5Afs for a Plastic Bag

With the kids from the Red Crescent Society (ICRC) orphanage/clinic/school

Work on our research project draws near its end. We have collected over 100 surveys from physicians and nurses; if you consider that the survey is 14 pages long, this is quite an accomplishment. We have also held focus groups at a majority of hospitals, both private and public, with doctors, nurses, technicians, and administrators. And we have personally visited (almost) every emergency room/department in Kabul. One of the mentioned focus groups was with the Minister of Public Health, Dr. Suraya Dalil two nights ago (we had previously spoken to the Deputy Minister, Dr. Sahar at the beginning of our trip and spoke about it in our second post "Tea with the Health Minister".)

Advanced Life Support in Obstetrics training with Dr. Goforth of Self Regional Healthcare

Though it will take months to sort through all the data we've collected, we are getting an idea for where we need to focus in the future. A most surprising trend we are hearing is the desire of the younger doctors for training. This includes access to the most current medical information. To this effect, one of our top priorities will be to establish access to online journals and review materials (such as Up To Date) for Afghan residents that have internet access. I am in the process of establishing a mailing list that is becoming quite extensive.

Given the proper conditions, including security, Afghans are capable of great deeds. We are inspiring people, and full of potential. Even after 3 decades of devastation, the loss of two generations, an 'improved' literacy rate of about 30%, and a national income that is a tiny fraction of the military budget, there is still a drive and initiative that is not only evident with the young physicians but also among the children that run to your car at traffic stops. There is an immense "survival culture" here and these kids are such sharp business men that they make a living on selling plastic grocery bags and given the challenge they can probably sell you sand at the beach. If any friends at home were expecting me to bring gifts back, know that I've been unwittingly coaxed out of all my money.

This kid above showed up at just the right time to sell me used plastic grocery bags for 5 Afs a piece. I had to add tip.

Today we learned another fact that is Afghanistan's claim to fame. Next time you buy a rose, with a warm sunny color that is meant to convey feelings less intense than its red counterpart, think of the gardens of Kabul.

The yellow rose had it's origins here.

The Legacy of Avicenna

Ali al-Hussain Abd-Ulla Ibn Sina, also know as Avicenna, was born in Bukhara during the time of the Persians. His family was from Balkh, a province of northern modern day Afghanistan. His travels in pursuit of higher knowledge and understanding bares resemblance to that of Rumi, but their philosophy and interests in study differed quite a bit. Instead of pursuing spiritual purity, poetry with a distinct tenacity to fulfill the senses, and a constant longing for a direct path to the One, Avicenna is instead known for his treatise on philosophy, paleontology, inertia and momentum, and of course: Medicine. Though Avicenna was born some 300 years before Rumi, they may not have drawn such distinction between them as I have; science and spirituality have drifted apart relatively recently.

As a tribute to his contribution to medicine, Ibn Sina General Hospital was built half a century ago during a more peaceful Afghanistan. Today it's original buildings still stand among ruins in its neighborhood--a reminder of a more recent tribute to the civil war that ravaged Kabul after the collapse of the Communist regime. Some 500 patients pass through its main gates every day, coming from all over the country with hopes of receiving treatment for a broad array of ailments. Of course the actual delivery of treatment is relative and ranges from denial of entry from the doorman, to a week-long stay to get blood work done, to surgery with counterfeit pain medications from Pakistan that have recently flooded the markets.

Patients from the main gates are ushered to seven 'emergency' rooms that are designated for each specialty: Internal medicine, general surgery, neurosurgery, dermatology, psychology, and cardiology/pulmonary (housed in a separate building and functions independently.) Interns and second year residents staff the rooms where patients with complaints that pertain to their specialty are sent to them, they evaluate the patient and determine whether they are to be admitted, sent out for labs/imaging, transferred, or sent home. There is no standardized system for receiving, triaging, stabilizing, or disposing of patients at hospitals and there is tremendous variation between hospitals. At Ibn Sina, aside from a obligate lack of general supplies, this was a more functional model for Emergency Medicine I've witnessed in Kabul thus far. The specialists where all right there waiting for their patients to arrive. These residents were some of the most clinically astute doctors I've ever come across: they could recite the entire patient presentation, etiology, pathophysiology, diagnosis, and a treatment plan that could be implemented by their history and physicals--the way were all thought in 3 year of medical school but never perfected. For these guys, that's all they have, and they are very good at it. Also of note is that they are the country's only pshych ER facility.

The Dam at Qarga: We drove about 15 minutes north of Kabul and spent Friday this beautiful body of water. The turquoise is unbelievable.

