Babies, Bleeding and “Bedje”

This is really a blog-by-proxy – it’s not about me really, it’s to try and give a little window into the life and amazing work of one of my teammates from Nasir – Ruth, our American midwife – who has the strength, tenacity, experience and drive of 10 women and who I am hopelessly in awe of. She will be leaving Nasir just as I get back from holiday in a few days’ time, and will be sorely missed by more than just myself.

Ruth has done a few missions with MSF, including Papua New Guinea and India, and has a particular passion for women’s rights and Sexual and Gender Based Violence (SGBV), of which providing medical aid to the victims is part of MSF’s remit of medical care.

In her six months here Ruth has not only been a fabulous, cheerful, active team mate and fantastic support to me especially, but has done a one in three on call rotation for the maternity unit with the other midwives. That’s one sleepless night out of every three – I barely function with a one in seven for the rest of the hospital! A word of warning to all you budding baby-catchers out there – babies like to be born at night! She’s done sensitisation for all the hospital national and expat staff on SGBV, and alongside the existing HIV programme in Nasir undertook the herculean task of setting up a PMTCT programme. For those of you less familiar with medical acronyms this stands for Prevention of Mother To Child Transmission (of HIV). I can’t even begin to describe the amount of hours she put into all of this, or the crazy complexity and planning it necessitated, but sufficed to say it was nothing short of superhuman.

She also has a divine mischievous streak and appears to wait until dinner time before gleefully bringing up her latest placenta/molar pregnancy related story from the delivery room, which inevitably sees the whole logistics team turn various shades of pale and queasily push their plates away. Gotta love messing with the non-medics!

Vaccinations MSF South Sudan

Gorgeously healthy twins brought by their mother for vaccinations in their moses basket. © Emma Pedley

 

So back to the title of this blog -“Bedje” is the Nuer word for pain and is often the only intelligible word I can make out when taking a medical history, alongside plaintive gesturing at the general area of the problem. Education here – let alone health education – is frighteningly minimal. Could you begin to imagine what it would be like to experience even a simple uncomplicated pregnancy and birth with no foreknowledge of what was happening to your body, or what to expect, other what you had seen in your mother and aunts growing up? Seeing babies and births (and deaths) happen within the small, curved, dirt walls of the family tukul, with maybe only the assistance of elder woman of the community with tribal, traditional remedies, which may harm rather than help.

And yet this is the reality that is faced by hundreds of thousands of women in South Sudan. So “bedje” can be any normal-ish pregnancy issue – from haemorrhoids to burning urinary tract infections – that are just utterly unknown, unexpected events for these women. Ruth (and Caroline and Jane and the rest of the maternity team) give as much education and reassurance as they do medical care. The treatment is often simple. A short course of antibiotics, advice to drink more fluids. Nothing fancy, nothing special, nothing you or I couldn’t look up the treatment for on Google, or pop into a local chemists to pick up. But nothing like that is an option for these women here. MSF’s maternity unit is the only health care in pregnancy for who-knows how many hundreds of miles around here.

Bleeding is what half the presentations to the maternity department seem to be. Some are natural spontaneous miscarriages that require care. The rest are made up of women who have spent so long alternately pregnant or breastfeeding that they have lost track of what a normal period is, and turn up at all hours concerned that there is something terribly wrong with them. Reading that back I realise how peculiar that sounds to those of us who grew up with good health education, but you couldn’t make this stuff up. It genuinely is the bread and butter of the day to day (or night to night?) work of the midwives here and Ruth is frequently called at all hours to deal with it.

MSF South Sudan

How to rehydrate a baby – I was sat here for well over an hour! This child’s mother had been sick for three days and she had no breastmilk left. © Emma Pedley

 

And babies. And this is where I can briefly write from my own experience again because along with everything else she has had on her plate Ruth found time to bring me into the delivery room so I could see, literally, the fruit of all the labours of the department that she works so hard for. This birth actually happened a couple of months ago, but it is extraordinarily vivid and fresh in my mind.

I hadn’t seen a birth since, ooh, 1999 I think, when I was in my nurse training so I was wee bit apprehensive! I don’t normally need to carry a radio except when I’m on call but wore one for 24 hours so Ruth could call me if any births looked imminent. The first birth of the day was what we would refer to as a “bob-sled baby” (i.e. in a hell of a hurry to get out!) and I skidded into the delivery room just too late for the big event. I was able to watch the baby be checked and weighed though. It will never cease to amaze me how such lean, skinny-looking women can push out such chunky infants… While I was rebuking myself for not having run a bit faster, another labouring woman arrived – and she was huuuuge! She was also very, very early on in her labour, so I left them to it and spent the rest of day distractedly wandering round the hospital checking my radio every five minutes to make sure the battery hadn’t died. It didn’t, but neither was this woman going to birth at a sociable hour either going by her progress, so I settled down to sleep that night with my radio by my pillow, grimly determined not to miss out on what was looking likely to be a twin birth. Whenever it happened.

Of course at 3am when Ruth’s voice crackled through the speaker into my ear, some of that determination had worn off, but it was so so worth waking up for! Ruth was already over in the delivery room so I shambled over across the deserted hospital compound to join her.

When I reached the maternity unit the long-limbed Nuer mum-to-be was laid on a delivery table with the scrunched up face I learnt was classic of women birthing here. Very little histrionics at the pain, very little noise, just a rumpled, disgruntled expression as they ride out their contractions. Ruth had done an ultrasound by this point and had confirmed that yes, we were definitely in for a double dose of baby pretty soon. This made her, me and Monica, the Nuer MSF trained birth assistant, all quite twitchy as obviously there is twice as much potential for things to get complicated with a multiple birth. That also put paid to my plans of observing quietly from the corner.

All hands needed on deck! I remember there was a gaggle of women – Sisters? Aunts? – also in the room under strict instructions to stay out of what I can only describe as the red zone. It’s had been a while since I had seen a birth true, but between the amniotic fluid and the blood I was grateful for the loan of some wellies. No joy wearing wellies and a plastic apron in that small sweatbox of a birthing room, I can tell you, but at least I got to stand still and rest, unlike mum, who must have felt like she was doing a workout in a sauna. The mum was pushing hard and although she was doing it quietly and without fuss, it was enough to make me want to forget that I also own a vagina and vaguely want to be a parent someday. Scratch that. Some distant day. The big moment happened surprisingly quickly and a baby boy slithered out into Ruth and Monica’s waiting hands. The cord was tied and cut and within seconds this slippery little scrap of humanity was passed into my slightly panicked arms while Ruth examined mum to check that twin two was still the right way up. Or something. To be honest I have almost no idea what was going on at that side of the room, because I hadn’t heard this boy cry yet and the tricky thing with assessing black-skinned babies is that it is much harder (to my untrained eye) to tell how well oxygenated they are, unlike colour-coded pale-skinned babies (pink – good, blue – not so good.)

I switched to functioning on nurse reflexes at this point and some sensible part of my brain told me that Ruth wouldn’t have given me the baby if she didn’t think both him and I were going to be ok with it. I started rubbing and stimulating the baby with the rough delivery towel and to my immense relief the little chest started heaving in and out and I took a breath too for what felt like the first time in several minutes. I was faintly aware of the soursharp, iron tang in the air of blood and sweat, but most of my attention was stuck wide-awake, adrenalin awestruck at this crumpled little being in front of me, who was coughing and spluttering amniotic fluid out of his tiny nostrils and unfurling damp hands into the unresisting air before curling them back in again as if in surprise at all the sudden space around him. His cries got clearer as I tipped him onto his front to clear his airways from the fluid and continued to rub him dry, and this person in my hands – this extra person in the room who wasn’t here five minutes ago – this small person was using those little lungs now to let me know that he was cross with me. And oh my, was he cross; cross with being dried, cross with being weighed, very, very cross indeed at the sharp intrusive sting of the vitamin K injection into his tiny thigh but it was over quickly and I swaddled him into a clean blanket, his surprisingly strident cries of complaint beginning to quieten down as he was passed to the waiting arms of one of the aunties in the corner.

