One common mantra of MSF is ‘be flexible.’ Although you may be employed for one job, take it for granted that you will be called upon to do many other things as well. So despite being the ‘expat gynaecologist,’ I knew I would inevitably be called to the emergency room (ER). I had been briefed on what to do and how to behave, and what I would likely encounter.
When one of my colleagues had been called to support the ER, she had the grim task of deciding whether two unidentifiable victims of an IED (improvised explosive device) should be transported in body bags or a casket. Due to the state of the remains, she authorised the purchase of caskets. As a medical professional, I have had countless gruesome medical discussions over the dinner table over the years. My non-medical family and medical colleagues alike can attest to this fact. Family in particular have developed strong stomachs and the ability to quickly change the subject should details become too graphic. Yet the look in my colleague’s eye, and the way she described the bodies over the dinner table that night, allowed me to understand that she was remembering a sight that she was unlikely to forget for decades to come.
So after the phone call came through requesting my presence in the emergency department, I was more than a little apprehensive. The case described to me over the phone seemed straight forward – stab wound to the neck. Large volume blood loss. Close physical location to the main blood vessel supplying blood to the brain. Clear-cut decision (touché) as far as I was concerned. This patient needed transfer to the nearest specialist surgical service, a three-hour drive away, to prevent him bleeding to death. Did they really need me to come in? Yet the national staff medical team were adamant they required my presence to assist with assessment and the decision to transfer.
I had not yet entered into the emergency department of our hospital, an area of any hospital that is usually the second home of any house doctor. But due to many cultural and religious factors, women were rarely in the emergency department of our project. I had been advised that should I be required to attend, I should behave like the meek, modest and demure woman that I have never been. Ensure your veil does not fall off. Do not make eye contact. Walk behind any male escorting you. Do not touch anyone unless medically require to do so.
I was obviously required to help with the case, so I sorted the security, and promptly presented to the emergency department, headscarf tightly pinned in place, walking behind the male who escorted me, eyes downcast and cautious not to make eye contact with anyone as we entered the building. Many things are incredibly different about hospitals here compared with home. But the main differences I noticed were in comparison to the maternal and child health zones of our project here.
This building had space. There were men everywhere, no women in sight. People milling about. We walked into the thick of the crowd. Raised voices. And a man holding a torch over a child’s wound while another man was suturing. But then it clicked, as this was the only patient in the room. No one had warned me the patient was a child. He was groaning with pain as each stitch was thrown, in a desperate attempt to stem the flow of bleeding. Puddles of blood were coagulating between the crease of the bed and his tiny, gaunt, pre-pubescent torso, rib spaces visible through the blood soaked skin.
My clinical brain finally stopped gawking and clicked on. Airway, breathing, circulation. IV access, fluid replacement, in this case blood or plasma, ASAP. His blood pressure and heart rate were holding, but each time the doctor removed the gauze to throw another stitch into the skin of the wound, a torrent of blood started to jet forth. The two inch long knife had been removed but the doctor had not sutured the deep tissues, as the damaged vessels needed microsurgery. Not that they needed me to state the obvious but I said it anyway “those stitches aren’t going to be enough. He needs surgery to repair that vessel and check his carotid hasn’t been nicked.” The local doc closed the skin with a final stitch, that miraculously stemmed the flow to an ooze, then covered his handy-work with a large wad of gauze and proceeded to wrap the patients head like a mummy. I signed the papers for transfer and got various people on the phone coordinating the movement.
Standing next to me my boss smiled at the kid, the kid smiled back, and via translation we learned that this 14-year-old had had a disagreement with his cousin. Like 14-year-old boys around the world, this kid let it be know that he was tough, fine and would now have great power over his cousin for causing him such harm (should he survive). The ambulance arrived before we knew it. While the patient was being transferred to a gurney – his lines, IVs, family members and paperwork organised – the proud ambulance driver insisted on showing me, the new expat, his shiny ambulance. I could not help but be impressed with how clean the back of the bus was. Here was a man who took pride in his work. I was also introduced to the lab tech who gave me an impressive rundown of his lab, as we could hear the ambulance leaving for it’s destination, precious cargo inside. My fingers were crossed that the patient would make it in time and that we had sent enough blood with them.
Despite my initial nervousness about what I might see and how I would be treated in this male-only emergency department, everything went fine. We started to walk home, but then the birth unit called and I was promptly back in my comfort zone, birthing babies and placentas. The complete opposite of home, here women and their families often push for a ‘quick’ induced labour. Multiple times per day I am asked to commence ‘the drip’ despite strong, frequent, effective natural contractions. When the drugs are not given due to a lack of appropriate clinical grounds (in accordance with MSF policy), often patients return hours later having had high doses of uterine stimulants infused and ingested out in the community. They present in a dire state, with massive blood loss, uterine rupture, failure to progress in labour or sometimes foetal death. Such situations break my heart, as you are faced with the decision to practise appropriate evidence based medicine with the patients’ best interests in the forefront of your reasoning, or surrender to their wishes knowing that if you do not they have a considerable chance of representing horribly unwell.
After the ER this evening, I was presented with one such case. A lady I had seen two days previous, in very early labour with her fifth child, had insisted on an induction. Without any legitimate grounds for induction, I asked her to represent a few hours later to check her progress, yet she did not attend. Instead she had received stimulants and represented to us exhausted, fully dilated with a baby that was stuck but thankfully alive. An hour or so later while I was sewing her back up and the baby happily screamed in the background, I could not help but reflect on the diversity of clinical practise in the field.
Few Australian doctors would treat a 14-year-old stabbing victim, explore some neck anatomy, receive a tour of an ambulance and a laboratory then perform a caesarean all on an average Monday evening. I also reflected on all the times back home I begged a woman to let us start an induction for either her or her child’s safety, yet was confronted with the patients desire for a ‘natural delivery.’ I am not sure where the right balance is, as often at home it is argued that doctors are too quick to intervene. Here I find myself being asked to intervene much more than I am trained to. I’m uncomfortably sitting on the fence, knowing that my hand will be forced, especially when a previous routine labour could represent with a uterine rupture after receiving induction medications elsewhere.
After I had finished in the operating room, checked the birth unit for any impending complications, I stifled a yawn and headed back home. I checked my work phone as I walked, which had numerous text messages from the national staff ER doctor. He had written to thank me for assisting him earlier. “Thank you very much for coming, I just needed you here to be more confident. Because when everyone came, the staff were away breaking the Ramadan fast, so I was all alone. ” With all the events happening around me, working in a foreign country, out of my comfort zone, not speaking the language, it is easy to get consumed by my own difficulties. I had not considered that a tough, male national doctor could have been as nervous as me. A nice reminder, that despite appearances, we all need some help sometimes.
Jess is an Australian doctor working with MSF in Pakistan remotely managing obstetric projects. She wrote this post in July 2013. Find out more about Jess and the MSF Pakistan blogging team.
MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières