Medicine at the frontier

Being a doctor entails now and then (and sometimes more often than that) dealing with strange situations at unusual hours. I have worked in emergency medicine on and off for nearly 10 years and some of the most interesting cases I have been involved with have needed help at some of the most cruel and dark times of the night.

Throughout my time here in Pakistan, the emergency room is regularly busy into the wee hours and I am frequently on the phone at those times helping the on-site staff make decisions about patient care. As a result of our recent withdrawal from the field due to security concerns, I am not able to be on site in the hospital at all at the moment, and I am now spending more time on the phone that ever.

I am not a 1am person. Sleep in all its essential deliciousness is very important to me and my brain shuts down somewhere round ten thirty in the evening. But here I have had to adapt to a different routine: the phone rings sometime after I have fallen asleep. Initially, the noise is incorporated as an aspect of my dream, but eventually I wake up. With scratchy eyes and croaky voice I answer. Frequently the line drops or the connection is too bad to make out the story on the other end (frustration!) and a little cycle of call-backs from both sides begins until finally we can hear one another clearly. It will be one of the MSF ER nurses. Perhaps there is a patient with a bad head injury after a road accident or assault. Maybe it is a known cardiac patient with severe chest pain and low blood pressure or a tiny newborn who is struggling to breath. What to do?

We go through the standard checklist of presenting problems, examination findings and vital signs. Are there any blood results available? What is the chronic medication? What treatment has been given so far? My team is well practiced and they know what I need to hear to grasp what is happening. We discuss the case until a plan can be made. Perhaps a dose of an emergency drug is needed, sometimes additional tests must be requested first. On difficult days it is a discussion about whether to terminate resuscitation for a patient that has collapsed and shows no signs of life despite a long and concerted effort at revival. We have faced all these scenarios together many times and I have come to rely on the sound judgement and dedicated efforts that my team makes for all our patients. Sometimes there will just be one phone call in a night and on rare occasions none at all – how I cherish those uninterrupted hours of sleep! But usually it is necessary to discuss a case several times before a final decision is made. These are often rushed conversations in urgent tones, there is no time to waste and the tired brains on both ends of the phone are urged into a higher gear. We do what we can, watch closely always ready to respond and hope for the best outcome. Sometimes all goes well, sometimes not and we know that tomorrow night we can expect more of the same.

I don’t think I will ever get quite used to the penetrating sound of the late night phone. It will probably remain an alien and unnatural thing. But, certainly here and now, it is a reality I must continue to face.

As a result of the excellent standard of care MSF staff continue to provide in our emergency room despite limited resources, more and more patients are presenting with emergency problems at all hours. Whilst before they would have bypassed our little hospital in (sometimes blind) hopes of better treatment in a bigger city, now they know to stop and let us help them. And so, to be woken a few times at night is really just part of the job, as it is for doctors all around the world. Though the rings under my eyes are darker than they were a few months ago, I am happy to be able to support a service that is there for people who really need it. So I better get off to bed and get a few hours in while I can!

Sleep well all of you who are able and, for those of you who, like me, are sometimes called on to guard the night, know that you are not alone and your efforts are not forgotten or in vain.

Patients with chronic diseases need regular follow-up, ongoing education about their illnesses and access to a reliable supply of quality medication. Unfortunately here in North West Frontier Province, this ideal is seldom if ever achieved. Due to many factors, including poverty and difficulties in regularly accessing healthcare facilities, many patients who should have close monitoring and support instead suffer through a confusion of haphazard and sporadic treatment. As a result, they progress through an inevitable and tragic deterioration.
Type 2 Diabetes is very common here and so are its complications, including problems like gangrene, kidney failure, blindness and metabolic derangement leading to coma and death. Because of the devastating damage it causes throughout the body, it is an important example of a disease that needs well-regulated control. But, most of the diabetic patients who come to the MSF emergency room and in-patient department have been denied this in the past and consequently they are often in very bad shape.
Ziarat Gul, a man currently admitted in our ward is no exception. Blind in one eye and with a long white beard he is a hunched, frail old man who has become well known to us over the past few months. He guesses his age is somewhere between 60 and 80, but he looks closer to 90 to me – the weathering of a life harder than it needed to be.
When he first presented he had a carbuncle – a large area of infected skin similar to an abscess – on his back that had been festering for some time. He had been unable to get proper treatment for the wound or afford to purchase his vital medication, and his blood sugar was dangerously high. Infections are a real problem for patients like this: the uncontrolled diabetes (caused by the missed medication) weakens immunity, increasing the likelihood of infection and, once an infection takes hold, it pushes the diabetes further out of control – a vicious cycle in which this man was trapped.
Luckily, once identified, the problem was simple enough to treat: a special diet, daily doses of the right tablets and dedicated wound care. Though it has taken a lot of patience on the part of the MSF nurses and several debridements by the MSF surgeon to remove the infected tissue, this previously neglected wound is dramatically improved. From a painful crater in his back, it is now a healthy, neat surgical wound after a successful operative closure today.
A success story like this is very gratifying for us because this man is one of the lucky ones. He managed to get to the MSF hospital while there was still time for us to help him. Others are not as fortunate. Over the months that I have been here, we have admitted many diabetics with infections whose disease is out of control because of chronically poor management. For most this means an extended stay in our hospital until things improve, for others it ends with the amputation of a foot or leg with all the long-term impairment that can bring. And for a few, it is their last illness in this world.
It is not easy having to accept that a person has suffered or died from a preventable cause, from something that, had it been seen to earlier, would have been completely treatable. And so we hope that the story of this old man who is now on the mend will be told, and will spread in the community and that others in need of similar help will come sooner to the hospital. Soon enough for us to nurse them and their neglected wounds back to health. Inshah-Allah.

