I have so much to say...I am absolutely bursting at the seams. I just don't know if I can remember each and every detail. First, I have to say that yesterday was not such a good day for Hannah and I. We both had upset stomachs. With her permission, I am now allowed to post one of the extraordinarily funny stories. Today, we had lunch at a "fast food" place, which is essentially a regular restaurant. All I noticed was that they bring the bill quickly rather than keeping it until we asked for it. Anyway, after lunch, we went for a walk, trying to find the main local market. About 15 minutes into our walk, Hannah's stomach turned. So, we found the nearest place that looked like it might have a toilet--which just happened to be a grungy looking bar. We went in and found that it was filled completely with only men and was smokey inside (this is sort of odd because very very few Eritreans smoke). We asked the man at the front if there was a bathroom she could use, all the while Hannah appeared quite uncomfortable. I couldn't help but just die laughing--I know that I would not be laughing if I was in her position. Finally after what seemed like an eternity for her, but was probably only a few seconds, she was taken through the back room and into the bathroom. The "back room" per her report was a very dark smoky room with a pool table surrounded by 40-some-odd men who all looked shocked and very surprised when she walked through the door. Apparently bars like this one aren't a place that women go unless they are prostituting. LOL. Anyway, the bathroom was much akin to those in India for people who have been there with a hole that she leaned over to go. Not a very clean situation. So, she finished her business and came out regretting that she wasn't able to take a picture before another man came in. I will say, you learn a lot about the people you travel with. :)
A few things I have learned before I start rambling on about the medicine here. First, I the other day that Hannah and I went to the old Italian cemetery where, out of nowhere, several hundred men and women came walking through with all of the women wearing white. They proceeded to stop in front of what I now know was a church and the women split of to one side of the street while the men split to the other. Hannah and I were taking pictures and chatting while we were passing through this group. I now know that this was, in fact, a funeral. Now I feel like a real jerk. So, for anyone who travels to Eritrea, be advised.
I learned also that inflation here has been a huge problem since Ethiopia and Eritrea went to war in 1997. Back then, $1 US = $7 Nafka. Now, with legitimate exchange $1 = $14 Nafka, but on the black market $1 US = $40 Nafka. To give you an idea about how much the people here make, I learned that the nurses get paid about $700 Nafka per month. When Hannah and I go out to lunch or dinner the price is usually somewhere between $150-300 Nakfa for the two of us. This answers the question as to why we never see people eating in the restaurants, and instead they are all drinking coffee or tea. The lack of eating around me in some of the restaurants makes me a little bit sad and uncomfortable. The Eritrean people, though, seem quite happy.
Now, ten random comments before the medical rambling: First, Hannah and I are starting to get a little sunburned. I think it is time to break out the sunscreen. Second, the fruit here is really very good, and the juice is even better. Third, the daily morning singing coming from the Mosque here is really starting to get annoying--it wakes me up even with earplugs. Fourth, the children here all wear uniforms to school and are super-cute. Fifth, its not a very good idea to give the beggar children stuff--they will haunt you. Sixth, Hannah and I saw a man pooping on the sidewalk today. But don't worry, I snapped an aftershot on our way home. Seventh, generally this city is actually very clean (don't get the wrong idea). Eighth, I can't wait to have a coke zero when we get to Frankfurt in 3 weeks. Ninth, I am very thankful that my hotel has a hair dryer. And finally, tenth, I am very impressed with the Eritrean's lack of excess here (everyone is skinny, no trash, no excess waste).
Today we met once again for morning report as we did yesterday at 8am. The first case today was a shocker. A 63 year old female with a history of coronary artery disease came in with "sharp" left sided chest pain that radiated to her back. She was admitted to the ER for rule-out ACS and was treated with "MONA" (morphine, oxygen, nitroglycerin, and aspirin). Her chest x-ray was unremarkable. When we got to the EKG, the intern explained that there were T wave inversions. So, we took a look--there were very very very obvious ST elevations in leads V1-V3. We explained that this was a STEMI and this is someone who would ordinarily be treated with immediate catheterization in the US. But, alas, there is no catheterization here. Although they do give heparin drips here, she was not started on one, but she was now pain free. I did get pictures of her EKG, which by the way is printed out as a telemetry strip rather than on a regular sheet of paper.
After report we went back to the medicine floor and I rounded once again with the intern with the attending on stand-by for consultation if needed. For the first time today, on rounds I actually felt useful. She presented to me a short blurb about each patient and I manically went through the vitals, which hang at the end of the bed, the chest x-ray, which are hidden underneath the bed, and the labs which may or may not be completely documented in the chart. Each patient here is remarkably sick and I feel like there is very little information to go on to make a firm diagnosis. Additionally, it is extremely hard to make day by day decisions on these people when there aren't up to date labs on people. Despite this, I did feel like I made some useful patient management contributions on rounds today.
There are interesting things here that are just NOT seen in the US. Case and point, there is a man who presented with fevers, hepatosplenomegaly (large liver and spleen) and ascites whose leishmaniasis testing returned positive. He has since been started on treatment for this with sodium stibogluconate, which is a drug that, until this trip, I had never heard of.
Another patient who came in just today is a 38 year old woman (who, by the way, looks like she is 70) who presented with chronic cough productive of very foul-smelling sputum. She came in because the smell had gotten so bad and the sputum was copious. She has had a chronic cough for 10 years and was diagnosed 4 years ago incidentally after she had a chest x-ray for a preoperative workup. She has been treated with multiple rounds of antibiotics, which here means penicillin, amoxicillin, and ceftriaxone. She has had fevers at home, but was afebrile on admission to the ward. Her last antibiotics were 3 months ago and since that time she has been having worsening symptoms. She was treated for Tb 3 years ago and received 8 total months of treatment. Her Chest x-ray (and previous ones) shows an obvious abscess in the right mid-lung with an air-fluid level. I should also mention that this patient has some wicked clubbing.
