The End of A Thing

Solomon said the end of thing is more blessed than the beginning but as I realized this morning this will be my last post for a few days (until I get to the airport’s internet) I have very mixed feelings.  So much to think about and consider. Today is (already) my last day in clinic; my last day to struggle through an interpreter; at least for now…who knows what the future holds. But onto funner things.

Yesterday I got to watch a surgery to remove a tumor.  An 18.118 kg tumor (which is about 40 lbs); it was so large one of the doctors would hold it and the other doctor would cut on it and then they would roll it the other was and cut on the other side.  You could tell it was an exciting surgery because every doctor on the compound was in there and the staff were all crowded in the hallway to see the tumor afterward.  It didn’t appear obviously like cancer so we are hoping it is benign and that the patient can recover and live a long wonderful life.  They were working on getting her some information in her own language so hopefully that came to fruition.  Can’t wait to show you pictures.

Last night we had a movie night with all the kids and watched Beauty and the Beast (except the guys who went elsewhere and played games…for obvious reasons) which was a very theatrical remake but enjoyable.  Well, I have to go…or I will be late on my last day!

Adventures in Cooking

Today, June 26th, is Eid in Bangladesh -- the end of Ramadan.  It is a huge holiday here, comparable to Christmas.  People visit family, eat traditional foods, and visit neighbors and friends.  It has mostly been a quiet day for me, which I have greatly enjoyed.  Josiah went to "tea" (which is at about 10 am) with a friend and then they went to the Wild Animal Park.  The price if you are a local is 20 taka (about a quarter) but if you are a visitor make that 400 :0)

But because everyone is off from work, we had to scrounge for ourselves today.  So, I got to try and cook in the kitchen here at the guest house...all I needed to do was boil water for the soup.  That's it, boil water and the soup finally got done 2 hours later.  Why?  Well, there are quirks here.  The outlets have to be turned on for power.  You can't use the water from the tap for cooking.  And the stove tops are difficult to turn on. 

To figure out which burner I was turning on I had to hold my hand over it and even then the electric stove top never got warm enough to boil the water.  The gas range was out of propane (which sits next to it in a large can...made me kinda nervous). Once that was replaced, by someone else :0) who also showed me how to turn it on (no fan allowed because it blows out the flame), it went tolerably quickly.  And the package of tortilla soup was reasonably good -- though nothing like New Mexico's. 

Ps. This is not mine.  This is from the market across the way.

Our Trip in Sound Bites (For the Easily...Squirrel!...Distracted).

A Few Rules for Bangladesh:

1.       If it feels like something is biting you, it probably is.

2.       Always where your orna (this is the scarf) in public.

3.       Fans are your best friend (and they are also why there is a paperweight in every room).

4.       No two clocks are the same so don’t expect them to be.

5.       Plastic bags don’t mean it doesn’t leak or that it is safe from the ants.

(I confess I will not miss: Killing the ants crawling through my toothbrush; killing ants biting me during dinner; killing ants on my food; killing ants I find crawling on my body after removing undergarments.)

Things I Finally Learned

1.       Md. Does not stand for medical doctor it stands for Mohammad.

2.       How an umbrella could be a dangerous weapon.  They are solid wood and so essentially you are carrying around a staff.

3.       What it feels like to worry about having enough money to pay for a child’s medication.  In the middle of our journey being unable to withdraw currency made money tight.

4.       Language barriers make you more direct.  You have to say exactly what you mean if you want to give you patient any chance at understanding what is going on.

5.       How it feels to stand in a woman’s only line… The women’s lines are always longer and not just for the restroom.

6.       For Asia, I am tall and this means that most kamizes (the long shirts) hit me much higher than most woman, near high mid thigh.  (You should have seen the man’s eyes when we told him that Josh was 4 inches taller than Josiah who is also considered tall :0).

7.       It's a good thing I have huge feet – because everyone takes off their shoes before going inside and since no one else can wear my shoes they won't walk away.

When Do You Go To AWANA?

I admit it – I am a purist.  I used to be more so…but I definitely still have those tendencies.  When I was a kid it is was like unto heresy to even think of having AWANA anytime but Wednesday night.  And then we found a church that had AWANA on Sunday nights and that became okay – because who doesn’t want to go to AWANA twice a week, hello!  Then it was Thursdays nights…and now, here in Bangladesh, Friday mornings, after church.

It is so exciting to see AWANA going on over here.  The one we attended was grades 1-8 in one club.  I wish our clubs could play games together!  I really couldn’t understand anything but I still had a rough idea of what was going on.  We sang songs (all with motions!), listened to a lesson, and broke into small groups by age.   Instead of using individual books, the leader has the book and teaches the lesson.  This decreases cost which is paramount here.

So much fun!  The kids are awesome.  Oh, and Blue Team won!  Go blue!

