Nancy goes on Safari!

The rare Murchison Falls rock climbing hippo!

our first leopard spotting...

Nancy wasted no time at demonstrating superior safari karma, as she managed to spot a leopard (so to speak) on her first morning out. Above she has a visit with Bella and her baby Augusto at the Ziwa rhino sanctuary. And below, one of the 3 male lions we saw fighting for the affections of the lioness three pics below.

do these spots make by butt look big?


Nancy at the top of Murchison Falls.

For more pictures of the trip, click here!

signing off for a while...

Nancy flew into Entebbe last night, after a brief stopover to visit Anabelle in Paris, and a quick plane change in Amsterdam. We treated her to the burning piles of trash tour of the Entebbe Road at night.

At the moment she’s back at the ranch taking a nap, but when she wakes up we’ll start checking out Kampala, and then greater Uganda. All this to say that the free time I would usually spend reflecting on the condition and meaning of life as manifested in rambling blog posts of questionable coherency will now be spent entertaining Nancy and making it up to her for leaving her alone in San Francisco for much of the past year. As such, this is likely to be the last posting for a while.

We are bound for the wine garage tonight and Murchison Falls for the weekend—hoping for some good safari karma, some rain-free mornings, and a kilometer or two of pothole free road.

On the housing front, we are still squatting at the old house. I did get an email from VSO last Thursday saying: “Hello Rob. Hope you are well, am writing to inform you that your house where you will be moving to is ready as per today i.e. its located in kironde in the same compound with the Cowans, hope you are ready to move please try to pass by office to receive the keys…” Needless to say, this piqued my interest, so I did pass by office to receive keys, and dropped by my new digs just to check things out. And, as you might expect, the place wasn’t quite ready for occupancy: the power was off, the water was off, there was no furniture other than a single bed, a small plastic table and four plastic chairs (this is a 2 bedroom house that I am going to share with another VSO couple, Richard and Pat, who apparently didn’t learn their lessons during their first placement and so are being forced to repeat them….), and there was not a single lightbulb to be found in the house. And, oh yeah, the place was a filthy mess.

So, as you might expect, I didn’t move in. Instead I wrote a polite email back pointing out the problems with the space that would need to be corrected to make it habitable. But I did cc the email to Richard. And apparently this struck a nerve because in September of ’08 they had been dumped into the exact same sort of situation at 5pm on a Friday night and were left to fend for themselves. So Richard shot off a rather scathing reply and cc’d to Kevin (IMG’s CEO) and Benon (director of VSO Uganda) saying something about turning right around and getting back on the plane… And apparently this got some people yelled at and rousted from their Easter Monday holiday, and this has made me immensely unpopular around the VSO and the IHK HR offices. Without even really trying.

I ran into Richard and Pat in the hall today (they are off on a drive to Lira tonight and back tomorrow, with Kevin, a punishment in its own right) and they suggested that the house might be ready to move into by the weekend…

And, in another interesting development, it appears that my little blog has come under scrutiny by the senior management of the hospital. The head of HR e-vited me into her office to “discuss your work in IHK, its value to both parties and agree on way froward/ specific achievable goals…” Appealing premise to address in the waning days of my placement, to say the least. It came out that although she herself had not read Random Uganda, others who had were afraid that my ‘cynical’ point of view might be ‘injurious’ to the Hospital. I explained to her that yes, I am a cynic by nature, but that I tried to find humor and amusement where I could find it. And I am not trying to be injurious to anyone, merely reflective on my own position here.

But it does beg the question. If the truth is injurious to an organization, what should that organization’s response be?

I will think about that. I will let you think about that. I am off to spend some time with the most beautiful, loving and understanding woman in the world.

Plight of the Bodas (part 2, up close and personal)

The boda boda crackdown (see previous post, plight of the bodas) has eased up. Unlicensed, unhelmeted bodas have returned as the majority. Still, even without the police harassment, the life of a boda driver, despite the cachet of riding a motorbike for a living, is a hard one. Fuel prices in Kampala have shot up six or seven hundred shillings a liter in the last few weeks, eating into narrow profit margins. (most of the drivers rent their Indian made Bajaj Boxer 5 bikes for about 40000 shillings a day, making it twenty 2000 shilling trips just to pay the owner of the bike) And one slight misjudgment at one of the many universally disregarded traffic lights can land them on one of the cushionless blood stained gurneys in Mulago’s casualty ward.

