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.