Uganda Update and Reflection

We've done a lot since my last post. Internet has been more difficult to come by, so sorry for the lack of updates! We've been spending a good amount of time working in the clinic, going on outreach, and finishing some basic physicals at the local Bushika school for orphans and vulnerable children. Too many experiences to cover them all! So instead is a personal reflection of mine:

The scope of what we see in our clinic pediatrics is huge, but for the most part, we see very young children, usually newborn to about 4 years of age. The most common problems are upper respiratory infections, gastroenteritis, skin rashes, malaria and pneumonias. The problems are similar to what we see in the US (other than malaria); on occasion, though, there are cases out of the ordinary. 

One such case was a patient being seem by another volunteer, a retired physician from the UK. I was passing by, and he asked my opinion. He pointed to the child's growth chart, at a mark ridiculously below the curve, so much so that I assumed it was a mistake. I looked at the child, held in the arms of an older woman. I could see some of his tiny body: the body, at first glance, of a newborn. 

I quickly demanded the translator ask the woman again what the birthdate was, stating that June, making the boy 8 months old, was clearly not correct. I realized after the words came out of my mouth that my voice was harsh and snappy. I was annoyed anyone would try to tell me this tiny child was anything more than a few days old, annoyed I would have to even consider a horrible possibility, so I blamed the translation or the old woman's lack of knowledge of months. 

She insisted June, the translator said. He weighed about 7 pounds. At 8 months of age, he should weigh about 20. Not possible. I would prove they were wrong... I unwrapped the child, convinced my physical exam would show them all what this child was: not more than a month old, a funny mistake, a confusion between June and January. 

General Appearance first. If those Clinical Skills classes taught me anything, it was that. So what was general appearance? First, what did I want to see? I wanted to see the taut, plush skin of a new baby, the blinking, wandering eyes of a child yet to see the world as we see it, vigorous limb movements, proportions that make sense. So student doctor? What did I see? A skull, broad and large, funneling down, with angles just a little too sharp, a little too steep, to a face sunken and loose. Eyes were large in their small surroundings, and irises followed objects... 4 months at least? Limbs were limp, with little movement. His arm, 8 cm in circumference, was covered in skin that seemed to only loosely fold around his baby arm-bone. I pinched it between my fingers. The skin stayed pinched when I let go, as if I had molded it. Tenting. A thought crossed my mind, I gripped his hands, and lifted them towards me. He picked up his head, brought it forward, neck muscles strengthened, just enough to tell me he must be at least 5 months old. I continued and finished my brief physical exam.

So 8 months? Believable. Along with unbelievable. 

At that moment when I finally understood the truth, I felt many things, some of which I'm not proud of. I felt angry, disgusted, naive for not believing it was possible. Mostly I just felt like running away. I'd like to say my voice was impassive as I gathered more history from the old woman cradling the child, but that would not be the truth, though I tried. Who was she? The grandmother. Where is the mother? Mad. Crazy. The father? The same. Has this child ever breastfed? No. What does he eat? Porridge. 

Don't ask me why, but it was this last answer, this last word, porridge, that really set me over my internal edge. Imagine a little baby, a little child, brain, muscles, bones, cells, all furiously trying to grow. On what? Porridge. 

I have seen many sad and disturbing cases since starting my clinical training, but only a few of them have such an impact on me, the others I acknowledge for what they are, and leave it at that. It's hard for me to predict which few these will be, and I doubt I will ever be able to. So does this make me soft? Is it inappropriate for me to ever have such emotions? Do these moments I have mean I may make a weaker doctor? These questions swam in my head and worried me as I reflected on my day that evening. They made me want to hide the experience from my colleagues in medicine. If the answer was yes, I didn't want anyone to know. 

So why do I choose to write about it now? Publish it for the world (though more likely only a handful of people) to read? As I'm writing this, I'm still thinking of just keeping it here, hidden away. The thing is, hiding it won't make it disappear. Actually, if some of my experiences in the past few years have taught me anything, it just emboldens the problems and the fears. Perhaps they are tucked away from others' lines of vision, but they become more ever present in my own. 

Regardless, that experience was important in my growth as a future physician, and I'm glad I had it. It added to what I've been thinking for a while: this 7 weeks has been a great capstone to my clinical years of medical school. It has somehow managed to encapsulate many of the most important learning points of all of third year, and reinforce them. It has helped me really think about what I want in a future career, and the roles I can, can't and shouldn't play in seeking to serve those around me. 

