Transporting patients to a hospital.

October 30, 2008

Vientiane, Laos Peoples Democratic Republic

Hospitals in Laos lack many of the resources that you would expect to see in an American or European hospital.  Most notably, patients have to make do without the support of nurses and aides.

When people check into a Lao hospital they must bring with them a family member who can tend to their needs: bathe them, do their laundry, prepare their meals and spoon feed them if necessary.  Those of us who are accustomed to American hospitals where nurses and other staff provide both care and comfort find it hard to imagine how a hospital can function without those employees.

Pause and think for a minute of the last time you walked down the corridors of a hospital or through the hallways of a medical clinic.  How many physicians did you see?  I’d guess that for every doctor on staff, an American medical center probably has ten workers providing support.

I recently delivered three patients to the National Rehabilitation Center in Vientiane: Latsamee, a girl with cerebral palsy who needed resized orthotics and a new wheelchair; Ta, a bomb victim without arms who needed adjustments to his prosthetic limbs and surgery on his remaining eye; and Bounmee, a teenager who lived with a broken femur for a year and a half before I found him and offered to take him for treatment.  Each of the patients we conveyed had at least one relative along who planned to stay for the full length of their family member’s hospitalization.

In my October 8, 2008 journal entry I introduced readers to these patients and the road conditions during our journey from their remote villages in Khammouan Province to the city of Vientiane.  Fortunately, after a few delays in assembling our traveling party and a long, hot day on the road, we made it safely to the capital.  We even achieved my goal of getting off the highway before sunset, since Lao road hazards multiple considerably after dark.

Looking back on the trip, I’m a bit embarrassed over how bossy I was, barking orders to our slow moving entourage in an attempt, if not to pick up the pace, to at least maintain forward progress.

The only thing I can offer in defense is that I was traveling with a high-maintenance group through high-risk territory. (Do you know how long pee breaks take when you are traveling with a girl in a wheelchair, a boy with a broken leg and a man without arms?  Don’t even ask about the guy with no arms; I’m a partner in a death pact with my assistant Yai that demands my silence!)

In the recent past, our trucks have faced many delays along the same route.  We’ve had vehicles trapped for hours, even days, behind floodwaters and rockslides.  We’ve collided with geese, goats, pigs and cows.  We’ve blown tires and burnt engines. The last time I carried amputees down Route 13 we ended up spending a long, hungry night in a one-water buffalo-town named Pak-a-ding when our truck blew a head gasket and lost compression.

Bottom line: it’s no fun to be stranded along a lonely road after dark when you’re the one who bears responsibility for the care and comfort of handicapped passengers.

Even when we hit the outer suburbs of Vientiane I refused to drop my guard.  In Laos, it’s never over ‘til it’s over.  (In a country full of skinny people you can wait a long time to hear a fat lady sing).  It wasn’t until we actually pulled onto the hospital grounds about an hour before dark that I let myself breath easy and relax. Not that we had vanquished every challenge.  I soon learned that one big hurdle still loomed ahead.

I began to sense a problem when no employee at the hospital would admit to having authority to accept patients and assign beds.  We asked everyone who looked like an employee; all disavowed knowing what to do or who could help.  I had never encountered such reticence before and quickly grew wary.

Finally, one staff member took pity on our group and reluctantly stepped forward to deliver the bad news that everyone else had declined to deliver.  While hiding behind a broad, false smile she explained that in spite of my having been encouraged, yesterday, to bring our patients from the boonies to the big city, there was, today, no room at the inn.  Apparently a variety of circumstances had filled the hospital to capacity.

Within seconds, the woman who delivered that sad pronouncement, not wanting to bear witness to our dismay, simply vanished. (Well…to be accurate, she did not “simply” vanish.  She vanished magically, as only a Lao responsible for bad news can do.)

Leaving Yai to calmly reassure our passengers (In Laos false hope is always preferable to no hope) I dashed around the buildings and grounds looking for one of my friends at COPE (Cooperative Orthotic and Prosthetic Enterprise) a non-government organization that provides a variety of services to patients at the center.  To my great relief, my friend Sanctavee was still at work.

