Dr. Ruby Dunlap’s Uganda Fulbright Blog
\nWhile in Kampala on Saturday, I received a frantic text message from Bob: \u201cCome home and look at my stomach.\u201d He was indeed in a pitiable state with an intensely itching rash and welts erupting all over him within a few hours. He was having an obvious allergic reaction to something. We thought at first it might be the laundry detergent. Perhaps Amina hadn\u2019t rinsed his clothing sufficiently? I gave him what I had: topical diphenhydramine and also topical cortisone I had purchased at a Mukono pharmacy on the way home. I also had him take Advil PM which has close to 40 mg of diphenhydramine per tablet. That made him sleep and calmed the itching for a little while. But the rash kept growing and I began to get suspicious of the doxycycline. Antibiotics are notorious for causing rashes like the one Bob was having. I instructed him not to take any more doxy and re-washed all of his clothing, rinsing everything until the water was perfectly clear.<\/p>\n
\nBy Sunday, he was no better and as miserable, he said, as he\u2019d ever been in his life. He\u2019d been taking two tablets of Advil PM every six hours, a whopping dose of diphenhydramine. I asked him if he wanted to go to the hospital. He said no. Then I said he at least needed to see an MD who could give him some steroids to reverse the allergic reaction that was going on. I called Doug, one of the expats here with whom Bob has developed a friendship. Doug immediately offered to take us to the International Hospital\u2019s walk-in clinic\/ER in Kampala.<\/p>\n
It was Eid, the end of Ramadan, and traffic was exceptionally heavy for a Sunday evening but we eventually arrived at a well-kept modern looking building which houses the complex of the International Hospital in Kampala. This institution was originally begun by an Irish physician and is, according to Doug, the only hospital in Kampala which comes close to Western standards of care. We signed Bob in and were immediately seen; the place was not busy. We were glad at that point that we had taken Doug\u2019s recommendation to be seen on Sunday rather than waiting for Monday which would surely have been much busier.<\/p>\n
It was entirely staffed by Ugandans. A petite Ugandan nurse weighed him and took blood pressure and pulse with an automated machine. She didn\u2019t check his temperature. Then we were taken to an examination room where a pleasant young Ugandan physician was waiting for us.<\/p>\n
\u201cHow did you know he was Ugandan?\u201d asked Doug later as we were reporting to him what transpired. Apparently Africans from many countries staff this hospital.
\n\u201cHe said, \u2018Hmmm\u2019 just like a Ugandan,\u201d we explained. And Doug laughed, completely understanding. Ugandans have a soft, almost musical way of \u201cHmmmmm\u201d as they speak with one another, a non-verbal communication of sympathy which we find charming. This young man was definitely Ugandan.<\/p>\n
His concern was gratifying when Bob showed him his rash but, of course, neither he nor we could be completely sure what had caused it. He asked a few questions about anything new or different Bob had experienced since arriving in Uganda five weeks ago. Of course we\u2019ve experienced many new and different things; how could one possibly know which of the many had triggered this reaction?<\/p>\n
\u201cI\u2019ll give you some steroids to relieve your itching,\u201d he said. \u201cBut when were you last de-wormed?\u201d<\/p>\n
We looked at him, puzzled and even shocked. It wasn\u2019t a question we were expecting. It doesn\u2019t show up as a patient interview question in Jarvis or in any other of the health assessment textbooks I\u2019ve read. \u201cWhen were you last de-wormed?\u201d has some assumptions in the question which I doubt that few American clinicians make in the U.S.
\n\u201cWhat does de-worming have to do with an allergic reaction?\u201d I asked. The MD patiently explained that parasites sometimes have an antigenic effect especially in a host who hasn\u2019t ever had an infestation before. \u201cAnd you can easily pick up worms from anywhere and anything in Uganda,\u201d he said. Bob told him he\u2019d never been de-wormed. (In fact, Doug and his family routinely take a de-wormer every six months and many Ugandans de-worm themselves every three months.)<\/p>\n
\u201cI\u2019ll give you de-worming medicine and a non-drowsy anti-histamine,\u201d the MD said. \u201cBut first we\u2019ll give you some steroid.\u201d We headed for the room he pointed to and there watched while our petite nurse prepared the hydrocortisone, mixing the powder in a vial with sterile water diluent.<\/p>\n
\u201cThat\u2019s an awfully big needle,\u201d said Bob, the concern showing in his face and voice.
\n\u201cAre you going to give that to him IM?\u201d I asked. \u201cNo, I\u2019m going to give it to him IV,\u201d said the nurse. Now it was my turn to be concerned. I had seen her open the sterile syringe and needle package. There was not a glove in sight. We Americans glove when a patient\u2019s shadow crosses our path. The international world of clinicians must think we are paranoid. But soon the nurse left and returned with a glove. I felt a little surge of reassurance.<\/p>\n
She, however, used the single glove to create a tourniquet around Bob\u2019s wrist and then, slowly, inject the hydrocortisone, 200 mg, directly into a vein of his hand. Gloving for IMs and SQs I know is beyond what international standards require but I hadn\u2019t expected non-gloving for an IV. But there it was being done right before our eyes. She efficiently placed a BandAid over Bob\u2019s hand and we headed to the cashier and pharmacy. We picked up Bob\u2019s de-worming medicine and Zyrtec (which I thought not entirely appropriate for the kind of reaction he was having) and paid our bill, a total of 71,000 Ugandan shillings or about 35 USD for the entire visit.<\/p>\n
\u201cSave the Zyrtec and take your Advil PM at least in the evening,\u201d I told him. He somewhat proudly (maybe a cultural rite of passage?) took the de-worming medicine and later reported to us that he had shared this information with his Ugandan friends: \u201cI\u2019ve been de-wormed!\u201d The IV steroid did blunt the acute misery but the itching was still sufficient to make him complain over the next day.<\/p>\n
Tuesday, when Bob and my Dad did the shopping\u2014I had to teach all day—I sent a note with him to purchase 21 tablets of 1 mg strength prednisone at any Kampala pharmacy so he could take a tapering dose over 6 days. He came back with 21 tablets of prednisolone 5 mg strength. We\u2019ll do the tapering dose with that. I also wrote a note to purchase a malaria prophylaxis alternative to doxy, the weekly kind, a 4 week supply. He came back with mefloquine. One can purchase for the asking almost any drug over the counter in Uganda. We have found that handy as you can see, a bright spot in an otherwise trying few days.<\/p>\n
On the other hand, my psychiatric nurse student told me that witchdoctors routinely purchase antipsychotics and mix them with their own brews to treat psychiatric patients. \u201cSo of course the behaviors stop,\u201d said my student, \u201cand the family gets some relief. But there is absolutely no control over what or how much the patients get.\u201d Such is the other side of unregulated pharmaceuticals.<\/p>\n","protected":false},"excerpt":{"rendered":"
Dr. Ruby Dunlap’s Uganda Fulbright Blog While in Kampala on Saturday, I received a frantic text message from Bob: \u201cCome home and look at my stomach.\u201d He was indeed in a pitiable state with an intensely itching rash and welts … Continue reading