I feel like everyone here has Tuberculosis. Everyone. I feel like I should really be wearing my N-95 face mask constantly while I am in the hospital. I learned today that Eritrea is a place where the BCG vaccine is given because it is such a problem. Every patient that I talk to, the first couple of questions include "are you having cough" and "are you having night sweats or weight loss". If the answer to either of those is yes, then I err on the side of wearing the mask. Case and point, one of the patients I admitted yesterday is a young female with a history of generalized weakness and edema. I'm not going to go into everything about her because she has a LOT of problems, but her rapid HIV was positive and she has been coughing up blood for several weeks. Thankfully, the second question I asked was about cough--then I put on the mask. Maybe I am too paranoid, but I just feel like everyone here should be on isolation.
In writing all of this, I should say that the diagnosis in many of these patients is something that is jumped to very quickly without a whole lot of consideration for differential. If something fits, then that is what it is. No questions.
That being said, I saw a patient today who really had an impact on me. I think it was the way that he looked at me. He is a young man with a history of apparent Tb pericarditis treated for Tb in both 2008 and 2010. He came in with volume overload and shortness of breath. An echo was done which showed a "restrictive filling pattern" (that is all the echo reports here say--there are no number, no EF, no nothing else). If this is the case, then I am presuming that he may have constrictive pericarditis now from his previous infection. And here, there is really nothing more that can be done. There are no cardiac surgeons here, so any sort of pericardial surgery is out of the question.
Another girl on Hannah's side has severe MS from rheumatic heart disease with resultant left sided failure, pulmonary congestion, right sided failure, and finally hepatic congestion, cirrhosis and ascites. There are a lot of reasons living her for her ascites, but it seems that in this case, her cardiac disease is the most likely. She is someone that we saw on the first day--we were both astounded by her crazy murmur. I don't think I have every heard or seen a 5/6 murmur, but now I have. She has an astounding thrill that can nearly be seen when looking at her chest. Needless to say she is hyperdynamic. Her ascites from her liver congestion also is quite honestly about the worst I think I have ever seen. Its remarkable that she can breath--she looks 15 months pregnant (thats a lot!). Unfortunately, I don't think there is much anyone can do for her now, so she is just sitting on the medicine floor without a clear plan.
Another patient we saw on the first day was a young man with Cushing's disease. He presented with hypertension and weakness as well as cool physical findings. He has facial plethora, moon facies, lower extremity edema, and most of all, the most amazing striae that I have ever seen. Not exaggerating, I would say they are on the order of 2 cm in thickness and run the entirety of his abdomen. Hannah learned today that he also has them on his butt. He did have a CT scan (because MRI isn't available here) which showed a macroadenoma. Neurosurgery was consulted today--funny story there--for consideration for surgery. Meanwhile, he is just hanging out on the wards, walking around, getting BP meds, and watching TV.
I have to say that many of the patients who are here in the hospital don't have a clear defined plan of care. Many of them don't necessarily need to be in the hospital, but are kept for various reasons that still aren't completely clear. On the patients without a clear plan and no appropriate treatment (my 2 cardiac patients mentioned above), I am still not sure what will happen or what usually happens for them. I'll keep you posted.
About Me
- Rachel Kilpatrick
- Arkansas, United States
- I am a busy mom first and foremost. This is about my attempt at being a mom and working. I'm not sure how people do it and make it look so easy. It is not easy. But we have fun doing it!
Friday, April 15, 2011
Thursday, April 14, 2011
GI upset
Today was our first full day on the medicine ward. We arrived at 8:00am to start morning report, which is where cases that were brought in overnight are presented and discussed and any other interesting cases are brought up. Amazingly, there were no admissions to the hospital, just one patient that was "admitted" to the ER for observation to rule out ACS. Their management of ACS--acute coronary syndrome (aka chest pain/heart attack)--is quite a bit different from that in the US. Here, the patient came in with a story that sounded unlike pain related to his heart. However, there were some nonspecific findings on EKG that required further evaluation. However, the evaluation here, as for many things, involves simply observing the patient without actually investigating anything. He did get nitroglycerin and morphine, but they were reluctant to give aspirin, which is a staple in this case without any contraindications. He will stay in the ER for some amount of time--I guess until they decide to send him home after a few hours maybe? The primary difference here is that there was no testing for cardiac biomarkers performed--no CK, no troponin. In our practice, these are mainstays of care to ensure no cardiac involvement.
After report, we dispersed to the wards--I went to my side and Hannah to hers. My intern started the day by getting breakfast much like we do when we are postcall as she had been on overnight. I started my day by interacting with a group of medical students who were very eager to hear about the US and how I liked my residency program. The medical students here are so cute and enthusiastic about seeing patients and learning. One of them made the comment to be that they all wanted to be where I am. Hearing this made me both thankful for my opportunity and sad for them because the fact is that it is unlikely any of them will get training like mine when they are through. Because the medical school here is free, they owe at least 2 years of service when they graduate. The medical school here was started just a few years ago and the first graduating class was in 2009--I think something like 30 or 35 students? There are residency programs here only in pediatrics, ob/gyn, and surgery. In speaking with one of the deans for the medical school, Dr. Andu, a couple of days ago he related that there are only 5 or 6 ob/gyns in Asmara. So, for these students, it is less likely that they will get to do a residency at all when they are finished. Hopefully they will be able to get a medicine residency going in the near future.
So, I rounded with my intern, Luam, today on my own with the medical students. After we covered the half-ward today, we were able to talk with the attending about cases and questions that we had. The patients are all very complicated and yet they are simplistic because the resources here are limited. We cannot order every test and look into every single abnormality like we would ordinarily do for these patients in the US.
Hannah and I returned to the hotel today for lunch where we went to our respective rooms for the first time and just napped or e-mailed. We each chose to have a granola bar for lunch--yep, as per the title of this post, it has happened. The African version of Montezuma's revenge has struck both of us unfortunately, so we are now starting our Cipro for travelers diarrhea. Sorry, too much information. On that same note, we are both now just spending the night at the hotel rather than exploring the city--its safer here as we are close to a bathroom.
So now, I will share some of my "random thoughts" about this place...
