Two Patient Stories

Organophosphates are compounds originally synthesized as pesticides, and later used as nerve gasses and biological weapons.  Several of these compounds have been outlawed in the United States due to their extreme toxicity, but here in Uganda and in many third world countries they are still used.  They are used mostly for farming and killing pests, but too often they are also used as an agent with which to commit suicide.

In humans, OPs inhibit acetylcholinesterase, increasing the levels of this chemical in the body.  This sends messages to certain cells in the body to form a “cholinergic” response, which is the opposite of the “fight or flight” response.  Pupils constrict and it’s hard to see, eyes water, noses run, saliva streams from the mouth.  You get very sweaty and your lungs fill with fluid.  Basically your body will drown in its own secretions.   It can be accidentally inhaled or absorbed through the skin – and in the rare cases we see toxicity from this at home it’s in these settings usually in rural farm towns.  Since I’ve been here in Mbarara I’ve seen at least 5-6 cases of men turning up bottles of the stuff.

This weekend on “attending-less” rounds I was seeing some patients in the male ward when I happened upon a gentleman who was unresponsive and whose clothes were soaking wet.  At first I thought his IV pole had leaked on him, but it turns out it was just sweat.  Before looking in the chart I saw his pupils were pinpoint and I knew what he had done.  Interestingly in America where we hardly ever see OP poisoning, we have very strict guidelines on how to deal with it.  You intubate and ventilate a patient, and keep them on a lot of the antidote called Atropine.  It is pretty much against medical law to “pump the stomach” because this increases the risk that the chemicals might come up and go into the lung.  You just support them through the effects of the drug.  Again as I’ve said, ventilators are a luxury here, and since OPs can stay in the system for days, you have to do what you have to do.  So every patient here gets their stomach pumped and gets activated charcoal.  For whatever reason this gentleman didn’t get pumped/charcoaled properly before getting shipped from the emergency ward to the regular medicine wards.  He had originally gotten better when he came in, but also as I’ve mentioned there are such few staff here that no one had checked on him until I came around and found him covered in sweat (interestingly that doing exactly the opposite of what we advise in America would have been the most beneficial thing for the patient here…). 

I rubbed on his sternum and shook him unfortunately with no response.  He had snot coming from his nose and the few breaths he was taking each minute were labored and fluid-filled.  He hadn’t gotten Atropine (which you can give every 5 minutes) in about 12 hours.  I ran over to the emergency department, grabbed a box of Atropine vials, and ran back to the ward.  After donning some gloves I started breaking open the vials and injecting them in his IV, meanwhile finding the transporter to take him back to the emergency ward where he could get more monitoring.  Unfortunately right as he got over there, he died.

In light of all the residents’ stories I’ve shared, I have a couple of thoughts on this.  On one hand, it’s hard for me to imagine surviving Idi Amin’s rule and Joseph Kony’s terror, just to go on and try to kill myself with poison.  On the other hand, perhaps after seeing all those things it’s just too hard to go on.  Interestingly it’s only men I’ve seen taking these OPs – and it usually seems to be after something somewhat insignificant – like having an argument with their wife or having a bad day at work.

With cases like that sometimes it’s hard to feel like you make a difference.  There were so many muzungus here at first I couldn’t participate in patient care as much as I’d like, but then ultimately I don’t have a license here and don’t speak one of the 52 languages of the locals.  There’re so many patients dying that even the residents can’t help a lot of them.  It’s frustrating.

But the other weekend I was rounding with on attending-less rounds.  We were seeing patients in the female ward this time and there was a girl (I say girl because she was younger than me) who was having a hard time.  She had just been diagnosed HIV+ at admission (called NYY here to reduce the stigma) when she came in with cough, fever, and shortness of breath.  We had no idea what her CD4 count was, which is what you measure to see how suppressed the immune system is in HIV.  She had been started on medications for pneumonia, but was too poor to afford a blood count or a chest X-ray.  She had been in the hospital 3 days by the time I saw her with Sam.  She was sitting straight up on her mat (on the floor as there wasn’t an available bed), bug-eyed, breathing around 60 times per minute (you should give it a try to see how fast that really is), and looked like crap.  She was scared and I was scared for her because she was going downhill fast.  We checked her oxygen level and it was so low that it didn’t register on the machine.  We moved her to the emergency room so she could get some oxygen if it was available, and I told Sam maybe we should treat her for this disease called PCP Pneumonia.  People with HIV (or immunosuppression) get this, but we couldn’t actually do a test to see if she had it for sure.  So we blindly started the medicine and hoped for the best.

Every day after that she still looked the same.  I rounded on her about 4 days after the new antibiotic, but then realized that because of lack of staff and lack of knowledge on the family’s behalf, the patient actually HADN’T EVER received the antibiotic!  I tried to keep myself from having a hissy fit, and eventually got the medication to the patient.  The next day, she was sitting up in bed eating some lunch, and only breathing 40 times per minute.  She still looked bad, but over the next few days her vital signs got better, and about a week ago she packed up her bed sheets and walked out of this hospital back to her family.

