Saturday, January 15, 2000

The Daro Debacle

My days as a doctor in Sarawak have been the most exciting times of my career.

Months ago, I took a long boat to Daro, a sleepy riverside village near Kuala Rejang. After the two- hour journey, I yawningly telephoned the district hospital ambulance to come pick me at the wharf.

Daro Hospital has three wards, one operation theatre and eight outpatient clinics. There’s an X-ray room, a lab and a blood bank. The hospital is run by some 80 staff (nurses, assistant nurses, attendants, medical assistants, clerical staff, laboratory technicians, cleaners, drivers, engineers) and one doctor.

Yes, one doctor. This one medical officer takes the ward round in the morning, sees patients in the clinic all day, performs routine and emergency surgery, and is on call all night long. He calls the shots. He diagnoses. He treats. And he sends patients home to the family or to heaven (or not).

In urban hospitals, doctors are given specific duties: surgical, paediatric, emergency. But in remote areas, I’m told, you hove to be ready for anything.

Day 1: Sunday afternoon

I saw a woman who claimed she couldn’t walk. Her son assaulted her, she said, pointing to her disabled hip.

After a few bedside knocks, pricks, and twists, I concluded that she wasn’t quite as incapacitated as she claimed. I told her to get up and try walking. She was okay. She went home.

Later in the night, the son turned up with the police. The poor man was suffering from a bad relapse of schizophrenia. He twisted his face and clenched his fists as he imagined tormentors attacking him. They want me dead, he shrieked. Clearly, I needed to administer a dose of strong neuroleptic to rest his tortured mind.

But he would hit us if we tried to coax him to stay still. Soon, we found ourselves chasing him up and down the hospital corridor It took six adult men to wrestle him to the ground before I could use the syringe on him, which knocked him out. We kept him sleeping in a locked roam, and we continued injections for another four days until he was free of his fits of violence. He went home calm and rested.

Day 2: Monday night

A middle-aged lady was brought in unconscious. She was paralysed on her right half from face to foot. With a background of being hypertensive and not taking her medication, it was fairly obvious she had suffered a stroke. Hypertension that is not controlled either causes brain vessels to burst or become blocked. Either way, some part of the brain dies. That’s a stroke.

I was in a bind. If she bled through a burst vessel, then her blood pressure must be brought down —just like you would tighten a leaking faucet. However, if she had a clot in a vessel, I needed to keep her pressure up and give her aspirin to prevent clotting.

But without a CT scan of the brain, I had no way of knowing whether to raise or lower the pressure. And getting a CT scan entailed a perilous, four-hour journey by speedboat through a network of rivers. Furthermore, it was night-time.

Judging from how deeply unresponsive she was, she probably bled in the brain rather than clotted. She was rushed to Sibu for a CT scan in the morning. It turned out she had a bleed in the basal ganglia, an area deep in her brain where nerve tissue converges. She was transferred back to Daro on the day I left. She had improved only slightly and would probably go home that way.

Day 3: Tuesday

In the mornings, I sit in the clinic and see outpatients. A sore throat here, a fever there, some back aches, red eyes, tummy pain, the usual take-two-of-these-and-you’ll be-all-right scenario. But I have to always be on the alert for some thing out of the ordinary.

Today, a 17-year-old married mother - seven months pregnant with her first child - told me she had stomach cramps and minor bleeding from below. I examined her. No contractions. It was too early for that anyway. Was the placenta coming loose inside? Was she having some indigestion? I put her in the ward for observation.

Four hours passed. No pain. No contraction. No bleeding. Not a word. Not a sound. Then, at 4 pm...

‘Head at perineum!’ my nurse screamed. My heart sank like a rock. So did my jaw. A premature baby was going to be born, and there was no stopping it.

