From base to boardroom to bedside
22 May 2013 Comments
Wednesday May 15th started early. I got up at 6:00am and took a cold refreshing shower. My mind was spinning with day ahead so I had not slept well. The night before was a late one in the MSF base office as Luigi, our Italian project coordinator and I, were analyzing data regarding our surge in malnutrition here in eastern Chad. We sat in his hot, bug-filled office with laptops strewn across his desk.
I got to the office early in the morning. Everything starts early in Amtiman. The mobile clinic team arrives at work at the base at 6:00am everyday and the hospital medical team takes a Land Cruiser to the hospital at 6:45am. My plan this day was to go to the Ministry of Health (MOH) to meet with other non-governmental organizations (NGOs), UNICEF and the MOH to discuss the malnutrition situation. I prepared graphs and figures to explain to our partners the significant increase in cases MSF was treating. Before leaving, I scanned my email inbox to try to deal with a few urgent administrative and medical matters. Even at 7:00am, the office was hot enough to make you sweat.
Luigi, Andrea our mobile clinic nurse from Switzerland, Saintho our Chadian data manager and I took a Land Cruiser to the local MOH office. We greeted colleagues old and new. Our meetings began, and lasted five hours. During this time, different government, NGO and UNICEF representatives explained their current situation, problems and potential solutions. Luigi and I presented our data and together with our partners we discussed some concerted means to deal better with the situation. We did not necessarily agree on everything. After almost four months in Chad, I felt comfortable with MSF’s data and work.
MSF Land Cruisers at Kash-Kasha where we are treating patients with severe malnutrition. © Raghu Venugopal
When we finally got out of our meetings, I walked over to the hospital. I had not done my ward rounds, but I was starving and thirsty. I had a quick lunch at our house and then headed back to the office. I talked about construction plans with our logistical coordinator, Ibrahim, from Canada and emailed to the capital team requests for transferring patients. Ibrahim, Luigi our new German doctor Andreas and I all went back to the hospital. We found our new Irish pharmacist, Louise, and reviewed plans for our new pharmacy construction. We balanced size, cost and quality in our discussion. Then Andreas and I rounded in the HIV/TB service. The mid-day heat was difficult to tolerate with a surgical mask on our faces.
Many new pulmonary tuberculosis patients had arrived. Kadjija, a 30-year-old mother with pulmonary tuberculosis sat with her young infant on her lap. I explained to Kadjija and her husband that the child needed to be treated prophylactically for TB as well as Kadjija herself taking a full course of treatment for six months. Since Andreas was new to our project and on his first mission, I took time to explain to him how the ward worked and the cryptic short-hand I use in my medical notes.
After rounds, we sat down for a longer conversation in a private office with Yvonne and her one-year-old child. Yvonne’s baby had meningitis, severe malnutrition and tested positive for HIV. Yvonne herself tested positive for HIV as well. When I first met Yvonne, she said she was not sure life was worth living being infected with HIV, but the Chadian national staff and I have taken a lot of time with her to inform her that she can live a healthy life with HIV with the medications and services available locally. Yvonne’s baby needs to be put on antiretroviral medications for HIV, but I was not yet sure Yvonne had the degree of adherence necessary for life-long treatment of her baby. I discussed with our HIV team how we need to spend more time with Yvonne – addressing her fears and sharing information with her.
The sun was starting to go down when Andreas and I left the hospital. I went back to the office and sat down in front of my computer. Back to email and strategic discussions. I shuttled from behind my desk to Luigi’s office to grapple together with a myriad of operational, medical and human resources issues.
At 6:30pm, the regional UNICEF representative came by. Outside of formal meetings in the boardroom earlier in the day, we wanted the chance to talk informally. Luigi served up a warm Coca-Cola for each of us. The UNICEF representative had worked many times with MSF in the past, so when we finished talking at about 8:30pm we had found many common ideas on how to deal with our malnutrition surge.
Luigi and I sat down outside with the rest of the MSF team in the evening heat. Minutes later, and urgent phone call came from the MOH hospital nurse. A truck crash had occurred and many were injured. He said he needed our help.
I ran to my room and grabbed a flashlight, put on an MSF t-shirt and grabbed my stethoscope. Having dealt with this before, I knew extra hands were needed – so I ran to the rooms being occupied by our colleagues en route to the emergency in Tissi – and called on them for help. We piled into a Land Cruiser and went to the hospital.
The hospital was a collection of bystanders, trauma victims and cars transporting the injured. I waded into the triage department. I went right to the back of triage area, being careful not to step on any of the bloodied souls that were all over the ground. The quietest patient is often the sickest. So I started looking for these patients. I examined abdomens, chests, limbs and heads. I contributed to the triage effort – sorting out what patient needed surgery, what patient could be admitted to a regular ward for minor injuries and which patient needed to go to the ICU.
The collaboration between the MOH and MSF was excellent. Patient by patient we took care of everyone. Sigrid, our midwife from Germany, coordinated the operating room. Our colleagues on their way to Tissi - Carlotta from Italy, Matthias from Belgium, Kalyani from India, Zahid from India – they dispersed to the intensive care and wards to receive patients. Eve, our Canadian nurse, prepared the wards and obtained extra dressings. Carla, our doctor from Germany, treated our regular critically ill patients and ensured all the injured patients had adequate pain treatment.
One by one, patients were triaged to the operating room, intensive care unit, or wards. The worse cases included an unconscious young women with a severe head injury, two men with open arm fractures, another man with a leg fracture and a child with a head injury who was unconscious. In the operating area, patients lay on the floor covered in blood. We inserted intravenous lines, dressed wounds and gave strong pain medications while they waited for the surgeon.
Sigrid called me to the operating room. She was worried about the young woman with the head injury, undergoing repair to her scalp. There was a worry that she also had an injury in her abdomen. I examined the woman’s abdomen while the surgeon’s continued their work at the head of the bed. After performing an ultrasound of her abdomen, I was reassured there was nothing worrisome going on. But later, we performed a hemoglobin level and found the patient anemic. At about midnight we transfused her blood the intensive care unit. Because of MSF’s construction of a new maternity ward at the hospital, we could not use our usual mobile gurney to move the patient from the operating room to the intensive care. I found five men milling around and asked them for help. We carried the young women across the hospital compound in the dark, stepping on each other’s feet, stumbling time to time, but never falling.
The night went on. Everyone got taken care of. No patient died. Pain was treated. Patients and families were comforted. The hospital, already bursting at its seams with the malnutrition peak, somehow took on the 40 or so trauma victims.
We got home eventually later in the night. The day and night had been long. I had gone from base to boardroom to bedside, but somehow it all made sense. The best moment was being with our injured patients, getting everyone taken care of one by one.
The next day, I made a round of the hospital to re-examine the worst trauma cases. The unconscious young woman was now talking. I repeated her abdominal ultrasound and it was normal. The little boy who was unconscious was now walking round.
A day in the life of MSF is never predictable. Each day can change based on any kind of emergency. The days are long, it is still really hot here, and on Wednesday May 15th, I think the MSF team and I earned our keep.
Farewell for now from the house-call….to Chad.
Note: all patient names are changed to protect patient identity