Physician Educator: Teaching the teacher

October 8 - November 28, 2016

Boda-boda ambulance
courtesy of USAID

Time flies.  I can't believe its been almost five months since the last update.  The past few months have been a crazy whirlwind of work, study, election analysis, travel back to the U.S., exams, interviews, travel through southern Africa, and finally returning home to Mbale, Uganda where the action never stops.


The last update involved a catastrophic postpartum hemorrhage and a perimortem cesarean section.  Missed that update?  Many people did.  Catch up here.

In between ward rounds, crazy emergencies, power outages, lecture preparation, and grading exams it is a relief to have a few scheduled breaks to get away and re-focus.

On October 8th and 9th Julia, Dennis, and I along with the best tour guide, Fred, took a weekend break to Kapchorwa, a beautiful area within the Mount Elgon National Park, complete with lush greenery, a beautiful waterfall, singing birds, and skittish monkeys roaming overhead.  The nature walks were beautiful and a breath of fresh air.  Our Saturday night entertainment was a lively conversation around a campfire, discussing a range of topics including the number of wives each of the men around the fire wished to have one day.  It was enlightening listening to the different thoughts on having one wife or multiple wives, as Ugandan culture shifts in between traditional polygamy and more modern monogamy.

On November 1st the Mbale crew celebrated Robert and Judith's 41st wedding anniversary with a potluck feast.  Julia, the baker, made delicious brownies, and saved some batter for Travis and me to enjoy on the stairwell.  Judith whipped up the most amazing homemade pita bread and Baba Ganoush, while Robert made sure to spoil his bride of 41 years with a house full of roses.


The stairwell itself has become somewhat sacred.  Upon returning home each evening everyone in the house can find Julia in her purple plastic chair on the stairwell, reading her Kindle or catching up with the latest person to come home.  At five o'clock it's happy hour, with Robert and Julia enjoying a glass of wine and discussing the latest books that they have read (both of them are incredible readers - you walk away with no less than 3 more books to add to your must-read list after sitting-in on happy hour).  It is not uncommon to find all seven of us sitting in the stairs, catching up on the day, discussing the latest political updates, or debating the best course of action to save the world over a glass of wine.

On November 3rd we traveled to Jinja, the source of the Nile river, for the Peace Corps / GHSP in-service training.  Before starting the training, Julia, Dennis, and I went white water rafting down the Nile River.  It was a beautiful day filled with sun, gorgeous green river banks, and of course the fast moving rapids of the Nile.  No crocodiles in site!  There are eight rapids in total, grades 3 to 5.  We shared our raft with a visitor from the Netherlands and a group Israelis followed along in another raft.  It is of doubtful coincidence that the other group's guide flipped the raft during the first six rapids, while our boat remained upright, then our boat being flipped on the last two rapids while the other boat remained upright.  It was an incredible rush to experience the power and force of the current in the Nile while waiting a few seconds to float up to the surface, then feel the waters moving you quickly downstream.  In addition to the boats there were several guides in kayaks available to assist in the water when the rafts overturned.  Julia was excited to get 'saved' by "The River God," a guide who was mostly without a shirt to show off his well developed muscles.


The rest of the weekend was spent catching up with fellow GHSP volunteers in other locations in Uganda, discussing our successes, challenges, and what we anticipate for the rest of the year to come.  On Saturday we were joined by our counterparts, including Dennis's counterpart Paul Oboth, and my counterpart Dr. Stephen Waiswa.  The schedule was packed with discussing goals and plans for the rest of the semester and year.  Between lectures, team building activities, planning, and lots of food, it was a busy but productive weekend.  

The following Tuesday, November 8th was election day in the U.S.  Since Uganda is 8 hours ahead of Eastern Standard Time, we awoke at 4:00am on Wednesday, November 9th to watch the election returns alongside several other Peace Corps Volunteers, streaming the coverage online and projecting it onto a wall in Julia's apartment.  I won't discuss our own thoughts or opinions on the election, but instead offer the reaction of my students and colleagues in Uganda.  Many at the university were surprised and shocked at the outcome of the election.  Others wondered how U.S. elections took place, if one candidate could win the popular vote and yet the other candidate won the election as a whole.  It is interesting to describe the electoral college and the role it plays in the elections.  The most pointed quote from a student was, "I wonder how the U.S. will be able to save face after this election."  As American citizens we are privileged to live in a country whose politics and policies are followed around the world, because they impact the rest of the world in so many ways.  I challenge our country to return that courtesy and pay mind to the impact the U.S. has on other countries and continents in business, agriculture, environment, health, and so many other facets.