When I signed up to work with MSF I wasn’t naïve enough to expect an easy ride or a soft experience. This organisation, by very specific intention, works in some of the most challenging contexts on earth: war zones, natural disasters and other humanitarian crises of all kinds. Despite the very real feeling of reward I get from doing this, I knew it was going to be a difficult job, a frustrating job, a demanding job and that at times I would be disheartened. I was right, for it has been all these things and more over the past few months. What I was not prepared for, and what has been hard to accept, is not being able to do my work at all.

As you may well know from following the news, there has been a dramatic rise recently in the number of violent attacks in Pakistan. Markets, police stations, army barracks, and even schools have been targeted and many have been killed and injured. This is devastating not just for all the victims and their families but for the country as a whole and, potentially, for the world at large. The ever-rising tensions here have implications far beyond the borders of this damaged land. North West Frontier Province (NWFP) where we work is one of the frontlines in the global war against terror and the events of recent weeks only add fuel to a fire of reciprocity that is already raging out of control.

Foreigners and NGO can also be direct or indirect victims of the ongoing conflict. MSF takes the safety and security of staff very seriously so as to limit as far as possible the likelihood of our personnel and medical activities being affected by violence. If an attack did directly involve MSF personnel or structures however, aspects of our work here would undoubtedly be suspended or drastically reduced. So, while we are here, at least in part, to help to alleviate some of the fallout from the ongoing violence, it is entirely possible that the violence itself could be precisely the reason we are unable to achieve this goal.

At this stage, we have not been directly affected by the current wave of incidents but, for the sake of caution, the movements and visibility of the staff on my project have been dramatically reduced and the expatriates had to go back to Islamabad for a few days – and so we come to the reason for my interrupted (and frustrated!) status…

Of course, I understand the rationale behind the restrictions and I am grateful to be working for an organisation that cares enough to impose them but, to be here in the midst of all this need and not be able to help directly (even if it is only for a couple of days) is hard to accept.

We will hopefully be back to normal medical activities soon. In the meantime, though, I find myself reflecting on the fragility of our efforts here. As long as this seemingly intractable conflict continues, there will almost certainly be a need for our presence in NWFP. Sadly though, precisely because of this same conflict, our position and contribution could all too easily be ripped away – both as individuals and as an organisation – by a bullet or bomb. A tragic irony indeed…

I am left to hope that, somehow, real and lasting change can come to this situation. And, considering the systems, ideas and people which are involved in what is an incredibly complex set of problems that exemplify much that is wrong with our world, I don’t think it is unreasonable to say that this is a challenge within which we all have a role. If hope is all we can justify at this stage, then as long as it is hope backed up by determined action, I think there is a chance. What do you think?

Though it is without question a fascinating and vitally important branch of medicine, cardiology has never been my strong suit. It requires a patience that I lack but which is essential to delve successfully into the stories behind the myriad factors and events which have usually conspired to produce a heart problem in any particular person. This is particularly true for the patients I am seeing here in NWFP, where access to quality health assessment, a reliable supply of medicines and adequate follow-up are far from guaranteed. As a result, the cardiology patients I see here on a daily basis are often in a very serious condition with complex and advanced problems that have been mismanaged or neglected entirely – I have really had to hit the books to keep up!

Tariq

It was a problem of the heart that brought a young man called Tariq into the resus room of the MSF ER the other day. Well, he actually came in because he felt very short of breath which would suggest a lung problem but this had in turn been caused by a kidney malfunction…and all of it related back to a throat infection he had caught several weeks earlier. See what I mean about the complexities of cardiology!

When I first saw Tariq he was breathing at over 60 breaths per minute. I challenge you to pause for a moment and try and do this consciously for a while. Exhausting isn’t it? Breathing at this rate for several hours had made him so tired he could barely sit upright or keep his eyes open – he was deteriorating fast and we needed act. The MSF team had already started oxygen and detected that he had a lot of fluid built up in his lungs which was causing the shortness of breath. Sorting this out was our first priority. Using a combination of intravenous and oral medications and a lot of encouragement we managed to stabilise our young patient and could then go about the task of figuring out exactly what had happened.

