As a reminder, my last post was out of my normal chronology, sorry about that. This one is about last week. I’ll stop being so confusing, I hope. A LOT happened this past week both clinically and socially, so lets get right into it.
If you didn’t already know (and I bet you didn’t), Ethiopians follow a completely different calendar from Europeans and Americans. As far as I understand it is a solar calendar deriving from the Egyptian calendar. They also have a different clock system coinciding with the sunrise. Meaning 6am for us, is actually zero o’clock for Ethiopians. So, when I tell the residents rounds are at 8am, I need to be clear that I mean European time. 8am for them is 2pm for us. However confusing it is, it makes a bit of sense. Problem is, most of the work runs off a different time and calendar so we are all constantly having to switch back and forth. Since, of course, its rooted in religion it will never change.
I mention this because this week features the New Years and our transition into 2011 (the gap in years is due to an alternative calculation of when the Virgin Mary would become the mother of Jesus). Thus, the weekend leading up to New Years (Monday night is the eve) was supposed to be relaxing. A time to shop for a goat to slaughter (Mekelle was overrun by goat herders), collect family members and prepare for a huge feast.
But, of course, this wasn’t the case for the Head and Neck Department. On Saturday we were presented with a 2.5-year-old with huge abscess over the mastoid tip and septic. Given how common chronic ear disease is here, my first assumption is a complication of mastoiditis. But the child had no history of ear disease and the middle ear looked normal. Now, I know its possible to have an inflammatory blockage of the antrum and collect infection only in the mastoid (sparing the middle ear space), but an astute observation by our residents discovered the true etiology, tinea capitis. It’s very common in children here and at times, it gets superinfected. This can lead to a supportive lymphadenopathy. Thus, rather than sedate the child for a CT (which we would do in the states), we just moved to treatment with I&D in the OR. The video is as satisfying as it is gross.
Inevitably, being the weekend and my aforementioned troubles with the microbiology department, neither a gram stain nor culture would be available over the weekend. I had the residents wash the wound out well and to palpate for bony dehiscence. There weren’t any. A glove drain was placed and she improved in 72 hours and was discharged. The exact same presentation appeared on the day she was discharged, this time in an 8-year-old. Again, no ear history and a huge post auricular abscess. This time, however, there was no clear source. I elected for a CT to rule out a complication of mastoiditis and drained in the clinic. As a rule in medicine, abnormal pathology comes in 3s, so I’m awaiting our next abscess to come walking through the door any minute now (the morning that I posted this the 3rd case appeared, a 6-month-old with tinea capitis, scalp abscess, and a pre-auricular abscess).
That night, I met up with my roomies and our Spanish friends from Wukro. We had dinner and went out to the bar of their choice, ironically named “Amigos.” There, they controlled the DJ station, playing only Spanish music. Now, it’s not a genre of music I would elect to listen to, but was a welcomed break from the ear-splitting, zombie-esk drone of local Tigrinya music. I don’t mean to be disparaging to a culture’s music, but as I currently write this a wedding is taking place about 200 meters from our house. The inhumanely loud music has persisted for the last 7 hours straight. I wish I were exaggerating, but I’m not. And I’m told this will continue until about 3am. I’ve never experienced anything like it really. There are 2-3 variations of chords laid onto a never-ending bass line resembling the beat of a heart. Each song averages 7-10 mins. When each song ends, you can feel your entire body relax, the gentle wind blow and a sense of calm return your center of peace. 10 seconds later, your tranquility is smashed by the crescendo leading to the next song, seemingly no different from the previous. I’ll bring this up again a bit later…I recorded some of the sound for your pleasure. When listening, imaging hearing it pound through your glass windows for 16 hours.
The best part about this night was the re-discovery of my favorite drink from 10 years ago. When I was in Botswana, I came across a very unique drink. There are these massive, beautiful trees in and around the Kalahari that produce a large fruit, high up in its branches. Perfect trunk-height for the huge African elephants. Well, inside the fruit, there is a large seed that they can’t digest. It passes in their feces and the locals collect them to produce one of the most delicious liquors I’ve ever had, Amarula. Sounds like something you wouldn’t want to put in your mouth, but its fine, trust me. Well, I hadn’t seen it in 10 years and one of the Spanish crew came across it looking for something other than Black Label whiskey. One sip teleported me to a camp in the Okavango Delta watching elephants feast around my tent in the middle of the night. Taste and smell have an amazing ability to recall memories you thought you had forgotten. Lucky for me, these memories are some of my favorites of all time and reliving them felt so good.
The next morning I awoke to the vibration of my phone. Not the alarm I had set, but to the ring of one of our residents. Turns out that, just as in the states, the combination of warm weather and the holiday brings in trauma. This 14-year-old that was probably walking his grandmother to church when two guys jumped him (the story of every trauma victim in the states) suffered a pretty impressive nasal injury from a stone.
