Resuscitation

Paging Dr. Stanger

2009-07-04T14:43:00.001-07:00

In the course of my first week as a doctor, there are three phrases I have said more often than in the rest of my life combined:

(1) “Have you passed any gas yet?”

(2) “Nurse, could you save that poop so that I can come up and take a look at it?”

(3) “Hi, this is Dr. Stanger. I was paged.”

I survived my first night of call.

It is beyond my limited skills as a writer to describe those first 24 hours of my life as a physician. In our hospital, as the intern on call, you are the "house officer" overnight. That means that you are in charge of ALL of the patients in the hospital, with the exception of the ICU and the pregnant women. Too much responsibility to grasp, honestly. So I just rolled, responding to the pages vibrating my belt every 2 minutes. Running up and down the stairs. Listening to hearts, looking at bleeding wounds, fidgeting with IV lines, adjusting oxygen levels, placing central lines. Picking up a pen, writing orders, signing them, realizing that patients all over the hospital were swallowing drugs with massive effects on their heart rates, blood pressures, respiratory rates, all because I signed my name on a piece of paper. Words can't describe the rush, the paralyzing fear, the adrenaline raging through my veins. I spent the majority of my energy praying, over and over again, my mantra through the night -- "Please, Lord, don't let anyone die because of me. Please Lord...."

It was quite a night.

But then, somehow, miraculously, the sun rose. The hospital elevators rolled back to life. My doe-eyed co-interns appeared one by one, fumbling through the paper charts, staring blankly at nurses who approached with reports such as, “Doctor, your patient Mr Clark vomited 3 liters of dark green emesis last night. Can I feed him?” “Ummm…..” I brushed my teeth, picked up my clipboard from the untouched bed in the call room, and blearily turned to my notes from morning rounds the day before. Only one day into my rotation, everything seemed sunnier and somehow possible. I had survived. Now that the rest of the docs were here, my pager stopped going off every 2 minutes, and I managed to round on all six of my patients in just a few hours. Next thing I knew, it was 11 am, and I was walking out the front doors. Thirty hours later, thirty years wiser. And very very tired.

I like to think I’m tough, and these 30 hours shifts don’t touch me. That I’m somehow built for them, and that anyone who can’t is somehow weak or whiney or just doesn’t have the stuff. This is the only way that I get through it – taking some kind of false pride in the self-sacrifice, pretending to support 30 hour shifts in residency, citing statistics about the patient safety costs of increased sign-out with shorter shifts.

Clearly, this is an entirely transparent coping mechanism based on complete bullshit.

Working thirty hours shifts SUCKS. And no one is built for them. Yes, you get used to them. But they still suck balls. One of the easiest ways to get through them is to know that they will end – they always have before. And we all have our low points, entirely predictable, utterly uncontrollable. Some people cry, some become manic, some get strange rashes, some start calling exes. It’s bad news. For example, I know that I become completely useless between the hours of 2 am and sunrise. Nothing I can do about it, though sometimes eating a cookie helps, for some reason. But 2 am, oh it sucks. I will stare at a chart for 10 minutes, trying to multiple 15 mg times 60 kg. Just doesn’t work. Nothing stays in my brain. My eyes dry out, my head spins, my knees buckle, and for some reason I don’t medically understand, my entire pelvis aches. Strange, perhaps too personal, but true.

But then, mercifully, the sun comes up, the circadian rhythms kick in, and I coast through the morning. I eat breakfast, laugh with my co-residents, write orders, discharge patients, relish the fact that I get to go home so soon, imagining taking a cat nap and then going for a run. Maybe buy some groceries, work on my journal, play the guitar, go out for dinner. The world is my oyster at 10 am post-call.

But then there’s the drive home.

This is often the first time I’ve sat down in 24+ hours. And, inevitably, within 5 minutes, I am a disaster. My eyes blur, I start crying, my feet start twitching. It’s very bad news. It is these times when I thank God I chose to live in Walnut Creek, a 15 minute drive from the hospital, rather than Oakland which is closer to 30 minutes away. Yes, frankly, I hate Walnut Creek. I spend great energy trying to look on the bright side of my new hometown, try to appreciate its conveniences and sunshine and security and multitude of chain stores, but to be totally honest, I hate it here. I would kill for the cultural integrity of Oakland, the funkiness of Berkeley, the warm familiar rhythms of my beloved San Francisco. Sigh. But when I’m post-call, I am thanking my bourgeois butt that I sold out and lived closer to the hospital. Because I have about 30 minutes tops from leaving those front sliding glass doors of CCRMC and complete physical, emotional, and mental collapse. Good thing for everyone that this isn’t happening in the middle of the Caldecott Tunnel.

