After the initial disorientation and muddle of my first week or two working alone, a small amount of sense and routine is beginning to emerge in my days here. I wake up at seven and spend an hour or so pottering about, doing yoga and enjoying the brief early morning coolness before trotting across the compound to the office for eight. After meeting with my outreach team and establishing what their routine will be today, the next hour is spent ensuring medication and equipment orders for the outpatient-department (OPD) are signed, filled and collected, gathering forms and paperwork together before I leave the hospital, bound for the Ministry of Health OPD facility across town. Grab mobile phone and radio, load car, one last dash back to the expat living area to fill my water bottle and empty my bladder (always capitalise on using the nice toilets where you can!), and I’m off to the OPD for the rest of the morning.
The MoH facilty is a large U-shaped building, white tiled throughout and with shaded veranda areas for the waiting people. And, oh my, there are plenty of them. For a patient visiting a family doctor in the UK, you would perhaps put an hour aside in your schedule for the appointment. Here, the patient flow, chaotic though it may appear at first, has more coherence than it seems: adults and children are registered in separate areas, and there is more often than not a 100-strong crowd lined up in front of each desk.
After queuing for registration and consultation, patients may go to the lab for malaria or stool tests – then back to the consulting room for prescription. Then, there is another queue at the dispensary to receive their medications. Forget about getting this done in a hour, once you allow for the fact that some people have walked for a couple of hours to get here, you are often looking at a whole day trip just to receive the most basic primary healthcare.
I walk slowly past the adult line first as I carry supplies from the car to the dispensary room, eyes peeled for anyone sat in the queue who looks particularly unwell. I deliver medication supplies, greet dispensary staff - prolonged handshaking all round! It all feels rather British at times. The next few hours of my day vary considerably – on an ideal day I’ll find the MOH staff supervisor and run around to each staff station to make sure that all is well and that everyone is present.
“Only three adult consultants? Where is the fourth?”
“OK, well stop registration at 70 patients and triage the rest of the queue.”
Hopefully I’ll get to spend an hour or two sitting in with each of the MoH consultants observing their history taking, diagnosis and prescribing skills. I correct and teach at every opportunity (oh blessed MSF clinical guideline book, how we do love thee) while trying to remain encouraging and maintaining their autonomy.
I walk out of consulting room weeping internally at how many patients are still randomly getting prescribed antibiotics for simple colds, etc. I haven’t yet found a way of convincing anyone here of the perils of breeding antibiotic resistance yet. I live in hope.
Inevitably, I’ll be pulled out of the consulting room to deal with an emergency case – which in the last week has ranged from several very unwell cases of severe malaria, a badly burned baby, a woman fitting, (not a true seizure, it turned out, much to my immense relief), a lady with horrid shortness of breath, a couple of very unwell dehydrated children and a semiconscious elderly man vomiting profusely.
My emergency department training kicks in here – Check the ABCs and shout for my translator. Get a rapid history from the family. The patient is carried to the stabilisation room. Here a delightful MOH health worker called Rita (who reads and speaks no English at all, but is bright, keen and possesses the happy skill of being able to get an IV cannula into just about anything) resides and between many muttered and repeated instructions an assessment is done, an IV started and a tentative diagnosis made. I run to the dispensary to grab necessary medications and the radio and run back calling MSF to send a car to collect the patient.
“Office, office for OPD nurse, do you copy?”
Silence. Then a burst of static and a disembodied but reassuring voice: “This is the office, we copy you, go ahead.”
“I have one green-light patient to come to MSF, please send the car and alert the emergency room”
“Copy that, will send car”
Trying to get anyone semiconscious into the back of a Land Cruiser without a stretcher is no picnic, less so when the concerned and inevitably extensive family tries to pile in too. Unceremoniously, they are evicted again bar one permitted caretaker, doors are slammed and we’re off; rattle, roll and bump over the dusty roads back to the hospital.
I’ll stick around to ensure the patient is stable – usually once the patient is in the Emergency Room – but after handing the patient over to the duty Clinical Officer it’s with a slight sense of shock that I realise it’s one pm; the morning is over and the OPD is now shut for two hours.
Lunch is a laid back affair with the others in the expat compound; rice, fried fish, curried goat, lentils, and the local staple grain – sorghum – all feature regularly. By now the mercury is pushing 40 degrees, so I have a cold shower and rinse some of the dust and tension from my body. A peaceful hour of reading follows – I am alternating between “Little Women” and the MSF malnutrition protocols at present!
Then, from three ‘til five thirty it’s generally back to the ODP again, I’ll try and follow paediatric registration and triage for a while this time, and check that the lab and dispensary staff aren’t getting too swamped.
Collect medication and equipment orders for the next day (“How have you lost your pens AGAIN?! More Child Health cards… ok…”) then back to MSF in the car trying to work out what, if anything, I have actually achieved during the course of the day.
Trying to untangle this in my head takes some time. Some days it feels like fighting a forest fire with a child’s water pistol. But sense is emerging slowly and I can at least rest in the satisfaction that one of the MOH consultants now knows what a hernia is. It’s important to celebrate the small victories here!
I have discovered that one of the best ways to undo all the tension of OPD craziness during the day when I get home is to pop over to the Inpatient Therapeutic feeding center in the hospital, straight across from the expat compound. Hanging out with malnourished sick kids may not be the pick me up you would first choose, but I have a secret weapon up my sleeve that transforms everything… bubbles!
The actual patients kept in for feeding-up are all below five-years-old, but as well as their mums, many of them have siblings staying with them – and children are children wherever you go. Where do boys learn to karate chop soap bubbles when they’ve never seen a TV in their little lives?! I swear there’s a bit of Jackie Chan in every boy’s Y-chromosome. I could only bring a couple of bottles of bubble mix in my luggage with me, but I’m already plotting with Margie the midwife to scour the market ASAP for glycerin and soap so we can blend some more. Bar the one toddler that backed away from the first stream of bubbles with a look of bewildered terror and promptly fled to the refuge of his mother’s lap, the children love it – but possibly not quite as much as I do!
One delicious boy who has been a patient here for almost a month now is still too weak to chase the bubbles about with the others, but just stands and laughs bashfully as they float past his face and burst on his body. I think I’m in love.
Some of the mums with the children are young – adolescence is brief here, childbearing is routine at 17 and very often younger. But there’s a worldliness that is visible as they shake their heads and laugh at me playing with their kids that is missing in teenagers in the West. Whether that is for better or for worse is hard to say. One thing’s for certain, the body language and facial expressions they exchange just prove that “crazy white girl” is yet another universal constant!
I am going to go back and woo that solitary scared toddler into loving the bubbles tomorrow.