Abscess Makes the Heart Grow Fonder

So I’ve been terribly bad about writing this past month. My apologies for that, but it’s been a combination of being incredibly busy and not having good internet. The internet café in town changed their service, and the new internet doesn’t like secure servers very much. Also haven’t been able to get into my school server or (and this is possibly the most tragic) my fantasy football team. The insanity never really slowed down. So my last post about the 91 patient day we’ve topped 80 again 7 times, and only had three days under 50. The plus side of that is I’ve finally found my defined role in work at the clinic. I’ve learned enough to be able to work in the diagnostic station, and there are a few areas of treatment that I’m more comfortable with than Rogers’ is, so I just float back and forth between Station 3 and Station 4. It depends on who the clinicians are and what the patient flow is like. Violah likes having me in with her, I think mostly just because the two of us have become really good friends and she likes having me around. She is also a pediatric specialist and really doesn’t like trauma stuff, so she appreciates my comfort with those sorts of things. Irene also likes having me around, just because she and I are much more comparable in terms of training level and I think we both appreciate being able to bounce stuff off each other. James is more like a PA, so he doesn’t really have a need for the help, but he likes teaching me things, so I end up in with him a lot anyway. I have gotten to the point where I’ll see patients on my own if we are really slammed (saw about 20 the other day). I’m trying really hard not to think about how far out of my scope of practice the things I’m doing are. Rogers and I work our asses off most days, with him doing most of the dispensing and me doing most of the trauma work, then tag teaming any of the procedures that come up. We had a day last week where for some reason we just got swamped with procedures. We had to do two ear syringeings, set a fracture, remove two different sets of stitches, massage and wrap a sprained knee, treat two second degree burns and a third degree burn, clean and dress two separate machete wounds, and drain an abscess on the butt of a 2 year old. This was the hardest, as it actually qualifies as a surgical procedure, but we really don’t have the space to work as effectively as we would like. I spent most of the procedure standing behind Rogers working over his shoulder, with one hand on each side, so we could both be where we needed to be. This was actually the second time I’ve assisted him with an abscess drain, but this one was way easier, as it wasn’t on myself. Which gets me to badass story number 1, and the basis of the punny post title.

So about 3 weekends ago, Molly (one of the aid-workers at Arlington) and I went for a hike out to this waterfall way up in the mountains about 6 miles from the clinic. While we cavorting in the falls it started raining, and it rained hard enough that it washed out the already pretty much non-existant path we hiked in on. Rather than trying to find our way back through the forest on our own (at this point we’d hiked into Mt. Elgon Nation Park, so there was no one around for a few miles at least) we decided we should hike back through the river, as that way we couldn’t get lost. This plan had lots of flaws, though I maintain our logic at the time was sound. The short version of a long long long story involving epic treks and falling into ravines and carrying people through neck deep water and such is that I fell down a waterfall. Not a huge one, maybe about 15 ft. high. This resulted in two injuries on my part, a partially dislocated shoulder and a pretty minor cut on my chest. The chest thing seemed like a total non-problem, and I was a lot more worried about my shoulder, but it proved to be the bigger problem. The cut got infected by the river water and turned into a MASSIVE abscess. Abscesses have to be treated, so Rogers and Violah determined on Tuesday morning (36 hours post-hike) that it needed to get drained. Unfortunately, this is really a two-person job, and I was the only person at work that day who was comfortable assisting on it so… I gloved up for the SELF-ASSIST! The process of incising and draining in abscess goes like this: first, stick a big old needle full of lidocaine in it and try to numb it as much as possible (which is not very much). Then you make a 3-5cm elliptical incision at the “point of origin” of the abscess. Then, you stick a closed clamp in the hole, open it, and work it around a bunch, thus widening the hole, until all the pus starts draining out. After it stops flowing on its own, you apply pressure to it for as long as it takes for all the pus to come out. After that, the tissue pocket that had previously been filled has to then be stuffed with gauze (mine required 2 ½ feet worth). Needless to say, it is excruciatingly painful. My abscess was about 4 ½ inches wide, and had about 2 inches of depth. So, while sitting through this being done to me, I was also having to assist on the procedure. One of the staff assistants held a mirror so I could see, and we just kinda, got it done. I was all set to go back to work right away, but Violah and Irene couldn’t believe I was gonna do that. I powered through for about 20 minutes and then took their advice and went to lie down for a few minutes. A few minutes turned into about an hour and a half long nap, which while I felt guilty about no one really begrudged me at all. It took a few weeks for it to fully heal, but as of five days ago I’ve been able to stop keeping it covered, and the sinus has fully closed, so aside from the scar tissue forming I think it’s safe to say it’s fully healed. I was extra sympathetic for the kid we drained last week though, as I totally understand how much pain he was feeling.

See “Abscess makes the heart grow fonder”. It’s clever cause I had an abscess, and abscess sounds like absence, and I haven’t posted in like a month.

Cool, time for story number 2! This actually happened before the whole abscess thing, but that’s ok. This is the story of Mary (not her real name, but I’m not supposed to post her real name for obvious reasons). This is mostly interesting because it was one of the first times I’ve really gotten to use my medic skills in the field. This happened during what we started calling “seizure week”. Between in clinic cases, two that I dealt with outside of work, and one James and Irene had near their house, our staff treated 11 seizures in a 5-day period. Just the way it goes sometimes I guess. Anyway, the story of Mary. Mary was the wife of Joseph, a stone-mason from Arimithea…kidding. Mary is a P5 student at Arlington. She’s about 12 years old, maybe 5’ 2”, 120 lbs. Anyway, Friday of about a month ago, Arlington was having a “marathon” as part of the celebration to finish their 3-month reading initiative. The “marathon” was a 5k race, and the school staff asked if I would run in the group with the teachers and the 12 and up students. I said sure, it seemed like fun. I knew I’d probably get my ass kicked, which I did. In my defense, we’re at a couple thousand feet of elevation, which they are all used to, and I was definitely not, so I think that makes up for the fact that most of them were only like 14. (7 teachers and I ran, the rest were all students. I finished 68th out of 92. I’m ok with it). Anyway, I got to the final stretch of the race, and a bunch of the kids who’d already finished ran out to meet me yelling “Doctor, doctor, hurry”. I thought they were cheering me on, but it turned out that one of the girls (Mary) who’d been running had finished the race and then collapsed and started convulsing. A few of the staff had been trying to help her, but doing nothing right (trying to stand her up, dumping water on her head, etc). Apparently, Molly had called Ryan and asked what to do, and Ryan had said to just wait for me (not really much else to do, and I was closer than anyone else on our staff). She’d also sent a Boda, assuming (correctly) that I might need it. Anyway, I got to the girl, and she was completely unresponsive and had clearly had a massive seizure. It took me all of about 20 seconds to decide there was nothing I could do for her there (especially since I’d been running a race and didn’t even have my basic first aid kit) and that she needed to get to the clinic. However, there is no EMS system and no ambulance or anything in the district, hence the Boda. I basically just scooped her in my arms and hoped on the back of the motorcycle. The driver was totally freaked, he just got told to go to this house and all of a sudden this sweat-covered shirtless white dude is jumping on the back of his bike with a half-naked unconscious girl in his arms yelling at him to go. Jankiest version of a load-and-go I’ve ever done for sure. Anyway, we got her to the clinic, which involved a dramatic motorcycle ride, a nasty burn on my leg, a nearly head on collision with a pick-up and some other just generally absurd occurrences. We got her in and got her treated, but almost ended up sending her to Bududa, because she remained post-ictal for really concerning amount of time. I got to her around 8:30, we got her to the clinic sometime between 8:40 and 8:50, and we got zero neurological response from her until about 2 PM. James and I had a pretty hefty disagreement about her treatment course, he thought her seizure was caused by heat-stroke or fever (which in fairness is about 80% of the time out here), while I was maintaining it was epileptic. The problem we ran into was being unable to confirm anything without getting a history about her, since we have no scan or EKG ability or anything like that. The problem we had was that the number AAH had for her parents didn’t work, so we couldn’t find them. Eventually we found another student who knew where she lived (about an hour and a half walking from the school), and Godfrey sent that girl with one of the teachers to find her parents. Her dad finally made it to the clinic around 4:30, at which point she had just regained consciousness. We found out from him that her family has a huge history of epilepsy (something like 5 people in her immediate family suffered from it). At the time that the clinic closed she was still weak to even consider going home, so we put her up for the night at Godfrey’s place. This got sort of absurd too. Godfrey’s house is just up the hill from the clinic, maybe 400’ away. Unfortunately, it had rained a ton that day, and the hill was crazy muddy. I was barefoot, as the shoes I’d had on were my running shoes, which hadn’t made it to the clinic with me when I brought her in in the morning. Mary couldn’t walk up the hill, so I was carrying her, but with the mud and the lack of shoes, I got about halfway up and then started sliding back down. Godfrey, in an attempt to help, put his shoulder into my back and started pushing us up. This wouldn’t seem that absurd, but Godfrey is about 5’ 4” and maybe weighs 140 lbs. So you’ve got this tiny little Ugandan man trying to push me, carrying this not insubstantial girl, up an absurdly slippery muddy hill. SOOOOOOO ridiculous. After a few moments of brief and absurd struggle a few of the AAH farm hands noticed our situation and came to our rescue. I felt super ridiculous, but they seemed to think it was mostly just funny, so I guess that’s good. Anyway, Mary was out of school for a few days, but we’ve gotten her onto epilepsy treatment now, and it seems like she is doing pretty well.

