More than just a T-shirt by Freda Newlands

This time last year I was in Jordan working as a doctor in Emergency Medicine with Medecins Sans Frontieres. Now, back in the Emergency Department in NHS Dumfries & Galloway, I have had time to reflect on choice, selection and how this affects our lives. I have had the opportunity to exercise and walk as much as I wish and sometimes I make excuses not to; it’s my choice. It’s curious how much we miss something when we are suddenly denied the opportunity.

Walking, walking obsessively walking. Since I left Jordan I have walked and walked and walked. I joined my son for about 125km on his Rhine-long walk from Switzerland to Rotterdam, I walk almost 10km daily near home, park the car in the furthest space from the hospital door, walk to buy the newspaper ( 5km ) and hiked in Andalusia, Arran, Tuscany and the Lake District. So grateful am I for my legs and the freedom to use them. The irony of my freedom to walk across Europe with no restriction unlike the felling refugees has not eluded me.

I had walked past a stationary treadmill in the expat house in Jordan at least twice a day for 8 weeks after I arrived in Ar Ramtha but I have allergy to indoor exercise, I mean, why would you do that when exercise is free, right outside the front door?

But then I was in Jordan, where security was an issue at our emergency mission, just a couple of kilometres from the relentless fighting in Syria. We couldn’t forget it, we heard the barrel bombs dropping and witnessed the Syrian people arriving in the emergency department as soon as they were allowed through the border to be treated. Not only had these people lost their homes, families and future, but also their immediate freedom.

Their limbs lost or severely injured, they were treated by the surgical and orthopaedic teams and nursed with tender compassion by the local staff. It didn’t seem very long before these brave people were demanding to go to our step-down rehabilitation ward as they had heard that there was fun to be had, children’s chatter to lighten the atmosphere and general camaraderie to enjoy.

Posters and slogans written in brightly coloured paints share hopes and fears encouraged by our amazing mental health team without whom the healing would take longer.

Occasionally we almost gave up hope for very ill patients, struggling to hold on to life in the intensive care unit (one bed) but then I must tell you about Ahmad.

He was delivered to our Emergency Department on a cold day in January, intubated but with no oxygen supplied to his fading body. His tiny teenage frame, bleeding from the traumatic amputation to his right leg, hardly breathing, fading fast.

We worked hard to resuscitate him and despatched him into the care of the surgeons. Long hours and careful surgical attention gave him a chance of survival and so he was admitted to our one bed intensive care unit. Tirelessly, our anaesthetist and ICU nurse looked after him and tried hard to wean him off his sedative cocktail. Without incubation he didn’t seem able to breathe alone and his oxygen saturations dipped too low for life. With some determination, he shook off urine and sputum multi-drug resistant infections (Acinectobacter Baumonii ) against the odds and eventually survived a tracheosotmy as he had been intubated really too long.

He was moved to the ward and nursed with kindness and great care. Slowly, he began to respond to touch and words and finally opened his eyes and could respond with eye movements. He soon became our most visited patient with every caller giving him extra care and attention. We were worried that his nutrition wasn’t enough through the naso-gastric tube so another surgical procedure was endured to insert a feeding tube into the jejunum.

This he tolerated and fed well.

Everything seemed to be improving, Ahmad was responding to everything appropriately.

I even began to contemplate assessment of his ability to swallow and thought that I might cautiously see whether he might manage without the tracheosotmy. Caution was surpassed by an over-enthusiastic relative who gave him a sandwich… he didn’t choke, the sandwich stayed down and Ahmad thoroughly enjoyed it, smiling from ear to ear!

All previous procedures were reversed and we watched in amazement and awe as Ahmad breathed through his mouth and nose, drank and ate freely, smiled and then, spoke our names.

He went from strength to strength, our miracle patient. Soon to be caught outside in the sunshine, sitting in a wheel chair initially but finally getting a lower limb prosthesis. This young man, given up on by some, given a chance by MSF, would yet again walk. Indeed we both left Jordan within a few days of each other; Ahmad desperate to go back to Syria and me to return to Scotland.

I tried that tiresome treadmill for a couple of weeks and quite enjoyed the challenge of a ‘bit of a work-out’. Then it broke and I felt quite cheated – never satisfied eh?

At least I have the freedom to choose.

http://blogs.msf.org/en/staff/authors/freda-newlands

http://blogs.msf.org/en/staff/blogs/syria-crisis/i-can-smell-syria

http://www.msf.org.uk/

Dr Freda Newlands is a Clinical Teaching Fellow in Emergency Medicine at NHS Dumfries and Galloway

A Journey to Africa by Dave Christie (@bagheera79)

At a little half past eight in the morning on the 25th of November last year I started on the ICU ward round with the team of residents, at the Black Lion Hospital in central Addis Ababa – the capital of Ethiopia. There were sixteen patients to see, with a high proportion of trauma – especially brain injury – and severe life-threatening infections. It looked so different from the unit here in Dumfries. It had big wide windows allowing in daylight, for a start. In a UK hospital, windows at this height would be securely fixed so as to avoid the kind of unfortunate incident that makes the headlines. Here, in Addis, one of the nurses was leaning right out of the window and yelling cheerfully to a colleague in the carpark over a hundred feet below.

As I looked around I took in more differences. The beds were quite close together, with a low wall separating the heads of beds between the divided area. Instead of uniform ranks of identical equipment all bought at the same time, the pumps and ventilators were a mishmash of ancient and relatively modern kit. Huge, head height tanks of oxygen sat beside each ventilator, as there was no built in oxygen supply in the walls. Beside most beds sat a big bottle of caramel liquid – it took me a moment to work out that this was nasogastric feed. Of course! – they don’t have the pumps to delivery a trickle of feed continuously, so they have a supply for the day and administer it at intervals. Each patient’s bedsheets were different, brightly coloured, and obviously donated or brought in from home. Nobody was wearing aprons, or gloves – the bright smurf blue and purple hands of healthcare that are so ubiquitous in UK ICU were nowhere to be seen. I could imagine our own infection control team spontaneously combusting at the sight. Of course, they would likely have already lost consciousness at the sight of an entire team of doctors standing around the bedside in long-sleeved white coats – something which has been verboten in the UK for years.

But then, I looked closer and readjusted. Put into context, they were doing the same stuff we do. Airways were protected. Patients were being rolled, washed, and cleaned every day, with a change of sheets. Physiological parameters were being diligently recorded on big charts in close detail. Because pumps were usually either broken or in very short supply, sedation and analgesia were given by injection at regular intervals. They were being fed – one way or another. Patients were receiving regular chest physiotherapy to try to shift stubborn sputum and prevent pneumonias. Blood tests. The nurses still laughed and joked and teased each other. It’s the same stuff that we do, but in a much simpler, less precise way. And, a lot of the time, it worked. Which, to be brutally honest, is just as true of our own, ‘modern’ intensive care.

I turned my attention to the lady in the bed. Clearly profoundly affected by a severe head injury as a result of trauma, she also had signs of a severe chest infection. Here in the UK, it would be standard practice to send sputum samples off to the lab to identify the offending organism, certain specific blood tests might be done, and a chest x-ray would be a routine investigation in order to see the extent of the infection. I asked if they could do any of those things. Dr. Woubadel looked at me with a wry, slightly sheepish smile. “Well, we can. But we only have two antibiotics and our microbiologists have refused to analyse our sputum samples. And the lifts are out at the moment.”

Right. Wait, what? “You only have two antibiotics?”

“Yes, ceftriaxone and ceftazidime.”

If you don’t speak antibiotic, that’s a little like going to the supermarket and discovering that the only two cleaning products available are napalm and a hydrogen bomb. Given that antibiotic resistance is a real and growing threat, this is a disaster for the future.