The Ticket System

This morning during a lull our outpatient department (OPD) “house supervisor” Becky (the nurse that helps keep everything flowing), showed me how patients get a ticket to be seen.

Early in the morning people come and line up outside the gate.  Two medics sit in little booths at the head of the line and triage everyone who comes.  They will decide who gets the tickets to see the doctors.  It is not first come first serve.  With only two surgeons (who are amazing), one family practice doctor (who astoundingly also does most of the C-sections -- 400 last year), a part time family practice doctor and myself (both of us are handicapped because we need translators) some patients will simply not be able to be seen.  Though I think this is less of an issue right now because everyone is fasting for Ramadan and fewer people come to be seen.

A green ticket means you get to see a surgeon.  A yellow ticket means you get to see a medic (and not a doctor).  A red ticket is an emergency ticket and that means you get to see me!  A white ticket is the most diverse.  It is a medical ticket – but it also includes OB, pediatrics, chronic disease, and acute medical problems.  An OB patient sees the full time family practice doc.  The young peds patients under 5 months (are supposed) to see the part time family practice doctor.  And we divvy up the others as they appear.

My last patient today was a tribal patient (I can tell because of the way she was dressed).  She is 6 weeks pregnant and has bad typhoid. This is her second pregnancy.  Her first baby was born dead.  I am hoping and asking for a healthy baby this time around.

Medicine is Hard & I Chose It

My first patient this morning was dying of gastric cancer.  The surgeon didn’t feel removing his stomach would extend his life.  Chemotherapy is limited in this country anyway but especially for the poor since everything must be paid for either by the patient or the hospital.  There was nothing to be done except have him see the social worker. 

Then just as my day was ending two young men came in from a motorcycle accident. Riding a motorcycle is very dangerous here; no one wears full clothing let alone helmet, leathers or closed toed shoes.  It is more dangerous with a passenger, in the rain, and it is worse if the driver his holding an umbrella in front of his face to avoid being pelted with rain (this came out later). 

The 16-year-old had a broken femur it was open but otherwise was okay.  He came through surgery fine after a few touch and go moments.  The driver was not okay.  He came in unresponsive pale and flailing.  Large abrasions to the trunk and legs, his oxygen was low, his blood pressure was low – initially normal heart rate then it got fast.  He had a flail chest.  The ultrasound show showed blood in the abdomen.  We rushed him to surgery and he died on the way.

We had no blood to give him – because blood has to be given on scene by a family member or staff and this takes time to match and draw.  Everything needed to be faster.  Only One knows if he could have been saved.  But I heard his wife crying.

The People Who Walk in Darkness

Over the last 2 days, Josiah and I have 2 very kind invites to meals at Bengali homes.  The first gentleman, Bemal, works with Josiah as a day laborer.   He is a skilled decorative welder who had owned his own successful business.  But now, as he repeated multiple times during dinner, he is poor.  His fortune stolen and his business pushed out by his neighbors who didn’t want a Hindu to be successful. His is a sad story but a generous spirit.

I watched him borrow the money for our dinner from another co-worker.  He led us to the edge of the market where he lives with his wife and 2 daughters. The floor was dirt.  One electric wire…that didn’t work the whole time we were there.  The roof was corrugated tin (which basically all roofs are in this area -- so much rain).  No windows beyond the holes in the wall and ceiling.  Dinner was by the light of a camping lantern, mango, grapes, and a Ramadan mix of specialty foods.  Gratefully, we did not get sick…though I fear we may have offended him trying to explain that we would get sick if we drank the water. 

Our second invitation was from a medic I work with.  His family was well established here until his three brothers emigrated to Michigan with his mother.  Now, the only family left in this country, he, his wife, and their 2 boys care for her father (which is a very important responsibility here).  She is an English teacher and we had a very nice visit over noodles, snack mix, cookies and coke. Since he had just gotten off of an overnight shift, I thought we should cut out visit short (only 2 1/2 hours).

Everyday

It didn’t rain today – or hardly at all – which is the first time in 3 days.  I should probably explain about seasons here.  Bangladesh has 6 seasons – a new season every two months starting (typically) on the 15^th. 

·         Greesho (Summer) – HOT!

·         Borsho (Monsoon Season) – starts tomorrow

·         Shawrawt (Autumn) – also hot and humid and everything molds (apparently)

·         Hemonto (Dewy Season)

·         Sheet (Winter) – 40s at night…sounds nice now

·         Bawshawnto (Spring)

Most mornings find me wandering down to the outpatient department with Josiah who goes up to the workshop in the new hospital.  Josiah is still measuring doors to get them hung…it’s a good thing he is detailed oriented.  It is still a challenge for me trying to remember the medications they use over here that are different and the different strengths.  I have, so far:

·         Diagnosed one case of typhoid fever (and she didn’t have a fever…so, I am not sure what to think :0)

·         admitted a 4 day old for high bilirubin (which is a problem here when it rains every day which it will essentially for the next 60 days)

·         seen a molar pregnancy (and the patient was basically bleeding to death from it)

·         seen congenital hypothyroidism (the pictures in the books are right!)