Case in point: upon returning home last Friday after my first call, I parked my car at 11:54 am and was in my bed, sound asleep, by 11:59. Slept like the dead until my alarm went off at 7 pm (I try to be sure to spend at least a couple of hours awake in the evenings, just for at least a gesture of normalcy). Woke up, felt surprisingly refreshed, and decided to make some delicious pasta primavera for dinner. Yum. So there I am, happily chopping zucchini, listening to Rodrigo and Gabriela and congratulating myself on what a fantastic doctor I am, singing high praises to the gods that I don’t have to work the next day and don’t have to see the hospital for at least 36 hours, when I gracefully and precisely slice directly through the meat of my left thumb.

Oh FUCK.

I grab my thumb with a napkin, pressing with all my might, praying it’s not as bad as it seemed, and gently raise the napkin. Shit shit shit. It’s deep, straight down the length of my thumb, and gushing out blood. Any 3^rd year medical student could take one look at it, and correctly state that it meets all criteria for lacerations that require stitches. Fuck. I’ve never needed stitches in my life, and I manage to do this on the first day of my SURGERY rotation. I’m supposed to be scrubbing into at least one operation every day, first-assisting my surgeon, and I’m technically not even supposed to enter the OR with so much as a scratch. And now I have the end-all-be-all of geysers shooting out of my thumb. Dammit. Strong work, Dr. Stanger.

But the worst part of it all was that I needed stitches..... and that would require going back to the hospital. I just couldn’t do it. Blood loss and scars be damned. I could not walk back into that building on my day off. Instead, in perhaps not my wisest decision of the month, I opted for some creative Band-Aiding, and a prayer. Woke up the next morning with a blood-stained pillow, but reattempted my Band-Aiding, and it stuck. Did ok until the next day when I was scrubbed into an operation, looked down at my (double-gloved) hand, and realized I was bleeding underneath the glove. For those not familiar with sterile technique, this is VERY bad form. Hmm. I discretely scrubbed out of the case, hopped into the elevator, rode down to the tribe of hot married doctors manning the emergency room, and told them my sad story. God bless their hot little hearts, they jumped right on me, testosterone raging, each eager to come up with his own perfect solution to my thumb-bleeding/needing-to-scrub-predicament. In the end, I walked happily out of the ER, my thumb plastered with a healthy layer of SuperGlue, and my spirits restored. Post-call thumb-slicing disaster averted. Back to the battlefield.

This is Dr. Stanger. I was paged.

Blog Resuscitation

2009-07-04T14:20:00.000-07:00

Friends, it's a miracle. I'm a real doggone doctor.

I'm hoping to resuscitate my blog from the Uganda days of last fall, in an effort to stay connected with my beloved friends and family, even as I disappear a bit into the 80 hour weeks of residency. I will relish your thoughts and reactions to my postings -- I have an inkling to try to document my experiences throughout all of residency, with the potential of using these entries as fuel for some more formalized purposes in the future. So please let me know what you think, and share with anyone who you think may have stories to contribute, perspectives to share. Medical and non-medical contributions cherished equally.

With love always,

Kali

Out of Africa

2008-11-22T06:34:00.000-08:00

It’s 4:23 in the morning, and I’m wide awake, ready to go. Sigh. Damn jet lag. I spent some time petting my cat, tried to fall back to sleep, took a bath, counted my bug bites (21), and am now creeping around our kitchen in Benicia, making myself a bowl of Cocoa Krispies, deciding to give up and just be awake. I have to write a bit, anyway.

Observation #1:
There are many things that are great about our country. Cocoa Krispies is one of them.

