december 30, 2008
The Serif Umra dispensary is in a transition phase. Large parts of the activities are still carried out in tents or in structures that were really meant for something else. The completion of the buildings is long overdue and some of them, though finished, need to have their floors redone, again.
It is, I believe, the sixth time that those floors are broken up and remade, the sledgehammers are never idle. The vision is not only a permanent structure for the present profile of the clinic, but also an expansion of the activities to surgical capacity and a laboratory. This always looks good on paper, while in reality it is a painful process of constructing the necessary facilities, ordering and waiting for the equipment, recruiting the human resources and organising their training. This is Africa and everything, absolutely everything, takes longer time than anticipated. In the meantime, the medical staff soldier on, trying to maximise the use of the present resources while knowing that with the capacity waiting around the corner, more lives could be saved.
One such thing is the possibility of performing blood transfusions. Coming from a haematology (disease of the blood, leukaemia etc.) ward in Sweden, where half a dozen blood transfusions in a work shift is not uncommon, I find this experience very sobering. It is one thing to order whatever you need in whatever quantity from the hospital blood bank and another to, after identifying the need, immediate or prospect, for a transfusion in a patient, having to start from scratch.
Current limitations simply don’t allow keeping a blood bank in Serif Umra. Hence you have to start by checking the blood group of the patient, then continuing with searching for and hopefully finding and interviewing a suitable donor (matching blood group, good haemoglobin and generally healthy), screening for infectious diseases such as hepatitis and HIV (time consuming, despite ingenious rapid tests), taking the blood, cross testing it for reactions with the recipient before finally being able to start giving it. Of course, this constitutes the minimum requirements for safe blood transfusions. It’s neither possible nor desirable to cut corners when doing this, or quality will be compromised. Consequently, this takes time, though necessarily so. Even when, like in this case, you have an experienced laboratory technician, you will probably need an hour for preparations, all depending on how lucky you are in your search for a donor. Then take into account that this still only means one bag of blood and only critical patients are considered for this treatment, sometimes needing more than just that one bag.
This means you need to find more donors, so whatever you do you’ll be fighting against time. The trick is, of course, to foresee an emergency. The other day we thought we did. A young pregnant women came to seek care for vaginal bleedings. The placenta had partly detached from the uterus, causing profuse bleeding. There was no saving the foetus, and the mother needed intensive care. To reach a hospital with anything resembling an ICU you have to travel no less than three hours on dirt roads in an aged Land Cruiser, our grand referral vehicle, and you’d better get there before nightfall. Obviously, only stable patients could be expected to survive the journey. As the bleeding diminished, it was decided we should try and use our new-found ability to transfuse blood and then do the referral in order to give this woman a chance. All good and well, we started looking for a suitable donor thinking we had time, but soon found that the woman’s condition was rapidly deteriorating. The intravenous therapy to maintain the blood volume was result-less, and the blood pressure already critically low. Before long, we are doing resuscitation instead of a transfusion, ultimately out of time. At this stage, our efforts are futile and the husband soon asks us to stop the attempts to revive her. ”It is Allah’s will”, he says. How do you respond to that, coming from a man who just lost his wife?
Death is a part of everyday life here, and for sure I’ve had to give up on patients in Sweden as well, but one can’t help but be frustrated and wonder what could have been done differently, or what it would have meant to have that blood just a phone call away. These are different realities, and you adjust. In the end, you can make a great deal of difference with small means, and I’d like to think we already do.