Medicine is Hard & I Chose It

My first patient this morning was dying of gastric cancer.  The surgeon didn’t feel removing his stomach would extend his life.  Chemotherapy is limited in this country anyway but especially for the poor since everything must be paid for either by the patient or the hospital.  There was nothing to be done except have him see the social worker. 

Then just as my day was ending two young men came in from a motorcycle accident. Riding a motorcycle is very dangerous here; no one wears full clothing let alone helmet, leathers or closed toed shoes.  It is more dangerous with a passenger, in the rain, and it is worse if the driver his holding an umbrella in front of his face to avoid being pelted with rain (this came out later). 

The 16-year-old had a broken femur it was open but otherwise was okay.  He came through surgery fine after a few touch and go moments.  The driver was not okay.  He came in unresponsive pale and flailing.  Large abrasions to the trunk and legs, his oxygen was low, his blood pressure was low – initially normal heart rate then it got fast.  He had a flail chest.  The ultrasound show showed blood in the abdomen.  We rushed him to surgery and he died on the way.

We had no blood to give him – because blood has to be given on scene by a family member or staff and this takes time to match and draw.  Everything needed to be faster.  Only One knows if he could have been saved.  But I heard his wife crying.

The People Who Walk in Darkness

Over the last 2 days, Josiah and I have 2 very kind invites to meals at Bengali homes.  The first gentleman, Bemal, works with Josiah as a day laborer.   He is a skilled decorative welder who had owned his own successful business.  But now, as he repeated multiple times during dinner, he is poor.  His fortune stolen and his business pushed out by his neighbors who didn’t want a Hindu to be successful. His is a sad story but a generous spirit.

I watched him borrow the money for our dinner from another co-worker.  He led us to the edge of the market where he lives with his wife and 2 daughters. The floor was dirt.  One electric wire…that didn’t work the whole time we were there.  The roof was corrugated tin (which basically all roofs are in this area -- so much rain).  No windows beyond the holes in the wall and ceiling.  Dinner was by the light of a camping lantern, mango, grapes, and a Ramadan mix of specialty foods.  Gratefully, we did not get sick…though I fear we may have offended him trying to explain that we would get sick if we drank the water. 

Our second invitation was from a medic I work with.  His family was well established here until his three brothers emigrated to Michigan with his mother.  Now, the only family left in this country, he, his wife, and their 2 boys care for her father (which is a very important responsibility here).  She is an English teacher and we had a very nice visit over noodles, snack mix, cookies and coke. Since he had just gotten off of an overnight shift, I thought we should cut out visit short (only 2 1/2 hours).

Everyday

It didn’t rain today – or hardly at all – which is the first time in 3 days.  I should probably explain about seasons here.  Bangladesh has 6 seasons – a new season every two months starting (typically) on the 15^th. 

·         Greesho (Summer) – HOT!

·         Borsho (Monsoon Season) – starts tomorrow

·         Shawrawt (Autumn) – also hot and humid and everything molds (apparently)

·         Hemonto (Dewy Season)

·         Sheet (Winter) – 40s at night…sounds nice now

·         Bawshawnto (Spring)

Most mornings find me wandering down to the outpatient department with Josiah who goes up to the workshop in the new hospital.  Josiah is still measuring doors to get them hung…it’s a good thing he is detailed oriented.  It is still a challenge for me trying to remember the medications they use over here that are different and the different strengths.  I have, so far:

·         Diagnosed one case of typhoid fever (and she didn’t have a fever…so, I am not sure what to think :0)

·         admitted a 4 day old for high bilirubin (which is a problem here when it rains every day which it will essentially for the next 60 days)

·         seen a molar pregnancy (and the patient was basically bleeding to death from it)

·         seen congenital hypothyroidism (the pictures in the books are right!)

·         and treated a bunch of coughs and colds.

Cox's Bazar

So on Saturday (which is the first day of the work week for most people) I had the opportunity to go to Cox's Bazaar with a couple new friends.  Both were short term teachers for William Carrey Academy in Chittagong and having finished up their commitments came out to our area for a few days’ vacation before leaving for the states.

Cox's Bazar is home to the longest beach in the world; 120 km or 75 miles of beautiful, soft sand.  It was a beautiful slightly cloud covered day which is perfect for redheads.  The waves were consistent, medium sized waves but no boogie boards – oh the sadness.  The beach itself was nearly deserted, being Ramadan, and there were zero other women in the water besides myself and the other female teacher.  We swam (and body surfed) fully clothed and I think it was probably still a bit scandalous.

After this we wandered around two bazars which are basically like flea markets except that people run their booths year round.  The snack foods range from a little odd to downright startling.  I was given a piece of tamarind to try…wow, it was heavily salted and spiced and I declined to have another piece ;0).  However, we also went out to eat and they squeezed me fresh mango juice which was quite possibly the best thing I have ever put in my mouth.

Between the two bazars we caught a CNG (compressed natural gas vehicle) and had a very exciting time as we were hit by another CNG.  PTL they were both steel construction and the worst injury was a bruise.  On the way to the restaurant, my new friends insisted we take a rickshaw so we did – segregated by sex of course, with the male teacher in his own rickshaw.  (I was informed that sometimes you can put three people of the same gender on one rickshaw with the third person balanced in the middle on the other two’s laps….hmmm.) 

