Memorable Patients

During one of my village health days, the man pictured below graciously allowed me to use his home (in the background) to see patients. Over the next four days, I worked in his living room and bedroom to diagnose and treat patients and to do ultrasound exams. I was amazed to see someone open his home so freely to sick people. Many of this things I saw and treated were not typical things you would welcome into your living space!

Midway through the week, he told me that he was having tooth pain. When he opened his mouth, I could see that his teeth were severely decayed and two of them were on the verge of falling out. There were so loose he was having trouble eating. I am certainly not an expert in dentistry, but I had a little bit of training in tooth extraction during my fellowship year in International Medicine. It looked like his teeth would need just a little tug and his pain could be alleviated. I did the extraction in his living room under the light of a headlamp and it turned out to be very easy (phew!). When I saw him the following day, he had a big smile on his face and was happy to report that his pain was gone and he was enjoying food again. 

At the end of the week he took me aside and whispered in my ear to ask if I could give him something in exchange for letting me use his house as a clinic. I had trouble understanding what he wanted and had to get some help from my translator. As I waited for clarification, I was a little worried that I wouldn't be able to meet his request. My translator came over to talk to the man and told me that all he was requesting was a bar of soap. We have found that soap here is a bit of a luxury item. Many people cannot afford to buy it. I was relieved that his request would be easy to meet. Stephanie wrapped up several bars of soap in a nice package and we were able to give them to this kind man as a gift at the end of the week. It was a vivid reminder to me of how few material possessions many people here have. This man was very content at the end of the week to have a few bars of soap and to be eating without pain again.

This little guy pictured above was having abdominal pain, distention and vomiting for 2 weeks. He was very tender and I was worried that he might have a ruptured appendix or bowel obstruction. I did an ultrasound to try to clarify the diagnosis. I was unable to see much of anything because his colon was full of air. I suspected a bowel obstruction. There was not much that I could do in a remote village that was far from the hospital. While thinking about what I could offer, I remembered that a common cause of bowel obstruction in African children is a parasitic infection called ascariasis. Inside the intestine the worms can become so large and numerous that they completely block the intestinal cavity. I decided to treat him with albendazole (an anti-parasitic medication) and recommended that his family take him to the nearest hospital for further evaluation in case he would need surgery. I prayed with the boy and his family because he looked very sick and I was concerned for his survival. I was delighted to see him one week later on follow-up. He no longer looked sick and his family told me that he had made a full recovery! His parents decided not to take him to the hospital and simply gave him the albendazole that I prescribed. He was cured with one dose, which is typical of ascaris infection.

Another memorable patient was a new mother who was in her late teens. She had delivered a baby 3 months before and had been getting progressively sicker during the course of her pregnancy. She was single and the baby's father was not involved in her life anymore. She looked to be near death when she was brought into clinic. She was unable to stand on her own and had to be carried in and out of the room. To make things more difficult, she was unable to speak. I found out that she had been mute since birth. I struggled to get a history, but found out that her main complaints were weakness, weight loss, poor appetite and cough. I had her caretaker help me to lay her down on a mat on the floor so I could examine her and do an ultrasound. When I lifted her, I estimated that she weighed about 75 pounds. After completing the exam, I still didn't have a firm diagnosis, but my best guess was that she had HIV, TB or an unidentified cancer that was causing her to waste away. I recommended that her family take her to a local hospital for further testing and I gave her a few medications that I hoped would help in the meantime. I knelt down next to her to pray and asked her name. Her friend told me that she was called Fragile. I got choked up when I heard this and had to take a few moments to compose myself. I thought it was so fitting for the patient lying in front of me - a 75 pound single mother who had been mute since birth and was wasting away from an unknown disease - to be named Fragile. I prayed that God would help this fragile woman who was teetering on the edge of life to receive an accurate diagnosis and treatment, or at least to receive comfort and compassionate care in her last days. I prayed also for the new baby that she was unable to nurse. I have not seen Fragile again since that clinic day, but I am comforted by the fact that God knows her name and by Jesus' words in Matthew 10. "Are not two sparrows sold for a penny? Yet not one of them will fall to the ground outside your Father's care. And even the very hairs of your head are all numbered. So don't be afraid; you are worth more than many sparrows." May God continue to be near to Fragile, one who is worth more than many sparrows.

