updates

Breaking news update on IHK:

IHK and its parent organization IMG (International Medical Group) now has a new vision statement, or is it mission statement: ‘Providing Healthcare to International Standards’

Not surprisingly, it took a 3-day strategic planning session with hired consultants and all of the IMG’s top managers to come up with this new mission/vision statement which is even slightly more vague and even more impossible to measure than the previous vision statement: ‘Making a Difference in Healthcare for Uganda.’

Healthcare, unfortunately doesn’t have any ‘international standards.’ Even the US and the UK can’t agree on something as simple as CPR (the American Heart Association teaches breaths before compression while the British Heart Association teaches compressions before breaths). Who’s going to set the ‘international standards?’ Will they be set in Europe, or Asia, or the Americas? Boston or Bangladesh? And if they are set, will they even be applicable in Uganda?

Wrecked in the Rwenzoris (Climbing in the Mountains of the Moon)

for more pictures of the hike

“Born to walk on pavement.”—Anonymous. (scrawled in charcoal on the wall of the Kitandara Hut, 4023 meters above sea level [ASL] in the Rwenzori National Park)

I have hiked and climbed in many places in this world, some of them paved, most not, but I have never felt my senses of balance and proprioception tested like this past week trekking the central circuit of the Rwenzoris. Apparently, given the graffito above, I am not alone.

I think in a previous posting, I mentioned the 1990 movie Mountains of the Moon. Reference to the Mountains of the Moon first appeared in Ptolemy’s Geography. Ptolemy or Ptolemaeus (a Greek guy, citizen of the Roman empire, living in Egypt in the first century AD) noted that the trader Diogenes got lost on his way back from India and landed in Rhapta in East Africa from where he traveled west for 25 days until he found a giant, snow-covered mountain range which he dubbed the Mountains of the Moon, and the source of the Nile. Diogenes, many believe, may have been the first european to view what is now known as the Rwenzori Mountain Range. Many others, however, believe that Diogenes was a fabricating sack of dog poop.

In either case, the Uganda Wildlife Authority UWA) refers to the Rwenzoris as the Mountains of the Moon, and the area has been given National Park and UNESCO World Heritage Site status. Herbert, my ever-so arrogant RMS lead guide still holds to Diogenes’ otherwise universally disregarded assertion that the snows of the Rwenzoris are the source of the Nile. The Rwenzori Mountaineering Service (RMS) has a monopoly on guiding in the Rwenzoris. So if you want to go hiking or climbing in the Rwenzoris, you will need to talk to Elisha or Jerome (‘tourist officers’ for the RMS), or, most likely, both of them… many times.

As a wannabe climber hanging in East Africa, naturally I have thought long and hard about climbing Kilimanjaro (5895 meters ASL)—the legendary dormant giant volcano in Tanzania that towers to Uhuru peak, Africa’s high point. But I must admit to being put off by the thought of climbing in the company of hundreds (about 15,000 people try to climb Kili a year: 40% of them succeed, on average 10 of them die) of my fellow tourists, most of them nauseated with altitude sickness, on wet-wipe littered hiking routes that require little or no mountaineering skill. Don’t get me wrong, it may be a walk up Kili, but it is a long and strenuous walk to a very high altitude and anyone who has made this walk should rightly feel proud of their achievement. But, in the end, I set my sights on a lower, slower (only about 200 people climb in the Rwenzoris each year), and more local summit: Margherita Peak of Mount Stanley (5109 meters ASL)—highest point in Uganda, third highest peak in Africa, and home to what will soon be the last remaining glaciers in Africa.

And so, after many phone calls (hint: don’t even bother with the email), and after many changes in dates and plans (the dry season, theoretically, ends the first half of march, so I was under some time constraints trying to get a trip planned, and Elisha was trying to tag me onto to a group of American climbers, but they canceled, so he put me in with a Polish team), and after a 12 hour bus experience, I found myself in Kasese at the Sandton Hotel having dinner with my four new trekking/climbing partners: Pavel, Magda, Janocz, and Janocz.

Magda is a second year psychiatry resident at the Mayo clinic. She would find herself, later in the week, in the position of interpreter, moderator, and voice of reason ('I have absolutely no testosterone.') for the group. Her father, Pavel, and the two Janoczs had traveled together and climbed Kilimanjaro in the past ('My father says there was nothing this hard on Kilimanjaro.' Magda would confide later). Magda had a brand new ice axe and pair of crampons in her pack.

The next morning, before breakfast, I met Herbert and we took a walk to the Bata shop to purchase the essential piece of Rwenzori mountaineering equipment: a pair of rubber boots. I opted for the 19000 shilling boots with the molded heel and tread as opposed to the more slippery soled 12000 shilling model. The extra 7000 shillings would turn out to be a worthwhile investment. Even so, the boots still had less padding under the balls of my feet than my flip-flops. I tried to have a conversation with Herbert about the conditions in the mountains, but couldn’t get him to contribute more than a few grunts and an enigmatic ‘it will be very wet and very hard.’ More than anything, he seemed annoyed that he’d had to get up 15 minutes early to make this errand.

I have been fortunate to climb with some excellent mountain guides. In the early stages of an expedition, most guides would be trying get some idea from the clients as to just exactly what their level of climbing skills were, so as to make an assessment on whether they were suitable to take into the mountains and what additional safety or climbing gear might be needed. Herbert had no such curiosity. He soon decided that the Poles could not understand what he said, so he addressed all of his comments to me—expecting me to tell the rest of the climbing team what to expect. Fortunately, Magda was able to re-direct.