·         and treated a bunch of coughs and colds.

Cox's Bazar

So on Saturday (which is the first day of the work week for most people) I had the opportunity to go to Cox's Bazaar with a couple new friends.  Both were short term teachers for William Carrey Academy in Chittagong and having finished up their commitments came out to our area for a few days’ vacation before leaving for the states.

Cox's Bazar is home to the longest beach in the world; 120 km or 75 miles of beautiful, soft sand.  It was a beautiful slightly cloud covered day which is perfect for redheads.  The waves were consistent, medium sized waves but no boogie boards – oh the sadness.  The beach itself was nearly deserted, being Ramadan, and there were zero other women in the water besides myself and the other female teacher.  We swam (and body surfed) fully clothed and I think it was probably still a bit scandalous.

After this we wandered around two bazars which are basically like flea markets except that people run their booths year round.  The snack foods range from a little odd to downright startling.  I was given a piece of tamarind to try…wow, it was heavily salted and spiced and I declined to have another piece ;0).  However, we also went out to eat and they squeezed me fresh mango juice which was quite possibly the best thing I have ever put in my mouth.

Between the two bazars we caught a CNG (compressed natural gas vehicle) and had a very exciting time as we were hit by another CNG.  PTL they were both steel construction and the worst injury was a bruise.  On the way to the restaurant, my new friends insisted we take a rickshaw so we did – segregated by sex of course, with the male teacher in his own rickshaw.  (I was informed that sometimes you can put three people of the same gender on one rickshaw with the third person balanced in the middle on the other two’s laps….hmmm.) 

And then, finally, to get home we took the bus and I swear the bus driver was nuts – passing on blind corners, squeezing the bus between to other smaller, more vulnerable vehicles, and, yikes!  I spent a week’s worth of adrenaline.  Only by His grace did we avoid a head on collision or other fatal accident.  As it was we hit one person and ironically, it was not the driver’s fault as the man walked into the front left corner of the bus.  We didn’t stop.  The value of life here is lower in general and varies based on gender, social status, and age.

A Typical Day

A Typical Day

Things move at a more relaxed pace here and this is accentuated right now (I am told) because it is Ramadan.  During Ramadan most do not eat, drink, or even swallow saliva during the day and feast at night.  Some are excused such as children, pregnant women, the elderly and infirm but many choose to keep the fast regardless.  (My first patient was a woman 9 months pregnant who was having intermittent contractions…my theory is from dehydration.)  This change in daily schedule means that people are less apt to come to the clinic and businesses close early. 

But even when it is not Ramadan the daily schedule looks like this:

Hospital rounds early in the morning (which I do not do)

Outpatient Clinic: 9:00 to 10:00

Tea: 10:00 to 10:30

Outpatient Clinic: 10:30 to 12:00

Lunch: 12:00 to 2:30 (and no one comes back early)

Finish up the day: 2:30 to 4:00

Tea: 4:00-4:15

(Ah, the power just went out as it does regularly (I do not use my computer plugged in because I am scared of frying it with a power surge).)

So far, my first morning was the busiest.  In an hour I saw about 6 patients – the nurse sure kept me busy.  But it didn’t even seem rushed because of the way they use their “medics” which function in limited way similar ways that physician assistants function in the US.  For me they are invaluable because I simply do not know what is available.  For example, I saw a young boy with a second degree burn on his foot.  In the US, we wash, update tetanus if necessary, bandage and instruct on use of sulfadiazine.  Here they check a CBC and Hepatitis B, have physical therapy wash the wound – he comes back to the doctor who checks it and the medics bandage and instruct on use of the cream and when to come back for a recheck.

Power is back – thank goodness!  The fans keep me sane.

Weekend!

The weekend is here! (If you have a calendar handy and a chart of the various time zones you should be thinking something like, “Alisha has finally lost her mind – the most it can possibly be is Friday.”  And you be absolutely correct – especially about the Friday part, the mind part is still at least partially debatable.)  The Banglaeshi weekend is Friday and Saturday, with Friday acting largely like our Sunday.  So all the activities you think about as being on Sunday happen on Friday here and Sunday is like Monday… confusing but true.