Oh I miss Africa. In a way I never have missed a place before. I spent time going through my photos yesterday, and was struck by how darned happy I look in just about all of them. This is a new phenomenon for me – my father always bugs me about my travel photos, “do you have to look so miserable in all of them?” It’s true – in Mexico, I looked sick; in Thailand, I looked sweaty; in Ecuador, I looked scared; in Europe, I looked tired. But not Uganda.

In so many ways, this trip was harder than any I’ve taken before – this was my first experience with clinical medicine in a developing country, and it delivered all of the challenges expected. The heaviness of the morbidity caught up with me over and over again, and I would struggle to put on a happy face for pleasantries as the days wore on. But it seemed that Uganda always redeemed itself in some dramatic, beautiful way. A breathtaking sunset as I walked home from the sobering death of a 2-year-old from malaria. The ancient echo of the salat call to prayer when I awake in the morning before another day in the dismal emergency room. The warmth of the sun, the smell of the jasmine, the primal songs from the nearby church, resonating in my bones, strangely feeling more like home than California ever has. I have a handful of theories to explain aspects of my experience in Uganda, and one of them is this: it is no wonder that we evolved in this land. Everything grows here. This is a land of life. Humans, giraffes, jacarandas, viruses, parasites, cobras, lions, warthogs…. Africa nourishes us all, which helps me grasp its seeming contrasts with a bit of forgiveness for what otherwise often seems a cruel, ironic place. Home feels good, to be sure, but honestly a bit antiseptic. I miss Africa.

Thank you so much to you, my friends and family, for your love and support this past month. Without a doubt, one of the highlights of my month was reading your emails and responses to my blog entries – you helped me through some low times, and brought me some valued perspective and appreciation for my trip. I am lucky enough to have the next 6 weeks off from any clinical duties as I launch into taking my boards exam (on Wednesday, gulp) and then my residency interviews, and I so look forward to seeing you all individually on my days off. I’m facing a big decision in the next couple of months re: Seattle vs. San Francisco for the next three years, and will need all the advice I can get. I can’t yet say whether this past month has pushed me in one direction or another (though I have a hunch); what I can say is that it unequivocally made me even more passionate about the kind of work I have long envisioned pursuing – given how much more developed we are in the US than so many countries, it is absolutely unacceptable that so many Americans are living without health care. I want to fix this. I feel conflicted about the fact that my international work always primarily leaves me with a clearer view of how I want to provide care back home – sometimes, it feels like I’m taking advantage of these hosting countries. But the thing is, I don’t really believe that. I believe that the change in Uganda needs to come from Ugandans, and that my presence there was part of a larger solution, a more complex kind of aid.

One final story, before I wrap up. For my last weekend in Uganda, I went on a 3-day safari through Murchison Falls National Park. On the last night, after a long day filled with giraffes and hippos, I was sitting around a campfire with my safari-mates, Wes and Alex. Wes is a Peace Corps volunteer working in eastern Uganda, now 18 months into his project. Alex is his buddy from Seattle, who came out with 2 other friends to visit Wes. Good friends, huh? Anyway, we were drinking some local beer, looking out onto the savannah lit by the harvest moon, falling into the rhythm of watching fireflies blink, when our conversation rather naturally turned to religion. There had been a horrific bus crash outside of Kampala just a few days before I arrived in October, and one of the victims had been from Wes’ village. Wes shared an impression, along the lines of, “You know, I think that’s why Ugandans are so religious. They have so little control in their lives, everything could be taken away at any point. You need God to get make sense of it all.” I think Wes is right. Well, I think Wes is half-right. Yes, Ugandans live with more uncertainty and instability than most of us Americans can imagine. Bus accidents, AIDS, military coups, malaria, sleeping sickness, the list goes on. Yet I think there’s another side to this, that makes it all even harder to explain or grasp: Uganda is filled with true, unparalleled beauty. And it’s everywhere – in the sky, the people, the rivers, the music, the flowers, it’s even in the dirt. There is such suffering. There is such beauty. Maybe you need God to make sense of it all.

What a month. Happy Thanksgiving to you, my friends and family! I am thankful for you all, and for the incredible privilege of travel. Please send me an email, give me a call – I can’t wait to see you all soon.

