A Day in the Life at Bangui General Hospital

 A twenty year old man shows arrives in a severe coma after being thrown from his motorbike.  There is blood coming from both ears. When he examined and given a strong painful stimulus he doesn’t open his eyes, makes some crude groaning sounds and flexes awkwardly on only the right side.  On the universal Glasgow coma scale he scores a very poor 6 out of possible 15, keeping in mind that an inanimate object achieves a score 3/15.  He pupils don’t react to bright light but they remain equal and only moderately dilated suggesting that the swelling on the brain isn’t enough to push the cranial contents toward the funnel at the base of the skull.

In a word, it’s bad.  Anywhere back home he would be immediately have a breathing tube inserted in the trachea and placed on a ventilator and taken to the CT scanner and to an operating room for decompression and to address any bleeding. It doesn’t take a brain surgeon to figure out that he needs access to an immediate operation and an intensive care unit to have any chance of recovery. 

In Bangui we have the capacity to do neither.  Our team has the capacity to do neither.  Our ICU consists of four beds staffed by two nurses, has the capacity to obtain regular vitals signs and provide oxygen from a concentrator up to 5 litres per minutes which isn’t that much.   We have two surgeons, an orthopod and a general surgeon.  If we bring him to the operating room and place him on one of our two ventilators he wouldn’t come off for days, weeks or never.   This would severely limit our ability to provide surgery for the rest of the population.  

Our French orthopedic surgeon from New Caledonia did some basic neurosurgery this week in response to a head injury from a grenade blast.  The patient was not severely injured in the sense that he was conscious but bleeding from his middle cerebral artery on the side of the head.   He was able to stop the bleeding and leave a drain on the layer just outside the brain. It is a very difficult decision but it turned out quite well as he is recovering with some occasional mild confusion.  If he doesn’t get infected he will likely do quite well. 

The bulk of the orthopedic patients we see are fractures from road traffic accidents.  Motorbikes are not your friend in CAR. Since internal fixation (placing rods and hardware in the bones to set them) isn’t possible due to infection risk most are splinted or placed in traction for 60 days.  At first it appears rather crude to see a trans-tibial nail but it is an effective treatment.  Jugs of water tied to the pin provide the counterweight required to maintain the traction.  The act of placing the pin doesn’t require much in the way of anesthetic.  A little freezing medication at the entry and exit site just below the knee, a few taps and it’s over.

There is no shortage of violent trauma in the form of gunshots and stabbings.  I suppose there is not a weapons shortage here. The ER only calls us for the severe ones.  This past week we had the grenade attack that brought two to the OR resulting in chest and abdominal trauma that resulted in a splenectomy and the minor brain surgery mentioned.  The same day there was a shooting by that resulted in 2 dead and three minor injuries that we took to the OR to remove Kalashnikov bullets from an arm and shoulder.  Machete or knife attacks seem to occur on a daily basis and the more significant ones are taken to the OR to explore and close the wounds. Travel by night is often very difficult and some patients arrive the following morning with significant wounds. 

We have been averaging about one bowel case per day often from longstanding hernias that acutely strangulate and cut off blood supply to the bowel.  The large abdominal incisions would certainly get an epidural back for pain relief back home but the conditions in which we work don’t allow such interventions.  I mitigate with an ultrasound guided abdominal nerve block at the end the case.  It is amazing how resilient these patients are in terms of pain resistance. In fact I have to scale back on morphine during the anesthetic because they take too long to wake up after the surgery. 

Fractures, stabbing, shootings and abdominal surgery makes up standard operating room caseload most everywhere in the world.  The frequency and severity of infections that present is rather impressive.  Every day patients arrive with week old infections of the hands, leg or feet that require significant debridement and in hospital treatment.  We are now doing a skin graft per day on old wounds that require coverage to complete the healing process.  In ripe infectious conditions like this it is a carefully weighted decision to provide a skin graft.

News from home included that the dog was acting a little off.  The subsequent veterinarian consult and options for investigations baffled me more than usual.  Since some of his bloodwork was off they offered to provide a steroid stimulation test and heart ultrasound.  I am always amazed at the capability for animal care especially when the customer is willing to pay.  The absurdity that my capacity to provide care for my dog outpaces what I can do for my patients in not lost on me.

The Backgrounder

Central African Republic does not top any list of exotic travel destinations.  This landlocked country of almost 5,000,000 inhabitants is about the size of Ukraine or Texas. It is bordered by Chad to the north, Sudan to the northeast, South Sudan to the east, the Democratic Republic of the Congo and the Republic of the Congo to the south and Cameroon to the west.   

Independence from France was achieved in 1960 but the aspirations of prosperity and civil liberty were quickly dashed.  A series of repressive military autocratic governments ruled for decades and free elections in 1993 failed to improve public confidence.  Further constitutional suspensions, military coups and fraudulent elections continued into the new millennia. 

