May 22nd, 2013 by INMED
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Fourth day on Peds.  Dr. Susan and I split the wards again today, but today I saw the sicker patients while she saw the more ambulatory ones.  Of the ones I saw, malaria seems to be the cause for the more severely ill.  One 4 year old boy who was admitted yesterday afternoon came in minimally responsive, almost obtunded.  We’ve been treating him with IV quinine and placed an NG tube to feed him as he refused to feed and at times is too unresponsive to take anything by mouth including fluids.  I wrote to repeat his malaria slide this afternoon because his original slide had >500 parasites per 200 WBC field.  Most slides have anywhere from 50 – 100, sometimes 200 parasites per field.  Meaning, that his parasite load was basically too high to count.  If his repeat count remains high we will keep him on IV quinine rather than the usual practice of switching to oral Coartem after 3 doses of either quinine or artesunate.

By the way, peds ward only encompasses ages 29 days to 5 years old.  If they are 28 days or younger, they go to NICU; if >5 years they go to adult male or female ward.  Obviously children are not “little adults,” the shift to the adult wards is to prevent Peds ward from becoming too overrun.  As it is Peds is the busiest ward here in the hospital, especially this time of year as it’s the rainy season and malaria is rampant.

Another if the sicker children I saw today is a 4 year old girl who also was admitted last night.  The admitting physician thought she had a surgical abdomen, meaning that her belly was rigid and she could hear no bowel sounds.  She also came in with malaria and a parasite load of about 200, but she is also very jaundiced (the bottom of her feet are yellow!).  The surgeon was unable to see her last night, which is actually not that uncommon.  Surgeons here do everything from circumcisions to C-sections to prostatic removals and all orthopedic procedures!   Not to mention the usual intra-abdominal surgical cases that you would see back in the States.  There’s just no other surgical specialists to help out.  Anyway, by the time I saw her this morning, her abdominal pain had lessened and she had bowel sounds.  She also had had a bowel movement, which was reassuring.  Her fever had also resolved, but she still obviously was sick and refused to take anything by mouth.  She was very restless, rolling over in bed and crying out.  Her father had initially refused any further blood tests on her because she cried so much when being stuck with needles, but I was able to convince him that we needed to test her for sickle cell, hepatitis, and typhoid fever as well as obtain some liver function tests.

These finally returned late in the day.  By that time I had gone by to review her again, but this time was much more worrisome.  I no longer heard any bowel sounds and her abdominal pain had become specified to her right upper quadrant, where her liver and gallbladder are located.  I called the surgeon and he came by about 20 minutes later.  By that point, she was no longer tender in her right upper quadrant, but was continuing to cry and moan whenever you touched her legs or arms.  Her liver function tests came back elevated (both gallbladder and liver tests) and he was concerned more for possible cerebral malaria causing her changes in attentiveness/alertness and the persistent crying.  However, he admitted this did not explain either her jaundice or her elevated liver tests.  The joint decision was to keep her on quinine for 3 more doses in case this was cerebral malaria, cover her for sepsis (a standard practice when children are diagnosed with cerebral malaria) and obtain an abdominal ultrasound tomorrow.

I have kept a running list of things necessary before coming overseas to help anyone deciding to come to Kiwoko and for my own future reference:

• You can not have too much hand sanitizer
• Loose fitting underwear is key in the tropics (to help reduce sweating and risk of itchiness, fungus in compromising places)
• Clotrimazole (see above — also for shower foot fungus)
• Shower shoes
• Cannot have too many foreign electrical outlet adapters
• Bleach (to disinfect toothbrush, wash fruits/vegetables, etc)
• Phenergan or other anti-emetic
• Cipro
• Immodium
• Enough Pepto for prophylactic doses AND treatment if needed
• Rain tops/bottom
• Drug pharmocopeia !!! (do not have instant access to Uptodate here – although the British National Formulary has been a lifesaver on the Wards, there should be an American counterpart!)
• Oxford guide to Clinical Medicine/Washington Manual
• Oxford guide to tropical disease

May 21st, 2013 by INMED
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Today was my third day on Pediatrics.  Dr. Susan and I will split the ward in half and see each patient, in theory at least.  She rounds on the sickest patients (i.e. those on oxygen) and I start seeing the other patients.  Today, however, there was a new admission from last night who is very ill.  He is a 2 year old with HIV and severe malnutrition.  He only ways 7 kg and is so malnourished that his skin is paper-thin and basically peeling off.  Very sad.  Susan spent most of the morning seeing him, while I saw the rest of the patients.  This was a good feeling, being able to manage a Peds ward.

