The Great Bwindi Quiz!

Since Barbara wrote about our experience tracking the gorilla’s, and many of our posts here have been somewhat long winded, I though I’d change it up a bit with a little multiple choice quiz. There’s no way to get them all right without guessing, but hopefully it’ll be fun. Answers at the end.

GETTING THERE AND BACK
1. What side of the road did we drive on?
   a. The right
   b. The left
   c. The shoulder
   d. All of the above

2. Where did our driver stop to relieve himself?
   a. A gas station
   b. A local McDonald’s
   c. The side of the road
   d. A random stranger’s house

3. What obstacles slowed the car down?
   a. People
   b. Speed bumps
   c. Herds of cattle
   d. All of the above
   e. None of the above

4. What music did we listen to on the way to Bwindi?
   a. Yanni
   b. Bob Marley
   c. Eminem
   d. Dave Matthews Band

5. How many times did we listen to it?
   a. One time
   b. Two time
   c. 31
   d. On uninterrupted loop

6. How fast did we go?
   a. 50 kmh
   b. 80 kmh
   c. 100 kmh
   d. As fast as possible

7. What ran in fear from our vehicle?
   a. Chickens
   b. Goats
   c. Palm Sunday revelers
   d. All of the above

8. How close did we come to actually hitting any people?
   a. Less than 3 feet
   b. Less than 1 foot
   c. Less than 6 inches
   d. Ouch!

9. What was the most common thing we heard kids say to us as we drove past?
   a. How are you?
   b. Hello!
   c. Give me!
   d. Help us!

AT BWINDI
10. What did our tour operator forget to bring?
   a. Our lodging reservation
   b. Our gorilla permits
   c. His driver’s license
   d. His cell phone

11. Which group of gorillas did we go to see?
   a. Mubare
   b. Habinyanja
   c. Runyankore
   d. Nkuringo

12. How close did we get to the gorillas?
   a. About 30 feet
   b. About 20 feet
   c. About 10 feet
   d. About 5 feet

13. Which of the gorillas made a brief charge at one of our guides?
   a. The silverback
   b. The black back
   c. The baby
   d. The mom

14. What was in the trees near where we found the gorillas?
   a. Chimpanzees
   b. Red tailed monkeys
   c. Baboons
   d. White colobus monkeys

15. Which of the following was not part of our pack lunch provided for the trek?
   a. A sausage
   b. Biscuits
   c. A peanut butter sandwich
   d. A slice of pineapple
   e. A boiled egg

16. What music was playing at the Uganda Wildlife Authority office when we purchased our tickets for the Muyanga Waterfall Trail?
   a. Yanni
   b. Bob Marley
   c. Eminem
   d. Dave Matthews Band

17. What excuse did our guides give for not seeing any monkies along the Muyanga Waterfall Trail?
   a. They are taking their afternoon nap
   b. They are sheltering from the rain
   c. The gorillas have scared them away
   d. They are shy and have run away from you noisy Americans

18. Who has been kicked out of the park?
   a. Farmers
   b. Poachers
   c. The Batwa Pigmies
   d. All of the above

19. Who received compensation for being kicked out of the park?
   a. Farmers
   b. Poachers
   c. The Batwa Pigmies
   d. a and c

20. Which of the following countries were not represented by people we met at Bwindi?
   a. Australia
   b. Malta
   c. China
   d. Austria
   e. Denmark


Answers:
GETTING THERE AND BACK
1. d - Basically, wherever the ride was the smoothest
2. c - No Big Mac's here
3. d, e - Either is appropriate depending on what part of the drive we're talking about
4. b - Overdubbed with Lugandan commentary
5. d - We had the one tape, and it did not change. I'm convinced it was the same on both sides, too.
6. d - Sometimes, it was a little scary...
7. d - I never got tired of watching things jump out of the way of our car, except when we came close to actually hitting things. Most of the time, things were jumping out of the way well in advance.
8. c - We did come awfully close a few times, and one guy got laughed at mercilessly by his friends for nearly getting hit by us.
9. a - We heard all of the choices, but How are you? was far and away the most common. It did not appear that most of them knew an appropriate English response. Choices c and d were only a couple of times total.

IN BWINDI
10. b - How you forget the permits, I have no idea, but they had the receipt and it all got worked out after I paid for some cell phone air time.
11. a - The M-group as we were called, also had the most difficult hike. Runyankore is the language spoken by most people in southwest Uganda.
12. c - We were told we were supposed to be about 7 meters (23 feet) away, but ultimately were less than half that. It was amazing.
13. b - The silverback grunted and left, but the black back actually made a move towards our guide when he got a little too close.
14. b - Red tailed monkeys were jumping in the trees at the forest edge
15. c - We had a cheese sandwich.
16. c - Dave Matthews may be the proudest monkey, but Eminem inspires the UWA.
17. b - While our gorilla trek was clear sun, we got rained on during our hike through the forest.
18. d - Poachers still go in occasionally, but they're fairly well under control and haven't shot a gorilla in Bwindi in over 10 years.
19. a - The farmers got money to purchase new land because they had lost the land they had cultivated. Sadly, the Batwa got nothing because they hadn't cultivated the land, destroying the forest as the farmers had. When the park was created, Uganda felt they could stay in the forest because they lived in harmony with it, but international donors insisted that no human remain, and all hunting and harvesting in the forest should cease.
20. c - We also met some women from the US and England.

Only 1 week left

It must seem like I've been spending all my time writing during this week given my volume of blogging but in reality, I've just been hoarding them up and being lazy about writing over the last 3 weeks and now that it's almost time to go, I've realizing I need to actually post them! I'm required to journal for my rotation anyway, so this has been a nice way for me to do that.

Anyway, as I write this, Frank is at this moment having a very serious discussion with the 5 year old twins about the afterlife. The alternatives I have heard so far are:

1. Frank is going to come back as a carrot in his next life.
2. Frank is going to go to his far-away home in the sky after he dies.
3. I am going to marry a good friend after Frank dies (???? What does this have to do with reincarnation???)
4. If Frank comes back as a bunny, will he have enough brains to want to be anything more than a carrot in the next life?