I first met this lady above in Bubukwanga at a camp for Internally Displaced Persons. She had to flee her home when it was burned down by a neighboring tribe during a recent conflict. She lost everything she had and was living in a tent city with 10,000 other people. She had many physical complaints that day that I think were the result of the recent psychological trauma that she had been through. I also found that she had high blood pressure, so I started her on a medication and asked her to follow-up with a local healthcare provider in 1-2 weeks. About 4 weeks later I saw her again at a village health clinic I was doing about 45 minutes drive from the camp where she was living. She said she heard that I was having a clinic again so she found a ride to come and see me so she could follow-up on her high blood pressure. I was amazed! We had a good laugh that she was able to find us from so far away. I asked her if she had been able to move home, as many people from the camp were able to return several weeks after the violence ended. She replied, "I am never going back after what my neighbors did to me." I asked when I would see her again and she said she would find me at my next clinic site. I was happy that she had been able to keep her sense of humor through all her trials. I like to think of her as my first continuity clinic patient since she is the first one to follow-up with me for a chronic condition.

These two babies were born to friends of ours in the past few months. I did ultrasound exams for both moms to provide a due date and to make sure that the babies were growing normally. Stephanie and I also saw them several times for pregnancy related concerns as they approached delivery and have been providing routine and sick care for them ever since. We were thankful that both moms delivered healthy babies with no complications, a blessing in a culture with high maternal mortality. Hailey was given the honor by the families of naming both babies! She chose Ruth for the first girl and Rachel for the second. How many five year olds get to name two babies in just a few months time?!?

Just a glimpse of what I have been seeing on the medical side of life lately. We are thankful God has us here to serve and look forward to meeting many more memorable patients.

Medical Ministry

My vision has been to provide healthcare in partnership with local churches so that together we can meet physical and spiritual needs in this remote corner of Uganda. Jesus said,"What does it profit a man to gain the whole world and forfeit his soul?" I have always thought the same thing about medicine. What have I done for my patient if I have cured his physical disease, yet have done nothing to care for his spirit? As a busy doctor with limited time and abilities, I feel that the most effective way I can do this is by partnering with local churches and pastors, who have the special gift and calling of caring for the spirit.

When I launched my medical ministry, I started by asking to meet with church leaders in our area so that I could explain my desire of providing healthcare in partnership with them. Here's a pic of our first meeting.

 From there, we began making plans on how we could best work together to serve our community. So far, I have travelled to 8 villages to provide medical care, often visiting over multiple days so that I can see the majority of the patients who present. I have been thankful for our Toyota SuperCustom van, a diesel, 4-wheel drive, beast of a car that has gotten me everywhere (well, almost!) that I have needed to go. I pack up medications, medical supplies, a portable ultrasound machine, and our healthcare team and we set off down potholed, dirt and mud roads with low hanging trees that often scrape on the roof rack of the van to reach remote villages. After spending 3 years working primarily in an office and hospital, it has been really exciting to set off in this mobile medical vehicle taking in the landscape of Uganda, bumping down small roads and footpaths, often with amazing views of the mountains to bring healthcare to people who need it the most. Here are some snapshots from one of my recent adventures...

 Thomas and Bihwa, two close friends who have been working as translator and church facilitator, respectively. Thomas is also my language helper and is fluent in 5 languages. I'm struggling to learn just one of those! Keep praying for me!

To date, this was the only village we could not reach by car. We had a big rain the night before and the road was very slick with mud. The van kept sliding and we had a hard time staying on the road. We decided it was safer to park and continue on foot. We briefly stopped here to ask for directions to make sure we were still heading the right way.

It was probably for the best that we left the car because the road soon turned into a foot path that went through a cocoa shamba.

After an hour of walking, we finally reached this church with a room full of patients waiting for us.

In each village we visit, we set up clinic in a church, roadside building, or home. Here are a few snapshots of "clinic" spaces we have used.

We usually draw a crowd of onlookers who stand at the doors and windows to see what is going on inside.

I have been so thankful for the portable ultrasound machine I brought from the U.S. (in the bag I am carrying), thanks to generous donations from our supporters and a grant from SonoSite. I cannot explain how helpful this has been while caring for patients in a place with limited diagnostic equipment. I have done many prenatal ultrasounds, abdominal ultrasounds, and echocardiograms for patients who would otherwise not have access to these services. Thank you to everyone who helped us to purchase this machine!!

