The end is near

november 5, 2008

Hello again!

Yes, the end is near and inevitable – in fact, after 10 weeks in the City I’m now on my way home! It’s been an extreme challenge with many and lasting impressions – actually way more than I had anticipated. I’ve learned and been exposed to so much that I don’t know where to start now that I have to summarize it all – in many aspects it far outweighs my previous 4 years of experience from home. Let me give you some numbers to put things into perspective:

During my 68 days in the city, I’ve worked 67 days (of which 51 consecutive) and 12 nights. I’ve done 122 cases under general anaesthesia (47 with intubation), 119 spinals, 23 laparotomies (11 during night), 1 thoracotomy, and each and every day except Sundays I’ve done pain rounds on approximately 65 pre- and postoperative patients. The EU law on working hours is as you understand not implemented here… BTW, did I say in my last post that I had the Sunday off? Well, that turned out to be not entirely true. At 00.10 the phone rang; the local anesthetist (out of approximately 10 to 15 in the whole City with a population of about of 2 million!) could not be on call and we had to go in and do a laparotomy on a pelvic gunshot wound. The patient was relative stable, but the blood bank fridge had little to offer – at the end of surgery he had an Hb of 42 g/l! Well, he made it, and a week later he got discharged home. I guess though that we won’t accept him as a blood donor for months to come…

Now for your questions that I promised to answer; first come first serve!

Rik: Yes! Let’s get wet when I come home – I can use some serious R&R! I’ll call you and you better stand up to your offer!

John: Well, now I’m on my way home as you can see and I also hope your food question has been answered. Yesterday it was Thursday and thus time for my weekly dose of mefloquine against malaria. Doxycycline is an alternative as some people have psychiatric side effects to mefloquine. However, I haven’t jonglerarnoticed anything; I’m completely normal, anybody saying the contrary has joined the conspiracy, nobody saw me, I’ve got an alibi, my friends made me, and does the voices in my head bother you?

Steffo: I think I have fully succeeded in one of my original goals, but the other goal has been a complete and utter catastrophe. I’ve rarely made it home before dark and it’s mostly been raining anyhow. However, indoors I have been able to perfect my 5 ball act somewhat, outdoor juggling has been impossible on all but a few occasions (see picture; and notice the Swiss leader on the top; thank you PPD-gang!). I guess my dream of 7 will be one that I won’t fulfill; and definitely not during this mission.

MJ: My previous experience with ketamine was extremely limited. I had the textbook knowledge, and I can remember using it twice: once on a ruptured aorta, and once on the field at the scene of a motorbike accident. I know it’s more widely used in other places, but by tradition (?) not so at my hospital at home. I definitely think I’ll now use it more frequently on severe traumas; I can in retrospect remember several cases that probably had been better off with ketamine. But one must remember that our resources are infinite at home; we have blood and fluid delivery systems that can keep up with virtually any blood loss, and our human resources and infrastructure is all but limitless. I know you folks at home might not agree with me on that; but trust me, we are extremely privileged.

Uffe: Yes, a bougie is same same as the blue thingy on the wall. It’s used to guide the breathing tube between the vocal cords when it’s tricky to get it down in the right place. It’s my favorite airway tool and I use it frequently, maybe too frequently as I should probably fiddle around a little more to get the perfect view without any additional tool. But, I’ve got a lifelong learning curve, so in a couple of years I might find myself using it less frequently. Thank you also for your warm and generous support to me and the Médecins Sans Frontières – you’ve probably already have more lives on your conscience (in a positive sense) than most!

Well, that concludes my story from my first mission with Médecins Sans Frontières! It seems like I’m off to my second mission in two weeks; this time to a country plagued by civil war and harsh weather. It’s not yet finalized and many changes might come down the road. I’ll continue this blog and add new posts; check in again in a couple of weeks to find out what’s happening!

Finally and again: thanks for all your support; I now understand just how much it means. Keep it up and I’ll try to do the same!

Annonser

Life goes on

oktober 24, 2008

Greetings!

