Click through to see my album entitled Rwanda

https://picasaweb.google.com/rafiki/Uganda2011Rwanda?feat=directlink

click through to see my album Around the Hospital

https://picasaweb.google.com/rafiki/Uganda2011AroundTheHospital?feat=directlink

click through to see my album entitled around town

https://picasaweb.google.com/rafiki/Uganda2011AroundTown?feat=directlink

Click through for portraits and pictures of people from Uganda

https://picasaweb.google.com/rafiki/Uganda2011PortraitsAndPeople?feat=directlink

Click for a link to all my scenery pictures

https://picasaweb.google.com/rafiki/Uganda2011Scenery?feat=directlink

So when we were getting our luggage after returning to Newark, the first thing we noticed was my toiletry bag all by itself going around on the luggage belt in a separate bin.  This was unusual because it was packed in my duffle bag.  The next thing we noticed was my duffle bag going around but it was half empty.  When we had checked it in it was entirely full.  Then, when I picked up my duffle bag it was wide open.  Not closed.  It had a tag on it that said inspected by Rwandan security.  What was missing was Chavi’s red bag that had been inside my duffle bag.  It had all her clothes.  It never came out.  What obviously happened is that they inspected my duffle bag in Rwanda and either were too lazy or to stupid to close it again so Chavi’s red bag that was inside it either was never put back in or fell out and my bag was open the entire way from Rwanda to Brussels and from Brussels to the US.  Chavi’s bag never came out.  It didn’t have its own separate tags saying send to Newark on it.  We went to file a claim report and waited in line.  The guy in front of us also had flown from Rwanda to Brussels to Newark. He didn’t get any bags. Then the woman that was supposed to file our claim said oh your story is too complicated and my computer is not working so go to terminal C to file a claim.  So then we took the air train to terminal C and waited in line there and filed a claim there.  The woman in terminal C said why did they make you come all the way here to file a claim, they could have done the same thing there.  A nice addition to add to our 48 hour journey.

Well the Passover seder is such an important yearly tradition to us that we were nervous we would be in Uganda and not get to have one.  So we prepared before we left.  I brought a hagadah, 2 boxes of matzah, some kosher wine, and kosher for passover candy fruit slices with me in my bags to Uganda.  I had to wrap the matzah in bubble wrap so it wouldn’t get crushed.  When we were there we started scavanging for other things we would need for the seder and the seder plate.  We bought eggs and hard boiled them.  For maror Chavi found large leafy lettuce on marketday.  We had to find nuts for charoset and we found some cashew nuts in one store.  We also heard about a fruit store across town that sold apples.    Each apple was 1,000 Ugandan schillings but we bought enough for the charoset.  We were also able to get some lemons there.  For the z’roah we asked our Ugandan friend Wilbroad if he could go to the marketplace on marketday and get the thigh bone of a lamb from a butcher.  He was able to actually get it so we boiled it.  It wasn’t kosher of course.  Then Chavi heard that the owner of a coffee shop in town had a supply of herbs so she went there and the woman who worked there actually had fresh parsley that we used as carpas.  We found a large metal platter and then drew pictures on paper with crayons for each item to be placed on the seder plate. 

Next, we had to make the menu of food to serve at the seder.  The only things to really eat in Uganda are beans, rice, and potatoes.  Well, also bananas, avocados, and cabbage.  So we decided we couldn’t keep kitniot. On the menu we had cabbage salad with mango, beans with peppers and onions, rice, ratatouille, Irish potatoes and sweet potatoes with rosemary that the woman at the coffee shop also had, mashed potatoes, and hard boiled eggs.  For dessert we had pineapple. And the afikomen of course.  Chavi worked very hard all day preparing the ratatouille, potatoes, and cabbage salad with a dressing for it.  When I got home I made the charoset with nuts apples and wine.  It tasted real!  Like real charoset.  I couldn’t believe it.  I also made the rice and salt water.  We had been cooking the beans all day but the med students who lived next door helped us whip the beans into a dish at the last minute and also helped us with the mashed potatoes too.  We used our kitchen their kitchen and the kitchen in a third house in the compund.  The med students also helped us by peeling the eggs cutting some vegetables and setting up their place to host the seder in. 

