Where There’s Always Another Way

Medics sure like to complain. About dispatch, about triage nurses, about patients…it seems there’s always something worth criticizing. Reflecting on my decade working on ambulances, this is no doubt a coping strategy, accompanying techniques like sarcasm and dark humor that involve things said in the front of the truck but never anywhere else.

But after a recent venture to work at a hospital in South Africa, I’ve returned silent, grateful for every fault in my system—because despite my whining, I’ve realized one thing very clearly: I have it really good.

I’ve returned from a month working in an underserviced, underresourced emergency department in Khayelitsha, a township about 30 kilometers outside of Cape Town where one in three people has HIV, where tuberculosis spreads like wildfire, and where diarrheal disease is still the most common cause of death in children under 5 years old. The case mix was unlike anything I’d seen at home in Canada. But it wasn’t the cases that I found challenging. It was the tape.

Actually it was the lack of tape. There was no tape. I was cursing under my breath constantly, not because of the acuity and new medicines and (very) old diseases I was treating, but because I didn’t have tape!

Pink tape, clear tape, trauma tape, brown tape, allergy-free vegan tape—you name it, there was no tape. Some days there would be Tegaderm, which we’d cut in half sparingly, but that was it. Such a benign stock item is actually used with nearly every patient, in rather critical ways, but I was without. How do you improvise tape?!

This was made all the more difficult by the roles I was expected to perform locally. I was responsible for drawing blood and starting cannulas; I needed tape for almost every patient I came across. Despite my inability to cope, the nurses, patients, and local doctors made things work just fine. Well, fine enough. IV lines were carefully wrapped around fingers and hands so as not to pull out cannulas, and patients paid extra attention to make sure they didn’t lose their lines. ET tubes were secured with rolls of gauze tied in figure-eight knots, a technique that was very secure when done right (read: when the nurses, not me, did it). And splint wraps were tucked into crevasses, which was good enough for the time being.

Tape was just the beginning. Other things were often missing or out of service too—things I wouldn’t have thought twice about back home.

One night we had only 16-gauge (grey) and 24-gauge (yellow) IV catheters. One night we had only 2-mL and 20-mL syringes. One night we had no lumbar puncture needles. Each time we made do.

While I struggled to cope with a lack of supplies, everyone around me plowed on. Each doctor seemed to have a MacGyver work-around every time something was lacking, creative make-dos to get by and keep the shop floor moving. Chest drains were manufactured out of any tubing we could find, scalpel blades without handles were held in our fingers, splints were assembled out of anything rigid. It was about the desired outcome, not the process.

Still, I was getting frustrated. I was seeing very few patients, spending the bulk of my time running around searching for supplies, or makeshift supplies. But the other doctors weren’t deterred; this was their normal. And when no work-around could be found, no solution pulled out of thin air, there was a resignation to the circumstances—that under difficult circumstances, you do what you can and then move on.

Resilience and Ingenuity

The resilience and ingenuity of the local doctors was remarkable. They couldn’t rely on tests like CT scans and blood work but rather depended on exceptionally strong clinical skills—palpation, percussion, auscultation, and the forgotten skill of observation. In my Canadian hospital, where we have bedside ultrasound, portable x-rays, and a CT scanner around the corner, I was quite out of practice when it came to the basics. I came to realize I overrely on expensive tests back home, bolstered by the inoculated belief that “old school” tests have poor statistical properties, that physical findings don’t produce adequate likelihood ratios, and that you can never really be sure of anything until you irradiate something.

But what do you do if you don’t have diagnostics—ECG machines, ultrasounds, CT scanners? We were fortunate to have 24-hour x-ray facilities and one ECG machine (with paper!), but the nearest CT for trauma patients was a 45-minute drive away and very busy. This meant patients would be observed in the department indefinitely, until we were confident their brain wasn’t bleeding, their heart wasn’t injured, or their belly wasn’t toxic. Other times, when the stakes were high, it meant assuming the test would be positive. Can you imagine not having a glucometer or a cardiac monitor and just treating “on spec”? In the field we often make assumptions—but our interventions are limited, so we don’t often have to pony up and test them by proceeding with interventions. This meant we would often treat for tuberculosis of the brain, abscesses in the abdomen, or presume cancer was present without actually knowing.

In settings where money is tight and health needs are great, it’s critical to spend every precious dollar wisely. With so many health needs, the emergency department was just one of many places sharing a relatively small pot of money. I felt ultimately underqualified to criticize what lacked; every system has to make resource-allocation decisions that are tough. What I took away from the experience is that when you don’t have what you’re used to, there’s almost always another way, and that other way is probably going to do the job just fine.

I’ll be forever grateful to my South African colleagues, from whom I learned so much about resiliency and improvisation. I wanted to stick a thank you note on the wall in the break room, but I didn’t have any tape.

Blair Bigham, MD, MSc, EMT-P, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. E-mail him at blair.bigham@medportal.ca.