Our patient from the other day first presented to an outside clinic, where there is no surgeon, when he still felt too weak to stand several days after being beaten with fists and sticks. He was admitted to the clinic with a swollen, distended abdomen and increasing pain, given intravenous fluids, evaluated with an X-ray and a blood count, suggesting blood loss, followed by a phone call to our project chief and a discussion with me about transfer. At home this patient would have had a CT scan to identify whether he had an injury to the spleen and/or liver, plus checked for signs of other injuries that would suggest he needed surgery. With a stable liver or spleen injury, he would be placed at bed rest to minimize the chance of recurrent bleeding. Here in the Central African Republic the choice was to risk leaving him at a facility that had no capability for an operation or transfer him to Paoua by LandRover with the risk of making any potential bleeding worse, as the trip is slightly less jarring than playing a game of rugby. We told them to send him over as soon as they could. Due to a combination of vehicle availability, road conditions and security issues, it was a full 24 hours before he arrived in Paoua, now almost six days from his initial injury.
I love surgery. I am grateful to be a surgeon. But I have always thought of it as something that I do for work, not who I am. However in Paoua, I am nothing more than the surgeon. It is who I am, what I do.
When the hospital radios the residential compound after hours, the call is for “le chirurgien,” not for me by name. MSF brought me here to be their surgeon. Their expectation was that I could practice broadly in my own field plus was willing and able to practice outside the realm of general surgery including performing c-sections. I am also asked to provide care for problems that back home would be handled by other specialists; orthopedic surgeons, ENT doctors, urologists and dentists to name a few.
In the US, I never practice outside the field of my expertise. Although my training covered a broad range of surgical specialties, I have pursued a sub-specialty practice over the years. In the US, if I see a patient with a problem that can be better addressed by another specialist with different training or experience, I refer the patient. In Paoua, I have no referral options. There are no other surgical specialists in Paoua and only a limited number in Bangui. Most people I see here have severely limited resources and are no more able to seek a consultation in the capital as to take a trip to the Mayo Clinic. If we can’t help them in Paoua, they don’t get help anywhere else.
In his latest blog post, US surgeon David Lauter describes having to decide whether or not to treat an infant girl for a gynecological condition outside his area of expertise. David is working in MSF’s hospital in Paoua, Central African Republic. Please leave your questions and comments for David in the comments box below his blog post.
If she passes the 18-20 month regimen and is cured of her disease, I wonder if she will remember her time here or will those surgical scars be the only shadows of her past.
We leave the hospital and I feel positive for Zulfia’s future.
Kartik Chandaria is a doctor writing from Tajikistan where he is working to treat children with multidrug-resistant tuberculosis. This is Kartik’s second mission as an MSF doctor. His first was in Liberia in 2007.
*Names of patients have been changed to preserve anonymity