And the lifts…. ah. The building of the Black Lion is definitely a little bit past its best, and was undergoing a phase of refurbishment. Almost all of the lifts were removed and in true, relaxed Ethiopian style, there was occasionally a warning sign. I had had a look at one of the lift shafts and it really was an open door onto a seven storey drop. Later that day, I watched a patient being taken urgently to theatre from one of the wards on the floor above the theatre complex. Four orderlies and a nurse were carrying the entire bed – with the patient lying on it – down a flight of stairs. Another nurse was carrying the drip. That morning, if they really wanted a chest x-ray, they’d have to do the same thing if the lift was out as there was no portable facility to take x-rays on the unit. And if need be, they’d have done it.

So why was I there? It’s worth pointing out that the Black Lion is a large teaching hospital in the city centre. It’s one of the lucky ones, as the facilities it has are relatively modern. They can even do cardiac bypass – provided there’s a visiting perfusionist from overseas to work the machinery. This definitely wasn’t one of the small hospitals out in the country. I was there along with Fanus Dreyer, a consultant in General Surgery here in Dumfries, to teach on a critical care course that he organises. The College of Surgeons of East, Central and Southern Africa overseas the training of surgeons in that part of the world, and the critical care course is part of the mandatory requirements of their training. It is a charity – the aim is to make the course (along with the others which deal with surgical skills, and research) self-sustaining in each of the involved countries. The idea behind all of this is to try to improve the healthcare in that part of the world, by standardising surgical training, ensuring basic competencies etc, in an area where healthcare is sporadic and frequently poor or non-existent. Peri-operative and critical care is a vital part of that – being able to competently do an emergency bowel operation is nothing if the patient dies post-operatively from a lack of care.

Being out there and teaching on the course was an extraordinary experience. Having had the chance to spend some time in the actual clinical areas, to see how they worked on a day-to-day basis, helped hugely as it helped give me direction on what the course attendants needed. The junior surgeons on the course had excellent clinical knowledge and ability – the real difference was the approach. They have the same knowledge as our junior surgeons – medicine is universal, fundamentally – but what they needed was guidance on how to organise the approach to sick patients, and how to structure their management. They were highly motivated, and very keen to learn. But as I knew, they would often be working in facilities that had next to zero resources, hundreds of miles from Addis. There’s no value in teaching about the potential uses of dialysis in critical care in that sort of scenario – but there is enormous benefit in teaching about the approach to sepsis. Being able to manage a patient with a critically endangered airway with simple techniques would be life-saving – even in the most rural surgical facilities there will be some sort of scalpel.

And over the two days of the course, in the four days that I spent there, I realised that the simplicity of approach is something that we are still striving to teach here, even with the advanced facilities available to us. Their ICU looked primitive in comparison to the UK, but it was still striving to provide the basics of critical care. I realised I was teaching the same things that I teach here – sort out the basics and communicate well. Recognise illness, recognise dying, and treat each thing in turn, with compassion. These things are universal – and we shouldn’t allow a distraction with technology to cost us our humanity.

 Dave Christie is a Consultant Anaesthetist at NHS Dumfries and Galloway

Three generations of surgeons, born in the wilderness by @fanusdreyer

Olifantshoek

Olifantshoek is a small town in the south-east corner of the Kalahari desert, in a “poort” where a seasonal river flows through. Seasons here are measured in years or decades, not months, but there is enough water so that the town dam only occasionally runs dry. In the Northern Cape and southern Namibia children regularly get to school age without ever having seen rain. In the 1920’s my grandfather was the Dutch Reformed minister in Olifantshoek.

One day in 1922 granddad travelled to Bloemfontein for the church synod. He was a bit of a technophile so he was one of the first in the region to own a car, although he did his parish visits on horseback due to the roughness of the terrain. After the synod he gave a lift home to a Rev Brink from Danielskuil, another small town on the edge of the Kalahari. They got to Danielskuil late afternoon, granddad was treated to an evening meal (the Brinks have always been superb cooks) and offered a bed for the night. He declined as his wife was nearing the end of her pregnancy and he wanted to get home that night. Rev Brink knew of a shortcut along farm roads but this had lots of gates to be opened and closed. He then offered that his six year old son could accompany Rev Dreyer, show him the shortcut and open and close the gates for him. Granddad gladly accepted and they got home by 1 am. And so it was that my future father-in-law helped my grandfather get home to my grandmother, who was expecting my father’s birth any day.