Concerning Tuberculosis, I learned that any patient that presents with a cough and an infiltrate on chest x-ray first gets a round of regular penicillin G. While the sputum is pending to rule out AFB (or tuberculosis), they look for improvement in the patient clinically. If the sputum comes back AFB positive, then they of course start tuberculosis treatment. If the sputum is negative and the patient does not improve on penicillin, then they empirically start tuberculosis treatment. This is simply due to the fact that it is so unbelievably common here. There is virtually no such thing as a negative ppd. Finally, the treatment regimen comes in combined pill, so there is no option for people who don't tolerate one or another drug. As an example, I have a patient who had an extraordinarily complicated presentation, but the bottom line is that she has Tb. During her first round of Tb treatment, she developed drug induced hepatitis presumably from the INH therapy. So, they stopped the therapy, allowed her to recover and then restarted the therapy. Now she is encephalopathic from recurrent drug-induced hepatitis. We stopped the Tb therapy again, but there is no option with respect to restarting her on medication because we do no have medications outside of the combination therapy.
I learned also that because Tb is so common here, that the nurses cannot work on the medicine service for longer than 6 months at any one time due to the high risk of developing active Tb. Instead, the rotate at least every 6 months to somewhere else such as the ER or surgery to decrease this risk. I found this astounding, bizzare, and a little scary. I just don't see how I am not going to convert to positive after this experience.
The treatment for a DVT (blood clot) is quite a bit different from the usual in the US. Whereas in the US, a patient would be started on either a heparin drip or lovenox plus coumadin to go home with, here they are started on heparin 10,000 unit loading dose followed by 5,000 unit q6 hours depending on the clotting time (checked also every 6 hours). After 7 days, they are started on coumadin and are kept until their INR is therapeutic. But, they only check PT/PTT (coagulation studies) every tuesday and thursday. What does that mean? That means your average patient (really no matter what the problem) stays in the hospital much much much much longer than your average patient in the US.
On an unrelated note, I have found that the process of ordering either water or dinner here is always an adventure. On our first day, Hannah and I first stated that we wanted a coke, then we changed our minds and instead ordered regular bottled water, and then ordered orange juice. From that order, we received orange juice, a coke, and water "with gas" as they say. Each time we order water, it seems we get something different. They always ask if you want it "with gas" or "no gas". Yesterday we both ordered water "with gas" and the lady brought both of us tonic water. I stopped her as she was opening mine and asked for regular "non-gas" water. With this, she became flustered and went to get another waitress to help us. That is another thing, the people here are very easily offended--so ordering water has become somewhat of a stressful event. The primary problem with all of this is that although much of the population does speak a fair amount of English, they don't every have to speak it, so they have terrible accents and are very hard to understand and they just aren't terribly fluent in the language (and that includes the interns that I am working with).
Another random thought...I was able to figure out my water heater situation last night after I had the lady at the front desk come and help me. The switch is on the wall to my room and not on the heater itself. So this morning was the first day that I have taken a warm shower in my own room. It was very refreshing and much-needed. The drawback though is that the water is quite limited, so I had just about enough water for another very quick 3-4 minute shower while turning off the water while washing. It makes me giggle just a little. :)
I was thinking today that I am surprised the people here are not completely anorexic (although they are generally quite thin). I say that because although I have been forcing myself to eat, and rather heavy meals at that, I have absolutely no appetite in this heat. I don't think it is all because of my new gi upset either--walking in the hot sun and being in non-airconditioned hospital rooms that cause the sweat to build up really takes away the appetite. Today I ate 2 out of the 3 times when I absolutely was not hungry. Lunch today consisted of a special K bar that I brought from the US. At dinner I was starving, but not in the way that I usually am. I had a headache, a low blood sugar, and a growling stomach, but still the thought of food wasn't too terribly appealing to me. Maybe the answer to the US obesity problem is to do away with air conditioning. That definitely works to curb the appetite.
Tomorrow I will try and post about some of the interesting cases that we have seen since we have been here. Good night!
After report, we dispersed to the wards--I went to my side and Hannah to hers. My intern started the day by getting breakfast much like we do when we are postcall as she had been on overnight. I started my day by interacting with a group of medical students who were very eager to hear about the US and how I liked my residency program. The medical students here are so cute and enthusiastic about seeing patients and learning. One of them made the comment to be that they all wanted to be where I am. Hearing this made me both thankful for my opportunity and sad for them because the fact is that it is unlikely any of them will get training like mine when they are through. Because the medical school here is free, they owe at least 2 years of service when they graduate. The medical school here was started just a few years ago and the first graduating class was in 2009--I think something like 30 or 35 students? There are residency programs here only in pediatrics, ob/gyn, and surgery. In speaking with one of the deans for the medical school, Dr. Andu, a couple of days ago he related that there are only 5 or 6 ob/gyns in Asmara. So, for these students, it is less likely that they will get to do a residency at all when they are finished. Hopefully they will be able to get a medicine residency going in the near future.
So, I rounded with my intern, Luam, today on my own with the medical students. After we covered the half-ward today, we were able to talk with the attending about cases and questions that we had. The patients are all very complicated and yet they are simplistic because the resources here are limited. We cannot order every test and look into every single abnormality like we would ordinarily do for these patients in the US.
Hannah and I returned to the hotel today for lunch where we went to our respective rooms for the first time and just napped or e-mailed. We each chose to have a granola bar for lunch--yep, as per the title of this post, it has happened. The African version of Montezuma's revenge has struck both of us unfortunately, so we are now starting our Cipro for travelers diarrhea. Sorry, too much information. On that same note, we are both now just spending the night at the hotel rather than exploring the city--its safer here as we are close to a bathroom.
So now, I will share some of my "random thoughts" about this place...
