Developing a New Routine

A New Routine

The six men sleep in one room, with varying degrees of mosquito nets atop us. The three women are in another. By 600 AM, all us are quite awake and rustling. Most of us were woken up by the roosters.  The sun is out. We get dressed and start heading out only to find our clinic now de facto church is having mass. The operating room does not begin until 9 AM and so it is unclear what our role is until then as we are all looking forward to taking care of patients.

We begin impromptu rounds at 730 AM and start on Medicine and Trauma wards. There are a few new patients to be seen. An HIV positive patient with a HgB of 4 has an infected gallbladder that needs to be addressed as we feel that she will not make it another night [untreated].

Rounds are interrupted by calls for help for “reanimation” in the emergency room. We run there as our typical trauma response which causes even more commotion. The patient has malignant hypertension and has aspirated. We leave Dr. Sarani in the ER to return to rounds.

"Nothing Like the States"

Now, rounds are nothing like the States. True, we have a nice Word document that is a list of all 120 or so patients. As we move through, we have very little idea of who these patients are, what their injuries are, or even if we are seeing the correct patient who we think it is. Wounds are dressed and the staff is reluctant to take down dressing unless there is pain medication on board (which an anesthesiologist needs to give). We start marking dressings with an “X” for change today, a “delta” symbol and date for later. Again, we keep adding patients to the schedule – Thursday and Friday and unknown injuries and wounds … it’s a bit overwhelming. After an hour and 15 minutes, we break off rounds without heading to the Church (now clinic) where another 50 patients need to be seen – oh, and the Peds unit.

A Day's Cases

After a rushed breakfast, we head to the OR. The ORs are amazingly efficient. The first case is a Posterior Wall Fx/Dx which in the States would be treated with a several hour open reduction and fixation. In this case, we simply place an external fixator and hope that the patient’s hip is located. We have no idea as we have no radiographs. In the other room, what was billed as an Malignant Otitis Externa is actually a fungating malignant lesion.

The day’s schedule includes a subtrochanteric femur fracture, multiple wound revisions, débridements, skin grafting, and new consults coming rapidly including an empyema, sacral decubitit, and a 6 week old supracondylar elbow in an 11 year old boy.

I am stunned at the turnover time. Patients are moved quickly. Post-operative recovery is at the bedside for all of a few minutes to at most an hour. Between cases, our wait time is less than 15 minutes – enough time to write orders and plan for the next case.

Thirteen cases later, night had fallen. The team was exhausted. The cases covered a wide variety of orthopaedic and general surgical procedures. It was a bit unsatisfying – knowing the queue of patients that needed to be treated, the lack of radiographs (no films available), and the continued need and desire to “check off boxes” – treat patients so that they would not need to keep coming back to the OR. That, as I am realizing, is not a real possibility.

We were supposed to do wound rounds, cast rounds, review new patients, have a team meeting, and meet with our PIH collegues … But, most of those things would have to happen the next day as the entire team put forth a ridiculous effort, only to realize that there were more “trucks to load tomorrow”.