Hello and welcome to my improvised blog! Please send your comments/questions/remarks to firstname.lastname@example.org for publication on this page! All is well and the best to you all; thank you also for all the positive feedback and encouraging words – trust me, they make a great deal of difference. Take care! / Henrik Jörnvall
For reasons of security this blog is (next to) completely anonymous; neither the location, the year, the Organization, nor any names but my own are spelled out. It might seem stupid/paranoid/over-cautious, but the fact is that the security of the Organization and its members has historically been compromised in blogs due to seemingly innocent information. Besides, by keeping the information anonymous I have the possibility and opportunity to openly write things that should definitely not be written due to security issues (for example the press release from the <…> government in December; post 10). Just mail me (“henrik” instead of “comments” in address above) and I’ll be happy to answer any questions you might have concerning any details that you might be missing. My non-humanitarian mission (post 18) doesn’t have any of those concerns, but I’ll keep the anonymity nevertheless – in some aspects is makes for an easier and less blurred description. In any event, it shouldn’t be too difficult to figure out the countries and agencies involved…
Last post is on top; earlier in order below
Post 1: Getting ready for my mission!
Post 2: First Week Impressions
Post 3: Honeymoon is over!
Post 4: Crash introduction to the operating theatre
Post 5: Starting to settle in
Post 6: Life goes on
Post 7: The end is near
Post 8: Act 2 has begun!
Post 9: Anesthesia with a spice!
Post 10: Intermission
Post 11: Déjà vû – but then not…
Post 12: Anticlimax
Post 13: Epilogue
Post 14: Welcome to Hell
Post 15: Home Sweet Home
Post 16: …and Hell returns
Post 17: Contrasts hit me again
Post 18: Apples and pears – different and incomparable
Post 18: Apples and pears – different and incomparable
It’s been a while, but as many of you know I’m now out on a mission again. This is my fourth mission to a war zone, but it’s nevertheless completely different from my earlier missions and experiences. This time I’m not with a humanitarian organisation, but instead, and as I will elaborate on, with an organisation with an entirely different agenda. I will not compare them both; and in fact the major reason I’m sitting here in the middle of the dessert is to be able to forcefully and with aid of my experience denounce any comparison of the two. However, and with that said, I’ll try to describe their differences… Indeed a thin line to walk; describing differences without comparing!
Again and to reiterate: the two organizations are not comparable. They don’t operate under the same rules (moral, ethical, legal); they don’t have the same goals; they don’t have any operational methods in common; they do not have any connection with each other; and they don’t rely on each other for their operational actions. Period.
Before continuing, please re-read the previous paragraph; it’s a very common area of misunderstanding and misconception. If you are a journalist or a politician: re-read it again. Your understanding of it has bearings on the people you are trying to help and on the people you send to execute your orders. And, I must unfortunately add, your track record of comprehension is, to say the least, sub optimal. Remind yourself that the former paragraph does not in any way rank the two organisations, or say that one is “better” or nobler than the other. Again, they are simply incomparable.
With that said I will point out some differences between the organisations, and describe my work and some thoughts from within them.
1. Medical action and priorities, and utilization of resources. During my last mission my team did 495 surgical interventions during the first 18 days after the catastrophic earthquake. All were on critical wounded patients and with a strict medical priority. It didn’t matter if you were a bad guy, a politician, young or old, rich or poor; your treatment was based on your medical need alone. The same principle of action was true in all my earlier missions. At my current mission we (a full surgical team (me, a surgeon, a scrub nurse, an anesthesia nurse and an intensive care nurse) with a (ridiculously) full set of equipment) are sitting in preparedness to treat wounded soldiers. In accordance with the Geneva Convention of 1949 we will treat soldiers of both sides and civilians wounded in combat action. However, we have strict orders not to engage in any other healthcare, and the numbers of enemy soldiers WIA (wounded in action) versus KIA (killed in action) doesn’t make the arrival of a wounded enemy soldier likely. I haven’t seen any indications that the enemy is treated in violation with the laws of war; the numbers are largely a consequence of our weapons systems and protective gear being light years from that of the enemy. Also, our local allies might, how should I phrase it so it doesn’t come out wrong, be less enthusiastic in hurrying wounded opponents to proper medical care.
In contrast, 50 meters from my room and over the Hesco (a bullet-/grenade-/shrapnel-proof protective barrier that surrounds our camp) is the harsh reality of one of the absolute poorest countries on earth. One of eleven females die during childbirth, the under-5-year pediatric mortality is second to worst in the world, and the overall life expectancy is 44 years. Inside the camp I’m living comfortably, eating better food than at home, and with more than double the salary. In this setting of immense and palpable need, how much medical work have I done during my first month of presence? Absolutely nothing. Not a single medical intervention. Zilch. Not even close (well that’s not exactly true; I have watched two cases at a neighboring allied base).
Misunderstand me correctly: the fact that my services haven’t been needed is not what disturbs me; that’s not different from being on call and in preparedness at home, and nobody would be unhappy if I don’t get to do anything at all during my current mission. No, the thing that disturbs me is the obvious ongoing waste of resources: less than five minutes away (by helicopter) is a fully equipped hospital with all services and specialists; including X-ray, neurosurgery and intensive care. The helicopters have yet to fail to pick up a patient within an hour of injury and there is no limit to the resources at the receiving hospital compared to us. We are instead spending much of the days doing inventories of the equipment and discarding expired drugs; among others $27 975 worth of coagulation factors that have a limited indication in trauma (the manufacturing company discontinued an ongoing study due to the lack of effect), and that implies and demands an higher level of care than the advanced resuscitation we are able to provide. Speaking of resources and helicopters: one of our major newspapers at home “decided” that the Swedish army needed to send helicopters; our politicians had no way of not complying with the demands in the articles and the accompanying voices of the people. The cost of those two helicopters is enormous, and their need is, to say the least, questionable. The US has dozens of fully operational helicopters, always ready to evacuate any of our wounded soldiers. Oh, yes, one more thing: the temperature here is at least 40 degrees in the shadow (as I write this it’s 44.6 in the shadow and 66.3 degrees in the sun). Would you care to guess at what maximum temperature our helicopters are able to fly (with enough fuel for a reasonable area of operational coverage)? But, wait! They can fly at night! Well, actually no, since they yet have to complete their training and equipment fine tuning. Meanwhile there is a continuous buzz of US helicopters above our camp… Journalists and politicians constitute the ultimate dream team of decision making!
2. Human rights and the concept of neutrality, impartiality and independence. Obviously my current employer is the complete opposite of being neutral, impartial or independent. Anything else would be plain stupid and I fully agree with, and understand, this fact. However, only now I fully appreciate the benefits of working with an organization that can rightfully claim those same values. All my former missions have been in violent and high security settings, but never have my freedom of movement nor my security been compromised as much as it has been during this mission. On my former missions I was protected by a 1 mm cotton T-shirt with a logo, and, most importantly, a massive interaction with and support of the local community. Since we were indisputable neutral, impartial and independent, we were no threat, and thus no target.
In contrary, at my current mission we are always a target and always armed (yes, always! I failed to learn in medical school whether one should wear the gun under (for sterility) or over (for easy access) the sterile garment in the operation theatre…) with heavy protection, security gear and ammunition (I won’t bore you with details, but I’m not (that) overweight and when fully dressed with all gear my BMI reaches a staggering 36; add 66 degrees Celsius to that and you have a given success…). At my former missions we would just hop into the car, roll down the windows and get going. Here it took us three hours to assemble a strong enough protection force to make the 30 minute ride from the airport thru the city and to the camp (and the windows are more than an inch thick and not possible to roll down). Again, I understand why it has to be like this, but nevertheless it’s fascinating to have experienced both sides. And yes: my humanitarian organisation is also present in this country. They have two hospitals; one in the capital and one in the rural south: an area much more violent and at more active war than my present location. So, aimed at the member of the governmental Swedish defense group I talked to before going here: armed forces are not necessary for humanitarian aid.
