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From The Doctors

Ethiopia – A Truly Humbling Experience

February 04, 2013

Hello all-

I’ve been asked to blog about my experience here in Ethiopia. It’s truly been amazing. I’ll start with discussing my first day at the hospital.

We have been sent to Gondar where the second largest medical school in Ethiopia is located. This is a beautiful city, of 250,000 people. The medical school is very large, and the medical system lot different than the United States. First I started in the ICU.
We rounded on the three patients in there. I was a bit nervous, however I realized that I was there to observe, and if they had any questions on how we do it in the United States, I could possibly tell them. I was in for a big surprise.

Here’s the thing, the science of medicine is very similar all over the world (just open the textbooks of medicine, surgery, and emergency medicine), the medicine practiced in each region of the world is totally different. For example the first patient I saw, had meningitis. Actually, it was a bit more complicated than that. He was 25 years old, and had cerebral meningitis. How many cases of cerebral meningitis have you seen? Personally, in the United States, I’ve see none. I have, however, seen about four cases in Haiti. That being said they see it all the time. Interestingly, the patient had a GCS of three. They do not have any functional ventilators on the medicine floor. They do have, ventilators, for the surgical patients in the Operating Rooms. For this reason they could not intubate the patient. When they saw the patient initially, he had a GCS of 6… When we saw the patient about 36 hours later, he was having focal seizures. As we were rounding on the patient has left arm was shaking. The attending, the residence, and the medical students watched it, but they did not do anything. As we discussed the case, it was evident that the patient was in critical condition, and I was afraid that he would not make it. He had agonal breathing, around 3 times a minute. His heart rate was about 120. And he was seizing. He was laid flat, with an NG tube. They did not intubated the patient for the reasons of not having a functional ventilator. We discussed the case at length. He had been given dilantin 1 g load. He was also getting it twice a day. Unfortunately, they cannot check levels. They added another drug because of the seizure. Patient had a high fever about 103°F. His pulse ox was 88 Percent. They asked me what I thought was going on, and they also asking what we have would have done in the United States.

We discussed intubating the patient for airway protection. This certainly would’ve been done. Because the patient did not have a secure airway, I was sure that the patient had an aspiration pneumonia. They agreed and ordered an x-ray, and there was an infiltrate/pneumonia in the right upper lobe. We discuss places for aspiration pneumonia can occur, and went through the pathophysiology and treatment. The patient was started on ceftriaxone and Flagyl. It was an unfortunate care, and I’m concerned he’ll die overnight. That being said, what can you do when you don’t have a ventilator? Although they were giving the best care to the patient that they could, without essential equipment, complications will occur. And in this case, it probably would have saved this young patient’s life. Now he’s battling hypoxemia due to a preventable aspiration pneumonia and cerebral meningitis…

Patient number two, was a sixty-year-old female with a history of rheumatic fever. She had congestive heart failure due to rheumatic heart disease. Again, in the US, we get these patients to the cardiothoracic surgeon for a valve replacement… They almost never develop heart failure due to this. Her ejection fraction was about 25% per cardiac echo. She was talking complaining of burning epigastrium. The monitor, which I assume was V1, showed ST elevation. We talked about the patient at length, however no other treatment was administered. No EKG was done. The patient was already on full dose treatment with Lasix, ace inhibitor, and other medications. They did not have nitroglycerine. The sad part is, she could not live for long without a valve replacement. There is no one in Gondar that can do this, and she nor her family did not have the money to get the surgery in Addis. She was doomed because medications could not fix her problem…

Unfortunately, 5 hours later, I was called to her bedside because of ventricular fibrillation. They had never used the defibrillator they had, so I helped them with this. Unfortunately, the defibrillator could only give the shock of 50 jules. This is certainly not enough to get her out of her rhythm. Also, they did not intubate the patient, as they do not have any ventilator. CPR was started and they awaited my arrival for defibrillation. The machine was old, but had simple instructions with pictures. I put in the maximum jules, but the metal pieces on… It was an old school defibrillator, had to put the gel on, stand over the patient, put the metal pieces on the correct area of the chest, and shock the patient.

It did take about 20 seconds to charge, which was frustrating. But then, it charged and we defibrillator the patient with 50 jewels. I did this about four times, but there was no way she would be converted with such little electricity. It is unfortunate, this patient needed a valve replacement. She was maxed out on medications, and could not be saved. I’m suspecting that her valve continued to fail with worsening heart failure, then had an Acute myocardial infarction (heart attack) and then had an arrhythmia. She passed away. The resuscitation was an interesting one. The mourning of the patient’s family was very similar to Haiti’s mourning. Lot’s of crying, yelling, and women passing out. I asked the team if any of the family was going to come in to see the body, and they told me no. They don’t allow family into the room after the patient dies because they fear hysteria and possibly violence. It’s very different than how we do it.

I also rounded in the ER… Amazing pathology… Significant Tuberculosis, AIDS with PCP, diabetic ketoacidosis with a severe hand infection and abscess, and 38 year old with a massive stroke with hemiparesis, multiple cases of malaria, and hypertensive emergency. Much of this stuff, we do not see in the US. I was at awe with what I saw. There was a theme, although our medical education and system is the greatest in the world, I could not diagnose and treat most of the diseases I saw today. Now that’s humbling.

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