Dispatch #3 - OBAT Clinic
Hard to believe I've been working here for six days already. Unlike an ED shift where volumes ebb and flow throughout the day, patients line up in the morning before we arrive and are then shuffled around the clinic until we see our last patients around 3:45PM. Similar to the ER, there's always someone else to see.
For starters, it was not easy to find an organization to volunteer with in a refugee camp. Naively, I thought it would be easy to find volunteer opportunities with organizations doing this type of work. I found a handful, emailed them, and none got back to me. So I sent another email, and then a third email. Finally I made a phone call and only after that did I hear back. And these were the organizations that returned my calls at all. I ended up signing on with MedGlobal after hearing many good reviews from fellow emergency docs. In Bangladesh, MedGlobal is working with OBAT Helpers and a local partner, Prantic Unnayan Society, to staff an outpatient clinic in Camp 4 of the Kutupalong refugee camp.
Only refugees are allowed to stay overnight in the camp. All NGO workers and volunteers have to stay outside the camp boundaries. While the camp does have defined boundaries, there is no barbed wire or obvious perimeter like I expected. The boundary between the camp and the local Bengali population alternates between a road running along the edge, jungle-filled mountainsides, and expanses of rice fields. Looking at the houses and living conditions, there isn't too much difference though the local population tends to have more land and larger house plots than the refugee camp itself. But there aren't obvious military check points, no large fences or signs, moats, or any other clear walls. The refugees could leave the camp but according to the local staff, Rohingya stick out from the local population in ways that are obvious to the locals though to an untrained observer it's hard to pinpoint. So some non-refugees stay in the towns immediately near the camp but most workers live in Cox's Bazar. A gaudy tourist beach town, home to 75 miles of the world's longest stretch of unbroken sandy beach, Cox is a 90-minute drive from the camp. The drive passes through miles of rice paddies and a few small road-side towns that appear to have some fried-food stands, the obligatory rickshaw repair shops, a welding shop or two, and at least one blacksmith shop.
The camp has very few vehicle-worthy roads. We drive about 7 minutes into the camp, hop off at the trail to the clinic, go down a steep hillside, cross a bamboo bridge, and up to the top of the next hill where the clinic is perched. To the west, the hill beyond the clinic lies in the Camp 4 expansion. To the east is the rest of Camp 4 and eventually, Myanmar. When you walk into the clinic, immediately to your right down three stairs is a small bamboo-thatched hut where the midwife runs a maternity clinic. We don't do many births at our clinic but she does prenatal checks and counseling. Opposite this hut, just inside the clinic's gate to the left, is the initial waiting area. When we walk in at 9AM there are usually 100+ people still waiting to be signed in. Take another 10 steps inside and then you're in front of the pharmacy and another pre-triage waiting area. Go another 5 steps and you're now inside the clinic. The first stop is a table with 4 Rohingya volunteers who are taking every patient's vital signs. These men have no medical training but are eagerly filling in the vital sign boxes on the patient chart. From here, patients now move into the main clinic which consists of a large open waiting area in the middle of the large square bamboo structure with 6 exam rooms around the edge of the waiting room. One wall holds the Emergency Department which has 4 stretchers, a few carts with medications, and a table where I sit and talk with patients who don't require a stretcher.
The ER team consists of my two interpreters, Zaw Ki and Hossain, a medical assistant, Pradip, a volunteer nurse from Australia, Jo, and myself. Zaw Ki and Hossain are both Rohingya refugees who have been living in the camp for the past 14-18 months. Both <30 10="" 130-200="" 15-25="" 9a-4p="" a="" abroad="" abscesses="" addition="" ago.="" ahead="" allowed="" always="" american="" an="" and="" angry="" are="" aren="" as="" asking="" bayzeed="" be="" beautiful="" because="" bengali="" between="" both="" but="" by="" can="" cellphone="" clinic:="" clinic="" clinical="" coordinator="" day.="" day="" distracted="" doctors="" doing="" dr.="" driven="" earn="" ed="" electronics="" employed="" english="" excellent="" experiences="" extensive="" extremely="" family="" for="" forgotten="" from="" full-time="" fun="" he="" help="" his="" hossain="" i="" in="" intelligent="" is.="" is="" ki="" kindly="" lacerations="" lancing="" local="" maryam="" me="" medglobal="" medical="" medicine="" meds="" myanmar.="" nbsp="" ngos="" nutrition="" obat="" occasionally="" of="" old="" older="" on="" or="" other="" out="" p="" patients.="" patients="" pediatrician="" per="" physicians="" placing="" practice="" prescribe="" private="" program="" refugees="" reminds="" remunerated="" residency="" retired="" s="" see="" seeing="" sees="" services.="" small="" smart="" speak="" speaks="" splints="" stall="" steps="" suturing="" synonyms="" t="" that="" the="" their="" there="" they="" things.="" this="" three="" to="" translating="" two="" typically="" ultrasounds="" un-backed="" us="" ve="" videos="" volunteer="" volunteers="" watching="" we="" week="" were="" whatever="" who="" whole="" will="" with="" word="" work="" worked="" years="" young="" younger="" youtube="" zaw="">
Compared to ERs I have seen in Ethiopia, Tanzania, and Jamaica, this clinic has the greatest number of resources on-hand and is a remarkably efficient practice setting. Here are some of the notable things I have at my disposal: an oxygen compressor, headlamps, a selection of IV antibiotics, a well-stocked pharmacy with multiple antibiotics, creams, blood pressure and diabetes meds, and various pain medications, multiple pulse oximeters, and TWO ultrasound machines (one is a great small portable one that was donated by a UK charity). Beyond the equipment, I have enough staff to help translate, give meds, teach patients how to take meds, and keep the flow moving. Thinking about it on the car ride home today, I think part of what makes our clinic work so well is that we have so many staff, but we can only have so many staff because they are all volunteers. In other places I've worked, where there are very few staff and chaos reigns, it is probably too expensive to hire enough staff that would be able to control the space and carry out treatments in a timely fashion.
