Kigali to Amsterdam

How is the summer almost over?! I cannot even believe that in just less than two weeks I am starting my second year of school. But I am still in a different time zone so I've got stories.

Kigali was great. I fell asleep early on the first night before Maddie left for her flight. Sarah and I got up early and enjoyed the Mille Collines breakfast spread (lots of breads, omelet bar, fresh yogurt, fresh fruit, etc.) and headed over to the genocide museum. I was just expecting exhibits with machetes and pictures. I learned though that this site also functions as a mass burial ground and over 250,000 people have been buried there. That number is too large to even fathom. And every year they still add bodies as more are discovered. Anyways, Sarah and I watched an introduction video and got the audio guide to share and we walked around the area. There are several gardens with plants to symbolize the history of Rwanda, beginning unified, becoming divided and then recovering after the genocide. There was one garden with only cacti to symbolize the self protection required by those individuals who survived the genocide. Then there were several pool sized blocks of raised cement that mark the locations of the mass grave. One section has plexiglass instead of cement so that you can see in and over the bodies were flags with crosses (so no visible remains). Inside the museum was an elaborate stained glass window that was designed and built by a survivor of the holocaust (nope not a typo, it was made by a man who survived Auschwitz). Walking through the museum took us through the history of Rwanda and the writing on the walls chronicled the events that came before during and after the genocide. There was a room of clothes and a room of just piles of bones. Sarah and I talked about that after, as students who recently finished anatomy we were both a bit horrified to find that we were looking for bony landmarks on the different leg bones. I also couldn't help but use the different skull suture lines to describe to myself where head trauma occurred. After this was a room to honor children who died. There were around one dozen pictures with details about the child and the last thing written was how they were killed. Child 1 likes playing with older sibling, burned alive in church. Or machete while in mothers arms. Or thrown against wall. And it just kept going. The final section of the museum was to commemorate other genocides that have occurred elsewhere. I never knew how many times in recent history people have just been horrendous to other people. Rwanda is interesting because it is an example where a population was truly decimated. This word is defined as one tenth of a population being killed and in 1994 this happened (1 million Rwandans killed). So after that emotional morning Sarah and I just hung out by the pool and then it was time for Sarah to go. I spent another night and day at the Mille Collines and then it was time for me to hit the road. I used the hotel car service and the driver asked me about my stay. I told him that I found the museum upsetting but how in awe of the population I am for being able to rebuild after such an event. One powerful story I saw both in my book and at the museum was how in 1996, Hutu power soldiers entered a school and told students to separate into Hutu and Tutsi groups. The students remained in their seats and said that they were all Rwandans, and would not move. Several were killed. My driver responded by saying that his family had been Tutsi and both of his parents were killed in 1994. He had been only 10 years old at the time. But he said he is Rwandan and that the way he sees it is that there are two countries, the one that existed before the genocide and the one that was built after and that he truly loves and is proud of this current Rwanda.

So after all that learning and experiencing it was time to leave Africa. The flight was uneventful, I slept for most of it and watched the new Divergent movie (Insurgent?) while I was still awake. I got to Amsterdam at 7 and went straight to my hotel. It was too early to check in so I dropped my bags and went to the Anne Frank house. I was told that line is infamous but because it was not yet 8 and the museum opened at 9 that this would be my best chance to go without waiting forever. So I went and the line was still short and I walked through the house. The rooms were actually rather large behind the bookcase, there was a kitchen and sinks and a bathroom and one of the bedrooms had a ladder up to an attic with a window. I was very surprised by that, I was expecting very cramped quarters. I also have never read Anne Frank's diary so the quotes on the wall that were excerpts from her diary truly surprised me. So much talent in such a young writer. I found myself wondering what this young woman would have been able to accomplish if she had been able to survive, or if the war had never happened. Do you think if it was her and not her father who survived that her diaries would have been published?
After that I walked around and figured out the surrounding area. Then I checked in and took a nap and at 4 it was time for my haircut! I had a really nice hairdresser and it was nice to chat with someone and learn about the culture of Amsterdam. When that was done, I took my new haircut for a stroll around because I happen to be in Amsterdam during pride weekend and there was just a lot to see. After that very long day I went to bed.
This morning I got up and had breakfast at the hotel. I walked 2 miles to the Rijksmuseum and strolled around that one and then went to the Van Gogh museum. Both were enjoyable but I was a bit bothered by the crowds at the second museum. It isn't very fun to try to push your way to the front to read a tiny description and then I feel badly if I take too long to look at the painting. So I was pretty museum-ed out by the end of this and I decided to chill outside by the I Amsterdam sign and finish my book. I was walking home when I decided it would be fun to go on a canal tour so I did that too. Then I went to dinner, all by myself (Liz Lewis and I once said that you would have to be so brave to do that, so check me out I am a fearless lone diner).
Tomorrow I think I will rent a bike and try to cover a lot of ground and maybe check out another park if I can find a book shop that sells english books.
Comparing Amsterdam to East Africa is not possible. I have netflix (ORANGE IS THE NEW BLACK!) and hot water here. They have gorillas and volcanoes there. But I do think that this trip has helped me to learn what I enjoy. I would likely be more excited about heading on a nature filled trip in the future, rather than heading back to a European city (note the city term...I would be thrilled to go somewhere like Tuscany or Southern France...see mom check out THAT precision of language).

So I have one more day in Amsterdam and then am headed to Ireland! Poor Bella has no idea what she has gotten herself into (lots of hiking in Killarney, maybe some boats, maybe an ATV, me driving on the LEFT side of the road etc.) but she is a trooper and she seems excited so that is great. Hopefully I will have internet at the hotels there so I can keep you updated.

Xoxo,
Hope

Chasing Summits or Go Big Then Go Home

This will be my last post from Uganda. I am writing from the outdoor seating area at the Travellers Rest Hotel, one of my favorite spots near our home here. I cannot even believe that the end is so soon but before I get all weepy about having to leave let me just tell you about my recent experiences.

Last week I returned from my wonderful stay at Lake Bunyonyi. I did some data entry on Tuesday afternoon because last week was the final push. Wednesday morning I was scheduled to go on supervision with Sam and he picked me up promptly at 8am. We went to the villages of Dometiera and Naomi, two of the new village health workers. In Dometiera’s village we spoke with a man who had been seen in the hospital for cirrhosis of the liver and met with two pregnant women to discuss prenatal care and their delivery plans (both will go to the health center near their village). Naomi’s village was very different from the others that I have seen. We train the village health workers to assess the quality of structures like kitchens, homes and latrines and then they assign the structure a grade: A-Highest quality, B-could be improved and C-looks like it could fall over, unsafe. Most of the villages are mostly Bs and Cs but Naomi had all As. She also had no patients for us to visit there, we had gone just to test her on her ability to evaluate the structures (she passed, she will now be certified as a village health worker). So I asked if her community was wealthier than the others. Her response really surprised me. She said that no, most people were farmers, but her community has very low levels of alcoholism. She said that as a result, she does not see many malnourished children in her role as the health worker. This information really surprised me. I know that there are very high levels of alcoholism. I also know that in this area there are very high levels of malnutrition. I had not thought that these things were connected or possibly even a cause and effect relationship. I do think that this would be an interesting thing to explore and if Naomi’s observation reflects the truth/data then it seems like Nutrition clinics shouldn’t just provide lumpy butter (high calorie foods), but they should also provide AA type services. And if alcoholism really is the cause of many problems here it would make sense for more dramatic interventions, right now it seems there is just an AA meeting at Kisoro hospital which last time was attended by 2 people.

Then the rest of the week was data entry time. We did all get up early on Thursday morning to climb Crater Hill and watch the sunrise, but it was cloudy so that was not too exciting. I was going to go again with Sarah on Friday morning but I decided to give my legs a rest before my big hike on Saturday. Which brings me to Muhabura…

Holy hell.