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Dad grew up during severe drought and the Runderpest in the 1920’s Great Depression; the only animals still alive in Olifantshoek were donkeys. It was so dry that grandma had to send a bottle round the streets; everyone who had a little bit of donkey milk to spare would put it in the bottle so she would have just enough to feed a future ground-breaking surgeon.

In the 1950s Dad helped to develop potassium cardioplegia for open-heart surgery while working with Sir Ian Aird, got married to Mum in Edinburgh with Dr Davidson (of the internal medicine textbook) as best man, then went back to Cape Town where in 1958 he did the first technical successful heart transplant in the laboratory by swapping two dogs’ hearts; they lived three days until rejection set in. He was invited to join Dr Willem Kolff (who had built the first dialysis machine) in Cleveland, Ohio, to work on the first artificial heart programme. On his return to Cape Town he went back to general surgery because he thought heart surgery was too boring.

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First patient, and a decision

It was 1975, somewhere in Southern Angola. I had decided to go for national service because I was not sure what to study. We were pions in a West-East imperialist war for future control of Angola’s riches. We drove into the ambush at dusk and James took a bullet through the ankle. Mark, James and I were lying under the same truck we were in 4 hours earlier. Angolan rain was no joke. We got his boot off; his ankle was getting bigger by the minute, and blue. We had no idea what to do, so gave him 4 Codis tablets and wrapped the ankle so we wouldn’t see the dark blood seeping through, but it looked like toilet paper on a stick. If only we had a proper medic.

The codeine-aspirin combination did not help much for James’ pain, but it made him talk. There was nothing more we could do, but lie next to him to keep him warm. And whisper. The sergeant was on the radio, trying to get an air evac. We knew the chopper pilots would not fly tonight, maybe drunk again. They’re sending an ambulance which will take hours, the road is mined.

At first light the ambulance arrives. James’ leg looks like it will fall off any moment. “Thanks boys” he says, “you’re good to sleep with”. “See you” we said.

We never saw him again but heard that the army doctors saved his leg. “Good outcome” they said. A stiff ankle gets you an honourable discharge for medical reasons. Not a good outcome for a champion 800m athlete. On an Eastern Cape farm you can ride a horse or pick-up truck; there’s no need to run.

The next week I got a message to Dad: “Please confirm that place in medical school, forget engineering”. It took me another 20 years to understand that often we can do nothing for patients except offer them comfort.

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Malawi boy

It is 1985. Every time I looked at her, she seemed more uncomfortable. Her legs were more swollen every day. Pre-eclampsia is not easy in the tropics but maybe it’s not easy anywhere. It was too late to fly her out to South Africa. After the scare with premature labour at 32 weeks she was not flying anywhere anyway. She was now 38 weeks, “so we made it” we thought. Our baby was going to arrive in a small mission hospital in Nkhoma in the Malawian bush. “Time for an induction”, I said, without thinking much of informed consent. Working amongst so much extreme poverty did not give time for reflection.

With the senior midwife we started her on Pitocin on the Saturday. No contractions followed and the cervix was not yet ready. Should we rupture the membranes or wait? We decided to wait 48 hours.

We tried again Monday morning. By now the blood pressure was borderline high and there was 1+ proteinuria. If the induction fails today she would need a C-section. “Who will do the Caesar”, the midwife asks. “I will” I say, “after all, the others ask me if they have a problem case”. This time she responds well to Pitocin. Within an hour she has good contractions and the membranes rupture spontaneously. I feel for a cord but there is none. Four hours later she is fully dilated. She has a lot of pain. I’m too brusque, so focused on being a doctor that I forget to be a husband and expectant father. She has a boy, 3460g, Apgar score 10/10. I suture the episiotomy; she’s embarrassed. “Don’t worry” I say, “nobody will do this better”.

That night we all slept in the same hospital room, our new son with his mother, our two year old daughter and I on a mattress on the floor. We shared a bathroom with an AIDS patient with resistant malaria, the first HIV positive patient diagnosed in our small hospital.