Concerning Tuberculosis, I learned that any patient that presents with a cough and an infiltrate on chest x-ray first gets a round of regular penicillin G. While the sputum is pending to rule out AFB (or tuberculosis), they look for improvement in the patient clinically. If the sputum comes back AFB positive, then they of course start tuberculosis treatment. If the sputum is negative and the patient does not improve on penicillin, then they empirically start tuberculosis treatment. This is simply due to the fact that it is so unbelievably common here. There is virtually no such thing as a negative ppd. Finally, the treatment regimen comes in combined pill, so there is no option for people who don't tolerate one or another drug. As an example, I have a patient who had an extraordinarily complicated presentation, but the bottom line is that she has Tb. During her first round of Tb treatment, she developed drug induced hepatitis presumably from the INH therapy. So, they stopped the therapy, allowed her to recover and then restarted the therapy. Now she is encephalopathic from recurrent drug-induced hepatitis. We stopped the Tb therapy again, but there is no option with respect to restarting her on medication because we do no have medications outside of the combination therapy.
I learned also that because Tb is so common here, that the nurses cannot work on the medicine service for longer than 6 months at any one time due to the high risk of developing active Tb. Instead, the rotate at least every 6 months to somewhere else such as the ER or surgery to decrease this risk. I found this astounding, bizzare, and a little scary. I just don't see how I am not going to convert to positive after this experience.
The treatment for a DVT (blood clot) is quite a bit different from the usual in the US. Whereas in the US, a patient would be started on either a heparin drip or lovenox plus coumadin to go home with, here they are started on heparin 10,000 unit loading dose followed by 5,000 unit q6 hours depending on the clotting time (checked also every 6 hours). After 7 days, they are started on coumadin and are kept until their INR is therapeutic. But, they only check PT/PTT (coagulation studies) every tuesday and thursday. What does that mean? That means your average patient (really no matter what the problem) stays in the hospital much much much much longer than your average patient in the US.
On an unrelated note, I have found that the process of ordering either water or dinner here is always an adventure. On our first day, Hannah and I first stated that we wanted a coke, then we changed our minds and instead ordered regular bottled water, and then ordered orange juice. From that order, we received orange juice, a coke, and water "with gas" as they say. Each time we order water, it seems we get something different. They always ask if you want it "with gas" or "no gas". Yesterday we both ordered water "with gas" and the lady brought both of us tonic water. I stopped her as she was opening mine and asked for regular "non-gas" water. With this, she became flustered and went to get another waitress to help us. That is another thing, the people here are very easily offended--so ordering water has become somewhat of a stressful event. The primary problem with all of this is that although much of the population does speak a fair amount of English, they don't every have to speak it, so they have terrible accents and are very hard to understand and they just aren't terribly fluent in the language (and that includes the interns that I am working with).
Another random thought...I was able to figure out my water heater situation last night after I had the lady at the front desk come and help me. The switch is on the wall to my room and not on the heater itself. So this morning was the first day that I have taken a warm shower in my own room. It was very refreshing and much-needed. The drawback though is that the water is quite limited, so I had just about enough water for another very quick 3-4 minute shower while turning off the water while washing. It makes me giggle just a little. :)
I was thinking today that I am surprised the people here are not completely anorexic (although they are generally quite thin). I say that because although I have been forcing myself to eat, and rather heavy meals at that, I have absolutely no appetite in this heat. I don't think it is all because of my new gi upset either--walking in the hot sun and being in non-airconditioned hospital rooms that cause the sweat to build up really takes away the appetite. Today I ate 2 out of the 3 times when I absolutely was not hungry. Lunch today consisted of a special K bar that I brought from the US. At dinner I was starving, but not in the way that I usually am. I had a headache, a low blood sugar, and a growling stomach, but still the thought of food wasn't too terribly appealing to me. Maybe the answer to the US obesity problem is to do away with air conditioning. That definitely works to curb the appetite.
Tomorrow I will try and post about some of the interesting cases that we have seen since we have been here. Good night!
Wednesday, April 13, 2011
First day on the ward...
First, I would like to say that I am quite thankful that the internet is working tonight. I am trying to send e-mails and update things as quickly as possible to capitalize on it. Needless to say it is painfully slow and only works when it feels like it. Anyway, today we were able to get our documents taken care of and were able to finally start on the medicine wards. We first met Dr. "Z"--the names here are just too much--and went along with him rounding on the half of the ward that he had today. To explain how it is structured here, Orotta is the a referral center caring for patients who were transferred from other hospitals as well as patients who come in from the ER that need to be admitted. There is essentially one floor that is split into two sides, 3A and 3B. 3A has around 35 beds while 3B has around 25 beds. There is an attending assigned to each side who oversees the work of an intern who is a 6th year medical student. The intern is essentially responsible for all of the work, orders, admitting, etc on the medicine ward. From what I gather so far, the intern and attending only round on one-half of the patients each day alternating days, so each patient only gets seen every other day unless they are really sick. Daily notes then obviously are also only written every other day on each patient. The interns also have the responsibility while on their medicine "attachment" which is what they call it of being on call for the ER every third night. When they do this they are on and cover the ER as well as any questions that come up on the medicine floor. Much like old school residency training, they don't get a day off, ever. The schedule is the same as for everyone in the country though--they generally get here around 8am for morning report which is where the patients that were brought in overnight are presented. They they take a 2 hour lunch which goes from 12-2:15pm and they admit then from 2:15 to around 4:00pm. The attendings are passionate about leaving at 4:00pm and aren't necessarily there for the interns on a daily basis, but are available via phone if needed.
Anyway, so that is the background...the medicine here is beyond different from that in the US. It is somewhat laughable actually at exactly how different it is. When we are taught to think about a differential diagnosis in the US we think of one set of problems--for obvious hepatitis for example--acute hepatitis>/= alcoholic hepatitis>drug induced>autoimmune, etc, etc. Here, the differential is, well, depending on the patient and where in the country they are from schistosomiasis, leishmaniasis, acute hepatitis, Tuberculosis, or in several patients in the hospital INH toxicity from Tb treatment? Say what? I literally have not thought about schistosomiasis or leishmaniasis since medical school. But, as soon as I finish this post, I plan on reading all about it. I found that one of the main questions that is asked in these patient is where they are from because that may change significantly which of the two is considered.
