Resuscitation

Chuck Norris. VanDamme. Jesus. King. Kingston. Ugandan. Indian. White man. Muzungu.

These are my names.

To Ugandans, I am pale, hirsute, and have the nose of a rancher.

Some children openly stare at me - making fun of the way I walk or talk. Others run up to me and hug my legs or hold my hand while they walk with me, trying to match my stride.

Some adults too, laugh about me as they correctly assume that I do not understand most of the Runyankore they speak in the rural southwest. Still many are so kind, generous, and welcoming that I cannot imagine them having more pureness of heart. It is perhaps the case that there is no facial expression more beautiful than a Ugandan smile.

Perhaps I have rediscovered my purpose. I can imagine Leo Tolstoy being jealous of me: “A quiet secluded life in the country, with the possibility of being useful to people to whom it is easy to do good, and who are not accustomed to have it done to them; then work which one hopes may be of some use; then rest, nature, books, music, love for one's neighbor — such is my idea of happiness.” Well maybe not a perfect fit, but good tailors are hard to come by these days.

For over 4 months, I have been living at a "large" Catholic hospital. There have been spans of: weeks without running water; days with no electricity; and hours when Internet access is down. Much of the hospital's staff also lives on the compound, although they are segregated from foreign volunteers of various organizations like mine.  My role is to manage ground operations for a program that trains a new cadre of allied health professionals called emergency medicine practitioners (ECPs). I learned early on that I would need to earn the respect and friendship of these care providers.

The outgoing Program Director worked with me for a few days before she returned to the U.S. Despite her willingness to help me get going, I was left with more questions than answers. A Ugandan-born graduate of Colorado College works as the research director here, although she is currently on leave. She and I have been handling the data collection and management when there are no research assistants. The research that we do here helps make the case to donors that our program is effective. It also helps us to narrow our interventional focus toward the areas of greatest need. We currently have two research assistants, which frees up some more of my time to work on program-related tasks. One of the research assistants is from Idaho, and is here longer-term - at least until July. She seems to fit naturally between the worlds of the locals and the expats. Another, from Burundi, is here until mid-July, but just got here a few days ago and is already having conversations with some of the ECPs in Swahili.

When I arrived, I shared our sex-segregated guesthouse with a well-traveled and severely honest non-traditional med student. He was the last research assistant here before the girl from Idaho showed up. I learned a lot about life here from him: mostly about how to deal with the water or power going out and how to burn trash without killing myself. That was a huge leap for a person who recycled everything that I possibly could. I think that living here, far away from his wife in the U.S. had taken its toll on that guy's well-being. He came off as very abrasive, even though I sensed he was a good guy. I even think I'm starting to get a little rough around the edges myself, although I'm trying not to.

There's another organization here that focuses on addressing childhood malnutrition. For the first few months I was here, the only American from that organization was living on the girls' side of the guesthouse. Just recently, she moved in with her husband, a Ugandan from Rukungiri, in anticipation of their huge wedding ceremony next week. I'm actually a signatory on her wedding license, as I was the only American around at the time. The weeks preceding the wedding (and I am sure the ceremony itself) have taught me a bit about Ugandan culture. They have wedding "meetings" which serve as fundraisers for the wedding. And there is a pre-wedding party called a "kiziki," which they also raise money for, in lieu of gifts, I presume. Some of her colleagues from a hospital in Kenya joined us a couple of months ago to hide out during the Kenyan elections. Things tend to get violent in African nations around election time - particularly in hometowns of candidates and big cities. About two weeks ago, another group from that organization showed up from Boston - not to hide out so much as to work here.

The Belgians were nursing and midwifery students from a Catholic institution that lived in St. Michael's for a few months. St. Michael's is a boarding house near the new chapel on the hospital grounds. (It's strange to me how spending is prioritized around here.) Only one Belgian spent much time hanging out with us for the first little bit, but the other two who are here with her were pleasant and enjoyable company at meals and the occasional card game. I learned a bit about their country and how to play a strange, but fun, Dutch game called "Boonanza" that is all about harvesting beans for gold.

