The best laid plans

Posted on May 22, 2013 by

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…

Posted in healthcare provision, Nurse, South Sudan | Tagged , , , , , | 14 Comments

An assortment of oncalls

Posted on May 2, 2013 by

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

Posted on April 17, 2013 by

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

Posted on March 14, 2013 by

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

Posted on March 5, 2013 by

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

Posted on February 28, 2013 by

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

Posted on February 21, 2013 by

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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Different kinds of happy

Posted on February 18, 2013 by

Some days it’s just not your day. Today opened that way – A fidgety and restless night’s sleep preluded waking to an uncharacteristically overcast morning. I’m stiff and sore as I crawl out from under my mosquito net and yawningly make my way for my morning yoga ritual to the river tukul – so called because it is raised up a few feet on stilts and thus affords a pleasant view of the river a few feet beyond the compound fence. Today the river is as sullen as the sky though, a dull stoney grey – as above so below – and as I look over towards the east I see that the cloud cover is concealing the sunrise which I normally love to begin my day watching. Yoga this morning is brief and perfunctory – more mechanical then meditative and I still have uncomfortable kinks in my back when I head to the breakfast table. Grump.

As if to add insult to injury one of the bats in the toilet tukul poops on my head just before I leave for the office.

The OPD is the same as ever when I arrive there at nine – full, busy, and as always just teetering along the edge of chaos. A couple of the senior staff on both the MSF and Ministry side are on leave at the moment, so I’ve somewhat uncomfortably taken on a general floor management role that I feel vastly under qualified for, but am muddling my way through anyway. I walk past the registration queue and deliver a few boxes of Bioline malaria tests* to the laboratory. These things are pretty amazing – a single drop of blood onto the test strip and just like on a pregnancy test, a small watermark creeps up the viewing window and within 5 mins you have a your result. One visible line – negative. Two visible lines – congratulations, you’re malarious!

The challenges come thick and fast today – medication in the dispensary has run low, patient registration cards have run out, three people have forgotten their pens… oh bother, I forgot to bring the spare ones. I take a deep breath and step over the squalling children in the Therapeutic Feeding Centre to borrow from their stock. Here however a new set of issues assail me – some of the Ready to Use food that we dispense for the kids seems to have gone missing. My heart sinks. I take note of the numbers and then head out again, the new problems playing on my mind. A couple of cases are brought to me:

Teenager, sky high fever – clothes off, cold water sponging, paracetamol, Bioline malaria test. Next.

Another fever. Same treatment.

A snake bite victim. How long ago? I ask. Over a week. Most likely a dry bite then, no envenomation, not emergency but still a potential infection risk. Tetanus booster, oral antibiotics, dressing room.

A toddler is bought to me – a vague history of vomiting and slight fever. No diarrhoea. No urine today either.

Huh?

My ears prick up – in this heat, even a short period of vomiting can make young children life-threateningly dehydrated. No urine is not good – and given that there are no such things as nappies here infant urine is generally a hard thing to miss. Although it’s happened before that an older sibling had already dealt with a wet baby that day without telling mum.

I take a look at the proffered child- a bit lethargic, not playful, but still vaguely interested in breast feeding. So some liquid is getting in at least. I undress the copious layers of clothing and gently pinch the skin on the belly to check for turgor – if it springs back, great, if it’s slow we need to treat urgently. It’s slightly delayed – but not terribly so. So moderate but not severe dehydration by our protocols. The malaria test was negative. I um and ah – It’s always best not to site an IV unnecessarily if we can coax the child into taking oral fluids. I elect to treat here rather than sending the family to the already busy MSF ER. Can we keep trying breast milk and rehydration solution here in the OPD for a couple of hours first? I’d feel better if we definitely saw urine. And if the kid’s hot then keep all those clothes off him!

There’s a chatter of translation. The mother nods her assent and is led off to the stabilisation room. I’ll check back in an hour.

As I turn away pondering my decision I thump my shoulder hard into the solid metal dispensary door. A feature of life here is that if you trip or hit something, so matter how clumsy and blatantly self-inflicted the injury, the Nuer people around you chime in with profuse apologies. Given the crowded location and my very audible yelp of pain, a loud chorus of “Oh Sorry! Sorry! Sorry sister. So sorry!” sets up all around me, which is gorgeously sweet and yet mortifyingly embarrassing.

I rub my smarting shoulder and smile through slightly gritted teeth at the needlessly woeful and apologetic faces around me. No-one and nothing to blame here but my own lack of coordination!

