Tuesday, November 1, 2011

Exploration and work

October 31, 2011

Greetings from Hawassa and Happy Halloween!

This is one of my favorite holidays and we miss spending tonight on Massasoit Street greeting the 500 or more little ones dressed in their ghoulish best. We get word, though, that there has been early ice and snow, with lots of remaining power outages and cold. We hope that you are safe and warm.

This has been a great week. We are learning more than we ever expected and are trying to give back a little.

I will leave El's report to his most-competent self. Except to say that his class keeps growing and he keeps learning more and more about the history and political situation in Ethiopia and also about how to say his students' names when he takes roll – yes, they do take roll at Hawassa University.

My work has expanded exponentially in scope and difficulty in just a week. I am now giving weekly seminars, it seems, after a successful presentation on tetanus last week. I saw my first case ever and worked with his intern to present the management questions. We searched the literature – god, I love the internet! – and did our best, but everything we presented had to then be recast in the context of severely limited resources. The ultimate treatment for tetanus is placing the patient on the ventilator so that all of his muscles can be blocked from use – called neuromuscular blockade. But.... there is neither ventilator or the chemical to do the blockade here. And, despite our excellent presentation our patient died for that very reason. A 25 year old man from the countryside with a penetrating wound to his leg who had probably never been immunized.

At rounds this morning there was much Monday morning quarterbacking about what should have been done. People with little power, as we all know, tend to blame themselves and others for loss, particularly of life. I spoke up forcefully that, though small mistakes may have been made, we all do that, the man died because he didn't have access to a ventilator.

On Wednesday I will be presenting again, this time on severe asthma. Again, what arises is that though we have knowledge and desire to treat well, we are missing things much more basic than a ventilator. I discussed with my co-presenting intern a case of a man with chronic asthma that died from an acute exacerbation and found that we do not have cheap, accessible means of evaluating the status of the patient – peak flow meters or oximeters. The first is available online for $13 each, the latter for $19.

Though I don't expect to change the world, I have been talking over with my higher-ups the possibility of ordering these and getting payment perhaps through the embassy, perhaps through the hospital itself. Meeting with the big boss – head of the school of medicine – tomorrow.

Today, when I went in, I was told that all the other staff Internists that teach medical students were gone and Dr. Birie, head of the Department, had to go to clinic. Sooooo.... would I teach 25 medical students bedside evaluation of a patient for 2 hours. Hmmmm. It was actually worse than this. There were actually 2 classes to be taught, today and tomorrow, and no-one but me to teach either class. Ok, my baseline spontaneity kicked in and I agreed to do it, totally unprepared. I was told that the patient had diabetic ketoacidosis (diabetic coma) and cerebral malaria. I dug in and started querying and waxing eloquent on causes of coma in each, but especially from DKA, spent about an hour on it, to get to the bedside and after another ½ hour to find that the patient never had diabetes and was just recovering from her cerebral malaria. Oh, well. Good for the patient, bad for me.
Hawassa teaches humility. We make it a point every day to provide some form of entertainment to Hawassans, through dress, stupid questions, poorly pronounced or chosen Amharic, enthusiasm over birds that folks have been living with all their lives. The medical students got theirs today.

We have employed the basics for survival now: we have an Amharic teacher, our young student friend Rhobot who lives the next floor down in the Guest House. We have employed 2 very sweet and funny young women to clean our house and pay them what they consider exorbitant wages – actually less than $2 each for a couple of hours work. And somebody who washes our clothes, since we don't have a reliable clothesline. (We have never seen a laundry machine in Hawassa.) We got a small refrigerator after much tsoris – the first one we bought bled cockroaches from the box and then just plain didn't work, after Elliot and a young man carried it up 3 flights (my feminism has its limits). So El and our friend (El's colleague) Wallelyn carried it back downstairs, somehow fitted it into a Toyota Corolla to take it back to the store and returned in that same Toyota Corolla to re-haul the new one up those 3 flights. Voila! A fridge! And we have located eggs (they don't have them in the supermarket) and fruit (also not in supermarket. And sugar (guess what – also not in supermarket. El has his eggs and I have my oatmeal and we can boil and filter and chill water. Breakfast! Hallelujah!

Yesterday we had a lovely though tough walk up Mount Tabor, which is the hill that extends next to Lake Hawassa between my hospital and the very interesting fish market. We got a fantastic view of the City which sprawls much farther than we figured. We went with our much younger, more agile and patient friends Emilia and Adam and glad that we had done it.

Also last week we went on a pretty boat trip on Lake Hawassa and felt its calming breeze and googled at the shorebirds.

We are making Ethiopian friends and find folks thoughtful and kind. We are grateful.

We have included pictures from the walk – the referral hospital and the lake from the hill, the faint specks of Colobus monkeys in the purple tree – and the boat-ride, and also of men and women harvesting the field around the Guest House. Please look at these. People sit or stoop and use a hand sickle, then gather the grass by hand and load it onto donkey carts to return to their farms to use the hay for dry-season fodder for their cattle, horses and goats. Life is not easy for the poor majority in Ethiopia. It is harsh, sometimes brutal and frequently short. These are our brothers and sisters.

Love to you.

Marty and El

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