It’s Sunday again and I actually have the day off! I’m spending the day at the house and just enjoy doing absolutely nothing for a change. Strange feeling! The house is in the nicer quarters of the City and I’ve only heard gunfire in the vicinity a couple of times… I have my own room and the ground service is fabulous; housekeeping, laundry and food are all taken care of by the logistic side of the Organisation. They have the explicit orders to do everything possible to enable us in the medical team to do our work as efficiently as possible – I wish the administration at my hospital at home had the same instructions and goal! The food is exceptional and delivered to the Hospital every day. The mission does not offer any hope of losing weight and I have to get the recipe for that homemade pizza!

The mission has tight security rules, but we are allowed to leave the house during daytime as long as we clearly indicate our association with the Organisation with T-shirts and logos. Kidnapping is a major source of income for some elements of society, so all movements and whereabouts must be declared and approved ahead of time, and we shall always be reachable

In the busy city of Port Harcourt, there is no social security and no one but us will take care of you if you don’t have the money. So when receiving a case it was never  an option not to treat the patient.

Preparing for a case I decided on a battle plan based on our airway algorithm from home. I prepared the equipment at hand and told nurse P what was happening in case I needed help. Anyhow, I was confident that I could open her mouth once she was asleep and muscle relaxed.

I was wrong… Her jaw remained locked rigid, but on the positive side was that she indeed was easy to ventilate and somehow I managed the airway with the help of a bougie – again, I don’t know if I did right or wrong and in retrospect I wouldn’t do it again, at least not without prior discussion, more equipment and, most of all, a red button…

Since my last post I have been joined by a French nurse anesthetist, and that has really changed things. We take turns for calls and just to have someone to discuss with makes all the difference. It’s only a couple of weeks left of my mission, but now I can for the first time relax a little and even get some administrative work done! Just like home reports have to be written, statistics compiled, and inventories made. Life goes on…

In my next post I’ll try to wrap things up and answer all your questions. Keep ‘em coming!

Starting to settle in

oktober 13, 2008

Hello again!

Last week’s description of the OT is not at all the weekday daily routine. It’s actually quite organized and not too unlike home. We finalize the operating list in the morning (and then modify it endlessly during the day…) and then set off to the OT. On a normal day it’s me and Paulinus and we take one theatre each, and do the cases as they come. The patients are delivered to the corridor outside the theaters on stretchers by an army of stretcher carriers; no trolleys or elevators at Teme!

For many cases I opt for a spinal and then try my best to explain to them what is going to happen. I now found out that my efforts at informed consent were largely in vain, and I’m better off pointing to my own back saying “injection” and then to their legs saying “no pain”. That seems to do the trick and they are all without exception extremely cooperative and even relaxed – I don’t know if I would be equally relaxed if I were in their place; badly wounded and with strangers that don’t talk your language to trust with your life. Anyhow, once the spinal is in place and the pain is relieved, most immediately fall asleep. The surgeons then do their thing; mostly external fixations and debridements (from minor to beyond major!), but we also do internal fixations and general surgery. When working on the upper extremities a ketamine sedation/anesthesia will often work, but in some cases intubation and airway control is of course inevitable.

At home there is a red button on the wall. If I’m in trouble I’d press the button and then take cover as within seconds a steady stream of world class anesthesiologists would pour into the room from every available door. At Teme in Port Harcourt there is no button. I use my skills and knowledge. We work as a team and finally we do a good, safe standard of work for a population tha would otherwise have no-where to go!

PS. I attach a picture of the wall of the OT; which emergency tool (the fly swatter or airway bougie) do you think is most frequently needed?

OT emergency tools

OT emergency tools

PSS. In my next post I think it’s time to describe our excellent living conditions (really!) and equally exceptional food!

PSS. It seems my mission is extended four weeks – great!

As I finished with in my last post, I got brutally thrown into reality when dr Albert left and Paulinus was off for the weekend. The surgical team (general surgeon, orthopedic surgeon, and I as anesthetist) work all days of the week and we’re always on call; so far relieved only approximately one night every two weeks. We’re supposed to have Sundays off, but today it’s Sunday and I just spent my 17:th consecutive day at work…

This particular Saturday we were doing a laparotomy on a ruptured spleen (great call dr Wiji!). I had my week of learning so I felt pretty relaxed and started the work enthusiastically.

