The City

I have received several requests by e-mail that I describe the city and life in Asmara. You mean you don't want to read for pages on end about the miserable state of pediatric care and the leagues of malnurished, dying children? For the life of me I can't figure why not... j/k ;)

Anywho, Asmara is a charming city. The first thing everyone here emphasizes is how safe it is. And as far as I have been able to tell, it's true. I feel very comfortable walking around alone, even at night. (Don't worry, Mom and Dad, I have not made a habit of wandering alone aimlessly at night. I am always safe and attentive to my surroundings). As was the case in Burkina (you'll notice I make a lot of comparisons to Burkina Faso. I hope it's self-explanatory why. there are not many beggars and homeless people on the street. My perception is that in general many of the African cultures do a better job of taking in and caring for family and friends in need. There are still the children selling gum, tissue paper and cigarettes on the street, but they are not too aggressive and usually more interested in practicing their English.

Also, much to my dismay, but good for the health of my intestines, there is no street food. I was just thinking about bisap last night and almost drooled on myself. There is however, an over abundance of cafes selling tea and capuccino. How exciting is it that I can come enjoy a slower pace of life, get away from whiny, spoiled Americans for a while and still have the luxury of a good cup of coffee?!?

As for the city layout, my guess is that the main part of Asmara is on par with Albany, CA as far as geographical size. It is easy to navigate (thankfully, for this traveller with absolutely no sense of direction), with only a few main streets, and almost all of the streets are paved. Another sign that Asmara is more prosperous than Ouagadougou is the number of cars. There are many more cars here, proportionally, and almost no motos at all. There are certainly the bicyclists (with the best African tool ever, the long piece of rubber used to tie to world to the back... In Burkina we called them "cow-shoes," which I believe is a bastardization of the pronunciation of the word for "rubber" in French), but in general much less traffic on the road. There are two reasons for this. One is that Asmara has a city bus line (which crowds people in like sardines). And the other is the ease with which one can walk places.

Still, when you look around, it is clear that you are in Africa. There are road and building projects everywhere that look like someone just walked away with the full intention of coming back to finish. But they remain that way indefinitely. And there is little organization to the layout of the city. Sure, there are many more shops and restaurants along the main roads. But trying to find a nail salon (my feet are in bad need of a pedicure from all this walking) or a store to buy a SIM card for my mobile phone has nothing to do with logic. The largest, fanciest restaurant or store can be found down a tiny, unpaved alley that otherwise leads to nowhere. And sometimes three boutiques all selling Magi, Omo and Nido will be located right next to each other on the same block.

As for the weather - it can't be beat. It is slightly warmer than San Diego, almost always sunny and there is practically no humidity. I wear light pants and a short sleave shirt every day. I don't even need a sweater or jacket at night.

OK, time's up. I need to run. Next time I'll let you know how my discussion with the medical director went (let's say for now, just about as expected) and talk about the food. Mmmm. Ciao.

Quality Assurance

I somehow ended up at a quality assurance seminar for hospital workers today. At first I thought it had the potential to be interesting. But then, about 70% was in Tagrinya (the common language) and only 30% was in English... And you thought your staff meeting today sucked!?!?!

I was surprised to note the introduction of several terms I am familiar with. For example, the "5 rights of medication administration" is a poster familiar to almost anyone who works in an American hospital setting. However, at the same time that the hospital is trying to combat medication errors, several more basic problems also need to be addressed - cleaning beds between patients, making restrooms and sinks available to patients and staff - a few minor things like that.

It is interesting to me this idea of western standards in a hospital in a developing country. How are we supposed to give the patients privacy and confidentiality when there's 6 families in one room? Does patient satisfaction really matter when they have no where else to go, literally? I guess I am being a little cynical. But I have become frustrated with the way we practice medicine here - if that's what you call it.

I mean, the WHO guidelines diagnose any child with tachypnea with pneumonia and recommend antibiotics for illness that are known to be most commonly viral in origin, because of the possibility of bacterial super-infection. Maybe it's not the guidelines themselves that bother me the most, but the strict adherence to them as protocol? It seems like every child with diarrhea gets an antibiotic - even if the child is already improving. And there is no faith in blood cultures. So a child who has a history consistent with a viral illness, has a negative blood culture, and is clinically improved after a day or two will still get a full course of antibiotics - "just in case." I figured there would be less antibiotic use here compared to the United States on the theory that one would want to conserve limited resources. But it's the other way around. If you only have one tool - use it on everyone.

I have certainly become more familiar with the diagnosis of rickets and the treatment for malnutrition. But I don't know that I've improved my clinical diagnosis skills.