A rambling blog about a lot of things

Allison (another girl I’m living with) and I had heard there was a young man in an alley behind the post office down town who roasts local g-nuts and makes peanut butter.  Obviously we went on a quest to find him.  We meandered downtown a while, dodging the boda-boda drivers on their motorcycles, and greeting calls of “hey muzungu”.  We finally happened upon the post office but couldn’t figure out how to actually get behind it as it was connected to other buildings and had a fence around back.  As we walked around and paid close attention, we started noticing light shining through some very thin alleys cut into the building.  We took the first one, hoping to see this man around the corner; instead we found a garbage dump and some people wondering what muzungus were doing in it.  We came back out and took the next alley: a hairdresser and a place selling fresh yogurt.  But there was another alley behind there!  We turned left around a corrugated metal fence and then … we smelled it!  Roasted nuts wafted on the air along with the sound of a very loud grinder.  You can only understand my excitement if you understand my love of peanut butter.  There sitting alone in the alley were two guys with a giant pot, grinding up nuts.  A blanket of drying nuts sat out in the sunshine across the street.  It smelled like I had stuck my face into a jar of Jif – except much better because this was about as “organic” and fresh as you could get!  We talked to the guys for a little while (I showed one a picture of snow on my iPhone which he thought was the wildest thing in the world), and we each bought two jars of peanut butter.  I just hope they don’t explode in my suitcase on the way home.

After that we headed home to rest in the shade for a while before throwing a “dinner party” for the residents here.  You know I love a good dinner party, but my skills have been limited as we have a tiny stove that sits on an uneven surface, an oven that only goes to a bit over 200 degrees, and water that sometimes doesn’t work or comes out brown.  So instead of my usual dinner party, we opted for pizzas.  Conveniently I have a phone that has been passed on by past UVA residents, and in it was a contact for “Pizza Garage”.  We called and ordered 5 pizzas for delivery.  They showed up 30 minutes late (as did the residents … Ugandan time we call it) and called to let me know to meet them at the gate.  I expected a car with a “pizza garage” sign on the side, but instead I just saw darkness.  All of a sudden from behind a bush I heard “is it you??” and on closer inspection there was a man on a boda boda with 5 pizzas in his lap.  The driver thought my name was Brad (the owner of the cell phone I used), and was wearing a leather jacket with a Hello Kitty winter hat on.  I wanted to ask if he knew it was 80 degrees outside, but I refrained.  Normally in America someone talking to me from behind a bush would be terrifying, but this is Uganda, and we were really hungry for pizza.

The residents came and we all enjoyed the pizzas (they were actually quite delicious) along with some Fanta.  The conversations, of course, are always the best part.  We discussed medical things of course, as well as our favorite places in Uganda.  Surprisingly toward the end of the night the conversation turned again as it did with Charles to Joseph Kony and the Lord’s Resistance Army.  I knew Charles’ story, but it turns out that all the other residents had similar stories.  None of them were captured by the army, but one had a grandmother killed in her home.  Another had seen babies strangled by their mothers to keep them from crying so the family hiding in the grass wouldn’t be captured and killed by the rebels.  Others walked over sleeping bodies while trying to care for patients in a hospital because everyone in the villages slept at the hospital to keep safe.  The stories went on and on, and then turned to current politics in Uganda and their hope (or lack of hope) for the future.  I can’t really write well enough to pass on the gravity of those conversations and how they make me feel.  I remember in college when I first heard about Kony and the LRA … I participated a program called Invisible Children where we watched a movie about child soldiers and slept outside for a night.  I remember feeling like I was saving the world by “raising awareness” for these poor Ugandans that no one else seemed to be thinking about.  But hearing these new friends’ perspectives … they hate Invisible Children.  They say it showed about 10% of what things were like here, but that no one wanted to see the real things going on … all the killings and that of course Kony was evil – but the government soldiers who were supposed to protect them were also raping women and killing entire families.

One of the more frightening things is that one resident, Sam, said a few years ago he was home with his mother and suddenly dozens of soldiers came to their house, started digging in their back yard, and uncovered hundreds of machine guns and grenades.  Apparently in villages all over this country the LRA has stockpiles of weapons buried, waiting for someone to come use them.  Fortunately the LRA is much less apparent these days, but Kony is still around, reportedly hiding out in the DR Congo.  Reportedly he’s in bad health, but no one knows if and when he or his soldiers might make a resurgence.

I had a tough time sleeping last night after thinking of all those things, and wondering how Ugandans can be the most welcoming people I’ve ever met (they greet you with “you are most welcome” for goodness’ sake) yet most all I meet on the streets and work with have lived through these terrible things.  I can’t imagine having a normal life after that, much less being an upbeat person. 

Then I went to church today with that same resident who had the guns in his yard, Sam.  The church was set back in a slum of Mbarara, and had probably 200 people at the service.  Everyone had on their finest, which ranged from bright green silk sport coats to dirt-stained sweaters, and everyone seemed happy to see a muzungu at their church.  The singing went on for an hour and a half – and I didn’t catch a single person glancing at their watch.  There was singing, shouting, swaying, some dancing, and even a lady blowing a whistle and waving a flag – all for the glory and praise of God.  The pastor talked of not having a spirit off fear, but one of faith.  About truly understanding salvation and how after that you can never fear or feel poor again.  I looked around at all the Bibles, much more tattered and marked with pen than my own, and as the church sang “I live to worship you”, I felt somewhat ashamed of myself for all the advantages I have and the lack of faith I have in even the little things.

Isaiah 35

The desert and the parched land will be glad;
    the wilderness will rejoice and blossom.
Like the crocus, ² it will burst into bloom;
    it will rejoice greatly and shout for joy.
The glory of Lebanon will be given to it,
    the splendor of Carmel and Sharon;
they will see the glory of the Lord,
    the splendor of our God.

