Thursday, March 6, 2008

Senegalese medical "care"

Other people’s medical emergencies seem to follow me wherever I go.

Maybe it’s a sign that I should finally take the plunge and go into the medical field (something I’ve been on the fence about for a long time). For better or for worse, my experience yesterday navigating the Senegalese medical system (if you can call it that) certainly re-motivated me to look into public health and nursing programs post-PC.

(I’m hesitant to even share this story because I know it’s going to make my mother cringe, but it has a happy ending and looking back on it there was never any serious danger, just a lot of confusion and delay.)

Around 11:40AM yesterday, I was in my town, at the post office picking up a package. I was sweating profusely in my brand new Senegalese outfit, (having dressed up to teach that morning, only to find out that the teachers were on strike of course) when my phone rang. It was our PC security officer (PCSO) (who is absolutely wonderful by the way). He explained that a fellow PCV nearby had fallen off of her bike and cut herself badly and asked me to get to her ASAP. So of course I accepted and told him I could be there in about an hour. Luckily I arrived at the garage to an almost full bus so we took off right away. En route the PCSO called and told me that she had been transported from where she fell, by charet, back to her village and now her village had called a car to take her to the Senegalese hospital in the big town between us. He also told me NOT to let the Dr. give her stitches, but to stabilize and clean the cut and that a PC car was on the way and would be there in several hours (little did they realize how far away we really are, because a trip they thought would take 5 hours, took them about 9). I called another volunteer in the area and told her to meet us there as well.

Here’s where it gets ridiculous…

I arrived just as they did, in the “Urgent Care” office. I walked in and there she was, sitting in a wheelchair with a borrowed bloodied headwrap wrapped around her knee. But instead of being treated, the duty Dr. is arguing with her about speaking in Pulaar. Classic. At this point, she is exhausted, dehydrated, and finished talking, so I take over and try to explain to him about the stitches. The majority of the day was spent speaking in French so it wasn’t nearly as challenging as it could have been had I had to use Pulaar.

The Dr. was really aggressive and angry and he has basically been yelling at her because we insisted on coming in the room with her and now he starts in on me saying that it’s ridiculous for us to refuse treatment, we can’t tell him what to do or how to treat, that if a Senegalese person came to America they wouldn’t question the Dr.’s authority etc etc.

I have to be really calm with him and I explain very clearly that it is unfair to yell at us, and especially not her because it is not up to us, and would he please speak to our PC Dr. who we have on the phone. He refuses of course and gets more pissed off. Meanwhile the assistant starts pulling at the PCVs pant leg so that he can get a look at the gash. Now I’m sorry, but any First Aid certified stooge knows that YOU DON’T PULL!! So I have to tell him “hey, stop it. Get scissors and CUT the pant leg OFF!”
(Insert various inappropriate curses in English said to myself).

Finally the Dr. talks to our PCDr. and has meanwhile called in another Dr./surgeon. We’re still sitting in the office, all of us are on various cell phones, the poor girl is still holding her own leg, so I pull over a chair for her to prop it up on so she can relax it. And the assistant just grabs a bottle of Betadine and is about to dump it all over her! I mean, we’re in the waiting room and still being yelled at for crying out loud!

So just so you have the scene in mind. I’m standing next to her in the wheelchair; she’s in tremendous pain (being super brave about it and keeps saying she can’t cry cuz Senegalese people don’t cry. Hilarious.), the other volunteer is on the phone with her counterpart who has meanwhile also gotten a car and is running around trying to find us and help in any way possible. The assistant finally stops messing with her pant leg, and the Dr. and I are passing the PCDr. Back and forth on the cell phone. Finally she gets the phone back and while we wait for the other Dr./surgeon to show up the Dr. starts asking me if I have a husband! “ARE YOU KIDDING ME?” I roared. “NOW?! You’re asking me NOW! While she’s sitting in urgent care with fat and tissue hanging out of her kneecap, waiting to be treated…SERIOUSLY??”

In walks Dr #2 and the first words out of his mouth are, “What’s all this I hear about you not accepting our treatment? This is ridiculous. What are you doing here? I refuse to talk to any other Dr. There are other patients waiting. If you don’t want our treatment get out.” So two doctors have now yelled at this poor PCV and I made the executive decision to get us out of there and I tell our PCDr. That this is no place for her to receive medical care and we wheel her out.