I won’t say that my current organisation is non-humanitarian, but it is definitely not a humanitarian organisation. What’s the difference? The humanitarian manifest, or the Universal Declaration of Human Rights, were agreed upon by the United Nations General Assembly on the 10:th of December 1948: Resolution 217 A (III). It’s a collection of 30 Articles, generally agreeable with all nations, religions and fractions thereof. However, there is one major paradox to the spirit of the United Nations and their declaration of the Human Rights: It clearly states (Article 3) that birth itself gives a human being “the right to life, liberty and security of person”; but what if he violates those rules himself? We (the good guys) have to in turn violate the same Human Rights when we set of to engage him in war. Are we then non-humanitarian? A paradox the philosophers among you can ponder on… Please tell me if you unexpectedly come to any conclusion.
3. What about the Three Big Questions: I) Should we fight this war? II) Are we doing any good? and III) Will anything good come out of it all? In all my modesty I’m happy that I now after a month can provide you with the answers…
I) Should we fight this war? The United Nations Security Council has issued numerous resolutions regarding the present conflict (see for example resolutions 1267 (“flagrant violations of established international law”), 1333 (“critical humanitarian needs”), and 1363 (“a threat to international peace and security in the region”); all of special interest since they were issued before 9/11 2001). The UN might be plagued with intrinsic problems and with a not always impeccable history, but nevertheless it’s the democratic institution most of us respect and confer to; at least it’s intentions. In its resolutions the current war is justified by this country’s repeated and chocking violations of human rights, its flagrant and constant opposition to any reasoning, and its proven and self acclaimed engagement in hostile and violent activities aimed at its own citizens and those of other countries. See for example point 5 in resolution 1368 of 9/12-2001: “Expresses its readiness to take all necessary steps to respond to the terrorist attacks of 11 September 2001, and to combat all forms of terrorism, in accordance with its responsibilities under the Charter of the United Nations”. I don’t think the UN can possibly be more explicit or clear – the parallel to WWII and the very purpose of the UN is obvious. There is little doubt that we are fighting the bad guys (at least that was what we were fighting the first couple of weeks when the war started in October 2001…). So yes: we should fight this war.
II) Are we doing any good? Experiencing a ride in the city among the locals (of course fully armed and behind the barrel of a loaded gun…) there is little doubt that we are doing something good. Most (not all!) faces are smiling and many children are running after our vehicles, waving and giving their thumbs up (I know it in this cultural setting can mean something completely different, but probably not so when delivered by smiling and waving children?). Clearly we are seen as something positive by the locals (who have a history of fighting and defeating two superpowers), and obviously we are doing at least something good. Girls are now to a large degree allowed to attend school, health care is improving slowly (from a very low level), and the former leadership by terror is suspended (unfortunately far from terminated). So yes: we are doing something good.
III) Will anything good come out of it all? If my answer to question I and II breathe optimism, my answer to question III is a clear and unequivocal no. There is simply no way our military presence or actions are going to make any long term difference to this community or country. Again, we won the war almost a decade ago - how come we yet haven’t won the people? How come we still can’t even go around the block without guns and heavy protection? How come the country still has the second to worst maternal mortality in the world? How come a devastating majority of the population still can’t read, still fear the war lords, and are still in reality ruled by whatever orders the underground rulers give? Yes, girls attend school now. But for that to make a difference, the same girls must graduate, form a family and raise their kids in an atmosphere of democracy and human rights. They better hurry up, because we are leaving 2014…a political decision not based on reality. Bottom line: there is no way that our sacrifice of human life and associated multibillion efforts will make any more long term difference than previous attempts. We’ve learned nothing and are simply making the same mistake as the previous players: focusing solely on superficial safety and peace, and completely and utterly forgetting and/or disregarding humanitarian needs, rights and the necessity of a vision of a better future among the people. So no: there is no chance that something good will come out of it all, and again it’s been proven that modern war (a contradiction of terms?) cannot be won by military means alone. However and with that said, hopefully there is something long term good coming out of the many other, more humanitarian, missions and organisations that are active in this country… Time alone will tell.
I’ll conclude with some pictures as they can tell you more than a 1000 words (or even the above 2299 words)!
Could have been the best of countries – too bad the sun is so often obstructed by tools of destruction and death
A plausible image of peace?
Happy children in the street
Everybody is always armed. I hope none of the contestants is a bad looser…
The last week has been a little on the cool side, almost dropped below 40 degrees Celsius… 66.5 in the sun – an hour on sundeck and you’ll end up medium rare!
In concordance with my habit, the text is on the longish side. In my next post I’ll try to describe the daily life a little further and answer some of the questions you might have been pondering on during your life: Can you actually cook with water that been heated by lying around in the sun? Just how dusty is the dessert when you travel off road in a tank? And how much fun is it to spend 13 hours in the same tank, only peeking (and peeing) outside twice for around 15 minutes? And how the %#¤ do you cook in absolute darkness due to light discipline among presumed enemies? And the ultimate question to them all: does the Finnish soldiers really make the effort to build a sauna when the outside temperature in the sun approaches 70 degrees Celsius? The answers to all those questions you didn’t even know you had will come in due time…
As usual I welcome any comments you might have. I’ve provided you with The Answers above, but historically I think I might have been slightly wrong on an occasion or two… I welcome any corrections, thoughts, additions, oppositions, or questions you might have.
Comments to post 18:
Augusti 7 kl. 16:22
I found your post via the PC in my project (I'm MTL in South Sudan, with obviously, <…>). I enjoyed reading what you wrote, and just in case you were wondering, we are always looking for some fabulous people to join the mission (although it's back to living in a mud and stick hut, and humanitarian principles and such, but I think you could probably be okay with that, no?).
Take care of yourself,
Augusti 12 kl. 12:52
Oh, yes, you can win the war.
But the cost is high and the means used currently are wrong. US has a good example of good propaganda war from Cold War era, when they spent millions for aggressive radio broadcasts to Eastern Europe. The money Soros put into revolutions of Tunisia, Belorus and Ukraina is bringing fruits.
While having similar standpoints to that of Eastern Europe, USA/NATO/EU is too different from asian Islamic countries to use an American Lifestyle as an atractive model for those countries. In this light, a massive immigration to industrialized countries is actually good for poor countries, because, one: part of the money ends up there while, two: the new class of westernized citizens who understand workings of their respecive countries of origin is growing. These people are the valuable medium for showing that the non-religious, democratic, open society such as of Holland or Sweden are better solution than closed, xenofobic, weapon-based plutocracies of Korea/Israel/Libya ilks. The invention of social interdependence gave human race a wedge to dominate other monkeys.
So don't dispair, your presence in the desert is for good, no matter how few wounded you will save. The important part is to win the hearts, and you have proved yourself already.
Politicians and times are achanging, new faces shall have a better understanding, even if Obama loses the election.
Augusti 12 kl. 21:04
Jag läste din blogg nu (efter tips från Johan O. ) - hoppas att den återstående tiden av ditt uppdrag blir lugn. Finns det anledning att vara försiktig med det du skriver på bloggen? Jag misstänker att man bör vara försiktig i alla avseenden därborta.
Ha det gott i solen! :)
Du blir nog ordentligt dyksugen, efter att uppdraget är över? Jag ser också fram emot resan!
Augusti 18 kl 22:58
Jag har läst din blogg som jag tyckte var intressant läsning. Jag tänker på dig och hoppas att allt går bra för dig och att du kommer hem helskinnad. Här hemma missar du ingenting. Vi har haft en ovanligt lugn sommar förutom förra veckan då 9 patienter dog på Civa i tur och ordning. Då blev det handledning. Men annars är allt frid och fröjd. Alla är tillbaka från sina semestrar...kanske tröttare än innan semestern...
Ta vara på dig så hoppas jag att vi ses snart.
Augusti 22 kl. 15:09
Inte mycket mera att säga än enormt stor tack för din iakttagelser!
Post 1: Getting ready for my mission!
