Passover

So, there was a Passover Seder here on base that a group of us from the hospital went to last week.  The Rabbi was flown in from Germany for the occasion, though I think he must be from New York originally because listening to him talk made me feel like I was at home.  At the conclusion of the evening he had us act out parts to a song.  One of the guys in our group shot a short video of the end of the song which features me acting out "fire".  The structure of the song reminded me of The Twelve Days of Christmas.  For those of you who were at the General Surgery Christmas party this year, you can tell me how my part here compares to my rendition of three french hens.

Not for the Faint of Heart: Poppies and Parasites Explained

Let me start with Poppies (with which I have no experience), then you can decide if you want to continue reading about Parasites (with which I have a growing experience).  

So, as is probably the case with any country torn by years of war, poverty, drought, corruption, and an untenable terrain, among other things, the statistics about Afghanistan aren't always straight forward.  While the World Bank reports a 49% increase in the opium production, the UN reports a 19% decrease between 2007 and 2008 with a further anticipated decrease in 2009.  One thing that everyone does seem to agree on is that Afghanistan has been the world's largest opium producer for at least a year.  The export value of the crop is somewhere around $4 billion and it has been reported that more land in Afghanistan is used to grow poppies than is used in Latin America to grow coca.  In the past year, the value of poppies has decreased, but still remains higher than most other agricultural products.  This is clearly one of the driving forces in its continued production.  Other influences include availability of irrigation, local need for foodstuffs, religion, government interventions, or the lack thereof, as well as the Taliban and its enemies.  This is clearly a multifaceted problem making its eradication a tremendous challenge.

Eradicating parasitic disease in an underdeveloped country is also challenging, though we are trying to do it one patient at a time.  Ascaris lumbricoides is a common parasitic worm infecting many of our patients.  The Ascaris life cycle is kind of interesting, and quite frankly, kind of disgusting.  The mature worm, which can set up residence in the human intestines, produces eggs which are shed in the feces.  In underdeveloped countries human feces are either indiscriminately disposed of, or are sometimes used as fertilizer, so feces are ubiquitous in the soil.  The eggs in the soil go through a process of embryonation and develop into larvae.  These larvae are then ingested through foodstuffs.  Alternatively children go out and play in the dirt and invariably dirty hands make it into their mouths and the larvae get swallowed.  Once ingested, the larvae penetrate the intestines, travel to the liver and eventually make it into the blood supply to the lungs.  (Here's were it gets really disgusting, if you haven't been totally grossed out already.)  At this point, the larvae perforate into the airspaces of the lungs and get coughed up.  They then get swallowed back down into the intestinal tract and become mature worms which excrete eggs and start the whole process all over again.

Compared to other parasites, Ascaris is considered to be a relatively short lived parasite with a life span of "only" 6-18 months, which is 6-18 months longer than I would like to have worms.  They can get to be quite long with lengths up to 40 cm.  An estimated 1 billion people in the world are infected and excrete somewhere around 25,000 tons of eggs on an annual basis.

My first encounter with Ascaris came during an abdominal exploration on a young girl who had sustained a penetrating injury to her abdomen from some sort of improvised explosive device.  One of the steps included in an abdominal exploration is a process called "running the bowel" where the small bowel is carefully inspected from one end to the other to make sure there are no injuries.  Because of the redundancy of the small bowel, the process includes passing the bowel from hand to hand to make sure that no segments are missed.  Normally the bowel is essentially a hollow tube, however, it feels like there are cords of rope in it when worms are present.  Needless to say, it's kind of gross.

Apparently when a patient is ill or dying, the worms are

able to recognize a bad situation and make a run for it.  So they can start crawling out the mouth, nose or out the other end.  The worm pictured to the right came out of a burn patient we have been treating here for the last several weeks.  Though she was not dying, we had induced diarrhea with her feeding regimen and this worm just got caught up in the current.  Incidentally, we try to provide an additional 10% in nutritional support to account for what the worms are eating.

There is medication to treat these infections.  We generally wait until the patients have recovered from their acute illnesses before we treat them.  The dead worms are excreted in the stool which has the potential to cause a bowel obstruction if there is a significant infestation.  We don't want to take the chance of causing such an obstruction while the patient is still recovering from his or her primary illness.  The infectious disease specialist who is here tells me he is planning to take a dose of the medication himself when he returns home - just in case.  Between his advice and the giant hair ball that was in my salad the other day, I will probably do the same.  Needless to say I don't think I will handle it very well if there are any positive results.

So, as you can tell, Afghanistan has some very redeeming qualities.  Unfortunately I think these two issues only represent the tip of the iceberg.