After breakfast we loaded up the gear and drove an hour on a dirt road out of Kasese into the mountains to the village of Nyakalengijo. At the RMS headquarters we were greeted by over a hundred men in rubber boots with their faces pressed through the gaps in the bamboo fencing. According the RMS fee schedule, the climbing fees include one guide and two porters per climber. The village men have been lining up here to carry loads into the mountains for over a hundred years since the Duke of Abruzzi came to climb the peaks of the Rwenzoris in 1906. It is not mentioned just how many men were involved in the first ascents in the range, although initially the string of porters was over a half a kilometer long. It also isn’t mentioned how many of the porters died on the initial expedition, but Herbert said that at least 3 fell to their deaths trying to ascend the Kicucu cliffs, the new path discovered by the Duke’s guides into the heart of the Rwenzoris.

I have some mixed feelings about using porters. Part of me feels the need to have the packstraps digging in around my shoulders to get the full-on masochistic climbing experience. The other part of me wishes the porters would carry up lawn chairs and a pony keg as well. But since the mines closed in the 60s and all of the game has been killed off, portering is one of the few opportunities for employment in the foothills, so I feel okay letting them carry my pack as a contribution (however small for the toil involved) to the local economy. The porter who gets my pack lucks out—it is a good five kilos under the 18 kg limit (maybe I should have brought more warm clothes).

For our first day we walk from Nyakalengijo to Nyabitaba camp (1600m-2651m). Herbert says it will take us a maximum of four hours. It takes us five. We walk with Nehemiah and Jomad, Hebert’s two subsidiary guides, who might speak English, but since they never opened their mouths, it was hard to tell. Jomad would walk a random number of steps (4-17), and then stop abruptly and turn to see if we were still following. Invariably we were. After bumping into him from behind on several occasions I learned not to follow Jomad too closely.

We walked along the Mobena river through a forest of moss drenched cedar and giant ferns. The occasional massive banana tree loomed unasked for by the side of the trail. We could hear monkeys in the trees and catch glimpses of them in the canopy. But we never got enough of a view to identify them as the rare red rwenzori colobus monkey as opposed to the usual black ones. At one point in time, the bush elephant roamed the foothills. It would have been an amazing thing to run into an elephant on a climbing trip, but they were killed off in the 70s or 80s, so it was not to be.

We reached the Nyabitaba hut just as the rain starts. An Austrian climber, Franc, has beaten us there. A rain-sodden Japanese team of four photo/video journalists dragged in just before dark and promptly set up their camera and start filming us taking our tea on the veranda (if you happen to be watching the Japanese Discovery channel next year and see a documentary on climbing in the Rwenzoris, please post it on You-tube and let me know). Franc and the Japanese will be the only Mzungus we encounter during our week in the mountains.

Pavel and the Janocz, in their limited English (but, much less limited than my Polish) show me why their packs are so much bigger than mine. They are loaded with Polish Cheese and Sausage and nearly a gallon of pre-mixed Margaritas. We toast irridescent green tequila containing substance to the peak we will never truly see: ‘Margherita!’

Rwenzori comes from the Bakonjo (Bakonzo?—one of the two local tribes that make up the recently established Rwenzururu kingdom, a splinter of the Toro kingdom) language and roughly translates as ‘place from where the rains come.’

The rains come down in earnest on our second day’s walk from Nyabitaba to John Matte hut (2651m-3505m). Herbert says the walk will take us a maximum of seven hours. It takes us eight. You may be picking up a trend here. We descend off the ridge to cross the Mobutu river just below its junction with the Bujuku river—both running brown and high with the recent influx of rain and mud. We criss-cross the Bujuku on increasingly more fragile bridges as we wander through a bamboo forest and then into thickets of mossy rhodedendron looking trees. Again, Jomad leads the way in his walk-stop, walk-stop hokey-pokey, but today he throws in the additional movement of bending over to probe the mud holes with his iceaxe. He doesn’t let us know the findings of his soundings, but we quickly learn to follow where his boots have gone.

That evening, waiting for the Japanese team to drag in with their embarrasingly long train of porters (carrying, among other things, a portable generator), the clouds break and we see a waxing moon, a few stars and our first sighting of Mount Baker (4843m). Herbert announces that the weather is changing and that tomorrow will be clear. The rain pounding on the corrugated metal roof wakes us at 5 am.

In Herbert’s defense, the third day’s walk from John Matte to Bujuku Hut (3505m-3962m) was relatively rainfree and there was a 20 second interval of sunshine. We crossed the Lower and Upper Bigo Bogs—huge expanses of wetland with African mountain swampgrass (carax runzorensis) and helichchrysis (a Labrador Tea looking shrub with closed up white flowers) interspersed with Giant Lobelias and Giant Groundsel trees. It was a surreal, other-worldly sort of landscape—beautiful but not quite graspable. The lower bog had a one-year old board walk, raised on plastic barrels with randomly spaced boards to keep your attention on your feet. The upper bog’s boardwalk had partially rotted away and was sunk beneath the surface of the swamp making the bog crossing problematic and messy.

Without the aid of a boardwalk, the porters each set their own path across the bogs, as using a single path would have quickly churned a waste deep trough of mud. If you were a wetlands conservationist, you would be driven to tears, or violence, at the destruction caused just by our group of travelers.

Hopping from tussock to tussock, with occasional slips into the boot-top deep mud, we made our way around the shore of Lake Bujuku to the Bujuku camp. At dusk, the clouds lifted just high enough to tease us with views of Mount Speke (4890m) to our north, Mount Baker to the south and Mount Stanley to the west. Herbert prognosticated that the weather was good and tomorrow would be clear.

The next morning Herbert told us that Nehemiah was suffering from altitude sickness and was heading back to base camp. Needless to say, this was an omen that didn’t bode well for our little group. Not only were the guides unacclimatized, but now we were left with only two guides, neither of whom really liked to talk to us. It would seriously limit our climbing and rescue options. Not that the rescue options were very good to begin with. The Rwenzori Rescue Plan (RRP) is, well, you die. Okay, so it’s a little more complicated than that—if there’s an emergency, one of the guides will return to a point where they can get mobile phone service (Nyabitaba hut or lower, if they have battery life, or airtime) and call a rescue team which will proceed on foot to the injured or sick climber. (even in good weather, neither of the two civilian helicopters in Uganda could make it that high into the Rwenzoris) So basically you would wait 2-3 days for a rescue party. Like I said, you die.

