Ebola isolation ward

I met Dr. Eric on his last rotation as an intern at Mulago, when he was on Ward 4A ID male. I recently learned that he had volunteered to work at the Ebola isolation ward, and asked to go with him to the ward. There are currently no patients there, so it would be a great opportunity to take a tour of the ward and get a grasp of the layout, so that when patients do arrive inflicted with the deadly disease, I’ll already have gotten my bearings and can go work there fearlessly, or at least less fearfully. And so I kept calling and hassling Dr. Eric to take me there. However, Dr. Eric is either the busiest man alive, or the flakiest, or maybe both. I even went to Mulago on Saturday as he told me he would be free to take me there in the morning. But after waiting for 4 hours with him refusing to pick up the phone, I finally gave up and left.

But I was not to be defeated in my quest. No. After morning rounds today, I asked one of the other doctors working on ID where the isolation ward was located. He showed it to me, and even gave me directions for getting there. So I straightened my white coat, tidied my hair, and found my own way to the isolation ward. When I arrived, I found the gate leading to the ward locked. The ward itself looked empty, which was no surprise. It really was more of a camp than a ward. It was located on the foot of Mulago hill, on a stretch of grassland. About 10 tents had been erected on the grounds, though the tents were so well-pitched, they looked like actual buildings from afar.

I knocked on the gate. “Hello? Anybody home?” No answer. I knocked harder, called louder. “Hello? Is anyone there? Hello?” Finally, as I was about to give up and walk away, a man dressed in green scrubs poked his head out of the tent nearest to the gate. “Hi!” I greeted him with excitement. I introduced myself, told him I wanted to volunteer to work there, and asked if I could tour the ward. “That is no problem,” he answered. He unlocked the gate, and off we went around the ward. He showed me the triage area, the dressing room for getting into the PPE before visiting the patients, the disinfection room for bleaching off the virus after seeing the patients, the tents where the suspected cases were kept, the tents where the confirmed cases were kept, the duty room for the doctors and nurses, the showers and bathrooms for the patients, and the waste disposal area. It was quite a small area, but everything had a cold, sterile feel to it. With nobody else around, the place felt like a cemetery. I felt a quiet shiver creep down my spine.

At the end of my tour, the nurse on duty came back from her lunch break. We sat in the duty room and chatted a little. I told her that I wanted to work there, and she put down my name and phone number on the doctor's duty roster. “We’ll call you if any new cases show up,” she told me. “Yes, please do!” I asked her what her family’s response had been when they found out that she had volunteered to work here. It turns out that she was somewhat of an isolation ward nurse. Whenever there was an outbreak of any epidemic, this area would get turned into an isolation ward, and she would work here. She was an experienced veteran, having worked through numerous Ebola and Cholera outbreaks.

She warned me to be very very careful. “You must not get careless. One mistake and you could die.” She told me about one of the doctors who had died during the last Ebola outbreak. “He knew he was going to die. He told me, ‘I’m dying.’ We said, ‘You don’t know that.’ But he did. He developed all the same signs and symptoms as the patients he had taken care of – those who died. He knew he was going to die. And there was nothing any of us could do.” She paused for a long while, lost in faraway thoughts and memories, recalling events probably best left forgotten. I thought she was going to cry, but she caught herself right at the brink of tears. She snapped back to the present. “We’ll definitely teach you how to properly wear your PPE when you show up for your first patient visit. Don’t worry. We’re very well-trained. The MSF people came here to train us.” I wasn’t worried at all. I knew she would keep me safe. I could see it in her defiant demeanor – there was no way she was losing another colleague to this nasty virus.

Unpleasant exchange

After a long day in theatre, I went to Ward 4A to check on Joyce. She was one of the new interns who had just started work in Mulago on Tuesday, and had been fortunate enough to be assigned to Ward 4A – Infectious Diseases. I had met her when I went to 4A on Tuesday to visit Dr. Etolu and help out on the ward. She had seemed quite lost and confused, but she was such a sweet girl. We had dinner together with Dr. Etolu at the Doctor’s cafeteria, and quickly became friends.

She had a Tetanus patient who was really really sick. The patient had not been feeding for days, and she was worried about the nutritional status of the patient. She had written the patient for 50% Dextrose TID, but the patient needed to get some food soon. Total Parenteral Nutrition was non-existent here. I received blank stares when I suggested it as an option. And so we had given the patient some Diazepam to reduce the spasms, and tried to pass an NG tube. However, the patient started gurgling and foaming at the mouth almost immediately when we inserted the NG tube, and his breathing had become so compromised that we were forced to stop. After removal of the NG tube, he seemed to be breathing better. The nurse suggested we find an anesthetist to come intubate the patient to protect his airway before we attempt to insert the NG tube again. Since it was after 5pm, the only anesthetist on duty would be the one in the Emergency theatre, so Joyce and I went there to plead our case for some assistance. There was no anesthetist there, and nobody had any idea when he/she would arrive. Yes, we were at Mulago – the National Regional Referral Hospital, and there was not a single anesthesiologist or anesthetist around. So if some poor patient comes in hemorrhaging from a ruptured spleen? Tough luck, can’t do an ex-lap with no anesthesia. Of all the travesties that I had seen here in Mulago, this had to be the absolute worst.

Anyways, that was yesterday. We had left the patient with 50% Dextrose hoping his condition would improve. It didn’t. In fact, his condition had deteriorated. Today, even without the NG tube, he was having frequent laryngospasms, and we were worried that he would clamp off his airway just long enough to induce death. Joyce wasn’t sure he would survive the night without intubation. So we went back to Emergency theatre, hoping that our luck would be better this time. It wasn’t. In fact, not only was the anesthetist not there, there were 3 emergency cases waiting to go back, so even if he/she arrived, he/she wouldn’t be able to help us. The surgery resident, Robert, waiting to go back with his 3 emergency cases was actually on my team. My team had been on call the night before (I hadn’t taken call, secondary to a lack of call room, and I wasn’t prepared to walk home alone after midnight), and he had been here all night taking call, and all day waiting to complete his cases. He was now exhausted, famished, utterly sleep-deprived, but waiting for the anesthetist to come so he could complete his cases. His patients needed him, so he would stay for them. I admired his spirit great. He understood our plight, and suggested we try the ICU – intensivists generally know how to intubate. What a great idea!