There is now also a group of students from Harvard here. I don't know them well, but they seem like kind and motivated young people. Meals get pretty crowded, as the nuns prepare them for us in Visitor's, which has a decently sized dining room when there are only about seven or eight of us. Now we eat in informal shifts. There's a small group of students from University of Texas Medical Branch that have been rotating through the hospital who also live in Visitor's. For a short while, there was a recent medical school graduate from Nottingham, England placed at our hospital through his school too. When he arrived early and his room in Visitor's wasn't ready yet, I took him in at the guesthouse. He's much younger than me, but still gave the impression of a very interesting and incredibly insightful guy. He's very competitive, loves Lil Wayne and Drake, and hates to lose at card games. His lust for life was inspiring. And I may not have rafted the Nile or done a safari in Queen Elizabeth if it were not for that kid's eagerness to go and have me along. I look forward to doing a bicycle tour with him on my first visit to the UK.

We've had some unique and entertaining personalities come through my own organization as well. One of the first during my time was a visiting resident physician from NYC. He's very sharp and has a fun easy-going attitude. Definitely the type of person born to be an ED physician. I'm sure he could even put out a decent album if he keeps practicing weird (read: Spanish version of Britney Spears and acoustic version of "Sexy and I Know It") songs on the guitar. I learned a lot about balancing work and fun from him. He accompanied me to Masaka when I visited the hospital there. We saw a lot of potential for expanding the program there, but unfortunately that hospital can't do anything without the go-ahead from Kampala.

There was an older couple from Maine that stayed here who were really fun and easy-going. They also contributed a great deal during their time here. The husband, who was an attending physician, gained the respect and admiration of our mid-level providers. His nurse practitioner wife in turn had a lot to offer the nursing students rotating through the Emergency Department. One of the nurses in maternity told them that I am going to marry their daughter someday, which became a fun inside joke...although you never know... They were a great example of how awesome two people can be as partners for the long haul.

We had an attending physician from Virginia too. She was always willing to speak her mind, which made things interesting. And she was not shy about sharing her knowledge either. She helped quite a bit with: evaluating a training that we did for village health workers; training some of the ECPs about treating dislocations; entering data into our database; and taking a malfunctioning ultrasound machine back to the U.S. for repairs. She reminded me of the idea that we all need to keep learning because eventually we have to teach someone what we know. She came down with malaria (while on malarone) at Lake Bunyonye. Not the the ideal way to end a trip overseas, in my opinion.

Another non-traditional medical guy came as a visiting resident. He had all sorts of impressive credentials yet seemed really down to earth. Before he left to do some in-country traveling with his friend, he began a discussion with the medical supervisor about adopting the two orphans that live in maternity. His wife was pregnant with their first child at the time and should have delivered in the last day or two. I was inspired by his willingness to do something for these orphans despite the chaos of: being a resident; his own wife's pregnancy; and the fact that they were both about to move. They are working with an adoption expert to try and push the process forward. It it's anything like the process my friends who adopted a kid from D.R. Congo went through, it's bound to be quite the adventure.

There was a pediatric emergency medicine physician that stayed in our house too. At the time, there was no more space on the girl's side, so she stayed on the side with me. We got along well for the most part, but I think our personalities clashed at times. One day, one of the ECPs went running with us. I could barely keep up with him and we left the doc in the dust. She was only here for about a week, and hadn't yet adjusted to the place, but had been here years earlier and knew two of the oldest ECPs. It must be strange and exciting coming back to a place that you left a long time ago. Some things change while other things stay the same. It's very likely she'll try and come back here and stay a little longer. That seems to be the only complaint that ECPs have with the visiting doctors.

A younger couple came to stay with us in the guesthouse recently. The man was a visiting resident and his wife recently quit her job in public relations. They seemed to integrate well here, particularly the resident, who already had some travel experience. He brought a lot of humor into his style of teaching and interactions with the ECPs in the ED. His wife enjoyed playing with the children who would come by the guesthouse. She took one in particular under her wing and taught him some sign language. The couple spent their anniversary with the mountain gorillas in Bwindi. I won't forget the scene of them testing themselves for malaria on the night before they left.