And then, finally, to get home we took the bus and I swear the bus driver was nuts – passing on blind corners, squeezing the bus between to other smaller, more vulnerable vehicles, and, yikes!  I spent a week’s worth of adrenaline.  Only by His grace did we avoid a head on collision or other fatal accident.  As it was we hit one person and ironically, it was not the driver’s fault as the man walked into the front left corner of the bus.  We didn’t stop.  The value of life here is lower in general and varies based on gender, social status, and age.

A Typical Day

A Typical Day

Things move at a more relaxed pace here and this is accentuated right now (I am told) because it is Ramadan.  During Ramadan most do not eat, drink, or even swallow saliva during the day and feast at night.  Some are excused such as children, pregnant women, the elderly and infirm but many choose to keep the fast regardless.  (My first patient was a woman 9 months pregnant who was having intermittent contractions…my theory is from dehydration.)  This change in daily schedule means that people are less apt to come to the clinic and businesses close early. 

But even when it is not Ramadan the daily schedule looks like this:

Hospital rounds early in the morning (which I do not do)

Outpatient Clinic: 9:00 to 10:00

Tea: 10:00 to 10:30

Outpatient Clinic: 10:30 to 12:00

Lunch: 12:00 to 2:30 (and no one comes back early)

Finish up the day: 2:30 to 4:00

Tea: 4:00-4:15

(Ah, the power just went out as it does regularly (I do not use my computer plugged in because I am scared of frying it with a power surge).)

So far, my first morning was the busiest.  In an hour I saw about 6 patients – the nurse sure kept me busy.  But it didn’t even seem rushed because of the way they use their “medics” which function in limited way similar ways that physician assistants function in the US.  For me they are invaluable because I simply do not know what is available.  For example, I saw a young boy with a second degree burn on his foot.  In the US, we wash, update tetanus if necessary, bandage and instruct on use of sulfadiazine.  Here they check a CBC and Hepatitis B, have physical therapy wash the wound – he comes back to the doctor who checks it and the medics bandage and instruct on use of the cream and when to come back for a recheck.

Power is back – thank goodness!  The fans keep me sane.

Weekend!

The weekend is here! (If you have a calendar handy and a chart of the various time zones you should be thinking something like, “Alisha has finally lost her mind – the most it can possibly be is Friday.”  And you be absolutely correct – especially about the Friday part, the mind part is still at least partially debatable.)  The Banglaeshi weekend is Friday and Saturday, with Friday acting largely like our Sunday.  So all the activities you think about as being on Sunday happen on Friday here and Sunday is like Monday… confusing but true.

Yesterday I got to take a tour of the new hospital!  Josiah also came but since he has been on the job site regularly it was significantly less exciting.  The new hospital is four stories tall with a useable roof with helipad.  Additionally it has weight bearing pylons extending through the roof for expansion.  From the roof you can see the hill country (the foothills of the Himalayas).  These are where the tribal peoples live including the Mru, Marma, Chakma, Tripura, Khummi, Khyang, and Tangchangka tribes. The saying is around the hospital is that if a Mru comes to the hospital and you can’t find anything wrong keep looking because “they are tough as nails”.  Example: A 22 year old woman, 20 something weeks pregnant, walked one day and traveled two more to make it to the hospital. Her hemoglobin was 2.4 (we automatically give blood in the states under 7 and normal for a woman is at least 11-12).  And she was walking…but I digress.

When completed the hospital will have 152 beds, including PACU (post anesthesia care unit) which right now essentially non-existent, 8 surgical suites, an Emergency Department, a small NICU, and once funds are provided, a CT scanner.  The hospital will continue to do its own laundry, will handle its own waste water, and incinerate its own medical waste.  Many people have sacrificed so much for this project and it is finally nearing fruition.  They hope to be completed in a year but there are still many challenges and needs. 

The Compound

Around 1960, while Victor Barnard was working among Bangladesh's tribal peoples his daughter, Mary, fell gravely ill and desperately needed a surgeon.  But there wasn't one for 400 miles (until Dhaka) and Mary did not make it. 

Thus, in response to this need the hospital was established, fortuitously, in 1966. This was just 5 years before Bangladesh’s war for independence from Pakistan (which everyone refers to as “the War” and looked at me blankly when I asked which one).  Between May and December, when Pakistan surrendered, millions of people lost their lives and many became permanently disfigured due to land mines. During the war, many of the doctors sent their families home and stayed behind to treat the wounded, for which the community remains grateful.  The hospital still has a talented prosthetics department which can make prostheses for about $20 which is insanely cheap.

The war left behind many widows and orphans, with essentially no way of providing for themselves, and this is why the hospital has a craft shop attached to it named Heart House.  About 40 ladies still work at the house making dolls, blankets (they claim there is a cold season :0), small hand crafts, and salwar/kamiz and saris (traditional dress with the mid abdomen showing).

The original hospital and outpatient clinic, where I have spent most of my time (no babies for me yet), are sizable but the new facility is downright impressive.  Josiah will be heading over there later today to measure doors so they can match the doors to the various hinge and handle heights (no standardization here :0).

Total, I would estimate the size of the compound at between ½ and ¾ square miles.  It houses about 18 families and singles who work at the hospital along with a primary school, health sciences college, and various other outbuildings. Just like the country of Bangladesh, no space is wasted and everything used to serve well.