Joyce went back to the floor to finish up some work, and I proceeded to the ICU to beg for help. When I got there, one of the sisters directed me to the doctor. I greeted her, and explained the situation to her, asking very very nicely if she could help us. I emphasized the fact that we were worried the patient would not survive the night if he were not intubated. The whole time I was talking to her, she simply kept writing in her chart, not looking up at me even once. When I finished talking, she threw down her pen in a fury and narrowed her eyes at me. “There are protocols to follow for these things!” she yelled. “Why did they send you, a mere visitor, to come talk to me? Who is your intern? She should know better. I’m all alone here, and I have very sick patients! I can’t go running all around the hospital intubating whoever needs to be intubated! Your intern would know to call the anesthetist on duty, who can come help you!”

I looked at her with utter bewilderment. A “no I’m too busy to help you” would’ve been fine. Why did she have to yell at me? “I don’t know what I did to make you so angry at me, but I’m a part of the medical team,” I told her calmly. “I’m not just a visitor. I’m a medical student. I take care of my patients, I take responsibility for them. And with all due respect, I’ve been here longer than the interns have, and know this hospital as well as its protocols better than they do.” “I’m not angry at you,” she continued yelling. Really? She could’ve fooled me. “But there are protocols. And you’re just a visitor. You students come here and you want to do everything. But you don’t know anything. The interns, they have 5 years of medical school experience. They know what to do. They know that they have to call the anesthetist on duty for these things!” Seriously? Did she just seriously say that I didn’t know anything?

“Listen, we tried to get the anesthetist on duty. In fact, we went to the Emergency theatre, but there’s no anesthetist there. They’re waiting for the anesthetist on duty too. And there are 3 emergency cases waiting, so even when the anesthetist comes, he can’t help us. The people in the Emergency theatre suggested we come here for help. That’s why I’m here. We’re out of options. This was our last resort.” She started writing in her chart again. “There are PROTOCOLS!” she screamed at her chart now. “They have to be FOLLOWED!!!! I can’t help the whole hospital.” “Okay then. Can we transfer our patient here to the ICU?” “No there are no beds available.” “Can we borrow intubation equipment to intubate our patient ourselves?” “No! Where is your intern? I can’t believe they sent a visitor!” “I’m sorry you’re so angry,” I told her, my voice raising in anger and frustration as well. “But I’m just here because I’m trying to do what’s best for my patient.” “I’m trying to do what’s best for my patients too!” she retorted. “All right. Thanks for your time.” I left and let the door slam shut behind me.

About 15 minutes later, I went back to get her name, so that I could file a formal complaint against her. People should not be allowed to talk to other people like that. I don’t care who you are, you should treat others with courtesy and respect. Or at least not yell at them for no good reason, telling them that they don’t know anything, and making them feel like trespassers on your personal property. But she was no longer there. She had left her seriously ill patients – all twelve of them – and gone home. So much for trying to do what’s best for her patients. And if they’re not her patients, they can live or die for all she cares.

I did get her name from one of the nurses – Dr. Jane Nakibuka, the head of the Intensive Care Unit. She was not only the most unpleasant physician I had ever come across, she was quite possibly the most unpleasantly-mannered human being I had ever met. I comforted myself with the thought that maybe she had had a really rough day, and was not usually like that. Perhaps she was just a decent person having a bad day. I went back to Emergency theatre to check on Robert. He was still waiting for the anesthetist, though rumor had it that he was on his way. Robert was very optimistic that the anesthetist would arrive within the hour. I stayed and chatted with him for a while, and told him of my unpleasant experience in the ICU. Robert laughed. He knew exactly who I was talking about. He had rotated through the ICU and had had a similarly unpleasant experience. Apparently, Dr. Nakibuka won’t give anyone below her level the time of day, won’t even glance at the residents, much less teach them. But she is super nice and sweet with her peers and superiors. She even chats and laughs with them. She knows how to laugh?!! So she’s definitely not a decent person having a bad day. Final verdict – Class A BITCH.

Ebola Task Force meeting

I arrived at Mulago early in the morning to attend an Ebola Task Force meeting. I wanted to learn more about the Ebola outbreak, and see if there were any ways to help out without putting my life in danger. Dr. Pierre Rollin from the CDC started us off with a talk about Ebolavirus in general, and Sudan Ebolavirus, the strain currently afflicting Uganda, in particular. I learned many reassuring things. First of all, I learned that Ebolavirus is generally very easy to destroy – UV light, bleach, heat (30 minutes at 60^oC will kill it), and even soap and water can easily kill the virus. It is however, very infectious, and can be found in all bodily fluids (though it is a matter of debate exactly how infectious the sweat of an Ebola patient really is). The virus can even be found in the semen of men who have been infected with Ebola up to 3 months after recovery – so men are advised against sex for at least 3 months, and to use condoms in case of emergency.

We were assured that with the right personal protective equipment correctly worn, coupled with diligent handwashing, we will be well-protected against the virus. And the most reassuring fact of all – you cannot spread the virus while you’re asymptomatic. Take home point – if you pay attention to your own health, and present yourself to the Ebola isolation ward as soon as you start feeling unwell, you will almost never endanger those around you to the devastations of Ebola.

So Ebola wasn’t so terrifying after all. I decided to volunteer to work at the isolation ward, especially after I got Dr. Etolu to promise to come take care of me if I happened to catch the virus. He is the best doctor I have ever met, so I figured with him as my personal physician, I would have the maximum chances of survival. But there were no Ebola patients there at the moment. Both the patients who were there had tested negative for Ebola. Well, I certainly hope that the Ebola outbreak has indeed died down, and that there will be no new Ebola patients admitted to our hospital. But if there are, I will be there to take care of them.

Outreach day

Every Friday and Sunday, the nurses from Kyenda clinic will go to an outreach site for a “Family Health Day”. They coordinate the visits with the help of the religious leaders in the community, so Fridays are targeted at the Muslims in the villages, and Sundays are targeted at the Christians. They rotate through four different sites, visiting them in turn, so that each site receives a Friday/Sunday visit about once a month. Amanda and I decided to go along with them this time, just to see what exactly entails a “Family Health Day”. The nurses sent me and Amanda with some non-perishable supplies first on a boda boda, and then the boda went back to the clinic to pick up the two nurses from Kyenda.

