Everyone has tuberculosis, tuberculosis, tuberculosis!!!

I have so much to say...I am absolutely bursting at the seams. I just don't know if I can remember each and every detail. First, I have to say that yesterday was not such a good day for Hannah and I. We both had upset stomachs. With her permission, I am now allowed to post one of the extraordinarily funny stories. Today, we had lunch at a "fast food" place, which is essentially a regular restaurant. All I noticed was that they bring the bill quickly rather than keeping it until we asked for it. Anyway, after lunch, we went for a walk, trying to find the main local market. About 15 minutes into our walk, Hannah's stomach turned. So, we found the nearest place that looked like it might have a toilet--which just happened to be a grungy looking bar. We went in and found that it was filled completely with only men and was smokey inside (this is sort of odd because very very few Eritreans smoke). We asked the man at the front if there was a bathroom she could use, all the while Hannah appeared quite uncomfortable. I couldn't help but just die laughing--I know that I would not be laughing if I was in her position. Finally after what seemed like an eternity for her, but was probably only a few seconds, she was taken through the back room and into the bathroom. The "back room" per her report was a very dark smoky room with a pool table surrounded by 40-some-odd men who all looked shocked and very surprised when she walked through the door. Apparently bars like this one aren't a place that women go unless they are prostituting. LOL. Anyway, the bathroom was much akin to those in India for people who have been there with a hole that she leaned over to go. Not a very clean situation. So, she finished her business and came out regretting that she wasn't able to take a picture before another man came in. I will say, you learn a lot about the people you travel with. :)

A few things I have learned before I start rambling on about the medicine here. First, I the other day that Hannah and I went to the old Italian cemetery where, out of nowhere, several hundred men and women came walking through with all of the women wearing white. They proceeded to stop in front of what I now know was a church and the women split of to one side of the street while the men split to the other. Hannah and I were taking pictures and chatting while we were passing through this group. I now know that this was, in fact, a funeral. Now I feel like a real jerk. So, for anyone who travels to Eritrea, be advised.

I learned also that inflation here has been a huge problem since Ethiopia and Eritrea went to war in 1997. Back then, $1 US = $7 Nafka. Now, with legitimate exchange $1 = $14 Nafka, but on the black market $1 US = $40 Nafka. To give you an idea about how much the people here make, I learned that the nurses get paid about $700 Nafka per month. When Hannah and I go out to lunch or dinner the price is usually somewhere between $150-300 Nakfa for the two of us. This answers the question as to why we never see people eating in the restaurants, and instead they are all drinking coffee or tea. The lack of eating around me in some of the restaurants makes me a little bit sad and uncomfortable. The Eritrean people, though, seem quite happy.

Now, ten random comments before the medical rambling: First, Hannah and I are starting to get a little sunburned. I think it is time to break out the sunscreen. Second, the fruit here is really very good, and the juice is even better. Third, the daily morning singing coming from the Mosque here is really starting to get annoying--it wakes me up even with earplugs. Fourth, the children here all wear uniforms to school and are super-cute. Fifth, its not a very good idea to give the beggar children stuff--they will haunt you. Sixth, Hannah and I saw a man pooping on the sidewalk today. But don't worry, I snapped an aftershot on our way home. Seventh, generally this city is actually very clean (don't get the wrong idea). Eighth, I can't wait to have a coke zero when we get to Frankfurt in 3 weeks. Ninth, I am very thankful that my hotel has a hair dryer. And finally, tenth, I am very impressed with the Eritrean's lack of excess here (everyone is skinny, no trash, no excess waste).

Today we met once again for morning report as we did yesterday at 8am. The first case today was a shocker. A 63 year old female with a history of coronary artery disease came in with "sharp" left sided chest pain that radiated to her back. She was admitted to the ER for rule-out ACS and was treated with "MONA" (morphine, oxygen, nitroglycerin, and aspirin). Her chest x-ray was unremarkable. When we got to the EKG, the intern explained that there were T wave inversions. So, we took a look--there were very very very obvious ST elevations in leads V1-V3. We explained that this was a STEMI and this is someone who would ordinarily be treated with immediate catheterization in the US. But, alas, there is no catheterization here. Although they do give heparin drips here, she was not started on one, but she was now pain free. I did get pictures of her EKG, which by the way is printed out as a telemetry strip rather than on a regular sheet of paper.

