This post first appeared as an op-ed piece in Latitude News, a news website covering the links and parallels between the US and the rest of the world.
It’s Wednesday afternoon in Paoua. We had an average busy day in the OR interrupted by only one emergency, another young woman with a ruptured ectopic pregnancy who needed emergency surgery. I was happy to see my blog postings appear on Monday but a bit taken aback when I read them. It seems to me I just talked shop about patients and operations (an easy bad habit for a surgeon to fall into) but failed to paint a picture of the hospital here and just how different it is, something that I want to do today. I am still learning more each day about how the hospital and MSF clinics work, about the area surrounding Paoua and the general situation of healthcare in the Central African Republic, but I’ll share my current impressions and what I have learned.
Although I’ve fallen into a routine here that is familiar to me as a surgeon, coming to the hospital in Paoua seems less like traveling to a different country and more like a different world or a different time. Western literature and film have presented various visions of a post-apocalyptic world with limited resources under adverse conditions, where remnants of a more sophisticated technology are still used and the human spirit abides and even sometimes soars. When I walk around the hospital compound, I sometimes feel that I am in such a world. We have technology but it is all very limited compared to what I am used to and completely dependent on the planning and abilities of our logistics team. The local people are so poor and have so little, but the common humanity is obvious; mothers stand canted to one side with their one-year-olds on their hips, brothers and sisters play and fight, men and women laugh at jokes, cry at sadness, all like at home.
In the morning I walk to the hospital, a 15-minute stroll down a dirt road made of sand and clay. If it rained the night before, there are new potholes and rivulets carved in the road, challenges for the infrequent vehicle. Almost everybody I see is walking. There is the occasional bicycle but the only vehicles I ever see on my morning walk are the MSF truck and a half dozen motorcycles belonging to young men who are working at the hospital and the occasional “moto-taxi”. I pass people on the road on foot the entire way. There are young men pushing two wheeled carts filled with wood they have gathered, women carrying pans of food or goods balanced on their heads and a baby strapped onto their back with a cloth, young men and some not so young, sometimes dressed in t-shirts and sandals but sometimes wearing a worn but clean sport coat headed toward the town center. As I get closer to the hospital I exchange greetings with the local hospital workers, the nurses, mid-wives and hospital assistants headed home from the night shift.
Our morning report is held in a concrete one room building, approximately 25 feet by 35 feet with a corrugated metal roof. The door and windows are gone with an older white vinyl tarp covering the largest window. We sit in a square on worn wooden benches while the occasional salamander scampers about on the wall, leaning forward to hear the report if it’s raining because of the noise from the roof. Just north of this building are a pair of raised concrete slabs, each about 50 feet square, covered by metal roofs but otherwise open to the elements. Patients’ families are able to sleep here and in the morning there is a great deal of activity with people getting up and about. There are no tents or screens for privacy, no cots or pads for comfort other than the occasional flattened cardboard or blanket.
After morning report, we start our rounds in the maternity ward, a large one story building adjacent to the Bloc Operatoire. There are plastic water barrels with a basin at the entrance to this building as well as the other patient wards to promote hand washing. In US hospitals, so called “hand hygiene” with diligent use of hand washing or disinfectant between patients is a high priority to minimize the spread of antibiotic-resistant bacteria from patient to patient, but here in Paoua the goal seems more to be a simple decrease in the bacterial load brought from the outside as everyone uses the same bar of soap and drying towel.
What has a higher priority than hand washing is that you are not allowed to wear your shoes from outside when coming into the ward. Patients and visitors walk in barefoot, their footwear in hand. Although no one insists that I wash my hands between patients (the nursing assistants are very good about being available with a bottle of spray disinfectant and I’m diligent about using it), I am not allowed to enter the ward unless I remove my shoes (I now wear sandals to work because of this) and put on a pair of plastic clogs that are kept on the ward for medical personnel (if you are squeamish about walking through airport TSA screening in the US barefoot, you would not like putting on plastic clogs worn by everyone and anyone at the hospital in Paoua). We check on the patients who have had deliveries by caesarian section in the past few days. Other than women in labor in the delivery rooms, the maternity patients are all grouped in four rooms with between three and six patient beds each. The beds are simple wood frames with a foam mattress and a mosquito net. The patients lay in bed with their newborns and rounds are made from bed to bed with little if any privacy for the women, much like the “ward rounds” I’ve heard about in US hospitals in the 1950s and 1960s.
