Thursday, May 24, 2012

Arua Rural Rotation (13 May - 23 May)

I spent last weekend in Kampala since on Sunday, Renee and I had to leave for our week long rural rotation in Arua - a town in northwestern Uganda near the Congo border. The weekend was pretty quiet. Renee and I went out on Friday night with our housemate Sarah and Lucy - the wonderful woman who runs Edge House. The place we went to was packed and everyone was dancing. Feeling tired from our week, Renee, Sarah, and I were the first to leave the dance party and head home. Saturday morning was lazy as well. I enjoyed sleeping in and relaxing at the Edge House and Makerere Guest House, reading and writing emails. That night we went out to watch football (soccer) at a local pub. We didn't get home early enough for the time we had to get up Sunday morning so the 6am alarm I set was quite unwelcome. Renee and I had a ride coming at 630 to bring us to the bus booking office to book our bus tickets and catch the 730 bus to Arua. It was a bit of an adventure to get our tickets and get on the bus. We were at the booking office by 645 but no one who worked there was around. We sat and waited. The bus to Arua arrived before any of the office workers did. Finally around 710, an office worker arrived and Renee got in line to buy our tickets while I watched our luggage. While she was not making any progress in the line, a man starting yelling "15 minutes until the bus leaves. 15 minutes!" then it was "10 minutes!" then "5 minutes!" Finally Renee made it to the front of the line and as the man was making the final call for bus boarding, we got our tickets, gave our luggage to the guy loading luggage under the bus and took our seats at the back.

The journey was pretty uneventful albeit long and not the most comfortable. It is between 7-8 hours from Kampala to Arua and for a bus ride that long, I definitely do not recommend sitting in the back of the bus. I was tired enough to sleep but too uncomfortable to actually get any meaningful sleep on the road. Every time I seemed to fall asleep, the bus would go over a pothole or one of the many speed bumps and Renee and I would be airborne - not so conducive to sleeping.

We made it to Arua a little before 3 in the afternoon and Renee called Dr. Alex, our supervising doctor for our time in Arua. We waited at the bus station for about 20-30 minutes for him to pick us up and take us to our lodging. Our home for the weeks is pretty nice. We are just outside Arua town adjacent to a golf course. We have a clean and comfortable room although there is only electricity for about 5-6 hours a day and although the shower has hot water, the shower head doesn't exactly work so I have to shower underneath the faucet. The restaurant has good food and we get breakfast so I really have no complaints. And it's cheaper than staying at the Edge House for a week. After getting settled and relaxing for a while on the porch outside our room, we ordered dinner. As soon as we ordered, Dr. Alex called us and said he wanted to take us out somewhere. We paused our dinner order and when we arrived, we discovered he was taking us to the hospital for a quick look. Apparently there was some trauma that was coming in and he was called in. It must not have been much of an emergency if he had time to pick us up before going and when we got there, there were no patients. The "emergency" never came in. We left the hospital and instead of going back to our lodging, Dr. Alex took us to his house where we met his mother and a friend of his. We hung out there and watched television - neither Renee nor I had any idea what was going on. Plus we were getting increasingly hungry and tired. After about a half hour, we got back in the car, this time with Dr. Alex's mother and friend and headed further out of town where we picked up some more people then went to the District Hospital to visit a patient who is somehow connected to Dr. Alex personally. It was interesting to see, but not on a Sunday night and after 8 hours on an uncomfortable bus. The best part about the hospital was when we saw a few cows wandering around on the grounds. After an hour, we finally were brought back to our lodging and had our dinner - fish and chips (French Fries). The fish was literally a whole fish, head, tail and all and Renee had to teach me how to eat it. It was really tasty and definitely welcome after not having eaten much all day. We went to bed exhausted and ready to start a new day at the hospital.

