Trauma - RTA, HBO, HBS,

Work at Ramallah general is unpredictable. You can be sitting having tea with the docs and nurses and relaxing, talking about how the day has been really quiet, when suddenly three people come in by ambulance from a road traffic accident and you don't have to time to think about anything else but what the next priority is for the patient. Its not a warzone as most people perceive this area to be, but we do see our fair share of trauma...some days way more than that.
There are three classifications for trauma patients here.
RTA (road trafffic accident)
HBO - (Hit by others [Assault, beatings, stabbings, shootings])
HBS (Hit by Soldier - any trauma inflicted by Israeli personnel)
Other trauma is simply called by mode of injury, eg. Falling down/fainting and subsequent head trauma etc.

On any day you can expect to see roughly 5-6 RTA's, more at night, and as many if not slightly more HBO's. On Fridays, when prayers at the Al Aqsa mosque are conducted, more people try and get across to ISraeli land to pray there, very often illegally and are the subject of Israeli abuse or police action, so we see more HBS those days.
An example of this sort of action was on Qadr (apologies for incorrect spelling), the night of prayer during Ramadan. People from all over the West Bank will try and get to the Al- Aqsa mosque, as one night of prayer here is equal to 50,000 prayers anywhere else. We saw a number of teenagers and young adults who tried to get over the fence due to Israeli patrols being stepped up this night along the wall. A number of kids were pulled down from the fence sufferinjg cuts to their legs as well as the occasional broken bone. I sutured two guys and their thigh wounds, and I asked one of em if he was going to try again or not...he replied with 'As soon as I'm out of the ER!'
One guy that night told me and the other docs in the history that he had been bitten by the settlers. I didn't believe him at first till I saw the bites, complete with bruising and bite marks, around the back of his arm and on his shoulder. FUcking animalistic.

On another note of HBO, one poor lady came during Eid to the ER after having been beaten severely by her husband, sustaining brusing to her chest and abdomen as well as revealing the sites of old bruises along her arms and shins. She had to be CT'd to exclude intra-abdominal bleeding. Much to my surprise, me and the ER surgeon on call were subjected to a torrent of complaints by the radiology technician, who said that as she wasn't an urgent case, she should not have been referred for CT scan. Thankfully he did shut up and do it, but I guess after having to use the limited resources available for critical RTA's and HBO's, this case didn't warrant a scan in his mind. Unthinkable thought track in any developed country.

Many of the critical and urgent trauma cases are referred to Israel to Hadassah hospital, with a much better equipped trauma centre there, and far less restrictions. Though one may have to wait an hour or two to clear the patient for transfer, I dare not think how many critical patients wouldn't make it if this option wasn't available. Two days ago I saw 4 RTA's come in, one of whom had to be transferred, after we suspected massive internal bleed and required more specialist guidance to repair the severe injuries he sustained to his chin and elbow.
Everyday we see injuries like that, and everyday I see nurses and junior residents do procedures you would be required to call an anaesthetist or specialist for in England such as emergency intubation. The worst thing is running out of equipment such as gauze or dressing sets for wounds, so that even if we have it for the RTA's, we quickly run out of it for the cases of falling down, which are mostly kids who require at least 2-3 sutures for their wounds. Oh and forget sterile technique...i lose count of how many times we've had to sterilise equipment such as needle holders and forceps by hand that should be autoclaved. One day last week, I sutured 7 people who sustained wounds to limb and scalp, often with no assistance.
That's another thing, the fact that we have nine beds and not enough doctors/nurses to attend to the patients, who keep on coming in by the tens. Some days there are intern doctors there and some days, its just me and the nurses/ senior docs on call.
Mental.

But its not just urgent trauma sustained by the mechanisms i mentioned above that come in, we see a wide range of medical emergencies such as cardiac arrest, pneumothorax and asthma, all of which i've seen at least once here.
I've seen three cardiac arrests in adult patients, one who made through alright, but the other two either sustained irreverisble brain damage, or died after 20 minutes. ATLS protocol is known but not often used properly. For example doctors here often wait to see if the patient will develop a rhythm or not at their whim, requiring us to stop CPR compressions, as opposed to conducting a rhythm check every two minutes. I have seen a hundreth of the cardiac arrest cases they have seen easily if not much less and I do not have knowledge of the research that backs up the protocol advocated by authors of British ATLS protocols. Hence I don't believe I am qualified to judge their technique. THey do follow the basics, its just the fine tuning and adaption that is carried out, that a more senior western emergency physician may object to.

I observed cardiac arrest in an infant below the age of one, who arrived dead to the ER. We resuscitated him for 20 minutes before the flat line continued for longer than the stipulated time to declare death. I will never forget the pain of the relatives, and the screaming of the mother and her throes as she heard the news will haunt me for a while to come.

Yesterday I saw critical 3rd degree burns in a 7 month old girl sustained two days prior to her coming to the ER. She had been taken by her parents to a local woman who claimed to be an expert in treating burns. TOtally unqualified medically. The equivlaent of a fucking witch doctor for all the good it did the girl. She had been dressed and bandaged twice at a cost of about 70 pounds a day, until her body finally gave out and the relatives took her to the ER. By that time the amount of fluid she had lost was too much and she died in front of our and the mother's eyes. Made me so so goddamn angry and feel so pitying for the parents, who probably knew no better than to trust the crook who claimed she could heal her.

In all that i've seen I've gone through a range of attitudes in my approach to critical patients, from feeling helpless and underqualified and sometimes unwilling to believe i could get to a stage where i could be of some use, to getting on with it but worrying i would fuck up (a very UK attitude) to now just putting the fear on the back burner and getting on with it. You know...I think I've now observed a real natural ability to put my emotion and worry away under lock and key, and just get on with it. I've told Pranjal my brother about it and he rightly says that its a valuable mentality, and one that will benefit my patients.
But I often wonder as to whether this is making me colder inside. Of course one has to get used to it dealing with the sphere of work that I have volunteered to do here and in any trauma unit across the world....but I find it difficult sometimes to remember the faces of the patients I have seen. I think I can recognize them instantly if I saw em again.
But lying down at night, its a blur to me. And it only really hit me what I had seen afterwards when I forced myself to think about it, and open the floodgates to my feelings that I had kept inside. The despair of the mother of baby who died of cardiac arrest almost was too much for me before I went to sleep, and it kept me awake. YOu don't have to understand arabic to understand what she was saying.

Fuck.