The recent history of political instability resulted in the government being overthrown once again by northern Muslim Séléka rebels in the spring of 2013.   Séléka means coalition in the local Sango language.  Once disbanded the Séléka rebels ran amok committing mass atrocities resulting in formation of Christian militia. 

Our surgical mission is based in the capital city of Bangui.  It lies on the northwestern shore of the river Ubangui which forms the border with Democratic Republic of Congo and finds its way to the Atlantic 1000kn downstream. Ten years ago in Rwanda I was also on the very edge of the DRC border without setting foot inside.  Perhaps another time.

To call this a city in a true sense is an exaggeration beyond superlatives.  Bangui is undoubtedly the least developed capital I have ever encountered.  The level of poverty is comparable to many places I have encountered but the most shocking element is that lack of development in the downtown of the capital.  I have seen one paved road and the potholes suggest that it has been carpet-bombed. We live and work at the General Hospital right downtown and you’d think we were in tucked away in a far away corner of the country.  The most recognizable structure resembling home are the two grocery stores that might as well be called NGO-mart.  As everything is flown in the prices are high even by European standards.   Given that the Human Development Index of ranks at 185th out of 187 countries, few locals are shopping there.   Unfortunately the greatest opportunity for employment for the local population appears to be the NGO sector.

Bangui is at 4 degrees north latitude and the weather is equatorial and very humid.  Some time after a shower it is difficult to tell if you are still damp or already sweating.  The only oasis comes from the air conditioning is in the OR but the relief only comes if you can position yourself directly under the unit which is not where the anesthetic machines are located. Cold showers are not an issue, are much appreciated and are taken at every opportunity in the common washroom. Rainy season is approaching in a couple of weeks so I can expect foggy mornings and a daily rain shower.  We had a front roll in that slammed the windows and dropped rain in drops so big you could see them individually.  The resulting break from the blanket of heat was certainly appreciated.

MSF has been in CAR since 1996.   Despite the exposure the expatriate staff get most of the work done by MSF is achieved by local staff.  There are five different bureaus in the country with operational centres in Paris, Barcelona, Amsterdam, Brussels and Geneva.  In all there are over 150 international staff in CAR from around the world.  Our project has about 20 international staff and 200 international workers including nurses, doctors, physiotherapists, social workrs, guards and drivers.

The project I joined is a surgical mission based out of the General Hospital in Bangui.   MSF international staff have taken on administration of the 100 bed surgical hospital and national staff runs the day-to-day operation.   The emergency room is the only 24-hour care in the country.  There are other projects operated by other NGOs that provide pediatric and obstetric care while there is some neurosurgery and urology that occurs during business hours only.  We have an orthopedic and a general surgeon and two operating rooms.  Patients arrive with a variety of injuries and presentations.  We see late presentation limb and visceral infections which often require urgent access to the OR. There has been a recent run of hernias and  bowel strangulations and we are regularly exposed to the rampant infections caused by injections of contaminated quinine for malaria.  The trauma that arrived is broad and violent.  Beyond the usual automobile and scooter accidents we regularly encounter patients with burns, armes blanches (machetes attack and stabbings), armes a feux (shootings) and this week we had a grenade attack that brought us three patients.

I have now been here over a week and am starting to get used to the routine.  More on the daily encounters to come. 

Along the Watchtower

As part of the orientation to join MSF I was invited to participate in a rather intense orientation session in Toronto in January.  There is no way to teach someone all they need to know about humanitarianism in two days no matter how intense.   The scope was broad and the level of depth was rather impressive for the time provided.   They packed thirty of us from all walks of NGO life into the office on Spadina Avenue and put us through the paces. The group was roughly half medical, nurses, doctors, pharmacists, epidemiologists (who are also docs) and half non-medicos, logisticians, engineers who specialize in water & sanitation, human resource officers and administrators led by a superb and very experienced staff.

I was thrilled to share the “Welcome Days” experience with my very good friend Michael, now an esteemed medical officer of health in Saskatoon.   After living together in Nairobi for a summer eleven years ago in medical school we have been kindred spirits since.  Perhaps the bond was forged on cross-country misadventures in northern Kenya enroute to utopian Lamu or trekking back to Nairobi from Lake Victoria by means of dozens of mutatu minibuses.  It was a great surprise to join together at the orientation around the corner from his first apartment in Toronto.

I remember at one they showed a promotional video depicting the work set to All Along the Watchtower a la Jimi Hendrix.  It was hard not be inspired.  We were going to kick ass and save lives.  On the flight just as Gibraltar passed on my right en en route to Bangui via Casablanca the same ballad came across my headphones.  In the context of being one of the very few physicians in a country of 4 million people I am considerably more apprehensive about what awaits.

To paraphrase the verses originally penned by Bob Dylan- I hope there isn’t too much confusion, few reasons to get excited and that I am able to get some relief.