Sanktavee’s attitude was, essentially, “ The place is full? There are no rooms? So… what’s the problem?” Together we walked back to our truckload of road weary passengers.  If my friend had a plan, he kept it to himself but his apparent confidence raised my spirits and emboldened the group.

Sanktavee grabbed hold of the situation and without asking for anyone’s cooperation, much less permission, he began moving patients and their relatives about.  He wheeled beds into and out of rooms.  He rolled wheelchair patients up and down hallways, parking them here while he created space there.  His frenetic shell game must have left some patients dizzily wondering whether they had been temporarily relocated or forcibly evicted.

In short order Sanktavee announced that he had created space for two of our patients and their families in a tiny room, previously filled but now vacant.  Then, he led our third family to a ward across the hall and proceeded to confidently shoehorn a purloined bed into space that hadn’t existed ten minutes earlier.

Although proud of the miracle he had performed, Sanktavee admitted that he had reached the limit of his powers.  The crowded conditions meant that only our three patients would actually have beds.  Their family members would have to claim sleeping space on whatever open patch of concrete floor they could find.  And no one, neither patient nor family member, could be given a sheet, blanket or pillow.

Fortunately, among the possessions that I was carrying back to Vientiane from Nakai I had an old cotton blanket and a large plastic floor mat.  I retrieved these from my backpack and offered them to the families.

Ta and his wife announced that, the weather being warm, they had no need for a blanket and that, what with Ta lacking arms, they could easily share a single bed.

Latsamee’s family took the plastic mat and Bounmee’s family the blanket.  No one, young or old, showed any indication that they had expected better accommodations or hoped for greater comfort. All disavowed a need for pillows or a mattress.  From everybody it was the same refrain: “Bo pen nyang, bo pen nyang” (No problem, no problem).

Yai joined in, “No problem.  No problem.  It’s the Lao way.  Everyone will be fine.”

I knew what was happening.  Everyone was trying to ease my disappointment and protect my feelings.  No one wanted to be a burden to anyone else.  That also is the Lao way.

Early the next day, Yai and I were back at the hospital eager to see how everyone had fared and to make a shopping list to take to the morning market.  It was still, “No problem.  No problem” all the way around.

Ta and his wife had slept nestled like spoons on their assigned bed and looked pretty chipper.  Bounmee, the boy with the broken leg, had shared his bed with his father.  They slept head to toe and, both being skinny guys, found comfort on the narrow cot. They looked no worse for wear.

Nine-year-old Latsamee and her mother had tried to share a bed but Latsamee, excited to be visiting a strange location just could not fall asleep.  She tossed, turned, kicked and rolled about until her mother finally could take it no more, banished her to the mat on the floor, and claimed the bed for herself.  In the morning, Latsamee looked bright eyed and bushytailed.  Her mother looked like five miles of bad road.

I had the impulse to share empathy with Latsamee’s mom, and tell her, “Been there.  Done that.”  But I refrained when a warning bell in my brain went off.  Some things just don’t translate well from English to Lao and I didn’t want to create the impression that I sometimes slept with little girls.

Latsamee’s teenage cousin, who was along to assist, and Bounmee’s mother had been strangers until I introduced them the day before. Still, they had no inhibition about sleeping side by side atop my thin blanket.  They claimed that the blanket took the chill off the concrete floor and that they’d been comfortable.  I found that hard to believe but pretended to accept their reassurance of  “No problem.  No problem.”

Sizing up the situation, Yai and I dashed off to buy mattresses and bedding for Latsamee and the ladies on the floor.  When we returned I also delivered a gift for each family, courtesy of students at DC Everest Middle School, near Wausau, Wisconsin.

During a recent visit to that school I described the condition of hospitals in Laos.  I told students that often impoverished people arrive with nothing more than the clothes on their back.  (Forget pajamas, bathrobe or slippers.  Forget even a spare shirt to wear while the one they’ve been wearing is laundered!)

Mrs. Thompson’s sixth and seventh grade students rallied and quickly organized a campaign to assemble  “hospitality kits” consisting of soaps, shampoo, toothpaste, toothbrush and other toiletries tied up in a large bath towel.  In the end, students collected nearly a hundred pounds of supplies that I then carried to Laos in my checked luggage.

