Tom Catena, MD, an American-trained physician, is the only doctor in the remote and war-torn region of the Nuba Mountains of southern Sudan. The Mother of Mercy Hospital, where he works, has limited resources, unreliable electricity and a minimally-trained staff.

Catena said he sees as many as 500 patients a day — mostly trauma cases from the fighting that has waged more than 50 of the last 65 years, according to Catena — and he cannot make referrals for even the most complicated cases. There is no one to refer patients to and no doctors nearby to offer consultation.

Stanford’s Center for Innovation in Global Health invited Catena to campus for one the Center’s quarterly Conversations in Global Health. Before an audience of 100-or-so students, residents, fellows and faculty, host Paul Costello, a Stanford senior communications strategist, interviewed Catena about how he works in such challenging circumstances and whether he considered leaving when the fighting broke out again in 2011.

“I knew very well if I left, that these people would die,” Catena said. “It was that simple. There was no way I could do that. I’d regret it for the rest of my life if I left.”

The people his hospital serves, however, might not have been surprised. Catena said they were suspicious when he arrived, wondering about his motives. “These were people who had been subjugated by outsiders for centuries,” he said. “We had to earn their trust.”

Catena said that one powerful local politician remained skeptical until he treated one of the man’s wives. She came to the hospital after a miscarriage and was suffering from complications. At one point, she was bleeding profusely and needed a transfusion. Catena and other members of his staff donated blood to save her. “We gave her eight units of blood and she improved,” he said. “And then the husband started to come around a bit and was more amenable to us.”

One of six children, Catena grew up in New York and earned his bachelor’s degree in mechanical engineering from Brown University, where he played football.

He connects the experience to his work today:

“I played offensive line so just got [up] all the time… You’re tired and getting beat up and you gotta keep pushing ahead for the good of the team. If you don’t do what you’re supposed to do, the whole team suffers. The idea of team work and sacrificing yourself for the good of the team, these are all… real principles that you can apply to life.

Now, if you fast forward 30 years, and doing work in a hospital, a lot of time you’re absolutely exhausted. You’re tired, you’re worn out. You’re sweating like a pig because the operating room doesn’t have air conditioning. And for the good of the patient and for the good of the surgical team, you’ve got to keep pushing ahead. These are lessons I learned on the football team years ago.”

As a medical student at Duke University, Catena said he took his first trip to Kenya, which altered the course of his life and led to his current work in Sudan. After graduation, he joined the Navy, served for four years, and then completed his residency in family medicine in Indiana. With his training complete, he returned to Kenya, to work in a hospital in Nairobi.

In Sudan, he performs surgery although he is not trained as a surgeon. “What are the ethical quandaries you face?” Costello asked.

Catena said he considers the ethical questions all the time and falls back on the admonition to do no harm. While not formally trained in surgery, he learned from surgeons in Kenya and studies on his own. And still, it’s a tough choice: When a patient requires surgery, Catena knows he can’t refer the patient to anyone else so he weighs the risks and benefits of performing surgery himself. “If I think I can do it, and get a better outcome than if I did nothing than I’ll go ahead and do it,” Catena said. “If I think I’ll cause more harm doing the operation than I don’t touch the patient and I explain why we’re not doing the operation.”

And on those days, when he cannot help the patient, Catena runs through another set of questions and considerations so that he isn’t overcome with grief.

“My role here is to be a faithful servant and do the best I can. God is the author of life and death, not me. If I do all I can, with love and compassion and all my energy and there’s a bad outcome, I’ve really done what I can…

And I really try to console myself because you can get paralyzed with grief. And I can be going from one patient to the next to the next and yet behind that person, there’s a whole line of patients that need your help. If you allow yourself to dwell in that grief and beat yourself up, and not continue on, all those people will suffer because of your feelings and I really have to bring myself back to that thought.”

Catena also thinks back to his residency. When he was faced with four or five patients, he’d ask himself how he could ever see so many patients? Later in Kenya, he’d have 40 patients to see and he’d ask himself the same question. “I just start with one, then two, then three and before you know it, you’ve seen 40 patients,” he said.

Now, when 500 people show up at his hospital in the mountains, he takes the same strategy and just starts with one.

Photo of Tom Catena speaking with Stanford surgeon Sherry Wren, MD, courtesy of Johann Voss, APCO Worldwide