I tried to write this post a couple of times whilst I was still out in
Slovenia but I just couldn’t find the time or energy to do it justice. Now I’m
home I’m trying to consolidate all the little notes I made to myself and I’m
afraid this is going to be a mammoth post about everything I was thinking,
feeling and witnessing whilst working the past week in Dobova. Its not the most
flowing piece of writing and I hope you can manage to get to the end!
In total we worked the initial shift I already blogged about and then two
24hr shifts with 24 hour rest in between then another 9 hour shift on Christmas
day. We saw 319 patients over those shifts with around 100 a day on the 24
hours shifts and a few less on the 9 hour shifts. Generally, the shifts were much busier in the
evenings and our first 24 shift started in a very chaotic way. A train had just
arrived at 9pm when our shift began and over 1000 people were coming into the
camp. We saw 40 patients in first 2 hours with another 55 in the next 6 hours
including 4 very sick patients. On our second 24-hour shift finishing at 9pm on
the 24th we ended up staying another hour as the team we were
handing over to consisted of just one doctor and when she arrived we had 2 very
sick patients plus reports of a third needing to be picked up at the train
station.
We noticed quickly that “batches” were much sicker than others and it
was linked to which route they had taken and how long they’d be travelling
without stopping. Those who had walked across Bulgaria rather than risk the sea
were much more exhausted and seemed to have been more neglected health wise.
Sometimes the make up of a train was mainly young healthy men and our only
consultations for hours would be coughs, colds and headache. Then the next
train would arrive and there would be large extended families with many
pregnant women, new born babies, young children and old sick grandparents. I
was so amazed at the resolve of families to bring along and continue to care
for every member of their families including
the wheelchair bound grandma with type 2 diabetes, the severely disabled
premature baby requiring urgent heart surgery to save his life and the granddad
requiring dialysis every 3 days! When we had a group like this, the clinic was
crazy and we were running around like mad trying to keep the flow of minor
cases moving whilst providing emergency care alongside. Luckily our team gelled
really well and we were able to adapt to the situation when the clinic was
heaving with sick people. I felt that as the 2 doctors (and I hope Elly agrees)
we had a very good mix of complimentary skills and I never felt like we lost
control and patients were always safe.
We saw several cases where people just could no longer keep it together
and something snapped. A young girl around 9 years old was rushed into the
clinic hysterically screaming in pain and unable to stand. I rapidly assessed
her and found she was very tender in her abdomen and was concerned she had
acute appendicitis. We checked her vital signs and actually everything was
normal. I gave her some simple analgesia (paracetamol and ibuprofen) and after
15 minutes she was up walking around smiling. She couldn’t really explain what
had happened and we observed her for another couple of hours and the pain had
completely resolved. One thing Elly and I talked about at the end of that shift
was the importance of sitting on people like this and waiting to see what
happened if it wasn’t immediately apparent there was a life threatening
condition. We saw this type of presentation a few times and we could only
really explain it as a psychological response to the extreme conditions they
were going through and that being seen by a doctor, being reassured and maybe
given any pill was enough to build the resilience back up and carry on with the
journey.
Elly and I shared out the task of going to the train station and
transferring cases by ambulance to the hospital. Our first referral was a 7-year-old
boy who presented with severe exacerbation of asthma. His mum stated he was on
inhalers in Syria before they left but all their belongings including his
medicine had been thrown into the sea by the smugglers to make the boat lighter
as they crossed from Turkey to Greece. He was really unwell but it was a
presentation I’m very used to dealing with in A&E in Lewisham and Woolwich.
As we had nebulisers and oxygen I was able to give a significant amount of
treatment to him in the clinic to see if he responded. Having experience with
these kids I knew pretty early on he wasn’t going to respond and would almost
definitely need referral to hospital but actually his clinical state was
completely irrelevant when negotiating the referral with the family. His
extended family were all travelling together and I think in total there were
around 20 people linked to the child. Our Arabic Translator Hakim was amazing
at mediating between the family and us and explaining the seriousness of the child’s
condition. Despite the mother and father realising how unwell he was there was
still severe resistance to the family being prevented from continuing with the
journey. Many of the extended family wanted to know exactly how many hours
they’d be kept in the camp, predictions we just couldn’t make. It was really
hard as a doctor to delay referral for a child who was clearly unwell to
appease the family until the point that we had everyone on board in order to
make sure the family wouldn’t be separated. Even once they had agreed to go we
had a hard time from the family every hour or so having to give updates and
trying to stop them boarding the next bus in the morning and wait for the kid
to come back from hospital. But about 9 hours later the child returned looking
almost unrecognisable to when we sent him to hospital and it was one of the
really great moments when he came back to the clinic to say goodbye.