When Amanda and I first arrived, there was quite a bit of commotion in the village. Not many foreigners come to visit them deep in the village. All the children ran out to greet us. And a really drunk man came to talk to us. When everything had quieted down a little, Amanda and I took out our reading materials and started to read while awaiting the arrival of the nurses.

When the nurses finally arrived, they were very annoyed that there were no patients waiting for them. “You didn’t tell us you were coming,” one of the villagers told us. “If we had known, we would’ve told everyone to come and wait for you.” The nurses sighed in exasperation. “We come here every month. Do we have to tell you every month?” And so we started to set up our little clinic area under the shade of a giant tree. Slowly, people started trickling into our clinic area. Mothers brought their children to update their immunizations – BCG, DTP, Measles, and Polio. We also saw some pregnant mothers, and gave them folic acid and tetanus boosters. More and more people came, as word of our presence spread through the whole village. A throng of people lined up to have their blood pressures taken, which kept Amanda busy all day. Many people came, even healthy young lads, to get their BPs taken. “You don’t have high blood pressure,” Amanda remarked to one of the young men, who looked fit as a bull. “You just want your blood pressure taken by a muzungu.” The young man smiled sheepishly.

By the end of the day, there were still many people to be seen, but we had to pack up and leave. We told everyone to come back on Sunday, when we would return. It was quite an interesting experience. These visits were filled with inefficiencies (we wasted at least 2 hours just waiting for patients to arrive), but they worked. At the end of the day, these visits ensured that most of the children in the villages received their immunizations, that pregnant mothers received multivitamins and some antenatal care, and that villagers with hypertension received referrals to the clinics in town. These villagers could not go and seek out healthcare, so we bring healthcare out to them.

Farmer for a day

I slept in late, and hung around the house reading one of Amanda’s books all morning. Amanda and I had a relatively early lunch, and then walked to Kyenda town. We first went to visit Emma’s orphanage. School was out and all the kids were on holiday, but some of the boys who were living at the orphanage and the girls living with us were at the orphanage. They were helping Emma and Nuliat dry the corn that Emma had harvested the day before. Amanda and I went to join them. We were basically sitting on an enormous pile of corn, and picking up corn from around us, throwing it away from us, so as to spread them out in the sun. It was quite fun actually, as long as you took care not to hit anyone, or get hit yourself, with flying corn.

After we had spread the corn fully around the orphanage grounds, Amanda and I went to the Kyenda clinic to use our computers. Amanda had worked at this clinic during her first week in Kyenda, before transferring over to work at Mubende Regional Referral Hospital due to a lack of anything for her to do at Kyenda clinic. The clinic had solar panels built in, and ran on solar power – they needed the electricity to run their refrigerators, where they stored the vaccines. So we happily plugged in our laptops and started our IT activities. After a while, we got a call from Emma asking us to return to the orphanage. Apparently, the person with the decobbing machine had no-showed, and Emma wanted us to help pack up the corn. So we went back, and with the help of all the children at the orphanage, we packed up most of the corn. As we were working on the final sack of corn, the decobbing machine arrived in all its glory on a boda boda. The owner of the machine however had yet to come. So we proceeded to empty all the sacks of corn we had worked so hard to pack up back onto the floor of the orphanage. The decobber guy finally arrived. It took him a while to set up the machine, and start the generator that ran it.

Finally, with a cough and a splutter, the decobbing machine suddenly roared to life. A flurry of activity ensued. We rushed to fill our pails with corn, and emptied them into the machine, and then rushed back to fill our pails with more corn. We had to hurry, and get all the corn decobbed before the fuel ran out. Once in a while, the decobber guy would stop his decobbing machine, and we would rush to get the kernels out from under the machine, and go through the cobs to see if any of them still had a significant amount of kernels on them. If so, we would throw them back to the pile of corn waiting to go through the giant jaws of the decobbing machine; if not, we would throw them in the other direction, where all the naked cobs lay in a haphazard pile. By the end of the whole process, we were all exhausted, sitting amongst the cobs with bits of corn in our hair, on our clothes, underneath our fingernails. I was very happy that I had not gone with agriculture as my profession of choice.

I was ready to go home, but Amanda was craving mangoes. So we decided to walk to Emma’s garden to go get some. Unbeknownst to me, the garden was really far away from the orphanage. We trekked along dirt paths, tripped over fallen trees and shrubs, detoured around gigantic ant hills (more like ant mountains is what I’d call them), and finally arrived at the garden. We picked some mangoes, and then made the equally long and windy return journey home. These mangoes had better be the most delicious thing I’ve ever tasted! I was about to collapse when we finally reached home. We took turns showering, and then had a sumptuous feast for dinner – rice, irish potatoes, cassava, beans, and of course, mangoes for dessert! We were all so hungry, we finished everything that Nuliat had prepared! And the mangoes were indeed delicious, but I’m in no hurry to go back to the garden to get more.

Village Life

Since I was on official sabbatical from the hospital, I decided to fully embrace the village life. I started out with helping to fetch water. I went with Amanda and two of the girls staying with us, Faoza and Nambasa, to the pond with jerry cans in our hands. On the way, we passed a herd of grazing cows, and had to carefully navigate our way in between them. Faoza accidentally stepped into some cow dung with her bare foot (she was not wearing any shoes), but she simply shook the dung off her foot and kept walking, unperturbed. We also saw some snake skin, recently shed, which was none too comforting. We climbed through a hole in a barbed wire fence – a shortcut to the pond only slender-ish people can take advantage of. When we finally reached the pond, I was absolutely horrified. The water was brown in color. BROWN. And everyone just steps into the middle of the pond with their feet/shoes recently adorned with cow dung, filling their jerry cans with the muddy brown water. That’s the water we’ve been drinking? No wonder we only ever drink tea – you can’t tell that the water is muddy, because the tea is also brown.

I was standing at the edge of the pond, wondering whether or not to remove my shoes, weighing the pros and cons of shoes versus bare feet. Muddy shoes versus muddy feet? I really didn’t feel like dirtying my shoes, but I also really didn’t want to step into those murky depths without any foot protection. Who knows what lurks at the bottom of those waters? “Come on,” Amanda says to me. I hesitated for a split second before stepping into the water. I did not remove my shoes. All the locals were watching us with great amusement. “Muzungu!” they cheered. They couldn’t believe we were fetching water from the pond. I almost couldn’t believe it either. As I was walking back to the shoreline with my filled jerry can, I saw to my absolute horror a gigantic pile of cow dung idly lying in the pond water. I almost cried. “Amazi ku amazzi!” I yelled, pointing at the cow dung. Shit in the water. Everybody shrieked with laughter.

