East Timor Medical Elective - Week 3 (Part 3 / 6)

“FRACTURE GIRL”

On Wednesday evening, I was about to leave BPC, but then got called into Dr. Dan's office.

I thought he was going to show me a patient with a heart murmur, so was surprised when he showed me a girl with a Greenstick Fracture. I looked at her arm, and she looked up to me with her big eyes. My heart “jolted” when he told me to put a temporary splint in the emergency room, and ride the ambulance with her and her Dad to GVNH's ED for an X-Ray and proper cast. Initially I got annoyed coz I wanted to go home and rest, but it quickly subsided as I felt really sorry for her and wanted to help, plus I was having another Adrenaline rush (which masked my fatigue), so said Yes to him.

A new “quest”. I forgot to take my medication that afternoon so was a bit scatter-minded. I needed to think things through methodically otherwise it'd be hard to get things done properly. 

Step 1, I had to bring them to the Emergency Room. I asked them to follow me to it. I walked a few steps, and they were behind me, stopping as I stopped (as I didn't want them to lose track of me). I felt like the Villager in Age of Empires who had to guide the Sheep back to the Town Centre. She entered the room, and I pushed the main bed away to make space for the chair for her to sit on.

After entering the Emergency Room was Step 2, finding a splint. I've never put on a splint before, but was aware that you needed a long solid object, wrapped in bandages to help immobilize the limb. I immediately visualized the “perfect” long plank of wood classically shown in First Aid Textbooks, and scanned the room up-down, left-right for it, triple-checking. Nope, it wasn't available. I then brainstormed of alternatives – long thin pieces of metal / plastic, cardboard. Nope, not available either. Time was ticking and I felt frustrated. Both the girl and her Dad were staring at me quietly.

I realized that I hadn't checked my bag yet, and as I opened it, realized I could use the cover of my note book as a (mediocre) splint. I ripped out the cover, rolling it into a cylinder and placed it around her arm, forgetting that it was only supposed to be on one side. I told her Dad to hold the cylinder up at her elbow level.

Step 3, find a bandage. This was much easier. There were bandages on the shelf, but I couldn't find the perfect textbook one, but didn't want to waste more time being indecisive, so took a guess and opened up the closest package to me, which was a thick, puffy one. I wrapped it around the cylinder, but couldn't let ago otherwise the bandage will go loose again.

Step 4, I needed string to secure it. Tetum time, I said “Hau presiza...” (I need...) whilst nodding at the bandage, but temporarily forgot the word for “tying”, in which case he said “kesi” (typing), and I said Yes! Then I had to obtain the word “string” in Tetum from my memory. I remembered “talin” being a unit of items being held by a string, and said it, and he understood.

He scanned, and then took out one that was hanging out of a folder. He brought it over, holding the bandage firm whilst I tied a few knots around it.

Step 5, find an ambulance driver to take us to GVNH. We walked out, and I couldn't see one. Dr. Dan was outside and I told him, in which case he asked another person to contact the driver to pick us up. He said that the driver will arrive in a few minutes, but those 5 minutes felt much longer. I looked at the “splint” I made, and felt rather embarrassed but proud of this “improvization”.

The ambulance driver arrived but I wasn't allowed to sit in the back with them. On the way to GVNH, I was constantly worried about her, wondering if the bumps on the road may have caused further trauma.

We arrived at GVNH, and I entered the ED. The first time I entered this place, it looked very “drab”, and even “greyer” by Australian standards. Step 6 was registration. The “Boss Level”. From my previous experience with the Cuban Radiologist, thought that I had to behave in a very meek manner without showing any signs of aggression or anger, as the Drs here have the potential to avoid helping patients with virtually ***NO*** medico-legal penalties compared to Australia. The extremely frightening reminder of this risk, was a furious-looking mother and her crying daughter of similar age to the “fracture girl”, screaming in Tetum to the Triage man. I suspected that they've been waiting for a while and haven't been seen by a Dr, despite the presence of empty beds, and Drs chatting at the counter. “Don't let them push your buttons, hide your feelings, censor yourself, don't get angry, don't get angry, don't get angry”, I repeated in my mind. 

I walked up to the Triage man, and in my most “formal” accent, slowly greeted him in English and introduced the girl's medical issue. He took further details from her Dad and pointed us to the main ED counter. The furious-looking mother immediately became even more outraged, which disturbingly confirmed my hypothesis. 

Step 7, the actual “Boss Battle”, or advocating for the Patient. The girl and her Dad followed me, as I walked slowly towards the ED counter. The Drs stopped chatting as they looked in our direction. I greeted them with the same accent again, and described her needs. I tried to add “weight” to my sentences by beginning them with “Dr. Dan Murphy”(needs / thinks / wants etc), hoping they'd be obliging to help secondary to my name-dropping.

As soon as I mentioned “X-Ray”, one of the Drs immediately said “The X-Ray machine is broken. She will need to come tomorrow to have the X-Ray done.”, followed by another Dr saying “Does she only need an X-Ray?”, seemingly ignoring my mentioning of the need for a cast.

I paused. The clincher: my answer to this question would determine if they would help us or kick us out. Say the wrong thing and I'd lose the level and prolong the girl's suffering. The answer was obviously “No”, but in the past (when un-medicated) I had a higher risk of saying the wrong answer, or forgetting to say important things at high points of stress. Surely the Drs knew that she needed a cast? It almost felt as if they didn't want to help in the evening, whether out of laziness or fatigue.

I worried that they'd give more excuses even if I said “No”, so formulated a sentence in my mind and quickly analyzed its truthfulness and influencing potential, coming up with:

“Dr. Dan Murphy needs her to have a cast put on her arm to stabilize her fracture, even if she doesn't receive an X-Ray today. It is important to have a cast, to prevent the greenstick fracture from potentially getting any worse.”

If the Drs disagreed, then it'd make them look really bad, even if they couldn't get sued. I wasn't aware of a way to argue out of delaying putting on a cast for a greenstick fracture in a haemodynamically stable patient. 

Thank Heavens the "Rivers Parted", and the Drs “agreed” to help us. They told us to go to another room, where a Dr started undoing my “splint”, and began preparing a cast. Unfortunately I wasn't able to watch the entire process, as the ambulance driver called me out to drop me off at home. On the way back, I was relieved but even more exhausted after that ordeal. 

Mission accomplished for the cast. What a diversion, I felt so “battered” by the time he dropped me home. I think this task was the one that so far (by end of Week 3) demanded the most of my improvization/flexibility and communication skills. I thought that advocating was a simple task, but in retrospect realized you needed to demonstrate the medical knowledge to justify your demands and facilitate delivery of treatment. G-d help the non-critical patients who come on their own without a Dr or medical student to escort them, especially when the public here are much less “medically literate”. 

Whilst I personally found their “Medical Innocence” endearing last week, I now understand how this can work against them in a potentially very dangerous sense. I'll never forget this episode...