Let me describe the setting:

We were called to the ER for a traffic accident. Due to the prevalence of malaria an enlarged spleen is quite common and prone to traumatic damage. Dr Wiji (the general surgeon) examined the patient and determined the correct diagnosis without any X-rays or lab tests; just the history, examination and the vitals – I’m still amazed at that. The patient seemed quite stable with a pulse around 80 and normal blood pressure and as almost all patients, young and fit. I had to do a preoperative assessment and investigation. The history and examination was done in a couple of minutes and I then had to pick what laboratory tests I wanted! That was quite easy as the lab only offer Hb (blood value), blood group and screen for safe transfusion, blood sugar, and malaria. The lab-tech was off for the weekend so I had to do the tests I wanted myself. I took some blood, found the keys to the lab and did the Hb (96 g/l) and blood group. I had never done it myself before, but it’s not rocket science: take three drops of blood on a white kitchen tile, add reagents, mix and see what antigens the patient carries. Open the fridge and see what the blood bank has to offer. Take your pick of compatible blood and do a cross check on the actual bag you choose and you’re ready to transfuse!

I did as we do at home and prepared the patient with two large bore IV-lines, checked my airway equipment (a laryngoscope, tubes, oropharyngeal airways, masks and bougie), prepared my drugs, made an action plan and backup plans, and put the tea-kettle on (that is, to get a bucket of warm water for the blood and IV-fluids). We were four people in the OT: myself, dr Wiji, an OT-nurse and an OT-assistant. Just then I suddenly realized that now I’m all alone as the only anaesthetist; no one to help or assist me, no one to fetch and find things or to set up and check the OT and equipment, no one to back me up or relieve me, no one to think for me when needed. I had trouble even reaching my cupboard with the stock of drugs and equipment as I had to manually and continuously ventilate the patient (the OT isn’t equipped with a ventilator).

The induction (with ketamine) was uneventful (dr Wiji injected and kept the cricoid pressure; it’s mandatory); but soon thereafter I got busy. The diagnosis was of course correct and there was roughly 2 liters of blood in the abdomen. I had from the ER given about 2 to 3 liters of fluid, but I reckoned it was time for another Hb: 59 g/l (low bloodcount)! The patient was still not so tachycardic (far less than 100 beats/min) and I still don’t understand why! Maybe his normal blood value was the original 96 g/l due to malaria and that I successfully transfused him to a normal volume but in so doing diluted him? He should still be tachycardic though!?

As you may well understand (and as I also suddenly understood): here I was aggressively transfusing, warming fluids, doing Hb checks, mixing and administrating drugs, maintaining anesthesia (with halothane using an OMV; thanks EDA-exam! (for the anesthetists of you)), checking vitals, taking notes of everything, and continuously ventilating the patient. As if that was not enough, I had to once set off to hunt down a mosquito!

Everything worked out and the patient woke up after the operation; he was a little (well, eh, actually quite extremely) tired and cold… The first I blame on me, my drugs (especially the halothane) and the temperature, the second was inevitable and I saw it coming; despite my efforts to keep him warm he had a temperature of (close your eyes at home!) 34.3 degrees! The next morning he was warm, stable and after another day ambulatory and eating.

After all that I have said its important to note that despite the basic standards and equipment the results are mostly like this case. Positive. For the patients who reach Teme alive nearly all stay that way and receive a standard of care not available elsewhere in the region, free of charge. Next week I think I’ll walk you thru the normal working conditions as they really are quite different from the laparotomy above.

Honeymoon is over!

september 29, 2008

They say that time flies when you are busy – well, in Port Harcourt time is supersonic…
I promised to walk you thru a day at work; why not start at the major source of work? On our daily bike-spotting on route to Teme we yesterday spotted a bike with six passengers – a single bike accident here can render more victims than an average bus accident at home!

