Random Thoughts Part Duex

So I learned an interesting fact that I thought I would love to share. Kabul, Afghanistan has the highest aerosolized fecal content of the world. An astonishing 20% of the air is feces. Initially I thought it was just a bunch of dust and dirt leaving a fine layer everywhere. Now I picture tiny particles of poop everywhere. Today we tried to think of all that have contributed to this condition: humans, multiple 4-legged mammals, birds. Just one big YUCK!



Along the same line – I had a realization today. Throughout Kabul there are these huge rose bushes. They are absolutely gorgeous, yet so out of place for this dirty place. There is garbage every where, animals roam down the middle of the street and just an overall dingy hue to the city. Intermittently dispersed amidst this mess are these bright, flowering bushes with roses as large as a softball. Not just in private gardens, but on public streets they bloom. Orange, red, peach and white with pink tips: a medley of colors. It just doesn’t make sense how something so richly pretty can flourish here. Then it hits me, they are generously fertilized with the aerosolized feculent air that Kabul is famous for.

I was thinking about a collection I have. From all my travels I like to find a representation from the country I visited to keep and display once a year. I have Israel, Kenya, Mexico, Peru and Costa Rica represented. Maybe I could find one to represent Afghanistan to add to my collection? Hmmm… probably not, when it is a nativity scene of the birth of Christ I am searching for! Does anyone see the irony of my plight?

One morning we had a group visit to children’s hospital here in Kabul. Our team has been supporting them a bit with much needed equipment and supplies. This year we were giving them several surgical set which we had carried all the way from the US in our luggage..

We arrived and were initially greeted by the president of the hospital. He welcomed us in to his office and told us a bit about the hospital. The numbers he shared were astounding. The hospital had 300 beds and at times they have more then 400 children. That means sometimes there is 2 to a bed – can you even imagine that in the states! Through their OPD (Out Patient Department) or clinics they see about 1000 kids a day. Their ER sees about 200 a day and admits 50-100. And this is only children remember. We were served the ceremonial tea and cookies

I was most curious to hear about some of their common clinical problems. Trauma is huge! As he began to list them off I thought to myself, “how many of these are preventable?” So many of the issues are related to safety! Road traffic accidents (RTA – AKA MVC) are common. Falls from roofs or window and burns are frequent. With the traffic conditions being terrible, little children are being hit as a pedestrian all the time. The congestion of cars, lack of adequate curbs or sidewalk and absence of clear cross walks are to blame. One doctor on the trauma floor was explaining that they have elevated crosswalks, but no one uses them because they are inconvenient. He says people don’t want to walk 20m up, 40 m over and then 20m down. He says that in India they construct underground passages for crosswalks and that they are more accepted/used by the people.
He also talked about foreign body aspiration being a common problem. He proudly told us about the fiberoptic bronchoscopy they have, but that the grasper is broken right now. I asked a bit more about that because even thought it happens in the US, it is quite rare thankfully. Reportedly there is a whistle like toy available to children that can have a piece break off and then become easily aspirated. The first thing I thought – Close down the company that is producing this health hazardous toy. That happens all the time in the US – recall it!!! This problem could be so easily preventable.

We then began our tour of the hospital. My first impression was, “I am sure their press ganey score for aesthetics would be low”. No nature sounds and soothing décor to welcome the patient to their hospital experience – just gray concrete everywhere. We were taken to their theater and boy was it bleak with virtually no equipment. Currently their anesthesia machine was down as they had no halothane. They were using ketamine and only had one laryngoscope blade.

We visited the NICU, burn unit, surgical ward and head injury ward. Minimalistic is generous in describing the setting here. One of the first observations was the lack of screens on the burn unit. Flies were everywhere; both airborne and perched on people and wounds. Just like in other developing countries I have visited, family members stay with the children through out their stay to help provide care.





Finally our tour ended in the ED. There was absolutely nothing there other than different designated rooms for different kinds of patients. I tried to encourage our guide by pointing out many of the similarities. Just as we were about end our tour, one of our Afghan staff came and whispered to our leader something in his ear. “Gotta go”, he said. We had been instructed that if at any time you heard those words, drop everything and follow the staff. Obediently we did and returned to our guesthouse. Later we heard that where had been some protest/riots in the Kabul that day. I just read that they were in response to the mistreatment that Afghans refugees were getting in Iran. Ultimately, no harm and I am safe

Henna Party

Yesterday was only a half day with a visit to a children’s hospital. We had the afternoon off and so the girls had a henna party. Six of us sat around and chatted about girl stuff. It was so much fun! The process was longer than anticipated, but this led to good time for all.








