Medicine at the frontier

The last day in the field is a blur: some final handover of reports and evaluations and lessons learned the hard way before I forget; a sumptuous lunch followed by a grand afternoon tea organised respectively by the wonderful staff in my two departments; pictures and hand-shakes and exchanging contact details…

I do not like saying goodbye. I would prefer to slip away quietly in the night, but to do so would not allow me the chance to say thank you to all the people who have worked so hard during my time here: the drivers and watchmen who have helped to keep me safe, the office and support teams for making so many things happen in the background so that I didn’t have to worry, our chef and house staff for taking such good care of us and the excellent clinical team for delivering the true purpose of our project: high quality patient care. Thank you to all of you, without your ongoing efforts, my presence in North-West Frontier Province in Pakistan would have been without value or result.

I spend my last evening in the field quietly: warm and watching a movie – a simple and unexpectedly special end to what has been at times an incredibly challenging period in my life. The next day I am up far too early for my liking. It is cold and all I want to do is stay in bed, but my transport to the capital is leaving. I say some final goodbyes to my expat team (my family away from home) and suddenly after weeks of being ready, I no longer want to leave…but all in a moment and a cloud of dust, Dargai is behind me.

My last days in Pakistan are spent debriefing and writing reports in Islamabad. On my last night, two of my expat team arrive unexpectedly from the field and I am treated to an impromptu farewell party including home made sushi, beautiful decorations and entertainment by a local musical duo. The packing I had planned to do is postponed and I enjoy another very special evening. On the final morning it takes all my will power to leave the warmth of my bed. The distinctive smell of 4am greets my nose as the driver and I shift through the deserted streets on the way to the airport. Silent for most of the way he eventually turns to me and asks: “Is your mission complete?” and, despite some reports to finish, despite the never-ending work that I leave behind, I am able to say “Yes”.  I have done what I came here to do.

We go through one last security check-point on the road: one last slalom between concrete barriers; one last pass in the firing line of the machine-gunner in his sand-bagged bunker; and I am reminded that I have just spent six months in Pakistan and it is the end of what has been a very long and difficult year for that country and myself.
The firm fleshy hand of the driver is my final farewell and then, I am gone.

I want to thank those of you who have followed this blog. The work of MSF relies on the support of people all around the world who recognise the need for what we do and agree to help us, whether through a period of work with the organisation or financially. Please spread the word about MSF to everyone you know. The more people who know about us and the efforts we make to bring healthcare and other services to populations in need, the greater the impact we will be able to have and the more projects (like our current ones in Pakistan) we will be able to operate.

And finally, whoever and wherever you may be, take time to appreciate the good things, the special things that you have in your life. If the last six months has taught me anything, it is that to be here (in this life) is an amazing opportunity, don’t waste it!

My six month mission with MSF in Pakistan is rapidly drawing to a close. My replacement, Fahad, another South African, has arrived and I have the time to look back over what I have done here. Certainly I have not managed to get finished all the things I had (with unrestrained idealism) hoped for at the outset, but some small progress has been made. Some further links with the local community. Some treatment success stories. Perhaps even some lasting influence on the way medicine is practiced here in NWFP. And if that is all, then it is enough for me. There is much more that still needs to be done, but it will be done by other hands than mine.

As the last few days wind down, despite my tiredness and my readiness to move on, I am torn. There are things here with the power to make me want to stay: places, opportunities to use and share my knowledge and experience but most of all, people. I have had the chance to meet and work with an incredible group of dedicated and talented people from Pakistan and from all around the world. Thank you to all of you for your commitment and hard work. Though it may not always seem so, it does make a difference.

Moving through town and at work, my brain records snippets of what is going on around me, filing them away. I see a small boy, running alongside the railway track; he is wearing a bright purple woolly hat against the early morning chill. He turns and smiles at me and I wonder: in this place where I have seen the tragic consequences of so much violence, when exactly that innocence will be lost? My bed and desk are covered with slips of paper that I pore over: lists, and list of lists of the things I need to get done before I leave, things I need to hand-over to my replacement, reports and summaries and protocols I need to write – a mountain of words to climb that seems impossible in the time I have left and yet it is essential, to ensure continuity, to ensure that any worthwhile momentum I may have generated in our work will not be lost.

The images of patients stays with me: the wizened, gaunt face of a man on his death bed, dwarfed by the size of his own white beard, his lungs severely scared by TB; the history in the eyes and hands of a woman with joint pain, who I am unable to help in the way I would like, partly because of the languages which divide us.