Obligatory Election Reflection

2008-11-13T03:41:00.000-08:00

Is anyone else experiencing severe writer’s block whenever you try to write about the election? I realize that my blogging hit a major wall last week on precisely November 5th – it felt wrong to post anything without mentioning the election, but whenever I try to write about that night, words just fail me, time and again. I wish I were a good enough writer to capture and share the energy of that night, the echoing cries of celebrating Ugandans upon the early morning announcement of Obama’s victory, the bittersweet tears upon listening to our new president’s victory speech as he acknowledged the importance of his election to those abroad, “huddled around radios,” just as we were. The world has never felt so small, so connected, so good. So maybe I don’t need to describe that night – I know I will always remember it. I can already picture telling my children about the night Barack Obama became our president, and how proud I was to be an American. And so I choose to just submit to the experience, allowing myself to enjoy these days, and appreciating the irreplaceable experience of being in Africa the day that America elected a black man as our new president.

I know this seems crazy, but ever since last Tuesday, I feel markedly safer here. This is largely ridiculous – first of all, for some still-unexplained reason, most Ugandans assume I’m Finnish (insert confused look here), or British, but rarely American. Yet I’ve noticed that many more people now ask me where I’m from, and upon hearing my response, promptly break into huge smiles, and quickly respond with one clear loving word – “Obama….” I meet eyes with people on the bus, and they smile, holding up newspapers with Obama headlines. I also have changed my own reply when asked where I’m from – long ago, I learned to answer “California”, which previously received a warmer reaction than “USA”. But now I’m eager for someone to ask me, as I respond with a proud smile, “I’m American.” Damn skippy.

(photo of me and Dana from post-election celebration party at local bar)

You Win Some...

2008-11-04T04:44:00.001-08:00

I got mugged yesterday.

Let’s just say that it was a very negative experience. I’m ok – just short one sentimentally-important-but-otherwise-not-particularly-valuable necklace (dude ripped it off my neck while I was walking down the street in downtown Kampala in broad daylight, surrounded by business-folk).

It really scared me.

I think the hardest part has actually been the fact that I’m fairly bruised and sore around my neck where he grabbed me, which is making it harder to distract myself and forget about it, which is just making me feel more scared and vulnerable, which is making me pissed off. Blech. It’s actually the first time in my life that another human being has hurt me, which of course is evidence of just how blessed I am. Anyway, I left work early to come home this afternoon, nesting and trying to simmer down. Most of all, it’s helping me to think about something my mom said when I called her last night, breaking down as I told her what happened – after recovering from the news, she quietly said, “Wow, that person must have been so desperate.”

My parents are so amazing. I know how much this has scared them, and that they must be reliving some pretty terrible times from 10 years ago when I was exposed to rabies while living in Ecuador, and they couldn’t contact me or get any information about how or even if I was receiving prophylaxis for what is a 100% fatal disease. I know them well, and I know that all they want right now is for me to get my butt on a plane and come home, sit at the dinner table, and eat meatloaf. But instead, they cheer me on. And not only that, they remind me of why I’m here. I’m here because they raised me to try to see the good in people, to forgive their weaknesses, and to protect the vulnerable. I am humbled and inspired by mother’s ability to empathize with the man who assaulted her daughter on the other side of the planet. It would be easy for me to get pissed and leave; I’d be lying if I didn’t say that it crossed my mind yesterday. But it feels better to thank God I’m ok, take a deep breath, give myself some time, eat some cookies, watch the election, and go back to work. All of this became much easier this morning, when I started my first day on the pediatric ward here. I caught myself for a second, in the midst of making fish-faces at a 2 year old with AIDS in an attempt to keep her quiet while I listened to her infected lungs – this is why I’m here, to learn, to serve, and to teach myself to be brave, even when things get scary. Because there is work to be done, and one of these days, I’m going to be trained enough to actually make a difference.

Happy Election Day, my loved ones. These are the days.

Compartmentalizing

2008-11-02T02:18:00.000-08:00

Wow, and I thought I relished my weekends last year. These past two weeks working in Mulago Hospital have been hugely rewarding and unforgettable, but I’m consistently panting for air by the time I reach Friday afternoon. I certainly feel a bit guilty as I practically run out of the hospital, looking forward to drinks with friends and not having to think about AIDS or death or orphans for two whole days – my patients don’t get to run out of there. But if there’s one thing I’ve learned in medical school, it’s that you have to find a way to leave work at work, or else you’ll go nuts. At least that’s how I have to play it. Compartmentalizing. Some smart people taught me that.

