Top 10 Things You Should Probably NOT Do In Africa:

1) Drink from the rivers
2) Pet a warthog
3) Go on a safari...on foot
4) Swim in African lakes
5) Ride in a boat among hippos and crocodiles
6) Text, talk, or even think about blinking while driving
7) Walk around barefoot
8) Ride on top of any vehicle, especially an oxen lorry
9) Get into a tussle with livestock
10) Tell your husbands 'If you don't hear from us in 24 hours we were eaten by crocodiles'

We've only done a few of these...we'll let you guess which ones!

It's Cultural

The night before the Wegner family left for the Congo, we had the opportunity to experience an Ethiopian coffee ceremony in our guesthouse.  This ceremony which is done for visitors to Ethiopia, friends and also on special occasions/religious holidays involves the roasting of green coffee beans over hot coals with incense (frankincense, myrrh), followed by the grinding of the beans usually with a wooden mortar and pestle and heating of water with the grounds in a jebena over the same fire.  The coffee is served with snacks (most often popcorn here).  The coffee with thick, rich, and not at all bitter.  We sat on our back porch for the ceremony and talked shop with Stephen while Anna laughingly complained that she needed new friends until the sun started to sink in the sky.  It was a nice way to punctuate the end of their time here.

The following day, we were invited to speak at an English class for young Ethiopian students between grades 3 and 7.  We weren't sure what to expect, the only advice we received was "just talk about where you are from and show pictures if you have them."  We stepped into the small classroom on the hospital grounds and were greeted by a smiling group of clapping children, singing us a welcome song in English.  Their instructor, Paulos, asked each student to stand up and say their name, grade, and school and then ask us a question about ourselves in English.  We were asked our names, where we were from, about our siblings/husbands/families, and about our favorites (food, colors, activities, etc).  Then we showed the kids pictures on our phones of our family and our dogs.  Paulos asked if we had other pictures of animals and I happened to have photos of a duckling and of a moose on my phone.  The kids recognized the duck easily, but the moose was a tough one -- cow, horse, and buffalo were popular guesses, only one little boy in the middle of the room recognized it.  Turns out, the word "moos" in Amharic means banana.  We all learned something in English class!

The meaning of names is important to Ethiopians and being asked what your name means after an introduction to someone is not uncommon.  We had to do a little research when we got here because neither of us really knew the origin of our names -- Kelsey means "ship's victory" and Auna means "grace."  Ferengi names can be hard for Ethiopians to pronounce, so when Jeremy first introduced us to people here, he tried to help by comparing our names to Amharic words -- Auna is similar to the word for "and" and has sounds common to Amharic.  Kelsey is closest to the word "kalsi" which means "socks."  Awesome.

Probably our favorite cultural discovery here is the Ethiopian gasp.  It wasn't obvious immediately, but as we became more accustomed to listening to our patients speaking Amharic and interacting with Ethiopian consultants, we started to really notice the gasp.  It is a noise that indicates agreement, kind of like our "uh huh" in conversation, but it is startling, especially in an emergency room!  Every time we heard a gasp, we'd look around for a femur fracture,  profuse bleeding, impending death but we would find...NOTHING!  Just a happy, agreeable patient before us.  This blog post really sums up exactly how the gasp strikes you when you first hear it: https://aloneinastrangetown.wordpress.com/2012/11/14/the-ethiopian-gasp/.  Please forgive us if you notice us gasping when we get back...it also seems to be contagious. Gasp!

English Class

Coffee Ceremony

Another week in Soddo

The sky is slowly turning from dark black to light grey.  You can start to see the outlines o the palms and avocado trees rocking in the wind.  They are strong, they've done this dance many times before.  It  is windy nearly every night. The sounds of gates, windows, and other lose pieces of hardware banging sporadically through the night sound much scarier in the dark.  The doors of the house moan and creak in the wind storm. It reminds me of a beach house - loud but resilient.

The family we share our guest house with is leaving today.  It's going to be strange to have the house so quiet. There are three kids in the family who can most often be found in avocado trees and sitting on top of swing sets (not anywhere near the actual swings).  We asked their daughter how she got on top of the swing set once and she replied, "it's easy, it's just like when you're climbing up walls." We will miss their company.

This week has been filled with more of the same in the ER, but as we sat in our living room last night swapping case stories with a couple (ortho resident and FP doctor) who arrived this week, we realized we are so absurdly excited about the patients we have seen here. We showed them pictures and described things we have read about but never seen before. We talked about the highs of our triumphs and the lows of our failures.  Although working in a county hospital makes you somewhat accustomed to witnessing the suffering of the world, it still hurts to see patients in pain or dying, especially from things that seem so easy to treat at home.  But, like most ER docs, we keep working in hopes that our next patient will have a better outcome.