We arrive at the hospital around eight and immediately start rounds. We are eight medical expats (five doctors, three nurses, and one physiotherapist) and we join forces at the hospital with national doctors and nurses. First the emergency room (ER) to see what has happened during the night; sometimes nothing (once!) but usually quite a lot. Next is the Intensive Care Unit (ICU), which is a little different from the ICU at home. To be honest, I don’t quite understand what is so “IC” about it, but there are more nurses around and they do their best to regularly take the vital signs of the patients. Sometimes corrective measures are initiated, but sometimes those actions are slightly suboptimal.
We next proceed to the wards; there are around 75 beds in three wards, separated by level of infection (green, blue and red). I do my best to assess pain and to adjust pain medications, but the work is sometimes just overwhelming. Besides, we have the current operating list to attend to (usually more than ten cases each day), and I must prepare and check the two operating theatres (OT).

For almost a week I was blessed by the company of dr Albert (we all go by first name here; I don’t even know his surname), a Canadian anesthetist whom I was replacing. The work didn’t seem so bad at the time, but when he left, and Paulinus (a local anesthetist nurse) was off duty for three days, I got thrown into reality. Please see the picture for the daily operating list; twelve patients of which four gunshot wounds (GSW) and the rest road traffic accidents (RTA). The fractures are typically quite complicated and many/most are open (with bone penetrating the skin). I won’t shock you with nasty pictures, but instead show a typical X-ray (maybe equally nasty…) of the lower leg after a gunshot. There have been a few days when we have not had any traumatic amputations…

Operating list

Gunshot wound

Most of the cases are done in a spinal (injection of local anesthetic in the back to anesthetize the lower part of the body), or sedation (which here is actually full blown anesthesia but with ketamine and thus (almost always…) preserving airway control). Complete anesthesia with intubation (airway control) is rarely needed (maybe once daily). Ketamine takes some getting used to (about half a day with the workload here…); the patients are in a dissociative state and can look up and sometimes talk (incomprehensible), but there is no pain or awareness, and the airway is relatively intact.

Well folks, that’s all for now! Next time I think I’ll tell you about my first laparotomy (abdominal operation) and how the OT is like.

First week impressions

augusti 29, 2008

Hello again!

It’s been more than a week since my last post, but I’ve actually only been three days on site in Port Harcourt. On route I spent two days of briefing in Paris and one day in Abuja; the capital of Nigeria. The trip was quite uneventful, although some aspects of the Nigerian culture requires some getting used to; when checking in at the airport for my flight to Port Harcourt, one could easily make the mistake of standing in the line to the counter marked “Check-in Port Harcourt”. Needless to say, when checking in to Port Harcourt you should of course stand in the line “Tickets Lagos”… But on the other hand the airport staff was extremely kind once my MSF status was known. I carried some orthopedic instruments, and when asked what it was I said they were for MSF and Teme hospital in Port Harcourt. The staff then greeted me, said I was welcome and made my airport troubles vanish. Even the security guy at the metal detector presented himself and said I was welcome; whatever MSF is doing at Port Harcourt, it must be good and the word has reached even Abuja!

So, how is the hospital, work, colleagues and patients? In my next post I’ll walk you thru a typical day at work, but I’ll give you a short tease of how the setting is:

Traffic is horrific (can’t think of any worse word, but if I could I would use that word instead); 5 (yes, five!) people on a single motorbike is nothing unusual (all barefooted with no helmets). Traffic accidents are thus a major and unlimited source of patients. Health care is extremely limited (or expensive) and local healers are commonly utilized. One patient came with an open fracture of the ankle that an healer tried to treat with a dressing soaked in feces; suffice it to say that the wound had some unmistakable signs of infection… Other sources are gunshot wounds, knife traumas, or just plain street violence. All patients are young; the oldest three patients I’ve had (out of 16 cases in my first three days) were 71, 53, and 39 years old; the rest being in their twenties.

These first days I’ve been struggling with TLAs (Three Letter Abbreviations), my English (which is not at all the English that people in Port Harcourt is speaking) and names (there are a lot of Miracle, Godsgift, Bigman, Precious, Lucky, and Friday; and should we really operate Saturday Sunday on Monday? Shouldn’t we operate him on Tuesday instead? Lots of confusion and a giggle or two…). For the anesthesiologists of you: Ketamine is now my drug of choice, an Hb of 55 g/l is not uncommon (or anything really troublesome; we don’t have much blood anyhow so there is no need/use of worrying), and despite what it says in textbooks an abdominal gunshot victim with an Hb of 59 g/l does not necessarily react with a tachycardia…

So much for my effort of keeping it short…next time I’ll try to throw in some pictures to lighten it up!