Part of me understands that we (toubabs) come in with this air of distrust and fear at the prospect of being treated in a Senegalese hospital cuz well, it’s just not good care! I mean I was the one telling the guy to CUT her pants, and I stabilized her leg. Worrisome. Now they told us that of course they would use local anesthetic and then do stitches, but at that point we were all so angry at each other that I told the PCDr. that I would clean and dress the wound and we’d get her to a hotel and stabilize her and wait for PC to arrive.

Now all PCVs are equipped with extensive medical kits, but in the rush to get to her I didn’t bring mine because at that point she was still in her village and had her own. So I go to the pharmacy AT THE HOSPITAL and ask if they sell gauze or antiseptic or codeine.

None of the above.

It’s a hospital pharmacy and all they sell is paracetemol. Awesome. Too bad she doesn’t have a headache, she’s had a major trauma to her kneecap!!

So the other PCV who lives close by races home and brings back her med kit while myself and the people from her village and the other girls’ counterpart all get her to a hotel room. Oh yeah, and the first hotel we went to was full so we had to go to a different one.

It’s now been about 2 ½ hours since the initial fall. She’s been put on a charet, in a car, taken to a hospital, left the hospital untreated, and now we settle her in at a hotel in some AC. The counterpart is amazing and he goes out and buys her codeine, water, food, and juice because she’s feeling faint from the heat and the shock and all the excitment.

The other PCV arrives and I clean it out with hydrogen peroxide, loosely dress the gash, give her food, codeine, juice, and water, and get some ice on the knee to reduce swelling. Meanwhile our PCSO tells us that there is a Senegalese military nurse on his way to us at the hotel. (One of our PC drivers’ brothers works at the base nearby. Gotta love family connections right?)

The military driver, the nurse, and a random Pulaar woman (a nurse assistant I think) all arrive and come up to the room. They check out the wound and basically insist that she needs stitches and that PC really won’t be able to get here in time. Which is true. You need to do stitches with 8 hours because you need live tissue.

He gets on the phone with our PC nurse who is en route (still about 6 hours away) and we all agree that he can do the stitches. He brings a local anesthetic and injects it right by the cut. Which is incredibly painful as you can imagine. Here is where she is SO brave. Later she nicknamed me her “stitches doula” which I thought was awesome. And it was really amazing how similar the “coaching” really was. There was so much commotion and chaos and pain that I had to get right up in her face, and hold her hand, and have her concentrate on me, and her breathing, and help cover her eyes and give her a play-by-play of what was going on so she didn’t have to look.

Now in Senegalese/Pulaar culture women barely even make noise when they give birth. They have this crazy relationship with pain that I cannot understand. So poor injured PCV is trying her best not to cry, (and crying out in Pulaar mind you, which I thought was pretty badass). But the needle with the local anesthesia is very intimidating and painful, especially for someone who already has a fear of needles.

Basically this guy had no bedside manner. I don’t doubt that he wasn’t trained, and the job got done, but certainly not in any way we’re accustomed to. Now typically with local anesthesia, you have to wait several minutes for it to take affect. So what does he do? He starts the first stitch immediately even though we’re pleading with him to STOP and WAIT! This poor girl, is in so much pain, and being so brave, but terrified because he isn’t taking her pain seriously.

We get our nurse on the phone and convince him to wait a few minutes, now that he’s already done the first stitch to see if the anesthetic will kick in. Ultimately, for whatever reason, the local anesthetic doesn’t take. He keeps pushing on her knee and asking her what she feels to which of course she responds “OW that HURTS!” But he doesn’t believe her. They keep saying it’s all in her head!

We tell him we need a timeout. She and I weighed her options: they can give her another anesthetic, but there are only two stitches left and they have other patients waiting for them (supposedly, though he was napping before the driver had brought him over so I think they were just annoyed with us and wanted to go to lunch).

She decided to just bear through the next two stitches, as long as I promised to cover her eyes, help her breathe, and give her a play by play with a break in between sutures. I have to hand it to her…she spoke Pulaar throughout the whole thing and barely even shed a tear. Very impressive.