It was all actions stations at mum’s end though. Twin two was in a hurry to join his missing brother, and with a final push and gush of fluid another little man was expelled, still shrouded in the caul of membrane that he had spent the last nine months surrounded by. It was unceremoniously torn open by Ruth’s fingers and the baby was released into this life and more or less straight into my arms already taking his first gasping breaths. I repeated all the steps that I had just been through with his elder brother, not immoderately relieved that this baby was breathing already. This boy had a thick head of hair – in these early days it is soft silky curls, although soon it will toughen into the wiry woolly thatch of adulthood.

The next hour or so was frankly a blur. All I can say with any confidence is that breastfeeding newborn twins looks like even less of a picnic than giving birth to them.

I eventually fell back into my bed at about 5am – that was a life-affirming couple of hours – and somehow fell asleep again. I met Ruth again at our “breakfast club” spot outside the expat house at 7am – she was up again at 5:30am with another birth – and after finishing her coffee she went on to run the antenatal clinic all day. I popped into the maternity ward after lunch and was greeted by a couple of gloriously healthy and content looking little bundles and a wanly smiling mum who was still gamely breastfeeding both of them at once. Ruth was wrapping up yet another delivery – number five in 24 hours or something insane. And she then went on to peruse PMTCT protocols and order supplies. I have no idea how she sustained this for weeks on end, but I feel immensely grateful to have seen into a small window of her work. And similarly grateful to turn in my radio and get an uninterrupted night’s sleep that evening.

MSF South Sudan

Our tukuls and expat house (my mud hut is the one on the right!) © Emma Pedley

 

Since this day happened a couple of months back I haven’t managed to make it back into maternity. The in-patient department has been pretty all consuming, but even just writing about it now makes me want to go back again as strange and scary as it was. Once Ruth’s left Nasir later this week her place will be taken by a Ugandan midwife called Stella who I met on my MSF PPD (pre-primary departure) course this time last year and who is also awesome.

Who knows maybe I’ll get to try my hand at baby catching again.

Cheerio Ruth. It has been a-mazing living and working with you. Hope our paths cross again someday in the future. Respect sister.

 

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Homesick?

I’m homesick. Well, sick at any rate. Not severely, but when you’re a long way from anything familiar any kind of sick is pretty unpleasant and having the stuffy, snotty wretched head cold that I do at the moment is just enough to tip me off over the edge of sensible into self pity.

I’ve done pretty well in my sick record here so far. I think everyone’s expectations of working in Africa is that you will immediately be struck down with exotic gastro bugs, effortlessly shed several kilos and emerge slender and sylph-like several months later when you return home, which will nicely set off your saint like humanitarian worker halo. Not much chance of that happening to me, I have been almost embarrassingly robustly healthy and actually managed to gain weight in my first two months here which was curiously annoying. Of course the one time I did get a dodgy tummy happened to be when we had a visitor from Amsterdam HQ – an MSF veteran whom I was seriously in awe of and as a result was very cross with myself that it was in front of her tukul that I noisily threw up one evening having failed to make it to the toilet tukul. She was very sweet and came out to check on me just in time to catch me throwing up again, except that with an audience this time I tried to supress it, with the unpleasant net result that rice ended up coming down my nose.

Anyway, I am snotty and sore throaty and am feeling whiny and sorry for myself. I’m away from project at the minute, in Nairobi, for a weeklong MSF field management training course followed by a few days holiday. And it is COLD! No one told me that Kenya got this chilly! I was huddled under my blankets last night at the nice-but-bland hotel we are staying in and got homesick for the warm stuffy sanctuary of my tukul – I don’t think it’s rose-tinted nostalgia speaking, I really do miss it. Resident fauna and all.

And so that was the weird part – I wasn’t homesick for home – my home, my house, the one I own and live in back in the UK, with my central heating and memory foam mattress. I missed my mud and straw hut, with its wonky concrete floor and saggy bed. That was a thoroughly unexpected realisation.

But maybe I should be less surprised that I’m not homesick for the UK but Nasir. Home for me has always been more of a feeling than a physical space. And it’s always alternated in my life with periods of intense distracted unsettledness, no matter how familiar spot I may be in. Where ever I have been in my life after a period of time, I always feel a faint pull, a tug, a nudge of desire to be “elsewhere” – nowhere specific usually, nowhere out of the ordinary, just a strange sense that despite an ability to feel at home pretty much anywhere in seconds, at the same time that pretty much nowhere actually IS home.

Is that unique to me? I doubt it. To aid workers and other travelling workers generally? Maybe more so. Who know how many peoples’ truth I’m telling here, but I doubt I’m alone.

There’s just a comforting familiarity to feeling like a stranger in a strange land. An itch that’s stranger still when that land begins to feel familiar in itself – like home and yet not like home – which propels me off again.

It’s not the prospect of putting down roots or shouldering responsibility in anyone place or job that repels me, the opposite in fact. I often get quietly frustrated at the lack of responsibility that I am given professionally. Now that isn’t something that I can exactly blame my employers for; most prize staidness as a trait in their employees, my patchwork CV hardly reflects that as one of my virtues. Due to travelling and moving so much in my first nine years as a qualified nurse the longest I stayed in any one job was 18 months, which hardly makes me as a role model of reliability in anyone’s books.

In a way though I think that this restlessness is just human, in some way reflected in everyone I know to some degree or another. Most just sensibly confine it to a smaller geographic patch than I do or manifest it in a more conventional way. People choose a corner of the country to settle down in and then buy a house as is expected of proper grown ups (yes I own one too, but on reflection I think that may have only happened while I was pretending to be a proper grown up for a few months) and then rip that house apart, renovate it, pick a colour scheme, decorate it, wait a year or two, pick another colour scheme, redecorate and then up sticks and move to a remarkably similar house 30 minutes away and start the whole process from scratch.

I think it’s that whole urge for home – but change – but home – but change – just a bit more static and a lot less obvious than what I’m doing.

It’s not that I don’t miss a lot of things too though. I missed a lot of family stuff in the last couple of months; a wedding, a number of birthdays including those of my mum and god-daughter. That feeling of connection, of welcome, of celebration, of family embrace was hard to know I was missing out on and gave me a couple of slightly morose moments in mid May. And even with the wonders of skype and email I hate missing seeing my friend’s babies getting bigger while I’m gone too. This is a dangerous direction to spend time thinking in to for too long – but I am now more than six months into my mission now, well over the halfway point to seeing everyone again in September.

Save me some birthday cake people. And if I do another MSF mission then some Christmas pudding too please…

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Hands up who’s heard of leprosy?

As much as I am loving working for MSF and am aware of the difference that our presence makes in the lives of people here I just want to write a short post about a woman whom I encountered briefly a while back whom we couldn’t help much – at least not more than we already had. I couldn’t give her much in the way of the medical care that she needed – but I want to give her a voice, and tell the tiny part of her story that I witnessed.

Hands up who’s heard of leprosy?

That’s most of you I’ll bet. And I’ll bet that along with the word come dreaded images of deformed people in the streets of some biblical town clad in rags, shouting “unclean, unclean” as they go. Leprosy is a disease that in the minds of most people belongs in the dark ages – it’s ancient history and as far off as the days of thumb screws and when people still thought the earth was flat.

