Hospital in the Middle of the Road

09 March 2010

I'm getting ready to leave. I'm trying to explain everything I know about how the hospital functions, and where the hiccups usually occur, to my successor. It includes the progress from where we've evolved since I arrived, to the nascent plans of what we?re trying to accomplish next. And I'm trying to verbalize all the details, orthopedic and psychosocial and otherwise, of our almost-100 inpatients.

When I arrived, there were about thirty. Truthfully, most of those are still with us: the nature of serious orthopedic problems is that they take a long time to heal. These are the patients for whom I know not only their names and pathologies, but also their families and moods. I can say I've personally witnessed clinical improvement in some, like "Bobby" who is strong on his crutches (but still recalcitrant in extending his knee), and nine year-old "Rebecca" whom I discharged today, walking firmly on her healed femur fracture. I think her limp will soon hardly be noticeable.

"Dearie" finally had her skin graft today after many days of waiting: hers was particularly large. I found her crying this morning about it. She is sweet but always sad, at 19 years old, she lost an infant in the earthquake and has no family to help her. I think she despairs for her future: as her wounds improve and she walks more easily (no longer needing crutches), she fears being well enough for us to discharge her. She has nowhere to go and, I think, no way to support herself. Could healing be more bittersweet?

Since my arrival, we've added tents and beds, and more tents, and more beds. Most wounds are no longer infected. Some have had skin grafts. We're starting to talk about taking people out of traction, or taking off external fixation sets. We're discussing weight-bearing and walking. But also: non-union, mal-union, infection. The phase of the emergency has changed. Tomorrow will be the first set of fitting sessions for amputees who need prosthetic limbs, through another NGO.

From thirty patients to just-under a hundred. We opened a Rehabilitation service, where patients need less intensive medical care, and more intensive physiotherapy. There are more patients than will fit in the beds available there. We did grand rounds there this afternoon: it is rather a marathon.

I joke that I am kind of like the Orthopedics resident: trying to keep things moving on the wards, understanding diagnoses, filling out paperwork, running around chasing things that need to be chased, without being much in the operating room, or deciding on the course of therapy. I have learned a lot. Orthopedics wasn?t my forte before this.

I have to admit that for the more recently-arrived patients, I am less able to keep their stories separate and straight. There are several young men with fractured femurs - now was that from a fall? Or a car accident? Or since the earthquake? I cannot see their X-rays in my mind's eye when the patient is in front of me. It's hard to do a good job telling the story to my colleague when I can?t keep the details straight.

But for others I can recount their medical history without checking my notes: one young woman who is a model patient, has a perfect external fixator, no pain, good technique on her physio exercises, and a perpetually sunny disposition.

Today I also failed to contain my frustration because somehow, a little girl with rosebud mouth and alphabet barrettes had been inadvertently discharged not once, but twice, when the intention was to hospitalize her for IV antibiotics for her potentially infected plate-and-screws that hold together her femur fracture. Her treatment has been delayed for four days as a result. It's time for me to go. My patience is too thin.

Much is left to be done. We need a proper emergency room with emergency physicians, if we want to call ourselves a trauma hospital. We want to expand to have a general paediatrics department. We should develop to have abdominal surgery capability.

Not long ago, this was a hospital in the middle of the road.