This conversation ends with someone running off in tears….not good….

Anyway, I had a very exhausting week last week, but very good, as my time with the medical students became more defined. I discovered that working with the 3^rd year medical students was a more comfortable place for me and I think they felt comfortable with me, so we had a lot of time together over the last few weeks.

So as I mentioned briefly, the students have quite a few case presentations they have to give, so I spent a lot of time listening to case presentations, which involved standing at the bedside, listening to a very thorough history and physical, and then about 10-15 minutes of me quizzing the student and trying to teach them something they didn’t know about the patient. Sometimes, other students came and listened too and contributed, so these sessions could last up to an hour. The teaching sessions are anything from discussing theoretical treatments for the suspected disease (i.e., if they were in America, which tests could they have done?), going over how to read a chest x-ray systematically, or trying to go over how to do a proper cardiovascular exam. And again, they are so bright, often I had to go home, pour over some book, draw some diagrams, and then come back the next day to tell them whatever it was I had forgotten.

The students also have “tutorial sessions”, where one student had a required topic to teach to the other students, and I precept these sessions. These also last at least one hour. The students also have required teaching sessions with a senior on parts of the physical exam, and then they are required to have me watch them do the physical exam and then critique them. It is so intense, what they have to do! Since the Ugandan doctors are very busy, sometimes it’s really hard for the medical students to find as much teaching time with the doctors as they want. So I was happy to do that for them. I think also that I am a lot softer on them than the Ugandan doctors so they were less afraid to make mistakes around me. (I'm not sure if I'm doing them any favors, though.) Some of the students had never heard a heart murmur or never had anyone watch them do a physical exam so they never knew if they were doing it right or not. And honestly, I remember there were many rotations in medical school where no one ever once saw me interact directly with a patient independently; I could have been the biggest jerk and made up a whole physical exam and I’m not sure anyone would have noticed. So it’s definitely not just in Uganda that this happens. But I’ve never taught as intensely as this before, it’s so exhausting! US doctors are in general not near as thorough in their physical exam skills as Ugandan doctors so I have had to read up very thoroughly on my physical exam. It's very embarrassing.

And every night, I have to go home and do reading as I’m seeing stuff I’ve never really seen before. We see so many patients with meningitis, and these people have true psychosis. Staring off into space in a VERY strange way, rigid in all their limbs, talking nonsensically or not talking at all, unable to bend their necks---I’ve never actually seen this in the US. And even more interesting is trying to figure out the best way to treat these patients, since it’s often done empirically. Meaning, often they can’t afford the lab test we want to do or the lab test was done too late or the patient is deemed too sick to wait for lab tests; therefore, we would do our best to guess what they have and then treat them appropriately. Sometimes, we treated them for the top 3 things. They problem is, if they get better, you have no idea which of the treatments actually helped so you’re left not knowing what diagnosis they actually had.

Today, Sarah, an immunologist from the UK, and I did rounds on my side of the ward (very interesting to try to do rounds without a doctor who spoke the local dialect) and here is an example of some of the patients we saw:

1. Pt with renal failure who had fluid everywhere in her body (and I mean everywhere!). Her lungs are getting flooded and I think it’s only a matter of days till she dies. She really needs dialysis.

2. Pt with a grossly distended belly, so much so that I thought she was 40 weeks pregnant but it turns out it was all fluid in her belly. Her heart filled her chest, crowding out her lungs and she had the loudest heart murmur I ever saw. We wondered if she had a dysfunctional heart valve?

3. 3 patients with meningitis. Most have HIV as well and fortunately, most were improving.

4. Pt with a very large left sided pleural effusion, meaning she had fluid filling her whole left lung. Any attempts to get fluid out of it has failed. She also has a bony chest mass sticking out of her sternum and a very, very large liver. We wonder if she has cancer? Maybe a surgeon can come do a biopsy for us?

5. 2 patients with probably STD’s which look very painful. One of them most likely needs to have an abscess opened but not sure how to contact the gynecologist?

6. Pt with a total body sloughing skin rash of some sort, and nobody knows why. Most likely a drug reaction, but who knows which drug she took?

7. A 14 year old girl who looks 7; she has very, very bad hypothyroidism which has stunted her growth but there is no hormone replacement available to her. She might never go through puberty.

8. 14 year old patient with the largest spleen I have ever felt, filling her whole abdomen, looking very pale and sick and breathing fast. Probably has a cancer and maybe malaria, but can’t afford any labs. Even if we could diagnose cancer, there is no chemotherapy, so the best option she would have is hospice.

9. 3 patients with TB---1 with plain old TB in the lung, but the other have TB everwhere---TB in the kidneys, TB in the brain, TB in the gut. They get transferred to TB ward once they are stable.

It’s amazing to me how long these patients will wait before they come to the doctor. In the US, I hardly ever see these kinds of physical exam findings as people come to the doctor way before it gets that serious. People here often think if they come to the hospital, they die, so they avoid it; but by doing so, it’s a self-fulfilling prophecy as they often come too late for us to help them. I wish there was a way to change this but it’s a cultural as well as a money issue. Thank goodness I’ve been lucky and most people on my side have gotten better.

Probably overall, the hardest thing is to try to keep a balance between being sensitive to the cultural differences and resource limitations here, but also wanting to keep patient care as excellent as possible. It’s easy to fall into either trap: On one hand, foreigners are often indignant and upset that this pt with meningitis didn’t get a lumbar puncture the day of admission, and why didn’t he get this morning’s dose of antibiotics, and why hasn’t he had iv fluids, and why didn’t anyone check his blood pressure more than once in 24 hrs? On the other hand, after a few days, it’s easy to see a very sick patient with chronic renal failure who doesn't make urine, but there is no dialysis, so all you can do is give water pills, hope the potassium is ok, and advise the family the pt will die soon; you move on without attempting to push for that ekg or serum creatinine or albumin to make sure you don’t miss something potentially curable or handle side effects of your treatments properly. I’ve come to the conclusion that though we have to learn to work gracefully with the limited resources that are here, we have to challenge the sometimes lackadaisical attitude of health care workers here to be as attentive as possible despite the limited resources (and of course this is a gross generalization); and that we also can’t forget that it’s unfair to have such incredibly disparate health care in the world; the status quo is not ok. I feel like I'm saying we should try to make sure that people here don't die of potentially curable diseases more often due to factors we might be able to help change such as apathy, drug availability and cost, but it is ok to accept that people die here more often due to many other problems that can't be changed fast or easily and we need to have patience and understanding. I think I'm doing a bad job at trying to understand a complex situation so forgive me if I just confused or offended anyone.

