Cliff Roberson

'Conditions change . . . you may all of a sudden have casualties of war when you thought you were going to be doing C-sections.'

I’ve been a nurse for 25 years, and I went back to school eight years ago to get a master’s of science from Columbia University, where I trained in anesthesia. I am currently finishing my doctorate at Vanderbilt University and my project is on obstetrical anesthesia crises resource management—in other words, training in developing health care systems. MSF was helpful in giving the clinical experience for my project, in terms of being able to talk the talk and walk the walk. I had substantial global health experience prior to MSF. I had done these sort of mom-and-pop missions in Vietnam, Mexico, and Palestine, often paying my own way.

Generally nurse anesthetists are part of an emergency response—such as in Libya or Haiti—or they’re in a surgical program, or both. My two experiences with MSF were in southern Sudan, now South Sudan, in a small village, Aweil; and in Haiti.

In Sudan, MSF had two or three programs, one of which was an obstetrics program to lower the maternal mortality and neonatal mortality—that was the reason I was there. I was charged with providing the anesthesia care for women undergoing gynecological or obstetrical procedures. At that time, MSF was renovating the operating theater, so we worked in a tent, but conditions were generally fairly good. There was air conditioning, but the air conditioner did break at one point and we were exposed to the external temperatures of the African plain. In Sudan, MSF also had inpatient and outpatient pediatrics and mother’s clinics, so it was a fairly large program of which the surgical piece was a small part.

"I think the most important attribute [of] someone who’s interested in working in the field with MSF is flexibility. Conditions change, the context where you’re working is dynamic, and you may all of a sudden have casualties of war when you thought you were going to be doing C-sections."

The role of the nurse anesthetist on paper was to provide the anesthesia services [for the women]. But as you become part of the interdisciplinary team, you find that you have certain skills or experiences that lend themselves to all of the activities that go on and that you might be consulted for a number of reasons.

So, for example, because we had the pediatric inpatients and outpatients, we saw a great deal of soft tissue injuries, snake bites, or fractures that required anesthesia. And although we didn’t have a pediatric surgeon or an orthopedist, the sort of position-du-jour would provide basic care and I’d provide a lot of anesthesia for that.

I think the most important attribute [of] someone who’s interested in working in the field with MSF is flexibility. Conditions change, the context where you’re working is dynamic, and you may all of a sudden have casualties of war when you thought you were going to be doing C-sections.

Typically in Sudan we had women who often would be post-birth—in the village they’d walk three or four days with severe hemorrhage, and they’d arrive really in extremis. So, I was often called on to put an IV in and do that sort of thing. You’re actually able to tangibly save lives. Using improvisation and flexibility to do that really makes it a great job. It really is a great thing to go in the next day and see a mother who was on death’s doorstep breast-feeding her baby in the post-operative ward. That sort of experience happens routinely, because women don’t have prenatal care. You’re exposed to complications you haven’t seen in decades here [in the United States] on a routine basis.

"You’re able to draw on deep levels of knowledge and there’s great cooperation between your surgeon colleagues, or your obstetrician colleagues."

I went for a month to Haiti in December 2011. I was working in a small town that was actually the epicenter of the earthquake, Leogane. Once again I was charged with the anesthesia care. This time I was not the sole expatriate anesthetist. There were three of us, and we shared the call responsibilities at night and worked closely together during the day. We also worked on training the national [Haitian] anesthetists and training the nurses to assist them. This was a very busy center—the OB was amazing. We did 600 deliveries in the month that I was there . . . we were doing 20 deliveries a day; probably 40 percent of those were C-sections. One night between 5 p.m. and 1 a.m., I did seven C-sections, and then there were two more pending. We also had surgeons, expatriate surgeons, an orthopedist, and also visceral or general surgery. So, in Haiti we did the cases we typically did not do in Sudan. We were doing the larger cases.

In Haiti, we actually had a meeting with the national staff and the expats every morning during the week which was a great venue to get to know and meet everyone—and it was also an hour every day in medical Creole or medical French, which was a great way to ease into the context with your language skills. We almost always had a full operating schedule during the week, so I would report to the operating theater, make sure my equipment and drugs were adequate, confer with the OR staff and OR supervisor as to what the plan of the day was, and after that I discussed the anesthetic plan with the surgeon, what I needed to do for the different cases and how to proceed.

For anesthesia, we were on 24 hours a day. You finish the day’s work and then you’re on call. And I was called a great deal, particularly in Sudan where we did a lot of C-sections in the middle of the night. You always have the people on the walky-talky in anticipation of that.

We did try to take down-time—that meant that you would need someone else to cover you, and that could happen in Haiti. In Sudan, there was a Sudanese anesthetist that I worked with and I really tried to get him down time. He was on 24 hours a day without any rest, so I tried to work with him and take calls for him sometimes at night. He was very skilled, and he had a great deal to teach me, so it’s not just one way knowledge. They have a great deal of experience in working in a context with limited resources and so that whole sense of improvisation I talked about, they master international initiatives, they master all that and there is a lot you can learn from them.

You do have the equipment you need, although it’s rudimentary and designed to function in the environment you’re in. So, besides flexibility, you’ve got to be able to improvise a great deal with the set of equipment and staff that you have—that is a new skill for many people. We [nurse anesthetists] pride ourselves on having the exact same equipment; the exact same procedure every day for safety, and that can really be a challenge [in the field]. But it’s also a great source of reward. You’re able to draw on deep levels of knowledge and there’s great cooperation between your surgeon colleagues, or your obstetrician colleagues.

"MSF appeals to me because I have the skills, I’m interested, I have a history of volunteerism, and for me it’s important to know that you’re not just providing care—you’re really giving people a voice that they wouldn’t otherwise have."

When I went to Sudan I quit my job. With anesthesia you can go on mission for a shorter amount of time: one month, 3 months. Any longer than that is too intense. You’re on 24 hours a day. I’m able to fit field work into my life because a nurse anesthetist’s pay is relatively high in the United States. I’ve worked at two hospitals in Maine and taught at the University of New England, so I work for six months, then plan to go on a mission. It’s possible because in 6 months you can do well financially. The time commitment is certainly one of the biggest impasses, finding a way to fit the work into your schedule.

I’ll absolutely go back into the field with MSF. I’ll get my doctorate in May [2012], and I’ve thought of doing more training with MSF and maybe taking more of a career path there. That’s something I’m exploring. For me, MSF is attractive because it works in contexts where no one else will—on the front lines of global health in extreme situations. It makes an immediate, tangible difference in people’s lives. MSF appeals to me because I have the skills, I’m interested, I have a history of volunteerism, and for me it’s important to know that you’re not just providing care—you’re really giving people a voice that they wouldn’t otherwise have. You’re witnessing the plight of people who don’t have access to adequate health care. That’s where MSF’s mission really gels with my own sense of self—that you’re able to bear witness to that. For me, that’s a very important aspect of the volunteering experience. For me, health care is a social justice issue.