The highlight of our week was a very critical patient who we were able to resuscitate enough to get him to the OR. We had to place a central line and start him on vasopressors in the ER. The nurses haven't done this before, so it was up to us to mix our own dopamine drip (the only pressor available that day). There aren't IV pumps available to adjust the rate of infusion either, which means we also had to calculate a rate....in drops per minute.  We mixed our concentration of dopamine into 1 liter of normal saline and then converted the dose we wanted our patient to get from mL/min to drops/min so the nurses could count approximately the amount of pressor the patient was getting per minute. Who says doctors can't do math?!  So far he is doing well post operatively.

The sky is bright now. Coffee is ready. Time to head off for another day.

P.S.  Some of our patient stories are intentionally vague.  Every single day here we have patients with shocking physical findings, great radiology studies, or interesting stories or we get to do procedures we've never done before, but we are trying to save some of the details to share with our UTSW residency friends at home...can't give away the answers too soon!

Weekend Edition

We were off for the weekend as far as ER work goes, but did work on some side projects (stocking an airway cart, updating the pharmacy formulary list, etc) and celebrated a second Thanksgiving on Saturday with a real American turkey.  For the past two weeks, we have been making mental notes of all of the ways working in Soddo is similar to and very different from working in a county hospital.  So, here is our top 10 list!

Top 10 Ways Soddo is County
1) Throngs of people waiting, everywhere...in the hallway, waiting room, outside, on the lawn, etc
2) We talk to patients in a chair, then examine them in a bed
3) Everyone has at least one non-specific complaint that is potentially a sign of bad pathology
4) Some patients just want to be radiated, even when it is not clinically indicated
5) In theory, we can use ketamine
6) Translators are a precious resource
7) We prescribe medications based on whether our patients can afford it
8) The nurses know what to do in emergencies, and they act immediately
9) The to-be-seen list is never zero
10) It is fun, rewarding, and exhausting

Top 10 Ways Soddo IS NOT County
1) Everyone takes a lunch break, including patients
2) People rarely complain of pain, and ibuprofen works
3) Hypoxic patients walk to x-ray, not to a booth
4) Fractures are treated immediately
5) GCS < 8 does not mean intubate
6) Anything that ends in -itis might be tuberculosis
7) People pay for their medical care (and stay in the hospital until they can pay, instead of being discharged)
8) Hand sanitizer and PPE are precious resources
9) Long ER dwell times, but patients wait at home and return for results the next morning
10) Clinics can actually see patients on the same day they are referred

Weekend relaxation below...

Day 11 - Code Black

The morning started off slow, then we had a mass casualty. One patient walked in with a head injury from a road traffic accident (RTA) and we started to evaluate him.  Auna was asking questions and getting the ultrasound for a FAST exam and when I turned around, suddenly there were two more young men on stretchers behind us.  They were from the same RTA, a lorry carrying oxen collided with a car.  One of the men was drowsy, very difficult to wake up, and wouldn't answer questions.  The second was alert and talking with abrasions to his arms and legs.  I started to evaluate the drowsy patient, when another young man from the RTA was rolled in on a stretcher in worse condition than the drowsy guy. This one was very difficult to wake up as well and was initially talking, but then stopped. Then, two more men walked in and sat in chairs, both from the RTA but in better condition than the 4 we had on beds. We saw each patient, did a FAST exam, wrote radiology and lab orders on each, and laid the paper slips on their beds.  We had no names, no charts.  We started each note and left those on the stretchers too.  We thankfully had extra nursing hands and one GP from the room next door to help carry some of the load. The two sickest patients, with altered mental status, each needed a CT scan but the friends with them only had money for one of the two patients.  The most altered went to CT scan and had a severe fracture of his C1 vertebra. It is a miracle he is not paralyzed.  He had to be transferred to the capital as we do not have a neurosurgeon here.  We don't know what kind of injury the other altered patient has (maybe a concussion, maybe a head bleed) but we could not get imaging. Maybe he will be observed in the hospital, maybe he will go home with his family if they can't afford the hospital stay. 

As soon as things started to calm down after the mass casualty, another patient was wheeled in on a stretcher salivating, vomiting, and lethargic.  He smelled of pesticides and his friends said he "drank poison."  Our first organophosphate poisoning!  The nurses immediately put an NG tube in the patient and started gastric lavage with normal saline (we don't intubate for airway protection here) and we gave him 2 mg atropine IV (we also don't have 2-PAM here).  His secretions cleared up almost immediately and he stopped vomiting.  We admitted him to the ICU for close observation and more atropine as needed. 