Our days left in Uganda are numbered, and we are trying to make the most of them! Below are a few pictures from the last few weeks. We are sad to leave this beautiful country soon, but excited to meet up with everyone else in LMU to share experiences! 

~ Monika 

Painting nails after physical exams at Bushika School for Orphans and Vulnerable Children

Checking BP for one of the clubs at the clinic

Uganda Updates - three weeks worth...

We have had very little internet access in the past couple weeks, but a couple of us are in Mbale now, the closest city to our little village, and we finally have access! So much has happened in the last few weeks, so I thought I'd just write a few highlights.

WEEK 3

A number of us spent the beginning of this week in the district hospital. We rounded with the one physician responsible for the whole hospital, including 3 30-bed wards (male, female, and pediatric), the operating theatre, labour and delivery, the 'casualty' ward AKA ER, and the outpatient HIV clinic. Obviously he doesn't see every case, but only the most critical. Everyone else is tended to by nurses or clinical officers, which there don't seem to be enough numbers of either. 

One patient we rounded on was a woman in a cot in the very corner of the large ward. As we approached her, the massive tumor on her neck became quickly obvious. It was the size of a pineapple, oddly shaped like one as well, sitting on the side of her neck and growing out of it. The doctor asked us what it was, and in true med student fashion we began to list off possible diagnoses and form a list, but when he didn't get his answer, he gave in and told us "TB adenitis." 

He had shown her to us as an example of a patient for whom surgery would be inappropriate, explaining that palliative care with pain meds and anti-TB meds was the right course of action. Androuw continued in this ward, and followed this woman as a patient. On his second day he realized that she was not taking meds, and quickly found out that she had only been taking her TB meds sporadically. We learned it is not the job of the nurses, but of the family members, to administer meds. The hospital was so disengaged with her, probably because they just didn't have the time. The family was so invested though, and yet the most critically ill patient in the ward was not being treated adequately because the most important pieces of information were lacking. Androuw was able toclear up the regimen with the family, but I'm sure there ad many similar cases. 

LAKE BUNYONYI

We spent our weekend at Lake Bunyonyi in far Southwestern Uganda, by the Rwandan border. After a 14 hour van ride across the country, we arrived to a late-night canoe transfer to the island our hostel was on. The starry ride was a perfect start to the weekend, which we spent canoeing in dugout canoes and exploring the 29 islands in the lake. Gorgeous! We had a stop at the equator on the way. 

Sunrise in Southwestern Uganda

Karthik on a rope swing over Bunyonyi

FIMRC volunteer Michael and John working hard in the canoe

Photo op at the Equator

WEEK 4

We arrived back to our little guest house of a home to the news that our water had run out. It's currently dry season in Uganda, and the water system is based on tanks that collect rain water, so we knew this was bound to happen some time! Our spoiled days of tap water are over... So we began collecting water just down the hill and carrying it up. It's interesting how acutely aware of your water use you become when you have to drag it up yourself! 

Otherwise this week was packed. Our friend and PA volunteer, Kristen, left Uganda the past weekend, so a few of us helped see the kids in the clinic during the transition to the local clinical officer. The more patients I'm seeing in the clinic, where the diagnostic tests we can order are basically limited to malaria, HIV, and urine dips, the more confident I'm becoming in my history and physical exam skills, I think this goes for our whole group. You begin to understand you can't use all those extra tests as a crutch... That a lot of the time you can get most of what you need from a good H&P. 

We also spent this week doing check-ups on kids in local orphan programs, mostly looking for tinea infections, or referring for other problems. We had a few pretty interesting cases, including one unfortunate little boy who was brought to us in tears, covered from head to toe in a rash. With the help of another FIMRC volunteer, Dr. David from the UK, we diagnosed him with chicken pox... Which might be one of the only times I'll see this in my career! All we could really do for him was reassure and educate, but it was interesting to see all the same.

Young boy with rash at the Bududa orphan program

A few of our group spent part of the week at the regional hospital and Cure hospital in Mbale, and then went rafting on the Nile. They had a great time! 

WEEK 5

Busy week so far! A couple of us are in Mbale at Cure and the regional hospital (see post below). 

