Such Sweet Sorrow

I am due to depart in a few hours. I will have to write about my trip to the Red Sea and the Eritrean city of Massawa after I get back to San Diego. (I will also need to finish writing about my trip to the city of Keren and post it.)

At Chrissy's suggestion I'll try to add one or two posts once I'm home describing the transition back.

And at last I will upload photos once I am home.

So stay tuned...

On a final note, I would like to thank everyone for joining me on my journey. The e-mails from those of you who wrote (Mom, Dad, Aunt Kathe, Uncle Ken, Lisa, Oliver, Dr. AchillesInAfrica, Ettie, The Bausermans, Yuliya, Pat, SuessFeet, The Other Anya, Ny, Ceylan, Nann, Anna, Flora, Chrissy), and anyone else I may be forgetting (it's been a very long day) were very much appreciated. For those of you who observed silently - I hope you got something out of it. Looks like we'll be doing this again in about a year, somewhere in Africa, if all goes as planned.

From Asmara,
Dehan kunu

My Last Day On Ward D

Today was my last day on Ward D. I will use the next couple of days to get some work done and to relax a little before I return to my 80-hour-work-week back in the states.

This morning my favorite doctor and I started rounding in our usual fashion at one end of the long hallway that comprises Ward D. It was straightforward enough – the child with diabetes whose blood sugar has been extremely difficult to control; the child with septic arthritis, responding well to antibiotics; the girl with an avulsion fracture of her elbow, still awaiting surgery after more than a week; and a child with HIV experiencing various side effects from his antiretroviral medication.

The next two children we round on are in beds in the hallway. They sit outside a room that is locked and never opened. It contains various supplies, including a half a dozen brand new tricycles. Why someone does not clean this room out, make use of the tricylces and put patient beds inside is beyond me.

The first of these two patients is a girl who was admitted over the weekend with a large swelling in her cheek. On first glance I think maybe she has mumps, or some other infectious parotitis. But on further inspection the origin of the swelling seems to be more consistent with a dental abscess. After getting the history that this has been going on for several months and inspecting the inside of the child’s mouth – which shows displacement of a molar forward at an odd angle by a firm mass protruding from the maxilla/buccal mucosa – it becomes clearer that this is likely a malignancy. My colleague suspects Burkitt’s lymphoma. A full physical exam reveals no further abnormalities, other than a nodule protruding from the scalp, concerning for a possible metastasis? At this point there is not much we can do. The CT scanner is finally up and running again after being broken for several weeks. So hopefully we can get a CT of the head and neck. And we will send her to the maxillofacial clinic for consultation regarding possible surgical removal. But without chemotherapy her prognosis is poor.

The next child is one who was admitted about a week ago with severe malnutrition. He has evidence of both marasmus and kwashiorkor. In fact, I believe he has Bitot’s spots on his sclera, a physical exam finding suggesting vitamin A deficiency that I have never seen before. Unfortunately his workup has been negative so far. While his nutritional history certainly is inadequate, it is not poor enough to account for the severity of his malnutrition. The rapid HIV test was non-reactive. But I’m wondering if it is a false negative. And his chest x-ray shows no evidence of TB, although this by no means excludes this diagnosis. So we will continue him on nutritional supplementation, start vitamin A and a multivitamin, and treat empirically for TB. He should also be receiving copper, zinc and folic acid supplements (as I have learned during my time here these comprise an important part of the malnutrition treatment regimen), but in this developing country where malnutrition is a major cause of childhood morbidity and mortality – these supplements are currently unavailable.

The next room seems to be doing well. The girl with a history of congenital heart disease who is in need of repeat surgery is doing much better and ready for discharge (with the anticipation that she will receive her surgery in the next couple of months). The boy with hemorrhagic cystitis is still having a significant urine output, although now it is no longer grossly bloody. The urine output was measured at 2.5 liters in one day (well above the usual 500mL – 1 liter usual for an adult), but unfortunately his intake was not measured at the same time. So the volume of his output is difficult to evaluate. We cannot test his urine electrolytes, making the workup even more challenging. At the very least he is improving. The boy with scrofula (who is being treated with an appropriate anti-TB regimen despite the fact that the medical director never showed up to approve of my dosing) is also doing better. My friend with the finger cellulitis has been discharged over the weekend, as has the girl with newly diagnosed diabetes.

