March 28th, 2022 by Kaitlyn Hite
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Today I depart from Kiwoko. It is really difficult to summarize the past month, and it would probably do my time injustice to try to do so in one blog post. I have started some reflection on my time, however, and plan to continue to reflect as I transition back to the United States. Some things that I have reflected on include difficulties that arose that I was not expecting. This ranged from difficult medical decisions to realizing two weeks in that people don’t start to actively listen to you unless you have exchanged pleasantries first. Once I started asking how peoples’ days were and greeting them (which took less than 20 seconds), I received my requested assistance or other such matter I was hoping to discuss with the individual. This is a huge contrast to the US were I feel everyone is trying to get off the phone before they even get on it (if you know what I mean). I have also been thinking about health equity which is a hot topic in the US and one that is even more apparent here even though it is not discussed much. The  many faceted medical system here illustrates the disparities. There are government hospitals which are not invested in and, therefore, may not provide the best care for the patient compared to private hospitals that are usually owned by foreign companies and provide excellent patient care but are extremely costly and out of reach economically for many Ugandans. The mission hospitals try to fill in the gap between and “level the playing field” so to speak for accessing healthcare, but there is still a strong tie between poverty and illness that is visible to anyone who visits these communities. Lastly, while all decisions in medicine require a holistic view of the person, that holistic view here is much wider and deeper than I have encountered prior. For example, the hospital would love to have equipment such as ventilators and laparoscopic instruments for surgery. The providers have either already been trained on these types of things or easily could learn them, but you have to consider what happens if they are to malfunction or if they need regular maintenance. Many times these types of things require representatives from the company to inspect and maintain them which would be near impossible in rural Uganda. Overall, looking back on the last month, I feel very blessed and fortunate to have been born in the US. While it may not always feel as such to everyone in the US, it really is a land of opportunity and abundance. This experience reinforced for me that I want to serve in these areas in some capacity in my career. My next steps will be to discern how this will look and how it may evolve over the years. For now, I will sign off. I wish everyone well who travels to Uganda. It truly is the “Pearl of Africa”. I close with a traditional farewell saying “safe journey”: teriimukabi olugendo.

March 26th, 2022 by Kaitlyn Hite
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It’s my second to last day in Kiwoko. I’m not sure I have said this prior, but Kiwoko is pronounced “chew-woke-oh”. Any K at the beginning of the word becomes a “ch” sound. Sorry it took me until now to mention that! I spent the day visiting my new friends around the hospital to say goodbye. I also returned to maternity to make a few short videos of some ultrasound principles on the requests of the medical officers. At the end of the day, I had a leisurely evening with friends, cooking a local dish of spiced pork and matoke (steamed bananas like plantains). It was delicious!

Tomorrow I will take some time to reflect on my time here as a whole but for now I will list all the medical concepts I have either been introduced to or learned more in depth while here. Hopefully no one thinks I am a bad doctor for just now learning some of these things!

1. HIV management in children and pregnant women
2. Patient sensitive HIV nomenclature
3. Malaria management, its pathogenesis, and prevention strategies
4. Malaria prophylaxis side effects (which I may or may not have experienced personally- I’m looking at you Malrone!)
5. How to scrub before surgery without sponges
6. How to assist in c-sections when the hospital power goes out because it is too hot outside and the generator only operates the one overhead light in the theater
7. How to assist in a c-section when it’s an emergency and everyone is speaking Lugandan
8. How to resuscitate a baby when it’s an emergency and everyone is speaking Lugandan
9. Translating between 3 languages at once
10. Understanding the education system an individual learned in helps you communicate more effectively with them
11. Tuberculosis signs and diagnosis in children
12. How to date a pregnancy without an ultrasound or reliable last menstrual period
13. Motivational interviewing from a faith based perspective
14. Starting a conversation about work up and treatment with the estimated cost of such things and subsequently negotiating with the patient to complete the most important
15. Cutaneous myiasis and the plight of mango flies
16. Acute malnutrition signs, diagnosis, and treatment
17. The importance of taking a complete, culturally appropriate and specific social history
18. Sickle cell disease diagnosis and management (specifically things to avoid in these patients and how to prevent  vaso-occlusive crises)
19. G6PD clinical presentation
20. Diagnosing obstructed labor and potential complications
21. The difference between typhoid/typhus and typhoid fever (This has always been confusing to me so I only hope this stays in my brain long enough for the boards exam!)
22. How to use a sterile cloth tie to tie off an umbilical cord (as opposed to a plastic clip)

I am sure there is loads more that I have learned, but these points are top of mind and shows the constant learning I have been doing since arriving. Medicine is a profession that emphasizes lifelong learning and a huge reason why I pursued it as a career. At home though I feel I sometimes fall into the trap of “just finishing the day”. I am hoping that the fulfillment I have gotten over the past month of constantly looking for new information will spill over into my work stateside and revitalize my love of learning.