Bwindi

We just got back from Bwindi Impenetrable Forest, and I wanted to get some thoughts out while my memory is still fresh since it was such a memorable experience! So if you’ve ever heard of the movie Gorillas in the Mist, you know there is a subset of gorillas called mountain gorillas, and they are some of the most sociable animals in the world. They live in family-groups of about 8-30, on average, consisting usually of one silverback, the leader of the group, 4-5 females, a bunch of juveniles (up to age 14), a bunch of infants (less than 1-2 yrs old), and maybe one black back, who will grow up the be the next silverback. They have no predators where they live. They live in only 2 places in the world, which are adjacent to each other: The Virungas National Park, which is shared by Democratic Republic of Congo and Rwanda, and Bwindi, in southwestern Uganda. They are an endangered species, and none have ever been successfully bred in captivity. So you can't see them anywhere else in the world.

In these three countries, there are habituated gorilla groups, meaning, they more or less have a defined area they call their permanent home and they are used to humans. The rangers told us it takes about 2 years to habituate a group. Now, language was a little bit of a problem but here’s what I gather happens, more or less. To do this, the rangers spend time tracking gorilla families; there’s about 30 families in total in Bwindi. Once the rangers find one that seems to more or less stay within one area so they are easily trackable, they assess them for potential of habituation. What they look for, I can’t tell you. But once they are deemed a potential, the rangers start to visit them every day for at least 1-2 hrs, just getting the gorillas used to their presence. Usually, gorillas won’t bother attacking anything as long as it isn’t too close. The silverback is about 200 kg, on average; they have no predators, and they are not carnivores. They only fight with other gorilla groups. Little by little, the rangers get closer and closer. At some point, the silverback decides the rangers are too close and charges. The rangers stand their ground; if they run, the silverback will jump them and attack; if they stand their ground, the silverback will growl and thump his chest and threaten but generally will not attack as long as he sees the rangers are doing nothing threatening. This goes on for about a year, until the gorilla group no longer charges the rangers even if they walk amongst the gorillas. You know how you sometimes see antelopes wandering around buffalo and neither of them particularly pay much attention to each other even if they’re right next to each other? Well, it’s something like that. The rangers then bring “mock visitors” as a trial. If this goes well, the group is habituated and it is deemed safe to bring tourists to visit them.

There are only 24 permits to go gorilla tracking in Bwindi a day; 8 for each of the 3 habituated groups. This is in part to limit the chance of the gorillas getting diseases from us and to make sure there isn’t careless trampling of the forest. We manage to get two and set off on Friday afternoon. It takes us 5 hrs to get there. The first 3 was spent basically driving straight west on a paved road with lots of potholes and speedbumps (I guess speedbumps are the equivalent of stop signs here), and then we hit this unpaved dirt road. It had even more potholes, lots of rocks, and it was dusty. It wound its way up and up and up into a lush hilly/mountainous area that was sparsely populated. We passed an infinite number of tea plantations, matoke (a kind of palm tree bearing bananas but not as we think of them), and fruit trees. Much of the scenery was looking out into a steeply terraced mountainside with goats and cows everywhere. It was misty and a little chilly, giving it an otherworldly, movie-like feel. Little dirty kids with only a long brown shirt one would run to the road and wave frantically at us, yelling “hello”, which I think is the only English many of them could say. If it weren’t for the endless jouncing about, it would’ve been a very pleasant drive. It took about 2 hrs, 5 villages, and a little bit of rain before we got there.

If it wasn’t for Bwindi, I can’t imagine any tourists would come to such a remote place. The town is called Buhoma and it’s just a tiny village that supports Bwindi. Everything revolves around the gorillas, but since there’s only 24 permits at a time, there aren’t more than 40 tourists at any given time there. Still, just within the park entrance there are about 5 guesthouses. We stayed at a modest one called Buhoma Community Rest Camp which was immaculately clean but not luxury. As with anywhere you go, we were served tea on arrival at their restaurant (an open air round hut about the size of our living room). You can actually pitch a tent there, stay in a 6-bed dormitory, or have your own “banda”, which is just a separate small enclosed “room”, anything from a small cement hut to what we ended up having. We have a “self contained” (has a private bathroom) structure, which consisted of a roofed shelter; under the shelter is a porch with a table and two chairs, a large room-sized tent with a queen bed, 3 tables, a pair of slippers and a mosquito net, and behind the tent is a cement bathroom with a shower, a table, a toilet, and a mirror. There is no sink and no divider between shower and toilet. Still, it was clean and had lots of toilet paper and constant hot water, yay! The hot water is from a firewood stove so it doesn’t depend on electricity but it smells like woodsmoke. The view is SPECTACULAR. Bwindi really is what looks like an impenetrable rain forest set on a bunch of steep mountains and our porch looked right onto one of the mountainsides. We could see monkeys in the trees from our porch. We did have to use kerosene lanterns at night but we didn’t stay awake much after dinner anyway so it wasn’t a big deal.

The next morning, at 7 sharp, we had a big breakfast, went through about 45 min of orientation, and off we went! It was fun to meet so many people from different countries even among the 12 of us who were there that day. We went with a young Australian couple, a guide, and two armed guards. Each of the three groups were in different areas. We ended up with the group with the hardest hike but the most spectacular view. We hiked for about 40 min up a steep old road, on a dirt path through a matoke forest, till we got to the top of one of the mountains. I felt a little bit like Julie Andrews in The Sound of Music as they struggled over the Austrian Alps except it was very sunny, humid, green, and buggy. We ascended about 1000 feet at this point. They had already sent rangers ahead to find the gorillas for us. We were in luck; the gorillas were in a glade in the forest that was pretty much free of trees and we were going to be able to see them quite clearly.

