Isme Aaminah Ana Tabeebah

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 24^th 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.

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.

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. 

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.

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. 

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.

Best selfie ever.