Lugandan word of the day: mukwano (“moo-kwawn-oh”, friend)

Medical learning point of the day: None today- see above.

Showing some ultrasound skills for the demonstration videos

Saying goodbye to new friends- two midwives in maternity (they are addressed as “Sister so-and-so”)

My last night cooking with friends

March 26th, 2022 by Kaitlyn Hite
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Today is my last official day of work (but tomorrow I may join in somewhere in the hospital). It has been such a bittersweet day as I said goodbye to many new friends but also reflected on all that I have learned in the past four weeks. I returned to maternity today and, surprisingly, there was not much going on besides rounds. This was good, however, as it left time in the afternoon to meet with the nurses and midwives to discuss natural family planning. There were 15 people in attendance! In discussion with them, it seems that being able to offer an option for family planning that does not include devices, barriers, or hormones is of great value to them. Some patients have  objections to using hormonal or device-based methods of contraception that include both religious reasons and personal beliefs. Also, many husbands do not allow their wives to use contraception, especially devices such as the arm implant or IUD. Furthermore, some patients have tried several methods of contraception already and have had side effects that have made them quit using those methods. Ugandan families are large with couples on average having 4-5 children. Large families are valued and having many children is a sign of being blessed. While couples typically desire many children, they usually also see the benefits of spacing their children so as to honor their responsibilities to their existing family (as well as for the health of the mother). For this reason, the midwives felt husbands would be motivated to use a natural method of family planning even if they objected to other forms of contraception. While my time with the midwives and nurses was not long enough to fully train them to teach an evidence-based natural family planning method, I believe we were able to introduce the topic and correlate the signs of fertility that are tracked in these methods with the physiology of a woman’s menstrual cycle. From here, I feel confident that these healthcare providers can seek further training and begin to notice signs of fertility that they can counsel patients to observe.

Lugandan word of the day: okuba olubuto (“oh-koo-buh oh-loo-boo-toe”, pregnancy)

Medical learning point of the day: When using IV primaquine to treat malaria (from Plasmodium vivax or ovale), infuse it with IV fluids containing dextrose as primaquine can cause severe hypoglycemia.

My last doctors’ meeting

March 25th, 2022 by Kaitlyn Hite
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On day four of my second maternity week, I started the morning with a presentation at the doctors’ meeting on one of my favorite topics- natural family planning! There was a lot of interest in the topic, and I was asked to present again tomorrow for some of the midwives and nurses. During working hours, I decided to focus on experiencing vaginal deliveries. The midwives manage labor and deliver the babies in uncomplicated vaginal deliveries. Labor management here adopts a very hands off approach compared to my experience on the labor and delivery floor in the US. If the mother is not on any labor augmenting medication, then they are monitored on the maternity ward with hourly vitals and fetal heart rates. If the mother is on labor augmenting medication, then they are brought to the labor suite, and they are placed on continuous fetal heart rate monitoring. As there is no central monitoring, the midwives check in periodically every 20 to 30 minutes and the goal is to make sure there is no sustained low or high heart rates. Regardless of how the labor is managed,  mothers will deliver their babies in the labor suite which is a separate area of the maternity ward that consists of four hospital beds separated by curtains. There is no coaching on how to push with contractions as most of this is left up to the mother’s attendant that accompanies them to the hospital which is usually their own mother or a close relative who has delivered a baby before. One of the most striking contrast between here and my prior experiences is that the labor suite is a relatively quiet area. Women are encouraged to be as quiet as possible when laboring and are somewhat discouraged from yelling out or groaning with contractions. For someone who wanted to observe this process and does not speak the local language, this made it very hard for me to know how patients were progressing. I accomplished my goal for the day though and was present for several vaginal deliveries. It is hard to believe but only one working day left. I am sad to see my time in Kiwoko coming to an end.

Lugandan word of the day: omulenzi (“oh-moo-len-zee”, noun, boy)

Medical learning point of the day: Because HIV is stigmatized, an alternate naming convention is used when communicating results among healthcare providers. TR is HIV negative. TRR is a new diagnosis of HIV. TRRK is known HIV positive. Lastly, TRRD is known HIV positive on antiretroviral therapy.

