Language learning

Some literal translations of some medical terms

The meniscus cartilage in your knee - "crescent cartilage"

Tonsils or enlarged lymph nodes - "almonds"

Scabies - "jarab." Someone who is very cheap is known as a jaraab, aka someone with scabies. Unfortunately I learned this word because there's 4 patients with scabies at the SCI house, and rumor has it scabies is rife in one of the Syrian camps in Amman.

A cold - "gribe", aka gripe, french for a cold

Duodenum - "the twelve" - bit of a longer story here. I was getting my haircut in the 7th Circle when my barber learned I was in medicine. He starts telling me he's had heartburn, stomach problems, and an "ulcer in the twelve" (قرحة بالاتنا عشر). The twelve what, I don't know, but I'm working on trying to figure that out. Given the context, I knew he was taking about his duodenum. But this reminded me of something. Back when I did a rotation at the San Francisco Free Clinic, I had a Cantonese patient who also had stomach problems. We had a volunteer translator who knew Cantonese well, but not always how to translate things into English, stumbling at one point when she told me that the patient had a problem in her "twelve finger organ" (no idea how that's said/written in Chinese). We had to go to Google Translate to figure out what exactly the twelve finger organ was, which is why it was such a memorable experience.

I wonder if the Chinese and Arab anatomists developed this name for the duodenum independently? It'd be an interesting history to learn who came up with it first and how it got from one language to the other.

New Patient

Abu Hayat arrived yesterday at the Spinal Cord Injury house. A man in his 30s injured in southern Syria, paralyzed from his belly-button down about three months ago. He was treated in a field hospital, transferred to a higher level of care in a nearby city where he had two surgeries: one on his back, and one in his belly. The patient isn't clear why he had either, nor if they took anything out of his belly, like his spleen.

Unfortunately, this is about the 4-5th patient I've seen after a laparotomy (open abdominal surgery) who has no idea what was done in his belly, if anything, during the surgery. This is important because if his spleen was removed, he will be at greater risk for certain infections, particularly pneumonias. And with no records, clinical notes or ability to communicate with those who did the surgery, unless we do another CT or MRI, we're not going to find out.

Its been three months since his injury, and he's learning for the first time about he needs to change positions every few hours or he'll get bed sores. Paralysis 101, but he hasn't yet had the course. Which means his 8x10in stage 4 decubitus ulcer will require a skin graft for any chance at healing.

I can't blame the patient. He's just been through a near-death experience. Plus Abu Hayat is lucky to be alive since the bullet (which is still in him) is only a few millimeters away from his aorta. I don't expect him to know all the details of his surgeries. But this means that by the time they get to us at the SCI house they're already doing poorly.

Blunt instruments

The law is a funny thing sometimes. A friend in the Sociology department once told me that its a very blunt instrument. It often has the effect you want, but either too little of it, or way too much, causing lots of other unintended effects.

I went to a lecture with a friend yesterday about the legal situation around humanitarian law, given by Naz Modirzadeh, a legal fellow at Harvard (ironic that I have to come to Amman to hear a Harvard Law talk). If what I heard is true, it turns out I can be prosecuted in the US for the aid that I'm giving to refugees and possibly have my assets frozen by the Treasury.

We went to Za'atari today, Dr. B and I. Worked in the General Med clinic, seeing ~35 urgent-care cases. Patients come in with a 2x2 card with their name, their waiting list number, and what kind of doctor they want to see. The nurse records their name and age. We take a brief history, focused physical exam, and write for a medication (even if we give saline drops, the cultural expectation is that patients will walk away with a script for something). The nurse writes down the diagnosis. Simple patients can be seen in 5 minutes.

You can tell what's common by what's missing in the pharmacy. There's no cough medicine - no syrup, no pills. Few antihistimines. There used to be some, but demand outstripped supply. There are few choices of antibiotics and no data on antibiotic resistance to guide our prescription choices.

You'd think everyone in the camp had an upper respiratory infection based on what we saw today. Everyone has a cough. Even walking around the camp, you hear coughing. Wet, dry, yellow phlegm. One woman with 11 kids said everyone in the house has a cough. Only a select few decide to show up at the clinic.

So I helped teach a 60 year old Bedouin woman how to use an asthma inhaler, convinced a number of kids to let us look in their ears, and looked in what felt like innumerable throats.

All that's probably kosher. All the patients I saw could have been part of Jabhat al Nusrah (on the US terrorism list), and I wouldn't know or care. You treat the patient. Same goes in the US - gang member or murderer, everyone deserves to be treated.

