Day 6

12/22/08

I slept so well last night! I think the sunburn knocked me out. I woke up at 6:30am, dressed, ate an egg and banana for breakfast along with some hot water and jinga (maybe she was saying ginger?). I reapplied the pregnancy cream (which is working great, lesson learned for future sunburns) and the van came at 7:30am to take me to the clinic. I went on rounds with Juliet and the nurses aides. We saw seven patients. The first was a 16 y/o male who had been in a motorcycle accident last night. He had a large laceration on his right knee and his teeth had punctured his upper lip. The lip was stitched last night but the injury to the knee cannot be stitched and was therefore cleaned with hydrogen peroxide and covered in gauze. The second patient was a 20-something y/o male with malaria and ringworm throughout his body. The first line treatment of malaria had not worked for him last week, so he has begun the second-line treatment of quinine injections and will be sent home today but must return for three more injections. We then proceeded to the women’s and children’s ward. The first patient was a baby with pneumonia, titis externia (not sure I spelled it correctly but it is an infection of the outer ear with discharge), and malaria. This child is obviously very sick and will remain in the clinic under observation for a few days.
The next patient was a baby with an upper respiratory infection and malaria. He is being treated with intramuscular injections of quinine. The next patient was the healthiest of all, a baby with only malaria. We then moved to the isolation ward where we saw a mid-40 y/o woman with Shingles. The last patient was also in the isolation ward, a baby with tetanus that he acquired after receiving his circumcision two weeks ago at home. The baby exhibited tremors and spasms of all four extremities and had difficulty focusing his gaze.

That was pretty rough to see so I went outside for some fresh air and then sat in the office for a few minutes to gather my thoughts and to recognize that 90% of those cases would never occur in the US. We then went to the examination room to receive new patients. The first patient was a baby with malaria who had received intramuscular quinine injection on Friday and was supposed to receive three more over the weekend but the mother did not bring the baby back to the clinic because she didn’t have the money for the last few treatments. The baby’s condition worsened and she came back today with money to start the treatment over. The next patient was a middle-aged man who came two weeks ago with symptoms of tuberculosis. His sputum test was negative but he was told to go for an X-ray at Mbale main hospital. He did not go due to lack of money. He came back today to the clinic with a worsened condition.
The next patient was a baby who had been diagnosed with malaria last week, received a full first-line treatment, but was up vomiting all of last night. An IV treatment will be started today. The next patient was a baby with symptoms of the flu, has a fever and cough, but her chest is clear. Upper respiratory tract infection and malaria tests will be done in the lab.

Juliet and I then spoke about TB here, how doctors in clinics, who likely see the highest percentage of TB cases, lack masks and gloves for protection. Most people here are exposed to TB at an early age and if they have a healthy immune system, build an immunity toward it. However, the discussion revealed the lack of attention on the protection of doctors in underdeveloped regions, something I think I’d like to research further. If the problem is as vast as it seems, maybe there is a need for an organization that serves to provide the necessary information and equipment to ensure the safety and protection of health workers in these places.

A 37 y/o female patient then came in with lower abdominal pain and some other symptoms that indicated a menstrual problem. It turns out that she had a miscarriage 3 days ago due to untreated malaria. She has had 4 children before, one of which died at 9 months old. She had never used any form of birth control. The treatment for the patient is a pill that induces the delivery of the undeveloped fetus. The clinic does not have any of the medication in stock, so we had to send someone to the only pharmacy in town which sells the drug for 5,000Ugh. The entire procedure will cost the patient roughly $2.50. I think every co-pay in the States for anything is more than that.

Juliet and I then talked about the seasons in the States. She was surprised to learn that we also have trees and that we have houses made of wood. She also told me that operations at the main hospital are free, but patients are required to supply all of the equipment. They are basically given a shopping list and told to go get the things in town, soap, scissors, etc, and then return for with the materials for the operation. Circumcisions are done at the clinic for 5,000 Ugh (= ~$2.50).

Another patient, a teenage boy from the “projects” (they have them here too, and after describing to you the conditions of those not living in them, you can imagine what they are like). He complained of a cough that is productive (mucus is expelled) that he has had for 4 days. He has no history of the diseases common here of which this type of cough is a symptom. Something I notice is that patients without an educated background find it difficult to describe their symptoms, due to a small vocabulary. This patient’s eyes are bloodshot and yellow, painful and itching so he is given drops for allergic conjunctivitis. He was then asked if he has a girlfriend and if so, when he last slept with her. He says he does and it was two days ago. Juliet asks if he has been tested for HIV before he had sex with her. He answers no and she offers to give him a test but he refuses, saying he doesn’t want to know whether he is infected or not.

The next patient was a toddler carried in by her mother. The mother laid the child down on the examination table and told us that she had been fine until about 2 weeks ago when she looked weak and fell while walking on the side of the road. Since then, she has not spoken or been able to stand on her feet. The child lay quiet, not reacting to forceful movement of her legs. She has some control over her arm movement but doesn’t seem to have enough energy to initiate any movement. She suddenly moans in pain and then quiets down again. The mother says that the onset was sudden, but Juliet felt that she was not being 100% honest since she told the nurses that she had not gotten all of the immunizations for her child but had then told Juliet that she had. The case was a classic of what I knew about polio and I asked Juliet if that is what is was. She agreed with my diagnosis and we referred the child to an NGO on the other side of town that provides physical therapy for polio victims. As the mother lifted her daughter she was teary-eyed, and the girl, sprawled out over her mothers shoulder began to throw her head from side to side. The behavior suggested a sort of mental deficit – I assume another effect of advanced polio.
I have not yet managed the courage to ask if it is okay to take pictures of patients, but after seeing a case of polio, I asked Juliet if it would be okay if I asked her each time, and she’d tell whether or not it would be a problem. She agreed.

We broke for lunch – rice, potatoes and cabbage. The rest of the day was pretty quiet. I still haven’t met Dr. Wafula, the man with whom I organized my trip, but he is returning from Kampala today and I should meet him tomorrow. I am going to the villages tomorrow to meet with the traditional birth midwives so that should be interesting (gloves and goggles?). I will probably leave here around 5pm and head into town to post this. Then a quiet night I think is in order with the family. Maybe we’ll watch a movie on my laptop (thanks againYoni). Goodnight everyone, and Happy Chanukah!