Tuesday, February 5, 2013


If you look in the dictionary you will find the following definitions for efficiency:

1) Accomplishment of or ability to accomplish a job with a minimum expenditure of time and effort.

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.