Monday morning we got up and had breakfast at the hotel. We were supposed to be picked up at 830 but didn't end up getting picked up until nearly 9. We were taken to Arua Regional Referral Hospital to the casualty ward. The hospital had a long queue of patients already waiting and the medical and surgical casualty were full. Renee and I met Dr. Alex and got to work seeing patients. It was nice that we had the autonomy to see patients on our own but then staffed our patients with Dr. Alex. It was nice to have the supervision and feedback. I saw a wide variety of pathology - two cases of malaria, several fractures, a late presentation of congestive heart failure due to mitral valve incompetence, a patient with a 16cm spleen due to liver failure and portal hypertension. It was great to get some exposure to things that I either don't see often if at all at home and to see diseases late in their natural course. At the same time, it is sad that those things exist here and although it is great for my medical education, it makes me sad that people do not have equal access to healthcare resources everywhere. The entire country is pretty resource poor so everyone is equal in the lack of resources unlike at home where we have the resources, but unequal access. After all that I have seen this year and working with so many international medical students who come from countries with healthcare systems that equally take care of everyone, I am more convinced than ever that healthcare should be a human right and everyone should have equal access.

I think Renee and I have gotten quite used to Ugandan time and both of us will have to switch back quickly when we get back home. This morning we were supposed to go to the HIV/TB ward for ward rounds which we were told started at 8:00am. We had plans to try and leave between 7:40 and 7:45 to walk to the hospital. We didn't leave our room until about 7:35 and then when we went to have breakfast, the breakfast wasn't ready. We ended up not leaving until a quarter after 8 and made it to the hospital by 8:30. At home, this would certainly not be acceptable. Here, the doctors had not even arrived on the ward yet. Arriving a half an hour late, we still managed to have time to get a complete tour of the ward with an introduction to all the patients before the ward rounds started. It was interesting to see these patients of which we rarely if ever see at home. They are some of the sickest looking patients I have seen so far during my time in Uganda. The worst part was how young most of them were. It's sad to see people my age or younger wasted away from the AIDS and riddled with TB - pulmonary, meningitis, effusions, was all there. The worst patient I saw was on re-treatment for TB after having stopped taking his medicines the first time around. Unfortunately for this patient, he had a severe drug reaction likely to one of the new TB medications causing him to develop horrible bleeding ulcers all over his mouth and gums and his skin to start sloughing off of his feet and legs. This drug reaction can be life threatening and so all TB medications were stopped in an effort to treat his drug reaction. After our morning on these ward rounds, Renee and I decided it was time for lunch before heading back to the casualty ward for the afternoon. When we arrived on the casualty ward, there were no consultants present. There was one nurse who was about to leave for her lunch break and a few nursing students around and that was it. The nurse told us that there was one very sick patient that she thought might have TB and told us to put on masks before we went to see him. Renee and I decided that if we were left alone, we would see patients together because two medical students, even though still not equivalent to one doctor, is better than just one medical student. The moment I saw this patient, I was reminded of the ward where we had spent our morning - he was emaciated, clearly sick, with a cup that was slowly filling with the sputum he was coughing out from his lungs. His BP was low and his heart rate was high so we decided to give him fluid resuscitation. There were no nurses or nursing students around at this point and so I placed the IV line myself. We finished taking his history and doing his exam then went to work on the paperwork to admit him and get him a chest xray, a PPD skin test, and a rapid HIV test. After this first patient, the patients continued to keep on coming. Together Renee and I managed two patients with hypoglycemia, a malaria patient, an acute abdomen, an gangrenous toe with cellulitis, and finally two nursing students who asked for us to consult for them since they were not feeling well. There may have been more, but when things get busy in the casualty ward, I don't always have time to record each patient that I see. The problem also is that the nursing students don't always understand what Renee and I ask them to do. For our two hypoglycemic patients, we gave them both dextrose to treat it. According to my Emergency Medicine Manual, you are to give a 50mL bolus of 50% dextrose then recheck the sugar, and if it's still low, repeat the bolus. The only bags of 50% dextrose we had were 100mL. I drew a line through the middle of the bag and asked the students (who had all appeared when previously when the likely TB/HIV patient was there had disappeared), to watch and stop the drip when the fluid level reached the line. The next time I glanced at those patients, both of them had received the entire 100mL of dextrose. Of course as a result, they went from being hypoglycemic to a not insignificant level of hyperglycemia. At least the body is able to compensate for a transient hyperglycemia better than the hypoglycemia so hopefully there isn't any long term iatrogenic sequelae. The best part about these episodes with both patients is that Renee and I are pretty sure we figured out the underlying cause for the hypoglycemia in the first place - one was probably a medication side effect in combination with not having eaten or drank anything all morning then going out to do physical therapy. The other one most likely has a gastric ulcer - she had not eaten or drank all day and when I asked why she said that for the past month she had stomach pain every time she ate. She also drinks a lot of coffee and was recently on a medication for heart palpitations. This may be the one and only time that I see the initial presentation of a gastric ulcer as a hypoglycemic episode.

