Full to the rafters

Every day at Kantha Bopha, where MSF operates out of, we're full to the rafters with patients. Three floors full. Any empty bed is usually filled as soon as it's cleaned and a new sheet put on. The courtyard is full of patients waiting to be seen in triage, or labouring and being followed by the delivery room staff. Today we arrived to the sight of a woman delivering in the courtyard, on the ground — fortunately being attended to by one of the midwives, but still, this is obviously far from ideal. And yet it is not so unusual an occurrence. As I said, empty beds are turned over pretty fast. I'd guess that most complicated cases stay about two or three days. Uncomplicated deliveries leave in six hours. 

And we can't deliver all the people who arrive. There are just too many. So we try to transfer the less complex, less urgent to other institutions. Transferring patients involves loading the LandCruiser with eight or ten pregnant and possibly labouring women, one midwife — armed with a delivery kit and some gloves, one administrative person, and the driver. The doctor on call for triage calls ahead to the receiving hospital, and then off they go. Busload of bellies.

Often, though, the receiving hospitals won't receive. Right now, one of the biggest hospitals isn't open because the operating rooms are closed. Problem with getting the anaesthetic machine fixed. Another hospital is often lacking surgical kits. Others only have an obstetrician during daytime hours. Another is often without an anaesthetist. I seem to be calling the same departmental heads almost every day to find out how their hospitals are doing, or what they're missing in order to function. Sometimes we can help with that, sometimes not.



Developing Projects + MSF Innovations


Three MSF start-up projects that could save lives in the future...

What do you do when you have a big idea at work, but aren’t sure how to make it happen, or even if it will really work? Ideas from our staff have the potential to revolutionize the way MSF / Doctors Without Borders works, in big and small ways.

The Sapling Nursery - a special fund that supports our staff to develop and test new ideas we hope will improve the care we provide to our patients. These four projects are now rolling and we will bring you updates soon. In the meantime, the Sapling Nursery opened its doors to new proposals once more last month.

Three ideas were chosen for their potential impact, feasibility, and innovation

The second bit of good news was that many of these came straight from our teams working on the ground, in our medical projects around the world. As in many large organizations, MSF sometimes struggles to provide opportunities to its staff on the ground to innovate for the future. Previous proposals have mainly come from our headquarters staff and specialists. They’re still great ideas, but it can mean that they aren’t always representative of the current needs of those working in the field, face to face with our patients.

Lastly, the quality of proposals was very high, and represented everything from from small inventions to potentially transformative projects. In the end, three ideas were chosen for funding, based on their potential impact, feasibility, innovativeness and the expert opinion of the funding committee. Here’s a brief description of the successful proposals, which will now be developed and tested...

  1. Lean Chemical Weapons Kit (LCWK)

Working in areas where there’s a threat from chemical weapons is stressful. Personal decontamination kits can offer some protection in the event of exposure to chemical weapons, but they are bulky and hard to store in the cramped conditions that our staff often find themselves working in, even though they should be within reach at all times. This contradiction can mean that precious time is wasted worrying about the kit rather than focusing on healthcare delivery for patients. Aiming to develop a discrete, efficient and ergonomic decontamination kit, designed to be ever-present, but barely noticeable, and with a foolproof procedure (in fact, it will be tested by blindfolded participants), meaning that staff working in these tough circumstances can be confident in their equipment and dedicate their attention to the patients in front of them.

2) Task-based modeling for safe nurse staffing levels

From providing intensive care to our sickest patients to leading the fight for infection control, nurses play a central role in MSF’s provision of healthcare to patients and are integral in all MSF teams. Ensuring that nurse staff levels are sufficient to ensure patient safety and maximise the level of care we provide is an important challenge for MSF.  This means ensuring the team on shift at any time has a suitable mix of education, skills and experience.


3) Malnutrition screening toolbox for children under 6-months old

Many of the infants below 6 months of age who are seen at MSF hospitals and clinics are there for treatment for infectious diseases. But in many of places where MSF works there is a high chance that these babies also have underlying malnutrition. Early treatment of this malnutrition increases the odds that the baby will survive, decreases the likelihood that they’ll catch disease and also helps them grow.

However, screening babies this young for malnutrition is not easy, partly due to the tools available to our medical staff. The most common approach at the moment is to use measuring boards to check the baby’s growth. These are cumbersome and heavy, and the paper forms used to measure levels of malnutrition are complicated and prone to human error. In MSF projects, malnutrition screening at this young age is not standard in many of our medical projects.

