Monday, October 8, 2007

XTB and Mandatory Volunteering

Her name is Maria. Her eyes staring at me over the blue paper face-mask are clouded with fatigue. She sits in silent surrender as the conversation, in English and Spanish, ricochets past. Her entire being concentrates upon lifting rail thin shoulders and pulling in tiny gasps of air into a concave chest. Maria is a beautiful 17 year- old girl and she has Pulmonary Tuberculosis (PTB). The clinical notes tell us it is of a type, resistant to almost every medication available to treat the disease. Maria has what the denizens of international health call Extensively Resistant Tuberculosis. Shortened to the acronym, XTB, it sounds like the name of a new sportscar. Without a miracle, Maria will not live to see her eighteenth birthday, she has what in the old days, before the advent of antibiotics, they called Consumption, virulent TB that is consuming her lungs and there are no longer drugs to cure her, she weighs 70lbs.

Maria is one of a dozen patients lined up quietly, trying to find shade from the stunning heat, outside the back door of the Coliseum Sports Stadium in Buena Ventura, a port city on the northwest coast of Columbia. They are at the back door to avoid the mass of people queueing at the front entrance. Those people are here to see the primary health care teams deployed from the USNHS COMFORT on this its eighth stop in its four month odyssey around the littoral of South America and the Carribean. Our small group of patients all has TB and each has a form of the disease resistant to many or all the medications known as first and second line TB drugs. At best they have Multi-Drug Resistant TB (MDR) at worst, XTB.

They have come to see us because…well because we are here and they have exhausted every other option. To be precise, a microbiologist from the local office of the Ministry of Health (MOH) responsible for the scientific work to determine the level of resistance amongst TB patients in the city, has identified and gathered together over two dozen patients in dire straits. Stricken by MRD TB they are unable to find or afford the expensive options. She has brought them along to get whatever help we can offer. In terms of immediate relief, it is not a great deal.

I am an observer, assistant to a quietly professional Infectious Disease physician, Lieutenant Commander Todd Gleeson, as expertly conducts a detailed examination of each patient and confers through his interpreter with the microbiologist, patient and relatives. Masked up, we escort each in turn to the portable xray machine where a masked technician quickly takes a chest xray and we confirm the extent of the damage through and instant image on a laptop screen. Only a couple of those we assess show any sign of improvement since their last examination. What more is to be done? We are somber when we consider the options. The dozen we have assessed are, we are told, only a few of many more.

When we consult with our collegues, including local medical practitioners, conducting the general primary care clinics, it is apparent that TB is a common disease in the City and in the Region. Equally worrying, conversations with the local practitioners and the symptomatic evidence of our patients suggest that HIV is very present in the community and increasing in frequency. What we are witnessing is a public health crisis in the making and there is little we can do other than sound the alarm.

Finally it is agreed that the COMFORT can provide some limited medication for the most needy and less resistant. A meeting is held with the local MOH authorities exhorting them to sound an urgent warning to the Columbian Government and to seek help from the NGO ‘Partners in Health’ – an organization with great experience and expertise in TB in Latin America. The MOH is also urged to ask for help from the CDC and the Pan-American Health Organization, an agency of the World Health Organization that deals with health issues in Latin America. Gleeson and I muse about the future and the very obvious re-emergence of TB as a global health threat. I offer that we might yet see the return of the Sanitorium as a key means of controlling the disease. We are both silent.

Challenging Travel
Columbia has been the most challenging and in many ways the most rewarding of COMFORT’s ports of call to date and not just because of the burden of disease. The Ship has not been able to reach its intended rendezvous, alongside at Buena Ventura and has anchored off the coast, some miles from the secondry destination Bahia Malaga. Though the latter provides demanding and rewarding medical work, the population is small. The weather has been awful, with heavy rain showers and low cloud.

Getting to and from Buena Ventura has been an adventure for most and a serious challenge for some. It has required us to leave the ship early in the morning, around 6am, travel by small boat to the Columbian naval base of Bahia Mallaga and there transfer to a US Army Blackhawk for a twentyfive minute flight into the City. At the end of a long, hot and damp day, the journey has been most times repeated in reverse, though by late in the afternoon the seas are often much much more lively and the return boat journey long, wet, stomach-churning and exhausting.

Occasionally the lucky few have been picked up from Bahia Malaga or even Buena Ventura, by the tireless and intrepid ship’s helicopters. On a couple of occasions the weather has been bad enough to strand medical staff in Buena Ventura. Thanks to the outstanding work of the US Embassy’s military contingent, known as the MILGP, being stranded has been a far from uncomfortable experience, which I for one, have very much enjoyed. It might have been better from the outset to plan for at least a cadre of medical and administrative staff to stay ashore throughout. Much valuable time, which could have been spent with patients, was consumed travelling.

Rewarding Moments
There have been many rewarding moments during the mission so far. Sometimes I have been lucky to observe the COMFORT’s crew when they happen. Often they have been found in the camaraderie generated by overcoming the challenges of difficult journeys, long demanding days, seemingly endless flows of patients and cooperation to determine a particular diagnosis and a plan of care. Other times they have been found in an individual heart-felt offer of thanks for a kindly ear, expert advice and medications where needed. Sometimes too, through the pride of a successful intervention that alters a life and the uninhibited gratitude of a patient.

