Updates

Luna came into the clinic yesterday for a weight check. She was up to 2.7kg!

We have visited her twice in her village, Wikedupa, which is just a few kilometers outside of Asmara. She seems to be well-cared for and loved. Last time we went I brought my stethoscope, otoscope and pen-light. Her physical exam was almost entirely normal and there was no sign of ear infection (although there did seem to be a little fluid behind one of the ear drums).

I ended up examining her grandmother as well - the first time I have done a physical exam on someone over 21 in two and a half years... I suspect she has peripheral vascular disease as well as other ailments common to folks over 60, but besides being unable to test for most of it, I am unable to treat most of it as well. I prescribed a daily aspirin and tried to reassure her.

I also examined one of Luna's brothers. He is the only one of her siblings who lives with her. The others live in another village with the aunt who spent most of her time caring for Luna when she was in the hospital. This boy has an impressive cough, but no evidence of pneumonia or other serious infection.

Part of me wishes he did have something I could treat with an antibiotic so I could help him to feel better. This boy is almost two years old and his mother just died a couple of months ago. He no longer has the comfort of the siblings he knows and his losses are visibly profound. It was a pretty big damper on an otherwise happy visit full of laughter and smiles.

As for the boy I found in severe pain the Sunday I went to the hospital several weeks back - he is doing much better. He eventually went to surgery and had a large abscess drained. He is the one I found on the surgical ward experiencing a severe allergic reaction several days later. I visited him again on Monday and found that I was only doctor to have visited him since his surgery. I was able to stop all the treatments I had started for his allergic reaction, including the steroids. Although he won't abduct his hip very far, I have reassured myself that the joint was most likely not involved in the infection. His father says he is eating well again. And I encouraged him to get the child up out of bed and walking around daily. So he brought him over to our medical ward yesterday to watch TV. It was great to see him playing with the other kids.

And the girl with the finger cellulitis/osteomyelitis is doing better as well. She is a joy to have around the ward, always smiling and playful. She has finally become comfortable enough to practice her English with me. She does not know many words, but is eager to learn more. And because of her efforts some of the other children have started eking out a few words of English as well.

Her finger is not yet healed to the point where I would be comfortable sending her home on oral antibiotics. I would really like an orthopedic surgeon to take a look at it, but that is a pretty much impossible wish. I guess at this point I must simply remain patient and hope that her immune system and the antibiotics will be sufficient.

What's Next?

So I've been trying to think of what to write about next.

It's weird how after a while what might have seemed strange and interesting at one point starts to seem normal or expected. I am also afraid of repeating myself. While there are new challenges and frustrations each day, they have started to follow similar patterns - child in heart failure being treated for pneumonia instead; child with kidney tumor waiting weeks for a surgical consult (when surgery is the only treatment option); children waiting weeks for echocardiograms because the one doc who performs them has been on vacation or had meetings to attend...

On a different note a group of people with Physicians For Peace is leaving tonight after a week-long visit. What a disappointment that has been.

Not long into their visit I began to notice that my presence here was being completely ignored. I have finally put a few things together and made more sense out of it all.

Physicians For Peace has been working with George Washington University in Washington, DC
for several years to put together a pediatric and a surgical residency program here in Asmara. Various people have made a handful of visits to Eritrea over the years with this purpose in mind. This most recent visit was the last one planned before both programs become operational in October.

My trip and my work here are completely incidental. I e-mailed PFP (as well as many other programs listed on the American Academy of Pediatrics website) a year ago inquiring about the possibility of doing just what I am doing right now. One woman in the organization thought my coming here would be "ideal" and indicated that their organization was just what I was looking for.

It turns out that PFP has never sent a pediatric resident to Eritrea before.

And despite the fact that two of the major players in the group that just came through knew about my work here well in advance of their arrival, they never thought to utilize me.

Still, once they were here I tried to inform them about some of the major obstacles I have run into (nurses and doctors refusing to give medications at doses other than what they are used to despite being shown multiple references indicating the doses being prescribed; the inability to get any vital sign other than temperature recorded, ever, even during a blood transfusion; the refusal to draw any labs after 3pm) - the types of things that will likely be problems even after the doctors begin their training. But no one wanted to hear it. Nor would they hear that the current residency-trained pediatricians (future attending physicians for the residency program) are completely out-dated in many of their practices and part of the problem.