After finishing in casualty, Renee and I were invited to dinner at the home of a Minnesota couple (United Methodists from New Ulm) working for the Peace Corps here in Arua. We had a delicious home cooked meal and a delightful time chatting and getting to know this husband and wife pair who have three children all around our ages and decided to join the Peace Corps because "we aren't dead yet." It was nice to be with people having a shared experience of being asked to do things beyond our training and comfort level. It was great to make some new friends. Feeling full after dinner and eating a few local mangoes, we headed back to the hotel very happy and content with our day. We may be extending our stay in Arua for a few days...

After two long and tiring days of working in the hospital, Renee and I decided that Wednesday would be a short day if it was nice and we would leave the hospital around lunch and head to the one and only pool in Arua for the afternoon. The day was beautiful - perfect for relaxing by the pool. At the hospital that morning we went to the pediatric ward to join the pediatric ward rounds. The doctor was later than we were in arriving and he was alone doing the ward rounds that morning. In one room alone, there were 25 patients. In the first hour, we only got through two of them and this was not because there was a lot of teaching happening, it was because of the disorganization of the files and the fact that many of the patients were new or were supposed to have various testing done and there was a search for results or a search in the record to find out why exactly the child was admitted. The consultant had a lot of work to be done and not a lot of time for teaching. After a few hours, Renee and I had figured out that we were not going to get much out of pediatric ward rounds and decided it would be better for us to leave and relax and recharge for the rest of the week. The pool in Arua is fairly small - not great for a pool workout but I attempted to get at least a long warm up in - but it is quiet and very relaxing and the adjacent restaurant had delicious food. Despite our repeat application of sunscreen, we both left the pool burnt after spending more than 6 hours of our afternoon there. I was able to finish my book (Cutting for Stone - great book!) and both of us left feeling much more refreshed.

Thursday we were back at work. We had planned to attend the Under 5 Clinic that morning. On our way there, the Peace Corps nurse from Minnesota caught us and took us around the maternity ward. The nice thing about this maternity ward compared to Mulago is that there are actually curtains between the women so they are not just lying out in the open laboring in front of 20-30 other women. When we arrived at the Under 5 Clinic, there was no doctor there yet and soon we were asked by the Peace Corps nurse to come see a child in casualty who had been referred to Arua from a nearby hospital for severe malaria and anemia and was in bad respiratory distress. The other hospital had told the family that there was nothing that could be done to save the child, but we were asked to take a look and give our opinion. This is definitely not a job for medical students but as again there were no consultants to be found in casualty, Renee and I reluctantly took charge. We put the child on oxygen (miraculously, they had this available in casualty) and started trying to start an IV line and also work to get the child admitted and under the care of the pediatrician who happened to be present on the pediatric ward.