Afterwards, we went to Doctor’s meeting and then Adult HIV Clinic.  This lasted much longer than Peds HIV Clinic, stretching right through lunch until about 3 in the afternoon.    I am learning much about HIV management, when to start anti-retrovirals, when to switch to second-line therapy, the adverse effects associated with each medication, and so on.  Most of the patients are fairly stable and therefore quick visits, but sick patients do arrive as well who need admission.  One lady was wheeled in by her family and she was obviously very ill, exhibiting wasting, a deep cough that brought up blood, severe weight loss, and diarrhea for several weeks.  She was almost so weak she could barely turn her head.  We obviously admitted her.

As for Peds, we see lots of malaria, some of it very severe with children who come in basically obtunded or unconscious.  Febrile seizures are fairly common here, as is malnutrition, sickle cell, and pediatric cardiac disease surprisingly.  Many of the complex cardiac patients eventually require referral to Mulago Hospital, which is the main University-based referral hospital in Kampala.  The way the health system works in Uganda is varying degrees of medical complexity.  At its most basic, there are local health clinics.  Based on what they provide, they are rated in a category from I-IV.  Then there are the local government hospitals.  Above those are regional referral hospitals, of which Kiwoko is considered one, although it is funded predominately as a missionary hospital rather than government based.  Our catchment area here is about half a million people.  Mulago meanwhile serves the entire population of Uganda.

Many patients do not want to make the trip to Mulago, mostly for financial reasons.  It is very difficult when we explain to parents that we would like to send patients for referral and they are either not able to pay for the consultation or even pay for transportation to Kampala.  Superstitions also play a major role here.  We had one patient leave with her baby (who has Down’s syndrome and known VSD found on echocardiography and is suffering from heart failure — she’s only 14 months old) yesterday without telling any of the staff because she had thought the parent of another baby had cursed her child.  Another patient told us yesterday that she believed her baby was cursed.  Coincidentally, she also has unexplained tachypnea (increased respiratory rate) and oxygen dependency without any fevers or signs of infection.  We wanted to refer her to Mulago as well, but the mother states that because her baby is cursed, the doctors at Mulago will not be able to help any more than the doctors here at Kiwoko and that she needs to see the local witch doctor instead.

I just realized that I have not described a typical day here.  Generally, the day starts at 8:15 with morning prayers, which we are all expected to attend.  Afterwards, we have Doctor’s Meeting from 9 until 10 AM.  This includes check-out from the night before as well as daily CME.  Ward rounds start after this and generally continue until lunchtime.  After lunch, we return to the wards for any admissions from OPD or “reviews” which are patients that OPD has sent over because the doctor there is not sure whether the patient actually requires admission.  We also round on some of the sicker patients again in the afternoons.

One last interesting fact:  just before I arrived a man was admitted to the hospital after he was attacked by a leopard!  Several of my housemates here before me were here when he was admitted.  He was out in his fields and farming when he was attacked by a leopard.  He suffered pretty severe lacerations around his skull but survived.  It was actually pretty near Kiwoko, which is a bit unnerving considering I go out running around here.  Not something you’d see back in the States, unless you’re out west where you have to worry about mountain lion attacks.  Tomorrow is my last day on Peds even though it’s the middle of the week.

Because I’m here for such a short time, I’m only cycling through each ward for only a few days at a time.  I’m headed to either Maternity or NICU after that.  And then, most excitingly, going this weekend to see the gorillas in Bwindi Impenetrable Forest!

May 15th, 2013 by INMED
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Very busy day today:  I left our usual doctor’s meeting/teaching rounds expecting to see my half of the Male Ward patients that I had rounded on yesterday.  However, the physician covering Female Ward called in sick and, since I had been on Female Ward last week, I was asked to cover for her.  I was happy (and a bit nervous) to do so, but it was still a bit of a shock going from covering half of a ward to a whole ward, and basically a brand new set of patients at that.  I was assigned my own medical student, and she was proved to be very helpful, recording while I interviewed the patients.

Of all the diseases encountered, HIV is by far the most prevalent.  On any given day, half to two-thirds of any ward (except NICU) consists of HIV positive patients.  Because of the stigma still associated with the disease, it undergoes two pseudonyms in the medical chart:  CTRR and ISS.  CTRR stands for Counseled, Tested, Resulted, and Reactive.  If the patient returns negative, it simply reads CTR in the chart.  ISS simply means Immunosuppressive Syndrome.