One of my fellow VSO volunteers has fallen for her boda driver. Michael is an affable young man with a tight leather jacket and a winning smile. It is good to see them together. I’m jealous, among other things, that, after only a few months, she’s conversant in Lugandan, while I’m still stuck in the basic phrases and counting to 9 that I sort of learned my first few days in Uganda.

Last Saturday night we had an eviction party. (Dorothy had told us we’d be kicked out last Friday, but, as of this writing, the sheriff has yet to come beating on the door, and alternative housing has yet to fully materialize, so I guess, at the moment, we are squatting) A good number of my fellow volunteers got stranded by a rainstorm at the Wine Garage on their way to the party (fortunately, they did not suffer overly much), but a small and enthusiastic crowd made it and kept the loud music going for the neighbors until the wee hours.

And shortly after getting to bed, my phone rang. Michael had been found in a ditch by one of his fellow boda drivers, unconscious and bleeding from facial wounds. His friend Issac was called and took him to Mulago where they were unable to locate a doctor or a nurse. From Mulago they traveled to a clinic on the other end of town in Kireka where some unusually crude suturing (even by Ugandan standards) was perpetrated on his face.

I had to apologize that my alcohol level was probably not within a level you’d want your doctor’s to be. But I put her in contact with the IHK ambulance driver and, a bit later, caught a boda over to meet them at the hospital just as the sun was peeking up over the Kampala hills. Michael reclined on one of the gurneys. His head enlarged to half again its usual size. His left eye was swollen shut. Moses, our night doctor had already seen him and ordered a CT scan and neck x-rays as well as requesting consultations from a plastic surgeon and a neurosurgeon. Fearing the worst, I leaned in and called Michael’s name.

Slowly his good eye opened and focused with a hint of recognition.

He was going to be okay. But given that I wasn’t his doctor, and I was operating on a sliver of sleep and an incipient hangover, I figured it best that he go through with the CT scan. Which, not surprisingly, meant that he had to get back into the ambulance and go to a hospital with a functional CT scanner. The radiologist’s report from Kampala Hospital pointed out the obvious extracranial soft tissue swelling and some ‘mild cerebral edema,’ a finding that might be concerning in a setting other than Kampala where nearly every CT comes back with a reading of cerebral edema. To my eyes, the brain looked normal, but I have to admit that I’m out of practice reading the CT scan in multiple little 3 inch squares of film, since CT scans on film (now we read them on a monitor) disappeared from my practice 15 years ago…

So, given that Michael’s injuries were proving mostly cosmetic, the plastic surgeon swooped in for the kill. He wanted to take Michael to the operating theatre to reopen his facial wound and close it nicely. Estimated cost: another million shillings ($500, on top of the million and a half for the hospitalization and ambulance and CT). A bargain by American standards, but when you consider that VSO only gives us 500,000 shillings a month as a living allowance (and some volunteers aren’t fortunate enough to have a loving wife back home to support them in their folly, and so actually have to live within their allowance), it seems a daunting amount. And, of course, completely and utterly out of the question for a boda driver or your average Ugandan.

So stop and think about it for a couple of minutes. What would you do? Your loved one has a facial wound. There’s going to be a scar. The plastic surgeon seems very concerned (concerned enough to charge for 3, count’em 3, consultations for a 1 inch wound) and wants to make the wound look better. But it’s going to cost you another 2 months salary, on top of the 3 months you already owe. Think about it. Then pray that you never ever have to make this call.

We tried to get Michael onto the Hope Ward (IHK’s charity ward), but it was getting late in the day and Jemimah, the ward’s gatekeeper doesn’t like to work with this particular plastic surgeon due to his excessive billing issues.