When we finally dragged our ridiculously heavy jerry cans filled with shit-water back to the house, I was absolutely exhausted, and ready for a shower. Until I remembered what water I was using to shower. I momentarily contemplated whether my showers were actually making me cleaner or dirtier. But I was sweaty and uncomfortable, so I decided to go for the shower. At least Nuliat boils the water for our showers. I took a tiny ounce of comfort in that thought. As I was taking my shower in the outhouse/pit latrine (we put the pail of shower water over the pit of the latrine, so that we don’t accidentally lose a limb in it), I dropped my soap onto the floor. This was the floor of the pit latrine – who knows what kind of nasty bodily excretions line this floor with their germ-filled existence? I was momentarily disgusted by this, and wondering if I had another bar of soap somewhere in my bag, when the image of the cow dung in the pond water flashed before my eyes. This floor couldn’t possibly be dirtier than my shower water. I picked up my soap, using it to finish my shower. I had become so economical with my shower water, that I actually had some water left to wash my underwear, which I proceeded to do using the same bar of pit latrine-laden soap. As I was walking back to the house after my shower, I accidentally dropped my recently-cleaned underwear on the ground. I once again saw the pile of cow dung in the pond water. I picked up my underwear, swatting the dirt off of it. I will hang it up to dry and wear it tomorrow.

A chain of unfortunate events

I arrived early in the morning and found Dr. Christopher on the surgical ward. We decided to quickly do some rounds. I told him to start with the female ward, since we had rounded on the male patients the day before, but I was fairly sure nobody had rounded on the female patients. Before we even got started, an emergency case had presented itself. A 9-year-old boy presented with fevers, abdominal pain with a distended abdomen; most likely diagnosis – intestinal perforation secondary to Typhoid. Dr. Christopher was thrown abruptly into a bad mood. “I’ve seen too many cases of this. Too many. There is some unsafe source of water around here, and we should figure out which pond or well it is, and seal it off. You know these children, we don’t always save them. We lost close to half of them. And it’s completely preventable.” I could see why he was angry. I was getting pretty angry myself. We took some blood from the boy, and sent it off for CBC and type and cross. The boy looked severely anemic, and would most definitely need blood before surgery.

Then, Dr. Christopher was called to a meeting with a public health official, and left me alone to start rounds with the nurse. Armed with my copy of the Uganda Clinical Guidelines in one pocket, and the Oxford Handbook of Tropical Medicine in my other pocket, as well as the extensive knowledge and experience of the nurse, we started rounds. Halfway through rounds, I realized that I was going to survive this. Surgical patients are not terribly different the world over – make sure that they’re wound is healing and not getting infected, they’re urinating well, passing flatus and stool, tolerating oral diets, ambulating, pain is controlled. I could actually do this! I could manage this ward. And I started to feel like I could possibly be close to something like a real doctor.

Towards the end of rounds, we saw a patient who was on the wards for diabetes. “Why is she on the surgical ward?” I asked the nurse. “She was admitted with a diabetic foot ulcer. Any type of wound, they end up on the surgical ward.” “But her ulcer is well-healed, and she’s mainly here for insulin management. We should transfer her to the medical ward.” “They won’t take her.” I sighed and moved onto the next patient. Exact same thing, except this patient looked sicker. She was sweating, shaking a little, hugging herself. I took her temperature – normal. Just then, Dr. Christopher came back from his meeting, and took me aside. “Doctor, I really must advise you not to touch the patients without wearing gloves.” “But I’m only taking her axillary temperature.” He came in closer and whispered, “With this Ebola outbreak, we all have to be more careful.” As it turned out, the meeting with the public health official had been about the recent Ebola outbreak in the neighboring Kibaale district. We had heard about a “mysterious disease” that had taken 16 lives in Kibaale district, but the news reports had been intentionally evasive about the exact nature of the disease, its symptoms, its speed of progression. After a few days of this “mysterious disease” business, the authorities finally confirmed it to be Ebola.

The tension and fear had spread to Mubende. Dr. Christopher’s fear was contagious. I looked at the diabetic patient whose temperature I had just taken. She looked sick, she had abdominal pain, she felt febrile even though my thermometer had informed me otherwise, but thermometers can be faulty after all. What if she had Ebola? It could be spread through any bodily fluid, including sweat, and this patient was sweating profusely! “Dr. Christopher, there’s something wrong with this patient. Doesn’t she look really really sick to you? As in really really sick?” I asked him in a panic. He glanced at her. “I think she’s in DKA.” Oh. Right. Of course. Diabetic patient with poor glucose control. What was more likely? Ebola or DKA? I felt ridiculous.

We quickly finished rounds, and I inquired what time we were going to operate on the boy with the intestinal perforation. “Oh him. His blood came back as O+, and we’re out of O+ blood, so we can’t transfuse him pre-op. We have to transfer him to Mulago.” “Do we have an ambulance?” I asked. “Yes, but I think it’s out of fuel. The boy’s family will have to buy the fuel.” “And if they can’t afford the fuel?” Dr. Christopher shrugged. It was just another one of the countless problems facing one of his countless patients. He couldn’t solve all the problems facing all his patients, so he was going to focus his efforts on the problems that he could solve and help the patients he could help. Unfortunately, this boy was not one of them.

Just then, I got a call from Robert. Tuesdays were circumcision days at Mubende Regional Referral Hospital, and I had mentioned to Robert that I wanted to learn how to do circumcisions. In the US, ObGyns are no longer trained in the technique of circumcision, and have to ask the pediatricians to do them. Personally, I would like to be able to deliver a baby and do the circumcision, if that is what the parents want for their baby boys. So I left Dr. Christopher, and went to find the circumcision room.