White board presentation on natural family planning (excuse my terribly drawn uteri- I’m no artist!)

I finally spotted the baby monkey in the local “troop” close enough to snap a pic!

March 24th, 2022 by Kaitlyn Hite
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Today I spent the day in the HIV antenatal clinic. It was very informative as I have not seen many patients in my training thus far with HIV, let alone pregnant patients. This clinic cares for pregnant patients, postpartum mothers, and infants/toddlers to the age of 18 months. As I discussed previously, every pregnant patient is tested for HIV at their first point of contact unless they have a recent result. Thereafter, it is recommended to test every 3 months until they have finished breastfeeding as HIV can be passed to the child (termed “mother-to-child- transmission”, or MCT) during pregnancy, at birth, and while breastfeeding.  Prevention of mother to child transmission (PMCT) is the goal. This can be achieved by ensuring the mothers are on medications, they receive an early diagnosis in pregnancy, and low counts of the virus in the mother are maintained, especially at delivery. The babies are also immediately placed on nevirapine to further reduce the risk of transmission. If they are a high risk baby, meaning any of the components above are not true, they will take this medicine for 12 weeks. If they are low risk, they will take it for 6 weeks. After birth, the babies are registered in a national registry so as to have close follow up in the first couple years of life. In an ideal situation, babies are evaluated at 4 weeks and if their HIV test is negative then they will be evaluated at 9 months, 6 weeks after cessation of breastfeeding, and 18 months. If they remain negative, then they are “discharged” from the HIV clinic. If at any time they are positive, then anti-HIV medications are stated. With all this coordination of care, it was very surprising to me that in a community that is so  geographically separated, where close to no one has reliable transportation and few have consistently working phones, most patients attend their visits as scheduled. This speaks to the excellent public health services in the country. Just like the community antenatal clinic, this clinic utilizes community members, called peer mothers, to keep track of and follow up with patients if needed, even if that means going to their homes. These women also act as a source of education for these mothers and as a support group as they have also been through the clinic themselves. Furthermore, the HIV clinic is the first place I have seen a computer in this hospital and the nurse was using a national electronic medical record to enter each patient’s information so that if they present to any hospital in Uganda, they can be tracked and cared for. The last component that helps maintain patient compliance is that all antenatal, HIV, and family planning services are free of charge in Uganda.

Lugandan word of the day: omuwala (“oh-moo-wall-uh”, noun, girl)

Medical learning point of the day: Exclusive breastfeeding is encouraged here for all mothers, including those with HIV (in contrast to the US), due to the affordability and great nutrition that breastmilk provides the infant. Mothers with HIV are encouraged to exclusively breastfeed until 6 months as early introduction of food could cause micro trauma to the esophagus and be a potential access point for HIV transmission through breastmilk. They are then strongly encouraged to stop breastfeeding when the infant is 12 months of age as the risk of HIV transmission at that point outweighs the potential benefit of further breastfeeding.

A tropical house gecko hanging out on the wall in maternity. There are no doors closing the hospital to the outside so many animals hang out in the hospital including ants, geckos, and the occasional bat or bird.

March 23rd, 2022 by Kaitlyn Hite
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My second maternity week continued today with more of the same but also some differences. An unfortunate theme of the day was birth asphyxia. Birth asphyxia is a common diagnosis here and one that I have witnessed first hand several times during my time here. This diagnosis is placed on babies that do not get oxygen quick enough at birth during a difficult delivery. This most commonly occurs during vaginal deliveries as c-sections involve directly going to get the baby from the uterus so it eliminates some of the variables related to birth asphyxia. The low oxygen can cause no effects on the baby or, depending on the length of time the baby is under stress, can result in poor oxygenation to the brain with resultant brain damage or even stillbirth. Today, there was a very difficult cesarean delivery of a baby whose mother had three prior c-sections (“scars” as they say here). These prior surgeries had caused extensive scarring of her abdominal muscles and uterus. When it was time to deliver the baby, the scarring was so constrictive that the baby’s head did not deliver quickly as it usually does. It took several minutes for the baby to be delivered and, subsequently, several minutes for the baby to breathe. The baby is in the NICU and doing well but I fear there may be some lasting damage. It is not uncommon here to meet women that have had 3, 4, or even 5 c-sections. More than 3 poses many risks to a pregnancy including risk of uterus rupture and the extensive scarring like was encountered in the scenario I am referencing. I am not sure of the exact statistics, but it does seem there is a high rate of c-sections here. In part this is because this hospital is known in the area for taking care of high risk patients but also there is no continuous fetal monitoring during labor. This means that if any abnormalities are detected during routine monitoring, the worst has to be assumed and patients are taken for c-sections. The midwives that attend to laboring patients are extremely skilled and knowledgeable within their scope of practice. If the technology was available for continuous monitoring, I am sure they would be able to learn how to use it and how to interpret the information. From what the staff tells me, this is not on the horizon any time soon but are dreams for the (hopefully not so distant) future in Uganda.