Their model for emergency care is by no means ideal; the specialized treatment rooms felt more like clinics; there was little communication between specialties; there were many complaints about lack of oversight and training; there is no functioning laboratory on site and most labs around town are not reliable; they don't have basic medications on a regular basis (i.e. nitroglycerin); there is a lack of security (from patients and their families who enter with guns); etc. All of this was relayed to us in a two hour conference where all the residents, attending, and nurses gathered in a huge conference room; we had asked for a small group of doctors and nurses for a discussion but the entire staff came. They had a lot to say and wanted to be heard. It was a humbling experience. A significant amount of data for our research will come from this hospital.

This blog was supposed to be about Afshar and Cure, but I wanted to give a brief presentation of Ibn Sina. You will likely hear much more about it from us. There are some very basic things that can be done to bring significant improvements.  Ibn Sina's 'emergency' rooms will become our side project to improve, develop, and hopefully restructure.

The Great Wall of Kabul

Its not the Great Wall of China, but the tales are just as grand. It was built as protection against the invading Arab armies and later used as shelter against the British (there are three fabled Anglo-Afghan wars, not including the current.) It stands among the newly built mud huts, sprawling the mountainsides. Looking up to the houses from the street, one can’t help but wonder how the slopes are traversed to get to some of these homes—especially in winter, with the snow. We had he best kabob at the foot of the Great Wall of Kabul. It was in fact the best I’ve ever had. Bourdaine has nothing on me.

The kabob was a treat after our visit to Rabia Balkhi—Kabul’s dedicated women’s hospital. It stands in name but in resources each hospital we visit is severely lacking in the basic things one needs to see to call it a hospital. We know that thi has become a running theme in our visits to each public hospital thus far. So how do the country’s hospitals and doctor’s run? With little resources and technology it therefore stands solely on the shoulders of physicians to diagnose based on the very basics that all of us as physicians learn early on in medical school- by physical examination. We have come to know these doctors as some of the most intelligent and clinically astute MD’s we have ever met. Many have told stories of seeing patients in the midst of gun-fire and rocket ships blaring from above the hospital ceilings. All Afghan doctors deserve a salute for their selfless giving, bravery, and humanity. But the place of female physicians is without question very special to us. Though most were still unwilling to be placed on film or have pictures taken mostly for security concerns, they shared with us their lengthy stories. They spoke of previous years where they saw patients secretly in their homes, performed surgeries and deliveries under the burqa, livied in hiding in hospital basements- for fear of being jailed or even killed by Taliban for practicing their beloved profession. Though today they practice freely, their woes are far from over. They do not have enough functional fetal monitors and no uterine contraction monitor at all; the blood product and drug shortage the plagues most public hospitals does not spare them; and they do not have a neonatal ICU.

Homes with a View

Rabia Balkhi, though, is still unique. Staffed by obstetricians, primary care physicians, and Midwives. The hospital is government run with oversight from the Ministry of Health but receives technical support from the International Medical Corps (IMC). It is a major referral center for all obstetrical emergencies and a major training center—including residency training programs and midwife training programs. The Midwife training program is meant to supplement the severe shortage of doctors in the rural setting which contributes to the one of the worst maternal mortality rates anywhere in the world. Because of the security situation, very few doctors are willing to leave the city itself; so the Basic Package of Health Services (discussed in our first, Project Overview) has set aside funding to train Midwives to supplement this shortage. They have an ambulance system, with only a few vehicles that are meant to transfer between hospitals and are generally reserved for transfer FROM outlying hospitals. Since these outlying hospitals are no more than rudimentary clinics and delivery centers as far as obstetrics is concerned, Rabia’s ambulances serves as the initial framework for prehospital care.

The destroyed presidential palace--Darul Aman

The entry to Rabia Balkhi is jammed by human traffic. Women swarm the 2x4 window etched in the main wooden gate to get registered. Wait times of greater than a week are not unheard of. Once they get to registration, the great majority are sent to the general labor and delivery section and a small minority are sent to the emergency section. We visited the emergency section with the deputy chief of obstetrics. It was rather rudimentary: 6 beds, one blood pressure cuff, one ultrasound machine, and one uterine contraction monitor that was out of service. There were 4 patients. One of the patients was a transfer from the south of Kabul: after giving birth she had hemorrhaged. She was brought in a day earlier and because the hospital did not have enough blood, they screened family members and designated a younger sibling as a donor. The patient was receiving her transfusion as her story was being told.

The broader picture of healthcare in Afghanistan has not improved much, but it is getting better. The greatest hope lies in the younger generation of doctors that are eager, willing, and more than able. We visited two newer training hospitals, Cure and Afshar, that were different and inspiring. We will talk about them in our next blog and also touch on the meaning of free healthcare, user fees, and the role of government.