One of our more interesting clinic days was in Bubukwanga, about a 25 minute drive from our home. Pictured above on the right is Holly, our team nurse. We worked at a small health center adjacent to a camp for internally displaced persons (IDP camp). This camp is home to 8,000 - 10,000 people who had to flee their villages during recent tribal conflict. The health center was overwhelmed by the number of patients who needed care and was severely depleted of medications. They also lost several staff members who fled out of fear of retribution from people in the camp because they were from conflicting tribes. Thomas' (above middle) mother was living in the camp at the time. More on that story in a later blog.

I hope to post a blog soon about some of our interesting cases. Stay tuned!

Safari!

For Eli's 7th birthday, we travelled to Queen Elizabeth National Park. Located in southwestern Uganda, this beautiful reserve stretches 764 square miles and is home to an array of African wildlife. We had a wonderful time relaxing at a safari lodge, driving into the park in search of animals, and taking a boat tour on Kazinga Channel, which connects Lake George and Lake Edward. Below are some snapshots from our trip.

View from Kingfisher Lodge with Mount Stanley (the 3rd highest peak in Africa) in the background.

The kids were excited to have great views from our van while on safari. Our guide didn't know how to drive, so Marc had the adventure of navigating through the mud and potholes in search of wildlife.

We saw lots of amazing animals. Here's a Water Buck grazing near Kazinga Channel.

Water Buffalo. We saw many of these in large herds.

Ugandan Cob - so graceful and beautiful.

Roadblock! We saw lots of these very close to the road. I guess you don't have to be afraid when you are bigger than most vehicles.

The kids enjoyed having a closer look at the animals from our roof rack.

Marabou stork. Queen Elizabeth is home to over 500 species of birds.

Monitor Lizard

Baboon mother and baby enjoying a banana.

Katelyn directing us to the animals.

Our favorite part of the trip was a boat ride where we got an up close look at some of the more dangerous wildlife.

Crocodile

Ahhh! Isaac and Katelyn made us so nervous as they ran all around the boat and insisted on getting as close to the edge as possible. We certainly didn't want to have to jump in after them if they fell in! Check out that hungry hippo submerged in the water.

Hippo family

Enjoying one of the many beautiful sunsets over the park.

The kids loved the pool, even though the water was frigid!

Had to stop for a pic as we crossed the equator.

It was a memorable birthday for Eli Marcus!

A New Car!

Hear the voice of Bob Barker from The Price is Right when you read that title. I never thought I would be so excited about purchasing a car that is 14 years old with 321,000 kilometers (199,000 miles). But I am! After three visits to Kampala to look at vehicles, and finding that the options were very limited, we finally came across a large van that met all the specifications we had in mind for our family car.

Thank you so much to each of our supporters who made this purchase possible. We are thrilled to have a reliable vehicle than can safely transport us back and forth from Kampala on our resupply trips. Now we can fit our family, groceries, and medical supplies and still have some breathing room after these weeklong trips. Thank you for your generous support towards this purchase!

Car shopping in Kampala was a surreal experience. Picture the shadiest used car lot you have ever been to, with the slickest used car salesman. That was pretty much our only option in Kampala. Each bonded warehouse (used car lot) was packed with vehicles bumper to bumper. There was almost no room in front of or behind the cars to even pass through. To really inspect a car, the salesman might have to move 10 or 15 cars out of the way to get to the one I was interested in. Most of the cars on the lots were fifteen to twenty years old, and many had odometer readings in the range of 40,000 - 60,000 miles. This was obviously suspect. Various people told me that most car lots wind the odometers back, so it is unwise to consider the mileage when making a purchase.

Another interesting quirk is that the vehicles on these lots are not registered in Uganda or given license plates until they sell. This is done so that the salesman can save money by not paying a registration fee for a car that might spend a long time sitting on the lot. Because the car is not registered and doesn't have plates, it cannot be taken off the lot for a test drive. So, I was left making a decision about a fifteen to twenty year old car without being able to look at it closely, with no idea how many miles it had, and without being able to go for a test drive! Quite a challenge, indeed.

Additionally, since almost no cars are manufactured in Africa, virtually everything is an import with an inflated price. To arrive at the sales price, the government takes the value of the car when it is imported, then adds 35% for an environmental tax, 25% for an import tax, 22.5% for sales tax, 6% for a withholding tax, and 1.5% for an infrastructure tax. The final price you pay is at least 190% of the value of the car, and maybe more if the seller has marked up the price!