The biggest limitation of the clinic is that there are no specialty services available. There is one nearby "hospital" that is also run by OBAT where I can easily send patients for continued IV hydration, IV antibiotics, or breathing treatments. And then there are a handful of secondary/tertiary level hospitals in the camps that have specialty services: general surgery (for appendicitis and other easily fixed surgical emergencies), orthopedic surgery, Ob-Gyn. it is possible to transfer patients to these hospitals but there always has to be a clear endpoint in mind. What exactly do I want this hospital to do for them and if they do that, will the patient be healed? If the answer is no, then we have a long, hard debate about whether or not this transfer is an "appropriate" use of resources (*cue future ethics debate). While there is no set number of transfers allowed, it's understood that we have to ration our transfers because we only have this privilege at the allowance of the other hospital. For example, the Malaysian field hospital, one of the three places with general surgery, just had a fire in one of their ORs and will not be accepting transfers for the next 3 days. So if we have a surgical emergency and the other two facilities don't accept the transfer, tough noogies.
Lastly, how do we physically transfer patients? If they can walk, that's preferable. If not, we call a "bambulance" or a "bamboo ambulance." This consists of a patient sitting inside of a large blanket with the corners tied that is then suspended from a long bamboo pole carried by two porters. These two men will carry the patient either to the road for transport by Tom-Tom (gas-powered tricycle) or 10-15 minute walk to the nearest hospital.
Alright, my eyes are closing in sweet anticipation of tomorrow's day off. Hopefully I'll get to spend part of it relaxing on the beach enjoying 80-degrees and sunshine on the Bay of Bengal.
In honor of the many goats we dodge each day while driving to the clinic, here's a classic youtube video of fainting goats.
For starters, it was not easy to find an organization to volunteer with in a refugee camp. Naively, I thought it would be easy to find volunteer opportunities with organizations doing this type of work. I found a handful, emailed them, and none got back to me. So I sent another email, and then a third email. Finally I made a phone call and only after that did I hear back. And these were the organizations that returned my calls at all. I ended up signing on with MedGlobal after hearing many good reviews from fellow emergency docs. In Bangladesh, MedGlobal is working with OBAT Helpers and a local partner, Prantic Unnayan Society, to staff an outpatient clinic in Camp 4 of the Kutupalong refugee camp.
Only refugees are allowed to stay overnight in the camp. All NGO workers and volunteers have to stay outside the camp boundaries. While the camp does have defined boundaries, there is no barbed wire or obvious perimeter like I expected. The boundary between the camp and the local Bengali population alternates between a road running along the edge, jungle-filled mountainsides, and expanses of rice fields. Looking at the houses and living conditions, there isn't too much difference though the local population tends to have more land and larger house plots than the refugee camp itself. But there aren't obvious military check points, no large fences or signs, moats, or any other clear walls. The refugees could leave the camp but according to the local staff, Rohingya stick out from the local population in ways that are obvious to the locals though to an untrained observer it's hard to pinpoint. So some non-refugees stay in the towns immediately near the camp but most workers live in Cox's Bazar. A gaudy tourist beach town, home to 75 miles of the world's longest stretch of unbroken sandy beach, Cox is a 90-minute drive from the camp. The drive passes through miles of rice paddies and a few small road-side towns that appear to have some fried-food stands, the obligatory rickshaw repair shops, a welding shop or two, and at least one blacksmith shop.
The camp has very few vehicle-worthy roads. We drive about 7 minutes into the camp, hop off at the trail to the clinic, go down a steep hillside, cross a bamboo bridge, and up to the top of the next hill where the clinic is perched. To the west, the hill beyond the clinic lies in the Camp 4 expansion. To the east is the rest of Camp 4 and eventually, Myanmar. When you walk into the clinic, immediately to your right down three stairs is a small bamboo-thatched hut where the midwife runs a maternity clinic. We don't do many births at our clinic but she does prenatal checks and counseling. Opposite this hut, just inside the clinic's gate to the left, is the initial waiting area. When we walk in at 9AM there are usually 100+ people still waiting to be signed in. Take another 10 steps inside and then you're in front of the pharmacy and another pre-triage waiting area. Go another 5 steps and you're now inside the clinic. The first stop is a table with 4 Rohingya volunteers who are taking every patient's vital signs. These men have no medical training but are eagerly filling in the vital sign boxes on the patient chart. From here, patients now move into the main clinic which consists of a large open waiting area in the middle of the large square bamboo structure with 6 exam rooms around the edge of the waiting room. One wall holds the Emergency Department which has 4 stretchers, a few carts with medications, and a table where I sit and talk with patients who don't require a stretcher.