Muhabura means “the guide” in Kinyarwanda and the name makes sense because you can see this volcano from most places near the Rwanda/Uganda border. It is massive, towering above its neighboring volcanoes. I had to do the climb alone because no one had any desire to even attempt it. We had all heard from Katrina that it was not enjoyable and she had gone slowly so at 11am the guide told her she would not make it to the top so she climbed a bit further and then went down. She said she made it around halfway. So I knew I was in for a tough time, but I was grateful that Emma was willing to hike with me because company is essential on these treks. So Emma and I climbed up to the lodge, I had to carry my backpack which contained two large water bottles, sandwiches, snacks, my good camera etc. I was horrified that I was winded by the time we got to the base lodge and thought about calling it quits there. Thanks for coming, lets go home. But I sat through the orientation and saw that Emma and I would be climbing with 3 other Ugandans, a guide, and my porter. Following behind us was a group of 30 college age Ugandan students who were there for a trip. We were told they race so they would blow by us. So we began climbing and I found that the Ugandan men were moving pretty slowly and stopping regularly. I asked the guide if it was ok for Emma, my porter and me to climb ahead because I had this fear of repeating Katrina’s experience. I climb for the feeling of reaching the top so being told halfway that I was done would have been a bummer. So the three of us headed off at a slow but steady pace. We reached the first of two huts and I was feeling good. We stopped, grabbed some water and continued. Then things just went downhill (figuratively of course, this mountain was entirely UPHILL at an incline of 45 degrees or greater). The distance between the first and second hut is 500 meters. This terrain was just rocks, ladders, brutal switchbacks and absurdly fast altitude gain. And I felt every step. I tried to keep drinking water but I think the altitude started affecting me and we had been climbing for 3.5 hours so my legs were really burning. The porter was ahead of me and keeping a pretty quick pace and I found myself needing to stop after each strenuous maneuver (climbing up a boulder, ascending a ladder) and trying to keep up made me feel like I was dying. So when we finally reached the second hut I told Emma I had had enough. I was done. I was tired and in pain and probably had sweat out the 1.5 liters I had consumed and I was cold and I couldn’t tell if my hands were numb from the cold or hypoxia. NOT a happy camper. But Emma said that we had just 1.5 hours left (JUST?!) and that he would be disappointed if I quit. So we regrouped and I asked to lead so I could set my own pace. So I just put one foot in front of the other. We passed students and were passed by students and somehow the trail just kept going but eventually we reached the top! I am not a very emotional person but I sort of get this feeling in my chest when I accomplish something like this hike. I got it when I did the marathon too. It sort of feels like you are about to cry but I always manage to pull it together. It was hard and parts sucked and I still had to make it down but I MADE IT, and in 4.5 hours instead of the predicted 5! We spent some time walking around the small crater lake, passing from Uganda to Rwanda and back. I watched the clouds speed by below and occasionally there was a break so I could see the lands and homes. We ate some food, drank water, took pictures and then we began the descent. Usually I LOVE the downhill. Sometimes I can run, if the terrain allows. This was SO difficult. My fatigued legs were shaking and balancing on the ladders was not something I was capable of at that time so my porter held my hand to help me balance on those. After 3 hours my knees started stinging and I worried that I had torn something in my left one but after a brief stop I realized they were just tired and sore after being used as a breaking system for 3 hours of steep descent. And then we were back at the starting point. 8 hours up and back! And we actually were the first group to return so the students were impressed ;) I am pretty competitive. Then Emma and I went to a 3 course meal at Travellers to celebrate. I am so grateful for his friendship, he has been so helpful all summer and I do not know what I would have done without him.

So this is the end. Tomorrow and Tuesday my peers and I will take the data and turn it into a presentation that we are delivering on Wednesday. Then Wednesday at 5pm we are heading back to Rwanda. Maddie is flying out to South Africa on Wednesday very late (technically Thursday as her flight is after midnight) and Sarah leaves Thursday night. Then I will head to the airport Friday evening and make my way to Amsterdam.

I feel like I should end the leg of this journey with some profound idea or statement. This trip has been unbelievable. I have never been bored here. I learned a lot and saw a lot and experienced so many new things. I am so grateful for everyone who made this trip possible. It has truly been transformative and I hope that I never forget it. I would like to leave you with this quote that popped up on my Facebook under the Gates foundation page (pages suggested for you...thanks Facebook) but I think it summarizes nicely something that I have learned or felt this summer:
“I cannot do everything, but still I can do something; and because I cannot do everything I will not refuse to do the something that I can do”- Helen Keller

Thank you all for following this, hopefully I will be able to continue the blog in Amsterdam and Ireland but in the event that I cannot I hope that you have all enjoyed this journey. I know I certainly have.

Love,
Hope

My Four-Day Getaway

(Actually a 3.5 day getaway but that just didn't sound as good)

Last week was a pretty uneventful week around the hospital. I attended a teaching round where Nori was giving a lesson on examining a patient for elevated JVP. The first patient we looked at was intended to demonstrate a normal finding. In healthy individuals, it can be pretty difficult to visualize the internal jugular vein because it runs in a bundle with the carotid artery and in general, seeing venous pulsations is not an easy task. Then we looked at a second patient who had visibly dilated jugular veins and they could be seen beyond her ear. Then I did a heart exam and felt a rocking motion (there is a displaced PMI and an off tempo atrial kick) and I could hear an irregularity.

After a week of charting and lots of work hours I was ready to get out of Kisoro. On Saturday morning, our guide picked up Maddie and me at 7am. We drove 6 hours, with minimal pit stops, and arrived at Queen Elizabeth park with just time to grab a chapati before our boat tour left at 2pm. While we were waiting for the waitress to bring our food out to us, I looked up and saw a HUGE elephant wandering over to try to grab scraps from the dumpster. Off to a good start. Then, we boarded a tour boat and made our way across the Kazinga channel. The channel acts as a watering hole for most of the large animals so when we reached the other side we were greeted by a large herd of more than 20 elephants, plus a herd of buffalo and several groups (schools?) of hippos. Every once in a while I saw a crocodile lurking in the shallow water by the beach and was worried I would have to witness some animal planet action (buh bye baby buffalo). Fortunately everyone kept their teeth/tusks to themselves so I didn’t have to see anything like that. The tour lasted two hours and we were able to see more of all of the above plus a wide array of birds and several different deer-like animals. Once we made it back to land, we headed on an evening game drive in our SUV. We drove along the grassland part of the park and saw warthogs, more deer things, and a male lion made a brief guest appearance. He was only standing for 15 seconds and spent the rest of the time hiding in the tall grass but it was still very exciting!

When the sun had set and we were losing daylight, we made our way to our accommodations for the night. We had arranged to stay in a large tent in the park. There was a briefing before we could head to bed…something along the lines of: Hippos will be grazing at night, they are aggressive, if you must leave your tent bring a flashlight and do not go near them or they will charge. So of course, at 3am my bladder had had enough and I had to grab my headlamp and bolt for the toilets. Fortunately, there were no hippo encounters. Then we got up at 5:45 for 6am breakfast so that we could meet our guide at 6:30 for another game drive. More of the same but we were lucky enough to see a large male lion just hanging out by a rock. He seemed pretty uninterested in us but I was still nervous having my window down to take pictures.

After a few hours of driving around it was time to hit the road. Off to my next stop…
LAKE BUNYONYI! I had asked other members of my group if they wanted to come, but since this is our last full week, they preferred to stay around Kisoro. I am not one to miss out on seeing/doing things that I want so I had no problems going myself. And thanks to my parents, I had a reservation at the beautiful Birds Nest Hotel. My guide dropped me off at the entrance and then I was on my own. I checked in, dropped my bags in my room, grabbed a book and headed for the hammock. I was walking through the sitting area and I heard someone call out “HOPE!” What the heck? I don’t know people in Uganda. But I turned around and there was Annette, the Australian psychologist that I had done psych outreach with (she and Immaculate are the psych workers here at the moment, Immaculate is here always and Annette is leaving on Sunday). I learned that she and her husband Dr. John (pediatrician) had spent a night at a nearby hotel and were waiting for my friend/driver/tour guide Emma to pick them up. I spoke with her for a bit, and was so happy to see Emma. He was surprised I was alone and actually texted me later that night to make sure I was enjoying myself. Once I was alone again I spent a lot of time outside reading my book on the Rwandan genocide. I would actually HIGHLY recommend it, it is very well written non-fiction and is called “We Wish to Inform You That Tomorrow We Will Be Killed with Our Families” by Philip Gourevitch. Living in Africa for the summer, I felt very ignorant about the governments and histories of surrounding areas so this allowed me to better understand the recent events in Rwanda/Uganda/Zaire now the Congo. So anyways I had my book and my hammock and a beautiful lake view. Then dinnertime rolled around and I tried the highly recommend garlic crayfish and they did not disappoint. Crayfish can be found in the lake but are not indigenous to the area; a foreigner brought them so I learned that older locals will not eat this animal. Then it was time for bed.