All in all there were 14 people who attended.  3 were Jews.  The third Jew was the medical resident Amos who is originally from Jerusalem.  Then there were 5 medical students, another medical resident, and some Ugandans that we invited.  They were Doctor Michael and his wife Jackie.  And Chavi’s friends Wilbroad, Twinnie, and then Wilbroad also brought Janet the little girl Chavi is putting through school.  We went through the Hagadah doing every portion of the seder and having a discussion.  I led it and Chavi and Amos chimed in a lot to help explain things.  We passed around the hagadah and people took turns reading parts of the story.  We sang all the songs as well.  The food was amazing.  We had to search for the afikomen and opened the door for Eliyahu.  Everyone said they had a really fun time.  Chavi got called in the middle to do a c-section but Dr. Michael went to the hospital and did it instead then returned to the seder. 

Here are pictures and videos of the seder:

https://picasaweb.google.com/rafiki/Uganda2011TheSeder?feat=directlink

So I wouldn’t expect anything less than a crazy last day to go out with a bang.  First thing when I came in the nurse told me my 19 year old pregnant woman with malaria just began having vaginal bleeding.  I went over to her and talked to her it began this morning.  It didn’t seem like a lot of blood.  It was her first pregnancy.  She was 17 weeks by her LMP.  I went and asked Chavi to take a look.  So we did a pelvic.  Her os was open.  An inevitable abortion.  I put an IV and started fluids.  Then we took her down to ultrasound and Chavi did an ultrasound.  We saw the fetal heart.  It was slow. 60.  Normal is above 110.  Also by measurements the fetus was 17 weeks and 4 days.  When we looked at the heart again it had stopped.  We told the mother.  Next she had to pass the fetus so she bought a plastic tarp and we put her in a private room.  Chavi hung pitocin and after a couple hours the fetus came out.  Chavi tied the cord then cut it.  Then we had to wait for the placenta.  If it didn’t pass in 4 hours she would need a D+C.  

The parents did not want to see the fetus.  We asked them if they wanted to take it home and bury it but they said they lived too far.  We asked the nurse what to do with it and she said the parents have to take it.  We asked the nurse what to put it in she said find a box.  So I found an empty box of gloves and put the fetus in it.  Then I taped it up and gave it to the parents.  They sent it with a relative who was traveling back to their village.  A couple hours later the placenta passed.  

Meanwhile, Amos called me over to the male ward.  There was a patient who walked in who had subcutaneous nodules all over his body.  They were firm, round, mobile, painless, about 2 cm.  The patient had developed them over the past year.  We had never seen anything like it before.  They were not in a distribution consistent with lymph nodes.  They were very superficial.  We started asking some questions and reading about a couple of diseases.  Usually cysticercosis manifests with neurologic symptoms most commonly seizures or focal deficits.  But in 25% of cases you can get subcutaneous nodules in the skin or muscle without involvement in the brain.  We asked him if he ate pork and he did.  We asked him if he ate raw pork and he said frequently when he was in Kampala he would get fried pork but they would not fry it well and it was raw.  So our best guess was that this was Taenia solium or pork tapeworm.  So we decided to give him the treatment for it.  