Caring for HIV patients — many of whom are extremely sick — has been one of the biggest challenges and changes from working in the US.  Almost every person admitted to the hospital has a screening HIV test and the majority return positive.  Once positive, they receive HIV counseling and are established in the outpatient HIV clinic once they are discharged from the hospital.  Many of the patients we see here have Stage IV AIDS under the World Health Organization classification for HIV/AIDS.  Stage IV is the worst. Patients are started on anti-retrovirals if their CD4 count (the white blood cells which are attacked by the HIV virus) is under 200 or if they have a Stage IV AIDS defining illness.  These include things like cryptococcus and toxoplasmosis.  Several of the HIV patients that I rounded on today had CD4 counts below 50.  We did see one patient with a CD4 count of 2 yesterday.

TB is another of the frequent opportunistic infections encountered here, and this includes extra-pulmonary TB including Potts disease (TB of the spine), hepatic TB, miliary TB, and lymphatic TB.  Pulmonary TB is generally treated for 6 months here and extra-pulmonary for 9 months.  The diagnosis is often tricky as it’s very difficult to obtain sputum samples and, at least in HIV patients, sputum samples are often negative for acid-fast bacilli (the test for TB), so the diagnosis is made on a combination of radiographic and clinical findings.  Another frequent opportunistic infection encountered here is diffuse candidiasis (a type of yeast causing pathologic disease).

All in all, the day was very tiring, as we had several new admissions as well as several “reviews” sent from Outpatient Department.  These are patients who may or may not warrant admission criteria and therefore the ward physician interviews and examines them and determines if they need to be hospitalized.  After all this, I was very happy once all the work was done, and dealt with the fatigue the best way I know how:  I went for a run.

Which, in and of itself, isn’t that big a deal, but here it’s a rather comic affair for the Ugandans to see a lone white person going for a run.  The children become most the most excited and will yell out “Bye Mzungu!” or “Run Mzungu run!” (making me feel rather Gumpish) and sometimes even join in with me for a few yards, laughing all the while.  In general everyone, young and old alike, laugh when I run by, but it’s good-natured.  Sometime people on the road ahead of me will hear me coming and stop and gape at me until I’ve passed.

An update on the boy with snakebite:  He’s being discharged tomorrow.  He made a dramatic recovery after his skin infection antibiotic was increased and he was placed on anti-malarials.  His leg looks great, and it definitely seems that it was a combination of cellulitis and malaria rather than snakebite.  At the end, it’s been a very tiring but rewarding day.

May 13th, 2013 by INMED
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This past weekend was Murchison Falls.  It deserves its own separate post and also deserves pictures.  Unfortunately I cannot upload over this internet connection.  Suffice to say that we saw plenty of antelope, hippos, crocs, herds of giraffe, monkeys, troops of baboons, a lion, had our way blocked by a herd of elephants, and also had a cape buffalo threaten to charge our van.  It was also a bit of a challenge arriving at the National Park as our clutch gave out several times and we were stranded at one point for over an hour, surrounded by Tsetse flies (whom our guide assured us “carried no diseases” — yet we had admitted a patient with African trypanosomiasis just the week before).  But pictures and more later….

Today was my first day on Male Ward.  I am working with Dr. Natasha.  We’ve had several interesting patients, including a 10 year old who was admitted for snakebite.  He stated that he had been swimming the day before (Sunday) and had felt a “bite” under water.  His father had watched him for most of the day but then brought him to the hospital on that evening.  He presented with a decreased level of consciousness (GCS score of 10 — which basically meant he was moaning and withdrawing from pain, but not much else) and continued to drift in and out of consciousness.  He also had labored breathing.  Due to this, and the history of snakebite, he was given anti-venom late last night.

Today, when the admitting physician came to see him, he was sitting up and talking in bed, no longer confused.  He’d had no bleeding, and his main symptoms had been decreased respiratory rate, hypotension, confusion, and pain/swelling in his left leg (the bitten leg).  He’d had no bleeding and had also been started on antibiotics (cloxacillin here staph/strep infections as they don’t have MRSA yet) the night before as well.

It didn’t really sound like a snakebite to me.  For one thing, puff adders are the main snakes here, and they are in the pit viper family, similar to rattlesnakes and copperheads, which produce an anti-coagulant and not neuropathic venom.  Cobras and black mambas are the other poisonous snakes here, but these produce neuropathic venom similar to coral snakes at home as they are all from the elapid family.  In the US at least, the two antivenoms are very different, and in the British Formulary (used here) they are not to be mixed.  No one here knows if the antivenoms are combined or separate.

