Back in Action!

So just when I had adjusted to the fact that my time away had been cut short and I was going to have a Christmas back home, I got a call last Thursday from DOTW asking if I could come back to Slovenia on Saturday to stay one week. I don’t think I fully appreciated the reality of “being on standby” for this kind of emergency, and it took me one evening to make a positive decision to come back. I owe everything to Bob as always for constantly supporting me to make these decisions and to his family for being so understanding about me missing Christmas with them.  

Since we left 10 days ago, our team on the ground have been working tirelessly to try negotiate with the Ministry of Health to agree to a long term presence for a DOTW camp in the currently used entry and exit points but to little avail. In Dobova (the main entry point), a team from a Slovakian University has been providing medical care for refugees when they enter Slovenia from Croatia. We have been asked by the Slovakian coordinator to step in to provide some much needed respite for their team of docs and nurses so they could have time off over Christmas. When we arrived we were really unsure as to how many staff members would be remaining, what kind of clinic we’d be stepping into and how many refugees, if any, there would be to treat.

Our little team from Gornja Radgona has grown a bit. In addition to Heather, myself and Claire our stand in coordinator/data collector (whilst Titi is on holiday), we have been joined by Elly an experienced Gp from Belgium who has volunteered in the Belgian MdM clinic for a few years, Hakim our Arabic interpreter from Morocco and Ramin our Farsi interpreter from Iran. We’re staying in a time capsule from post soviet 1960’s complete with wood panelling and VERY patterned carpets and cosy shared rooms.

We got stuck straight in on Sunday and went to meet the Slovakian team quite early in the morning. The Slovakian coordinator is a fiercely efficient lady who has clearly cultivated a very functional and efficient clinic and is quite rightly protective of her operation. They have an amazing clinic that is heated with a well stocked pharmacy and good space for consultations. They have an ultrasound machine, capacity to give medicines intravenously, provide nebulisers, do ECGs and defibrillators if someone’s heart stops!

Consultation space to have some privacy

Pharmacy (bit better than our mobile one!)

Ultrasound, defibs and emergency bags

Unlike Gornja Radgona there seems to be no plan as to when refugees arrive and the medical team have to be on standby to run the clinic 24/7. The Slovaks have decided to run the clinic in 24 hour shifts so they work from 9pm one night until 9pm the next night and start 24 hours later. The clinic runs with 2 doctors and 1 nurse and sometimes final year nursing students. The reason for 2 doctors is first, to manage the numbers of refugees they are seeing in short time periods and second, to provide cover for the train station.

Refugees transit through Dobova in 2 ways. They are either brought from trains or buses to be registered at Dobova camp where they will wait an undefined period for the next bus or train. Whilst they are waiting in Dobova this clinic provides an opportunity for healthcare, food, clean clothes and toilets. There are heated tents but no formal sleeping areas as people do not tend to stay “overnight” despite arriving through the night, normally the next bus or train arrives in a few hours to take them across Slovenia. The other possibility is that they are brought by train to Dobova and are taken off one train and made to wait an undefined period on the platform of the train station before boarding the next train.

At the train station there has been a need for medical care as people wait at the platform. The Slovakian team has been providing a doctor and a paramedic with an ambulance to wait on the platform and identify anyone who needs urgent medical care and bring them to the Dobova camp or if necessary take them to the local hospital.

I’m not really sure why some people are brought to the camp for registration and why some people stay at the train stations. Its also unclear if those who are kept at the station are registered or not in Slovenia. Obviously without the possibility of visiting a camp those basic human rights are not being met and people are made to wait in the cold for the next train.

The set up of the camp is similar to Gornja Radgona but is extremely militarised and very controlled. The presence of lots of heavily armed uniformed officers creates a pretty bleak and oppressive environment not helped by the unending dense fog that only let up today. From the moment the refugees enter the camp all we hear is “quick, quick… fast, fast…” and people run from one barrier to the next scared they will be separated from their family or miss the next bus. There is SO little information sharing with the refugees and the whole system appears very dehumanising. Almost all officers wear masks and gloves and the people are just pushed through as fast as possible. The clinic is only signposted at the very first tent when the refugees enter where there is a small sign saying “if you need a doctor just ask” translated in Farsi and Arabic only. There are Slovenian volunteers and the red cross providing clothes and distributing food but its done very much on a production line and although the majority of volunteers are kind they are forced to wear gloves and masks too.