When I got up the next day I grabbed breakfast and headed out on a 2 hour tour of the lake. I got to see many of the islands (one had zebras imported by the wealthy owner, another has a hospital and a school). The smallest island at the center of the lake is called “Punishment Island” and up until 80 years ago, community members would leave pregnant unmarried women on the island to die. If a poor man could not afford a wife he could come in the nighttime and take one off of the island but was then forced to move away from his village. Pretty harsh. After more reading, I took the hotel canoe for a spin around the immediate area but the giant dugout canoe proved pretty tricky to maneuver. I ate dinner and then sat by the fire where I began talking to two girls who looked my age. Their names were Emma and Jenny and they are from London. Jenny is a nurse who was working in the north and Emma had left her job and has an open-ended trip here in Africa. They had met in Jinja and decided after their programs ended to just travel around together. It was great to have people to talk to and we stayed up until 11 just exchanging stories about our time here (cue Diane Haddad saying "This one time, in Africa"). They were staying at a hostel just a short boat ride from my hotel and they actually came back this morning to hang out with me while I waited for Emma.

It was such a WONDERFUL weekend and I am so glad I had the opportunity to travel around. Now it seems that all that is left here on my Uganda itinerary is work this week and our presentation next week, broken up by my attempt to climb Muhavura (some sites spell it with a B not a V..who knows) on Saturday.

Thanks for following along on this crazy journey. I will update you guys either Sunday (to discuss the hike) or once I am in Kigali on Wednesday the 29th or Thursday.
PS I did my last Humira injection in Africa today (signals I have less than 2 weeks here, which we know since I actually have 1 week as of tomorrow)! Last one for my time abroad will be in Amsterdam.

Love you all,
Hope
Aka Hope (who is now comfortable going) Solo

Sabyinyo

I was feeling better after my medical scare (thanks dad, international sos, Keflex and the inventors of a non penicillin antibiotic) so I decided to join my friends on their attempt to hike mount Sabyinyo. This is the oldest of the three volcanoes and the name translates to mean tooth because it looks like a molar with its multiple peaks. The summit is at 3,645 meters or 11,959 feet (Wikipedia) and at the third peak it is possible to stand in Uganda, Rwanda and the Congo.

So we set off at 6:20 am and arrived at the mountain by 7. We were very lucky in that we were the only group climbing Sabyinyo that day and so we did not have to wait for any other tourists. This time I was smart enough to hire a porter to carry my backpack because schlepping my bag up Gahinga was not an easy task and I heard that this mountain has some difficult ladders near the top.

Here is a brief summary of my inner monologue:
First minutes: Ugh I feel lightheaded. I have not had my coffee yet. Why did I sign up for this? This guide needs to slow down or my friends in the back are going to die

Hours 1-2: Just keep walking, just keep walking. IthinkicanIthinkican. OOOh look at the bamboo. Oh crap, I see peak 3. WHAT ARE THOSE LADDERS?!

Hour 3: They said we were halfway to peak 1 like 30 minutes ago? Why do they always lie about this stuff?

Hour 4: Yay! Made it to peak 1. Now we just have to climb down the other side. Then up to peak 2. Then down the other side. Then up the ladders. Piece of cake :/

Hour 5: Don’t look down. Probably not a good idea to look up either. How is Sarah standing directly over my head?!
And then once I was up the ladders there was a 5 foot narrow path/cliff where I found myself hugging the face of the mountain and inching across. I made Sarah hold my hand after I made the mistake of looking down.

And then we had done it! All four of us, plus our guides and our porters had made it to the top! We stopped for a brief lunch and lots of photos and then it was time to head back down. Sarah and I were in the lead and decided to sing broadway/Disney songs to distract us from the terrifying ladders that somehow were worse going down than up. The others had an even tougher time so we did some waiting but I really did not mind having the chance to rest my legs. So we made it to the bottom of the mountain and then had to make the several mile trek back to the starting point. When we finished it was nearly 5pm and we had spent over 9 hours hiking. So the next stop was the Gahinga lodge for a three course dinner! The girls played banagrams and I called my mom to tell her I was still alive and then I ate a feast! So delicious at the time but I paid for it later when my stomach reminded me that I have been eating a low fat, mostly vegetarian diet all summer. Not fun.

Today, Tuesday, I shadowed at Mutolere again. I saw two Caesarian sections and they let me hold the babies and show the mothers that they had sons! I also saw two hernia repairs and got to help put a cast on a fractured wrist. I really love the OR but it has been hard to only be able to watch here. I really look forward to going home and having more opportunities to scrub in and assist (even retracting is interesting to me and it is less taxing on your back when you can lean into the table/are distracted by the work you are doing).

Coming Up:
This Saturday Maddie and I are going to Queen Elizabeth for safari. We are sleeping in tents near where the hippos graze and Robert has planned several different safaris/boat trips/ drives for us to see while we are there. Stay tuned for pictures.
Also, next week is my last full week in Uganda. This summer has FLOWN by and I am still having a hard time believing that it is already July. Most of the other students are taking the last week to hang out in Kisoro but I see it as my opportunity to get in any last minute trips. So, I booked a nice hotel room by lake Bunyoni for Sunday and Monday night and will have some quality time to myself. The hotel overlooks a beautiful lake and there are really interesting islands that you can tour. There is also free wifi, good food, a pool and canoes so I am sure I will enjoy myself (and I promised the other students I would bring patient charts so I can get work done too…lets hope I can stay motivated with all of these great distractions).

Still on my to do list:
I have climbed 2/3 of the volcanoes in Uganda. All that is left is that monster Muhabura. I could adopt the medical school approach..65% is passing and I have climbed 66.67% of the volcanoes. But I am so not ok with that, so I plan to spend one of my last weekend days attempting to climb this last one. I also would love to do a sunrise hike of crater hill. I would like to get back to lake Mutanda but it is ok if that doesn’t happen (Bunyoni is like the bigger better version). Deus promised to take us on the coffee tour so I plan to do that too. And if he can find a free morning I really want Deus to teach me how to drive a motorcycle.

So that is it for now. I will probably not blog until next week because I am really just trying to enjoy every second that I have left here because frankly, it is just not enough.
I hope you are all well!
Love,
Hope

My Return to Kisoro

Oh my goodness I cannot even begin to tell you how happy I am to be back in Kisoro! I don’t think I truly appreciated this place until I was nearly forced to leave. Sure it has its problems, we have had no running water on several days this past week and I sometimes get tired of the limited food options, but I really cannot recall a time when I have been more carefree and content.

To ease back into a schedule after feeling so crappy I started with two days of data entry this week. We are trying to take the patient records from the chronic care clinic and amass data with the goal of presenting our findings and making suggestions about improvements by the end of the summer. On Wednesday, I was able to shadow Dr. Nori in clinic. I saw a diabetic foot ulcer, listened to a diastolic rumble on a teenager with rheumatic heart disease (I opted to have Nori give him the penicillin shot-I am allergic and we didn’t have gloves available so I was a bit nervous), took blood pressures and saw many other cases in the 5.5 hours of clinic. I even figured out how to do a urine dipstick and read it on a patient with a nephrotic syndrome (found 3+ protein still but he seems to not be getting any worse and his creatinine is going down on prednisone..mom this is a different case from the one I called you about, clearly if you ever feel like traveling the world there is a great need for nephrologists here). One more unfortunate incident was that an elderly patient decided that she did not feel safe taking a motorcycle to clinic (costs 2,000 or less than $1), so she used all of her money and paid 50,000 ugandan to get her to clinic. But, she did not have the money to get home. She has a history of asthma and just needed a med refill so it was foolish for her to even have come, she could have sent a younger relative for the prescription. Even more frustrating was the fact that the clinic only carried one of her three medications so she would be forced to pay for the others at a pharmacy. Again, the money for the ride could have been much better spent elsewhere. So, she ended up needing to stay over at the hospital, probably on the floor since the women’s ward was at capacity and had to wait for the people of her village to find the money to send for a car to pick her up. Oy.

