Kampala Calling

After an unplanned, frustratingly exhausting 30 hour tour of Africa courtesy of Egypt Air which included such notorious airports as Cairo, Dar es Salaam, Kilimanjaro and yes, eventually Entebbe I am now back in Uganda! I had the most surreal experience during my 5 hour tour of the Dar es Salaam airport. Having come through Madrid in Europe, many of my fellow diverted continent-touring comrades were from Spain. So when we were grumbling and groaning about our predicament, naturally, I spoke Spanish, however, when we were given our breakfast coupons (yeah for chips and chicken as the only option for breakfast at 5am!) I ended up sitting with a lovely Tanzanian bloke who works as a lawyer at the Arusha Human Rights Tribunal who had also come from Madrid, so naturally, I switched to Kiswahili….much to the confusion of my newly acquired buddies from Barcelona who hadn’t been able to place my Spanish accent to start with. Surreal. I was post-call equivalent as it was which probably heightened the dream-like nature of the event.

I got to the guesthouse from the airport at 3pm, showered and dropped by the office to check in with our research program assistant. Our to do list was long and I just wanted to pop by, say hi and outline our plan of attack. I found not the woman I had seen in January, no, alas, there was a very very pregnant woman sitting at the desk….very. The baby squirmed visibly across the tautness of her belly beneath her clothes. Although she was expecting me, she looked rather….well, sheepish I suppose. My mzungu self blew up inside of me, why on EARTH would this not be something you would mention to the research program so they could make some adjustments?! But FORTUNATELY, the lovely culturally sensitive, accepting inner being took over, congratulated her exhuberantly and enveloped her sheepishness in a hug. I need to zen out and get with the African way of doing things. When I asked how the pregnancy was going she said “Sheona, why do I feel these contractions every 20 minutes, I don’t understand?” She’s due in three days…life happens, awesome, complicated, real.

As I sit writing this the clatter of the monkeys scurrying mischievously across the tin roof startles me occasionally. I’m staying at the Mulago Hospital guesthouse for a few days before moving into my apartment. The guesthouse consists of two, not quite rustic, not quite luxurious house-like structures set on the slope of Mulago hill surrounded by deep green grass scattered with brilliant purple jacaranda blossoms fallen from the trees and the occasional sharply textured globular Jack fruit, cracked and oozing its sweet white nectar onto the surrounding celebrating ants. In addition to the resident monkeys there are a few large Ibis who wander, searching for bugs in the grass with their long smooth beaks. I’m exhausted, overwhelmed by both the logistics of research and the epi and stats MPH courses that I’m starting. But I’m also overwhelmed by gratefulness, for the opportunity to be here, the thrill of the daily realities of life in Uganda and excitement for the next phase of the project. Life is crazy, but good.

MIA for a Year

There was an intense yet fascinating two week at Hopkins. I’m taking a part-time Master’s of Public Health that will allow me to spend the majority of the year between Uganda and Ecuador working on a cervical cancer research project. The John Hopkins School of Public Health turned 95 years old this year. A world-revered institution that churns out research at an incredible rate and who’s motto is (seriously folks) “promoting health, saving lives….millions at a time.” I can’t take them seriously. The Hopkins medical center is a state of the art institute of modern medicine situated splat in the middle of a ghetto. They shuttle us back and forth from the residence to the medical campus for safety reasons. Looking out the smudged window of the bus I see row after row of brick houses with boarded windows. Is it not a deep irony that this desperately poor and crime ridden community, somewhat of a public health disaster, surrounds one of the world’s leading school’s of public health? With disproportionately high rates of HIV in the African American population that lives there and statistics that show if you are an African American man you will die 30 years before your Caucasian counterpart it makes me suspicious of the program I’ve just signed on for.

Regardless of all the irony and healthy ego of the institution, I am awed by my classmates. I become quick friends with Sara, a young soft-spoken Southeast Asian pediatric ICU physician from Stanford who loves climbing and road biking and has set up a peds ICU in Kathmandu. One of my small group members was an adviser on the Bush administration’s bioethics committee, needless to say he had to find a new job when Obama came in and is now a health policy analyst at the NIH (National Institute for Health). The list goes on, but I quickly learn that those who surround me are without a doubt the biggest resource I have.

I returned to Vancouver for a frantic two weeks of baby catching which completed the requirements for my Baby Mill Chief rotation! Although unlike gyne oncology, it was far from passing with flying colours, I met expectations. I’ll take that and run. I pray that I never eat my words in the future but if I EVER sign up to work at the Baby Mill when I’m done residency someone please slap me, churning out babies at that pace isn’t good for my soul. July 1st was my last day of call at the Mill. A few of my favourite nurses took me out on the weekend and said the loveliest of things about how much they liked working with me, they can’t possibly have any idea how much it meant to hear that.