Anyhow, that's enough griping for now. I've decided to talk to the medical director about a few "suggestions". Maybe being proactive and feeling like I have something to add will help my mood?

In case you're wondering, the suggestions I have include
1. Take a complete history and physical... How about asking about sick contacts? relevant family history? Specifics of the symptoms? And what about a complete physical exam? Isn't there anything important on exam besides listening the heart and lungs, checking the skin turgor and looking for palmar pallor? A neuro exam perhaps? Development anyone?
2. Is it really too hard to record more vital signs that just the child's temperature? They are called "vital" for a reason...
3. How about documentation? If you're going to add steroids and a bronchodilator several days into an infant's hospital stay can you put a note in the chart please? There may not be lawyers breathing down your neck here, but maybe the next doc to come along might be interested in the thought process???

Oh, my list goes on. But seriously, I can't change the WHO guidelines. And I can't make expensive equipment materialize out of thin air. But maybe I can remind these guys of stuff even Osler would have considered important...

On Friday I had my first patient die since arriving in Asmara.

The infant was 7 months old and weighed only 4.5kg on admission. She was dysmorphic, but I was unable to identify a specific syndrome.

When we saw her first thing in the morning she warranted admission to a PICU. She was in moderate to severe respiratory distress and had extremely poor perfusion. Her extremities were cool from her toes to her hips and her skin turgor was poor. And she was hypoglycemic with a blood sugar of 17.

We gave her a fluid bolus (but did not write for anymore fluids after the initial 20mL/kg, because my attending thought it would be better to wait and see) and a bolus of glucose. By the time all of this was up and running she was in worse respiratory distress - now grunting and kussmaul breathing. But we did not have the ability to get a blood gas or to provide any more respiratory support than several liters of oxygen per minute via nasal cannula. The chest x-ray revealed only lobar pneumonia in one lung field, but thankfully no evidence of congenital heart disease or pulmonary edema. By giving her continued IV fluid at an unknown rate, antibiotics and some supplemental oxygen we had done all we could. We had to wait and see.

I went to lunch with a heavy heart. When I returned I found that the infant had begun vomiting bilious fluid and her skin had taken on a more dusky color. Her perfusion and skin turgor had improved to a small degree, but her breathing had become agonal. I decided to be more aggressive. Even though we had no ventilator and the staff was not accustomed to rescusitating infants - didn't I come to help? There was more I could do for this child and I thought maybe I could save her life. Because, as I stood there looking at her I knew that if I did not, she would surely die.

I asked what had happened to all of the supplies I brought. It turned out that they were still sitting in a closet, untouched. Even though we do not have a pediatric ICU, I know there is an adult ICU. Could they not use the laryngoscope and endotrachial tubes? What about the medications? Epinephrine, antibiotics and toradol can be used almost anywhere in the hospital. But I did not have time to further contemplate these things. I had a sick patient to attend to.

What a disaster!?!? I don't know what I was thinking. We didn't even have sufficient suction equipment available. I was able to intubate her (thanks to all my practice in the controlled setting of an operating room before I left home), but it was too late. I still don't understand why her color did not improve despite bagged ventilation with 100% oxygen. I attempted to suction through the endotrachial tube with an NG tube - but to no avail.

Not long after the rescusitation started I suddenly noticed that the CO2 detector was no longer changing color. I re-checked the placement of the tube, but it was still in place. My second assumption was the correct one - she no longer had a heart beat. Of course a monitor would have alerted me to a problem before she went asystolic, but I had no monitor.

After several rounds of CPR we pronounced this poor child dead.

I suppose we could have made more of an attempt to save her life, using medications to help with the rescusitation - but what was the point? We still had no monitors, no ventilator, no real support for a critically ill child.

I feel like a fool. I came here thinking I could make a small difference, in the lives of a few children. But I have nothing to offer. I have been trained to practice medicine in the United States. I don't know what to do without my modern equipment - blood gases, CT scans, monitors and ventilators. Effective suction for crying out loud!

But then again, that is really why I am here. To learn. To learn how to practice medicine without all the accroutements of the developed world. To learn about life in Asmara. To learn humility.

Perceptions

About a week before I left for Eritrea I had an amusing experience while I was trying to change my mobile phone service. When I walked into the store I was still wearing scrubs, having just finished covering a shift in the emergency department. While attempting to make friendly conversation with me, one of the customers next to me asked if I was a nurse. Semi-exasperated, I responded that no, actually I was a doctor, commenting that "girls can be doctors too." The guy back-pedalled and tried to explain himself, stating that his neighbors were nursing students, etc, etc. I assured him that I was not overly-offended, that indeed this was something that happened quite often. In fact, my exasperation came from the fact that I had *never* been asked if I was a doctor. The first assumption on finding out that I work at a hospital or seeing me in scrubs is that I am a nurse. (Actually, there is one man in my building who still insists on calling me "nurse" even after I have corrected him several times.) I finally finished my buisness, and as I was on my way out when I overheard the same customer mention to the guy behind the counter that he would never make that mistake again. He figured that no matter what the evidence to the contrary was, in the future he would probably begin by asking a woman in the health field if she was a doctor.

So this morning I was on my way to the hospital when I decided to stop for some juice. After the usual questions about how I was finding Asmara and Eritrea, ensuring that I was enjoying my stay, the man behind the counter asked me how long I would be here for. "Six weeks," I informed him. "Are you working at the hospital?" (which was just down the street) he wanted to know. "Yes, I am." To my astonishment and delight, he responded by asking if I was a doctor!

It took coming half way around the world to a developing country, less than 15 years old, but someone finally assumed that I was doctor!

The Infant's Ward

I started my rotation at Oroto Children's Hospital on Wednesday on the infant ward - ages 1 month to 1 year. Our team consists of the attending - Dr. Tewelde, myself and two interns.

The ward occupies the second floor of the hospital, stretching north to south, divided in the middle by the landing between flights of stairs. The nurse's station is just south of this landing and therefore the more acute patients are located on this side of the ward.

There are about 10 or 12 rooms in all, each housing between 3 and 6 1950's dormitory/orphanage-style metal frame children's beds. (They remind me of the "Madeline" books I read as a kid.).The beds are all pushed up against the walls, leaving a space in the middle of the room for us to round.

Each bed has one or two children in it and at least one adult planted in a chair adjacent to it - to vigilantly swat away the flies, comfort the children and administer medication. In just about all cases this adult is the child's mother. But one mother is poignantly missing. Her father is attending to the infant instead, as the mother herself is hospitalized, presumably with tuberculosis.

The first room past the nurse's station holds the wards most critical children - most of whom require some form of respiratory support. Unfortunately the hospital only has the ability to provide supplemental oxygen via nasal cannula - there is not even high flow oxygen, let alone any form of mechanical ventilation. In fact, all of the children who require support are hooked up, via an impressive maze of plastic tubing, to the same, lone oxygen tank.

As I step into the room I instinctively begin breathing through my mouth - an attempt to blunt the effect of the odor emanating from the room, a combination of body odor, diarrhea and food. The lone window at the far end of the room is as wide open as possible, to little effect. The air refuses to circulate.

Some of the children in this first room, those who are the most accutely ill, are relatively straightforward. They have bronchiolitis or pneumonia - diseases I can almost manage with my hands tied behind my back (that is, when I have the appropriate support available). But the lack of proper suction and oxygen support are by no means my biggest hurdles. Almost all of these children are also severely malnourished. And the questions continue to linger - who among these kids has HIV? Who has TB? Who simply needs more time and who needs more/different medications?

The more challenging children in this room are the ones with congenital heart disease. (No Brian, I am not drooling.) Unfortunately, the physician who performs and reads the echocardiograms is on vacation for the next couple of weeks. So we are left with a chest x-ray and physical exam to make the diagnosis. Not that it really matters. There are no fellowship-trained cardiologists here - interventional or otherwise. And no pediatric heart surgeons. I clearly have my work cut out for me.

As one progresses down the hallway, away from the nurse's station, the cases become less acute. At the very end of the ward is a room for the chronic patients - the ones we cannot improve enough to send home in a week or two's time. The first child in this room presented in a coma, with decerebrate posturing and a fever. After completing a treatment for presumptive bacterial meningitis she has minimally improved. She no long postures, though she only reacts non-focally to pain. The next child has spastic quadriplegic cerebral palsy, a seizure disorder, and is severely malnourished. As for the last child in this room - I can't remember anything about her. This is the twenty-somethingth child of the morning and I need a break. I need to sit down. I need some water. I need some fresh air.

Pre-departure

Less than 48 hours to go.
Just about ready.
Tickets, passport, visa and travel insurance in hand.
Still need to empty out my bank account and turn it into traveler's checks. (When I was in Burkina Faso I had a bank account the Peace Corps deposited money into each month. It didn't occur to me until recently that my ATM card and credit card might not work on this trip like they did when I went to South Africa two years ago.)
Everything is packed - my clothes and toiletries, entertainment for the 40-ish hours of travel time. And medical supplies. Thanks to "running doc" I can ventilate and hydrate a small pre-school and either kill a small army or save the lives of some very sick kids.
Just need to take care of a few more things...