Part 2 – Work (read part 1 here)
My first night has been warm and humid. My only cover is a sheet and even that is too warm. My pillow is soaking wet from my sweat. The team before us bought in ventilators with one of these miracle machines placed in each tent and they give at least some respite from the heat. It is only four o’ clock in the morning, but I’m wide awake. I don’t know it yet, of course, but this is going to be a permanent feature: Early beds and up at sparrow’s fart. I take a quick cold shower (warm showers are not available right up to the end of my stay) and then we eat breakfast just after dawn at 6.30 am (again rice, with eggs or every now and again some meat) and then the first bus leaves for our field hospital at 7.15 am. ICRC rules are strict: No delegate is allowed to drive, all transport of personnel is done by well-instructed and carefully selected drivers. The reason for this is, of course, that most injuries and fatalities among delegates on international missions are due to traffic accidents. As for my other worries, by the way: The NPA has declared a cease-fire and is nowhere to be seen; there is absolutely no looting, and I haven’t seen any spiders or snakes yet. The dengue mosquitos, meanwhile, are kept at bay by abundant layers of insect repellent. I feel a bit stupid now for worrying at all, but I quickly decide to blame it on the jet-lag. No reason to suffer unnecessary dents in my self-confidence at this early stage. By the way, there is no Malaria on Samar and I choose therefore not to take any prophylaxis.
The ICRC field hospital is located in a basketball hall right at the waterfront in Basey. When the wave hit it knocked out all the walls, but the concrete pillars and -most importantly- the roof are still in place. It gives protection both against the sun and the rain. A perfect location really. A lot of people parked their cars inside the hall before the storm assuming that they would be well protected. When the walls came down, the hall turned into a giant washing machine tossing cars and rubble around for the duration of the storm. The hall was cleared in record time (again, the Philippinos don’t exactly sit on their hands).
The battered cars are still neatly parked round the hospital. The hospital consists of inflatable tents, mostly. There are two ward tents, one for adults and one for children. Mixing men and women in one ward is an acceptable solution in the Philippines. There is an emergency tent and an outpatient tent. When the hospital opened in the middle of november, there were between 200 and 300 patient consultations every day. Interestingly, surgical patients represented only a small proportion right from the start. The people who lost their lives in Yolanda mostly drowned and there were relatively few injuries. Respiratory problems, particularly in children, represented a large patient group, due to the damp conditions after the storm and the rains. The hospital ran quickly out of nebulizers, but everything is resupplied now. There is one tent for x-rays ( a simple, traditional x-ray machine) and an operational theatre (OT) which will be my working place. There is also an administration tent and yes, in case you wonder, admin people are needed in emergencies, too. In fact, very much-needed and doing a great job.
My first day will turn out to be very different from what I expected. The surgeons who were there before me had started operating lumps and bumps (essentially benign skin and subcutaneous tumors) and while they probably only had a couple of these every day, word has spread by now and there are between twenty and thirty patients in the outpatient department eagerly waiting to get their little embarrassments removed. There is just no way that we can treat so many. Basically, opening up for lumps and bumps in a population which has had only basic surgical services for many years is like opening Pandorra’s box. I have no choice but to close down this flourishing business that basically boils down to cosmetic surgery. So on my first day I have to send a lot of patients home disappointed. Not a good start.
But there are enough patients that really need surgery and who will not get treatment anywhere else unless they pay for it. The sums charged by the public hospitals for even basic surgery in this country are usually well beyond the means of the poor. And the poor are many. In Leyte and Samar between 30 and 40% of the population earn less than 17 000 pesos (roughly 380$) per capita per year, while the price of a hernia operation is just shy of 400$. So we do hernias – at least one a day- operate cancers and do hysterectomies, do wound dressings and skin transplants. A lot of the operations I have to do aren’t exactly my daily bread at home, but if I don’t do it, nobody will. I’m not in my comfort zone, but then again, a steady hand, a solid knowledge of anatomy, a good team and some googling every now and again gets you a long way.
I had done some caesarean sections together with the gynecologists back at home and the lessons pay off. I get to do three during my stay and all 6 patients, mothers and children, left the hospital alive and in good health. Monica, our midwife from Østfold in Norway, and quite an outspoken representative of her trade, asks me before the first cesarean: ‘Are we going to do stuff now that Sven can’t do?’ ‘Cheeky bugger’, goes through my mind, but we quickly agree on a policy which would prove to be an unmitigated success: Monica is going to cheer me along during the first part of the procedure and will then take the baby away from me as quickly as possible. Easy! It is good to have her there.
