Doctor

Stephanie Jones is a medical doctor from New Zealand, who is now based in Monbulk, Victoria. She has been in Rukumkot, in the Rukum district of Nepal, since early June working on a Primary Health Project. This is Stephanie's first mission with Médecins Sans Frontières.

I woke at 5.45am, and lay in bed reading until 7am, when I was pretty sure that the coffee would be ready. It was a beautiful day – scrapings of blue sky, mist gently shrouding the valleys, gentle breeze stroking the banana leaves and nothing but the sound of rustling leaves and goats bleating in the distance. After drinking my coffee, reading my book, eating my potato and dried pea curry with two chapattis smeared with vegemite, and having a cup of sweet milky tea, I went to work.

The first priority was to do another x-ray on the young girl who was badly beaten by her father the day before. The initial x-ray showed a fractured arm, but after switching off the generator and putting on the plaster cast it transpired that one of the blows was to the back of her hand. She had ruptured the tendons that straighten her fingers and was most probably fractured around her knuckles. So, we needed to x-ray her hand and change the cast.

This set the tone for the day – trauma, trauma and more traumas. Stones and rocks, it transpires, are amongst one of the most dangerous single objects in this environment. We had the x-ray machine purring away all day, as patient after patient were laboriously carried into the room, suffering injuries from variously degrees of “hit by stone”, “fell onto stone”, “cut by stone” and my favourite “bitten by stone” (instead of “beaten”).

During this consulation I was informed there was an outbreak of “high fever, sometimes nausea, sometimes headaches” occurring in Rukumkot; there had been around 10 cases seen in the morning alone.

Oscillating between the inpatient department (IPD), x-ray, dressing room and the outpatient department (OPD) rooms I discovered that one of our inpatients had only passed 200ml of urine despite being there for a day receiving four litres of intravenous fluid in the same time period. On examination I found his bladder to be the size of a football and him in considerable distress when I tried to examine him.

Things seemed to be under reasonable control when I went down for lunch, but the dhal and rice was merely lulling me into a false sense of security. When I got back up the hill, it all went pear shaped. I spent the entire afternoon running from one emergency to the next. I spent an hour in the dressing room supervising the excision of a large cyst and trying to read x-rays while dashing through the rain from the IPD to OPD.

To set the scene for my pear shaped afternoon, let me describe our inpatient department. It is in a large room, maybe 6m by 8m, with 8 beds. There is a partition that separates it from the 2 maternity beds, and the nurses’ station. The beds have “Dunlop” mattresses with protective black sheeting. There are crude wooden shelves for the patients to put belongings, pieces of 4x2 wood are nailed onto stands, with nails at the top for hanging intravenous infusions and multi-coloured mosquito nets hang from string suspended from large nails in the ceiling. The floor is concreted for easy washing. Fly screen windows and doors cover every aperture in an attempt to keep out flying nuisance.

The nurses station comprises a desk, 2 cupboards and a bucket in the corner with a tap above it. We have no oxygen, we have no resuscitation equipment, we have no suction, we have drugs and a selection of cannulas, catheters, bandages and tape. Doors lead to the delivery room, the emergency room and to the “main entrance” – an opening to the intrigue of the hospital for all the local pedestrian traffic.

I do ward rounds at the beginning and end of the working day, every day, and am followed around from patient to patient by 5 health workers, my translator, 2 nurse-midwives, the staff-nurse, the logistician if he’s around, the field-coordinator if she’s around and usually the cleaner, pushing a mop full of chlorine around our ankles. We usually average 4-6 inpatients at a time and, as having an IPD is a recent development at the Rukumkot health post, managing intravenous infusions, regular medications and patient care is still a bit of a struggle.

Which is why my heart sunk to my well-worn boots when I entered the IPD at 6pm to find the following situation:

Bed 1 – 19 year old with high fever, urinary catheter, IV fluids, IV antibiotics and no idea what’s causing his fever ( will never take access to diagnostic laboratories for granted again).

Bed 2 – long-stay patient, treated leprosy but large ulcer on his foot, which is failing to heal even after 3 weeks of regular dressings.

Bed 3 – 2 year old moderately malnourished child with an ulcer 10x6cm on an area of skin previously seriously burnt a year ago – infected wound, unwell child.

Bed 4 – “fell onto stone” – walked for 3 days to get to us (usually takes a well person 1 day) 4 weeks after her injury, x-rays show a crush fracture of a lumbar vertebra.

Bed 5 – “hit by stone” – haematoma in her arm, bruising to entire upper body, pain on breathing.

Bed 6 – “fell from tree onto stone”, hit the back of his head 2 days ago and has had reduced consciousness since then, still confused, urinary catheter, IV fluids, IV steroids to reduce brain swelling, now has a pulse of 40/minute

Bed 7 – “hit by stone” on Achilles tendon, can’t walk, wound infected, also found to be pregnant and requesting medical abortion

Bed 8 – 8 month old with severe pneumonia, temperature of 39.3C and not feeding properly.

Bed 9 – (hang on, aren’t I supposed to only have 8 inpatient beds) – a woman with an infected finger who had pus discharging out both ends of the finger which was swollen out of all proportion. We had done an incision and drainage during the afternoon, and she was now receiving IV antibiotics and pain relief.

Bed 10 – a man in florid heart failure who had arrived at 5.30pm gasping for breath with a heart murmur loud enough to hear from the end of the bed. He was charted IV treatment and close monitoring.

Delivery room – (uh-oh, what am I going to do with this one – all the other beds are full) – a 17 year old girl who had been in labour for 16 hours with her first baby.

After spending an hour doing the round, making treatment plans and making sure that the nurses were all able to manage all the intensive cares required for our 11 patients, the health workers and I managed to leave at 7pm.

I returned home in a cold and persistent drizzle and took myself off to the shower before reading my emails for the day (mostly work related) and having dinner. Just as I spooned the last mouthful of dhal the watchman from the health post arrived swinging his torch and whistling cheerfully to inform me that there was a problem with the lady in labour, so I pulled on my Médecins Sans Frontières shirt and boots and negotiated the treacherous track in pallid moonlight and the gleam of my torch.

However we had a situation of “bijouli china” (no electricity), so by torch and kerosene light I found our patient panting, sweating, straining and moaning in the delivery room. Manu, the staff nurse, told me that the baby was too big to be delivered normally and was developing foetal distress. With encouragement for the patient to push, a vacuum extractor and significant effort on her part, Bless Manu managed to pull the poor little guy out into the big dark rainy world. whereupon he lay limp and blue until I resuscitated him with ventilation by AmbuBag and vigorous suction. I almost fainted with relief when he took a few pitiful breaths by himself and let out a weak wail of insult. After warming baby, stitching Mum and ensuring that they appeared stable I was able to once again return home at 11pm and collapse into bed.

Thankfully, this is an unusual day for us – and one I would not want to repeat in a hurry, but full credit to all the staff up there – they managed things remarkably well, all the patients were improving by the morning and everyone learnt a lot from the day!