However, for this patient, he’d had no bleeding.  He had had neurological symptoms, but not the ones typical of snake bite, which is almost an like Guillan-Barre in that it is ascending paralysis (if bitten on a lower limb). Later today, when we rounded on him, he had a clearly red and unilaterally swollen limb and still had fevers.  He had no fang marks, indeed no skin breakage of any kind on his foot, which is where he swelling was the most pronounced and where he thought he’d been “bitten.”  There was definitely no signs of skin necrosis, which would be expected if he’d had enough venom injected to cause systemic symptoms.  It looked much more like he had a case of bad cellulitis.

Interestingly, as we were discussing him his blood smear came back positive for malaria. This explained the fluctuating fevers and altered level of consciousness.  We started him on anti-malarials as well as increasing the dose of his cloxacillin.  Dr. Natasha is not convinced that it’s not snakebite, but she did hold off on any further antivenom (he became confused and disoriented a few minutes after we rounded on him, but improved greatly this afternoon after being started on his meds).  More to follow on him tomorrow.

We also had a patient with blood pressures of >200/>100.  He has diabetes, hypertension, and chronic renal disease.  It’s just like being back home!  Otherwise, many patients had gastroenteritis, HIV including cryptococcal meningitis and two with toxoplasmosis, malaria, typhoid fever, TB, and a couple of patients that we’re still trying to figure out.  One of the patients positive for toxo titers also has what seems to be hemi-neglect (meaning he totally ignores/doesn’t see the left side of his visual field) as well as total left-sided weakness and persistent myoclonic jerks (meaning his left arm and left leg constantly jerk) that doesn’t respond to diazepam or phenobarb.  I

Also of note, regarding blood transfusions — they don’t transfuse blood unless the hemoglobin (called Hb here) unless its lower than 5.  In the States, the transfusion threshold is 7.  We routinely see Hgb’s of 2 and 3, sometimes in kids who were running around and playing earlier that day. Otherwise, all’s well, back to Male Ward tomorrow.

May 7th, 2013 by INMED
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Second day on the wards.  I split the female ward with Dr. Diana (the physicians here go by their first names, signing the same way in their charts) and was actually able to get through my half, including a new admission, who was a 32 yo female with LLQ abdominal/pelvic pain.  She had had an ultrasound but the report said she needed to have a repeat once her bladder was full.  Unfortunately, but the time this occurred, the ultrasound machine was down, which is evidently a not uncommon occurrence here.

Our other new admission here was also very interesting.  When I first met her,  I thought the young 17 yo female girl had nephrotic syndrome due to her facial congestion/edema.  However when I asked Dr. Diana, she said that it was a condition known as EMF, endomyocardial fibrosis.  Evidently EMF was first discovered in Uganda in 1940 and is a form of restrictive cardiomyopathy.  Here’s the paragraph on Epidemiology for this condition:

EPIDEMIOLOGY — EMF was first recognized in Uganda during the 1940s and accounts for as much as 20 percent of cardiac cases sent for echocardiography in that country in contemporary series. Although accurate epidemiologic data are lacking, EMF is estimated to the most common form of restrictive cardiomyopathy worldwide

According to the physicians here, the hallmark sign is abdominal edema without pedal/lower extremity involvement.  I actually saw 2 patients today with this.  The second was also a known EMF patient who shows up at the hospital once a month for paracentesis.  She had stick-thin legs and an extremely swollen belly, just as described.

We did an EKG on the patient, which was very interesting for 2 reasons.  Evidently the Ugandan physicians  do not learn EKGs in medical school (more on their training later, it’s actually very impressive).  Dr. Diana had seen 3 in med school.  I walked her through the diagnosis — unfortunately the patient had Mobitz II 2nd degree heart block as well as very prolonged QT syndrome.  She’s not doing well at the moment.  After reading about it, EMF patients are treated like diastolic restrictive heart failure patients, which is very difficult.  The true treatment is surgery, for which we have to refer her to the main hospital in Kampala.  However she is too unstable at the moment to make the 2 hour journey over rough roads.