Later in the week, I went to teaching rounds. The case presented was a 14 year old girl who had low exercise tolerance and complained of vomiting blood. There were signs that this was a more chronic process-she came in with a fever of 100 but said that she was not ever febrile and she did say that she would wake up drenched in sweat (signs that this fever was occurring on a cycle, breaking at night). She also had ascites, when she was admitted the resident asked if she could be pregnant. I don’t know much about tuberculosis but I know it is common here and coughing blood I know is a symptom so I asked if she had been tested for that. The resident told me to wait until we did review of systems. Eyes- conjunctiva and sclera were pale, likely indicating anemia. Lungs- both percussion and auscultation revealed that her right lung had been compressed upward and there was a dull sound, it was possible to discern a line where the sound went from being resonant and normal to dull. Auscultating abdomen-normal bowel sounds. Percussing abdomen- soft, not tender. Then we saw an X-ray that showed most of her right lung had been whited out and it was possible to see the bronchioles in some places, or the white material that lined them. I learned that all of these findings do point to a diagnosis of extrapulmonary tuberculosis. TB usually begins in the lung and can spread either via blood or orally to other parts of the body, so this likey has TB in her gut which is causing her to vomit blood. They will do further testing. I also asked the patient how many siblings she has-answer is 7, so the whole family should be screened. Nori said that in a recent study in Malawi they found that 1 in 4 children from an infected home will require treatment for TB at some point so I am hopeful that if we do confirm TB in this patient, the rest of the family should come in to be examined and tested.

Today (Saturday) I went on the mental health outreach again. Today we talked about suicide prevention. I learned that 3 young people had come to the hospital this week after trying to kill themselves so this was a very relevant topic to this community. So, Immaculate and the Australian psychologist lead a discussion about warning signs and possible interventions. Immaculate also used the gathering as an opportunity to talk about the “Gafura” procedure, which is a health concern here. Basically, if a child has a headache, cough, cold etc, they can be taken to an elder and their tonsils are scraped. It is not a precise procedure and it can lead to infection. So Immaculate showed a video of a procedure being done on a child and told the group that only 3 days later, the child in the video had died. The women in the community looked HORRIFIED and I am thinking based on the reactions that Immaculate was very successful in conveying the dangers of this horrific practice.

Other than work not much has gone on. There have been some good meals (banana pancakes at travelers lodge!) and a lot of quality time hanging out and making smores by the fire at night. Tomorrow we are ALL going to attempt to hike mount sabino together. This volcano has 3 peaks, the third allows you to stand in Uganda, Rwanda and the Congo simultaneously and the views should be great. I always just feel very triumphant when I get to the top and so I hike for that feeling of fulfillment. I am sure if I make it tomorrow it will feel even more proud of myself, in light of recent health issues/obstacles.

Hope everyone is well and sorry for the scare.
Love,
Hope

The Pros and Cons of My Chronic (Crohns-ic?) Life

I did not plan to write this post, in fact I really hoped it could be avoided. But alas, it is the time so here goes.

I was diagnosed with Crohn's disease when I was 15. I was terribly ill then and then got better quickly and enjoyed 7 years of remission mediated by some relatively benign medications (minus prednisone, I hated that and would not wish it on my worst enemy..I don't look forward to having to prescribe it for others). Then, after college I had problems again and the old medications no longer worked. This was followed by several very difficult months of trying a new treatment, feeling better, developing hepatitis from this treatment , going back to square one and trying something new, feeling slowly better and finding a way to maintain that. It was a brutal time but I have been very happy and healthy on Humira for the past year. But my new miracle med is also a pretty terrifying drug with some less than desirable potential side effects and it leaves me immune suppressed, so what may be no big deal to someone else can become a crisis for me.

Which brings me to today...

Crohn's Con:
I had been feeling a bit under the weather this week. It started when I woke up with a red eye on Monday and that improved with antibiotic eye drops over the next 3 days. Later this week I felt a bit tired and had a fever and headache one night. My other housemates have been sick with various things since coming to Africa so I didn't think much of anything. But this morning I woke up and my right cheek was swollen above my sinus. I have said this before, Kisoro is a beautiful place for healthy people. It is freaking terrifying if you are sick. So I texted my dad (it was a reasonable hour at home) and asked if I should be on antibiotics. This led to a conversation about potential causes/complications and so I woke Sarah up and she calmly advised me to call international SOS. I chose to call the South African branch, they are close enough and their accents are so wonderful I figured it could only be a pleasant interaction. They shared my father's concerns, that if this were something like an abscess and with my immune system and geographic location, things could become very bad very quickly. They wanted me to get to somewhere to be seen and get a CT scan and would prefer if that location had a major airport. SO my friends were kind enough to cancel their hike and they let me borrow our guide, Emma and Andrea joined me for the trip. We packed our things quickly and headed off for the 3 hour drive to Kigali (negotiated down from the 10 hour drive that international SOS wanted me to take to Kampala...no way jose). Once at Kigali, Andrea was very helpful at explaining the situation and what I needed. The Doctor I met with was an overworked resident who just wanted me to take an antihistamine and some blood tests. But we prevailed and I got a CT with and without contrast and we even lucked out and there was a radiologist there to read it. No abscess, no fluids, nothing that looked concerning. I just need a course of antibiotics.


Crohn's Pro: So for anyone else this ordeal would have been overkill. But for me and my immunosuppressed self it is considered necessary medical protocol. In fact, when it looked like a radiologist may not be available, International SOS was ready to fly Andrea and me to South Africa to be seen by a doctor there. We reached a compromise. I wanted to just go back to Kisoro after we realized it was not a concerning finding. They wanted me in South Africa. We settled on me staying in Kigali for the night, seeing how I feel tonight, marking my swelling and seeing how things go and deciding in the morning. What this then meant was that International SOS had to provide housing for Emma, Andrea and me. I asked for the name of the hotel and couldn't understand the woman on the phone so I asked her to spell it...hotel d e s m i l l. Emma stopped me as I was repeating the letters "Hotel des Mille Collines?!" Me: Uh yeah that seems to be where she is going with this. Andrea: that is the hotel Rwanda hotel! SO without my asking, this insurance company has put us up in the fanciest hotel in Kigali. There is a pool. And free brunch. And a great shower and clean linens and oh man it is amazing.

So sometimes having a chronic illness can be a big pain in the butt. I have had more colonoscopies than most 60 year olds. But some days, like today, there can be some pretty wonderful silver (or five star) linings. So Thank you international SOS for providing me and my family with peace of mind in a pretty difficult situation and thank you for the wonderful accommodations :)

Xoxo,
A recovering Hope who is a happy camper in her white bathrobe

(Photo taken Sunday morning, clearly looking less puffy/red and much happier)

Gorillas!!!

If you read the first post then you know how excited I was for this part of the trip. I LOVE animals and I was beyond thrilled to have the opportunity to see an extremely rare animal in its natural habitat. Despite having a fever the previous night (not confirmed with thermometer but at this point I can usually tell), I was not sure if hiking to see gorillas would be feasible. After deliberation and speaking with Emma I decided I was well enough to hike and I didn't want to put off the trek. So at 7:15am we headed to the base of mount Muhavora (the big volcano in all of my photos). I met the two guides and the one other tourist on the trip (a 22 year old South African guy who was on break after finishing college) and we began to walk. We had to cross through village fields and climb over a wall and then we were on these tiny dirt "trails" making our way through a rainforest. After 1.5 hours of getting cut up by thorns and pointy leaves I was told we were near the trackers and to get my camera out. I was pretty cranky at this point but Once I rounded the corner and saw a GIANT silverback male I forgot about the fact that my arms looked like I had an encounter with an angry cat. The first gorilla was pretty obscured by the trees but then we saw a 6 year old female who came very close to us. Her name was Machete and she was quite a character. She sort of seemed to recline against trees and pose for photos. Then when we moved along to the next gorilla she would follow us quite closely. I took a selfie standing several feet in front of her and then I heard a roar and some chest pounding and turned around to see her only 2 feet from my face. OY! The guides explained this was her way of playing. I still was not so sure about the proximity. We saw two more silverback males (this family group has 5 males! This is rare, they usually fight so it is pretty cool). Then there was a mom and her 2 year old baby and because she liked the human attention, Machete came over and played with her little brother. Great photo op. After the hour was up and on the hike back I still could not believe what I had just had the privilege to experience. There are only several hundred mountain gorillas left in the world, they can only live in the wild and efforts to have them mate or live in captivity have been unsuccessful. But getting to hang out with these gentle giants in their home for a day was so amazing/terrifying/awe inspiring.