Saturday is Monday

Everyone back to work with somber faces. We had an appointment with the Chief of Medicine to get a tour of one of the more efficient ICUs of Kabul. Again, it is unfortunate that we cannot upload video because of the slow internet speeds. We conducted a very touching interview with him. He has been through the ups and downs of the hospital; through regime change; through the Taliban; and has never given up hope or given up on building this unit. Focusing on the current issues, his most pressing seemed to be the lack of drugs/blood and the lack of a working CT machine.

There are things we take for granted that were obvious when we first arrived: Latex gloves, disposable gowns, IV tubing, and even needles. But consider a regional trauma center without a functioning CT scanner, where most of the drugs have already expired (within the past month, if you're lucky), and blood products that have to be brought from the bank (on the other side of town.)

The ICU: We were rounding at the other end with Surgery setting up for a gastrostomy; Physical therapists assist a patient at the bed next to us.

We joined in on rounds being conducted on a patient that had been involved in a car accident. He had a negative CT scan initially, but because he required intubation he was transferred to this ICU where they have 10 ventilators (more than most hospitals). Here I have to commend their clinical skills: they have since given the diagonsis of temporal hematoma, but no scans have been repeated because this hospital has not had a working CT for the past 2 years. When I asked if the Neurosurgeon was willing to place a drain based on his clinical acumen, I got no more than a weary smile. Questions kept coming: what about ICP measurement to aid the diagnosis? No more than a blank nod. They have eager surgeons but no monitors for this purpose. We decided not to address questions of efficiency on this visit.

The ENT Resident, supervised by his Attending, placing final touches on a tracheostomy.

Our talks about this patient revealed more issues: He has been receiving Ensure by a Nasogastric tube for the past week. On the other side of the bed stood the surgery resident who explained he would be placing a gastrostomy tube today (ENT performs the tracheostomy); however, the patient had outlasted his supply of Ensure. The hospital has a quota, not only on Ensure, but also blood products and most drugs. When the quota is met, the family is expected to purchase the drug/blood products from outside and bring them to the nurses. We will not be addressing the cost of drugs/blood products on either the patient or the family on this visit.

ON the right, Leeda evaluates a patient who had returned for evaluation of a swollen and painful right foot. Kabul traffic is crazy; pedestrians and cars blend into a medley at major intersections. A car had run over her foot many weeks ago. Her foot had been plastered twice, but she continue to have pain and swelling over the dorsum of the foot. She had been waiting for the second day here, outside the main orthopedic emergency department.

Friday in Kabul

Friday is the official weekly holiday--the one-day weekend. Thursday night (considered 'friday night') the city comes to life; music starts blaring out of every corner; hot coals cook kabobs on the sidewalks and are carried into the restaurants; hooka/sheesha and tea rooms are at every corner; but by the time Friday morning comes around, everything shuts down and the usually gridlocked streets are emptied of traffic. Everyone stays home. We learned this late and made plans to go out on the streets on Friday afternoon, but next week we'll know better.

Khalifa lecturing us on Afghan politics.

We dressed in our best Afghan attire and left our apartment early in the afternoon, walked about half a mile down the street and caught a taxi on the main street. This was a first for us on this trip as on our work days we have a private driver. Our destination: the world famous CHICKEN STREET in Shar-e-now. The ease with which we caught a cab should have been a hint that this wouldn't be a very productive day. Meet our driver: Khalifa (picture above.) He has been a taxi driver in Kabul since the Prime Minister Dawod Khan was overthrown in the 1970's, followed by the Communist overtake, then the Russian invasion to support the weak Communist government, the subsequent fall of the Communists to the Reagan-backed Mujahideen (if you haven't seen Charlie Wilson's War, please go rent it tonight), through the Taliban, and now the Karzai administration. His final judgement is that there has been no functioning government since Prime Minister Dawod Khan.

Chicken Street was mostly deserted. Half the shops were closed and the usually bustling streets had few people roaming them, except for a few awkwardly placed students from the U.S. and us. The shops were all tourist-oriented with some carrying rare and antique guns and knives from all the provinces. Flower vases and plates frequently exhibited flags of the US and NATO nations along side the Afghan flag.

Tomorrow we visit a busy ICU with new ventilators and the Kabul's largest dedicated women's hospital that is a regional referral center for Obstetrical emergencies. We are hoping for a really enlightening interview with the director, but unfortunately we are not able to upload video due to the really slow internet speeds.

I'm sure we'll have plenty to talk about though.

Anesthesia Absent

The degree to which specialists are needed in treating emergently ill unstable patients is relative, though their contribution to definitive care is indisputable. It is my personal opinion that no services should be withheld if they benefit the immediate situation; that is as long as the doctor in attending has the competence to deliver.

