Honora continues to inspire

What is it about Honora Englander's plain-spoken dispatches from Uganda that make me smile and feel good about the future of medicine? I hope you feel the same way. Here's an excerpt from her latest:

The time here is flying by; my days are full and each day holds something new and unexpected. Some days I am wakened as early as 5:30 am by trucks barreling by my window or by the howling choir of neighborhood dogs. At 6:00 I can hear the beautiful morning prayer from a nearby mosque, and this is followed by the birds' dawn. I've been rounding on the wards with residents and students from 9 until about 1:00 or 2:00, and then teaching in the afternoons for several hours. Monday was diabetes and chest x-rays, Tuesday physical diagnosis rounds, and today was a marathon lecture on EKGs. The students are bright, well read, caring, and very eager.

Though likely of less interest for those not in medicine, I suspect that many of you will find some of the patient stories and diseases we see here fascinating. In the first bed on the left is a 31-year-old man with newly diagnosed HIV/tuberculosis co-infection who presented with cough and weight loss, and developed seizures on his first hospital day. He stopped seizing after benzos and a dilantin load, but we've been unable to establish a clear diagnosis due to his reluctance to have a repeat lumbar puncture (the first was lost after being sent for India Ink which was negative). A chest x-ray showed miliary TB and is gradually improving on empiric therapy for TB and bacterial meningitis. His mother and father tend to him daily, and their faces appear increasingly relieved as the memory of his seizures fade and he gains a small amount of strength.

In the next bed is a 66-year-old man with refractory hypertension, anemia, melena, and a pleuropericardial friction rub of unclear etiology. He speaks English well, which is a luxury for me, as so much history is lost using students as translators. Many students are from the region and thus speak the local language, but many come from other parts of the country and their comfort in Riankole is variable.

In the next bed is a 14-year-old boy who presented with lightheadedness and gum bleeding several weeks after a dental extraction, and is found to have a WBC of 1.1, Hemoglobin of 2.7 and platelets of 8. His spleen is enlarged (grade III) but other than a slight S3 and looking young and frightened, his physical exam is unremarkable. We are ruling him out for infection (TB, brucella, typhoid, severe malaria) but are all concerned about a likely lymphoma. In the meantime we are treating with antibiotics, antimalarials, packed red cells and vitamin K, and today there was a suggestion that we get platelets from Kampala while we wait for a bone marrow biopsy.

Next to him lies a young man who was transferred from the psychiatry ward where he was said to have had a psychotic episode after newly learning is his HIV positive, however his clinical course and exam suggest a chronic meningitis, and thus he was transferred to our ward. In the bed next to him is a charming 84-year-old man who was admitted with dysphagia. There was talk of endoscopy but the cost is prohibitive, so instead we are waiting for his son to arrive from the village with money so that he can get a much more affordable barium swallow. In the mean time he is cared for by a wife and young daughter who can't be more than 10 years old. Their dress suggests that they are Muslim, and each time I see his daughter in the halls she smiles shyly and then kneels.

While there are few specialists, the team of physicians here is a tremendous resource. Some days I round with a Ugandan attending, but often I am alone with my team of a first year resident and the students. The providers that I lean on most are a mix of Ugandans (mostly PGs - i.e., residents) as well as the exceptional group of European and American doctors who are here. The extent of disease, decisions around testing in the face of limited resources, and the social and cultural aspects of care are both challenging and fascinating.

My evenings are often quiet and provide down time to relax, have a leisurely dinner, read, or turn in early. Tonight on my evening run I smiled as I was passed by four waving, knee-high children in school uniforms who were crammed on the back of a boda-boda (motorcycle), and I was struck by the mix of new and old traditions that coexist here. I passed a 2-inch wide ribbon of ants crossing the road and cows grazing in the pasture. Just adjacent was the golf course where a group of Ugandan men were teeing off and barefoot children played soccer with a ratty deflated ball. A woman sped by talking on her cell phone, and just minutes later I watched a woman who was learning to drive harmlessly careen off a gravel road into some hedges (hitting the accelerator instead of the brake!)

It is near 9:30 now and I'm ready to turn in.