This is my first attempt at a blog, but I’ll do my best in the challenge to convey my experiences and impressions from my six week mission with a humanitarian organisation in a large city somewhere in the world. I’ll try to keep it short and down to the point so you surely can find the time to read it, but bear with me as this first post is a little longer! I’ll try to keep you updated every week, but I can’t promise anything. Also, please let me know how I’m doing and give me feedback for improvement!
When writing this first entry I’m still at home in Sweden. I’m working as an anesthesiologist at a university hospital (Karolinska Sjukhuset) in Stockholm, and I’ve been in the pipeline for a long time to go on a mission with the Organisation. Finally it’s becoming a reality and all my training and preparatory courses are done with.
The reasons for me to volunteer with the Organisation are not in any way complicated nor with a belief of doing something heroic or altruistic. I volunteer for the same reasons I’m working back home: with a strong wish of doing something meaningful and helping people in need. However, and in contrast with my work at home, I think my ambition will be much more condensed with the Organisation and the results hopefully more obvious. At home we have next to endless resources and there is always a fully manned and equipped team to help me if I need – this will not always be true in the field! I strongly sympathize with the ethics and charter of the Organisation (more of this later); but, again, I don’t see any fundamental difference from my humanitarian work back home or my coming work in abroad. It’s the same humans, with the same medical and humanitarian needs. Maybe I’ll soon find out how incorrect and naïve my vision is…
Now for some background so you’ll get an idea of the humanitarian world! My hospital at home has an annual budget of 1 213 million Euro (yes, 1.2 billion Euro!). With those more than a thousand of million Euro there are 15 000 employees that annually deliver 10 000 babies, perform 60 000 operations, and do 1.5 million consultations. The Organisation on the other hand has a total worldwide budget of 568 million Euro. However, in spite of less half of the funding, the Organisation manages to annually employ some 30 000 people in more than 70 countries, deliver 100 000 babies, perform 64 000 operations, and do 10 million consultations. Those already quite impressive figures become even more impressive realizing that much of the work is done in a setting with extremely poor infrastructure and social and/or political instability. I feel honored to become a part of that work, but before anybody at home gets mad I must also emphasize that I really value and cherish my work at home! My friends and colleagues deliver first class health care and they are all a great bunch to work with. After all, if that was not so, I don’t think I would be ready for my mission with the Organisation. Thus, gang at home: keep it up, you are the best!
So – what am I up to? In less than a week I’m off to a trauma hospital in a large city. I don’t have the setting 100% clear, but I think the expat crew will consist of me, an anesthetist nurse, a general surgeon and an orthopedic surgeon. Together with logisticians and coordinators we make a total of 10 expatriates in the mission.
The Hospital is active in a very turbulent city with a large number of victims of violence. I’m told there are around 20 knife or gun traumas every week; the city also has its share of “ordinary” traffic, work and domestic traumas. I’ll describe an ordinary day at work as soon as I can, but I think I can safely assume that the days will be very long and extremely challenging.
Speaking of challenge; I conclude this first entry by stating my two goals of my mission, each of equal importance: first I’m determined to do my best. For sure I’ll make mistakes, for sure there will be times when I feel insufficient or frustrated due to a lack of resources, knowledge, or energy. However, I’m determined to nevertheless do my best and to be able to say to my patients, colleagues, the Organisation, and (most importantly) myself that I always did my best. I leave it to others to evaluate if my best was enough; at least I’ll rest assured knowing that I can’t do better, no matter the outcome.
The second goal might seem unrelated, unimportant, or even irrelevant; but in reality it’s not: I’ll try to learn to juggle seven balls during my mission. Considering the expected workload and my determination towards the first goal, I’m sure I need lots of stress relief, rest and recreation; I can’t think of any better or more effective than try to improve my juggling skills! While I’m determined to fulfill my first goal, I will merely attempt the second - we’ll see how well I succeed in my mission!
Comments to post 1:
Augusti 17 kl. 23:50
Lycka till käre vän!
Med både jonglering och intubering.
Ta hand om dig så bjuder jag på middag på framsidan vid hemskomst!
Augusti 18 kl. 7:03
Vill bara önska dig stort lycka till! Jag hoppas att du, trots betydligt förändrade förhållanden, får det riktigt bra. Jag önskar att det fanns fler som du i världen och att jag själv ska våga göra något liknande någon gång!
stor kram, Evisen
Ps. jag föredrar att läsa svart text med något ljusare bakgrund.
Augusti 18 kl. 17:15
Lycka till Dr H !!!!
Watch out for scary people with guns and knives
Lite dykning när du kan komma hem ? ….
Augusti 18 kl. 20:10
Jag önskar dig lycka till!
Caroline Sällbom säger:
Augusti 18 kl. 21:56
Fantastiskt spännande och bra!
Önskar dig mycket lycka till samt ytterlgare en påminnelse o att du ska vara mycket rädd om dig i ett land så annorlunda vårt…
Caroline-narkossyster i natten
Augusti 19 kl. 10:37
Stort tack för i lördags! Uffe ser verkligen fram emot att måla i trappan (not!) så att tavlan kommer upp :-). Ville bara visa att jag hittat till din blogg nu! Var rädd om dig!
Augusti 19 kl. 18:53
Vi läser din blogg, Dex och jag. Kul! Är så stolt över dig att du gör detta! Se bara till att komma hem igen! Låt inte internetcaféet bli till en fara P&K Nina och Dex
Augusti 21 kl. 7:52
Kunde man just tänka sej att du skulle göra nå´t så´nt här! Beundransvärd är du! Lycka till!!!
Många hälsningar! Gugge.
Augusti 21 kl. 13:52
Vilken bonusson jag har!
Lycka till med både det ena och det andra och var rädd om dig!
Augusti 21 kl. 17:26
Vi tänker på dig, Magnus och jag:-D
Kör så det ryker! När du blir för trött och hjärnan är på väg att logga ut, kom ihåg ABCDE och trajectory, trajectory, trajectory…
Kristina H-J säger:
Augusti 28 kl. 12:47
Följer Din blogg och hoppas att Du kommer hem till oss i vår, fulfilled och utan alltför svåra ärr vare sig på kroppen eller i själen. Vet att Du alltid gör Ditt bästa och att det är bättre än vad de flesta av oss kan hoppas på att åstadkomma…
Var rädd om Dig!
Augusti 29 kl. 10:41
Sjalv har jag nu ocksa kommit pa plats i <...> och mitt uppdrag i <...>. Ser med spanning fram emot att lasa om hur du har det, vet ju fran egen erfarenhet forra aret i <...> att det kan vara lite av en utmaning….Lycka till!!!
Post 2: First Week Impressions
It’s been more than a week since my last post, but I’ve actually only been three days on site in the City. On route I spent two days of briefing in Europe and one day in the capital of my mission country. The trip was quite uneventful, although some aspects of the new culture requires some getting used to; when checking in at the airport for my flight to the City, one could easily make the mistake of standing in the line to the counter marked “Check-in” to the City. Needless to say, when checking in to the City you should of course stand in the line “Tickets”-some other city… But on the other hand the airport staff was extremely kind once my status with the Organisation was known. I carried some orthopedic instruments, and when asked what it was I said they were for the Hospital in the City. The staff then greeted me, said I was welcome and made my airport troubles vanish. Even the security guy at the metal detector presented himself and said I was welcome; whatever the Organisation is doing in the City, it must be good and the word has reached even the capital!
So, how is the Hospital, work, colleagues and patients? In my next post I’ll walk you thru a typical day at work, but I’ll give you a short tease of how the setting is:
Traffic is horrific (can’t think of any worse word, but if I could I would use that word instead); 5 (yes, five!) people on a single motorbike is nothing unusual (all barefooted with no helmets). Traffic accidents are thus a major and unlimited source of patients. Health care is extremely limited (or expensive) and local healers are commonly utilized. One patient came with an open fracture of the ankle that a healer tried to treat with a dressing soaked in feces; suffice it to say that the wound had some unmistakable signs of infection… Other sources are gunshot wounds, knife traumas, or just plain street violence. All patients are young; the oldest three patients I’ve had (out of 16 cases in my first three days) were 71, 53, and 39 years old; the rest being in their twenties.