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Happy Mustafa back from hospital |
Another patient I transferred was a desperately sick little baby who was
only 2 months old and had been born just before the family left Syria. The
child had a respiratory infection and was unable to feed and was in bad
respiratory distress. The mum and dad and baby were travelling together with no
extended members and we managed to negotiate with the hospital to keep all of
them at the hospital together. They had already been admitted in Turkey for a
few days during their travel and I think they knew that the child was still
unwell. The mum was only 20 years old but she was so strong and really sorted
the Dad out when he started talking about missing the next train. The
paediatrician I referred to was an amazing old school doctor who had excellent
English and was clearly very skilled. Her first action when we brought the baby
in after a thorough history and examination was to give the baby a bath! I
found it very weird especially as the child needed urgent IV antibiotics in my
head! Anyway, she was amazing at reassuring the parents and was very empathetic
offering them showers and to wash all their clothes whilst they were in
patients. I thought the child would have to be admitted for at least 48 hours
and the paediatrician agreed but it was nice to see the family in a safe space
and all together.
The other interesting part of the job was going to the train station to
collect patients who were extremely unwell. When I went to the train it was an
evening train with around 1000 people arriving. The station was crazy and
chaotic and there was one doctor on the station with a handful of meds making
direct referrals to us in the camp if she was concerned. When I arrived the
patient in question was a young man who had a very high temperature and had
collapsed on the train. She had to physically take him off the train and was
trying to assess what was wrong with him. Whilst I started assessing him
someone started pulling my coat and asking me to see someone else. A 9-month
pregnant lady was so exhausted she also couldn’t get off the train and was
unable to walk. I decided neither was so sick they desperately needed to go
straight to hospital and brought them to the camp. Both turned out to be fine
after a period rest, observation, IV fluids and some basic meds and didn’t need
referring to hospital but the whole visit to the train station gave me a
different perspective.
Although it sounds dramatic I couldn’t help but compare it to pictures
I’d seen of the holocaust where people were transported on trains and then
taken without knowing where they were going to these heavily militarised camps.
They were going to be transported to be stored in empty warehouses for an
unknown period of time all clutching a handful of personal items with the hope
of finally reaching somewhere safe. When I looked in the train on my way out of
the station it had clearly been horrendously overcrowded, vomit on the floors
and just so dehumanising. When it was suggested to think about providing a
clinic on a train I was quite excited about the logistical challenge. However,
seeing that situation now I feel it’s so totally inappropriate to provide care in
that setting as this would further legitimise the way the crisis was being
managed. People have the right to stop, rest, eat, drink, feed their babies, change
their clothes, have showers and seek medical care in a calm and controlled
environment whilst making this horrendous journey. The priority should not be
shuttling people across your country as fast as you can so its someone else’s
problem.
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Sleeping overnight at the camp |
A case that I got really emotionally involved in was a young teenager
who had a congenital heart problem that required surgery. I wasn’t really sure
why he hadn’t had the surgery as a baby but the family were very keen that he
gets to Germany where he could have proper care and follow up. He was brought
into the clinic having collapsed whilst waiting in the registration line in the
cold. When he came in he was completely blue and short of breath. His oxygen
level was 55% (normally >95% in healthy adults) and we put him on oxygen
immediately. Within 5 minutes he was much better and once he’d warmed up we
decided that his background oxygen level was normally around 75% which he
stabilised to.
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Severely clubbed fingers (for the medics) |
We worked out that the reason he had decompensated so badly was
being made to stand in the cold so we wrote a medical note and went to speak to
the police to ask if he could be fast tracked through the queue and not made to
wait in line. After an hour or so he wanted to go back with his family and
sleep in the main tent until the bus arrived in the morning so we let him go
with the note to the police to ensure he wasn’t made to stand outside again.
Only 30 mins later he was rushed back in, in the same condition as before. This
time we decided the only way to ensure he was warm and ok was to keep him in
the clinic. So we identified the whole family and managed to get access to the
mother and baby container (run by another charity WAHA) to allow his 23 family members
to sleep there where we would collect them from when the morning bus arrived.
Early in the morning the police chief came to say him and his family needed to
get on the bus now so we started waking everyone up and getting them on the
bus. The chaos of trying to wake up and dress 13 children ready with all your
belongings for another journey was indescribable. I was so stressed the family
would miss the bus I was running around picking children up, putting their
shoes and coats on and collecting them together. Even though it was only 15 or
20 minutes I was involved in helping them get on the bus I had totally adopted
the stress of the family and felt fully responsible for keeping everyone
together. The relief and emotion I felt when I finally got the last kid on the
bus and double checked to make sure everyone was there together was a small
taster of what the adults in these families must be going through at every
stage.