Speaking of the team: I cannot praise the surgical team enough. Both the local and the international OT nurses are fantastic. And then there’s Kirsti, the anesthesiologist (the one I travelled with from Norway), who is just plain wonderful. We don’t have a single disagreement during our tenure (the like of which has never happened before in the history of surgery and anesthesiology) and in the end we are so synced that we even order the same meals at restaurants. And, most importantly, we don’t lose a single patient due to surgery or anesthesia.
But we do lose one patient despite the surgery. It is my second night in the camp, when one of the drivers wakes me up. Communication between the camp and the hospital is really bad, so the doctor on-call at the hospital often has to send out a driver at night to alert the surgical team. When we get to the hospital we find Barbara, our GP from Australia, in a bit of a sweat and compressing the wound of a young man who has been badly mauled by a machete and who is bleeding profusely from a head wound. We do the emergency surgery at night to stop the bleeding and some more reconstructive surgery the day after, the head wound isn’t by far the only one. But he has lost too much blood and we don’t have a blood bank or any other means to do transfusions. His lungs and his breathing take a turn for the worse and we have to transfer him to Tacloban, because we don’t have any ventilators either. We later get a report that he died the same night. It is another lesson learned: Although we can achieve a lot with the means at our disposal, our resources are limited, and patients who would have survived back at home, will not make it here. And that’s just the way it is.
There is a lot to learn and a lot to get used to. Being an experienced surgeon at home is a very different thing from being an experienced surgeon out here. I am fortunate to meet Roland at our hospital, a Swiss doctor from Zürich, who is deployed as a GP. But Roland has also been a surgeon for over two decades and he’s worked in Lesotho for a couple of years. So he knows what surgery is like under conditions that are very different from home. During the week we get to work together I learn a lot of the tricks of the trade, what I can do and what I shouldn’t do and how to make the most of the resources at my disposal. These are invaluable lessons and they can only be learned in the field. The increasing subspecialisation at home will lead to a lack of real generalists in the future. And it is generalists you need out here. In my opinion, every surgeon who goes on a first mission ought to get the opportunity to work with a colleague who has been on many missions and for at least for two weeks. A lot can be taught and learned in two weeks. Roland left for Switzerland a week after my arrival, but I can honestly say that I made the most of the time we were in Basey together. He also taught me how to operate cleft lips. Although one could argue that this is cosmetic surgery, too, it is certainly a life changer. It will make it much easier for these kids to find a partner later in life. The surgery takes only fifteen to twenty minutes, but you have to move fast because of the bleeding and the anesthesia is probably the most challenging part. Again, Kirsti did her job superbly. For the week and all the things I learnt, thank you, Roland!
Back at the camp things have started to turn sour after a couple of days: The sun is gone and the rain is back, and it is back with a vengeance. For the average European, I feel I have to come with some specifications about the term ‘rain’. Even if you are from Bergen, you cannot possible imagine what I’m talking about. Picture the kind of rainfall we get every now and again on one of these hot summer days in Europe, when it can rain pretty intensely for about twenty to thirty minutes. Ok? Well, then imagine that this kind of rain just won’t stop, but instead continues 24/7 at the same intensity. This is the sort of rain we are dealing with here. We find it hard to fathom where it all comes from. After a couple of days most of my clothes are wet and so are my sheets. My pillow has started to rot and my flip-flops which used to be black have definitely turned green. For a while I entertain the hope that it might be one of these exotic alghes which light up in the dark which would make it much easier to find the flip-flops in the dark. But it is not and since the smell which comes with the change of colour isn’t too cool either, both the flip-flops and the pillow have to go. Elisabeth, one of the nurses from Oslo, finds a little tree in her shoes, which she had left unattended for a couple of days. In the evenings we huddle round the tables under the sun shelters to eat our meals. In just ten days we get over one meter of rain and for the first time in my life I go to the drastic step of buying an umbrella. One has to know when to admit defeat.
The rain is bad enough, but as the wind increases and bigger waves start hitting our little beach and the tents, it becomes obvious to everyone (even the ICRC) that our lives as happy campers have come to an end. Alex, our Croatian (soon Icelandic) technician and quite a character, cuts through the crap, and -with the help of a bunch of Philippino carpenters and some plywood turns the conference room of the hotel of the resort into a row of little rooms. The roof has been repaired and for the first time in a long time we are dry. Although plywood isn’t exactly sound proof and snoring is an issue, we feel like kings and queens in our 1.5 x 3m luxury suites. Life is good!
To be continued