I am currently in Eritrea on the away elective. I have been e-mailing my family and friends updates and here is the one I sent on Friday, 30 April, with reflections on my first week here:
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Hello All,
Greetings from Eritrea! I am finished with my first week of work (weekends off – it’s great!). It has been quite an experience so far. The following e-mail/update is long and written as stream of consciousness (sorry :)).
First, the country and life outside of work. The hotel I am staying at is nice and the food in the restaurant is good. The internet, like elsewhere, is shady – best late at night and early in the morning. In the room, I fight a battle between staying cool and getting annoyed by bugs/mosquitoes at night – either to leave the window open or closed. The roosters don’t seem to get that they are only supposed to crow in the morning when the sun comes up – they crow all day and all night long. There’s also a dog that likes to bark until midnight outside my window. I have to think like I am in Syria for the shower because I have to remember to turn on the hot water heater 30 minutes before I shower – it’s an adjustment or there’s always the option of a cold shower (sometimes plausible when I’m so hot from outside).
The weather is beautiful but hot, especially around lunch time. It’s cool enough in the evening that I wear a sweater. The hospital basically closes for 2 hours at lunch so I walk back to the hotel (and up 4 flights to my room) but I am usually drenched in sweat with that. The hospital wards are pretty cool (though no air conditioning). The “national” food is not to my liking unfortunately – it is grains, lentils, barley in some combination with meat (usually beef) but they tend to make it all very spicy. I am trying to be more adventurous but it’s hard with my wimpy palette. I ate with two of the interns at their cafeteria at the medical school and that was way too spicy but I tried – I ended up eating lots of bread. They always have other food on the menu – including Italian food (Eritrea was once an Italian colony) and regular stuff like sandwiches and grilled fish or beef. The fish is pretty good – we are going to the seaside this weekend so I should eat some pretty good fish there. The restaurants are nice but a little scattered (more walking). People don’t have a lot of money so you see people (especially the young couples and groups) just going to the restaurant for coffee or a drink and not ordering food. A full dinner at a restaurant costs about $15-20. The grocery stores are like in Syria – basic supplies and then people go to the downtown markets for fruits, grains, etc. Most people you pass in the street are nice and will smile back. Children will follow us, asking for chocolate or money, and one person approached Ahmad asking if he wanted to change money on the black market (illegal). The special things to buy seem to be leather products and ceramics. I found a shop 2 doors down from my hotel that sells hand-made leather handbags (I saw them in the back working) for <$40 (it is very tempting and I may save up for one myself). I can get to most anything on foot. There are taxis and buses but I don’t want to take a bus because they are crowded and everyone seems to have TB here. A lot of the culture is still caught up in the war with Ethiopia and many patients have wounds from battle. The military is the largest employer in the country. I haven’t explored the city much more than beyond the first day because I have been exhausted every evening when I get back from work (and sore feet) and I usually try to get some reading done before going to dinner.
For the weekend, Ahmad and I are going to Massawa, a town on the Red Sea coast. We had to apply for a travel permit to leave the city (this is how they keep track of people and especially those trying to flee the country) from the Interior Ministry. Our permit says specifically what roads we can take and how we are traveling. The dean at the medical school and the lab director (our contacts here – so nice!) have been helping arrange this. We will leave Saturday morning and drive 3 hours to there. We plan on sitting on the beach (maybe ride a camel!) and seeing the town and heading back on Sunday. There’s the Catholic church in Asmara but I haven’t figured out mass times yet – I don’t know if I will have time this weekend.
