Saturday, April 18, 2015

Working With The Enemy: part 1

يا ﺑﻨﻲ ﺍﻟﺴﻮﺩﺍﻥ ﻫﺬﺍ ﺭﻣﺰﻛﻢ
ﻳﺤﻤﻞ ﺍﻟﻌﺐﺀ ﻭﻳﺤﻤﻲ ﺃﺭﺿﻜﻢ

I’m blogging about my experience working in the Military Hospital in Sudan for several reasons. First, it’s been quite a while since I left the hospital and took to the offices, and my clinical experience in Sudan has been limited but overwhelmingly traumatic. Second, I have been curious about how things work inside the army from all the rumours I’ve heard and the figures I’ve seen. And third and most important, I have been curious about the differences between health care in Sudan and that in Oman/the Gulf which I have heard so much about but haven’t had much experience with as a doctor (albeit a lot of experience as an attendant of a sick patient).
My first impression is almost the same impression I had when I first entered the civil health sector, i.e. the Ministry of Health. When I was getting my papers done, I was overwhelmed by the sheer number of people employed there, and by how poor they looked. The guy delivering the newspapers had the hems of his trousers poorly sewn with a thick white thread which I think he had done himself, and he brightly smiled back at me when I said hi. The guy sitting inside the tower next the gates where I had to get my card was wearing a printed shirt that reminded me of the Beatles, and didn’t smile back at me or look in any way moved when I said hi, or thank you, or bye.
My first shift was a nightshift which I approached with much horror and apprehension, because it was a weekend and, according to my past experience in Oman, the floor would be overflowing with sick and angry patients. I worried about car accidents and heart attacks and stab victims, and the ‘missions’ I kept hearing about where critically injured soldiers were flown in from conflict areas all over the country (mainly Darfur). I was surprised that after the first hour, the place was almost empty except for the few patients staying over from the previous shift, and only one new patient (with a stroke) showed up until the next morning. This I attributed to the fact that getting around in Sudan is not as easy as getting around in Oman. Personal cars are a luxury unaffordable by the majority, and public transport does not exist after midnight. I believe there may be a lot of people waiting for morning to come to bring their sick relatives to the hospital, and I wonder how they manage. My second observation that night was more surprising: everyone working the nightshift stayed up until morning; even the 3 consultants stashed away in their office (I’m surprised there are even consultants covering the floor 24 hours), and even though there was actually not much to do. All the doctors collected at the big marble counter in the middle of the ER and chitchatted, studied, laughed at stuff on their phones, etc., and the nurses did the same at their stations. I remember when my grandmother Allah yer7amha was lying in the ICU a few years ago, the place was empty and there was no one to call for help because all nurses and doctors locked themselves in their rooms until morning, except for 1 or 2 stray people. Actually, it’s even difficult to find someone during the day. But here, everyone stayed where they were supposed to.
Which brings me to my third observation: everyone does their job and minds their own business. This I observed throughout this first week, and has been an equally surprising discovery especially in terms of nurses who are notorious for their attitude and refusal to do anything (in Sudan). I don’t remember having to ask for anything twice or getting any dirty looks or smart comments or anything at all. In the few shifts back in 2012 when I worked in that small private hospital, the nurses actually refused to carry out orders in critically ill patients, and overrode them and insisted on their own (wrong) management and medication doses, and in one incidence walked away in the middle of a CPR. It was a traumatizing experience. Here, despite most of them being so young, orders are carried out promptly and efficiently and the general atmosphere is one of respectful and friendly companionship. I am pleasantly surprised.
The second 2 shifts were mornings, which were quite busy but not half as busy as SQUH. This is also due to the much larger team size (10 doctors, 2-3 consultants and 1-2 senior residents), and that there are separate rooms for trauma, intensive care, very critical patients and others. The best thing is that everyone is covered by military insurance and almost everything is available and at hand. Actually this was one of the main reasons why I chose to work here, because the idea of asking patients to pay first before receiving treatment is one that I couldn’t get used to. All investigations are collected, sent and reported back in an hour, maximum 2 (the magic of Vaccutainers). I attended my first CPR which was not very well managed, mainly because there was only one nurse running around without any help. I also watched, with some interest and pity, how the doctors kept ordering the attendants to ‘get out’, and remembered my own self 4 years ago when the sight of an attendant(s) in the room while managing critically ill patients irritated me, because they ‘shouldn’t’ be there and were getting in the way and made everyone nervous. I also noticed how poor/shabby everyone (the patients and their attendants) looked. The military is actually a small and quite accurate version of the entire country: a tiny minority of the comfortable and well-off on the top, and a large majority of the poor and miserable on the bottom. And most of them, especially the soldiers, were very young and scared looking. I wondered how this was the force that ran the country and fought on the front lines.