So here’s what I know about leprosy. A slow growing bacteria it is related to TB – which makes it thankfully fairly hard to catch but harder to treat. It attacks selected peripheral nerves causing them to swell within their sheaths and stop functioning – meaning that you lose some movement but crucially and most devastatingly all sensation in the areas supplied by those nerves. Hands, feet, face… This doesn’t sound particularly catastrophic at first, but we rely on these nerves for warnings of minute injuries – splinters, blisters, burns – all of which then serve to make us conscious of the tissue damage so we can treat it and allow it to heal. You stop and pick out the splinter. You change your shoes for a pair that doesn’t rub. You swear and drop the hot teapot and run cold water over your scald. Except when you have leprosy you don’t feel anything so you don’t do any of these things. The splinter festers into a sore. The blister becomes a deep ulcer. The 1st degree burn becomes a 3rd degree burn and all without you wincing or even noticing. And then infection sets in and so on and so forth in a cycle of skin, muscle, bone and eventually limb damage.

The treatment is a fairly tedious process of combination antibiotics taken daily for six months to eliminate the bacteria that caused the nerve damage in the first place. But as the late great Christopher Reeve could attest too nothing can repair a nerve that is already damaged. The disease is technically cured but nothing can restore the sensation that has been lost and end the ongoing cycle of damage and tissue loss and gradual limb erosion.

So there’s the biology bit. And here’s the person part.

It was an averagely hectic day at the hospital and I was walking past the thankfully quiet emergency department (ED) when a folded up figure on the ground outside caught my eye. The older people of this community still aren’t exactly au fait with the concept of chairs so it’s not uncommon to find them squatting on the ground next to a completely deserted bench. The ED staff however, are VERY au fait with the concept of chairs and the nurse required rousing out of his comfy plastic lawn seat inside to help translate for me. After spending six months here leprosy is easy to spot – irregularly eroded stumps where fingers used to be, a curious and distinctive pronunciation of facial features and milky scarred eyes (did I mention that you don’t feel pain and irritation from your eyes either? So you don’t make tears, or blink enough and gradually the cumulative damage turns you blind)

As the nurse starts asking the old woman what’s brought her to MSF today, I crouch down and take her leathery wrist in my hand checking for temperature and assessing her radial pulse. A few seconds assessment later it’s all seeming normal and non-urgent except now the nurse is bent down and bellowing a stream of high decibel Nuer out mere inches from this woman’s face and my own.

Ah. That answers my next question already.

One of the less pleasing side effects of the six month course of antibiotics is that they can affect your hearing. Up to the point of total loss. The translation relayed confirms what I have already worked out – the leprosy treatment was completed from MSF some four years ago.

So what’s brought her here today I ask?

By this time the woman’s relative – a sister? a co-wife? someone equally wizened and elderly at any rate – has come back from wherever she was and conversation resumes between her and the nurse at a more normal volume somewhere at head height. I stay where I am on the ground level with the patient – she has enough sight to tell at this short range that I am one of the medical “kawajas” (“foreigners”) and starts urgently gesturing at herself – her arms, her back, her knees… pretty much everywhere.

I’m baffled to begin with but with the translator a picture gradually forms. Joint pain. Deep sensation not peripheral. Knees, hip, back… getting on for over a year now. Even though this woman cannot feel pain in most of her body and this is what has crippled and blinded her to begin with, what is crippling her now is nothing more exotic than ordinary, everyday, common-or-garden arthritis.

In some great sick sort of a cosmic joke this woman has been robbed of pain for years and is now being given it all back.

Leprosy. Should. Not. Exist.

It’s up there on a list of things that people should not have to suffer in this day and age – it’s the 21st century for God’s sake – like rheumatic fever, dying in childbirth, polio, all of which are nigh unheard of back home. It sounds like ancient history and that’s where it should be, in the history books with small pox and bubonic plague, not out there shuffling around in human form and reminding us of what a god-awful mess we have made of this planet with its politics and economics and financial crisis bollocks that some countries are off the top of the scale wealth-wise and others are so impoverished that a well-functioning health system (let alone a social care one) is still a distant dream.

But that is why I’m telling this tiny, five-minute story from over a month ago. It’s been so hard to write about this woman but I want to make her story matter. She is totally anonymous, I can’t even remember her name but I will probably never forget her and I think her situation and life deserve telling. Just because I’m out here working in a developing country (and trust me half the time I don’t even feel like I’m helping much) doesn’t mean that people at home can’t make a difference too. Buy fair trade. Don’t support sweatshops retailers. Stop whining about petrol prices. Support medical research for neglected diseases like leprosy. Give an Oxfam goat for Christmas. Or if that’s too hard (and I’ve been there, I haven’t entirely shed my former life, and yes it is hard) then maybe just try this – next time you stub your toe, or skin your knuckles on a wall, or cut yourself while you’re cooking, just pause for a second and be grateful for this amazing weird healthy brilliant blessed body you’ve got that tells you when you’ve hurt yourself. Because some people don’t even have that.

(For a truly great (?) book on leprosy and the humans and healers behind the disease look up “The Gift Of Pain” by Dr Paul Brand who pioneered leprosy research and treatment in the mid twentieth century. I read it about five years ago and was so blown away by its humility and human scope that after finishing it I went on a first date with a guy I had recently met and realised part way through the evening with a faint sense of horror that I had been enthusing about leprosy treatments and centres for a full half hour over dinner. To his great credit this lad still finished his food and somewhat unaccountably still asked me for a second date afterwards. To find out more about research for neglected diseases check out www.dndi.org one of MSF’s partner organisation. I’ll get off my soap box now. Thanks for hearing me out.)

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The best laid plans

So it’s my birthday weekend. My birthday is actually Monday, but that is a universally crap day to celebrate anything, so I had planned to spend the weekend beforehand generally lazing around: have a lie-in, maybe do some yoga with Michelle (my project coordinator) and have a cake bake-off with Stefan (our techlog). Maybe drink a beer or two. Nothing too taxing.

Apparently nothing too realistic either, because the way the weekend has panned out has been somewhat different! I’m learning it’s a little risky to plan too far ahead here…

Let’s go back to 6:30am on Saturday morning when I was abruptly woken up by Michelle banging on my tukul door…

Thump, thump. “Emma… Emma! I need to talk to you…”

I stagger sleep-drunk out of my tukul, rubbing my eyes and unaccountably anxious that somehow I have managed to do something wrong during the night. My drowsiness vanishes rapidly as I’m told that there have been reports of fighting in a nearby village with multiple wounded in villages downriver. I need to be ready to get in a boat with a small team to retrieve patients within the hour. I’m telling you, it’s better than a triple espresso waking to news like that.

The compound is filled with expats in varying states of dress and alertness, carrying everything from toothbrushes to sat phones and emergency medical kits as we all scramble to prepare for whatever the day ahead is bringing. The logisticians are kitting out the boats and starting the generators early; the surgeons (of whom happily we have two at present as they are in their ten-day handover period – Christina our incoming first mission surgeon is in for a baptism of fire) are preparing to call in the operating theatre (OT) team; Michelle is fielding phone calls and trying to get accurate reports of how many injured we need to prepare for.

By 7:10 I am on the first boat heading downriver where we find our first casualty already headed our way in a dugout canoe – a  six-year-old with a horrific wound to his abdomen. Christina and I elect to “scoop and run” rather than try and treat on scene – we’re only ten minutes away from the hospital.

The tiny shell-shocked mother and another small son climb into the MSF boat and huddle on the floor and the boat speeds back. I have my hand on the cloth holding this child’s intestines in and I have a queer sick feeling in my stomach. Not from the wound – I’ve seen worse – but from the visceral fear of the weapon that caused this much damage to this small a person. I know – rationally, intellectually know – that the gun is nowhere near. It’s hours and miles away, but still… the sick feeling lingers.

We arrive back at the hospital and the child is handed over to the waiting team on the river bank and whisked to the OT. With barely time to draw breath we are en route back downstream, with both boats this time, to the village an hour or so away that we are told has the highest concentration of casualties. The river is gorgeous at dawn – the air in our faces is cool, we are surrounded by greenery and birds erupt up from the water as we whizz past. It’s hard to be blind to the beauty but harder to forget our purpose.

MSF South Sudan

The boats turn down a small tributary of the main river and into a large shallow lake. There are some frustrating but vaguely comic moments as both boats repeatedly run aground on the concealed mud flats and Stefan resorts to climbing overboard and towing us through the worst sections. As we approach the village we can see a large crowd gathered by the water’s edge.

The next half hour is nothing short of sheer pandemonium. Triage and treatment is near impossible in the melee of distressed and vociferous families, so we scoop and run again – six patients in one boat, three in the other. All women and children. The wounds, as far as we have been able to assess, are terrible: one child is bleeding persistently and worryingly from a thigh wound; the woman nearest me has both heels blasted off, with shattered leg bones clearly visible.

My earlier nausea has gone now and I’m thankful for the years of training that help me to push some of these emotions down and deal with the urgency of here and now. There’s a price to pay of course – whatever you push down will surge up again at some point. But for now I’m just glad that we are here to offer help and hope to these people.

Michelle’s phone beeps. She grimaces as she looks down at the message on it, then relays to me that the first boy from this morning hasn’t survived surgery. I feel like something has taken my heart and twisted it tightly. Despite our efforts we were too late for that child. I’m impatient to get back to the hospital so we can get these people the treatment that they need and avoid any more needless deaths.

We arrive back at the hospital. In the two hours since we left it has been transformed. Ruth, who has taken over coordinating, and the rest of the medical team have worked some miracles. The two most severe patients are offloaded straight to the surgery teams in the OT. The emergency room (ER) has been rearranged as a receiving and triage station. The inflatable OT tent that has been waiting for use during building refurbishment is ready to do service as a temporary pre-surgical ward. Blankets and beds are ready and waiting, IV fluids are hanging ready to go. Tun Thiha, our Burmese log admin, is hurrying past with a cold chain box full of tetanus vaccine. An extraordinary amount of national staff are here as well on their day off, staffing the pre-surgical ward and translating for the doctors in the ER.

I turn on a tap to wash my hands and note that the water pressure in the taps seems low – I mention it and within minutes someone is scaling the water treatment tower to check the levels and pump more from the borehole. The energy here is amazing.

My nursing OCD takes over briefly when I get into the chaotic ER and I spend time collating notes and drug cards neatly into files – with this much happening at once, it’s all too easy for patients’ cards to get mislaid or muddled. And mini-muddles are definitely happening! At one point I lose track of the keys to the central pharmacy where all our medical stock is kept. The OT needs gauze. Um, I already gave them gauze? Not that gauze, I’m informed, bigger ones! I narrowly escape running round like a headless chicken to find a logistician to break into the pharmacy for me when Erik, our Dutch doctor, calmly takes the keys from round his neck and hands them to me with a beatific smile. I could hug him. Extra gauze, extra IV fluids, extra soap. Call staff to work the next 24 hours in the pre-surgical ward. Juggle for staff cover elsewhere. Extra gloves, extra morphine, extra iodine. Go, go, go.

At about lunchtime Michelle brings a smartly-dressed smiling Nuer woman to me – she is a nurse who is visiting her family in Nasir from Australia and wants to volunteer her services during the emergency. Local registered nurses are like gold dust here, female nurses more so, and volunteers nigh on unheard of. I DO hug her, and then delightedly introduce her to the intensive care unit where the first patients are arriving after their surgery. Talk about a godsend.

At 3 pm we receive news of wounded men at another village upriver. Stefan and I grab the emergency box and head towards the boat again. Azat, who is to be our techlog when Stefan leaves, joins us. The emergency box feels suspiciously light in my hands. I pause and then run back to the ER and fill my shoulder bag with IV fluids and cannulas. We don’t have far to go this time, only 15 minutes upriver, but it turns out that we are ahead of the game here – the men we find at the riverbank shake our hands enthusiastically and inform us that four patients are en route to the village but are still almost an hour inland where we can’t reach them. We exchange looks and resign ourselves to wait.

At first the enforced respite is almost annoying – when you’ve been going at a million miles a minute all day, it’s hard to change gears. But we rest by the river bank and take a breath. We are in an area with a fair amount of military in it and there’s a skeleton of a jeep that we sit in for a bit while I phone Michelle and tell her we’re going to be a while. Men wander past with spears and guns. I regard the weapons surprisingly calmly. For all my initial fear at the gunshot wound this morning, I feel no threat here. We are wanted. MSF’s reputation long precedes us as individuals here and they know that we will treat them for their medical needs without questions or judgement. Not for the first time today I feel a bubble of pride well up inside at being a part of it all.

A few hundred metres away some shots ring out. Happy shooting, I’m told by the men sitting under the tree with us. Into the air, not at anyone. Hmm, slightly reassuring I guess.

Our patients arrive eventually, borne on the shoulders of their companions, and I sort through them. One minor wound, three severe. Face, abdomen, knee. Pints of congealed blood and flies. I put a hand to their wrists and it only takes a few seconds to assess that they are all tachycardic from their blood loss. I cannulate and hang IVs to replace the lost fluids while Stefan sorts through the growing group around us to extract healthy-looking men who are willing to be blood donors.

At one point I look up from putting a patchwork dressing onto one man’s chest and am mildly perturbed to see the now huge crowd around me veritably bristling with guns and spears. A distinctly adolescent-looking individual is brought to me as a potential blood donor and I shake my head and regretfully explain that we need bigger, older men to be able to take a decent donation from. As the translation is done a ripple of laughter spreads through the men and they slap their legs and pinch their biceps to show how big and strong the rest of them are. The boy smiles as he is shoved back through the crowd and other men shoulder their way forward smiling. I grin back and tell him to eat more. Maybe next year!

After a litre of fluid each, the pulses of my patients are slower and stronger and I deem them ready for transport. The river is still low and the banks steep but somehow, surefootedly, they are carried to the boat on stretchers and loaded on. I skid somewhat unsteadily down the gravelly sides and join them on board.

As we travel I am hit by a sudden tiredness. Not just body-tired, although I am that too, but soul-tired from witnessing the outcomes of all the violence. This is when the emotions hit in.

The hospital is still busy when we get back but there’s a steadiness to the pace now – more of a sense of settling in for the marathon than the sprint. We have received 19 patients with gunshot wounds in total, and although the next few days may see a few walking wounded arriving, we devoutly hope that the initial rush of severe cases is over.

The expat team straggle together in the compound as it gets dark and flop into chairs. Cold Pepsis are poured, plates are piled with food – I finally have my long awaited beer! – and the team share their experiences of the day. Hectic but good appears to be the general consensus. We are all exhausted. Most of us started the day tired after a long week and I wasn’t the only one planning a low-key weekend. The surgeons still have to check on their post-ops, and poor Tommy, who spent most of the day in the ER, is scheduled to be on-call tonight. Michelle, who started receiving phone calls in the wee small hours of last night, is on the phone again updating the MSF country capital team on the day’s events.

Worn out though we are, there are few complaints. This is what we are here for after all. And we would do it all again tomorrow if we had to.

But for the moment we’re not planning anything…

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An assortment of oncalls

It’s hard to give an idea of the bewildering breadth of patients that we are presented with during on calls. Even used as I am to the variety of humanity that compiles the average Emergency Department back at home, I am still frequently taken aback with the range of problems that the radio calls that I receive during the night require me to somehow deal with. The only part of the hospital that I don’t cover during the night is maternity, so the scope of cases I am called for range from ER cases that need admission, to malnourished children in the Inpatient Therapeutic Feeding Centre ( ITFC) who can deteriorate with frightening suddenness during the night, to unstable patients in the ICU….