These first days I’ve been struggling with TLAs (Three Letter Abbreviations), my English (which is not at all the English that people in the City is speaking) and names (there are a lot of Miracle, Godsgift, Bigman, Precious, Lucky, and Friday; and should we really operate Saturday Sunday on Monday? Shouldn’t we operate him on Tuesday instead? Lots of confusion and a giggle or two…). For the anesthesiologists of you: Ketamine is now my drug of choice, an Hb of 55 g/l is not uncommon (or anything really troublesome; we don’t have much blood anyhow so there is no need/use of worrying), and despite what it says in textbooks an abdominal gunshot victim with an Hb of 59 g/l does not necessarily react with a tachycardia…
So much for my effort of keeping it short…next time I’ll try to throw in some pictures to lighten it up!
Comments to post 2:
Augusti 30 kl. 12:09
Följer din blogg, Uffe är i Kina och där är denna sida stängd så jag får kopiera och skicka den via mail istället. Vi tänker på dig och hoppas att du har det ok. Imorgon skall jag & Nina träffas och käka middag. Sköt om dig! Kram Å
Augusti 31 kl. 9:22
Hej vännen! Läser givetvis din blogg. Underhållande! Som du ser i Åsas inlägg så skall vi käka middag! Blogga vidare och ha kul!
Puss och Kram
Nina och Dex
September 1 kl. 8:13
Hola Henrik, min första blog jag läser och det är bra.
Mäktigt att du vågar göra ngt jag känner att jag borde göra fast jag vet att jag ej kommer göra. För bekväm och feg. Lägger istället mitt krut på att gå runt och samla in namnunderskrifter på KI och KS. Känns nu ganska torftigt.
Ser fram emot nästa inlägg.
September 3 kl. 12:03
Hi there! Doing fine, I see
Although I have no doubt that you will complete the first of the two goals you mentioned in your first post, I admit to be quite skeptical when it comes to master the 7 balls juggling in a 6-week time. But you are the one who taught me that Swedes easily manage with “flera bollar i luften”, so why not! Wait and see I take the bet…
I recently saw some pictures of the <…> Hospital and needless to say that it looked quite rudimentary. But with your strong will, your excellent skills and your happy nature I am quite sure that you might even be able to bring some grateful smiles on the faces of people who have only known pain, misery and death.
You are doing well Bunny
Tusen Puss and Purr
CB, Mint and Buddy
September 5 kl. 11:30
Hej Henrik! Vad grymt att du är i <...> med <...>! Spännande läsning! Kommer fortsätta läsa din blogg alla gånger. Ha det bra och take care out there!
Sophie på Sahlgrenska:)
September 5 kl. 15:18
Lycka till Henrik !! Kul att du bloggar, så blir även vi hemma i soffan lite mer upplysta. Sköt om dig! Lotta på Niva
september 8 kl. 9:59
Hej Henrik !
Nyss hemkommen från Kina och hade hoppas på att få bli “walked thru a typical day at work” nu när jag äntligen har access till din spännande blogg.
Känns verkligen som vi har blivit “teased” tillräckligt länge…. Skippa jongleringen nu och “blogga på” lite rejälare….
Sticker till Portugal om en timme och hoppas att jag kan få läsa nå´t spännade från ditt äventyr (behöver få in lite “excitements”i mitt inrutade arbetsliv.
Hoppas att allt är väl med dig och att du snart kommer hem till Sverige. Vi hjälper Nina med “vinterstängning” den 19/9
Har läst lite om logistikfunktionen hos <...> och det kan kanske bli ett alternativ för mig om Åsa åker som syrra nå´n gång i framtiden..
Lycka till med fortsättning av ditt åtagande !!
Post 3: Honeymoon is over!
They say that time flies when you are busy – well, in the City time is supersonic...
I promised to walk you thru a day at work; why not start at the major source of work? On our daily bike-spotting on route to the Hospital we yesterday spotted a bike with six passengers – a single bike accident here can render more victims than an average bus accident at home! Sometimes I wonder if I’m still on the same planet.
Anyhow, we arrive at the Hospital around eight and immediately start rounds. We are nine medical expats (five doctors, three nurses, and one physiotherapist) and we join forces at the Hospital with national doctors and nurses. First the emergency room (ER) to see what has happened during the night; sometimes nothing (once!) but usually quite a lot. Next is the Intensive Care Unit (ICU), which is, to put it mildly, a little different from the ICU at home. To be honest, I don’t quite understand what is so “IC” about it, but there are more nurses around and they do their best to regularly take the vital signs of the patients. As I’ve learned the hard way, taking and recording vital signs doesn’t necessarily mean that anybody reacts or anything is done to correct abnormal values. Sometimes corrective measures are initiated, but sometimes those actions are, in my opinion, slightly suboptimal. After all, a pulse of 158 should be ok if the blood pressure is ok? And 80 mg of furosemide (a diuretic) should help when the kidneys haven’t produced any urine; yes, the patient has a gunshot wound to the abdomen, but he has already received 2 liters of fluid and he still doesn’t produce any urine!
We next proceed to the wards; there are around 75 beds in three wards, separated by level of infection (green, blue and red). I do my best to assess pain and to adjust pain medications, but the work is sometimes just overwhelming. Besides, we have the current operating list to attend to (usually more than ten cases each day), and I must prepare and check the two operating theatres (OT).
For almost a week I was blessed by the company of dr A (we all go by first name here; I don’t even know his surname), a Canadian anesthetist whom I was replacing. The work didn’t seem so bad at the time, but when he left, and P (a local anesthetist nurse) was off duty for three days, I forcefully and brutally got thrown into reality. Please see the picture for the daily operating list; twelve patients of which four gunshot wounds (GSW) and the rest road traffic accidents (RTA). The fractures are typically quite complicated and many/most are open (with bone penetrating the skin). I won’t shock you with nasty pictures, but instead show a typical X-ray (maybe equally nasty...) of the lower leg after a gunshot. Or to put it another way: there have been a few days when we have not had any traumatic amputations...
Most of the cases are done in a spinal (injection of local anesthetic in the back to anesthetize the lower part of the body), or sedation (which here is actually full blown anesthesia but with ketamine and thus (almost always...) preserving airway control). Complete anesthesia with intubation (airway control) is rarely needed (maybe once daily). Ketamine takes some getting used to (about half a day with the workload here...); the patients are in a dissociative state and can look up and sometimes talk (incomprehensible), but there is no pain or awareness, and the airway is relatively intact.
Well folks, that’s all for now! Next time I think I’ll tell you about my first laparotomy (abdominal operation) and how the OT is like.
PS. I seems like I’m to stay longer than the originally planned six weeks! Again, time is supersonic!
Comments to post 3:
September 27 kl. 05:26
Väldigt intressant (spännande?). Och det ska blir ännu mera intressant att lära var någonstans du befinner dig - antagligen efter du har återkommit. När blir det? Lyckas till! Mvh, John
September 27 kl. 11:13
Nu blev d lite jobbigt faktiskt. Har klarat den första månaden galant, men om jag ska vara utan datasupport någon längre tid vet jag inte om jag fixar det. Sköt om dig!!!! / Bettan i natten
September 28 kl. 17:12
Ojoj - nog vore det lugnare hemma.... När Du är åter låter vi Dig köra hela C-op ensam med ketalar och lite återanvända LM-masker. Var försiktig, och gå inte ut sent på kvällen i fel område med västgrejor.
Hälsningar / CF
September 29 kl. 12:26
Du ska akta dig för att lägga ut patientbilder på nätet - Lex Karolinska!
Hoppas du har någon tid, som kan kallas fritid, under ditt behjärtansvärda uppdrag.
Sköt om dig/Sten
Post 4: Crash introduction to the operating theatre
As I finished with in my last post, I got brutally thrown into reality when dr A left and nurse P was off for the weekend. The surgical team (general surgeon, orthopedic surgeon, and I as anesthetist) work all days of the week and we’re always on call; so far relieved only approximately one or two nights every week. We’re supposed to have Sundays off, but today it’s Sunday and I just spent my 45:th consecutive day at work...