At the end of the day, she took him home with the Frankensteinian sutures still in place.

I saw them on Wednesday. Michael was on his feet and looked one hundred percent better. His left eye was open and his smile was back. I wish I knew exactly how the scar is going to look a year from now. I can only hope it won’t be too bad.

Further Impressions of Mulago, Part 1

A small boy walks tentatively into Casualty. In his left hand he clutches a fiber-plastic sack of clothes, in his right, a sheaf of rain and mud speckled papers. It’s about 5pm and all four stretchers are occupied by young men either coming to grips with their newly crippled status or completely oblivious of the fact due to the severity of their head injuries. Since you seem to be only one in the crowded room who will meet the occasional upward flicker of his sunken eyes, the boy shuffles over within reach. His scalp is a flaking field of scabs. He is dirty, dehydrated, and underfed. When he raises his right hand to offer you his paperwork, the minimal weight of his hand and its contents causes his forearm to droop like Harry Potter’s after Gilderoy Lockhart accidentally removed the bones.

The papers suggest that he is twelve years old, but to your eyes he’s an eight year old boy with eighty year old eyes. He has been abused by his father and step-mother. The police intervened and he was removed from the home and placed with, well, placed in the care of the state. In a country where the state has a lot more to worry about than the well-being and whereabouts of a lone 12 year old boy.

You examine his injured right arm. Both of the bones—the radius and the ulna—have been snapped in half. Then you notice that the arm holding the bag sways unnaturally as well. Both of his arms have been broken and untreated, from the dates on the papers, for at least 10 days.

You walk the boy over to the cast room and introduce him to the orthopedic house officer. Best as you can tell from the conversation, the house officer bawls the boy out for not coming sooner—now he’ll need surgery to fix the arms.

Later you find the boy on the crowded surgical holding ward. The boy now has plaster casts on both arms to above his elbows. His look of desperation grabs you by the trachea. You go to the canteen and buy a Fanta orange and a plate of chicken and chips and bring it back to the ward, feeling guilty as you walk by nine or ten other equally hungry patients. The boy looks at the food, and then to his hands—neither of which can now even begin to approach his mouth.

To the best of your ability, you feed the boy the greasy chicken and fries. You wipe the chicken fat and dirt from the boy’s mouth with a waxy napkin. You’ve heard, but never witnessed, that you can offer the nurses a little something to get them to actually pay attention to a patient, so, even though you have sworn to yourself that you would never do this, you go looking for a nurse. But 8pm is rapidly approaching and the nurses are making an exodus. At 8pm the ward will be down to night staffing: one nurse, one intern, 30 or 40 patients.

The night nurse and intern are nowhere to be found. You understand that the intern is probably in the process of barricading himself inside his call room. Much as you wish to help the boy, you have experienced what it is like to be the lone person in a white coat on a ward full of injured and dying patients (and their families) where you don’t speak the languages and you have nothing to offer more than another bottle of normal saline (if the IV fluids have been restocked today) and a helpless facial expression. You slink out the door behind the nurses.

The next afternoon you try to track the boy to the orthopedic ward and can find no evidence that he was ever in the hospital.

A relatively calm week in Kampala

Last week was a week of mourning for the Baganda (people of the kingdom of Buganda). Many of them wore a strip of bark cloth or olubugo tied around their waist or pinned to their clothing. The inner bark of the Mutuba tree (ficus natalensis) is harvested after the rainy season and then beaten with wooden mallets to make a suede-like, terra-cotta colored cloth that swaddled and draped the Buganda royalty. The bark cloth reportedly dates back some 600 years to the second Kabaka. In more ancient times, the cloth was used as a shroud for the dead. As such the cloth is a potent symbol of Buganda culture and a sign of mourning.

The mourning Baganda also mounted photos of the Kabaka (Ronald Mutebi, king of Buganda) on their bicycles and motorcycles and matatus. The loss of the Kasubi tombs (see last week’s post) has hit the people hard. It is difficult for us to understand how people can mourn the loss of a tomb (the bodies of the four previous Kabakas, interred in the tombs, were undisturbed by the fire). In a way it seems odd to mourn for what has already been mourned for, but for the Baganda, fighting to maintain their culture in a rapidly changing world, it seems like the tombs were their link to the past glories of their kingdom. The tombs will be rebuilt. Maybe this time with better security, or wiring, but will they be the same?