But at the end of the day we drove to a tent on the outskirts of the camp. We were greeted by an elderly lady who emerged from her tent, in her black flowing dress and matching hijab, inviting us inside to meet her son, who I'll call Abu Hurriya. He's lying down in the dark tent, his temples hollowed and eyes sunken from days or weeks of poor nutrition. We're told he's a hero, having fought for the Free Syrian Army (FSA). He arrived 5 days ago from Syria, where he was shot three times. They asked us to look at his wounds. The bullet hole in his left hip was still bleeding.

According to US law, I should stop there. It is against US law (the Patriot Act, to be specific) to provide "material support" to terrorists. This includes direct support or indirect support. "Material support" is so vague that it applies in a number of cases. It of course applies in direct assistance or funding. But it also applies in providing things like food or medical aid, on the principle that doing so allows the organization to divert more funds to terrorism. And these clauses reach through, meaning that if funds come from US organizations (USAID, etc.), your organization must ensure that any downstream benefits from your funding do not materially support terrorist organizations. If they do, you are also liable.

Surely there must be an exception for providing medical services? There isn't.

The currently applicable exemption for ‘medicine’ does not appear to encompass anything other than medicine itself and therefore seems to exclude all other activities (such as medical treatment or technical training) and resources (such as medical supplies or equipment) associated with the provision of medical assistance.

It makes sense. A law that prevents people from providing material support to terrorists seems natural. Who would want to support terrorists? But the law was written in such a broad way that humanitarian agencies are jittery. They are at risk of losing funds or being prosecuted if they somehow, even indirectly, provide material support to a group deemed to be a terrorist organization by the US government. This means trying to provide medical aid in Southern Lebanon where you would be required to coordinate with Hezbollah. This means a delay in getting food aid to Somalia during a famine because humanitarian aid agencies needed a waiver from the law in order to provide food in Shabaab-controlled areas. This meant some Muslim charities aiding Palestinians in Gaza after the 2008 Israeli bombings and invasion were prosecuted for coordinating with Hamas on recovery and reconstruction.

Even providing education on how to resolve conflicts peacefully is not protected by the first amendment and considered illegal according to a Supreme Court ruling. Such terrorist groups are "so tainted" by their terrorist actions that support of any kind is against the law.

The FSA is known to coordinate with Jabhat al Nusra. That makes providing any medical services or education to Abu Hurriya is technically against US law (there is an extraterritorial component to the law where any actions committed abroad can be prosecuted upon arrival in the US). Technically, once back on US soil, I could be fined or imprisoned up to 15 years. There is no statue of limitations. International law is moving in the same direction.

I won't say what I did. Abu Hurriya had already been injured by blunt instruments. We didn't allow another blunt instrument to keep him from getting help.

Photo credit: Adriana Reyes

Faux pas

A couple things I've learned here so far (probably the start of a series):

1. Do NOT put bottles filled with urine samples on religious books. This makes people (understandably) angry. It was unintentional and nothing got dirty so all was forgiven, but Mental Note - read book titles before putting potentially dirty things down on them.

2. Light stoves or gas heaters with long matches. Being a novice at this technique (turn gas on, try to light gas with lighter), I've singed all the hair off my right hand.

3. Don't try to get out of a taxi on the left. In Amman, taxi doors only open on the right side of the car.

Za'atari

Za'atari. It wasn't a city before, but now it is. A city with communal bathrooms. Where pretty much everyone is poor.

But its a Syrian city so the smells of Damascus and Dara'a fill the main street. Sweet shops with knafe, shwarma, a coffee shop with men packed in to watch a soccer game. Vegetables, gas, clothes. You can buy it all. Electricity stolen from the camp infrastructure will cost you 75 Dinar a month (over $100). Its a street teeming with life and with people.

And the numbers are staggering. As of today, 131,000 in the camp - approximately doubling in the past month or so. With the situation in Syria likely to get worse before it gets better, refugees will keep streaming out of the country.

So life goes on in the camp. Instead of distributing tents, there are now some small sheds. One family came to the admin building while we were getting permission to enter the camp. They arrived 10 days ago, but were hoping to get a second shed for "guests". Guests are important. And culture finds a way to survive even in conditions of deprivation.

A midwife told me pregnancies are common, though there is only one c-section place for all of the camp, at the Moroccan hospital. Why have kids here, I asked? Who knows when the crisis will end. In the meantime, one must be human.

And humans get sick. Just walking around we saw one kid with Hepatitis A (AST and ALT >3k each). Heard about a lot of diarrhea secondary to poor sanitation. Water is distributed in the camp (still trying to find out the quantity) but there's not enough. So people reuse it, making themselves sick by cleaning themselves with dirty water.