And I’ve succeeded entirely this weekend – properly absorbed in the predominant themes of my non-hospital time in Uganda: (1) obsessing over the US election, (2) reflecting on nuances of life as an ex-pat, and (3) marveling over the fact that I’m still alive despite the unrelenting risks inherent to living in Uganda.

Like most days in Uganda, I’m thanking God I’m alive today. I heard it articulated beautifully the other day: “Life in Uganda is just a series of risks.” The streets are a nightmare – there are more per capita motor vehicle accident deaths in Uganda than almost any other country in the world, and it takes about two seconds on a Kampala street to see why. I think I’ve prayed more in the past two weeks than in the previous two decades of my life. I could share specific stories, but my mother is reading this. Suffice to say, I count my blessings to be alive every day. Even today, Dana and I chose to keep it low-key by opting to take a boat to a chimpanzee reserve rather than go whitewater rafting. We woke up early to take a bus to Entebbe, where we boarded a speedboat to be taken to the Ngamba Chimpanzee Reserve on an island in the middle of Lake Victoria (largest lake in the world, remember?)……we were about 15 minutes into our idyllic boat ride when we realized that the “horizon” was actually a massive storm cloud. Thus began the single most terrifying and exhilarating 45 minutes of my life. It would be impossible to describe what it was like to be stuck on a tiny speedboat in a massive thunderstorm, lightning everywhere, being pelted with rain, tossed around by black waves, clinging to the arms of strangers, and frantically scanning the horizon for signs of land. I shit you not. This really happened to us. The fear was so consuming that I shook for hours afterwards, high as a kite out of sheer amazement that we made it to the dock alive.

Oh - and the chimps were awesome, by the way.

Thoughts as I Eat Pineapple Before My Massage...

2008-10-29T07:42:00.000-07:00

Quick entry today – probably a nice break from my long-winded sentimental philosophizing to date. I do have a good hospital story from today, but I’ll wait to write about it later. Besides, it’s still cooking…

Here’s a quick photo taken of our apartment building here in Kampala. Nice taste of how gorgeous the skies are here…. And it shows off my new camera (!), to replace my misplaced beloved Samsung, may it forever rest in peace. Buying a camera in Kampala was one of the more ulcer-provoking activities I’ve partaken in recently, but seems to have worked out so far. At least it hasn’t spontaneously combusted yet.

Some random things:

(1) Turns out that I totally biffed on my phone number earlier – it’s actually (256) 779624422. I think. Still unclear. We’ll see.
(2) The pineapple here is delicious.
(3) For all y’all planning residency interviews, or any other travels, I have a finalized interview schedule (!) and am 100% down for coordinating any hotels, shuttles, extracurricular activities. I’ll be in Seattle from December 8th thru 11th, Portland from December 11th thru 12th, Chicago from December 17th thru 20th, and Ventura on January 8th. Shoot me an email if something coincides with your schedule, or if you wanna come along just because.

[Sorry Elly and Andrew – I bailed on the Boston interview – just couldn’t picture living alone in the suburban boonies in the snow as an intern, without my family or Chicago’s hot dogs to abate my misery, surrounded by insufferable Red Sox fans. You understand.]

Stay posted tomorrow – Dana, Patrick, and I are getting massages tonight at the local country club (um, I know it's tacky, but how can you say no? It’s $10 for an hour! Yes, please.) Excellent photos will ensue, to be sure. And I need to write about the upcoming election – as expected, it’s pretty unique to be experiencing it here. FYI, Obama’s father is from Kisumu, Kenya, which is about 400 km from here. Very cool.

Laundry, Waterfalls, and Mary

2008-10-27T07:44:00.000-07:00

It’s Monday afternoon, and I’m watching my clothes dry. This is one of my secret pleasures in life. As I often complain about at full volume, I HATE doing laundry at home. I hate hunting for quarters. I hate hauling my clothes down our sketchy back stairwell, praying it doesn’t collapse as I plummet to my doom. I hate trying to stuff my folded pajamas into my bottom drawer filled to the brim with old Stanford t-shirts and countless pairs of scrubs. I hate doing laundry at home.