On my side of town, Prasandan and I taught an ACLS-type course to the medical staff at IHK. Prasandan is the cardiac anesthetist from Kerala who has landed the unenviable task of starting the new IHK Heart Centre (this morning I asked a medical officer what the EKG showed for a patient that had gone into shock—and was told that the hospital’s lone functioning EKG machine was broken). ACLS is Advanced Cardiac Life Support and is a copyright of the American Heart Association, and, as such, if we were to teach an ACLS course here we would have to have the blessings and sanctions of the AHA, which we did not, hence ‘ACLS-type.’

ACLS mostly focuses on the skills and knowledge needed for resuscitation of people in cardiac arrest, although lately it gives some emphasis to the early treatment of heart attack and stroke as well. In a US hospital, the paramedics, most of the ER and critical care nurses, and many of the doctors would be certified in ACLS. Here in Uganda, where resuscitation is a new thing, the only people certified in ACLS are ex-pats or medical personnel that trained abroad. Given that IHK is about to become a ‘Heart Centre,’ I thought it a good idea that we begin teaching our medical staff the basics of cardiac life support. Prasandan agreed.

I will, up front, confess that my ACLS instructor certification expired during the Clinton administration. But I did manage to research the current ACLS curriculum and guidelines and put together an impressive array of shamelessly copied powerpoint slides. And our doctors stayed awake, for the most part, even after the traditional 1300hr bolus of matoke and gravy. Although they did seem amused by a few of the ACLS recommendations. For instance, the thought that you could get an EKG within five minutes of coming to the ER (at IHK, the EKG machine, when it works, is in cardiology, and you send the patient, without a monitor, to cardiology to get the EKG. The walk to cardiology alone would take up your 5 minutes). Or a head CT within 45 minutes (even if it worked, it would take that much time just to locate the key to the room). Too dang funny. What kind of stuff is the AHA smoking anyway?

My evenings in the Casualty ward at Mulago were a little less didactic. At least this week no one was shot (or, if they were, they weren’t brought to Mulago while I was in attendance). But, at one point I was taking care of 3 patients with Glasgow Coma Scales of less than 8. (the Glasgow Coma Scale or GCS was, not surprisingly developed in Scotland as a prognosticator of head injuries, anything below 9 is considered a major head injury) As is typical of my unflagging optimism, I tried to get some CT scans of my patients damaged brains. Unfortunately, the tech that runs the scanner had gone home and ‘couldn’t be called back in unless it was a true emergency…’

I have decided that I really do not wish to be around Mulago when the ‘true emergency’ comes through the doors.

Fortunately I was not at Mulago on Friday when the Baganda mourning was brought to a close and the bark cloth was unknotted and the tears were dried. The Kabaka and the Nnabagereka (his queen) came to Kasubi to officially bring an end to the mourning period. The tens of thousands of people at the site pushed forward to see the Kabaka and between 150 and 250 people were injured and 2 people trampled to death.

another trauma update

Last Friday we had a case conference to discuss a trauma patient who sat around at IHK for over two weeks with an undiagnosed, unstable neck fracture. The conference, in itself is progress—actually getting doctors together to talk about a bad outcome and make plans for prevention of future occurrences is a huge step forward here. (I’ve been trying to get IHK to start having a monthly morbidity and mortality conference since I got here, but, as it turns out, nobody really wants to talk about minor details like how many patients died last month) Granted, if we had been having this particular case conference back home, we would have been sitting down with our insurance company to decide just how much money we should give the patient and the patient’s lawyer to keep them from suing the bejesus out of us.