I found 2 clinical officers in the midst of speed-circumcision. They were each competing to see who could circumcise at a faster rate, with better cosmetic outcomes, etc. I learned that there were two main techniques of circumcision – the dorsal slit and the forceps-guided methods. I also learned that neither of the clinical officers were very good teachers. At the end of the day, I guess I could do a circumcision on my own in an emergency situation (but who really needs an emergency circumcision?), but otherwise, I would still not be comfortable doing the procedure without any supervision. And the last thing I learned – I never want to circumcise a young child without general anesthesia. The only form of anesthesia we had available was local. We received so many young boys brought in by their parents for circumcision. They started howling as soon as they were placed on the operating table. The boys cried and screamed the whole way through, looking at us like we were trying to murder them. And we could never tell whether they were actually feeling pain, or were just scared. This was another reminder of why I hated pediatrics so much. I walked away from the day knowing that I had deeply traumatized and psychologically scarred several young boys, possibly for life. Would they trust any doctor ever again?

Towards the end of the day, amidst the screams of the young boys undergoing torture/circumcision, we received some disturbing news. A patient suspected of having Ebola was brought to the hospital for treatment. A chill traveled up my spine. Ebola. The word struck fear into the very deepest part of my soul. I couldn’t think of a worse way to die. But what happened to helping people? What happened to taking care of the sick? If doctors run away from diseases, what will become of the patients?

That night, I did some soul-searching. What was I so scared of? Was I really that terrified of death? I could take the necessary precautions to give myself the best protection against the virus. I could wear goggles, gloves, a mask and gown, and wash my hands scrupulously. But what about all those healthcare professionals who were wearing personal protective equipment but still died during the Ebola outbreak in Gulu? How did they catch the virus? How did they die?

In the end, I realized one thing – I’m afraid of dying, I really am, but I’m even more afraid of not living fully. I cannot allow the fear of death to prevent me from fulfilling my duties as a doctor, from taking care of my patients, especially if I have a reasonable chance of survival. But I absolutely cannot die before my mother. I don’t think she would be able to stand that loss. The weight of all of her hopes and expectations, her happiness and sorrow, her life and death, they all rest on my shoulders and mine alone. We are two in the world, and I cannot leave her alone. I bear the burden of an only child of a divorced mother, and what an awful burden that is to bear. I owe my mother my life – from the moment of my birth till the second of my death. I live for me, but more than that, I must live for her. And the second issue that crossed my mind – I would never forgive myself if I brought the disease home to the people I stay with, and they died because of me. I would not be able to live with myself (provided that I actually ended up surviving). And so I decided to stay away from Mubende Regional Referral Hospital until further notice. I'm running away from my obligations as a doctor, I'm going back on my Hippocratic Oath, but it is the only choice I have. I am neither proud nor ashamed of my decision.

Mubende Regional Referral Hospital

I had traveled the day before with Amanda to Kyenda, a small town about half an hour away from Mubende by car. I had met Amanda randomly at Garden City where I had been inquiring after wireless internet options. She was a pre-med student who had just completed college, and was volunteering in Uganda for the summer. Since she was from Missouri, and I go to school in Missouri, we had an instant connection. We traded contact info, and stayed in touch over the next few weeks. I had put her in touch with Dr. Sylvester at Gulu, who had hosted Amanda and two of her friends when they visited Gulu. He had even allowed her to scrub into a c-section when she was shadowing him for a few days. And now I was visiting her in Kyenda before her departure from Uganda in mid-August.

We were staying with Pastor Emma, who was running a local orphanage in Kyenda. The house had no power and no running water. In fact, I later learned that the whole town had no power and no running water. We had arrived at night, and we had to use torches and battery-powered lamps to light the way. Of course, with no running water, there was no flushing toilet either, but the house had a pit latrine that Nuliat, Emma’s wife, cleaned regularly. Emma and Nuliat welcomed us warmly into their home, and even prepared pork (pork!!!) for dinner on the night of our arrival. They had given up the only room in the whole house for Amanda to use, and I was to be sharing the room with her. Emma and his wife had put a partition in the living room, and was using half of the living room as their bedroom, where they slept with their two young children, Prosper and Praise. That was so typically Ugandan, to give up the best to your guests. There were also 5 girls from the orphanage staying with us. Apparently, the landlord of the house that Emma had been renting for these girls to stay in had suddenly raised the rent by an atrocious degree, so that Emma could no longer afford to house the girls there. And so the girls had moved in with him and his family. They also slept in the living room with Emma and Nuliat, as well as Prosper and Praise. So it was a full house.

In the morning, Amanda and I ate some bread with our sweet tea, which made up our breakfast. Then, we caught a taxi into Mubende town, and rode a boda from town to the hospital. When we arrived, I met Robert, who was the head of the Physiotherapy/Orthopedic department. He was a big jovial man, reminding me of an African Santa Claus. We left our bags in his office, which was always locked (Amanda had an extra copy of the key). Then, he introduced me to the Hospital Director, the Principal Nursing Officer, both of whom welcomed me warmly to their hospital. Then, he took me on a tour of the hospital, and introduced me to every single one of the health personnel working there. Finally, he took me to two clinical officers running the surgical ward, and left me to do ward rounds with them. It was a slow and painful process, since it was obvious these two had never rounded on any of the patients ever. One of the patients hadn’t been rounded on in ten days!! The last note in his chart was from July 20^th. I was astounded. When we finished rounding on the male ward, Dr. Christopher, the medical officer (the only one currently in the whole hospital) arrived, and the clinical officers left. “You can continue rounding on the female patients with the doctor,” they told me as they almost ran out of the ward. The doctor told me he would be dropping off some things in his office, but promised to be back. After waiting for half an hour, I also left. I went to Robert’s office to take my lunch.

After lunch, I went to theatre to see if there were any cases – there weren’t. But I met Aggred, a student from Gulu University who had been working here for the past month. He had had a great experience and had learned to do most of the common surgeries. I was super excited to follow in his footsteps. However, he was leaving the next day, partly because it was nearing the end of his vacation, and partly because Ebola had broken out in the neighboring district. He took me to see his room that he had been renting – I was looking for closer accommodations for my next visit, as I wanted to be able to scrub into the emergency surgeries at night.

