Visas are a daily topic of conversation, as the lack of a visa means working in remote locations. For the Chaman project, this means at any given time we have at least one staff member back in Islamabad awaiting a visa. The situation is made even more difficult when the whole expat team is in Islamabad, as we spend the entire day emailing and phoning the national staff in Chaman. It is a symphony of voices in our office, as we mindlessly talk on the phone and wander around, our phones to our ears.
Mosquitoes feast on my toes every morning as I sit by the front door, listening to a hand over, over the phone. Our senses are cut off; you no longer have the sense of sight, smell, sound, touch, or taste. You cannot ‘feel’ the project. My eyes and ears on the ground, the maternity department supervisor, calls me multiple times per day with regular updates. I do a ward round in my head asking her to ask the patients questions for me. What are their vital signs? What drugs have been prescribed? Did she have a bowel movement yet?
Chinese whispers could so easily develop here, and the sheer effort required to remain involved in the team is astounding. I have to trust what is reported to me, trust in their training, trust that I am being told about all the issues that occur. I no longer have quite so many daily dramas – does this mean that they are not occurring or that someone else is managing them? Or does it mean that no one is managing them and all hell is breaking loose? It is a double edged sword – I find myself thankful for a break from the lack of sleep, high stress and extreme environment. Yet this makes me guilty to leave the staff. Phone call after phone call starts and ends with “When are you coming back?” Inshallah [God willing] very soon.”
The constant phone calls result in constant interruptions. I can’t finish one conversation, one email or one trip to the loo without being interrupted. I find myself day-dreaming about dropping my phone from my second floor balcony, watching the plastic casing shatter whilst the battery and SIM card fly across the concrete. But I can’t even finish the day-dream before my phone rings again.
I have been called by the birth unit midwives – we have a woman who is in labour and about to deliver her 12th baby. She looks pale so they have checked her blood level. It is 5.9 and we normally start transfusing at a level of 7. Each blood transfusion brings the level up by one point. Normal is 11.
I’m uncomfortable when you start labour with a level below 9, as it is expected you will lose blood in labour. So, naturally, I call the blood bank to organise a transfusion. We have none of her type. None! There is no time to transfer her to the next town where they do have blood, as it is four hours away and she is already pushing.
I start asking the staff to prepare for a massive post-partum haemorrhage and get the supplies ready for when we need them. I lay out all the necessary medications and supplies nearby and insert two intravenous catheters ready for their inevitable use. Call the anaesthetist and gynaecologist, warn them about the case, ask them to be on standby for a ‘super’ emergency over the next hour. If we call, it’s for a life saving hysterectomy. We end the phone call, so the staff have all their hands free to work. They will call me when it’s over, or if things go wrong. I cross my fingers, toes, arms and legs.
Five minutes later, they call back. The baby is out and she is bleeding. They have given our 1st, 2nd and 3rd line drugs. We go through the protocol together, she tells me what they have already done and I tell her what needs to be done next. I’m trying to paint a picture of the scene – I envision myself as a fly on the wall. I ask her to describe the blood volume, the consistency of the uterine contraction and the physical state of the patient. The crackling phone line, thick accent and panic in her voice only make me feel more helpless and disempowered as I try to place my consciousness in the birth suite, while my body is in an office 1000km away. I ask her to hold the phone with her shoulder and be my hands – she inserts a catheter & performs bimanual uterine compression while another staff member call the anaesthetist and gynaecologist for surgical help. We hang up so that she can assist transporting the patient to theatre.
I’m happy to hear 15 minutes later that she finally stopped bleeding, uterus intact. Everything worked fine, the staff performed perfectly, but I feel terrible. I don’t feel like I can do the job that I am here to do when I am not actually there. I am powerless on the end of the phone, a nagging voice in their ear, unable to actually do anything. Sure, I am the person they ask question when they don’t know the answers, but I can’t actually do anything. It’s a feeling I’ve never had before in medicine; I’m a surgeon not a physician. I like to do things. This job is challenging me in was I never thought it would.