Anyhow, as I mentioned earlier, this particular Saturday we were doing a laparotomy on a ruptured spleen (great call dr W!). I had my week of learning so I felt pretty relaxed and started the work enthusiastically. Half way thru I suddenly realized what an absurd situation I had put myself in; completely different from at home. Let me describe the setting:
We were called to the ER and a traffic accident. Due to the prevalence of malaria an enlarged spleen is quite common and prone to traumatic damage. Dr W (the general surgeon) examined the patient and determined the correct diagnosis without any X-rays or lab tests; just the history, examination and the vitals – I’m still amazed at that. The patient seemed quite stable with a pulse around 80 and normal blood pressure and as almost all patients, young and fit. Well, I had to do a preoperative assessment and investigation, didn’t I? The history and examination was done in a couple of minutes and I then had to pick what laboratory tests I wanted! That was quite easy as the lab only offer Hb (blood value), blood group, blood sugar, and malaria. Besides, the lab-tech was off for the weekend so I had to do the tests I wanted myself. So, I took some blood, found the keys to the lab and did the Hb (96 g/l) and blood group. I had never done it myself before, but it’s not rocket science: take three drops of blood on a white kitchen tile (yes!), add reagents, mix and see what antigens the patient carries. Then open the fridge and see what the blood bank has to offer. Take your pick of compatible blood and do a cross check on the actual bag you choose and you’re ready to transfuse!
Well, at the time I wasn’t so confident about dr W’s diagnosis, so I was quite relaxed. Nevertheless, I did as we do at home and prepared the patient with two large bore IV-lines, checked my airway equipment (a laryngoscope, tubes, oropharyngeal airways, masks and bougie), prepared my drugs, made an action plan and backup plans, and put the tea-kettle on (that is, to get a bucket of warm water for the blood and IV-fluids). We were four people in the OT (and actually in the whole building, except ward staff and patients): myself, dr W, an OT-nurse and an OT-assistant. Just then I suddenly realized that now I’m all alone; no one to help me or assist me, no one to fetch and find things or to set up and check the OT and equipment, no one to back me up or relieve me, no one to think for me when needed. I had trouble even reaching my cupboard with the stock of drugs and equipment as the OT wasn’t equipped with a ventilator. Once the patient was asleep and muscle relaxed, I had to manually and continuously ventilate him (not that I had any choice anyhow; I couldn’t move an inch in the minimalistic OT with all tubes, hoses and IV-lines).
The induction (with ketamine) was uneventful (dr W injected and kept the cricoid pressure; it’s mandatory even here...); but soon thereafter I got busy. The diagnosis was of course correct and there was roughly 2 liters of blood in the abdomen. I had from the ER given about 2 to 3 liters of fluid, but I reckoned it was time for another Hb: 59 g/l (low!)! The patient was still not so tachycardic (far less than 100 beats/min) and I still don’t understand why! Maybe his normal blood value was the original 96 g/l due to malaria and that I successfully transfused him to a normal volume but in so doing diluted him? He should still be tachycardic though!?
Anyhow, as you understand (and as I also suddenly understood): here I was aggressively transfusing (well, actually not so aggressively as I only had two units of blood), warming fluids, doing Hb checks, mixing and administrating drugs, maintaining anesthesia (with halothane using an OMV; thanks EDA-exam! (for the anesthetists of you)), checking vitals, taking notes of everything, and continuously ventilating the patient. As if that was not enough, I had to once set off to hunt down a mosquito!
Well, somehow everything worked out and the patient woke up after the operation; he was a little (well, eh, actually quite extremely) tired and cold... The first I blame on me, my drugs (especially the halothane) and the temperature, the second was inevitable and I saw it coming; despite my efforts to keep him warm he had a temperature of (close your eyes at home!) 34.3 degrees! Well, the next morning he was warm, stable and after another day ambulatory and eating. His, and our, greatest trouble right now is to find a pneumococcal vaccine for him (after you remove the spleen you are very prone to infection with the bacteria pneumococcus and thus need a vaccination).
Next week I think I’ll walk you thru the normal working conditions as they really are quite different from the laparotomy above. Maybe I’ll even throw in a quiz/question or two along the line...
Comments to post 4:
Oktober 7 kl. 11:24
Hej Henrik !
Betade nyss av ”chapter 4” och hoppas genast att vi får läsa lite mer om dina äventyr snarast möjligt !
Igår besökte jag Europas södra utpost ” Europa Point” på Gibraltar och där borta under molnen kunde jag faktiskt se Afrika. Visserligen <...> mil ifrån <...> men på nå´t vis så kändes det nära så mina tankar for genast till dig och de få människor som försöker göra världen till en bättre plats.
Kände att dessa människor måste hedras på något sätt och det enda tillgängliga var genom en inofficiell skål. Jag letade rätt på bussens enda fyllda pava och fann en flaska VAT 69 (€4.90/liter). Jag fyllde en kapsyl med denna ljumma och inte alltför angenäma vätska och sa högt för mig själv
- SKÅL och Tack Henrik och alla på <...> (och alla andra frivilliga organisationer)
Som betraktare av Er insats känns det nästan som att man skäms lite iom att min insats mest verkar bestå i att dricka vin och spela golf så nu blir det till att börja ge månatliga donationer till Er organisation !!
Ser fram emot när du kommer hem så vi kan umgås alla fyra (okej 5 med dex). Jag ska försöka hjälpa Nina med lite vedhuggning så ni får det varmt och gott i stugan till vintern
Var rädd om dig !!
Uffe (Åsa hälsar)
Oktober 8 kl. 21:04
Kors, ni verkar ha en del att göra käre vän!
Hur går det då med jonglerandet?
Nef på tisdag, jag hälsar.
Tag väl hand om dig!
Oktober 11 kl. 04:53
Kul att patienten klarade sig under alla primitiva villkor - gratulerar! Vilken sorts antimalarieller brukar folk som dig tar för sig själv där borta? Och eftersom du jobbar dygnet runt, vad brukar du äta?
Caroline The landlady säger:
Oktober 12 kl. 17:07
Vi i gbg följer din blogg religiöst.Alla blåshjud hälsar och hoppas att du är rädd om dig.
Post 5: Starting to settle in
Hello again! Last week’s description of the OT is not at all the weekday daily routine. It’s actually quite organized and not too unlike home. We finalize the operating list in the morning (and then modify it endlessly during the day...) and then set off to the OT. On a normal day it’s me and nurse P and we take one theatre each, and do the cases as they come. The patients are delivered to the corridor outside the theaters on stretchers by an army of stretcher carriers; no trolleys or elevators at the Hospital! I take their history (so far I have not met a single patient who knows what an allergy is) and ask them if they have been operated before. I have found that most patients answer “yes” to whatever you ask them, so when they say that they have been operated before I ask them to show me their scar. It then always turns out that they have not been operated at all (with one single exception!) and most have never even been in a hospital (not even at their own birth...).
For many cases I opt for a spinal and then try my best to explain to them what is going to happen. I now found out that my efforts largely were in vain, and I’m better off pointing to my own back saying “injection” and then to their legs saying “no pain”. That seems to do the trick and they are all without exception extremely cooperative and even relaxed – I don’t know if I would be equally relaxed if I were in their place; badly wounded and with strangers that don’t talk your language (pidgin English) to trust with your life. Anyhow, once the spinal is in place and the pain is relieved, most immediately fall asleep – I guess I have to work harder on the pre-operative pain medication... The surgeons then do their thing; mostly external fixtures and debridements. When working on the upper extremities a ketamine sedation/anesthesia will often work, but in some cases intubation and airway control is of course inevitable.
So, here is a question for the anesthetists of you (my apologies to you others): you have a young and slim woman in her twenties (thus probably easy to ventilate!) with an old and completely healed gunshot to her face. The bullet entered just besides the nose and is lodged along the rim of the lower jaw. On X-ray you see the bullet, and it is far away from the joint (so also its path of travel). The problem is that the patient can only open her mouth slightly; less than 2 cm, she then says it is too painful. The surgeon wants to explore the region because of an abscess and he says it can be messy due to probable involvement of the parotid gland. How do you solve the case? Available equipment: standard and basic anesthetic airway control; a (yes, a single one of each size!) LMA and bougie are your difficult airway tools. Human resources: you.