And then, on my 4th day which was a nightshift, I came to work to find a scene of chaos. One of those much feared missions had come in from somewhere in Aldamazen, where bombs had exploded and villages were burnt and all those things you hear about on the news. I looked into Room A and there were 3 patients instead of 2. At first I didn’t know what I was looking at, because the things lying on 2 of the beds weren’t supposed to be there. I stepped out and looked inside Room B, which was the ICU. 3 more of those things were there, and another 2 ‘regular’ patients on ventilators. Then down the corridor and into the Trauma room were all hell had broken loose, and I realized what was wrong with what I was seeing. Among all those injured adults and their relatives, there were children, and they were all severely burnt. Another child was not burnt but something had exploded and hit her face, and there was a hole all the way through to the inside of her nose. How could children be brought in from the front lines? Apparently, the front lines were right in the middle of some of the villages, and the family that got burnt had had a bomb dropped on their house, and some had died. Who had dropped the bomb? The rebels or the military?
It was the military.
By mistake.
Throughout that shift I kept passing by to look in on those 4 children and their mother. The mother I had initially mistaken for another child because she was so small and her face was unrecognizable from the burns and swelling, and only realized who she was when the child in the bed next to her was crying out for his/her mother and the nurse pulled the curtain closed so it wouldn’t see her in the next bed and get frightened by the condition she was in. I also wondered how silent and resigned they were. They didn’t cry or ask for anything, or even move, except for that one child in Room B, and that was only once. They weren’t sleeping but their eyes were swollen almost shut, their little feet protruding from under the bed sheets. I asked one of them if he was in pain, and what his name was, and if he was ok, but he wouldn’t/couldn’t answer me, and I wondered if maybe he didn’t speak Arabic. Then after a while he replied, with all the misery in the world, that something did hurt. I think it was his neck. I couldn’t take it and was relieved when they were finally admitted to the wards upstairs. This was the first time I had seen and touched the actual victims of this stupid, stupid, STUPID war, right in front of me, and not a picture on my Facebook page.
The rest of the shift was uneventful, except for the time when I did a bedside ultrasound for a nice old lady to check for gallstones, and had to get permission from 3 different people to get the machine from the ultrasound room because ever since someone had broken the other machine, this one was kept under lock and key. After locating the stone-free gallbladder I turned around and found a small crowd of people behind me, watching in wonder, including the surgical consultant, who asked a lot of questions and then turned around and told his residents not to ask for anymore ultrasounds and just ask this doctora to do it for them instead, and then asked me to please time my duties every Thursday so that we could work together. I immediately put my cool face on and tried (and failed) not to brag about it in front of everyone I knew.
This first week has shown me that a well funded and well organized health system can do wonders in this country. The military scoops up almost all the money that goes into the health system from the federal transfers and taxes at the expense of the rest of the government health system, which is one of the many reasons why public hospitals and health centers are starved and poorly run. Here, I didn’t see anyone bullying anyone or shirking their duties or not showing up to work, or anything, simply because they don’t need to. The system in place isn’t perfect, but it’s still a system and gets the job done, and no one has any reason not to do their job. The doctors I met also still have that question of wanting to leave, but I notice they’re not as desperate as others and are willing to take their time about it, especially those already in residency programs. They feel relatively secure here and are able to do their jobs.  
Apparently, money is the answer to everything after all.