Back in the village we are pushing women's health changes at our clinic in Bududa, spearheaded by Karthik. He gave a lecture last week on basic work-up for various gynecological conditions and cervical cancer screening in low-resource settings. A few of our group got the necessary supplies this past weekend, and along with the slides and speculums Dr. Maurer donated during his time here, this week the clinic has already done their first cervical cancer screenings! We plan to do the first wet preps this week as well.

We have so little time left, we hope to make the most of it! Not sure when my next internet access will be, but I will post another update when we get it!

~ Monika and the LMU Uganda Team

Cure Hospital - Uganda

Since being in Uganda, a few of us have had the fortune of visiting a hospital for pediatric neurosurgery in Mbale called Cure Hospital (http://cure.org/hospitals/uganda/). The hospital was founded by an American neurosurgeon, but is now almost completely Ugandan run and staffed. They specialize in hydrocephalus, which they treat often with a groundbreaking new procedure called endoscopic third ventriculostomy (ETV), and spina bifida.

Carolina and I had the fortune of observing surgeries yesterday and today. We saw ETVs, traditional shunt placements, as well as a spina bifida procedure today. This last procedure was really remarkable. 

Picture a 7 day old child, tiny lungs receiving air through a tube in her mouth, little monitors all over her body, laying on her stomach as she is draped with sterile sheets for surgery. The myelomeningocele is the mass protruding from her lower back, the sign that her spinal cord did not correctly form and is bulging out. It means she may be at risk for paralysis, absent bladder control, chronic constipation, and other problems. 

Picture taken with permission - myelomeningocele on the lower back of a 7-day-old infant

Everyone in the room closed their eyes to say words of protection for the child, then scalpel is handed to the surgeon, and to the tune of gospel music, he makes the first cut. We watched in awe as the a small fountain of fluid splashed out, and was quickly sucked up by the scrub tech's syringe. The mass that had looked so solid quickly deflated before our eyes, and skin was further opened up to tackle the damaged spinal cord, that quarter-sized piece of nervous tissue that would dictate so much of this child's future. 

Over the next 45 minutes, he separated out the cord, all the while explaining the procedure to us. He expertly wrapped it in the dura, as if swaddling it, and sutured it closed, after which he finished up by closing the skin. 

It's true that these problems are rare, far less common than malnutrition, malaria, or diarrhea in a child. However, there was something so profound in seeing this procedure, in seeing a small child get a chance she may have otherwise not have received. My experience at Cure really stimulated my thoughts regarding access to medical care in low resource settings. I have no answers, but only thoughts on more questions. Where should resources be funneled? Does every child have a right to a cure, if it exists? If so, what impact does this have on low-resource, high-need care? 

That seems to be the theme of this trip: so many questions, and few answers! 

Another update soon to come,

~ Monika

Mountain, Orphanage, and Rural Health Clinic

Welcome to Huaytapallana, a nearby mountain and glacier. Last Saturday, we reached a altitude of 17,400 feet and all experienced dyspnea first-hand. We enjoyed hiking together with our faithful guides to help us along the way.

Laurie was the first to go

We even got to go sledding with trash bags at the top! Since there was an edge leading to rocks below, we caught each other with a rope to avoid injuries.

Chris and Phil keeping Laurie alive

This was not exactly fail-safe, but it worked!

Phil, Laurie, Danielle, and Chris (not pictured: John and Jared)

During last week, we resumed our individual work at doctors offices. Please read Phil's great verbal account of the many things we have been able to experience here in Huancayo.

Another great experience has been going to an orphanage for children with HIV/AIDS, or who have been physically abused. We spent our first visit playing games like Red Light Green Light, Duck-Duck-Goose, and Simon Says. These children were a pleasure to meet.

Chris helping a child with Red-Light Green-Light; Laurie tries to cheat with her child for the win

Another great experience occurs in a nearby town called San Agustin de Cajas at the Centro de Salud. Phil and John have been going here frequently, but Chris and Danielle paid a visit this past week as well. Doctor Ingrid and Doctor Lily have been very wonderful to teach us as they examine patients here. We will be working with these two doctors to understand how they screen, diagnose, and treat diabetes in the community.

