Sunday, August 31, 2014

Compound Life

I am the only non-African on this MSF Mission in Jahun– the others  are from Kenya, Sierra Leone, Ivory Coast, Congo, Malawi, Ethiopia and Burkina Faso The MSF compound where we  all live is walled, and there is razor wire along the top of it.  From my room next to the wall I can easily hear the sounds of sheep goats chooks and people in the side street and  from the house in the  next compound, of kids mostly, of their early morning recitations from the Koran, of their crying and grizzling, playing, shouting…and often at night a generator is tuned on that drowns out everything. Last night welcome heavy rain drowned even that noise out, and cooled everything down.

Big steel gates open to let the vehicles in and out, and there is a watchman on duty all the time, but there are no guns. Inside, there are several buildings close together, basic offices, an eating and kitchen area, an aircondtiotned  lounge room with soft chairs, and old books and a satellite TV, and we each have a room of our own with shared bathrooms.  Theres no hot water. Our lunches and dinners are cooked every day by a local woman who serves it in large plastic  containers with lids supposed to keep it warm, and we serve ourselves whenever we  can. Typically we have rice, potato or sweet potato, or noodles or couscous, with chicken or a meat casserole, some spinach, chopped up cabbage and carrot , and various spicy tomato sauces. Once she served up some sort of  local dish that was so slimy and gelatinous it reminded me of mucus with peas and mince swimming in it – just couldn’t bring myself to even try it but the Africans all scooped it up! Today there are nine of us resident, but last weekend we had a few extra guests who came up from Head Office for meetings..
The Security Area
My daily routine is more or less unvaried – I am either eating, resting in my room, sleeping or busy at the hospital. Occasionally I watch the news on TV and have a choice between CNN, Sky, Al-Jazeera and BBC World, but its all Ukraine, or ISIS and Syria and nothing much else. The Business reports don’t interest me but the sport  sometimes does and I found I could watch live Rugby if only it didn’t coincide with the need to be at work. So I managed to see the first Wallabies-All Black match, the one that was a draw, but unfortunately missed the next one , the one where the Wallabies got hammered!  It would have been great to watch that!

To get to the hospital I walk to the front of the building where the Security guys are and they drive me in – I could walk there in five but we are not allowed to.
In addition to myself there are five young Nigerian doctors and a Nigerian Specialist who rotates from a nearby major center for  six days at a time, to share the Specialist Call with the MSF Specialist. So, if he has been on Call for the night, I go in for the morning, he covers the afternoon and the night is mine.

All of these Doctors have taught me an enormous amount – the  volume, the severity and the complexity of the  cases that we see here are beyond – way beyond – anything I have  had to deal with before, even in South Sudan and Ethiopia – and we have had to deal with these women with more or less complete absence of any sort of Laboratory tests or other back-up to help.  The very fundamentals of Medicine, which is history taking, basic observations, careful examination, clinical judgement and experience is all we have to go on – and fortunately for me, these guys have seen it all before, many times, and usually can work out what to do.

So, at 8am each day we do a round of the  Intensive Care Ward There are eight beds, the room is airconditioned  but the resemblance to a real ICU is slight – its really just a place where we can more closely monitor  the vital signs – ie Blood pressure, Pulse, Temperature, Respiratory rate and urine output of critically ill women – there are no fancy machines of any kind and no access to any tests other than of haemoglobin and no X ray.

All the postoperative patients go there initially and once stable get sent to the “Annexe” a huge  open ward like a shed, recently built by MSF for the postnatal patients, designed I believe for 40 but often crammed with 60 or 80, along with their family supports, many on the concrete floor. It is so big, and there are so many patients that the few nurses working there take for ever to get to see everyone, and several times while I have been here, the nurses or the Doctors have simply stumbled across people “in extremis” who have been quietly deteriorating, unnoticed  in the crowding and noise and bedlam of the place.

After ICU we go to the PreDelivery Ward, the place where all the frantic action and obstetric  calamities are unfolding, also often full, there may be women on matresses on the floor or even sharing a bed for a short time. Once we have seen everyone and sorted them out, I remain in the PDW at the desk, and as new work arrives, help out as I can.
The PreDelivery Ward looking unusually quiet and under control
Now, I apologize to the non-medical reader  in advance for what follows, but it is a list of the actual patients we saw on the PDW round the other morning, a snap-shot of a typical caseload - you will notice a number of women with "Eclampsia" - it is such a rare condition that in all my years of practice in Australia and New Zealand I saw three cases - seeing three in a DAY here is not unusual:

Bed One : Eclampsia : 18 year old woman, second pregnancy, brought in because she had been fitting at home ( having convulsions ) She was so restless and confused she was tied to the bed, Labour to be  induced. Eclampsia is the MOST feared pregnancy complication : it kills mothers and babies
Bed Two : Eclampsia and Malaria, and by the  Coca-Cola colour of her scant urine has HELLP syndrome as well ( dangerous complication of an already dangerous disease) . Also confused, semiconscious  and tied to the bed
Bed Three:  Eclampsia  and Malaria in a 15 year old,  in Labour. BP 180/100
Bed Four : Heart failure  2 weeks after home delivery. 25 years old. Responding to diuretic therapy. Cause of heart failure unknown and unknowable out here. The woman is just sitting there breathing fast and looking weak and near collapse but theres little more we can do.
Bed Five: Eclampsia : 17 years old Admitted for Observation of high BP, 1st pregnancy, then began fitting. We have to induce her labour and deliver the baby in the next 12 hours.
Bed Six : two women on one mattress on the floor ; one had a normal birth of a live baby, the other is half way through her sixth pregnancy but the baby has died. We don’t know why the baby is dead. We hardly ever know why. We have to induce her labour.
Bed Seven : Eclampsia : 1st Pregnancy, began fitting  in labour at home. Tied to bed. Baby alive.
Bed Eight :  Placenta Praevia at eight months – previous Caesarean ( this woman has dangerous bleeding from the placenta)
Bed Nine : Severe anaemia  (Hb 4.3) and malaria in pregnancy ; For blood transfusions.
Bed Ten : polyydramnios ( a hugely distended pregnant abdomen becauase of excessive fluid around the baby which is abnormal)

Bed Eleven : She came in with lots of bleeding during labour. The baby is out and they are both OK.

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