We stopped by the four "hospitals" in the camp. French, Moroccan, Italian and Saudi, usually a collection of tents, maybe trailers, or an RV for a makeshift lab. The first two are run by the military, so everything from people to medicines are brought from their home country. The French hospital does measles and polio vaccines, leaving the rest to the Jordanian Ministry of Health (didn't get a chance to visit). They have two hours of general medicine daily. But they focus on surgery, stabilizing those injured in the war and sending them on to hospitals in Amman. The Moroccan hospital is more comprehensive with an ICU, surgical tent and tents for primary care. Medicines brought from Morocco.

Italian hospital was closed, but we spent most of our time at the Saudi hospital which focuses on primary care and has their own pharmacy. But medicine access seems to be a huge issue. The French hospital's pharmacy provides meds only to those patients that saw docs there. Same at the Moroccan hospital and Saudi hospital. But this means that, from what I could tell from a few hours there, there are 2 general pharmacies for 130k people. And these are limited pharmacies. For skin problems you have two choices of medicine at the Saudi hospital - anti-fungals or moisturizing cream.

All of this was preliminary, unverified info. If all works out, I should be able to volunteer with Dr. B at the Saudi hospital and will have a chance to get to know things a bit better.

Madaba Refugee clinic

A bit more on the refugee clinic in Madaba earlier this week. As I mentioned, there aren't many organized resources available for refugees who aren't in camps. So this group of volunteers with the Jordanian Women's Association has built up a mobile clinic structure with paper records, and a team of people that includes admin folks, a pharmacist and a doctor. They're based in Amman and go out to various towns on weekend days.

We saw bread and butter primary care with a few more complicated cases thrown in. The bread and butter were lots of upper respiratory infections, many patients with kidney stones (they call it urinary sand in Arabic), and lots of musculoskeletal pain. There was even a plastic surgery request from one teenage girl. But then there's the different cases like a very cute and shy young girl who likely had intestinal worms. A two year old boy with a foreign body in his ear. A five year old boy with an undescended testicle that must be surgically treated or he is at greater risk for testicular cancer. A three year old with a very audible ventrical septal defect, also needing surgery. His mother also thought he had transposition of the great vessels, but that seemed unlikely since the kid was rosy red and playing around with his brother. Once we see the records days later it turns out he has L-TGA, meaning both his great vessels and ventricles are transposed. This explains why he's not blue, but unfortunately he already has severe, irreversible pulmonary hypertension. We're working on trying to get a group to sponsor him for surgery in France.

The more complicated cases were a woman who had a cardiac catheterization showing narrowed arteries but couldn't afford stents. A man in his 60s with high blood pressure he thought was controlled (it wasn't) who had a high fasting blood sugar. Not only does he now seem to have diabetes, but is already having neurological problems in his legs, protein leaking from his kidneys and eye problems, all complications from diabetes. Plus with his blood pressure 190/95 he's at risk for even greater complications. We hope to see him again this Friday to follow up.

But when I say clinical care is a patchwork quilt, I mean that this is one of many volunteer clinics being organized out of Amman. But from what I hear the different groups organizing the clinics aren't coordinating to either concentrate geographically or on certain days of the week. So when the patients came to see us, unless they tell us, we have no idea what other services they are getting, what other clinics they are seeing, etc. There's rumors of this in the camps as well, where there are various hospitals/clinics run by different nations - Moroccan, Saudi, etc. Some patients go to a clinic a day, collecting medications for their ailments which they then sell in the camps.

So will we see these patients again? Who knows? The chances of being lost to follow-up seem very high. We took the names and numbers of those that needed surgeries to try and follow up with them once we can find a surgeon and some funding.

What determines whether a refugee goes into a camp or not? Basically two things - having a passport and the location of crossing. Syrians with passports can get a visa and enter Jordan like anyone else. Those without a passport are often fleeing imminent danger so have no ability to go through the official channels to enter the country normally. They arrive at the border, register with UNHCR and then are processed to go to one of the camps. However, there are a number of refugees without passports that have slipped over the border illegally. These refugees are especially vulnerable because they haven't registered with UNHCR, which theoretically makes them eligible for support from the UN agency.

الجرجير

I'm invited to join a picnic at the SCI house. Abu Amr goes to the wall around the house and picks some grass. There's some other leafy greens some other guys have picked. We munch on bread, olive oil, tomato and a green pepper. Abu Amr gives me some of the grass to eat, telling me its garlic. I have no idea what's crawled through that 'garden', so fingers crossed there's no hookworm around.

