Dr Kim’s baby

Hello friends and family!

As always, I hope this finds you well and happy. Today is the first day of the next year in the Islamic calendar, so welcome all to the year 1393! It seems to be the proper way to celebrate here is a massive picnic in one of the northern provinces, but for those of us who can’t make it up there we’ll just appreciate a day off with beautiful spring weather.

Things are moving along here. We’re headed into a season of “end of mission” for some of my team members. I think four of the team of 16 are leaving within the next month. A few of their replacements have arrived and it’s mixed emotions. Sad to see these people I have bonded with under intense circumstances move along, but excited for their ‘release’ and next adventures. Also, fun to get new personalities and talents in the group – they haven’t heard our stories yet!

Preparations are being made to ensure the safety of the project as the presidential and provincial elections near. Historically this is a time of increased conflict, but we are constantly reassured that this population is very specific and selective in their targeting. We believe we are a benefit to all actors involved and therefore have no reason to fear for our safety. From everything I’ve seen, I agree with this and will keep my head in the PICU/NICU sand trying to do my best for the patients there.

I’ve hit the mid-way mark for this mission and I’m trying to take a moment to reflect. Especially in such an isolated context, it’s easy to get frustrated by the huge boulder of need and inertia in our path, but I’m also seeing the downward slope ahead of me as I finish my time here. There are so many goals I’ve set or have been set for me that I’d like to see through, I’m starting to get frantic. No more excuses, just feet to the ground, pushing forward. At this point I feel like I have the trust and confidence of the staff and my MSF superiors, so I just have to take advantage of the time I have.

I continue to have extraordinary patient encounters. Most of them can’t be captured in pictures, many of them disappear without giving me the chance to see the result of our work. Sometimes I am struck by the horrible circumstances these families face, other times I am humbled by their perseverance and ability to show love despite what life has dealt them. For a couple of weeks we had a newborn in the NICU that the nurses called “Dr. Kim’s baby.”

I received a phone call from the medical director of the trauma hospital next door run by Emergency NGO. They had a married couple who were injured when they drove over a landmine, the husband lost both legs above the knees, the child in the car died, and the wife lost one leg up to the hip joint. The wife was pregnant, basically term, and the baby was in peril by the time they got to the hospital. They had done an emergency C-section and had no neonatology at their hospital, so I was taken over by ambulance with oxygen to retrieve the baby. They had done an amazing job resuscitating the baby and I was presented with a blanket-filled box (similar to one full of reams of printer paper) with small tube sticking out the top and the ambubag [bag valve mask] attached.

I dug into the blankets to find a pink, chunky baby who wasn’t very responsive to touch. We rushed him back to our hospital where the nurses were waiting to place the IV and start the fluids. I was surprised to hear a weak shriek and realized we had lost the endotracheal tube during transport, but the sound was melodious in my ears. He was placed in the incubator (next to another neonate, of course) to stay warm, have oxygen and get IV fluids and when I came in the next morning the nurses said “take your baby! He’s been crying all night!”

As the mother would not be able to take care of him and no family members were coming, the expat nurse and I did our best to fill in. We did feedings, changed diapers, gave baths, and generally held him as much as possible. He joined me as I checked other neonatal intensive care (NICU) baby charts, visited the doctors lounge for a respite from the noisy NICU, and was adored by all his “uncles” – NICU nurses and doctors.

MSF Afghanistan

Me, Evita and Mustafa

 

Unfortunately, we couldn’t fill in 24-7 so we found another NICU mother to help care for him when we couldn’t be there. She was a 13 year old first time mother (her story is another astonishing one) and had more than enough milk for her 1.3kg (2lb 13oz) baby. She doted on him daily, but he proved to be a difficult feeder and required nasogastric feeding.

About a week after the accident and his precipitous delivery we were given permission to take him over to see his mother. Such a beautiful scene, no words to describe it. She hadn’t realized she’d given birth until two days after the accident and had been asking about him daily since. She spent a quiet 40 minutes with him before we had to return to the hospital and she gave him the name Mustafa. At one point I laid him on her bed to wrap him as we left and realized I had placed him where her leg should have been. His improvement in feeding was very slow going and ultimately his family came and took him home against medical advice. Daily I pray for the family to have patience with him and his feeding and that his mother heals quickly so she can join him at home.

MSF Afghanistan

Mustafa

 

Recently I’ve come to realize the PICU/NICU doctors and nurses are truly my personal heroes. Of course, I get frustrated with them on occasion as any supervisor does. However, this is an arduous job and these men have been doing it for a long time before I came and they will continue to do it well after my nine months are done. I admire their endurance and commitment to their work and caring for their community.

Thanks as always for your love and well wishes. Happy new year to you and your family!

Love,

Kim


Kimberly Sudheimer – Doctor

Kim wrote this post on 21st March 2014.

Kimberly is a paediatrician and is currently working as a paediatric supervisor at Boost Hospital in Lashkar Gah, Helmand province. Boost is one of the only two functioning referral hospitals in southern Afghanistan. MSF started to support Ministry of Public Health to work in the hospital from 2009 to help improve the provision of medical care in various departments, including maternity and paediatrics.

All the people featured have given their consent to appear on Kimberly’s blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Focus on the positive

Hello friends and family!

Sorry it’s been so long. Yes, I’m healthy and happy and still in southern Afghanistan. I’ve thought about you all a lot lately, but struggle at times with what I want to share with you from here.

The last month has been mixed – hitting a mental and emotional exhaustion point just in time for a week holiday in Spain with friends. MSF and other NGO’s make their field workers take breaks every 6 weeks or so (either a long weekend or a full week) trying to keep workers in a functional state by anticipating stress. I have seen the effects on colleagues that for one reason or another have to delay these breaks and often it causes more problems than it prevents.