After we sent the child straight away to the pediatric ward, we had two unconscious patients. One I'm pretty sure has tetanus (we were also considering cerebral malaria and bacterial meningitis). She was completely rigid all over including her jaw. Apparently one month ago she was given tetanus toxoid (we couldn't get more history than that) and I'm thinking that as a result of whatever happened at that time, she ended up developing tetanus. The other unconscious patient was in respiratory distress. She had delivered a stillborn baby via cesarean section 5 months ago and had had abdominal pain since that time. We didn't come up with a diagnosis for her (my top concern was a pulmonary embolism) and so we admitted her to the ward. We had a couple of really sick kids with malaria and one with measles. I saw a diabetic patient who I'm pretty sure was in renal failure with a huge amount of fluid retained everywhere - lungs, abdomen, legs. There was one other unconscious adult - Renee and I diagnosed malaria again since it seems that is what everyone had here if they have a fever and some other vague symptom. We saw a patient who was oozing pus out his belly button. His abdomen was tense and tender and he had an abscess in the left lower quadrant. He also had a chronic cough with sputum production and was completely emaciated. He smelled like TB/HIV (literally - it has a smell) and so we admitted him and I'm pretty sure he has HIV and TB and who knows what that abscess is - probably TB. I started a few IV lines including one in a child.

There was one patient that really got to me today that I was concerned about and would have felt responsible had something bad happened to her. It was a young woman in her early 20s who that morning had witnessed her father die in a motor vehicle accident. She was hyperventilating in respiratory distress. She herself was not involved in the accident. Her family was really concerned about her - understandably although we could find nothing physically wrong with her. Renee and I were both pretty sure that she was in a state of mental shock had an acute stress disorder at that moment which was why she was in the state she was in. At the same time she was there, we had several other really sick patients and so she just wasn't a top priority after we ruled out everything serious. She would quiet down for a while and then all of a sudden scream and start hyperventilating again. Apparently she had been seen by someone while Renee and I were out for lunch and had been given "an injection" of something. No one there knew what she had been injected with and there was no note. I was guessing that she had been given diazepam but I didn't know. I asked all the nurses and the clinical officer I found in clinic but none of them had seen this patient and there were no notes or records anywhere for her. We had given her a bag to breathe into but that was also not helping. I decided to give diazepam thinking that the vial only contained 5mg and according to my Medscape reference, you can give 10mg in one dose. So I filled the syringe and quickly checked the vial - diazepam 5mg/mL - and it didn't register until after I gave it to her and she quieted within a minute that the vial contained 2mL - 10mg of diazepam, not 5mg. Again, this would be okay except for the fact that I wasn't sure what "injection" she had been given earlier and if it was diazepam, I had no idea how much had been given. So I was terrified that I would put in her in respiratory arrest and we don't have a ventilator (let alone an ICU) and if she died from respiratory arrest because I OD'd her on diazepam, it would have been all my fault. We had decided to admit her to the psych ward and thankfully by the time she was headed there, she was awake and breathing okay and no longer hyperventilating. That was the most terrified I have been yet for sure in Uganda (it even surpasses being left alone in the surgical casualty at Mulago). It also made me question if what I am doing here is really helping the patients. I wonder if I am actually making a difference for anyone...