Today he is 30, has taught in Africa with me, and recently we shared working together in Dumfries. A few weeks before he was born I went to an East Africa surgeons’ meeting and heard Dr Imre Loeffler speak, a Hungarian-Austrian surgeon who gave his whole life to surgery in Africa. He said that a first class surgeon could operate in a hammock slung between two palm trees on a beach and have better outcomes than a second class surgeon working in the most modern theatre. A few months later, when in South Africa to show the new boy to the family, I went to see the prof to get a training post. I started one year later.

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Full circle

Before starting surgical practice in 1992 in Upington, the main town of the Kalahari, I went to see GPs in the region, and that took me to dr Jan Meyer in Olifantshoek. He promised to support me. After our meeting I thought to try and find the old Dutch Reformed manse where Dad had been born 70 years before. Dad’s brother had told me that the building commission drew the house plan in the dust with a stick, and according to that the building started. Now there was a new church and manse, and I opened the gate with the “Pastorie” sign, rang the doorbell and asked the young inhabitants if they knew where the old manse was. Nobody knew. I walked dejectedly to my car and, as I started the engine, an old man walked past; he looked part-Tswana, part-San. I rolled down the window and asked him if he maybe knew where the old NG Kerk Pastorie was. “Oh I know exactly where it is”, he said, “it is the house with a wind pump in the back garden”. I asked him to take me there and he got in, moving very slowly because of rheumatism. It was two blocks down, around the corner in a dusty street, a small little square house, still with a wind pump in the back garden, watering all sorts of vegetables and maize patches. I got out to take a picture. The owner came out and asked what I was doing. When I said my father had been born in the house he showed me round. Afterwards I drove my guide to his house in the old African township and I asked him how he knew the house. “When I was a schoolboy, I used to work there on Saturdays for a Reverend Dreyer”, he said; “He paid my school fees. If it was not for him I would not have been able to read and write”. I stopped the car and we both shed a tear for this generous and humble man whose names I wear with pride.

Jan Meyer kept his promise. The first patient I operated on after setting up practice in Upington was an elderly diabetic from Olifantshoek. His father was the lead elder when my grandfather was appointed minister. Granddad did his catechism and I took out his gallbladder; it was beginning to become gangrenous, typical of a diabetic.

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My father and my son have surgical dispositions, much more than I could ever have. When the boy was working in Dumfries, staff kept telling me how he was becoming more like me. That was only half the truth as I was also learning from him. It is when the son not only emulates the father but the father subconsciously starts to emulate the boy that the relationship becomes complete, like my 93 year old father has become dependent on our conversations as much as I once needed his advice. And so we live and learn, love and one day die, in sync and at peace.

@fanusdreyer

http://www.albacccd.com

Global Surgery, Public Health and MDGs by @fanusdreyer

@fanusdreyer chairs the International Development Committee of ASGBI, is a member of Edinburgh University’s Global Health Academy and of the WHO’s Global Initiative on Essential and Emergency Surgery.

What is the primary care of obstructed labour, or a cleft lip, an imperforate anus or other birth defect? In the mid-1980s I worked in a small mission hospital at Nkhoma, Malawi as a medical officer. One day a boy was born with imperforate anus. It was the rainy season and there was no way he could be sent to the city. So I looked in the book how to do a defunctioning colostomy in a newborn, gave him ketamine and did the operation. Afterwards he stopped breathing every few minutes but started again when we flicked the soles of his feet. Our few incubators were all in use, each with three prem babies inside. So, over lunchtime and while the nurses kept our baby breathing, I built a wooden incubator, with plastic sheeting as a transparent top. That way we could give him oxygen, put two warm water bottles next to him and keep watch. I sat with our boy through the night, stroking him and flicking his soles so he would breathe, until the ketamine had worn off by the early hours of the next morning. He left hospital a few days later, ready to wait for the Canadian paediatric surgeon who was visiting a few months later. And I learnt that surgery can be primary care …

The declaration of Alma Ata (1978), which is a cornerstone of WHO healthcare states in section VII.3 that primary health care “includes at least: education concerning prevailing health problems,…maternal and child health care, …appropriate treatment of common diseases and injuries.” What place then for surgical conditions within “prevailing health problems”?