Women Peace Keepers

I am currently writing this from my new favorite place. I had previously enjoyed the view from the top of crater hill but yesterday I decided to get adventurous and climb hospital hill by myself. This “trail” takes the climber up an impossibly steep face (scrambling is required) and once at the first plateau it is possible to see the three volcanoes, the hospital, and most of Kisoro including my compound. Then you head up another grassy climb and traverse the ridge to find yourself overlooking lake Mutanda. So this is where I am coming to you guys from, sitting on the grass overlooking the lake. It is unlike anything I have ever seen.

If I were more of a poet I could come up with something about how the people in this area break my heart and the mountains put it back together again but I guess I will just tell you about what I have done so far this week. Yesterday, we went back to the Congo refugee camp. When we pulled in I could already see that there were new tents and more people. The population has swelled to nearly one THOUSAND people there. Our assignment was to give talks about STIs and HIV and to discuss safe sexual practices. In the past, after giving this talk, women shared with Andrea (4th year) some horror stories about rape and violence that they had encountered in the Congo. This inspired her work and future projects and she is working to establish a database or something similar pertaining to human rights violations among refugee populations. We did not have a similar experience yesterday, just some of the men asked Maddie (in French) about how they could obtain condoms. When we asked if people had questions for us they raised their hands and asked if we could speed up transports because the camp is too crowded (we cannot control that) or if we could do something about getting sugar for the porridge (again, not our area of work).

Today I went on a psych outreach with Immaculate. Immaculate is a nurse at the hospital who also runs outreach programs and organizes AA meetings and I am sure this does not even cover all of what she does. We drove (in a car!) to a village healthworker’s home where we met a group of about 20 women. Immaculate explained that they had planned on doing mental health talks in the community on various topics but last time they came and spoke about depression, many of the women identified themselves as having this illness and so they were working on turning this into a support group. Today, the Australian psychologist (who is in Kisoro for 3 months) gave a talk about stress and techniques used to reduce stress. When asked about what makes these village women stressed they responded with answers like poverty, not having enough to feed my children, raising children when the husband is away most of the time, fighting in the home and so on. The Australian women talked about healthy and unhealthy coping mechanisms and walked the villagers through some breathing exercises. Immaculate also talked to the women about the importance of supporting one another and discussing problems with people outside of the home, and then she asked them what they want this support group to be called, answer: The Women Peace Keepers.

At the onset of the meeting there had been a bit of a discussion because one of the women of the community had attempted suicide last night. She was currently at the clinic across the street so someone went and got her for the meeting. I kept an eye on her the entire time. When others laughed and joked, she remained so serious. She stayed after so we could talk with her and I learned that she has four children. Her husband has work and money but uses it to pay for prostitutes, he even brings them to his home and forces his wife to sleep on the floor in the common room. She said her children often go to bed hungry and there is no money to pay for them to go to school. She took out loans to pay for land to farm but her husband never bought seeds and now she has no way to repay the debt. I asked how much she owes and it is around 300,000 of the Ugandan currency or roughly $100. Seeds would also cost around $100. My first instinct was to just offer to pay this but I realize this is not a sustainable solution and there are so many people here who need help. In fact, I learned from Immaculate today that suicide rates are at around 30%. I knew that alcohol consumption per capita is the second highest in the world here and that alcoholism is an epidemic, but I did not realize that suicide rates where so astronomically here too. This woman promised that she will come to the hospital for help and I truly hope that she shows up. I really do wish there was more that I or anyone could do to help but I really have no ideas (thoughts I have had: I heard of the Heiffer project, I wonder if they have something where people donate money for seeds and then get back a certain percentage at harvest time? If so, why is that not here? Or in farming communities like this could they have a collective fund so when some people have lots and others have a bad year there is a safety net?). I probably should have taken an ECON class or something…

Updates

Good Afternoon!
I hope everyone is having a nice weekend. All is well in Uganda, and the sun has finally decided to come out. It had been thunder storming every afternoon for the first week or so that I was here but these days have been so nice.
Last week we decided to go back to Mutolere to watch the Dutch surgeon on Thursday. Since my last blog was mostly about procedures I will just quickly summarize what I saw this time. I saw a Casearian section where the placenta was not completely delivered (I have not taken repro or done an ob/gyn rotation so I am not sure what the specific cause of this was..Steph?) so rapid suturing was required to stop the internal bleeding . The other interesting procedure was seeing a transfemoral amputation on a man who had a gangrenous lower leg. I will refrain from providing too many details but it looked like a pretty physically demanding procedure without the use of electric tools. And they did it under spinal block so the patient was awake the entire time.

Yesterday, Saturday, we went to lake Chahafi. I had planned to go on safari at Queen Elizabeth national park but when we realized that this weekend is Andrew’s last weekend we decided to all do something together and I moved queen Elizabeth to the weekend of the 18th. Robert, a guide and friend of our group is also an avid birder so he led us on a nature walk. There were kites, crested cranes, raptors, herons, king fishers and many other birds at the lake. The cranes are still my favorite...they mate for life and if their partner dies they will not find a new mate. That seems such a unique behavior in nature. I also think they are pretty funny looking and seem so large and uncoordinated on land that it still amazes me that they can take off and fly.

Today we are having a bonfire and Katrina has invited over all of the Ugandans that the fourth years have befriended in their time here. We have tried to introduce as many people to s’mores as possible so this will be another opportunity to spread our American ways. Haha.

This week I am going back to the Congo refugee camp on Monday, psych outreach on Tuesday and will probably work on data related tasks for Wednesday and Thursday. Then, we have a three day weekend so I am going to see the gorillas on Friday and am trying to peer pressure Sarah Maddie and Katrina to hike Sabino with me on Saturday. Stay tuned for updates!

Xoxo,
Hope

Surgery!

I think that today has provided me with sufficient evidence to support my theory that surgery is incredible. There is currently a Dutch surgeon visiting/working at the private hospital near Kisoro. The surgeon had met us when he was visiting Kisoro and said we (Maddie, Sarah and I) were welcome to shadow, so today we took him up on his offer. Our day began at 7:45 when we left for the hospital. After waiting outside of the surgical theatre for 15min we were greeted by the surgeon and met up with the Dutch students and Ugandan surgeons. The first case was a direct hernia repair. There is no laparoscopy here so it was an open procedure and they do not use mesh because it increases risk of infection. Instead they use absorbable sutures. The surgeon pointed out relevant anatomy and answered our many questions. Next up was a recurring cyst that I learned was due to abnormal embryological development of one of the branchial/pharyngeal pouches (sorry embryology is NOT my thing so I don’t know which precise arch). Anyways, the patient had had recurring cyst formation due to poor surgical technique. I learned that most surgeons remove only the cyst. But, there is also a tract that is where the fluid is draining from and so this surgeon found this, traced it back to its origin in the hyoid bone, cut the hyoid bone (no adverse consequences from this, I asked) and removed the cyst with the tract. The patient should never have this problem again. We briefly walked across the hall to the other OR and saw the end of a Caesarian section. The next case was a young boy who suffered from osteomyelitis. Treatment here involves drilling holes into the femur and trying to find where pus instead of blood is what seeps from the hole. Then the surgeon used a chisel to open up the bone in the areas where he found evidence of infection. The patient will have to stay in the hospital for some time to allow the wound to drain. After this we watched one surgeon apply casts to a baby with clubbed feet and another surgeon drain an abscess in clinic.