About 20 min later, we’re there. They were sitting right in a glade of tall grass, leaves and small trees about 5 feet tall, eating, about 200 feet away from some very tall forest trees. We just saw some rustling branches; then, all the sudden, we saw a gorilla not even 10 feet away from us! It was indescribable. They’re about human height but weigh closer to 150 kg, I’d guess. There were 9 of them, including 1 baby. They were just sitting there, munching on leaves and branches. As we stared at them and took picture after picture, they didn’t even look at us half the time. It’s like they really didnn’t care that we were right there. The silverback didn’t like us much, when we got too close he’d roar a little and beat his chest and walk away, but otherwise, he left us alone. The baby was so curious, it was just like a human baby. He had soft long silky fur and kept looking at us and inching closer until the mom got fed up with him crawling away and grabbed him and put him in her lap. Then the baby started sucking his thumb! It was amazing. The rest of the family just ate with clear enjoyment all around us and casually watched us watch them. We spent our allowed one hour with them, then trekked back.

I’ve been trying to think why we are so fascinated with them. In part, it’s the movie; in part, it’s what they represent: a species of animals who exist in a very small part of our world, and whose habitat is threatened by human expansion. We are becoming much more aware of these species and we cherish them; but there’s not many animals who will let us see them in their natural setting like these gorillas will so it’s a rare experience. I think it’s also that they live in this incredibly beautiful place which we’d love to see anyway (would I travel a crazy distance to walk through a boggy swamp or trek in -50 degree weather to see the gorillas? Honestly, no; I’m too wimpy for that). Finally, there’s something very human about the gorillas that I just can’t explain. They are very intelligent and seem to express emotions. They form very strong relationships and have loyalty. The mothers love their babies and keep a very close eye on them. The gorilla babies are very curious and toddle about as cutely as any human toddler. They use their hands to cram food in their mouths and chew with as much relish as any person eating a burger at a barbeque. And if you’re like me, you’re happy to see them in the wild. As much as I know zoos are a good thing, I often feel like some of the more intelligent animals just aren’t happy there. They’re not able to do what they were born and bred to do and somehow, they know it. In the wild, they’re in their element, literally. They’re healthy and peaceful and they belong there. I think it reminds us that there is a right place for everything, that we all on this world have our spot. Animals and humans alike are an equal part of this complex dance of life and when we respect that, it’s a beautiful thing. God had an order and purpose in mind when He made us and everything in this world, and there’s nothing like being reminded that everything on this earth is cherished by God, so we should too. Ugh, I'm cliche-ing. Let me stop.

Small kindnesses

Yesterday, I met the first patient here who really made me want to cry. If I hadn’t gone to Nigeria, I think I would’ve been more shocked at the seemingly more futile nature of medicine here, but I was worrying that maybe I’d gotten too hardened. It seemed to me that I too quickly was able to shake my head, say “what a shame”, and move on, with too many patients. For instance, we see many patients who have chronic kidney disease. In the US, they would be seen by a nephrologist, had many tests done to diagnose the cause, put on many kidney-saving medications, get routine lab checks to make sure we’re preventing complications, and eventually, if they need it, be on dialysis. Here, if they have plenty of money, these things might happen; but most of them can’t even afford what we consider the most basic of labs or medications. People with kidney disease are put on meds that can cause dangerously low potassium; but there’s no use checking potassium levels, as there’s no supplemental potassium to give. They patients often come into the hospital with fluid everywhere in their body, as their kidneys can’t get rid of water appropriately. So we see these patients on rounds, we give them what meds we can and hope the side effects won’t kill them. We tell them they’ll die of their disease in a year, most likely, and we discharge them still fluid overloaded, but what can we do? And I have very quickly learned to accept that this is ok, as it’s just how it is. So we move on to the next patient. Don’t get me wrong, patients here do get excellent care and the doctors are so smart, but the reality is, they just don’t have as many resources as we have in the US. Of course, despite this lack of resources, many patients who come to the hospital are healed as well, but sometimes it’s easy to forget that when I see so many people die of curable diseases.

But yesterday, one of the students took me to the TB ward. We see LOTS of TB here. (I coughed just once today and freaked out---unlikely I’ll get it, but still!) One of the things I have been doing like crazy this week is to listen to case presentations. The 3^rd year medical students are required to have a number of observed case presentation and physical exams, and I am most definitely less daunting than their usual “seniors” (that’s what they call anyone in a higher position than them). One part of the case presentations is that I’m expected to quiz them endlessly in the Socratic method so it ends up being a very involved teaching session. So I walked with the student to the TB ward, a building at the far end of the hospital. Unlike the very crowded medicine ward, the TB ward seems deserted. There are only about 10 patients here and capacity is probably about 40 beds. It is very quiet and only half the patients have “attendants” (in Uganda, most of the patient’s care is provided by their family; the family is responsible for feeding them, bringing sheets, changing clothes, making sure labs get done, giving meds, etc; they are called attendants). If there is no attendant, if the nurse has time, she will attempt to give meds and maybe feed the patient. If the patient has no money, he can’t get any labs done, he can only get the few meds provided for free from the hospital and he only gets food if someone is feeling charitable towards him (I think it’s often a fellow patient or a nurse or student). This particular patient was a young 25 year old man without any attendant or money. He had bad TB which we thought had gone to his brain, so he was psychotic. He couldn’t talk. When we approached his bed, my med student waved his hand in front of this man’s face and the man didn’t react at all. He just started blankly in space. He hadn’t moved from the position he had been placed in on arrival about 18 hrs prior. The bowl of potatoes someone had given him the night before was still sitting on his bedside table untouched. His free medications from the morning had not been given. He was very cold to touch and dehydrated and looked AWFUL. The day before, the med student told me, the patient had been lying in his own diarrhea for 24 hrs and since he had no attendant, no one cleaned him. The med student took pity on him and had a nurse help him clean the patient up and brought in a pair of pants for the man to wear.