But, strangely, I have always loved it while traveling in developing countries. And my favorite part is hanging the clothes up to dry. It forces me to slow down, to think about each article of clothing and its history – my scrub pants from my ob/gyn rotation at the General, my Obama t-shirt that draws so many excited comments here, my gym socks already turned dusty red from Ugandan hiking adventures, my despised white coat that I’m forced to wear every day on the wards here in order to fit in with the immaculately dressed Ugandan medical students. Socks, shirts, pants, skirts, they’re all dancing in the warm equatorial breeze now…. Probably been dry for a while, but I like watching them, and so they stay.

Technically, I’m playing hooky this afternoon, having slipped away after morning rounds with the Infectious Disease team. I need a break. Last week sucked me dry, emotionally, brought to a morbid finale on Friday morning. For those who aren’t familiar with the medical student gig, we spend the last two years of medical school exclusively in clinical settings, where we are assigned individual patients for whom we are responsible. We conduct the initial interview and physical exam, order diagnostic studies, choose treatment regimens, and then follow throughout their hospitalization to assess progress and make any necessary diagnostic or therapeutic adjustments. Here in Kampala, this responsibility is taken to the extreme – thus far, I am often the only person to examine a patient, to read their X-rays, to order their treatment, to discuss their care with their family members. And so, it was natural for Mary’s cousin to seek me out on Friday morning, grabbing my arm as I walked onto the ward, stating, “Doctor, my patient’s breathing is different.”

Mary is a 35 year old woman* who had suffered a massive hemorrhagic stroke 3 weeks prior, thought to be due to a protozoal brain infection, the end-stage result of her undiagnosed HIV infection. She was neurologically devastated from the stroke, unable to speak, paralyzed on her right side, but had been relatively stable throughout the week. In fact, I was already broaching the idea of discharge, brainstorming some kind of homemade physical therapy to maximize her recovery at home. Hard to believe now… (for obvious reasons, I changed Mary's name here)

I am not a doctor. The scary truth is that I’m pretty darn close, but I’m still years away from anything resembling expertise on anything. There are days when my cat knows more about medicine than I do. But somewhere over the past 18 months, I am grateful to have somehow developed what is arguably the most important skill a physician can have – knowing when to worry. I took one look at Mary, and my stomach dropped to the floor. She was breathing at twice the normal rate, clutching her sheet, pleading to me with her eyes, still unable to speak. Shaking, I took off my stethoscope, listened to her lungs, clear. Listened to her heart, racing. Took her pulse, barely palpable. Shit.

I ran to the next room, scanning each bedside for my resident. Nowhere. I finally found our intern, kneeling on the floor next to a new patient shaking with chills from malaria. I grabbed his arm, pulling him to my patient’s bedside, telling him everything I had just found, sharing that I was afraid that she had a pulmonary embolism – a dreaded blood clot in the lung vessels that can quickly kill patients. My intern looked at the patient with wide eyes, listened to her lungs, said something in Luganda to her attendant, and walked back to his malaria patient. I interrupted him again, assuming he disagreed with my analysis, praying that I was just being a paranoid medical student, and that my patient was fine. Instead, he looked at me and said, “No, you might be right. We can order a chest x-ray if you’d like, but she could die on the way down there. And I don’t know if they have the money for it, anyway.”

I’ve never seen someone die. I know that seems odd, but most medical students haven’t. The truth is, we’re pretty good at “controlling” death in the US. Patients die at home, in nursing homes, in ICUs after months on a ventilator. They don’t die at age 35 of reversible conditions brought on by treatable diseases, with only a medical student at the bedside. But my Mary did. Slowly, as the morning stretched on, while I frantically scanned the hallways for any attending physician who would suggest some alternate therapy, Mary grew tired. Her eyes glazed. Her breathing slowed. Her brother David pleaded with me, “Isn’t there anything you can do? Can’t you call the neurosurgeons?” I looked at Mary, and said aloud what I was only just realizing – “We don’t have the time. She is dying.” A few moments later, Mary took one last, gasping breath, like every movie you’ve ever seen. And then she just didn’t take another. Some dusty part of my brain remembered what to do: I shined my light in her eyes, no pupillary response; listened to her heart, nothing. And nothing. And nothing. I knew what that meant, but could not find the words. I looked into the kind eyes of her brother, and found myself as mute as Mary had been. Finally, I met the eyes of the Dutch medical student standing with me, and nodded to him. He put his hand on David’s shoulder and said simply, “I’m so sorry, sir. She is dead.”