“Expect the unexpected” seems to be the watchword of taking over the radio responsibility. Owing to both the language barrier and variable training level of the staff that are on duty at any one time, it can be very hard to tell from the radio call exactly how severe a patient you are called to see is. Especially “convulsions” – a term that seems to be a firm favourite with the staff here – which can cover anything from a true epileptic fit, to someone writhing in pain, to a bout of hysterics, to the profound rigors and shivering that people experience when in the grips of a high fever. And occasionally we are just called over to deal with a stubborn patient who just wants to talk to the “Kawaja” (foreigner) and won’t accept the instruction of the national staff. The best policy I have for dealing with calls is ask for as much information over the radio as possible whilst simultaneously making my way over the hospital as rapidly as I can – at 3am over the rough ground in torch light a brisk trot is about all I can achieve!

What follows are just a few of the more memorable cases of the sort I have experienced during my on calls in the last couple of months – they didn’t all occour during the same night thankfully!

8pm

“Oncall for ER – Emma oncall for ER – we are very busy, please come?” I push my half eaten dinner away and head over. When I get to the ER I regard the collection of people outside and sigh. With the OPD now across town at the Ministry of Health we are still getting a lot of non-urgent patients turning up at the MSF ER. Placating the harassed looking ER staff member inside I leave them seeing a forlorn looking child with malaria while I go and fish a nurse out of the ICU to help. They act as my translator as I move through the crowd triaging and assessing severity. Three out of four people are told politely but firmly to go home and go to the OPD the next day. Within 30 minutes the crowd has dissipated and a sick looking man and a couple of babies are left to be more thoroughly assessed and treated. No worries. Much better.

I’m about to go back to my congealing dinner when another couple of figures emerge out of the darkness, a mother with a small girl in tow. Neither exactly looks sick on first glance. I can’t help but growl internally. It would be so much better for everyone if people didn’t come to the hospital so late in the evening when they’ve been sick for a few days already… and I turn to the nurse to help me translate. When I look back at the three-year-old though I relent. She has diarrhoea and it turns out that these two have walked for over two hours to come here; the child looks exhausted. I do a mental inventory of the wards and decide paediatrics can squeeze them in. Along with the oral rehydration an IV overnight won’t hurt. I can review and discharge the child before handing over in the morning.

9pm

“Hello… hello oncall? This is paediatric ward….” I’m already sat in the ICU scribbling some notes when this call comes, so I amble across the walkway into the children’s ward. A seven-year-old boy is… well, not right. Vague history of abdominal pain, no appetite, has been in for four days now, looks a bit more peaky tonight. Treatment for amoebiasis doesn’t appear to have helped. The boy is curled up on the bed. He doesn’t object as I gently reposition him and palpate his belly, but I notice his skin is covered with a faint sheen of sweat, and he curls up again as soon as I finish. No vomiting. Vital signs normal other than a very mild fever. I’m totally perplexed. Nothing I can put my finger on is wrong, but internally all my cumulative nursing experience is screaming at me that this child is a lot sicker than he looks. I move the child to ICU for closer observation during the night and hesitantly call the surgeon for a second opinion. The subsequent day the boy is diagnosed with typhoid fever and bowel perforation and undergoes extensive surgery. Typhoid fever masks the usual fast heart rate of a septic patient with paradoxical slowing of the pulse, making it appear normal. Thank god for following my instincts.

10pm

“Oncall for ICU- we need one IV cannula”… this is my second ever night on call, first ever solo radio call for ICU. An IV cannula, how hard can that be? Bread and butter of my days at home, I muse as I wander over to the hospital. Except at home I was never required to put in an IV cannula on a three-day-old baby in respiratory distress. The old cannula has stopped working – taking out the baby’s left hand as a possibility – and leaving me with two fragile thready veins on the back of the right hand to get a line into. Up to this point the youngest person that I have done this one is a teenager. I gather all my equipment, ask a nurse to act as a tourniquet and stare unhappily in the torchlight at the tiny, almost translucent hand now held in my own.

My first attempt is not successful – the baby squawks in protest at the restraint of being held so tightly by his mother who I notice now is looking at me with an expression of complete trust and confidence. More confidence than I have. I debate calling the doctor… but I’m not going to get away from the fact that I will have to do this one day without backup. Now is as good a time as any. I grit my teeth and try again in the second vein, at an infinitesimally different angle to the first time and – miracle – a tiny flash of red in the cannula’s viewing chamber. I’m almost too taken aback to carry on, but happily the ICU nurse isn’t and between us we secure the line in place and restart the child’s IV fluids.

I look up from my cramped position squatting on the floor by the bed and grin at the nurse – he grins back and we do a little high five in front of the uncomprehending mother, who clearly never doubted the “kawaja’s” abilities.

11:30pm

“Hello oncall for ITFC?” Oh bugger, I’ve been dreading being called there. Infants are not my forté. I’m snatching a quick shower when this call comes and hurriedly towel off and pull clothes onto my still damp body. I cautiously walk into the semi-dark ward which full as it is of babies is never entirely quiet. There are soft sleepy cries from the beds on both sides of me as I walk towards the pool of torchlight that indicates where the staff member is crouched by a patient.

A teeny tiny naked baby is laid next to his mother waving all four stick thin limbs in the air. One of week-old premature twins. Hypothermic. Sweating as I am in the 30 degree evening is hard to believe that hypothermia is possible here, but there you go – babies internal body thermostats take a few months to kick in. The baby is only 32 degrees – urgh, that really is low.

We scramble about for one of the silvery reflective survival blankets to wrap him in but it turns out that one is torn and the other is on a child in the ICU. And it’s not like we have an incubator we can pop him into. I pause – and then remember something from my tropical nursing course. With the night staff we persuade mum to disrobe her top half and lay flat on her back. Her tiny mewling son is laid naked on her chest and we bundle blankets around them both. Kangaroo care. Back to basics. Skin to skin. The baby’s temperature comes up within an hour. Magic.

1am

“Oncall for Adult ward… yes , we have one severe patient… please come.” I roll out from under the mosquito net fully dressed, grab a torch and yawningly exit my tukul. Once in the adult ward I am led to a bed in dark corner where a semi-conscious old man is laying, his breathing harsh and erratic. His diminutive grey haired wife is huddled on a corner of the bed. This does not look good. I put my stethoscope into my ears and bend down to listen to the chest – crackles and bubbling galore – and leaf hurriedly through the notes when they are brought to me, squinting at the clinical officer’s spidery handwriting interspersed with the doctor’s scrawl. Probable heart failure. Blood pressure too low for a diuretic during the day, lungs too wet to give fluids to treat the blood pressure now. This is the extent of the treatment we can offer here.

This man is dying. But we can make him comfortable at least. A smidge of IV opiate later and the laboured breathing eases. I kneel by the wife and explain with the translation of the nurse that there is nothing else we can do, but we can relieve his distress. Her milky cataracted eyes look at me and she nods. No denial, no debate – death here is a part of life. I hope she has some family who can look after her when he’s gone. Later in the night I check back – the man is still breathing but slower now. His wife keeps her vigil at the foot of his bed. At 6am I’m called again – the breathing has stopped. His still body is resting now, in counterpart to his wife who is rocking back and forth chanting softly. Across from the hospital compound a riotous singing has started up at the early morning church service and I feel a burst of indignation at the seeming inappropriate contrast between the sound of the cheerful hymn and the tragic tableau in front of me. The widow has to go and get some family to help her carry the body home and she shuffles out of the hospital gates into the lightening dawn.

My indignation fades with the retreating night and I watch dawn spread across the sky. She has family. He died peacefully, cared for, with his wife by his side and music in his ears. There are worse things in this world.