Rather than use my experience as a learning tool, a road map of danger areas to be considered before American doctors come here and bang their heads against the same walls I am, they chose to ignore my negativism and chalk up my problems to the fact that I am not an entire residency program.

The good part of all of this (if there is any) is that I have learned the reason for some of my frustrations.

The current attending physicians will not initiate any of my suggested changes on their own because they are waiting for everything to happen in October.

The WHO guidelines are meant for medical personnel who are not doctors to use out in the field. They are guidelines for the lay-people and triage workers in rural areas. However, the minister of health has ordered everyone, including the doctors, to follow the WHO guidelines as a strict protocol, not as guidelines (just as I have observed). He does not trust anyone, including the doctors, to think for themselves.

And so on.

So I have comforted myself by focusing on my small successes. The patients I have helped directly. The ideas I have planted in the minds of the young doctors. The compassion and integrity I bring with me every day to the hospital...

A Ray of Hope

So I thought I'd post a few good things.

This morning on my way to the hospital I ran into the mother of a girl I had taken care of on Ward D. She (again) profusely thanked me for taking care of her daughter. She mentioned that the girl is still doing well and that she is now brushing her teeth daily (she had been treated for a horrible mouth infection, likely related to the absence of oral hygiene).

After arriving at the hospital I went to the surgical ward to check on a patient who had been on the medical ward under my care for a couple of days. This was the boy I mentioned on Sunday who I found in profound pain. He finally had surgery on Tuesday and had his wounds drained. When I went to check on him yesterday he appeared to be experiencing a severe allergic reaction - he was extremely edematous, he had urticaria on his trunk and groin and he appeared to have some difficulty breathing. I immediately changed his antibiotics from a penicillin to a cephalosporin, I started him on steroids and I had the pharmacy dig up the benadryl I had brought with me to give to him. This morning he was still alive and much more comfortable (although still somewhat swollen).

When I got to Ward D the charge nurse commented on how well the two lumbar punctures I had done the day before went. He in part attributed my success to the use of lidocaine to anesthetize the area first (what a concept!?!). It sounded like he plans to make lidocaine available for all future lumbar punctures on the ward.

While I was chatting with the charge nurse a father who speaks pretty good English wandered by. He thanked me for my good care. He made a point of mentioning that his appreciation was not just on behalf of his daughter, but for all the patients on the ward.

The other doctor finally showed up and we rounded on the patients together. We were able to discharge a few who had significantly improved. And the patient with the finger cellulitis vs. osteomyelitis showed us how much better her finger was. The cultures finally came back from the fluid I drained off her finger a couple weeks ago. They had not tested for sensitivity to two of the most commonly used antibiotics, although they did test for sensitivity to the antibiotics I would love to use if they were available here. But still, I was pleased that we had positive culture results available. Because so often cultures are not done here out of the belief that they are never positive/useful. (And there was demonstrated sensitivity to at least one of the available antibiotics). There is no guarantee that anyone will draw any cultures after I leave here. But I feel like they're one step closer.

It feels good to see patients get better, to hear appreciation from families and to think that maybe there will be a tiny bit of lasting change...

Sunday, Bloody Sunday

I went to the hospital today to check on a few patients. I was horrified at what I found.

I saw one patient who has one of the worst cases of cellulitis I have ever seen. In fact, I’m still wondering if she has osteomyelitis. I asked if she was still soaking her finger daily in hot, aseptic water as I had prescribed (I knew that two or three times per day was too much to ask for). It turns out that the surgical ward is closed on Sundays. And sterile gauze is not available on the medical floors. So she would have been unable to re-wrap her finger if she removed the dressing. She would have to wait until tomorrow.

I then checked on the child with hydronephrosis and pyelonephritis. His father complained that he was not getting any medicine. I checked with the nurse. For some reason the order I wrote to start antibiotics a week ago was never transcribed to the medication sheet. He was receiving the medication that had been written for the day after admission for worms in his stool, but had not received one single dose of antibiotics for his pyelonephritis. Because he had been improving daily since admission I had no reason to suspect he was not receiving the treatment I ordered (which just goes to show that we probably don’t need a good portion of the antibiotics prescribed). I was ready to pull my hair out, wondering what had prompted me to come in in the first place.

