April 15th, 2018 by Daniel Boron-Brenner

This post is one I’ve been ruminating on for a few weeks now. Ever since I got to Macha, I’ve noticed that time moves, well, a little differently here than in other hospitals (and places) I’ve been to. I don’t know if this is due to something endemic to the culture, to the low-resource setting (where things like immediate blood transfusions are necessarily held up because of a lack of supplies), or because of my own, perhaps rigid, concept of punctuality and time. Regardless, things move to their own rhythm and it has taken a little while to get used to.

Ward rounds nominally start at 8 am but can begin at 8:30 (“half 8”) or even 9. Clinic is open 6 days a week, from 8 am until around 4, but doctors may or may not appear. People work 6 days a week, but just a little longer than half days, and the only truly free day off is on Sunday, where most people spend their morning (and part of their afternoon) in church. In the United States, I am used to a strictly enforced work schedule, particularly when on a busy service. During internal medicine, I would get to the hospital around 6:30 (for a rounding start time of 8 am), and work until I was dismissed, usually 4-5 in the afternoon. To be fair, the Americans have a bit of flexibility regarding their start and end times too (things get in the way) but the residents and attendings always showed up. To do otherwise would be to invite disaster.

Urgency in the hospital is also in strange supply. Yesterday, during rounds in a side ward, a nurse walked up to the physician we were working with and quietly asked him to come take care of something. I didn’t think much of it, her voice was much too low to discern anything concerning, and so we finished rounding without him. When we were done, we went to find him in the main section of the ward and discovered that he was attempting to resuscitate a pulseless patient by himself. A cardiac arrest in the United States is (rightfully) a cause for excitement, people descending on a recently lifeless body and attempting to push life back in with medications, electricity, and CPR. Here, it was almost sedate. He gave epinephrine and performed chest compressions but the understanding that she was “gone” had already settled in.

It was a shock to see the scene unfold. While I understand that this approach is predicated on a number of considerations–the lack of resources to continue care should her heart start beating again being a big one–for a second, I couldn’t understand what was happening. As both a former EMT and a medical student, I’ve participated in many cardiac arrests and I am used to the intense focus that settles on you when a pulseless patient comes in. Because of the critical nature of the arrest, time is parsed into the smallest discernible moment because even seconds count with these patients. Instead, as I felt my heartbeat pick up, I looked around the room and I found the ward trundling along much as it had when we first started. A nursing assistant came up to me and politely asked if I needed anything. Sensing that things would not go the way I was used to, I very hesitatingly said no and went back to the patient. By this time, the code (such as it was) was over and the doctor was pronouncing her. He wrote her death note, they erected a screen around the body (which, a few minutes later, fell down on the patient in the next bed) and that was it.

Fortunately, things are not always so grim or confounding. Outside of the hospital, there is a gentle cadence to life here. There is not much to do in Macha, and so we take walks and have game nights for fun. There is school for the children but they are on break right now and I see them running around constantly. There is also some electricity in town, enough to illuminate houses and shops and a few spare street lamps at night. Outside of work, and even sometimes inside of it, I feel like I am moving slower here, as the sense of distraction, of immediacy, is less apparent than at home. I once lived in a tent for almost six weeks in college while working construction in a small town in southern Colorado. We had few amenities, mostly flashlights, sleeping bags, and canned food, and we tethered our days to the rise and fall of the sun. That was probably the last time I felt the same way. I suspect that by the time all is said and done it will be a shock to go back to the States and see how rushed things are there. And then the re-adjustment will begin again.