After that, I just hung out with Amanda and her PT patients, and then we headed home. No cases all day! What a downer! Robert gave us a ride into Mubende town from the hospital, and we climbed into an almost-full taxi. However, Amanda ran into a shared private hire cab driver who was her mukwano. So we got out of the taxi and got into his cab. Both of us sat in the front passenger seat. There was a little cushion placed between the driver’s seat and the shotgun seat, where Amanda sat. I looked behind me – there were two rows of seats, each meant to fit 3 people comfortably, but the cab driver was making them squeeze five to a row. Finally, he squeezed a young mother and her toddler son in the front seat with Amanda and me. “How is this going to work?” Amanda asked. There was not enough space for all of us. The cab driver made Amanda straddle the gear box, with one foot almost stepping on the clutch, and her other foot stepping on my foot. We were off! After about 20 minutes, we finally arrived in Kyenda, where we untangled ourselves from the mess of bodies, and were welcomed home by the girls from the orphanage waving ecstatically to us.

Letting loose

After a whole day packing and preparing for my trip to Mubende the following day, I was thoroughly exhausted, especially since we had stayed up super late the night before for Gerie’s birthday party. I was supposed to go to Mulago to work for a bit and say goodbye to Dr. Etolu, but I was simply too tired to make the 25-minute journey there. I just stayed home all day, transferring all my photos from my camera to my computer, charging all my electronics, packing, watching TV and lazing around. So it came as a surprise even to me that when Gerie asked me after dinner whether I wanted to go out with her, Paul and some visiting students from Boston, I actually said yes. I guess I was ready for my first clubbing experience since arriving in Uganda. We had gone to a place called Little Flowers the weekend before, but that didn’t count. It was the “club” where AFRIGO band, the oldest band in Uganda (with a sprinkling of both old and new members) would play old Ugandan songs, with some super talented dancers shaking their booties on stage. And Gerie and I were the youngest people there – most of the other customers were in their mid to late fifties, but that didn’t stop them from shakin’ and jigglin’ the whole night through. It was great fun, but it was no club – not the type I mean when I say “club”.

So Gerie and I got all dolled up for the night out. I wore a black tank top and my Guess denim shorts, while Gerie wore a cute striped dress with a denim jacket. We looked totally cool, if I may say so myself. And then we proceeded to wait, and wait, and wait… We were ready by around 9.30pm, which was when we thought we were supposed to leave. Paul didn’t get to the house until 11pm. I was almost asleep by then, and if he had called just a few minutes later, I would’ve been so soundly asleep nothing short of an earthquake would have been able to wake me. But as it was, I dragged myself off my bed, and went out to the car. Paul was very flashily dressed with a glossy shirt and dress pants. We made a good-lookin’ party of partyers!

The club was abright with technicolored dance lights. Heavy beats pounded in our eardrums. I was super excited! We passed through security, and the security guard gave me the once-over, shook her head, and told me “Too short.” “Excuse me?” I asked her. She pointed at my shorts. “Too short,” she repeated. I gaped at her in bewilderment. I looked at the customer that she had let in right before me – her dress barely covered her ass, but my shorts were too short? I told Gerie and Paul about this. Paul talked to the head of security, who came over to “inspect” my outfit. “So, we have a dress code in this club,” he told me. “Is this your first time here?” “Yes,” I replied, and it may well be my last time here, what with the royal treatment I’m getting so far. Ok, so tell me about this dress code of yours. What does it entail? Do your shorts have to be less than a certain length from the knees, or more than a certain length from the butt?” I asked him. “Well, we don’t allow shorts… I mean we do, but they have to be longer, you see. They have to cover the butt, with no part of the butt showing.” I turned around and grabbed my ass. “See here? This is where my butt ends. Do you see how far lower my shorts end? Can you see any part of my butt? Please tell me.” The head security officer laughed. “No, your shorts are not too short, but it’s sometimes difficult for our security guards to tell, so I have to be called to make the final decision.” “Well yeah, maybe it’s difficult for them to tell my butt from my legs, since I don’t have a gravity-defying curvaceous bum like your African women here do. Or maybe that security guard lady just doesn’t like the way I look.” The head security officer laughed again. “No, no, it’s fine.” And he waved us through. I honestly didn’t know why he was laughing. I was not cracking any jokes. What a way to start the night.

But we went into the club, and I started feeling better. There were two floors in the club, with the lower level playing mostly “world music”, and the top level playing mostly Ugandan music. We each got a Nile Special and headed to the top level. Nobody was dancing. “What’s wrong with everybody here? The music is great, but nobody’s dancing!” I exclaimed. A really great song came on, and Gerie and I got up to start dancing. For about 3 songs, we were the only ones dancing, but slowly, others joined in. Finally, the whole club was alive with gyrating hips and jiggly bums. It was so much fun! We each got another Nile Special, and the fun bumped up a notch on the fun-o-meter. Finally, Paul’s visiting student friends came to join us, along with some local students that they had been hanging out with during their trip. It was such a weird mix of American club dancing and African club dancing – a fusion of cultures and dance moves. Finally, Paul was ready to leave. Gerie and I could’ve stayed longer, but I had to wake up early to meet a friend the next morning, not to mention my trip to Mubende the next day. So we reluctantly exited the club to return to the quietness of the night.

Birthday party

Today, it was Gerie’s birthday. I had never seen anyone work so hard on their birthday. She baked a huge cake, put delicate icing all over it, and cooked all afternoon for all the guests that she had invited. I was the first one home, because my day had ended early. It was the last day of our cervical cancer screening training session. We had just taken the final exam, talked a little about our action plan to starting cervical cancer screening clinics back home, and had our closing ceremony. It was a big deal, with the director of MildMay hospital, where the training had taken place, officiating the ceremony. We even had a celebratory cake!

When I got home, I found another big cake waiting. What a good start to the evening! Gerie was busy in the kitchen with 2 of her friends from cake school. I took the opportunity to look around my in luggage for her presents – a body spray, a mini bottle of hand sanitizer, and a matching set of shampoo, conditioner, and body lotion. I found the items, and hid them in my backpack.

Soon, the boys arrived – Gerie’s brothers Simon and Paul, and her cousin, Cliff. Shortly thereafter, Nellie, her boyfriend also showed up, with Olive following on his heels. Now the party was ready to start! One of Gerie’s friends from cake school had to leave, but we promised to save her a piece of cake. Dinner was served, and it was absolutely delicious! We had rice, tomatoes, avocados and grilled pork! Pork! What a treat! I love pork! We all dug in. There was absolute silence for a few minutes while we all devoured our food.