2am

“Oncall, oncall for ICU – we have one child yes, they are convulsions…” I jolt into wakefulness and am out of my bed and running over to the hospital as fast as I can go telling the nurses to prepare IV diazepam down the radio as I go. This could be anything, but always think worst case scenario… I arrive on the ward and yes, this is actual convulsions, a four-year-old with cerebral malaria. IV diazepam, prone position to prevent vomiting, rectal paracetamol, cold bathing, check blood glucose, give fluids… the fit slows and stops. The child is stable for now. Not sure I’m going to be able to get back to sleep though…

3am

“Hello oncall for ER… hello? … HELLO ONCALL?” I fumble for the radio handset in the darkness and belatedly croak a response into it. A scorpion bite in the ER, I’m informed. Ooh, interesting – although I’ve read about them I haven’t seen one of these before. The nights are hotter now and I pull my T shirt on, stoop out of my tukul and drag my sweat-damp hair into a ponytail as I walk across the compound.

I can hear a whimpering that gets louder as I approach the ER. As I step into the well lit room I am simultaneously aware of two things. One; my MSF T shirt is back to front and inside out – whoops, hardly professional – and two; this woman is in agony.

The people of this place have what appears to me a sky high pain tolerance – postoperative children who would be bed bound on morphine drips at home are sat up looking cheerful within 24 hours, women cruise daily through labour and delivery with no analgesic assistance, men unflinchingly watch you poke their rhino-hide skin with needles as you search for veins. The elderly woman in front of me is sat on the concrete floor whimpering and clutching at her ankle, rocking rhythmically, her face twisted with pain. This is no sham. She was stung whilst walking out of her tukul to the toilet. Her sons who have carried her for an hour to get here flop exhausted against the wall and expectantly regard the dishevelled apparition of a “kawaja” that has just walked in. I put them to work again carrying her to an examination couch and unlock the cupboard where the local anaesthetic lives.

As hideously unexpected and unpleasant as the scorpions here are, they are not lethal – just excruciating. I draw up a syringe of anaesthetic and the nurse helps me to clean and prepare the woman’s foot for the injection. Her crying crescendos every time we touch her leg and she buries her face in her shawl wailing as I approach her foot with the needle. Her skin is tough and calloused but I persist and squeeze in a few millilitres of lignocaine around the minute puncture site that is the source of all her distress.

Within seconds the crying stops – literally, it is that fast – and she looks up incredulously at the blessed numb relief. We all – including her sons -start laughing at her expression of evident surprise. Ten minutes later she is smiling and ready to go home. Her sons shake my hand as they file out and she clasps both my hands and croons delightedly at me in Nuer before walking erectly away- this woman who couldn’t stand when she arrived. I grin. Who cares which way round my T shirt is?

And finally, from this week at 5:30am

“Hello oncall, this is surgical ward – we need some paracetamol.” I bury my head in my pillow and stifle a groan. Why, oh why couldn’t they have foreseen the lack of paracetamol when they came on duty last night? I shamble over to the ward, rubbing my eyes, there’ll be no point going back to bed after this. I grumblingly examine the chart – yes, the patient is due paracetamol, jolly good, I’ll go and get it. I discontentedly wander around the hospital after I’ve solved the drug shortage. Paediatric ward are preparing their IV medications. ITFC is a cacophony of noise as children are awoken for their early morning milk feed. The ICU patients are thankfully stable. A pregnant woman with severe pneumonia who was struggling to breathe last night is finally sleeping. Humph. Lucky her.

En route back to the expat house I meet Ruth, our American midwife, who if possible looks tireder than I feel, having been up delivering not one, but three babies overnight. We both have busy days ahead of us, her in antenatal clinic, me supervising the IPD. We sit down to share a coffee and brief moan as day breaks and wonder aloud why we have chosen such a demanding job with such antisocial hours.
Is it really worth it? Really??

I think back over the patients I have seen on my last few on calls. The boy with typhoid fever. The scorpion bite. The hypothermic baby. Even the man who died. I’ve made many people more comfortable; some in their last moments, some in their first few days of life, and maybe even helped save one or two lives. A contentment spreads through me that no amount of tiredness can steal away.

Is it worth it?

Oh, yes. Every single sleep deprived second.

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Shifting scenes

I’ve been somewhat neglectful of writing in the last couple of weeks largely because since moving from the outpatients to inpatient nursing role I’ve feel like I’ve been floundering around somewhat while I get reorientated to the new job – and I really, really want to write a post where I sound like I know what I’m doing for a change!

As much as it’s a relief not to have the pressure of the OPD handover solely on my shoulders anymore, I had at least got some routine established in my days there and it’s unsettling to consider that I’m nearly three months into my nine month mission here and feel almost like I’m just starting out again. However, thanks to the numerous weekend and night on calls that I have done, I’m actually settling in far faster than I anticipated and am beginning to get a feel for how I can contribute to the training and skills of the nurses and various paramedical staff that work here. Individual staff names are beginning to emerge from the blur, although on average it still takes me a couple of goes to get some people correct … “Hello Joseph – no, Gatloak!-  No, Koang!” and similar greetings take place on average every 10 minutes as I walk around.

I spent a dubiously delightful couple of days catching up with a bit of a backlog of materials and consumption monitoring – spreadsheets and tallys and coding, oh my! In my life to date, Excel spreadsheets have largely been something that I have diligently avoided and I pride myself on a cultivated ignorance of the meaning of terms like “formatting cells”, but alas those days are now gone. After couple of days spent behind the computer in the office I emerged slightly cross eyed from squinting at data tables a with a whole new respect for how meticulously MSF accounts for every penny of its donations spent – each department in the hospital orders supplies weekly, counts what is left from the week before and the needs and trends are monitored by pharmacists and supply logisticians who endeavour to ensure that we never run low on essential medicines and materials, which would be catastrophic for our project. All our supplies are flown in due to the lack of road access in most of South Sudan – bad planning or running out of essential  supplies would necessitate costly extra flights, but happily, this seems to be very rare!

Once that was done, I took to pottering from ward to ward, chatting to the national staff nurse supervisors and finding out where they want me to help them. Project one – grubby wards. In this dry and dusty climate any surface is coated with a thin powdery film of dirt within a few hours of wiping it and despite the best efforts of the cleaning team it’s pretty  hard to sweep and mop effectively around a ward full of patients and caretakers. And even though the mosquito nets and blankets are washed between patients bed bugs are pretty rife too, as the pattern of viciously itchy bites on the backs of my legs achieved from sitting on the edges of beds while doing consultations attest to. So the next day chaos reigned as nurses and caretakers and cleaners alike carried beds out into the sun and nets and blankets were shaken and spread out on fences to kill the bugs. I helped out untying and carrying out nets and then retired briefly to the expat house and removed a couple of stray bedbugs from my bra, clearly optimistically bent on hitchhiking to my tukul. No such joy!

The cleaners embarked on a no-hold-barred floor to ceiling scrub of the wards followed by vector control insecticide spraying. As much as this was needed, my timing for doing it was a little poor – half of the big central hospital compound which we emptied the wards into was roped off as the logisticians assembled a giant semi-inflatable tent that is going to serve as our operating theatre (OT) for the next few months while construction work is done to improve our somewhat elderly current buildings. The chattering mass of mothers and children off to one side watched fascinated as the team laid out a base and pushed and shoved enormous bulky bundles of tarpaulin into position. Our poor clinical officers picked their way through the sprawling crowd in the shaded verandas trying in vain to complete their ward rounds and consultations in the midst of chaos. The same 40 degree sunshine that was hopefully spelling death for our insect infestation was also beating down on the backs of the logistic workers and I could only watch and wonder as they kept going even during the hottest part of the day. The log team retired exhausted well past 6pm; the inflatable OT-to-be was laid out waiting to be finished on the morrow. By dusk, a semblance of order was restored to the hospital and things had finally quietened down– patients, mums and babies alike returned into the wards  although they all decided to sleep on the floor that night in order to allow the beds to stay out and cook another day. I couldn’t ever imagine that working in the UK but everyone seemed very content with the arrangement here!

