini physical examination by me and Sister Marie. This includes measuring their head circumference to screen for hydrocephalus. Hydrocephalus is a common and often overlooked issue in infants, and if not treated a child will not survive.
The following day we went to a small village known as the Giseke Trading Center. Here we set up shop in a rustic little building with dirt floors, rickety wooden benches, and no running water. The women and babies poured in, and at one point I counted 20 babies waiting to get vaccinated. Interestingly, there was rarely a peep from each child, aside from a small yelp after an injection. All of the infants appeared well-nourished and well-developed. It was amazing to see how committed these very poor village women were at keeping their babies vaccinated. The final day of child wellness outreach involved going to the dusty town center that also serves as a library. I was able to get in on the action and give babies vaccinations and chart their growth pattern since it was only Sister Marie and I at the outreach. It pained me to give injections to the sweet little unsuspecting bundles of love, but of course all for a good cause.
Visiting the antenatal clinic was a particular highlight of the week. Depending on if it is market day, (market day is a very busy day in town) anywhere from 30-80 pregnant women are seen. Sister Jolly, the nurse in charge of expecting mothers, gave me hands on teaching of assessing a mother and her fetus. I learned to tell with my fingers how far along a mother is based on the height of the fundus, (her abdomen). Palpating the abdomen to find the baby's head and butt was fascinating, and listening to the fetal heart beat was done with a rudimentary listening device that worked quite well. After the expectant mother was assessed the mother would pop anti-malarial and de-worming pills. Pregnant mothers definitely have different concerns here in Uganda in comparison to the US, where the only pills women need to take are prenatal vitamins. The average woman we saw that day was in her early 30's getting ready to have her 5th or 6th child. According to Ugandan values I have a lot of catching up to do!
Friday was a big day where we visited a very rural health center to do a cervical cancer screening outreach. Apparently cervical cancer is a leading cause of death for women in Uganda. In the Kisoro District 10% of the women screened are HPV positive and a high risk for cervical cancer, and about 4% have advanced cancer.
It was an amazing turnout of at least 80 women. It was quite moving to witness this large group of Ugandan women lounging on the grass in their colorful wraps, as a nurse mid-wife gave a presentation on women’s health issues, and what to expect during the exam. There were three providers to conduct the pelvic exams which included a full female physical exam. Peggy and I worked together as a team conducting the female examinations. I won’t go into too many details, but I now know what to look for when examining a cervix. I learned a lot from taking health histories, such as a husband refusing to get treated for Syphilis and therefore re-infecting his wife. Also, many women had multiple oddly placed scars on their bodies, which I learned from one woman that it was a treatment for being bewitched. Basically, they make small cuts in the skin and then place herbs in the wound in an effort to heal an affliction. Overall it was a successful and eye-opening screening day.
The more time I spend in Uganda, it is glaringly obvious that I am from a VERY fast paced culture. The team for the cervical cancer outreach left 2.5 hours late due to “transportation issues,” and no one seemed the least bit phased as we sat around and waited. When we arrived to the health center and the waiting women, before we could begin our exams, we had to stop for tea and chapatti. Many women that day waited upwards of 5 hours to have a pelvic exam. I don't know a woman in the US who would do that. I guess we can all learn something from these women. Patience is a virtue I know I need to work on.
My weekend was quite lovely. I visited a popular holiday spot called Lake Bunyoni, which means “place of little birds.” I identified 7 new birds, my favorite being the colorful Malachite Kingfisher. Peggy and I only had to travel two hours north to get to this serene lakeside, which is one of the few safe freshwater places to swim here. The lake has 28 small islands, some with a unique history. After hiking up to watch the sunset over the lake, while enjoying a refreshing beer, I was told the story of Punishment Island.