Franc, the lone Austrian, and his guide had decided that the weather would be clear as well and they would go for the summit from the Bujuku hut (as opposed to the higher Elena hut), so the fourth day started with the sounds of Franc’s alarm watch in addition to the driving rain on the tin roof at 4:30 am. Unfortunately, Franc couldn’t find his guide, so he rewoke us coming back to bed. Franc and his guide would leave about seven.

We continued our trek—from Bujuku Hut to Elena Hut (3962m-4541m)—in a drizzle, up hill through the bog until we hit rainslick granite and quartz boulders which gradually transform into cliff faces. Still wearing our rubber boots, we began to make progressively more technical rock climbing moves. In the rock-climbing vernacular, this would be called ‘pretty freakin’ gnarly, dude.’ But in layman’s language, you would have to call this a recipe for disaster.

So naturally, while walking along a tiny ledge, Pavel slips. Luckily, he manages to grab the ledge as he slides by, because the alternative would have been a long, bone-crushing fall. Herbert’s reaction to this is: ‘sorry’ along with a contemptuous look that indicates he thinks Pavel is clearly retarded for not being able to negotiate a two inch crack while wearing hip-waders. We manage to get Pavel up to a safe flat spot, but he isn’t moving his right arm. On examination he has a dislocated shoulder. (Oh, no, I can hear you say, enough with the dislocated shoulders… Okay, so it is basically a party trick, but, hey, if you only have one trick, it’s good that the people getting hurt around you are cooperative enough to play into it)

We (Pavel and I, Herbert seems to think that Pavel is faking not being able to move his arm) manage to get Pavel’s shoulder relocated and get him up to the Elena hut otherwise unscathed. I suggested to Herbert that we at least get a harness on Pavel and get him short-roped to someone, but, as you might expect, Herbert had nothing of the sort in his pack. Neither, I am sad to say, did I—one problem with letting the porters carry all your gear.

I haven’t been able to identify the Elena that the Elena hut is named after. When the hut was first put up nearly fifty years ago, the glaciers started at the front door. Now they have retreated to small crescents on the horizon and a slippery rock face slopes down to the cabin. Two rock pillars guard the entrance to Mount Stanley: Nyabibuya to the left and Kitsemba to the right—named for to Bakonzo deities thought to reside in the mountains and strike down those who perform acts contrary to the cultural norm (i.e. mountain climbing).

Somewhere a little further up in the hanging clouds lurks Margherita peak.

Pavel initially thinks that the rocks may dry up, and that he will continue the climb. But our general anxiety over what has happened to Franc, who we last saw in the early morning, supersedes further discussion. According to the guides, Franc should have been down hours ago. I ask Herbert is he has been in contact with Robert, Franc’s guide. He tells me that their cell phones won’t work up here. I ask if we should start putting a party together to go up and look for Franc. He looks at me like I’m deranged.

Just as the last vestiges of light are disappearing, Franc and Robert appear on the ridge top and start slipping down the rocks. The summit attempt that Herbert says should take a maximum six hours has taken them eight. Pavel asks Franc about the advisability of trying for the summit using one hand. Franc smiles and shakes his weary head. No.

Pavel, Magda and the Janoczs sit down with their remaining bottle of Margarita and confer. They decide that, in the morning, they will all head down to Kitandara Hut with Jomad. That leaves me and Herbert to make the try for Margherita. Herbert looks at the momentarily clear sky and tells me that we will have good weather in the morning. He announces we will leave at five. I tell him that I won’t be doing the rock face above the camp in the dark if it is raining. He says it won’t be raining. The weather has told him all he needs to know.

0400: wake to pounding rain on the tin roof
0415: Elisha, our cook, puts a thermos of hot water on the table (I stay in my sleeping bag)
0430: Elisha puts French toast on the table and tells me breakfast is ready (I still stay in my bag)
0445: Elisha comes and shines his head light in my face and tells me breakfast is ready (still in bag)
0450: Herbert comes in and shines his light in my face and says that the weather is good and we’ll leave at five. (still in bag)
0500: I get out and dressed and just about kill myself in the slippery fog outside the hut trying to pee. I find Herbert and reiterate my statement of the night before about not climbing the rock face in the dark when it’s raining.
0700: The sun starts to cast a dim light through the low clouds and the drizzling rain. I get up and dressed again, eat some cold French toast and go looking for Herbert.
0745: We head up the hill.

Words that you really don’t want to hear from your mountain guide: ‘Can you put the rope in your pack?’
Something that makes these words more frightening: you notice that he’s not bringing a pack. (Usually on summit day, the guide has the biggest pack—he/she will be carrying the rope, the climbing gear [including appropriate snow or rock anchors] and survival gear, in addition to the usual food, water and extra clothing) Herbert has a couple of beeners and an ATC clipped on his harness, nothing else. I’m carrying a backpack designed to carry my laptop, stuffed to capacity.
Something that makes it even worse: the rope he hands you isn’t even a legitimate climbing rope, its 7 or 8mm cord.

I foolishly ignore all the warning lights and sirens going off in my head (it is hard, after slogging uphill through mud for four days, to suddenly let go of the climb a few hours short of the peak) and follow Herbert up the slick rocks above camp. All I can think of as we shimmy up the rock face into the face of the small cascades of rainwater is just how scary it will be to come down. But we manage to make the ridge top and the lower edge of Stanley glacier.

Mount Stanley, in case you were wondering, was named for Henry Morton Stanley, of the ‘Dr. Livingstone, I presume’ fame. Stanley, a Welsh journalist, explorer, and mercenary who managed to fight for (and desert from) both sides of the American civil war, led an expedition into the interior of Africa to rescue the Emin Pasha and in 1889 was with the first modern Europeans to see the Rwenzoris.