My med student started to present the case to me, but two seconds later stopped. He didn’t have the heart to continue with the man in such a sorry state. So, instead, he put the chart down and started to feed the man a small bottle of a high-protein beverage which someone had donated to him. The man could hardly swallow and still couldn’t focus his eyes on us but he was clearly pathetically eager to drink something. We coaxed him to take his meds and ever so patiently, my med student fed him the whole bottle. After doing that, we tried to find a nurse to help us give him his iv fluids and a few other treatments. The med student then presented the case to me. We discussed his problems, discussed what we should do to treat it, and then went back to find the nurse. She had a tray of things prepared for the man, but she indicated that she didn’t have time to do it and that we should do it. Now mind you, the med student had no obligation to do this. My student was in the medicine ward; once the patient is transferred to the TB ward, he’s officially under the care of another team and my student has no responsibility to him anymore. It was 4:30 PM; the student had come back of his own volition to present a case to me for his own learning and no other reason. He certainly could’ve told the nurse, “have the next shift nurse do it”, and left it at that. But he decided to follow up on it and do it himself, as we feared no one would do it in time if we didn’t.

Of course, the man was so sick, he could die no matter what we do. But I just thought it was so sad, that this man had a disease that could be curable, but he would probably die because there was no one there to give him his meds, or feed him. It seemed so awful that he should lie alone and forgotten in a hospital bed, and if it hadn’t been for one medical student’s compassion, he wouldn’t even have a pair of pants on. But if he were to live, in large part it would be due to one student’s kindness. And it was this that made me aware again that no matter how futile or unjust it all can seem, and no matter how hard it is to feel you can make any difference, you still have to try. Even the small things matter. Despite having more limitations, Ugandans use a combination of kindness, smarts, and strength of will to heal each other and themselves and I will endeavor to be remember that this can prevail while still being aware of the need to equalize care everywhere.

Higher Mathematics

Originally written on Thursday, March 6
One of the problems with going on a working vacation with no plans is that you don’t really know what kind of work you’ll end up doing until you speak to someone after arriving. That makes it impossible to prepare. Along those lines, Claudia’s husband Joel came here with the idea that he’d try to give some supplemental tutoring or teaching at one of the local schools. So on Monday he invites me to come along to the International Window School here in Mbarara. We have no introduction, but Joel figures we can walk in and offer our services.

To me, this sounds a bit presumptuous. Here come the white Americans, offering to teach at the Ugandan school where of course they could use our help. I’m not entirely comfortable with the setup. In addition, Joel’s plan involves me teaching math. He figures I’m an engineer, so I should be pretty good at math. The school is primary up through secondary (essentially elementary school and high school combined), so I really have no idea what I might end up teaching if they want us to do so.

When we got to the school, I discover that it’s a boarding school for girls only. This was something Joel had neglected to tell me. I’m not really sure if that makes me more or less comfortable about the idea. There’s a large metal gate at the entrance large enough to let a small truck through. When we knock, a small door in the gate opens and we introduce ourselves to the gate keeper. He tells us to wait, and a few minutes later comes back with a visitor slip for us to fill out. We write down that we’re inquiring about teaching, and a few minutes after handing it back, are ushered inside.

We’re greeted by Edith, who’s role in administration isn’t entirely clear, but she’s very friendly despite what appears to be some annoyance with this unannounced intrusion into her day. Joel tells her that he’s heard of the school and its good reputation, and that we were wondering if we might provide some supplemental teaching for the students. He mentions that I’m an engineer and could teach math or English, and that he could teach either of those or geography. Quick side note – Joel teaches geography in Portland and his 5-year old son Will has been working on drawing various maps with an earnestness that is absolutely wonderful to watch.

Edith thinks briefly, then tells us that she’s not the person to talk to and goes to fetch Geoffrey. Geoffrey’s exact role in the administration is never fully explained, either, but it’s clear that he has some authority over the curriculum and the teachers. His demeanor also suggests that our intrusion isn’t entirely welcome, but he feels obliged to entertain us and our impression is that he’s trying to figure out exactly what he might get out of this whole business. Joel goes through his pitch again, and Geoffrey talks about the difficulty of having us inserted into the middle of the semester and interrupting what the regular teachers are teaching. We also share that we’re here for only a few weeks, which makes it additionally difficult to figure out how to get involved. Finally, we settle on some after school sessions in which we can answer student questions for the highest level students (Secondary 4 or S4). We’ll each have our own classroom. I’ll do math and Joel his geography. At this point, Joel offers to have us come back that afternoon. He seems to be ignoring the fact that I haven’t really looked at high school math since, well, high school.

Thankfully, Geoffrey suggests we come back after classes the next day (Tuesday), so the students have some time to come up with questions they’d like to ask. I’m thinking he’s just not prepared for our intrusion quite yet. Either way, he takes us along to introduce us to the S4’s who will be invited to our sessions. We interrupt three different classrooms, are introduced by Geoffrey, and then head off.

At home in the evening, I went over what I could remember from algebra and geometry and also reviewed an algebra book that Claudia’s oldest daughter, Madeleine has with her to do some exercises in. She’s only in 5th grade, but quite smart. The book goes from very basic stuff to some more advanced high school stuff, so the latter parts are potentially useful to me. In reality, though, I have no idea what to expect.

Tuesday afternoon, Joel and I head back to the school to meet up with Geoffrey and find our classrooms. This time, we’re let right in when we get there and soon Geoffrey ushers us upstairs to the classrooms in which we’ll teach. The girls in the school are done for the day, but those that wanted to could come to our sessions. Geoffrey asks us to do about an hour and a half, and then we drop Joel off at his classroom. At this point, I’m very aware that I’m totally alone on this, my big fear being that they’ll ask me to solve a problem for them that I have no idea how to do and I’ll be a total flop. Geoffrey’s billed me as an engineer and an “expert” in math, so being unable to solve any problem is going to be quite embarrassing.