Other than that, not too much else going on here.  The weather has still been pretty rainy which has kept the tempo down.  And, we have another surgeon who has joined the rotation, so the call schedule is now even more spread out.

There is another medical unit which is going to be stationed here which means more people.  Unfortunately there isn't more housing available, so my room of 4 is going to become a room of 6.  The additional furniture gets moved in sometime next week and the additional people are allegedly arriving the first week in May.  I'm hoping to be in the process of packing to leave at that point.  6 women in a room?  Holy giant cat fights...

Up On the Roof Top, Click, Click Click...

So, I've got the wrong holiday, but we were up on the rooftop.  Actually the group picture is from Easter Eve.  There was a gazebo built on top of the hospital for the purpose of smoking cigars.  Since I was planning to go to Mass after the smoking break, I decided to refrain, but the weather was really pleasant and it was nice to get outside and get some "fresh" air.  The hospital is right adjacent to the flight line, so "fresh" air usually includes a mix of burning aviation fuel, and on this occasion, cigar smoke as well.

On the days when the weather is nice out, I try to get up to the gazebo to read.  The fact that it's adjacent to the flight line sometimes makes it difficult to concentrate on the reading - watching the planes coming and going is often a lot more interesting.  And, on clear days, the view is really spectacular with the mountains in the background.

I hope everyone has had a Happy Easter and a Joyous Passover.

Doing Time

So I realized it's been about a week since I last posted to the blog.  On one hand, it's hard to remember exactly where the week went, on the other hand it seems like it was a long time ago...

It's very easy to lose track of time here for many reasons.  First of all, everyday is pretty much the same routine - we start at 6:30 in the morning reviewing X-rays and then make rounds in the ICU.  This is followed by a quick breakfast and then off to the "No Issues" meeting - so named because all the departments in the hospital meet to discuss issues, but nobody ever has any.  We then round on the ward.  Once rounds are done, the rest of the day consists of (not necessarily in this order) cases in the OR (if there are any to do), going to the gym, taking a nap, either dropping off or picking up laundry, reading, waiting for the pager to go off, checking the mail, dinner, and often times a movie in the "Doc Box" (the room in the hospital where we spend a great deal of time).  Everyday I tell myself I'm going to get to sleep early, but invariably I either end up chatting with Greg on Facebook, or reading, or both, and don't quite get to bed as early as hoped.  (This explains the necessity for the daily nap.)  The one day of the week which is different is Sunday because instead of starting at 6:30, we start at 7:30, but as you may well guess, this isn't a very big distinction.

The second reason it is difficult to keep track of time is because I'm also trying to keep track of time back home - so when it's today here, it's yesterday there.  And when it's today there, it's tomorrow here.  I still have my watch set to San Antonio, I guess I sort of did that as a way to feel connected to home, and maybe to deny the fact that I am not there.  But invariably I still look at my watch and end up having to do complex math to figure out the local time.

The math is complex because Afghanistan is one of those few rare places in the world where the time is off by a half hour.  So when I look at my watch, I have to subtract 2-and-a-half hours and make it tomorrow to have the local time.  For those of you who I have spoken to about this half-hour difference, I have to correct myself regarding the number of countries in the world that are not on the hour.  I thought there were only 4 countries on the half hour, but I looked it up on Wikipedia and actually Newfoundland, India, Iran, Venezuela, Burma, the Marquesas (in the South Pacific) and parts of Australia are also on the half hour.  And to take it a step further, Nepal and the Chatham Islands of New Zealand are on the quarter hour.  And, China is just in one big time zone.  (Oddly enough, we don't observe daylight savings time here, so it's getting very bright in the mornings.)

To further complicate the time issue, the patient charts are supposed to maintained in Zulu time.  This is to help standardize things as the patients move through the system from Afghanistan to Germany and on to the US which has it's own variety of time zones.  So, some of the clocks in the hospital are local and some are Zulu, and some people are adamant about doing everything in Zulu and some aren't.

Despite all this confusion, one lesson that I first learned as a medical student and fully appreciated as a resident is that no matter what "they" try to do to you, they can't stop the clock.  So every minute spent here is one less minute that I have to spend here.  I'm fairly certain that I'm at about the halfway mark, so the time ahead of me is less than the time behind me, and the light at the end of the tunnel is shining a little brighter each day.

Regarding the daily activity of checking the mail I have to say again the support that I have received from everyone back home has been incredible and has made all the difference in the world.  Thank you.

And, for one more exciting update, earlier this week I was reunited with my missing laundry bag after three long weeks.  I now have so much clean underwear that I'm tempted to change it in the middle of the day just because I can.