After we had all finished dinner, it was time for cake! We lit one huge candle in the middle of the cake, and I turned off the light. This apparently was not part of Ugandan birthday customs, because everyone was surprised when the lights went off, but they got used to the idea quickly enough. The whole room was lit by the flames of the sole candle burning fiercely to fight off the darkness. We sang happy birthday in both Chinese (me) and English (everyone else). We then had to repeat the song, as Simon wanted to record it on his phone. Finally, Gerie made a wish and blew out the candle. Time for presents!!

She opened Cliff’s present first. It was a bag of gummy candy and a very chic coffee cup, with a black exterior and lime green interior, with a stirring spoon standing in a hole specially cut-out to hold it in the handle of the cup. When I had first heard that Cliff had bought Gerie a cup, I had reprimanded him. I mean, what a lousy idea for a present! But when we finally saw the cup, it was actually very nice and classy. I took back my belittling words directed at Cliff’s present, which made him very happy. Then, everyone wanted a round of drinks, so while Gerie was distracted with pouring drinks for everyone, I took the wrapping paper from Cliff’s cup, and wrapped my presents in it. When Gerie finally settled down to continue unwrapping her gifts, I handed her my hurriedly wrapped present.

“So, as it turns out, I went to the same gift-wrapper as Cliff.” Gerie laughed so hard she almost fell over. “I didn’t even see you steal the wrapper and wrap the present,” She exclaimed. “I’m sneaky like that.” She opened my present and started screaming in delight. She immediately sprayed herself all over with the body spray, and applied the lotion to her hands. I was super happy that she liked the presents.

Then, it was time to open Olive’s present. I already knew what it was, based on what she had told me in terms of her options for gifts, and the shape and weight of the box. Gerie opened the present to find a Star Times decoder, which is basically the equivalent of a cable box. This was an amazing gift, because we had been struggling so much with getting good signal on our TV, and our antenna was basically on its last leg of life. Gerie had been talking about getting a new antenna to watch her favorite soap opera, Tusker Project Fame, and other programs. Gerie started screaming when she saw the present. She was so unbelievably happy. We were all excited as well. The boys set to work setting up the decoder and hooking it up to her television set. And we all got distracted going through the amazing variety of channels that the new decoder offered up.

Amidst all the commotion, Gerie had already opened Nellie’s present. It was a gorgeous pair of dangly earrings and a make-up set. Gerie loved it too, but it was sort of an anticlimax after Olive’s gift, which overshadowed all the rest. So we spent the rest of the night chatting, fooling around, drinking Sherry (Simon’s present) and watching television. It was a great evening and an awesome birthday party. All of Gerie’s amazing preparation efforts had totally paid off!

Failures - yours and mine

After my cervical cancer screening practicum, which ended at around 5pm, I went to Ward 4A to find Dr. Etolu and see if he had any LP’s for me to do. Unfortunately, he didn’t. He also had to go meet with his consultant to go over some cases, and I told him I would just wait for him on the floor. I wanted to hang out a little with him before I left for Mubende. I didn’t how long I would be gone, or when I’d get to work with him again.

So I decided to make myself useful on the floor. I went to help Dennis with his work. He had recently switched over to the GI ward (still in Ward 4A), and was still finishing up rounds. “What have you been doing all day?” I asked him. “It was a tough day. The consultant came to round with us, questioning our every clinical decision, and we had to defend our diagnoses and treatment plans. Long day.” Well, at least the consultant bothered to show up, I thought. And it sounded like he even made a decent effort to teach! But I did understand how everything took longer with the consultant rounding, so I did my best to help him out.

I did all the blood draws, filled out all the lab request forms, even wrote some of the notes for him. I ran the samples to the lab downstairs, more blood draws, more samples to the lab. We had two patients with severe anemia secondary to upper GI bleeding. Blood draws, type and cross, request for 2 units of packed RBCs (though we almost invariably get whole blood). And then a third patient with the same thing. As I was running down the third sample to the haematology lab, the first patient’s blood was ready for collection. I picked up one unit first (following the advice of the lab technician, who told me that the second packet usually just lies on the patient’s bed overnight, and it would spoil overnight; he advised me to just transfuse the second unit the following morning), warmed it against the patient’s body (he was feeling hot, and welcomed the cool respite from the icy cold packet of blood, so it worked out well for all parties), and hooked it up to the patient’s IV line. I went down to check on the other 2 patient’s blood. They were both O+, and we were out of O+ blood. One of the lab technicians had gone to an elusive “somewhere” to try and obtain more blood. ETA – maybe around an hour.

I went back to the floor to report this to Dennis. It was close to 8pm. I was exhausted, I was starving, I had to do laundry tonight in order for my clothes to dry in time for my trip to Mubende, and I had to wake up at 6.30am the next morning for the long journey to MildMay hospital. I was ready to call it a day. But Dennis, as it turned out, had already left. He had three patients on his ward with severe anemia secondary to upper GI bleeding, whom he had requested urgent transfusions for, and he had left for the day. This was his ward, these were his patients. I didn’t even work here. I was so angry. He had left me in a terrible position. Either I could stay the hour (and when they say one hour, it will most likely be closer to two), and collect the blood – basically do the responsible thing, do his job for him, or I could just go home, and the patients would suffer. I did a few quick calculations in my head. It would definitely not be safe for me to walk home at 10pm by myself. The patients would almost definitely survive the night, barring any massive hemorrhages overnight, in which case a unit of blood now wouldn’t help them anyway. I called Dr. Etolu – he was still with the consultant. I told him I was exhausted and heading home. I was too angry to even tell him about what had happened on the ward. Then I walked home feeling like the most irresponsible, selfish doctor in the world.

World-wide search

After my cervical cancer screening practicum, I went to find Dr. Etolu on Ward 4A. I had promised to help him with data entry for his research project. I called him, and he told me that he was on his way. About an hour later, he finally showed up on the ward. He told me that he had to go see a VIP patient on the 6^th floor (private floor with paying patients) with his consultant. So I followed him there. And for the first time, I saw Dr. Etolu being pimped, or as they call it here, being percussed/squeezed. Dr. Etolu handled it very well, with absolute calm and amazing precision. Man, if only I could become a doctor like him!