The rest of the day passes in much the same fashion. Cases and patients are passed rapidly before me and I prioritise the best I can – tallying drug consumption, trying to deal with overprescribing, anticipating low stock for the next day. I plan the week’s immunisation schedule with the Ministry official  and congratulate the registrars on triaging well. I take a peek at the dehydrated baby as I pass – looks like he’s breastfeeding a bit – good.

The early cloud cover has long cleared and by afternoon the sky is clear and the sun is punishingly bright, as if to make up for it’s earlier absence. It’s easily mid thirties today. Squinting into the light is giving me a headache and my shoulder throbs so I chase back some ibuprofen with the last bloodwarm dregs of my bottle of water.

Heavy heat, heavy head, heavy heart. I miss my senior staff.

Before I know it it’s 5pm and as I start to wearily gather all my things together into the landcruiser one of the consultants trots up to me to remind me about the baby still in the stabilsation room.

What baby, there have been dozens?

The one you wanted to pass water.

Oh that baby.

Not one but three hours have flown by since I first saw that child.

For a tired girl I pick up an impressive turn of speed on my way to the stabilization room and only narrowly escape repeating my earlier trick of careering full tilt into the door. The baby is flaked out on the bed next to mum. Despite apparently feeding earlier he hasn’t taken much breast milk. Hard to tell how much of the rehydration solution he has drunk and how much he’s wearing from the soggy state of his T-shirt. The blanket and trousers however remain stubbornly dry. Crap. I recheck the skin pinch. No worse, but definitely no better either. Double crap.

Right, into the car with them, I’m not even going to waste time trying to site an infant cannula and start an IV, they are tricky at the best of times and a thumping head and stressed out is not the best of times. Let’s just get to the MSF ER.

As we rattle back over the uneven roads to the hospital I’m panicking internally and – right now with the tight band of headache pressing round my skull I feel like I’m not thinking straight and my mind heads straight for worst-case scenarios – what if that kid does have concurrent malaria? Diagnostically the quick malaria tests aren’t 100% infallible, but at MSF the microscopy blood films are… What if this drowsiness isn’t just from dehydration, but from low blood sugars? What if the mother was right, what if that child really hasn’t passed urine all night as well as all morning as well as all afternoon? What if he really didn’t take any of that rehydration solution? What if I’d taken the other option and sent him straight to the ER? What if, what if, what if…? Despite my training and qualifications I feel so so unprepared for parts of this job sometimes – not so much professionally, but experientially, emotionally… unprepared for the heat … my heart feels leaden inside me and I’m barely holding back tears as I berate myself.

We arrive at the compound and pull up outside the Emergency room. Running around to the back of the land cruiser I take the sleeping child from his mother’s arms to carry him into the ER. Somehow during the short journey the mother has bundled the child back up into all his clothes again! – a long sleeved cotton top, a big fleecy jumper and matching trousers and a blanket… It’s 35 degrees here for heaven’s sake!!! I plonk myself onto a bench by the ER and start undressing him again. As I unwind the blanket, the child rouses and starts crying – a weak, fitful cry that healthcare workers know and dread – the cry of a child with scant energy reserves left to cry with.

My heart sinks a little further, and I start tugging a little faster at the child’s clothes. His head lolls back mid-wail and on catching a glimpse of the pale and unexpectedly unfamiliar face above, his eyes suddenly flip into focus on me.

The crying pauses … I pause … the startled black eyes below unblinkingly regard the worried brown ones above … a few heartbeats and a few hundred years pass… and suddenly the little man in my arms is crying – and I mean proper crying – a lusty, full lunged bawling with all the might and main he can muster and I feel like I’ve never heard a more beautiful sound in my life, because any child that can cry that hard is OK, not 100% OK, but OK none-the -less. And my heart feels like it’s going to burst with relief. And then there is a sudden warmth spreading across my lap and I jump up startled, still cradling the now half-naked yelling baby, watching the dampness seep across his trousers and mine and its OK. He’s passing urine, lots of urine, fantastic amazing brilliant amounts of wonderful urine that I’ve scared out of him, that tell me that the kidneys are working perfectly, and the urine is streaming down my arms and legs and puddling at my feet and the baby is crying and the mother is clucking and fretting at the urine on me, and I’m laughing because I’m so relieved, and I’m laughing so hard because who knew a crying baby peeing all down me could make me so so happy and then without knowing quite why I’m crying too, and my heart is bursting wide open, and all the stress is pouring out and there are tears pouring down my cheeks and the urine is still pouring down my arms and they all mean the same thing – the baby is OK, I’m OK, everything is going to be OK.

The damp baby is passed over to the bemused ER staff with a somewhat garbled handover. This much urine? He’ll be just fine.