Our next stop is the Medical/Surgical ward where they are not as concerned about shoe hygiene and I get to keep my sandals on. We see the patients who have had operations and the ones that will have elective surgery today. Unlike home where everything is done on an outpatient basis, patients will come into the hospital the night before surgery here and often stay for several days to be certain there is no infection at their incision. Yesterday morning we saw a young man from the night before who had been brought by a friend on a “moto-taxi” after being stabbed in the chest, one inch to the left of his midline and below the collarbone, a potentially lethal injury. In the US, he would have had a battery of x-ray tests but in Paoua, even a chest x-ray wasn’t available until the morning so our best option was to examine him (his blood pressure was normal and equal in both arms and you could hear breath sounds on both sides of his chest, making it unlikely that he had an injury to a large artery or collapsed a lung) and watch him overnight for signs of worsening problems. Luckily, he was fine and went home today (and hopefully won’t go out tonight).
The Pediatrics ward comes next. Frustratingly, they always have the door closed and bolted even though we arrive at the same time every day; I think it’s to keep out visitors during the morning floor mop cleaning but the surgical team here, like all surgical teams (actually it’s just me, the anesthesiologist and the OR charge nurse), hates to be slowed up on rounds. Each of the ward buildings is one-story with an unpainted concrete slab floor and they are mopped multiple times each day. The pediatric ward always seems the busiest; it may be the case or it may be the crying babies that gives that impression. There are three rectangular rooms with six beds each at the north end, with the center one reserved for the pediatric ICU (another place that practices “footwear hygiene”) and the other two for the older children. In the center of the building are two individual exam rooms for the medical doctors on pediatrics to see new patients plus an exam table that doubles as a place to start IVs and a resuscitation center for emergencies (I continue to be impressed with the wards ability to obtain and maintain IV access in the children, even the infants). At the south end are three other rectangular rooms where we find the infants and small children. Again we make “ward rounds” with little privacy for the patients or families. Sometimes there will be two infants in the same bed though I haven’t figured out whether this is more the mothers being social or overcrowding. There is an overflow ward behind the main building. To get there you walk outside to a concrete walk with mud puddles on either side, past the kitchen which feeds the entire hospital to another long, masonry, one story building with approximately 30 wood frame beds set up barracks style.
The kitchen feeds all the patients in the hospital. I believe it also feeds many of the patients’ families. The logistics coordinator here, a young man from Arizona, told me they purchase corn from another NGO, contract with local women to supply fresh vegetables but that meat is only served once a week at the hospital. I am aware there are MSF nutrition initiatives in place here, especially for the children under five, but I haven’t yet made time to find out those details.
Next it’s off to the OR or as it is called here, the Bloc. This is where I spend most of my day and the occasional night. The operating room has worked well for me here because I remember the advice given to me once during residency (big thanks to Dr. Julie Freischlag, now chair of surgery at John Hopkins, in case she reads this) that a surgeon needs to learn to operate with the instruments that he/she is given. Every set here has two pair of scissors, a Metzenbaum and a Mayo, and usually one of them is sharp. The needle drivers are generic (no asking for my special eight-inch, fine tipped vascular needle driver with the gold colored finger holes), and the forceps come either long or short, toothed or not (no fine tipped Adsons here). Choice of sutures and needles are limited, but here again it always seems that I have everything needed to do the operations. Plus the staff is great; whenever I need something in the middle of an operation, they either have it ready or get it within a few moments.
At the end of the workday, I walk back to the residential compound. The sky has been either clear or clearing most days and it is a dramatic, beautiful sky with wild and varied cloud formations streaked with yellow and red hues, sometimes with enormous grey thunderheads in one direction or the other. There is more activity on the road in the afternoon; roadside vendors with peanuts, potatoes and cigarettes, the occasional large truck filled with bags of peanuts or beans or goods or work men headed south toward Bangui or north toward Chad, more “moto-taxis” and bicycles, but still all at a rural pace. The small children playing by the local houses, one story, clay brick buildings with thatched roofs and no plumbing, wave and call out “Bonjour” and I wave back and ask “Ca va?”. I have easily become accustomed to the work and living conditions of my new normal here, though that may be partly due to the fact that I know it is only temporary. The degree of deprivation here compared to home is dramatic (though I know there is also a face of poverty in America that I don’t see in my day to day life there) and I am still on the steep part of my learning curve about Paoua and the CAR. After only two weeks, I have a long way to go from making these early observations to having anything close to a true understanding of the situation here. I’ve downloaded an MSF report on the CAR from 2011 titled “Central African Republic: A State of Silent Crisis” and plan to read it tonight as the next step in my education.
That’s all for today. This has been a bit long for a blog so thanks for hanging in until the end. In the next few days I’ll post about a young girl with an interesting problem, talk about some of the challenges of diagnosis and treatment unique to being here and the surgical personality.
Read David's post on Latitude News