Yesterday I got to take a tour of the new hospital!  Josiah also came but since he has been on the job site regularly it was significantly less exciting.  The new hospital is four stories tall with a useable roof with helipad.  Additionally it has weight bearing pylons extending through the roof for expansion.  From the roof you can see the hill country (the foothills of the Himalayas).  These are where the tribal peoples live including the Mru, Marma, Chakma, Tripura, Khummi, Khyang, and Tangchangka tribes. The saying is around the hospital is that if a Mru comes to the hospital and you can’t find anything wrong keep looking because “they are tough as nails”.  Example: A 22 year old woman, 20 something weeks pregnant, walked one day and traveled two more to make it to the hospital. Her hemoglobin was 2.4 (we automatically give blood in the states under 7 and normal for a woman is at least 11-12).  And she was walking…but I digress.

When completed the hospital will have 152 beds, including PACU (post anesthesia care unit) which right now essentially non-existent, 8 surgical suites, an Emergency Department, a small NICU, and once funds are provided, a CT scanner.  The hospital will continue to do its own laundry, will handle its own waste water, and incinerate its own medical waste.  Many people have sacrificed so much for this project and it is finally nearing fruition.  They hope to be completed in a year but there are still many challenges and needs. 

The Compound

Around 1960, while Victor Barnard was working among Bangladesh's tribal peoples his daughter, Mary, fell gravely ill and desperately needed a surgeon.  But there wasn't one for 400 miles (until Dhaka) and Mary did not make it. 

Thus, in response to this need the hospital was established, fortuitously, in 1966. This was just 5 years before Bangladesh’s war for independence from Pakistan (which everyone refers to as “the War” and looked at me blankly when I asked which one).  Between May and December, when Pakistan surrendered, millions of people lost their lives and many became permanently disfigured due to land mines. During the war, many of the doctors sent their families home and stayed behind to treat the wounded, for which the community remains grateful.  The hospital still has a talented prosthetics department which can make prostheses for about $20 which is insanely cheap.

The war left behind many widows and orphans, with essentially no way of providing for themselves, and this is why the hospital has a craft shop attached to it named Heart House.  About 40 ladies still work at the house making dolls, blankets (they claim there is a cold season :0), small hand crafts, and salwar/kamiz and saris (traditional dress with the mid abdomen showing).

The original hospital and outpatient clinic, where I have spent most of my time (no babies for me yet), are sizable but the new facility is downright impressive.  Josiah will be heading over there later today to measure doors so they can match the doors to the various hinge and handle heights (no standardization here :0).

Total, I would estimate the size of the compound at between ½ and ¾ square miles.  It houses about 18 families and singles who work at the hospital along with a primary school, health sciences college, and various other outbuildings. Just like the country of Bangladesh, no space is wasted and everything used to serve well.

Where To Start?

Well, first things first.  Internet is a bit limited – thus, the tardiness of this first update.  But here we are in green, sub-tropical, humid and hot Bangladesh (which is pronounced Bong-la-desh, meaning the land of the Bangla-speaking people).  Apparently “bang” is the word for frogs and so pronouncing it Bang-la- desh is tantamount to calling it the land of frogs, of which I have not seen any beyond the stuffed ones in Heart House (I shall explain next post). 

But that is not to say I have not seen any animals.  Within an hour of leaving the Cox Bazar Airport, we saw (all wandering freely) dogs (on the runway), cats, goats, sheep, cows (considered tasty by most of the population), and chickens (on the road). The traffic here is intense though not as terrible as Nairobi.  They drive on the left and roughly stay in their lanes except to pass…which is essentially all the time since unmotorized rickshaws that are bike/man powered and small motorized rickshaws that are pulled by underpowered motorcycles share the same lanes.

Within an hour of arriving here at compound’s guest house (which is like one of the old style Route 66 motels a single row of joined rooms), Josiah realized he had a special roommate – which is not me since that is considered unacceptable since he is an adult.  He promptly named him Gary…the Gecko (or (forgive the spelling) a tick-ticki…the Bangla word for this kind of gecko).  Tick tickis are pretty ubiquitous but apparently there are also larger blue spotted lizards – that bite, large wolf spiders with bodies the size of a half dollar, and beetles that are the size of duck eggs.  And while I haven’t seen the spider (which I am okay with), Josiah and I did see one of the massive beetles crushed on the road – and yes, they are huge.

6,645 Miles from Boston

The Dubai airport is very modern, the people incredibly diverse, and their TSA equivalent is very thorough. But the most exciting thing so far has been that our duck tape was confiscated in Dubai. And the sad part was it was a new roll. Oh well, easy come and easy go.

Within an hour of being here an Arabic prayer came on over the loudspeaker, apparently it is the month of Ramadan. There is an interesting struggle between truth and devotion. We easily acknowledge human errors in reasoning and understanding, especially in others, yet we also affirm absolute truth exists. Often these two compete and we struggle to balance devotion to the truth with the search for truth.

Just the ravings of a sleep deprived traveler.

RIP duck tape.

Ps. Yeah for flip phones: My phone can get texts! But it costs 50 ¢ a reply. So, if you send a text, I will be very grateful but likely wait until July to tell you so.