³ Strengthen the feeble hands,
    steady the knees that give way;
⁴ say to those with fearful hearts,
    “Be strong, do not fear;
your God will come,
    he will come with vengeance;
with divine retribution
    he will come to save you.”

⁵ Then will the eyes of the blind be opened
    and the ears of the deaf unstopped.
⁶ Then will the lame leap like a deer,
    and the mute tongue shout for joy.
Water will gush forth in the wilderness
    and streams in the desert.
⁷ The burning sand will become a pool,
    the thirsty ground bubbling springs.
In the haunts where jackals once lay,
    grass and reeds and papyrus will grow.

⁸ And a highway will be there;
    it will be called the Way of Holiness;
    it will be for those who walk on that Way.
The unclean will not journey on it;
    wicked fools will not go about on it.
⁹ No lion will be there,
    nor any ravenous beast;
    they will not be found there.
But only the redeemed will walk there,
¹⁰     and those the Lord has rescued will return.
They will enter Zion with singing;
    everlasting joy will crown their heads.
Gladness and joy will overtake them,
    and sorrow and sighing will flee away.

STD's!

Today Anem and I taught class at the local university.  We were invited (somewhat serendipitously) to teach this class to a young group of students majoring in Women’s Health and Gender Studies.  Once they knew there were going to be some American doctors visiting, they specifically requested we teach them about our health system as well as STDs.   I was a little nervous for two reasons.  First, the class was scheduled for two hours and it’s been a while since I’ve stood up in front of 40 people to teach something.  Second, I had a little taste of “Montezuma’s Revenge” this morning, and I didn’t want to have to run out of class suddenly for that.  Anem and I had planned for several hours for this class – her part on the American Healthcare System, and my part on STD’s.  Taking some Imodium and antibiotics, along with knowing we’d planned a lot in advance, settled my nerves and stomach for the session.

The class was made of all girls and 2 boys, and was held in an airy classroom with hard wooden desks and a chalkboard that would barely write.  By airy classroom I mean that all the windows were open and the door wouldn’t shut, so we heard cars, people walking outside, and noise from all the changing classes and people visiting outside our room. 

We introduced ourselves and then Anem started the talk.  We basically asked them what they knew about the American healthcare system, and we filled in the blanks from there.  It was really amazing how little they knew about our (complicated) system, but how they were able to predict its problems once we laid it out for them.  They had a lot of interesting and insightful questions like “what happens to healthcare when people get old and sick”, or “what happens to your insurance if you lose your job”, and “why don’t rich people want to pay for healthcare for poor people”?  Hopefully I would have made Stuart proud for the answer I gave to that last one!

Then my topic came.  I was a little nervous talking to a new group in a relatively new culture about a pretty taboo topic.  In a lot of cultures it’s probably not great for a woman to stand in front of class and use words like “penis” and “discharge”, but it’s also important to be blunt with those topics so as not to risk giving misinformation (or not enough information).  I had a lengthy discussion planned, but fortunately/unfortunately because of all their questions we couldn’t make it all the way through!  We did talk about the individual and societal impacts of STDs and how these are disproportionate towards women, and then went through all the STD’s in a bit of detail in terms of how you contract them and the symptoms they give.  I learned a few things, like apparently in some areas in Uganda you automatically get treated for Syphilis before you get married because there’s such a high incidence of it.  Also a lot of people think that women are “bewitched” if they can’t conceive.  Hopefully I corrected that assumption somewhat as I told them that actually untreated Chlamydia is the #1 worldwide cause for infertility.  Before we could get to a rousing and controversial discussion on prevention of STDs, we ran out of time!  It was really quite flattering that everyone seemed disappointed, and actually probably half of the class stayed late for more discussion.  We just had a question and answer session for an additional hour.

One of the more interesting things that came out of that was a discussion on homosexuality.  You may know that President Musevini here has recently signed a bill that effectively outlaws homosexuality, and can actually put someone in prison for being gay.  In my conversations with a few people here, it seems that most Ugandans think homosexuality is immoral, but overall feel this bill was a ploy used for re-election purposes.  Interestingly homosexually has technically been “banned” here since Uganda was a British colony in the 19^th century, so this bill really isn’t anything new.  Regardless I was quite shocked to be asked “if a homosexual man contracted HIV, would you still treat him” and “what would you do if you found out your family member was gay”?  Definitely off topic, but still good questions to talk about and hopefully we educated these young co-eds a little along the way!

A Hospital Story

I walked into rounds and there was a crowd of medical students around one of my patients.  Never a good sign.  She’s a 40 year old lady with 6 children at home, and she has terrible heart failure.  We’re unsure of the etiology, but interestingly there are a lot of young people here in Uganda that have heart failure – a specific kind called dilated cardiomyopathy.

Anyway, the day before she didn’t look very well.  Her arms and legs were cool to the touch (meaning her heart wasn’t beating well enough to send blood down there) and she was standing up and leaning on the bed to try and support her breaths.  Anyone in America like that would go to the ICU and be on really aggressive medications, but not the case for her.  It was more like the opposite.  She was supposed to get several doses of Lasix (a diuretic) daily, but since there are so few nurses for so many patients she had missed the last three doses.  Consequently she hadn’t urinated, and so fluid was consistently building up and making it harder on her heart to pump.