Continental Conflict Zone Roulette

So it begins.  Since my MSF application was first submitted nearly a year ago the process has rumbled along while the daily activities of life and work provided distraction from the pending reality.  There were moments where it really hits home.  This past week has been full of them.  In the context the changing locations and dates I bid farewell to my little family twice.

I’ve left home many times before but the destinations were always more touristic. This won’t be the longest time I’ve been away from my very understanding wife.  Five weeks away is nothing in the context of most MSF missions.  I’m only special because I’m an anesthesiologist we along with surgeons are treated a little different due to the intensity of the work. This goodbye for many reasons is different. The biggest is that we now have a little boy, 9 months old and that changes everything.  He’s not crawling yet.  He’s damn good at sitting and eating but still rather stationary.  But he’s on the verge.  I installed the stairway gates the week before I left with the expectation that he’ll take off while I’m away.  The good news is that he (seems) to recognize me on video chat. Or perhaps like all humans he is simply mesmerized by a bright interactive digital screen and any figure making faces and noises is enough to capture his attention. I’ll have to ask him when he’s older.

Spin the globe, where it stops no one knows. Yemen, Gaza, Nigeria, Haiti, Central African Republic.  The last couple of weeks have been a blur of continents, countries and conflicts.  My MSF human resources handler/broker/torturer/agent in Montreal has guided me though the process with an expert hand.  That being said his threshold for declaring a region stable is rather relative.

How did I finally end up en route to CAR of all places? It is a matching process based on availability and need run out of OCP- Operation Central Paris, the central bureau that runs 80% of MSF surgical missions worldwide. They take my skill set, available dates and do their best to find a suitable mission in the context of global upheaval.  Unfortunately for those back home who would prefer very stable conflict free locales MSF tends to operate based on need and surgical missions are often associated with some level of instability (read: violence).  This doesn’t always hold true but is often the case.  

My first option was northern Yemen inside the Houti rebel controlled northern province of Amran.  It was supposed to be a safe location and a good candidate for a first time mission.  At the time of selection in January the poorest country on the Arabian Peninsula was not in the news but as winter progressed the news reports became increasingly concerning. The Houthi rebels overthrew the government and placed President Hadi on house arrest before he escaped to Aden and eventually fled to Saudi Arabia. The ensuing confusion and power vacuum allowed Al-Qaeda to increase its presence and resulted in a mass casualty suicide bombing at a mosque in the capital city of Sana’a killing 142 and injuring hundreds more.  Every time I inquired and received a reassurance of stability another non-reassuring event would create a headline.  To say the least family and colleagues were rather concerned particularly when the Saudis and Iran got into the mix and a bombing campaign against the Houthis ensued.

Eventually the faceless name at the Paris desk who was playing continental conflict zone roulette with my life agreed that Yemen wasn’t the place for a newbie like me.  Over the next couple weeks the list of options are various times included Gaza (a pediatric reconstruction project), Nigeria and Haiti.  I would have liked Haiti mostly due to my perception that the risks of kidnapping and aerial bombardment were both considered to be rather remote.

Then one day the wheel landed on exotic Central African Republic (CAR).  As it turns out I was needed to replace the anesthesiologist who is now headed to Yemen. Oh my! The most common reaction I heard when CAR was mentioned as the destination du jour was 1) Is that a country? And the follow up 2)What was it called before?  The answers to which are 1) Yep 2) Central African Republic.  It certainly isn’t on the radar or the map for most Canadians outside the humanitarian space. 

So after bumping my dates around and getting some support from my rather understanding colleagues in Ottawa I was off to Paris for a brief briefing where I was able to meet face à face with my handler’s handler.  Most importantly I had one free day to get lost again in the city of lights.  I also got my MSF jersey (read: T-shirt).  Made of heavy cotton and slightly poorly fitting, I slipped into a cramped OCP washroom to try it on.  It may not have been the same spectacle as getting my name called in the NHL draft but for me, in that dimly lit water closet it was the same feeling.  I felt as though I’d finally made it. This is my big league and as a Canadian, hockey and the NHL is the best reference.  I’ll stop shy of asking mom to stitch my name across the back.

This journey has been over a decade in the making.  As soon as I was in medical school in Winnipeg I was engaging the local MSFers to speak to the student body about humanitarianism.  When asked about how my spouse accepted the notion of my departure for a far off land my response was simple. She knew for ten years this was coming.  We were last in Africa/mother continent in 2005 as wide-eyed medical students on a rotation in Uganda.  I’ll concede it was part education, part medico-tourism.  But I loved it. There was something very grounding about the experience.  It certainly provided us with a sense of perspective about the world we live in.  My only regret is that it has taken this long to return. 

This mission is no tourist safari.  This is real.  In MSF parlance, this is my first rodeo.  I hope I don’t get bucked off.