Our lunch break was much needed after a ridiculously busy morning!  The afternoon was much quieter at least in the ER, but a crowd of people gathered outside on the hospital grounds to watch a helicopter land and stood staring until long after the passengers left.  We ended our work day with an airway lecture and intubation practice with the GPs and some nurse anesthetists at the hospital, with an encore lecture/lab planned for Friday.  Then, we celebrated our first of two Thanksgivings with the family with whom we share our house.  Our second celebration will be on Saturday, and the word is we will have a Butterball turkey thanks to a staff member at the American embassy!

Happy Thanksgiving friends and family!

Day 11 - Lessons

Waste not, want not. It is amazing how little is wasted here, in the hospital particularly. At home, when we do a procedure on a patient we grab extra supplies (needles, syringes, gauze, gloves, IV cannulas, etc) and whatever remains is more often than not just thrown away. Because our sterility and cleanliness is scrutinized.  We are so afraid to risk contamination of another patient that we don't want to use supplies that have potentially touched another person. We repeat the mantra "foam in, foam out" so often that I find myself washing my hands with sanitizer or soap and water nearly every 5 minutes, sometimes if I am just talking about something that seems dirty or if I feel like it has been too long since my last dose of sanitizer.  I frequently don gloves at home to examine patients, even if I will not be touching body fluids or a wound.  All of this has gone out the window in Ethiopia. We brought with us one box of small gloves and 3 small bottles of hand sanitizer.  Our first day in the ER/ICU, we shoved a handful of gloves in each of our white coats. We were examining patients and using the ultrasound and Auna used about 2 pair of gloves within 15 minutes. We quickly realized we would not have enough gloves for the month if we continued to use them like we do in America.  We were also using hand sanitizer after touching patients, doors, dialysis solutions, charts, etc on the first day.  There is hand sanitizer on the walls in the hospital, but when Auna used it initially, the smell was pungent and irritating. By halfway through the first day in the ER, we realized our sanitizer from home was not going to last.  Yesterday, I reached in my pocket for the hand sanitizer when Auna said "Stop! You haven't touched anyone, you aren't dirty! Save the sanitizer!" It is just habitual. I had touched a door and elbowed through the busy hallway outside the ER, and I felt dirty.  The smell of the local sanitizer is now comforting in its cleanness.  When patients buy medication from the pharmacy and it comes in a vial, they buy the entire vial not just their dose. At home, we throw away nearly full bottles of lidocaine and other medications in glass bottles that are now deemed "single use."  Here, we put a piece of tape over the top and hand the vial back to the patient or family to keep for when they are due for another dose, if it is a medication that will be repeated. Patients also have to buy each syringe, IV cannula, and even sterile gloves for procedures.  Not just pay for the materials we use, but actually physically walk to the pharmacy to purchase the supplies.  There is no room for careless use of supplies.  There is no waste here because our patients, and the hospital, cannot afford it. While our hands our tied by CMS and hospital standards at home, and we cannot reuse or recycle much, working and living in this environment will change how we use medications, supplies, and materials at home. 

Random photos...

Macchiatos in Soddo

Neighbor dog, Peanut

Lawn trimmer, blood agar supplier, and Peanut-chaser.  There are three sheep, we call them all Dexter.

Pretty flowers outside our house

Day 8, 9, & 10

Happy Thanksgiving from Ethiopia!  We had a full day at work today, followed by a great dinner with the family we share the guest house with, the Wegners, and a few other staff from the hospital.  We are thankful for the friends we've made here and the hospitality of everyone at Soddo Christian Hospital, the wonderful nurses who translate for us and help us take care of patients, Jeremy and the GPs who teach us something new daily, and for all of the great experiences we are having in Ethiopia! Our gift to all of you at home is three new blog posts...enjoy!

Every morning, one of us rounds in the ICU and the other starts seeing patients in the ER.  Monday was our first official day at work.  I started in the ER and was waiting for Kelsey to return from the ICU so that I could hear an update on our dialysis patient. It was only the first hour and a little slow. I had seen a couple of fractured wrists and nasty nasal abscess when a man ran into the room with a pile of blankets in his arms -- "Please, emergency, I need oxygen."  I looked into the bundle of bloody blankets and there was a newborn baby...a blue newborn baby. I grabbed the baby and began to dry him off with the blankets. The nurse told me he was born across the street at the health center immediately before arriving at the ER across.  I asked for oxygen and a bulb suction. "We don't have here for him" was the response (in other words: we don't have baby stuff in this room). The baby began to look a little less blue with the vigorous drying and let out a whimper, the first noise he had made since he came through the door. Luckily Jeremy was nearby and suggested that we go to the L+D ward where there is an incubator. I wrapped the baby up and ran across the hospital grounds in the rain. Once we were in the delivery room, we got him under the warmer and I was able to suction him. With oxygen he started to pink up and became a little more responsive. The baby's father stood with us with tears in his eyes, his first baby. It was only then that I heard screaming. They had brought another woman into the delivery room and she was giving birth about two feet away from us. As I looked up, the new baby was crowning. Now that my baby was looking better, I left to write for dextrose (the glucometer is not working so we just treat), fluids, and antibiotics.  Jeremy called the pediatrician who would come see the baby once he was done with his clinic. Welcome to the ER.