I start with 5 students and no chalk. The eraser is a piece of sponge, which works far better than most erasers I’ve used in the US in the past. I start by saying “Good afternoon and welcome!” - which draws a chorus of laughter. Hmm… ok, I’m not sure why that’s so funny, but I suppose it’s just funny to hear my odd American accent. I check to make sure all the buttons on my shirt are buttoned. I then grab a half inch piece of chalk I spotted on the floor, but a few moments later one of the girls hands me some from her bag. I tell them that I’m going to help them with some problems, so if they give me a problem, then I’ll do it with them on the board, however I’m going to ask them to solve the problem and I’ll help them when they get stuck. This is my big secret plan, hoping that they won’t get stuck and I’ll just write on the board what they tell me. Maybe they’ll jog my memory a bit.

Ready for a good algebraic equation to solve, I ask for the first problem and am given one with the height and vertex angle of a cone, needing to find the surface area. Naturally, I have no idea what the formula is for the surface area of the cone is. Sure, I used to know it, but that was about 15 years ago, so my big secret plan is put to the immediate test. I ask the students what the formula is for the surface area of a cone, and one of them mumbles something so quietly that I’m not sure if she’s thinking to herself or really trying to answer. Thinking about it, I’m not really sure how much interaction they normally have with their teachers. Maybe it’s all lecture. Maybe wrong answers are so embarrassing to them that they’re afraid to state something boldly. They’re almost certainly unsure of what to make of their muzungu teacher.

I manage to coax a formula out of the student and proceed to use basic trig functions, at the students prompting to solve the problem. About halfway through it, someone from the school delivers some brand new chalk to me, allowing me to return my other chalk to the student. Of course, as soon as I use the new chalk, I break it, and find out later that Joel had the same problem with his chalk, so it’s not just me. Anyway, the students are pretty bright despite how incredibly shy they are with me. While I started out with 5 students, more keep coming into the room. I continue to get occasional burst of laughter as I’m writing something on the board, but just have to ignore it and keep going.

Filling the hour and a half turns out to be fairly easy, but I’m very grateful when it’s over. By this point, I’ve got about 40 students in my room, and I’m working on a 4th problem. I had another cone problem (find the volume of the solid left by cutting the top off of a cone) and an algebraic expression to factorize which looked really hard at first but proved to be very easy. The last problem, however, is one that I wasn’t sure at all about. I was given a circle and two secants meeting at a point outside the circle. Some additional lines are drawn, and given two of the angles in the drawing, we need to find two others. I’m really not sure where to go with this. The angles I’m given don’t give me a lot of information, and I can’t remember the properties of angles inside a circle. The students also instruct me to give one angle an incorrect measure. I tried to show them why their mistake wasn’t possible, but they continue to ignore it, and happily, that’s when the time is up. Happily, because I know their choice is wrong, but I don’t have a correct answer for them.

We’re going back on Friday, and I promised to follow up with them then, but unfortunately, I still haven’t been able to solve the problem. I’ve researched some of the properties of the triangles and keep coming back to the conclusion that there are multiple solutions to the problem. In other words, I need another predefined value in order to come up with a unique solution. Joel looked at it too and came to the same conclusion, but he admits that his knowledge of the subject isn’t beyond mine. It’s entirely possible the solution is not intended to be unique, but the way the problem is defined, it looks like it should be. Maybe they copied it down wrong and left something out, I don’t know, but it’s very frustrating! We’ll see how it goes tomorrow.

Epilogue (written Monday, March 10)
At some point you’ll hear more about what happened on Friday during the day, but for now I thought I’d just finish this post by telling you how my experience returning to International Window School went on Friday afternoon. When Joel and I got to the school, it didn’t take long before we were off to the classrooms, along the way greeting the students we recognized from last time. Although we were there at 4:30, the S4 students were still in a class, and as a result, we didn’t have any students at all for a little while.

Around 5 pm or so, a few students walked in to my classroom, but they were all younger students, so I decide to wait with a repeat of my geometry problem until some S4 students showed up. After all the preparation and agonizing over the problem, it turned out that not a single S4 came, so I never did the problem with them! I am going back tomorrow afternoon (Tuesday), so perhaps I’ll see them then, but I don’t have any idea if they’ll still be interested or not.

In many ways, I enjoyed the Friday session more than the first one. The students that were there numbered about 6, and the small number allowed them to cluster around the front of the room and interact far more with me individually than the larger group did. The problems were all algebra problems, which was fun and fairly easy, and I felt like they got a better understanding of how to do the problems since the group was small. They also were very good about asking questions and responding to mine, which really helped me feel like they were learning.

EDITOR'S NOTE: I just wanted to say that for some reason, our slow internet connection has made it difficult to post pictures on the blog from here (although the one above seems to have taken). We'll post if we are able, and certainly put some up when we get back, but for the meantime, you'll have to deal with text only. Sorry!

hospital staff

So the work I do here will have to be spread out in many blogs, since there's so much to tell! I thought I’d try to explain the hospital a little bit today. The hospital is similar to ones I’ve seen in other parts of Africa. There are a series of interconnecting buildings for each ward; I spend most of my time in the female and male general wards, which consist of two rooms with two rows of about 25 beds in each row. There is an ICU of some sort which I haven’t found yet; and there are three small rooms where the new patients are admitted to the hospital before a bed assignment happens. There is about 1 nurse per ward, and I haven’t quite figured out what they do yet beside give some iv medicines, answer a few questions for the patients, and occasionally help us position a patient or organize a chart. I’m sure they do more but I’m not sure what. The families of the patients feed the patient, give oral meds, bathe the patient, and generally take care of them. They often just lie on a pallet on the floor in between each patient’s bed (about 2 feet of space!). Privacy for procedures only occurs when a small screen is dragged in.

The medical students really seem to be the main force behind patient care here. There are 30 of them on our wards at once. 30!! In Portland, there are 6 at most at any given time. They do EVERYTHING. They check vitals, give iv meds, draw blood, take urine samples, run slides to the labs, do biopsies, counsel the patients and their families, get patients to pay for laboratory tests in advance and then chase down the results of the labs and put them in the chart, start iv’s, start oxygen, etc. They actually even get to decide to admit patients themselves; they see them in the outpatient clinic and if they think a patient should be admitted, they walk them over to the general wards, put them into a small holding room, and write out this huge history and physical. They then present the patients to the attending and senior resident in post-take rounds and hope the attending agrees to admit the patient; I honestly don’t know what happens if the attending does not agree!