And other scenes from this other world that I have been part of for a while that refuse to be overlooked: heavily armed soldiers on guard duty outside the fort with the sweeping panorama of the mountain rising above them in the distance; the menagerie of sheep and goats, cows and chickens, donkeys and buffalo, walking and grazing and toiling in the narrow streets; the sun setting to the sound of the evening prayer as I walk on the roof, learning some basic Spanish with the help of a new colleague.

All these things will stay with me. For though I will soon leave Pakistan, it will never leave me as I find myself profoundly changed by having been here. Wherever I go in the world after this, whatever I do, I will carry these images, these snapshots of how life is in this other place. I will be forever grateful for the perspective I have gained, for the things I have learned, and I know that they will help me to be more appreciative of just how fortunate I am in life. Holding onto this, perhaps I can go on to take full advantage of the many opportunities I have with renewed vigour, in the sound knowledge that there are many who cannot even imagine such chances. A worthwhile goal I think, and a responsibility I now accept with profound gratitude.

Awareness of road safety is not big here in NWFP. Firstly, many of the roads hardly deserve the name and that certainly doesn’t help. But more significant is the general attitude of what I can only describe as recklessness (or perhaps carelessness?) displayed by most drivers and pedestrians alike. The result: road accidents are a frequent cause of the local population presenting at our emergency room, and the injuries are often horrific.

 On the way to and from work, I have my eyes closed half the time (no, I don’t drive myself) and find that I catch my breath at regular intervals as a result of the various manifestations of traffic chaos that are happening all around me.

The vehicles here are a kaleidoscope: from lumbering, elaborately decorated trucks to battered donkey carts; minivans and rickshaws; huge tractors with trailers in tow and, of course, there are motorbikes everywhere (though helmets are vanishingly rare). And all of them are heavily loaded (with people – inside and out – livestock, and every type of merchandise, material and equipment) to the point that I marvel they are able to move at all. Every junction point, street market and crossing is a seething mass of impatience – everybody wants to be first, in front, going faster and will do everything they can to make sure this is so. Add pedestrians to this mix, all with a bundle, bag or tiny child (!) to slow them down or obscure their view, all trying to squeeze through the smallest of rapidly closing gaps between the vehicles, and you can begin to understand why this is a catastrophe waiting to happen. It doesn’t have to wait long.

Everyday they come to the ER: broken arms and legs, lacerations and bruises – and those are the minor cases. Then there are those with head trauma, the crushed chests and abdomens, the terminally mangled bodies….But, this is why I am here and the other day this is how I met two 20 year old lads. If only we had met under different circumstances.

They had been on a motorbike together, riding, carefree but too fast. In the crash they both sustained multiple injuries: each had broken a leg, fractured several ribs and both were unconscious.

I was not in the resus room when they first arrived and by the time I got there the MSF nurses on shift had already done a lot to stabilise them. I am lucky to work with an excellent team but we were all pushed to the limit that day. The demands of an emergency like this are hard to relate. Both patients needed my immediate and undivided attention but this was obviously impossible. And in those first few moments I want to shake them, to shout “WHY WEREN’T YOU WEARING HELMETS? WHY WERE YOU DRIVING SO FAST?!?” but what use would that be…

All that is left is to slip into the familiar routine: Airway, Breathing, Circulation, are the cannulas in, lets speed up that IV fluid and keep ventilating, have we checked the back, please get a chest drain kit open for number 2…ok (breathe…), what’s the blood pressure now, let’s review what we’ve done so far. My well-trained team are slick and practiced in their movements and over the next hour and half we do what we can to stabilise our patients. One is beginning to wake up – a good sign – but he is far from out of danger. As for the other, I am concerned that he may already be too far-gone. We manage to get a unit of emergency blood for him, the transfusion might just be enough to keep him alive during the two hour ambulance transfer to the nearest trauma surgery centre, but even if he makes it that far there are no guarantees he will survive.

In another well-practiced routine, we prep and package them for the ambulance. As it rolls away from the hospital, I can’t help thinking that it is all such a tragedy for such young lives. We are exhausted, our only comfort being a job well done. There is every chance we will face the same thing tomorrow.

South Africa has a road accident problem that can easily rival what I have encountered here. So I want to end by asking that wherever you are driving today or tomorrow, please be careful. Wear your seatbelt, put your child in the safety seat (everytime!) and SLOW DOWN. To do otherwise, well, it’s just not worth it.