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.

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.

"Pashto Peak" as seen from the rooftop of our house

Sundays have become very important to me here, particularly Sunday afternoons. We officially have a six day work week, and though most Sundays I have to go into the hospital as well, it is usually only for a quick ward round or to assist with one or two emergency patients.

This means that Sundays give me some time to myself to read, to think and to write – very valuable moments to myself during what can be a hecti
c pace of life.

Most of these blogs you have been reading are conceptualised on quiet Sunday afternoons, often while sitting on the expansive flat roof of our house. The view is one of greenery and the slopes of the jagged mountain range that surrounds our town.

As a Capetonian far from home, it is a great comfort to me to be living in sight of a mountain again – yes, yes I know how we “Capies” like to go on about our famous mountain, but it really is beautiful to me and I miss it a great deal.

So, “Pashto Peak” as I have unofficially dubbed the closest part of the range (after the Pashto language which is predominantly spoken here), has become a favourite point of contemplation. This brings me to the challenges of providing medical care when you are twice removed from the patient by the barriers of language.

If my combined language abilities were to be somehow summed up on a cocktail menu, then I would be mixer of the following: A large portion of English Lager, a generous dash of Afrikaans “Mampoer” (this is a form of South African moonshine a little bit like schnapps but quite a lot stronger), a squirt of Xhosa Umqombothi (a traditionally home brewed beer) and a tiny drop of Spanish Sangria.

Now I have no idea how this would taste in reality, or what it might be called – “Lost in Translation” perhaps? – but so far it has served me pretty well in the working and social environments in which I have found myself.

Here in Pakistan, however, this cocktail is quite useless (not to mention the fact that  alcoholic drinks are forbidden, and mention of such is considered culturally insensitive…). I am totally reliant on translation in order to function effectively here, and it has re-emphasised for me the importance of good communication in healthcare settings.

The two senior staff with whom I work most closely in the clinical context both speak very good English, which is a good first step. But, neither of them is from this region, so their first language is Urdu rather than the locally spoken Pashto. But almost all the patients we see in the ER and IPD (inpatient department) speak only Pashto…and so we are stuck again!

Luckily, almost all the more junior nursing staff speak Pashto as their first language and Urdu as their second and so altogether, and with much patience (and not a little bit of frustration), we navigate patient interviews as follows: me to the senior nurse in English to junior nurse in Urdu to patient in Pashto.

The patient then contemplates a response and then: patient to junior nurse in Pashto, to senior nurse in Urdu, and back to me in English.

Phew!

During much of the sometimes lengthy discussions, I am silent and this has been an interesting experience in improving my ability to interpret facial expressions and body language (not always too accurately I’m afraid).

Exactly how much is lost in this tautological transfer of information is hard to say, but I am often surprised by the answers that eventually come back to me: either far too short, far too long or totally off the point altogether. Not to mention the frequent intrusions by family members of the patients who are very fond here of giving their version of the story which, once translated, not infrequently turns out to be rather different from the patient’s own version…sigh. And so, we start again with a re-phrased enquiry until finally, the necessary details start to become clear.

This slows things down a lot of course, but the staff and patients are very tolerant of my persistent questioning and somehow we manage to get it done.

Oh, how much easier things would be if we all just spoke the same language! Except of course that with language and culture being so closely linked, how much unique and valuable diversity would be lost as well?

In the end then, there is nothing for it but to push on through and keep sipping this new language cocktail, which is starting to taste better and better by the day.

Perhaps, by the end of my time here I will be able to add a sprinkle of spicy Urdu and Pashto to my own cocktail of languages and they might just be the secret ingredients which turn it into something truly delicious.

So, for now I will say: “Pa ma cha de cha” (travel well on the road ahead) until next time.