Way more has happened in the last month than I could attempt to make up for, so I’ll try to get back on top of posting for the last stretch of my time here. If you’ve made it through the last stretch, well done. October was ridic, we saw 1,258 patients, which breaks down to like 62 per day.

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Insanity Insanity Insanity

Totally beat. We have had by far the busiest week of the time I’ve been here. Last monday we saw 74 patients, followed by 68, 59, 64 and 57. Then Saturday was slow, only about 25, then on Monday of this week we had 91! That puts us well over 400 in that seven day period, and Monday was one of the craziest days of my life. Viola was sick, so were short staffed. Normally if we get over 50 patients Irene will see patients as well as Viola or James, but with Viola out sick, Irene was the only nurse. She had delivered two babies on her way to work, so was tired to begin with. I spent most of the day moving back and forth between working with Irene doing the physical exams of the patients while she was speaking with them or their mothers, and helping Rogers in Station 4. It wasn’t just that we had so many patients, but the first 10 took us almost 2 hours to get through. I was pussed on, peed on, seized on and sprayed in the face with Diclofenac by a faulty syringe, all before 11 AM. We had a boy who has a seizure caused by fever, another boy in acute respiratory distress, and a girl with on of the most disgusting and absurd infections I’ve ever seen. This next part is going to be kind of gross, so if you’re squeamish skip a few lines. This girl had an infected, like, pus bubble on her head, that was huge. Imagine if someone had half a mango on their head, it was about that size. Anyway, Irene touched it, to see whether it was ready to be drained, and it straight up just POPPED. There is no other word for it. So the girl (who was maybe….6 or 7?) starts screaming, there is pus, like oozing everywhere, so I’m running through the clinic, carrying this child, trying to keep the pus from dripping on my skin (I think Alice burned the pair of scrubs I was wearing that day. Rightfully so). We had to Incise & Drain it, which the kid hated, and she was thrashing around so much that Rogers almost cut his finger open with the surgical blade. We had to get Muse Wilson in to help us hold onto this girl, and even then, I got kicked twice and he took a shot straight to the groin. It was actually kinda funny, he shrugged it off and said “I am old, I don’t need these anymore”. Rogers and I went through about seven pairs of gloves, and this kids head leaked for a solid 15 minutes. It was soooooo gross, but I’m not gonna lie, I was into it in that weird way you can be into gross things like that. Not like the pus and stuff, just the experience of it. The diclofenac spray came after we tried to give it to the boy who had had a seizure while waiting on the porch. Diclo is a fever-reducer. Anyway, we were injecting it into the kids rear, and the syringe was faulty, so when Irene pushed the injector down it sprayed straight backwards instead. She was giving the shot and I was helping to hold the kid, and we both got it in the face. Much worse things to get sprayed in the face with that diclofenac, but it was still absurd. This was from the same kid who peed on us, which was totally my fault. He was post-ictal following the seizure, and I was doing a quick exam of him since we’d not seen him at all prior to the beginning of his convulsions. I did a babinski test on him, since determining neurological status with an infant is a lot harder than with an adult, and immediately after his response to the babinski he started peeing on me. I don’t think urination is a typical response to a babinski, but given his state, I’m guessing that the surprise and the reflex from the test caused him to lose whatever bladder control he had. I felt way ahead of the game with the kid in respiratory distress, as we were treating him with albuterol given in one of those inhaler chamber tubes that I used when I was a kid. We were so worried about him that we had him on one of our two cots and I spent a solid half hour just sitting with him and monitoring his breathing. He normalized somewhat after about 3 doses of albuterol and some dexo, but we were worried for awhile.Wednesday was very exciting for me, I did a surgical debridement on my own. Not to get into overly disgusting detail but that is where you cut infected tissue out of a wound so as to be able to clean it. We have lots of surgical blades at the clinic, though none of the handles or traditional scalpels, so it’s kind of like using a loose razor blade. The boy was maybe 5 years old. I had actually seen him the day before. Robert and I were walking home from work and his grandmother stopped us and asked us to look at her grandson’s wound (from a bike accident). It was a terrible cut, maybe 3” x 3’, taking up most of the outside of his foot between the ankle and the heel. It was badly infected, and had been uncovered and untreated for almost a week, and the boy was sporting a fever. I told the grandmother there was nothing I could do at that moment, but we were only a few minutes from my house so I ran back to get supplies to bring back to her. When I returned 5 or so minutes later they had gone. Obviously there is nothing to do at that point, but suffice it to say I was very relieved when they came into the clinic a little after 10 this morning. The procedure was brutal for the boy. We have a small supply of local anesthetics and pain relievers, but we have to use them very sparingly, and wound care generally doesn’t qualify as needing it. I really wanted to use some, but Irene kept telling me that the cut wasn’t bad enough, so we gave the kid a rag to bite and something to squeeze and he toughed it out. It took a little over five minutes, and the kid was screaming in pain most of that time. His grandmother was very grateful, but I’m pretty sure he will hate me forever. And I don’t really blame him. That said, I was very pleased with my work, medically speaking, as I’d never done a surgical debridement before and got it all in one go with a loose surgical blade on an un-anesthetized five year old screaming at me by myself. It was kind of exhausting though, I have new respect for surgeons who spend 10 hours operating. We also had a patient come in last week who was suffering from injury-induced petallar-femoral syndrome, which is the healable rather than chronic version of the knee problem I have, so I told Viola, “Girl, you know I got this one” and gave the guy a probably 20 minute PT routine he could do at home.

