Amanda

Amanda passed away this past Friday night with her family by her side. She fought a long hard battle against her burn injuries after an airshow accident back in March. My love and prayers go out to her family including her loving husband, Kyle, her mother, Jeanie, her brother, Matt, and her sister-in-law, Michelle. Amanda will be sorely missed by the airshow world and, of course, by her family.

I have to say that since I learned of her death, it hasn't seemed real. It is absolutely tragic and unfair that someone so young and beautiful would be taken from this earth so prematurely. She will be remembered by all of us. I hope that now she is happy to be reunited with her dad and Jackson.

The Way Home

Hannah and I wrapped up our trip to Eritrea yesterday with a driving tour around Asmara with Tsige, Melles' wife. She showed us one of the three dams that is responsible for collecting the water supply for the entire city. The water at this time of year in the very small "lake" formed by the dam was extremely low, which indicated to me just how dependent upon the rainy season the people are. She took showed us one of the engineering colleges that reminded me of the food science campus at the University of Arkansas with basically a high fence around a field containing many small buildings that served as the classrooms. The drive from the city to the college is quite long and not practical on a daily basis, so the 2000+ students that go there live in the dorms on the campus, which are radically different from what we think of as dorms. All of these things she showed us were down the path of a dirt road and lead to many small villages that comprised the population of Asmara.

Tsige was very excited to take us out for some reason. I felt sorry that we had not been able to spend more time with her while we were there, but the time just got away from us. Talking with her, she explained much more to us about the culture and the battle for independence. She explained how the guerilla fighters were finally able to capture the city of Massawa which served as a major port for northern Ethiopia in 1990 after fighting since 1961. Then gradually some time later the Ethiopian fighters left the city of Asmara and independence was declared in 1991. She also explained, however, that Eritrea was not recognized as a country by the United Nations until 1993. Hearing her story about the country and how there was virtually no support from the western world gave me a better understanding of why Eritrea is the way it is now, limiting the outside world in an effort to do things on its own (though I still don't think this is the best for them).

We said our goodbyes to the hotel staff and gave our last tips to the restaurant personnel and the doorman (who was at the door literally all day long every day with a smile on his face). We had our last meal of shiro, addis, injera, and a spinach dish I still can't remember the name of. We ordered our last B.P.W. or big plastic water and finally our trip came to an end with Melles and his daughter picking us up to make our trek to the airport. We were sad to go but were thankful to be finally heading home after a month. After a good 20 checks of our passports by nearly ever person we ran into at the airport, we made it to our gate and eventually onto the plane that took us from Asmara then to Jeddah then to Frankfurt. Hannah and I both got our long-awaited coke zeros on the plane, which we found weren't as good as we had hoped. In the Frankfurt airport I went a little nuts and bought a good $60 worth of German and Belgian chocolates. I do plan on giving some of it away though--at least that is what I keep telling myself to feel better about the ridiculous amount of money I spent (the weakness of the dollar over her really inhibited my chocolate buying abilities).

Hannah and I are planning our last 2 days of freedom before heading back to the ICU and the every third night call schedule requiring a good 90+ hours a week out of us. I'm afraid it will be a bit of a shock after the relatively relaxed schedule in Eritrea that gave us the weekends off and 2 hour lunch breaks. But it will be bittersweet--the ICU is a lot fun and I am very much welcoming back the practice and plentiful resources that make American medicine possible.

One last coffee ceremony

Yesterday Hannah and I were greeted by new interns at the usual resident report. Our old interns moved on to their surgical rotations and these new interns will be on service for the next month, which means Danielle (a fellow resident) will get to work with this group when she gets here next week. I made rounds with my intern, Victoria, and my goal was to make sure that we got as many people out of the hospital as possible and to make sure that every patient we rounded on had a good solid plan for discharge. I could tell that she might have been a little bit overwhelmed, particularly since she had been on call the night before. We also rounded with another sort of sub-attending who was an intern last year and has been assigned to the medical ward as part of his national service after medical school. He will act somewhat like a resident over the intern and the attending will continue to oversee both of them. I am glad that he is there since our attending is not there consistently for the intern.

After rounds and finishing up discharge paperwork yesterday, the nurses had planned a coffee ceremony in the hospital for us. Hannah and I are now very well educated about the process of a coffee ceremony since this was our fifth one. The head nurses from both sides came--Sister Fegadu on my side and Akbaret on Hannah's side. The other nurses including the nursing assistants also attended as well as our interns from the month. I had 2 cups of the coffee and Hannah had one. I think she has about had her fill of coffee ceremonies (as have I). The coffee ceremony included the usual popcorn, which seems to be a must during these events, as well as candy and some crackers. One of the nurses on my side also brought injera and shiro for the group, all of which was consumed by the end.

After our 5th and hopefully final coffee ceremony, Hannah and I took off to a nearby restaurant where we read for about and hour before we returned to the hospital for admissions. In the afternoon we had another thoracentesis (there are a lot of those here!) to do on a patient with a unilateral pleural effusion for symptom control. I have been impressed with the number of patients with pleural effusions here. At times it seems like everyone has one.

After work, we made it to one of the souvenir shops to pick up some last minute gifts for people before having dinner at the hotel. My intern, Luam, and her boyfriend came to our hotel and had dinner with us at the hotel restaurant. They were very cute together and I found him to be very up on his American culture. For some reason, we started talking about geography, so I proceeded to draw a map of the US in my notebook and Hannah and I started to label and name all of the 50 states. Then we started talking about African geography, and he impressed us all with a drawing of Africa in which he labelled all 54 countries. Did you know there is a country called Seashell? Its true! I had no idea. I hope to stay in touch with Luam to know where her life takes her in the future. And to have another contact in Eritrea should I come back to visit.

Hannah and I are now counting down to coming home. We have plans for each leg of our trip back--coke zero on the flight to Germany, then breakfast in Frankfurt, then family phone calls in Chicago, and finally home. We are looking forward to heading out tomorrow, but I admit that some part of me will miss this place and the time that I have had here and particularly the people.

Keren trip

Hannah and I were able to take a short day-trip to Keren, which is a town to the north east of Asmara yesterday. We took this trip simply because our travel permits were delayed the other two weekends we were in Asmara, and we really wanted to make the most of our time here while we were here. We decided to sort of "rough-it" on our Keren trip and did so by taking the public bus. The trip cost a total of $23 Nakfa (or about $1.50 USD). We showed up via cab at the bus station yesterday morning, and our cab driver made sure someone was there to help us. There were very long lines of people waiting for various buses, but somehow we were ushered on to one before it filled. We didn't leave right away, so I decided to get off the bus and use the bathroom before we left. This turned out to be an bad decision because the bathroom I ended up using was the grossest I have been in since the start of our visit (there was a lot of gagging involved), and because I also nearly missed the bus. Luckily, Hannah had the bus driver hold the bus while I emptied my bladder, and I did make it.

We made the 3 hour journey to Keren without any difficulty both of us reading our books on the way there. The bus itself was very old and worn out of course without air conditioning and the road was quite bumpy and curvy on the way there. Despite this, we did ok with the trip and enjoyed the undivided reading time that we had. I do have to add that I am reading Cutting for Stone by Abraham Verghese (almost done now), which is such an amazing book although I don't think I would have appreciated it as much if I wasn't a doctor or if I wasn't in Eritrea.

On arrival on the city of Keren, we were guided by a young guy that we met on the bus. He was actually looking over Hannah's shoulder during the bus ride, reading her book along with her, page by page. He showed us the old and the new markets. The "old" market was really the reason we came to Keren in the first place. It was a Monday-only market with plenty of items including scarves, soap, and coffee, but also included the very large Camel market. We spent quite a lot of time taking photos of the camels, posing with them, and petting them until we were yelled at by one of the camel market men. I love camels--they are soooooooo cool.

After the camel market, we just made our way through the new market, which was an area with more enclosed shops containing very bright colored clothing. The overall appearance of Keren was very very different from that of Asmara. The people were all wearing more traditional clothing with the men wearing white gowns and the women dressed in bright colored gowns. There were many more women were burqas and the population was definitely much more Muslim in their faith compared to that of Asmara. The architecture of the city was clearly not as influenced by the Italians with most of the houses and businesses in the very plain plaster boxy look. Not sure how else to describe it. The city was quite a bit smaller than Asmara obviously and most of the roads that we walked on were unpaved made up of sand. The primary thing that I took away from the city was the colorfulness of the people's wardrobe, which differed quite a lot from the people of Asmara. I was very glad that we made it because it was so culturally different from Asmara. It was clear that the people don't get visitors hardly EVER because Hannah and I were the only white people we saw when we were there and we were a spectacle among the young school-aged children.

After a coke break (which we later learned was Sudanese coke) and a rest from the very hot sun in Keren, Hannah and I found an old Italian cemetery behind the grain market in the city. Behind the Italian cemetery was a hill on top of which we were able to see the whole of the small city. We then took a taxi to a sacred Baobab tree that was believed to be a tree of fertility by the locals around which a church had been built. Hannah and I made a point to touch the tree and to climb around hits huge base before taking the bus back to Asmara. On the ride back, we found that throughout the way, the bus would stop at random small villages along the way and just pick random people up that it would drop off after a short drive. I guess it allows people from these small villages to really hitch a ride to other nearby villages. We made it back to Asmara via the bus extremely hot, sweaty and tired, but very satisfied with our outing that allowed us to see a very different, and pleasant side of the country.