“Pushing through” doesn’t work as well as we all think it might and rarely do we have the insight to admit this to ourselves. My holiday was quite perfect – a time of restoration, renewal; a time to appreciate nurturing friendship, the art of food, wine, and the human potential for beauty – the list goes on.

At times I felt a bit frantic, wanting to satisfy every craving I’ve had the last few months, anticipating the seclusion to come. But I guess that’s a personal lesson in first-world excess: what I used to consider standard is truly luxury, and I’m no worse off for that change.

The work has been good lately. Lashkar Gah had snow for the first time in 20 years (depending on who you ask), so most admissions dropped a bit – hard for the more rural people to get into town. However, burn patients have reached an all-time high.

Just before I left for holiday we received a second expat pediatrician. He’s from Kenya and with experience in malnutrition, so he’ll be supervising in the therapeutic feeding center and general pediatric wards. It’s a huge relief for me because I realized that being spread so thin among the different wards I wasn’t doing anything very well. Each place deserves a lot more attention and focus. Now I get to devote more time and energy to the ICU’s (Intensive Care Unit) and do my best to maximize the potential of the resources and staff there. I have 6 more months here and I want to make the most of it.

We’ve had a number of memorable children lately. In the neonatal ICU (NICU) we had a mother who had given birth to triplets, making it to maybe 34 weeks gestation, with only two of the children surviving. These two were in the NICU for a couple weeks getting nasogastric tube feeds  and struggling to gain weight. The mother was very excited about her children and would bring them up to me each day to make sure I appreciated their beauty. Her husband (and most likely her mother-in-law) was very anxious to have her come home – many duties in the home that only the wife can do – and so despite our pleading, the family went home when the children were still only 2lbs 13oz (1.3kg). We haven’t seen them since, so I’m hoping for the best for them.

Tender Loving Care in the NICU.

 

In the pediatric ICU (PICU) we’ve all bonded with Jaylani. He’s a slight, feisty 8 year old who developed pneumothorax, a complication of pneumonia, and needed a chest tube. When I first met him he could barely speak because he was so exhausted just from breathing. I imagine laying flat with a heavy piece of furniture sitting on my chest, making it hard to fully open my lungs – that’s what it must have felt like.

For a number of reasons he was in this condition for about 5 days and I wonder how much longer he could have hung in there. His father was with him, watching me closely, scared about why his son was sick and wanting him to drink more water. After the chest tube was placed, Jaylani spent the first night in the general ICU (adult) because the pediatric ICU was just too full. The adult ICU does not allow caretakers, so that was probably the first night in his life Jaylani had ever been without his family.

I knew he was improving when I came to see him first thing in the morning and the doctors asked me to transfer him out as quickly as possible because he was bossing them around, crying for water and food. He wasn’t in pain anymore, he could breathe much easier, but he was fed up with our hospital!

This last week he has been in the PICU and everyday he is stronger and more irritated with us. Mostly he missed his father; his grandmother had to come stay with him as only female caretakers are allowed in the PICU. This was a rollercoaster week in the PICU and I wonder what a bizarre torture it must be to an 8 year old to witness this scene 24 hours a day for the last 7 days, especially considering he’s likely only been to an outpatient clinic once or twice in his life, no television, no sense of the world beyond his rural Afghan home.

The nurses have bonded with him, bringing him special food, having him help with his own care – I think they liked having a patient they could interact with. Even though he may have been able to be transferred to a general ward two days ago, they never once asked for it. I can tell they are invested in his cure, want to watch him walk out of the hospital healthy and with a normal child’s energy. I admit I’m anxious for that day as well.

We’ve had plenty of sad cases, frustrating cases, baffling cases, but I’m reminded of the importance of keeping focus on the positive, the triumphs in life. Hope you are all well and appreciating all your blessings! Sending lots of love your way.

Kim


Kimberly Sudheimer – Doctor

Kimberly is a paediatrician and is currently working as a paediatric supervisor at Boost Hospital in Lashkar Gah, Helmand province. Boost is one of the only two functioning referral hospitals in southern Afghanistan. MSF started to support Ministry of Public Health to work in the hospital from 2009 to help improve the provision of medical care in various departments, including maternity and paediatrics.

All the people featured have given their consent to appear on Kimberly’s blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Baby, it’s cold outside!

Hello friends and family!

Winter is definitely here in southern Afghanistan. I may have thought it arrived earlier, but I underestimated what was coming. It is generally ~30F/-1C in the morning and evenings, gets a little warmer during the day. I’m not quite used to these temps anymore, so I find myself layering under my MSF vest and appreciating the head scarf I have to wear.

We have very nice heaters in our rooms on the compound, kind of a modified window unit, but if I have to use the restroom in the middle of the night it’s a serious internal debate – is it worth bulking up and braving the cold? The generator stays on until 1am then they turn it off until 6am. My strategy to deal with this is to get the room toasty when I first fall asleep so the heat will keep until I wake. Generally works fairly well, but it doesn’t make it any easier to get up in the mornings.

The locals have made an art of dressing for the weather. The children have one or two shirts on under their salwar kameez (long shirts). Then a jacket or sweater over that, finally bundled in a random assortment of blankets that likely double as diapers at some point.

My favorites though are the hats. I have seen every variety of head gear you can imagine on these kids. Most of them have a bit of a cone shape, often with sequins or appliqued flowers. Even the sickest child can look quite festive when they first arrive to the PICU (paediatric intensive care unit).

The men stylishly speed through chaotic traffic on motorbikes, brisk wind slapping their faces. They have their heads wrapped up in 6-8 feet of fabric with a heavier blanket material draped around their shoulders. If they are not too fast, you can notice the 4-year-old perched just in front of them on the seat of the motorbike, eyes wide in half glee, half terror, sometimes a woman behind in a burka.

Various head gear on the children in winter © Kimberly Sudheimer

Our logistics team dutifully worked hard to winterize the hospital. This involved putting more mud down on the roof to be sure it will be thick enough to endure the coming rain/snow. An inventory of heaters was also done as there is no central heat source or duct work for the hospital. This is true for most buildings in the area and families use “buccari’s”, or gas powered space heaters.

