If you look in the dictionary you will find the following
definitions for efficiency:
2) A concept that does not exist in Timor Leste.
Let me explain.
One of our patients is a woman who has suffered a severe drug reaction
after being treated with dapsone for leprosy (a sulfone reaction to be
precise). This hascaused her skin
to become inflamed and start peeling off her entire body. At present her skin – where it has not
broken or peeled off leaving raw oozing sites – is a thick, stiff shell. So stiff in fact that she cannot even
close her eyes. Another potential
danger exists with this type of drug reaction. One’s red blood cells (RBCs) can be destroyed.
And this has happened to our patient over the last 24
hours.
Her hematocrit (a measure of RBC concentration) dropped from
30 (already low) to 15 virtually overnight. The number one priority of the day outlined this morning on
ward rounds became secure this women 3 units of blood to replenish what she
lost (and then start her on prednisone to stop the auto-immune process
destroying her RBCs). No problem
right, just get a cross match done and order up the 3 units right? Not so easy.
The lab at the clinic either did not understand or did not
know how but for whatever reason they did not draw blood to check the patient’s
blood type. Though asked to do so
around 930am initially, at 3pm on a recheck we realized the patient was still
not receiving blood. The staff had
been unable to find a vein as the woman’s skin was thick and stiff. But they had neglected to tell anyone
about it! Eventually a foreign
doctor who had just joined the clinic team today was able to do a radial artery
puncture to obtain the requisite sample.
The patient was determined to have O + blood.
A quick call was put in to the National Hospital Blood
bank. The reply, we are out of O +
(and O – blood, which could also be used). Sorry.
We then asked the family if anyone was willing to be tested
as potential donors. Perhaps 8
family members were present but no one stepped forward. I was not quite sure why as my language
skills are still in their infancy.
We took a pole among volunteers and found two among us who knew they
were O + and were willing to donate.
I am O – (universal donor) and knew I could donate as well. The three donors to be hopped in the
back of the ambulance along with Stephanie as our support person and a Bairo
Pite clinic lab technician and sped over to the National hospital. Though they normally close around 4pm
they sympathized with our case and agreed to stay open.
There was only a quick form to fill out, not the extensive
questioning like in the states, and then onto the table – I made sure he pulled
out a needle from a sterile pack – and then lay back as the red stuff
flowed. I forgot how large the
needles are!
When all three of us had donated we sat around to wait for
the cross match process (a quick mix of our RBC’s with the patient’s serum to
make sure no antibodies from the patient attack our donated cells – a way to
ensure the donation will work).
After 10 minutes or so the technician came out and said the patient’s
sample had been delivered in the wrong tube and he could not cross match. We knew we had put her blood in two
tubes, one of them correct, and it seemed the Bairo Clinic lab had sent along
the wrong tube. Doh!
It was now nearing 6pm and the clinic staff member along
with us called back to our lab.
They had indeed sent along the wrong tube. We waited another 30 minutes as the correct sample was raced
over by motor-bike. During this
time our clinic staff member/translator had to leave.
Finally the blood was ready. I peered in the ice-pack chilled box and saw only one
unit. One, we needed three! With our Tetun-fluent clinic compatriot
gone my Tetun was the strongest of the group and believe me – it’s not so
hot. I tried to explain why we
needed all three but he didn’t seem to agree. He said something about a fridge and that we should come
back when we needed each additional unit.
I said we planned to give them all successively and he should just hand
them over, that it made no sense for us to come back for each unit. It was a stalemate. Finally we had the idea to call Dr. Dan
who after I handed over the phone fixed things somehow. He added in the two additional units are we were ready to roll.
So, case settled right? Remember the definition? Efficiency: not in Timor. The trip back to the clinic was uneventful besides lots of
traffic. We handed off the blood
to the night nursing team around 6:30pm with detailed instructions and made
sure they understood. I gave them
my phone number and told them to call with any questions.
At around 8:30pm I received a call, “umm, the patient’s
fever has not gone down with with Tylenol.”
“Did the fever start after starting the blood?” I replied.
“No, we haven’t given the blood yet. We are trying to get the fever down.”
“What?! The
patient needs this blood as soon as possible, please start it, I am coming over
as soon as I can.”
Arriving at the clinic I saw the ambulance pulling out
(apparently a man had been hacked in the arm by a machete and it was too much
to deal with at the clinic).
Making my around back to the patient’s isolation room I saw a great
number of her family crowded around.
Let there be blood I said in silent prayer. Making my way inside I saw the patient’s mother fanning her
to keep the flies off and there, hanging triumphantly, a unit of whole blood,
drip dripping away.
Efficiency. It
does not exist in Timor Leste.
But, usually, somehow, things do happen here. It just takes a little extra time, prayer, hard work, and
luck.