Another young resident came at the same time as this couple. She did a great job of teaching about online resources to the ECPs and left an iPod behind for them to listen to medicine-related Podcasts. After she left, a woman came to the ED with a basket full of fruit looking for her. The resident donated some money to have the woman's child's nose stitched up (since the mother arrived at the hospital without the money to pay for the ED visit) and the woman came back to thank her. We're hoping more physicians will sign up since nobody is scheduled to come for another two months.

It's fascinating to think that I know people who have had or even may actively have malaria. I may have even had malaria myself, despite being on prophylaxis. Most days I accumulate a mosquito bite or two. Some days I feel extremely tired after not having done much at all. But living in the tropics has its share of physical and mental demands. For example:

My traveling companion and I left in a mutatu at around 8:30. I was annoyed by her badgering to leave "on time" and she was annoyed by me being annoyed. We quickly got over it and began our long journey. By the time we got to Ntungamo, we had to switch taxis. The mutatu we were in had some problems that needed to be fixed beyond the work that was done for the 30-45 minutes we waited when stopped near a garage at the bus park. The conductor charged us 5000 shillings each and suggested we catch another mutatu to Mbarara. Our butts were already sore, but it didn't take long before we were in a taxi and on our way through a good amount of road works. Everytime I take a high-speed trip along the chaotic dirt roads of Uganda, I can't help but think about all the road traffic accident victims we see in the ED. Eventually, we made it to Mbarara around noon and were led to the Swift Safaris tent by some enterprising people waiting at the bus park. We sat in the chairs and waited for the next bus. When it arrived, a large line formed. Somehow, despite being in the back of the line, we managed to get on the bus and get seats. A woman with two little girls sat between me and the window while Anna had the aisle seat. After several hours, we arrived in Kampala's Kisenyi bus park. Anna's driver, Stephen, found us quickly. I said goodbye to Anna and was persuaded into taking a ride in a car with Edward, Stephen's friend who apparently once worked as a guard in Iraq. He proved quite an expert driver and got me to the hotel where I wanted to stay. But he asked for 50,000 shillings and I’d be damned if I paid him that much. I gave him 10000 (all I kept in my wallet) and explained that I needed to use the ATM to get any more than that. He told me to call him before I left Kampala so that I could pay him some more. (Which I never did.) I went inside the New City Annex and asked which rooms were available. The cheapest was a 3 bed room for 60,000 a night. I went back out and unsuccessfully looked around for more appropriate places to stay. Eventually, I hit the ATM and a place called Bon Appetit. Despite ordering an egg roll, they brought me a giant fried ball. When I opened it, there was mashed potato surrounding a boiled egg! After my meal, I went back to New City and got the room. I left in the morning refreshed and within walking distance of the Ministry of Internal Affairs. Once I got there, I waited in a chair under the tent they had set up outside. The office opens at 9 and I was early - eager to finally get my work permit after waiting three months. Once I had waited until 9, I went in the open door and was told to speak to Stephen, who seemed to be the man in charge there. He redirected me to speak with Dennis, the man who I spoke with the last time. Dennis was busy with another applicant, but soon turned his attention to me. I explained that I needed a work visa and showed him my materials. Unsurprisingly, they still found a reason not to accept the application. We had not submitted a registered constitution or permit to operate - something they told me that they had sent to our lawyer some time before I made the day-long journey to Kampala. Irritated, and knowing from experience that persistence was futile, I decided to get an early start on the long journey back to the country.