Phil and Danielle are fantastic at all they do

I (Chris) was impressed with the attention placed on vaccinations. On the outside wall of the clinic hung a sign with information about free vaccinations for patients. This is a very good investment for long-term health change for communities like Cajas. I wonder how medical students like us can support vaccinations even more in the future as we complete our global health work.

Another fantastic long-term work is improving hand-washing and hygiene. I have noticed that in our hospitals, certain items are missing for hand-washing. In this case, it was running water. Sometimes it is soap. Other times it is something to dry hands with.

A visting lecturer from the USA spoke to the Medical Society in Huancayo about hand washing. I think it was a good topic for the doctors here as hand-washing seems to be sparsely observed.

Education and provisions of alcohol-sanitizer, soap, running water in clinics, and hand dryers might be a good use of energy in our future endeavors.

Well it's time to run to dinner! Thanks for reading the update. I'll end with a cool chart in the health clinic. It is the stages of development for children, with pictures! Till next time!

Peru Update-Clapham

Day 24:

Last Friday our group did a hypertension education and screening campaign in a smaller pueblo in the hills outside of Huancayo. It took us about 30 mins in bus to arrive, through dusty roads that wound enough that one of our girls got car sick. When we arrived I realized we had been there the previous Saturday on one of our tourist excursions with our family. In the center of town is a cathedral loaded with religious icons. And outside the church is a huge stone cross that my señora told me is 500 years old. It has four sides, of the two large sizes, one depicts the crucifixion (very defaced making it the most difficult image to appreciate) and the other side has the Virgin with baby Jesus. The two smaller sizes have images of two monks, I don't know if they are particular ones or not. Around this cross on all sides people come and burn candles to ask God for something. And they wait until the candles burn entirely down. Different colors and arrangements signify different types of requests I was told. The aura of devotion of the faithful that are gathered is impressive. Chris took good pictures when we were there the first time. This time, our work was across the street from the cathedral in a convent. On arrival there were maybe 20 mostly old people that were seated in a big open room that had a few tables and chairs where we would do our visits. Laurie introduced us and gave an overview of blood pressure, hypertension, and preventative measures. Then we split up into teams. The really old people gravitated to one corner of the room where Danielle checked their BP and talked to them about various health concerns. Like in the States, the old folks took longer than the other patients. I laughed when I was done checking my patients' pressures and I saw that Danielle had a lot of old folks seated around her table waiting their turn for a SECOND consult to discuss more issues.

Peruvian medical student Freddy was working with Danielle

After the intro, I went to one corner of the room and started "seeing patients." I asked their name, age, medical history, social history and wrote this all down on a paper and then took their BP twice and and then their pulse and respiratory rate. Then I listened to their lungs and heart with my stethoscope (mostly just to oblige them bc they saw the other students in our group auscultating patients at their stations). This town and this population was distinctly different than Huancayo, I could tell as soon as I started to be near the people. This was truly the Andean pueblo. The women I thought were 50 were in their mid 30's. Most women wore the dress of the campo (five layers of skirts of worn fabric and straw hats). When I inquired about occupation, 90% told me they worked in the "chacra," which means intense manual labor farming. And their worn leathered hands proved their response. Their speech was markedly more difficult for me to distinguish than my Huancayo host family members and physician friends. More than one was illiterate. More than these pieces of evidence though, is just the palpablility of poverty that was present, I've seen it in patients I've met in the Hurley ED, and it was the same here. Part of it is a smell, but a bigger part of it is a deeper feeling from your soul that tells you that this fellow human lives at a lower standard of living than you do.

Most of my "patients" had systolic blood pressure below 100. Probably because they physically exerted themselves for long hours each day and nobody smoked and nobody drank alcohol and nobody had diabetes and nobody had a family history of heart disease or hypertension and nobody was overweight. But everybody wanted to talk about a health issue. And like I've experienced already once or twice in Peru, they all gave my medical opinion great deference, and showed me that they cared deeply about their health, and said "thank you doctor" and "bless you doctor" about 1000 times.

