IN THE MAIL Letters to the Editor should be kept as brief as possible. Anonymity loill be preserved, if requested.

Editor’s Note: Arthur A . Kirk, M.D., a Virginia orthopedic surgeon, spent a month in Afghan- istan under the Medico plan. Prior to his trip he received a letterfrom the nurse in charge of the operating room at Avicenna Hospital, Kabul, Afghanistan. The letter and Dr. Kirk’s remarks are printed below in full.

Dear Visiting Surgeon: First of all, let me welcome you to Afghan-

istan. We are always most happy to hear that you are coming, for you have a lot to contrib- ute to our knowledge, and we learn much from your visits. The Afghan nurses and doctors are especially happy to hear that you are coming, and they look forward to your arrival.

So that you will enjoy your visit here to the utmost, I would like to describe to you the situation in Afghanistan and at Avicenna Hos- pital. “Forewarned is forearmed,” as the fa- miliar saying goes.

The doctors, of course, all speak English; however, your scrub nurse speaks very little English, if any, but she does understand most commands. Ulcers are a fairly common com- plaint with the Afghan people, but this comes from drinking excessive amounts of tea, NOT from the ruah and pressure of a hustling, bustling modern world. Our 8 A.M. cases are usually rolling along at 9 or 9: 15, and there are any number of reasons:

1) Someone forgot to book the operation, or to give the correct name, room or bed.

2) Hbg, pre-op orders, or a physical were

3) The anesthetist arrived too late to work. 4) Scrub nurses and circulating nurses ar-

rived even later to work. 5 ) Your instruments were used late yester-

day afternoon, 80 they are non-sterile now, and you must wait until they are autoclaved. (We have no flash autoclaves here-one is on order now. If you drop an instrument, or forget to ask for a special instrument, i t will be approxi- mately 30 minutes before it can be sterilized for you, provided our small autoclave is in working condition.)

6) The orderly has disappeared, and no one has brought the patient to the OR.

7) The patient wasn’t shaved last night. The miracle is that we actually do start

operating (once you’ve found your residents who were there “just a minute ago.”) So, don’t get upset; don’t lose your temper. Relax, and for goodness sake, don’t go home with that ulcer I was speaking about!

We are lucky to have all the wonderful supplies from New York, but Afghanistan is a poor country and frequently we lack supplies that are obtained locally. Though I have been here only a year, I have seen operations can- celled because there is no ether, or no gauze sponge, or no alcohol or iodine for the prep, or no sterile linen (it rained yesterday and the laundry is not yet dry), no water from the taps

Continued on page 157

neglected.

Janwry 1970 155

Continued from page 155 to scrub, and even no nurse. Each of these vicissitudes we must take in our stride.

The Afghans are wonderful people. You will doon have a warm affection for them. But they do not know or understand the concern for the patient as a human being, as you and I do. Nor are they too concerned over maintaining good sterile technique, although they have studied all

about it. Should a patient develop an infection post-operatively, the response is “Inshallah” (God’s will), not “Where did our aseptic tech- nique break down?”

We work summer hours 1 4 3 0 p.m.; winter hours 9 a.m.-3:30 p.m.; and Ramazan (month of fasting) hours 9 a.m.-2 p.m. Thursday after- noon and Friday are regular days off. Hospitals run rather like stores over here. When it is closing time, it is closing time, and everyone leaves. Again I must stress that the Afghans do not have the same concem for the patient’s well-being as we have. This, of course, affects your operating room schedule. We have a slow start, and we stop on time.

Since my nurses consider their job just a job and not a profession, and since their salary is $10 per month, and since they are nearly all married and have families at home waiting for them, and since there is no “evening” staff to take over, and since overtime pay in unheard of, and since our operating room schedule is SO busy that I am unable to give back in time the over-work time, I am very, very loath to ask any of my nurses to work late. Visiting sur- geons come and go, but the Afghan staff re- mains here and they cannot work late every day to complete your operations. So consideration for the Afghan customs and the Afghan person- nel is greatly appreciated by everyone.