The second reason the EKG experience was so interesting was that in placing the EKG leads.  None of the nurses knew how to do it and turned to me to do it!  Although I know about reading them, I don’t know much about actually placing them.  Luckily there was a British medical student present who walked me through it. Those were the 2 most interesting tidbits from today:  EMF and EKGs.  2 more days on female ward and then it’s off to Murchison’s Falls for the weekend.  More to follow…

May 6th, 2013 by INMED
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In my previous post, I mentioned working with INMED.  For those who don’t know:  INMED stands for the Institute for International Medicine and is a program based in Kansas City which offers multiple courses in International Health.  I am currently a diploma candidate.  To certify for the Diploma in International Medicine and Public Health, one must complete an online course at the end of which is an on-site, hands-on practicum and final exam.  Also required for the Diploma is the completion of an international medical elective, performed at one of their many training sites around the world.  There is also the option to complete the online courses in either International Medicine or International Public/Health to just obtain the Certificate or just attend one of the electives.  INMED also offers several other courses as well which can be completed online. I learned about the program when I was in Ghana in medical school.  Two Peds residents from Iowa attended through the INMED program, as Baptist Medical Center in Nalerigu where I attended my medical school elective also happens to be an INMED site. After learning more about the program, it seemed perfect.

I wanted to return to Africa and chose Uganda to get a flavor of East Africa and compare it to West.  I was there in the dry season in Ghana and this is the rainy season, so for one thing it is much greener here now.  Though, according to the locals, it rains throughout the year as well, just more focused during the rainy season.  Evidently Lake Victoria is large enough to produce it’s own weather patterns, and we are near enough to the lake to see continuous effects of rain, even during the dry season.  I chose Kiwoko (despite the fact that here physicians are expected to wear ties! very different from the scrubs and flip-flops of Ghana) due to the mix of wards available and training opportunities.

Work started today.  After introductions at morning prayers (I’ll describe a typical day in a later post), we had our usual AM physicians meeting and then I was assigned to the Female Medical Ward.  I’ll be on Male medical ward next week.

Already today we’ve seen a wide variety of patients.  Some of the diagnoses seen just today:

• Brucellosis (there is a rapid antigen test here for this)
• HIV/TB/combination of these
• malaria
• sickle cell
• strongyloides in the lung phase of its life cycle (larvae found incidentally in sputum of TB patient!)
• stool sample positive for Giardia
• separate stool sample positive for strongyloides (different patient from above)

Besides the wide variety of diagnoses, the other main difficulty is translating the British abbreviations as well as British laboratory values.  For example, O is short for edema (oedema).  RBG is for random blood glucose, and they use VERY different ranges for blood glucose here!  Insulin here is also prescribed as “soluble versus insoluble” with names I have never heard. That’s probably enough for today.  Plan on doing some reading about the insulin used here as well as malaria treatment.  Stay tuned for more…

May 3rd, 2013 by INMED
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“You are welcome to Uganda!” This is the universal greeting here in Uganda. I’ve heard it everywhere since coming here. It’s been a whirlwind trip so far, 30 hour transit time, got into Entebbe late last night (after midnight), was able to sleep in this morning, and then started the 3 hour trip north to Kiwoko at 9 am after breakfast. It’s the rainy season, so the roads are pretty bad and my driver had to take a few side routes because the road had flooded in several areas.

There’s been a flurry of sights and images so far: flying in over the pitch black of Lake Victoria, no lights whatsoever before touching down so that when the wheels bumped earth it was actually a surprise. Waking to a thunderous rain (and thunderous storm) that in only a few short minutes had swamped the short, grassy walkway leading to breakfast (only about 10 yards) so that I was walking through ankle deep water. Returning from breakfast 20 minutes later after the rain had stopped and being surprised to find that the ground–although not totally dry–had already soaked up the majority of the water. The guinea fowl roaming the courtyard of the Entebbe Airport Guesthouse where I stayed my first night and having them tap on my glass door while I dressed. The smog and traffic as we approached the capital city Kampala. Our “side detour” through the Kampala slums and the expressions on the faces of the slum dwellers who, as they stood on higher ground, watched as the muddy waters flooded their shacks.

Kiwoko is a small village located about 15 km from the nearest town, Luwero, and is reached via a winding, dirt track that is currently more mud than dirt. The main thing here is the hospital, very little of which I have seen thus far. Having come in Friday afternoon, most of the physicians had already finished their morning rounds and were off this afternoon. The staff volunteer coordinator plans to show me around this weekend and gave me the afternoon to unpack and settle in.

May 1st, 2013 by INMED
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Hello! My name is Jeffrey Walden. I am a resident physician at  Moses Cone Family Practice Program, and I’m starting my INMED service-learning experience at Kiwoko Hospital in Uganda beginning in May 2013.