At home there is a red button on the wall. If I’m in trouble I’d press the button and then take cover as within seconds a steady stream of world class anesthesiologists would pour into the room from every available door. At the Hospital in the City there is no button... Next time I’ll tell you what happened with the case; I don’t know if I did right or wrong – I don’t even know if there is a right and wrong. Anyhow, I did what I did and it worked. In any event it would have been great to have a button or at least someone to discuss with.
PS. I attach a picture of the wall of the OT; which emergency tool (the fly swatter or airway bougie) do you think is most frequently needed?
PSS. In my next post I think it’s time to describe our excellent living conditions (really!) and equally exceptional food!
Comments to post 5:
Oktober 13 kl. 14:58
Myggjagare kan vara mycket, men jag tror att jag ser er på fotot :-) Verkar ha sin självklara plats även den så att alla snabbt kan nå den :-)
Puss och Vifft Nina och Dex
Oktober 17 kl. 22:31
I am writing to you on behalf of an asylum-seeker who came to Sweden from <…> almost four years ago. I have obtained your address from <…>.
This person has had his asylum claim rejected and is to be expelled from Sweden. After being in Sweden a while he noticed diffuse pains in his arms and legs. The pains increased and two years ago he was diagnosed with Parkinson’s disease with rapid progression. He has not yet reached thirty years of age and the disease is already severely handicapping him.
My question to you is if you know if it is possible to obtain treatment including medication, physiotherapy and supportive counselling. Is there a possibility for him to obtain daily help with cooking food, hygiene and care? The diagnosis shows that he will soon be confined to bed. If he is not given care his life will be radically shortened. He risks a prison sentence because of his political and religious activities. He was an active Christian also in his home country.
What are the possibilities of receiving regular medical care in prison?
I would be very grateful for an early response to my inquiry.
Birgitta Krona, Chairperson
Sundsvall Asylum Committee and
Board member of the Swedish Network of Asylum seeker and refugee Support Groups (FARR)
Oktober 21 kl. 12:43
May one ask you, what are your previous experiences with ketamine?
Post 6: Life goes on
It’s Sunday again and I actually have the day off! I’m spending the day at the house and just enjoy doing absolutely nothing for a change. Strange feeling! The house is in the nicer quarters of the City and I’ve only heard gunfire in the vicinity a couple of times… I have my own room and the ground service is fabulous; housekeeping, laundry and food are all taken care of by the logistic side of the Organisation. They have the explicit orders to do everything possible to enable us in the medical team to do our work as efficiently as possible - I wish the administration at my hospital at home had the same instructions and goal! The food is exceptional and delivered to the Hospital every day. The mission does not offer any hope of losing weight and I have to get the recipe for that homemade pizza!
The mission has tight security rules, but we are allowed to leave the house during daytime as long as we clearly indicate our association with the Organisation with T-shirts and logos. Kidnapping is a major source of income for some elements of society, so all movements and whereabouts must be declared and approved ahead of time, and we are always reachable by cellular or VHF and carry our security packs. When travelling by car it’s the expat that sits besides the driver that handles the VHF; all locations have codes and each morning we leave Mike Alpha (the house) for Tango Echo (the Hospital). For the first weeks I was very jealous at the people I heard going to the Whiskey Hotel; finally I learned it was a code for the warehouse…
Now for the quizzes and questions from last post! The most frequently needed emergency tool is (unfortunately) the airway bougie. Why? Because the operating theatre is equipped with an ultra modern electric fly zapper (see picture)!
How about the airway case? Well, that is a slightly more complex question. First I suggest you make a pause after reading this sentence and instead search the Internet for “life expectancy” in the country I’m in.
Welcome back! Now you know that among all the busy people in the City, no one is more busy than Mr. Darwin, and the woman from the case, and indeed most of our patients, would soon be at his mercy. There is no social security and no one but us will take care of you if you don’t have the money. “Oh, you got stabbed in the abdomen and your intestines are hanging out? No problem, we’ll treat you as soon as you put your money on the table. Or you got shot? We’d be happy to treat you but you might be a criminal (and you don’t have any money to pay with) – it doesn’t matter if you are four years old, you might still be a criminal (and you still don’t have any money).”
So, not doing the case was not really an option (I told you she was slim…); preparing for the case I decided on a battle plan based on our airway algorithm from home. I prepared the equipment at hand and told nurse P what was happening in case I needed help. Anyhow, I was confident that I could open her mouth once she was asleep and muscle relaxed.
I was wrong… Her jaw remained locked rigid, but on the positive side was that she indeed was easy to ventilate and somehow I managed the airway with the help of a bougie – again, I don’t know if I did right or wrong and in retrospect I wouldn’t do it again, at least not without prior discussion, more equipment and, most of all, a red button…
Since my last post I have been joined by a French nurse anesthetist, and that has really changed things. We take turns for calls and just to have someone to discuss with makes all the difference. It’s only a couple of weeks left of my mission, but now I can for the first time relax a little and even get some administrative work done! Just like home reports have to be written, statistics compiled, and inventories made. Life goes on…
In my next post I’ll try to wrap things up and answer all your questions. Keep ‘em coming!
Comments to post 6:
Oktober 21 kl. 15:41
Eller om jag ska drista mig att saga.. Hej Kollega! då jag numera sällat mig till gänget ”Fältsupporter”
Känns i alla fall som man bidrar med nå´t vettigt ….ett antal kirurg-kits (har inte en susning vad det är, men gissningsvis bra grejor) kommer förmodligen till stor användning med tanke på alla insatser på ”op-teatern” du berättat om.
Skönt att se att du fått lite avlastning och för att inte nämna det ,ett bollplank, mycket bara att ha i akut situationer (minns min svunna tid som utryckningsbefäl inom den svenska räddningstjänsten)
Här hemma händer inte så mycket förutom det som händer i övriga I-världen. Världsekonomin kraschar. Såg i DN att 7% trodde att vi just nu gick in i bättre tider, undrar vilka nyheter dom hängt med i. Undrar just vad befolkningen i <...> tror om framtiden, känns på nå´t sätt som vi i I-världen prioriterar fel saker, men det kanske är en del i det naturliga ”ecorest-loppet”, mycket vill ha mer sas.
Håller tummar för att det prel datumför hemresa inte förändras för vi ser i alla fall fram emot den dag du kommer hem igen, vi har mycket att prata om, planera (köpt en grym bok om Sydafrikas vingårdar), äta (har en frys full med älgkött), och en del att dricka (hört att du gillar amarone) finns en del till jag tror du kommer att gilla.
Ps hade lätt lagt en hundring på myggsmällan (vad är en bougie och vad är den långa blåa slangen på bilden vi myggsmällan? Same Same Or??)
Oktober 23 kl. 19:30
Snart bara en vecka kvar tills du är hemma hos oss igen. Dexter viftar frenetiskt på sin svans när jag säger "husse" och så börjar han att leta.
Älgkött i Uffe och Åsas frys.... Bättre kött än så finns inte och med tanke på senaste bjudningen där.... MUMS!!!! Vi satsar på det helgen efter hemkomst! Du kan behöva ladda batterierna och vila dina triceps, vilka jag antar tränats med myggjagaren...
Du har verkligen gjort en fantastisk insats dessa veckor sedan 18 augusti! Full av beundran genom våra samtal! Bloggen har varit uppskattad från många håll och jag är säker på att alla dina vänner kommer att följa dig i ditt nästa uppdrag från november.
Puss och välkommen hem!
PS: Nina som är tacksam för att mejl, blogg och telefon fungerar. Hoppas nästa ställe erbjuder det samma :-)
Oktober 25 kl. 19:57
Följer bloggen med intresse och tycket att det är skönt att någon är ute och bidrar till en bättre värld medan man själv sitter framför en dator och försöker få något så trivialt som en skanova Adsl-order att komma tillbaka...