We rope up. I put a rescue coil (extra rope to lower into a crevasse) at my end of the rope. Herbert doesn’t. I rig up my prussics for crevasse self-rescue. Herbert looks on in bored disinterest. Herbert probably weighs 50kg with all his gear. Me, 85. I might be able to pull Herbert out of a crevasse. There would be no chance in hell of Herbert pulling me out. I suspect that his plan for the event of my crevasse fall would be to cut the rope and move on.

We are now climbing over 5000 meters and the air is scarce. I am panting like an overheated Saint Bernard. We traverse the Stanley Glacier and the buttress for Alexandra Peak and head up Margherita Glacier into a snowstorm. I don’t know if you remember the scene in the mountains from The Fellowship of the Ring where Legolas, the elf, is walking on top of the snow while the rest of the party pushes through waist deep snow, but this is how I felt on the glacier—Herbert walked easily on top of the crust while I broke through up to my knees. Herbert kept tugging on the rope and turning to look at what was wrong with me.

There were some rickety ladders blowing in the wind at the peak. I used a prussic for a margin of safety on the frayed fixed line and we manage the remaining climb to the summit. I had hoped for some view of the Rwenzoris from the top, but it was not to be. I could see a couple hundred feet down the ridge, and that was all. I snapped a few pictures, and we got the hell out of there.

I was walking first down the Margherita Glacier as it flowed over a hump in the mountain—a decompression zone in the glacier where cracks and crevasses form. Herbert chose this moment to shorten the distance between us by holding several coils of rope in his hand—increasing the risk of both of us falling into the same crevasse, and ensuring that if I did fall, the speed and depth of my fall would be exponentially increased by the length of rope in his hand. Fortunately, most of the crevasses were fairly well defined and of jumpable width. Unfortunately, Herbert had the annoying habit of yanking the rope taught just as I would start to make the jump over a crevasse, stopping my forward momentum and nearly dropping me in the crevasse on several occasions.

We managed to get down the glaciers without further incident. At the final rock face, Herbert unroped, despite my suggestion that we stay roped up until the hut. He clearly did not trust my rock-climbing skills enough to want to be tied into me on this part of the descent. I stooped to take off my crampons, but he indicated I should leave them on. Granted, the rain was still sheeting down and the rocks were slippery, but I didn’t think the crampons were going to make them any less so. A bit later, as we made a traverse around a large boulder in a narrow crack, I leaned just a bit to far into the rock, and the width of my boots levered the relatively narrower crampons out of the crack and I slid for nine or ten feet down the rock into a heap at the bottom. I took my crampons off.

Adrenaline, and a thorough understanding of the Rwenzori Rescue Plan, got me to my feet and down to the hut and, a bit later, down to the Kitandara Hut (4023m), where I could finally sit down and make an assessment: right leg—one huge coalescing bruise from the hip down to the ankle; right knee—sore, creaky, but no unstable ligaments; right ankle—swollen, purple, but stable and probably not broken; left knee—sore but stable. I am dehydrated (Herbert drank over half my water on the summit climb as he brought none of his own) and starving.

Pavel and the other climbers had made it safely off the wet rock and were enjoying the relatively warmer weather and the beautiful lake at the lower hut.

The next day we climbed back up over 4000 meters into Freshfield pass and took one last fleeting look at Mount Baker and Mount Luigi di Savoia (the Duke of Abruzzi). And then descended gingerly to the Guy Yeoman Hut (3450m). Ski poles and consistent doses of ibuprofen kept me upright. The final day we descended under the cliffs of the Kicucu rock shelter and down into the bogs to enjoy the sensation of mud overflowing the boot-tops one final time before rejoining the trail just above the Nyabitaba hut and making the descent back to Nyakalengijo.

I bought the porters a well-deserved round or two of lukewarm beer and soda at the base-camp tavern. Strangely enough the number of porters suddenly doubled.

Herbert told the Polish climbers that ‘next time they would reach Margherita Peak.’ Magda translated and they all started laughing. What was said in Polish was no doubt something like ‘not a chance in hell will there be a next time.’

I have to agree. I am glad that I hiked the circuit in the Rwenzoris. Even in pouring rain the landscape and mountainscape is unique and beautiful around every muddy bend in the trail. But I am also glad that I won’t have to do it again.

The 2006 book Don’t climb Kilimanjaro (Climb the Ruwenzori) will no doubt increase the traffic of hikers and climbers into a park where infrastructure is not in place to protect the environment and the guides and the rescue systems are not prepared to keep the hikers from harm. This is too bad. My recommendation would be that if you do wish to climb in the Rwenzori, unless you are an expert climber, that you travel with one of the several groups per year that bring their own European mountain guides.

In Kasese I said my goodbyes and shook hands with Herbert. ‘I feel fortunate to have survived climbing with you.’ It was hard to read any more into his fixed facial expression of general disdain. I’m sure he was thinking, ‘likewise.’

Pushing the envelope of helicopter medevac…

kampala, looking east to lake victoria


Mbarara district referral hospital in the right lower corner.


Kampala's old taxi park (left lower corner), from the air


Dave flies the helicopter with a couple of patients lying next to him



February 21st

It’s Sunday afternoon and I’m visiting Guustaaf out in Ntiinda. I’ve decided to go climbing in the Rwenzoris next week and Guustaaf has been kind enough to lend me some of his gear.

(Just in case you get worried that postings here are drying up and I’ve disappeared or checked into detox or something—no, I’ll just be in the mountains for 8 or 9 days.)

Tom calls and asks if I want to fly to Mbarara. I say sure, but tell him I’m in Ntiinda (about 20 minutes by boda or 40 minutes by matatu from IHK). He says that they want to take off right away. I give him the option of sending Dr. Christine from OPD or waiting for me to boda over. He talks to Dr. Christine and tells me to get on a boda.

