Places We Go: Bangladesh

In this limited series, we present personal write-ups from emergency providers that do international medicine.  We hope by sharing stories, we can learn from each other and build a network of ideas and experiences.

Background

In August 2017, there was an accelerated, forced exodus of Rohingya Muslims from Rakhine State in Myanmar to Bangladesh.  Nearly one million refugees fled from the terror amid beatings, rape, abductions and mass killings.  Currently, the stateless Rohingya are entrenched in dozens of makeshift camps.  Through the Islamic Medical Association of North America (imana.org), I briefly worked in the camps in March 2018.

The conditions of the camps were harsh and very difficult to witness.  Makeshift bamboo and tarp housing stretched as far as the eye could see.  Every conceivable open space was occupied with shanty dwellings carved into the dry, dirt hilltops.  The elevated housing was meant to protect the refugees from expected flooding during the annual monsoons from June to September.  Open sewage and rivers of runoff water were interspersed throughout the camps.  Malnourished and overheated children wandered through the camp often times naked and exhausted.

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There were many non-governmental organizations (NGOs) working on the ground in this vast complex.  We worked in a small section of Camp 11.  Our organizers were a mix of locals plus a group of junior physicians from Dhaka Medical College.  We brought four doctors: an internist, a family physician, an emergency physician and a clinical psychologist.  We all flew in from different parts of the U.S. and Canada to Dhaka then continued to Cox’s Bazar.  Each morning, we drove an hour to the camps and worked in varying locations within Camp 11.  Each day, we saw approximately 300 to 400 patients in the span of six hours.  Our local organizers worked it out each day so that we could use a large hut being used as a schoolhouse for our clinic.

Patients lined up in the hot sun for hours before the clinic.  Our local organizers ran triage with a priority on women and children being seen first.  This was very informal and chaotic due to the small space we had, the heat and volume of patients (many families came together to be seen all at the same time).  At each exam station, we paired a local junior physician with one of us.  Both physicians had translators.  The translators were locals and helped tremendously with crowd control and vital signs.

For documentation, we used pre-made carbon triplicate forms.  We had no access to lab or radiology testing.  We used a separate, pre-filled medication selection sheet created by IMANA for the major conditions the advance team encountered.  This was particularly useful for pediatric dosing and helped organize the physicians to develop a practice pattern.  Medications were donated or purchased daily by IMANA from local distributors and hauled into the camp by locals.  For transfers, we had an “ambulance” van that had no discernible emergency supplies.  On the main artery through the camps, Teknaf Highway, there was a Doctors Without Borders field hospital, a Malaysian field hospital and a Danish Red Cross hospital within 5-6 kilometers.  Given the traffic congestion, just getting from our camp to any of those hospitals took 25 minutes.

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The biggest limitations were a) the sheer volume of patients; it was hard to spend more than five minutes with a patient, b) lack of follow-up, c) running out of medications and d) as a conservative Muslim population, it was challenging for us to examine female patients as they were clad in burkas.  If a female patient was ill, after a lot of cajoling, we walked her to our makeshift covered area and our female psychologist served as a chaperone.  Even then, no breast or pelvic exams were allowed.

What I Will Remember Most

My uncle is one of the wisest men I know.  Just before graduating medical school, I visited him in 2005 in Bhubaneshwar, Odisha (one of the poorest areas of India), near our family’s ancestral village home.  We sat in a car at a traffic stop and watched a man covered in dirt and limestone toiling in the 100-degree heat as several others begged for change and food around him.  My uncle looked at me and plainly stated: ‘human beings know no end to their suffering.’  I carried that phrase with me (and still do).  However, now 13 years later (and hopefully having a lot more medical knowledge and life experience), after seeing the Rohingya people survive, I would counter my uncle’s saying by noting that “human beings also have no end to their resilience.”

So many of the women we met watched their loved ones taken away, beaten and/or murdered by the Myanmar Army.  Many were also raped afterwards.  Several dozen women we met (in just a small subset of the full camp population) were seven months pregnant—coinciding with the forced exodus in August.  These women endured the worst imaginable trauma and violence, yet still found the strength to walk miles across the border and live in the harshest conditions.  I learned that many women picked up orphaned children along the way and made them a part of their family.  The depth of their suffering was unimaginable, but their compassion and strength was palpable and beyond anything I have witnessed to date.

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Lessons Learned

As a combat veteran of Iraq and Afghanistan, I like to think I am focused and prepared in my professional and personal life.  However, nothing can prepare you to see people in such difficult conditions with no clear end to their plight.  In real time, I made some notes about lessons I learned that I think could help anyone going into such a situation as a provider:

Look within…and ask what can I offer?

Personally, I have found it can be a struggle for veterans like myself to find a place in civilian medicine after doing combat tours.  For me, when I am able to do it, going on humanitarian missions allows me to lead and use my combat experiences to help others.  One of the best lessons I learned in the Army was ask yourself before you do anything, what can I bring to the table? For weeks, I thought about what I could contribute to this mission that hasn’t been done by prior groups.  I decided I could offer two things: emergency medicine specific supplies and a portable ultrasound machine.

For the supplies, I reached out to a great organization, Partners in World Health (www.partnersforworldhealth.org).  They have a program of donating expired, but fully functional medical supplies to use on medical missions.  For a $250 donation, I got nearly $3,000 worth of basic emergency supplies that I was able to bring on the trip with me in an extra duffle bag.  I ended up using a few of the supplies in our clinic (the nebulizer masks were invaluable to the small children needing bronchodilator therapy) and then donated the rest to future IMANA clinics and a local Malaysian field hospital.  Full disclosure: many countries have difficult customs and quite honestly, had I not spoken the local language, I would likely not have been able to get those supplies across customs.