After this very full morning, the Dutch students took us to their compound to eat a quick lunch and then we got back to the OR. A woman had come to the hospital with a profoundly distended abdomen. It felt firm when I palpated. After trying (unsuccessfully) to relieve the pressure using less invasive methods (sorry, I will keep this blog non med friendly so we won’t go there) the surgeon decided to open her up to see what was causing this problem. He made one long vertical incision from below her belly button to between her ribs and then he placed his arms in the incision and pulled out what looked to be an inflated balloon. IT WAS HER LARGE INTESTINES! I was informed that some patients have long colons and these, for reasons yet to be discovered, may twist leading to obstruction. So the surgeon unwound the colon, used suction to remove the air, and placed it back in the cavity. He added some sutures and it was done. The woman had gone from looking 9 months pregnant to very thin in a matter of minutes. I have never seen anything like it!

We thought after this case we were done for the day but someone came in and announced that a boy had been hit by a motorcycle and that he had an open tibial fracture. We decided to stick around. I am glad I have shadowed in trauma surgery at Jacobi because I have seen some pretty gnarly things. This though was a pretty profound injury and the boy required a blood transfusion when his blood pressure became too low. This surgery took the most time and we ended up leaving right after bandages were applied at around 7:30pm.

It was a very long day. But, while watching the surgeon work I had a lot of time to think. Here is some of what goes on in my head: Surgery is incredible and you can fix so many things! Surgeons also deal with very sick people, and sometimes you cannot fix everything. Today, when we were walking through the SICU, I learned that two children were comatose after being involved in two separate motorcycle accidents. While we were looking at another patient in the back room, one of those children died. I was not at all involved in this patient’s care and I still felt devastated. I actually think that when you are a surgeon, unless you are an OB/Gyn and deliver babies, you are seeing your patient on the worst day of his or her life. They come to you in pain, you and your scalpel inflict more pain. But sometimes, in a short period of time, you can have a profound impact on that person’s life. I watched this surgeon today save a boy’s leg and his life, cure several conditions, and provide interventions that will improve quality of life. And I was there for LESS than 12 hours! So, while I have a long way to go in my medical education and I really have no idea what I plan to do with my career, I do think I will be drawn to an area of medicine where rapid results can be achieved.

Weekend Adventures

Hello All,
Thank you for allowing me some time to recover from my hike yesterday before writing. My arms are fine but my lower legs are still on fire, I guess I spent a lot of time on my toes yesterday. But I am getting ahead of myself, so why don’t we start with Saturday.

On Saturday we woke up and the sun was shining so the crew headed to Lake Mutanda. The fourth years had previously found a hotel right on the lake where they had enjoyed many weekends so they were very nice in sharing their special spot with us. After a very long and bumpy car ride we arrived at the hotel, a bit nauseous but no worse for the wear. The hotel was right on the water and had a porch that overlooked the lake. We spent all day just sitting outside, eating, reading and bird watching. Andrew and Sarah were brave and went swimming but after chatting with dad about schistosomiasis I have decided that lake swimming just is not in the cards for me. When we got home after 7 I loaded up my backpack with my hiking essentials and went to bed.

On Sunday I set my alarm for 5:45 but I couldn’t sleep after 5, I was just too excited. Emma (Ugandan tour guide, picked us up in Rwanda earlier in the trip, now is my favorite person ever) arrived at 6:30, informed me he would be hiking with me as my guide and then we set off to the base of the volcanoes. I was having a hard time choosing between Sabyinyo and Gahinga but ultimately decided to start with the smallest and work my way up. Keep in mind that this smallest volcano still took me to an elevation of 3,474 meters or 11,398 feet OR 2.16 miles above sea level. The top of the mountain is half in Rwanda and half in Uganda. But we certainly have not reached the top yet.
After deciding it would be Gahinga, we had to wait for 2 tourists to arrive for orientation. We met the park guides and learned that the guide in the front would be hiking with a machine gun because sometimes there are wild elephants and buffalo and they need to be scared away with shots fired into the air. Awesome. The two other hikers were a couple in their 50s and they opted to hire the Ugandan version of a Sherpa to carry their bags. I am stubborn so I carried my own pack. If Baby can carry a watermelon I could certainly carry my REI pack that had been designed for hiking! So we started off at a brisk pace. The first 2+ hours took us on a slow, gently sloping trail through fields and two bamboo forests. It was beautiful and I was having a great time, except that I stepped in buffalo poop (in some areas it was just unavoidable). There were some elephant tracks that made the path a bit more difficult to navigate but sadly no animal sightings.
Then we got to the first ladder. Guide: “Now is where we begin the hike/ascent.” Me: “Wait what? I thought we were already climbing? Holy S#*!”.
But fine, I am not a quitter so I got onto the ladder and started the climb. The next hour was a steep scramble through ankle deep mud followed by scaling a sketchy ladder followed by a sequence of switchbacks. At one point I made the mistake of asking Emma how much time was left. He said 50 minutes to the group but when we took a break he took me aside and said there was more than 1 hour 50 minutes left (he said he lied to be encouraging). I calmly explained the rule of restaurant reservations...It is better to overestimate than underestimate. From then on, every 15 minutes Emma would turn around to ask me how I was doing. For some time everything was fine. Then we got above a certain height and balancing on the ladders got very tricky. Putting one foot in front of the other seemed far more difficult than it should. I just told him I could keep going but I needed to go slowly. And eventually, when I was ready to kill Emma for his inaccurate time predictions (I yelled at him for lying to me, he found this hilarious) the trees cleared and we were at the top! It was such a bizarre landscape. I was above the clouds and the crater at the top is now a swamp so there were strange looking plants and trees everywhere. The clouds moved so quickly that in one moment I couldn’t more than a few feet around me and the next it was clear skies and great visibility. Then, after only 15 minutes of enjoying the view, it was time to climb down.

If the ladders were tough on the way up they became nearly impossible going down. I actually decided to try one backwards, the way Pompey Merrill instructed me to do on the boat. With three points of contact at all times I felt very secure and was able to go down much more quickly than the people who were trying to balance. Eventually, even the guides adopted my method and any time there was a steep ladder the guide would say OK time for the Hope method. I found this very amusing. There were a few very slippery portions of the trail and at these points Emma went ahead of me, held my hand, and allowed me to use his boot to break my slide. I was so thankful for his assistance and the hike down was uneventful, likely due to Emma making sure I didn’t fall/slip/slide off of the mountain. Finally, after what felt like forever but was really 6-6.5 hours of nearly constant climbing it was over. My shoes were soaked through, I had mud up to my ankles, and some random scrapes on my arms but I was so excited that I had done it! Since he had been so ridiculously helpful (and because I felt bad for yelling at him...even though he DID lie to me) I took Emma to dinner and drinks. We had a good discussion about his family (his parents are Rwandan, his brother stayed there during the 90s and is now still in the military) and his life in Uganda. I am very lucky to have such a knowledgeable and friendly guide, he is actually going to be the one to drive us back to Kigali at the end of the summer and he has offered to stay over in Rwanda so that on Friday, before my flight, he can take me around the city and through the genocide museum.

Tomorrow Maddie, Sarah and I have arranged to go to a different hospital to shadow the Dutch surgeon that is here until the end of the week. Should be interesting to see how things are done here, it seems like it would be impossible to prevent postop infections in some of these rural settings but I am looking forward to learn about how they attempt this task.

New Places

I went with Sam yesterday on a supervising visit. Sam has a degree as a PA and an additional degree in public health. His role with Doctors for Global Health is that he visits the village health workers and examines the patients that they have assessed during the week/month. What this actually means is hiking up mountains and through fields to very remote homesteads in the hopes of finding people who may or may not have already left home for work that day. He then may advise patients on pertinent topics and then provides medications to the village health worker each Friday which they then distribute to their own community. Needless to say, it is a tough job. The first village we visited was a farming area. We checked on a newborn and the baby’s mother. We visited a man who had 4 wives and more sensitive illness that I am not going to discuss on a blog. As we strolled through the rows of potatoes and wheat I could not help but notice that most mothers were accompanied by their very young children. I learned from the village health worker that her area had a great deal of poverty, malnutrition and alcoholism. It is in areas like this where the village health workers seem so useful. These individuals are part of the community and are able to help their peers and so I think it is a very effective model (as opposed to having outsiders come in or forcing people to travel long distances for healthcare).

