Fieldset
Stormy week

Once again, it has been a surprisingly pleasant Saturday here in Hangu. It was, however, a very stormy week – literally and metaphorically speaking. It is meant to be the dry season at the moment, where the days languidly get longer and hotter.

Once again, it has been a surprisingly pleasant Saturday here in Hangu. It was, however, a very stormy week – literally and metaphorically speaking. It is meant to be the dry season at the moment, where the days languidly get longer and hotter. But lately we have experienced uncharacteristic storms. Deep, growling thunder rumbles dark threats, erupting every now and then; the gods must be rolling around clutching their bellies in laughter as they strike out at each other with lightning. Often the storms pass through in the afternoon, cleansing the day of the usually tumultuous morning.

No Wellington boots are required here though, contradictory to what I would have expected and indeed have heard of many other MSF missions. In a credit to the project, the hospital compound has an impressive drainage system which leaves it dry within hours of a downpour, whilst providing the pleasant illusion that we are surrounded by a small river of sorts. Sometimes however, the storms roll in at night. These are my favourite, as they are the most impressive sound and light shows I have seen; nature demonstrating her unlimited power as she sends electricity ferociously arcing across the sky, illuminating the night. I am humbled and elated by its beauty.

As I said, it’s been a challenging week. To put it bluntly, I’d have to say I’ve felt a little like the ‘grim reaper’ with too many deaths, too much devastatingly unnecessary losses of life. How to make sense of it all? Some of the pathology, I can at least rationalise as the by-product of poor education, limited public health and access to primary care, too much sweet tea and too many pakhoras (vegetable fritters).

Cardiovascular disease here is rampant, with very few people on medication, and those few are rarely compliant. Almost every day we receive patients with acute coronary syndrome, acute myocardial infarction (heart attack) or heart failure. And it would seem that the incidence increases with the rains. As does the incidence of acute watery diarrhoea. In and of itself, this generally causes some mild dehydration and can be managed at home. However, for the vulnerable – that is, the very young, the elderly (which here is not so old), and those with pre-existing illness – diarrhoeal disease can rapidly lead to severe dehydration and shock. We try our best, walking the tightrope between fluid resuscitation and overload. Staff and resources spread thinly across too many patients.

These however, are not the patients that haunt me. I think I’ve already mentioned the ‘Oxytocin clinics’ and this week we all suffered the consequences. The midwives tell us of all the stillborns they are forced to deliver as the women present too late to the maternal and child health unit; the surgeon and the anaesthetist fight to save the lives of women with uterine rupture; and in the ER we continue to resuscitate newborns who often present with no signs of life. Sometimes we are able to resuscitate them, but too often we end up asking ourselves why, when we realise the damage has already been done; others are already with Allah.

A man with sad eyes, a weathered face, and a good heart stands back as we resuscitate his grandson. He watches attentively. This perfect little life in my hands, his heart beating strongly, his skin soft and pink, and yet he is dependent on every breath I give him – a service we cannot offer here. We have to stop and slowly he slips away. His grandfather gently wraps him in his arms, but before leaving the resuscitation room, he turns and with so much genuine gratitude, thanks each of us for what we have done. I feel a mixture of profound sadness for this man and all the people who are losing their newborns as a result of these practices, and intense frustration and anger at the very seemingly preventable nature of the problem.

I was shocked to learn however, that prescribing ‘malpractice’, for want of a better word, is perhaps far more pervasive than I had first realised. This week we had a series of young women who each presented with a different complaint, but all had received a concerning cocktail of medications in “private clinics” earlier that day. One young woman had an anaphylactic reaction to an injection of “vitamins” she was receiving because she was pregnant; another had a reduced level of consciousness after being prescribed eight medications including a sedative, anti-nausea medication, an anti-spasmodic, an anti-inflammatory and some others I didn’t know; while the third went into cardiac arrest shortly after presenting and was unable to be resuscitated. At the time I could not make sense of how a young woman with no previous significant medical history could arrest. It was only later, when I was informed that she too had attended one of these clinics, that I couldn’t help but wonder if this was the devastating effect of a drug interaction or a side effect.

As doctors, we prescribe medications every day. Many people are on medications for the better part of their lives. But these medications, these drugs, they are not benign. One of the first things you will do as a doctor is probably make a prescribing error: the wrong dose, the wrong drug, the wrong timing interval, a dangerous combination…the list of possibilities to get it wrong are endless. And this is a great cause for anxiety and distress when starting out in your career. No-one forgets their first couple of mistakes.

Fortunately – in hospitals in Australia at least – there are many checks and balances to reduce the likelihood of these mistakes or to avoid causing harm. We also have regulatory bodies which monitor the quality of drugs available and restrictions around prescribing. From what I have experienced here so far, this sort of regulation is an enigma. People can buy any drug over the counter, and anyone can prescribe drugs, whether they have a qualification or not. One of the national ER doctors told me with a sad, knowing smile, “In Pakistan, we are ‘Jacks of all trades’. Everyone is an accountant, an electrician, a nurse and a doctor. People will fix their own house wiring (resulting in electrocution from what I have seen). People will make diagnoses and write prescriptions, and people will even administer intra-venous injections of medications and fluids at home.”

However, I don’t mean to dwell on the devastating, as there is a lot of beauty, love, life and laughter here in Hangu which I want to share with you also. Every day I enjoy seeing the national staff greet each other with joyful embraces, and I think of how Australian men would be so uncomfortable with the level of intimacy the men show each other here. The women shyly greet me with a gentle holding of the hand.

Every day I also continue to learn a little more Pashtun. Some words useful, others merely playful. It is always a delight to greet patients and ask them questions in their own language – bridging a great divide between us. Funnily enough however, it is often not until I inform people, “Pashtun nishte”, that they realise I am not from around here. With a veiled face and blue eyes, I’m not so different. I was also shown so much generosity this week, as one of the doctors in the ER brought dried figs from his home town for me; one of the watchmen gave me sweet bread made by his mother; one of the OT nurses bought lettuce for me from the market; and a nurse assistant on the surgical ward gave me a cake! Taking the time to sit with people and talk is one of the absolute pleasures of being here. It is amazing to learn about their lives and the world outside the compound. Many of the people here are so willing to share a part of themselves and their stories with me, which I lap up with a great thirst for knowing and understanding and a great sense of privilege.

Highlights of expat living this week have also included my recently planted vegetable seeds budding into life, bringing me so much joy as they grow a little bigger every day. We also received our monthly supply of food from Islamabad including chocolate, cheese, pasta, and tinned goods. Perhaps even more exciting for me however, was receiving a new guitar string to make up for the two I have already broken in my brief time here. Clearly not really a guitar player, but what can I say, I’m trying. We also watched a whole movie in Hindi because we couldn’t get the subtitles to work. Amazing how you can still get the gist.

So there you have it. The highs and lows.

As I say when I leave the ER, “Rusto ba milawigo. Si masala vi, phone kawa.” (See you later. If you need anything, just call.)