In the 1930’s it was common to banish young woman who had become pregnant out of wedlock to this tiny island. Men who wanted many wives or men who could not afford the dowry for a wife would go to this island where the girls had no choice but to go with the men. Although there is a woman still alive in the village who was a victim of this mistreatment, it is no longer practiced today. What is still practiced, I have come to find out, is the high bride-price for a wife. I will explain more about this in a future blog entry.
The next entry will be about my first week on the female ward. Thank-you for taking the time to read about my experiences.
Sunday, January 24, 2010
The 3 day training session consisted of approximately 45 experienced VHW’s who have attended 2 years of regular training sessions, (1 day training monthly and 3 day training quarterly) and 25 new VHW’s who have no previous training in health care. Some are professionals, most have completed secondary school, and about 50% only speak the local language of Rufimbira. The experienced VHW’s, were tested for the first half of each day so that the program organizers could assess where the learning gaps are. The new VHW’s attended classes in the morning, some of which I taught. All 65 met back together in the afternoon to learn about physical examination of infants, children, and children with disabilities.
On Wednesday morning I, along with Morgen presented a lesson on Family Planning. The Hesperian books, Where There Is No Doctor and Where Women Have No Doctor, were invaluable resources, when I planned my lessons. I taught a 2 hour class for two groups of about 12 VHW’s, using a translator. It was a challenge to remain culturally sensitive, since I had only arrived in Uganda a few days prior. I figured the best way was to ask them questions about their thoughts on family planning. This is where I learned a lot. First, I learned that the average family in each village has 8-12 children in their family. This provided a great opportunity to find out if the VHW’s thought that this number was too high. They agreed that having too many children can negatively impact mother and child health, if not spaced properly. They also understood that if there were too many children, there often would not be enough food for each child and not enough land for each son. According to the VHW’s the perfect number of children was six. I realized that I might be imposing my western views, if I stated that having more than 4 children increases the mother’s risk of death during childbirth. Here I learned that family planning is defined as, “having the number of children you want, when you want them.”
The second part of the family planning lesson, is where I explained the 6 different family planning methods available for free at Kisoro District Hospital. The VHW’s explained to me that the preferred method was the hormone injection that prevents pregnancy for 3 months. I learned that often husbands don’t want their wives to use family planning and the injection was the most discreet. The concern with the injection was that the shot in the arm may affect a woman’s ability to shovel. Condoms were the most unpopular option in the group, because there were questions about weather or not it would work if used improperly, (for example if the man was drunk) and if used, one partner would think it was being implied that the other had multiple sex partners. The Intra Uterine Device (IUD) was somewhat lost on them, even though we showed them the device, and explained how it works, they were concerned it would harm the man. The biggest concerns overall is that family planning might cause harmful side effects and that a woman may not be able to get pregnant when she wants, once she stopped using the birth control method. Overall, I think the presentation cleared up a lot of myths for some of the VHW’s and helped me understand how to be more culturally sensitive in the future on this subject. After giving a lesson for almost 4 hours straight I have a whole new appreciation for what teachers do!
The next day I gave a presentation on Health History Taking. Here I learned that medical translation from English to Rufimbira can sometimes be confusing. I instructed the VHW’s on the value of developing a positive rapport with each villager, since it requires asking so many personal questions, taking someone’s health history can feel invasive. After explaining what types of questions to ask, it was fun to watch the VHW’s begin to see how all of body systems work together. This initial introduction really helped them in the upcoming classes where they were taught how to do a head to toe examination and take vital signs. When I taught a small group how to measure heart rate, respiratory rate, and take blood pressures, the VHW’s were so interested, and when it really cliqued with them, it was very exciting to see their eyes light up.