By the time we were done (seeing that one patient took close to 2 hours!!), it was dark, and I was ready to call it a day. Dr. Etolu told me that he had actually already finished the data entry for the cases that we had collected so far over the weekend, so there was no work to do. He brought me to the doctor’s mess, where we each got a soda, and split a meal of rice with chicken (nkoko!!!). It was delicious! We chatted about medicine, about his research project, about Mulago, about Soroti, about medical training here as compared to medical training in the US. And by the time we were done, I was half convinced to just move to Uganda and practice medicine here for the rest of my life!

Anyways, by the time we were done with dinner, it was quite late, so I hurried home. I got home just before 10pm. When I arrived, the household was in turmoil. Gerie greeted me with a mixture of joy and frustration. As it turned out, they had started worrying about me when I hadn’t reached home by 8pm. They tried calling me but my phone battery had died during the day, so they couldn’t get through to me. They called Cliff, Boni, Simon, posted on my facebook wall, was going to start contacting all my facebook friends to see if anyone knew where I was. Cliff had called a friend of his who was an intern at Mulago, and the intern was getting ready to scour the hospital for me. Olive and Gerie had formed a prayer circle, and they were all praying for my safe return home. What a frightful situation! I promised to always keep my phone charged, and gave them the phone numbers of all of my new acquaintances in Uganda. I also told them that if I am ever late coming home, and they knew I was in Mulago, then they should try calling Dr. Etolu first. Chances are, I’m hanging out with him on his ward or completing his research project.

I felt so terrible for causing these girls to worry. “I’m so sorry. Nsonyiwa.” “It’s ok. We’re just happy you came home safely,” Gerie replied. And for the first time, I realized that this had truly become my home, and these girls, their family and friends, they had all become my family.

Medical Error

I was participating in a training course in cervical cancer screening with the Visual Inspection with Acetic Acid technique. We had had three full days of classroom instruction, and had finally progressed to the clinical practicum stage. I was excited to be back at Mulago for the first time since I had left Kampala. I had passed through the ID ward to say hi to Dr. Etolu. I had missed him greatly during my time away.

When I got back to Ward 5B (GYN Oncology), the screening had finally started. I tried to seek out the English-speaking patients so that I could clerk them. Under the guidance of the nurses and our trainer, we started doing speculum exams and conducting screening using the VIA technique in earnest.

Towards the end of the day, we ran out of acetic acid. I asked Gina, one of the other course participants, where we could get more. She saw a bottle of acetic acid underneath the counter, and asked Stew, one of our colleagues, to pour some more acetic acid into our tray. Since I was assisting in this case, I soaked a cotton swab in the acid, and handed it to Deo, who was the one conducting the screening on this patient. The smell of acetic acid permeated the whole room. A funny feeling started brewing in the bottom of my stomach. Something about the whole situation just wasn’t quite right. Deo applied the acid to the patient’s cervix, and immediately, the patient started shouting in pain. Gina held onto the patient’s hand and talked to her gently, trying to calm her down. The patient’s pain increased, and so did her yelling. Suddenly, Gina said, “Remove the cotton swab, now! Get another swab soaked with distilled water!!” We did as told. Deo quickly wiped the acid off the patient, and continually applied cotton swabs soaked through with distilled water onto the patient’s cervix, changing the swabs as quickly as I could prepare new swabs and hand them to him. Finally, the patient started to calm down. I was still confused as to what had happened.

“I don’t understand. Why was the patient in so much pain?” I asked. “The acid we put on the patient was too strong. It hadn’t been diluted,” Gina whispered to me. Everything suddenly clicked into place. Everything made perfect sense. I almost started to cry. “I’m so sorry,” I told the patient. Someone pushed me roughly from behind. I turned around. Gina was shaking her head at me. The others quickly escorted the patient out of the room.

“We need to tell the patient what happened.”

“It’s ok. We’ll just tell her to come back in 6 months for the re-screening.”

“But it is our responsibility to tell her the truth. And if we don’t, she’ll think that cervical cancer screening is the most painful process ever, and she won’t ever come back. That lady is going to die of cervical cancer, and it’ll be our fault!”

“Don’t worry. She’ll definitely be back. She’s HIV-positive, and those people take their health seriously. She’ll come back when we tell her to.”

“It’s not right. If nobody wants to tell her the truth, I will.”

I walk out the room to find the patient. But she had already left.

Last day in Soroti

I picked up the chart and flipped it open. I recognized the name immediately – I had assisted on her c-section the morning before. I smile at her. “I know you.” She didn’t return my smile. As I started to write my daily progress note, I saw a note written by the midwife the day before – “After 55 minutes of resuscitation, the infant died at 10.54am. May his soul rest in peace.” The bad news didn’t quite register for a second or so. I looked at the patient, then back at her chart. I re-read the midwife’s note just to make sure I hadn’t made a mistake. The baby had had pretty low Apgar scores – 4 at 1 minute, and 6 at 5 minutes. But I had seen low Apgar scores like that before, especially in cases of c-section due to fetal distress, and the babies usually did fine. I had assumed that this baby would follow suit.

I threw down the chart in frustration and took a moment to collect myself. I sat down by the patient on her bed. “I’m really sorry Toto. I’m so sorry.” The patient had a bland expression on her face. I wasn’t sure if she registered what I was saying. I took her hand in mine and looked into her eyes. “I’m really sorry for your loss. We did our best. I’m really really sorry.” The patient maintained her stoic expression. Her stoicism made me all the sadder. I felt tears creeping into my eyes. “Do you understand what I’m saying?” I ask. “Yes. I understand.” And she started to cry. Her tears came and went in a matter of seconds. I could tell she wasn’t used to showing emotion, at least not in front of strangers. Her face went blank again. But I could still see the shadow of her pain written starkly across her features. I couldn’t bear it anymore. I couldn’t stand to face the woman we had failed, the woman whose baby we had not managed to save. None of us even knew that her baby had died. Nobody had bothered to check.

“I’m sorry.” I told her one more time. And then I turned around and walked away – away from her pain, away from her stoicism, away from her resignation to the unfairness of life. I joined the rest of the team on the other side of the ward. I was still sniffling. “Everyone is getting allergies these days,” Lucy remarked. “Seriously,” I replied. A few minutes later, having said my goodbyes to everyone on the team, I walked out the door of the hospital and onto a bus heading back to Kampala. I passed right by the patient without even glancing at her. I never looked back. I will regret that moment for as long as I live.