After morning duties, I took the early part of the afternoon and visited the 'receiving' department of another local hospital. Their claim to fame is the triage of greater than 300 patients per day through this department. After going through the typical bounce through different offices, the 'communication director' personally escorted me to meet the Chair of the department. The department was relatively well lit and clean; it was a long hallway with individual rooms holding patients on single cots--most rooms without any other equipment in the room. There was a crowd of people around a room; most staring quietly; a few screaming, crying. The Chair walked out and greeted us, follow by a tray carrying all the requisite materials for intubation, and a few (reusable) needles. They had been waiting for anesthesia to intubate, but they never showed up. I didn't ask any further questions, but it was obvious an important step in this patient's management wasn't completed.

On another note check out Kabul early at sunrise from my balcony. It is amazingly green--the entire city. Apparently the local government underwent a massive tree planting campaign to replenish all that's been lost over decades of war. They pretty much made it a law to plant a tree, which was given to them. Aside from what you may read or hear on foreign news channels, I don't feel like I'm in a war zone.  A not to distant blog is going to focus on the Wedding Halls of Kabul... reminds me of Vegas. kinda.

Tea with the Health Minister

This was our second day in Kabul, but our first day working exclusively on our project. The beaurocracy here can be debilitating if you don't have the right contacts. Everyone is the boss; everyone is trying to push their weight around. We started out the morning chasing beaurocratic channels at the "400-bed" military hospital in the heart of Kabul. This hospital was built 3 decades ago and is relatively well-funded. It has an 'emergency department' that is divided into two sections: the trauma unit and the general medicine unit. These two departments provide relatively basic services and generally rely on in-house specialists for treatment (i.e. Anesthesia for intubation.) Patients that are deemed more "acutely ill" are transferred straight to the 3rd floor ICU department that is staffed by surgeons.

With our 14-page survey in hand, we were ping-ponged through various secretarial offices so we can be referred to the appropriate department head that can allow us access to physicians that staff the 'ED'. We were told more than once to come back tomorrow, but luckily found the office of the ED chief. His attitude was the exact opposite: He sat in his office with us and discussed extensively our project, its implementation, and we arranged for a return visit to spend the day with his staff physicians and to observed the department. He had called for tea but...

We were already en route to the Ministry of Public Health. Dr. Sadruddin Sahar, the Deputy Ministry pictured second from left, was very amicable and will surely prove to be quite instrumental in the coming days. He had his own deputy from the Foreign Relations office draft a letter, addressed to the directors of each hospital we plan to visit, giving his own full support for our work and requesting their full cooperation. Then we had tea. I'm hoping we'll be spending more time drinking tea and less time chasing beaurocrats.

Project Overview

Welcome.

Thank you for visiting our Blog. You are here because you already know us or you've been referred by someone else because you share our interest. Please feel free to forward this URL to anyone who you feel may benefit, contribute, advise, or simply like to read about our experience. Lets begin with a brief description of our project and a very brief foray into why we believe our work is not only important to Afghanistan itself, but for the developing world at large and health care delivery as a whole.

 

Project: An Assessment of Emergency and Acute Care in Afghanistan in the Current Conflict Setting.

Afghanistan’s healthcare has suffered tremendously after decades of war and civil unrest. The country is currently entrenched in an insurgency that is fueled by social problems- including lack of access to basic healthcare services. The current US strategy of Counter Insurgency and State Building seeks to diminish these gaps in an effort to curb terrorism and promote sustainable peace and growth.

  

One of the key focal points is that of actual health care delivery. Afghanistan has the some of the world’s worst health indicators and recognized as such, the major donor organizations such as USAID and the World Bank implemented what is known as the Basic Package of Health Services (BPHS). The BPHS seeks to address key areas such as mass vaccinations, infectious diseases such as HIV/TB and Malaria, and Maternal and child mortality.

We are currently in Kabul, spending our days in clinics and intermittently implementing our project.

Our goal is to use an evidence based approach to help identify gaps at the initial phase of patient interaction. Local physicians and healthcare workers have no formal training in Emergency Medicine and each hospital has a unique approach to the triage of patients--with or without receiving initial evaluation. Our work will seek to assess the capacity of Primary as well as Local Healthcare Providers’ to deliver acute resuscitation and stabilization as well as their capacity to transfer to definitive care through a series of surveys, small group discussions with physicians and nurses that staff these emergency departments, as well as personal observation.

As previously mentioned, the BPHS addresses some basic healthcare needs of Afghans. The BPHS is unique in that it is the first of its kind being implemented in a conflict region and has the philosophy of delivering healthcare as a human right. We hope that our work in Emergency Medicine can compliment the goals of BPHS, and expand to other regions of the health sector and eventually other countries.