Instead I find a child with an enlarged liver, an enlarged spleen, fevers and pancytopenia. I am concerned about leukemia and lymphoma. While I am examining him he starts having a seizure. Fortunately it stops on its own. I immediately consider the necessary workup. I have no way of measuring his oxygen saturation, but I have no reason to believe hypoxemia to be the cause. I can get an immediate blood glucose level – 115 – certainly not the cause of his seizure. I ask my colleague if there is any chance of getting serum electrolyte results within an hour. He reassures me that it’s possible. In the mean time I decide to perform a lumbar puncture and start treatment for meningitis. It is highly unusual for me to stop rounds in order to do a procedure. But given his neutropenia and the paucity of antibiotics I have to choose from, I don’t want to delay treatment.

We finally move on to the other end of the hallway. In the last room at the end are the three children being treated for active pulmonary TB. It is less than ideal to have them all in one room together, but better than having each of them in a room with other susceptible children.

Unfortunately, over the weekend the ward ran out of beds and a couple more patients were added to this room. One girl appears to have a dental abscess. The other, severe cellulitis. The infection looks like it started on her knee and has spread up and down the leg from there. There is something about this one that I find unsettling. Maybe it is the nature of the skin discoloration or the severity of her pain, but I am worried that the antibiotics we have might not be enough. I ask about a surgical consult and am told that tomorrow morning is a possibility. I don’t want to wait that long and am told that potentially this afternoon we can get someone to come by and take a look at her. I draw a line around the area of erythema, sigh, and move on.

At this point we are given the results of the serum electrolytes I ordered on the child who seized!!! Hallelujah! It truly feels like a miracle. I ordered STAT labs and was actually able to get them STAT. But I do not have much time to rejoice. The boy’s potassium is low. Not low enough to cause a cardiac arrhythmia (and certainly not the cause of the seizures), but low enough that I want to start supplementation right away. The other abnormality is the boy’s calcium. At 6.8 (corrected to 5.9 once his albumin level was available) it is certainly low enough to have been the cause of his seizure. We need to get some calcium into him right away.

When I ask about my options for electrolyte supplementation no one is certain of what is available. After a few minutes of hemming and hawing I decide to go to the pharmacy myself. When I show up and explain briefly why I am there I am told to have the charge nurse call instead. I repeat that a child has just had a seizure on the ward from a low calcium level and I need to get some calcium into him urgently. Can I please find out what is available? The woman initially shows me potassium chloride?!?! While this is something I need, it is not calcium. After a brief argument about whether KCl is potassium or calcium, I notice a box labeled “calcium gluconate” on the shelf. Aha! I ask if there is any other calcium supplement available – like an oral form. She insists that there is not. While I hate giving calcium through a peripheral IV due to the nasty burns it causes if the IV infiltrates, I am satisfied that at least I can treat the cause of the boy’s seizures. With five vials in hand I head back to the ward.

Unfortunately the charge nurse is both wary of IV calcium (as he should be) and busy recording all the orders written on the patients on one end of the hallway. Can we discuss this later?, he asks. I try to explain again that this child had a seizure a little while ago because his calcium level was too low. This is not something that can wait until “later.” (Why do I continually have to explain the urgency of this?) He is not happy about it, but I think in order to get me out of his hair, he brings me to another nurse and tells her to follow my orders.

Right after the nurse changes the IV site, before we can do anything else, the child seizes again. Again the seizure stops spontaneously after less than 90 seconds. We then start giving the calcium. I try to tell the nurse that it needs to be very slow. And she acts like she understands me. But she pushes the first portion in faster than I would like.

At this point I’m a little freaked out. At home one of the charge nurses won’t even let me give pharmacy-approved IV calcium supplementation to children on monitors on her floor. She insists on sending them up to a higher level of care first. And here I am without any monitors, let alone any means of correcting a problem were I to detect one, with a nurse who is pushing a calcium bolus faster than I’m comfortable with. I don’t even know if the fluid is supposed to be diluted first.

I take a deep breath and watch as the nurse delivers the rest of prescribed dose. I try to tell her to go more slowly, but it doesn’t take. At this point all I can do is keep my every sense focused on this child, watching him breath, feeling his heart beat, tuning in to his every movement, and pray that nothing bad happens. He seems to get through the whole bolus alive. The nurse draws the rest of the labs I’ve ordered since finding out the electrolyte results and sets up the child’s IV fluid with potassium in it. I really wish I could give him an oral supplementation to help increase the level faster, safely. But I try to be thankful for the few options I do have.