The alarm went off Friday morning and as the week has gone on, it has become more and more difficult to get up when the alarm sounds. I laid in bed for an extra 15 minutes before I could get the energy to move. We decided to try and avoid the casualty ward again today and since yesterday was so intense, thought that maybe a half day with the afternoon spent at the pool (in the shade this time) if it was nice outside would be a good idea. It was another beautiful day as we walked to the hospital. When we arrived, we found that again there were no doctors in the Under 5 Clinic so we thought we would try and make our own ward rounds on the patients we had admitted from the day before. If you can imagine, it was really difficult to find our patients. Not only are the wards themselves all in separate buildings and unlabeled, but there is also not often a doctor present or anyone who knows the patients that are on the wards. Plus it didn't help that we didn't have any of the patient names written down - just the diagnoses we had contemplated and the ward we had sent them to. We did find a few of our patients - the woman we thought had tetanus/cerebral malaria/meningitis was actually conscious although she was still rigid and her jaw was still clamped shut. After making our rounds, we decided to see what was happening in the minor operating theater. There were a few procedures that morning that we observed. We saw drainage of a foot abscess, a circumcision on a 1 year-old child, removal of an inguinal lipoma, evacuation of a hematoma, and suturing of a laceration secondary to an assault with a knife. It was pretty interesting although sterile technique here definitely doesn't match the sterile technique either Renee or I was taught at home. The worst of the procedures to watch was the circumcision. There is a big campaign to get men circumcised since research has shown that it can reduce the likelihood of HIV transmission. Unfortunately, most of these circumcisions are done well after birth at an age when the boys or men can remember it happening. This one-year old was supposed to have his circumcision under general anesthesia but because his parents had fed him an hour before, he would have to wait 6 hours for the procedure. At home, I think they would have waited and done it later under general, but here, they decided to just do with local anesthesia and no sedation. They strapped the child down to the table with dad holding down his arms and chest and mom holding down his feet. It was borderline barbaric to watch. The child screamed throughout the procedure and for a while afterwards. Once all the procedures of the morning were done and there were no more patients waiting, Renee and I decided it was a good time to call it a day and head to the pool. We had a beautiful day and I was able to get in a short swim and do some reading and take a nap. It was very relaxing. We are both looking forward to sleeping in this weekend and resting up for our final few days in Arua next week.

The weekend in Arua was pretty quiet. Renee and I enjoyed sleeping in. Saturday was rainy but we managed to make it to the market in between the rains. The market is huge and busy and easy to get lost in. There are a lot of fabrics, clothing (new and used), toiletries, name it, it's probably in the market somewhere. The adjacent food market is also crowded with vendors selling a whole assortment of fruits, vegetables, beans, bread, grains, meats, and the delicacy fried flying ants. The rest of the day was pretty quiet. We read and lounged and then headed to the Indian Restaurant for dinner. After a delicious meal ending in tea, we headed back to the hotel to watch the Premier League championship match. The restaurant was crowded with mostly fans for Chelsea. It was an exciting football match and we went to bed quite late afterwards. Sunday morning we slept in a little then headed to the pool for some lounge time. In the afternoon we went to a dinner party hosted by some of the peace corps volunteers stationed in the West Nile region, including the couple we had dinner with earlier in the week. It was a great day and a very relaxing way to head into our final few days in Arua.

Monday we planned to go to the operation theater but they only operate on Tuesdays, Thursdays, and Fridays in the main theater so we went back to the casualty ward. Dr. Alex was back today after his nearly week long trip to Kampala so there were consultants present in the ED. This seemed to make everything a bit more chaotic as they tried to shuffle patients in and out as fast as possible. Instead of being able to evaluate a patient and consider the diagnoses and management plan, Renee and I mostly ended up just being scribes for the history and physical exam. There was not as much learning because there was not much teaching and we weren't given the time to really consider what we thought might be happening with the patients. Regardless, we saw a variety of pathology including a man with elephantiasis, a woman with a cervical and uterine prolapse, a facial tumor, a throat tumor, TB, infected wounds, and some lacerations that we each got to practice suturing. I sutured my first lip laceration which was good experience. All in all the day was okay but the best part came after we returned from the hospital. During lunch, Renee and I reserved our bus tickets for Wednesday to head back to Kampala. While on our way back from the bus office, we stopped by a sports store and bought a football (soccer ball), a pump, and I got myself a Ugandan Nationals shirt. The football we had played with back at Edge House belonged to some British students who have since left. Renee and I want to start playing again when we get back to Kampala so we bought a ball. We decided to try it out this afternoon and our kicking the ball around was interrupted by a group of young boys heading home after school. They joined us in playing a game where we all stood in a circle and one person was in the middle. The ball was passed around the circle until the person in the middle intercepted it and then whoever lost the ball was the new person in the middle. It was a blast and turned our day from kind of mediocre to really fun. Now we are relaxing again in the evening waiting for a our final day on our rural rotation.

