GI upset

Today was our first full day on the medicine ward. We arrived at 8:00am to start morning report, which is where cases that were brought in overnight are presented and discussed and any other interesting cases are brought up. Amazingly, there were no admissions to the hospital, just one patient that was "admitted" to the ER for observation to rule out ACS. Their management of ACS--acute coronary syndrome (aka chest pain/heart attack)--is quite a bit different from that in the US. Here, the patient came in with a story that sounded unlike pain related to his heart. However, there were some nonspecific findings on EKG that required further evaluation. However, the evaluation here, as for many things, involves simply observing the patient without actually investigating anything. He did get nitroglycerin and morphine, but they were reluctant to give aspirin, which is a staple in this case without any contraindications. He will stay in the ER for some amount of time--I guess until they decide to send him home after a few hours maybe? The primary difference here is that there was no testing for cardiac biomarkers performed--no CK, no troponin. In our practice, these are mainstays of care to ensure no cardiac involvement.

After report, we dispersed to the wards--I went to my side and Hannah to hers. My intern started the day by getting breakfast much like we do when we are postcall as she had been on overnight. I started my day by interacting with a group of medical students who were very eager to hear about the US and how I liked my residency program. The medical students here are so cute and enthusiastic about seeing patients and learning. One of them made the comment to be that they all wanted to be where I am. Hearing this made me both thankful for my opportunity and sad for them because the fact is that it is unlikely any of them will get training like mine when they are through. Because the medical school here is free, they owe at least 2 years of service when they graduate. The medical school here was started just a few years ago and the first graduating class was in 2009--I think something like 30 or 35 students? There are residency programs here only in pediatrics, ob/gyn, and surgery. In speaking with one of the deans for the medical school, Dr. Andu, a couple of days ago he related that there are only 5 or 6 ob/gyns in Asmara. So, for these students, it is less likely that they will get to do a residency at all when they are finished. Hopefully they will be able to get a medicine residency going in the near future.

So, I rounded with my intern, Luam, today on my own with the medical students. After we covered the half-ward today, we were able to talk with the attending about cases and questions that we had. The patients are all very complicated and yet they are simplistic because the resources here are limited. We cannot order every test and look into every single abnormality like we would ordinarily do for these patients in the US.

Hannah and I returned to the hotel today for lunch where we went to our respective rooms for the first time and just napped or e-mailed. We each chose to have a granola bar for lunch--yep, as per the title of this post, it has happened. The African version of Montezuma's revenge has struck both of us unfortunately, so we are now starting our Cipro for travelers diarrhea. Sorry, too much information. On that same note, we are both now just spending the night at the hotel rather than exploring the city--its safer here as we are close to a bathroom.

So now, I will share some of my "random thoughts" about this place...

Concerning Tuberculosis, I learned that any patient that presents with a cough and an infiltrate on chest x-ray first gets a round of regular penicillin G. While the sputum is pending to rule out AFB (or tuberculosis), they look for improvement in the patient clinically. If the sputum comes back AFB positive, then they of course start tuberculosis treatment. If the sputum is negative and the patient does not improve on penicillin, then they empirically start tuberculosis treatment. This is simply due to the fact that it is so unbelievably common here. There is virtually no such thing as a negative ppd. Finally, the treatment regimen comes in combined pill, so there is no option for people who don't tolerate one or another drug. As an example, I have a patient who had an extraordinarily complicated presentation, but the bottom line is that she has Tb. During her first round of Tb treatment, she developed drug induced hepatitis presumably from the INH therapy. So, they stopped the therapy, allowed her to recover and then restarted the therapy. Now she is encephalopathic from recurrent drug-induced hepatitis. We stopped the Tb therapy again, but there is no option with respect to restarting her on medication because we do no have medications outside of the combination therapy.

I learned also that because Tb is so common here, that the nurses cannot work on the medicine service for longer than 6 months at any one time due to the high risk of developing active Tb. Instead, the rotate at least every 6 months to somewhere else such as the ER or surgery to decrease this risk. I found this astounding, bizzare, and a little scary. I just don't see how I am not going to convert to positive after this experience.

The treatment for a DVT (blood clot) is quite a bit different from the usual in the US. Whereas in the US, a patient would be started on either a heparin drip or lovenox plus coumadin to go home with, here they are started on heparin 10,000 unit loading dose followed by 5,000 unit q6 hours depending on the clotting time (checked also every 6 hours). After 7 days, they are started on coumadin and are kept until their INR is therapeutic. But, they only check PT/PTT (coagulation studies) every tuesday and thursday. What does that mean? That means your average patient (really no matter what the problem) stays in the hospital much much much much longer than your average patient in the US.

On an unrelated note, I have found that the process of ordering either water or dinner here is always an adventure. On our first day, Hannah and I first stated that we wanted a coke, then we changed our minds and instead ordered regular bottled water, and then ordered orange juice. From that order, we received orange juice, a coke, and water "with gas" as they say. Each time we order water, it seems we get something different. They always ask if you want it "with gas" or "no gas". Yesterday we both ordered water "with gas" and the lady brought both of us tonic water. I stopped her as she was opening mine and asked for regular "non-gas" water. With this, she became flustered and went to get another waitress to help us. That is another thing, the people here are very easily offended--so ordering water has become somewhat of a stressful event. The primary problem with all of this is that although much of the population does speak a fair amount of English, they don't every have to speak it, so they have terrible accents and are very hard to understand and they just aren't terribly fluent in the language (and that includes the interns that I am working with).

Another random thought...I was able to figure out my water heater situation last night after I had the lady at the front desk come and help me. The switch is on the wall to my room and not on the heater itself. So this morning was the first day that I have taken a warm shower in my own room. It was very refreshing and much-needed. The drawback though is that the water is quite limited, so I had just about enough water for another very quick 3-4 minute shower while turning off the water while washing. It makes me giggle just a little. :)

I was thinking today that I am surprised the people here are not completely anorexic (although they are generally quite thin). I say that because although I have been forcing myself to eat, and rather heavy meals at that, I have absolutely no appetite in this heat. I don't think it is all because of my new gi upset either--walking in the hot sun and being in non-airconditioned hospital rooms that cause the sweat to build up really takes away the appetite. Today I ate 2 out of the 3 times when I absolutely was not hungry. Lunch today consisted of a special K bar that I brought from the US. At dinner I was starving, but not in the way that I usually am. I had a headache, a low blood sugar, and a growling stomach, but still the thought of food wasn't too terribly appealing to me. Maybe the answer to the US obesity problem is to do away with air conditioning. That definitely works to curb the appetite.

Tomorrow I will try and post about some of the interesting cases that we have seen since we have been here. Good night!