It is pretty clear my boda driver has no idea where IHK is. I have to turn him around after he makes a turn on Kira road towards town. So we’re headed down the Lugogo bypass (picture a big white guy sitting on the back of a small motorcycle wearing a backpack with an iceaxe attached to it…) and another bigger motorcycle goes by, slows, looks at me, looks at the iceaxe. Turns out its Dave, the helicopter pilot. I tell my driver to follow the guy with the yellow helmet and we make the illegal U-turn across Jinja road and scream through the industrial area. I show my driver the shortcut through the slum up onto Namuwongo road, so we beat Dave to the hospital by a good five seconds.

It turns out that a 4x4 full of evangelists blew a front tire about 9am outside of Ntungamo and rolled several times. An elderly couple from Tennessee were pretty banged up and couldn’t walk and a couple of other people were injured as well. They wanted to know if we could fly all four to Kampala—in a helicopter designed to carry 5 passengers seated. Typically, if we fly for a patient that needs to lie down, we take out the front passenger seat and fold up the back seats—which barely allows room for a stretcher to be strapped to the floor. Dave did the numbers, though, and figured we could carry 3 patients and me and my medical gear. We decided that instead of the stretcher, (or spine board, or any of that crap) we would just put a bunch of cushions down on the floor and squeeze the two supine patients in between the control column and the door…

While I was on the phone trying to track down the doctors in Mbarara, Dave was on the phone getting a guarantee of payment. (missionaries or no, the helicopter is a strictly mercenary business—Dave said he told the guy what the per hour charges were and how long the flight time, and the guy said okay, he’d pay for one hour of flight time, and Dave would just have to fly faster!) I managed to get one of the doctors at Mbarara district referral hospital on the phone. He said that he was taking one of the patients to the theatre. He said we should come and pick the patient in four hours. I told him that in four hours it would be dark. And we don’t fly in the dark. He said something to the effect that we had a big problem. And hung up on me. And didn’t answer his phone the next 4 times I called.

Fortunately the thunder storms from Friday night had abated and we have clear flying to the football pitch across the road from the hospital. Fortunately, as well, the field is surrounded by fencing which keeps most of the Mbararans from running into the area where helicopter blades are spinning (although later on we had to shout at the spectators snapping pictures of the injured patients with their cell-phones). Moving the patients to the helicopter proved problematic. Actually even moving them through hospital—strangely enough not equipped with ramps for wheelchairs or gurneys—was difficult. But we managed to get them slid onto the floor of the hospitals ambulance and over to the football field without damaging them any further.

Without being indiscreet, or violating patient confidentiality, let’s just say that our patients are not small people. And that getting them loaded into a space smaller than a twin mattress and getting the door shut took some doing.

The flight back to Kampala was relatively uneventful. Dave’s record of 9 years of flight time and never having an airsick passenger was interrupted as the third patient (sitting next to me) hurled into a plastic bag that later proved leaky. And the other two patients kept complaining of being hot. As I tried to explain to them that both the windows were open as far as they went and the helicopter didn’t come with A/C.

But we all survived the flight and managed to get them checked into the ICU without further drama or trauma and still able to move all their toes and fingers. Some where along the line, some perky 3rd year American internal medicine resident who somehow was related to the church sponsoring our patients showed up and started barking orders at the ICU nurses: ‘why haven’t the neck x-rays been done?’; ‘what are the CBC results?’; ‘what do you mean they haven’t had a CT scan done yet?’; etc., etc. I had to take him outside and explain to him that one (in case it wasn’t painfully obvious) IHK is not Mass General, and two, he didn’t have privileges work in Uganda, let alone IHK, and that he should just shut up and enjoy the ride.

As of this morning, the patients were doing well and getting ready to leave the ICU.

For a very unflattering picture of me (that’s me bending over, stabilizing the patient’s head and neck as he vomits next to the helicopter) in one of Uganda’s national newspapers.

trauma update

Trauma Update: 12 February 2010

I’ve been having weekly sessions with our A&E (accident and emergency) nurses for almost a half a year now. We talk about trauma, and emergency medicine, and ambulance transport (most ambulance calls here go out with a non-medical driver and a nurse—there are no paramedics here, although I’ve been agitating to hire some clinical officers and train them to be paramedics), and other topics. Most days I think we’ve come a long way. At least they’ve started to laugh at my jokes.

Last Friday afternoon I was looking forward to the quickly approaching weekend and a cold beer at Fuego when Justine, senior sister (compare to nurse manager) in charge of OPD (outpatient dept.) and Linda, my emergency team leader, come and grab me to come see a RTA (road traffic accident—UK medical lingo). I’m a little disappointed that Linda feels it necessary to come with Justine as opposed to taking charge of her team, but I smile and head to the trauma room. Which is empty. (not a huge deal, since I’ve come to accept the fact that the trauma room is really a place to store obsolete, broken and esoteric unusable equipment) The patient is in one of the unmonitored beds in main 5 bed casualty ward. There are 3 nurses standing around him, none of them touching him, all of them watching as one after the other pushes the button for the automatic blood pressure cuff, which won’t seem to give a blood pressure value.

The patient was in a car crash earlier in the day in Masindi (about 3-4 hours north of Kampala by car—I've visited Masindi district hospital, see the Sept. 2009 post, it might explain why he didn’t seek care in Masindi). His coworkers tied a big piece of wood to his obviously fractured leg, threw him in the back to truck, and drove him to Kampala where, reportedly his health scheme covered his care at Kampala International Hospital.

It didn’t take much clinical prowess to see why they couldn’t get his blood pressure. He didn’t have one. He was cold, sweaty, pale (after 8 months, I am finally starting to get the nuances of just how pale a black man can be and what it means) and has no peripheral pulses. One hand on his left upper quadrant tells me that his spleen has ruptured, and the majority of his blood is now pooling inside his peritoneal cavity.