On another note, I brought books with me to study--a book on tropical disease that I purchased that I think is produced by the WHO. While it will be useful to learn the basics about the disease, it wont tell me a darn thing about how the people here actually treat the diseases. For example, chloramphenicol is the main antibiotic that is used here for serious infections. Say what? Again, something I have banished from my memory because we never use it in the US due to side effects.
I was somewhat surprised though today--I found that the physicians here care for the patients as best they can with the resources they have. They are not focused like we are at all on the patients history--getting a past history, medications, family and social history. They focus on the problem at hand. We are able to get studies here--labs including CBC, BMP, coags, x-rays, but those things take times, several days to come back. CT scans can be ordered, but the CT scanner--just one--is at another hospital, so the patients must be taken to that hospital for his or her study. Because you can't get things instantly to help you make decisions quickly like you can in the US, they simply treat based on their initial impressions. The medical students--whom Hannah had interactions with today--are apparently extraordinarily keen on their physical exam skills debating amongst themselves about the specifics of a horrifically loud murmur or being able to determine with feeling if a patient has even the slightest splinting on inspiration. It is sort of sad and we very much take it for granted as US physicians, but I really don't think that we focus NEARLY as much on the physical exam now simply because we just don't have to. Certainly, without the lack of instant-gratification answers from labs, imaging, etc, that is something that I will have to get better at while I am here.
On the one hand, I feel sort of inept with taking care of the medical problems they see frequently, I do have something to offer. There are things that we see much more frequently in the US because we have the luxury of instant labs. For example, I was able to talk with the intern and teach her today about the diagnosis and management of hypernatremia (high level of sodium on blood test). I ran into a problem though--in explaining the full work up, we ordinarily might order urine studies to help discern the cause if the cause was not clear. I found here today though that urine electrolytes and osmolality aren't things that are done here. It wasn't necessary on this particular patient because the cause was obvious, but it really does change the way you have to approach things when the labs that are normally used aren't available.
On other notes from today, on our 2 hour lunch break, Hannah and I went to an old Italian cemetary which sits above the hospital on a hill. It was sort of creepy and very ornate--I wish I could post pictures, but the internet here just wont allow it. On our way to lunch from that there was some sort of an Islamic ceremony going on--I really don't want to sound stupid, but to us it looked like some sort of mid-day blessing. The men and women separated across the street from one another-the women were all wearing white head scarves and the men were just in regular clothes. After a man in white did some talking and then passed by people, they were able to disperse. Anyone know what this was?
We had Cappuccino tonight after work. Again, the Cappuccino here is amazing. There a ton of restaurants that only serve coffee, tea, and pastries. No real food. I guess in a way it reminds me a little bit of their version of Starbucks except not. Something that came up when Hannah and I were at dinner last night was how the restaurants all really start to fill up at 8:00pm. We took note, however, that although they start to eat at 8, they cafes are full of people every night drinking tea and coffee. The people here are very social and are so much later than in the US. The coffee shops like the one I mentioned are full of people most of the time getting drinks--but whereas in the US they are all there for a purpose--reading the newspaper, working on a computer, to discuss something--the people here are all there just to chit chat. The people here do not have an agenda like we do in the US. Even with walking--here it truly appears that people here walk just to walk--in the US we would only walk for a purpose; to get somewhere we had to go, to walk the dog, to lose weight, etc.
Anyway, that is enough for now. I realized while at dinner just now that I have only been here 2 days, but those 2 days have felt like at least 5. Maybe that has something to do with the 2 hour lunch making the day seem split or the fact that I don't have an agenda here.
Anyway, so that is the background...the medicine here is beyond different from that in the US. It is somewhat laughable actually at exactly how different it is. When we are taught to think about a differential diagnosis in the US we think of one set of problems--for obvious hepatitis for example--acute hepatitis>/= alcoholic hepatitis>drug induced>autoimmune, etc, etc. Here, the differential is, well, depending on the patient and where in the country they are from schistosomiasis, leishmaniasis, acute hepatitis, Tuberculosis, or in several patients in the hospital INH toxicity from Tb treatment? Say what? I literally have not thought about schistosomiasis or leishmaniasis since medical school. But, as soon as I finish this post, I plan on reading all about it. I found that one of the main questions that is asked in these patient is where they are from because that may change significantly which of the two is considered.
On another note, I brought books with me to study--a book on tropical disease that I purchased that I think is produced by the WHO. While it will be useful to learn the basics about the disease, it wont tell me a darn thing about how the people here actually treat the diseases. For example, chloramphenicol is the main antibiotic that is used here for serious infections. Say what? Again, something I have banished from my memory because we never use it in the US due to side effects.
I was somewhat surprised though today--I found that the physicians here care for the patients as best they can with the resources they have. They are not focused like we are at all on the patients history--getting a past history, medications, family and social history. They focus on the problem at hand. We are able to get studies here--labs including CBC, BMP, coags, x-rays, but those things take times, several days to come back. CT scans can be ordered, but the CT scanner--just one--is at another hospital, so the patients must be taken to that hospital for his or her study. Because you can't get things instantly to help you make decisions quickly like you can in the US, they simply treat based on their initial impressions. The medical students--whom Hannah had interactions with today--are apparently extraordinarily keen on their physical exam skills debating amongst themselves about the specifics of a horrifically loud murmur or being able to determine with feeling if a patient has even the slightest splinting on inspiration. It is sort of sad and we very much take it for granted as US physicians, but I really don't think that we focus NEARLY as much on the physical exam now simply because we just don't have to. Certainly, without the lack of instant-gratification answers from labs, imaging, etc, that is something that I will have to get better at while I am here.
On the one hand, I feel sort of inept with taking care of the medical problems they see frequently, I do have something to offer. There are things that we see much more frequently in the US because we have the luxury of instant labs. For example, I was able to talk with the intern and teach her today about the diagnosis and management of hypernatremia (high level of sodium on blood test). I ran into a problem though--in explaining the full work up, we ordinarily might order urine studies to help discern the cause if the cause was not clear. I found here today though that urine electrolytes and osmolality aren't things that are done here. It wasn't necessary on this particular patient because the cause was obvious, but it really does change the way you have to approach things when the labs that are normally used aren't available.
