Wednesday 2/28/24 8:30pm

Hello Friends!

This will be a long one! I do not know when the Wi-Fi will be consistent enough to send this, but I have decided to at least try to write a bit daily and possibly send it all at once at the end of the week. 

Monday night we were joined by 4 Americans who would be joining us for a short portion of the Surgical Camp. They have their own NGO, specializing in Urology, and are hoping to work in partnership with Bulamu.  We lost power multiple times during dinner, then out for good around midnight. The rain did not return, so my room was hot and muggy, especially without the fan. My travel fan was only partially charged, so that did not get me through the night either. 

Breakfast on Tuesday was a good-natured, but groggy endeavor, all of us desperate for caffeine, and commiserating about our uncomfortable evening. After breakfast, we all loaded into the van and drove a few minutes to the surgical camp.

The Ultrasound room was a portion of one of the waiting rooms, closed off by a newly constructed wall and door. There is an exam table and a regular table, for two ultrasound stations, and small tables to hold our machines and supplies.

This is how the Surgical Camp is organized, which is different from when I am training at clinical facilities...Patients see a clinician first, where they are triaged and given orders for labs, ultrasound, and/or ECG if needed, before returning to the clinician to receive treatment and/or possibly continuing to surgery. Not all patients get an ultrasound, many are treated, or go straight to surgery, or are referred and taken elsewhere for treatment not available at the camp. The Bulamu surgical Camp is incredibly well organized, with large banners at each station/treatment areas, and plenty of workers with bright yellow vests always on the move throughout the camp, offering assistance, delivery messages, etc... This was a last-minute request (by Bulamu) for use of our machines and additional sonographer assistance, and I offered to fund my part in order to show them what a potential partnership with ITW could offer. 

When a patient comes to me with an Ultrasound order, I look over the paperwork, with the help of a nurse or the Radiographer working with me, scan the necessary exam, write a report, giving results, diagnosis and any possible differentials. I may have explained this, when writing about my prior trips, but a Radiographer in Uganda is not the same as a Radiologist in the states, although we do have Radiographers also. Radiographers are legally allowed to diagnose patients based on imaging, but the education to do so in the US is much more intensive, often requiring mentorship with a Radiologist, as well as additional education. Radiographers in Uganda also require more education, but not to the extent as the US. Sonographers in Uganda, I have observed, also have much less education and limited clinical experience comparatively. This is mainly due to the lack of resources, which is why I do this volunteer work. I had to apply and get approved for a Ugandan Practitioners license in order to write my own reports, which is especially necessary at the Surgical Camp, and also at any of the training locations I will be working at, where a Ugandan Clinician is not available. This is often a challenge for Sonographers coming from the US, because it is illegal for us to give results and considered "diagnosing without a license". Side note, this is why your Ultrasound Tech gets annoyed when you ask us to give you results, we could lose our license! The comfort level is also quite varied, depending on the skillset and experience of the Sonographer. I am quite lucky to have had experience and education in Veterinary Medicine, because I was trained to "think like a doctor", spending extra time with my patients to complete a medical history, and using that history along with symptoms to come up with a list of differential diagnosis (DDs). Although at home I do not share DDs with the patients, I do often list them on my Ultrasound reports that are read by the Radiologists. I truly believe that I am responsible for being the eyes of the Radiologists and try to think like they would if they were able to watch me scan in real time. It is one of the most challenging aspects of my job and I big reason why I love it so much.

So, moving forward, after setting up my station I scanned 24 patients in approximately 7 hours. This is a pretty crazy number of exams in that time frame, and I try to save some time by dictating measurements to the nurse and then quickly writing up my report while the nurse puts the patient in the waiting area and gets a new patient on the table for me. I do not save any images, no one is available to read them, so my interpretations are made in real time. The language barrier is a big challenge, and often medical terms and abbreviations are different from what I am used to. My nurse is not a Sonographer, so I have to train her how I want measurements written out, etc... deciding on the fly if it saves more time for her to do it, or for me to stop in the middle of imaging to make notes. 

Rain creates additional challenges, because many of these patients are traveling a great distance to get to the camp, often by Boda-bodas (motorcycle taxis). The roads become treacherous, and everyone must drive much slower or wait out the rain altogether. Then the rain stops and patients start to arrive again. 

After returning to the hotel, we joined the other Americans for dinner on the patio, relieved that the rainy day brought the temperature down a great deal, finally retiring to our rooms around 9:30pm. 

Wednesday: I wish I could say I slept better Tuesday, due to the cooler temperatures, rain throughout the night and a constant fan running, but no such luck! I have some chronic pain issues caused by prior injuries, and a long shift standing on concrete, combined with a rock-hard mattress means I am often woken up in the night. I bring along OTC pain meds and tiger balm back patches, but I gave up trying to go back to sleep and got up at 4am. After some stretching, I started a few lists of project ideas bouncing around in my monkey brain and joined the crew for breakfast at 7am. 

I am a bit of a bull in a china shop on the best of days, and it only gets worse when I am tired. First thing this morning I managed to slip and fall in the mud, stepping over a deep crevice, leaving a beauty of a bruise on my knee and scrapes along my lower shin, then managed to crack the back of my skull on a large metal cage that hangs from the wall in my exam room. Imagine a less graceful version of the 3 stooges! Allan was horrified, I managed to laugh about it, headache and all. 

