First day on the ward...

First, I would like to say that I am quite thankful that the internet is working tonight. I am trying to send e-mails and update things as quickly as possible to capitalize on it. Needless to say it is painfully slow and only works when it feels like it. Anyway, today we were able to get our documents taken care of and were able to finally start on the medicine wards. We first met Dr. "Z"--the names here are just too much--and went along with him rounding on the half of the ward that he had today. To explain how it is structured here, Orotta is the a referral center caring for patients who were transferred from other hospitals as well as patients who come in from the ER that need to be admitted. There is essentially one floor that is split into two sides, 3A and 3B. 3A has around 35 beds while 3B has around 25 beds. There is an attending assigned to each side who oversees the work of an intern who is a 6th year medical student. The intern is essentially responsible for all of the work, orders, admitting, etc on the medicine ward. From what I gather so far, the intern and attending only round on one-half of the patients each day alternating days, so each patient only gets seen every other day unless they are really sick. Daily notes then obviously are also only written every other day on each patient. The interns also have the responsibility while on their medicine "attachment" which is what they call it of being on call for the ER every third night. When they do this they are on and cover the ER as well as any questions that come up on the medicine floor. Much like old school residency training, they don't get a day off, ever. The schedule is the same as for everyone in the country though--they generally get here around 8am for morning report which is where the patients that were brought in overnight are presented. They they take a 2 hour lunch which goes from 12-2:15pm and they admit then from 2:15 to around 4:00pm. The attendings are passionate about leaving at 4:00pm and aren't necessarily there for the interns on a daily basis, but are available via phone if needed.

Anyway, so that is the background...the medicine here is beyond different from that in the US. It is somewhat laughable actually at exactly how different it is. When we are taught to think about a differential diagnosis in the US we think of one set of problems--for obvious hepatitis for example--acute hepatitis>/= alcoholic hepatitis>drug induced>autoimmune, etc, etc. Here, the differential is, well, depending on the patient and where in the country they are from schistosomiasis, leishmaniasis, acute hepatitis, Tuberculosis, or in several patients in the hospital INH toxicity from Tb treatment? Say what? I literally have not thought about schistosomiasis or leishmaniasis since medical school. But, as soon as I finish this post, I plan on reading all about it. I found that one of the main questions that is asked in these patient is where they are from because that may change significantly which of the two is considered.

On another note, I brought books with me to study--a book on tropical disease that I purchased that I think is produced by the WHO. While it will be useful to learn the basics about the disease, it wont tell me a darn thing about how the people here actually treat the diseases. For example, chloramphenicol is the main antibiotic that is used here for serious infections. Say what? Again, something I have banished from my memory because we never use it in the US due to side effects.

I was somewhat surprised though today--I found that the physicians here care for the patients as best they can with the resources they have. They are not focused like we are at all on the patients history--getting a past history, medications, family and social history. They focus on the problem at hand. We are able to get studies here--labs including CBC, BMP, coags, x-rays, but those things take times, several days to come back. CT scans can be ordered, but the CT scanner--just one--is at another hospital, so the patients must be taken to that hospital for his or her study. Because you can't get things instantly to help you make decisions quickly like you can in the US, they simply treat based on their initial impressions. The medical students--whom Hannah had interactions with today--are apparently extraordinarily keen on their physical exam skills debating amongst themselves about the specifics of a horrifically loud murmur or being able to determine with feeling if a patient has even the slightest splinting on inspiration. It is sort of sad and we very much take it for granted as US physicians, but I really don't think that we focus NEARLY as much on the physical exam now simply because we just don't have to. Certainly, without the lack of instant-gratification answers from labs, imaging, etc, that is something that I will have to get better at while I am here.

On the one hand, I feel sort of inept with taking care of the medical problems they see frequently, I do have something to offer. There are things that we see much more frequently in the US because we have the luxury of instant labs. For example, I was able to talk with the intern and teach her today about the diagnosis and management of hypernatremia (high level of sodium on blood test). I ran into a problem though--in explaining the full work up, we ordinarily might order urine studies to help discern the cause if the cause was not clear. I found here today though that urine electrolytes and osmolality aren't things that are done here. It wasn't necessary on this particular patient because the cause was obvious, but it really does change the way you have to approach things when the labs that are normally used aren't available.

On other notes from today, on our 2 hour lunch break, Hannah and I went to an old Italian cemetary which sits above the hospital on a hill. It was sort of creepy and very ornate--I wish I could post pictures, but the internet here just wont allow it. On our way to lunch from that there was some sort of an Islamic ceremony going on--I really don't want to sound stupid, but to us it looked like some sort of mid-day blessing. The men and women separated across the street from one another-the women were all wearing white head scarves and the men were just in regular clothes. After a man in white did some talking and then passed by people, they were able to disperse. Anyone know what this was?

We had Cappuccino tonight after work. Again, the Cappuccino here is amazing. There a ton of restaurants that only serve coffee, tea, and pastries. No real food. I guess in a way it reminds me a little bit of their version of Starbucks except not. Something that came up when Hannah and I were at dinner last night was how the restaurants all really start to fill up at 8:00pm. We took note, however, that although they start to eat at 8, they cafes are full of people every night drinking tea and coffee. The people here are very social and are so much later than in the US. The coffee shops like the one I mentioned are full of people most of the time getting drinks--but whereas in the US they are all there for a purpose--reading the newspaper, working on a computer, to discuss something--the people here are all there just to chit chat. The people here do not have an agenda like we do in the US. Even with walking--here it truly appears that people here walk just to walk--in the US we would only walk for a purpose; to get somewhere we had to go, to walk the dog, to lose weight, etc.

Anyway, that is enough for now. I realized while at dinner just now that I have only been here 2 days, but those 2 days have felt like at least 5. Maybe that has something to do with the 2 hour lunch making the day seem split or the fact that I don't have an agenda here.