The reason she attracted all the med students was that she blacked out on her way to the bathroom a few hours before our arrival to the wards.  She didn’t have an attendant to help her, so another patients’ attendant helped her back to the bed.  No doctor or nurse was called.  The patient became progressively confused, and started screaming nonsense words across the ward by the time we arrived, likely due to the fact that her brain wasn’t getting oxygen.  This time her arms and legs were ice cold, she was breathing about 50 times per minute in between her groans, and I could barely feel a pulse.  She had no blood pressure that was measurable.  Her abdomen was distended with fluid so that she looked pregnant, and her legs were so swollen she could barely move them. 

There was some report in the record that she had an echocardiogram a few months prior (not repeated this admission for lack of money), and someone thought she might have had some fluid around her heart.  If there’s a lot of fluid around the heart, the heart can’t pump against it and that can cause severe heart failure like this lady had.  I grabbed one of the Ugandan residents and we rushed to the locked cabinet where the handheld ultrasound was.  Luckily it was charged, and I brought it over to her (while all the other patients were watching) and found her heart with the ultrasound probe.  Unfortunately there was no fluid (otherwise we were planning to stick a needle in her chest and drain it off to help her), and her heart was barely squeezing.

We realized then there was really nothing we could do for this dying woman.  Ideally she’d be on a constant infusion of medicine to help her heart pump and support her blood pressure, and also probably a constant infusion of medicine to pull fluid off of her.  She’d be in the ICU with big IVs and machines constantly monitoring her and probably be on a ventilator.  But here, we only had 1 vial of the medication to help her heart and blood pressure – we had to mix it ourselves to make a constant infusion that unfortunately only lasted about 30 minutes.  Then the fluid medicine we just gave as we thought appropriate and tried to not drop her blood pressure further and kill her.  At one point I asked the resident, “Should I do CPR if she dies”?  The answer was “no”.  In America I probably could be fired for telling someone to not do CPR.  But doing CPR implies that if (IF) you get the patient back, you then must support them on a ventilator, with constant aggressive medications, and in an ICU.  Then perhaps in this patient’s case you could keep her stable until she could have a device implanted in her heart to help it pump.  But those things won’t happen here.  The patient has to pay for her own medication which is on short supply already, there are only a few ventilators in the hospital and they are rationed, and even if we got her back – what would we do then?  She’d be right back in the same situation in a day or so.

Of course there are a lot of questions that go along with this.  Why can’t we get better local government or international funding in our resource limited settings like Uganda to help poor patients like this one (which is a particularly interesting question in Uganda where currently the Ugandan government is spending money trying to outlaw homosexuality)?  In a place when you don’t have much to offer, how do you decide who gets scarce resources and who doesn’t?  More controversially does this change my opinion about what we offer our patients with end stage chronic diseases in the US – when an insane percentage of our health care dollars are spent within the last 6 months of life?

There definitely aren’t easy answers to those questions, and there’s not an easy answer for this woman – and most of the other women lying around her in the ward here and in hospitals in resource-limited settings across the globe.

You never know what you might encounter while traveling.  Yesterday at “tea and chapati rounds” after post-take, I decided to order this dish I had tried previously called katogo (cat-oh-go).  Last time I had it it was a delicious mixture of plaintains, potatoes, tomatoes, peas and some sort of broth.  Yes for breakfast – it was phenomenal.  Anyway after I ordered it one of the residents informed me that “katogo” means “mixture”, and it can be different every time you have it depending on what’s available.  Well the plaintains potatoes and tomatoes were the same, but this time there was a strange meat in the mixture – TRIPE.  I ate about a third of the tripe and most of the plantains.  That was definitely a new dish for me.  It wasn’t as rubbery as I had imagined, but had a strange musty flavor, and the feeling of intestinal villi across your tongue isn’t very appetizing.

Then last night we went with some girls here from Harvard to a local aerobics class.  It’s in a dimly lit room that is actually a club at night, which is in a back ally somewhere in downtown Mbarara.  Of course there’s no air conditioner and no fans, and you run around and wallow around on a dirty floor.  There’s also a sauna next door so when you walk in there are random men with towels around their waists.  The class was a solid hour of consistent movement – it’s definitely the most I’ve sweat in a while and I’m definitely super sore today!  The class was about 1/3 muzungus and the rest Ugandans … and I may or may not have worked out in the “chubby lady” section of the class so as not to embarrass myself.  However, my nervousness/embarrassment disappeared whenever “Call Me Maybe” by the DJ in the corner started off the dance party.  When we came out of class the downtown area had totally transformed – ladies with leftover vegetables from the market were selling them on the street, and there were dozens of vendors that materialized out of nowhere making grilled goat on a stick, chapatis, fried eggs, etc.  I was tempted to eat some, but after the tripe that morning I didn’t want to tempt fate.

Then today after work we went downtown.  First we went to a UN (I think) sponsored place that helps a local village by selling their handmade jewelry.  I didn’t need to, but I bought a necklace or two that I was really excited about.  Then while walking downtown we happened upon a back alley FULL of tailors with sewing machines – it was quite odd.  They could custom make just about anything you wanted for a pretty fair price.  Then finally we went to the market for some fresh veggies.  I perused a while and then got okra, tomatoes, green beans, of course some passion fruit, avocado, an “African tomato” which I have no idea what I should do with, and finally Jack fruit.  When I went to India a few years ago, one of the girls there from California told me I needed to try it.  Turns out Cali is one of the few places it grows, so I’ve never been able to try.  But lo and behold I found one today!  I had the seller cut me a giant slice – which in hindsight wasn’t a great idea considering it’s the size of a small melon and I had to carry it home – and then enjoyed it when we got back.  It’s a super weird fruit – spiky and green on the outside, and full of large seeds with some inedible and some edible fruit on the inside.  The edible part is amazing, but then there’s also this slimy goo that literally turns to glue on your lips and hands after you eat it.  I need to figure out a better way to tackle it tomorrow.  Then I cooked a rather humble market-fresh dinner, and ate it while preparing a lecture!  Thursday Anem and I have been invited to give a lecture to one of the local college classes.  The students are working on a degree in women’s health, and have a few things they want to hear from some American doctors about.  One is how the American healthcare system works (or doesn’t work), which Anem will talk about.  The other is STDs, presented by yours truly.  So I enjoyed my meal over some engrossing reading on Gonorrhea, etc and social implications of STD’s. Should be a fun talk  =)

The sharp demarcation from our road to where downtown begins

My market buys!

