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.

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.

It isn’t easy getting from Cape Town in South Africa to the North West Frontier Province of Pakistan.

To do so means spending a lot of time in airports: Cape Town to Johannesburg, then to Zurich, Brussels and finally, Islamabad. The rest of the way is by rough road and only with the permission of the military at several checkpoints.

But this is not just a journey of distance and time, it is also one of mindset. To work for Doctors Without Borders (MSF) – as I will be doing here for the next 6 months – is to agree to represent an organisation that aims to reach out to those in need in some of the most challenging and complex environments on earth. It means to adopt a code of impartiality, advocacy and the giving of assistance irrespective of race, gender or political/religious ideology.

Joe with friends

I am an emergency room doctor and I arrived here to join a team of doctors, nurses and support personal currently bolstering the standard of healthcare in a region that has suffered a great deal in recent years. In the week since we stepped into the exhausting 50 ^oCelsius (122 F) heat, it has become very clear to me that the needs of the people here are great.

As an international organisation that has its origins in the western world, it has not been easy for MSF to be accepted here, but the high standard and dedication of local and international staff has opened the way and we are now welcomed and appreciated.

Looking ahead, it is clear that this is going to be one of the most challenging jobs of my life. But, I am proud to be working for an organisation that changes lives and I feel immensely privileged to have the opportunity to help people in what is, metaphorically speaking, an axis for one of the turning points in the history of the modern world.

I look forward to sharing my experiences with you here over the coming weeks and months.

Joe Starke

Jonathan (Joe) Starke is a South African doctor with a keen interest in emergency medicine. He is currently on his first mission with MSF and is working in an emergency room and inpatient department in Pakistan’s North-West Frontier Province. So far he has encountered cholera, endured sweltering heat, monsoon rains and survived a bout of dysentery. He finds the entire experience exhilarating and this is his blog…

“Working with MSF has been a long standing dream for me. In many ways, the previous jobs I have chosen to do have been, in part, a preparation for going on an MSF mission.

The time I spent practicing emergency medicine has prepared me well for my current position, but even more important has been my Remote Site experience. I spent 15 months on mainland Antarctica and a total of 12 months on two sub-Antarctic islands, (Marion Island and Gough Island) over the past few years doing medical support for the researchers of the South African National Antarctic Expedition.

The challenges of the isolation and restricted living environment in those beautiful places have prepared me rather well for the isolation and restriction that we face in Pakistan’s North-West Frontier Province. But it also prepared me for the vital role that team work plays in all MSF projects.

Outside of medicine, my interests orbit mostly around questions of the future of humanity and what role the individual has within the unfolding of this challenge.

I like to read, enjoy writing and find great pleasure in spending time in nature – something that it is a little difficult at the moment, but which I look forward to finding time for as soon as possible.”