Photo by Danielle Chang

I talked to an elderly man with BPH, another elderly man with the most knee crepitus that I've ever appreciated, a lady from Lima that was visiting the cathedral to make supplication to God who carried a tomagraphy film of her face that showed a maxillary sinus mass and who wanted my opinion (I didn't ask, but I wonder if she made the journey to ask God to heal her), multiple patients with gastritis, an 18 year old girl who had recently graduated high school and had aspirations to be a lawyer. I gave lots of advice about healthy diets and exercise. To the patients with medical concerns, I offered an opinion about the source of their symptoms and directed them to see a doctor if possible to receive treatment. And to the young girl I beseeched her to follow her dream and make wise choices in regards to her lifestyle and her relationships. I felt that within this environment that I've been describing, that a young person would have thoughts of pursuing an education and a life beyond manual labor in the campo, was a special thing that needed nurturing and even though it was just free advice, I hope it motivated and stoked her ambition to follow her dream.

Among these events though, stands out a particular encounter. After a few hours of sitting at the same table and having conversations, I was feeling ready for a break. Then she came and sat down after another patient vacated the chair at my table. I'd be lying if I didn't admit I wanted just to be done with talking to her before we even started. She smelled liked poverty. She had only a few teeth. I couldn't understand her hardly at all. She had food crumbs all over her lap and her dress was tattered. I knew it was going to be hard for me, practically and emotionally and I didn't want it at that moment. Finally after a few minutes I decided that I would seek a translator, which I hadn't needed to do yet. I decided this because I thought she was telling me that her son was punching her. And also I thought she was telling me that she was having bloody nipple discharge. Then Natalia, our Peruvian FIMRC director, came over and translated. The patient told that her husband had beat her for years and now her sons were following suit. She told that her husband forced her to work by begging on buses.  She told that she had no family in the area, except her husband's extended family, who all hated her. I had to get this story later because I could understand neither her nor Natalia's Spanish through their sobs. Also because I had to maneuver her husband to another area of the room when he approached the table and accused her of lying and dementia.

I didn't talk to her after I guided her husband away. The sisters and someone Natalia talked to them for about 1-2 more hours. Now I don't know what will happen to her. The experience was another lesson for me about the assumptions I make without realizing or intending to and how easy it is for me to misjudge a person and a situation. Easily she was the patient that had the most at stake that morning.

All in all, it was a demanding morning, both mentally and emotionally. It really covered a lot of of the primary care roles: health screening, education, patient reassurance, and unplanned psychosocial troubleshooting (of the utmost importance).

Lunch with Nuns and Community Volunteers after the campaign - Delicious!

Nicaragua - outreach programs

Hola again from Nicaragua! It's hard to believe another week has gone by here. Our last week entailed another day in the operating room in Rivas, more clinic time and community outreach. We also started doing needs assessments for a future micro-health insurance program and working on a quality improvement project for the clinic.

At the Rivas hospital in the ER

Micro-health Insurance Program

One of the homes in the pilot micro-health insurance program

We are helping one of the FIMRC interns on a project to evaluate community needs and interest in a micro-health insurance program. The program would be opt-in and members would be required to attend one educational talk per month on public health topics. Members would give their permission for spontaneous home-visits where FIMRC would conduct home evaluations to make sure members were following the advice such as covering their latrines, covering all standing clean water, using mosquito nets, etc. For complying with various aspects of the program, members earn points and when they earn enough points they are eligible for gifts to help improve their health in the home such as a gas stove or mosquito nets. 

Cooking over a wood fire in proximity or
within the home is very common in this community

We piloted the home inspection program by visiting the homes of pediatric patients who are repeatedly getting ill to evaluate for possible causes of chronic issues with parasites, respiratory infections, etc. We realized how much information can truly be gleaned about the health of our patients by visiting their environments. It also gave us more insight in to ways to prevent some of the problems that patients struggle with here such as educating about not cooking of wood fires indoors to help patients with respiratory problems. 

Quality Improvement Project

Having worked at the community health post for the last few weeks, we have noticed a few aspects of the clinic that desperately need some improvement.  The most glaring problem is the absolute MOUNTAIN of unorganized charts that piles a large bookshelf.  The health post where we work is the largest in the area-with over 3,000 patients.  And with over 600 new children born per year-the volume of patients is always growing.  