My humble, but quite delicious, market dinner (please ignore that my beans from last week sprouted)

QENP, day 3

The last morning we woke up early again for breakfast around dawn, unfortunately checked out of our amazing hotel, and headed to Kalinzu Forest for Chimpanzee tracking.   I had more awesome coffee at breakfast, and then had to use another not-so-awesome pit latrine at the entrance to the park.  The coffee was worth it.

It was an overcast day, and there was a thick mist settled into the valleys between the mountains.  A fine drizzle was falling, making everything smell fresh.  It was nice and cool and there was some soft thunder in the distance.  Our guide walked out – her name was Rachel and she was about our age – the difference was she was dressed in much better climbing gear and had a machete.  She gave us some rubber boots to put on, and then we marched out toward the jungle.

As soon as we entered, the canopy was so thick that it immediately got darker.  The leaves were all dripping from the early morning rain, and you could hear at least 5 different birds calling at the same time.  Unfortunately as I had a huge smile on my face from taking this all in I wasn’t looking where I was going and slipped down a muddy hill, landing in an almost-perfect splits position.  Turns out the rest of the hike was like that – up and down dirt-turned-mud hills with a layer of wet partially decaying vegetation on top.  Combine that with the thin-soled rubber boots I had on that let you feel every tree root you stepped on – it was quite an adventure!  Then about 10 minutes in to our 3.5 hour hike it started pouring rain!  I quickly discovered my rain coat is no longer rain-proof, but still had the hike of my life!  It was really something like out of Jurassic Park or Tarzan.  There were so many plants I had never seen before … and then … a chimpanzee comes in to view!  We only saw one of them, Sosee, jumping in the canopy from limb to limb.  He eventually climbed down the tree toward us, and then actually broke a branch and fell to the forest floor!  We quickly (or not so quickly) hacked down plants and bushes to walk over to where we thought he’d be – but we lost him.  We “tracked” him while in the trees for a good thirty minutes or so, so that was fun.  But overall I think the best part of the trip was just hiking through the jungle in a thunderstorm!  I couldn't take too many pictures because of the rain, and mostly wound up taking pictures of pretty plants.  Hope you enjoy anyway!

Mist over the valley we hiked in.  Please ignore the power lines.

Can you find the trail we just hiked through?

Chimp!

Our guide, Rachel, leading the way through some pretty high water

Cant remember the name of this fruit, but monkeys like it!

exiting the hike onto a tea plantation

Big Safari - part 2

After our evening game drive I took a hot shower (while standing!  Yes!!) and went to bed.  We started the next morning with an early breakfast overlooking dawn in the Great Rift Valley.  I had a feast fit for a king with porridge, a poached egg with toast to sop it up, and a platter of fresh fruit.  The cherry on top, though, was the thermos of piping hot black coffee I requested the night before.  I can’t remember if I’ve talked about this yet, but Ugandans seem to not like bitter things.  Ugandan coffee is about 1/5 a cup of coffee mixed with 4/5 cup of hot milk, with at least two teaspoons of sugar.  Tea is done the same way.  I’ve tried multiple times to like them but can’t convince myself … kind of like goat meat.

Anyway, after breakfast our driver Charles took us out to the park for 4 hours of “game hunting”.  I had my head hanging out the roof most of the time and consequently got a bit of a tan, which is exciting after the Virginia winter.  We spotted kobs, bush bucks, buffalo, elephants, and finally a LION!  As we pulled up we noticed the kobs (lion food) seemed a bit skiddish.  We slowly drove around looking for predators, and Charles with his keen eyes spotted a male lion sleeping in a cactus tree!  We offroaded a bit and pulled up within 20 feet of the lion in the tree!!!  It was sleeping soundly (somehow) curled up in the branches of a cactus.  It never woke up the whole time we were there, but did super cute things like scratch its nose and rub its face against a branch.  I really wanted to pet it, but withheld.

After watching the lion for a while, all that coffee set in.  Unfortunately we were in the middle of nowhere and there could be a lion behind every bush!   Fortuitously we “happened upon” a little shack in the middle of the park that (1) just so happened to have a bathroom and (2) just so happened to have a lot of souvenirs.  I’m sure the driver found it on purpose, but regardless we really had to go.  And when you really have to go, you use whatever bathroom is around – even a pit latrine.  I had visions of past bad memories of a trip to Gatlinburg with my family when I tried to use a port-a-pot and wasps flew out of the seat.  A similar thing happened here, but I latched the door shut and just went with it.  Everything turned out ok!  Then we were super grateful to the ladies who owned the place and had to buy an item or two from them (Reid and VK – you have a present coming)!