By this time there are now 5 nurses around the patient, still none of them touching him. Both the medical officers assigned to casualty have disappeared without a trace.

I try to nudge Linda into taking charge by reminding her of the ABCs (airway, breathing, circulation) and asking her what should we be doing first. ‘Well, we need to get the vital signs first.’ Sigh.

I coax the nurses into putting down the automatic blood pressure cuff and starting an IV line on our man (they look at me like I’m mad when I ask for a second line—‘can’t you see we just started one?’ I make a generally hopeless request for oxygen and a cervical collar. I track down one of our surgeons who agrees with me that the man needs to go to the theatre for a laparotomy.

And then the reception staff take over the casualty unit and everybody starts talking very fast in Lugandan. There’s been a slight misunderstanding. The patient’s health scheme pays for care at Kampala Hospital, not International Hospital of Kampala.

Suddenly my nurses, who have mostly been milling about for twenty minutes, leap into action and get the man loaded back up into the truck. The surgeon shrugs and says something to the effect that there is nothing we can do. This feeling is echoed by Justine. ‘What can we do?’
I feel like screaming, but I keep my voice well modulated. ‘We can do the right thing, and operate on him and possibly save his life.’
‘But he will have to pay cash for it.’
‘Can’t we worry about the money later?’

Apparently not. I tried to explain to the patient and his coworkers that he could easily die in the 20 minutes it was going to take for him to get across town. But they were having none of it.

I called over to Kampala Hospital and, after a number of transfers, spoke to their surgeon. He listened to my story, seemed surprised that I had taken the time to call, and thanked me for the heads up. Understand that in the US, making a call to say that you had just transferred a patient without a blood pressure in need of an emergent laparotomy (not even to mention in the back of a freakin’ truck) would basically be like begging to have your license to practice medicine revoked and all of your personal assets taken from you.

The patient survived his surgery.

He left the hospital 3 days later. The nurse I spoke with was unable to confirm if he was alive upon discharge.

Plight of the Bodas

one last boda ride?
(photo credit: Irene Curley)


boda boys out of gulu

obeying the helmet law
(photo credit: kampala fan facebook page)



February 19th

Boda Boda Crackdown

I’m sure my previous posts have given the pros and cons of the Boda Boda, Kampala’s ubiquitous motorcycle taxis.

The daily carnage of the bodas is well documented and, now that I’m spending some time at the public hospital, has been presented to me on a personal level as well. But I don’t have a car here in Kampala (and even if I did, wouldn’t have a place to park it anywhere near Mulago) and it’s a long walk between IHK and Mulago and the trip in a matatu (2 minivan taxis, one from Namuwongo to the taxi park and the other from the park to Mulago) takes over an hour in good traffic and a third of a lifetime in the jam. So I have been forced to rely more and more on the bodas.

In my post from August 13th, I marveled at how the bota drivers in Kigali, Rwanda (they’re called motos there) all wear helmets (and carry one for their passenger). I mentioned to a Ugandan surgeon how this might help diminish the high rate of head injuries from boda accidents. He smiled. As it turns out, Uganda passed a law several years ago requiring boda drivers to wear helmets, reflective vests, and to carry a helmet for their single passenger (it’s not uncommon to see bodas with 2 or 3 passengers—plus a toddler sitting on the handlebars).

And, surprisingly enough, just in the last two weeks, the police in Kampala have started enforcing this law. News reports focus on the police jumping out of bushes and whacking the drivers over the head with clubs and confiscating their bikes if they don’t have the required permit, helmets and vest.

At the beginning of the crackdown, Friday before last, things were oddly amiss at Reste corner (the center of the south Kampala, vso volunteer universe—the Italian market, Palm café pizza, the wine garage and fuego cocktails all being within a stone’s throw). It took a while for it to sink in. There was not a single boda to be seen on a corner where usually you have to beat them off with a stick. That turned out to be because down the road in Kabalagala the police were actually beating them off their bikes with sticks. (the last time they had a boda crackdown, I’m told, there were riots in the downtown area, so this time the police have come with bigger forces and concentrated on one neighborhood at a time)

Two weeks later, there are still noticeably fewer bodas on the road. And many (but by no means all, or even the majority) have the vests and helmets. Although that doesn’t necessarily mean they have permits as a friend of mine found out the other day when his boda was stopped. He figured, since he’d only gotten half way, that he would only pay the driver for half the ride, but the police officer yelled at him and told him to give the driver full fare (so that the boda boy would have more extortable cash on him).

The boda drivers that hang in the lot across the street from the hospital know that I want to go across town to Mulago (going out of Namuwongo to town increases the risk of police apprehension), so they ignore my wave, unless they have the helmets. And the drivers with helmets have suddenly raised their fares 500 or even a 1000 shillings (25-50 cents—outrageous). And the helmets they are wearing range from the comical to the downright nasty. I was issued a helmet by VSO, but, I confess, had become a little lackadaisical in its use—until one of the drivers handed me this strapless bucket of a helmet smelling strongly of mildew and month-old perspiration. Now, the helmet travels with me.

I tried to get one of the residents in casualty excited about doing a study to compare pre and post crackdown head injury rates. He just gave me a wan smile as if to say, ‘silly mzungu, things here will never change…’

Rafting the Nile

(didn't take my camera rafting, this picture shamelessly stolen off the Adrift website)

Rafting the Nile (or LSU medical students gone wild in Africa)

February 16th

I’m riding the shuttle bus to go rafting. In addition to being the world’s longest river, the Nile also has some kickass whitewater, and I’ve been meaning to check it out for a while. I had to get up early to catch the bus, so I’m hoping to snooze a little on the 2 hour trip to Jinja, but I happen to overhear a young man’s voice bragging: “…well, all of us know CPR and a third of us know how to do a crike.” I open my eyes. A group of young people has just boarded. Medical students, I think. Then the same dark haired, thick-browed young man goes on, “Yeah, I could do a crike with my swiss army knife. No problem.” Pure, unadulterated hubris. Definitely a fourth year med student.