It’s hard to comprehend the differences in the role of the medical student here. It seems at times as if the medical student has too much responsibility and not enough supervision, but at the same time, I think we in the US often baby our medical students because we don’t want to offend patients. No one wants to be the first patient who a medical student tries an iv on, you know? And we are reluctant to ask. Plus, we are spoiled by having nurses who do everything in the US. I haven’t started an iv since medical school. Here, no one else will do it but the medical student, so there is no choice. In part, the residents and doctors are so busy, they don’t have time to help each of the students as much as they would like, so the student learn more independently than we do in the US. But in another part, I think there is simply the expectation that the medical students should be more independent, too. They do work really hard. The old British system seems to be a harsher system than we have in the US, and medical students are “pimped” (asked question upon question about a certain disease until no one knows any more answers) quite a bit more than I am used to. I think it generates more independent reading and memorization than I ever did. I am amazed at the amount of knowledge they retain. They have a much more formal relationship with their attendings than I am used to and sometimes I feel sorry for them as they seem a bit fearful of their attendings but it could also just be me not understanding the cultural deference that young people give to their elders here. They seem so eager to have any personal teaching time so I am happy to do that for them. I worry sometimes I may not have much to teach them but I’m trying to be confident that two years of residency DOES make a difference! They are all very polite and nice and I enjoy working with them. In fact, everyone I work with has been kind and fun and polite, which is what I had heard about Uganda. You do have to spend a lot of time greeting people before getting to anything else in the conversation but it does seem quite genuine, actually, not just a mumbled “how are you doing” without waiting for an answer but true concern for “how are you? How was your morning? How are your children?” etc, etc.

As for the residents, there are only 2 interns here and they have 12 hrs on, 12 hrs off EVERYDAY; no days off! During their 12 hrs, they do all new admissions and any cross-cover calls on all the patients with a little help from the senior on call (I think). After intern year, they do a year or two of research and clinical practice of some sort. Then they come back for 3 post graduate years. So I am the equivalent of a post graduate level 1 since I just finished my internship, but the level of proficiency is not the same; I think experience-wise I might be closer to a PG level 2. There are 3 residents in each PG level. I won’t even attempt to explain their convoluted schedule to you!

I haven't yet figured out how many attending physicians there are but I think there are about 8. A few of them are UK doctors who are just the brightest, funnest people and thanks to them, our white faces aren't too strange here so I don't get stared at quite as much as I thought I might. All of them seem to be incredibly devoted to constantly up-ping the standard of care in this hospital and I think it is just great.

Chicken?

I just noticed there's what appears to be a chicken on the Uganda flag Frank put on our blog page...is it supposed to be there? I thought the flag just had 3 bars of black, red, and yellow. I feel too stupid to ask a Ugandan about it and the time it takes to load an image on dial up is too long for me to look it up online.

Greetings from Uganda! Before I get too far, I want to give a caveat to my blogging. Anyone who knows me well, knows that I often say things in a way that isn’t always the most tactful, even if I had the best intentions. Sometimes when I blog, it just comes out all wrong and occasionally I don’t proofread. So then, sometimes when I write I thoughtlessly offend someone, and I apologize in advance for that. I think I can honestly say I never mean to be hurtful but I know it doesn’t always come off that way.

Frank has told you about our trip to Uganda so I won't rehash. I'll start from our home here.

We live in a house with essentially 8 other people, 3 kids and 3 adults; there is another couple who doesn’t actually have a room in the house but they are here all the time so it’s like the 10 of us are living together. 5 of them are part of one family-- one of the attending doctors from Portland and her family; the other couple is her brother and sister in law, and the last person is an ob/gyn resident. There will be two more doctors joining us shortly. You would think sharing 2 showers and 3 toilets would be a problem, but it really isn’t at all. It’s fun having so many people as there is always someone to do things with and always someone making yummy meals. And the food! Though we are missing some things, in general, the fruits and vegetables are fabulous---the pineapples! Passionfruit! Mangos! Cucumbers! Tomatoes! Mmmhhhh…the first day, Frank and I ate a whole pineapple for lunch; then snacked on passionfruits; then for dinner I wolfed down a salad full of tomatoes, avocados, cukes, carrots, and garlic; and my stomach told me in no uncertain terms to please never eat so many uncooked acidic foods in one go ever again. All the fruit we have lying around generates a lot of fruit flies but fortunately, there is a baby lizard living under our fruit basket so that helps a lot. The Ugandan food is similar to Nigeria’s with some sort of starchy mashed staple and a meat “stew” of some sort, but they have this deep-fried samosa-naan-tortilla thing that is SOOO good, yet so unhealthy….and they drink a lot of tea. British influence, I guess. Though there are a lot of Indian people here, Ugandans can’t take hot foods of any sort in general so they don’t understand our obsession with the expensive Indian restaurants.

My days here have already gotten into a pattern. We are generally at the hospital from 8AM-12:30 PM, starting with some sort of meeting or lecture; then at 9, we have “post-take” rounds, where we talk about last night’s admissions. At 10 AM, we do work rounds, seeing every patient. I'll tell you more about the actual work and patients later. We break for lunch, and since I live across the street from the hospital, I come home. In the afternoon, I try to have teaching sessions with the medical students a few times a week and the other days I spend the afternoon preparing for the sessions. It’s actually a hard task because Ugandan students ALWAYS want to know EVERY detail. If you tell them a medication helps preserve kidney function, they want me to explain the mechanism behind it. If you tell them a burn patient may have low potassium, they want me to explain why. And they can patiently sit for 1.5 hrs asking question after question until we tell them that’s it for today! Then at 5PM we try to go back for afternoon post-take rounds, where we go over admissions of the day time, and then we’re done. I have no call here, as my task is primarily to teach, so evenings are always a big dinner, clean up, and then a few hours to talk, email, read, and play games, mainly. The weather here is perfect, almost always highs in 70-80’s, at night in the 50-60’s, and it rains madly, like a monsoon, about 1 hr a day, then clears up. The equator is a nice place! There aren’t that many bugs, either. It’s actually quite safe and we leave our windows and doors wide open till the last person goes to sleep. Tonight, we stood on our covered porch and watched first the many stars, then the lightning while rain poured down. It abruptly went away and now there’s just a cool breeze with the sounds of crickets everywhere. It's such a change from life in the US; so much slower, and social. You feel like you can savor every minute.