Massawa

The rest of the story of Massawa…after experiencing the sand storm, we quickly opted to wait inside our hotel for the taxi driver to return. An hour and fifteen minutes after our planned meeting time, he came and took us to the Massawa beach. On the beach, the air was much cooler than in the city and the Red Sea was a very welcome site. The wind was still quite strong and that made pretty large waves that Hannah and I both took advantage of. Throughout our trip, Hannah decided that one of her goals was to see and ride a camel on the beach. She asked around, and found that the camels had been put up for the day because the beach was nearly completely devoid of people. But, with some luck, the camel man got one of his camels out specially for us. Hannah finally got to ride the camel, and I took a spin for myself. We got a myriad of pictures of her, myself, and then the two of us together riding the camel on the beach, through the water. They are very gentle animals, always chewing, and will talk with some provoking. They sort of remind me of cats, only bigger, and useful.

After we'd had enough of the beach, we went back to our hotel where we had quick showers and then we were off to dinner and to see the city. We were taken to the port area where presumably the city center was or had been. As I said before, to describe the city of Massawa, I would use the word Bizarre. On the surface the city looked impressive from afar with large, majestic-looking buildings, many of which were probably built by the Italians. The creepy part came in realizing that basically all of these huge buildings were essentially vacant. And around them within the town, the roads were dirt and people lived in the sides of buildings with very, very little. We wandered around finding a "new" hotel that was apparently the place to be. This place was huge with a nearly olympic-sized outdoor pool at the center. It looked like the perfect place that had been constructed for tourists. That was all on the surface. The hotel itself looked already run-down and was completely empty. There wasn't a soul in the pool and it seemed almost like we were trespassing into some secret hideaway when we went exploring. It was like it was built for something that never quite materialized.

There was a bar there and since the restaurant we planned to eat dinner at didn't open until 7pm, we opted to get an appetizer at this hotel. We ordered fried shrimp because we thought that would be safe and two glasses of red wine. What we got instead was two glasses of red-label whiskey further driving home the concept that you never really know what you are going to get when you order anything in this country. We tried our best to give the whiskey away, asking nearby people if they wanted it, but no one did. Unfortunately, we did end up paying for it in the end despite the mistake. I would like to add that at dinner the topic of our conversation centered around the absolute bizarreness of the city and its apparent vacantness.

When 7pm finally rolled around, we made our way to our dinner restaurant, a place called Selam Restaurant, which was recommended by everyone who has ever been to Massawa. Not for the food so much as the experience. The restaurant is literally a hole in the wall place that even the local people of Massawa didn't seem to know much about. They serve fish--medium or large--and bread, which is made of only flour, salt, and water. You get to go in the back of the kitchen and pick your fish--no specific species, presumably just whatever they caught that day. The fish and the bread are both cooked in a hole, which is essentially just a fire pit. The fish are first cut in half and rubbed with Berber (my favorite Eritrean spice) and then are put in the fire pit to cook. The bread is smashed on the wall of the fire pit flat and is much like Indian naan. The restaurant seating is all outside and there were swarms of cats around the tables begging for fish and having the occasional fight underneath some lucky person's chair. We ate our fish and bread, which really wasn't too bad and then spent the rest of the time feeding our left overs to the crazy cats underneath our table. At the most, we counted I think 9 cats under our table. All of which were skin and bone.

We both crashed that night at our hotel with our air conditioner blasting. The following morning, we headed back to the beach bright and early before 9am where we stayed for a good 2-3 hours reading and wave riding. We had lunch at the beach restaurant and then took showers before heading back to our safe-haven of Asmara around noon. As I mentioned, on the way back, we had to stop to air up the front passenger-side tire as it was going flat. It was the second leg of the trip that I noticed a wire sticking out of the drivers side dash board that was smoking and the taxi driver would periodically play with it. Not sure what it was. I'm very thankful we made it home.

We stopped at a small village on the way back so that our driver could buy some road-side watermelon. There, three little girls were selling peanuts and some other grain and were very intent on selling some to us. One thing I have observed is that the people will take any opportunity to sell something if possible or to beg for money or whatever we have. Luckily for these three little girls, I had some extra granola bars--nature valley fruit and nut variety--that I passed out. The girls were extremely eager to grab at these bars, but of course they kept on begging for more, more, more. To get them to stop, we made a game out of making funny faces at each other, which included smashing my face up against the cab window, which they all found hilarious.

Hannah and I were ecstatic to make it back to Asmara and the safety and comfort of our hotel rooms after our weekend trip. Massawa gave us a new perspective on the country as a whole, and it wasn't all pleasant. The large empty buildings, which reminded us of a vacant movie set, was eerie, but the people were still just has friendly and welcoming.

Sand storm

If I had to use one word to describe our trip to Massawa, it would be HOT. If I had to use one word to describe Massawa, it would be Bizarre.

Our adventure to Massawa started a little later than planned at 8:30 Saturday morning. When our taxi driver got there, we entered the cab with initial feelings that this cab was quite a bit better than those we had driven in through the city. It took us to the end of the trip to realize this may not have been true. The cab, which had over 500,000 miles on it had a cracked windshield, no speedometer, of course no AC which was not surprising, but it also had a near-flat tire towards the end of the trip, some raw wires sticking out of the drivers side panel that were smoking (and which our driver played with on the ride home), some serious exhaust fumes, and, my favorite, a pack of roaches that graced us with their presence when we made it to Massawa. I have realized that I have sort of a phobia when it comes to roaches, and Hannah can vouch for my fear of them. Luckily though we only saw them the once, and on our trip back to Asmara I doused myself, my stuff, Hannah, Hannah's stuff, and the interior of the cab in a plume of OFF. Our taxi driver did not really speak English, but he did enough for us to communicate on a very basic level.

So, we set out for Massawa, but not before we clarified that we wanted to go through Filfil on the way there, which is supposed to be the country's one and only opportunity to see forest and animals. With that, he made a U turn and then we were off. The drive to Filfil was very curvy. Actually, to say it is curvy by American standards is somewhat of an understatement. If I can describe, you go 100 yards in one direction on the edge/top of a mountain, and then you make a U turn and you go 100 yards in another direction. With Asmara being at over 7,000 feet, we had a long, long way to go to get down to sea level where we were going. There is no direct way to do that, so it is a series of U-turns back and forth gradually taking you down the mountain. The roads make the back roads of Arkansas look like a major interstate. Dramamine was an absolute must for me on this driving adventure, and I'm happy to say there was no carsickness.

We did stop for a photo-op at the top of the mountain where the view was quite incredible. The mountains are covered in a thin layer of trees, spaced apart so that you can see the dry rock beneath. We also stopped for a hot coke break at a place in the literal middle of nowhere that had a sitting area and apparently a hotel. How this place had electricity, running water, or really anything, I have absolutely NO idea being that it was situated half way up a mountain, a good hour and a half drive from Asmara.

As we travelled down the mountain, the temperature gradually increased so that the last 2 hours of our 4 hour trip was almost unbearable. I can't describe the heat with words. The best I can do is to say that when we had reached sea level and everything turned to dessert, the heat coming through the windows, which were open to help us keep breathing, was nauseating. I kept repeatedly checking my feet because they felt like they were getting burned in the sun, and each time that it turned out that the sun was not shining on them, I had to reassure myself that they were just burning from the heat in the cab. I have never, ever been that hot in my entire life. It was the sort of hot that absolutely sucked the life out of you. I can now understand more why the business model is to close during the hottest hours of the day. I would also like to comment and say that the Danakil area of Eritrea is apparently one of the hottest places on earth. And we were pretty far away from it. Why or how anyone could every go there is beyond me.

On our drive through the dessert, we passed people and animals living in places that I never would have thought possible. There were herds of goats, the occasional cow, and camels on the trip. Then there were villages made up of shacks constructed from pieces of metal where people obviously lived. Throughout the drive through the villages, people were herding goats and cattle. What struck me the most about this area we passed was that there was no water anywhere. Everywhere we saw what looked like a river or stream bed, it was completely bone dry. The only thing I could come up with was that they must have a well dug and that is why their villages are placed where they are because there is no obvious source of water that I could see.

Being in this heat, I was, of course, sweating profusely as I always do. I had to keep reminding myself to keep my mouth closed because even opening it for a few seconds caused it to dry out and I worried it would help make me even more dehydrated. Hannah and I failed to bring gadorade with us, so we we hydrating with only water. I'm sure we became hyponatremic (low sodium) on this short trip.

After having driven for nearly 4 hours, we finally made it into an area that appeared to be populated and looked sort of like a town and we found our hotel. This was lucky because right about the time we were driving up to our hotel, a pack of roaches came out from nowhere and started crawling all over our stuff and on the taxi driver. Although I was wearing a dress, I stood on my tip-toes in the back seat of the cab, waiting for it to stop so that I could get out. I had not yet taken note of the scenery of the city.

Inside the hotel felt like a sauna as we got checked in and made it to the third floor of the hotel where our room was. Thankfully, our room was cool and had an air conditioner. We took a moment to cool off before we got ready for the beach and made our way to the hotel lobby for lunch--the granola bars we brought, a cold coke, and a water. After lunch we decided to look next door to our hotel for the internet cafe that was apparently there. It was at this point, when we stepped outside, that we realized we weren't in Kansas anymore. The picture was basically that of Dessert storm, or Saudi Arabia, or a winter white-out. The city of Massawa could not be seen, and all we could see was the dessert that sat across from our hotel and the white sand blowing through. We chose to wear dresses to the beach, and they were being blown this way and that all the while, our skin was becoming absolutely caked with sand and dirt from being out in the sand storm. I would like to add that I am still finding areas of my body containing or caked with sand--particularly my ears--after this experience.