We ran. We arrived in time to catch the tiny baby, which missiled out some five feet from her womb, followed by a glob of placenta. Oh, God! We cut the cord and rushed the baby to the incubator. We gave it oxygen, sucked its mouth and wrapped it up to give it warmth. It cried gustily. Soon, it began grunting in that helpless way all premature infants do because the alveoli in their immature lungs aren’t able to expand easily. Any expulsion of foetus before week 28 is a miscarriage, after which it is a premature infant. This kid was hanging an for dear life at week 29.

We worked on this baby for hours. We gave it intravenous fluids by passing a tiny catheter through its umbilical cord vein. An incubator kept the baby’s skin warm. We flooded it with oxygen. Antibiotics were sent through the umbilical catheter to prevent infection. We prayed.

I wanted to send the baby to Sibu, but the hospital had no ventilators left. Because of that, the Sibu paediatrician decided at 5 pm that the baby had a better chance in my inexperienced hands in Daro than in a boat to the neonatology unit in Sibu.

Hours passed. By 9 pm, it was obvious this baby couldn’t keep it up for very much longer. She was gasping for air, and her chest wall sucked in with every breath.

We made a decision to transfer her to Sibu to be put on a ventilator (God knows how they were going to find one). The young mum swooned a couple of times as she watched us sweat and struggle over the tiny life that was expelled from her womb.

It was imperative to pass a tube into the child’s trachea to help it breathe. I passed a tiny tube down the baby’s vocal cords and fed it oxygen. The tube slipped out repeatedly.

The entire night crew was there. They were giving their all. They ran helter-skelter. X-rays. Oxygen tanks. Hot-water bottles. Ambu-bag. Laryngoscope.

When we were ready, the emergency transfer team took over. We surrendered her to a kindly nurse who bundled the baby in warm blankets while everyone surrounding her carried the tanks, tubes and hanging bottles. We moved like one big spider to the waiting ambulance. We rushed to the wharf where they got onto the growling speedboat.

We wished them well. We prayed silently. Moments later, the boat was swallowed by the dark night. Thunder rumbled from afar and cracks of lightning heralded the journey. I returned to the unmanned hospital, thinking of the perils of the journey. They could get lost. The boat could crash and ricochet off unseen logs. The storm could capsize them. And the baby, who came into the world a little too early, now struggles to live outside the safe confines of her mother.

I called Joan who was in Kota Bharu from the hospital phone and asked her to pray for them.

I tried to sleep. About five hours later, the phone rang — a call had come from Sibu. I was informed that the team, along with the mother and her baby, made it to Sibu after four hours. Alas, soon after reaching the neonate intensive care unit, the baby died.

Day 4 : Wednesday

It is quiet this morning. Storks, flapping their wings, come to roost on this field beside the hospital. The clouds are gone.

We try to comfort each other. I know we are all grieving. If you love life, you never stop crying. We entrust the life that slipped through our hands into the loving Father’s hands above. We pray for comfort, healing and new life for the broken ones left behind. I never got to see the young mother again... God bless her and her husband, give them courage to begin again. I have a commitment to the living. And I go on.

I operated on a 10-year-old girl who had appendicitis. She recovered quickly and was able to walk and eat by the time I left. A 6- month-old girl had a shard of glass or plastic impacted on her eye. I gingerly flicked it off with a needle while the anaesthetist kept her under. Her mum was crying outside the whole time, I think.

I saw a man whose abdomen was so bloated with fluid that we collected 2 litres of it. I wonder what the tests will show.
I took care of two babies that lay side by side, tanning under the UV light, recalcitrantly yellow.

Day 5 : Thursday

A 2-year-old boy came to the hospital, pale as paper and vomiting blood. A quick blood test and my worst fears were confirmed. Leukaemia. This was the first case of leukaemia ever in Daro.

The boy hardly had enough hemoglobin to live on. I had never seen a leukemic child alive with only 2 grams/dL of hemoglobin (normal is 10 and above). We gave him blood. Very slowly. Any faster and we would have flooded his heart. He needed a bone-marrow examination quickly.

Day 6 : Friday

In the morning, we put mother, father, and child onto the speed boat. I joined them in the journey back to Sibu. The debacle at Daro was over.


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