And now for a year that will beat to a different drum, I won’t hear the rhythmic thumping of the fetal heart Doppler, the reassuring snapping of sterile gloves on my hands or the smoothness of a scalpel sliding through skin. I’m excited, ungrounded and apprehensive all at once. Uganda, Ecuador, Egypt, Spain…oh yeah, and Baltimore, here I come.

Maternal Death and iPhone 4s

It was a standard beginning to Sheona-style traveling. I book a flight post-call…why not, it’s a wasted day anyway, right? Packing in a mad rush, semi-comatose through security and then exhausted I finally slide into my seat on the plane. Complete relief envelops me and I promptly pass out. I awake foggy brained, dry mouthed and with drool caked down the side of my cheek as we begin descent into Toronto. The perfect opportunity for the lovely Nigerian couple (of ‘traditional African build’ as Mma Ramostwe would say) beside me to engage in conversation. They are profs in Washington DC and think Hopkins isn’t such a bad school for me to go to.

After a short flight on a plane smaller than the ones they use to fly to Yellowknife I find myself in a taxi in Baltimore. Ayaad, the driver, is originally from Eritrea.

You know where that is? He turns with a wide smile of surprise on his face.

Ayaad is driving taxi part-time while finishing his engineering degree. We discuss East African politics, Somali-Ethiopian relations and after discovering my profession he tells me the story of how his mother died while birthing his younger sister.

You see, they just don’t have the technology… so women die during childbirth. He explains.

I suggested it is perhaps not the technology at issue but access to it.

We reach the hotel and I hand him my credit card. He pulls out his iPhone, plugs in a little white box to the top and swipes my credit card. I sign the screen with my finger and he emails me the receipt. He notices that I’m quite impressed by the transaction.

You haven’t seen this before? Oh, you much not travel much!

Oh Ayaad, if you only knew.

I need to download the Preventing Maternal Death App.

Chief what?!?

Their times of birth were 1526h, 1527h and 1528h. Three babies in three minutes. Her life has been suddenly changed from the quiet days of strict bed rest up on the ante-partum ward were she was learning to knit and working on putting a quilt together. Now hurled into the reality of having three premature babies, one of which weighs less than a kilogram. She is a recent immigrant to Canada, trained as a nurse. She and her husband have a one bedroom basement suite and he works the graveyard shift at Tim Hortons every night. The Canadian dream, eh?

Somehow I have become a chief resident. No, contrary to life on Grey’s Anatomy, this is not a prestigious position you apply for, it’s a mandatory part of a residency in obstetrics and for the most part I hate it. Your junior residents have an obligation to dislike you because you make the call schedule, and no matter what, it will be horrible because of the sheer volume of hours they have to work. They will always consider it unfair, regardless of how many hours you invest in planning ahead, spreading out their call days and weekends. Your attendings somehow hold you responsible for any case that goes awry, either because you didn’t show up for it, or because you did. Oh yeah, and they don’t like how you make the call schedule either. Nobody is happy.

But enough whining, what I love about being a chief resident is the staff clinic. A clinic run by the chief residents for women who don’t yet have health care coverage. The women are mostly recent immigrants and refugees who go through a financial assessment to qualify to be there. Occasionally they manage to jump through the hoops and a patient shows up with a purse worth several weeks salary but for the most part these women are facing huge barriers to getting care. Not only financial stress but imagine the terror of arriving at a hospital in labour and not speaking a word of English. I love the colourful spectrum of languages and cultures that traipse through the clinic, their faces containing such depth of heartache and hope that it fills me with both. This clinic is a glimpse of why I chose to embark on this journey.

The obstetrician who oversees staff clinic asked what type of patients we would like to see referred, then she laughed as she remembered, “That’s right, you don’t like rich people at all, I’ll try to screen them a bit better!”

Orchids, 70-year olds and Dengue Fever

And then I went from -32 to +37. Ten and a half hours driving through blizzards and freezing rain with logging trucks, not everyone’s idea of a fun day. Then it was my mom’s 70th birthday. She is a phenomenal woman my mother. Its hard to put into words the mentorship she has provided to dozens of people over her career. Her passion for the marginalized often setting her apart from the right wing Calgary community she worked within, who often preferred to turn a blind eye in self-righteous indignation to the needs of the global poor as well as those on their own front step instead of being faced with the discomfort of inequality. But I digress, point is, she’s amazing. After the big party we hopped on a plane together, through Bogota to Guayaquil in Ecuador and then on a bus to Machala, the malaria and dengue capital of Ecuador! Then with some trepidation we put mom on a bus to the Peruvian border, where she caused a minor riot, watched the bus drive off with her luggage and eventually got to the airport in Tumbes to get on the newly minted Peruvian airlines on a flight to Lima for another birthday celebration with my sister. She’s decided to celebrate turning 70 all year, this seems like a good start.

