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To end tearful and start stronger

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A post-op septic man, two very very sick babies on oxygen, and a five-year-old girl seizing and comatose probably as a result of meningitis. Genuinely one of the most frightening things I have ever been around.

In retrospect, one of the most dominant emotions during that whole experience was not what I expected. Fear? Yes. Concern? Check. Sympathy? Tick... But revulsion?

It took over 24 hours and three more trips to the ICU during the course of the next day to sift through that one. The revulsion was not at the fitting child itself - who would do that? But at the full frontal experience at the barefaced wrongness that is a system, a country, a world, where a child could be this sick and not have more done for it. In any western country that child would have been sedated, ventilated, monitored, have a central line, a feeding tube, a catheter, a BIS neuro monitor taped to the tiny forehead to catch low grade seizure activity...

But here, the only way for us to gauge seizure activity is to test the arms for rigidity, or lift the eyelid and look for the faint flickering movement that betrays an electrical storm going on inside the brain. I watched and learnt to stay calm, use the protocol in the book, base your fluid boluses and IV diazepam on their vital signs, monitor regularly. Too much diazepam and you depress the effort of breathing, making it shallow and ineffective. Too much and the seizure continues unchecked...

Somehow they all made it through the night. And so did I. Albeit tense, tired and slightly tearful.

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Myanmar: IDP Buthiduang

Buthiduang, where the stateless Bengali Muslims & Rohingyas struggle to survive. It is a medium-sized town south of Maungdaw. It feels incredibly remote, surrounded by mountains, dense untouched rainforests and a sleepy winding river. I like it a lot. The house for the medical field staff (me, the other doctor and two nurses) is as basic as they come. I’m still trying to work out if we have any electricity. The downstairs outdoor squat loo has me praying I don’t get diarrhea. 

The clinic manager was on leave for a few days, so I took on the role. Working with staff from different communities means that differences of opinion easily become political, and mediating these discussions was both time-consuming and stressful. Even simple tasks, such as dividing duties among the medical team to organising lunch breaks, every decision required some convuluted discussion. It is understandable that many staff members use me as a neutral listening ear, something that has also become quite common in Buthidaung. 

Stress levels are high here, and most staff have incredibly difficult living conditions. Doubling up as a clinic manager meant I really had little time to see patients this week. It was an interesting role though, and I did enjoy the power of telling people when they could go for lunch.

My first patient of the morning was a 15 day old baby with newly acquired spasms and poor feeding. I almost missed the diagnosis of neonatal tetanus, and looking back it was fairly straight forward.

The mother had a home delivery, and had used a kitchen blade to cut the cord. Easy marks on the diploma of tropical medicine exam, but it was the first time I’d been faced with it in real life, so it took me some time. The rest of the morning was spent dealing with incredibly sick patients: an obstructed labour, a severely immunocompromised pregnant lady who did not stop vomiting and had probably miscarried, dog bites, and acute watery diarrhea galore.

It was pretty busy, especially with limited equipment and only a nurse and midwife to help while a few others left for Outreach (bringing medical help on foot to remote villages). Important to remind ourselves we are doing our best. 

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Myanmar: Hidden Genocide

“I hate being a Rohingya. We are being tortured in Myanmar. Now in Bangladesh, we have no rights. Nothing. We don’t have a roof. We are living under the sky. We have no future”
— 27 year-old Rohingya Refugee fled Bangladesh in February when her husband went missing.
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In Myanmar the preconditions for genocide are now firmly in place. Racism has been normalized among the ethnical Burman population and the Rohingyas have already been subject to communal violence, state oppression and have been forced into both internal and external exile. 

A powerless minority is the victim of effective ethnic cleansing, in an environment where they are hated by their neighbors and actively discriminated against by state authorities. Despite the grim situation there is much that can be done, both domestically and internationally, to help the Rohingyas and hopefully avoid a genocide- but a real will to take action is needed, rather than the continuation of "business as usual" in the hope that nothing actually happens in Rakhine to make us complicit through inaction in a repeat of the genocide in Rwanda. 

Rohingya IDP camps, rekindling fears of being displaced and losing loved ones all over again. 

No adjectives to describe sufferings of Rohingya refugees especially after the monsoon. No shelter and nowhere to go in the middle of the monsoon. These are the poor conditions the Rohingya live in. Small dirty shacks in the mud, rain comes in, chickens walking in and out. in constant fear they will be attacked again. 

My time here in Sittwe, the major town of Rakhine State. Sittwe is the first place I’d ever been to that has a curfew, imposed in response to the civil unrest and violence that rocked the state last year. The beautiful landscape and bustling asian market mask the deep tensions that divide this part of Myanmar. One needs to have knowledge of the recent history of the area to appreciate the constant threat of violence that hangs over the town. It's impossible not to feel something when walking past numerous piles of rubble marked with red signs to highlight where houses once stood.

Yesterday afternoon a patient came in after being in labor for 48 hours at home. She’d been pushing for over 12 hours. She was running a high fever and the baby was dead. It’s head was visible when she pushed but it was mostly “caput”, the swelling of the top of the baby’s head.

The midwife I’m working with, Sally (originally from Australia but now living in Atlanta) tried delivering it with the vacuum extractor but the baby’s head was too large. I tried to place the forceps but the head was too large so, for exactly the second time in my career (the first was in Sierra Leone), I had to do a destructive delivery, making a stab incision with a scalpel through the soft spot in the baby’s skull in order to drain some of the brain matter and decompress the baby’s head making it small enough to pull out.

It’s a gruesome procedure and it was made worse by the awful smell of this mother’s infection. There’s a part of you that just disengages from the reality of what’s happening, thank goodness. We were able to get the baby out though, saving the mother an operation through an infected abdomen and pelvis. The baby had obviously been dead for several days which I guess made it easier to come to terms with.

I don’t think five years ago I could’ve imagined doing things like this. The most horrifying thing is not that I’m relatively comfortable doing it now, but the fact that there are places in the world where it’s necessary.

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