On other notes from today, on our 2 hour lunch break, Hannah and I went to an old Italian cemetary which sits above the hospital on a hill. It was sort of creepy and very ornate--I wish I could post pictures, but the internet here just wont allow it. On our way to lunch from that there was some sort of an Islamic ceremony going on--I really don't want to sound stupid, but to us it looked like some sort of mid-day blessing. The men and women separated across the street from one another-the women were all wearing white head scarves and the men were just in regular clothes. After a man in white did some talking and then passed by people, they were able to disperse. Anyone know what this was?
We had Cappuccino tonight after work. Again, the Cappuccino here is amazing. There a ton of restaurants that only serve coffee, tea, and pastries. No real food. I guess in a way it reminds me a little bit of their version of Starbucks except not. Something that came up when Hannah and I were at dinner last night was how the restaurants all really start to fill up at 8:00pm. We took note, however, that although they start to eat at 8, they cafes are full of people every night drinking tea and coffee. The people here are very social and are so much later than in the US. The coffee shops like the one I mentioned are full of people most of the time getting drinks--but whereas in the US they are all there for a purpose--reading the newspaper, working on a computer, to discuss something--the people here are all there just to chit chat. The people here do not have an agenda like we do in the US. Even with walking--here it truly appears that people here walk just to walk--in the US we would only walk for a purpose; to get somewhere we had to go, to walk the dog, to lose weight, etc.
Anyway, that is enough for now. I realized while at dinner just now that I have only been here 2 days, but those 2 days have felt like at least 5. Maybe that has something to do with the 2 hour lunch making the day seem split or the fact that I don't have an agenda here.
Tuesday, April 12, 2011
Capuccino
I woke up this morning 50 minutes before my alarm and later learned that for whatever reason I was an hour ahead of local time. I went to wake Hannah up this morning at what I thought was 9am, but learned that it was actually 8am. Its a little funny considering the title of my last post. I am pretty firm in knowing the current time now--currently it is 12:45pm here and 4:45am back home. I think.
I went to bed last night with the door to my balcony open and I woke up with the sun shining in to my room from the east. My curtains are yellow as is the blanket on my bed, so my room appeared to be glowing when I woke up. Quite the welcome way to wake up on my first day here. I thought I would be smart and get up before my alarm today so that I could turn on the water heater for my shower. Unfortunately, I ended up turning my water heater OFF, so I had the joy of taking a cold extraordinarily fast shower this morning. I think I have quite a bit of conditioner residue in my hair due to the rushed nature of my rinsing.
Last night Teddy told us that he would pick us up late today--whenever we called him. Unfortunately however, that was not the case and instead Dr. Andu, the dean of the medical school here was at our hotel bright and early at 8am to pick us up. He called the room, so we quickly got ready. I was rushed even more by my nice cold shower. We met him in the hotel restaurant where he seemed very relaxed and didn't mind that we went ahead and had breakfast. Even at breakfast I could already tell quite the difference in the Eritrean people. They are remarkably relaxed--in no hurry and on no schedule to get things done. It is so refreshing coming from a place where I always feel stressed and like I should always be doing something. The default here is to take a break and relax.
Hannah ordered and egg for breakfast which came with toast and a banana. I had a piece of toast with their jelly. The bread seemed so hearty. They made fresh squeezed orange juice for use, and this was absolutely delicious. Something I could definitely get used to.
After breakfast, we drove with Dr. Andu to the medical center where the medical school and hospitals are. On this short trip we got to see more of the city. The architecture is very distinct and reminds me of Italian villas or southern Spain. Everything is very close and within walking distance, which will be good for Hannah and me getting to work each day. The place is so pedestrian friendly, which seems funny to say because very few people have cars relative to the population. There are people walking the streets everywhere. Above all, the people have an air of friendliness. The city is also remarkably clean and has a very safe air to it. The buildings are left with the windows and doors open without a second thought.
At Dr. Andu's office, we sat down to get our paperwork in order so that we could go to the Ministry of Health to get our permission to practice medicine. There was a problem with getting all of the documentation that we needed for today because the minister was at a meeting all day. We will return tomorrow and hopefully with have everything together then to be able to start. We thus got the second half of the day to wander the city, which is nice since Hannah and I are still so jet-lagged.
Before taking us back to our hotel, Dr. Andu took us for a Capuccino at a cafe on one of the main streets. Being a previous Italian colony, Eritrea is known for its coffee and also apparently has very good Italian food. I will say that the Capuccino that he bought us was absolutely the best I have ever had. I did add a good 3 tsp of sugar to it, but with that it was amazing. Much milder than what we are used to getting at Starbucks and actually pleasurable to drink without the bitterness I'm used to. It was also a nice pick-me-up because I am so jet-lagged. Dr. Andu talked to us quite a bit at the cafe about the politics of Eritrea and how the American media tries to influence the culture here. It was quite interesting, but Hannah and I could not understand everything he was saying unfortunately. One lesson he did leave us with though was that Eritreans have a very relaxed culture except when they drive--they drive like maniacs.
So, now I am sitting on the roof top of our hotel in the 75 degree weather in the beautiful sun enjoying the day. This place is absolutely beautiful with its architecture, the people, the blooming flowers, and the quietness. There is no traffic noise. I can hear the sounds of the music--maybe Muslim call to prayer--kids playing, roosters crowing, birds chirping. I could get used to this.
I went to bed last night with the door to my balcony open and I woke up with the sun shining in to my room from the east. My curtains are yellow as is the blanket on my bed, so my room appeared to be glowing when I woke up. Quite the welcome way to wake up on my first day here. I thought I would be smart and get up before my alarm today so that I could turn on the water heater for my shower. Unfortunately, I ended up turning my water heater OFF, so I had the joy of taking a cold extraordinarily fast shower this morning. I think I have quite a bit of conditioner residue in my hair due to the rushed nature of my rinsing.