After the latrine and some more game watching, it was time for lunch.  We drove quite a way across the park to Lake Edward, and enjoyed a very fancy lunch at a very fancy lodge that we very much could not afford to stay at.  It was full of muzungus (while I’m proud to say our lodge had some Ugandans staying there) and had many leather bound books and smelled of rich mahogany.  I had an awesome tilapia (whole, with eyes and everything) and we cooled off a while before heading down to the lake for a boat tour.  The tour was led by a guy named Daniel who was encyclopedic in his knowledge of the mammals and birds lining the shore.  Afterward we headed back to the lodge and watched the sunset over the valley before enjoying our dinner with Charles.

Sunset off our porch overlooking the Rift Valley

A "stubborn elephant" in the words of our guide Charles.  He kept crossing the road back and forth and wouldn't let us pass!

Baboon and baby

LION!!!!!!!!!

My whole tilapia is under all those tomatoes

Hippo yawn

BIG safari - part 1

There’s really no better way to appreciate God’s majesty than riding with your head and shoulders stuck out of the open roof of a Land Cruiser while driving through the Great Rift Valley in Uganda.  Unless of course you’re also spotting lions in trees and elephants in the road.

This weekend Anem and I traveled to Queen Elizabeth National Park.  It’s the second largest park in Uganda and you can find 4 of the “Big 5” of Africa – elephants, leopards, lions, and buffaloes.  Rhinos are the 5^th but are only found in the north part of the country.  Anem and I took a guided safari tour through a couple of “game drives”; you could discern that on those you just drive around looking for game.  Then there was a boat tour of Lake Edward where you could see the same animals but from the prospective of the water.  And then, finally a chimpanzee track, where you climb around through the jungle and find families of chimpanzees.  We had perfect weather for all of it: sunny and hot for the safaris, and while we were hiking through the jungle it was a little rainy with some thunder in the background – like Jurassic Park or something!  We also had a great tour guide named Charles, who, after 3 days and all our meals spent with him we’re all pretty good friends now!  He was a great guide and really taught us a lot about the park, the animals, and the culture.

I filled up my memory card about 6 times (note to self … buy a 16G memory card), got a sweet farmers’ tan, and saw God’s miracle of creation about as close as you can get.  I found myself saying numerous prayers that sounded like a Sunday School kid, like “thank you God for that weird cactus tree and for creating a leopard that sleeps in it.”  Stuff like that.  We stayed in a “mid-range hotel”, which was pretty affordable and probably one of the nicest places I’ve ever stayed on vacation.  Honestly the money we spent on accommodations were worth it just for the shower!  The shower in our house in Mbarara is a bathtub with a little handheld sprayer that doesn’t quite get the job done when you have sequential layers of sweat, bug spray, dirt, and more sweat.  This shower washed all that off and got me ready for another week and a half!

Here’s some pictures of the first day's game drive.  More to come later:

Tea plantation on the way to Queen Elizabeth NP

View from our "budget hotel", overlooking the Great Rift Valley floor

Pool at the hotel ... too bad I didn't bring a swimsuit

Kobs - the deer of Africa (female and baby)

Look hard and see some spots?  That's a leopard!

Over 600 species of birds are in the park

Charles'story

Sometimes I get pensive and sit and reflect on my life.  I wonder things like “what if I had stayed a psychology major”, or “what if I had gone to a different medical school, would I have ever met Stuart?”  There are so many decisions we make – big and small - that along with Gods sovereign plan influence the direction our lives take. 

Tonight I went to dinner with some muzungus as well as several of the residents here.  One of the residents, Charles, is from the north of Uganda – the part which shares a border with Sudan.  I haven’t had many conversations with Charles yet, but one of our other dinner partners had, and towards the end of dinner they asked him to share “his story” with us.  He laughed and gave a big smile, so I figured he had something humorous to tell us – like how he fell off a bodaboda once, or got chased by a hippo.  Somehow he kept on smiling and told us this story:

Charles lived in northern Uganda during the time that the Lord’s Resistance Army (LRA) was terrorizing thousands of citizens during their attempt to overthrow the Ugandan government, and unfortunately the government soldiers fighting against them weren’t much better.  They are most infamous for abducting children and forcing them to become soldiers to kill other villagers, as well as rape, looting, etc.

Charles lived in a village that hardly anyone was brave enough to venture outside of for fear of being killed or (probably worse) captured by the rebels.  Sometimes they would walk to school, hear gunshots, and turn around and run back to safety.  But the village wasn’t always safe.  Charles liked to hang out with boys his age, just as any child would.  Sometime around the age of 7, he was spending the night in an empty building with about 10 friends his age.  He and his friends always slept with large knives just in case the rebels tried to capture them.  In the middle of the night they heard noises, and eventually there was someone banging on the door telling them to come outside.  They knew they were in trouble.  Two boys were so scared they ran outside naked, and the rebels laughed at them telling them to put on clothes and come back – that they would wait for them.  Charles saw the two boys get tied together with ropes and they disappeared.  Another boy jumped up with his knife and shouted at the rebels to go away.  He was immediately severely beaten with a club, and taken away.  Charles was left alone.  The rebels came in to get him.  He told them he didn’t want to go with them, but they told him if he did he could see his friends and family again.  He knew he didn’t really have a choice.  Instead of tying him together with all the other prisoners (which turned out to be many people from his village), they made him a personal servant to one of the rebels.  He was made to carry very heavy cargo as the rebels marched themselves and their prisoners north to Sudan.  They walked miles and miles through the night, to the point where Charles’ feet were swollen and wounded.  The packs he carried were so heavy that he once had to stop – and immediately his life was threatened. 