Lugandan word of the day: okusanyusa (please)

Medical learning point of the day: The current Ugandan guidelines for cervical cancer screening state it is to performed on all women from age 25-49 years old with either visual inspection (if premenopausal and has not had a child in the past 6 months) or by Pap smear cytology. This should be done every 3 years for HIV negative patients and annually for HIV positive patients. HPV testing is only available in a research setting.

Commuting to work

March 22nd, 2022 by Kaitlyn Hite
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Week 2, day 1 of maternity. I can’t believe it’s my last week in Kiwoko. I’m sad it is already coming to an end as I feel like I have so much more to learn. I’m glad I get to spend another week in maternity as it is a very busy ward in the hospital and you get the full experience there- mothers, babies, surgery, tropical diseases, genetic diseases, and pregnancy complications. Apart from the medicine, an interesting part of the day was related to language and translation. I worked with a medical officer that is not from this area of Uganda and, therefore, he did not know Lugandan. In Uganda, because of the influence of missionaries and educational services, English was adopted as the official language and remains the official language today even though a majority of the population does not speak it. There was an attempt to spread Swahili as the official language as it is African born, but many of the areas of Uganda did not agree with this as they were afraid it would ruin their local languages. There are 43 distinct languages in Uganda that can be broken up into four categories based on geography- Bantu, Nilotic, Central Sudanic, and Kuliak. Of the native Ugandan languages, Lugandan is the most widely spoken geographically. If you are in a city or doing business, people will usually be speaking English, Lugandan, or Swahili. If anyone has received a high school education, they will know some English. People that speak languages that are spoken geographically near each other can typically understand one another much in the same way that Portuguese and Spanish speaking persons can communicate without speaking each other‘s language. If people speak languages that are geographically separate from one another, however, it is nearly impossible to understand one another. This is the situation we found ourselves in today and this needed double translation for all of our patient encounters. Just as is in the US, I was left to wonder how much information was being conveyed properly to the patient and how much we were receiving correctly back. At the end of the day, I chalked it up as another reminder to always holistically assessing barriers with each patient.

Lugandan word of the day: okubaaga (“oh-koo-bog-uh”, noun, surgery)

Medical learning point of the day: G6PD deficiency is a condition that causes red blood cells to break down in response to a trigger. It is common in males and people of African descent. Triggers include infections, stress, fava beans, aspirin and other drugs. The symptoms include dark urine, fever, back pain, and pallor. While severe malaria can cause dark urine, consider G6PD if multiple people in the family develop dark urine while ill or if when they become ill they seem to fare worse than their peers.

A painting of the hospital

March 21st, 2022 by Kaitlyn Hite
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It’s the end of the third week. Time is flying! I spent Sunday going to church, finishing a book, and at a BBQ the ex-pat doctors hosted. After church I spent some time with a friend I met there. She is the secretary for the parish and lives there at the church. We had breakfast of spaghetti and cucumbers then we made juice together. The juice was basically everything that grows well here, blended up, and then strained. We put carrots, ginger, cucumbers, lime juice, orange juice, passion fruit, and a tablespoon of sugar in it. It took us about 2 hours from start to clean up, and it was delicious! In the evening was the BBQ which was a lot of fun. Everything was cooked over an open flame and the mosquitos weren’t so bad because of the smoke from the fire. All in all, not a super packed day but enjoyable and restorative for the week ahead. I’m planning to return to maternity and hopefully continue some ultrasound lessons. Last week in Kiwoko, here we go!

Lugandan word of the day: eddagala (noun, medicine)

Medical learning point of the day: If concerned for congenital malaria (pregnant mother with prolonged untreated malaria during pregnancy), take a cord blood sample or smear of the placental tissue at delivery to analyze for parasites.

Grilling at the BBQ.