Getting ready for Nigeria!

augusti 14, 2008

Dear all!

This is my first attempt at a blog, but I’ll do my best in the challenge to convey my experiences and impressions from my six week mission with Doctors Without Borders, or MSF (Médecins Sans Frontières), in Port Harcourt, Nigeria. I’ll try to keep it short and down to the point so you surely can find the time to read it, but bear with me as this first post is a little longer! I’ll try to keep you updated every week, but I can’t promise anything. Also, please let me know how I’m doing and give me feedback for improvement!

When writing this first entry I’m still at home in Sweden. I’m working as an anesthesiologist at a university hospital (Karolinska Sjukhuset) in Stockholm, and I’ve been in the pipeline for a long time to go on a mission with MSF. Finally it’s becoming a reality and all my training and preparatory courses are done with.

The reasons for me to volunteer with MSF are not in any way complicated nor with a belief of doing something heroic or altruistic. I volunteer with MSF for the same reasons I’m working back home: with a strong wish of doing something meaningful and helping people in need. However, and in contrast with my work at home, I think my ambition will be much more condensed with MSF and the results hopefully more obvious. At home we have next to endless resources and there is always a fully manned and equipped team to help me if I need – this will not always be true in the field with MSF! I strongly sympathize with the ethics and charter of MSF (more of this later); but, again, I don’t see any fundamental difference from my humanitarian work back home or my coming work in Nigeria. It’s the same humans, with the same medical and humanitarian needs. Maybe I’ll soon find out how incorrect and naïve my vision is…

Now for some background so you’ll get an idea of the MSF world! My hospital at home has an annual budget of 1213 million Euro (yes, 1.2 billion Euro!). With those more than a thousand of million Euro there are 15000 employees that annually deliver 10000 babies, perform 60000 operations, and do 1.5 million consultations. MSF on the other hand has a total worldwide budget of 568 million Euro. However, in spite of less half of the funding, MSF manages to annually employ some 30 000 people in more than 70 countries, deliver 100000 babies, perform 64000 operations, and do 10 million consultations. Those already quite impressive figures become even more impressive realizing that much of the work is done in a setting with extremely poor infrastructure and social and/or political instability. I feel honored to become a part of that work, but before anybody at home gets mad I must also emphasize that I really value and cherish my work at home! My friends and colleagues deliver first class health care and they are all a great bunch to work with. After all, if that was not so, I don’t think I would be ready for my mission with MSF. Thus, gang at home: keep it up, you are the best!

So – what am I up to? In less than a week I’m off to Teme Hospital Trauma Center in Port Harcourt, Nigeria. I don’t have the setting 100% clear, but I think the expat crew will consist of me, an anesthetist nurse, a general surgeon and an orthopedic surgeon. Together with logisticians and coordinators we make a total of 10 expatriates in the mission.

The Teme Hospital is active in a very turbulent city with a large number of victims of violence. I’m told there are around 20 knife or gun traumas every week; the city also has its share of “ordinary” traffic, work and domestic traumas. I’ll describe an ordinary day at work as soon as I can, but I think I can safely assume that the days will be very long and extremely challenging.

Speaking of challenge; I conclude this first entry by stating my two goals of my mission, each of equal importance: first I’m determined to do my best. For sure I’ll have to learn, for sure there will be times when I feel insufficient or frustrated due to a lack of resources, knowledge, or energy. However, I’m determined to nevertheless do my best and to be able to say to my patients, colleagues, MSF, and (most importantly) myself that I always did my best. I leave it to others to evaluate if my best was enough; at least I’ll rest assured knowing that I can’t do better, no matter the outcome.

The second goal might seem unrelated, unimportant, or even irrelevant; but in reality it’s not: I’ll try to learn to juggle seven balls during my mission. Considering the expected workload and my determination towards the first goal, I’m sure I need lots of stress relief, rest and recreation; I can’t think of any better or more effective than try to improve my juggling skills! While I’m determined to fulfill my first goal, I will merely attempt the second – we’ll see how well I succeed in my mission!