As they marched to Sudan the rebels told the newly captured boys that if they fought with the LRA they would have special powers.  They were told that bullets could not kill them, their enemies could not see them, and if they threw rocks at the enemy – they would turn to bombs (from what I’ve read – this along with hallucinogenic drugs and fear are how they convinced these children to become soldiers).  All along the way Charles saw fellow villagers being killed or beaten by the rebels.  Some had their lips cut off, or their limbs and were left to die.

At one point in the walk gunshots were heard ahead.  The rebels made everyone lie down in the bush beside the road.  While the rebels were distracted, the prisoners, including Charles, figured this might be their only time to escape.  He had found his father in the group, and during a moment of gunfire ahead they jumped up and ran left of the road, toward a river.  Some other prisoners ran right, some were too scared to run at all.  The ones who went to the right got re-captured by the rebels, but Charles and his dad ran freely until they came to the river.  Charles could swim but his father could not.  They both jumped in, and Charles had to save his father from drowning in the river before reaching pseudo-safety on the other side.  Without food, water, or money, they spent the night hiding under bushes from the rebels who were looking for their lost prisoners.  The next day they were able to start walking, and ultimately made it safe back to their village.

Our lives are shaped by every decision we make.  My life has been shaped by choosing to come to Uganda and hearing a story from this amazing man who is now a doctor because he chose to run to the left rather than to the right.

Weekend Review

Weekends here are nice.  The “work-week” is not terribly busy, but as I may have mentioned there are a lot of other Muzungus around which makes it sometimes difficult to get the full hospital experience I think.  On the weekends though, most people travel out of the area and the hospital is quiet.  The residents here have it pretty rough on the weekend as they cover the entire medicine ward (around 50 patients) while they, an intern, and a medical student also admit patients.

We decided to work this weekend to help offload some work off the resident and also to get some more one-on-one patient experience.  So we went to post-take rounds both days and then after that rounded on patients in the female ward.  The Ugandan resident took care of the men while Anem and I split up the women.  We each saw patients with the help of a medical student who could translate for us (some patients speak English, but very few).  We reviewed the charts, did an exam, and decided what the patient needed that day.  Unfortunately a lot of the things they needed (labs, ultrasound, etc) can’t get done on the weekend – but at least I wrote them in the chart!  It was really kind of weird seeing patients without an attending … a bit of preparation for when I am responsible after graduation in a little less than a year and a half!

After working we headed to the canteen for lunch around 1pm.  A young guy named David took our order, and decided to sit with us during lunch.  He’s a student at the university here, studying information technology.  He goes to school full-time but also works at the canteen to supplement his income.  He was so kind, and gave Anem and I a list of things to do around town, as well as free bananas for dessert.  Ugandans are really so friendly, and it wasn’t too surprising to have a total stranger sit down to lunch with us and have a great conversation.

After lunch we headed home to take a nap (which seems to be a daily occurrence) and then went to the city market with our roommate Allison to get some things to cook this week!  I got brave enough to take a few photos and also bought some beets, beans, and cabbage all for about $2!  The beans are so beautiful I kind of just want to look at them and not eat them.  We’ll see what concoctions I can whip up with our very limited kitchen tools this week.

I must mention that yesterday after work we happened upon a soccer game close to our house.  It was between the first and third years of the Mbarara University. They were decked out in their uniforms and there was a huge crowd there.  The field didn’t have any markings, so it seemed the boundaries were marked by the bodies of the fans.  We walked up right as there was a giant cheer and half of the fans ran out onto the field.  Apparently the first years beat the third years, and this was the end of a tournament of some sorts.  The most interesting part was that the winner of the game won a bull, and the runner up got a goat.  Both animals were out on the field I guess as motivation to the teams of what their dinner would be like afterwards.  The animals, however, did not enjoy being there.  The bull actually got loose at one point and ran around on the field and started chasing people!  Fortunately we were a far enough distance away to not get chased.  But the crowd was unphased.  I guess because they knew it would get roasted soon!  Otherwise the evening was marked (literally) by the fact that I got pooped on by one of those giant storks while standing under a tree watching the game.  It washed off easily.

The goat slaughter (warning - some graphic descriptions and pictures!)

A few months ago I read a book called The Omnivore’s Dilemma.  It’s a great book about where your food comes from, and really thinking about that when you’re in the grocery store and in your kitchen preparing your family’s meals.  Each chapter focuses on a different part of your meal (corn which is in everything, meat, etc), and the final chapter talks about the “perfect meal” being one you forage, hunt, and prepare yourself.  That way you know where everything comes from, what everything is made of, and what it takes to get the meal on your plate.

Today I had a front-row seat for watching where my dinner came from.  As I’ve said before, there’s a big multidisciplinary UVA team here this week, and they’ve been working on collaboration with MUST (Mbarara University of Science and Technology).  In Ugandan culture (and lots of other cultures) they official way to confirm a collaboration or agreement is with blood.  So yesterday we confirmed our collaboration with the blood of a goat.  Also we just really wanted to throw a BBQ party.

After coming back from our mini-safari at Lake Mburo, we discovered some butchers in our yard.  We had heard earlier in the day that we would celebrate the last evening of the entire UVA team being here by having a good old fashioned Ugandan “goat roast” at our house.  I assumed, just like my roasts at home, that we would pick up some meat from the market and start cooking.  Apparently that’s not the case.  A few minutes later, a car pulled up to our curb.  The driver popped the trunk, and the bleating of two goats rang out.  The goats were pulled out and delivered promptly to our back yard under a nice tree … along with a machete.  You got it – the goats were going to be slaughtered AND cooked at our house.  I began to get a little nauseous and tachycardic.

