an NGT as a catheter?? why not.

Day 9...mosquito bites 1,000,000, New Bangla words learned 10, number of patients lost...1. I was following a patient with suspected Hirschsprung's Disease, which is basically a disease of the larege intestine in which the nerve cells that allow for motility are missing, this is a congenital anomaly and can present with abdominal swelling, vomiting, constipation, basically signs and symptoms of obstruction. The patient passed this morning from an undetermined cause...the team believes it may have been aspiration pneumonia.

Yesterday a 7 y.o. boy presented in front of me with blood dripping from his groin, his entire genital area was wrapped in gauze which was drenched in blood. His father told me that they had him ritually circumcised by the Hazam of their village. From what I can gather this is the equivalent of the muslim priest (imam) who performs this ritual...although these men are not doctors they have some experience with performing this procedure and can even give local anesthetics if they choose to do so, but often do not place any stitches. In this case, the foreskin was literally sliced and diced leaving a completely botched circumcision. The child was then brought to us to have it fixed. I cannot place judgement on this process but I do think that if these guys are going to perform off the books surgery in their villages they should learn the proper technique! This kid was losing copious amounts of blood and had to travel about two hours from his village just to be seen in our ward!

In other news-the mother of one of my patients keeps pulling out the catheter when she's washing and dressing the baby..like many of the patients she's not very educated and has difficulty following instructions. She was asked to acquire a new catheter and when she returned she tracked me down and handed it to me. the bag said "feeding tube"...I scratched my head thinking..umm...wrong end of the body....I looked at the feeding tube again and thought..well i guess it kind of looks like a foley catheter just doesn't come with a bag for urine collection, but she had that already from the previous catheterization...one of the senior residents must've caught me looking completely confused and walked over--he said that the feeding tubes are much cheaper than the catheters and they basically work the same, they can be connected to the collecting bag with a 5 cc plastic syringe...and voila you have a urinary catheter...I placed the catheter without a problem and started to realize that in these circumstances it is extremely important to be creative and think outside the box in an attempt to reach treatment goals with such limited supplies.

Realized something kind of intresting today--most of the patients we see here at Dhaka Medical College Hospital present in the later stages of their respective disease processes. The reason I bring this up is because the concept of the "appendiceal lump" came up today. A patient presented to our ward with abdominal pain for approximately a week's time. The pain was described as very severe, on physical exam everybody kept asking if I could feel a "lump"--if so then the treatment would be conservative no questions asked. As far as I can remember from my surgery rotation...there was no mentioning of a "lump"..although i shamefully will admit that I often had "lecture narcolepsy" so maybe I missed this. In any case upon asking this "lump" was described as the body's response to so called "chronic appendicitis". The omentum (junk surrounding the intestines) basically formed a capsular ball around the appendix thereby creating a palpable lump on physical exam. The reason this is treated conservatively is that there is a high risk of intestinal perforation upon surgical removal of the appendix. However the patient should be monitored closely for abscess formation or signs of infection. Usually from my experience patients come running to the hospital right away when they have any kind of pain,real or imagined...but here cases such as testicular torsion (twisting of the testicles, Extremely painful) or necrotizing fascitis are seen when there is not much that can be done but damage control. In one case of testicular torsion the scrotum was opened and the most horrible smell erupted...the testicle was completely necrotic (rotten)!

On a completely non-medical note. I think coming to Bangladesh on my own was a huge step for me-exploring my own interests here, thinking of my own projects, creating my own connections. The upper level residents took us to the canteen (cafeteria) for some coffee and sweets. We refer to them as bhaiya/apa (older brother/sister). This creates a very family oriented feel, so much so that everyone is very protective, they create a great learning/working environment and I feel completely comfortable. The culture here is incredible. No one will eat in front of you without offering or insisting that you eat with them. Our attendings will have us meet in their office for some shingara and cha (spicy, salty potato pastry thing, and tea) while we discuss an interesting case or new admissions. But at the same time when it comes to business everyone is extremely serious, minor mistakes are considered major teaching points and everyone is accountable.