The Handover

On a Doctors Without Borders mission, the ritual of "the handover" is played out across continents, languages and projects. Sometimes in person. Sometimes only by written word. It's the process of taking everything you've learned, everything you've done and everything you've planned, then transplanting that knowledge into your replacement.

My handover today is of the Emergency Department, Hospital General Nuevo Laredo, Mexico.

After two months here, I can tell you -- Nuevo Laredo is not a destination hot spot. What was once a thriving border town has been engulfed in such extensive violence, it's become a ghost town. With violent ghosts. Prior to 2000, gringos came over the bridge to shop, party, have their teeth fixed ... and now it's all shut down. No marketplace. Vacant houses and shop fronts. Bars in windows. Empty at dusk. War between the drug cartels (and between the government and the drug cartels) has led to tens of thousands of gruesome murders. Migrants from Central America hoping for a better life are dumped here or stranded, abused, threatened and coerced into crime. Anyone with the means has left already.

It's jaw dropping to see what comes through the doors of the only public health hospital in the city and the scarcity of resources to address the emergency medical needs of this city of 400,000+. General practice doctors, nurses with no ED training, no EKG machine, no clot buster drugs, no pharmacy (if patients have no family to go outside and buy meds, the nurses pay from their own pockets), no data collection ... Yet day in and day out, staff does their best to care for their family and friends: 50 - 100 patients per day from sore throats to gunshot wounds. And a system that treats everyone the same, regardless of urgency of the presenting complaint.

Enter DWB. I was brought in to create a project proposal and detailed implementation plan for the ED: Human Resources, physical layout changes, systems and protocols and training plans, equipment and pharmacy, lab and x-ray. It's been an interesting process, aided by a Mexican doctor and support from our Columbian and French upper management team. Although an emergency response organization, DWB/Medecins Sans Frontieres has not historically developed hospital EDs, and to a great degree, that which is second nature to us ED folk is a foreign language to the organization.

My first MSF mission was six months in Darfur in 2004 - 5, after what has been called "genocide" by the world community. Six months in northern Uganda followed - the aftermath of Joseph Kony and his Lords Resistance Army which forced 1.6 million citizens into camps; western Ethiopia - a neglected distant land with virtually no infrastructure; South Sudan after the civil war and an unsettled "peace"; the southern Philippines island of Mindanao where the Catholic government battles the Muslim separatists and civilian flee the violence; a sudden surge of malnutrition in northeastern Nigeria; sexual violence in Guatemala City- volunteering as nurse, project coordinator, medical coordinator, troubleshooter.

And now, Nuevo Laredo. I hand over to a French nurse: reams of electronic files, drawings of treatment rooms and electrical outlets, contact information, lists of equipment to be purchased, systems to be implemented ... but she's not an ED nurse. So my handover is more detailed, more specific: explain the rationale behind triage, fast track, the role of charge nurse and ED manager, a manual of how to calculate and mix medications where there is no pharmacy. On this first day, it seems endless and daunting.

But I know she will understand. She will implement my vision and my plan. She will tweak it and put her own signature on it. And then final part of my handover: letting go.

Sue Averill is a 30-plus year veteran of Emergency Departments in the Seattle-Tacoma area and has volunteered on dozens of missions. She co-founded the non-profit One Nurse At A Time to support and encourage nurses to volunteer their knowledge and expertise at home and abroad. Together, we can change the world, one nurse at a time.