The ER team consists of my two interpreters, Zaw Ki and Hossain, a medical assistant, Pradip, a volunteer nurse from Australia, Jo, and myself. Zaw Ki and Hossain are both Rohingya refugees who have been living in the camp for the past 14-18 months. Both <30 10="" 130-200="" 15-25="" 9a-4p="" a="" abroad="" abscesses="" addition="" ago.="" ahead="" allowed="" always="" american="" an="" and="" angry="" are="" aren="" as="" asking="" bayzeed="" be="" beautiful="" because="" bengali="" between="" both="" but="" by="" can="" cellphone="" clinic:="" clinic="" clinical="" coordinator="" day.="" day="" distracted="" doctors="" doing="" dr.="" driven="" earn="" ed="" electronics="" employed="" english="" excellent="" experiences="" extensive="" extremely="" family="" for="" forgotten="" from="" full-time="" fun="" he="" help="" his="" hossain="" i="" in="" intelligent="" is.="" is="" ki="" kindly="" lacerations="" lancing="" local="" maryam="" me="" medglobal="" medical="" medicine="" meds="" myanmar.="" nbsp="" ngos="" nutrition="" obat="" occasionally="" of="" old="" older="" on="" or="" other="" out="" p="" patients.="" patients="" pediatrician="" per="" physicians="" placing="" practice="" prescribe="" private="" program="" refugees="" reminds="" remunerated="" residency="" retired="" s="" see="" seeing="" sees="" services.="" small="" smart="" speak="" speaks="" splints="" stall="" steps="" suturing="" synonyms="" t="" that="" the="" their="" there="" they="" things.="" this="" three="" to="" translating="" two="" typically="" ultrasounds="" un-backed="" us="" ve="" videos="" volunteer="" volunteers="" watching="" we="" week="" were="" whatever="" who="" whole="" will="" with="" word="" work="" worked="" years="" young="" younger="" youtube="" zaw="">
Compared to ERs I have seen in Ethiopia, Tanzania, and Jamaica, this clinic has the greatest number of resources on-hand and is a remarkably efficient practice setting. Here are some of the notable things I have at my disposal: an oxygen compressor, headlamps, a selection of IV antibiotics, a well-stocked pharmacy with multiple antibiotics, creams, blood pressure and diabetes meds, and various pain medications, multiple pulse oximeters, and TWO ultrasound machines (one is a great small portable one that was donated by a UK charity). Beyond the equipment, I have enough staff to help translate, give meds, teach patients how to take meds, and keep the flow moving. Thinking about it on the car ride home today, I think part of what makes our clinic work so well is that we have so many staff, but we can only have so many staff because they are all volunteers. In other places I've worked, where there are very few staff and chaos reigns, it is probably too expensive to hire enough staff that would be able to control the space and carry out treatments in a timely fashion.
The biggest limitation of the clinic is that there are no specialty services available. There is one nearby "hospital" that is also run by OBAT where I can easily send patients for continued IV hydration, IV antibiotics, or breathing treatments. And then there are a handful of secondary/tertiary level hospitals in the camps that have specialty services: general surgery (for appendicitis and other easily fixed surgical emergencies), orthopedic surgery, Ob-Gyn. it is possible to transfer patients to these hospitals but there always has to be a clear endpoint in mind. What exactly do I want this hospital to do for them and if they do that, will the patient be healed? If the answer is no, then we have a long, hard debate about whether or not this transfer is an "appropriate" use of resources (*cue future ethics debate). While there is no set number of transfers allowed, it's understood that we have to ration our transfers because we only have this privilege at the allowance of the other hospital. For example, the Malaysian field hospital, one of the three places with general surgery, just had a fire in one of their ORs and will not be accepting transfers for the next 3 days. So if we have a surgical emergency and the other two facilities don't accept the transfer, tough noogies.
Lastly, how do we physically transfer patients? If they can walk, that's preferable. If not, we call a "bambulance" or a "bamboo ambulance." This consists of a patient sitting inside of a large blanket with the corners tied that is then suspended from a long bamboo pole carried by two porters. These two men will carry the patient either to the road for transport by Tom-Tom (gas-powered tricycle) or 10-15 minute walk to the nearest hospital.
Alright, my eyes are closing in sweet anticipation of tomorrow's day off. Hopefully I'll get to spend part of it relaxing on the beach enjoying 80-degrees and sunshine on the Bay of Bengal.
In honor of the many goats we dodge each day while driving to the clinic, here's a classic youtube video of fainting goats.
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