Now a couple of days later the wards look (and feel too I imagine) much better. It’s possible to sit down to chat with a patient without picking up unwanted bloodthirsty hitchhikers and I capitalise on this fully during our ward rounds. I plop myself down on beds, shake hands, check how long cannulas have been in, palpate spleens and cuddle every cute baby going.

My only worry now is getting hopelessly addicted to hanging out in the wards. Already I find myself “just popping over” frequently in the evenings to check on a particularly poorly patient, or say hi to a nurse that has just come onto the night duty – “Good evening err… Simon? Bol? Gatwech!”. The OT is fully inflated and almost ready to go now – walking past it as I go from surgical ward to the ICU at ten one still evening, part of it began to move, spookily illuminated by my torch.  It bulged alarmingly in one wall nearly giving me a heart attack before the billowing fabric parted and gave birth to Eric, our French visiting logistician who backed out looking as startled to see me as I was him – turns out he was capitalising on the cool of the evening to do a bit of extra work too.

Nice to know that I’m not the only one unable to stay away!

 

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Village visits

Outreach has been great the last couple of months. As my focus to date has mostly been on the OPD handover to the Ministry of Health I only get to go out with the team one day a week, but it is a day I seriously looked forward to.

Outreach for MSF can vary hugely from project to project – from running whole medical clinics, to antenatal services, immunisations, health education – you name it, it’s been done. And there’s variation in how you get about too – bike, donkey cart, boat, flying… Currently in this project we content ourselves with travelling in the rather more prosaic Land Cruiser, with the occasional boat trip.

There is a focus on childhood immunisations, but coupled in with that the team take health education materials out with them, screen for malnourished children and actively refer sick people and pregnant women back to the MSF hospital services. One week was mental – 84 children vaccinated in one morning – I had to dash back to the hospital for more vaccines!

It’s rather beautiful to watch the women and children criss-crossing the vast dusty expanses toward the tree or tukul you have set the clinic up under. Nuer people are tall and thin– and I mean really tall – and so long-limbed and slender! Women range from 5’ 8” steeply upwards and men often get well over the 6’ mark. At 5’7” and built decidedly on the curvy side I look positively stumpy stood beside them. And the women’s posture is perfect – a lifetime of carrying firewood and water containers on their head has given them balance and deportment flawless enough to make Kate Middleton weep and turn in her tiara. The day South Sudanese people decide to learn ballet is the day the whole of Covent Garden can hang up their pointe shoes in despair. The terrain underfoot here is a crazy-paving patchwork of mud plates that have cracked and fissured apart as the flooding from the wet season has receded. I gracelessly trip and traipse my way across, never able to take my eyes from the ground for more than a few seconds at a time, but even when bearing heavy loads, the women here walk erectly and evenly, almost gliding, their long bright sarongs fluttering around their legs.

And it’s not just food and fuel they carry on their heads – when I first got here I was at a loss to explain how women carried their very young babies here as I hadn’t seen any of the sarong slings across women’s backs that I had semi-expected, but even babies are carried largely hands free, balanced on their heads… No safety nets, no seat straps, no fancy carseats here!  The women weave long reed baskets with lids which they line with blankets and carry their babies inside. Balanced atop their heads I find it heart-stoppingly precarious. Their gait even with this precious cargo aboard is stately, unworried, unhurried.  I’ve never once seen a woman trip on the rough ground, or even falter. Once they reach our vaccination station the baskets are lifted down and the lids untied – nestled inside you will find a newborn infant, or sometimes twins, like so many little cocoa-coloured Moses’s snug in their reed cradles, lulled to sleep by the gentle swaying walk of their mothers below them. We vaccinate children under five only, but often if mum is busy you’ll get a shy and leggy nine-year-old walk up in lieu of her, trailing a reluctant chain of smaller siblings behind her all clutching their tattered vaccination cards.

Malnutrition screening worldwide for children is done using a simple tool which measures round a child’s arm – Mid Upper Arm Circumference, or MUAC for short. A traffic-light-colour-coded arm band is used; Green = chubby and healthy; Red= refer for urgent inpatient treatment; anything in between is referred to the OPD Ambulatory feeding center. It’s a well-established and astonishingly reliable indicator of nutrition status, as it can be used on any child between the age of six months and five years old. Currently the early part of the dry season season is the fat time of year in South Sudan so there are a delightful amount of chubby children around, and at the end of the day our MUAC tally recording sheet is reassuringly dense on the “Green” side. Lean season will start soon though and will run til June/July time. In the hunger gap between crops it’s not unknown for the attendance of the inpatient and ambulatory feeding centers to increase fourfold or higher from then on. But for now, it’s great to see the children healthy and well fed on the milk from the family cows.

MSF MUAC assessment, Yida refugee camp, South Sudan © Louise  Roland-Gosselin/MSF

MSF staff conducting MUAC assessments for child malnutrition in refugee camps, Upper Nile State, South Sudan. June 1012 © Louise Roland-Gosselin/MSF

 

In that vein however, it was a tad unnerving on my last trip downriver with the outreach team to see a diminutive toddler of no more than 18 months old pottering about amongst the cows tethered in the village, his pudgy form wobbling between the legs and bodies of these comparatively massive beasts while the unconcerned mother sat calmly with her back to him milking another heifer. And I guess I haven’t seen or heard yet of a single cow related injury at the hospital, so I know that child was safe, but it did rather put my heart into my mouth to watch nonetheless!

A more arresting sight still was when I spotted the woman milking get up, go around to the rear end of the cow, lift its tail and placidly proceed to plant her face firmly into the cows backside and blow hard not once, but several times, into its vagina, before resuming her seat and continuing milking again. Once I had unfrozen with horror I managed to dredge up some memory of hearing about this technique being used for stimulating more milk flow from the udders. Had never seen it in practice though. Rather puts the apparent bother of having to pop down to the corner shop for an extra pint when the fridge is empty into perspective! Could you imagine having to do that every time you wanted milk for your morning cuppa? Nope, me either.

The Nuer tribal culture here centres almost entirely around cattle. They are their livelihood, their diet, their security and their identity. No major life event is separate from them – deaths, marriages, court settlements and many other events all involve strict traditions of purchasing, exchanging and killing cows. They are an integral way of life and there are always cows and calves visible, tied up outside every home tukul in the villages. Herds and their grazing needs determine the ebb and flow of population and seasonal migration of the tribes all across South Sudan, and blur our conventional political borders into the surrounding countries too. Here, wealth is measured in how many cows you have.

Put quite simply – here currency is cattle.

To such an extent that the introduction here within the last century of Western paper and coin currency was initially viewed with not-immoderate suspicion – and quite reasonably so when you stop to consider it. When you know no banking system, no investments; when there are no stocks, shares or interest to be earned, money in its physical self is an inert, lifeless, loveless thing. As a quote from a Neur man in a book on the culture here beautifully expresses “…There’s something I don’t understand about money. Money is not like the cow, because the cow has blood and breath and, like people, gives birth. But money does not. So tell me do you know whether God or man created money?

Give to Caesar what belongs to Caesar indeed.

There is a quite lovely symbiosis in the relationship between man and beast here, and one that I don’t think I’ve ever seen so close, so dependant, so umbilical before in any other culture I’ve been close to. And yet if you tried to take the monetary value of a heifer – about USD$800 – and imagine a parallel closeness between the people and the paper bills – well, you just can’t. Despite the multitude of problems here and the poverty, there is something very beautiful and organic in the relationship that cold hard currency could never and I hope will never replace.