Various head gear on the children in winter © Kimberly Sudheimer

 

As the temperatures have dropped, our census of burn victims has risen, often due to these space heaters or other warming methods. Two new burn units (one for men, one for women) were quickly put together in the beginning of December and help to keep these vulnerable patients as protected from infection as possible. Our expat surgeon has altered her teaching priorities to perfect our burn protocols with the surgeons and nurses.

Last week we had a family of six all brought in with serious burns, the father and some of the children died. Yesterday I was asked to come help with an eight-month-old with over 60% third degree burns, mostly on his face and chest, although only one foot was a possible site for IV placement. As we looked for a way to give him relief, I was overwhelmed with the smell of burnt hair and skin. The baby had an needle inserted into his tibia and he received morphine and IV fluids until he finally died about 12 hours later.

We currently have to use these space heaters in the hospital. The generator we have now cannot support electric heaters throughout the hospital, so many rooms have these propane tank space heaters. After a busy day of trying to prepare the NICU (neonatal intensive care unit) so the electricians could turn off the power for maintenance, I was happy to head home and calm down over dinner yesterday.

I became suspicious something was up when our logistician got up mid-conversation to answer the phone and never returned. About half an hour later we were informed one of the space heaters had been leaking gas in a room and there was an explosion – a fireball that melted the mattresses through the beds, plastic off the light switches, broke the windows and charred the walls. There were three to four patients and caregivers present (differing reports) with minimal burns considering the state of the room.

The staff present in the hospital at the time quickly extinguished the fire and evacuated the hospital until the acrid smoke cleared. This morning the maintenance staff was already at work when I went to marvel at the scene. It’s just another example of the daily reality people here experience – even just trying to stay warm can be risky.

Various head gear on the children in winter © Kimberly Sudheimer

I may look back on these winter days fondly once summer surfaces, but for now I count this simple duvet and hooded sweatshirt as blessings. I’m grateful for a warm cup of tea before bed and the chance to go back tomorrow and see what the night brought us.


Kimberly Sudheimer – Doctor

Kimberly is a paediatrician and is currently working as a paediatric supervisor at Boost Hospital in Lashkar Gah, Helmand province. Boost is one of the only two functioning referral hospitals in southern Afghanistan. MSF started to support Ministry of Public Health to work in the hospital from 2009 to help improve the provision of medical care in various departments, including maternity and paediatrics.

All the people featured in the photos have given their consent to appear on Kimberly’s blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Day 12: Midnight Trepanation of the Skull

I do not like quiet periods. It means that something is going on. In the ICU three out of the four beds are vacant. The doctors in the emergency room stare at the wall, not a molecule of air is moving in the hospital… It is clear, that something terrible is about to happen!

During the day I am just dilly-dallying with nothing concrete to do. I am releasing the boy who was shot through the heart from the hospital. The patient with the torn liver is also finally going home and all other laparotomy patients are healing surprisingly well. The people here are robust…

Time passes slowly and there’s time for an afternoon trip to the base. Perhaps today I’ll even manage to join the group that aims to spend an hour in a local “pub”. I am working my way through the department and my last stop is in the emergency room. They have a little girl there following a car accident.

She suffered a severe impairment of consciousness, bleeding from the left ear, a comminuted [splintered] fracture of the skull, a fracture of the left humerus [upper arm] and an open fracture of the tibia [shin].  Finally I discover that she also has a totally unstable pelvic fracture and that if nothing is done about it immediately she will die… In the end everything turned out for the best, but it was this that started the onslaught that I had been expecting all day!

Trepanation of the skull. So here it is!

There was then an ageing man of about 50 years old. It was a few hours after a serious car accident before they managed to drag him here. He is in a coma, but to me the brain does not seem too screwed up. We have some sort of manual here that was put together by neurosurgeons and neurologists who understand these things. It has pictures designed specifically for idiots such as myself. The X-rays and the subsequent CT showed a fracture on the left side in the area between the temple and the top of the head – an impression. I suggest a craniotomy and surprisingly everyone agrees. They say that during the year long existence of the hospital, no one else had done it here. They say we do have the equipment though, so hooray!

Xray showing the skull impression Tomas operated on. © MSF

 

Our mission in Kuduz is to help people, if possible, to do no harm and mainly to train local staff. Together with the local orthopaedist, Dr. Samsoor who’s on duty, we are opening-up the man’s head. I’m already an expert on skin incision. We find the impressed area and clean it immediately. We will need to drill holes into the head. I am showing my Afghan colleague how to make the first one. Because we’re both decent drillers, we don’t have any problems with the manual drill and smoothly puncture it twice. I then show him a trick where I slip a saw beneath the bone and then to cut it. Carefully we remove the fragments of fractured bones and rising from beneath is the dura mater [the membrane that separates the skull from the brain] which is fortunately intact.

When we have a hole of about 8 to 10 cm, it is solved. No more bone pushing on the brain. I pluck up my courage and stick a needle in just beneath the dura mater to suck out at least some of the bleeding that is coming from beneath there. If I were sure that we could successfully close this entire wound and that the risk of infection would be minimal, I would close that dura mater straight away and then flush it thoroughly. But I’m not sure, so we leave it closed. Samsoor obviously enjoyed it, he was puncturing and drilling like crazy. He definitely enjoyed the special taboo that accompanies head injuries and surgery!

When we are closing it, we carry out some very minor plastic surgery and make a skin flap so that we can close it as effectively as possible.Seven minutes before the end of the surgery all the lights go off for a few minutes… This time the backup generator does not even kick in and since it is eleven at night and it’s dark outside it’s dark as hell in here My colleague actually finishes the sewing thanks to the LED lights from three mobile phones. It’s quite touching that here we are struggling in these conditions in the light of these modern ‘candles’. It feels like a convergence of people and of nations.