I didn’t mean to write about this today. I planned to write about my weekend adventures in Sipi Falls on the Kenyan border with Dana and Patrick, fun travel stories about losing my camera, crazy matatu rides, watching my friends repel down waterfalls, the most amazing hike of my life. And I’m sure that’s what most people would rather read about. But Mary has been on my mind. I never heard her voice, never met her children, never shook her hand. But she had one of those faces you remember, that seemed familiar as soon as I met her. It was good to get away this weekend, to distract myself, laugh with good friends, old and new, hike in the pouring rain, stand meters away from the most powerful waterfall I’ve ever seen, struggling to stand against the wind and spray that drenched me to my core, marveling at the primal beauty of this land. But beneath it all was Mary. I pray for her family, and that she has found peace. And I pray for a world that would not tolerate the death of someone so young. She deserved more.

In Mulago

2008-10-22T08:47:00.000-07:00

It’s funny how quickly your perception of a place can change. I smile to read back over my entry from just four days ago – it oozes with that syrupy giddiness unique to travelers in a new land. I see Kampala so differently now. What a difference a few days on an African AIDS ward can make.

To be honest, I feel too deeply entrenched in the experience of my hospital work to adequately reflect on it now. Suffice to say, it is haltingly sobering, and instructive in something that I can’t even begin to understand yet. I feel so old, so tired, and almost nauseated at the idea of going back again tomorrow, seeing the same patients, watching them die. But despite the overwhelming despair, I know that this is a good place for me to be; I am already a better doctor for being here. I am left again reminded of why I love my profession – we are privileged with a front seat on all of the greatest human experiences, the most profound joys, the deepest suffering.

And so, given that I’m still rather paralyzed by it all, I’ll stick to data reporting for now rather than any kind of analysis… med students are good at that approach, anyway. I’m working at Mulago Hospital on the women’s Infectious Disease Ward, which translates here into the AIDS Ward, although you’ll never see the terms “HIV” or “AIDS” written on a chart – they call it “ISS” here for “Immune Susceptibility Syndrome” out of concern for stigma/discrimination. Most of my patients are discovering their HIV status only upon presenting to the hospital with opportunistic infections characteristic of end-stage AIDS: cryptococcal meningitis, disseminated tuberculosis, neurotoxoplasmosis. For medical folks, the highest CD4 count that I’ve seen has been 180 – the majority fall closer to the teens/20s. These patients are so sick.

Patient care is structured so differently here – almost all traditional nursing duties are taken on by the patient’s “attendant”, who is usually her mother, sibling, cousin. And there is no social contracting for the sick here – you are responsible for paying for your health care, end of story. As we round each morning, we hand the patient’s attendant a list of labs, studies, medications that we are ordering for the day. The attendant is then responsible for finding the money, going to the pharmacy, going to the lab, wheeling the patient to the x-ray machine, cleaning the patient’s bedpan, washing the bedsheets. Nurses perform very limited duties – mainly limited to pushing IV doses, which the patient’s family has purchased and brought to the bedside. To be honest, the family role feels almost appropriate at times – at home, we distance ourselves from sick loved ones with layers of nurses, nursing aids, physical therapists. Here, your family truly cares for you, which at its best feels loving and right. But there is a dark side to this system, seen in patients without attendants who are left on their own, with no one to pay for their treatment or assist with their nursing needs. These are often women whose husbands have died, whose families have condemned them, or whose partners have abandoned them. They lie alone on their sheetless beds, with our neatly written order sheets left unfilled by their feet. They haunt me.

And there I go, reflecting without being ready. I promise that every entry won’t be quite so gloomy – at the very least, I’ll be traveling throughout Uganda and Kenya during the weekends, and should be able to come up with some good lion stories. I almost feel like it isn’t fair to Uganda that I delved so quickly into its troubles…. I know that there is much more to this country than its AIDS epidemic. And so I push through the week, rolling with the punches, and finding meaning in the raw education here. It’s a blessing and privilege to be here, and I already treasure the weeks to come.