Why come to Machala you ask? Well, the spousal-unit does Dengue fever research here. People describe it as Donde el Diablo perdio su poncho (where the devil lost his poncho). But I must say, it does have a certain sweaty-banana plantation-mango paradise-type of charm once you get a handle on the 37 degrees part. Last weekend we went on a hiking trip through Podocarpus National Park. In the lowlands of the park there were hundreds of orchids in dense humid forests, with plentiful rivers and waterfalls to jump in for refreshment from the oppressive heat. The highlands had amazing bird life and a bit too much of an adrenaline rush in a climb and descent along a steep ridge for several kilometers. Although the view was breathtaking on both days we hiked about 8 km longer than our legs were happy with. We’re turning into old farts.

Back at work this week in Machala, I’m working on a manuscript but did get the opportunity to go to a Dengue community meeting in one of the communities the TDR project is being run in. There was a certain irony in the fact that I got eaten by mosquitoes for the duration of the evening meeting…oh dear. Amazing to see how the project actually works on the ground though.

Eau De Prince George

The sweet yet sour smell of skim milk powder, part chemical, part organic. It wafts across the valley and settles thinly over everything, permeating the environment. Apparently its from the pulp mill, the billowing towers you can see from most parts of town. As I open my front door in the darkness of early morning I get smacked in the gizzard both by the sharp, biting cold accompanied by the tangy odour singeing my nostrils. I've nearly been up here three months now, granted with a short interlude in Uganda, but it will rank among the best rotations of residency.

Its a strange medical community Prince George, like none other I've seen, they may have missed a memo. There's no open shaming and ridiculing of residents. No pointless scut work to help you build character. The attendings genuinely seem to care about your learning. Strange, very strange. Invites to obstetricians' houses to 'drop by whenever just to hang out', you tend to see your attendings in a different light after competing against them and their kids in Wii dancing.

I didn't know why everyone seemed to care about the HUGE solar flare that happened last week. Northern lights dumb city kid. Shimmering fluidly across the sky, only fading next to the full moon. PG is positively charming, I listetned to a home grown white boy reggae band on Friday night, not something I would have done in Vancouver. Although, unfortunately I started mocking them with the lead guitarist standing right behind me...shoot. Next to my front door are a pair of Sorel boots, snowshoes, hockey skates and cross-country skis...it just depends how much time I have and how cold it is.

The cold was a shock to my now pansy-fied Vancouver-accustomed system and the irony of spending an hour digging my car out of a snowdrift so I could go for a swim in the local pool was not lost on me. Also, FYI, snowshoeing at -32 C is not recommended without significant toe frostbite protection, my eyelashes were fluttering with ice at the end of it. But the benefit of the all too accessibly snow is that 15 minutes after you get off work you can be out at Otway skiing for a few hours, either as the sun sets, turning the clouds yellow to peach to brilliant orange or under the brightness of the stars above.

Whereas at other community rotation sites where residents have the highest chance of being called a ‘tard’ (as in retard) or ‘cretin’ for their OR skills, in PG you have the highest chance of being called ‘sweetie’, ‘buddy’ or ‘love’ and fed by the frequent OR ‘food fests’ to within inches of your life with delicious homemade dishes. I felt affirmed, respected and embraced as part of a team. Although I didn’t expect it, I would absolutely work here in the future if given a chance, my soul fund has been topped up.

And now back to the big smoke and the baby mill…well, with an Ecuadorian interlude that is.

My Screaming Ovaries

There is a divine and messy moment after birth. I peeked my head around the door to see if the baby had been born yet. It was one of those consults that causes obstetricians to go into early retirement. A recommendation for assisted delivery had been made, and it had been declined. One can only step away and wait. Regardless, the parents were lovely, both well along in successful careers.

So it was with a wave of relief that I witnessed this tender moment. An exhausted but exhilarated mother holding her naked child against her chest, the father leaned in close, tears streaming down his face, tenderly kissing the top of his daughter's head, telling his partner how much he loved them both.

But the pediatrician walked back and forth restlessly, the babe had to go to NICU. She was much sicker than expected and needed multiple interventions. Later that night I found out baby had been urgently flown down south for further care. Mom and dad were going with.

Dread. Nausea. Sadness. Guilt. I can't find words to describe the feeling. Should I have made a fuss? Demanded delivery? Pulled the "your baby will be gorked if we don't deliver it now" line? Would that have made any difference? No one can say.

The next day I called the NICU down south to see how baby was doing. Not good. On ECMO (a heart-lung machine for babies) with uncontrolled pulmonary hypertension. The baby had a common trisomy and the parents were giving her up for adoption.

My ovaries screamed in unison and my heart exploded. I jumped in my car, drove the 10 hours down to Vancouver in the snow, only wanting to wrap that baby in my arms and love her for however long her life might be. My soul aching, thinking of that tiny baby all alone in a NICU far away.

Okay, I didn't actually get in the car. More just a compulsion to do so.

Damn ovaries.