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Be flexible…and creative

For the ultrasound, I reached out to the Clarius ultrasound representatives (clarius.com).  Through their generous help, I was able to bring one of their devices with me.  After getting a feel for the patient needs after Day 1 of the clinic, I decided it was time to get creative using the ultrasound.  The high patient flow in the oppressive heat was staggering and we did not have 10-15 minutes to spare for ultrasounds.  Sitting down with my team, I decided to focus on an aspect of care that prior groups could not provide: obstetrics.  We used some tarps, tables and chairs to set-up a small ultrasound area.  Through the help of our local physicians and our psychologist, we took aside pregnant women and provided basic ultrasound images of their babies.  It was easily the most emotional part of the trip for me.  By Day 3 of our clinic, word had spread amongst the women in the camp and we were able to image several cases.  I had no idea beforehand that the portable ultrasound I borrowed would be used in this way, but I was so thankful we had the machine with us!

Love patient care…again

The grind of generating RVUs, fighting with insurances, pharmacies and overcrowding is draining.  Working in an environment with minimal resources and no support helps you hone in on what matters — a patient in need and nowhere else to turn to for help.  We were keenly aware of just how much and in what ways we could help the Rohingya.  After seeing a few patients and soaking in the horrid conditions of the camp we were in, I realized that cough, body aches and diarrhea seemed to be present in everyone.  I know some may cringe at this, but as a result, I took the approach of giving nearly every child vitamins (we ran out of those every single day), de-worming medication and if they had any cough, diarrhea and/or even a low grade fever, antibiotics.  I figured that we might be the only doctors they see for months on end and without any diagnostic testing, the symptoms they had were related to the camp conditions.  While some might view this type of medicine as contributing to burnout, I have found it to be completely the opposite.  I come back from these trips refreshed, eager and motivated.

Personally, I find much of that renewal comes from simply working in an austere environment.  Working with high volumes yet little time and resources, I find you adapt and develop a leaner clinical style.  The pace alone keeps you sharp on using all of your senses and physical exam skills to determine those patients that are sick versus those that are not sick.  I found nearly every patient was tachycardic—likely a combination of poor nutrition, lack of sleep, volume depletion and stress/anxiety.  Fevers were always concerning to me as was even a borderline low oxygen saturation.  But, without labs, imaging or specialists you can consult, we all had to harken back to things learned in the pre-clinical years of medical school.  I always like to tell my students and residents, a little bit of fear can be the most powerful motivation to a doctor.

Be a leader…teach others and improve on your weaknesses

I love teaching our students and residents here in the U.S.  In my experiences, that love of educating is even more amplified overseas.  The students and residents are eager to learn any information you have to impart—particularly on new technology.  The residents gravitated towards using the Clarius machine and at our farewell dinner, they noted they were most grateful for the meticulous yet reassuring style in which we taught them.  Several of them keep in touch with me via What’s App and my hope is that the brief time I taught them will inspire them to teach others.

Equally useful on these trips, is the chance to improve on your weaknesses.  I don’t see pediatrics cases that often and so, I made sure to see as many cases as I could.  My first patient on Day 1 was a two-week-old with lethargy, poor feeding and vomiting.  It had been a while since I saw a sick newborn, but I knew that he wasn’t acting quite right and the red flag of possible meningitis came to mind.  The fear of this newborn having meningitis and seizing or worse drove me to flag down our transporter and go with him to take this newborn and her mother to the Danish Red Cross hospital 5 kilometers away.  None of the Rohingya wanted to be transferred to hospitals because they feared that if they left their temporary housing for too long, others would take over their possessions and space.  Ultimately, the Danish team monitored the baby for one night and determined it was malnourishment and dehydration, not sepsis.  That was the only case all week I was able to get transferred to a larger facility.

See the World

It was incredible for me to see this part of the world.  My father grew up in Dhaka in the 1930s, when it was part of India.  My main focus of the trip was to help the Rohingya, but using some creative scheduling I was able to spend time in the city were my dad lived, 70 years ago.  I spent one day walking around the city, seeing the street where he was born and then walking to the law college where my grandfather received his Master of Laws degree.  It was an incredible experience that helped me historically frame the clinical work I was doing.  Our discussions as father and son after my trip were some of the most insightful and rewarding ones of my life.

While I don’t think these trips should turn into medical tourism, we are all human and seeing so much pain and suffering daily is not easy to process.  Using the downtime wisely after you provide medical care is crucial to maintain positive energy for the trip.  After a particularly hot and difficult second day, our group hiked up to see the Himchori waterfall, but sadly there was no water yet (we arrived two months before the rainy season)!  As we watched the sun set beyond us, I realized how important such moments are for resilience and teambuilding.  Our last night, we took the local Dhaka physicians to a restaurant that served some of the best regional fish dishes.  It was a highlight of the trip to be able to share a meal, relax, discuss and reflect on our time together!

Acknowledgements:

• IMANA:  Zahid Mahmood, Drs. Ismail Mehr, Ahmed Ibrahim, Waheed Khan, Shamaila Khan.
• Dr. Anamul & Muktadir and the rest of our talented, selfless Dhaka physicians, translators and organizers.
• Clarius: Ms. Audra Kreger for her generosity and time.
• US Army: SFC David Macias for his advice and constant enthusiasm.