The aimless wanderer

At midnight, fireworks lite up the night signalling the 50^th anniversary of Uganda’s independence. Singing continued into the morning. I only slept about 4 hours but I can’t really blame the celebration. Four hours isn’t completely out of keeping for me back home and though I’m feeling a lot more tired than usual, I suspect it is the heat, dehydration and being anywhere near the traffic. Maybe it’s Malaria, but I’ll wait for more symptoms.

Security is a big thing in Uganda. Posters like these try to protect children from handling explosives. They also try to imply that a bomb can be hidden in an envelope.

The morning began early at Mulago hospital with the orthopedic team, including a contingent of surgeons from Vancouver on a similar mission as ourselves. They had been on hold in the OR for the last two days due to the autoclave (the sterilization system) being broken and had a back log of patients building up. Today we were rounding with their whole team to assess orthopedic patients that might benefit with plastic surgery. Last night’s celebration had brought with it a high number of causalities and a number of fresh injuries were on the ward as well as many that had been admitted for weeks. The Ortho ward was typical of the hospital’s  1960s era design and the condition reflected that. Paint hung off the walls in large sheets like a peeling sunburn. A large quiet crowd of family members stood in the hallway, banished temporarily from the wards during morning rounds, a daily occurrence. Large windows allowed in a merciful amount of light, giving the room an almost homey feel. Patient beds were packed in beyond capacity with stretchers placed where there normally would be the aisles. I remarked about the tight spacing. I was told this was nothing and in busier times, patients will be on mats on the floor between the beds. Twine dangled from the ceiling over each bed to hang fluids. A large sink for washing sat against the wall with no facet, simply a bucket of water, and emptied out a hole onto a grate in the floor.

Virtually every patient had the same wound and a similar story. Open tibia/fibula fractures, breaks in the two bones of the lower leg, typically inflicted by motorcycle crashes. These injuries would be managed immediately in the OR with Exfixes: Steel pins driving through the skin into bone and stabilized with heavy bars holding the fracture in proper position until healed. Internal plates and rods through the centre of the bones would be better, certainly the choice in Canada, but those treatments were not covered by the Ugandan health care system, so the much bulkier Exfixes were almost always the only option except for the privileged. Though the bones may be fixated most also had large wounds over the fracture site that remained open for weeks, managed with nothing by simple daily dressings. Healing time would be weeks to months and infection, particularly infection down into the exposed bone was common and disastrous. Plastic surgeons could perform flap reconstruction to cover these wounds, something beyond the skill set of our ortho comrades, but these could be long procedures and time was always limited. Many would have to wait and hope they healed the old fashion way. It is this protracted course in hospital that discourages many from presenting even with severe injuries, until complicating factors force them to come in days later.

One side of the crowded Ward 3A. After seeing this it is hard to sympathize with Canadian patients who complain about sharing a room with one other person.

One of the bigger shocks I had was seeing patients taking down their own dressings. Much of patient care is delegated to family and the patients themselves. Each one rushed to peel off rusty brown gauze loosened with squirts of saline, grimacing with pain as we worked our way down the line towards them. No scissors and no pain meds were available and limited nursing meant it could be hours until a fresh dressing could be placed back on.

This is Casualty (ie the ER), now relatively quiet after a busy night. What you can't see are the four corpses piled up behind the blue screen in the back just a few feet from where people are sitting.

It wasn’t all motor vehicles. One gentleman had attempted to get treated for his hydrocele (a benign but uncomfortable urological condition) but was refused by his wife who managed the household’s money. When he stole the money to secure the surgery, she promptly shot him in the leg. He will likely lose it but remained on regular dressing changes while his wound darkens and rots until he agrees to this management. Amputation, while clearly not popular in Canada, is severely stigmatized in Uganda. Even a partial amputation of a finger can label someone as a leper, essentially ostracizing them from their community. Sadly amputation can be the only option that will return a person back to regular life much quicker than longer courses of dressing care followed by a poorly functioning limb, but this cultural issue continues to make prompt management a challenge.

Another man came in with a disintegrated hand he claimed was the result of a tear gas canister going off as he tried to throw it away from a crowd of people. In reality he was an arms dealer that had misjudged a grenade’s timer in his inventory. The hand was unsalvageable and will be amputated.

A patient curled up with a surgical mask laid ignored. He too had a complex fracture but also active Tuberculosis. Ideally he would be in isolation on another ward but his injury was not considered appropriate for this transfer and remained where he was, a serious infection risk for everyone on the floor. I suspect he gets very little attention from the nurses in a system that is already woefully under serviced.

Small impromptu tent cities and cleaning stations pop up all over the hospital grounds as family do chores, not just for the admitted patients, but often for the other families members they have been forced to bring with them.

The list of patients went on and by the end we had more than we could possibly accomplish during our 16 days in the region, already fully booked with our own slate of patients. We would do what we could, running between ORs to perform what was needed before rushing back to the next patient.

With the national holiday in full swing, nothing else was left for us to do and we were leaving Mulago by 11am. Not wanting to waste the opportunity a decision was made to go river rafting. I wanted to go ATVing, but was narrowly out voted everyone to my one. Arrangements were made and our driver took us two hours west to the longest river in the world. The Nile.

Cows aren't sacred in Uganda so we are free to chase them out of the way with the horn as we please. Run Forest! Run!