A crike, for the uninitiated, would be a crichothyroidotomy, an emergency surgical procedure that involves cutting a hole in someone’s neck and inserting a breathing tube. I can think of a lot of scary things to do at work, and a crichothyroidotomy would top the list every time.

I think about engaging him in conversation… ‘So, buddy, assuming you’ve been very lucky and you’ve managed to get your ballpoint pen into the patient’s trachea (as opposed to the carotid artery or the esophagus), and you are now blowing air into a small tube in a poorly sealed hemorrhaging wound in some poor bastard’s throat, what are your gonna do next? Call 911?’ But, nah, I was him once. I turn up my iPod and tune him out.

The source of the Nile has been the subject of controversy for a number of years. In 1858, John Speke was the first to suggest that the Nile originated from the lake he named Lake Victoria. His travel partner, Richard Burton (get the 1990 movie Mountains of the Moon on netflix), called this a bunch of rubbish. Even now, the purists will tell you that the waters of Lake Victoria (and hence the Nile) come from many sources, the most remote being the Akagera river, which starts as the Rukarara River in the Nyungwe rainforest of Rwanda.

For rafting purposes, however, the Nile starts somewhere below the Owen Falls Dam in Jinja. (Although a new dam currently under construction at Bujagali Falls will eventually submerge most of the rapids we'll raft over). Unlike most of the canyon whitewater I’ve been exposed to in the US (certainly not an exhaustive survey, mind you) which is more narrow, rocky and continuous, the Nile is big and wide and has long stretches of flat water punctuated by high volume, waterfall-like rapids perfect for flipping rafts in. Fortunately, the water is warm, and the rapids spaced far enough apart to allow you time to find your paddle and get back into the boat.

Prior to the first big rapid, we practiced flipping the raft. Tutu, our guide wanted us to hang onto our paddles with one hand and the safety rope of the raft with the other. As we were flopping into the water with the raft on top of us, I felt an unnatural torquing sensation in my shoulder and thought, this would be the perfect way to dislocate a shoulder.

And sure enough, on the last rapids before lunch, the raft in front of us was tossed and one of the rafters was floating at an odd angle in the water holding his right arm against his lifevest. We pulled him along side and headed for shore. About this time the boat with the med students shows up and my buddy starts barking out orders about bed sheets and traction and makes the poor guy with a dislocated shoulder take his wet shirt off (next time you dislocate your shoulder, try taking your shirt off). The med student wants to use the traction/counter-traction method of reducing the dislocation—probably the most painful way ever devised to put a shoulder back in.

Lee, the lead guide, has been given the impression that the med students are doctors. Upon questioning, however, the young man has to sheepishly admit that no, he doesn’t graduate from medical school until June, and, no, he’s never reduced a shoulder dislocation in his life. But he points to one of his fellow med students and says that she is going to be an orthopedist and that she’s ‘put in hundreds of shoulders.’ (Turns out that she’s only a 3rd year student and, although, she would like to be an orthopedist when she grows up, she hasn’t even done her orthopedic rotation yet.)

Before the 4th year can do any more damage, we gingerly load the patient into our raft. On the flat stretch of river before the lunch island, I talk the man into extending his arm out to about ninety degrees and the shoulder pops back into place. At lunchtime, the man is ignoring the sling I put him in and is eating with both hands. The raft company pulls him from the trip, however, to go get an x-ray in Jinja.

We flip our boat in the rapids below the ‘Bad Place.’ I don’t hang onto the rope, or my paddle. I float the whitewater feet first and wait for Tutu to get the raft turned over.

another short, sweet trip to the Sudan

in the cabin of the 206
Torit International Airport
Torit, South Sudan, from the air
The Irmatong mountains
Over Lake Kyoga


February 10th

Monday’s hash was in Bugolobi, or Mbuya, or somewhere toward the southeast outskirts of town. We got lost trying to find the starting point at Daytona Bar, so I was playing catch up from the get go. My phone kept going off. I know, you say, how stupid to run with a phone, but on the Kampala Hash getting lost is such a frequent occurrence you never know when you’re going to need to call a friend. On the hash, answering a mobile phone is a punishable offense (punishable by the threat of having to drink extra free beer at the finish…), so naturally I answered it.
Tom from transport was looking for a doctor to fly to Arua about seven in the morning to help transfer a patient down to Kampala.

So I said sure.

Modified phone log:

1900hr: Call from Tom. He has just texted me the phone number for the Doctor at the hospital in Arua.

1905hr: Call the doctor in Arua. No Answer.

1915hr: Call the doctor in Arua. No Answer.

1930hr: Call the doctor in Arua. Very bad connection. He’s in the theatre (that means the operating room here, not the cinema) can I call him back in a half an hour.

2030hr: Call the doctor (Patrick) in Arua. Ask about the patient. ‘Oh, he’s fine.’ Okayyy. He (the patient) just has end-stage liver disease with cirrhosis, portal hypertension and bleeding esophageal varices. He just had an upper GI bleed the other morning with a blood pressure of 70 and required a blood transfusion. I ask him what the patient’s hemoglobin level is now. He says he doesn’t know, but ‘clinically’ the patient is not anemic. I ask about when the last time Dr. Patrick saw the patient was. ‘Oh. I haven’t seen him all day, I’ve been in the Theatre.’ I ask him to go check on the patient and call me with his current status. (no further contact with Patrick.)

2045hr: Call our hematology lab to see if we have any O negative (free of the major blood antigens, so you can give it to anyone) they could pack up for me to take on the flight with me. ‘No.’ We have no blood, let alone Oneg.

2355hr: Tom calls to let me know the time of the flight has been pushed earlier. Can I be at the hospital at 5:30? A.M.? I tell him at 0530 he’s going to have to send a driver to pick me up. He agrees.

