Monday, August 2, 2010

Week 2 at Ayder

On Monday, I began my shadowing work at the Surgical Unit of Ayder Hospital. I had already been introduced to Dr. Grimay, the chief of surgery, on Friday by Dr. Lulu as I wrapped up my work at Internal Medicine. I was a bit late to the daily morning sessions that each unit holds with its interns to check up on new admissions and to follow-up on exisiting ones. However, the minute I entered, Dr. Grimay paused talking, smiled at me and welcomed me to the session. He also asked me to introduce myself to the interns and I recited the usual details about who I was and what I had come to do. After the session, I followed Dr. Grimay to begin the bedside teaching rounds with first year clinical students. Unlike medical education in the U.S., medical education begins right after grade 12, that is if you're one of the fortunate and intelligent ones to get accepted out of thousands to one of five medical schools in the country. Dr. Grimay, himself was educated in ferengi-land (abroad) in Cuba and Mexico. He is one of the few physicians in the country and the only one in Tigray region that specializes in cardio-thoracic surgery. Perhaps, it's his personality more than his academic and professional accolades that gravitates his students and his patients towards him. Despite his extensive clinical and surgical knowledge, he is humble and patient as he teaches his students and always finds a way to make an otherwise awkward or serious moment for a student into a humorous one. Many of the patients that I saw in the ward were cases of appendicytis that had just gone through appendectomys. There were also many variations of gastro-intestinal obstruction cases, with one of the more serious cases being a patient who had an interocutaneous fistula, which failed to close despite being operated twice. There was nothing left to be done for this patient. There were also some cases of amputation, patients who had severe electrical burns while doing their jobs and with no other surgical option other than contain the spread of the harmful burn effects to other tissues through amputation. Some of these patients were young and it was tough to imagine what kind of a life they would be able to lead without the use of their limbs and hands.

I observed a total of seven procedures the next day at the OR. Despite a lack of the most up-to date surgical technologies that are available in the U.S., the surgeries were quick and went smoothly. One of the three interesting cases I saw that day was a procedure known as patent process vaginalis. This procedure was conducted on a child, who had a right sided hydrocephale, or accumulation of peritoneal fluid on the left side of his testes. This procedure would ligate the vaginalis nerve carrying the fluid to the scrotum to eliminate the hydrocephale. The second procedure was something unique that is now almost rarely performed in the U.S. It was known as a partial thyroidectomy, which was conducted on a patient with goiter and consisted of removing the majority of the enlarged thyroid tissue around the neck. The final and one of the more prolific surgeries conducted that day involved the removal of a large malignant mass that was obstructing the gastro-intestinal system. I thought that the mass they removed during the first case was big, but as they repeated the procedure on another patient, the mass was twice as huge and looked like something you would see in a sci-fi movie. I was surprised by how efficiently the residents and interns worked to wrap up all the procedures by lunchtime.

I spent my last two days in the Pediatric Unit. This was perhaps my favorite unit to shadow and to learn as the interns were so knowledgeable and so friendly that they not only shared all their extensive knowledge about the various cases in their unit, but they allowed me to see and experience the team-work, camaraderie and fun they had with each other in their work. Many of the kids were admitted due to mal-nutrition and anemia and several were only around the age of 1 or 2. Some of the harder cases to observe were young patients who were co-infected with multiple deadly conditions. One of them was a 14 year old boy, who looked like he was around 10 and was co-infected with HIV, TB, and was mal-nutritioned as well. Another patient who was only about 3 years old and already in the most advanced stages of HIV infection was slipping in and out of a coma during the first day I was at the unit. During the second day, she died. This was the first time I was experiencing death of such a young patient with whom only a day earlier I had held her hand and smiled reassuringly at her mother. It made me stop and realize how fragile life is and hearing the mother’s heart-break revealed to me the limits that medicine had in preventing death. Despite this, I was amazed by the humility and clinical knowledge that both the physicians and interns possessed at Ayder Hospital. Even though there was a severe shortage of life-saving drugs and technologies, resources that are so easily accessible to physicians and students in the U.S., the medical students in this resource-poor setting are so rigorously trained and have the capacity to identify, examine, and treat the various challenging cases of their patients.

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