To address this gap, my team and I proposed to implement and test a new toolkit, including a digital infantometer (a length measuring device for babies) and a z-score calculator (that calculates malnutrition levels from weight and height readings), developed by the World Health Organisation. These tools will be evaluated to assess their feasibility in MSF projects and to see whether their use can mean an increase in the number of infants under 6 months we can screen and, therefore, treat for malnutrition.

If these ideas bear fruit, we hope they can have a positive impact on our work, but even if they are tested and fail, we can learn a huge amount from them.

Wish us Luck!! 



Myanmar: On going, a part of me.

Going through my journal entries I reflect my time working at the Kutupalong, Myanmar, clinic a months back. The clinic is the largest MSF facility in the area providing emergency, outpatient, maternity, mental health and inpatient care for the Rohingya and local population.

Before the influx, there were three international staff doctor working at the clinic, one which I replaced. I am in admiration of how he managed to cope in the job single-handed. There are two of us now, but today the other two doctor went on a trip to visit the MSF health posts that provide primary health care in the camp, so I was left to my own devices!

When you are by yourself in the clinic, you spend your day here, there and everywhere. You are called to review patients in all departments, make decisions and support the Bangladeshi staff. These are some of the patients I saw today:

1.      A boy with a fracture to his femur having fallen in a drain.

2.      A girl who was shot in the eye and was well following surgery. She had a simple case of conjunctivitis and could go home.

3.      A 20-year-old woman who fled Myanmar one month ago and has since had seizures. She has had 15 episodes this month alone.

4.      A man who had cut the tendons in his hand with a knife whilst working. We referred him to a surgical department for repair.

5.      A child with an acute asthma attack.

6.      A baby with low oxygen levels and likely congenital heart disease who we will discharge with advice as we have no treatment available.

7.      A lady who has been taking HIV treatment for approximately 10 years. She ran out of medication whilst crossing the border. Her son is also HIV positive. We will arrange for them both to restart treatment.

8.      A 70-year-old man who had a stroke one month ago, he had weakness of the right arm and leg. We will arrange physiotherapy.

9.      A young boy with a badly fractured wrist with the bones no longer in line.  


10.  Lots of patients with chronic lung disease; women from cooking on open fires without ventilation and men from smoking and open fires. Some required oxygen.

11.  An 18-year-old woman who had fallen on the cooking pot and burnt a large area on her chest.

12.  A five-year-old boy with Henoch Schonlein Purpura (an autoimmune disease) who was now improving having developed a very badly infected rash. He is receiving antibiotics and sitting under a mosquito net to protect the wounds.

13.  A family of four children and their mum. One of the children had fallen and hurt her jaw whilst crossing the border. She had been referred by an MSF mobile border clinic as she was unable to eat. She was now running around the ward with her sisters waiting for discharge to the UNHCR (the United Nations' refugee agency) registration point where hopefully someone will help them find shelter.

14.  A 15-year-old boy who looked like he was six having not grown since then. He was withdrawn and not socialising. We offered counselling to support his mental health.

15.  A boy with recurrent nose bleeds and a low haemoglobin who needed a blood transfusion. His family accompanied him to see if they could donate blood.

16.  A one-day-old baby with low blood sugar and an infection.

17.  Many patients looking fed up with their measles in the isolation tent.  

18.  An 18-year-old girl with heart failure. Who knows why? We will never know.

19.  A drowsy child with watery diarrhoea and dehydration.

20.  A one-year-old boy with malnutrition and a chest infection who was breathing rapidly and requiring oxygen. He was given antibiotics and admitted for the feeding programme.  

21.  A patient with a longstanding cough and weight loss. We suspect TB and will investigate.

22.  A 35-year-old man who had a pelvic fracture when he was hit by a car. Although it was repaired, he now walks with a Zimmer frame. He was admitted with pain and was distressed as he has nowhere to go and no family to help.

I saw an array of other patients, too long to list. It puts my normal job in the US in perspective; I imagine I may be a more relaxed doctor when I get home.. 

The poor conditions that most Rohingyas live in have a direct impact on their health. At one point we received 13 people who had been bitten by a rabid dog that had run through the settlement. There’s no end to their suffering. When I am sitting at home and it starts raining heavily, it’s hard knowing they are trying to sleep outside under the rain. I don’t even know if it’s worse when it’s raining, or when it’s burning hot and they have no clean water.

This is not the only conflict in the world, but it's very frustrating seeing the suffering with your own eyes, and then seeing what's considered important back home. 515,000 might seem like an abstract number, but as a doctor here you see what that actually means. People are in profound need of help. Currently still working on the Obstetrics to Midwife program so that one day midwives in Myanmar will be ok with out the presence of MSF. Looking forward to returning to what feels like my 2nd home.