Children look on as cows head home for the evening in Nasir, South Sudan. April 2012. © Brendan Bannon/MSF

Children look on as cows head home for the evening in Nasir, South Sudan. April 2012. ©Brendan Bannon/MSF

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Wild life

With half the team away from the hospital on the mobile clinics, you’d think that we’d be in for some quietish time in the evenings – but this was not to be! Anabel our visiting WatSan [water and sanitation] specialist wound up with the dubious responsibility of dealing with a truly enormous hive of bees that had taken up residence in a tree in our fenced off TB treatment area. Enthusiastic and impractical suggestions on how to deal with it came thick and fast from the rest of the team – from smoking them out, to spraying them out, to constructing some sort of flamethrower. Can’t say I envied the poor girl that task!

Eventually she determinedly set off with some of the local hospital staff (who were keen to preserve the nest and the honey it contained) to deal with them one evening just after sunset – while the rest of us sat safely behind the meshed off veranda shouting dubious pieces of advice after her. Ten minutes later she was back shaking with suppressed laughter and proceeded to describe how one of our staff had set up a mosquito net on the floor under the tree, while another scaled up and cut the nest down onto it. The second it came crashing down into the net, the first guy bundled it up and set off pell mell for the nearest gate dragging the net and nest behind him in an attempt to avoid the retribution of the sleepy, but no doubt seriously pissed-off, bees that had detonated out of it upon landing. His attempts at running out of the compound might have been a tad more successful had he in fact checked for the location of the nearest gate first – as it was he sprinted needlessly round nearly the entire perimeter of the compound, nest in tow, before eventually locating a door and escaping through it into the night, still running. We were in hysterics. I just hope he’s enjoying his honey now where ever he is.

The next night it was the turn of the unfortunate hawks to get our attention. I say hawks – we don’t really know what they are, some sort of raptor, but bigger than any British hawk – more the size and colouring of a buzzard. Anyway, they are endemic here and yet another tree next to the expat compound had become the chosen site for one particular pair to build their nest in. All well and good, until they decided that that we had sinister designs on their offspring and took to aggressively swooping down on hapless members off staff walking to and from their tukels and clawing at their hair. I was the luckless recipient of one such attack, and whilst somewhat startling, it didn’t really hurt, so we were mostly going to ignore them until one of them actually flew down and clawed at Stefan’s eye. This was rather more than he was prepared to put up with, so, after a week of eye ointment and dire mutterings in their direction we came to another evening, and another nighttime raid on the unsuspecting wildlife’s aerial residence. I’m sorry to report that this particular pair won’t be raising any chicks this year, but it is something of a relief to be able to walk about the place without having to anxiously scan the sky every few seconds!

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Never a dull moment

There’s a lot going on in Nasir at the moment. Last week our project dispatched a small team downriver on an explo mission to find the source of an alarming amount of cases of Kala Azar – a sandfly borne parasitic disease that attacks your spleen and bone marrow with disastrous consequences. They found their source – and then at the weekend while they were planning to return and do further assessment and treatments there were reports of a large attack on people migrating with their cattle in the same area. So the team was dispatched but with a different remit this time.

The conditions and work demands of running these mobile clinics sound seriously arduous – and the expat and national staff members that are out there for a few days at a time are giving it their all and are coming back dirty, sunburned and exhausted after only a few days. I may well find out what it’s like for myself in the not-too-distant future! Other organizations are also mobilising. MedAir and World vision have done an assessment and are planning to do a distribution of non-food items (Mosquito nets, cooking pots etc) and the UN are doing an assessment too.

From what we know at the moment it sounds like a large population was on the move for their annual migration – taking their cattle to better grazing grounds – when the attack happened. We may be running mobile clinics for the people who fled – and are now displaced without the basics of shelter, food, or clean water – for the foreseable future.

It’s incredible to watch how fast MSF responds in these evolving situations – the boat went out on Monday –  and on Tuesday was sent back to the hospital containing seven patients, mostly women and children with gunshot wounds. A further five arrived the next day. I don’t think I’ve ever looked after a braver patient than the trembling mite of a five-year-old girl with the bullet wound to her shoulder who sat still and tense, holding back sobs while I examined her.

Our amazing surgical team worked long days to ensure that all the patients were operated on as soon as possible – the wounds were already three days old by the time they got to us, and in the tropical heat infection can set in fast. I am happy to say that all the patients are doing really well now following their treatment – but it’s a sobering thought that we were only able to assist the ones who had survived without medical aid for over 72 hours already – anybody seriously injured never even made it as far as our team in the field, let alone our hospital.

Meanwhile Nasir has had some drama too – a landmine victim was brought in one morning earlier this week, something this area has not seen for a long time and I haven’t seen – well, ever. Somewhat unfortunately for me I had chosen the previous evening to drink a couple of beers and was feeling a trifle fragile on my pilgrimage over to the office at 8am, looking forward to an uneventful hour or so on the computer whilst waiting for the ibuprofen to kick in before heading to the OPD. But just as I approached the office a cluster of people carrying a stretcher rounded the corner of the ER and I before I knew it was examining the tattered remains of this man’s leg before urgently grabbing my radio and squawking into it for the surgeon to come NOW please.

Cannula, fluids, painkillers… less than an hour later I was able to join the team in surgery and watch as Robert, our Nigerian surgeon, skillfully cut away the useless remains of foot and craft a neat below-knee stump. Luckily this man’s other leg was entirely spared from the blast, so he’ll be up and about on crutches and then a prosthesis, if we can get one, very soon.

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All change

A few days after the events of my last post Michiel my Project Coordinator (boss) approaches me and asks if he can have “a word”.

I quail internally as I obediently follow him outside, racking my brains for whatever misdemeanor I might have recently committed that I am about to be pulled up on. None as it turns out – as we stroll around the hospital compound he asks me if I wanted to swap job roles – from my current OPD nurse position based at the MOH hospital to the Inpatient Department Nurse (IDP) role based at the MSF hospital. I blushingly recall my overreaction to the not-so-dehydrated baby from earlier in the week and can’t help but ask whether the move is for the project’s benefit or my own.

Both, he tells me, bluntly but not unkindly.

Tommy our current IDP nurse has offered to extend his mission with MSF in Nasir if he can have a change of role.

Plus the handing over a segment of a project from MSF to another actor is a huge deal and in the post conflict context of South Sudan, an immensely difficult one. There are no doubts as to my clinical abilities, but also for my first mission it makes more sense to keep me at the main MSF hospital so I can really absorb myself with not only the medical protocols but also the organisational ethics and team spirit that make up the beating humanitarian heart that drive our work here.

Any resistance I could have felt to this proposition is melting away – Tommy, a Sierra Leonese MSF veteran is beyond a doubt way better placed to steer through the challenges of the OPD handover than I am.

We walk on in silence for a few moments – I ask for 24 hours to think it though. But I know that the decision’s made internally really.

It’ll be tough leaving behind the network of relationships that I’m beginning to build with the OPD staff and start again so soon at the hospital. I think of Paul, who has just returned from taking some leave and beamingly informed me that he had just got married during the week; Rita in the stabilisation room whose English and clinical skills are coming on together in leaps and bounds under my inexpert tutelage; the adorable cleaner whose name I still can’t pronounce, but who always looks unashamedly delighted to see me every day and pours out a stream of largely incomprehensible Nuer greetings which I’m just learning to respond to falteringly in kind.

As challenging and frustrating as the OPD can be, it’ll be an unexpected wrench to let go of all of that. But Tommy is the perfect person to move it forward. I tell my PC the next day that I accept the transfer – we’ll do a formal handover in the next week or so. But I think I’ll still go visit occasionally.

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