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?

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!