Days at the hospital vary to some degree, but generally involve me fulfilling requests made of me from: the ECPs; the organization's board of directors; or visiting volunteers. When in the ED or on the wards, I see firsthand that patients in Uganda have a level of problems beyond what we deal with in the U.S. Private hospitals are better than public hospitals here, but: we still run out of paracetamol syrup for the children in pain; we still run out of reagents to test patients for AIDS; splints are still made from used cardboard boxes; and the list goes on. An example of a recent day here:

I opened the Emergency Department, which involves: unlocking the doors and letting the cleaning staff in; pulling the computers out and setting them up for the day; and generating a patient follow-up form to check on the status of patients still in the hospital who came through our ED. After doing the follow-ups, I attended Kristin's presentation on accessing online resources. The ECPs have limited access to computers and even more limited access to the Internet. But the hospital administration has assured me that will change in the near future. After the presentation, I returned to the ED and taught JB how to enter charts into the database we keep of all patients that come through the department. Later, I took our phone follow-up list to a nursing student who was working an evening shift in maternity. We have an agreement with her to call and check up on patients who have been discharged from the hospital within a week and a half of being seen in the ED. While in maternity, I took some time to play with Joseph (one of the two orphans being cared for by the hospital) before putting him to bed. After this, I went to the ED and watched our staff deal with an obtunded ISS-positive (HIV/AIDS) young man whose foley catheter stopped draining and whose urethra was likely torn. The place was literally a bloody mess when we closed at 11.

In the day-to-day we get one little thing done at a time. "Haba na haba," as they say in Swahili. I am learning little bits and pieces of Runyankore, the local language, and making friends with locals at the hospital and in town. It's been difficult to tell whether people truly like me or just see me as an opportunity: perhaps someone that they can, in time, guilt into giving them money. In some ways, parts of Uganda are not so different from what I imagine it's like to be rich or famous in the U.S. And yet at times there is the random act of kindness done by someone who clearly wants no other reward than the feeling of knowing they did something for you. There is a sense of honesty about many Ugandans that many Americans could learn from. Whether it's a good, bad, or ugly truth, astonishingly few people try to deceive.

I'm trying to widen the path I walk between Oscar Wilde's definitions of cynicism and sentimentality. The price of living in such a needy part of the world is a constant test of the soul. And if I could lift every desperate person around me out of poverty, maybe I would. But the sad fact is that I can't. And part of me even knows that I shouldn't do things that way. What does that mean? You do people a disservice by paying them instead of empowering them. It is the lazy way to placate a guilt for being born into relative privilege. I'm proud of our sustainable emergency care model and admire the work that the malnutrition and HIV outreach programs are doing. Every week there are new cases of children with kwashiorkor or marasmus: many of them accompanied by young mothers who don't know the first thing about feeding a baby. So the program staff teach the mothers while they treat the children. And every week there are stories like Mary's: shunned by her nieces and nephews who won't eat off the same plate because she has HIV. People try to kill themselves with organophosphates (poison used by ranchers to kill the ticks on cows) because of the shame and depression that comes with the diagnosis and the disclosure. While HIV is no longer a death sentence, that doesn't keep people from trying to carry it out anyway.

What I want to accomplish is much more than a checkbook can do. Yes, it takes some money to fuel these seemingly grandiose aspirations. And in some ways there is a lot of money already in Uganda. But the money we spend in my program is a means to an end that I feel is nobler than the path most money in this world takes. That's something that I think leaders or rulers all over the world don't seem to get. Two roads diverged and ours is taking the one less traveled-by. One day, at the end of each road in Uganda will be an emergency department with highly-skilled emergency medical providers ready to handle just about any patient that isn't already dead. I would be delusional if I didn't recognize that day is likely to come long after I have gone. Still I keep Prefontaine's words in mind: that success is about the distance traveled and not how far we got.

There are times when I think of giving up. Days when I get so frustrated with demands and disillusioned with the lack of progress. Things move slowly and I don't always accomplish the goals that I set for myself and our program. But wiser and more capable people than I have attempted and accomplished far greater things. Misquoted yet meaningful words of Mohandas Gandhi, the Mahatma:

"First they ignore you. Then they laugh at you. Then they attack you. Then you win."

And if Africa could speak, maybe she'd say this: