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.