I scanned approximately half the number of patients today, but saw twice as much pathology, so the day was much longer. I saw my first patient around 8:30am, worked through lunch, and got back to the hotel at 7pm. Some of the pathology is so fascinating for me, for instance there is a condition that I have never seen in 12 years of scanning at numerous hospitals all over the US (Canal of Nuck), and I have seen it twice in 2 days. Others are emotionally draining because they are more common, but the patient may not have access to treatment here, where in the US they could be easily treated. It's all so incredibly rewarding, both the opportunity to learn and see something novel to me and also the opportunity to utilize the knowledge and skills I work so hard to acquire when I am back home. 

The power has gone out twice this evening, luckily not for long, but I think I will cut my losses, take another Aleve for my ever-increasing injuries (ha-ha) and log off for the night. Sleep well!

Thursday: Up and at it again! The Bulamu team meet daily to discuss the prior day, manage any problems and make improvements moving forward. This morning, the Radiographer came to me with a criticism from one of the ordering clinicians. The clinician ordered an Abdominal Ultrasound, which I did, but was upset that I did not also do a Pelvic exam, which was not ordered. When I asked why I was supposed to do a pelvic exam, when he only ordered an Abdomen, I was told that I was supposed to read through the clinical notes and perform any exam that was necessary...even if it wasn't ordered. 😕 This is definitely something that is not done in the US. 

My morning started out a bit slower, but still steady, and then after lunch it blew up. I had to take my machine over to the Pre-op Surgery center to scan 3 different emergent patients. One patient had to be rushed to the nearest hospital by ambulance based on my findings, the 2nd needed emergent surgery (again based on my findings) that could be handled at the camp, and the third who needed imaging to confirm there were no secondary issues that might complicate the surgery. 

The pathology that I found reminded me of how much I love working in a high triage and trauma level environment. I love the pressure and the challenge, the collaboration with the surgeons, and seeing a direct consequence of my labor. It's so fulfilling, rewarding, and meaningful. I am a purpose-driven person and thrive when I feel like I am helpful. I am also the type of person to obsess about my own mistakes, overthink and often torture myself for not being good enough and second guess myself almost constantly. Yin and Yang. The Good, the Bad, and the Ugly. Enough therapy! 😂

Towards the end of the day, Allan was acting as my medical assistant, my usual nurse and the other Radiographer were off somewhere. Allan would grab the paperwork of the patients waiting for an ultrasound and triage them so we could put them in order by how emergent their case was. He went out the door for my next patient but returned with a young woman who had arrived doubled over in pain, crying, and barely able to get on my exam table. The moment I put my transducer on her, I could see why...I saw a large 15cm loculated cyst along with a 13cm complex mass, both completely filling her pelvis to above her umbilicus and completely obscuring her pelvic organs. She most likely had ovarian torsion, or it could have been just the size of the masses causing her excruciating pain, either way this poor woman was headed to surgery.

Had she been an outpatient at my facility, we would have called down to the ER, a team would have brought a gurney, and she would be loaded with meds and fluids while ambulance transport was arranged to take her to our main hospital. Here at the surgical camp, while this woman had a clawlike grip on my hand, Allan had to make multiple phone calls to find the Radiographer, who then wanted to see for himself (that's another story in itself! The Patriarchy is alive and well here) before walking back over to the surgery area to talk to a surgeon. He came back with a couple of guys who wanted her to GET ON THE BACK OF A BODA so they could drive her the 50 or so yards to the surgery suite. I said, "ARE YOU KIDDING ME???" (The response was that the ambulance was on route somewhere) "You can't CARRY her over there??" Response: It's fine, the women do this all the time, let's get her over there instead of wasting time talking about it." Those of you who know me best can probably imagine the control it took me to bite my tongue. As they started to get her off the table, she grabbed my arm, dropped to the floor and immediately started vomiting in the trashcan, all the while the men were telling ME to let HER go so they could get her across the road. I did say "I think you are confused about who is holding on to who, help me get her up!" which they finally did. I had to stay behind to finish the last patients. 

Now I share this story for multiple reasons. The first is to highlight the strength of these African women, which I have mentioned so many times on prior trips. The mental and physical load that these women must carry on a daily basis is humbling at its best and heartbreaking at its worst. As frustrating as this entire scenario was, it also is a testament to how much these people do with so much less than we have. Having met two of the surgeons earlier in the day, one of them an African woman that stunned me with her obvious intelligence, compassion and efficiency, I knew this woman would be in more than capable hands. It also highlights the constant challenge I am faced with when I am on these volunteer trips, the line that I walk between being culturally sensitive and respectful, while still maintaining my ethical compass of putting the patient (especially my women patients) first. Which battles do I chose? Which hill do I want to die on? Will this battle make a difference or is it a waste of my energy? When do I acquiesce and when do I throw down? And this is only the first of 10 weeks I will be here, potentially faced with these types of challenges.

Its a lot to think about. With that I am going to call it a day. Wi-Fi is out, so I will try again tomorrow, or you will get a massive post on Saturday. 😊 Thank you for joining me on this adventure and for allowing me to unburden some of my Monkey Brain.

Much love, Jo/MB

**I'm am trying to attach a number of photos, but I don't think it's going to work. More photos to come!*