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The family in the WAHA container before they went to bed |
When we did get a break in the flow of patients we sometimes took a
moment to lie down for a couple of hours. It was very disorientating sleeping
inside the medical tent where you can hear the movements of everyone else in
the camp around. Towards the end of the first shift and definitely in all of
the rest of the shifts my brain had shifted to a hyperarousal state. The
smallest noise or movement inside or outside the tent and I would wake up
immediately expecting a huge flow of people into the clinic. Those who know me
well, know I’m prone to sleep talking and predictably I woke up Heather and
Elly! One night I shouted out in the middle of the night “When does the next
train arrive?!” and would only lie back down once Elly reassured me we were in
the hotel I could go to sleep.
Consciously I hadn’t realised that being in a militarised environment
was affecting me but I had several dreams about being shot by the soldiers or
about the clinic being bombed. I found it really weird that this was my
subconscious reaction as my personal interaction with the police and military
was mostly very pleasant and respectful. However, we witnessed every day
unnecessary shouting and some pushing/shoving the refugees as they were were
boarding buses or being registered. I can’t imagine how it must feel to have
fled a war zone where your life was actually threatened by militia and then
have to spend every day being pushed from pillar to post by more military
actors. The entire team spoke about how unnecessary it was for the police and
soldiers to be so heavily armed and how just that simple presence of guns
changed the entire feeling of the camp. Individual police and soldiers were
very pleasant and often when the treatment of refugees was at it worse it
turned out that they were being forced to work unpaid overtime or had been
drafted to work without notice that morning. The camp did run “efficiently” and
the flow of people was managed well but overall it was just so unnecessary to
have so many physical barriers and escorting people often children, with huge
weapons to just go to the toilet.
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Open access to healthcare.... |
I have so many more stories of individuals and families that we were
privileged enough to share a small part of their journey and feel this post is
becoming way too long again! One of our observations I touched on earlier was
actually defining the mandate of the clinic. Our team had a very shared ethos
where we wanted the clinic to be a humanitarian space and we really wanted the
clinic to run as an open access self referral system. This means that if anyone
wants to see a doctor they are able to and there should never be any triaging
by police or military to decide if your sick “enough” to see the doctor. Trying
to define the role of clinic is difficult as defining medical care is not as
clear cut in this setting. Providing rest is the treatment to exhaustion,
providing nappies and a space to feed the treatment for an irritable baby,
rewarming the treatment for hypothermia and play the treatment for kids who
have been travelling non stop for days. However, when we had acutely sick
people like a lady who was maybe having a heart attack or the boy with severe
asthma our clinic suddenly morphed into an A&E majors department and we
went from blowing bubbles to cannulas in a heartbeat. Many health actors are
stepping in to provide the humanity in this setting and actually there
shouldn’t really need to be a “humanitarian space”. The whole camp should be
made with humanitarian principles as a priority not the logistical issues. After
all these are people fleeing war and persecution not criminals or cattle or
cargo.
Another thing we talked about as a group was seeing ordinary Slovenians
differentiating themselves from the state and providing that humanity to
people. All the food distribution, escorting to and from the clinic and
providing of new clothes, nappies etc was being managed by unpaid volunteers
working with Slovenian Philanthropy. They were incredibly responsive to our
presence and really amazing at trying to improve the position of the people
they were helping in whatever ways they could find despite the barriers created
by the system. This crisis so far will be remembered for the terrible way our
state organised activities have failed these refugees and how ordinary people
and voluntary organisations have stepped in to pick up the slack.
One final point I want to make is that I have noticed the softening of
the media to the plight of Syrians and there seems to be accepted that Syrians
have the right to flee. This is of course welcome news and vital to help apply
pressure onto the government to accept more refugees. However, everyone has the
right to escape persecution and claim asylum in any state. Because Macedonia’s
policy is still in place, where only Syrians, Iraqis and Afghanis (SIA) are
allowed to cross the border we only saw people from those countries or pretending
to be from SIA countries. This means that anyone who is black is unable to pass
for SIA and is returned immediately on arrival. We saw 2 Somali girls who were
detained at the camp and sent to a detention centre in Slovenia despite having
every right to claim asylum. The Syrians we met sure have every reason to be
fleeing, but so do the Afghanis, the Somalis, the Pakistanis pretending to be
Afghanis and the Iranians pretending to be Afghanis and everyone else the world
over who’s countries are so fragile or poor they have no prospect of a future.
People are people and we need to stop making a distinction between those who
have the right to flee and those who don’t. No one would put their children and
disabled mother in a boat and travel thousands of miles to Europe if there was
not the hope that life would be better than where they left.
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Best selfie ever. |