Fences to control the movements of refugees

The clinic should be open access whereby anyone who wants to see a doctor can, but I can already see there are so many barriers to care seeking. Refugees first have to feel comfortable enough to spend time visiting the clinic and not worry they will miss the next bus/train, they also need to know that there IS a clinic with doctors and nurses in it and then they have to inform one of the staff members they want to see a doctor. In order to come to the clinic they are not allowed to walk over freely and join a queue. They have to be escorted by either a volunteer or the police/military which is not the most welcoming of starts to a consultation.

Right so hopefully that has explained the context of Dobova camp, although I’m not sure I will ever fully understand what dictates the flow of people. The only people who seem to have a permanent handle on this are the police and military. Back to Sunday, we were asked to do our first shift immediately at 12pm until 9pm and the coordinator has asked us to work as an independent team in the rota she has created. When we are working the Slovak docs have time off and we hand over to them each evening.

So in our “short” shift we got stuck straight in and saw a total of 41 patients. It took a while for us to manage the flow and I would describe the way the clinic works as feast and famine. A bus arrives and there are suddenly 100 more people in the camp within a few minutes several people will be escorted to the clinic and we could get up to 10 patients arriving in 10 minutes which is explained by families or groups coming together. Then after a bus leaves it could be up to 2 hours when the camp is empty and we have no patients in the clinic at all.

Most of the patients we saw were minor illnesses such as coughs and cold but we saw several exaccerbations of asthma, diabetes and other chronic conditions. We also saw injuries people sustained during their journey, one diabetic gentleman had a poorly healing wound on his toe which happened when he was trying to get out of the boat in Greece and another young man who had been pushed to the ground by police and injured his hand in Belgrade. We saw lots of families and children mainly with coughs and colds but also one child who was rushed off a bus as it was leaving having a convulsion associated with high fever.

 

Mid consultation

We also had one lady who was 8 weeks pregnant and had abdominal pain. She was mostly well but dehydrated from vomiting which had been going on since the start of her pregnancy. The worry was she was tender in her lower abdomen. In England I would have rushed her to hospital with a possible ectopic pregnancy (where the baby grows out of the womb usually in the fallopian tube) as even though she was well at this stage it’s a life threatening condition. I was really glad to have Elly there to talk through the case with and despite neither of us having training in performing ultrasounds we had a go and Elly managed to visualise the baby bobbing away in the womb. I doubt if we had told the patient to go to hospital she would have, but regardless it shows the difficult decisions we have to make providing care in this setting. In a way not having the ultrasound would have simplified things and we would have to suggest she goes to hospital and put her through the trauma of having to decide to stop her journey or continue knowing the risk she was taking. Having the ultrasound allowed us to rule out one of the most dangerous diagnoses but we still had to be very careful explaining the warning signs of other possible diagnoses and hope that she sought care further down the line. It’s really hard to face the reality that health is not a priority for people and although they want to see a doctor moving forward and continuing their journey is the most important thing.

I’ve already written so much and as always have so much more to talk about, but to finish I want to try and describe why the clinic is so valuable. The medical care we’re giving is really secondary in most cases. Most people have minor illnesses that could go with or without the paracetamol or strepsils we give out, for a few we’re staving off serious illness for another couple of days and for even fewer we’re genuinely treating a serious condition. The key provision the clinic provides is a humanitarian space, free from “fast, fast” and guns and running to the next barrier. It’s warm and welcoming and gives people the space to breathe and think about themselves and their health and take stock of what’s happening and what they’ve been through. It’s the chance to be greeted by someone who touches you without gloves and smiles at you not from behind a mask and takes the time to listen to whatever you want to say and wishes you well. It’s simply a place to be a normal human which has been lost as the logistic problem of solving the “European refugee crisis” has been “solved”.