I went back to the female ward and saw my other old patients and 2 new admissions one 80 year old woman with COPD and PNA satting 80%.  Another 16 year old girl with a very high fever 104 degrees.  As I was about to go to lunch the nurse said, “Doctor, there is a new admission, she is very sick they just brought her in on a stretcher.”  Man.  So I go over.  She was very sick.  Unconscious.  Not responsive to painful stimuli.  Not protecting her airway.  Breathing in a gurgling way.  In America we would have intubated her.   Her pupils were constricted and not reactive.  She did not have a corneal reflex or an occulocephalic reflex.   The family gave the story that she had been ill but was getting better.  This morning she complained of pain in her fingernails then the children saw her shaking.  Ever since then she was unconscious.   She must have had some kind of neurologic event.  I told the family the way she was breathing she would probably get worse until she stopped breathing.  I tried to position her to open her airway but it didn’t help too much.  Her vitals at first were normal.  Normal BP, normal pulse, O2 sat 95%.  I put an NG tube and crushed up some dilantin and gave it to her in case she was in status epilepticus.  A long shot but her only hope.  They don’t have any IV antiepileptics and valium would have suppressed her respiratory drive.  So I told them she probably didn’t have long and then went to grab some lunch.  When I got back her breathing was worse.  Her O2 sat was down to 70%.   I came back a few minutes later it said 45%.  She didn’t have long now.  A few minutes later she stopped breathing.  I removed the NG tube then they took the body.  

My next patient was 35 and had fever chills nausea right flank pain and dysuria.  On exam she had right CVA tenderness.  When examining her belly I asked does your belly always look this way.  She looked kind of fat.  Most Ugandans are very skinny.  She said ya it always looks like this.  I asked when was your last period.  She said 2 and half years ago after I had my last child.  She had five children.  So I dipped her urine and it had white blood cells consistent with my presumed diagnosis of pyelonephritis.  Then for fun I decided to check a pregnancy test.  Positive.  I told her congratulations. Based on your fundal height it is about 14-15 weeks.  I wanted to give her ceftriaxone because pyelonephritis in pregnancy can cause severe illness.  The nurse said we only have one bottle and it is for another patient.  The pharmacy isn’t open 24 hours.  It is only open in the morning and they restock the wards based on what is ordered for each patient daily.  Great.

It was getting dark.  My interpreter wanted to leave.  Her name was Antonia.  She said, “I was hoping I could get out early today because it is Good Friday and I wanted to go to Mass.”  I was like, “sorry.”  She missed all the masses.  I had to pay her for her work with me.  I had already paid her for the first 2 weeks.  6,000 schillings a day for 12 days. (72,000 schillings = $30 for 8 hours a day for 12 days.)  And I owed her 5 more days of work so 30,0000 more schillings.  I only had a 50,000 schilling bill and she only had 1,000 schillings in change so I took the 1,000 in change and told her I would get the rest the next time I returned.  We took pictures with each other.  

Then I went back to the pregnant woman with pyelonephritis.  It was dark so I put on my head lamp and placed an 18 gauge Ugandan IV in her antecube.  I finally mastered their crappy IV’s.  Most of the time we use American IV’s we bring with us.  Then I went down to the OR and found some ceftriaxone and brought it back to the nurse.  I said this is for my patient with pyelo.  And that was my last act in the hospital.  It was 8 PM by the time I got home.

 First of all most people look older than their stated age.  Life is tough over here in Uganda and it wears on the body.  Like I had a 30 year old pt who looked 45.  Some patients in their 40’s look like they are in their 60’s.  80 year olds look the same anywhere they are.  

Actually,  a lot of people here don’t know their age.  I mean my grandfather didn’t know his exact birthday but he knew his birth year.  For example, one day I asked a woman it says here on this paper you are 30.  Are you 30?  She began laughing then said this is my daughter she is 26 how can I be 30?  So I said well then how old are you?  She said I don’t know but my daughter is 26, my mother was supposed to tell me how old I was but she died.  So in my write up I wrote this is a woman of unkown age but her daughter is 26.  She presented with etc etc.

You know sometimes birds fly into the ward and get stuck and fly back and forth across the ward.  I mean this also happens at the supermarket I go to in the US.  But it is just weird seeing a bird flying around a medical ward.   Doesn’t totally fit.