Before I left the ward I was asked to see a “critical patient” who was admitted yesterday. I found a 4-year-old boy who appeared pale, somewhat listless and in severe pain. When I examined him it seemed most likely that he had inguinal cellulitis with associated lymphadenitis and possibly osteomyelitis or septic arthritis. But his abdomen was distended, he had decreased bowel sounds and was complaining of abdominal pain. As unlikely as it was, I was concerned that he might have an incarcerated inguinal hernia. But because it was Sunday he could not get the x-ray of his hip that had been ordered the day before (and never done). I decided to contact the surgeon on call and to give the boy some pain medication. But guess what! Because it was Sunday the pharmacy was closed and I could not get anything besides Tylenol for him.

At this point I was completely fed up. This was absurd. What happened to patients who were in accidents and came into the emergency department from off the street? No one seemed to know. I decided to visit the emergency department and see for myself.

Sometimes an ineffective, unorganized system works to your advantage. While I was waiting for the emergency department doctor to show up I wandered into the trauma bay. All the medications were sitting in an un-locked cabinet just waiting to be liberated. And liberate I did. I helped myself to some morphine and a strong NSAID as well as a medication to reverse an opiate over-dose, just in case. Eventually the doctor showed up. I told him that I was a pediatrician from the United States and that I had a patient on the ward whose finger wound I had drained who was in need of some sterile dressing. I received a nice full bag of sterile gauze and a pair of sterile gloves with a smile. And I was on my way.

After returning to the ward I set up the girl with the finger cellulitis to soak her finger. And I gave the boy with abdominal pain some morphine. But while I was waiting for the surgeon to show up the doctor who was actually on call and supposed to be responsible for these patients told me that a baby was being admitted to the NICU. He asked if I would come help him out. The child we admitted seemed to be doing ok. His mother had been admitted to the hospital for an infection, presumed to be due to retained placenta. And because the infant was found to be febrile he was admitted for a sepsis rule-out. Except they weren’t planning on getting any cultures. How can you possibly rule something out if you don’t test for it?!?!

At any rate, I soon noticed that in the crib next to the infant we were admitting was a severely jaundiced child. I have never before seen a baby who is bright yellow all the way down to the toes the way this child was. I looked in the chart and noticed that he had been transfused for anemia, but it did not appear that any workup for the anemia had ever been done. And I found no record of a single bilirubin level. I could not contain myself. Of course the lab was closed, because it was Sunday. So I had no way of knowing what the actual bilirubin level was. And I certainly did not want to perform an exchange transfusion unless I was absolutely certain that it was necessary. So I had phototherapy started and ordered a bilirubin level for first thing in the morning. How depressing. Because today is Sunday this infant will likely end up with cerebral palsy and deafness from something completely preventable.

At least I was able to relieve one child of his pain and help heal another. But these are truly small comforts in the grand scheme of things.

I know that the Sabbath is supposed to be a day of rest. But I don't understand how you can rest comfortably knowing that so many children are suffering.

Ward D

I apologize for the lack of posts this past week. I have finally established an internet connection in the apartment I am staying in – but it is not the most reliable connection I have ever had. Needless to say, I have been experiencing technical difficulties once again.

At any rate, I switched to Ward D this week. This is the ward for children ages 3 years and up. It looks much like the infant’s ward (Ward B), only larger. But I have been much happier on Ward D for several reasons.

One big difference is the variety of pathology. On the infant’s ward the vast majority of patients have respiratory or diarrhea illnesses. And most of them will get better in time, whether we do anything for them or not. On Ward D there is no majority. We have patients with type I diabetes, pneumonia and asthma (although they are slow to diagnose asthma here – often treating for pneumonia instead). There are children with congenital heart disease who underwent repair when they were younger, but are in need of surgery again. One child has chronic nephrotic syndrome – presumed to be minimal change disease, but undiagnosed without a kidney biopsy. One child has a kidney mass, likely Wilm’s tumor, awaiting surgery. There is a child with pemphigous vulgaris and one with severe cellulitis in her finger. There are children with HIV and children with failure to thrive. And the list goes on.