Here is something fun, I figured out how to find (kind of) the clinic on google maps.If you search for Bulobi Primary School, Bududa Ring, Bududa, Uganda, you will find a school that I run past when I exercise in the mornings. My house is just up the road (called the Bududa ring on google maps) from that school, 1/3 of a a KM at most. You can actually see my house in the satellite image, it’s the second house on the left in the small cluster of house on the main due north of the maps flag for Bulobi Primary.If you put in Beatrice Tierney Clinic, Bududa, Eastern Region, Uganda, you can see where the clinic itself is. Bushiyi (one of my three favorite place name shere. It’s pronounced BOO-SHE-EEEEEeee, with the eeeee drawn way out. My other two are Bumwalukani (Boom-WAH-loo-ka-knee) and Sakusaku (sa-coo-sa-coo)) health center is shown on the map nearby, that is a lie, it doesn’t exist. K. Time for me to go Sasa (pee). Sorry for going nuts with the writing

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Football

This is Emma and I. Emma is the Clinic’s lab tech

 

I should start with a clarification. The name of the midwife is in fact Zipola. The reason I thought her name was Shiraz is because many of the staff call her that. Apparently in Lugisu it means something along the lines of “ornery old matron”, but is a term of endearment rather than a derogatory one, so she responds to it and is in no way offended by it.

