Sunday, October 10, 2010

Saturday is Monday

Everyone back to work with somber faces. We had an appointment with the Chief of Medicine to get a tour of one of the more efficient ICUs of Kabul. Again, it is unfortunate that we cannot upload video because of the slow internet speeds. We conducted a very touching interview with him. He has been through the ups and downs of the hospital; through regime change; through the Taliban; and has never given up hope or given up on building this unit. Focusing on the current issues, his most pressing seemed to be the lack of drugs/blood and the lack of a working CT machine.

There are things we take for granted that were obvious when we first arrived: Latex gloves, disposable gowns, IV tubing, and even needles. But consider a regional trauma center without a functioning CT scanner, where most of the drugs have already expired (within the past month, if you're lucky), and blood products that have to be brought from the bank (on the other side of town.)
The ICU: We were rounding at the other end with Surgery setting up for a gastrostomy; Physical therapists assist a patient at the bed next to us.
We joined in on rounds being conducted on a patient that had been involved in a car accident. He had a negative CT scan initially, but because he required intubation he was transferred to this ICU where they have 10 ventilators (more than most hospitals). Here I have to commend their clinical skills: they have since given the diagonsis of temporal hematoma, but no scans have been repeated because this hospital has not had a working CT for the past 2 years. When I asked if the Neurosurgeon was willing to place a drain based on his clinical acumen, I got no more than a weary smile. Questions kept coming: what about ICP measurement to aid the diagnosis? No more than a blank nod. They have eager surgeons but no monitors for this purpose. We decided not to address questions of efficiency on this visit.
The ENT Resident, supervised by his Attending, placing final touches on a tracheostomy.
Our talks about this patient revealed more issues: He has been receiving Ensure by a Nasogastric tube for the past week. On the other side of the bed stood the surgery resident who explained he would be placing a gastrostomy tube today (ENT performs the tracheostomy); however, the patient had outlasted his supply of Ensure. The hospital has a quota, not only on Ensure, but also blood products and most drugs. When the quota is met, the family is expected to purchase the drug/blood products from outside and bring them to the nurses. We will not be addressing the cost of drugs/blood products on either the patient or the family on this visit.

ON the right, Leeda evaluates a patient who had returned for evaluation of a swollen and painful right foot. Kabul traffic is crazy; pedestrians and cars blend into a medley at major intersections. A car had run over her foot many weeks ago. Her foot had been plastered twice, but she continue to have pain and swelling over the dorsum of the foot. She had been waiting for the second day here, outside the main orthopedic emergency department.