Last but certainly not least is the main reason I am here – work. It has been a bit of culture shock this week, working in a new hospital. As I said earlier, the patient population seems younger. The line between adult medicine and pediatrics is blurred – I have a 15 and 16 year old and Ahmad has a 13 year old type 1 diabetic. Like in the U.S., the surgeons like to dump their admissions on medicine and medicine has the same frustrations with surgery. The hospital I am at (Orotta) is the main referral hospital for the country. Patients are admitted to the ward through the emergency department or the outpatient department (OPD). The OPD sees cases sent from smaller regional hospitals and also citizens of Asmara. They may get seen several days in a row in the OPD for work up and then eventually admitted. Patients carry all their lab and radiology studies with them. The OPD is very busy in general – my attending saw 20 patients in a morning in the cardiology clinic – and chronically understaffed. The ER is similar to the U.S. but you can’t start regular drugs as easily and it’s harder to get labs/imaging done there than on the ward. People can stay in the ER for more than 24 hours before being admitted. There tends to be 1-3 deaths a night for the medicine service (about 60 patients on wards + 10 ICU + ER) and CPR seems non-existent. Every morning there is report where the intern who was on duty last night presents the new admissions, new ER presentations, and death reports. This is attended by the medicine interns and a smattering of attendings. After that, everyone disperses to their jobs. I go upstairs and with my intern and most of the time by attending we round on the service. Our ward is 35 patients and we see a hallway worth (half the ward each day formally. My intern and I will then see the sick people on the other hallway and quickly everyone else. We do the discharges. The ward work closes down every day from 12 to 2 pm. You can’t discharge anyone in the afternoon. Procedures are done in the afternoon usually – the interns have great skills at this because most have already done surgery. Bone marrow biopsies are done in the sternum (not hip – eecks!) and splenic aspirations are common. Thoracenteses and parcenteses are done by gravity drainage (IV tubing to an old IV fluid bottle). Foley catheters are also connected to old IV fluid bottles. Supplies are okay to find but sterile technique is not the best. I think ordering tests is the hardest thing to tolerate. You order a test and fill out a sheet for it and then you WAIT – e.g. 1 day for a CBC, 1-3 days for chest x-ray, 2-5 days for blood chemistries, 1-3 days for fluid studies, 1 week for cultures. It’s intensely frustrating and difficult to adapt to because you feel like you can’t alter management as well. I guess it also teaches you to go more by exam and history but GRR! All bone marrow biopsies are sent to the U.S. for examination and the date when the next set of specimens is sent is not exactly known so I have a gentleman with leukemia sitting on my ward who is awaiting a bone marrow biopsy but will probably go home and get called back when we can send the specimens to the U.S. The medicines available here are also different and not always there. There is crystalline penicillin, chloramphenicol, ampicillin, and occasionally ceftriaxone (not right now). Anti-parastitics, fluconazole, and anti-TB, and HAART are readily available. Furosemide, spirinolactone, and digoxin seems to be the standard CHF regimen. There are ACE inhibitors and beta blockers but the options aren’t great. No anti-depressants in the hospital but they are available as an outpatient (I’ve heard about amitriptyline only). I am still a little confused as to how patients get their medicines at discharge and about the discharge process and follow up. I have an Eritrean guy on my service who is living in the U.S. He got a DVT (leg blood clot) flying back here to see family. I started him on warfarin but I have no clue how his INR is going to be followed until he flies back to the U.S. As I said before, everyone has TB. The HIV is bad HIV that is diagnosed late and with many complications. There still needs to be informed consent and counseling by someone to get someone tested for HIV – a little frustrating because it doesn’t happen right away. There are things to think about in the differential that I would never think about in the states (schistosomiasis, leshminiasis, malaria, tropical splenomegaly syndrome) and I think the combination of my experience in medicine as a resident and my intern’s local knowledge, we do a fairly okay job. The interns are over-worked. Medical school here is 6 years after high school and only the best go to medical school. The medical school just graduated its first class last year. The medical students are eager to learn but there are a lot of them around. The “internship” is 10 weeks in different specialties (OB, peds, medicine, surgery, outpatient, etc.). The interns will then chose what they want to do – most are deciding whether to do general practice, specialize in a surgical specialty (more well-established here) or go abroad. There are formal OB, peds, and surgery residencies – they are trying to start a medicine residency program. The medical school is Eritrean run but staffed in most divisions by Cubans. Cubans, which I didn’t know, supposedly go on “missions” for 2 years at a time to establish medical schools all over the world. The medicine interns are on-call every 6th night but they don’t get to go home after being on call. They have to round alone on Saturday and then if they are not on call on Sunday, they get it off. They generally will admit 3-5 new patients a day and 1-2 overflow patients from the night before. They don’t write progress notes everyday – maybe every few days. I am trying to encourage them to write notes on especially sick or confusing patients or if they do a procedure. I am also encouraging/demonstrating better understanding by keeping track of patient data in a more organized fashion. The nurses are nice but a language barrier exists. My Arabic helps in some ways because I can pick up some words. It’s kind of frustrating when the intern or attending communicate with nursing and then I don’t know what’s going on. I am trying to learn simple words to speak with patients like “good morning”, “how are you”, “open your mouth”, “sit up” and “take a deep breath.” My attending thinks I will be fluent by the time I leave because I already speak 3 languages so this one shouldn’t be too hard to pick up. I am beginning to understand the concept of “brain drain” and why doctors (and regular people) want to leave the country because it is frustrating. Overall, I think I am helping and I think I am learning.
Well, that’s it.
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