The last lesson I taught was, in a way, the most challenging. At this point the VHW’s had learned the developmental milestones of infants and children, they learned about how to do a physical exam on infants and children, and they were able to practice doing an exam on a healthy infant. The final physical exam practicum was on a disabled child. A mother brought her 4 year old child that was developmentally delayed and could not talk. Signa and I, along with about 9 VHW’s examined the child. The mother brought in medical papers that stated he had Downs Syndrome, but Signa and I agreed that he did not have the typical markers of someone with Downs Syndrome. The VHW’s began by taking the baby’s health history from the mother. The mother stated that she was very sick during pregnancy and did not eat much, but did drink a lot of alcohol. She assured us that she no longer drank alcohol This raised a red flag for Signa and I because we immediately thought that the baby may have Fetal Alcohol Syndrome. More questions were asked about her alcohol intake and the mother stated that she began to feel judged. The mother did not seem to make the connection that her drinking may have caused her son’s developmental delay, yet it seemed insensitive to reiterate this to the mother, given that she was already feeling attacked. We made sure to tell her she had been doing a great job with her son, because he was physically very healthy, and although he was unable to talk he was walking, interacting with other children, and had the ability to communicate his needs without words. We explained to the mother that for him, reaching his developmental milestones would take longer. We had a debriefing with the VHW’s, after the examination, and explained that this was the perfect example of building trusting relationships with families. If the villagers distrust or feel condemned by health care workers in any way, it is unlikely that they will seek care in the future.
I have learned so much this week and look forward to next week, when I will follow Sister Maria Kagame, the Public Health Nurse around the community. My third week here I will begin to be oriented to the female ward, where I will work as a nurse. I just wanted to let you know that it has been difficult to remain in regular contact, because the power has been out during the day all week and the internet café is too far to walk to in the dark. Love you and miss you! Please keep in touch.
Saturday, January 23, 2010
My first week in Uganda has not disappointed. I arrived in Entebbe airport, and was picked up by Dr. Michael’s cousin, Nicholas, who drove me to Kampala which is Uganda’s capital, where I would spend one night before traveling to Kisoro. The Namirembi Guest House, where I stayed, was lovely. I watched the sun set over Kampala, got drenched in my first Ugandan downpour, devoured my first taste of barbecue goat, and awoke to the early morning Islamic prayer calls, as I braced myself for the long bus ride to Kisoro.
The road to Kisoro from Kampala is considered one of the best roads in Uganda, yet it took 11 hours to travel 180 km, with only one stop long enough to use the bathroom. The woman I sat next to on the bus, Gertrude, was a Ugandan nursing student, coming to Kisoro for a community health research project on sanitation. She was very sweet and kept trying to feed me roasted maize on a stick. The long bus ride really gave me a sense of how breathtakingly beautiful the very southern Kigezi region is, from the tall, pointy volcanic mountains, and the thick bamboo forests, to the treacherous roads that looked down on bright green terraced hillsides.
When I first arrived in Kisoro on Saturday I was accosted by the boda boda’s, all wanting to give me a ride on their motorcycle to my final destination. Fortunately, a nice man on the bus let me use his cell phone to call Dr. Michael to come pick me up. When I gave him the number he said, “Oh, its Dr. Michael’s number, he is my doctor and is already in my phone. Tell him I said hello!”
Dr. Michael Baganizi, came promptly, and gave me a brief tour of the town Kisoro, before taking me to the compound where I would be staying. The compound is where many local health care workers and volunteers live, and it is a 5 minute walk from Kisoro District Hospital, (KDH) where I have been spending most of my time this week. I have made myself quite at home in the 2 bedroom concrete abode. My bedroom is well equipped with a bed and a mosquito net. The kitchen has a two burner propane stove, and an electric kettle to boil water. The living room consists of the typical couch, chairs and coffee table, but it is also where the refrigerator is. I am happy to report that although there is no hot water for showers, the toilet is a sit down one, which isn’t the norm in Uganda.