Once he finished, they started asking if we had anti-biotics, and anti-imflammatories, and offered to give her a tetanus shot. Basically they were going to give her every drug known to man. Kind, but unnecessary, and not good care. This is a huge problem in Senegal-over prescribing. People come home with bags of medicine for a headache and are given huge long prescriptions that they can’t read and don’t know which one is the most important because they usually can’t afford to buy all of them.

We refused all of the above noting our PCnurse told us not to and that she already had codeine, and local anesthetic coursing through her system. He wraps up the knee (MUCH to tight mind you, so I cut it off after they left).

We thank them, they leave and as I’m walking them out they mention again to me that it was all in her head and that she wasn’t really in pain. That the local anesthetic worked but she was just scared. Yeah, um…doubtful.

The upshot of the rest of the day was that the three of us hung out in AC, we gave her more codeine so she was feeling pretty great, we all finally ate lunch and hydrated (it was about 4pm by then), and watched DVDs on a portable DVD player while we waited for PC to arrive.

At 8:45pm the PCnurse, our PCSO and the driver arrived. They had already stopped by the military base and thanked them for their help and given them the appropriate “cadeaux” for their services. Our nurse told us that while the cut had looked really deep and severe, that the stitches looked well done and that there really had been no alternative, and that she had to have them done ASAP and PC wouldn’t have made it in time. She got her started on anti-biotics and anti-inflammatories, now that she didn’t have quite so many painkillers in her system.

That night the other PCV got a stomach bug, and had a fever so the two of them camped out in bed and got a full night’s sleep. I had a lovely dinner with the PC staff and then got my own hotel room, and watched Family Guy in the AC until I unwound from the adrenaline rush and fell asleep.

Looking back on the whole experience, initially I was upset with Peace Corps for being so unclear and indecisive and moving her around so much, but I realize now that it is really difficult to pronounce on the severity of an injury over the phone and they did everything in their power to help. Apparently it’s unheard of for them to drive all the way for a “minor” trauma. Of course in a more serious or life-threatening emergency we would be med-evacked to a more appropriate location. But in the end it was a good relationship to establish because the head of the military base told our PCSO that he should be our first emergency contact, at any time, for any reason because he is well-connected and they have lots of people all over the region that can get to us in no time flat and he is happy to help.

So while there was no bedside manner to speak of, and the quality of care was zero, the job was done and she is fine and on her way to Dakar today in the comfort of a PC car.

I can’t help but wonder if we had just accepted the treatment in the first place at the hospital would it have been that bad once the “proper” Dr. arrived? But the fact that they used Betadyne only was worrisome. Hydrogen peroxide is a much more effective tool (whereas Betadyne is typically used topically and takes several minutes to sanitize) and the military nurse in fact did not even know what hydrogen peroxide was! The collaborative effort of all involved though was comforting- from PC staff, to other volunteers, to village families, counterparts, and hotel staff. Bottom line is she is going to be just fine.

And as a result, I’m going to spend my morning looking up Public Health and Nurse practitioner programs in America. Because if there is anything this experience has taught me, it’s the importance of GOOD MEDICAL CARE EVERYWHERE, and it really highlighted the total lack thereof.

My reproductive health course at LSE included an entire section on the importance and dearth of Quality of Care, but now I really understand firsthand the difference it makes in a medical setting and why people in my town hesitate to see the Dr. and wait until the very last moment, which sometimes comes too late.

Hopefully that will be my last impromptu medical emergency, but now at least I have a better understanding of how to handle them here in Senegal.

And if nothing else, all of these experiences make great stories right?


Barry said...

If you go to nursing school you won't be hands on nursing long. Someone will hire you, discover your talents and put you in charge of the hospital.

Caitlin said...

Spoken like a truly very proud father. Thanks Dad. I know you're my biggest fan.

Jen Rosenbush said...

hey're doing such amazing work! and your blog is fantastic! this winter, i was volunteering at a hospital in southern india and it was so inspirational to read about all your work and how you overcame some of the same sorts of challenges i was struggling with. so thanks for that and i would be happy to send you a couple things if you let me know the address.

take care,
jen rosenbush