We spent our final day in Arua in the major operating theater. Before going to the theater, Renee and I decided to take pictures of the hospital. Our photo taking continued as we dressed in the very non-matching scrub uniforms that they had us wear for our time in the OT. The surgeons had a variety of operations scheduled. There are two theaters but in general only one is used and the other is reserved for emergency cesarean sections. The surgeons do a bit of everything - general surgery, orthopedics, and ob/gyn surgery. I was impressed by their speed of operating and the room turnover speed as well. They got through the morning's cases very quickly. We saw a variety of operations including two hernia repairs, a cesarean, a thyroidectomy, an appendectomy, and debridement for osteomyelitis. There were a lot of things that were done differently in Arua compared to at home. Like in Haiti, there were a lot of ants and flies in the OT and during the osteomyelitis case, one fly landed on several of the surgical instruments and the surgeon's hand and the surgery continued without spraying the instruments or the surgeon changing the best of circumstances, osteomyelitis is difficult to cure, but here it seems like it may be nearly impossible. This operation seemed like a last effort to get rid of the infection before this 6 year old boy will need to have his leg amputated. Both hernia repairs (epigastric and femoral) were done with local anesthesia only. The surgeons injected lidocaine at the site of the incision and down into the tissues and when the patient cried in pain, they would inject some more. After the surgeries were done, the patient was asked to get up off the table themselves and walk out of the OT. They did use general anesthesia for the thyroidectomy and appendectomy but general anesthesia here is with ether gas and there are no monitoring devices for the anesthesiologist to use to measure heart rate, blood pressure, or oxygen saturation. These measurements were not even taken manually during the surgery. Perhaps the lack of monitoring is part of the reason why they use local anesthesia instead of general for as many cases as possible. The anesthesiologist also did not listen to the chest after intubating the patient either - at least the surgeons operate pretty quickly in the event that the tube was not in the right position... The cesarean was an interesting case. The mother had 4 previous cesareans and this pregnancy was complicated with high blood pressure and placenta previa. Because of all these factors, the baby was delivered at 31 weeks - pretty early especially in a setting where there is no NICU. The baby was only about 3lbs but had a vigorous cry after delivery and seemed to be doing okay. Being premature in a place where so many children die before the age of 5 due to malnutrition, malaria, diarrhea, or respiratory illnesses is really a disadvantage. It's hard to be hopeful in a case like this. The thing that I was most happy about was that the mother consented to a tubal ligation with her cesarean - with a 5th uterine scar, her chances of a uterine rupture if she were to become pregnant again would be quite high.

After the OT, Renee and I had some lunch then went back to the casualty ward one last time. We saw a couple of malaria patients and got them admitted then took some last photos with the staff of Arua Regional Referral Hospital. After we said our goodbyes there, we made one last stop at the home of Marcy and Tom (the peace corps volunteers from Minnesota). Although it was sad to say goodbye, we were both excited to get back to Kampala. Our bus trip Wednesday morning was uneventful except for when we got to the one bridge traversing the Nile that connects the West Nile region to the rest of Uganda. There is a security checkpoint here as a result of the LRA and Joseph Kony and everyone has to get off the bus, show their ID and have their bags searched. It was nice to get off the bus for a few minutes in the middle of our 8 hour bus ride. The funnies part was the sign that pointed out an animal checkpoint. I'm not really sure what they search the animals for, but apparently even animals are not exempt from the security checkpoint. We arrived safely back in Kampala and were able to celebrate with our friends Sarah and Ruth who were leaving that night and the following day, respectively. It is always hard to say goodbye especially to Ruth who had been with us since the beginning of our time in Uganda. It is the friends we have made while sharing these intense experiences that help to keep us sane and to take a step back and still be able to enjoy everyday.

Location:Arua, Uganda

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