Since the time difference is 11 hours ahead, last night was the first night I was able to sleep 8 hours and not start my day at 4 am. Today I woke up at the normal time of 6:15 am, which is exactly when the millions of birds begin to sing me awake. I have already identified several birds. The Gray Crowned Crane and the Hadada are beautiful birds that are unique to this area. For those of you that are into birds you should look up the Marabou, it is a VERY scary looking bird that is as tall as a child. My backyard is a lush and hilly thoroughfare of people traveling up, up, and up the steep trails to their villages, always carrying something VERY heavy on their heads, and often with a baby bump tightly wrapped in colorful cloth on their backs. My favorite is when the goats and cows with GIANT horns mingle right outside my window.
A few characters in my daily life include my neighbor, Phillip, who is a medical student, essentially acting as the pediatrician and maternity ward doctor at the hospital. He is working at KDH on his holiday, and will be leaving in one week. Not only has he shown me around town, but he has given me a great orientation on Ugandan culture and customs. Since men are not taught to cook in Uganda, (apparently women fear men who can cook?) if we are cooking at home, Phillip often will come knocking on our door.
Peggy is a public health nurse and my partner in crime. She is a vivacious nurse practitioner in her 60’s, and is spending one month in Kisoro, volunteering as a public health nurse. Peggy is the director for a nurse run community health clinic in Pennsylvania, which she started from the ground up in the19 80’s, serving mainly the Latino population. I have learned so much from her in just 1 week, she is also a great dinner companion, and surprisingly enjoys cocktail hour here in Kisoro.
Signa, my housemate, is spending her last day of a 4 week stay in Kisoro today. She is a 4th year resident from the Bronx and has been so much fun to cook dinners with, swap crazy stories of our day, and just decompress from the general culture shock of traveling. She has been doing amazing work as the ONLY doctor on the male ward of the hospital. When she leaves, there will be no doctor for a week until the next resident comes from New York. Dr. Michael will be there, but there is only so much one doctor can do for an entire hospital!
I should explain that Doctors for Global Health (DGH) has a working relationship with Montfiore Hospital and Einstein College in New York, which assists Kisoro District Hospital, (KDH) where there is need. Not only do they fundraise for the hospital, but it is arranged that almost every month, 1-2 Residents come to cover a ward at the hospital. Also, a few times a year, a small group of medical students fill in where they can. Their professor on these trips is the famous Dr. Paccione, who has been coming to Kisoro for several years now. He and his students assess the needs of the community, gather data, and implement and evaluate programs, not only in the hospital, but out in the villages as well. Programs such as cervical cancer screenings and evaluation of services for children with disabilities have been implemented by the medical students.
In addition, the most successful community health program they have been working on is the Village Health Worker (VHW) program. The VHW program is run by Jason and Morgen, the amazing duo, who are in their 4th month of a 10 month stay in Kisoro. They have been an invaluable resource in adjusting to life in Kisoro. I am now a proud owner of a Ugandan cell phone, which is a must have in this community. Every store in town you can buy airtime, (minutes) for your phone, which go quickly. After the first week I already have 10 contacts programmed into my phone! Morgan and Jason also took me to my first market day, and pointed me to the local fast food restaurant or “bean place.” Yesterday was my first time there, and I was the only non-African in the joint. The bean place is convenient, because anywhere else you go to eat takes a minimum of one hour for your food to arrive. The typical fare is beans and a choice of starch, which I am still learning about. My meal yesterday cost just a little over 50 cents or 700 shillings, and it was quite filling.
The dozens of Ugandans I have been introduced have all be VERY gracious, and always tell me that I am welcome here. Everywhere I go there are shouts of jubilant children yelling out, “mazungu! mazungu! (white person)” or “hello! how are you?!” These greetings are nothing short of adorable.
That is all I have for now. I will post pictures when I can figure out how to download them without it taking all day. Read the next posting for what I did as a volunteer in the community last week. Please keep in touch everyone. Little stories of your daily life REALLY help stave off homesickness!
Tuesday, January 12, 2010
DGH Mission Statement
To improve health and foster other human rights with those most in need by accompanying communities while educating and inspiring others to action.