The ER at Soddo has four small beds and two nurses who translate for us and complete all medication administration. We see one or two patients at a time in chairs (sound familiar?) and then move them to a bed for examination. Some patients are walked back and placed directly on beds without a card (chart) and are called "emergencies" but the triage system is unclear. Long bone fractures are the only things that are reliably walked back to a bed.  And people who cannot stand on their own.  We write lab and radiology orders on slips of paper that are handed to the patient.  The patient then takes the slip of paper to either lab or x-ray, where they pay for each service, have their blood drawn or films taken, and then wait for the results.  Sometimes x-rays (on actual film) are brought back to us by the patient, sometimes by a porter who carries both the lab and radiology results.  The only patients that don't go to the lab themselves are the ones that are too sick to walk. In this case, the family is responsible for carrying or wheeling in a stretcher or wheelchair the patient to lab/X-ray. Sometimes our nurses will draw labs and have a family member walk the specimen to the lab.  Needless to say, sometimes the blood or other specimens don't actually make it to the lab.  It is shocking who we send out of the ER by foot to lab or x-ray.  Kelsey had a hypoxic patient with saturations of 76% who actually looked clinically well (walking and talking without problems) who we sent to radiology and didn't see for 4 hours. She, like many of our patients, will leave the hospital grounds for breakfast, lunch, church, etc. Some will even leave completely and return the next day for results (a 24 hour ER stay without actually staying in the ER building).

We have learned so much in this first week. We each had a patient with large painful knee effusions. Both knee taps came back as septic arthritis and tested positive for tuberculosis. We have come to realize that anything here can be (and often is) tuberculosis (as Jeremy said, we "are starting to get the hang of it!").  We've seen things here that we rarely even think about in the US.  Kelsey saw a 14 year old girl with right lower quadrant abdominal pain. She had never had a period.  Her belly looked big when she stood up to walk to an examination bed.  Pregnant?  We took a look at her abdomen with our ultrasound and she had a large fluid collection in her right lower quadrant and her uterus was huge. It didn't look like a pregnancy, but it didn't make sense. Kelsey did a pelvic exam and the girl had an imperforate hymen.  Thankfully Jeremy was around to even suggest this diagnosis as it is not uncommon here.  We sent her to gyn clinic for a curative operation.  A toxic looking four year old came in with a high fever. He had been vomiting for one day. He was seen the day before in the ER and his family took him home to wait for results. He looked terrible when he returned.  His malaria test had been positive a week before. Chest x-ray and urine were negative for infection.  His WBC count was 28. One of the Ethiopian residents asked if we had performed a lumbar puncture. She agreed he didn't have meningeal signs (a stiff neck) but she said sometimes they have outbreaks and his parents told her that the child was having a severe headache.  They performed the LP and we started him on steroids and antibiotics and admitted him to the hospital. While he was waiting for his bed, his LP results returned -- gram negative diplococci on the gram stain, likely Neisseria meningitidis.  We wrote prescriptions for our nurses/staff for ciprofloxacin meningitis prophylaxis and took our own cipro at home.  Jeremy called the zone medical board to report it and informed us that he has never had a patient survive bacterial Neisseria meningitis. Hopefully, our patient will be the exception.

There have been a lot of ups and downs this first week. The first afternoon was overwhelming and I needed a break. I ran to the house to refill my water bottle and on the way back I went to check on our dialysis patient. There was wailing in the ICU. I walked in and told the nurse that I was working with Dr. Kelsey and Dr. Jeremy on the sick patient. She responded "Oh, he has died." The wailing was the family. I must've looked shocked and asked her when it happened. "I don't know" she replied.  I asked if she needed anything and she said no. I didn't say much else--we all knew that even if he was in the US he probably would've died. I walked back to the ER and told Kelsey. We both didn't say much...and then we got back to work. Some things are the same no matter where you are.

Auna and the blue baby

Our Thanksgiving table