I have been forced to become my own consultant, relying on my own knowledge and text books when I would prefer to rely on the sub-specialists at Rady Children's Hospital. I am finally honing my physical diagnosis skills and making alternate decisions without access to all the diagnostic and treatment modalities I have come to know so well. I don’t have any misconceptions that this medicine is any better or more satisfying than the medicine we practice in the U.S. But it feels good to stretch my brain in new directions. And it feels even better when doing so helps some of these children get better.

Another reason I am enjoying this ward is the staff. The doctor who covers most of these children has not had any official training beyond medical school (i.e. no pediatric residency). But he has been working on this ward for years, so his practical knowledge is extensive. He is willing to learn from me, but also capable of teaching me at the same time. We have a good rapport, with an open exchange of information. He does not always do things my way, but at least acknowledges that my points may be valid. And he is openly appreciative when I teach him things he thinks are useful and valuable.

The charge nurse is also an asset to this ward. He is organized and knowledgeable. He is helpful. And his English is much better than average here. He can actually understand what I say and works quite well as a translator when I need it. He also respects my knowledge and experience. He does not question my every action or decision.

But yesterday I ran into the invisible wall I have been banging my head against since I got here.

I have a patient with bilateral cervical lymphadenopathy that I presume is scrofula (an infection caused by tuberculosis), but I can’t be certain. I decided that given my options the safest thing for this child would be to treat presumptively for TB and see how the child responded.

I pulled out my handy Nelson’s Pocket Book of Pediatric Antimicrobial Therapy – a favorite among pediatrics residents in San Diego. (Thank you to Dr. Bradley and Dr. Leake). And I wrote for the appropriate doses of Isoniazid, Rifampin and Pyrazinamide. The charge nurse balked. The doses I wrote for were well above any dose he had ever seen before. I went to my e-pocrates and my Johns Hopkins Antibiotics Guide to double check. My dosing was correct. The nurse decided to call the medical director. He agreed that my dosing seemed high and said that he would come to the ward to help resolve the issue.

Because the director had not arrived by lunch time I went by his office after I finished eating. Of course he was not there. And the entire place was locked up so I could not consult the Red Book, the American Academy of Pediatrics guide to infectious diseases that I brought with me as a gift for the hospital. So I went to the medical library located on the hospital campus. There I found a Red Book from 1997. Not the most up-to-date, but reliable none-the-less. Indeed the dosing listed in this book was the dosing I wanted to use. But alas, I could not check the book out of the library. All books are for use on the premises only.

I went back to Ward D and tried to figure out what to do next. The medical director never showed up, big surprise there. So I finally consulted Hospital Care For Children – Guidelines for Management of Common Illnesses with Limited Resources – the handbook produced by the World Health Organization. Lo and behold here was the dosing the Eritreans were using. The doses listed were half of the lower limit my resources indicated.

The WHO guidelines suggest antibiotics for known viral illnesses. They indicate that tachypnea (fast breathing) should be considered pneumonia first and foremost. And they under-dose medications for TB, one of the top three infectious causes of morbidity and mortality in the developing world. My initial reaction is to think that maybe these lower doses are safe and effective and save limited resources in the third world. But then I think about Paul Farmer and Mountains Beyond Mountains. And I realize that the WHO is actually doing these people a disservice.

I wonder if I have the strength, the determination, the status and the ability to effect the changes that Paul Farmer has. Can I convince anyone in Eritrea to use the appropriate dose of medication to treat TB? Can I convince the WHO that they need to change their guidelines? Maybe. Eventually. But for now I conceded to the lower doses. Because this child needs some treatment. And if I spend too much time arguing about it he won’t get any medication at all.

East vs. West

I am surprised at the number of similarities between East and West Africa.

To some people it might seem obvious or expected. But considering the vast distance this continent spans, and the lack of infrastructure connecting the two coasts they are almost worlds apart.

But the affinity for gaudy, 1980's-style velvet furniture shared by the two regions is uncanny.