Last night Teddy told us that he would pick us up late today--whenever we called him. Unfortunately however, that was not the case and instead Dr. Andu, the dean of the medical school here was at our hotel bright and early at 8am to pick us up. He called the room, so we quickly got ready. I was rushed even more by my nice cold shower. We met him in the hotel restaurant where he seemed very relaxed and didn't mind that we went ahead and had breakfast. Even at breakfast I could already tell quite the difference in the Eritrean people. They are remarkably relaxed--in no hurry and on no schedule to get things done. It is so refreshing coming from a place where I always feel stressed and like I should always be doing something. The default here is to take a break and relax.
Hannah ordered and egg for breakfast which came with toast and a banana. I had a piece of toast with their jelly. The bread seemed so hearty. They made fresh squeezed orange juice for use, and this was absolutely delicious. Something I could definitely get used to.
After breakfast, we drove with Dr. Andu to the medical center where the medical school and hospitals are. On this short trip we got to see more of the city. The architecture is very distinct and reminds me of Italian villas or southern Spain. Everything is very close and within walking distance, which will be good for Hannah and me getting to work each day. The place is so pedestrian friendly, which seems funny to say because very few people have cars relative to the population. There are people walking the streets everywhere. Above all, the people have an air of friendliness. The city is also remarkably clean and has a very safe air to it. The buildings are left with the windows and doors open without a second thought.
At Dr. Andu's office, we sat down to get our paperwork in order so that we could go to the Ministry of Health to get our permission to practice medicine. There was a problem with getting all of the documentation that we needed for today because the minister was at a meeting all day. We will return tomorrow and hopefully with have everything together then to be able to start. We thus got the second half of the day to wander the city, which is nice since Hannah and I are still so jet-lagged.
Before taking us back to our hotel, Dr. Andu took us for a Capuccino at a cafe on one of the main streets. Being a previous Italian colony, Eritrea is known for its coffee and also apparently has very good Italian food. I will say that the Capuccino that he bought us was absolutely the best I have ever had. I did add a good 3 tsp of sugar to it, but with that it was amazing. Much milder than what we are used to getting at Starbucks and actually pleasurable to drink without the bitterness I'm used to. It was also a nice pick-me-up because I am so jet-lagged. Dr. Andu talked to us quite a bit at the cafe about the politics of Eritrea and how the American media tries to influence the culture here. It was quite interesting, but Hannah and I could not understand everything he was saying unfortunately. One lesson he did leave us with though was that Eritreans have a very relaxed culture except when they drive--they drive like maniacs.
So, now I am sitting on the roof top of our hotel in the 75 degree weather in the beautiful sun enjoying the day. This place is absolutely beautiful with its architecture, the people, the blooming flowers, and the quietness. There is no traffic noise. I can hear the sounds of the music--maybe Muslim call to prayer--kids playing, roosters crowing, birds chirping. I could get used to this.
Monday, April 11, 2011
What time is it anyway...
Well, Hannah and I made it safe and sound to the Crystal Hotel here in Asmara (www.crystalhoteleritrea.com). Just getting here was quite the laughable adventure. Our flight from St Louis to Washington DC was relatively uneventful. The flight from DC to Frankfurt, Germany on the other hand was quite comical. As we boarded the plane we joked about how we hoped there wouldn't be any kids--and I joked about the fact that on my flight to London in 2009, there were 2 kids sitting directly behind us. So, we passed the first section of seats on our huge plane and low and behold entered our section--where around us sat 6 children, all under the age of 3. The lady in front of us had a baby--probably 4-5 months old and I learned that on international flights they can attach small cribs to the cabin wall. So, always avoid the front row on any international flight. This flight was 7.5 hours long and on it were 2 probably Saudi Arabian women dressed in full garb who were older--likely 60s--and who were obviously uncomfortable. One of them was having some "blood pressure" problems initially and then later the two of them both were up and down in their seats and kept trying to switch seats with people around them. Finally, one of them took the opportunity to lie down in 4 seats when her friend and the two unrelated gentlemen sitting next to her left for the bathroom. Luckily we were sitting right across the aisle, so we go to experience the whole bit.
After landing in Frankfurt and finding what we thought was our gate, Hannah and I thought it would be a splendid idea to take a nap sprawled out in the empty terminal where our flight was supposed to be. So, we laid down at around 8:30 or so local time and then around 12:11pm Hannah woke me up. Our flight left at 12:35 and somehow we had slept nearly through the boarding. I woke up in a dazed half-asleep, sleepy-eyed frenzy grabbing my blanket, jacket, and backpack (but not my damn travel pillow I had so proudly bought for this trip) and went out to find information about where our flight really was leaving from because our terminal was completely empty. Much to our chagrin, our flight was nearly 20 gates away. So, we did what any American would do in a foreign country, we started to giggle and ran to our gate. Thankfully we did make it in time for the last bus which drove us out a good 10-15 minutes to the giant plane we took from Frankfurt to Jeddah, Saudi Arabia and then finally on to Asmara.
This flight was also quite an experience with an Eritrean passenger sitting directly in front of us giving the stewardess problems about the meal--first saying she was vegetarian and pretending not to speak English. She refused the economy class fish meal, but after getting a first class meal that was pasta with cheese, she complained and finally got the fish from the first class. It was comical.
Landing in Saudi Arabia (after another 5 hours) was exciting even though we didn't get off the plane simply because it somewhere I never thought I would set foot (and technically I guess I didn't). From above, the skyline of Jeddah reminded me just a little bit of a more industrial-looking Paris. They made an announcement overhead that all alcohol was forbidden there, which I found interesting and astounding (I wonder if they have any Al Capones there). After a long hour or more wait to refuel, we finally took off to our final destination.
Landing in Eritrea was exciting--and quite different from anywhere else I had ever landed. There are virtually no lights to see as you fly over at night and even when we did land it took a while before we got to the airport where there finally were some lights. The women around us--clearly Eritrean in origin--were interested and seemed excited that we were coming to visit. Most of the people that we interacted with did speak English which was nice. After getting off of the plane there were just people standing around. There wasn't anyone telling us where to go. So, once again, like the good travelers from America we were, we took out our cameras and shot a couple of pictures (until we got yelled at). Finally after making it through customs, we met our contact--"Teddy"--because I have no idea what is real name is.