0500hr: Safari James from transport calls. ‘Did Tom tell you about the medevac to Arua?’
‘Uhhh… Yes, he did. He said you’d come pick me up at five-thirty.’
‘Are you ready to go yet?’
‘Is it five-thirty yet?’
‘Oh.’

0515hr: Safari James calls. ‘Can I come pick you now?’
‘Is it five-thirty yet?’
‘Oh.’
‘Come pick me up at five-thirty. I’ll be standing on Kironde Road.’

0540hr: (because the accepted behavior here for arriving at a closed gate is to lay on your horn until someone opens it, I have chosen to exit the gate and save my housemates from awakening to the sound of the ambulance horn. I have now been standing in the rain for 10 minutes.) Safari James calls. ‘I am leaving now. Are you ready to go?’

0620hr: We arrive at the Kajjansi Airfield. Aside from the night watchman that we wake up with our horn, we are the only people there.

About 0700hr a couple of people with luggage wander in. I’m thinking, ‘hmmm… what exactly has Tom signed me up for this time.’ Then the guy with the uniform wants to inspect the medical kit.
‘Do you have anything dangerous in there?’
‘No.’ Unless you consider an oxygen cylinder, a scalpel, and enough diclofenac (an injectable relative of advil that seems to be the preferred pain-killer and anti-pyretic in Uganda) to put the pilot into renal failure. I don’t bother to explain to him that if I was going to hijack anybody anywhere it would be back to my bed…

Then Dave, the pilot for MAF, comes in and explains our flight plan. First we’re going to fly to Entebbe to pick up two more passengers and clear immigration (Immigration? I thought Arua was in Uganda?). And then we’re going to fly to Torit. Torit? Torit, as it turns out, is in South Sudan… (you know that imaginary line that VSO has asked us not to cross? Torit is way across the line.) And then we’ll fly to Arua to pick up the guy who’s bleeding from his gut. So much for being back in Kampala for lunch. And I don’t have my passport. (VSO still has my passport—almost 8 month in and no work permit yet). Dave says he’s going to list me as crew, so I won’t need a passport.

At Entebbe, Dave checks the fuel to make sure it hasn’t been watered down, loads the luggage of the additional passengers, gives us a safety briefing, and says a prayer. (MAF stands for Missionary Aviation Fellowship) If the only guy standing between me and crash-landing somewhere out in the African bush where the chances of rescue are next to nothing wants to pray, then by god, let him pray. I say a little prayer for Dave’s continued health as he prays for the success of my mission to Arua.

We fly north over Lake Kyoga at 10000 feet. The dry season is in full effect up North and the sky is thick with dust and smoke from burning fields. Below, the land is a parched yellow brown. In the haze on the horizon sits the purple line of mountains just north of the Sudanese border.

Dave picks out a low point between peaks in the Irmatong mountains to pilot his Cessna 206 through. The mountains are free of trails and cell towers. Red rock with sparse green scrub.

A few more nautical miles (why do airplanes measure distance in nautical miles?) and the mountains subside, we cross a dry river bed, a few tracks appear on the plain, and Torit comes into view.

My time in Torit didn’t include the city tour, so my impressions were mostly from the air: a large sprawling village with a few rectangular single level buildings, but mostly round huts arrayed in packed dirt compounds set haphazardly on an irregular street grid. A creek or small river meanders southwest of town giving life to a winding swath of greenery and trees. The runway angles away from the east end of town. When the UPDF (Ugandan Peoples Defense Force—the army) chased the LRA (Lord’s Resistance Army) out of Uganda, the LRA hid in the Irmatong mountains and wreaked havoc on the people of the Torit district. At some point in the conflict, the LRA was reportedly receiving military assistance from the Sudanese government as payback for the Ugandan government’s support of the South Sudanese Liberation Army…

A WFP (world food program) plane is getting ready to take off as we land, and the crowd of people surrounding it moves to encircle ours. But we haven’t brought any food, only missionaries. Francis shakes my hand, ‘God bless you Dr. Riley.’ Motorcycles and bicycles criss-cross the runway as a herd of emaciated cattle stagger by in the dusty heat. There are no Sudanese immigration officials checking passports, so I go looking for a tree to pee against (the Torit International airport lacks a tower, terminal, even a latrine). I have to walk quite a ways. The huts line both sides of the runway. Their roofs are more peaked than in the north of Uganda, but otherwise similar.

We flew another hour or so west (and a little south) to get to Arua. Arua sits at the northwest corner of Uganda. Supporting aid delivery for a large refugee population from Sudan and the DRC (Democratic Republic of Congo), as well supplies being shipped by road into South Sudan, has made the Arua Airport the second busiest airport in Uganda next to Entebbe. When we land, however, aside from an Eagle Air LET-410 taxing out, the only other plane at the airport is an Antonov AN-2, a 1940s Russian biplane that the UPDF uses to drop paratroopers.

I was expecting an ambulance. But I have learned never to expect too much. I called the contact number for his employer at the UNDP and was told that the patient was at the airport. I notice a sick looking, emaciated man lying by himself on a bench by the small terminal building. Sure enough, that’s my patient. Fortunately, he still has a blood pressure. Fortunately, he was kind enough not to throw up blood all over the back of the Cessna, and we had an uneventful flight home. Naturally we had to drive at breakneck speed back into Kampala with the lights flashing and the sirens blaring.

On arrival at Kampala Hospital by the golf course (the patient’s doctor doesn’t come to IHK) we wheeled the patient onto the ward. The nurse asked, ‘Where’s the patient’s family.’ The ambulance driver said the patient was alone. ‘Well. Who is going to make the patients bed?’ Who indeed. I was carrying the patient’s suitcase. I asked him if he had sheets in there. He did. I put the sheets on the bed. And the transfer was completed.

for more pictures of the flight