March 19th, 2022 by Kaitlyn Hite
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Today I said goodbye to the three German medical students that have been in the guest house with me for the past three weeks. Hopefully our paths cross again in the future! The rest of the day was very quiet and relaxed, filled with studying for my board exam and the doctors’ and medical officers’ kids playing soccer and tag outside. I also perused the house’s bookshelf and found a guide to Ugandan culture (see below). It was a short read so I finished it in a couple hours and, after being here for three weeks, I can attest that it is very accurate and would be extremely helpful to read ahead of time for anyone visiting Uganda. In this book, it opens with a poem from Rudyard Kipling which I think really embodies a lot of the feelings that we can have when inserted into a society different than our own and reminds us to be openminded during those times as well. I thought for today’s post I would include it here for your reflection. Enjoy!

We and They:

Father and Mother, and Me,

Sister and Auntie say

All the people like us are We,

And every one else is They.

And They live over the sea,

While We live over the way,

But-would you believe it? –

They look upon We

As only a sort of They!

We eat pork and beef

With cow-horn-handled knives.

They who gobble Their rice off a leaf,

Are horrified out of Their lives;

While they who live up a tree,

And feast on grubs and clay,

(Isn’t it scandalous? ) We look upon

As a simply disgusting They!

We eat kitcheny food.

We have doors that latch.

They drink milk or blood,

Under an open thatch.

We have Doctors to fee.

They have Wizards to pay.

And (impudent heathen!)

They look upon We

As a quite impossible They!

All good people agree,

And all good people say,

All nice people, like Us, are We

And every one else is They:

But if you cross over the sea,

Instead of over the way,

You may end by (think of it!)

Looking on WE

As only a sort of They!

Lugandan word of the day: mwattu (“muah-too”, please)

Medical learning point of the day: Antibiotic resistance is a rapidly increasing problem in developing nations, especially sub-Saharan Africa. The nations here have been using the same handful of antibiotics for the past 50 years and, whether because of supply chain issues or finances, are not able to easily access other more potent antibiotics. For example, a small study at this hospital showed that over 50% of cultures that grew E. coli (urine and wounds) were resistant to ceftriaxone which is one of the best IV antibiotics they are able to give here.

A hadada ibis that landed on the soccer pitch between games

The very helpful Uganda culture guidebook- a must read for all visitors!

March 19th, 2022 by Kaitlyn Hite
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Today was day five of maternity week. The day consisted of, as always, rounds and C-sections. Today felt very surreal to me though because I had two experiences where the tables had turned and instead of me playing the part of student, I instead played the part of teacher. Firstly, one of the medical students from Germany wanted to assist on a C-section as it is her last day at Kiwoko. As she is new to assisting, I stayed in the operating room to help show her which instruments did what and when the surgeon would need those instruments. Later, I was speaking to a couple of medical officers and found out that they were interested in learning some principles of point of care ultrasound. While the hospital has two ultrasounds, one in the outpatient department and one in maternity, medical officers get no training on ultrasound during schooling and had not found time to learn with the gynecologist yet. In the US, I’ve been very fortunate to be exposed to ultrasound since medical school and have used it regularly throughout residency. So, I paid back the medical officers for all the teaching they have given me thus far on tropical diseases, sickle cell disease, and surgical obstetrics by ending the day with an introductory course to ultrasound. We reviewed the controls and functions of the ultrasound, the types of exams and how to program the machine for each exam, and the types of probes and how/when to use them. We also were very lucky as there is a pregnant patient that is staying at the hospital awaiting induction of labor on the 21st as she lives very far away. She was very gracious and allowed us to do an ultrasound scan on her to measure fluid volumes around the baby. We are hoping to continue building on ultrasound principles over the next week until I leave. I guess I was surprised to be in this role here because everything is so new and different to me that I have been very much in the mindset of a learner since I arrived. Medicine, however, is a profession that requires continuous learning and education. This naturally leads to an exchange of information among providers. Today reminded me that it is not only important to continue learning yourself but also to be committed to sharing knowledge with others so that they too may grow in their practice of medicine, no matter where you are in the world. I hope I did my US faculty justice!

Lugandan word of the day: omusawo (noun, doctor)

Medical learning point of the day: While not evidence-based, in low resource settings or places of poverty where hygiene may be an issue, consider giving prophylactic antibiotics after a C-section, such as a combination of amoxicillin and metronidazole, to prevent endometritis and surgical site infections.

One of the medical officers and me during a c-section (surgery omitted for patient privacy and my squeamish family).

The ultrasound in maternity