Arrival

Well, we made it to Mbarara after a rather long trip. Barbara got off work at around 7 am on Thursday, came home and showered, and then we were off to the airport. Everything went remarkably smoothly. Our flight to Seattle was uneventful, the only frustration being that we were sitting on the left side of the plane. A morning trip to Seattle from Portland is much nicer to sit on the right side due to the fact that all the large mountains (Hood, St. Helens, Rainier), go by on the right, and they’re quite majestic in the morning light. From Seattle we caught our 9 hour flight to Amsterdam. While waiting there for our flight, we ran into one of the ICU nurses from Providence who is also spending some time in Uganda. We didn’t realize we’d be on the same flight, so that was rather fun. The other funny thing that happened was while going through the security line at the gate in Amsterdam, I beeped while going through the metal detector, so the security guard took me aside and checked me for any hidden items. He spoke to me in English the whole time, then asked for my passport and upon seeing that it is a Dutch passport, immediately apologized embarrassingly and finished the process in Dutch.

And that was the most eventful thing that happened, which given the length of the trip, I thought was pretty nice. We landed in Entebbe after an 8 hour flight from Amsterdam and a driver from our hotel was there to pick us up. All our bags came in ok and the immigration and customs control didn’t give us any issues, either. The hotel, which is right on Lake Victoria was a bit strange. It struck us as rather expensive for Africa, and we found out that Bill Clinton had stayed there while President. Needless to say, we didn’t stay in his suite.

We had no trouble obeying the signs not to feed or play with monkies given the fact that there weren’t any around. However, there were a number of pretty neat birds and one of the hospital staff chased a 4 foot lizard of some sort off the grounds.

Our driver to Mbarara, James, was exceptionally punctual, and we loaded our bags for the 6 hour drive and headed out. Probably the first thing that was striking was how green everything was. A variety of palm trees were scattered in amongst the other flora. The reddish clay seems remarkably similar to the clay we encountered on our trip to Nigeria two years ago (yes, yes, I told you I’d try to avoid the Nigeria comparisons, but it’s really hard not to compare!). Shops line the main road where you can buy all sorts of things from motorcycle tires to cell phones to fresh produce from whatever is being grown by the people that own the land nearby.

Traffic was heavy, and the main road was a single lane almost the whole way. Passing is common, and due to the common presence of large vehicles on the road and blind turns, drivers use their turn signals to warn people not to pass them when traffic is coming. Uganda was a British colony, so people drive on the left side of the road. Our driver James would use his right turn signal to tell drivers not to pass when traffic was coming, and we got the impression that he used it quite frequently. It was pretty common to be passing someone and have traffic coming pretty much head on with little chance to get out of the way, but we always made it. We also felt that James would come very close to hitting things as he was going by, but he never did and we weren’t really worried about it after a while.

About halfway to Mbarara, we took a quick stop at the equator to take a picture and grab a drink. There’s a souvenir store there that’s part of an AIDS help network, with all the proceeds going to support the fight against AIDS. You can also pay to watch water swirl down a drain in opposite directions on opposite sides of the equator line. They even have a drain right on the equator where it all just flows in straight, but we didn’t really think it was worth the money to see water go down a hole, so we just took a picture.

The roads were filled with vehicles carrying all sorts of things. We saw a motorbike carrying a passenger who was transporting a large pane of glass. I’m not sure if it was a window or a windshield but he was holding it perpendicular to the wind, which struck me as rather un-aerodynamic, but I have a feeling that holding it sideways would’ve been physically rather difficult. There were also numerous trucks carrying thousands of bananas each. These trucks are about the size of a standard UPS truck, but open on top instead of in the back. They were filled with bananas, all still attached to their bunches (I estimate about 100 in a bunch) to the point where they were overflowing out of the top. We also saw trucks carrying various other things, including cattle and lumber and other produce.

At any rate, we arrived safely in Mbarara thanks to James, and were happy to feel the air get cooler as we traveled. Mbarara is a bit higher in elevation than Entebbe and Kampala, and the difference in temperature was quite apparent. Mbarara is cattle country, and the main rotunda as you enter the city has a statue of a longhorn right in the middle. These cattle are different from the Texas longhorn that Americans are familiar with, their horns sticking out more vertically than horizontally.

One of the things that really surprised us was the prevalence of speed bumps. All along our drive down from Entebbe, we’d slow down in the towns and trading centers due to a series of anywhere from 3 to 10 speed bumps, typically spaced a few hundred yards apart. Most of these come in the 2 to 4 inch variety that you can drive over without really slowing down much, but in Mbarara they have some that are a good 1-2 feet tall. These are really great at slowing down traffic. In addition, they’re really good at keeping us up at night. One of these just happens to be on the main road right outside our apartment. Traffic slows down some at night, but those that do come by don’t typically take the bump all that slowly. These also tend to be large trucks transporting fuel or goods from Rwanda up to Kampala, meaing they’re large, industrial trucks. Large, noise, clangy, banging trucks. Very restful.

The other sound that has been keeping up at night are dogs. We have yet to figure out if it’s just dogs or if it’s dogs with the occasional hyena response, but either way, it’s noisy. As for other animals in the city, there aren’t very many of interest. Among birds, it’s a bit more interesting. Storks are incredibly common, and I keep praying that none of them will be dropping any babies off at our apartment. They’re certainly large enough to do so. We also nearly had an ibis walk in yesterday afternoon, but he thought better of it.