In a way, this introduction to Massawa was the most funny (though distressing at the time) part of the trip. The rest of it was notable as well, but the heat, sweat, and sand made us ask ourselves number one, how do people live here, and number two, how did we get there. There is too much to tell about the rest of the trip. That will have to be for tomorrow. Good night!

Some random thoughts

Today was nice. Hannah and I met for our usual morning breakfast in the hotel cafe. Every morning we both have a macchiato served in a play-sized coffee cup. We brought the last of the things we are giving away to the medical school and people here today. On our way here we both brought numerous books, which made our luggage quite heavy and which now will be a part of the medical school library here. I am giving away the 2 white coats I brought, but I have to keep one until the last day of course. And then there are random things I brought like a couple of notebooks, my reflex hammer, some gloves, an extra flash drive, some N95 masks, some alcohol hand sanitizer, a small but very powerful flashlight I have been using for a pen light/when the power goes out at the hotel, and in Hannah's case some clothes that we gave away today. If I had known how much little things like these were needed I would have brought more extra stuff that I have laying around my house. The people here appreciate all of these little things so much--so much more than I do--because it is so hard for them to get things here. Anyway, we got rid of the last of our stuff today because our interns will be changing on monday, and we wanted them to have a lot of this stuff.

Hannah and I both made rounds today on our respective sides of the medical ward. For some reason today seemed to be much smoother on my side than usual. I felt like I actually had a decent plan on people, which in many cases actually included consideration for discharge. Apparently the rate of discharges goes up quite a lot when we visit simply because we are so oriented to getting people out of the hospital. We also recognize sometimes more readily when the patients really shouldn't be in the hospital for outpatient issues and in the case where there isn't really anything that can be done for the patient in the hospital setting. I don't have a lot of cool patient stories because most of my ward has left and now there are a lot of chronic players. And as I have said before, there aren't tons of new admissions all of the time like in the US.

Henish made it out last night and should be back in the US sometime today. While he was here, he made quite a lot of corny quasi-jokes and his joking sort of brought out my idiotic sense of humor. When we were driving with Tsige the night before he left, we were driving behind a one-horse carriage. He then said, "look, its one horse power". This is probably a "you just had to be there" sort of moment, but it was really funny at the time.

After rounds today, we made it back in time to watch the royal wedding in full. It worked perfectly that it happened to be right a lunch. We sat in the hotel cafe in front of their flat screen TV where we watched the whole thing. I honestly can't remember a time when I was more into something on the TV. For us girls though, I think there is something magical about the royal wedding because we all sort of grow up dreaming about being a princess. It was so exciting to see a regular girl turn into a princess with an "I do". It was also awesome to see all of the dress for the affair including, of course, her dress. I was a little bit disappointed with the kiss, but I guess I will give them that it was very "British". :) There are two older men from Britain (Yorkshire) who are here on business working for the government while they are here. We see them every morning in the hotel restaurant eating breakfast while watching BBC news which is always on. We've talked to them a few times about what there is to do in Asmara and about going to Massawa. So, one of them came up to us today as we were watching the royal wedding and handed us some paper-towels for all of our tears--as a joke of course. I would like to say that not a tear was shed from either of us during the royal wedding today.

Hannah and I are going to be heading to Massawa this weekend for a one night stay in one of the hottest areas of this country. We are excited to finally see the Sea (ha!) and to see the countryside on our way there. Before we go, I would like to share some random thoughts/comments about our trip to Eritrea:
-The first several days here we were out of breath because of the altitude. Thats gotten a little bit better.
-In nearly every restaurant or even coffee bar, there is a full liquor selection, but there is never anyone drinking any of it. They all just drink the Asmara beer, which is the only beer available here.
-The cakes all taste like bananas.
-Every morning, I have to peel Hannah's banana. lol. She wont touch the bananas here because they have black on them, but if I peel it she will eat it.
-The exhaust on the streets is really bad because of all of the old cars even though there are relatively few cars here.
-The dogs like to pretty much only bark at night while we are trying to sleep. Thus, I wear ear plugs to sleep every night and sometimes by ears wake up hurting from them.
-Every item served in a restaurant is served from a tray. Even if you order a bottle of water, they will bring it over on a tray. If you order a banana, it will come on a tray and on its own little plate.
-Everyone here takes a 2.5 hour lunch break from 12:00 to 2:30. We also learned that if it is a hot day, they will take longer unannounced breaks and sometimes not come back (to open stores) until 3:30 or 4:00.
-I usually trip at least once per day while walking.
-Even though most of the people here speak only Tigrinya and not Arabic, most of the commercials are in Arabic and feature people from middle eastern countries. Presumably there is no such thing as Eritreawood to make movies and commercials.
-If a public bathroom has a toilet, it will invariably not have a toilet seat nor will it have toilet tissue. Luckily there a women on most street corners selling packs of facial tissue and gum.

We also constructed a top 10 list of things that we wish they had in the hospital here readily available. Number 10) A cath lab (or tPA). Number 9) Statins. Number 8) A pathologist. Number 7) Soap (consistently) Number 6) Pyridoxine (B6) for inpatients. Number 5) Ejection fractions. Number 4) Gloves (consistently). Number 3) Blood sugar test strips (consistently). Number 2) Oxygen on the floors. Number 1) Oral potassium chloride.

Thats all I've got for a couple of days. Hopefully we will come back with plenty of stories from Massawa this weekend.

Diabetes clinic day

I had a change of pace today which was nice. Instead of my usual inpatient medicine, I went to Halibet hospital instead, which is on the outskirts of Asmara for a day in the diabetes clinic. The day started with a cab ride to the hospital since it is too far to walk. On the ride I spoke with the cab driver about his medical problems which includes diabetes, hypertension, and probably diabetic gastroparesis. He showed me his medications and I gave him some advice. I actually felt sort of useful giving this guy some medical advice. When we arrived at the hospital, it was in no way what I was expecting. Halibet is arranged in a series of small buildings all of which are disconnected from one another. It is structured in sort of a compound with a different building for each area--one building for the ER, one for the OPD (outpatient department or clinic), one for the chronic medical condition clinic (diabetes, hypertension, cardiac, HIV, Tb), one for the pharmacy, one for the hospital, etc. I wandered around until I finally found the medical director's office only to learn that he was at the Ministry of Health for the morning. One of his office staff then escorted me to the diabetes clinic where I spent the morning.

It was interesting to see how the diabetes clinic functions here. I learned that the patients all come in by 8am (probably by Eritrean time) fasting and they are educated first in a group with discussion about diabetes, diet, exercise, and diabetes complications. Then they are each taken back individually to the diabetes educator nurse who addresses specific things with each patient depending on the needs--whether it be diet for blood pressure, diabetes, or the need for more exercise. Each patient gets some individual attention. After this, they go to a different room where they get a fasting blood sugar done and a Hemoglobin A1c checked if it is due (although this takes a week to come back). After that, the patient along with the chart go into see the nurse who is responsible for making changes to the diabetes regimen based on the patient's report and the patient's fasting blood sugar. Certainly this model may not be perfectly ideal, but they do fairly well with improving blood sugar control and blood pressure in this clinic. The number of drugs used here is quite limited--only Metformin and one sulfonylurea for oral medications and only Lente and regular insulin for the patients on insulin. The lack of options makes things run much more quickly in the clinic because decisions can be made based on these 4 drug choices. Not all of the patients have blood sugar monitors, and I really suspect most of them, especially those on oral medications, probably don't.

In terms of the mechanics of the clinic, I learned that the insulin requiring patients are seen on Monday, Wednesday, and Friday, while those on oral hypoglycemics are seen on Tuesdays and Thursdays. The insulin requiring patients come in every 2 months while the oral patients come in every 3 months. Everyone gets a Hemoglobin A1c about every 6 months or so. All of these clinics for chronic medical conditions are free for the patients. When the patient gets a script for a 3 month supply of oral hypoglycemic medication, they go directly to the pharmacy where they are given their full 3 month supply to last them until the next visit. If they have problems in the mean time, they can come in before their next appointment to see a nurse. The benefits of this model of caring for chronic medical conditions is that the clinic easily and quickly improves education and sees a large volume of patients. I think the drawback though is that each medical condition is addressed by a different practitioner so there isn't one person who actually knows each individual patient. The patients do come with their chart or card as it is called here that has their clinic history on it.

All of the chronic condition clinics are structured similarly with the HIV and Tb clinics providing education about safe sex, importance of medication compliance, and perinatal counseling to prevent mother to infant vertical transmission of HIV. The medical director informed me that previously the vertical transmission rate of HIV was 1.3% here, but in the last year it has actually decreased further to only 0.9%. Eritrea is quite lucky that the prevalence of HIV here is only around 3%, which is much much lower when compared to most other African countries. The HIV patients get a 6 month supply of their medications at a time with each clinic visit.

After my time in clinic, I went and visited the outpatient pharmacy and the pharmacy warehouse where all of the medications are stored in bulk. On the walk to the pharmacy warehouse, we had to pass through several fields with various animals including goats, sheep, cows, and some sort of squirrel-prairie dog mix. The warehouse contained large shipments of basic medications for the chronic conditions I mentioned as well as some hospital and surgical supplies. The variety of medications found in even a standard Walgreens in the US wasn't there, but the mainstay of treatment for these conditions was available.

After clinic, I returned to Orotta hospital to check on the ward and to see if there were any admissions. I was struck by the fact that the nurse came to me to ask which patients we could either stop checking or decrease the frequency of blood sugar checks because the supply of glucometer strips is so limited--like 20 or so for the day. I'm not sure if they will be getting more, but I went ahead and made the necessary changes. It struck me that the resources have to really be rationed and allotted to only those who absolutely must have them. I brought in 2 notebooks that I haven't used, and the nurses seemed so thankful because even basic things like these are limited. I really respect the nurses here because I think they have the job of balancing what the hospital has with what patients need. What a different world of medicine here.

One last statement about the medicine here. I have found it extremely difficult to take histories here. There is no clear cut translating on the part of the staff here, and even with translating by the nurses, the understanding of English is sometimes fairly limited. With that, I feel like I have really had to rely on my physical exam skills because that is sometimes all of the information I have. That is not to say I am a super pro with my exam, but it has forced me to become more proficient and observant when doing a physical. Thats all for now. Trying to keep these things shorter.

Photo op

So last night the three of us went bowling. There is only one bowling alley in Asmara (and my guess is only one in the whole country), and we just happened to make our way there yesterday afternoon to play a game. We invited one of the medical students who had never played and had never been to a bowling alley before. The bowling alley itself, I think, had 6 lanes in total. There were numerous big screened TVs with nintendo systems hooked up to them for the kids to play. There were also multiple pool tables, but thankfully none of the smoke that usually comes with a pool-table-containing establishment. The bowling game itself was interesting with all of the pins being manually reset by young boys who were responsible for this chore. There wasn't any sort of automatic pin-resetter. The actual lanes were a little bumpy and the entire establishment was just a little run down in true Eritrean style. It was a lot of fun though. The final scores were: medical student (first time bowling in his life) 150, me 123, Henish 57, Hannah 53. In Hannah's defense, her initial ball choice was the lightest ball I have ever seen--like 3 or 4 lbs and apparently had a twist to it, so somehow it always ended up in the gutter. I don't have an excuse for Henish.

Today was a much better day than yesterday. The little boy I mentioned in my last post is still alive and is now producing urine with the help of lasix. His respiratory status has improved a tiny bit, but I still think he should be dialyzed in the short term. The attending, however, thinks that we should wait. He also thinks we should wait to try a trial of steroids until his 24 hour urine protein returns. I just pray that he makes it another day. In other patient news, I diagnosed a patient today with likely hepatocellular carcinoma. She presented with several months of right upper quadrant (where the liver is) swelling and tenderness. Her liver function tests were very nonspecific and suggested a chronic process. So, despite the fact that the initial ultrasound said cirrhosis, I took her down to the ultrasound tech and had him redo her ultrasound. This time, this guy saw she had multiple discrete masses with no clear liver tissue, which correlates with her history (also included a large weight loss) and severe hepatomegaly. Based on this read, I think she has HCC. I don't have any way to confirm the diagnosis, and getting a CT is too expensive. So, hopefully she will be able to go ohm soon.

Today for lunch we went to Asmara Palace where we confirmed that most of the restaurants here in Asmara will not have a lot of the food that they have on the menu. Hannah and I asked prior to ordering if they had the salmon, crab, or lobster that they put on the menu, and the answer was no. In terms of fish on the menu, the only food they had was red snapper. Luckily that sounded good, so that is what we got, and it turned out to be ok. After lunch we decided to brave a piece of cake from the bar and, as per the cake we had on Easter, it tasted like banana. This cake was supposed to be dark chocolate, but all we could taste was banana, so we opted to not eat it.

After work today we met with Tsige, Melles' wife who showed us around Asmara. She first took us to the "recycling center" which was really more like an organized junk yard with a bunch of people taking scraps and making them into something. At the entrance there was a grain market different from what we had seen at the main market in town. We saw men pounding on giant pieces of metal making flour sifters, containers for brewing Suwa, benches, etc. There were people doing wood work. Everywhere there were piles of old parts, old tires, old doors, and just random trinkets. I was sort of in visual and auditory stimuli overload while I was there. It is definitely a place where a photographer could go crazy taking pictures. Hannah and I both did go a little nuts with pictures.

After the recycling center, Tsige took us to the road that leads to Massawa, the coastal city here. There we were finally able to see just how high up in the mountains we are being in Asmara. The view was absolutely beautiful and finally we were really able to see the landscape here, which is more like what I pictured Africa to be. We also got lucky and saw our first camels, which Hannah and I both took pictures with. Seeing the road to Massawa made us excited about our upcoming trip there this weekend just so we can see the country-side since we haven't been out of Asmara yet.

After our photo-ops, Tsige to us to another market to show us more shopping. Somehow we had missed this market in our initial wanderings. We did find some stuff worth buying. My big purchase of the evening was a hand carved wooden Ostrich. There really isn't a whole lot of bargaining here, and these trinkets are relatively expensive. Our night ended with dinner in the hotel where the three of us (Hannah, Henish, and me) lost track of time and ended up chatting in the restaurant for a good 3 hours.

Hard day

Today was hard for me from a patient care standpoint. I have to keep reminding myself that I am not practicing medicine in the US right now. I am in Africa.

The day started with a death report on a patient who had been in the hospital for 5 months initially admitted with DKA, but then who was treated twice for Tuberculosis and developed drug-induced hepatitis from the therapy. Then rounds proceeded today as per usual during which time I decided that this 40 year old guy who came in with jaundice likely has pancreatic cancer. He has had a huge weight loss over the last several months and presented with painless jaundice for the last 2 weeks. On exam he has an obvious mass in his epigastrium. His chest x-ray appears to have evidence of multiple circular lesions throughout the lung fields that I first thought might have been an infectious process, but putting the whole story together, I'm fairly certain are metastatic lesions. I still don't have any labs back yet, and the abdominal ultrasound only commented on hepatic cirrhosis. My plan now is to get the labs--hopefully they will be back tomorrow, and wheel him down myself to redo an ultrasound with my own eyes. It may sound crazy, but the ultrasounds are done by techs who read them as well (not done or read by an MD), and they are of very limited diagnostic value. My attending who is an oncologist from Italy agreed with my assessment of him, but because it is a diagnosis that means he will go home to die, I need to make sure of it somehow. I cannot just order a CT scan outright because he will have to pay for it himself and there is no such thing as a tissue diagnosis here at this time because there is no pathologist. There is no CA 19-9 or the like, so I will be relying on my very limited ultrasound skills tomorrow to try and make the diagnosis.

The case the really made my day difficult was a new patient who was admitted the previous afternoon with complaints of anasarca (generalized body swelling). He is a 15 year old previously healthy boy from a remote are in Eritrea and because of this he does not speak Tigrinya, so the usual staff cannot communicate well with him or his family. Just to speak to him today, we had to find another patient's family member who spoke the same language in order to speak with him. The short of the story is that he came in with 3 weeks of anasarca, hematuria (bloody urine), and pulmonary edema (fluid on the lungs). We transferred him to the ICU this morning because when I came in, I checked his pulse ox and found it to be between 20-40%. He was still awake and breathing and the machine was working properly. In the ICU, he had an ABG done which showed he was acidotic and hyperkalmic--both being 7.2 (the first time I've had that happen). He apparently only urinated once overnight, and is clearly in renal failure. I treated what I could medically--treating his hyperkalemia and giving him some lassie to see if he would urinate with that, but the bottom line is that he needed to be dialyzed. The intern in the ICU called the physician in charge of dialysis, but he refused to dialyze without the approval of the ICU attending. So, she called the ICU attending who decided that the patient should not be dialyzed based on the fact that he thinks that the patient's renal failure is chronic. At the time she spoke to the attending, the patient's labs had come back and revealed a BUN in the 200s, Creatinine of 9.9, and a bicarb of 11. His CBC revealed a normocytic anemia with a hemoglobin level of 4. Based on this, he refused to allow the patient to be dialyzed because there is only one dialysis machine at the hospital and they cannot dialyze people who have chronic renal failure due to lack of resources. I understand obviously that because of the severely limited resources here there cannot be chronic dialysis. It is just so difficult to see this young boy and know that there is almost nothing I can do for him, but in the US it would be so easy to treat him appropriately. I did what I could medically for him, but the thing that is hard to accept is that he very well will likely be gone in the morning.

His case is one that more than any other case I have seen since I have been here has made me thankful for all of the medical resources we have in the US.

Lots of laughs

There isn't really any way that I will be able to fully convey the amount of giggling that went on today amongst Hannah, Henish, and myself. It started out like any other day and ended very appropriately with the power to our hotel going out while I was brushing my teeth requiring use of my flashlight. Before I go into what made it so hilarious, I thought I should spend some time talking about the medicine we've seen...

Back to work again today. I made rounds as per usual with the intern today (Hannah's intern didn't show up for rounds today), but different from last week, a large group of about 10 or so medical students rounded with us. Because all of the patients had not been seen over the weekend consistently, we made rounds on the entire ward instead of just the usual half. Having to get through all of the patients in only 3 hours seemed daunting while trying to teach medical students, but we made it through. Unlike in the US, many of the patients on the ward end up staying in the hospital for a very long time, so there isn't a whole lot of patient turnover and thus not a whole lot of different cases on a day to day basis like in the US. The reason for this is largely due to the fact that the time it takes to get labs and imaging studies back takes much longer than in the US.

We did get some new patients in over the weekend. An interesting one is a patient who is from rural Eritrea and therefore does not speak Tigrinya who presented from an outside hospital with a pending diagnosis of liver hepatoma vs abscess. More so than in the US, I have realized that you absolutely cannot trust the information that comes from an outside hospital here. It is best to just pretend like you don't know anything about the patient in taking a history. In this particular patient, I have absolutely no idea why they were thinking abscess other than the fact that she has right upper quadrant pain. They didn't do any studies as far as I can tell and the patient has not been having any fevers or diarrhea. At this point her labs are pending, but we were able to get a right upper quadrant ultrasound today miraculously and that just showed hepatomegaly with a normal spleen. It is very difficult to decide what to do for her since we don't have any labs back and they will presumably take a couple of days to come back, and I can't just order a CT scan like I would in the US. Much like with other patients, I feel like I have so little information on which to base medical decisions here, its like shooting in the wind and praying to hit the target.

One other interesting note about this patient is that she has had treatment for her pain from an "herbal doctor" (I'm not exactly sure where though). We have seen a fair amount of this since being here, but this was the most elaborate I have seen. She has a cross scraped on the skin over her liver at the right rib border and there are a series of cauterization sites arranged in a circle around the cross with fresh scabs. This was quite shocking on first examination to see with the diameter of the circle measuring probably 30 cm or so. We have seen quite a lot of people who have visited "herbal doctors" with evidence of cautery on their chests or upper arms. I even have a patient that I saw in clinic who was from Sudan when I was on Ambjar (the ambulatory residency month) that had cautery to his chest for chest pain. Another herbal treatment that we have seen unfortunately is something that is given for jaundice which causes renal failure. Hannah had a young guy (in his 20s I think) on her service with renal failure after taking some herbal medicine for jaundice who was totally coo-coo from being uremic.

There are so many people with liver disease, hepatomegaly (enlarged liver), hepatosplenomegaly (enlarged liver and spleen), jaundice, or right upper quadrant pain, and in each case I feel like so often we don't have a clear diagnosis as to why. It seems easy when the patient presents with fevers and hepatosplenomegaly, but in the patients with chronic liver disease, I have to think outside of my American box and think much more broadly and infectious. We did actually admit a patient last week who had clear cut acute viral hepatitis though, and it was such a relief to finally feel like I had a patient with an obvious diagnosis. This is still going off of clinical presentation as it was a classic presentation and the serologies (we only test for Hep B and C here) are still pending. His LFTs are now downtrending and his icterus is resolving. As it relates to these liver players or any other medical problem for that matter, I feel like I have to keep asking myself what I would do for the same patient in the US. The answer is invariably something totally different than what we are doing here. It is difficult to know how far to take the work up for each of these patients when coming from a society where we order any and every lab test possible.

Case and point, as I was filling out discharge paperwork today, Hannah came over and with urgency in her voice asked if I could come to her side to help her with a patient who was having a seizure. This guy is nearly the most physically wasted person I have seen. He is second only to a patient that we admitted to medicine last fall for hospice who ended up dying the same night of admission. She explained that this was a new patient she didn't know about, and on rounds today her attending said that he was getting treatment for presumed Tuberculosis. He said that he should be continued on therapy and he did not want any further discussion of the patient. Things always happen to the patients that we don't know anything about and this is a perfect example of that. When she had finished rounding with the medical students, he started seizing and she gave him two separate rounds of IV diazepam, which did stop his seizing. After this, she tried to get information from the nursing staff to find out if he had been responsive prior to this episode because following the seizure, he was unresponsive with a left sided gaze preference and what appeared to be spontaneous upward nystagmus. His breathing was labored and extremely shallow and the only pulses we were really able to feel were his carotids and femorals. We had absolutely NO information about the patient except what we could gather from physical exam, which showed extreme severe wasting of his entire right side that we later learned was congenital. The chart actually said that he was being admitted for Tuberculosis and as a rule-out DVT, but clearly there was more to it than that. We had no labs to go on, but we did have a chest x-ray that showed multiple bilaterally patchy opacities throughout the lung fields. He was on therapy for Tuberculosis and penicillin for possible community acquired pneumonia.

After fully looking over this guy and realizing that we were helpless to do anything (trust me, we were with the lack of information and resources) for him, we did the best we could, which was going over the possible differential for his seizure and treating the only thing we could. So, we took down his bag of D5 (5% dextrose in water) that was hanging (they absolutely LOVE D5 here) and instead hung a bag of normal saline and ran it wide open. The only information that we did have was that he was a monk from the mountains and the intern who admitted him over the weekend thought he had likely been starving himself for lent. Apparently that is a pretty common practice here. Actually, because of that, the medical staff initially refused to test him for HIV, but we insisted given his wasted appearance although it was negative. So, because we thought that it was likely he was extremely volume depleted and likely hyponatremic from not eating, we ran fluids to see if he would improve. With the fluids (and nothing more than that), miraculously after 2 hours this guy actually woke up and started talking. In all honesty, when I came to see him, I thought that there was no way on this earth that he would live another day. I guess it goes to show what can be done for a patient with only basic thinking (or maybe just luck). Unfortunately, we still don't have labs on him (it is was too late in the day for the lab to run anything), but hopefully we will get things sent off at least first thing in the morning.

Ok, now for the giggling part of the day. So, Hannah and I took off for lunch and decided to stay close to the hospital today, so we went to a nearby restaurant rather than going back to the hotel. We were both very tired and hungry when we got there and we were excited to be there because it was a place we had eaten previously and found it to be quite good. So, an Eritrean waitress came to our table and took our order--a large plastic water (1.5 L), a tuna sandwich, and a hamburger ala bismark (with egg). She clearly did not speak any English and had to flip between the English and Tigrinya pages of the menu to get our order numbers down. She clearly turned to the Sandwich menu on the Tigrinya side and pointed to #4 and #8, which corresponded to the English menu. Hannah and I waited for 40 minutes or so during which time we never got a water. Finally, a waitress started walking towards our table with two fresh pizzas in her hands. I made the comment "oh, those pizzas look really good"--keep in mind we were really hungry by this point. And to this, Hannah joked that maybe she would bring them to our table. I watched her walk, and sure enough she came to our table with our order--a fish pizza with what I think was sardines on it and an egg pizza topped with hard boiled eggs. We both looked beyond puzzled and Hannah said that this was not what we ordered, but the waitress again didn't speak English. So, we did the next best thing and just laughed and laughed and laughed. We took photos with our respective pizzas--mine was the fish and hers was the egg. Then, we proceeded to try our fish and egg pizzas. They were about as good as they sound--not good at all. We were so hungry at this point though, we each ate bits and pieces of the pizza. The fish pizza was nearly completely inedible, so we stuck with the egg pizza. I was extremely hungry to try this because I really cannot stand hard boiled eggs.

One interesting thing about Eritrea is that the people get very upset if you don't understand them or if they make a mistake. Whereas in the US, we would never have had to eat the wrong order or pay for it, here the waitresses were obviously offended and upset that we said we had the wrong order. All in all, the grossness of the meal was worth all of the giggling we got out of the deal. We made sure to get pictures of the pizza after we had eaten bits of it. We also tried to give our pizza away because there was nearly 2 whole pizzas left over, but even the guys sitting near us didn't want to have anything to do with it. After this experience, and in light of yesterday, we were so desperate to find something tasty to eat we decided we would go and get some gelato, which is something we had not yet eaten. We asked the guys next to our table and a random girl on the street where to go to get gelato and we did find our way to it. It was not before we walked past the lower half of a goat's leg and hoof laying in the street, presumably from the Easter celebration yesterday. We made sure to get a picture of that as well. When we did finally make it to the gelato place, we were so happy to have something that tasted so good, we didn't even mind that all of the flavors we were served were mixed together.

After work, Hannah and I, headed on our usual walk when I was hit with severe stomach cramps. I will leave the story here with, we had to hail a taxi to take us home, and Hannah had to pay because I was sprinting for my room when we got to the hotel. Needless to say, after a nice post work break, we were both very hungry. Maybe not hungry so much as needing something to feel satisfied. So, the three of us this time decided we would go to a nearby Indian restaurant for dinner. This place was on the top floor of a nearby hotel and upon walking in, it seemed clear that it was going to be good based on how nice the place looked. We got our menus after sitting down and we all three seemed very hopeful initially because the food sounded so good. We all got a little excited and ended up ordering wayyyyyyyy too much food. Everyone ordered an appetizer, there were 2 orders of Naan, and we each had an entree. While we were waiting for our food, Henish kept proclaiming how excited he was about this restaurant and how he was going to eat there every day until he leaves this Thursday. I'll just leave it at, it took a good 2.5 hours for us to get in and out of this restaurant and the food wasn't as good as we thought it would be. We had a LOT of leftovers, which we brought back to the hotel and gave to the staff. Henish was fairly disappointed, but I did enjoying saying "I told you so" as I tried to tell him not to get his hopes up. For what it was worth, his garlic Naan was pretty good. Right as we were leaving the restaurant, Henish got eaten up by a bug or bugs and sustained a good 7 itchy bites. He had a mini flip-out in the restaurant before we left, but I think he will be ok. All the while throughout dinner, we all could not stop laughing and the bug bites for Henish were the last straw. Or so I thought…I got one more really good laugh in my room when all of the power went out while I was brushing my teeth and I had to use my flashlight to finish. LOL.