This is how it went down. Two of the girls that are here in Kabul full time did application. They were experts of the trade and so I knew we were in good hands. Initially I was concerned about how long it would last. I had no idea: 1 week, a month or longer. I so wanted to do it, but I was kind of concerned about returning to work with henna on my hands. No one could really give me a good answer, so I threw my apprehension aside and went for it.

Henna is a natural substance that comes in a paste-like preparation. It is in tubes that remind me of cake frosting piping. We used stencils to help with the designs. Once the henna was applied, we carefully placed our hands in plastic bags. This was meant to help make the staining a deeper, richer, red color. Next was waiting for it dry. After more than an hour of waiting, the time to reveal was here. We slowly pulled back the stencils to behold beautiful designs of red on our hands and feet. What do you think?

Day 3 of clinic

On my third day of clinic, I was able to use my EM skills a bit more. The plan was for me to be in the women’s room where I could help see the infants and children. My first patient was a middle ages Kuchi women. I know have touched on the Kuchi people, and later I will hope to describe in more detail their appearance. Anway, this woman came in with complaint of body pains and mental illness. My gestalt was that she was a healthy person, and when you think about the life they lead – you know they have to be very strong. I was able to hold her hand and listen to her concerns through an interpreter. It sounded like sleeping was an issue, so I gave her some benadryl and Tylenol for her body pains. I then looked her straight in the eyes, touched her shoulder and smiled.


I was then called in to see a child who was burned. My EM mind started spinning and I grabbed some gloves. A Kuchi mother brought in a 4 year boy in her arms who was wrapped in a scarf. She sat down and put the boy on her knee. As she unwrapped him, the extent of his burn became evident. He had a large area of second-degree burns to his back and right upper arm. There was this bright orange something all over the dried burn. The history was that he was splashed with hot water 4 days ago. The orange stuff was a topical oinitment used in Afghanistan to treat burns. As I assessed his burns, I was initially concerned that his elbow was already becoming contracted in a flexed position. The whole upper arm was circumferentially burned and blisters already broken and dried. He had a strong radial pulse and his cap refill was good. I came to the conclusion that he need a good debridment of all the dried blisters. I tried to premedicate him with Tylenol and applied wet gauze to help soften the blisters. My plan was to let him sit for 30 min and then do it. Let’s just say, the best laid plans…

A staff came to me and said we have an emergency for you to see. Again I grabbed my gloves and followed. In another room was a woman sitting on a bed – frame, with piece of plywood covered with a sheet. She was holding her R arm out in front her, with her L hand on her shoulder. Her face showed she was in pain. I also noticed she had an IV in her R hand. Can anyone guess the situation? In the room was an Afghan female physician to translate, an Afghan male doctor who was treating the women, the woman’s husband, and another woman all dressed in black except for her face sitting at the patient’s side. I tried to get some history and quickly the volume in the room escalated. Everyone was yelling and I understood nothing. Finally I was told the woman had been treated in Kabul, given a prescription for IV meds, bought them and was to have them administered at the clinic. The male doctor and just given her the meds for asthma and she was having pain to her R arm. My differential was: drug reaction, infiltrated IV, thrombophlebitis, anaphylaxis and psychosomatic. She seemed to relay that her pain was worse in her shoulder. Looking at her hand – no swelling or rashes, pulse good, IV site looked good, no boney tenderness. Her whole arm looked normal. I then tried to palpate her shoulder and she whelped. I then moved her through ROM and she had not difficulty. By this time, my overall impression was there was nothing physically wrong with her. I have had a few clinical encounters with Islamic women and sometimes there can be a bit of drama. Anyway, multiple verbal exchanges at a yelling volume continued and I tried reassure the patient. Through the interpreter, I told her her arm was good. I tried to think of some of the interventions I had available to me at this time that might help the situation. How about taking out the IV and some Tylenol/ibuprofen? I took out the IV and placed a big blue band-aid on it. As we gave her a couple Tylenol and ibuprofen, she swooned and laid down with her arm across her face. We were told she had a reaction to the medication. Confirmation for drama! Her husband now was yelling, grabbing her hand and trying to pull her out of the clinic. She had a good pulse, no respiratory distress and good color. Again I tried to reassure the patient that she was OK. After a few minutes of hand holding and smiles, she got up and walked out. Apparently she was cured!