Liver 2.0

Before I have completed the head surgery, they bring in a patient who has been shot. The bullets have gone through the right hypochondrium [upper abdomen] and it emerged in the left frontal area of the chest. It will be a mess in there, probably another damaged liver. As Samsoor has started struggling with an open femur fracture in the next room, this time I’ll work by myself, alone. It is half past eleven at night.

Again I cut it through the centre and just to the right under ribs. There’s a hole in the liver the size of a cow, again the liver almost in two halves, and again ounces of dark blood in the abdomen. I had plenty of practise from my last patient with a torn liver,, so this time I quickly stick dozens of pieces of gauze under and behind the liver and with a beautiful, sharp – and also the largest – skin needle that I have, I proceed to connect the left lobe of the liver to the right one. Normally a special needle is used for this and usually three surgeons are working on it together over a period of hours.  I have sewn the liver together in twenty minutes.

With my left hand I raise the chest while pumping out blood, while with the right hand I sew and add new stitches using a needle that I’ve placed on the liver. The left hand of the nurse helping me keeps the liver away from the diaphragm and he cuts using his right hand. This is it. Everything works. I even have a splendid view of the surgical field. I’m not afraid. It has become routine!

With the liver sorted I continue my reconnaissance of the terrain. His stomach is also cut in two. I carry out B1 anastomos – simply cutting off the dead parts and sewing the live ones together. I then stop the bleeding from the interstitial suspension. The spleen is ok, as are the intestines. After an hour the fight is over. While I’m washing my elbows that are covered with blood, Sergio the anaesthesiologist comes to announce in a resigned manner that in the Emergency Room there is a patient with a puncture wound to the abdomen. It is one o’clock in the morning

When I arrive in the Emergency Room there are already two stabbed people … We don’t finish-up until 2:30 am. I came to the hospital the morning before at 7.45 a.m. Since then I’ve had nothing to eat, nothing to drink and haven’t even been to the toilet.


MSF Afghanistan

Tomas is a surgeon from the Czech Republic working in the Kunduz Trauma Centre in northern Afghanistan. The trauma centre specialises in providing free and high quality surgerical care for victims of general trauma like traffic accidents, as well as those with conflict-related injuries, from bomb blasts or gunshots.
Find out more from Tomas and the MSF Afghanistan blogging team…

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Day 8: Postponed Walk

Until now, we had not been allowed to walk to the hospital but today there was the first opportunity to go on a hiking trek through Kunduz to the hospital. Five of us were going. One of them was myself and I felt OK about that. It had been in preparation for months with the help of some of the locals so that everybody was 100 per cent certain that no one would be shooting our arses off.

Wake-up call at 6:00, I brush my teeth, go to the toilet and have breakfast. I was looking forward to the morning walk through Kunduz which was due to start at 7:00. At 6:35 we have a phone call: “We’ve had an explosion,”

“Shit,”  I say.

“Exactly,” The doctor’s voice responds on the other end. “With an unstable home-made grenade; injured pelvis, possibly blood in the abdomen so please come, okay?”

A home-made grenade stuck between the buttocks…

That’s not the song name of some hard-core start-up band. It’s the reality of this morning. When I arrived at the hospital – by this time we were really hurrying – the patient was already in the operating theatre. In the place where the right hip should’ve been he had a hole the size of a gate that led into the abdomen. As soon as I opened up the abdomen, waves of dark venous blood came rolling out. This time it was not be a torn liver, judging by the direction of the explosion. On the X-ray I also saw small fragments impaled throughout the whole pelvic area.

The intestines are good, both the large and the small so I take a look at the spleen. Then I see it. The entire retroperitoneum (the area between the abdomen and spine) has been lifted-up. There it’s really bleeding. As soon as I make a hole in it a jet of blood sprays onto my chest. When I open it up properly the blood tsunami continues. From three minutes of suction there are two litres of pure blood in the suction flask. I don’t think he will survive this.

I can’t see anything, the pump does not manage to remove the blood fast enough and I’m sweating like a pig. I wrap one cloth over the top of the area that’s bleeding the most and another under it and SQUEEZE, Mr. Assistant, SQUEEZE! This alleviated the blood flow enough that what we had been searching for appears below the vacuum pump. Oh My God! Almost two centimetres of the common pelvic vein is ripped. This vein is garden hose calibre. I scroll through my brain to the relevant chapter and decide that we will sew it up.

Sweat was pouring off me like raindrops. It dropped off me everywhere, even inside my glasses but especially into the open abdomen. My hands however remained absolutely calm. At moments like this they always cease to belong to me; they work independently and I look down on them from above, just watching. The shaking comes later, after many long minutes have gone-by. Stitch by stitch, with a fine needle and using thread that’s nearly invisible, I sewed the mess together.

We went through the abdomen and we removed just a single piece of shrapnel, otherwise, nothing really. We went through everything twice; I hope we didn’t miss anything. My fist would have fitted into the hole in his side. I have a big fist, it doesn’t fit into my mouth and I have a big mouth! Anyway, enough of the measurements!

He was bleeding from everywhere; his torn buttocks, the ilium bone that is blown off and from which most of the blood flowed. Unfortunately, we can’t stop this bleeding and we didn’t have any wax for the bones. So it was a case of washing-out, removing the plastic cap from the grenade, putting gauze inside and tamponing the bleeding. He was stable, with a haemoglobin level of 42, so we put him in the ICU.  I felt a kind of temporary victory until the evening, when I actually saw him after six transfusions. He was quite calm, hardly restless at all so we’ll see in the morning…

Painful rounds

Here in Afghanistan you have to accept the fact that you cannot do everything, and certainly not all of it at a 100% level. Adapting to that takes a week or two. I’m almost there, but it still bothers me when I see how some patients have been treated before they arrive at the MSF hospital: wires pierced where they shouldn’t be, people with rotted limbs because nobody did a fasciotomy after they had been shot in a limb. They have more antibiotics than you could stuff into an ox but those who need them don’t get any. During rounds we have 60 beds so we only have time for just two minutes with each patient. One has to focus on what matters the most and leave the rest to Allah.