One of my favorite moments occurred in Buena Ventura. It concerned a man who was brought to see us in a wheelchair, having been shot in the back some six months previously. He was a fit-looking fifty-year old with a young wife and son. His clinical notes indicated he had a ‘paralyzed left leg’ with a lower leg brace to prevent foot drop. He had been unable to move his leg and confined to the wheelchair since the attack. He has come to the COMFORT convinced we could remove a bullet purportedly lodged in his back and with that enable him to walk again. When he was told that was not possible (an old x-ray showed a small-calibre bullet resting against a lumbar vertebra but not near the spinal column) his face crumpled and the whole family began to cry.

Nonplussed by this sad display we began a detailed physical examination. This showed, other than his wasting left leg, a very fit man with a ‘fully functional physiology’. Yet he had been in the wheelchair from the moment he had left his hospital bed, almost immediately after surgery. Asked if he had ever been encouraged to stand on his ‘good leg’ he shook his head. As luck would have it, the COMFORT’s Physical Therapy Department had deployed a comprensive capability in the Coliseum. Expert advice was sought, from the USAF and Candanian Medical Services PTs.

In short shrift our patient was gently but firmlycajoled and assisted to stand up from his chair and offered a pair of crutches. After some basic instruction he took a faltering step. The first in six months. To his obvious delight and with the encouragement of all around him he soon was able not only to bear weight on and move his ‘good leg’ but also to push his ‘paralyzed leg’ past the good one. In the expert opinion of the physical therapists, our patient would walk, probably unaided within weeks, given intensive therapy. A physician from the local hospital promised the therapy. The family cried again, this time because they were happy.

Volunteering Not Compulsory
No better story exemplifies the challenges of the Columbia Mission and the character of the ship’s crew, military and civilian, than the saga of our last day ashore. It began in the usual way, staggering out of our ‘racks’ (bunk beds) at 4:30am. Shower, shave, coffee, breakfast for those with cast-iron constitutions and muster in the CASREC (Casualty Receiving Department and the launching point for every move ashore) by 5:30am.
It did not take long to determine today was going to be a dificult day. The seas were choppy, the mist was dense and there was a continous drizzling rain. We adopted the usual posture, known to paratroopers as “hurry-up and wait”.

After an hour, the weather was little changed and it was pretty certain the ship’s helicopters would not fly, but at least one of the ship’s small utlity boats, known as hospitality boats, was prepared to make a run for Bahia Malaga where the weather was better and the Army Blackhawks would ferry us to Buena Ventura. Twentyfive volunteers were asked for. It was important we go because we had made commitments to patients from the day before and we had a great deal of medical equipment still in the Coliseum. Of the twentyfive who stood up to go, most were what I called ‘the usual suspects’ the same group of doctors, nurses and medics who seemed to be in every difficult mission, four were Project HOPE Volunteers, two doctors, two nurses, all younger than me - just. I had no choice but be the fifth.

Almost the moment we crossed from the lowered lifeboat to the hospitality boat, the rain began in ernest. As soon as we rounded the Ship from the sheltered leeward side, the boat began to rock and roll. Trying hard to avoid the rain and the sea spray we eyed the waves and held on to the boat, some including me, chattering away to settle the nerves. It wasn’t the choppy seas that bothered us, we trusted the Mariners piloting the boat; it was being seasick.

Half an hour into the journey the boat really began to bounce about, caught by increasing cross-winds and a rip-tide running up the river, a river we had to enter. Our craft began to buck so alarmingly, I would not have been surprised to see Captain Ahab on the prow with a harpoon and a big whale to port. Finally, after many more exciting and drenching moments, the boat made the relatively calm waters of the estuary and from there chugged quietly up to the pier in Bahia Malaga.

There we found to our dismay that the weather had beaten us ashore and the helicopters would not be flying until the rain and very dense low cloud cleared. Not to be defeated, we regrouped, cared for those who were seasick, found shelter and food and hunkered down to to wait out the weather. I wandered to the water’s edge with a couple of the boat crew, seasoned sailors; they were in no hurry to fight the tides and the seas back to the ship. Their advice was we all get some rest. I took it, determined I would not rush to take the boat back, I advised the four Volunteers to do the same. I was sure the weather would clear and the ship’s helicopters would pick us up, eventually. I was going to wait for them; they agreed to do the same.

I scrounged some old mats and a piece of plastic and was soon snoring; only to be woken by the boat’s coxwain who quietly informed me he was, “about to make a run back for the Ship and that much to his dismay, the four, the ‘HOPIES’ were volunteering to accompany him.” More than a little grouchy I found my intrepid comrades and crossly demanded to know what on earth they were thinking, the journey back would be as miserable as the one in and it was poor judgment to make the boat crew responsible for them. My final admonishment was, “Just because you are HOPE Volunteers, it doesn’t mean that *@##* Volunteering is Mandatory!” Chastened, the four settled down to wait. Two hours later the weather began to clear and the air was soon filled with the welcome thump of helicopter blades. We were on our way ‘home’.

As a young army officer, I once had a Commanding Officer who told me, “Your job is to give your soldiers tales to tell without getting them killed”. I think its fair comment that COMFORT’s time in Columbia gave many of its crew, civilian and military, tales to tell. Tales they will enjoy for years to come and which set them apart from the people who were not here with us.

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