Sometime later, after a lot of patience and some detailed questioning, the story started to unfold: several weeks earlier Tariq had had a sore throat.

Though he managed to see a medical practitioner relatively quickly, the treatment he received was inappropriate. The infection resolved several days later of its own accord and he thought nothing further of it. Then, about a week before he presented in such a serious condition to the ER, he noticed that his feet and face were starting to swell up. A few days later he began to get more and more short of breath, and finally the problem was so severe that he was rushed to the hospital. What had caused this unfortunate chain of events? Well: in response to the untreated throat infection, Tariq’s immune system (as it was designed to do) produced antibodies to attack and kill the invading organisms – so far so good – but then something went wrong. The antibodies circulating in his blood got “confused” and started to identify his own cells as invaders, and began attacking them in the membranes of his kidneys – the body, what a mysterious beast! During our assessment, we had already picked up that there was blood and protein in Tariq’s urine which was the evidence of the kidney damage and because his kidneys were no longer able to excrete fluid as normal, it began to build up in his body (hence the swelling) and eventually built up to such an extent that his heart could no longer cope with the load. And so we come to the problem of his heart: drowning in fluid it had begun to fail, fluid was forced into his lungs and very shortly thereafter he was fighting for his life.

Tariq

Things could have been very different for Tariq. Had his throat infection been diagnosed and treated properly, that would have been the end of it. Even if he had developed this rare complication but had been able to easily and rapidly access quality healthcare, the problem could have been managed very simply when it was far less severe. But, Tariq is very poor and he lives in a part of the world with a very poorly developed healthcare system. Luckily he managed to get to our ER and as a result, his heart will be beating for many years to come, but this story could easily have been the end of him.

A close friend of mine died tragically in recent days. While he didn’t have a problem of the heart, his death has caused me to reflect once more on the fact that none of use knows how many heartbeats we have left. Don’t waste yours for each one is precious.

If life is a ceaseless river of time, then moments are the droplets making up the rushing stream. Moments are the opportunity we have to be aware of ourselves in the world, to realise that we are indeed alive.

But, most of these momentary opportunities pass us by because we are lost somewhere else in time, lost in the past or the future – anywhere but the here and now. This is why it can feel like life is somehow slipping through our fingers, even though we never mean for this to happen.

Only by grasping the moment we are in when we are in it, can we slow life down enough to really be there and experience it. And when we do, it truly is an incredibly elaborate mosaic.

I am over the halfway mark in my MSF mission. The time has passed both quickly and slowly; sometimes smooth and easy, but just as often it has been a grinding, halting struggle.

I can feel the passing of this time in the length of my hair and beard (I am in quite bad need of a trim) and the growing weariness in my body. I mark it by the daily dwindling of my vital supply of multivitamins. I know it by the comfort I now feel in once unfamiliar surroundings and the ease with which I now interact with those who were once strangers.

Being here has included some truly unconventional moments; and while some have been difficult to bear, I still feel privileged to have been present.

The jumble is hard to unravel sometimes, as it fits no standard pattern. There have been moments of anticipation, like waiting for a desperately sick child to show some sign of recovery; and ones of relief such as the blissful instant when the cool wave of air from the fan first hits my sweaty skin after the power has been out for a while on an impossibly hot day. There have been moments of despair while watching life slip from the eyes of a premature baby whose only mistake was being born in the wrong place at the wrong time. Moments of joy in watching buffalos bathing and children playing dusty, care-free games; and moments of exhaustion and resignation after another long but ultimately unsuccessful patient resuscitation. Even, occasionally, there have been moments of hope that things can and will be better for the people here and that we are a small part of making that happen.

Each of these moments is like a mini-life all of its own – a complete existence encapsulated in time. I believe that bound up somehow in each is the key or answer to life itself. If we can be fully and honestly present in any moment, whether it be superficially “great” or “terrible”, I believe we have the chance to glimpse something of this elusive secret.

It is said that there is no time like the present. I think it is more correct to say that there is no time but the present. So, if we fail to engage these moments in time as they present themselves to us, we are denying ourselves the chance to live.

My time in Pakistan continues to teach me many things. Most of all though, it has reinforced for me that the more time I spend being here, now (i.e. present in the moments of my life) the more alive I am. And only when I am alive like this is the power that I have to effect change (small though it may be) given its opportunity to work.

I am about to go on a much-anticipated leave. I need it body and mind. I am looking forward to moments of relaxation and fun and excitement, moments of escape and rest. My wish for you, whoever and wherever you are, is that you will find a way into the moments of your life, the ones that are there all the time, just waiting for you to enter. Because, they are where the magic happens…