I miss you all, and thank you for reading my musings. I am so lucky to have you all as my attendants.

Arrival Email

2008-10-22T07:25:00.000-07:00

[email written to my family upon arrival on October 18th -- sorry for the repeat, guys]

I am so glad I decided to bring my laptop.... our internet is slower than dirt, but I'm typing this sitting on my bed in Kampala, which is so much better than sitting in some hot dirty internet cafe, getting charged by the minute for the slowest connection imaginable. Instead, I'm listening to the radio, eating pineapple, and taking mini-naps whenever I try to send/receive something. It's lovely. And crazy to think back to just ten years ago, when I was in Ecuador and had to send snail mail or tolerate hideous phone delays to communicate with you guys. It's a brave new world.

Today was a good day. I woke from the deepest sleep of my life, only to be informed by Dana that my alarm had been going off for two hours. Hmmm. Hopefully that doesn't happen tomorrow morning when I have to go work. Anyway, we made ourselves a delicious fruit salad from the pineapple, papaya, passion fruit, and bananas that we bought in the outdoor market last night, and watched some Aljazeera. Then Dana took me out to teach me how to use the matatus, which are the East African version of a taxi -- I'll be taking these pretty much everywhere to get around, and you have to be pretty savvy to figure out how to flag one down, get where you want to go, figure out how much to pay, etc. I survived our first trip, and am gearing up for our second adventure this evening, when we're heading downtown to get some Indian food to celebrate my arrival.

I love it here, and feel completely at home now only 24 hours into my stay. You know me -- I had my room set up and pretty within hours of arriving. The apartment is shockingly comfortable, as you can probably tell from the photos. This is definitely a new kind of developing-world-travel for me -- paying the extra cash for a comfortable place, cooking for myself, wireless internet -- and I like it. Even though the laptop occasionally sends tiny electrical shocks up my arms..... a small price to pay.

And Uganda is just breathtaking. I love all of the colors -- the hills are deep deep green dotted by violet jacarandas and red-roofed huts, the sky is crystal clear blue with huge billowing white clouds that periodically turn deep black, dump rain onto the red dirt for an hour, and then disappear. The people are beautiful, wearing bright colors and carrying their infants wrapped around their waists with long cloth, with quick smiles and gentle mannerisms. And you should smell the air.... oh it's so wonderful. Who would think that the smell of burning banana leaves would forever catch my heart.... it whisks me back 11 years, and I'm fifteen again, standing on our front stoop in Ecuador, inhaling the thick evening air laced with coffee and jasmine and sweat and bananas. Our dry California air is a blessing, but we miss out on the smells.

Ok, time for dinner, but one more thing: I got a cell phone today! I know, this seems nuts, but everyone has one here and they're dirt cheap (we're talking $10 for the whole shabang). To call me in Uganda, dial 256 (Ugandan country code) and then 77960244226. This is cheapest to do if you guys buy one of those uber-cheap Costco international phone cards -- it's insanely expensive for me to call you, but I may call from time to time and ask you to call me right back, once you guys find a card. I think evenings will probably be best for me (first thing in the morning for you guys -- we're 10 hours ahead of Pacific Time). Let me know how finding a card goes.

First day of work tomorrow -- can't wait! I'll write again soon, and tell all.

Love you so much -- give kisses to my Boo,
Kali

Heading Out

2008-10-15T11:35:00.000-07:00

I'm having a good day.

It was just two days ago when I was sitting enjoying some delicious late afternoon beers with my good friend Brian, lamenting that I wish there was a way to share my upcoming Uganda adventures with all of my friends and families in some coherent, stylish way that also featured photos, songs, etc. It was at this time that our brillant Brian asked, "why don't you start a blog?" A what? And so that is how, all in the course of the past 24 hours, I accomplished the following:
(1) Learned what a blog is
(2) Found out that you can write these things for FREE
(3) Started my own

Of course, the best laid plans of mice and men..... lord knows if I'll even end up having any internet access in Kampala. Not highly likely. But still, I create this blog in good faith. At the very least, I have something to distract me while I count the now less than 24 hours until I get on my plane....

Gotta love those pre-travel jitters.