Back to the burn boy. We moved into their ER – literally a room, and I began to take off the dressings. Unfortunately the wet dressing had now turned dry because I had spent too much time with the other woman. I was hoping for soft skin to help the process. I tried to explain to the mother through the interpreter what I was about to do. With lots of water and gauze, I did my best to remove the dried blisters. I felt just terrible as the little boy screamed because I had nothing better for analgesia than the Tylenol I had given. Mother was really good at helping hold him, but it was a moving target for sure. Once I had the hard, dried blisters removed, I tried to extend his arm gently and slowly. I can only image the pain. I held his arm in extension for a bit and then released and repeated. I had the mother demonstrate the same, because I knew with some PT, the boy would have significantly decreased function of his right harm due to contracture. Mother was wonderful! I replaced a dress of Xerofoam and gave the mother enough to do daily changes. Supposedly the little clinic we were at had a burn clinic and we instructed them to return in 2 days for a check. I truly have no idea what kind of prognosis this boy with have with his arm, but I pray the best for him.

Kuchi

Outside of the city of Kabul, in the plains at the foot of the mountains, the Kuchi people live. They are a tribe of Afghans that live a nomadic life; herding sheep and goats. Over the 3 days at this outlying clinic, I had many interactions with them, primarily the women and children. They are fascinating people!

The first thing you notice is their brightly colored attire. Starting from the bottom up, you have foam sandals on dusty, calloused feet. Their legs are covered with bright, solid colored balloon-like pants that go all the way to their ankles. Their body is covered by an intricately decorated dress. It is long sleeved and fitted on the top. There is a long, full skirt that drops below the knee. This dress has brightly-colored, detailed embroidery, beadwork and metal amulates. Their hands have red henna on the palms and nails. They also have gold rings on their fingers and bangle bracelets on both wrists. Over their head is another colored scarf. It is covering dark hair that is sometimes braided and decorated with colored threads. It is pressed closely to their foreheads, almost to give the impression that it is a wig. They don’t wear a burka, but do cover their face with the scarf when needed. Their face is scared with hyper pigmented spots from Leischmaniasis. Some of them had black tattoos on their chin and forehead. Many of them also had a gold nose piercing. Their eyes were captivatingly large and really draw you in. Throughout clinic, I would look into their eyes as I took their history and could see my own reflection there. It was a weird moment.

I posted some pictures yesterday of some of the Kuchi children. Can you see how huge their eyes are? On the infants, they place black eyeliner around the eyes. I was told it was ward off evil spirits.

The Kuchi Children

Today was a full day at the clinic. I so wish I had a scribe right now to put all my words to writing so I wouldn't have to! Just a few pictures for now.

Random thoughts:MREs and ear wax

Today I had a MRE for lunch. Reported you can buy them in the market in Kabul. How they make it to the market is a good question. We were told that when they “fall off a truck”, the boxes are taken to market to be sold. It was the coolest experience. In a box of 12 were a variety of dinners. It was like a full menu of choices and even a vegetarian could be accommodated with a hot meal. There was chili, sloppy joes, spaghetti, chicken and dumpling and quesadillas. Mine was meatloaf and mashed potatoes. I figures out how to open the blessed packet, I took stock of all it contained. Sizing up the portions and menu, I am sure if I had been able to eat every bit of it I would have had double, even triple daily weight watcher points. But look who they are cooking for!

So the scientist in me was totally enthralled with the exothermic heating process of the meal. All the necessary equipment was present: a special bag, water and the foiled seal meatloaf. Just pour a bit water in the bag, stick the meatloaf in and in 10+ minus you have hot meatloaf that didn’t taste too bad. I heated to the mashed potatoes just to taste and they weren’t the greatest. There were crackers and jelly, a cookie, tootsie rolls, hot chocolate and instant lemon flavored tea. An interesting fact is that MREs also contain an after dinner mint. It looks like a chicklet piece of gum and you’re thinking, “great I can clean my palate!” Truth is the gum/mint contains sorbitol, which is meant to act as a laxative. Good to know before I ate them – which I didn’t mind you!

I saw a little 10 yo boy who said he had headaches and was dizzy. Dizzy is one of the complaints I truly don’t like to see because it is so vague and individual. This can make it hard to work up. My gestalt of the child was he was overall well. No murmur or tachycardia and a quick neuron check was normal. I did though find a R ear that was cerumen impacted. I washed that ear out and got the satisfaction of removing one large piece of hard ear booger! I pray this was contributing to his dizziness and now he will be cured. If not, at least his hearing will be improved.