Baaah Baaah Baaahhhhd Day

For some reason, my ability to post to this blog was inhibited for a
while. But, now I'm up and running again. I woke this morning around
7am and spent the first 2.5 hours of my day reading and updating
myself on the world. I have heard that Lambert Airport in St Louis was
hit badly by a tornado and is at least mostly closed. I'm not sure how
this is going to affect my flight home, but I do know that Dr. Windus
had to drive home from Chicago. Hopefully that will not be the case
for Hannah and I (or Henish who is leaving this thursday). We will be
leaving Thursday May 5th and will arrive home in St Louis on Friday
afternoon on May 6th. Hopefully some things will be fixed enough by
then that we will be able to get home. We are both extremely excited
about our flight back as we are both missing home a lot these days. I
can't wait to have a meal in the Frankfurt airport, and I also can't
wait to stock up on German chocolate while I am there. There isn't
much of a chocolate market in Eritrea.

And now, about our Easter Sunday...

Hannah and I spent the first part of our day in the hotel restaurant
writing in our journals and reading for a good 2 hours. It was quite
relaxing. Around 1:30 pm then, a friend of my intern, Joseph, came
and picked us up to take us to his house for Easter Sunday lunch. The
late hour of the lunch was due to the fact that they had slaughtered
the goat that very day and had to prepare the meal from it. Food here
doesn't come from a package in a grocery store like in the US. Wisely
Henish, who is a vegetarian, opted to skip out on the event, and this
proved to be the best idea ever. The house was very different from
the other three houses that we have been to with this family clearly
much poorer than the others. At the entrance of the house we were
greeted by two cats chowing down on a dead animal, likely a piece of
the goat. We were taken from entrance to the house into the living
area that couldn't have been any larger than 10ft by 10ft. In the
living room they had prepared a spread of fruit including mango,
bananas, guava, and orange all unpeeled. The small room
overwhelmingly smelled of sour fruit.

We sat on the small couch and took note of the room which was packed
with stuff including china, books piled nearly to the ceiling, and
very old stuffed animals. The TV was on playing the world news and
the family, particularly the father, spent most of the meal watching
the television. I'm not sure what he was getting from the TV because
he didn't speak a word of English, but he seemed quite intrigued. We
did meet both his mother and father, again who did not speak a word of
English, but did know a couple of words in Italian. To set the stage,
Hannah, myself and Joseph were on a very small couch, his father was
on a chair, and his mother was on a stool from where she was able to
serve the food. This arrangement in seating is apparently the usual
way that things are done in the house. Throughout the meal, his
parents did not speak except to say that we should keep eating, which
we were trying to do.

Joseph's mother brought in a large dish with injera (the round
traditional bread) onto which the rest of the food was served and out
of which we all ate. She brought in 3 different dishes and served
them individually. The first, was really the highlight of the meal
called Dulot. This delicacy, which they presumably don't eat very
often is made up of the goat's stomach and intestines. I'm not really
sure what to compare it to except that it was like very fine ground up
tan colored rubber with a flavor that was unlike anything I have ever
tasted (or ever want to taste again). This is eaten the same as the
rest of the national food that we have had, with injera. The dulot
was served first and we did try it, but were simply unable to stomach
it. We were saved by the fact that the meal was on a communal plate,
so we were helped by the rest of the family. Now do understand that I
fully respect this country and its culture, its just that goat
intestine is not something I'm really accustomed to eating. Also,
this family had prepared for our coming, and with only one dish in
front of us, there was no way we could not eat it (that would be very
rude). So, we tried our best to take down what we could, grabbing
with our injera very small microscopic portions.

The second course included something called Qulwa tseda, or goat meat
with the bones and marrow mixed with potatoes in a sort of stew. We
also lucked out and were served then at the same time Zigni, which is
sort of akin to spicy chili with only meat and spices (mostly onion),
which is where we gravitated to show that we were eating. Throughout
the meal, we had to balance the appearance of eating the food to show
respect and to accept this family's hospitality with our gag reflex.
I did try some of the goat meat-potato mixture and determined it just
wasn't for me. So, Hannah and I basically ate a whole lot of injera
with small dabbings of the various goat dishes, mostly Zigni. To
drink, Joseph served us some of the traditional drink, which we found
out only later was actually an alcoholic beverage, called Suwa. This
drink sort of looks like the the grass water you can get a whole foods
and did appear to separate upon standing. We each tried it, but again
couldn't stomach it, so instead we were given beer. Despite my
overall dislike for beer, I was relieved and happy to have one to have
something to drink that I knew was safe (aka. not diarrhea-provoking)
and could rinse my mouth with. Prior to ending the meal, Joseph gave
us each a shot of Arachi, which is a liquor he said was for
"digestion". This liquor tasted like licorice and made my esophagus
burn with even just a small sip. At the end of the main meal, they
brought a salad with an oil and vinegar dressing on it, which we ate
despite the concern for future diarrhea. When the main meal was over,
it was ended the way it started, with a prayer that was spoken in
Tigrinya and was lead by Joseph's father.

Joseph and his mother then removed the food from the table and served
us the fruit that was displayed in the room. We used the time they
left the room with his father focused on the TV to pour the Arachi
liquor into my water bottle and stash it away in my purse for disposal
at a later time. Because we had not had guava, Joseph made a special
point to have me peel a guava to try, which we found had very hard
seeds--tooth cracking almost. We split an orange, which although
green in this country, are very sweet and was the highlight of the
meal. Finally, we each had some popcorn and a piece of candy and the
meal came to an end.

This whole Easter lunch experience was good in one way--the family was
inviting and did serve us the traditional meal eaten by most Eritreans
on Easter (although most of them actually have lamb). However, it was
also traumatizing in another way simply because we were sort of forced
to eat these things that we couldn't stomach in order to avoid being
rude and inconsiderate. Despite our attempts to look like we were
eating, his parents continued to say throughout the meal that we
should eat more and more, which we did try to do. I felt very much
like an intruder since I didn't speak their language and the family
was quiet throughout the meal. I felt like the only thing I could do
to really show respect since we couldn't talk was to eat, but that was
obviously not possible.

After this event, we headed to Luam's house (my intern) for a coffee
ceremony. This experience was quite a bit different. She met us in
her Sunday dress, which looked just like something worn in the US (and
actually was sent from the US). Her mother was dressed in the
traditional Easter white dress we saw the night before, but was decked
out in 24 carat gold jewelry--large gold earrings, necklace, and
bracelets. Her hair was done specially for Easter with 5 large
sections of her hair sort of formed into a triangle and topped with a
braid in each section. Their house was extremely clean and inviting
and was the structure of a typical Italian villa, but was quite large.
Her mother, although she didn't really speak English, was very
inviting and talkative throughout our time there using Luam as a
translator. She was very interested in us and made us feel very at
home even asking if we would sleep over. She served us homemade lemon
cake, which wasn't too bad as well as a cake that they actually got
from a bakery in town (I didn't even know they had a bakery here). In
an effort to get the goat intestine out of our mouth, we each drank an
entire regular coke to start the afternoon. They had a coffee
ceremony for us, and I had I think 3 cups, again I think in more of an
effort to clear my mouth of goat. We had good conversation throughout
our time there, but after a good two and a half hours, Hannah and I
were exhausted from all of the not eating and awkward interactions
from the day. We took a taxi back to our hotel where we met up with
Henish and proclaimed our happiness that he did not go to lunch (being
a vegetarian and all).

So, what do I take away from this day? I'm glad I got to see Easter
in Eritrea--the dress, the singing, the tradition, the excitement of
the people. I, how shall I say this, respect the Easter Sunday feast
they prepare, but I don't want to experience this particular aspect
again. I love the people here--most of them are so inviting and
friendly, but I have had my fill of the exotic food. I don't want
people to think that the whole trip is about food because it certainly
is not, it is just a very VERY notable part of the trip. It did
certainly dominate the majority of this day. The policy for the rest
of the trip is to stick to a vegetarian diet and no more
experimenting. With all of the different houses we have been to since
arriving and more than that, with all of the actual hours we have
spent at people's houses, I feel as though I have a decent
understanding of the culture here. As with interviews for residency,
I can now say that for the time being, I am out of questions. Really
this is good because now I think I can relax and just take it all in
and stop asking questions. Goat anyone?

Easter eve

Today Hannah, Henish, and myself spent our time walking around Asmara through the markets and going in and out of little shops along the way. The market was busy like last weekend, but in contrast to last weekend, we noticed that there were a lot more people with animal. There were a lot of women with live chickens, holding them upside down, and men leading goats around the streets by their ears. All of these animals are in preparation for tomorrow's Easter Sunday feast the the people will have. Even yesterday at Melles' house, he had a lamb in his back yard for tomorrow. Basically all of the people here unless they are Muslim, have a celebration on Easter that starts with the sacrificing of an animal--sheep being very common. Usually the man of the house is supposed to sacrifice the animal, but some have people come into the home to do it. Children are not supposed to watch this tradition, and as we learned last night most of them don't want to watch any way. Then the animal is cut up by the women of the family, some of it stored, and some of it cooked for the day's celebration and end to the vegetarian diet they had all been following.

The people here are very religious with most everyone that we have encountered being either Catholic or Orthodox Christian. The religious nature of the people here is something that I wasn't expecting coming from the US. There are four religions recognized by Eritrea: Catholicism, Orthodox Christian, Baptist, and Muslim. The people essentially have to be one of these 4 recognized religions. Although Baptist is apparently recognized, I have yet to either see a Baptist church or meet someone who is Baptist. It seems that most of the people here we have spoken with are Orthodox.