Of the global disease burden 11% needs surgery, mainly due to injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%) and peri-natal conditions (4%). Only 3.5% of 234 million annual surgical procedures worldwide are performed on the poorest 33% of people, but 80% of surgical deaths occur in low and middle income countries (LMICs). About 800 women die every day due to complications of pregnancy and childbirth e.g. obstructed labour, haemorrhage, sepsis, uncontrolled high blood pressure and unsafe abortion, i.e. mostly conditions that can be managed surgically. A significant complication for mothers who survive obstructed labour is obstetric fistula, which means that they are continually wet, smell badly and are ostracised by families and communities. With appropriate training fistulae can be repaired by non-doctors.

 

In non-communicable diseases (NCDs), the diseases of “rich countries” e.g. diabetes, vascular disease, hypertension and cancer, the highest incidences and mortality are in LMICs. The WHO expects 16million cancer deaths by 2020; 70% of these will occur in LMICs. Worldwide 5.8 million people die yearly from injuries, which is 32% more than from malaria, TB and HIV/AIDS combined. That means that 2300 children die daily from injuries. Road traffic crashes are responsible for 23% of all injury deaths, with 20 injured patients per fatality, reaching epidemic proportions in sub-Saharan Africa (50/100000 vehicles compared with 1.7/100000 in high income countries).

Household surveys in Rwanda and Sierra Leone have shown that the immediate surgical need is higher than the HIV rate, that 15-25% of respondents had a surgical need in the previous year that affected their ability to earn a living or their quality of life significantly, and that 25% of household deaths in the preceding year were due to surgical conditions.

 

The Millennium Development Goals (MDGs) have to report in 2015. At present there is a worldwide review of what global goals should replace the MDGs, with the WHO, the Gates Foundation and other philanthropic institutions all recently asking for submissions. The problem is that only MDG 1 (eradicating extreme poverty and hunger by >50%) is expected to be achieved worldwide by 2015. There has been some progress with MDGs 4, 5 (Child and Maternal Health) e.g. in Ethiopia through the work of community health workers, but in sub-Saharan Africa it might be that Rwanda is the only country to achieve all targets. The question can rightly be asked “Did the MDGs fail because these were drawn up in a room by rich countries for poor countries?”. For development to be real and sustainable it needs to be based on indigenous knowledge and solutions, not donor-led philanthropy.

What role then for global surgery after 2015? I have no doubt that the provision of safe and effective surgery should form part of the post-2015 development goals, and surgeons have a responsibility to contribute to this global debate. How can this be achieved? When we started our critical care teaching programme in Africa, now under the name of Alba CC Course Design, we first went to Hawassa in rural Ethiopia to teach health officers (non-doctors) who were doing an MSc course in emergency surgery. With funding from the Clinton-foundation they are taught to do 12 operations well and look after these patients; this covers 85-90% of surgical emergencies in rural Ethiopia e.g. Caesarean section, ectopic pregnancy, incarcerated hernia, debridement of open fracture. When I asked the first intake of students in Hawassa “Why are you doing this course?”, 6 of 8 answered “Because I have seen women in obstructed labour die”. When we went back for a second visit 18 months later, one of those same students had already done 70 Caesarean sections, under spinal, alone in theatre except for a midwife and a scrub nurse. Now that is public health worth fighting for.

Cost studies in surgery provision in Bangladesh and Sierra Leone have shown that the cost per disability life-year (DALY) averted is equivalent to the costs of a measles vaccination programme. Providing essential and emergency surgery saves more than it costs.

With various other groups we are proposing a programme called “15-by-15”, which will aim to teach 15 essential and emergency operations to the same minimum standard worldwide by 2015, to decrease the physical, psychological, social and economic burdens of untreated surgical disease in even the poorest communities. Everyone has “the right to heal” (http://vimeo.com/59388957).

(References available on request).

Next weeks blog will be by Penny Halliday, Non-Executive Director of NHS Dumfries and Galloway and is titled “Woman Interrupted”