Gör inget dumt, så ses vi när du är tillbaka.
Oktober 28 kl. 8:21
Jäklar vad grymt…hur går det för dig. Hittade dig på sidan av en slump.
Ta hand om dig.
Post 7: The end is near
Yes, the end is near and inevitable - in fact, after 10 weeks in the City I’m now on my way home! It’s been an extreme challenge with many and lasting impressions – actually way more than I had anticipated. I’ve learned and been exposed to so much that I don’t know where to start now that I have to summarize it all - in many aspects it far outweighs my previous 4 years of experience from home. Let me give you some numbers to put things into perspective:
During my 68 days in the city, I’ve worked 67 days (of which 51 consecutive) and 12 nights. I’ve done 122 cases under general anaesthesia (47 with intubation), 119 spinals, 23 laparotomies (11 during night), 1 thoracotomy, and each and every day except Sundays I’ve done pain rounds on approximately 65 pre- and postoperative patients. The EU law on working hours is as you understand not implemented here… BTW, did I say in my last post that I had the Sunday off? Well, that turned out to be not entirely true. At 00.10 the phone rang; the local anesthetist (out of approximately 10 to 15 in the whole City with a population of about of 2 million!) didn’t agree on him being on call and we had to go in and do a laparotomy on a pelvic gunshot wound. The patient was relative stable, but the blood bank fridge had little to offer - at the end of surgery he had an Hb of 42 g/l! Well, he made it, and a week later he got discharged home. I guess though that we won’t accept him as a blood donor for months to come…
Now for your questions that I promised to answer; first come first serve!
Rik: Yes! Let’s get wet when I come home – I can use some serious R&R! I’ll call you and you better stand up to your offer!
John: Well, now I’m on my way home as you can see and I also hope your food question has been answered. Yesterday it was Thursday and thus time for my weekly dose of mefloquine against malaria. Doxycycline is an alternative as some people have psychiatric side effects to mefloquine. However, I haven’t noticed anything; I’m completely normal, anybody saying the contrary has joined the conspiracy, nobody saw me, I’ve got an alibi, my friends made me, and does the voices in my head bother you?
Steffo: I think I have fully succeeded in one of my original goals, but the other goal has been a complete and utter catastrophe. I’ve rarely made it home before dark and it’s mostly been raining anyhow. However, indoors I have been able to perfect my 5 ball act somewhat, outdoor juggling has been impossible on all but a few occasions (see picture; and notice the Swiss leader on the top; thank you PPD-gang!). I guess my dream of 7 will be one that I won’t fulfill; and definitely not during this mission.
Birgitta: I’m sorry to say that your client has little hope of getting any support of any kind once back in his home country. As I explained in post 6, there is no social security what-so-ever, no one but your family will do anything for you unless you pay, and even if you pay, the level of care is very low. Yet more disturbing is that even your family might abandon you. You are simply too expensive to pay for, your care takes too much resources and time from the family and they might otherwise all succumb with the loss of income as a consequence of your caretaking. When it comes to medications the situation is even more grave. You can find everyday drugs, but rare and special drugs are not to be found, or they are prohibitively expensive. Moreover, you would probably end up paying for placebo as there is no control over the drug market, and you would have no way of knowing if you were sold the right drug. Your only option would be to obtain the drugs overseas. But, there is no functioning postal service, so you must personally buy them outside the country or have them hand delivered. During my 10 weeks at the Hospital I have not met a single patient that is taking any regular medication. As for the level of care in prison, I don’t know but I can imagine… However, on the positive side I don’t think his religion poses any problem. The south is Christian and the north Muslim; all levels of society are extremely religious and it’s an ever present fact in the daily life.
MJ: My previous experience with ketamine was extremely limited. I had the textbook knowledge, and I can remember using it twice: once on a ruptured aorta, and once on the field at the scene of a motorbike accident. I know it’s more widely used in other places, but by tradition (?) not so at my hospital at home. I definitely think I’ll now use it more frequently on severe traumas; I can in retrospect remember several cases that probably had been better off with ketamine. But one must remember that our resources are infinite at home; we have blood and fluid delivery systems that can keep up with virtually any blood loss, and our human resources and infrastructure is all but limitless. I know you folks at home might not agree with me on that; but trust me, we are extremely privileged.
Uffe: Yes, a bougie is same same as the blue thingy on the wall. It’s used to guide the breathing tube between the vocal cords when it’s tricky to get it down in the right place. It’s my favorite airway tool and I use it frequently, maybe too frequently as I should probably fiddle around a little more to get the perfect view without any additional tool. But, I’ve got a lifelong learning curve, so in a couple of years I might find myself using it less frequently. Thank you also for your warm and generous support to me and the Organisation – you’ve probably already have more lives on your conscience (in a positive sense) than most!
Well, that concludes my story from my first mission with the Organisation! It seems like I’m off to my second mission in two weeks; this time to a country plagued by civil war and harsh weather. It’s not yet finalized and many changes might come down the road. I’ll continue this blog and add new posts; check in again in a couple of weeks to find out what’s happening!
Finally and again: thanks for all your support; I now understand just how much it means. Keep it up and I’ll try to do the same!
Comments to post 7:
November 1 kl. 10:22
Välkommen hem käre vän!
Det har varit kul, intressant och inspirerande att få läsa dina erfarenheter från <...>. Glöm nu inte kvar bollarna så kanske du kan få tid till lite jonglerövningar (yeah, right..) hemmavid.
Anders N säger:
November 6 kl. 10:07
Mycket imponerande Henrik, det skulle finnas fler som du.
November 17 kl. 11:58
Jag låg uppenbarligen efter med läsandet. Jag förstår förstås inte detaljerna och implikationerna i och av det tekniska, men det är för mig som håller till bakom ett skrivbord lärorikt på mer än ett sätt.
Tufft jobbat! Intressant och roligt skrivet, väldigt roligt att du tar dig tid till det!
Post 8: Act 2 has begun!
It’s been a while!
Finally I’m back in the field! I was supposed to have a two week break between the missions, but due to problems of obtaining a visa and working permit for my new country I ended up spending a whole month back home. For sure I needed a break, but the extra wait and uncertainty was among the most frustrating things yet with my work with the Organisation. But our presence here is not fully appreciated by all parties, so bureaucracy and security does have a tendency to be on the slow side.
So, where am I? I left a country of wealth but with a complete collapse and absence of infrastructure. Instead I was sent to a country plagued by a long and devastating civil war and recently also of extreme and unforgiving weather and floods. My new city is north east of my last city; or more specifically 5 degrees, 1 minute and 42.10 seconds north and 73 degrees, 14 minutes and 8.31 seconds east. Now that should keep you busy… In my briefing literature there were references about the ongoing conflict since years BC, so solving the conflict is definitely not an objective or goal of the Organisation. However, in the remote areas the health care system is grossly inadequate, mainly due to a lack of supplies and human resources since the educated long since taken any opportunity to leave the area and country for a more prosperous life abroad. In fact, one of the doctors from my last mission and earlier posts is a native of my current country (no, I’m not in Canada…)!
Getting here was an experience on its own. Due to an unfortunate misprint of my passport number, I had to spend two extra days at the capital before heading north. Airport security (actually air force base security) is ridiculously tight and check-in procedures for the domestic flight took almost six hours! After two X-ray screenings, three body searches and five security check points, I could finally sit down in my airplane seat. The only item in my luggage I had difficulty explaining was the seven soft balls containing a suspicious bean-like substance (I have not given up on my original goals!)… In other aspects my luggage could well be some new form of biological warfare since it was loaded with cheese and goodies brought in to the expat team. Once we had landed we were transported in a bus without windows for another security check and photography; then the passengers were dumped outside a barb wire fence. Luckily (well probably not entirely by chance…) the Organisation had arranged for a pickup and I was swiftly taken to my new home.