Before rounds we receive a general report that begins with a safety report by my colleague Purdel. He reports that the situation in Kunduz is quiet and activity is normal. The Security Level is one, which is the lowest. Then, however, he reports that several people have been killed in the vicinity, a few mass casualties on the roads and a murder. I cannot imagine what level two is like! Nor how many levels this scale has, for God’s sake!


MSF Afghanistan

Tomas is a surgeon from the Czech Republic working in the Kunduz Trauma Centre in northern Afghanistan. The trauma centre specialises in providing free and high quality surgerical care for victims of general trauma like traffic accidents, as well as those with conflict-related injuries, from bomb blasts or gunshots.
Find out more from Tomas and the MSF Afghanistan blogging team…

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Food for thought

Hello to all!

I hope you are well and thanks as always for the kind emails and messages. The internet has been a bit dodgy lately, so it only compounds my normal delay in responding. Still, I love to hear from you.

So, I’ve been thinking a lot about food lately. We’re enjoying the end of our weekend now and we’ve kinda already started planning what we’re going to do (and cook) next weekend. During the week we get home from work around 5:30pm and it would be difficult for each of us to cook for ourselves in one kitchen. It’s much more efficient and people are happy to have a meal prepared by a locally hired cook. For me and a couple other expats here, cooking is one of the few things we can do here that can feel pretty close to normal life. If we plan ahead, our cook can pick up most of the things on our shopping list and have them ready for us. If the items we’re craving aren’t found here locally, occasionally we can get someone to bring it with them as they return from Kabul or a holiday abroad somewhere. Sometimes we have to get creative, but that’s part of the fun, in my opinion. We recently had a lot of people bring in cheese, so last night we made baked macaroni and cheese with a cabbage salad and apple crumble. Pretty darn good! It’s an escape of the mind, a way to work together for a fun purpose, not related to our mission here, and we all enjoy the rewards together at the end.

Pomergranate

A nice juicy pomegranate! © Kimberly Sudheimer

These were comfort foods for some of us, but as we started thinking about our cooking plans for Christmas, I was reminded of the diversity of backgrounds within our expat group. Therefore, not everyone will get as excited about a sage stuffing and pumpkin pie as I will. When I started listening, I realized my Japanese colleague has a fish and rice dish to celebrate. The British doctor has started plotting a Yorkshire pudding. I’m sure the Germans, Dutch, Nigerian, Congolese and Zimbabwean friends can also think of something that reminds them of the holiday.

Food may be a universal language, but it certainly has regional dialects. I had no idea of the typical Afghan food staples before I came. There are many varieties of rice and beans (or lentils, or chick peas), sometimes with goat, beef or chicken, often cooked in a LOT of oil. The bread we get daily is leavened, but is very flat and can either be round or long. My favorite Afghan food so far is mantoo, which is a sort of meat dumpling, similar maybe to wonton. And to finish it off, you must have a nice juicy pomegranate!

I can’t discuss food without thinking about the other side of the issue here and around the world. The issue of malnutrition in Afghanistan is probably the biggest tragedy, in my mind. I feel like so much of the world knows about the military and political issues happening here, but few are mentioning the practical implications. Food insecurity due to lack of access for those in remote settings where many cannot go to market for fear of encountering violence, women not getting an education which has been proven to increase malnutrition rates for their children, using agricultural land for poppy growing (opium) instead of food because of the much higher income generated, etc. No matter the reason, malnutrition is a real and painful problem here. I can’t help but look at the children in our therapeutic feeding center and re-evaluate the term “comfort food.”

On that note, I’m off to dinner. I hope you all have a great week! Happy holidays!
Kim


Kimberly Sudheimer – Doctor

Kimberly is a paediatrician and is currently working as a paediatric supervisor at Boost Hospital in Lashkar Gah, Helmand province. Boost is one of the only two functioning referral hospitals in southern Afghanistan. MSF started to support Ministry of Public Health to work in the hospital from 2009 to help improve the provision of medical care in various departments, including maternity and paediatrics.

All the people featured in the photos have given their consent to appear on Kimberly’s blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Day 6: This is not a fairytale

They banned motorcycles here. That is why it is relatively calm, they say. At night nobody woke me up too frequently. They banned them because targeted assassinations were carried out on them. One drives and the other shoots at a target – usually very accurately. The cops commandeered all the motorbikes in Kunduz.

The guy with the torn liver is fine. The drain from above the liver carries about 250 ml per day and the secretion is decreasing. It is filled with a sort of liver juice. Another drain is almost dry and it would definitely be soaked if he were in a sitting position. Beneath the liver, around the gallbladder, there is nothing. Overall the abdomen is calm, with no sign of irritation. The guy is stable, no more bleeding. We are moving into phase two and there could be complications. They have not started yet but I’m not sure what the outcome will be.

The boy who had heart surgery is just fine. This fourteen year old boy, who was shot by his brother, is sitting on his bed and having a lively discussion with his relatives. Tomorrow we will move him from the ICU into the normal department. Eva carried out a control ultrasound today. A crescent of fluid has remained in the pericardium and the apex shows signs of a possible injury, but otherwise he is ok.

But this is not a fairy tale. Not everything ends happily here. An elder who I was treating died today. He died because he was sixty, which they say is a very old age to reach in Afghanistan. By the way, Afghanistan is number three in the world in terms of infant mortality prior to reaching the age of one. An average family has from five to ten children, sometimes more than ten, but never less than five.