Thanks to the students, I was able to give Ta, Bounmee, and Latsamee each a kit to share with their family.  The mothers in the group all agreed that the towels that the students donated were so large, thick and plush that, in a pinch, they would suffice as a blanket.  My friends at COPE will continue to distribute the remaining kits to other needy patients who are certain to arrive in the weeks ahead.

Luckily, before I had to depart on my flight back to the states, I witnessed all three of our patients making progress toward their modest goals.

Within days of arrival Ta got his artificial arms repaired and could wear them with greater comfort.  But the good news was the relief he got from the pain in his eye.

To everyone’s shock, doctors discovered an obvious reason for Ta’s long-standing complaint about his eye.  As long as I’ve known him, Ta has been rubbing and scratching at that eye and wondering aloud whether he’d ever find relief from the itching and burning.  What with all the rubbing, I was worried that Ta would open a wound and introduce infection that would cost him his remaining vision.

It turns out that, more than five years ago, when surgeons operated on his eye to repair the lacerated tissues around it, they left sutures in place that should have been removed within a few days. Somehow everyone forgot about the stitches.  They remained imbedded in the soft tissue around his eye, had never dissolved, and ultimately became the source of Ta’s torment.  The day after doctors finally dug out the old sutures, Ta grinned and told me that his eye hadn’t felt so good in years.

Latsamee’s family initially got frustrating news.  In the two years since Latsamee got her first wheelchair she had put on weight and grown a couple of inches, leaving her cramped in her small chair.  When her mother inquired about getting a larger chair someone at the center mistakenly told her that, while they did provide poor people with free chairs, a patient was entitled to only one per lifetime.

Latsamee’s mother stoically accepted this mistaken verdict.  As a recipient of aid, she couldn’t image questioning a benefactor’s right to give or withhold assistance.  She simply resolved to take Latsamee home without a chair and resume her old practice of carrying her from place to place.

It didn’t take much for Yai to cut through the confusion and resolve the misunderstanding.  Within a couple of days the staff at the center’s wheelchair workshop offered Latsamee a newly refurbished chair that another child had outgrown and traded in.

Technicians also fitted Latsamee with new orthotics properly sized for her growing legs.  Yai and I emphasized to Latsamee’s mother that, from year to year, it was perfectly natural for her daughter to outgrow wheelchairs and medical devices.  We emphasized that, while it would take courage, she must overcome her shyness and not hesitate to advocate for her daughter.

Bounmee got both bad news and good.  It turns out that my amateur medical diagnosis was correct: his fracture, unhealed after nearly 18 months, is not going to improve without surgery.  His X-rays clearly show that the two ends his broken femur are not even close to rejoining; the ligaments in his leg have shortened and now prevent a proper setting of the fracture.

Staff at the center emailed copies of his X-rays to an orthopedic surgeon in the UK who consultants on difficult cases.  Within hours that doctor responded with a candid assessment and recommended treatment consistent with the limited resources available in Vientiane.

(If Bounmee were a patient in Britain, doctors would probably place him in traction for weeks, or even months, and slowly lengthen his tendons and ligaments permitting them to properly position the broken bones.  That lengthy procedure would be unrealistic in Laos, given the shortage of equipment and staff, not to mention the fact that Bounmee’s family has crops to tend at home at the same time that their son would need their assistance in the hospital).

Bounmee’s best chance for recovery in a Lao hospital calls for expedited treatment.  Surgeons will forego using traction to pull the bones into position and will simply cut away the overlapping pieces.  This quicker path to recovery will, unfortunately, leave Bounmee with one leg a few inches shorter than the other.  He’ll eventually walk out of the hospital, but with a limp.  However, that problem will be minimized once he is fitted with an orthopedic shoe.

Unfortunate as the alternative is, Bounmee considers himself lucky.  He looks forward to throwing his crutches away.  He figures that a short leg won’t be much of a handicap in his life as a rice farmer and fisherman. True, he’ll have to give up the freedom of romping barefoot, but he knows there are worse curses in life.  He’s had eighteen months to ponder other scenarios.

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