But, as it were, we sat down with the director of nursing, the director of OPD, the orthopaedist, the radiologist, the ward doctor, the head of physio, and the medical director (one of 3) for the hospital and talked about what went wrong. Well, okay, actually the discussion seemed to focus on what went right. We didn’t kill the patient (or worse, make the patient a ventilator dependent quadriplegic) despite having multiple opportunities and trying really hard several times. And the physiotherapist didn’t choke the living shit out of the ‘spine specialist’ even though she had every reason.

It turns out, according to the orthopaedist who removed the patients stiff collar based on his ‘clinical judgment’ (despite looking at an x-ray, which, albeit a pretty crappy excuse for a film, showed the fracture on the patient’s first night in the hospital), that missing neck fractures is an everyday occurrence and we shouldn’t make a big deal of it. He suggested that we ‘Google missed cervical fractures’ and we would find loads of them. I was going to do this, but the internet is down today.

I tried to suggest how following certain protocols for patients with multiple trauma—such as the one where patients with head injuries or distracting injuries (another painful injury that might take the patient’s mind off their neck) similar to this patient had to have a complete series of neck x-rays (not done) and maybe a CT (not done) and have those films reviewed by someone who actually knows how to read x-rays (not done) prior to the collar being removed—might keep this from happening again. But I was shouted down by the orthopaedist and the radiologist. They weren’t going to start ordering a bunch of extra films or CTs on patients just because we missed one little neck fracture.

The general consensus among the doctors present seemed to be that the care was ‘good enough for Uganda,’ and that my ideas for a trauma team, and protocols, and forcing the radiologist to actually look at all x-rays taken in the ICU, well, they were all well and nice for ‘over there,’ but they just weren’t practical for IHK.

So my question of the other day has been answered. (see one of the updates posts where I mentioned that IHK/IMG has a new vision statement—to deliver medical care to ‘international standards’) To which international standards are we striving?

Here’s to the international standard of being good enough for Uganda.

Crazy week in Kampala

The Kasubi Tombs go up in flames (photo credit: Fans of Kampala FB page)

President Musaveni's security detail clear the way for the presidential visit by 'shooting into the air' (photo credit: Fans of Kampala FB page)


It has been a crazy week in Kampala

Kampala made the New York Times last week. That doesn’t happen very often.

Monday afternoon I was giving my emergency preparedness and basic first aid lecture to a large but near-comatose group of employees at Total (the Ugandan affiliate of the French mega-oil corporation). The employees at Total Uganda have their health coverage from IAA (International Air Ambulance--the health insurance arm of IMG which, ironically enough, doesn’t cover air evacuation or, for that matter, even have an air ambulance), and as part of this coverage they get to have little health promotion talks from people like me who haven't figured out how to say no loudly or quickly enough. David, from IAA sales, and Lorna, from customer care, had arranged my visit. Despite doing everything but smack myself in the face with a two by four, I couldn’t get an iota of audience participation to save my life. Until I put up the slide with ‘Questions?’ Suddenly hands all over the room flew up.

Wow, I thought, they really were paying attention and actually have an interest in the subject. I called on one eager looking man at the back of the room who, strangely, was holding a file full of x-rays.

And the man launched into a lengthy diatribe about a knee injury several years before when he worked for another employer, seen my multiple doctors in Uganda, surgically repaired in India, now causing him pain, referred to an orthopaedist at IHK who doesn’t accept IAA and only takes cash. The man with the sore knee finished off his tirade by pointing his rolled up x-ray folder at me and asking, ‘So I just want to know if you doctors are interested in helping people or are just in it to make money?’ Not exactly the question I was expecting to come to Uganda as a volunteer to hear, I will have to admit.

David and Lorna, as you may have guessed, had set me up. My lecture hadn’t been well attended out of an interest in first aid. Instead, almost every man and woman in the room had a beef or a horror story to share about their health insurance.