They tell me to eat one leaf, that it'll make me strong and manly. I figure they mean something like put hair on my chest. It looked kinda like an oak leaf but tasted a bit like spinach. They joke its a shame I'm alone here in Jordan. Turns out this leaf is given to newlyweds. They're using words like "hadid" (iron) and "qoom" (standing), as well as a few others I don't understand, but their meaning becomes clear.

Turns out the leaf was الجرجير - al jarjeer. Aka arugula. Who knew?

More Kuwaitis

More Kuwaiti sheikhs came through today. Giving golden handshakes to the tune of a Benjamin with all the patients. Literally a Benjamin. Figuring, hey, we've got some intractable urinary tract infections here, maybe the Kuwaitis would be willing to buy the meds? So they did - Meropenem and Fluconazole - to the tune of about $700:

Another night in the hospital

"Ma bidy rooh hella, doctoor. Fena nastana hata bukra lnaml soora?"

Abu Hussein asked me this, covered in blankets to his ears, still shivering. "I don't want to go now, Doctor. Can we wait until tomorrow for the x-ray?" What do you say to a man who has been through so much, to convince him to go through yet another hospital visit? Where every transfer to a new bed means pain, where they don't know if they'll be able to pay? But I was worried about his left lung. There were no breath sounds. In the context of his chills, increased heart rate, increased productive cough, and an episode of blood when he coughed today, I didn't feel comfortable waiting until tomorrow.

Its unclear what "normal" is for Abu Hussein. He arrived on Sunday to the SCI house. Shot through the spine on the outskirts of Damascus about three weeks ago, this 50 year old father has slowly made his way to Amman after a couple hospital visits on the way. He's hoping for surgery, hoping he may still be able to walk again. His brother has been taking care of him as best he can. But he doesn't know the risks people with spinal cord injuries face. As a result Abu Hussein has an unstageable bed sore on his bum about the size of a softball (I'll spare you the photo).

Earlier today he had gone to a hospital for an MRI to find out the location of his spinal cord lesion and see if any surgeries would help. I wasn't there, but his brother mentioned they had no stretchers available and moved him around in a wheelchair. At one point Abu Hussein fell from the chair onto the floor.

Plus, we knew from the MRI he had some broken ribs (before he fell):

In a place where there are not unlimited resources, where there are 13 other patients with spinal cord injuries among whom the resources must be split, I questioned myself repeatedly - does he really need an x-ray now? Already I've felt this economic question has gotten in the way of seeking the best care for the patients at the SCI house, so I gathered myself, spoke to Dr. B and talked to Abu Amr about taking Abu Hussein to the hospital So we piled in the car. Five of us, two in the front, the patient supine in the back of a Ford Explorer-like vehicle. The remaining three crowded around him.

At the first hospital a doc came out, did no examination, declared him stable, then said he should go to a different hospital just in case he needs the ICU. I was as confused as the next guy with that contradictory statement, but away we went. At the next hospital, we arrived in the ER and spoke to the docs. After 30 minutes, no vitals were taken, so we took them ourselves. ِAnother 30 and we finally got the x-ray:

Strange x-ray that just doesn't seem to match why I heard no breath sounds on the left. No obvious signs of pneumonia or fluid around the left lung. But the left lung isn't normal. Neither is the right, really, though his injury and some diaphragmatic paralysis might explain some of the right side. No one else at the hospital seemed to know what was causing his symptoms. So he was admitted and we'll see him tomorrow. (Comments/suggestions from those with more experience is very welcome!)

We get back to the apartment and Abu Amr kisses me on both cheeks and the top of my head, praising me for sounding the alarm, asking for the x-ray. I hope I earn that compliment. Abu Hussein, despite his pleas, is spending another night in the hospital. I hope for his sake something good comes of it.

Kuwaitis

Some Kuwaitis were at the SCI house, possibly to provide support. In addition to bringing fantastic dates, they wanted to take a picture with the docs working there.

Left to right is me, Dr. B, Dr. L and then two of the Kuwaitis (never got their names).

State of the refugees

By the way, in a strange turn of circumstance, two of the largest refugee camps sound the most delicious. Za'atari here in Jordan means "thyme-y" - like the spice. One of the largest refugee camps in Turkey is in the town of Rayhanli, which means "basil-y" - again like the spice.