The second and last visit (time constraints) was up in the mountains. We had to park the motorcycle in the nearby village and hike until we met Jane, the village health worker from her community. Jane is a warrior (not actually, but this woman is tough). She is 52 years old, has 9 children (6 boys, 3 girls) and 3 grandchildren. And she is influential enough in her village that she got over 40 people to sign up for the insurance plan that the hospital offers (provides transport to hospital, reduced price for meds/free meds when possible). I thought when we reached Jane that was the end of the hike. Wrong. So wrong. We climbed about one mile and met a man who had been gored by a bull and had received surgery to remove several ribs. The surgical incision was oozing pus…not good. Sam informed this man that Jane would bring him antibiotics on Friday. Then so much more climbing. At the edge of the community, right by the wall that marks the beginning of the national park (think elephants, gorillas, large cats etc) we checked on a newborn and her mother. Sam also tried to discuss family planning with the men at this homestead. One of the guys has 8 children but he said in his own family he was baby number 10 so if his dad had considered family planning he would not be alive. Tough logic to reason with. Sam told the men that they marry for love and if their wives have 10 children it means they have less love or time for the husband. I am not so sure about this but it seemed to get the men to actually consider family planning as an option so sure why not. Then we descended the mountain, saw a few more patients and took the long, bumpy, rocky, hilly ride home (not my favorite motorcycle day).

Today we visited the Congo refugee camp. Whoever settled this continent and made the country lines really messed up when it came to the Congo. It is a HUGE country with no stable government and lots of resources. This has lead to regular emergence of rebel groups claiming areas for their own and has forced entire villages to flee. The camp that I visited is a short-term camp. People stay for 5 days-3 weeks and are then transferred to the more permanent camps. In 2013 the rebel fighting resulted in the camp housing 8,000 refugees in the month of March. There are currently around 200 people there but the numbers change on a daily basis. I was not permitted to take a picture but it was just several large white tents where people sleep, one larger building where there were 8 children in “school” and a hut where meals were being prepared. We walked in to the building where the children were and I watched as they built towers out of blocks. The person leading the tour pointed to a sign on the wall that listed activities for the week, which included singing and dancing. We were told that they try to have activities to distract the kids and adults from the difficult situation that they are in, though I am not so sure how successful these efforts have been.

I was there around breakfast time and watched as people took these orange plastic cups (look like our baking measuring cups) and received one cup full of porridge. Residents receive 3 basic meals per day. We were able to speak with the nurses at the camp and I learned that the 5 major illnesses that are seen are 1. Upper respiratory infections 2. Malaria 3. Diarrhea 4. Skin problems 5. Chronic illnesses. There is also a very high rate of malnutrition among the refugees. I didn’t really have the opportunity to speak with anyone who is staying there but we are returning one week from Monday so I will have more stories then.

When we got back we got to shadow in the chronic care clinic and are now working on database entry.

As I am now settling into a routine I will probably be blogging less often but I will make sure to keep you updated with any interesting stories.

Til next time,
Hope

Motorcycle Diaries

It has been a few days but there had not been much to report. We are familiarizing ourselves with the charting method here so that we can attempt to create a computerized database so that has taken up most of the time (this is the main project and is my job for the summer). After work yesterday Sarah and I climbed crater hill. We are all trying to get in shape so that we can climb the tallest volcano here (>8 hour hike). I don’t think I am quite there yet.

MORE EXCITING THINGS
Today was my favorite day so far. I was assigned to do community outreach with Jerome. This program involves visiting the more rural villages and checking in on patients who were discharged from the hospital but did not show up for follow-up appointments.
The trip took us along the mountainside and above lake Mutanda so the views were spectacular. We stopped first on the near side of the river to speak with a woman who had been seen for hypertension. I learned through the interview that she did not go to clinic as often as she was told because it was expensive to get a ride in from the villages. There had been times where she had managed to make the 2 hour trip down from the mountains to clinic and the clinic had already run out of her pills. When this was the case, she had been told to purchase them on her own. This was not something that she could afford. When asked about what she believed to be the cause of her hypertension she said “I lost many children.” This is something that I really struggle with here. On the one hand, if you have been following my Facebook photo uploads, you will see that everything is BEAUTIFUL. But that is really just one side of the story here. From an outsider’s perspective, it looks like life can be very difficult here. Children die and this is not a rare occurrence. In the more rural areas I see people walking around without shoes. Jerome told me that he got his first pair of shoes when he was 11 and he said that without shoes his feet would freeze in the morning and burn during the dry season. I also learned that the best schools here cost a lot of money and that these students do the best and then receive government scholarships to college. In the rural area that I was in today there was only one school between 12 villages. If education is the key to a better life, it seems like there is very little opportunity for social mobility here (ie. Wealthy parents send their kids to the best schools, these kids get to go to college on government scholarships and get better paying jobs).

Our second stop required us to park the bike on the side of the road and scale a mountain to reach a small hut. Jerome had asked around for directions and actually met a family member of the patient we were trying to see. So this elderly woman (I am guessing 80-90 years old) led us up a steep slope. Jerome kept turning around to see how I was doing with all of the hiking and I felt pretty winded but there was no way I was stopping. That elderly woman kicked my butt and did it without shoes on. So we met with the patient and his wife promised to bring him to the hospital this week. We then headed on our way, hiked around a bit, got lost a bit more and eventually we had to skip the last two patients and just head home. After such a long day (6 hours on that motorcycle!) I asked Jerome if he would have dinner with me. I was very grateful for his help with translating and for making sure that I felt safe on some pretty rough terrain. I really love when I have the opportunity to talk with the local Kisoro clinic workers, they always have very interesting life stories and introduce me to new ideas. Hopefully I will have the chance to get to know more of them with these outreach trips.
But yes today was my favorite day. Any time I get to be outside is the best and I spent all of today hiking and motorcycling around some spectacular settings. Please do check out the photos, they don’t do it justice but I really tried.

White Knuckles and Skinny Babies

I didn’t blog yesterday because it was a pretty uneventful day. Went to the hospital to watch the village health workers interview the standardized patient (we do this at Einstein as part of our training too) and then Sarah and Maddie peer pressured me to go for a run. I told the girls that Deus told me the road we were on lead to the Congo border and when I got back we realized I was right. Had we all been in better shape we could have found ourselves in a pretty interesting situation (sorry mom!).

Today (Saturday) was our first day out in the community. It was also my first time on the back of a motorcycle and the roads here are terrible. Since this is going to be a necessary mode of transportation here, I am not going to vent and scare my mom but please ask me about it when I am home and I will gladly share all of the terrifying details. Needless to say, the white-knuckle component of the title was inspired by my trip today.
So, Katrina (fourth year), Deus and I took a 30-minute ride toward the volcanoes and out into the more rural villages. We were seeing patients that are part of the chronic care management program so patients met us for medication refills and to be examined. We made three stops and each clinic location was truly different from the others. The first was held at a very nice farmhouse in a rather large town. Most of the patients at this location suffered from asthma, diabetes and hypertension. I got to take blood pressures and listen to some interesting lung sounds and observed as Katrina and Deus instructed patients on proper medication schedules. I kept getting distracted by all of the farm animals but I don’t think anyone noticed or minded.
The second clinic was located outside of a small home in a more rural setting. One of the patients at this location was a woman who had lost sight in one eye as a child. Last year she lost sight in her other eye so she was functionally blind. Katrina described this woman as having a very poor quality of life. BUT thankfully, Jerry’s program was able to provide the funds for this woman to see the eye doctor and later to have cataract surgery. She is now able to see and I was able to meet her and her two young daughters. It was great to see what a profound effect medicine can have in a person’s life here.
The last stop was the most difficult for me. We headed even further out of town and ended up at the base of the volcano. Some background information: malnutrition rates in children in Kisoro are at around 50%. Illnesses related to malnutrition like Kwashiorkor occur at rates of 2%. The interesting thing is that it is not clear if the malnutrition is due to lack of food/money or if it is due to lack of knowledge about what the right foods to be eating are (there are lots of carbs available but protein is hard to come by here). The home where the last clinic was held was built out of mud with a tin roof. I entered the room and first noticed that there was no electricity so it took my eyes some time to adjust. Then I looked around and saw that most of the patients were young women with babies on their backs. Katrina explained that in this village there is a high rate of malnutrition so screening would be a large part of our time there. Thankfully, most of the babies had gained weight since their last visit and most looked great. One child though did not appear well. He was two years old and looked severely underweight. While his MUAC was within the normal limit, there was just something wrong with his overall appearance, he was so small. While the other kids squirmed around and interacted with their environments, this boy remained stationary and seemed to struggle to keep his eyes open (lethargic). His mom had a cough and a two month old child that she was nursing while we examined the boy. The mother informed us that her son had been coughing for one month and that she had been struggling to get him to eat. He had visited the nutritionist in May and been given the nut butter weight gain compound we use here but she said he wasn’t eating it. His respiration rate was fast for his age group. In the US this boy would have been sent to the emergency room to be evaluated. Since it is Saturday here there is no one at the hospital to see him so he will have to wait until Monday. I really hope that he gets the medical help that it seems he needs.