On our wandering around the city today, we found the main Orthodox Christian church that people have been telling us about--St Mary's. We went around the back of the church and found a conference hall and a Sunday school classroom. There were some children who were getting a lesson it appeared in the conference hall and we were able to snap some pictures of them. We then went and had lunch and took our daily afternoon nap in preparation for this evening.

The festivities in the churches--both Orthodox and Catholic--happen mostly at night. Around town during our walk, there were people with palms tied around their heads, the palm-made rings they had made the week before, and just pieces of palms everywhere. There is service at both churches from 8pm until apparently 2-3 in the morning. The three of us decided this is something we should go and see since we are here. We hit the town tonight around 8:15pm and hit up the Catholic cathedral on the main street where they were holding mass in Italian. After a few minutes there, we eventually made our way back to St Mary's Orthodox Church where there were people--mostly women--lining the gates to the church and the outside of the church dressed in all white. The speakers for the church were broadcasting the singing from inside the church and after going in we realized why there were so many people outside--it was wayyyyyyy hot.

In the church, men and women were traditional white clothing, but women cover their heads. Since we are foreigners, we get a pass, but Hannah and I did wear skirts and covered our heads. She was lucky and was wearing a white shirt with a hood that she wore into the church while I wore a blue scarf that I bought the first day I was here. We looked like a pair of idiots, but no one minded. At the entrance to the church, which by the way has very plain architecture on the outside, there were palms over the ground. We had to take our shoes off at this point and we stepped into the church barefoot. Inside, was quite the sight--everyone was wearing white with most of the men on the left of the church and women on the right and everyone was standing throughout the service. The women were heavily clothed with their traditional white robes despite the heat. There was singing unlike anything I have heard, and which sounded much like I imagine the early churches many millenia ago would sing. Of course both the singing and the service were conducted in Tigrinya, so we didn't understand anything. The non-singing part reminded me some of Catholic mass, but was a little less scripted. In true Eritrean style, it didn't seem to be quite as organized as church usually is in the US. We did notice that they kept bringing in lots of candles throughout the service, which will presumably be used for the midnight service with lights off and candles on (sounds like a real fire hazard). The church was pretty packed already and it no doubt will continue to fill all night until the services end.

Now, I am sitting in my hotel room with my window open listening to the Orthodox Christian church singing that can be heard throughout the city. The Catholic cathedral church bell tower just rang, and I imagine will continue to ring periodically throughout the night until Easter Sunday finally arrives. We are very lucky that we are getting to experience this country's most beloved and serious holiday. Tomorrow, we will go to an Easter Sunday lunch where I believe a goat is on the menu.

Its a Good Friday

Today is Good Friday, which means that it is a really big holiday here in Eritrea. Basically everything is closed and most people have the day off. Even the medical students and the interns have the day off. The nurses in the hospital are off and there is a skeleton staff covering. No orders can be changed for the patients, so things are on stand-by until tomorrow when things go back to normal. The Christian people here fast all day until around 6pm or so when they go to church for Good Friday festivities.

I had a great morning, which started with a phone call from Denton around 6:40am. It was a nice way to wake up as we have only spoken 3 times on the phone since I have been here. The day then started at 11am Eritrean time (which means 11:45 because nothing starts right on time here) with lunch at Andu's house. Andu is the associate dean of the medical school here whose first class graduated in 2009. With the help of Jack Ladenson who is a PhD at Wash U they were able to supply the medical school with all of the books necessary to run the school. Andu is originally from Eritrea but spent 30 years in the US during the majority of the Ethiopian-Eritrean war getting his PhD in Immunology. He is married to an American woman and has 3 children, all of whom live in the US. He came back to Eritrea in the early 2000s to help with the initiation of the medical school.

Andu took us out to his house which is on the outskirts of Asmara. Driving there we passed through an area with a lot of newer construction (circa 1998) of large houses that was sort of the Eritrean equivalent of the suburbs. The difference is quite obvious though with groups of cows and goats being shuffles through the streets, people on bicycles riding on the main roads, and the soil around the construction is all red and unearthed like new construction in the US. Andu lives in a large, very nice house in the Eritrean "burbs" on a dirt road that is quite a bumpy ride. He gave us a tour of his house which is 3 stories tall and features a living room, a den, a formal dining room, a large kitchen with granite counter-tops, 5 bedrooms, and an attic bonus-room on the third floor with two separate balconies. It is built in sort of Spanish-villa style with all tiled floors, a red clay roof, and a separation between 2 of the guestrooms and the laundry room from the main house. It was very nice and in stark contrast to the house that we visited last week.

For lunch, he served national food including Injera with Shiro and another meat-containing dish, fried potatoes, salad, and spinach all of which was so delicious and healthy. After the main meal, we had a coffee ceremony during which I took an obscene amount of pictures. The coffee beans start out raw for the ceremony, which is something I have never seen before. They are actually green before they are roasted. His niece, who lives with him and did all of the cooking, roasted the beans in a small pan over a miniature coal fire in the living room until they turn brown-black. Part of the ceremony involves taking the smoking beans in the pan around the room and allowing everyone to smell them. Then, they are poured into a small container where she mashes them into coffee grinds with a wooden tool. At this point, she takes them and pours them onto a straw mat that is used to funnel them into the vase that the beans are cooked in with water to make the coffee. The coffee is brewed water and beans all together (no filter) in the vase over the small coal stove in the living room and each time it starts to boil over, she pours some out and then back in. She does this several times until she feels the coffee has brewed long enough. Then, the cups are filled with sugar and the coffee is poured and served. After being at another one of these, it seems that the typical food to serve with this even is freshly popped popcorn. We each had 3 cups of this coffee while snacking on the popcorn.

Spending time with Andu in this setting was very different from being at his office at the beginning of our trip. He seemed very at-ease at his house. During lunch, he talked about the industry here in Eritrea and the mining of gold, which is a relatively new resource that was discovered for the country. It has been just in the last year that the gold mining has started with production. Eritrea's other big exports are fish and salt.

We talked some about the possibility of increasing tourism here because now that I have been here I can see that there is a lot of potential for this country. He did say that there is talk of increasing tourism, but it doesn't sound like there are any immediate plans to increase the publicity for the country. Before I knew about this program for the residents, I didn't know that Eritrea was a country. I also would never have thought to visit because of the surrounding countries--Sudan, Ethiopia, and the close proximity to Somalia. Now that I have been here, however, I see that this small country is actually very safe and relatively tourist friendly. The problem though with the lack of knowledge about this place and the perception of this part of Africa is still a huge hindrance. Another major problem with tourism here is the lack of freedom for visitors. A permit has to be obtained to go almost anywhere in the country. Also, there needs to be more for tourists to do while they are here and some of the restrictions on travel need to be lifted. Regardless of what happens, I do see this as a place that I would love to come back to someday.

Generally, the people here are beyond friendly. They are also very beautiful and definitely gracious in everything that they do. Above all they lack that air of stress that Americans have. The culture is so relaxed (almost annoyingly so), which is indicative in the 2.5 hour lunch break that they take every day. The lunch break is also a necessity so that they can return home for lunch because people are relatively poor here. One thing that I love seeing are the older men--in their 50s to 70s even out in their suits (because a large part of the older male population wears suits) riding their bicycles. Very few people have cars, and bicycle is a very common and reasonable way to get around this city. There are also a lot of buses, but due to the crowding on the bus and the fact that so many people have Tb, we have avoided those.

The second half of our Good Friday involved going to Melles' house where we were able to meet his two kids, talk with his wife, Tsige (pronounced see-gay), and once again eat dinner. We started the evening with a more formal coffee ceremony again. So, today, I have had essentially 5 shots of espresso. ZZZZZzzzztttzzz...zzzztttzzz...(I may need an ambien and some benadryl to fall asleep tonight!). As it was 2 nights ago, the food was incredible. I don't want it to seem like all I'm doing here is eating, but much like in the US, the social gatherings are centered around food. Tonight's conversation with Melles and his family was the most natural and entertaining that we've had since we've been here. His family is so nice and easy to talk to. His children also speak excellent English with almost an American sort of sound. Tonight was a fun night with plenty of jokes and another lesson on the Tigrinya language. It was a good ending to our time with Dr. Windus who had to leave to head back to US tonight. Tomorrow should be another busy day of exploring the city Hannah and I and now Henish as well.

Rainy days

I have to say that I was so tired last night while I was writing that I was actually falling asleep while I was typing. I had to go back to read what I wrote because I didn't remember. Needless to say, the sleep deprivation here is taking a toll on me. It didn't help that I took a benadryl right before starting to write--that stuff is way more potent and sleep inducing than ambien! Unfortunately, due to the benadryl, I had a benadryl-hangover this morning and really all day. I was just completely out of it basically all day. But, somehow I did manage to get out of bed and get the day going.

I have to make a comment about last night's dinner. We went to a restaurant not too far from our hotel where Melles' wife's sister works (got it?). They placed the order for what we would be having the night before and all of the food was specially made for us. Unfortunately, the menu was not something that I could go out and just order here on my own because it was a special order, but it was so unbelievably good. I haven't mentioned this, but Hannah and I have been to several different restaurants around town and apart from the Chinese place, the menu is the same every where: Italian (spagetti, pizza, lasagna--but NOTHING like we have it in US, less tasty), burgers, fish of various kinds and national food. I have had more burgers here in the last 2 weeks than I have cumulatively in the last year simply because initially there just wasn't anything that sound appealing, especially in the heat. The Italian is OK and actually tonight we had pizza at the hotel and by far it was the best we have had thusfar. They put hardly any pizza sauce on the pizza. The fish is generally very good and comes with "vegetables" including potatoes, carrots, and squash. The national food is the typical Ethiopian dish found in American restaurants with injera and some sort of meat soup-goop in the center that is eaten with the hands. This is by far my favorite. Thats what I've got about the food here for now.