Remembering what I’d read in The Omnivore, I tried to pump myself up.  Eventually I convinced myself that (1) when in Rome, you should do as Romans do and that (2) this would be a great chance to really appreciate where my meal came from and to see firsthand the sacrifice that an animal makes before it winds up as dinner on my plate.

(warning – graphic description below)

The two goats had their feet tied to keep them from running away.  They were nice and calm after they were put under the tree, and I don’t think they knew what was coming.  Or at least if they did, they seemed to accept it.  The butcher stepped beside the first goat, flipped it over on its back, and with one swift motion sliced its throat straight through the great vessels.  It was quick, and I don’t think the goat suffered.  After it passed, it was immediately skinned, and then hung from the tree to let all the rest of the blood drain out while the butcher removed the organs.  Since the blood was to celebrate the collaboration, my attending Dr Moore was asked to kill the next goat.  Obviously as a muzungu he’s never done that before.  But he stepped up and killed his goat as well.  It was promptly skinned, organs were removed, and both goats were chopped up and landed on the coals.

I really thought it would bother me, but it didn’t.  It was quick and seemed relatively painless for the animal.  Afterwards we said some words of thankfulness for the goats’ sacrifice.  I think I agree with Michael Pollan even more now, in that we don’t appreciate at all what goes into our food.  It was moving to be present for the goats’ sacrifice, and I think it was definitely the meal I’ve appreciated most.

The meat roasted for several hours, alongside some African tilapia (scales, eyeballs and all), a few chickens and some plantains.  We also had a nice tomato salad.  While the food was cooking, folks starting showing up!  Keep in mind, this was all done in our front yard.  One of the attendings here who also owns a DJ business brought about 10 speakers and a DJ table.  Of course the butchers had their grills and knives everywhere, and they also set up a giant tent with chairs in case it rained.  Everyone mixed and mingled, and danced a lot!  Those Ugandans sure can dance!  I mostly watched and chatted with everyone.  The food was finally served – the tomato salad was fresh and delicious, the tilapia was flaky, and the goat … was like a piece of rubber.  The taste was good, though it was pretty much the taste of the charcoals, but it was so sinewy that I had a hard time eating it.  I was hoping after watching all that it would have been the best meal of my life, but unfortunately it was not.  A good time was had by all, and I think it turns out to be the best dinner party I’ve ever hosted!  And surely I will never look at meat on my plate in the same way again.

I have some actual pictures of the goat, but those likely are not blog-appropriate.  Instead I'll give you some pictures of the party!

Roasting of chicken pieces and tilapia

Our house, filled with Muzungus and Ugandans

Amir - likely the guy I'll be doing research with next time.  He exclaimed "I love protein!"

Us with Professor Tony - the head of Internal Medicine here

Mini - safari!

Thursday morning we went to resident lecture followed by post-take rounds.  We’ve learned a new trick – apparently after post-take rounds all the upper level residents go to the canteen and get chapatti (kind of like a tortilla) and tea.  Anem and I had been showing up on the wards right after post-take and then sitting there for 30 minutes until everyone else showed up.  So there’s the answer – tea and chapati!  After post-take rounds we actually left the hospital a little early so that we could get on the road to Lake Mburo!

Lake Mburo is one of Uganda’s national parks.  Legend has it that there were two brothers, Mburo and another one who I can't remember/pronounce his name.  One night the other brother had a dream that they were in danger where they lived in the valley and they needed to move to the mountains.  Mburo refused, and stayed camped in the valley while the other brother moved to the hills.  That night, a great flood came and Mburo drowned in the valley, and the lake was subsequently named after him.  This is one of Uganda’s smallest national parks, but specifically has a lot to offer in the way of birding, and has several big game animals to see. 

We had planned to travel here a month or so ago along with the other UVA group that’s here.  We filled up two 4x4 vehicles, and headed across the countryside for an hour and a half drive.  We passed a lot of beautiful scenery, and once we got closer to the lake we drove through several small villages where children who are used to seeing Muzungus in their territory would run up to the cars and wave.  Once we entered the park we were immediately greeted by some monkeys and impalas before heading to our tent camp.

Now the name “tent camp” doesn’t quite do this place justice.  It was a beautiful setting with a main open-air lodge where we had our meals and visited, then a short walk down a gravel path were several luxury tents.  Apparently they were designed after what Ernest Hemmingway lived in many moons ago.  There was mosquito netting inside the tent, warm water for washing, and we even had our own room attendant named Sunday who brought us hot tea in the mornings.  The setting was beautiful, but it turns out I’m a bit of a weeny as I stayed awake a lot of the night listening to mysterious sounds and getting scared I was going to get eaten by a buffalo or something.

While we were there we did a boat ride on the lake where we spotted hippos, a crocodile, and several beautiful birds.  We also did a walking safari at dawn where we saw zebras, bush bucks, impala, buffalo, a mongoose or two, some baboons, and a big trail of African fire ants.  We did the walking safari with an armed park ranger as several years ago some tourists were killed by a buffalo in the park. 

It was really a wonderful trip, even though it was just for a day!

On the way to the lake

Probably my favorite picture I've ever taken!

Me and Pumba

Our gang, with Lawrence the armed ranger