The insistence on hand-shaking at every opportunity (and the preference for shaking a wrist if the hand is "dirty") is also common to both coasts. As are the greetings that last several minutes (asking about health, family, life, etc each time).

Drinking tea with friends is another common tradition. And although Ethiopia was under British rule for a while, this certainly cannot be the explanation in West Africa where many of the countries are former French colonies. Additionally, the tradition does not simply refer to the drinking of tea, but to the tea brewing and insistence on 3 cups of tea as well.

In one post I mentioned Nido, Omo and Magi - powdered milk, powdered bleach (used to clean everything from clothes to dishes) and MSG flavor cubes, respectively. They seem to be a staple everywhere from Asmara, Eritrea to Pama, Burkina Faso. Sure, powdered milk will be in many places where electricity is hard to come by, but the same brands? including the soap and the flavor cubes? Even the plastic buckets are the same brand.

One thing in common that is not surprising is African ingenuity. We were joking before I left that you could probably get a mobile phone illegally "unlocked" and a SIM card exchanged a lot easier in the middle of Africa than you could in any major city in the US. But it's comforting to know that almost anything can be fixed here. I blew my surge protector the day I got here (don't ask me how). And wouldn't you know it - the man who was selling outlets and other similar electrical devices that I brought it to - fixed it. (Now I'm not sure it will function as a surge protector anymore, but it certainly lets me plug in my computer and my Treo at the same time and charge them...)

In fact, the only major difference I have found is the food. In both places food is a communal affair - people eating with their hands from a common dish. But the food itself is vastly different.

In Burkina the staple food was "Tô," a congealed solid made by boiling millet powder (think grits left out over night), with a sauce usually containing among other things over-cooked okra and dried fish. I simply could not stomach the stuff. At one point after I had been cooking three meals a day for myself I decided to get food from the school cafeteria for lunch. The only meal I could ever stand was black-eyed peas with rice (to which I added vinegar and tobasco sauced).

But here the food is amazing. The injeera (a spongy, thin bread-like food) is more sour than what you find in the states. But the meat and vegetable dishes are delectable! Almost everything has just the right amount of spiciness and the flavors are so rich. Add to that the many Italian restaurants and the isolated Indian restaurant and I'm a happy camper...

Luna

Don't know why I lost the entire blog yesterday....

At any rate, my first day on the infant ward I met an American nurse named Angela. She is here with several other American nurses working with the ministry of health and the nursing school. She was on the ward visiting baby Luna.

Luna was born at home, like most children in Eritrea. Unlike most chlidren in Eritrea she was born with a cleft lip and cleft palate. Therefore, soon after her birth Luna's mother brought her to the hospital.

It is unclear the details of what happened next. What is known is that the doctors thought that Luna's mother was anemic and required a blood transfusion. Sometime after the transfusion started Luna's mother died. Was it because she received a transfusion with the wrong blood type? Was it because she went into fulminant heart failure? Was it because she had an anaphylactic reaction to the transfusion? None of this is known. But it is not surprising.

In the United States when a patient receives a blood transfusion all of the information is double- and triple-checked by nurses before being administered - is it the right patient? is the blood product the right blood type? etc. When I was in South Africa (where the health care system was 100 times more sofisticated than here) there was no double checking to ensure that the patient received the proper blood product. I simply went to the blood bank and picked up a brown paper bag, brought it back to the ward where a nurse hooked it up to the patient.

Moreover, in the United States when a patient receives a transfusion vital signs are recorded every 15 minutes. When I asked for vital signs to be recorded every 30 minutes on a patient receiving a transfusion not a single number was recorded.

This is why it is not surprising that Luna's mother died. And her father is schizophrenic. So Luna's care (plus that of her siblings) has been left to her 2 aunts, who each have 4 children of their own.

When Angela went to their home to check on baby Luna she found her lying in a crib, covered by flies, emaciated, dehydrated and forgotten. She was down an amazing 25% from birth weight and was not expected to live. Luna has now been in the hospital for more than 2 weeks and she is back up to birth weight. Her aunts, through the dedication of these American nurses, have been convinced of Luna's worth and her ability to survive. She will likely be discharged tomorrow. It's nice that some stories have happy endings, isn't it?