Here I’m just starting to settle in. We are a team of four doctors: a gynecologist/obstetrician, a surgeon, an emergency doctor and myself as anesthetist. A field coordinator completes the expat crew, so the team of five is considerably smaller than at my last mission. Housing is, well, should I say different…? I do have my own room and there is electricity (now and then not so…), so I don’t have any complaints whatsoever. Again, the Organisation does everything to make our life easy, and so far they have managed very well with nice food and, more importantly, a fantastic team. Who needs hot water anyway when it’s 30 degrees outside?
Everybody says the hospital activity is a breeze compared to my last mission, but it seems to me that there will be plenty of work to keep me more than busy. I spend the first day (a calm Sunday) with a mini laparotomy in a spinal, and then to fiddle around with my equipment (I was discretely advised by a team member to rephrase that…). It took some time to figure out a brand new anesthesia machine without a manual and with its tubing disconnected in a box! This one even has a isoflurane vaporizer (but there is no isoflurane to fill it with, but I’d probably now choose halothane anyhow given my previous experience). With the exception of the end tidal carbon dioxide, I think I got it all to work; let’s hope there is no intubations tomorrow… The hospital is not a dedicated trauma hospital, but instead handles general cases in the general population. Every third night I relieve the emergency doctor for her call (today!) and I’ve read up on the most common reasons for emergency visits: asthma, diabetes, cardiac infarction and snake bites. The first three I at least had a clue about, the last I’ve now learned there is little to do expect supportive care since we run out of antiserum for the venom. As I said, I think I’ll be busy here too…
I conclude with a telling quote from dr M as she was showing my around at the hospital: “Who let the cows in?”
Hang in there!
Comments to post 8:
Jaha så var Nina gräsänka igen då...
Spännande att läsa din blogg, hoppas att du har det bra, vi tänker på dig!
/ Kram Åsa med familj.
December 12 kl. 00:06
Kul att höra från dig!
Med allt det besvär jonglerbollarna förde med sig i security får du lägga manken till med cirkuskonsterna denna gång. Tänkte själv försöka mig på tvenne bollar... Lycka till med det mer professionella värvet också, kämpa väl och tag ordentligt hand om dig.
December 12 kl. 17:58
Just read your blog. Very interesting. Is food as good as it looked in Dr. J’s video??
December 14 kl. 01:14
Jag inte skulle har misstänkte att du ska befinner dig åter i sadel igen så snabbt. Lyckas till!
Post 9: Anesthesia with a spice!
I’ve now been a little more than a week on my new mission and it’s like learning to walk all over again. I thought I had it all sorted out from my last mission on how to do anesthesia in a low resource setting. Boy was I wrong! Yes, I had one solution on how to do things; now I’m learning that there are several other ways. As the saying goes, there are several roads to Rome!
My only means to monitor anesthesia here is by pulse, blood pressure and oxygen saturation – no high tech machines or monitors that go “BLING” as soon as some variable, gas or vital sign is out of its normal range. I have a halothane OMV for anesthetic gas (but no means to monitor delivered concentration), basic airway equipment (but no carbon dioxide monitor to confirm that the tube is in the right place), and no ventilator but a manual bellows (and again no carbon dioxide monitor to give a clue how I’m doing ventilating the patient). At this mission I’m also much more affected by the setting; the fact that we’re surrounded by a war is evident and most drugs are in low supply. Morphine is the only available opioid, and only in a limited number of vials that soon expire. However, there are plenty of ketamine, suxamethonium, halothane, diazepam, local anesthetics, and antibiotics around; why would anybody ever need anything else? Come to think of it, it’s actually not so different from my last mission, but lacking the carbon dioxide monitor makes a large difference, and everything is just a little bit different. I know it doesn’t make a lot of sense, but it’s hard to explain.
So how is work? One word would describe it adequately: variable! Some days we rest (yes, the Sundays off are actually off! (except emergencies of course…)), and some days such as today we do seven laparotomies! Actually, most were tuba ligatures in mini laparotomies, but we also had a cystectomy, a caesarian, and an appendectomy. At home we would do the appendectomy intubated in a general anesthesia without any considerations; but here we have exactly that: considerations! The appendectomy was done in a spinal even though the patient was only 12 years old. “You did what?!?” I hear you say at home. “An appendectomy in a spinal in a 12-year old?!” Well, I told you, I’m not saying that I would do it at home, I’m just saying that it’s another story over here with other factors and aspects to consider. Besides, it worked beautifully! Two days ago we did one on a 10-year old and I think I’m getting the hang of the pediatric spinal doses!
The cystectomy was more of an adventure: a previously healthy and young woman with a large cyst on an ovary. The anesthesia and surgery went without any trouble what so ever. She was manually ventilated (approximately every six seconds, with approximately correct volume of air, with approximately appropriate concentration of oxygen from the oxygen concentrator, with approximately a perfect mix of halothane…), and the surgery was superbly done by the gynecologist and the general surgeon with a minimal of blood loss and without contamination (and with only two power cuts during the operation!). The patient then woke up as planned and was cleanly extubated (I’ve learned from my previous mission to aggressively combat low temperature!). After some hour the problems begun: she was fully awake and no signs of bleeding, but with a heart rate approaching 140 and a temperature and respiratory rate both approaching 40 with struggling oxygen saturation! Yanks! What is that? Infection and pain is easy to suspect, but an infection so fast? In a clean surgery? And she said she had no pain! Disturbing thoughts about malignant hyperthermia and thyroid storm came to mind… How do you diagnose those out here?!? How do you treat them!?! Unfortunately, we all knew the answers to those questions: no way to diagnose and no way for specific treatment. So, we ended up fighting the symptoms: ice packs can do wonders to a fever! We will never know what it was (and I don’t think it’s worth trying to smuggle a blood sample past military security…), but she survived despite our lack of knowing what was going on or what we were treating. Something must have done the trick!
Believe it or not, but my current mission is soon over as I’m leaving at the end of December. Next week I’ll wrap it up and let you know how Christmas was; rumor has it that Santa might be on his way with a long overdue carbon dioxide probe! We’ll see…
Merry Christmas to ya all!
PS. A quiz for the medics of you: You are starting an insulin infusion on a diabetic ketoacidosis. Your only available blood analyses are Hb and glucose; how do you know how much potassium to add?!?
Comments to post 9:
December 17 kl 15:16
Kul att höra hur du har det. Vi hörde också lite från Nina när hon åt middag hos oss i söndags. Den 21/12 åker vi och kommer lite närmare dig, men ändå långt ifrån. Lycka till, ha det bra och många gratulationer på födelsedagen! Vi ses nästa år.
/Ann-Margreth o Hans
December 18 kl. 06:05
Grattis på födelsedagen! Hipp, hipp, hurra!!!
Dexter och jag har ätit tårta i sängen och firat dig trots din frånvaro. Hoppas att de vet att du fyller år och firar dig där du är!
Det hälsas till dig från alla håll från fotobutiker till ålderdomshem! Man säger att du gör ett beundransvärt arbete. Kan bara hålla med! Är så stolt över dig och din insats! Och...
...du är varmt välkommen hem igen!J
/Puss och kram
December 19 kl. 16:12
Grattis på födelsedagen min vän ! Hela familjen hälsar och gratulerar så gott !!
Härligt att se att även du har en mängd utmaningar att lösa pga. avsaknad av hjälpmedel (trots att det är för tragiskt att det inte finns några). Men det som gör mig mest orolig är att jag inte sett ett enda bevis/fakta/omnämnande att du tillgång till en bougie (he he…I know what it is..)
Vi uppskattar verkligen det du gör där nere i xxxxx (…know that too.. but ”can´t” say…)…men man får en lite otäck känsla när man läser om det påtagliga krig som pågår i din närmiljö så vi hoppas att du snart får en ersättare och kommer hem snarast möjligt.
Hoppas vi hinner träffas (men föga troligt) innan du drar iväg på din nästa ”arbetsresa”
Var rädd om dig och GOD JUL
Post 10: Intermission
Time has again passed in fast forward! My second mission is already over and I’m sitting in the capital waiting for my flight home. In three days I’m leaving for Kenya and four weeks of shooting animals (with a camera that is…) – a vacation long overdue!