I Got to Decide

Awere Health Centre, in the camp of Awere, in Gulu District, Uganda. It's a building rehabilitated by the Médecins sans Frontières (MSF) team, and now has two small consultation rooms, a room for ORS (rehydration), a room for dressings and injections, a room for antenatal consultations, and a room for deliveries. There's a pharmacy with the limited drugs that we stock. There are two rooms for observation. It is organized. It is clean.

If you look closely, you can see the bullet holes from the attack in August.

For now it is calm. The clinic is closed, but just wait until 8am. Then the people start to arrive from the camp and from the surrounding camps that have no healthcare. The front steps and porch are soon covered with seated women and children. The odd very ill man can be found amongst the crowd.

They begin to enter to get registered. Their data is collected (name, age, village) and they are weighed. The infants and small children are put into a sling and hung up to a weighing scale (like meat in the market) and their weight is written down. Their MUAC (middle upper arm circumference) is taken to assess for malnutrition. If they fall into the yellow or red zones, their height is also taken to fully assess their nutritional status.

'Consultations' take a few minutes. There is rarely much of a clinical examination. There is not enough time. There are so many people waiting to be seen, and not enough time/space/staff, so diagnosis is mostly made by history and a look at the patient. The treatment plan is decided and the patient moves to either the pharmacy for meds, to the dressing room for dressings or IM/IV injections, to the ORS corner for treatment for dehydration, or to the paracheck corner to be tested for malaria. The most common conditions in the ORS corner are malaria, diarrhea, respiratory tract infections, and skin problems (scabies, infection, fungus). Usually they get intravenous treatment. Sometimes they die. Sometimes they live until we arrive and are able to transport them to the hospital. Sometimes they die on the way to the hospital. Sometimes they arrive at the hospital, but the doctors are not around for days, so they die there.

I arrive at Awere at about 1:30pm. We were a bit late getting started, and I am disappointed that we are not going to spend the night. I am immediately called to the delivery room. The midwife is off and the traditional birth assistant is having difficulty with a delivery. I come into the crowded room. I am kicking myself for not having reorganized the room as I had intended to on my last visit. There is very little room, and I am faced with a mild shoulder dystocia (head out but shoulders stuck). I am finally able to convince the assistant and the woman to allow me to help with the manoeuvres that are second nature to me – obviously not to them. The baby is delivered and we all breathe a sigh of relief. But by the time all is done, baby weighed and assessed, it is almost time to go back.

I go to review the patients in the observation rooms and to discuss the potential referrals for the hospital. The clinical officer points out four people who need to go to the hospital. An old man with severe pneumonia, a woman with severe cough and bloody sputum, a man with ascites, and a child with what appears to be a severe abscess on her entire buttock, and unable to walk. The child is burning with fever and can't move her hip at all. Is this just superficial? Am I dealing with a septic hip here as well? She looks terrible.

We realize that all four can't fit into the car. Neither the old man nor the child can sit, and each need a caregiver to go with them. The clinical officer decides to send the man with ascites first, because he missed transport the week before. I take one look at him, find out that this ascites has been present for at least one month, and decide that he could wait. I know that the child has to go. I make my decision and tell the others. We load up the child and the old man and I feel relief. I feel good. I feel happy that I have the power. I know who is ill. I wouldn't have slept if the child had stayed, and I can feel good with the decision. I got to decide ….

Just one millisecond later I feel horrible. Horrible because I got to decide. I got to decide which of the four very ill patients actually made it to the hospital. What a terrible decision to have to make. Triage of patients – not just who will be seen when, but who has a chance at life and who does not.

But these are the choices that must be made when there is no ambulance, no local hospital, no infrastructure. And you have a car. And you are a doctor where there are none.

The old man died. The child is doing better despite the fact that there were no doctors to see her at the hospital for the first three days of her stay. She was finally seen after I spent 45 minutes waiting to speak to the head of the hospital about her case – he ensured she got treatment. The man with ascites and the woman with suspected TB got to the hospital later that week. He is missing, so it is unclear if he left the hospital or if he died. She is receiving treatment on the TB ward.

It is now Sunday and tomorrow a car goes back to Awere. I'm not going out until Thursday, so I have time to prepare all of the training I intend to do. And again, I will have to decide. It is becoming easier. Not because it is any easier, but because that is just how it has to be. And the children still come to greet me, and there is traditional dancing at night in Awere. Security is better and people are now dancing. I love to watch the dancing … maybe life will one day be better here, and the people will dance in a proper village and the camps will be gone.

One day …

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For another story by Dr. Bernard, see What is a Hospital?.

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