 

The trip was cramped but uneventful. Our speed regularly slowed by waves of suspension destroying speed bumps, the kryptonite of Ugandan drivers. The road was dotted by the poorest looking shanty villages only to be out done by an even more ramshackle village. Brick makers ran their fires under huge stacks of fresh brick to cure their product. Abattoirs hung limbs and innards on wires, identifiable from a distance by the large flocks of birds circling over head. Children milled about in the mud, being kids, sometimes yelling out to our car “Muzungu! Muzungu! Muzungu! Give me money”.

A busy street crammed with BodaBodas, the common motorcycle driven in the country. BodaBoda likely translates loosely to "'imminent death or maiming".

A shot of a quiet piece of the Nile, fresh from lake Victoria, before it makes its long way to Egypt

Muzungu could be interpreted as Uganda’s somewhat derogatory word for ‘white guy’ (though I don’t sense any malice in its use) but translates more accurately to “aimless wander”. Now you see, I didn’t know this, because I’m an idiot (as previous noted). So for the last 3 bloody days I thought it meant Hello. I’m mean seriously. Kids kept running up and saying it as greeting. What am I supposed to think? I’m sure you know where this is going.

I’ve been calling people the white equivalent of ‘nigger’ for 3 days. 

I wasn’t very happy when I learned this but no doubt some people got a good laugh from it. I put this humiliation out of my mind as no doubt a new one would need the space as we approached the rafting company, Adrift, near the city of Jinja. A small but pleasant bar sat on a high cliff overlooking the ancient river. Rhesus monkeys were on the verge of over running the facility and would aggressively go for any small item not nailed down. Phones, food, cigarettes and hats were all open targets and we literally fled from the area to our rafts though I could have hung out with them all day if time allowed.

Munkays! These little criminals regularly terrorize the local canteen. I still fed them anyhow because they were cute. They also stole someone's car keys, but not ours. So it's funny. Very funny.

Adrift, features river rafting, ATVing and for those that want a quick death, bungee jumping into the Nile. Crocodiles cost extra.

The rafting trip was fantastic...to a point. The craft was large enough to accommodate the six of us and the New Zealand instructor who would call out orders and help steer the boat. The Nile was a lush and wide body, lined with steep slopes seeded with maize. Cormorants aired out their wings on the rocks, Egrets dove for fish and a black cobra slithered just above the water in parallel and terrified everyone. Children bathed naked at the water’s edge (yelling Muzungu of course, the little snots). A small otter poked its head up to check us out before disappearing.

Our starting point for the rafting trip. Given the need to always have your hands free, cameras were strongly discouraged, and given the ending of our trip this was a wise choice.

The rapids themselves were rated 4 and 5, which I NOW KNOW is quite challenging (again, idiot). We negotiated a total of 5 rapid areas separated by smooth, meandering zones. The first four gave us reasonable excitement but no real issues.

The last almost killed us.

As we approached the rapid that was known as ‘the Club’, because that is what it does to your head, we were cautioned that we might just possibly flip and to follow the safety instructions given earlier. This sounded kind of bad to me, but we were clearly committed and heading right for it. The group paddled furiously to keep speed, which in turn gave us crucial maneuverability. We crashed through the first sets of 5 foot breakers, flooding the boat and sending the front two paddlers off their seating but not into the water. We lost our point and glanced the Club, about 7 feet in size, with the left tip of the craft submerging. The down current sucked the two paddlers on our rear left into the drink but that was just the start. We surfed. Surfing in water rafting is when a boat is able to ride the retrograde current constantly flowing around the underlying structure, a rock in this case. If you think of a large rapid as a stationary wave, then you can imagine a raft riding this wave in one spot.  It is apparently a very sought after maneuver in river rafting and considered very advanced technique. From my perspective it felt as if we were going 80 km per hour but not actually moving. Like a scene in a movie during a helicopter crash, we spun on our axis as water sprayed from all directions. Our instructor yelled “Dump the paddles!” which at this point would do us no good and only become debris to clobber us with. I relayed the command with a slightly nerdier tone “Jettison Paddles!” to the others as we all cowered in the bottom of the boat. The episode lasted about 20 seconds  but felt like a minute. Some of us at the time thought we would pop out of the rip we were in to safety, but I knew what was coming. The right side, my side, caught the edge as the current tore at us. We flipped. Hard. The left side passengers were thrown up and out while I rolled under with the boat. The first thing I did was swallow a mouth full of Nile water. My thoughts went the bathing children and the advisory about not swimming in the Nile, let alone drinking it. My leg hung up on ballast in the boat. Even though I’m sure I was only 3 feet below the surface, it was dark. The current continued to pull me in all directions and I focused on freeing my leg. My lungs started to comment on the situation and I finally got free. The boat ripped off of me as the lower current pulled me down river. After a final spin from an undertow the darkness lifted. As I surfaced, I only got about .3 of a second to celebrate before I came face first with another huge rapid. With no time to get that critical first breath, down I went fighting the urge to cough up the inhaled water I had taken. Another 10 seconds and I popped back up in clear, smooth water. The capsized boat floated past while the three kayaking assistants cawed a strange noise with smiles on their face as they collected the others from the water. Apparently the noise was the victory call for a successful ‘surf’. We dragged ourselves to shore and walked up to the pickup area. We were pretty buzzed but clearly the instructor had set up the surf attempt with a group not ready or experienced for such a technique. It was irresponsible and could have killed someone. I gave him an extra $20 for the experience.

A calmer view of the Nile, where we enjoyed drinks and local food from a large guest hut overlooking a farm following our river raft.

It was dusk as we returned home. We had completely missed the days celebrations but that was probably for the best. For now I just wanted to get this Nile water out of my ear.

Tomorrow we go to OR. Time to get some sleep. I'll be in touch.