Teddy met both of us with kisses to the cheek and helped us get our necessary paperwork together. We got our luggage and then he asked if we wanted anything from the small meager-looking (by our standards) duty-free shop. I said no as did Hannah, so Teddy decided to help get our papers together and to help himself to the luxury that our passports offered him. He went in to the shop where the hottest commodity was cigarettes and liquor and proceeded to buy $350 dollars worth of duty-free liquor consisting of I think vodka, whiskey, and 8 cases of Heineken beer. This was the highlight of the night. I was laughing so hard I thought I was going to get in trouble. Sounds like Teddy is going to have a party.
Well, we made it to the hotel, which is pretty nice considering--certainly nothing like the US, but nice nonetheless. I switched rooms so that I could be on the same level as Hannah and my new room has a balcony which we are stoked about. Teddy is going to come by in the morning to pick us up and give us a tour.
I am really looking forward to this experience both from a personal and a professional standpoint. I don't think it really hit me until we were finally on the last leg of our flight that the thing I had been looking forward to for the last year has finally come to fruition. Having never studied abroad, I am really looking forward to getting to know the people of Eritrea and so far they seem very easy-going. I am hoping I will take away a respect for the people here, a respect for what we have in the US, and a respect for the medical advances that we have there.
After landing in Frankfurt and finding what we thought was our gate, Hannah and I thought it would be a splendid idea to take a nap sprawled out in the empty terminal where our flight was supposed to be. So, we laid down at around 8:30 or so local time and then around 12:11pm Hannah woke me up. Our flight left at 12:35 and somehow we had slept nearly through the boarding. I woke up in a dazed half-asleep, sleepy-eyed frenzy grabbing my blanket, jacket, and backpack (but not my damn travel pillow I had so proudly bought for this trip) and went out to find information about where our flight really was leaving from because our terminal was completely empty. Much to our chagrin, our flight was nearly 20 gates away. So, we did what any American would do in a foreign country, we started to giggle and ran to our gate. Thankfully we did make it in time for the last bus which drove us out a good 10-15 minutes to the giant plane we took from Frankfurt to Jeddah, Saudi Arabia and then finally on to Asmara.
This flight was also quite an experience with an Eritrean passenger sitting directly in front of us giving the stewardess problems about the meal--first saying she was vegetarian and pretending not to speak English. She refused the economy class fish meal, but after getting a first class meal that was pasta with cheese, she complained and finally got the fish from the first class. It was comical.
Landing in Saudi Arabia (after another 5 hours) was exciting even though we didn't get off the plane simply because it somewhere I never thought I would set foot (and technically I guess I didn't). From above, the skyline of Jeddah reminded me just a little bit of a more industrial-looking Paris. They made an announcement overhead that all alcohol was forbidden there, which I found interesting and astounding (I wonder if they have any Al Capones there). After a long hour or more wait to refuel, we finally took off to our final destination.
Landing in Eritrea was exciting--and quite different from anywhere else I had ever landed. There are virtually no lights to see as you fly over at night and even when we did land it took a while before we got to the airport where there finally were some lights. The women around us--clearly Eritrean in origin--were interested and seemed excited that we were coming to visit. Most of the people that we interacted with did speak English which was nice. After getting off of the plane there were just people standing around. There wasn't anyone telling us where to go. So, once again, like the good travelers from America we were, we took out our cameras and shot a couple of pictures (until we got yelled at). Finally after making it through customs, we met our contact--"Teddy"--because I have no idea what is real name is.
Teddy met both of us with kisses to the cheek and helped us get our necessary paperwork together. We got our luggage and then he asked if we wanted anything from the small meager-looking (by our standards) duty-free shop. I said no as did Hannah, so Teddy decided to help get our papers together and to help himself to the luxury that our passports offered him. He went in to the shop where the hottest commodity was cigarettes and liquor and proceeded to buy $350 dollars worth of duty-free liquor consisting of I think vodka, whiskey, and 8 cases of Heineken beer. This was the highlight of the night. I was laughing so hard I thought I was going to get in trouble. Sounds like Teddy is going to have a party.
Well, we made it to the hotel, which is pretty nice considering--certainly nothing like the US, but nice nonetheless. I switched rooms so that I could be on the same level as Hannah and my new room has a balcony which we are stoked about. Teddy is going to come by in the morning to pick us up and give us a tour.
I am really looking forward to this experience both from a personal and a professional standpoint. I don't think it really hit me until we were finally on the last leg of our flight that the thing I had been looking forward to for the last year has finally come to fruition. Having never studied abroad, I am really looking forward to getting to know the people of Eritrea and so far they seem very easy-going. I am hoping I will take away a respect for the people here, a respect for what we have in the US, and a respect for the medical advances that we have there.
Thursday, April 7, 2011
Happy Birthday Denton!
Today is Denton's 29th Birthday. Happy Birthday! We went to dinner--enjoying tapas at Barcelona Tapas in Clayton. We discussed some of his interesting stories about the insurance business...
In other news my grandfather,Jim, turned 82 4 days ago. I have attached some pictures from his birthday a couple of days ago. For those of you who don't know him, he invented the modern-day autopilot and currently runs Trutrak Flight Systems (which is where I worked in college). www.trutrakap.com. Check it out!
Tuesday, March 22, 2011
Word of the week: thankful
This week, with my cousin's accident, Japan, and, heck, just being in the Barnes ER, I have realized just how lucky I am. I could go on and on about how lucky I was to be born where I was when I was or how lucky I am to have made it to where I am now, but I wont. I just want the world to know just how thankful I am to have the life I have right now. Thats all.
Today show video from Kyle's interview after the crash:
http://today.msnbc.msn.com/id/26184891/vp/42190777#42190777
Today show video from Kyle's interview after the crash:
http://today.msnbc.msn.com/id/26184891/vp/42190777#42190777
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