The days are getting longer and hotter. The time is going faster and faster. Each day, and night, I am spending more and more time in the emergency department. And yet every time I feel overwhelmed or tired by the ever increasing number of patients presenting, I remind myself that for every patient's care I am involved in, the national staff see and treat at least ten times more. And through our shared efforts at caring for the people of Hangu and the surrounding FATA [Federally Administered Tribal Areas] regions, I feel a growing sense of solidarity and friendship for which I am indescribably grateful.
Over the last few weeks there has been a number of outstanding experiences and cases I feel a compulsion to share.
The first was the case of a young boy who was brought into the ER. "Red case" sounded the triage nurse, the signal for us to flock to the resuscitation room. We were presented with a boy having a seizure and gasping. But what struck us more than anything was the powerful smell of kerosene filling the room. The seizure abated with some diazepam and his saturations were stable with face-mask oxygen.
We were told a mixed story by the family. Initially that he had ingested kerosene. Later that the family thought he was chocking on a banana (of all things!) and so the women had rubbed kerosene on his chest to try and help with his breathing. On examination, there was no banana to be seen, and kerosene could be smelt on his clothes and skin. Both seizures and chemical pneumonitis [inflammation of lung tissue] causing respiratory distress can be consistent with kerosene toxicity, making it a priority that this boy got to a bigger hospital in the likely event of deterioration.
Unfortunately however, our inability to provide this boy with the definitive care he was likely to need was misinterpreted by the family as a lack of diagnostic acumen on our behalf. The father proceeded to chastise us, saying "I am a mechanic, when someone brings me a car, within minutes I can diagnose the problem, and proceed to fix it. How can you call yourselves doctors, and yet you cannot diagnose or fix my son?"
I found the analogy an interesting one, and not the first time I have heard it, but saddened by the fact the family did not appreciate that we had in fact come to a likely diagnosis, but did not have the facilities to treat the consequences. They took their son, hopefully to another medical facility, where Inshallah, he will have made a good recovery.
On an almost daily basis, we continue to battle an ancient scourge - measles. Knowing that many of the patients we see do not attend school, are often refugees or internally displaced, living in crowded conditions, with limited to no access to primary health care, it comes as no surprise that the majority are unimmunised. To their credit, the government is attempting to address this by running measles vaccination campaigns. These too however have faced many challenges. Vaccine quality, administration, coverage and acceptance to name a few. Back in Australia, measles is fortunately something we know about but rarely see, and yet now, I've seen too many.
Most of the cases we see here are mild, presenting with high grade fevers, the pathognmonic morbilliform rash and usually poor oral intake necessitating some IV fluid rehydration. However, we also see too many with measles complications, including bacterial pneumonia and encephalopathy. Such as a 15-month-old child who presented to us recently with the typical history of measles a week back and a persisting high grade fever and all the signs of being systemically unwell - respiratory distress with oxygen saturations in the 70s, pale and mottled skin, lethargic and unresponsive. The severity of this child's condition is an all too common a problem as people present so late in the course of their illness.
We administered oxygen, began aggressive fluid resuscitation, IV antibiotics and cold sponging to reduced her fever. She responded well to the fluid and her oxygenation improved. I knew this child was still very sick, and I encouraged the staff to inform the family as such, but I couldn't help but hold a glimmer of hope that her condition was improving. She stabilised for a while and we decided to transfer her to the infectious disease hospital. However, when I went to review her before loading her into the ambulance, I found her condition had once again deteriorated. I could not send her like this.
Deep down, I knew she wouldn't make it. The mother, in her ever stoic manner said that of course they understood; "you know best, the child's life is in the hands of Allah". The young girl passed away only moments later. I held the mother in a private, quiet embrace as she silently let her tears fall. My own heart breaking at witnessing yet another preventable death.
Sometimes you just getting a feeling, and I knew by the anxiety in his voice that this case was likely to be bad. "There's a young man with a gun shot wound to his right chest" was all the doctor told me over the phone before hanging up.
It was around 10pm. On arrival to the resus room the patient was agitated but breathing. He had a gun shot entry wound almost in the centre of his chest, and on further examination of his back, a palpable bullet to the right of his spine. On ultrasound I was not all together surprised to find that his right chest was full of fluid and he had fluid collecting around his heart.
There was a buzz of activity as the staff were getting IV access, administering fluids and antibiotics. I quickly called the surgeon asking her to join me. On inserting a chest drain my suspicion was confirmed, he had a chest full of blood (of which I was now partly covered in....). And the blood was draining rapidly. We started collecting it for auto-transfusion and we were able to start transfusing this young man with his own blood within minutes of draining it from his body. The surgeon arrived, and after attempting to drain some of the blood from around the patient's heart, only to see it continue to fill, decided to take him to theatre for an attempt at a life saving thoracotomy (opening the chest).
I joined the team in the OT where I was filled with respect. The slick administration of anaesthesia and successful placement of the breathing tube down the left main bronchus to ventilate only the left lung leaving the right deflated for repair; the efficient manner in which the nursing staff performed their tasks often before even being asked, like a well choreographed dance; and the skilful and determined nature of the surgeon who quickly and quietly identified the damage and began repair.
And what she identified was what we had all feared but suspected - the bullet had damaged the heart. With barely a moment's hesitation from the surgeon, or pause in the rhythmic beating of the patient's heart, the hole was repaired. For hours the surgical team worked away with this young man's life in their hands. He received his whole blood volume more than twice over and we even had to operate a second time when he failed to stop bleeding.
In the end, the team sat and waited with the patient through the early hours of the morning to see if he would stabilise enough to cope with the three hour transfer to Peshawar. And their efforts were rewarded. As the sun rose, so too did the spirits of not only the team but also the hopes of the patient's family. He was still critical but stable, and was thus able to be transferred to a cardiothoracic intensive care unit.
I am so proud of my team in the ER for how they initiated this young man's management in a case where every minute counts, and full of admiration for my colleagues in the operating theatre, it was an honour to be part of this team.
As I said, its been a busy time, and I'm a little apprehensive as I'm told in the Holy month of July it will only become more so. Not only has this meant less sleep, but also less time for some of the other activities I was previously doing in an attempt to stay sane. I can't remember the last time I ran on the treadmill, and in all honesty, its starting to get too hot anyway. I would do anything to go swimming, but I know this is just a dream. Even writing to friends or staying in touch with family is something I've had little time for of late.
But as I also said, spending more time in the ER has brought with it a different sense of joy. Every day my colleagues, who I would rather now refer to as friends, continue to teach more about their life, culture and religion, and more often than not have me in fits of laughter. They even started teaching me Pashto poetry, which I have taken to reciting, and of which I highly commend as some of the most beautiful writing I have read.
"Pa makh me okhki bahedo ta pregda" - Isra Atal
Leave me be to let these tears fall upon my face