At this point the surgeon walks in. My colleague had actually gone and found him and told him to come to the ward now. When we find the patient with the bad leg infection I notice that it has already spread beyond the borders I drew maybe half an hour earlier. Unfortunately the surgeon does not find this fact nearly as alarming as I do. He does not feel any fluctuance and reassures himself that her distal pulses are strong. He decides she does not need surgery.

I think back to accounts I have read about patients with necrotizing fasciitis written by a surgeon in the U.S. I remember him stating that sometimes there was nothing specific on the patient’s exam to tip a surgeon off to the disastrous nature of the infection he or she was harboring; that sometimes a doctor had to rely on intuition to make the correct diagnosis. I want to mention this to the surgeon and tell him that my intuition is screaming at me that this child’s leg isn’t right. But I have learned enough in my time here to know that would be useless. I wish I could get an MRI of the leg to be more certain. Instead I accept his advice to continue the current antibiotic regimen (which does not include my top two choices in such a situation), to start anti-inflammatory medication and order splinting of the leg and elevation of the foot. I add in a few blood tests as well.

I wish I could say that the fun ended here.

Instead, after lunch I decide to check on the medication record for the patient who seized earlier in the morning. I don’t usually do this, but for some reason I want to make sure the calcium supplementation was recorded correctly. Thank goodness I checked! The nurse had transcribed the order as 5mL of potassium boluses every 6 hours (not the calcium I had ordered) – easily enough potassium to cause a fatal cardiac arrhythmia in no time.

Unfortunately this is not the only mistake I find. I notice that the volume of potassium I had written for to be added to the maintenance IV fluid was incorrect. I wrote the dose correctly, but when I converted it to volume I totally screwed up. While a nurse in the US would have caught my error immediately (and if she didn’t certainly someone in the pharmacy would have), the nurses here are not in the practice of re-calculating medication doses (or thinking about what they are for that matter – IV potassium boluses every six hours!?! Ack!) Both mistakes are corrected and I heave a small sigh of relief.

The rest of the afternoon is relatively uneventful. We admit another girl with a finger cellulitis (related to the traditional henna tattooing, I think) after draining the abscess and sending it for culture. I prescribe finger soaks and IV antibiotics again, hoping that this will become routine treatment.

At this point I am glad the day is over.

It is a good thing that today was my last day. I don’t think my blood pressure could handle one more. I only hope that when the residency program starts in October that more changes will be made. And that somehow the children will survive in the mean time.

Martyr's Day

Today was Martyr's Day in Eritrea, the day of remembrance for all those who died in the struggle against Ethiopia. Just about everyone has a friend, parent or sibling who was lost to this war - either as a soldier or as a civilian.

Last night everyone lit a candle and walked from the city's main square to the martyr's cemetery where many of the war's victims are buried.

There are candle holders up all over town and people selling candles on every street corner - some homemade, some factory-made. And country flags are up everywhere at half-mast. I wonder if anyone else has noted the irony of the olive branch on these flags.

The struggle is not over. There are still men and women deployed on the border where the dispute over town ownership continues.

After the last year of high school all boys and girls are sent to Sawa, a town where they undergo military training. Many of Eritrea's youth try to avoid enlisting in the army. Although service was once limited to two years, the time limit no longer applies. No one has any idea when they will get out.

Enlistment is required for everyone under a certain age. For women the limit used to be 27 years of age. But the age limit has just been increased to 40. So the women who have been hiding, biding their time until their 27th birthday now have 13 more years to wait.

There was a football match between Kenya and Eritrea over the weekend. Entry was free for everyone. It turns out that this was a ploy to get more people to attend. The military used this opportunity to round up thousands of young men at the game who have not yet served and have been hiding from the authorities.

People here are very patriotic and thrilled about independence from Ethiopia. But the dispute over the border has ceased to be important to most. In their minds it is time to move on and focus on re-building Eritrea.

But the government has been able to use the border dispute as an excuse for everything - from shutting down the University of Asmara to limiting government spending on social services. "The struggle" has become an excuse for everything. Sounds familiar, doesn't it?

As we approach the middle of the "rainy season" without having had much rain this year the desperation increases. Famine is on the horizon. Opportunities for the future are at an all time low. And no one is given permission to leave.

This Martyr's Day there is a lot to consider. Family and friends are still sorely missed. No one wants them to have died in vain. But everyone wonders how this war will end.

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.