Monday night, the final rowdy campaigning for the student guild president of Makerere University (Uganda and perhaps East Africa’s most prestigious higher education institution) got a little out of hand at the God Is Able Guest House. The supporters of the Kenyan candidate tried to shut out the supporters of the Ugandan NRM (national resistance movement—Musaveni’s party) and things got a little nasty and the private security guard for the guest house thought that some of the car’s parked at the guest house might be damaged. The guard, who was described in the Monitor as ‘not a regular drunkard’ but ‘harsh and violent toward the students,’ discharged his rifle ‘into the air as a warning.’ Thus answering the question in all of our minds about whether or not those elephant guns left over from Ernest Hemingway’s last safari that the private guards carry are actually loaded.

Yes, they are. Or at least this one was. The bullet passed through one boy’s chest, through another’s and finally penetrated a third boy’s neck. The boys lay ‘in a pool of blood for about an hour’ until their fellow students got enough money together for a ‘special hire’ taxi to take them to Mulago where the two boys with chest wounds were pronounced dead.

Tuesday the students rioted. They broke into a carpenter’s shop to steal a coffin with which to parade around Makerere and into several confrontations with the riot police. At one point the word was passed that they were marching to Mulago (where I was helping take care of the students with baton injuries) to get the bodies out of the morgue so that they could be buried in the central square of Makerere. Apparently, riot police cut the march short with batons and tear gas. Students these days. No follow through.

Tuesday night, as I left Mulago, I noticed a glow in the western sky that I couldn’t quite place.

The Kasubi Tombs, final resting place of the last four Kabakas (Kings of the Buganda kingdom), were burning. As the ‘world’s largest grass thatched roof structure,’ you can imagine it went up like, well, like a (grass) house on fire.

The Baganda (the people of Buganda) gathered to express their grief at the loss of this monument to their culture, and, in doing so, reportedly blocked the Kampala fire brigade’s only two fire engines (one of them, reportedly, a tanker truck that no longer holds water) from responding to the fire. Both trucks were damaged and six firefighters assaulted.

The Tombs on Kasubi Hill occupy the site of the palace of Kabaka Mutesa I—the Muziba Azala Mpanga, built in 1882—the 30th Kabaka of Buganda, who was later buried there. Mutesa was the first Kabaka buried with his facial bones intact. The Baganda believed that a man’s soul resided in his jawbone, so it was removed prior to burial and a special shrine was made to the disarticulated mandible. You can imagine what the missionaries had to say about that.

The Tombs have been listed as a UNESCO World Heritage Site and they are Kampala’s biggest (only, if the truth be known, unless you consider kabalagala at 4am) tourist attraction. I am sad to say, lameass tourist that I am, I had not been to the tombs yet. (my excuse being that I thought it would be something that Nancy and I could do during her upcoming [!!]5 week visit to Uganda)

On Wednesday, President Museveni came to the Tombs to inspect the damage and offer his condolences to the Baganda. As you may remember, the riots that occurred last September involved a presidential edict limiting the travel of the Kabaka, so there is no love lost between the two leaders. A large crowd of angry people tried to block Museveni’s convoy from entering. To gain control of the situation, the presidential guard fired their weapons ‘into the air, as a warning.’ Again, defying most Newtonian Laws of Physics, six men were injured by these warning shots—the two that were later pronounced dead in the resuscitation room at Mulago had gunshot wounds to their chests.

Things have been relatively quiet since Wednesday. But there is much speculation about the possibility of arson. Some suggest that the fire was set by the opposition in order to further the rift between the Baganda and the NRM in advance of the 2011 presidential elections, whereas the Baganda seem to be accusing the NRM of setting the fire to deprive them of tourist income and out of general nastiness.

A UNESCO report from a year or so ago has surfaced suggesting that the wiring for the structure was unsafe. Additionally, part of the shrine was a fire kept continuously burning to symbolize the living Kabaka as part of the unbroken lineage dating back to the 13th or 14th century. So arson and political sabotage may not be the only explanation to what amounts to a huge loss for the Baganda and the people of Uganda as a whole.

Later in the week an announcement was made by the Assistant Chief Inspector of Police that private security guards at student hostels in Makerere will not longer be allowed to carry lethal weapons. We can only hope that maybe they'll expand this to all of Kampala. Although I wouldn't want to be the guy who comes to take away Wilbuforce's (who guards our gate) bow and arrows...