Out of my depth in East Timor

Author: Geoffrey C Mullins

Med J Aust 2009; 191 (11): 664-665. || doi: 10.5694/j.1326-5377.2009.tb03372.x
Published online: 7 December 2009

“I vont to do an emergency caesar, quick!” Andre’s voice crackled into my heavy, hand-held emergency telephone, which I had not yet mastered. Andre was a tall, good-natured Dutch general practitioner who had been working at Dili National Hospital for over a year and did much of the obstetrics when the hospital lacked a specialist obstetrician (a frequent occurrence). I had warmed to him immediately; he was one of the very few people employed in the hospital who spoke English, and he had an air of confidence that was reassuring. He told me that the operating room was already preparing for the procedure, he would be there in 30 minutes, and he hoped I could have the patient anaesthetised and ready by that time.

It was my second day as the only anaesthetist at the only tertiary referral hospital in East Timor, and I had just discovered that, at that time (August 2001), I was the only specialty trained anaesthetist in the country. I was already finding my job challenging.

Dili National Hospital (formerly, the Indonesian State Hospital) had had an eventful recent history. After the referendum supervised by the United Nations in August 1999, when the people of East Timor voted overwhelmingly for independence from Indonesia, the Indonesian army and its local militia withdrew — burning, looting and killing as they went. When the International Committee of the Red Cross took over temporary management of the hospital in September 1999, they found that the buildings were intact but much of the equipment had been looted or damaged, and only 10 nurses remained caring for 37 patients. With the support of the Red Cross and the local population, the hospital was re-established and handed over to the new Government of East Timor on 30 June 2001.

The hospital’s bed capacity was 226, and it was greatly in need of external support, especially specialty medical staff, technical assistance, equipment and drugs.

The challenges for an anaesthetist at this time in East Timor have been well described.1 The limited facilities for anaesthesia, the minimal laboratory and radiological investigations available, the lack of drugs, and the scarcity of blood for transfusion were major daily concerns.

However, by far the greatest difficulty I faced was the language barrier. The languages spoken in East Timor are Indonesian, Tetum and Portuguese. Apart from a few expatriate medical practitioners, very few of the more than 300 East Timorese hospital staff spoke any English, and it was rare to find a patient with any understanding of English. In particular, none of the staff working in the operating room spoke or appeared to understand English.

My initial approach was that commonly used by English speakers when faced with people who don’t speak English. I would speak very slowly, opening my mouth wide and carefully enunciating my words, which of course they didn’t understand. Next, I would raise my voice in the hope that loud English words would penetrate further into the brain of the listener, perhaps to a part of the brain that somehow understood English. Failing this, I would add some crude improvised hand and arm movements in an attempt at sign language. Finally, if my listener still had that gentle, bemused look that I was becoming very familiar with, I would reach into my pocket for my Indonesian–English dictionary. I would find the appropriate word and point at it repeatedly, while staring at my listener hoping for some indication that all was now clear and that he or she understood what in the hell I was talking about. This was a slow process to be sure and, as I was to discover, fraught with risks.

Part of my responsibility was to instruct the East Timorese male nurse anaesthetists when they were in the operating room. So, on my first day, when confronted with a patient who developed tachycardia during anaesthesia, I decided this was an excellent opportunity to begin my teaching sessions.

Applying the communication techniques described above, I soon had the attention of the entire operating room staff. With a raised voice, I slowly and loudly enunciated the words “too fast”. I then repeatedly pointed at the rapid electrocardiogram trace on the patient monitor, saying “too fast”. Unconvinced that I was being fully understood, I took out my dictionary, found the word “fast” and pointed at the word and then at the monitor. Suddenly, to my delight, the two nurse anaesthetists both smiled knowingly, but then strangely began to make blowing noises through their pursed lips, much to the amusement of the rest of the operating room staff. Somewhat bemused, I finally looked down at the dictionary and found that my finger had inadvertently been pointing at the word “fart”, not the word “fast”. This early incident, although highlighting the difficulties I would face in communicating easily and effectively, also paradoxically helped me rapidly establish a casual rapport with the staff that lasted for my stay at the hospital!

Responding to Andre’s request for my anaesthesia services, I hurried to the maternity ward to see my first obstetrical patient in Dili. Neither the patient nor the staff spoke or understood English but, by observing the patient and looking up her records, I did glean some important clinical details. She was a distressed 32-year-old multigravida with severe pre-eclampsia. She was in strong labour with ruptured membranes and meconium-stained liquor. Her eyes were puffy, she was photophobic, her blood pressure was between 180/140 and 240/170 mmHg, and there was protein in her urine.

There were no antihypertensive drugs on the ward; in fact, there were none in the entire hospital. This was indeed an emergency situation. There was no time for me to practise my communicating skills, so I hurried to the operating room, trusting that Andre and the nursing staff had explained the need for a caesarean section to the patient.

I arrived in the operating room closely followed by the patient on a trolley. Two male nurses were present. They were scrubbed and gowned and busily preparing instruments as I moved the patient onto the operating table and positioned her on her side in preparation for a spinal anaesthetic. I was about to place monitors and insert an intravenous line when she suddenly had a strong, painful contraction. I stopped my preparation and began massaging her lumbar region, while murmuring quiet, reassuring English words (gibberish to her ears) and waited for the end of the contraction. Without warning, there was a sudden thud and a loud cry. Looking down at my feet, I saw a wailing, meconium-stained baby on the floor. I looked at the mother and saw, emerging from between her legs, an umbilical cord that had obviously broken off as the baby fell to the floor. The two nurses standing behind their instrument trays were wide-eyed and aghast and appeared unable to move. I picked up the now screaming, slippery baby boy and was holding him in my arms when a midwife entered the theatre. I immediately tried to communicate to her that the baby had fallen on the floor, and probably on his head. This I did by repeatedly hitting my head with my free hand, as I held the baby in my other arm. At the same time I was imploring the scrub nurses, who still seemed unable to move, to “Get Andre! Get Andre!” Meanwhile, the mother had now rolled onto her back and was staring in disbelief at the long umbilical cord between her legs and then at my antics with the baby.