We went to work as per usual this morning and went to report once again at 8am. Today, we heard a death report on a patient that Hannah transferred to the ICU just 2 days ago. The case was very complicated with many details that I am leaving out, but ultimately before the patient was transferred to the ICU, she became unconscious for no clear reason despite an LP that was essentially unremarkable and broad spectrum antibiotics to cover meningitis and other infections. She passed away this morning, which given her multiple other serious problems was not unexpected, but she was only in her 20s. What I took away from report this morning though was that there wasn't really a review by the interns as to why she actually died and what the events were that lead up to her death. Any time a patient dies in the US, we always try to do a full review and make sure we really know what happened unless it is very obvious. That isn't something that is really emphasized as much here.

After report, rounds followed on the side of our ward with more significant problems. Our attending rounded on the entire side with us today, and it was actually nice to have him there for rounds today. I realized something about the medical system here today. First, I have to say that when I arrived here, the medical system actually seemed much more sophisticated than I was expecting. They have quite a lot of labs that can be ordered, x-rays, a CT scan, ultrasound, etc. But, the problem with a lot of this is that much of it takes a long time to come back (days), so it is quite difficult to manage patients who are acutely ill. I feel like a lot of decisions are made based on very little information, especially to what we would have making these same decisions here in the US. I would also like to comment on physician work hours related to this. Here, the typical day starts at 8am and goes to noon when there is really a 2.5 hour lunch break. Then there are admissions from 2:30 to 4:00 and then everyone goes home. The physician who is on call can leave shortly and then must return to be on call overnight, which they are every 3rd night. The limited time in which patient care is done here I think really speaks to the need for physicians to work long hours to be able to provide the best patient care possible. Additionally, I have found it extremely difficult to know everything that is going on with my 22 patients each day with a work day that only includes 5.5 hours of actual work. By the time we see the patients, review the vitals, get the lab results back, look at imaging, and admit new patients everyday, that doesn't leave a lot of extra room for reviewing charts or doing procedures. I understand with this system why only half of the patients are seen every day--there is just too much to do each day.

On that note, I did another thoracentesis today on a patient with a unilateral pleural effusion. These are a little more cumbersome in terms of removing the fluid as compared to doing them in the states because I was having to remove the fluid with a 20cc syringe. This patient today had about three-quarters of her right hemithorax full of fluid, so I needed to take quite a lot of fluid off. Because there are no vaccutainers here and the fluid doesn't drain really very well on its own, I had to aspirate the fluid over and over again with this syringe. But, we did end up getting a little of 800cc out, so hopefully she will at least feel a little bit better. The two patients that I have done these on likely have tuberculosis and I have learned that straw colored fluid is the expected appearance in this setting. I had to walk the fluid to the national health laboratory today myself, which involved a 2 block trek outside of the hospital. We'll see if the fluid is at all revealing.

It was quite cool today for a change and it finally did start raining at about 3pm and has been off and on raining since then. This is not the rainy season (July is), but it has been quite rainy, cool and cloudy for the last couple of days. Its sort of nice though if for no other reason than my room is now nice and cool. I'm also hoping this will keep the bugs away so that I wont have to apply my OFF! before going to bed tonight. Henish actually gave me something called Jungle Juice last night that is 98% DEET. Yes, that means it probably causes cancer. I sprayed it on the comforter of my bed as well as the curtains in my room hoping maybe this will keep the bugs away.

We have decided to stay in Asmara this Saturday to show Henish around and, quite honestly, to take it easy. We may also take a train to a nearby city this Easter Sunday since we wont have much else going on that day. We may try and go to some of the church festivities on Saturday night that goes on most of the night, but that may only be if we can get a hold of the appropriate dress. Tomorrow will be an eat-fest with lunch happening at the associate dean Andu's house, and then dinner with a coffee ceremony at Melles' house. I should get my fill of national food with that. :)

Taking Tea

Dr. Windus, Hannah, Henish and myself were up late last night talking about Eritrea and the medicine. Because I was up past my "bedtime" and because I slept horribly, I felt like I had been hit by a truck this morning when I woke up. Being a light sleeper is tough in a foreign place. One positive though was that I have decided to start turning on my water heater at night instead of some random time in the night when I wake up. The hotel requests that we turn it on 30 minutes before, but when the shower is the first event of the night, that really is difficult to do. No more lukewarm showers for me.

We all walked to the hospital today together. Dr. Windus showed us a new way that isn't really a whole lot faster, but it sure is nicer. Most of cars here are all old, probably from the 80s and early 90s, and its not like they have emissions testing here, so they all spue out exhaust. That has made our route on one of the main roads to the hospital somewhat unpleasant in the mornings. The buses here which provide a large part of the transporation for people are the worst. They seriously need some new vehicles. Or some better mechanics. So our new route bypasses the main road and is much cleaner and quieter. The main drawback is that we miss out on seeing all of the little children all dressed in their respective uniforms walking to school. If I haven't mentioned it, all of the kids here either go to school from 8 to 12 or from 2 to 6. They all wear uniforms that is determined by their grade. The youngest wear these long blue shirts that look almost like dresses with collars and black pants. They are adorable. I have a lot of pictures of random kids on the streets.

So we went to morning report this morning as per usual, but this time with the company of Dr. Windus and Henish. The case this morning was one of a 37 year old male with a 3 days history of anuric acute renal failure who was admitted with mental status changes and suddenly developed large volume hemoptysis overnight. On admission he was started on dialysis using the only dialysis machine they have at the whole hospital. He was essentially unconscious on admission and there wasn't any obvious explanation nor was there an investigation as to why. Then with the development of hemoptysis, he was intubated but there was no chest x-ray. I'm not going to keep on about this case, but it demonstrated the difficulty with very complex cases that are seen here. It was nice during this case to get the input from Dr. Windus and Henish.

So, after report, I started rounding on my own even without the intern. I feel like I am understanding better what is going on with my patients, but the problem is that it just takes soooooooooooooooooo long for anything to happen. After lunch today, for example, I spoke with my nurses about some chest x-rays that were supposed to be done, but they had not been doing even with having ordered them 2 days ago. A patient with an aleged sodium of 177 (I think this is lab error) was supposed to have labs drawn last week, but I learned they were never drawn. There is just so much more to stay on top of here with these patients that it makes it difficult and its not like there is a computer on which we can keep a list.

So, today I was able to do the first procedures that I have done since I have been here. I did a diagnostic paracentesis on a 23 year old female with type 1 diabetes and anasarca likely related to diabetic nephropathy. I also did a diagnostic and therapeutic thoracentesis on a 67 year old female with a history of weight loss, night sweats, fevers, shortness of breath, left sided chest pain and a whopping pleural effusion on the left filling up the entire left lung. During both of these procedures, I essentially used an 18 gauge IV line to do them with and Hannah and I both found this method to be infinitely easier than using the kits that are provided for us in the US. With this method, there is no need for any lidocaine because the needles are so small and go in so easily. I think that we should consider this method in the US.

After my procedures, I came out of the rooms intending to get some work done---like writing progress notes that don't get written very often. But, alas, my attending wanted to go have tea, so at 11:15am I took a tea break. After tea, I went to lunch. Oh, how difficult life is. ;) On our tea break I learned that my attending did his undergraduate training in Addis Ababa in Ethiopia, and then he did all of his medical training in Italy. He was initially trained for 5 years as a general internist and then he underwent training for treatment of solid tumors. He came back to Eritrea because this is where his family is and because they are constructing an oncology hospital which he will essentially be the one physician for. Currently, in this country, there is no such thing as chemotherapy at all. You have cancer, you either go to another country to get treatment or you die. I was thinking about having this cancer hospital, and I just don't know yet if I think it is a good use of resources for this particular country considering everything else they need (faster labs, better radiology facilities, books for the medical students, etc).

On our lunch break, Hannah and I returned to our hotel where we ate lunch and then took a quick nap. As per usual, we returned to work at about 2:30. We did bring a large delivery of books to the library as a donation. It was nice to get rid of them because of the weight they added in shipping them with our luggage. Because we will have essentially one free suitcase each, we should be able to do quit a bit of souvenier shopping to fill them back up. We still haven't really found anything that we want to buy though.

My afternoon went quickly, but Hannah had a new admission, which was quite interesting. 58 year old lady presented with a 1 year history of lower extremity paralysis and pack pain, chronic watery diarrhea for 6 months, and today she just became unconscious. Cord compression anyone? Oh, and there is not an MRI machine in the whole country and as far as I can tell the CT scans are all done without contrast.

Tonight we went to dinner with Melles and his wife at a restaurant where his sister in law works. The food was specially made for us and included a mix of Eritrean and Sudanese food. The menu included vegetables, spinach, two types of delicious fish, some sort of toasted corn thing, some eggplant dish, some lentil dish, broccoli, and bread. By far, I thought it was the best food that we have had since we arrived in Eritrea.

I have a lot to say, but alas, we stayed up late again talking. I guess I'll have to save it for another night.