Instrument limitation is another one of our big problems. We work from pre-sterilized in- strument trays. We have two basic trays; one Laparotomy tray, one chest tray, one vascular tray, two biopsy sets, one hemorrhoid and one orthopedic tray. Once a tray is used, it takes about one and a half hours to get the instru- ments washed. counted and resterilized. That means you won’t be able to do two laparoto-

mies simultaneously, or one following the other. In fact, it is extremely difficult to do two laparotomies in one day. Or, if you are an orthopod, two major orthopedic operations in one day is a physical hnpossibility; but we do manage to make minor sets, and if you can get everyone moving fast enough you might do four ops in a day.

Essentially, the schedule runs as follows: general surgery, Monday, Wednesday and Fri- day; orthopedics, Tuesday, Thursday and Sunday mornings; biopsies, Sunday; eye surgery Tuesday afternoon.

We must always be careful of our supplies, as an order I place in New York in March may not actually reach Avicenna Hospital until January or February of the following year. So we are very careful about the use of adhesive tape, stockinette, plaster of Paris, and 80 on. This brings another subject to mind, one that wiIl annoy you constantly while you are up here. Everything, absolutely everything (even the bathroom) is locked up, and you will have to find the right person with the right key. Things have disappearing ways in Afghanistan. It is one of those facts of life, and for a month, at least, you will have to learn to live with it. Your instruments are in sad condition. But

there is nowhere to sharpen them, nowhere to send them in for repairs, and I can’t just pick up the telephone and call the repairman or representative of the instrument company.

I don’t mean to frighten you with my description of the conditions. I just want you to know that you are not going to be working in an American Hospital with American sup- plies and American staff and American tech- niques and American “know-how.” You are not in a modem hospital in New York or Chicago or Los Angeles; you are in Kabul, Afghanistan, and it will be for you a most memorable hospital and a most memorable surgical month. You are badly needed here, so please overlook the not-so-nice aspects, which are really not as bad as I have pictured them.

For all our failmgs I apologize. But despite all these failings I know, in fact I am very sure,

Continued on page 158

January 1970 157

Continued from page 157 that you will have a most enjoyable experience out here, and you will make many new friends amongst the Afghans. It is an exciting country.

Most sincerely, Nancy Caw, RN

REACTIONS Upon arrival, I found that Dr. Hankins and Dr. Hutchinson, chiefs of surgery, were attend% a conference at Kola Lampa Malasia. To my surprise, this put me in charge of the surgery department. Actually, I did not encounter any real problems because the capable residents continued to keep things running smoothly.

There were many more people than time would permit to be seen at the clinics each day. It was pathetic to see crowds at the door trying to be worked-in before the clinics closed. We could see only a limited number before we had to return to the hospital for our other duties.

During my stay I saw quite a large number of patients with tuberculosis of the spine and many others with particularly bad results from fractures, includmg three severe cases of Volk- mann’s contracture. About one of every ten persons seen had white scars on his eyes and was partially blind from severe trachoma. Even one of the OR nurses had damage to one eye as a result of this.

Nancy Cam, a quiet, pretty girl from Canada, was in charge of the operating room and was the one who had forewarned me in her letter of some things I would find quite different from our hospitals in the states. She spent much of her time teaching and directing those she would leave behind when her tour of duty was completed.

The standard saying in the OR seemed to be “Doctor, you wouldn’t believe it, but-” and I soon began to respond quickly, “Yes, I would!”

For instance, one morning we arrived in surgery and were told there was no running water in the OR. We quickly improvised and pulled a garden hose from a working faucet in the yard through a window, had running water and proceeded to scrub for surgery.

The weather was quite warm, thus many

flies were about and it seemed that Nancy spent much of her time trying to keep the surgery doors closed. We finally drove nails in the top of the doors and used the rolled bands from the cuffs of discarded gloves over the nails to help the doors remain closed.

I was given a cap and mask when I arrived, and told that those would have to last me for the month I was to be there. This meant I washed my cap and mask each day.

There are three vital needs of Afghanistan: irrigation, sanitation and education. It is a land-locked country with no outlet to the sea.

When the month of duty was complete, we felt we had helped the residents and nurses. Much time had been spent teaching and I had learned a great deal also. During my stay the Queen of Afghanistan

came to see us. She was a gracious and lovely lady. She spoke to us in English, shook my hand warmly and thanked me for coming to help her people.

Arthur A. Kirk, M.D.

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158 AORN Journal