I clean off by the simple expedient of sticking my fully clothed arms and legs under the outside tap – blissful coolness! -and squelch my way back to the expat house.

A colleague joins me later out in the darkness at the back of the compound where I’m drinking beer spread-eagled out on the ground staring at the constellations overhead. Calm down he tells me. No need to be so intense. Stay focussed. No-one fails in their first month. This is followed up with some wryly insightful experiences from his first few missions.

I smile ruefully up at the stars. Sage advice indeed. I remember receiving similar advice when I first arrived. Who knows, I might actually manage to follow it sometime soon.

But for now, I’m just happy to lie here on the floor in the darkness looking out into the universe which never fails to bring me peace and perspective. The unfaltering points of starlight are joined by hundreds of fireflies above me, and for a while the familiar lines of Orion and Gemini are blurred with dozens of seeming dancing stars around them.

Stars. Fireflies. Peeing babies. My heart feels wide open again. I breathe.

And I’m happy.

* SD Bioline HRP2 test

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Sometimes it’s hard to be a woman…

Posted on February 11, 2013 by

One of the things that has come up unexpectedly for me as a result of a few conversations here is being feminine (being womanly, being girly however you want to phrase it) while you are out with MSF is a surprising challenge.

And although it may not be the be all and end all, there is no denying the fact that from the moment you are born, whatever your take on gender equality, what sex you are will subtly determine and direct much of the rest of your life and behaviours. Even and especially when you don’t want to. And it has to be said it leaves something of a void when it suddenly no longer seems to be much of a factor in your existence.

One thing is certain, I have learnt from ten years working in the highly female-dominated profession of nursing that it is surprisingly hard to feel feminine amongst a group that is exclusively female. Something oddly counterintuitive about that… you can feel bonded with, bitched at and anyone of a dozen things in between including a fantastic sense of sisterhood and nurturing community, but you don’t feel feminine. I suppose the thing about femininity is that it stands as a counterpart to masculinity. To have a sense of one, you must somewhere have the other by definition.

Anyway, what these musings are heading towards is how on earth do you do that here? “Here” being just about anywhere with MSF I should imagine. One of the common denominators in developing world context is the comparatively low status of women relative to men – especially in a working environment, which is almost exclusively male. An interesting upshot of this is that in order to reconcile the gender/power reversal amongst the male national and local staff that I am loosely “in charge of” is that I seem to be regarded as curiously asexual. I am not treated like a woman of their culture and community – but nor do they treat me as men of my culture and community would treat me. As an “Expat” I am accorded a similar/same level of respect as a male elder of their own community – respect is given to my education, experience and the organisation that I represent. And the issue of my gender is quietly shuffled off to one side and ignored. I feel that if I were writing this blog in German, I would be using the third gender, or neuter, to describe myself in my day to day work. Which now that I’m aware of it I’m can’t honestly say I’m 100% comfortable with!

Like many western women not a small portion of my sense of identity as a female is wedded to my own perception of my attractiveness. How comfortable I feel in my own skin and the level of acceptance I have of my own reflection in the mirror. (I’m not saying this is necessarily a good thing, just a true one!)

Well feeling attractive is a certainly challenging here. My pride and joy – normally fairly blemish free skin- is covered in a gritty permafilm of sun-cream, sweat, insect repellent and dirt, overlaying the polkadot effect of insect bites. The daily dress code is baggy MSF t-shirt and combat trousers, with a stethoscope sticking out of one pocket and a VHF radio sticking out of the other (by day and more of the same but add in a fetching socks and sandals combo by night). My normally decent posture is wilting in the 35-40 degree heat and my hair… actually, probably best not to get me started on the state of my poor hair. I can’t cook sumptuous meals for my friends like I did in my home – and I do love being a hostess. I’m not a parent – so my maternal drive is as of yet somewhat latent. And there’s scant chance for salsa dancing out here which always made me feel wonderful and gorgeous at home!

In a small bid for frivolity I have bought my favourite nail varnish out here with me and am foolishly pleased with the daily effect of shiny red toenails peeking out from my grubby hiking sandals – but that is about as girlie as I’m able to get. And frivolous it may be, but it puts me a little in mind of a story that I’ve heard from the second world war when the Bergen-Belsen concentration camp was liberated in 1945. This story is taken and paraphrased from the diary of of Lieutenant Colonel Mervin Willett Gonin who was part of the army medical relief crew first on scene. There he relates how in the midst of an overwhelmingly desperate need for food and medical supplies for the Jewish inmates who were dying in droves from starvation, neglect and a multitude of diseases, an unexpected and unordered crate of red lipstick arrived. This lipstick transformed the wretched lives of the internees in an unprecedented way – emaciated women still lay clad in rags lay on the floor the same as before, but with bright scarlet lips; the corpse of one woman was even found with a lipstick still clutched in her hands. After years of being treated worse than animals the lipstick gave them back their interest in their humanity – their femininity – and thus in their lives in a way that no amount of food or medical care ever could have.