After report we went back to the medicine floor and I rounded once again with the intern with the attending on stand-by for consultation if needed. For the first time today, on rounds I actually felt useful. She presented to me a short blurb about each patient and I manically went through the vitals, which hang at the end of the bed, the chest x-ray, which are hidden underneath the bed, and the labs which may or may not be completely documented in the chart. Each patient here is remarkably sick and I feel like there is very little information to go on to make a firm diagnosis. Additionally, it is extremely hard to make day by day decisions on these people when there aren't up to date labs on people. Despite this, I did feel like I made some useful patient management contributions on rounds today.

There are interesting things here that are just NOT seen in the US. Case and point, there is a man who presented with fevers, hepatosplenomegaly (large liver and spleen) and ascites whose leishmaniasis testing returned positive. He has since been started on treatment for this with sodium stibogluconate, which is a drug that, until this trip, I had never heard of.

Another patient who came in just today is a 38 year old woman (who, by the way, looks like she is 70) who presented with chronic cough productive of very foul-smelling sputum. She came in because the smell had gotten so bad and the sputum was copious. She has had a chronic cough for 10 years and was diagnosed 4 years ago incidentally after she had a chest x-ray for a preoperative workup. She has been treated with multiple rounds of antibiotics, which here means penicillin, amoxicillin, and ceftriaxone. She has had fevers at home, but was afebrile on admission to the ward. Her last antibiotics were 3 months ago and since that time she has been having worsening symptoms. She was treated for Tb 3 years ago and received 8 total months of treatment. Her Chest x-ray (and previous ones) shows an obvious abscess in the right mid-lung with an air-fluid level. I should also mention that this patient has some wicked clubbing.

I feel like everyone here has Tuberculosis. Everyone. I feel like I should really be wearing my N-95 face mask constantly while I am in the hospital. I learned today that Eritrea is a place where the BCG vaccine is given because it is such a problem. Every patient that I talk to, the first couple of questions include "are you having cough" and "are you having night sweats or weight loss". If the answer to either of those is yes, then I err on the side of wearing the mask. Case and point, one of the patients I admitted yesterday is a young female with a history of generalized weakness and edema. I'm not going to go into everything about her because she has a LOT of problems, but her rapid HIV was positive and she has been coughing up blood for several weeks. Thankfully, the second question I asked was about cough--then I put on the mask. Maybe I am too paranoid, but I just feel like everyone here should be on isolation.

In writing all of this, I should say that the diagnosis in many of these patients is something that is jumped to very quickly without a whole lot of consideration for differential. If something fits, then that is what it is. No questions.

That being said, I saw a patient today who really had an impact on me. I think it was the way that he looked at me. He is a young man with a history of apparent Tb pericarditis treated for Tb in both 2008 and 2010. He came in with volume overload and shortness of breath. An echo was done which showed a "restrictive filling pattern" (that is all the echo reports here say--there are no number, no EF, no nothing else). If this is the case, then I am presuming that he may have constrictive pericarditis now from his previous infection. And here, there is really nothing more that can be done. There are no cardiac surgeons here, so any sort of pericardial surgery is out of the question.

Another girl on Hannah's side has severe MS from rheumatic heart disease with resultant left sided failure, pulmonary congestion, right sided failure, and finally hepatic congestion, cirrhosis and ascites. There are a lot of reasons living her for her ascites, but it seems that in this case, her cardiac disease is the most likely. She is someone that we saw on the first day--we were both astounded by her crazy murmur. I don't think I have every heard or seen a 5/6 murmur, but now I have. She has an astounding thrill that can nearly be seen when looking at her chest. Needless to say she is hyperdynamic. Her ascites from her liver congestion also is quite honestly about the worst I think I have ever seen. Its remarkable that she can breath--she looks 15 months pregnant (thats a lot!). Unfortunately, I don't think there is much anyone can do for her now, so she is just sitting on the medicine floor without a clear plan.

Another patient we saw on the first day was a young man with Cushing's disease. He presented with hypertension and weakness as well as cool physical findings. He has facial plethora, moon facies, lower extremity edema, and most of all, the most amazing striae that I have ever seen. Not exaggerating, I would say they are on the order of 2 cm in thickness and run the entirety of his abdomen. Hannah learned today that he also has them on his butt. He did have a CT scan (because MRI isn't available here) which showed a macroadenoma. Neurosurgery was consulted today--funny story there--for consideration for surgery. Meanwhile, he is just hanging out on the wards, walking around, getting BP meds, and watching TV.

I have to say that many of the patients who are here in the hospital don't have a clear defined plan of care. Many of them don't necessarily need to be in the hospital, but are kept for various reasons that still aren't completely clear. On the patients without a clear plan and no appropriate treatment (my 2 cardiac patients mentioned above), I am still not sure what will happen or what usually happens for them. I'll keep you posted.