The elder had chronic kidney failure. He came to the hospital in this condition, as our lab tests showed. After surgery, his potassium-level gradually increased and despite the dedicated and constructive interventions of Eva it would not decrease – nor, at the same time, did his other parameters. They decided to relocate him somewhere where they could offer him dialysis. I took a look at his abdomen. It seemed healthy and I could see nothing life threatening there, but then he died.

Dust is flying everywhere. Since the wind picks it up from the desert there is tons of it in the air. The whole town lies below the level of the surrounding sand dunes. It’s an oasis on each side of the Kunduz River. The vicinity is completely deserted. Some doctors go to Germany to study, so that they can come back here again. Hats off to them…


MSF Afghanistan

Tomas is a surgeon from the Czech Republic working in the Kunduz Trauma Centre in northern Afghanistan. The trauma centre specialises in providing free and high quality surgerical care for victims of general trauma like traffic accidents, as well as those with conflict-related injuries, from bomb blasts or gunshots.
Find out more from Tomas and the MSF Afghanistan blogging team…

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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A patient I will always remember

It’s the end of my weekend (often Islamic cultures take Thursday and Friday as rest days) and I thought I’d give you an update. The weather is certainly getting colder, most notably at night. It can be comfortable during the day, even stuffy in the hospital, but the skies are quite clear at night and the heat quickly leaves. There is no light pollution, though, and you can see every star twinkle brightly. The rains will be coming soon.

Things in the hospital are going well, though I’m still adjusting. The paediatric and neonatal Intensive Care Units (ICU) are a difficult place to work, and I’m reminded why I never desired to pursue a career there. Typically I arrive in the Paediatric ICU just after a doctor’s meeting around 8:30am and find a swarm of humanity. There are 7 standard size twin beds with thin, torn foam mattresses and a single sheet on each bed in a 25ft by 25ft room. Also, you’ll find a baby-warmer in one corner, a simple sink, a bureau with medication and forms and an island in the middle of the room that serves as a resuscitation table when a patient is unstable.

This week, I’m fairly certain our census varied between 12 and 18 patients, usually 2 patients and their mother per bed. We often bring in an extra bed to squeeze in just in front of the door. It would be rare for a patient (or the mother) to be bathed at all during their stay and often there will be a child in shock who would need a warm environment, so we try to keep the windows closed. I’ll let you imagine the odour that greets me when I first come to the door. About 80% of our critical paediatric patients are severely malnourished and can be precarious to try to pull back from the brink.

© Vivian Lee

Newborn babies on treatment in the NICU of the Boost Hospital ©Vivian Lee/MSF

 

Upstairs is the Inpatient Therapeutic Feeding Center (ITFC) and general paediatric wards. The general ward is a large open room that has around 40 twin beds that the 4-5 female nurses will wander amongst, trying to get vital signs and administer medication in an organized manner. The room is painted a dark green and has fluorescent lighting, so it’s not terribly kid-friendly, and the odour situation somehow seems intensified here.

I spend more time examining each patient in the paediatric ICU and neonatal ICU, so when I get to the paediatric wards I usually just do a walk through, looking at special cases the physician has questions about or just surveying things on my own.

I’ve gotten more accustomed to healthy older siblings following me around and staring at me while mothers grab the edge of my vest or shove their screaming baby in my face, gesturing for me to listen to their chest. They will fervently explain to me their child’s malady with charades, but I still can’t discern any familiar words yet. In contrast the ITFC is starkly quiet. In the first stage of re-feeding the children are too weak to cry or even do their own eating. Most are fed by a tube through the nose and will graduate when they are taking the food by mouth regularly.

© Vivian Lee

A doctor examines paediatric patients in the morning round ©Vivian Lee/MSF

 

Yesterday I discharged a patient I will remember forever. Her name is Fatema and she is 14 years old. She was admitted in diabetic ketoacidosis which is a potentially life threatening complication of Diabetes Type I (juvenile). She had been diagnosed with Diabetes a few years ago, but lives far away from any health care. Her father tried his best to give her the insulin as prescribed, but they have no electricity and therefore no refrigeration so the insulin quickly became ineffective. I first met him when I found him crying at the base of the stairs holding his bottle of crystalised insulin. I first met her in the adult ICU because we cannot afford to have a full size patient taking up a bed where we could put two children. She was safely (and impressively, considering the resources) pulled out of crisis and was then transferred to general paediatric wards. Due to nursing/doctor/documentation confusion it took us about two weeks to finalize her treatment regimen and prove her sugars were safe. For the medically savvy, it was decided to have her managed only on NPH (12h) and no regular insulin so as to avoid any potential complications of medication confusion – completely unheard of in the US/Europe.

Her father couldn’t stay with her during her hospitalisation because the general paediatric wards allow only female caregivers, but he faithfully visited her everyday and had a smile that expressed more gratitude than I’ve seen in a long time. When we started growing more confident we had the correct regimen we tried to start educating her and her father about the details of her new system. Quickly it was clear that neither could read or write and neither could recognize numbers. So, while we made an exception and gave her a glucometer, she couldn’t write her results down or comprehend what extreme levels really meant. One translator spent hours with Fatema alone practicing writing numbers and I spent two afternoons with the pair drilling how to give herself the injection, how to check the glucose, how to log it on the chart. My exuberant reactions to correct answers were amusing to them, even though they were completely genuine.

At the time of discharge I walked them through the hospital to ensure she got all of the proper supplies from the pharmacy. Fatema liked to hold my hand when she would see me coming up the stairs, so of course we did on the walk out. I got a big hug from her and was completely dumbfounded when her father reached out to shake my hand (the “no-touching” inter-gender rule here is quite strict). I cannot pretend to be optimistic about her future. Even if they get everything right, they still have neither electricity nor refrigeration for her medication, so I fully expect her to be quite ill again soon. If she makes it two weeks she will return to see me to review her results and see if she needs changes. Please add her and her family to your thoughts.

Enough for now. Thanks always for your support and encouraging words. The obscenity of blessings I have received is more real to me each day here.