Documentation of health records in Nicaragua is an absolute mess.  When someone is born, the government issues that person one health card with a number on it.  If they lose the card, it's gone forever.  So when someone enters the clinic for a visit-it's really a toss up of if they still have their health card or not.  Because the charts are organized by this issued number-it is impossible to find someone's chart without the number. The doctor then sees the patient without a past medical history and simply writes about the encounter on a piece of paper.  All around the health post, piles of these loose papers sit without knowing which chart they belong to.  In talking to Domingo, the current physician at the health post, he says that it is one of his greatest challenges.  He sees patients who present with new complaints but do not know why they were hospitalized a month ago.  He is continually making decisions without an adequate view of the patient. Then without this documentation, it is very difficult for him to follow up on a patient.

Our goal for the next few weeks is to create a system that the nurses are able to easily use to find patients.  We have made a notecard look-up system where the patient can be looked up alphabetically by first name (everyone has a few last names and prefers to go by a different one). The notecard has name, issued number, and birthdate on it. Then we bought new folders for all of the charts (the old ones were falling apart) and organized them by a brightly labeled patient's number.  This way, if a patient comes in and does not know their number (most patients), they can be looked up by first name, then using their number, their file can be found Hopefully this will then allow Domingo to have a full picture of the patient and also practice better follow-up.

Prenatal Program

This week we embarked on more prenatal home visits with FIMRC’s Nicaraguan prenatal coordinator, Roxana. In a half day we are able to visit about 5-6 women in their homes and within the community they have about 50 pregnant ladies at a time. We set out with our supplies including a scale, blood pressure cuff, stethoscope and binder of information.

Jenny and one of our prenatal patients giving a talk 

Upon arriving at each woman’s home (often by foot), we generally navigate some form of barbed wire fence to enter the property. At almost every home we have then been greeted kindly and someone in the family immediately goes to grab stackable plastic chairs for however many guests there are. We are often set up just outside of the home for our prenatal meetings.

Every visit begins with a quiz that investigates the level of knowledge that the patient has on the topic we will be covering.  The program entails visiting once a month during the pregnancy with a different topic dedicated to each month.  After conducting the pre-quiz, we begin with the educational portion. FIMRC has designed a great handbook for all of the talks so we are able to use the handbook to read and educate the women. After the talk, or Charla, we ask women the same set of questions for our post-test to gauge how effective the program is. Before leaving we always weigh the women and take their blood pressure. Because Roxana is not a doctor, the women still visit the doctor where he checks things like the fetal heart rate and fundal height.

Checking blood pressure at prenatal visit

Going on the home visits has been a great way to educate the women in the community. Some of the topics include: nutrition during pregnancy, fetal development, taking care of newborns and complications such as preterm labor and pre-eclampsia. To be enrolled in the program, all women agree to deliver at the hospital. This has helped reduce the rates of maternal and fetal mortality in the community because the nearest hospital is about 1.5 hours away so when complications would arise in the past, it was not uncommon for women to pass away en route to the hospital. Women in this rural community tend to have many children and to start at a young age. The educational program seems to be especially useful for the young mothers in their teens.

Las Salinas, one of our communities

Diabetic Home Visits

The diabetic home visit program is newer to FIMRC and is less formal than the prenatal program as of now. FIMRC’s diabetic coordinator (also Nicaraguan and from the community) is named Esmalda. For these visits, we check in on the homes of known diabetics in the community and measure their blood glucose (almost no one in the community has their own glucometer) and to check their blood pressure. We were often greeted kindly on these visits as well although sometimes with more hesitation because they knew our visit would entail a finger prick.

 

Girls hanging laundry at one of the home visits

In one morning of home visits, we traveled the dirt roads of Las Salinas to about 10 different homes of diabetics in the community. We inquired about what the patient’s had eaten so far in the day and most of them responded “solo café y pan”. Esmalda let us known that they tend to load their coffee up with ample sugar and whole grain bread is not easily found in the homes in these communities. Most of the patients had glucose readings over 300! We were happy when we finally found one in the 170s but had multiple readings in the 500s. As medical students, we were concerned about these numbers and asked the patients how they were feeling- if they were nauseous, had headaches, etc. Most of them responded that they felt normal; we advised these patients to visit the Health Post to see the doctor. While Esmalda was impressed by the high numbers, she also did not seem surprised.

This coming week the community is hosting a medical brigade with doctors, PA's, nurses and a dentist from Texas. They are all fluent in Spanish and have been to the community before. Each day we will be traveling to different remote areas with them to set up free clinics. It should be a fun week!