That makes the situation sound better than it is. Just to give some scale, according to the boss of the place I work, which I'll call the Middle East Refugee Relief Administration (MERRA), there are over 3,000 Syrian refugees crossing into Jordan daily. There are over 320,000 refugees outside of the camps, and about 70-80,000 in Za'atari, the largest camp in the north. This totals about 6.5% of the population of Jordan. That's the equivalent of about 20 million refugees flooding into the US in less than two years. The group I work with focuses on aiding those outside the camps.

These stats are about a week old, but last I heard there were 1,700 injured Syrians in Jordan. 78 have paralysis of some sort, of which five are less than 12 years old. There are 282 injured in various hospitals scattered throughout the country and 650 kids with chronic diseases in need of treatment.

While it sounds like things aren't perfect in Za'atari, including riots earlier this year, things are being run under UNHCR. Outside the camps, there is little organization/coordination between organizations as I understand it. So keeping track of needs and aid and distributing it is quite a challenge. I'll write more about this as I learn more.

Some have asked me if I've gone to the camp in Za'atari. I haven't gone yet, and I won't go until I have some permission to do some work there. A number of people are taking trips just to see UNHCR tents and snap photos. Seems a bit humiliating to be visiting people like its a human zoo. I saw similar "poverty tourists" when I volunteered on Saturdays in Shatila, a Palestinian refugee camp on the outskirts of Beirut (as an aside, the massacre there was the subject of a great 2008 film, Waltz with Bashir). I understand the need to raise awareness about an issue, but it needs to be balanced with respect for the way people live.

Spinal cord injury and long bone fractures

Some of the work we are doing is volunteering with a group of refugees who all have spinal cord injuries, meaning they're paralyzed from the site of their injury down. In this house, there are 14 guys, one as young as 19. I've only had a few patients with injuries like this, so I know a bit about UTIs and pneumonia in these patients, but I'm learning quickly. One lesson was when one day one of the guys was injured during regular morning exercise with the physiotherapist.

That's his femur. Its a sizeable spiral fracture for those scoring at home. With spinal cord injury, both the immobility and the lack of sympathetic innervation lead to reductions in bone density, usually around 25% in the shaft of long bones. So what would be to us regular exercises broke this patient's leg. Thankfully he didn't feel much pain due to his spinal cord injury.

Unfortunately, there was no ambulance bay (or ambulances) at the hospital, so to get him there we had to manually put him from his bed to the car, manually transfer him from the car to another wheelchair, then from the wheelchair to a stretcher once in the hospital. Three transfers, each time possibly risking further injury where his razor-sharp bone fragments might sever his femoral artery. By the time we got the x-rays, he started to become hypotensive with a pretty swollen leg. All the moving made him bleed. Thankfully he was resuscitated with 2L saline.

سن الأمل

Went to a refugee clinic in Madaba today. Three physicians saw 76 patients. Extremely well organized clinic. Everything was packed and put in cars in the morning, we set up in Madaba, and things worked like clockwork from the patient intake, to seeing the physician, the possibility of getting a handful of tests (blood sugar, urine analysis, blood pressure - sounds basic but these are not always available) and getting free medicines if available from a pharmacist who volunteered with us. A pic of the crew is below.

Big day, so am a bit tired. Quite a range of illnesses, from undescended testes, to massively impacted/inflamed teeth. A surprising amount of kidney stones, felt like 1/5 of patients had them. But before we went to the clinic today, we met at a clinic in Amman where they had some nice posters on the walls. I liked the one below the best. In Arabic, the word for menopause is "سن اليأس" which roughly translates as "despondent age". Probably the most depressing thing I can think of. But the poster below, which has info on menopause, is titled "سن الأمل" - age of hope. Much better.

There was another poster at the Specialist Hospital that I thought was very cute. It means in Arabic "we take care of you". But they've worked a stethoscope into the word itself. That's a pharmaceutical advertisement in the lower right.

View from my window

Took a little bit to find an apartment, but I got a little lucky in finding one with a nice roommate, a guy who works for a Palestinian literature magazine called Filistini Shabab.

I lucked out also on the area, Jebel Amman, which is in a pretty nice part of town, and on the price. You can see the view from my window during the call to prayer here.

I've zoomed in on the King Abdullah Mosque.

Amman

Hi everyone, thanks for reading. This is my first blog where I'm just putting things out there for people to read. I've done email lists previously, so please bear with me as I work out kinks, both in terms of nuts and bolts and in content. Hopefully it won't be too cringeworthy, and if it is, please let me know.

The goal of this is to document some of my observations and experience while I'm in Amman helping Syrian refugees. If you need background on the situation, check out Syria Deeply, a great resource on past and current happenings in Syria. If you want stats and figures, SyriaTracker is the place to turn.

Happy reading!