Love to all,
Kim


Kimberly Sudheimer – Doctor

 

 

 

 

 

Kimberly is a paediatrician and is currently working as a paediatric supervisor at Boost Hospital in Lashkar Gah, Helmand province. Boost is one of the only two functioning referral hospitals in southern Afghanistan. MSF started to support Ministry of Public Health to work in the hospital from 2009 to help improve the provision of medical care in various departments, including maternity and paediatrics.

All the people featured in the photos have given their consent to appear on Kimberly’s blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

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Day 5: goats and gunshots

Let’s just say that today I experienced a more direct feeling of having saved a life than usual. He is fourteen and came here with a bullet through his heart, probably. But first things first…

Where we live

I’m right on the roof of a two-storey villa almost exactly in the centre of Kunduz. I’m sitting in an armchair made for about 15 people which our local logisticians designed. Opposite is a large canvas sheet and every night some kind of film is screened on it. The origin of the film is usually in accordance with whoever brought it and from where it came. It’s a sort of endless film-festival! While the others chat, I am writing these few lines.

There are actually two villas, side by side with concrete backyards around them. In total they hold 30 people so everyone lives in his or her own room. On each floor there is a shared shower and toilet, the usual Turkish style. There is one washing machine and in the kitchen there are two local chefs who cook perfectly; today it was goat…

MSF Afghanistan

The kitchen where the MSF volunteers have their food prepared. ©Tomas Sebek/ MSF

 

In the basement there is a drying room and a gym, nearly as big as a football field as well as a communal dining room. In the backyard there are our two field Landcruisers, so typical for MSF or the Red Cross. There is also a booth for the MSF guards and the radio operators. The whole thing looks like a sheikh’s palace. The house has a red and white ball the same size of a weather balloon on the roof. I do not understand its functioning but it’s a local design. Somewhere else they might have a crescent, for example…

MSf Afghanistan

"Funny ball" on roof of our guesthouse, does anyone has clue what is the function? Nice anyway ©Tomas Sebek/MSF

 

Afghan football in the basement

If you want to get into contact with an Afghan, just open your mouth however it can be difficult when he or she does not speak English.

Yesterday I was running twenty times up and down two flights of stairs and then I did about a hundred circuits of the basement; I have started training for the ultra marathon inside the barracks. One guy from our guard came to see me.

He stares at me for about five minutes so I kick a football that we have in the basement towards him. He juggles it in the air, two loops and he scores a goal. Damn it! I cannot play football, it’s not a power-sport! So, I kick it with all the force I have. He goes after it like Petr Čech from Chelsea, leaps on top of it and kicks it into my half.

After half an hour we are completely bathed in sweat, I shake his hand and say “Tashakor” (Thank you) the only word I have learnt so far. He says something too, probably in Pashto. Perhaps something like: “Bro, you are playing like an amateur!” We did not say a single word apart from those at the end and we are friends.

The next day, in the parking lot, he pretends to pass the ball to me … As a part of the humanitarian aid in war zones all over the world I would distribute footballs and it would all be finished, peace. Everybody would just play football!

Morning report with a goat

Before the morning report starts I run to the ICU. The champ from yesterday, the one with the torn liver, is lying calmly on the bed asleep. In the night he got one more dose of blood and his morning haemoglobin level is 110.The bandages around three drains are only somewhat drenched.

In the hospital in Prague they taught me a trick with stomach bags installed around the drains. When I am attaching the bag in the morning and in the evening there is only up to 200 ml of a kind of brown liquid (old blood mixed with bile) and the other two drains lead only a small amount of reddish water – either I did something wrong or a miracle happened! I got advice from home from really experienced people. So far I am ecstatic, this guy does not need anything; his abdomen is calm. Well, we shall see in the next few days…

They killed a goat in the hospital. It is not my cup of tea, but it was not an arbitrary act. Eva from ICU wanted to teach the emergency room doctors and also my surgeons how to insert a drain into the chest. It is better to try it out on a goat than on a patient. Together with Dr Samir we gave a great lecture.

MSF Afghanistan

Practical training on a goat ©Tomas Sebek/MSF

 

I was surprised how Eva deals with the ultrasound. I want to have it fine tuned by next time. I was in charge of the practical training on the goat. Green flies kept us company in multitudinous numbers and so we, about fifteen doctors, were in the backyard behind the hospital sticking chest drains into the old goat, one after another. From a distance it might have looked like some very strange ritual. Then we pulled the goat out of the hospital grounds and in the evening, in order not to waste it, we ate it.

Shot in the heart

At lunchtime, my phone rings. It’s Dr. Safi, a young and rather gung-ho doctor. Apparently I have to come to the Emergency Room immediately as they have a patient with gunshot wound to the chest and he already has a drain in the chest with 250 millilitres of blood in it.

I already react to these things much more calmly than during my first mission. When you hear it at least twice a day it leaves you icy-calm. Like an emeritus professor I drift with deliberate steps to the emergency room and there, somewhere by the door, I forget my calmness…

A brother shot his brother in the heart…

A little boy is lying on the table as pale as the wall at the edge of consciousness, breathing hard. A chest tube has already drained 400ml of blood and is draining more. What’s worse is that the connected monitor shows a pressure level of 45/25. At that moment I sweat like those poor local doctors who were waiting for their lax comrade expat to crawl in. But from my interpretation of the call I did not get that he was dying!

Eva from ICU has been running around him selflessly for a long time while I was just strolling about somewhere. She looks at his chest using ultra-sound, his lungs with the monitor and the effusion from his chest. I listen through a phonendoscope to the lung, at least two-thirds of which is breathing. He has not lost too much blood either. It is running through the drain and the amount is not enough to kill him, so what the heck is wrong with him?

When your brain is dominated by adrenalin, all the cells in your head breathe it in, it aerates a little, it sparks the little grey cells. In my case it was just a single cell, however today it has done wonders. He has haemopericardium (an injury when fluid fills the space between the heart and its outer lining)! I’m yell my diagnosis to Eva. She zooms the ultrasound to the heart.

It is there. The heart is swimming in blood and the sheath which surrounds it is compressing the heart more and more tightly. In a minute it would be the end. This is called a cardiac tamponade. Eva praises me, I feel like Dr. House, but we are only half way there; I have not completed it yet. They give get me a broad twenty centimetre long spinal needle and a large syringe.

Before I think about it and imagine the appropriate image of how to pierce the heart, I thrust the needle six inches deep where I think that the heart is. It’s on the left, right? At first, nothing. Visualising via ultrasound fails. I back up and there it goes! I pull out a hundred cc’s of blood. Before I pull out I ask Eva to check it. According to the ultrasound a few millilitres remain over the apex of the heart, otherwise nothing. Nothing!

MSF Afghanistan

Treating a patient with gunshot wound on his chest ©Tomas Sebek/MSF

 

After two minutes, his pressure is 60/40 and after five minutes 100/90. He is breathing calmly now and reacts to his name, moving his hands. Only minimal liquid has been collected through the chest tube. This is good. He still has not won yet, however. If the bullet passed through the heart and the boy survived, it can still swell tight from the pressure. It could also just have glanced off the heart with the lung sustaining the most damage. However, even according to the drain it now does not look like thoracotomy (open chest surgery) will be needed. The boy is stable, unlike me!

We will put him in the ICU for monitoring and I’m leaving. Even as a professor emeritus, I have not lost face there. Dr. House, dude. This is simply the role of emeritus professors, but since I am not any kind of professor and I’m not emeritus, behind the door the floor starts to swing a little bit and the horror is making the hair on my back rise. The endorphins that pour out beat that. So, I probably helped to save his life. That’s great; at home this does not happen so often. I also watch the boy in the evening, he is all right. Eva also reports this, so I hope so…


MSF Afghanistan

Tomas is a surgeon from the Czech Republic working in the Kunduz Trauma Centre in northern Afghanistan. The trauma centre specialises in providing free and high quality surgerical care for victims of general trauma like traffic accidents, as well as those with conflict-related injuries, from bomb blasts or gunshots.
Find out more from Tomas and the MSF Afghanistan blogging team…

All the people featured in the photos have given their consent to appear on Tomas’ blog.

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières

Posted in Afghanistan, healthcare provision, Surgeon | Tagged , , , , | 2 Comments

Kunduz, The City

Part of my job in Kunduz was to assess the market: go into the city and find out if there are new, cheaper suppliers, that can provide us with good quality items and services. Then I’ll meet them, talk with them and sometimes negotiate. It is a great way to discover Afghan culture.

The commercial part of the city is very well organized: one street for one type of product., that is to say, all carpet sellers are in the same street, all wood sellers are together in the next street. Food suppliers are gathered in the same place called Haikiri market.

I went to ask for a quotation in an electronics shop and received a very warm welcome. I had to go inside and sit down (as a foreign woman, it is almost mandatory not to upset them). When the man, who seemed to be the owner, was talking with my colleague and a second man comfortably sat behind his desk, completing the quotation form, a young boy of not more than 10 years old was dealing with customers.

This kind of situation, where very young children work for their relatives, exists everywhere in the city. Once it was a welder, another time they manage the little corner bakery, or else they pull a big heavy trolley full of fresh fruits to sell. These same kids will once in a while take a short break, just enough time to take a bite of cucumber with a pinch of salt as lunch. When we stopped in front of a shop to ask some questions, most of the time, boys no older than 15 years old were helping us.

A bit further on, we stop at a fuel station to collect some samples of gas and diesel for quality control. Fuel consumption is so important in MSF projects that it is essential to ensure the good quality of fuel. Whereas I was expecting to receive a small pot (like for a urine sample), I saw the owner taking a bottle of water from his stock, drink it all, and fill it with fuel from the pump. For the second sample, we receive it in a cooking oil bottle, the last of which was probably used a few hours before during lunch preparations!

Back in the car, I have time to watch the street and street shops. Most of them are the same as the ones seen in other countries, mainly selling fruits and vegetables. The carrot seller is the one who surprised me the most. Surprised? Well yes, because the carrot seller provides peeled carrots! Big step towards a marketing strategy to beat its competitor; the seller of unpeeled carrots!

On the way back to the hospital, after what I thought was a great, full and instructive afternoon, I learned one last thing: how to bring bricks from the street to the first floor terrace. Naturally, my first answer would be via the stairs or elevator (even if I don t think there are any of these in small buildings such as these). However, Afghans developed a local, not very safe, but very efficient way to do this: Throwing the bricks. The principle is really simple: Two people, one downstairs who throws the bricks, and one upstairs who catches them with fluidity, consistency and ease. Fascinating!

During walks in the heart of the city, which is relatively clean thanks to dozens of large purple bins stationed at every street corner, I had a glimpse into the daily lives of the Afghan people. I was especially happy to see the butchers prepare meat for sale. I will not go into details at the risk of the most carnivorous of you becoming vegetarian for life. I, myself, am more happy with a good pasta dish, devoid of cattle, sheep or any other animal!

I also have come to understand the importance of adaptability. We all know the coloured pens we use at school. Here, these items are probably too expensive for some people, so they created a home-made two colour pen which is one blue pen and one red pen attached together with a good piece of tape. Good to know!


Astrid Rombaut, MSF logistician
Astrid Rombaut

Astrid Rombaut, 26, arrived Afghanistan in December 2012 and is currently working as Flying Supply Support for the mission. Her role is to ensure all the medical and non-medical items are supplied to all the MSF projects in Afghanistan.

Read more about Astrid and the MSF Afghanistan blogging team…

MSF Field Blogs reflect the views of the author alone and not necessarily those of Médecins Sans Frontières.

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