Learning to stop postpartum hemorrhage
through uterine balloon tamponade with
a condom and foley catheter

After the elections it was a struggle to put away the stream of articles on post-election analysis and speculation about the incoming administration.  It was time to focus and study for the most daunting test - the American Board of Obstetrics and Gynecology Oral Examination.  

Tutorial session

Yes, another test.  After completing residency training, the next step is to become board certified.  This entails collecting the cases of all of the patients cared for in one year, entering them (HIPAA friendly!) into a database, playing a jigsaw puzzle game to ensure you have the correct number and categories to fulfill each of the requirements, submitting the list to the board, having the list reviewed and hopefully accepted, then being given a date during the one week that examinations take place in either November, December, or January.  All exams take place in Dallas, Texas.  

Grand Rounds Presentation

Then it's time to start studying...

Fortunately studying becomes easier when each day you have the opportunity to teach incredibly bright medical students and interns.  With every complicated case presented during the morning meeting, every question asked during ward rounds or clinic session, each tutorial session held, and for each lecture prepared the knowledge and ability to clearly articulate your answer is tested.  While I was teaching, I guarantee that I was being taught even more.  To all of the BUFHS students and the interns who were working hard on obstetrics and gynecology, thank you.

GHSP champion Steven -
smallest person
with the largest meal

AMR Conference

During November Dennis was doing amazing work taking care of me throughout the study preparations, and more importantly solidifying plans and providing technology support to GHSP volunteer Jennifer Lasman for the first antimicrobial resistance conference in Uganda.  

The conference was a year in the making, and brought together experts from all over Uganda to discuss and bring awareness to the ever growing problem of antimicrobial resistance. Nearly every patient admitted to the ward, for whatever the reason, even if no infection is present, receives two antibiotics: ceftriaxone and metronidazole.   The indiscriminate use of antibiotics has brought about a multitude of resistant bacteria, let alone the effects of intermittent anti-retroviral medication use on the emergence of HIV resistance.  

Interns extraordinaire

During the time of the conference, I was helping to care for a young patient who was initially admitted with what was presumed to be spontaneous bacterial peritonitis following a vaginal delivery complicated by pre-eclampsia with some ascites.  She had been treated for the peritonitis and was improving, but later developed a decrease in her mental status that progressively deteriorated until one day she began seizing due to presumed encephalitis. Why do I say presume?  The family could not afford many of the laboratory tests, and imaging is not available at the hospital.  If imaging is possible at another facility, the cost is incredibly prohibitive.  From what we could obtain, blood cultures revealed Staphylococcus aureus, resistant to almost all medications except for meropenem. That's right, meropenem, one of the strongest and last line / big gun antibiotics.  It costs 75,000 UGX ($20) per dose, when primary school teachers make approximately 400,000 UGX per month.  This doesn't count the cost of other laboratory tests, medications, food, lost wages by the family who is caring for the patient, or the cost of a much needed CT scan of the head.  Unfortunately, the patient later passed despite valiant efforts by the team to save her.

Getting ready for
Thanksgiving
football in Mbale

For each patient cared for, and for each patient who passes, a lesson is learned in the difficulty of living and working in a limited resource setting.  A phrase is often heard in each maternal mortality review: let the dead help the living.  With each death, learn what occurred and find a way to continue to help the other patients that will come your way.

At such a time, Thanksgiving was a celebration of the many, many things for which we are thankful.  My students might not have been the most thankful on that day as they had their end of clerkship examination, although many did offer congratulations on our national "turkey day." To celebrate the holiday, several Peace Corps Volunteers from around Uganda came to Mbale to join us for dinner.  The menu included roasted chicken, soy-sauce glazed pork, mashed potatoes, stuffing, fruit salad, guacamole, hummus, pita, deviled eggs, and about five different kinds of dessert.  While listing what we were most thankful for, the recurring theme was family, both our families at home and the family that we have created here in Uganda.  And then we all started singing Mariah Carey's "All I Want For Christmas" at the top of our lungs.  Classic.

After a final weekend of crazy studying, on November 28th Dennis and I made the long 40 hour trek back to the US and then on to Dallas for the ABOG Oral Board Examination :)

Daily sunrise view from our front door