It’s an extraordinary story, but one that in some small way is played out all around if you look close enough. The Nuer women here may be poor, desperately so by our standards, but their hair is gorgeously and meticulously braided and styled, no matter how simple or threadbare their clothing may be. Here though, femininity rests on far more than attractiveness – it also rests on your fertility. I’ve said in a previous posting that child bearing here begins young , often at 17 or before.

There is one particularly heart-breaking case on my mind at present – that of a very young woman in our ICU who came some days ago in severely obstructed labour – we’re talking days and days of failure to deliver here. Eventually her uterus ruptured necessitating in an emergency hysterectomy during the Cesarean. The baby sadly, was long dead. The girl – and she is barely more than a girl – has stormy recovery ahead of her following major surgery and sepsis resulting from the dead child inside her, but if she recovers then in her culture her value is near nil as a barren woman. I was sat by her for a while during my on call this week, prescribing fluids and trying to bring her raging fever down with cold compresses on her beautifully braided head. At the moment she is blessedly unconscious. She doesn’t yet know the outcome of her surgery and the profound and irreversible impact this will have on her future if she survives. But it somewhat put my struggles with maintaining a sense of femininity into perspective.

So maybe part of my femininity is going to diminish for a time here. But I think that is something I can live with – just as long as I have red toenails.

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Things that go bump in the night….

Posted on February 8, 2013 by

I spent the first two weeks in Nasir living out of my suitcase in one of the guest rooms in the main house in the expat compound. Since then I have tentatively moved into what was my predecessors tukul, or traditional mud hut, of which there are several dotted round the compound. I say tentatively because the first bit of unexpected wildlife that comes my way in the night and I’m moving straight back! I still have remarkably vivid memories of what it was like to have a rat land on my face one night in Nepal…

There is plenty of wildlife around here for me to be wary of! Because of our proximity to the river – which borders one long side of the rectangular hospital compound – there is a profusion of insects in the area. Beetles, mozzies, flies, enormous khaki coloured crickets and diminutive dragonflies are everywhere and (ecology lesson alert!) where you have wee animals you will inevitably find bigger ones busy eating them. So we find spindly, alien-looking praying mantises stalking across the tables; huddles of bats chittering and roosting in the toilet tukul and on the office ceiling; hundreds of disproportionately noisy little birds pecking around the veranda; sleek lizards and shy geckos peering down from the walls and flabby toads crouching under the beds and in the shower room.

And busy eating all of them are the next level in the food chain – scrawny, unkempt semi-feral cats which contrast sharply with the gorgeous sleek and sinuous civets; big brown eagles, giant Nile monitor lizards and occasional snake. At least I sincerely hope they are occasional.

And diligently avoiding all of the above you will find… me! Although that may well be easier said than done – last night one of the civets that live in the rafters of the main house was in the kitchen as I entered it, and it actually ran out of the door over my feet and between my legs. I may have shrieked a bit! The river has the most amazing huge pelicans, storks and ibises along its length which I get to see up close when I go with the outreach team on the boat.

There are also quite a lot of domestic animals wandering about the place. Chickens and goats roam at will about the hospital grounds, and in the town, cows, sheep and donkeys constitute most of the traffic on the roads! Incidentally, I have discovered that donkeys make the singularly most appalling noise I have ever heard… none of this dignified sounding “hee-haw” that we teach nursery age children, oh no… I was helping out in one of the consulting rooms at the OPD this week and was treated to a prolonged serenade from directly outside the window of what sounded like a cross between an elderly foghorn alternating with fingernails running down a blackboard magnified many, many times. Made taking a decent medical history very, very tricky!

By yesterday I was getting a bit fed up of laying in bed apprehensively staring up at the cloth and straw roof of my tukul above me every time it rustled, so by dint of strategic and slightly nervous poking at the ceiling I managed to get the largest and noisiest of my night-time neighbours to reveal himself to me – a chubby and distinctly disgruntled looking eight-inch gecko, who legged it down the wall away from my assaults and sought shelter under my shelves. I have christened him MacDougal in remembrance of the Scottish prayer that begins “From ghosties and ghoulies and longlegged beasties and things that go bump in the night…” Am more than happy to have him for company as he will keep the insects at bay!

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