On a brighter note tomorrow is Sunday and will be our first full day off since getting to Kisoro. I think we are going to head to the lake because the view is supposed to be spectacular.

SIDE NOTE: Please see facebook for my photos, my internet is too slow to post them here.

Umezute (Hi How are you)

Hi friends,
It has been a busy time since I last left you so I will try to cover as much as possible without boring you.
Yesterday, our driver Emma met us at the hostel and brought us to Kisoro. The trip was a short three hours and the view was spectacular all along the way. One of the funnier moments on the road was when we got stuck behind a truck that was carrying cattle so all we could see were these bobbing cow heads in front of us. Also, people on bikes hang off of the back of trucks to make ascending the hills easier…not sure how safe that option is. Once we got to Kisoro, Emma took us on a tour of the town and showed us where we can buy groceries, how to exchange currency, and then he brought us to a good place for lunch. I have already learned that the diet here consists mostly of fruits, vegetables, rice and beans so I am sure I will be eating a lot of that during my stay. When we finished with these errands it was only 5pm so Sarah, Maddie and I decided to go for a walk around our neighborhood. It is just so beautiful. We live near three volcanoes that can be seen from anywhere in the town. The first two traverse the Rwanda/Uganda boarder and the third is in Rwanda/Uganda/the Congo. It sort of feels like being in the middle of everything, all of these places are so close together. We plan to hike the largest of the three volcanoes at some point but I have heard it is a challenging 8+ hour hike so we may wait until we are more accustomed to the altitude.
When we got back, the fourth years had returned from clinic so we got to hang out and inundate them with all of our questions. They have been here since September so they are extremely helpful. I stayed out until about 9pm but then I was struggling to keep my eyes open so I went to bed.

Today, Deus, another Ugandan who works with Dr. Paccione (Gerry) met us for orientation. The first stop was a tour of the hospital. We were led around the entire facility and got to meet a lot of the staff. When walking through the inpatient ward I noticed that a lot of the beds were empty or missing mattresses. Then Deus pointed outside and said that most patients spend the days laying outside in the sun and that you know when someone is really ill because those are the people who stay in bed. Not something you see in the states. After the tour we headed to the large outdoor market. Every Monday and Wednesday here there is a huge market where we can buy fresh produce. If anyone can figure out how I can send pineapples back to the states please let me know, they are so much better here. We then headed back to the hospital to shadow the fourth years in the clinic.

MEDICAL THINGS (feel free to skip this section if this is not something you are interested in): The first patient we saw was a woman who was 11 weeks pregnant and had presented with edema in one leg earlier in her pregnancy. She had suffered a DVT and I learned you can’t use warfarin during pregnancy so she was prescribed heparin. In the states, a person would receive this treatment for the duration of the pregnancy. This woman received 3 days worth because that was what was available. She was at her return visit and her leg looked fine and her pulmonary exam was normal (you worry about pulmonary embolism in someone who has had DVT) but they will continue monitoring her and she was educated about the symptoms of DVT and PE so she knows to come back should she find herself with any of these problems. The second case we saw was an elderly woman who had come in because of chest pain. She was being seen by the 4th year to be discharged after having been in the hospital for 10 days. On gross exam she appeared to be emaciated and when she removed her shirt so we could listen to her heart and lungs it was possible to see her entire ribcage. She was actually so thin that her PMI could be seen (usually this is something you feel). When we listened it was possible to hear a diastolic murmur that was the loudest in the middle of her sternum. Her formal diagnosis was heart failure and there was also a finding of hepatomegaly, which I learned can be a finding in individuals with heart failure. I am really excited to have the opportunity to shadow the fourth years in the future, they have told us that the clinical findings here are unlike anything we will see in the US.

Wow this post got pretty long so I will leave it there. Was planning on including pictures but my internet is pretty temperamental.

Xx,
Hope

Have Courage and Be Kind

Just a brief post because the only thing that has happened so far is that I took a 7.5 hour flight from NY to Amsterdam and then a second, 10 hour flight that stopped in Kilimanjaro and then arrived in Rwanda. The flights were uneventful, I watched 3 movies on the first flight and slept for most of the second. Thank you Bella for recommending that I watch 50 shades of gray on a crowded plane, wasn't awkward or anything (sarcasm). The title of the blog post is actually a recurring line in the new Cinderella movie and I thought it was good advice for me going forward this summer. But, it is now nearly midnight here and I am tucked under my mosquito net at my hostel in Kigali so I think it is time for bed. I will catch up with you guys as soon as I have internet access in Uganda.

xx,
one very grateful traveler (YAY ALL OF MY BAGS MADE IT!)

Uganda Summer 2015!

Hi friends, family, random person who stumbled upon this,
I am currently in my apartment in the Bronx surrounded by luggage that may or may not include a uv water purifier and a personal mosquito head net. Yes that is the official term, I looked it up. In ~30 hours I will be leaving for 8 weeks in Uganda followed by one week in Ireland. Less than 48 hours ago I was preparing for my last final of the first year of medical school. Needless to say, it has been a hectic time. A quick note on MS1: I am SO glad I decided to go to Einstein, I cannot say enough positive things about my classmates. It is going to be so strange to be away from everyone for so long but I am sure there will be great stories come August when we all reunite. I think I will use this space to address some recently posed questions regarding my summer plans:
1. Why Africa?
2. What about ebola/boko haram/any other dangers?
3. What are you most looking forward to?
4. Are you nervous?

Answers:
1. I wish I had some eloquent and well thought out answer for this one. The truth is, I am on Humira (adalimumab for my med school friends who took pharm) and it requires refrigeration, so that limited my travel options. I am interested in learning more about global health and I attended a panel where the second years discussed their completed summer projects. Those who traveled with Dr. Paccione to Uganda seemed to have had a good learning experience and the program sounded very well organized. These factors guided me to pick this specific program.
2. Different coast/country/ I read the international SOS warnings. That last part was actually pretty comical because I am traveling to both Uganda and Ireland and International SOS/Einstein emailed me the travel warnings for both countries. The page on Uganda looked a bit like the warning label you see on a drug commercial (caution: may cause malaria, rabies, yellow fever etc.) There are no warnings for Ireland. I had a long chat with my GI doc about my summer plans and we reached the conclusion that obviously the safest thing to do would be to not go. Having acknowledged this point we then moved on to discuss how I could travel and do so in the safest way possible. So, I have prepared and packed and purchased as many things as are necessary for me to feel that I am undertaking this trip in a responsible manner.
3.GORILLAS. I am so excited to get to see how the clinic works there and to get to travel to the various villages to learn more about how people with chronic illnesses manage symptoms in this setting. I cannot wait for all of the hiking and it is amazing that I will get to explore one of the only places where you can find gorillas in the wild. I feel like a rebellious teenager because I get to ride a motorcycle to work some days and this has been forbidden here (Dad works in the ED...too many horror stories). Oh and did I mention the gorillas?!
4. Yup. I could lie to you and say that I only have positive feelings about going to Uganda for 2 months. But honestly, it is a bit terrifying. Full disclosure: my immune compromised self cannot get the yellow fever vaccine (I got a waiver) and so, warranted or not, this is something I will worry about. I am also not sure what I will encounter in the villages or at the hospital or in the Congo Refugee facility and, for someone who likes to be prepared, this uncertainty is not an easy thing to deal with.

Anyways, I have a very long to do list that I need to get started with if I plan to make it to Natalie's graduation party on time today. I will do my best to keep up with this, even if it is only for myself to look back on later.

Xoxo,
Hope