This unfortunate boy also had to travel from Adigrat to Mekelle (about 3.5 hour drive) with his nose wide open. I’ve dealt with these nasal injuries all the time in the states, but this was dramatic. Every aspect of nasal structure and function was interrupted. From the nasal bony vault to cartilaginous lateral support, to the internal nasal valve and to the tip support and columella. Repairing this required rebuilding each of the support structures by salvaging what cartilage was left. It was fun to teach the residents how to do it and the cosmetic and functional results are great so far. Since I’m posting last week’s blog a little late, I have all the follow-up photos. The left ala and columella look a little funky, but they don’t collapse during deep inspiration, so I’m happy. I’m eager to see how he scars over the next couple of months, but I doubt he will return to see me.
As an update for that young girl with the necrotizing infection of the lacrimal duct: I asked Judith, an expat nutritionist that has been here for 6 years to come consult. Now, I haven’t talked about her much on this blog, but I’ll take the chance to do so now. She is an amazing, selfless person and one of my favorite people here. She left her life as a physician in Venezuela to move to Mekelle and instituted herself as the only nutritionist in the entire Tigray area. She has learned Tigrinya and has helped countless people return from the dead with nutrition or has given the dying joy through delicious food before passing. She explains that her passion is just her Venezuelan nature, but its clear to everyone how much she cares about the wellbeing of those around her. So, I introduced her to this malnourished child with a hole in her face and she took charge. Armed with her cook at her side, she developed a nutritional and global health plan to get this kid healthy for her reconstruction next month. A week later, the child is a new person moving from weak moaning lifelessness, to playful and charming. Judith sent me a video of them playing together which melted my heart. I’d share it here, but I can’t protect her identity on a video (I’m not that savvy). Just trust me that its cute and heartwarming.
We made arrangements for someone to fly to Addis and pick up special lacrimal stents to we can attempt to reconstruct the lacrimal duct path while reconstructing this with a paramedian forehead flap (if anyone has other good ideas for this recon, I’m all ears). We will probably do it in 2 weeks after she gets some more vital nutrition.
Monday was actually a normal day at the office with teaching and working with the residents in the OPD. Challenging them to make a clinical diagnosis is fun. I know they have the book knowledge down, so when we connect the dots to real life patients, their eyes light up. As I’m sure mine do as well.
Monday night was that last night of 2010. I was lucky enough to be invited to the lovely home of a GI attending with his wife, two kids and Yilkal’s wife and little baby. This was held in an apartment building on Ayder’s campus. We ate amazing food washed down with homemade honey wine. The sustenance with liquid encouragement culminated in the entire apartment building meeting outside to dance and sing around a fire. I didn’t have these experiences growing up and certainly felt out of place but feeling this type of uniting culture gave me a sense of honor to be a part of it.
A small group of us broke away to join a bar up by the business campus (pretty close to where I live). There, Yilkal and I came up with our next research project related to the unrelenting blasting Tagrinya music. At midnight, with sky devoid of interference, fireworks jumped from the cross which could be clearly seen all the way on the other side of town. It was totally unexpected and beautiful. I announce the American tradition of kissing someone at the stroke of midnight, but no one believed me. Oh well.
It turns out that the Prime Minister would spend his new year’s day making political history. He joined with the Eritrean President to de-militarize the Ethiopian/Eritrean border. The savvy political move won the hearts of the northern Ethiopian Tigrinyans (the area I am in) because when the border was closed 20+ years ago, many families were separated. These families were able to meet again for the first time in over 20 years creating an amazing and emotional start to 2011. Eritreans flooded into Mekelle buying goods and seeking healthcare here at Ayder. Its been a very interesting experience to watch and everyone here is so happy. I can’t wait to take a weekend to travel up north and set foot in Eritrea.
On New Year’s day (Jon, Alaine, Judith, Waldei and myself) joined forces to make an amazing New Year’s lunch (well, I didn’t actually do much to help). We took corny pictures and ate extremely well. I spent the next couple hours sipping a scotch and watching a movie while the open windows invited an ever-present cool breeze. For those hours, I wasn’t an expat in Ethiopia, I was at home with my wonderful friends.
If that wasn’t enough cuteness for the day, we returned home for a puppy bath day! They didn’t appreciate it as much as I did. This is a video of Gordi “enjoying” her bath.
The rest of the clinical days were spent teaching and doing simple cases including a Functional Endoscopic Sinus Surgery for a Sampter’s triad patient. Nasal polyps, asthma, and sensitivity to Aspirin and NSAIDs. The New England Journal of Medicine came out with a review article on the subject on the same day as the surgery. It was a good opportunity to teach the residents something new. These days were relatively light clinically due to the holiday.
The week culminated, Friday night, with an invitation to “The American’s” house. This couple (with a new baby) has been living in Ethiopia for years, but are soon returning to the states. They are beautiful people and have a beautiful home. We had homemade pizza and I fell in love with Greg when he offered me Bulleit bourbon with some fresh mint they grow in the backyard. It was so, so good and such a perfect ending to the week. We relaxed and listened to stories of how, when they return to the states, they will have ready a custom school bus fitted to take them across the US during their first year back. Amazing…I asked if I could join when I returned.
For the next week to come, you already know how Monday went, but the rest will be coming in the next blog soon.