A typical car lot in Kamapala. How do they get those cars in there?!?

To find a car, I went shopping on three separate trips to Kampala. By my final count, I had looked at sixty cars on fifteen different lots. I learned a lot in the process and was thankful for the experience, but in the end I was worn out. I did come away with information on how to do business in Uganda, how to negotiate for prices, and how to navigate around the capital. In the end, those lessons were probably worth it.

After spending five months in a borrowed Toyota LandCruiser (thank you Rhett and Holly!), we decided that our family needed a bigger vehicle. We settled on a Toyota Super Custom - a rugged eight seater van with lots of space in the trunk. These cars are plentiful in Uganda and are often used as commuter vehicles. It's big brother, the Toyota Hiace, is used as a shared taxi called a Matatu. It looks very similar to the Super Custom, but has additional seats so it can hold as many as twelve passengers. After settling on a Super Custom as our desired vehicle, I went on a search throughout Kampala for one that was in good condition. Sounds easy, right?

When I found a car that I liked, the first test was to see if it would start. Since all the cars here are imports, with most coming from Japan, they have been traveling for several months before finally arriving at the car lot. I found that almost all of the batteries were dead or had been removed for the overseas journey. The salesman would have to get someone to bring a new battery and then jump the car to get it to start. 

Yes, he is jumping this car without jumper cables by holding exposed wires with his bare hands!

Once I got a car to start, which did not always happen, I had to make a decision without a test drive. I checked all the gauges, windows, locks, mirrors, looked under the car, examined the engine, looked at the oil and radiator fluid, surveyed for water damage and rust, and revved the engine to look at the exhaust. Very few cars passed this inspection. When I made a short list of vehicles in our price range that looked to be in good shape, I called a local mechanic to come and thoroughly inspect the cars. The salesmen almost always tried to talk me out of this. They questioned my trust in them, they offered a small warranty if I would agree to not bring in a mechanic, and generally tried to dissuade me from taking this extra step. When I persisted and brought a mechanic in, he often found something concerning like a radiator leak, rusted chassis, damaged exhaust system, etc, that would knock the car off my list. Round and round we went. Sixty times.

Eventually, I became so frustrated that I decided to import a car directly from Japan to cut out the middle man. I found one that I liked and made plans to buy it through an importer. After telling me that I could purchase the car remotely at an auction in Japan and have the importer ship it over for me, at the last minute he changed his mind and said that he would buy the car at auction and sell it to me later. Deflated by this news, I had to wait to see what his price would be after he bought the car. After several days of waiting, I found out that he did not bid high enough at the auction and lost the vehicle.

So, back to the drawing board. I finally found another car that I had my heart set on. Good condition, good inspection, good price. Unfortunately, it sold to another buyer just after my mechanic finished looking at it.

Feeling deflated by these experiences, we had one last trip to Kampala to find a car before the one we borrowed had to be returned. I went from lot to lot for the third time and finally found a GREAT car that met all of our needs. It was a 2002, which was about six years newer than anything else I had seen. It had arrived in Kampala from Japan the day before, and the odometer was showing 321,000 kilometers. This was much higher than any other car I had seen. Since it was a new arrival, I think the dealer hadn't had time to wind the miles back yet, so I felt like I had a good idea of how much wear was on this car. Additionally, this particular salesman seemed to be more honest than any of the others I had met. He offered me a three month warranty on the engine and radiator by agreeing to repair any problems that came up for free.

The car looked to be in great shape and passed the inspection from my mechanic. But without a test drive, I was very nervous. However, with no other options I took the plunge and bought the car. When I got it to the car repair shop for a more thorough check, I was thrilled to find out that there were no major issues. The mechanic told me it had been very well maintained. He predicted it would last us for many years to come. 

Sealing the deal on our new car.

Our first upgrade was to add a full length roof rack that can hold up to 600 lbs! This has come in so handy for all the items we have been buying for our building project. Pictured above we are transporting 300 meters of hose pipe to bring water to our construction site.

We love how many people we can fit in this car. Here we are transporting eleven people for an outing to a traveling zoo. There are a few kids hiding in the back!

Thank you again for your prayers and support for our car buying adventure. We love traveling in this new (well, 14 year old) vehicle. We can load up all our groceries and supplies and still have room to move around. If you come to visit us in Uganda, we would love to take you for a spin!