So I think I need to break from medicine for a bit to talk about Football. Unsurprisingly it’s the focus of all athletic intrigue around here. The English Premiere League is the most popular by a long shot. For whatever reason, Arsenal is the team of choice for most people in Bududa. There are a few Man U fans (as there are wont to be wherever you go) but I felt very isolated in my Chelsea love. I’d like to say I’m a QPR fan to the core haha, but no one here really cares about them and the games are almost never on, so Chelsea is a safer bet as far as cultural acceptance. I spent my Saturday afternoon watching football in Bushika (the trading center a few villages down the road). It was a crazy fun time. I went with James (one of the two Clinical Officers) and Richard (the Health Outreach Coordinator at the clinic. He is also a pastor and head teacher of a small primary school he and his wife started. Also just had a baby boy like a week ago). Anyway, we went to Bushika, got these delicious sodas called “Mirandazes” that tasted kind of like bubble gum, and went to the football watching hut. This place is like a really old school theater. It’s a big mud building, maybe 100′ x 50′. It’s filled with these decrepit, hand made wooden benches and in the back corner is one 15 year old 32″ LG TV (probably weighs about 20 lbs.). They pack 250 people into this thing (all men. Women culturally wouldn’t be allowed in this environment) and charge 500 shillings to watch (that’s like 15 cents American). We got there early enough that we got the good seats near the front, that had back rests, but it wasn’t even close to comfortable because we ended up with people sitting on a shorter bench in front of us using our legs as backrests. At first this weirded me out, but it’s clearly a totally normal culture thing. So picture me in the middle of a huge cuddle pile of Arsenal fans aged anywhere from 11-60, the only white person, and the only Chelsea supporter within about a 5 mile radius. I got a lot of street-cred with the guys for accurately predicting Chelsea would win 2-1 and that Torres and Mata would be the goal scorers. It was awkward when I lept up cheering when Chelsea put the first one in and no one else was excited. James said something in Lugisu and the men all laughed, but I definitely felt like I was in hostile territory. Some Man U fans came in at halftime, and while they were not so much pro-Chelsea as they were anti-Arsenal, the back-up was nice. It started raining right before halftime, which of course killed the signal, on account of it being old school super jenky satellite cable, but they got it working again in about 10 minutes and a riot was averted. The signal cut out constantly, but usually only for a few seconds. This resulted in lots of moments of tense “OH! WHAT JUST HAPPENED????”All in all it was an excellent experience, I think it will likely become a Saturday routine.

I also played football with some of the Arlington students a few days ago, which was great fun. The boys wanted to do boys vs. girls, which I agreed to, but said I would play on the girls team to even it out a bit. I broke the boys’ hearts when I scored the only goal of the game two minutes before their lunch break ended. This is not a normal field that we play on though. It’s not even close to flat, is full of pot holes, and there aren’t sidelines. The upper side of the pitch is a dirt wall separating off a farmers field (you can play balls off the wall, and it’s angled enough that you can run along it too, so sometimes you end up playing at like a 30 degree angle). The far side is an uneven drop off to a bunch of houses, so kids were constantly having to jump down about 4 or 5 feet, get the ball, throw it in, then climb back up. The goals are made with big banana leaves that we stick in the ground. These are not the biggest challenge though. The biggest challenge is the cows. See, the field that we play in is also the grazing field for all the neighborhood cows, and they are utterly indifferent to the presence of 30 school children and a Muzungu EMT. So as you are playing, jumping pot holes, leaping mud pits, you are also constantly having to dodge both nice big cow pies, and the cows themselves. One kid nearly made what would likely have been the play of the century. He was hemmed in up against one of the cows by two defenders. Rather than trying to break free from them, he kicked the ball between the cows legs, then rolled over it’s back, down the other side, and gathered the ball. It was just him vs. the goalie at that point and it looked like it would be the highlight of the season when he had an unfortunate large- pile-of-cow-dung-induced face-plant and lost control of the ball. It was hugely funny, though also one of the great tragedies of sports this year (right up there with D-Rose’s injury in game 1 of the Philly series and Lance’s verdict).

The kids usually play football with a bunch of plastic bags bundled up together, so the fact that I have a real ball is freakishly exciting to them. It’s already totally rallied, and I will probably need to replace it by mid-October, but they are only like $7 in town so I can live with that I think.

 

 

A few photos to follow:

This is me with “The Mafia” the kids who live near the clinic. Solomon, the startled looking boy in front, discovered a few days ago that I could swing him with one arm if he picked his feat up. I spent most of the next work day with a three-year old attached to me, which, while cute, made treating patients a bit interesting

This is me with some of the staff. Robina, the girl, is the student nurse. Robert is one of the intake staff. The one I’m cuddling with is Rogers, who runs Station 4. I spend most of my time at work with him

 

None of us could figure out what was up with this kids foot. We had a few theories, but no way to test any of them, so sent him to the hospital in Mbale.

 

This is just Bududa being pretty

This is just Bududa being pretty

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